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Haplo-identical Transplantation for Severe Aplastic Anemia, Hypo-plastic MDS and PNH Using Peripheral Blood Stem Cells and Post-transplant Cyclophosphamide for GVHD Prophylaxis

Primary Purpose

Severe Aplastic Anemia (SAA), Hypo-Plastic Myelodysplastic Syndrome (MDS), Paroxysmal Nocturnal Hemoglobinuria (PNH)

Status

Recruiting

Phase

Phase 2

Locations

United States

Study Type

Interventional

Intervention

Cyclophosphamide

Peripheral Blood Stem Cells

About this trial

This is an interventional treatment trial for Severe Aplastic Anemia (SAA) focused on measuring Haploidentical CD34+cells, Non-Myeloablative

Eligibility Criteria

4 Years - 75 Years (Child, Adult, Older Adult)All SexesDoes not accept healthy volunteers

INCLUSION CRITERIA - RECIPIENT:
Diagnosed with severe aplastic anemia with bone marrow cellularity <30% (excluding lymphocytes) associated with RBC or platelet transfusion dependence and/or neutropenia (absolute neutrophil count less than or equal to 1000 cells/ microL or for patients receiving granulocyte transfusions, absolute neutrophil count less than or equal to 1000 cells/ uL before beginning granulocyte transfusions).

--History of severe aplastic anemia transformed to MDS. that meet the following criteria: a) International Prognostic Scoring System (IPSS) risk category of INT-1 or greater, b) <5% myeloblasts and <30% of cellularity in the bone marrow on screening morphologic analysis.

--PNH that is either refractory to treatment with eculizumab/ravulizumab or occurs in patients who don t have access to treatment with eculizumab associated with either a) life- threatening thrombosis and/or b) cytopenia associated with transfusion dependence and/or c) recurrent and debilitating hemolytic crisis.

Subjects with severe aplastic anemia, hypoplastic MDS or PNH with associated bone marrow failure syndromes who have intolerance of or failure to respond to standard immunosuppressive therapy.
Availability of at least one HLA- haploidentical (i.e. > 5/10 and less than or equal to 8/10 HLA match) related donor (HLAA,

B, C, DR, and DQ loci) who is available to donate stem cell graft (6-75 years old).

The patient does not have any HLA antibodies detectable against any of the mismatched HLA alleles expressed by the haplo-donor.
Ages 4-55 years inclusive.
Ability to comprehend the investigational nature of the study and provide informed consent. The procedure will be explained to subjects aged 4-17 years with formal consent being obtained from parents or legal guardian.

EXCLUSION CRITERIA - RECIPIENT (ANY OF THE FOLLOWING):

Availability of an HLA identical or 9/10 HLA matched (HLA A, B, C, DR, and DQ loci) -relative to serve as a stem cell donor.
The patient is deemed to be a candidate for a 10/10 HLA matched unrelated stem cell transplant (availability of a donor and resources required for such a transplant).
The patient is eligible for transplantation using an ex vivo expanded cord blood unit on NHLBI protocol 17-H-0091
ECOG performance status of 2 or more.
Major anticipated illness or organ failure incompatible with survival from transplant.
Current pregnancy, or unwillingness to take oral contraceptives or use a barrier method of birth control or practice abstinence to refrain from pregnancy, if of childbearing potential for one year.
HIV positive.
Diagnosis of Fanconi s anemia (by chromosome breakage study).
Diffusion capacity of carbon monoxide (DLCO) <40% using DLCO corrected for Hgb or lung volumes (patients under the age of 10 may be excluded from this criterion if they have difficulty performing the test correctly and thus are unable to have their DLCO assessed).
Left ventricular ejection fraction <40% (evaluated by ECHO)
Transaminases > 5x upper limit of normal.
Direct bilirubin >3 mg/dl.
Creatinine clearance < 50 cc/min/BSAm2 by 24-hour urine collection adjusted by body surface area.
Serum creatinine > 2.5 mg/dl
Presence of an active infection not adequately responding to appropriate therapy.
History of a malignant disease liable to relapse or progress within 5 years.

INCLUSION CRITERIA - DONOR:

Donor deemed suitable and eligible, and willing to donate, per clinical evaluations who are additionally willing to donate blood for research. Donors will be evaluated in accordance with existing Standard NIH Policies and Procedures for determination of eligibility and suitability for clinical donation. Note that participation in this study is offered to all donors, but is not required for a donor to make a stem cell donation, so it is possible that not all donors will enroll onto this study.

EXCLUSION CRITERIA - RELATED DONOR:

None

Sites / Locations

National Institutes of Health Clinical CenterRecruiting

Arms of the Study

Arm 1

Arm Type

Experimental

Arm Label

Treatment Arm

Arm Description

G-CSF mobilized peripheral stem cells and post haplo-identical transplantation cyclophosphamide

Outcomes

Primary Outcome Measures

Evaluate 1 year chronic GVHD-free survival rate

evaluate 1 year chronic GVHD-free survival rate (defined by the percentage of patients who are alive with no evidence of moderate or severe chronic GVHD at 1 year) of using G-CSF mobilized peripheral stem cells and post haplo-identical transplantation cyclophosphamide in subjects with severe aplastic anemia or refractory anemia (RA) or SAA subjects

Secondary Outcome Measures

Full Information

NCT ID

NCT03520647

First Posted

May 9, 2018

Last Updated

June 29, 2023

Sponsor

National Heart, Lung, and Blood Institute (NHLBI)

1. Study Identification

Unique Protocol Identification Number

NCT03520647

Brief Title

Haplo-identical Transplantation for Severe Aplastic Anemia, Hypo-plastic MDS and PNH Using Peripheral Blood Stem Cells and Post-transplant Cyclophosphamide for GVHD Prophylaxis

Official Title

Haplo-identical Transplantation for Severe Aplastic Anemia, Hypo-plastic MDS and PNH Using Peripheral Blood Stem Cells and Post-transplant Cyclophosphamide for GVHD Prophylaxis

Study Type

Interventional

2. Study Status

Record Verification Date

June 28, 2023

Overall Recruitment Status

Recruiting

Study Start Date

February 19, 2019 (Actual)

Primary Completion Date

June 1, 2025 (Anticipated)

Study Completion Date

June 1, 2028 (Anticipated)

3. Sponsor/Collaborators

Responsible Party, by Official Title

Sponsor

Name of the Sponsor

National Heart, Lung, and Blood Institute (NHLBI)

4. Oversight

Studies a U.S. FDA-regulated Drug Product

Yes

Studies a U.S. FDA-regulated Device Product

5. Study Description

Brief Summary

Background: Severe aplastic anemia (SAA), and myelodysplastic syndrome (MDS), and paroxysmal nocturnal hemoglobinuria (PNH) cause serious blood problems. Stem cell transplants using bone marrow or blood plus chemotherapy can help. Researchers want to see if using peripheral blood stem cells (PBSCs) rather than bone marrow cells works too. PBSCs are easier to collect and have more cells that help transplants. Objectives: To see how safely and effectively SAA, MDS and PNH are treated using peripheral blood hematopoietic stem cells from a family member plus chemotherapy. Eligibility: Recipients ages 4-55 with SAA, MDS or PNH and their relative donors ages 4-75 Design: Recipients will have: Blood, urine, heart, and lung tests Scans Bone marrow sample Recipients will need a caregiver for several months. They may make fertility plans and a power of attorney. Donors will have blood and tissue tests, then injections to boost stem cells for 5-7 days. Donors will have blood collected from a tube in an arm or leg vein. A machine will separate stem cells and maybe white blood cells. The rest of the blood will be returned into the other arm or leg. In the hospital for about 1 month, recipients will have: Central line inserted in the neck or chest Medicines for side effects Chemotherapy over 8 days and radiation 1 time Stem cell transplant over 4 hours Up to 6 months after transplant, recipients will stay near NIH for weekly physical exams and blood tests. At day 180, recipients will go home. They will have tests at their doctor s office and NIH several times over 5 years.

Detailed Description

Severe aplastic anemia (SAA),myelodysplastic syndrome (MDS), and paroxysmal nocturnal hemoglobinuria (PNH) are life-threatening bone marrow disorders. For SAA patients, long term survival can be achieved with immunosuppressive treatment. However, of those patients treated with immunosuppressive therapy, one quarter to one third will not respond, and about 50% of responders will relapse. Although allogeneic stem cell transplantation (allo-SCT) offers the opportunity of cure, HLA-matched donors are available for only half the patients needing a transplant. Combined haplo-cord transplantation has recently been shown to be a viable transplant option for those patients lacking an HLA matched donor. In our ongoing protocol 08-H-0046, we have utilized this approach in 29 patients with SAA, and SAA evolving to MDS with 27/29 patients having sustained engraftment and achieving transfusion independence. However, engraftment patterns have varied substantially and, in some patients,, cord engraftment was profoundly delayed or never occurred. Haploidentical peripheral blood stem cell transplantation (haplo-SCT) has the advantage over cord transplantation of immediate allograft availability, higher stem cell doses, and the feasibility of repeating cell collections if necessary for collecting CD34+ cells for stem cells boosts or lymphocytes to treat or prevent disease relapse or infection. Recently, the use of post-transplant cyclophosphamide (Cy) has been shown to be an effective strategy to prevent GVHD in recipients of haploidentical HSCT, but most reports have focused on patients with hematological malignancies. At present, few data exist on the use of haploidentical transplantation using post-transplant cyclophosphamide for patients with aplastic anemia that have ATG-refractory disease and are heavily-transfused and HLA-alloimmunized. These patients are at an exceedingly high-risk for graft rejection compared to other patient populations. This research protocol is therefore designed to evaluate the safety and effectiveness of using an unmanipulated GCSF mobilized peripheral stem cell allograft from a haploidentical donor and post-transplant cyclophosphamide for patients with SAA,SAA evolving to MDS, or PNH that has proven to be refractory to conventional therapy in patients who lack an HLA-matched donor (sibling/ or matched unrelated donor) and who do not have access to a good quality umbilical cord product that meets criteria for expansion (due to insufficient numbers of TNC and/or CD 34+ cells and/or inadequate HLA match) on NHLBI protocol number # 17-H-0091. The primary endpoint of the study is chronic GVHD-free survival (defined as the percentage of patients who are alive with no evidence of moderate or severe chronic GVHD at 1-year post-transplant). Secondary endpoints will include engraftment, 100 day and 200-day treatment related mortality (TRM), and standard transplant outcome variables such as non-hematologic toxicity, incidence and severity of acute and chronic GVHD, and relapse of disease. Health related quality of life will also be assessed as secondary outcome measure.

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study

Severe Aplastic Anemia (SAA), Hypo-Plastic Myelodysplastic Syndrome (MDS), Paroxysmal Nocturnal Hemoglobinuria (PNH)

Keywords

Haploidentical CD34+cells, Non-Myeloablative

7. Study Design

Primary Purpose

Treatment

Study Phase

Phase 2

Interventional Study Model

Single Group Assignment

Masking

None (Open Label)

Allocation

Non-Randomized

Enrollment

56 (Anticipated)

8. Arms, Groups, and Interventions

Arm Title

Treatment Arm

Arm Type

Experimental

Arm Description

G-CSF mobilized peripheral stem cells and post haplo-identical transplantation cyclophosphamide

Intervention Type

Drug

Intervention Name(s)

Cyclophosphamide

Intervention Description

This research protocol is therefore designed to evaluate the safety and effectiveness of using an unmanipulated G-CSF mobilized peripheral stem cell allograft from a haploidentical donor and post-transplant cyclophosphamide for patients with SAA, or SAA evolving to MDS, or PNH that has proven to be refractory to conventional immunosuppressive therapy (IST) in patients who lack an HLA-matched donor (sibling/ or matched unrelated donor.

Intervention Type

Other

Intervention Name(s)

Peripheral Blood Stem Cells

Intervention Description

Primary Outcome Measure Information:

Title

Evaluate 1 year chronic GVHD-free survival rate

Description

Time Frame

one-year

10. Eligibility

Sex

All

Minimum Age & Unit of Time

4 Years

Maximum Age & Unit of Time

75 Years

Accepts Healthy Volunteers

Eligibility Criteria

INCLUSION CRITERIA - RECIPIENT: Diagnosed with severe aplastic anemia with bone marrow cellularity <30% (excluding lymphocytes) associated with RBC or platelet transfusion dependence and/or neutropenia (absolute neutrophil count less than or equal to 1000 cells/ microL or for patients receiving granulocyte transfusions, absolute neutrophil count less than or equal to 1000 cells/ uL before beginning granulocyte transfusions). OR --History of severe aplastic anemia transformed to MDS. that meet the following criteria: a) International Prognostic Scoring System (IPSS) risk category of INT-1 or greater, b) <5% myeloblasts and <30% of cellularity in the bone marrow on screening morphologic analysis. OR --PNH that is either refractory to treatment with eculizumab/ravulizumab or occurs in patients who don t have access to treatment with eculizumab associated with either a) life- threatening thrombosis and/or b) cytopenia associated with transfusion dependence and/or c) recurrent and debilitating hemolytic crisis. Subjects with severe aplastic anemia, hypoplastic MDS or PNH with associated bone marrow failure syndromes who have intolerance of or failure to respond to standard immunosuppressive therapy. Availability of at least one HLA- haploidentical (i.e. > 5/10 and less than or equal to 8/10 HLA match) related donor (HLAA, B, C, DR, and DQ loci) who is available to donate stem cell graft (6-75 years old). The patient does not have any HLA antibodies detectable against any of the mismatched HLA alleles expressed by the haplo-donor. Ages 4-55 years inclusive. Ability to comprehend the investigational nature of the study and provide informed consent. The procedure will be explained to subjects aged 4-17 years with formal consent being obtained from parents or legal guardian. EXCLUSION CRITERIA - RECIPIENT (ANY OF THE FOLLOWING): Availability of an HLA identical or 9/10 HLA matched (HLA A, B, C, DR, and DQ loci) -relative to serve as a stem cell donor. The patient is deemed to be a candidate for a 10/10 HLA matched unrelated stem cell transplant (availability of a donor and resources required for such a transplant). The patient is eligible for transplantation using an ex vivo expanded cord blood unit on NHLBI protocol 17-H-0091 ECOG performance status of 2 or more. Major anticipated illness or organ failure incompatible with survival from transplant. Current pregnancy, or unwillingness to take oral contraceptives or use a barrier method of birth control or practice abstinence to refrain from pregnancy, if of childbearing potential for one year. HIV positive. Diagnosis of Fanconi s anemia (by chromosome breakage study). Diffusion capacity of carbon monoxide (DLCO) <40% using DLCO corrected for Hgb or lung volumes (patients under the age of 10 may be excluded from this criterion if they have difficulty performing the test correctly and thus are unable to have their DLCO assessed). Left ventricular ejection fraction <40% (evaluated by ECHO) Transaminases > 5x upper limit of normal. Direct bilirubin >3 mg/dl. Creatinine clearance < 50 cc/min/BSAm2 by 24-hour urine collection adjusted by body surface area. Serum creatinine > 2.5 mg/dl Presence of an active infection not adequately responding to appropriate therapy. History of a malignant disease liable to relapse or progress within 5 years. INCLUSION CRITERIA - DONOR: Donor deemed suitable and eligible, and willing to donate, per clinical evaluations who are additionally willing to donate blood for research. Donors will be evaluated in accordance with existing Standard NIH Policies and Procedures for determination of eligibility and suitability for clinical donation. Note that participation in this study is offered to all donors, but is not required for a donor to make a stem cell donation, so it is possible that not all donors will enroll onto this study. EXCLUSION CRITERIA - RELATED DONOR: None

Central Contact Person:

First Name & Middle Initial & Last Name or Official Title & Degree

Melissa M Spencer, R.N.

Phone

(301) 402-5609

melissa.spencer@nih.gov

First Name & Middle Initial & Last Name or Official Title & Degree

Richard W Childs, M.D.

Phone

(301) 451-7128

childsr@nhlbi.nih.gov

Overall Study Officials:

First Name & Middle Initial & Last Name & Degree

Richard W Childs, M.D.

Organizational Affiliation

National Heart, Lung, and Blood Institute (NHLBI)

Official's Role

Principal Investigator

Facility Information:

Facility Name

National Institutes of Health Clinical Center

City

Bethesda

State/Province

Maryland

ZIP/Postal Code

20892

Country

United States

Individual Site Status

Recruiting

Facility Contact:

First Name & Middle Initial & Last Name & Degree

For more information at the NIH Clinical Center contact Office of Patient Recruitment (OPR)

Phone

800-411-1222

Ext

TTY8664111010

prpl@cc.nih.gov

12. IPD Sharing Statement

Plan to Share IPD

Undecided

Links:

URL

https://clinicalstudies.info.nih.gov/cgi/detail.cgi?A_2018-H-0090.html

Description

NIH Clinical Center Detailed Web Page

Learn more about this trial

Haplo-identical Transplantation for Severe Aplastic Anemia, Hypo-plastic MDS and PNH Using Peripheral Blood Stem Cells and Post-transplant Cyclophosphamide for GVHD Prophylaxis

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