Gene Therapy Approach for Chronic Granulomatous Disease
5 Years
N/A
Both
Chronic Granulomatous Disease, Communicable Disease
Trial Information
Gene Therapy Approach for Chronic Granulomatous Disease
This is a Phase I/II clinical trial to determine the efficacy and safety of a method of ex
vivo gene therapy to treat both X-linked gp91phox deficient Chronic Granulomatous Disease
(CGD) and autosomal recessive p47phox deficient CGD. CGD is an inherited immune deficiency
in which blood neutrophils and monocytes fail to produce superoxide and other antimicrobial
oxidants, and patients get recurrent life-threatening infections. 30 CGD patients of either
sex at least 5 years of age may be enrolled in addition to the 5 patients enrolled in the
first phase of this trial. Patients less than 16 years of age must have an active infection
or a recent relapse of infection at the time of enrollment. Patients may receive up to 6
cycles of stem cell mobilization for gene therapy at intervals of 4 weeks or longer. For up
to first 3 cycles, a cycle of stem cell mobilization for gene therapy will begin with 8
daily subcutaneous injections of the combination of flt3-ligand (flt3L) at 50 micro g/kg/day
plus granulocyte-macrophage colony stimulating factor (GM-CSF) at 5 micro g/kg/day for
mobilization of CD34+ cells. For 3 or more of the cycles of mobilization of CD34+ cells for
gene therapy (up to the maximum of 6 cycles total), the mobilization will begin with 6 daily
injections of granulocyte colony stimulating factor (G-CSF) at 10 micro g/kg/day. On the
last two or three days of marrow growth factor administration for mobilization of CD34+
cells, the patients will have an apheresis procedure to harvest blood mononuclear cells,
thus completing a cycle of mobilization and stem cell harvest. CD34+ progenitors will be
selected from the apheresis collection using the Isolex(Registered Trademark) 300i anti-CD34
monoclonal antibody/magnetic bead selection system. The purified CD34+ cells may either be
placed directly into culture or may be cryopreserved as per standard blood bank procedure
(freezing in autologous serum with 10% dimethylsufoxide {DMSO}) and stored frozen at liquid
nitrogen temperature until thawed for ex vivo culture and transduction. For a specific gene
therapy treatment of intravenously infused, gene corrected stem cells, the purified CD34+
stem cells collected, purified and frozen from one or more cycles of mobilization will be
thawed and then pooled at the time of placement into culture for transduction with the virus
vector. CD34+ cells will be cultured in PL2417 gas permeable plastic containers that have
been pre-coated with fibronectin fragment CH-296. The growth medium will be serum-free
X-VIVO 10(Registered Trademark) supplemented with 1% human serum albumin, 100 ng/ml
flt3-ligand, 50 ng/ml PIXY321 and 50 ng/ml stem cell factor (SCF). Cultured CD34+
progenitors will be transduced on each of 3 or 4 days with either MFGS-p47phox or
MFGS-gp91phox retrovirus vectors. The retrovirus vectors are replication defective packaged
in amphotropic envelope lines engineered with the CRIP packaging elements (5'
LTR-gag-pol-3'SV40polyA; 5'LTR-AMenv-3'SV40polyA). MFGS-p47phox is packaged in the murine
psi-crip line, while MFGS-gp91phox is packaged in the human 293-SPA line. The clinical
retrovirus vector supernate will be animal protein-free and serum free. Safety testing for
endotoxin, sterility, and absence of replication competent retrovirus will be performed on
the retrovirus producer lines, virus particle lots, and transduced cells. Transduced CD34+
cells will be infused into the CGD patient. Thus, there will be a total of up to six cycles
of stem cell mobilization, but because the CD34+ cells from one or more cycles of
mobilization may be cryopreserved and then later pooled for culture to produce a single gene
corrected stem cell product for infusion, there may be fewer than six rounds (and possibly
only one round) of gene therapy treatments for a patient who participates in this study.
Blood will be tested periodically for the appearance and persistence of neutrophils that are
functionally corrected by the gene therapy. The efficacy goal for this study is to allow
CGD patients to produce autologous gene-corrected functionally normal NADPH oxidase positive
neutrophils to a level of at least 1 in 1000 circulating neutrophils for at least four
weeks. This may provide clinical benefit in the form of increased host defense against an
ongoing or potential infection. The clinical status of patients will be monitored for any
evidence of toxicity. Information obtained from this study will provide information
important for achieving the ultimate goal of the development of gene therapy for CGD that
will be a permanent cure for this disorder.
Inclusion Criteria
- INCLUSION CRITERIA:
Male or female; if concurrent infection is present or there has been recent multiple
relapse of infection with likely potential for additional relapse, then subjects may
include minors 5 to 17 years of age and adults of any age; if no concurrent infection is
present at enrollment then subjects must be adults of any age or minors 16-17 years of
age.
History of severe infections (two infections requiring hospitalization and intravenous
antibiotics).
Confirmed diagnosis of Chronic Granulomatous Disease as defined by less than 2 percent of
normal oxidant production by all circulating neutrophils.
Confirmed CGD genetic subtype of gp91(phox)-deficiency or p47(phox)-deficiency as defined
by the absence or deficiency of the phox subunit protein using an antibody detection assay
(western blot, ELISA, or flow cytometry) of patient granulocytes.
Subjects without current active infection or recent multiple recurrence of infections must
have adequate organ function as defined by renal function (creatinine less than or equal
to 2 mg per dl; less than or equal to 2+ proteinuria); hepatic function (bilirubin less
than or equal to 1.5 mg per dl; prothrombin time less than or equal to 1.3 x control);
hematologic function (WBC greater than or equal to 2500 per mm(3); granulocytes greater
than or equal to 1200 per mm(3); platelet greater than or equal to 100,000; hematocrit
greater than or equal to 26).
Successful mobilization as demonstrated by greater than or equal to 10 CD34+ cells per
microliter in peripheral blood on the day of the planned apheresis.
Must weigh at least 15 kg.
If a female of childbearing potential, then the patient must have a negative serum
pregnancy test within one week of beginning administration of combination flt3L and GM-CSF
or single agent G-CSF. Both male and female must use a barrier or other effective form of
contraception during marrow growth factor administration and for at least three months
following the last reinfusion of the transduced CD34 + PBHP.
Written informed consent, conforming to institutional guidelines obtained from patient
(and/or parent or guardian if a minor).
EXCLUSION CRITERIA:
Female patients who are pregnant or lactating as determined by history and/or positive
pregnancy test.
While patients may have an active infection under treatment and still be included in the
study, patients are excluded who are in shock, manifested by severe hypotension (less than
100 systolic or less than 60 diastolic) or severe hypoxia requiring mechanical ventilation
and piO(2) greater than 40 percent.
HIV antibody/antigen positive or hepatitis B, C antigen positive. (Exceptions to this
exclusion may be made on a case by case basis in consultation with the Transfusion
Medicine staff where severe bacterial or fungal infection is present).
Any condition which in the opinion of the attending physician or the Apheresis Unit staff
contraindicates apheresis procedures, such as cardiovascular instability, severe anemia
(hematocrit/hemoglobin below less than 26/8), in adequate venous access, and/or severe
coagulation disorder. Patients with severe infection who have a hematocrit/hemoglobin
below less than 26/8 and might benefit clinically from participation in this protocol may
undergo apheresis at the discretion of the physician in charge of the Apheresis Unit. In
that setting RBC transfusion may be used to raise the hematocrit/hemoglobin to a level
safe for apheresis.
Any condition which in the opinion of the principal investigator or the patient's primary
physician contraindicates administration of bone marrow growth factors at the indicated
doses, such as preexisting severe autoimmune vasculitis or other severe autoimmune
inflammatory conditions where augmentation of immune responses or infiltration of
granulocytes may exacerbate the condition.
Type of Study:
Interventional
Study Design:
Primary Purpose: Treatment
Authority:
United States: Federal Government
Study ID:
950134
NCT ID:
NCT00001476
Start Date:
June 1995
Completion Date:
December 2010
Related Keywords:
- Chronic Granulomatous Disease
- Communicable Disease
- CD34+ Progenitor
- Retrovirus
- Leukapheresis
- Transduction
- Granulocytes
- Chronic Granulomatous Disease
- Communicable Diseases
- Infection
- Granulomatous Disease, Chronic
- Granuloma
Name | Location |
|---|---|
| National Institutes of Health Clinical Center, 9000 Rockville Pike | Bethesda, Maryland 20892 |
