Antibody Mediated Rejection of Lung Transplant
Conditions
Keywords
lung transplant, antibody mediated rejection, transplant rejection, IL-6 blockade, donor specific antibodies
Brief summary
Antibody-mediated rejection after lung transplantation commonly results in allograft failure and death in spite of current therapeutic regimens. We are testing the safety and tolerability of the addition of a novel immunosuppressive medication to routine treatment for antibody-mediated rejection. Future studies will be needed to assess efficacy if this study demonstrates safety
Detailed description
Long-term outcomes after lung transplantation remain disappointing, and the median survival is 6.7 years. Chronic lung allograft dysfunction (CLAD) is the leading cause of death beyond the first year after lung transplantation. Antibody-mediated rejection (AMR), which is increasingly recognized after lung transplantation, is caused by donor-specific antibodies (DSA) to mismatched human leukocyte antigens (HLA) and frequently results in CLAD and death. Recent multicenter studies using intensive monitoring for AMR report an incidence over 25%. Treatment for AMR has generally focused on antibody depletion and prevention of additional antibody development. Various combinations have been used including high-dose corticosteroids, intravenous immune globulin (IVIG), Rituximab, Carfilzomib, anti-thymocyte globulin (ATG), and plasma exchange (PLEX). However, there have been no randomized controlled trials to guide management, and outcomes after AMR are dismal. One-year allograft survival after AMR is approximately 50%, and 2-year survival is only 20%. IL-6, initially identified as B-cell stimulating factor 2 (BSF-2), is a pleiotropic cytokine that drives deleterious inflammatory, alloimmune, and fibrogenic responses. In conjunction with other cytokines, IL-6 is responsible for normal antibody production and is critical for the induction of follicular helper T cells as well as the production of IL-21 which regulates immunoglobulin synthesis. IL-6 is also crucial for B-cell differentiation into plasmablasts and for enhancing plasmablast survival. These characteristics make IL-6 an especially attractive cytokine to target in the management of AMR. Human studies examining the role of IL-6 signaling blockade in the management of AMR after kidney transplantation have shown promising results, even in refractory cases. Preliminary experience with use of IL-6 signaling blockade in a very small number of lung transplant recipients with AMR has been encouraging. The principal hypothesis for this study is that IL-6 signaling blockade added to routine immunosuppressive treatment for AMR will improve clinical outcomes. However, evaluating the safety of this approach is necessary before examining efficacy in larger clinical trials because infections are the most common serious adverse events associated with IL-6 signaling blockade and a common cause of death at all timepoints after lung transplantation. This study is a Phase 1 clinical trial using Siltuximab, a monoclonal antibody to IL-6, in addition to routine immunosuppressive therapy for AMR to examine safety and define the optimal dose for the treatment of AMR. The primary endpoint is safety and tolerability, and secondary endpoints include pharmacodynamics and functional biological measures relevant to AMR (e.g., DSA, cell-free DNA). Data from this trial will inform the design of a future Phase 2 clinical trial that assesses efficacy. Carefully designed and implemented clinical trials are necessary to improve outcomes after lung transplantation.
Interventions
DRUGSiltuximab
Interleukin-6 blockade
DRUGPlacebo
Siltuximab placebo IV
Sponsors
Washington University School of Medicine
National Heart, Lung, and Blood Institute (NHLBI)
University of Utah
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
TRIPLE (Subject, Caregiver, Investigator)
Intervention model description
Randomized 1:1:1
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
1. 18 years of age or older, 2. Single or bilateral lung transplant recipient, 3. New diagnosis of clinical definite, probable, or possible antibody-mediated rejection according to the 2016 International Society for Heart and Lung Transplantation (ISHLT) definition with plans to be treated with Carfilzomib and/or anti-thymocyte globulin, 4. Admitted to the hospital for treatment of AMR, 5. Donor-specific antibodies (DSA) to human leukocyte antigens (HLA) with a Mean Fluorescence Intensity (MFI) \> 1000, 6. Able to understand the purpose of the study and willing to participate and sign informed consent.
Exclusion criteria
1. Pregnant or breast feeding, 2. Airway anastomotic dehiscence on bronchoscopy, 3. Thoracotomy incision dehiscence, 4. Underwent lung transplantation less than 6 months before enrollment, 5. Treated with rabbit anti-thymocyte globulin (ATG) for induction immunosuppression at the time of lung transplantation, 6. Underwent other invasive surgical procedure less than 6 weeks before enrollment, 7. History of lymphoma or hematologic malignancy, 8. Treatment with IL-6 signaling blockade with 6 months of enrollment, 9. Planned treatment with plasma exchange (PLEX) for AMR, 10. Cancer other than non-melanoma skin cancer with disease-free period \< 3 years, 11. Positive respiratory virus PCR detected within 7 days of enrollment, 12. Active cytomegalovirus infection within 7 days of enrollment, 13. Positive respiratory culture for Mycobacterium tuberculosis, Mycobacterium abscessus, Mycobacterium chelonae, or Mycobacterium avium complex within 4 weeks of enrollment, 14. Absolute neutrophil count (ANC) \< 1,000 cells/mm3 at enrollment, 15. Platelet count \< 75,000 cells/mm3 at enrollment, 16. Hemoglobin ≥ 17 g/dL at enrollment, 17. ALT or AST \> 2.5 times upper limit of normal at enrollment, 18. Total bilirubin \> 2.5 times upper limit of normal at enrollment, 19. Uric acid ≥ 7 mg/dL at enrollment. 20. History of gastrointestinal tract perforation, 21. History of diverticulitis (diverticulosis is not an exclusion), 22. Plan for surgical procedure (other than bronchoscopy) within 120 days of enrollment. 23. Inability or unwillingness to give written informed consent or comply with the study protocol, 24. Any condition that in the opinion of the site investigator introduces undue risk by participating in this study or impacts the quality or interpretation of the study results.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Incidence of CTCAE ≥ grade 3 | From Randomization to Day 90. | The primary objective is to assess the safety and tolerability of Siltuximab added to routine immunosuppressive treatment for AMR after lung transplantation. The dose of siltuximab (11mg/kg or 5.5 mg/kg) with the least side effect profile will be use for future trials of siltuximab in antibody mediated rejection in lung transplantation. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Hyperlipidemia | between randomization and day 180 | Hyperlipidemia requiring the initiation or dose increase of medical therapy |
| incidence of CTCAE ≥ grade 3 | during a period of 180 days after randomization | — |
| serum high-sensitivity CRP | Up to 90 and 180 days after randomization | Pharmacodynamic measure of Il-6 pathway blockade. |
| Blood Sultiximab levels | Up to 90 days after randomization | pharmacokinetic measure |
| Clearance of donor specific antibodies | From randomization to day 180 | — |
| Infections | Between randomization and day 180 | Confirmed bacterial, CMV (defined as a positive blood viral load ≥ 200 IU/mL), mold, mycobacterial, community-acquired respiratory viral infection (each assessed independently), or other opportunistic infection |
| Change in Forced Vital Capacity (FVC) | between randomization and day 180 | — |
| Change in Forced Expiratory Volume in One Second (FEV1) | between randomization and day 180 | — |
| Development of Chronic Lung Allograft Dysfunction | between randomization and day 180 | Development of probable CLAD according to the 2019 ISHLT criteria |
| Hyperuricemia | between randomization and day 180 | Blood uric acid \> 7 mg/dL |
| Allograft survival | between randomization and day 180 | Allograft survival defined as death or undergoing re-transplantation |
Countries
United States
Contacts
PRINCIPAL_INVESTIGATORRamsey Hachem, MD
University of Utah
PRINCIPAL_INVESTIGATORDerek Byers, MD, PhD
Washington University School of Medicine
Outcome results
None listed