Insulin Therapy for the Prevention of New Onset Diabetes After Transplantation Prospective Study in Non-Diabetic De Novo Kidney Transplant Recipients

NCT ID: NCT03507829

Last Updated: 2019-02-19

Basic Information

• Recruitment Status: COMPLETED
• Clinical Phase: PHASE3
• Total Enrollment: 263 participants
• Study Classification: INTERVENTIONAL
• Study Start Date: 2012-11-21
• Study Completion Date: 2018-05-22

Brief Summary

This study aims to assess the effects of early basal insulin therapy in previously non-diabetic de novo kidney transplant patients in reducing the incidence of new onset diabetes in particular and abnormal glucose metabolism in general during subsequent follow-up.The ITP NODAT study should be seen in connection with the Vienna SAPT-NODAT study (clinicaltrials.gov record number: NCT01680185), as for the final analysis, the data yielded from the three arms in those two studies will be used for an pooled analysis.

Detailed Description

New-onset diabetes after transplantation (NODAT) is strongly associated with postoperative hyperglycemia, and reduced patient as well as graft survival. In our recent proof-of-concept clinical trial (TIP), we have shown that immediate post-transplant basal insulin therapy decreases hyperglycemia and reduces the prevalence of NODAT by improving pancreatic β-cell function.

In consequence, this study as an interventional trial comparing aggressive glycemic control with early institution of insulin therapy to standard of care (dietary precaution, life-style modification, oral hypoglycemic agents and/or insulin as needed) aims to assess the effects of early basal insulin therapy in previously non-diabetic de novo kidney transplant patients in reducing the incidence of new onset diabetes in particular and abnormal glucose metabolism in general during subsequent follow-up.

Patients will be enrolled through the University of Michigan and the Medical University of Vienna, Austria (MUV), who is the official sponsor of the European part of the ITP-NODAT study. This record only refers to the European part of the ITP-NODAT study, specifically to all study patients from the following study Centers: MUV; Medical University of Graz, Austria; Charité Berlin, Germany; Hospital Del Mar, Barcelona, Spain. For the patients enrolled through the University of Michigan (i.e., the US-part of the ITP-NODAT study), a separate records exists (responsible PI: Dr. Akinlolu Ojo).

This study will involve previously non-diabetic ESRD patients undergoing kidney transplantation with either a deceased or living donor kidney who will receive standard triple immunosuppression regimen including a calcineurin inhibitor (once-daily tacrolimus in Europe, twice-daily tacrolimus in the U.S.), an anti-metabolite (mycophenolate mofetil) and corticosteroids (prednisone) and be followed at each transplant center's outpatient clinic for at least 2 years following transplantation according to the established standard center protocol.

Methods: Combining the study presented here (ITP-NODAT) and the SAPT-NODAT study mentioned above will yield three study arms, with 28 patients in each arm, namely: [1] the control arm, treated by standard-of-care; [2] the basal insulin arm, treated predominantly with intermediate acting NPH insulin (human insulin isophane, Humulin N, Eli Lilly); [3] the SAPT arm, treated with short acting insulin (Insulin lispro, Humalog, Eli Lilly), applied continuously by SAPT technology. Adult patients with absence of diabetes will be randomized prior to renal transplantation and stratified by deceased donor or living donor, if they are capable of understanding the study and are willing to give informed written consent for all three study arms. Patients will receive standard triple immunosuppressive medications (twice-daily tacrolimus, mycophenolate mofetil or mycophenolic sodium and steroids) with predefined tacrolimus targets and steroid doses. The algorithm for insulin administration is designed to account for the prominent evening peak of hyperglycemia observed in our previous TIP-study. The primary endpoint is HbA1c (in rel.%), at 3 months, and superiority will be assumed if a statistically significant difference between the SAPT-treatment group versus the standard-of-care control group can be determined, by two-sided Student's t-test. Secondary endpoints will be compared between all three groups and will include hypoglycemic events, glycemic variability, 2h glucose ≥200 mg/dL (by oral glucose tolerance test [OGTT] to determine prevalence of diabetes, prediabetes and normal glucose tolerance), beta cell function and insulin sensitivity derived from OGTT, serum creatinine, quality of life measures, patient and graft survival. All secondary endpoint comparisons relying on OGTTs will be made at 6, 12 and 24 months after kidney transplantation, respectively. The result of the 6-months OGTT will be blinded to patients and investigators to prevent subsequent treatment bias.

Conditions

Hyperglycemia

Study Design

• Allocation Method: RANDOMIZED
• Intervention Model: PARALLEL
• Primary Study Purpose: TREATMENT
• Blinding Strategy: NONE

Study Groups

Basal insulin

NPH Insulin Titration Regimen : Pre-dinner Capillary blood glucose NPH dose initiation (IU/day) NPH dose adjustment(IU/day) \> 240 mg/dl 14 Increase by 4 \> 180 mg/dl 12 Increase by 4 \> 140 mg/dl 10 Increase by 4 \> 120 mg/dl 0 Increase by 2 100 to 119 mg/dl 0 Maintain the dose 80 - \<100 mg/dl 0 Decrease by 4 60 - \<80 mg/dl 0 Decrease by 8 \< 60 mg/dl 0 Give ½ of previous dose

Group Type: ACTIVE_COMPARATOR

Human insulin isophane, Humulin N (Eli Lilly)

Intervention Type: DRUG

Human insulin isophane, Humulin N (Eli Lilly)

Standard of care

Patients assigned in this arm will receive standard of care following their kidney transplantation

Group Type: ACTIVE_COMPARATOR

Standard of care

Intervention Type: DRUG

Sliding scale short acting insulin for hyperglycemia; Sulphonylurea for NODAT

Sensor-augmented Insulin Pump

Continuous subcutaneous sensor-augmented insulin-pump therapy (SAPT) with an insulin pump from Medtronic (Paradigm® Velo) for a period of approximately 3 months post-transplantation.

Group Type: ACTIVE_COMPARATOR

Insulin lispro, Humalog (Eli Lilly) in insulin pump

Intervention Type: DRUG

Insulin lispro, Humalog (Eli Lilly) in insulin pump

Interventions

Human insulin isophane, Humulin N (Eli Lilly)

Human insulin isophane, Humulin N (Eli Lilly)

Intervention Type: DRUG

Standard of care

Sliding scale short acting insulin for hyperglycemia; Sulphonylurea for NODAT

Intervention Type: DRUG

Insulin lispro, Humalog (Eli Lilly) in insulin pump

Insulin lispro, Humalog (Eli Lilly) in insulin pump

Intervention Type: DRUG

Eligibility Criteria

Inclusion Criteria

1. Adult patients with end stage renal disease undergoing kidney transplantation with a deceased or living donor kidney.

2. Absence of diabetes prior to kidney transplantation, defined according to American Diabetes Association guideline (not on oral hypoglycemic agents or insulin with fasting glucose < 126 mg/dl).

3. Receiving standard triple immunosuppressive medications that include tacrolimus (once-daily in Europe, twice-daily in the U.S.), mycophenolate mofetil or mycophenolic sodium and steroids.

4. Capable of understanding the study and willing to give informed written consent for study participation.

Exclusion Criteria

1. Patients with a diagnosis of diabetes mellitus prior to kidney transplantation, or receiving anti-diabetic medications, or having pre-transplant fasting glucose level equal or greater than 126 mg/dl on two occasions at least three days apart.

2. Patients receiving an organ transplant other than kidney.

3. Patients receiving an unlicensed drug or therapy within one month prior to study entry.

4. Patients with history of hypersensitivity to injectable insulin.

5. Patients with documented HIV infection.

• Minimum Eligible Age: 18 Years
• Eligible Sex: ALL
• Accepts Healthy Volunteers: No

Sponsors

Charite University, Berlin, Germany

OTHER

Sponsor Role: collaborator

Medical University of Graz

OTHER

Sponsor Role: collaborator

Hospital del Mar

OTHER

Sponsor Role: collaborator

Medical University of Vienna

OTHER

Sponsor Role: lead

Responsible Party

Assoc. Prof. Dr. Manfred Hecking, MD PhD

Ass.Professor Dr.

Responsibility Role: PRINCIPAL_INVESTIGATOR

Principal Investigators

Manfred Hecking, MD

Role: PRINCIPAL_INVESTIGATOR

Medical University of Vienna

References

Schwaiger E, Krenn S, Kurnikowski A, Bergfeld L, Perez-Saez MJ, Frey A, Topitz D, Bergmann M, Hodlmoser S, Bachmann F, Halleck F, Kron S, Hafner-Giessauf H, Eller K, Rosenkranz AR, Crespo M, Faura A, Tura A, Song PXK, Port FK, Pascual J, Budde K, Ristl R, Werzowa J, Hecking M. Early Postoperative Basal Insulin Therapy versus Standard of Care for the Prevention of Diabetes Mellitus after Kidney Transplantation: A Multicenter Randomized Trial. J Am Soc Nephrol. 2021 Aug;32(8):2083-2098. doi: 10.1681/ASN.2021010127.

Reference Type: DERIVED

PMID: 34330770 (View on PubMed)

Other Identifiers

EUDRACT-Nr. 2012-000225-51

Identifier Type: -

Identifier Source: org_study_id