Tacrolimus to Sirolimus Conversion for Delayed Graft Function (RAPA)

Delayed Tacrolimus to Sirolimus Conversion in Renal Transplant Recipients With Delayed Graft Function

The objective of this study is to evaluate the safety and efficacy of conversion from tacrolimus to sirolimus early after kidney transplantation in patients with delayed graft function (DGF)and slow graft function (SGF) in improving graft function and delaying chronic allograft nephropathy. The investigators hypothesize that conversion from tacrolimus to sirolimus in renal transplant recipients with DGF/SGF in early months after surgery will improve graft function and decrease the progression of graft fibrosis.

Study Overview

• Status: Terminated
• Conditions: Kidney Transplant; Delayed Graft Function
• Intervention / Treatment: Drug: Tacrolimus; Drug: Sirolimus

Detailed Description

Eligible study subjects will be randomized into two groups 8-18 weeks after surgery. One group will be maintained on tacrolimus according to the standard of care at our center. In the second group tacrolimus will be converted to sirolimus, with one week overlap between sirolimus therapy and tacrolimus taper. All the deceased donor kidney transplant recipients transplanted at our center who experience DGF/SGF are eligible for inclusion in this study, if they meet the inclusion/exclusion criteria as detailed later.

Data will be collected on patient demographics, duration on dialysis, history of diabetes and chronic hepatitis C, previous transplantation, PRA, donor source, warm and cold ischemia time, donor demographics and comorbidity such as diabetes and hypertension, serum creatinine at the time of organ removal, early graft function, number of dialysis treatments after transplantation, induction agent and immunosuppressive regimen including the dose or level of the drugs at 3, 6, 9, 12, 18, and 24 months. Similar data regarding use of ACE inhibitors/ARBs, erythropoietic agents, number of anti-hypertensives and lipid lowering agents will be collected. In addition, the following tests and procedures will be obtained for this study.

1. GFR measurement by cold iothalamate method at one year after transplantation.
2. Evaluation of routine surveillance graft biopsies for chronic changes at 3 and 12 months posttransplant by morphometric analysis.
3. Spot urine protein, albumin, and creatinine measurement at 3 and 12 months.
4. Estimate GFR at 3, and 12 months using MDRD, CG, and Nankivell formulas
5. Examine the surveillance and indicated biopsies for acute rejection and BK nephropathy.
6. Fasting lipid profile at 3 and 12 months for all patients, and 24 months for those with at least 2 years of follow up.
7. Office blood pressure measurements at 3 and 12 months for all patients, and 24 months for those with at least 2 years of follow up.
8. Measurement of CRP, IL-6, and MCP at 3 and 12 months.

The safety measures will include:

Incidence of leukopenia (WBC < 3000) or thrombocytopenia (PLT < 100,000); hemoglobin level at 12 months; proteinuria at 12 months; incidence of oral aphthous ulcers; incidence of new onset diabetes, incidence of CMV infection and rate of drug withdrawal due to side effects.

• Study Type: Interventional
• Enrollment (Actual): 32
• Phase: Phase 4

Contacts and Locations

Study Locations

• United States
  • Maryland
    • Baltimore, Maryland, United States, 21201
      • University of Maryland Medical Center

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 80 years (ADULT, OLDER_ADULT)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

1. Age => 18.
2. Recipient of a deceased donor kidney transplant.
3. Delayed graft function, defined as need for dialysis during first week after surgery or slow graft function, defined as creatinine >=3.0 by post-op day 5 without requiring dialysis
4. Stable serum creatinine for 2 weeks prior to enrollment.
5. Able to give informed consent.
6. Compliant with medical regimen and clinic visits.

Exclusion Criteria:

1. Episode of acute rejection within 4 weeks prior to enrollment.
2. Calculated GFR < 30 ml/min.
3. Interstitial fibrosis & tubular atrophy in transplant biopsy higher than grade II (Banff"05 update).
4. Proteinuria > 500 mg/24 h or spot urine protein/creatinine > 0.5.
5. Total fasting cholesterol level > 300 mg/dl or triglyceride > 500 mg/dl despite optimal lipid lowering therapy.
6. Recipient of pancreas or liver allografts.
7. Leukopenia (WBC < 3000 mm3) within 2 weeks prior to enrollment.
8. Leukopenia (WBC < 2000 mm3) within 4 weeks prior to enrollment.
9. Thrombocytopenia (platelets count < 100,000/mm3) within 2 weeks prior to enrollment.
10. Unwilling to comply with study protocol.
11. Enrollment in another drug trial that precludes use of sirolimus.
12. Diagnosis of malignancy within 2 years prior to enrollment, except adequately treated non-melanoma skin cancer.
13. For women, pregnancy.
14. Allergy to iodine

Study Plan

How is the study designed?

Design Details

• Primary Purpose: TREATMENT
• Allocation: RANDOMIZED
• Interventional Model: PARALLEL
• Masking: NONE

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
ACTIVE_COMPARATOR: Tacrolimus; Tacrolimus will be continued with target 12-hour trough level 7-10 ng/ml (tandem mass spectrometry) during the first year and 5-8 during second year.	Drug: Tacrolimus; 3-10 mg, PO, BID based on 12 hour trough on serum blood levels, adjusted according to protocol; Other Names: FK506, Prograf
ACTIVE_COMPARATOR: Sirolimus; 5 mg, PO , daily	Drug: Sirolimus; 5 mg, PO, daily based on 24 hour serum blood levels, adjusted according to protocol; Other Names: Rapamune, Rapamycin

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Time Frame
The Composite Endpoint of Reduction of e eGFR at One Year by More Than 15% & the Progression in Fibrosis Score at One Year by >=20% Compared With the Baseline Values	One year

Secondary Outcome Measures

Outcome Measure	Time Frame
eGFR	One year
Change in eGFR From Baseline to 1-year	1 year
Graft Survival (Actual, Actuarial)	1 year
Incidence of Acute Rejection (Actual, Actuarial)	1 year
Incidence of BK Nephropathy (Cumulative)	1 year
Change in Inflammatory Marker : CRP From Baseline	1 year
Change in Inflammatory Marker, IL-6 From Baseline	1 Year
Change in Inflammatory Marker, MCP, From Baseline	1 year

Collaborators and Investigators

• Sponsor: University of Maryland, Baltimore
• Collaborators: Wyeth is now a wholly owned subsidiary of Pfizer
• Investigators: Principal Investigator: Abdolreza Haririan, MD, MPH, University of Maryland

Study record dates

Study Major Dates

• Study Start: April 1, 2009
• Primary Completion (ACTUAL): June 1, 2014
• Study Completion (ACTUAL): July 1, 2014

Study Registration Dates

• First Submitted: June 29, 2009
• First Submitted That Met QC Criteria: June 30, 2009
• First Posted (ESTIMATE): July 2, 2009

Study Record Updates

• Last Update Posted (ACTUAL): March 31, 2022
• Last Update Submitted That Met QC Criteria: March 29, 2022
• Last Verified: March 1, 2022

More Information

Terms related to this study

• Keywords: kidney transplant; Acute rejection; tacrolimus; Graft survival; sirolimus; delayed graft function; Chronic allograft nephropathy
• Additional Relevant MeSH Terms: Pathologic Processes; Delayed Graft Function; Physiological Effects of Drugs; Molecular Mechanisms of Pharmacological Action; Anti-Infective Agents; Enzyme Inhibitors; Antineoplastic Agents; Immunosuppressive Agents; Immunologic Factors; Anti-Bacterial Agents; Antibiotics, Antineoplastic; Antifungal Agents; Calcineurin Inhibitors; Tacrolimus; Sirolimus
• Other Study ID Numbers: HP-00042201