Trial Outcomes & Findings for Using Donor Stem Cells and Alemtuzumab to Prevent Organ Rejection in Kidney Transplant Patients (NCT NCT00183248)

NCT ID: NCT00183248

Last Updated: 2012-10-02

Results Overview

Recruitment status

COMPLETED

Study phase

PHASE1/PHASE2

Target enrollment

9 participants

Primary outcome timeframe

One year post kidney transplant

Results posted on

2012-10-02

Participant Flow

One center in the United States enrolled nine subjects who were recipients of living-related (1-haplotype-matched) donor kidney transplants between September 2004 and November 2006.

Participants underwent procedures at screening to establish inclusion/exclusion criteria.

Participant milestones

Participant milestones
Measure
DBMCs
Recipients of 1-haplotype human leukocyte antigen (HLA) matched living-donor related kidney transplantation were randomized to receive (CD34+ stem cell purified) Donor-specific Bone Marrow Cells (DBMCs). Induction therapy included alemtuzumab and steroid-free dose maintenance immunosuppression consisting of mycophenolate mofetil, tacrolimus and sirolimus. Refer to section titled 'Detailed Description' for additional treatment information.
Control Group
Recipients of 1-haplotype human leukocyte antigen (HLA) matched living-donor related kidney transplantation were randomized to receive induction therapy with alemtuzumab and steroid-free dose maintenance immunosuppression consisting of mycophenolate mofetil, tacrolimus and sirolimus. Refer to section titled 'Detailed Description' for additional treatment information.
Overall Study
STARTED
4
5
Overall Study
COMPLETED
3
4
Overall Study
NOT COMPLETED
1
1

Reasons for withdrawal

Reasons for withdrawal
Measure
DBMCs
Recipients of 1-haplotype human leukocyte antigen (HLA) matched living-donor related kidney transplantation were randomized to receive (CD34+ stem cell purified) Donor-specific Bone Marrow Cells (DBMCs). Induction therapy included alemtuzumab and steroid-free dose maintenance immunosuppression consisting of mycophenolate mofetil, tacrolimus and sirolimus. Refer to section titled 'Detailed Description' for additional treatment information.
Control Group
Recipients of 1-haplotype human leukocyte antigen (HLA) matched living-donor related kidney transplantation were randomized to receive induction therapy with alemtuzumab and steroid-free dose maintenance immunosuppression consisting of mycophenolate mofetil, tacrolimus and sirolimus. Refer to section titled 'Detailed Description' for additional treatment information.
Overall Study
Lost to Follow-up
0
1
Overall Study
Focal glomerulosclerosis proteinuria
1
0

Baseline Characteristics

Using Donor Stem Cells and Alemtuzumab to Prevent Organ Rejection in Kidney Transplant Patients

Baseline characteristics by cohort

Baseline characteristics by cohort
Measure
DBMCs
n=4 Participants
Recipients of 1-haplotype human leukocyte antigen (HLA) matched living-donor related kidney transplantation were randomized to receive (CD34+ stem cell purified) Donor-specific Bone Marrow Cells (DBMCs). Induction therapy included alemtuzumab and steroid-free dose maintenance immunosuppression consisting of mycophenolate mofetil, tacrolimus and sirolimus. Refer to section titled 'Detailed Description' for additional treatment information.
Control Group
n=5 Participants
Recipients of 1-haplotype human leukocyte antigen (HLA) matched living-donor related kidney transplantation were randomized to receive induction therapy with alemtuzumab and steroid-free dose maintenance immunosuppression consisting of mycophenolate mofetil, tacrolimus and sirolimus. Refer to section titled 'Detailed Description' for additional treatment information.
Total
n=9 Participants
Total of all reporting groups
Age, Categorical
<=18 years
0 Participants
n=5 Participants
0 Participants
n=7 Participants
0 Participants
n=5 Participants
Age, Categorical
Between 18 and 65 years
4 Participants
n=5 Participants
5 Participants
n=7 Participants
9 Participants
n=5 Participants
Age, Categorical
>=65 years
0 Participants
n=5 Participants
0 Participants
n=7 Participants
0 Participants
n=5 Participants
Age Continuous
41.0 years
STANDARD_DEVIATION 12.0 • n=5 Participants
41.8 years
STANDARD_DEVIATION 7.9 • n=7 Participants
41.4 years
STANDARD_DEVIATION 9.7 • n=5 Participants
Sex: Female, Male
Female
2 Participants
n=5 Participants
0 Participants
n=7 Participants
2 Participants
n=5 Participants
Sex: Female, Male
Male
2 Participants
n=5 Participants
5 Participants
n=7 Participants
7 Participants
n=5 Participants
Region of Enrollment
United States
4 participants
n=5 Participants
5 participants
n=7 Participants
9 participants
n=5 Participants

PRIMARY outcome

Timeframe: One year post kidney transplant

Population: Intent-to-Treat

Outcome measures

Outcome measures
Measure
DBMCs
n=4 Participants
Recipients of 1-haplotype human leukocyte antigen (HLA) matched living-donor related kidney transplantation were randomized to receive (CD34+ stem cell purified) Donor-specific Bone Marrow Cells (DBMCs). Induction therapy included Alemtuzumab and steroid-free dose maintenance immunosuppression consisting of mycophenolate mofetil, tacrolimus and sirolimus. Refer to section titled 'Detailed Description' for additional treatment information.
Control Group
n=5 Participants
Recipients of 1-haplotype human leukocyte antigen (HLA) matched living-donor related kidney transplantation were randomized to receive induction therapy with Alemtuzumab and steroid-free dose maintenance immunosuppression consisting of mycophenolate mofetil, tacrolimus and sirolimus. Refer to section titled 'Detailed Description' for additional treatment information.
Overall Participant Survival at One Year Post Kidney Transplant
4 participants
5 participants

PRIMARY outcome

Timeframe: One year post kidney transplant

Population: Intent-to-treat

Number of participants that did not experience kidney graft failure\[1\] at one year post-transplant \[1\]Graft failure is defined as the institution of chronic dialysis (at least 6 consecutive weeks, excluding participants with delayed graft function), transplant nephrectomy, or retransplantation.

Outcome measures

Outcome measures
Measure
DBMCs
n=4 Participants
Recipients of 1-haplotype human leukocyte antigen (HLA) matched living-donor related kidney transplantation were randomized to receive (CD34+ stem cell purified) Donor-specific Bone Marrow Cells (DBMCs). Induction therapy included Alemtuzumab and steroid-free dose maintenance immunosuppression consisting of mycophenolate mofetil, tacrolimus and sirolimus. Refer to section titled 'Detailed Description' for additional treatment information.
Control Group
n=5 Participants
Recipients of 1-haplotype human leukocyte antigen (HLA) matched living-donor related kidney transplantation were randomized to receive induction therapy with Alemtuzumab and steroid-free dose maintenance immunosuppression consisting of mycophenolate mofetil, tacrolimus and sirolimus. Refer to section titled 'Detailed Description' for additional treatment information.
Overall Kidney Graft Survival at One Year Post-Transplant
4 participants
5 participants

SECONDARY outcome

Timeframe: Three years post kidney transplant

Population: Intent-to-Treat

Outcome measures

Outcome measures
Measure
DBMCs
n=4 Participants
Recipients of 1-haplotype human leukocyte antigen (HLA) matched living-donor related kidney transplantation were randomized to receive (CD34+ stem cell purified) Donor-specific Bone Marrow Cells (DBMCs). Induction therapy included Alemtuzumab and steroid-free dose maintenance immunosuppression consisting of mycophenolate mofetil, tacrolimus and sirolimus. Refer to section titled 'Detailed Description' for additional treatment information.
Control Group
n=5 Participants
Recipients of 1-haplotype human leukocyte antigen (HLA) matched living-donor related kidney transplantation were randomized to receive induction therapy with Alemtuzumab and steroid-free dose maintenance immunosuppression consisting of mycophenolate mofetil, tacrolimus and sirolimus. Refer to section titled 'Detailed Description' for additional treatment information.
Participant Survival at Three Years Post Kidney Transplant
4 participants
5 participants

SECONDARY outcome

Timeframe: Three years post kidney transplant

Population: Intent-to-Treat

Number of participants that did not experience kidney graft failure\[1\] at three years post-transplant \[1\]Graft failure is defined as the institution of chronic dialysis (at least 6 consecutive weeks, excluding participants with delayed graft function), transplant nephrectomy, or retransplantation.

Outcome measures

Outcome measures
Measure
DBMCs
n=4 Participants
Recipients of 1-haplotype human leukocyte antigen (HLA) matched living-donor related kidney transplantation were randomized to receive (CD34+ stem cell purified) Donor-specific Bone Marrow Cells (DBMCs). Induction therapy included Alemtuzumab and steroid-free dose maintenance immunosuppression consisting of mycophenolate mofetil, tacrolimus and sirolimus. Refer to section titled 'Detailed Description' for additional treatment information.
Control Group
n=5 Participants
Recipients of 1-haplotype human leukocyte antigen (HLA) matched living-donor related kidney transplantation were randomized to receive induction therapy with Alemtuzumab and steroid-free dose maintenance immunosuppression consisting of mycophenolate mofetil, tacrolimus and sirolimus. Refer to section titled 'Detailed Description' for additional treatment information.
Graft Survival at Three Years Post-Transplant
4 participants
5 participants

SECONDARY outcome

Timeframe: Three years post kidney transplant

Population: Participants who experienced an acute rejection

Biopsy-proven acute renal (kidney) rejection\[1,2\]. 1. Diagnosis of acute rejection was made by renal biopsy using the Banff 97 criteria. The Banff 97 diagnostic category for renal allograft biopsies is an international standardized histopathological classification. Acute rejection is defined by a renal biopsy demonstrating a Banff 97 classification of Grade IA or greater, with higher scores indicating more severe rejection\[2\] 2. Ref: Racusen LC et al. The Banff 97 working classification of renal allograft pathology. Kidney Int, 55: 713-723, 1999

Outcome measures

Outcome measures
Measure
DBMCs
n=1 Participants
Recipients of 1-haplotype human leukocyte antigen (HLA) matched living-donor related kidney transplantation were randomized to receive (CD34+ stem cell purified) Donor-specific Bone Marrow Cells (DBMCs). Induction therapy included Alemtuzumab and steroid-free dose maintenance immunosuppression consisting of mycophenolate mofetil, tacrolimus and sirolimus. Refer to section titled 'Detailed Description' for additional treatment information.
Control Group
n=1 Participants
Recipients of 1-haplotype human leukocyte antigen (HLA) matched living-donor related kidney transplantation were randomized to receive induction therapy with Alemtuzumab and steroid-free dose maintenance immunosuppression consisting of mycophenolate mofetil, tacrolimus and sirolimus. Refer to section titled 'Detailed Description' for additional treatment information.
Number of Kidney Biopsy-proven Acute Rejection
1 Rejection Events
1 Rejection Events

SECONDARY outcome

Timeframe: Three years post kidney transplant

Population: Participants who experienced nephropathies

Number of chronic allograft nephropathies\[1,2,3\] at 3 years post kidney transplant. 1. Chronic allograft nephropathy is defined as renal biopsies with Banff 97 Grade I or greater\[2\] with higher numeric scores indicating more severe nephropathy 2. The Banff 97 diagnostic category for renal allograft biopsies is an international standardized histopathological classification\[3\] 3. Reference: Racusen LC, Solez K, Colvin RB et al. The Banff 97 working classification of renal allograft pathology. Kidney Int, 55: 713-723, 1999

Outcome measures

Outcome measures
Measure
DBMCs
n=4 Participants
Recipients of 1-haplotype human leukocyte antigen (HLA) matched living-donor related kidney transplantation were randomized to receive (CD34+ stem cell purified) Donor-specific Bone Marrow Cells (DBMCs). Induction therapy included Alemtuzumab and steroid-free dose maintenance immunosuppression consisting of mycophenolate mofetil, tacrolimus and sirolimus. Refer to section titled 'Detailed Description' for additional treatment information.
Control Group
n=1 Participants
Recipients of 1-haplotype human leukocyte antigen (HLA) matched living-donor related kidney transplantation were randomized to receive induction therapy with Alemtuzumab and steroid-free dose maintenance immunosuppression consisting of mycophenolate mofetil, tacrolimus and sirolimus. Refer to section titled 'Detailed Description' for additional treatment information.
Number of Chronic Allograft Nephropathies
6 Nephropathy Events
2 Nephropathy Events

SECONDARY outcome

Timeframe: Three years post kidney transplant

Population: Intent-to-Treat

A disease caused when cells from a donated stem cell graft attack the normal tissue of the transplant patient. Symptoms include jaundice, skin rash or blisters, a dry mouth, or dry eyes. Also called graft-versus-host disease.

Outcome measures

Outcome measures
Measure
DBMCs
n=4 Participants
Recipients of 1-haplotype human leukocyte antigen (HLA) matched living-donor related kidney transplantation were randomized to receive (CD34+ stem cell purified) Donor-specific Bone Marrow Cells (DBMCs). Induction therapy included Alemtuzumab and steroid-free dose maintenance immunosuppression consisting of mycophenolate mofetil, tacrolimus and sirolimus. Refer to section titled 'Detailed Description' for additional treatment information.
Control Group
n=5 Participants
Recipients of 1-haplotype human leukocyte antigen (HLA) matched living-donor related kidney transplantation were randomized to receive induction therapy with Alemtuzumab and steroid-free dose maintenance immunosuppression consisting of mycophenolate mofetil, tacrolimus and sirolimus. Refer to section titled 'Detailed Description' for additional treatment information.
Number of Graft-versus-host Disease (GVHD) Events
0 GVHD Events
0 GVHD Events

Adverse Events

DBMCs

Serious events: 4 serious events
Other events: 4 other events
Deaths: 0 deaths

Control Group

Serious events: 3 serious events
Other events: 5 other events
Deaths: 0 deaths

Serious adverse events

Serious adverse events
Measure
DBMCs
n=4 participants at risk
Recipients of 1-haplotype human leukocyte antigen (HLA) matched living-donor related kidney transplantation were randomized to receive (CD34+ stem cell purified) Donor-specific Bone Marrow Cells (DBMCs). Induction therapy included alemtuzumab and steroid-free dose maintenance immunosuppression consisting of mycophenolate mofetil, tacrolimus and sirolimus. Refer to section titled 'Detailed Description' for additional treatment information.
Control Group
n=5 participants at risk
Recipients of 1-haplotype human leukocyte antigen (HLA) matched living-donor related kidney transplantation were randomized to receive induction therapy with alemtuzumab and steroid-free dose maintenance immunosuppression consisting of mycophenolate mofetil, tacrolimus and sirolimus. Refer to section titled 'Detailed Description' for additional treatment information.
Renal and urinary disorders
Mesangioproliferative glomerulonephritis
25.0%
1/4 • Number of events 1
0.00%
0/5
Renal and urinary disorders
Nephrotic syndrome
25.0%
1/4 • Number of events 1
0.00%
0/5
Vascular disorders
Hypertension
25.0%
1/4 • Number of events 1
0.00%
0/5
General disorders
Chest pain
0.00%
0/4
20.0%
1/5 • Number of events 1
General disorders
Pyrexia
0.00%
0/4
20.0%
1/5 • Number of events 1
Immune system disorders
Kidney transplant rejection
25.0%
1/4 • Number of events 1
0.00%
0/5
Infections and infestations
Tonsillitis
25.0%
1/4 • Number of events 1
0.00%
0/5
Infections and infestations
Urinary tract infection
50.0%
2/4 • Number of events 2
0.00%
0/5
Injury, poisoning and procedural complications
Drug toxicity
25.0%
1/4 • Number of events 1
0.00%
0/5
Injury, poisoning and procedural complications
Post procedural haematoma
25.0%
1/4 • Number of events 1
0.00%
0/5
Investigations
Blood creatinine increased
75.0%
3/4 • Number of events 12
40.0%
2/5 • Number of events 2
Renal and urinary disorders
Glomerulonephritis membranoproliferative
25.0%
1/4 • Number of events 1
0.00%
0/5

Other adverse events

Other adverse events
Measure
DBMCs
n=4 participants at risk
Recipients of 1-haplotype human leukocyte antigen (HLA) matched living-donor related kidney transplantation were randomized to receive (CD34+ stem cell purified) Donor-specific Bone Marrow Cells (DBMCs). Induction therapy included alemtuzumab and steroid-free dose maintenance immunosuppression consisting of mycophenolate mofetil, tacrolimus and sirolimus. Refer to section titled 'Detailed Description' for additional treatment information.
Control Group
n=5 participants at risk
Recipients of 1-haplotype human leukocyte antigen (HLA) matched living-donor related kidney transplantation were randomized to receive induction therapy with alemtuzumab and steroid-free dose maintenance immunosuppression consisting of mycophenolate mofetil, tacrolimus and sirolimus. Refer to section titled 'Detailed Description' for additional treatment information.
Blood and lymphatic system disorders
Anaemia
75.0%
3/4 • Number of events 4
40.0%
2/5 • Number of events 2
Blood and lymphatic system disorders
Leukopenia
25.0%
1/4 • Number of events 1
20.0%
1/5 • Number of events 1
Blood and lymphatic system disorders
Neutropenia
25.0%
1/4 • Number of events 1
0.00%
0/5
Cardiac disorders
Palpitations
50.0%
2/4 • Number of events 2
0.00%
0/5
Cardiac disorders
Tachycardia
25.0%
1/4 • Number of events 1
0.00%
0/5
Congenital, familial and genetic disorders
Hydrocele
0.00%
0/4
20.0%
1/5 • Number of events 1
Ear and labyrinth disorders
Ear pain
25.0%
1/4 • Number of events 1
0.00%
0/5
Eye disorders
Vision blurred
25.0%
1/4 • Number of events 1
0.00%
0/5
Eye disorders
Visual acuity reduced
25.0%
1/4 • Number of events 1
0.00%
0/5
Gastrointestinal disorders
Constipation
0.00%
0/4
40.0%
2/5 • Number of events 2
Gastrointestinal disorders
Diarrhoea
0.00%
0/4
40.0%
2/5 • Number of events 2
Gastrointestinal disorders
Palatal oedema
25.0%
1/4 • Number of events 1
0.00%
0/5
Gastrointestinal disorders
Stomatitis
25.0%
1/4 • Number of events 1
0.00%
0/5
Gastrointestinal disorders
Swollen tongue
25.0%
1/4 • Number of events 1
0.00%
0/5
Gastrointestinal disorders
Vomiting
0.00%
0/4
20.0%
1/5 • Number of events 1
General disorders
Face oedema
25.0%
1/4 • Number of events 1
0.00%
0/5
General disorders
Oedema peripheral
75.0%
3/4 • Number of events 4
0.00%
0/5
General disorders
Pain
0.00%
0/4
20.0%
1/5 • Number of events 1
General disorders
Pyrexia
25.0%
1/4 • Number of events 1
0.00%
0/5
Infections and infestations
Body tinea
25.0%
1/4 • Number of events 1
0.00%
0/5
Infections and infestations
Fungal infection
25.0%
1/4 • Number of events 1
0.00%
0/5
Infections and infestations
Gastroenteritis viral
25.0%
1/4 • Number of events 1
0.00%
0/5
Infections and infestations
Herpes zoster
25.0%
1/4 • Number of events 1
0.00%
0/5
Infections and infestations
Oral candidiasis
25.0%
1/4 • Number of events 1
0.00%
0/5
Infections and infestations
Oral herpes
50.0%
2/4 • Number of events 2
0.00%
0/5
Infections and infestations
Upper respiratory tract infection
50.0%
2/4 • Number of events 2
40.0%
2/5 • Number of events 2
Infections and infestations
Urinary tract infection
75.0%
3/4 • Number of events 5
0.00%
0/5
Infections and infestations
Viral infection
0.00%
0/4
20.0%
1/5 • Number of events 1
Investigations
Blood alkaline phosphatase increased
25.0%
1/4 • Number of events 1
0.00%
0/5
Investigations
Blood triglycerides increased
0.00%
0/4
20.0%
1/5 • Number of events 3
Investigations
Gamma-glutamyltransferase increased
0.00%
0/4
20.0%
1/5 • Number of events 1
Investigations
Hepatic enzyme increased
25.0%
1/4 • Number of events 1
60.0%
3/5 • Number of events 3
Investigations
Platelet count decreased
25.0%
1/4 • Number of events 1
0.00%
0/5
Investigations
Platelet count increased
25.0%
1/4 • Number of events 1
0.00%
0/5
Investigations
Red blood cell count decreased
25.0%
1/4 • Number of events 1
0.00%
0/5
Investigations
White blood cell count decreased
25.0%
1/4 • Number of events 1
0.00%
0/5
Metabolism and nutrition disorders
Fluid overload
0.00%
0/4
20.0%
1/5 • Number of events 1
Metabolism and nutrition disorders
Hypercholesterolaemia
0.00%
0/4
20.0%
1/5 • Number of events 1
Metabolism and nutrition disorders
Hyperglycaemia
25.0%
1/4 • Number of events 1
40.0%
2/5 • Number of events 3
Metabolism and nutrition disorders
Hyperlipidaemia
25.0%
1/4 • Number of events 1
20.0%
1/5 • Number of events 1
Metabolism and nutrition disorders
Hypertriglyceridaemia
0.00%
0/4
60.0%
3/5 • Number of events 4
Metabolism and nutrition disorders
Hyperuricaemia
0.00%
0/4
20.0%
1/5 • Number of events 2
Metabolism and nutrition disorders
Hypocalcaemia
25.0%
1/4 • Number of events 1
0.00%
0/5
Metabolism and nutrition disorders
Hypokalaemia
50.0%
2/4 • Number of events 3
0.00%
0/5
Metabolism and nutrition disorders
Hypomagnesaemia
50.0%
2/4 • Number of events 2
0.00%
0/5
Metabolism and nutrition disorders
Hypophosphataemia
25.0%
1/4 • Number of events 1
20.0%
1/5 • Number of events 1
Nervous system disorders
Burning sensation
25.0%
1/4 • Number of events 1
0.00%
0/5
Nervous system disorders
Headache
50.0%
2/4 • Number of events 2
0.00%
0/5
Psychiatric disorders
Insomnia
0.00%
0/4
40.0%
2/5 • Number of events 2
Renal and urinary disorders
Bladder spasm
25.0%
1/4 • Number of events 1
20.0%
1/5 • Number of events 1
Renal and urinary disorders
Dysuria
25.0%
1/4 • Number of events 1
20.0%
1/5 • Number of events 1
Renal and urinary disorders
Glycosuria
0.00%
0/4
20.0%
1/5 • Number of events 1
Renal and urinary disorders
Haematuria
25.0%
1/4 • Number of events 1
20.0%
1/5 • Number of events 1
Renal and urinary disorders
Pollakiuria
25.0%
1/4 • Number of events 1
0.00%
0/5
Renal and urinary disorders
Proteinuria
75.0%
3/4 • Number of events 4
40.0%
2/5 • Number of events 3
Reproductive system and breast disorders
Menorrhagia
25.0%
1/4 • Number of events 3
0.00%
0/5
Reproductive system and breast disorders
Ovarian cyst
50.0%
2/4 • Number of events 2
0.00%
0/5
Reproductive system and breast disorders
Testicular pain
25.0%
1/4 • Number of events 1
0.00%
0/5
Respiratory, thoracic and mediastinal disorders
Bronchospasm
0.00%
0/4
20.0%
1/5 • Number of events 1
Respiratory, thoracic and mediastinal disorders
Cough
25.0%
1/4 • Number of events 1
0.00%
0/5
Respiratory, thoracic and mediastinal disorders
Dyspnoea
50.0%
2/4 • Number of events 2
20.0%
1/5 • Number of events 1
Respiratory, thoracic and mediastinal disorders
Oropharyngeal discomfort
25.0%
1/4 • Number of events 1
0.00%
0/5
Respiratory, thoracic and mediastinal disorders
Oropharyngeal pain
0.00%
0/4
20.0%
1/5 • Number of events 1
Respiratory, thoracic and mediastinal disorders
Pulmonary oedema
0.00%
0/4
20.0%
1/5 • Number of events 1
Respiratory, thoracic and mediastinal disorders
Tonsillar ulcer
25.0%
1/4 • Number of events 1
0.00%
0/5
Skin and subcutaneous tissue disorders
Acne
75.0%
3/4 • Number of events 3
60.0%
3/5 • Number of events 4
Skin and subcutaneous tissue disorders
Rash
0.00%
0/4
60.0%
3/5 • Number of events 3
Skin and subcutaneous tissue disorders
Urticaria
50.0%
2/4 • Number of events 2
20.0%
1/5 • Number of events 2
Vascular disorders
Hypertension
50.0%
2/4 • Number of events 3
80.0%
4/5 • Number of events 6

Additional Information

George W. Burke III, M.D.

University of Miami

Phone: (305) 355-5060

Results disclosure agreements

  • Principal investigator is a sponsor employee
  • Publication restrictions are in place