Study of Rituximab to Treat Chronic Renal Transplant Rejection

Study Overview
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Brief Summary
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Purpose of clinical trial; Evaluate the effectiveness of rituximab in C4d+ CAN Primary objective; To determine whether anti-CD20 therapy can stabilize or improve renal function and/or proteinuria in patients with C4d+, chronic (humoral) rejection in whom standard therapeutic approaches have failed. Secondary objective (s); To compare patient and graft survival between control and rituximab-treated groups To evaluate the adverse effect profile of rituximab in this group To correlate changes in circulating B cell numbers, anti-HLA and non-HLA Ab profiles and titre with responses to standard therapy and / or rituximab To correlate changes in T cell responsiveness to alloantigens with responses to standard therapy and / or rituximab Study Design; Prospective, randomised, two arm, open-labeled Study Endpoints; Primary Rate of deterioration in renal function, defined by slope of reciprocal creatinine plot, on samples taken 3-5 months post-randomisation. Change in degree of proteinuria, where present, at 3-5 months post-randomisation 2˚ endpoints, determined at 3-5 months post-randomisation and at 1, 2 and 3 years post-recruitment are; Rate of deterioration in renal function, defined by slope of reciprocal creatinine plot, determined by analysis of samples taken since previous assessment. Patient survival Graft survival Incidence of culture positive infection Incidence of malignancy Degree of proteinuria Changes in circulating CD20+ cells in peripheral blood Changes in anti-graft Ab titres, (measured every 3 months) Changes in T cell responsiveness to alloantigens (measured every 3 months). Sample Size; 15 patients to be randomised to each arm (i.e. 30 patients randomised). Up to 120 patients will need to be enrolled into the study. In addition, in those participants that received a living donor kidney, these donors will be approached to provide up to 5 samples of blood to help with the in vitro analyses. Summary of eligibility criteria; Male or female renal allograft recipients 18-70 years of age more than 6/12 post-transplantation Either deteriorating allograft function on reciprocal creatinine plot or significant proteinuria or both. C4d+/- CAN on renal allograft biopsy Investigational medicinal product and dosage; Rituximab, 1g on day 0 and 1g on day 14 Active comparator product(s); None Route(s) of administration; Intravenous infusion Maximum duration of treatment of a subject; 14 days with rituximab. The treatment arms of the study, including optimisation period, formal run-in and post-randomisation phase lasts for 10 months post-recruitment. Procedures; Screening & enrollment. Potentially eligible patients will be identified by screening renal allograft biopsies performed for 'creeping creatinine' and/or proteinuria. Recruitment by informed consent prior to enrollment. Procedures; Baseline. In addition to routine tests, blood for anti-HLA and non-HLA antibody analysis and for peripheral blood mononuclear cell (PBMC) purification. Procedures; Treatment period. 3 month run-in period on optimal conventional immunosuppressive therapy, preceded by up to 2 months to allow tailored-optimization. Patients will be reviewed at least six times in their normal transplant clinic appointments for routine blood biochemistry, full blood count and urine analysis. At the end of the run-in period, further blood will be taken for anti-graft antibody analysis and PBMC purification. Those patients in whom allograft function stabilises and/or proteinuria improves will have normal transplant clinic follow-up appointments and have blood taken for further anti-graft antibody and PBMC purification up to every 3 months for 3 years. Those with continued deterioration in either allograft function or persisting or worsening proteinuria will be randomised. These patients will be reviewed during their normal transplant clinic appointments until the primary end-point and will need to have at least 6 routine blood biochemistry, full blood count and urine analysis during the final 3 months of this period, post-randomisation. At the primary end-point, further blood will be taken for anti-graft antibody analysis and PBMC. Procedures; End of Study. •Follow up will continue for 3 years, with blood taken for anti-graft antibody analysis and PBMC purification every three months Procedures for safety monitoring during trial; Regular patient interviews and examination, routine haematological and biochemical analyses. Serious adverse events will be reported and forwarded to the sponsor, MHRA, LREC and Roche as appropriate The WLRATC transplant research committee will discuss the trial and any safety concerns at their regular three monthly meetings. Data will be reviewed after 30 and also after 60 people have been enrolled. Criteria for withdrawal of patients on safety grounds; Serious adverse effects related to rituximab infusion

Official Title
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Randomised Trial of Anti-Cd20 in C4d+ Chronic Allograft Nephropathy

Conditions
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Kidney Transplantation, Graft Rejection, Immunosuppression

Intervention / Treatment
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* Drug: Rituximab
* Other: Control arm


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Functioning kidney allograft (with estimated (e) GFR by MDRD >20) and be >6/12 post-transplantation Deteriorating allograft function as defined by linear regression of reciprocal creatinine plot. Deterioration will be defined as a negative slope over at least the preceding 3 months (with at least 6 creatinines included) with an adjusted r2 >0.35 and a p value of ≤0.05 compared to horizontal baseline. Deterioration will be confirmed by reduction in Cockcroft-Gault (CG) eGFR over the same period (to exclude increases in body mass as a cause of a negative slope on reciprocal creatinine plots) OR significant proteinuria as assessed by a urine protein/creatinine ratio of ≥50 CAN, by Banff '97 criteria, and/or transplant glomerulopathy on renal allograft biopsy performed within 6/12 of enrolment Diffuse, linear C4d deposition on at least 25% of peritubular capillary (PTC) and/or glomerular EC of renal transplant biopsy when assessed by immunoperoxidase or >50% of PTC (alone) when assessed by immunofluorescence OR PTCitis OR glomerulitis with combined PTC/g score of ≥2. Exclusion Criteria: Ages below 18 years of age Suspicion of pregnancy confirmed by positive HCG pregnancy test Untreated ureteric obstruction on ultrasound of allograft History of acute allograft rejection in preceding 3/12 History of MI in preceding 3/12 History of malignancy in previous 5 years (excluding tumours limited to skin) Symptomatic IHD Recipient of simultaneous pancreas/kidney transplant Recipient of ABO-incompatible kidney Recipient who underwent an HLA desensitisation procedure prior to transplantation Evidence, on examination of renal allograft biopsy specimen, of recurrent or de-novo disease (except IgA deposition in absence of mesangial proliferation) Evidence, on examination of renal allograft biopsy specimen, of CNI toxicity IF ACCOMPANIED by mostly supra-therapeutic CNI trough levels in the 6 month period preceding biopsy. Documented allergy to mouse or chimeric human/mouse proteins HepBsAg+, HepBcAb+, HCV Ab+ or HIV+.

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 70 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: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Rituximab<br>Infusion of 2 x 1g of rituximab, 14 days apart | Drug: Rituximab<br>* 2 doses of 1g 14 days apart<br>* Other names: Mabthera;|
| Sham Comparator: 2<br> | Other: Control arm<br>* Continue of optimised oral immunosuppression<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Rate of deterioration in renal function, defined by slope of reciprocal creatinine plot |  | 3-5 months post-randomisation | 
| Change in degree of proteinuria, where present |  | 3-5 months post-randomisation | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Rate of deterioration in renal function, defined by slope of reciprocal creatinine plot, determined by analysis of samples taken since previous assessment |  | 1, 2 and 3 years post-recruitment | 
| Patient survival |  | 5 months post-randomisation and at 1, 2 and 3 years post-recruitment | 
| Graft survival |  | 5 months post-randomisation and at 1, 2 and 3 years post-recruitment | 
| Incidence of culture positive infection |  | 5 months post-randomisation and at 1, 2 and 3 years post-recruitment | 
| Incidence of malignancy |  | 5 months post-randomisation and at 1, 2 and 3 years post-recruitment | 
| Degree of proteinuria |  | 1, 2 and 3 years post-recruitment | 
| Changes in circulating CD20+ cells in peripheral blood |  | 5 months post-randomisation and at 1, 2 and 3 years post-recruitment | 
| Changes in anti-graft Ab titres |  | 3 monthly to 3 years post-recruitment | 
| Changes in T cell responsiveness to alloantigens |  | 3 monthly to 3 years post-recruitment | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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chronic allograft nephropathy, C4d, Anti-CD20, B cells, Antibody