A Study to Investigate DSA Rebound in Patients Treated With Imlifidase Prior to Transplantation
- Conditions
- Kidney Transplantation in Highly Sensitized Patients
- Registration Number
- NCT05049850
- Lead Sponsor
- Hansa Biopharma AB
- Brief Summary
The purpose of this study is to assess whether imlifidase in combination with bortezomib, belatacept, rituximab and IVIg can suppress donor specific antibodies (DSA) and the occurrence of antibody-mediated rejection (AMR) in highly sensitized patients with chronic kidney disease with a positive crossmatch towards their living donor during a period of 3 months from transplantation.
- Detailed Description
Imlifidase is an immunoglobulin G (IgG)-degrading enzyme of Streptococcus pyogenes that is highly specific for IgG. The cleavage of IgG generates one F(ab')2- and one homodimeric Fc-fragment and efficiently neutralizes Fc-mediated activities of IgG. Clinical studies with imlifidase have demonstrated that the treatment enables transplantation in patients otherwise highly unlikely to be transplanted, by converting a positive crossmatch to a negative.
However, as with other desensitization methods, DSA tend to reappear within weeks after treatment and transplantation, which may cause AMR and increased risk of graft loss. In this study, treatment with imlifidase in combination with approved drugs that prevent or suppress DSA rebound by targeting antibody-producing plasma-cells and their B-cell precursors is suggested. These drugs include (i) bortezomib, a proteasome inhibitor which has activity against mature plasma cells, the source of DSA, (ii) belatacept, a fusion protein which is crucial in blocking T-cell co-stimulation and which is effective in reducing de novo DSA generation in humans, (iii) rituximab, an anti-CD20 monoclonal antibody that targets B-cells and which is an immunomodulatory agent, and (iv) intravenous immunoglobulin (IVIg) which is commonly used in desensitization regimens and for the treatment of AMR.
After being informed about the study and potential risks, all patients giving written informed consent will undergo a 2-week screening period to determine eligibility for study entry. Patients who meet the eligibility requirements will then start treatment with belatacept and bortezomib about 3 weeks prior to the imlifidase infusion and transplantation. Rituximab will be initiated 8 days after transplantation and IVIg 10 days after transplantation. Induction and maintenance immunosuppression will also be administered. The patients will be hospitalized for approximately 2 weeks following transplantation and after that 9 follow-up visits to the clinic will take place up to 6 months after transplantation.
Recruitment & Eligibility
- Status
- ACTIVE_NOT_RECRUITING
- Sex
- All
- Target Recruitment
- 3
-
Signed Informed Consent obtained before any trial-related procedures
-
Male or female age 18 to 70 years at the time of screening
-
Highly sensitized patients registered on the UNOS waiting list for kidney transplantation, with either of the following:
- cPRA ≥ 99.9%
- cPRA ≥ 98% and have been in kidney paired donation or kidney paired exchange programs for at least 1 year
-
A positive crossmatch towards a living donor
-
Willingness and ability to comply with the protocol
- Previous treatment with imlifidase
- Previous high dose IVIg treatment (2 g/kg) within 28 days prior to imlifidase treatment
- Breast-feeding or pregnancy
- Women of child-bearing potential not willing or able to practice FDA-approved forms of contraception. Two medically acceptable methods of highly effective contraception must be used for the duration of the study (e.g. oral, transdermal, intravaginal, injectable or implantable contraceptive; intrauterine device; intrauterine hormone-releasing system; vasectomized partner; bilateral tubal occlusion; or double-barrier method). For a woman to be considered postmenopausal this ascertainment must be made according to medical records and clinical history and may be aided by measurement of elevated postmenopausal serum gonadotropin levels (FSH).
- ABO blood group incompatible transplantations (A2 and A2B kidneys will not be accepted for B recipients)
- Positive serology for HIV
- Clinical signs of HBV, HCV, CMV, or EBV infection
- EBV seronegative or with unknown EBV serostatus
- Positive SARS-CoV-2 tests at any time point from screening to transplantation
- Active tuberculosis
- Ongoing serious infections as judged by the investigator
- Severe other conditions requiring treatment and close monitoring e.g. cardiac failure ≥ grade 4 (New York Heart Association), unstable coronary disease or oxygen dependent respiratory disease
- A history of a proven hypercoagulable condition
- Present, or history of, thrombotic thrombocytopenic purpura (TTP) or known familial history of TTP
- Intake of investigational drugs (other than imlifidase) within 5 half-lives
- Contemporaneous participation in a medical device study
- Known allergy/sensitivity (except local reactions) to imlifidase or to any drug (or the excipients) specified in the protocol
- Known mental incapacity or language barriers precluding adequate understanding of the Informed Consent information and the trial activities
- Inability by the judgement of the investigator to participate in the trial for any other reason
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- SINGLE_GROUP
- Primary Outcome Measures
Name Time Method Proportion of patients with DSA rebound Up to 3 months after transplantation The recurrence of DSA may cause AMR and increased risk of graft loss.
Rebound of DSA is defined as:
1. If positive flow cytometry crossmatch test (FCXM) at screening is due to low titer, non-complement binding (C1q-negative) DSAs;
1. Immuno-dominant DSA: a post-transplant MFI value that is ≥50% the pre-imlifidase value OR
2. Total DSAs: a post-transplant serum where ≥50% of the DSA prior to imlifidase have a MFI value ≥50% of the pre-transplant MFI value AND the sum MFI must be ≥50% of the pre-transplant value
2. If FCXM at screening is due to high titer, complement binding (C1q-positive) DSAs;
1. Immuno-dominant DSA: a post-transplant MFI value at 1:16 dilution that is ≥8000 MFI OR
2. Total DSAs: a post-transplant 1:16 diluted serum where ≥50% of the DSA prior to imlifidase have an MFI value that is ≥50% of the pre-transplant MFI value AND the sum MFI must be ≥8000
- Secondary Outcome Measures
Name Time Method Proportion of patients with kidney biopsy proven AMR Up to 6 months after transplantation The standardized international Banff classification 2019 for assessment of renal allograft biopsies will be used to assess AMRs reported from the study based on for cause and protocol biopsies.
Proportion of patient with DSA rebound Up to 6 months after transplantation See description to primary outcome measure
Proportion of patients with negative FCXM Up to 24 hours after imlifidase treatment Imlifidase is highly efficacious in converting a positive crossmatch to a negative
Kidney function assessed by protein/creatinine ratio in urine Up to 6 months after transplantation The protein/creatinine ratio in urine is a measure of kidney function. Will be measured unless patients are anuric.
Graft survival 6 months after transplantation Graft survival will be summarized by end of trial.
Kidney function assessed by estimated glomerular filtration rate (eGFR) Up to 6 months after transplantation Estimated glomerular filtration rate (eGFR) is a measure of kidney function. eGFR will be calculated as described by the modification of diet in renal disease (MDRD) equation.
eGFR for a kidney with normal function is 90 mL/min/1.72m2. Kidney disease is characterised by a decreased eGFR.
value.Imlifidase pharmacokinetics (Vz) Within 4 hours before imlifidase dose until Day 15 Vz = Apparent volume of distribution during terminal phase
Levels of DSA Within 4 hours before imlifidase until Day 181 Analysis of DSAs before and after imlifidase will be done. The mean fluorescence intensity (MFI) will be presented for the individual patients' DSAs.
Safety as measured by adverse events (AEs) Up to 6 months after transplantation Safety is assessed as type, frequency and intensity of adverse events (AEs)/Serious adverse events (SAEs) including clinically relevant changes in clinical laboratory tests, vital signs and ECG)
Imlifidase pharmacokinetics (AUC) Within 4 hours before imlifidase dose until Day 15 AUC = Area under the imlifidase plasma concentration versus time curve
Levels complement binding (C1q) DSA Within 4 hours before imlifidase until Day 181 Analysis of C1q DSAs before and after imlifidase will be done. The mean fluorescence intensity (MFI) will be presented for the individual patients' C1q DSAs.
Patients survival 6 months after transplantation Patient survival will be summarized by end of trial.
Kidney function assessed by creatinine Up to 6 months after transplantation P-creatinine is a measure of kidney function.
Imlifidase pharmacokinetics (Cmax) Within 4 hours before imlifidase dose until Day 15 Cmax = Maximum observed plasma concentration of imlifidase following dosing
Imlifidase pharmacokinetics (tmax) Within 4 hours before imlifidase dose until Day 15 tmax = Time point for maximum observed plasma concentration of imlifidase following dosing
Imlifidase pharmacokinetics (t1/2) Within 4 hours before imlifidase dose until Day 15 t1/2 = Terminal half-life of imlifidase
Imlifidase pharmacokinetics (CL) Within 4 hours before imlifidase dose until Day 15 CL = Clearance of imlifidase
Pharmacodynamics Within 4 hours before imlifidase dose until Day 10 Concentration of IgG in patient serum will be measured. Scoring of IgG fragments will be done.
Anti-drug antibodies (ADA) levels Up to 6 months after imlifidase Immunogenicity towards imlifidase will be assessed by the measurement of ADA levels in patient serum using a customized ImmunoCAP analysis.
Change in patient-reported life participation, as measured PROMIS-SF-8a At screening and Day 181 The PROMIS Social Health domain "Ability to participate in social roles \& activities PROMIS-SF-8" will be used as a measure of the patients' health related quality of life.