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l d l d dCan Autologous Cord Blood Correct Acquired 

Brain Injuries in Pediatric Patients?

Joanne Kurtzberg, MDPediatric Blood and Marrow Transplant Program

J li R b C ll l d T l i l Th PJulian Robertson Cellular and Translational Therapy ProgramCarolinas Cord Blood Bank

Duke University Medical Center

-“First do no harm” does not mean do nothing?-Studies spanning the bench to the bedside and back againare needed to develop the next steps forward in medicine.-

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1988 2008First in ManIn a childNo preclin tox

UCBT History

1st Transplant, France 1988 – MRD

1st bank NYBC 19921st bank, NYBC 1992

1st unrelated transplant, Duke 1993

Now >30 ,000 transplants; >140 banks

Inventory ~180K US, 800K worldwide

FDA Licensure 10/20/2011

NMDP IND 10/20/2011NMDP IND 10/20/2011

CW Bill Young Cell Transplantation Program– Coordinating centers, registry, outcomes database

– NCBI banking network; sibling program

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How does  SCT correct inborn errors of metabolism?

Marrow and immunoablation

Replacement with donor cells

Donor leukocytes produce enzyme which is distributed through blood circulation

Cells cross blood brain barrier, replace enzyme in brain “Cellular Enzymeenzyme in brain “Cellular Enzyme Replacement Therapy”

Non‐hematopoietic cell engraftment

Is this Non‐Homologous use?

DiagnosisDiagnosis NN (%)(%)

ALDALD 1313 8.2%8.2%

GM1 GangliosidosisGM1 Gangliosidosis 11 0.6%0.6%

Hunters SyndromeHunters Syndrome 55 3.1%3.1%

Hurlers SyndromeHurlers Syndrome 5050 31.4%31.4%

MA PrepBu/Cy/ATG

GvHD ProphylaxisCSA/S i

Hurlers SyndromeHurlers Syndrome 5050 31.4%31.4%

II--cell diseasecell disease 11 0.6%0.6%

Krabbe diseaseKrabbe disease 3636 22.6%22.6%

LeschLesch--Nyhan diseaseNyhan disease 44 2.5%2.5%

MLDMLD 1313 8.2%8.2%

MaroteauxMaroteaux--LamyLamy 11 0.6%0.6%

NeimanNeiman--Pick BPick B 22 1.3%1.3%

CSA/SteroidsCSA/MMF

IVIGExtensive Supportive Care

PMDPMD 11 0.6%0.6%

Sandhoff diseaseSandhoff disease 33 1.9%1.9%

Sanfillipo SyndromeSanfillipo Syndrome 1919 11.9%11.9%

Tay SachsTay Sachs 99 5.7%5.7%

Alpha manosidosisAlpha manosidosis 11 0.6%0.6%

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VP16

Slide 8

VP16 10 years of age; oldest brother died; transplanted at 3 weeks and 13 months of age; cognitively normal but motor involvement

Gina (yellow T-shirt) There was one normal child born; Transplanted at 5 weeks of age

Madison Tierney - delivered early and transplaned at around 38 weeks gestation; PGD failure; Now 3 years old; Picture at 2 years; AIHAVinod Prasad, 4/12/2007

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SCT for Krabbe Disease

*NB Screeningg

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Engraftment of UCB cells in Brain

Choroid plexusCortical White Matter

Brain sections of a female Krabbe patient who died 1 year post UCBT. XY Fish demonstrates male (donor, blue dot) cells engrafting in and differentiating in brain.

Fiber Tract Analysis in Newborns with Krabbe Disease

M Escolar, CDL, NFRD, UNC-CH

VP18

Slide 12

VP18 aLL 2-3 DAYS OF AGE tIERNEY, bORRASSA, Degan Miles;Cerebral pudencle - k4 and k6 are normal (yellow is myelination) Middle - Bourassa - less fibres, no myelin; the outcome of the motor function worse in the middle child.Vinod Prasad, 4/12/2007

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FA RatioRight Corticospinal Tract

1.25

ControlsKrabbe

FA RatioLeft Corticospinal Tract

1.25

ControlsKrabbe

FA Ratio of the Corticospinal Tracts in Krabbe Newborns Compared to Controls

0.75

0.83

0.92

1.00

1.08

1.17

FA

rat

io (

actu

al F

A/E

xp

ec

ted

FA

)

KrabbeControl MeanKrabbe Mean

0.75

0.83

0.92

1.00

1.08

1.17

FA

rat

io (

actu

al F

A/E

xpec

ted

FA

)

KrabbeControl MeanKrabbe Mean

0.66

250 260 270 280 290 300 310 320 330 340 350

Gestational Age at Scan (days)

0.66

250 260 270 280 290 300 310 320 330 340 350

Gestational Age at Scan (days)

The red triangles represent the 6 Krabbe patients while the blue diamonds show the typical controls. The horizontal black lines represent the standard deviations based on the controls.

Escolar et al, AJNR Am J Neuroradiol. 2009 May;30(5):1017-21.

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Shiverer Neuronal Cell/UCB-Derived Oligodendrocyte Co-Culture demonstrating oligodendrocyte (circled) closelyCulture demonstrating oligodendrocyte (circled) closely

associated with myelinated shiver neuron axonal process

Next Steps – “O‐cell” Phase I

Submit IND for Safety/Phase I trial in children ith d d LSDwith advanced LSDs

‐Intrathecal Administration

‐If safe, combine with tacrolimus

If safe, combine with standard transplant for infants with GLD and damaged cortico spinalinfants with GLD and damaged cortico‐spinal tracks

Potential Collaboration with Cellsense to track cells and monitor duration of engraftment 

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Autologous UCBT at Duke

CP, HIE, congenital hydrocephalus, other b i i j ibrain injuries

Hypotheses:  – UCB contains anti‐inflammatory cells that could inhibit the 

inflammatory response  or induce endogenous repair through paracrine effects after acute injury

– UCB contains neural cell progenitors that could facilitate repair and regeneration.

– UCB cells cross the blood brain barrier

– UCB cells reach brain and improve motor function in a HIE model in rabbit pups (Tan et al)

**Is durable engraftment necessary or is transient engraftment enough?

Cellular Therapy for Acquired Neurological Injury

Animal models of brain injury via stroke, hypoxia, and trauma demonstrate benefit of UCB cells in neurologic outcome and survival

Rabbit model of HIE & cerebral palsy:

Ligate uterine artery one day prior to birth

Peripheral IV infusion of UCB or control

MRI @ 24 hours 

control Feridex‐labeled UCB 

Ji X. et al, Stroke 2007, 38 (2 Suppl), 731‐5.

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Autologous UCBT at Duke

HIE Study “Babybac”l / fCooling +/‐ UCB infusion

Auto UCB infusion (volume reduced, fresh CB)

HLHS/ECMOCryopreseved cord blood

HIE/pre CP: 14 day‐12 month old study/p y yCryopreserved cord blood

CP ages 1‐6 Cryopreserved cord blood

HIE Pilot Study

• After verbal assent, UCB collected in standard anticoagulant bag citrate phosphate dextrose (CPD)bag citrate‐phosphate‐dextrose (CPD)

• If baby meets eligibility for HIE and cooling, written consent obtained 

• CB RBC and Plasma depleted on Sepax after incubation with Hespan

• Baby pretreated with hydrocortisone  prior to infusion

• Cells dosed 1 5 x 107 cells q24 hours x 4 max; done by 72• Cells dosed 1 ‐ 5 x 107 cells q24 hours x 4 max; done by 72 hours postnatal (cells must be frozen by 72 hours)

• Volume < 5 ml per kg; RBC <2cc/kg

• Monitor vital signs during and after infusions

• Record AE and SAE, 12 month follow‐up 

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-Baby born, in distress;-OB obtains assent to collect CB;-CB collected, mom consented for study;-CB processed into 4, 5ml aliquots;-Baby dosed daily x 4 (<6h, 24h, 48h, 72h)72h).

Small, critically ill babies, limited time.

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Cord blood collections, infants cooled, and subjects enrolled 7/09‐ 3/11

MFM collaboration February 2010

64 Units collected

28 Cooled*

15 enrolled;No misses

Subject Characteristics

Characteristics n = 15 Mean (range) or N (%)

Gestational Age, wks 37.5 (35, 40)

Birthweight kg 3 2 (2 1 4 6)Birthweight, kg 3.2 (2.1, 4.6)

Abruption 3 (20)

Non-reassuring fetal heat rate 6 (40)

Males 6 (40)

Outborn 3 (20)

5 minute Apgar < 5 12 (80)

10 minute Apgar < 5 10 (67)

Moderate encephalopathy 14 (93)

Cord pH 6.96 (6.6, 7.3)

Base Deficit -19 (-10, -32)

Seizures 5 (33)

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Feasibility Measures

Measures Mean (range) or N (%)

Verbal consent for cord blood collection 10 (67)

Volume Collected, ml 43 (3, 171)

# Cells Collected (x 108) 7.7 (0.97, 31.2)

Time to first infusion< 6 hr> 6 hr

25 hr (3.9, 220)5 (33)

10 (67) +1

Number of infusions4 10 (67)4321

10 (67)3 (20) + 1

0 (0)2 (13)

Infusion volume ml 4.3 (1.1, 10)

Efficacy Endpoints

• Descriptive in Pilot

• Identical to neonatal network cooling study for randomized study

– Survival at 18 months

– Incidence and severity of CP at 18 monthsIncidence and severity of CP at 18 months

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Autologous UCB in Children with Acquired Neurologic Disorders – Phase I

Auto UCB infusions in children with acquired neurological disorders to assess safety andneurological disorders to assess safety and feasibility

Patients were self‐referred or referred by their treating physicians & voluntarily traveled to Duke 

Most CBUs were retrieved from private cord blood banksbanks

Retrospectively analyzed quality parameters of autologous CBUs and compared to CBUs publicly banked at the Carolinas Cord Blood Bank

CBU Acceptance Criteria for Infusions

Pre‐cryopreservation cell count documented

TNC:  ≥ 1 x 107 cells/kg

Bacterial culture performed and negative

Maternal infectious disease markers performed and negative

Identity confirmed (HLA)

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Patient Characteristics

3/2004 to 12/2009

184 patients, 198 infusions

Gender:  99 male, 85 female

Age:  median 2.3 years, range 6 days – 9 years

Diagnoses:Cerebral palsy, 76%

Congenital hydrocephalus, 12%

Other injuries, 12%

Infusions

Well‐tolerated

Three infusion reactions (urticaria, wheezing)Responded to Benadryl, bronchodilators

2/3 infusions stopped, cells discarded

One mother developed hives, treated with oral Benadryloral Benadryl

No clinically apparent infections

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?Efficacy?

Very hard to determinePlacebo effectsPlacebo effectsEmpowerment

Many positive anecdotes Impressions of benefit in babies with severe HIE and congenital hydrocephalus

Impressions of benefit in children with mild to d Cmoderate CP

A randomized trial is needed to answer the question

Total Nucleated Cell Counts

14% would meet NCBI criteria

Median TNC 4.8x108

Median TNC 10.9x108

Volume 60.1ml

Volume 89.0ml

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““CPCP‐‐ACAC”” (IND)(IND)

•• Randomized, placeboRandomized, placebo‐‐controlled trial of autologous controlled trial of autologous CB in children with spastic CPCB in children with spastic CPCB in children with spastic CPCB in children with spastic CP–– Ages 1Ages 1‐‐6 6 yrsyrs–– Eligible cord bloodEligible cord blood–– GMFM level (IIGMFM level (II‐‐IV)IV)

•• Blinded/crossBlinded/cross‐‐over over designdesign–– Baseline, 1 Baseline, 1 yryr, 2yrs, 2yrs

•• Evaluations by examEvaluations by exam neurocogneurocog//fxnlfxnl testing MRItesting MRIEvaluations by exam, Evaluations by exam, neurocogneurocog//fxnlfxnl testing, MRI testing, MRI (functional in older pts), (functional in older pts), TMS, CB microarrays, QOLTMS, CB microarrays, QOL

•• Primary Primary EndpointEndpoint: >30% increase in predicted : >30% increase in predicted GMFM GMFM score at 1 yearscore at 1 year

•• Activated 7/2010, currently enrolling, n=30 to dateActivated 7/2010, currently enrolling, n=30 to date

Phone screen

Qualifiyingi i

CBU screen and CBU screen and shipment to 

duke

visit

*Placebo = TC199 + 1% DMSO

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High-Resolution DTI Tractography3x3x3 mm3

2x2x2 mm3

1x1x1 mm3

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High Resolution DTI Tractography

Face

Hand

Foot

Cerebrospinal Tract (CST)

ROIs(Seed Areas)

3x3x3 mm3 2x2x2 mm3 1x1x1 mm3

HealthyC b l

Motor Cortex

DTI in Cerebral Palsy

HealthyControlCerebralPalsy(left hemiplegic)

cst(right)

cst(left)

Spine

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WhatWhat’’s Next?s Next?

Randomized multicenter trial in HIERandomized multicenter trial in HIECooling alone vs Cooling + UCBCooling alone vs Cooling + UCBCooling alone vs Cooling + UCBCooling alone vs Cooling + UCB

Feasibility pilot collecting and characterizing Feasibility pilot collecting and characterizing UCB from premature infants for possible UCB from premature infants for possible treatment post IVH in premiestreatment post IVH in premiesUCB in HLHSUCB in HLHSUCB in TBI/StrokeUCB in TBI/StrokeUCB in TBI/StrokeUCB in TBI/StrokeOligo trialOligo trialOther targeted cell therapiesOther targeted cell therapies

ObstaclesObstacles

CostsCostsDo we need animal models?Do we need animal models?Do we need animal models?Do we need animal models?

Safety Safety vsvs efficacyefficacyMaybe not?Maybe not?

Animal models do not mimic human pediatric diseasesAnimal models do not mimic human pediatric diseasesIf risk is small, not necessary?If risk is small, not necessary?

AccrualAccrualWhat about patients without auto cord blood?What about patients without auto cord blood?What about patients without auto cord blood?What about patients without auto cord blood?

EndpointsEndpointsChildren improve anyway, Children improve anyway, distinquishingdistinquishing natural natural improvement from treatment effects is difficult.improvement from treatment effects is difficult.

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BLA:  Public Cord Blood BanksBLA:  Public Cord Blood Banks

•• Applying drug regs to cellsApplying drug regs to cells•• 1 batch = 1 unit1 batch = 1 unit

S bili /E i i dS bili /E i i d•• Stability/Expiration datesStability/Expiration dates•• ?Pre?Pre‐‐clinical tox clinical tox ––already in man for 20+ yearsalready in man for 20+ years•• Requalifying FDA approved supplies/reagentsRequalifying FDA approved supplies/reagents•• Increased costs!Increased costs!•• Disconnects between existing networks and FDADisconnects between existing networks and FDA

–– E.g. CIBMTR/NMDP outcomes reportingE.g. CIBMTR/NMDP outcomes reporting•• RetroRetro‐‐fitting regulations on clinical practicefitting regulations on clinical practice

•• Metabolic IndicationsMetabolic Indications•• Metabolic IndicationsMetabolic Indications–– Rare diseases, few patientsRare diseases, few patients–– Fatal infantile forms, must be studied in babiesFatal infantile forms, must be studied in babies–– Late effects/followLate effects/follow‐‐ups not a bank responsibilityups not a bank responsibility–– Indications cannot be bank centric as units are selected by cell Indications cannot be bank centric as units are selected by cell 

dose and matchdose and match–– Currently FDA will license CB for Hurler, ALD, Krabbe.   Other Currently FDA will license CB for Hurler, ALD, Krabbe.   Other 

similar diseases have not been included.   similar diseases have not been included.   

Ideas for change

• We need………………………….

– New regs for cellular therapies

– Novel statistical methods to assess short term endpoints that correlate with long term outcomes

– Revisions of regulations for infants and children to participate in clinical trials

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Pediatric Blood and Marrow Transplant Team Pediatric Blood and Marrow Transplant Team at Dukeat Duke

Research Fellows: Kevin Shoulars, Research Fellows: Kevin Shoulars, Jessica Sun, Lisa Tracy, Rael CasperiJessica Sun, Lisa Tracy, Rael Casperi

Acknowledgements

Stem Cell LaboratoryStem Cell Laboratory

Carolinas Cord Blood BankCarolinas Cord Blood Bank

Duke DTMI/CT2 Duke DTMI/CT2

Jessica Sun/Mohamed Mikati/Gordon WorleyJessica Sun/Mohamed Mikati/Gordon Worley

Allen SongAllen Song

Katie Gustufson and ND TeamKatie Gustufson and ND Team

Sid TanSid Tan

Mike Cotton and Ron GoldbergMike Cotton and Ron Goldberg

Maria Escolar and her team at UNCMaria Escolar and her team at UNC

NHLBI & The EMMES CorpNHLBI & The EMMES Corp

HRSA & NMDPHRSA & NMDP

The Julian Robertson FoundationThe Julian Robertson Foundation

Our Patients and their parents and families