Prevention of Cardiac Allograft Vasculopathy Using Rituximab (Rituxan) Therapy in Cardiac Transplantation

Prevention of Cardiac Allograft Vasculopathy Using Rituximab (Rituxan) Therapy in Cardiac Transplantation (CTOT-11)

All people who have a heart transplant are at risk for developing cardiac allograft vasculopathy (CAV). CAV means narrowing of the heart transplant vessels, which is associated with poor heart transplant function. People who develop antibodies after transplant have a higher risk of developing CAV. Infections, high cholesterol, and rejection also increase the risk of developing CAV. People who develop CAV usually have to receive another transplant.

Study Overview

• Status: Terminated
• Conditions: Cardiac Allograft Vasculopathy; Heart Transplant Recipients
• Intervention / Treatment: Biological: Rituximab induction/conventional immunosuppression (tacrolimus, MMF, and steroid taper); Drug: Rituximab placebo/conventional immunosuppression (tacrolimus, MMF, and steroid taper)

Detailed Description

The purpose of this research study is to see if a study drug called rituximab (Rituxan®) prevents CAV. Rituximab destroys certain types of white blood cells called B cells. B cells are important cells in the immune system that help the body fight infection by producing substances called antibodies. B cells and the antibodies they produce are also involved in some kinds of rejection after organ transplantation. Rituximab decreases the number of B cells in the blood and other tissues. The goal of this study is to determine if decreasing B cells with Rituximab can prevent injury to the transplanted heart.

• Study Type: Interventional
• Enrollment (Actual): 362
• Phase: Phase 2

Contacts and Locations

Study Locations

• United States
  • California
    • Beverly Hills, California, United States, 90211
      • Cedars Sinai Heart Institute
    • Los Angeles, California, United States, 90095
      • Ronald Regan UCLA Medical Center
    • Palo Alto, California, United States, 94304
      • Stanford University/Palo Alto VA
    • San Francisco, California, United States, 94143-0124
      • University of California San Francisco
    • Stanford, California, United States, 94305
      • Stanford University
  • Illinois
    • Chicago, Illinois, United States, 60611
      • Northwestern University
  • Maryland
    • Baltimore, Maryland, United States, 21201
      • University of Maryland
  • Massachusetts
    • Boston, Massachusetts, United States, 02115
      • Brigham and Women's Hospital
    • Boston, Massachusetts, United States, 02114
      • Massachusetts General Hospital
    • Boston, Massachusetts, United States, 02111
      • Tufts Medical Center
  • Minnesota
    • Minneapolis, Minnesota, United States, 55455
      • University of Minnesota
    • Minneapolis, Minnesota, United States, 55407
      • Minneapolis Heart Institute
  • New York
    • New York, New York, United States, 10029
      • Mount Sinai School of Medicine
    • New York, New York, United States, 10032'
      • Columbia University Medical Center
  • Ohio
    • Cleveland, Ohio, United States, 44195
      • Cleveland Clinic Foundation
  • Pennsylvania
    • Philadelphia, Pennsylvania, United States, 19104
      • University of Pennsylvania
    • Philadelphia, Pennsylvania, United States, 19102
      • Drexel University College of Medicine
    • Pittsburgh, Pennsylvania, United States, 15212
      • Allegheny General Hospital
  • South Carolina
    • Charleston, South Carolina, United States, 29425
      • Medical University of South Carolina
  • Texas
    • Dallas, Texas, United States, 75230
      • Medical City Dallas Hospital/CRSTI
    • Houston, Texas, United States, 77030
      • The Methodist Hospital
  • Utah
    • Murray, Utah, United States, 84157
      • Intermountain Medical Center
    • Salt Lake City, Utah, United States, 84132-2401
      • University of Utah
  • Wisconsin
    • Madison, Wisconsin, United States, 53792
      • University of Wisconsin

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 75 years (ADULT, OLDER_ADULT)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria for Initial Enrollment:

• Subject must be able to understand and provide informed consent;
• Male or Female, 18 to 75 years of age;
• Candidate for a primary heart transplant (e.g., listed for heart transplant only);
• Historical panel reactive antibodies (PRA) less than 30%;
• Calculated GFR ≥ 40 mL/minute using the Chronic Kidney Disease Epidemiology Collaboration equation (CKD-EPI);
• Female and male subjects with reproductive potential, must agree to use FDA approved methods of birth control for the duration of the study

Inclusion Criteria for Randomization / Post-transplant:

--Negative PRA within 12 weeks prior to transplant (Local HLA Center Testing) using one of the following:

• One Lambda's LABScreen® Mixed Class I & II (presence or absence), or
• Less than 10% by One Lambda's LABScreen® PRA Class I and II with an MFI of <2000, or
• Calculated panel reactive antibodies (cPRA) less than 10% by LABScreen® Single Antigen testing (Anti-HLA-A, -B, -DR, -DQ). The antigens reported will include those with an MFI >2000.

The Luminex Gen-Probe beads are equivalent to the One Lambda and may be used as an alternative;

• Calculated GFR ≥ 40mL/minute using the CKD-EPI at time of randomization;
• Serum immunoglobulin G (IgG) level greater than 500mg/dL within 90 days prior to randomization;
• Negative test for HIV, HBsAg, HBcAb, and HCV Ab within 12 months prior to transplant. If documentation is not present to support that the testing was performed in the past 12 months, then a blood sample will be collected prior to transplant and sent for local testing. Results may be available after randomization. If positive result, the oversight committee will review the case and provide further recommendations.
• Female subjects of childbearing potential must have a negative pregnancy test.

Exclusion Criteria for Enrollment:

• Prior history of organ transplantation;
• Previous treatment with Rituximab (MabThera® / Rituxan ®);
• Transplant physician intention to use any induction agents;
• History of severe allergic anaphylactic reactions to humanized or murine monoclonal antibodies;
• History of severe reaction to previous therapy with IVIG;
• Active systemic infection at time of enrollment;
• Any history of serologic positivity to HIV, HBsAg, HBcAb, and HCV Ab;
• History of less than 5 years remission of malignancy. Any history of adequately treated in-situ cervical carcinoma, or adequately treated basal or squamous cell carcinoma of the skin will be permitted;
• Any condition that, in the opinion of the investigator, would interfere with the subject's ability to comply with study requirements;
• Use of other investigational drugs within 4 weeks of enrollment;
• Currently breast-feeding or plans to become pregnant during the timeframe of the study follow-up period.

Exclusion Criteria for Randomization/Post-transplant:

• Recipient of multiple solid organ or tissue transplants;
• Previous treatment with Rituximab (MabThera® / Rituxan ®);
• Use of any induction agents;
• History of severe allergic anaphylactic reactions to humanized or murine monoclonal antibodies;
• History of severe reaction to previous therapy with IVIG; Lack of IV venous access;
• Active systemic infection at time of randomization;
• Any history of serologic positivity to HIV, HBsAg, HBcAb and HCV Ab;
• Any condition that, in the opinion of the investigator, would interfere with the subject's ability to comply with study requirements;
• Use of other investigational drugs within 4 weeks prior to randomization;
• Receipt of a live vaccine within 30 days prior to randomization;
• Currently breast-feeding or plans to become pregnant during the timeframe of the study follow-up period.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: PREVENTION
• Allocation: RANDOMIZED
• Interventional Model: PARALLEL
• Masking: QUADRUPLE

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
EXPERIMENTAL: Rituximab; Rituximab induction/conventional immunosuppression	Biological: Rituximab induction/conventional immunosuppression (tacrolimus, MMF, and steroid taper)
PLACEBO_COMPARATOR: Rituximab Placebo; Rituximab Placebo / conventional immunosuppression	Drug: Rituximab placebo/conventional immunosuppression (tacrolimus, MMF, and steroid taper)

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in Percent Atheroma Volume (PAV)	Nominal or noticeable change, bad or good, from baseline to 1 year in percent atheroma volume (PAV) which is a measure of the degree of coronary arterial obstruction due to host alloimmune processes measured by intravascular ultrasound (IVUS) in a target coronary artery. Thus a decrease in PAV would be an indicator of less obstruction and a better outcome.	Baseline, 1 year

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Death	Participants who died within 12 months post-transplant	12 months
Re-transplantation or Re-listed for Transplantation	Re-transplantation is defined as the receipt of a subsequent heart transplant and re-listed for transplantation is being listed back on the heart transplant list to be re-transplanted.	6 to 12 months
Number of Episodes of Biopsy Proven Acute Rejection (BPAR) of Any Grade Per Participant	The number of times a participant experienced biopsy proven acute rejection (BPAR). Biopsy proven acute rejection is when an examination of tissue removed from the transplanted organ indicates that the subject's immune system is trying to reject the graft. BPAR was defined as a biopsy that met the International Society for Heart & Lung Transplantation (ISHLT) criteria to be graded as 1R or greater rejection and was determined by a single, central pathology laboratory.	6 to 12 months
Incidence of BPAR (Any Grade)	The number of subjects who experienced any grade of biopsy proven acute rejection (BPAR) within the clinical trial. Biopsy proven acute rejection is when an examination of tissue removed from the transplanted organ indicates that the subject's immune system is trying to reject the graft. BPAR was defined as a biopsy which met The International Society for Heart & Lung Transplantation (ISHLT) criteria to be graded as 1R or greater rejection and was determined by a single, central pathology laboratory.	6 to 12 months
Incidence of AMR	The number of participants who experienced antibody- mediated rejection (AMR). Antibody-mediated rejection (AMR) occurs when the subject develops antibodies directed against the transplanted heart. This was assessed based on local pathology biopsy reads.	6 to 12 months
Incidence of Cellular Rejection	Cellular Rejection refers to the organ recipient's immune system recognizing a transplanted organ as foreign and mounting a response to it via cellular mechanisms. Cellular rejection was defined as a biopsy which met The International Society for Heart & Lung Transplantation (ISHLT) criteria to be graded as 1R or greater rejection and was determined by a single, central pathology laboratory	6 to 12 months
Incidence of Any Treated Rejection	The number of participants who were treated by their local physician for any type of rejection including, but not limited to cellular rejection and antibody- mediated rejection (AMR) of the transplanted heart regardless of the presence of a biopsy.	6 to 12 months
Number of Participants With Episodes of Rejection Associated With Hemodynamic Compromise (HDC)	The number of participants that experienced at least one episode of rejection associated with hemodynamic compromise (HDC). Rejection associated with HDC is when there is insufficient blood flow to the transplanted heart in association with acute rejection found in a biopsy. Local biopsies were used for this outcome measure.	6 to 12 months
Number of Participants With Development of Angiographically Evident Cardiac Allograft Vasculopathy	Cardiac allograft vasculopathy is an aggressive form of atherosclerosis that is characterized by the development of fibrosis affecting cardiac arteries that result in concentric narrowing of the arteries and, ultimately allograft failure. Development of cardiac allograft vasculopathy can be diagnosed via an angiograph which is an X-ray of the cardiac arteries by injecting a radiopaque substance such as iodine.	1 year
Number of Participants With Post-transplant Serious Infections Requiring Intravenous Antimicrobial Therapy	Number of participants experiencing at least one serious infection requiring intravenous antimicrobial therapy which is used to kill the growth of microorganisms such as bacteria, fungi, or protozoans.	Transplantation through end of study, up to 1 year post transplantation.
Number of Participants With Post-transplant Incidence of PTLD	The number of participants experiencing at least one post-transplant lymphoproliferative disorder (PTLD) occurrence during this trial. Post-transplant lymphoproliferative disorder is an uncontrolled proliferation of B cell lymphocytes latently infected with Epstein-Barr virus.	Transplantation through end of study, up to 1 year post transplantation.
Post-transplant Safety Outcomes Among Participants: Safety and Tolerability of Rituximab	Defined as participants that experienced at least one adverse event that was possibly, probably, or definitely related to the study drug (i.e., Rituximab or Placebo). Serious adverse events were used to evaluate this endpoint and the attribution was based on the DAIT Medical Monitor's assessment.	Transplantation through end of study, up to 1 year post transplantation

Collaborators and Investigators

• Sponsor: National Institute of Allergy and Infectious Diseases (NIAID)
• Collaborators: National Heart, Lung, and Blood Institute (NHLBI); Genentech, Inc.; Rho Federal Systems Division, Inc.; Clinical Trials in Organ Transplantation
• Investigators: Principal Investigator: Mohamed Sayegh, MD, Brigham and Women's Hospital/Harvard; Study Chair: Anil Chandraker, MD, Brigham and Women's Hospital/Harvard

Publications and helpful links

General Publications

• Starling RC, Armstrong B, Bridges ND, Eisen H, Givertz MM, Kfoury AG, Kobashigawa J, Ikle D, Morrison Y, Pinney S, Stehlik J, Tripathi S, Sayegh MH, Chandraker A; CTOT-11 Study Investigators. Accelerated Allograft Vasculopathy With Rituximab After Cardiac Transplantation. J Am Coll Cardiol. 2019 Jul 9;74(1):36-51. doi: 10.1016/j.jacc.2019.04.056.

Helpful Links

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

Study record dates

Study Major Dates

• Study Start: September 1, 2011
• Primary Completion (ACTUAL): October 1, 2015
• Study Completion (ACTUAL): October 1, 2015

Study Registration Dates

• First Submitted: January 16, 2011
• First Submitted That Met QC Criteria: January 16, 2011
• First Posted (ESTIMATE): January 19, 2011

Study Record Updates

• Last Update Posted (ACTUAL): August 25, 2020
• Last Update Submitted That Met QC Criteria: August 12, 2020
• Last Verified: August 1, 2020

More Information

Terms related to this study

• Keywords: prevention; rituximab; cardiac transplantation; cardiac allograft vasculopathy (CAV)
• Additional Relevant MeSH Terms: Cardiovascular Diseases; Vascular Diseases; Physiological Effects of Drugs; Molecular Mechanisms of Pharmacological Action; Enzyme Inhibitors; Antirheumatic Agents; Antineoplastic Agents; Immunosuppressive Agents; Immunologic Factors; Antineoplastic Agents, Immunological; Calcineurin Inhibitors; Rituximab; Tacrolimus
• Other Study ID Numbers: DAIT CTOT-11