Leukemia, Lymphoma, MDS
Conditions
Keywords
ATLG, ATG, immune reconstitution, allo-HSCT
Brief summary
Allogeneic hematopoietic stem cell transplantation is the only curative treatment for malignant hematologic diseases. However, immune rejection is a major limitation in its application. In the "Beijing Protocol", the use of granulocyte colony-stimulating factor (G-CSF) in combination with anti-thymocyte globulin (ATG) can achieve "everyone has a donor". The use of ATG, however, can interfere with the recovery of immune function after transplantation, increasing the risk of life-threatening complications such as viral infections or graft-versus-host disease. Rabbit anti-human T-lymphocyte immunoglobulin (ATLG) is currently approved for the prevention of organ transplant rejection, which is produced differently from ATG. Previous studies have shown that transplant preconditioning with ATLG is effective in preventing graft-versus-host disease and even reduces the incidence of cytomegalovirus, etc. after transplantation. In this study, we will prospectively apply containing ATLG in a cohort of allogeneic hematopoietic stem cell transplantation for malignant hematologic diseases and dynamically observe the state of immune reconstitution of patients after transplantation. We will also compare it with a matched cohort of conventional combined ATGs during the same period to explore the impact of ATLG on immune reconstitution after transplantation.
Detailed description
Hematological malignancies (referred to as malignant hematological diseases) are a class of major diseases that pose a significant threat to human health. Currently, allogeneic hematopoietic stem cell transplantation (allo-HSCT) remains an effective, if not the sole, treatment option for hematological tumors. Due to the potential for immune rejection, HSCT has historically been constrained to HLA-compatible siblings or non-consanguineous donors, significantly restricting its clinical application. In consideration of the findings from preceding studies, Huang's research team employed the immunomodulatory property of G-CSF in conjunction with anti-thymocyte globulin (ATG) to undertake the non-in vitro eradication of T lymphocytes for haplotype-conjugate HSCT. A series of studies were published in 2004 and 2013 that utilized G-CSF in combination with ATG to facilitate HSCT implantation. These studies demonstrated a correlation between the degree of HLA non-conformity and the degree of graft-versus-host disease (GVHD). This suggests that G-CSF combined with ATG successfully crosses the human leukocyte antigen (HLA) barrier, and that haploidentical transplantation has gradually become the most clinically utilized type of transplantation. However, clinical studies and real-world results have demonstrated that the application of ATG has the potential to enhance the risk of post-transplant cytomegalovirus (CMV), EBV activation or even infection, and post-transplant lymphoproliferative disease (PTLD). A study published in 2023 utilized a retrospective analysis of clinical outcomes to examine patients who received two distinct sources of allogeneic T-cell-depleted (ATG) transplants. The findings indicated that patients who received ATLG during transplantation exhibited a reduced incidence of cytomegalovirus (CMV) infection. In a seminal study, Wang Shunqing and colleagues investigated the role, toxicities, and effects of ATG/ATLG on transplantation complications in non-myeloablative hematopoietic stem cell transplantation. Their findings demonstrated that the administration of ATG/ATLG during non-myeloablative hematopoietic stem cell transplantation was both safe and effective. Notably, it was observed to promote the implantation of hematopoietic stem cells, reduce the incidence of acute graft-versus-host disease (aGVHD), and decrease its severity. Huang Wenrong and colleagues investigated the effectiveness and safety of ATLG/ATLG in unrelated donor allogeneic peripheral hematopoietic stem cell transplantation. The study demonstrated that ATLG significantly reduced the incidence of cGVHD, decreased the occurrence of adverse events, and effectively controlled the occurrence of aGVHD. Lu Daopei et al. investigated the effectiveness and safety of ATG/ATLG in haploidentical hematopoietic stem cell transplantation to prevent graft-versus-host disease (GVHD). Their findings indicated that the dosage of ATG, at 7.5 mg/kg, was equivalent to the dosage of ATLG, at 20 mg/kg, in the context of haploidentical hematopoietic stem cell transplantation. Consequently, ATLG has been extensively utilized for immunosuppressive therapy in patients with hematologic disorders undergoing hematopoietic stem cell transplantation. A paucity of studies currently exists on the effect of ATLG on immune reconstruction after HSCT and on comparison with ATG treatment modalities. The objective of this study is to prospectively apply ATLG pretreatment in a cohort of allogeneic HSCT for malignant hematologic diseases. The study will dynamically observe the status of immune reconstruction in post-transplantation patients and compare it with a cohort of conventional combined ATG during the same period. The primary research question guiding this study is to explore the effect of ATLG on immune reconstitution after transplantation.
Interventions
DRUGRabbit Anti-Human T-Lymphocyte Immunoglobulin (ATLG)
Patients in the ATLG arm receive ATLG instead of ATG as part of the routine conditioning regimen before allo-HSCT; ATLG is given intravenously by infusion for 4 consecutive days, after which they undergo routine transplantation.
Sponsors
Peking University First Hospital
Study design
Allocation
NON_RANDOMIZED
Intervention model
SINGLE_GROUP
Primary purpose
PREVENTION
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* 1）Age ≧18 years, gender is not limited; * 2）Histologically or cytologically confirmed diagnosis of malignant hematologic diseases; * 3\) First time undergoing allogeneic hematopoietic stem cell transplantation; * 4\) ECOG score 0-2; * 5\) Hepatic and renal function, cardiopulmonary function meet the following requirements. * Serum creatinine ≤ 1.5 ULN; ②Left ventricular ejection fraction ≥ 45%; * Blood oxygen saturation \>91%; * Total bilirubin ≤ 2 × ULN; ALT and AST ≤ 3 × ULN; for ALT and AST abnormalities due to disease (e.g., liver infiltrates or bile duct obstruction), in the judgment of the investigator, the values may be adjusted to ≤ 5 × ULN; * 6\) Expected survival is longer than 12 weeks; * 7\) The subjects will voluntarily and strictly comply with the requirements of the study protocol and will sign a written informed consent form.
Exclusion criteria
* 1\) Prior treatment with ATG, ALG, or ATLG drugs within the past six months; * 2\) Allergic to any component of ATLG or ATG; * 3\) Bacterial, viral, parasitic, or mycobacterial infections not adequately controlled by treatment, i.e., inability to undergo hematopoietic stem cell transplantation due to severe infection. 4\) Women who are pregnant or breastfeeding, or participants of childbearing potential who are unwilling or unable to use effective methods of contraception; 5) Participants enrolled in another clinical trial (of any investigational drug or device) within 30 days prior to the subject's baseline visit. (Subjects enrolled in observational studies are eligible to participate). 6\) Any other circumstance that, in the judgment of the investigator, may interfere with the conduct of the clinical trial and the determination of the results of the trial.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Incidence of viral infections after hematopoietic stem cell transplantation | From enrollment to 1 year after allo-HSCT | Incidence of CMV reactivation (CMV DNA ≥10\^3) and CMV disease, incidence of EBV reactivation (incidence of EBV DNA ≥10\^5) and lymphoproliferative disorders (PTLD), incidence of hemorrhagic cystitis, incidence of herpes simplex, adenovirus, or other viruses in both groups. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Incidence and severity of acute GVHD (aGVHD) | From enrollment to the 100days after transplantation | Acute GVHD is assessed and graded based on the modified Glucksberg criteria or the Mount Sinai Acute GVHD International Consortium (MAGIC) criteria, which evaluate the degree of involvement of the skin, gastrointestinal tract, and liver. Severity is classified as grade I (mild), II (moderate), III (severe), or IV (life-threatening). The cumulative incidence of overall aGVHD, as well as grade II-IV and grade III-IV aGVHD, will be evaluated at day 100 post-transplantation. |
| Incidence and Severity of Chronic Graft-Versus-Host Disease (cGVHD) | With a minimum follow-up of 2 years for all enrolled patients | Chronic GVHD is diagnosed and graded according to the National Institutes of Health (NIH) consensus criteria, which classify cGVHD as mild, moderate, or severe based on the number of organs involved and the degree of functional impairment in each affected organ. The cumulative incidence of cGVHD will be evaluated at 6 months, 12 months, and 24 months post-transplantation |
| Immune Reconstitution Profiles Post-Transplantation | From enrollment to the one year after trandplant | Immune reconstitution is assessed by measuring the absolute counts of peripheral blood lymphocyte subsets using multi-color flow cytometry. The following cell populations are quantified: CD4+ T helper cells, CD8+ cytotoxic T cells, CD19+ B cells, and CD3-CD56+ natural killer (NK) cells. Measurements are performed at four pre-specified time points post-transplant: day 30, day 60, day 90, and day 180. The absolute counts (cells/µL) and the recovery kinetics of each lymphocyte subset will be analyzed and compared between treatment groups. |
| Overall Survival (OS) | From enrollment to the 2 years post-transplantation. | Overall survival is defined as the time interval from the date of hematopoietic stem cell transplantation to the date of death from any cause. Patients who are alive at the last follow-up will be censored. OS rates will be estimated using the Kaplan-Meier method and reported at 100 days, 1 year, and 2 years post-transplantation. |
| Disease-Free Survival (DFS) | From enrollment to the 2 years post-transplantation | Disease-free survival is defined as the time interval from the date of hematopoietic stem cell transplantation to the date of first documented disease relapse, disease progression, or death from any cause, whichever occurs first. Patients who remain alive and in complete remission at the last follow-up will be censored. DFS rates will be estimated using the Kaplan-Meier method and reported at 1 year and 2 years post-transplantation. |
| Cumulative Incidence of Relapse (CIR) | From enrollment to 2 years post-transplantation | Cumulative incidence of relapse is defined as the probability of hematologic disease recurrence after transplantation, with death from any cause without prior relapse considered as a competing risk. Relapse is defined according to standard disease-specific criteria, including bone marrow morphology, flow cytometry, cytogenetics, or molecular assays as clinically indicated. The cumulative incidence of relapse will be estimated using the competing risk method at 1 year and 2 years post-transplantation. |
| Transplant-Related Mortality (TRM) | From enrollment to the Transplant-Related Mortality (TRM)2 years post-transplantation | Transplant-related mortality is defined as death occurring during the post-transplant period without evidence of disease relapse or progression. Causes of death are attributed to transplantation-related complications, including but not limited to severe GVHD, infections, organ toxicity, graft failure, or other treatment-related adverse events. TRM will be estimated using the cumulative incidence method, with relapse as a competing risk, and reported at 100 days, 1 year, and 2 years post-transplantation. |
| Non-Relapse Mortality (NRM) | From enrollment to the 2 years post-transplantation. | Non-relapse mortality is defined as death from any cause other than disease relapse or progression. This endpoint is closely related to transplant-related mortality and encompasses all deaths occurring while the patient is in complete remission or without evidence of active malignancy. Competing risk analysis will be performed, with relapse treated as a competing event, and cumulative NRM rates will be estimated at 100 days, 1 year, and 2 years post-transplantation. |
| Incidence of Adverse Events Related to ATLG Administration | From enrollment to the 1 week of last dose of ATLG infusion | Adverse events are monitored and recorded throughout the study period from the initiation of ATLG infusion through day 100 post-transplantation. Specific adverse events of interest include infusion-related reactions (e.g., chills, rigors, hypotension, or anaphylaxis), rash, fever (defined as body temperature ≥38.3°C), and shock. All adverse events are graded according to the Common Terminology Criteria for Adverse Events (CTCAE) version 5.0. The incidence of any adverse event, as well as the incidence of grade 3 or higher adverse events, will be summarized descriptively. |
Countries
China
Contacts
CONTACTJialin Zhu, MD
CONTACTBingjie Wang, MD
Outcome results
None listed