Donor Stem Cell Transplantation for Congenital Immunodeficiencies
Summary
This study uses transplantation to treat patients with problems in their immune system. The immune system cells come from the bone marrow where they grow from special cells called stem cells. Giving patients stem cells from someone else may help to cure many patients with certain immune diseases. This is called 'bone marrow transplantation'. This procedure can have side effects that are life-threatening. To try to make transplantation safer we are using lower doses of the medications used in preparing the patient for the transplant.
'Conditioning' treatments are given to patients to create space in their bone marrow. This lets the cells of the donor go into the bone marrow and produce normal immune cells. This study will use lower doses of a drug called busulfan and lower doses of radiation than what are currently being used in other kinds of bone marrow transplantation for other diseases.
Another problem that can occur with bone marrow transplantation is 'graft-versus-host disease'. This happens when the cells of the donor attacks different parts of the patient's body. This study will use a medicine called sirolimus instead of the usual medicine, cyclosporine, to prevent graft-versus-host disease.
To go onto this study, you must have:
1. A severe immune deficiency, such as chronic granulomatous disease or leukocyte adhesion deficiency.
2. Have problems from the disease that call for stem cell transplantation.
3. You must also be between the ages of 3 and 65 years.
Two groups of patients are included in this study:
1. Patients who have a brother or sister that have stem cells that match the patient. This is known as an allogeneic matched sibling transplant.
2. Patients who do not have a matched sibling donor but have a donor that matches in the National Marrow Donor Program. This is know as matched unrelated donor transplantation.
Patients will have the following procedures:
- To create space in the bone marrow, patients are given two drugs, Campath-1H and busulfan. To prevent the body from getting rid of the donated cells, patients are given sirolimus. On the day before the BMT, patients in the matched unrelated donor group also receive a low-dose of whole-body radiation. This will further improve the chances that the patients body will accept the donor cells.
- Patients will get the donor stem cells through an intravenous (IV) line that goes into a vein in their body. The cells make the...
Description
Congenital immunodeficiencies - including chronic granulomatous disease, leukocyte adhesion deficiency and others - comprise a group of disorders in which the immune system fails to develop normally due to a genetic defect. As a result, affected patients suffer from recurrent infections and have a significantly shortened life expectancy. The current management of these patients is limited to close surveillance for infections, administration of prophylactic antimicrobials, and rapid and aggressive treatment of suspected and documented infections with broad-spectrum antibiotics. Although often effective, these treatments can require long hospitalizations, impacting on the overall quality of life significantly, and lead to significant morbidity, such as renal failure and deafness.
Currently, the only available cure for these disorders is bone marrow transplantation, which most commonly uses an HLA-matched related sibling as the donor (Allogeneic Stem Cell Transplantation). However, as only 30% of patients in the general population have an HLA- matched related sibling, allogeneic related transplantation is often not an option, resulting in the need for matched unrelated donor transplantation. The National Marrow Donor Program serves as both a national registry of volunteers who are willing to donate progenitor cells to eligible recipients as well as a repository of cord blood products. Despite continued improvement in the use of transplantation schemas - including the development of nonmyeloablative regimens - there remain significant morbidity and mortality associated with transplantation, in particular, graft versus host disease (GvHD).
GvHD is a result of the graft recognizing host antigens as foreign, typically in the presence of inflammation, and results in a type of iatrogenic autoimmune disease. For patients with non-malignant diseases, the aim of the transplant is solely to replace the defective or deficient cell population. Furthermore, as a graft versus tumor effect is not required, regimens designed to establish tolerance induction and/or stable mixed chimerism may be preferable for cure in this patient population; therefore, alternate transplant strategies can and should be used to further suppress the development of any GvHD effects. To reduce the morbidity and mortality associated with transplantation, we propose to use a combination of uniquely designed conditioning regimens to achieve adequate engraftment in congenitally immunodeficient patients, using either alloPBSC transplantation for patients with an HLA-matched related sibling donor, or MUD transplantation for those without an appropriate HLA-matched related sibling donor. For the alloPBSC transplantation (Group 1), we propose using a novel busulfan-based, nonmyeloablative conditioning regimen combined with Campath-1-H or h-ATG, an immunosuppressive monoclonal antibody, and sirolimus, a tolerance inducing immunosuppressant used for GvHD prophylaxis. For the MUD transplantation (Group 2), we will also use a similar conditioning regimen, with a few modifications (due to the increased risk of graft rejection with HLA-matched but unrelated cells) to perform matched unrelated and cord blood transplantation in patients with immunodeficiencies. Given its novelty, this combination will be tested in a pilot trial and will be compared to historical controls.
Study Design
Allocation: Non-Randomized, Control: Uncontrolled, Endpoint Classification: Pharmacokinetics Study, Intervention Model: Parallel Assignment, Masking: Open Label, Primary Purpose: Treatment
Conditions
MUD Transplant
Intervention
Busulfan, Campath-1 H, Sirolimus, BMT, Apheresis, Total Body Irradiation, GCSF Injections
Location
National Institutes of Health Clinical Center, 9000 Rockville Pike
Bethesda
Maryland
United States
20892
Status
Recruiting
Source
National Institutes of Health Clinical Center (CC)
Results (where available)
Links
- Source: http://clinicaltrials.gov/show/NCT00426517
- Information obtained from ClinicalTrials.gov on July 15, 2010
Medical and Biotech [MESH] Definitions
Hemibody Irradiation
Irradiation of one half or both halves of the body in the treatment of disseminated cancer or widespread metastases. It is used to treat diffuse metastases in one session as opposed to multiple fields over an extended period. The more frequent treatment modalities are upper hemibody irradiation (UHBI) or lower hemibody irradiation (LHBI). Less common is mid-body irradiation (MBI). In the treatment of both halves of the body sequentially, hemibody irradiation permits radiotherapy of the whole body with larger doses of radiation than could be accomplished with WHOLE-BODY IRRADIATION. It is sometimes called "systemic" hemibody irradiation with reference to its use in widespread cancer or metastases. (P. Rubin et al. Cancer, Vol 55, p2210, 1985)
Whole-body Irradiation
Irradiation of the whole body with ionizing or non-ionizing radiation. It is applicable to humans or animals but not to microorganisms.
Busulfan
An alkylating agent having a selective immunosuppressive effect on BONE MARROW. It has been used in the palliative treatment of chronic myeloid leukemia (MYELOID LEUKEMIA, CHRONIC), but although symptomatic relief is provided, no permanent remission is brought about. According to the Fourth Annual Report on Carcinogens (NTP 85-002, 1985), busulfan is listed as a known carcinogen.
Sirolimus
A macrolide compound obtained from Streptomyces hygroscopicus that acts by selectively blocking the transcriptional activation of cytokines thereby inhibiting cytokine production. It is bioactive only when bound to IMMUNOPHILINS. Sirolimus is a potent immunosuppressant and possesses both antifungal and antineoplastic properties.
Body Burden
The total amount of a chemical, metal or radioactive substance present at any time after absorption in the body of man or animal.
Clinical Trials
Stem Cell Transplant for Hemoglobinopathy
This study tests the clinical outcomes of one of two preparative regimens (determined by available donor source) in patients with non-malignant hemoglobinopathies. The researchers hypothe...
The purpose of this study is to evaluate the OS, RFS, and TRM after HCT with low-dose total body irradiation, fludarabine, and busulfan conditioning.
Allogeneic Transplantation for Pediatric Leukemias With Unrelated Donors
The study proposes the use of Fludarabine, Busulfan, Anti Thymocyte Globulin Rabbit (ATG) and Total Body Irradiation as a preparative regimen before hematopoietic stem cell transplant from...
RATIONALE: Peripheral stem cell transplantation may be able to replace immune cells that were destroyed by chemotherapy or radiation therapy used to kill tumor cells. It is not yet known i...
Campath-1H/Tacrolimus/Sirolimus Withdrawal in Renal Transplantation
To investigate the safety and efficacy of a treatment regimen consisting of induction therapy with Campath-1H and tacrolimus, followed by sirolimus monotherapy in renal transplant patients...
PubMed Articles
BACKGROUND: Busulfan treatment as a chemotherapeutic agent has been considered an alternative approach in xenograft model because it offers a simple, convenient, effective, and less toxic conditioning...
Abstract Conditioning regimes used during stem cell transplantation provide prolonged control or cure of the disease in patients with acute lymphoblastic leukemia (ALL). In this study, we presented a...
Certain patients who receive granulocyte colony-stimulating factor (GCSF) for autologous hematopoietic stem cell (AHSC) collection fail to mobilize well enough to proceed with transplant. When plerixa...
BACKGROUND: Kidney transplantation is the best treatment for patients with end-stage renal failure, but uncertainty remains about the best immunosuppression strategy. Long-term graft survival has not...
We conducted a phase I trial to determine the maximum tolerated dose (MTD) of clofarabine with high-dose busulfan followed by allogeneic stem cell transplantation (SCT) in patients with high-risk and...
