Evaluation of a strategy based on the 3-month
screening biopsy to optimize the
immunosuppression in renal transplantation:
the I4BiS study
Study protocol
AFSSAPS research registration number:
Registration number in http://clinicaltrials.gov/:
1
TABLE OF CONTENTS
1. GENERAL INFORMATION ........................................................................................... 4
2. STUDY RATIONALE ..................................................................................................... 7
2.1. Current issues in renal transplantation .................................................................... 7
2.2. Screening renal biopsies ......................................................................................... 7
2.3. Inflammatory intragraft subclinical infiltrates: the new aspects of rejection? ........... 8
2.4. Uncertainties and investigation perimeter ............................................................... 8
3. FOCUS OF RESEARCH ............................................................................................. 10
3.1. Primary objective ................................................................................................... 10
3.2. Secondary objectives ............................................................................................ 10
3.3. Justification of research objectives ........................................................................ 11
4. RESEARCH DESIGN.................................................................................................. 12
4.1. Primary endpoint ................................................................................................... 12
4.2. Secondary endpoints............................................................................................. 13
4.3. Experimental design .............................................................................................. 13
4.3.1. Study design.................................................................................................... 13
4.3.2. Comparison of management strategies ........................................................... 14
4.3.3. Randomization ................................................................................................ 15
4.3.4. Measures to reduce the potential bias ............................................................. 15
4.3.5. Duration of the study ....................................................................................... 16
4.3.6. Schedule ......................................................................................................... 16
4.3.7. Study feasibility: prediction for patient recruitment .......................................... 16
5. SELECTION AND EXLUSION OF PATIENTS ............................................................ 18
5.1. Inclusion criteria .................................................................................................... 18
5.2. Exclusion criteria ................................................................................................... 18
6. STATISTICAL ANALYSIS ........................................................................................... 20
6.1. Analysis population ............................................................................................... 20
6.2. Patient number calculation .................................................................................... 20
6.3. Statistical analysis ................................................................................................. 21
6.4. Handling of missing data ....................................................................................... 22
7. ADVERSE EVENTS .................................................................................................... 23
7.1. Adverse events...................................................................................................... 23
7.2. Serious adverse events ......................................................................................... 23
7.2.1. Definition of a serious adverse event .............................................................. 23
7.2.2. Action to be taken by the investigator in case of an adverse event ................. 23
2
7.2.3. Responsibility of the sponsor........................................................................... 24
7.3. Independent monitoring committee ....................................................................... 24
8. Right of access to the data and source documents ..................................................... 25
8.1. Case report forms.................................................................................................. 25
8.2. Source documents ................................................................................................ 25
8.3. Archiving ............................................................................................................... 25
8.4. Computerized data management .......................................................................... 25
9. QUALITY CONTROL AND ASSURANCE ................................................................... 26
9.1. Quality control of the data ..................................................................................... 26
9.2. Monitoring ............................................................................................................. 26
10. Ethical considerations ............................................................................................... 27
10.1.
Patient information letter ..................................................................................... 27
10.2.
Informed consent................................................................................................. 27
10.3.
Compensation for participants ............................................................................. 27
10.4.
Data confidentiality .............................................................................................. 27
10.5.
Law and Good Clinical Practice guidelines ......................................................... 27
10.6.
Submission of the protocol to the CPP and approval from the AFSSAPS........... 28
10.7.
Protocol amendments ......................................................................................... 28
10.8.
Computerization of the data ................................................................................ 28
10.9.
Curriculum vitae and signature of the protocol .................................................... 28
11. FUNDING AND INSURANCE ................................................................................... 29
12. RULES RELATING TO THE PUBLICATION ............................................................ 30
13. REFERENCES .......................................................................................................... 31
Appendix 1: Banff 2009 classification ................................................................................ 34
Appendix 2: Flow chart of the I4BIS study .......................................................................... 35
Appendix 3: I4BIS study patient follow-up program ............................................................ 36
3
1. GENERAL INFORMATION
Evaluation of a strategy based on the 3-month screening biopsy to optimize
the immunosuppression in renal transplantation: the I4BiS study
(Inflammatory intragraft subclinical infiltrates and screening biopsy)
Sponsor:
Direction à la Recherche Clinique et à l’Innovation
Hospices Civils de Lyon
3 quai des Célestins
69621 LYON Cedex 02
Tel: 0033 (0)4 72 11 52 13
Fax: 0033 (0)4 72 11 51 90
valerie.plattner@chu-lyon.fr
Principal Investigator:
Dr Olivier Thaunat
Service de Néphrologie, Transplantation et Immunologie Clinique
Hospices Civils de Lyon
5 place d’Arsonval
Hôpital Edouard Herriot, Pavillon P
69437 LYON Cedex 03
Tel: 0033 (0)4 72 11 01 50
Fax: 0033 (0)4 72 11 02 71
olivier.thaunat@chu-lyon.fr
Associated Investigators (alphabetical order)
Name
Town, Country,
Surname
Hospital
Emmanuel
Lyon, France,
Morelon
Edouard Herriot
Email
Tel
Speciality
emmanuel.morelon@chu-lyon.fr
(+33)47211 Nephrology
0150
hospital
Dany
Paris, France,
dany.anglicheau@nck.aphp.fr
Anglicheau Necker hospital
Gilles
Nantes, France,
Blancho
Hotel Dieu
(+33)14449 Nephrology
5355
gilles.blancho@chu-nantes.fr
(+33)24008 Nephrology
7410
hospital
4
Elisabeth
Nice, France,
Cassuto
Pasteur hospital
Lionel
Bordeaux,
Couzi
France, Pellegrin
cassuto.e@chu-nice.fr
(+33)49203 Nephrology
7910
lionel.couzi@chu-bordeaux.fr
(+33)55679 Nephrology
5538
hospital
Denis
Paris, France,
Glotz
Saint-Louis
denis.glotz@sls.aphp.fr
(+33)14249 Nephrology
9630
hospital
Marc
Lille, France,
Hazzan
Calmette hospital
Alexandre
Paris, France,
Hertig
Tenon hospital
Nassim
Toulouse,
Kamar
France, Rangueil
marc.hazzan-2@univ-lille2.fr
(+33)32044 Nephrology
6770
alexandre.hertig@tnn.aphp.fr
(+33)15601 Nephrology
6510
kamar.n@chu-toulouse.fr
(+33)56132 Nephrology
2335
hospital
Yannick
Brest, France,
Le Meur
Cavale Blanche
yannick.lemeur@chu-brest.fr
(+33)29834 Nephrology
7074
hospital
Jean-Yves
Lyon, France,
Scoazec
Edouard Herriot
jean-yves.scoazec@chu-lyon.fr
(+33)47878 Pathology
2974
hospital
Organization responsible for project management:
Centre d'Investigation Clinique (CIC 0201)
Dr Catherine Cornu
Hôpital Louis Pradel
28, avenue Doyen Lépine
69500 Bron
catherine.cornu@chu-lyon.fr
Tél : (+33)472357231
Fax : (+33)72357364
Organization responsible for quality assurance:
Centre d'Investigation Clinique (CIC 0201)
Dr Catherine Cornu
Hôpital Louis Pradel
28, avenue Doyen Lépine
5
69500 Bron
catherine.cornu@chu-lyon.fr
Tél : (+33)472357231
Fax : (+33)72357364
Organization responsible for data management and statistics:
Service de Biostatistique et Laboratoire Biostatistique-Santé
Dr Fabien Subtil
162 Av. Lacassagne
69424 Lyon Cedex 03
fabien.subtil@chu-lyon.fr
Tel : (+33)472115749
Fax : (+33)472115141
This study is supported by the CENTAURE Transplantation Research
Network.
6
2. STUDY RATIONALE
2.1.
Current issues in renal transplantation
Every year in France, 3000 renal transplantations are performed. Renal
transplantation indeed represents currently the best therapeutic alternative for endstage renal failure, not only in terms of patient outcomes (better quality of life and
longer survival), but also in terms of costs to the society (1, 2).
The progress achieved in the last 20 years, notably in immunosuppression, has
resulted in a drastic reduction of the incidence of “classic” acute cellular rejection
episodes, i.e. sudden rises in serum creatinine prompting the physicians to biopsy
the graft, which reveals infiltration of the interstitium and graft tubules by cytotoxic
lymphocytes (3).
Unfortunately, and rather unexpectedly, this progress has had hardly any effect on
the frequency of the loss of kidney transplants beyond the first year, as shown by
the stagnation of the grafts' half lives (4).
Furthermore, the use of immunosuppressant combinations that are more and more
powerful has an impact on adverse effects in recipients, including an increased
incidence of infections, cancers, but also metabolic complications (diabetes,
osteoporosis, dyslipidemia, etc.), which are cause of significant morbi-mortality (3).
2.2.
Screening renal biopsies
In an attempt to improve on these disappointing outcomes, some teams have
offered to perform screening biopsies: i.e. routine biopsies at specific time points
during the follow up, irrespective of graft function (5).
These screening biopsies, performed on easily accessible grafts (heterotopic iliac
location of kidney transplants just under the skin) and usually with ultrasound
guidance, show low morbidity (6). Their primary interest is to allow an pathological
analysis of the graft at an early stage, i.e. when potential histological lesions allow
for a diagnosis but prior to these lesions inducing a change in the graft's function.
Indeed, it has been clearly shown that therapeutic adjustments intended to protect
the grafts are most effective when introduced early (7).
There was a fairly broad consensus to determine the best time to perform these
biopsies which, in most centers, are now performed three months and one year after
the transplantation (5).
Performing screening biopsies has lead to the identification of "subclinical" forms of
rejection, i.e. graft infiltration by recipient immune effectors meeting the Banff
7
histological criteria (pathological classification (8), which currently represents the
gold standard for interpreting renal graft biopsies, see Appendix 1), but without
sudden increases in creatinine (the latter fluctuating within a range of values
compatible with the dosage reproducibility, meaning <10% of the baseline).
2.3.
Inflammatory intragraft subclinical infiltrates: the new aspects of
rejection?
Today, the incidence of classic acute rejection is about 5-8%, while the incidence of
subclinical rejection is significantly higher (it varies from 10 to 45% depending on the
studies) (9). It is notoriously higher in recipients with "high immunological risk"
(young patient, second graft, high HLA mismatch, etc.) and when the
immunosuppressive regimen is reduced (no induction therapy, etc.) (9).
Evidence suggesting that subclinical rejection is deleterious to the graft include the
work by Necker's team (10), which reports that patients who develop chronic
rejection with no prior “classic” acute rejection can be identified by the detection of a
subclinical rejection on the routine screening biopsy at 3 months. The best argument
in favour of the deleterious role of subclinical rejection remains the results of studies
showing that treating subclinical rejections has a positive impact on both graft
survival (their function and the importance of interstitial fibrosis) and the subsequent
development of symptomatic rejection (11, 12).
Assuming that about 10% of screening biopsies performed at 3 months reveal a
subclinical rejection, which needs to be treated, the management strategy for the
remaining 90% of patients (whose biopsies show either a more discreet
inflammatory infiltrates or the complete absence of immune effectors in the graft) is,
on the other hand, very poorly standardized.
2.4.
Uncertainties and investigation perimeter
We have shown above that the face of rejection in renal transplantation have
significantly changed in the last 20 years. The “classic” acute rejection, which was
clinically suspected (rise in serum creatinine), has become rare. The clinically patent
forms of rejection are now "beheaded" by modern immunosuppressants and
replaced by subclinical forms, which are just as deleterious on graft survival but
whose diagnosis is a lot more difficult.
Screening biopsies, notably 3 months after transplantation, allow the diagnosis of
subclinical rejection for which treatment is necessary, but their use has raised new
issues for which no prospective randomized studies are currently available in the
8
literature. In particular:
A) There is no consensus on the way to respond when faced with patients
who show, on a screening biopsy, intragraft inflammatory infiltrates that do not meet
the Banff rejection criteria (also known as "borderline" infiltrates) (13). Are these
"borderline" infiltrates future bona fide rejection episodes that need to be treated as
such (14) or are they forms that were unexpectedly discovered and will abort
spontaneously, and which should therefore be ignored? Even more, recent
immunological progress has revealed that not all immune effectors have the same
function. Indeed, whereas some lymphocyte populations (including memory cells, B
cells and Th17 cells) appear to be particularly aggressive (15, 16), the presence of
regulatory T cells in the graft (15, 17-19) seems to be associated with a better
prognosis. In theory, the treatment of such regulatory infiltrates might even be
unfavorable.
B) Also the management strategy required for the immunosuppression of
patients whose grafts is not infiltrated by immune effectors, is not clearly
established. In particular, could these patients benefit from a reduction of their
immunosuppression by withdrawing one of the therapeutic classes of their
maintenance therapy?
The renal toxicity of calcineurin inhibitors is well documented but, unfortunately, their
withdrawal is associated with a significant increase in the risk of rejection (20, 21).
Long-term corticotherapy also leads to numerous adverse effects. Although the
literature shows that early withdrawal (up to 3 months post transplantation) of
corticosteroids is associated with a decrease in metabolic adverse effects at the
cost of an increased rejection risk for some patients (22, 23), there is no certainty
that systematic biopsy at 3 months allows the selection of the patients that will be
able to stop taking corticosteroids without any immunological risks.
We therefore propose to conduct a prospective randomized trial to answer these
questions
simultaneously
by
evaluating
a
strategy
to
optimize
the
immunosuppression of renal graft recipients based on the presence or
absence of subclinical intragraft inflammatory infiltrates in the screening
biopsy performed at 3 months post transplantation.
9
3. FOCUS OF RESEARCH
3.1.
Primary objective
To evaluate a strategy of adaptation of the immunosuppression based on the
presence or absence of subclinical intragraft inflammatory infiltrates in the screening
biopsy performed at 3 months post renal transplantation with the objective of
minimizing intragraft inflammatory infiltrates at 1 year post transplantation.
Patients :
A) with "borderline" infiltrates at 3 months will be randomized to receive a
treatment for rejection (sub-study A), with the aim of demonstrating the superiority
of this strategy in terms of infiltrates involution (superiority study).
B) without significant infiltrates at 3 months will be randomized for
maintenance corticotherapy withdrawal (sub-study B), with the aim of showing that
this strategy does not cause an increase in the percentage of "borderline" infiltrates
compared to the strategy that maintains the corticotherapy (non-inferiority study).
3.2.
Secondary objectives
1) To evaluate a strategy of adaptation of the immunosuppression based on the
presence or absence of subclinical intragraft inflammatory infiltrates in the screening
biopsy performed at 3 months post renal transplantation with the objective to
optimize graft function at one-year post transplantation.
2) To evaluate a strategy of adaptation of the immunosuppression based on the
presence or absence of subclinical intragraft inflammatory infiltrates in the screening
biopsy performed at 3 months post renal transplantation with the objective to reduce
the progression of chronic histological lesions between 3 months and 1 year post
transplantation.
3) To evaluate, over a period of 9 months (3 months-1 year post transplantation),
the immunological risk associated with the different strategies for corticosteroid use.
4) To evaluate, over a period of 9 months (3 months-1 year post transplantation),
the tolerance (in particular in terms of metabolism and infection) of the different
strategies for corticosteroid use.
5) To evaluate, over a period of 9 months (3 months-1 year post transplantation),
the impact of the different strategies for corticosteroid use on quality of life.
10
3.3.
Justification of research objectives
New immunosuppressive drugs have changed the face of allograft rejection and
made it clinically undetectable. The screening biopsy at 3 months post
transplantation has become the gold standard for the diagnosis of these subclinical
rejections (approximately 10% of patients), the treatment of which has shown to
improve the long-term prognosis of renal grafts. The use of screening biopsy has
raised questions about the management strategy required for the remaining 90% of
patients:
A) Should "borderline" infiltrates be treated as bona fide rejections?
B) Can we minimize the immunosuppression in patients without
infiltrates?
In other words: can we rely on the results of the screening biopsy at 3 months to
optimize the immunosuppressive regimen in renal transplant recipients?
Finally, I4BIS study also offers a unique opportunity to establish a large biocollection
of graft biopsies. This precious material will be used in cognitive ancillary studies
aiming at providing insights into the mechanisms involved in graft destruction.
These studies will be the object of separate financing through a tender managed by
the CENTAURE network, with the same protocol used for the PHRC TRIBUTE.
11
4. RESEARCH DESIGN
4.1.
Primary endpoint
The evaluation of the primary endpoint is based on the Banff 2009 classification (i+t
score; see Appendix 1), which allows the grading of the intragraft inflammatory
infiltrates. Several studies have indeed shown the pejorative prognostic value of this
inflammatory score on the long-term survival of kidney renal grafts (24).
-Sub-study A: proportion of patients showing a reduction in the inflammatory score
≥ 2 points on the Banff classification on the 1-year biopsy compared to the 3-month
biopsy AND without acute rejection proven by biopsy between the randomization (3
months) and the end of the follow-up (1 year).
-Sub-study B: proportion of patients presenting a "borderline" infiltrates [i.e. tubulitis
regardless of its importance (t1-3) with minimal interstitial infiltration (i0-i1) or
interstitial infiltration (i2-3) without significant tubulitis (≤ t1)] on the 1-year biopsy OR
with an acute rejection as proven by biopsy between the randomization (3 months)
and the end of the follow-up (1 year).
The Banff classification was developed for the diagnostic of acute rejections (25,
26). Available studies show that the interobserver reproducibility decreases
significantly when the histological lesions are more discreet, particularly for
"borderline" infiltrates (73% agreement for acute rejections versus 42.86% for
borderline changes (27)). In these conditions, a centralized reading of the study
biopsies seems essential.
For each patient meeting the inclusion criteria (see paragraph 5), 4 slides (PAS,
Masson’ trichrome, HES, and silver stain) of the systematic graft biopsy performed
at 3 months will immediately be sent to the pathology laboratory of Edouard Herriot
Hospital (Lyon, Pr Scoazec), where a trained renal pathologist (Dr McGregor) will be
in charge of the centralized reading. The inflammatory lesions will be graded
according to the Banff 2009 classification (see above and Appendix 1).
The results will be communicated by mail to the local co-investigator within 15 days.
This organization will allow for the timely randomization of the patient into the
appropriate sub-study (time set to 4 weeks after the 3 month-biopsy, see paragraph
4.3.1).
The transfer of the slides of 1-year screening biopsies will occur only once for the
final analysis at the end of the study.
12
4.2.
Secondary endpoints
1) Measurement of the glomerular filtration rate by iohexol clearance at 1 year post
transplantation.
2a) Evolution of the interstitial fibrosis percentage (absolute value) between the two
screening biopsies at 3 months and 1 year.
Interstitial fibrosis will be quantified using a computerized color image analysis
technique recently published by our team (28) and available for the study.
2b) Evolution of the score of the four chronic basic lesions in Banff 2009
classification (chronic glomerular damage [cg]; interstitial fibrosis [ci]; tubular fibrosis
[ct]; vascular intimal thickening [cv]) between 3 months and 1 year
3a) Percentage of patients showing the appearance of donor specific anti-HLA
antibodies using the Luminex method® between the randomization (3 months) and
the end of follow-up (1 year)
3b) Proportion of patients showing an increase in humoral lesions (Banff score
g+ptc) ≥ 2 on the screening biopsy at 1-year between the randomization (3 months)
and the end of follow-up (1 year)
3c) Proportion of patients showing ≥ 1 acute rejection episodes (cellular or humoral)
proven by biopsy between the randomization (3 months) and the end of follow-up (1
year)
4a) Comparison of the data from the Holter monitor, the orally induced
hyperglycemia test, the lipid profile, and the bone mineral density, taken between 3
months and 1 year post-transplantation
4b) The number of infectious episodes requiring treatment during the follow-up
period between the randomization (3 months) and the end of follow-up (1 year)
5) Evolution of the patients' quality of life using self-questionnaires, adapted and
validated for the French language (SF36; (29)), between the randomization (3
months) and the end of follow-up (1 year)
4.3.
4.3.1.
Experimental design
Study design
A multicentric, prospective, randomized, open-label study.
The flow chart of the study can be found in Appendix 2.
The consent form will be signed during the 3-month post-graft visit and inclusion into
the study will occur within 4 weeks of the 3-month biopsy.
The patient follow-up program is shown in Appendix 3.
13
4.3.2.
Comparison of management strategies
All the patients will receive the same immunosuppression regimen consisting of a
monoclonal (Simulect) or polyclonal (ATG) antibody induction, and a triple
maintenance immunosuppression [anti-calcineurin: cyclosporine (trough levels:
150<T0<300), or tacrolimus (trough levels: 8<T0<12); mycophenolate mofetil, and
corticosteroids] until the randomisation (see inclusion criteria paragraph 5).
Sub-study A: Patients with "borderline" infiltrates on the screening biopsy
performed at 3 months
Experimental arm:
Intensification of the corticotherapy in accordance with the validated protocol for the
treatment of "classic" and subclinical acute rejections: 3 x 15mg/kg bolus (without
exceeding 1g) every 48 hours then decreasing over 1 month starting at 1mg/kg/d
down to the maintenance dose. An anti-pneumocystis and anti-CMV prophylaxis will
be systemically introduced for 3 months.
The rest of maintenance immunosuppressive regimen (mycophenolate mofetil and
anti-calcineurin) will remain unaltered.
Control arm:
No therapeutic modification: continuation of the corticotherapy at the maintenance
dose and maintaining unaltered the rest of immunosuppressive treatment
(mycophenolate mofetil and anti-calcineurin).
Justification of proposed treatments
There is no evidence in the literature indicating a benefit in systematically treating
"borderline" inflammatory intragrafts identified on a screening graft biopsy.
The possibility that these infiltrates represent early forms of subclinical or "classic"
rejections favors treatment. The demonstrated regulatory role of certain immune
infiltrates and the well-documented adverse effects associated with an increase in
corticotherapy, are against it.
Sub-study B: Patients without any significant "borderline" infiltrates on the
screening biopsy performed at 3 months
Experimental arm:
Immediate withdrawal of maintenance corticotherapy.
Maintaining unaltered the rest of immunosuppressive treatment (mycophenolate
mofetil and anti-calcineurin).
Control arm:
No therapeutic modification: continuation of the corticotherapy at the maintenance
14
dose and maintaining unaltered the rest of immunosuppressive treatment
(mycophenolate mofetil and anti-calcineurin).
Justification of proposed treatments
The
infectious
and
metabolic
adverse
effects
associated
with
long-term
corticotherapy are well-documented. There is therefore a benefit in removing it from
the
long-term
immunosuppressant
combination
used
in
patients
whose
immunological risk is low (and thus compatible with a reduction in the level of
immunosuppression without increasing the risk of rejection). On the other hand,
there is no evidence in the literature indicating that screening biopsies at 3 months
can be used to identify patients at "low immunological risk".
4.3.3.
Randomization
Within each of the "sub-studies" A and B, the randomization will be centralized and
stratified on i) the investigational center for the study, and ii) for sub-study A only,
the presence of non-donor specific anti-HLA antibodies.
Indeed, non-donor specific anti-HLA antibodies do not have a deleterious effect
per se on the graft, but the literature suggests that their presence indicates a
stronger humoral reactivity in these patients. Their presence is therefore a specific
exclusion criteria for the sub-study B. Of note, the presence of donor specific antiHLA antibodies is an exclusion criteria for both sub-studies (see section 5-2).
The attribution of an included subject to an assignment group will be based on the
chronological order of entry of the subject into the study, according to a balanced
randomization list, which is pre-defined for each investigational center.
The declaration of inclusion of a patient into the study will be performed by an
investigator who will fax the inclusion declaration document to the coordination
center indicating: the center number, the patient number, the initials of the patient,
the date of inclusion, sub-study A or B with the validation of the inclusion and
exclusion criteria, the validation of the signature of the informed consent form.
In return, the investigator will receive, by fax, the randomization group, and by letter,
the follow-up schedule established for the patient.
4.3.4.
Measures to reduce the potential bias
To limit confounding bias, the attribution of an included subject to an assignment
group will depend upon a randomization process that will be centralized and
stratified on the investigational center for the sub-studies A and B, and the presence
of non-donor specific anti-HLA antibodies for sub-study A.
The determination of the Banff score on the screening biopsy at three months and
one year will be centralized and performed by a single person in order to assure the
15
reproducibility of the assessment.
The assessment of the Banff score on the screening biopsy at one year will be blinded to
the randomization arm in order to limit interpretation bias.
4.3.5.
Duration of the study
2 years for inclusion and 9 months for follow-up (up to 1 year post-transplantation),
i.e. a total duration of 33 months for the protocol.
4.3.6.
Schedule
Research protocol validation by the CPP and the AFSSAPS before 31/06/2014
Inclusion: 01/10/2014 – 01/10/2016
Follow-up: 9 months for all patients, end of follow up: 01/07/2017
Statistical analysis: 4th quarter 2017
4.3.7.
Study feasibility: prediction for patient recruitment
In 2012, 1268 patients underwent renal transplantations in the 10 centers
participating in the study (Table 1). The number of patients and their repartition
between the centers in that year are representative of the previous years and of the
years to come.
A minimum of 80% (n=1014) of these transplantations match the inclusion criteria
detailed in paragraph 5.
Table 1
Name Surname
Center
Nb of renal
Expected
transplantations
enrollment
in 2012
Total (patient/month)
Emmanuel Morelon
Lyon
167
48 (2)
Dany Anglicheau
Paris, Necker
159
48 (2)
Gilles Blancho
Nantes
175
48 (2)
Elisabeth Cassuto
Nice
95
25 (1.04)
Lionel Couzi
Bordeaux
136
15 (0.62)
Denis Glotz
Paris, Saint-Louis
136
44 (1.83)
Marc Hazzan
Lille
126
45 (1.87)
Alexandre Hertig
Paris, Tenon
69
20 (0.83)
Nassim Kamar
Toulouse
165
45 (1.87)
Yannick Le Meur
Brest
40
8 (0.33)
1268
346
16
We have systematically retrieved all the systematic renal graft biopsies at 3 months
performed in Lyon (site of the centralized reading) during the last 2 years (n=145).
Nine showed an acute subclinical rejection (6.2%) and one showed signs of humoral
rejection (0.7%), which are both exclusion criteria (see paragraph 5.2). Of the 135
remaining biopsies, 16 showed a "borderline" infiltrate (11%; patients who could be
enrolled in sub-study A) and 119 (82%) were considered as normal (patients who
could be enrolled in sub-study B).
An inclusion period of 2 years is planned. Therefore, the theoretical population who
could be enrolled in sub-study A is 1014 x 2 years x 11% of biopsies, i.e. 233
patients (for an estimated required number of 86 patients, cf Justification of the
number of patients, section 6.2). The inclusion of 39% of potential candidates would
therefore be sufficient to meet the objectives.
For sub-study B, the theoretical population (1014 x 2 years x 82% of biopsies) is
1663 patients for a required number of 260 (see justification of the number of
patients, section 6.2). The inclusion of 16% of potential candidates would be enough
to meet the recruitment objectives.
Note that the prediction resulting from the estimated number of patients who will be
included in each center (see the letter of support by each co-investigators in
Annex I) shows that the inclusion rate per center does not exceed 2 patients/month
(Table 1).
17
5. SELECTION AND EXLUSION OF PATIENTS
5.1.
Inclusion criteria
Common to both sub-studies
-Renal transplant patient aged between 18 and 70.
-Patient who received a first or second renal graft
-Immunosuppressive treatment consisting of an anti-calcineurin [cyclosporine
(trough
levels:
150<T0<300)],
or
tacrolimus
(trough
levels:
8<T0<12),
mycophenolate mofetil, corticosteroids, and a monoclonal (Simulect) or polyclonal
(ATG) antibody induction.
-Patient who benefited from a screening renal biopsy 3 months after the graft
-Patient who gave their informed consent
-Patient affiliated to a social security scheme or being a beneficiary of such a
scheme
Specific to sub-study A
-Presence of "borderline" inflammatory infiltrates on the screening biopsy at 3
months as defined by the Banff classification 2009:
absence of vascular lesions (v0) and:
* tubulitis regardless of its significance (t1-3) with minimum interstitial infiltrate
(i0-i1)
OR
* interstitial infiltrates (i2-3) without significant tubulitis (≤ t1)
Specific to sub-study B
-Absence of significant inflammatory infiltrates (i0-1 and t0) on the screening biopsy
at 3 months
5.2.
Exclusion criteria
Common to both sub-studies
-Histological subclinical rejection criteria on the screening biopsy at 3 months (Banff
2009: > i2+t2)
-Donor specific antibodies in historical serum or de novo appearance during the first
3 months
-Humoral lesions on the 3-month biopsy (Banff score g+ptc>2 and C4d>0)
-"Classic" acute rejection episode proven by biopsy during the first 3 months
-Multiorgan transplantation
18
-3rd (or subsequent) renal transplantation
-BK virus-associated nephropathy on the screening biopsy
-Contraindication to the 1-year screening biopsy
Specific to sub-study B
-Initial nephropathy with a high risk of recurrence on corticosteroid withdrawal:
segmental and focal and segmental glomerulosclerosis, lupus nephritis, vasculitis,
or membranous glomerulonephritis
-Presence in the circulation of non-donor specific anti-HLA antibodies at inclusion
19
6. STATISTICAL ANALYSIS
6.1.
Analysis population
Intent-to-treat analysis: analysis performed on all of the patients randomized
according to the treatment assigned at the time of randomization, regardless of
eligibility criteria, whether or not they are assessable for the primary endpoint.
Per-protocol analysis: analysis performed on all the patients randomized,
assessable for the primary endpoint, with no major protocol deviations. Major
deviations will be defined before data analysis in the context of the primary
endpoint.
Analysis for the assessment of tolerance: analysis performed on all the patients
randomized in the study who received at least one dose of the treatment from the
study arm.
The analysis of the primary endpoint for sub-study A will be performed on an intentto-treat basis. A secondary analysis performed on the per-protocol population will
supplement this first analysis. For the sub-study B, the analysis of the primary
endpoint will be performed according to the per-protocol population (the design of
this sub-study being that of a non-inferiority study).
6.2.
Patient number calculation
Patient number calculations were performed using the nQuery Advisor 5.0 software.
-Sub-study A:
The assumption is that 20% of "borderline" infiltrates on the 3-month screening
biopsies will evolve spontaneously (without treatment) versus 50% if the patient
benefits from an intensification of the corticotherapy (i.e. rejection treatment). The
inclusion of 39 patients in each arm will allow the demonstration of a difference of
30% with a power of 80% for a two-sided alpha risk of 5% (30). Sub-study A will
therefore require the inclusion of 78 patients in total.
-Sub-study B:
The objective is to show that the discontinuation of maintenance corticotherapy
does not lead to an increase in the percentage of "borderline" infiltrates or acute
rejections between the 3-month and 1-year biopsies compared to the percentage
estimated for the arm maintaining corticotherapy. The assumption is that P = 10% of
patients without significant inflammatory infiltrates will show a "borderline" infiltrate
on a systematic biopsy at one year or an acute rejection between 3 months and 1
year, despite triple immunosuppression. Taking into account the expected benefits
20
of corticotherapy discontinuation, an absolute increase of δ = 10% of this
percentage will be tolerated in patients in whom long-term corticosteroids will have
been discontinued at 3 months (i.e. 20% of these patients). To show that the
difference between the two groups does not exceed the threshold δ with a power of
80% for a single-sided alpha risk of 5%, it will be necessary to include 118 patients
per arm (31), which is 236 patients in total for sub-study B. The calculation method
used is that of a non-inferiority study.
The total number to include is therefore 314 patients for the whole protocol.
Taking into account the type of patients (organ-transplanted) and the time of the
study (first year of the post-graft follow-up), we estimate that the risk of lost to followup is minimal. On the other hand, we take into account the fact that 10% of included
patients will not undergo an assessable biopsy at one year (premature death,
containdication, refusal, etc.) To compensate for this loss of power, we plan to
include 43 patients in the 2 arms of sub-study A and 130 patients in the 2 arms of
sub-study B, which means a total of 346 patients for the whole study.
6.3.
Statistical analysis
Qualitative data will be described using numbers and percentages. Quantitative data
will be described using averages, medians, standard deviations, minimal and
maximal values, and first and third quartiles.
A description of the clinical characteristics of the patients at the time of inclusion will
be performed per treatment arm.
Analysis of the primary endpoint will be performed using the Mantel-Haenszel Chi²
test, adjusted for the stratification criteria (center for the 2 sub-studies, and presence
of donor non-specific anti-HLA antibodies in sub-study A). The magnitude of effect
for the treatment arm, in terms of reduction of the inflammatory score for sub-study
A, and the appearance of a "borderline" infiltrate for sub-study B, will be quantified
using the Mantel-Haenszel odds ratio adjusted for the stratification criteria together
with its 95% confidence interval (bilateral for sub-study A and unilateral for substudy B). Non-inferiority will be proven for sub-study B if the upper limit of this
confidence interval excludes the odds ratio value equivalent to an absolute increase
of δ = 10% of the percentage of "borderline" infiltrates or acute rejections compared
to the arm maintaining corticotherapy.
Secondary analyses of the primary endpoint will be performed by logistic regression
adjusted for both the stratification factors and other potential prognostic factors
(including clinical parameters such as age of the recipient, age of the donor, cold
21
ischemia time).
No intermediate analysis is planned.
Comparison of the evolution of the fibrosis percentage and comparison of the renal
modification will be performed using a Wilcoxon test. A description of the tolerance
parameters will be performed at one year per treatment arm.
Comparison of the evolution of the fibrosis percentage and the glomerular filtration
rate will be performed using a Wilcoxon test. A description of the tolerance
parameters will be performed at one year per treatment arm.
The scores of the eight dimensions of the SF36 questionnaire will be calculated and
the relative variations of these scores at 1 year, compared to the scores determined
at the time of randomization, will be described per treatment arm.
6.4.
Handling of missing data
For the intent-to-treat analysis of the primary endpoint in sub-study A, when the
evolution of the inflammatory score between 3 months and one year is assessable,
patients will be considered as showing no reduction in the inflammatory score.
22
7. ADVERSE EVENTS
7.1.
Adverse events
Any untoward medical occurrence in a patient participating in a biomedical research,
whether or not that occurrence is related to the research.
7.2.
7.2.1.
Serious adverse events
Definition of a serious adverse event
A serious adverse event is an event that:

results in death,

is susceptible to be life-threatening,

causes an invalidity or an incapacity,

requires in-patient hospitalization or prolongation of a hospitalization,

leads to a congenital anomaly/birth defect,

or all other events not meeting any of the qualifications listed above, but
which may be considered as "potentially serious", including some biological
anomalies or pertinent medical events, at the discretion of the investigator.
The phrase "susceptible to be life-threatening" is restricted to an immediate threat to
life, at the time of the adverse event, and regardless of the potential consequences
of a corrective or palliative treatment. The terms "invalidity " and "incapacity"
correspond to all significant clinical disabilities, whether temporary or permanent.
7.2.2.
Action to be taken by the investigator in case of an adverse event
The investigator will evaluate each adverse event taking into account its severity.
The investigator must notify the sponsor, without delay from the day it is reported to
them, all serious adverse events (Declaration form set out in the protocol appendix)
occurring during the study, with the exception of those identified in the protocol as
not requiring immediate notification.
Délégation à la Recherche
FAX: 0033 (0)4 72 11 51 90
The form must be signed and dated by a declared investigator
This initial notification is the subject of a written report and must be followed, if
necessary, by one or several additional detailed written report(s).
The investigator must document, to the best of their ability, the event (using copies
of laboratory results or reports of examinations or hospitalizations, giving information
relative to the serious adverse event, including pertinent negative results, without
omitting to make the documents anonymous and to mark down the patient's number
23
and code), the medical diagnosis, and establish a causal link (related/not related)
between the serious adverse event and the experimental product(s) and/or the
research.
The investigator must ensure that pertinent follow-up information is communicated
to the sponsor within 8 days of the initial declaration.
The investigator must monitor the patient who suffered an SAE until its resolution,
the stabilization to a level deemed acceptable by the investigator, or the return to
the previous state, even if the patient has left the study, and inform the sponsor by
fax on +33 (0)4 72 11 51 90, using the form (tick the box: follow-up).
7.2.3.
Responsibility of the sponsor
The sponsor will declare all unexpected serious adverse effects, new safety
information, and will create an annual safety report in accordance with the law of
August 9th, 2004.
7.3.
Independent monitoring committee
An independent monitoring committee consisting of 3 members will be implemented,
if the study is approved to enable early detection of excessive levels of morbimortality within the two study groups.
24
8. Right of access to the data and source documents
8.1.
Case report forms
All information required by the protocol must be provided and an explanation must
be given for all missing data. Both clinical and paraclinical data must be transferred
to the case report forms as it becomes available. Data must be copied to the case
report forms in a clear and legible manner using a black ball-point pen (in oder to
facilitate duplication and data entry). The end of each sheet shall be dated and
initialed by the investigator, thus signifying his agreement with the data contained in
the case report form.
8.2.
Source documents
Source documents are original documents, data and records from which the
patient's data is transferred to the case report form. These include, amongst others,
the reports of examination results, the nurse's monitoring sheet and/or medical
notes, the prescription/dispensation sheets, and the medical correspondence.
The investigator will have to undertake to authorize a direct access to the study
source documents during the CRA monitor visits, audits or inspections.
8.3.
Archiving
The following documents will be archived by the sponsor and by the investigator in a
locked room reserved for that purpose, for a period of 15 years from the date of the
end of the study:
-
the approved version of the protocol,
-
any protocol amendment forms,
-
the informed consent forms (kept by the investigator),
-
the original copies of the case report forms,
-
the approval forms from the CPP and the AFSSAPS,
-
the correspondence between the sponsor and the investigator,
-
the curriculum vitae (CVs) of all the investigators.
8.4.
Computerized data management
The study data will be encoded in accordance with the data protection and freedom
of information law. The data entered for this study will be done so according to the
reference methodology of the CNIL.
25
9. QUALITY CONTROL AND ASSURANCE
9.1.
Quality control of the data
The Clinical Research Associate, mandated by the sponsor, is responsible for the
inspection of the case report forms at regular intervals, in accordance with the study
monitoring plan and throughout the whole duration of the study, in order to verify the
compliance with the protocol, as well as the conformity to the source documents,
data consistency, and compliance with the regulations for the conduct of clinical
research. The appointed Clinical Research Associate must have access to the
patient medical records and any other records relating to the study and required for
the verification of the study case report forms.
9.2.
Monitoring
The visits will be carried out in the investigation centers in accordance with the study
monitoring plan and according to the rate of inclusions.
26
10. Ethical considerations
10.1.
Patient information letter
Patients can only participate in this study if they have given their written consent.
They will all have received oral and written information beforehand from their doctor
regarding: the aim of the study, the duration of their participation, the procedures
that will be performed, the benefits, the foreseeable risks, the drawbacks that could
result from the treatments and examinations, the data confidentiality, the insurance
cover, the coverage of the study-related expenses.
All this information will be summarized in the information letter given to every
patient.
10.2.
Informed consent
The consent form will be signed in duplicate by the subject and by the study
investigator. A copy of this document will be given to the person participating in the
trial, the investigator must keep the second copy in the archives for a minimum of 15
years.
10.3.
Compensation for participants
No compensation is planned for the patients participating in the study.
10.4.
Data confidentiality
All the data recorded will be treated anonymously by falling under medical
confidentiality.
The investigator must ensure that patient confidentiality is maintained. On the case
report forms and all other documents submitted to the sponsor, patients must only
be identified by their initials (three letters) and their study number.
The investigator undertakes to authorize the persons mandated by the sponsor
and/or Health Authorities, to have direct access to the original patient medical
records for the verification of the study procedures and data. The investigator will
inform the patient that their records relating to the study will be reviewed by the
aforementioned representatives without violating their confidentiality.
10.5.
Law and Good Clinical Practice guidelines
The investigator undertakes that this study will be performed in accordance with the
current legislation of the Public Health Code (Law No 2004-806 of August 9th, 2004
and related applicable texts), as well as in agreement with the Good Clinical
27
Practice guidelines and the Declaration of Helsinki.
10.6.
Submission of the protocol to the CPP and approval from the
AFSSAPS
Before the start of the study, the sponsor will submit the protocol:
to the Comité de Protection des Personnes (Ethics committee) for their opinion
to the AFSSAPS for their approval,
in agreement with the current legislation of the Public Health Code.
The evaluation of the benefit-risk balance of the participation in the study will be
sent to the CPP.
10.7.
Protocol amendments
There will be no change to the protocol without the agreement of all the
investigators and the sponsor. In the event of such an agreement, the planned
modifications must be the subject of an amendment, which will be joined to the
protocol. All amendments, before their instigation, must have obtained the favorable
opinion of the CPP who examined the application and the approval from the
AFSSAPS, as appropriate.
10.8.
Computerization of the data
In accordance with the current data protection and freedom of information law, the
patient has the right of access, of communication, of opposition and rectification of
personnel information, which they can exercise by a simple written request
addressed to the investigator. The study will be declared to the Commission
Nationale Informatique et Liberté (CNIL) by the Hospices Civils de Lyon as part of
the methodology of reference.
10.9.
Curriculum vitae and signature of the protocol
Before starting the study, the principal investigator will provide the representatives of
the sponsor with a copy of his personal Curriculum Vitae, dated and signed, as well
as those of all the co-investigators.
28
11. FUNDING AND INSURANCE
The study will be promoted by the Hospices Civils de Lyon (3 quais des Célestins,
BP 2251, 69229 Lyon Cedex 02). In accordance with the law, the sponsor will
subscribe to an insurance policy with the Société Hospitalière d’Assurance Mutuelle,
18 rue Edouard Rochet, 69008 Lyon.
29
12. RULES RELATING TO THE PUBLICATION
The final study report will be written in collaboration with the investigator, the coinvestigators, and the person responsible for data analysis.
This report will be submitted to each of the investigators for their opinion and once a
consensus has been reached, the final version must be endorsed by their
signatures.
The results of the study, whatever they may be, will be submitted for publication.
The rules concerning the publication of the results will follow the recommendations
of the editors of the medical journals described in “International Committee of
medical journal editors: Uniform requirements for manuscripts submitted to
biomedical journals” (32). The sponsor will be mentioned.
Prior to the start of inclusion, the study will be entered into a register meeting the
specifications of the ICMJE (International Committee of Medical Journal Editors).
30
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Meier-Kriesche HU, Schold JD, Kaplan B. Long-term renal allograft survival: have
we made significant progress or is it time to rethink our analytic and therapeutic
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Thaunat O, Legendre C, Morelon E, Kreis H, Mamzer-Bruneel MF. To biopsy or not
to biopsy? Should we screen the histology of stable renal grafts? Transplantation.
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Furness PN, Philpott CM, Chorbadjian MT, Nicholson ML, Bosmans JL, Corthouts
BL, et al. Protocol biopsy of the stable renal transplant: a multicenter study of methods and
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Afzali B, Taylor AL, Goldsmith DJ. What we CAN do about chronic allograft
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Sis B MM, Haas M, Colvin RB, Halloran PF, Racusen LC, Solez K, Baldwin WM
3rd, Bracamonte ER, Broecker V, Cosio F, Demetris AJ, Drachenberg C, Einecke G, Gloor
J, Glotz D, Kraus E, Legendre C, Liapis H, Mannon RB, Nankivell BJ, Nickeleit V,
Papadimitriou JC, Randhawa P, Regele H, Renaudin K, Rodriguez ER, Seron D, Seshan
S, Suthanthiran M, Wasowska BA, Zachary A, Zeevi A. Banff '09 meeting report: antibody
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Snanoudj R, Martinez F, Sberro Soussan R, Thervet E, Legendre C. [Screening
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Legendre C, Thervet E, Skhiri H, Mamzer-Bruneel MF, Cantarovich F, Noel LH, et
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Choi BS, Shin MJ, Shin SJ, Kim YS, Choi YJ, Kim YS, et al. Clinical significance of
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Beimler J, Zeier M. Borderline rejection after renal transplantation--to treat or not to
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Min SI, Park YS, Ahn S, Park T, Park DD, Kim SM, et al. Chronic allograft injury by
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Deteix C, Attuil-Audenis V, Duthey A, Patey N, McGregor B, Dubois V, et al.
Intragraft Th17 infiltrate promotes lymphoid neogenesis and hastens clinical chronic
rejection. J Immunol. 2010;184(9):5344-51.
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Sarwal M, Chua MS, Kambham N, Hsieh SC, Satterwhite T, Masek M, et al.
Molecular heterogeneity in acute renal allograft rejection identified by DNA microarray
profiling. The New England journal of medicine. 2003;349(2):125-38.
17.
Grimbert P, Mansour H, Desvaux D, Roudot-Thoraval F, Audard V, Dahan K, et al.
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18.
Mansour H, Homs S, Desvaux D, Badoual C, Dahan K, Matignon M, et al. Intragraft
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Zuber J, Brodin-Sartorius A, Lapidus N, Patey N, Tosolini M, Candon S, et al.
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Vanrenterghem Y, Lebranchu Y, Hene R, Oppenheimer F, Ekberg H. Double-blind
comparison of two corticosteroid regimens plus mycophenolate mofetil and cyclosporine
for prevention of acute renal allograft rejection. Transplantation. 2000;70(9):1352-9. Epub
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24.
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cyclosporine measurements in renal transplantation using triple therapy. Transplantation.
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Marcussen N, Olsen TS, Benediktsson H, Racusen L, Solez K. Reproducibility of
the Banff classification of renal allograft pathology. Inter- and intraobserver variation.
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26.
Solez K, Hansen HE, Kornerup HJ, Madsen S, Sorensen AW, Pedersen EB, et al.
Clinical validation and reproducibility of the Banff schema for renal allograft pathology.
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27.
Gough J, Rush D, Jeffery J, Nickerson P, McKenna R, Solez K, et al.
Reproducibility of the Banff schema in reporting protocol biopsies of stable renal allografts.
Nephrol Dial Transplant. 2002;17(6):1081-4.
28.
Meas-Yedid V SA, Noël LH, Panterne C, Landais P, Hervé N, Brousse N, Kreis H,
Legendre C, Thervet E, Olivo-Marin JC, Morelon E. New computerized color image
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33
Appendix 1: Banff 2009 classification
Adapted from Sis et al, (reference #8)
34
Appendix 2: Flow chart of the I4BIS study
35
Appendix 3: I4BIS study patient follow-up program
The same evaluations will be performed in both arms of the 2 sub-studies:
Visits
(period posttransplantation)
V-1
Selection
(3
months)
Informed consent
Demographics
Inclusion and
exclusion criteria
Medical and
surgical history
Clinical
examination
Screening renal
biopsy
Anti-HLA
antibodies
screening by
Luminex
Biological checkup
Randomization
Automated fibrosis
analysis
Renal function
evaluation
Quality of life
questionnaire
Infectious morbidity
investigation
Blood pressure
monitoring (holter)
OGTT (Oral
Glucose Tolerance
Test)
Osteodensitometry
Lipid profile
Adverse effects
X
X
V0
Inclusion
(< 4
months)
V1
Followup
(1
year)
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
--------------------
36