ISRCTN - ISRCTN46157828: Optimized TacrolimuS and MMF for HLA Antibodies after Renal Transplantation

Plain English Summary

Background and study aims
Treatment of kidney disease accounts for a significant proportion of NHS spending. Transplantation is the best treatment for kidney failure, in terms of length and quality of life. It is also more cost-effective than dialysis. However, most transplants fail after 10-12 years and patients have to go back onto dialysis, placing a considerable burden on the NHS. Damage by the immune system, called 'chronic rejection' accounts for 50% of failing transplants and it is now possible to identify patients at risk by screening for a biomarker of chronic rejection called HLA antibodies (found in the blood). All transplant units in the UK can do this, but routine screening of patients has not been adopted because it is not clear how best to treat patients with antibodies. This study will test a screening and treatment protocol for HLA antibodies. The aim is to reduce transplant failure rates over 3 years.

Who can participate?
The trial is open to all kidney transplant recipients aged 18-70 years who have had their transplant for 12 months or more and currently have good kidney function.

What does the study involve?
Participants with antibodies will be randomly allocated to one of two groups: the biomarker-led (BLC) group or the standard care (SC) group. In the BLC group, test results are revealed and recruits will have their anti-rejection drugs changed to a regime of three drugs, prednisone, tacrolimus and MMF, each already licensed for use in transplant recipients. We have evidence that this treatment will be effective at preventing dysfunction and expect this to feed through to improvements in graft survival. In the SC group, screening results are not made available and participants will remain on their current treatments. Participants without antibodies will be randomly allocated to one of two groups: a group called blinded screening where results will not be given or a group called unblinded screening where results will be given. They will remain on standard treatment. Testing will continue every 8 months. Recruits in the SC group will move into the BLC group if they become antibody positive.

What are the possible benefits and risks of participating?
As well as the potential impact on transplant failure, the drugs used here are associated with better cholesterol profiles and lower blood pressures than others in common usage. There are potential risks. Tacrolimus is associated with an increased risk of diabetes mellitus and enhanced immunosuppression in general is associated with an increased incidence of infection, especially viral and with an increased risk of malignancy. It is difficult to predict such risks in this study. The incidence of diabetes, infection and malignancy will be monitored carefully on this trial.

Where is the study run from?
The study is run and coordinated by a team from King's College London, based at Guy's Hospital (UK).

When is the study starting and how long is it expected to run for?
Recruitment will begin in June 2013 and finish by May 2016. The study is scheduled to finish in May 2019.

Who is funding the study?
National Institute for Health Research through an EME programme grant (UK)

Who is the main contact?
Professor Anthony Dorling
anthony.dorling@kcl.ac.uk

Trial website

Contact information

Type

Scientific

Primary contact

Prof Anthony Dorling

ORCID ID

Contact details

MRC Centre for Transplantation
Dept. of Nephrology and Transplantation
Guy's Hospital Great Maze Pond
London
SE1 9RT
United Kingdom
-
anthony.dorling@kcl.ac.uk

Additional identifiers

EudraCT number

2012-004308-36

ClinicalTrials.gov number

Protocol/serial number

13990

Study information

Scientific title

A randomized controlled clinical trial to determine if a combined screening /treatment programme can prevent premature failure of renal transplants due to chronic rejection in patients with HLA antibodies

Acronym

OuTSMART

Study hypothesis

Treatment of kidney disease accounts for a significant proportion of NHS spending. Although transplantation is the best treatment for kidney failure, most transplants do not survive for the recipient's natural lifespan, but instead fail after 10-12 years. Damage by the immune system, called 'chronic rejection' accounts for 50% of failing transplants and it is now possible to identify patients at risk by screening for 'HLA antibodies' in the blood. This application is to test a screening and treatment protocol for antibodies in a randomised controlled trial. Those with antibodies will be randomised into biomarker-led (BLC) or standard care (SC) groups. In the former, test results are revealed and recruits will have their anti-rejection drugs changed to a regime of prednisone, tacrolimus and MMF, each already licensed for use in transplant recipients. We have evidence that this regime is effective at preventing graft dysfunction and expect this to feed through to improvements in survival. In the SC group, screening results are double blinded and recruits will remain on their current therapies. In those without antibodies, recruits will be randomised to either blinded or unblinded screening and remain on standard treatment. Testing will continue every 8 months; recruits in the unblinded screening group will move into the BLC group if they become antibody positive. The primary outcome is kidney failure rates within 3 years of randomisation in HLA antibody+ recruits, predicted to be approximately 20% in the SC but <10% in the BLC groups. Secondary outcomes include rates of deterioration, the incidence of infections, cancers and diabetes, an analysis of the role of non-adherence with medication, and a scientific study to identify new biomarkers associated with outcomes. A cost analysis will confirm whether the screening programme and treatment protocol can save money by keeping kidney transplants functioning for longer.

The recruitment target is to enroll 1900 HLA antibody-negative patients. This should allow recruitment of sufficient numbers of HLA antibody-positive patients.

More details can be found at: http://public.ukcrn.org.uk/Search/StudyDetail.aspx?StudyID=13990

Ethics approval

NRES Committee London - Hampstead, 14/01/2013, ref: 12/LO/1759

Study design

Randomised; Interventional; Design type: Screening, Treatment

Primary study design

Interventional

Secondary study design

Randomised controlled trial

Trial setting

Hospitals

Trial type

Treatment

Patient information sheet

Not available in web format, please use the contact details below to request a patient information sheet

Condition

Topic: Renal and Urogenital; Subtopic: Renal and Urogenital (all Subtopics); Disease: Renal

Intervention

Optimized Treatment protocol, The 'optimized treatment' protocol in the recruits with HLA Ab in unblinded group will be:
1. Mycophenolate mofetil bd, tds or qds, or enteric coated mycophenolic acid bd, with daily dose determined according to local unit guidelines. The patient will be stabilized on the maximum tolerated dose.
2. Tacrolimus od or bd, according to local unit preference, with dose titrated to achieve 12-hour post-dose levels of 4g/L to 8g/L (4-8 ng/ml). The patient will be stabilized on the maximumtolerated dose that achieves these levels.
3. Prednisolone od. Starting at 20mg for two weeks, then reducing by 5 mg od every two weeks down to a maintenance dose of 5mg od.
Screening for HLA antibodies, Serum prepared from 10mls of blood will be used in the commercially available 'LABScreen' tests, containing fluorescently tagged beads coated with purified HLA antigens. All participating centres have 'Luminex' equipment for analysis of these tests and the skills to process samples and interpret results. Therefore, the tests will be performed in each of the centres.

Follow-Up Length: 36 month(s)

Intervention type

Drug

Phase

Not Applicable

Drug names

Mycophenolate mofetil, tacrolimus, prednisolone

Primary outcome measure

Renal Transplant Failure Rates; Timepoint(s): 3 Years post-recruitment

Secondary outcome measures

1. Analysis of adherence and perceptions of risk; Timepoint(s): 3 years
2. Change in estimated Glomerular Filtration Rate; Timepoint(s): 3 years
3. Patient Survival; Timepoint(s): 3 years
4. Proteinuria; Timepoint(s): 3 years
5. Rate of acute rejection; Timepoint(s): 3 years
6. Rates of biopsy proven malignancy; Timepoint(s): 3 years
7. Rates of Culture-positive infection; Timepoint(s): 3 years
8. Rates of Diabetes Mellitus; Timepoint(s): 3 years
9. Scientific analyses of humoral & cellular immunity and CD34+ cells; Timepoint(s): 3 year

Overall trial start date

01/06/2013

Overall trial end date

31/05/2019

Reason abandoned (if study stopped)

Eligibility

Participant inclusion criteria

1. Renal transplant recipients >1 year post transplantation
2. Aged 18-70 years, male and female
3. Estimated glomerular filtration rate (eGFR) of >=30

Participant type

Patient

Age group

Adult

Gender

Both

Target number of participants

Planned Sample Size: 3000; UK Sample Size: 3000; Description: 3000 is approximate

Participant exclusion criteria

1. Recipient requiring HLA desensitisation to remove antibody for a positive XM transplant
2. Recipient known already to have HLA antibody who has received specific intervention for that antibody or for CAMR / chronic rejection
3. Recipient of additional solid organ transplants (e.g. pancreas, heart, etc).
4. History of malignancy in previous 5 years (excluding non-melanomatous tumours limited to skin)
5. HBsAg+,HBcAb+, HepC+ or HIV+ recipient (on test performed within previous 5 years)
6. History of acute rejection requiring escalation of immunosuppression in the 6 months prior to screening.
7. History of an ongoing or previous infection (no time limit) that would prevent optimization of immunosuppression, including ocular Herpes simplex.
8. Known hypersensitivity to any of the IMPs
9. Known hereditary disorders of carbohydrate metabolism
10. Patient enrolled in any other studies involving administration of another IMP at time of recruitment
11. Pregnancy or breastfeeding females (based on verbal history of recipient)
12. Pre-menopausal females who refuse to consent to using suitable methods of contraception throughout the trial.

Recruitment start date

01/06/2013

Recruitment end date

31/05/2016

Locations

Countries of recruitment

United Kingdom

Trial participating centre

MRC Centre for Transplantation
London
SE1 9RT
United Kingdom

Sponsor information

Organisation

King's College London (UK)

Sponsor details

MRC Centre for Transplantation
Dept. of Nephrology and Transplantation
Guy's Hospital Great Maze Pond
London
SE1 9RT
United Kingdom

Sponsor type

University/education

Website

http://www.kcl.ac.uk

Funders

Funder type

Government

Funder name

NIHR (UK) - Efficacy and Mechanism Evaluation; Grant Codes: 11/100/34

Alternative name(s)

Funding Body Type

Funding Body Subtype

Location

Results and Publications

Publication and dissemination plan

Not provided at time of registration

Intention to publish date

Participant level data