Extended Release Tacrolimus vs. Twice-Daily Tacrolimus

Once-Daily Extended-Release Tacrolimus vs. Twice-Daily Tacrolimus: Impact on T-Cell Subpopulations and Markers of Renal Tubule-toxicity in Kidney Transplant Patients

The overall aim of the study is to prospectively investigate the impact of two maintenance calcineurin inhibitor immunosuppressive regimens: once-daily extended release tacrolimus and twice-daily tacrolimus on subpopulations of T and B cells and alloreactive T cells as well as on renal allograft function.

Kidney transplantation is the treatment of choice for most patients with end-stage renal disease. Lifelong immunosuppressive therapies are required to prevent organ rejection. However, long term exposure to immunosuppressive therapy after kidney transplantation can place patients at risk for multiple adverse events. The optimal immunosuppressive therapy is not well established. Tacrolimus, a calcineurin inhibitor (CNI) is highly effective in preventing acute rejection after organ transplantation (2). It is used as part of the immunosuppression regimen for the majority of kidney and liver transplant recipients (3). However, treatment with current formulation of Tacrolimus generates high peaks and low troughs in drug concentrations in the blood. It is known that high exposure to CNI is associated with renal toxicities and adverse events (4). New once-daily dosage formulations are now developed with the hope of minimizing side effects while maintaining excellent outcomes (5-8). LCP-Tacro (Envarsus® XR, Veloxis Pharmaceuticals), a new once-daily formulation of tacrolimus, was approved by the FDA in 2015 for conversion from twice-daily tacrolimus in kidney transplant recipients. It is a prolonged-release tacrolimus formulation, utilizing a MeltDose drug delivery technology designed to improve the bioavailability of drugs with low water solubility (1). Recent clinical data demonstrated that once-daily LCP-Tacro has improved pharmacokinetic bioavailability, rapid achievement of therapeutic trough levels, less fluctuation and swing in whole blood concentration, non-inferior efficacy and similar safety, with lower tacrolimus dose than other tacrolimus formulations. The target population is adult recipients of immediately functioning living and deceased donor renal allografts. Immediate function will be defined as the absence of the need for hemodialysis in the first week following renal transplantation. Prospective randomized single center open label study of 2 groups of kidney transplant patients Group 1 : standard of care (SOC) control group will receive tacrolimus twice-daily (n=25) Group 2 : LCP-Tacro (Envarsus® XR) group will receive LCPT tablets once daily (n=25)

change in the mean eGFR from the baseline (2 weeks post transplant), 3 months (post transplant) , and 12 months (post transplant).

Blood, urine and kidney tissue analysis via serial flow cytometric immunophenotyping (includes regulatory T and B cell populations as well as immune functions).

Tissue analysis via immunohistopathological staining and microscopic examination Moderate acute tubular necrosis => presence of focal coagulative necrosis or infarction on histopathologic examination Arteriolar hyalinosis grade 2 means: Replacement of degenerated smooth muscle cells by hyaline deposits in more than 1 arteriole, without circumferential involvement Global glomerulosclerosis >grade 2, means glomerulosclerosis affecting more than 50% of glomeruli in the biopsy sample IFTA : Interstitial fibrosis and tubular atrophy: Inflammation in 26% to 50% of scarred cortical parenchyma

Inclusion Criteria: 1. Patients who are males or females aged 18-65 years. 2. Use of the following induction medications: basiliximab and rituximab. 2. Donors aged 18-65 years. 3. No prior organ transplant 4. Patients who are single-organ recipients (kidney only). 5. Women who are of childbearing potential must have a negative serum pregnancy test before transplantation and agree to use a medically acceptable method of contraception throughout the treatment period. 6. Subject (recipient) is able to understand the consent form and give written informed consent Exclusion Criteria: Delayed graft function (please see above). Known sensitivity or contraindication to alemtuzumab, Envarsus® XR, tacrolimus or MMF. Use of the following induction medications: basiliximab and rituximab Patient with significant or active infection. Patients with a positive flow cytometric crossmatch using donor lymphocytes and recipient serum. Patients with PRA > 40% Patients with current or historic donor specific antibodies Body Mass Index (BMI) of < 18 or > 35 Patients who are pregnant or nursing mothers. Patients whose life expectancy is severely limited by diseases other than renal disease. Ongoing active substance abuse, drug or alcohol. Major ongoing psychiatric illness or recent history of noncompliance. Significant cardiovascular disease (e.g.): Significant non-correctable coronary artery disease; Ejection fraction below 30%; History of recent myocardial infarction. Malignancy within 3 years, excluding non-melanoma skin cancers. Serologic evidence of infection with HIV or HBVs-Ag positive. Patients with a screening/baseline total white blood cell count < 4,000/mm3; platelet count < 100,000/mm3; triglyceride > 400 mg/dl; total cholesterol > 300 mg/dl. Investigational drug within 30 days prior to transplant surgery. Anti-T cell therapy within 30 days prior to transplant surgery. Diagnosis of atypical-Hemolytic Uremic Syndrome (aHUS). Subjects transplanted with a Hepatitis C NAT-positive kidney.