TRIALS, TRIBULATIONS, Tregs ... NO RELEVANT DISCLOSURES + - - PDF document

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TRIALS, TRIBULATIONS, Tregs ... NO RELEVANT DISCLOSURES + - - PDF document

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9/26/2018 TRIALS, TRIBULATIONS, Tregs ... NO RELEVANT DISCLOSURES + DISCUSSION OF EXPERIMENTAL TOLERANCE INDUCTION PROTOCOLS Sandy Feng, MD, PhD September 20, 2018 PATIENTS WANT TRANSPLANTS WITHOUT IMMUNOSUPPRESSION PATIENTS WANT TRANSPLANTS

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9/26/2018 1

TRIALS, TRIBULATIONS, Tregs ...

Sandy Feng, MD, PhD September 20, 2018

NO RELEVANT DISCLOSURES + DISCUSSION OF EXPERIMENTAL TOLERANCE INDUCTION PROTOCOLS

PATIENTS WANT TRANSPLANTS WITHOUT IMMUNOSUPPRESSION

Allard J et al., Transplantation Direct 2017

PATIENTS WANT TRANSPLANTS WITHOUT IMMUNOSUPPRESSION

Tolerance   Graft survival

Allard J et al., Transplantation Direct 2017

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9/26/2018 2

CHIMERISM

Stanford MGH Northwestern

CONCEPTUALLY SIMPLE

  • Bone marrow/stem cell transplant recipients for

hematologic malignancies can accept a kidney from their bone marrow donor without immunosuppression

  • Create a chimera of recipient and donor

 Acceptance of donor bone marrow  acceptance of

donor kidney

BUT DIFFICULT TO ACHIEVE

Host Donor

GvHD Infection Kidney Rejection

Chimerism

BUT DIFFICULT TO ACHIEVE

Host Donor

GvHD Infection Kidney Rejection

Chimerism

Current approaches to mixed chimerism have not achieved the optimal donor-recipient balance

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9/26/2018 3

IMMUNOSUPPRESSION WITHDRAWAL

INTRAHEPATIC TOLERANCE MECHANISMS

CLINICAL MANIFESTATIONS OF THE TOLEROGENIC LIVER

  • Livers are the only organ that is transplanted without

cross-matching.

 Susceptible to antibodies against blood type antigens  But resistant to antibodies against HLA antigens

  • Recipients of livers, compared to those of other organs,

require less immunosuppression.

  • Rejection episodes portend less poorly for future graft

survival.

  • Liver allografts are less susceptible to chronic injury.

SINGLE CENTER REPORTS OF “TOLERANT” LIVER TRANSPLANT RECIPIENTS

Levitsky and Feng, Hum Immunol 2018 Center Year N Adult or Pediatric DD vs LD Time from LT to ISW (yrs) Biopsy Tolerant* N (%) Pre Post Pittsburgh 95, 97, 07 95 Both DD 8.4 ± 4.7 Y N 18 (19%) London/King’s 98, 07 18 Adult DD 7 (5-11) N N 2 (11%) Murcia 03,09 20 Adult DD 3.4 ± 2.2 Y N 8 (40%) Rome 06, 08, 14 34 Adult DD 5.3 ± 1.7 Y Y 7 (20%) New Orleans 05 18 Adult DD >0.5 per protocol N N 1 (6%) Winnipeg 07 26 Adult DD 4.6 ± 1.8 Y Y 11 (42%) Miami 05, 10 104 Adult DD 4.1 ± 0.3 N N 23 (22%) Pamplona 13 24 Adult DD 9.3 (6-13.3) Y N 15 (63%) Kyoto 02, 07, 09, 12 115 Pediatric LD >2 per protocol N N 49 (42%) Palo Alto 02, 07, 09, 12 38 Pediatric Both 2.9 ± 3.5 N N 17 (45%) Taipei 15 16 Pediatric Both 7.8 ± 5.4 Y Y 5 (31%)

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Tolerant

N (%)

Interval since tx

(months)

ISW

(months)

Follow-up (months) Benitez 2013 41/102 (40%) 131 ± 43* 8.0 ± 4.6* 48.9 ± 7.7* OPTIMAL NA >50 yrs: 3-6 yrs <50 yrs: >6 yrs variable NA LIFT NA variable NA Feng 2012 12/20 (60%) 101 (72-124)^ 8.2 (8.1, 8.8)^ 119.0 (110.0, 122.1)^ iWITH 33 / 88 (38%) >6 years 36-48 wks NA

COMPLETED/ONGOING MULTI-CENTER IMMUNOSUPPRESSION WITHDRAWAL TRIALS

*Mean ± SD ^Median (IQR)

INCREASED TIME AFTER TRANSPLANT

Benitez et al.,

Hepatology, 2013

Yrs since transplant Tolerant N %

3.0-5.7 3/24 12.5% 5.7-10.6

19/50 38.0%

>10.6

19/24 79.2%

AWISH (ITN030ST)

1-2y after transplant Tolerant N %

HCV+ 5/30 16.7% Non-immune, non-viral 6/46 13.0% TOTAL 11/76 14.5%

WISP-R

Tolerant (N=12) Non-Tolerant (N=7)

8.4 (6.0-10.3) yrs 6.1 (4.8-6.2) yrs

RATIONALE FOR TOLERANCE INDUCTION

  • Spontaneous tolerance emerges years after

transplant.

 Need to accelerate

  • Approach must balance risks and benefits.

 Often prohibitive disease severity  Requires strong safety profile

  • Timing is unpredictable.

 Living donor transplants uncommon

REGULATORY T CELL THERAPY

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SLIDE 5

9/26/2018 5 Tregs ARE AT THE CENTER OF IMMUNE HOMEOSTASIS AND TOLERANCE

B cell/DC naive T cell TCR

AutoAb CD3

Teff IL

  • 10

T GF-

Activated Macrophage

IFN- TNF- IL-12 IL-23 IL-1 IL-6 IL-15

Treg

thymic Treg General Immune Homeostasis

Treg

peripheral Treg Local Regulation

Ag

MHC/pep

Tregs ARE AT THE CENTER OF IMMUNE HOMEOSTASIS AND TOLERANCE

Bcell/DC naive T cell TCR

AutoAb CD3

Teff IL

  • 10

T GF-

Acti vated Macrophage

IFN- TNF- IL-12 IL-23 IL-1 IL-6 IL-15

Treg

thymic Treg General Immune Homeostasis

Treg

peripheral Treg Local Regulation

Ag

MHC/pep

Allergy & Asthma Autoimmune Disease Inflammatory Bowel Disease Graft versus Host Disease Organ Transplantation Allergy & Asthma Autoimmune Disease Inflammatory Bowel Disease Graft versus Host Disease Organ Transplantation

GROWING EVIDENCE THAT Tregs ARE POTENTIAL THERAPEUTICS

  • Tregs have efficacy to prevent GvHD
  • Treg therapy for GvHD does not appear to inhibit anti-tumor responses
  • Donor-specific Treg therapy does not appear to inhibit responses to

viral pathogens or vaccines in mouse models

  • Can Treg therapy be applied to reduce or eliminate

non-specific immunosuppression in humans?

Treg Teff Self tolerance Immune protection Induced tolerance

A SIMPLIFIED CONCEPT OF TOLERANCE TREG:TEFF BALANCE

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9/26/2018 6

Clinical trials

Clinical Treg team Products

Co-Directors Qizhi Tang and Jonathan Esensten Advisor Jeff Bluestone Regulatory Jingying Xu, Ashley Leinbach QA Flory Dekovic, Lizzy Lama, Alice Tam Manufacturing Amy Putnam, Angela Lares Mike Lee, Vinh Nguyen, Karim Lee, Joey Leung QC Weihong Liu, Alyssa Mullenix

PolyTreg arTreg

T1D/I T1D/II TILT cSLE Pemphigus DART TASK1 deLTa LITTMUS IsletTx CB-T1D

CBTregs ARTEMIS

completed ongoing planning Mixed chimerism

T1D Skin disease

Kidney Tx Liver Tx

UCSF CLINICAL Treg CELL THERAPY PROGRAM

TRIALS IN KIDNEY

Safety Subclinical Inflammation ONE Study TASK

TRIALS IN KIDNEY

Safety Subclinical Inflammation ONE Study TASK

UCSF POLYCLONAL Treg PRODUCTION

Putnam et al., Diabetes 2009; FDA Master File 17507

#1: Polyclonal -CD3/28 beads #2: Polyclonal CD3/28 Beads Harvest; Release assays

10 10 10 5 4 3 10 5 10 4 10 3

CD127 CD25 parameters CD4 CD8 FOXP3 criteria >95% <5% >60%

Release criteria

Expansion

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9/26/2018 7

UCSF POLYCLONAL Treg EXPANSION

Putnam et al., Diabetes 2009; FDA Master File 17507

PolyTreg 16 32 64 128 256 512 1024 2048

Fold expansion

0.0 2.5×109 5.0×109 7.5×109 1.0×1010 1.3×1010 1.5×1010 Total Treg produced

identity/purity – FOXP3 expansion yield Potency

TASK PILOT

TregADOPTIVE THERAPY FOR SUBCLINCAL INFLAMMATION IN KIDNEY TRANSPLANTATION

Subclinical inflammation in 6m protocol biopsy

  • Re-biopsy in

14d

  • Infused Tregs in

circulation

  • Biomarkers

PolyTreg 400+/-100 million n=15 Chandran et al., AJT 2017

TASK PILOT

TregADOPTIVE THERAPY FOR SUBCLINCAL INFLAMMATION IN KIDNEY TRANSPLANTATION

Subclinical inflammation in 6m protocol biopsy

  • Re-biopsy in

14d

  • Infused Tregs in

circulation

  • Biomarkers

Pt 1 Pt2 Pt3 Age 62 58 46 ESRD cause Membranous glomerulonephritis ? Hypertensive GS FSGS Immunosuppression Basiliximab; Tac, MMF, prednisone 6 month bx i1, t1, ti2 i0, t1, ti1 i1, t1, ti1 PolyTreg dose 320 x106 318.9 x 106 363.8 x106

PolyTreg 400+/-100 million n=15 Chandran et al., AJT 2017

514.0 337.2 18.9 126.1 469.1 303.5 74.9 278.0 454.4 CD45+ cells/mm2

P r e

  • T

r e g P

  • s

t

  • T

r e g 50 100 150 200 250 Normalized Cxcl9 conc. (pg/ml)

Cxcl9

P r e

  • T

r e g P

  • s

t

  • T

r e g 100 200 300 400 Normalized Cxcl10 conc. (pg/ml)

Cxcl10

Urine biomarkers

Pt 1 Pt 2

TASK PILOT BIOPSIES

Pt 3 Baseline 2 weeks 6 months

Tregs

Chandran et al., AJT 2017

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9/26/2018 8

7 14 21 28 2 4 6 8 Day Post Infusion

% Deuterium enrichment in circulating Tregs

TASK002 TASK003 T1D 002-015 T1D 007-103 TASK004 T1D 002-017

PK OF INFUSED POLYCLONAL Tregs

unlabled Labeled 20 40 60 %Enrichment 59.8% 0.0%

Macallan, et. al, Nat. Prot. 2009

Chandran et al., AJT 2017

TRIALS IN LIVER

Safety Minimization Tolerance deLTa ARTEMIS LiTTMUS

TRIALS IN LIVER

Safety Minimization Tolerance deLTa ARTEMIS LiTTMUS

HOKKAIDO TRIAL: DONOR-SPECIFIC Treg PRODUCTION

Donor Recipient LDLT

Day 0 Day -1 1-to-4 wks before LT Day +13 Lymphocytes Frozen until use Irradiate

Cultured cells

Infusion

Co-culture

2 weeks aCD80 mAb aCD86 mAb

Todo et al. Hepatology 2016

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9/26/2018 9

1M 6M 9M

Steroid MMF

Tacrolimus / Cyclosporine Once daily

Cyclophosphamide

40 mg/kg

Cell infusion Time after LDLTx

12M 15M 18M Trough 8-12 ng/mL

IS off

3X/wk 2X/wk 1X/wk

Day 5 Day 13

20 mg/d 500-1500 mg/d

Twice daily

* CNI dose reduction

  • LT: normal
  • LBx: no rejection

LBx LBx LBx LBx LBx 第49回 日本移植学会総会、京都

Todo et al. Hepatology 2016

HOKKAIDO TRIAL PROTOCOL

Total Cells Infused x106 CD4+CD25+Foxp3+ Cells Infused x106 x106/kg^ Time after LDLT* ALT / GGT IU/L Current IS Months

  • ff IS

610 31 0.44 4y 9m 11 / 14 none 3y 1m 590 33 0.47 3y 5m 8 / 28

FK 4mg/d

AR d365 630 43 0.61 4y 11 / 15

FK 5mg/d

AR d394 790 94 1.34 4y 6m 17 / 48 3y 1,180 272 3.89 3y 10m 15 / 29

MMF 500mg/d Pred 7.5mg/d

AR d311 1,200 289 4.12 3y 2m 10 / 16 1y 8m 700 304 4.34 3y 7m 20 / 32 1y 9m 2,590 318 4.54 3y 9m 28 / 24 2y 3m 2,450 441 6.30 4y 3m 3 / 10 2y 9m 2,540 466 6.66 4y 7m 41 / 24 3y Todo et al., Hepatology 2016

7 OUT OF 10 SUBJECTS WERE TOLERANT

Antigen-specific primary expansion with sBc Polyclonal secondary expansion using anti- CD3/28 beads Harvest & Release assays

10 10 10 5 4 3 10 5 10 4 10 3

CD127 CD25 Donor B cell activation Irradiated GMP K562-hCD40L Putnam et al., AJT 2013; FDA Master File 15431 Parameters CD4 CD8 FOXP3 CD19 BCR-ABL Criteria >95% <5% >60% <1% Neg

Release criteria

Process continuation Assessment – EBV-

UCSF DONOR SPECIFIC Treg PRODUCTION

Putnam et al., AJT 2013; FDA Master File 15431

1:5 1:25 1:125 20 40 60 80 100 Treg:Tresponder ratio % Suppression PolyTreg drTreg 1:5 1:25 1:125 20 40 60 80 100 Treg:Tresponder ratio % Suppression PolyTreg drTreg

0.0 5.0×108 1.0×109 1.5×109 2.0×109 2.5×109 3.0×109 3.5×109 Total Treg produced 60 70 80 90 100

% TSDR demthylation

ArTreg TSDR

identity/purity expansion yield

arTregs 4 8 16 32 64 128 256 512 1024

Fold expansion

potency

UCSF DONOR-SPECIFIC Treg EXPANSION

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SLIDE 10

9/26/2018 10 UCSF LIVER Treg TRIAL PORTFOLIO

Name Time Deceased / Living Depletion Treg infusion Agent Time after tx Maintenance IS Timing deLTa de novo; delayed deceased Thymo- globulin <72 hours tacrolimus + everolimus 12 wks ARTEMIS pre- existing living None tacrolimus prednisone or mycophenolate 2-6 yrs after tx LiTTMUS de novo; delayed both Cyclophos- phamide 1-6 months tacrolimus + everolimus 1-6 mos after tx

25 50 75 100 20 40 60 80 100 % IS reduction

darTreg infusion

Primary endpoint Secondary endpoint

AWISH iWITH

  • Tac monotherapy
  • 75% reduction

ARTEMIS: Safety of Donor Alloantigen Reactive Tregs to Facilitate Minimization and/or Discontinuation of Immunosuppression in Adult Liver Transplant Recipients

Historical reference

% rejection-free survival

% CNI reduction

  • Tolerance

1 2 3 6 5 4 7 OFF Treg infusion

START ISW

Treg production

PRIMARY Endpoint SECONDARY Endpoint

ARTEMIS: PATIENT STATUS

378 x 106 187 x 106

U1 M1 M2 M3

461 x 106 100 x 106

MET 1° endpoint 27 wks after Tregs: Indeterminate to mild TCMR 10 wks after Tregs: TCMR 1 wk after infusion: Minimal evidence of TCMR. BX BX NW1

127 x 106

U2 U3

10 20 30 40 50 60 70 80 90 100 1 2 3 4 5 Day Post Infusion

% Deuterium enrichment in circulating Tregs

ART1 ART2 DART ART3

PK OF INFUSED DONOR-SPECIFIC Tregs

1, 2

Kidney

3 days after tx

Liver

years after tx

Days after infusion % deuterium enrichment in circulating Tregs

Courtesy of Q. Tang

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9/26/2018 11

2 4 6 8 10 12 14 16 2×106 4×106 8×106 6×107 2×107 4×107 8×108 6×108 2×108 4×109

Days in culture ATREMIS arTreg Expansion

ARTEMIS: Treg MANUFACTURING

1.07 5.37 2.68 1.34 6.71 3.36 1.68 8.39 4.19 2.10

Cell number Days in culture

100m 300m

S 08001 S 60003 S10002 06001 06002 S 10001a S 08002 S 10001b

Reduced donor reactivity cannot be recovered by:

  • Provision of higher amount of IL-2 or IL-15
  • Addition of antibodies to PD1, TIM3, or LAG3
  • Using donor monocyte-derived mature DCs as APCs

Tregs ATF frequency l u n g k i d n e y l i v e r A R T E M I S

0.0 0.1 0.2 0.3 0.4

p=0.036 p=0.156 p=0.021

Lung: 39 patients, pre-transplant Kidney: 16 patients, pre-transplant Liver: 16 patients, pre-transplant ARTEMIS: 6 patients, 2-6 years post liver transplant

EXPLANATION FOR POOR ARTEMIS Treg EXPANSION

Tregs

ATF frequency

2 w k 1 m

  • 2

m

  • 3

m

  • 6

m

  • 1

y r 2 y r A R T E M I S

0.0 0.2 0.4 0.6

ATF frequency

Treg: kinetics in lung Tx vs ARTEMIS

arTreg kinetics: Lung transplant versus ARTEMIS

Artemis deLTa TASK DART T1D

50 100 10 Treg per ul

Treg count per ul of blood

Total Treg counts arTreg frequency

LOSS OF Tregs: SPECIFIC TO ARTEMIS PATIENTS AND SELECTIVE TO THE LIVER DONOR

Total Treg counts arTreg frequency

Treg count/ l blood

Liver Kidney T1D post pre post pre donor 3rd party sBcs

CONCLUSIONS: Tregs IN TRANSPLANTATION

  • Tregs have accumulated a strong safety record in many

disease settings, including transplantation, making them an attractive strategy to modulate the immune response.

  • Several phase 1/2 trials are underway testing the safety

and/or efficacy of different Treg products for endpoints from subclinical rejection to tolerance induction.

  • These outcome of these initial trials will guide the design of

2nd generation Treg products as well as new trials.

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9/26/2018 12

ACKNOWLEDGMENTS

Clinical Treg team

Amy Putnam, Angela Lares, Weihong Liu, Mike Lee, Vinh Nguyen, Karim Lee, Flory Dekovic, Lizzy Lama, Joey Leung, Susanna Cheng, Lisa Masiello, Giulia Giunti, Alice Tam, Jingying Xu, Jonathan Esensten, & Jeff Bluestone Funding: NIAID, NIDDK, ITN, JDRF, ONEStudy, UCSF-CTSI, BD PharMingen, Epiontis Gmbh, Calarius, John & Nancy Lang

Study Participants and Families

UCSF Transplant

Sang-Mo Kang Flavio Vincenti Sindhu Chandran Zoltan Laszik Minnie Sarwal Sharon Blaschka Chris Ferguson Erica Taveras Crystal Lala Peggy Millar Kalpana Harish

Collaborators

John Bucuvalas Alberto Sanchez-Fueyo

  • A. Jake Demetris

Allan Kirk Drew Lesniak Juanjo Lozano Bryna Burrell Sai Kanaparthi Katie Spain Kristen Mason David Ikle