The purpose of this study is to determine whether bilateral orthotopic lung transplantation (BOLT) followed by cadaveric partially-matched CD3+/CD19+ depleted bone marrow transplant (BMT) is safe and effective for individuals aged 10 through 45 years with the diagnosis of primary immunodeficiency (PID) and end-stage lung disease. The enrollment goal: 8 participants who receive both BOLT and BMT.
The primary purpose of this study is to evaluate the safety and efficacy of performing bilateral orthotopic lung transplantation (BOLT) followed by cadaveric, partially HLA-matched CD3+/CD19+-depleted hematopoietic stem cell transplantation (HSCT) from the same donor for participants with primary immunodeficiency diseases (PID) and end-stage lung disease. For many patients with primary immunodeficiencies, HSCT, which we refer to as Bone Marrow Transplant (BMT) is a curative, life-saving therapy, resulting in restoration of function in the immune system. Patients with primary immunodeficiencies often develop pulmonary complications as a result of chronic or recurrent infections, making them ineligible for BMT due to the high risk of mortality and pulmonary complications. Lung transplant prior to BMT would allow for restoration of pulmonary function prior to BMT, allowing PID patients to proceed to BMT , which would be curative for the patient's underlying immunodeficiency. As a secondary aim, after successful engraftment with donor bone marrow, the feasibility of participants tolerating planned withdrawal of immunosuppression and achieving eventual freedom from all immunosuppressive drugs and attaining a tolerant state will be assessed. This is a single center study in which participants receive a cadaveric, partially Human Leukocyte Antigen (HLA)-matched lung transplant followed by a CD3+/CD19+ depleted bone marrow transplant (BMT) from the same donor. In this study, the investigators will use a ≥ 2/6 HLA-matched T cell depleted bone marrow transplant from a cadaveric organ donor with an identical ABO blood type as the recipient. Participants will undergo: * Bilateral orthotopic lung transplant (BOLT) utilizing basiliximab induction or an alternate induction therapy based on their underlying disease. Rituximab may be initiated prior to the lung transplant, with tacrolimus as the ongoing maintenance immunosuppression. * BMT utilizing CD3+/CD19+-depleted bone marrow with bone marrow conditioning beginning no less than 8 weeks after BOLT. The duration of participant involvement in the trial is up to 2 years post-BMT.
Study Type
INTERVENTIONAL
Allocation
NA
Purpose
TREATMENT
Masking
NONE
Enrollment
5
Negative selection for CD3/CD19 will be performed on a CliniMACS® depletion device within 36 hours of collection, and cryopreserved for later marrow transplantation. BMT conditioning and transplantation will start at least 8 weeks or more post lung transplant - once the participant is clinically judged suitable to undergo BMT conditioning and transplantion.
Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania, United States
Safety: Death
How many, if any, participants die during study participation.
Time frame: Average of approximately 31 months for those who received an initial transplant
Safety: Engraftment Syndrome
How many, if any, participants develop engraftment syndrome.
Time frame: Average of ~7.5 months of time post BMT for those receiving both lung and BMT transplants.
Engraftment Failure
Time frame: Average of ~7.5 months of time post BMT for those receiving both lung and BMT transplants.
Grade 4 or 5 Events Potentially Attributable to Rituximab
Time frame: Average of ~25 months.
BOS at 1 Year Post BOLT
Diagnosis of BOS (Bronchiolitis Obliterans Syndrome) at any time up to 1 year post BOLT. BOS is one of the undesirable complications of lung transplantation.
Time frame: throughout the first year post BOLT
Efficacy: Count of Participants With Requirement for Supplemental Oxygen and/or Ventilatory Support
The number of participant(s) who need either supplemental oxygen and/or ventilator support (noninvasive/invasive) will be assessed using the Bronchiolitis Obliterans Syndrome (BOS) Classification Score for pulmonary function (e.g., the Forced Expiratory Volume in 1 Second (FEV1). FEV1 is air volume exhaled in 1 second during spirometry, a lung function test. (Continuing dependence on supplemental oxygen or ventilatory support is an undesirable outcome of lung transplantation).
Time frame: at 1 Year Post Lung Transplant (BOLT)
Efficacy: Count of Participants With T-cell Chimerism
The number of participants who have ≥ 25% donor T-cell chimerism.
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Time frame: 1 Year Post Bone Marrow Transplant (BMT)
Efficacy: Count of Participants With Myeloid Chimerism
The number of participants with myeloid disorders (e.g. Chronic Granulomatous Disease \[CGD\]) who attain ≥ 10% myeloid chimerism.
Time frame: 1 Year Post Bone Marrow Transplant (BMT)
Efficacy: Count of Participants B-cell Chimerism
The number of participants with B-cell disorders who attain ≥ 10% B-cell chimerism.
Time frame: 1 Year Post Bone Marrow Transplant (BMT)
Count of Participants Able to Proceed to BMT
The number of participants for which it is feasible to proceed to BMT within 6 months following lung transplant.
Time frame: 6 Months Post Lung Transplant (BOLT)
Count of Participants Who Achieve Tolerance
The number of participants who develop tolerance to both the host and pulmonary graft. Definition of tolerance: A participant's successful withdrawal from systemic immunosuppression for 6 weeks with no increase cGVHD score and stable or improving PFTs.
Time frame: Average of ~7.5 months of time post BMT for those receiving both lung and BMT transplants.
Long Term Complications of Combined Solid Organ and Bone Marrow Transplant
Summary of long-term complications of combined solid organ and bone marrow transplant (BMT).
Time frame: Average of ~7.5 months of time post BMT for those receiving both lung and BMT transplants.
Count of Participants Who Develop Acute Cellular Rejection and Graft Failure
The number of participants who develop acute cellular rejection and graft failure post BMT.
Time frame: Average of ~7.5 months of time post BMT for those receiving both lung and BMT transplants.
Count of Participants Able to Initiate Withdrawal of Immunosuppression
The number of participants who are able to start immunosuppression withdrawal.
Time frame: 1 year following BMT
Time to Withdrawal of Immunosuppression
Time from BMT to withdrawal of immunosuppression.
Time frame: Average of ~7.5 months of time post BMT for those receiving both lung and BMT transplants.
Time to Independence From Treatment Dose Antimicrobial Drug
A measure of pathogen-specific immunity.
Time frame: Average of ~7.5 months of time post BMT for those receiving both lung and BMT transplants.
Post-BMT Achievement of Normal Lymphocyte Count for T-cell Lymphopenias
For participants with immune deficiencies with T cell lymphopenias, number of participants achieving age adjusted, low limit normal range lymphocyte count by 1-year post-BMT.
Time frame: 1 year post BMT
Count of Participants Who Develop Acute Graft-Versus-Host Disease (GVHD)
The number of participants who develop acute graft-versus-host disease (GVHD) following tandem BOLT and BMT.
Time frame: Average of ~7.5 months of time post BMT for those receiving both lung and BMT transplants.
Count of Participants With Chronic Graft-Versus-Host Disease (GVHD)
The number of participants who develop chronic graft-versus-host disease (GVHD) following tandem BOLT and BMT.
Time frame: Average of ~7.5 months of time post BMT for those receiving both lung and BMT transplants.
Count of Participants Who Develop Chronic Lung Allograft Dysfunction or Allograft Failure
A significant development in chronic lung allograft dysfunction (as evidenced by a change in BOS stage) or allograft failure at 1 year and up to 2 year post lung transplant (for lung transplant alone and BOLT-BMT subjects.
Time frame: up to 2 years post BOLT
Count of Pre-BMT Conditioning Rituximab Related Adverse Events
The number of Grade 4 or 5 adverse events possibly related to the use of rituximab prior to the start of BMT conditioning.
Time frame: Average of approximately 9 months.