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Reduced Intensity Conditioning for Non-Malignant Disorders Undergoing UCBT, BMT or PBSCT (HSCT+RIC)

Primary Purpose

Primary Immunodeficiency (PID), Congenital Bone Marrow Failure Syndromes, Inherited Metabolic Disorders (IMD)

Status
Recruiting
Phase
Phase 2
Locations
United States
Study Type
Interventional
Intervention
Hydroxyurea
Alemtuzumab
Fludarabine
Melphalan
Thiotepa
Sponsored by
Paul Szabolcs
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional treatment trial for Primary Immunodeficiency (PID) focused on measuring Severe Combined Immune Deficiency (SCID), Omenn Syndrome, Bare Lymphocyte Syndrome (BLS), Combined Immune Deficiency (CID) syndromes, Combined Variable Immune Deficiency (CVID) syndrome, Wiskott-Aldrich Syndrome, Leukocyte adhesion deficiency, Chronic granulomatous disease (CGD), X-linked Hyper IgM (XHIM) syndrome, IPEX syndrome, Chediak - Higashi Syndrome, Autoimmune Lymphoproliferative Syndrome (ALPS), Hemophagocytic Lymphohistiocytosis (HLH) syndromes, Lymphocyte Signaling defects, Dyskeratosis Congenita (DC), Congenital Amegakaryocytic Thrombocytopenia (CAMT), Osteopetrosis, Mucopolysaccharidoses, Hurler syndrome (MPS I), Hunter syndrome (MPS II), Leukodystrophies, Krabbe Disease, Metachromatic leukodystrophy (MLD), X-linked adrenoleukodystrophy (ALD), Alpha mannosidosis, Gaucher Disease, Thalassemia major, Sickle cell disease (SCD), Diamond Blackfan Anemia (DBA), Crohn's Disease, Inflammatory Bowel Disease, Hematopoietic Stem Cell Transplant (HSCT), Congenital transfusion dependent anemias, Globoid cell leukodystrophy, Hereditary diffuse leukoencephalopathy with spheroids (HDLS), Systemic Juvenile Idiopathic Arthritis (sJIA)

Eligibility Criteria

2 Months - 55 Years (Child, Adult)All SexesDoes not accept healthy volunteers

Inclusion:

  1. A 4/6, 5/6 or 6/6 HLA matched related or unrelated UCB unit available that will deliver a pre-cryopreservation total nucleated cell dose of ≥ 3 x 10e7 cells/kg, or double unit grafts, each cord blood unit delivering at least 2 x 10e7 cells/kg OR an 8 of 8 or 7 of 8 HLA allele level matched unrelated donor bone marrow or peripheral blood progenitor graft.
  2. Adequate organ function as measured by:

    1. Creatinine ≤ 2.0 mg/dL and creatinine clearance ≥ 50 mL/min/1.73 m2.
    2. Hepatic transaminases (ALT/AST) ≤ 4 x upper limit of normal (ULN).
    3. Adequate cardiac function by echocardiogram or radionuclide scan (shortening fraction > 26% or ejection fraction > 40% or > 80% of normal value for age).
    4. Pulmonary evaluation testing demonstrating CVC or FEV1/FVC of ≥ 50% of predicted for age and/or resting pulse oximeter ≥ 92% on room air or clearance by the pediatric or adult pulmonologist. For adult patients DLCO (corrected for hemoglobin) should be ≥ 50% of predicted if the DLCO can be obtained.
  3. Written informed consent and/or assent according to FDA guidelines.
  4. Negative pregnancy test if pubertal and/or menstruating.
  5. HIV negative.
  6. A non-malignant disorder amenable to treatment by stem cell transplantation, including but not limited to:

    1. Primary Immunodeficiency syndromes including but not limited to:

      • Severe Combined Immune Deficiency (SCID) with NK cell activity
      • Omenn Syndrome
      • Bare Lymphocyte Syndrome (BLS)
      • Combined Immune Deficiency (CID) syndromes
      • Combined Variable Immune Deficiency (CVID) syndrome
      • Wiskott-Aldrich Syndrome
      • Leukocyte adhesion deficiency
      • Chronic granulomatous disease (CGD)
      • X-linked Hyper IgM (XHIM) syndrome
      • IPEX syndrome
      • Chediak - Higashi Syndrome
      • Autoimmune Lymphoproliferative Syndrome (ALPS)
      • Hemophagocytic Lymphohistiocytosis (HLH) syndromes
      • Lymphocyte Signaling defects
      • Other primary immune defects where hematopoietic stem cell transplantation may be beneficial
    2. Congenital bone marrow failure syndromes including but not limited to:

      • Dyskeratosis Congenita (DC)
      • Congenital Amegakaryocytic Thrombocytopenia (CAMT)
      • Osteopetrosis
    3. Inherited Metabolic Disorders (IMD) including but not limited to:

      • Mucopolysaccharidoses

        • Hurler syndrome (MPS I)
        • Hunter syndrome (MPS II)
      • Leukodystrophies

        • Krabbe Disease, also known as globoid cell leukodystrophy
        • Metachromatic leukodystrophy (MLD)
        • X-linked adrenoleukodystrophy (ALD)
        • Hereditary diffuse leukoencephalopathy with spheroids (HDLS)
      • Other inherited metabolic disorders

        • alpha mannosidosis
        • Gaucher Disease
      • Other inheritable metabolic diseases where hematopoietic stem cell transplantation may be beneficial.
    4. Hereditary anemias

      • Thalassemia major
      • Sickle cell disease (SCD) - patients with sickle disease must have one or more of the following:

        • Overt or silent stroke
        • Pain crises ≥ 2 episodes per year for past year
        • One or more episodes of acute chest syndrome
        • Osteonecrosis involving ≥ 1 joints
        • Priapism
      • Diamond Blackfan Anemia (DBA)
      • Other congenital transfusion dependent anemias
    5. Inflammatory Conditions

      • Crohn's Disease/Inflammatory Bowel Disease

Exclusion:

  1. Allogeneic hematopoietic stem cell transplant within the previous 6 months.
  2. Any active malignancy or MDS.
  3. Severe acquired aplastic anemia.
  4. Uncontrolled bacterial, viral or fungal infection (currently taking medication and with progression of clinical symptoms).
  5. Pregnancy or nursing mother.
  6. Poorly controlled pulmonary hypertension.
  7. Any condition that precludes serial follow-up.

Sites / Locations

  • UPMC Children's Hospital of PittsburghRecruiting

Arms of the Study

Arm 1

Arm 2

Arm Type

Experimental

Experimental

Arm Label

UCBT:transfusion dependent anemias or increased rejection risk

BMT, PBSCT and not transfusion dependent UCBT

Arm Description

Day -21 to -19: Alemtuzumab + Hydroxyurea; Day -18 to -10: Hydroxyurea; Day -9 to -5: Fludarabine + Hydroxyurea; Day -4 to -3: Melphalan; Day -2: Thiotepa; Day -1: Rest; Day 0: Transplant

Start of conditioning to Day -15: Hydroxyurea; Day -14 to -13: Alemtuzumab + Hydroxyurea; Day -12 to -10: Hydroxyurea; Day -9 to -5: Fludarabine + Hydroxyurea; Day -4 to -3: Melphalan; Day -2: Thiotepa; Day -1: Rest; Day 0: Transplant

Outcomes

Primary Outcome Measures

Post-transplant treatment-related mortality (TRM)
The number of deaths related to the research intervention at day 100, 6 months, and 1 year post-transplant.
Neurodevelopmental milestones
Evaluation of the pace of attaining neurodevelopmental milestones after reduced-intensity conditioning as compared to myeloablative conditioning historical controls from the target population(s).
Immune Reconstitution
Evaluation of the pace of immune reconstitution.
Severe opportunistic infections
Evaluation of the incidence of severe opportunistic infections.
GVHD occurrence
Description of the incidence of acute graft versus host disease (GVHD) (II-IV) and chronic extensive GVHD.

Secondary Outcome Measures

Donor cell engraftment
Determination of the feasibility of attaining robust donor cell engraftment (>50% donor chimerism at 6 months) following reduced-intensity conditioning (RIC) regimens prior to HSCT in the target population(s).
Normal enzyme level
Determination of the feasibility of attaining and sustaining normal enzyme levels in the target population(s).
Neutrophil recovery
Determination of the pace of neutrophil recovery.
Platelet recovery
Determination of the pace of platelet recovery.
Grade 3-4 organ toxicity
The number of grade 3-4 organ adverse events.
Late graft failure
Evaluation of the incidence of late graft failure.

Full Information

First Posted
October 10, 2013
Last Updated
October 3, 2023
Sponsor
Paul Szabolcs
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1. Study Identification

Unique Protocol Identification Number
NCT01962415
Brief Title
Reduced Intensity Conditioning for Non-Malignant Disorders Undergoing UCBT, BMT or PBSCT
Acronym
HSCT+RIC
Official Title
A Phase II Study of Reduced Intensity Conditioning in Pediatric Patients and Young Adults ≤55 Years of Age With Non-Malignant Disorders Undergoing Umbilical Cord Blood, Bone Marrow, or Peripheral Blood Stem Cell Transplantation
Study Type
Interventional

2. Study Status

Record Verification Date
October 2023
Overall Recruitment Status
Recruiting
Study Start Date
February 4, 2014 (Actual)
Primary Completion Date
November 2024 (Anticipated)
Study Completion Date
November 2024 (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
Product Manufactured in and Exported from the U.S.
No
Data Monitoring Committee
Yes

5. Study Description

Brief Summary
The objective of this study is to evaluate the efficacy of using a reduced-intensity condition (RIC) regimen with umbilical cord blood transplant (UCBT), double cord UCBT, matched unrelated donor (MUD) bone marrow transplant (BMT) or peripheral blood stem cell transplant (PBSCT) in patients with non-malignant disorders that are amenable to treatment with hematopoietic stem cell transplant (HSCT). After transplant, subjects will be followed for late effects and for ongoing graft success.
Detailed Description
For some non-malignant diseases (NMD; i.e., thalassemia, sickle cell disease, most immune deficiencies) a hematopoietic stem cell transplant may be curative by healthy donor stem cell engraftment alone. HSCT in patients with NMD differs from that in malignant disorders for two important reasons: 1) these patients are typically naïve to chemotherapy and immunosuppression. This may potentially lead to difficulties with engraftment. And 2) RIC with subsequent bone marrow chimerism may be beneficial even in mixed chimerism and result in decreased transplant-related mortality (TRM). Nevertheless, any previous organ damage, as a result of the underlying disease, may remain present after the HSCT. For other diseases (metabolic disorders, some immunodeficiencies, etc.), a transplant is not curative. For these diseases, the main intent of the transplant is to slow down, or stop, the progress of the disease. In select few cases/diseases, the presence of healthy bone marrow derived cells may even prevent progression and prevent neurological decline. In this research study, instead of using the standard myeloablative conditioning, the study doctor is using RIC, in which significantly lower doses of chemotherapy will be used. The lower doses may not eradicate every stem cell in the patient's bone marrow, however, in the presented combination, the intention is to eliminate already formed immune cells and provide maximum growth advantage to healthy donor stem cells. This paves the way to successful engraftment of donor stem cells. Engrafting donor stem cells can outcompete, and donor lymphocytes could suppress, the patients' surviving stem cells. With RIC, the side effects on the brain, heart, lung, liver, and other organ functions are less severe and late toxic effects should also be reduced. The purpose of this study is to collect data from the patients undergoing reduced-intensity conditioning before HSCT, and compare it to the standard myeloablative conditioning. It is expected there will be therapeutic benefits, paired with better survival rate, less organ toxicity and improved quality of life, following the RIC compared to the myeloablative regimen.

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Primary Immunodeficiency (PID), Congenital Bone Marrow Failure Syndromes, Inherited Metabolic Disorders (IMD), Hereditary Anemias, Inflammatory Conditions, Systemic Juvenile Idiopathic Arthritis (sJIA)
Keywords
Severe Combined Immune Deficiency (SCID), Omenn Syndrome, Bare Lymphocyte Syndrome (BLS), Combined Immune Deficiency (CID) syndromes, Combined Variable Immune Deficiency (CVID) syndrome, Wiskott-Aldrich Syndrome, Leukocyte adhesion deficiency, Chronic granulomatous disease (CGD), X-linked Hyper IgM (XHIM) syndrome, IPEX syndrome, Chediak - Higashi Syndrome, Autoimmune Lymphoproliferative Syndrome (ALPS), Hemophagocytic Lymphohistiocytosis (HLH) syndromes, Lymphocyte Signaling defects, Dyskeratosis Congenita (DC), Congenital Amegakaryocytic Thrombocytopenia (CAMT), Osteopetrosis, Mucopolysaccharidoses, Hurler syndrome (MPS I), Hunter syndrome (MPS II), Leukodystrophies, Krabbe Disease, Metachromatic leukodystrophy (MLD), X-linked adrenoleukodystrophy (ALD), Alpha mannosidosis, Gaucher Disease, Thalassemia major, Sickle cell disease (SCD), Diamond Blackfan Anemia (DBA), Crohn's Disease, Inflammatory Bowel Disease, Hematopoietic Stem Cell Transplant (HSCT), Congenital transfusion dependent anemias, Globoid cell leukodystrophy, Hereditary diffuse leukoencephalopathy with spheroids (HDLS), Systemic Juvenile Idiopathic Arthritis (sJIA)

7. Study Design

Primary Purpose
Treatment
Study Phase
Phase 2
Interventional Study Model
Parallel Assignment
Masking
None (Open Label)
Allocation
Non-Randomized
Enrollment
100 (Anticipated)

8. Arms, Groups, and Interventions

Arm Title
UCBT:transfusion dependent anemias or increased rejection risk
Arm Type
Experimental
Arm Description
Day -21 to -19: Alemtuzumab + Hydroxyurea; Day -18 to -10: Hydroxyurea; Day -9 to -5: Fludarabine + Hydroxyurea; Day -4 to -3: Melphalan; Day -2: Thiotepa; Day -1: Rest; Day 0: Transplant
Arm Title
BMT, PBSCT and not transfusion dependent UCBT
Arm Type
Experimental
Arm Description
Start of conditioning to Day -15: Hydroxyurea; Day -14 to -13: Alemtuzumab + Hydroxyurea; Day -12 to -10: Hydroxyurea; Day -9 to -5: Fludarabine + Hydroxyurea; Day -4 to -3: Melphalan; Day -2: Thiotepa; Day -1: Rest; Day 0: Transplant
Intervention Type
Drug
Intervention Name(s)
Hydroxyurea
Other Intervention Name(s)
hydroxycarbamide, Hydrea, Droxia
Intervention Description
Oral administration at 30 mg/kg/day.
Intervention Type
Drug
Intervention Name(s)
Alemtuzumab
Other Intervention Name(s)
Campath
Intervention Description
Intravenous (IV) administration. The first dose for each arm will be a test dose (0.2 mg/kg max 5 mg). The treatment doses of alemtuzumab will be based on the patients' assigned stratum as determined by their age, lymphocyte count and presence of infection. Stratum 1: 1 mg/kg (max dose of 30 mg); Stratum 2: 0.5 mg/kg (max dose of 30 mg); Stratum 3: No treatment dose, test dose only.
Intervention Type
Drug
Intervention Name(s)
Fludarabine
Other Intervention Name(s)
Fludara
Intervention Description
IV administration at 30 mg/m2/day or 1 mg/kg/dose, whichever is lower.
Intervention Type
Drug
Intervention Name(s)
Melphalan
Other Intervention Name(s)
Melphalan hydrochloride, Alkeran
Intervention Description
IV administration at 70 mg/m2/dose.
Intervention Type
Drug
Intervention Name(s)
Thiotepa
Intervention Description
IV administration at 200 mg/m2/dose
Primary Outcome Measure Information:
Title
Post-transplant treatment-related mortality (TRM)
Description
The number of deaths related to the research intervention at day 100, 6 months, and 1 year post-transplant.
Time Frame
1 year post-transplant
Title
Neurodevelopmental milestones
Description
Evaluation of the pace of attaining neurodevelopmental milestones after reduced-intensity conditioning as compared to myeloablative conditioning historical controls from the target population(s).
Time Frame
1 year post-transplant
Title
Immune Reconstitution
Description
Evaluation of the pace of immune reconstitution.
Time Frame
1 year post-transplant
Title
Severe opportunistic infections
Description
Evaluation of the incidence of severe opportunistic infections.
Time Frame
1 year post-transplant
Title
GVHD occurrence
Description
Description of the incidence of acute graft versus host disease (GVHD) (II-IV) and chronic extensive GVHD.
Time Frame
1 year post-transplant
Secondary Outcome Measure Information:
Title
Donor cell engraftment
Description
Determination of the feasibility of attaining robust donor cell engraftment (>50% donor chimerism at 6 months) following reduced-intensity conditioning (RIC) regimens prior to HSCT in the target population(s).
Time Frame
6 months post-transplant
Title
Normal enzyme level
Description
Determination of the feasibility of attaining and sustaining normal enzyme levels in the target population(s).
Time Frame
1 year post-transplant
Title
Neutrophil recovery
Description
Determination of the pace of neutrophil recovery.
Time Frame
1 year post-transplant
Title
Platelet recovery
Description
Determination of the pace of platelet recovery.
Time Frame
1 year post-transplant
Title
Grade 3-4 organ toxicity
Description
The number of grade 3-4 organ adverse events.
Time Frame
1 year post-transplant
Title
Late graft failure
Description
Evaluation of the incidence of late graft failure.
Time Frame
1 year post-transplant

10. Eligibility

Sex
All
Minimum Age & Unit of Time
2 Months
Maximum Age & Unit of Time
55 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
Inclusion: A 4/6, 5/6 or 6/6 HLA matched related or unrelated UCB unit available that will deliver a pre-cryopreservation total nucleated cell dose of ≥ 3 x 10e7 cells/kg, or double unit grafts, each cord blood unit delivering at least 2 x 10e7 cells/kg OR an 8 of 8 or 7 of 8 HLA allele level matched unrelated donor bone marrow or peripheral blood progenitor graft. Adequate organ function as measured by: Creatinine ≤ 2.0 mg/dL and creatinine clearance ≥ 50 mL/min/1.73 m2. Hepatic transaminases (ALT/AST) ≤ 4 x upper limit of normal (ULN). Adequate cardiac function by echocardiogram or radionuclide scan (shortening fraction > 26% or ejection fraction > 40% or > 80% of normal value for age). Pulmonary evaluation testing demonstrating CVC or FEV1/FVC of ≥ 50% of predicted for age and/or resting pulse oximeter ≥ 92% on room air or clearance by the pediatric or adult pulmonologist. For adult patients DLCO (corrected for hemoglobin) should be ≥ 50% of predicted if the DLCO can be obtained. Written informed consent and/or assent according to FDA guidelines. Negative pregnancy test if pubertal and/or menstruating. HIV negative. A non-malignant disorder amenable to treatment by stem cell transplantation, including but not limited to: Primary Immunodeficiency syndromes including but not limited to: Severe Combined Immune Deficiency (SCID) with NK cell activity Omenn Syndrome Bare Lymphocyte Syndrome (BLS) Combined Immune Deficiency (CID) syndromes Combined Variable Immune Deficiency (CVID) syndrome Wiskott-Aldrich Syndrome Leukocyte adhesion deficiency Chronic granulomatous disease (CGD) X-linked Hyper IgM (XHIM) syndrome IPEX syndrome Chediak - Higashi Syndrome Autoimmune Lymphoproliferative Syndrome (ALPS) Hemophagocytic Lymphohistiocytosis (HLH) syndromes Lymphocyte Signaling defects Other primary immune defects where hematopoietic stem cell transplantation may be beneficial Congenital bone marrow failure syndromes including but not limited to: Dyskeratosis Congenita (DC) Congenital Amegakaryocytic Thrombocytopenia (CAMT) Osteopetrosis Inherited Metabolic Disorders (IMD) including but not limited to: Mucopolysaccharidoses Hurler syndrome (MPS I) Hunter syndrome (MPS II) Leukodystrophies Krabbe Disease, also known as globoid cell leukodystrophy Metachromatic leukodystrophy (MLD) X-linked adrenoleukodystrophy (ALD) Hereditary diffuse leukoencephalopathy with spheroids (HDLS) Other inherited metabolic disorders alpha mannosidosis Gaucher Disease Other inheritable metabolic diseases where hematopoietic stem cell transplantation may be beneficial. Hereditary anemias Thalassemia major Sickle cell disease (SCD) - patients with sickle disease must have one or more of the following: Overt or silent stroke Pain crises ≥ 2 episodes per year for past year One or more episodes of acute chest syndrome Osteonecrosis involving ≥ 1 joints Priapism Diamond Blackfan Anemia (DBA) Other congenital transfusion dependent anemias Inflammatory Conditions Crohn's Disease/Inflammatory Bowel Disease Exclusion: Allogeneic hematopoietic stem cell transplant within the previous 6 months. Any active malignancy or MDS. Severe acquired aplastic anemia. Uncontrolled bacterial, viral or fungal infection (currently taking medication and with progression of clinical symptoms). Pregnancy or nursing mother. Poorly controlled pulmonary hypertension. Any condition that precludes serial follow-up.
Central Contact Person:
First Name & Middle Initial & Last Name or Official Title & Degree
Paul Szabolcs, MD
Phone
412-692-5427
Email
paul.szabolcs@chp.edu
First Name & Middle Initial & Last Name or Official Title & Degree
Shawna McIntyre, RN
Phone
412-692-5552
Email
mcintyresm@upmc.edu
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Paul Szabolcs, MD
Organizational Affiliation
University of Pittsburgh
Official's Role
Principal Investigator
Facility Information:
Facility Name
UPMC Children's Hospital of Pittsburgh
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 McIntyre, RN
Phone
412-692-5552
Email
mcintyresm@upmc.edu
First Name & Middle Initial & Last Name & Degree
Maria Escolar, MD
First Name & Middle Initial & Last Name & Degree
Randy Windreich, MD
First Name & Middle Initial & Last Name & Degree
Jessie Barnum, MD
First Name & Middle Initial & Last Name & Degree
Craig Byersdorfer, MD

12. IPD Sharing Statement

Plan to Share IPD
No
Citations:
PubMed Identifier
32634238
Citation
Vander Lugt MT, Chen X, Escolar ML, Carella BA, Barnum JL, Windreich RM, Hill MJ, Poe M, Marsh RA, Stanczak H, Stenger EO, Szabolcs P. Reduced-intensity single-unit unrelated cord blood transplant with optional immune boost for nonmalignant disorders. Blood Adv. 2020 Jul 14;4(13):3041-3052. doi: 10.1182/bloodadvances.2020001940. Erratum In: Blood Adv. 2020 Aug 11;4(15):3508.
Results Reference
derived

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Reduced Intensity Conditioning for Non-Malignant Disorders Undergoing UCBT, BMT or PBSCT

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