Clinical trial NCT03444103: A Pilot Trial of Clazakizumab in Late ABMR
Official title: Safety, Tolerability and Efficacy of Anti-IL-6 Antibody Clazakizumab in Late Antibody-Mediated Rejection After Kidney Transplantation - a Pilot Trial
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: PHASE2
Conditions: Antibody-mediated Rejection
Keywords: IL-6 blockade
Lead sponsor: Medical University of Vienna
Sponsor class: OTHER
Collaborators: name: CSL Behring
name: University of Alberta
name: Charite University, Berlin, Germany
First posted: 2018-02-23
Enrollment: 20
Sex: ALL
Minimum age (years): 18
Maximum age (years): 100
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Intervention model: PARALLEL
Primary purpose: TREATMENT

Brief summary: This bi-center study (Medical University of Vienna \& Charité Berlin) is an investigator-driven pilot trial designed to assess the safety, tolerability, pharmacokinetics, pharmacodynamics and efficacy (preliminary assessment) of humanized anti-IL-6 monoclonal antibody clazakizumab in kidney transplant recipients with late antibody-mediated rejection (ABMR). The study is designed as a phase 2 trial and has two subsequent sub-parts, a randomized placebo-controlled trial (part A) of 12 weeks, where recipients are allocated to receive either anti-IL-6 antibody clazakizumab (n=10) or placebo (n=10), followed by an open-label prospective study, where all 20 study patients will receive clazakizumab for a period of 40 weeks. Study protocol biopsies will be performed at the end of part A and part B.

Detailed description: Part A:

Patients positive for anti-HLA donor-specific antibodies (DSA) and with biopsy-proven late ABMR (Acute/active or chronic/active phenotype according to the Banff 2015 classification) will be identified and recruited at the kidney transplantation outpatient services of the two center sites. Participants will be randomized to receive either clazakizumab or placebo subcutaneously (1:1 randomization stratified for ABMR type) for a period of 12 weeks (administration of clazakizumab/placebo at day 0, and after 4 and 8 weeks). After 12 weeks, patients will be subjected to a first follow-up biopsy. Primary goals of this part of the trial are to assess the safety, tolerability, pharmacokinetics and pharmacodynamics of a short course of treatment. Moreover, part A will allow for a first preliminary assessment of the impact of clazakizumab on ABMR-associated inflammation detected in peripheral blood and in the rejecting organ allograft, on the pharmacokinetics of pantoprazole as a probe drug to investigate influence of IL-6 blockade on cytochrome P450 (CYP) dependent drug metabolism (potential effects on the half-life of CYP-metabolized drugs such as pantoprazole, and on the short-term course of DSA mean fluorescence intensity (MFI) and kidney allograft function (eGFR, urinary protein excretion). The randomization sequence will be unblinded for a first data analysis after the last patient has completed the 12-week follow-up period.

Part B:

After completion of part A after 12 weeks, all study patients will enter part B, an open-label part of the study. All 20 subjects will receive subcutaneous clazakizumab in 4-weekly intervals until the end-of-study (EOS) visit after 52 weeks and will then be subjected to a second protocol biopsy. Major goals of part B are to evaluate the safety and tolerability of a prolonged period of treatment with clazakizumab and the long-term impact of this antibody on the evolution of ABMR, rejection-associated biomarkers and kidney allograft function and survival over a period of 12 months.

Eligibility criteria: Inclusion Criteria:

* Voluntary written informed consent
* Age \>18 years
* Functioning living or deceased donor allograft after ≥365 days post-transplantation
* eGFR \>30 ml/min/1.73 m2
* Detection of HLA class I and/or II antigen-specific antibodies (preformed and/or de novo DSA).
* Acute/active or chronic/active ABMR (±C4d in PTC) according to Banff 2013/2015
* Molecular ABMR score (ABMRpm) ≥0.2

Exclusion Criteria:

* Patients actively participating in another clinical trial
* Age ≤18 years
* Female subject is pregnant or lactating
* Index biopsy results:
* T-cell-mediated rejection classified Banff grade ≥I
* De novo or recurrent severe thrombotic microangiopathy
* Polyoma virus nephropathy
* De novo or recurrent glomerulonephritis
* Acute rejection treatment \<3 month before screening
* Acute deterioration of graft function (eGFR decline within 1-3 months \>25%)
* Nephrotic range proteinuria \>3500 mg/g protein/creatinine ratio
* Active viral, bacterial or fungal infection precluding intensified immunosuppression
* Active malignant disease precluding intensified immunosuppressive therapy
* Abnormal liver function tests (ALT, AST, bilirubin \> 1.5 x upper limit of normal)
* Other significant liver disease
* Latent or active tuberculosis (positive QuantiFERON-TB-Gold test, Chest X-ray)
* Administration of a live vaccine within 6 weeks of screening
* Neutropenia (\<1 G/L) or thrombocytopenia (\<100 G/L)
* History of gastrointestinal perforation, diverticulitis, or inflammatory bowel disease
* Allergy against proton pump inhibitors
* History of alcohol or illicit substance abuse
* Serious medical or psychiatric illness likely to interfere with participation in the study

Primary outcomes:
measure: Number of adverse events and severe adverse events (AE's, SAE's)
timeFrame: 12 months
Secondary outcomes:
measure: Anti-clazakizumab antibodies in serum
timeFrame: At 0, 12 and 52 weeks
measure: Clazakizumab serum concentration
timeFrame: At 0, 12 and 52 weeks
measure: Pantoprazole serum concentration
timeFrame: At 0, 12 and 52 weeks
measure: Protocol biopsy results - microcirculation inflammation
timeFrame: At week 11 and at week 52
measure: Protocol biopsy results - chronic damage
timeFrame: At week 11 and at week 52
measure: Protocol biopsy results - molecular signs of ABMR
timeFrame: At week 11 and at week 52
measure: Protocol biopsy results - ABMR phenotype
timeFrame: At week 11 and at week 52
measure: Anti-HLA antibody levels - antibody strength
timeFrame: At 0, 12 and 52 weeks
measure: Anti-HLA antibody levels - number of DSA
timeFrame: At 0, 12 and 52 weeks
measure: Anti-HLA antibody levels - broadness of antibody reactivity
timeFrame: At 0, 12 and 52 weeks
measure: Allograft function - eGFR
timeFrame: At day 0, week 1, 2, 3, 4, 5, 6, 7, 8, 11, 12, 16, 20, 24, 28, 32, 36, 40, 44, 48, 51 and 52
measure: Allograft function - protein excretion in spot urine
timeFrame: At day 0, week 1, 2, 3, 4, 5, 6, 7, 8, 11, 12, 16, 20, 24, 28, 32, 36, 40, 44, 48, 51 and 52
measure: Total IgG concentration
timeFrame: At 0, 12 and 52 weeks
measure: Total IgM concentration
timeFrame: At 0, 12 and 52 weeks
measure: Total IgA concentration
timeFrame: At 0, 12 and 52 weeks
measure: IgG subclass 1 (IgG1)
timeFrame: At 0, 12 and 52 weeks
measure: IgG subclass 2 (IgG2)
timeFrame: At 0, 12 and 52 weeks
measure: IgG subclass 3 (IgG3)
timeFrame: At 0, 12 and 52 weeks
measure: IgG subclass 4 (IgG4)
timeFrame: At 0, 12 and 52 weeks
measure: Effect on leukocyte subsets in peripheral blood
timeFrame: At 0, 12 and 52 weeks
measure: Cytokine patterns and endothelial activation/injury markers in serum
timeFrame: At 0, 12 and 52 weeks
measure: Effect on IL-6 gene expression in peripheral blood cells
timeFrame: At 0, 12 and 52 weeks
measure: Effect on IL-6R gene expression in peripheral blood cells
timeFrame: At 0, 12 and 52 weeks
measure: Patient survival
timeFrame: 12 months
measure: Graft survival
timeFrame: 12 months
measure: Occurrence of biopsy-proven acute rejection necessitating rejection treatment
timeFrame: At week 52
Other outcomes:
Locations:
city: Vienna
country: Austria
facility: Medical University of Vienna
city: Berlin
country: Germany
facility: Charité University
Study officials:
affiliation: Department of Clinical Pharmacology, Medical University Vienna
name: Bernd Jilma, MD
role: PRINCIPAL_INVESTIGATOR
References:
citation: Mease PJ, Gottlieb AB, Berman A, Drescher E, Xing J, Wong R, Banerjee S. The Efficacy and Safety of Clazakizumab, an Anti-Interleukin-6 Monoclonal Antibody, in a Phase IIb Study of Adults With Active Psoriatic Arthritis. Arthritis Rheumatol. 2016 Sep;68(9):2163-73. doi: 10.1002/art.39700.
citation: Choi J, Aubert O, Vo A, Loupy A, Haas M, Puliyanda D, Kim I, Louie S, Kang A, Peng A, Kahwaji J, Reinsmoen N, Toyoda M, Jordan SC. Assessment of Tocilizumab (Anti-Interleukin-6 Receptor Monoclonal) as a Potential Treatment for Chronic Antibody-Mediated Rejection and Transplant Glomerulopathy in HLA-Sensitized Renal Allograft Recipients. Am J Transplant. 2017 Sep;17(9):2381-2389. doi: 10.1111/ajt.14228. Epub 2017 Mar 10.
citation: Eskandary F, Regele H, Baumann L, Bond G, Kozakowski N, Wahrmann M, Hidalgo LG, Haslacher H, Kaltenecker CC, Aretin MB, Oberbauer R, Posch M, Staudenherz A, Handisurya A, Reeve J, Halloran PF, Bohmig GA. A Randomized Trial of Bortezomib in Late Antibody-Mediated Kidney Transplant Rejection. J Am Soc Nephrol. 2018 Feb;29(2):591-605. doi: 10.1681/ASN.2017070818. Epub 2017 Dec 14.
citation: Mayer KA, Doberer K, Halloran PF, Budde K, Haindl S, Muhlbacher J, Eskandary F, Viard T, Casas S, Jilma B, Bohmig GA. Anti-interleukin-6 Antibody Clazakizumab in Antibody-mediated Kidney Transplant Rejection: Effect on Donor-derived Cell-free DNA and C-X-C Motif Chemokine Ligand 10. Transplant Direct. 2022 Nov 10;8(12):e1406. doi: 10.1097/TXD.0000000000001406. eCollection 2022 Dec.
citation: Muhlbacher J, Schorgenhofer C, Doberer K, Durr M, Budde K, Eskandary F, Mayer KA, Schranz S, Ely S, Reiter B, Chong E, Adler SH, Jilma B, Bohmig GA. Anti-interleukin-6 antibody clazakizumab in late antibody-mediated kidney transplant rejection: effect on cytochrome P450 drug metabolism. Transpl Int. 2021 Aug;34(8):1542-1552. doi: 10.1111/tri.13954. Epub 2021 Jul 8.
citation: Eskandary F, Durr M, Budde K, Doberer K, Reindl-Schwaighofer R, Waiser J, Wahrmann M, Regele H, Spittler A, Lachmann N, Firbas C, Muhlbacher J, Bond G, Halloran PF, Chong E, Jilma B, Bohmig GA. Clazakizumab in late antibody-mediated rejection: study protocol of a randomized controlled pilot trial. Trials. 2019 Jan 11;20(1):37. doi: 10.1186/s13063-018-3158-6.