Eculizumab Therapy for Chronic Complement-Mediated Injury in Kidney Transplantation

Phase 1

Completed

Brief Summary: This study is designed to assess the effectiveness of eculizumab in recipients of kidney transplantation with donor-specific antibodies (DSA) and worsening kidney function and to assess if eculizumab improves endothelial cell injury in the kidney.

The investigators hypothesize that complement inhibition with eculizumab will reduce allograft injury, resulting from less complement-mediated injury of endothelial cells and less endothelial cell activation.

Detailed Description: This study will address the clinical challenge that currently exists in the management of kidney transplant recipients who have developed de novo DSA, have deteriorating graft function, yet have no established treatment alternative.

This is a randomized, open-label, pilot intervention trial. Post transplant patients with deteriorating renal function (defined as 20% reduction in GFR) will be screened for the development of DSA and biopsied for the presence of C4d deposition. All patients with DSA and those meeting inclusion/exclusion criteria will undergo protocol renal biopsy and will be assessed for C4d deposition. Participants will be randomized to treatment with eculizumab plus standard of care (SOC) or SOC only. Randomization will be stratified by C4d status (C4d+/C4d-) with 10 subjects (7 eculizumab, 3 SOC only) in each stratum.

Eculizumab is an antibody that has been developed to inhibit the complement protein C5. Eculizumab will be delivered via IV according to the following schedule:

* Eculizumab Induction 600mg IV every 7 days for 4 doses

* Eculizumab 900mg IV 7 days later

* Eculizumab Maintenance 900mg IV every 14 days for total of 26 weeks

Recruitment & Eligibility

Inclusion Criteria

Kidney transplant recipients greater than 6 months from the date of transplant
Must be on standard immunosuppression: tacrolimus, mycophenolate mofetil, prednisone and have stable tacrolimus trough levels over past 3 months
Deteriorating renal function, as defined by 20% reduction in GFR (MDRD calculation)
Presence of DSA, as defined as MFI > 1100
Renal biopsy demonstrating no diffuse, irreversible end-stage organ injury (i.e. stage IV Fibrosis)
Renal biopsy demonstrating C4d deposition (stratum 1) or no C4d deposition (stratum 2)

Exclusion Criteria

History of CMV, BK, HSV or other viral infections
History of chronic, recurrent bacterial infections
Evidence of tubulitis on renal biopsy or other morphological features of acute cellular rejection or acute humoral rejection
Renal biopsy demonstrating diffuse, irreversible end-stage organ injury
Absolute GFR < 25 (MDRD calculation)
Inability to provide informed consent
History of poor vascular access
Refusal to use double barrier contraception during study participation
Patients actively enrolled in other clinical trials

Arm && Interventions

Group	Intervention	Description
Eculizumab	eculizumab	eculizumab will be given in addition to standard immunosuppression regimen (oral tacrolimus or equivalent, MMF \[mycophenolate mofetil \], prednisone)

Primary Outcome Measures

Name	Time	Method
Baseline eGFR (Estimated Glomerular Filtration Rate)	Baseline
Estimated Glomerular Filtration Rate (eGFR) at Months 2,3,4,5,6	Months 2,3,4,5,6	Primary statistical analysis of change from baseline was conducted with mixed effects modeling providing calculated estimates.
Group Difference Percentage Change in 6-month Estimated Glomerular Filtration Rate (eGFR)	6 months	These data were calculated by mean 6-month eGFR minus baseline mean eGFR divided by baseline eGFR. Presented below are the between groups results. These results were derived from the results in the outcome "Estimated Glomerular Filtration Rate (eGFR) at Months 2,3,4,5,6".

Secondary Outcome Measures