Semaglutide Treatment for Hyperglycaemia After Renal Transplantation

Summary

Background: Post-transplant hyperglycaemia occurs frequently in renal transplant recipients within the first two weeks after transplantation. Standard-of-care is primarily based on insulin treatment with the adherent risk of hypoglycaemia and weight gain. Semaglutide produces an effective lowering of plasma glucose in diabetes patients with chronic kidney disease (CKD) and leads to a reduction in weight and the incidence of hypoglycaemia. The efficacy of semaglutide is untested in renal transplant recipients, and safety concerns remain, primarily on renal graft function. Objectives: The primary objective is to establish whether tablet semaglutide (Rybelsus) compared with placebo, both as add-on to standard-of-care, is non-inferior in regulating plasma glucose in patients with hyperglycaemia after renal transplantation. Secondary objectives aim to evaluate the effect of tablet semaglutide on renal graft function, weight, use of insulin, cardiovascular parameters and safety parameters (plasma semaglutide concentration, gastrointestinal side effects, dose of immunosuppressants). Design: An investigator-initiated, placebo-controlled, double-blinded, parallel-group, randomised trial. Population: Patients (n = 104) with post-transplant hyperglycaemia or type 2 diabetes and an estimated glomerular filtration rate (eGFR) \> 15 ml/min/1.73 m2. Methods: Participants diagnosed with post-transplant hyperglycaemia or type 2 diabetes, 10 to 40 days post-transplant, will be randomised 1:1 to either 14 weeks of tablet semaglutide once daily or placebo both as add-on to standard glucose-lowering therapy. Participants will maintain weekly contact with the clinic during the first five weeks and at two to four weeks intervals during the remaining study period. During the trial, each patient will be monitored according to blood laboratory values with safety assessed at every visit by a nephrologist. Pre-prandial plasma glucose will be measured in the morning and evening to adjust glucose-lowering therapy after consultation with an endocrinologist. Double blinded continuous glucose monitoring (CGM) will be performed for 10-14 days from baseline and at weeks 5, 9, and 13. Primary endpoint: \- Mean sensor glucose (mmol/L) evaluated by CGM Key secondary endpoints: * Incidence of hypoglycaemia * Body weight (kg) * Creatinine (μmol/L) * Daily insulin dose (IE per day) * Plasma concentration of semaglutide (nmol/L) * Blood concentrations of cyclosporine and tacrolimus (μg/L)

Eligibility

Inclusion Criteria:

1. Written informed consent obtained before any trial-related procedures are performed
2. Male or female; age: 18-80 years
3. Diagnosis of post-transplant hyperglycaemia 10 to 40 days after transplantation: Fasting plasma glucose ≥ 7.0 mmol/L or an oral glucose tolerance test with at plasma glucose ≥ 11.1 mmol/L or Pre-transplant type 2 diabetes: Receiving glucose-lowring treatment prior to kidney transplantation
4. An eGFR \> 15 ml/min/1.73 m2 10 to 40 days after renal transplantation
5. Subject must be willing and able to comply with trial protocol

Exclusion Criteria:

1. Type 1 diabetes
2. Dialysis
3. High risk immunological transplantation (not including ABO-incompatible or re-transplantation)
4. Early graft rejection (all rejections verified by biopsy, except borderline rejections. Study initiations can begin 5 days after last dose of rejection treatment with methylprednisolone)
5. Chronic pancreatitis/previous acute pancreatitis
6. Known or suspected hypersensitivity to trial or related products
7. Use of DPP-4 inhibitors within five days prior to screening
8. Use of GLP-1RA within 10 days prior to screening
9. Malignancy (except basal cell carcinoma)
10. Inflammatory bowel disease
11. Previous bowel resection
12. Cardiac disease defined as decompensated heart failure (New York Heart Association class III-IV) and/or diagnosis of unstable angina pectoris and/or myocardial infarction within the last six months
13. Any acute condition or exacerbation of chronic condition that would in the investigator's opinion interfere with the initial trial visit schedule and procedures.
14. Females of childbearing potential who are pregnant, breast-feeding, intend to become pregnant, or are not using adequate contraceptive methods
15. Impaired liver function (plasma ALAT \> two times upper reference levels)
16. Elevated amylase (plasma amylase \> two times upper reference levels)
17. Untreated proliferative diabetic retinopathy, untreated diabetic macular edema or active conditions of this type that are not under therapeutic control according
18. Any condition that clinically significantly impairs the observation of the fundus or anterior chamber

Conditions3

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