Randomized Trial for Mixed Acute Rejection

The purpose of the study is to determine safety and efficacy of treatment if mixed (cellular and antibody) mediated acute rejection with addition of B-cell depleting therapy to Thymoglobulin in kidney and simultaneous kidney pancreas allograft recipients.

Inclusion criteria

Each subject must meet all of the following inclusion criteria to be enrolled in the study:

• Voluntary written informed consent before performance of any study-related procedure not part of normal medical care, with the understanding that consent may be withdrawn by the subject at any time without prejudice to future medical care.
• Female subject is either post-menopausal or surgically sterilized or willing to use two acceptable methods of birth control (i.e., a hormonal contraceptive, intra-uterine device, diaphragm with spermicide, condom with spermicide, or abstinence) for the duration of the study.
• Male subject agrees to use an acceptable method for contraception for the duration of the study.
• Subject is between 18 and 65 years of age, inclusive.
• Subject has a transplant dysfunction indicated by an increase in creatinine of 0.3 mg/dL or 15% (lipase >3 X ULN for kidney/pancreas recipients) over baseline necessitating an allograft biopsy to assess for allograft rejection.
• Presence of light microscopic histologic changes consistent with acute cellular rejection of a Banff 97 (2005 update) grade IA or greater and at least one of the following:
• Donor-specific antibody (DSA) positive via Luminex
• Presence of C4d in the peritubular capillaries or glomeruli
• Subject must have no known contraindications to treatment with bortezomib, boron or mannitol, thymoglobulin, or rituximab.
• Recipients of kidney or simultaneous kidney pancreas organ transplant.

Exclusion criteria

Subjects meeting any of the following exclusion criteria are not to be enrolled in the study.

• Subject has a platelet count < 100,000/mm3 within 7 days before enrollment.
• Subject has an absolute neutrophil count of < 1,000/mm3 within 7 days before enrollment.
• Subject has Grade 2 peripheral neuropathy within 14 days before enrollment.
• Myocardial infarction within 6 months prior to enrollment or has New York Heart Association (NYHA) Class III or IV heart failure (see section 8.4), uncontrolled angina, severe uncontrolled ventricular arrhythmias, or electrocardiographic evidence of acute ischemia or active conduction system abnormalities. Prior to study entry, any ECG abnormality at Screening has to be documented by the investigator as not medically relevant.
• Subject has received other investigational drugs with 14 days before enrollment
• Serious medical (other than renal disease) or psychiatric illness likely to interfere with participation in this clinical study.
• Subjects that have previously received an organ transplant other than kidney or simultaneous kidney pancreas.
• Subjects who are recipients of A-B-O incompatible transplants, all cytotoxicity (CDC) crossmatch positive transplants
• Recipients of a simultaneous kidney pancreas transplant that only have pancreas rejection.
• Subjects unable to tolerate a dose of mycophenolate mofetil 1-3g/day (or equivalent mycophenolic acid dose).
• Subjects who are anti-HIV-positive, or HBsAg-positive. Anti-Hepatitis C Virus (HCV) positive patients are excluded, except patients with negative pathologic complete remission-result.
• Recipients of a kidney from a donor who tests positive for HIV, HBsAg or anti-HCV
• History of malignancy within the past 5 years that is not considered to be cured, with the exception of localized basal cell carcinoma of the skin (excised ≥ 2 years prior to randomization)
• Subjects with current or recent severe systemic infections within the 2 weeks prior to randomization.
• Receipt of a live vaccine within 4 weeks prior to study entry
• Evidence of severe liver disease with abnormal liver profile (aspartate aminotransferase (AST), alanine aminotransferase (ALT) or total bilirubin > 3 times upper limit of normal (ULN)) at screening.
• Pregnant or nursing (lactating) women.
• EBV sero-mismatch (EBV + donor organ transplanted to EBV - recipient)
• CMV sero-mismatch (CMV + donor organ transplanted to CMV - recipient)