Dosing Regimen of Eculizumab Added to Conventional Treatment in Positive Cross Match Living Donor Kidney Transplant

Phase 1

Completed

Conditions: Kidney Transplant

Interventions: Drug: Eculizumab

Registration Number: NCT00670774

Lead Sponsor: Mark Stegall

Brief Summary: A strongly positive crossmatch has long been considered an absolute contraindication to kidney transplantation and most patients with anti-human leukocyte antigen (HLA) antibody never were able to receive a kidney transplant. Over the past decade, significant progress has been made in overcoming early antibody-mediated renal allograft injury. Our group has performed more than 200 such transplants providing the possibility of transplant to previously untransplantable patients. Despite our best efforts, transplantation in these patients is still complicated by a high rate of acute humoral rejection (AHR).

Patients included in this study will be those who have demonstrable anti-HLA antibody specific for their living donor. It is our hypothesis that blockade of terminal complement activation at the time of transplant in combination with our current protocols will reduce the incidence of AHR in patients with anti-donor HLA antibody.

Detailed Description: The eculizumab dosing regimen was modified from that used in the treatment of paroxysmal nocturnal hemoglobinuria and consisted of 1200 mg immediately prior to transplantation, 600 mg on postoperative day 1, and 600 mg weekly thereafter for 4 weeks. At week 4, assessment of DSA levels was performed. Eculizumab was discontinued in patients whose DSA had significantly decreased (B flow crossmatch channel shift\<200). In patients with persistently high DSA and thus believed to have continued high risk for AMR, eculizumab treatment continued (1200 mg week 5, and then every 2 weeks). Another DSA assessment was performed at week 9 and eculizumab was discontinued if the B flow crossmatch channel shift was \<200.

The eculizumab group were compared to a historical control group consisting of consecutive transplants between 1/1/2005 and 1/10/2017 who met the inclusion criteria. The historical control group had been treated with a similar plasma exchange based protocol without eculizumab.

Recruitment & Eligibility

Status: COMPLETED

Sex: All

Target Recruitment: 31

Inclusion Criteria

18 years of age
Has end stage renal disease (ESRD) and is to receive a kidney transplant from a living donor (LD) to whom he/she has either:
1. A positive crossmatch requiring pretransplant desensitization (defined as a positive T-cell FCXM of greater than or equal to 300 but less than 450 prior to desensitization, or as a positive B-cell FCXM of > 300 but < 450 prior to desensitization with demonstrable Class II donor specific alloantibody (DSA) on solid-phase assays). Subsequent to desensitization, patient must have, at the time of transplant, a T-cell and B-cell FCXM less than 300; or
2. A positive crossmatch not requiring desensitization (defined as FCXM between 200 and 299)
Willing to comply with the protocol
Females of child-bearing potential must have a negative pregnancy test (serum β-HCG) and sexually active females must agree to use a reliable and medically approved method of contraception
Willing and able to give written informed consent
Vaccinated against Neisseria meningitides (quadrivalent vaccine), Pneumococcus or H. influenzae at least two weeks prior to beginning desensitization

Exclusion Criteria

Unstable cardiovascular condition
Previous splenectomy
Active bacterial or other infection which is clinically significant in the opinion of the investigator
Known or suspected hereditary complement deficiency
Participation in any other investigational drug study or was exposed to an investigational drug or device within 30 days of randomization
Pregnant, breast-feeding, or intending to conceive during the course of the study, including the two month follow-up period after drug discontinuation
Known hypersensitivity to the treatment drug or any of its excipients
History of illicit drug use or alcohol abuse within the previous year
History of meningococcal disease
Medical condition that, in the opinion of the investigator, might interfere with the patient's participation in the study, pose an added risk for the patient, or confound the assessment of the patient (e.g. severe cardiovascular or pulmonary disease)
Previously been enrolled in this trial.

Study & Design

Study Type: INTERVENTIONAL

Study Design: SINGLE_GROUP

Arm && Interventions

Group	Intervention	Description
Eculizumab	Eculizumab	Patients received eculizumab intravenously according to details provided in the intervention description.

Primary Outcome Measures

Name	Time	Method
Number of Subjects With Antibody-Mediated Rejection (AMR) in the First 3 Months After Living Donor Kidney Transplantation	up to 3 months	AMR can cause acute graft loss or shorten allograft survival. Renal allograft biopsies were obtained percutaneously using ultrasound guidance processed for light microscopy and immunofluorescence for peritubular capillary staining for C4d. All biopsies were reviewed by a pathologist in a blinded fashion. AMR was diagnosed using standard Banff criteria in combination with graft dysfunction (increase in serum creatinine \>/=0.3 mg/dL over nadir.)

Secondary Outcome Measures

Name	Time	Method
Number of Patients Developing High DSA Levels at Less Than or Equal to 3 Months	3 months	High DSA levels were defined as B flow cross match channel shift \>350 at any time point in the first 3 months.
Number of Patients Requiring Splenectomy	1 year	A splenectomy is a surgical operation involving removal of the spleen. Splenectomy was performed for severe AMR in the setting of a rising serum creatinine (usually \>2.0) and a rising serum DSA level despite daily plasma exchange treatments.
Graft Dysfunction in First Month Post Transplant	1 month	(Maximum serum creatinine-nadir serum creatinine)
Length of Follow-up	up to 15 months	Following the completion of dosing, subjects were to return for follow-up visits at 3 and 6 months post transplant to obtain biopsies and collect follow-up data. Subjects who continued the drug for 12 months were to receive their final assessment at 15 months.
Number of Subjects With Graft Survival at One Year	1 year	Graft survival means the kidney has not been rejected by the body.
Number of Subjects Receiving Posttransplant Plasma Exchange (PE)	up to one year	Plasma exchange is needed when there is poor kidney functioning, and donor specific alloantibody (DSA) is high
Transplant Glomerulopathy Incidence at One Year	1 year	Transplant glomerulopathy is a morphologic lesion of renal allografts that is characterized histologically by duplication and/or multilayering of the glomerular basement membrane. It is widely accepted as a manifestation of chronic antibody-mediated rejection (AMR). This is determined by histology.