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

Overview

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.

Interventions

• 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
• Drug Alemtuzumab
  Transplantation Conditioning
• Drug Fludarabine
  Transplantation Conditioning
• Drug Thiotepa
  Transplantation Conditioning
• Drug G-CSF
  Transplantation conditioning
• Drug Hydroxyurea
  Transplantation Conditioning

Primary outcome measures

• Death [Time frame: Up to 2 years post stem cell transplant]
• Engraftment failure [Time frame: Up to 2 years post stem cell transplant]
• Non-hematologic events [Time frame: Up to 2 years post stem cell transplant]
• Hematological events [Time frame: after 30 days post stem cell transplant]
• BOS Score [Time frame: at 1 year post lung transplant]
• T-cell Chimerism [Time frame: at 12 months post stem cell transplant]
• Myeloid chimerism [Time frame: at 12 months post stem cell transplant]
• Restoration of blood cell count (in absence of growth factors) [Time frame: at 12 months post stem cell transplant]

Secondary outcome measures (12)

• Feasibility of patients able to proceed to BMT within 6 months following lung transplantation [Time frame: Up to 2 years post stem cell transplant]
• Independence [Time frame: up to 2 years post stem cell transplant]
• Independence [Time frame: Up to 2 years post stem cell transplant]
• Tolerance development to both host and pulmonary grafting [Time frame: Up to 2 years post stem cell transplant]
• Long-term complications [Time frame: Up to 2 years post stem cell transplant]
• Acute cellular rejection [Time frame: Up to 2 years post stem cell transplant]
• Acute graft-versus-host-disease (GVHD) [Time frame: Up to 2 years post stem cell transplant]
• Chronic graft-versus-host-disease (GVHD) [Time frame: Up to 2 years post stem cell transplant]
• Ability to withdrawal immunosuppression [Time frame: By 1 year post stem cell transplant]
• Time to withdraw immunosuppression [Time frame: Up to 2 years post stem cell transplant]
• Prophylactic antimicrobial drugs [Time frame: Up to 2 years post stem cell transplant]
• Treatment antimicrobial drugs [Time frame: up to 2 years post stem cell transplant]

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.

Criteria are shown verbatim from the registry (in English). Final eligibility is always assessed by the study center.

Healthy volunteers: No

Study design

Allocation

N/A

Model

Single group

Masking

Open label

Primary purpose

Treatment

Study locations

United States · 2 centers

• UPMC Presbyterian — Pittsburgh
• Children's Hospital of Pittsburgh of UPMC — Pittsburgh

Identifiers

NCT: NCT03500731 · STUDY19110120

Primary sources (government registries)

• ClinicalTrials.gov (US NIH)

View this study on ClinicalTrials.gov ↗