This study is NOT currently recruiting participants.
Number
11-I-0007
Sponsoring Institute
National Institute of Allergy and Infectious Diseases (NIAID)
Recruitment Detail
Type: Clinical hold/Recruitment or enrollment suspended Gender: Male Min Age: 2 Years Max Age: 40 Years
Referral Letter Required
Yes
Population Exclusion(s)
Adults who are or may become unable to consent
Keywords
T cell, B cell, NK cell; Gene Transfer; Peripheral Blood Stem Cells; Common Gamma Chain (gamma c); Immune Reconstitution
Recruitment Keyword(s)
None
Condition(s)
X-linked Severe Combined Immunodeficiency (XSCID)
Investigational Drug(s)
autologous CD34+ hematopoietic stem cells transduced with the lentivector, VSV-g
Investigational Device(s)
Intervention(s)
Drug: Palifermin Drug: Busulfan Biological/Vaccine: Ex vivo culture and transduction of the patient's autologous CD34+ HSC with lentivirus vector VSV-G pseudotyped CL20- 4i-EF1alpha-hgammac-OPT vector
Supporting Site
National Institute of Allergy and Infectious Diseases
At the NIH the patient blood stem cells will be cells collected previously under NIH protocol 94-I-0073 or collected on this protocol. In most cases the harvested blood stem cells are put into frozen storage before use in this protocol. When the patient enrolled in this protocol has the required number of blood stem cells harvested, then the patient s blood stem cells will be grown in tissue culture and exposed to the lentiviral gene transfer vector containing the corrective gene. These gene corrected blood stem cells will be administered by vein to the patient. To increase engraftment of the corrected blood stem cells, patients will receive on 2 days before the gene transfer treatment a chemotherapy drug called busulfan at a total dose of 6 mg/kilogram body weight (3 mg/kilogram body weight/daily times 2 days) that is a little more than one- third the dose used in many standard bone marrow transplants. Patients will also be given another drug called palifermin that helps prevent the main side effect from the busulfan that is a type of inflammation the mouth, stomach and bowels called mucositis. After this treatment, patients will be monitored to see if the treatment is safe and whether their immune system improves. Patients will be followed at frequent intervals for the first 2 years, and less frequently thereafter so that the effectiveness in restoration of immune function and the safety of the treatment can be evaluated.
XSCID is a genetic disease caused by defects in common gamma chain, a protein found at the surface of immune cells called lymphocytes and necessary to their growth and function. XSCID patients cannot make T-lymphocytes necessary to fight infections, and their B-cells fail to make essential antibodies. Without normal T- and B-lymphocyte function patients develop fatal infections in infancy unless they are rescued by a bone marrow transplant from a healthy donor. The best type of transplant is from a tissue matched healthy brother or sister, but most XSCID patients do not have a tissue-matched sibling, and are treated with a transplant from a parent who is only half- matched by tissue typing. While a half-matched transplant from a parent can be life-saving for an infant with XSCID, a subset of patients fail to achieve sufficient long lasting restoration of immunity to prevent infections and other chronic problems.
Recent trials of gene transfer treatments using mouse retrovirus vectors for infants with XSCID have been performed and have demonstrated that this type of gene transfer can be an alternate approach for significantly restoring immunity to infants with XSCID. However, among the 18 infants with XSCID benefiting long-term from the gene transfer treatment, 5 developed T-lymphocyte leukemia and 1 died of this leukemia. Furthermore, when older children with XSCID were treated with gene transfer, the restoration of immunity was very much less than seen in the infants. These observations of gene transfer treatments using mouse retrovirus vectors to treat infants and older patients with XSCID suggests that safer and more effective vectors were needed, and that there also may be a need to give chemotherapy or other mode of conditioning to increase engraftment in the marrow of the gene corrected blood stem cells. Our data and other published studies suggest that lentivectors that are derived from the human immunodeficiency virus and have the properties of our highly modified vector called CL20-4i-EF1 - h >=c-OPT have a reduced interaction with nearby genes and therefore less of a tendency to activate genes that may lead to cancer formation. Also, this type of lentivector may work better at getting into blood stem cells.
The study purpose is to evaluate safety and effectiveness of lentiviral gene transfer treatment at restoring immune function to 23 XSCID patients who are 2 to 40 years of age, and have significant impairment of immunity. Early evidence for effectiveness will be defined by appearance and expansion in the circulation of the patient s own gene corrected T-lymphoc...
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INCLUSION CRITERIA: -A proven mutation in the common gamma chain gene as defined by direct sequencing of patient DNA -HLA typing of the patient will have been performed before enrollment -No available HLA matched sibling donor as determined before enrollment. -Must be between 2 and 40 years of age and weigh greater than or equal to 10 kg -If previously transplanted, must be greater than or equal to 18 months post haploidentical HSCT -Expected survival of at least 120 days. -Documented to be negative for HIV infection by genome PCR -The patient must be judged by the primary evaluating physician to have a suitable family and social situation consistent with ability to comply with protocol procedures and the long-term follow-up requirements. -Medical lab data (historical) of severe B cell dysfunction (low or absent IgG levels, failed immune response to vaccines); OR demonstrated requirement for intravenous gamma globulin (IVIG) (significant drop over 3 to 6 weeks between peak and trough IgG levels). -Must be willing to have blood and tissue samples stored IN ADDITION, patients must satisfy the following Laboratory Criteria AND Clinical Criteria -Participants of reproductive potential must agree to consistently use highly effective contraception throughout study participation and for at least 2 years post-treatment. Acceptable forms of contraception are: - For males: Condoms or other contraception with partner. Laboratory Criteria: (greater than or equal to 1 must be present) i. CD4+ lymphocytes: absolute number less than or equal to 50 percent of the lower limit of normal (LLN) ii. CD4 plus CD45RA+ lymphocytes: absolute number less than or equal to 50 percent of the LLN OR T-cell receptor excision circles (TRECs)squared less than or equal to 5 percent of normal for age. iii. Memory B Cells: absolute numberless than or equal to 50percent of LLN iv. If serum IgM<normal for age v. NK cells: absolute number less than or equal to 50 percent of LLN vi. Lymphocyte proliferative response to each of 2 mitogens, phytohemagglutinin (PHA) and concanavalin A (ConA), is squared 25 percent with a normal control. vii. Molecular spectratype analysis- absent or very oligoclonal (1-3 dominant peaks) in greater than or equal to 6 of the 24 V- Beta T-cell receptor families. Clinical Criteria: (greater than or equal to 1 must be present): i Infections (not including molluscum, warts or mucocutaneous candidiasis; see vii and viii below): greater than or equal to 3 significant new or chronic active infections during the 12 months preceding evaluation for enrollment. Infections are defined as an objective sign of infection (fever greater than 38.3 degrees C [101 degrees F] or neutrophilia or pain/redness/swelling or radiologic/ultrasound imaging evidence or typical lesion or histology or new severe diarrhea or cough with sputum production). In addition to one or more of these signs/symptoms of possible infection, there also must be at least 1 of the following criteria as evidence of the attending physician s intent to treat a significant infection (a. and b.) or objective evidence for a specific pathogen causing the infection (c.) -Treatment (not prophylaxis) with systemic antibacterial, antifungal or antiviral antibiotics greater than or equal to 14 days OR -Hospitalization of any duration for infection OR -Isolation of a bacteria, fungus, or virus from biopsy, skin lesion, blood, nasal washing, bronchoscopy, cerebrospinal fluid or stool likely to be an etiologic agent of infection ii Chronic pulmonary disease as defined by: -Bronchiectasis by x-ray computerized tomography OR -Pulmonary function test (PFT) evidence for restrictive or obstructive disease that is less than or equal to 60 percent of Predicted for Age OR -Pulse oximetry less than or equal to 94 percent in room air (if patient is too young to comply with performance of PFTs). iii Gastrointestinal enteropathy: -Diarrhea-watery stools greater than or equal to 3 times per day (of at least 3 months duration that is not a result of infection as defined in criterion above) OR -Endoscopic evidence (gross and histologic) for enteropathy (endoscopy will only be performed if medically indicated) OR -Other evidence of enteropathy or bacterial overgrowth syndrome: including malabsorption of fat soluble vitamin(s), abnormal D-xylose absorption, abnormal hydrogen breath test, evidence of protein losing enteropathy (for example increasingly high or frequent dosing of intravenous gamma globulin supplement required to maintain blood IgG level). iv Poor nutrition: Requires G-tube or intravenous feeding supplement to maintain weight or nutrition. v Auto- or allo-immunity: Examples must include objective physical findings that include, but are not limited to any one of alopecia, severe rashes, uveitis, joint pain with redness or swelling or limitation of movement that is not a result of infection, lupus-like lesions, and granulomas (Does not include auto- or allo-immune enteropathy which is criterion iii). Where possible and appropriate, diagnosis will be supported by histopathology or other diagnostic modality. vi Failure to grow in height: less than or equal to 3 rd percentile for age vii Skin molluscum contagiosum OR warts (this criterion is satisfied if molluscum consists of greater than or equal to 10 lesions or there are two or more lesions at each of two or more widely separated anatomic sites; or there are greater than or equal to 3 warts at different anatomic sites at the same time; or the patient has both molluscum and warts) viii Mucocutaneous candidiasis (chronic oral thrush or candida esophagitis or candida intertriginous infection or candida nail infections; must be culture positive to satisfy this criterion) ix Hypogammaglobulinemia: requires regular IgG supplementation EXCLUSION CRITERIA: -Any current or pre-existing hematologic malignancy -Current treatment with any chemotherapeutic agent (becomes eligible if not on treatment for at least 3 months) -Documented HIV-1 infection -Documented active Hepatitis B infection -Childhood malignancy (occurring before 18 years of age) in the patient or a first degree relative, or previously diagnosed known genotype of the subject conferring a predisposition to cancer (no DNA or other testing for cancer predisposition genes will be performed as part of the screen for this protocol)
-A proven mutation in the common gamma chain gene as defined by direct sequencing of patient DNA
-HLA typing of the patient will have been performed before enrollment
-No available HLA matched sibling donor as determined before enrollment.
-Must be between 2 and 40 years of age and weigh greater than or equal to 10 kg
-If previously transplanted, must be greater than or equal to 18 months post haploidentical HSCT
-Expected survival of at least 120 days.
-Documented to be negative for HIV infection by genome PCR
-The patient must be judged by the primary evaluating physician to have a suitable family and social situation consistent with ability to comply with protocol procedures and the long-term follow-up requirements.
-Medical lab data (historical) of severe B cell dysfunction (low or absent IgG levels, failed immune response to vaccines); OR demonstrated requirement for intravenous gamma globulin (IVIG) (significant drop over 3 to 6 weeks between peak and trough IgG levels).
-Must be willing to have blood and tissue samples stored IN ADDITION, patients must satisfy the following Laboratory Criteria AND Clinical Criteria
-Participants of reproductive potential must agree to consistently use highly effective contraception throughout study participation and for at least 2 years post-treatment.
Acceptable forms of contraception are:
- For males: Condoms or other contraception with partner.
Laboratory Criteria: (greater than or equal to 1 must be present)
i. CD4+ lymphocytes: absolute number less than or equal to 50 percent of the lower limit of normal (LLN)
ii. CD4 plus CD45RA+ lymphocytes: absolute number less than or equal to 50 percent of the LLN OR T-cell receptor excision circles (TRECs)squared less than or equal to 5 percent of normal for age.
iii. Memory B Cells: absolute numberless than or equal to 50percent of LLN
iv. If serum IgM<normal for age
v. NK cells: absolute number less than or equal to 50 percent of LLN
vi. Lymphocyte proliferative response to each of 2 mitogens, phytohemagglutinin (PHA) and concanavalin A (ConA), is squared 25 percent with a normal control.
vii. Molecular spectratype analysis- absent or very oligoclonal (1-3 dominant peaks) in greater than or equal to 6 of the 24 V- Beta T-cell receptor families.
Clinical Criteria: (greater than or equal to 1 must be present):
i Infections (not including molluscum, warts or mucocutaneous candidiasis; see vii and viii below): greater than or equal to 3 significant new or chronic active infections during the 12 months preceding evaluation for enrollment.
Infections are defined as an objective sign of infection (fever greater than 38.3 degrees C [101 degrees F] or neutrophilia or pain/redness/swelling or radiologic/ultrasound imaging evidence or typical lesion or histology or new severe diarrhea or cough with sputum production). In addition to one or more of these signs/symptoms of possible infection, there also must be at least 1 of the following criteria as evidence of the attending physician s intent to treat a significant infection (a. and b.) or objective evidence for a specific pathogen causing the infection (c.)
-Treatment (not prophylaxis) with systemic antibacterial, antifungal or antiviral antibiotics greater than or equal to 14 days
OR
-Hospitalization of any duration for infection
-Isolation of a bacteria, fungus, or virus from biopsy, skin lesion, blood, nasal washing, bronchoscopy, cerebrospinal fluid or stool likely to be an etiologic agent of infection
ii Chronic pulmonary disease as defined by:
-Bronchiectasis by x-ray computerized tomography
-Pulmonary function test (PFT) evidence for restrictive or obstructive disease that is less than or equal to 60 percent of Predicted for Age
-Pulse oximetry less than or equal to 94 percent in room air (if patient is too young to comply with performance of PFTs).
iii Gastrointestinal enteropathy:
-Diarrhea-watery stools greater than or equal to 3 times per day (of at least 3 months duration that is not a result of infection as defined in criterion above)
-Endoscopic evidence (gross and histologic) for enteropathy (endoscopy will only be performed if medically indicated)
-Other evidence of enteropathy or bacterial overgrowth syndrome: including malabsorption of fat soluble vitamin(s), abnormal D-xylose absorption, abnormal hydrogen breath test, evidence of protein losing enteropathy (for example increasingly high or frequent dosing of intravenous gamma globulin supplement required to maintain blood IgG level).
iv Poor nutrition: Requires G-tube or intravenous feeding supplement to maintain weight or nutrition.
v Auto- or allo-immunity: Examples must include objective physical findings that include, but are not limited to any one of alopecia, severe rashes, uveitis, joint pain with redness or swelling or limitation of movement that is not a result of infection, lupus-like lesions, and granulomas (Does not include auto- or allo-immune enteropathy which is criterion iii). Where possible and appropriate, diagnosis will be supported by histopathology or other diagnostic modality.
vi Failure to grow in height: less than or equal to 3 rd percentile for age
vii Skin molluscum contagiosum OR warts (this criterion is satisfied if molluscum consists of greater than or equal to 10 lesions or there are two or more lesions at each of two or more widely separated anatomic sites; or there are greater than or equal to 3 warts at different anatomic sites at the same time; or the patient has both molluscum and warts)
viii Mucocutaneous candidiasis (chronic oral thrush or candida esophagitis or candida intertriginous infection or candida nail infections; must be culture positive to satisfy this criterion)
ix Hypogammaglobulinemia: requires regular IgG supplementation
EXCLUSION CRITERIA:
-Any current or pre-existing hematologic malignancy
-Current treatment with any chemotherapeutic agent (becomes eligible if not on treatment for at least 3 months)
-Documented HIV-1 infection
-Documented active Hepatitis B infection
-Childhood malignancy (occurring before 18 years of age) in the patient or a first degree relative, or previously diagnosed known genotype of the subject conferring a predisposition to cancer (no DNA or other testing for cancer predisposition genes will be performed as part of the screen for this protocol)
Principal Investigator
Referral Contact
For more information: