The Effect of Rituximab on the Development of Anti-Donor Antibodies

The Effect of Rituximab on the Development of Anti-Donor Antibodies and Resolution of B Cell Infiltration in the Renal Allograft of Patients Undergoing Rejection

The aim of the study is to find out if Rituximab, which is an antibody against specific white cells involved in rejection, when combined with standard anti-rejection treatment can more effectively reverse the rejection process.

Our hypothesis is that with acute rejection there is activation of B cells and the subsequent development of anti-donor antibodies that ultimately lead to graft loss. More effective therapy targeted at B cells may abort the development of anti-HLA antibodies, prevent renal injury and have a favorable effect on long-term graft outcome.

Study Overview

• Status: Completed
• Conditions: Renal Transplant Rejection
• Intervention / Treatment: Drug: Rituximab; Drug: No Rituximab

Detailed Description

This is a two center, randomized pilot study of the effects of Rituximab on treatment of acute rejection. A total of 24 patients (including patients transplanted at University of California San Francisco and University of Alabama Birmingham) will be enrolled in the study, 16 randomized to Rituximab and 8 to no-Rituximab (control arm). Fifteen (15) subjects will be recruited at UCSF with 10 patients randomized to Rituximab and 5 to no-Rituximab (control arm). If either center is a slow enroller the patient mix could be altered.

Procedures:

This is an open label trial of patients with rejection with B cell infiltrates on kidney biopsy who will be randomized to either receive Rituximab or no Rituximab in and 2:1 ratio. Patients who have rejection on kidney biopsy and on immunohistochemistry there is evidence of B cells infiltration will be enrolled in the study and randomized 2:1 to receive Rituximab or no Rituximab. Rituximab will be administered in 2 doses of 1,000 mg. The first dose will be administered while the patient is still in the hospital being treated for rejection and the second dose will be administered 2 weeks later in the outpatient facility in the GCRC at UCSF. The patients' acute rejection episode will be treated according to standard therapy as per the treating transplant physician. Below is the table (table 1) detailing when the patient will have blood drawn for flow cytometry, anti-HLA antibodies, PK studies, serum creatinine as well as 24 hour urine protein. At 3 months after enrollment in the study, the patient will undergo a follow-up biopsy to determine the extent of the resolution of the cellular infiltrate.

• Study Type: Interventional
• Enrollment (Actual): 18
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • Alabama
    • Birmingham, Alabama, United States, 35294
      • University of Alabama at Birmingham
  • California
    • San Francisco, California, United States, 94143
      • UCSF-Kidney Transplant Clinic

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 14 years to 61 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Recipients of a kidney transplant or kidney-pancreas transplant with predominant findings on kidney biopsy of acute rejection and the presence of as B cells by immunohistochemistry
• Patients between 18 and 65 years of age
• Patients known not to be allergic to Rituximab
• Able and willing to give written informed consent and comply with the requirements of the study protocol
• Adequate renal function as indicated by serum creatinine less than 6 mg/dL
• negative serum pregnancy test (for women of child bearing age)
• Men and women of reproductive potential must agree to use an acceptable method of birth control during treatment and for twelve months (1 year) after completion of treatment.
• Patients who have received a kidney-pancreas transplant.
• Patients who on immunohistochemistry have evidence of B cell infiltration

Exclusion Criteria:

• Patients who have undergoing multi-organ transplant except for kidney-pancreas patients.
• Patients who have been administered an experimental drug in the 3 months preceding enrollment in the study
• Receipt of a live vaccine within 4 weeks prior to randomization
• Previous Treatment with Rituximab (MabThera® / Rituxan®)
• History of severe allergic or anaphylactic reactions to humanized or murine monoclonal antibodies
• History of HIV (positive HIV, HIV conducted during screening if applicable)
• History of Hepatitis B and/or Hepatitis C (Hep B/C at screening)
• History of recurrent significant infection or history of recurrent bacterial infections
• Known active bacterial, viral fungal mycobacterial, or other infection (including tuberculosis or atypical mycobacterial disease, but excluding fungal infections of nail beds) or any major episode of infection requiring hospitalization or treatment with i.v. antibiotics within 4 weeks of screening or oral antibiotics within 2 weeks prior to screening
• Lack of peripheral venous access
• History of drug, alcohol, or chemical abuse within 6 months prior to screening
• Pregnancy (a negative serum pregnancy test should be performed for all women of childbearing potential within 7 days of treatment)
• Concomitant malignancies or previous malignancies within the last five years, with the exception of adequately treated basal or squamous cell carcinoma of the skin or carcinoma insitu of the cervix.
• History of psychiatric disorder being treated with medications
• Significant cardiac or pulmonary disease (including obstructive pulmonary disease) Laboratory Exclusion Criteria (at Screening)
• Hemoglobin: < 7 gm/dL
• Platelets: < 100,000/mm
• Known history of positive Hepatitis B or C serology
• Known history of positive HIV

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: 1; Rituximab Group: The Rituximab dose is 1000mg (1gm) given as an IV infusion every two weeks for 2 doses (days 1 and 15) and followed up monthly for 1 year. Biopsy was done Baseline and Month 3 and other labs (CBC/Diff, Platelets, HACA, PK, Serum Creatinine, 24-hour protein, HLA antibodies, flow cytometry, and serology testing). Physical exam and vital signs were done.	Drug: Rituximab; Rituximab infusion on Day 1 and Day 15; Other Names: Rituxan
Active Comparator: 2; No Rituximab: received standard immunosuppression and was followed up monthly for 1 year. Labs (CBC/Diff, Platelets, HACA, PK, Serum Creatinine, 24-hour protein, HLA antibodies, flow cytometry, and serology testing) vital signs, and physical exam was done.	Drug: No Rituximab; No Rituximab

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in Biopsy Cell Densities From Baseline to Follow-up	Follow-up biopsy was done 3-6 months after study treatment. Study follow-up monthly for 1 year.	1 year

Collaborators and Investigators

• Sponsor: University of California, San Francisco
• Collaborators: Genentech, Inc.
• Investigators: Principal Investigator: Flavio Vincenti, M.D., University of California, San Francisco

Study record dates

Study Major Dates

• Study Start: August 1, 2004
• Primary Completion (Actual): December 1, 2010
• Study Completion (Actual): December 1, 2010

Study Registration Dates

• First Submitted: June 9, 2008
• First Submitted That Met QC Criteria: June 10, 2008
• First Posted (Estimate): June 11, 2008

Study Record Updates

• Last Update Posted (Estimate): March 26, 2014
• Last Update Submitted That Met QC Criteria: February 7, 2014
• Last Verified: February 1, 2014

More Information

Terms related to this study

• Keywords: Rituximab; B cells; Renal Transplant Rejection; Patients with biopsy proven acute rejection cellular infiltrate, B cells
• Additional Relevant MeSH Terms: Physiological Effects of Drugs; Antirheumatic Agents; Antineoplastic Agents; Immunologic Factors; Antineoplastic Agents, Immunological; Rituximab
• Other Study ID Numbers: GNE Rituxin