Kidney Failure Clinical Trial
Official title:
Sirolimus Monotherapy to Optimize Activation Induced Cell Death (AICD) in Renal Transplants Following Lymphocyte Depletion Induction With Thymoglobulin
This study will test the safety and effectiveness of two drugs, Sirolimus and Thymoglobulin,
for preventing rejection of transplanted kidneys. Standard anti-rejection therapy uses a
combination of drugs, such as cyclosporine, tacrolimus, azathioprine, steroids, and others,
that are taken daily for life. However, even with this daily therapy, more than half of
kidney recipients slowly reject their transplant within 10 years. Both Thymoglobulin, an
antibody, and Sirolimus, an anti-rejection drug, prevent rejection by lowering the response
of the immune system to the transplanted organ. Thymoglobulin is given in the pre- and
postoperative period, and Sirolimus is taken long term.
Patients who receive a kidney transplant at the National Institutes of Health Clinical Center
are eligible for this study. Candidates will be screened with a medical history, physical
examination, and blood and urine tests.
Participants will undergo a kidney transplant. Before the surgery, a central line
(intravenous catheter), through which blood and medicine can be given, is placed in the neck
or chest. Patients may also undergo leukapheresis, a procedure for collecting white blood
cells. The cells can be stored for transfusion later if white cell counts drop following
Thymoglobulin treatment. For this procedure, blood is drawn from a needle placed in the arm
and flows into a machine that separates the blood components by spinning. The white cells are
collected in a bag and the red cells and plasma are returned through a second needle in the
other arm.
Thymoglobulin will be given intravenously the day before the transplant and days 1 through 9
after the operation. Sirolimus will be taken by mouth, mixed with water or orange juice.
Sirolimus therapy starts the day of the transplant and continues for life.
Follow-up study visits will be scheduled weekly for the first month after the transplant,
then every 6 months for 1 year and then once a year for 4 years. Procedures during these
visits may include blood and urine tests, physical examination, and check of vital signs
(i.e., blood pressure, heart rate, breathing rate, temperature). Kidney biopsies (removal of
a small piece of tissue for examination under the microscope) will be done at 2 weeks, 1
month and 6 months after surgery and then yearly for 4 years to check for any damage to the
kidney. In addition, a local doctor will do routine laboratory tests 2 to 3 times a week for
the first 2 to 3 months aft...
This protocol will test a novel dual agent combination therapy for its ability to prevent
human renal allograft rejection. Thymoglobulin (Sangstat), a FDA-approved polyclonal
rabbit-IgG antithymocyte preparation, will be given for ten days at the time of
transplantation to achieve profound lymphocyte depletion. This will be paired with chronic
therapy with Sirolimus (rapamycin, Wyeth-Ayerst), an oral immunosuppressant agent recently
approved by the FDA. Rapamycin allows for antigen specific T cell activation but prevents T
cell clonal expansion by interrupting IL-2 receptor beta-chain signal transduction. The
rationale for this combination is to eliminate existing alloreactive T cell clones that could
initiate a rejection at the time of transplantation, and to promote graft specific activation
induced cell death (AICD) in repopulating T cells such that an allospecific T cell deficit is
induced. The desired effect of this therapy is to prevent allograft rejection without the
chronic use of calcineurin inhibitors or glucocorticosteroids, and in doing so, develop a
regimen for transplantation that avoids most of the chronic drug toxicities inherent in the
use of these two classes of immunosuppressants.
Twenty people will be evaluated in this pilot protocol. Ten will receive living donor kidney
allografts and ten will receive cadaveric kidney allografts. Patients will be treated with
Thymoglobulin beginning prior to graft implantation and continuing for ten days.
Glucocorticosteroids will be given during the Thymoglobulin treatment to limit monocyte
activation and prevent the cytokine release syndrome associated with this antibody
preparation. Patients will be given Sirolimus orally beginning the day after transplantation
and continuously thereafter. Patients will then be monitored for evidence of allograft
rejection using standard functional parameters and protocol allograft biopsies. In addition,
patients will be followed for a specific desired effect, allospecific AICD, that should
promote the development of allospecific graft tolerance. This will be accomplished by
assaying peripheral blood and allograft biopsies for apoptosis and peripheral blood for
evidence of alloreactive T cell clone depletion.
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