CD19-BCMA CART Cell Therapy for Refractory SLE-LN, SSc, and pSS-PAH

Inclusion Criteria 1. Refractory Lupus Nephritis（LN）: Patients who meet all the following requirements can be enrolled in the group.

Definition: Failure to achieve induction remission after 3 to 6 months of treatment with at least one immunosuppressive agent (including glucocorticoids, cyclophosphamide [CTX], tacrolimus, mycophenolate mofetil, and cyclosporine), accompanied by no reduction (or worsening) in proteinuria or persistent positive autoantibodies.

Diagnostic criteria : According to the 2019 American College of Rheumatology (ACR) criteria, and confirmed by renal biopsy in accordance with the 2018 International Society of Nephrology (ISN)/Renal Pathology Society (RPS) criteria (Appendix 3), were diagnosed with active, proliferative lupus nephritis (LN), including Class III or IV [excluding Class III (C), IV-S (C), and IV-G (C)], or combined Class III/IV with Class V.

1. Male or female, aged 10-65 years;

2. Meeting the 2019 American College of Rheumatology (ACR)/European League AgainstRheumatism (EULAR) Classification Criteria for Systemic Lupus Erythematosus (Appendix 4);

3. The ANA result is positive which means ANA titer≥ 1:80 (based on the equivalentdetection results by Hep-2 immunofluorescence assay or enzyme immune assay), and/oraccording to the detection results from center laboratory, during the screeningvisit,the anti dsDNA serum antibody test is positive (based on ELISA assay, ≥30IU/mL);

4. B cell CD19+ expression, and stop using immunosuppressant more than one week.

5. The lymphocyte count in the subject's blood routine >0.5×109/L, and nocontraindications for cell collection;

6. No serious allergic constitution;

7. ECOG score: 0-2:

8. Expected survival ≥90 days:

Subjects and/or their guardian can understand and sign the informed consent form.

2. SSc: Patients who meet all the following requirements can be enrolled in the group.

3. Patients or their legal representatives sign the informed consent form;

4. Male or female, aged 18-65 years.

5. According to the SSc classification criteria proposed by American College ofRheumatology (ACR)/European League Against Rheumatism (EULAR), chose the highestscore under the same condition. If the score ≥9, it can be classified SSc. (Appendix

4. Satisfy a sufficient condition: the skin on the fingers of both hands is thickenedand extend to the proximal end of metacarpophalangeal joint;

5. The lymphocyte count in the subject's blood routine >0.5×109/L, and nocontraindications for cell collection.

6. pSS-PAH: Patients who meet all the following requirements can be enrolled in the group.

7. Patients or their legal representatives sign the informed consent form;

8. Male or female, aged 18-65 years;

9. Refractory connective tissue disease (PAH)patients: a) Satisfy the 2002 AECG or 2016 ACR/2016 EULAR classification criteria, can bediagnosed as pSS (Appendix 6); b) Confirmed by Right heart catheterization, satisfythe diagnose criteria of PAH: mPAP at rest ≥20mmHg; PAWP≤15mmHg; PVR at rest>2WUs.

10. Low-risk patients whose PAH do not reach the risk stratification. The patientsshould meet: WHO cardiac function grading I-II; 6 minutes walking distance>440 m;BNP<50ng/L or NT-proBNP<300ng/L; RAP<8mmHg and CI≥2.5 L·min-1·m-2;

11. Subjects have received standard treatment in stable dose before first use of studydrug, include: Glucocorticoids (prednisone 0-30mg/day, or other equivalentpreparations) ≥4 weeks; Antimalarial drugs, single-agent immunosuppressants (MMF≤1.5g/day, AZP or 6-MP≤2mg/kg/day, MTX≤15mg/week, Leflunomide ≤ 20mg/day) ≥12weeks, and do not add or change in 24 weeks after drug treatment; Use PAH targetdrugs <3 before drug treatment(PGAs, ETRA,PDE-5 inhibiter, GCCA), and stable atleast 4 weeks, and do not add or change in 24 weeks after drug treatment;

12. After clinician evaluate the disease condition of patients, they will allow usingglucocorticoids no more than 10mg or other equivalent dose and stop allimmunosuppressants (exclued hydroxychloroquine);

13. Reproductive-aged female patients with negative blood human chorionic gonadotropin (HCG) test within 7 days before trial pre-conduct treatment; Any child-bearing maleand female patients must agree to take effective contraceptive method during theprocess of study and within at least 1 year after cell infusion. Child-bearingpatients refer that he or she has the biological ability to born alive baby and havenormal sex life. Female patients without the ability of born: hysterectomy orovariectomy, or medically confirmed ovarian failure, or medically confirmedpostmenopausal (without pathological or biological reason, amenorrhea last for atleast 12 months);

14. Have appropriate organ function, the criteria are as follows: a) AST≤3 times upper limit of normal (ULN); b) ALT ≤3 times ULN; c) T-Bil ≤2 timesULN, unless the patient has a record of Gilbert syndrome; Patients with Gilbertsyndrome can be enrolled satisfied the condition of Bil≤3 times ULN and DBIl ≤1.5times ULN; d) Must have the lowest level of lung reserve, oxygen saturation undernon-oxygen inhalation state >95%; e) The lymphocyte count in the subject's bloodroutine >0.5×109/L, and no contraindications for cell collection.

4.AID Definition: Based on the reliable laboratory test, it is confirmed that one or more definite disease-related antibodies in serum are positive, laboratory results and clinical symptoms have reasonable association. Including systemic lupus erythematosus, sjogren's syndrome, systemic sclerosis, rheumatoid arthritis, connective tissue diseases, overlap syndrome, etc. At the same time exclude other etiology may cause similar symptoms and signs, infections, malignant tumors, metabolic diseases, primary organ failure, etc.

1. Male or female, aged 10-65 years; Patients who do not meet the inclusive criteria ofthree groups above, meet any one below can be enrolled.

2. ANA titer<1:80 (based on the equivalent detection results by Hep-2immunofluorescence assay or enzyme immune assay), and/or during the screening visit,by the detection results from center laboratory, anti dsDNA serum antibody test isnegative (based on ELISA assay, <30 IU/mL);

3. In conventional therapy, occur recurrent infections, leading to intolerance ofconventional therapy, but no active infection, serious infection(tuberculosis)currently;

4. Patients who cannot use drugs anymore, because of bone infarction, osteonecrosis,severe bone pain caused by long term use of drugs.

5. Patients who cannot use drugs anymore, because of vision changes, retinopathy,fundus hemorrhage caused by long term use of drugs.

6. Patients who cannot use drugs anymore, because of endocrine-related changes (premature closure of the femoral shaft, severe obesity, diabetes, impact on growthand development, etc.) caused by long term use of drugs.

7. Severe toxicity of blood system (≥grade3;neutrophil<110^9/L,platelet<5010^9/L,hemoglobin<80g/L);

8. Abnormal liver function (ALT ≥3 times ULN; ALT≥3 times ULN; T-Bil ≥2 times ULN);

9. After 3 months of regular treatment, there are still have disease progression (eg.urine protein index increased by 3 times);

10. Previously received CAR-T therapies, there are still have disease progression.

Exclusion criteria:

An individual who meets any of the following criteria will be excluded from participation in this study:

1. Refractory Lupus Nephritis (LN):

2. Intracranial hypertension or disorder of consciousness;

3. Symptomatic heart failure or severe arrhythmia;

4. Symptoms of severe respiratory failure;

5. Complicated with other types of malignant tumors;

6. Diffuse intravascular coagulation;

7. Suffering from septicemia or other uncontrollable infections;

8. Patients with uncontrollable diabetes and other endocrine diseases;

9. Severe mental disorders;

10. Obvious and active intracranial lesions were detected by cranial magnetic resonanceimaging (MRI);

11. Have received organ transplantation (excluding bone marrow transplant);

12. Reproductive-aged female patients with positive blood human chorionic gonadotropin (HCG) test;

13. Positive screening for hepatitis (HBV and HCV included), HIV and syphilis;

14. The subject is unable to undergo PBMC collection, nor are there cryopreserved PBMCsavailable for CAR-T cell manufacturing;

15. eGFR CKD-EPI < 30 ml/min/1.73m^2;

16. Any active skin disease that may interfere with the assessment of systemic lupuserythematosus (SLE) research, including but not limited to psoriasis,dermatomyositis, systemic sclerosis, non-SLE cutaneous manifestations (e.g.,cutaneous vasculopathy, perivascular telangiectasia, sclerodactyly, rheumatoidnodules, erythema multiforme, leg ulcers), or drug-induced lupus;

17. Previously received other CAR-T therapies except CD19-CART.

2.SSc

1. Other connective tissue disease: Rheumatoid Arthritis, System Lupus or InflammatoryMyopathies;

2. Clinical manifestations can be explained by disease similar to SSc: hand jointlesions related to nephrogenic systemic fibrosis, generalized morphea, eosinophilicfasciitis, diabetic scleredema, scleromyxedema, erythromelalgia, porphyria, lichensclerosus, graft-versus-host disease, diabetes mellitus, and other endocrine andmetabolic diseases;

3. Patients who have severe active central nervous system (CNS) lupus, includingepileptic seizures, pyschosis, cerebrovascular accident or CNS vasculitis requiringtreatment intervention within 60 days after baseline;

4. Dialysis patients or Ccr <30ml/min;

5. Pregnant or suckling period;

6. Combined with active infection (eg. septicemia, bacteremia, fungemia, uncontrolledpulmonary infection, and active tuberculosis);

7. Detection positive: HBsAg, HbeAg; HBe-Ab, HBc-Ab (the copy number of HBV-DNA isgreater than the measurable low limit); HCV-Ab, HIV-Ab, TP-Ab;

8. Patients have undergone big surgeries which evaluated by investigators as unsuitablefor enrollment within 4 weeks before screening;

9. Previously received other CAR-T therapies except CD19-CART.

3.pSS-PAH

1. PH caused by other reasons: Portal hypertension, hereditary hemorrhagictelangiectasia, etc.; congenital heart disease; suspected drugs and toxicants;pulmonary hypertension related to chronic hypoxic diseases: moderate or severeobstructive pulmonary disease: FEV1 < 55%; moderate or severe restrictive pulmonarydisease: TLC < 60%; pulmonary hypertension due to chronic thromboembolic disease:pulmonary ventilation/perfusion imaging suggests moderate or high suspicion ofpulmonary thromboembolism;

2. Patients who have severe active central nervous system (CNS) lupus, includingepileptic seizures, pyschosis, cerebrovascular accident or CNS vasculitis requiringtreatment intervention within 60 days after baseline;

3. Dialysis patients or Ccr <30ml/min;

4. Pregnant or suckling period;

5. Combined with active infection (eg. septicemia, bacteremia, fungemia, uncontrolledpulmonary infection, and active tuberculosis).

6. Detection positive: HBsAg, HbeAg; HBe-Ab, HBc-Ab (the copy number of HBV-DNA isgreater than the measurable low limit); HCV-Ab, HIV-Ab, TP-Ab;

7. Patients have undergone big surgeries which evaluated by investigators as unsuitablefor enrollment within 4 weeks before screening;

8. Previously received other CAR-T therapies except CD19-CART.

6. Detection positive: HBsAg, HbeAg; HBe-Ab, HBc-Ab (the copy number of HBV-DNA is greater than the measurable low limit); HCV-Ab, HIV-Ab, TP-Ab; 7) Patients have undergone big surgeries which evaluated by investigators as unsuitable for enrollment within 4 weeks before screening; 8) Previously received other CAR-T therapies except CD19-CART. 4. AID

1. Intracranial hypertension or disorder of consciousness;

2. Symptomatic heart failure or severe arrhythmia;

3. Symptoms of severe respiratory failure;

4. Complicated with other types of malignant tumors;

5. Diffuse intravascular coagulation;

6. Suffering from septicemia or other uncontrollable infections;

7. Patients with uncontrollable diabetes and other endocrine diseases;

8. Severe mental disorders;

9. Obvious and active intracranial lesions were detected by cranial magnetic resonanceimaging (MRI);

10. Have received organ transplantation (excluding bone marrow transplant);

11. Reproductive-aged female patients with positive blood human chorionic gonadotropin (HCG) test;

12. Positive screening for hepatitis (HBV and HCV included), HIV and syphilis;

13. The subject is unable to undergo PBMC collection, nor are there cryopreserved PBMCsavailable for CAR-T cell manufacturing;

14. eGFR CKD-EPI < 30 ml/min/1.73m^2.