Thymus Transplantation Safety-Efficacy

• Descriptive Study - Immune Outcomes [ Time Frame: 6 Months & 1 Year Post-Transplantation ] [ Designated as safety issue: No ]
  • Total CD3, CD4, CD8, naïve CD8 TCRαβ, TCRγδ, total B cells and total NK cells at 6 months and 12 months post-transplantation.
  • TCR repertoire as assessed by flow cytometry 12 months post-transplantation.
  • PHA response, a response to CD3 and tetanus toxoid at 12 months post-transplantation.
• Naive CD 4 T Cell Count [ Time Frame: One Year Post-Transplantation ] [ Designated as safety issue: No ]
  Assess total naïve T cell count at 12 months post-thymus transplantation. The hypothesis is that greater than 50% of subjects will have >100 naïve T cells at one year post-transplantation. An additional hypothesis is that the dose of thymus tissue transplanted will affect the naïve CD4 count at one year.
• Descriptive Study - GVHD [ Time Frame: 1 Year Post-Transplantation ] [ Designated as safety issue: Yes ]
  • Grade of skin GVHD in the first year post-transplantation.
  • Grades of upper & lower intestinal GVHD in the first year post-transplantation.
  • Grade of liver GVHD in the first year post-transplantation.
• Descriptive Study - Infections [ Time Frame: 1 Year Post-Transplantation ] [ Designated as safety issue: Yes ]
  Recording and tabulation of infections during the first 12 months post-transplantation including the organism, infection site, and severity.
• Descriptive Study - Autoimmune Disease [ Time Frame: 1 Year Post-Transplantation ] [ Designated as safety issue: No ]
  Autoimmune disease will be recorded and tabulated in first year post-transplantation.
• Descriptive Study - Persistent Rashes [ Time Frame: 1 Year Post-Transplantation ] [ Designated as safety issue: No ]
  Description and location of any rashes persisting over 2 weeks will be recorded.
• Descriptive Study - Thymus Donor T Cell Presence [ Time Frame: 3 Months Post-Transplantation ] [ Designated as safety issue: No ]
  Tabulate the presence of donor T cells in the blood 3 months post-transplantation.
• Descriptive Study - Other Adverse Events [ Time Frame: 1 Year Post-Transplantation ] [ Designated as safety issue: Yes ]

  Other adverse events possibly, probably and/or definitely transplant-related will be recorded and tabulated.

  • For any cancer, the type of cancer, location and genetic identity.
  • For any granuloma, the location and description.

• Descriptive Study - Immune Outcomes [ Time Frame: 6 Months & 1 Year Post-Transplantation ] [ Designated as safety issue: No ]
  • Total CD3, CD4, CD8, naïve CD8 TCRαβ, TCRγδ, total B cells and total NK cells at 6 months and 12 months post-transplantation.
  • TCR repertoire as assessed by flow cytometry 12 months post-transplantation.
  • PHA response to CD3 and tetanus toxoid at 12 months post-transplantation.
• Naive CD 4 T Cell Count [ Time Frame: One Year Post-Transplantation ] [ Designated as safety issue: No ]
  Assess total naïve T cell count at 12 months post-thymus transplantation. The hypothesis is that greater than 50% of subjects will have >100 naïve T cells at one year post-transplantation. An additional hypothesis is that the dose of thymus tissue transplanted will affect the naïve CD4 count at one year.
• Descriptive Study - GVHD [ Time Frame: 1 Year Post-Transplantation ] [ Designated as safety issue: Yes ]
  • Grade of skin GVHD in the first year post-transplantation.
  • Grades of upper & lower intestinal GVHD in the first year post-transplantation.
  • Grade of liver GVHD in the first year post-transplantation.
• Descriptive Study - Infections [ Time Frame: 1 Year Post-Transplantation ] [ Designated as safety issue: Yes ]
  Recording and tabulation of infections during the first 12 months post-transplantation including the organism, infection site, and severity.
• Descriptive Study - Autoimmune Disease [ Time Frame: 1 Year Post-Transplantation ] [ Designated as safety issue: No ]
  Autoimmune disease will be recorded and tabulated in first year post-transplantation.
• Descriptive Study - Persistent Rashes [ Time Frame: 1 Year Post-Transplantation ] [ Designated as safety issue: No ]
  Description and location of any rashes persisting over 2 weeks will be recorded.
• Descriptive Study - Thymus Donor T Cell Presence [ Time Frame: 3 Months Post-Transplantation ] [ Designated as safety issue: No ]
  Tabulate the presence of donor T cells in the blood 3 months post-transplantation.
• Descriptive Study - Other Adverse Events [ Time Frame: 1 Year Post-Transplantation ] [ Designated as safety issue: Yes ]

  Other adverse events possibly, probably and/or definitely transplant-related will be recorded and tabulated.

  • For any cancer, the type of cancer, location and genetic identity.
  • For any granuloma, the location and description.

Complete DiGeorge anomaly (cDGA) is a disorder in which there is no thymus function. With no thymus function, bone marrow stem cells do not develop into T cells, which fight infection. Complete DiGeorge anomaly patients cannot fight infection and are immunodeficient. Without successful treatment, complete DiGeorge patients usually die by age 2 years.

Thymus transplantation with and without immunosuppression (drugs given before and after transplantation) has resulted in the development good T cell function in complete DiGeorge anomaly subjects.

This Phase I/II study continues thymus transplantation safety and efficacy research for the treatment of complete DiGeorge anomaly. Eligible participants undergo thymus transplantation and biopsy. Immune function testing is continued for one year post-transplantation.

Complete DiGeorge anomaly (cDGA) is a congenital disorder characterized by athymia. Without successful treatment, children remain immunodeficient and usually die by age 2 years. In complete DiGeorge subjects, thymus transplantation with and without immunosuppression has resulted in diverse T cell development and good T cell function. The purpose of this Phase I/II study is to continue thymus transplantation safety and efficacy research for the treatment of complete DiGeorge anomaly. Until thymus transplantation is FDA approved as standard care for DiGeorge anomaly, research study participation is the only means by which a patient may have access to this potentially life-saving procedure.

This protocol includes 4 groups: one for subjects who do not require immunosuppression; and 3 immunosuppression groups for subjects with different T cell function levels to be suppressed adequately.

Eligible subjects undergo thymus transplantation and an allograft biopsy. Protocol specified studies continue until approximately one year post-transplantation.

Study participation lasts two years.

• Complete DiGeorge Anomaly
• DiGeorge Syndrome
• DiGeorge Anomaly
• Complete DiGeorge Syndrome

• Biological: Thymus Tissue for Transplantation
  Potential thymus recipient subjects are screened for eligibility. Thymus tissue (unrelated donor), donor, & donor's mother screened for safety. Thymus transplantation is done under general anesthesia in the operating room. Thymus tissue is transplanted into the subject's quadriceps. Two to three months post-transplantation, if medically stable, the subject undergoes allograft biopsy. At the time of transplantation and biopsy, skin biopsy conducted. Subjects undergo laboratory testing for approximately one year post-transplantation. At year 2 post-transplantation, subjects are contacted for data collection.
  Other Name: Thymus Tissue Transplant
• Procedure: Blood Draw
  Biological Mothers of Thymus Recipients are asked to participate in the study and undergo phlebotomy to allow for testing of T cell identity in the complete DiGeorge subjects. If blood is not obtainable, then a buccal swab may be done.
  Other Name: Venipuncture
• Drug: Rabbit anti-thymocyte globulin
  Three doses of 2 mg/kg IV prior to thymus transplantation. Each dose is given over 12 hours. RATGAM is usually given on days -5, -4, and -3 prior to thymus transplantation.
  Other Name: RATGAM
• Drug: Cyclosporine
  Csa may be given every 8 to 12 hours orally or IV before and after thymus transplantation. The Csa dose is dependent on T cell numbers and the target CSA trough levels. Csa is weaned as per protocol.
  Other Name: Csa
• Drug: Tacrolimus
  If unable to tolerate cyclosporine, then FK506 is given. FK506 may be given every 8 to 12 hours orally or IV before and after thymus transplantation. FK506 dose is dependent on T cell numbers and the target FK506 trough levels. FK506 is weaned as per protocol.
  Other Name: FK506
• Drug: Methylprednisolone or Prednisolone
  Steroids IV or orally may be given before and/or after thymus transplantation. Administration and dosage depends on T cell numbers. Steroids are weaned as per protocol.
  Other Name: Steroids
• Drug: Basiliximab
  A single dose of Basiliximab 5 mg/kg IV may be given. Administration of Basiliximab depends on T cell numbers and T cell activation. A single dose of Basiliximab may be given after the administration of rabbit anti-thymocyte globulin and before thymus transplantation. If Basiliximab is not given before thymus transplantation, and, depending on the T cell numbers and T cell activation, a single dose of Basiliximab may be given 3 to 5 days after thymus transplantation.
  Other Name: Simulect
• Drug: Mycophenolate mofetil
  Mycophenolate mofetil may be given if the T cell count remains elevated 5 days after thymus transplantation. If MMF is given, the dose is 15 mg/kg/dose every 8 hours IV or orally. MMF may be stopped at 35 days or continued for up to six months after thymus transplantation.
  Other Names:

  • MMF
  • CellCept

• Experimental: #1: Typical cDGA No Immunosuppression
  Subjects receive thymus transplant. Subjects do not receive any pre or post-transplantation immunosuppression.
  Interventions:

  • Biological: Thymus Tissue for Transplantation
  • Procedure: Blood Draw
• Experimental: #2:Typ & Atyp cDGA Immunosuppression

  Group two will receive three doses of 2 mg/kg of rabbit anti-thymocyte globulin IV pre transplantation.

  Medications (diphenhydramine, steroids, and acetaminophen) are given with rabbit anti-thymocyte globulin.

  Interventions:

  • Biological: Thymus Tissue for Transplantation
  • Procedure: Blood Draw
  • Drug: Rabbit anti-thymocyte globulin
• Experimental: #3: Atypical cDGA Immunosuppression
  Pre-transplant cyclosporine (Csa) as soon as complete DiGeorge anomaly is diagnosed. Csa continued with target trough levels of 180 to 220 ng/ml. When trough levels are outside of range, dosing is modified appropriately. If subject cannot tolerate Csa, Csa may be changed to tacrolimus (FK506) with target trough level 7 to 10 ng/ml. When trough levels are outside of this target range, dosing will be modified appropriately. Pre-transplant steroids are used for atypical subjects if pre-transplant T cells >4,000/mm3. Three doses of 2 mg/kg of rabbit anti-thymocyte globulin IV are given pre-transplantation. Medications (diphenhydramine, steroids, and acetaminophen) are given with rabbit anti-thymocyte globulin.
  Interventions:

  • Biological: Thymus Tissue for Transplantation
  • Procedure: Blood Draw
  • Drug: Rabbit anti-thymocyte globulin
  • Drug: Cyclosporine
  • Drug: Tacrolimus
  • Drug: Methylprednisolone or Prednisolone
• Experimental: #4: Atypical cDGA Additional Suppression
  Pre-transplant cyclosporine (Csa) and steroids are started after atypical complete DiGeorge anomaly is diagnosed. After PHA response is documented >40,000 cpm on suppression, peri-transplant Csa is maintained at target levels 250 to 300 ng/ml. (When levels outside of range, dose modified.) If subject cannot tolerate Csa then may be changed to tacrolimus (FK506) with target level 10 to 15 ng/ml. When levels are outside of range, dosing is modified. Three doses of 2 mg/kg rabbit anti-thymocyte globulin IV are given pre-transplantation. Medications (diphenhydramine, steroids, and acetaminophen) are given with rabbit anti-thymocyte globulin. Additional immunosuppression: Basiliximab, 5 mg/kg single dose IV; Mycophenolate Mofetil (MMF), 15 mg/kg/dose every 8 hours IV or enteral.
  Interventions:

  • Biological: Thymus Tissue for Transplantation
  • Procedure: Blood Draw
  • Drug: Rabbit anti-thymocyte globulin
  • Drug: Cyclosporine
  • Drug: Tacrolimus
  • Drug: Methylprednisolone or Prednisolone
  • Drug: Basiliximab
  • Drug: Mycophenolate mofetil

• Markert ML, Devlin BH, Alexieff MJ, Li J, McCarthy EA, Gupton SE, Chinn IK, Hale LP, Kepler TB, He M, Sarzotti M, Skinner MA, Rice HE, Hoehner JC. Review of 54 patients with complete DiGeorge anomaly enrolled in protocols for thymus transplantation: outcome of 44 consecutive transplants. Blood. 2007 May 15;109(10):4539-47. Epub 2007 Feb 6.
• Markert ML, Devlin BH, McCarthy EA. Thymus transplantation. Clin Immunol. 2010 May;135(2):236-46. Epub 2010 Mar 16. Review.
• Markert ML, Devlin BH, Chinn IK, McCarthy EA, Li YJ. Factors affecting success of thymus transplantation for complete DiGeorge anomaly. Am J Transplant. 2008 Aug;8(8):1729-36. Epub 2008 Jun 28.
• Markert ML, Alexieff MJ, Li J, Sarzotti M, Ozaki DA, Devlin BH, Sedlak DA, Sempowski GD, Hale LP, Rice HE, Mahaffey SM, Skinner MA. Postnatal thymus transplantation with immunosuppression as treatment for DiGeorge syndrome. Blood. 2004 Oct 15;104(8):2574-81. Epub 2004 Apr 20.
• Selim MA, Markert ML, Burchette JL, Herman CM, Turner JW. The cutaneous manifestations of atypical complete DiGeorge syndrome: a histopathologic and immunohistochemical study. J Cutan Pathol. 2008 Apr;35(4):380-5.
• Chinn IK, Devlin BH, Li YJ, Markert ML. Long-term tolerance to allogeneic thymus transplants in complete DiGeorge anomaly. Clin Immunol. 2008 Mar;126(3):277-81. Epub 2007 Dec 26.
• Markert ML, Li J, Devlin BH, Hoehner JC, Rice HE, Skinner MA, Li YJ, Hale LP. Use of allograft biopsies to assess thymopoiesis after thymus transplantation. J Immunol. 2008 May 1;180(9):6354-64.
• Hudson LL, Louise Markert M, Devlin BH, Haynes BF, Sempowski GD. Human T cell reconstitution in DiGeorge syndrome and HIV-1 infection. Semin Immunol. 2007 Oct;19(5):297-309. Epub 2007 Nov 26. Review.
• Markert ML, Devlin BH, Chinn IK, McCarthy EA. Thymus transplantation in complete DiGeorge anomaly. Immunol Res. 2009;44(1-3):61-70.
• Markert ML, Alexieff MJ, Li J, Sarzotti M, Ozaki DA, Devlin BH, Sempowski GD, Rhein ME, Szabolcs P, Hale LP, Buckley RH, Coyne KE, Rice HE, Mahaffey SM, Skinner MA. Complete DiGeorge syndrome: development of rash, lymphadenopathy, and oligoclonal T cells in 5 cases. J Allergy Clin Immunol. 2004 Apr;113(4):734-41.
• Markert ML, Sarzotti M, Ozaki DA, Sempowski GD, Rhein ME, Hale LP, Le Deist F, Alexieff MJ, Li J, Hauser ER, Haynes BF, Rice HE, Skinner MA, Mahaffey SM, Jaggers J, Stein LD, Mill MR. Thymus transplantation in complete DiGeorge syndrome: immunologic and safety evaluations in 12 patients. Blood. 2003 Aug 1;102(3):1121-30. Epub 2003 Apr 17.

Transplant Inclusion:

• Must have 1 of following: 22q11 or 10p13 hemizygosity; hypocalcemia requiring replacement; congenital heart disease; CHARGE association or CHD7 mutation
• Complete DiGeorge: <50 CD3+ T cells/cumm or <50 CD3+ T cells/cumm that are CD62L+ CD45RA+, or <5% of CD3+ cells are CD62L+ CD45RA+
• Atypical DiGeorge must have, or have had, a rash.

Group 1

•Typical cDGA whose T cells have a PHA response < 5,000 cpm and < 20 fold PHA response.

Group 2

•Typical cDGA whose T cells have a PHA response >5,000 cpm and <50,000 cpm and >20 fold PHA response

Group 3

• Typical cDGA whose T cells have PHA response >50,000 cpm
• Typical cDGA with maternal engraftment
• Atypical cDGA whose T cells have PHA response <40,000 cpm when on immunosuppression or <75,000 cpm to PHA when not on immunosuppression
• Atypical cDGA with group 3 PHA response & maternal engraftment

Group 4

• Atypical cDGA with PHA responses >75,000cpm while on no immunosuppression or PHA responses >40,000cpm while on immunosuppression
• Atypical cDGA with maternal engraftment and group 4 PHA response

Transplant Exclusion:

• Heart surgery <4 wks pre-transplantation
• Heart surgery anticipated w/in 3 months after proposed transplantation
• Rejection by surgeon or anesthesiologist as surgical candidate
• Lack of sufficient muscle tissue to accept transplant of 4 grams/m2 body surface area
• HIV infection
• Prior attempts at immune reconstitution, such as bone marrow transplant or previous thymus transplant
• CMV on 2 tests for Groups 2, 3, and 4

Biological Mother Inclusion/Exclusion:

• Must be biological mother of thymus recipient

• National Institutes of Health (NIH)
• National Institute of Allergy and Infectious Diseases (NIAID)
• Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)