Combined Bone Marrow and Renal Transplantation for Hematologic Disorders With End Stage Renal Disease

The induction of transplantation tolerance involves the specific elimination of the immune response to the transplant but not to other antigens. In the realm of kidney transplantation, tolerance means that the recipient is unable to detect the donor transplant kidney as foreign, and therefore the recipient is unable to reject the kidney. Donor bone marrow engraftment leads to kidney graft tolerance in animal models. Renal failure is a major complication of multiple myeloma and AL amyloidosis for which the only known cure is allogeneic bone marrow transplantation. Standard bone marrow transplantation is associated with prohibitive toxicities in patients with end stage renal disease, and is generally not considered an option for those patients. Patients with multiple myeloma and AL amyloidosis are excluded from conventional renal transplantation protocols because of their underlying malignancy. A less toxic bone marrow transplantation protocol, utilizing low dose total body irradiation and anti-thymocyte globulin, combined with renal transplantation, could provide an opportunity for cure of the myeloma or amyloidosis and correction of end stage renal disease. In addition, successful marrow engraftment may be expected to lead to a state of tolerance. Successful implementation of tolerance would be a major benefit to transplant recipients. The significance of developing tolerance is that the patient could be spared the disabling complications of indefinite immunosuppression, which include infections, cataracts, osteoporosis, diabetes, atherosclerosis, hypertension, and malignancy.

Participant Inclusion Criteria

• Participants with end-stage renal failure due to or in association with multiple myeloma or systemic AL amyloidosis which hematopoietic cell transplantation is appropriate and a ≥ 50% five-year survival probability with transplantation is expected. This includes, but is not limited to:
• Multiple myeloma (MM), ISS stage II or III in complete or very good partial remission
• AL amyloidosis without significant cardiac disease
• Males or females 18 - 65 years of age.
• Participants must have an HLA-matched or one of six HLA A, B, or DR antigen-mismatched related donor, with high resolution molecular class I and II allele typing.
• Men and women of reproductive potential must agree to use a reliable method of birth control during the treatment, and women should do so for a period of 2 years following the transplant.
• Participants should be on dialysis or have a CrCl <20 ml/min.
• Patients should not have evidence of renal recovery of their renal failure over a 90 day period of therapy for their underlying malignancy or other blood disorder.
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• Patients with a history of other malignancies excluding basal cell carcinoma of the skin and carcinoma in situ of the cervix with a disease-free survival interval of >2 years. Patients with the following malignancies must demonstrate a 5 year disease-free survival:

• Breast cancer with positive nodes
• Malignant melanoma (other than in situ)
• Colorectal cancer (other than Dukes Stage A or B1)
• Patients with multiple myeloma must have received previous treatment with a bortezomib-based regimen.

Patients with AL amyloidosis must have received previous treatment with a bortezomib-based regimen and/or autologous stem cell transplantation

• Patients with a history of malignant melanoma must be reviewed by an independent oncologist prior to enrollment.
• Recipient ability to understand and provide informed consent.

Participant Exclusion Criteria

• Evidence of active infection as defined by: a) clinical syndrome consistent with viral or bacterial infection (e.g., influenza, URI, UTI) or b) fever with a clinical site of infection identified, or c) microbiologically documented infection, including, but not limited to, bacteremia or septicemia.
• Participation in other investigational drug use at the time of enrollment.
• Contraindication to therapy with any one of the proposed agents (e.g., history of allergy to horse serum in ATG).
• Serologic positivity to HIV or HCV.
• Women of childbearing age in whom adequate contraception cannot be maintained.
• AST/ALT > 3 x normal or bilirubin > 1.5 x normal (unless due to Gilbert's syndrome).
• Pregnancy or uncontrolled serious medical illness not related to underlying myeloma.
• Cardiac ejection fraction < 40% by echocardiogram.
• FEV1 < 50% predicted or corrected DLCO < 50% predicted.
• ABO blood group incompatibility in the host-vs-graft direction.

• Diagnosis of myelodysplastic syndrome

Donor Inclusion Criteria

• HLA-matched or one of six HLA A, B, or DR antigen-mismatched related male or female donor 18-65 years of age.
• ECOG performance status 0 or 1.
• Excellent health per conventional pre-donor history (medical and psychosocial evaluation).
• Acceptable laboratory parameters (hematology in normal or near-normal range; liver function < 2 times the upper limit of normal and normal creatinine).
• Compatible ABO blood group.
• Negative donor lymphocyte crossmatch.
• No positive testing for viral infection (HbsAg, HIV, HCV, HTLV-1).
• Cardiac/Pulmonary evaluation within normal limits (CXR, EKG).
• Donor ability to understand and provide informed consent.