Parathyroid and Thymus Transplantation in DiGeorge #931

Detailed: DiGeorge Syndrome is a complex of three problems, 1) cardiac defects, 2) parathyroid deficiency, and 3) absence of the thymus, resulting in profound T-cell deficiency. There is a spectrum of disease in DiGeorge syndrome with respect to all three defects. There is no safe and effective treatment for DiGeorge Syndrome and most patients die by the age of two. For patients with a severe T cell defect, the PI has shown that thymus transplantation is safe and efficacious under other clinical protocols. Subjects with complete typical and atypical DiGeorge syndrome were eligible for this study. Subjects with athymia and profound hypoparathyroidism were eligible for parental parathyroid transplantation in this protocol. DiGeorge syndrome infants, who have successful thymus transplants but have hypoparathyroidism, must go to the clinic for frequent calcium levels and to the hospital for calcium infusions; infants with hypoparathyroidism are at risk for seizures from low calcium. Approximately ½ of infants with profound hypoparathyroidism will develop nephrocalcinosis. Depending on T cell phenotype and function, subjects were given one of two different immunosuppression regimens. Typical complete DiGeorge subjects (with proliferative T cell function < 50,000 cpm) received Thymoglobulin pre-transplantation. Typical complete DiGeorge subjects (with proliferative cell response to PHA > 50,000 cpm) and atypical DiGeorge subjects (with proliferative T cell response to PHA < 75,000 cpm) received Thymoglobulin (pre-transplantation) and cyclosporine (pre-transplantation and post-transplantation). Thymoglobulin was used in part to prevent graft rejection and also to deplete any T cells in the donor parathyroid. Cyclosporine was used to deplete activated T cells in the recipient. For all subjects, acetaminophen, diphenhydramine, and methylprednisolone were given concurrently with the rabbit anti-human thymocyte globulin. The thymus was cultured in standard medium for 10-21 days to deplete mature thymocytes which could cause GVHD. In the operating room, thymus tissue was placed in the quadriceps muscle in one or both legs. The parathyroid donation was preferably done at the same time as the thymus transplantation. Parathyroid tissue was placed in the quadriceps muscle in only one leg, using the same incision as the thymus transplantation. Depending on post-transplant immune status, subjects may have received cyclosporine and steroids.

For 3 months after thymus transplantation, T cells were monitored by flow cytometry approximately every 2-4 weeks. Alternatively, absolute lymphocyte count was used as the maximum possible T cell number. At 2-3 months post-transplant, the subject may have had a thymus allograft biopsy, done under general anesthesia in the operating room. The biopsy was approximately 4 pea-sized (3x3mm) portions of muscle tissue where the thymus transplant had been inserted. Using immunohistochemistry, the biopsy determined thymopoiesis and any graft rejection. The parathyroid was not biopsied because it is very small; doing a biopsy could remove all of the parathyroid tissue. A research skin biopsy (at site of skin incision at the time of transplantation) was done to determine whether T cells were present pre-transplantation. A skin biopsy was also done at the time of thymus graft biopsy to look for clonal T cell populations. For all subjects who developed T cells, post-transplantation pneumocystis prophylaxis was used for approximately 1 year and IV immunoglobulin for approximately 2 years.

Transplant Inclusion:

• Complete DiGeorge syndrome (typical or atypical) - may have DiGeorge as part of 22q11 hemizygosity, CHARGE association, or diabetic embryopathy or they may have no associated syndromes.
• Must have 1 of following:

• Circulating CD3+ T cells < 50/mm3; or
• Circulating CD3+ T cells that also positive for CD45RA and CD62L must be <50/mm3 or must be < 5% of total T cells.
• Must be <24 months old
• Laboratory studies must be done w/in 1 month of treatment:

• Thyroid studies - if abnormal must be on therapy, if recommended by endocrinology:
• PT and PTT must be <2x upper limits of normal (ULN)
• Absolute neutrophil count must be >500/mm3
• Platelet count must be >50,000/mm3
• AST and ALT must be <5x ULN
• Creatinine must be <1.5 mg/dl
• Parents must agree to have infant stay in Durham until thymus biopsy is done 2-3 months post-treatment.
• Typical subjects must not have a rash with T cells on biopsy nor lymphadenopathy.
• Atypical subjects have rash with T cells on biopsy; may have lymphadenopathy.
• PHA proliferative responses must be tested 2x • Atypical: PHA response must be <75,000cpm on 2 tests; test can be done while on immunosuppression.

Additional Criteria for Parathyroid Treatment Inclusion

• Hypoparathyroidism
• At least 1 parent must agree to be parathyroid donor
• Must require calcium supplementation to maintain ionized calcium >1.0 mmol/L. Alternatively, intact PTH must be <lower limit of normal when ionized calcium is <1.2 mmol/L. (Intact PTH measured 2x pre-treatment.)

DiGeorge Treatment Exclusion:

• Heart surgery conducted <4 weeks pre-treatment
• Heart surgery anticipated w/in 3 months of treatment
• Rejection by surgeon or anesthesiologist as surgical candidate
• Lack of sufficient muscle tissue to accept 0.2gms/kg treatment
• Prior attempts at immune reconstitution, such as bone marrow treatment or previous thymus treatment
• Doesn't commit to remaining at Duke until thymus allograft biopsy

Parathyroid Donor Inclusion:

• Serum calcium in normal range
• Normal parathyroid hormone function
• HLA typing must be consistent with parentage.
• Must not be on anticoagulation or can come off
• Parent chosen for donation will be the 1 sharing most HLA alleles with thymus donor
• HLA-DR matching preferred over HLA class I matching. If there no HLA matching at all, then either parent will be acceptable if meets other criteria.
• Negative for EBV; CMV; HIV-1; Syphilis; West Nile virus; Hepatitis B; Hepatitis C; pregnancy; & evidence of head/neck infection
• Fiberoptic nasolaryngoscopy shows vocal cords functioning normally.
• Normal thyroid function
• No history of cancer
• The infant-recipient has 2 living involved parents.

Parathyroid Donor Exclusion:

• Infant recipient doesn't have 2 living involved parents
• Animal tissue/organ recipient
• EBV
• CMV
• HIV-1
• Syphilis
• West Nile virus
• Hepatitis B
• Hepatitis C
• Pregnant
• Evidence of head/neck infection
• Vocal cords not functioning normally.
• Thyroid abnormalities
• Hyperparathyroidism
• History of cancer
• Mad cow disease (positive)
• SARS(and exposure)
• Smallpox exposure

Biological Mother of DiGeorge Subjects Inclusions:

Mother must be competent to consent or assent to study participation and willing to provide blood sample. No other inclusion/exclusion.