Conditions: Late Complication From Kidney Transplant
Keywords: Kidney transplantation Inflammation
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 33
Healthy volunteers: no

Brief summary:
Randomized open label clinical trial in which 48 renal transplant recipients with inflammation in the 6 month allograft biopsy will either continue usual immunosuppression or receive monthly Actemra (Tocilizumab) infusions for 6 months in addition to usual immunosuppression.

Detailed description:
This is a prospective randomized controlled study of kidney transplant recipients with SCI on 6-month surveillance kidney biopsies. SCI for the purpose of this study is defined as 10-50% total parenchymal mononuclear inflammation (Banff ti1-ti2) with \<i2,t2 concurrent lesions.

After enrollment, study participants subjects will be randomized to group 1 (standard of care group) or group 2 (tocilizumab (TCZ) group). Block randomization will be performed by the UCSF investigational pharmacy using computer-generated random numbers. The pathologist will be blinded to the randomization.

Group 1 (standard of care group) will continue their usual immunosuppression and not receive any specific intervention.

Group 2 (TCZ group) will receive tocilizumab 8 mg/kg intravenously at four-week intervals for a total of 6 doses.In addition, they will continue their usual immunosuppressive regimen.

As noted above, both groups will continue their usual maintenance immunosuppression regimen. Therefore, recipients who are already receiving prednisone will continue it at 5 mg/day. Recipients on prednisone-free regimens will remain prednisone-free. Mycophenolate mofetil will be continued at the same dose as at the time of the biopsy. Tacrolimus dosing will be adjusted to aim for trough levels of 5-8 mcg/L.

The study period will be 12 months (6 months of therapy plus 6 months of extended follow up- see Study Schema). Any episodes of infections, renal allograft dysfunctions, rejections or other clinical events during the study period will be treated per the usual standard of care.

All participants will be seen by the study PI or co-investigator at monthly study visits. A focused history and physical exam will be performed, including queries for drug toxicities and signs/ symptom of infections. All participants will obtain laboratory tests at intervals of 4 weeks, consisting of a complete blood count, serum electrolytes, BUN and serum creatinine, fasting glucose, liver function tests and 12-hour trough tacrolimus levels. Lipid panels will be obtained at baseline, then every 12 weeks an at study termination.The outpatient electronic medical record will be queried twiceweekly by the study coordinator for any new laboratory results on study participants. Laboratory data on all study participants will be reviewed weekly by the study PI.

The 12-month surveillance biopsy will be performed at the end of therapy (6 months after study enrollment).

Arms:
arm 1: Will continue usual immunosuppression and not receive any specific intervention. arm 2: Will receive tocilizumab 8 mg/kg intravenously at four-week intervals for a total of 6 doses. In addition, will continue usual immunosuppressive regimen.

Interventions: intervention 1: Tocilizumab
Intervention descriptions: intervention 1: Will receive tocilizumab 8 mg/kg intravenously at four-week intervals for a total of 6 doses. In addition, will continue usual immunosuppressive regimen.

Protocol document:
Prot_SAP_000.pdf: 
Study Title: 
Protocol ML29092: A Phase II Trial of the Efficacy and Safety of Tocilizumab for Treatment of 
Inflammation and Rejection in the Renal Allograft 
 
NCT02108600 
 
Protocol v11.0, date 27 April 2016 


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UNIVERSITY OF CALIFORNIA, SAN FRANCISCO
SYNPOSIS
Study Title
Protocol  ML29092:  A Phase II Trial of the Efficacy 
and Safety of Tocilizumab for Treatment of 
Inflammation and Rejection in the Renal Allograft
Short Title
Tocilizumab for Renal Graft Inflammation and 
Rejection
Study Drug
Tocilizumab (ACTEMRA®)
Support Provided By
Genentech
Clinical Phase
Phase II
Sponsor Investigator
Flavio Vincenti
Sub-Investigators
Sindhu Chandran
Zoltan Laszik
Research Coordinator
Niloufar Abdollahi
Accrual Objective
48 
Study Design
Randomized open label clinical trial in which 48 
renal transplant recipients with inflammation or 
acute rejection within the first year post-
transplant will either receive standard of care 
immunosuppression or receive monthly Actemra 
(Tocilizumab) infusions for 6 months in addition to 
standard of care immunosuppression 
Study Duration
It will take 12 months to enroll 48 patients. 
Actemra (Tocilizumab) will be administered for 6 
months with an extended follow up period for 
each participant of 6 months for a total study 
duration of 24 months
Primary Endpoint
Primary outcome will be a 40% decrease in 
inflammation on repeat renal allograft biopsy at 
the end of treatment
Secondary Endpoint
Secondary outcomes are the change in urinary 
cytokines, development of donor specific anti-HLA 
antibody and the incidence of subsequent acute 
rejection
Protocol Version:
11.0
Date:
27 April 2016


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LIST OF ABBREVIATIONS
AE
Adverse effect 
AI
Allograft inflammation
AR
Acute rejection
CFR
Code of federal regulations
DMARD
Disease modifying anti-rheumatic drug
GFR
Glomerular filtration rate
IF/TA
Interstitial fibrosis and tubular atrophy
IL-6
Interleukin-6
MMF
Mycophenolate mofetil
MPA
Mycophenolic acid
REMS
Risk evaluation and mitigation strategy
SAE
Serious adverse event
SCI
Subclinical inflammation
SCR
Subclinical rejection
TCZ
Tocilizumab
ULN
Upper limit of normal


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Table of Contents
1.0
INTRODUCTION..............................................................................................................5
1.1
Background on Inflammation and Rejection in Kidney Transplants..........................................5
1.2
Tocilizumab Background..........................................................................................................9
1.3
Study Rationale.......................................................................................................................9
2.0 
OBJECTIVES .................................................................................................................11
2.1 
Primary Objective.................................................................................................................11
2.2 
Secondary Objective.............................................................................................................12
3.0
STUDY DESIGN .............................................................................................................12
3.1
Study Description ..................................................................................................................12
3.1.1 
Study Schema........................................................................................................................13
3.2
Rationale for Study Design and Dose .....................................................................................13
3.3
Outcome Measures ...............................................................................................................14
3.3.1
Primary Outcome Measure....................................................................................................14
3.3.2
Secondary Outcome Measures ..............................................................................................15
3.4
End of Study ..........................................................................................................................15
4.0
STUDY POPULATION.....................................................................................................15
4.1
Overview...............................................................................................................................15
4.2
Inclusion Criteria ...................................................................................................................16
4.3
Exclusion Criteria...................................................................................................................16
4.4
Immunization during TCZ therapy..........................................................................................17
4.5
Criteria for Premature Withdrawal ........................................................................................18
5.0
TREATMENT PLAN........................................................................................................18
6.0
STUDY MEDICATION.....................................................................................................20
6.1
Tocilizumab ...........................................................................................................................20
6.1.1
Tocilizumab Dosage and Administration................................................................................20
6.1.2
Tocilizumab Storage...............................................................................................................21
6.1.3
Tocilizumab Overdosage........................................................................................................21
6.2
Other Study Drugs .................................................................................................................21
7.0
 DOSE MODIFICATION/TOXICITY MANAGEMENT..........................................................21
7.1
Tocilizumab ...........................................................................................................................22
7.2
Other Study Drugs .................................................................................................................25
8.0
CRITERIA FOR SUBJECT DISCONTINUATION ..................................................................26
8.1
Tocilizumab-Specific Criteria..................................................................................................26
8.2
General Criteria .....................................................................................................................27
9.0
STOPPING RULES..........................................................................................................27
9.1
Ongoing Review ....................................................................................................................27


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9.2
Stopping Rule Guidance.........................................................................................................27
10.0
CLINICAL AND LABORATORY EVALUATIONS ...............................................................28
10. 1 Visit windows.........................................................................................................................28
10.2
Schedule of Assessments.....................................................................................................29
10.3
Pre-Treatment Evaluations in both groups ..........................................................................30
10.3.1 Evaluations During Treatment in group 2 (TCZ group) ............................................................30
10.3.2 Evaluations During Treatment In Group 1(Standard of Care group) .......................................31
10.4
Post-Treatment Evaluations in both groups.........................................................................32
11.0
REPORTING OF ADVERSE EVENTS...............................................................................32
11.1
Adverse Event and Reporting Definitions ............................................................................32
11.2
Reporting of Serious Adverse Events Associated with Tocilizumab ......................................37
11.3
Actemra Events of Special Interest ......................................................................................39
11.4
Study Close Out...................................................................................................................40
12.0
EVALUATION OF RESPONSE........................................................................................40
13.0
STATISTICAL CONSIDERATIONS ..................................................................................41
13.1  
Determination of Sample Size............................................................................................41
14.0
RETENTION OF RECORDS............................................................................................42
15.0
REFERENCES...............................................................................................................42
16.0
APPENDIX ..................................................................................................................47
APPENDIX A:  STUDY FLOW CHART/SCHEMA ..................................................................................47
APPENDIX B:  BANFF 1997 QUANTITATIVE CRITERIA FOR RENAL ALLOGRAFT BIOPSIES...................48
APPENDIX C:  FDA MEDWATCH 3500A FORM..................................................................................49
APPENDIX D: SAFETY REPORTING FAX COVER SHEET.......................................................................50


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1.0
INTRODUCTION
1.1
Background on Inflammation and Rejection in Kidney Transplants
Improved renal allograft survival over the past decades has been mostly driven by dramatic reductions 
in early acute rejections and first-year graft loss, accompanied by only very modest gains in long-term 
graft attrition (1, 2). A major contributor to graft loss is interstitial fibrosis and tubular atrophy (IF/TA) (3, 
4), previously called chronic allograft nephropathy (CAN), which is the result of cumulative allograft 
damage of immunologic and non-immunologic origin. Studies of protocol biopsies have provided 
important clues on how early changes in graft histology relate to long-term graft survival. Early 
sequential post-transplant protocol biopsies show a rapid increase in the prevalence of IF/TA, to over 
50% at one year in most studies, which constitutes nearly 2/3rds of the total fibrosis burden seen at 10 
years (4-5). This means that the majority of IF/TA- a marker of previous injury and chronic damage- 
occurs early in the life of the kidney transplant. IF/TA on a 1-year biopsy is associated with inferior graft 
survival (6-7) and can be used as a surrogate marker of long-term survival (8-9). 
The Banff 1997 classification (10), updated 2007 (11), of renal allograft pathology uses semi-quantitative 
lesion scoring and has proven to be reproducible and useful for the diagnosis, grading and management 
of acute rejection in kidney transplants (Appendix 1). “Acute T-cell-mediated rejection” is defined by a 
minimum threshold of i2 t2, i.e., interstitial inflammation (>25% of the cortex) and moderate tubulitis (> 
4 mononuclear cells/ tubule). Inflammation which is insufficient to meet criteria for acute rejection is 
classified as “borderline change” or “suspicious” if there is tubulitis (t1, t2 or t3) with minor interstitial 
inflammation (i0 or i1) or interstitial inflammation (i2, i3) with mild (t1) tubulitis. 
Early studies clearly established acute rejection (AR) as one of the strongest correlates of reduced 
allograft survival (12-14). Despite a decline in incidence rates of acute rejection (AR) in the modern era 
of immunosuppression, it is clear that AR remains a major risk factor for late graft loss.  Even early 
episodes of acute rejection, such as those within the first year, have lasting impact on the graft.  In a 
study (15) of 28,867 recipients of deceased donor kidney transplants between 1995 and 2005, AR 
anytime during the first post-transplant year was shown to confer risk (hazard ratio for graft survival to 
1.35 for patients with rejection 0-90 days, 2.05 with rejection 91-180 days, and 2.74 with rejection 181-
365 days post-transplant). These risks are seen in low immunologic risk populations as well. A study (16) 
of 797 living donor kidney transplant recipients from 1998-2010 found that 15.2% of recipients had AR 
diagnosed by protocol or clinical biopsies within the first year. In this analysis “borderline” changes were 
analyzed as an AR event. Compared to no-AR, all histologic types of AR (including borderline change) led 
to abnormal histology in 1 and 2 years protocol biopsies, including more fibrosis + inflammation (6.3% 
vs. 21.9%), moderate/severe fibrosis (7.7% vs. 13.5%) and transplant glomerulopathy (1.4% vs. 8.3%, all 
p < 0.0001). AR were associated with reduced graft survival (HR = 3.07). Finally, another study (17) of 
270 patients found that all types of AR, including borderline change and Banff type 1 T-cell mediated 
rejection, shortened long-term graft survival. From these observations, it is clear that despite the 
remarkable success of modern immunosuppressive regimens in reducing the rates of incident AR and 
the effectiveness of available treatments for acute rejection, an episode of AR continues to have a 


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significant negative impact on graft outcome. Detailed follow up of allograft histology following AR, 
including even those episodes which are clinically and histologically mild, has shown that one-third of 
cases have residual inflammation and eventually develop a pattern of fibrosis + inflammation.  Studies 
which identified AR as a strong predictor of death-censored graft survival (12, 14) found that most of 
that risk relates to a higher rate of late graft loss following the episode of rejection. These data indicate 
that conventional therapy of acute rejection, while improving graft function temporarily, may not be 
effective at preventing persistent inflammation and progressive fibrosis.  
Importantly, the negative impact of AR on graft survival is not limited to those episodes which manifest 
clinically with elevations in serum creatinine. Subclinical rejection (SCR) is the presence of AR on routine 
biopsies in patients with stable kidney function. Subclinical inflammation (SCI) is a term that is often 
used to indicate the presence of inflammation on routine biopsies that is insufficient to meet criteria for 
acute rejection. SCI and SCR are common, reported in 11-44% of surveillance biopsies within the first 
year (18-20) and emerging data suggest that they are not benign. 
It has been shown that immune-mediated injury, even if subclinical, precedes and/or worsens IF/TA. A 
study of 961 prospective protocol kidney biopsies (21) over 10 years from 119 diabetic recipients of a 
kidney-pancreas transplant and one kidney transplant alone found that SCR (including Banff borderline 
lesions) was a frequent finding early after transplantation (in 61 and 46% of biopsies at 1 and 3 months 
after transplant). If SCR persisted, it was not only associated with a higher degree of IF and TA but also 
resulted in significantly decreased renal function at 2 years after transplantation. Another study of 124 
sequential protocol biopsies performed at 2, 3, and 5 years after transplantation in 46 patients who 
exhibited histologic evidence of CAN at 1 year found that the presence of SCR in association with CAN 
correlated significantly with histologic progression defined as an increased chronic allograft damage 
index (CADI) score of the follow-up biopsies (22). Furthermore, a group of patients who exhibited 
repeated SCR in the sequential follow-up biopsies had a lower creatinine clearance at 5 years after 
transplantation and worse long-term graft survival. In contrast, the absence of evidence of acute 
inflammation in association with CAN at any time point was associated with minimal deterioration in 
renal function or progression of renal lesions during the observation period. 
According to the Banff classification, the significance of sub-threshold inflammation seen on surveillance 
biopsies is unclear. However, even when the level of inflammation does not meet the threshold for 
acute cellular rejection, it has been shown to have the same molecular nature and similar impact on 
graft pathology and function as AR. A study of clinically stable renal allograft biopsies showed that 
histologic features of rejection were often accompanied by enhanced expression of pro-inflammatory 
gene transcripts, despite the absence of clinically overt graft dysfunction (23). In this study, biopsies with 
borderline change, i.e., those with inflammation which did not meet the threshold for acute rejection 
had a level of expression of inflammatory gene transcripts which was intermediate between that shown 
by histologically normal biopsies and those with AR. Another study which correlated renal function with 
routine histology, immunohistochemical analysis, and quantitative assessment of 72 relevant immune 
function gene transcripts found that a transcriptional profile indicative of activated TH1 type T cells, but 
not the magnitude or composition of the infiltrate, uniquely defined a functionally significant allograft 
rejection (24). Thus it appears that the immune response is qualitatively similar but quantitatively 


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reduced in SCI, indicating that SCI carries the same potential for allo-immune damage as clinical or 
subclinical AR. This is borne out by studies showing early SCI is associated with progression of IF/TA as 
well as worsened renal function. In a cohort of kidney transplant recipients treated with rapid steroid 
withdrawal who underwent sequential protocol biopsies, patients with SCI on their 1-month or 4-month 
biopsy had a higher risk of IF/TA score > 2 on the 1-year biopsy (18). In a protocol biopsy analysis of a 
subpopulation of the CONCEPT study, SCI was observed in 30.5% of patients with an evaluable biopsy at 
1 year (20). At 30 months, SCI was associated with a significantly lower level of estimated glomerular 
filtration rate. 
In addition, graft inflammation,  with or without tubulitis, may not be benign or insignificant as 
previously considered, but is in fact associated with poor outcomes. A study of 124 biopsies for cause 
found that the sum of inflammation in atrophic and non-atrophic parenchyma (Banff “ti” or total i-score) 
showed stronger correlations with microarray-based gene sets representing major biological processes 
during allograft rejection than the Banff i-score, which only looks at inflammation in non-atrophic areas 
(25). In this study, the total-i score was also found to be a better predictor of graft survival than the 
Banff i-score. In another study, a decision tree analysis of the molecular changes in biopsies with acute 
cellular rejection, borderline and non-rejection showed that i-total >27% and tubulitis extent >3% 
matched the molecular diagnosis of acute cellular rejection in 85% of cases (26). This analysis indicated 
that the histologic assessment of rejection is more accurate when it relies primarily on interstitial 
inflammation, and that inflammation >27% (which by Banff 2007 classification is barely above the 
threshold of 25% for a score of i2), even when associated with rare tubulitis, is a marker of immune 
mediated injury. These findings are supported by studies showing that SCI occurring in association with 
IF/TA predicts progressive decline in kidney function and reduced graft survival. In a study of 151 living-
donor recipients, the combination of fibrosis and inflammation in 1-year protocol biopsies was 
associated with reduced graft function and survival as well as a rejection-like gene expression signature, 
even among recipients with no clinical risk factors for poor outcomes (27). Similarly, a study of 1-year 
surveillance biopsies of 292 kidney transplant recipients found that the presence of fibrosis and 
inflammation predicted poorer survival whereas mild fibrosis alone did not. Importantly, the degree of 
inflammation associated with fibrosis generally did not qualify for the diagnosis of borderline rejection 
(6). Another study of 833 protocol and 306 indicated biopsies found that the only predictor of allograft 
function outcome was persistent inflammation in sequential biopsies (28). The investigators calculated 
the cumulative inflammatory burden by summing up the number of inflammatory infiltrates in 
sequential biopsies (at 1.5, 3, and 6 months after transplant) and found that the persistence of 
inflammation in sequential biopsy specimens regardless of its severity, localization, or cellular 
composition predicted creatinine clearance at 1 and 2 years. The study concluded that as detected by 
sequential biopsies, persistence of any inflammation including those infiltrates currently not considered 
by the Banff classification should be regarded as a morphological correlate of ongoing allograft damage.  
The appropriate clinical management for patients showing SCI on routine biopsies remains an area of 
uncertainty. The response (or lack) of SCI to treatment remains unclear, as studies that treated SCI have 
not clearly differentiated between the level or type of inflammation when looking at graft outcomes (54-
58).


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Cytokines play an important role in regulating alloimmune responses (29). Interleukin-6 (IL-6) is 
synthesized by T cells and macrophages upon immune challenge, and is further induced by the action of 
other cytokines (IL-1 and tumor necrosis factor), also generated in the context of an immune stimulus 
(30). Initially identified as a B-cell maturation factor (31, 32) IL-6 also serves as an immunoregulator of T 
cell growth and differentiation (33-35) and is critical for Th17 development. A subtype of Th cells, Th17 
cells specifically secrete Il-17, which is responsible for neutrophil proliferation and migration, 
endothelial cell activation, and fibroblast activation and proliferation. Due to its strong anti-apoptotic 
properties, IL-6 can increase the effector/memory T-cell population (36) and has also been shown to 
skew Th cell differentiation toward a Th17 phenotype and to prevent the development of regulatory T 
cells (37). 
The exact role of IL-6 and Th17 cells in solid organ transplantation has not been fully elucidated; 
however, there are now considerable data linking them to immune mediated injury. In a mouse skin 
transplantation model, IL-6 synergized with tumor necrosis factor-α to promote T-cell alloimmune 
responses and impaired the ability of regulatory T cells to suppress effector T-cell alloimmune responses 
(38). IL-6 along with interferon-c was found to be the major cytokine upregulated during allograft 
rejection in fully major histocompatibility complex (MHC)-mismatched mouse model of cardiac 
transplantation (39). In this model, neutralization of IL-6 by a monoclonal IL-6 antibody along with 
costimulation blockade inhibited rejection and facilitated allograft survival. IL-6 and Th17 have also been 
found to play a pathogenic role in the development of acute and chronic lung rejection (40, 41).   
In renal transplant recipients, IL-6 expression in serum, urine and biopsy tissue is elevated during renal 
allograft rejection (42-48) and has been correlated with the degree of inflammatory cell infiltration (45, 
46). Interestingly, the demonstration of the strongest immunostaining for IL-6 in atrophic tubular areas 
(45) and increase in soluble IL-6 receptor in urine 12 and 6 months before late graft failure (49), raises 
the possibility that IL-6 may play a significant role in mediating chronic graft injury a. A biopsy study of 
40 stable renal allograft recipients 2-3 years after transplantation detected IL-6 transcripts in 18% and 
these were correlated with lymphocytic infiltrate, fibrosis, and tubular atrophy (50). Of the cytokines 
studies, IL-6 held the most consistent negative predictive value for histological injury. Epidemiologic 
studies also support a role for IL-6 in chronic rejection and potentially graft loss. A G/C single nucleotide 
polymorphism at position –174 within the 5′ flanking region of the IL-6 gene is known to be associated 
with differential plasma levels of IL-6 in healthy individuals (51). In kidney transplant recipients, the high 
IL-6 producer phenotype for this genetic polymorphism (GG or GC) has been associated with the 
production of donor-specific HLA antibodies post-transplantation (52) as well as reduced 5-year graft 
survival (53). These data collectively indicate that IL-6 plays a prominent role in immune mediated graft 
injury.  
In summary, the varying combinations of interstitial inflammation and tubulitis in the renal allograft, 
whether clinically manifest or silent, whether designated acute rejection or borderline change or non-
specific inflammation, appear to be part of the same spectrum of immune-mediated injury to the graft.  
Conventional immunosuppressive treatments and modifications have failed to eliminate immune-
mediated injury and its negative impact on long-term graft outcome and have only made this injury 
more subtle and thus less easily recognizable both clinically and histologically. The  Graft inflammation 


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and acute rejection and within the first year  therefore represent the earliest stages of allogeneic 
immune injury, and an intervention at this stage, such as the inhibition of IL-6 which is a major cytokine 
regulator of T cells and the inflammatory alloresponse, has the potential to arrest or slow the 
development of IF/TA and improve long-term renal graft survival. 
1.2
Tocilizumab Background
Tocilizumab (TCZ), formerly known as myeloma receptor antibody is a recombinant humanized 
antihuman monoclonal antibody of the immunoglobulin IgG1 subclass directed against the IL-6R and 
produced by recombinant DNA technology. Clinical efficacy and safety studies of TCZ have been 
conducted or are ongoing in various disease areas, including adult-onset RA, systemic-onset juvenile 
idiopathic arthritis and polyarticular juvenile idiopathic arthritis.
The elimination half-life of TCZ can be approximately 12.9 days. The TCZ exposures were stable over 2- 
years of treatment in the WA17823 study of 841 patients. The observed mean (± SD) Ctrough at 8 mg/kg IV 
was 15.9 ± 12.0 µg/ml at week 24 and 19.9 ± 17.0 µg/ml at week 104. The observed mean (± SD) Ctrough 
at 4 mg/kg was 1.02 ± 6.14 µg/ml at week 24 and 1.09 ± 2.77 µg/ml at week 104.
The Roche clinical development program in adult RA, comprised five pivotal Phase 3 trials and two open-
label, long-term treatment extension studies. Further information on TCZ can be found in the 
Investigator’s Brochure (IB).
1.3
Study Rationale
We performed a retrospective analysis of 380 consecutive 6-month surveillance kidney transplant 
biopsies performed at UCSF Medical Center between July 27, 2009 and May 9, 2011. These biopsies 
were scored by a single pathologist using the revised Banff 2007 classification. Multivariable Poisson 
regression with robust variance estimators was used to calculate relative risks of acute rejection and 
total inflammation. Multivariable linear regression was used to analyze associations with the estimated 
glomerular filtration rate (eGFR) by MDRD (Modification of Diet in Renal Disease) equation.
The analysis identified subclinical acute cellular rejection in 7.3% (n=28) of all surveillance biopsies; of 
these 5.5% (n=21) had Banff type 1a rejection. Subclinical inflammation (SCI) insufficient to meet criteria 
for acute rejection was found in 32% (n=122) of all surveillance biopsies. This included biospies with 
borderline change and non-specific inflammation. Both interstitial fibrosis (Banff ci-score) and tubular 
atrophy (Banff ct-score) were significantly associated with the presence of inflammation.
Table 1: Association of graft inflammation with interstitial fibrosis and tubular atrophy  
 
Without Inflammation 
(ti-score =0)
With Inflammation 
(ti-score >0)
P value
ci-score >0
14%
62%
<0.001
ct-score >0
53%
78%
<0.001


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Inflammation was also found to be associated with lower eGFR by MDRD at 6 months and 12 months 
post-transplant in univariate analysis. This difference remained statistically significant at 6 months in a 
fully adjusted multivariate analysis. 
Table 2: Association of graft inflammation with eGFR in univariate and multivariate analysis
 
Without Inflammation 
(ti-score =0)
With Inflammation 
(ti-score >0)
P value
Total number 
254
98
 
Median MDRD eGFR at 6 
months (ml/min/1.73 m2)
67
60
<0.001
Median MDRD eGFR at 12 
months (ml/min/1.73 m2)
68
58
<0.001
FULLY ADJUSTED ANALYSIS
 
With Inflammation 
(ti-score >0)
95% CI
P value
Estimated difference in MDRD 
eGFR at 6 months 
(ml/min/1.73 m2)
-7.0
(-10.8, -3.2)
0.0003
Estimated difference in MDRD 
eGFR at 12 months 
(ml/min/1.73 m2)
-2.1
(-4.6, 0.31)
0.087 (NS)
Therefore, in this analysis, the presence of SCI and SCR was found to be significantly associated with 
both the development of chronicity and a decrease in graft function at 6 months.  
Additionally, in 23 kidney transplant recipients who were found to have either inflammation or rejection 
on their 6-month protocol biopsy, a follow up biopsy was performed 6 months later, i.e., at 12 months 
post-transplantation. The 12-month biopsy found persistent inflammation in the majority. All patients 
with subclinical rejection had been treated with IV methylprednisolone pulse and intensification of 
baseline immunosuppression. Additionally, 2 had been treated with Thymoglobulin and 3 with IVIg. 
Patients with SCI on their initial biopsy received oral prednisone pulse (5 patients) or no specific 
treatment (5 patients). 


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Table 3: Evolution of graft inflammation found on 6-month surveillance biopsy 
12-MONTH BIOPSY
6-MONTH BIOPSY
SCR
SCI
No inflammation or 
rejection
SCR
13
2
6
5
 SCI
10
1
4
5
Overall, therefore, of these 23 patients, over half (56.5%) of those with SCR or SCI at 6 months were 
found to have persistent inflammation on a follow up biopsy at  12 months, indicating ongoing injury to 
graft despite conventional treatment. 
It is not clear, therefore, that temporary intensification of the immunosuppression alters the course of 
the immune response to the graft. Additionally, these patients are all on dual or triple 
immunosuppressive therapy and any further increases in conventional immunosuppressive agents carry 
with them the risks of opportunistic infections and toxicities including BK virus infection and post-
transplant lymphoproliferative disorder. Given the emergence of evidence supporting a key role for IL-6 
and Th17 pathway in immune-mediated injury, we believe that targeting IL-6 or its signaling pathway 
can prove to be a useful clinical strategy to control inflammation and rejection in the graft and 
potentially facilitate improved long-term graft survival. Immune modulation via the administration of 
TCZ has the potential to suppress the immune response and alter the balance of the inflammatory cell 
infiltrate in the graft towards a regulatory rather than an effector phenotype. The advantages of 
intervening within the first year are that the renal allograft function is usually preserved and the injury is 
often acute and potentially reversible, so that the effect of immune modulation may be readily 
detected.    
2.0 
OBJECTIVES
To conduct a prospective randomized controlled study to examine the histologic and clinical outcomes 
in kidney transplant recipients with acute cellular rejection (Banff type 1a) or  graft inflammation (Banff 
borderline change or mononuclear infiltrates in 10-50% of the cortical area without tubulitis) on kidney 
transplant biopsies within the first year post-transplant, who will be randomized to either continue their 
usual immunosuppression with or without pulse steroids (standard of care group) OR continue their 
usual immunosuppression with or without pulse steroids PLUS receive 4-weekly TCZ infusions (TCZ 
group) for 24 weeks.
2.1 
Primary Objective
The primary objective is a 40% decrease in inflammation in the follow-up biopsies at the end of therapy. 


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2.2 
Secondary Objective
The secondary objectives are to measure the effect of TCZ on 
(a) Inflammatory urinary cytokines
(b) Renal allograft histologic biomarkers
(c) Development of donor specific anti-HLA antibody
(d) Incidence of acute rejection on biopsy at 6 and 12 months after study enrollment
3.0
STUDY DESIGN
3.1
Study Description
This is a prospective randomized controlled study of kidney transplant recipients with acute rejection or 
inflammation on kidney transplant biopsies within the first year post-transplant. AR for the purpose of 
this study is defined as Banff type 1a acute cellular rejection. Inflammation (AI) for the purpose of this 
study is defined as including Banff borderline change or 10-50% mononuclear inflammation (Banff i1-i2) 
without tubulitis. 
After enrollment, study participants subjects will be randomized to group 1 (standard of care group) or 
group 2 (TCZ group). Randomization will be stratified to ensure equal numbers of AR and AI in each 
group. Block randomization will be performed by the UCSF investigational pharmacy using computer-
generated random numbers. The pathologist will be blinded to the randomization.
The study period will be 12 months (6 months of therapy plus 6 months of extended follow up- see 
Study Schema). Any episodes of infections, renal allograft dysfunctions, rejections or other clinical 
events during the study period will be treated per the usual standard of care.
All participants will be seen by the study investigator at monthly study visits during the treatment period 
and per usual standard of care in the follow up period. A focused history and physical exam will be 
performed, including queries for drug toxicities and signs/ symptom of infections. All participants will 
obtain laboratory tests at intervals of 4 weeks, consisting of a complete blood count, serum electrolytes, 
BUN and serum creatinine, fasting glucose, liver function tests and 12-hour trough tacrolimus levels. 
Lipid panels will be obtained at baseline, then every 3 months and at study termination. The outpatient 
electronic medical record will be queried twice weekly by the study coordinator for any new laboratory 
results on study participants. Laboratory data on all study participants will be reviewed weekly by the 
study PI. 
The follow up surveillance biopsy will be performed at the end of therapy (6 months after study 
enrollment).  


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3.1.1 
Study Schema
Obtain 
Informed 
Consent
Screening 
(Inflammation 
or Acute 
Rejection on 
Allograft 
biopsy)
Treatment 
Period
 Day 0 “Start of 
Study” to 
Month 6
 
Randomization 
Group 1
 Standard of care
Group 2 
Monthly IV 
Tocilizumab 
Primary 
Endpoint
Follow up 
biopsy 
Month 6 
Follow-Up 
Period 
Month 6 to 
Month 12 
 
3.2
Rationale for Study Design and Dose
At UCSF Medical Center, transplant kidney biopsies are performed for cause (e.g, for renal graft 
dysfunction) or for surveillance (kidney transplant surveillance biopsies at 6 months post-transplant in 
all patients, and at 3-6 months following previous biopsies showing acute rejection or graft 
inflammation). Currently we perform 30-40 renal allograft biopsies per month. All kidney transplant 
biopsies are obtained under real-time ultrasound guidance using a 16-gauge automated biopsy needle. 
Two cores are generally obtained. All biopsies are read by UCSF Renal Pathology and are interpreted 
using the Banff 1997 criteria (updated 2007). C4d staining (for the diagnosis of acute antibody-mediated 
rejection) is done on all biopsies. Patients with biopsies showing AR or AI on surveillance or for-cause 
biopsies undergo repeat surveillance biopsies 3-6 months later. Patients with AR, whether clinical or 
subclinical, are usually treated with IV steroids. Due to uncertainty regarding the benefits of treatment 
in general and lack of data supporting the efficacy of increasing usual immunosuppressive agents, 
patients with AI (borderline change or nonspecific inflammation) are not currently treated with any 
specific therapy. Therefore, these patients who receive the standard of care treatment (steroids and/or 
continuation of their maintenance immunosuppressive regimen) form an ideal group in which to test 
the efficacy of treatment with TCZ. Based on available literature and our preliminary data, over 12 
months approximately 90-100 patients will fulfill entry criteria and with a 50% enrollment rate, 50 
patients are likely to consent to the trial. 
The currently recommended dose of TCZ for adult patients with rheumatoid arthritis (the FDA approved 
indication) is 8 mg/kg given once every four weeks as an IV infusion. Given the accumulated efficacy and 
safety data for this dose, we will plan to use the same dose in kidney transplant recipients in this study. 


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3.3
Outcome Measures
Evaluation of response to TCZ therapy will be primarily based on histologic assessments as described 
below.
Semiquantative assessment of inflammation on kidney transplant biopsies for each subject at baseline 
and at 6 months follow-up will be performed using the Banff “i” and “t” scores.  In addition, more 
precise estimates of the inflammation will be obtained using computer assisted image analysis to 
determine the inflammatory cell density per sq.mm in the renal cortex (glomeruli excluded) of baseline 
and follow-up biopsies which will include LCA, CD4, CD18, CD20, CD68, FoxP3, and T-bet.  Results will be 
expressed as % of the cortex with inflammatory cells and the number of cells per sq mm of cortex.  The 
% value for any variable (inflammation or fibrosis) on the qualifying biopsy will be taken as the baseline, 
and the increase or decrease in the variable at follow-up biopsy calculated = (% value at follow up minus 
% value at baseline)/ (% value at baseline).
In addition, we will perform quantitative in situ hybridization for IL-6 mRNA and protein expression on 
paraffin sections. Frozen or paraffin sections of the kidney biopsy will be stained (by 
immunofluorescence/ immunohistochemistry) for downstream IL-6 mediated inflammatory response 
genes (SAA2 and CRP), Janus kinase (JAK) and signal transducer and activator of transcription 3 (STAT3).    
We have recently validated an in situ hybridization analysis in biopsies of renal allografts.  The IL6 signal 
is present with inflammation and tubulitis (acute cell mediated rejection) but is absent in acute or 
chronic antibody medicated rejection.  The use of this assay may further validate the therapeutic effect 
of blockade of the IL-6 pathway.
For the measurement of urinary cytokines, urine samples will be collected from enrolled patients on day 
0 and monthly till the end of the study at 12 months post-enrollment. The sample will be divided into 
supernatant and cell pellets prior to banking so that soluble mediators and gene expression by cellular 
sediments can be analyzed separately.  The urine cell pellets will be analyzed using qRT-PCR for the 
presence of inflammatory mediators. We will use a combination of multiplex Luminex and ELISA to 
measure urinary protein in the supernatant, with focus on inflammatory mediators that are likely made 
by infiltrating leukocytes or induced by local inflammation and proteins that are reflective of kidney 
function, using a customized multiplex Luminex assay to profile inflammatory mediators reported to be 
altered in rejection or subclinical inflammation. Molecules to be profiled include CXCL-9 and CXCL-10, 
both of which have been reported to be elevated in the urine of patients with graft inflammation. PCR 
primers for these genes are available from Qiagen and a SYBR Green-based real-time PCR assay will be 
used to quantify the transcripts.
3.3.1
Primary Outcome Measure
The primary outcome measure will a  40% decrease in inflammation between kidney biopsies at baseline 
and 6 months later as measured by a composite endpoint of either a 1-point reduction in the Banff “i” or 
“t” scores or by computer-assisted quantitative image analysis of the percentage of renal cortex 
infiltrated with interstitial LCA (leukocyte common antigen)-positive cells. 


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3.3.2
Secondary Outcome Measures
(a) Change in the quantity and fraction of macrophages (CD68 positive cells) and regulatory T cells 
(FoxP3 positive cells) in the inflammatory infiltrate, as measured by computer-assisted quantitative 
image analysis, at baseline and 6 months follow-up.
(b) Change in the level of urinary cytokines CXCL-9 and CXCL-10 (also known as IP-10) at baseline and 6 
months follow up.
(c) Change in the expression of intragraft IL6 (by in-situ hybridization).
(d) Incidence of de novo donor specific anti-HLA antibody between baseline and 6 months follow up.
(e) Incidence of clinical acute T-cell mediated rejections, defined as Banff type 1A acute rejection or 
greater, on biopsies performed for elevated serum creatinine between enrollment and 6 months follow 
up.
(f) Incidence of opportunistic infections, including bacterial urinary tract infections, pneumonia, sepsis 
and TB; viral infections with CMV, EBV, or BK virus; and any systemic fungal infections between 
enrollment and 6 months follow up.
(g) Estimated GFR by MDRD at 6 months and 12 months following enrollment.
(h) Death or graft loss at 6 months and 12 months following enrollment
 3.4
End of Study
The study period will be a total of 12 months, including study drug administration for 6 months and an 
extended follow up period of 6 months for each participant after therapy is completed. 
4.0
STUDY POPULATION
4.1
Overview
The target population includes kidney transplant recipients with stable kidney function at 6 months 
post-transplantation who are incidentally found to have acute rejection or graft inflammation on a 
biopsy within the first year post-transplant. 
AR for the purpose of this study is defined as Banff type 1a acute cellular rejection. 
AI for the purpose of this study is defined as including Banff borderline change or 10-50% total 
parenchymal mononuclear inflammation (Banff i1-i2) without tubulitis.


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4.2
Inclusion Criteria

All kidney transplant recipients with AR or AI (as defined above) on kidney transplant biopsy 
within the first year post-transplant.

Maintenance immunosuppression regimens containing tacrolimus and MMF with or without 
prednisone.

Ability to provide written informed consent for the study.

Men and women of reproductive potential must agree to use an acceptable method of birth 
control during treatment and for six months after completion of treatment.
4.3
Exclusion Criteria
A patient will be excluded if the answer to any of the following statements is “yes”.
General:

Major surgery (including joint surgery) within 8 weeks prior to screening or planned major 
surgery within 6 months following randomization.
Excluded Previous or Concomitant Therapy:

Treatment with any investigational agent within 4 weeks (or 5 half-lives of the investigational 
drug, whichever is longer) of screening.

Immunization with a live/attenuated vaccine within 4 weeks prior to baseline.

Previous treatment with TCZ (an exception to this criterion may be granted for single dose 
exposure upon application to the sponsor on a case-by-case basis). 

Current treatment with other biological disease-modifying anti-rheumatic drug (bDMARD)

Any previous treatment with alkylating agents such as chlorambucil, or with total lymphoid 
irradiation.
 Exclusions for General Safety:

Acute antibody mediated rejection or severe acute cellular rejection defined as exceeding Banff 
type 1a rejection on the qualifying biopsy or requiring therapy with Thymoglobulin.

History of BK virus infection that is currently active (defined as detectable BK viremia >1000 
copies/ml within 1 month prior to the biopsy).

History of severe allergic or anaphylactic reactions to human, humanized or murine monoclonal 
antibodies.

Evidence of serious uncontrolled concomitant cardiovascular, nervous system, pulmonary 
(including obstructive pulmonary disease), renal, hepatic, or endocrine (include uncontrolled 
diabetes mellitus) disease.

History of diverticulitis, diverticulosis requiring antibiotic treatment or chronic ulcerative lower 
GI disease such as Crohn’s disease, ulcerative colitis or other symptomatic lower GI conditions 
that might predispose to perforations.


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
History of pre-existing CNS demyelination

Current liver disease as determined by principal investigator unless related to primary disease 
under investigation.

Known active current or history of recurrent bacterial, viral, fungal, mycobacterial or other 
infections (including but not limited to tuberculosis and atypical mycobacterial disease, 
Hepatitis B and C, and herpes zoster, but excluding fungal infections of nail beds).

Any major episode of infection requiring hospitalization or treatment with IV antibiotics within 
4 weeks of screening or oral antibiotics within 2 weeks prior to screening.

Active TB requiring treatment within the previous 3 years. Patients should be screened for 
latent TB and, if positive, treated following local practice guidelines prior to initiating TCZ. A 
negative screen for latent TB within the previous 2 years will be considered acceptable. Patients 
treated for tuberculosis with no recurrence in 3 years are permitted. 

Primary or secondary immunodeficiency (history of or currently active) unless related to kidney 
transplant immunosuppressive medications.

Evidence of active malignant disease, malignancies diagnosed within the previous 10 years 
(including hematological malignancies and solid tumors, except basal and squamous cell 
carcinoma of the skin or carcinoma in situ of the cervix uteri that has been excised and cured), 
or breast cancer diagnosed within the previous 20 years.

Pregnant women or nursing (breast feeding) mothers. 

Patients with reproductive potential not willing to use an effective method of contraception.

History of alcohol, drug or chemical abuse within 1 year prior to screening.

Patients with lack of peripheral venous access.
Laboratory Exclusion criteria (at screening):

Serum creatinine > 1.6 mg/dL (141 µmol/L) in female patients and > 1.9 mg/dL (168 µmol/L) in 
male patients. Patients with serum creatinine values exceeding limits may be eligible for the 
study if their estimated glomerular filtration rates (GFR) are >30 ml/min/1.73 m2.

Alanine aminotransferase (ALT) or aspartate aminotransferase (AST) > 1.5 times upper limit of 
normal (ULN)

Total Bilirubin > 1.5 times ULN 

Platelet count < 100 x 109/L (100,000/mm3)

Hemoglobin < 85 g/L (8.5 g/dL; 5.3 mmol/L) 

White Blood Cells < 3.0 x 109/L (3000/mm3)

Absolute Neutrophil Count < 2.0 x 109/L (2000/mm3)

BK virus quantitative DNA PCR (plasma) >1000 copies/ml 
4.4
Immunization during TCZ therapy
Live/attenuated vaccines should not be given within 4 weeks prior to baseline and during the study as 
clinical safety has not been established. Because IL-6 inhibition may interfere with the normal immune 
response to new antigens, patients should be brought up to date on all recommended vaccinations, 
except for live vaccines, prior to initiation of therapy with TCZ.


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4.5
Criteria for Premature Withdrawal
Patients have the right to withdraw from the study at any time for any reason. There will be an attempt 
to have all patients complete the withdrawal visits or follow-up phone calls as detailed in the Schedule 
of Assessments.
If the patient decides to prematurely discontinue study treatment (“refuses treatment”), he/she will be 
asked if he/she can still be contacted for further information. The outcome of that discussion will be 
documented in both the medical records and in the CRF. A complete final evaluation at the time of the 
patient’s withdrawal will be made with an explanation of why the patient is withdrawing from the study. 
Before categorizing a patient as lost to follow-up, we will attempt to contact the patient or a responsible 
relative by telephone followed by registered mail to determine if any new AEs occurred, follow-up of 
any ongoing AE and to establish as completely as possible the reason for the withdrawal.
When applicable, patients will be informed of circumstances under which their participation may be 
terminated by the investigator without the patient’s consent. The investigator may withdraw patients 
from the study in the event of intercurrent illness, adverse events, treatment failure, lack of compliance 
with the study and/or study procedures (e.g., dosing instructions, study visits), or any reason where it is 
felt by the investigator that it is in the best interest of the patient to be terminated from the study. The 
reason(s) for withdrawal will be documented and explained to the patient.
If the reason for removal of a patient from the study is an adverse event, the specific event will be 
recorded on the CRF. There will be an attempt to follow the patient until the event has resolved or 
stabilized.
An excessive rate of withdrawals can render the study non-interpretable; therefore, unnecessary 
withdrawal of patients will be avoided. Should a patient decide to withdraw, all efforts will be made to 
complete and report the observations prior to withdrawal as thoroughly as possible. 
5.0
TREATMENT PLAN
Phase II clinical trial of TCZ plus standard of care vs. standard of care alone for kidney transplant 
recipients with AR or AI noted on kidney biopsy within the first year post-transplant. 
After enrollment, subjects will be randomized to group 1 (standard of care group) or group 2 (TCZ group. 
Randomization will be stratified to include equal numbers of participants with AR and AI in each group. 
Block randomization will be performed by the UCSF investigational pharmacy using computer-generated 
random numbers. The pathologist will be blinded to the randomization. 
In Group 1 (standard of care group):

Participants with AI will continue their usual immunosuppression and not receive any specific 
intervention. 


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
Participants with AR will receive IV methylprednisolone pulse (500 mg IV daily for 3 doses) 
followed by oral prednisone taper over 2 weeks down to 5 mg prednisone per day in addition to 
continuing their usual immunosuppression 
In Group 2 (TCZ group):
Participants will receive TCZ 8 mg/kg intravenously at four-week intervals for a total of 6 doses in 
addition to the standard of care described for group 1. This means that:

Participants with AI will receive TCZ 8 mg/kg intravenously at four-week intervals for a total of 6 
doses in addition to continuing their usual immunosuppression

Participants with AR will receive TCZ 8 mg/kg intravenously at four-week intervals for a total of 6 
doses. In addition, they will receive IV steroids and oral prednisone taper identical to SCR 
participants in group 1 and continue their usual immunosuppressive regimen.
Usual maintenance immunosuppression regimen is defined as follows:

Recipients who are already receiving prednisone will continue it at 5 mg/day. 
Recipients on prednisone-free regimens will remain prednisone-free (if they have SCI) or start 
maintenance prednisone after pulse steroids (if they have SCR). 

Mycophenolate mofetil (MMF) dosing will be maintained or adjusted per standard of care to 
dose ranging from 500-3000 mg daily. 

Tacrolimus dosing will be maintained or adjusted to aim for trough levels of 4-10 mcg/L.
 
Although we believe that it is extremely unlikely that the addition of TCZ to standard post-transplant 
immunosuppression will increase the probability of fibrosis, we nevertheless used a two-tailed 
alternative hypothesis and set alpha at 0.05. Based on a review of the relevant literature and our 
previous experience, we anticipate that 50% of study participants randomized to group 1 (standard of 
care group) will manifest persistent inflammation at 12 months compared with 10% of study 
participants randomized to group 2 (TCZ group). We will have 83% power to detect an effect of this 
magnitude, i.e., a 40% absolute difference between groups with a sample size of 24 per group, or a total 
N=48.
Currently we perform 6-month surveillance biopsies of about 20-30 renal allografts per month. Based on 
available literature and our preliminary data, approximately 7-10 patients per month will have AR or AI  
on their biopsies. We aim to enroll 4-6 patients per month, so the period of recruitment will be 
approximately 12 months to accrue 48 patients. The study period will be 12 months (6 months of 
therapy + 6 months of follow up) so that total duration will be 24 months from the enrollment of the 
first subject. 


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This research study protocol allows the subject to receive up to 6 infusions of TCZ.  Even if the treatment 
is shown to be of benefit, additional infusions of TCZ beyond that allowed in the protocol cannot be 
given to the subject while she/he is participating in this study.
6.0
STUDY MEDICATION
6.1
Tocilizumab
Tocilizumab (ACTEMRA®) is a recombinant humanized anti-human IL-6 receptor monoclonal antibody of 
the immunoglobulin IgG1κ (gamma 1, kappa) subclass with a typical H2L2 polypeptide structure. Each 
light chain and heavy chain consists of 214 and 448 amino acids, respectively. The four polypeptide 
chains are linked intra- and inter-molecularly by disulfide bonds. TCZ has a molecular weight of 
approximately 148 kDa.
TCZ is supplied as a sterile, preservative-free solution for intravenous (IV) infusion at a concentration of 
20 mg/mL. TCZ is a colorless to pale yellow liquid, with a pH of about 6.5. Single-use vials are available 
containing 80 mg/4 mL, 200 mg/10 mL, or 400 mg/20 mL of TCZ. Injectable solutions of TCZ are 
formulated in an aqueous solution containing disodium phosphate dodecahydrate and sodium 
dihydrogen phosphate dehydrate (as a 15 mmol/L phosphate buffer), polysorbate 80 (0.5 mg/mL), and 
sucrose (50 mg/mL). 
TCZ will be provided free of charge by Genentech. The Sponsor or designee of the study will ensure 
maintenance of complete and accurate records of the receipt, dispensation, and disposal or return of all 
study drug in accordance with 21 Code of Federal Regulations (C.F.R.), Part 312.57 and 312.62 and 
Genentech requirements.”
6.1.1
Tocilizumab Dosage and Administration
The recommended dose of TCZ for adult patients is 8 mg/kg given once every four weeks as an IV 
infusion. TCZ is currently approved for use alone or in combination with methotrexate and/or other 
disease modifying anti-rheumatic drugs.
TCZ will be diluted to 100 mL by a healthcare professional with sterile 0.9%w/v sodium chloride solution 
using aseptic technique. TCZ will be administered as an IV infusion over 1 hour. For individuals whose 
body weight is more than 100 kg, the maximum dose per infusion will not exceed 800 mg.
One vial containing 400 mg TCZ or two vials containing 200 mg TCZ will be required for each 50 kg body 
weight to achieve an 8 mg/kg dose.  The number of vials to be used depends on the patient’s body 
weight as follows:
1.         One 400-mg vial (or two 200-mg vials) will be used for patients with a body weight ≤50 kg.
2.         Two 400-mg vials (or four 200-mg vials) will be used for patients with a body weight >50 kg 
combination of the 400-mg and 200-mg vials may be used but the total dose will not exceed 800 mg.


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Given the rarity of infusion reactions, subjects may be monitored per discretion of the investigator for 
30 minutes after the first infusion. They do not need monitoring after subsequent infusions.
6.1.2
Tocilizumab Storage
TCZ will not be used after the expiry date (EXP) shown on the pack.
For vials: Vials will be stored between 2ºC – 8ºC, will not freeze. The container will be kept in the outer 
carton in order to protect from light.
For prepared infusion solution: The prepared infusion solution of TCZ is physically and chemically stable 
in 0.9% w/v sodium chloride solution at 30ºC for 24 hours. From a microbiological point of view, the 
prepared infusion will be used immediately. If not used immediately, in-use storage times and 
conditions will not be longer than 24 hours at 2ºC – 8ºC, unless dilution has taken place in controlled 
and validated aseptic conditions.
6.1.3
Tocilizumab Overdosage
There are limited data available on overdoses with TCZ. One case of accidental overdose was reported in 
which a patient with multiple myeloma received a dose of 40 mg/kg. No adverse drug reactions were 
observed. No serious adverse drug reactions were observed in healthy volunteers who received single 
doses of up to 28 mg/kg, although all 5 patients at the highest dose of 28 mg/kg developed dose-limiting 
neutropenia.
In case of an overdose, the patient will be monitored for signs and symptoms of adverse reactions. 
Patients who develop adverse reactions will receive appropriate symptomatic treatment.
6.2
Other Study Drugs    
All study participants will be on standard post-transplant maintenance immunosuppression containing 
tacrolimus, MMF/ MPA, with or without prednisone. Study subjects will continue their maintenance 
immunosuppression as usual (if they have AI) or receive a pulse of IV methylprednisolone at 500 mg 
daily for 3 days (if they have AR). Subjects who are already receiving prednisone will continue it at 5 
mg/day. Subjects on prednisone-free regimens will remain prednisone-free (if they have AI) or start 
maintenance prednisone after the pulse of IV methylprednisolone is completed (if they have AR). MMF 
or MPA doses will be continued as per standard of care with doses ranging from 500-3000 mg daily, with 
tacrolimus dosing adjusted to aim for trough levels of 4-10 mcg/L. All prescribers in the study will be 
required to enroll in the Mycophenolate REMS program as noted below in Section 7.2.2.
7.0
 DOSE MODIFICATION/TOXICITY MANAGEMENT
A number of measures will be taken to ensure the safety of patients participating in this study.  These 
measures will be addressed through exclusion criteria (see Section 4.2) and routine monitoring as 
follows.  


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Patients enrolled in this study will be evaluated clinically and with standard laboratory tests before and 
during their participation in this study.  Safety evaluations will consist of medical interviews, recording of 
adverse events, physical examinations, blood pressure, and laboratory measurements at 1-monthly 
intervals.  Subjects will be evaluated for adverse events (all grades), serious adverse events, and adverse 
events requiring study drug interruption or discontinuation at each study visit for the duration of their 
participation in the study.  
7.1
Tocilizumab
Kidney Function and Acute Rejection
Significant nephrotoxicity has not been demonstrated in clinical trials of TCZ to date. However, the 
effect on kidney transplant function and the development of acute rejection is unknown. Kidney 
function will be monitored closely in study participants. If there is a suspicion for acute rejection, kidney 
biopsy will be performed as per usual standard of care and at the discretion of the PI. Patients who 
develop acute rejection will be withdrawn from the study.  
Opportunistic Infections and Serious Infections 
The most commonly reported infections (5% to 8% of patients) in clinical studies of rheumatoid arthritis 
were upper respiratory tract infections and nasopharyngitis. In the 24 week, controlled clinical studies, 
the rate of serious infections in the TCZ monotherapy group was 3.6 per 100 patient-years compared to 
1.5 per 100 patient-years in the methotrexate group. The most common serious infections included 
pneumonia, urinary tract infection, cellulitis, herpes zoster, gastroenteritis, diverticulitis, sepsis and 
bacterial arthritis. Among opportunistic infections, tuberculosis, cryptococcus, aspergillosis, candidiasis, 
and pneumocystosis have been reported with TCZ. TCZ will not be administered in patients with active 
infection. The effects of TCZ on CRP, neutrophils, and the signs and symptoms of infection will be 
considered when evaluating a patient for a potential infection. Vigilance for timely detection of serious 
infection will be maintained for kidney transplant recipients receiving TCZ as signs and symptoms of 
acute inflammation may be lessened due to concomitant immunosuppressive therapy. Patients will be 
instructed to contact their physician immediately when any symptoms suggesting infection appear, in 
order to assure rapid evaluation and appropriate treatment. If a patient develops a serious infection, 
administration of TCZ will be interrupted and the patient will be withdrawn from the study.
 Gastrointestinal Perforations  
During the 24 week, controlled clinical trials, the overall rate of gastrointestinal perforation was 0.26 
events per 100 patient-years with TCZ therapy. Reports of gastrointestinal perforation were primarily 
reported as complications of diverticulitis including generalized purulent peritonitis, lower GI 
perforation, fistula and abscess. Patients with known history or uncontrolled GI disease such as 
diverticulitis or inflammatory bowel disease are excluded from participation. Patients will be made 
aware of the symptomatology potentially indicative of diverticular disease, and will be instructed to 
alert their healthcare provider as soon as possible if these symptoms arise. Patients who develop GI 
perforations will be withdrawn from the study.


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Demyelinating Disorders 
The impact of treatment with TCZ on demyelinating disorders is not known; multiple sclerosis and 
chronic inflammatory demyelinating polyneuropathy were reported rarely in clinical studies of 
rheumatoid arthritis.  Patients with known CNS demyelinating disorders will be excluded from 
participation. All subjects will be closely monitored for signs and symptoms potentially indicative of 
central demyelinating disorders.  Treatment with TCZ will be interrupted during assessment of a 
potential demyelination event and if confirmed, patient will be withdrawn from the study. 
Hematologic Abnormalities and Bleeding Events
Decreases in neutrophil and platelet counts have been observed following treatment with TCZ in 
combination with MTX. 
In the 24 week, controlled clinical studies, decreases in neutrophil counts <1000/mm3 occurred in 1.8% 
and 3.4% of patients in the 4 mg/kg and 8 mg/kg TCZ plus DMARD group, respectively, compared to 
0.1% of patients in the placebo plus DMARD group. Approximately half of the instances of ANC 
<1000/mm3 occurred within 8 weeks of starting therapy. In the same studies, decreases in platelet 
counts <100,000/mm3 occurred in 1.3% and 1.7% of patients on 4 mg/kg and 8 mg/kg TCZ plus DMARD, 
respectively, compared to 0.5% of patients on placebo plus DMARD, without associated bleeding events. 
It is possible that there may be an increased risk of neutropenia and thrombocytopenia in kidney 
transplant recipients who are concurrently receiving MMF/ MPA, a known myelosuppressive agent.
The risk mitigation strategies for neutropenia and thrombocytopenia are summarized in Tables 4 and 5, 
respectively.  
Table 4 : Neutropenia risk mitigation 
ANC (cells/mm3)
Action
> 1000
Maintain dose.
500 – 1000
Interrupt TCZ dosing. When ANC increases to > 1000, resume TCZ 
at 4 mg/kg and increase to 8 mg/kg as clinically appropriate
< 500
Discontinue TCZ.
ANC = absolute neutrophil count
Patients withdrawn from TCZ treatment due to a reduced neutrophil count will be monitored for signs of 
infection, with treatment as deemed appropriate by the PI, and will have a repeat white blood cell count 
with differential performed weekly until the ANC is above 1000 cells/mm3 (1.0 x 109/L). If the ANC does 
not return to above 1000 cells/mm3 (1.0 x 109/L) within 2 months (or sooner if deemed necessary by the 
PI), a hematology referral will be considered.
Table 5: Thrombocytopenia risk mitigation


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Platelet count (cells/mm3)
Action
> 100,000
Maintain dose.
50,000 – 100,000
Interrupt TCZ dosing. When platelet count increases to > 100,000, 
resume TCZ at 4 mg/kg and increase to 8 mg/kg as clinically 
appropriate
< 50,000
Discontinue TCZ.
Patients withdrawn from TCZ treatment due to a reduced platelet count will have a repeat platelet count 
performed weekly until the count is above 100,000 cells/mm3 (100 x 109/L). If the platelets do not return 
to above 100,000 cells/mm3 (100 x 109/L) within 2 months (or sooner if deemed necessary by the PI), a 
hematology referral will be considered.
Elevated Liver Enzymes and Hepatic Events
Treatment with TCZ was associated with a higher incidence of transaminase elevations in clinical studies 
in rheumatoid arthritis, particularly when it was used in combination with DMARDs. Mild elevations (up 
to 3X ULN) of ALT and AST were common, seen in 36% and 22% respectively of patients receiving TCZ 
monotherapy, and especially frequent when TCZ 8 mg/kg was used in combination with DMARDs (48% 
and 41% respectively compared to 23% and 17% with placebo + DMARDs). Severe elevations of ALT and 
AST (to >5X ULN) were seen in 1.5% and 0.2% receiving TCZ 8 mg/kg plus DMARDs vs. 0.3% and <0.1% in 
the group receiving placebo  plus DMARDs.    These elevations did not result in apparent permanent or 
clinically evident hepatic injury in clinical trials. The effects on ALT and AST when TCZ is used in 
combination with tacrolimus and mycophenolate mofetil/ mycophenolic acid are not known.
Table 6: Risk mitigation for abnormal liver enzymes
Lab Value
Action
> 1 to 3x ULN
For persistent increases in this range, reduce TCZ dose to 4 mg/kg 
or interrupt TCZ until ALT/AST have normalized. Restart with 4 
mg/kg or 8 mg/kg, as clinically appropriate
> 3 to 5x ULN 
(confirmed by repeat 
testing)
Interrupt TCZ dosing until < 3x ULN and follow recommendations 
above for >1 to 3x ULN. 
For persistent increases > 3x ULN, discontinue TCZ
> 5x ULN
Discontinue TCZ
Patients withdrawn from TCZ treatment due to elevated liver function tests will have repeat tests 
performed, as clinically appropriate, until levels return to baseline.  If the patient’s liver function tests 
have not returned to baseline within 6 months (or sooner, if deemed necessary by the PI), an ultrasound 
and/or liver biopsy will be considered.


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Cardiovascular Events and Elevated Lipids
Increases in lipid parameters (total cholesterol, LDL, HDL, triglycerides) were observed at 6 weeks 
following initiation of TCZ in the controlled 24 week clinical trials and remained stable thereafter. Mean 
increased in LDL, HDL and LDL/HDL ratio at week 24 in the TCZ 8 mg/kg plus DMARD group were 20 
mg/dl, 5 mg/dl and 0.15 respectively. Elevated lipids responded to lipid lowering agents. Patients with 
kidney disease have an increased risk for cardiovascular disorders; therefore, risk factors for 
cardiovascular disease (e. g., hypertension, hyperlipidemia) will be managed as part of their standard of 
care.  
Malignancies
Exposure-adjusted incidence of malignancies was similar in the TCZ groups (1.32 events per 100 patient-
years) and in the placebo plus DMARD group (1.37 events per 100 patient-years). There is a known 
increased incidence of malignancies associated with post-kidney transplant immunosuppression. 
Although no imbalance of malignancies was observed in controlled clinical trials of TCZ, malignancies 
may become a concern when it is used concomitantly with post-kidney transplant immunosuppression.  
TCZ will be discontinued in patients with malignancies (with the exception of local basal or squamous 
cell carcinoma of the skin that is completely excised with free margins).
Infusion Reactions, Hypersensitivity or Anaphylaxis:
An infusion/dose reaction is defined as an adverse event occurring during and within 24 hours after the 
infusion or subcutaneous injection of TCZ. This may include hypersensitivity reactions or anaphylactic 
reactions. In the 24 week, controlled clinical studies, infusion reactions were reported in 8% and 7% of 
patients in the 4 mg/kg and 8 mg/kgTTCZ plus DMARD group, respectively, compared to 5% of patients 
in the placebo plus DMARD group. The most frequently reported event for both doses during the 
infusion was hypertension (1% for both doses), while the most frequently reported event occurring 
within 24 hours of finishing an infusion were headache (1% for both doses) and skin reactions (1% for 
both doses), including rash, pruritus and urticaria. These events were not treatment limiting. 
Hypersensitivity reactions requiring treatment discontinuation, including anaphylaxis, associated with 
TCZ were reported in 0.1% (3 out of 2644) in the 24 week, controlled trials and in 0.2% (8 out of 4009) in 
the all-exposure population. These reactions were generally observed during the second to fourth 
infusion of TCZ.
Signs of a possible hypersensitivity reaction include but are not limited to: fever, chills, pruritus, 
urticaria, angioedema, skin rash, cardiopulmonary reactions, including chest pain, dyspnea, hypotension 
or hypertension.
Healthcare professionals administering TCZ infusions  will be trained in the appropriate administrative 
procedures, be able to recognize the symptoms associated with potential anaphylactic or 
hypersensitivity reactions, and have the appropriate medication available for immediate use in case of 
anaphylaxis or hypersensitivity reaction during or after administration of TCZ.  Study subjects will be 


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instructed to seek medical attention if they experience symptoms of a hypersensitivity reaction outside 
of the clinic.
If a patient has symptoms of anaphylaxis or serious hypersensitivity, or requires an interruption of the 
study drug because of symptoms of anaphylaxis or hypersensitivity, administration of TCZ will be 
discontinued permanently and the patient will be withdrawn from the study.  The patient will be treated 
according to the standard of care for management of the hypersensitivity reaction.  A blood sample for 
the presence of anti-TCZ antibodies and PK/PD testing will be obtained at time of event and at least 6 
weeks after the last dose.
Viral Reactivation
Viral reactivation has been reported with immunosuppressive biologic therapies and cases of herpes 
zoster exacerbation were observed in clinical studies with TCZ. No cases of Hepatitis B reactivation were 
observed in the trials; however patients who screened positive for hepatitis were excluded. Reactivation 
of viral and other serious infections (e.g. EBV or TB) has been observed with standard post-transplant 
immunosuppression and patients will be monitored carefully during the study for this event.
Drug Interaction
The formation of CYP450 enzymes may be suppressed by increased levels of cytokines (eg, IL-6) during 
chronic inflammation. Therefore, it is expected that for molecules that antagonize cytokine activity, such 
as TCZ, the formation of CYP450 enzymes could be normalized. When starting or stopping therapy with 
TCZ, patients taking medications which are individually dose-adjusted and metabolized via CYP450, 3A4, 
1A2, or 2C9 (e.g. atorvastatin, calcium channel blockers, theophylline, warfarin, phenytoin, ciclosporin, 
or benzodiazepines) will be monitored as doses may need to be adjusted to maintain their therapeutic 
effect. In particular, attention will be paid to the levels of tacrolimus, a CYP3A4 substrate, and doses will 
be adjusted as needed to maintain levels of 4-10 mcg/L. Given long elimination half-life (t1/2) of TCZ, 
the effect on CYP450 enzyme activity may persist for several weeks after stopping therapy.
Reproductive Issues
Adequate and well-controlled studies with TCZ have not been conducted in pregnant women. All 
females of reproductive potential will be required to use acceptable contraception for the duration of 
the study. All females of reproductive potential will screened for pregnancy prior to enrollment and 
before infusion of every dose of TCZ. If pregnancy is discovered, participants will be terminated from the 
study. There is a pregnancy exposure registry that monitors pregnancy outcomes in women exposed to 
TCZ during pregnancy. The study investigator will register any pregnant patients and pregnant women 
will be encouraged to register themselves by calling 1-877-311-8972.
7.2
Other Study Drugs
7.2.1  Post-transplant maintenance immunosuppression


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The standard post-transplant immunosuppressive regimen which the subjects have been on prior to 
enrollment in the study will be continued during the study. Enrollment will include all kidney transplant 
recipients with graft inflammation who are on maintenance immunosuppressive regimens containing 
tacrolimus, mycophenolate mofetil/ mycophenolic acid with or without prednisone.  At UCSF, typically 
about 30% of kidney transplant recipients are maintained on prednisone free immunosuppression. 
Therefore, some study subjects will be on prednisone (5 mg daily) at the time of enrollment and others 
will not be on prednisone. Those who are on prednisone will remain on it and those who are not on 
prednisone will remain prednisone free (if they have AI) or receive pulse IV methylprednisolone and 
start maintenance prednisone (if they have AR). During randomization, we will aim to keep the 
proportion of patients on prednisone equal in both arms. As with standard post-transplant care, all 
participants will undergo a physical exam, medical interview and laboratory testing (complete blood 
count, serum electrolytes, BUN and serum creatinine, fasting glucose, liver function tests and 12-hour 
trough tacrolimus levels) every month and they will be queried and examined for known drug toxicities 
and signs/ symptom of infections. Doses of tacrolimus, MMF/ MPA acid and prednisone will be modified 
if needed to address toxicity or infectious concerns. 
6.2.2 Mycophenolate REMS
All prescribers participating in the study will be required to enroll in the FDA Mycophenolate REMS (risk 
evaluation and mitigation strategy) program. Of note, all study participants will already have been on a 
maintenance regimen containing MMF/MPA and will not be started on it as part of the study. 
Use of MMF/MPA during pregnancy is associated with an increased risk of first trimester pregnancy loss 
and an increased risk of congenital malformations. Females of reproductive potential will be made 
aware of these risks and will be counseled regarding pregnancy prevention and planning. All females 
must be willing to use acceptable contraception during the entire period of the study. Patients will be 
made aware that MMF/MPA reduces blood levels of the hormones in the oral contraceptive pill and 
could theoretically reduce its effectiveness. Urine pregnancy test is part of the screening laboratory tests 
and will be repeated at each follow-up visit. Results of all pregnancy tests will be discussed with the 
patient.  
For those females who are discovered to be pregnant either at study screening or enrollment or during 
the study and who are on MMF/MPA or within 6 weeks of discontinuing therapy, the study investigators 
will report the pregnancy to the Mycophenolate Pregnancy registry (1-800-617-8191) and strongly 
encourage the patient to enroll in the pregnancy registry. When appropriate, pregnant patients will be 
switched to alternative immunosuppression with less potential for embryofetal toxicity after a 
discussion of maternal and fetal risks and benefits.     
8.0
CRITERIA FOR SUBJECT DISCONTINUATION
8.1
Tocilizumab-Specific Criteria
Subjects who meet the following criteria will be discontinued from the study:


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•
Anaphylaxis or hypersensitivity reaction or requires an interruption of the study drug because of 
symptoms of anaphylaxis or hypersensitivity (TCZ will be permanently discontinued from these 
patients)
•
ALT or AST value > 5X ULN or persistent elevation > 3X ULN
•
Platelet count (cells/mm3) < 50,000
•
ANC (cells/mm3) < 500
8.2
General Criteria
•
Biopsy proven acute rejection during the study
•
Serious infection including but not limited to sepsis, BK viremia (>10,000 copies/m/L), CMV 
infection, EBV infection, TB, or systemic fungal infections during  the study 
•
Inability of subject to comply with study requirements
•
Determination by the investigator that it is no longer safe for the subject to continue therapy
9.0
STOPPING RULES 
9.1
Ongoing Review 
The progress of the study will be monitored by a two-member DSMB, which includes 2 transplant 
surgeons (Dr. Ryutaro Hirose and Dr. Chris Freise). The DSMB will be chartered to perform independent 
oversight for the trial through regular review of enrollment and safety information provided in tables, 
listings and figures generated from the clinical database. If the trial is suspended for any reason they will 
monitor the reassessment and potential restarting of the trial. 
The DSMB will have the authority to suspend the trial. The trial will be suspended if the board 
determines that the risks to study participants exceed the originally described risks and/or that 
modifications to the protocol are needed to minimize the risks. The DSMB will receive safety data at 
least every 6 months following treatment of first subject. The DSMB will be informed immediately if a 
criterion for stopping the trial is met. The DSMB will also be informed if the principal investigator or co-
investigator judges at any time that a review of safety experience is warranted.
9.2
Stopping Rule Guidance 
The following will lead to suspension of enrollment and to review: 

Any unexpected death or death from opportunistic infection in the TCZ patients

Any event which in the opinion of the clinical investigators merits review prior to further 
enrollment 

Graft loss due to thrombosis in the TCZ patients
If any of these criteria are met, the principal investigator and sub-investigators will conduct a review of 
all safety data and a report will be provided to the DSMB, IRB, and FDA. Enrollment will not resume until 
these agencies approve reopening the enrollment. 


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10.0 CLINICAL AND LABORATORY EVALUATIONS
All participants will have 12 months of monitoring (6 month of therapy plus extended follow up for 6 
months) as outlined in the schedule of assessments. Any episodes of infections, renal allograft 
dysfunctions, rejections or other clinical events during the study period will be treated per the usual 
standard of care. 
Physical Exam: All participants will be seen by the study PI or co-investigator at monthly study visits 
during treatment and per usual standard of care in the extended follow up period. A focused history and 
physical exam will be performed, including queries for drug toxicities and signs/ symptom of infections. 
Laboratory testing: All participants will obtain laboratory tests at intervals of 4 weeks, consisting of a 
complete blood count, serum electrolytes, BUN and serum creatinine, fasting glucose, and 12-hour 
trough tacrolimus levels. Liver function tests (total bilirubin, AST and ALT) will be monitored monthly 
while on therapy and every 3 months in the follow up period. Lipid parameters (total cholesterol, LDL, 
triglycerides, HDL) will be assessed once 4-8 weeks after the initiation of TCZ therapy, and then every 3 
months till the end of the study. For females of reproductive potential, urine pregnancy tests will be 
obtained at screening and every follow up study visit.  The outpatient electronic medical record will be 
queried once weekly by the study coordinator for any new laboratory results on study participants. 
Laboratory data on all study participants will be reviewed weekly by the study PI. 
Safety Monitoring: Any episodes of infections, renal allograft dysfunctions, rejections or other clinical 
events during the study period will be recorded. These episodes will be treated per the usual standard of 
care. An interim analysis will be performed once 50% of subjects are enrolled to capture any excess 
adverse events.  
10.1 Visit windows
All scheduled study visits must occur within the time limits specified in Table 7. Visits that occur outside 
of the specified windows will be considered protocol deviations.
Table 7
VISIT
WINDOW
Visit -1
Day -28 to day 0
Visit 0
No window
Visit 1 through 5
±3 days
Visit 6
± 5 days
Visit 7-12
± 7 days


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10.2
Schedule of Assessments
Part 1: First 6 months (On therapy)
Time from enrollment 

Screening
(Variable)
Baseline 
(Day 0)- At 
enrollment
Month 1
Month 2
Month 3
Month 4
Month 5
Month 6
Visit number
-1
0
1
2
3
4
5
6
Kidney Biopsy 
X
X
Inclusion/ Exclusion 
criteria
X
IV methylprednisolone 
pulse
X
Tocilizumab infusion in 
group 2 only
X
X
X
X
X
X
Physical Exam 
X
X
X*
X*
X*
X*
X*
X*
Safety Monitoring 
X
X
X
X
X
X
X
Laboratory Tests
CBC with differential, 
chem-10, tacrolimus 
levels
X
X
X
X
X
X
X
LFT, BK virus PCR
X
X
X
X
X
X
X
Lipid panel
X
X
X
X
Regulatory T cells
X
X
X
Donor specific antibody
X
X
PK/PD, 
Immunogenicity/Anti-
TCZ testing in group 2 
only
X
X
X¶
Urine pregnancy test
X
X
X
X
X
X
X
X
Urine cytokines
X
X
X
X
X
X
X
*In group 2 only. Physical exam frequency can be per usual standard of care in group 1 
¶Or at termination of therapy


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Part 2: 6-12 months (extended follow-up period)
Time from enrollment 
Month 7
Month 8
Month 9
Month 10
Month 11
Month 12
Visit number
7
8
9
10
11
12
Physical Exam*
X
X
Safety Monitoring 
X
X
CBC with differential, chem-10, 
tacrolimus levels
X
X
X
X
X
X
LFT, lipid panel
X
X
Urine pregnancy test
X
X
*Or per usual standard of care
10.3
Pre-Treatment Evaluations in both groups
The following evaluations will be performed within 1 month prior to the date of each patient's initial 
treatment with TCZ:

Pregnancy test (serum or urine) for women of childbearing potential.

Medical history and documentation of the rationale for treatment of the patient's disease with TCZ.

Physical examination, including vital signs, blood pressure, performance status and toxicity 
assessment.

Hematology: complete blood count (CBC) with differential and platelet count.

Serum Chemistries: BUN, creatinine, electrolytes (Na, K, Cl, CO2, Ca, Mg, Phos), fasting glucose, total 
bilirubin, SGOT(AST), and SGPT (ALT) 

Tacrolimus trough level

Lipid Panel (total cholesterol, triglycerides, LDL, HDL)

Serum BK virus quantitative PCR
10.3.1 Evaluations During Treatment in group 2 (TCZ group)
Baseline (prior to 1st dose):

Anti-TCZ antibody testing

PK/ PD

Pregnancy test (serum or urine) for women of childbearing potential

Regulatory T cell count

Donor specific anti-HLA antibody 


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Every month:

Pregnancy test (serum or urine) for women of childbearing potential.

Physical examination, including vital signs, blood pressure, performance status and toxicity 
assessment.

Hematology: complete blood count (CBC) with differential and platelet count.

Serum Chemistries: BUN, creatinine, electrolytes (Na, K, Cl, CO2, Ca, Mg, Phos), fasting glucose, total 
bilirubin, SGOT(AST), and SGPT (ALT) 

Tacrolimus trough level
 Every 3 months:

Serum BK virus quantitative PCR

Regulatory T cell count
At 1 month, 3 months and then every 3 months:

 Lipid Panel
At 6 months:

Donor specific anti-HLA antibody
All patients will provide samples for anti-TCZ antibody testing as described in the Schedule of 
Assessments (baseline, 12 weeks and at termination of therapy).  In addition, samples for PK/PD will be 
tested for each time point when an anti-TCZ antibody test is done.  All patients experiencing events 
related to serious hypersensitivity or anaphylactic reactions that cause the patient to be withdrawn from 
TCZ treatment will need to have anti-TCZ and PK/PD testing at time of event, and also 6 weeks after the 
last dose for anti-TCZ and PK/PD testing.    All samples collected for immunogenicity assays will be tested 
using a screening assay and, if positive, by a confirmation assay to determine specificity.  If the 
confirmation assay is positive, a neutralizing assay will be performed to test for the ability to inhibit the 
activity of TCZ. Reports of the results of these analyses will be provided by Genentech to the investigator 
for patients testing positive for anti-TCZ antibodies. Samples will be shipped as described in Appendix B.  
10.3.2 Evaluations During Treatment In Group 1(Standard of Care group)
Baseline (within 1 month after randomization):

Donor specific anti-HLA antibody

Regulatory T cell count


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Every month:

Hematology: complete blood count (CBC) with differential and platelet count.

Serum Chemistries: BUN, creatinine, electrolytes (Na, K, Cl, CO2, Ca, Mg, Phos), fasting glucose, total 
bilirubin, SGOT(AST), and SGPT (ALT) 

Tacrolimus trough level
 Every 3 months:

Serum BK virus quantitative PCR

Regulatory T cell count
At 6 months

Donor specific anti-HLA antibody
Per usual standard of care:

Pregnancy test (serum or urine) for women of childbearing potential.

Physical examination, including vital signs, blood pressure, and performance status.
10.4
Post-Treatment Evaluations in both groups
Subjects will continue to obtain monitoring for an additional 6 months after therapy is completed. This 
will include:
•
Medical interview and physical examination every 3 months or per usual standard of care.
•
Pregnancy test (serum or urine) for women of childbearing potential at every study visit 
•
Complete blood count (with differential and platelet count) every month
•
Serum chemistries: BUN, creatinine, electrolytes (Na, K, Cl, CO2, BUN, creatinine, Ca, Mg, Phos), 
fasting glucose every month
•
Tacrolimus trough levels every month
•
Total bilirubin, AST and ALT every 3 months
•
Lipid panel every 3 months
11.0 REPORTING OF ADVERSE EVENTS
11.1
Adverse Event and Reporting Definitions
An adverse event (AE) is any untoward medical occurrence in a subject participating in an 
investigational trial or protocol regardless of causality assessment.  An adverse event can be an 
unfavorable and unintended sign (including an abnormal laboratory finding), symptom, syndrome or 
disease temporally associated with or occurring during the use of an investigational product whether or 
not considered related to the investigational product.
Additionally, an AE can be any of the following: 


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Any new disease or exacerbation of an existing disease (a worsening in the character, frequency, or 
severity of a known condition) 
Recurrence of an intermittent medical condition (e.g., headache) not present at baseline.
Any deterioration in a laboratory value or other clinical test (e.g., electrocardiogram, x-ray) that is 
associated with symptoms or leads to a change in TCZ or concomitant treatment or discontinuation from 
TCZ.
In the event of an adverse event, the first concern will be for the safety of the subject.  Investigators are 
required to report to Genentech Drug Safety any serious adverse event, and non-serious adverse events 
of special interest, whether expected or unexpected, and whether or not considered related to the TCZ.
The study sponsor or designee further agrees to forward reports to Genentech of serious adverse events 
and non-serious adverse events of special interest, regardless of attribution to the Investigational 
medicinal product. 
All events meeting these criteria will be reported for the time period beginning with any amount of 
exposure to TCZ through the protocol-defined follow-up period.  Serious criteria, definitions, and 
guidance for reporting follow.
Serious adverse events (SAE) (Immediately Reportable to the Sponsor) are adverse events occurring at 
any dose which meet one or more of the following serious criteria:

Results in death (i.e. the AE caused or lead to death)

Is life-threatening (i.e. the AE placed the subject at immediate risk of death; it does not apply to an 
AE which hypothetically might have caused the death if it were more severe)

Requires or prolongs inpatient hospitalization (hospitalizations for elective medical/surgical 
procedures, scheduled treatments, or routine check-ups are not SAEs by this criterion)

Is disabling (i.e. the AE resulted in a substantial disruption of the subject’s ability to carry out normal 
life functions)

Is a congenital anomaly/birth defect (i.e., an adverse outcome in a child or fetus of a subject 
exposed to the trial drug prior to conception or during pregnancy)

It does not meet any of the above serious criteria but may jeopardize the subject and may require 
medical or surgical intervention to prevent one of the outcomes listed above
SAEs include any sign, symptom or medical condition that meets any of the above criteria and emerges 
during TCZ treatment or during a post-treatment follow-up period that (1) was not present at the start 
of treatment and is not a chronic condition that is part of the patient’s medical history, OR (2) was 
present at the start of treatment or as part of the patient’s medical history but worsened in severity 
and/or frequency during therapy.


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Expected adverse events are those adverse events that are listed or characterized in the current 
Investigator Brochure. 
Assessment of Adverse Events
All AEs and SAEs whether volunteered by the subject, discovered by study personnel during questioning, 
or detected through physical examination, laboratory test, or other means will be reported 
appropriately. Each reported AE or SAE will be described by its duration (i.e., start and end dates), 
regulatory seriousness criteria if applicable, suspected relationship to theTCZ (see following guidance), 
and actions taken.
To ensure consistency of AE and SAE causality assessments, we will apply the following general 
guideline:
Yes
There is a plausible temporal relationship between the onset of the AE and administration of TCZ, and 
the AE cannot be readily explained by the subject’s clinical state, intercurrent illness, or concomitant 
therapies; and/or the AE follows a known pattern of response to the TCZ; and/or the AE abates or 
resolves upon discontinuation of the TCZ or dose reduction and, if applicable, reappears upon re-
challenge.
No
Evidence exists that the AE has an etiology other thanTCZ (e.g., preexisting medical condition, 
underlying disease, intercurrent illness, or concomitant medication); and/or the AE has no plausible 
temporal relationship to TCZ administration (e.g., cancer diagnosed 2 days after first dose of study drug).
Unexpected adverse events are those not listed in the current Investigator Brochure or not identified.  
This includes adverse events for which the specificity or severity is not consistent with the description in 
the Investigator Brochure  For example, under this definition, hepatic necrosis would be unexpected if 
the Investigator Brochure only referred to elevated hepatic enzymes or hepatitis.
The terms “severe” and “serious” are not synonymous.  Severity refers to the intensity of an AE (rated as 
mild, moderate, or severe; see section on “Assessment of Severity of Adverse Events”); the event itself 
may be of relatively minor medical significance (such as severe headache without any further findings).
Severity and seriousness need to be independently assessed for each AE recorded on the CRF.
Eliciting Adverse Events
A consistent methodology for eliciting AEs at all subject evaluation timepoints will be adopted. Examples 
of non-directive questions include: 
“How have you felt since your last clinical visit?”
“Have you had any new or changed health problems since you were last here?” 


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Specific Instructions for Recording Adverse Events
Investigators will use correct medical terminology/concepts when reporting AEs or SAEs. Avoid 
colloquialisms and abbreviations.
a.
Diagnosis vs. Signs and Symptoms
If known at the time of reporting, a diagnosis should be reported rather than individual signs and 
symptoms (e.g., record only liver failure or hepatitis rather than jaundice, asterixis, and elevated 
transaminases). However, if a constellation of signs and/or symptoms cannot be medically characterized 
as a single diagnosis or syndrome at the time of reporting, it is ok to report the information that is 
currently available. If a diagnosis is subsequently established, it should be reported as follow-up 
information.
b.
Deaths
All deaths that occur during the protocol-specified AE reporting period (see Section 5.1.2), regardless of 
attribution, will be reported to the appropriate parties. When recording a death, the event or condition 
that caused or contributed to the fatal outcome should be reported as the single medical concept. If the 
cause of death is unknown and cannot be ascertained at the time of reporting, report “Unexplained 
Death”. This includes death attributed to progression of underlying disease.
Death should be considered an outcome and not a distinct event.  The event or condition that caused or 
contributed to the fatal outcome should be recorded as the single medical concept on the Adverse 
Event CRF.  Generally, only one such event should be reported.  The term “sudden death” should only be 
used for the occurrence of an abrupt and unexpected death due to presumed cardiac causes in a patient 
with or without preexisting heart disease, within 1 hour of the onset of acute symptoms or, in the case 
of an unwitnessed death, within 24 hours after the patient was last seen alive and stable.  If the cause of 
death is unknown and cannot be ascertained at the time of reporting, “unexplained death” should be 
recorded on the Adverse Event CRF.  If the cause of death later becomes available (e.g., after autopsy), 
“unexplained death” should be replaced by the established cause of death. If the death is attributed to 
progression of underlying disease, progression should be captured on the Adverse Event CRF. 
c.
Preexisting Medical Conditions
A preexisting medical condition is one that is present at the start of the study. Such conditions should be 
reported as medical and surgical history. A preexisting medical condition should be re-assessed 
throughout the trial and reported as an AE or SAE only if the frequency, severity, or character of the 
condition worsens during the study. When reporting such events, it is important to convey the concept 
that the preexisting condition has changed by including applicable descriptors (e.g., “more frequent 
headaches”).
d.
Hospitalizations for Medical or Surgical Procedures


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Any AE that results in hospitalization or prolonged hospitalization should be documented and reported 
as an SAE. If a subject is hospitalized to undergo a medical or surgical procedure as a result of an AE, the 
event responsible for the procedure, not the procedure itself, should be reported as the SAE. For 
example, if a subject is hospitalized to undergo coronary bypass surgery, record the heart condition that 
necessitated the bypass as the SAE.
Hospitalizations for the following reasons do not require reporting:
•
Hospitalization or prolonged hospitalization for diagnostic or elective surgical procedures for 
preexisting conditions
•
Hospitalization or prolonged hospitalization required to allow efficacy measurement for the 
study or
•
Hospitalization or prolonged hospitalization for scheduled therapy of the target disease of the 
study.
e.
Pregnancy
If a female subject becomes pregnant while receiving investigational therapy or within 90 days after the 
last dose ofTCZ, a report will be completed and expeditiously submitted to the Genentech, Inc. Follow-
up to obtain the outcome of the pregnancy should also occur. Abortion, whether accidental, 
therapeutic, or spontaneous, will always be classified as serious, and expeditiously reported as an SAE. 
Similarly, any congenital anomaly/birth defect in a child born to a female subject exposed to TCZ will be 
reported as an SAE.  A Clinical Trial Pregnancy Reporting Form will be completed by the sponsor within 
24 hours after learning of the pregnancy Pregnancy should not be recorded on the Adverse Event CRF.  
The sponsor will counsel the patient, discussing the risks of the pregnancy and the possible effects on 
the fetus.  Monitoring of the will should continue until conclusion of the pregnancy.
Abortions
Any spontaneous abortion will be classified as an SAE (as the sponsor considers spontaneous abortions 
to be medically significant events), recorded on the Adverse Event CRF, and reported to the sponsor 
within 1 working day after learning of the event (see section on “Reporting Requirements for 
Pregnancies”).  
Congenital Anomalies/Birth Defects
Any congenital anomaly/birth defect in a child born to a female patient or female partner of a male 
patient exposed to TCZ will be classified as an SAE, recorded on the Adverse Event CRF, and reported to 
the sponsor within 1 working day after learning of the event (see section on “Reporting Requirements 
for Pregnancies”).
f.
Post-Study Adverse Events
The investigator will expeditiously report any SAE or non-serious AESI occurring after a subject has 
completed or discontinued study participation if attributed to priorTCZ exposure regardless of how 


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much time has elapsed since study participation. If the investigator should become aware of the 
development of cancer or a congenital anomaly in a subsequently conceived offspring of a female 
subject who participated in the study, this will be reported as an SAE. All unrelated SAEs must be 
reported during the study and up to 3 months after the last dose ofTCZ, even if the study has been 
closed.
g.
Reconciliation
The sponsor agrees to conduct reconciliation for the product. Genentech and the Sponsor will agree to 
the reconciliation periodicity and format, but agree at minimum to exchange monthly line listings of 
cases received by the other party. If discrepancies are identified, the Sponsor and Genentech will 
cooperate in resolving the discrepancies. The responsible individuals for each party shall handle the 
matter on a case-by-case basis until satisfactory resolution.
11.2
Reporting of Serious Adverse Events Associated with Tocilizumab
Immediate Reporting Requirements
The Investigator must report the following events to Genentech Drug Safety within 24 hours after 
learning of the event, regardless of relationship to study drug:
SAEs.
Non-serious and serious AEs of special interest.
All Non-Serious Adverse Events originating from the Study will be forwarded in a quarterly report to 
Genentech.
Pregnancies.
The Investigator must report new significant follow-up information for these events to Genentech Drug 
Safety within 1 working day after becoming aware of the information.  New significant information 
includes the following:
New signs or symptoms or a change in the diagnosis.
Significant new diagnostic test results.
Change in causality based on new information.
Change in the event’s outcome, including recovery.
Additional narrative information on the clinical course of the event.
Investigators must also comply with local requirements for reporting SAEs to the local health authority 
and IRB/EC.


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All serious adverse events (SAEs) for which there is a reasonable possibility the experience may have 
been caused by TCZ (this applies to both expected and unexpected events) should be recorded on a 
MedWatch 3500A Form and faxed to:
Genentech Drug Safety 
Tel:
(888) 835-2555
Fax:
(650) 225-4682 or (650) 225-5288
This must be reported to Genentech within 24 hours.  
AND:
Principal Investigator: Flavio Vincenti, M.D.
Telephone:
415-353-1322
Fax:
415-353-8974
E-mail:
Flavio.Vincenti@ucsf.edu
Study Coordinator:
Niloufar Abdollahi
Telephone:
415-353-8380
Fax:
415-353-8387
E-mail:
Niloufar.Abdollahi@ucsf.edu
Study Coordinator #2:  Erica.Tavares@ucsf.edu
Telephone:
415-353-8380
Fax:
415-353-8387
E-mail:
 Erica.Tavares@ucsf.edu
AND:
IRB Contact information:
UCSF-Committee on Human Research
Telephone:
415-476-1814
Fax:
415-502-1347
E-mail:
chr@ucsf.edu


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MedWatch 3500A Reporting Guidelines:
In addition to completing appropriate patient demographic and suspect medication information, the 
report should include the following information within the Event Description (section 5) of the 
MedWatch 3500A form:

Treatment regimen (dosing frequency, combination therapy)

Protocol description (and number, if assigned)

Description of event, severity, treatment, and outcome if known

Supportive laboratory results and diagnostics

Investigator’s assessment of the relationship of the adverse event to each investigational product 
and suspect medication
Follow-up information:  
Additional information may be added to a previously submitted report by any of the following methods:

Adding to the original MedWatch 3500A report and submitting it as follow-up

Adding supplemental summary information and submitting it as follow-up with the original 
MedWatch 3500A form 

Summarizing new information and faxing it with a cover letter including subject identifiers (i.e. 
D.O.B. initial, subject number), protocol description and number, if assigned, suspect drug, brief 
adverse event description, and notation that additional or follow-up information is being submitted  
(The patient identifiers are important so that the new information is added to the correct initial 
report)
Occasionally Genentech may contact the reporter for additional information, clarification, or current 
status of the subject for whom and adverse event was reported.  For questions regarding SAE reporting, 
you may contact the Genentech Drug Safety representative noted above.
11.3
Actemra Events of Special Interest
Adverse events of special interest (non-serious and serious) are required to be reported by the 
Investigator to Genentech Drug Safety within 24 hours after learning of the event (see Section 11.2 for 
reporting instructions).  Non-serious and serious AEs of special interest for this study include the 
following:
Infections including all opportunistic infections and non-serious infections as defined by those treated 
with IV anti-infectives
Myocardial infarction/acute coronary syndrome.


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GI perforation and related events.
Malignancies.
Hypersensitivity reactions.
Demyelinating disorders.
Stroke.
Bleeding events.
Hepatic events.
Guided questionnaires have been prepared for the AEs of special interest.  
The notification of AEs of special interest (including non-serious events of special interest) will follow the 
established procedures for AEs and SAEs in the study (i.e., documented and reported to Genentech Drug 
Safety or its designee within one working day).  Guided questionnaires have been prepared for the AEs 
of special interest and will be sent to the investigator(s) to obtain more detailed information, as 
necessary.  The documentation and reporting requirements for those AEs of special interest will be 
further described in a separate document (Actemra Events of Special Interest Guidance Document).
11.4
Study Close Out
Any study report submitted to the FDA by the Sponsor or designee should be copied to Genentech. This 
includes all IND annual reports and the Clinical Study Report (final study report). Additionally, any 
literature articles that are a result of the study should be sent to Genentech. Copies of such reports 
should be mailed to the assigned Clinical Operations contact for the study:
Clinical Operations Contact: 
E-mail: Actemra IST Central Mailbox: actemra-gsur@gene.com
12.0 EVALUATION OF RESPONSE
Evaluation of response to TCZ therapy will be primarily based on histologic assessments as described 
below.
Semiquantative assessment of inflammation on kidney transplant biopsies for each subject at baseline 
and 6 months follow up will be performed using the Banff “t” and “i” scores. Computer assisted image 
analysis will be used to calculate the quantity of interstitial LCA positive cells, CD68 positive cells and 
FoxP3 positive cells on biopsies at 6 months and 12 months and the results will be expressed as a 
percentage (%) of the total cortex (for LCA positive cells and collagen expression) or as a percentage (%) 
of the total number of cells (for CD68 positive and FoxP3 positive cells). The % value for any variable 
(inflammation or fibrosis) at 6 months will be taken as the baseline, and the increase or decrease in the 


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variable at 12 months calculated = (% value at 12 months minus % value at 6 months)/ (% value at 6 
months)
In addition, we will perform quantitative in situ hybridization for IL-6 mRNA and protein expression on 
paraffin sections. Frozen or paraffin sections of the kidney biopsy will be stained (by 
immunofluorescence/ immunohistochemistry) for downstream IL-6 mediated inflammatory response 
genes (SAA2 and CRP), Janus kinase (JAK) and signal transducer and activator of transcription 3 (STAT3).    
For the measurement of urinary cytokines, urine samples will be collected from enrolled patients on day 
0, monthly till the end of the treatment at 12 months post-transplant, and on the day of the biopsy. The 
sample will be divided into supernatant and cell pellets prior to banking so that soluble mediators and 
gene expression by cellular sediments can be analyzed separately.  The urine cell pellets will be analyzed 
using qRT-PCR for the presence of inflammatory mediators. We will use a combination of multiplex 
Luminex and ELISA to measure urinary protein in the supernatant, with focus on inflammatory 
mediators that are likely made by infiltrating leukocytes or induced by local inflammation and proteins 
that are reflective of kidney function, using a customized multiplex Luminex assay to profile 
inflammatory mediators reported to be altered in rejection or subclinical inflammation. Molecules to be 
profiled include CXCL-9 and CXCL-10, both of which have been reported to be elevated in the urine of 
patients with graft inflammation. PCR primers for these genes are available from Qiagen and a 
Sybrgreen-based real-time PCR assay will be used to quantify the transcripts.
The primary endpoints are  
(a) A 40% decrease in the quantity of inflammation between kidney biopsies at baseline and 6 months 
follow up as measured by Banff “ti” scores and by computer-assisted quantitative image analysis of 
interstitial LCA (leukocyte common antigen)-positive cells. 
(b) The change in the quantity and fraction of macrophages (CD68 positive cells) and regulatory T cells 
(FoxP3 positive cells) in the inflammatory infiltrate, as measured by computer-assisted quantitative 
image analysis, at baseline and 6 months follow up.
13.0 STATISTICAL CONSIDERATIONS
13.1  Determination of Sample Size     
The main question is a comparison of proportion of subjects with persistent inflammation in group 1 
(standard of care) vs. group 2 (TCZ group).
The null hypothesis is:
Ho: The proportion of participants with persistent inflammation at 6 months follow up in group 1 is the 
same as the proportion of participants with persistent inflammation at 6 months follow up in group 2.
The alternative hypothesis is:


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Ha: The proportion of participants with persistent inflammation at 6 months follow up in group 1 is 
different from the proportion of participants with persistent inflammation at 6 months follow up in 
group 2.
Although we believe that it is extremely unlikely that the addition of TCZ to standard post-transplant 
immunosuppression will increase the probability of fibrosis, we nevertheless used a two-tailed 
alternative hypothesis and set alpha at 0.05. Based on a review of the relevant literature and our 
previous experience noted above, we anticipate that 50% of study participants randomized to group 1 
(standard of care group) will manifest persistent inflammation at 6 months follow up compared with 
10% of study participants randomized to group 2 (TCZ group). We will have 83% power to detect an 
effect of this magnitude, i.e., a 40% absolute difference between groups with a sample size of 24 per 
group, or a total N=48. Once consent is obtained, patients will be randomized (1:1) by block 
randomization to group 1 or group 2. 
13.2 Analysis of Study Endpoints
Continuous data will be expressed as mean +/- standard deviations and dichotomous data as 
percentages. The chi-square test will be used to examine differences in categorical data (e.g., incident 
acute rejections) and the Mann-Whitney U-test to examine differences in continuous variables (e.g. 
mean Banff scores) between groups as these variables are not normally distributed. To determine 
differences between % of inflammation and change in % inflammation and fibrosis, comparison 
between groups will be made with a t-test or Mann-Whitney U test, depending on the distribution of 
the data). We will consider P values of 0.05 to be statistically significant.
14.0 RETENTION OF RECORDS
We will retain all documentation of adverse events, records of trial drug receipt and dispensation, and 
all IRB correspondence for at least 2 years after the investigation is completed.
15.0 REFERENCES
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5. Cosio FG, Grande JP, Larson TS, et al. Kidney allograft fibrosis and atrophy early after living donor 
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20. Thierry A, Thervet E, Vuiblet V, et al. Long-term impact of subclinical inflammation diagnosed by 
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25. Mengel M, Reeve J, Bunnag S, et al. Scoring total inflammation is superior to the current Banff 
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29. Steinman L. A brief history of T(H)17, the first major revision in the T(H)1/T(H)2 hypothesis of T cell-
mediated tissue damage. Nat Med. 2007 Feb;13(2):139-45. Erratum in: Nat Med. 2007 Mar;13(3):385. 
30. Akira S, Hirano T, Taga T, et al. Biology of multifunctional cytokines: IL 6 and related molecules (IL 1 
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33. Lotz M, Jirik F, Kabouridis P, et al. B cell stimulating factor 2/interleukin 6 is a costimulant for human 
thymocytes and T lymphocytes. J Exp Med. 1988 Mar 1;167(3):1253-8.
34. Holsti MA, Raulet DH. IL-6 and IL-1 synergize to stimulate IL-2 production and proliferation of 
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35. Okada M, Kitahara M, Kishimoto S, et al. IL-6/BSF-2 functions as a killer helper factor in the in vitro 
induction of cytotoxic T cells. J Immunol. 1988 Sep 1;141(5):1543-9.
36. Rochman I, Paul WE, Ben-Sasson SZ. IL-6 increases primed cell expansion and survival. J Immunol. 
2005 Apr 15;174(8):4761-7.
37. Weaver CT, Hatton RD, Mangan PR, et al. IL-17 family cytokines and the expanding diversity of 
effector T cell lineages.  Annu Rev Immunol. 2007;25:821-52.
38. Shen H, Goldstein DR. IL-6 and TNF-alpha synergistically inhibit allograft acceptance. J Am Soc 
Nephrol. 2009 May;20(5):1032-40.
39. Zhao X, Boenisch O, Yeung M, et al. Critical role of proinflammatory cytokine IL-6 in allograft 
rejection and tolerance. Am J Transplant. 2012 Jan;12(1):90-101.
40. Vanaudenaerde BM, De Vleeschauwer SI, Vos R, et al. The role of the IL23/IL17 axis in bronchiolitis 
obliterans syndrome after lung transplantation. Am J Transplant. 2008 Sep;8(9):1911-20.
41. Nakagiri T, Inoue M, Morii E, et al. Local IL-17 production and a decrease in peripheral blood 
regulatory T cells in an animal model of bronchiolitis obliterans. Transplantation. 2010 Jun 
15;89(11):1312-9.
426. Van Oers MH, Van der Heyden AA, Aarden LA. Interleukin 6 (IL-6) in serum and urine of renal 
transplant recipients. Clin Exp Immunol. 1988 Feb;71(2):314-9.
43. Vandenbroecke C, Caillat-Zucman S, Legendre C, et al. Differential in situ expression of cytokines in 
renal allograft rejection.  Transplantation. 1991 Mar;51(3):602-9.
44. Krams SM, Falco DA, Villanueva JC, et al. Cytokine and T cell receptor gene expression at the site of 
allograft rejection. Transplantation. 1992 Jan;53(1):151-6.
45. Raasveld MH, Weening JJ, Kerst JM, et al. Local production of interleukin-6 during acute rejection in 
human renal allografts. Nephrol Dial Transplant. 1993;8(1):75-8.
46. Waiser J, Budde K, Katalinic A, et al. Interleukin-6 expression after renal transplantation. Nephrol Dial 
Transplant. 1997 Apr;12(4):753-9.
47. Casiraghi F, Ruggenenti P, Noris M, et al. Sequential monitoring of urine-soluble interleukin 2 
receptor and interleukin 6 predicts acute rejection of human renal allografts before clinical or laboratory 
signs of renal dysfunction. Transplantation. 1997 May 27;63(10):1508-14.
48. Liang Y, Christopher K, Finn PW, et al. Graft produced interleukin-6 functions as a danger signal and 
promotes rejection after transplantation. Transplantation. 2007 Sep 27;84(6):771-7. Erratum in: 
Transplantation. 2007 Nov 27;84(10):1375. 
49. Sadeghi M, Daniel V, Wiesel M, et al. High urine sIL-6R as a predictor of late graft failure in renal 
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50. Kirk AD, Jacobson LM, Heisey DM, et al. Clinically stable human renal allografts contain histological 
and RNA-based findings that correlate with deteriorating graft function. Transplantation. 1999 Nov 
27;68(10):1578-82.
51. Fishman D, Faulds G, Jeffery R, et al. The effect of novel polymorphisms in the interleukin-6 (IL-6) 
gene on IL-6 transcription and plasma IL-6 levels, and an association with systemic-onset juvenile 
chronic arthritis. J Clin Invest. 1998 Oct 1;102(7):1369-76.
52. Martin J, Worthington J, Harris S, et al. The influence of class II transactivator and interleukin-6 
polymorphisms on the production of antibodies to donor human leucocyte antigen mismatches in renal 
allograft recipients.  Int J Immunogenet. 2009 Aug;36(4):235-9.
53. Kocierz M, Siekiera U, Kolonko A, et al. -174G/C interleukin-6 gene polymorphism and the risk of 
transplanted kidney failure or graft loss during a 5-year follow-up period. Tissue Antigens. 2011 
Apr;77(4):283-90.
54. Rush D, Nickerson P, Gough J, et al. Beneficial effects of treatment of early subclinical rejection: a 
randomized study. J Am Soc Nephrol. 1998:9:2129
55. Kee TY, Chapman JR, O’Connell PJ, et al. Treatment of subclinical rejection diagnosed by protocol 
biopsy of kidney transplants. Transplantation 2006: 82: 36
56. Rush D, Arlen D, Boucher A, et al. Lack of benefit of early protocol biopsies in renal transplant 
patients receiving TAC and MMF: a randomized study. Am J Transplant 2007: 7: 2538
57. Veronese FV, Noronha IL, Manfro RC, et al. Prevalence and immunohistochemical findings of 
subclinical kidney allograft rejection and its association with graft outcome. Clin Transplant 2004 Aug; 
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16.0 APPENDIX
APPENDIX A:  STUDY FLOW CHART/SCHEMA
Obtain 
Informed 
Consent
Screening 
(Inflammation 
in 6 month 
Allograft 
biopsy)
Treatment 
Period
 Day 0 “Start of 
Study” 
 
Randomize 
Group 1 Standard 
of care; Group 2 
monthly 
tocilizumab 
infusions 
Repeat 
Biopsy 
Study Period 
Month 6 
 
Follow-Up 
Study Period 
Months 7- 
12 
 
APPENDIX B:  BANFF 1997 QUANTITATIVE CRITERIA FOR RENAL ALLOGRAFT 
BIOPSIES 
Tubulitis “t” score


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t0: No mononuclear cells in tubules
t1, t2, and t3: Foci with 1-4 cells, 4-10 and >10 cells/ tubular cross-section
Mononuclear cell interstitial inflammation “i” score in unscarred parenchyma
i0: <10% of unscarred parenchyma
i1, i2, and i3: 10-25%, 26-50% and >50% of parenchyma inflamed
Mononuclear cell inflammation “ti” score in total parenchyma (scarred and unscarred)- Banff 07 update
ti0: <10% of total parenchyma
ti1, ti2, and ti3: 10-25%, 26-50% and >50% of parenchyma inflamed
Interstitial fibrosis “ci” score
ci0: Interstitial fibrosis in up to 5% of cortical area
ci1, ci2, and ci3: Interstitial fibrosis in 6-25%, 26-50% and >50% of cortical area
Tubular atrophy “ct” score
ct0 No tubular atrophy
ct1, ct2, and ct 3: Tubular atrophy <25%, 26-50%, and >50% of the area of cortical tubules


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APPENDIX C:  FDA MEDWATCH 3500A FORM


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APPENDIX D: SAFETY REPORTING FAX COVER SHEET
SAFETY REPORTING FAX COVER SHEET
Investigator Sponsored Trials
SAE FAX No: (650) 225-4682
Alternate Fax No: (650) 225-5288
Study Number
(Genentech study number)
Principal Investigator
Site Name
Reporter name
Reporter Telephone #
Reporter Fax #
Initial Report Date
(DD/MON/YYYY)
____ / _____ /_____
Follow-up Report Date
(DD/MON/YYYY)
____ / _____ /_____
Subject Initials
(Please enter a dash if the patient 
has no middle name)
____ - ____ -____
PLEASE PLACE MEDWATCH REPORT or IND SAFETY REPORT BEHIND THIS COVER 
SHEET
Please contact Genentech Safety for any questions regarding SAE or IND Safety reporting 
at (888) 835-2555
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