Conditioning Regimen for Allogeneic Hematopoietic Stem-Cell Transplantation

  • STATUS
    Recruiting
  • days left to enroll
    28
  • participants needed
    40
  • sponsor
    University of Florida
Updated on 19 October 2021
malignant disease
hysterectomy
stem cell transplantation
graft versus host disease
fludarabine
anemia
immunodeficiency
busulfan
anti-thymocyte globulin
ejection fraction
deficiency
lfts
cell transplantation
t-cell depletion
bone marrow procedure
gilbert's syndrome
transplant conditioning
thiotepa
shortening fraction
antithymocyte globulin
cytopenia
thrombocytopenia
hemolysis
replacement therapy
follicle stimulating hormone
malnutrition
metabolic disorders
hurler's syndrome
thrombocytopenia, congenital
pulse oximetry
bilateral tubal ligation
follicle-stimulating hormone
conditioning regimen
lymphoproliferative disorder
diamond-blackfan anemia
neutropenia
hemoglobinopathy
undernutrition
sickle cell anemia
hla typing
x-linked lymphoproliferative disease
lymphohistiocytosis
wiskott-aldrich syndrome
lymphoproliferative disease
hemophagocytic lymphohistiocytosis
thalassemia
ratg
familial hemophagocytic lymphohistiocytosis
anti-thymocyte globulin (rabbit)

Summary

In this study, the investigators test 2 dose levels of thiotepa (5 mg/kg and 10 mg/kg) added to the backbone of targeted reduced dose IV busulfan, fludarabine and rabbit anti-thymocyte globulin (rATG) to determine the minimum effective dose required for reliable engraftment for subjects undergoing hematopoietic stem cell transplantation for non-malignant disease.

Description

Hematopoietic stem cell transplantation is the only curative choice for a number of inherited bone marrow failure syndromes, hemoglobinopathies, metabolic disorders and primary immune deficiencies. While survival of these patients is typically better than survival of patients with malignancies, toxicities of conditioning regimens and failure of engraftment remain challenges. Most children with non-malignant disorders present with normocellular or even hypercellular bone marrow, posing a barrier to engraftment and requiring intensive conditioning. Commonly used backbone of busulfan and fludarabine, although well tolerated, results in variable engraftment, in particular with mismatched unrelated donors and cord blood recipients. In this study, the investigators test 2 dose levels of thiotepa (5 mg/kg and 10 mg/kg) added to the backbone of targeted reduced dose IV busulfan, fludarabine and rabbit anti-thymocyte globulin (rATG) in order to determine the minimum effective dose required for reliable engraftment. Subjects are stratified in groups A and B based the risk of graft failure.

Details
Condition hurler syndrome, Diamond-Blackfan anemia, Lymphoproliferative disorders, SICKLE CELL ANEMIA, Hemolytic anemia, Chronic granulomatous disease, Severe Combined Immunodeficiency, Common Variable Immunodeficiency, Common Variable Immunodeficiency (CVID), Bone Marrow Failure Disorders, Primary Immunodeficiency Disorders, Wiskott-Aldrich Syndrome, alpha-Mannosidosis, Bone Marrow Failure Syndromes, Thalassemia, X-linked Lymphoproliferative Disease, Acquired Thrombocytopenia, Hurler's Syndrome, Mannosidosis, Sickle Cell Disease, scid, Adrenoleukodystrophy, Hemophagocytic lymphohistiocytosis, Lymphoproliferative Disorder, Immunodeficiency, Acquired Neutropenia in Newborn, dysostosis multiplex, Bone Marrow Failure Syndrome
Treatment Thiotepa--single daily dose, Thiotepa--escalated dose
Clinical Study IdentifierNCT03513328
SponsorUniversity of Florida
Last Modified on19 October 2021

Eligibility

Yes No Not Sure

Inclusion Criteria

Diagnoses
Hemoglobinopathies (e.g. thalassemia or sickle cell disease)
Cytopenias (e.g.Diamond-Blackfan anemia, congenital or acquired neutropenia, congenital or acquired thrombocytopenia, congenital or acquired anemia, and others, regardless clonality)
Hemophagocytic lymphohistiocytosis
Primary immunodeficiencies (e.g. Wiscott Aldrich Syndrome, chronic granulomatous disease, common variable immune deficiency, X-linked lymphoproliferative disease, NK+ severe combined immune deficiencies)
Metabolic disorders (Hurler's syndrome, mannosidosis, adrenal leuko-dystrophy)
Other non-malignant disorders for which there is published evidence that HSCT (hematopoietic stem cell transplant) is a curative therapy
Donor Requirements
Related or unrelated donor who is suitable and willing to donate bone marrow or peripheral blood stem cells. HLA typing should be done by high-resolution typing at A, B, C, DrB1 and DQ loci and the donor should be at a minimum 8/10 match (with one antigen/allele mismatch allowed at A, B, or C-loci and other at DQ loci)
Cord blood units must be matched at a minimum of 6/8 antigens/alleles at A, B, C and DrB1 loci. High resolution typing at all loci is required. The minimum TNC dose pre-cryopreservation must be 3.7 x10^7/kg of recipient's weight, if a single cord blood unit is used, or at least 2x10^7/kg per unit, if two cord blood units are used. The mismatches cannot be at the same loci (e.g. double A mismatch)
Haploidentical related stem cell donor who is suitable and willing to donate peripheral blood stem cells. T-cell depletion is required if haploidentical donors are used. Pharmacologic GVHD prophylaxis will not be used for T-cell depleted transplant recipients
Adequate organ function defined as
Cardiac: ejection fraction 55% or shortening fraction 30%
creatinine clearance 70 ml/min/1.73m2
Pulse oximetry >95% on room air or FEV1/DLCO >60%
LFTs < 3 x ULN, Total bilirubin <3 mg/dl (unless due to non-hepatic cause (e.g. Gilbert's syndrome or hemolysis)
Lansky/Karnofsky score 60%
Written informed consent obtained from the subject or parental/guardian permission child's assent per institutional guidelines
Women of childbearing potential (WOCBP) must be using an adequate method of contraception to avoid pregnancy for at least 1 month after completion of conditioning. WOCBP include any woman who has experienced menarche and who has not undergone successful surgical sterilization (hysterectomy, bilateral tubal ligation, or bilateral oophorectomy) or who is not post-menopausal. Post-menopause is defined
as
Amenorrhea that has lasted for 12 consecutive months without another cause, or
For women with irregular menstrual periods who are taking hormone replacement therapy (HRT), a documented serum follicle-stimulating hormone (FSH) level of greater than 35 mIU/mL
Males with female partners of childbearing potential must agree to use physician-approved contraceptive methods (e.g., abstinence, condoms, or vasectomy) for at least one month after completion of conditioning

Exclusion Criteria

Diagnoses that do not require myeloablative transplant for cure (e.g. NK- SCID patients), unless the subject previously did not engraft with non-myeloablative or reduced intensity conditioning transplant
Known or suspected sensitivity to chemotherapy or radiation (e.g Fanconi's anemia, Dyskeratosis congenita, Ligase IV deficiency, etc)
Subjects with fast-progressing neurodegenerative disorders (e.g. Krabbe disease or adrenal leukodystrophy with Loes score of 10)
Cytopenias with increased blasts (>5%)
Presence of anti-donor HLA antibodies (positive anti-donor HLA antibody is defined as a positive cross-match test of any titer (by complement-dependent cytotoxicity or flow cytometric testing) or the presence of anti-donor HLA antibody to the high expression loci HLA-A, B, C, DRB1 with mean fluorescence intensity (MFI)>3000 by solid phase
Prior allogeneic stem cell transplant, except for patients with immune deficiencies who underwent previous non-myeloablative or reduced intensity transplants
Haploidentical donor using in vivo T-cell depletion (e.g. post-transplant cyclophosphamide)
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
Seropositive for HIV
Active Hepatitis B or C determined by a detectable viral load of HBV or HCV by PCR
Bridging fibrosis or liver cirrhosis
Females or males of childbearing potential who are unwilling or unable to use an acceptable method to avoid pregnancy for the entire study period and for at least 1 months after the end of conditioning
Females who are pregnant or breastfeeding
History of any other disease, metabolic dysfunction, physical examination finding, or clinical laboratory finding giving reasonable suspicion of a disease or condition that contraindicates the use of protocol therapy or that might affect the interpretation of the results of the study or that puts the subject at high risk for treatment complications, in the opinion of the treating physician
Subjects demonstrating an inability to understand the study and comply with the study and/or follow-up procedures
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