Impact of Rituximab (RTx) Induction and Living Donation on Immunoregulation and Virus Control in Renal Transplantation

Impact of Rituximab Induction and Living Donation on Immunoregulation and Virus Control in Renal Transplantation - a Prospective Pilot Study

This project comprises immunological and virological analyses within a prospective clinical study of Rituximab (Rtx)-treated blood group incompatible living donor (LD) renal transplant recipients compared to blood group compatible LD recipients without Rtx induction, and of living donor compared to deceased donor renal transplant recipients treated with tacrolimus (Tacr)/mycophenolate sodium (MPS). Aim of this project is to assess short- and long-term effects of immunosuppressive therapy (Rtx induction) and of living donation on immunological and histological parameters of graft outcome and on viral replication (BK virus (BKV), JC virus (JCV), cytomegalovirus (CMV), Epstein Barr virus (EBV)) with the potential to improve long-term graft outcome and to enable risk estimation of virus disease.

Study Overview

• Status: Completed
• Conditions: Kidney Transplantation; Immunology; Virus; Living Donors; Rituximab (RTx)
• Intervention / Treatment: Drug: Rituximab; Procedure: living donor transplantation; Procedure: deceased donor transplantation

Detailed Description

Objective. Blood group incompatible (ABOi) LD renal transplantation represents a recognized treatment modality in Germany. In this setting, ethical considerations allow for a detailed study of short- and long-term immunological and virological effects of Rtx induction therapy, including sequential protocol biopsies. In the proposed project we will perform analyses on peripheral blood, iliac lymph nodes and protocol biopsies. Protocol biopsies are routinely obtained 3 and 12 months posttransplant at the Universities of Giessen and Freiburg. In this prospective, open pilot study, immunological parameters of graft outcome and control of polyomavirus, EBV and CMV replication will be compared between RTx-treated ABOi LD renal transplant recipients (n=25-30, group 1) and blood group compatible LD renal transplant recipients without Rtx induction (n=25-30, group 2) but otherwise comparable immunosuppressive treatment (MPS and Tacr, switch to Tacr-MR (modified release) within 2 weeks posttransplant; follow-up of 5 years). The same analyses will be done in DD renal transplant recipients treated with Tacr (switch to Tacr-ME) and MPS (n=25-30, group 3). This study design allows to analyze the impact of living donation on immunoregulation and virus control (groups 2 versus 3).

Background. There is growing evidence that humoral mechanisms play a major role in chronic allograft dysfunction, which was shown to be significantly associated with de-novo formation of donor-specific antibodies against human leucocyte antigens (HLA). However, B cells appear to act not only in humoral responses against the graft but may play a significant role in T-cell mediated antidonor responses due to their role as effective antigen-presenting cells. This is further suggested by the fact that Rtx is effective in primarily T-cell mediated diseases such as rheumatoid arthritis or multiple sclerosis.

Hypothesis/specific aims. We hypothesize that Rtx induction may alter immunoregulation short- and long-term after renal transplantation with the potential to improve long-term outcome. Graft protective effects of Rtx induction may be provided by B cell depletion and the resulting effects on humoral as well as T cell responses, and also by altered responses after B cell repopulation. Possible negative effects of Rtx on polyomavirus and CMV control as well as protective effects on EBV replication, de-novo monoclonal gammopathy and regulation of lymphoma growth factors (interleukins 6 and 10 (IL-6, IL-10)) will be analyzed. Furthermore, B cell subset analysis in peripheral blood and the probably associated impact of Rtx on B cell depletion in graft draining iliac lymph nodes may enable us to establish an optimized Rtx dosage and thereby allow successful ABOi renal transplantation without the currently observed 15% drop outs.

Preliminary results. We have performed clinical studies showing the predictive power of immune parameters such as regulatory anti-Fab autoantibodies, sCD30, CD4 (cluster of differentiation 4) helper activity, and CD4 cell IL-4 (interleukin 4) and IL-10 (interleukin 10) responses on graft outcome. The long-term effect of Rtx induction therapy and of living donation on these parameters will be analyzed.

Previously, we found that patients at risk of polyomavirus nephropathy may be recognized early posttransplant by sequential reverse transcriptase polymerase chain (rt-PCR) assessment of polyomavirus replication in urine. Sequential rt-PCR testing of polyomavirus replication in urine and plasma will be used to analyze effects of Rtx induction on polyomavirus control.

Proposed methods. Immune parameters will be analyzed mainly pretransplant, 3 months and 1, 2 and 5 years posttransplant. Flow cytometry (including regulatory T cells, B cell subsets, expression of cytokine receptors, costimulatory and adhesion molecules), mitogen-stimulated allogeneic cocultures, protein-A plaque assay (B cell responses, CD4 helper activity), intracellular cytokine analysis of CD4+ and CD8+ (cluster of differentiation 8) T cells, B cells and monocytes, rt-PCR for virological studies (BKV, JCV, CMV, EBV) and immunofluorescent staining of iliac lymph nodes (obtained at time of transplantation) and protocol biopsies will be used. Donor-specific antibodies will be detected using lymphocytotoxicity, HLA class I and II ELISA and Luminex assays. Donor-specificity will be confirmed by T- and B-cell crossmatch with donor cells. Regulatory IgG (immunoglobulin G) and IgA (immunoglobulin A) anti-Fab autoantibodies, neopterin and sCD30 will be assessed by ELISA.

Expected results. We expect that Rtx induction will show an impact on immunological parameters of graft outcome, such as de-novo posttransplant antidonor HLA antibody formation. This pilot study may allow for improved long-term kidney graft outcome in recipients with immunologic risk parameters by virtue of patient-tailored immunosuppressive therapy. In ABOi renal transplantation, this study may prevent the current 15% drop out rates by allowing an optimized Rtx dosage based on the intended dose response analysis (B cell subset analysis in blood and graft draining lymph nodes). Furthermore, this study will allow risk estimation of Rtx administration with respect to CMV and polyomavirus replication, and may provide clues concerning protection against EBV replication and posttransplant lymphoproliferative disease. The latter point is of great clinical importance in patients with an enhanced PTLD (posttransplant lymphoproliferative disease) risk such as EBV negative recipients of EBV positive grafts.

• Study Type: Interventional
• Enrollment (Actual): 85
• Phase: Phase 2

Contacts and Locations

Study Locations

• Germany
  • Giessen, Germany, D-35392
    • Department of Internal Medicine, University of Giessen

Participation Criteria

Eligibility Criteria

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

Description

Inclusion Criteria:

• De-novo kidney transplantation
• Deceased donors (blood group compatible) and living donors (blood group incompatible / blood group compatible)
• First, second and third renal transplants
• Immunized and non-immunized graft recipients
• Age of recipients 18 years or older
• Negative pregnancy test before transplantation

Exclusion Criteria:

• Contra-indications to use Tacr and MPS, respectively
• Contra-indications to use Rtx in the group of ABOi LD transplants
• Chronic hepatitis B, C or HIV infection
• Recurrent infectious disease
• Previous hepatitis B, if no prophylactic antiviral therapy is used
• Previous tuberculosis
• Hemoglobin<8,5g/dl, thrombocytes<80.000/ul or leucocytes<3000/ul
• Previous vaccination with a living vaccine <4 weeks pretransplant
• Significant enterogastric disease such as diverticulitis (contra-indicates MPS treatment)
• Children and adolescents (age less than 18 years)
• Pregnancy and breast-feeding women
• Refusal of an effective contraception in women capable of bearing children
• Combined transplantations such as simultaneous islet/kidney transplants

Study Plan

How is the study designed?

Design Details

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

Number of Arms

3

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: LD kidney transplantation, ABOi; Living donor (LD) kidney transplantation, ABO incompatible (ABOi); Immunosuppressive treatment: Tacrolimus (Tacr)/ Mycophenolate sodium (MPS), Basiliximab induction, Rtx induction	Drug: Rituximab; 375mg/m2 4 weeks before ABOi LD transplantation; Other Names: Blood group incompatible (ABOi) living donor (LD) renal transplantation; Anti-CD20 (cluster of differentiation 20) Monoclonal Antibody (MoAb); Procedure: living donor transplantation; living donor transplantation (ABO compatible) to be compared with deceased donor transplantation (ABO compatible) in its impact on immunological parameters of graft outcome and on viral replication (CMV, EBV, BK/JC), respectively; Other Names: Blood group compatible (ABOc) LD NTx
Active Comparator: LD kidney transplantation, ABOc; Living donor (LD) kidney transplantation, ABO compatible (ABOc); Immunosuppressive treatment: Tacr/MPS, Basiliximab induction	Procedure: living donor transplantation; living donor transplantation (ABO compatible) to be compared with deceased donor transplantation (ABO compatible) in its impact on immunological parameters of graft outcome and on viral replication (CMV, EBV, BK/JC), respectively; Other Names: Blood group compatible (ABOc) LD NTx
Active Comparator: DD kidney transplantation; Deceased donor (DD) kidney transplantation, ABO compatible; Immunosuppressive treatment: Tacr/MPS, Basiliximab induction	Procedure: deceased donor transplantation; deceased donor transplantation (ABO compatible) to be compared with living donor transplantation (ABO compatible) in its impact on immunological parameters of graft outcome and on viral replication (CMV, EBV, BK virus (BKV), JC virus (JCV)), respectively; Other Names: Deceased donor (DD) renal transplantation

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Impact of Rtx on immune parameters predictive of graft outcome including B cell responses	immune parameters of graft outcome: see "detailed description"	5 years posttransplant
Impact of living donation on immune parameters predictive of graft outcome including B cell responses	parameters of graft outcome: see "detailed description"	5 years posttransplant
Impact of Rtx on virus replication	outcome measure description: EBV PCR (in blood)	5 years posttransplant
Impact of Rtx on virus replication	outcome measure description: CMV PCR (in blood)	5 years posttransplant
Impact of Rtx on virus replication	outcome measure description: BKV PCR (in blood)	5 years posttransplant
Impact of Rtx on virus replication	outcome measure description: BKV PCR (in urine)	5 years posttransplant
Impact of Rtx on virus replication	outcome measure description: JCV PCR (in blood)	5 years posttransplant
Impact of Rtx on virus replication	outcome measure description: JCV PCR (in urine)	5 years posttransplant
Impact of living donation on virus replication	outcome measure description: EBV PCR (in blood)	5 years posttransplant
Impact of living donation on virus replication	outcome measure description: CMV PCR (in blood)	5 years posttransplant
Impact of living donation on virus replication	outcome measure description: BKV PCR (in blood)	5 years posttransplant
Impact of living donation on virus replication	outcome measure description: BKV PCR (in urine)	5 years posttransplant
Impact of living donation on virus replication	outcome measure description: JCV PCR (in blood)	5 years posttransplant
Impact of living donation on virus replication	outcome measure description: JCV PCR (in urine)	5 years posttransplant

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Patient survival	patient survival 5 years posttransplant will be analyzed	5 years posttransplant
Graft survival	Graft survival 5 years posttransplant will be analyzed	5 years posttransplant
Graft function and proteinuria	5-year graft function will be analyzed by serum creatinine and measured creatinine clearance, proteinuria by proteinuria within a 24h urine collection period	5 years posttransplant
Graft function	5-year graft function will be analyzed by serum creatinine and measured creatinine clearance, proteinuria by proteinuria within a 24h urine collection period	5 years posttransplant
Graft function	5-year graft function will be analyzed by measured creatinine clearance	5 years posttransplant
Proteinuria	5-year proteinuria will be analyzed urine collected 24 hours	5 years posttransplant
Incidence of acute rejection	incidence of biopsy proven acute rejection within 1 year posttransplant will be analyzed	1 year posttransplant
Incidence of acute rejection	incidence of biopsy proven acute rejection within 2 years posttransplant will be analyzed	2 years posttransplant
Incidence of acute rejection	incidence of biopsy proven acute rejection within 5 years posttransplant will be analyzed	5 years posttransplant
Incidence of chronic allograft dysfunction	Chronic allograft dysfunction (progressive decline of graft function) will be analyzed at 5 years posttransplant.	5 years posttransplant
Incidence of severe infectious disease	severe infectious disease as defined by need for in-hospital treatment	5 years posttransplant
Incidence of malignancy	all types of malignancies within 5 years posttransplant will be evaluated	5 years posttransplant
Incidence of side effects associated with Rtx	all side effects of Rtx treatment which have been described in literature, will be listed	5 years posttransplant

Collaborators and Investigators

• Sponsor: University of Giessen
• Collaborators: Novartis; Astellas Pharma US, Inc.; German Cancer Research Center; Heidelberg University
• Investigators: Principal Investigator: Rolf Weimer, Prof. Dr., University of Giessen, Department of Internal Medicine

Publications and helpful links

General Publications

• Weimer R, Mytilineos J, Feustel A, Preiss A, Daniel V, Grimm H, Wiesel M, Opelz G. Mycophenolate mofetil-based immunosuppression and cytokine genotypes: effects on monokine secretion and antigen presentation in long-term renal transplant recipients. Transplantation. 2003 Jun 27;75(12):2090-9. doi: 10.1097/01.TP.0000058808.37349.23.
• Weimer R, Melk A, Daniel V, Friemann S, Padberg W, Opelz G. Switch from cyclosporine A to tacrolimus in renal transplant recipients: impact on Th1, Th2, and monokine responses. Hum Immunol. 2000 Sep;61(9):884-97. doi: 10.1016/s0198-8859(00)00152-x.
• Hackstein H, Renner FC, Bohnert A, Nockher A, Frommer T, Bein G, Weimer R. Dendritic cell deficiency in the blood of kidney transplant patients on long-term immunosuppression: results of a prospective matched-cohort study. Am J Transplant. 2005 Dec;5(12):2945-53. doi: 10.1111/j.1600-6143.2005.01101.x.
• Sadeghi M, Daniel V, Weimer R, Wiesel M, Hergesell O, Opelz G. Differential early posttransplant cytokine responses in living and cadaver donor renal allografts. Transplantation. 2003 Apr 27;75(8):1351-5. doi: 10.1097/01.TP.0000063706.52369.ED.
• Staak A, Renner F, Suesal C, Dietrich H, Rainer L, Kamali-Ernst S, Ernst W, Padberg W, Opelz G, Weimer R. Immunoglobulin induction therapy in renal transplant recipients: Effects on immunoglobulin and regulatory antibody levels. Transplant Proc. 2006 Dec;38(10):3483-5. doi: 10.1016/j.transproceed.2006.10.041.
• Weimer R, Staak A, Susal C, Streller S, Yildiz S, Pelzl S, Renner F, Dietrich H, Daniel V, Rainer L, Kamali-Ernst S, Ernst W, Padberg W, Opelz G. ATG induction therapy: long-term effects on Th1 but not on Th2 responses. Transpl Int. 2005 Feb;18(2):226-36. doi: 10.1111/j.1432-2277.2004.00047.x.
• Weimer R, Susal C, Yildiz S, Staak A, Pelzl S, Renner F, Dietrich H, Daniel V, Kamali-Ernst S, Ernst W, Padberg W, Opelz G. Post-transplant sCD30 and neopterin as predictors of chronic allograft nephropathy: impact of different immunosuppressive regimens. Am J Transplant. 2006 Aug;6(8):1865-74. doi: 10.1111/j.1600-6143.2006.01407.x. Epub 2006 Jun 9.
• Daniel V, Naujokat C, Sadeghi M, Renner FC, Weimer R, Opelz G. Association of high IFN-gamma plasma levels with low B-cell counts in renal transplant recipients with stable long-term graft function. Clin Transplant. 2010 Mar-Apr;24(2):281-9. doi: 10.1111/j.1399-0012.2009.01067.x. Epub 2009 Aug 27.
• Susal C, Dohler B, Opelz G. Graft-protective role of high pretransplantation IgA-anti-Fab autoantibodies: confirmatory evidence obtained in more than 4000 kidney transplants. The Collaborative Transplant Study. Transplantation. 2000 Apr 15;69(7):1337-40. doi: 10.1097/00007890-200004150-00021.
• Susal C, Pelzl S, Dohler B, Opelz G. Identification of highly responsive kidney transplant recipients using pretransplant soluble CD30. J Am Soc Nephrol. 2002 Jun;13(6):1650-6. doi: 10.1097/01.asn.0000014256.75920.5b.

Study record dates

Study Major Dates

• Study Start (Actual): January 1, 2010
• Primary Completion (Actual): June 18, 2019
• Study Completion (Actual): June 18, 2019

Study Registration Dates

• First Submitted: June 2, 2010
• First Submitted That Met QC Criteria: June 2, 2010
• First Posted (Estimate): June 3, 2010

Study Record Updates

• Last Update Posted (Actual): October 8, 2019
• Last Update Submitted That Met QC Criteria: October 7, 2019
• Last Verified: October 1, 2019

More Information

Terms related to this study

• Keywords: Immunology; Rituximab; Kidney Transplantation; Cytomegalovirus (CMV); Living Donor; ABO Incompatible (ABOi) Transplantation; Epstein Barr virus (EBV); Polyomavirus
• Additional Relevant MeSH Terms: Infections; Virus Diseases; Physiological Effects of Drugs; Antirheumatic Agents; Antineoplastic Agents; Immunologic Factors; Antineoplastic Agents, Immunological; Rituximab
• Other Study ID Numbers: NTx-RTx-LD-001; 2009-012198-36 (EudraCT Number)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: Yes
• IPD Plan Description: all individual participant data are available to the members of the study group who treat the patients in the Department of Internal Medicine, University Clinic of Giessen (i.e. all participants of the study group working in the Department of Internal Medicine)
• IPD Sharing Time Frame: data will be available up to 1year post study completion
• IPD Sharing Access Criteria: seen above
• IPD Sharing Supporting Information Type: Study Protocol; Statistical Analysis Plan (SAP); Informed Consent Form (ICF); Clinical Study Report (CSR); Analytic Code