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Acute GVHD Suppression Using Costimulation Blockade to Expand Non-malignant Transplant

  • Clinicaltrials.gov identifier

    NCT03924401

  • Recruitment Status

    Recruiting

  • First Posted

    April 23, 2019

  • Last update posted

    June 22, 2020

Study Description

Brief summary:

The ASCENT Trial is a single arm, multi-center, phase II study. The primary objective is to determine the rejection-free, severe graft-versus-host disease (GVHD)-free survival in pediatric patients with serious non-malignant hematologic diseases (NMHD) undergoing mismatched unrelated donor (URD) hematopoietic stem cell transplantation (HSCT) with abatacept added to conventional GVHD prophylaxis. The secondary objective is to characterize the impact of abatacept on infection and the reconstitution of protective immunity to infection. Transplanted patients will be followed for 3 years. Weight-based peripheral blood samples will be drawn longitudinally through two years to evaluate immune reconstitution. The study will enroll 28 pediatric patients with serious NMHD undergoing mismatched URD HSCT. The trial will include two strata, based on donor matching. Stratum 1 (n=14) will be for patients with 7/8 donors and stratum 2 (n=14) will be for those with 8/8 (matched) donors. All participants will receive 8 doses of abatacept (10 mg/kg intravenously on days -1, +5, +14, +28, +56, +84, +112, and +150). Recruitment is expected to last for about 2 years and participants will be followed for up to 3 years. This trial will test the hypothesis that extended abatacept administration (combined with a standard regimen of tacrolimus and mycophenolate mofetil) will effectively prevent acute and chronic GVHD in children and adolescents receiving mismatched URD HSCT, without compromising their engraftment or reconstitution of protective immunity to infection.

  • Condition or Disease:Graft Versus Host Disease
  • Intervention/Treatment: Drug: Abatacept
  • Phase: Phase 2

Detailed Description

Many serious NMHD affecting children, including SAA, FA, sickle cell disease (SCD), and thalassemia can be cured by allogeneic HSCT. While the best results are achieved with HSCT from human leukocyte antigen (HLA)-matched siblings, most children lack such donors, and many children with NMHD are therefore transplanted with grafts from adult URD. Because URD grafts are less histocompatible, they are more likely to cause GVHD, a process driven by the reaction of donor T cells against incompatible host tissues. Despite the routine administration of immune suppression for GVHD prophylaxis, GVHD claims the lives of many and plagues others with incapacitating chronic illness. For NMHD, the threat of GVHD limits the use of URD HSCT to only the most severely affected children. In African-Americans and other ethnic minorities, the situation is compounded by the fact that most of these children lack fully matched URD and typically receive mismatched grafts, which carry an increased risk for graft rejection. A more effective form of GVHD prophylaxis that does not compromise engraftment is urgently needed, both to improve outcomes for those children undergoing HSCT as well as to allow expansion of this curative therapy to the many children with NMHD who forego transplantation because of the risk for GVHD. The researchers have investigated the use of the co-stimulation blocking agent CTLA4-Ig (abatacept) to prevent GVHD. Study results to date indicate that abatacept strongly inhibits allo-reactive donor T cells and is clinically safe and effective. The clinical experience has included a variety of recipients: children and adults, peripheral blood stem cells (PBSC) and bone marrow (BM) grafts, as well as mismatched and matched unrelated and matched related donors; all have involved the administration of four IV doses of abatacept, on days -1, +5, +14, and +28, in combination with standard calcineurin inhibitor-based GVHD prophylaxis. Collectively, the results to date suggest that this combination, including abatacept, very effectively prevents acute GVHD. However, these results also suggest that protection against chronic GVHD is more limited. In this current trial, the researchers will attempt to more effectively prevent chronic GVHD by extending the administration of abatacept, giving eight doses (additional doses days +56, +84, +112, and +150). This trial will test the hypothesis that extended abatacept administration (combined with a standard regimen of tacrolimus and mycophenolate mofetil) will effectively prevent acute and chronic GVHD in children and adolescents receiving mismatched URD HSCT, without compromising their engraftment or reconstitution of protective immunity to infection. The study will enroll 28 pediatric patients with serious NMHD undergoing mismatched URD HSCT. The trial will include two strata, based on donor matching. Stratum 1 (n=14) will be for patients with 7/8 donors and stratum 2 (n=14) will be for those with 8/8 (matched) donors. Study participants will be admitted to the hospital ten or eleven days prior to the day of transplant (day -10 or day -11) to complete a conditioning regimen to prevent the donor cells from being rejected. Patients will receive one of three reduced toxicity or intensity conditioning regimens based upon underlying disease and/or physician preference: (1) anti-thymocyte globulin, fludarabine, and a low dose of cyclophosphamide (FA patients only); (2) anti-thymocyte globulin, fludarabine, cyclophosphamide, and a low dose of total body radiation (SAA and other bone marrow failure disorders); or (3) alemtuzumab, fludarabine, melphalan, and thiotepa (hemoglobinopathy and non-SAA bone marrow failure disorders). All participants will receive 8 doses of abatacept (10 mg/kg intravenously on days -1, +5, +14, +28, +56, +84, +112, and +150). Recruitment is expected to last for about 2 years and participants will be followed for up to 3 years.

Study Design

  • Study Type: Interventional
  • Estimated Enrollment: 28 participants
  • Intervention Model: Single Group Assignment
  • Intervention Model Description: The trial will include two strata: one for patients with a 7/8 matched donor (n=14) and one for those with a matched 8/8 donor (n=14).
  • Masking: None (Open Label) ()
  • Primary Purpose: Prevention
  • Official Title: Acute GVHD Suppression Using Costimulation Blockade to Expand Non-malignant Transplant (ASCENT)
  • Actual Study Start Date: August 2019
  • Estimated Primary Completion Date: December 2023
  • Estimated Study Completion Date: December 2023

Arms and interventions

Arm Intervention/treatment
Experimental: Participants Receiving Abatacept
Pediatric participants who are undergoing 7/8 URD HSCT for serious NMHD will receive 8 doses of abatacept in addition to conventional GVHD prophylaxis.
Drug: Abatacept
All patients will receive 8 doses of abatacept (10 mg/kg intravenously on days -1, +5, +14, +28, +56, +84, +112, and +150) in addition to conventional GVHD prophylaxis.

Outcome Measures

  • Primary Outcome Measures: 1. Event-free survival [ Time Frame: Up to 3 years ]
    Event-free survival is a composite endpoint defined as rejection-free, severe GVHD-free survival. Events for this outcome include death, severe (grade II-IV) acute GVHD up to day 100, moderate to severe chronic GVHD up to 1 year, and/or graft rejection up to 1 year.
  • Secondary Outcome Measures: 1. Cytomegalovirus (CMV) Viremia [ Time Frame: Up to Day 180 ]
    The number of participants experiencing cytomegalovirus (CMV) viremia will be reported. CMV viremia will be defined as the occurrence of a positive polymerase chain reaction (PCR) test prior to Day 180.
  • 2. CMV Invasive Disease [ Time Frame: Up to 2 years ]
    The number of participants experiencing CMV invasive disease will be reported. CMV invasive disease will be defined in accordance with the Blood and Marrow Transplant Clinical Trials Network Manual of Procedures.
  • 3. Post-transplant lymphoproliferative disease (PTLD) [ Time Frame: Up to 2 years ]
    The number of participants experiencing post-transplant lymphoproliferative disease (PTLD) will be reported. PTLD will be defined in accordance with the World Health Organization's (WHO) Classification of Tumours of Haematopoietic and Lymphoid Tissues.
  • 4. Regimen-Related Toxicity [ Time Frame: Day 42 Post-transplant ]
    The number of participants experiencing regimen-related toxicity (RRT) will be reported. RRT will be scored according to the Bearman scale. Major RRT, defined as grade 4 (causing death) in any organ system or grade 3 for pulmonary, cardiac, renal, oral mucosal, neurologic, or hepatic, will be recorded.
  • 5. Neutrophil Recovery [ Time Frame: Up to Day 60 ]
    The time to neutrophil recover, in days, will be reported. Neutrophil recovery will be defined as the first of 3 consecutive days following the nadir that the absolute neutrophil count is at least 500/microliter of blood.
  • 6. Platelet Recovery [ Time Frame: Up to Day 60 ]
    The time to platelet recover, in days, will be reported. Platelet recovery will be defined as the first day that the platelet count is at least 50,000/microliter of blood, without a transfusion in the preceding 7 days.
  • 7. Non-Engraftment [ Time Frame: Day 28 ]
    The number of participants experiencing non-engraftment will be reported. Non-engraftment will be defined as lack of neutrophil recovery, or neutrophil recovery with lack of myeloid donor chimerism.
  • 8. Secondary Graft Failure [ Time Frame: Up to 3 years ]
    The number of participants experiencing secondary graft failure will be reported. Secondary graft failure will be defined by initial engraftment but subsequent development of an absolute neutrophil count (ANC) < 500/μl for fourteen consecutive days.
  • 9. Graft Loss [ Time Frame: Up to 3 years ]
    The number of participants experiencing graft loss will be reported. Graft loss will be defined by initial engraftment (assessed by neutrophil recovery and donor chimerism) with the subsequent loss of donor myeloid chimerism (regardless whether persistent neutropenia develops).
  • 10. Acute GVHD [ Time Frame: Up to 1 year ]
    The number of participants experiencing acute GVHD (including all grades and stratified by grades) will be reported. Acute GVHD will be assessed according to the Blood and Marrow Transplant Clinical Trials Network Manual of Procedures.
  • 11. Chronic GVHD [ Time Frame: Up to 2 years ]
    The number of participants experiencing chronic GVHD (including overlap syndrome) will be reported. Chronic GVHD will be assessed according to the Blood and Marrow Transplant Clinical Trials Network Manual of Procedures.
  • 12. Immune Suppression-Free Survival [ Time Frame: Year 2 ]
    The number of participants experiencing immune suppression-free survival will be reported. Immune suppression-free survival is measured as participant survival while off all systemic immunosuppressive agents.
  • 13. Immune Suppression-Free/Disease-Free Survival [ Time Frame: Year 2 ]
    The number of participants experiencing immune suppression-free/disease-free survival will be reported. Immune suppression-free/disease-free survival will be defined as rejection-free survival off all systemic immunosuppressive agents.
  • 14. Rejection-free survival [ Time Frame: Up to 3 years ]
    The number of participants experiencing rejection-free survival will be reported. Rejection-free survival will be defined as survival without non-engraftment, secondary graft failure, or graft loss.
  • 15. Overall survival [ Time Frame: Up to 3 years ]
    The number of participants experiencing surviving at the end of the study follow up period will be reported.

Eligibility Criteria

  • Ages Eligible for Study: up to 20 / (18 to 64 years)
  • Sexes Eligible for Study: All
  • Accepts Healthy Volunteers: No

Criteria

Inclusion Criteria:

- Patients with sickle cell disease (stratum 1) must be between the ages of 3-20.99
years and patients with other diseases (stratum 2) between the ages of 0-20.99 years
at the time of admission for transplant.

- Must have one of the following diseases:

- Glanzmann thrombasthenia

- Chronic granulomatous disease

- Severe congenital neutropenia (with resistance to granulocyte colony-stimulating
factor (GCSF) or chronic requirement of GCSF doses ≥10 mcg/kg)

- Leukocyte adhesion deficiency

- Shwachman-Diamond syndrome

- Diamond-Blackfan Anemia (DBA; transfusion dependent, including steroid failure or
inability to wean steroids)

- Thalassemia major

- FA

- Dyskeratosis congenita

- Chediak Higashi syndrome

- Acquired (immune; non-inherited, non-congenital) SAA

- SCD (Hgb SS or S beta 0 thalassemia) with severe disease, defined as one or more
of the following criteria:

- Previous clinical stroke, as evidenced by a neurological deficit lasting
longer than 24 hours, which is accompanied by radiographic evidence of
ischemic brain injury and cerebral vasculopathy.

- Asymptomatic cerebrovascular disease, as evidenced by one the following:

- Progressive silent cerebral infarction, as evidenced by serial MRI
scans that demonstrate the development of a succession of lesions (at
least two temporally discreet lesions, each measuring at least 3 mm in
greatest dimension on the most recent scan) or the enlargement of a
single lesion, initially measuring at least 3 mm. Lesions must be
visible on T2-weighted MRI sequences.

- Cerebral arteriopathy, as evidenced by abnormal TCD testing (confirmed
elevated velocities in any single vessel of time-averaged mean of the
maximum velocity (TAMMV) > 200 cm/sec for non-imaging TCD) or by
significant vasculopathy on magnetic resonance angiograph (MRA; greater
than 50% stenosis of > 2 arterial segments or complete occlusion of any
single arterial segment).

- Frequent (3 or more per year for preceding 2 years) painful vaso-occlusive
episodes (defined as episode lasting 4 hours or more and requiring
hospitalization or outpatient treatment with parenteral opioids). If patient
is on hydroxyurea and its use has been associated with a decrease in the
frequency of episodes, the frequency should be gauged from the 2 years prior
to the start of this drug.

- Recurrent (3 or more in lifetime) acute chest syndrome events which have
necessitated erythrocyte transfusion therapy.

- Any combination of 3 or more acute chest syndrome episodes and
vaso-occlusive pain episodes (defined as above) yearly for 3 years. If
patient is on hydroxurea and its use has been associated with a decrease in
the frequency of episodes, the frequency should be gauged from the 3 years
prior to the start of this drug.

- Other inherited or congenital marrow failure syndromes complicated by SAA

- Other inherited or congenital red blood cell disorders requiring monthly chronic
transfusion therapy.

- Congenital platelet disorders requiring frequent platelet transfusions (patient
must have received at least 10 transfusions in the last 3 years).

- Other inherited or congenital granulocyte disorders resulting in at least three
inpatient hospitalizations in the past three years for infection.

- Must have an unrelated adult donor (marrow or PBSC) who is a 7 or 8/8 match

- All patients and/or their parents or legal guardians must sign a written informed
consent. Assent, when appropriate, will be obtained according to institutional
guidelines.

- Must have been evaluated and adequately counseled regarding treatment options by a
pediatric hematologist.

- Negative serum pregnancy test for females of childbearing potential only. Pregnancy
must be excluded before the start of treatment with study drugs and prevented
thereafter by reliable contraceptive methods.

Exclusion Criteria:

- HLA matched related donor

- Pulmonary dysfunction defined as diffusing capacity of the lungs for carbon monoxide
(DLCO; corrected for hemoglobin), forced expiratory volume in one second (FEV1), or
forced vital capacity (FVC) < 40% of predicted. In a child unable to perform pulmonary function testing, a chronic need for supplemental oxygen will serve as the exclusionary criterion. - Renal dysfunction defined as estimated glomerular filtration rate (GFR) of <60 ml/min/1.73m2. - Severe cardiac dysfunction defined as shortening fraction < 25%. - Bridging (portal to portal) fibrosis or cirrhosis of the liver - Clinical stroke within 6 months of anticipated transplant - Karnofsky or Lansky functional performance score < 50% - HIV infection - Uncontrolled viral, bacterial, fungal, or protozoal infection at the time of study enrollment. - Patient with unspecified chronic toxicity serious enough to detrimentally affect the patient's capacity to tolerate HSCT. - Patient or patient's guardian(s) unable to understand the nature and risks inherent in the HSCT process. - History of non-compliance severe enough in the estimation of the treating team to preclude the patient from undergoing unrelated donor transplantation. - Patient is pregnant or lactating. - Patient with a 7/8 URD donor and HLA antibody testing (see below) demonstrating an antibody directed against a donor disparate HLA molecule.

Contacts and Locations

Contacts

Contact: Ben Watkins, MD 404-785-1272 benjamin.watkins@emory.edu

Contact: Elizabeth Stenger, MD, MSc stengereo@upmc.edu

Locations

United States, Alabama
Children's of Alabama
Birmingham

United States, Delaware
Nemours/Alfred I. DuPont Hospital for Children
Wilmington

United States, Georgia
Childrens Healthcare of Atlanta
Atlanta

United States, Illinois
Ann & Robert H. Lurie Children's Hospital of Chicago
Chicago

United States, Massachusetts
Dana-Farber Cancer Institute
Boston

United States, New Jersey
Hackensack Meridian Health
Hackensack

United States, New York
Oishei Children's Hospital
Buffalo

Sponsors and Collaborators

Emory University

Thrasher Research Fund

Sickle Cell Transplant Advocacy & Research Alliance (STAR)

Aflac Cancer and Blood Disorders Center

Bristol-Myers Squibb

Investigators

Principal Investigator: John Horan, MD Emory University

More Information

  • Responsible Party: Emory University
  • ClinicalTrials.gov Identifier: NCT03924401 History of Changes
  • Other Study ID Numbers: IRB00108549
  • First Posted: April 23, 2019 Key Record Dates
  • Last Update Posted: June 22, 2020
  • Last Verified: June 2020
  • Individual Participant
    Data (IPD) Sharing
    Statement:

  • Plan to Share IPD: No
  • Studies a U.S. FDA-regulated Drug Product: Yes
  • Studies a U.S. FDA-regulated Device Product: No
  • Keywords provided by Emory University: Thalassemia
    Hematopoietic stem cell transplantation
    Non-malignant hematologic diseases
    Sickle cell disease
    Mismatched unrelated donor
    Pediatrics
    Severe aplastic anemia
    Fanconi anemia
  • Additional relevant MeSH terms: Graft vs Host Disease