Lung and Bone Marrow Transplantation for Lung and Bone Marrow Failure

• ClinicalTrials.gov Identifier: NCT03500731
• Recruitment Status: Recruiting
• First Posted: April 18, 2018
• Last Update Posted: February 11, 2022
• Sponsor: Paul Szabolcs
• Information provided by (Responsible Party): Paul Szabolcs, University of Pittsburgh

Study Description

Brief Summary:

The purpose of this study is to determine whether a lung transplantation prior to bone marrow transplantation (BMT) would allow for restoration of pulmonary function prior to BMT, allowing to proceed to BMT, to restore hematologic function.

Condition or disease	Intervention/treatment	Phase
Idiopathic Pulmonary Fibrosis; Emphysema or COPD	Biological: CD3/CD19 negative hematopoietic stem cells; Drug: Rituximab; Drug: Alemtuzumab; Drug: Fludarabine; Drug: Thiotepa; Drug: G-CSF; Drug: Hydroxyurea	Phase 1; Phase 2

Detailed Description:

The primary purpose of the study is to evaluate the safety and efficacy of performing lung transplantation followed by cadaveric, partially HLA-matched (≥1/6 HLA-match with an identical ABO blood type) CD3+/CD19+ depleted bone marrow transplantation in bone marrow failure and end-stage lung disease. Idiopathic pulmonary fibrosis (IPF) is a chronic, progressive, and fatal interstitial lung disease for which lung transplantation is the only therapy shown to prolong survival. Given the association of IPF with hematologic cytopenias and bone marrow failure, it is proposed that a tandem lung transplantation and bone marrow transplantation from a single cadaveric donor could be successful. This protocol focuses on performing combined transplantation for candidates that are unable to undergo standard lung transplantation. Lung transplantation prior to bone marrow transplantation (BMT) would allow for restoration of pulmonary function prior to BMT, and to restore hematologic function post BMT transplantation. The secondary objectives are to evaluate the feasibility and long-term complications associated with combined solid organ and BMT including the ability to initiate and successfully withdraw from immunosuppression following BMT and to attain independence from growth factors, red blood cell or platelet transfusions.

Study Design

• Study Type: Interventional (Clinical Trial)
• Estimated Enrollment: 8 participants
• Allocation: N/A
• Intervention Model: Single Group Assignment
• Masking: None (Open Label)
• Primary Purpose: Treatment
• Official Title: Lung Transplant in Tandem With Bone Marrow Transplant for Combined Lung and Bone Marrow Failure
• Actual Study Start Date: April 19, 2018
• Estimated Primary Completion Date: December 2023
• Estimated Study Completion Date: December 2026

Arms and Interventions

Arm

Intervention/treatment

Experimental: Lung and Bone Marrow Transplantation; All patients will undergo a cadaveric, partially HLA-matched lung transplantation followed by a CD3+/CD19+ depleted BMT from the same donor. In this study, the investigators will use a ≥1/6 HLA-matched T cell depleted bone marrow transplantation from a cadaveric organ donor with an identical ABO blood type as the recipient. Prior to transplantation, the marrow will be negatively selected for CD3/CD19 using a CliniMACS® depletion device. Subjects will undergo lung transplantation utilizing standard induction regimens selected by the CO-PIs based on the subject's underlying comorbidities and allosensitization. Rituximab may be initiated prior to the lung transplantation with tacrolimus as the ongoing maintenance immunosuppression. Subjects will undergo BMT utilizing CD3+/CD19+-depleted bone marrow with bone marrow conditioning beginning no less than 8 weeks after lung transplantation. Bone marrow will be recovered alongside solid organs and will be processed and cryopreserved.

Biological: CD3/CD19 negative hematopoietic stem cells; Negative selection for CD3/CD19 will be performed on CliniMACS® depletion device and given at time no less than 8 weeks post lung transplantation; Drug: Rituximab; Transplantation Conditioning; Other Name: Rituxan; Drug: Alemtuzumab; Transplantation Conditioning; Other Name: Campath-1H; Drug: Fludarabine; Transplantation Conditioning; Other Name: Fludara, Oforta; Drug: Thiotepa; Transplantation Conditioning; Drug: G-CSF; Transplantation conditioning; Other Name: Neupogen, Granix, Zarxio, Filgrastim; Drug: Hydroxyurea; Transplantation Conditioning

Outcome Measures

Primary Outcome Measures :

1. Death [ Time Frame: Up to 2 years post stem cell transplant ]
   How many, if any, patients die
2. Engraftment failure [ Time Frame: Up to 2 years post stem cell transplant ]
   How many, if any, develop engraftment failure
3. Non-hematologic events [ Time Frame: Up to 2 years post stem cell transplant ]
   Any Grade 4 event that happens at any time points
4. Hematological events [ Time Frame: after 30 days post stem cell transplant ]
   Any Grade 4 hematological events
5. BOS Score [ Time Frame: at 1 year post lung transplant ]
   Bronchiolitis Obliterans Syndrome (BOS) score based off patient pulmonary function testing. Graded on scale (BOS0 to BOS3), BOS0 having a better outcome then BOS3
6. T-cell Chimerism [ Time Frame: at 12 months post stem cell transplant ]
   The number of patients who have ≥25% donor T-cell chimerism
7. Myeloid chimerism [ Time Frame: at 12 months post stem cell transplant ]
   The number of patients with myeloid disorders who attain ≥ 10% myeloid chimerism
8. Restoration of blood cell count (in absence of growth factors) [ Time Frame: at 12 months post stem cell transplant ]
   Absolute neutrophil count (ANC)≥1000 per microliter of blood, platelets ≥50000 per microliter of blood and hematocrit ≥8 grams per deciliter of blood

Secondary Outcome Measures :

1. Feasibility of patients able to proceed to BMT within 6 months following lung transplantation [ Time Frame: Up to 2 years post stem cell transplant ]
   The number of patients who are able to proceed to BMT within 6 months following lung transplantation
2. Independence [ Time Frame: up to 2 years post stem cell transplant ]
   The number of patients who are able to be independent from transfusions and growth factors for at least 7 days
3. Independence [ Time Frame: Up to 2 years post stem cell transplant ]
   The number of patients who are able to be independent from transfusions and growth factors for at least 1 month
4. Tolerance development to both host and pulmonary grafting [ Time Frame: Up to 2 years post stem cell transplant ]
   Development of tolerance to both the host and pulmonary graft
5. Long-term complications [ Time Frame: Up to 2 years post stem cell transplant ]
   Long-term complications of combined solid organ and BMT
6. Acute cellular rejection [ Time Frame: Up to 2 years post stem cell transplant ]
   The number of patients who develop acute cellular rejection
7. Acute graft-versus-host-disease (GVHD) [ Time Frame: Up to 2 years post stem cell transplant ]
   The number of patients who develop acute graft-versus-host-disease (GVHD)
8. Chronic graft-versus-host-disease (GVHD) [ Time Frame: Up to 2 years post stem cell transplant ]
   The number of patients who develop chronic graft-versus-host-disease (GVHD)
9. Ability to withdrawal immunosuppression [ Time Frame: By 1 year post stem cell transplant ]
   The number of patients who are able to start immunosuppression withdrawal.
10. Time to withdraw immunosuppression [ Time Frame: Up to 2 years post stem cell transplant ]
    Time from BMT to withdrawal of immunosuppression
11. Prophylactic antimicrobial drugs [ Time Frame: Up to 2 years post stem cell transplant ]
    Time from BMT to independence for prophylactic antimicrobial drugs
12. Treatment antimicrobial drugs [ Time Frame: up to 2 years post stem cell transplant ]
    Time from BMT to independence from treatment antimicrobial drugs
13. Chronic lung allograft dysfunction [ Time Frame: 1 year post lung transplant ]
    The number of patients who develop chronic lung allograft dysfunction post lung transplant for all subjects, lung only and lung +stem cell transplant.

Other Outcome Measures:

1. Pace of immune reconstitution [ Time Frame: Up to 2 years post stem cell transplant ]
   The pace of immune reconstitution, systemically and in mucosal surfaces
2. Mixed chimerism [ Time Frame: at Months 1, 3, 6 and 12 post stem cell transplant ]
   The number of patients who have the incidence of mixed chimerism (.5% host cells)
3. In vitro immune tolerance [ Time Frame: Up to 2 years post stem cell transplant ]
   The number of patients who have in vitro immune tolerance

Eligibility Criteria

• Ages Eligible for Study: 18 Years to 60 Years (Adult)
• Sexes Eligible for Study: All
• Accepts Healthy Volunteers: No

Criteria

Inclusion Criteria:

Individuals must meet all of the following criteria in order to be eligible for this study.

1. Subject must be able to understand and provide informed consent.
2. Male or female, 18 through 60 years old, inclusive, at the time of informed consent.
3. Meet criteria for UNOS listing for lung transplantation.

4. Patients must have evidence of end stage lung disease. Examples of such diseases include but are not limited to:

   • Pulmonary Fibrosis
   • COPD/Emphysema

5. Patients must have evidence of bone marrow failure with abnormal low cell count in at least one hematopoietic line, making the patient a poor candidate for long-term immunosuppressive therapy. Eligible patients must meet at least one of the following criteria:

   • Unexplained, non-drug induced neutropenia with absolute neutrophils counts of <1500/µL the previous year, confirmed by repeat testing
   • Unexplained, non-drug induced thrombocytopenia with mean platelets counts of <100,000/µL the previous year, confirmed by repeat testing
   • Unexplained, non-hemolytic anemia, with a hemoglobin level of < 12 g/dL the previous year, confirmed by repeat testing
6. GFR ≥45 mL/min/1.73 m2.
7. AST, ALT ≤4x upper limit of normal, total bilirubin ≤ 2.5 mg/dL, normal INR, albumin >3.0 g/dL
8. Cardiac ejection fraction ≥ 40% or shortening fraction ≥26%.
9. Negative pregnancy test for females, unless surgically sterilized.
10. All females of childbearing potential and sexually active males must agree to use a FDA approved method of birth control for up to 24 months after BMT or for as long as they are taking any medication that may harm a pregnancy, an unborn child or may cause birth defect.
11. Subject will also be counseled regarding the potential risks of infertility following BMT and advised to discuss sperm banking or oocyte harvesting.

Exclusion Criteria:

Individuals who meet any of these criteria are not eligible for this study.

1. Inability or unwillingness of a participant to give written informed consent or comply with study protocol.
2. Patients who have underlying malignant conditions.
3. Patients who have non-malignant conditions not requiring BMT.
4. HIV positive by serology or PCR, HTLV positive by serology. If HTLV serology is positive, it will be confirmed by nucleic acid testing (NAT). If HTLV NAT is negative, subject will remain eligible regardless of HTLV serology result.
5. Females who are pregnant or who are lactating.
6. Allergy to DMSO or any other ingredient used in the manufacturing of the stem cell product.
7. Uncontrolled pulmonary infection, as determined by radiographic findings and/or significant clinical deterioration. NOTE: Pulmonary colonization with multiple organisms is common and will not be considered an exclusion criterion.
8. Uncontrolled infection, as determined by the appropriate imaging and/or confirmatory testing e.g. blood cultures, PCR testing, etc.
9. Recent recipient of any licensed or investigational live attenuated vaccine(s) within 4 weeks of transplant.
10. Past or current medical problems or findings from physical examination or laboratory testing that are not listed above, which, in the opinion of the investigator, may pose additional risks from participation in the study, may interfere with the participant's ability to comply with study requirements or that may impact the quality or interpretation of the data obtained from the study.

Contacts and Locations

Contacts

Contact: Paul Szabolcs, M.D.; 412-692-5427; Paul.Szabolcs@chp.edu

Contact: Shawna H McIntyre, RN; 412-692-5552 ext 4126925552; mcintyresm@upmc.edu

Locations

United States, Pennsylvania

UPMC Presbyterian; Recruiting

Pittsburgh, Pennsylvania, United States, 15214

Contact: John McDyer, MD 412-648-6161 mcdyerjf@upmc.edu

Children's Hospital of Pittsburgh of UPMC; Recruiting

Pittsburgh, Pennsylvania, United States, 15224

Contact: Shawna H McIntyre, RN 412-692-5552 mcintyresm@upmc.edu

Principal Investigator: Paul Szabolcs, MD

Sponsors and Collaborators

Paul Szabolcs

More Information

• Responsible Party: Paul Szabolcs, Chief, Division of Blood and Marrow Transplantation and Cellular Therapy, University of Pittsburgh
• ClinicalTrials.gov Identifier: NCT03500731
• Other Study ID Numbers: PRO17110400
• First Posted: April 18, 2018
• Last Update Posted: February 11, 2022
• Last Verified: February 2022

Individual Participant Data (IPD) Sharing Statement:

• Plan to Share IPD: No

• Studies a U.S. FDA-regulated Drug Product: Yes
• Studies a U.S. FDA-regulated Device Product: No

Keywords provided by Paul Szabolcs, University of Pittsburgh:

Lung Transplantation; Stem Cell Transplantation; Idiopathic Pulmonary Fibrosis; Emphysema or COPD; Bone marrow transplantation; Cadaveric donor; Unrelated donor; HLA-Mismatch; BMT; HSCT; IPF; Pulmonary fibrosis

Additional relevant MeSH terms:

Pulmonary Fibrosis; Idiopathic Pulmonary Fibrosis; Pulmonary Emphysema; Bone Marrow Failure Disorders; Pancytopenia; Fibrosis; Emphysema; Pathologic Processes; Lung Diseases; Respiratory Tract Diseases; Pulmonary Disease, Chronic Obstructive; Lung Diseases, Obstructive; Bone Marrow Diseases; Hematologic Diseases; Rituximab; Alemtuzumab; Fludarabine; Thiotepa; Hydroxyurea; Antineoplastic Agents, Immunological; Antineoplastic Agents; Immunologic Factors; Physiological Effects of Drugs; Antirheumatic Agents; Molecular Mechanisms of Pharmacological Action; Immunosuppressive Agents; Antineoplastic Agents, Alkylating; Alkylating Agents; Myeloablative Agonists; Antisickling Agents