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Clinical Trials for Immunosuppression in Transplantation: The Case for Reform and Change in Direction.
Transplantation
July 2017
1 Centre for Transplant and Renal Research, Westmead Institute for Medical Research, University of Sydney at Westmead Hospital, Sydney, NSW, Australia. 2 Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium. 3 Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL. 4 Division of Organ Transplantation, Feinberg School of Medicine, Northwestern University, Chicago, IL. 5 Department of Renal Medicine, University of Sydney at Royal Prince Alfred Hospital, Australia. 6 The Division of Nephrology, St. Paul's Hospital, Vancouver, British Columbia, Canada. 7 Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada. 8 Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. 9 Transplant Immunology Laboratory, University of Manitoba, Winnipeg Blood Centre, Winnipeg, Manitoba, Canada. 10 Department of Nephrology and Hypertension, Cleveland Clinic, Cleveland, OH. 11 Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH. 12 Department of Surgery, University of California San Francisco, San Francisco, CA. 13 Department of Nephrology, Hospital Universitari Vall d'Hebron, Universitat Autónoma Barcelona, Barcelona, Spain. 14 Department of Medicine, University of Cincinnati, College of Medicine, Cincinnati, OH. 15 Division of Transplantation, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD. 16 Department of Nephrology, Universitätsklinikum Charité, Humboldt University, Berlin, Germany. 17 The Comprehensive Transplant Center, Cedars-Sinai Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA. 18 Service de Néphrologie-Transplantation, Hôpital Necker, Paris, France, Université Paris Descartes, Sorbonne Paris Cité, Paris France. 19 INSERM U845, Hôpital Necker, Paris, France. 20 Department of Nephrology and Kidney Transplantation, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France. 21 Division of Transplant Surgery, University of California San Francisco, San Francisco, CA. 22 Division of Transplantation, Department of Surgery, The Johns Hopkins University, Baltimore, MD. 23 Departments of Surgery and Immunology, von Liebig Transplant Center, Mayo Clinic, Rochester, MN. 24 Transplant Surgery Division, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA. 25Division of Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH. 26 Stanford University School of Medicine, Stanford, CA.
Currently trials of immunosuppression in transplantation are in decline because their objectives remain focused on improving acute rejection rates and graft survival in the first 12 months. With 1 year renal graft survival rates of greater than 90% the best that can be hoped for is noninferiority trial outcomes compared with current standard of care. Current trial design is not leading to novel therapies improving long-term outcomes and safety, and hence important unmet clinical needs in transplantation remain unanswered.
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