Rituximab Versus Steroids and Cyclophosphamide in the Treatment of Idiopathic Membranous Nephropathy (RI-CYCLO)

A Randomized Controlled Trial of Rituximab Versus Steroids and Cyclophosphamide in the Treatment of Idiopathic Membranous Nephropathy

University of Bari, Azienda Ospedaliera Brotzu, University of Messina, University of Milan, Universita di Verona, University of Chieti, University of Bologna, Azienda Sanitaria Locale Roma E, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Regione Piemonte, University of Modena and Reggio Emilia, University of Pisa, University of Milano Bicocca, Humanitas Hospital, Italy, Azienda Ospedaliera Universitaria Policlinico, Fondazione Salvatore Maugeri, University of Bern, University of Alberta, Istituto Giannina Gaslini

Idiopathic Membranous nephropathy (IMN) is an auto-immune glomerular disease. Recent studies suggest that circulating auto-antibodies against the podocyte surface antigens phospholipase A2 receptor1 (PLA2R1) and thrombospondin type 1 domain-containing 7A (THSD7A) cause the disease in the majority of the patients. Additional autoantibodies, directed to podocyte neo-expressed cytoplasm proteins have been described, including aldose reductase (AR), Mn-superoxide dismutase (SOD2) and alpha-enolase (alpha-ENO). The commonest presentation of IMN is nephrotic syndrome. Data from placebo arms of interventional studies show that 30-40% of the untreated patients with persistent nephrotic syndrome (NS) progress to end-stage renal disease (ESRD). The best-validated treatment regimen of IMN is combination therapy with steroids and cyclophosphamide, capable to induce remission of protenuria in two-third of the patients. Despite this evidence of efficacy, there are concerns about the use of cyclophosphamide, since it may be associated with adverse events, including bone marrow suppression, gonadal toxicity, infections and oncogenic effects. Thus, the availability of alternative therapies highly effective but with a greater safety profile is desirable. Given the key role of IgG antibodies in IMN, B cell depletion may favourably impact the glomerular disease. The anti-CD20 monoclonal antibody Rituximab is a selective B cell depleting agent. There is evidence that Rituximab is effective in the treatment of other diseases in which B cells play a key role, such as ANCA-related vasculitis. Observational studies in IMN provided encouraging data; in addition, the drug seems well tolerated. Head-to-head comparisons between Rituximab and steroid plus ciclophosphamide in randomized clinical trials are missing. The investigators propose this study in order to test, in a randomized controlled trial, the hypothesis that Rituximab is more effective than cyclical steroid/alkylating-agent therapy in inducing remission in patients with IMN and NS undergoing the initial treatment. In addition, the levels of the above-mentioned pathogenetic autoantibodies will be measured at baseline and during treatment. Finally, the study will compare the safety profile of steroid plus cyclophosphamide and Rituximab by evaluating the rate and severity of adverse events

Idiopathic Membranous nephropathy (IMN) is an immune-mediated glomerular disease characterized by deposition of IgG4 antibodies in the subepithelial area of the glomerular basement membrane (GBM). Proteinuria is the hallmark of the disease. The commonest presentation of IMN is nephrotic syndrome with preserved kidney function. The natural course of the disease can be variable and may be punctuated with spontaneous remissions and relapses. In about 20% of patients, there is spontaneous complete remission of the nephrotic syndrome, and another 15-20% undergo partial remission; about 30% of patients may remain with fluctuating proteinuria and about 30% may progress to end-stage renal disease (ESRD). However, data from natural history studies and placebo arms of intervention studies with follow-up lasting more than 10 years show that about 30-40% of the untreated patients with persistent nephrotic syndrome progress to ESRD. Complete remission of nephrotic syndrome predicts excellent long-term kidney and patient survival, and partial remission also significantly reduces the risk of progression to ESRD. Therefore, persisting remission of the nephrotic state is an acceptable surrogate end-point to assess efficacy of treatment. The primary aims of treatment, therefore, are to induce a lasting reduction in proteinuria. The best-validated regimen is combination therapy with corticosteroids and cyclophosphamide ("Ponticelli" regimen). This treatment is superior to supportive therapy alone in inducing remissions and preventing long-term decline of kidney function in patients with idiopathic MN and persisting nephrotic syndrome. However, there are concerns about the use of cyclophosphamide, since its use may be associated with adverse events, leading to treatment interruption in about 9% of patients. These adverse events include bone marrow suppression, gonadal toxicity, infections and oncogenic effects. Thus, the availability of alternative therapies highly effective but with a greater safety profile is desirable. Recent human studies confirmed that MN is an autoimmune disease, suggesting that the disease may be triggered by isotype specific autoantibodies directed against podocyte enzymes and podocyte receptors that are recognized as antigens, including M-type phospholipase-2 receptors(PLA2R1) and thrombospondin type 1 domain-containing 7A (THSD7A). The podocyte expression of these autoantigens can trigger the production of specific antibodies and in situ deposits of immune complexes, with consequent activation of complement cascade, oxygen radicals, and other inflammatory pathways leading to tissue injury and fibrosis. Additional autoantibodies, directed to podocyte neo-expressed cytoplasm proteins have been described, including aldose reductase (AR), Mn-superoxide dismutase (SOD2) and alpha-enolase (alpha-ENO). However, the mechanisms eliciting the expression of these neoantigens on podocytes and regulating the deposition of the auto-antibodies on the subepithelial surface of the glomerular basement membrane is not known. Considering the potential role of IgG antibodies in the pathogenesis of IMN, B cell depletion may favourably impact the glomerular disease as reflected by a reduction in proteinuria. The anti-CD20 monoclonal antibody Rituximab is a selective B cell depleting agent, capable to maintain B cells undetectable for 3-12 months. There is evidence that this strategy is effective in the treatment of other diseases in which B cells play a key role, such as ANCA-related vasculitis and humoral allograft rejection. Preliminary studies in IMN are promising, with observational studies providing encouraging data; in addition, the drug seems well tolerated with minimal adverse events. Head-to-head comparisons between Rituximab and steroid plus ciclophosphamide in randomized clinical trials are missing. The investigators propose this study in order to test in a randomized controlled trial the hypothesis that selective B lymphocyte depletion obtained with Rituximab is more effective than cyclical corticosteroid/alkylating-agent therapy in inducing long-term remission of proteinuria in patients undergoing the initial treatment of with IMN and nephrotic syndrome. In addition, since specific assay for the above-mentioned autoantibodies are now available, the levels of these pathogenetic autoantibodies will be measured at baseline and during treatment. Finally, the study will compare the safety profile of steroid plus cyclophosphamide and Rituximab by evaluating the rate and severity of adverse events. Design and Power Considerations The investigators hypothesized that the remission probability in the RTX arm will be greater than in the active comparator group (superiority design). Available data (Ponticelli 1998) suggest that the probability of complete remission with standard therapy is 15% at one year. The investigators plan to enroll 70 patients in this pilot RCT. This sample size will be able to detect with a power of 80% (and a two-sided P of 0.05) an odds ratio of 3, i.e. change in probability from 0.15 to 0.45 - a very optimistic effect. Smaller (and likely more reasonable) effects would require larger studies. The study will provide an estimate of this true effect, if it exists. Adverse effects: Patients will be directly questioned every two weeks during the drug exposure and then at monthly intervals during follow-up. In addition a contact number will be provided to the subjects to call if they experience any adverse affect or if they suspect adverse effect at any time between specific visits Definition Of Proteinuric Status UP = urinary protein (g/24h) Complete remission (CR) UP ≤ 0.3 g Partial remission (PR): Reduction in UP of > 50% plus final UP ≤ 3.5 g but >0.3g Non-response (NR): Reduction in UP of < 50% (includes increase in UP <50%) Neither CR nor PR Progression: Proteinuria /S. creatinine increases by > 50% over the baseline

Month 1, 3 and 5: 1g IV methylprednisolone daily for 3 doses; oral methylprednisolone (0.4mg/kg/day) or prednisone (0.5/mg/kg/day); Month 2, 4 and 6: Oral Cyclophosphamide (2.0 mg/kg/day)

Methylprednisolone 1 g IV daily for 3 doses, then oral methylprednisolone (0.4 mg/kg/day) or oral prednisone (0.5mg/kg/day) for 27 days during Month 1, 3, 5.

change in probability of complete remission (proteinuria < 0.3 g/day) Primary Outcome Measures The primary outcome measure is the change in probability of complete remission (proteinuria < 0.3 g/day) at one year (see Design and power considerations).

The primary outcome measure is the change in probability of complete remission (proteinuria < 0.3 g/day) at one year

CR (Complete Remission) or PR (Partial Remission: Reduction in UP of > 50% plus final UP ≤ 3.5 g but >0.3g )

Frequency of auto-antibodies and its relation to therapy and proteinuria response in a subgroup of patients

Frequency of auto-antibodies and its relation to therapy and proteinuria response in a subgroup of patients at baseline and 3 days, 1 month, 3 months, 6 months and 12 months after treatment

serious side effects: Death, Life-threatening event, Hospitalization, Disability in the patient's body function/structure or physical activity or quality of life, Congenital anomaly, Intervention to prevent permanent impairment or damage)

serious side effects: Death, Life-threatening event, Hospitalization, Disability in the patient's body function/structure or physical activity or quality of life, Congenital anomaly, Intervention to prevent permanent impairment or damage.

Inclusion Criteria: Biopsy-proven diagnosis of idiopathic MN performed within the past 24 months Proteinuria > 3.5 g/24h on three 24-hour urine collection (once a week for 3 weeks) Estimated GFR (MDRD formula) ≥ 30ml/min/1.73m2 under ACEI/ARB therapy Post-menopausal females, or females surgically sterile or practicing a medically approved method of contraception (no birth-control pill) Three months of ACEI and/or ARB therapy before treatment Blood Pressure <130/80 mm Hg HMG-CoA reductase inhibitor therapy Patients remaining with proteinuria >3.5g/24h after 3 months of ACEI and/or ARB therapy and Blood Pressure <130/80 mm Hg may be randomized to RTX / cyclical corticosteroid/alkylating-agent therapy without the need of the run-in/conservative phase of the study. Exclusion Criteria: serum creatinine >2.5 mg/dl; Estimated GFR < 30 ml/min/1.73m2 previous treatment with Rituximab, Steroids, Alkylating Agents, Calcineurin Inhibitors, Synthetic ACTH, MMF, Azathioprine Presence of active infection Secondary cause of MN (e.g. hepatitis B, SLE, medications, malignancies). Testing for HIV, Hepatitis B and C should have occurred < 6 months prior to enrollment into the study Type 1 or 2 diabetes mellitus Pregnancy or nursing for safety reasons Renal vein thrombosis documented prior to entry by renal US or CT scan

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