American Journal of Transplantation 2015; 15: 2655–2664 Wiley Periodicals Inc.
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Copyright 2015 The American Society of Transplantation and the American Society of Transplant Surgeons doi: 10.1111/ajt.13327
Reduced Incidence of Cytomegalovirus Infection in Kidney Transplant Recipients Receiving Everolimus and Reduced Tacrolimus Doses H. Tedesco-Silva1,*, C. Felipe1, A. Ferreira1, M. Cristelli1, N. Oliveira1, T. Sandes-Freitas1, W. Aguiar2, E. Campos3, M. Gerbase-DeLima3, M. Franco4 and J. Medina-Pestana1 1
Nephrology Division, Hospital do Rim - UNIFESP, S~ ao Paulo, Brazil 2 Urology Division, Hospital do Rim - UNIFESP, S~ ao Paulo, Brazil 3 Department of Immunogenetic, AFIP S~ ao Paulo, Sao ~ Paulo, Brazil 4 Department of Pathology, UNIFESP, Sao ~ Paulo, Brazil Corresponding author: Helio Tedesco-Silva, [email protected] This study compared the incidence of CMV infection/ disease in de novo kidney transplant recipients receiving everolimus or mycophenolate and no CMV pharmacological prophylaxis. We randomized 288 patients to receive a single 3 mg/kg dose of antithymocyte globulin, tacrolimus, everolimus, and prednisone (r-ATG/ EVR, n ¼ 85); basiliximab, tacrolimus, everolimus, and prednisone (BAS/EVR, n ¼ 102); or basiliximab, tacrolimus, mycophenolate, and prednisone (BAS/MPS, n ¼ 101). The primary end-point was the incidence of first CMV infection/disease in the intention-to-treat population at 12 months. Patients treated with r-ATG/ EVR showed a 90% proportional reduction (4.7% vs. 37.6%, HR 0.10, 95% CI 0.037–0.29; p < 0.001), while those treated with BAS/EVR showed a 75% proportional reduction (10.8% vs. 37.6%, HR 0.25, 95% CI 0.13–0.48; p < 0.001) in the incidence of CMV infection/disease compared to BAS/MPS. There were no differences in the incidence of acute rejection (9.4 vs. 18.6 vs. 15.8%, p ¼ 0.403), wound-healing complications, delayed graft function, and proteinuria. Mean estimated glomerular filtration rate was lower in BAS/EVR (65.7 21.8 vs. 60.6 20.9 vs. 69.5 21.5 ml/min, p ¼ 0.021). In de novo kidney transplant recipients receiving no pharmacological CMV prophylaxis, reduced-dose tacrolimus and everolimus was associated with a significant reduction in the incidence of CMV infection/disease compared to standard tacrolimus dose and mycophenolate (ClinicalTrials.gov NCT01354301). Abbreviations: BAS, basiliximab; BCAR, biopsy-confirmed acute rejection; CMV, cytomegalovirus; eGFR, estimated glomerular filtration rate; EVR, everolimus; HLA, human leukocyte antigen; MDRD, modification of
diet in renal disease; MPS, mycophenolate sodium; mTORI, mammalian target of rapamycin inhibitors; rATG, rabbit antithymocyte globulin; TAC, tacrolimus Received 22 January 2015, revised 05 March 2015 and accepted for publication 25 March 2015
Introduction Cytomegalovirus (CMV) infection is associated with significant morbidity and mortality after solid organ transplantation (1–3). In the absence of preventive strategies, the incidence of CMV infection and disease is high among kidney transplant recipients. Universal prophylaxis and preemptive therapy have been used to manage CMV infection, but both are associated with disadvantages (1,2,4). Universal prophylaxis is not fully effective, its duration, 3–6 months, varies according to the perceived risk, is associated with bone marrow adverse events possibly leading to drug dose discontinuation (5,6), and is associated with significant incidence of late CMV infection and drug resistance (2,7–9). Pre-emptive therapy does not prevent viral replication, an event that has been associated with inferior transplant outcomes, and requires intensive logistical coordination (2,4,10–12). Importantly, both strategies are associated with increased costs (3). Several studies and meta-analysis have shown that the use of mammalian target of rapamycin inhibitors (mTORI, sirolimus, and everolimus), either de novo (13–15) or as a conversion strategy (16), are associated with lower rates of CMV infection. In all these trials, the population and management of CMV infection were largely heterogeneous with low representation of patients receiving no prophylaxis, who would benefit the most, primarily in transplant centers where CMV prophylaxis is not available or reimbursed. In these studies, CMV events have been captured as adverse events without predefined uniform criteria for diagnosing and reporting, including cut-off points for quantitative nuclear amplification tests or pp65 antigenemia. Most importantly, there are no studies comparing immunosuppressive regimens adequately powered to analyze CMV infection as primary end-point (17). Therefore, we devised a prospective study to compare the incidence of CMV infection/disease in de novo kidney transplant 2655
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recipients receiving tacrolimus (TAC)-based immunosuppressive regimens combined with everolimus (EVR) or mycophenolate sodium (MPS).
strategy consisting of weekly monitoring of CMV viral replication (pp65 CMV antigenemia test) for 6 months. All patients received oral nystatin for 30 days and trimethoprim-sulfamethoxazole for 12 months.
Definitions
Methods Study design This was a single-center, prospective, randomized, 12-month open label controlled trial aiming to compare the incidence of CMV infection/disease in de novo kidney transplant recipients receiving mTOR inhibitor or mycophenolate and no CMV pharmacological prophylaxis. The relevance of this study relies on the premise that within the government-funded national transplant program, there is no specific reimbursement for CMV prophylaxis. The authors designed the protocol, acquired and maintained the data, and conducted the statistical analysis. The protocol was approved by an independent ethics committee and registered in the ClinicalTrials.gov database, number NCT01354301. All subjects signed a written informed consent before enrollment and the study was conducted according to good clinical practices and the Declaration of Helsinki. Novartis partially funded this study.
Population Low/moderate immunological risk adult recipients of first ABO-compatible renal transplants from living or deceased donors were considered for enrollment. We excluded recipients of kidneys from HLA identical or expanded criteria deceased donors. Patients with a positive cytotoxic crossmatch or panel reactive antibody equal to or above 50%, class I or class II, were also excluded. Women of childbearing potential had to agree in using approved contraceptives methods during the duration of the study.
Delayed graft function was defined as the need for dialysis during the first week after transplantation, excluding technical failures and a single dialysis for hypervolemia and/or hyperkalemia. Biopsy confirmed acute rejection (BCAR) episodes were graded according to Banff 2009 classification (20). In patients with multiple biopsies, the most severe score was used for statistical analysis. Treated acute rejection included BCAR and those treated episodes (at least 500 mg of methylprednisolone for 3 consecutive days) without biopsy confirmation, including borderline changes. Steroid-resistant rejections were treated with polyclonal agents.
Primary end-point The primary end-point was the cumulative incidence of CMV infection/ disease during the first year after transplantation. CMV infection was defined based on detection of CMV viral replication (at least 10 positive cells per 200 000 cells by CMV pp65 antigenemia) in asymptomatic patients. CMV disease was defined based on the evidence of CMV infection with related symptoms. Symptomatic patients could be treated with lower number of CMV pp65–positive cells. CMV infection/disease was treated with intravenous ganciclovir with weekly monitoring of viral replication. Treatment was prolonged for 1 week after the first negative CMV pp65 antigenemia test (5). Recurrent CMV infection/disease was defined as a new CMV event in a patient who had no evidence of viral replication after treatment.
Secondary end-points
Eligible patients were randomized (1:1:1) before the transplant surgery to one of three immunosuppressive regimes. Randomization was stratified according to donor source (living or deceased donors). A computer-generated randomization sequence was obtained and placed in sequentially numbered opaque envelops. Transplant surgeons were blinded to treatment allocation.
Secondary outcomes included treatment failure, defined as a composite end-point of first BCAR (IA or higher), graft loss, death, and loss to follow up; incidence, severity, timing, and treatment of first treated acute rejection episodes. We also evaluated the incidence and duration of DGF, renal function (eGFR by MDRD formula [21]), and spot urine protein/creatinine ratio (U p/c). Safety analysis included vital signs and incidence of adverse events, malignancies, and laboratorial abnormalities.
Treatments
Statistical analysis
In group 1 (r-ATG/EVR), a single 3 mg/kg dose of r-ATG was administered intravenously beginning within the first 24 h after graft revascularization. On day 1, patients received TAC 0.05 mg/kg twice daily, adjusted to maintain whole blood trough concentrations between 3 and 5 ng/ml, based on the very low TAC regimen of the Asset trial (18) and EVR 1.5 mg twice daily adjusted to maintain EVR whole blood trough concentrations between 4 and 8 ng/ml. In group 2 (BAS/EVR), patients received basiliximab (BAS) induction on days 0 and 4. On day 1, patients received TAC 0.1 mg/kg twice daily, adjusted to maintain whole blood trough concentrations between 3 and 8 ng/ ml for the first 3 months then reduced to 3–5 ng/ml, based on low TAC arm of the Asset trial (18) and EVR 1.5 mg twice daily, adjusted to maintain EVR whole blood trough concentrations between 4 and 8 ng/ml. In group 3 (BAS/ MPS), patients received BAS induction on days 0 and 4. On day 1, patients received TAC 0.1 mg/kg twice daily, adjusted to maintain whole blood trough concentrations between 6 and 8 ng/ml, based on the Symphony trial (19), and MPS 720 mg twice daily. All patients received 1 g methylprednisolone before graft revascularization followed by oral prednisone 0.5 mg/kg/day (maximum dose of 30 mg) beginning on day 1 tapered to 5 mg/day by day 45.
The sample size was calculated based on the incidence of CMV infection/ disease of 10% in at least one of the EVR groups and 27% in the MPS group in the absence of pharmacological prophylaxis. With a two-sided type I error of 5% and 85% test power to detect the difference, the estimated sample size is 276 patients (92 per group). Assuming 5–10% drop out rate we randomized 300 patients. Primary and secondary end-points were analyzed in the intention-to-treat population using Kaplan–Meier estimates and groups were compared using the Log-rank test. For the primary end-point, we used Cox regression analysis to calculate event rate ratios and 95% confidence interval (CIs). Frequency distributions were provided for categorical variables, and treatment groups were compared with x2 or Fisher’s exact tests. Continuous variables and differences were analyzed using ANOVA complemented by Tukey’s test. All statistical tests were twosided and were conducted using the 0.05 level of significance.
Randomization
Prophylaxis against infections No pharmacological prophylaxis for CMV infection was used, including valganciclovir, acyclovir, or valacyclobir. Instead, we used pre-emptive
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Results Population and disposition Patients were enrolled in this trial between July 11, 2011 and May 4, 2013, and were followed up to May 9, 2014. We screened 397 patients, randomized 300, and 288 were American Journal of Transplantation 2015; 15: 2655–2664
Reduced CMV Infection With Everolimus
transplanted and received first study drug dose (r- ATG/ EVR ¼ 85; BAS/EVR ¼ 101; BAS/MPS ¼ 102, Figure 1). There was no difference in the proportion of patients completing the study (94 vs. 92 vs. 89%, p ¼ 0.457). The only significant difference in baseline demographic characteristics was a higher mean final creatinine of deceased donors in the r-ATG/EVR group (Table 1). Immunosuppression At days 30, 90, and 365, mean TAC whole blood trough concentrations were 5.1 1.7, 4.7 1.8, and 4.7 1.5 ng/ ml in the r-ATG/EVR group, 7.4 2.6, 5.6 2.1, and 5.0 2.1 ng/ml in the BAS/EVR group, and 8.1 3.1, 7.1 2.4, and 6.2 3.3 ng/ml in the BAS/MPS group, respectively (Figure 2A). Mean EVR whole blood trough concentrations were 5.2 2.1, 5.9 2.1, and 6.5 2.2 ng/ ml in the r-ATG/EVR group, and 4.9 1.5, 5.6 1.6, and 6.0 2.2 ng/ml in the BAS/EVR group, respectively (Figure 2B). Mean plasma MPA concentrations were 4.8 4.3, 4.3 3.4, and 4.9 6.6 mg/ml in the BAS/MPS group, respectively (Figure 2B). There were no differences in mean prednisone doses at days 30 (11.9 4.1 vs. 12.9 5.3 vs. 12.6 5.0 mg/day, p ¼ 0.368), 90 (5.2 1.7 vs. 5.3 1.7 vs. 5.4 2.7 mg/day, p ¼ 0.614), and 365
(5.3 1.8 vs. 5.3 2.6 vs. 5.0 0.0 mg/day, p ¼ 0.447), respectively. Primary end-point Patients receiving EVR showed a lower incidence of CMV infection/disease compared to those receiving MPS (4.7 vs. 10.8 vs. 37.6%, p < 0.001, Table 2). Similar findings were observed when we analyzed the incidence of CMV infection or disease independently. While a statistically significant difference was also observed for the most prevalent pretransplant donor(þ)/recipient(þ) CMV serostatus combination, no statistically significant differences were observed for the high-risk donor(þ)/recipient() CMV serostatus combination (Table 2). Patients treated with rATG/EVR showed a 90% proportional reduction, while those treated with BAS/EVR showed a 75% proportional reduction in the incidence of CMV infection/disease compared to BAS/MPS (Figure 3). There were no differences in mean time to first CMV infection/disease or in the duration of treatment comparing the three groups. Patients in BAS/EVR and BAS/MPS groups showed a higher number of CMV infection/disease recurrences, yielding a higher total number of CMV infection/disease events (4.7 vs. 17.6 vs. 57.4%, p < 0.001), respectively. None of the patients
397 potential subjects 67 declined to participate
330 signed informed consent 30 did not meet inclusion/exclusion criteria 300 underwent randomization
89 were assigned to receive r-ATG plus everolimus 3 did not receive a transplant 1 did not receive treatment 85 received treatment and transplantation
106 were assigned to receive basiliximab plus everolimus 3 did not receive a transplant 1 transplanted in another center 102 received treatment and transplantation
105 were assigned to receive basiliximab plus mycophenolate 3 did not receive a transplant 1 transplanted in another center 101 received treatment and transplantation
3 died * 1 was lost to follow-up 1 graft loss 5 discontinued treatment
5 died *,# 1 was lost to follow-up 3 graft loss 13 discontinued treatment
4 died 7 graft loss * 13 discontinued treatment
80 (94%) completed 12 months 76 (89%) receiving initial treatment
94 (92%) completed 12 months 82 (80%) receiving initial treatment
90 (89%) completed 12 months 78 (77%) receiving initial treatment
* 1 patient with prior treatment discontinuation; # 1 patient with prior graft loss Figure 1: Patient disposition. All patients who were randomized, transplanted, and received assigned treatment were included in the intention-to-treat population.
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Tedesco-Silva et al Table 1: Demographic characteristics of the transplant recipients Variable Recipient age, years (mean SD) Recipient gender, male, N (%) Recipient race, Caucasian, N (%) Body mass index (kg/m2) Cause of chronic kidney disease, N (%) Glomerulonephritis Hypertension Diabetes mellitus Undetermined Other Time on dialysis, months (mean SD) Type of treatment, hemodialysis, N (%) Panel reactive antibodies, (%) Class I (mean SD) Class II (mean SD) HLA mismatches (mean SD) CMV IgG serologic status, N (%) Donor (þ)/Recipient (þ) Donor (þ)/Recipient () Donor ()/Recipient (þ) Donor (unk)/Recipient (þ) Donor age, years (mean SD) Donor gender, male, N (%) Donor race, Caucasian, N (%) Donor type, N (%) Living Deceased Death due to cerebrovascular accident Final creatinine, mg/dL (mean SD)* History of hypertension, N (%) Cold ischemia time, hours (mean SD)
r-ATG/EVR (N ¼ 85)
BAS/EVR (N ¼ 102)
BAS/MPS (N ¼ 101)
43.7 13.6 54 (63) 41 (48) 24.4 3.5
45.1 14.0 68 (67) 51 (50) 24.5 4.1
44.8 12.2 68 (67) 55 (54) 24.6. 4.1
13 (15) 9 (11) 7 (8) 33 (39) 23 (27) 37.1 30.9 78 (92)
15 (15) 7 (7) 6 (6) 46 (45) 28 (27) 42.2 42.2 97 (95)
9 (9) 12 (12) 17 (17) 38 (37) 25 (25) 43.8 38.7 93 (92)
3.2 8.1 1.5 6.5 2.6 1.2
1.2 4.9 1.1 5.1 2.7 1.2
3.3 10.5 1.1 10.2 2.7 1.2
71 (83) 4 (5) 3 (4) 7 (8) 39.9 11.4 52 (61) 50 (59)
80 (78) 5 (5) 6 (6) 11 (11) 42.6 12.1 58 (57) 55 (54)
81 (80) 6 (6) 4 (4) 10 (10) 40.8 11.3 62 (61) 57 (56)
18 (21) 67 (79) 28 (42) 2.2 2.2 11 (16) 21.4 5.0
36 (35) 66 (65) 35 (53) 1.6 1.1 17 (26) 20.6 4.7
36 (36) 65 (64) 34 (52) 1.6 1.3 15 (23) 20.5 4.7
ATG, antithymocyte globulin; BAS, basiliximab; EVR, everolimus; MPS, mycophenolate sodium; Unk, unknown. (r-ATG/EVR vs. BAS/EVR, p ¼ 0.042; r-ATG/EVR vs. BAS/MPS, p ¼ 0.052).
*
developed tissue invasive CMV disease. The number of first CMV events after treatment for acute rejection was higher in patients receiving BAS/EVR and BAS/MPS compared to r-ATG/EVR. In the r-ATG/EVR group, none of the five patients who discontinued EVR (days 73, 133, 238, 246, and 327) developed CMV infection/disease, thereafter. In the BAS/EVR group, five patients developed the first episode of CMV infection/disease after discontinuation of EVR (day 15, 21, 24, 52, and 215) and eight did not, including two early (days 19 and 28) and six late (after day 108) EVR discontinuations. In the BAS/MPS group, 12 patients were converted from MPS to EVR after the first (n ¼ 10) and second (n ¼ 2) recurrent episode of CMV infection/disease with only one CMV relapse. Because the differences in the induction agent and TAC blood concentrations among the groups could also be confounding risk factors associated with CMV infection/ disease, we then performed a multivariable analysis. Use of a single 3 mg/kg dose of r-ATG induction (vs. BAS, odds ratio ¼ 0.343, p ¼ 0.113, 95% CI 0.091–1.287) and higher time averaged TAC blood concentrations over the first three 2658
months (>6.8 ng/ml vs. 0.5 mg/dl. None of the patients developed polyomavirus nephropathy (Table 3). Patients in the BAS/MPS group showed a higher incidence of serious adverse events compared to the EVR groups (38.8 vs. 51 vs. 73.3%, p < 0.001, Table 4), primarily due to the higher incidence of CMV events. No differences were American Journal of Transplantation 2015; 15: 2655–2664
observed in the incidence of adverse events leading to drug discontinuation (4.7 vs. 6.9 vs. 12.9%, p ¼ 0.107, Table 4). Patients in the r-ATG/EVR group showed higher incidence of acne (23.5 vs. 10.9%, p ¼ 0.04), aftous ulcers (21.2 vs. 8.9%, p ¼ 0.01), and dyslipidemia (34.1 vs. 16.8%, p ¼ 0.009) compared to the BAS/MPS group. Patients in the BAS/EVR group showed higher incidence of aphthous ulcers (19.6 vs. 8.9%, p ¼ 0.04), dyslipidemia (39.3 vs. 16.8%, p ¼ 0.001), and peripheral edema (46.1 vs. 31.7%, p ¼ 0.044) and lower incidence of leucopenia (1 vs. 9.9%, p ¼ 0.005) compared to the BAS/MPS group. There were no differences in the incidence of infections (excluding CMV) (Table 4). None of the patients developed pneumonitis and only one patient in the BAS/MPS group presented a 2659
Tedesco-Silva et al Table 2: Incidence of CMV infection/disease
Incidence of first CMV event, N (%)* Infection* Disease** Pretransplant CMV serostatus, N (%)1 Donor (þ) Recipient (þ)* Donor (þ) Recipient () Donor () Recipient (þ) Donor (unk) Recipient (þ)* Time to first CMV event, days (mean SD) Duration of treatment, days (mean SD) Recurrent CMV events, N Total number of CMV events First CMV event after treated acute rejection, N (%) First CMV event after EVR discontinuation, N(%)
r-ATG/EVR (N ¼ 85)
BAS/EVR (N ¼ 102)
BAS/MPS (N ¼ 101)
4 (4.7) 1 (1.2) 3 (3.5)
11 (10.8) 4 (3.9) 7 (6.9)
38 (37.6) 26 (25.7) 12 (11.9)
2 (2.8) 2 (50.0) 0 0 65.8 21.5 20.3 5.0 0 4 (4.7) 1 (1.1) 0
6 (7.5) 3 (60.0) 0 2 (18.2) 75.7 68.1 21.1 4.3 7 18 (17.6) 5 (4.9) 5
26 (32.0) 5 (83.3) 2 (50.0) 5 (50.0) 68.3 48.0 26.0 10.2 20 58 (57.4) 13 (12.9) Na
ATG, antithymocyte globulin; BAS, basiliximab; EVR, everolimus; MPS, mycophenolate sodium; Na, not applicable; Unk, unknown. * p ¼ 0.000, **p ¼ 0.037 Log Rank test. 1 Percentages were calculated based on the prevalence of each CMV serostatus combination described in Table 1.
Figure 3: Cumulative incidence of CMV infection/disease during the 12 months of follow up.
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Reduced CMV Infection With Everolimus Table 3: Secondary endpoints r-ATG/EVR (N ¼ 85) Treatment failure, N (%) First biopsy confirmed acute rejection, N (%) IA IB IIA IIB Antibody-mediated changes Acute antibody-mediated rejection Death, N (%) Graft loss, N (%) Loss to follow up, N (%) Patient survival, (%) Graft survival, (%) Death-censored graft survival, (%) First treated acute rejection, N (%) Antibody treated rejection, N (%) Wound-healing complications, N (%) DGF, N (%) Duration of DGF, days (mean SD) Creatinine, mg/dL (mean SD) eGFR, ml/min (mean SD)* Urine protein/creatinine ratio, (mean SD) Proteinuria > 0.5 mg/L, N (%)
BAS/EVR (N ¼ 102)
13 8 1 5
(15.3) (9.4) (1.2) (5.9) 0 0 1 (1.2) 1 (1.2) 3 (3.5) 1 (1.2) 1 (1.2) 96.5 95.3 98.8 19 (22.3) 1 (1.2) 20 (23.5) 32 (47.0) 11.3 5.3 1.4 0.64 65.7 21.8 0.4 0.7 21 (26.5)
BAS/MPS (N ¼ 101)
23 19 5 7 6 1
(22.6) (18.6) (4.9) (6.9) (5.9) (1.0) 0 0 5 (4.9) 3 (2.9) 1 (1.0) 95.1 93.1 97.1 35 (34.3) 7 (6.9) 35 (34.3) 32 (48.5) 14.7 14.3 1.5 0.5 60.6 20.9 0.4 0.8 21 (22.8)
24 16 4 2 6 3 2
(23.8) (15.8) (4.0) (2.0) (5.9) (3.0) (2.0) 0 4 (4.0) 7 (6.9) 0 96.0 89.1 93.1 29 (28.7) 8 (7.9) 23 (22.8) 27 (41.5) 9.9 5.8 1.3 0.5 69.5 21.5 0.2 0.4 16 (18.0)
ATG, antithymocyte globulin; BAS, basiliximab; EVR, everolimus; MPS, mycophenolate sodium. First treated acute rejection was defined as the first episode of acute rejection, confirmed or not by biopsy that was treated with either methylprednisolone or polyclonal antibody. * BAS/EVR vs. BAS/MPS, p ¼ 0.016.
Table 4: Adverse events r-ATG/EVR
BAS/EVR
BAS/MPS
r-ATG/EVR vs. BAS/MPS
BAS/EVR vs. BAS/MPS
Adverse events (AE), n (%)
(N ¼ 85)
(N ¼ 102)
(N ¼ 101)
RD% (95% CI)
RD% (95% CI)
Patient with at least 1 AE Patient with at least 1 serious AE Patients with AE leading to drug discontinuation AEs with incidence >10% Infections and infestations Urinary tract infection Upper respiratory tract infection Adverse events of special interest Acne Aftous ulcers Anemia Leukopenia Thrombocytopenia Hyperglycemia Posttransplant diabetes mellitus Dyslipidemia Epigastric pain Constipation Acute gastroenterocolitis Diarrhea Proteinuria Peripheral edema
85 (100) 33 (38.8) 4 (4.7)
102 (100) 52 (51) 7 (6.9)
101 (100) 74 (73.3) 13 (12.9)
– 34.4 (21, 47.9)* 8.2 (0.2, 16.1)
– 22.3 (9.3, 35.3)* 6 (-2.2, 14.2)
18 (21.2) 28 (32.9)
21 (20.6) 28 (27.4)
32 (31.7) 30 (29.7)
10.5 (-2.1, 23.1) 3.2 (-16.6, 10.2)
11.1 (-0.9, 23.1) 2.3 (-10.2, 14.7)
20 18 21 4 0 20 13 29 9 9 10 20 10 38
13 20 23 1 0 15 11 40 9 11 12 24 9 47
11 9 18 10 1 15 6 17 16 16 8 32 7 32
(23.5) (21.2) (24.7) (4.7) (0) (23.5) (16.7) (34.1) (10.6) (10.6) (11.8) (23.5) (11.8) (44.7)
(12.7) (19.6) (22.5) (1) (0) (14.7) (11.6) (39.2) (8.8) (10.8) (11.8) (23.5) (8.8) (46.1)
(10.9) (8.9) (17.8) (9.9) (1) (14.9) (7.2) (16.8) (15.8) (15.8) (7.9) (31.7) (6.9) (31.7)
12.6 12.3 6.9 5.2 1.0 8.7 9.4 17.3 5.3 5.3 3.8 8.2 4.8 13.0
(-23.5, -1.6)* (-22.6, -2)* (-18.7, 4.9) (-2.2, 12.6) (-0.9, 2.9) (-20.1, 2.7) (-18.3, -0.4) (-29.7, -4.8)* (-4.7, 14.9) (-4.7, 14.9) (-12.5, 4.8) (-4.6, 20.9) (-13.3, 3.6) (-27, 0.9)
1.9 10.7 4.7 8.9 1.0 0.1 4.8 22.4 7.0 5.1 3.8 8.2 1.9 14.4
(-10.7, 7.0) (-20.2, -1.2)* (-15.7, 6.3) (-2.8, 15.1)* (-0.9, 2.9) (-9.6, 9.9) (-12.4, 2.7) (-34.3, -10.4)* (-2.0, 16) (-4.3, 14.4) (-12, 4.3) (-4.1, 20.4) (-9.3, 5.5) (-27, -1.1)*
ATG, antithymocyte globulin; BAS, basiliximab; EVR, everolimus; MPS, mycophenolate sodium; RD, risk difference. Fisher test, p < 0.05.
*
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squamous cell carcinoma. At 12 months, higher mean cholesterol (211.9 41.2 vs. 223.1 52.9 vs. 185 49 mg/ dl, p < 0.02) and triglyceride (228.3 227.5 vs. 222.6 115.7 vs, 167.7 96.3 mg/dl, p < 0.02) concentrations were observed in the EVR groups, respectively. Mean lymphocyte counts were lower in those patients receiving rATG (1631 696 vs. 2124 716 vs. 1804 642 N/mm3, p ¼ 0.007), respectively.
occurred late, after CMV peak viral replication. Finally, TAC concentrations were lower during the first 3 months in the r-ATG group. It has been described that TAC concentrations are associated with CMV viral replication and development of CMV-specific cell-mediated responses (29). Altogether, high efficacy for the prevention of acute rejection, low early EVR discontinuation and lower exposure to TAC may be associated with the lowest incidence of CMV infection/disease in this group.
Discussion
There are no published trials comparing EVR and MPS in kidney transplant recipients receiving TAC. Our study was not powered to detect differences in efficacy and we did not observe any difference in treatment failure. While the known mTORI-associated adverse events described in patients receiving de novo combination with CNI were clearly observed in this cohort of patients, we were not able to detect statistical differences in wound-healing complications, delayed graft function, and proteinuria among the three groups, as observed in trials using cyclosporine-based immunosuppressive regimens (30,31). Interestingly, efficacy and safety of the BAS/EVR group were inferior compared to the r-ATG/EVR group. Because there was no difference in EVR concentrations or prednisone doses between these two groups, we speculate that the higher incidence of treated acute rejections, perhaps due to the type of induction agent, and higher early discontinuations may account for these findings, including higher incidence of wound-healing events and lower renal function at 12 months. In preliminary analysis of the US92 trial (ClinicalTrials.gov number NCT01025817), a prospective multicenter study in kidney transplant recipients receiving TAC-based immunosuppressive therapy showed that treatment failure in patients receiving EVR did not meet the predefined 10% noninferiority margin compared to MPS (32,33).
In this trial conducted in low/moderate immunological risk kidney transplant recipients receiving no CMV pharmacological prophylaxis, the incidence of CMV infection/disease was significantly lower in those receiving EVR and reduceddose TAC compared to mycophenolate and standard-dose TAC. Furthermore, use of EVR was associated with lower rates of CMV recurrent episodes. Except for the underrepresented high risk (Dþ/R) population, these data suggest that kidney transplant recipients receiving EVR may not need CMV prophylaxis (15) and that only patients treated for acute rejection or those with early discontinuation of EVR should undergo routine pre-emptive CMV monitoring, an alternative strategy that would be associated with significant cost savings. There are several possible molecular mechanisms accounting for the inhibitory effects of mTOR inhibitors on CMV viral replication that were recently reviewed (17). CMV invasion occurs in part by inhibition of TH1-specific interferon-g–producing T cells, which are stimulated by mTOR inhibitors (22). In vitro, mTOR inhibitors increase the proliferation of gd T cells, which have the ability of eliminate CMV infected cells (23). Translation of CMV viral proteins relies on host mTOR activity (24). Finally, mTOR inhibitors enhance the quantity and quality of virus-specific CD8 T cells (25). This effect appears to occur when the antigen is presented by the pathogen but not in the context of an allograft (26). Remarkably, patients receiving a single r-ATG dose combined with EVR showed the lowest incidence of CMV infection/disease and no recurrence. Although the use of r-ATG induction has been associated with higher incidence of CMV infection (27), there are some possible reasons associated with this finding. First, the single 3 mg/ kg r-ATG is at least half of the usual doses used in current immunosuppressive regimens (27). Second, the r-ATG/EVR regimen showed high efficacy for the prevention of acute rejection. First CMV events occurred in 1, 5, and 13 patients after treatment for acute rejection, respectively. Higher incidence of CMV disease has been demonstrated after treatment of acute rejection (28) and reinitiation of prophylaxis or pre-emptive therapy has been recommended (3). Third, early EVR discontinuation was associated with development of CMV infection/disease. The r-ATG group showed the lowest discontinuation rate, which 2662
The main limitation of our study is its single-center nature. Also, the results of this study cannot be extrapolated to higher immunological risk populations or to those receiving higher r-ATG doses. Long-term follow-up is necessary to analyze the influence of these regimens and consequent differences in CMV infection/disease on kidney transplant outcomes. Finally, although there is evident reduction in the burden of CMV infection/disease, a pharmacoeconomic analysis is also necessary to clearly define the costeffectiveness of this strategy. In summary, in de novo kidney transplant recipients receiving no pharmacological CMV prophylaxis, reduceddose TAC, and EVR was associated with a significant reduction in the incidence of CMV infection/disease compared to standard TAC dose and MPS. The overall safety profile apparently did not mitigate this beneficial effect, especially in those patients receiving r-ATG induction therapy. Because of the low prevalence of the high risk population (Dþ/R) in this cohort, we cannot extrapolate these findings for this population. American Journal of Transplantation 2015; 15: 2655–2664
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Acknowledgments This is an investigator initiative trial that was partially supported by Novartis.
10.
Disclosure
11.
The following authors of this manuscript have conflicts of interest to disclose as described by the American Journal of Transplantation: Helio Tedesco-Silva has received speaker’s fees and travel or accommodation expenses for development of educational presentations and scientific advice from Novartis, Pfizer, and Roche. Jose MedinaPestana has received speaker’s fees and travel or accommodation expenses for development of educational presentations and scientific advice from Bristol-Myers Squibb, Novartis, Pfizer, and Roche. Claudia Felipe has received speaker’s fees for development of educational presentations and travel or accommodation expenses from Novartis and Pfizer. Marina Cristelli has received speaker’s fees for development of educational presentations and travel or accommodation expenses from Novartis and Pfizer. Taina Sandes-Freitas has received speaker’s fees for development of educational presentations and travel or accommodation expenses Novartis and Pfizer. The institution, Hospital do Rim, has received Research Grants for clinical studies from Novartis, Pfizer, Astellas, Bristol-Myers Squibb, Roche, and LifeCycle Pharma.
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References 18. 1. De Keyzer K, Van Laecke S, Peeters P, Vanholder R. Human cytomegalovirus and kidney transplantation: A clinician’s update. Am J Kidney Dis 2011; 58: 118–126. 2. Kotton CN. CMV: Prevention, diagnosis and therapy. Am J Transplant 2013; 13: 24–40. 3. Kotton CN, Kumar D, Caliendo AM, et al. Updated international consensus guidelines on the management of cytomegalovirus in solid-organ transplantation. Transplantation 2013; 96: 333–360. 4. Beam E, Dioverti V, Razonable RR. Emerging cytomegalovirus management strategies after solid organ transplantation: Challenges and opportunities. Curr Infect Dis Rep 2014; 16: 419. 5. Kotton CN, Kumar D, Caliendo AM, et al. International consensus guidelines on the management of cytomegalovirus in solid organ transplantation. Transplantation 2010; 89: 779–795. ~as MC, Casto n JJ, et al. GESITRA6. de la Torre-Cisneros J, Farin SEIMC/REIPI recommendations for the management of cytomegalovirus infection in solid-organ transplant patients. Enferm Infecc Microbiol Clin 2011; 29: 735–758. 7. Santos CAQ, Brennan DC, Fraser VJ, Olsen MA. Delayed-onset cytomegalovirus disease coded during hospital readmission after kidney transplantation. Transplantation 2014; 98: 187–194. 8. Arthurs SK, Eid AJ, Pedersen RA, et al. Delayed-onset primary cytomegalovirus disease and the risk of allograft failure and mortality after kidney transplantation. Clin Infect Dis 2008; 46: 840–846. 9. Stern M, Hirsch H, Cusini A, et al. Cytomegalovirus serology and replication remain associated with solid organ graft rejection and
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graft loss in the era of prophylactic treatment. Transplantation 2014; 98: 1013–1018. Preiksaitis JK, Brennan DC, Fishman J, Allen U. Canadian society of transplantation consensus workshop on cytomegalovirus management in solid organ transplantation final report. Am J Transplant 2005; 5: 218–227. Reischig T, Jindra P, Hes O, Svecova M, Klaboch J, Treska V. Valacyclovir prophylaxis versus preemptive valganciclovir therapy to prevent cytomegalovirus disease after renal transplantation. Am J Transplant 2008; 8: 69–77. Roman A, Manito N, Maria Campistol J, et al. The impact of the prevention strategies on the indirect effects of CMV infection in solid organ transplant recipients. Transplant Rev 2014; 28: 84–91. Webster AC, Lee VWS, Chapman JR, Craig JC. Target of rapamycin inhibitors (Sirolimus and Everolimus) for primary immunosuppression of kidney transplant recipients: A systematic review and meta-analysis of randomized trials. Transplantation 2006; 81: 1234–1248. Brennan DC, Legendre C, Patel D, et al. Cytomegalovirus incidence between everolimus versus mycophenolate in de novo renal transplants: Pooled analysis of three clinical trials. Am J Transplant 2011; 11: 2453–2462. Andrassy J, Hoffmann VS, Rentsch M, et al. Is cytomegalovirus prophylaxis dispensable in patients receiving an mTOR inhibitorbased immunosuppression? A systematic review and metaanalysis. Transplantation 2012; 94: 1208–1217. Lim WH, Eris J, Kanellis J, et al. A systematic review of conversion from calcineurin inhibitor to mammalian target of rapamycin inhibitors for maintenance immunosuppression in kidney transplant recipients. Am J Transplant 2014; 14: 2106–2119. Nashan B, Gaston R, Emery V, et al. Review of cytomegalovirus infection findings with mammalian target of rapamycin inhibitorbased immunosuppressive therapy in de novo renal transplant recipients. Transplantation 2012; 93: 1075–1085. R, Vitko S, et al. Everolimus plus early tacrolimus Langer RM, Hene minimization: A phase III, randomized, open label, multicentre trials in enal transplantation. Transplant Int 2012; 25: 592–602. Ekberg H, Tedesco-Silva H, Demirbas A, et al. Reduced exposure to calcineurin inhibitors in renal transplantation. N Engl J Med 2007; 357: 2562–2575. Sis B, Mengel M, Haas M, et al. Banff ’09 meeting report: Antibody mediated graft deterioration and implementation of Banff working groups. Am J Transplant 2010; 10: 464–471. Levey AS, Stevens LA, Schmid CH, Zhang YL, Castro AF III., Feldman HI. A new equation to estimate glomerular filtration rate (vol 150, pg 604, 2009). Ann Intern Med 2011; 155: 604– 612. Saemann MD, Haidinger M, Hecking M, Horl WH, Weichhart T. The multifunctional role of mTOR in innate immunity: Implications for transplant immunity. Am J Transplant 2009; 9: 2655– 2661. Li H, Pauza CD. Rapamycin increases the yield and effector function of human gammadelta T cells stimulated in vitro. Cancer Immunol Immunother 2011; 60: 361–370. Clippinger AJ, Maguire TG, Alwine JC. The changing role of mTOR kinase in the maintenance of protein synthesis during human cytomegalovirus infection. J Virol 2011; 85: 3930–3939. Araki K, Turner AP, Shaffer VO, et al. mTOR regulates memory CD8 T-cell differentiation. Nature 2009; 460: 108–112. Ferrer IR, Wagener ME, Robertson JM, et al. Cutting edge: Rapamycin augments pathogen-specific but not graft-reactive CD8þ T cell responses. J Immunol 2010; 185: 2004–8.
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31. Dantal J, Berthoux F, Moal MC, et al. Efficacy and safety of de novo or early everolimus with low cyclosporine in deceased-donor kidney transplant recipients at specified risk of delayed graft function: 12-month results of a randomized, multicenter trial (vol 23, pg 1084 JT 2010). Transplant Int 2012; 25: 1084–1093. 32. Qazi Y, Shaffer D, Kaplan B, et al. Efficacy and safety of everolimus with low-dose tacrolimus in de Novo renal transplant recipients: 12-month randomized study. Am J Transplant 2014; 14: 80. 33. Vincenti F, Qazi Y, Kaplan B, et al. Influence of induction therapy on the efficacy of everolimus vs mycophenolate based regimen in de novo renal transplant recipients. Am J Transplant 2014; 14: 539–540.
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Copyright 2015 The American Society of Transplantation and the American Society of Transplant Surgeons doi: 10.1111/ajt.13327
Reduced Incidence of Cytomegalovirus Infection in Kidney Transplant Recipients Receiving Everolimus and Reduced Tacrolimus Doses H. Tedesco-Silva1,*, C. Felipe1, A. Ferreira1, M. Cristelli1, N. Oliveira1, T. Sandes-Freitas1, W. Aguiar2, E. Campos3, M. Gerbase-DeLima3, M. Franco4 and J. Medina-Pestana1 1
Nephrology Division, Hospital do Rim - UNIFESP, S~ ao Paulo, Brazil 2 Urology Division, Hospital do Rim - UNIFESP, S~ ao Paulo, Brazil 3 Department of Immunogenetic, AFIP S~ ao Paulo, Sao ~ Paulo, Brazil 4 Department of Pathology, UNIFESP, Sao ~ Paulo, Brazil Corresponding author: Helio Tedesco-Silva, [email protected] This study compared the incidence of CMV infection/ disease in de novo kidney transplant recipients receiving everolimus or mycophenolate and no CMV pharmacological prophylaxis. We randomized 288 patients to receive a single 3 mg/kg dose of antithymocyte globulin, tacrolimus, everolimus, and prednisone (r-ATG/ EVR, n ¼ 85); basiliximab, tacrolimus, everolimus, and prednisone (BAS/EVR, n ¼ 102); or basiliximab, tacrolimus, mycophenolate, and prednisone (BAS/MPS, n ¼ 101). The primary end-point was the incidence of first CMV infection/disease in the intention-to-treat population at 12 months. Patients treated with r-ATG/ EVR showed a 90% proportional reduction (4.7% vs. 37.6%, HR 0.10, 95% CI 0.037–0.29; p < 0.001), while those treated with BAS/EVR showed a 75% proportional reduction (10.8% vs. 37.6%, HR 0.25, 95% CI 0.13–0.48; p < 0.001) in the incidence of CMV infection/disease compared to BAS/MPS. There were no differences in the incidence of acute rejection (9.4 vs. 18.6 vs. 15.8%, p ¼ 0.403), wound-healing complications, delayed graft function, and proteinuria. Mean estimated glomerular filtration rate was lower in BAS/EVR (65.7 21.8 vs. 60.6 20.9 vs. 69.5 21.5 ml/min, p ¼ 0.021). In de novo kidney transplant recipients receiving no pharmacological CMV prophylaxis, reduced-dose tacrolimus and everolimus was associated with a significant reduction in the incidence of CMV infection/disease compared to standard tacrolimus dose and mycophenolate (ClinicalTrials.gov NCT01354301). Abbreviations: BAS, basiliximab; BCAR, biopsy-confirmed acute rejection; CMV, cytomegalovirus; eGFR, estimated glomerular filtration rate; EVR, everolimus; HLA, human leukocyte antigen; MDRD, modification of
diet in renal disease; MPS, mycophenolate sodium; mTORI, mammalian target of rapamycin inhibitors; rATG, rabbit antithymocyte globulin; TAC, tacrolimus Received 22 January 2015, revised 05 March 2015 and accepted for publication 25 March 2015
Introduction Cytomegalovirus (CMV) infection is associated with significant morbidity and mortality after solid organ transplantation (1–3). In the absence of preventive strategies, the incidence of CMV infection and disease is high among kidney transplant recipients. Universal prophylaxis and preemptive therapy have been used to manage CMV infection, but both are associated with disadvantages (1,2,4). Universal prophylaxis is not fully effective, its duration, 3–6 months, varies according to the perceived risk, is associated with bone marrow adverse events possibly leading to drug dose discontinuation (5,6), and is associated with significant incidence of late CMV infection and drug resistance (2,7–9). Pre-emptive therapy does not prevent viral replication, an event that has been associated with inferior transplant outcomes, and requires intensive logistical coordination (2,4,10–12). Importantly, both strategies are associated with increased costs (3). Several studies and meta-analysis have shown that the use of mammalian target of rapamycin inhibitors (mTORI, sirolimus, and everolimus), either de novo (13–15) or as a conversion strategy (16), are associated with lower rates of CMV infection. In all these trials, the population and management of CMV infection were largely heterogeneous with low representation of patients receiving no prophylaxis, who would benefit the most, primarily in transplant centers where CMV prophylaxis is not available or reimbursed. In these studies, CMV events have been captured as adverse events without predefined uniform criteria for diagnosing and reporting, including cut-off points for quantitative nuclear amplification tests or pp65 antigenemia. Most importantly, there are no studies comparing immunosuppressive regimens adequately powered to analyze CMV infection as primary end-point (17). Therefore, we devised a prospective study to compare the incidence of CMV infection/disease in de novo kidney transplant 2655
Tedesco-Silva et al
recipients receiving tacrolimus (TAC)-based immunosuppressive regimens combined with everolimus (EVR) or mycophenolate sodium (MPS).
strategy consisting of weekly monitoring of CMV viral replication (pp65 CMV antigenemia test) for 6 months. All patients received oral nystatin for 30 days and trimethoprim-sulfamethoxazole for 12 months.
Definitions
Methods Study design This was a single-center, prospective, randomized, 12-month open label controlled trial aiming to compare the incidence of CMV infection/disease in de novo kidney transplant recipients receiving mTOR inhibitor or mycophenolate and no CMV pharmacological prophylaxis. The relevance of this study relies on the premise that within the government-funded national transplant program, there is no specific reimbursement for CMV prophylaxis. The authors designed the protocol, acquired and maintained the data, and conducted the statistical analysis. The protocol was approved by an independent ethics committee and registered in the ClinicalTrials.gov database, number NCT01354301. All subjects signed a written informed consent before enrollment and the study was conducted according to good clinical practices and the Declaration of Helsinki. Novartis partially funded this study.
Population Low/moderate immunological risk adult recipients of first ABO-compatible renal transplants from living or deceased donors were considered for enrollment. We excluded recipients of kidneys from HLA identical or expanded criteria deceased donors. Patients with a positive cytotoxic crossmatch or panel reactive antibody equal to or above 50%, class I or class II, were also excluded. Women of childbearing potential had to agree in using approved contraceptives methods during the duration of the study.
Delayed graft function was defined as the need for dialysis during the first week after transplantation, excluding technical failures and a single dialysis for hypervolemia and/or hyperkalemia. Biopsy confirmed acute rejection (BCAR) episodes were graded according to Banff 2009 classification (20). In patients with multiple biopsies, the most severe score was used for statistical analysis. Treated acute rejection included BCAR and those treated episodes (at least 500 mg of methylprednisolone for 3 consecutive days) without biopsy confirmation, including borderline changes. Steroid-resistant rejections were treated with polyclonal agents.
Primary end-point The primary end-point was the cumulative incidence of CMV infection/ disease during the first year after transplantation. CMV infection was defined based on detection of CMV viral replication (at least 10 positive cells per 200 000 cells by CMV pp65 antigenemia) in asymptomatic patients. CMV disease was defined based on the evidence of CMV infection with related symptoms. Symptomatic patients could be treated with lower number of CMV pp65–positive cells. CMV infection/disease was treated with intravenous ganciclovir with weekly monitoring of viral replication. Treatment was prolonged for 1 week after the first negative CMV pp65 antigenemia test (5). Recurrent CMV infection/disease was defined as a new CMV event in a patient who had no evidence of viral replication after treatment.
Secondary end-points
Eligible patients were randomized (1:1:1) before the transplant surgery to one of three immunosuppressive regimes. Randomization was stratified according to donor source (living or deceased donors). A computer-generated randomization sequence was obtained and placed in sequentially numbered opaque envelops. Transplant surgeons were blinded to treatment allocation.
Secondary outcomes included treatment failure, defined as a composite end-point of first BCAR (IA or higher), graft loss, death, and loss to follow up; incidence, severity, timing, and treatment of first treated acute rejection episodes. We also evaluated the incidence and duration of DGF, renal function (eGFR by MDRD formula [21]), and spot urine protein/creatinine ratio (U p/c). Safety analysis included vital signs and incidence of adverse events, malignancies, and laboratorial abnormalities.
Treatments
Statistical analysis
In group 1 (r-ATG/EVR), a single 3 mg/kg dose of r-ATG was administered intravenously beginning within the first 24 h after graft revascularization. On day 1, patients received TAC 0.05 mg/kg twice daily, adjusted to maintain whole blood trough concentrations between 3 and 5 ng/ml, based on the very low TAC regimen of the Asset trial (18) and EVR 1.5 mg twice daily adjusted to maintain EVR whole blood trough concentrations between 4 and 8 ng/ml. In group 2 (BAS/EVR), patients received basiliximab (BAS) induction on days 0 and 4. On day 1, patients received TAC 0.1 mg/kg twice daily, adjusted to maintain whole blood trough concentrations between 3 and 8 ng/ ml for the first 3 months then reduced to 3–5 ng/ml, based on low TAC arm of the Asset trial (18) and EVR 1.5 mg twice daily, adjusted to maintain EVR whole blood trough concentrations between 4 and 8 ng/ml. In group 3 (BAS/ MPS), patients received BAS induction on days 0 and 4. On day 1, patients received TAC 0.1 mg/kg twice daily, adjusted to maintain whole blood trough concentrations between 6 and 8 ng/ml, based on the Symphony trial (19), and MPS 720 mg twice daily. All patients received 1 g methylprednisolone before graft revascularization followed by oral prednisone 0.5 mg/kg/day (maximum dose of 30 mg) beginning on day 1 tapered to 5 mg/day by day 45.
The sample size was calculated based on the incidence of CMV infection/ disease of 10% in at least one of the EVR groups and 27% in the MPS group in the absence of pharmacological prophylaxis. With a two-sided type I error of 5% and 85% test power to detect the difference, the estimated sample size is 276 patients (92 per group). Assuming 5–10% drop out rate we randomized 300 patients. Primary and secondary end-points were analyzed in the intention-to-treat population using Kaplan–Meier estimates and groups were compared using the Log-rank test. For the primary end-point, we used Cox regression analysis to calculate event rate ratios and 95% confidence interval (CIs). Frequency distributions were provided for categorical variables, and treatment groups were compared with x2 or Fisher’s exact tests. Continuous variables and differences were analyzed using ANOVA complemented by Tukey’s test. All statistical tests were twosided and were conducted using the 0.05 level of significance.
Randomization
Prophylaxis against infections No pharmacological prophylaxis for CMV infection was used, including valganciclovir, acyclovir, or valacyclobir. Instead, we used pre-emptive
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Results Population and disposition Patients were enrolled in this trial between July 11, 2011 and May 4, 2013, and were followed up to May 9, 2014. We screened 397 patients, randomized 300, and 288 were American Journal of Transplantation 2015; 15: 2655–2664
Reduced CMV Infection With Everolimus
transplanted and received first study drug dose (r- ATG/ EVR ¼ 85; BAS/EVR ¼ 101; BAS/MPS ¼ 102, Figure 1). There was no difference in the proportion of patients completing the study (94 vs. 92 vs. 89%, p ¼ 0.457). The only significant difference in baseline demographic characteristics was a higher mean final creatinine of deceased donors in the r-ATG/EVR group (Table 1). Immunosuppression At days 30, 90, and 365, mean TAC whole blood trough concentrations were 5.1 1.7, 4.7 1.8, and 4.7 1.5 ng/ ml in the r-ATG/EVR group, 7.4 2.6, 5.6 2.1, and 5.0 2.1 ng/ml in the BAS/EVR group, and 8.1 3.1, 7.1 2.4, and 6.2 3.3 ng/ml in the BAS/MPS group, respectively (Figure 2A). Mean EVR whole blood trough concentrations were 5.2 2.1, 5.9 2.1, and 6.5 2.2 ng/ ml in the r-ATG/EVR group, and 4.9 1.5, 5.6 1.6, and 6.0 2.2 ng/ml in the BAS/EVR group, respectively (Figure 2B). Mean plasma MPA concentrations were 4.8 4.3, 4.3 3.4, and 4.9 6.6 mg/ml in the BAS/MPS group, respectively (Figure 2B). There were no differences in mean prednisone doses at days 30 (11.9 4.1 vs. 12.9 5.3 vs. 12.6 5.0 mg/day, p ¼ 0.368), 90 (5.2 1.7 vs. 5.3 1.7 vs. 5.4 2.7 mg/day, p ¼ 0.614), and 365
(5.3 1.8 vs. 5.3 2.6 vs. 5.0 0.0 mg/day, p ¼ 0.447), respectively. Primary end-point Patients receiving EVR showed a lower incidence of CMV infection/disease compared to those receiving MPS (4.7 vs. 10.8 vs. 37.6%, p < 0.001, Table 2). Similar findings were observed when we analyzed the incidence of CMV infection or disease independently. While a statistically significant difference was also observed for the most prevalent pretransplant donor(þ)/recipient(þ) CMV serostatus combination, no statistically significant differences were observed for the high-risk donor(þ)/recipient() CMV serostatus combination (Table 2). Patients treated with rATG/EVR showed a 90% proportional reduction, while those treated with BAS/EVR showed a 75% proportional reduction in the incidence of CMV infection/disease compared to BAS/MPS (Figure 3). There were no differences in mean time to first CMV infection/disease or in the duration of treatment comparing the three groups. Patients in BAS/EVR and BAS/MPS groups showed a higher number of CMV infection/disease recurrences, yielding a higher total number of CMV infection/disease events (4.7 vs. 17.6 vs. 57.4%, p < 0.001), respectively. None of the patients
397 potential subjects 67 declined to participate
330 signed informed consent 30 did not meet inclusion/exclusion criteria 300 underwent randomization
89 were assigned to receive r-ATG plus everolimus 3 did not receive a transplant 1 did not receive treatment 85 received treatment and transplantation
106 were assigned to receive basiliximab plus everolimus 3 did not receive a transplant 1 transplanted in another center 102 received treatment and transplantation
105 were assigned to receive basiliximab plus mycophenolate 3 did not receive a transplant 1 transplanted in another center 101 received treatment and transplantation
3 died * 1 was lost to follow-up 1 graft loss 5 discontinued treatment
5 died *,# 1 was lost to follow-up 3 graft loss 13 discontinued treatment
4 died 7 graft loss * 13 discontinued treatment
80 (94%) completed 12 months 76 (89%) receiving initial treatment
94 (92%) completed 12 months 82 (80%) receiving initial treatment
90 (89%) completed 12 months 78 (77%) receiving initial treatment
* 1 patient with prior treatment discontinuation; # 1 patient with prior graft loss Figure 1: Patient disposition. All patients who were randomized, transplanted, and received assigned treatment were included in the intention-to-treat population.
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Tedesco-Silva et al Table 1: Demographic characteristics of the transplant recipients Variable Recipient age, years (mean SD) Recipient gender, male, N (%) Recipient race, Caucasian, N (%) Body mass index (kg/m2) Cause of chronic kidney disease, N (%) Glomerulonephritis Hypertension Diabetes mellitus Undetermined Other Time on dialysis, months (mean SD) Type of treatment, hemodialysis, N (%) Panel reactive antibodies, (%) Class I (mean SD) Class II (mean SD) HLA mismatches (mean SD) CMV IgG serologic status, N (%) Donor (þ)/Recipient (þ) Donor (þ)/Recipient () Donor ()/Recipient (þ) Donor (unk)/Recipient (þ) Donor age, years (mean SD) Donor gender, male, N (%) Donor race, Caucasian, N (%) Donor type, N (%) Living Deceased Death due to cerebrovascular accident Final creatinine, mg/dL (mean SD)* History of hypertension, N (%) Cold ischemia time, hours (mean SD)
r-ATG/EVR (N ¼ 85)
BAS/EVR (N ¼ 102)
BAS/MPS (N ¼ 101)
43.7 13.6 54 (63) 41 (48) 24.4 3.5
45.1 14.0 68 (67) 51 (50) 24.5 4.1
44.8 12.2 68 (67) 55 (54) 24.6. 4.1
13 (15) 9 (11) 7 (8) 33 (39) 23 (27) 37.1 30.9 78 (92)
15 (15) 7 (7) 6 (6) 46 (45) 28 (27) 42.2 42.2 97 (95)
9 (9) 12 (12) 17 (17) 38 (37) 25 (25) 43.8 38.7 93 (92)
3.2 8.1 1.5 6.5 2.6 1.2
1.2 4.9 1.1 5.1 2.7 1.2
3.3 10.5 1.1 10.2 2.7 1.2
71 (83) 4 (5) 3 (4) 7 (8) 39.9 11.4 52 (61) 50 (59)
80 (78) 5 (5) 6 (6) 11 (11) 42.6 12.1 58 (57) 55 (54)
81 (80) 6 (6) 4 (4) 10 (10) 40.8 11.3 62 (61) 57 (56)
18 (21) 67 (79) 28 (42) 2.2 2.2 11 (16) 21.4 5.0
36 (35) 66 (65) 35 (53) 1.6 1.1 17 (26) 20.6 4.7
36 (36) 65 (64) 34 (52) 1.6 1.3 15 (23) 20.5 4.7
ATG, antithymocyte globulin; BAS, basiliximab; EVR, everolimus; MPS, mycophenolate sodium; Unk, unknown. (r-ATG/EVR vs. BAS/EVR, p ¼ 0.042; r-ATG/EVR vs. BAS/MPS, p ¼ 0.052).
*
developed tissue invasive CMV disease. The number of first CMV events after treatment for acute rejection was higher in patients receiving BAS/EVR and BAS/MPS compared to r-ATG/EVR. In the r-ATG/EVR group, none of the five patients who discontinued EVR (days 73, 133, 238, 246, and 327) developed CMV infection/disease, thereafter. In the BAS/EVR group, five patients developed the first episode of CMV infection/disease after discontinuation of EVR (day 15, 21, 24, 52, and 215) and eight did not, including two early (days 19 and 28) and six late (after day 108) EVR discontinuations. In the BAS/MPS group, 12 patients were converted from MPS to EVR after the first (n ¼ 10) and second (n ¼ 2) recurrent episode of CMV infection/disease with only one CMV relapse. Because the differences in the induction agent and TAC blood concentrations among the groups could also be confounding risk factors associated with CMV infection/ disease, we then performed a multivariable analysis. Use of a single 3 mg/kg dose of r-ATG induction (vs. BAS, odds ratio ¼ 0.343, p ¼ 0.113, 95% CI 0.091–1.287) and higher time averaged TAC blood concentrations over the first three 2658
months (>6.8 ng/ml vs. 0.5 mg/dl. None of the patients developed polyomavirus nephropathy (Table 3). Patients in the BAS/MPS group showed a higher incidence of serious adverse events compared to the EVR groups (38.8 vs. 51 vs. 73.3%, p < 0.001, Table 4), primarily due to the higher incidence of CMV events. No differences were American Journal of Transplantation 2015; 15: 2655–2664
observed in the incidence of adverse events leading to drug discontinuation (4.7 vs. 6.9 vs. 12.9%, p ¼ 0.107, Table 4). Patients in the r-ATG/EVR group showed higher incidence of acne (23.5 vs. 10.9%, p ¼ 0.04), aftous ulcers (21.2 vs. 8.9%, p ¼ 0.01), and dyslipidemia (34.1 vs. 16.8%, p ¼ 0.009) compared to the BAS/MPS group. Patients in the BAS/EVR group showed higher incidence of aphthous ulcers (19.6 vs. 8.9%, p ¼ 0.04), dyslipidemia (39.3 vs. 16.8%, p ¼ 0.001), and peripheral edema (46.1 vs. 31.7%, p ¼ 0.044) and lower incidence of leucopenia (1 vs. 9.9%, p ¼ 0.005) compared to the BAS/MPS group. There were no differences in the incidence of infections (excluding CMV) (Table 4). None of the patients developed pneumonitis and only one patient in the BAS/MPS group presented a 2659
Tedesco-Silva et al Table 2: Incidence of CMV infection/disease
Incidence of first CMV event, N (%)* Infection* Disease** Pretransplant CMV serostatus, N (%)1 Donor (þ) Recipient (þ)* Donor (þ) Recipient () Donor () Recipient (þ) Donor (unk) Recipient (þ)* Time to first CMV event, days (mean SD) Duration of treatment, days (mean SD) Recurrent CMV events, N Total number of CMV events First CMV event after treated acute rejection, N (%) First CMV event after EVR discontinuation, N(%)
r-ATG/EVR (N ¼ 85)
BAS/EVR (N ¼ 102)
BAS/MPS (N ¼ 101)
4 (4.7) 1 (1.2) 3 (3.5)
11 (10.8) 4 (3.9) 7 (6.9)
38 (37.6) 26 (25.7) 12 (11.9)
2 (2.8) 2 (50.0) 0 0 65.8 21.5 20.3 5.0 0 4 (4.7) 1 (1.1) 0
6 (7.5) 3 (60.0) 0 2 (18.2) 75.7 68.1 21.1 4.3 7 18 (17.6) 5 (4.9) 5
26 (32.0) 5 (83.3) 2 (50.0) 5 (50.0) 68.3 48.0 26.0 10.2 20 58 (57.4) 13 (12.9) Na
ATG, antithymocyte globulin; BAS, basiliximab; EVR, everolimus; MPS, mycophenolate sodium; Na, not applicable; Unk, unknown. * p ¼ 0.000, **p ¼ 0.037 Log Rank test. 1 Percentages were calculated based on the prevalence of each CMV serostatus combination described in Table 1.
Figure 3: Cumulative incidence of CMV infection/disease during the 12 months of follow up.
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Reduced CMV Infection With Everolimus Table 3: Secondary endpoints r-ATG/EVR (N ¼ 85) Treatment failure, N (%) First biopsy confirmed acute rejection, N (%) IA IB IIA IIB Antibody-mediated changes Acute antibody-mediated rejection Death, N (%) Graft loss, N (%) Loss to follow up, N (%) Patient survival, (%) Graft survival, (%) Death-censored graft survival, (%) First treated acute rejection, N (%) Antibody treated rejection, N (%) Wound-healing complications, N (%) DGF, N (%) Duration of DGF, days (mean SD) Creatinine, mg/dL (mean SD) eGFR, ml/min (mean SD)* Urine protein/creatinine ratio, (mean SD) Proteinuria > 0.5 mg/L, N (%)
BAS/EVR (N ¼ 102)
13 8 1 5
(15.3) (9.4) (1.2) (5.9) 0 0 1 (1.2) 1 (1.2) 3 (3.5) 1 (1.2) 1 (1.2) 96.5 95.3 98.8 19 (22.3) 1 (1.2) 20 (23.5) 32 (47.0) 11.3 5.3 1.4 0.64 65.7 21.8 0.4 0.7 21 (26.5)
BAS/MPS (N ¼ 101)
23 19 5 7 6 1
(22.6) (18.6) (4.9) (6.9) (5.9) (1.0) 0 0 5 (4.9) 3 (2.9) 1 (1.0) 95.1 93.1 97.1 35 (34.3) 7 (6.9) 35 (34.3) 32 (48.5) 14.7 14.3 1.5 0.5 60.6 20.9 0.4 0.8 21 (22.8)
24 16 4 2 6 3 2
(23.8) (15.8) (4.0) (2.0) (5.9) (3.0) (2.0) 0 4 (4.0) 7 (6.9) 0 96.0 89.1 93.1 29 (28.7) 8 (7.9) 23 (22.8) 27 (41.5) 9.9 5.8 1.3 0.5 69.5 21.5 0.2 0.4 16 (18.0)
ATG, antithymocyte globulin; BAS, basiliximab; EVR, everolimus; MPS, mycophenolate sodium. First treated acute rejection was defined as the first episode of acute rejection, confirmed or not by biopsy that was treated with either methylprednisolone or polyclonal antibody. * BAS/EVR vs. BAS/MPS, p ¼ 0.016.
Table 4: Adverse events r-ATG/EVR
BAS/EVR
BAS/MPS
r-ATG/EVR vs. BAS/MPS
BAS/EVR vs. BAS/MPS
Adverse events (AE), n (%)
(N ¼ 85)
(N ¼ 102)
(N ¼ 101)
RD% (95% CI)
RD% (95% CI)
Patient with at least 1 AE Patient with at least 1 serious AE Patients with AE leading to drug discontinuation AEs with incidence >10% Infections and infestations Urinary tract infection Upper respiratory tract infection Adverse events of special interest Acne Aftous ulcers Anemia Leukopenia Thrombocytopenia Hyperglycemia Posttransplant diabetes mellitus Dyslipidemia Epigastric pain Constipation Acute gastroenterocolitis Diarrhea Proteinuria Peripheral edema
85 (100) 33 (38.8) 4 (4.7)
102 (100) 52 (51) 7 (6.9)
101 (100) 74 (73.3) 13 (12.9)
– 34.4 (21, 47.9)* 8.2 (0.2, 16.1)
– 22.3 (9.3, 35.3)* 6 (-2.2, 14.2)
18 (21.2) 28 (32.9)
21 (20.6) 28 (27.4)
32 (31.7) 30 (29.7)
10.5 (-2.1, 23.1) 3.2 (-16.6, 10.2)
11.1 (-0.9, 23.1) 2.3 (-10.2, 14.7)
20 18 21 4 0 20 13 29 9 9 10 20 10 38
13 20 23 1 0 15 11 40 9 11 12 24 9 47
11 9 18 10 1 15 6 17 16 16 8 32 7 32
(23.5) (21.2) (24.7) (4.7) (0) (23.5) (16.7) (34.1) (10.6) (10.6) (11.8) (23.5) (11.8) (44.7)
(12.7) (19.6) (22.5) (1) (0) (14.7) (11.6) (39.2) (8.8) (10.8) (11.8) (23.5) (8.8) (46.1)
(10.9) (8.9) (17.8) (9.9) (1) (14.9) (7.2) (16.8) (15.8) (15.8) (7.9) (31.7) (6.9) (31.7)
12.6 12.3 6.9 5.2 1.0 8.7 9.4 17.3 5.3 5.3 3.8 8.2 4.8 13.0
(-23.5, -1.6)* (-22.6, -2)* (-18.7, 4.9) (-2.2, 12.6) (-0.9, 2.9) (-20.1, 2.7) (-18.3, -0.4) (-29.7, -4.8)* (-4.7, 14.9) (-4.7, 14.9) (-12.5, 4.8) (-4.6, 20.9) (-13.3, 3.6) (-27, 0.9)
1.9 10.7 4.7 8.9 1.0 0.1 4.8 22.4 7.0 5.1 3.8 8.2 1.9 14.4
(-10.7, 7.0) (-20.2, -1.2)* (-15.7, 6.3) (-2.8, 15.1)* (-0.9, 2.9) (-9.6, 9.9) (-12.4, 2.7) (-34.3, -10.4)* (-2.0, 16) (-4.3, 14.4) (-12, 4.3) (-4.1, 20.4) (-9.3, 5.5) (-27, -1.1)*
ATG, antithymocyte globulin; BAS, basiliximab; EVR, everolimus; MPS, mycophenolate sodium; RD, risk difference. Fisher test, p < 0.05.
*
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squamous cell carcinoma. At 12 months, higher mean cholesterol (211.9 41.2 vs. 223.1 52.9 vs. 185 49 mg/ dl, p < 0.02) and triglyceride (228.3 227.5 vs. 222.6 115.7 vs, 167.7 96.3 mg/dl, p < 0.02) concentrations were observed in the EVR groups, respectively. Mean lymphocyte counts were lower in those patients receiving rATG (1631 696 vs. 2124 716 vs. 1804 642 N/mm3, p ¼ 0.007), respectively.
occurred late, after CMV peak viral replication. Finally, TAC concentrations were lower during the first 3 months in the r-ATG group. It has been described that TAC concentrations are associated with CMV viral replication and development of CMV-specific cell-mediated responses (29). Altogether, high efficacy for the prevention of acute rejection, low early EVR discontinuation and lower exposure to TAC may be associated with the lowest incidence of CMV infection/disease in this group.
Discussion
There are no published trials comparing EVR and MPS in kidney transplant recipients receiving TAC. Our study was not powered to detect differences in efficacy and we did not observe any difference in treatment failure. While the known mTORI-associated adverse events described in patients receiving de novo combination with CNI were clearly observed in this cohort of patients, we were not able to detect statistical differences in wound-healing complications, delayed graft function, and proteinuria among the three groups, as observed in trials using cyclosporine-based immunosuppressive regimens (30,31). Interestingly, efficacy and safety of the BAS/EVR group were inferior compared to the r-ATG/EVR group. Because there was no difference in EVR concentrations or prednisone doses between these two groups, we speculate that the higher incidence of treated acute rejections, perhaps due to the type of induction agent, and higher early discontinuations may account for these findings, including higher incidence of wound-healing events and lower renal function at 12 months. In preliminary analysis of the US92 trial (ClinicalTrials.gov number NCT01025817), a prospective multicenter study in kidney transplant recipients receiving TAC-based immunosuppressive therapy showed that treatment failure in patients receiving EVR did not meet the predefined 10% noninferiority margin compared to MPS (32,33).
In this trial conducted in low/moderate immunological risk kidney transplant recipients receiving no CMV pharmacological prophylaxis, the incidence of CMV infection/disease was significantly lower in those receiving EVR and reduceddose TAC compared to mycophenolate and standard-dose TAC. Furthermore, use of EVR was associated with lower rates of CMV recurrent episodes. Except for the underrepresented high risk (Dþ/R) population, these data suggest that kidney transplant recipients receiving EVR may not need CMV prophylaxis (15) and that only patients treated for acute rejection or those with early discontinuation of EVR should undergo routine pre-emptive CMV monitoring, an alternative strategy that would be associated with significant cost savings. There are several possible molecular mechanisms accounting for the inhibitory effects of mTOR inhibitors on CMV viral replication that were recently reviewed (17). CMV invasion occurs in part by inhibition of TH1-specific interferon-g–producing T cells, which are stimulated by mTOR inhibitors (22). In vitro, mTOR inhibitors increase the proliferation of gd T cells, which have the ability of eliminate CMV infected cells (23). Translation of CMV viral proteins relies on host mTOR activity (24). Finally, mTOR inhibitors enhance the quantity and quality of virus-specific CD8 T cells (25). This effect appears to occur when the antigen is presented by the pathogen but not in the context of an allograft (26). Remarkably, patients receiving a single r-ATG dose combined with EVR showed the lowest incidence of CMV infection/disease and no recurrence. Although the use of r-ATG induction has been associated with higher incidence of CMV infection (27), there are some possible reasons associated with this finding. First, the single 3 mg/ kg r-ATG is at least half of the usual doses used in current immunosuppressive regimens (27). Second, the r-ATG/EVR regimen showed high efficacy for the prevention of acute rejection. First CMV events occurred in 1, 5, and 13 patients after treatment for acute rejection, respectively. Higher incidence of CMV disease has been demonstrated after treatment of acute rejection (28) and reinitiation of prophylaxis or pre-emptive therapy has been recommended (3). Third, early EVR discontinuation was associated with development of CMV infection/disease. The r-ATG group showed the lowest discontinuation rate, which 2662
The main limitation of our study is its single-center nature. Also, the results of this study cannot be extrapolated to higher immunological risk populations or to those receiving higher r-ATG doses. Long-term follow-up is necessary to analyze the influence of these regimens and consequent differences in CMV infection/disease on kidney transplant outcomes. Finally, although there is evident reduction in the burden of CMV infection/disease, a pharmacoeconomic analysis is also necessary to clearly define the costeffectiveness of this strategy. In summary, in de novo kidney transplant recipients receiving no pharmacological CMV prophylaxis, reduceddose TAC, and EVR was associated with a significant reduction in the incidence of CMV infection/disease compared to standard TAC dose and MPS. The overall safety profile apparently did not mitigate this beneficial effect, especially in those patients receiving r-ATG induction therapy. Because of the low prevalence of the high risk population (Dþ/R) in this cohort, we cannot extrapolate these findings for this population. American Journal of Transplantation 2015; 15: 2655–2664
Reduced CMV Infection With Everolimus
Acknowledgments This is an investigator initiative trial that was partially supported by Novartis.
10.
Disclosure
11.
The following authors of this manuscript have conflicts of interest to disclose as described by the American Journal of Transplantation: Helio Tedesco-Silva has received speaker’s fees and travel or accommodation expenses for development of educational presentations and scientific advice from Novartis, Pfizer, and Roche. Jose MedinaPestana has received speaker’s fees and travel or accommodation expenses for development of educational presentations and scientific advice from Bristol-Myers Squibb, Novartis, Pfizer, and Roche. Claudia Felipe has received speaker’s fees for development of educational presentations and travel or accommodation expenses from Novartis and Pfizer. Marina Cristelli has received speaker’s fees for development of educational presentations and travel or accommodation expenses from Novartis and Pfizer. Taina Sandes-Freitas has received speaker’s fees for development of educational presentations and travel or accommodation expenses Novartis and Pfizer. The institution, Hospital do Rim, has received Research Grants for clinical studies from Novartis, Pfizer, Astellas, Bristol-Myers Squibb, Roche, and LifeCycle Pharma.
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