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Randomized Controlled Trial
. 2024 Jul;38(7):e15383.
doi: 10.1111/ctr.15383.

A Randomized Trial Comparing Imlifidase to Plasmapheresis in Kidney Transplant Recipients With Antibody-Mediated Rejection

Fabian Halleck  1   2 , Georg A Böhmig  3 , Lionel Couzi  4   5 , Lionel Rostaing  6 , Gunilla Einecke  7   8 , Carmen Lefaucheur  9 , Christophe Legendre  10   11 , Robert Montgomery  12 , Peter Hughes  13   14 , Anil Chandraker  15 , Kate Wyburn  16 , Phil Halloran  17 , Angela Q Maldonado  18 , Kristoffer Sjöholm  18 , Anna Runström  18 , Paola Lefèvre  18 , Jan Tollemar  18 , Stanley Jordan  19
Affiliations
Randomized Controlled Trial

A Randomized Trial Comparing Imlifidase to Plasmapheresis in Kidney Transplant Recipients With Antibody-Mediated Rejection

Fabian Halleck et al. Clin Transplant. 2024 Jul.

Abstract

Background: Antibody-mediated rejection (ABMR) poses a barrier to long-term graft survival and is one of the most challenging events after kidney transplantation. Removing donor specific antibodies (DSA) through therapeutic plasma exchange (PLEX) is a cornerstone of antibody depletion but has inconsistent effects. Imlifidase is a treatment currently utilized for desensitization with near-complete inactivation of DSA both in the intra- and extravascular space.

Methods: This was a 6-month, randomized, open-label, multicenter, multinational trial conducted at 14 transplant centers. Thirty patients were randomized to either imlifidase or PLEX treatment. The primary endpoint was reduction in DSA level during the 5 days following the start of treatment.

Results: Despite considerable heterogeneity in the trial population, DSA reduction as defined by the primary endpoint was 97% for imlifidase compared to 42% for PLEX. Additionally, imlifidase reduced DSA to noncomplement fixing levels, whereas PLEX failed to do so. After antibody rebound in the imlifidase arm (circa days 6-12), both arms had similar reductions in DSA. Five allograft losses occurred during the 6 months following the start of ABMR treatment-four within the imlifidase arm (18 patients treated) and one in the PLEX arm (10 patients treated). In terms of clinical efficacy, the Kaplan-Meier estimated graft survival was 78% for imlifidase and 89% for PLEX, with a slightly higher eGFR in the PLEX arm at the end of the trial. The observed adverse events in the trial were as expected, and there were no apparent differences between the arms.

Conclusion: Imlifidase was safe and well-tolerated in the ABMR population. Despite meeting the primary endpoint of maximum DSA reduction compared to PLEX, the trial was unsuccessful in demonstrating a clinical benefit of imlifidase in this heterogenous ABMR population.

Trial registration: EudraCT number: 2018-000022-66, 2020-004777-49; ClinicalTrials.gov identifier: NCT03897205, NCT04711850.

Keywords: immunosuppressant; kidney (allograft) function/dysfunction; plasmapheresis/plasma exchange; rejection: antibody‐mediated (ABMR).

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References

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