Use of anti-IL-6 antibodies, such as crazakizumab, for desensitization of solid organ transplant recipients and / or prevention, stabilization, or mitigation of antibody-mediated rejection (ABMR).

Abstract

This invention provides a pharmaceutical composition for use in a method of preventing antibody-mediated rejection (ABMR) in subjects who have undergone solid organ transplantation by preventing complement activity. [Solution] A pharmaceutical composition comprising an anti-human interleukin-6 (IL-6) antibody or an anti-human IL-6 antibody fragment for use in a method of preventing, stabilizing, or reducing complement activity in a subject who is scheduled to receive, has received, or has received a solid organ transplant, wherein the method comprises administering to a subject a prophylactic or therapeutically effective amount of the antibody or antibody fragment, the pharmaceutical composition comprising a variable light chain polypeptide containing a CDR of a specific sequence, and a variable heavy chain polypeptide containing a CDR of a specific sequence.

Description

[Technical Field]

[0001] Claim of priority This invention claims priority to U.S. Provisional Application No. 62 / 613,447, filed 4 January 2018; U.S. Provisional Application No. 62 / 684,870, filed 14 June 2018; U.S. Provisional Application No. 62 / 736,205, filed 25 September 2018; and U.S. Provisional Application No. 62 / 773,630, filed 30 November 2018. The contents of each of these provisional applications are incorporated herein by reference in their entirety.

[0002] Sequence List The present invention includes a sequence list comprising exemplary anti-IL-6 antibody sequences suitable for use in the claimed treatment. field

[0003] The present invention relates to the use of an anti-IL-6 antibody, such as crazakizumab, to prevent, stabilize, or mitigate antibody-mediated rejection in patients undergoing solid organ transplantation, such as those receiving transplants of a kidney, heart, liver, lung, pancreas, intestine, skin, or any combination thereof.

[0004] The present invention further relates to the use of an anti-IL-6 antibody or anti-IL-6 antibody fragment, e.g., crazakizumab, as part of a desensitization protocol for treating patients who are awaiting or have become highly sensitized after allogeneic transplantation, e.g., patients who are to receive solid organ transplants, e.g., kidney, heart, liver, lung, pancreas, intestine, skin, stomach, gallbladder, or any combination thereof. The aforementioned treatment can be carried out in combination with one or more other immunosuppressive regimens or other desensitization procedures. [Background technology]

[0005] Despite significant improvements in pre- and post-transplant care, current graft survival rates, both short-term and long-term, remain suboptimal. Many patients awaiting transplantation may remain on the waiting list for extended periods due to sensitization to antigens present in the donor organ (e.g., human leukocyte antigen (HLA) and non-HLA antigens). These patients typically develop donor-specific antibodies (DSAs) pre-formed against the donor organ, often due to transfusions, pregnancy, or a history of previous transplantation. Such patients are at risk of acute and chronic rejection, allogeneic transplant failure, and post-transplant death. For a successful transplant, these patients need to undergo pre-transplant desensitization procedures to eliminate or reduce these DSAs. However, these treatments are not always successful, and many patients remain sensitized or require prolonged desensitization before transplantation.

[0006] Furthermore, many patients develop antibody-mediated rejection (ABMR) after transplantation, regardless of whether they were sensitized before transplantation. ABMR is now recognized as a leading cause of allogeneic transplant failure after transplantation. While mild ABMR can begin immediately after transplantation, it often leads to clinical signs of allogeneic graft dysfunction and ultimately to transplant failure months or even years after the transplant procedure. Moreover, ABMR is not well-suited to treatment with immunosuppressants, which are the current standard of care, despite the availability of clinical tests to predict patients at risk and diagnose ABMR.

[0007] The underlying pathophysiology of ABMR involves the primary role of B cells and plasma cells in producing DSAs against HLA and non-HLA antigens present in the donor organ. These antibodies damage the organ via complement and non-complement pathways. Recently developed diagnostic tests enable the prediction and early diagnosis of ABMR, and these tests include assays for detecting pre-formed novel HLA DSAs (particularly those detecting complement-binding DSAs such as C1q) and assays for non-HLA antibodies associated with ABMR. Histological features of antibody damage include allogeneic renal transplant biopsies, evidence of microangiogenic inflammation, complement deposition in peritubular capillaries (C4d), peritubular capillary inflammation, glomerulitis, and transplant glomerulopathy (double glomerular basement membrane contour). Similar histological features caused by ABMR are observed in other transplanted organs. Active antibody-mediated rejection (ABMR), particularly chronic active antibody-mediated rejection (CABMR), is currently recognized as the most common cause of allogeneic transplant failure after successful kidney transplantation. Current standard anti-rejection therapies target cell-mediated (i.e., T-cell-mediated rejection (TCMR)) processes and do not affect the antibody-mediated processes. Currently, there are no approved treatments for active ABMR, including CABMR. [Overview of the Initiative]

[0008] The present invention relates to the use of an anti-IL-6 monoclonal antibody (mAb), such as crazakizumab, for the treatment of AMBR or CABMR in transplant recipients, such as kidney transplant recipients, by inhibiting the production of DSA alloimmune responses. Clazakizumab comprises the heavy chain sequence and light chain sequence described below. (Heavy Chain) Sequence ID No. 745 EVQLVESGGGLVQPGGSLRLSCAASGFSLSNYYVTWVRQAPGKGLEWVGI IYGSDETAYATSAIGRFTISRDNSKNTLYLQMNSLRAEDTAVYYCARDDS SDWDAKFNLWGQGTLVTVSSASTKGPSVFPLAPSSKSTSGGTAALGCLVK DYFPEPVTVSWNSGALTSGVHTFPAVLQSSGLYSLSSVVTVPSSSLGTQT YICNVNHKPSNTKVDKRVEPKSCDKTHTCPPCPAPELLGGPSVFLFPPKP KDTLMISRTPEVTCVVVDVSHEDPEVKFNW YVDGVEVHNAKTKPREEQYA STYRVVSVLTVLHQDWLNGKEYKCKVSNKALAPIEKTIS KAKGQPREPQ VYTLPSREEMTKNQVSLTCLVKGFYPSDIAVEWESNGQPENNYKTTPPV LDSDGSFFLYSKLTVDKSRWQQGNVFSCSVMHEALHNHYTQKSLSLSPGK (Light chain) Sequence ID 746 AIQMTQSPSSLSASVGDRVTITCQASQSINNELSWYQQKPGKAPKLLIYR ASTLASGVPSRFSGSGSGTDFTLTISSLQPDDFATYYCQQGYSLRNIDNA FGGGTKVEIKRTVAAPSVFIFPPSDEQLKSGTASVVCLLNNFYPREAKVQ WKVDNALQSGNSQESVTEQDSKDSTYSLSSSTLTLSKADYEKHKVYACEVT HQGLSSPVTK SFNRGEC

[0009] The object of the present invention is to provide a therapeutic protocol for treating or preventing ABMR or CAMBR using specific anti-IL-6 antibodies and anti-IL-6 antibody fragments in patients who require such treatment, particularly in patients undergoing solid organ transplantation.

[0010] Another object of the present invention is to provide a novel protocol for desensitization of allograft recipients awaiting transplantation and highly sensitized allograft recipients after transplantation by using specific anti-IL-6 antibodies and antibody fragments, such as clazakizumab.

[0011] More specifically, an object of the present invention is a method for preventing, stabilizing or reducing antibody-mediated rejection (ABMR) in a subject who has received or has received a solid organ transplant, comprising administering to the subject a prophylactically or therapeutically effective amount of an anti-human interleukin-6 (IL-6) antibody or anti-human IL-6 antibody fragment, wherein the antibody or antibody fragment comprises a variable light chain polypeptide comprising the CDRs of SEQ ID NOs: 4, 5, and 6, and a variable heavy chain polypeptide comprising the CDRs of SEQ ID NOs: 7, 8 or 120, and 9, for example, the antibody comprises a V polypeptide that is at least 90, 95, 96, 97, 98, or 99% identical to the polypeptides of SEQ ID NOs: 657 and 709, respectively, and a V H and V L polypeptide, preferably the antibody is clazakizumab. In an exemplary embodiment, the solid organ is selected from the kidneys, heart, liver, lungs, pancreas, skin, intestine, stomach, skin, gallbladder, bladder, or any combination of the foregoing, or preferably the kidney.

[0012] An object of the present invention is to perform the treatment or prevention of ABMR by using specific anti-IL-6 antibodies and antibody fragments, such as clazakizumab, in a patient who needs it, particularly in a patient who has received a solid organ transplant. For example, the evaluation includes detection of pre-formed novel HLA DSAs (particularly those that detect complement-binding DSAs such as C1q), detection of non-HLA antibodies associated with ABMR, or identification of at least one histological feature characteristic of antibody-mediated organ damage.

[0013] The object of the present invention is to treat or prevent ABMR using specific anti-IL-6 antibodies and antibody fragments, such as crazakizumab, in patients in need, particularly in patients undergoing solid organ transplantation, in which the patient is evaluated for histological features characteristic of antibody-mediated organ injury, which are detected by obtaining a biopsy from the transplanted organ, and which, optionally, include any of the following histological features characteristic of antibody-mediated organ injury: microangiitis, complement deposition (C4d), and capillary vasculitis.

[0014] Another, more specific object of the present invention is to treat or prevent ABMR with the use of specific anti-IL-6 antibodies and antibody fragments, such as crazakizumab, in patients in need, particularly in patients undergoing solid organ transplantation, where the patient is evaluated to diagnose the onset or progression of ABMR, and the evaluation includes, for example, the detection of pre-formed novel HLA DSAs (particularly those detecting complement-binding DSAs such as C1q), the detection of non-HLA antibodies associated with ABMR, or the identification of at least one histological feature characteristic of antibody-mediated organ injury, where the transplanted organ is a kidney, and the histological feature characteristic of antibody-mediated organ injury includes any of the following: microangiitis, complement deposition in peritubular capillaries (C4d), peritubular capillary inflammation, glomerulitis, and transplant glomerulopathy (double glomerular basement membrane contour).

[0015] Another, more specific object of the present invention is to treat or prevent ABMR by the use of specific anti-IL-6 antibodies and antibody fragments in patients in need, particularly in patients undergoing solid organ transplantation, the treatment further comprising at least one other immunosuppressant, e.g., standard pre- or post-transplant immunosuppressants, optionally anti-CD20 such as thymoglobulin, basiliximab, mycophenolate mofetil, tacrolimus, or rituximab. This includes administration of either an mAb or a corticosteroid.

[0016] Another, more specific object of the present invention is to treat or prevent ABMR in patients in need, particularly patients undergoing solid organ transplantation, using specific anti-IL-6 antibodies and antibody fragments, such as crazakizumab. The antibodies are administered intravenously or subcutaneously.

[0017] Another, more specific object of the present invention is the treatment or prevention of ABMR by the use of specific anti-IL-6 antibodies and antibody fragments, such as crazakizumab, for patients who require it, in particular, solid This procedure is performed in patients undergoing organ transplantation, and the anti-IL-6 antibody is administered in doses ranging from approximately 0.01 mg to 5000 mg, more typically from 0.1 to 1000 mg, and even more typically from 1 to 500 mg, preferably intravenously or subcutaneously.

[0018] Another, more specific object of the present invention is to treat or prevent ABMR in patients in need, particularly patients undergoing solid organ transplantation, using specific anti-IL-6 antibodies and antibody fragments, such as crazakizumab, which are administered intravenously in doses ranging from approximately 5 mg to 50 mg or subcutaneously in doses ranging from 10 mg to 50 mg.

[0019] Another, more specific object of the present invention is to treat or prevent ABMR in patients in need, particularly patients undergoing solid organ transplantation, using specific anti-IL-6 antibodies and antibody fragments, such as crazakizumab, the antibodies being administered approximately every 4, 8, 12, 16, 20, or 24 weeks.

[0020] Another, more specific, object of the present invention is to treat or prevent ABMR in patients in need, particularly those undergoing solid organ transplantation, using specific anti-IL-6 antibodies and antibody fragments, such as crazakizumab, the antibodies being administered within approximately one month of detecting signs of ABMR.

[0021] Another, more specific object of the present invention is to treat or prevent ABMR with the use of specific anti-IL-6 antibodies and antibody fragments, such as crazakizumab, in patients in need, particularly in patients undergoing solid organ transplantation, the antibodies being administered for several months before and several months or even several years after transplantation to prevent or mitigate antibody-mediated damage to the transplanted organ.

[0022] Another object of the present invention is to provide a method for preventing, stabilizing, or mitigating pre- or post-transplant sensitization in subjects who have undergone or are scheduled to undergo solid organ transplantation, comprising administering a prophylactic or therapeutically effective amount of an anti-human interleukin-6 (IL-6) antibody or antibody fragment, for example, crazakizumab, wherein the antibody or antibody fragment comprises a variable light chain polypeptide containing the CDRs of sequence numbers 4, 5, and 6, and a variable heavy chain polypeptide containing the CDRs of sequence numbers 7, 8, or 120 and 9, for example, the antibody comprises VH and VL polypeptides that are at least 90, 95, 96, 97, 98, or 99% identical to the polypeptides of sequence numbers 657 and 709, respectively, and is preferably crazakizumab.

[0023] Another object of the present invention is to provide a method for preventing, stabilizing, or mitigating pre- or post-transplant sensitization in a subject who has received or is scheduled to receive a solid organ transplant, comprising administering a prophylactic or therapeutically effective amount of an anti-human interleukin-6 (IL-6) antibody or antibody fragment, such as crazakizumab, wherein the antibody or antibody fragment comprises a variable light chain polypeptide containing the CDRs of sequence numbers 4, 5, and 6, and a variable heavy chain polypeptide containing the CDRs of sequence numbers 7, 8, or 120 and 9, and the solid organ is selected from the kidney, heart, liver, lung, pancreas, skin, intestine, stomach, or any combination thereof.

[0024] Another object of the present invention is a method for preventing, stabilizing, or mitigating pre- or post-transplant sensitization in subjects who have received or are scheduled to receive solid organ transplants, comprising administering a prophylactic or therapeutically effective amount of anti-human interleukin-6 (IL-6) antibody or antibody fragment, such as crazakizumab, as described above, provided that the patient is at risk of sensitization due to blood transfusion, pregnancy, or a history of previous transplants. The goal is to provide a method for sensitization.

[0025] Another object of the present invention is to provide a method for preventing, stabilizing, or mitigating pre- or post-transplant sensitization in a subject who has received or is scheduled to receive a solid organ transplant, comprising administering a prophylactic or therapeutically effective amount of anti-human interleukin-6 (IL-6) antibody or antibody fragment, such as crazakizumab, as described above, wherein the patient has pre-formed donor-specific antibodies (DSAs) against the donor organ.

[0026] Another object of the present invention is to provide a method for preventing, stabilizing, or mitigating pre- or post-transplant sensitization in a subject who has undergone or is scheduled to undergo a solid organ transplant, comprising administering a prophylactic or therapeutically effective amount of anti-human interleukin-6 (IL-6) antibody or antibody fragment, such as crazakizumab, as described above, further comprising a pre-transplant desensitization procedure for the patient to eliminate or reduce these alloantibodies (DSAs).

[0027] Another object of the present invention is to provide a method for preventing, stabilizing, or mitigating pre- or post-transplant sensitization in subjects who have undergone or are scheduled to undergo solid organ transplantation, comprising administering a prophylactic or therapeutically effective amount of an anti-human interleukin-6 (IL-6) antibody or antibody fragment, such as crazakizumab, as described above, wherein the desensitization treatment comprises plasma exchange therapy or plasma exchange in combination with, optionally, one of the following: intravenous immunoglobulin, an anti-B cell agent such as rituximab (anti-CD20 mAb), and a plasma cell inhibitor such as bortezomib (proteosome inhibitor).

[0028] Another object of the present invention is to provide a method for preventing, stabilizing, or mitigating pre- or post-transplant sensitization in a subject who has undergone or is scheduled to undergo solid organ transplantation, comprising administering a prophylactic or therapeutically effective amount of an anti-human interleukin-6 (IL-6) antibody or antibody fragment, such as crazakizumab, as described above, wherein the antibody is administered intravenously or subcutaneously.

[0029] Another object of the present invention is to provide a method for preventing, stabilizing, or mitigating pre- or post-transplant sensitization in subjects who have undergone or are scheduled to undergo solid organ transplantation, comprising administering a prophylactic or therapeutically effective amount of anti-human interleukin-6 (IL-6) antibody or antibody fragment, e.g., crazakizumab, as described above by the use of a specific anti-IL-6 antibody and antibody fragment, for example, the antibody being administered in doses ranging from about 0.01 mg to 5000 mg, more typically 0.1 to 1000 mg, and even more typically 1 to 500 mg, preferably intravenously or subcutaneously.

[0030] Another object of the present invention is to provide a method for preventing, stabilizing, or mitigating pre- or post-transplant sensitization in subjects who have undergone or are scheduled to undergo solid organ transplantation, comprising administering a prophylactic or therapeutically effective amount of anti-human interleukin-6 (IL-6) antibody or antibody fragment, such as crazakizumab, as described above, wherein the antibody is administered intravenously in a dose of 5 mg to 50 mg or subcutaneously in a dose of 10 mg to 50 mg.

[0031] Another object of the present invention is a method for preventing, stabilizing, or mitigating pre- or post-transplant sensitization in subjects who have undergone or are scheduled to undergo solid organ transplantation, comprising a prophylactic or therapeutically effective amount of anti-human interleukin-6 (IL-6) antibody or antibody filtration. One method, for example, involves administering crazakizumab as described above, wherein the antibody is administered approximately every four or eight weeks, starting several months (e.g., six months) prior to transplantation.

[0032] Another object of the present invention is to provide a method for preventing, stabilizing, or mitigating pre- or post-transplant sensitization in subjects who have undergone or are scheduled to undergo solid organ transplantation, comprising administering a prophylactic or therapeutically effective amount of anti-human interleukin-6 (IL-6) antibody or antibody fragment, e.g., crazakizumab, as described above, wherein the patient is periodically evaluated by pre-desensitization using various antibody detection methods (e.g., cytotoxic crossmatch, flow cytometry crossmatch, Luminex antibody test) to detect the level of DSA during the desensitization treatment process.

[0033] Another object of the present invention is to provide a method for preventing, stabilizing, or mitigating pre- or post-transplant sensitization in a subject who has received or is scheduled to receive a solid organ transplant, comprising administering a prophylactic or therapeutically effective amount of an anti-human interleukin-6 (IL-6) antibody or antibody fragment, e.g., crazakizumab, as described above, wherein a positive reaction (e.g., conversion to a positive-to-negative cytotoxic crossmatch) is used to determine that the patient is eligible for transplantation and may proceed with transplantation.

[0034] Another object of the present invention is to provide a method for preventing, stabilizing, or mitigating pre- or post-transplant sensitization in a subject who has undergone or is scheduled to undergo solid organ transplantation, comprising administering a prophylactic or therapeutically effective amount of an anti-human interleukin-6 (IL-6) antibody or antibody fragment, such as crazakizumab, as described above, wherein the patient is treated with the antibody, preferably crazakizumab, before and / or after transplantation.

[0035] Another object of the present invention is to provide a method for preventing, stabilizing, or mitigating pre- or post-transplant sensitization in a subject who has received or is scheduled to receive a solid organ transplant, comprising administering a prophylactic or therapeutically effective amount of an anti-human interleukin-6 (IL-6) antibody or antibody fragment, such as crazakizumab, as described above, wherein the administration of the antibody is continued for several months or years after transplantation to prevent or treat early acute rejection or late chronic rejection.

[0036] Another object of the present invention is to provide a method for preventing, stabilizing, or mitigating pre- or post-transplant sensitization in a subject who has undergone or is scheduled to undergo solid organ transplantation, comprising administering a prophylactic or therapeutically effective amount of an anti-human interleukin-6 (IL-6) antibody or antibody fragment, e.g., crazakizumab, as described above, wherein the patient is monitored for clinical signs of rejection, such as increased serum creatinine and / or proteinuria, or decreased eGFR in kidney transplantation, or the development of new DSAs (novel DSAs).

[0037] Another object of the present invention is to provide a method for preventing, stabilizing, or mitigating pre- or post-transplant sensitization in a subject who has received or is scheduled to receive a solid organ transplant, comprising administering a prophylactic or therapeutically effective amount of an anti-human interleukin-6 (IL-6) antibody or antibody fragment, such as crazakizumab, as described above, wherein the patient is monitored for histological signs of organ rejection.

[0038] Another object of the present invention is a method for preventing, stabilizing, or reducing pre- or post-transplant sensitization in subjects who have received or are scheduled to receive solid organ transplants, The objective is to provide a method comprising administering a therapeutically or therapeutically effective amount of an anti-human interleukin-6 (IL-6) antibody or antibody fragment, e.g., crazakizumab, as described above, wherein ABMR organ damage is confirmed by biopsy evidence (e.g., microangiitis, interstitial fibrosis, transplant glomerulopathy, CD4 deposition).

[0039] Another object of the present invention is to use any of the above methods in combination with standard immunosuppressive regimens (e.g., thymoglobulin, basiliximab, mycophenolate mofetil, tacrolimus, and corticosteroids) that are typically administered to patients before and after transplantation.

[0040] Another object of the present invention is to use any of the aforementioned methods, wherein the anti-IL-6 antibody or antibody fragment comprises an Fc region that has been modified to alter effector function, half-life, proteolysis, and / or glycosylation.

[0041] Another object of the present invention is to use any of the aforementioned methods, wherein the anti-IL-6 antibody is selected from humanized, single-chain, or chimeric antibodies, and the antibody fragment is selected from Fab, Fab', F(ab')2, Fv, or scFv.

[0042] Another object of the present invention is to use any of the above methods, wherein the dose of the anti-IL-6 antibody is about 0.001 to 100 mg / kg of the recipient patient's body weight, more preferably 0.01 to 20 mg / kg of body weight.

[0043] Another object of the present invention is to use any of the aforementioned methods in which an antibody or fragment inhibits the binding of IL-6 to gp130 and / or the binding of IL-6 to IL-6R1.

[0044] Another object of the present invention is to use any of the above methods, wherein an anti-IL-6 antibody or antibody fragment, such as crazakizumab, comprises a human constant region.

[0045] Another object of the present invention is to use any of the methods described above, wherein the anti-IL-6 antibody, for example, crazakizumab, contains a human constant region such as the IgG1, IgG2, IgG3, or IgG4 constant region, or preferably the human IgG1 constant region.

[0046] Another object of the present invention is to provide a method for preventing, stabilizing, or mitigating antibody-mediated rejection (ABMR) in a subject who is scheduled to receive, is receiving, or has received a solid organ transplant, comprising administering to the subject a prophylactic or therapeutically effective amount of anti-human interleukin-6 (IL-6) antibody or anti-human IL-6 antibody fragment, wherein the antibody or antibody fragment comprises a variable light chain polypeptide containing the CDRs of SEQ ID NOs. 4, 5, and 6, and a variable heavy chain polypeptide containing the CDRs of SEQ ID NOs. 7, 8, or 120, and 9.

[0047] Another object of the present invention is to provide a method for reversing, stabilizing, or slowing active antibody-mediated rejection (AMBR) in a transplant recipient in need thereof, comprising administering an effective amount of anti-IL-6 antibody or antibody fragment, wherein the antibody or antibody fragment comprises a variable light chain polypeptide containing the CDRs of SEQ ID NOs: 4, 5, and 6, and a variable heavy chain polypeptide containing the CDRs of SEQ ID NOs: 7, 8, or 120 and 9.

[0048] Another object of the present invention is to propose a method in which an anti-human IL-6 antibody comprises the heavy chain polypeptide of SEQ ID NO: 704 or 745 and the light chain polypeptide of SEQ ID NO: 702 or 746. It is to provide.

[0049] Another object of the present invention is to provide a method, as specified above, in which an anti-human IL-6 antibody is administered for at least one year.

[0050] Another object of the present invention is to provide a method, as specified above, in which an anti-human IL-6 antibody is administered for at least two years.

[0051] Another object of the present invention is to provide a method, as specified above, in which an anti-human IL-6 antibody is administered for at least three years.

[0052] Another object of the present invention is to provide a method, as specified above, in which an anti-human IL-6 antibody is administered for at least four years.

[0053] Another object of the present invention is to provide a method, as specified above, in which an anti-human IL-6 antibody is administered for at least 5 years.

[0054] Another object of the present invention is to provide a method, as specified above, for administering an anti-human IL-6 antibody for more than five years.

[0055] Another object of the present invention is to provide a method, as specified above, in which a transplant recipient optionally has at least one instance of active antibody-mediated rejection (AMBR) or chronic active antibody-mediated rejection (CABMR) within a period of 1 to 6 months prior to treatment, at the time treatment is optionally initiated.

[0056] Another object of the present invention is to provide a method, as specified above, in which a transplant recipient is diagnosed with having AMBR or CAMBR prior to administration of an anti-IL-6 antibody.

[0057] Another object of the present invention is to provide a method, as specified above, in which treatment with an anti-IL-6 antibody optionally stabilizes or increases the estimated glomerular filtration rate (eGFR) during treatment and throughout the entire treatment period.

[0058] Another object of the present invention is to provide a method, as specified above, in which treatment with an anti-IL-6 antibody optionally stabilizes or increases the estimated glomerular filtration rate (eGFR) during treatment, throughout the treatment period, and optionally maintains such stabilization or increase of eGFR for at least 3, 6, 9, or 12 months after the completion of treatment.

[0059] Another object of the present invention is to provide a method, as specified above, in which, at the time treatment is initiated and / or during the treatment regimen, the patient being treated does not have neutropenia (less than 1,000 mm3) or thrombocytopenia (less than 50,000 mm3).

[0060] Another object of the present invention is to provide a method, as specified above, in which the patient to be treated has not received intravenous immunoglobulin during a period of 0 to 6 months prior to treatment.

[0061] Another object of the present invention is to provide a method as specified above, wherein the patient to be treated has human leukocyte antigen (HLA) DSA prior to treatment, and this is optionally confirmed by an assay that detects human leukocyte antigen (HLA) DSA within a period of 0 to 6 months prior to treatment.

[0062] Another objective of the present invention is that the treatment is as follows: (i) Reduction or elimination of donor-specific antibodies (DSAs), (ii) Decrease in CCL2 level, (iii) Reduction of complement activation, and / or reduction of the amount of C5b, C9, and / or C5b / C9 complex detected. (iv) Reduction in the number of plasma cells that secrete DSA, (v) Prevention of loss of allografts, (vi) Prevention of return to dialysis, (vii) Prevention of allogeneic nephrectomy, and / or (viii) Prevention of the need for re-transplantation, (ix) Estimated glomerular filtration rate (eGFR) is at least ≥ 15 mL / min 1.73 m 2 The objective is to provide a method, as specified above, that induces one or more of the following: maintaining or increasing a certain condition.

[0063] Another object of the present invention is to provide a method of transplantation, such as the one specified above, which includes a solid organ.

[0064] Another object of the present invention is to provide a method as specified above, wherein the solid organ includes a kidney, heart, lung, bladder, pancreas, liver, gallbladder, thyroid gland, skin, or any combination thereof.

[0065] Another object of the present invention is to provide a method of transplantation, as specified above, in which the transplantation includes or comprises a kidney.

[0066] Another object of the present invention is to provide a method, as specified above, in which the transplant is from a living or deceased donor.

[0067] Another object of the present invention is to selectively modify diet in renal disease by detecting, at least partially, eGFR levels, the effectiveness of the treatment, during or after treatment, and the effectiveness of the treatment. 4) To provide a method, as specified above, that is evaluated using the (MDRD4) equation.

[0068] Another object of the present invention is to provide a method, as specified above, whose effectiveness is evaluated by evaluating the histology of a renal biopsy at least in part according to the Banff 2015 lesion grading score.

[0069] Another object of the present invention is to provide a method, as specified above, in which effectiveness is evaluated at least partially by detecting DSA titer and / or mean fluorescence intensity (MFI) score.

[0070] Another object of the present invention is to provide a method, as specified above, whose effectiveness is evaluated by at least partially evaluating the incidence of acute rejection episodes (TCMR and ABMR).

[0071] Another object of the present invention is to provide a method, as specified above, in which efficacy is evaluated by evaluating the efficacy of treatment for albuminuria, at least in part.

[0072] Another object of the present invention is at least partially a comparative and / or conventional AMBR or CA The objective is to provide a method, as specified above, in which effectiveness is evaluated by assessing survival rates compared to MBR treatment.

[0073] Another object of the present invention is to provide a method such as the one described above, in which the antibody IL-6 comprises a human IgG1 constant region, for example, the human IgG1 constant region comprises the constant light chain polypeptide of SEQ ID NO: 586 and the constant heavy chain polypeptide of SEQ ID NO: 588.

[0074] Another object of the present invention is to provide a method, as specified above, in which an anti-human IL-6 antibody comprises the variable heavy chain polypeptide of SEQ ID NO: 657 and the variable light chain polypeptide of SEQ ID NO: 709.

[0075] Another object of the present invention is to provide a method, as specified above, in which an anti-human IL-6 antibody comprises a heavy chain polypeptide of SEQ ID NO: 704 or 745 and a light chain polypeptide of SEQ ID NO: 702 or 746.

[0076] Another object of the present invention is to provide a method, as specified above, in which an anti-IL-6 antibody is administered intravenously or subcutaneously every four weeks or monthly.

[0077] Another object of the present invention is to provide a method, as specified above, in which an anti-IL-6 antibody in a dose of 25 mg or 12.5 mg is administered intravenously or subcutaneously every four weeks or monthly.

[0078] Another object of the present invention is to provide a method, as specified above, in which Claza is administered subcutaneously every four weeks or every month in doses of 25 mg or 12.5 mg.

[0079] Another object of the present invention is to provide a method, as specified above, in which treatment is performed for at least one, two, three, four, or five years without a return to dialysis, allogeneic nephrectomy, re-transplantation, or an adverse event selected from eGFR ≤ 15 mL / min / 1.73m2.

[0080] Another object of the present invention is that transplant recipients can optionally: (i) Azathioprine (e.g., 1.0-2.0 mg / kg / day), (ii) Calcineurin inhibitors (CNIs), (iii) Mycophenolate mofetil (MMF) (e.g., 1.0-2.0 g / day) / Mycophenolate (MPA) (e.g., 720-1440 mg / day) (iv) mTOR inhibitors (e.g., tacrolimus, everolimus, sirolimus (e.g., target trough level of 5-8 ng / ml)), (v) Low doses of corticosteroids (e.g., prednisone / prednisolone ≤ 10 mg / day), (vi) Antihypertensive drugs (e.g., angiotensin-converting enzyme inhibitors (ACEIs)), (vii) Angiotensin II receptor blockers (ARBs), (viii) Cyclosporine (e.g., target trough level 50-150 ng / ml), (ix) Antidiabetic drugs, The objective is to provide a method as specified above, which is further treated by (x) or any combination of the foregoing.

[0081] Another object of the present invention is that transplant recipients may optionally receive prophylaxis to Pneumocystis iloveti pneumonia (PJP), e.g., trimethoprim (e.g., 80 mg pills daily) and / or sulfamethoxazole (e.g., 160 mg pills three times a week), inhaled pentamidine, or oral dapsone (optionally initiated at least one week before treatment). The objective is to provide methods, as specified above, that are further treated by the following:

[0082] The method according to any of the prior claims, wherein if the transplant recipient experiences acute TCMR, the transplant recipient is treated with a pulsed steroid, such as oral prednisone (e.g., 200 mg / day).

[0083] Another object of the present invention is that, during anti-IL-6 antibody therapy, the transplant recipient optionally undergoes the following during a period of 0, 1, 2, 3, 4, 5, or 6 months prior to the start of treatment: (i) Rituximab, (ii) Eculizumab, (iii) Proteasome inhibitors, (iv) Intravenous immunoglobulin (IVIG) (excluding treatment of hypogammaglobulinemia), (v) Plasma exchange (PLEX), beratacept, (vi) Anti-IL-6R antibody, and / or (vii) To provide a method as specified above, which is not treated by any combination of any of the above.

[0084] Another object of the present invention is that the transplant recipient is: (i) Must be between 18 and 75 years old, (ii) Treatment must be initiated at least six months after transplantation. (iii) The following: Diagnosis of CABMR according to the BANFF 2015 diagnostic criteria, including CABMR confirmed by biopsy (i.e., chronic glomerulosynovitis (cg) > 0 with / without C4d staining) (repeated biopsies should be performed if the previous biopsy was not within 6 months of screening), (iv) If the subject has received treatment for ABMR (including CABMR) or TCMR, repeated biopsies (to indicate continued CABMR) must be performed, and the subject must not have evidence of chronic tissue damage on a light microscope, but must have glomerular basement membrane contour (cg1a) on an electron microscope to be eligible. (v) the presence of human leukocyte antigen (HLA) DSA after transplantation (using a single antigen bead-based assay), to provide a method as specified above, comprising any or all of the above.

[0085] Another object of the present invention is that the transplant recipient is: (i) Not having received treatment for ABMR, CABMR, or TCMR within 0 to 3 months or 0 to 6 months following IL-6 antibody treatment or screening. (ii) Not having received any T-cell depletion agent, ABMR (including CABMR), or TCMR treatment within 3 months of screening or treatment, (iii) Not having received a T-cell depletion agent (e.g., alemtuzumab, antithymocyte globulin) within 3 months of screening or IL-6 antibody treatment. (iv) No biopsy showing pure TCMR or advanced interstitial fibrosis (ci3), (v) Absence of progressive tubular atrophy (ct3), (vi) Absence of vascular fibrous intimal thickening (cv3) or other serious causes of renal dysfunction (e.g., polyomatous BK virus (BKV) nephropathy, glomerulonephritis), (vii) No renal dysfunction resulting from damage to the transplanted allograft (e.g., renal artery stenosis, hydronephrosis). (viii)eGFR<25mL / min / 1.73m 2 Or >65 mL / min / 1.73 m 2 (viii) Absence of (MDRD4), (viii) Spot urine protein-creatinine ratio (UPCR) ≥ 3,000 mg / g (≥ 300 mg / mmol) or spot urine albumin No nephrotic-range proteinuria defined as a creatinine ratio (UACR) ≥ 2,200 mg / g (≥ 220 mg / mmol). (ix) Not pregnant or breastfeeding, (x) No history of anaphylaxis. (xi) Absence of abnormal liver function tests (LFT) (alanine aminotransferase (ALT) / aspartate aminotransferase (AST) / bilirubin > 1.5 × upper limit of normal) or other serious liver disease. (xii) No history of active tuberculosis (TB), (xiii) Unless the subject has completed the entire course of prophylactic treatment, there is no history of latent tuberculosis without a history of active TB (e.g., a positive QuantiFERON TB test), (xiv) No history of human immunodeficiency virus (HIV) infection, or not positive for HIV. (xv) Not serologically positive for hepatitis B surface antigen (HBsAg). (xvi) Not positive for Hepatitis C virus (HCV) RNA. (xvii) There is no known Epstein-Barr virus (EBV) mismatch, the donor is seropositive, and the recipient is seronegative. (xviii) No history of gastrointestinal perforation, diverticular disease, diverticulitis, or inflammatory bowel disease. (xix) Neutropenia (<1,000 / mm 3 ) or thrombocytopenia (<50,000 / mm³) 3 ) is not present. (xx) No active infection requiring systemic antibiotics that has not resolved prior to screening. (xxi) No history or current history of invasive fungal infections or other opportunistic infections, including but not limited to nontuberculous mycobacterial infections, aspergillosis, pneumocystis, and toxoplasmosis; (xxii) No active viral infections such as BKV, cytomegalovirus (CMV), or EBV based on polymerase chain reaction (PCR) testing; (xxii) Currently or recently (no treatment for a period of 0-3 months or 0-6 months prior to treatment) (xxiii) Within six weeks of screening, have not received any live vaccines, including but not limited to adenovirus, measles, mumps, rubella, oral polio, oral typhoid, rotavirus, varicella-zoster, or yellow fever, and have no history of alcohol or illegal drug (including marijuana) abuse. (xxiv) No current or past (within the last 3 years) malignant tumors, except for basal cell carcinoma, squamous cell carcinoma of the skin that has been completely excised, or non-recurrent (within the last 5 years) cervical intraepithelial neoplasia. (xxv) The absence of any conditions or abnormalities that could impair safety or life expectancy (i.e., clinically significant endocrine, autoimmune, metabolic, neurological, psychiatric / psychological, renal, gastrointestinal, hepatic, and hematological or any other systemic abnormalities that are not controlled by standard treatment). (xxvi) No history of intolerance to trimethoprim and / or sulfamethoxazole, no prior treatment with anti-IL-6 antibodies, and / or (xxvii) To provide a method as specified above, which does not include one or more of any of the combinations described above.

[0086] Another object of the present invention is to provide a method for preventing, stabilizing, or reducing complement activity in a subject in need thereof, comprising administering to the subject a prophylactic or therapeutically effective amount of an anti-human interleukin-6 (IL-6) antibody or antibody fragment, for example, the antibody or antibody fragment comprising a variable light chain polypeptide containing the CDRs of SEQ ID NOs: 4, 5, and 6, and a variable heavy chain polypeptide containing the CDRs of SEQ ID NOs: 7, 8, or 120 and 9.

[0087] Another object of the present invention is to provide a method, as specified above, for measuring complement activity in a subject before, during, or after treatment.

[0088] Another object of the present invention is to provide a method as specified above, wherein the antibody comprises VH and VL polypeptides that are at least 90, 95, 96, 97, 98, or 99% identical to the polypeptides of SEQ ID NOs. 657 and 709, respectively.

[0089] Another object of the present invention is to provide a method as specified above, wherein the antibody comprises heavy and light chain polypeptides that are at least 90, 95, 96, 97, 98, or 99% identical to the polypeptides of SEQ ID NOs. 704 or 745 and 702 or 746, respectively.

[0090] Another object of the present invention is to provide a method such as the one described above, wherein the antibody is crazakizumab.

[0091] The objective is to provide a method as specified above, in which a solid organ is selected from the kidney, heart, liver, lung, pancreas, gallbladder, skin, intestine, stomach, or any combination thereof.

[0092] Another object of the present invention is to provide a method, as defined above, in which a solid organ includes or comprises a kidney.

[0093] Another object of the present invention is to provide a method such that a patient is evaluated and diagnosed as having ABMR or CAMBR prior to treatment, and the evaluation comprises, for example, one or more of the following: detection of a pre-formed novel HLA DSA (in particular of those that detect complement-binding DSAs such as C1q), detection of non-HLA antibodies associated with ABMR, and / or identification of at least one histological feature characteristic of antibody-mediated organ injury, and / or the histological feature characteristic of antibody-mediated organ injury is detected by obtaining a biopsy from a transplanted organ, and / or the histological feature characteristic of antibody-mediated organ injury includes any of microangiitis, complement deposition (C4d), or capillary vasculitis.

[0094] Another object of the present invention is to provide a method such that a patient has a transplanted organ consisting of a kidney, and the histological features characteristic of antibody-mediated organ injury include any of the following: microangiitis, complement deposition (C4d) in peritubular capillaries, peritubular capillary inflammation, glomerulitis, and transplant glomerulopathy (double glomerular basement membrane contour).

[0095] Another object of the present invention is to provide a method as specified above, wherein the treatment further comprises the administration of at least one other immunosuppressant, for example, at least one other immunosuppressant being an immunosuppressant of standard pre- or post-transplant treatment.

[0096] Another object of the present invention is to provide a method such as the one specified above, in which the treatment further comprises the administration of at least one other immunosuppressant, for example, at least one other immunosuppressant comprising any of the following: thymoglobulin, basiliximab, mycophenolate mofetil, tacrolimus, rituximab, and corticosteroids.

[0097] Another object of the present invention is to provide a method, as specified above, by which an anti-IL-6 antibody is administered intravenously or subcutaneously.

[0098] Another object of the present invention is that anti-IL-6 antibodies can be administered in doses ranging from 0.01 to 5000 mg. The objective is to provide a method as specified above.

[0099] Another object of the present invention is to provide a method, as specified above, in which an anti-IL-6 antibody is administered in a dose ranging from 0.1 to 1000 mg.

[0100] Another object of the present invention is to provide a method, as specified above, in which an anti-IL-6 antibody is administered in a dose ranging from 1 to 500 mg.

[0101] Another object of the present invention is to provide a method, as specified above, in which an anti-IL-6 antibody is administered intravenously in a dose ranging from about 5 mg to 50 mg, or subcutaneously in a dose ranging from about 10 mg to 50 mg.

[0102] Another object of the present invention is to provide a method, as specified above, in which an anti-IL-6 antibody is administered in doses of about 25 mg at intervals of about 2 weeks, 4 weeks, 6 weeks, 8 weeks, 12 weeks, 16 weeks, 20 weeks, 24 weeks, monthly, every other month, every 2 months, every 3 months, every 4 months, every 5 months, every 6 months, annually, or less.

[0103] Another object of the present invention is to provide a method, as specified above, in which an anti-IL-6 antibody is administered approximately every 4 weeks, 8 weeks, 12 weeks, 16 weeks, 20 weeks, or 24 weeks.

[0104] Another object of the present invention is to provide a method, as specified above, in which an anti-IL-6 antibody is administered subcutaneously every four weeks or monthly in doses of 25 mg or 12.5 mg.

[0105] Another object of the present invention is to provide a method, as specified above, in which an anti-IL-6 antibody is administered within approximately one, two, or three months to detect signs of ABMR or CAMBR.

[0106] Another object of the present invention is to provide a method, as specified above, in which an anti-IL-6 antibody is administered for several months prior to transplantation and for several months or years after transplantation to prevent, stabilize, or mitigate antibody-mediated damage to a transplanted organ.

[0107] Another object of the present invention is to provide a method for preventing, stabilizing, or mitigating pre- or post-transplant sensitization in subjects who have undergone or are scheduled to undergo solid organ transplantation, comprising administering a prophylactic or therapeutically effective amount of anti-human interleukin-6 (IL-6) antibody or antibody fragment, wherein the antibody or antibody fragment comprises a variable light chain polypeptide containing the CDRs of sequence numbers 4, 5, and 6, and a variable heavy chain polypeptide containing the CDRs of sequence numbers 7, 8, or 120 and 9.

[0108] Another object of the present invention is to provide a method, as specified above, in which an anti-IL-6 antibody comprises VH and VL polypeptides that are at least 90, 95, 96, 97, 98, or 99% identical to the polypeptides of SEQ ID NOs. 657 and 709, respectively.

[0109] Another object of the present invention is to provide a method as specified above, wherein the antibody comprises the same VH and VL polypeptides as those of the polypeptides of SEQ ID NOs. 657 and 709.

[0110] Another object of the present invention is to provide a method as specified above, wherein the antibody comprises the same light-chain and heavy-chain polypeptides as those of polypeptide SEQ ID NOs. 702 or 746 and 704 or 745, respectively.

[0111] Another object of the present invention is to provide a method such that a patient is transplanted with a solid organ, the solid organ being selected from the kidney, heart, liver, lung, pancreas, skin, intestine, stomach, or any combination thereof.

[0112] Another object of the present invention is to provide a method, as defined above, in which a solid organ includes or comprises a kidney.

[0113] Another object of the present invention is to provide a method, as specified above, for a patient who is at risk of or has been sensitized due to a history of blood transfusion, pregnancy, or a previous transplant.

[0114] Another object of the present invention is to provide a method, as specified above, in which a patient has pre-formed donor-specific antibodies (DSAs) against a donor organ before and / or during anti-IL-6 antibody treatment.

[0115] Another object of the present invention is to provide a method, such as the one specified above, which further comprises a pre-transplant desensitization procedure for removing or reducing donor-specific alloantibodies (DSAs), for example, the desensitization treatment comprising plasma exchange therapy or plasma exchange in combination with, optionally, one of the following: intravenous immunoglobulin, an anti-B cell agent such as rituximab (anti-CD20 mAb), and a plasma cell inhibitor such as bortezomib (proteosome inhibitor).

[0116] Another object of the present invention is to provide a method, as specified above, by which an anti-IL-6 antibody is administered intravenously or subcutaneously.

[0117] Another object of the present invention is to provide a method, as specified above, in which an anti-IL-6 antibody is administered in a dose ranging from 0.01 to 5000 mg.

[0118] Another object of the present invention is to provide a method, as specified above, in which an anti-IL-6 antibody is administered in a dose ranging from 0.1 to 1000 mg.

[0119] Another object of the present invention is to provide a method, as specified above, in which an anti-IL-6 antibody is administered in a dose ranging from 1 to 500 mg.

[0120] Another object of the present invention is to provide a method, as specified above, in which an anti-IL-6 antibody is administered in doses of about 25 mg at intervals of about 2 weeks, 4 weeks, 6 weeks, 8 weeks, 12 weeks, 16 weeks, 20 weeks, 24 weeks, monthly, every other month, every 2 months, every 3 months, every 4 months, every 5 months, every 6 months, annually, or less.

[0121] Another object of the present invention is to provide a method, as specified above, in which an anti-IL-6 antibody is administered approximately every four or eight weeks, starting several months later (for example, within a period of 0 to 6 months prior to transplantation).

[0122] Another object of the present invention is to provide a method, as specified above, in which a patient is periodically evaluated during treatment by pre-desensitization using one or more antibody detection methods (e.g., cytotoxic crossmatch, flow cytometry crossmatch, Luminex antibody test) to detect the level of DSA during the desensitization treatment process, and for example, a positive reaction (e.g., conversion from positive to negative cytotoxic crossmatch) is used to determine whether the patient is or is still eligible for IL-6 antibody therapy and / or transplantation.

[0123] Another object of the present invention is to provide a method, as specified above, in which a patient is treated with an anti-IL-6 antibody, such as crazakizumab, after transplantation.

[0124] Another object of the present invention is to provide a method, as specified above, in which the administration of the anti-IL-6 antibody is continued for several months or years after transplantation to prevent or treat early acute rejection or late chronic rejection.

[0125] Another object of the present invention is to provide a method, as specified above, in which a patient is monitored for clinical signs of rejection, such as increased serum creatinine and / or proteinuria, or decreased eGFR in kidney transplantation, or for the development of new DSA (novel DSA).

[0126] Another object of the present invention is to provide a method, as specified above, by which a patient is monitored for histological signs of organ rejection.

[0127] Another object of the present invention is to provide a method, as specified above, for preventing, stabilizing, or mitigating pre-transplant, intra-transplant, and / or post-transplant ABMR organ damage, which is confirmed by biopsy evidence (e.g., microangiitis, interstitial fibrosis, transplant glomerulopathy, CD4 deposition).

[0128] Another object of the present invention is to provide a method, as specified above, in which crazakizumab is used in combination with standard immunosuppressive regimens (e.g., thymoglobulin, basiliximab, mycophenolate mofetil, tacrolimus, and corticosteroids) that are typically administered to patients before and after transplantation.

[0129] Another object of the present invention is to provide a method, as specified above, in which an anti-IL-6 antibody or antibody fragment comprises an Fc region modified to alter effector function, half-life, proteolysis, and / or glycosylation.

[0130] Another object of the present invention is to provide a method such as the above, in which an anti-IL-6 antibody is selected from a humanized, single-stranded, or chimeric antibody, and an antibody fragment is selected from Fab, Fab', F(ab')2, Fv, or scFv.

[0131] Another object of the present invention is to provide a method as specified above, in which the antibody dose is approximately 0.001 to 100 mg / kg of the recipient patient's body weight.

[0132] Another object of the present invention is to provide a method, as specified above, in which the dose of the anti-IL-6 antibody is approximately 0.1 to 20 mg / kg of the recipient patient's body weight, or approximately 25 mg.

[0133] Another object of the present invention is to provide a method, as specified above, in which an anti-IL-6 antibody or fragment inhibits the binding of IL-6 to gp130 and / or IL-6R1.

[0134] Another object of the present invention is to provide a method such that an anti-IL-6 antibody or antibody fragment comprises a human constant region, for example, the human constant region comprises an IgG1, IgG2, IgG3, or IgG4 constant region, or the human constant region comprises an IgG1 constant region.

[0135] Another object of the present invention is that the anti-IL-6 antibody is crazakizumab, as specified above. The goal is to provide such a method.

[0136] Another object of the present invention is that the treated subject has late or advanced AMBR (Banff The objective is to provide a method as specified above, having an acute / active or chronic / active phenotype according to the 2015 classification.

[0137] Another object of the present invention is to provide a method as specified above, wherein the administered anti-IL-6 antibody is crazakizumab, and the treated subject has late or advanced AMBR (acute / active or chronic / active phenotype according to the Banff 2015 classification).

[0138] Another object of the present invention is that the treated subject is age-related macular degeneration (AMD) (wet and dry), Alzheimer's disease, glomerular diseases, such as atypical hemolytic uremic syndrome (aHUS), hemolytic uremic syndrome caused by Shiga toxin-producing E. coli (STEC-HUS), thrombotic thrombocytopenic purpura (TTP), systemic lupus erythematosus (SLE), antiphospholipid syndrome (APS), antineutrophil cytoplasmic antibody (ANCA)-induced vasculitis, inflammatory microangiopathy caused by autoantibodies against neutrophil components, antibody-dependent (i.e., in women with APS), pregnancy loss with C5a-mediated impairment of placental angiogenesis, paroxysmal nocturnal disorders. The objective is to provide a method for a complement-mediated hemolytic disorder such as interhemoglobinuria (PNH), aHUS and cold agglutinin disease (CAD), ischemia-reperfusion injury, and complement-related conditions selected from age-related and degenerative diseases such as trauma, sepsis, shock, and cardiopulmonary bypass (CPB) surgery, CPB-cardiopulmonary bypass surgery, allergic asthma, stroke caused by periodontitis, myocardial infarction, bone-related disorders and bone injuries associated with abnormal complement activation (e.g., via the effect of anaphylatoxins on osteoclast formation), and acute conditions, in which the host is facing a dramatic increase in injury and / or pathogen-related molecular patterns, as specified above. [Brief explanation of the drawing]

[0139] [Figure 1] This includes experimental results demonstrating the effects of crazakizumab on the transcription of HLA-DR, CD54, IL-6, and PDL-1. [Figure 2] The following outlines the pretreatment of epithelial cells (ECs) with crazakizumab before co-culturing with allogeneic PBMCs. [Figure 3] This includes experimental results showing IL-6 secretion in co-culture with crazakizumab. [Figure 4] This includes experimental results demonstrating the effect of direct addition of crazakizumab to EC-allo PBMC co-cultures. [Figure 5] This includes experimental results demonstrating the effects of crazakizumab on the transcription of IL-6, MCP-1, and RANTES in EC-PBMC co-cultures. [Figure 6] This includes experimental results demonstrating the effect of crazakizumab on the proliferation of Tmem and Treg cells in EC co-culture with allo-PBMCs. [Figure 7] This includes experimental results demonstrating the effect of crazakizumab on the proliferation of T17 and Th1 cells in co-cultures of EC-PBMCs. [Figure 8] This includes experiments demonstrating that IL-6R secretion does not change after EC stimulation. [Figure 9] A schematic diagram illustrates the effects of Claza on EC proliferation and EC phenotype. [Figure 10] We present an experiment demonstrating that Claza does not alter EC growth. [Figure 11] This paper presents an experiment demonstrating the effects of Claza on homogeneous mediators. [Figure 12] A schematic diagram illustrates the experiment demonstrating the effect of Claza on the EC phenotype. [Figure 13] A schematic diagram illustrates the experiment demonstrating the effect of Claza on IL-6 ELISA. [Figure 14] An experiment demonstrating the effect of Claza on IL-6 secretion by EC is illustrated. [Figure 15] An experiment demonstrating the effect of Claza on EC co-culture regarding EC allogeneity is illustrated. [Figure 16] This diagram illustrates an experiment demonstrating that Claza reduces CCL-2 production in EC-PMBC co-cultures. [Figure 17] An experiment demonstrating the effect of Claza on CD4+ T cell activation is illustrated. [Figure 18] Experiments demonstrating the proliferation of Th17 and Th1 cells in the presence of Claza are illustrated. [Figure 19] An experiment demonstrating the mitigating effect of craza on the Th1 response in allogeneic CD4+ T cells is illustrated. [Figure 20] An experiment demonstrating the proliferation of Th1 cells in the presence of "low doses" of Claza is illustrated. [Figure 21]This diagram illustrates an experiment demonstrating the effect of Claza on the expression of complement regulatory proteins (ECs). [Figure 22] An experiment demonstrating the effect of Claza on complement activation is illustrated. [Figure 23] Further illustrations illustrate the effects of Claza on complement activation. [Modes for carrying out the invention]

[0140] In the field of the art, there is a need for methods to improve transplant success, including improvements in pre-transplant desensitization and post-transplant ABMR treatment and prevention. Interleukin-6 (IL-6) is a cytokine that exerts a potent stimulating effect on B cells and plasma cells and, in combination with other cytokines, is responsible for normal antibody production. IL-6 also has a potent stimulating effect on T cell-mediated inflammatory processes. The present invention relates to the use of specific anti-IL-6 antibodies or antibody fragments for treating organ transplant recipients before, during, or after organ transplantation. Specifically, the present invention relates to methods for improving survival and / or quality of life in transplant recipients in need, particularly sensitized pre-transplant patients, e.g., patients at risk of sensitization to transplanted donor tissue or organs due to a history of transfusion, pregnancy, or previous transplantation; pre-transplant or post-transplant patients showing signs of ABMR or CAMBR; or any patient who may be at risk of developing ABMR or CAMBR.

[0141] Specifically, the present invention provides a novel therapeutic protocol for treating or prophylactic ABMR or CAMBR using specific anti-IL-6 antibodies and antibody fragments, such as crazakizumab, in patients in need, particularly those undergoing solid organ transplantation.

[0142] The present invention also provides a novel treatment protocol for desensitization of allograft recipients awaiting transplantation and highly sensitized allograft recipients after transplantation, by use of specific anti-IL-6 antibodies and antibody fragments, such as clazakizumab, and others having the sequences disclosed in U.S. Patent No. 9,452,227 (the content of the sequence listing is incorporated by reference in its entirety).

[0143] More specifically, the present invention provides a method for preventing, stabilizing, or reducing antibody-mediated rejection (ABMR) or chronic antibody-mediated rejection (CAMBR) in a subject who has received or is receiving a solid organ transplant, the method comprising administering to the subject a prophylactically or therapeutically effective amount of an anti-human interleukin-6 (IL-6) antibody or antibody fragment, wherein the antibody or antibody fragment comprises a variable light chain polypeptide comprising the CDRs of SEQ ID NOs: 4, 5, and 6, and a variable heavy chain polypeptide comprising the CDRs of SEQ ID NOs: 7, 8 or 120, and 9, for example, the antibody comprises a V H and V L polypeptide that is at least 90, 95, 96, 97, 98, or 99% identical to the polypeptides of SEQ ID NOs: 657 and 709, respectively, or the antibody comprises heavy and light chain polypeptides that are at least 90, 95, 9 6, 97, 98, or 99% identical to the polypeptides of SEQ ID NOs: 704 and 702, respectively, and preferably the antibody is clazakizumab. In an exemplary embodiment, the solid organ is selected from the kidneys, heart, liver, lung, pancreas, skin, intestine, stomach, or any combination thereof, or preferably is a kidney.

[0144] The present invention also provides a method for preventing, stabilizing, or mitigating pre- or post-transplant sensitization in a subject who has received or is scheduled to receive a solid organ transplant, comprising administering a prophylactic or therapeutically effective amount of anti-human interleukin-6 (IL-6) antibody or antibody fragment, wherein the antibody or antibody fragment comprises a variable light chain polypeptide containing the CDRs of SEQ ID NOs. 4, 5, and 6, and a variable heavy chain polypeptide containing the CDRs of SEQ ID NOs. 7, 8, or 120 and 9, for example, the antibody contains VH and VL polypeptides that are at least 90, 95, 96, 97, 98, or 99% identical to the polypeptides of SEQ ID NOs. 657 and 709, respectively, or the antibody contains heavy chain and light chain polypeptides that are at least 90, 95, 96, 97, 98, or 99% identical to the polypeptides of SEQ ID NOs. 704 and 702, respectively, and preferably, the antibody is crazakizumab.

[0145] In some embodiments, the anti-IL-6 antibody comprises a specific CDR, as described in U.S. Patent No. 9,452,227, the disclosure thereof is incorporated herein by reference in whole. In preferred embodiments, the anti-IL-6 antibody is an antibody or antibody fragment that specifically binds to a linear or conformational epitope(s) on a humanized variant of Ab1 (see, for example, U.S. Patent No. 9,452,227), such as crazakizumab, or on an intact human IL-6 polypeptide fragment identical to crazakizumab or containing the same CDR as this antibody.

[0146] Exemplary anti-IL-6 antibodies and antibody fragments include a variable light chain polypeptide comprising the CDRs of SEQ ID NOs. 4, 5, and 6 and having at least 90% identity with the variable light chain polypeptide of SEQ ID NOs. 709, and a variable heavy chain polypeptide comprising the CDRs of SEQ ID NOs. 7, 8, or 120, and 9 and having at least 90% identity with the variable heavy chain polypeptide of SEQ ID NOs. 657, the antibody or antibody fragment specifically binds to IL-6, antagonizes one or more activities associated with IL-6, and specifically binds to the same IL-6 epitopes(or epitopes) as the anti-IL-6 antibodies comprising the variable light chain polypeptide of SEQ ID NOs. 709 and the variable heavy chain polypeptide of SEQ ID NOs. 657. (All sequences identified herein are described in U.S. Patent No. 9,452,227).

[0147] In a particularly preferred embodiment, the anti-IL-6 antibody used in the method of the present invention is crazakizumab. Clazakizumab is a humanized monoclonal antibody that binds to and inhibits IL-6. This antibody potently inhibits or prevents IL-6 from binding to IL-6R and gp130. Clazakizumab has demonstrated efficacy in clinical and preclinical studies evaluating patients with rheumatoid arthritis, psoriatic arthritis, cancer, and cachexia, and has potential applications in the treatment of many diseases characterized by chronic inflammation.

[0148] The present invention relates to a method for treating a patient before, during, or after transplantation, or any combination thereof. The graft (transplant) may be any organ, tissue, or cell(s) that is introduced into / on the patient receiving the transplant (recipient). In preferred embodiments, the graft organ, tissue, or cell(s) may be allogeneic, so that the graft is an allograft. The intestines (large and / or small intestines) and solid organs (e.g., kidneys, heart, liver, lungs, gallbladder, skin, stomach, and pancreas) are also preferred.

[0149] Treatment with the target anti-IL-6 antibody, such as crazakizumab, may improve the effectiveness of the desensitization procedure in pre-transplant patients. Specifically, antibody therapy may improve the effectiveness of the desensitization procedure in patients who have failed to desensitize. This may improve transplant rates or shorten transplant time in these sensitized patients. Pre-transplant treatment with anti-IL-6 antibodies, such as crazakizumab, may also improve transplant success in non-sensitized patients. Treatment with anti-IL-6 antibodies, such as crazakizumab, may also improve the effectiveness of treatment in post-transplant patients by preventing, mitigating, or improving damage caused by ABMR.

[0150] As used herein, “improved,” “improvement,” and other grammatical variations include any beneficial change resulting from treatment. A beneficial change is any way in which the patient’s condition is better than if no treatment had been performed. “Improved” includes the prevention of an undesirable condition, the slowing of the rate at which a condition deteriorates, the delay of the onset of an undesirable condition, and the increase in the rate at which a desired condition is reached. For example, improvement in a sensitized patient includes any reduction in sensitization, as well as any increase in the amount or rate at which DSA is prevented, eliminated, or mitigated. As another example, improvement in a transplant recipient includes any prevention, reduction, delay, or slowing of the rate or amount of antibody-mediated damage or loss of function to the transplanted organ.

[0151] Anti-IL-6 antibodies, such as crazakizumab, may be administered to pre-transplant patients with or without one or more additional standard desensitization therapies (e.g., plasma exchange therapy or intravenous plasmapheresis, anti-B cell agents such as rituximab (anti-CD20 mAb), and plasma cell inhibitors such as bortezomib (proteosome inhibitor)). In some embodiments, anti-IL-6 antibodies, such as crazakizumab, are administered intravenously (e.g., in doses ranging from 0.01 to 5000 mg, more typically 0.1 to 1000 mg or 1 to 500 mg, in exemplary embodiments in the range of 5 mg to 50 mg) or subcutaneously (e.g., in doses ranging from 0.01 to 5000 mg, more typically 0.1 to 1000 mg or 1 to 500 mg, in exemplary embodiments in the range of 10 mg to 50 mg) every four weeks, starting several months prior to treatment (e.g., six months).

[0152] Treated patients can be periodically evaluated during the desensitization treatment process by prior desensitization using various antibody detection methods (e.g., cytotoxic crossmatch, flow cytometry crossmatch, Luminex antibody test). Positive reactions (e.g., conversion from positive to negative cytotoxic crossmatch) allow patients to proceed with transplantation and reduce the risk of antibody-mediated rejection after transplantation.

[0153] Treatment with anti-IL-6 antibodies, such as crazakizumab, can prevent or treat early acute or late chronic rejection when continued for several months after transplantation (e.g., 1 to 36 months). Early acute rejection episodes are usually T cell-mediated, while late chronic rejection episodes are usually antibody-mediated. Rejection episodes are generally characterized by nonspecific evidence (e.g., increased serum creatinine and / or proteinuria, or decreased eGFR in kidney transplants) and / or the development of new DSAs (novel DSAs), and may be confirmed by evidence from known diagnostic blood tests and biopsies (e.g., organ biopsies) (e.g., microangiitis, interstitial fibrosis, transplant glomerulopathy, CD4 deposition). Anti-IL-6 antibodies may be administered with or without one or more additional immunosuppressants (e.g., anti-CD20 mAbs such as thymoglobulin, basiliximab, mycophenolate mofetil, tacrolimus, rituximab, and corticosteroids).

[0154] In addition, in post-transplant patients experiencing or at risk of antibody-mediated rejection (ABMR) or chronic antibody-mediated rejection (CABMR), plasma levels of IL-6 are significantly elevated and decrease as rejection weakens. Therefore, regardless of whether the patient was treated with anti-IL-6 antibodies before transplantation, post-transplant administration of anti-IL-6 antibodies is triggered by HLA and non-HLA DSA in ABMR patients. It may be useful in improving or mitigating antibody-mediated injury.

[0155] Similarly, in ABMR patients, an anti-IL-6 antibody, such as crazakizumab, may be administered intravenously (e.g., 0.01–5000 mg, more typically 0.1–1000 mg or 1–500 mg, in exemplary embodiments in the range of 5–50 mg) or subcutaneously (e.g., 0.01–5000 mg, more typically 0.1–1000 mg or 1–500 mg, in exemplary embodiments in the range of 10–50 mg) every four weeks, starting before treatment, at the time of transplantation, or when evidence of rejection develops. In this case as well, the first signs of rejection usually include nonspecific evidence such as elevated serum creatinine or the development of proteinuria, and confirmation of ABMR can be performed using known diagnostic blood tests and biopsies. Treatment with anti-IL-6 antibodies may be continued for several months (e.g., from one month to several years) to prevent antibody-mediated damage to the allograft and the resulting loss of function, which can ultimately lead to complete loss of the transplanted organ.

[0156] In some embodiments, the present invention provides a pharmaceutical composition suitable for preventing or treating ABMR, or for treating or preventing sensitization in organ transplant recipients. The pharmaceutical composition comprises crazakizumab and a pharmaceutically acceptable carrier or excipient, and may optionally comprise one or more other immunosuppressants.

[0157] Pharmaceutical compositions for use in the methods according to the present invention may contain any pharmaceutically acceptable excipients. Examples of excipients include, but are not limited to, starches, sugars, microcrystalline cellulose, diluents, granulators, lubricants, binders, disintegrants, wetting agents, emulsifiers, colorants, release agents, coating agents, sweeteners, flavoring agents, fragrances, preservatives, antioxidants, plasticizers, gelling agents, thickeners, curing agents, preservatives, suspending agents, surfactants, humectants, carriers, stabilizers, and combinations thereof.

[0158] In various embodiments, the pharmaceutical compositions according to the present invention may be formulated for delivery via any route of administration. This may include, for example, aerosol, nasal, oral, transmucosal, transdermal, parenteral, or enteral delivery.

[0159] "Pareral" refers to routes of administration generally associated with injection, including intraorbital, infusion, intra-arterial, intracapsular, intracardiac, intradermal, intramuscular, intraperitoneal, intrapulmonary, intraspinal, intrasternal, subarachnoid, intravenous, subarachnoid, subcapsular, subcutaneous, transmucosal, or transtracheal. Via parenteral routes, compositions may exist in the form of solutions or suspensions for infusion or injection, or as lyophilized powders. Via parenteral routes, compositions may be in the form of solutions or suspensions for infusion or injection. Via enteral routes, pharmaceutical compositions may be in the form of tablets, gel capsules, sugar-coated tablets, syrups, suspensions, solutions, powders, granules, emulsions, microparticles or nanoparticles, or lipid vesicles or polymer vesicles that allow for controlled release. Typically, compositions are administered by injection. These methods of administration are known to those skilled in the art.

[0160] The pharmaceutical composition according to the present invention may contain any pharmaceutically acceptable carrier. For example, the carrier may be a filler, diluent, excipient, solvent, or encapsulating material of the liquid or prophylactic body, or a combination thereof.

[0161] To further describe the present invention, the following examples are provided.

[0162] Example 1 Use of crazakizumab as part of a desensitization protocol for highly sensitized patients awaiting transplantation after allogeneic transplantation.

[0163] Patients awaiting kidney transplantation who have been previously sensitized or are at risk of sensitization due to the presence of antigens in the donor organ (e.g., due to blood transfusion, pregnancy, or previous transplantation) are treated therapeutically or prophylactically to reduce, eliminate, or prevent sensitization to antigens (e.g., HLA and non-HLA antigens) present in the donor organ. For example, patients are treated with plasmapheresis, or plasma exchange, optionally in combination with intravenous immunoglobulin and anti-B cell agents such as rituximab or plasma cell inhibitors such as bortezomib (a proteosome inhibitor). These procedures are repeated as needed and typically continue until organ transplantation is performed, and may continue after organ transplantation.

[0164] Additionally, to enhance the effectiveness of the desensitization treatment regimen, patients are further treated therapeutically or prophylactically with an anti-IL-6 antibody, such as crazakizumab. This anti-IL-6 antibody is administered intravenously in doses ranging from 5 mg to 50 mg, or subcutaneously in doses ranging from 10 mg to 50 mg. Antibody administration is started every four weeks or monthly, preferably about one month or several months before transplantation, for example, about one to six months before transplantation.

[0165] In addition to prior desensitization, throughout these desensitization procedures, patients are also regularly evaluated by one or more antibody detection methods (e.g., cytotoxic crossmatch, flow cytometry crossmatch, Luminex antibody test) to assess their DSA levels.

[0166] In the case of a positive reaction (e.g., conversion from positive to negative cytotoxic crossmatch), the patient is determined to be suitable for organ transplantation, and a donor kidney is then transplanted according to known procedures.

[0167] Concurrently or post-transplant, patients are treated with crazakizumab for several months (for example, to prevent or treat early acute or late chronic rejection, initiated at or about one month after transplantation, and continued for several months or years post-transplant, e.g., 6, 12, 18, 24, 30, 36 months, or even 5, 10, 20 years post-transplant). Early acute rejection episodes are usually T-cell mediated, while late chronic rejection episodes are usually antibody-mediated.

[0168] An episode of rejection may be manifested by the development of a new DSA (novel DSA), which can be confirmed by one or more clinical signs (e.g., increased serum creatinine and / or proteinuria, or decreased eGFR in kidney transplantation), biopsy evidence (e.g., microangiitis, interstitial fibrosis, transplant glomerulopathy, CD4 deposition), or a new DSA, if present in the transplant recipient.

[0169] In addition, patients may also be treated with other standard immunosuppressive regimens (e.g., thymoglobulin, basiliximab, mycophenolate mofetil, tacrolimus, and corticosteroids). These additional immunosuppressive regimens are administered pre- and post-transplant, for example, starting approximately 1–6 months pre-transplant and continuing for several months or years post-transplant. After transplantation, patients are regularly evaluated for clinical signs of rejection, such as increased serum creatinine and / or proteinuria or decreased eGFR. If any such clinical reaction is observed, patients may be treated more aggressively with immunosuppressants, for example, by increasing the dose of immunosuppressants or by being treated more frequently with immunosuppressants, and / or by being treated with other immunosuppressants to stabilize or eliminate rejection.

[0170] Example 2: Use of crazakizumab in hyper-HLA sensitized patients awaiting kidney transplantation. Patients who have previously experienced allogeneic transplant failure are sensitized to high levels of human leukocyte antigen (HLA). This is a major problem for transplant centers because patients are unlikely to undergo another transplant without significant desensitization. According to this invention, eligible transplant patients will generally receive up to six monthly doses of 25 mg of crazakizumab pre-transplant. If a patient undergoes an HLAi transplant during treatment, the participant may continue to receive an additional six months' worth of 25 mg of crazakizumab, followed by a six-month protocol biopsy. If improvement is seen after the sixth dose of crazakizumab, the patient will receive six more doses over a six-month period. Patients with evidence of persistent allogeneic transplant failure may have a non-protocol biopsy as the cause. Patients who have received 12 doses of crazakizumab post-transplant will generally undergo a 12M protocol biopsy.

[0171] Patients considering further treatment may first receive PLEX (5-7 sessions) + IVIG, followed by crazakizumab 25 mg SC one week after IVIG. If no safety / tolerability / efficacy issues are observed after the initial dose, patients may receive 5 additional injections at Q4W. If the patient has undergone HLAi transplantation, crazakizumab will be continued for 6 months for 6 doses of 25 mg SC at Q4W (starting from post-transplant day 5). A protocol biopsy may be performed at 6 months post-transplant to evaluate the allogeneic graft for evidence of ABMR or CAMBR, including C4d staining and TG, using the Banff 2015 criteria. If improvement is seen after the 6th dose of crazakizumab, the patient will continue to receive 6 more doses over 6 months. Patients with evidence of persistent allogeneic transplant failure may have a non-protocol biopsy as the cause. Patients who have received 12 doses of crazakizumab post-transplant may undergo a 12M protocol biopsy. If a patient does not show improvement after receiving six doses of crazakizumab, further treatment is generally not recommended.

[0172] Treated subjects will generally be followed up to determine whether the use of crazakizumab for desensitization in this high-risk transplant population is safe and does not pose an infection risk. In addition, the efficacy of crazakizumab treatment against HLA antibodies will be evaluated. Renal biopsies will be evaluated at 6 months and may be repeated at 12 months (e.g., for patients who have received 12 doses). Transplanted patients will then be evaluated to similarly determine the number of allogeneic grafts of viable and functioning kidneys to maintain.

[0173] Generally, patients receive crazakizumab monthly. Patients will generally receive up to six doses before transplantation. If a patient is transplanted during IL-6 Ab treatment, the patient may receive six doses of crazakizumab (monthly), and a biopsy may be performed as part of a six-month protocol. Based on the biopsy results and laboratory findings, a PI (Patient Inspection) is determined to assess whether the patient should continue monthly doses for up to six more doses. Patients who have received 12 doses of crazakizumab post-transplant may then undergo a biopsy as part of a twelve-month protocol.

[0174] Example 3: Use of crazakizumab in the treatment of patients with late-stage AMBR The safety, tolerability, pharmacokinetics, pharmacodynamics, and efficacy (preliminary evaluation) of the humanized anti-IL-6 monoclonal antibody crazakizumab in kidney transplant recipients will be assessed in patients with late-stage antibody-mediated rejection (ABMR). This study is designed as a Phase 2 trial with two subparts: a 12-week randomized, placebo-controlled trial (Part A) in which recipients are assigned to receive either the anti-IL-6 antibody crazakizumab (n=10) or placebo (n=10); and a subsequent open-label, prospective study in which all 20 study patients will receive crazakizumab for 40 weeks. Study protocol biopsies will be performed at the end of Parts A and B.

[0175] Part A: Patients who are positive for anti-HLA donor-specific antibodies (DSA) and have late-stage ABMR (acute / active or chronic / active phenotype according to the Banff 2015 classification) as confirmed by biopsy will be identified and recruited at the kidney transplant outpatient services of two center sites. Participants will be randomly assigned to receive either crazakizumab or placebo subcutaneously for a 12-week period (1:1 randomization stratification for ABMR type), with administration of crazakizumab / placebo on day 0 and at weeks 4 and 8. After 12 weeks, patients will generally undergo their first follow-up biopsy. The primary objective of this part of the trial is to evaluate the safety, tolerability, pharmacokinetics, and pharmacodynamics of a short-term treatment. Furthermore, Part A provides an initial preliminary assessment of the effects of crazakizumab on ABMR-related inflammation detected in peripheral blood and rejected organ allografts, regarding the pharmacokinetics of pantoprazole as a probe drug to investigate the effects of IL-6 blockade on cytochrome P450 (CYP)-dependent drug metabolism (half-life of CYP metabolites such as pantoprazole, and potential effects on short-term mean fluorescence intensity (MFI) of DSA and renal allograft function (eGFR, urinary protein excretion).

[0176] Part B: After completing Part A at 12 weeks, study patients can proceed to Part B, the open-label part of the study. Participants will generally receive subcutaneous crazakizumab at 4-week intervals until the End of Study (EOS) visit at 52 weeks, followed by a second protocol biopsy. The primary objectives of Part B are to evaluate the safety and tolerability of long-term treatment with crazakizumab, as well as the long-term effects of this antibody on ABMR progression, rejection-related biomarkers, and renal allograft function and survival over 12 months.

[0177] Example 4: Use of crazakizumab as a treatment for patients with antibody-mediated rejection (ABMR) after transplantation. Identify patients who show signs of developing antibody-mediated rejection (ABMR) or who have undergone solid organ transplantation (e.g., kidney, heart, liver, lung, pancreas, skin, gallbladder, stomach, intestine, or combination thereof) and are showing signs of ABMR. Unfortunately, as described herein, these patients are not suitable for treatment with current standard immunosuppressant therapies, which is a major cause of allogeneic transplant failure after transplantation.

[0178] Specifically, patients are monitored post-transplant with diagnostic tests that enable prediction and early diagnosis of ABMR. For example, patients may be evaluated using one or more tests that detect pre-formed novel HLA DSAs (particularly those that detect complement-binding DSAs such as C1q) and / or assays that detect the presence of non-HLA antibodies associated with ABMR.

[0179] Furthermore, transplanted organs may be investigated for histological signs of ABMR-mediated injury, which can be detected by using renal allogeneic transplant biopsy and screening biopsy samples for pathological symptoms characteristic of ABMR-mediated organ injury, such as peritubular capillary inflammation, peritubular capillary vasculitis, glomerulitis, and microvascular inflammation and complement deposition (C4d) in transplant glomerulopathy (double glomerular basement membrane contour).

[0180] Next, identified patients, i.e., individuals showing clinical or histological signs of developing antibody-mediated rejection (ABMR) or chronic antibody-mediated rejection (CABMR), or individuals showing ABMR or CABMR, will be treated prophylactically or therapeutically with crazakizumab to prevent, stabilize, or reverse the development of ABMR. This treatment, i.e., administration of an anti-IL-6 antibody, should improve or reduce ABM damage caused by these HLA and non-HLA DSAs.

[0181] The patient also received standard post-transplant immunosuppressant medications (e.g., thymoglobulin, basilicum). Treatment may involve a combination of anti-CD20 mAbs (such as simab, mycophenolate mofetil, tacrolimus, or rituximab, and corticosteroids) and crazakizumab, typically administered intravenously (at doses of 5-50 mg) or subcutaneously (at doses of 10-50 mg), starting at the time of transplantation or when evidence of rejection develops, and administered every four weeks. The first signs of rejection usually include nonspecific evidence such as elevated serum creatinine or the development of proteinuria. Confirmation of ABMR or CAMBR is achieved by the specific diagnostic blood tests and organ biopsies described above.

[0182] Treatment with crazakizumab may be continued for several months (e.g., from one month to several years) to prevent antibody-mediated damage to the allogeneic graft and the resulting loss of function, which can ultimately lead to complete loss of the transplanted organ.

[0183] To further establish proof of concept, experiments were conducted to evaluate the effects of crazakizumab on co-culture including allogeneic cells, proliferation of specific immune cells, and expression of cytokines involved in rejection.

[0184] Specifically, experiments were conducted to evaluate the effects of crazakizumab on the transcription of HLA-DR, CD54, IL-6, and PDL-1. These experiments are described in the following examples.

[0185] Example 5: Effect of antagonist anti-IL-6 antibody (crazakizumab) on EC proliferation The presence of endothelial cells in co-culture was observed to induce increased IL-6R secretion by PBMCs (see Figure 8). In contrast, binding of anti-HLA-DR Ab to endothelial cells did not alter IL-6R secretion by PBMCs.

[0186] Based on this, it has been theorized that IL-6 secretion by EC in co-culture with PBMCs may depend on transsignaling and autocrine EC reactions. Based on the above, experiments were conducted to study the effects of different doses of the antagonist anti-IL-6 antibody (Claza) on endothelial cell proliferation. As schematically illustrated in Figure 9, the effects of the antagonist anti-IL-6 antibody (clazakizumab) on EC proliferation and phenotype were confirmed.

[0187] In particular, endothelial cell cultures were exposed to and not exposed to 1 μg / ml of Claza, 20 μg / ml of Claza, and 50 μg / ml of Claza. As shown in Figure 10, there was no effect on endothelial cell proliferation regardless of the dose of IL-6 antagonist antibody administered.

[0188] Example 7: Effect of crazakizumab on homogeneous mediators Experiments were conducted to evaluate the effect of an IL-6 antagonist antibody (crazakizumab) on the transcription of genes involved in alloimmune responses. As is clear from the experiment shown in Figure 11, the transcription of specific genes known to be involved in alloimmune responses was not altered by crazakizumab.

[0189] Specifically, in these experiments, levels of HLA-DR, CD54, IL-6, PDL-1, and glyceraldehyde-3-phosphate dehydrogenase (GADPH) mRNA were assayed using fluorescence-based real-time PCR after 3 days of treatment with different doses of crazakizumab, with or without IFNγ, and total RNA was isolated from endothelial cells (ECs) using the TRI reagent (Ambion, Applied Biosystems, Thermo Fischer Scientific) protocol.

[0190] RNA was quantified using a spectrophotometer (ND-1000; Nanodrop) and converted to cDNA (1 μg RNA / reaction) by reverse transcription (RT) using a SuperScript III First-Strand Synthesis System for RT-PCR (Invitrogen Life Technologies). Real-time PCR was performed using the ViiA 7 Real-time PCR System (Applied Biosystems, Thermo Fischer Scientific) and the TaqMan gene expression assay (Applied Biosystems, Thermo Fischer Scientific).

[0191] The primer and probe sets used for this study were IL-6 (Hs00174131_m1), CD54 (Hs00164932_m1), HLA-DR (Hs00219575_m1), PDL1 (Hs01125301_m1), and GAPDH (Hs027558991_g1).

[0192] The threshold cycle (Ct) was determined as the average of two measurements. The difference in relative mRNA levels was calculated as ΔCt (target gene - GAPDH "housekeeping" gene), expressed as a percentage of the control condition (endothelial cells incubated with IFNγ). The mean ± SEM values ​​are shown in Figure 11.

[0193] Example 8: Effect of clazakizumab on EC phenotype Experiments were conducted to evaluate the effect of an IL-6 antagonist antibody (crazakizumab) on the EC phenotype. As demonstrated by the experiment shown in Figure 12, the EC phenotype was unaffected by the anti-IL-6 antibody after 7 days of treatment.

[0194] In these experiments, endothelial cells were cultured in tissue culture flasks with 20 ng / ml (Eurobio) interferon-γ (IFN-γ) and incubated with different doses of crazakizumab for 3 days, as shown in Figure 12.

[0195] The following antibodies were used for phenotypic analysis of endothelial cells: HLA-DR APC (clone L243, Biolegend), CD54 PacBlue (clone HCD54, Biolegend), and CD274 PC7 (clone MIH1, BD Pharmingen).

[0196] EC cells were trypsinized with 0.05% trypsin in EDTA (Gibco), washed with 1 ml of cold phosphate-buffered saline (PBS) containing 0.5% bovine serum albumin (BSA), and centrifuged at 4°C. Monoclonal antibody was added, and the cells were incubated on ice for 30 minutes. The cells were then washed again using the same washing conditions, resuspended in PBS 0.5% BSA, and analyzed on a FACS Canto II (BD Biosciences) scale.

[0197] As shown in Figure 12, the results of these experiments are expressed as the percentage of cells expressing the relevant antigen, with mean ± SEM values ​​shown. Seven days after treatment, the EC phenotype was found to be unaffected by the anti-IL-6 antibody.

[0198] Example 9: Efficacy of clazakizumab for ELISA detection of IL-6 Experiments were also conducted to evaluate the effect of an IL-6 antagonist antibody (crazakizumab) on the amount of IL-6 detected in an ELISA assay. Specifically, we evaluated whether crazakizumab interfered with the detection of IL-6 when IL-6 was quantified using a Biolegend enzyme-coupled immunosorbent assay (ELISA) detection kit, which was used according to the manufacturer's protocol.

[0199] In these experiments, IL-6 was assayed using supernatant containing known concentrations of IL-6, with or without the addition of crazakizumab (20 μg / ml). Control conditions were included, either without the addition of a secondary antibody or without coating the ELISA plate with the detection antibody. A schematic of the different conditions tested is shown in Figure 13. Results are expressed in absorbance units.

[0200] Based on the results in Figure 13, crazakizumab does not appear to interfere with the detection of IL-6 using enzyme-coupled immunosorbent assay (ELISA).

[0201] Example 10: Effect of crazakizumab on IL-6 secretion As shown in Figure 14, experiments were also conducted to evaluate the effect of an IL-6 antagonist antibody (crazakizumab) on IL-6 endothelial cell secretion. In these experiments, endothelial cells were cultured in tissue culture flasks with or without 20 ng / ml (Eurobio) interferon-γ (IFN-γ), and incubated with different doses of crazakizumab, as shown in Figure 14.

[0202] Three days later, IL-6 was quantified in the supernatant of EC using a Biolegend enzyme-coupled immunosorbent assay detection kit, used according to the manufacturer's protocol. The results shown in Figure 14 are expressed as the amount of secreted IL-6. The figure shows the mean ± SEM value (*p<0.05 and **p<0.01, paired t-tests).

[0203] Figure 14 shows the effect of detecting IL-6 antagonist antibody (crazakizumab) at different drug concentrations.

[0204] Example 11: Effect of crazakizumab on CCL-2 production in EC-PBMC co-cultures As schematically shown in Figure 15, experiments were also conducted to evaluate the effect of the IL-6 antagonist antibody (crazakizumab) on allogeneic mutations observed in EC co-culture. Specifically, as shown in Figure 16, experiments were also conducted to evaluate the effect of the IL-6 antagonist antibody (crazakizumab) on CCL-2 production in EC-PBMC co-culture. In these experiments, EC was activated with IFNγ (20 ng / ml (Eurobio)) for 3 days, then starved of IFNγ overnight, and co-cultured with PBMCs with mismatched HLA. The EC was washed and irradiated with 20 Gy.

[0205] As shown in Figure 16, the irradiation process did not prevent cytokine secretion by EC within the following 3 days. Carboxyfluorescein succinimimidyl ester (CFSE)-labeled PBMCs (2.5 μM, molecular probe / Invitrogen) were stimulated with EC (1:1) irradiated in RPMI-10% human AB serum (EFS) for 7 days.

[0206] In T0, different concentrations of crazakizumab were added to EC / PBMC co-cultures, as shown in Figure 16. The supernatant of the co-cultures was collected after 72 hours and assayed to detect the amounts of IL-6, CCL2, and RANTES using a Biolegend enzyme-coupled immunosorbent assay detection kit, and repeated according to the manufacturer's protocol. The results of these experiments, shown in Figure 16, are expressed as the amount of secreted cytokines. Mean ± SEM values ​​(*p<0.05, paired t-test) are shown. The results indicate that the IL-6 antagonist antibody (crazakizumab) reduces CCL-2 production in EC-PBMC co-cultures.

[0207] Example 12: Effect of IL-6 antagonist Ab (crazakizumab) on EC-mediated T-CD4+ activation As shown in Figure 17, T-CD4 by EC + IL-6 antagonist antibody against ( Experiments were also conducted to evaluate the efficacy of crazakizumab. In these experiments, EC / PBMC co-cultures were obtained as previously described. After 7 days of co-culture, carboxyfluorescein succinimimidyl ester (CFSE)-labeled PBMCs were treated with CD4 + CD45 RA- CD25 高 CD127 低 FoxP3 明 Treg and (CD4) identified as + CD45 RA- FoxP3 低 It was used to study the proliferation of Tmem, which was identified as a subpopulation.

[0208] For flow cytometry, the following antibodies were used: CD4 PB (clone RPA-T4), CD45RA PE / Cy7 (clone H100), CD25 PE (clone M-A251), and CD127 PerCP / Cy5.5 (clone A019D5) (Biolegend). Intracellular staining for FoxP3 was performed using the anti-human Foxp3 staining set APC (clone 236A / E7) (eBioscience). Flow cytometry was performed on a FACS Canto II (BD Biosciences).

[0209] The results are expressed as the percentage of each T cell subset and the percentage of proliferating cells in those populations. The median (red line) is shown.

[0210] Example 13: Effect of IL-6 antagonist Ab (crazakizumab) on endothelial proliferation of Th17 and Th1 cells As shown in Figure 18, experiments were also conducted to evaluate the effect of the IL-6 antagonist antibody (crazakizumab) on endothelial proliferation of Th17 and Th1 cells. In these experiments, EC / PBMC co-cultures were obtained as previously described. After 7 days of co-culture, PBMCs were stimulated for 4 hours with 50 ng / mL of phorbol 12 myristate 13 acetate (PMA) and 1 μM ionomycin (Cell Signaling Technology) along with 1× GolgiStop (BD Biosciences), and Th17 (CD3 + CD8 - IL17 + ) and Th1(CD3 + CD8 - IFNγ + Subpopulations were analyzed by flow cytometry to detect intracellular cytokines.

[0211] The following antibodies were used for flow cytometry: IFN-γFITC (clone B27) (BD Pharmingen, BD Biosciences), CD4 PE (clone RPA-T4), CD3 PerCP (clone SK7), CD8 PB (clone RPA-T8) (Biolegend), and IL-17 efluor660 (eBioscience). Flow cytometry was performed on a FACS Canto II (BD Biosciences). The results in Figure 18 are shown as percentages for each T cell subset. The median (red line) is shown (*p<0.05, paired t-test).

[0212] Based on the results in Figure 18, it can be seen that there was a significant decrease in IFNγ-producing cell (Th1) proliferation in the presence of IL-6 antagonist antibodies.

[0213] Example 14: Identical CD4 + The effect of the IL-6 antagonist Ab (crazakizumab) on the Th1 response of T cells. As shown in Figure 19, experiments were also conducted to evaluate the effect of the IL-6 antagonist antibody (crazakizumab) on the Th1 response of allogeneic CD4+ T cells. This figure shows the distribution of Th1 cells in various donors and compares the control condition with conditions using various doses of crazakizumab, as shown in the 7-day co-culture. As previously described, an analysis of the Th1 population was performed. These results show that crazakizumab is effective against allogeneic CD4+ T cells. + This demonstrates a consistent reduction in the Th1 response induced by T cells.

[0214] Example 15: Low dose of IL-6 antagonist Ab (Clazaki) for Th1 cell proliferation The effects of zumab As shown in Figure 20, experiments were also conducted to evaluate the effect of the IL-6 antagonist antibody (crazakizumab) on Th1 cell proliferation in the presence of "low-dose" crazakizumab. The results in Figure 20 show the distribution of Th1 cells in various donors and compare the control condition with the condition with the addition of various doses of crazakizumab, as shown in the 7-day co-culture. An analysis of the Th1 population was performed as previously described.

[0215] The results indicate that the distribution of Th1 cells was reduced even at low doses of Claza antibody.

[0216] Example 16: Effect of IL-6 antagonist Ab (crazakizumab) on EC expression of complement regulatory proteins As shown in Figure 21, experiments were also conducted to evaluate the effect of IL-6 antagonist Ab (crazakizumab) on complement regulatory protein EC expression. In these experiments, endothelial cells were cultured in tissue culture flasks with 20 ng / ml (Eurobio) interferon-γ (IFN-γ) and incubated with different doses of crazakizumab (0.5, 5, 20, and 50 μg / ml for 3 days), as shown.

[0217] Phenotypic analysis of endothelial cells was performed using the following antibodies: CD55 FITC (clone JS11), CD46 PC7 (clone TRA-2-10), and CD59 PE (p282(H19)) (Biolegend).

[0218] The EC cells were separated using Versene 1X (Gibco), washed with 1 ml of cold phosphate-buffered saline (PBS) containing 0.5% bovine serum albumin (BSA), and then centrifuged at 4°C. mAbs were added and incubated on ice for 30 minutes. The cells were then washed again and resuspended in PBS with 0.5% BSA, as previously described.

[0219] Figure 21 shows an overlay of histograms of expression for each antigen at all tested concentrations of crazakizumab. Isotype controls are represented by dotted lines, and controls without crazakizumab are represented in gray.

[0220] Example 17: Effect of IL-6 antagonist Ab (crazakizumab) on complement activation As shown in Figure 22, experiments were also conducted to evaluate the effect of the IL-6 antagonist antibody (crazakizumab) on complement activation. In these experiments, endothelial cells were cultured in tissue culture flasks with 20 ng / ml (Eurobio) interferon-γ (IFN-γ) for 3 days. Next, the ECs were isolated with 0.05% trypsin in EDTA (Gibco), the supernatant from the 3-day culture was saved, and reused on re-seeded cells. After 18 hours, 10 μg / ml of crazakizumab was added, or the culture was left unadded for a further 45 minutes at 37°C.

[0221] Following the above steps, human AB serum was added to produce a 10% human AB serum solution, rabbit serum was added to produce a 5% rabbit serum solution, and 5 μg / ml mAbs directed to HLA-DR or VE-cadherin were added. The antibodies were left at 37°C for 4 hours to allow for complement cascade activation.

[0222] To study complement activation, the fixation of C5b9 on EC was quantified by flow cytometry. The following antibodies were used: SC5b9 biotinylation (Quidel, San Diego) and streptavidin A647 (Invitrogen).

[0223] The EC was separated using Versene 1X (Gibco), washed with 1 ml of cold phosphate-buffered saline (PBS) containing 0.5% bovine serum albumin (BSA), and centrifuged at 4°C.

[0224] C5b9-biotinylated mAb was added and incubated on ice for 30 minutes. Next, the cells were washed again as previously described and stained with streptavidin A647 at 4°C for 15 minutes. Finally, the EC cells were washed twice with PBS 0.5% BSA and then flow cytometry analysis was performed.

[0225] The results in Figure 23 are expressed as the percentage of C5b9-positive cells relative to fixation. These results indicate that the IL-6 antagonist antibody (crazakizumab) significantly reduces complement activation and is highly suitable for treating AMBR or CAMBR, and other indications in which complement activity is involved in disease pathology. Furthermore, experimental results obtained in EC-PBMC co-culture demonstrated that crazakizumab itself leads to a reduction in Treg cells and further reduces the proliferation of Th1 pro-inflammatory lymphocytes.

[0226] Example 18: Clazakizumab acts on endothelial cells to limit antibody-mediated damage. Human microvascular endothelial cell expression of HLA class II antigens is potently increased both in vitro and in vivo under inflammatory conditions. HLA class II antibodies that bind to endothelial cells enhance IL-6 secretion, thereby inducing pro-inflammatory Th17 CD4 expression mediated by IL-6-dependent activation of Stat-3 (Taflin PNAS 2011, Lion Am J Trans. 2016). + It increases the ability of lymphocytes to activate and differentiate. We studied crazakizumab, an interleukin-6 specific antibody, to determine its ability to act on HLA II-expressing endothelial cells.

[0227] method: Endothelial cells were pre-incubated with crazakizumab before and during co-culture with PBMCs from unrelated individuals. Furthermore, when HLA-specific antibodies bind to endothelial cells, complement is activated and C5b-C9 deposition occurs. This was examined in the presence of crazakizumab. CD4 + T cell subpopulations were identified by intracellular cytokine staining, and C5b-C9 cells were detected by multicolor flow cytometry.

[0228] Results: This study reports that pre-incubation of endothelial cells with Clazakizumab decreased IL-6 secretion by human endothelial cells. Clazakizumab also decreased the level of the chemoattractant CCL2 in co-cultures of endothelial cells with allogeneic PBMCs. Furthermore, the proliferation of endothelium-mediated pro-inflammatory Th17 and Th1 populations was decreased. Deposition of C5b-C9 was determined after HLA antibodies bound to endothelial cells and was significantly decreased when Clazakizumab was present.

[0229] Conclusion: Taken together, these data support the idea that Clazakizumab acts directly on endothelial cells. The combination of outcomes of decreased CCL2 production, decreased pro-inflammatory CD4 + -T differentiation, and decreased formation of the C5b-C9 complex should result in an overall protective effect on allogeneic endothelium in the context of chronic humoral rejection reactions associated with HLA-specific alloantibodies.

[0230] Therefore, these results indicate that the tested IL-6 antagonist antibody (Clazakizumab) significantly reduces complement activation and is well suited for the treatment of AMBR or CAMBR and other indications in which complement activity is involved in disease pathology. Such conditions include age-related macular degeneration (AMD) (wet and dry), Alzheimer's disease, glomerular diseases, e.g. Examples include atypical hemolytic uremic syndrome (aHUS), hemolytic uremic syndrome caused by Shiga toxin-producing E. coli (STEC-HUS), thrombotic thrombocytopenic purpura (TTP), systemic lupus erythematosus (SLE), antiphospholipid syndrome (APS), antineutrophil cytoplasmic antibody (ANCA)-induced vasculitis, inflammatory small vessel disease caused by autoantibodies against neutrophil components, antibody-dependent (i.e., in women with APS), pregnancy loss with C5a-mediated impairment of placental neovascularization, paroxysmal nocturnal hemoglobinuria (PNH), aHUS and cold agglutinin disease (CAD), complement-mediated hemolytic disorders such as ischemia-reperfusion injury, and age-related and degenerative diseases such as stroke and myocardial infarction caused by trauma, sepsis, shock, and cardiopulmonary bypass (CPB) surgery. Furthermore, complement-mediated conditions that can be treated according to the present invention include, in particular, transplant-related complications when organs are transplanted after donor circulatory arrest, which can lead to the induction of IRI. Both production (via B-cell costimulation) and the effects of alloantibodies (via CP / LP activation) are complement-driven events in antibody-mediated rejection (ABMR). In islet Langerhans transplantation in diabetic patients, the occurrence of a thromboinflammatory response known as an "immediate blood-mediated inflammatory response" is caused by rapid complement activation, limiting transplant efficiency due to islet destruction. A phenomenon of particular interest in the context of transplantation, but not yet fully understood, is the adaptation of transplanted cells to become "resistant" to complement-mediated destruction. Such incompatible responses may affect the outcome of CPB cardiopulmonary bypass surgery, during which substrate materials, the blood / air interface in the prolific lung, activated platelets, and protamine complexes (produced to neutralize soluble heparin at the end of the procedure) may activate complement and contribute to systemic inflammatory response syndromes.

[0231] Other inflammatory diseases in which complement contributes include allergic asthma and periodontitis. The relationship between complement and asthma has long been recognized, but its involvement appears complex. In the asthmatic state, complement is not only activated through CP via allergen-antibody complexes, but C3 and C5 can also be cleaved by proteases derived from specific allergens (e.g., house dust mite). The resulting C3a and C5a act synergistically to create an allergen-inducing immune environment, but C5a may also protect from maladaptive type Th2 immunity during allergen sensitization. The important but complex role in asthma is also due to C5L2. Previous treatment attempts have focused on the C5aR, but the scope has recently been expanded to include inhibitors of C5 and C3 levels. In this regard, C5a is also involved in the exacerbation of chronic obstructive pulmonary disease. Finally, complement-mediated processes are recognized as important for bone-related disorders and injuries (e.g., the effect of anaphylatoxins on osteoclast formation), suggesting another potential area of application for complement therapy.

[0232] Perhaps the most profound impact of complement activation is seen in the acute phase state, often associated with SIRS, where the host is faced with a dramatic increase in injury and / or pathogen-associated molecular patterns. For example, in trauma, the initial traumatic effects combined with post-traumatic IRI can trigger a devastating cascade of immune-inflammatory responses with a complement contribution that may sustain SIRS. As a complication of trauma or as an independent event, large-scale infections overwhelm the protective functions of complement and other innate immune components (e.g., TLRs), causing immune cell activation in sepsis, cytokine storms, and coagulation disorders that can cause SIRS and may persist even after the pathogen has been eliminated, and C5a-dependent signaling appears to play a major role in these devastating events.

[0233] These experimental results suggest that crazakizumab can be used to treat or prevent AMBR or CAMBR for long-term duration in the target population, namely allogeneic or heterogeneous cells, tissues, or one or more organs, such as immune cells, fibroblasts, skin cells, nerve cells, adult stem cells, or other allogeneic or heterogeneous cells used in gene or cell therapy, or the kidneys, bladder, lungs, heart, liver, skin, pancreas, stomach, intestines, or any combination of the above. This further supports the idea that it can be performed on patients who are scheduled to receive, have already received, or are currently receiving solid organ transplants.

[0234] Example 19: Clazakizumab clinical regimen for treating AMBR or CAMBR Patients who should be treated with an immediate AMBR or CAMBR clinical regimen will generally include the following selection criteria: 1. Ages 18-75, 2. Kidney transplant recipients from living / deceased donors must be at least 6 months old since the transplant. 3. The diagnosis of CABMR (according to the Banff 2015 diagnostic criteria) includes all of the following: i. CABMR (i.e., chronic glomerulosynovitis (cg) > 0) confirmed by biopsy, regardless of whether C4d staining is performed or not. ii. Presence of HLA DSA after transplantation (using a single antigen bead-based assay).

[0235] Patients excluded from treatment in the clinical regimen in question include those who meet all of the following exclusion criteria: 1. Multiple organ transplant recipient. 2. Treatment of ABMR (including CABMR) or TCMR within 3 months of screening. 3. The patient received T-cell depletion therapy (e.g., alemtuzumab, anti-thymocyte globulin) within three months of screening. 4. Biopsy showing pure TCMR or advanced interstitial fibrosis (ci3), advanced tubular atrophy (ct3), vascular fibrous intimal thickening (cv3), or other significant causes of renal dysfunction (e.g., BKV nephropathy, glomerulonephritis). 5. Renal dysfunction resulting from damage to the transplanted allograft (e.g., renal artery stenosis, hydronephrosis). 6.eGFR<25mL / min / 1.73m 2 Or >65 mL / min / 1.73 m 2 . 7. Nephrotic range proteinuria is defined as a spot urine protein-creatinine ratio (UPCR) ≥ 3,000 mg / g (≥ 300 mg / mmol) or a spot urine albumin-creatinine ratio (UACR) ≥ 2,200 mg / g (≥ 220 mg / mmol). If the spot UPCR or UACR exceeds the defined limit, repeat the test on another day (or collect a 24-hour urine to confirm nephrotic range proteinuria (≥ 3.0 g / day)). 8. During pregnancy, breastfeeding, or during the study period, and within 5 months after the last dose of crazakizumab, there is no certainty of practicing highly effective contraception. 9. History of anaphylaxis. 10. Abnormal LFT (alanine aminotransferase (ALT) / aspartate aminotransferase (AST) / bilirubin > 1.5 × upper limit of normal) or other serious liver disease. 11. History of active tuberculosis (TB). 12. History of latent TB without a history of active TB (e.g., positive QuantiFERON TB test) unless the subject has completed the entire course of prophylactic treatment. 13. History of human immunodeficiency virus (HIV) infection or positive for HIV. 14. Serum-positive for hepatitis B surface antigen (HBsAg). 15. Positive for Hepatitis C virus (HCV) RNA. 16. Known EBV mismatch: Donor is seropositive, recipient is seronegative. 17. History of GI perforation, diverticular disease, diverticulitis, or inflammatory bowel disease. 18. Neutropenia (<1,000 / mm 3 ) or thrombocytopenia (<50,000 / mm³) 3 ). 19. Active infection requiring systemic antibiotics and not having resolved before screening. 20. The following: A history or current history of invasive fungal infections or other opportunistic infections, including (but not limited to) nontuberculous mycobacterial infections, aspergillosis, pneumocystis, and toxoplasmosis. 21. Active viral infections such as BKV, CMV, or EBV, based on polymerase chain reaction (PCR) testing. 22. Current or recent (within the last 3 months) participation in a crazakizumab trial. 23. Administration of live vaccines within 6 weeks of screening, including but not limited to the following. i) Adenovirus ii) Measles, mumps, and rubella iii) Oral polio iv) Oral typhoid fever v) Rotavirus vi) Varicella zoster vii) Yellow fever 24. History of alcohol or illegal drug abuse (including marijuana). 25. Current or past (within the last 3 years) malignant tumors, excluding basal cell carcinoma, squamous cell carcinoma of the skin that has been completely excised, or non-recurrent (within the last 5 years) cervical intraepithelial neoplasia. 26. The presence of any condition or abnormality in the opinion of the principal investigator that could impair patient safety, life expectancy, or data quality (i.e., any clinically significant endocrine, autoimmune, metabolic, neurological, psychiatric / psychological, renal, GI, hepatic, hematological, or any other systemic abnormality that is not controlled by standard treatment). 27. History of intolerance to trimethoprim and / or sulfamethoxazole. This criterion does not apply if the subject has already inhaled pentamidine or oral dapsone for Pneumocystis jirovecii pneumonia (PJP) prophylaxis, or if the subject has started taking any of these drugs at least one week before the baseline visit (Visit 2) on Day 1. 28. Past exposure to clarazakizumab.

[0236] Administration of anti-IL-6 antibody may be permanently discontinued in the subject when any unacceptable adverse event (AE) selected from the following occurs. 1. AST or ALT > 5.0 × normal upper limit (ULN) 2. Total bilirubin > 3.0 × ULN 3. AST or ALT > 3.0 - 5.0 × ULN and total bilirubin ≥ 2.0 × ULN (or international normalized ratio (INR) > 1.5)

[0237] Administration of anti-IL-6 antibody may be permanently discontinued in the subject due to neutropenia and / or thrombocytopenia. Specifically, in the subject who meets any of the following conditions during treatment, treatment with anti-IL-6 antibody administration may be discontinued. 1. Neutrophil count per mm 3 less than 1,000 cells 2. Platelets per mm 3 less than 50,000

[0238] Administration of anti-IL-6 antibody may be permanently discontinued in the subject due to BKV, CMV, or EBV viral infection. For example, in the subject who meets any of the following conditions at any time during treatment, clarazakizumab treatment may be discontinued. 1. BKV ≥ 10,000 copies / mL (by PCR) or BKV nephropathy proven by biopsy 2. CMV peripheral organ disease (e.g., hepatitis, colitis, pneumonia, retinitis) 3. EBV ≥ 10,000 copies / mL (by PCR) or post-transplant lymphoproliferative disorder or primary EBV infection in seronegative recipients

[0239] Curaza treatment regimen Clazakizumab is generally available in dosage forms of 25 mg / mL and 12.5 mg / mL. Excipients include L-histidine, L-histidine monohydrochloride, sorbitol, polysorbate-80, and water for injection. Dosage forms include single-dose vials suitable for injection (25 mg / mL and 12.5 mg / mL).

[0240] Antibodies should be stored in a light-shielded environment at -20±5℃ (-4±9°F) or below.

[0241] Concurrent trimethoprim / sulfamethoxazole prophylactic therapy Oral trimethoprim / sulfamethoxazole is prescribed to the study site for PJP prophylaxis, either daily in the form of a single-dose pill (80 mg of trimethoprim) or three times per week in the form of a double-dose pill (160 mg of trimethoprim). Trimethoprim / sulfamethoxazole is generally initiated at least one week before the baseline visit on day 1 (visit 2) (for subjects who have not yet taken trimethoprim / sulfamethoxazole prior to entering the study and have not yet received inhaled pentamidine or oral dapsone).

[0242] Concomitant inhaled pentamidine and oral dapsone prophylactic therapy Subjects who are already receiving inhaled pentamidine or oral dapsone for PJP prevention at screening will generally continue taking these medications and will not initiate trimethoprim / sulfamethoxazole. Subjects who are intolerant to trimethoprim / sulfamethoxazole and have not yet received inhaled pentamidine or oral dapsone will generally begin taking one of these medications at least one week before the day 1 baseline visit (visit 2).

[0243] Dosage and administration of crazakizumab Clazakizumab is administered via SC injection at a targeted dose of 25 mg every four weeks (Q4W), or at a lower dose of 12.5 mg every Q4W, supporting potential dose reduction as indicated by the safety parameters defined in the protocol. Each 25 mg / 12.5 mg dose is administered as a 1 mL injection of crazakizumab (25 mg / mL / 12.5 mg / mL).

[0244] Clazakizumab is generally prepared and dispensed in identical, color-coded syringes. Each color-coded syringe typically includes a label with details such as protocol number, subject ID, visit number, and dispensing date. The pharmacist will typically record the number of kits / vials dispensed for each subject, including the date and time of dispensing, on a management log. Prepared syringes can be stored in a refrigerator at 2°C–8°C (36°F–46°F) for up to 24 hours, with up to 4 hours of that time at room temperature of 15°C–25°C (59°F–77°F). Prepared syringes must be protected from light. Before administration, prepared syringes must be allowed to reach room temperature by being removed from the refrigerator for 30–60 minutes before use.

[0245] To ensure patient safety, the latest LFT and CBC analyses and viral surveillance results from previous visits (scheduled or otherwise) are generally reviewed before administration. All protocol-specific evaluations for a given visit are generally completed before administration of crazakizumab.

[0246] Packaging Clazakizumab is generally supplied as a single-dose vial. The vial contains a minimum of 1.1 mL (25 mg or 12.5 mg) to deliver 1 mL (25 mg or 12.5 mg). It is a 2 mL flint glass containing 12.5 mg / mL of crazakizumab.

[0247] keep Clazakizumab is preferably stored in a light-shielded place at -20±5°C or below.

[0248] Change in crazakizumab dosage During crazakizumab treatment, patients are typically monitored for abnormal LFT, neutrophil and platelet counts, as well as viral infections with BKV, CMV, and EBV. Based on the results of these assessments, the dose of crazakizumab may be reduced to 12.5 mg SC Q4W, temporarily withdrawn, or permanently discontinued.

[0249] In general, discontinuation or reduction of crazakizumab for abnormal LFTs is at the discretion of the clinician treating any laboratory anomaly, depending on the severity of the adverse event according to the General Toxicity Criteria (CTCAE) (CTCAE Grade 1 (mild), Grade 2 (moderate), Grade 3 (severe or medically significant)) and the corrective actions taken. In cases of neutropenia or thrombocytopenia, guidelines for changing mycophenolate mofetil (MMF) / mycophenolate (MPA) / azathioprine (AZA) may be affected.

[0250] Furthermore, discontinuation or reduction of crazakizumab may affect any other clinically significant infection. Once treatment and resolution of the infection are complete, the clinician may, at their discretion, restart crazakizumab at a reduced dose or increase it up to 25 mg SC Q4W. If crazakizumab has been discontinued for three or more doses due to an adverse event, the clinician may typically consider permanently discontinuing crazakizumab.

[0251] Dose modification of crazakizumab and / or background immunosuppression due to abnormal LFT, neutropenia, or thrombocytopenia. During the clinical regimen, monitoring for LFT abnormalities, neutropenia, and thrombocytopenia should be performed at the start of treatment and every 4–12 weeks thereafter. Depending on the severity of the CTCAE, discontinuation or reduction of crazakizumab (up to 12.5 mg SC Q4W) may be influenced by events of abnormal LFT (i.e., AST / ALT), neutrophil, or platelet count. In the event of any LFT abnormality, neutrophil, or platelet count meeting CTCAE grade ≥ 3, crazakizumab may be discontinued.

[0252] Table 1 below provides further guidelines regarding dose adjustments and / or background immunosuppression of crazakizumab based on CTCAE severity grades. Decisions regarding dose changes should be made in consultation with the clinician. [Table 1] [Table 2]

[0253] Furthermore, CNI levels are monitored throughout the clinical regimen. CNI levels are also monitored every two weeks after any change / discontinuation of crazakizumab dose (or change in CNI dose) until the target CNI trough level is achieved.

[0254] Monitoring of BKV, CMV, and EBV infections During treatment, monitoring for BKV, CMV, and EBV infection is performed by PCR testing at screening and every 8–12 weeks thereafter. If PCR DNA testing is positive (i.e., exceeding the lower limit of quantification) or if the viral load increases, clazakizumab may be discontinued or reduced (up to 12.5 mg SC Q4W). In cases of BKV, CMV, or EBV infection meeting the criteria, clazakizumab may be discontinued (see Table 2). Table 2 provides additional guidelines regarding dose adjustments and / or background immunosuppression of clazakizumab due to viral load as detected by PCR testing. Decisions regarding dose changes should be made in consultation with the treating clinician. [Table 3] [Table 4]

[0255] Generally, if crazakizumab is reduced to 12.5 mg SC Q4W, the reduced dose is continued for one or two doses, and after PCR monitoring, the crazakizumab dose is increased to 25 mg SC Q4W. After the initial restoration of the crazakizumab dose to 25 mg SC Q4W, MMF / MPA / AZA is restarted / increased or CNI levels are increased. CNI levels are also monitored throughout the clinical regimen. In addition, CNI is monitored every two weeks after changes in CNI dose or changes in crazakizumab dose / discontinuation of crazakizumab until the target CNI trough level is achieved.

[0256] Prohibited treatments and combination therapies No other treatments for ABMR (including CABMR) and TCMR will be given during treatment. For patients who have received these treatments at any time prior to the 3-month prior screening period, a renal biopsy will be performed after discontinuation of treatment to confirm eligibility according to the following inclusion criteria.

[0257] The following substances are usually excluded during treatment. 1. Rituximab 2. Eculizumab 3. Proteasome inhibitors 4. IVIG, excluding treatment for hypogammaglobulinemia. 5. PLEX 6. Veratacept 7. Other crazakizumab / treatments 8. Anti-IL-6 / IL-6R receptor mAbs (both approved and under investigation)

[0258] Permitted concomitant medications The following concomitant medications are permitted during treatment for Il-6 Ab. 1. Recommended AZA dose: 1.0-2.0 mg / kg / day (however, in cases of neutropenia / thrombocytopenia or viral infection, the AZA dose may be reduced as shown in Tables 1 and 2.) 2. CNI 3. Recommended target tacrolimus plasma trough level: 5-8 ng / ml 4. Recommended target cyclosporine plasma trough level: 50-150 ng / ml 5. In the case of a viral infection, the target level of CNI may be modified as shown in Table 2. 6. CNI trough levels are monitored on day 1, and throughout treatment, at 1 and 4 weeks after the first dose of crazakizumab, then every 4 to 12 weeks thereafter, and then every 8 weeks thereafter. Additionally, CNI is monitored every 2 weeks after any change in the CNI dose or after any change in the crazakizumab dose / discontinuation of crazakizumab until the target CNI trough level is achieved. 7. MMF / MPA (Recommended MMF dose: 1.0-2.0 g / day), Recommended MPA dose: 720-1,440 mg / day, however, the MMF / MPA dose may be reduced in cases of neutropenia / thrombocytopenia or viral infection. 8. mTOR inhibitors (everolimus, sirolimus). 9. Low-dose corticosteroids (prednisone / prednisolone ≤ 10 mg / day). 10. Antihypertensive drugs (e.g., angiotensin-converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs)) (ACEIs and ARBs should be initiated and the dosage stabilized for at least two months prior to the screening visit). 11. Antidiabetic drugs. 12. Acceptable treatment for acute TCMR: pulse steroids (e.g., oral prednisone 200 mg / day) and tapering gradually towards baseline levels over two weeks. 13. CMV infection should be treated with oral valganciclovir or IV ganciclovir. 14. Trimethoprim / sulfamethoxazole or inhaled pentamidine or oral dapsone 15. In general, the use of herbal medicines and homeopathic remedies (e.g., St. John's wort, echinacea, hydrastis, Schisandra sphenanthera extract) is not recommended.

[0259] Preventive therapy The subjects will generally receive prophylactic treatment for PJP. Oral trimethoprim / sulfamethoxazole will generally be prescribed. If the subject has already received trimethoprim / sulfamethoxazole prior to treatment, the dose should be stabilized for at least one week prior to the screening visit. If the subject has not received trimethoprim / sulfamethoxazole prior to treatment (and has not yet received inhaled pentamidine or oral dapsone), trimethoprim / sulfamethoxazole will generally be started at least one week before the day 1 baseline visit (visit 2).

[0260] If a patient is already receiving inhaled pentamidine or oral dapsone for PJP prevention, they should continue taking these medications and should not be initiated with trimethoprim / sulfamethoxazole. Patients who are intolerant to trimethoprim / sulfamethoxazole and have not yet received inhaled pentamidine or oral dapsone should generally be treated with You should start taking one of these medications at least one week before the start of treatment.

[0261] infection Because crazakizumab may reduce the immune response to infection, it should generally not be administered to patients with bacterial, viral, or fungal infections, or to patients who meet certain laboratory criteria that may predispose them to infection (e.g., low absolute neutrophil count). Therefore, clinicians should monitor patients for any signs or symptoms of infection during treatment. Infections should be monitored and treated according to standard care, and in cases of severe opportunistic infections, the principal investigator should consider withholding and / or discontinuing crazakizumab treatment and / or reducing background immunosuppression. Decisions regarding dose changes should be made in consultation with the clinician.

[0262] Virus monitoring During treatment, routine monitoring for BKV, CMV, and EBV infections will generally be performed by PCR testing at the initial screening and every 8–12 weeks thereafter. If favorable results are obtained, dose changes of crazakizumab and / or background immunosuppression may be considered. These guidelines may be followed for any other clinically significant infections.

[0263] Liver function Treatment with crazakizumab may increase transaminases. Therefore, patients with evidence of significant liver disease and a history of alcohol or illegal drug use are generally excluded from Claza treatment. Liver function tests and hepatobiliary AEs are closely monitored during treatment. LFT is also routinely monitored at screening and every 4–12 weeks thereafter. In cases of mild to moderate LFT abnormalities, the crazakizumab dose may be changed, and in cases of severe LFT abnormalities (CTCAE grade ≥ 3), treatment with crazakizumab is generally discontinued. To ensure patient safety, the latest LFT is generally reviewed before administering crazakizumab.

[0264] Hematological parameters Treatment with crazakizumab is associated with a decrease in platelet and neutrophil counts; therefore, platelet and neutrophil counts are monitored during treatment. During treatment, CBCs are performed at the start of treatment and every 4–12 weeks thereafter. In cases of mild to moderate neutropenia or thrombocytopenia, the dose of crazakizumab and / or background immunosuppression may be modified, and in cases of severe neutropenia or thrombocytopenia (CTCAE grade ≥ 3), treatment with crazakizumab may be discontinued (see Table 1). To ensure patient safety, the latest neutrophil and platelet counts are generally reviewed before administering Claza.

[0265] lipid abnormality Treatment with crazakizumab is associated with dyslipidemia. Therefore, routine monitoring of lipid levels is typically performed in patients being treated with crazakizumab.

[0266] Gastrointestinal perforation In a study of Crohn's disease patients given high doses of crazakizumab (i.e., 150 mg IV, 300 mg IV / 100 mg SC, and 600 mg IV), three cases of GI perforation were observed. Based on these findings, transplant recipients with a history of inflammatory bowel disease, diverticular disease, or GI perforation would generally not be treated with crazakizumab.

[0267] malignant tumor Malignant tumors are a known risk associated with long-term immunosuppression. Malignant tumors have been identified as a potential risk to immunomodulatory therapies and should generally be monitored during crazakizumab treatment.

[0268] autoimmune The development of certain autoimmune diseases is associated with some biological therapies for RA. Therefore, signs of autoimmunity will generally be monitored during treatment with crazakizumab.

[0269] immunogenicity The development of anti-drug antibodies (ADAs) is associated with many therapeutic antibodies. Such antibodies may lead to reduced efficacy or affect safety. To date, ADAs have not been detected in healthy volunteers treated with clazakizumab. In contrast, ADAs have been detected in some subjects with RA and PsA treated with Claza. Therefore, the presence of anti-clazakizumab antibodies is typically monitored during immediate Claza treatment.

[0270] Drug interactions Formal clinical drug interaction studies of crazakizumab have not been conducted. However, in vitro studies have shown that crazakizumab has a similar effect to TCZ in that it reverses the effect of IL-6 on the downregulation of mRNA levels of multiple CYP enzymes. Therefore, as observed with TCZ, treatment with crazakizumab may restore CYP enzyme-mediated drug clearance, potentially leading to a reduction in systemic exposure to drugs metabolized by CYP enzymes. This effect may be particularly important for CYP enzyme substrate drugs with narrow therapeutic indices where doses are individually adjusted. Therefore, caution may be necessary when co-administering crazakizumab with CYP3A4 substrate drugs (e.g., oral contraceptives, 3-hydroxy-3-methyl-glutaryl-coenzyme A reductase inhibitors) where a decrease in efficacy is undesirable.

[0271] Furthermore, considering the possibility of drug interactions between crazakizumab and CNI, CNI trough levels are typically monitored for the remainder of the study, on day 1, and at 1 and 4 weeks after the initial dose of crazakizumab, then every 4 to 12 weeks thereafter, and then every 8 weeks thereafter. CNI may also be monitored every 2 weeks after a change in the dose of CNI or a change in the dose of crazakizumab / discontinuation of crazakizumab until the target CNI trough level is achieved.

[0272] Overdose There is no specific antidote or treatment for crazakizumab injection overdose. Patients should be treated with appropriate supportive care.

[0273] Events at the injection site and injection-related (allergic) reactions Injection site reactions (ISRs) have been reported with SC administration, most frequently as erythema. The reactions were mild to moderate and resolved without treatment. To date, there have been no reported infusion reactions associated with IV administration of crazakizumab.

[0274] As with any protein-based therapeutic agent, it carries a risk of serious allergic reactions (infusion reactions). Clazakizumab should generally not be administered to patients who have previously experienced any allergic reaction to mAbs. Both allergic reactions and ISRs should be treated with standard care. A serious allergic reaction to crazakizumab is... Those who caused the incident should generally not try again.

[0275] Clinical laboratory evaluation Patient blood samples will generally be analyzed using standard, validated methods. Blood and urine samples for the following efficacy and safety evaluations will generally be collected at years 1-5 and thereafter, where applicable. Blood and urine samples will generally be collected before medication administration during clinical visits. A summary of such laboratory evaluations is provided in Table 3. [Table 5] [Table 6] [Table 7]

[0276] eGFR The estimated glomerular filtration rate will generally be determined using the MDRD4 equation.

[0277] eGFR = 175 × (serum creatinine [mg / dL]) - 1.154 × (age) - 0.203 × (0.742 for females, 1 otherwise) × (1.212 for black, 1 otherwise)

[0278] eGFR is usually determined at almost every visit (Q4W) throughout Treatment 3.

[0279] DSA titer and MFI score DSA will typically be determined using a single-antigen bead-based assay. 1. The MFI score for HLA DSA is typically determined as follows: Visit 1 (screening), Visit 2 (baseline), 6, 10, 16, 22, 28, 34, 40, 46, 52, 58, 64, and 68. 2. DSA titers are typically determined using Visit 1 (screening), Visit 2 (baseline), 6, 10, 16, 28, 40, 52, 64, and 68 (EOS).

[0280] The screening results can be used to determine the eligibility criteria for DSA. If the presence of HLA DSA is confirmed within six months of screening, there is no need to repeat the test to confirm eligibility.

[0281] plasma IL-6 Total IL-6 (ligands bound to / unbound to soluble IL-6 receptors and ligands bound to / unbound to crazakizumab) and free IL-6 (ligands not bound to soluble IL-6 receptors and ligands not bound to crazakizumab) levels can generally be measured using a valid SIMOA® assay.

[0282] Plasma IL-6 levels (total and free) are typically measured at 2 (baseline), 6, 9, 15, 21, 27, 33, 39, 45, 51, 57, 63, and 68 (EOS).

[0283] Plasma crazakizumab Validated enzyme-coupled immunosorbent assays are generally used to measure the concentration of clazakizumab in serum. Plasma clazakizumab levels are generally measured at levels 2 (baseline), 6, 9, 15, 21, 27, 33, 39, 45, 51, 57, 63, and 68 (EOS).

[0284] Anti-crazakizumab antibody Validated electrochemiluminescence immunoassays are generally used to measure the titer of clazakizumab antibodies in serum. Plasma anti-clazakizumab antibody levels can generally be measured at levels 2 (baseline), 6, 9, 15, 21, 27, 33, 39, 45, 51, 57, 63, and 68 (EOS).

[0285] MPA level Serum / plasma MPA levels can be measured, for example, by validated quantitative liquid chromatography-tandem mass spectrometry (LC-MS / MS). Generally, MPA levels can be measured at visits 2 (baseline), 4, 5, 6, 8, 10, 12, 14, 16, 19, 22, 25, 28, 31, 34, 37, 40, 43, 46, 49, 52, 55, 58, 61, 64, 67, and 68 (EOS). During these visits, prophylactic treatment with MMF / MPA is generally withheld until MPA levels are determined.

[0286] CNI level The trough levels of CNI (tacrolimus and cyclosporine) in serum / plasma can be measured, for example, by validated quantitative LC-MS / MS methods. The CNI trough levels are, For example, it can be measured at visits 2 (baseline), 3-6, 8, 10, 12, 14, 16, 18, 20, 22, 24, 26, 28, 30, 32, 34, 36, 38, 40, 42, 44, 46, 48, 50, 52, 54, 56, 58, 60, 62, 64, 66, and 68 (EOS). In these visits, prophylactic treatment with CNI is generally withheld until the CNI level is determined.

[0287] Additionally, CNI will be monitored every two weeks after any changes in CNI dose or changes in crazakizumab dose / discontinuation of crazakizumab, for example, until the target CNI trough level is achieved.

[0288] Physical examination Typically, during Visit 1 (screening), a complete physical examination based on standard treatment is generally performed by a physician. Additional, abbreviated physical examinations may be performed, for example, during Visit 2 (baseline) and at each visit from Visit 4 (week 4) to Visit 68 (week 260). Generally, the subject's weight will be recorded at each physical examination.

[0289] Vital signs Vital signs are generally measured at almost every visit (Q4W) throughout treatment. Generally, these assessments are performed after the subject has sat up following a 5-minute rest. To avoid variability, the same method of obtaining body temperature is generally used throughout treatment.

[0290] The following vital signs are generally measured. 1. Blood pressure (systolic and diastolic) 2. Heart rate 3. Body temperature (°C or °F), armpit or eardrum 4. Breathing

[0291] Standard 12-lead electrocardiogram A standard 12-lead electrocardiogram (ECG) is generally performed, the results are generally evaluated by a qualified physician, and generally retained as source documentation. Any results containing abnormalities are recorded in an eCRF.

[0292] An electrocardiogram (ECG) will typically be digitally recorded after the subject has been at rest in a supine position for at least 5 minutes. Significant abnormalities, including findings that may prompt discontinuation of crazakizumab, should be evaluated. Typically, an ECG is performed during one or all of the following visits: Visit 1 (screening) and Visits 6, 9, 15, 21, 27, 33, 39, 45, 51, 57, 63, and 68 (EOS).

[0293] Tuberculosis screening Evaluating eligibility for Claza treatment typically requires screening for active and latent tuberculosis. The following steps are generally necessary: 1. A complete physical examination and medical history to assess whether subjects with a history of exposure to TB and latent TB (without active TB) have completed the entire course of prophylactic treatment. 2. Chest X-ray 3. QuantiFERON-TB Gold Interferon-γ Release Assay

[0294] A positive result from the interferon-gamma release assay is usually not repeated. An inconclusive result may be repeated once. If the second test is positive or inconclusive, the result is usually considered positive for that subject. A third test is not performed. Subjects newly diagnosed with TB are usually treated according to appropriate standard therapy, and crazakizumab is discontinued. It needs to be managed.

[0295] Kidney biopsy A biopsy-confirmed CABMR (according to the Banff 2015 diagnostic criteria within 6 months of screening) is usually required for eligibility for treatment. If the previous biopsy was not within 6 months of screening, a repeat biopsy is usually performed. If the subject is receiving treatment for ABMR (including CABMR) or TCMR, a repeat biopsy is usually performed (to indicate continued CABMR).

[0296] Biopsy eligibility for participation in Claza treatment is typically based on the pathologist's diagnosis and Banff's scoring. Repeat biopsies per protocol may be performed at the 16th visit (week 52). Ad-hoc biopsies may be performed at any time if clinically necessary. If a biopsy for a valid reason is performed within two months of week 52, a repeat biopsy at week 52 is usually not necessary.

[0297] Screening visit (evaluation visit 1) The screening visit (Visit 1) may generally take place within 28 days prior to Visit 2 (Baseline, Day 1). The initial screening evaluation may include obtaining informed consent, reviewing inclusion / exclusion criteria, a full physical examination, measuring vital signs including weight and height, medical history (including historical serology for viral infections), urine pregnancy test (in the case of WOCBP), TB screening, 12-lead ECG, SOE, eGFR, collection of blood and urine samples for central laboratory evaluation for each standard urine test, spot urine collection (for UPCR / UACR determination), 24-hour urine collection (if necessary), serology for HIV and HBsAg in the case of seronegative or unknown medical history, PCR monitoring for BKV, CMV, and EBV DNA, and for HCV RNA, review of past concomitant medications and initiation criteria.

[0298] Determining fasting blood glucose and lipid / triglyceride levels typically requires a minimum of 10 hours of fasting. Any adverse events (AEs) occurring after informed consent and before the second visit are generally recorded as part of the medical history.

[0299] Biopsy diagnoses to determine eligibility for treatment are typically based on the pathologist's diagnosis and Banff's scoring. Screening can use laboratory results to determine DSA eligibility criteria. If the presence of HLA DSA is confirmed within six months of screening, repeated testing is usually not necessary. Individuals deemed to have screening failures may typically be re-evaluated once.

[0300] Treatment Procedure Throughout the treatment period (visits 2-68), patients generally receive 25 mg of Claza subcutaneously every four weeks. Prior to administration, the following evaluations are usually performed at the second visit and visits 4-67. 1. AEs and concomitant medications (to be collected and recorded before any other research evaluations are conducted). 2. Omitted physical examination (including vital signs). 3. Pregnancy testing for WOCBP. 4. Blood collection for central laboratory analysis of eGFR. 5. Review of recent LFT and CBC analyses and viral surveillance results from previous visits (scheduled or otherwise) to determine whether the subject is eligible to receive crazakizumab in accordance with the safety limits of these criteria, or whether dose modification and / or background immunosuppression of crazakizumab is necessary / recommended (see Section 7.5).

[0301] As detailed in SOE, additional assessments may be performed every 4–12 weeks before medication administration, and may include the following assessments: 1. Confirm all inclusion / exclusion criteria (Visit 2 (Baseline, Day 1) only). 2. Collection of blood and urine samples for additional central laboratory analysis as detailed in Table 7 and SOE. A minimum of 10 hours of fasting is required to determine fasting blood glucose and lipid / triglyceride levels. CNI will be withheld until blood samples are collected to determine trough levels of CNI during the relevant visit for each SOE. 3. HRQoL Questionnaire. These questionnaires must be completed during the relevant visit, prior to any other evaluations. 4. Renal biopsy (visit 16; may be performed on a previous visit if clinically necessary).

[0302] During visit 3, typically the only assessment performed involves collecting a blood sample to monitor the CNI trough level. As mentioned above, CNI is usually withheld until a blood sample is collected to determine the CNI trough level.

[0303] Procedure for ending treatment Once treatment is complete, the following evaluations may be performed. 1. AEs and concomitant medications (to be recorded before conducting other research evaluations). 2. Omitted physical examination (including vital signs). 3. Pregnancy testing for WOCBP. 4. Collection of blood and urine samples for central laboratory analysis. A minimum of 10 hours of fasting is required to determine fasting blood glucose and lipid / triglyceride levels. CNI will be withheld until blood samples are collected to determine the trough level of CNI. 5. Renal biopsy (if the patient is weaned before week 52).

[0304] Follow-up procedure In general, all patients being treated will be evaluated monthly to detect any new AEs, SAEs, or pregnancies. Patients who discontinued crazakizumab due to graft loss may undergo an EOS evaluation (visit 68) and be followed up monthly with TCs for 5 months after the last dose of crazakizumab.

[0305] All patients who have withdrawn from the treatment typically complete an EOS assessment (68 visits) and, if possible, are followed up with monthly TCs for 5 months after the last dose of crazakizumab and may receive medical visits at the physician's discretion.

[0306] Unplanned visit For safety reasons, unscheduled visits may occur during the course of treatment. Additionally, patients who have discontinued crazakizumab may be seen at the clinic for emergency visits.

[0307] Definition of an adverse event An AE is defined as any adverse medical event or exacerbation of a pre-existing condition in a clinical study participant treated with crazakizumab, and is not necessarily causally related to the treatment. Therefore, an AE may be any undesirable, unintended sign (such as an abnormal laboratory finding), symptom, or condition temporarily associated with the use of crazakizumab, regardless of whether the event is assessed as being related to crazakizumab.

[0308] A therapeutic adverse event (TEAE) is defined as any event that did not exist before exposure to crazakizumab, or any pre-existing event that worsens in either intensity or frequency after exposure to crazakizumab.

[0309] Definition of adverse drug reactions In pre-approval clinical experience of new drugs or new uses, especially when therapeutic doses may not be established, all adverse and unintended reactions to a drug associated with any dose may generally be considered adverse drug reactions (ADRs). The phrase "reaction to a drug" means that there is at least a reasonable possibility of a causal relationship between the drug and the adverse event; that is, the relationship cannot be ruled out.

[0310] Definition of unexpected adverse events / adverse drug reactions An AE / ADR may be considered unexpected if the nature, severity, or frequency of the event is inconsistent with the risk information previously described for the research drug. This specification describes the identified potential risks for crazakizumab.

[0311] Definition of a serious adverse event SAEs are generally defined as adverse events or suspected adverse reactions that result in one of the following outcomes: 1.Death. 2. Life-threatening accidents (AEs). (Note: In SAEs, the definition of a life-threatening accident refers to an event in which the subject was exposed to a risk of death at the time of the event, and does not refer to an event that, if more severe, could potentially cause death.) 3. Hospitalization of inpatients, or extension of their current hospital stay. 4. Persistent or marked inability or substantial impairment of the ability to perform normal daily living activities. 5.Congenital abnormalities / birth defects. 6. Important medical events (see below).

[0312] A significant medical event that is not life-threatening, requires hospitalization, or is not likely to result in death may be considered serious if, based on appropriate medical judgment, it could endanger the subject and require medical or surgical intervention to prevent one of the outcomes listed in this definition. Examples of such medical events include allergic bronchospasm requiring intensive care in the emergency room or at home, a blood disorder or seizure in a hospitalized patient that does not result in hospitalization, or the onset of drug dependence or abuse.

[0313] The following hospitalizations are generally not considered SAEs in this specification. 1. Visits to the emergency room or other hospital departments for less than 24 hours that do not require hospitalization (unless considered a critical medical or life-threatening event). 2. Selective surgery planned before signing informed consent for this study. 3. Protocol-based hospitalization for planned medical / surgical procedures (e.g., renal biopsy). 4. Routine health assessments requiring hospitalization for baseline / health status trends (e.g., routine colonoscopy). 5. Medical / surgical hospitalizations other than for the treatment of illness, and planned prior to participation in research. In these cases, appropriate information management is required. 6. Hospitalization due to facing an alternative living environment that does not affect health and does not require any medical / surgical intervention (e.g., lack of housing, financial difficulties, caregiver rest, family circumstances, administrative reasons).

[0314] Definition of suspected unexpected serious adverse reactions A SUSAR is defined as any ADR that is considered serious, unexpected, and likely to have a reasonable causal relationship with crazakizumab.

[0315] Definition of adverse events requiring special attention (AESI) Specially targeted adverse events (AESIs) are scientific or medical concerns for which continued monitoring and rapid communication are important. These may include events specific to clazakizumab or events that may be clinically significant to treatment in general. Thus, AESIs may or may not be related to clazakizumab. The following AESIs are defined for clazakizumab: LFT abnormalities, neutropenia, thrombocytopenia, hyperlipidemia, GI perforation, hypersensitivity and anaphylaxis, malignancy, opportunistic infections, and pregnancy. Each of these AESIs is discussed herein.

[0316] LFT abnormalities, neutropenia, thrombocytopenia, and hyperlipidemia Throughout treatment with Claza, patients will generally undergo regular hematological and biochemical laboratory tests to monitor for abnormal LFT, neutropenia, thrombocytopenia, and hyperlipidemia. Generally, these, along with any other abnormal test results of grade 3 (severe) or higher, should be considered an AESI, and discontinuation of clazakizumab treatment should be potentially considered.

[0317] Specifically, treatment with crazakizumab may be discontinued for patients who meet any of the following criteria, which are typically considered to be associated with AESI (Antimicrobial Simic Infection). 1. AST / ALT > 5 × ULN 2. Total bilirubin > 3 × ULN 3. AST / ALT > 3 ≤ 5 × ULN and total bilirubin ≥ 2 × ULN (or INR > 1.5) 4. Neutrophil count (mm) 3 <1,000 cells per cell 5. Neutrophil count (mm) 3 <50,000 cells per cell

[0318] Furthermore, the following total cholesterol and triglyceride levels are considered AESI (Autism Spectrum Disorder Indication). 1. Regardless of baseline level, total cholesterol >400 mg / dL or >10.34 mmol / L 2. Regardless of baseline level, triglycerides > 500 mg / dL or > 5.7 mmol / L

[0319] Gastrointestinal perforation Gastrointestinal perforation is a known risk associated with treatment with anti-IL-6 antibodies and has been reported as an AESI (Antimicrobial Stem Infection).

[0320] Hypersensitivity and anaphylaxis Hypersensitivity reactions and anaphylactic reactions, such as those that meet the definition of the Joint NIAID / FAAN Second Symposium on Anaphylaxis, are generally considered AESI (Antimicrobial Stem Illness). 1. Diseases affecting the skin, mucous membranes, or both (e.g., generalized urticaria, pruritus or flushing, swelling of the lip-tongue-uvula) and at least one of the following acute onsets (from a few minutes to several hours): 2. Respiratory dysfunction (e.g., dyspnea, wheezing / bronchospasm, wheezing, decreased peak expiratory flow, hypoxemia) 3. Symptoms of decreased blood pressure or associated peripheral organ dysfunction (e.g., hypotonia (collapse), syncope, incontinence)

[0321] malignant tumor Any new malignant tumor or progression of an existing malignant tumor (excluding non-melanoma skin cancer (squamous cell or basal cell carcinoma)) is usually considered an AESI.

[0322] Opportunistic infections Throughout Claza treatment, monitoring for potential infections will typically be carried out in accordance with the recommendations of the American Society of Transplantation and / or KDIGO guidelines. Recognized viruses that can cause significant morbidity in kidney transplant recipients include BKV, CMV, and EBV, and their presence will typically be monitored by PCR at regular intervals of 8–12 weeks, for example.

[0323] The following infections are considered AESI (Antimicrobial Simic Infections). 1. Any bacterial pneumonia or bronchitis 2. Gram-negative bacterial GI infections (including Salmonella (enterica serotype, Typhimurium, and Enteritidis), Shigella, Campylobacter, Escherichia coli, and Clostridium difficile) 3. BKV nephropathy 4. CMV infection / disease 5. Cryptosporidiosis associated with Cryptosporidium 6. Invasive Candidiasis 7. Invasive mycoses, including cryptococcosis, histoplasmosis, aspergillosis, and coccidioidomycosis. 8. JC virus infection (progressive multifocal leukoencephalopathy) 9. Hepatitis B virus (HBV) and HCV infection 10. Human papillomavirus (HPV) disease 11.HIV infection 12. Pneumocystis pneumonia with Pneumocystis ilvetii 13. Tuberculosis infection and other tuberculosis infections (e.g., Mycobacterium kansasii, Mycobacterium avium) 14. Non-CMV diseases, including herpes simplex virus type 1 (HSV-1) and type 2 (HSV-2) diseases, varicella-zoster virus disease, and human herpesvirus-8 (HHV-8) disease. 15. Toxoplasmosis infection caused by Toxoplasma gondii

[0324] The above list is not exhaustive, and other infections not commonly observed in kidney transplant populations may also be monitored.

[0325] Treatment with crazakizumab may be discontinued for patients who meet any of the following criteria, and these abnormalities are considered to be AESIs. 1. BKV ≥ 10,000 copies / mL or BKV nephropathy confirmed by biopsy. 2. CMV peripheral organ diseases (e.g., hepatitis, colitis, pneumonia, retinitis) 3. Primary EBV infection in recipients with EBV ≥ 10,000 copies / mL or in post-transplant lymphoproliferative disorders or seronegative recipients.

[0326] pregnancy Any pregnancy occurring in a female subject or a male subject's female partner during treatment or within 5 months after the last dose of crazakizumab should be considered an AESI and should be recorded / reported for any specific type of pregnancy. In the event of pregnancy, the subject will usually need to discontinue crazakizumab treatment.

[0327] Classification of adverse events Classification of intensity / severity The severity of all adverse events (AEs) is typically assessed and graded according to the National Cancer Institute's CTCAE version 5.0 (see Table 4). [Table 8]

[0328] The term "severe" is often used to describe the intensity (severity) of a particular event, however the event itself may have relatively minor medical significance (e.g., a severe headache). This is not the same as "serious" based on the outcome or activity criteria of the subject / event.

[0329] Relationship with crazakizumab For all collected AEs, the clinician investigating and evaluating the patient will generally determine the causal relationship of the AE based on the temporal relationship and their clinical judgment. The degree of certainty regarding causality is generally graded using two categories (related / unrelated), as shown in Table 5. [Table 9]

[0330] Classification of outcomes Outcomes of AEs should generally be classified as follows: recovery / remission (i.e., no sequelae), recovery / remission with sequelae, recovery / remission, no recovery / no remission, fatal, or unknown (when follow-up is not possible).

[0331] Existing medical condition A pre-existing medical condition is a condition that exists before treatment (unless the event is a SAE). A pre-existing medical condition should only be recorded as an AE if its frequency, severity, or characteristics worsen during the study.

[0332] Symptoms of the disease under study Signs and symptoms of the disease under study (CAMBR or AMBR) are generally not classified as adverse events (AEs) as long as they fall within the normal daily fluctuations of the disease. However, exacerbations of symptoms may be classified as AEs.

[0333] Clinical laboratory evaluation Changes in laboratory safety survey values ​​may be reported as adverse events (AEs) if the changes are considered clinically relevant, or if a shift from normal to pathological values ​​of laboratory parameters is observed during treatment with Claza, or if a worsening of pathological values ​​has already been observed.

[0334] Physical examination and vital signs Any deterioration of physical examination findings or vital signs, or any new deterioration of physical examination findings, may be reported as an adverse event (AE) if the change is considered clinically relevant, or, in the case of vital signs, if a change from normal to pathological values ​​is observed.

[0335] Reporting of adverse events If any adverse event (AE) is reported, the date of onset, its relationship to crazakizumab, any actions taken, the date of resolution (or whether it is ongoing or chronic), the outcome, the severity (worst at any point during the event), and whether the AE was severe at any point during the event may be recorded. To determine the duration of any SAE, the dates of admission and discharge, or any other dates on which the SAE criteria were met, may be recorded.

[0336] The AE reporting period generally depends on the Informed Consent Form (ICF) used. The follow-up period begins at the time of signing and continues until the end of treatment or until the 5-month follow-up period after the last dose of crazakizumab. If a subject reports an adverse event (AE), the clinician will generally have sufficient information to assess causality. This may require additional laboratory tests, physical examinations, or telephone contacts.

[0337] Generally, SAEs are followed until satisfactory resolution is achieved, or until the clinician in the field considers the event chronic or stable, or until the subject loses follow-up. The onset date of an SAE is generally defined as the day the signs and symptoms / diagnosis became severe. The resolution date of an SAE is defined as when the symptoms have resolved, or when the event is considered chronic or stable, and / or when the severity criteria no longer apply.

[0338] Pregnancy announcement Any pregnancy occurring in a female subject or a female partner of a male subject during the study or within 5 months after the last dose of crazakizumab should be reported to the clinician. The clinician should advise the subject (or, in the case of a male subject, their partner) to discuss the risks of continuing the pregnancy and any potential effects on the fetus. Monitoring of female subjects for pregnancy should continue until the pregnancy is terminated. Women who test positive for pregnancy during treatment should generally discontinue crazakizumab permanently.

[0339] Pregnancy itself is not a SAE. However, complications of pregnancy, such as miscarriage (spontaneous or induced), premature birth, or birth defects, are considered SAEs and generally need to be documented.

[0340] Data Analysis Tables 6 and 7 below provide estimates of the sample size and an analysis of the predicted data. [Table 10]

[0341] An interim efficacy analysis may be performed when approximately 200 subjects (100 per group) are randomized to receive treatment with crazakizumab for at least 52 weeks and differences between treatment groups are assessed. As shown in Table 6, a fixed sample size of 180 subjects (90 per group) had 90% power (two-sided alpha of 0.05) and the minimum difference in eGFR at 52 weeks between treatment groups was 4.515 mL / min / 1.73 m². 2 (eGFR was 0.75 mL / min / 1.73 m² in the placebo group) 2 It will decrease at a rate of / month, and it is assumed that crazakizumab will reduce the eGFR decline by 50%. The determination of sample size for the fixed design will be based on the baseline. Two-sided alpha of 0.05 and 9.252 mL / min / 1.73 m² for mean eGFR change from week 52. 2 This is based on the common standard deviation (effect size = 4.515 / 9.252 = 0.488). The planned sample size was increased to a minimum of 200 participants to allow for a 10% loss of participants due to follow-up or dropout. [Table 11]

[0342] If at least 100 subjects (50 per group) receive crazakizumab for at least 52 weeks, the planned sample size reestimation for the 200 subjects can be performed using an inverse normal method with a pre-specified information velocity (0.5556, 1) to control for type I error rates. With an assumed eGFR effect size of 0.488, the sample size reestimation guarantees 95.9% power. Under these assumptions, the mean sample size is 202 evaluable subjects (corresponding to approximately 224 enrolled subjects, assuming a 10% loss due to follow-up or dropout). With an assumed eGFR effect size of 0.368, the power is 79.6%, and the mean sample size is 218 evaluable subjects (approximately 242 enrolled subjects). The sample size for the surrogate endpoint of the interim efficacy analysis would typically not exceed a total of 250 evaluable subjects (approximately 280 enrolled subjects).

[0343] Treatment efficacy endpoint The primary efficacy endpoints described herein are generally return to dialysis, allogeneic nephrectomy, re-transplantation, and eGFR < 15 mL / min / 1.73 m². 2 This includes a composite clinical endpoint of time to all-cause allograft loss, defined as death from any cause (including death while the allograft is functioning). (Temporary (≤60 day) return to dialysis due to acute kidney injury (AKI) is usually excluded.)

[0344] eGFR<15mL / min / 1.73m 2 This is generally confirmed by repeated measurements 14–30 days later to meet the definition of the primary endpoint of graft loss, which is due to <15 mL / min / 1.73 m³. 2 A temporary (≤60-day) decrease in eGFR is excluded.

[0345] Return to dialysis or confirmation of a decrease in eGFR (<15 mL / min / 1.73 m) after a duration of more than 60 days. 2 (To) is considered permanent and meets the endpoint of allograft loss. Help.

[0346] AKI is identified as an AE (can be one or more) leading to acute deterioration of graft function, accompanied by the presence of one or more of the following: (including, but not limited to, acute glomerulonephritis, acute thrombotic events, dehydration, drug toxicity, or exposure to known nephrotoxic substances, interstitial nephritis, sepsis, urinary tract obstruction, urinary tract sepsis, exacerbation of diabetes mellitus, and exacerbation of heart failure). 1. An increase in serum creatinine of ≥0.3 mg / dl within 48 hours of the onset of the associated AE.

[49] 2. An increase in serum creatinine of ≥1.5, known or estimated to have occurred within 7 days prior to the onset of the associated AE.

[49] 3. Histologically confirmed acute rejection or any other acute condition confirmed by graft biopsy.

[0347] A stratified log-rank analysis is used to compare the median time to events across each treatment group. Incidence and hazard ratios are also presented.

[0348] To assess the robustness of the primary efficacy analysis, the primary efficacy variable can be repeated in a sensitivity analysis using the PP set. Optionally, an additional sensitivity analysis can be performed to address the nature of all-cause allogeneic graft loss as a recurrent event.

[0349] Secondary endpoints The following secondary efficacy endpoints may also be analyzed. 1. Incidence of allogeneic graft loss and time to censorship due to death (return to dialysis, allogeneic nephrectomy, re-transplant, or eGFR < 15 mL / min / 1.73 m²). 2 (Defined as such, but excluding death from any cause) 2. Change in mean eGFR from baseline to EO 3. Change from Spot UACR baseline to EOS 4. Changes from baseline to EOS of DSA titer and MFI intensity score 5. Incidence of acute rejection episodes (TCMR and ABMR) from baseline to endoscopy (EOS) 6. Changes in the grading score of Banff lesions in renal biopsies from before treatment to after treatment (52 weeks) (2015 criteria) 7. Overall patient survival rate

[0350] In addition, secondary endpoints related to healthcare use and patient-reported outcomes can be investigated, such as the following: 1. Healthcare use related to ABMR treatment in week 52 and up to EOS 2. Changes in patient-reported outcomes, including HRQoL, from baseline to 52 weeks and EOS.

[0351] Additional analysis IL-6 (free and total) levels, the presence of anti-clazakizumab antibodies, and other assessments / evaluations may be presented.

[0352] CNI and MPA levels are generally measured throughout treatment. Analysis can be performed to analyze the concentrations of these drugs. Comparison of these concentrations between the clazakizumab group and the control group can be used to determine whether any significant drug-pharmacokinetic interactions occurred after the initiation of clazakizumab. The analysis also investigates and explains any significant differences in the dosages of these drugs during the trial between the clazakizumab group and the control group.

[0353] Safety evaluation The following safety endpoints may be further evaluated and analyzed. 1. TEAE, severe TEAE, and AESI 2. Surveillance of viral infections for BKV, CMV, and EBV by PCR 3. Laboratory tests including LFT, CBC, plasma lipids, and high-sensitivity CRP. 4. Vital signs, ECG, and physical examination

[0354] interim analysis Once approximately 100 participants are randomized and administered crazakizumab, an interim safety analysis can be conducted. Further interim safety analyses can also be evaluated.

[0355] Two formal interim effectiveness analyses may also be conducted. 1. Reestimation of sample size: After at least 100 subjects have been randomized and administered crazakizumab for at least 52 weeks, a formal interim analysis may be conducted by an independent statistician to assess the validity of the sample size for an interim efficacy analysis of the 52-week eGFR endpoint. 2. An interim efficacy analysis of the 2.52-week eGFR endpoint (i.e., the mean change in eGFR from baseline to week 52) may be performed when approximately 200 subjects (100 per group) are randomized and receive treatment with crazakizumab for at least 52 weeks.

[0356] Intermediate efficacy endpoints are analyzed using a mixed model repeat measurement approach. The model may include terms for treatment, stratification factors, baseline eGFR, and other predefined covariates.

[0357] Sensitivity analysis may include the following: 1. Missing values ​​are attributed using the mean of the observed values ​​at that time within the same treatment group. 2. For subjects with missing values ​​after experiencing an adverse event (AE), the missing values ​​are attributed to the worst (lowest) eGFR value observed in the control group at a given time point. For subjects with missing values ​​for reasons other than AE, the missing values ​​are attributed to the mean of the observed values ​​at that time within the same treatment group. 3. Use the delta adjustment method to estimate the turning point at which aggressive treatment has undesirable effects. 4. Nonparametric rank-based method. Subjects are first graded at the time they last provided data, and then graded by their eGFR value at that visit. The Wilcoxon rank-sum test can then be applied to compare treatment groups using their ranks.

[0358] These modifications can be made to the present invention in light of the modes of carrying out the invention described above. In general, the terms used in the following claims should not be construed as limiting the invention to the specific embodiments disclosed herein and in the claims. Accordingly, the present invention is not limited by this disclosure, and instead, the scope of the invention should be determined as a whole by the following claims.

[0359] References 1.Keller ET, Wanagat J, Ershler WB.Molecular and cellular biology of interleukin-6 and its receptor.Front Biosci.1996;1:d340-57. 2. Hirano T, Taga T, Nakano N, Yasukawa K, Kashiwamura S, Shimizu K, et al.Purification to homogeneity and characterization of human B-cell differentiation factor(BCDF) or BSFp-2).Proc Natl Acad Sci USA.1985 Aug;82(16):5490-4. 3.Kawano MM, Mihara K, Huang N, Tsujimoto T, Kuramoto A.Differentiation of early plasma cells on bone marrow stromal cells requires interleukin-6 for escaping from apoptosis.Blood.1995 Jan 15;85(2):487-94. 4.Muraguchi A,Hirano T,Tang B,Matsuda T,Horii Y,Nakajima K,et al.The essential role of B cell stimulatory factor 2(BSF-2 / IL-6)for the terminal differentiation of B cells.J Exp Med.1988 Feb 1;167:332-44. 5.Lotz M,Jirik F,Kabouridis P,Tsoukas C,Hirano T,Kishimoto T,et al.B cell stimulating factor 2 / interleukin 6 is a costimulant for human thymocytes and T lymphocytes.J Exp Med.1988 Mar 1;167(3):1253-8.6.Okada M,Kitahara M,Kishimoto S,Matsuda T,Hirano T,Kishimoto T.IL-6 / BSF-2 functions as a killer helper factor in the in vitro induction of cytotoxic T cells.J Immunol.1988 Sep 1;141(5):1543-9. 7.Jordan SC,Choi J,Kim I,Wu G,Toyoda M,Shin B,et al.Interleukin-6,a cytokine critical to mediation of inflammation,autoimmunity and allograft rejection:therapeutic implications of IL-6 receptor blockade.Transplantation.2017 Jan;101(1):32-44. 8.Gaston RS,Cecka JM,Kasiske BL,Fieberg AM,Leduc R,Cosio FC,et al.Evidence for antibody-mediated injury as a major determinant of late kidney allograft failure.Transplantation.2010 Jul 15;90(1):68-74.9.Thomas KA,Valenzuela NM,Reed EF.The perfect storm:HLA antibodies,complement,FcγRs,and endothelium in transplant rejection.Trends Mol Med.2015 May;21(5):319-29. 10.Wiebe C,Gibson IW,Blydt-Hansen TD,Karpinksi M,Ho J,Storsley LJ,et al.Evolution and clinical pathologic correlations of de novo donor-specific HLA antibody post kidney transplant.Am J Transplant.2012 May;12(5):1157-67. 11.Wiebe C,Gibson IW,Blydt-Hansen TD,Poc hinco D,Birk PE,Ho J,et al.Rates and determinants of progression to graft failure in kidney allograft recipients with de novo donor-specific antibody.Am J Transplant.2015 Nov;15(11):2921-30. 12.Hariharan S,McBride MA,Cherikh WS,Tolleris CB,Bresnahan BA,Johnson CP.Post-transplant renal function in the first year predicts long-term kidney transplant survival.Kidney Int.2002 Jul;62(1):311-8.13.Kasiske BL,Israni AK,Snyder JJ,Skeans MA.The relationship between kidney function and long-term graft survival after kidney transplant.Am J Kidney Dis.2011 Mar;57(3):466-75. 14.Clayton PA,Lim WH,Wong G,Chadban SJ.Relationship between eGFR decline and hard outcomes after kidney transplants.J Am Soc Nephrol.2016;27:3440-6. 15.Eskandary F,Bond G,Schwaiger E,Kikic Z,Winzer C,Wahrmann M,et al.Bortezomib in late antibody-mediated kidney transplant rejection(BORTEJECT Study):study protocol for a randomized controlled trial.Trials.2014 Apr 3;15:107.p.1-9. 16.Stegall MD,Gaston RS,Cosio FG,Matas A.Through a glass darkly:seeking clarity in preventing late kidney transplant failure.J Am Soc Nephrol.2015 Jan;26(1):20-9.Epub 2014 Aug 5. 17.Kidney Disease:Improving Global Outcomes(KDIGO)Transplant Work Group.KDIGO clinical practice guideline for the care of kidney transplant recipients.Am J Transplant.2009 Nov;9 Suppl 3:S1-155. 18.Roberts DM,Jiang SH,Chadban SJ.The treatment of acute antibody-mediated rejection in kidney transplant recipients-a systematic review.Transplantation.2012 Oct;94(8):775-83. 19.Wan SS,Ying TD,Wyburn K,Roberts DM,Wyld M,Chadban SJ.The treatment of antibody-mediated rejection in kidney transplantation:an updated systematic review and meta-analysis.Transplantation.2018 Apr;102(4):557-68. 20.Bailly E,Blancho G,Ville S,Morelon E,Bamoulid J,Caillard S,et al.Five-year outcomes after randomization treatment by rituximab in early acute antibody-mediat ed rejection in renal transplantation:long term outcomes of the RITUX ERAH Study.Am J Transplant.2017;17(Suppl 3). 21.Sautenet B,Blancho G,Buchler M,Morelon E,Toupance O,Barrou B,et al.One-year results of the effects of rituximab on acute antibody-mediated rejection in renal transplantation:RITUX ERAH,a multicenter double-blind randomized placebo-controlled trial.Transplantation.2016 Feb;100(2):391-9. 22.Kulkarni S,Kirkiles-Smith NC,Deng YH,Formica RN,Moeckel G,Broecker V,et al.Eculizumab therapy for chronic antibody-mediated injury in kidney transplant recipients:a pilot randomized controlled trial.Am J Transplant.2017 Mar;17(3):682-91.23.Eskandary F,Regele H,Baumann L,Bond G,Kozakowski N,Wahrmann M,et al.A randomized trial of bortezomib in late antibody-mediated kidney transplant rejection.J Am Soc Nephrol.2018;29:591-605. 24.Moreso F,Crespo M,Ruiz JC,Torres A,Gutierrez-Dalmau A,Osuna A,et al.Treatment of chronic antibody mediated rejection with intravenous immunoglobulins and rituximab:a multicenter,prospective,randomized,double-blind clinical trial.Am J Transplant.2018;18:927-935. 25.Pineiro G,Rovira J,De Sousa-Amorim E,Villarreal J,Sole M,Revuelta I,et al.Treatment of active chronic antibody-mediated rejection with rituximab,IVIG and plasma exchange Am J Transplant.2017;17(Suppl 3). 26.Choi J,Aubert O,Vo A,Loupy A,Haas M,Puliyanda D,et al.Assessment of tocilizumab(anti-interleukin-6 receptor monoclonal)as a potential treatment for chronic antibody-mediated rejection and transplant glomerulopathy in HLA-sensitized renal allograft recipients.Am J Transplant.2017;17:2381-9. 27.Choi J,Aubert O,Louie S,Ammerman N,Vo A,Peng A,et al.Extended experience using tocilizumab(anti-IL6R,TCZ)for the treatment of chronic antibody mediated rejection(CABMR)Am J Transplant.2017;17(Suppl 3). 28.Puliyanda D,Kim I,Choi J,Haas M,Zhang X,Vo A,et al.Safety and efficacy of tocilizumab(anti-IL6R,TCZ)therapy in the treatment of chronic antibody mediated rejection(cABMR)in pediatric renal transplant recipients Am J Transplant.2017;17(Suppl 3). 29.Venkatachalam K,Reem D,Andrew M,Delos Santos R,Alhamad T.Efficacy and safety of tocilizumab in treatment of acute antibody mediated rejection.Am J Transplant.2017;17(Suppl 3). 30.Chandran S,Leung J,Laszik Z,Tang Q,Hu C,Sarwal M,et al.IL-6 inhibition with tocilizumab to promote tregs and control renal graft inflammation:a prospective randomized controlled trial.Am J Transplant.2017;17(Suppl 3). 31.Patel S,Mohan S,Fernandez H,Batal I,Ratner L,Crew J.Tocilizumab stabilizes renal function in kdney transplant recipients with chronic active antibody mediated rejection(CAAMR)Am J Transplant.2017;17(Suppl 3). 32. Vo AA, Choi J, Kim I, Louie S, Cisneros K, Kahwaji J, et al. A phase I / II trial of the interleukin 6 receptor specific humanized monoclonal (tocilizumab) + intravenous immunoglobulin in difficult to desensitize patients. Transplantation. 2015;99(11):2356 - 63. 33. Investigator’s Brochure Clazakizumab. Version 4.0. Final report. Victoria(BC): Vitaeris Inc.; 2018 May 1. 34. Actemra (registered trademark) (tocilizumab) injection, for intravenous or subcutaneous use. Prescribing Information. Genentech, Inc. USA. 2017 Aug. 35. RoActemra 20mg / ml concentrate for solution for infusion. Summary of Product Characteristics. Roche Products Limited, Garden City, Herfordshire, UK. 2018 Apr 12. 36. Final report. Quantitative assessment of the relationship between change in estimated glomerular filtration rate and risk of allograft failure in patients diagnosed with active antibody - mediated rejection following kidney transplantation. Vancouver(BC): Vitaeris Inc.; 2018 Jun 1. 37.Loupy A,Haas M,Solez K,Racusen L,Glotz D,Seron D,et al.The Banff 2015 Kidney Meeting Report:current challenges in rejection classification and prospects for adopting molecular pathology.Am J Transplant.2017;17(1):28-41. 38.Clinical study report IM133001.Phase IIB,randomized,multi-center,double-blind,dose-ranging,placebo / active controlled study to evaluate the efficacy and safety of BMS-95429 subcutaneous injection with or without methotrexate in subjects with moderate to severe rheumatoid arthritis(RA)with inadequate response to methotrexate.Final report.Bristol-Myers Squibb Company;2014 Sep 12.Report No.:IM133001. 39.Hoffmann-La Roche Inc.Tocilizumab Arthritis Advisory Committee.2008 Jul 29. 40.Clinical trial results summary IM133066.A Phase IIb,randomized,multi-Center,double-blind,dose-Ranging Study to evaluate the efficacy and safety of Clazakizumab in subjects with moderate to severe active rheumatoid arthritis who have experienced an inadequate response to TNF inhibitors.Report in preparation.Preliminary results available upon request.Report No.:IM133066. 41.Zhao Q,Pang J,Shuster D,Hung C,Baglino S,Dodge R,et al.Anti-IL-6 antibody Clazakizumab is more potent than tocilizumab in blocking in vitro and in vivo IL-6-induced functions.ACR / ARHP Annual Meeting;2013 Oct 25-30;San Diego,CA.Poster 2385. 42.National Cancer Institute.Common Terminology Criteria for Adverse Events(CTCAE).Version 5.0.2017 Nov 27. 43.Bohmig GA,Budde K.Safety,tolerability and efficacy of anti-IL-6 antibody Clazakizumab in late antibody-mediated rejection after kidney transplantation-a pilot trial.Medical University of Vienna;2018. 44.Kevzara(sarilumab)injection.Prescribing Information.Regeneron Pharmaceuticals,Inc. / sanofi-aventis U.S.LLC,USA.2017 May. 45.Levey AS,Coresh J,Greene T,Stevens LA,Yaping Z,Hendriksen S,et al.Using standardized serum creatinine values in the m odification of diet in renal disease study equation for estimating glomerular filtration rate.Ann Intern Med.2006 Aug 15;145(4):247-54. 46.Sampson HA,Munoz-Furlong A,Campbell RL,Adkinson NF,Bock SA,Branum A,et al.Second symposium on the definition and management of anaphylaxis:summary report-Second National Institute of Allergy and Infectious Disease / Food Allergy and Anaphylaxis Network Symposium.Ann Emerg Med.2006 Apr;47(4):373-80. 47.Humar A,Michaels M.American Society of Transplantation recommendations for screening,monitoring and reporting of infectious complications in immunosuppression trials in recipients of organ transplantation.Am J Transplant.2006;6:262-74. 48.Tong A,Sautenet B,Poggio ED,Lentine KL,Oberbauer R,Mannon R,et al.Establishing a core outcome measure for graft health:a standardized outcomes in Nephrology-Kidney Transplantation(SONG-Tx)Consensus Workshop Report.Transplantation.2018 Aug;102(8):1358-66. 49.Kidney International Supplements.Section 2:AKI Definition.KDIGO Clinical practice guideline for acute kidney injury.Kidney Int Suppl.2012;2:19-36. 50.World Medical Association.World Medical Association Declaration of Helsinki.Ethical principles for medical research involving human subjects.JAMA.2013 Nov;310(20):2191-4. 51.ICH Harmonised Tripartite Guideline.Guideline for good clinical practice.E6(R1)1996 Jun 10. 52.Pharmaceutical Research and Manufacturers of America.Principles on conduct of clinical trials.Communication of Clinical Trial Results.Washington(DC);2014 Dec.Available from:http: / / phrma-docs.phrma.org / sites / default / files / pdf / 042009_clinical_trial_principles_final_0.pdf. 53.International Committee of Medical Journal Editors Criteria.Defining the role of authors and contributors.C2018[accessed 2018 Jul 27].Available from:http: / / www.icmje.org / recommendations / browse / roles-and-responsibilities / defining-the-role -of-authors-and-contributors.html.

Claims

1. A method for preventing, stabilizing, or mitigating antibody-mediated rejection (ABMR) in a subject who is scheduled to receive, has received, or has received a solid organ transplant, comprising administering to the subject a prophylactic or therapeutically effective amount of an anti-human interleukin-6 (IL-6) antibody or anti-human IL-6 antibody fragment, wherein the antibody or antibody fragment comprises a variable light chain polypeptide containing the CDRs of SEQ ID NOs: 4, 5, and 6, and a variable heavy chain polypeptide containing the CDRs of SEQ ID NOs: 7, 8, or 120 and 9.

2. A method for reversing, stabilizing, and / or slowing active antibody-mediated rejection (AMBR) in a transplant recipient in need thereof, comprising administering an effective amount of anti-IL-6 antibody or antibody fragment, wherein the antibody or antibody fragment optionally comprises a variable light chain polypeptide containing the CDRs of SEQ ID NOs: 4, 5, and 6, and a variable heavy chain polypeptide containing the CDRs of SEQ ID NOs: 7, 8, or 120 and 9.

3. The method according to claim 1 or 2, wherein the anti-human IL-6 antibody comprises the heavy chain polypeptide of SEQ ID NO: 704 or 745 and the light chain polypeptide of SEQ ID NO: 702 or 746.

4. The method according to any one of the prior claims, wherein the anti-human IL-6 antibody is administered for at least one year.

5. The method according to any one of the prior claims, wherein the anti-human IL-6 antibody is administered for at least two years.

6. The method according to any one of the prior claims, wherein the anti-human IL-6 antibody is administered for at least three years.

7. The method according to any one of the prior claims, wherein the anti-human IL-6 antibody is administered for at least four years.

8. The method according to any one of the prior claims, wherein the anti-human IL-6 antibody is administered for at least five years.

9. The method according to any one of the prior claims, wherein the anti-human IL-6 antibody is administered for a period of more than five years.

10. The method according to any one of the prior claims, wherein the transplant recipient optionally has at least one instance of active antibody-mediated rejection (AMBR) or chronic active antibody-mediated rejection (CABMR) within a period of 1 to 6 months prior to treatment when treatment is optionally initiated.

11. The method according to any one of the prior claims, wherein the transplant recipient has been diagnosed with AMBR or CAMBR prior to administration of the anti-IL-6 antibody.

12. The method according to any one of the prior claims, wherein treatment with the anti-IL-6 antibody optionally stabilizes or increases the estimated glomerular filtration rate (eGFR) throughout the entire treatment period.

13. The treatment with the aforementioned anti-IL-6 antibody is, during treatment, optionally throughout the treatment period, estimated The method according to any of the prior claims, wherein the glomerular filtration rate (eGFR) is stabilized or increased, and the stabilization or increase of the eGFR is optionally maintained for at least 3, 6, 9, or 12 months after the completion of treatment.

14. When treatment is initiated and / or during the treatment regimen, the patient being treated has neutropenia (1,000 mm) ３ (less than) or thrombocytopenia (50,000 mm) ３ The method according to any of the prior claims, which does not have less than (

15. The method according to any of the prior claims, wherein the patient being treated has not received intravenous immunoglobulin during the period of 0 to 6 months prior to treatment.

16. The method according to any one of the prior claims, wherein the patient to be treated has human leukocyte antigen (HLA) DSA prior to treatment, and this is optionally confirmed by an assay that detects human leukocyte antigen (HLA) DSA within a period of 0 to 6 months prior to treatment.

17. The method according to any one of the prior claims, wherein the anti-IL-6 antibody is administered over a period of 0-3, 1-3, 1-4, 1-5, or 1-6 months prior to transplantation.

18. The aforementioned treatments are as follows: (i) Reduction or elimination of donor-specific antibodies (DSAs), (ii) Decrease in CCL2 levels, (iii) Reduction of complement activation, and / or reduction of the amount of C5b, C9, and / or C5b / C9 complex detected, (iv) Reduction in the number of plasma cells that secrete DSA, (v) Prevention of loss of allografts, (vi) Prevention of return to dialysis, (vii) Prevention of allogeneic nephrectomy, and / or (viiii) Prevention of the need for re-transplantation, (ix) Estimated glomerular filtration rate (eGFR) is at least ≥ 15 mL / min / 1.73 m ２ A method according to any of the prior claims, which induces one or more of the following: maintaining or increasing a certain condition. 。

19. The method according to any of the prior claims, wherein the graft includes a solid organ.

20. The method according to any of the prior claims, wherein the solid organ includes a kidney, heart, lung, bladder, pancreas, liver, gallbladder, thyroid gland, skin, or any combination thereof.

21. The method according to any one of the prior claims, wherein the solid organ includes or consists of a kidney.

22. The method according to any of the prior claims, wherein the graft is from a living or deceased donor.

23. The method according to any of the prior claims, wherein the effectiveness during or after treatment is evaluated using the Modified Dietary Therapy 4 (MDRD4) equation in renal disease, at least partially by detecting eGFR values.

24. The method according to any of the prior claims, wherein the effectiveness is evaluated by assessing the histology of a renal biopsy at least in part according to the Banff 2015 lesion grading score.

25. The method according to any of the prior claims, wherein effectiveness is evaluated by detecting at least partially DSA titer and / or mean fluorescence intensity (MFI) score.

26. The method according to any of the prior claims, wherein the treatment is effective and its effectiveness is evaluated by selectively assessing the incidence of acute rejection episodes (TCMR and ABMR) at least partially.

27. The method according to any of the prior claims, wherein the effectiveness is evaluated by evaluating the effectiveness of the treatment for albuminuria, at least partially.

28. The method of any of the prior claims, wherein efficacy is evaluated by assessing survival rates at least partially compared to a control and / or conventional AMBR or CAMBR treatment.

29. The method according to any one of the prior claims, wherein the antibody IL-6 comprises the human IgG1 constant region.

30. The method according to claim 29, wherein the human IgG1 constant region comprises the constant light polypeptide of SEQ ID NO: 586 and the constant heavy polypeptide of SEQ ID NO:

588.

31. The method according to any one of the prior claims, wherein the anti-IL-6 antibody comprises the variable heavy chain polypeptide of SEQ ID NO: 657 and the variable light chain polypeptide of SEQ ID NO:

709.

32. The method according to any one of the prior claims, wherein the anti-IL-6 antibody comprises a heavy chain polypeptide of SEQ ID NO: 704 or 745 and a light chain polypeptide of SEQ ID NO: 702 or 746.

33. The method according to any one of the prior claims, wherein the anti-IL-6 antibody is administered intravenously or subcutaneously every four weeks or monthly.

34. The method according to any one of the prior claims, wherein the anti-IL-6 antibody is administered intravenously or subcutaneously every four weeks or monthly in doses of 25 mg or 12.5 mg.

35. The method according to any of the prior claims, wherein Claza is administered intravenously or subcutaneously every four weeks or monthly in doses of 25 mg or 12.5 mg.

36. The aforementioned treatment is effective for at least one, two, three, four, or five years, during which time a return to dialysis, allogeneic nephrectomy, re-transplantation, or eGFR ≤ 15 mL / min / 1.73 m² is not possible. ２ The method according to any of the prior claims, performed without adverse events selected from the prior claims.

37. The transplant recipient may optionally choose the following: (i) Azathioprine (e.g., 1.0–2.0 mg / kg / day), (ii) Calcineurin inhibitors (CNIs), (iii) Mycophenolate mofetil (MMF) (e.g., 1.0-2.0 g / day) / Mycophenolic acid (MPA) (e.g., 720-1440 mg / day) (iv) mTOR inhibitors (e.g., tacrolimus, everolimus, sirolimus (e.g., target trough level of 5-8 ng / ml)), (v) Low doses of corticosteroids (e.g., prednisone / prednisolone ≤ 10 mg / day), (vi) Antihypertensive drugs (e.g., angiotensin-converting enzyme inhibitors (ACEIs)), (vii) Angiotensin II receptor blockers (ARBs), (viiii) Cyclosporine (e.g., target trough level 50-150 ng / ml), (ix) Antidiabetic drugs, The method according to any of the prior claims, further treated by (x) or any combination of the foregoing.

38. The method according to any of the prior claims, wherein the transplant recipient is optionally further treated with prophylaxis for Pneumocystis iloveti pneumonia (PJP), e.g., trimethoprim (e.g., 80 mg pills daily) and / or sulfamethoxazole (e.g., 160 mg pills three times weekly), inhaled pentamidine, or oral dapsone (optionally initiated at least one week before treatment).

39. The method according to any of the prior claims, wherein if the transplant recipient experiences acute TCM, the transplant recipient is treated with a pulsed steroid, such as oral prednisone (e.g., 200 mg / day).

40. During anti-IL-6 antibody therapy, optionally, within a period of 0, 1, 2, 3, 4, 5, or 6 months prior to the start of treatment, the transplant recipient has the following conditions: (i) Rituximab, (ii) Eculizumab, (iii) Proteasome inhibitors, (iv) Intravenous immunoglobulin (IVIG) (except for the treatment of hypogammaglobulinemia), (v) Plasma exchange (PLEX), beratacept, (vi) Anti-IL-6R antibody, and / or (vii) The method according to any of the prior claims, which is not treated by any of the combinations described above.

41. The transplant recipient may optionally choose the following: (i) Being between 18 and 75 years old, (ii) Treatment must be initiated at least six months after the transplant. (iii) The following: Diagnosis of CABMR according to the BANFF 2015 diagnostic criteria, including CABMR confirmed by biopsy (i.e., chronic glomerulosynovitis (cg) > 0 with / without C4d staining) (repeated biopsies should be performed if the previous biopsy was not within 6 months of screening). (iv) If a subject has been treated for ABMR (including CABMR) or TCMR, repeated biopsies (indicating continued CABMR) are performed, and the subject is eligible if there is no evidence of chronic tissue damage on a light microscope, but there is glomerular basement membrane contour (cg1a) on an electron microscope. The method according to any of the prior claims, comprising any or all of the following: (v) the presence of human leukocyte antigen (HLA) DSA after transplantation (using a single antigen bead-based assay).

42. The transplant recipients are as follows: (i) Not having received treatment for ABMR, CAABMR, or TCMR within 0 to 3 months or 0 to 6 months following IL-6 antibody treatment or screening. (ii) Not having received any T-cell depletion agent, ABMR (including CABMR), or TCMR treatment within three months of screening or treatment. (iii) Not having received a T-cell depletion agent (e.g., alemtuzumab, antithymocyte globulin) within three months of screening or IL-6 antibody treatment. (iv) No biopsy showing pure TCMR or advanced interstitial fibrosis (CI3) 、 (v) Absence of progressive tubular atrophy (CT3), (vi) Absence of vascular fibrous intimal thickening (CV3) or other serious causes of renal dysfunction (e.g., polyomatous BK virus (BKV) nephropathy, glomerulonephritis), (vii) No renal dysfunction resulting from damage to the transplanted allograft (e.g., renal artery stenosis, hydronephrosis). (viii) eGFR<25mL / min / 1.73m ２ Or >65 mL / min / 1.73 m ２ (MDRD4) is absent, (viiii) there is no nephrotic range proteinuria as defined as a spot urine protein-creatinine ratio (UPCR) ≥ 3,000 mg / g (≥ 300 mg / mmol) or a spot urine albumin-creatinine ratio (UACR) ≥ 2,200 mg / g (≥ 220 mg / mmol), (ix) Not pregnant or breastfeeding, (x) No history of anaphylaxis. (xi) Absence of abnormal liver function tests (LFT) (alanine aminotransferase (ALT) / aspartate aminotransferase (AST) / bilirubin > 1.5 × upper limit of normal) or other serious liver disease. (xi) No history of active tuberculosis (TB), (xiii) Unless the subject has completed the entire course of prophylactic treatment, there is no history of latent tuberculosis without a history of active TB (e.g., a positive QuantiFERON TB test), (xiv) No history of human immunodeficiency virus (HIV) infection, or not positive for HIV. (xv) Not serologically positive for hepatitis B surface antigen (HBsAg), (xvi) Not positive for Hepatitis C virus (HCV) RNA. (xvii) There is no known Epstein-Barr virus (EBV) mismatch, the donor is seropositive, and the recipient is seronegative. (xviiii) No history of gastrointestinal perforation, diverticular disease, diverticulitis, or inflammatory bowel disease. ((xix) No hypogammaglobulinemia (< 1,000 / mm ３ ) or thrombocytopenia (< 50,000 / mm ３ ). (xx) No active infection requiring systemic antibiotics that has not resolved before screening. (xxi) No history or current history of invasive fungal infections or other opportunistic infections, including but not limited to nontuberculous mycobacterial infections, aspergillosis, pneumocystis, and toxoplasmosis; (xxii) No active viral infections such as BKV, cytomegalovirus (CMV), or EBV based on polymerase chain reaction (PCR) testing; (xxii) Currently or recently (no treatment for a period of 0-3 months or 0-6 months prior to treatment) (xxiii) Within six weeks of screening, have not received any live vaccines, including but not limited to adenovirus, measles, mumps, rubella, oral polio, oral typhoid, rotavirus, varicella-zoster, or yellow fever, and have no history of alcohol or illegal drug (including marijuana) abuse. (xxiv) No current or past (within the last 3 years) malignant tumors, except for basal cell carcinoma, squamous cell carcinoma of the skin that has been completely excised, or non-recurrent (within the last 5 years) cervical intraepithelial neoplasia. (xxv) The absence of any conditions or abnormalities that could impair safety or life expectancy (i.e., clinically significant endocrine, autoimmune, metabolic, neurological, psychiatric / psychological, renal, gastrointestinal, hepatic, and hematological or any other system abnormalities that are not controlled by standard treatment). (xxvi) No history of intolerance to trimethoprim and / or sulfamethoxazole, no prior treatment with anti-IL-6 antibodies, and / or (xxvii) The method according to any of the prior claims, which does not include one or more of the combinations described above.

43. A method for preventing, stabilizing, or reducing complement activity in a subject in need thereof, comprising administering to the subject a prophylactic or therapeutically effective amount of an anti-human interleukin-6 (IL-6) antibody or antibody fragment, for example, the antibody or antibody fragment comprising a variable light chain polypeptide containing the CDRs of SEQ ID NOs: 4, 5, and 6, and a variable heavy chain polypeptide containing the CDRs of SEQ ID NOs: 7, 8, or 120 and 9.

44. The method according to any one of the prior claims, wherein complement activity is measured in the subject before, during, or after treatment.

45. The antibody is at least 90%, 95%, 96%, 97%, 98%, or 99% identical to the polypeptides of SEQ ID NOs. 657 and 709, respectively. Ｈ and V Ｌ The method according to any of the prior claims, comprising a polypeptide.

46. The method according to any of the prior claims, wherein the antibody comprises heavy-chain and light-chain polypeptides that are at least 90, 95, 96, 97, 98, or 99% identical to the polypeptide of SEQ ID NO: 704 or 745 and 702 or 746, respectively.

47. The method according to any one of the prior claims, wherein the antibody is crazakizumab.

48. The method according to any of the prior claims, wherein the solid organ is selected from the kidney, heart, liver, lung, pancreas, gallbladder, skin, intestine, stomach, or any combination thereof.

49. The method according to any one of the prior claims, wherein the solid organ includes or consists of a kidney.

50. The method according to any of the prior claims, wherein the patient is evaluated and diagnosed with having ABMR or CAMBR prior to treatment.

51. The method according to claim 49, wherein the evaluation includes one or more of the following: detection of a pre-formed novel HLA DSA (particularly one that detects complement-binding DSAs such as C1q), detection of non-HLA antibodies associated with ABMR, and / or identification of at least one histological feature characteristic of antibody-mediated organ injury.

52. The method according to claim 49, wherein the histological features characteristic of the antibody-mediated organ injury are detected by obtaining a biopsy from the transplanted organ.

53. The method according to claim 49, wherein the histological features characteristic of the antibody-mediated organ injury include any one of microangiogenic inflammation, complement deposition (C4d), and capillary inflammation.

54. The method according to claim 49, wherein the transplanted organ is a kidney, and the histological features characteristic of the antibody-mediated organ injury include any one of the following: microangiogenic inflammation, complement deposition (C4d) in peritubular capillaries, peritubular capillary inflammation, glomerulitis, and transplant glomerulopathy (double glomerular basement membrane contour).

55. The method according to any of the prior claims, wherein the treatment further comprises the administration of at least one other immunosuppressant.

56. The method according to claim 54, wherein the at least one other immunosuppressant is an immunosuppressant used as standard treatment before or after transplantation.

57. The method according to claim 54, wherein the at least one other immunosuppressant comprises any of the following: thymoglobulin, basiliximab, mycophenolate mofetil, tacrolimus, rituximab, and corticosteroids.

58. The method according to any one of the prior claims, wherein the anti-IL-6 antibody is administered intravenously or subcutaneously.

59. The method according to any one of the prior claims, wherein the anti-IL-6 antibody is administered in a dose in the range of 0.01 to 5000 mg.

60. The method according to any one of the prior claims, wherein the anti-IL-6 antibody is administered in a dose in the range of 0.1 to 1000 mg.

61. The method according to any one of the prior claims, wherein the anti-IL-6 antibody is administered in a dose in the range of 1 to 500 mg.

62. The method according to any one of the prior claims, wherein the anti-IL-6 antibody is administered intravenously in a dose in the range of about 5 mg to 50 mg, or subcutaneously in a dose in the range of about 10 mg to 50 mg.

63. The method according to any one of the prior claims, wherein the anti-IL-6 antibody is administered in a dose of about 25 mg at intervals of about 2 weeks, 4 weeks, 6 weeks, 8 weeks, 12 weeks, 16 weeks, 20 weeks, 24 weeks, monthly, every other month, every 2 months, every 3 months, every 4 months, every 5 months, every 6 months, annually, or less frequently.

64. The method according to any one of the prior claims, wherein the anti-IL-6 antibody is administered approximately every 4 weeks, 8 weeks, 12 weeks, 16 weeks, 20 weeks, or 24 weeks.

65. The method according to any one of the prior claims, wherein the anti-IL-6 antibody is administered subcutaneously at a dose of 25 mg or 12.5 mg every four weeks or monthly.

66. The method according to any one of the prior claims, wherein the anti-IL-6 antibody is administered within about one, two, or three months to detect signs of ABMR or CAMBR.

67. The method according to any one of the prior claims, wherein the anti-IL-6 antibody is administered for several months prior to transplantation and for several months or years after transplantation to prevent, stabilize, or reduce antibody-mediated damage to the transplanted organ.

68. A method for preventing, stabilizing, or mitigating pre- or post-transplant sensitization in subjects who have undergone or are scheduled to undergo solid organ transplantation, comprising administering a prophylactic or therapeutically effective amount of anti-human interleukin-6 (IL-6) antibody or antibody fragment, wherein the antibody or antibody fragment comprises a variable light chain polypeptide containing the CDRs of sequence numbers 4, 5, and 6, and a variable heavy chain polypeptide containing the CDRs of sequence numbers 7, 8, or 120 and 9.

69. Claim 6, wherein the antibody comprises VH and VL polypeptides that are at least 90%, 95%, 96%, 97%, 98%, or 99% identical to the polypeptides of SEQ ID NOs. 657 and 709, respectively. The method described in 8.

70. The method according to claim 68, wherein the antibody comprises the same VH and VL polypeptides as the polypeptides of SEQ ID NOs. 657 and 709.

71. The method according to claim 68, wherein the antibody comprises the same light-chain and heavy-chain polypeptides as the polypeptide of SEQ ID NO: 702 or 746 and 704 or 745, respectively.

72. The method according to any of the prior claims, wherein the patient has been transplanted with a solid organ selected from the kidney, heart, liver, lung, pancreas, skin, intestine, stomach, or any combination thereof.

73. The method according to any one of the prior claims, wherein the solid organ includes or consists of a kidney.

74. The method according to any of the prior claims, wherein the patient is at risk or sensitized due to a history of blood transfusion, pregnancy, or a previous transplant.

75. The method according to any one of the prior claims, wherein the patient has pre-formed donor-specific antibodies (DSAs) against the donor organ before and / or during anti-IL-6 antibody treatment.

76. The method according to any of the prior claims, further comprising a pre-transplant desensitization procedure for removing or reducing donor-specific alloantibodies (DSAs).

77. The method according to claim 76, wherein the desensitization treatment comprises plasma exchange therapy or plasma exchange in combination with, optionally, one of the following: intravenous immunoglobulin, an anti-B cell agent (anti-CD20 mAb) such as rituximab, and a plasma cell inhibitor (proteosome inhibitor) such as bortezomib.

78. The method according to any one of the prior claims, wherein the antibody is administered intravenously or subcutaneously.

79. The method according to any one of the prior claims, wherein the antibody is administered in a dose in the range of 0.01 to 5000 mg.

80. The method according to any one of the prior claims, wherein the antibody is administered in a dose in the range of 0.1 to 1000 mg.

81. The method according to any one of the prior claims, wherein the antibody is administered in a dose in the range of 1 to 500 mg.

82. The method according to any one of the prior claims, wherein the antibody is administered in a dose of about 25 mg at intervals of about 2 weeks, 4 weeks, 6 weeks, 8 weeks, 12 weeks, 16 weeks, 20 weeks, 24 weeks, monthly, every other month, every 2 months, every 3 months, every 4 months, every 5 months, every 6 months, annually, or less frequently.

83. The method according to any of the prior claims, wherein the antibody is administered approximately every four or eight weeks, starting several months later (for example, within a period of 0 to 6 months prior to transplantation).

84. During the desensitization treatment process, the patient used one or more antibody detection methods (e.g., cytotoxic crossmatch, flow cytometry crossmatch, luminescence) to detect the level of DSA in the aforementioned patient. The method according to any of the prior claims, wherein prior desensitization (by kus antibody testing) is periodically evaluated during treatment.

85. The method according to claim 84, wherein a positive reaction (e.g., conversion to a positive-to-negative cytotoxic crossmatch) is used to determine whether the patient is eligible for IL-6 antibody therapy and / or transplantation.

86. The method according to any one of the prior claims, wherein the patient is treated with the anti-IL-6 antibody, for example, crazakizumab, after transplantation.

87. The method according to any of the prior claims, wherein the administration of the anti-IL-6 antibody is continued for several months or years after transplantation to prevent or treat early acute rejection or late chronic rejection.

88. The method according to any of the prior claims, wherein the patient is monitored for clinical signs of rejection, such as increased serum creatinine and / or proteinuria, or decreased eGFR in kidney transplantation, or for the development of a new DSA (novel DSA).

89. The method according to any of the prior claims, wherein the patient is monitored for histological signs of organ rejection.

90. The method according to any of the prior claims, wherein damage to the ABMR organ is confirmed by biopsy evidence (e.g., microangiitis, interstitial fibrosis, transplant glomerulopathy, CD4 deposition).

91. The method according to any one of the prior claims, wherein crazakizumab is used in combination with a standard immunosuppressive regimen (e.g., thymoglobulin, basiliximab, mycophenolate mofetil, tacrolimus, and corticosteroids) that is typically administered to the patient before and after transplantation.

92. The method according to any of the prior claims, wherein the anti-IL-6 antibody or antibody fragment includes an Fc region that is modified to alter effector function, half-life, proteolysis, and / or glycosylation.

93. The method according to any one of the prior claims, wherein the anti-IL-6 antibody is selected from a humanized, single-chain, or chimeric antibody, and the antibody fragment is selected from Fab, Fab', F(ab')2, Fv, or scFv.

94. The method according to any one of the prior claims, wherein the dose of the antibody is approximately 0.001 to 100 mg / kg of the recipient patient's body weight.

95. The method according to any one of the prior claims, wherein the dose of the anti-IL-6 antibody is approximately 0.1 to 20 mg / kg of the recipient patient's body weight, or approximately 25 mg.

96. The method according to any one of the prior claims, wherein the anti-IL-6 antibody or fragment inhibits the binding of IL-6 to gp130 and / or IL-6R1.

97. The method according to any one of the prior claims, wherein the anti-IL-6 antibody or antibody fragment comprises a human constant region.

98. The human constant region includes the IgG1, IgG2, IgG3, or IgG4 constant region. The method according to claim 97.

99. The method according to claim 97, wherein the human steady-state region includes an IgG1 steady-state region.

100. The method according to any one of the prior claims, wherein the anti-IL-6 antibody is crazakizumab.

101. The method according to any of the prior claims, wherein the treated subject has a late or advanced AMBR (acute / active or chronic / active phenotype according to the Banff 2015 classification).

102. The method according to any one of the prior claims, wherein the administered anti-IL-6 antibody is crazakizumab, and the treated subject has late or advanced AMBR (acute / active or chronic / active phenotype according to the Banff 2015 classification).

103. The treated subjects include age-related macular degeneration (AMD) (wet and dry), Alzheimer's disease, glomerular diseases such as atypical hemolytic uremic syndrome (aHUS), hemolytic uremic syndrome caused by Shiga toxin-producing E. coli (STEC-HUS), thrombotic thrombocytopenic purpura (TTP), systemic lupus erythematosus (SLE), antiphospholipid syndrome (APS), antineutrophil cytoplasmic antibody (ANCA)-induced vasculitis, inflammatory microangiopathy caused by autoantibodies against neutrophil components, antibody-dependent (i.e., in women with APS), pregnancy loss with C5a-mediated impairment of placental neovascularization, paroxysmal nocturnal hemoglobinuria (PNH), aHUS and cold agglutinin disease (CAD), ischemia-reperfusion injury, etc. The method according to any of the prior claims, wherein the host has a complement-related condition selected from age-related and degenerative diseases such as complement-mediated hemolytic disorders, e.g., trauma, sepsis, shock, and cardiopulmonary bypass (CPB) surgery, CPB-cardiopulmonary bypass surgery, allergic asthma, stroke caused by periodontitis, myocardial infarction, bone-related disorders and bone injuries associated with abnormal complement activation (e.g., via the effect of anaphylatoxins on osteoclast formation), and an acute phase condition, and the host is facing a dramatic increase in injury and / or pathogen-related molecular patterns.

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