Anti-rejection medicines, also known as immunosuppressive drugs, are prescribed to organ transplant recipients to prevent rejection of the new organ. Long-term use of these medicines places transplant recipients at higher risk of serious infections and certain types of cancer. The purpose of this study is to determine if: * it is safe to give mesenchymal stromal cells (MSCs) to kidney transplant recipients, and * the combination of the immunosuppressive (anti-rejection) study drugs plus the MSCs can allow a kidney transplant recipient to slowly reduce and/or then completely stop all anti-rejection drugs, without rejection of their kidney (renal) allograft, a process called "immunosuppression withdrawal".
Background:The most common problem following a kidney transplant is the development of acute or chronic rejection. Rejection is the immunologic reaction in which the body refuses to accept the transplanted organ. The body's immune system will make destructive antibodies that will attempt to attack the transplanted organ. In order to prevent organ rejection, all patients receiving an allograft (a graft transplanted between genetically non-identical individuals of the same species) must take anti-rejection (immunosuppressive) therapy. These medications function by lowering the body's natural immune system. Often these medications are associated with significant side effects ranging from infections to cancer. Study: This is a single center, open label, dose-escalation clinical trial in 6 adult recipients of Human Leukocyte Antigen (HLA)- non-identical, living-donor renal allografts. All participants will receive induction therapy with alemtuzumab followed by maintenance therapy with sirolimus and belatacept. A total of 2 dosing cohorts of 2 recipients each will receive 12 infusions of donor-derived MSCs starting on Day 42 post-transplant and every 4 weeks starting on Day 56 post-transplant, with a minimum of 7 days between the first and second MSC infusions. The primary objective is to determine whether immune reconstitution after lymphocyte depletion in the setting of co-stimulatory blockade and systemic MSC-derived donor antigen can promote operational tolerance in recipients of kidney allografts. Participants will be evaluated for eligibility for sirolimus withdrawal any time between week 52 and week 104 post-transplant. Participants who successfully complete sirolimus withdrawal will remain on belatacept monotherapy for at least 24 weeks before being assessed for eligibility to discontinue belatacept. Participants who successfully complete Immunosuppression Withdrawal (ISW) will then undergo 24 weeks of high frequency follow up followed by 132 weeks of standard follow up. Study participation may continue for up to seven (7) years after kidney transplant surgery. \*\*\* IMPORTANT NOTICE: \*\*\* The National Institute of Allergy and Infectious Diseases and the Immune Tolerance Network do not recommend the discontinuation of immunosuppressive therapy for recipients of cell, organ, or tissue transplants outside of physician-directed, controlled clinical studies. Discontinuation of prescribed immunosuppressive therapy can result in serious health consequences and should only be performed in certain rare circumstances, upon the recommendation and with the guidance of your health care provider.
Study Type
INTERVENTIONAL
Allocation
NON_RANDOMIZED
Purpose
TREATMENT
Masking
NONE
Enrollment
8
These MSCs are a cellular product derived from bone marrow and propagated ex vivo using FDA-approved, clinically applicable methods. Their use in kidney transplantation has been associated with a good safety profile.
Alemtuzumab, 30 mg, given once intravenously (IV) over three hours. The infusion of alemtuzumab shall begin within 24 hours of transplantation surgery and shall be given prior to the first dose of belatacept.
Belatacept will be given as an intravenous (IV) infusion of 10mg /kg over 1 hour on transplantation postoperative Day 0, Days 5 and 14, then every 2 weeks (± 2 days) for 5 additional doses.Thereafter, belatacept will be given once every 4 weeks (± 5 days) at 10 mg/kg through 24 weeks post-transplant, then at 5 mg/kg every 4-weeks until the participant is evaluated for belatacept discontinuation.
Rapamune® (sirolimus) (Wyeth Pharmaceuticals Inc., Philadelphia, PA) will be started on transplantation postoperative day 1 at a dose of 2 mg/day orally and adjusted to maintain goal 24-hour trough levels of 8-10 ng/ml. Participants who experience grade 3 sirolimus toxicity will undergo dose reduction.
Per protocol, and, only permitted in cases of sirolimus intolerance.
Per protocol, and, only permitted in cases of sirolimus intolerance.
Per protocol, and, only permitted in cases of sirolimus intolerance.
Duke University Health System
Durham, North Carolina, United States
Proportion of Participants who Achieve Operational Tolerance
Operational tolerance (to their kidney transplant) defined by participant remaining off all immunosuppression for 52 weeks after completion of Immunosuppression Withdrawal (ISW) with: * No evidence of biopsy-proven allograft rejection after initiation of ISW; * Acceptable renal function, defined as an estimated GFR \> 60 ml/min/1.73cm\^2 calculated using the CKD-EPI equation or a serum creatinine that has increased no more than 25% above baseline, as assessed at the week 52 visit after completion of ISW; * No evidence of sustained transplant renal derived pathologic proteinuria, defined as a persistent protein creatinine ratio of greater than 0.5; and * No Donor Specific Antibodies (DSA) at any time after completion of ISW.
Time frame: 52 weeks after completion of Immunosuppression Withdrawal (ISW)
Proportion of Participants who Remain Off Immunosuppression
For the duration of their study participation, after completion of immunosuppression withdrawal (ISW).
Time frame: From ISW completion to end of study participation (up to approximately 5 years)
Proportion of Participants who Return to Immunosuppression
Resumption of immunosuppressive therapy post completion of Immunosuppression Withdrawal (ISW), per standard of care.
Time frame: From ISW completion to end of study participation (up to approximately 5 years)
Proportion of Participants who Achieve Belatacept Monotherapy
Belatacept monotherapy, defined as remaining on belatacept as the sole maintenance regimen for 48 weeks with: * No evidence of biopsy-proven allograft rejection, while on belatacept monotherapy; * Acceptable renal function, defined as an estimated GFR \> 60 ml/min/1.73m\^2 calculated using the CKD-EPI equation or a serum creatinine that has increased no more than 25% above baseline, as assessed at week 48 on belatacept monotherapy; * No evidence of sustained transplant renal derived pathologic proteinuria, defined as a persistent protein creatinine ratio of greater than 0.5, while on belatacept monotherapy; and * No Donor Specific Antibodies (DSA) at any time while on belatacept monotherapy.
Time frame: 48 weeks from the time of last sirolimus dose
Proportion of Participants who Die
This analysis will include all participants who provide informed consent for study participation and receive any form of study therapy including alemtuzumab, sirolimus, belatacept, or MSC infusions.
Time frame: From kidney transplant with alemtuzumab induction to to completion of study (up to approximately 6.5 years)
Time from Transplant to the First Episode of Rejection
Kaplan-Meier Analysis of time-to-occurrence to the first episode of kidney allograft rejection.
Time frame: From kidney transplantation to completion of study (up to approximately 7 years)
Incidence of Participants who Develop Donor Specific Antibody (DSA)
Participants that Develop de novo Anti-Human Leukocyte Antigen (HLA) Antibody or Donor Specific Antibodies (DSA).
Time frame: From study enrollment to completion of study (up to approximately 7 years)
Incidence of Adverse Events Attributable to Mesenchymal Stromal Cells (MSC) Administration
According to medical assessment/outcomes, investigator's brochure for MSCs, literature et al.
Time frame: From initial MCS infusion (day 42 post kidney transplant) to end of study participation (up to 7 years)
Frequency of Select Adverse Events (AEs)
Select AEs include: * Infection * Malignancy * Wound complications, defined as wound dehiscence, hernia or lymphocele
Time frame: From kidney transplantation to completion of study (up to approximately 7 years)
Incidence of Post-Transplant Diabetes
New onset diabetes status post transplant (posttransplantation diabetes mellitus \[PTDM\])
Time frame: From post kidney transplantation to completion of study (up to approximately 7 years)
Frequency of Antibody-Mediated Acute Cellular Rejection
Using the 2017 Banff Classification of Renal Allograft Pathology.
Time frame: From kidney transplant to completion of study (up to approximately 7 years)
Frequency of Antibody-Mediated Chronic Rejection
Using the 2017 Banff Classification of Renal Allograft Pathology. As measured by the incidence of biopsy-proven chronic allograft nephropathy/IF/TA
Time frame: From kidney transplant to completion of study (up to approximately 7 years)
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