Nonmyeloablative Peripheral Blood Mobilized Hematopoietic Precursor Cell Transplantation for Sickle Cell Disease and Beta-Thalassemia in Individuals With Higher Risk of Transplant Failure
Phase: PHASE2
Conditions: Sickle Cell Disease, Thalassemia, Stem Cell Transplantation, Graft vs Host Disease
Sponsor: National Heart, Lung, and Blood Institute (NHLBI)

 
 Protocol with Statistical Analysis Plan Cover Page:   
 
Official Title: 
Nonmyeloablative peripheral blood mobilized hematopoietic precursor cell 
transplantation for sickle cell disease and β-thalassemia in individuals with 
higher risk of transplant failure 
NCT number: 
 
NCT02105766 
Document Type:  
Protocol with Statistical Analysis Plan (SAP)  
Document Date: 
February 13, 2024 
 

14-H-0077 
Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
1 | P a g e  
CLINICAL RESEARCH PROTOCOL 
 
 
                                                                  Protocol# 14-H-0077  
 
 
 
 
 
Drug: Pentostatin / Cyclophosphamide / Alemtuzumab 
 
 
 
 
 
IND: Exempt 
 
Date: 13 FEB 2024 
 
Title: Nonmyeloablative peripheral blood mobilized hematopoietic precursor cell transplantation for sickle cell 
disease and β-thalassemia in individuals with higher risk of transplant failure 
 
Other underlying words: Peripheral blood stem cells, graft-versus-host disease, sirolimus (Rapamune®), low dose 
irradiation, alemtuzumab (Campath®), cyclophosphamide (Cytoxan®), pentostatin (Nipent®)  
 
Principal Investigator:  Matthew Hsieh MD, CMTB, NHLBI 
 
 
 
 
 
 
Subjects of study: 
 
Number 
 
Sex 
 
Age range 
 
Patients: 
 
   81 
 
 
either  
≥4 years 
 
Donors  
 
   81 
 
 
either  
10-80 years 
 
 
 
 
 
Project involves ionizing radiation? 
 
Yes  
Off site project? 
 
 
 
No 
Multi-Institutional project? 
 
 
No 
DSMB  
 
 
 
 
Yes 
 
 
 
Referral Contact:  
NIH Office of Patient Recruitment 1-800-411-1222 (TTY 1-866-411-1010) 
 
 

14-H-0077 
Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
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PRECIS 
 
Our ongoing nonmyeloablative allogeneic peripheral blood stem cell (PBSC) transplant protocol (03-H-0170) for 
patients with severe sickle cell disease (SCD) and β-thalassemia from HLA-matched family donors has excellent 
results thus far.  Our long term leukocyte engraftment rate is 85-90% with the same disease-free survival.  None of 
the engrafted patients had acute sickle-related events, significant toxicity associated with the conditioning regimen, 
or any evidence of graft versus host disease (GVHD).   
 
While these results rival the transplant outcomes from low risk transplant patients with β-thalassemia, there are 
areas for improvement.  The first is the 10-15% graft rejection rate, where a majority of these individuals were male 
donor and female recipient pairs.  Another limitation is the significant delay in donor red cell engraftment in one 
recipient who had pre-existing allo-antibody to donor red cells from previous transfusions.  Also we have excluded 
another group of individuals with preformed antibodies, recipients having major ABO incompatibility to the donors.   
 
To overcome these limitations (and reduce the transplant failure rate) in this new protocol, we will continue our 
nonmyeloablative approach in the patients with SCD and β-thalassemia with HLA-matched family donors, but 
using an increased intensity regimen in a subset considered at high risk for transplant failure. This modified regimen 
consists of pentostatin and oral cyclophosphamide, which we hypothesize will reduce both the T cells that mediate 
leukocyte rejection and the B/plasma cells that produce anti-donor erythrocyte antibodies.  The main transplant 
backbone will remain as alemtuzumab, low dose total body irradiation of 300 cGy, and sirolimus; the transplant 
graft will remain as unmanipulated G-CSF mobilized, T-cell replete, PBSC product for hematopoietic and lymphoid 
reconstitution. 
 
The primary endpoint of this study is the percentage/number of patients who have sustained donor type hemoglobin 
at 1 year post transplant for male donors – female recipients.  The primary endpoint for those with pre-existing 
antibodies is the presence of donor red cells with reticulocytes ≥30 k/uL at 2 years post-transplant. Other endpoints 
include the toxicity of the pentostatin-cyclophosphamide regimen, the degree of donor-host chimerism necessary 
for long-term graft survival and disease amelioration, incidence of acute and chronic GVHD, incidence of graft 
rejection, transplant-related morbidity, as well as disease-free and overall survival.  Since SCD and β-thalassemia 
are non-malignant disorders of red cells, severe GVHD, lack of donor erythrocyte (prolonged donor red cell 
aplasia), or graft rejection is collectively considered transplant failure. 
 
 

14-H-0077 
Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
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TABLE OF CONTENTS 
 
1.0 
Objectives 
2.0 
Background 
3.0 
Scientific and Clinical Justification 
4.0 
Study Design 
5.0 
Eligibility Assessment and Patient Selection 
6.0 
Clinical Evaluation and Plan- Patient 
7.0 
Treatment Plan 
8.0 
Clinical Evaluation and Plan- Donor 
9.0 
Management of Patient Complications 
10.0 
Research Studies 
11.0 
Biostatistical Considerations 
12.0 
Data and Safety Monitoring 
13.0 
Human Subject Protections 
14.0 
Conflict of Interest 
15.0 
CIBMTR  
16.0 
Pharmaceuticals – including rationale for IND exemption 
 
References 
Appendices: 
 
 
A 
ECOG Performance Status Scale 
 
B 
Transfusion of Red Cells to Recipients of ABO Incompatible Marrow 
 
C 
Transfusion Medicine Guidelines for Apheresis Procedures for Sickle Cell Patients 
 
 
Receiving Nonmyeloablative Allogeneic PBSC Transplants 
 
D 
Ideal Body Weight, Adjusted Body Weight, and Practical Body Weight Calculations 
 
E 
Administration Scheme for Busulfan 
 
F 
Addendum A: quality of life and neuropsychologic testing 
 
G 
Addendum B:  Reproductive Health Assessment 
 
 
 
 
 
SEE ALSO:  
BONE MARROW TRANSPLANT CONSORTIUM GUIDELINES 
 
 
 
 
Marrow stem cell transplant section 
 
 
 
 
 
 
 
 
Hematology branch, NHLBI 
 
 
 
 
 
 
 
 
 
http://intranet.cc.nih.gov/bmt/  
 
 
 
 
 
 
 

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Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
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1.0 
OBJECTIVES 
Using a nonmyeloablative preparative regimen followed by HLA-matched, related donor allogeneic 
granulocyte colony-stimulating factor (filgrastim, G-CSF) mobilized peripheral blood stem cell transplant 
in (PBSCT) in patients with sickle cell disease (SCD) and β-thalassemia at increased risk for transplant 
failure, we hope to: 
1.1 
determine if the addition of pentostatin and cyclophosphamide improves engraftment rate in male donor-
female recipient pairs (cohort 1) and allows clinically meaningful donor erythropoiesis in those with pre-
existing antibody (cohort 2) 
1.2 
determine the regimen failure rate, defined as graft rejection, severe GVHD (acute GVHD grade 3 or higher 
or extensive chronic GVHD), or prolonged donor red cell aplasia (>2 years post-HSCT) 
1.3 
examine the level of chimerism required to maintain both graft survival as well as hematologic normalcy 
using a regimen containing pentostatin, cyclophosphamide, alemtuzumab, and low total body irradiation.  
1.4 
evaluate the safety, efficacy, and toxicity of the pentostatin and oral cyclophosphamide regimen, including 
disease-free survival, transplant-related mortality, overall survival, and compare this new regimen to 03-H-
0170 
1.5 
evaluate the longitudinal effects of this transplant on neuropsychological functioning and quality of life (see 
Addendum A), and other end organ function 
 
2.0 
BACKGROUND 
Introduction 
Allogeneic hematopoietic stem cell transplantation (HSCT) is the only available cure for patients with sickle cell 
disease (SCD) and β-thalassemia, but has been infrequently pursued due to its associated complications.  The majority 
of patients who are otherwise eligible for bone marrow transplant (BMT) do not have a suitable donor.   In addition, 
the unacceptable risk of death from conventional BMT renders many patients, especially those with nonmalignant 
disorders, ineligible for what may otherwise be curative therapy.  Recently however, in both malignant and non-
malignant disorders, it has been shown that these high intensity regimens are not necessary for engraftment and 
survival, and many centers are currently exploring nonmyeloablative conditioning regimens in order to reduce the 
toxicity associated with this treatment modality.  While successful engraftment has been reported in the majority of 
patients conditioned with reduced intensity regimens, these regimens still carry significant toxicity and have not 
significantly reduced the risk of GVHD.  For patients with congenital severe anemias, the replacement of abnormal 
or absent erythroid cells with normal donor-derived erythroid cells is required for disease amelioration.  These 
disorders constitute an ideal situation for a nonmyeloablative conditioning regimen as only a proportion of normal 
cells will need to engraft given the survival and proliferative advantage of the donor-derived erythroid cells as 
compared to the host cells.  Further, as a nonmyeloablative regimen will allow autologous recovery with a low risk 
of adverse consequences to the recipient if the graft should fail, graft failure is preferable to the development of severe 
GVHD.  As such, we propose the development of an immunosuppressive but nonmyeloablative transplant regimen 
consisting of pentostatin and cyclophosphamide before our backbone of alemtuzumab, low dose radiation, and 
sirolimus, in patients with either SCD or β -thalassemia. 
 
Sickle Cell Disease 
SCD is a well described genetic disorder associated with significant morbidity and mortality.  It affects one of every 
600 African-Americans in the United States alone 1.  The disease is characterized by recurrent vaso-occlusive crises 
as a consequence of abnormal hemoglobin polymerization in areas of low oxygen tension.  As a result, patients 
develop functional asplenism leading to a high risk of infections from encapsulated organisms, recurrent pain crises, 
acute chest syndrome, pulmonary hypertension, kidney failure, and neurologic events, as well as sudden death as the 
most serious consequences of this disease.2  More recently, sickle hepatopathy and iron overload have been discovered 
to increase mortality in patients with SCD, as patients with ferritin >1000 ug/L or direct bilirubin >0.4mg/dL led to 

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Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
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significantly decreased survival as compared to patients with ferritin <1000ug/L and direct bilirubin <0.4 mg/dL 
(Jordan Feld and Theo Heller, manuscript in preparation).   
The medical costs of this disease are enormous, with estimates of $40,000 per patient per year (year 2000 figures) for 
chronic transfusion therapy and chelation alone, but do not include the impact on quality of life of those with the 
disease3.  An overlapping symptom complex also occurs in patients with the double heterozygous forms of SCD, 
sickle-C, and sickle β-thal0 disease, and in fact, these patients cannot always be differentiated clinically but only by 
means of a laboratory test.  While transfusions can prevent further neurologic events in patients at risk, iron overload 
is common, resulting in significant end-organ toxicity.  The most common form of treatment in SCD had been 
erythrocyte transfusions, and more recently hydroxyurea.4-6  Hydroxyurea results in a significant reduction in the 
number of painful crises per year and a decreased frequency of acute chest syndrome,4 and has become the treatment 
of choice for many individuals with SCD.  Unfortunately, hydroxyurea is not curative, and does not appear to reverse 
established end-organ damage. 
Several important interventions have led to an improvement in the overall life expectancy of patients with SCD, most 
notable among these are the use of pneumococcal vaccines and the prophylactic use of penicillin during childhood.  
Hydroxyurea has also been suggested to improve survival in patients with SCD.7  However, life expectancy remains 
significantly shortened compared to the national average with that of an affected male being 47 years versus the 
national average of 72.2  There are no factors to predict better survival among patients, further complicating the 
decision to proceed with higher risk treatments, especially during childhood when such treatments may be better 
tolerated.  In one study of 3,764 patients, 18 percent of the patients died with overt organ failure, and early mortality 
was highest among patients with symptomatic disease.  Importantly however, another 33 percent who appeared to be 
clinically free of organ failure died during an acute sickle crisis.2  
The only established cure for patients with SCD remains allogeneic BMT; however, the procedure has only been 
applied to highly selected children.8-10  In adults, the higher burden of accumulated end-organ damage would be 
expected to result in higher transplant associated morbidity and mortality, beyond that reported in children, including 
seizures and intracranial hemorrhage.  As a result, this method has traditionally only been offered to those patients 
less than the age of 16 with either end-organ damage or symptomatic disease due to their demonstrated higher early 
mortality rate. 
We currently have an ongoing protocol for adult patients with severe congenital anemias and a 6/6 human leukocyte 
antigen (HLA)-matched sibling donor using a conditioning regimen consisting of alemtuzumab, 300 cGy total body 
irradiation (TBI), and sirolimus for GVHD prophylaxis.  Our results to date show a leukocyte engraftment rate a 
disease-free survival of 85%.  These data are excellent, and are very close to the results achieved with myeloablative 
conditioning in children.  However, with additional experience and sufficient accrual to date, we have experienced 
some limitations with this current approach (See section 3.0). 
Thalassemia 
Thalassemia is the most common genetic disorder worldwide,11 and is a result of either  defective or absent synthesis 
of one or more of the globin chain subunits of the hemoglobin tetramer.  Inadequate accumulation of the globin 
subunits results in ineffective erythropoiesis.  There is marked heterogeneity ranging from profound anemia resulting 
in death in utero to a relatively benign anemia.  Thalassemias are designated by the globin chain, α or β, whose 
synthesis is affected, and by major or minor, denoting homozygosity or heterozygosity.  β-thalassemia major, or 
Cooley’s anemia, is a clinically severe anemia caused by the inheritance of two β -thalassemia alleles.  As a result, 
circulating red blood cells are small and distorted, containing very small amounts of hemoglobin.  Further, the 
accumulation of free α-globin molecules in erythrocytes results in ineffective erythropoiesis.   
 
In patients with β-thalassemia major, the resulting anemia is so severe that most patients require lifelong red blood 
cell transfusions.  This chronic transfusion therapy necessitates the use of iron chelation to prevent the long-term 
consequences of iron overload.  Other treatments such as butyrate and hydroxyurea have been explored, but these 
have had only limited success, are not well tolerated (especially butyrate), and most importantly, are not curative. 
 
Prior to the regular use of deferoxamine for iron chelation, only 25% of patients survived to the age of 25 years.  For 
patients born after 1967, for whom such chelation has been available, one study estimated that the probability of being 

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Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
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alive at 20 years of age remains low at 67%,12 and only 40% among 20 year old patients will be free of complications.  
The most common cause of death related to iron overload is heart disease, followed by infection and liver disease.13 
 
Even with chelation, red cell transfusion incurs other risks including transmission of blood borne pathogens such as 
HIV and hepatitis C, as well as the risk of transfusion reactions.  Alloimmunization makes access to blood products 
more difficult, and even more expensive to continue.  Deferoxamine, although necessary to prevent iron overload, is 
itself not benign.  Side effects from iron chelation include visual and auditory neurotoxicity, and allergic reactions, 
including anaphylaxis.14-17  Moreover, the therapy is not well tolerated, impact on quality of life, and often results in 
poor compliance, especially in adolescents.  There are oral alternatives now, deferasirox  and deferiprone, with 
equivalent iron unloading, more tolerable side effect profile, and improved compliance.      
 
The only available cure for β-thalassemia major is bone marrow transplantation; however, myeloablative BMT has 
many potential associated risks.  Risk groups have been identified based upon three variables: hepatomegaly >2 cm, 
portal fibrosis of any degree, and inadequate compliance with chelation therapy, with Class I, II, and III having none, 
1-2, or all three of the variables, respectively.  Bone marrow transplantation is most successful in Class I children 
who undergo transplantation early, with a DFS of 90-93% and TRM of 3-4%.18  For higher risk patients, the survival 
and DFS decrease to 86 and 82% and drops further to 62 and 51% in the highest risk category.  Results in adults (>16 
years of age) are similar at 65 and 62% disease free and overall survival, respectively.19  These studies have been 
performed using HLA-matched sibling donors. Although there are newer iron chelators available, cost/access to 
medication and compliance continues to be the main issues in suboptimal chelation. In the present day, the morbidity 
associated with iron overload remains, and extends into transplant related outcomes.     
    
As adults have a higher rejection rate and also a higher incidence of GVHD, better conditioning regimens are needed.  
For high risk children (Class II or III), improvements have been seen when using lower dose conditioning, resulting 
in less morbidity and mortality, suggesting the rational to apply nonmyeloablative methods to adults.20, 21  The use of 
Pesaro classification are still being used currently. 
 
3.0 
SCIENTIFIC AND CLINICAL JUSTIFICATION 
Unlike patients who undergo allogeneic peripheral blood stem cell (PBSC) transplantation for malignant indications, 
patients with non-malignant disorders such as SCD and thalassemia do not require full and/or rapid donor engraftment 
to cure their disease.9, 22-24  While it is generally accepted that GVHD is less severe in patients conditioned with low 
intensity preparative regimens,25 graft rejection is preferable to debilitating GVHD in the setting of severe congenital 
anemias. 
 
Host T and B lymphocytes remaining at the time of allogeneic HSCT can mediate a host-versus-graft response 
(rejection) that results in failure to engraft.  In our current study (03-H-0170) of allogeneic HSCT using matched 
sibling donors with the platform of host conditioning with alemtuzumab followed by 300 cGy of TBI, the overall 
graft rejection rate is 10-15% (success rate of 85-90%); 0% in sex-matched pairs, 14% in female-into-male recipient, 
and 50% in male-into-female transplant combination (P=0.0164 Fisher’s exact test, male-to-female compared to all 
other combinations together). Higher graft rejection rate seen in male-into-female pairs has been observed in murine26 
and human transplant settings.27, 28 Thus with our low intensity approach, antigens on the Y chromosome and perhaps 
other minor HLA antigens may represent important immunologic barrier to overcome. 
 
Another limitation of the current study  is pre-existing red cell antibody to donor red cells.  One patient who had anti-
JKa antibody pre-transplant; this antibody persisted post-transplant, caused red cell aplasia for up to 1.5 years post 
transplant, and rendered him transfusion dependent during this time. There were two other patients who were 
reticulocytopenic and required red cell support for a similar duration post-transplant.  Additionally, we have been 
excluding individuals with major ABO incompatibility or patients demonstrating strong titer red cell antibody to 
donor red cells.  Thus in these settings, additional pre-transplant interventions are justified to reduce the risk of 
transplant failures.  In this protocol, we hypothesize that adding immune-depleting and immune-suppressive 
chemotherapy regimen prior to the alemtuzumab/TBI therapy will reduce the risk of graft rejection.  The 
chemotherapy regimen that we will evaluate consists of pentostatin plus daily, dose-adjusted, oral cyclophosphamide 
(“PC regimen”).   

14-H-0077 
Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
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Pentostatin is an FDA-approved medication that is primarily used for the treatment of hairy cell leukemia29 and 
chronic lymphocytic leukemia.30, 31  Pentostatin, which has a unique mechanism of action that involves inhibition of 
the enzyme, adenosine deaminase (ADA), that is deficient in a large proportion of patients with severe combined 
immune deficiency (SCID), also mediates significant immune suppression and immune depletion.32  The immune 
modulating effects of pentostatin, which comprise a significant side effect in cancer therapy, can be harnessed in the 
transplantation setting to prevent graft rejection.  An initial study by Pavletic et al demonstrated the lymphodepleting 
effects and safety of pentostatin (a total of 12 mg/m2 over three days) when administered in sequence with 
nonmyeloablative doses of TBI (200 cGy) in the context of allogeneic HSCT.33  In another study, pentostatin (a total 
of 8 mg/m2 over two days) was safely administered in sequence with 600 cGy of TBI prior to allogeneic HSCT.34  As 
such, pentostatin can represent an effective component to host conditioning regimens for the purpose of preventing 
graft rejection.  However, to date, pentostatin has been used less frequently than other immune modulating 
conditioning, which has primarily involved the purine analogue fludarabine. 
 
In murine transplantation models, we set out to compare the immune depleting and immune suppressive effects of 
pentostatin relative to fludarabine35. In these studies we found that pentostatin was advantageous relative to 
fludarabine because at a given level of host myeloid cell depletion, there was a significantly greater magnitude of 
host B and T cell depletion. In addition, host T cells that remained after pentostatin-based conditioning were 
significantly more immune supppresed relative to host T cells remaining after fludarabine-based conditioning.  
Importantly, in these studies, we found that optimal host immune modulation was achieved when intermittently dosed 
pentostatin was administered in combination with daily dosing of cyclophosphamide.  These results indicated that, 
pentostatin, which can have a biological half-life (in terms of inhibiting the ADA enzyme) of up to one week, is best 
administered in combination with low-dose therapy with DNA alkylators to achieve maximal immune depletion while 
minimizing myeloid cell depletion.  Finally, in these experiments, we found that host recipients of 
pentostatin/cyclophosphamide (PC) conditioning were significantly less likely to reject a fully MHC-disparate 
hematopoietic cell transplant relative to recipients of fludarabine/cyclophosphamide conditioning. 
 
Based on these murine results, we initiated a pilot clinical trial of PC conditioning in the setting of HLA-matched 
sibling allogeneic HCT at the NIH Clinical Center (NCI Protocol 08-C-0088; Low Intensity Allogeneic 
Hematopoietic Stem Cell Transplantation Therapy of Metastatic Renal Cell Carcinoma Using Early and Multiple 
Donor Lymphocyte Infusions Consisting of Sirolimus-Generated Donor Th2 Cells).  In an attempt to maximize host 
immune depletion with relative sparing of host myeloid cells, we designed a 21-day pre-transplant host conditioning 
regimen consisting of a total of 12 mg/m2 of pentostatin administered in equal doses on days 1, 8, and 15 of the 21-
day regimen; and, in this context, patients received a flat, daily dose of cyclophosphamide at the relatively modest 
dose of 200 mg per day, each day of the 21-day regimen.  However, to ensure sparing of host myeloid cells, we also 
designed a dose adjustment scheme whereby daily doses of cyclophosphamide would be held in the event that an 
ANC value were to be reduced.  Using this regimen, in 12 consecutive patients, we achieved the protocol-defined 
target level of immune depletion (end of regimen ALC value of < 200) without a single case of significant neutropenia 
(no case of grade 3 toxicity).  And, each of the 12 patients achieved prompt alloengraftment without any case of graft 
rejection.  These results indicate that the PC regimen can be safely administered and is effective when used alone for 
the prevention of graft rejection. 
 
In other murine models, we next evaluated the ability of the PC conditioning to abrogate host immune responses 
against foreign protein, namely the anti-cancer immunotoxin SS1P.36  Immunogenicity of foreign protein therapies is 
a significant clinical obstacle, as many patients are limited to only a single course of protein therapy due to 
neutralizing antibody formation; such antibody formation is induced by B cells, with significant cooperativity from 
host T cells.  As such, we hypothesized that the PC regimen might be particularly effective for preventing host 
immunogenicity to SS1P.  Indeed, in these murine studies, we found that the PC regimen safely modulated host 
immunity and allowed for up to six cycles of immunotoxin therapy without induction of neutralizing antibody 
formation.  Based on these results, we initiated a clinical translation of SS1P therapy preceded by host immune 
modulation with the PC regimen (NCI Protocol 11-C-0160; A Pilot Study of Pentostatin Plus Cyclophosphamide 
Immune Depletion to Decrease Immunogenicity of SS1P in Patients with Mesothelioma).  To improve the feasibility 
of the regimen, this protocol is evaluating a somewhat truncated version of the PC regimen, with pentostatin currently 

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Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
8 | P a g e  
being administered at a dose of 4 mg/m2 (on days 1, 5, 9, and 13) with daily, dose-adjusted cyclophosphamide being 
administered on days 1 through 14 of the regimen. Initial results from the first 10 patients treated on this protocol 
indicate that the PC regimen indeed is safe and is effective in preventing or delaying host immune responses against 
the foreign protein therapy.  In combination, the results of our studies in the allogeneic and autologous setting indicate 
that the dose-adjusted PC regimen can be safely administered and yield effective immune modulation. 
 
In sum, these results suggest that adding PC regimen may represent an effective modality to reduce graft rejection or 
antibody production against donor red cells in the setting of allogeneic HSCT in the population with SCD and β-
thalassemia.  The combined regimen already contain 3 lymphodepleting agents (pentostatin, cyclophosphamide, and 
alemtuzumab) 8-12mg of dexamethasone is used as premedication for each pentostatin dosing, and TBI. The addition 
of ritixumab pre-transplant for patients with pre-existing antibody to donor red cells may be necessary, especially in 
those with severe hemolysis from allo- (transfusion related) or auto-antibodies.  We may have these patients undergo 
plasma exchange (section 7.2) if they have major ABO mismatch to their donors.       
 
We hypothesize that the duration of neutropenia (ANC<500) with the PC and transplant regimen should be similar 
to the currently protocol, average of 16-21 days.  An important objective of the current protocol will evaluate the 
safety and efficacy of the PC regimen when administered over a 14-day interval.  To maximize safety of 
administration, the PC therapy is administered separately and followed by the alemtuzumab and TBI. And to further 
ensure safety of this regimen in a SCD or β-thalassemia patient that may have increased end-organ dysfunction 
relative to the cancer patient population, the dose of pentostatin will be reduced to a level of 2 mg/m2/day, which has 
been shown to be effective in the lymphoid neoplasia setting.31 We also intend to transplant male donors – female 
recipients first and measure appropriate antibody titers pre- and post-HSCT (see section 11.1).  Knowing the duration 
of neutropenia and the degree of antibody reduction with this combined regimen will help us decide if any anti-plasma 
cell therapy, e.g. bortezomib, lenolidomide, and/or others, given pre- or post-HSCT, would be necessary. 
 
4.0 
STUDY DESIGN 
 
Pentostatin will be given on days -21, -17, -13, -9 and oral cyclophosphamide from days -21 to -8, with the intention 
to be administered in the outpatient setting.  Alemtuzumab will follow on days –7 to –3, and 300 cGy TBI on day –
2. Sirolimus will start at a loading dose for three doses on day -1 and adjusted to maintain trough levels between 5-
15 ng/mL.  The PBSC graft targeted to deliver 10 x 106 CD34+ cells/kg (minimum 5 x 106) will be infused on day 
0.     
 

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Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
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The proposed number of subjects will include both cohorts.  The first cohort of patients will be male donor – female 
recipients to see if this new regimen will yield higher rate of durable donor leukocyte chimerism.  We will also 
measure anti-A, anti-B, and/or other red cell antibody titers from this initial cohort to determine the feasibility of 
transplanting patients with pre-existing antibodies (major ABO mismatch or other anti-donor red cell antibody).  The 
information gathered from this cohort of patients will help to determine the degree of antibody titer reduction in those 
with pre-existing antibodies and determine if anti-plasma cell therapy is needed.   
 
The second cohort of patients will be patients with pre-existing antibodies (major ABO mismatch or other anti-donor 
red cell antibody).  The primary endpoint for this group will be different than the first cohort (section 11.1 and 11.2). 
It is very likely that red cell aplasia (6 months to 2 years post-transplant) and prolonged duration of red cell transfusion 
are expected in this second group, thus a later time point to determine treatment success is justified.  Once we begin 
to enroll in the second cohort, enrollment in the first cohort may occur concurrently. 
 
5.0 
ELIGIBILITY ASSESSMENT AND PATIENT SELECTION 
 
The target subject population is a subset of patients who have severe disease and HLA matched family donors, and 
who are at increased risk for transplant failure, defined as male donors and female recipients, major ABO 
incompatibility to the recipient (Appendix B), or presence of antibody in the recipients to donor red cells from 
alloimmunization.  The remainder of the inclusion and exclusion criteria is very similar to the other HLA matched 
transplant study (03-H-0170).   
 
5.1 
Inclusion criteria- recipients (must fulfill one disease category in 5.1.1 and all of 5.1.2) 
5.1.1 
Disease specific 
5.1.1.1 Patients with severe sickle cell disease (not limited to Hb SS, SC, or Sβ-thal) at high risk for disease-related 
morbidity or mortality, defined by having severe end-organ damage (A, B, C, D, or E) or potentially 
modifiable complication(s) not ameliorated by hydroxyurea or sickle specific therapy (F): 
A. Stroke defined as a clinically significant neurologic event that is accompanied by an infarct on cerebral 
MRI or cerebral arteriopathy requiring chronic transfusion therapy; OR 
B. Sickle cell-related renal insufficiency defined by  a creatinine level ≥ 1.5 times the upper limit of normal 
and kidney biopsy consistent with sickle cell nephropathy OR nephrotic syndrome OR creatinine clearance 
less than < 50mL/min OR requiring peritoneal or hemodialysis37-39; OR 
C. Tricuspid regurgitant jet velocity (TRV) of ≥ 2.5 m/s40, 41 at baseline; OR 
D. Recurrent priapism defined as at least 2 episodes of an erection lasting >4 hours involving the corpora 
cavernosa and corpus spongiosa42; OR 
E. Sickle hepatopathy defined as EITHER ferritin >1000mcg/L OR direct bilirubin >0.4 mg/dL at baseline  
 
 
 

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Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
10 | P a g e  
Any one of the below complications: 
F.  
 
Complication 
Eligible for hydroxyurea 
Eligible for HSCT 
Vaso-occlusive crises 
At least 3 hospital admissions 
in the last year 4 
More than 1 hospital admission per year while 
on therapeutic dose of  hydroxyurea or sickle 
cell therapy2 
Acute chest syndrome 
2 prior ACS  
any ACS while on hydroxyurea  43 
Osteonecrosis of 2 or more 
joints 
And significantly affecting 
their quality of life by 
Karnofsky score 50-60 
(Appendix B) 
And on hydroxyurea where total hemoglobin 
increases <1 g/dL or fetal hemoglobin  
increases <2.5 times the baseline level 
Red cell alloimmunization 
Transfusion dependent 
Total  hemoglobin increases <1 g/dL while on 
hydroxyurea 
 
5.1.1.2  Patients with beta-thalassemia who have grade 2 or 3 iron overload, determined by the presence of 2 or more 
of the following: 
- portal fibrosis by liver biopsy 
- inadequate chelation history (defined as failure to maintain adequate compliance with chelation with 
deferoxamine initiated within 18 months of the first transfusion and administered subcutaneously for 8-10 
hours at least 5 days each week) 
- hepatomegaly of greater than 2cm below the costochondral margin 
5.1.2 
 Non-disease specific: 
5.1.2.1  Age >4 years 
5.1.2.2  6/6 HLA matched family donor available 
5.1.2.3  Ability to comprehend and willing to sign an informed consent 
5.1.2.4  Negative -HCG, when applicable  
 
5.2 
Exclusion criteria –recipient (any of the following would exclude the subject from participating) 
5.2.1 
ECOG performance status of 3 or more (See Appendix A) 
5.2.2 
Evidence of uncontrolled bacterial, viral, or fungal infections (currently taking medication and progression 
of clinical symptoms) within one month prior to starting the conditioning regimen.  Patients with fever or 
suspected minor infection should await resolution of symptoms before starting the conditioning regimen. 
5.2.3 
Major anticipated illness or organ failure incompatible with survival from PBSC transplant 
5.2.4 
Pregnant or lactating 
 
5.3 
Inclusion criteria –donor 
5.3.1 
6/6 HLA matched family donor deemed suitable and eligible, and willing to donate, per clinical 
evaluations who are additionally willing to donate blood for research. Matched related donors will be 
evaluated in accordance with existing Standard NIH Policies and Procedures for determination of eligibility 
and suitability for clinical donation. Note that participation in this study is offered to all matched related 
donors, but is not required for a donor to make a stem cell donation, so it is possible that not all related 
donors will enroll onto this study. 
 
5.4 
Exclusion criteria- donor 
5.4.1 
None 
 
 
6.0 
CLINICAL EVALUATION OF THE PATIENT  

14-H-0077 
Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
11 | P a g e  
Bone marrow aspirates and biopsies will be read by a pathologist.  Samples will be ordered and tracked through the 
CRIS screens.  Should a CRIS screen not be available, the NIH form 2803-1 will be completed and will accompany 
the specimen and be filed in the medical record. 
 
6.1 
Pre-Study Evaluation 
Pre-transplant 
Screening 
X= required 
O=Optional 
Procedure: Consent Forms 
14-H-0077 Treatment consent 
X  
Procedure: History & Physical 
 
Medical history (to determine baseline symptoms) 
X 
Physical examination 
X 
ECOG or Karnofsky Performance Status, Lansky 
(pediatrics only) 
X 
Vital signs, Weight 
X 
Height 
X 
Procedure: Blood for clinical laboratory tests 
Local lab: Hematology 
 
CBC w/diff 
X 
Reticulocyte Count 
X 
PT/PTT 
X 
D-dimer 
X 
Hemoglobin Electrophoresis 
X 
Genotyping Analysis of Hemoglobin A, F, SS, SC or Sβ- 
Thalassemia patients and donors only  
O 
RBC Phenotype 
X 
STR profile, recipient 
X 
WBC chimerism (post-transplant) 
  
Type and antibody screen (anti-red cell antibodies) 
X 
Isohemagglutinin titer 
X 
Direct Antiglobulin Screen 
X 
CMV/EBV PCR; Quantitative, Blood  
-On the first day of Pentostatin  
O 
Local lab: HLA typing 
HLA – A, B, C and DR, DQ (low resolution) 
X 
HLA Confirmatory A,B,C, DRB1 
X 
HLA Antibody Screen- Class 1 A, B, C 
X 
HLA Antibody Screen - Class 2 DRB1, DQB1 
X 
KIR Genotype  
X 

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Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
12 | P a g e  
Sequence Based HLA-C 
X 
Local lab: Chemistry 
 
Acute care panel 
X 
Mineral panel 
X 
Hepatic panel 
X 
Creatine Kinase 
X 
Lactate Dehydrogenase 
X 
Protein, total 
X 
Uric Acid 
X 
Lipid panel  
X 
Lipoprotein Profile  
O 
Apolipoprotein Panel 
O 
Iron and Transferrin (include ferritin) 
X 
Folate 
O 
Vitamin B12 
O 
Troponin I 
X 
Β-HCG serum pregnancy (females only) 
X 
Pre-albumin 
O 
Local lab: Endocrine testing 
 
Thyroid Stimulating Hormone 
X 
T3/Triiodothyronine (total) 
X 
FT4/ Thyroxine, Free 
X 
Growth hormone 
X 
Insulin-like growth factor 1 
X 
Adrenocorticotropic hormone 
X 
Morning cortisol 
X 
Fasting insulin 
X 
Fasting glucose 
X 
Hemoglobin A1C (for Thalassemia patients)  
 X 
Serum fructosamine (for SCD patients) 
X 
25 hydroxy Vitamin D 
X 
Follicle Stimulating Hormone (males and females) 
X 
Luteinizing Hormone (males and females) 
X 
Testosterone, Total and Free (males only) 
X 
Anti-mullerian hormone (females only) 
X 
Prolactin (females only) 
X 
Estradiol (females only) 
X 

14-H-0077 
Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
13 | P a g e  
Progesterone (males and females) 
X 
Local lab: Blood for DTM viral markers 
 
HBs Ag, Screening  
X 
Anti-HCV Antibody  
X 
Anti-HTLV-I/II Antibody  
 
Anti-HBc Antibody  
 
Anti-HIV-1/2 Antibody  
 
West Nile Virus  
 
HIV-1/HCV/HBV NAT  
X 
T. cruzi Antibody  
X 
RPR RPR/ Syphilis Total Antibody, Serum 
X 
Anti-Cytomegalovirus IgG, IgM Antibody 
X 
Anti-EBV Antibody Panel 
X 
Anti-HAV Antibody, Total 
X 
Anti-HAV IgM 
X 
Anti-HBc IgM 
X 
Anti-HBs Antibody 
X 
Anti-HSV Type 1/2 Antibody, IgG 
X 
Anti-Toxoplasma IgG 
X 
Anti-Toxoplasma IgM (Mayo) 
X 
Anti-Varicella-Zoster Virus IgG 
X 
Local lab: Blood for immunological studies 
 
Lymphocyte Phenotyping TBNK 
X 
Immunoglobulins, Quantitative  
X 
Pro-BNP/ Pro Brain Natriuretic Peptide 
X 
Haptoglobin 
X 
Local lab: Evaluate sickle nephropathy 
 
Blood 
 
Cystatin C 
X 
CRP, High Sensitivity, Comprehensive 
X 
Osmolality, 
serum 
X 
Random urine 
 
Urinalysis 
X 
Phosphorus, Inorganic, Urine 
X 
Uric acid 
X 
Protein /Creatinine Ratio 
X 
Albumin/Creatinine Ratio 
X 

14-H-0077 
Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
14 | P a g e  
Osmolality, 
urine 
X 
24 hour urine 
 
Creatinine 
X 
Protein 
X 
Albumin 
X 
Phosphorus, Inorganic, Timed Urine 
X 
Uric acid 
X 
Creatinine 
clearance 
X 
Electrophoresis, Timed Urine 
X 
Blood for storage: Research samples 
 
Pre transplant research labs (One 10ml EDTA and one 
4mL SST)  
X 
CD34 Sample to be drawn when collecting autologous 
PBCS for backup:  
-Draw Pre Plerixafor and approximately 4hrs post 
Plerixafor (at the start of apheresis) labs. The timing of 
these blood draw may be changed per PI discretion.  
X  X  
Procedures/ Consults: 
 
Collection of Autologous PBSC for Backup  
O 
Bone Marrow Harvest  for Backup  
O 
ACTH stimulation (CRIS order: Cortisol Serial 01-08) 
X 
Oral glucose tolerance test (OGTT) 
X 
Echocardiogram 
X 
EKG 
X 
Pulmonary function tests  
X 
6-min walk 
X 
24 hour Holter monitor 
X 
Chest x-ray (CRIS order: DX Chest-Pa & Lat) 
X 
Bone marrow aspirate and biopsy 
X (cytogenetics, next 
gen sequencing – 
mayo test NGSHM) 
Liver MRI 
 X 
Cardiac MRI 
X 
Bone dexa scan 
X 
Reproductive health assessment 
X 
Sperm / testicular tissue or oocyte banking, if 
requested 
X 
Brain MRI/MRA 
X 
Quality of life tests: Neuropsychology/PROMIS-57 
X 
Dental consult 
X 
Ophthalmology consult 
X 

14-H-0077 
Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
15 | P a g e  
 
 
 
6.2 
Day 0- Day 100 
 
X=Required 
O=Optional 
 
 
 
 
Inpatient 
Day 30 
(+/-7 days) 
Day 60 
(+/-7 days) 
Day 100 (+/-7 
days) 
Procedure: History & Physical 
Medical history (to determine baseline symptoms) 
Per Inpatient 
team 
X 
X 
X 
Physical examination 
Per Inpatient 
team 
X  
X  
X 
ECOG or Karnofsky Performance Status, Lansky (pediatrics 
only) 
 
 
 
X 
Vital signs, Weight 
X   
X  
X  
X  
Procedure: Blood for clinical laboratory tests 
Local lab: Hematology 
 
 
 
CBC w/diff 
X  
X  
X  
X  
Reticulocyte Count 
X twice weekly 
 
 
 
PT/PTT 
X twice weekly X  
X  
X  
Hemoglobin electrophoresis 
 
X 
X 
X 
RBC Phenotype 
O 
WBC chimerism 
 
X  
X  
X  
Type and antibody screen (anti-red cell antibodies) 
X weekly 
X  
X  
X  
Isohemagglutinin titer 
X 
CMV/EBV PCR; Quantitative, Blood 
X weekly 
X  
X  
X  
Local lab: Chemistry 
 
 
 
 
Acute care panel 
X    
X  
X  
X  
Mineral panel 
X   
X  
X  
X  
Hepatic panel 
X    
X  
X  
X  
Social work consult 
X 
Pre-transplant education class 
X 
Venous assessment 
X 
Exchange or simple transfusion 
X 
Transfusion Medicine Consult 
X 
Abdominal ultrasound 
X 
Miscellaneous protocol requirements: 
Plasma exchange (major ABO mismatch recipient as 
needed) 
O 
Discontinue: Iron chelation 2 days before starting PC 
regimen 
X 
Discontinue: Hydroxyurea or other SCD therapy 1-3 
days prior to starting PC regimen 
X 

14-H-0077 
Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
16 | P a g e  
Creatine Kinase 
 
X  
X  
X  
Lactate Dehydrogenase 
 
X  
X  
X  
Uric Acid 
 
X  
X  
X  
Lipid panel 
X every 2 weeks X 
X 
 X 
Iron and Transferrin (include Ferritin) 
 
 
 
X 
Β-HCG serum pregnancy (females only) 
 
 
 
O 
Pre-albumin 
X twice weekly 
 
 
 
Sirolimus level 
X 2-3 per week 
X  
X  
X 
Local lab: Evaluate sickle nephropathy 
 
 
 
 
Random urine 
 
 
 
 
Urinalysis 
 
X 
X 
X 
Protein Creatinine Ratio, Urine 
 
X 
X 
X 
Albumin/Creatinine Ratio, Urine 
 
X 
X 
X 
Blood for storage: Research samples 
 
 
 
 
Post-Transplant Research labs (One 6ml EDTA and one 4mL 
SST)  
 
X 
X 
X 
Campath research levels (One 4mL SST)- Day 7, 14, 21, 28/30 
post- transplant (+/-2 days) 
XXXX* 
X  
 
 
Procedures/ consults: 
 
 
 
 
Echocardiogram 
 
 
 
X 
Pulmonary function tests   
 
 
 
X 
6-min walk 
 
 
 
X 
Bone marrow aspirate +/- biopsy 
 
 
 
O 
Quality of life tests: Neuropsychology/PROMIS-57 
 
 
 
X (Monitoring Test 
Battery) 
*denotes multiple procedures  
 
 
6.3 
Beyond Day 100 
It is our intention to have patients return for all these follow-up visits. However, some patients, especially 
international ones, may have financial, visa related, or other difficulties that limit their visits. In those situations, we 
will work with their local physicians to get some of the testing done and/or mail kits for blood testing and provide 
vaccinations if needed. 
X=required; O=optional  
M6 (+/-
1month) 
M12 
(+/-1 
month) 
M18 
(+/-1 
month) 
M24 
(+/-1 
month) 
M36 
(+/-6 
month) 
M48 
(+/-6 
month) 
M60 
(+/-6 
month) 
 
Procedure: History & 
Physical 
Medical history (to determine 
baseline symptoms) 
X 
X 
O 
X 
X 
X 
X 
Physical examination 
X 
X 
O 
X 
X 
X 
X 
ECOG or Karnofsky 
Performance Status, Lansky 
O 
X 
O 
X 
X 
X 
X 

14-H-0077 
Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
17 | P a g e  
X=required; O=optional  
M6 (+/-
1month) 
M12 
(+/-1 
month) 
M18 
(+/-1 
month) 
M24 
(+/-1 
month) 
M36 
(+/-6 
month) 
M48 
(+/-6 
month) 
M60 
(+/-6 
month) 
(pediatrics only) 
Vital signs, Weight 
X 
X 
O 
X 
X 
X 
X 
height 
O 
X 
O 
X 
X 
X 
X 
Procedure: Blood for clinical 
laboratory tests 
Local lab: Hematology 
 
 
 
 
 
 
 
CBC w/diff 
X 
X 
O 
X 
X 
X 
X 
Reticulocyte Count 
X 
X 
O 
X 
X 
X 
X 
PT/PTT 
X 
X 
O 
X 
X 
X 
X 
D-dimer 
X 
X 
O 
X 
X 
X 
X 
Hemoglobin electrophoresis 
X 
X 
O 
X 
X 
X 
X 
RBC Phenotype 
O 
O 
O 
O 
O 
O 
O 
WBC chimerism 
X 
X 
O 
X 
X 
X 
X 
Type and antibody screen 
(anti-red cell antibodies) 
X 
X 
O 
X 
O 
O 
O 
Isohemagglutinin titer 
X 
X 
O 
X 
O 
O 
O 
CMV/EBV PCR 
X 
X 
O 
X 
O 
O 
O 
Local lab: Chemistry 
 
 
 
 
 
 
 
Acute care panel 
X 
X 
O 
X 
X 
X 
X 
Mineral panel 
X 
X 
O 
X 
X 
X 
X 
Hepatic panel 
X 
X 
O 
X 
X 
X 
X 
Lactate Dehydrogenase 
X 
X 
O 
X 
X 
X 
X 
Lipid panel 
X 
X 
O 
X 
X 
X 
X 
Iron and Transferrin (include 
Ferritin) 
X 
X 
O 
X 
X 
X 
X 
Β-HCG serum pregnancy 
(females only) 
O 
O 
O 
O 
O 
O 
O 
Sirolimus level 
X 
X 
O 
O 
O 
O 
O 
Local lab: Endocrine testing 
 
 
 
 
 
 
 
Thyroid Stimulating Hormone O 
X 
O 
X 
X 
X 
X 
T3/Triiodothyronine (total) 
O 
X 
O 
X 
X 
X 
X 
FT4/ Thyroxine, Free 
X O 
X 
O 
X 
X 
X 
X 
Serum fructosamine 
O 
X 
O 
X 
X 
X 
X 
25 hydroxy Vitamin D 
O 
X 
O 
X 
X 
X 
X 
Follicle Stimulating Hormone 
(males and females) 
O 
X 
O 
X 
X 
X 
X 
Luteinizing Hormone (males 
and females) 
O 
X 
O 
X 
X 
X 
X 

14-H-0077 
Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
18 | P a g e  
X=required; O=optional  
M6 (+/-
1month) 
M12 
(+/-1 
month) 
M18 
(+/-1 
month) 
M24 
(+/-1 
month) 
M36 
(+/-6 
month) 
M48 
(+/-6 
month) 
M60 
(+/-6 
month) 
Testosterone, Total and Free 
(males only) 
O 
X 
O 
X 
X 
X 
X 
Anti-mullerian hormone 
(females only) 
O 
X 
O 
X 
X 
X 
X 
Estradiol (females only) 
O 
X 
O 
X 
X 
X 
X 
Progesterone (females only) 
O 
X 
O 
X 
X 
X 
X 
Local lab: Blood for 
immunological studies 
 
 
 
Lymphocyte TBNK 
O 
X 
O 
X 
O 
O 
O 
Immunoglobulins, 
quantitative 
O 
X 
O 
X 
O 
O 
O 
Haptoglobin 
O 
X 
O 
X 
O 
O 
O 
Local lab: Evaluate sickle 
nephropathy 
 
 
 
 
 
 
 
Blood 
 
 
 
 
 
 
 
Cystatin C 
O 
X 
O 
X 
O 
O 
O 
CRP, High Sensitivity, 
Comprehensive 
O 
X 
O 
X 
O 
O 
O 
Random urine 
 
 
 
 
 
 
 
Urinalysis 
O 
X 
O 
X 
O 
O 
O 
Protein/Creatinine ratio 
O 
X 
O 
X 
O 
O 
O 
Albumin/Creatinine ratio 
O 
X 
O 
X 
O 
O 
O 
Blood for storage: Research 
samples 
 
 
 
 
 
 
 
Post-Transplant Research 
Labs (One 6ml EDTA)  
X 
X 
O 
X 
X 
X 
X 
Procedures/ consults: 
 
 
 
 
 
 
 
Echocardiogram 
O 
X 
O 
X 
O 
O (one betw 
yr 4 and 5) 
O 
Pulmonary function tests  
O 
X 
O 
X 
O 
O (one betw 
yr 4 and 5) 
O 
6-min walk 
O 
X 
O 
X 
O 
O (one betw 
yr 4 and 5) 
O 
Brain MRI/MRA 
O 
X 
O 
X 
O 
O (one betw 
yr 4 and 5) 
O 
Bone dexa scan 
O 
X 
O 
X 
O 
O (one betw 
yr 4 and 5) 
O 
Bone marrow aspirate +/- 
biopsy 
O 
O 
O 
O 
O 
O 
O 
Liver MRI 
O 
O 
O 
O 
O 
O 
O 
Cardiac MRI 
O 
O 
O 
O 
O 
O 
O 
Reproductive health 
assessment 
O 
X 
O 
X 
O 
O 
O 
Quality of life tests: 
Neuropsychology 
PROMIS-57 
O 
X 
O 
X 
O 
O 
O 

14-H-0077 
Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
19 | P a g e  
 
After 5 years follow-up visits are not mandatory, but yearly communication with the patient and the referring 
physician may continue.  
7.0 
TREATMENT PLAN 
 
7.1 
Exchange Transfusion (Appendix C) 
Prior to the PC regimen, those patients with SCD who are not routinely (exchange) transfused  may undergo an 
exchange transfusion per Department of Transfusion Medicine (DTM) procedure for a goal HbS <30% just prior to 
receiving the preparative regimen in order to decrease the likelihood of neurologic and other sickling events that may 
be precipitated by the transplant procedure. Exchange transfusion may be omitted, and rituximab may be used instead, 
in selected individuals with prior severe transfusion or auto-antibody related hemolysis. 
7.2 
Plasma Exchange 
For patients with major ABO mismatch, plasma exchange may be performed prior to the PC regimen as this procedure 
is effective in removing these antibodies, which are more of the IgM type.  For patients with antibodies to minor 
antigens on donor red cells, which are typically IgG type and less efficiently removed by plasma exchange, we will 
discuss with DTM and consider plasma exchange.  
 
7.3 
Collection of Autologous Peripheral Blood Stem Cells (PBSC) (Appendix C)  
Collection of autologous PBSC for backup in case of graft rejection and delayed autologous recovery may be 
performed before the start of the preparative regimen in patients with thalassemia.  Use of G-CSF as a mobilizing 
agent has yielded unreliable results in this setting.  However, plerixafor  has been effectively used as a sole agent to 
mobilize stem cells in patients with severe -thalassemia, including those with and without prior splenectomy44.  The 
target stem cell dose will be > 2 x 106 CD34 cells/kg, and the minimum dose for proceeding to transplant will be > 1 
x 106 CD34 cells/kg.  If use of plerixafor does not result in collection of a sufficient number of CD34 cells, G-CSF 
may be added to plerixafor in a subsequent synergistic attempt to improve CD34 yield.  Both agents have also been 
used to safely mobilize a patient with thalassemia44.  
 
Collection of back up hematopoietic stem cells in individuals with SCD poses risks that outweigh the potential 
benefits.  G-CSF has been associated with extensive morbidity (including vaso-occlusive crises, acute chest 
syndrome, and multi-organ failure) and mortality in patients with SCD45.  Plerixafor is currently being studied in 
patients with SCD, so the risks are unknown.  Bone marrow harvest is also being studied in patients with SCD 
undergoing gene therapy studies.  The risk of general anesthesia may be significant in patients with severe disease, 
and fluid shifts associated with removal of bone marrow may lead to significant morbidity.  Therefore, the risks of 
autologous cell collection may outweigh the benefits in patients with SCD, and hence autologous cells will not 
routinely be collected in that patient population. There may be clinical situations where autologous cells may be 
collected, e.g. a small or young donor with a very large recipient, less than target number of stem cells collected from 
the donor,  a recipient having HLA-antibodies, or other concern that may hinder engraftment. 
7.4 
Peripheral blood progenitor cell collection (Appendix C) 
 
Donors will sign NHLBI standard of care protocol for HSC mobilization and collection. This section further clarifies 
the target HSC dose and type of HSC graft needed for this study. The target collection number for progenitor cells is 
10 x 106 CD34+ cells/kg. 
 
For adult donors, this product will be collected in advance and cryopreserved.  The volume processed per apheresis 
procedure will be determined by DTM medical staff on the day of apheresis, based on peak CD34 cell mobilization 
response to filgrastim (G-CSF) and the CD34 cell dose needed, based on kilogram weight of the recipient.  This will 
range from 15 to 35 liters processed per day for 2 to 3 days, not to exceed a total of 75 liters over 3 days.  A day 3 
apheresis procedure will only be performed if the minimum dose of 5 million per kg is not met after the first two day 
collection. The minimum dose for proceeding to transplant will be  5 x 106 CD34 cells/kg.  In order to meet the 
minimum dose, the donor may undergo a second mobilization a minimum of 2 weeks later. If after two such attempts, 

14-H-0077 
Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
20 | P a g e  
an inadequate cell number has been collected, the patient and donor will be withdrawn from the protocol, unless 
another donor is available.  Red cells in the graft may be removed in major ABO incompatible grafts and minor ABO 
incompatible grafts may have plasma removed per Transfusion Medicine protocol. Additional mobilization agent, 
e.g. plerixafor, may be used with GCSF as per standard of care/Bone Marrow Transplant Consortium Standard 
Operating Procedures. 
 
For adult donors who undergo G-CSF mobilization and PBSC collection outside of the NIH Clinical Center, the 
volume of each apheresis to be processed and the days of apheresis will be determined by the institutional practice of 
that outside facility. The goal is to target 5 x 106 CD34 cells/kg. Also, refer to sections 8.1.15 and 8.2. 
 
Pediatric donor cell collections will be done as per routine standard of care/Bone Marrow Transplant (BMT) 
Consortium Standard Operating Procedures. PBMC will be cryopreserved at the NIH Department of Transfusion 
Medicine until use. 
 
7.5 
Preparative regimen  
All drugs will be given intravenously if possible based on the dosing formulation. All other concomitant medications 
or special procedures noted in the protocol shall follow standard NHLBI transplant protocols/procedures. Iron 
chelation should be discontinued about 2 days before initiating the pentostatin and cyclophosphamide (PC) regimen.  
Hydroxyurea should be discontinued 1-3 days prior to first dose of PC regimen to avoid overlapping 
myelosuppression. 
 
The 14-day PC regimen will be administered just proximal to the alemtuzumab and the TBI with the intent to be 
administered as an outpatient.  As such, pentostatin will be administered at a dose of 2 mg/m2 on days -21, -17, -13, 
and -9. A total pentostatin dose of 8 mg/m2 will be utilized, which is equal or somewhat reduced dose relative to 
previous transplantation studies. On the day of each pentostatin infusion, 8-12 mg of dexamethasone (IV or PO) and 
8mg IV or 16-24 mg PO of ondansetron will be administered 30-60 minutes prior to, and 1 L of 0.9% saline will be 
infused over 60-120 minutes prior to pentostatin infusion.  Pentostatin, diluted in 500 mL of 0.9% sodium chloride, 
will then be infused IV over 30-60 minutes.  Oral dexamethasone of 4mg may be administered on days -20, -19; -16, 
-15; -12, -11; -8 and -7; oral ondansetron, 8mg twice daily, may be administered throughout the 14-day PC regimen.  
Changes in the anti-emetics, hydration, or administration of pentostatin are allowed at the discretion of the PI or 
designee. 
 
Although pentostatin is >90% renally excreted, there is no established consensus on how to dose in those with 
impaired renal functions.  Page 2 of pentostatin package insert reports that after a dose of 4mg/m2, the terminal half-
life was measured to be 6 hours in patients with creatinine clearance (CrCl) >60 mL/min vs 18 hours in those with 
CrCl <50 (http://hemonc.org/docs/packageinsert/pentostatin.pdf ).  Lathia and colleagues46 reduced pentostatin 
dosing based on CrCl and found the drug exposure and toxicity was comparable in all groups (CrCl >60 mL/min – 4 
mg/m2, 41-60 mL/min – 3 mg/m2, 21-40 – 2mg/m2, ≤20 mL/min – 1 mg/m2).  Thus serum creatinine or cystatin C 
levels will be obtained prior to each dose of pentostatin, and since our starting dose is already at 2mg/m2, dose 
adjustment for renal dysfunction is as follows: 
• 
2 mg/m2 of pentostatin if CrCl ≥ 60 mL/min/1.73m2, 1.5 mg/m2 of pentostatin if CrCl 40-59 
mL/min/1.73m2 
• 
1.0 mg/m2 of pentostatin if CrCl 20-39 mL/min/1.73m2, 0.5 mg/m2 of pentostatin if CrCl <20 
mL/min/1.73m2 
Estimate of creatinine clearance is obtained by 24-hour urine, creatinine or cystatin C.  
 
 
Cyclophosphamide will be administered at a daily dose of 200 mg per day on days -21 through -8 as per the schema 
detailed below. In children <16 years of age, 3mg/kg of cyclophosphamide, rounded to the nearest 25mg increment 

14-H-0077 
Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
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(not to exceed 200mg), will be used. Cyclophosphamide will be either reduced or omitted depending on whether the 
lymphocyte depletion target has been achieved and whether there is any myeloid cell toxicity.  The stated goal of the 
PC regimen is to enter the interval of alemtuzumab therapy with substantial immune depletion (absolute lymphocyte 
count [ALC] value < 100) and without grade 3 neutrophil toxicity (absolute neutrophil count [ANC] value <1000). 
 
Cyclophosphamide dose adjustment based on ALC and ANC values 
 
 
Day of 
cycle1 
 
ALC value at time 
of evaluation 
 
ANC value at time 
of evaluation2 
 
 
Cyclophosphamide 
dose3 
-21 
 
Any 
 
> 1000 
 
200  
 
 
 
 
 
 
 
-17 
 
≥ 400 
 
> 1000 
 
200 
 
 
200-399 
 
500-999 
 
100  
 
 
< 200 
 
< 500 
 
0 
 
 
 
 
 
 
 
-13 
 
≥ 200 
 
> 1000 
 
200 
 
 
101-199 
 
500-999 
 
100  
 
 
< 100 
 
< 500 
 
0 
 
 
 
 
 
 
 
-9 
 
≥ 100 
 
> 1000 
 
200 
 
 
50-99 
 
500-999 
 
100  
 
 
< 50 
 
< 500 
 
0 
 
 
 
 
 
 
 
1 Pentostatin will not be dose-adjusted based on ALC/ANC values. 
2 For ANC values <1000, decrease in cyclophosphamide dosing only – patients will not receive G-CSF. 
3 Cyclophosphamide dose indicated will be continued daily until the next ALC/ANC measurements (performed on days -17, 
-13, and -9). For young children, dose will be 3mg/kg, rounded to the nearest 25mg increment. 
 
 
Days –7 to –3 Alemtuzumab (Campath®) IV given in an escalating dose over a total of 5 days Diphenhydramine 
doses and/or route of administration can be adjusted as per inpatient or research team 
Day –7:  Diphenhydramine 1mg/kg (maximum 50mg) IV and acetaminophen 10-15mg/kg (maximum 650mg) PO, 
then followed 30 minutes later by alemtuzumab 0.03mg/kg in 100mL normal saline infused over 2 hours 
Day –6:  Diphenhydramine 1mg/kg (maximum 50mg) IV and acetaminophen 10-15mg/kg (maximum 650mg) PO, 
then followed 30 minutes later by alemtuzumab 0.1mg/kg in 100mL normal saline infused over 2 hours 
Day  -5 to Day -3:  Diphenhydramine 1mg/kg (maximum 50mg) IV and acetaminophen 10-15mg/kg (maximum 
650mg) PO, then followed 30 minutes later by alemtuzumab 0.3 mg/kg in 100mL normal saline infused over 2 hours. 
For obese patients, alemtuzumab may be capped at 30mg per dose 
Day -2: Total body irradiation, dose of 300 cGy, delivered as per the Department of Radiology standard of practice 
Day –1:  Sirolimus (Rapamune®) will be started at 5mg PO q4h x three doses at day -1, and continued at 5mg PO 
daily to target trough levels of 5-15 ng/mL. For children <16 years of age, 1mg/m2 PO q4h (not to exceed 5mg per 
dose) x three doses at day -1, and continued 1mg/m2 PO daily will be administered. 
Day 0: Infusion of unmanipulated G-CSF - mobilized peripheral blood stem cells 
 
7.6 
TBI 
Energy:  All patients should be treated with a linear accelerator using energies higher than 4MV. 
 
Timing:  It is anticipated that TBI will be delivered on day -2. 
Technique:  TBI will be delivered with lateral fields using extended SAD values of 600cm. Tissue compensators 
will be used as appropriate for all patients.  Gonadal shielding will be used in male patients. 

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Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
22 | P a g e  
 
Dose/Fractionation: Patients will receive TBI to a total dose of 300 cGy in a single fraction.  
 
Dose Modifications:  Occasionally, the total dose/technique of TBI may require modifications due to patient factors 
(unexpected or severe (grade 4-5) adverse events, serious medical illnesses not conducive to stable patient transfer, 
patient refusal, etc) or treatment factors (linear accelerator machine offline, etc.) Modifications to the radiation 
treatment will be at the discretion of the treating radiation oncologist in collaboration with the Principal 
Investigator.   
7.7 
GVHD prophylaxis  
Sirolimus (Rapamune®) will be started on day -1 with goal trough levels of 5-15ng/ml. The dose may be reduced in 
the presence of hepatic or renal insufficiency. The sirolimus will be given for a minimum of one year; however, the 
total duration of administration will be determined by the presence or absence of GVHD and the level of donor 
/recipient chimerism.  
 
If at least one year post-transplant the recipient displays >50% lymphoid donor chimerism, the sirolimus dose can 
be tapered.  Donor/recipient chimerism levels will be checked periodically during and after the taper.  If lymphoid 
and/or myeloid donor chimerism levels decrease by > 20%, the sirolimus dose may be increased back to the most 
recent dose at which donor chimerism was maintained; other immunosuppression may be used as clinically 
indicated. 
 
Subjects will be advised not to take medication with grapefruit juice and not to take St. John’s wort while on 
sirolimus.  Subjects must also be advised about limiting exposure to sunlight and UV light due to an increased risk 
of skin cancer. Women of childbearing potential will be informed of the potential risks during pregnancy and that 
they should use effective contraception prior to initiation of drug. 
 
7.8 
Central venous line placement 
A central venous catheter will be placed by a surgeon, interventional radiologist, or vascular access device specialist 
prior to transplantation. 
 
7.9 
Infection Prophylaxis   
Penicillin VK 250 mg PO BID (or equivalent) from day 0 until pneumococcal vaccinations are completed post-
transplant. Prophylaxis of pneumocystis will begin when neutrophil engraftment is established, which may be later 
than day 30.  Because of possible liver dysfunction, nystatin or micafungin may be used first line, but other anti-
fungal agents may be substituted for prophylaxis.  Prophylaxis and treatment of infections will otherwise be 
administered according to BMT consortium guidelines.  
 
Patients will be offered influenza vaccination, as seasonally indicated, when they are at least 6 months post-
transplant per CDC HSCT guidelines. 
 
7.10 
Fever Regimen: see BMT Consortium guidelines 
 
7.11 
Bleeding prophylaxis and blood product support (See Appendix C) 
When possible, platelet counts will be maintained at or higher than 50,000/ul for patients with SCD (which is higher 
than usually maintained for non-sickle cell patient transplants) throughout the transplant to diminish the risk of 
intracranial bleeding.  Peri-transplant target hemoglobin will be kept above 9 g/dL in patients with SCD.  
Otherwise, packed red blood cell and platelet transfusions will be given according to BMT consortium guidelines. 
 
7.12 
Contraindication 
Filgrastim (G-CSF) is a relative contraindication for all patients with sickling disorders and will only be given with 
the consent of the principal investigator, lead associate investigator, or the attending protocol investigator. 
 

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Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
23 | P a g e  
7.13 
Cardiac MRI 
Cardiac MRI may be performed at baseline and 1 year post-transplant to assess factors such as cardiac structure, 
cardiac volumes, left ventricular ejection fraction, iron deposition, myocardial fibrosis, and extracellular volume 
fraction with gadolinium enhanced methods where indicated. We may evaluate the effect of transplant on those 
factors. 
 
8.0 
MANAGEMENT OF PATIENT COMPLICATIONS 
 
The major complications are viral reactivation, acute and chronic GVHD, and relapse of the original disease.  
Patients with these complications will be treated along the following lines: 
8.1 
Viral reactivation: see BMT consortium guidelines 
8.2 
Acute GVHD: Sirolimus may be continued and treated according BMT consortium guidelines 
8.3 
Chronic GVHD: Sirolimus may be continued and treated according BMT consortium guidelines  
8.4 
Graft rejection and falling chimerism (poor engraftment): This transplant protocol uses a 
nonmyeloablative preparative regimen.  Therefore, autologous recovery (relapse of disease) is anticipated 
in patients who fail to engraft. For falling chimerism in the myeloid and/or CD3 compartment, another 
course of alemtuzumab as in the conditioning or unselected stem cell product (‘boost’) from the original 
donor may be used after preconditioning  with Busulfan IV 3.2 mg/kg on days -5, -4, and -3, and Campath 
IV 0.03mg/kg on day -7, 0.1mg/kg on day -6, and 0.2mg/kg on days -5 and 4, followed by sirolimus or 
equivalent immunosuppressant as in protocols 14-H-0111 and 15-H-0098. These medications are widely 
used at the Clinical Center and other transplant centers, and their side effects are well known.  Autologous 
rescue collection before stem cell boost is likely not needed, but may be considered if one or more risk 
factors for pancytopenia post infusion are present (e.g. age >35, low stem cell number of the boost, or low 
blood counts before at the start of the pre-conditioning regimen).  
 
For patients who had initial donor engraftment and subsequent graft rejection (donor myeloid and CD3 
chimerism of 0%), there is currently no standard approach; watch and wait until resurgence of sickle related 
complications (pain crisis, acute chest syndrome, etc), restart hydroxyurea or sickle specific therapy, or 
another stem cell transplant are all options one can consider.  We will discuss these options, and the patient 
can be offered to participate in other applicable clinical trials, or be referred back to their primary physician 
depending on what is considered to be in the best interest of the patient.     
 
8.5 
Post-transplant hemolysis: IVIg, corticosteroids, eculizumab, rituximab, or other therapies may be used to 
treat the hemolysis as per published literature or practice guidelines. 
 
9.0 
RESEARCH STUDIES 
The amount of blood that may be drawn from adult recipients for research purposes shall not exceed 10.5 mL/kg or 
550 mL, whichever is smaller, over any eight week period. 
 
For pediatric recipients, no more than 5 mL/kg may be drawn for research purposes in a single day, and no more 
than 9.5 mL/kg may be drawn over any eight-week period.  
Up to 50 mL of donor (adult or pediatric) blood may be collected prior to cell donation (and prior to GCSF 
mobilization) for research. Once a standard leukapheresis product from a donor has been found to meet target cell 
dose, 1mL of additional cells from the collection can be used for research under this protocol. 
Storage:  Research specimens will be stored under the supervision of the principal investigator. Samples will not be 
labeled with the patient’s name. Samples will be assigned a unique code known only to the principal investigator, 
which will serve as a link to the patient’s clinical information collected as part of this research protocol.  No 
samples will be provided to investigators outside the branch without IRB notification and an executed MTA. 
Therefore confidentiality is protected. 

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Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
24 | P a g e  
Tracking:  Samples will be ordered and tracked through the CRIS Research Screens.  Should a CRIS screen not be 
available, the NIH form 2803-1 will be completed and will accompany the specimen and be filed in the medical 
record.  Samples will not be sent outside NIH without IRB notification and an executed MTA.  
End of study procedures:  Samples from consenting subjects will be stored until they are no longer of scientific 
value or if a subject withdraws consent for their continued use, at which time they will be destroyed.  
Loss or destruction of samples:  Should we become aware that a major breech in our plan for tracking and storage 
of samples has occurred, the IRB will be notified. 
Data management: The principal investigator will be responsible for overseeing entry of data into an in-house 
password protected electronic system or locked research file system and ensuring data accuracy, consistency and 
timeliness. The principal investigator, associate investigators/research nurses and/or a contract data manager will 
assist with the data management efforts.  
All human subjects’ personally identifiable information (PII), eligibility, and consent verification will be recorded.  
Primary data obtained during the conduct of the protocol will be kept in secure network drives or in approved 
alternative sites that comply with NIH security standards.  Primary and final analyzed data will have identifiers so 
that research data can be attributed to an individual human subject participant, e.g., study-specific identifying 
number (SSPIN or other unique code, or minimum PII required for subject identification.   
  
Data will be abstracted from Clinical Center progress notes as well as from progress notes forwarded from home 
physicians. Laboratory data from NIH will be imported electronically from CRIS into an in-house database. 
Laboratory values from referring home physicians will be entered into the system. 
End of study procedures:  Data will be stored in locked cabinets and in a password protected database until it is no 
longer of scientific value.  
 
Loss or destruction of data:  Should we become aware that a major breech in the plan to protect patient 
confidentiality and trail data has occurred, the IRB will be notified.  Data will not be sent outside NIH without IRB 
notification and an executed MTA or CTA. 
9.1 
Chimerism studies 
We will use PCR analysis of microsatellites to identify the contribution of the donor marrow to post transplant 
hematopoiesis and to detect donor lymphocytes according to the schedule listed in Section 6.0.    
 
9.2 
Bone Marrow Samples – exploratory  
Up to 32 mL of bone marrow aspirate and biopsy will be collected for research studies at the pre-transplant 
evaluation. Bone marrow aspirate and/or biopsy may be collected at day 100 post-transplant, and/or when sustained 
donor erythroid chimerism is attained or if clinically indicated.  These may help elucidate the contribution of the 
progenitor cells to the circulating component. 
 
9.3 
Transthoracic Echocardiography – exploratory  
Transthoracic echocardiography will be performed to assess TR jet velocity at study onset Echoes may be 
performed yearly post transplantation, or more frequent as clinically indicated.   
 
9.4 
Immune reconstitution – exploratory  
Lymphocyte subpopulations (percentage and absolute number of CD3, CD4, CD8, CD16, CD56, and CD19 cells) 
and immunoglobin levels (IgG, IgA, and IgM) will be qualified  
  according to Section 6.0.  
 
9.5 
Assessment of cytokines and lymphocyte function – exploratory  

14-H-0077 
Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
25 | P a g e  
Donor serum and lymphocytes will be collected pre-transplant.  Patient serum and lymphocytes will be collected 
pre-transplant and post-transplant.  Serum tumor necrosis factor, interferon-gamma, and interleukin-17 may be 
quantified.  Levels may continue to be followed based on the results. 
 
Patient effector T cell subsets may be measured at each time point by intracellular cytokine staining for interferon 
gamma, interleukin-4, interleukin-17, and FoxP3.  Biochemical analysis of mTOR signaling complexes in patient T 
cells will be measured by Western blot for phospho p70 S6 kinase and phospho AKT in response to anti CD3 plus 
anti CD28 stimulation in vitro. 
 
CMV pp65 specific T cell responses may be measured in cases where either donor or recipient is CMV positive.  
These will be assessed by intracellular cytokine staining for interferon-gamma and FoxP3 in response to pooled 
overlapping pp65 peptides. 
 
In cases where patient/donor pairs have received influenza vaccine due to the seasonal timing of the transplant, we 
may measure influenza specific T cell responses by intracellular cytokine staining for interferon-gamma, 
interleukin-4, interleukin-17, and FoxP3 in response to influenza peptides. 
 
In cases where GVHD or graft rejection is observed, we may assess donor/host allo-reactivity by CFSE dilution 
assay in the presence and absence of sirolimus in vitro.  We may also measure mTOR signaling in patient T cells by 
Western blot for phospho p70 S6 kinase and phospho AKT in response to anti CD3 plus anti CD28 stimulation in 
the presence or absence of sirolimus in vitro. 
 
All of these research tests may be run at the laboratory of Dr. Jonathan Powell at Johns Hopkins Hospital.   Samples 
will be assigned a unique code known only to the principal and associate investigators. Samples will not be sent 
outside NIH without an executed material transfer agreement or collaborative research agreement. 
9.6 
Neuropsychologic testing:  see Addendum A – exploratory  
9.7 
Quality of life testing: see Addendum A – exploratory  
9.8 
Other potential studies: as described on the IRB list of approved Laboratory Research Studies 
 
10.0 
BIOSTATISTICAL CONSIDERATIONS 
10.1 
Study Endpoints and Sample Size 
Cohort 1: male donors – female recipients, the primary endpoint is treatment success at 1 year post-transplant, 
defined as sustained donor type hemoglobin on hemoglobin electrophoresis for patients with SCD and transfusion 
independence for patients with β-thalassemia.  We intend to enroll 4-6 patients in this cohort before enrollment in 
the next cohort.  Once the enrollment in cohort 2 has begun, simultaneous enrollment to both cohorts can occur.  
Cohort 2: patients with pre-existing antibody to donor red cells (either major ABO mismatch or other anti-donor red 
cell antibody), the primary endpoint is presence of donor red cells, detected by hemoglobin electrophoresis or donor 
type red cell antigen, and reticulocyte count ≥30 k/uL at 2 years post-transplant. It is very likely that red cell aplasia 
(6 months to 2 years post-transplant historically observed at NIH in non-myeloablative transplants) and prolonged 
duration of red cell transfusion are expected in this second group, thus a later time point to determine treatment 
success is justified. 
This study will start with a sample size of 81 recipients, which will include both cohorts of subjects.  We anticipate 
a 2:1accrual pattern (male donor/female recipients: pre-existing antibody recipients). 
The sample size estimation for cohort 1 is based on a one-sided 0.05 hypothesis test with null hypothesis the true 
success rate is  <= L, where we examine different sample sizes associated with different values of L, We plan to 
enroll 56 subjects in this cohort.  Table below shows the number of patients needed to achieve a lower one-sided 
95% confidence bound of success rate ranging from 0.50 to 0.70 under different actual success rate. Based on our 
previous study 03-H-0170 (success rate of 85%), we target the overall success range of 75%-95%. For example, if 

14-H-0077 
Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
26 | P a g e  
the true success rate is 85% then 24 subjects are required to have 80% power for the lower 95% confidence interval 
to exceed 0.60, and 56 subjects are needed to have 70% power for the lower confidence interval to exceed 0.70.    
Sample size table based on one-sided significance level of 0.05 and 80% power for cohort 1 
 
True success rate 
Lower 1-sided 95% Confidence bound 0.75 0.8 
0.85 0.9 0.95 
>0.50 
27 
19 
13 
10 
8 
>0.55 
40 
26 
18 
13 
9 
>0.6 
68 
38 
24 
16 
11 
>0.65 
142 
63 
35 
22 
14 
>0.7 
520 
129 56 
31 
18 
The results from protocol 03-H-0170 suggest that the male-into-female transplant regime has a failure rate of at 
least 50%.  Consequently, there is interest in demonstrating the success rate of the regimen tested here is greater 
than 50%. In this cohort, we propose that our primary analysis formally test the null hypothesis that the success rate 
is ≤ 50% with a one-sided test and alpha level of 0.05.  For a final sample size of N=56 and a true success rate of 
75% then there is 98% power to reject this null hypothesis; if the true rate is 70% then power falls to 91%. 
The sample size estimation for cohort 2 is calculated based on a wide range of possible success rate since we do not 
have data available to estimate the actual rate. We plan to enroll 25 subjects in this cohort. For example, if the 
actual success rate is 50%, then the sample size would be sufficient to give a lower 95% confidence bound of ≥25% 
with 80% power.  
Sample size table based on one-sided significance level of 0.05 and 80% power for cohort 2 
 
True success rate 
Lower 1-sided 95% Confidence bound 0.2 
0.3 
0.4 
0.5 
0.6 
0.7 
0.8 
>0.15 
361 49 
20 
11 
7 
5 
4 
>0.25 
 
502 63 
25 
13 
8 
6 
>0.35 
 
 
592 71 
27 
14 
9 
>0.45 
 
 
 
634 74 
27 
14 
>0.55 
 
 
 
 
625 71 
26 
>0.65 
 
 
 
 
 
567 63 
>0.75 
 
 
 
 
 
 
460 
Secondary endpoints 
1. CD34+ cell dose, CD3+ cell dose 
2. Degrees of donor-recipient lymphoid and myeloid chimerism by microsatellite PCR analysis; erythroid 
chimerism by CBC, reticulocyte count, hemoglobin electrophoresis, red cell phenotype for donor 
antigen, or if necessary by flow analysis.  Peripheral blood or bone marrow samples will be used for 
chimerism on days +30, +60 and +100, and periodically thereafter. More frequent monitoring may be 
required. 
3. Incidence of acute and chronic GVHD, graft rejection, or red cell aplasia >2 years after transplant.  
These together count toward the combined endpoint for regimen failure (section 11.2). 
4. Transplant-related mortality, disease-free survival and overall survival 
5. Neutrophil recovery (days to neutrophil count of 0.5 x 109/L) 
6. Platelet recovery (days to platelet count of 50 x 109, days to transfusion independence) 
7. Red cell recovery (days to recovery of reticulocyte count ≥30 k/uL, detection of donor red cells, 
transfusion independence) 
 

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Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
27 | P a g e  
 
Exploratory endpoints  
1. Anti-A, anti-B, and/or other red cell antibody titer pre- and post-HSCT 
2. Immune reconstitution, cytokines levels, and lymphocyte function post-transplant 
3. Quality of life and neuropsychologic function post-transplant (Addendum A) 
4. Effect of transplant on neurologic, cardio-pulmonary, renal, liver, and gonadal organ 
function  
 
10.2 
Stopping Rules 
Because this regimen is expected to have very low mortality in patients with non-life threatening conditions, the 
study will be stopped and the design re-evaluated after any death. We will also monitor for graft rejection (at 1 year 
post-transplant), severe GVHD (acute grade III-IV and chronic extensive at any time point post-transplant), or 
prolonged red cell aplasia (at >2 years post-transplant), which we would collectively consider as regimen failure.  
We will stop the study if posterior probability that the regimen failure rate is greater than 30% exceeds 0.90. 
Stopping means that serious consideration will be given to modifying or terminating the protocol.  Stopping 
boundaries are given in the table below.  Beta prior distributions are used for these calculations with parameters 
alpha, beta = 2.1, 4.9 for regimen failure.  
Note that one need not evaluate all the number of patients in the first column in order to stop.  For example, if 4 of 
the first 4 patients fail to engraft, we will have crossed the boundary given in the first row.  For 25 patients, 
stopping rule would be met if 12 patients failed. The monitoring plan was evaluated by simulation.  If the true 
regimen failure rate is .3, we will stop about 20% of the time.  True regimen failure rates of .2, .4, and .6 entail 
stopping about 2%, 72% and >99% of the time respectively.  This is acceptable performance for a stopping rule. 
Table:  Stopping rule for cohort 1 (male donor-female recipient)  
# of patients with at primary endpoint determination  Regimen Failures 
5 
4 
10 
6 
15 
8 
20 
10 
25 
12 
30 
13 
35 
15 
40 
17 
45 
18 
50 
20 
55 
22 
60 
24 
 
Table:  Stopping rule’s operating characteristics for cohort 1 
Probability of regimen failure = p 
0.20 
0.30 
0.40 
0.60 
Proportion of Stopped Studies 
1.7% 20.2% 71.6% >99% 
Average number of subjects 
59.2 
52.8 
35.0 
11.2 

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Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
28 | P a g e  
Average number of failures 
11.8 
15.8 
14.0 
6.7 
Similar stopping rules with its operating characteristics can be calculated for cohort 2 (see tables below). For this 
cohort, the study will be stopped if posterior probability that the regimen failure rate is greater than 30% exceeds 
0.90.  
 
Table:  Stopping rule for cohort 2 (antibody group)  
# of patients with at primary endpoint determination  Regimen Failures 
5 
4 
10 
6 
15 
8 
20 
10 
25 
12 
 
Table:  Stopping rule’s operating characteristics for cohort 2 
Probability of regimen failure = p 
0.20 
0.30 
0.40 
0.60 
Proportion of Stopped Studies 
1.4% 11.2% 38.6% 94.5% 
Average number of subjects 
24.8 
23.6 
20.3 
10.8 
Average number of failures 
5.0 
7.1 
8.1 
6.5 
 
As of July 2022, 4 patients (see table below) have developed acute leukemia or myelodysplasia. The 
timing when these events occurred post-HSCT, type of leukemia, and predisposing factors are very 
different. The causes of these events are uncertain, but may include any of the following: severe sickle 
cell disease, inflammatory marrow from frequent vaso-occlusive crises, iron overload with increased 
reactive oxygen species adding additional marrow inflammation/injury, prior hydroxyurea, chemotherapy 
in the transplant process, radiation, immunosuppression, viral infection or reactivation, and other yet 
unknown. Based on the review of literature (as of March 2021), the rate of leukemia (including acute, 
chronic, and myelodysplasia) is estimated <10% (Brunson et al, Blood 2017; Seminog et al, JRSM 2016; 
Li et al Mod Path 2019; Eapan et al Lancet Haem 2019).  Thus, if another patient develops acute 
leukemia, chronic leukemia, or myelodysplasia, the protocol would stop accrual and discussion with 
DSMB and IRB would follow to determine the next steps for the protocol. This criterion was met based 
on data reported to DSMB in January 2022, which recommended cohort 1 to stop accrual, cohort 2 to 
continue enrollment, and report each additional patient who develop leukemia or myelodysplasia. 
 
Patient  
Heme 
malignancy/MDS 
Donor chimerism at 
heme malignancy finding 
Comments  
Inclusion in 
DSMB report 
7 (cohort 1) 
Ph+ ALL, 3 yrs after 
transplant 
CD3 36%, CD14/15 89% 2.5 yrs 
post HCT, dropped to CD3 
25%, CD14/15 30% at ALL 
diagnosis,  
recovered to CD3 
20% and CD14/15 
100% after chemo 
2020 

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Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
29 | P a g e  
26 (cohort 2) 
Complex cytogenetics, 
treatment related AML, 3 
months after transplant 
CD3 10% 
CD14/15 16% 
 
Included in the 
initial 2022 
DSMB report  
9 (cohort 2) 
Inv 3(q21,26), 20q 
deletion, 4 yrs after 
transplant 
CD3 58% 
CD14/15 97%. These numbers 
have been same and stable 
throughout post-HCT 
 
2022 
16 (cohort 2) 
7q deletion in marrow 3.5 
yrs after transplant 
0%, patient had primary graft 
failure with autologous 
recovery 
 
2022 
 
10.3 
Interim Analysis 
We propose an interim efficacy analysis of the primary null hypothesis that the success probability is ≤ 0.50  after 
N=28 outcomes have been evaluated. An O’Brien-Fleming spending function will be used to calculate the p-value 
threshold used for this interim analysis.  For conducting the interim analysis with N = 28 (corresponding to 
information time = 0.50) the nominal p-value threshold is approximately 0.0056. The flexibility of the spending 
function allows for interim analyses to be conducted at other times, or for more than one interim analysis. However, 
as this is an unblinded trial it is preferable to have an a priori specified time for analysis. If the trial is not stopped 
early the p-value threshold used at the end of the study will be adjusted to reflect any interim analysis that were 
conducted. 
Also, given the strong interest in secondary outcomes and obtaining greater precision regarding the success 
probability, the investigators may continue to enroll to the N=56 ceiling even if a significant finding is discovered at 
the interim analysis. In this way, the discovery of a significant finding at the interim analysis would support the 
early disclosure of a promising therapy but still allow for additional learning opportunities and treatment for others 
in this cohort. 
No interim analysis is planned for the second cohort of 25 participants due to the small size of the group. 
10.4 
Off study criteria 
10.4.1 Withdrawal by the patient from the transplant procedure 
Patients and their donors will be given ample opportunity to withdraw from the study prior to admission for 
transplant.  Thereafter, the nature of the procedure does not permit safe withdrawal from the protocol. The patient 
and donor have the right at any time to elect not to participate in the research aspects of the protocol (donation of 
blood and bone marrow for non-routine tests). 
10.4.2 Withdrawal by the physician from experimental protocol  
Patients with disease relapse may be taken off protocol but will continue to be monitored by our institution for a 
minimum of 6 months post-transplant for possible infectious complications related to the conditioning regimen.  
The patient will then be consented to the Hematology Branch evaluation and treatment protocol (94-H-0010) for 
alternative treatments or referred back to his/her referring physician depending on what is considered to be in the 
best interest of the patient.  
 
11.0 
DATA SAFETY AND MONITORING 
11.1 
Safety Monitoring 

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Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
30 | P a g e  
Principal Investigator: The safety of interventions and treatments associated with this protocol will be under 
continuous review by the investigative team.  Accrual, efficacy and safety data will be monitored by the PI.   
IRB. Prior to implementation of this study, the protocol and the proposed patient consent forms will be reviewed 
and approved by the properly constituted Institutional Review Board (IRB) operating according to the 45 CFR 46 
code of federal regulations.  This committee will also approve all amendments to the protocol or informed consent, 
and conduct continuing annual review so long as the protocol is open to accrual, follow up of subjects, or data 
analysis continues.  
DSMB: The NHLBI Data safety and Monitoring Board will review the protocol at regular intervals.  A progress 
report will be forwarded to the DSMB at these times and their recommendations will be expeditiously implemented. 
The DSMB may recommend early termination of the study for considerations of safety and efficacy. 
11.2 
Grading of adverse events 
The AEs will be attributed (unrelated, unlikely, possibly, probably or definitely) to study medication and/or disease 
and graded by severity utilizing CTCAE version 4.0.  A copy of the criteria can be down-loaded from the CTEP 
home page at   http://ctep.cancer.gov/reporting/ctc.html. 
 
Grading of adverse events 
Grade 
Category  
 
Description 
1 
Mild  
 
Mild; asymptomatic; clinical or diagnostic observations only; intervention not 
indicated  
2 
Moderate  
 
Moderate; minimal, local or noninvasive intervention indicated; limiting age-
appropriate instrumental ADL  
3 
Severe  
 
Severe or medically significant but not immediately life-threatening; 
hospitalization or prolongation of hospitalization indicated; disabling; limiting 
self-care ADL  
4 
Life 
threatening  
 
Life-threatening consequences; urgent intervention indicated 
5 
Death  
 
Death related to AE  
 
Attribution of adverse events 
Relationship  
Attribution  Description  
Unrelated to investigational 
agent/intervention1 
Unrelated  
The AE is clearly NOT related to the intervention  
 
Unlikely 
The AE is doubtfully related to the intervention 
Related to investigational 
agent/intervention1 
Possibly 
The AE may be related to the intervention 
Probably 
The AE is likely related to the intervention  
Definitely 
The AE is clearly related to the intervention  
1NOTE: AEs listed as ‘possibly, probably, or definitely’ related to the investigational agent/intervention are considered to have a 
suspected ‘reasonable causal relationship’ to the investigational agent/intervention (ICH E2A). 
 
11.3 
NIH IRB and CD reporting 

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February 13, 2024 (Amendment DD) 
 
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Expedited Reporting 
Events requiring expedited reporting will be submitted to the IRB per Policy 801 “Reporting Research Events”. 
Reports to the IRB at the time of Continuing Review: 
The PI or designee will refer to HRPP Policy 801 “Reporting Research Events” to determine IRB reporting 
requirements. 
Reports to the CD: 
The PI or designee will refer to NHLBI DIR guidelines to determine CD reporting requirements and timelines. 
Grade 3 or higher adverse event recording will start at the time of conditioning regimen, will be followed until 
satisfactory resolution, through final study visit, and reported to the IRB at the time of continuing review, unless 
otherwise noted below. 
The research team will be responsible for assessing AEs. Information on AEs will be solicited from subjects 
through questions from study personnel and/or information volunteered by the subject. 
12.0 
HUMAN SUBJECT PROTECTIONS 
12.1 
   Rationale for subject selection 
All patients with confirmed thalassemia or SCD, as defined in section 5.1, will be considered for the protocol.  
Gender, ethnic background, and/or race will not be taken into consideration. 
Strategies for patient recruitment: Hematologists and internists throughout the country will be informed of the 
protocol by letter.  Information about the protocol will be posted on Clinicaltrials.gov, Clinical Center studies, and 
the NHLBI Patient recruitment websites. The protocol will also be listed in the physician’s data query (PDQ).   
12.2 
   Participation of children  
12.2.1  As stem cell transplant recipients 
As the risk of this new regimen is better known and the protocol with alemtuzumab and 300 cGy TBI (03-H-0170) 
being successfully adopted in children with little toxicity, we will begin to include  children from age 4 and older.  
12.2.2 As participants in laboratory research studies   
Pediatric participants may participate in those laboratory studies that the IRB finds involves no greater than minimal 
risk to children provided that adequate provisions are made for soliciting the assent of the children and the 
permission of their parents or guardians (see section 13.6). 
12.3 
Hazards and discomforts- recipient  
12.3.1 Related to the transplant 
The mortality from conventional BMT may be as high as 40%.  While transplant-related morbidity and mortality is low 
in our current study (03-H-0170), the HSCT procedure nevertheless carries significant risk.  It is therefore only 
appropriate to carry out this experimental procedure in the context of debilitating conditions and with full informed 
consent from the patient, donor, and immediate family.  The specific hazards of this study using a nonmyeloablative 
preparative regimen and high PBSC content graft are graft rejection, graft-versus-host disease, disease relapse, and 
infectious complications.  Major discomforts are those of nausea, anorexia, diarrhea, fever, malaise, and intolerance of 
the isolation period. It is estimated that approximately 10% or more of transplant patients experience depression, which 
may worsen after transplant. Additionally, the transplant process may worsen pre-existing medical condition(s).      
Side effects of those drugs novel to nonmyeloablative transplantation are described in detail below: 
 

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Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
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12.3.2 Related to Alemtuzumab (Campath®) 
 
 
The safety and efficacy of alemtuzumab were evaluated in a multicenter, open-label, non-comparative study in 93 
patients with refractory B-cell chronic lymphocytic leukemia (B-CLL) who had been previously treated with 
alkylating agents and had failed treatment with fludarabine, and side effects are detailed below.  Previous treatment 
with alkylating agents and fludarabine may have contributed to both the range and severity of the side effects 
observed. 
 
Infusion-related: adverse events resulted in discontinuation of alemtuzumab therapy in 6% of the patients. The most 
commonly reported infusion-related adverse events include rigors in 89% of patients, drug-related fever in 83%, 
nausea in 47%, vomiting in 33%, and hypotension in 15%. Other frequently reported infusion-related events include 
rash in 30% of patients, fatigue in 22%, urticaria in 22%, dyspnea in 17%, pruritus in 14%, headache in 13%, and 
diarrhea in 13%. Acute infusion-related events were most common during the first week of therapy. Antihistamines, 
acetaminophen, antiemetics, meperidine, and corticosteroids, as well as incremental dose escalation were used to 
prevent or ameliorate infusion-related events. 
 
Infections:   In the earlier studies all patients were required to receive anti-herpes and anti-PCP prophylaxis.  Forty 
(43%) of 93 patients experienced 59 infections (one or more infections per patient) during treatment or within 6 
months of the last dose. Of these, 34 (37%) patients experienced 42 infections that were of Grade 3 or 4 severity; 11 
(18%) were fatal.  Fifty-five percent of the Grade 3 or 4 infections occurred during treatment or within 30 days of 
the last dose. In addition, one or more episodes of febrile neutropenia (ANC 500 cells/L) were reported in 10% of 
patients.  The following types of infections were reported: Grade 3 or 4 sepsis in 12% of patients with one fatality, 
Grade 3 or 4 pneumonia in 15% with five fatalities, and opportunistic infections in 17% with four fatalities.  
Candida infections were reported in 5% of patients; CMV infections in 8% (4% of Grade 3 or 4 severity); 
Aspergillosis in 2% with fatal Aspergillosis in 1%; fatal Mucormycosis in 2%; fatal Cryptococcal pneumonia in 
1%; Listeria monocytogenes meningitis in 1%; disseminated Herpes zoster in 1%; Grade 3 Herpes simplex in 2%; 
and Torulopsis pneumonia in 1%.  PCP pneumonia occurred in one (1%) patient who discontinued PCP 
prophylaxis.  In one of the earlier studies where anti-herpes and anti-PCP prophylaxis was optional, 37 (66%) 
patients had 47 infections while or after receiving Campath therapy. 
 
Immunosuppression/Opportunistic Infections:  Alemtuzumab induces profound lymphopenia. Anti-infective 
prophylaxis is recommended upon initiation of therapy and for a minimum of 2 months following the last dose of 
Alemtuzumab or until CD4+ counts are 200 cells/L.  The median time to recovery of CD4+ counts to 200/L was 2 
months, however, full recovery (to baseline) of CD4+ and CD8+ counts may take more than 12 months. Because of 
Boxed Warning 
 
Hematologic Toxicity: Serious and, in rare instances fatal, pancytopenia/marrow hypoplasia, autoimmune 
idiopathic thrombocytopenia, and autoimmune hemolytic anemia have occurred in patients receiving Campath 
therapy. Single doses of Campath greater than 30 mg or cumulative doses greater than 90 mg per week 
should not be administered because these doses are associated with a higher incidence of pancytopenia.  
 
Infusion Reactions: Campath can result in serious, and in some instances fatal, infusion reactions. Patients 
should be carefully monitored during infusions and Campath discontinued if indicated.  Gradual escalation to 
the recommended maintenance dose is required at the initiation of therapy and after interruption of 
therapy for 7 or more days.  
 
Infections, Opportunistic Infections: Serious, sometimes fatal bacterial, viral, fungal, and protozoan infections 
have been reported in patients receiving Campath therapy. Prophylaxis directed against Pneumocystis carinii 
pneumonia (PCP) and herpes virus infections has been shown to decrease, but not eliminate, the occurrence of 
these infections.                                 

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Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
33 | P a g e  
the potential for transfusion-associated GVHD in severely lymphopenic patients, irradiation of any blood products 
is recommended. 
 
Hematologic: 
• 
Pancytopenia/Marrow Hypoplasia: Alemtuzumab therapy was permanently discontinued in six (6%) patients 
due to pancytopenia/marrow hypoplasia. Two (2%) cases of pancytopenia/ marrow hypoplasia were fatal. 
• 
Anemia: Forty-four (47%) patients had one or more episodes of new onset NCI-CTC Grade 3 or 4 anemia. 
Sixty-two (67%) patients required RBC transfusions.  In addition, erythropoietin use was reported in nineteen 
(20%) patients.  Autoimmune hemolytic anemia secondary to Alemtuzumab therapy was reported in 1% of 
patients. Positive Coombs test without hemolysis was reported in 2%. 
• 
Neutropenia: Sixty-five (70%) patients had one or more episodes of NCI-CTC Grade 3 or 4 neutropenia. 
Median duration of Grade 3 or 4 neutropenia was 28 days (range: 2 – 165 days). 
• 
Thrombocytopenia: Forty-eight (52%) patients had one or more episodes of new onset Grade 3 or 4 
thrombocytopenia. Median duration of thrombocytopenia was 21 days (range: 2 – 165 days). Thirty-five (38%) 
patients required platelet transfusions for management of thrombocytopenia. Autoimmune thrombocytopenia 
was reported in 2% of patients with one fatal case of Alemtuzumab -related autoimmune thrombocytopenia. 
• 
Lymphopenia: The median CD4+ count at 4 weeks after initiation of Alemtuzumab therapy was 2 (two)/L, at 2 
months after discontinuation of Alemtuzumab therapy, 207/L, and 6 months after discontinuation, 470/L. 
The pattern of change in median CD8+ lymphocyte counts was similar to that of CD4+ cells. In some patients 
treated with Alemtuzumab, CD4+ and CD8+ lymphocyte counts had not returned to baseline levels at longer 
than 1-year post therapy. 
 
Cardiac: The following were reported in at least one patient treated on studies where Campath-1H was used as a 
single agent: cardiac failure, cyanosis, atrial fibrillation, cardiac arrest, ventricular arrhythmia, ventricular 
tachycardia, angina pectoris, coronary artery disorder, myocardial infarction, and pericarditis. Some of these cardiac 
abnormalities may be irreversible.  For this reason, we will monitor subjects with an echocardiogram, a 24 hour 
holter monitor and serum troponin levels before treatment begins. After the last dose of Campath-1H, and at the 3 
month follow up visit these tests may be obtained as clinically indicated. We will also closely monitor subjects for 
cardiac symptoms and ask them to immediately report any cardiac symptoms (palpitations, irregular pulse, 
difficulty in breathing, dizziness, swelling in the ankles, chest discomfort or pain).  
 
12.3.3 Related to Sirolimus: Those reported with > 3% and <20% incidence in patients on 
Sirolimus treatment are listed here. Refer to the package insert for additional side 
effects. 
 
• 
Body as a Whole: abdomen enlarged, abscess, ascites, cellulitis, chills, face edema, flu syndrome, generalized 
edema, hernia, Herpes zoster infection, lymphocele, malaise, pelvic pain, peritonitis, sepsis; 
• 
Cardiovascular System: atrial fibrillation, congestive heart failure, hemorrhage, hypervolemia, hypotension, 
palpitation, peripheral vascular disorder, postural hypotension, syncope, tachycardia, thrombophlebitis, 
thrombosis, vasodilatation;  
• 
Digestive System: anorexia, dysphagia, eructation, esophagitis, flatulence, gastritis, gastroenteritis, gingivitis, 
gum hyperplasia, ileus, liver function tests abnormal, mouth ulceration, oral moniliasis, stomatitis;  
• 
Endocrine System: Cushing’s syndrome, diabetes mellitus, glycosuria, hypercholesterolemia, hyperlipidemia; 
• 
Hematologic and Lymphatic System: ecchymosis, leukocytosis, lymphadenopathy, polycythemia, thrombotic 
thrombocytopenic purpura / hemolytic-uremic syndrome; 
• 
Metabolic and Nutritional: acidosis, alkaline phosphatase increased, BUN increased, creatine phosphokinase 
increased, dehydration, healing abnormal, hypercalcemia, hyperglycemia, hyperphosphatemia, hypocalcemia, 
hypoglycemia, hypomagnesemia, hyponatremia, lactic dehydrogenase increased, SGOT increased, SGPT 
increased, weight loss;  
• 
Musculoskeletal System: arthrosis, bone necrosis, leg cramps, myalgia, osteoporosis, tetany, muscle injury  
• 
Nervous System: anxiety, confusion, depression, dizziness, emotional lability, hypertonia, hyperesthesia, 
hypotonia, insomnia, neuropathy, paresthesia, somnolence;  

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Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
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• 
Respiratory System: dyspnea, changes in PFTs, asthma, atelectasis, bronchitis, cough increased, epistaxis, 
hypoxia, lung edema, pleural effusion, pneumonia, rhinitis, sinusitis, diffuse alveolar hemorrhage;  
• 
Skin and Appendages: fungal dermatitis, hirsutism, pruritus, skin hypertrophy, skin ulcer, sweating;  
• 
Special Senses: abnormal vision, cataract, conjunctivitis, deafness, ear pain, otitis media, tinnitus;  
• 
Urogenital System: albuminuria, or proteinuria, bladder pain, dysuria, hematuria, hydronephrosis, impotence, 
kidney pain, kidney tubular necrosis, nocturia, oliguria, pyelonephritis, pyuria, scrotal edema, testis disorder, 
toxic nephropathy, urinary frequency, urinary incontinence, urinary retention, kidney injury.  
 
Less frequently occurring adverse events included: mycobacterial infections, Epstein-Barr virus infections, BK 
virus-associated nephropathy, skin cancer, lymphoma, pericardial effusion, posterior reversible encephalopathy 
syndrome (PRES), and pancreatitis.  
 
12.3.4 Related to Pentostatin 
Pentostatin is cleared by a renal mechanism (90%).  As such, the pentostatin dose must be reduced for renal 
insufficiency.  The primary toxicity is related to opportunistic infection due to T cell depletion or low blood counts.  
Common (>10%) side effects include fever, headaches, fatigue, nausea, vomiting, diarrhea, rash, pain, 
myelosuppression, and respiratory symptoms. Occasional (1-10%) side effects include changes in liver function tests, 
electrolytes, kidney function tests, blood pressures, heart rhythms; also chills, sweating, anxiety, confusion, dizziness, 
dry or itchy skin.  At higher doses, CNS toxicity may include seizures, coma, and death.  Interstitial pulmonary 
toxicity or edema has also been described.   
 
12.3.5 Cyclophosphamide  
Most commonly (>10%), patients may develop anorexia, nausea, vomiting, diarrhea, mucositis, myelosuppression, 
gonadal dysfunction, alopecia, and immunosuppression.  Occasionally (1-10%), they may develop hemorrhagic 
cystitis, nasal stuffiness with rapid administration, flushing, rash, kidney tubular necrosis (which usually resolves 
with drug discontinuation) or SIADH.  Rarely (<1%), patients may experience transient blurred vision, cardiac 
toxicity with arrhythmias, hyperpigmentation, impaired wound healing, myocardial necrosis, hepatotoxicity, 
weakness, hemorrhagic colitis, nail changes, bladder fibrosis, pulmonary fibrosis, and secondary malignancies.   
12.3.6 Related to Hydroxyurea 
Hydroxyurea most commonly leads to myelosuppression, and blood counts will be frequently monitored during 
hydroxyurea administration.  Less commonly, hydroxyurea can cause alopecia, dermatomyositis-like skin changes, 
hyperpigmentation, nail discoloration/atrophy, skin ulcers, drowsiness, anorexia, constipation, diarrhea, nausea, 
vomiting, and elevated hepatic enzymes.  Rarely, hydroxyurea can cause edema, chills, fever, dizziness, 
disorientation, hallucinations, headache, malaise, seizure, facial/peripheral erythema, skin atrophy, hyperuricemia, 
pancreatitis, peripheral neuropathy, weakness, increased creatinine, pulmonary fibrosis, and acute diffuse 
pulmonary infiltrates.   Secondary leukemias have been described after prolonged use in patients predisposed to 
developing leukemia.   
12.3.7 Related to Radiation 
Side effects of radiation have been well described.47  The most common include nausea and mucositis.  There also 
exists a risk of hypothyroidism, cataracts, interstitial pneumonitis, nephropathy, and an unspecified long term risk 
of developing secondary malignancies.48   Importantly, the majority of the non-neoplastic effects were sub clinical 
and/or reversible. 49    There is also a risk of sterility following TBI.  Recovery of gonadal function has been 
reported to be 10-14% with a pregnancy incidence of <3% following TBI50, 51.  However, these results are reported 
in patients who have history of hematologic malignancies, and therefore have also received prior chemotherapy.  
Further, the dose of TBI that they received was higher, at least 1000cGy.  The incidence of sterility has not been 
reported in patients with nonmalignant hematologic diseases who have received lower doses of TBI.  However, the 
risk of sterility exists, but is presumed to be lower than previously reported results.  In a further attempt to decrease 
the risk of sterility, testicular shielding will be applied.  We will discuss the option of gamete storage with subjects 
of child-bearing age.  Studies attempting to evaluate the risk induced by radiation alone suggest that there is a 
higher rate of solid tumors after radiation based regimens.  Curtis et al. reported on 19,229 patients and found a 
cumulative incidence rate of 2.2% at 10 years, and 6.7% at 15 years, with higher doses of TBI associated with a 

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Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
35 | P a g e  
higher risk of solid cancers.52  However, the more important risk factor appears to be related to the level of 
immunosuppression, as GVHD was also strongly linked to an increased risk of solid tumor development. In fact, 
some studies have shown no increased risk with radiation therapy,53, 54 but the highest risk factor was felt to be the 
presence of chronic GVHD and long term treatment with cyclosporine.55, 56  Therefore the actual risk cannot be 
quantified for the low dose of 300cGy to be used in this trial; however the risk is presumed to be lower.  The 
radiation exposure from bone density scans are very low, even lower than chest x-rays, thus in comparison to the 
300 rads of TBI, the additional risk from bone density scans are negligible.   
 
12.3.8 Related to Antimicrobials in general 
Allergic reactions, renal impairment (gentamicin, vancomycin, amphotericin, acyclovir), “red man” syndrome 
(vancomycin), hepatic damage (acyclovir, rifampicin) 
 
12.3.9  Related to bone marrow aspirate and biopsy:   
No major risks are involved with bone marrow aspirate and biopsy. However, there is a small risk of infection, pain, 
bleeding, and hematoma formation at the site of the aspiration with the procedure. 
 
12.3.10 Related to blood draws 
No major risks are involved with blood draws. Minor complications including bleeding, pain, and hematoma 
formation at the site of blood draws; vasovagal reactions, thrombus formation, or infection may rarely occur. 
 
12.3.11 Related to cardiac monitoring 
EKG:  An electrocardiogram (EKG) is a test that measures the electrical activity of the heartbeat.  With each beat, 
an electrical impulse (or “wave”) travels through the heart.  This wave causes the muscle to squeeze and pump 
blood from the heart.  A technician will put patches (electrodes) on the chest, arms and legs.  The electrodes are soft 
and don’t cause any discomfort when they’re put on or taken off by the technician.  The machine only records the 
EKG.  It doesn’t send electricity into the body.  There’s no pain or risk associated with having an electrocardiogram 
 
Transthoracic ECHO:   The ECHO uses sound waves to visualize and evaluate the function of the heart. There are 
no associated risks 
 
Holter Monitor: The Holter involves wearing a monitor for 24 hours during which time the electrical activity of 
the heart is recorded. There are no associated risks other than the inconvenience of wearing the apparatus.  
 
12.3.12 Related to central line placement 
A catheter may be placed in a large vein of the neck, chest, or arm using local anesthetic. Patients will sign a 
separate consent for the line placement procedure. Only trained experienced staff will place the line in order to 
minimize these procedure-related risks 
 
The risks from the procedure are low; they include bleeding, bruising, or infection at the site of insertion. Very 
rarely (less than 1% of the time), the line placement may nick a vein causing one lung to collapse during line 
insertion. If the lung collapses, a tube may have to be inserted into the chest and remain in place until the lung re-
expands. Because of this risk, patients will have a chest x-ray following the procedure to make sure the line is in the 
correct place and that the lung is not collapsed. Once placed, the line will remain in place until drug administration 
is complete.   
 
12.3.13 Related to brain magnetic resonance imaging 
There is a very small risk that the patient will experience an allergic reaction, and these are usually easily controlled 
with medications.  Anaphylactic reactions can rarely occur.  Patients with severe kidney disease requiring dialysis 
who undergo MRI with intravenous contrast can develop a rare but severe disease called nephrogenic systemic 
fibrosis that leads to hardening of skin, joints, internal organs, and eyes.  Patients with severe kidney disease will 
not receive intravenous contrast.  The majority of patients will not require sedation.  However, all patients that do 
require sedation will be offered monitored anesthesia care through the Department of Anesthesia and Surgical 
Services (DASS), Clinical Center, NIH, and a separate consent will be completed as needed. 

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Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
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Gadolinium-based contrast agents (GBCAs): Gadolinium is an FDA approved medication used to improve MRI 
images. Gadolinium contrast is an injected medication used to improve MRI images. Most patients experience a 
metallic taste when gadolinium contrast is injected. Some (2%) report mild symptoms such as headache, nausea or 
vomiting, or a rash near the injection site. Rarely (<0.1%) patients experience severe symptoms such as wheezing, 
shortness of breath, and low blood pressure as part of an allergic (anaphylactoid) reaction that may require 
emergency medical treatment. 
In a few cases per million, usually in patients with severe kidney disease, gadolinium contrast can cause a rare, 
debilitating or even fatal, skin disease called Nephrogenic Systemic Fibrosis (NSF) that cause thickening of the skin 
and other organs. Since physicians became aware of the disease, began screening patients at risk of kidney disease, 
and switched to safer (“macrocyclic”) forms of gadolinium contrast, new reports of NSF are much more rare. 
There are also reports of gadolinium retained in the brain, bone, and skin. It is not known whether this is important 
to health. We use “macrocyclic” forms of gadolinium contrast, such as gadolinium contrast, such as gadobutrol, that 
are thought to reduce this risk. 
12.3.14  Related to  neuropsychological testing 
Depending on the patient’s age, neuropsychological testing will take up to 1.5 to 2 hours to perform.  During this 
time, the patient may experience frustration, fatigue, or distress.  If these symptoms occur, the patient will be 
allowed to take a break.  He or she will not have to answer every question, and testing will be discontinued if the 
patient asks.  The clinical social worker and/or study investigators will be available if the patient would like to 
discuss his/her concerns. 
 
12.3.15 Related to Busulfan (Busulfex®) 
The most common adverse events (>10%) expected with busulfan are as follows: 
Cardiovascular: Fast heart rate, swelling in your legs, chest pain, high blood pressure, low blood pressure 
Central nervous system: Insomnia, headache, fever, chills, dizziness, anxiety, depression, confusion 
Dermatologic: Rash, hair loss, itching 
Endocrine and Metabolic: Electrolyte imbalance, high blood sugar 
Gastrointestinal: Nausea, vomiting, diarrhea, inflammation of the digestive tract, poor appetite, abdominal pain 
Hematologic: decrease in blood cell production 
Hepatic: changes in liver enzymes 
Local: Site injection reaction 
Musculoskeletal: Back pain, weakness, joint pain, muscle pain 
Renal: Kidney damage 
Respiratory: Cough, runny nose, shortness of breath, pneumonia, sore throat 
 
Less common (1-10%) include abnormal heart rhythm, heart failure, hallucination, delirium, seizures, brain 
hemorrhage, severe rash, blockage of the intestine, inflammation of the pancreas, blood in the urine or lungs, 
asthma, and liver failure.  
 
12.4 
Hazards and discomforts- donor 
12.4.1 Related to blood draw 
No major risks are involved with blood draws. Minor complications including bleeding, pain, and hematoma formation at the 
site of blood draws, vasovagal reactions or infections may rarely occur. 
12.4.2 Related to  neuropsychological testing (Donors and Recipients)  
Depending on the patient’s age, neuropsychological testing will take up to 1.5 to 2 hours to perform.  During this 
time, the patient may experience frustration, fatigue, or distress.  If these symptoms occur, the patient will be 
allowed to take a break.  He or she will not have to answer every question, and testing will be discontinued if the 

14-H-0077 
Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
37 | P a g e  
patient asks.  The clinical social worker and/or study investigators will be available if the patient would like to 
discuss his/her concerns.  
12.5 
Risks in relation to benefit 
12.5.1 For adult transplant subjects 
Clinically the approach is ethically acceptable because we are targeting a patient group with a debilitating and often 
lethal hematological disease, incurable with conventional treatments other than allogeneic BMT.  The protocol aims 
to decrease the risk of transplant rejection and related mortality, thus making more patients candidates for 
potentially curative therapy.  
12.5.2 For adult donors 
The risks of the study procedures for adult donors under this protocol are minimal. By being in this study, donors 
will receive medical evaluation of their health. While there are no direct benefits of neuropsychological testing, 
psych test results may reveal personal strengths and weaknesses. Adult donor participation in this study may also 
help inform future studies and contribute to new ways of making transplant procedures safer and more effective. 
The clinical team will communicate all risks to the subjects at the time of consenting. 
12.5.3 For pediatric transplant subjects (ages 4-18) 
The inclusion of children satisfies the criteria set forth in 45 Code of Federal Regulations 46, Subpart D as follows: 
(a) the risk is justified by the anticipated benefit to the subjects: We are offering pediatric subjects with a probably 
lethal hematological disease, incurable with conventional treatments other than allogeneic BMT, an alternative to 
symptomatic therapy. 
(b) the relation of the anticipated benefit to the risk is at least as favorable to the subjects as that presented by 
available alternative approaches. The protocol aims to decrease the risk of transplant-related mortality, thus 
making more patients candidates for potentially curative therapy; and 
(c) adequate provisions are made for soliciting the assent of the children and permission of their parents or 
guardians, as set forth in 46.408. 
12.5.4 For pediatric participants involved in laboratory research studies   
The inclusion of children satisfies the criteria set forth in 45 Code of Federal Regulations 46, Subpart D: 46.404 as 
follows: 
(a) 
The research does not involve greater than minimal risk.  Blood specimens for research are obtained 
concurrently with clinically indicated sampling.  Therefore, there is no risk associated with sample 
collection for research because research will only be performed on material obtained during standard 
clinical intervention. 
(b) 
 Only those laboratory tests approved by the IRB and involving not greater than minimal risk will be 
conducted.  Research will not include genetic testing.  Therefore, there is no genetic testing-associated risk.  
(c) 
 Adequate provisions are made for soliciting the assent of the children and permission of their parents or 
guardians, as set forth in 46.408.   
 
12.6 
Informed consent 
Informed consent will be conducted following OHSRP Policy 301- Informed Consent. 
An IRB-approved consent form will be provided to the subject electronically or by hard copy for review prior to 
consenting. The initial consent process as well as re-consent, when required, may take place in person or remotely 
(e.g., via telephone or other NIH approved platforms).The investigational nature and objectives of this trial, the 
procedures, and their attendant risks and discomforts and potential benefits will be carefully explained to the subject 
in a private setting. The subject will be given as much time as they need to review the document and to consult with 
their family, friends, and personal health care providers. In addition, a study team member will be available to 
answer any questions. 

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Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
38 | P a g e  
A signed and dated informed consent document will be obtained by any investigator authorized to consent  prior to 
entry onto the study. Consent may be obtained with required signatures on the hard copy of the consent  or on the 
electronic document.   
When a document that is in electronic format is used for obtaining  consent, this study may use the iMed platform 
which is 21 CFR, Part 11 compliant, to obtain the required signatures. 
During the consent process, participants and investigators may view the same approved consent document 
simultaneously when participant is being consented in person at the Clinical Center or both may view individual 
copies of the approved consent document on screens in their respective locations remotely. Signatures may be 
obtained either by both directly signing on the device that the consenting investigator is using (when in person) or 
through iMed Mobile Signature Capture  (remotely) which allows texting or emailing a link to the participant. That 
link allows the participant to review the consent, then proceed to sign on the device they are using. 
Whether hard copy or electronic consent, both the investigator and the participant will sign the document with a 
hand signature using a pen, finger, stylus, or mouse. 
When done remotely, if the participant prefers to sign a hard copy, they may be instructed to sign and date the 
consent document during the discussion and mail, secure email or fax the signed document to the consenting 
investigator. 
Whether in person or remotely, the privacy of the participant will be maintained. 
Finally, the fully signed informed consent document will be stored in the electronic medical record, and the subject 
will receive a copy of the signed informed consent document. 
If the patient is a minor, the parent who signs the consent for the minor must be a legally recognized parent or 
guardian.  Where deemed appropriate by the clinician, and the child's parent or guardian, the child will also be 
included in all discussions about the trial and a minor's assent will be obtained.  Assent will only be used in children 
who can understand it. In cases where parents share joint legal custody in making medical decisions of their child 
(e.g. by a custody agreement or court order) both parents must give their parental permissions regardless of level of 
risk of the research. Exceptions may be made if one parent is deceased, becomes incompetent or is not reasonably 
available (e.g. in prison).  The parent or guardian will sign on the designated line on the informed consent attesting 
to the fact that the child had given assent.  
 
Consent for Minors when they reach the age of majority:  
When a pediatric subject reaches age 18, continued participation will require consenting of the now adult with the 
standard protocol consent document to ensure legally effective informed consent has been obtained. Should sample 
or data analysis continue following completion of active participation and the subject has reached 18 years of age, 
we will attempt to contact the subject using the last known contact information to obtain consent for continued use 
of data or samples collected during their prior visit. Given the length of time that may have transpired for some of 
the subjects since their last visit for this study, we request waiver of informed consent for those individuals who 
after good faith efforts to contact them, we are unable to contact or who were taken off study.  
Requirements for Waiver of Consent consistent with 45 CFR 46.116 (d), each of which must be addressed in 
relation to the protocol:  
(1) The research involves no more than minimal risk to the subjects.  
a. Analysis of samples and data from this study involves no additional risks to subjects.  
(2) The waiver or alteration will not adversely affect the rights and welfare of the subjects.  
a. This is an FDA-regulated study and as such, we are mandated to retain all samples, once collected, regardless of 
the age of the subject at the time of collection. Retention of these samples or data does not affect the welfare of 
subjects.  
(3) The research could not practicably be carried out without the waiver or alteration.  

14-H-0077 
Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
39 | P a g e  
a. Considering the length of time between a minor’s enrollment and their age of majority, it is possible that more 
than a few subjects may be lost to follow up. A significant reduction in the number of samples analyzed could 
impact the quality of the research.  
(4) Whenever appropriate, the subjects will be provided with additional pertinent information after participation.  
a. We only plan to request a waiver of re-consent for those subjects who have been lost to follow-up. 
At any time during participation in the protocol that new information becomes available relating to risks, adverse 
events, or toxicities, this information will be provided orally or in writing to all enrolled or prospective patient 
participants.  Documentation will be provided to the IRB and if necessary, the informed consent amended to reflect 
relevant information. 
13.0 
CONFLICT OF INTEREST 
The Principal Investigator will assure that each associate investigator listed on the protocol title page receives a 
copy of the NIH Guide to preventing conflict of interest.  Investigators added subsequent to the initial circulation 
will be provided a copy of the document when they are added and a copy of the Conflict of Interest Statement will 
be forwarded to the Clinical Director.  Any potential conflicts will be reported to the IRB and the resolution of the 
conflict summarized.    
14.0 
CIMBTR 
Data reporting requirements for the NMDP Coordinating Center include:  Baseline confirmatory data, pre-
conditioning, 100 day, 6 month, 1 year and annually post-transplant outcome data for the recipients’ life span.  Data 
reporting requirements for the NMDP Donor Center include: 30 day, 6 months and 1 year post transplant updates. 
For the purposes of quality assurance (i.e. accreditation of the NHLBI Transplant program), data without identifiers 
will be released to the Center for International Blood and Marrow Transplant Research (CIBMTR) according to 
federally mandated policies and procedures. 
15.0 
PHARMACEUTICALS 
15.1 
Alemtuzumab (CAMPATH-1H, Campath®) 
Supply: Available through the Campath Distribution Program (The Sanofi Foundation for North America 1-877-
422-6728). Vials are provided through this program upon completion of a patient specific request form. Prior to 
submission of a drug request the patient must provide authorization for the release of medical information (NIH-
527). Refer to the Pharmacy Department or Clinical Pharmacy Specialist for additional details on drug 
procurement. 
Product description: Alemtuzumab is available in single use vials. Each single use, clear glass vial of Campath 
contains 30 mg Alemtuzumab in 1 mL of solution (8.0 mg sodium chloride, 1.44 mg dibasic sodium phosphate, 0.2 
mg potassium chloride, 0.2 mg monobasic potassium phosphate, 0.1 mg polysorbate 80, and .0187 mg disodium 
edetate dehydrate). No preservatives are added. Each carton contains three Campath vials (NDC 50419-357-03) or 
one Campath vial (NDC 50419-357-01). 
Storage and stability: Vials of Alemtuzumab should be stored at 2-8°C (36-46°F) and protected from sunlight. The 
vial should not be frozen; if the vial has been frozen it should be discarded. Alemtuzumab contains no antimicrobial 
preservative. An internal NIH Pharmacy (Pharmaceutical Development Section) conducted study demonstrated 24 
hour stability of alemtuzumab when diluted in 0.9% sodium chloride to a concentration range of  6.67 mcg/mL to 
120 mcg/mL at room temperature (Goldspiel JT, et.al. Stability of alemtuzumab solutions at room temperature. Am 
J Health –Syst Pharm, accepted for publication). Alemtuzumab solutions prepared in the concentration range 
described above may be stored at room temperature (15-30°C) for up to 24 hours.  If diluted outside of this 
concentration range, alemtuzumab should be used within 8 hours after dilution. Alemtuzumab solutions may be 
stored at room temperature (15-30°C) or refrigerated. Alemtuzumab solutions should be protected from light. 
Preparation: The vial should be inspected for visible particulate matter and discoloration prior to administration. If 
particulate matter is present or the solution is discolored, the vial should not be used. The vial should not be shaken 
prior to use. The necessary amount of alemtuzumab should be withdrawn from the vial into a syringe. The vial 

14-H-0077 
Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
40 | P a g e  
contains no preservatives and is intended for single use only; the vial should be discarded with any unused portion 
after 6 hours. The desired dose is then injected into 100 mL sterile 0.9% Sodium Chloride USP or 5% Dextrose in 
Water USP. The bag should be gently inverted to mix the solution. The syringe is discarded. 
Administration: Alemtuzumab should be administered intravenously only. The infusion should be administered 
over a 2-hour period. 
15.2 
Filgrastim (G-CSF, Neupogen®) 
Supply: Commercially available. 
Product description: Filgrastim injection is available in a concentration of 300mcg/ml in 1ml (300mcg) and 1.6ml 
(480mcg) vials. 
Preparation: For subcutaneous administration, the appropriate prescribed dose is drawn up from the vial with no 
further dilution prior to administration. For intravenous administration, the commercial solution for injection should 
be diluted prior to administration. It is recommended that the prescribed dose be diluted with dextrose 5% in water 
(DO NOT DILUTE WITH NORMAL SALINE) to a concentration greater than 5mcg/ml. Filgrastim diluted to 
concentrations between 5 and 15mcg/ml should be protected from absorption to plastic materials by the addition of 
Albumin (Human) to a final concentration of 2mg/ml. When diluted in 5% dextrose or 5% dextrose plus Albumin 
(Human), filgrastim is compatible with glass bottles, PVC and polyolefin IV bags, and polypropylene syringes. 
Storage and Stability: Filgrastim for injection should be stored in the refrigerator at 2o to 8oC (36o to 46oF). Avoid 
shaking. 
Route of administration: Subcutaneous injection or intravenous infusion over 15-30 minutes. 
 
15.3 
Sirolimus (Rapamune®) 
Supply: Commercially available. 
Product description: Sirolimus is available in 0.5, 1, and 2 mg tablets and an oral solution (1 mg/mL concentration) 
in a 60 mL amber glass bottle. 
Preparation: For administration of the oral liquid, the measured dose may be diluted in water or orange juice prior to 
administration. Empty the correct amount of sirolimus oral liquid into only a glass or plastic container holding at 
least two ounces of water or orange juice. No other liquids, including grapefruit juice, should be used for dilution. 
Stir vigorously and drink at once. Refill the container with an additional volume (minimum 4 ounces or 120 mL) of 
water or orange juice, stir vigorously, and drink at once. 
Storage and Stability: Oral tablets should be stored at room temperature: 20-25 °C (68-77 °F). Oral solution should 
be refrigerated (2-8 °C or 36-46 °F). Once the oral solution bottle is opened, the contents should be used within one 
month. If necessary, the patient may store the bottles at room temperatures up to 250 °C for a short period of time 
(e.g. not more than 15 days for the bottles). 
Route of administration: Oral. 
15.4 
Pentostatin (Nipent®) 
Supply: Commercially available 
Product description: Pentostatin is available as a lyophilized powder in vials containing 10 mg of drug. 
Preparation: The lyophilized powder will be reconstituted according to manufacturer instructions, into a solution of 
a 2 mg/ml concentration. The appropriate dose of the reconstituted pentostatin solution will be further diluted with 
500 ml of 0.9% sodium chloride and infused over 30 to 60 minutes. 
Storage and Stability- Upon reconstitution, the pentostatin can be stored at room temperature but should be used 
with 8 hours of reconstitution.  

14-H-0077 
Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
41 | P a g e  
Route of administration: Intravenous infusion. Subjects will receive one liter of 0.9% sodium chloride by 
intravenous infusion as pre-hydration prior to the pentostatin delivery. Pentostatin will be infused over 30-60 
minutes.   
 
15.5 
Cyclophosphamide (Cytoxan®) 
Supply: Commercially available. 
Product description: Cyclophosphamide is available for oral use as tablets providing 25 mg or 50 mg of 
cyclophosphamide.  
Storage and stability: Oral tablets should be stored at controlled room temperature 15-30oC (59-86oF).  
Route of administration: Oral. 
 
Filgrastim and sirolimus are used as labeled in the prescribing information. Alemtuzumab, pentostatin, and 
cyclophosphamide are used as part of this transplant regimen and considered to be exempt from IND based on the 
fulfilling the following criteria:   
- 
All 3 drugs are lawfully marketed in the US;  
- 
their use is not intended to be reported to FDA as a well-controlled study in support of a new indication and 
there is no intent to use it to support any other significant change in the labeling of the drug;  
- 
their use does not involve a route of administration, dose, patient population, or other factor that 
significantly increases the risk (or decreases the acceptability of the risk) associated with the use of the drug 
product;  
- 
their use is conducted in compliance with the requirements for review by an IRB (21 CFR part 56) and with 
the requirements for informed consent (21 CFR part 50); 
- 
The investigation is conducted in compliance with the requirements of § 312.7 (i.e., the investigation is not 
intended to promote or commercialize the drug product).    
 
15.6 
Busulfan 
Busulfan is a bifunctional alkylating agent approved for use as a conditioning agent prior to allogeneic 
hematopoietic stem cell transplantation. The IV formulation is commercially available as busulfan (Otsuka 
America Pharmaceutical, Inc.) 
- 
Generic: busulfan  
- 
Classification: alkylating agent  
- 
Action: Alkylates and crosslinks DNA. It has a more marked effect on myeloid cells than on lymphoid 
cells.  
- 
Source: For patient administration, IV busulfan is purchased by the NIH Clinical Center Pharmacy 
Department from commercial sources. The drug is supplied as a clear, colorless sterile solution in 10mL 
single use vials. Each vial of busulfan contains 60mg (6mg/mL) of busulfan. 
- 
Stability and Storage: Unopened vials of parenteral busulfan are stable until the date indicated on the 
package when stored under refrigeration at 2-6 degrees C (36-46 degrees F).  
- 
Product description: Injection  
- 
Preparation: Parenteral busulfan must be diluted prior to use with either 0.9% sodium chloride or 5% 
dextrose injection. The diluent quantity should be 10 times the volume of busulfan so that the final 
concentration of busulfan is approximately 0.5mg/mL. Busulfan should be administered intravenously via a 
central venous catheter as a 3-hour infusion every 24 hours for a total of 3 doses over 3 days.  
- 
Route: Intravenous 
- 
 
16.0 
Compensation 
Compensation will be provided to donors for their time and inconvenience. They will receive $150 for 
testing at their 1 year post- transplant visit. 1 night of lodging will be paid for returning for testing. For 
patient under 18 years old an additional $20 will be paid for escort fee. 
 

14-H-0077 
Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
42 | P a g e  
Procedure 
Inconvenience Unit (IU) or Time 
Payment 
Neuropsychological Exam  
4 hours  
$50.00  
Neuropsychological Exam 
(memory testing, processing, 
verbal and nonverbal reasoning 
and the quality of life 
questionnaires)  
10 IU  
$100.00  
Total Compensation  
$150.00  

14-H-0077 
Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
43 | P a g e  
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Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
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Fitzhugh CD, Hsieh MM, Bolan CD, Saenz C, Tisdale JF. Granulocyte colony-stimulating factor (G-CSF) 
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Bhatia S, Louie AD, Bhatia R, et al. Solid cancers after bone marrow transplantation. J Clin Oncol. 
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Kolb HJ, Socie G, Duell T, et al. Malignant neoplasms in long-term survivors of bone marrow 
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Deeg HJ, Socie G, Schoch G, et al. Malignancies after marrow transplantation for aplastic anemia and 
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57. 
Gertz MA, Lacy MQ, Bjornsson J, Litzow MR. Fatal pulmonary toxicity related to the administration of 
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Kopp HG, Horger M, Faul C, et al. Granulocyte colony-stimulating factor induced pulmonary hemorrhage 
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59. 
Fernandez de Larrea C, Rovira M, Mascaro JM, Jr., et al. Generalized cutis laxa and fibrillar glomerulopathy 
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therapy. Eur J Haematol. Feb 2009;82(2):154-158. 
 

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February 13, 2024 (Amendment DD) 
 
46 | P a g e  
  
APPENDIX A: ECOG PERFORMANCE STATUS SCALE 
 
GRADE 
DESCRIPTION 
0 
Fully active, able to carry on all pre-disease activities without restriction. 
1 
Restricted in physically strenuous activities and able to carry out work of a light or sedentary nature, e.g. 
light housework, office work. 
2 
Ambulatory and capable of all self-care but unable to carry out any work activities.  Up and about more 
than 50% of waking hours. 
3 
Capable of only limited self-care; confined to bed or chair more than 50% of waking hours. 
4 
Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair. 
5 
Dead. 
 
 
APPENDIX B: TRANSFUSION OF RED CELLS TO RECIPIENTS OF ABO INCOMPATIBLE 
MARROW 
 
Major ABO incompatible recipie–t - donor 
Patient  
 
 
Donor  
 
 
Transfused RBC = patients group 
O 
 
 
 
A, B or AB 
 
 
 
O 
A 
 
 
 
B or AB 
 
 
 
A or O 
B 
 
 
 
A or AB 
 
 
 
B or O 
 
Minor ABO incompatibility recipient - donor 
Patient  
 
 
Donor  
 
             Transfused RBC = donor group 
A, B or AB 
 
 
O 
 
 
 
             O 
AB 
 
 
 
B 
 
 
 
             B or O 
AB  
 
 
 
A 
 
 
 
A or O 
 
 
APPENDIX C:      TRANSFUSION MEDICINE GUIDELINES FOR APHERESIS PROCEDURES IN 
 
SICKLE CELL PATIENTS RECEIVING NONMYELOABLATIVE ALLOGENEIC 
PBSC TRANSPLANTS 
 
 
Introduction 
 
Sickle cell disease (SCD) patients are at risk for vaso-occlusive crises such as cerebrovascular accidents and the 
acute chest syndrome which occur due to the viscosity and sickling properties of sickle hemoglobin S.  Pre and peri-
transplant maneuvers, such as transfusion or red cell exchanges with allogeneic red cells, may be performed to 
reduce the risk of ischemic events by reducing the levels of hemoglobin S.  Pre-transplant coordination with the 
Department of Transfusion Medicine (DTM) is critical because these patients may have had prior transfusions and 
have developed alloantibodies.  In addition, the distribution of red blood cell phenotypes in patients with SCD will 
reflect their ethnic heritage and may differ from that in the NIH donor pool.  Obtaining prior transfusion records, 
prior antibodies and/or transfusion reactions, and recruitment of adequate numbers of compatible units thus requires 
careful advance planning and knowledge of the patient’s phenotype and antibody screen.  
 
Allogeneic transplant patients who receive a lymphocyte-replete PBSC graft will also be at risk for increased red 
cell requirements if there is an ABO incompatibility with the donor.  Minor ABO incompatibility, such as O donors 
into A, B or AB recipients, is associated with hemolysis due to production of anti-recipient isohemagglutinins by 
passenger lymphocytes.  The appropriate transfusion policy in the peri-transplant period for the ABO group of red 
cell, plasma and platelet transfusions in patients with ABO incompatible donors is also managed according to 
standard DTM transplant policies.  In addition, the DTM will use red cell serologic testing to carefully monitor 

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those patients who have minor ABO incompatibility with the donor for evidence of hemolysis in the peri-transplant 
period using a standard operating procedure.   
 
Major ABO incompatibility, such as A or B donors into O patients, may be associated with a delayed onset of 
effective donor erythropoiesis resulting in pure red cell aplasia after conversion to sustained donor hematopoiesis. 
This event appears to be most common after non-myeloablative conditioning regimens that are permissive for 
persistent production of anti-donor, host-type isohemagglutinins.  These patients may have a further increased red 
cell requirement and need for advance planning and recruitment.  
 
A potential adverse event in hematopoietic transplantation for congenital anemias is rejection of the PBSC graft, 
especially in patients who have been heavily transfused.  Obtaining higher numbers of donor stem cells may reduce 
the risk of graft rejection.  To achieve this goal, the DTM will collect stem cells using a single very large volume 
apheresis (4-5 donor blood volumes) on day 5 after filgrastim (G-CSF) administration, which reduces the 
incidence of thrombocytopenia in the donor associated with apheresis, reduces apheresis time and the time with 
which central venous catheters remain in place, and produces the same yields as two smaller donor blood volume 
procedures performed consecutively on days 5 and 6.    
 
All sickle cell transplant candidates and their identified donors will need to have a full red cell phenotype, antibody 
screen, and quantitative hemoglobin electrophoresis obtained during initial evaluation, well in advance of any 
apheresis procedures. The DTM will enter appropriate restrictions for blood product transfusion based on this 
information.  
 
 
Procedures for Red Cell Exchanges 
 
Sickle cell patients who are not receiving long term transfusion therapy will be evaluated by the DTM fellow/senior 
staff and considered for a prophylactic red cell exchange prior to transplant to bring the target fraction of 
hemoglobin S to less than 30% to reduce the incidence of post-transplant stroke and other events that may be 
associated with high hemoglobin S levels. ADSOL leukoreduced packed red cells will be used for the exchange.  
 
These patients will have a hemoglobin electrophoresis performed to determine their initial fraction of hemoglobin S 
(% HbS).  They must also have a full type and screen performed to identify alloantibodies and allow for recruitment 
of donors prior to the exchange.  The patient total blood volume will be computed from an algorithm using the 
COBE computer, and the volume of replacement PRBC required for the exchange estimated by utilizing this 
computer in conjunction with the initial HbS content and the desired end hematocrit and HbS concentration.   For 
this protocol, the calculation of the COBE computer may be verified using the following calculations for 
determination of the volume of replacement PRBCs needed for the red cell exchange.  
 
Blood volume x patient hct = Pati’nt's Total Packed Red Cell Volume (PRCV) 
(PRCV) x % HbS = Patient Total Packed RBC Volume of HbS (PRCV-S) 
The volume of ADSOL PRBC needed to bring the residual fraction of red cells to 30% is 1.25 exchange 
volumes. (= 1.25 x (PRCV-S)) 
 
Since increasing the hematocrit in patients with high levels of HbS may precipitate vaso-occlusive crises, the red 
cell exchange will replace the red cells that are removed with an equal volume of infused red cells.  Patients who 
are significantly anemic may have further transfusions given after the exchange to bring their final hematocrit up to 
35%.  In these cases, the target % HbS should be 30% after the final transfusions bring the hematocrit up to 35%.   
The target for the % HbS after the exchange (before additional transfusions) is 35/Hct x 30%, where Hct is the 
patient hematocrit before the exchange.  After the exchange the patient will then receive a volume of red cells equal 
to approximately (0.35-Hct)(wt)(70 ml/kg). 
 
Patients undergoing red cell exchange may experience citrate toxicity from the anticoagulant used in the apheresis 
procedure and contained in the ADSOL red cells.  A citrate infusion rate will be calculated by the DTM 
fellow/senior staff based on the flow rate of returned red cells plus 2/3 of the citrate infusion rate.  Patients who 

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receive more than 1.2 mg of citrate per kilogram per minute will receive intravenous calcium through the return line 
at a rate of 0.5 mg of calcium ion per 21 mg of citrate.   
 
Donor apheresis procedures 
I.  
Donor stem cell mobilization with filgrastim (G-CSF) 
After medical evaluation and clearance for suitability as an allogeneic donor, each donor will undergo mobilization 
with G-CSF, usually as an outpatient.  The G-CSF will be administered in a dose of 10 to 16 ug/kg/day for 6-7 
days, subcutaneously.  The doses for days 1-4 may be given at any time of day, but the doses for day 5 and if 
necessary, day 6 must be given early in the morning, at least one hour prior to starting apheresis. Day 5 evening 
dosing may substitute the early morning dosing of day 6.  Predictable side effects of G-CSF, including headache, 
bone pain, and myalgia, will be treated with acetaminophen or ibuprofen.  Prophylactic treatment of these side 
effects with the same medications may be elected.  Other side effects will be evaluated and treated accordingly. 
 
II. Donor stem cell collection 
The target CD34 dose is 10 x 106/kg, and the minimum is 5 x 106/kg.   Donors will receive calcium chloride 
prophylaxis to prevent citrate toxicity in accordance with standard DTM policies.  
 
The volume processed per apheresis procedure will be determined by DTM medical staff on the day of apheresis, 
based on peak CD34 cell mobilization response to filgrastim (G-CSF) and the CD34 cell dose needed, based on 
kilogram weight of recipient.  This will range from 15 to 35 liters processed per day for 1 to 3 days, not to exceed a 
total of 75 liters over 3 days.   
 
The goal is to provide a sufficient number of CD34 cells to ensure engraftment and test the efficacy of this modality 
against disease relapse. Second cycle of mobilization and collection may be needed in donors whom insufficient 
number of stem cells were collected. Plerixafor may be added in selected patients according to standard of 
care/BMT Consortium Guidelines Standard Operating Procedures. 
 
III. Filgrastim (G-CSF) administration.  
G-CSF will be administered according to a vial-based algorithm to reduce wastage, improve patient compliance, 
and increase the total G-CSF dose to lighter weight donors in order to improve CD34 yields. 
 
Donor Weight  
Total filgrastim (G-CSF) Dose (range) 
38-48 kg                       600 mcg (12.5 to 15.8 mcg/kg) 
49-56 kg                       780 mcg (13.9 to 15.9 mcg/kg) 
57-60 kg                      900 mcg (15.0 to 15.8 mcg/kg) 
61-67 kg                      960 mcg (14.3 to 15.7 mcg/kg) 
68-108 kg                     1080 mcg (10.0 to 15.9 mcg/kg) 
> 109 kg                      1200 mcg (11.0 or less) 
 
IV. Ex vivo processing of PBSC and lymphocytes 
 
The target cell doses for the PBSC graft are outlined in the section above. 
 
For this protocol, there will be no T cell depletion of the PBSC or bone marrow. The PBSC and lymphocyte 
products will be cryopreserved in 5% DMSO/pentastarch for later thawing and infusion.  In cases of RBC 
incompatibility, product manipulations will be done prior to cryopreservation.  For minor ABO or other red cell 
incompatibility, PBSC products may undergo plasma removal, with resuspension in an infusible isotonic solution, 
according to standard operating procedures in the DTM Cell Processing Laboratory. 
 
All products will be prepared for infusion by SOPs of the DTM Cell Processing Laboratory. 
Recipient apheresis procedure 

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Recipient stem cell mobilization with plerixafor +/- G-CSF 
For patients ≥10 years of age, plerixafor will be given at a dose of 240 ug/kg subcutaneously in the early morning, 
followed by apheresis 4-6 hours after the dose.  If the goal CD34 yield is not met, the patient can receive a second 
dose of plerixafor 240 ug/kg subcutaneously followed by a second apheresis the next day.  The patient will return 
within one week (+/- 2 days) for history and physical exam and complete blood count with differential.  If the 
minimum CD34 count is not reached after 2 aphereses, the patient can return a minimum of 1 month later to be 
treated again with plerixafor monotherapy or plerixfor with G-CSF based on the patient’s previous response. 
 
If at least 2 patients do not successfully achieve target CD34 yields after two apheresis procedures with plerixafor 
monotherapy, subsequent patients including patients who have undergone unsuccessful apheresis with plerixafor 
monotherapy may be treated with G-CSF in addition to plerixafor.  Patients will be treated with hydroxyurea at a 
dose of at least 20 mg/kg/day prior to initiating G-CSF, and hydroxyurea will be held for at least 2 weeks prior to 
G-CSF mobilization.  The G-CSF dose for each patient will be discussed between the PI and DTM but will range 
from 5-10 ug/kg (total dose adjusted to the nearest vial).  G-CSF will be given subcutaneously for five consecutive 
days.  On the evening of the fourth day, plerixafor at a dose of 240 ug/kg subcutaneously will be given followed by 
apheresis 10 hours later.  If the goal CD34 yield is not met, the patient can receive a 6th dose of G-CSF on the 
evening of the 5th day as well as a second dose of plerixafor followed by second apheresis 10 hours later.  Complete 
blood count with differential will be frequently obtained while the patient receives G-CSF.  The patient will return 
within one week of apheresis (+/- 2 days) for history and physical and complete blood count with differential.  
 
Recipients younger than 10 years-old will likely undergo bone marrow harvest.  
 
II.  Recipient stem cell collection 
The minimum CD34 dose is 1 x 106/kg, target is ≥2 x 106/kg.   Recipients will receive calcium chloride prophylaxis 
to prevent citrate toxicity in accordance with standard DTM policies.  The volume processed per apheresis 
procedure will be determined by DTM medical staff on the day of apheresis based on peak CD34 cell mobilization 
response to plerixafor and/or G-CSF, the CD34 cell dose needed, and body weight of the recipient.  This typically 
range from 15 to 30 liters processed per day for 1 to 2 days, not to exceed a total of 60 liters over 2 days.  
 
The target for marrow harvest in those <10 years-old is 1x108 cells/kg.  
 
APPENDIX D:  IDEAL BODY WEIGHT, ADJUSTED BODY WEIGHT, AND PRACTICAL BODY 
WEIGHT CALCULATIONS 
 
Ideal Body Weight Formula: 
 
Males: 50 kg + (2.3 x the number of inches > 5 feet) 
Females: 45 kg + (2.3 x the number of inches > 5 feet) 
Pediatrics (age 4-20): consider weight based on the same percentile as stature (height) for age, using CDC weight 
for stature growth curves. 
 
Adjusted Ideal Body Weight Formula: 
 
[(actual weight – ideal weight) x 25%] + ideal weight 
 
Note: If the patient is ““morbidly obese”” (BMI > 35), adjusted ideal or practical weight (average of ideal and 
adjusted ideal body weight) may be used after discussion with pharmacist or other transplant providers. 
 
 
 
 

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APPENDIX E: Administration Scheme for Busulfan 
 
Busulfan will be administered at a dose based on the calculated AUC of a busulfan test dose of 0.8 mg/kg that will 
be given 5-14 days prior to the preparative regimen. The busulfan conditioning dose will then be calculated to 
obtain a targeted AUC of 4800 µM.min. (The PI will have discretion to use a target range of 3600 to 6000 
µM.min.)  If the test dose cannot be completed or the pharmacokinetic data from the test dose cannot be accurately 
interpreted, the conditioning busulfan dose will default to a dose of 3.2 mg/kg/dose once daily for 3 consecutive 
days via IV infusion.  The total cumulative dose of the regimen is about 75% of the myeloablative dose.  Keppra 
(levetiracetam) and clonazepam will be initiated at least 12 hours before the first dose of the conditioning dose of 
busulfan for seizure prophylaxis and both drugs will be discontinued following the morning dose after the last dose 
of busulfan.  To further minimize the risk of seizures and other neurologic complications, magnesium deficiency 
will be corrected, arterial hypertension will be strictly controlled, and the goal hemoglobin will be 9g/dL and goal 
platelet count 50K/uL peri-transplant. 
 
Busulfan dosing (default of 3.2mg/kg or by pharmacokinetic testing) will be based on ideal body weight (Appendix 
D) or actual body weight, whichever is lower. For children age 4 through 16, busulfan dosing is based on actual 
body weight, although the ideal body weight may be used for the test dose if it is lower than the actual body weight. 
For recipients who are greater than 120% of ideal body weight, busulfan will be dosed on an adjusted ideal body 
weight (ideal body weight plus 25% of the difference between ideal and actual weight). Four busulfan blood 
samples will be drawn following the administration of the test dose in a green top (sodium heparin) collection tube 
(1 mL specimen volume). Optimally, samples should be obtained from a peripheral vein in the arm opposite to the 
central line where busulfan is infused. If a peripheral vein sample is not feasible, the samples should be obtained 
from a different central catheter lumen than that used for the busulfan infusion. The first specimen should be drawn 
immediately after termination of the 2-hour intravenous infusion of 0.8 mg/kg busulfan. Additional specimens 
should also be drawn at 1 hour, 2 hours and 4 hours after termination of infusion. Each sample should be placed on 
wet ice immediately after collection. All samples will be sent to outside laboratory for pharmacokinetic monitoring. 
 
If the test dose cannot be completed for unforeseen reasons or if the pharmacokinetic data obtained cannot be 
accurately interpreted, the busulfan conditioning dose may default to 3.2mg/kg by IV infusion over three hours once 
daily, based on the ideal body weight or actual body weight, whichever is lower. PK data from the first 1 or 2 days 
of busulfan dosing may be obtained to adjust dosing for day 3 or 4.  
 
 
 

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APPENDIX F: Addendum A: Neuropsychological functioning and quality of life in patients with severe 
congenital anemias (Donors and Recipients) 
 
1.0 Objectives 
1.1 Primary Objectives: 
1.1.1 To examine the neuropsychological functioning of patients and explore their cognitive strengths and 
weaknesses among the following main outcome measures: 
 
- Wechsler Abbreviated Scale of Intelligence – Full Scale IQ 
 
- California Verbal Learning Test – Total Trials 1 – 5 T-score  
 
- Digit Span Backwards scaled score  
 
- Test of Everyday Attention Elevator Counting raw score (adults)  
 
- Processing Speed Index  
 
- DKEFS Trailmaking Condition 4 scaled score  
 
1.1.2  To compare, in an exploratory fashion, the neuropsychological functioning between and within the 
patients and their donor siblings (control group), using the primary measures listed above.  
 
1.2 Secondary Objectives: 
1.2.1 To examine patterns of scores on other neuropsychological tests and behavioral questionnaires and on the 
QOL/pain measures in patients and sibling donors.2 To explore the relationships of neuropsychological and 
behavioral functioning and QOL with medical, neuroimaging, and family variables. 
 
1.2.3 To explore the sibling donors’ experience using the following measures: 
• 
Sibling Pre-Donation Questionnaire 
• 
Sibling Post-Donation Questionnaire 
 
2.0 Background/Scientific and Clinical Justification 
 
2.1 Neuropsychological and emotional functioning in individuals with severe congenital anemiaa. 
Sickle cell disease 
Patients with sickle cell disease (SCD) are at risk for neuropsychological deficits, often related to the occurrence of 
ischemic injury.1 [Gold et al, 2008] Impairments often are first evident in childhood.  Global cognitive deficits have 
been found among youth with overt cerebrovascular accidents as well as those with silent infarcts.  Some evidence 
suggests that even children with SCD with no known history of infarcts (i.e., no visible brain abnormalities on MRI 
scans) perform worse on cognitive measures compared to healthy children.  According to existing literature, 
measures of specific cognitive abilities, such as attention and executive functions, may be more sensitive to the 
effects of the disease than global cognitive (IQ) scores.3  
 
The long-term consequences of such deficits in childhood appear to impact adult functioning in a variety of ways, 
although neurocognitive outcomes in adults with SCD have not been widely reported in the literature to date.6  
Cognitive test scores continue to be lower in adults with SCD compared to healthy controls in global cognitive 
functioning and specific areas such as working memory, processing speed, and executive function (Vichinsky et al., 
2010 – PMID 20460621).  Some research suggests that cognitive difficulties worsen in adulthood and impact 
activities of daily living (Feliu et al., 2011 – PMID 22035043).   
 
Studies of emotional functioning among children and adults with SCD have produced conflicting reports.  While 
some have found normal levels of emotional well-being7, others have found a substantial portion of these patients to 
have internalizing problems, such as anxiety and depression, in the clinical range.   Further, symptoms of anxiety 
and depression are related to lower quality of life among children and adults with SCD. 10,11  Another factor that can 
impact QOL significantly is pain, which is one of the hallmarks of sickle cell disease.12  [Ballas et al 2012] Other 
variables related to poor quality of life in this population include sleep disturbances and disease-related parenting 

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stress.10, 13  Additional studies are needed to elucidate the factors predictive of impaired psychological well-being 
and quality of life among patients with SCD.   
 
b. Beta-thalassemia 
Comparatively little is known about the neuropsychological sequelae of beta-thalassemia.  Only one report in the 
literature was identified that used standardized tests to describe the cognitive functioning in children with this 
disorder.14  Results indicated that a significant proportion of these youth demonstrate below average global 
cognitive abilities.14  A study of adults with beta-thalassemia found low performance relative to healthy controls on 
tests of executive functioning, attention, visual-spatial skills, and memory.15  With respect to emotional functioning, 
research has shown that children and adults with beta-thalassemia have increased levels of depression, anxiety, and 
poor self-image16, 17, as well as impaired quality of life.18   
 
2.2 Neuropsychological and emotional outcomes in patients undergoing stem-cell transplantation (SCT) 
In addition to the neuropsychological complications of SCD and beta-thalassemia, further risk is inherent in the 
SCT process.  Individuals who undergo a SCT may exhibit subsequent impairments due to exposure to neurotoxic 
agents, including total-body irradiation and high dose ablative chemotherapies, as well as those used for 
prophylaxis of GVHD.21-23  Published reports on neuropsychological outcomes in SCT patients have produced 
mixed results.  Numerous studies have reported significant delays, including difficulty with receptive and 
expressive language, attention24, processing speed25, visual and perceptual motor skills23, memory24-26, [Iampietro, 
Giovannetti & Tarazi 2014]  and adaptive functioning.21  Others have described normal neurodevelopment and no 
declines in functioning among children following BMT or SCT.21,22,28,29   
 
The current protocol uses low dose radiation in an attempt to decrease toxicities.  Past studies have demonstrated a 
deleterious impact of higher doses of radiation on cognitive outcomes.30, 31  However, some negative effects are 
evident among patients receiving lower doses as well.32  In addition to dose of radiation, other specific risk factors 
for neurocognitive deficits post SCT/BMT include younger age at time of treatment23,33, treatment with both cranial 
radiation and systemic or intrathecal chemotherapy, poor pre-transplant functioning22,29, and female gender.34, 35 
Finally, most studies have examined neuropsychological functioning at 1 to 2 years post-transplant 22, 23, 29 but they 
have not looked at changes in functioning during the transplant process.  It is important to identify early cognitive 
difficulties that might occur in addition to investigating the long-term outcome to better understand the pattern of 
changes throughout the process. 
 
For transplant patients, the demands of SCT including physical isolation, absence from school or work, and 
neurocognitive and physical changes may result in impaired quality of life.  Studies of psychological sequelae of 
BMT/SCT suggest increased symptoms of anxiety, depression, anger, sadness, hypervigilance, hostility, and social 
withdrawal36-39 accompanied by reports of increased fatigue, sleep disturbance, appetite loss, and decreased activity. 
36, 39-41  Many studies report peaks in these symptoms during the weeks immediately following transplantation.  
However, others have reported peaks in emotional distress immediately before transplant, suggesting that patients 
may enter the hospital with an already heightened level of distress. 39, 42 Some pediatric longitudinal studies have 
reported that symptoms of psychological distress typically return to admission levels 4 to 6 weeks post-SCT and 
dissipate several months post-transplant.36, 39, 41  Other studies have found persistent psychological distress 6 to 12 
month’s post-BMT.28, 43  Specific risk factors for impaired quality of life include increased worry, reduced 
communication (e.g., with family and physicians), poor family cohesion, older age, and increased medical symptom 
severity post-BMT.36, 39, 44 
 
2.3 Functioning of sibling donora. Use of sibling donors as a comparison group in research 
A thorough understanding of the neuropsychological functioning and QOL of patients who undergo SCT is made 
complicated by the numerous variables that can impact cognitive outcomes, including factors related to the disease 
and its associated treatment.  Differentiating these potential causal factors from genetic and environmental factors is 
extremely challenging and often impossible.  One method of resolving this problem involves comparing the 
functioning of patients with their biological siblings.  The authors of a meta-analysis3 noted the appropriateness of 
using a sibling control group for examining the cognitive effects of SCD while accounting for the unique roles of 
family environment and genetics.  One recent study of children treated with SCT was able to demonstrate that the 

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cognitive deficits in the patient group were not accounted for by environmental factors, since the siblings scored 
significantly higher and in the normal range.45  Further studies utilizing this method are needed in order to 
characterize the neuropsychological profile of individuals undergoing SCT.    
 
b. Coping of sibling donors 
With respect to the emotional well-being of sibling donors, a recent review article noted several studies that 
identified these youngsters as being at risk for depression, withdrawal, behavioral problems, and lowered self-
esteem.46  Being a stem cell donor can be a stressful experience for pediatric siblings and can potentially lead to the 
development of long-term distress responses.  Outcomes following SCT appear to have a direct affect on the sibling 
stem cell donors’ psychosocial adjustment.  Feeling responsible for the transplant outcome is of notable concern for 
sibling donors. As the outcome of a SCT relies in part on the histocompatibility of the donor and recipient, when the 
recipient experiences transplant complications, sibling donors may believe that they caused the complications 
because their marrow or stem cells were not “good enough”.47 The literature has found that: (a) education about the 
HSCT process alone is inadequate preparation48,49, (b) children should receive preparatory information and have 
opportunities to express concerns and questions in order to manage anxiety and guilt50, (c) children should have the 
opportunity to express emotions throughout the SCT process51, and (d) parents should be involved in the donor’s 
preparation and follow-up to ensure family communication during SCT.49 A positive response to the donor 
experience, such as improved family relationships, along with heightened intimacy between recipient and donor has 
also been described in previous research on conventional BMT donors 52, 53. Whether or not the transplant is 
successful, each sibling’s family life will be interrupted by the transplant experience. Therefore, for clinical 
purposes, obtaining a psychosocial assessment of the sibling donors strengths and vulnerabilities prior to and 
following the transplant process and having a solid understanding of how the sibling might cope if the transplant is 
unsuccessful are essential components to the donation process. However, as no studies were identified that 
examined the experiences specific to SCD in sibling donors, this study will explore in a qualitative, preliminary 
manner, the sibling donor experiences (secondary objective 1.2.3). 
  
3.0 Eligibility Assessment 
 
3.1 Eligibility Criteria 
3.1.1 
Every patient who enrolls on the transplant protocol will be eligible to participate in the 
neuropsychological and QOL/pain assessments.   
 
3.1.2 
All sibling donors who enroll on the transplant study will be eligible to participate in the 
neuropsychological and QOL assessments.   
3.2 Exclusion Criteria 
3.2.1 
Presence of psychotic symptoms, extreme behavioral difficulties, and/or severe cognitive 
impairment that, in the judgment of the Principal or Associate Investigator(s), would 
compromise the patient’s or sibling’s ability to engage in the neuropsychological testing or 
QOL assessment or is likely to interfere with the study procedures or results.  
 
4.0 Study Design 
 
4.1 Neuropsychological and QOL/pain assessment in patients with severe congenital anemias 
 
We plan to examine the longitudinal neuropsychological profiles of children (ages 16 and 17) and adults (18+) 
undergoing SCT by assessing the domains of global cognitive functioning, memory, attention, processing speed, 
executive functioning, academic functioning, and fine motor skills using a battery of age-appropriate 
neuropsychological measures.  As part of this battery of tests, we also will assess psychological and behavioral 
functioning. All of the neuropsychological tests and questionnaires have been validated for use in children and/or 
adults with chronic illness.  Some of the tests have Spanish versions, and any Spanish-speaking patients enrolled on 
the protocol will be administered these measures and/or administered the nonverbal measures by translating the 
instructions into Spanish.  The neuropsychological tests will be administered by members of the Health Psychology 

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and Neurobehavioral Research Group consisting of licensed psychologists, psychology associates, or supervised 
graduate students in psychology. 
 
The comprehensive neuropsychological test battery will be administered to patients at baseline (Week –1) and 12 
and 24 months post-SCT, and a brief monitoring battery will be given at 100 days post-transplant .  The estimated 
total time for administration of the tests in the comprehensive battery ranges from 90 to 105 minutes, depending on 
patient age.  The parent report questionnaires that are part of the comprehensive battery will take about 60 minutes 
to complete and can be done while the patient is being evaluated.  The brief monitoring battery takes approximately 
30 minutes to administer, and the parent questionnaires that are part of the brief monitoring battery take about 25 
minutes to complete.  Patients will not be tested when they are febrile or are not able to eat by mouth.  Breaks will 
be taken as needed throughout the test session.  
 
A brief assessment of quality of life and pain may be administered before transplant, and at (+/- 7 days) 1 month, 2 
months, 100 days, 6 months, 12 months, 18 months, and 24 months post-transplant, as designated in the assessment 
schedule. Questions will focus on areas such as physical activity, emotional well-being, social functioning, and 
academic achievement.  Since health related quality of life has been reported to be negatively impacted by high 
reported frequency of pain as well as high ratings of current pain, we will complement the quality of life 
measurements with a separate pain questionnaire that includes two visual-analogue items.  The QOL/pain 
assessments will take approximately 10 minutes to complete.   
 
4.2 Neuropsychological and QOL assessment in sibling donors 
In addition to evaluating the patients, we will assess sibling donors of all ages as well. The same comprehensive 
neuropsychological battery and QOL measures will be administered to the siblings at baseline and 12 months post-
transplant. The pain questionnaires that are part of the patients’ QOL assessment will be omitted for the siblings’ 
QOL assessment.   
 
4.3 Clinical assessment of sibling donors 
Each sibling donor will have a pre-transplant clinical assessment conducted by a member of the Psychosocial 
Support and Research team, administered for clinical purposes. This individual, either a social worker, 
psychologist, child psychiatrist, or supervised graduate student, will also provide a brief telephone follow-up at one 
month post stem cell donation with both the sibling and the siblings’ parent (for siblings living with their parents 
and/or under age 25) to assess for any subsequent distress associated with the donation process.  
 
Sibling donors will also be administered a short qualitative pre-donation and post-donation questionnaire designed 
for this study to explore the siblings’ experience being a stem cell donor. The pre-donation questionnaire will be 
administered at the visit pre-donation and the post-donation questionnaire will be administered at 12 months post-
transplant.  These questionnaires are designed for sibling donors ages 7 and older and are conducted via an 
interview format with a member of the Psychosocial Support and Research team. Each child will be asked if they 
are comfortable participating in the interview without a parent present. If they are not, the parent will be invited to 
be present. 
 
4.4 MRI studies 
Each patient will undergo a brain MRI at pre-transplant, and at 12 and 24 months post-transplant.  A neurologist or 
neuroradiologist will review and categorize each scan as (1) normal (no CNS pathology), or (2) evidence of cerebral 
infarction.  It is anticipated that the majority of participants will not require sedation in order to tolerate 
neuroimaging.  However, all participants requesting sedation will be offered monitored anesthesia care through the 
Department of Anesthesia and Surgical Services (DASS), Clinical Center, NIH, and a separate consent will be 
completed as needed.  
 
 4.5 Off Study Criteria 
4.5.1 
Completion of study. 
4.5.2 
Parent or patient/sibling request. 

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4.5.3 
Participant withdraws as a patient from an NHLBI protocol either due to untreatable progressive disease 
or death.   
4.5.4 
Participant is documented to have a serious mental disorder/psychiatric condition that warrants 
therapeutic intervention and which in the judgment of the Principal or Associate Investigators or consulting 
psychiatrist would compromise the patient’s ability to engage in testing or otherwise interfere with the study 
procedures or results. 
4.5.5 
Study cancelled or stopped. 
4.5.6  Study discontinuation at the request of the patient, parent of the patient/sibling, or at the discretion of 
the Principal Investigator or Study Chairperson if they determine that study withdrawal is in the patient’s 
best interest. 
   
5.0 Data Collection 
 
5.1 Neuropsychological Assessments 
The neuropsychological assessments will be administered by members of the Health Psychology and 
Neurobehavioral Research Group of the Pediatric Oncology Branch (POB) of the National Cancer Institute (NCI).  
This group is comprised of licensed psychologists Psychology Associates, and graduate level psychology students.  
The Psychology Associate and graduate students are supervised by one of the licensed psychologists.  The 
psychologists have extensive experience with neuropsychological testing with patients of all ages.   
 
The neuropsychological test data are handled in compliance with Clinical Center policies, the Health Insurance 
Portability and Accountability Act (HIPPA), and the ethical principles relating to psychological data as outlined by 
the American Psychological Association.  These data are stored in the NCI neuropsychological database that is 
currently located on the secure and well-maintained Titan mainframe computer system at the NIH Computer Center 
that can be accessed from the psychologists’ desktop computers.   Given that the mainframe is scheduled to be shut 
down in the near future, the database is in the process of being transferred to a SAS system on the secure 
Psychology server.  The secure neuropsychological database includes names of the NIH patients but the 
accompanying lines of data are not interpretable without a separate password-protected SAS program.  No 
identifying information will be included in any presentation of findings, including publications in peer-reviewed 
journals or conference presentations.  
 
5.2 QOL/Pain Assessments 
The QOL/pain assessments will be conducted by a member of the Neuropsychology Testing and Research Group or 
the sickle cell medical team. These data will be entered into the NCI neuropsychological database along with the 
results from the neuropsychological testing.   
 
5.3 Statistical Considerations  
The two primary statistical objectives are (1) to explore the cognitive strengths and weaknesses by examining mean 
scores in congenitally anemic patients’ neuropsychological functioning and changes over time, and (2) to compare 
the neuropsychological functioning between patients and their sibling donors on six primary outcome measures.  
Given the small sample size expected, data analyses for these objectives will be done in an exploratory fashion and 
results will be used as hypothesis-generating for future studies.  The specific test scores that will be used to address 
this objective are: the WASI Full-Scale IQ (global intelligence), the CVLT Trials 1 – 5 T-score (verbal learning and 
memory), the Digit Span Backward scaled score (working memory), the TEA Elevator Counting raw score, the 
Processing Speed Index (processing speed), and the DKEFS Trailmaking Condition 4 scaled score (executive 
function).  Possible strengths and weaknesses in functioning will be identified as individual scores that are one 
standard deviation above or below the normative mean.  The success rate will be reported by age group, but the 
study does not have sufficient power to test for differences among age groups.    
 
To assess the secondary objective 1.2.1 of examining patterns of scores on other neuropsychological tests and on 
the QOL/pain measures in patients and siblings, a large number of secondary evaluations will be performed in an 
exploratory fashion.  Specifically, repeated measures ANOVAs will be performed to look at differences between 
and within groups over time, and the results interpreted as secondary and hypothesis generating.  The following 

14-H-0077 
Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
56 | P a g e  
measures will be included in these analyses:  neuropsychological test results (e.g., WASI Verbal and Performance 
IQ, WRAT-IV Reading and Arithmetic standard scores, Cancellation scaled score, Grooved Pegboard dominant 
hand z-score); psychological functioning (parent report questionnaire: BASC-II Composite and subscales for 
adolescents ages 16 – 21 years), adaptive functioning (parent report questionnaire for adolescents and young adults 
ages 16 – 25): Vineland Daily Living and Socialization domain standard scores), and behavior (self-report 
questionnaires: Conners Adult ADHD Rating Scale subscales or parent report questionnaire: Conners Parent Rating 
Scale subscales).  Possible strengths and weaknesses in functioning will be identified as individual scores that are 
one standard deviation above or below the normative mean.   
 
Another secondary objective (1.2.2) is to assess the relationships of neuropsychological functioning and QOL to 
medical, neuroimaging, and family variables.  We will perform Pearson r or Spearman rank correlations between 
the following variables: cognitive test results (e.g., IQ, memory, attention, processing speed, and executive 
function), QOL and pain scores, and hematocrit levels.  Patients’ MRI scans will be categorized as normal or as 
having evidence of a cerebral infarction.  The scans that show evidence of an infarction will be further divided into 
those with a clinical history of an overt CVA, and those with no clinical history of a CVA (these will be considered 
to have had silent infarcts).  This classification will result in three final categories: (1) normal, (2) overt CVA, and 
(3) silent infarction. A multivariate ANOVA will be conducted to compare neuropsychological function between 
these three groups.  Also, among patients whose scans show evidence of infarctions, exploratory analyses will be 
conducted to assess the relationship between lesion location (e.g., frontal vs. parietal, cortical vs. subcortical) and 
neuropsychological test scores.   
 
For the secondary objective that explores the sibling donors’ experience of the transplantation process, responses to 
the pre- and post-donation questionnaires will be reported descriptively.  Quantitative data will be reported in terms 
of frequencies of responses to individual questions relating to their satisfaction, understanding, and decision-making 
around donation of stem cells.  Qualitative responses to the open-ended questions about their feelings about having 
a sibling with a severe congenital anemia and the donation experience will be coded and organized using NVivo8.0 
qualitative software54 and a content analysis will be conducted.  
 
Because of the large number of parameters being evaluated to assess the secondary objectives, it is impractical to 
correct for multiple comparisons.  However, we will set more stringent criteria for statistical significance by setting 
the alpha level at .01.  Moreover, results of these analyses will be considered exploratory and hypothesis-generating 
for future studies.  Careful discussion regarding interpretation of results in this context will be included in any 
written reports based on these data.   
 
6.0 Human Subjects Protection 
 
6.1 Evaluation of Risks and Benefits: 
The primary goal of this neuropsychological/QOL study is to assess the neurocognitive functioning, emotional 
well-being, and QOL of children prior to, during, and following stem cell transplantation.  Minimal risk is involved 
in participating in these assessments, and potential benefits may be derived.  After the testing, patients (and/or 
parents, as appropriate) will be provided with feedback about the patient’s neurocognitive strengths and 
weaknesses, which can be helpful in educational and career planning.  We can also provide specific 
recommendations to facilitate academic achievement, optimal job performance, and improvements in adaptive 
functioning.  Most people find neuropsychological testing to be interesting and enjoyable.  However, some parts 
may be challenging and some people may become frustrated or tired.  Similarly, it may be upsetting for some 
participants to answer questions about their emotional functioning.  If a participant becomes significantly distressed 
during testing, the evaluator will initiate a break.  Any patient or sibling can choose to stop the testing if he or she 
does not want to continue and participants do not have to answer every question.  A licensed psychologist or 
supervised psychology associate will be available to speak with any participants who become distressed at any point 
during or following the testing.  Referrals to local mental health providers will be made if necessary.   
 
Another part of this study involves the clinical assessment and monitoring of the sibling donors to be conducted by 
a clinical social worker.  Expected benefits include facilitating communication about psychological concerns in 

14-H-0077 
Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
57 | P a g e  
these donor siblings.  If the participant reports discomfort in discussing these issues, the interview will end.  The 
siblings and their parents will be informed that not participating in this clinical assessment will not affect their 
treatment or status on the protocol in any way.   
 
6.2 Consent and Assent Process and Documentation 
Since the neuropsychological and QOL/pain assessments will be done as part of the primary medical protocol, no 
separate consent for these studies will be obtained.  The consent and assent forms for the patients and siblings 
enrolling on the medical protocol include information about the neuropsychological and QOL/pain evaluations.  
The consent and assent forms for the sibling donors include additional information about the clinical assessment 
that will be conducted with those participants.   
 
 

14-H-0077 
Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
58 | P a g e  
Neuropsychological Test Battery* 
 
Domain 
Test 
Time 
(min) 
Comprehensive 
(Baseline, 1 yr, 2 yrs) 
Monitor 
(100 days) 
General 
Intelligence 
Wechsler Abbreviated Scale of Intelligence#  
(4 subtests) 
     45 
 
√ 
 
Memory & 
Learning 
California Verbal Learning Test-II#  
 
  20 
     
√ 
 
Working 
Memory 
Digit Span (WAIS-IV)# 
 
    5 
     
√ 
√ 
Attention 
 
TEA Elevator Counting Subtest# 
WAIS Cancellation subtest 
    5 
    5 
√ 
√ 
 
√ 
Processing 
speed 
Processing Speed Index# (WAIS-IV Coding, Symbol 
Search subtests) 
  
    5 
 
√ 
 
√ 
Executive 
function 
DKEFS Trailmaking Conditions 2 – 4#  
 
    5 
    
√ 
 
√ 
 
Fine Motor 
 
Grooved Pegboard  
    5 
√ 
√ 
Academic 
Function 
Wide Range Achievement Test-IV 
(Reading/Arithmetic) 
  15 
√ 
 
Behavior 
 
Parent Report Questionnaires: 
BRIEF-Parent/Adult 
BASC-II 
Vineland Scale (Daily Living/Social) 
Conners Parent Rating Scale 
 
Patients  
BASC-II (16-17 yrs) or BSI (adults 18+) 
CAARS  
 
     10 
     15 
     15 
       5 
 
 
  10 
    5 
 
             √ 
             √ 
             √ 
             √  
 
          
             √ 
             √ 
 
 
      
 
     √  
 
 
 
      √ 
Background 
Information 
Background Information Form (baseline and update) 
    5 
√ 
√ 
Estimated time of the comprehensive assessment:$ 115 minutes  
Estimated time of the monitoring battery:$  35 minutes (all ages) 
 
* Other tests may be administered to more comprehensively assess the patient as deemed appropriate by the 
examiner. 
# These tests comprise the primary measures specified in objective 1.1.1.  The remaining tests are referred to in 
secondary objectives 1.2.1 and 1.2.2. 
$ The actual times may be longer depending on the examinee’s learning style and behavior as some are slower to 
respond than others and some may need more breaks.   
 
 

14-H-0077 
Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
59 | P a g e  
Quality of Life (QOL)/Pain Assessment  
 
Domain 
Test 
Time (min) 
    QOL 
Pediatric Quality of Life Inventory (Peds QL)  
(–6 - 25 years) 
Medical Outcomes Study (MOS) SF-36  
(23+ years) 
5 
 
5 
    Pain 
PedsQL Pain Perception Questionnaire–e - VAS only 
(16 – 18 years) 
Short Form McGill Pain Scale – VAS only  
(>18 years) 
  5 
 
  5 
Estimated time of QOL assessment: 10 minutes 
 
 
Schedule of Neuropsychological and Quality of Life/Pain Assessments 
 
 
Baseline 
1 mo. 
2 mo. 
100 days 
6 mo. 
12 mo. 
18 mo. 
24 mo. 
Patients: 
 
 
 
 
 
 
 
 
  Neuropsych. Testing 
C 
 
 
M 
 
C 
 
C 
  QOL/Pain 
√ 
 
 
√ 
 
√ 
 
√ 
 
 
 
 
 
 
 
 
 
Sibling Donors: 
 
 
 
 
 
 
 
 
  Neuropsych. Testing 
C 
 
 
 
 
C 
 
 
  QOL 
√ 
 
 
 
 
√ 
 
 
C = Comprehensive Test Battery 
M = Monitoring Test Battery 
 
Clinical Assessment of Sibling Donors* 
• 
Pre-transplant 
 
Parental interview 
− Parental perceptions of donation process for family 
− Level of discussion that has occurred with donor, recipient 
Donor Interview 
− Assess donors‚ age-appropriate understanding of the process 
− Dispel any misconceptions 
− Ensure the absence of coercion, confirm perception of voluntary choice 
− Anticipatory guidance regarding process 
− Administer the pre-donation questionnaire (see page 10) 
 
• 
Post-transplant 
− Assess donors’ perception of the process 1 month following procedure 
− Obtain additional parental report 1 month post-donation 
− Assess any disturbance in donors’ mood, sleep, appetite, symptoms of post-traumatic stress 
− If transplant is unsuccessful/patient dies, additional follow-up with donor if feasible 
− Administer post-donation questionnaire 12 months post donation (see pages 13-17) 
 
* Adapted from Phipps, S., 2009 
 
 

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

14-H-0077 
Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
68 | P a g e  
34) 
Is there anything else you would like to share with us about having a sibling with a severe anemia? 
__________________________________________________________________________________
________________________________________________________________________________ 
THANK YOU! 
 
 

14-H-0077 
Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
69 | P a g e  
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617. 

14-H-0077 
Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
70 | P a g e  
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28. 
Phipps S, Brenner, M, Heslop, H, Krance, R, Jayawardene, D, Mulhern, R. Psychological effects of bone 
marrow transplantation on children and adolescents: Preliminary report of a longitudinal study. Bone 
Marrow Transplant 1995; 15(6): 829-835. 
29. 
Simms S, Kazak, AE, Gannon, T, Goldwein, J, Bunin, N. Neuropsychological outcome of children 
undergoing bone marrow transplantation. Bone Marrow Transplant 1998; 22(2): 181-184. 
30. 
Grill J, Renaux, VK, Bulteau, C, et al. Long-term intellectual outcome in children with posterior fossa 
tumors according to radiation doses and volumes. International journal of radiation oncology, biology, 
physics 1999; 45(1): 137-145. 
31. 
Kieffer-Renaux V, Bulteau, C, Grill, J, Kalifa, C, Viguier, D, Jambaque, I. Patterns of neuropsychological 
deficits in children with medulloblastoma according to craniospatial irradiation doses. Developmental 
medicine and child neurology 2000; 42(11): 741-745. 
32. 
Merchant TE, Kiehna, EN, Li, C, et al. Modeling radiation dosimetry to predict cognitive outcomes in 
pediatric patients with CNS embryonal tumors including medulloblastoma. International journal of 
radiation oncology, biology, physics 2006; 65(1): 210-221. 
33. 
Barrera M, Atenafu E, Andrews GS, Saunders F. Factors related to changes in cognitive, educational and 
visual motor integration in children who undergo hematopoietic stem cell transplant. Journal of Pediatric 
Psychology 2008; 33(5): 536-546. 
34. 
Brouwers P, Poplack, D. Memory and learning sequelae in long-term survivors of acute lymphoblastic 
leukemia: Association with attention deficits. The American journal of pediatric hematology/oncology 
1990; 12(2): 174-181. 
35. 
Smedler AC, Bolme, P. Neuropsychological deficits in very young bone marrow transplant recipients. Acta 
Paediatrica 1995; 84(4): 429-433. 
36. 
Barrera M, Boyd-Pringle, LA, Sumbler, K, Saunders, F. Quality of life and behavioral adjustment after 
pediatric bone marrow transplantation. Bone Marrow Transplant 2000; 26(4): 427-435. 
37. 
Ferry C, Gemayel, G, Rocha, V, et al. Long-term outcomes after allogeneic stem cell transplantation for 
children with hematological malignancies. Bone Marrow Transplant 2007; 40(3): 219-224. 
38. 
Hjermstad MJ, Loge, JH, Evensen, SA, Kvaloy, SO, Fayers, PM, Kaasa, S. The course of anxiety and 
depression during the first year after allogeneic or autologous stem cell transplantation. Bone Marrow 
Transplant 1999; 24(11): 1219-1228. 
39. 
Phipps S, Dunavant, M, Garvie, PA, Lensing, S, Rai, SN. Acute health-related quality of life in children 
undergoing stem cell transplant: I. Descriptive outcomes. Bone Marrow Transplant 2002; 29(5): 425-434. 
40. 
Bevans MF, Mitchell, SA, Marden, S. The symptom experience in the first 100 days following allogeneic 
hematopoietic stem cell transplantation (HSCT). Support Care Canc 2008; 16(11): 1243-1254. 
41. 
Rodrigue JR, Graham-Pole, J, Kury, S, Kubar, W, Hoffmann, RG, 3rd. Behavioral distress, fear, and pain 
among children hospitalized for bone marrow transplantation. Clin Transplant 1995; 9(6): 454-456. 
42. 
Fife BL, Huster, GA, Cornetta, KG, Kennedy, VN, Akard, LP, Broun, ER. Longitudinal study of adaptation 
to the stress of bone marrow transplantation. J Clin Oncol 2000; 18(7): 1539-1549. 
43. 
Nespoli L, Verri, AP, Locatelli, F, Bertuggia, L, Taibi, RM, Burgio, GR. The impact of paediatric bone 
marrow transplantation on quality of life. Qual Life Res 1995; 4(3): 233-240. 

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February 13, 2024 (Amendment DD) 
 
71 | P a g e  
44. 
Felder-Puig R, di Gallo, A, Waldenmair, M, et al. Health-related quality of life of pediatric patients 
receiving allogeneic stem cell or bone marrow transplantation: results of a longitudinal, multi-center study. 
Bone Marrow Transplant 2006; 38(2): 119-126. 
45. 
Titman P, Pink, E, Skucek, E, et al. Cognitive and behavioral abnormalities in children after hematopoietic 
stem cell transplantation for severe congenital immunodeficiencies. Blood 2008; 112(9): 3907-3913. 
46. 
Wiener L, Steffen-Smith, E, Fry, T, Wayne, A. Hematopoeitic Stem cell donation in children: A review of 
the sibling donor experience. J Psychosoc Oncol 2007; 25(1): 45-66. 
47. 
Rappaport BS. Evolution of consultation-liaison services in BMT. General Hospital Psychiatry 1988; 10: 
346j-351. 
48. 
Gardner GG, August, CS, Githens, J. Psychological issues in bone marrow transplantation. Pediatr 1977; 
(4): 625-631. 
49. 
Heiney SP, Bryant, LH, Godder, K, Michaels, J. Preparing children to be bone marrow donors. Oncol 
Nursing Forum 2002; 29(10): 1485-1489. 
50. 
Kinrade LC. Preparation of sibling donor for bone marrow transplant harvest procedure. Canc Nurs 1987; 
10(2): 77-81. 
51. 
Packman WL, Crittenden, MR, Schaeffer, E, Bongar, B, Fischer, JBR, Cowan, MJ. Psychosocial 
consequences of bone marrow transplantation in donor and nondonor siblings. J Dev Behav Pediatr 1997; 
18(4): 244-253. 
52. 
MacLeod KD, Whitsett, SF, Mash, EJ, Pelletier, W. Pediatric sibling donors of successful and unsuccessful 
hematopoietic stem cell transplants (HSCT): A qualitative study of their psychosocial experience. J Pediatr 
Psychol 2003; 28(4): 223-230. 
53. 
Wiley FM, Lindamood, MM, Pfefferbaum-Levine, B. Donor-patient relationship in pediatric bone marrow 
transplantation. J Assoc Pediatr Oncol Nurses 1984; 1(3): 8-14. 
54. 
Welsh E. Dealing with data: Using NVivo in the qualitative data analysis process. Forum Qualitative 
Sozialforschung/Forum: Qualitative Social Research 2002; 3(2): Art. 26. 
 
 

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APPENDIX G: Addendum B to protocol 14-H-0077: Reproductive questionnaires in patients with severe 
congenital anemias before and after transplant  
 
1. Objectives 
 
1.1. To obtain detailed medical, surgical, medication, social, family, and other relevant history, through the use 
of questionnaires, to complement endocrine related laboratory testing before and after hematopoietic stem 
cell transplant (HSCT) 
1.2. To accumulate possible qualitative changes before and after stem cell transplant in the hypothalamic, 
pituitary, adrenal, and gonadal organs, with the emphasis on reproductive potential. 
1.3. To estimate the magnitude and need of fertility related issues among transplanted patients. 
 
 
2. Background and Scientific Rationale 
 
Male and female patients with sickle cell disease (SCD) or thalassemia frequently suffer from endocrine and 
reproductive health problems, which can have multiple and complex etiologies.  The underlying cause(s) can not 
only be related to the diseases themselves, but are frequently also a consequence of the treatment(s), which the 
patients have received in the past or are receiving currently. This area is under-studied in the literature; searching 
for “sickle cell” and “fertility” yielded only 87 entries in Pubmed with 19 relevant reports. Searching for “sickle 
cell” and “reproduction” yielded 1464 entries, spanning 1960’s to 2013.  258 entries were about prenatal or 
newborn screening, 297 were about pregnancy management or pregnancy outcomes, 29 were about contraception, 
and only 39 entries were relevant to the reproductive potential in sickle cell population.  Thus these reports (19+39) 
are limited to address the causes of infertility (male or female factors), the effects of hydroxyurea, blood transfusion 
(and iron overload), iron chelators on gonadal function, or what magnitude and effects does chronic vaso-occlusion 
have on gonadal reserve.  Half of the combined 58 articles discussed priapism, but only on medication or surgical 
management 1-3 – not on fertility potential. There were only case reports of fertility or fertility rates in women4,5, but 
again are limited in addressing the causes of fertility potential with SCD and/or treatment6. 
 
Additionally, the literature about effects of hydroxyurea on fertility in male patients with SCD is mixed.  Some 
report irreversible reduction in sperm production even with hydroxyurea discontinuation7,8, while others report 
modest recovery 9. There are no reports on the effects of hydroxyurea on gonadal function in women with SCD.   
 
Currently HSCT is the only cure for patients with SCD and thalassemia.  The most common type of HSCT employs 
full or myeloablative conditioning, which renders 60-85% of all transplant recipients infertile 10-12.  Reduced 
intensity or non-myeloabaltive regimens such as the one on this protocol theoretically should be less toxic on 
gonadal function. Different drug combinations and varying dosing schedule make the results from other transplant 
reports difficult to apply to this study13,14.  Furthermore, our regimen uses total body irradiation, where testes are 
partially shielded but not ovaries, and alemtuzumab which targets CD52 on lymphocytes and spermatocytes 15.  
These are unique features that make studying post-transplant endocrine effects (fertility potential) especially 
important.   
When we previously approached the reproductive endocrinology group in NICHD about how best to follow our 
patients, they offered to evaluate our patients on as needed basis and pointed out their limitation – namely only for 
female patients as they are medically and surgically trained as obstetricians and gynecologists. There is currently no 
andrology support at this time. In order to determine whether the measures we initiate in association with HSCT 
contribute to negatively impact the patients’ endocrine health in general and their reproductive health in particular, 
we propose to start with a questionnaire, designed for male and female patients, which complements the endocrine 
related laboratory testing we are currently performing in this protocol (sections 6.1.21 and 6.4).  Our interest is 

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focused on determining whether our treatment (HSCT and associated medications) worsen the patients’ endocrine 
balance, and if yes, to what extent.  By ruling out other potential confounding factors, we will be able to better 
understand the role that our treatment may play. 
3. Methods 
There are several publicly available fertility related questionnaires (see web links after references). They include 
questions that are standard in the reproductive science field, as they address the patients’ family, social, medical, 
and surgical histories, their medications, and prior treatments. With regard to the social history part of the 
questionnaire, a patient’s lifestyle may provide clues or suggest any endocrine or reproductive health problems, as 
would be the case e.g. if patients were exposed to hazardous agents at work, or if they used certain recreational 
drugs. 
There are no questionnaires that are specific for SCD or any other disorder; all the questionnaires are general – one 
for all patients.  Thus we reviewed all the available questionnaires, took all the standard questions, and added 
relevant questions for SCD and hemoglobinopathies. Our implementation method includes the following: 
3.1. The questionnaire is voluntary, as other addenda to this protocol are voluntary.  Subjects 18 years old and 
older are our intended focus:  male questionnaire (3 pages), female questionnaires (3 pages). 
3.2. For prospective patients, we plan to administer the questionnaire pre-HSCT, 1 year post-HSCT, and 2 year 
post-HSCT. The remaining 19 subjects (50 accrual ceiling – 31 transplanted subjects) should allow us to 
identify if there are any qualitative changes.  
3.3. For patients who have already been transplanted, we also plan to administer the questionnaire annually for 
2 times with the annual follow-up visits (for example, year 3 and 4 or year 6 and 7 depending on the 
patient). The answers from these patients would help to estimate the need of fertility related issues post-
transplant.  
3.4. The questionnaires are to be administered by the protocol providers or research coordinators with the 
patients to ensure uniformity. The questionnaires are not meant be filled out by the patients alone. 
3.5. While it is common to obtain detailed history from partners of patients, we are omitting this aspect for 
several reasons.  This effort is a pilot study with fact finding intent, thus we would like to focus on the 
patients first. Many of our patients currently do not have a stable partner to consider family planning, and 
we want to avoid re-administering the questionnaire if the partner were to change.  Partner consenting to 
this addendum, possible impact of participating in questionnaire on the ongoing relationship, and 
confidentiality also make administering questionnaires to partners impractical for our team at this time.   
 
4. Potential outcomes/results and data collection/analysis 
4.1. Previously we had 2 male subjects that reported decreased libido and erections in the first 6 months after 
transplant. As a result, we have sent them to for endocrine evaluation and related lab testing. We also had 1 
female subject who has been trying to get pregnant, and we have sent her to see medical and reproductive 
endocrinology for evaluation. Since often these patients have many transplant or medical issues, fertility 
related history is often neglected. This questionnaire helps to create a more complete set of data of fertility 
related issues/symptoms before and after transplant.   
 
As we have done for the 3 patients listed in 4.1 of this section, when we identify area(s) of need in the 
patients in medical or reproductive endocrinology, we will inform the patients and refer them for suitable 
consultation either here at the Clinical Center or near patients’ home residence, depending on the patients’ 
input.  If social work, psychologic, and other types of counseling is needed, we will find the most suitable 
consultation and/or referral. 
4.2.    
 
 

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4.3. Responses for men and women will be cataloged separately and proportion of patients with certain SCD 
treatment (e.g. how many red cell transfusions), symptoms (e.g. priapism or oligomenorrhea), or previous 
medical illness (e.g. infections) will be tabulated.   
4.3.1. Responses from prospective patients will estimate the magnitude of fertility related needs or patterns 
before and after transplant, how/if they change after transplant short and long term.  
4.3.2. Responses from already transplanted patients will add to the estimate of fertility need after transplant, 
and make the long term data immediately available.  
 
4.4. Much of the data will be descriptive.  The history portions of the questionnaires are intended to be 
compared qualitatively, and likely will be analyzed non-parametrically, similarly to this report16.  
 
When possible we will try to correlate the history portions with the laboratory testing, focusing on the 
reproductive of the hypothalamic-pituitary-adrenal-reproductive axes.  Some examples include do lower 
libido correlate with lower sex hormone levels, what are FSH and LH levels in women with irregular 
menses and how do they change over time 
4.5. ?  
 
References for Addendum B 
1. 
Bivalacqua TJ, Musicki B, Kutlu O, Burnett AL. New insights into the pathophysiology of sickle cell 
disease-associated priapism. The journal of sexual medicine. 2012;9(1):79-87. 
2. 
Broderick GA. Priapism and sickle-cell anemia: diagnosis and nonsurgical therapy. The journal of sexual 
medicine. 2012;9(1):88-103. 
3. 
Burnett AL, Bivalacqua TJ, Champion HC, Musicki B. Long-term oral phosphodiesterase 5 inhibitor 
therapy alleviates recurrent priapism. Urology. 2006;67(5):1043-1048. 
4. 
Ballas SK, McCarthy WF, Guo N, et al. Exposure to hydroxyurea and pregnancy outcomes in patients with 
sickle cell anemia. J Natl Med Assoc. 2009;101(10):1046-1051. 
5. 
Italia KY, Jijina FF, Chandrakala S, et al. Exposure to hydroxyurea during pregnancy in sickle-beta 
thalassemia: a report of 2 cases. Journal of clinical pharmacology. 2010;50(2):231-234. 
6. 
Dovey S, Krishnamurti L, Sanfilippo J, et al. Oocyte cryopreservation in a patient with sickle cell disease 
prior to hematopoietic stem cell transplantation: first report. Journal of assisted reproduction and genetics. 
2012;29(3):265-269. 
7. 
Jones KM, Niaz MS, Brooks CM, et al. Adverse effects of a clinically relevant dose of hydroxyurea used 
for the treatment of sickle cell disease on male fertility endpoints. International journal of environmental research 
and public health. 2009;6(3):1124-1144. 
8. 
Lukusa AK, Vermylen C, Vanabelle B, et al. Bone marrow transplantation or hydroxyurea for sickle cell 
anemia: long-term effects on semen variables and hormone profiles. Pediatric hematology and oncology. 
2009;26(4):186-194. 
9. 
Berthaut I, Guignedoux G, Kirsch-Noir F, et al. Influence of sickle cell disease and treatment with 
hydroxyurea on sperm parameters and fertility of human males. Haematologica. 2008;93(7):988-993. 

14-H-0077 
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75 | P a g e  
10. 
Thibaud E, Rodriguez-Macias K, Trivin C, Esperou H, Michon J, Brauner R. Ovarian function after bone 
marrow transplantation during childhood. Bone marrow transplantation. 1998;21(3):287-290. 
11. 
Matsumoto M, Shinohara O, Ishiguro H, et al. Ovarian function after bone marrow transplantation 
performed before menarche. Archives of disease in childhood. 1999;80(5):452-454. 
12. 
Sanders JE, Hawley J, Levy W, et al. Pregnancies following high-dose cyclophosphamide with or without 
high-dose busulfan or total-body irradiation and bone marrow transplantation. Blood. 1996;87(7):3045-3052. 
13. 
Walters MC, Hardy K, Edwards S, et al. Pulmonary, gonadal, and central nervous system status after bone 
marrow transplantation for sickle cell disease. Biology of blood and marrow transplantation : journal of the 
American Society for Blood and Marrow Transplantation. 2010;16(2):263-272. 
14. 
Vlachopapadopoulou E, Kitra V, Peristeri J, et al. Gonadal function of young patients with beta-thalassemia 
following bone marrow transplantation. Journal of pediatric endocrinology & metabolism : JPEM. 2005;18(5):477-
483. 
15. 
Focarelli R, Francavilla S, Francavilla F, Della Giovampaola C, Santucci A, Rosati F. A sialoglycoprotein, 
gp20, of the human capacitated sperm surface is a homologue of the leukocyte CD52 antigen: analysis of the effect 
of anti-CD52 monoclonal antibody (CAMPATH-1) on capacitated spermatozoa. Molecular human reproduction. 
1999;5(1):46-51. 
16. 
Gallo AM, Wilkie D, Suarez M, et al. Reproductive decisions in people with sickle cell disease or sickle 
cell trait. Western journal of nursing research. 2010;32(8):1073-1090. 
Web links to publically available fertility questionnaires 
1. http://www.cdc.gov/reproductivehealth/Global/PDFs/RHAToolkitQuestionnaireUpdatedSeptember2011_FI
NAL_Tag508.pdf  
2. http://shirenaturalfertility.com.au/wp-content/uploads/2011/06/First-Visit-Form.pdf  
3. http://coe.ucsf.edu/ivf/forms/FORM_411-Male_Reproductive_Health_Questionnaire.pdf  
4. http://urology2008-2012.ucsf.edu/patientGuides/pdf/maleInf/MaleIntake.pdf  
5. http://www.racha.org.kh/rc2008/105/RPH-024-Eng.pdf  
6. http://www.utswmedicine.org/hospitals-clinics/pob-2/ob-gyn/reproductive-health-questionnaire.pdf  
7. www2.massgeneral.org/Vincent/images/ivf_infertilityquestionnaire1.pdf  
8. infertility.wustl.edu/wp-content/uploads/2013/07/Medical-History-Questionnaire.pdf 
9. www.uwmedicine.org/patient-care/our-services/medical-services/gynecology/documents/male-infertility-
history.pdf 
10. Obgyn.ucla.edu/workfiles/new_patients/patient_history_obgyn.pdf  
11. www.uamshealth.com/upload/docs/clinics/women%20health/fertility-history-uams.pdf 
12. www.shadygrovefertility.com/your_first_visit  
 
 
 
 
 
 
 
 
 
 

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Female Reproductive Health Questionnaire  
 
Question  
Picklist  
Format 
1. Married or committed relationship? 
No 
dropdown 
  
Yes 
dropdown 
Yes - Number of years: 
  
text 
2. At what age did you have your first 
menstrual period? 
  
string 
3. How are your menstrual periods? 
Regular (21-35 days) 
dropdown 
  
Irregular - Since when? 
dropdown 
Irregular - Since when? 
  
text 
4. When was the first day of your most recent 
menstrual period? 
  
string 
5. How would you describe your bleeding? 
Light (< 3 pads) 
dropdown 
  
Average (3 - 5 pads) 
dropdown 
  
Heavy (> 5 pads) 
dropdown 
6. Do you bleed or spot between periods or 
after intercourse? 
No 
dropdown 
  
Yes 
dropdown 
Yes - Since when? 
  
text 
7. When was your most recent:          
 
 
Pap Smear? (mm/dd/yyyy) 
  
string 
Mammogram? (mm/dd/yyyy) 
  
string 
Pelvic ultrasound? (mm/dd/yyyy) 
  
string 
8. Did you ever have an abnormal Pap Smear? 
No 
dropdown 

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February 13, 2024 (Amendment DD) 
 
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Yes 
dropdown 
Yes - When? 
  
text 
9. How many times per week (on average) do 
you have intercourse? 
  
text 
10. Do you use contraception? 
No 
dropdown 
  
Yes 
dropdown 
Yes - What type and since when? 
  
text 
11. Have you ever attempted to become 
pregnant? 
No 
dropdown 
  
Yes - successful 
dropdown 
  
Yes - unsuccessful 
dropdown 
Yes - successful -  How many times have you 
been pregnant? 
  
text 
12. Did you become pregnant naturally? 
No 
dropdown 
  
Yes 
dropdown 
13. Did you delivery at term? 
No 
dropdown 
  
Yes 
dropdown 
No - Please explain: 
  
text 
14. Did you ever have a miscarriage? 
No 
dropdown 
  
Yes 
dropdown 
Yes - How many times? 
  
text 
During which trimester of pregnancy? 
  
text 
15. Have you been evaluated for infertility in 
the past? 
No 
dropdown 
  
Yes 
dropdown 

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Yes - Comment (if any): 
  
text 
16. Did you have infertility treatment? 
No 
dropdown 
  
Yes 
dropdown 
Yes - Type/treatment: 
  
text 
17.  If you have children:        
 
 
A. Did you have them with your current 
partner? 
No 
dropdown 
  
Yes 
dropdown 
Yes - Comment (if any): 
  
text 
B.  Are your children healthy?            
Children with current partner: 
No 
dropdown 
  
Yes 
dropdown 
Children with a previous partner: 
No 
dropdown 
  
Yes 
dropdown 
C. If they have health problems what type of 
health problems do they have?      
Children with current partner: Please describe: 
  
text 
Children with a previous partner: Please 
describe 
  
text 
18.  Has your weight changed more than 15 
lbs in the last year? 
No 
dropdown 
  
Yes 
dropdown 
Medical History  
 
header 
1. Thyroid Disorder 
No 
dropdown 
  
Yes 
dropdown 

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Yes - What type of disorder? 
  
text 
When where you diagnosed? (mm/yyyy) 
  
string 
Treatment? 
  
text 
2.  Fibroids endometriosis polycystic ovary 
syndrome or other GYN pathology? 
Yes 
dropdown 
  
No 
dropdown 
Yes - please describe: 
  
text 
3. Frequent urinary tract infections? 
No 
dropdown 
  
Yes 
dropdown 
Yes - Since when? (mm/yyyy) 
  
text 
How frequently per three months (on 
average)? 
  
text 
Treatment: 
  
text 
4.  Sexually transmitted disease? 
No 
dropdown 
  
Yes 
dropdown 
Yes - Type: 
  
text 
Treatment: 
  
text 
5. Cancer? 
No 
dropdown 
  
Yes 
dropdown 
Yes - Which year? (YYYY)   
  
string 
Type: 
  
text 
Treatment: 
  
text 
6.  Neurological Problems? 
No 
dropdown 
  
Yes 
dropdown 

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Yes - Type: 
  
text 
Treatment: 
  
text 
Treatment:  From when to when?  
  
text 
7. Have you ever taken hydroxyurea? 
No 
dropdown 
  
Yes 
dropdown 
Yes - From when to when? 
  
text 
At what dose? 
  
text 
If you stopped taking the drug what was 
reason for it? 
  
text 
Surgical History 
header 
1. Dilatation and curettage? 
No 
dropdown 
  
Yes 
dropdown 
Yes - Date/year (if known): (mm/yyyy) 
  
string 
What was the reason? 
  
text 
2.  Cervical cone biopsy? 
No 
dropdown 
  
Yes 
dropdown 
Yes - Date/year (if known): (mm/yyyy) 
  
text 
What was the reason? 
  
text 
3. Surgery of the ovary? 
No 
dropdown 
  
Yes 
dropdown 
Yes - Date/year (if known): (mm/yyyy) 
  
string 
What was the reason? 
  
text 
4. Surgery of the Fallopian tube? 
No 
dropdown 
  
Yes 
dropdown 

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February 13, 2024 (Amendment DD) 
 
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Yes - Date/year (if known): (mm/yyyy) 
  
string 
What was the reason? 
  
text 
5. Surgery of the uterus? 
No 
dropdown 
  
Yes 
dropdown 
Yes - Date/year (if known): (mm/yyyy) 
  
string 
What was the reason? 
  
text 
6. Laparoscopy? 
No 
dropdown 
  
Yes 
dropdown 
Yes - Date/year (if known): (mm/yyyy) 
  
string 
What was the reason? 
  
text 
Exposure History  
header 
1. Do you currently smoke tobacco? 
No 
dropdown 
  
Yes 
dropdown 
Yes - Since how many months 
  
string 
Years: 
  
string 
How much (per day): 
  
string 
2.  If you quit smoking how long has it been?       
# of months 
  
string 
# of years 
  
string 
3.  Do you use any of the following:          
Alcohol? 
No 
dropdown 
  
Yes 
dropdown 
Consumption 
Less than 2 drinks/day 
dropdown 

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More than 2 drinks/day 
dropdown 
Marijuana? 
No 
dropdown 
  
Yes 
dropdown 
Frequency: 
Up to 3x/month 
dropdown 
  
More than 3x/month 
dropdown 
Other types of recreational drugs? 
No 
dropdown 
  
Yes 
dropdown 
Yes - Type: 
  
 
Frequency: 
Up to 3x/month 
dropdown 
  
More than 3x/month 
dropdown 
4. What is your job? 
  
text 
For how long have you had this job? (years) 
  
text 
What was/were your previous job(s)? 
  
text 
5. Do you consider your job stressful? 
No 
dropdown 
  
Yes 
dropdown 
Stress level: 
Low stress 
dropdown 
  
Moderately stress 
dropdown 
  
High stress 
dropdown 
  
Extremely stress 
dropdown 
6. Do you perform regular vigorous exercise? 
No 
dropdown 
  
Yes 
dropdown 
Yes - How frequently per week (on average): 
  
text 
What type(s)? 
  
text 

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Family History  
1. Do you have a positive family history of 
infertility? 
Yes 
dropdown 
  
No 
dropdown 
  
Dont know 
dropdown 
Yes - Who? 
  
text 
Cause/problem (if known): 
  
text 
2. Are there any adopted children in your 
family? 
No 
dropdown 
  
Yes 
dropdown 
Yes - Who? 
  
text 
3. Any miscarriages in the immediate family? 
No 
dropdown 
  
Yes 
dropdown 
Yes - Comment (if any): 
  
text 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Male Reproductive Health Questionnaire  
 
1. Married or committed relationship? 
No 
dropdown 
  
Yes 
dropdown 
Yes - Number of years: 
  
text 
2. How many times per week (on average) do you have intercourse? 
text 
3. Have you ever attempted to impregnate your partner? 
No 
dropdown 
  
Yes 
dropdown 
Yes - How many months trying to impregnate your partner? 
string 
Years? 
  
string 
4.  Prior pregnancies between you and your partner? 
No 
dropdown 
  
Yes 
dropdown 
Yes- Number of pregnancies carried to term and delivered: 
Number of miscarriages: 
 
string 
Number of abortions: 
  
string 
5. Have you had prior infertility treatments? 
No 
dropdown 
  
Yes 
dropdown 
Yes - Type: 
  
text 
Method(s) used? 
  
text 
6. Do any of the following concern you:     
...your ability to get an erection? 
No 
dropdown 
  
Yes 
dropdown 
Yes - comment (if any): 
  
text 
...your ability to maintain an erection? 
No 
dropdown 

14-H-0077 
Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
85 | P a g e  
  
Yes 
dropdown 
Yes - Comment (if any): 
  
text 
...ejaculating before your partner is ready? 
No 
dropdown 
  
Yes 
dropdown 
Yes - Comment (if any): 
  
text 
Medical History  
 
Header 
1. Undescended testicles at birth? 
No 
dropdown 
  
Yes 
dropdown 
Yes - Which side? 
Right 
dropdown 
  
Left 
dropdown 
2. Mumps after puberty with painful testes? 
No 
dropdown 
  
Yes 
dropdown 
Yes - Comment (if any): 
  
text 
3. Cancer? 
No 
dropdown 
  
Yes 
dropdown 
Yes - Which year? (YYYY)   
string 
Type: 
  
dropdown 
Treatment: 
  
text 
4.  Neurological Problems? 
No 
dropdown 
  
Yes 
dropdown 
Yes - Type: 
  
text 
Treatment: 
  
text 
5. Infection of the urinary tract? 
No 
dropdown 

14-H-0077 
Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
86 | P a g e  
  
Yes 
dropdown 
Yes - Type: 
  
text 
Treatment: 
  
text 
6. Infection of the prostate (prostatitis)? 
No 
dropdown 
  
Yes 
dropdown 
Yes - Comment (if any): 
  
text 
7. Infection of the epididymis? 
No 
dropdown 
  
Yes 
dropdown 
Yes - Comment (if any): 
  
text 
8.  Sexually transmitted disease? 
No 
dropdown 
  
Yes 
dropdown 
Yes - Type: 
  
text 
Treatment: 
  
text 
9. Do you or did you ever have priapism (painful erections)? 
Yes 
dropdown 
  
No 
dropdown 
Yes - Frequency: 
  
text 
Severity of episodes: 
Mild 
dropdown 
  
Moderate 
dropdown 
  
Severe 
dropdown 
Age at first episode: 
  
text 
Treatment: 
  
text 
Requirement for interventions (e.g. drainage) 
No 
dropdown 
  
Yes 
dropdown 

14-H-0077 
Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
87 | P a g e  
Frequency: 
Once 
dropdown 
  
Less than 3 
times 
dropdown 
  
Three or 
more times 
dropdown 
10. Have you ever taken hydroxyurea? 
No 
dropdown 
  
Yes 
dropdown 
Yes - From when to when? 
  
text 
At what dose? 
  
text 
If you stopped taking the drug what was reason for it? 
  
text 
11. Are you bothered by problems with urination? 
No 
dropdown 
  
Yes 
dropdown 
Yes - Type: 
  
text 
Treatment: 
  
text 
12. Injury to the testicles that needed hospitalization? 
No 
dropdown 
  
Yes 
dropdown 
Yes - Type: 
  
text 
Treatment: 
  
text 
Surgical History 
Header 
1. Hernia operation? 
No 
dropdown 
  
Yes 
dropdown 
Yes - Date/year (if known): (mm/yyyy) 
string 
2. Bladder or penis operation as a child? 
No 
dropdown 
  
Yes 
dropdown 

14-H-0077 
Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
88 | P a g e  
Yes - Date/year (if known): (mm/yyyy) 
string 
3. Pelvic or back surgery? 
No 
dropdown 
  
Yes 
dropdown 
Yes - Date/year (if known): (mm/yyyy) 
string 
4. Testis surgery? 
No 
dropdown 
  
Yes 
dropdown 
Yes - Date\year (if known): (mm/yyyy) 
 
string 
5. Vasectomy? 
No 
dropdown 
  
Yes 
dropdown 
Yes - Date/year (if known): (mm/yyyy) 
string 
6. Infertility surgery? 
No 
dropdown 
  
Yes 
dropdown 
Yes - type 
  
string 
Exposure History  
Header 
1. Do you currently smoke tobacco? 
No 
dropdown 
  
Yes 
dropdown 
Yes - Since how many months 
string 
Years: 
  
string 
How much (per day): 
  
string 
2.  If you quit smoking how long has it been?         
# of months 
string 
# of years 
  
string 
3.  Do you use any of the following:         

14-H-0077 
Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
89 | P a g e  
Alcohol? 
No 
dropdown 
  
Yes 
dropdown 
Consumption 
Less than 2 
drinks/day 
dropdown 
  
More than 
2 
drinks/day 
dropdown 
Marijuana? 
No 
dropdown 
  
Yes 
dropdown 
Frequency: 
Up to 
3x/month 
dropdown 
  
More than 
3x/month 
dropdown 
Other types of recreational drugs? 
No 
dropdown 
  
Yes 
dropdown 
Yes - Type: 
  
text 
Frequency: 
Up to 
3x/month 
dropdown 
  
More than 
3x/month 
dropdown 
4. What is your job? 
text 
For how long have you had this job? (years) 
string 
What was/were your previous job(s)? 
  
text 
5. Do you consider your job stressful? 
No 
dropdown 
  
Yes 
dropdown 
Yes - Stress level: 
Low stress 
dropdown 

14-H-0077 
Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
90 | P a g e  
  
Moderately 
stress 
dropdown 
  
High stress 
dropdown 
  
Extremely 
stress 
dropdown 
6. Are there any radiation or harmful chemical(s) used on the job? 
No 
dropdown 
  
Yes 
dropdown 
Yes - type: 
  
text 
Length of exposure: 
  
text 
7. Any exposure to prolonged heat in work / hobbies? 
No 
dropdown 
  
Yes 
dropdown 
Yes - Type: 
  
text 
Length of exposure: 
  
text 
ENDOCRINE HISTORY / REVIEW OF SYSTEMS 
Have you ever ben told (or know) that you have any of following: 
1. Difficulty with smell? 
No 
dropdown 
  
Yes 
dropdown 
Yes - Comment (if any): 
  
text 
2. Difficulty with vision (besides needing glasses)? 
No 
dropdown 
  
Yes 
dropdown 
Yes - Comment (if any): 
  
text 
3. Problems with growth when you were young? 
No 
dropdown 
  
Yes 
dropdown 
Yes - Comment (if any): 
  
text 

14-H-0077 
Matthew Hsieh, M.D. 
February 13, 2024 (Amendment DD) 
 
91 | P a g e  
4. Did your voice change later than your friends? 
No 
dropdown 
  
Yes 
dropdown 
Yes - Comment (if any): 
  
text 
5. Any tenderness to your breasts? 
No 
dropdown 
  
Yes 
dropdown 
Yes - Comment (if any): 
  
text 
Family History  
 
Header 
1. Do you have a positive family history of infertility? 
Yes 
dropdown 
  
No 
dropdown 
  
Dont know 
dropdown 
Yes - Who? 
  
text 
Cause/problem (if known): 
text 
2. Are there any adopted children in your family? 
No 
dropdown 
  
Yes 
dropdown 
Yes - Who? 
  
text 
3. Any miscarriages in the immediate family? 
No 
dropdown 
  
Yes 
dropdown 
Yes - Comment (if any): 
  
text 
4. Did your mother ever take DES (diethylstilbesterol)? 
No 
dropdown 
  
Yes 
dropdown 
  
Dont know 
dropdown