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Using mTOR Inhibitors in the Prevention of BK Nephropathy

The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Read our disclaimer for details. Identifier: NCT01649609
Recruitment Status : Completed
First Posted : July 25, 2012
Results First Posted : February 28, 2018
Last Update Posted : February 28, 2018
Cornell University
Information provided by (Responsible Party):
Sumit Mohan, MD, Columbia University

Brief Summary:
BK virus infections after kidney transplant are increasing and can result in damage to the transplanted kidney. Currently, the universally accepted treatment is to decrease the strength of the antirejection medications but it is unclear what medications should be lowered and to what extent. The investigators propose to perform a study with patients who have BK virus detected in their blood during routine screening that appears to be increasing. The investigators will use two different strategies that involve different combinations of standard anti-rejection medications at lower dosages. Patients will be assigned to one of the two groups in a random manner across the two hospitals participating in the study. Patients will be followed for at least a year to determine if one strategy was more effective than the other in preventing an increase in the number of viruses in the blood stream and whether either one was more effective in reducing the negative impact of the infection on the functioning of the transplanted kidney.

Condition or disease Intervention/treatment Phase
BK Viremia BK Nephropathy Drug: Tacrolimus Drug: Mycophenolate acid Drug: Sirolimus Not Applicable

Detailed Description:

The incidence of BK viremia, an early complication after renal transplantation and the associated rates of graft loss resulting from BK nephropathy have been steadily rising since a series of cases that were reported in the mid-1990's. While this is at least partly related to the introduction of newer immunosuppressive agents, recent United Network for Organ Sharing (UNOS) data analyses suggest that there is a continuing rise in the incidence of BK viremia and associated nephropathy with a 3.5% incidence rate in 2009 representing a dramatic rise from just 0.9% only 4 years earlier. Single center data reports have suggested much lower rates of BK viremia and nephropathy in cohorts treated with mTOR (mammalian target of rapamycin) based immunosuppressive regimens when compared to the overall national incidence rates. Recent data has demonstrated that calcineurin inhibitors at concentrations routinely used in clinical practice interfere with the BK virus specific T cell responses; an interference that is not seen to occur with mTOR inhibitors. Further, recent evidence that inhibition of the mTOR pathway has a direct and consequential negative impact on BK infected cells provides additional insight into the observed benefit associated with mTOR inhibitors. The growing problem of BK viremia among renal transplant patients is further compounded by the absence of effective management strategies that have been tested in a rigorous or controlled setting - a fact that was highlighted in a recent systematic review. The cornerstone for management so far has been the reduction of immunosuppression, largely based on the outcome of a single center study of screening patients for viremia and following with preemptive lowering of immunosuppression. Conversion from calcineurin inhibitors to mTOR inhibitors has been reported in small case series to be an effective measure that appears to be superior to merely lowering immunosuppression; however, this approach has not been tested with a robust clinical study design.

Currently, the diagnosis of BK nephropathy requires a renal biopsy, an invasive procedure with its own risks. In addition, identification of patients with viremia who progress to nephropathy and subsequent graft failure i.e. prognostication does not appear possible with the renal biopsy results at present. Validation of potential non-invasive biomarkers provides a unique opportunity for both detection and risk stratification of patients with BK viremia subsequent failure, which could lead to more informed therapeutic interventions while supporting the development of newer therapies.

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Study Type : Interventional  (Clinical Trial)
Actual Enrollment : 40 participants
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)
Primary Purpose: Prevention
Official Title: Using mTOR Inhibitors in the Prevention of BK Nephropathy
Study Start Date : March 2012
Actual Primary Completion Date : December 2016
Actual Study Completion Date : December 2016

Arm Intervention/treatment
Active Comparator: Reduction of standard immunosuppression
Low dose Tacrolimus with low dose Mycophenolate acid
Drug: Tacrolimus
Reduction of standard immunosuppression - The standard of care immunosuppression treatment commonly used for renal transplant patients
Other Name: Prograf

Drug: Mycophenolate acid
Myfortic or CellCept - The standard of care immunosuppression treatment most commonly used for renal transplant patients
Other Name: mycophenolate antimetabolite

Active Comparator: mTOR Arm
Low dose Sirolimus with low dose Mycophenolate acid (mTOR Substitution)
Drug: Mycophenolate acid
Myfortic or CellCept - The standard of care immunosuppression treatment most commonly used for renal transplant patients
Other Name: mycophenolate antimetabolite

Drug: Sirolimus
mTOR Substitution - Replacing tacrolimus (a calcineurin inhibitor) with sirolimus (an mTOR inhibitor) along with reduction of mycophenolic acid
Other Name: Rapamune

Primary Outcome Measures :
  1. Number of Participants With BK Viral Load <600 Copies/mL [ Time Frame: Up to 12 months from enrollment ]
    A Viral load of <600 copies/mL for at least 3 months indicates sustained clearance of BK viremia, confirmed by blood test

Secondary Outcome Measures :
  1. Number of Participants With Incidence of BK Nephropathy [ Time Frame: Up to 24 months from randomization ]
    The number of people with incidence of BK Nephropathy in each of the two Arms

Information from the National Library of Medicine

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Ages Eligible for Study:   18 Years and older   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No

Inclusion Criteria:

  • Renal transplant recipients age 18 years or over

Exclusion Criteria:

  • Patients with multiorgan transplants
  • Patients on immunosuppressive regimens that include steroids or Sirolimus at the time of detection of viremia
  • ABO incompatible renal transplants
  • Three or more previous renal transplants
  • Patients with contraindications to tacrolimus, sirolimus, mycophenolate mofetil or mycophenolic acid.

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its identifier (NCT number): NCT01649609

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United States, New York
Columbia University Medical Center
New York, New York, United States, 10032
Weill Cornell Medical Center
New York, New York, United States, 10065
Sponsors and Collaborators
Columbia University
Cornell University
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Principal Investigator: Sumit Mohan, MD Columbia University

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Responsible Party: Sumit Mohan, MD, Assistant Professor of Clinical Medicine, Columbia University Identifier: NCT01649609     History of Changes
Other Study ID Numbers: AAAI9004
WS2036051 ( Other Identifier: Pfizer )
First Posted: July 25, 2012    Key Record Dates
Results First Posted: February 28, 2018
Last Update Posted: February 28, 2018
Last Verified: January 2018
Keywords provided by Sumit Mohan, MD, Columbia University:
BK Viremia
BK Nephropathy
mTOR inhibitor
renal transplant
Additional relevant MeSH terms:
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Kidney Diseases
Urologic Diseases
Virus Diseases
Systemic Inflammatory Response Syndrome
Pathologic Processes
Mycophenolic Acid
Immunosuppressive Agents
Immunologic Factors
Physiological Effects of Drugs
Calcineurin Inhibitors
Enzyme Inhibitors
Molecular Mechanisms of Pharmacological Action
Anti-Bacterial Agents
Anti-Infective Agents
Antibiotics, Antineoplastic
Antineoplastic Agents
Antifungal Agents
Antibiotics, Antitubercular
Antitubercular Agents