Renal Allograft Fibrosis Study

Last updated: June 27, 2024
Sponsor: Icahn School of Medicine at Mount Sinai
Overall Status: Active - Enrolling

Phase

N/A

Condition

Scar Tissue

Treatment

N/A

Clinical Study ID

NCT05058170
GCO 20-2690
R01DK129888
  • Ages > 18
  • All Genders

Study Summary

Despite the reduction in acute rejection episodes in renal transplant patients due to modern immunosuppression, proportionate improvements in long-term allograft survival have not been achieved. Virtually any disease or injury affecting renal allografts can culminate in irreversible injury of tubular epithelial cells and the development of interstitial fibrosis and tubular atrophy (IFTA). Renal allograft fibrosis drives chronic kidney disease (CKD) progression, predicts allograft failure and is associated with increased patient mortality. Other prognostic and/or actionable diagnoses described by the pathologic Banff scheme, such as inflammation, often co-exist and contribute to IFTA. Immune cell infiltration within allografts and within areas of IFTA (i-IFTA) can drive progressive kidney injury, fibrosis and worsened outcome. Pathology is the reference standard for IFTA; however, allograft biopsy has many well-known limitations and is not an ideal method for monitoring patients during trials of new therapies aimed at improving allograft survival. There is an urgent and unmet need for non-invasive assessment of renal allograft IFTA.

Multiparametric MRI (mpMRI), including relaxometry [the spin-lock relaxation time T1ρ, a marker of interaction of water with macromolecules in tissues; the spin-lattice relaxation time T1, a marker of interstitial edema and collagen volume fraction)] and advanced diffusion [intravoxel incoherent motion diffusion-weighted imaging (IVIM-DWI), a marker of diffusion and perfusion] provides insight into renal structure and function. Validation of advanced MRI methods as markers of renal allograft IFTA would be of major clinical significance to enable early detection, assess the efficacy of novel anti-fibrotic agents, and provide longitudinal disease monitoring. The study team has established proof-of-concept in renal allografts with stable function and IFTA without confounding rejection or infection that mpMRI techniques are feasible for measuring fibrosis, especially using the combination of T1 and DWI. The study has established that urinary biomarkers for renal allograft fibrosis are also promising and have been validated against pathology in initial studies.

In this proposal, the researchers will develop a short, non-contrast multiparametric MRI (mpMRI) protocol, consisting of advanced relaxometry (T1 mapping and T1ρ) and advanced diffusion weighted imaging (IVIM-DWI) to accurately detect and stage allograft fibrosis, taking into account confounding Banff variables of inflammation and tested against biopsy. The researchers will also assess the added value of urinary biomarkers of IFTA and if successful, this study will benefit a large population of patients with renal allograft fibrosis in the United States, enabling early diagnosis, optimized treatment planning, prognostication and longitudinal disease monitoring.

Eligibility Criteria

Inclusion

Inclusion Criteria:

  • Patients post renal transplantation, with acute or chronic allograft dysfunction,referred for biopsy based on clinical grounds (indication biopsy). Patients with beconsidered to have allograft dysfunction if: 1. Patients will be considered to haveacute allograft dysfunction if there is a 15% decline in eGFR or a 0.3-mg/dLincrease in sCr level, with laboratory and clinical findings that exclude pre-renalor post-renal dysfunction. 2. Patients will be considered to have chronic allograftdysfunction if there is a sustained >50% increase in sCr/decrease in eGFR (overtheir post-transplant nadir creatinine), occurring over a period of >3 months, withlaboratory and clinical findings that exclude pre-renal or post-renal dysfunction.

  • Patients with stable allograft function and donor-specific antibody (DSA)positivity, referred for surveillance biopsy at 3 and 12 months posttransplantation. Patients with be considered to have stable allograft function if:

  1. Patients will be considered to have chronic stable allograft function if theyhave a stable eGFR > 45 ml/min & a spot urine protein:creatinine ratio < 0.2; 2.Stable creatinine/eGFR (i.e. <25% change in serum creatinine (Cr) and/or eGFR frompost transplant baseline).
  • Patient is able to give informed consent for this study.

  • Study team will recruit patients after 1 month post-transplant period since theearly post transplant course is associated with increased risk of acute dysfunction (i.e. acute tubular necrosis or acute rejection episodes).

  • Healthy volunteers with no renal disease will be recruited for protocol optimizationand to serve as controls.

  • Potential renal donors undergoing clinical non-contrast or contrast-enhanced MRIwill be recruited to serve as controls.

Exclusion

Exclusion Criteria:

  • Age less than 18 years.

  • Renal transplantation <1 month prior to scanning.

  • Evidence of large vessel or urinary tract complication of the renal transplant.

  • Unable or unwilling to give informed consent.

  • Contra-indications to MRI

  1. Electrical implants such as cardiac pacemakers or perfusion pumps.

  2. Ferromagnetic implants such as aneurysm clips, surgical clips, prostheses,artificial hearts, valves with steel parts, metal fragments, shrapnel, tattoosnear the eye, or steel implants.

  3. Ferromagnetic objects such as jewelry or metal clips in clothing.

  4. Pregnant subjects.

  5. Pre-existing medical conditions including a likelihood of developing seizuresor claustrophobic reactions.

The inclusion and exclusion criteria are identical at ISMMS and WCMC.

  • Screening for eligibility will be performed by the transplant nephrology team atboth centers. Data relevant to eligibility will be reviewed, including age, presenceof allograft dysfunction and its ascertainment (clinical, laboratory and priorbiopsy data), and MRI safety will also be reviewed by the study coordinator.

  • There are no exclusions based on race, sex/gender, preferred language.

Study Design

Total Participants: 280
Study Start date:
February 04, 2022
Estimated Completion Date:
October 31, 2026

Connect with a study center

  • Icahn School of Medicine at Mount Sinai

    New York, New York 10029
    United States

    Site Not Available

  • Weill Cornell Medicine

    New York, New York 10021
    United States

    Site Not Available

Not the study for you?

Let us help you find the best match. Sign up as a volunteer and receive email notifications when clinical trials are posted in the medical category of interest to you.