Rilparencel (Renal Autologous Cell Therapy-REACT®) for Chronic Kidney Disease and Type 1 and 2 Diabetes: Phase 2 Trial Design Evaluating Bilateral Kidney Dosing and Re-Dosing Triggers

INTRODUCTION

Autologous cell-based therapies (CBT) to treat Chronic Kidney Disease (CKD) with diabetes are novel and can potentially preserve renal function and decelerate disease progression. CBT dosing schedules are in early development and may benefit from individual bilateral organ dosing and kidney-dependent function to improve efficacy and durability. The objective of this open-label, phase 2 randomized controlled trial (RCT) is to evaluate participants' response to rilparencel (Renal Autologous Cell Therapy-REACT®) following bilateral percutaneous kidney injections into the kidney cortex with a prescribed dosing schedule versus re-dosing based on biomarker triggers.

METHODS

Eligible participants with type 1 or 2 diabetes and CKD, eGFR 20-50 ml/min/1.73 m2, UACR 30-5000 mg/g, Hemoglobin > 10 g/dL and glycated hemoglobin A1c < 10% were enrolled. After a percutaneous kidney biopsy and bioprocessing ex vivo expansion of Selected Renal Cells, participants were randomized 1:1 into two cohorts determined by the dosing scheme. Cohort 1 receives two cell injections, one in each kidney three months apart, and Cohort 2 receives one injection and the second dose only if there is a sustained eGFR decline of ≥20 ml/min/1.73 m2 and/or UACR increase of ≥ 30% confirmed by re-testing.

CONCLUSION

This multicenter phase 2 RCT is designed to investigate the efficacy and safety of rilparencel with bilateral kidney dosing and comparing two injection schedules with the potential of preserving or improving kidney function and delaying kidney disease progression among patients with Stages 3a-4 CKD with diabetes.

Renal Autologous Cell Therapy in Type 2 Diabetes with Late Stage 4 Diabetes-Related Chronic Kidney Disease: Trial Design and Early Analysis

INTRODUCTION

Cell-based therapies potentially delay the trajectory toward end-stage kidney disease (ESKD) in late stage 4 diabetic chronic kidney disease (DKD). We describe the trial design, baseline patient characteristics, and early results of an IRB-approved phase II multicenter clinical trial, utilizing Renal Autologous Cell Therapy (REACT) in adults with pre-ESKD due to type 2 DKD. The trial objectives were safety and tolerability of REACT by assessment of the procedure, product administration, and renal-specific adverse events in addition to evaluate the impact on renal function following injection.

METHODS

Ten adults with an eGFR of 14-20 mL/min/1.73 m2 were enrolled in a single-arm open-label trial. Following a percutaneous kidney biopsy, an ex vivo expansion of selected renal cells that form the REACT was injected into the cortex of the biopsied kidney with CT image guidance. Each participant received two doses of the REACT product at 6-month intervals. A 6-month observation pre-trial was required to establish patients' "own" baseline and rate of DKD progression.

RESULTS

Five men and 5 women underwent 19 REACT injections (1 participant received only one injection). Their baseline characteristics were as follows: 3 Hispanic/Latino, 7 non-Hispanic, 7 white; mean (SD) age: 58.9 years (5.22), BMI 35.8 (8.2), eGFR (sCR) 15.5 (2.72), eGFR (sCR + Cys-C) 17.7 (3.67) mL/min/1.73 m2, sCr 3.6 mg/mL (0.73), Cys-C 2.6 mg/mL (0.52), and log random UACR 7.9 mg/g (1.01). The pre- and post-injection eGFR slope was -6.5 mL/min/1.73 m2 and -3.9 mL/min/1.73 m2. No cell-related adverse events occurred, and two procedure-related hematomas required observation without transfusion or angiographic interventions. Dialysis was delayed a mean of 16 months (range 6-28 months). At 15 months, 2 patients (20%) have eGFR slope stability and have not commenced renal replacement therapy.

CONCLUSION

Trials that include patients with an eGFR of <20 mL/min/1.73 m2 are uncommon, and none to date involve autologous homologous cell-based treatments. REACT has the potential to stabilize or delay dialysis in high-risk late stage 4 DKD.

Renal Autologous Cell Therapy (REACT®) to Stabilize Function in Diabetes-Related Chronic Kidney Disease: Corroboration of Mechanistic Action with Cell Marker Analysis

Introduction

Methods

Results

Conclusion

Novel Renal Autologous Cell Therapy for Type 2 Diabetes Mellitus Chronic Diabetic Kidney Disease: Clinical Trial Design

BACKGROUND

Cell therapies explore unmet clinical needs of patients with chronic kidney disease with the potential to alter the pathway toward end-stage kidney disease. We describe the design and baseline patient characteristics of a phase II multicenter clinical trial utilizing the novel renal autologous cell therapy (REACT), by direct kidney parenchymal injection via the percutaneous approach in adults with type 2 diabetic kidney disease (T2DKD), to delay or potentially avoid renal replacement therapy.

DESIGN

The study conducted a prospective, multicenter, randomized control, open-label, phase II clinical trial between an active treatment group (ATG) receiving REACT from the beginning of the trial and a contemporaneous deferred treatment group (DTG) receiving standard of care for 12 months before crossing over to receive REACT.

OBJECTIVES

The objective of this study was to establish the safety and efficacy of 2 REACT injections with computed tomography guidance, into the renal cortex of patients with T2DKD administered 6 months apart, and to compare the longitudinal change in renal function between the ATG and the DTG.

SETTING

This was a multicenter study conducted in major US hospitals.

PATIENTS

We enrolled eighty-three adult patients with T2DKD, who have estimated glomerular filtration rates (eGFRs) between 20 and 50 mL/min/1.73 m2.

METHODS

All patients undergo an image-guided percutaneous kidney biopsy to obtain epithelial phenotype selective renal cells isolated from the kidney tissue that is then expanded ex vivo over 4-6 weeks, resulting in the REACT biologic product. Patients are randomized 1:1 into the ATG or the DTG. Primary efficacy endpoints for both study groups include eGFR measurements at baseline and at 3-month intervals, through 24 months after the last REACT injection. Safety analyses include biopsy-related complications, REACT injection, and cellular-related adverse events. The study utilizes Good Clinical and Manufacturing Practices and a Data and Safety Monitoring Board. The sample size confers a statistical power of 80% to detect an eGFR change in the ATG compared to the DTG at 24 months with an α = 0.05.

LIMITATIONS

Blinding cannot occur due to the intent to treat procedure, biopsy in both groups, and open trial design.

CONCLUSION

This multicenter phase II randomized clinical trial is designed to determine the efficacy and safety of REACT in improving or stabilizing renal function among patients with T2DKD stages 3a-4.

Rapid On-site Evaluation (ROSE) for Fine Needle Aspiration of Thyroid: Is It Helpful?

Introduction: Thyroid nodules are very common. Many are detected incidentally due to increased head and neck imaging. The majority are benign; however, malignancy can’t be excluded in many cases and tissue sampling is needed. Ultrasound guided fine needle aspiration is an easy and effective way to sample g thyroid nodules. Inadequate sampling was reported in 10-40% of the cases. Rapid On-site Evaluation (ROSE) was proposed to assess obtained sample for adequacy. The aim of this study is to identify the benefit of applying ROSE with US-FNA of thyroid nodules within our institution. Materials and methods: Patients who underwent FNA for thyroid nodules with ROSE availability documented in their procedure note between January 2017 to December 2018 were retrospectively included. All procedures were done by experienced radiologists. Aspirated material was Diff Quik stained for immediate evaluation. The final cytological diagnosis and specimen adequacy was based on The Bethesda system for reporting thyroid cytopathology. Specimen adequacy was compared between ROSE and non-ROSE groups. Results: 442 thyroid nodules were biopsied. ROSE was available for 65 nodules. Non-diagnostic rate with ROSE was 10.8% compared to 13.8% without ROSE with the difference being statistically insignificant. ROSE availability improved sample adequacy of nodules less than 3 cm with statistically significant difference of 100.0% with ROSE vs. 87% without ROSE. Conclusion: The current study does not justify the routine use of ROSE. However, ROSE availability is beneficial with smaller sized thyroid nodules and less experienced radiologists performing the procedure. Doi: 10.28991/SciMedJ-2021-0301-1 Full Text: PDF

Protocol and Baseline Data on Renal Autologous Cell Therapy Injection in Adults with Chronic Kidney Disease Secondary to Congenital Anomalies of the Kidney and Urinary Tract

BACKGROUND

Advanced cell therapies with autologous, homologous cells show promise to affect reparative and restorative changes in the chronic kidney disease (CKD) nephron. We present our protocol and preliminary analysis of an IRB-approved, phase I single-group, open-label trial that tests the safety and efficacy of Renal Autologous Cell Therapy (REACT; NCT04115345) in adults with congenital anomalies of the kidney and urinary tract (CAKUT).

METHODS

Adults with surgically corrected CAKUT and CKD stages 3 and 4 signed an informed consent and served as their "own" baseline control. REACT is an active biological ingredient acquired from a percutaneous tissue acquisition from the patient's kidney cortex. The specimen undergoes a GMP-compliant manufacturing process that harvests the selected renal cells composed of progenitors for renal repair, followed by image-guided locoregional reinjection into the patient's renal cortex. Participants receive 2 doses at 6-month intervals. Primary outcomes are stable renal function and stable/improved quality of life. Additional exploratory endpoints include the impact of REACT on blood pressure, vitamin D levels, hemoglobin, hematocrit and kidney volume by MRI analysis.

RESULTS

Four men and 1 woman were enrolled and underwent 5 cell injections. Their characteristics were as follows: mean 52.8 years (SD 17.7 years), 1 Hispanic, 4 non-Hispanic, and 5 white. There were no renal tissue acquisition, cell injection, or cell product-related complications at baseline.

CONCLUSION

REACT is demonstrating feasibility and patient safety in preliminary analysis. Autologous cell therapy treatment has the potential to stabilize or improve renal function in CAKUT-associated CKD to delay or avert dialysis. Patient enrollment and follow-up are underway.

Computed tomography-guided preoperative localization of abdominal wall endometrioma

A multiparous obese patient with prior abdominal surgeries complained of cyclic abdominal pain located near the surgical scar. A 1 cm lesion was identified on imaging. Computed tomography-guided needle localization was performed immediately before surgery. This allowed for complete excision of the abdominal wall endometrioma and resolution of the cyclic, focal abdominal pain.

β-blockers for infantile hemangiomas: a single-institution experience

Propranolol has become first-line therapy for the treatment of infantile hemangiomas in many centers. Of 302 children with hemangiomas seen at the University of North Carolina from 2008 through 2010, 15.6% were treated with oral propranolol alone, 5.6% with topical timolol (a propranolol derivative) alone, and 2.3% with both. The use of these agents increased over time from 7% of patients seen in 2008 to 54% of patients first seen in 2010. Starting doses of propranolol ranged from 0.25 to 1 mg/kg/d, with target doses of 1 to 4 mg/kg/d. Serious side effects, noted in 6/54 (10.9%) patients, included somnolence, bradycardia, hypotension, hypoglycemia, and mottling of extremities.The authors confirm the variation in use of propranolol for vascular lesions and extend experience with timolol. They suggest daily home monitoring of patients for the first 2 weeks of initiating or increasing doses. Frequent feeding of infants and young children on this drug is recommended.

Treatment of childhood kaposiform hemangioendothelioma with sirolimus

Sirolimus (Rapamune), a mammalian target of Rapamycin (mTOR) inhibitor, which has been used extensively in children following solid organ transplantation, has been demonstrated to have anti-angiogenic activity in pre-clinical models. Limited experience suggests that it may have application to the treatment of vascular lesions. We describe our experience with a 1-year-old female with a kaposiform hemangioendothelioma and Kasabach-Merritt phenomenon who had rapid and dramatic response to sirolimus (0.1 mg/kg/day). This case provides further rationale for clinical trials of sirolimus in the treatment of vascular lesions.

Vessel target location estimation during the TIPS procedure

Creation of a transjugular intrahepatic portosystemic shunt (TIPS) requires passage of a needle toward a moving target that is only seen transiently by X-ray prior to needle passage. Intraoperative, 3D target localization would facilitate target access and improve the safety of the procedure. The clinical assumption is that patients undergoing the TIPS procedure possess rigid, cirrhotic livers that undergo only intraoperative translation without significant deformation or rotation. Based upon this assumption, we hypothesize that the position of any unseen, 3D target point within the liver can be determined intraoperatively by precalculation of the relative positions of the target point to a different 3D point that can be tracked intraoperatively. This paper examines this hypothesis using intraoperatively acquired, biplane, X-ray images of seven patients. In six, we tracked the effects of cardiac and respiratory motion, and in three the effects of needle pressure. Methods involved reconstruction of 3D vessel bifurcation and other trackable intrahepatic points from biplane angiograms, measurement of liver deformation by examining changing distances between these 3D points over time, and comparison of expected to actual displacements of these points with respect to a fixed reference point in the liver. We conclude that, for the rigid livers associated with patients undergoing TIPS, that there is less intraoperative deformation than previously reported by other groups addressing healthy liver deformation, and that the location of an unseen target can be predicted within 3mm accuracy.

Symptomatic intracranial pneumatocele from mastoid sinus of spontaneous origin. Case report

A case of a large intracranial pneumatocele arising from mastoid air cells is reported. The patient became symptomatic after multiple coughing spells and required craniotomy for repair of the dural hiatus. The possible etiology of such a large spontaneous pneumatocele is discussed in the context of a review of the pertinent literature.

Percutaneous drainage of infected and noninfected thoracic fluid collections

Radiologically guided aspiration and drainage of thoracic fluid collections is an improvement on standard "blind" techniques for chest-tube insertion. Specific indications for radiologic drainage are broadening, and instead of failed surgical cases only, patients now are commonly referred for drainage. Most of these procedures are effective and the complication rate vis-à-vis alternatives is acceptable. Soft 12-F catheters suffice in most cases and are relatively comfortable to large-bore tubes.

Localization grid for MR-guided biopsy

A localization grid for use with magnetic resonance (MR)-guided biopsies was designed and evaluated. First, the signal intensities of various concentrations of Gd-DTPA in polyethylene tubes of different sizes and at various pulse sequences were evaluated. The optimal signal intensity on all pulse sequences was obtained with a concentration of 500 microM. A grid was then made with 5-mm-diameter polyethylene tubes filled with 500-microM Gd-DTPA. The grid has provided excellent localization for MR-guided biopsy and fluid aspiration.

Inferior glenohumeral dislocation

Presented is the case of a 55-year-old alcoholic with an inferior glenohumeral dislocation of his right shoulder. The patient was unable to move his right arm, which was flexed at the elbow and locked in an overhead position. After roentgenographic confirmation of the dislocation, traction-counter-traction was employed for reduction. Reduction was indicated by an audible click. The shoulder was immobilized and the patient was discharged for follow up in two weeks. Luxatio erecta is the result of a severe hyperabduction mechanism frequently associated with significant rotator cuff injury. Immediate reduction followed by surgical repair of the rotator cuff at a later date is the standard treatment.