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Stringer D, Gardner L, Shaw O, Clarke B, Briggs D, Worthington J, Buckland M, Danzi G, Hilton R, Picton M, Thuraisingham R, Borrows R, Baker R, McCullough K, Stoves J, Phanish M, Shah S, Shiu KY, Walsh SB, Ahmed A, Ayub W, Hegarty J, Tinch-Taylor R, Georgiou E, Bidad N, Kılıç A, Moon Z, Horne R, McCrone P, Kelly J, Murphy C, Peacock J, Dorling A. Optimized immunosuppression to prevent graft failure in renal transplant recipients with HLA antibodies (OuTSMART): a randomised controlled trial. EClinicalMedicine 2023; 56:101819. [PMID: 36684392 PMCID: PMC9852275 DOI: 10.1016/j.eclinm.2022.101819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 12/14/2022] [Accepted: 12/22/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND 3% of kidney transplant recipients return to dialysis annually upon allograft failure. Development of antibodies (Ab) against human leukocyte antigens (HLA) is a validated prognostic biomarker of allograft failure. We tested whether screening for HLA Ab, combined with an intervention to improve adherence and optimization of immunosuppression could prevent allograft failure. METHODS Prospective, open-labelled randomised biomarker-based strategy (hybrid) trial in 13 UK transplant centres [EudraCT (2012-004308-36) and ISRCTN (46157828)]. Patients were randomly allocated (1:1) to unblinded or double-blinded arms and screened every 8 months. Unblinded HLA Ab+ patients were interviewed to encourage medication adherence and had tailored optimisation of Tacrolimus, Mycophenolate mofetil and Prednisolone. The primary outcome was time to graft failure in an intention to treat analysis. The trial had 80% power to detect a hazard ratio of 0.49 in donor specific antibody (DSA)+ patients. FINDINGS From 11/9/13 to 27/10/16, 5519 were screened for eligibility and 2037 randomised (1028 to unblinded care and 1009 to double blinded care). We identified 198 with DSA and 818 with non-DSA. Development of DSA, but not non-DSA was predictive of graft failure. HRs for graft failure in unblinded DSA+ and non-DSA+ groups were 1.54 (95% CI: 0.72 to 3.30) and 0.97 (0.54-1.74) respectively, providing no evidence of an intervention effect. Non-inferiority for the overall unblinded versus blinded comparison was not demonstrated as the upper confidence limit of the HR for graft failure exceeded 1.4 (1.02, 95% CI: 0.72 to 1.44). The only secondary endpoint reduced in the unblinded arm was biopsy-proven rejection. INTERPRETATION Intervention to improve adherence and optimize immunosuppression does not delay failure of renal transplants after development of DSA. Whilst DSA predicts increased risk of allograft failure, novel interventions are needed before screening can be used to direct therapy. FUNDING The National Institute for Health Research Efficacy and Mechanism Evaluation programme grant (ref 11/100/34).
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Affiliation(s)
- Dominic Stringer
- Biostatistics and Health Informatics, The Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- King's Clinical Trials Unit, King's College London, London, UK
| | - Leanne Gardner
- King's Clinical Trials Unit, King's College London, London, UK
- Centre for Nephrology, Urology and Transplantation, Department of Inflammation Biology, King's College London, Guy's Hospital, Great Maze Pond, London, SE1 9RT, UK
| | - Olivia Shaw
- Clinical Transplantation Laboratory, Viapath Analytics LLP, London, UK
| | - Brendan Clarke
- Transplant Immunology, Level 09 Gledhow Wing, St James's University Hospital, Beckett Street, Leeds, LS9 7TF, UK
| | - David Briggs
- NHSBT Birmingham, Vincent Drive, Edgbaston, Birmingham, B15 2SG, UK
| | - Judith Worthington
- Transplantation Laboratory, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK
| | - Matthew Buckland
- Clinical Transplantation Laboratory, The Royal London Hospital, 2nd Floor, Pathology and Pharmacy Building, 80 Newark Street, London, E1 1BB, UK
| | - Guilherme Danzi
- Renal Unit, Hospital das Clínicas da Universidade Federal de Pernambuco, Av. Prof. Moraes Rego, 1235 - Cidade Universitária, Recife - PE, 50670-901, Brazil
| | - Rachel Hilton
- Department of Nephrology and Transplantation, Guy's Hospital, Great Maze Pond, London, SE1 9RT, UK
| | - Michael Picton
- Department of Renal Medicine, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK
| | - Raj Thuraisingham
- Department of Renal Medicine and Transplantation, Barts Health NHS Trust, London, E1 1BB, UK
| | - Richard Borrows
- Renal Unit, University Hospital Birmingham, Edgbaston, Birmingham, B15 2LN, UK
| | - Richard Baker
- Renal Unit, St James's University Hospital, Beckett Street, Leeds, LS9 7TF, UK
| | - Keith McCullough
- Renal Unit, York Teaching Hospital NHS Foundation Trust, York, YO31 8HE, UK
| | - John Stoves
- Renal Unit, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, BD5 0NA, UK
| | - Mysore Phanish
- Renal Unit, Epsom and St Helier University Hospitals NHS Trust, Surrey, UK
| | - Sapna Shah
- Renal Unit, King's College Hospital, London, SE5 9RJ, UK
| | - Kin Yee Shiu
- UCL Department of Renal Medicine, Royal Free London NHS Foundation Trust, London, NW3 2QG, UK
| | - Stephen B. Walsh
- UCL Department of Renal Medicine, Royal Free London NHS Foundation Trust, London, NW3 2QG, UK
| | - Aimun Ahmed
- Renal Unit, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, PR2 9HT, UK
| | - Waqar Ayub
- Renal Unit, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, CV2 2DX, UK
| | - Janet Hegarty
- Renal Unit, Salford Royal NHS Foundation Trust, Salford, M6 8HD, UK
| | - Rose Tinch-Taylor
- Biostatistics and Health Informatics, The Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- King's Clinical Trials Unit, King's College London, London, UK
| | | | - Natalie Bidad
- Centre for Behavioural Medicine, UCL School of Pharmacy, University College London, London, WC1H 9JP, UK
| | - Ayşenur Kılıç
- Centre for Behavioural Medicine, UCL School of Pharmacy, University College London, London, WC1H 9JP, UK
| | - Zoe Moon
- Centre for Behavioural Medicine, UCL School of Pharmacy, University College London, London, WC1H 9JP, UK
| | - Robert Horne
- Centre for Behavioural Medicine, UCL School of Pharmacy, University College London, London, WC1H 9JP, UK
| | - Paul McCrone
- King's Clinical Trials Unit, King's College London, London, UK
- Faculty of Education, Health and Human Sciences, University of Greenwich, London, UK
| | - Joanna Kelly
- King's Clinical Trials Unit, King's College London, London, UK
| | - Caroline Murphy
- King's Clinical Trials Unit, King's College London, London, UK
| | - Janet Peacock
- School of Life Course and Population Sciences, King's College London, London, UK
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Dartmouth College, USA
| | - Anthony Dorling
- Centre for Nephrology, Urology and Transplantation, Department of Inflammation Biology, King's College London, Guy's Hospital, Great Maze Pond, London, SE1 9RT, UK
- Corresponding author.
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