Screening for basiliximab exposure–response relationships in renal allotransplantation

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Abstract
The immunosuppressant basiliximab – a chimeric monoclonal antibody specific to the interleukin‐2 receptor on activated T‐lymphocytes – significantly reduces the incidence of acute cellular rejection following renal transplantation. Screening for exposure–response relationships was performed within a randomized, blinded, placebo‐controlled efficacy trial in which patients received 40 mg basiliximab (20 mg on days 0 and 4) by intravenous infusion in addition to cyclosporine and corticosteroids. In a subset of patients, serum samples were collected pre‐transplant and once in weeks 2, 3 and 4 for determination of basiliximab concentrations. A population pharmacostatistical model was used to derive individual empirical Bayes estimates of each patient’s pharmacokinetic parameters. Biopsy‐confirmed acute rejection episodes were recorded to month 6 post‐transplant. Forty basiliximab‐treated patients were evaluated, 30 men and 10 women, aged 48±12 yr (range, 24–73) and weighing 72.4±12.9 kg (range, 52.5–107.5). The basiliximab distribution volume was 7.5±1.7 L, the half‐life 7.5±2.5 d and the clearance 33±12 mL/h. There was no clinically relevant influence of weight, age, or gender on basiliximab disposition. Receptor‐saturating serum basiliximab concentrations (>0.2 μg/mL) were maintained for 41±23 d. Twenty‐five patients remained rejection‐free over the 6‐month observation period, while a total of 26 biopsy‐confirmed acute rejection episodes occurred in the remaining 14 patients. Of these episodes, 12 occurred during receptor blockade. No apparent relationship to basiliximab concentration on the day of onset was observed (range, 0.1–9.0 μg/mL) nor did the time of suppression offset represent a period of increased risk for rejection episodes. Fourteen rejection episodes occurred after basiliximab had cleared from the serum. The durations of receptor suppression preceding these events did not differ compared with those in patients who remained rejection‐free: 32±11 versus 45±26 d, respectively (p=0.1269). Given the durations of receptor saturation achieved with the chosen basiliximab regimen, this screen for exposure–response relationships did not identify the duration of receptor saturation in peripheral blood as a predictive factor for acute rejection episodes. Further exploration for exposure–effect relationships in a larger population is warranted.