Hematopoietic Stem Cell Transplant for Sickle Cell Disease

STATUS

Recruiting
End date

Jun 14, 2023
participants needed

25
sponsor

Case Comprehensive Cancer Center

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Updated on 14 June 2022

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stroke

sirolimus

fludarabine

tacrolimus

bone marrow transplant

anti-thymocyte globulin

direct bilirubin

hemoglobin s

blood transfusion

conjugated bilirubin

acute chest syndrome

chest syndrome

thalassemia

sickle cell trait

sickle hemoglobin

hemoglobin c disease

Summary

This is a phase I/II study of patients with sickle cell disease. It aims to find out if people with sickle cell disease can be cured by changing their immune system before they have blood stem cell transplants. Doctors will give patients a new drug (fludarabine) to see if this drug changes patients immune system and reduces the patient's cells (host) from rejecting donor cells (graft) after the patient gets a Hematopoietic (blood) stem cell transplant.

Description

Primary Objective

To evaluate the safety and feasibility of hematopoietic stem cell transplant (HSCT) after treatment with fludarabine in adult patients with Sickle Cell Disease (SCD).

Secondary Objective(s), in HSCT for SCD

To evaluate the rates of disease-free and overall survival in both MSD and alternate graft donor (MUD, haploidentical, or cord blood-derived) recipients
To evaluate fertility in matched sibling and alternate-donor graft recipients
To evaluate GVHD rates in MSD and Alternate Graft Donor recipients in SCD.
To evaluate cerebral, pulmonary, renal, and generalized vasculopathy before and after HSCT in SCD.
To evaluate hematopoiesis and erythropoiesis before and before HSCT in SCD.
Modulation of SCD Phenotype by Allogeneic Transplantation. Rigorous clinical follow-up will be performed, per routine care, to evaluate those consequences of SCD that will be modified by allogeneic transplantation in the short-term (4-12 weeks), in the medium-term (12-24 weeks) and in the long-term (>24 weeks). Short-term changes would include disappearance of stress hematopoiesis and erythropoiesis; medium- and long-term changes would include effects on pain, fertility (TSH, LH), cognition (routine cognitive assessments), and end-organ damage (including urine albumin-to-creatinine ratios and tricuspid regurgitant jet velocities, as indicated).

Procedures

The study will start with at least 10 and up to 25 patients. They will be given the lowest starting dose of fludarabine. This is done to make sure it is safe. Researchers will watch the patients during what is called the dose-limiting toxicity (DLT) period. Their safety will be monitored by a Safety Monitoring Committee, which is made up of people who run research studies. The study will not take new patients until the DLT period is done.

If at least 3 of the 10 patients enrolled do not benefit, the maximum tolerated dose (MTD) will be considered exceeded. After the DLT period is complete, patients will receive a stem cell transplant from a genetically matched donor. Patients will be continued to be monitored for a year after the transplant.

To prepare for the transplant patients will have to undergo the following treatments:

an exchange transfusion
a stem cell graft infusion from either a:
perfectly matched sibling donor (called MSD),
perfectly matched but unrelated donor (called MUD),
a half-matched related donor (called Haploidentical), or
a cord blood donor
rabbit antithymocyte globulin (ATG)
cytoxan (a type of chemotherapy)
Fludarabine (you get this medicine a few weeks before transplant and again, as part of the routine chemotherapy treatment). This is the main drug being studies in this research
total body irradiation (also called TBI)
tacrolimus, mycophenolate (MMF) and/or methotrexate (MTX). These drugs will weaken your immune system. They are given to lower your chances of getting GVHD and rejecting the donor cells.

Patients will be in the study for approximately 14 months.

Details

Condition	Sickle Cell Disease, Sickle Cell Anemia, SCD
Treatment	Fludarabine, Hematopoietic Stem Cell Transplant (HSCT), Hematopoietic Stem Cell Transplant (HSCT)
Clinical Study Identifier	NCT02065596
Sponsor	Case Comprehensive Cancer Center
Last Modified on	14 June 2022

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Eligibility		Yes	No	Not Sure
Inclusion Criteria
	Patients must have one of the following inherited hemoglobin gene disorders
	a. Hemoglobin SS
	b. Hemoglobin SC
	c. Hemoglobin S-Beta-zero-Thalassemia or
	d. Hemoglobin S-Beta-plus Thalassemia with an episode of multi-organ failure within 5 years of eligibility
	Patients must meet one of the following risk criteria
	Low Risk (Red Light. Stop and consider therapy closely): Must have matched sibling donor grafts, failed conventional therapy as determined by the PI, and evidence for morbid disease (one of the following)
	a. 2 or more painful episode/year (requiring Emergency Department or inpatient care) x 2 years or
	b. 1 or more diagnoses of Acute Chest Syndrome within 5 years, or
	c. 2-year mortality 5-10% or
	d. Baseline LDH>600 IU or
	e. History of sepsis, with or without a WBC>13.5, or
	f. On chronic transfusions
	Moderate Risk (Yellow Light. Reasonable to proceed, but with caution): May have
	alternate donor grafts (haploidentical or matched unrelated donor), if MSD is
	a. Urine Albumin to Creatinine Ratio of >300mg/g or eGFR 50-90 ml/min x 2 evaluations within 3 months or
	b. History of overt clinical stroke, or progressive cerebral vasculopathy radiographically or
	not available. Must have history of high-level vasculopathy, as defined by at
	least one of the criteria below
	c. 1 or more diagnoses of Acute Chest Syndrome, multi-organ failure, or sickle hepatopathy within 7 years, or
	d. Excessively morbid disease manifest as VOCs at a rate of 2 or more per year x 2-years or uncontolled retinal disease attributed to SCD. These patients can be considered for moderate-risk alternate donor transplants. The palliative nature of the transplant will be explicit in the consent
	e. 2-year mortality >10-15%
	i. Baseline WBC>13.5 and on chronic transfusions or baseline LDH>600 or age >35 years old
	iii. Chronic transfusion therapy and age >35 years old or male gender
	iv. Baseline LDH>600 and age >35 years old or history of sepsis
	v. History of sepsis and age >35 years old or male gender
	ii. Baseline TRV ≥3 m/s
	f. History of multi-organ failure
	b. Baseline WBC>13.5 and chronic transfusions or baseline LDH>600 or age >35 years old
	c. Age >35 years old and chronic transfusions
	High Risk (Green light, proceed if possible): All donor types are eligible. Must have
	To determine eligibility as a bone marrow transplant patient
	high risk disease and a >15% risk of 2-year mortality as defined by at least
	Available suitable donor
	one of the criteria below
	a. Baseline TRV ≥3 m/s and baseline WBC >13.5 or on chronic transfusions or history of sepsis or age >35 years old
	a. 6/6 HLA-matched sibling donor (HLA A, B, and DRB1), bone marrow only
	b. 8/8 HLA-matched unrelated donor (HLA A, B, C, DRB1), bone marrow only
	c. 4/8, 5/8, 6/8, 7/8 Haploidentical donor, bone marrow only
	Patients must have adequate hematologic, hepatic, and renal function as defined below
	Direct bilirubin within 3 X normal institutional limits
	ALT (SGPT) < 3 X institutional upper limit of normal
	Creatinine clearance >21 mL/min/1.73 m^2 for subjects with creatinine clearance values below 50 mL/min/1.73 m^2, the principal investigator may use discretion for appropriate fludarabine dose adjustment as noted
	Patients must have adequate pulmonary function as defined by Pulmonary function: DLCO r40% (adjusted for hemoglobin) and FEV1r50%
	Subjects must have the ability to understand and the willingness to sign a written informed consent document
	Contraception/Child Bearing The effects of Fludarabine, cytoxan, ATG
	tacrolimus/sirolimus and MTX are cumulatively known to be deleterious to the
	health of the developing human fetus. For this reason, and because of
	teratogenic potential, all women of child-bearing potential and men must agree
	to use adequate contraception (double barrier method of birth control or
	abstinence) for the duration of study participation and for 12 months after
	completing treatment
	Performance Status: Eastern Cooperative Oncology Group (ECOG) Performance Status ≤ 2
Exclusion Criteria
	Red cell alloimmunization to a degree that precludes extended transfusion
	Patients with uncontrolled intercurrent illness including, but not limited to ongoing or active infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia, or psychiatric illness/social situations that would limit compliance with study requirements
	eGFR <21 ml/min
	Hepatic cirrhosis (Biopsy Proven)
	HIV positive, ineligible because of the increased risk of lethal infections when treated with marrow suppressive therapy. Appropriate studies will be undertaken in patients receiving combination antiretroviral therapy when indicated
	Pregnant or breastfeeding women are excluded from this study because the immunomodulatory treatment, preparative regimen, and anti-GVHD therapy contain agents with the potential for teratogenic or abortifacient effects
	Evidence of uncontrolled bacterial, viral, or fungal infections (currently taking medication and progression of clinical symptoms) within 1 month prior to starting the conditioning regimen. Patients with fever or suspected minor infection should await resolution of symptoms before starting the conditioning regimen
	Prior allogeneic marrow or stem cell transplantation
	Subjects must not have evidence of impaired liver function due to iron overload, +/- hepatitis. Patients will be evaluated by liver consult if ferritin >1500, history of hepatitis,or ALTis ≥3 X Upper limit of normal (ULN). Recommended evaluations could include liver biopsy if there is evidence for significant hepatic iron deposition or fibrosis/cirrhosis on T2 MRI of the liver
	≥2.0 liter-per-minute pm home oxygen requirement
	An estimated Left Ventricular Ejection Fraction ≤40% (echo or MUGA)

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Hematopoietic Stem Cell Transplant for Sickle Cell Disease