Phase I/II Safety and Efficacy Study of Gene Transfer for Artemis-Deficient Severe Combined Immunodeficiency (ART-SCID) in Newly Diagnosed Patients Using Self-Inactivating Lentiviral Vector (AProArt) to Transduce Autologous CD34 Hematopoietic Cells

Children with SCID generally do not survive beyond the first year of life without definitive treatment. The most effective current cure is hematopoietic stem cell transplant (HCT) with a human leukocyte antigen (HLA) matched sibling. While a matched sibling HCT can successfully treat ART-SCID, fewer than 20% of affected children have such a donor, and even when a matched sibling donor is available there is often incomplete T and B cell immune reconstitution. ART-SCID is the most difficult type of SCID to cure by hematopoietic stem cell transplant using alternative donors. Engraftment typically requires intensive conditioning with high dose alkylating agents to prevent rejection and to open marrow niches. These patients also have a high risk of developing graft versus host disease (GVHD) when alternative donors are used. The great majority of patients have absent B cell reconstitution and require lifelong administration of immunoglobulin infusions. Patients with ART-SCID who do receive high doses of alkylators, especially when 2 agents are used, have poorer survival, abnormal dental development, endocrinopathies, and short stature in comparison with children exposed to no or limited alkylators or children with SCID types that are not associated with a DNA repair defect. For these reasons, a safer, more effective approach to curing ART-SCID is needed. Autologous gene-corrected hematopoeitic stem cell transplant may eliminate both the risk of GVHD and the need for alkylators to prevent rejection.

The study design is a single-cohort, longitudinal experiment using non-randomized patients treated once with a lentiviral vector for gene-correction of Artemis-deficient SCID after conditioning with low-dose busulfan. No formal control group is planned for gauging safety; rather, intensive monitoring of the initial 6 enrollees was undertaken to preclude continued accrual in the presence of safety signals. This enrollment stage was completed in 2019 with no safety signals identified, and long-term safety will be monitored for 15 years. Bone marrow stem cells will be harvested from participants, and CD34 cells will be isolated using the CliniMACS® CD34 Reagent System cell sorter device. The CD34 cells will be transduced with the AProArt lentiviral vector, and cryopreserved. Aliquots of the cells will undergo safety testing and be reserved for potency evaluation. All patients will receive busulfan conditioning targeted over 2 days to achieve a cumulative area under the curve (AUC) of 20 mg*hr/L (an ablative cumulative AUC is 60-90mg*hr/L).

Following the infusion of AProArt-transduced cells, patients will be assessed weekly through 12 weeks post-transplant and at week 16, monthly through month 6 post-transplant, every 3 months through month 24, every 6 months during years 2-5, and then annually through year 15. Assessments will include physical examination, clinical laboratory tests, collection of specimens for research studies, and completion of Quality of Life questionnaires. Neurodevelopmental testing will be performed at age-appropriate time points.

At weeks 4, 6, 8, 12, 16, and 24, research specimens will be evaluated for evidence of gene transduced peripheral blood mononuclear cells and when possible, cell lineages including T, B, NK and granulocyte/myeloid cells. If there is no evidence of gene transduced cells at 6 weeks (42 days) post infusion, planning for an alternative treatment will begin, with the final decision regarding further therapy to be based on gene-marking results at 10 weeks.

If the absolute neutrophil count is < 200/µl or platelets < 20,000/µl on 3 independent determinations after day 42 post infusion of transduced cells, the patient may receive an allogeneic hematopoeitic stem cell transplant. Patients who were neutropenic prior to conditioning (SCID-related neutropenia) but responsive to granulocyte-colony stimulating factor (GCSF) will not be considered to have failed, provided the absolute neutrophil count can be maintained above >300/µl with GCSF.