Cytokines Evaluation in Early Calcineurin Inhibitors Withdrawn on Renal Transplant

• Sponsor: Andre Barreto Pereira (Other)
• Overall Status: Completed
• CT.gov ID: NCT01239472
• Collaborator: Novartis (Industry)
• Enrollment: 30
• Location: 1
• Arms: 2
• Duration (Months): 53
• Patients Per Site Per Month: 0.6

Study Details

Study Description

Brief Summary

Currently, acute kidney injury is diagnosed by increased serum creatinine. However, creatinine is not a reliable marker for acute changes in renal function.

The biology of the renal graft is influenced by chemokines from reperfusion (just after the kidney transplant) and throughout its course, when acute and chronic inflammatory changes occurs. Moreover, the evaluation of changes in urinary cytokines reflects kidney interstitial patterns, and can predict renal function, acute rejection episodes and their response to treatment.

Today there are several studies comparing the relative immunosuppression of renal function, but few noticed its relationship with cytokines and chemokines. Thus, we proposed studying the inflammatory consequences of early calcineurin inhibitors (ICN) withdrawing in transplant patients by urine analysis. Kidney biopsy was done before ICN withdrawn and replaced by everolimus (3 months after transplant), and 1 year after transplant.

Condition or Disease	Intervention/Treatment	Phase
Renal Transplant Rejection; Immunosuppression	Drug: Everolimus	Phase 4

Detailed Description

1. Research objectives

OBJECTIVES

Main Objectives:

• Evaluate the urinary chemokines in kidney transplant patients taking prednisone, tacrolimus and mycophenolate sodium compared to those in use prednisone, mycophenolate sodium and everolimus as maintenance immunosuppression.

Secondary Objectives:

• Assess renal function (serum creatinine and its clearance estimated by the Cockcroft-Gault) and a composite outcome (acute rejection, graft loss, death and abandonment of the study) in patients taking prednisone, tacrolimus and mycophenolate sodium compared to those taking prednisone, mycophenolate sodium and everolimus as maintenance immunosuppression.

1. Scientific background, relevance and justification of the research

In current clinical practice, acute kidney injury is typically diagnosed by measuring serum creatinine. Unfortunately, creatinine is an unreliable indicator during acute changes in kidney function. First, serum creatinine concentrations may not change until about 50% of kidney function has already been lost. Second, serum creatinine does not accurately depict kidney function until a steady state has been reached, which may require several days. Chemokines can influence at least three aspects of the biology of the renal graft: 1 - the restoration of blood flow in the graft can lead to injury type ischemia / reperfusion in which chemokines recruit leukocytes; 2 - receptor responses to infection during immune suppression involve chemokines and 3 - the inflammatory components in the acute rejection (RA) and interstitial fibrosis / tubular atrophy (IF/TA) are controlled by chemokines.

Current data have showed urinary cytokines predicting renal function by months in renal transplanted patients. In the evaluation of urinary cytokines and chemokines in the presence of acute rejection, taken together the studies reported elevations of urinary levels of Protein-3 alpha (MIP-3α/CCL20), interleuxin-8 (IL-8/CXCL8), interleuxin-6 (IL-6), tumoral necrosis factor (TNF), interleukin- 10 (IP-10), interferon (IFN), monocyte chemoattractant protein-1 (MCP-1 / CCL2), Interferon gamma-induced protein 10 (IL-10), Monokine induced by gamma interferon (MIG/CXCL9), Interferon-inducible T-cell alpha chemoattractant (I-TAC/CXCL11), regulated upon activation normal T cell expressed and secreted (RANTES/CCL5). As predictors of complications and future changes in renal function, levels of Transforming growth factor beta (TGF-β) and interferon-gamma inducible protein 10 (IP-10/CXCL10) were associated with renal function 6 months and 4 years after transplantation (15-16). IP-10/CXCL10, MIG/CXCL9, G protein-coupled receptor 9 (GPR9/CXCR3), RANTES/CCL5 and the percentage of binding of interleukin-2 (IL-2) were associated with the occurrence of RA. IP-10/CXCL10 and MIG/CXCL9 were also considered useful as predictors of response to treatment of RA. Nankivell et al reported in 2003 that after 1year of renal transplant, 94% of patients present with chronic rejection grade I (BANFF score) and 76% present with calcineurin nephrotoxicity, although there is insufficient data about urinary cytokines at these situations. And adding new information, Hu et al reported in 2009 urinary major intrinsic protein-delta (MIP-δ), osteoprotegerin (OPG), IP-10/CXCL10, MIG/CXCL9 as good biomarkers for acute renal rejection and IF/TA.

Nowadays there is a lot of studies comparing immunosuppression in relation to renal function but not so much in relation to chemokines and cytokines, which are more representative of allograft inflammation and fibrosis.

So, we proposed studying the inflammatory consequences of early CNI withdrawn in renal transplant patients before the immunosuppression modification (3 months after transplant) and 1 year after kidney transplant.

Study Design

• Study Type: Interventional
• Actual Enrollment: 30 participants
• Allocation: Randomized
• Intervention Model: Parallel Assignment
• Masking: None (Open Label)
• Primary Purpose: Prevention
• Official Title: Cytokines Evaluation in Early Calcineurin Inhibitors Withdrawn on Renal Transplant
• Study Start Date: Jan 1, 2011
• Actual Primary Completion Date: Jun 1, 2015
• Actual Study Completion Date: Jun 1, 2015

Arms and Interventions

Arm	Intervention/Treatment
No Intervention: tacrolimus Kidney transplant patients with living or deceased donors using tacrolimus, mycophenolate sodium and prednisone.
Active Comparator: everolimus Kidney transplant patients with living or deceased donors using tacrolimus, mycophenolate sodium and prednisone, and converted for everolimus, mycophenolate sodium, and prednisone 90 days after renal transplantation.	Drug: Everolimus; Replacement of tacrolimus by everolimus, 30 days after transplat. It was done after kidney biopsy (excluding acute rejection), blood and urine analysis.; Other Names: Certican

Outcome Measures

Primary Outcome Measures

1. Cytokines Evaluation [Urine and biopsy data are collected 90 days and 365 days after transplant.]

   Cd106(VCAM-1) , IP-10/CXCL10, MIG/CXCL9, MCP-1/CCL2, IL-1, RANTES, IL-8, IL12p70, TNF, IL-10, IL-6, IL-1, VEGF, FGF, CD54(ICAM-1) were analysed in urine 90 days after transplant (before randomization), and 365 days after transplant. Material were conserved at -80 Celsius, and analysed by ELISA at same time. Data was shown in MFI units

Secondary Outcome Measures

1. Evaluation of Renal Function [90 days after transplant and 365 days after transplant]

   Evaluation of renal function (serum creatinine) 90 days after transplant and 365 days after transplant.

Eligibility Criteria

Criteria

• Ages Eligible for Study: 18 Years to 65 Years
• Sexes Eligible for Study: All
• Accepts Healthy Volunteers: No

Inclusion Criteria:

• Patients over 18 years old and under 65 years old

• Recipients of first kidney transplant

• Donor younger than 65 years old

• PRA (panel reactive antigen) ≤ 30% in class I or class II

• No acute rejection episodes

• Proteinuria <1000 mg / day

Exclusion Criteria:

• multiple organ transplant recipient

• Chronic liver failure

• Asymptomatic bacteriuria or urinary infection at randomization time

• Creatinine ≥ 2 mg / dL at randomization time (90 days after transplant)

• Presence of uncontrolled hypercholesterolemia (≥ 350 mg / dL, ≥ 9.1 mmol / L) or hypertriglyceridemia (≥ 500 mg / dL, ≥ 5.6 mmol / L) at randomization time (90 days after transplant)

Contacts and Locations

Locations

	Site	City	State	Country	Postal Code
1	Santa Casa de Misericórdia de Belo Horizonte	Belo Horizonte	Minas Gerais	Brazil	30150221

Sponsors and Collaborators

• Andre Barreto Pereira
• Novartis

Investigators

• Principal Investigator: Andre B Pereira, PhD, Marieta Konder Bornhausen Hospital and Maternity

Study Documents (Full-Text)

None provided.

More Information

Publications

• Devarajan P. Emerging biomarkers of acute kidney injury. Contrib Nephrol. 2007;156:203-12. Review.
• Di Paolo S, Gesualdo L, Stallone G, Ranieri E, Schena FP. Renal expression and urinary concentration of EGF and IL-6 in acutely dysfunctioning kidney transplanted patients. Nephrol Dial Transplant. 1997 Dec;12(12):2687-93.
• Grandaliano G, Gesualdo L, Ranieri E, Monno R, Stallone G, Schena FP. Monocyte chemotactic peptide-1 expression and monocyte infiltration in acute renal transplant rejection. Transplantation. 1997 Feb 15;63(3):414-20.
• Hauser IA, Spiegler S, Kiss E, Gauer S, Sichler O, Scheuermann EH, Ackermann H, Pfeilschifter JM, Geiger H, Gröne HJ, Radeke HH. Prediction of acute renal allograft rejection by urinary monokine induced by IFN-gamma (MIG). J Am Soc Nephrol. 2005 Jun;16(6):1849-58. Epub 2005 Apr 27.
• Hu H, Aizenstein BD, Puchalski A, Burmania JA, Hamawy MM, Knechtle SJ. Elevation of CXCR3-binding chemokines in urine indicates acute renal-allograft dysfunction. Am J Transplant. 2004 Mar;4(3):432-7.
• Hu H, Knechtle SJ. Elevation of multiple cytokines/chemokines in urine of human renal transplant recipients with acute and chronic injuries: potential usage for diagnosis and monitoring. Transpl Rev 2006;20:165-71
• Hu H, Kwun J, Aizenstein BD, Knechtle SJ. Noninvasive detection of acute and chronic injuries in human renal transplant by elevation of multiple cytokines/chemokines in urine. Transplantation. 2009 Jun 27;87(12):1814-20. doi: 10.1097/TP.0b013e3181a66b3e.
• Jiménez R, Ramírez R, Carracedo J, Agüera M, Navarro D, Santamaría R, Pérez R, Del Castillo D, Aljama P. Cytometric bead array (CBA) for the measurement of cytokines in urine and plasma of patients undergoing renal rejection. Cytokine. 2005 Oct 7;32(1):45-50.
• Kanmaz T, Feng P, Torrealba J, Kwun J, Fechner JH, Schultz JM, Dong Y, Kim HT, Dar W, Hamawy MM, Knechtle SJ, Hu H. Surveillance of acute rejection in baboon renal transplantation by elevation of interferon-gamma inducible protein-10 and monokine induced by interferon-gamma in urine. Transplantation. 2004 Oct 15;78(7):1002-7.
• Kotsch K, Mashreghi MF, Bold G, Tretow P, Beyer J, Matz M, Hoerstrup J, Pratschke J, Ding R, Suthanthiran M, Volk HD, Reinke P. Enhanced granulysin mRNA expression in urinary sediment in early and delayed acute renal allograft rejection. Transplantation. 2004 Jun 27;77(12):1866-75.
• Nankivell BJ, Borrows RJ, Fung CL, O'Connell PJ, Allen RD, Chapman JR. The natural history of chronic allograft nephropathy. N Engl J Med. 2003 Dec 11;349(24):2326-33.
• Prodjosudjadi W, Daha MR, Gerritsma JS, Florijn KW, Barendregt JN, Bruijn JA, van der Woude FJ, van Es LA. Increased urinary excretion of monocyte chemoattractant protein-1 during acute renal allograft rejection. Nephrol Dial Transplant. 1996 Jun;11(6):1096-103.
• Rüster M, Sperschneider H, Fünfstück R, Stein G, Gröne HJ. Differential expression of beta-chemokines MCP-1 and RANTES and their receptors CCR1, CCR2, CCR5 in acute rejection and chronic allograft nephropathy of human renal allografts. Clin Nephrol. 2004 Jan;61(1):30-9.
• Sibbring JS, Sharma A, McDicken IW, Sells RA, Christmas SE. Localization of C-X-C and C-C chemokines to renal tubular epithelial cells in human kidney transplants is not confined to acute cellular rejection. Transpl Immunol. 1998 Dec;6(4):203-8.
• Smith SD, Wheeler MA, Lorber MI, Weiss RM. Temporal changes of cytokines and nitric oxide products in urine from renal transplant patients. Kidney Int. 2000 Aug;58(2):829-37.
• Sorrentino S, Landmesser U. Nonlipid-lowering effects of statins. Curr Treat Options Cardiovasc Med. 2005 Dec;7(6):459-66.
• Tatapudi RR, Muthukumar T, Dadhania D, Ding R, Li B, Sharma VK, Lozada-Pastorio E, Seetharamu N, Hartono C, Serur D, Seshan SV, Kapur S, Hancock WW, Suthanthiran M. Noninvasive detection of renal allograft inflammation by measurements of mRNA for IP-10 and CXCR3 in urine. Kidney Int. 2004 Jun;65(6):2390-7.
• Teppo AM, Honkanen E, Finne P, Törnroth T, Grönhagen-Riska C. Increased urinary excretion of alpha1-microglobulin at 6 months after transplantation is associated with urinary excretion of transforming growth factor-beta1 and indicates poor long-term renal outcome. Transplantation. 2004 Sep 15;78(5):719-24.
• Yamada K, Hatakeyama E, Arita S, Sakamoto K, Kashiwabara H, Hamaguchi K. Prediction of chronic renal allograft dysfunction from evaluations of TGFBeta1 and the renin-angiotensin system. Clin Exp Nephrol. 2003 Sep;7(3):238-42.

• Responsible Party: Andre Barreto Pereira, MD, Msc, PhD, Santa Casa de Misericórdia de Belo Horizonte
• ClinicalTrials.gov Identifier: NCT01239472
• Other Study ID Numbers: CRAD001ABR14T
• First Posted: Nov 11, 2010
• Last Update Posted: Feb 7, 2020
• Last Verified: Jan 1, 2020

• Individual Participant Data (IPD) Sharing Statement: Yes
• Plan to Share IPD: Yes
• Studies a U.S. FDA-regulated Drug Product: No
• Studies a U.S. FDA-regulated Device Product: No
• Product Manufactured in and Exported from the U.S.: No
• Keywords provided by Andre Barreto Pereira, MD, Msc, PhD, Santa Casa de Misericórdia de Belo Horizonte: chronic allograft nephropathy; cytokines; kidney transplant; calcineurin inhibitors withdrawn
• Additional relevant MeSH terms: Everolimus

Study Results

Participant Flow

Arm/Group Title	Tacrolimus	Everolimus
Arm/Group Description	Kidney transplant patients taking tacrolimus, mycophenolate sodium and prednisone the whole study	Kidney transplant patients taking tacrolimus, mycophenolate sodium and prednisone, whom switched tacrolimus to everolimus 90 days after renal transplantation. Since then the patients kept taking everolimus, mycophenolate sodium and prednisone
Period Title: Overall Study
STARTED	15	15
COMPLETED	10	12
NOT COMPLETED	5	3

Baseline Characteristics

Arm/Group Title	Tacrolimus	Everolimus	Total
Arm/Group Description	Kidney transplant patients taking tacrolimus, mycophenolate sodium and prednisone with low immunologic risk .	Kidney transplant patients taking tacrolimus, mycophenolate sodium and prednisone with low immunologic risk, and converted for use of mycophenolate sodium, everolimus, and prednisone after 90 days of kidney transplantation.	Total of all reporting groups
Overall Participants	10	12	22
Age (Count of Participants)
<=18 years	0 0%	0 0%	0 0%
Between 18 and 65 years	10 100%	12 100%	22 100%
>=65 years	0 0%	0 0%	0 0%
Sex: Female, Male (Count of Participants)
Female	5 50%	6 50%	11 50%
Male	5 50%	6 50%	11 50%
Region of Enrollment (participants) [Number]
Brazil	10 100%	12 100%	22 100%

Outcome Measures

1. Primary Outcome

Title	Cytokines Evaluation
Description	Cd106(VCAM-1) , IP-10/CXCL10, MIG/CXCL9, MCP-1/CCL2, IL-1, RANTES, IL-8, IL12p70, TNF, IL-10, IL-6, IL-1, VEGF, FGF, CD54(ICAM-1) were analysed in urine 90 days after transplant (before randomization), and 365 days after transplant. Material were conserved at -80 Celsius, and analysed by ELISA at same time. Data was shown in MFI units
Time Frame	Urine and biopsy data are collected 90 days and 365 days after transplant.

Outcome Measure Data

Analysis Population Description

15 patients were enrolled in each group. However in "tacrolimus" group 5 patients didn't want to be submitted to other biopsy and to collect urine 365 days after transplant. And in "everolimus" group 3 patients had adverse events and was switched back to tacrolimus.

Arm/Group Title	Tacrolimus	Everolimus
Arm/Group Description	Kidney transplant patients taking tacrolimus, mycophenolate sodium and prednisone, during the whole study. This is the no intervention group.	Kidney transplant patients taking tacrolimus, mycophenolate sodium and prednisone at beginning, but whom switched tacrolimus to everolimus at 90 days after transplant. This is the intervention group
Measure Participants	10	12
IP10 90days	380	893
IP10 365days	763	147
MCP1 90days	2349	4119
MCP1 365days	1306	1375
MIG 90days	396	433
MIG 365days	287	580
RANTES 90days	148	145
RANTES 365days	144	155
IL8 90days	495	624
IL8 365days	641	435
IL12 90days	116	124
IL12 365days	124	124
TNF 90days	136	146
TNF 365days	153	157
IL10 90days	155	164
IL10 365 days	179	182
IL6 90days	282	349
IL6 365days	281	262
IL1 90days	212	215
IL1 365days	228	228
VEGF 90days	82	70
VEGF 365days	84	45
FGF 90days	39	43
FGF 365days	30	29
CD106 90days	43222	28564
CD106 365days	18324	19614
CD54 90days	1512	1293
CD54 365days	696	1664

Statistical Analysis 1

Statistical Analysis Overview	Comparison Group Selection	Tacrolimus, Everolimus
	Comments
	Type of Statistical Test	Superiority
	Comments
Statistical Test of Hypothesis	p-Value	<0.05
	Comments
	Method	Wilcoxon (Mann-Whitney)
	Comments

2. Secondary Outcome

Title	Evaluation of Renal Function
Description	Evaluation of renal function (serum creatinine) 90 days after transplant and 365 days after transplant.
Time Frame	90 days after transplant and 365 days after transplant

Outcome Measure Data

Analysis Population Description

[Not Specified]

Arm/Group Title	Tacrolimus	Everolimus
Arm/Group Description	Kidney transplant patients with living donors starting with the use of tacrolimus, mycophenolate sodium and prednisone without induction.	Kidney transplant patients with living donors starting with the use of tacrolimus, mycophenolate sodium and prednisone without induction, and converted for use of mycophenolate sodium, everolimus, and prednisone after 90 days of kidney transplantation.
Measure Participants	10	12
Cr 90days	1.6	1.3
Cr 365days	1.4	1.4

Statistical Analysis 1

Statistical Analysis Overview	Comparison Group Selection	Tacrolimus, Everolimus
	Comments
	Type of Statistical Test	Superiority
	Comments
Statistical Test of Hypothesis	p-Value	<0.05
	Comments
	Method	Wilcoxon (Mann-Whitney)
	Comments

Adverse Events

Time Frame	Adverse events data were collected during the followup of the study, which was done until the last biopsy, 1 year after transplant.
Adverse Event Reporting Description	Because the access to patients and files by the PI were limited as previous explained, serious adverses events were considered all cause mortality, and graft failure. Other adverse event was biopsy acute rejection. Withdrawn of the study by patient option, or because everolimus serum level was not reached, was recorded but not considered a adverse event. Hospitalizations were not considered adverse events because sometimes it weren't recorded by the office, and not reported to the PI.
Arm/Group Title	Tacrolimus		Everolimus
Arm/Group Description	Kidney transplant patients starting taking tacrolimus, mycophenolate sodium and prednisone, and keeping it the whole study.		Kidney transplant patients taking tacrolimus, mycophenolate sodium and prednisone, and whom switched tacrolimus to everolimus 90 days after renal transplantation. Therefore the patients were taking everolimus, mycophenolate sodium and prednisone since 90 days after the transplant, and kept this way during the whole study
All Cause Mortality
	Tacrolimus		Everolimus
	Affected / at Risk (%)	# Events	Affected / at Risk (%)	# Events
Total	0/15 (0%)		0/15 (0%)
Serious Adverse Events
	Tacrolimus		Everolimus
	Affected / at Risk (%)	# Events	Affected / at Risk (%)	# Events
Total	0/15 (0%)		1/15 (6.7%)
Renal and urinary disorders
graft failure	0/15 (0%)	0	1/15 (6.7%)	1
Other (Not Including Serious) Adverse Events
	Tacrolimus		Everolimus
	Affected / at Risk (%)	# Events	Affected / at Risk (%)	# Events
Total	0/15 (0%)		1/15 (6.7%)
Renal and urinary disorders
biopsy proven acute rejection	0/15 (0%)	0	1/15 (6.7%)	1

Limitations/Caveats

Principal Investigator was out of Santa Casa de Misericordia de Belo Horizonte in the periods august-2012 to september-2013, and after december-2014. Data was so restricted mainly to cytokine analysis, acute rejection, graft failure and mortality.

More Information

Certain Agreements

Principal Investigators are NOT employed by the organization sponsoring the study.

There is NOT an agreement between Principal Investigators and the Sponsor (or its agents) that restricts the PI's rights to discuss or publish trial results after the trial is completed.