Tacrolimus After rATG and Infliximab Induction Immunosuppression—RIMINI Trial

Abstract

Background. Infliximab selectively targets recently activated effector cells and, as an induction agent, might enable the safe elimination of mycophenolate from maintenance immunosuppression in kidney transplantation. Methods. This is a phase II international multicenter open-label single-arm confidence interval (CI)–based clinical trial of the BIO-DrIM EU consortium aimed at assessing the efficacy and safety of rabbit antithymocyte globulin and infliximab induction in kidney transplantation. Sixty-seven primary kidney transplant recipients at low risk (panel-reactive antibodies <20%, no donor-specific antibodies [DSA]) received rabbit antithymocyte globulin (2 × 1.5 mg/kg, postoperative days 0 and 1) and infliximab (5 mg/kg, postoperative day 2), followed by mycophenolate-free tacrolimus-based immunosuppression for 12 mo. The primary endpoint was efficacy failure, defined as a composite of acute rejection, graft loss, or poor graft function (estimated glomerular filtration rate <40 mL/min) at 12 mo and was based on the endpoint of the comparator study. Additionally, a historical propensity-matched control cohort was established. Results. Primary endpoint occurred in 22 of 67 patients (32.84%), with upper bound of an exact 1-sided 95% CI of 43.47%, which met the predefined criteria (efficacy failure of <40% and upper-bound 95% CI of <50%) and was similar in the historical matched cohort. By 12 mo, 79.1% of patients remained on the study protocol. Lower rates of BK replication (6% versus 22.4%; P = 0.013) but higher rates of de novo DSAs (11.9% versus 1.5%; P = 0.039) were observed in the study cohort. Conclusions. A similar efficacy of the study immunosuppression regimen to the comparator study and the historical matched cohort was found. However, a higher de novo DSA emergence points to an increased risk of antibody-mediated rejection (NCT04114188).

Minimization of Transplant Immunosuppression: An Elusive Goal

“…In this issue of Transplantation, the RIMINI investigators further our knowledge of IFX by hypothesizing that induction with rabbit antithymocyte globulin (3 mg/kg) followed by IFX (5 mg/kg) can safely allow a 2-drug regimen of tac/steroids with MMF avoidance. 6 It was a prospective, single-arm, open-label, international multicenter study following 67 primary KTRs with calculated panel reactive antibody <20% and absent dnDSAs at randomization. The primary endpoint is defined as "efficacy failure" (composite of BPAR, graft loss, or poor graft function defined as eGFR <40 mL/min/1.73 m 2 at 12 mo).…”