Reduced Intensity BMT for Immune Dysregulatory and Bone Marrow Failure Syndromes Using Post-Transplant Cyclophosphamide

Reduced Intensity BMT for Immune Dysregulatory and Bone Marrow Failure Syndromes Using Post-Transplant Cyclophosphamide

Phase II Trial of Reduced Intensity Conditioning Hematopoietic Stem Cell Transplantation for Primary Immune Deficiencies, Immune Dysregulatory Syndromes, and Inherited Bone Marrow Failure Syndromes Using Post-Transplant Cyclophosphamide

This is a Phase II prospective trial to assess the rates of donor engraftment using reduced intensity conditioning (RIC) hematopoietic stem cell transplant (HSCT) and post-transplant cyclophosphamide (PTCy) for patients with primary immune deficiencies (PID), immune dysregulatory syndromes (IDS), and inherited bone marrow failure syndromes (IBMFS).

Allogeneic blood and marrow transplantation (alloBMT) is the only curative therapy for many primary immune deficiencies (PID), immune dysregulatory syndromes (IDS), and inherited bone marrow failure syndromes (IBMFS). The best reported outcomes are with human leukocyte antigen (HLA)- matched sibling donors, however, only 30% of children in need of a BMT have an HLA-matched sibling. Use of alternative donors has been limited by unacceptably high rates of transplant-related mortality (TRM), graft rejection, infection, and graft-versus-host disease (GVHD). Reduced intensity conditioning (RIC) regimens have been used for this patient population with improved survival and decreased TRM, but graft failure and sustained donor chimerism have emerged as significant obstacles. Thus, there is an urgent need to develop a RIC platform that improves survival and decreases TRM while maximizing donor engraftment, which is essential for cure. A large and growing body of literature demonstrates that post-transplant cyclophosphamide (PTCy) allows for the safe and effective use of HLA-matched and mismatched related and unrelated donors and haploidentical related donors after RIC alloBMT. PTCy offers a unique opportunity to 1) broaden donor availability, 2) promote durable engraftment of donor cells, 3) achieve low rates of GVHD and TRM, 4) foster robust immune reconstitution and immunity, and 5) shorten the duration of additional post-transplant immune suppression (IS) required to prevent GVHD. The investigators proposed platform is uniquely suited for success in this context, to broaden the scope of RIC alloBMT with PTCy as a curative therapy for patients with PID/IDS and IBMFS. This is a Phase II single arm trial to prospectively study a RIC BMT with PTCy to enhance durable engraftment of donor cells and improve outcomes for patients with PID/IDS and IBMFS. Treatment Plan: Indwelling central venous catheter Placement of a double lumen central venous catheter will be required for administration of IV medications and transfusion of blood products. Pre-treatment Evaluation All patients will require documentation of a detailed history and physical examination and standard evaluation of cardiac, pulmonary, liver and renal function. All patients will undergo disease evaluation. Pre-BMT blood will be drawn for correlative labs. Preparative regimen Alemtuzumab: administered as an IV infusion on days -14 to -12. For patients >10 kg, 3 mg IV test dose over 2 hours followed by 10 mg IV over 2 hours on day -14, 15 mg IV over 2 hours on day -13, and 20 mg IV over 2 hours on day -12. For patients <10 kg, doses are 3 mg, 10 mg, 10 mg, and 10 mg. Fludarabine: administered as an IV infusion over 30 minutes on days -7 to -3. The dose will be 30 mg/m2/dose (adjusted for renal function). Melphalan: Recommended to be administered as an IV infusion over 30-60 minutes, depending on volume, on days -3 and -2. The dose will be 70 mg/m2/dose. Alternatively, may be given as 140 mg/m2/dose as a single dose IV infusion per institutional standards on day -2. Other institutional infusion standards are acceptable and will not be a protocol deviation. Total body irradiation: 200 centigray (cGy) anterior-posterior-posterio-anterior (AP/PA) with 4 megavolt (MV) or 6 MV photons at 8 12 cGy/min at the point of prescription (average separation of measurements at mediastinum, abdomen, and hips) will be administered in a single fraction on day -1. This is only for patients with PID/IDS. Bone marrow transplantation Bone Marrow will be harvested and infused on day 0. Institutional guidelines for the infusion of bone marrow (i.e. major or minor blood type group (ABO) incompatible bone marrow, etc.) will be followed. The marrow infusion will be done by designated members of the BMT team. The bone marrow graft will not be manipulated to deplete T cells. The donor will be harvested with a target yield of 4 x 10^8 nucleated cells/kg recipient ideal body weight (IBW). The lowest acceptable yield is 2 x 10^8 nucleated cells/kg. The cluster of differentiation (CD)-34+, CD4+, CD8+, and CD3+ cell count in the marrow will be quantified by flow cytometry. Bone marrow graft should be hung to gravity (not infused with a pump). If possible, the total infusion time should be no more than four hours. GVHD prophylaxis Post-transplantation Cyclophosphamide (PTCy) Cyclophosphamide (Cy) 50mg/kg will be given on D+3 post-transplant (within 60-72 hr of marrow infusion) and on D+4 post-transplant. Cyclophosphamide will be given as an IV infusion over 1- 2 hours (depending on volume). Dosing of cyclophosphamide is based on ideal body weight for subjects whose ideal body weights less than or equal to subjects' actual body weight. On occasion, a subject's actual body weight may be less than his/her ideal body weight, in which case cyclophosphamide will be dosed using the subject's actual body weight. Patients will be instructed to increase fluids overnight before cyclophosphamide administration. Hydration with normal saline at 3 cc/kg/hr iv will be started 8 hr prior to cyclophosphamide, then the rate will be reduced to 2 cc/kg/hr for 1 hr pre-cyclophosphamide and continued for at least 8 hr post-cyclophosphamide or administered per institutional standards. Mesna will be given IV at 10 mg/kg/dose concurrent with cyclophosphamide infusion, followed by 40 mg/kg/dose IV over 24 hours, or administered per institutional standards. Mesna dose will be based on the cyclophosphamide dose being given. The total daily dose of mesna is equal to 100% of the total daily dose of cyclophosphamide. It is crucial that no immunosuppressive agents are given until 24 hours after the completion of the post-transplant Cyclophosphamide. This includes steroids as anti-emetics. Steroids for disease treatment will attempt to be weaned but are allowed if wean is not possible. Physiologic and stress dose steroids are allowed if necessary. Steroids are allowed as pre-medications if needed. Tacrolimus On day +5, patients will begin prophylaxis with Tacrolimus (oral (PO) or intravenous (IV) as per institutional standards for starting this prophylaxis).Tacrolimus begins on Day 5, at least 24 hours after completion of post-transplantation Cy. The tacrolimus starting dose will be given per institutional standards for adult or pediatric patients. The recommended, but not required, The starting dose of tacrolimus is 0.015mg/kg IBW/dose IV over 4 hours every 12 hours. , or per institutional standard. Serum trough levels of tacrolimus should be measured around D+7 and the dose should be adjusted based on this level to maintain a level of 5-15 ng/ml. Tacrolimus should be converted to oral dosing when patient has a stable, therapeutic level and is able to tolerate food or other oral medications. For pediatric patients, the oral dosing is approximately two to four times the IV dosing. It is recommended that serum trough levels should be checked at steady state after any dose modification and when switching from IV to oral to ensure therapeutic trough concentrations. Serum trough concentrations should be checked at a minimum weekly thereafter and the dose adjusted accordingly to maintain a level of 5-15 ng/ml. Tacrolimus will be discontinued after the last dose on Day 60 for matched related donors, Day 120 for matched unrelated donors, and day 180 for haploidentical related or mismatched unrelated donors; or may be continued if active GVHD is present. This should be discussed with the PI. Mycophenolic acid mofetil (MMF) MMF will be given at a dose of 15 mg/kg PO three times daily (TID) (based upon actual body weight) with the maximum total daily dose not to exceed 3 grams (1 g PO TID). MMF prophylaxis will be discontinued after the last dose on day 35. Growth factor support Patients will receive Granulocyte-colony stimulating factor (GCSF) (Filgrastim®) 5µg/kg/d subcutaneous (SC) or IV starting at Day 5 and continuing until the absolute neutrophil count (ANC) >1000/mm3 x 3 days. For use in the case of fungal infections or subsequent neutropenia (ANC <500/mm3), GCSF should be continued at the discretion of the treating physician. Transfusion support Platelet and packed red cell transfusions will be given per current institutional recommendations. Infection prophylaxis and therapy All infection prophylaxis and therapy will be administered and discontinued as per institutional requirements. The following are recommendations only. i) During pre-transplant evaluation patients will be screened for respiratory syncytial virus (RSV) and influenza A and B, as well as parainfluenza and other respiratory viruses if symptomatic. Assays of these viruses must be negative for patients to be admitted for transplant. Consideration should be given to institution of antiviral therapy if positive prior to transplant. ii) Oral hygiene will be maintained according to institutional standards. iii) Antifungal prophylaxis will be administered according to institutional practices. It is important to follow levels of tacrolimus for patients receiving one of the azole antifungal medications. The combination of both drugs can raise the levels of the immunosuppressant to toxic levels. If a patient on tacrolimus is started on an azole antifungal medication, a dose reduction of the tacrolimus is required and levels should be obtained to ensure patients are not in the toxic range. iv) Pneumocystis jiroveci pneumonia (PJP) prophylaxis will be administered according to institutional practices. Recommendations include administering during the preparative regimen, and then restarting approximately one month post-BMT (or later if white blood cell count (WBC) not recovering) and continuation until at least one year post-BMT. v) Viral prophylaxis for herpes simplex virus (HSV) and varicella zoster virus (VZV) will be administered according to institutional practices. Recommendations include continuation for at least one year post-BMT and/or while on immunosuppressive medications. vi) Prophylactic and empiric antibiotics as well as intravenous immunoglobulin (IVIg) will be administered according to institutional practices. vii) Re-immunization may be performed according to institutional practices. Anti-ovulatory treatment Menstruating females will are recommended to should be be started on an anti-ovulatory agent, such as Lupron prior to the initiation of the preparative regimen. The treatment administered will be at the discretion of the treating physician. Post-BMT evaluation Patients will be followed during (i) the initial post-BMT period (ii) after discharge to the referring physician as per standard practice.

Alemtuzumab IV infusion over 2 hours on days -14, -13, and -12. Day -14 3 mg followed by 10 mg. Day -13 15 mg (or 10 mg if <10 kg). Day -12 20 mg (or 10 mg if <10 kg). Fludarabine 30 mg/m2/day IV infusion over 2 hours on days -6 to -2. Melphalan 70 mg/m2/day IV infusion over 30-60 minutes on days -3 and -2. (Or may be given as a single infusion of 140 mg/m2/day on day -2.) Total body irradiation: 200 cGy will be administered in a single fraction on day -1. Bone Marrow will be harvested and infused on day 0. Post-transplantation Cyclophosphamide 50mg/kg will be given on D+3 post-transplant (within 60-72 hr of marrow infusion) and on D+4 post-transplant. Tacrolimus begins on day 5, at least 24 hours after completion of posttransplantation Cy at 0.015mg/kg IBW/dose IV over 4 hours every 12 hours. Mycophenolic acid mofetil (MMF) begins on day 5 at a dose of 15 mg/kg PO TID (based upon actual body weight) with the maximum total daily dose not to exceed 3 grams (1 g PO TID).

Alemtuzumab IV infusion over 2 hours on days -14, -13, and -12. Day -14 3 mg followed by 10 mg. Day -13 15 mg (or 10 mg if <10 kg). Day -12 20 mg (or 10 mg if <10 kg). Fludarabine 30 mg/m2/day IV infusion over 2 hours on days -6 to -2. Melphalan 70 mg/m2/day IV infusion over 30-60 minutes on days -3 and -2. (Or may be given as a single infusion of 140 mg/m2/day on day -2.) Bone Marrow will be harvested and infused on day 0. Post-transplantation Cyclophosphamide 50mg/kg will be given on D+3 post-transplant (within 60-72 hr of marrow infusion) and on D+4 post-transplant. Tacrolimus begins on day 5, at least 24 hours after completion of posttransplantation Cy at 0.015mg/kg IBW/dose IV over 4 hours every 12 hours. Mycophenolic acid mofetil (MMF) begins on day 5 at a dose of 15 mg/kg PO TID (based upon actual body weight) with the maximum total daily dose not to exceed 3 grams (1 g PO TID).

Overall Survival (Defined as alive) in patients receiving using reduced intensity conditioning (RIC) hematopoietic stem cell transplant (HSCT) and post-transplant cyclophosphamide (PTCy) for patients with primary immune deficiencies (PID), immune dysregulatory syndromes (IDS), and inherited bone marrow failure syndromes (IBMFS).

Overall Survival (Defined as alive) in patients receiving using reduced intensity conditioning (RIC) hematopoietic stem cell transplant (HSCT) and post-transplant cyclophosphamide (PTCy) for patients with primary immune deficiencies (PID), immune dysregulatory syndromes (IDS), and inherited bone marrow failure syndromes (IBMFS).

Event-Free Survival (defined as alive without graft failure) in patients receiving using reduced intensity conditioning (RIC) hematopoietic stem cell transplant (HSCT) and post-transplant cyclophosphamide (PTCy) for patients with primary immune deficiencies (PID), immune dysregulatory syndromes (IDS), and inherited bone marrow failure syndromes (IBMFS).

Event-Free Survival (defined as alive without graft failure) in patients receiving using reduced intensity conditioning (RIC) hematopoietic stem cell transplant (HSCT) and post-transplant cyclophosphamide (PTCy) for patients with primary immune deficiencies (PID), immune dysregulatory syndromes (IDS), and inherited bone marrow failure syndromes (IBMFS).

Disease-Free Survival (defined as without recurrence of underlying disease, without graft failure, and alive) in patients receiving using reduced intensity conditioning (RIC) hematopoietic stem cell transplant (HSCT) and post-transplant cyclophosphamide (PTCy) for patients with primary immune deficiencies (PID), immune dysregulatory syndromes (IDS), and inherited bone marrow failure syndromes (IBMFS).

Disease-Free Survival (defined as without recurrence of underlying disease, without graft failure, and alive) in patients receiving using reduced intensity conditioning (RIC) hematopoietic stem cell transplant (HSCT) and post-transplant cyclophosphamide (PTCy) for patients with primary immune deficiencies (PID), immune dysregulatory syndromes (IDS), and inherited bone marrow failure syndromes (IBMFS).

This will be assessed using rates of sustained donor engraftment defined as detectable donor chimerism and without evidence of recurrence of the underlying disease at Day 100, 6 months, 1 year, and 2 years post-BMT, without infusion of additional stem cell products.

To estimate the rates of failure of sustained engraftment as assessed by the incidence and timing of: primary graft failure (< 5% donor cells by Day +60) the infusion of second stem cell product graft loss (< 5% donor cells at any time from initial engraftment through 2 years)

To determine the cumulative incidence of neutrophil recovery, defined as absolute neutrophil count >/500/ul for three consecutive days.

To determine the cumulative incidence of platelet recovery, defined as platelet count >/20,000/ul for three consecutive days, without platelet transfusion in the preceding seven days.

To determine the cumulative incidence by competing risks analysis of acute GVHD as defined by Przepiorka criteria stages the degree of organ involvement in the skin, liver and gastrointestinal (GI) tract, based on severity, with Stage 1+ being least sever and Stage 4+ being most severe. Grading of acute GVHD is as follows: Grade I (skin involvement stages 1+ to 2+, with no liver or GI involvement), Grade II (skin involvement stages 1+ to 3+, liver 1+, GI tract 1+), Grade III (skin involvement stages 2+ to 3+, liver 1+, GI tract 2+ to 4+), Grade IV (skin involvement stages 4+, liver 4+).

To determine the cumulative incidence by competing risks analysis of chronic GVHD as defined by the NIH Consensus criteria.

To assess the incidence of transplant-related complications including hepatic veno-occlusive disease, idiopathic pneumonia syndrome, transplant-associated thrombotic microangiopathy, and other immune mediated complications.

To determine the cumulative incidence of transplant related mortality, from the start of the preparative regimen through the time of death.

To assess the pace and characterization of immune reconstitution by analyzing T cell subsets in patients at Days 30, 60, 90, 180, one year, and two years.

To assess recipient T cell alloreactivity pre and post BMT and correlate with loss of donor chimerism after BMT.

To assess the incidence of viral reactivation (i.e. Cytomegalovirus (CMV), Epstein Barr Virus (EBV), BK), viral disease (i.e. CMV, EBV, adenovirus), bacterial infection necessitating systemic antibiotics, and invasive fungal infections.

Feasibility of early cessation of tacrolimus in a subset of patients (with matched related or matched unrelated donors)

Feasibility will be assessed by the number of patients who do not develop GVHD after tacrolimus is stopped. Tacrolimus will be stopped at day 60 for matched related donors and day 120 for matched unrelated donors, and patients will be monitored closely for the development of GVHD.

Inclusion Criteria: Confirmed diagnosis of: Primary Immune Deficiencies: Chronic granulomatous disease (CGD) Wiskott-Aldrich syndrome (WAS) Hyper-Immunoglobulin M (IgM) syndrome Common variable immunodeficiency (CVID) Leukocyte adhesion deficiency-1 (LAD-1) Severe Combined Immunodeficiency (SCID) Immune Dysregulatory Syndromes: Immunodysregulation polyendocrinopathy enteropathy X-linked (IPEX) syndrome Hemophagocytic lymphohistiocytosis (HLH) Inherited Bone marrow failure disorders Congenital amegakaryocytic thrombocytopenia (CAMT) Diamond Blackfan anemia (DBA) Shwachman Diamond Syndrome (SDS) Thrombocytopenia Absent Radii (TAR) Glanzmann's thrombasthenia (GT) Kostmann syndrome Other PID, IDS, and IBMFS diagnoses as deemed appropriate by the PI. Available donor as follows: Cohort A --- Fully HLA matched sibling or other first-degree family member. Cohort B --- Fully HLA matched unrelated 10/10 donor using high-resolution DNA-based typing at the following genetic loci: HLA-A, -B, -C, DRB1, and DQB1. Cohort C Mismatched unrelated donor at 8 or 9/10 alleles, using high-resolution typing as above. HLA-haploidentical family members of any degree who match at least one allele of each of the following genetic loci: HLA-A, -B, -C, DRB1, and DQB1. A minimum match of 5/10 is therefore required, and will be considered sufficient evidence that the donor and recipient share one HLA haplotype. The patient and/or legal guardian must sign informed consent for BMT. Patients with adequate organ function as measured by Cardiac: Left ventricular ejection fraction (LVEF) at rest must be ≥ 35%. For patients aged <13 years, shortening fraction (SF) > 25% by echocardiogram or LVEF by multigated acquisition scan (MUGA) may be used. Hepatic: Bilirubin ≤ 3.0 mg/dL; and alanine aminotransferase (ALT), aspartate aminotransferase (AST), and Alkaline Phosphatase (ALP) < 5 x upper limit of normal (ULN). Renal: Serum creatinine within normal range for age, or if serum creatinine outside normal range for age, then renal function (creatinine clearance or glomerular filtration rate (GFR)) > 40 mL/min/1.73m2. Pulmonary: forced expiratory volume-one second (FEV1), forced vital capacity (FVC), diffusing capacity of the lungs for carbon monoxide (DLCO) > 50% predicted (corrected for hemoglobin); if unable to perform pulmonary function tests, then O2 saturation > 92% on room air. Karnofsky or Lansky performance status ≥70% Females and males of childbearing potential must agree to practice 2 effective methods of contraception at the same time, or agree to abstinence. Exclusion Criteria: Patients will not be excluded on the basis of sex, racial or ethnic background. Positive leukocytotoxic crossmatch. Prior allogeneic stem cell transplant. Uncontrolled bacterial, viral, or fungal infection at the time of enrollment. Uncontrolled is defined as currently taking medication and with progression or no clinical improvement on adequate medical treatment. Diagnosis of idiopathic aplastic anemia, Fanconi Anemia, Dyskeratosis Congenita, or other short telomere syndrome. Seropositivity for the human immunodeficiency virus (HIV) Active Hepatitis B or C determined by serology and/or nucleic acid test (NAT) Female patients who are diagnosed as pregnant by beta human chorionic gonadotropin (bHCG) testing (per institutional practice) or who are breast-feeding. Active malignancy or within the timeframe for significant concern for relapse of prior malignancy Donor Eligibility: Donor must be medically, socially, and psychologically fit to donate Bone marrow should be requested from all allogeneic donors. Peripheral blood stem cells (PBSCs) are allowed only if the donor is unable or unwilling to give marrow, and no other bone marrow donor is available. Cord blood is not permitted. First-degree relatives should be tested for degree of HLA match, CMV serology, ABO type, and complete blood count (CBC). An unrelated donor search should be initiated at the time the patient is referred for BMT. Age ≥5 years Donors must meet the selection criteria as defined by the Foundation for the Accreditation of Hematopoietic Cell Therapy (FACT). Lack of recipient anti-donor HLA antibody in recipient Note: In some instances, low level, non-cytotoxic HLA specific antibodies may be permissible if they are found to be at a level well below that detectable by flow cytometry. This will be decided on a case-by-case basis by the PI and one of the immunogenetics directors. In inherited disorders, family members must be tested for carrier and disease status of the underlying disorders. In the event that family members are unaffected carriers, their eligibility as donors will be decided upon by the PI on a case-by-case basis. In the event that two or more eligible donors are identified, the donor will be selected per institutional standards. Suggested criteria include the following: Related is preferred over unrelated. The potential donor that is youngest in age is preferred. For CMV seronegative patients, a CMV seronegative donor is preferred. For CMV seropositive patients, a CMV seropositive donor is preferred. Red blood cell (RBC) compatibility, in order of preference: RBC cross match compatible Minor ABO incompatibility Major ABO incompatibility If the patient is male, male donors are preferred.

Klein OR, Bapty S, Lederman HM, Younger MEM, Zambidis ET, Jones RJ, Cooke KR, Symons HJ. Reduced Intensity Bone Marrow Transplantation with Post-Transplant Cyclophosphamide for Pediatric Inherited Immune Deficiencies and Bone Marrow Failure Syndromes. J Clin Immunol. 2021 Feb;41(2):414-426. doi: 10.1007/s10875-020-00898-0. Epub 2020 Nov 6.