Proportion of CMV Seropositive Kidney Transplant Recipients Who Will Develop a CMV Infection When Treated With an Immunosuppressive Regimen Including Everolimus and Reduced Dose of Cyclosporine Versus an Immunosuppressive Regimen With Mycophenolic Acid and Standard Dose of Cyclosporine A (EVERCMV)

A Multicenter, Two Arms, Randomized, Open Label Clinical Phase IV Study Investigating the Proportion of CMV Seropositive Kidney Transplant Recipients Who Will Develop a CMV Infection Within the First 6 Months Post-transplantation When Treated With an Immunosuppressive Regimen Including Everolimus (Certican®) and Reduced Dose of Cyclosporine A (Neoral®) Versus an Immunosuppressive Regimen With Mycophenolic Acid (Myfortic®) and Standard Dose of Cyclosporine A (Neoral®).

Cytomegalovirus (CMV) infection is the most frequent opportunistic viral infection after transplantation. It is associated with an increased incidence of acute rejection and lower graft and patient survivals. The goal of this study is to demonstrate that an immunosuppressive regimen associating everolimus and reduced dose of cyclosporine A can prevent acute rejection episodes as efficiently as standard regimen but also efficiently reduce the incidence of CMV infection at 6 months post-transplantation.

Study Overview

• Status: Completed
• Conditions: Transplantation Infection; Cytomegalovirus Infection
• Intervention / Treatment: Drug: Everolimus; Drug: mycophenolic acid

Detailed Description

Cytomegalovirus (CMV) infection is the most frequent opportunistic viral infection after kidney transplantation. Therefore most of the patients receive an universal prophylaxis. On the contrary to CMV naïve patients, seropositive recipients (R+) have already mounted a specific immunologic response directed against the virus, which is not completely abrogated by immunosuppressive drugs. Although CMV infection management guidelines offer little guidance on immunosuppressive therapy for preventing CMV infection and disease, recent data plead for reappraising the place of mTOR inhibitors in this situation. The potential anti-CMV action of these molecules could be added to their potential antitumor effect and their equivalent immunosuppressive efficacy in kidney transplant recipients at low immunological risk. By the way, it could represent an alternative of a systematic universal prophylaxis in R+ kidney transplant recipients. However, the proof of this anti-CMV action must be confirmed in vivo in a study, which could have a close monitoring of CMV infection.

We therefore designed a prospective multicentric randomized controlled trial comparing an immunosuppressive regimen based on everolimus and reduced dose of cyclosporine A to a regimen based on mycophenolic acid and standard dose of cyclosporine A, in order to demonstrate the superiority of the first one in the prevention of CMV infection.

Subjects will be randomized to one of the two treatment arms and will be followed for a period of 12 months. Whole blood CMV real time PCR will be performed every week during the first three months, then every two weeks from Month 3 to Month 6, then at Months 8, 10 and 12. Incidence of CMV infection will be compared between the two arms at 6 and 12 months post-transplantation.

• Study Type: Interventional
• Enrollment (Actual): 186
• Phase: Phase 4

Contacts and Locations

Study Locations

• France
  • Bordeaux, France, 33000
    • CHU de Bordeaux
  • Brest, France, 29609
    • CHU La Cavale Blanche
  • Caen, France, 14033
    • CHRU Caen - Hôpital de Caen
  • Limoges, France
    • CHU de Limoges - Hôpital Dupuytren
  • Lyon, France, 69003
    • Hopital Edouard Herriot
  • Paris, France, 75015
    • APHP - Hopital Necker
  • Paris, France, 94275
    • APHP - Kremlin Bicêtre
  • Strasbourg, France
    • CHRU Strasbourg
  • Toulouse, France, 31000
    • CHU de Toulouse - Hôpital Rangueil

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Age ≥ 18 years.
• End stage kidney disease and a suitable candidate for primary renal transplantation or re-transplantation.
• Patient seropositive for CMV (confirmed within two weeks post-transplant) and having received an allograft from a CMV seropositive or seronegative donor.
• Receiving a kidney transplant from a deceased or living donor with compatible ABO blood type.
• Female subject of childbearing potential must have a negative serum pregnancy test at enrollment and must agree to maintain effective birth control during the study and two months later the discontinuation of the test drug.
• Total ischemia time below 36 hours.
• Capable of understanding the purpose and risks of the study.
• Fully informed and having given written informed consent (signed Informed Consent has been obtained).
• Affiliation to the social security regimen

Exclusion Criteria:

• CMV seronegative patient.
• Historical or current TGI (French equivalence of calculated PRA) > 85 %
• Presence of historical or current anti-HLA donor specific antibodies
• Patient who received anti-CMV therapy within the past 30 days prior to screening.
• Receiving or having previously received an organ transplant other than a kidney.
• Receiving a graft from a non-heart-beating donor.
• Patient known to be positive for Human Immunodeficiency Virus (HIV), Hepatitis B (HBV; HBs Ag positive) or Hepatitis C (HCV; anti-HCV Ab positive).elevated SGPT/ALT and/or SGOT/AST and/or total bilirubin levels ≥ 2 times the upper value of the normal range of the investigational site or receiving a graft from a hepatitis C or B positive donor.
• Significant, uncontrolled concomitant infections and/or severe diarrhea, vomiting, active upper gastro-intestinal tract malabsorption or active peptic ulcer.
• Known allergy or intolerance to everolimus, valganciclovir, ganciclovir, mycophenolic acid, basiliximab, corticosteroids, or cyclosporine A or any of the product excipients.
• Severe hyperlipidemia defined by: total cholestérol ≥ 9,1 mmol/L (≥ 350 mg/dL) et/ou triglycérides ≥ 8,5 mmol/l (≥ 750 mg/dL) in spite an adequate medication.

• Patient has adequate hematological post-transplant defined as:

  1. Absolute neutrophil count (ANC) > 1000 cells/μL.
  2. Platelet count > 50,000 cells/μL.
  3. Hemoglobin > 8.0 g/dL.
• Requiring initial therapy with induction immunosuppressive antibody preparations, such as anti-thymocyte globulins or rituximab or IVIG.
• Currently participating in another clinical trial investigating drugs. Observational studies are not considered as an exclusion criteria
• Any form of substance abuse, psychiatric disorder or condition which, in the opinion of the investigator, may complicate communication with the investigator.
• Unlikely to comply with the visits scheduled in the protocol.

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
Experimental: Everolimus; Everolimus + reduced dose of cyclosporine A	Drug: Everolimus; Everolimus : 0.75 bid, targeted to 3-8 ng/ml Cyclosporin A : CsA target ranges for Arm 1 will be 100-200 ng/mL from Day 3 to Month 2, decreasing to 75-150 ng/mL from Month 2 to Month 4 and 25-50 ng/mL from Months 6 to 12. Corticosteroids : Méthylprednisolone: 500 mg at Day 0, 120 mg à Day 1. Prednisone or equivalent: 20 mg/d from Day 3. Corticosteroid dosing will be tapered according to center standard practice but to not less than 5 mg per day for the duration of the 12-month study Basiliximab :Day 0: 20 mg ; Day 4: 20 mg
Active Comparator: mycophenolic acid; mycophenolic acid + standard dose of cyclosporin A	Drug: mycophenolic acid; Mycophenolic acid : 1080 mg bid for one month, then 720 mg bid Cyclosporin A : CsA target ranges for Arm 1 will be 100-200 ng/mL from Day 3 to Month 2, decreasing to 75-150 ng/mL from Month 2 to Month 4 and 25-50 ng/mL from Months 6 to 12. Corticosteroids : Méthylprednisolone: 500 mg at Day 0, 120 mg à Day 1. Prednisone or equivalent: 20 mg/d from Day 3. Corticosteroid dosing will be tapered according to center standard practice but to not less than 5 mg per day for the duration of the 12-month study Basiliximab :Day 0: 20 mg ; Day 4: 20 mg

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Number of participants without CMV infection and without graft loss in CMV seropositive kidney transplant recipients.	The primary objective of this study is to compare the survival without CMV infection and without graft loss in CMV seropositive kidney transplant recipients, within the first 6 months post-transplantation when treated with an immunosuppressive regimen including everolimus (Certican®) and reduced dose (RD) of cyclosporine A (Néoral®) versus an immunosuppressive regimen with mycophenolic acid (Myfortic®) and standard dose (SD) of cyclosporine A (Néoral®).	6 months post-transplantation

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Proportion of patients who will develop CMV disease	The proportion of patients who will develop CMV disease during the first 6 and 12 months post-transplantation (CMV disease includes both CMV syndrome and CMV tissue-invasive disease).	6 and 12 months post-transplantation
Proportion of patient with graft loss, death and loss of follow-up		12 months post-transplantation
Proportion of patient with acute rejection, graft loss, death and loss of follow-u		12 months
Level to the first CMV DNAemia		Throughout the study
Time to the first CMV disease		Throughout the study
Proportion of patients treated for CMV infection in both groups		6 months
Half-life of decreasing of DNAemia		after initiation of anti-CMV therapy
Occurrence of treatment failure, defined as the absence of viral eradication.		Day 49 (or 8 weeks) after the initiation of anti-CMV therapy
Occurrence of CMV mutation (UL97 ou UL54) associated with a resistance to an anti-CMV therapy.		Throughout the study
Graft function	Graft function defined as glomerular filtration rate (GFR) estimated by simplified MDRD formula and proteinuria/creatininuria ratio.	6 and 12 months post-transplantation
Proportion of patients with biopsy-proven acute rejection (BPAR)		6 and 12 months post-transplantation
Degree of interstitial fibrosis/tubular atrophy		12 months on protocol biopsies
Graft and patient survival		6 and 12 months post-transplantation
Proportion of BK virus viremia		month 1, 3, 6 and 12
Proportion of patients with adverse events (AE) and/or serious adverse events (SAE) including opportunistic infections and neoplasias.		12 months
Proportion of patients with haematological disorders	The proportion of patients with haematological disorders (neutropenia, anaemia, thrombopenia)	12 months
Proportion of patients with diarrhea		12 months
Proportion of dyslipidemia		12 months
Proportion of patients with occurrence of New Onset Diabetes Mellitus as defined by American Diabetic Association (ADA) criteria.		12 months
Proportion of patients who will discontinue the immunosuppressive treatment and the reasons why.		12 months
Proportion of patients with delayed graft function		12 months
Proportion of lymphocele		12 months
Time to the first CMV DNAemia		Throughout the study

Collaborators and Investigators

• Sponsor: University Hospital, Bordeaux
• Collaborators: Novartis
• Investigators: Principal Investigator: Lionel COUZI, MD, University Hospital, Bordeaux

Publications and helpful links

General Publications

• Kaminski H, Marseres G, Yared N, Nokin MJ, Pitard V, Zouine A, Garrigue I, Loizon S, Capone M, Gauthereau X, Mamani-Matsuda M, Coueron R, Duran RV, Pinson B, Pellegrin I, Thiebaut R, Couzi L, Merville P, Dechanet-Merville J. mTOR Inhibitors Prevent CMV Infection through the Restoration of Functional alphabeta and gammadelta T cells in Kidney Transplantation. J Am Soc Nephrol. 2022 Jan;33(1):121-137. doi: 10.1681/ASN.2020121753. Epub 2021 Nov 1.

Study record dates

Study Major Dates

• Study Start (Actual): May 2, 2014
• Primary Completion (Actual): October 10, 2018
• Study Completion (Actual): October 10, 2018

Study Registration Dates

• First Submitted: September 1, 2014
• First Submitted That Met QC Criteria: December 29, 2014
• First Posted (Estimate): December 31, 2014

Study Record Updates

• Last Update Posted (Actual): November 14, 2018
• Last Update Submitted That Met QC Criteria: November 12, 2018
• Last Verified: November 1, 2018

More Information

Terms related to this study

• Keywords: Everolimus; mTOR inhibitor; Cytomegalovirus infection and disease; CMV-seropositive recipients; preemptive strategy
• Additional Relevant MeSH Terms: Pathologic Processes; Virus Diseases; Disease Attributes; DNA Virus Infections; Herpesviridae Infections; Infections; Communicable Diseases; Cytomegalovirus Infections; 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; Antitubercular Agents; Antibiotics, Antitubercular; Mycophenolic Acid; Everolimus
• Other Study ID Numbers: CHUBX2012/29