Alloantibodies in Pediatric Heart Transplantation

The purpose of this study is to determine the clinical outcomes of sensitized pediatric heart transplant recipients with a positive donor-specific cytotoxicity crossmatch and to compare this group with outcomes in nonsensitized heart transplant recipients.

Study Overview

• Status: Terminated
• Conditions: Pediatric Heart Transplantation; Pediatric Heart Transplant Recipients
• Intervention / Treatment: Drug: Induction Therapy; Drug: Tacrolimus; Drug: Mycophenolate Mofetil; Procedure: Intraoperative plasma exchange/pheresis; Procedure: Short-term post-operative plasmapheresis; Drug: Immunoglobulins, Intravenous; Drug: Prednisone

Detailed Description

There is currently a renewed interest in alloantibodies in transplantation. In 1966, Kissmeyer and colleagues reported that pre-existing antibodies directed against donor cells could cause hyperacute rejection of the renal allograft. Three years later, in a landmark study, Patel and Terasaki showed that a lymphocytotoxic assay to identify donor-specific antibodies was highly predictive of acute graft failure. These observations led to the practice of performing prospective, donor-specific crossmatches by lymphocytotoxicity assay for all kidney transplants and for heart and lung transplants when the candidate has a positive panel reactive antibody (PRA) assay. A concept evolved that transplantations should not be performed across a positive cytotoxicity crossmatch. The purpose of this study is to determine the clinical outcomes of sensitized pediatric heart transplant recipients with a positive donor-specific cytotoxicity crossmatch and to compare this group with outcomes in nonsensitized heart transplant recipients.

This study plans to enroll 370 pediatric heart transplant recipients over a period of 3 years. The follow-up period will last up to 3 years. All participants will be enrolled pretransplant. In the pretransplant phase, visits will occur every 6 months. These routine visits will continue until transplant or the end of the study. They will coincide with routine pretransplant status visits. At the time of transplant, the participants will be assigned to one of two groups. Group A will include participants who are allo-antibody negative (less than 10% by AHG CDC-PRA and ELISA in all DTT-treated serum samples). Cohort B will include participants who have the presence of a DTT-treated AHG CDC-PRA of greater than or equal to 10% and/or an ELISA-PRA greater than or equal to 10% in any pretransplant sample.

Both cohorts will receive standard transplantation care. This study has no interventions. All participants will undergo regular blood tests, and, those in the sensitized group will have additional blood testing performed after the transplant and lasting until the end of the study. Post-transplant visits will occur while participants are recovering in the hospital; at Months 1, 3, and 6; and annually until the study closes.

The information collected for the study include data from a physical exam, routine testing, adverse (AEs) and serious adverse (SAEs) events assessments, and blood collection. Each time a biopsy is done, the study will ask to review the biopsy tissue and to collect a sample. If stored tissue is not available, none will be collected.

• Study Type: Observational
• Enrollment (Actual): 290

Contacts and Locations

Study Locations

• Canada
  • Ontario
    • Toronto, Ontario, Canada, M5G 1X8
      • Hospital for Sick Children, Labatt Family Heart Centre
• United States
  • Massachusetts
    • Boston, Massachusetts, United States, 02115
      • Children's Hospital Boston, Harvard Medical School
  • Missouri
    • St. Louis, Missouri, United States, 63110
      • St. Louis Children's Hospital, Washington University
  • New York
    • Bronx, New York, United States, 10467
      • Children's Hospital at Montefiore
    • New York, New York, United States, 10032
      • Children's Hospital of New York, Columbia University Medical Center
  • Pennsylvania
    • Philadelphia, Pennsylvania, United States, 19104
      • Children's Hospital of Philadelphia, University of Pennsylvania
    • Pittsburgh, Pennsylvania, United States, 15213
      • Children's Hospital of Pittsburgh of UPMC
  • Tennessee
    • Nashville, Tennessee, United States, 37232
      • Vanderbilt University

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: No older than 21 years (Child, Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

• Sampling Method: Non-Probability Sample

Study Population

Pediatric heart transplantation candidates

Description

Inclusion Criteria:

• All participants listed for heart transplantation at participating CTOT-C study sites.

Exclusion Criteria:

• Listed for multiple organ transplant
• Inability or unwillingness of the participant or parent/guardian to give written informed consent or comply with the study protocol
• Condition or characteristic which in the opinion of the investigator makes the participant unlikely to complete at least one year of follow-up
• Current participation in other research studies that would, or might, interfere with the scientific integrity or safety of current study (e.g. by interference with immunosuppression management guidelines, study endpoints, excessive blood draws or SAE evaluation).

Study Plan

How is the study designed?

Number of groups / cohorts

2

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
Cohort A: Non-Sensitized; Cohort A will include participants who are alloantibody Luminex(TM) LABScreen. There is no study mandated care or treatment. All care given is clinical site standard of care. All sites follow a similar standard of care regimen. Non-sensitized recipients receive steroid-free maintenance immunosuppression: Induction Therapy (anti-T cell antibody induction); Tacrolimus (Prograf®); Mycophenolate Mofetil- MMF (CellCept®).	Drug: Induction Therapy; Per standard of care guidelines for immunosuppression at each clinical site.; Other Names: anti-T cell antibody induction; Drug: Tacrolimus; Per standard of care guidelines for immunosuppression at each clinical site.; Other Names: Prograf®; Drug: Mycophenolate Mofetil; Per standard of care guidelines for immunosuppression at each clinical site.; Other Names: MMF; CellCept®
Cohort B: Sensitized; Cohort B will include participants who are alloantibody positive (Sensitized) as determined by Luminex LabScreen for Class I or Class II with specificities identified by single antigen testing. There is no study mandated care or treatment. All care given is clinical site standard of care. All sites follow a similar standard of care regimen. Sensitized recipients receive: Induction Therapy (anti-T cell antibody induction); Intraoperative plasma exchange/pheresis; Short-term post-operative plasmapheresis; Post-transplant course of intravenous immunoglobulin (IVIG) therapy; Maintenance corticosteroids (Prednisone); Tacrolimus (Prograf®); Mycophenolate Mofetil-MMF (CellCept®).	Drug: Induction Therapy; Per standard of care guidelines for immunosuppression at each clinical site.; Other Names: anti-T cell antibody induction; Drug: Tacrolimus; Per standard of care guidelines for immunosuppression at each clinical site.; Other Names: Prograf®; Drug: Mycophenolate Mofetil; Per standard of care guidelines for immunosuppression at each clinical site.; Other Names: MMF; CellCept®; Procedure: Intraoperative plasma exchange/pheresis; Per standard of care guidelines for immunosuppression at each clinical site.; Other Names: plasmapheresis; Procedure: Short-term post-operative plasmapheresis; Per standard of care guidelines for immunosuppression at each clinical site.; Other Names: pheresis; Drug: Immunoglobulins, Intravenous; Post-transplant course of intravenous immunoglobulin therapy per standard of care guidelines for immunosuppression at each clinical site.; Other Names: IVIG; Drug: Prednisone; Maintenance corticosteroids per standard of care guidelines for immunosuppression at each clinical site.; Other Names: corticosteroid

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Percentage of Participants Positive for Event of Death, Graft Loss or Rejection With Hemodynamic Compromise at 12 Months Post-Transplantation	This is a composite outcome of death, graft loss or rejection with hemodynamic compromise. Rejection was considered to be with hemodynamic compromise if the rejection event had new onset echocardiographically measured from fractional shortening <26% with ≥5% fall from last echocardiogram or the rejection event had new onset of heart failure.	12 months post-transplantation

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Time to Production of Post-Transplant de Novo Donor-specific Alloantibodies	Time (in days) from transplant to development of de novo donor-specific alloantibodies (DSA). This measure is calculated as time from transplant until the earliest time of development of any de novo DSA. The DSA is a newly developed alloantibody that is against the donor organ. Alloantibodies are important mediators of acute and chronic rejection.	Transplantation to first year post transplant (up to 12 months post transplant).
Percentage of Participants Positive for de Novo Donor-Specific Alloantibody Production in the First Year Post-Transplantation	A de novo donor-specific alloantibody (DSA) is a newly developed alloantibody that is against the donor organ. This measure includes all de novo DSA (≥1000 MFI) regardless of is persistence or timing within the first year post-transplant. Alloantibodies are important mediators of acute and chronic rejection.	Transplantation to first year post transplant (up to 12 months post transplant).
Percentage of Participants- Mortality While on Transplantation Wait-List	Death that occurred while on the transplantation wait-list, and thus before receiving a heart transplant.	Pre-transplantation
Time From Participant Listing on Organ Wait-List to Receiving Organ Transplant, Death or De-Listing	Time (in days) from listing on the organ wait-list to receiving an organ transplant, death or de-listing. This measure is calculated as time from listing on the organ wait-list until the earliest time among transplantation, death and de-listing.	Study enrollment to transplantation
Percentage of Participants With the Presence of Anti-HLA IgG Antibodies by Luminex SA Testing	Luminex SA testing was used to detect the presence of anti-HLA IgG Antibodies for all samples at a central laboratory.	Pre-transplantation
Percentage of Participants -Quantification of Anti-HLA IgG Antibodies by Luminex SA Testing	Quantification of anti-HLA IgG antibodies is measured in mean fluorescence intensity (MFI). The maximum MFI for the given subject is provided.	Pre-transplantation
Percentage of Participants With the Presence of Anti-MICA Antibodies by Luminex TM Assay	Major histocompatibility complex class I chain-related gene A (MICA) is an antigen that is a potential marker of rejection. Luminex TM assay was used to detect its presence.	Pre-Transplantation
Percentage of Participants -Overall Participant and Graft Survival	This measure looks at the participants who did not die and/or did not receive a subsequent heart transplant.	Transplantation to the end of study (up to 4 years post transplant).
Presence of C4d on Endomyocardial Biopsy (EMB)	The biopsy of the heart stained positive for the presence of C4d, a potential marker of rejection.	Transplantation to the end of study (up to 4 years post transplant).
Percentage of Participants With Occurrence of Re-Hospitalization(s)	Hospitalization is defined as any hospitalization lasting greater than 24 hours.	Transplantation to the end of study (up to 4 years post transplant).
Percentage of Participants Positive for Severe Infection(s)	Severe infections are defined as a clinical illness considered likely infectious in origin that leads to hospitalization.	Transplantation to the end of study (up to 4 years post transplant).
Time to Diagnosis of Chronic Rejection	Time (in days) to the diagnosis of chronic rejection. Chronic rejection is defined as stenosis, irregularity, or ectasia of the epicardial vessels, or severe peripheral pruning of the distal coronary artery tree. Time to diagnosis is time from transplantation until the first diagnosis of chronic rejection.	Transplantation to the end of study (up to 4 years post transplant).
Time to Post-Transplantation Lymphoproliferative Disorder	Time (in days) post-transplant lymphoproliferative disorder (PTLD). PTLD is defined as histopathological evidence of lymphoid proliferation (nodal or extranodal) fulfilling the criteria of the revised classification of the WHO 2008 (Swerdlow 2008). Time to PTLD is time from transplantation until the diagnosis of PTLD.	Transplantation to the end of study (up to 4 years post transplant).
Time to New-Onset Diabetes Mellitus	Time (in days) to new-onset diabetes mellitus. New-onset diabetes mellitus is defined as the new onset of insulin dependency or the need for oral hypoglycemic agents lasting more than 30 days post-transplant. Time to new-onset diabetes is time from transplantation until the diagnosis of new-onset diabetes.	Transplantation to the end of study (up to 4 years post transplant).
Percentage of Participants Experiencing Acute Rejection	Acute rejection is defined as any one of the following types of rejection: acute cellular rejection (International Society for Heart and Lung Transplant (ISHLT)) system for grading rejection grade 2R or greater), acute refractory cellular rejection (acute cellular rejection unresponsive to two sequential courses of corticosteroids), acute antibody mediated rejection (histological evidence of unequivocal acute capillary injury, with complement deposition and margination of macrophages with or without neutrophils), acute mixed rejection (evidence of acute antibody mediated rejection with ISHLT grade 1R or greater), or acute clinical rejection (clinically-based acute rejection, no matter the ISHLT grade, leading to an acute augmentation of immunosuppression).	Transplantation to the end of study.
Time to Acute Rejection	Time (in days) to acute rejection. Acute rejection is defined as any one of the following types of rejection: acute cellular rejection (International Society for Heart and Lung Transplant (ISHLT) system for grading rejection grade 2R or greater), acute refractory cellular rejection (acute cellular rejection unresponsive to two sequential courses of corticosteroids), acute antibody mediated rejection (histological evidence of unequivocal acute capillary injury, with complement deposition and margination of macrophages with or without neutrophils), acute mixed rejection (evidence of acute antibody mediated rejection with ISHLT grade 1R or greater), or acute clinical rejection (clinically-based acute rejection, no matter the ISHLT grade, leading to an acute augmentation of immunosuppression). Time to acute rejection is time from transplantation to first acute rejection date.	Transplantation to the end of study.

Collaborators and Investigators

• Sponsor: National Institute of Allergy and Infectious Diseases (NIAID)
• Collaborators: National Heart, Lung, and Blood Institute (NHLBI)
• Investigators: Study Chair: Stephen A. Webber, MBChB, MRCP, University of Pittsburgh

Publications and helpful links

General Publications

• Rose ML, Smith JD. Clinical relevance of complement-fixing antibodies in cardiac transplantation. Hum Immunol. 2009 Aug;70(8):605-9. doi: 10.1016/j.humimm.2009.04.016. Epub 2009 Apr 16.
• Patel R, Terasaki PI. Significance of the positive crossmatch test in kidney transplantation. N Engl J Med. 1969 Apr 3;280(14):735-9. doi: 10.1056/NEJM196904032801401. No abstract available.
• Lamour JM, Mason KL, Hsu DT, Feingold B, Blume ED, Canter CE, Dipchand AI, Shaddy RE, Mahle WT, Zuckerman WA, Bentlejewski C, Armstrong BD, Morrison Y, Diop H, Ikle DN, Odim J, Zeevi A, Webber SA; CTOTC-04 investigators. Early outcomes for low-risk pediatric heart transplant recipients and steroid avoidance: A multicenter cohort study (Clinical Trials in Organ Transplantation in Children - CTOTC-04). J Heart Lung Transplant. 2019 Sep;38(9):972-981. doi: 10.1016/j.healun.2019.06.006. Epub 2019 Jun 20.

Helpful Links

• National Institute of Allergy and Infectious Diseases (NIAID) website
• National Heart Lung and Blood Institute (NHLBI) website
• Clinical Trials in Organ Transplantation in Children (CTOT-C) website

Study record dates

Study Major Dates

• Study Start: January 1, 2010
• Primary Completion (Actual): December 1, 2014
• Study Completion (Actual): December 1, 2014

Study Registration Dates

• First Submitted: October 27, 2009
• First Submitted That Met QC Criteria: October 28, 2009
• First Posted (Estimate): October 30, 2009

Study Record Updates

• Last Update Posted (Actual): April 20, 2017
• Last Update Submitted That Met QC Criteria: March 9, 2017
• Last Verified: March 1, 2017

More Information

Terms related to this study

• Keywords: cohort study; allosensitization; allo-antibodies
• Additional Relevant MeSH Terms: Physiological Effects of Drugs; Molecular Mechanisms of Pharmacological Action; Anti-Infective Agents; Enzyme Inhibitors; Anti-Inflammatory Agents; Antineoplastic Agents; Immunosuppressive Agents; Immunologic Factors; Glucocorticoids; Hormones; Hormones, Hormone Substitutes, and Hormone Antagonists; Antineoplastic Agents, Hormonal; Anti-Bacterial Agents; Antibiotics, Antineoplastic; Antitubercular Agents; Antibiotics, Antitubercular; Calcineurin Inhibitors; Antibodies; Immunoglobulins; Immunoglobulins, Intravenous; Prednisone; Tacrolimus; gamma-Globulins; Rho(D) Immune Globulin; Mycophenolic Acid
• Other Study ID Numbers: DAIT CTOTC-04; 7U01AI077867-02 (U.S. NIH Grant/Contract)