C1INH Inhibitor Preoperative and Post Kidney Transplant to Prevent DGF & IRI

Early graft function has a long-term effect on graft survival. Poor early graft function and
delayed graft function (DGF) contributes to decreased short- and long-term patient and graft
survival, increased incidence of acute rejection, prolonged hospitalization, and higher costs
of transplantation. Although multiple factors contribute to the impaired graft function,
ischemia-reperfusion injury (IRI) is the underlying pathophysiology leading to poor early
graft function and DGF. A >35% incidence of DGF has remained constant over time despite
significant improvements in immunosuppressive strategies and patient management. This may be
due to increased use of kidneys from "extended-criteria" and/or non-heart-beating donors,
where even greater rates (>60%) of DGF have been reported.

More than 96,680 people are currently waiting for a kidney transplant in the United States
(United Network for Organ Sharing (UNOS); UNOS.org 3/22/13). Of the 15,092 kidney transplants
performed in the US in 2011, ~11,000 (62%) were from deceased donors. Of these, approximately
17% were from expanded-criteria donors. The USRDS reports that more than 50% of patients on
the waiting list are willing to accept a kidney from an expanded-criteria donor (ECD) or
donors after cardiac death (DCD).

From the investigators previous studies with C1INH (Berinert®) for prevention of antibody
mediated rejection (ABMR), the investigators noted that no patients developed ABMR during
treatment with C1INH, the investigators also noted a near significant reduction in DGF due to
IRI (ClinicalTrials.gov(NCT01134510), FDA Investigational New Drug (IND#): 14363). These
findings suggest an important role for complement in the mediation of IRI and that inhibition
of early complement activation using C1INH in patients receiving at risk kidneys for IRI
should reduce this costly and often devastating complication of kidney transplantation. In
addition, numerous other studies in animal models have shown dramatic improvements in IRI
models with the use of C1INH. Complement activation is detectable in animal and in human
kidneys models after IRI and experimental data suggests that use of C1INH prior to induction
of IRI significantly reduces IRI as well as inflammatory cell infiltrates. Based on this, the
investigators hypothesize that the use of C1INH in patients receiving deceased donor (DD)
kidney transplants with high risk for DGF will show significant reductions in DGF and
improved outcomes post-transplant compared with patients receiving DD transplants who do not
receive C1INH treatment. Here, the investigators propose to investigate the application of
pre-operative and post-transplant doses of C1INH (Berinert®) vs. placebo in adult subjects
receiving a DD renal allograft considered at high-risk for IRI and DGF. The investigators
hypothesize that C1INH treated patients will demonstrate improved function of the kidney
allograft compared to placebo, with equivalence in safety. The primary objectives of this
study are: Using a double blinded, placebo controlled format, the investigators will:

1. Evaluate and compare the safety of C1INH (50 units/kilogram, round to the nearest 500
unit) administered pre-transplant and 24 hrs post-transplant in recipients of kidney
allografts from high risk for IRI deceased donors.

The secondary objectives are to:

1. On the basis of safety and efficacy, determine appropriate Berinert® study dose for
Phase III investigation, and

2. Determine appropriate endpoint choice for Phase III investigation.

Inclusion Criteria:

- 18-70 yrs of age; recipient of ECD/DCD/ECD&DCD with risk index 3-8 for DGF based on
specific criteria

- recipient who are ABO compatible with donor allograft

- pretransplant with meningococcal vaccination

- understand and sign a written consent prior to any study specific procedure.

Risk index (minimum 3- maximum 8):

DGF scale: Donor Age (<40yr = 0, 41-49yr = 1, 50-54yr = 2, 55-59yr = 3, >60yr=6), Cold
Ischemia Time (0-12= 0, 13-18=1, 19-24=2, 24-30=3, 31-36=4, >37=6; Recipient Race (nonblack
= 0, black =1); Donor death due to Cerebrovascular Accident (CVA) (donor age <50yrs = 0,
donor age >50yrs = 3).

Exclusion Criteria:

- patients with known prothrombotic disorder (e.g. factor V leiden)

- history of thrombosis or hypercoagulable state excluding access clotting

- history of administration of C1INH containing products or recombinant C1INH within 15
days prior to study entry

- patients with known contraindication to treatment with C1INH

- patients with abnormal coagulation function (INR >2, partial thromboplastin time (PTT)
> 50, platelets <80,000)

- who are not on anti-coagulation

- patients with known active presence of malignancies

- Polymerase chain reaction (PCR) positive for hep B/hep C/or HIV

- preemptive kidney transplantation recipient

- recipients of multi-organ transplants (kidney and any other organ)

- recipients of kidney allograft from DD who: cold ischemia time (CIT) <18h, terminal
serum creatinine preservation for any period prior to transplantation, recipient of kidney allograft
from a living donor, female subject who are pregnant or lactating.