Assessment of Biomarker Guided CNI Substitution in Kidney Transplantation

目前肾移植(KTX)受者的护理标准仅略有改善 总计移植物和/或患者存活率，确定一个关键的未得到满足的医疗需求。作为高危的KTX人群 是异质性的，目前使用的和相对同质的治疗方法 在美国和加拿大，KTX的免疫抑制是次优的，并导致相当大比例的过度- 免疫抑制的受体，许多人有他克莫司相关的毒性。在此U01应用程序中，Co-Pis Heeger Nickerson将在他们过去富有成效的合作努力、他们建立的多中心试验的基础上再接再厉 财团和基础设施，以及他们在生物标记物和机械研究方面的专门知识，以解决这一问题 未得到满足的需求。拟议工作的首要目标是确定人类白细胞抗原DR/DQ的效用 分子错配(MMM)评分，作为KTX的危险分层生物标志物。而回溯研究显示 人类白细胞抗原DR/DQ MMM评分与急性髓细胞白血病的发病风险密切相关 排斥反应(BPAR)和/或供体特异性抗体(DSA)，没有前瞻性研究测试人类白细胞抗原MMM 评分作为免疫性KTX损伤的风险分层生物标志物。也没有任何研究试图测试 人类白细胞抗原DR/DQ MMM评分是否以及如何作为预后的预测指标 移植免疫抑制。在此，我们提出了一项多中心的观察性研究，包括嵌套的 随机对照(RCT)试验以解决这些不足。我们将前瞻性地测试 HL A-DR/DQ MMM评分作为原发同种免疫[T细胞介导的排斥反应(TCMR)]的预后生物标志物， DSA和抗体介导的排斥反应(ABMR)](目标1,800例KTX的观察性研究)。我们还将 测试人类白细胞抗原DR/DQ MMM评分是识别KTX接受者的预测性生物标志物的假设 世卫组织将容忍用自我给药、皮下注射的Abatacept取代钙调神经磷酸酶抑制剂 (共刺激阻断)，不会增加BPAR的不可接受的风险，同时降低CNI的发病率 偏离目标的效果(300KTX，具有非劣势终点的嵌套随机对照试验，目标2)。伴生机构 研究(目标3)将提供新的免疫学和分子洞察力，这也有助于解释移植物。 以及试验的受试者结果。如果成功，这项工作将提供能够积极、 并直接影响临床护理。拟议工作的结果也有可能影响到 通过提供基于HLA-DR/DQ MMM分数的分层或 将受试者纳入试验的丰富策略最有可能为建议的研究代理提供信息-- 从而增加了在尽可能短的时间内试验成功的可能性。

Current standard of care for kidney transplant (KTx) recipients has only modestly improved long-term aggregate graft and/or patient survival, identifying a crucial unmet medical need. As the at-risk KTx population is heterogeneous, the currently employed and relatively homogeneous therapeutic approach to immunosuppression in KTx in the US and Canada is suboptimal, and results in a significant proportion of over- immunosuppressed recipients, many with tacrolimus-related toxicities. In this U01 application, Co-PIs Heeger and Nickerson will build upon their past, productive collaborative efforts, their established multicenter trial consortium and infrastructure, as well as their expertise in biomarkers and mechanistic studies to address this unmet need. The overarching goal of the proposed work is to determine the utility of the HLA-DR/DQ molecular mismatch (mMM) score, as a risk stratifying biomarker in KTx. While retrospective studies showed strong correlations between the HLA-DR/DQ mMM score and the risk of developing biopsy proven acute rejection (BPAR) and/or donor specific antibodies (DSA), no prospective studies have tested the HLA mMM score as a risk stratifying biomarker for immunological KTx injury. Nor have any studies attempted to test whether and how the HLA-DR/DQ mMM score performs as a predictor of outcome following a change in transplant immunosuppression. Herein, we propose a multicenter observational study with a nested randomized controlled (RCT) trial to address these deficiencies. We will prospectively test the utility of the HLA-DR/DQ mMM score as a prognostic biomarker of primary alloimmunity [T cell mediated rejection (TCMR), DSA, and antibody mediated rejection (ABMR)] in KTx (Aim 1, observational study of 800 KTx). We will also test the hypothesis that the HLA-DR/DQ mMM score is a predictive biomarker that identifies KTx recipients who will tolerate substituting the calcineurin inhibitor with self-administered, subcutaneous abatacept (costimulatory blockade), without an unacceptable increased risk of BPAR, while reducing the morbidity of CNI off-target effects (300 KTx, Nested RCT with a non-inferiority endpoint, Aim 2). Accompanying mechanistic studies (Aim 3) will provide novel immunological and molecular insights that will also aid in interpreting graft and recipient outcomes of the trial. If successful, the work will provide crucial information capable of positively, and directly affecting clinical care. The results from the proposed work also have the potential to influence positively the design of future RCTs by providing an HLA-DR/DQ mMM score-based stratification or enrichment strategy for enrolling subjects into trials most likely to be informative for the proposed study agent-- thereby increasing likelihood of trial success in the shortest possible time.