This research study is for liver transplant recipients and their respective living donors. The purpose of this study is: 1. To see if it is safe for liver recipients to receive one dose of donor reactive T regulatory cells (Tregs) 2. To see if the Tregs allows a liver recipient to take less, or completely stop medications normally taken after receiving an organ transplant.
Doctors give drugs called immunosuppressants (IS) to people who receive a liver transplant. IS must be taken every day to prevent the body from injuring the transplanted liver by a process called rejection. Liver transplant recipients usually have to take these drugs for the rest of their lives. These drugs have harmful side effects. Researchers are looking for ways to keep a transplanted liver working normally with as little IS medications as possible. Finding a way to lower and then stop these medications will allow the liver recipient to avoid unwanted side effects. Another area of research looks at how blood cells work to reject or accept an organ transplant. Studies show that some of the recipient's own cells, called T regulatory cells (Tregs), may play a part in accepting the transplanted liver and preventing rejection. A recipient's Tregs can be grown in the laboratory to increase their number. Exposing the recipient's Tregs to the liver donor's cells will stimulate the Tregs that recognize the liver donor to grow vigorously. Giving these "donor reactive" Tregs back to the transplant recipient through a vein (intravenously) might allow a liver transplant recipient to take lower doses of IS, or perhaps to stop them altogether, without rejecting the liver. The study team will collect information about the Treg infusion, liver tests and drug doses during IS withdrawal, and any problems that may arise in the study. Blood, liver tissue, and buccal (cheek) cells will be collected for research tests.
Study Type
INTERVENTIONAL
Allocation
NA
Purpose
TREATMENT
Masking
NONE
Enrollment
A single intravenous infusion as described administered over a 20-30 minute interval with close monitoring prior to, during, and after the infusion.
Pre-medication for darTregs infusion. A dose of 15 mg/kg will be administered 30 to 60 minutes prior to the darTregs infusion.
Pre-medication for darTregs infusion. A dose of 1-2 mg/kg diphenhydramine will be administered 30 to 60 minutes prior to the darTregs infusion.
University of California at San Francisco
San Francisco, California, United States
Northwestern University Comprehensive Transplant Ctr
Chicago, Illinois, United States
Mayo Clinic in Rochester
Rochester, Minnesota, United States
Number of Participants Who Experienced Grade 3 or Higher Adverse Events (AEs) Deemed Attributable to darTreg Infusion
The National Cancer Institute - Common Terminology Criteria for Adverse Events (CTCAE) version 4.0 was used to grade the severity of all AEs. A participant was considered to have met this endpoint if they experienced at least one CTCAE Grade 3 or higher AE deemed attributable (i.e., considered at least possibly related) to darTreg infusion (infusion reaction, cytokine release syndrome).
Time frame: From initiation of immunosuppression withdrawal to 24 weeks after darTregs infusion
Number of Participants With Study Defined Grade 3 or Higher Infections
The following grading system was applied to AEs of infection: * Grade 1: asymptomatic; clinical or diagnostic observation only; intervention with oral antibiotic, antifungal, or antiviral agent only; no invasive intervention required * Grade 2: symptomatic; intervention with intravenous antibiotic, antifungal, or antiviral agent; invasive intervention may be required * Grade 3: any infection associated with hemodynamic compromise requiring pressors; any infection necessitating intensive care unit level of care; any infection necessitating operative intervention; any infection involving the central nervous system; any infection with a positive fungal blood culture; any proven or probable aspergillus infection; any tissue invasive fungal infection; any pneumocystis jiroveci infection * Grade 4: life-threatening infection * Grade 5: death resulting from infection A participant was considered to have met this endpoint if they experienced at least one Grade 3 or higher infection.
Time frame: From initiation of immunosuppression withdrawal to 24 weeks after darTregs infusion
Number of Participants With Any Malignancy
Number of participants with any malignancy, including Post -Transplant Lymphoproliferative Disorder (PTLD). PTLD is a specific type of malignancy that can occur following transplantation of a solid organ and is characterized by a proliferation of B cells, which may result in lymphoma.
Time frame: From initiation of immunosuppression withdrawal to 24 weeks after darTregs infusion
Proportion of Liver Transplant Recipients Who Are Able to Reduce Calcineurin Inhibitor Dosing by 75 Percent and Discontinue a Second Immunosuppression Drug (if Applicable) With Stable Liver Function Tests (LFTs) for ≥ 12 Weeks
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Subjects:1.) who fulfill study eligibility criteria will withdraw IS 2.) enter the study on calcineurin inhibitor (CNI) monotherapy or a CNI-based regimen with either Prednisone or MMF as a second IS medication 3.) will proceed with changes in CNI dosing according to the protocol's CNI withdrawal algorithm.During the last 2 weeks of IS withdrawal (e.g., Step 2 in algorithm -CNI reduced 25%-"pre darTregs"), a single dose of darTregs will be infused IV. The subject will then, if eligible, proceed with IS withdrawal within 2 weeks after the infusion. Eligible subjects meeting the primary endpoint of 75% reduction in CNI from baseline after darTregs will be offered the opportunity to continue IS withdrawal until complete discontinuation of IS.
Blood draws (venipuncture); collection of peripheral blood mononuclear cells (PBMCs) by a procedure known as leukapheresis or venipuncture; buccal (cheek) swab for HLA typing; liver biopsies (per protocol and for cause).
The ability to reduce baseline, standard of care calcineurin inhibitor dosing following transplantation was measured by determining the number of subjects who were able to tolerate a 75 percent reduction in their calcineurin inhibitors along with discontinuation of either prednisone or mycophenolate mofetil following initiation of immunosuppression withdrawal.
Time frame: From initiation of immunosuppression withdrawal to 24 weeks after darTregs infusion
Number of Liver Transplant Recipients Who Experience the Composite Outcome
This measure includes refractory acute rejection, chronic rejection, re-transplantation, and death. Rejection was diagnosed based on local pathology. Participants are considered to have met this endpoint if they experience any one of these events at least once.
Time frame: From initiation of immunosuppression withdrawal to 52 weeks after darTreg infusion
Number of Participants Who Experience at Least One Episode of Biopsy Proven Acute Rejection, Clinical Acute Rejection, or Chronic Rejection
A participant was considered to have met this endpoint if they experienced at least one episode of biopsy proven acute rejection, clinical acute rejection, or chronic rejection based on local pathology. Biopsy proven acute rejection was assessed as Grade I or higher based on the Banff (1997) global criteria featuring the following grades: * Indeterminate * Grade I Mild Acute Rejection * Grade II Moderate Acute Rejection * Grade III Severe Acute Rejection. Clinical AR was determined based on the participant receiving treatment for rejection with or without biopsy confirmation of rejection. Chronic rejection was determined by the presence of abnormal total and direct bilirubin in the conjunction with liver pathology fulfilling the Banff (2000) criteria as outlined: * Early Stage Chronic Rejection * Late Stage Chronic Rejection.
Time frame: From initiation of immunosuppression withdrawal to 52 weeks after darTreg infusion
Count of Participants by Severity of Biopsy Proven Acute Rejection and/or Chronic Rejection
Participants are counted in each grade of rejection they experienced; however, a participant is only counted once within a specific grade. Biopsy proven acute rejection and Chronic rejection were graded based on local pathology according to the Banff (1997 for Acute Rejection; 2000 for Chronic Rejection) global assessment criteria as outlined below. Biopsy proven acute rejection was assessed as Grade I or higher using the following grades: * Indeterminate * Grade I Mild Acute Rejection * Grade II Moderate Acute Rejection * Grade III Severe Acute Rejection. Chronic rejection was determined by the presence of abnormal total and direct bilirubin in the conjunction with liver pathology fulfilling the Banff criteria as outlined: * Early Stage Chronic Rejection * Late Stage Chronic Rejection.
Time frame: From initiation of immunosuppression withdrawal to 52 weeks after darTregs infusion
Number of Participants Achieving Efficacy Status Post Receipt of a Single Intravenous (IV) Dose of Donor Alloantigen Reactive Regulatory T Cells (darTregs)
Efficacy was assessed by determining the number (and percentage) of participants who have received darTreg infusion and are identified as operationally tolerant, defined by maintaining stable allograft function (assessed by liver tests) and histology (determined by central pathologist reading in comparison to screening liver biopsy at study entry) in the absence of immunosuppression for one year.
Time frame: From initiation of immunosuppression withdrawal to 52 weeks after darTreg infusion