Combined Bone Marrow and Renal Transplantation for Hematologic Disorders With End Stage Renal Disease
Combined Bone Marrow and Renal Transplantation for Hematologic Disorders With End Stage Renal Disease
This pilot trial offers the unique opportunity for both the treatment of multiple myeloma or
 systemic AL amyloidosis for which hematopoietic stem cell transplantation would be ordinarily
 indicated and the reversal of end-stage renal failure, while avoiding the risks associated
 with long-term standard anti-rejection therapy used in renal transplantation. The primary
 objectives of this study are to assess renal allograft tolerance (that is, the acceptance of
 the kidney without the need for anti-rejection therapy), assess anti-tumor response rates in
 multiple myeloma and AL amyloidosis, and assess complication rates for genetically (HLA)
 matched related donor combined bone marrow and kidney transplantation using a low dose total
 body irradiation based preparative regimen.
The induction of transplantation tolerance involves the specific elimination of the immune
 response to the transplant but not to other antigens. In the realm of kidney transplantation,
 tolerance means that the recipient is unable to detect the donor transplant kidney as
 foreign, and therefore the recipient is unable to reject the kidney. Donor bone marrow
 engraftment leads to kidney graft tolerance in animal models. Renal failure is a major
 complication of multiple myeloma and AL amyloidosis for which the only known cure is
 allogeneic bone marrow transplantation. Standard bone marrow transplantation is associated
 with prohibitive toxicities in patients with end stage renal disease, and is generally not
 considered an option for those patients. Patients with multiple myeloma and AL amyloidosis
 are excluded from conventional renal transplantation protocols because of their underlying
 malignancy. A less toxic bone marrow transplantation protocol, utilizing low dose total body
 irradiation and anti-thymocyte globulin, combined with renal transplantation, could provide
 an opportunity for cure of the myeloma or amyloidosis and correction of end stage renal
 disease. In addition, successful marrow engraftment may be expected to lead to a state of
 tolerance. Successful implementation of tolerance would be a major benefit to transplant
 recipients. The significance of developing tolerance is that the patient could be spared the
 disabling complications of indefinite immunosuppression, which include infections, cataracts,
 osteoporosis, diabetes, atherosclerosis, hypertension, and malignancy.
Participant Inclusion Criteria

 -  Participants with end-stage renal failure due to or in association with multiple
 myeloma or systemic AL amyloidosis which hematopoietic cell transplantation is
 appropriate and a ≥ 50% five-year survival probability with transplantation is
 expected. This includes, but is not limited to:

 -  Multiple myeloma (MM), ISS stage II or III in complete or very good partial remission

 -  AL amyloidosis without significant cardiac disease

 -  Males or females 18 - 65 years of age.

 -  Participants must have an HLA-matched or one of six HLA A, B, or DR antigen-mismatched
 related donor, with high resolution molecular class I and II allele typing.

 -  Men and women of reproductive potential must agree to use a reliable method of birth
 control during the treatment, and women should do so for a period of 2 years following
 the transplant.

 -  Participants should be on dialysis or have a CrCl <20 ml/min.

 -  Patients should not have evidence of renal recovery of their renal failure over a 90
 day period of therapy for their underlying malignancy or other blood disorder.

 -  .

 -  Patients with a history of other malignancies excluding basal cell carcinoma of the
 skin and carcinoma in situ of the cervix with a disease-free survival interval of >2
 years. Patients with the following malignancies must demonstrate a 5 year disease-free
 survival:

 -  Breast cancer with positive nodes

 -  Malignant melanoma (other than in situ)

 -  Colorectal cancer (other than Dukes Stage A or B1)

 -  Patients with multiple myeloma must have received previous treatment with a
 bortezomib-based regimen.

 Patients with AL amyloidosis must have received previous treatment with a bortezomib-based
 regimen and/or autologous stem cell transplantation

 -  Patients with a history of malignant melanoma must be reviewed by an independent
 oncologist prior to enrollment.

 -  Recipient ability to understand and provide informed consent.

 Participant Exclusion Criteria

 -  Evidence of active infection as defined by: a) clinical syndrome consistent with viral
 or bacterial infection (e.g., influenza, URI, UTI) or b) fever with a clinical site of
 infection identified, or c) microbiologically documented infection, including, but not
 limited to, bacteremia or septicemia.

 -  Participation in other investigational drug use at the time of enrollment.

 -  Contraindication to therapy with any one of the proposed agents (e.g., history of
 allergy to horse serum in ATG).

 -  Serologic positivity to HIV or HCV.

 -  Women of childbearing age in whom adequate contraception cannot be maintained.

 -  AST/ALT > 3 x normal or bilirubin > 1.5 x normal (unless due to Gilbert's syndrome).

 -  Pregnancy or uncontrolled serious medical illness not related to underlying myeloma.

 -  Cardiac ejection fraction < 40% by echocardiogram.

 -  FEV1 < 50% predicted or corrected DLCO < 50% predicted.

 -  ABO blood group incompatibility in the host-vs-graft direction.

 -  Diagnosis of myelodysplastic syndrome

 Donor Inclusion Criteria

 -  HLA-matched or one of six HLA A, B, or DR antigen-mismatched related male or female
 donor 18-65 years of age.

 -  ECOG performance status 0 or 1.

 -  Excellent health per conventional pre-donor history (medical and psychosocial
 evaluation).

 -  Acceptable laboratory parameters (hematology in normal or near-normal range; liver
 function < 2 times the upper limit of normal and normal creatinine).

 -  Compatible ABO blood group.

 -  Negative donor lymphocyte crossmatch.

 -  No positive testing for viral infection (HbsAg, HIV, HCV, HTLV-1).

 -  Cardiac/Pulmonary evaluation within normal limits (CXR, EKG).

 -  Donor ability to understand and provide informed consent.