Conditions: Renal Transplant Rejection
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 20
Healthy volunteers: no

Brief summary:
This research evaluates the effectiveness of a new drug called belatacept (Nulojix) for the prevention of acute rejection and preservation of kidney function in transplant patients. Belatacept was approved in 2011 by the United States Food and Drug Administration (FDA) and is being marketed as Nulojix. The pharmaceutical company sponsoring this study is Bristol-Myers Squibb.

Belatacept is a prescription medicine used in adults to prevent transplant rejection in people who have received a kidney transplant. Transplant rejection happens when the body's immune system senses that the new transplanted kidney is different or foreign, and attacks it. Belatacept is used with corticosteroids and certain other medicines to help prevent rejection of your new kidney.

The purpose of the research is to understand whether the new drug, belatacept, is better than other anti-rejection drugs, such as cyclosporine and tacrolimus that are typically used in the treatment against kidney rejection in transplant patients.

Detailed description:
Research Hypothesis: Switching to a belatacept-based immunosuppression regimen after kidney transplant will have a significant impact on antibody and T cell-mediated immune response as compared with control patients as measured in peripheral blood at 6 months after belatacept switch and comparable safety and efficacy as compared with calcineurin inhibitor (CNI) based regimens.

Primary Objective: To analyze the effect of switching from CNI to belatacept in patients with evidence of CNI toxicity on the development and maintenance of immune memory in response to both alloantigen and viral antigens commonly encountered after transplant, and to assess the safety and efficacy of conversion to belatacept as maintenance immunosuppression in combination with prednisone and mycophenolate mofetil.

Study Design: Open label, single center clinical trial. Patients with evidence of CNI toxicity will be eligible for switch to belatacept-based regimen within the first three months after transplant. All enrolled subjects will also receive concomitant maintenance immunosuppression with mycophenolate mofetil and corticosteroids.

Duration of Study: 6 months, with option to extend to 12 months of belatacept treatment Number of Subjects: 20 Study Population: Kidney transplant recipients within the first three months of their first transplant with evidence of CNI toxicity.

Test Product, Dose and Mode of Administration, Duration of Treatment: Study patients will receive intravenous belatacept at 5mg/kg every two weeks at day 1 and weeks 2, 4, 6, and 8, and then monthly at months 3, 4, and 5. At month 6 patients may elect to continue for an additional six month period of belatacept administration. Peripheral blood mononuclear cells (PBMCs) and sera for antibody testing will be collected at time of study entry and at 4, 8, 12, and 24 weeks after belatacept start, frozen and banked at our center, and analyzed in batch fashion for development of humoral and cell mediated immunity. Patients who elect to receive an additional 6 months of belatacept treatment will undergo additional immunologic analysis at 1 year after study entry.

Arms:
arm 1: Survival and rejection in patients switched to belatacept.

Interventions: intervention 1: Belatacept
Intervention descriptions: intervention 1: Subjects will receive intravenous belatacept at 5mg/kg every other week starting from day 1 and continuing with weeks 2, 4, 6, and 8, and then monthly at months 3, 4, 5, and 6. At month 6 patients may elect to continue for an additional six-month period of belatacept administration.

Protocol document:
Prot_SAP_000.pdf: 
Mechanisms of belatacept effect on alloimmunity and antiviral response after 
kidney transplantation 
 
 
1 
 
Mechanisms of belatacept effect on alloimmunity and antiviral response after kidney 
transplantation 
 
 
 
 
 
An Investigator-Initiated Research Proposal 
Concept # 56950 
BMS study # IM 103-309 
 
 
 
 
 
 
 
 
Suphamai Bunnapradist, M.D. 
Principal Investigator 
UCLA Division of Kidney Transplantation 
BOX 957306, 1033 Gayley Ave. Ste. 208 
Los Angeles, CA 90095-7306 
310-794-8516 
 
 
Elaine Reed, Ph.D. 
Co-investigator 
Director of the UCLA Immunogenetics Center 
Department of Pathology and Laboratory Medicine 
BOX 951652, 15-20 Rehab, 1000 Veteran Ave 
Los Angeles, CA 90095-1652 
 
 
Joanna Schaenman, M.D., Ph.D. 
Co-investigator 
UCLA Division of Infectious Diseases 
BOX 951688, 37-121 
Los Angeles, CA 90095-1688 
 
 
 


Mechanisms of belatacept effect on alloimmunity and antiviral response after 
kidney transplantation 
 
 
2 
 
 
SYNOPSIS  
 
 
 
Title of Study: Mechanisms of belatacept effect on alloimmunity and antiviral response after 
kidney transplantation 
 
Estimated Number of Study Centers and Countries/Regions: 1 
Study Phase: 4 
Research Hypothesis: Switching to a belatacept-based immunosuppression regimen after 
kidney transplant will have a significant impact on antibody and T cell-mediated immune 
response as compared with control patients as measured in peripheral blood at 6 months 
after belatacept switch and comparable safety and efficacy as compared with calcineurin 
inhibitor (CNI) based regimens. 
 
Primary Objective: To analyze the effect of switching from CNI to belatacept in patients with 
evidence of CNI toxicity on the development and maintenance of immune memory in 
response to both alloantigen and viral antigens commonly encountered after transplant, and 
to assess the safety and efficacy of conversion to belatacept as maintenance 
immunosuppression in combination with prednisone and mycophenolate mofetil.  
 
Study Design: Open label, single center clinical trial. Patients with evidence of CNI toxicity will 
be eligible for switch to belatacept-based regimen within the first three months after 
transplant. All enrolled subjects will also receive concomitant maintenance 
immunosuppression with mycophenolate mofetil and corticosteroids.  
 
Duration of Study: 6 months, with option to extend to 12 months of belatacept treatment 
Number of Subjects: 20  
Study Population: Kidney transplant recipients within the first three months of their first 
transplant with evidence of CNI toxicity.  
 
Test Product, Dose and Mode of Administration, Duration of Treatment: Study patients will 
receive intravenous belatacept at 5mg/kg every two weeks at day 1 and weeks 2, 4, 6, and 8, 
and then monthly at months 3, 4, and 5. At month 6 patients may elect to continue for an 
additional six month period of belatacept administration. Peripheral blood mononuclear cells 
(PBMCs) and sera for antibody testing will be collected at time of study entry and at 4, 8, 12, 
and 24 weeks after belatacept start, frozen and banked at our center, and analyzed in batch 
fashion for development of humoral and cell mediated immunity. Patients who elect to 
receive an additional 6 months of belatacept treatment will undergo additional immunologic 
analysis at 1 year after study entry. 
 
Reference Therapy, Dose and Mode of Administration, Duration of Treatment: Immunologic 
evaluations performed on study patients will be compared with a matched group of 20 


Mechanisms of belatacept effect on alloimmunity and antiviral response after 
kidney transplantation 
 
 
3 
control patients receiving conventional immunosuppressive therapy and participating in an 
ongoing observational trial regarding immunologic mechanisms contributing to rejection in 
kidney transplant patients. 
 
Criteria for Evaluation:  
 
Primary Outcome Measures:  
 
• Donor specific antibody testing at Month 6 
• Cell surface cytokine secretion in response to donor cell antigen by direct and indirect 
stimulation at Month 6 
• Cell surface cytokine secretion in response to CMV and EBV antigens by direct and 
indirect stimulation at Month 6 
• Immunophenotyping to determine overall immune profile at Month 6 
• Patient and functional graft survival in stable renal transplant recipients  
 
Secondary Outcome Measures:  
 
• Donor specific antibody testing at Months 1 and 3 (and month 12 if continuing in 
study) 
• Cell surface cytokine secretion in response to donor cell antigen by direct and indirect 
stimulation at Months 1 and 3 (and month 12 if continuing in study) 
• Cell surface cytokine secretion in response to CMV and EBV antigens by direct and 
indirect stimulation at Months 1 and 3 (and month 12 if continuing in study) 
 
 
Statistical Methods: A sample size of 20 subjects will be enrolled. Because of the exploratory 
nature of this study is not possible to estimate power for this study size. 
Comparison between groups will be performed by Mann Whitney U test. In addition, a 
comparison will be made between patients’ baseline and week 24 levels. ANOVA repeated 
measurement analysis will be used to evaluate immune measurements taken over time as 
compared with control patients. 
 
 
 
 
 


Mechanisms of belatacept effect on alloimmunity and antiviral response after 
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TABLE OF CONTENTS  
 
TITLE PAGE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1  
 
SYNOPSIS. . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . .. . . 2  
 
 
TABLE OF CONTENTS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4  
 
1 INTRODUCTION. . . . . . . . . . . . . . . . . . . . . . . . . . . .   . . . . 9  
 
1.1 Research Hypothesis. . . . . . . . . . . . . . . . . . . .  . . . . . . 9 
  
1.2 Study Rationale. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 
 
1.3 Rationale for Dosing . . . . . . . . . . . . . . . . . .  . . . .  . . . 11  
 
1.4 Overall Risk/Benefit . . . . . . . . . . .. . . . . . . . . . . . .. . . 11 
  
2 STUDY OBJECTIVES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 
 
2.1 Primary Objectives. . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 
 
2.2 Secondary Objectives. . . . . . . . . . . . . . . . . . . . .  . . . . 11 
 
3 STUDY DESIGN AND EVALUATION. . . . . . . . . . . . .  . 12 
 
3.1 Study Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 
 
3.1.1 Duration of Study . . . . . . . . . . . . . . . . . . . . . . .. . . . . 12 
 
3.1.2 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 
 
3.1.3 Primary Outcome Measures and Justification. . 12  
 
3.1.4 Safety Monitoring.. . . . . . . . . . . . . . . . .  . . . . . . . . .  . .13  
 
3.2 Study Population . . . . . . . . . . . . . . . . . . . . .  . . . . .  .  . . 13  
 
3.3 Criteria for Evaluation. . . . . . . . . . . . . .  . . . . . . .. . . . . 14  
 
3.4 Sample Size Determination . . . . . . . . .  . . . . . . . . ... . . 14  
 
3.5 Interim Analyses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . 14  


Mechanisms of belatacept effect on alloimmunity and antiviral response after 
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4 STATISTICAL METHODOLOGY. . . . . . . . . . . . . . . .  . . . . . 15  
 
4.1 Data Set Descriptions. . . . . . . . . . . . . . . .  . . . . . . . . . . . . 15  
 
4.2 Analyses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15  
 
 
5 SUBJECT SELECTION CRITERIA. . . . . . . . . . . . . . . . . . . . 15  
 
5.1 Inclusion Criteria. . . . . . . . . . . . . . . . . . . . .  . . . . . . . . . . . 16  
 
5.2 Exclusion Criteria. . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . 16  
 
6 STUDY CONDUCT. . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . 18  
 
6.1 Ethics. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .  . . .. . . . . . . . . 18 
 
6.2 Study Therapy . . . . . . . . . . . . . . . . . . . .. . . . . . ... . . . . . . . 19 
 
6.2.1 Treatment and Subject Identification. . .. .. . ...  . . .19  
 
6.2.2 Administration of Belatacept. . . . . . . . . . . . . . .   . . . 19  
 
6.2.3 Dose Modifications. . . . . . . . . . . . . . . . . . . . . . . . . .. . . 19  
 
6.2.4 Discontinuation of Therapy. . . . . . . . . . . . . . . . . . . . 20  
 
6.2.5 Treatment Compliance. . . . . . . . . . . . . . . . .  . .. . . . . . 20  
 
6.2.6 Prior and Concomitant Therapy. . . . . . . . . . . . . .. . .20  
 
6.2.6.1 Corticosteroids. . . . . . . . . . . . . . . .  . . . . . . . . . . . . . . 20  
 
6.2.6.2 Mycophenolate Mofetil . . . . . . . . . . . . .  . . . . . . . . . 20  
 
6.2.6.3 Basiliximab Dosing. . . . . . . . . . . . . . .. . . . . . .. . . . . . 20  
. 
6.2.6.4 Prophylaxis Medications . . . . . . . . . . .  . . . .  . . . . . 20  
 
6.2.6.5 Diagnosis and Treatment of Acute Rejection. .  21  
 
6.3 Blinding/Unblinding. . . . . . . . . . . . . . . . . . . . . . ... . .. . . . 21  
 
6.4 Prohibited and Restricted Therapies During the Study 21  


Mechanisms of belatacept effect on alloimmunity and antiviral response after 
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6.4.1 Prohibited Therapies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21  
 
6.4.2 Precautions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  . . . . . . . . 21  
 
6.4.2.1 Vaccinations. . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . .. . . . . . 21 
 
6.4.2.2 Monitoring for EBV reactivation 
 
6.5 Non-therapy Precautions and Restrictions . . . . . . . .. . . . 21 
 
6.5.1 Precautions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . 21 
 
6.6 Withdrawal of Subjects from Study. . . . . . . . . .  . . . . . . . . 21 
 
6.6.1 Discontinued Subjects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 
 
7 STUDY PROCEDURES AND OBSERVATION. . . . . . . . . . . . . 22  
 
7.1 Time and Events Schedule . . . . . . . . . . . . . . . . . . .. . . .  . . . . 24  
 
7.2 Procedures by Visit. . . . . . . . . . . . . . . . . . . . .  . . . .. . . . . . . . . 24  
 
7.2.1 Screening/Baseline Evaluations . . . . . . . . . .. . . . .. .  . . . 24 
 
7.2.2 Day 1 (First Dosing Day) . . . . . . . . . . .  . … . . . . . ... . . . . . 25  
 
7.2.3 Infusion-only Visit Procedures . . . . . . . . . . . . . . . . . . . . . 25 
 
7.2.4 Standard Study Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26  
 
7.2.5 Early Termination Procedures . . . . . . . . . . . . . . .  . . . . . . 26  
 
7.2.6 Visit Windows. . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . .. . . 26  
 
7.3 Details of Procedures. . . . . . . . . . . . . . . . . . . . .  . . . . . . . . . . . . 26  
 
7.3.1 Study Materials. . . . . . . . . . . . . . . . . . . . . . .  . . . . . . . . . . . . . . 27  
 
7.3.2 Safety Assessments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27  
 
7.3.2.1 Events of Special Interest. . . . . . . . . . . .  . . . . . .. . . . . . . .. 27  
 
7.3.3 Other Assessments. . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . 27  
 


Mechanisms of belatacept effect on alloimmunity and antiviral response after 
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7 
7.3.3.1 Kidney Allograft Biopsy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27  
 
7.3.4 Laboratory Test Assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . 27  
 
7.3.5 Immunologic Assessments . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . 28 
 
7.3.5.1 Primary Assessments . . . . . . . . . . . . . . . . . .  . . . . . . . . . . . . . . .28 
 
7.3.5.2 Secondary Assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28 
 
7.3.5.3 Brief summary of methods immunologic assessment. . . 29 
 
7.3.6 Potential for premature termination of clinical trial. . . . .. . 29 
 
 
8 DRUG PRODUCT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  . . . 29  
 
8.1 Drug Product Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29  
 
8.2 Packaging and Labeling. . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . 29  
 
8.3 Handling and Dispensing of  Product . . . . . . . . . . . . . .  . . . . . . .  29  
 
8.3.1 Drug Product Preparation. . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . 29  
 
8.3.2 Recommended Storage Conditions . . . . . . . .. . . . . . . . . . . . . . . 31  
 
8.4 Drug Product Records at Site. . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . 31  
 
8.5 Return and Destruction of Product . . . . . . . . . . . . . . . . . .  .. . . .  . 31  
 
9 ADVERSE EVENT REPORTING IN CLINICAL TRIALS . . . . . . . .. . 31  
 
9.1 Importance of Adverse Event Reporting. . . . . . . . . . . . . . . .  . . . 32  
 
9.2 Collection of Safety Information . . . . . . . . . . . . . . . . . . . . . . . . . . . 33  
 
9.3 Potential Drug-Induced Liver Injury (DILI) . . . . . .  . . . . . . . . .  . 34 
 
9.4 Adverse Events Related to Study Conditions. . . . . . . . . . .  . . . . 34  
 
9.5 Handling of Serious Adverse Events (SAEs) . . . . . . . . . . .  . . . . 34  
 
9.6 Laboratory Test Abnormalities . . . . . . . . . . . . . . . . . . .  . . . . . . . . 35  
 
9.7 Other Safety Considerations . . . . . . . . . . . . . . . . . . . .. . .. . . . .. . . . 35  


Mechanisms of belatacept effect on alloimmunity and antiviral response after 
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9.8 Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . 36  
 
10 ADMINISTRATIVE SECTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 38  
 
10.1 Compliance with the Protocol and Protocol  
Revisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . 38  
 
10.2 Informed Consent. . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . 38  
 
10.2.1 Informed Consent Procedures . . . . . . .. . . . . . . . . . . . . . . . . .  40  
 
10.2.2 Subjects Unable to Give Informed Consent . . . . . . . . . . . . . 40  
 
10.2.2.1 Minors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . 40 
 
10.2.2.2 Subjects Experiencing Acute Events or Emergencies. . 40 
 
10.2.2.3 Mentally Impaired or Incapacitated Subjects . . . . . . .   . 40  
 
10.2.2.4 Other Circumstances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . 41 
 
10.2.3 Illiterate Subjects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  . . . . . . . 41  
 
10.2.4 Update of Informed Consent. . . . . . . . . . . . . . . . .  . . . . . . . . . . 41 
 
10.3 Monitoring for Protocol Compliance . . . . . . . . . . . . .   . . . . . . . 42 
 
10.4 Records and Reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42  
 
10.5 Institutional Review Board (IRB) . . . . . . . . . . . . . . . . . . . . . . . . 42  
 
10.6 Records Retention . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . 42  
 
11 GLOSSARY OF TERMS AND LIST OF  
ABBREVIATIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  . . . . . . . . . . . . . . . 43  
 
11.1 Glossary of Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43  
 
11.2 List of Abbreviations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43  
 
12 REFERENCES . . . . . . . . . . . . . . . . . . . . . .  . . . . . . . . . . . . . . . . . . . . . . . 46  
 
    
 


Mechanisms of belatacept effect on alloimmunity and antiviral response after 
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9 
 
 
 
 
 
1 INTRODUCTION  
 
1.1 Research Hypothesis  
 
Primary Hypothesis:  
 
Conversion from CNI-based therapy to belatacept will be safe and effective for prevention of 
rejection, with a significant impact on antibody and T cell-mediated immune response as 
compared with control patients as measured in peripheral blood at 6 months after belatacept 
conversion. 
 
Outcomes to be tested:  
 
• Belatacept-treated subjects will not have a greater incidence of SAEs as compared with 
control patients 
• Belatacept-treated subjects will have similar rates of acute rejection as compared with 
control patients 
• Belatacept-treated subjects will have a lower donor-specific antibody level at 6 months 
compared with control patients 
• Belatacept-treated subjects will have a decrease in the frequency of alloantigen specific T 
cells over time as compared with control patients 
• Belatacept-treated subjects will have a decrease in the frequency virus specific T cells over 
time as compared with control patients 
• Belatacept-treated subjects will have a greater percentage of naïve and central memory T 
cells and a lower percentage of activated T cells as compared with control patients 
 
1.2 Study Rationale  
 
As belatacept comes into increasing clinical use, it is important to reach a better 
understanding of its immunologic mechanism of action. As the drug was engineered as a co-
stimulation pathway inhibitor, we would hypothesize that its main effects would be on the 
activation of naïve T cells; however, an impact on pre-existing memory cells may also be seen. 
Both direct and indirect immunity play a role in allograft rejection after transplant, and it is 
important to differentiate between these two mechanisms as belatacept may affect each 
pathway differently: Direct recognition of alloantigen occurs when donor antigen presenting 
cells (APCs) present antigen to host T cell, as seen in early rejection, in contrast indirect 
recognition occurs when host APCs present either allo-antigen or viral antigen to host T cells. 
 
It is known from Phase III trials that decreased formation of donor specific antibodies (DSA) 
are seen in patients treated de novo with belatacept compared with cyclosporine with both 


Mechanisms of belatacept effect on alloimmunity and antiviral response after 
kidney transplantation 
 
 
10 
standard and extended-criteria donors, [1,2] however, the mechanism behind this 
observation is unknown, and it is unclear whether this same affect might be anticipated in 
patients switched to belatacept one to three months post transplant. Finally, an increased 
frequency of post-transplant lymphoproliferative disorder in patients naïve for EBV with EBV 
positive donors (D+/R-) was also seen in these studies; this may reflect inhabitation of the 
development of antiviral immunity, but it is unclear how important the presence or lack of 
virus-specific memory T cells is in this response. Our laboratory is uniquely suited to perform 
a study of this nature given our experience and expertise in studies of immunity in transplant 
recipients as the designated investigative laboratory for the NIH-sponsored Clinical Trials in 
Organ Transplantation Study 2 (CTOT-2). 
 
 
 
 
 
 
Figure 1: Model of belatacept action in alloimmunity and viral antigen recognition 
 
 
Belatacept was designed as a co-stimulation inhibitor that is able to bind to CD80 molecules 
on the surface of antigen presenting cells, inhibiting the CD80-CD28 interaction that is 
required for T cell activation (figure 1).[3] Rodent models cannot be used for its study as the 
drug does not exhibit strong binding to murine CD80; preliminary efficacy and safety studies 
were therefore performed in primate models (see Investigator Brochure for additional 
details). No safety signal was seen in human Phase I trials, and Phase III studies have shown 
equivalence with or superiority to cyclosporine in prevention of death, graft loss, and chronic 
rejection, and an improved GFR as compared with cyclosporine treatment.[1,2] Overall safety 
profile was similar to cyclosporine, with the exception of PTLD which was seen with more 
frequency in the belatacept group, especially in patients naïve to EBV receiving transplants 
from an EBV seropositive donor.[4,5]  


Mechanisms of belatacept effect on alloimmunity and antiviral response after 
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11 
 
The calcineurin inhibitors, namely cyclosporine and tacrolimus, are widely used for 
immunosuppression in kidney transplantation. They have improved short term outcomes 
compared with earlier regimens such as azathioprine and steroids, but long term outcomes 
continue to be decreased by the nephrotoxicity related to long term calcineurin inhibitor 
use.[6] 
 
1.3 Rationale for Dosing  
Based on the IM 103-116 study of conversion from CNI to belatacept for maintenance of 
immunosuppression in kidney transplant recipients, a similar dosing schedule will be used 
with belatacept 5mg/kg every two weeks for a total of 5 doses followed by monthly 
administration of belatacept at the 5mg/kg dose.  
 
1.4 Overall Risk/Benefit Assessment  
Belatacept is an immunosuppressive drug with a novel mechanism of action compared with 
existing therapies that has been shown to be safe and efficacious in previous trials as 
described above. By enrolling patients exhibiting toxicity with standard CNI-based therapy, 
we will maximize the potential benefit to enrollees by allowing them the option to switch to a 
non-CNI based regimen with likely renal function improvement compared with standard 
therapy. The potential risk of increased acute rejection and PTLD will be meliorated by the 
close supervision that subjects will receive by the study team. Therefore, this study offers a 
favorable risk-benefit relationship to potential enrollees. 
 
2 STUDY OBJECTIVES  
 
2.1 Primary Objectives  
 
Primary Outcome Measures:  
 
• Donor specific antibody testing at Month 6 
• Cell surface cytokine secretion in response to donor cell antigen by direct and indirect 
stimulation at Month 6 
• Cell surface cytokine secretion in response to CMV and EBV antigens by direct and 
indirect stimulation at Month 6 
• Immunophenotyping to determine overall immune profile at Month 6 
• Survival and rejection in patients switched to belatacept at 12 months post transplant 
as compared with patients treated with conventional therapy at our center. 
 
 
2.2 Secondary Objectives  
 
Secondary Outcome Measures:  
 


Mechanisms of belatacept effect on alloimmunity and antiviral response after 
kidney transplantation 
 
 
12 
• Donor specific antibody testing at Months 1 and 3 (and month 12 if continuing in 
study) 
• Cell surface cytokine secretion in response to donor cell antigen by direct and indirect 
stimulation at Months 1 and 3 (and month 12 if continuing in study) 
• Cell surface cytokine secretion in response to CMV and EBV antigens by direct and 
indirect stimulation at Months 1 and 3 (and month 12 if continuing in study) 
 
 
3 STUDY DESIGN AND EVALUATION  
 
3.1 Study Design  
This study is an open label, single center clinical trial. All subjects will also receive ongoing 
immunosuppression with mycophenolate mofetil and corticosteroid maintenance therapy.  
 
 
3.1.1 Duration of Study  
The duration of the study is 6 months, with the possibility to extend an additional 6 months. 
The decision to participate in an additional 6 months of belatacept administration will be 
based on patient preference. 
 
3.1.2 Overview  
This is an open label, single center clinical trial. All subjects will have undergone kidney 
transplantation with induction immunosuppression and will be on maintenance therapy with 
a CNI (tacrolimus or cyclosporine) plus mycophenolate mofetil and corticosteroid 
maintenance therapy at the time of enrollment. 20 subjects with evidence of CNI toxicity (see 
definition below) in the first three months after transplant will be enrolled to switch to the 
belatacept regimen. These enrolled subjects will be compared with 20 matched patients from 
an ongoing observational study of kidney transplant patients at our center. 
 
All subjects will also receive induction with basiliximab and a background maintenance 
immunosuppressive regimen of MMF and corticosteroids.  
 
Study patients will receive intravenous belatacept at 5mg/kg every two weeks at day 1 and 
weeks 2, 4, 6, and 8, and then monthly at months 3, 4, and 5. At month 6 patients may elect to 
continue for an additional six-month period of belatacept administration 
 
3.1.3 Primary Outcome Measures and Justification  
Patients switched to the belatacept-based regimen will be compared to a group of matched 
patients on standard CNI-based immunosuppression regimen on the following primary 
outcome measures: (1) the donor specific antibody level, (2) the frequency of alloantigen and 
viral antigen reactive cells as measured by cell surface cytokine analysis, and (3) the 
frequency of immunophenotypes described below at Month 6. Matching will be performed 
based on age within 10 years, sex, deceased versus living transplant, and DSA level at time of 
enrollment. 
 


Mechanisms of belatacept effect on alloimmunity and antiviral response after 
kidney transplantation 
 
 
13 
The intent is to investigate differences in these measures as a means to determine the 
immunologic mechanism of action of belatacept. These endpoints were selected based on 
previous research showing that these measures are key determinants of immune function in 
transplant patients. In addition, baseline levels at time of enrollment of these endpoints will 
be compared with results from months 1, 3, and 6, as well as month 12 if patients elect to 
continue for an additional 6 months of belatacept therapy. Month 6 will be used as the 
primary measure of outcome for the immunologic assays, with months 1, 3 and 12 if 
applicable as the secondary measures. 
 
To perform these mechanistic studies, blood from subjects will be collected at each study time 
point as described below and peripheral blood mononuclear cells (PBMCs) will be isolated 
and frozen for future analysis. 
 
For analysis of response to alloantigen stimulation, PBMCs will be incubated with either intact 
donor cells or membrane preparations from donor cells to test either direct or indirect 
immunity, respectively. Following incubation, a cocktail of fluorescent-conjugated monoclonal 
antibodies will be added to detect relevant immunologic subclasses of cells as well as relevant 
surface cytokines and the percentage of each lymphocyte subset will be analyzed using flow 
cytometry according to previously published protocols developed at the UCLA 
Immunogenetics Center [7].   
 
For analysis of response to viral antigens, PBMCs will be extracted and stored as described 
above using well-characterized CMV or EBV antigens for stimulation during the incubation 
period using a similar protocol adapted for detection of relevant antiviral immune 
lymphocytes. 
 
Overall immune profile will also be analyzed by immunophenotyping using multiparameter 
flow cytometry using the panels described below: 
 
 
 
 
 
 
 
 
 
 
 
 
In addition we will analyze rates of rejection and patient and graft survival at 6 and 12 
months post transplant as compared with patients receiving conventional 
immunosuppression regimens at our center. 
 
3.1.4 Safety Monitoring  
 
Defined Cell Population 
FITC 
PE 
PerCP APC 
Pac 
Blue 
PE-
Cy7 
1 Central/effector 
memory, naïve T cells 
CD57 
CCR7 
CD3 
CD45RA CD8 
CD4 
2 Activation, memory 
CD45RA CCR5 
CD3 
CD95 
CD8 
CD4 
3 Activation, effectors 
CD45RA HLA-DR 
CD3 
CD38 
CD8 
CD4 
4 NK cells 
CD161 
CD94 
CD3 
CD56 
CD16 
 
5 B cells 
CD19 
CD27 
CD20 
CD38 
CD3 
 
6 T regs 
FoxP3 
CD103 
CD4 
CD25 
CD3 
 


Mechanisms of belatacept effect on alloimmunity and antiviral response after 
kidney transplantation 
 
 
14 
A Data Safety Monitoring Board will not be used for this study given that it is a small scale, 
single center study. However, safety including SAEs will be monitored by study staff in an 
ongoing fashion during patient study participation. 
 
3.2 Study Population  
The study population includes recipients of renal allografts in the first three months after first 
episode of transplantation that demonstrate side effects from the standard calcineurin 
inhibitor based regimen. CNI toxicity is delineated as follows: 
1. 
Neurologic toxicity, defined as tremor, altered mental status, or seizure 
2. 
Renal toxicity, defined as GFR <60 
3. 
Metabolic toxicity, defined as a new requirement for medication to control 
hyperglycemia 
4. 
Hematologic toxicity, defined as development of thrombotic microangiopathy 
History of induction therapy with either basiliximab or antithymocyte globulin is permissible 
for study entry; as our center primarily uses basiliximab this will be the predominant 
induction therapy for study participants. 
 
3.3 Criteria for Evaluation  
Primary Measures:  
 
• Donor specific antibody testing at Month 6 
• Cell surface cytokine secretion in response to donor cell antigen by direct and indirect 
stimulation at Month 6 
• Cell surface cytokine secretion in response to CMV and EBV antigens by direct and 
indirect stimulation at Month 6 
• Immunophenotyping to determine overall immune profile at Month 6 
• Patient and functional graft survival in stable renal transplant recipients  
 
 
Secondary Outcome Measures:  
 
• Donor specific antibody testing at Months 1 and 3 
• Cell surface cytokine secretion in response to donor cell antigen by direct and indirect 
stimulation at Months 1 and 3 (and month 12 if continuing in study) 
• Cell surface cytokine secretion in response to CMV and EBV antigens by direct and 
indirect stimulation at Months 1 and 3 (and month 12 if continuing in study) 
 
Definitions 
 
Acute and chronic rejection will be defined using the Banff 97 working classification of kidney 
transplant pathology.[8] Standard clinical and histologic criteria for calcineurin inhibitor 
associated nephrotoxicity will be used.[9] Full Banff criteria analysis will be provided for each 
biopsy performed. 
 


Mechanisms of belatacept effect on alloimmunity and antiviral response after 
kidney transplantation 
 
 
15 
 
3.4 Sample Size Determination  
 
Because of the exploratory nature of this analysis, it is not possible to estimate power for this 
study, a goal of 20 patients was used similar to other immunologic pilot studies and is a 
reasonable goal for rapid accrual at our center. 
 
3.5 Interim Analyses  
 
No interim analyses will be performed. However, safety and any SAEs will be monitored on a 
continuous basis. 
 
4 STATISTICAL METHODOLOGY  
4.1 Data Set Descriptions  
 
Data sets will be generated for all patients enrolled in the study with recorded frequency of 
alloantigen specific cells at weeks 0, 4, 12, and 24 after study start after both direct and 
indirect stimulus, frequency of anti CMV and anti EBV specific cells at weeks 0, 4, 12, and 24, 
and frequency of cell populations as determined by immunophenotyping analysis at weeks 0, 
4, 12, and 24. A representative group of 20 control patients receiving standard 
immunosuppressive medications will be identified from an ongoing observational study at 
our center using matching criteria described above. Patient matching will be performed in a 
blinded fashion. The ongoing observational study at UCLA is led by Dr. Reed and all patients 
undergoing kidney transplantation at UCLA are eligible for enrollment for an ongoing 
evaluation of immunologic predictors of rejection. PBMCs have been aliquoted and stored 
from these patients at time points post transplantation similar to those described in this 
protocol so they will be an ideal source for comparative analysis.  
 
4.2 Analyses  
 
Immunologic mechanisms  
 
Primary endpoints will be patient immune analysis at 24 weeks (end of study) as compared 
with control patients at a comparable time point for DSA, frequency of alloantigen and viral 
antigen reactive cells, and frequency of the immunophenotypes described above, comparison 
to be performed by Mann Whitney U test. In addition, a comparison will be made between 
patients’ baseline and week 24 levels. ANOVA repeated measurement analysis will be used to 
evaluate immune measurements taken over time as compared with control patients 
 
Efficacy and safety 
 
As an additional primary analysis, subject and graft survival at 6 months will be determined 
within each group. GFR measured at baseline and months 1, 3, 6, and 12 months will be 
descriptively summarized. Cumulative rates of acute and chronic rejection, and chronic 
allograft nephropathy, will be summarized, as well as incidence of post-transplant diabetes. 


Mechanisms of belatacept effect on alloimmunity and antiviral response after 
kidney transplantation 
 
 
16 
All AEs and SAEs since transplantation will be summarized for the patients receiving 
belatacept. For the control patients, rates of rejection, PTLD, and death will be summarized. 
 
 
5 SUBJECT SELECTION CRITERIA  
 
For entry into the study, all subjects must meet the following criteria.  
 
5.1 Inclusion Criteria  
Signed Written Informed Consent  
 
1) The subject is willing to provide signed written informed consent  
 
Target Population  
 
2) The subject is a first-time recipient of a living or deceased donor kidney transplant  
3) Evidence of calcineurin inhibitor side effects during the first 3 months after transplant as 
defined as  
 
1. Neurologic toxicity, defined as tremor, altered mental status, or seizure 
2. 
Renal toxicity, defined as GFR <60 
3. 
Metabolic toxicity, defined as a new requirement for medication to control 
hyperglycemia 
4. 
Hematologic toxicity, defined as development of thrombotic microangiopathy 
 
 
Age and Gender  
 
4) Men and women, ages 18 and older, inclusive  
5) Women of childbearing potential (WOCBP) must be using an adequate method of 
contraception to avoid pregnancy throughout the study and for up to 8 weeks after the study 
in such a manner that the risk of pregnancy is minimized . See section 9.7 below for details 
regarding handling of WOCBP subjects. 
 
WOCBP includes any female who has experienced menarche and who has not undergone  
successful surgical sterilization (hysterectomy, bilateral tubal ligation, or bilateral  
oophorectomy) or is not postmenopausal (defined as amenorrhea ≥ 12 consecutive  
months; or women on hormone replacement therapy with documented serum follicle  
stimulating hormone level > 35 mIU/mL). Even women who are using oral, implanted, or  
injectable contraceptive hormones or mechanical products such as an intrauterine device  
or barrier methods (diaphragm, condoms, spermicides) to prevent pregnancy or practicing  
abstinence or where the partner is sterile (e.g., vasectomy), should be considered to be of  
child bearing potential. WOCBP who are taking MMF must in addition use methods of birth 
control as stipulated in the package insert, namely: 


Mechanisms of belatacept effect on alloimmunity and antiviral response after 
kidney transplantation 
 
 
17 
Either intrauterine device, or partner with vasectomy, or one hormone (oral contraceptive 
pill, transdermal patch, vaginal ring, or progesterone injection or implant) and one barrier 
method (diaphragm or cervical cap with spermicide, contraceptive sponge, or male or female 
condom), or two barrier methods as described above. 
 
WOCBP must have a negative serum pregnancy test (minimum sensitivity 25 IU/L or  
equivalent units of human chorionic gonadotropin [HCG]) within 72 hours prior to the  
start of study medication then every 3 months during the period of study participation.  
 
 
6) Men must use an adequate method of contraception throughout the study, and for up  
to 8 weeks after the last infusion, so that the risk of pregnancy to their partners is  
minimized.  
 
7) MMF must be dosed at 500 mg by mouth twice daily or greater at the time of study entry 
 
8) Prednisone must be dosed at >=10 mg by mouth daily for patients less than 6 weeks post-
transplantation, and at >=5mg by mouth daily for patients greater than 6 weeks post-
transplantation at the time of study entry. 
 
5.2 Exclusion Criteria  
Gender and Reproductive Status  
 
1) WOCBP who are unwilling or unable to use an acceptable method to avoid pregnancy for 
the entire study period and for up to 8 weeks after the last infusion.  
 
2) Women who are pregnant or breastfeeding  
 
3) Women with a positive pregnancy test on enrollment or prior to study drug administration  
 
4) Males unwilling or unable to use an adequate method of contraception for the entire study 
period and for up to 8 weeks after the last infusion of study medication  
 
Immunologic status 
 
5) Subjects with PRA ≥ 30% at time of transplant 
 
6) Subjects with zero HLA antigen mismatched donors (either from related or unrelated 
donor) 
 
7) Subjects with any prior solid organ transplant (including kidney)  
 
8) Subjects receiving a concurrent solid organ (heart, liver, pancreas) or cell (islet, bone  
marrow, stem cell) transplant  
 


Mechanisms of belatacept effect on alloimmunity and antiviral response after 
kidney transplantation 
 
 
18 
9) Subjects with a history of biopsy-proven acute rejection post-transplant (humoral or 
cellular) in the first three months post transplantation 
 
 
Infection related risks 
 
10) Subjects who are hepatitis C antibody-positive or polymerase chain reaction  
 
(PCR)-positive for hepatitis C  
 
11) Subjects who are hepatitis B surface antigen-positive or PCR-positive for hepatitis B  
 
12) Subjects with known human immunodeficiency virus (HIV) infection  
 
13) Subjects with active tuberculosis (TB) requiring treatment within the previous 3 years or 
any subject who previously required triple (or more) combination therapy for TB. 
 
14) Subjects who are EBV antibody negative and have received grafts from EBV antibody 
positive donors. 
 
 
Prohibited Therapies and/or Medications  
 
15) Subjects who have used any investigational drug within 30 days prior to the Day 1  
visit  
 
16) Subjects previously treated with belatacept  
 
18) Use of mTOR inhibitors at any time after transplantation 
 
Other Exclusion Criteria  
 
18) Prisoners or subjects who are compulsorily detained (involuntarily incarcerated) for  
treatment of either a psychiatric or physical (e.g., infectious disease) illness must not  
be enrolled into this study.  
 
19) Subjects who have difficult i.v. access or other reasons that would likely preclude 
medication administration 
 
6 STUDY CONDUCT  
 
6.1 Ethics  
This study will be conducted in accordance with the ethical principles that have their origin in 
the current Declaration of Helsinki, and will be consistent with International Conference on 
Harmonization Good Clinical Practice (ICH GCP) and applicable regulatory requirements.  


Mechanisms of belatacept effect on alloimmunity and antiviral response after 
kidney transplantation 
 
 
19 
 
The study will be conducted in compliance with the protocol. The protocol and any  
amendments and the subject informed consent will receive Institutional Review Board  
(IRB) approval prior to initiation  
of the study.  
 
Freely given written informed consent must be obtained from every subject or their  
legally acceptable representative prior to clinical trial participation, including informed  
consent for any screening procedures conducted to establish subject eligibility for the  
trial.  
 
For further details on informed consent, see Section 10.2.  
 
The rights, safety and well-being of the trial subjects are the most important  
considerations and should prevail over interests of science and society.  
 
Study personnel involved in conducting this trial will be qualified by education, training,  
and experience to perform their respective task(s).  
 
This trial will not use the services of study personnel where sanctions have been invoked  
or where there has been scientific misconduct or fraud (e.g., loss of medical licensure,  
debarment).  
 
Systems with procedures that assure the quality of every aspect of the study will be  
implemented.  
 
6.2 Study Therapy  
6.2.1 Treatment and Subject Identification  
Study subjects will be switched to belatacept using the regimen described above. These 
treatments will be administered with concurrent maintenance therapy with MMF and 
corticosteroids. At the time of switch to belatacept, ongoing CNI therapy will be tapered to off 
over a 30 day course, as follows: 100% on day 1, 40-60% on day 15, 20-30% on day 23, and 
none on day 29 and beyond, following the previously published protocol[10]. An exception to 
this taper schedule would be made in the case of CNI toxicity with thrombotic 
microangiopathy, where tapering may be done over a two week time course. 
 
MMF dosing will be maintained at a minimum of 500 mg by mouth twice daily. 
 
For patients less than 6 weeks post-transplantation, prednisone dosing must be 10mg by 
mouth daily at the time of study entry and can be tapered to 5mg by mouth daily after 6 
weeks post-transplantation. For patients who are greater than 6 weeks post-transplantation, 
prednisone must be at a minimum of 5mg by mouth daily and will be maintained at this level 
throughout the duration of the study. 
 
At the time of enrollment, immediately after written informed consent is obtained and  


Mechanisms of belatacept effect on alloimmunity and antiviral response after 
kidney transplantation 
 
 
20 
before performing any study-related procedures, each subject will be assigned a unique  
sequential subject number for identification throughout the study. This subject number must 
not be reused for any other participant for the study.  
 
6.2.2 Administration of Belatacept 
Day 1 is defined as the day of study drug administration (screening is Day 0). 
Infusion doses will be based on the subject’s actual body weight at study Day 1, and will not 
be modified during the course of the study, unless there is a change of body weight ± 10% 
(see  
Section 8.3.1). Study drug should be administered to the subject at a relatively constant  
rate over 30 minutes. See Section 8.3.1 for details on the preparation and administration  
of the study medication. See Section 7.2.6 for details on infusion visits and visit windows. 
 
On study visit days, when the subject is to have peripheral blood collected, these measures are 
to be completed prior to belatacept  
dosing.  
 
Belatacept  Regimen  
 
Subjects will receive intravenous belatacept at 5mg/kg every other week starting from day 1 
and continuing with weeks 2, 4, 6, and 8, and then monthly at months 3, 4, 5, and 6. At month 
6 patients may elect to continue for an additional six-month period of belatacept 
administration. 
 
6.2.3 Dose Modifications  
In the absence of AEs deemed at least possibly related to study drug treatment, subjects  
will complete their scheduled infusions as prescribed by protocol. In the event of new,  
serious, and unexpected toxicity potentially related to belatacept, study drug 
administration should be interrupted..  
 
6.2.4 Discontinuation of Therapy  
Study therapy MUST be immediately discontinued for the following reasons:  
 
• Withdrawal of informed consent (subject’s decision to withdraw for any reason)  
• Any clinical AE, laboratory abnormality, or intercurrent illness which, in the opinion  
of the investigator, indicates that continued treatment with study therapy is not in the  
best interest of the subject  
• Pregnancy  
• Imprisonment or the compulsory detention for treatment of either a psychiatric or  
physical illness (e.g., infectious disease).  
 
6.2.5 Treatment Compliance  
All medications specified in this protocol must be administered as described within the  


Mechanisms of belatacept effect on alloimmunity and antiviral response after 
kidney transplantation 
 
 
21 
protocol. Study medication usage is to be reviewed, and compliance is to be discussed with 
subjects at each visit to assure compliance. All study medication and concomitant medication 
usage will be collected, and any deviations from specified administration should  
be clearly documented.  
 
6.2.6 Other Guidance: Prior and Concomitant Therapy  
6.2.6.1 Corticosteroids  
All subjects in this study will be treated with daily corticosteroids.  
 
6.2.6.2 Mycophenolate Mofetil  
All subjects in this study will be treated with MMF. Daily MMF should be administered  
in 2 divided doses on a consistent schedule in relation to time of day and meals.  
 
6.2.6.3 Basiliximab Dosing  
Basiliximab dosing is up to the discretion of the treating physician using common practice at 
the study institution, typically given at two doses of 20 mg each. 
 
6.2.6.4 Prophylaxis medications 
 
Medications commonly in use for antibiotic prophylaxis will be continued following normal 
transplant protocols in place at our center. These medications include 
sulfamethoxazole/trimethoprim and valganciclovir or acyclovir. To summarize, patients who 
are antibody negative for CMV (R-) receiving transplants from CMV antibody positive donors 
(D+) will receive valganciclovir prophylaxis for the first 6 months post transplant at 900 mg 
daily by mouth, or as adjusted for their renal function. Patients with other CMV serology 
combinations (D-/R-, D+/R+, and D-/R+) will receive acyclovir 400 mg daily by mouth for the 
first 3 months post transplant. In addition, single-strength trimethoprim-sulfamethoxazole is 
given daily by mouth for the first 3 months post transplant. 
 
6.2.6.5 Diagnosis and Treatment of Rejection  
 
Screening for acute and chronic rejection will be performed using standard protocols in place 
at our center. Biopsy performance will be per center standard protocols. Treatment will be up 
to the discretion of the treating transplant nephrologist. The severity of acute rejection will be 
determined using the Banff 97 classification. Full Banff subscores will be obtained and 
reported. 
 
 6.3  Blinding/Unblinding 
 
As this is an open label study, no arrangements need to be made for blinding or potential 
unblinding. 
 
6.4 Prohibited and Restricted Therapies During the Study  
6.4.1 Prohibited Therapies  
No prohibited therapies.  


Mechanisms of belatacept effect on alloimmunity and antiviral response after 
kidney transplantation 
 
 
22 
 
6.4.2 Precautions  
6.4.2.1 Vaccinations  
There is limited information available regarding the effectiveness of immunizations in  
non-human primates and humans that have been treated with belatacept. No data are  
available on the effect of therapeutic vaccinations in subjects receiving belatacept.  
 
Due to the risk of infection, vaccination of subjects with any live vaccine is  
absolutely contraindicated during the course of the study, as is the administration of  
LIVE oral polio vaccine to household contacts. The Centers for Disease Control  
recommend that subjects should not be administered a live virus vaccination for at least 3  
months after discontinuing high dose corticosteroid therapy (defined as > 20 mg/day of  
prednisone for > 2 weeks). In view of the long half-life of belatacept, study subjects  
should not be administered a live virus vaccine for a minimum of 3 months following the  
last dose of study medication.  
 
6.4.2.2 Monitoring for EBV reactivation 
EBV seronegative patients who have received organs from EBV seropositive donors are 
excluded from participation to decrease the risk of developing PTLD. In addition, evidence of 
EBV replication will be assessed using PCR testing throughout the period of study drug 
administration. 
 
6.5 Non-therapy Precautions and Restrictions  
6.5.1 Precautions  
None.  
 
6.6 Withdrawal of Subjects from Study  
All efforts should be made to follow all subjects for the entire duration of the study.  
Withdrawal of a subject from study medication (Section 6.2.4) does not imply that the  
subject is withdrawn from the study. Section 7.2.4 details study-related procedures for  
subjects who discontinue study medication.  
 
Subjects MUST be discontinued from study therapy AND withdrawn from the study for  
the following reasons:  
 
• Withdrawal of informed consent (subject’s decision to withdraw for any reason)  
• Any clinical AE, laboratory abnormality, or intercurrent illness which, in the opinion  
of the investigator, indicates that continued treatment with study therapy and further  
participation in the study (including obtaining vital status of the subject and allograft)  
is not in the best interest of the subject  
• Termination of the study  
• Subjects who become prisoners or become involuntary incarcerated for treatment of  
either a psychiatric or physical (e.g., infectious disease) illness.  
For discontinuation of study therapy, see Section 6.2.4.  
 


Mechanisms of belatacept effect on alloimmunity and antiviral response after 
kidney transplantation 
 
 
23 
6.6.1 Discontinued Subjects  
The investigator should accept only those subjects who give a reasonable indication that  
they will complete the study. An evaluation that reflects the status of the subject at  
premature termination, with a final assessment and reasons for termination, must be  
provided by the investigator.  
 
See Section 7.2.4 for a list of the procedures to be completed for subjects who  
discontinue study medication.  
 
7 STUDY PROCEDURES AND OBSERVATION  
7.1 Time and Events Schedule  
 
See figure 2 below and Table for outline of events. 
 
 
 
Figure 2: Schematic of study design 
 
 


Mechanisms of belatacept effect on alloimmunity and antiviral response after 
kidney transplantation 
 
 
24 
Table: Study Procedures 
 
*Belatacept will be administered at 5mg/kg  
**If applicable 
*** Standard of care laboratory testing will be performed at each visit following standard care practices 
at our center 
#For patients who elect to continue additional 6 months of belatacept therapy 
a +/- 2 days 
b +/- 3 days 
c +/- 7 days for patients who elect to continue additional 6 months of belatacept therapy 
 
 
 
 
7.2 Procedures by Visit  
Study procedures for the screening, baseline, and post-belatacept administration period  
are detailed in chart form in the table above and described further below.: 
 
7.2.1 Screening/Baseline Evaluations   
a) Screening may occur at any time for subjects 0 to 3 months after kidney transplantation 
who may meet study criteria  
 
b) If patients appear to be possible candidates for enrollment, obtain written informed 
consent and enroll the subject. Consent must be obtained prior to any change in medical 
therapy or any procedure performed solely for the purpose of this study (A subject is 
considered enrolled in the study upon signing informed consent. Some standard-of-care  
 
Baseline 
Day 
1 
Week 
2 
Week 
4 
Week 
6 
Week 
8 
Week 
12 
Week 
16 
Week 
20 
Week 
24 
Week 
48# 
Obtain informed 
consent 
X 
 
 
 
 
 
 
 
 
 
 
Confirm 
inclusion/exclusion 
criteria 
X 
 
 
 
 
 
 
 
 
 
 
Full medical 
history 
X 
 
 
 
 
 
 
 
 
 
 
Physical exam 
X 
 
 
 
 
 
X 
 
 
X 
 
Weight/Vital signs 
X 
X 
X 
X 
X 
X 
X 
 
 
X 
 
Drug infusion* 
 
X 
Xa 
X b 
X b 
X b 
X b 
X b 
X b 
X b 
X c 
Donor specific Ab 
testing 
X 
 
 
X 
 
 
X 
 
 
X 
X 
Study labs 
X 
 
 
X 
 
 
X 
 
 
X 
X 
Pregnancy test** 
X 
  
 
 
  
 
X 
 
 
X 
X 
Review 
concomitant 
medications 
X 
X 
X 
X 
X 
X 
X 
 
 
X 
X 
AE monitoring 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Local laboratory 
testing** 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
EBV PCR testing 
X 
 
 
X 
 
 
X 
 
 
X 
X 


Mechanisms of belatacept effect on alloimmunity and antiviral response after 
kidney transplantation 
 
 
25 
procedures routinely obtained for transplant subjects, regardless of study involvement, are 
likely to be obtained prior to study participation consent date, and  
should be documented as such.)  
 
c) Assign a unique study number to the patient 
 
d) Obtain complete medical history and physical examination.  
 
e) Obtain body weight (clothes on, shoes off), and measure vital signs (blood  
pressure (BP), heart rate, temperature, and respiration).  
 
f) Study labs will be drawn by obtaining whole blood and sending it via courier to the 
Immunogenetics Center for separation into PBMC and serum and storage. PCR testing will be 
performed. 
 
g) DSA testing 
 
h) Check and record all concomitant medications 
 
7.2.2 Day 1 
 
a) Confirm all inclusion/exclusion criteria.  
 
b) Obtain height and body weight (clothes on, shoes off), and measure pre-dose vital  
signs (BP, heart rate, temperature and respiration). Height and weight recorded for  
Day 1 can be obtained 1 day prior, if necessary. 
 
c) Assess and record AEs pretreatment.  
 
d) Check and record any changes in concomitant medications.  
 
e) Ensure all pretreatment (baseline) laboratory assessments and procedures have  
previously been obtained, or obtain at Day 1 prior to start of any study dosing (i.e., a  
negative serum pregnancy test must be confirmed within 72 hours of initiation of  
study dosing, if previous test is not within 72 hours, repeat prior to dosing at Day 1).  
Draw baseline whole blood for immunology analysis if not previously drawn 
 
f) Administer study medication (belatacept 5 mg/kg over 30 minutes i.v. ) 
 
g) Continue daily dosing of prednisone, MMF, doses to be determined by the subject’s treating 
physician, to continue throughout the duration of the study following practices of standard 
medical care 
 
7.2.3 Infusion-only Visit Procedures  
 


Mechanisms of belatacept effect on alloimmunity and antiviral response after 
kidney transplantation 
 
 
26 
a) To occur on Days 1 as above, as well as weeks 2, 6, 8, 16, and 20 
 
b) Obtain weight and vital signs 
 
c) Review for changes in concomitant medication and AEs 
 
d) Administer study medication  
 
 
7.2.4 Standard Study Visits 
 
a) To occur on Weeks 4, 12, and 24 as well as week 48 for those electing to continue in the 
study 
 
b) Assess and record AEs pretreatment. 
 
c) Check and record any changes in concomitant medications 
 
d) Obtain weight and vital signs 
 
e) Draw whole blood for immunology analysis, to be sent by courier to the Immunogenetics 
Center 
 
f) DSA testing 
 
g) EBV PCR testing 
 
h) WOCBP will undergo pregnancy testing at weeks 12 and 24 as well as week 48 for those 
continuing in the study 
 
i) Administer study medication   
 
 
7.2.5 Early Termination Procedures  
 
For randomized, transplanted, and treated subjects who received at least 1 dose of study  
medication and discontinue from study medication for any reason, if informed consent 
continues to be provided we will continue to perform study procedures scheduled for weeks 
4, 12, and 24  including an additional study lab draw at the time of drug discontinuation if it is 
not within 14-days of one of the above listed study visits 
 
7.2.6 Visit Windows  
To facilitate scheduling the infusion-only visits, the following windows are permitted for 
subsequent doses:  
 


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27 
Visit   
 
Visit Window  
 
Week 2  
 
Target date ± 2 days  
Week 4 - Month 6  
Target date ± 3 days  
Month 12 
 
Target date ± 7 days 
 
 
7.3 Details of Procedures  
All assessments should be performed or administered prior to study drug administration  
unless otherwise indicated.  
 
7.3.1 Study Materials  
Local laboratory will be used for all testing 
 
7.3.2 Safety Assessments  
Safety assessments include AEs, clinically significant changes in vital signs, physical 
examination, and laboratory test abnormalities. The investigator will determine the severity 
of each AE as mild, moderate, severe, or very severe. In addition, the investigator will 
determine the relationship of the AE to the administration of the study drug.  
 
Physical examinations may be performed by a Doctor of Medicine, Doctor of  
Osteopathy, Physician’s Assistant, or Nurse Practitioner.  
 
Urine or serum pregnancy tests will be performed prior to the first dose for all WOCBP. If any  
female subject becomes pregnant, she will be immediately discontinued from study  
medication.  
 
In addition, for women who become pregnant while using MMF or within 6 weeks of 
discontinuing therapy, study personnel or the patient’s healthcare practitioner will report the 
pregnancy to the Mycophenolate Pregnancy Reference Registry (1-800-617-8191) and will strongly 
encourage the patient to enroll in the pregnancy registry. The patient will also be apprised of the 
potential hazard of mycophenolate products to the fetus. The risks and benefits of MMF will be 
discussed with the patient. In certain situations, the patient and her healthcare practitioner may 
decide that the maternal benefits outweigh the risks to the fetus. 
 
7.3.2.1 Events of Special Interest  
 
• Subject death or graft loss (Confirmation of graft loss by a SCr criterion [see  
Section 3.3 for definition] requires determination of central SCr ≥ 6 mg/dL for  
≥ 4 weeks. Therefore, an additional central laboratory test(s) may be required.)  
• Acute rejection  
• PTLD  
• Infections  
 
7.3.3 Other Assessments  


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7.3.3.1 Kidney Allograft Biopsy  
Allograft biopsies are to be performed as determined by the patient’s treating physician 
following standard practice at the study institution.  The Banff 97 working classification of 
kidney transplant pathology will be used for grading of rejection. 
 
7.3.4 Laboratory Test Assessments  
Study labs for immunologic monitoring should be obtained prior to infusions. In addition, 
standard lab testing will be performed as part of the patient’s ongoing clinical care under the 
direction of their treating physician. Laboratory personnel will be blinded to the patient’s 
demographic characteristics and clinical status. Any laboratory test result that the  
investigator considers clinically relevant will be recorded as an AE. 
 
List of tests: 
 
Immunology testing: 
 
Whole blood will be collected at baseline and at Weeks 4, 12, and 24. 
Samples must be taken prior to beginning the infusion of belatacept. Additionally, a sample 
for immunologic testing should be obtained at the time of any suspected rejection episode(s).  
 
Anti-donor Antibody Determination:  
 
Anti-donor antibody testing will be performed at baseline, and at Weeks 4, 12, and 24 
 
All samples should be taken prior to beginning infusion of belatacept. Additionally,  
a sample for anti-donor antibodies (pre-dose) should be obtained at the time of any  
suspected rejection episode(s).  
 
Pregnancy Tests:  
 
A serum pregnancy test (minimum sensitivity 25 IU/L of ß-HCG) must be performed at a  
local laboratory for all WOCBP within 72 hours prior to the first dose of study  
medication (baseline or Day 1).  Additional testing will occur at weeks 12 and 24, and week 48 
for those continuing in the study. 
 
If a female subject becomes pregnant, she will be discontinued from the study.  
 
 
7.3.5 Immunologic Assessments  
 
7.3.5.1 Primary Assessments 
 
• Donor specific antibody testing at Month 6 
• Cell surface cytokine secretion in response to donor cell antigen by direct and indirect 
stimulation at Month 6 


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29 
• Cell surface cytokine secretion in response to CMV and EBV antigens by direct and 
indirect stimulation at Month 6 
• Immunophenotyping to determine overall immune profile at Month 6 
 
7.3.5.2 Secondary Assessments  
 
• Donor specific antibody testing at Months 1 and 3, and month 12 if electing to continue 
in study 
• Cell surface cytokine secretion in response to donor cell antigen by direct and indirect 
stimulation at Months 1 and 3, and month 12 if electing to continue in study 
• Cell surface cytokine secretion in response to CMV and EBV antigens by direct and 
indirect stimulation at Months 1 and 3, and month 12 if electing to continue in study 
 
7.3.5.3 Brief summary of methods immunologic assessment 
 
Cell surface cytokine secretion will be performed using both alloantigen and viral antigen 
stimuli following our previously published protocol [7]. Cells previously banked from kidney 
transplant donors will be used to analyze allospecific cells for the presence of both direct and 
indirect immune response. A cocktail of fluorescent conjugated monoclonal antibodies against 
cell surface markers and secreted cytokines will be used to distinguish between alloreactive 
naïve versus memory T cells using multiparameter flow cytometry. Results will be expressed 
as percentage of cells expressing either IFN-g or IL-10 per each of the various lymphocytes 
subsets.   
 
Analysis of virus-specific cytokine secretion will be performed in a similar fashion for analysis 
of indirect immune response to virus. PBMCs will be incubated with commercially available 
overlapping peptide pools for major CMV and EBV antigens and incubated in the presence of 
anti-CD28 antibody. 
 
Immunophenotyping will be performed to further dissect the influence of belatacept on the 
immune response. PBMCs at each time point will be assessed by multiparameter flow 
cytometry using panels aimed at characterization of T cell immunophenotypes including 
central memory, effector memory, and naïve cells, activated cells, B cells, NK cells, and T 
regulatory cells. 
 
See also section 3.1.3 above for table of antibody panels to be used and justification of 
approach.   
 
7.3.6 Potential for premature termination of clinical trial 
 
The incidence of acute rejection during the first year post-transplant is typically about 10% 
for a cyclosporine based immunosuppression regimen [4]. If a two-fold or greater (>=20%) 
incidence of acute rejection is observed, the patient demographics and data collected will be 
reviewed and the trial will be considered for premature termination. Because of the small 


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30 
number of patients participating in this trial, an up to two-fold deviation from expected rates 
was established. 
 
8 Drug Product 
 
8.1 Study Product  
Bristol-Myers Squibb will supply Belatacept.:  
 
Identification 
 
Belatacept is supplied as a sterile, white or off-white lyophilized powder for intravenous 
administration. Prior to use, the lyophile is reconstituted with a suitable fluid to obtain a clear 
to slightly opalescent, colorless to pale yellow solution, with a pH in the range of 7.2 to 7.8. 
Each 250 mg single-use vial of belatacept also contains: monobasic sodium phosphate (34.5 
mg), sodium chloride (5.8 mg), and sucrose (500 mg). 
 
8.2 Packaging and Labeling  
 
Belatacept for Injection will be supplied in a 250 mg/vial, and is administered by IV injection. 
Belatacept for Injection, 250 mg/Vial 
Belatacept for Injection, 250 mg/Vial, is a sterile non-pyrogenic lyophilized powder. Each vial 
contains 275 mg of belatacept, 550 mg of sucrose, 38.0 mg of sodium phosphate monobasic 
monohydrate, 6.4 mg of sodium chloride, and 1 N sodium hydroxide/1 N hydrochloric acid 
solution sufficient to adjust pH to 7.5. A 10% overfill is included in each vial to account for 
VNS holdup. 
 
8.3.1 Drug Product Preparation  
Belatacept :  
 
A pharmacist or qualified personnel at the site, not otherwise associated with the conduct  
of the study, will reconstitute the drug for i.v. administration.  
 
Care must be taken to assure sterility of the prepared solution, as the drug product does  
NOT contain any antimicrobial preservatives or bacteriostatic agents.  
 
Recommended safety measures for preparation and handling include protective clothing, 
gloves, and safety cabinets. Unused drug product solution should be discarded as per the site 
procedures. Constituted solutions of belatacept may foam; therefore, shaking should be 
avoided.Error! Bookmark not defined. 
 
Belatacept is provided as a lyophilized powder in preservative-free, single-use vials. Each vial 
provides 250 mg of belatacept for intravenous administration. Each vial must be 
reconstituted with 10.5 mL of a suitable reconstitution fluid, using a silicone-free syringe. 
Deleted: 


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Suitable fluids for reconstitution include sterile water for injection, 0.9% sodium chloride 
injection or 5% dextrose injection. The reconstituted solution must be further diluted with 
either 0.9% sodium chloride injection or 5% dextrose injection to belatacept concentrations 
between 2 mg/mL and 10 mg/mL, before administration by intravenous infusion. The diluted 
reconstituted solution must be administered as an intravenous (IV) infusion at a relatively 
constant rate over 30 minutes.  
 
Prior to administration, the belatacept infusion solution should be inspected visually for 
particulate matter or discoloration, and the solution should be discarded if any particulate 
matter or discoloration is observed. The entire, fully diluted belatacept infusion should be 
administered over a period of 30 minutes and must be administered with an infusion set and 
a sterile, non-pyrogenic, low protein binding filter (pore size of 0.2 μm to 1.2 μm). Following 
administration, it is recommended that the intravenous line be flushed with infusion fluid to 
ensure administration of the complete dose Any unused portion of the infusion solution 
should not be stored for reuse.  
 
Other medicines: belatacept should not be infused concomitantly in the same intravenous line 
with other agents. The investigational product should be stored in a secure area according to 
local regulations. The investigator is responsible for ensuring that it is dispensed only to study 
subjects and only from official study sites by authorized personnel, as dictated by local 
regulations. 
See Section 6.2.2 for additional details on study medication administration.  
 
No data are available on the compatibility of Belatacept  with other i.v. substances.  
Other drug substances should not be added or infused simultaneously through the same  
 
i.v. line. Assure adequate, appropriate flushing between each drug substance if multiple  
drugs are administered through the same line sequentially.  
Other protocol-required drug products:  
 
Other protocol-required drug products should be administered to subjects according to  
the dosing details provided in Section 6.2.6.  
 
 
8.3.2 Recommended Storage Conditions  
  
The investigator is responsible for ensuring that the product is stored under the appropriate 
environmental conditions (temperature, light, and humidity), and will be stored and 
reconstituted as per the belatacept (Nulojix) package insert. 
 
8.4 Drug Product Records at Site 
It is the responsibility of the investigator to ensure that a current record of drug  
product disposition is maintained at each study site where drug product is  
inventoried and disposed.  
 


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32 
Records or logs must comply with applicable regulations and guidelines, and should  
include:  
 
• Amount received and placed in storage area  
• Amount currently in storage area  
• Label identification number or batch number and use data or expiry date  
• Dates and initials of person responsible for each drug product inventory  
entry/movement  
• Amount dispensed to each subject, including unique subject identifiers  
• Non-study disposition (e.g., lost, wasted, broken)  
 
8.5 Return and Destruction of Investigational Product  
Not applicable 
 
8.6 Retained Samples for Bioavailability/Bioequivalence Studies  
Not applicable.  
 
9 ADVERSE EVENT REPORTING IN CLINICAL TRIALS  
 
9.1 Importance of Adverse Event Reporting  
Timely and complete reporting of safety information assists BMS in identifying any  
untoward medical occurrence, thereby allowing: (1) protection of the safety of study  
subjects; (2) a greater understanding of the overall safety profile of the drug  
product; (3) recognition of dose-related toxicity; (4) appropriate  
modification of study protocols; (5) improvements in study design or procedures; and  
(6) adherence to worldwide regulatory requirements.  
 
9.2 Collection of Safety Information  
An Adverse Event (AE) is defined as any new untoward medical occurrence or worsening of a 
pre-existing medical condition in a patient or clinical investigation subject administered an 
investigational (medicinal) product and that does not necessarily have a causal relationship 
with this treatment. An AE can therefore be any unfavorable and unintended sign (including 
an abnormal laboratory finding, for example), symptom, or disease temporally associated 
with the use of investigational product, whether or not considered related to the 
investigational product. 
Adverse events can be spontaneously reported or elicited during open-ended questioning, 
examination, or evaluation of a subject. (In order to prevent reporting bias, subjects should 
not be questioned regarding the specific occurrence of one or more AEs.) 
 
A Serious Adverse Event (SAE) is any untoward medical occurrence that at any dose:  
• results in death 


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• is life-threatening (defined as an event in which the subject was at risk of death at the time 
of the event; it does not refer to an event which hypothetically might have caused death if 
it were more severe) 
• requires inpatient hospitalization or causes prolongation of existing hospitalization (see 
note below for exceptions) 
• results in persistent or significant disability/incapacity 
• is a congenital anomaly/birth defect 
is an important medical event, defined as a medical event that may not be immediately 
life-threatening or result in death or hospitalization but, based on appropriate medical 
and scientific judgment, may jeopardize the subject or may require intervention (e.g., 
medical, surgical) to prevent one of the other serious outcomes listed above. Examples 
of such events include but are not limited to intensive treatment in an emergency 
department or at home for allergic bronchospasm; blood dyscrasias or convulsions that 
do not result in hospitalization. Potential drug induced liver injury (DILI) us also 
considered an important medical event (see Section 7.6 for the definition of potential 
DILI. 
Suspected transmission of an infectious agent (e.g., any organism, virus or infectious particle, 
pathogenic or non-pathogenic) via the study drug is an SAE. 
Although pregnancy, overdose and cancer are not always serious by regulatory definition, 
these events must be handled as SAEs (See Section 7.5 for reporting pregnancies). 
NOTE: The following hospitalizations are not considered SAEs: 
• a visit to the emergency room or other hospital department lasting less than 24 hours that 
does not result in admission (unless considered an “important medical event” or a 
life-threatening event) 
• elective surgery planned before signing consent 
• admissions as per protocol for a planned medical/surgical procedure 
• routine health assessment requiring admission for baseline/trending of health status (e.g., 
routine colonoscopy) 
• medical/surgical admission for purpose other than remedying ill health state that was 
planned before study entry. Appropriate documentation is required in these cases. 
• admission encountered for another life circumstance that carries no bearing on health 
status and requires no medical/surgical intervention (e.g., lack of housing, economic 
inadequacy, caregiver respite, family circumstances, administrative). 
 
Adverse events can be spontaneously reported or elicited during open-ended questioning, 
examination, or evaluation of a subject. To prevent reporting bias, subjects should not be 
questioned regarding the specific occurrence of one or more adverse events. 
 


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34 
If known, the diagnosis of the underlying illness or disorder should be recorded, rather than 
its individual symptoms. The following information should be captured for all AEs: onset, 
duration, intensity, seriousness, relationship to investigational product, action taken, and 
treatment required. If treatment for the event was administered, it should be recorded in the 
medical record. The investigator must supply BMS and the IRB/IEC with any additional 
information requested, notably for reported deaths of subjects. 
All SAEs, whether related or unrelated to belatacept, and all pregnancies must be reported to 
BMS (by the investigator or designee) within 24 hours.  
All SAEs should be reported via confirmed facsimile (fax) transmission, or scanned and 
reported via electronic mail to:  
SAE Email Address: Worldwide.Safety@BMS.com 
SAE Fax Number: <<609-818-3804>> 
For studies conducted under an Investigator IND, any event that is both serious and 
unexpected must be reported to the Food and Drug Administration (FDA) as soon as possible 
and no later than 7 days (for a death or life-threatening event) or 15 days (for all other 
SAEs) after the investigator’s or institution’s initial receipt of the information. BMS will 
be provided with a simultaneous copy of all adverse events filed with the FDA. SAEs should be 
reported on MedWatch Form 3500A, which can be accessed at: 
http://www.accessdata.fda.gov/scripts/medwatch/. 
 
MedWatch SAE forms should be sent to the FDA at: 
MEDWATCH 
5600 Fishers Lane 
Rockville, MD 20852-9787 
Fax: 1-800-FDA-0178 (1-800-332-0178) 
http://www.accessdata.fda.gov/scripts/medwatch/ 
All SAEs should simultaneously be faxed or e-mailed to BMS at: 
Global Pharmacovigilance & Epidemiology 
Bristol-Myers Squibb Company 
Fax Number: 609-818-3804 
Email: Worldwide.safety@bms.com 
If an ongoing SAE changes in its intensity or relationship to study drug or if new information 
becomes available, a follow-up SAE report should be sent within 24 hours to the BMS using 
the same procedure used for transmitting the initial SAE report. All SAEs should be followed 
to resolution or stabilization. 
The collection of non-serious adverse event (NSAE) information should begin at initiation of 
study drug. NSAE information should also be collected from the start of a placebo lead-in 
period or other observational period intended to establish a baseline status for the subjects. 
NSAEs should be followed to resolution or stabilization, or reported as SAEs if they become 


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35 
serious. Follow-up is also required for NSAEs that cause interruption or discontinuation of 
study drug, or those that are present at the end of study treatment as appropriate. All 
identified NSAEs must be documented appropriately. 
 
9.3 Potential Drug-Induced Liver Injury (DILI) 
 
Wherever possible, timely confirmation of initial liver-related laboratory abnormalities 
should occur prior to the reporting of a potential DILI event. All occurrences of potential 
DILIs, meeting the defined criteria, must be reported as SAEs (see Section 7.2.1 for reporting 
details). 
Potential drug induced liver injury is defined as  
1. AT (ALT or AST) elevation > 3 times upper limit of normal (ULN) 
AND 
2. Total bilirubin > 2 times ULN, without initial findings of cholestasis (elevated serum 
alkaline phosphatase), 
AND 
3. No other immediately apparent possible causes of AT elevation and 
hyperbilirubinemia, including, but not limited to, viral hepatitis, pre-existing chronic or 
acute liver disease, or the administration of other drug(s) known to be hepatotoxic. 
 
 
9.4 Adverse Events Related to Study Conditions  
If the investigator believes that an SAE is not related to the drug product, but is  
potentially related to the conditions of the study, (such as withdrawal of previous therapy,  
or complication of a trial procedure), the relationship should be specified in the narrative  
section of the SAE page of the CRF.  
 
 
9.5 Laboratory Test Abnormalities  
All laboratory test values captured as part of the study should be recorded on the  
appropriate laboratory test results pages of the CRF, or be submitted electronically from a  
central laboratory. In addition, in order for BMS to collect additional information about  
clinically important laboratory abnormalities, at a minimum, the following laboratory  
abnormalities should be captured on the AE or SAE pages of the CRF as appropriate:  
 
• Any laboratory test result that meets the criteria for a SAE  
• Any laboratory abnormality that required the subject to have drug product  
discontinued or interrupted  
• Any laboratory abnormality that required the subject to receive specific corrective  
therapy.  
It is expected that wherever possible, the clinical, rather than the laboratory term would  
be used by the reporting investigator (e.g., ‘anemia’ vs. ‘low hemoglobin value’).  
 
9.6 Other Safety Considerations  


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36 
Any clinically significant changes noted during interim or final physical examinations,  
ECGs, x-rays, and any other potential safety assessments, whether or not these  
procedures are required by the protocol, should also be recorded on the appropriate AE  
page of the CRF (i.e., non-serious or serious).  
 
9.7 Pregnancy  
Sexually-active WOCBP must use an effective method of birth control during the course  
of the study, in a manner such that risk of failure is minimized. (See Section 5.1 for  
definition of WOCBP).  
 
Precautions 
WOCBP should be advised against becoming pregnant from the beginning of the study 
until 8 weeks or 5 half lives (whichever is greater) after administration of the last dose.  
Subjects should be instructed to contact the Investigator immediately if pregnancy is 
suspected (e.g., missed or late menstrual period). Male subjects should be advised to 
avoid unprotected sex throughout the study and until sperm produced during the period 
of drug exposure has been cleared. Drug-exposed sperm may be present in the semen 
for 3 months following the passage of 5 half lives of the study drug.  
Subjects should be advised to notify the Investigator of any change in birth control 
method during exposure to Study Drug or if they need to take any prescription drug or 
other medication not prescribed by the Investigator. The Investigator should be aware of 
changes in birth control method so that the use of a study-prohibited contraceptive 
method is identified. 
Hormonal contraceptives could be depressed from drug-drug interactions with the 
study drug or other concomitant medications. Hormonal contraceptives should not be 
used to prevent pregnancy until a Drug-Drug Interaction (DDI) study has verified that 
the pharmacokinetics of the hormone contraception remain at therapeutic levels, and 
this can be substantiated by appropriate PK studies and the investigator believes that 
this is appropriate for the subject. 
Testing Methods and Timing 
Methods for Pregnancy Testing 
Blood or urine testing is acceptable. Urine pregnancy tests must have a minimum test 
sensitivity of at least 25 IU/L. Kits measuring either total human chorionic gonadotropin 
(hCG) or the beta (β) fraction.  
 
Timing of Pregnancy Testing  
Outpatient Trials: WOCBP should be tested: 
• At screening 


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37 
• Every 3 months during period of study participation 
• Whenever pregnancy is suspected 
 
Pregnancy Reporting 
In the event that a WOCBP becomes pregnant during a clinical trial, the implications (on 
the health of the mother and fetus) of treatment suspension must be reviewed and 
considered. If it is determined that continued treatment is desirable, the IRB must 
approve continued treatment and participation.  
 
The investigator must immediately notify BMS of this event and complete and forward a 
Pregnancy Surveillance Form to BMS within 24 hours and in accordance with SAE 
reporting procedures described in Section 7.2.1. The pregnancy should also be reported 
to the National Transplant Pregnancy Registry. (U.S.) 
 
Follow-up information regarding the course of the pregnancy, including perinatal and 
neonatal outcome and, where applicable, offspring information must be reported on the 
Pregnancy Surveillance Form.  
 
Any pregnancy that occurs in a female partner of a male study participant should be 
reported to BMS. Information on this pregnancy will be collected on the Pregnancy 
Surveillance Form. If required by local regulations or IRB/IEC requirements, the female 
partner should be asked to sign a Medical Information Release Form to acknowledge 
agreement for disclosure of information if additional information is requested by BMS. 
(Some countries may require the acknowledgement prior to the initial report of 
pregnancy.) 
Pregnancy Reporting Check List 
• 
Confirm in the pregnancy report if study medication has been 
discontinued. 
• 
Enter positive pregnancy test results on the Case Report Form. 
• 
Submit a completed Pregnancy Surveillance Form to BMS and report the 
pregnancy to the National Transplant Pregnancy Registry (U.S.) 
• 
Provide clarification or follow-up information that is requested by BMS. 
 
Pregnancy Counseling 
When a pregnancy is confirmed, the investigator should offer counseling to both parents 
regarding potential adverse health effects including teratogenic effects. A prenatal 
evaluation should be provided, along with a list of health care providers specialized in 
obstetrical care if this information is available. Available information should be reviewed 
on the potential for complications and possibility for birth effects due to exposures from 


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38 
study drug(s). The pregnant subject (or the pregnant partner of a male subject) should 
be requested to sign a Medical Information Release Form. If required by local regulations 
or IRB/IEC requirements, the subject should be asked to sign a new Informed Consent 
Form (ICF) if BMS requests additional information  
If the pregnant patient is not of legal age, the parent or legal guardian may need to be 
involved in the conversations. 
 
 
10 ADMINISTRATIVE SECTION  
 
10.1 Compliance with the Protocol and Protocol Revisions  
The study shall be conducted as described in this approved protocol. All revisions to the  
protocol must be discussed with BMS. The investigator should not implement any deviation 
or change to the protocol without prior review and documented  
approval/favorable opinion from the IRB/IEC of an amendment, except where necessary  
to eliminate an immediate hazard(s) to study subjects. Any significant deviation must be  
documented in the CRF.  
 
If a deviation or change to a protocol is implemented to eliminate an immediate hazard(s)  
prior to obtaining IRB/IEC approval/favorable opinion, as soon as possible the deviation  
or change will be submitted to:  
 
• IRB/IEC for review and approval/favorable opinion  
• BMS  
• Regulatory authority(ies), if required by local regulations.  
Documentation of approval signed by the chairperson or designee of the IRB(s)/IEC(s)  
must be sent to BMS.  
 
If the revision is an administrative letter, investigators must inform their IRB(s)/IEC(s).  
 
If an amendment substantially alters the study design or increases the potential risk to the  
subject: (1) the consent form must be revised and submitted to the IRB(s)/IEC(s) for  
review and approval/favorable opinion; (2) the revised form must be used to obtain  
consent from subjects currently enrolled in the study if they are affected by the  
amendment; and (3) the new form must be used to obtain consent from new subjects prior  
to enrollment.  
 
10.2 Informed Consent  
Investigators must ensure that subjects or their legally acceptable representatives are  
clearly and fully informed about the purpose, potential risks, and other critical issues  
regarding clinical trials in which they volunteer to participate.  
 
 
10.2.1 Informed Consent Procedures  


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39 
Preparation of the consent form is the responsibility of the investigator, and must include  
all elements required by ICH, GCP, and applicable regulatory requirements, and must  
adhere to GCP and to the ethical principles that have their origin in the Declaration of  
Helsinki. The consent form must also include a statement that regulatory  
authorities have direct access to subject records. Prior to the beginning of the study, the  
investigator must have the IRB/IEC’s written approval/favorable opinion of the written  
informed consent form and any other information to be provided to the subjects.  
 
The investigator must provide the subject or legally acceptable representative with a copy  
of the consent form and written information about the study in the language in which the  
subject is most proficient. The language must be non-technical and easily understood.  
The investigator should allow time necessary for subject or subject's legally acceptable  
representative to inquire about the details of the study, then informed consent must be  
signed and personally dated by the subject or the subject's legally acceptable  
representative and by the person who conducted the informed consent discussion. The  
subject or legally acceptable representative should receive a copy of the signed informed  
consent and any other written information provided to study subjects prior to subject's  
participation in the trial.  
 
10.2.2 Subjects Unable to Give Informed Consent  
10.2.2.1 Minors  
Investigators must follow standard procedures to ensure that the minor’s parents or  
legally acceptable representatives are able to give fully informed written consent. (In the  
event that the parents or legal guardians are unable to read, then follow ICH  
Guideline 4.8.9). Whenever feasible, minors who are judged to be of an age of reason  
must also give their written assent by signing and dating the completed informed consent.  
All local laws, rules and regulations regarding informed consent of minors must be  
followed.  
 
10.2.2.2 Subjects Experiencing Acute Events or Emergencies  
A legally acceptable representative or legal guardian must provide informed consent  
when consent of the subject is not possible prior to clinical trial participation, e.g., for  
subjects experiencing an acute medical event such as myocardial infarction or stroke.  
Informed consent of the subject must additionally be obtained if they become capable of  
making and communicating their informed consent during the clinical trial. All local  
laws, rules and regulations regarding informed consent of adult subjects incapable of  
giving informed consent must be followed.  
 
10.2.2.3 Mentally Impaired or Incapacitated Subjects  
Investigators should determine whether or not a mentally impaired or incapacitated  
subject is capable of giving informed consent and should sign a statement to that effect. If  
the subject is deemed mentally competent to give informed consent, the investigator  
should follow standard procedures. If the subject is deemed not to be mentally competent  
to give informed consent, a fully informed legal guardian or legally acceptable  
representative can be asked to give consent for, or on behalf of, the subject. All local  


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40 
laws, rules and regulations regarding informed consent of mentally impaired or  
incapacitated subjects must be followed.  
 
Subjects who are involuntarily hospitalized because of mental illness must not be  
enrolled in clinical trials.  
 
10.2.2.4 Other Circumstances  
Imprisonment or the compulsory detention for treatment of either a psychiatric or  
physical (e.g., infectious disease) illness must not be enrolled in clinical trials.  
 
In circumstances where a subject’s only access to treatment is through enrollment in a  
clinical trial, e.g., for subjects in developing countries with limited resources or for  
subjects with no marketed treatment options, the investigator must take special care to  
explain the potential risks and benefits associated with the trial and ensure that the subject  
is giving informed consent.  
 
When a subject may be in a dependent relationship with the investigator, a well-informed  
physician who is not engaged in the clinical trial and is completely independent of the  
relationship between the subject and investigator should obtain the subject’s informed  
consent.  
 
10.2.3 Illiterate Subjects  
If the subject or legally acceptable representative is unable to read, a reliable and  
independent witness should be present during the entire informed consent discussion. The  
choice of the witness must not breach the subject’s rights to confidentiality. A reliable  
independent witness is defined as one not affiliated with the institution or engaged in the  
investigation. A family member or acquaintance are appropriate independent witnesses.  
After the subject or legally acceptable representative orally consents and has signed, if  
capable, the witness should sign and personally date the consent form attesting that the  
information is accurate and that the subject or legally acceptable representative has fully  
understood the content of the informed consent agreement and is giving true informed  
consent.  
 
10.2.4 Update of Informed Consent  
The informed consent and any other information provided to subjects or their legally  
acceptable representatives should be revised whenever important new information  
becomes available that is relevant to the subject's consent, and should receive IRB/IEC  
approval/favorable opinion prior to use. The investigator, or a person designated by the  
investigator, should fully inform the subject or the subject's legally acceptable  
representative of all pertinent aspects of the study and of any new information relevant to  
the subject's willingness to continue participation in the study. This communication  
should be documented.  
 
During a subject's participation in the trial, any updates to the consent form and any  
updates to the written information will be provided to the subject.  


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10.3 Monitoring for Protocol Compliance  
Representatives of BMS must be allowed to visit all study site locations periodically to  
assess the data, quality and study integrity. On site, they will review study records and 
directly compare them with source documents, discuss the conduct of the study with the  
investigator, and verify that the facilities remain acceptable.  
 
In addition, the study may be evaluated by BMS internal auditors and government  
inspectors who must be allowed access to CRFs, source documents, and other study files.  
BMS audit reports will be kept confidential.  
 
THE INVESTIGATOR MUST NOTIFY BMS PROMPTLY OF ANY INSPECTIONS  
SCHEDULED BY REGULATORY AUTHORITIES, AND PROMPTLY FORWARD  
COPIES OF INSPECTION REPORTS TO BMS.  
 
10.4 Records and Reports  
An investigator is required to prepare and maintain adequate and accurate case histories  
designed to record all observations and other data pertinent to the investigation on each  
individual treated with the drug product. 
 
The confidentiality of records that could identify subjects must be protected, respecting  
the privacy and confidentiality rules in accordance with the applicable regulatory  
requirement(s).  
 
10.5 Institutional Review Board (IRB)  
Before study initiation, the investigator must have written and dated approval/favorable  
opinion from the IRB/IEC for the protocol, consent form, subject recruitment  
materials/process (e.g., advertisements), and any other written information to be provided  
to subjects. The investigator or sponsor should also provide the IRB/IEC with a copy of  
the IB or product labeling and information to be provided to subjects and any updates.  
 
The investigator or sponsor should provide the IRB/IEC with reports, updates, and other  
information (e.g., ESR, amendments, administrative letters) according to regulatory  
requirements or institution procedures.  
 
10.6 Records Retention  
The investigator must retain drug product disposition records, copies of CRFs  
(or electronic files), and source documents for the maximum period required by  
applicable regulations and guidelines, or institution procedures, or for the period  
specified by the sponsor, whichever is longer. The investigator must contact BMS prior  
to destroying any records associated with the study.  
 
BMS will notify the investigator when the trial records are no longer needed.  
 
If the investigator withdraws from the study (e.g., relocation, retirement), the records shall  


Mechanisms of belatacept effect on alloimmunity and antiviral response after 
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42 
be transferred to a mutually agreed upon designee (e.g., another investigator, IRB). Notice  
of such transfer will be given in writing to BMS.  
 
 
11 GLOSSARY OF TERMS AND LIST OF ABBREVIATIONS  
 
11.1 Glossary of Terms  
Not applicable.  
 
11.2 List of Abbreviations  
Term Definition  
ACR American College of Rheumatology  
AE adverse event  
ANOVA analysis of variance  
APC antigen-presenting cell  
BCG Bacille Calmette-Guerin  
BMS Bristol-Myers Squibb  
BMS-188667 CTLA4Ig (abatacept)  
BMS-224818 LEA29Y (belatacept)  
BP blood pressure  
BPAR biopsy-proven acute rejection  
BUN blood urea nitrogen  
C2 plasma concentration 2 hours post-dose  
CAN chronic allograft nephropathy  
CI confidence interval  
CIT cold ischemia time  
CLT total body clearance  
CMV Cytomegalovirus  
CNI calcineurin inhibitor  
CRF case report form  
CsA cyclosporine  
CSBPAR clinically-suspected and biopsy-proven acute rejection 
CTC Common Toxicity Criteria  
CTLA4Ig BMS-188667 (abatacept)  
CVA cerebrovascular accident  
DBP diastolic blood pressure  
DCD donor with cardiac death  
DGF delayed graft function  
DSMB Data Safety Monitoring Board  
D5W dextrose 5% in water for injection  
Term Definition  
 
EAC Event Adjudication Committee  
EBV Epstein-Barr virus  
ECD extended criteria donor  


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43 
ECG electrocardiogram  
ESR expedited safety report  
ESRD end-stage renal disease  
FPG fasting plasma glucose  
GCP Good Clinical Practice  
GFR glomerular filtration rate  
HbA1c hemoglobin A1c  
HCG-human chorionic gonadotropin  
HDL high-density lipoprotein  
HIV human immunodeficiency virus  
HLA human leukocyte antigen  
IB Investigator Brochure  
ICH International Conference on Harmonization  
Ig immunoglobulin  
IL interleukin  
IRB Institutional Review Board  
ITT intent-to-treat  
i.v. intravenous(ly)  
IVRS interactive voice response system  
KM Kaplan-Meier  
LEA29Y BMS-224818 (belatacept)  
LDL low-density lipoprotein  
LI less intensive  
MAP mean arterial pressure  
MedDRA Medical Dictionary of Drug Regulatory Activities  
MI more intensive  
MMF mycophenolate mofetil (CellCept.)  
NKF-K DOQI National Kidney Foundation Kidney Disease Outcomes Quality  
Initiative  
NSS 0.9% normal saline solution  
OR operating room  
PCR polymerase chain reaction  
PG plasma glucose  
PK pharmacokinetic(s)  
p.o. oral(ly)  
PPD purified protein derivative (test)  
PRA panel reactive antibodies  
PTDM post-transplant diabetes mellitus  
PTLD post-transplant lymphoproliferative disorder  
QoL quality of life  
Term Definition  
 
RA rheumatoid arthritis  
SAE serious adverse event  
SBP systolic blood pressure  


Mechanisms of belatacept effect on alloimmunity and antiviral response after 
kidney transplantation 
 
 
44 
SCr serum creatinine  
SD standard deviation  
SeBP seated blood pressure  
SF-36 Short Form-36  
TB tuberculosis  
TGs triglycerides  
TLC therapeutic lifestyle changes  
UNOS United Network of Organ Sharing  
VSS steady-state volume of distribution  
WBC white blood cell  
WOCBP women of childbearing potential  
 
 
 
 
 


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45 
 
 
12 REFERENCES  
 
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Vincenti F, Larsen CP, Alberu J, et al. Three-Year Outcomes from BENEFIT, a 
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2. 
Medina Pestana JO, Grinyo JM, Vanrenterghem Y, et al. Three-Year Outcomes From 
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3. 
Wekerle T, Grinyó JM. Belatacept: from rational design to clinical application. 
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6. 
Casey MJ, Meier-Kriesche H-U. Calcineurin inhibitors in kidney transplantation. Current 
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7. 
Korin YD, Lee C, Gjertson DW, et al. A Novel Flow Assay for the Detection of Cytokine 
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Racusen LC, Solez K, Colvin RB, et al. The Banff 97 working classification of renal 
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Naesens M, Kuypers DRJ, Sarwal M. Calcineurin Inhibitor Nephrotoxicity. Clinical 
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Rostaing L, Massari P, Garcia VD, et al. Switching from Calcineurin Inhibitor-based 
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