Combination Immunosuppressive Therapy to Prevent Kidney Transplant Rejection in Adults

Study Overview
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Brief Summary
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Transplant rejection occurs when a patient's body does not recognize the new organ and attacks it. Patients who have kidney transplants must take drugs to prevent transplant rejection. Alemtuzumab is a man-made antibody used to treat certain blood disorders. The purpose of this study is to test the safety and effectiveness of using alemtuzumab in combination with two other drugs, sirolimus and tacrolimus, to prevent organ rejection after kidney transplantation. This study will also test whether this combination of medications will allow patients to eventually stop taking antirejection medications entirely. Study hypothesis: A new strategy of immunosuppression using alemtuzumab, tacrolimus, and sirolimus for human renal transplantation will permit a step-wise withdrawal from immunosuppressive drugs.

Detailed Description
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Drugs that suppress the immune system, such as sirolimus and tacrolimus, have contributed to increased success of transplantation. However, to prevent organ rejection, transplant recipients need to take immunosuppressive drugs for the rest of their lives, and these drugs make patients more susceptible to infection, endangering their health and survival. Regimens that are less toxic to or can eventually be withdrawn from transplant recipients are needed. Alemtuzumab is a monoclonal antibody that binds to and depletes excess T cells in the bone marrow of leukemia patients. This study will determine the effects of intravenous alemtuzumab and oral sirolimus and tacrolimus after kidney transplantation. The study will also evaluate this regimen's potential to allow eventual discontinuation of components of long-term immunosuppressive therapy. This study will last up to 4 years. Participants will undergo kidney transplantation on Day 0 and will receive intravenous doses of alemtuzumab, acetaminophen, and diphenhydramine on Days 0, 1, and 2, as well as methylprednisolone on Day 0. After transplant, patients will receive up to 10 days of valganciclovir or acyclovir. Participants will take tacrolimus daily by mouth for at least 60 days after transplant and sirolimus daily by mouth for at least 12 months after transplant. As part of opportunistic infection (OI) prophylaxis, participants will also take sulfamethoxazole-trimethoprim by mouth 3 times a week, valganciclovir or acyclovir for up to 10 days post-transplant, and clotrimazole or nystatin by mouth for at least 3 months post-transplant. There will be a minimum of 62 study visits spread out over 4 years after transplant. Vital signs measurement, adverse event and OI reporting, medication history, physical exam, and blood collection will occur at selected visits. Sirolimus withdrawal will begin when a participant meets certain study criteria. The withdrawal process will occur over a minimum of 3 months at an approximate rate of 33% of the pre-withdrawal dose per month. Participants eligible for sirolimus withdrawal will undergo several kidney biopsies, including one 2 weeks prior to the start of withdrawal, 6 and 12 months after completion of withdrawal, 1 year after study enrollment, and annually thereafter.

Official Title
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The Use of Campath-1H, Tacrolimus, and Sirolimus Followed by Sirolimus Withdrawal in Renal Transplant Patients

Conditions
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Kidney Transplantation, Kidney Disease

Intervention / Treatment
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* Drug: Alemtuzumab
* Drug: Sirolimus
* Drug: Tacrolimus
* Procedure: Kidney transplant
* Drug: Methylprednisolone (or equivalent)
* Drug: Acetaminophen
* Drug: Diphenhydramine
* Drug: Trimethoprim (TMP)/Sulfa (Bactrim, Septra)
* Drug: Valgancyclovir
* Drug: Acyclovir
* Drug: Pentamidine
* Drug: Clotrimazole
* Drug: Nystatin


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria Kidney transplant with primary cadaveric or non-Human Leukocyte Antigen (HLA)-identical living donor kidney (0-3 HLA-antigen mismatch) Receiving only a kidney and no other organs Able to take medications by mouth Willing to use acceptable methods of contraception Exclusion Criteria Received HLA-identical living-donor kidney transplant HLA-antigen mismatch greater than 3 Panel reactive antibody (PRA) value greater than 10% at any time prior to enrollment Received a non-heart-beating donor allograft Received a kidney from a donor who is greater than 60 years of age End-stage Renal Disease (ESRD) due to Focal Segmental Glomulerosclerosis (FSGS) Previous kidney transplant Received multiorgan transplant Concomitant systemic corticosteroid therapy for other medical diseases Known hypersensitivity to alemtuzumab, tacrolimus, methylprednisolone, or sirolimus Human Immunodeficiency Virus (HIV) infected Hepatitis C virus infected Positive for hepatitis B surface antigen Received dual or en-bloc pediatric kidneys Anti-human Globulin (AHG) or T cell crossmatch positive Investigational drug within 6 weeks of study entry Known clinically significant cardiovascular or cerebrovascular disease Previous or current history of cancer or lymphoma. Patients with adequately treated basal or squamous cell skin carcinoma are not excluded. Clinically significant coagulopathy or a requirement for chronic anti-coagulation therapy precluding biopsy Cytomegalovirus (CMV)-negative recipient, if received kidney is from a CMV-positive donor History of a psychological illness or condition that, in the opinion of the investigator, may interfere with the study Graves disease. Patients who have been previously adequately treated with radioiodine ablative therapy are not excluded. Active systemic infections Platelets less than 100,000 cells/mm^3 at study entry Pregnant or breastfeeding

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 65 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Non-Randomized
Intervention Model: Single Group Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Alemtuzumab<br> | Drug: Alemtuzumab<br>* 30mg intravenous infusion on days 0 (transplant), 1, and 2<br>Drug: Sirolimus<br>* 2mg/day orally within 24-48 hrs post-transplant, and adjusted to achieve blood levels of 8-12 ng/mL for 1 year<br>Drug: Tacrolimus<br>* 2mg orally twice daily, on days 1-60<br>Procedure: Kidney transplant<br>* Kidney transplant with primary cadaveric or non-HLA-identical living donor kidney (0-3 HLA-antigen mismatch)<br>Drug: Methylprednisolone (or equivalent)<br>* 250 mg intravenous infusion 60 minutes prior to first dose of alemtuzumab<br>Drug: Acetaminophen<br>* 650 mg may be given 30-60 minutes prior to start of each infusion of alemtuzumab to prevent infusion related side effects such as fever, skin rash and pruritis<br>Drug: Diphenhydramine<br>* 25 mg may be given 30-60 minutes prior to start of each infusion of alemtuzumab to prevent infusion related side effects such as fever, skin rash and pruritis<br>Drug: Trimethoprim (TMP)/Sulfa (Bactrim, Septra)<br>* 1 double strength tablet 3 times a week from day 1 through 1 year post-transplant.<br>Drug: Valgancyclovir<br>* Given orally beginning on day 1 for up to 10 days post-transplant (until participant discharged from hospital if prior to 10 days). Dose adjusted based on participants calculated creatinine clearance<br>Drug: Acyclovir<br>* 400 mg orally twice daily or 800 mg orally four times daily (dose adjusted based on calculated creatinine clearance and cytomegalovirus antibody serologic status of donor and recipient) for a minimum of 3 months starting when valganciclovir discontinued.<br>Drug: Pentamidine<br>* 300 mg/6 mL inhalation therapy once monthly for a total of 6 treatments. First treatment given within one week post-transplant for participants with a known allergy or intolerance to sulfa<br>Drug: Clotrimazole<br>* 10 mg orally four times daily for a minimum of 3 months post-transplant (subjects take either clotrimazole or nystatin, not both)<br>Drug: Nystatin<br>* 500,000 units/5 mL orally four times daily for a minimum of 3 months post-transplant (subjects take either nystatin or clotrimazole, not both)<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of Acute Rejections in All Enrolled Participants | Number of acute rejections[1] in all enrolled subjects from the time of transplantation to the end of the trial (four years post-transplant) Acute rejection is defined as a biopsy-proven rejection: a renal biopsy demonstrates acute cellular or humoral rejection of Banff[2] Grade 1B or greater; or presumed rejection in the absence of biopsy-proven rejection, the participant is treated for an unexplained 20% increase in serum creatinine. Reference: Racusen LC, Solez K, Colvin RB et al,The Banff 97 working classification of renal allograft pathology. Kidney Int,55: 713-723, 1999 | Four years post-transplant | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of Acute Rejections in All Enrolled Participants Following Sirolimus Withdrawal | Following sirolimus withdrawal, the number of acute rejections[1] in all enrolled participants 1] Acute rejection is defined as a biopsy-proven rejection: a renal biopsy demonstrates acute cellular or humoral rejection of Banff[2] Grade 1B or greater; or presumed rejection in the absence of biopsy-proven rejection, the participant is treated for an unexplained 20% increase in serum creatinine. [2] Reference: Racusen LC, Solez K, Colvin RB et al,The Banff 97 working classification of renal allograft pathology. Kidney Int,55: 713-723, 1999 | Transplantation to end of study (up to four years post-transplant) | 
| Number of Acute Rejections Between Initiation of Sirolimus Withdrawal and End of Study | Acute rejections[1] between initiation of sirolimus withdrawal and end of study 1] Acute rejection is defined as a biopsy-proven rejection: a renal biopsy demonstrates acute cellular or humoral rejection of Banff[2] Grade 1B or greater; or presumed rejection in the absence of biopsy-proven rejection, the participant is treated for an unexplained 20% increase in serum creatinine. [2] Reference: Racusen LC, Solez K, Colvin RB et al,The Banff 97 working classification of renal allograft pathology. Kidney Int,55: 713-723, 1999 | Initiation of sirolimus to end of study (up to four years post-transplant) | 
| Time From Transplantation to Acute Rejection in Participants for Whom Sirolimus Withdrawal Was Not Initiated | Time (days) to acute rejection[1] for participants where sirolimus was not initiated 1] Acute rejection is defined as a biopsy-proven rejection: a renal biopsy demonstrates acute cellular or humoral rejection of Banff[2] Grade 1B or greater; or presumed rejection in the absence of biopsy-proven rejection, the participant is treated for an unexplained 20% increase in serum creatinine. [2] Reference: Racusen LC, Solez K, Colvin RB et al,The Banff 97 working classification of renal allograft pathology. Kidney Int,55: 713-723, 1999 | Transplantation to acute rejection (up to four years post-transplantation) | 
| Time From Transplantation to Acute Rejection in Participants for Whom Acute Rejection Occurred During the 1 Year Post-transplant Period | Time (days) to acute rejection[1] for participants occurring during the year following transplantation 1] Acute rejection is defined as a biopsy-proven rejection: a renal biopsy demonstrates acute cellular or humoral rejection of Banff[2] Grade 1B or greater; or presumed rejection in the absence of biopsy-proven rejection, the participant is treated for an unexplained 20% increase in serum creatinine. [2] Reference: Racusen LC, Solez K, Colvin RB et al,The Banff 97 working classification of renal allograft pathology. Kidney Int,55: 713-723, 1999 | Transplantation to acute rejection (up to one year post-transplant) | 
| Number of Deaths Stratified by Sirolimus Withdrawal Status | Participants who died during the study, all cause(s) | Transplantation to Death (up to four years post-transplant) | 
| Number of Participants Who Experienced Graft Loss Stratified by Sirolimus Withdrawal Status | Participants who experienced graft loss[1] during study [1]Graft loss is defined as the institution of chronic dialysis (at least 6 consecutive weeks, excluding participants with delayed graft function), transplant nephrectomy, or retransplantation | Transplantation to Graft Loss (up to four years post-transplantation) | 
| Number of Severe Acute Rejections Stratified by Sirolimus Withdrawal Status | Participants who experienced severe acute rejections[1] during study Severe acute rejection is defined as that which requires treatment with anti-lymphocyte antibody or is histologically evaluated as Type IIA or greater using the Banff 1997 criteria[2] Reference: Racusen LC, Solez K, Colvin RB et al,The Banff 97 working classification of renal allograft pathology. Kidney Int,55: 713-723, 1999 | Transplantation to severe acute rejection (up to four years post-transplantation) | 
| Number of Participants Requiring Anti-lymphocyte Therapy for an Acute Rejection, Stratified by Sirolimus Withdrawal Status | Participants who experienced acute rejection[1] during study which required anti-lymphocyte (OKT3, ATG) therapy 1] Acute rejection is defined as a biopsy-prove rejection: a renal biopsy demonstrates acute cellular or humoral rejection of Banff[2] Grade 1B or greater; or presumed rejection in the absence of biopsy-proven rejection, the participant is treated for an unexplained 20% increase in serum creatinine. [2] Reference: Racusen LC, Solez K, Colvin RB et al,The Banff 97 working classification of renal allograft pathology. Kidney Int,55: 713-723, 1999 | Transplantation to acute rejection (up to four years post-transplantation) | 
| Number of Alemtuzumab Associated Adverse Events, Stratified by Sirolimus Withdrawal Status |  | Transplantation to end of study (up to four years post-transplant) | 
| Number of Tacrolimus Associated Adverse Events, Stratified by Sirolimus Withdrawal Status |  | Transplantation to end of study (up to four years post-transplant) | 
| Number of Sirolimus Associated Adverse Events, Stratified by Sirolimus Withdrawal Status |  | Transplantation to end of study (up to four years post-transplant) | 
| Number of Side Effects of Conventional Immunosuppression, Stratified by Withdrawal Status | Side effects of conventional immunosuppression include increased body weight and hypertension | Transplantation to end of study (up to four years post-transplant) | 
| Change in Renal Function as Measured by Serum Creatinine, Stratified by Withdrawal Status | Mean change from transplantation to Month 48 in serum creatinine. Normal serum creatinine range is from 0.7 - 1.4 mg/dL. In a transplant population, starting serum creatinine is higher than normal range. A negative change indicates better renal function | Transplantation to end of study (up to four years post-transplant) | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Immunosuppression, Renal Failure