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Lung and Bone Marrow Transplantation for Lung and Bone Marrow Failure

Primary Purpose

Idiopathic Pulmonary Fibrosis, Emphysema or COPD

Status
Recruiting
Phase
Phase 1
Locations
United States
Study Type
Interventional
Intervention
CD3/CD19 negative hematopoietic stem cells
Rituximab
Alemtuzumab
Fludarabine
Thiotepa
G-CSF
Hydroxyurea
Sponsored by
Paul Szabolcs
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional treatment trial for Idiopathic Pulmonary Fibrosis focused on measuring 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

Eligibility Criteria

18 Years - 60 Years (Adult)All SexesDoes not accept healthy volunteers

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.

Sites / Locations

  • UPMC PresbyterianRecruiting
  • Children's Hospital of Pittsburgh of UPMCRecruiting

Arms of the Study

Arm 1

Arm Type

Experimental

Arm Label

Lung and Bone Marrow Transplantation

Arm Description

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.

Outcomes

Primary Outcome Measures

Death
How many, if any, patients die
Engraftment failure
How many, if any, develop engraftment failure
Non-hematologic events
Any Grade 4 event that happens at any time points
Hematological events
Any Grade 4 hematological events
BOS Score
Bronchiolitis Obliterans Syndrome (BOS) score based off patient pulmonary function testing. Graded on scale (BOS0 to BOS3), BOS0 having a better outcome then BOS3
T-cell Chimerism
The number of patients who have ≥25% donor T-cell chimerism
Myeloid chimerism
The number of patients with myeloid disorders who attain ≥ 10% myeloid chimerism
Restoration of blood cell count (in absence of growth factors)
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

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

Full Information

First Posted
March 30, 2018
Last Updated
February 10, 2023
Sponsor
Paul Szabolcs
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1. Study Identification

Unique Protocol Identification Number
NCT03500731
Brief Title
Lung and Bone Marrow Transplantation for Lung and Bone Marrow Failure
Official Title
Lung Transplant in Tandem With Bone Marrow Transplant for Combined Lung and Bone Marrow Failure
Study Type
Interventional

2. Study Status

Record Verification Date
February 2023
Overall Recruitment Status
Recruiting
Study Start Date
April 19, 2018 (Actual)
Primary Completion Date
December 2023 (Anticipated)
Study Completion Date
December 2026 (Anticipated)

3. Sponsor/Collaborators

Responsible Party, by Official Title
Sponsor-Investigator
Name of the Sponsor
Paul Szabolcs

4. Oversight

Studies a U.S. FDA-regulated Drug Product
Yes
Studies a U.S. FDA-regulated Device Product
No
Data Monitoring Committee
Yes

5. 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.
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.

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Idiopathic Pulmonary Fibrosis, Emphysema or COPD
Keywords
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

7. Study Design

Primary Purpose
Treatment
Study Phase
Phase 1, Phase 2
Interventional Study Model
Single Group Assignment
Masking
None (Open Label)
Allocation
N/A
Enrollment
8 (Anticipated)

8. Arms, Groups, and Interventions

Arm Title
Lung and Bone Marrow Transplantation
Arm Type
Experimental
Arm Description
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.
Intervention Type
Biological
Intervention Name(s)
CD3/CD19 negative hematopoietic stem cells
Intervention Description
Negative selection for CD3/CD19 will be performed on CliniMACS® depletion device and given at time no less than 8 weeks post lung transplantation
Intervention Type
Drug
Intervention Name(s)
Rituximab
Other Intervention Name(s)
Rituxan
Intervention Description
Transplantation Conditioning
Intervention Type
Drug
Intervention Name(s)
Alemtuzumab
Other Intervention Name(s)
Campath-1H
Intervention Description
Transplantation Conditioning
Intervention Type
Drug
Intervention Name(s)
Fludarabine
Other Intervention Name(s)
Fludara, Oforta
Intervention Description
Transplantation Conditioning
Intervention Type
Drug
Intervention Name(s)
Thiotepa
Intervention Description
Transplantation Conditioning
Intervention Type
Drug
Intervention Name(s)
G-CSF
Other Intervention Name(s)
Neupogen, Granix, Zarxio, Filgrastim
Intervention Description
Transplantation conditioning
Intervention Type
Drug
Intervention Name(s)
Hydroxyurea
Intervention Description
Transplantation Conditioning
Primary Outcome Measure Information:
Title
Death
Description
How many, if any, patients die
Time Frame
Up to 2 years post stem cell transplant
Title
Engraftment failure
Description
How many, if any, develop engraftment failure
Time Frame
Up to 2 years post stem cell transplant
Title
Non-hematologic events
Description
Any Grade 4 event that happens at any time points
Time Frame
Up to 2 years post stem cell transplant
Title
Hematological events
Description
Any Grade 4 hematological events
Time Frame
after 30 days post stem cell transplant
Title
BOS Score
Description
Bronchiolitis Obliterans Syndrome (BOS) score based off patient pulmonary function testing. Graded on scale (BOS0 to BOS3), BOS0 having a better outcome then BOS3
Time Frame
at 1 year post lung transplant
Title
T-cell Chimerism
Description
The number of patients who have ≥25% donor T-cell chimerism
Time Frame
at 12 months post stem cell transplant
Title
Myeloid chimerism
Description
The number of patients with myeloid disorders who attain ≥ 10% myeloid chimerism
Time Frame
at 12 months post stem cell transplant
Title
Restoration of blood cell count (in absence of growth factors)
Description
Absolute neutrophil count (ANC)≥1000 per microliter of blood, platelets ≥50000 per microliter of blood and hematocrit ≥8 grams per deciliter of blood
Time Frame
at 12 months post stem cell transplant
Secondary Outcome Measure Information:
Title
Feasibility of patients able to proceed to BMT within 6 months following lung transplantation
Description
The number of patients who are able to proceed to BMT within 6 months following lung transplantation
Time Frame
Up to 2 years post stem cell transplant
Title
Independence
Description
The number of patients who are able to be independent from transfusions and growth factors for at least 7 days
Time Frame
up to 2 years post stem cell transplant
Title
Independence
Description
The number of patients who are able to be independent from transfusions and growth factors for at least 1 month
Time Frame
Up to 2 years post stem cell transplant
Title
Tolerance development to both host and pulmonary grafting
Description
Development of tolerance to both the host and pulmonary graft
Time Frame
Up to 2 years post stem cell transplant
Title
Long-term complications
Description
Long-term complications of combined solid organ and BMT
Time Frame
Up to 2 years post stem cell transplant
Title
Acute cellular rejection
Description
The number of patients who develop acute cellular rejection
Time Frame
Up to 2 years post stem cell transplant
Title
Acute graft-versus-host-disease (GVHD)
Description
The number of patients who develop acute graft-versus-host-disease (GVHD)
Time Frame
Up to 2 years post stem cell transplant
Title
Chronic graft-versus-host-disease (GVHD)
Description
The number of patients who develop chronic graft-versus-host-disease (GVHD)
Time Frame
Up to 2 years post stem cell transplant
Title
Ability to withdrawal immunosuppression
Description
The number of patients who are able to start immunosuppression withdrawal.
Time Frame
By 1 year post stem cell transplant
Title
Time to withdraw immunosuppression
Description
Time from BMT to withdrawal of immunosuppression
Time Frame
Up to 2 years post stem cell transplant
Title
Prophylactic antimicrobial drugs
Description
Time from BMT to independence for prophylactic antimicrobial drugs
Time Frame
Up to 2 years post stem cell transplant
Title
Treatment antimicrobial drugs
Description
Time from BMT to independence from treatment antimicrobial drugs
Time Frame
up to 2 years post stem cell transplant
Title
Chronic lung allograft dysfunction
Description
The number of patients who develop chronic lung allograft dysfunction post lung transplant for all subjects, lung only and lung +stem cell transplant.
Time Frame
1 year post lung transplant
Other Pre-specified Outcome Measures:
Title
Pace of immune reconstitution
Description
The pace of immune reconstitution, systemically and in mucosal surfaces
Time Frame
Up to 2 years post stem cell transplant
Title
Mixed chimerism
Description
The number of patients who have the incidence of mixed chimerism (.5% host cells)
Time Frame
at Months 1, 3, 6 and 12 post stem cell transplant
Title
In vitro immune tolerance
Description
The number of patients who have in vitro immune tolerance
Time Frame
Up to 2 years post stem cell transplant

10. Eligibility

Sex
All
Minimum Age & Unit of Time
18 Years
Maximum Age & Unit of Time
60 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
Inclusion Criteria: Individuals must meet all of the following criteria in order to be eligible for this study. Subject must be able to understand and provide informed consent. Male or female, 18 through 60 years old, inclusive, at the time of informed consent. Meet criteria for UNOS listing for lung transplantation. Patients must have evidence of end stage lung disease. Examples of such diseases include but are not limited to: Pulmonary Fibrosis COPD/Emphysema 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 GFR ≥45 mL/min/1.73 m2. AST, ALT ≤4x upper limit of normal, total bilirubin ≤ 2.5 mg/dL, normal INR, albumin >3.0 g/dL Cardiac ejection fraction ≥ 40% or shortening fraction ≥26%. Negative pregnancy test for females, unless surgically sterilized. 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. 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. Inability or unwillingness of a participant to give written informed consent or comply with study protocol. Patients who have underlying malignant conditions. Patients who have non-malignant conditions not requiring BMT. 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. Females who are pregnant or who are lactating. Allergy to DMSO or any other ingredient used in the manufacturing of the stem cell product. 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. Uncontrolled infection, as determined by the appropriate imaging and/or confirmatory testing e.g. blood cultures, PCR testing, etc. Recent recipient of any licensed or investigational live attenuated vaccine(s) within 4 weeks of transplant. 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.
Central Contact Person:
First Name & Middle Initial & Last Name or Official Title & Degree
Paul Szabolcs, M.D.
Phone
412-692-5427
Email
Paul.Szabolcs@chp.edu
First Name & Middle Initial & Last Name or Official Title & Degree
Shawna H McIntyre, RN
Phone
412-692-5552
Ext
4126925552
Email
mcintyresm@upmc.edu
Facility Information:
Facility Name
UPMC Presbyterian
City
Pittsburgh
State/Province
Pennsylvania
ZIP/Postal Code
15214
Country
United States
Individual Site Status
Recruiting
Facility Contact:
First Name & Middle Initial & Last Name & Degree
John McDyer, MD
Phone
412-648-6161
Email
mcdyerjf@upmc.edu
Facility Name
Children's Hospital of Pittsburgh of UPMC
City
Pittsburgh
State/Province
Pennsylvania
ZIP/Postal Code
15224
Country
United States
Individual Site Status
Recruiting
Facility Contact:
First Name & Middle Initial & Last Name & Degree
Shawna H McIntyre, RN
Phone
412-692-5552
Email
mcintyresm@upmc.edu
First Name & Middle Initial & Last Name & Degree
Paul Szabolcs, MD

12. IPD Sharing Statement

Plan to Share IPD
No

Learn more about this trial

Lung and Bone Marrow Transplantation for Lung and Bone Marrow Failure

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