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.
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
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
NONE
Enrollment
186
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
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
CHU de Bordeaux
Bordeaux, France
CHU La Cavale Blanche
Brest, France
CHRU Caen - Hôpital de Caen
Caen, France
CHU de Limoges - Hôpital Dupuytren
Limoges, France
Hôpital Edouard Herriot
Lyon, France
APHP - Hôpital Necker
Paris, France
APHP - Kremlin Bicetre
Paris, France
CHRU Strasbourg
Strasbourg, France
CHU de Toulouse - Hôpital Rangueil
Toulouse, France
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®).
Time frame: 6 months post-transplantation
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).
Time frame: 6 and 12 months post-transplantation
Proportion of patient with graft loss, death and loss of follow-up
Time frame: 12 months post-transplantation
Proportion of patient with acute rejection, graft loss, death and loss of follow-u
Time frame: 12 months
Level to the first CMV DNAemia
Time frame: Throughout the study
Time to the first CMV disease
Time frame: Throughout the study
Proportion of patients treated for CMV infection in both groups
Time frame: 6 months
Half-life of decreasing of DNAemia
Time frame: after initiation of anti-CMV therapy
Occurrence of treatment failure, defined as the absence of viral eradication.
Time frame: 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.
Time frame: Throughout the study
Graft function
Graft function defined as glomerular filtration rate (GFR) estimated by simplified MDRD formula and proteinuria/creatininuria ratio.
Time frame: 6 and 12 months post-transplantation
Proportion of patients with biopsy-proven acute rejection (BPAR)
Time frame: 6 and 12 months post-transplantation
Degree of interstitial fibrosis/tubular atrophy
Time frame: 12 months on protocol biopsies
Graft and patient survival
Time frame: 6 and 12 months post-transplantation
Proportion of BK virus viremia
Time frame: month 1, 3, 6 and 12
Proportion of patients with adverse events (AE) and/or serious adverse events (SAE) including opportunistic infections and neoplasias.
Time frame: 12 months
Proportion of patients with haematological disorders
The proportion of patients with haematological disorders (neutropenia, anaemia, thrombopenia)
Time frame: 12 months
Proportion of patients with diarrhea
Time frame: 12 months
Proportion of dyslipidemia
Time frame: 12 months
Proportion of patients with occurrence of New Onset Diabetes Mellitus as defined by American Diabetic Association (ADA) criteria.
Time frame: 12 months
Proportion of patients who will discontinue the immunosuppressive treatment and the reasons why.
Time frame: 12 months
Proportion of patients with delayed graft function
Time frame: 12 months
Proportion of lymphocele
Time frame: 12 months
Time to the first CMV DNAemia
Time frame: Throughout the study
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