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Study of Rituximab to Treat Chronic Renal Transplant Rejection (RituxiCAN-C4)

This study is ongoing, but not recruiting participants.
Sponsor:
Collaborators:
Medical Research Council
Roche Pharma AG
Information provided by (Responsible Party):
A. Dorling, King's College London
ClinicalTrials.gov Identifier:
NCT00476164
First received: May 18, 2007
Last updated: January 9, 2017
Last verified: January 2017
  Purpose

Purpose of clinical trial; Evaluate the effectiveness of rituximab in C4d+ CAN

Primary objective; To determine whether anti-CD20 therapy can stabilize or improve renal function and/or proteinuria in patients with C4d+, chronic (humoral) rejection in whom standard therapeutic approaches have failed.

Secondary objective (s);

  • To compare patient and graft survival between control and rituximab-treated groups
  • To evaluate the adverse effect profile of rituximab in this group
  • To correlate changes in circulating B cell numbers, anti-HLA and non-HLA Ab profiles and titre with responses to standard therapy and / or rituximab
  • To correlate changes in T cell responsiveness to alloantigens with responses to standard therapy and / or rituximab

Study Design; Prospective, randomised, two arm, open-labeled

Study Endpoints; Primary

  • Rate of deterioration in renal function, defined by slope of reciprocal creatinine plot, on samples taken 3-5 months post-randomisation.
  • Change in degree of proteinuria, where present, at 3-5 months post-randomisation 2˚ endpoints, determined at 3-5 months post-randomisation and at 1, 2 and 3 years post-recruitment are;
  • Rate of deterioration in renal function, defined by slope of reciprocal creatinine plot, determined by analysis of samples taken since previous assessment.
  • Patient survival
  • Graft survival
  • Incidence of culture positive infection
  • Incidence of malignancy
  • Degree of proteinuria
  • Changes in circulating CD20+ cells in peripheral blood
  • Changes in anti-graft Ab titres, (measured every 3 months)
  • Changes in T cell responsiveness to alloantigens (measured every 3 months).

Sample Size; 15 patients to be randomised to each arm (i.e. 30 patients randomised). Up to 120 patients will need to be enrolled into the study. In addition, in those participants that received a living donor kidney, these donors will be approached to provide up to 5 samples of blood to help with the in vitro analyses.

Summary of eligibility criteria;

  • Male or female renal allograft recipients 18-70 years of age
  • more than 6/12 post-transplantation
  • Either deteriorating allograft function on reciprocal creatinine plot or significant proteinuria or both.
  • C4d+/- CAN on renal allograft biopsy

Investigational medicinal product and dosage; Rituximab, 1g on day 0 and 1g on day 14

Active comparator product(s); None

Route(s) of administration; Intravenous infusion

Maximum duration of treatment of a subject; 14 days with rituximab. The treatment arms of the study, including optimisation period, formal run-in and post-randomisation phase lasts for 10 months post-recruitment.

Procedures; Screening & enrollment. Potentially eligible patients will be identified by screening renal allograft biopsies performed for 'creeping creatinine' and/or proteinuria. Recruitment by informed consent prior to enrollment.

Procedures; Baseline. In addition to routine tests, blood for anti-HLA and non-HLA antibody analysis and for peripheral blood mononuclear cell (PBMC) purification.

Procedures; Treatment period. 3 month run-in period on optimal conventional immunosuppressive therapy, preceded by up to 2 months to allow tailored-optimization. Patients will be reviewed at least six times in their normal transplant clinic appointments for routine blood biochemistry, full blood count and urine analysis. At the end of the run-in period, further blood will be taken for anti-graft antibody analysis and PBMC purification. Those patients in whom allograft function stabilises and/or proteinuria improves will have normal transplant clinic follow-up appointments and have blood taken for further anti-graft antibody and PBMC purification up to every 3 months for 3 years. Those with continued deterioration in either allograft function or persisting or worsening proteinuria will be randomised. These patients will be reviewed during their normal transplant clinic appointments until the primary end-point and will need to have at least 6 routine blood biochemistry, full blood count and urine analysis during the final 3 months of this period, post-randomisation. At the primary end-point, further blood will be taken for anti-graft antibody analysis and PBMC.

Procedures; End of Study. •Follow up will continue for 3 years, with blood taken for anti-graft antibody analysis and PBMC purification every three months

Procedures for safety monitoring during trial; Regular patient interviews and examination, routine haematological and biochemical analyses. Serious adverse events will be reported and forwarded to the sponsor, MHRA, LREC and Roche as appropriate The WLRATC transplant research committee will discuss the trial and any safety concerns at their regular three monthly meetings. Data will be reviewed after 30 and also after 60 people have been enrolled.

Criteria for withdrawal of patients on safety grounds; Serious adverse effects related to rituximab infusion


Condition Intervention Phase
Kidney Transplantation
Graft Rejection
Immunosuppression
Drug: Rituximab
Other: Control arm
Phase 4

Study Type: Interventional
Study Design: Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Open Label
Primary Purpose: Treatment
Official Title: Randomised Trial of Anti-Cd20 in C4d+ Chronic Allograft Nephropathy

Resource links provided by NLM:


Further study details as provided by King's College London:

Primary Outcome Measures:
  • Rate of deterioration in renal function, defined by slope of reciprocal creatinine plot [ Time Frame: 3-5 months post-randomisation ]
  • Change in degree of proteinuria, where present [ Time Frame: 3-5 months post-randomisation ]

Secondary Outcome Measures:
  • Rate of deterioration in renal function, defined by slope of reciprocal creatinine plot, determined by analysis of samples taken since previous assessment [ Time Frame: 1, 2 and 3 years post-recruitment ]
  • Patient survival [ Time Frame: 5 months post-randomisation and at 1, 2 and 3 years post-recruitment ]
  • Graft survival [ Time Frame: 5 months post-randomisation and at 1, 2 and 3 years post-recruitment ]
  • Incidence of culture positive infection [ Time Frame: 5 months post-randomisation and at 1, 2 and 3 years post-recruitment ]
  • Incidence of malignancy [ Time Frame: 5 months post-randomisation and at 1, 2 and 3 years post-recruitment ]
  • Degree of proteinuria [ Time Frame: 1, 2 and 3 years post-recruitment ]
  • Changes in circulating CD20+ cells in peripheral blood [ Time Frame: 5 months post-randomisation and at 1, 2 and 3 years post-recruitment ]
  • Changes in anti-graft Ab titres [ Time Frame: 3 monthly to 3 years post-recruitment ]
  • Changes in T cell responsiveness to alloantigens [ Time Frame: 3 monthly to 3 years post-recruitment ]

Enrollment: 62
Study Start Date: January 2007
Estimated Study Completion Date: April 2017
Primary Completion Date: May 2015 (Final data collection date for primary outcome measure)
Arms Assigned Interventions
Experimental: Rituximab
Infusion of 2 x 1g of rituximab, 14 days apart
Drug: Rituximab
2 doses of 1g 14 days apart
Other Name: Mabthera
Sham Comparator: 2 Other: Control arm
Continue of optimised oral immunosuppression

  Eligibility

Ages Eligible for Study:   18 Years to 70 Years   (Adult, Senior)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

  • Functioning kidney allograft (with estimated (e) GFR by MDRD >20) and be >6/12 post-transplantation
  • Deteriorating allograft function as defined by linear regression of reciprocal creatinine plot. Deterioration will be defined as a negative slope over at least the preceding 3 months (with at least 6 creatinines included) with an adjusted r2 >0.35 and a p value of ≤0.05 compared to horizontal baseline. Deterioration will be confirmed by reduction in Cockcroft-Gault (CG) eGFR over the same period (to exclude increases in body mass as a cause of a negative slope on reciprocal creatinine plots) OR significant proteinuria as assessed by a urine protein/creatinine ratio of ≥50
  • CAN, by Banff '97 criteria, and/or transplant glomerulopathy on renal allograft biopsy performed within 6/12 of enrolment
  • Diffuse, linear C4d deposition on at least 25% of peritubular capillary (PTC) and/or glomerular EC of renal transplant biopsy when assessed by immunoperoxidase or >50% of PTC (alone) when assessed by immunofluorescence OR PTCitis OR glomerulitis with combined PTC/g score of ≥2.

Exclusion Criteria:

  • Ages below 18 years of age
  • Suspicion of pregnancy confirmed by positive HCG pregnancy test
  • Untreated ureteric obstruction on ultrasound of allograft
  • History of acute allograft rejection in preceding 3/12
  • History of MI in preceding 3/12
  • History of malignancy in previous 5 years (excluding tumours limited to skin)
  • Symptomatic IHD
  • Recipient of simultaneous pancreas/kidney transplant
  • Recipient of ABO-incompatible kidney
  • Recipient who underwent an HLA desensitisation procedure prior to transplantation
  • Evidence, on examination of renal allograft biopsy specimen, of recurrent or de-novo disease (except IgA deposition in absence of mesangial proliferation)
  • Evidence, on examination of renal allograft biopsy specimen, of CNI toxicity IF ACCOMPANIED by mostly supra-therapeutic CNI trough levels in the 6 month period preceding biopsy.
  • Documented allergy to mouse or chimeric human/mouse proteins
  • HepBsAg+, HepBcAb+, HCV Ab+ or HIV+.
  Contacts and Locations
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Please refer to this study by its ClinicalTrials.gov identifier: NCT00476164

Locations
United Kingdom
University Hospital Birmingham
Birmingham, United Kingdom, B15 2LN
East Kent Hospitals University NHS Foundation Trust
Canterbury, United Kingdom, CT1 3NG
Univeristy Hospital of Wales
Cardiff, United Kingdom, CF14 4XW
Epsom & St Helier University Hospitals Trust
Carshalton, United Kingdom, SM5 1AA
Western Infirmary
Glasgow, United Kingdom, G11 6NT
Hull Royal Infirmary
Hull, United Kingdom, HU3 2JZ
St Jame's University Hospital
Leeds, United Kingdom, LS9 7TF
The Royal Free Hospital
London, United Kingdom, NW3 2PF
King's College London, Guy's Hospital
London, United Kingdom, SE 19RT
Imperial College London and West London Renal & Transplantation Centre
London, United Kingdom, W12 0NN
Manchester Royal Infirmary
Manchester, United Kingdom, M13 9WL
Sponsors and Collaborators
King's College London
Medical Research Council
Roche Pharma AG
Investigators
Principal Investigator: Anthony Dorling, PhD FRCP King's College London
  More Information

Responsible Party: A. Dorling, Professor of Transplant Inflammation and Repair, King's College London
ClinicalTrials.gov Identifier: NCT00476164     History of Changes
Other Study ID Numbers: 2006-002330-38
Study First Received: May 18, 2007
Last Updated: January 9, 2017

Keywords provided by King's College London:
chronic allograft nephropathy
C4d
Anti-CD20
B cells
Antibody

Additional relevant MeSH terms:
Rituximab
Antineoplastic Agents
Immunologic Factors
Physiological Effects of Drugs
Antirheumatic Agents

ClinicalTrials.gov processed this record on March 28, 2017