Lymphocyte Depletion and Stem Cell Transplantation to Treat Severe Systemic Lupus Erythematosus

Background:

• Systemic lupus erythematosus (SLE) is a systemic autoimmune disease that can involve almost any organ and can range in severity from mild to life-threatening. In spite of significant improvements in survival of SLE patients over last 20 years, a small but significant portion of patients still develop progressive therapy-refractory disease that impairs organ function and overall survival.
• Since 1996, more than 500 patients have been treated worldwide in pilot trials of autologous hematopoietic stem cell transplantation (autoHSCT) for autoimmune diseases, including about 80 patients with SLE.
• The rationale for autoHSCT in autoimmune disease is to ablate autoreactive immune effectors and allow reconstitution of a new self-tolerant immune system from the

hematopoietic stem cell. Studies have demonstrated acceptable safety and promising short term efficacy of high-dose cyclophosphamide-based (200 mg/kg) autoHSCT for about 60% of patients with advanced refractory SLE and reacquisition of sensitivity to conventional drugs have been demonstrated in many cases. However, these trials were designed to address the primary endpoint of safety and were inadequate for assessing the disease response.

-Numerous questions about the true efficacy of autoHSCT, optimal transplant regimen, patient selection and mechanisms of action remain unaddressed.

Objectives:

• The primary objective is to assess the rate of continuous relapse-free complete clinical responses at 24 months post-transplant, with statistical power of 84% to detect, if greater than 70 percent of patients meet the primary endpoint.
• The long-term goal of this research is to develop a basis for future transplant protocols that would incorporate new cellular or other immunotherapeutic interventions to further improve results of transplants with the ultimate goal to cure SLE.

Eligibility:

-Subjects age 15-40 years who fulfill at least 4 of the 11 criteria for SLE as defined by the

American College of Rheumatology

-Have severe and active lupus, refractory to immunosuppressive therapy. Included are subjects with nephritis, central nervous system (CNS) lupus, pulmonary lupus or hematologic disease

Design:

• Fourteen patients with active and standard dose cyclophosphamide-resistant SLE will be enrolled on this phase II pilot study.
• Study design is intended to improve the efficacy of autoHSCT. A lymphoablative conditioning regimen (rituximab, fludarabine and cyclophosphamide) is explored for the first time in autoimmune disease.
• The treatment schedule consists of two parts; the priming regimen prior to stem cell mobilization and collection, and the conditioning regimen with transplant.
• In contrast to other studies, this study has precisely defined eligibility and disease response criteria with strict schema of tapering immunosuppression that should allow accurate interpretation of the treatment results.
• The study includes a carefully chosen battery of laboratory research studies designed to investigate SLE biology and mechanisms of post-transplant responses.

-INCLUSION CRITERIA

• Age 15-40 years
• Must fulfill at least 4 of the following 11 criteria for systemic lupus erythematous (SLE) as defined by the American College of Rheumatology:

-Malar rash. Fixed erythema, flat or raised, over the malar eminences, tending to spare the nasolabial folds.

• Discoid rash. Erythematous raised patches with adherent keratotic scaling and follicular plugging; atrophic scarring may occur in older lesions.
• Photosensitivity. Skin rash as a result of unusual reaction to sunlight, by patient history or physician observation.
• Oral ulcers. Oral or nasopharyngeal ulcerations, usually painless, observed by a physician.
• Arthritis. Nonerosive arthritis involving two or more peripheral joints, characterized by tenderness, swelling, or effusion.
• Serositis. a.) Pleuritis - convincing history of pleuritic pain or rub heard by a physician or evidence of pleural effusion

OR

b.) Pericarditis - documented by electrocardiogram (ECG) or rub or evidence of pericardial effusion

-Renal disorder. a.) Persistent proteinuria greater than 0.5 grams per day or greater than 3+ if quantitation not performed

OR

b.) Cellular casts - may be red cell, hemoglobin, granular, tubular, or mixed.

• Neurologic disorder. a.) Seizures - in the absence of offending drugs or known metabolic derangements; eg, uremia, ketoacidosis, or electrolyte imbalance

OR

b.) Psychosis - in the absence of offending drugs or known metabolic derangements; eg, uremia, ketoacidosis, or electrolyte imbalance

-Hematologic disorder. a.) Hemolytic anemia - with reticulocytosis

OR

b.) Leukopenia - less than 4000/ L total on two or more occasions

OR

c.) Lymphopenia - less than 1500/ L on two or more occasions

OR

d.) Thrombocytopenia - less than 100,000/ L in the absence of offending drugs

• Immunologic disorder. a.) Anti-deoxyribonucleic acid (DNA): antibody to native DNA in abnormal titer

OR

b.) Anti-SM: presence of antibody to SM nuclear antigen

OR

c.) Positive finding of antiphospholipid antibodies based on (1) an abnormal serum level of immunoglobulin G (IgG) or immunoglobulin M (IgM) anti-cardiolipin antibodies, (2) a positive test result for lupus anticoagulant using a standard method, or (3) false positive serologic test for syphilis known to be positive for at least 6 months and confirmed by Treponema Pallidum immobilization or fluorescent treponemal antibody absorption test

-Antinuclear antibodies. An abnormal titer of ANAs by immunofluorescence or an equivalent assay at any point in time in the absence of drugs known to be associated with drug-induced lupus syndrome.

• Have severe and active lupus, refractory to immunosuppressive therapy, defined as one of the following (a-d):

a.Nephritis: Biopsy proven Diffuse Proliferative Glomerulonephritis (World Health Organization (WHO) Class IV) with or without superimposed membranous changes

i.Active disease:

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• A kidney biopsy within three months of enrollment showing active WHO Class IV disease. Activity will be determined based on the presence of endocapillary cellular proliferation compromising the capillary loops or cellular crescents or necrosis on light microscopy or subendothelial deposits on electron microscopy.
• If a biopsy is contraindicated patients can be enrolled if they had a previous biopsy showing Diffuse Proliferative Glomerulonephritis (WHO Class IV) and at the time of enrollment have all of the following:

• Proteinuria greater than 1gm/day
• Active urine sediment defined as hematuria (greater than 10 red blood cell (RBC)/hpf (high power field) on a nephrology urinalysis of a 50 mL urine sample) with dysmorphic RBC and/or cellular casts on a nephrology urinalysis of a 50 mL urine sample
• Low C3 (less than 69 mg/dL) and/or elevated dsDNA antibodies (greater than 25EU)
• Need for prednisone greater than 20 mg/day due to increased renal activity after at least 6 months of cyclophosphamide.

ii. Treatment resistant:

• Patients with active disease after at least 6 months of intravenous pulse cyclophosphamide +/- iv methylprednisolone and daily oral prednisone, or
• Early flare: those who have reactivation of their nephritis during or within 6 months of completing cyclophosphamide therapy
• Recalcitrant disease: two or more recurrences of lupus nephritis within five years of enrollment. All flares must have received adequate therapy and least one of the episodes must have been treated with minimum 6 months of intravenous pulse cyclophosphamide plus iv methylprednisolone and maintenance oral prednisone.

Central nervous system (CNS) lupus: Lupus CNS manifestations indicative of encephalitis or myelitis or vasculitis. Concomitant CNS diseases should be excluded. (e.g. infections, multiple sclerosis; patients fulfilling multiple sclerosis (MS) and SLE criteria will be excluded). Clinical signs and symptoms must be supported by objective findings of CNS inflammation.

i. Active disease:

Signs/symptoms that are accepted for disease activity:

-Clinical signs and symptoms compatible with focal CNS damage -Severe global neurocognitive/psychiatric impairment (eg: psychosis, organic brain syndrome, severe depression)

-Intractable seizures

Clinical findings must be supported by at least one of the following:

• Magnetic resonance imaging (MRI) findings consistent with transverse myelitis or

Central nervous system (CNS) vasculitis

• Signs of inflammation on MRI are either the presence of Gadolinium (Gd)-enhancing lesions, or the increase of the number and/or volume of T2-weighted lesions (or lesions showing up on fluid attenuated inversion recovery (FLAIR) imaging). We will use the standard MS protocol sequences, which are routinely used in the Clinical Center to evaluate inflammatory CNS lesions.
• If patient has seizures/psychiatric signs and symptoms in the absence of clear signs of vasculitis or cerebritis by MRI, the cerebral spinal fluid (CSF) should show protein elevation above normal levels and abnormal number of white blood cells (WBCs) or intrathecal IgG synthesis/or oligoclonal bands.
• Need for prednisone greater than 20 mg/day due to increased CNS activity (see above) after at least three months of cyclophosphamide therapy.

ii-Treatment resistant:

a) Active disease after a minimum of three months of oral or intravenous cyclophosphamide, or

b) Early flare: reactivation of CNS lupus within 6 months of completing cyclophosphamide therapy

c. Recalcitrant disease: two or more recurrences of CNS lupus within five years of enrollment. All flares must have received adequate therapy and at least one of the episodes must have been treated with minimum three months of oral or intravenous cyclophosphamide.

Pulmonary lupus

i. Active disease:

• Lung biopsy showing active pneumonitis, alveolitis or pulmonary vasculitis after the minimally required therapy within one month of enrollment or
• If a biopsy is contraindicated within one month of enrollment, patients may be included if they had a biopsy at the start or during cyclophosphamide treatment showing active pneumonitis, alveolitis or pulmonary vasculitis (as above) and have abnormal or worsening pulmonary function tests with a chest computed tomography (CT) consistent with active pneumonitis, alveolitis or vasculitis within 2 weeks of enrollment and at the time of enrollment have a CT consistent with active disease.
• Need for prednisone greater than 20 mg/day due to increased pulmonary lupus activity after minimum of three months of cyclophosphamide.

ii. Treatment resistant:

• Ongoing or recurrent active pulmonary lupus after a minimum of three months of oral or intravenous cyclophosphamide, or
• Early flare: reactivation of pulmonary lupus (as defined above) within 6 months of completing cyclophosphamide therapy.
• Recalcitrant disease: two or more recurrences of pulmonary as described above within five years of enrollment. All flares must have received adequate therapy and at least one of the episodes must have been treated with minimum 3 months of oral or intravenous cyclophosphamide.

i) Active disease:

a) Severe immune-mediated thrombocytopenia (platelet count less than 20,000/mm^3 or less than 50,000/mm^3 with history of bleeding), or

b) Severe immune-mediated anemia (requiring transfusions to maintain hemoglobin (Hb) greater than 8.0 g/dL or to treat symptoms of anemia) c) Need for prednisone greater than 20 mg/day due to increased hematologic lupus activity after therapy as described in section ii.a).

ii) Treatment resistant:

a) Active disease as defined above after a minimum of three months of high dose oral or pulse corticosteroids +/- intravenous immunoglobulin (IVIg) (or WinRho) and splenectomy, or

b) Early flare: reactivation of hematologic lupus (as defined above) within 6 months of completing above therapy.

c) Recalcitrant disease: two or more recurrences of immune-mediated thrombocytopenia or anemia, as described above, within five years of enrollment. All flares must have received adequate therapy and at least one of the episodes must have been treated by splenectomy.

Exclusion criteria

• Inability to provide written informed consent prior to entry in the protocol

• Pregnant or lactating women. Women of childbearing potential are required to have a negative pregnancy test at screening

• Women of childbearing potential who are not practicing or who are unwilling to practice birth control during the entire study

• Men who are unwilling to practice birth control for the first 6 months after the transplant

• Evidence of infection with hepatitis B, hepatitis C, or human immunodeficiency virus (HIV)

• History of malignancy other than basal cell carcinoma of the skin

• Carbon monoxide diffusing capacity (DLCO) corrected less than 45%

• Left ventricular ejection fraction (LVEF) less than 45%, determined by ECHO cardiogram or MUGA

• Serum glutamic oxaloacetic transaminase (SGOT) or serum glutamic pyruvic transaminase (SGPT) greater than 2x upper limit of normal (unless active myopathy is proven by elevation of serum aldolase levels and the patient has no obvious hepatic disease) and/or bilirubin greater than 2.0 (unless due to isolated hemolysis).

• Calculated glomerular filtration rate less than 30 ml/min using the modification of diet in renal disease (MDRD) equation estimate:

Glomerular filtration rate (GFR) (ml/min/173 m^2) =186.3 x (Pcr) exponential -1.154 x (age) exponential -0.203 x 1.212 (if black) x 0.742 (if female)

• Late flare (patients who have target organ flare, that is not within the time frame defined as early flare, will not be considered as treatment failures until they receive the minimally required therapy for this flare episode and fail to respond to it)

• Abnormal bone marrow cytogenetics

• Significant concurrent medical condition or any significant circumstance that could affect the patient's ability to tolerate or complete the study

• Live vaccines within 4 weeks of starting the priming regimen