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出境医 / 临床实验 / CNI Transient Replacement by Belatacept From 3 to 12 Months Post Transplantation in Patients With Early Graft Dysfunction (TRANSIBELA)

CNI Transient Replacement by Belatacept From 3 to 12 Months Post Transplantation in Patients With Early Graft Dysfunction (TRANSIBELA)

Study Description
Brief Summary:
Calcineurin inhibitors (CNI) remain the standard treatment in renal transplantation to prevent rejection. Currently the main limitation of kidney transplantation is the occurrence of chronic graft dysfunction due to the CNI nephrotoxicity. Thus, strategies to minimize or stop CNI have been developed as belatacept, a fusion protein (CTLA4-Ig) blocking the ligand of the main CD28 costimulatory molecule. In the original phase III trial, used de novo in combination with MMF (without CNI) belatacept allowed to obtain a better renal function as soon as 1 year and a better graft and patient survival after 7 years. Despite these excellent results, belatacept has not become the gold standard due to a higher incidence of early rejection. In addition, belatacept is not covered by the french social security policy, because benefits are considered insufficient with respect to the cost. Patients with poor early graft function are a preferred indication of belatacept. It is then used instead of CNI at 3 months post-transplant allowing to improve kidney function without over-risk of rejection. Currently after conversion, belatacept is maintained indefinitely due to the supposed CNI chronic nephrotoxicity. However this one is more and more questionable. Thus, the investigators assume that in patients with poor function at 3 months posttransplantation the belatacept's benefit could be obtained by a transient replacement of CNI by belatacept from 3 to 12 months post-transplantation. It is the feasibility of this strategy and its medico-economic impact that the investigators wish to study.

Condition or disease Intervention/treatment Phase
Chronic Kidney Failure Drug: Belatacept 250 Milligram Intravenous Powder for Solution Phase 3

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Study Design
Layout table for study information
Study Type : Interventional  (Clinical Trial)
Estimated Enrollment : 48 participants
Allocation: N/A
Intervention Model: Single Group Assignment
Masking: None (Open Label)
Primary Purpose: Treatment
Official Title: CNI Transient Replacement by Belatacept From 3 to 12 Months Post Transplantation in Patients With Early Graft Dysfunction
Estimated Study Start Date : September 1, 2020
Estimated Primary Completion Date : July 9, 2022
Estimated Study Completion Date : July 9, 2022
Arms and Interventions
Arm Intervention/treatment
Experimental: transient belatacept Drug: Belatacept 250 Milligram Intravenous Powder for Solution

Phase 1 (from 3 to 12 months post transplantation): conversion to belatacept (IV, 5mg/Kg days 1, 15 and 30 then every months) and CNI withdrawal.

Phase 2 (from 12 to 18 months post transplantation) : belatacept arrest and CNI resumption (tacrolimus target 6 ng/ml)


Outcome Measures
Primary Outcome Measures :
  1. Feasibility of a transient replacement of CNIs by belatacept in renal transplant patients with early graft dysfunction. Creatinine clearance did not decrease by more than 25% from the cessation of belatacept 6 months after reintroduction of CNI. [ Time Frame: Month 15 ]

    Feasibility was defined by preserved renal function and good tolerance 6 months after reintroduction of CNI.

    Renal function was defined as preserved if creatinine clearance (according to Chronic Kidney Disease - Epidemiology Collaboration (CKD-EPI)) did not decrease by more than 25% from the cessation of belatacept.

    The good tolerance of CNI was defined by the absence of complications leading to the cessation of treatment.



Secondary Outcome Measures :
  1. Evaluate the effectiveness of belatacept treatment on renal function (creatinine clairance) and to prevent rejection. (Number of rejection épisodes) [ Time Frame: Day 0, Month 3, Month 6, Month 9 ]
    Longitudinal monitoring of renal function (Day 0, Month 3, Month 6, Month 9) and collection of rejection episodes.

  2. Evaluate the tolerance of treatments (belatacept during phase 1 and CNI during phase 2). Number of adverse events. [ Time Frame: Month 3, Month 6, Month 9, Month 12, Month 15 ]
    Collection of infectious episodes and neoplasias

  3. Estimate the cost of care (from 3 months to 18 months post-transplant) and compare with the cost of a theoretical arm benefiting from belatacept continuously and a theoretical arm benefiting from CNIs continuously. [ Time Frame: Month 3, Month 6, Month 9, Month 12, Month 15 ]
    Number of care resources used for treatment : number of medication, number of hospitalization, number of transportation, number of consultations, number of medical procedures, possible home help and associated costs over 15 months of follow-up, and collection of cost data in the literature for the comparison.

  4. Evaluate the evolution of the quality of life during the 15 months of follow-up and compare it to a theoretical arm benefiting from belatacept continuously, and a theoretical arm benefiting from CNIs continuously: generic EuroQol-5D scale [ Time Frame: Month 3, Month 6, Month 9, Month 12, Month 15 ]
    Measurement of quality of life scores (generic EuroQol-5D scale) every 3 months for 15 months and collection of quality of life data in the literature for comparison.

  5. Evaluate the impact of CNI and belatacept on the amount of regulatory T lymphocytes (+ constitution of a collection). [ Time Frame: Month 3, Month 6, Month 9, Month 12, Month 15 ]
    Flow cytometry measurement of the absolute and relative amount of regulatory T lymphocytes (cluster of differentiation 3 + / cluster of differentiation 4 + / cluster of differentiation 25 + / cluster of differentiation127low / FOXP3 +)


Eligibility Criteria
Layout table for eligibility information
Ages Eligible for Study:   18 Years and older   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

  • adult older than 18 years old.
  • transplantation of a deceased or living donor kidney (non-human leukocyte antigen(HLA)-identical) with blood type (ABO) compatibility
  • no contraindication to the protocol graft biopsy (10 weeks post transplant)
  • treatment by CNI / MPA +/- prednisone
  • renal function estimated by creatinine clearance according to CKD-EPI <30 ml / min / 1.73m2.
  • having no difficulty in understanding and communicating with the investigator and his representatives.
  • benefiting from a Social Security policy.
  • results of the 10-week post-transplant renal biopsy finding no rejection or BK virus (member of the polyomavirus family) nephropathy, no recurrence, no thrombotic microangiopathy, no cortical necrosis.
  • Seropositivity for Epstein-Barr virus (EBV)
  • negative pregnancy test and agreement on the use of effective contraception throughout the study

Exclusion Criteria:

  • Presence of Donor Specific Antibody during kidney transplant or appeared at 3 months post-transplantation.
  • seropositivity for HIV
  • another history of other solid organ transplants (outside the kidney)
  • primary non-function (persistence of a need for dialysis at 3 months post-transplantation)
  • participation in progress to another interventional clinical study
  • any clinical condition that the investigator considers incompatible with the course of the study.
  • contraindication to belatacept.
Contacts and Locations

Contacts
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Contact: Simon VILLE, PH 0240087453 simon.ville@chu-nantes.fr

Locations
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France
CHU de Nantes
Nantes, France, 44000
Contact: Simon VILLE    0240087453    simon.ville@chu-nantes.fr   
Principal Investigator: SIMON VILLE, PH         
Sponsors and Collaborators
Nantes University Hospital
Tracking Information
First Submitted Date  ICMJE July 2, 2019
First Posted Date  ICMJE July 10, 2019
Last Update Posted Date March 31, 2020
Estimated Study Start Date  ICMJE September 1, 2020
Estimated Primary Completion Date July 9, 2022   (Final data collection date for primary outcome measure)
Current Primary Outcome Measures  ICMJE
 (submitted: July 5, 2019)
Feasibility of a transient replacement of CNIs by belatacept in renal transplant patients with early graft dysfunction. Creatinine clearance did not decrease by more than 25% from the cessation of belatacept 6 months after reintroduction of CNI. [ Time Frame: Month 15 ]
Feasibility was defined by preserved renal function and good tolerance 6 months after reintroduction of CNI. Renal function was defined as preserved if creatinine clearance (according to Chronic Kidney Disease - Epidemiology Collaboration (CKD-EPI)) did not decrease by more than 25% from the cessation of belatacept. The good tolerance of CNI was defined by the absence of complications leading to the cessation of treatment.
Original Primary Outcome Measures  ICMJE Same as current
Change History
Current Secondary Outcome Measures  ICMJE
 (submitted: July 5, 2019)
  • Evaluate the effectiveness of belatacept treatment on renal function (creatinine clairance) and to prevent rejection. (Number of rejection épisodes) [ Time Frame: Day 0, Month 3, Month 6, Month 9 ]
    Longitudinal monitoring of renal function (Day 0, Month 3, Month 6, Month 9) and collection of rejection episodes.
  • Evaluate the tolerance of treatments (belatacept during phase 1 and CNI during phase 2). Number of adverse events. [ Time Frame: Month 3, Month 6, Month 9, Month 12, Month 15 ]
    Collection of infectious episodes and neoplasias
  • Estimate the cost of care (from 3 months to 18 months post-transplant) and compare with the cost of a theoretical arm benefiting from belatacept continuously and a theoretical arm benefiting from CNIs continuously. [ Time Frame: Month 3, Month 6, Month 9, Month 12, Month 15 ]
    Number of care resources used for treatment : number of medication, number of hospitalization, number of transportation, number of consultations, number of medical procedures, possible home help and associated costs over 15 months of follow-up, and collection of cost data in the literature for the comparison.
  • Evaluate the evolution of the quality of life during the 15 months of follow-up and compare it to a theoretical arm benefiting from belatacept continuously, and a theoretical arm benefiting from CNIs continuously: generic EuroQol-5D scale [ Time Frame: Month 3, Month 6, Month 9, Month 12, Month 15 ]
    Measurement of quality of life scores (generic EuroQol-5D scale) every 3 months for 15 months and collection of quality of life data in the literature for comparison.
  • Evaluate the impact of CNI and belatacept on the amount of regulatory T lymphocytes (+ constitution of a collection). [ Time Frame: Month 3, Month 6, Month 9, Month 12, Month 15 ]
    Flow cytometry measurement of the absolute and relative amount of regulatory T lymphocytes (cluster of differentiation 3 + / cluster of differentiation 4 + / cluster of differentiation 25 + / cluster of differentiation127low / FOXP3 +)
Original Secondary Outcome Measures  ICMJE Same as current
Current Other Pre-specified Outcome Measures Not Provided
Original Other Pre-specified Outcome Measures Not Provided
 
Descriptive Information
Brief Title  ICMJE CNI Transient Replacement by Belatacept From 3 to 12 Months Post Transplantation in Patients With Early Graft Dysfunction
Official Title  ICMJE CNI Transient Replacement by Belatacept From 3 to 12 Months Post Transplantation in Patients With Early Graft Dysfunction
Brief Summary Calcineurin inhibitors (CNI) remain the standard treatment in renal transplantation to prevent rejection. Currently the main limitation of kidney transplantation is the occurrence of chronic graft dysfunction due to the CNI nephrotoxicity. Thus, strategies to minimize or stop CNI have been developed as belatacept, a fusion protein (CTLA4-Ig) blocking the ligand of the main CD28 costimulatory molecule. In the original phase III trial, used de novo in combination with MMF (without CNI) belatacept allowed to obtain a better renal function as soon as 1 year and a better graft and patient survival after 7 years. Despite these excellent results, belatacept has not become the gold standard due to a higher incidence of early rejection. In addition, belatacept is not covered by the french social security policy, because benefits are considered insufficient with respect to the cost. Patients with poor early graft function are a preferred indication of belatacept. It is then used instead of CNI at 3 months post-transplant allowing to improve kidney function without over-risk of rejection. Currently after conversion, belatacept is maintained indefinitely due to the supposed CNI chronic nephrotoxicity. However this one is more and more questionable. Thus, the investigators assume that in patients with poor function at 3 months posttransplantation the belatacept's benefit could be obtained by a transient replacement of CNI by belatacept from 3 to 12 months post-transplantation. It is the feasibility of this strategy and its medico-economic impact that the investigators wish to study.
Detailed Description

The standard maintenance regimen in renal transplantation combines calcineurin inhibitor (CNI: ciclosporin or tacrolimus) and anti-metabolite drugs (mycophenolate mofetil (MMF) or mycophenolic acid (MPA)). CNI in the 1980s made kidney transplantation possible by drastically reducing acute rejection rates in the first year. Currently the main limitation of kidney transplantation is the occurrence of chronic graft dysfunction. While half of patients die with a functional graft, the other half return to dialysis and require retransplantation. Paradoxically, CNI has been identified as a leading cause of chronic graft dysfunction. Indeed, these molecules are nephrotoxic both : acutely and transitory due to a vasoconstrictor effect that modulates intra-renal hemodynamic and chronically due to extensive fibrosis. In the late 1990s, with the development of a new class of immunosuppressants, mammilian target of rapamycin (mTor) inhibitors (sirolimus and everolimus), CNI-free protocols were developed. The results were disappointing due in part to the undesirable effects of these treatments and secondly to the occurence of chronic rejections related to the appearance of Donor Specific Antibody (DSA) antibodies.

Finally in the mid-2000s belatacept is a fusion protein (CTLA4-Ig) blocking the ligands of the main costimulatory molecule (CD28) emerged. In the Phase III princeps assay (BENEFIT), this molecule was used as a maintenance treatment following transplantation (de novo) in combination with MMF (without CNI). Compared to the control group with CNI, patients receiving belatacept had better renal function from 1 year and after 7 years survival (graft and patient) were better. These benefits were attributed, on the one hand, to the absence of CNI and, on the other hand, to a very good control of the alloimmune response demonstrated by a lower incidence of DSA in the belatacept group.

Despite these excellent results, belatacept has not become the gold standard in renal transplantation for two main reasons. First, when it is used de novo (as in BENEFIT), there is a significant incidence of early rejection, known as "costimulation blockade resistant". The second issue is medico-economic. Indeed, to date and despite the accumulation of favorable data, in France and in most countries, belatacept has marketing authorization but is not supported by social security policy due to benefits regarded as insufficient with respect to the cost (related to the IV administration requiring hospital environment every month).

Consequently, it is important to precise which recipients may benefit more from this molecule. Patients, often elderly, with poor early function of the graft due to the poor quality of a marginal / "extended criteria" donor, are a good indication of belatacept not used de novo but after 3 months instead of CNI. This conversion most often allows to significantly improve the renal function of these patients to a much more acceptable level which remains stable beyond and without cost in terms of rejection (probably because of the time interval with the transplant). In this situation, several series reported success rates ranging from 80 to 100% with a rejection incidence between 0 and 20%. Failures are most often due to patients with non-primary graft function.

Currently after the conversion, belatacept is always maintained indefinitely most often in association with MMF. This usage generates significant costs and in fact, limits the access of belatacept for other patients. This practice is based on the dominant idea that chronic nephrotoxicity of CNI is the cause of chronic graft dysfunction.

However, while reversible acute toxicity, mediated by hemodynamic changes in intra-renal vascularization, is undeniable, the importance and even the reality of chronic, cumulative, irreversible CNI toxicity has been questioned during the last decade, while the importance of chronic anti-donor antibody (DSA) rejection to explain chronic graft dysfunction was demonstrated. The chronic toxicity of CNI is probable when high doses are necessary to prevent rejection during the first year but uncertain beyond.

Thus, the investigators assume that in patients with poor graft function at 3 months post-transplantation most of the benefit of belatacept could be obtained by a transient replacement of CNI from 3 to 12 months post-transplantation.

Indeed, in these often elderly patients, who have most often received an "extended criteria" graft (derived from a marginal donor), presenting chronic lesions, CNI-induced intra-renal vasoconstriction could more easily evolve to irreversible lesions in the context of ischemia-reperfusion inherent in the graft itself. At 1 year after transplantation the reintroduction of CNIs at minimized doses could only moderately alter the renal function allowing to maintain them at long term.

The purpose of this study is to demonstrate the feasibility of this transient treatment strategy (from 3 to 12 months post transplantation) in patients with poor function at 3 months.

From 3 months post-transplantation, patients will receive for 9 months (phase 1) a treatment with belatacept allowing to stop CNI. Then CNI will be reintroduced (phase 2) with a follow-up period of 6 months which will make it possible to judge the feasibility of this strategy.

Belatacept is the only biotherapy introduced successfully in transplantation. But this treatment, because of the limitations raised, has not yet found a definite place. Our project is to study a practical question: can the investigators stop belatacept after having introduced it early in the context of an early dysfunction while preserving the benefits. The decisive contribution of this study would be to prove the concept of a transient treatment by belatacept which has not been reported. The medico-economic consequences would be major, the cost of a long-term treatment by belatacept, especially because of its administration in hospital, being much higher than that of a conventional treatment.

A secondary objective is to measure by flow cytometry the evolution of the absolute and relative amount of regulatory T lymphocytes. Indeed, the negative effect of belatacept on this essential lymphocyte population remains very controversial.

Study Type  ICMJE Interventional
Study Phase  ICMJE Phase 3
Study Design  ICMJE Allocation: N/A
Intervention Model: Single Group Assignment
Masking: None (Open Label)
Primary Purpose: Treatment
Condition  ICMJE Chronic Kidney Failure
Intervention  ICMJE Drug: Belatacept 250 Milligram Intravenous Powder for Solution

Phase 1 (from 3 to 12 months post transplantation): conversion to belatacept (IV, 5mg/Kg days 1, 15 and 30 then every months) and CNI withdrawal.

Phase 2 (from 12 to 18 months post transplantation) : belatacept arrest and CNI resumption (tacrolimus target 6 ng/ml)

Study Arms  ICMJE Experimental: transient belatacept
Intervention: Drug: Belatacept 250 Milligram Intravenous Powder for Solution
Publications *
  • Vincenti F. Belatacept and Long-Term Outcomes in Kidney Transplantation. N Engl J Med. 2016 Jun 30;374(26):2600-1. doi: 10.1056/NEJMc1602859.
  • Le Meur Y, Aulagnon F, Bertrand D, Heng AE, Lavaud S, Caillard S, Longuet H, Sberro-Soussan R, Doucet L, Grall A, Legendre C. Effect of an Early Switch to Belatacept Among Calcineurin Inhibitor-Intolerant Graft Recipients of Kidneys From Extended-Criteria Donors. Am J Transplant. 2016 Jul;16(7):2181-6. doi: 10.1111/ajt.13698. Epub 2016 Mar 2.

*   Includes publications given by the data provider as well as publications identified by ClinicalTrials.gov Identifier (NCT Number) in Medline.
 
Recruitment Information
Recruitment Status  ICMJE Not yet recruiting
Estimated Enrollment  ICMJE
 (submitted: July 5, 2019)
48
Original Estimated Enrollment  ICMJE Same as current
Estimated Study Completion Date  ICMJE July 9, 2022
Estimated Primary Completion Date July 9, 2022   (Final data collection date for primary outcome measure)
Eligibility Criteria  ICMJE

Inclusion Criteria:

  • adult older than 18 years old.
  • transplantation of a deceased or living donor kidney (non-human leukocyte antigen(HLA)-identical) with blood type (ABO) compatibility
  • no contraindication to the protocol graft biopsy (10 weeks post transplant)
  • treatment by CNI / MPA +/- prednisone
  • renal function estimated by creatinine clearance according to CKD-EPI <30 ml / min / 1.73m2.
  • having no difficulty in understanding and communicating with the investigator and his representatives.
  • benefiting from a Social Security policy.
  • results of the 10-week post-transplant renal biopsy finding no rejection or BK virus (member of the polyomavirus family) nephropathy, no recurrence, no thrombotic microangiopathy, no cortical necrosis.
  • Seropositivity for Epstein-Barr virus (EBV)
  • negative pregnancy test and agreement on the use of effective contraception throughout the study

Exclusion Criteria:

  • Presence of Donor Specific Antibody during kidney transplant or appeared at 3 months post-transplantation.
  • seropositivity for HIV
  • another history of other solid organ transplants (outside the kidney)
  • primary non-function (persistence of a need for dialysis at 3 months post-transplantation)
  • participation in progress to another interventional clinical study
  • any clinical condition that the investigator considers incompatible with the course of the study.
  • contraindication to belatacept.
Sex/Gender  ICMJE
Sexes Eligible for Study: All
Ages  ICMJE 18 Years and older   (Adult, Older Adult)
Accepts Healthy Volunteers  ICMJE No
Contacts  ICMJE
Contact: Simon VILLE, PH 0240087453 simon.ville@chu-nantes.fr
Listed Location Countries  ICMJE France
Removed Location Countries  
 
Administrative Information
NCT Number  ICMJE NCT04013620
Other Study ID Numbers  ICMJE RC19_0062
Has Data Monitoring Committee No
U.S. FDA-regulated Product
Studies a U.S. FDA-regulated Drug Product: No
Studies a U.S. FDA-regulated Device Product: No
IPD Sharing Statement  ICMJE
Plan to Share IPD: No
Responsible Party Nantes University Hospital
Study Sponsor  ICMJE Nantes University Hospital
Collaborators  ICMJE Not Provided
Investigators  ICMJE Not Provided
PRS Account Nantes University Hospital
Verification Date March 2020

ICMJE     Data element required by the International Committee of Medical Journal Editors and the World Health Organization ICTRP

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