Conditions: Antibody-mediated Rejection Hyperacute Rejection of Cardiac Transplant Left Ventricular Dysfunction Cardiac Allograft Vasculopathy Heart Graft Dysfunction
Keywords: cardiac transplantation immunosuppression acute cellular rejection antibody mediated rejection sensitization antibody production in cardiac patients panel reactive antibodies desensitization strategies in heart transplant patients complement activation complement c3d and c4d deposition terminal complement inhibition complement C5 binding Eculizumab monoclonal antibody donor specific antibodies
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 36
Healthy volunteers: no

Brief summary:
All individuals who receive a heart transplant are at risk for developing antibody-mediated rejection (AMR). An antibody is a protein produced by the body's immune system when it detects a foreign substance, called an antigen. The mechanism of an antibody is to attack an antigen. In antibody mediated rejection, antibodies will attack the transplanted heart, causing injury to the heart. The purpose of this investigation is to determine if a study drug, called eculizumab (Soliris), is safe to use in heart transplant recipients, and determine if it reduces risk of antibody-mediated rejection.

Detailed description:
The growing proportion of sensitized cardiac recipients presents an additional challenge to the transplant practitioner attempting to minimize the occurrence of antibody mediated rejection (AMR). Patients pre-exposed or "sensitized" to antigen exposing events (i.e.: blood transfusions, multiple pregnancies, prior organ transplantations, ventricular support devices) are more likely to both possess preformed and develop de-novo antibodies. Sensitized patients with panel reactive antibodies \> 25% are at risk for increased risk of rejection, development of cardiac allograft vasculopathy and increased mortality after heart transplantation.

A central component of antibody-mediated cell injury is complement activation. The inhibition of terminal complement activation may be the missing link to decreasing possibly both complement-mediated AMR and cellular rejection (CR) by inhibiting both the inflammatory effects of both circulating antibodies and cytokine induced cell death.

Eculizumab is a monoclonal antibody that specifically binds to complement protein C5 with high affinity, thereby inhibiting its cleavage to C5a and C5b and preventing the generation of the terminal complement complex C5b-9. By this mechanism, eculizumab (Soliris®) inhibits terminal complement mediated intravascular hemolysis in paroxysmal nocturnal hemoglobinuria patients.

This study is a non-randomized, open-label, investigator-initiated safety and efficacy trial investigating the de-novo use of eculizumab alongside conventional therapy to prevent antibody mediated rejection. The duration of the study will include an open enrollment period and at least 12 months of follow-up (post-transplant). We will consent up to 45 eligible patients, highly "sensitized", with a panel reactive antibody score greater than 70%, who are not previously or currently enrolled in another ongoing trial. Of these 45 participants, up to 20 of these patients will be treated with eculizumab (Solaris), the study drug. The use of eculizumab will be un-blinded to all study and research practitioner participants.

Arms:
arm 1: Administration of Eculizumab to heart transplant recipients at Cedars Sinai Medical Center with a panel reactive antibody (PRA) ≥ 70%, for the prevention of antibody-mediated rejection.

Interventions: intervention 1: Eculizumab
Intervention descriptions: intervention 1: At the time of transplantation, 1200mg of Eculizumab will be administered via a 35 minute IV infusion, followed by thymoglobulin 1.5 mg/kg intravenous piggyback (IVPB). The administration of thymoglobulin will be repeated (if blood counts permit) for a total of five doses.

On Day 1 post-transplant, 900 mg of Eculizumab will be given via an IV infusion.

On Day 5 post-transplant, intravenous immunoglobulin (IVIG) 1 gram/kg will be administered daily for two consecutive days.

On post-transplant days 7, 14, and 21 (+/- 2 days) 900mg of Eculizumab will be given via an IV infusion at each scheduled visit.

On post-transplant days 28, 42, and 56 (+/- 2 days) 1200 mg of Eculizumab will be given via an IV infusion at each scheduled visit.

Protocol document:
Prot_SAP_000.pdf: 
 
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STUDY PROTOCOL  
The De-novo Use of Eculizumab Alongside Conventional Therapy in 
Presensitized Patients Receiving Cardiac Transplantation: An Open-Label, 
Investigator-Initiated Pilot Trial:  [The DUET Cardiac Trial] 
Protocol Version 
 
Date of Protocol 
 
Proposal 
July 9, 2015 
Reference Number 
TBD 
This study will be conducted in compliance with the protocol, ICH-GCP and any 
applicable regulatory requirements. 
Study Sponsor 
 
Patel, Jignesh K., MD 
 
Address 
8536 Wilshire Blvd #302 
Beverly Hills, CA 90211 
Phone 
310-248-8300 
FAX 
310-248-8333 
Investigational Agent 
Supplier 
 
Alexion Pharmaceuticals 
 
Address  
352 Knotter Drive Cheshire, CT 06410 
Phone  
203-272-2596 
FAX  
203-271-8198 


 
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1.1 TABLE OF CONTENTS: 
1.0 General Information………………………………………………………………...….….1 
1.1 Table of Contents………………………………………………………………….2 
 
2.0 Background ……………..………………………………………………………………....4 
2.1 Schematic: The Complement Cascade and the Mechanism of Action of 
Eculizumab………………………………………………………………………….6 
2.2 References……………………………………………………………………….....7 
 
3.0 Trial Objectives & Purpose………………………………………………………………8 
3.1 Primary Outcome Measure………………………………………………...….…8 
3.2 Secondary Outcome Measure…………………………..……………….……...8 
 
4.0 Trial Design…………………………………………………………………………….......8 
4.1 Immunologic Risk Factor Surveillance..………………………………………8 
4.2 Treatment Success……………………………………………………….……….9 
4.3 Sample Size and Power……………………………………………….……….…9 
4.4 Statistical Methods…………………………………………………….……….…9 
 
5.0 Patient Selection ………………………………….……………………………….…….10 
5.1  Inclusion Criteria……………………………….…………………………...…..10 
5.2  Exclusion Criteria…………………………………………...………….............11 
5.3 Subject Identification…………………………………………………………....11 
5.4 Demographic Data………………………………………………………...….....11 
5.5 Medical History……………………………………………….…………………..11 
5.6 Withdrawal of Subjects from the Study…………..…………………...……..11 
 
6.0 Therapeutic Protocol Design…………………………………………………………..11 
6.1 Dosage, Administration, and Pharmacokinetics……..………………….…12 
6.2 Treatment Modification………………………………………………………….13 
6.3 Investigational Product Identity…………………………………………...…..13 
6.4 Adverse Events……………………………………………………………...……14 
 
7.0 Immunosuppression+ Desensitization Pre + Post Transplant…….………….…15 
 
8.0  Treatment of Rejection…………………………………………………………………18 
 
9.0 Prophylactic Medication……………………………………………………………..…19 
 
10. Safety Monitoring and Evaluation Schedule ……………………………………….20 
 
11.0 Clinical and Laboratory Assessment…………………………………………….…24 
 


 
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12.0 Drug Accountability……………………………………………………………………24 
 
13.0 Data Handling and Quality Assurance…………………………………………......24 
 
14.0 Ethics……………………………………………………………………………………. 25 
 
15.0 Confidentiality…………………………………………………………………………..26 
 
Appendix A: Eculizumab Constitutional Symptoms ADE Evaluation………………27 
 
Appendix B: Eculizumab: Investigational Medication Brochure………………….…28 
 
Appendix C: ISHLT Grading of Acute Cellular and Antibody Mediated Rejection.31 
 
Appendix D: Eculizumab Safety Monitoring & Evaluation Schedule: ….Attachment 
 
 
 
 


 
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2.0 BACKGROUND  
There is a missing link in the present armamentarium to prevent antibody mediated 
rejection (AMR) in solid organ transplantation.  In cardiac transplantation, it is 
associated with more hemodynamic compromise, cardiac allograft vasculopathy and a 
higher mortality even when asymptomatic1,2,3,4 With the unavailability of better treatment 
options, present day maintenance therapies remain little changed to treatment 
strategies used over thirty years ago. In the early eighties, with the introduction of 
cyclosporine and later tacrolimus, the one year actuarial survival rate in cardiac 
transplantation escalated significantly from 40% to over 90%.1,3 Today, however, 
despite the identification of the deleterious effects of both cellular and antibody 
mediated rejection, cardiac transplantation long-term survival rates remain stagnant 
possibly due to the inability of present regimens to effectively target the humoral 
pathway. By preferentially blocking interleukin II production, contemporary doses of 
calcineurin inhibitors have less of an effect on humoral rejection. Although tacrolimus 
possesses the ability to decrease MHC expression and modulate B cell responses 
through T cell down-regulation, its efficacy on antibody mediated rejection is limited due 
to dose related side effects (i.e. namely, renal dysfunction, diabetes, anemia, 
neutropenia, hyperkalemia, and hypomagnesiemia).  Likewise, despite the ability of 
selective medications to abrogate the potentiation of either antibody production (i.e.: 
IVIG, bortezomib, rituximab) or cytokine expansion (i.e. sirolimus, everolimus, 
mycophenolate), the mortality rate of AMR, accounting for up to 20% of all long-term 
cardiac transplantation deaths, continues to remain high1,3,4. 
 
The growing proportion of sensitized cardiac recipients presents an additional challenge 
to the transplant practitioner attempting to minimize the occurrence of antibody 
mediated rejection.  Patients pre-exposed or “sensitized” to antigen exposing events 
(i.e.: blood transfusions, multiple pregnancies, prior organ transplantations, ventricular 
support devices) are more likely to both possess preformed and develop de-novo 
antibodies.  Sensitized patients with panel reactive antibodies > 25% are at risk for 
increased mortality after heart transplantation 5,6.  Present desensitization strategies aim 
to decrease antibodies in the hope of facilitating the likelihood of transplantion.7,8 
However, such strategies may in turn be increasing the recipient’s likelihood for AMR 
and subsequent graft failure due to B-cell memory and post-transplant antibody 
rebound. The search for newer therapeutic strategies in solid organ transplantation 
should therefore not only aim to increase the number of sensitized patients eligible for 
transplantation, but to also prolong post-transplant survival and reduce morbidity. 
 
A central component of antibody-mediated cell injury is complement activation. 
Histologically, evidence of complement activation with the presence of complement c3d 
and c4d deposition and evidence for endothelial cell injury, is highly supportive of the 
diagnosis of AMR and is now an important component in the pathological classification 
of AMR in cardiac transplantation 6,7,8.  Clearly the best approach to treating AMR is by 
blocking the cytolytic effects of alloantibody at its initial presentation. One strategy 
would involve prevention of complement activation.   


 
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Eculizumab is a monoclonal antibody that specifically binds to complement protein C5 
with high affinity, thereby inhibiting its cleavage to C5a and C5b and preventing the 
generation of the terminal complement complex C5b-9 9,10.(See Schematic 2.1: 
Description of the Complement Cascade and the Mechanism of Action of Eculizumab)  
By this mechanism, eculizumab (Soliris®) inhibits terminal complement mediated 
intravascular hemolysis in paroxysmal nocturnal hemoglobinuria patients.9  
 
In cardiac transplant recipients, the inhibition of terminal complement activation may be 
the missing link to decreasing possibly both complement-mediated AMR and cellular 
rejection (CR) by inhibiting both the inflammatory effects of both circulating antibodies 
and cytokine induced cell death.  A recent clinical trial in renal transplantation with 
terminal complement inhibition using eculizumab has shown very promising results, 
significantly reducing the incidence of AMR in the first 3 months after transplant from 
41.2% to 7.7% compared to a historical control cohort 5.  At one year post renal 
transplantation, there was a significant decrease in transplant glomerulopathy, a 
process of chronic rejection analogous to chronic allograft vasculopathy in cardiac 
transplantation5,6. 
 
Furthermore, the use of terminal complement inhibition (at complement protein C5) and 
not earlier in the immune cascade, allows the opsonization of bacteria and the 
clearance of immune complexes to remain intact, potentially minimizing the likelihood 
for the adverse event of infection.9-12 Carrying a limited side effect profile (of headache, 
naso-pharyngitis, back pain, nausea, and fatigue8) and the feasibility of administering a 
thirty minute infusion, eculizumab may be easily given at the time of a normally 
scheduled post-operative clinical follow-up.  Additionally, by using eculizumab 
immediately post transplant and then continuing use for the first eight weeks post 
transplantation1-5 (when the risk of AMR is the greatest), the devastating repercussions 
of the complement cascade are potentially obviated.  Thus, eculizumab may have the 
potential to minimize the occurrence of AMR, limit graft dysfunction, limit development 
of cardiac allograft vasculopathy and prolong long-term cardiac transplantation survival. 
In cardiac transplantation, the development of accelerated cardiac allograft 
vasculopathy as defined by an increase in maximal intimal thickness at matched sites of 
≥0.5mm has been shown to be a surrogate marker for increased mortality, non-fatal 
major adverse cardiac events and development of angiographic vasculopathy at 5 
years16. 
 
 
 
 
 
 
 
 


 
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2.1 SCHEMATIC:  
THE COMPLEMENT CASCADE & THE MECHANISM OF ACTION OF ECULIZUMAB 
 
 
Eculizumab 
binds 
complement 
protein C5 with 
high affinity  
C5 
Eculizumab 
Inhibits the formation of 
C5b-9 (MAC: membrane 
attack complex) which 
forms pores in cell 
membranes compromising 
the cell’s integrity. 
Eculizumab 
Potentially hinders the 
formation of C5a (a potent 
inflammatory mediator) 
which increases vascular 
permeability and attracts 
phagocytes. 
 
 
 
Complement protein 
C1 to C4 
 
The opsonization of 
microorganisms and 
clearance of immune 
complexes remain 
intact. 
Eculizumab 
blocks the 
cleavage by C5 
convertase to 
C5a and C5b 
C5 convertase 


 
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2.2 REFERENCES 
 
1. Kfoury AG, Hammond ME, Snow GL, et al. Cardiovascular mortality among heart transplant recipients 
with asymptomatic antibody mediated or stable mixed cellular and antibody-mediated rejection. J Heart 
Lung Transplant 2009;28:781-84. 
 
2. Uber WE, Self SE, Van Bakel AB, et al. Acute antibody-mediated rejection following heart 
transplantation. Am J Transplant 2007;7: 2064-74. 
 
3. Wu GW, Kobashigawa JA, Fishbein MC, et al. Asymptomatic antibody- 
mediated rejection after heart transplantation predicts poor outcomes. J Heart Lung Transplant 
2009;28:417-22. 
 
4. Michaels PJ, Espejo Ml, Kobashigawa J et al.: Humoral rejection in cardiac transplantation: risk factors, 
hemodynamic consequences and relationship to transplant coronary artery disease. J Heart Lung 
Transplant 22(1), 58-69 (2003). 
 
5. Stegall MD, Diwan T, Raghavaiah S wt al. Terminal Complement Inhibition Decreases Antibody-
Mediated Rejection in Sensitized Renal Transplant Recipients. Am J of Transplant 2011 Sept 22. 
 
6. Nwakanma L, Williams J, Weiss E, Russell S et al. Influence of pretransplant panel-reactive antibody 
on outcomes in 8,160 heart transplant recipients in recent era. Ann Thor Surg 84(5), 1556-1562. 
 
7.Kobashigawa, K; Crespo-Leiro, MG; Ensminger, SM etal. Hermann Reichenspurner, Annalisa Angelini, 
Gerald Berry, Margaret Burke, Lawrence Czer, Nicola Hiemann, Abdallah G. Kfoury, Donna Mancini, Paul 
Mohacsi, Jignesh Patel, Naveen Pereira, Jeffrey L. Platt, Elaine F. Reed, Nancy Reinsmoen, E. Rene 
Rodriguez, Marlene L. Rose, Stuart D. Russell, et al.Report from a consensus conference on antibody-
mediated rejection in heart transplantation. JHLT 2011; 30(3):252-69.  
 
8. Gerald J. Berry, Annalisa Angelini, Margaret M. Burke, Patrick Bruneval, Michael C. Fishbein, Elizabeth 
Hammond, Dylan Miller, Desley Neil, Monica P. Revelo, E. Rene Rodriguez, Susan Stewart, Carmela D. 
Tan, Gayle L. Winters, Jon Kobashigawa, Mandeep R. Mehra; The ISHLT working formulation for 
pathologic diagnosis of antibody-mediated rejection in heart transplantation: Evolution and current status 
(2005–2011)  The Journal of Heart and Lung Transplantation, Volume 30, Issue 6, June 2011, Pages 
601-611 
 
9. Eculizumab: Soliris® [package insert]. Cheshire, CT: Alexion Pharm Inc; 2009 
 
10. Locke JE, Magro CM, Singer AL, Segev DL, Haas M, Hillel AT, et al. The use of antibody to 
complement protein C5 for salvage treatment of severe antibody-mediated rejection. Am J Transplant 
2009 Jan;9(1):231-5. 
 
11. Wang H, Arp J, Liu W, Faas J, et al.  Inhibition of Terminal Complement Components in Presensitized 
Transplant Recipients Prevents Antibody-Mediated Rejection Leading to Long-Term Graft Survival and 
Accommodation. Journal of Immunology 2007, 179, 4451-4463. 
 
12. Thomas TC, Rollins SA, Rother RP et al. Inhibition of Complement by Humanized Single Chain Fv. 
Molecular Immunology 1996; 33: 1389-1401. 
 
13. Rinder CS, Rinder HM, Smith BR et al. Blockade of C5a and C5b-9 generation inhibits leukocyte and 
platelet activation during extracorporeal circulation. J Clin Invest 1995; 96: 1564-1572. 
 


 
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This document contains information which should be kept confidential to those responsible for the organization and execution of this protocol.  
 It is intended ONLY for the use of such persons, and should not be disseminated except with the expressed permission of the investigators. 
 
14. Kobashigawa JA, Katznelson S, Laks H et al. Effect of pravastatin on outcomes after cardiac 
transplantation. NEJM 1995; 333: 621 –627. 
 
15. Fang et al. Effect of vitamins C and E on progression of transplant-associated arteriosclerosis: a 
randomised trial. Lancet. 2002 Mar 30;359(9312):1108-13. 
 
16. Kobashigawa JA, Tobis JM, Starling RC, et al.: Multicenter intravascular ultrasound validation study 
among heart transplant recipients: outcomes after five years. J Am Coll Cardiol 2005;45:1532-7. 
 
 
3.0 TRIAL OBJECTIVES AND PURPOSE 
This investigational pilot trial is being conducted to determine the safety, tolerability and 
efficacy of the de-novo use of eculizumab to prevent AMR Grade ≥ 2 in cardiac 
transplantation recipients in the first year post transplantation. 
 
3.1 PRIMARY OUTCOME MEASURE 
 
Assess the safety, tolerability and efficacy of eculizumab after heart transplantation. 
A. Safety: Incidence of hospitalization due to any intravenously treated infections in the 
1st year 
B. Tolerability: Incidence of patient withdrawal or loss to followup 
C. Efficacy: Assess a composite end-point of: 
 
i) Incidence of pathologic AMR Grade ≥ 2 in the first 26 weeks post heart           
 
transplantation 
 
ii) Incidence of left ventricular dysfunction in the first 26 weeks defined as LVEF≤  
40% or a decrease of >15% from baseline prior to initiation of treatment with 
eculizumab. 
 
 
 
3.2 SECONDARY OUTCOME MEASURE. 
 
• Incidence of HDC: hemodynamic compromise (defined as a decrease in left 
ventricular ejection fraction (LVEF) by 20% from baseline or a LVEF <40%, a 
25% decrease in cardiac index from baseline or a cardiac index < 2.0, and the 
need for inotropic support) at 6 months and 1 year after transplantation 
• Incidence of ACR Grade ≥2R in the first year 
• Patient survival at 12 months post heart transplantation 
• Development of cardiac allograft vasculopathy at 1 year determined by 
intravascular ultrasound defined as change in site-matched maximal intimal 
thickness ≥ 0.5mm from baseline to 1 year. 
• Presence of inflammatory and complement biomarkers at the time of routine 
endomyocardial biopsy for the first year post transplantation. 
• Assess change in PRA from baseline to 1 year after transplantation 
• Assess presence and strength of DSA: donor specific antibody post 
transplantation 


 
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• First year incidence of any treated rejection 
• Number and duration of hospitalizations 
 
4.0 TRIAL DESIGN 
This study is a non-randomized, open-label, investigator-initiated safety and efficacy 
trial investigating the de-novo use of eculizumab alongside conventional therapy to 
prevent antibody mediated rejection. The duration of the study will include an open 
enrollment period and at least 12 months of follow-up (post-transplant). The trial will 
treat a total of 20 sensitized patients with a panel reactive antibody score of ≥70% and 
not previously or currently enrolled in another ongoing trial.  At the time of initial 
baseline screening prior to transplantation, patients willing to consent to the 
investigational use of eculizumab will receive the drug.    
 
4.1 IMMUNOLOGIC RISK FACTOR SURVEILLANCE 
Surveillance during the first year will consist of a minimum of ten right ventricular 
endomyocardial biopsies; performed weekly for the first month after transplantation, 
then biweekly until the third month, monthly until the sixth month, and bimonthly, 
thereafter, until completion of the first year. If a patient is treated for rejection, a follow-
up biopsy will be performed 2 weeks following treatment to document regression or 
resolution of rejection. All biopsy specimens will be graded according to the 
International Society for Heart and Lung Transplantation (ISHLT) 2011 grading 
schemes for both humoral and cellular rejection. Angiograms will be performed at 
baseline (4-8 weeks after transplant and at one year and will include assessment by 
intravascular ultrasound to assess and quantitate intimal thickening.  At the time of 
transplantation and prior to the initiation of any cytolytic therapy a retrospective cross 
match will be sent. Please refer to Appendix D:  Eculizumab Safety Monitoring and 
Evaluation Schedule for additional procedure and trial laboratories. 
 
Alloantibody Serology Assessment  
Alloantibody will be measured using single antigen flow beads (SAFBs, LABscreen, 
One Lambda, Canoga Park, CA) each coated with a specific HLA type (Class I and 
Class II types). Samples will be collected  per standard of care. 
 
 
4.2 TREATMENT SUCCESS 
Success of treatment will occur if safety, tolerability, and efficacy (a decreased 
incidence of AMR Grade ≥2 in eculizumab treated patients) is demonstrated. 
4.3 SAMPLE SIZE AND POWER  
This is a small scale preliminary trial which will enroll a total of up to 20 patients. This 
pilot trial is not meant to be nor will it be expected to achieve sample population power. 
The necessary sample size to achieve power and test the hypothesis that eculizumab 
reduces the incidence of rejection is not feasible as a single center study. Analyses from 
this single center study will be descriptive. 


 
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4.4  Demographic Data 
Demographic data will include age (donor and recipient), race, sex, cytomegalovirus 
(CMV) seropositivity, whether the etiology of the recipients heart failure was due to 
ischemic cardiomyopathy or not, positive peri-operative T or B cell flow cytometry and 
complement dependent cytotoxicity crossmatch, and ischemic time; these data will be 
presented in the following manner: continuous data (i.e., age, ischemic time) will be 
summarized descriptively by mean, standard deviation, median, and range. Categorical 
data (i.e., sex, CMV seropositivity, positive peri-operative T or B cell flow cytometry and 
complement dependent cytotoxicity positive crossmatch, whether the etiology of the 
recipients heart failure was ischemic or not, and race) will be presented as 
enumerations and percentages.  
 
. 
 
5.0 PATIENT SELECTION  
All patients worked up for a heart transplant at the Heart Institute at Cedars-Sinai 
Medical Center (CSMC) with a panel reactive antibody (PRA) ≥ 70% at any time prior to 
screening. 
5.1 INCLUSION CRITERIA 
Each patient must meet all of the following inclusion criteria to be enrolled in the study: 
• Patient is greater than or equal to 18 years of age 
• Patient with a panel reactive antibody (PRA) ≥ 70% at any time prior to screening 
• Patient is considered compliant and intends to be available for at a minimum follow-
up study period of 1 year 
• Patient must be vaccinated against Neisseria meningitides at least 2 weeks prior to 
receiving treatment therapy 
• Voluntary written informed consent is obtained before performance of any study-
related procedure not considered routine medical care, with the understanding that 
consent may be withdrawn by the subject at any time without prejudice to future 
medical care 
• Female subject is either post-menopausal or surgically sterilized or willing to use two 
acceptable methods of birth control (i.e., a hormonal contraceptive, intra-uterine 
device, diaphragm with spermicide, condom with spermicide, or abstinence) for the 
duration of the study and for up to 2 months after the last dose of study medication 
 
5.2 EXCLUSION CRITERIA 
Patients meeting any of the following exclusion criteria are not to be enrolled in the 
study: 


 
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• Donor or recipient age < 18 years or > 75 years 
• Cold ischemia time > 6 hours 
• Patient at risk for tuberculosis (TB):  
o Current clinical, radiographic, or laboratory evidence of active or latent TB as 
determined by local standard of care 
o History of active TB: 
▪ Within the last 2 years, even if treated 
▪ Greater than 2 years ago, unless there is documentation of adequate 
treatment according to locally accepted clinical practice 
o Patient at risk of reactivation of TB precludes administration of conventional 
immunosuppression (as determined by investigator and based upon 
appropriate evaluation) 
• Receipt of desensitization treatment with rituximab less than 1 week prior to therapy  
• Receipt of a live vaccine within 4 weeks prior to study entry 
• Patients with current or recent severe systemic infections within the 2 weeks prior to 
transplantation. Patients must be cleared by the heart transplant team in conjunction 
with the infectious diseases specialists 
• Prior history of splenectomy 
 
5.3 SUBJECT IDENTIFICATION 
After signing the informed consent form, the subject will be identified by a subject 
identification number. 
 
5.4 DEMOGRAPHIC  
Summary descriptive statistics for baseline and demographic characteristics will be 
provided for all enrolled participants. Demographic data will include age, race, sex, body 
weight, and height; these data will be presented in the following manner: continuous 
data (i.e., age, body weight, and height) will be summarized descriptively by mean, 
standard deviation, median, and range. Categorical data (i.e., sex and race) will be 
presented as enumerations and percentages. 
 
5.5 MEDICAL HISTORY 
Medical history will be collected, including the existence of current signs and symptoms 
and clinical significance for each body system. The etiology of each recipient’s pre-
transplant heart failure will be further enumerated by statistical analysis. 
 
5.6 WITHDRAWAL OF SUBJECTS FROM STUDY 
Subjects may be withdrawn from the study for the following reasons (At their own 
request or at the request of their legally acceptable representative): 
• At any time during the study and without giving reasons, a subject may decline to 
participate further. The subject will not suffer any disadvantage as a result 
• If, in the investigator’s opinion, continuation of the study would be harmful to the 
subject’s well-being  


 
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• Occurrence of adverse drug reactions that from the investigator’s point of view have 
a negative impact on the subject’s health or well-being  
• If the subject becomes pregnant 
• If the subject is noncompliant with the protocol or instructions given by the 
investigator 
• If the sponsor stops the study 
 
If a study subject decides to discontinue participation prematurely for any reason the 
subject will not require a study related termination visit and will no longer be seen for 
any study-related follow-up or procedure; including study clinical assessments, study 
laboratory assessments, or study therapy. No data will be further submitted on any 
study subject after the date of termination with the exception of pregnancy. If the reason 
for discontinuation is pregnancy, then additional data regarding outcome of pregnancy 
and status of newborn data will be collected 
 
Additionally, subjects maybe terminated due to one of the following: 
1. The subject elects to withdraw consent from all future study activities, including 
follow-up. 
2. The subject is lost to follow-up. 
3. The subject dies. 
 
6.0 THERAPEUTIC PROTOCOL DESIGN 
This study is a non-randomized, open-label, investigator-initiated safety and efficacy 
trial investigating the de-novo use of eculizumab alongside conventional maintenance 
therapy to prevent rejection. The duration of the study will include an open enrollment 
period and at least 12 months of follow-up (post-transplant). The trial will enroll a total of 
up to 20 sensitized patients with a panel reactive antibody score of ≥70% and not 
previously or currently enrolled in another ongoing trial.  At the time of initial baseline 
screening prior to transplantation, patient’s willing to consent to the investigational use 
of eculizumab will be enrolled..  
 
6.1 DOSAGE, ADMINISTRATION, AND PHARMACOKINETICS 
At the time of transplantation the patient will receive 1200 mg of eculizumab via a 35 
minute peripheral IV(IVBP) infusion 35 minutes prior to release of the recipient’s cross 
clamp (immediately prior to reperfusion) followed by thymoglobulin 1.5 mg/kg IVPB.  
The thymoglobulin will be repeated (if blood counts permit) for a total of five doses.  On 
Day 1, 900 mg of eculizumab will be repeated.  On Day 5, the patient will receive IVIG 1 
gram/kg daily x 2 Days.  On post-operative day 7, 14, 21 +/- 2 days eculizumab (900 
mg) will be repeated.  On days 28, 42, and 56 +/- 2 days the patient will receive 1200 
mg of eculizumab as a 35 minute infusion at each scheduled visit. 
 
 
Terminal 
 


 
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Complement 
Inhibition 
Protocol 
(N=20) 
 
Assigned Medication Interventions 
 
 
Vaccination:  
Meningococcal Vaccine 0.5 mg SQ x1 (2 weeks to 5 years prior to transplant) 
 
Initial Therapy: 
Each dose of eculizumab as an IVPB over 35 minutes. 
 
Day 0:                       1200 mg (Administered prior to cross-clamp (or reperfusion) at 
the time of cardiac transplantation) 
Day 1:                        900 mg  
Day 7   +/- 2 days:     900 mg 
Day 14 +/- 2 days:     900 mg  
Day 21 +/- 2 days:     900 mg  
 
Maintenance Therapy:  
Each dose of eculizumab as an IVPB over 35 minutes. 
 
Day 28 +/- 2 days:           1200 mg 
Day 42 +/- 2 days:          1200 mg 
Day 56 +/- 2 days           1200 mg 
Day 60-360                     900 mg (Treatment Modification: defined below*) 
 
The dosage, administration, and pharmacokinetics as described above is part of 
standard of care and serves as a guideline only.  
 
6.2 TREATMENT MODIFICATION 
*If the patient receives any additional plasmapheresis or fresh frozen plasma within the 
first year post-transplantation, 900 mg of eculizumab will be provided as a infusion 
immediately afterwards. (Note: this contingent dose was placed on the Eculizumab 
Safety Monitoring and Evaluation Schedule: Appendix D) on Day 180 but applies to day 
60-360 post transplant in a contingent fashion)   
 
6.3 INVESTIGATIONAL PRODUCT IDENTITY 
Eculizumab is a monoclonal antibody that binds with high affinity to compliment protein 
C5, which inhibits its cleavage to C5a and C5b and prevents the generation of the 
terminal complement complex C5b-9. In patients with paroxysmal nocturnal 
hemoglobinuria (PNH), eculizumab is FDA approved to inhibit terminal complement 
mediated intravascular hemolysis.  Eculizumab is a FDA Pregnancy Category C agent.  
Patients must be administered a meningococcal vaccine at least two weeks prior to 


 
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 It is intended ONLY for the use of such persons, and should not be disseminated except with the expressed permission of the investigators. 
 
initiation of eculizumab therapy. It is a contraindication to provide any patient 
eculizumab with an unresolved Neisseria meningitides or pneumococcus infection.  
 
Eculizumab is supplied as an intravenous solution supplied as 300 mg in a 30 ml vial. 
The dose will require dilution to a final concentration of 5 mg/mL by adding appropriate 
amounts D5W to a final infusion volume is 120 mL for 600 mg doses and 180 mL for 
900 mg doses.  Admixed solutions are stable for 24 hours at 2 to 8 degrees Celsius (36 
to 46 degrees Fahrenheit) and at room temperature.  Each dose will be administered via 
IV infusion over 35 minutes via gravity feed, a single-type pump, or an infusion pump; 
total infusion time should not exceed 2 hours. Doses should not be administered by IV 
push or IV bolus injection. 
 
   6.4 ADVERSE EVENTS  
Possible adverse events with eculizumab include: gastrointestinal: nausea (16%, 
musculoskeletal: Backache (19%), neurologic: headache (44% ), respiratory: cough 
(12% ), nasopharyngitis (23% ), other: fatigue (12% ), immunologic: viral disease (2% )9.  
Patients will be instructed to report signs/symptoms of meningococcal infection (e.g.: 
fever of 103 degrees F (39.4 degrees C) or higher; severe muscle aches with flu-like 
symptoms, and eyes sensitive to light; fever and a rash; confusion; or moderate to 
severe headache with nausea and vomiting, fever, or stiff neck or back) with the 
transplant study investigators.  
 
7.0 IMMUNOSUPPRESSION+ DESENSITIZATION PRE + POST TRANSPLANT 
 
Records of all desensitization will be recorded. 
 
Pre-Transplantation:  
Patients may receive antibody reduction therapies (with high dose IVIG and rituximab, 
and/ or bortezomib desensitization) prior to transplantation in an attempt to decrease 
the PRA. While awaiting transplantation a PRA and subsequent cPRA are performed on 
a monthly basis. Patients will not be eligible for eculizumab therapy less than one week 
of completing of rituxumab desensitization therapy and CD20 count >2%. 
 
Sandwiched Desensitization: HD (high dose) IVIG-Rituxan-Rituxan- HD IVIG:  
(Reference: Jordan, S et al. Current approaches to treatment of antibody-mediated 
rejection. Pediatric Transplantation Volume 9, Issue 3, pages 408–415, June 2005 ) 
Pre-transplant each patient with a calculated PRA ≥ 70% and stable outside the hospital 
awaiting or being worked up for transplantation will receiveup to 3 cycles of IVIG-
Rituxan-IVIG.  Human polyclonal intravenous immune globulin (Gamunex 10% 2 g per 
kilogram of ideal body weight (up to a maximum of 140 grams) will be administered over 
2 days on day 0, 1 and day 30,31 of therapy. On day 7 and 22, rituximab 1gram or 375 
mg/m2 (if the patient is < or = 50 kg) will be administered. To reduce the frequency of 
infusion-related side effects, 30 to 60 minutes before scheduled infusions of intravenous 


 
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 It is intended ONLY for the use of such persons, and should not be disseminated except with the expressed permission of the investigators. 
 
immune globulin or rituximab, all patients were given intravenous methylprednisolone 
(40-100 mg), oral acetaminophen (650 mg), and oral diphenhydramine (50 mg). Flow 
PRAs are sent at baseline, day 22 and day 44 of therapy. 
 
Bortezomib Desensitization: (Reference: Patel J, Everly M, Chang D, Kittleson M, 
Reed E, Kobashigawa J: Reduction of alloantibodies via proteosome inhibition in 
cardiac transplantation. J Heart Lung Transplant 2011;30:1320-6.) Pre-transplant each 
patient with a calculated PRA > 70% and in the hospital awaiting listing or 
transplantation (ie: UNOS listed 1A status) will receive up to 3 cycles of bortezomib 1.3 
mg/m2 via IV push over 3-5 seconds on a day 2, 5, 8, and 11 schedule with a 10 day 
rest period. Plasmapheresis will be given on days 1 and 2, 4 and 5, 7 and 8 and 10 and 
11 of each cycle pre-transplant to speed up antibody removal from circulation. On 
plasmapheresis days the bortezomib dose is to be administered after plasmapheresis. If 
not taken for transplantation sooner, a maximum of 3 pre-transplant cycles of 
bortezomib/plasmapheresis may be given to achieve a PRA <50% If platelet count ≤30 
×0109/L or ANC ≤0.75 x 109/L on a bortezomib dosing day (other than day 1) the dose 
will be held until If platelet count >30 ×0109/L or ANC >0.75. Flow PRA are sent at 
baseline and day 18 of therapy.  Patients refractory to IVIG-Rituximab or UNOS listed 
Status 1A patients with a calculated PRA ≥ 50% requiring desensitization will be 
considered for bortezomib therapy. 
 
Post-Transplantation:  
Induction therapy will include up to five days of rabbit antithymocyte globulin 
(Thymoglobulin®).  Maintenance immunosuppression therapy will include  tacrolimus, 
mycophenolate mofetil, and prednisone. Patients with evidence of post-transplant 
rejection (ACR≥2R or AMR≥2 will be transitioned from mycophenolate to either 
sirolimus or everolimus at 3-6 months after transplant. 
 
Thymoglobulin®  
Doses of Thymoglobulin® will be given as part of the post-transplant protocol. 
Specifically, a dose of 1.5 mg/kg/dose intravenously over 6 hours will be given on post-
operative days 0, 1, 2, 3 and 4,.  If the patient develops hematologic toxicity, dose 
adjustments will occur as below.  
 
Dose Adjustment for Thymoglobulin®  
WBC> 3000 /mm3 or Platelets > 75,000 cells/µL 
NO Change 
WBC 2000 - 3000/mm3 or Platelets ≤ 75,000 cells/µL 
Reduce dose of 
Thymoglobulin® by 50% 
WBC ≤ 2000/mm3or Platelets ≤ 50,000 cells/µL 
Hold dose 
 
 
Tacrolimus  
Tacrolimus will be initiated immediately postoperatively at 0.5 mg naso-gastrically or by 
mouth (if tolerating) twice a day and titrated upwards to achieve the following trough 


 
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goals. 
Month 1: 10-15 ng/ml 
Month 2-3: 8-12 ng/ml 
Month 4 and onward: 5-10 ng/ml 
Rejection: 8-12 ng/ml 
Trough levels will be checked daily in house while hospitalized and routinely with every 
scheduled clinic and EMB visit for life long management. This frequent monitoring of 
therapeutic blood levels will be used as a surrogate marker for compliance. 
 
Mycophenolate Mofetil  
All patients will be initiated on mycophenolate mofetil (MMF) 1500 mg IVPB Q12H 
immediately post-operatively. When the patient tolerates orals, the same dose will be 
provided by mouth. Doses will we adjusted for gastrointestinal tolerance, infection, and 
bone marrow suppression (see below) if necessary. Goal MPA levels are to be 1.5 to 4 
ng/ml.  
 
Dose Adjustment for Mycophenolate 
WBC cells/µL 
Reduction in current MMF dose 
>2000 cells/µL  
None 
< 2000 and ANC > 1000 cells/µL 
Decrease current dose by 50% 
< 2000 with ANC < 1000 cells/µL 
Hold until ANC > 1000 cells/µL, G-CSF may 
be administered per physician discretion; 
Once ANC > 1000 cells/ µL, restart MMF at 
30-50% lower dose 
 
 
Corticosteroids: Prednisone 
At cross clamp the patient will receive 500 mg of methylprednisolone. When the patient 
enters the ICU the patient will receive an additional 500 mg of methylprednisolone as a 
continuous infusion over 24 hours. Subsequently, the patient will receive 100mg of 
methylprednisolone daily x 3 days as a pre-medication for Thymoglobulin® and then 40 
mg IVP daily as a pre-medication for IVIG. On post-operative day 3, if the patient is 
tolerating orals, the patient will transition to an oral steroid taper as follows: (Note if the 
patient does not tolerate orals, an equivalent dose of methylprednisolone will be 
provided IV.) 
Prednisone 40mg bid x 1 day (2 doses) 
Prednisone 35mg bid x 1 day (2 doses) 
Prednisone 30mg bid x 1 day (2 doses) 
Prednisone 25mg bid x 1 day (2 doses) 
Prednisone 20mg bid x 1 day (2 doses) 
Prednisone 15mg bid x 1 day (2 doses) 
Prednisone: 10 mg BID until 1 month post-transplant 
At 1 month: taper by 1 mg q2wks so patients go from 10 BID to 10 QD by month 3 
At 3 months: taper by 1 mg q2wks so patients go from 10 QD to 5 QD by month 6 


 
P a g e  | 17 
 
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The immunosuppression + desensitization pre + post transplant as described above is 
part of standard of care and serves as a guideline only.  
 
8.0 TREATMENT OF REJECTION 
Cellular Rejection: 
Grade 1R biopsy results does not require treatment. 
 
Grade 2R-3A rejection: Asymptomatic: Pt. will be treated with a steroid pulse as 
follows: 
Prednisone 50mg bid x 3days 
Prednisone 40mg bid x 1 day 
Prednisone 30mg bid x 1day 
Prednisone 25mg bid x 1day 
Prednisone 20mg bid x 1 day 
Prednisone 15mg bid x 1day 
Prednisone 10mg bid x 1day 
Prednisone 10mg qd until further notice 
Repeat Biopsy in 2 weeks. 
 
Switch mycophenolate to either sirolimus (target trough 4-8 ng/ml) or everolimus (target 
trough 3-5 ng/ml) 
 
Grade 2R-3A; Symptomatic Rejection:  
Hemodynamic compromise (decreased LVEF <40% or CI<2.0) Start IV solumedrol 
500mg QD x 3days.  
Start rATG 1.5mg/kg x 5-7days.  
Consider plasmapheresis for 3-5 days.  
After completion of rATG, patients will begin prednisone bolus and taper as follows: 
Prednisone 50mg bid x 1day 
Prednisone 40mg bid x 1 day 
Prednisone 30mg bid x 1day 
Prednisone 25mg bid x 1day 
Prednisone 20mg bid x 1 day 
Prednisone 15mg bid x 1day 
Prednisone 10mg bid x 1day 
Prednisone 10mg qd until further notice 
 
Antibody-Mediated Rejection:. 
 
For asymptomatic AMR (AMR≥2) with preserved left ventricular function and 
hemodynamics, patients will receive oral prednisone bolus and taper. 
 


 
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For symptomatic patients (AMR≥2) with LVEF≤40% patients will be treated as per 
Grade 2R-3A above with the addition of IVIG after completion of ATG and 
plasmapheresis (if utilized). 
 
If hemodynamic compromise is present follow above treatment for symptomatic 2R-3A 
rejection but all patients with receive plasmapheresis followed sucrose-free IVIG 
(Gammunex® 10%) 1 gm/kg x 2days in a row.  
 
Switch mycophenolate to either sirolimus (target trough 4-8 ng/ml) or everolimus (target 
trough 3-5 ng/ml) 
 
The treatment of rejection as described above is part of standard of care and serves as 
a guideline only.  
 
9.0 PROPHYLACTIC MEDICATION 
 
1. Antipneumocystic: PCP Prophylaxis: 
Bactrim SS 1 tab Qday on Mon, Wed, Fri for 1 year.  
 
If sulfa allergic: Check G6PD. If no issues, start Dapsone 100mg Qday for 1 year.  
 
If the patient has a G6P deficiency, then Mepron 1500mg Qday will be prescribed for 
1 year.   
 
2. Antiviral: CMV Prophylaxis 
A. Recipient Negative/Donor Negative 
Acyclovir 800mg PO bid for 6months. 
 
B. Recipient Positive/Donor Positive or Recipient Pos/Donor Negative:  
Valcyte 450mg PO bid for 6 months 
 
C. Recipient Negative/Donor Positive 
Valcyte 450mg PO bid for 12months  
 
3. Anti-fungal: Thrush Prophylaxis 
Mycelex troche 10mg PO BID for a 3month duration.  
 
Note: For rejection episodes/steroid bolus, all prophylaxis will be restarted for 3 
months. 
 
4. Chronic Allograft Vasculopathy Prophylaxis: 
A. Statin Therapy: Pravastatin: Pravachol® 20 mg PO QHS will be initiated 
immediately after transplantation if liver function tests (LFTs) are within 


 
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]normal limits. If LFTs are elevated the statin will be held until resolution of 
liver function is achieved. Treatment will be lifelong. Reference: [Reference 
(11): Kobashigawa JA, Katznelson S, Laks H et al. Effect of pravastatin on outcomes after cardiac 
transplantation. NEJM 1995; 333: 621 –627] 
 
B. Vitamin Supplementation: Vitamin C 500 mg PO BID and Vitamin E 400 
Units PO BID will be initiated one week post transplantation. Treatment 
will be lifelong. [Reference(12): Fang et al. Effect of vitamins C and E on progression of transplant-
associated arteriosclerosis: a randomised trial. Lancet. 2002 Mar 30;359(9312):1108-13.] 
 
Anitiplatelet Therapy: Baby aspirin 81 mg PO Qday will be initated one week post 
transplantion after the pacing wires have been pulled. Treatment will be lifelong. 
 
The prophylactic medication as described above is part of standard of care and serves 
as a guideline only.  
 
 
10.0 SAFETY MONITORING AND EVALUATION SCHEDULE 
 
Eculizumab will be administered only to eligible patients under the supervision of the 
investigator or identified sub-investigator(s).  Patients may be treated on an out-patient 
basis, if possible.   
 
The pharmacist will prepare the drug under aseptic conditions.  The amount (in mg) of 
drug to be administered will be determined based time since transplantation.   
Day 0:                        1200 mg  
Day 1:                        900 mg  
Day 7   +/- 2 days:   900 mg 
Day 14 +/- 2 days:   900 mg  
Day 21 +/- 2 days:   900 mg  
Day 28 +/- 2 days:   1200 mg 
Day 42 +/- 2 days:   1200 mg 
Day 56 +/- 2 days    1200 mg 
 
The appropriate amount of Eculizumab will be drawn from the indicated number of 
injection vial (300 mg/30 ml) and administered as an intravenous infusion over 30 
minutes followed by a standard saline flush.  Each 300 mg/30 ml of eculizumab are for 
single use administration.   
 
Before each drug Eculizumab dose, the patient will be evaluated for possible toxicities 
that may have occurred after the previous dose(s).   
 


 
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Toxicities are to be assessed according to the NCI Common Terminology Criteria for 
Adverse Events (CTCAE), Version 3.0.See Appendix A: Eculizumab Constitutional 
Symptoms Adverse Drug Event Evaluation 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/docs/ctcaev3.pdf  
 
Adverse Event Definitions 
An adverse event (AE) is any untoward medical occurrence in a patient administered a 
pharmaceutical product, which does not necessarily have a causal relationship with the 
treatment.  An adverse event can be any unfavorable and unintended sign (eg, 
including an abnormal laboratory finding), symptom, or disease temporally associated 
with the use of the drug, whether or not it is considered to be drug related.  This 
includes any newly occurring event or previous condition that has increased in severity 
or frequency since the administration of drug. 
 
Serious Adverse Event Definition 
A serious adverse event (SAE) is any adverse event, occurring at any dose and 
regardless of causality that: 
• Results in death. 
• Is life-threatening.  Life-threatening means that the patient was at immediate 
risk of death from the reaction as it occurred, i.e., it does not include a reaction 
which hypothetically might have caused death had it occurred in a more severe 
form. 
• Requires inpatient hospitalization or prolongation of existing hospitalization.  
Hospitalization admissions and/or surgical operations scheduled to occur during 
the study period, but planned prior to study entry are not considered AEs if the 
illness or disease existed before the patient was enrolled in the trial, provided 
that it did not deteriorate in an unexpected manner during the trial (e.g., surgery 
performed earlier than planned). 
• Results in persistent or significant disability/incapacity.  Disability is defined 
as a substantial disruption of a persons’ ability to conduct normal life functions. 
• Is a congenital anomaly/birth defect. 
• Is an important medical event.  An important medical event is an event that 
may not result in death, be life-threatening, or require hospitalization but may be 
considered an SAE when, based upon appropriate medical judgment, it may 
jeopardize the patient or subject and may require medical or surgical intervention 
to prevent one of the outcomes listed in the definitions for SAEs.  Examples of 
such medical events include allergic bronchospasm requiring intensive treatment 
in an emergency room or at home, blood dyscrasias or convulsions that do not 
result in inpatient hospitalization, or the development of drug dependency or drug 
abuse.   
 


 
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All AEs will be assessed and documented by the investigator according to the 
categories detailed below. 
 
Seriousness  
 
For each AE, the seriousness must be determined. 
 
Intensity  
 
The intensity of an AE should be classified as either mild, moderate, or severe. 
 
Casual Relationship  
 
The assessment of the casual relationship between an AE and the administration of 
treatment is a clinical decision based on all available information at the time of the 
event. The assessment is based on the question whether there was a “reasonable 
casual relationship” to the study treatment in question. Possible answers are “yes” or 
“no.” 
 
The assessment of a possible casual relationship between the AE and protocol-required 
procedure(s) is based on the question whether there was a “reasonable casual 
relationship” to protocol-required procedure(s). Possible answers are “yes” or “no.” 
 
Action taken with study treatment 
 
Any action on study treatment (Eculizumab) to resolve the AE is to be documented 
using the categories listed below. 
  
- Drug interrupted 
- Drug discontinued 
 
Outcome 
 
- Recovered/resolved 
- Recovering/resolving 
- Recovered/resolved with sequelae 
- Not recovered/not resolved 
- Fatal 
- Unknown 
 
Assessments and documentation of adverse events 
 
AEs (including SAEs) observed, volunteered, and solicited will be recorded. AEs will be 
documented event-based, with change documentation in cases of increases in intensity. 


 
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All AEs occurring from the time the subject signed informed consent and 30 days after 
the subject has completed the study will be documented on the subject’s record.  
 
All documented AEs will be followed up until an outcome has been reported or until at 
least 30 days after the subject has completed the study.  
 
Reporting of serious adverse events 
 
The investigator will be responsible for reporting relevant SAEs to the IRB. Pregnancies 
will be immediately reported to the IRB although a pregnancy will not be considered an 
SAE. The pregnancy will be followed and the outcome reported, including the status of 
the new born. For the pregnancy of a study subject’s partner, all efforts should be made 
to obtain similar information on course and outcome, subject to the partner’s consent. 
 
Monitoring of adverse events 
 
Life threatening complications following study drug administration will be reported to the 
Independent Medical Monitor within 15 calendar days and deaths within 7 calendar 
days. Serious and unexpected adverse events following study drug administration will 
be submitted as expedited reports to the monitor on a quarterly basis. 
 
Throughout the study, the Independent Medical Monitor will review safety data on a 
quarterly basis unless it is an adverse event that requires expedited report. Reports will 
be submitted to the IRB biannually. 
 


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11.0 CLINICAL AND LABORATORY ASSESMENTS 
 
Laboratory assessments 
Laboratory evaluations will be performed at certified laboratories according to the study 
schedule.  Required tests are specified in the study flow/budget chart. Please refer to 
Appendix D:  Eculizumab: Safety Monitoring and Evaluation Schedule for 
additional procedure and trial laboratories. 
 
 
Clinical assessments 
All patients will undergo clinical evaluation by the investigator or investigator's designee 
at times specified on the study flow-charts. Please refer to Appendix D:  Eculizumab 
Time Schedule and Budget for additional procedure and trial laboratories. 
Clinical evaluations will include assessments of sitting blood pressure, patient weight 
changes, serious adverse events, study drug doses, allograft rejection, infection, need 
for dialysis, hospitalizations, re-transplant status, and other immunosuppressive 
medications. 
 
 
Serious Infection is defined as any of the following: 
• Treatment with an INTRAVENOUS antimicrobial agent for a specific clinical 
syndrome (not prophylaxis) 
• Positive cultures, pathologic identification of microbial agents, or significant 
serologic changes related to clinical symptoms 
• Typical clinical presentation documented by investigator or appropriate 
consultant. 
 
 
 
12.0 DRUG ACCOUNTABILITY 
No study drug will be administered to subjects before approval is received from the 
institutional review board (IRB). 
 
All study drugs will be stored at the Research Pharmacy at Cedars-Sinai Medical Center 
in accordance with applicable regulatory requirements and the instructions given by the 
manufacturer providing the study drug. Study drugs will be inaccessible to unauthorized 
personnel. All study medication will be dispensed by the research pharmacist.   
 
13.0 DATA HANDLING AND QUALITY ASSURANCE 
Data will be recorded onto case report forms using source documentation available at 
the study site.  
 
Data Processing 
Subject data necessary for analysis and reporting will be entered or transmitted into a 
validated database or data system.  


 
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14.0 ETHICS 
The procedures set out in this protocol, pertaining to the conduct, evaluation, and 
documentation of this study, are designed to ensure that the investigator abide by Good 
Clinical Practice (GCP) guidelines and under the guiding principles detailed in the 
Declaration of Helsinki. The study will also be carried out in keeping with application 
local laws and regulations.  
 
Documented approval from the IRB will be obtained before the start of the study, 
according to GCP, local laws, and regulations. When necessary, an extension, 
amendment or renewal of IRB approval must be obtained. The IRB is organized and 
operates according to GCP and applicable laws and regulations. 
 
Strict adherence to all specifications outlined in this protocol is required for all aspects of 
study conduct. 
 
The investigator may implement a deviation from, or a change of, the protocol to 
eliminate an immediate hazard(s) to the trial subjects without IRB approval. As soon as 
possible, the implemented deviation or change, should be reported to the IRB. Any 
deviations from the protocol must be explained and documented by the investigator. 
 
Subject information and consent 
All relevant information on the study will be summarized in informed consent form. The 
investigator will explain all relevant aspects of the study to each subject prior to his/her 
entry into the study (i.e. before any examinations and procedures associated with the 
selection for the study are performed or any study-specific data is recorded on study-
specific forms). 
 
The investigator will also mention that written approval of the IRB has been obtained. 
Each subject will have ample time and opportunity to ask questions and will be informed 
about the right to withdraw from the study at any time without any disadvantage and 
without having to provide reasons for this decision. Only if the subject voluntarily agrees 
to sign the informed consent form and has done so, may he/she enter the study. 
Additionally, the investigator will personally sign and date the form. The subject will 
receive a copy of the signed and dated form. 
 
The signed informed consent statement is to remain in the subject’s research chart. 
The informed consent form and any other written information provided to subjects will 
be revised whenever important new information becomes available that may be relevant 
to the subject’s consent, or there is an amendment to the protocol that necessitates a 
change to the content of the subject information and/or the written informed consent 
form. The investigator will inform the subject of changes in a timely manner and will ask 


 
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the subject to confirm his/her participation in the study by signing the revised informed 
consent form. Any revised written informed consent form and written information must 
receive the IRB’s approval prior to use.  
 
15.0 CONFIDENTIALITY 
All records identifying the subject will be kept confidential and, to the extent permitted by 
the applicable laws and/or regulations, will not be made publicly available. Only the 
subject number will be recorded. As part of the informed consent process, the subjects 
will be informed in writing that representatives of the IRB or regulatory authorities may 
inspect their medical records to verify the information collected, and that all personal 
information made available for inspection will be handled in strictest confidence and in 
accordance with local data protection laws. If the results of the study are published, the 
subject’s identity will remain confidential. 
The investigator will maintain a list to enable subjects to be identified.


 
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APPENDIX A:  
 
ECULIZUMAB CONSTITUTIONAL SYMPTOMS /ADVERSE EVENT 
QUESTIONAIRE 
 
 
 
Please circle or mark one number per line to indicate your response as it applies. 
 
The day after my last infusion of 
eculizumab 
Not at 
all 
A little 
bit 
Some-
what 
Quite 
a bit 
Very 
much 
I  had a headache 
0 
1 
2 
3 
4 
I  had a runny nose 
0 
1 
2 
3 
4 
I had some nausea  
0 
1 
2 
3 
4 
I was very tired 
0 
1 
2 
3 
4 
 
 
Add values for each row for a total score _____/16 
 


 
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APPENDIX B: 
 
INVESTIGATIONAL MEDICATION BROCHURE 
eculizumab injection  
Alexion Pharmaceuticals 
_______________________________________ 
Read the Medication Guide before you start eculizumab and before each dose 
(infusion). This Medication Guide does not take the place of talking with your doctor 
about your condition or your treatment. Talk to your doctor if you have any questions 
about your treatment with eculizumab.  
What Is The Most Important Information I Should Know About eculizumab? 
Eculizumab is a medicine that affects your immune system. Eculizumab can lower the 
ability of your immune system to fight infections. 
• Eculizumab increases your chance of getting serious and life-threatening 
meningococcal infections. 
1. You must receive a meningococcal vaccine at least 2 weeks before your first 
dose of eculizumab  
2. unless you have already had this vaccine.  
3. If you had a meningococcal vaccine in the past, you might need a booster dose 
before starting eculizumab. Your doctor will decide if you need another dose of a 
meningococcal vaccine.  
4. A meningococcal vaccine does not prevent all meningococcal infections. You 
must be aware of the following signs and symptoms of a meningococcal 
infection:  
o moderate to severe headache with nausea or vomiting  
o moderate to severe headache and a fever  
o moderate to severe headache with a stiff neck or stiff back  
o fever of 103° F (39.4° C) or higher  
o fever and a rash  
o confusion  
o severe muscle aches with flu-like symptoms, and eyes sensitive to light  


 
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This document contains information which should be kept confidential to those responsible for the organization and execution of this protocol.  
 It is intended ONLY for the use of such persons, and should not be disseminated except with the expressed permission of the investigators. 
 
Call your doctor or get emergency medical care right away if you have any of these 
symptoms. 
What Is Eculizumab? 
Eculizumab is a medicine called a monoclonal antibody. Eculizumab is FDA Approved 
for the treatment of patients with a disease that affects red blood cells called 
Paroxysmal Nocturnal Hemoglobinuria (PNH). You are receiving this medication as an 
investigational therapy to prevent organ rejection.  
Eculizumab works by blocking part of your immune system. This can possibly reduce 
the risk of rejection but it can also increase your chance for infection. It is important that 
you: 
Who Should Not Receive Eculizumab? 
Do not receive Eculizumab if you: 
• 
have a meningococcal infection  
• 
have not been vaccinated with, or you are not up-to-date with a meningococcal 
vaccine. Note: Your doctor will vaccinate you before you begin the study. 
Tell your doctor if you: 
• 
have an infection or fever  
• 
are pregnant, become pregnant, or are breastfeeding. Eculizumab has not been 
studied in pregnant or nursing women.  
How Do I Receive Eculizumab? 
• 
Eculizumab is given through a vein (I.V. infusion) over 35 minutes.  
• 
You will most likely receive 8 eculizumab infusions on approximately 
0,1,7,14,21,28,42,56  days post transplant. 
• 
Following each infusion, you may be monitored for up to one hour afterwards for 
allergic reactions.  
What If I Miss a Dose or Stop Eculizumab Treatment? 
• 
If you forget or miss a Soliris infusion, call your doctor right away.  
• 
Stopping treatment with Soliris may interfere with the medications efficacy to 
reduce graft rejection.  
What Are The Possible Side Effects With Eculizumab? 


 
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This document contains information which should be kept confidential to those responsible for the organization and execution of this protocol.  
 It is intended ONLY for the use of such persons, and should not be disseminated except with the expressed permission of the investigators. 
 
Serious side effects with Eculizumab include: 
• 
Serious and life-threatening infections. See “What is the most important 
information I should know about Eculizumab?”  
Common side effects with Eculizumab include: 
• 
headaches  
• 
runny nose and colds  
• 
sore throat  
• 
back pain  
• 
nausea  
Call your doctor if you have any of these side effects. These are not all the side effects 
with Soliris. Ask your doctor for more information.  
General Information About Eculizumab 
Medicines are sometimes prescribed for conditions other than those listed in a 
Medication Guide. If you have any concerns about Eculizumab, ask your doctor. Your 
doctor or pharmacist can give you information about Eculizumab that was written for 
health care professionals.  
Medication contains Eculizumab in a solution of water, polysorbate, sodium phosphate 
and sodium chloride. 
Manufactured by Alexion Pharmaceuticals, Inc., 352 Knotter Drive, Cheshire, CT 06410 
USA. 


 
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This document contains information which should be kept confidential to those responsible for the organization and execution of this protocol.  
 It is intended ONLY for the use of such persons, and should not be disseminated except with the expressed permission of the investigators. 
 
APPENDIX C: ISHLT GRADING OF ACUTE CELLULAR AND ANTIBODY 
MEDIATED REJECTION ON ENDOMYOCARDIAL BIOPSY 
 
 
ISHLT: Working Formulation classification: ACUTE CELLULAR REJECTION  
 
2004 ISHLT 
Nomenclature 
Grade 
1990 ISHLT 
Nomenclature 
Grade 
Histopathological Description after EMB for 
ACUTE CELLULAR REJECTION 
OR  
 0  
No cellular rejection 
1R 
1A 
Mild focal lymphocytic infiltrate without myocyte 
injury 
1R 
1B 
Mild diffuse but sparse infiltrates without 
myocyte injury 
1R 
2 
Mild lymphocytic infiltrate with up to one focus of 
myocyte damage 
2R 
3A 
Moderate multifocal prominent infiltrates with 
myocyte injury 
3R 
3B 
Diffuse infiltrates with myocyte injury 
3R 
4 
Diffuse lymphocytic infiltrates with myocyte 
injury and hemorrhage, edema, 
polymorphonuclear leukocytes and/or vasculitis 
 
ISHLT: Working Formulation classification: ANTIBODY-MEDIATED REJECTION  
 
2011 ISHLT Nomenclature 
Grade 
Histopathological  + Immunologic Description 
after EMB  for ANTIBODY-MEDIATED 
REJECTION 
AMR 0: None. 
Negative immunologic stain(s) and negative 
histology. 
AMR 1: Suspicious 
Positive immunologic stain(s) or histology (but 
not both). 
AMR 2: Definite 
Positive immunologic stain(s) and positive 
histology. 
AMR 3: Severe 
Positive immunologic stain(s)  and positive 
histology with findings of advanced rejection 
(interstitial hemorrhage, edema, neutrophils, 
vasculitis) 
AMR Immunopathology:  
 Immunofluorescence: C3d, C4d, HLA (to assess endothelial capillary integrity) 
Immunoperoxidase: C3d, C4d, CD68