Safety and Efficacy of CD19 Chimeric Antigen Receptor T-Cell Immunotherapy (CAR-T) in the Treatment of Refractory Membranous Nephropathy
Phase: PHASE1
Conditions: Refractory Membranous Nephropathy
Sponsor: The First Affiliated Hospital of Air Force Medicial University

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Project Source and Number：
A Study of the Safety and Efficacy of Chimeric Antigen
Receptor T-Cell Immunotherapy (CAR-T) in Patients with
Refractory Membranous Nephropathy
Principal Investigator: He Lijie
Responsible Department: Department of Nephrology
Contact Phone: 029-89661611
Undertaking Institution: The First Affiliated Hospital of Air Force
Medical University
Study Period: August 1, 2025 - July 31, 2028
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Table of Contents
Project Summary
1.Background ..................................................................................................错误！未定义书签。
2.Research objectives...................................................................................... 错误！未定义书签。
3.Research design............................................................................................ 错误！未定义书签。
4.Study population.......................................................................................... 错误！未定义书签。
4.1 Inclusion Criteria....................................................................................................
11
4.2 Exclusion Criteria.........................................................................................................14
4.3 Criteria for Terminating the Study............................................................................... 16
5.Research Methods and Technical Route.......................................................................
17
5.1 Intervention Measures ................................................................................................17
5.2 Sample Size Determination..........................................................................................21
5.3 Data Collection and Follow-up....................................................................................21
5.3.1 Collected Data ...................................................................................................21
5.3.2 Data Integrity ......................................................................................................26
5.4 Technical Route Chart
...............................................................................................27
6.Observation Items and Testing Time Points .................................................................. 27
6.1 Primary Endpoints........................................................................................................27
6.1.1 Dose-Limiting Toxicity (DLT) .............................................................................27
6.1.2 Adverse Events (AE) ............................................................................................29
6.2 Secondary Endpoints....................................................................................................30
6.2.1 Remission or Relapse of Refractory Membranous Nephropathy (rMN)
............31

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6.2.2 Renal Function, Immune Characteristics and Dynamic Changes of Cells............ 32
6.2.3 Testing Time Points ...............................................................................................32
7.Observation and Management of Adverse Events...........................................................34
7.1 Lymphodepletion Phase............................................................................................... 34
7.2 After CAR-T Cell Infusion...........................................................................................35
7.2.1 Cytokine Release Syndrome (CRS).................................................................. 36
7.2.2 Immune Effector Cell-Associated Neurotoxicity Syndrome (ICANS) ............ 38
7.2.3 Immune Effector Cell-Associated Hemophagocytic Lymphohistiocytosis-Like
Syndrome (IEC-HS) .................................................................................................. 41
7.2.4 CAR-T Associated Coagulopathy (CARAC) ....................................................44
7.2.5 Immune Effector Cell-Associated Hematotoxicity (ICAHT) ........................... 46
7.2.6 B-Cell Aplasia/Hypogammaglobulinemia.................................. 错误！未定义书签。
7.2.7 Infection....................................................................................... 错误！未定义书签。
7.2.8 Allergic Reaction.................................................................................................55
7.2.9 Abnormal Proliferation of CAR-T Cells.............................................................56
8.Quality Control and Quality Assurance of the Study......................................................57
9.Statistical Analysis...............................................................................................................57
10.Ethical and legal aspects...................................................................................................58
11.Study Schedule............................................................................................错误！未定义书签。
12.References list.....................................................................................................................59

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Project
Summary
Project
Safety and Efficacy of Chimeric Antigen Receptor T-Cell
Immunotherapy
(CAR-T)in
the
Treatment
of
Refractory
Membranous Nephropathy
Objectives
To preliminarily evaluate the safety and efficacy of CD19
CAR-T in refractory membranous nephropathy (rMN), with the
aim of providing new insights for optimizing the treatment and
management of the disease.
Study Design
This study is a single-center, prospective, exploratory Phase I
clinical trial initiated by the team led by Associate Professor He
Lijie from the Department of Nephrology, Xijing Hospital.
Prior to receiving CAR-T cell therapy, patients will undergo
lymphodepletion
chemotherapy
with
cyclophosphamide
(fludarabine will be added if necessary). After prophylactic
administration of antihistamines and acetaminophen, patients
will be infused with CD19 CAR-T cells at a dose of 1 × 10⁶
cells/kg.
In the subsequent 2 weeks, patients will be hospitalized for
monitoring of vital signs and adverse reactions. The planned
follow-up duration of this study is 1 years.
Total Number
of Cases
5
Case Selection
Inclusion Criteria:
（1）Confirmed
diagnosis
of
primary
membranous

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nephropathy (PMN) by renal biopsy;
（2）Refractory membranous nephropathy (rMN) with
moderate or high risk;
（3）Patients aged ≥18 years;
（4）Estimated glomerular filtration rate (eGFR) ≥
30
ml/min/1.73m ² , without severe cardiac, hepatic, or
pulmonary dysfunction;
（5）Signed written informed consent form.
Exclusion Criteria:
（1）Secondary membranous nephropathy;
（2）Active bacterial, fungal, or viral (excluding common
cold/flu) infections requiring intravenous antibiotic treatment, or
active pulmonary tuberculosis, or positive serology for hepatitis
B
virus
(HBV),
hepatitis
C
virus
(HCV),
human
immunodeficiency virus (HIV), Treponema pallidum (TP),
Epstein-Barr virus (EBV), or cytomegalovirus (CMV)；
（3）Severe comorbidities or underlying diseases;
（4）History of malignant tumors;
（5）Exclusion based on treatment history: meeting any of
the following criteria:a. Previous receipt of any cell therapy
(e.g., mesenchymal stem cells, etc.);b. Receipt of major surgery
within 24 weeks prior to enrollment, or planned surgery within
24 weeks after enrollment;c. Planned kidney transplantation
within 3 years;d. History of substance abuse;

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（6）Participation in other interventional clinical trials
within 3 months prior to enrollment;
（7）Pregnant or lactating women;
（8）Inability to understand the study or provide informed
consent (e.g., severe dementia, psychiatric disorders);
（9）Any other conditions that the investigator deems may
increase risks, interfere with evaluation, or affect compliance.
Interventions
The main intervention measures received include peripheral
blood mononuclear cell (PBMC) collection, lymphodepleting
chemotherapy, and autologous CAR-T cell infusion.
Assessment
Primary endpoint: Safety evaluation, with the type and incidence
of dose-limiting toxicity (DLT) and adverse events (AE) after a
single CAR-T infusion as the evaluation indicators.
Secondary Endpoints: Efficacy Assessment ：①Remission or
relapse of rMN (renal Membranous Nephropathy). This includes
the proportion of subjects who maintain complete remission or
partial remission after cell infusion, the duration of remission,
and the occurrence of relapse.②Changes in renal function,
immune
characteristics,
and
cellular
dynamics,
including
changes in proteinuria, eGFR (estimated Glomerular Filtration
Rate),
serum
anti-PLA2R
(Phospholipase
A2
Receptor)
antibodies,
infection
markers,
complement
levels,
immunoglobulin levels, cytokine levels, changes in peripheral
blood immune cell subsets, and the expression level of CD19 on
the surface of peripheral blood B cell subsets.

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Statistical
Methods
All statistical analyses will not account for cases such as poor
subject
compliance,
premature
withdrawal,
or
loss
to
follow-up.Due to the small sample size of this study, all data will
be presented as individual values.The study will use descriptive
statistical methods to report specific parameters during the
baseline and follow-up periods.Statistical analyses and data
visualization
will
be
performed
using
SPSS
Version
27.0 and GraphPad Prism Version 9.0.
Study Duration
August 2025 – July 2028

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1. Background
Primary Membranous Nephropathy (PMN) is an autoimmune
disease mediated by pathogenic antibodies produced by autoreactive B
lymphocytes. These antibodies reach the kidneys through the bloodstream
and bind to specific antigens on the glomerular basement membrane to
form in-situ immune complexes. These complexes then trigger a series of
pathological effects, ultimately leading to glomerular podocyte damage
and massive proteinuria [1].Currently, the global incidence of PMN is
approximately 8-10 cases per million people [2], while the incidence rate
reported in China is 23.4% [3]. The specific etiology of PMN remains
unknown, and the remaining cases are associated with drug use or
underlying diseases such as systemic lupus erythematosus, hepatitis B
virus infection, or malignant tumors.Although approximately one-third of
patients may achieve spontaneous complete or partial remission through
conservative treatment, another one-third of patients face an increased
risk of disease progression, which may lead to end-stage renal disease
within 10 years [4].
Over the past decade, significant progress has been made in research
on the pathogenesis and therapeutic strategies of primary membranous
nephropathy (PMN).More than ten target antigens associated with PMN
have been identified so far, among which approximately 70% of cases are
mediated by antibodies against phospholipase A2 receptor (PLA2R) [5].

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Targeting the core pathological process of antibody production, the
current main therapeutic strategy is to selectively eliminate B cells that
produce autoantibodies and their terminally differentiated plasma cells
[6].Anti-CD20 monoclonal antibodies, represented by Rituximab (RTX),
are currently widely used targeted drugs in the clinical treatment of PMN.
Their mechanism of action involves specific binding to the CD20 protein
on the surface of B cells, thereby eliminating B cells. Although RTX and
similar agents are considered safe and effective for PMN patients, their
efficacy is still limited—about 30% of patients show no response. This
insufficient response may be attributed to high titers of anti-PLA2R
antibodies [7].In addition, some patients may develop anti-drug antibodies
after receiving RTX treatment, which can also lead to accelerated drug
clearance, reduced efficacy (drug resistance), or disease recurrence [8].
Patients with such refractory membranous nephropathy (rMN) — i.e.,
those non-responsive to RTX treatment (manifested as long-term
unresolved
proteinuria) — have
a
significantly
increased
risk
of
progressing to end-stage renal disease (ESRD) [9, 10].These patients are
defined by the following characteristics:Positive anti-PLA2R antibodies
at diagnosis, with persistently high or no significant changes in
anti-PLA2R antibody titers after receiving adequate and full-course
first-line immunosuppressive therapy;Persistently negative anti-PLA2R
antibodies, but with unresolved nephrotic syndrome for more than 6

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months
despite
continuous
first-line
immunosuppressive
therapy.Therefore, it is necessary to explore alternative therapies with
better efficacy.
Chimeric Antigen Receptor T-cell (CAR-T)
therapy involves
isolating mononuclear cells from peripheral blood via leukapheresis,
followed by genetic engineering in vitro to express chimeric antigen
receptors. Therefore, CAR-T cells can recognize specific antigens on
target cells without the need for antigen processing and presentation.
Once genetically modified, CAR-T cells undergo extensive proliferation
in vitro; after lymphodepletion chemotherapy, these cells are reinfused
into the patient's body. A key advantage of this therapy is that the body
develops long-lived memory CAR-T cells, which can provide sustained
efficacy against newly generated target cells without the need for
repeated administration [11].
Due to the targeted effect of CAR-T therapy, its clinical application
has gradually become widespread, and it has also shown promising
application prospects in autoimmune diseases, including kidney diseases.
In August 2021, the first case report was published about a patient with
severe Systemic Lupus Erythematosus (SLE) who received CD19 CAR-T
cell therapy and achieved favorable therapeutic effects [12]. Subsequently,
in September 2022, the same research team reported another 5 cases of
refractory SLE patients treated with CD19 CAR-T cells. All patients

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experienced disease improvement, with lupus nephritis achieving clinical
cure, and serum complement as well as double-stranded DNA antibodies
returning to normal levels [13]. In February 2024, the team published the
research results on CD19 CAR-T therapy for autoimmune diseases. This
study enrolled 15 patients with autoimmune diseases, including 8 SLE
patients, 4 systemic sclerosis patients, and 3 idiopathic myositis patients.
These patients had signs of active organ involvement, had failed at least
two immunotherapy regimens, and their diseases were severe with
life-threatening potential. After 15 months of follow-up post-CAR-T
therapy, all 8 SLE patients achieved disease remission, the disease
activity index of the 4 systemic sclerosis patients decreased, and the
disease of idiopathic myositis patients was also well-controlled [14].
In the treatment of autoimmune diseases, the adverse reactions of
CAR-T therapy are consistent with those in hematological malignancies.
The most prominent one is cytokine release syndrome (CRS), while other
potential
side
effects
include:
immune
effector
cell-associated
neurotoxicity
syndrome
(ICANS),
immune
effector
cell-associated
hemophagocytic
lymphohistiocytosis-like
syndrome
(IEC-HS),
CAR-T-associated
coagulopathy
(CARAC),
immune
effector
cell-associated
hematotoxicity
(ICAHT),
B-cell
deficiency
or
hypogammaglobulinemia, and infections [15].Existing studies have shown
that the incidence of acute toxic reactions induced by CAR-T cell therapy

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is low and the severity is mild, with favorable short-term safety.
Particularly, it exhibits excellent tolerability in autoimmune diseases. The
main risks are mild CRS and manageable infections, and there have been
no treatment-related deaths or severe complications (e.g., no cases of
disseminated intravascular coagulation, multiple organ failure, or the
need for ventilator support) [13, 14, 16-18].In conclusion, the results from
small-sample clinical studies of CAR-T cell therapy in autoimmune
diseases conducted in the early stage indicate that this therapy holds
broad application prospects in the treatment of autoimmune diseases.
Potential targets for MN antigen-specific therapeutic regimens
include
autoantibody
production,
antibody-antigen
interaction,
and
immune-mediated podocyte injury
[19]. In rMN, impeding antibody
production is clearly of key significance. CAR-T cell therapy is a
promising strategy that can not only eliminate specific pathogenic
antigens and their epitopes (e.g., CD19+B cells) but also induce the
generation of memory CAR-T cells in vivo, enabling the potential for
long-term and sustained clearance [20].Therefore, the objective of our
study is to preliminarily evaluate the safety and efficacy of CD19 CAR-T
therapy in rMN through a prospective, small-sample clinical trial, with
the aim of providing a better therapeutic strategy for rMN.
2. Research Objectives
Currently,
rMN
patients
who
do
not
respond
to
first-line

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immunotherapy or targeted therapy have a significantly increased risk of
progressing to end-stage renal disease. Therefore, there is still a need to
further explore effective treatment methods for rMN. The achievements
of CAR-T cells in clinical research on autoimmune diseases suggest that
they may have good potential and application prospects in rMN. Thus,
the objective of our study is to preliminarily explore the safety and
efficacy of CAR-T therapy in rMN through a prospective, small-sample
clinical trial, aiming to provide a better treatment strategy for rMN.
3. Study Design
Patients will undergo peripheral blood mononuclear cell (PBMC)
collection 1-4 weeks prior to autologous CAR-T cell therapy. Shaanxi
Yisaier Biotechnology Co., Ltd will be responsible for cell sorting and
purification, T cell activation, CAR gene transduction, and in vitro
expansion of CAR-T cells. After undergoing washing, formulation,
cryopreservation, testing, and release procedures, the cells will be
transported via cold chain to the laminar air flow ward for intravenous
infusion.All patients will receive lymphodepleting chemotherapy 3-7
days before CAR-T cell therapy to reconstitute the immune environment.
The preferred regimen is cyclophosphamide (CTX) 400 mg/day for two
consecutive days. On the third day, the degree of peripheral blood
lymphocyte depletion will be assessed. If the depletion effect is
unsatisfactory, fludarabine (Flu) 25 mg/m²/day will be administered for

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1-2 days. CD19 CAR-T cells (1×10⁶/kg) will be infused more than 2
days after lymphodepleting chemotherapy. Before intravenous cell
infusion, prophylactic antihistamines (such as chlorpheniramine or
diphenhydramine) and acetaminophen will be administered.All patients
will be hospitalized in the laminar air flow ward for at least 10 days of
observation. For patients with severe adverse events such as grade 3 or
higher cytokine release syndrome (CRS), the observation period will be
extended to 14 days. The planned follow-up period for the entire study is
1 year, and long-term follow-up will continue after the study concludes.
During the study, the enrollment interval between each subject will
be no less than 28 days.
4. Study population
4.1 Inclusion Criteria
1) Confirmed as primary membranous nephropathy (PMN) by
renal biopsy;
2) Moderate-risk or high-risk rMN;
a.
Definition of moderate risk: eGFR ≥90 ml/min/1.73m²,
24-hour urinary protein > 3.5g/d, and the reduction in
urinary protein is no more than 50% within 6 months of
receiving renin-angiotensin system inhibitors (RASi);
b. Definition of high risk: eGFR < 60 ml/min/1.73m² and/or
persistent proteinuria > 8g/d for more than 6 months; or

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normal eGFR with proteinuria > 3.5g/d, and the reduction
in urinary protein is no more than 50% within 6 months of
receiving RASi, and at least one of the following
conditions is met:
Serum albumin < 25g/L
PLA2Rab>50 RU/mI，
Urinary α1-microglobulin > 40 μg/min
Urinary IgG > 1 μg/min，
Urinary β2-microglobulin > 250 mg/d
Screening
coefficient
(IgG
clearance/albumin
clearance) > 0.20;
c.
Definition
of
rMN:
After
receiving
adequate
and
full-course
(
≥
6
months)
standard
first-line
immunosuppressive therapy (including but not limited to:
glucocorticoid
+
cyclophosphamide
(CTX)
regimen,
calcineurin inhibitor [CNI], or rituximab (RTX)), any of
the following conditions is met:
Anti-PLA2R antibody remains persistently positive
with high titer or shows no significant decrease.
For patients with negative anti-PLA2R antibody,
they continuously present with nephrotic syndrome
(24-hour urinary protein > 3.5g, serum albumin <

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30g/L);
24-hour urinary protein reduction < 50%
3) Patients aged ≥18 years;
4) Key organ functions meet the following requirements:
Renal function: eGFR≥30 ml/min/1.73m²；
Hepatic function: ALT and AST ≤2.5×upper limit
of normal (ULN), total bilirubin ≤1.5×ULN;
Cardiac function: Left ventricular ejection fraction
(LVEF) ≥50%;
heart
failure
with
NYHA
functional class Ⅰor Ⅱ; no clinically significant
arrhythmias requiring intervention (e.g., ventricular
tachycardia,
ventricular
[atrial]
fibrillation,
third-degree atrioventricular block, etc.). No acute
coronary syndrome, stroke, aortic dissection, or
other cardiovascular and cerebrovascular events
within the past 6 months.
Respiratory function: Pulse oxygen saturation >
92% in a non-oxygen-dependent state.
5) Have a full understanding of the study's purpose, risks, and
benefits, voluntarily participate in the study, and sign a written
informed consent form (by the patient themselves and their
legal guardian, if applicable).

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4.2.Exclusion Criteria
1) Secondary membranous nephropathy (e.g., caused by SLE,
tumors, drugs, infections, etc.);
2) Active
bacterial,
fungal,
or
viral
(excluding
common
cold/influenza) infections requiring intravenous antibiotic
treatment; active pulmonary tuberculosis; or positive viral
serology, meeting any of the following criteria:
HBsAg (+) and/or HBcAb (+) with HBV DNA >
lower limit of detection;
HCV Ab (+) and HCV RNA (+);
HIV Ab (+)；
Active EBV/CMV infection: EBV IgM (+) or
EBV-DNA > normal value; CMV IgM (+) or
CMV-DNA > normal value;
Treponema pallidum (TP) antibody positive (active
infection needs to be evaluated).
3) Severe
comorbidities/underlying
diseases,
such
as:
uncontrolled hypertension (e.g., persistent systolic blood
pressure > 160 mmHg or diastolic blood pressure > 100
mmHg); uncontrolled diabetes mellitus (HbA1c > 8% or
random
blood
glucose
≥11.1
mmol/L)
or
diabetic
nephropathy; history of symptomatic deep vein thrombosis or

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pulmonary embolism within the past 6 months; history of
active peptic ulcer and/or gastrointestinal bleeding within the
past
6
months;
congenital
or
acquired
severe
immunodeficiency (e.g., HIV, primary immunodeficiency
diseases); severe central nervous system diseases (e.g.,
catastrophic
antiphospholipid
syndrome,
uncontrolled
epilepsy); or end-stage organ failure not caused by PMN;
4) History of malignant tumors: A history of malignant tumors
within
5
years,
except
for
cured
basal/squamous
cell
carcinoma of the skin, cervical carcinoma in situ, and thyroid
cancer;
5) Exclusion based on treatment history, meeting any of the
following criteria:
Previous
receipt
of
any
cell
therapy
(e.g.,
mesenchymal stem cell therapy, hematopoietic
stem cell transplantation, etc.)
Having undergone major surgery within 24 weeks
before enrollment, or planning to undergo surgery
within 24 weeks after enrollment;
Planning to undergo kidney transplantation within 3
years;
History of substance abuse

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6) Having participated in other interventional clinical trials
within 3 months before enrollment;
7) Pregnant or lactating women
8) Inability to understand the study or provide informed consent
(e.g., severe severe severe dementia, mental illness);
9) Any conditions that, in the investigator's judgment, may
increase
risks,
interfere
with
assessments,
or
affect
compliance.
4.3.Criteria for Termination of the Study
Criteria for withdrawal of study subjects include:
1) Safety events: Occurrence of severe adverse events (SAEs)
related
to
study
treatment
(e.g.,
lymphodepleting
chemotherapy, CAR-T infusion) or intolerable toxicity, where
the investigator determines that permanent discontinuation of
treatment is necessary;
2) Subject's willingness: The subject or their legal guardian
voluntarily requests to withdraw from the study;
3) Loss to follow-up or death of the subject.
4) Occurrence of severe complications unrelated to PMN (e.g.,
newly developed malignant tumors, severe infections) that
require priority management.
5) Acute deterioration of PMN condition (e.g., acute kidney

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injury requiring dialysis), where the investigator determines
that continuation of the trial is inappropriate.
6) The investigator judges that continuing the study is not in the
subject's
best
interest
(e.g.,
ineffective
treatment
with
increased risks) or that major protocol violations affect the
assessment of primary endpoints.
7) Request for termination of the study by regulatory authorities
or ethics committees.
Post-withdrawal management: The reasons for withdrawal, date, and
details of the last treatment should be documented thoroughly. Standard
treatment should be provided, and safety and efficacy should be followed
up continuously (unless refused by the subject). Collected data will be
used for statistical analysis under the premise of ethical compliance.
5.Research Methods and Technical Roadmap
5.1Intervention Measures
All patients will receive CD19 CAR-T cell therapy on the basis of
standard symptomatic and supportive treatment.
（1）Symptomatic and supportive treatment
All patients will receive conservative treatment at the maximum
tolerable level, mainly including:
①Drugs for blood pressure control and renal function protection,
including but not limited to: renin-angiotensin-aldosterone system

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inhibitors (RAASi), other first-line antihypertensive drugs (e.g., diuretics,
β -blockers, CCBs, α -blockers, or centrally acting agents, etc.), and
sodium-glucose cotransporter 2 inhibitors (SGLT-2i);
②Lipid-regulating drugs, including but not limited to: statins,
fibrates, ezetimibe, and PCSK9 inhibitors, etc.;
③Uric acid-lowering drugs, including but not limited to: febuxostat,
allopurinol, etc.;
④Calcium and phosphorus metabolism regulators, including but not
limited to: calcium supplements, calcitriol, etc.;
⑤Anti-anemic drugs, including but not limited to: iron supplements,
folic acid, etc.;
⑥Other necessary non-immunosuppressive or regulatory drugs.
（2）CD19 CAR-T cell therapy
All patients will receive a single dose of 1×10⁶/kg autologous
CD19 CAR-T cell therapy, with the main procedures as follows:
①Peripheral blood mononuclear cell collection: Blood from patients
will be collected using a blood component separator to isolate T
cell-containing blood. The expected volume of collected blood is 120 ml,
with a minimum of no less than 50 ml. During the collection process, the
blood flow rate will be set at 50–70 ml/min; if necessary, the collection
personnel will adjust the rate based on actual collection conditions, and
the collection time is expected to be 2–4 hours.

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②Lymphodepleting chemotherapy: The study will adopt the CTX±
Flu regimen. After a comprehensive assessment of the patient's condition
to confirm tolerance to lymphodepleting chemotherapy, CTX 400 mg/day
will be administered intravenously for two consecutive days, with a total
dose of 800 mg. On the third day, the degree of peripheral blood
lymphocyte
depletion
will
be
tested;
if
the
depletion
effect
is
unsatisfactory, Flu 25 mg/m²/day will be added for 1–2 days.
③
Infusion
of
autologous
CD19
CAR-T
cell
injection:
Acetaminophen derivatives and antihistamines (e.g., chlorpheniramine or
diphenhydramine) will be administered 30–60 minutes before infusion.
The CD19 CAR-T cell injection will be infused intravenously using a
non-filtered infusion tube to prevent loss of effective cellular components,
which could reduce efficacy. The infusion procedure is as follows:
flushing with 100 ml normal saline →cell infusion →flushing with
100 ml normal saline. The infusion rate will be controlled at 2–3 ml/min
for the first 15 minutes to ensure patient tolerance; if no adverse reactions
occur,
the
rate
can
be
adjusted
to
5 – 10
ml/min.

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Figure 1 Main Interventions and Procedures of the Study
Table 1 Research Process Schedule

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5.2Sample Size Determination
This study is a phase I clinical exploratory trial, with a preliminary
plan to enroll 5 patients with rMN.
5.3Data Collection and Follow-up
5.3.1 Collected data
All subjects are required to complete the collection of data and
Stage
Time
Key Activities
Assessment Focus
Patient Screening
-6~-4w
Medical history review,
laboratory tests, imaging
examinations
Meet the criteria for refractory MN,
organ function up to standard
Cell Preparation
-4~-1w
Patient assessment,
leukapheresis, CAR-T
modification, expansion, and
quality inspection
Cell viability and safety compliance
Lymphodepleting
Pretreatment
-7~-3d
Cyclophosphamide ±
Fludarabine regimen
Lymphocyte depletion, infection
prevention
CAR-T Infusion
Day 0
Intravenous infusion of CAR-T
cells
Infusion reaction monitoring
In-hospital
Monitoring
d0-d14
CRS/ICANS management,
infection prevention, early
efficacy assessment
Acute event control, B-cell
depletion
Intensive
Follow-up
≤3m
Monthly clinical assessment,
laboratory tests
Renal response, immune indicators
Medium- and
Long-term
Follow-up
3~12m
Regular comprehensive
assessment, immune
reconstitution monitoring
Drug-free remission status,
recurrence signs
Extended
Follow-up
>12m
Recurrence rate, long-term side
effect tracking
Long-term safety, quality of life

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information such as signing of the informed consent form, medical
history
information,
physical
examination,
electrocardiogram/echocardiography, renal assessment,
routine tests,
concomitant medication records, and endpoint outcome assessment at
different study stages (Table 2). Such data and information include but
are not limited to:
1 Demographic data: including name, gender, date of birth, ethnicity,
education level, occupation, marital status, current address, and
contact information.
2 Concomitant medication records: mainly including the usage of
drugs related to blood pressure lowering, lipid regulation, blood
glucose lowering, immunomodulation, adjuvant therapy, and
vaccination, etc.
3 Vital signs: mainly including heart rate, blood pressure, body
temperature, etc.
Table 2. Schedule of Study Activities and Assessments
Plan
Screenin
g Period
CAR-T
Preparat
ion
Period
Baseline
Period
In-hospit
al
Follow-u
p Period
Intensive
Follow-u
p Period
Medium-
and
Long-ter
m
Follow-u
p
Follow-
up at
Study
Complet
ion
Follow-up after
Study
Completion
(Extended
Follow-up)
Time
-6 to -4w
-4 to -1w
-2d to d0
d0 to d14
≤3m
3 to 12m
12y
>12m
Informed Consent
×
Inclusion and
Exclusion Criteria
×
Demographic
×

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Data
Past Medical
History
×
Medication
History
×
Concomitant
Medications
×
×
×
×
×
×
×
×
Physical
Examination
×
×
×
×
Weight, Height
×
×
×
×
×
×
Vital Signs
×
×
×
×
×
×
×
×
Electrocardiogra
m/Echocardiogra
phy
×
×
Renal Ultrasound
×
Laboratory Tests
×
×
×
×
×
×
×
Endpoint
Assessment
×
×
×
×
×
AE Assessment
×
×
×
×
×
Study Procedures and Follow-up Plan
1
Screening phase: Potential subjects will be screened according
to the inclusion and exclusion criteria. Eligible subjects (or their legal
representatives) will sign the informed consent form. Data including
demographic information, past medical history, medication history,
concomitant medications, physical examination results, and vital signs
will be collected. A 12-lead electrocardiogram, echocardiography, and
renal ultrasound will be performed. Routine tests (blood, urine, and stool),
liver and kidney function, blood lipids, blood glucose, electrolytes,
coagulation function, anti-PLA2R antibodies, infection screening (HBV,
HCV, syphilis, HIV, EBV, CMV, etc.), urine microalbumin/creatinine

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ratio (UACR), and urine protein quantification will be completed.
2
CAR-T
preparation
phase:
Data
such
as
concomitant
medications, physical examination results, and vital signs will be
recorded. Routine tests (blood, urine, and stool), liver and kidney function,
blood lipids, electrolytes, coagulation function, and infection screening
(HBV, HCV, syphilis, HIV, EBV, CMV, etc.) will be completed.
3
Baseline phase: Data including concomitant medications,
physical examination results, and vital signs will be recorded. Laboratory
tests will be performed, including routine tests (blood, urine, and stool),
liver and kidney function, blood lipids, blood glucose, electrolytes,
coagulation function, C-reactive protein (CRP), procalcitonin (PCT),
anti-PLA2R
antibodies,
ferritin,
complements,
immunoglobulins,
cytokines, peripheral blood lymphocyte subsets, peripheral blood CD19 B
cells,
UACR,
and
24-hour
urine
protein
quantification.
An
electrocardiogram will also be conducted.
4
In-hospital follow-up phase: Data such as concomitant
medications, physical examination results, and vital signs will be
recorded. Laboratory tests will be completed, including routine tests
(blood, urine, and stool), liver and kidney function, electrolytes,
coagulation
function,
CRP,
PCT,
anti-PLA2R
antibodies,
ferritin,
complements, immunoglobulins, cytokines, peripheral blood lymphocyte
subsets, peripheral blood CD19 B cell expression, CAR copy parameters,

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UACR, and 24-hour urine protein quantification.
5
Intensive follow-up phase: A total of 3 follow-ups are planned.
The first post-discharge follow-up (Follow-up 1) will be conducted on
Day 28 after infusion. Laboratory tests will include routine blood and
urine tests, liver and kidney function, coagulation function, CRP, PCT,
anti-PLA2R
antibodies,
ferritin,
complements,
immunoglobulins,
cytokines, peripheral blood lymphocyte subsets, UACR, and 24-hour
urine protein quantification. The second and third follow-ups (Follow-up
2 and 3) will be conducted at Month 2 and Month 3 after treatment,
respectively. Planned laboratory tests include routine blood and urine
tests, liver and kidney function, anti-PLA2R antibodies, complements,
immunoglobulins, peripheral blood lymphocyte subsets, peripheral blood
CD19 B cell expression, CAR copy parameters, UACR, and 24-hour
urine protein quantification. Data such as concomitant medications and
vital signs will also be recorded at each follow-up.
6
Medium- and long-term follow-up phase: From Month 3 to
Month 12 after treatment, follow-ups will be conducted every 3 months,
totaling 3 planned follow-ups: Follow-up 4 (Month 6 after treatment),
Follow-up 5 (Month 9 after treatment), and Follow-up 6 (Month 12 after
treatment), with Follow-up 6 also serving as the study completion
follow-up. At each follow-up, laboratory tests will include routine blood
and urine tests, liver and kidney function, anti-PLA2R antibodies,

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complements, immunoglobulins, CAR copy parameters, UACR, and
24-hour urine protein quantification. Follow-up 4 will additionally
include tests for peripheral blood lymphocyte subsets and peripheral
blood CD19 B cell expression. Data such as concomitant medications and
vital signs will be recorded at each follow-up.
7
Extended follow-up phase: This phase is a post-study
follow-up with no strict scheduled plan. Patients are advised to undergo
necessary laboratory and imaging tests at our center or local medical
institutions every 3 to 6 months on their own initiative. The research team
will continuously follow up on the patient’s basic vital signs and disease
changes via phone calls, text messages, WeChat, etc.
5.3.2Data Integrity
1 Data Collection for Routine Clinical Visits
This study will use paper-based Case Report Forms (CRFs) for data
collection,
the
Epidata
database
for
data
management,
and
the
double-entry comparison method for data entry and verification, with
corresponding data validation and cleaning conducted. During the study
period, researchers will, in principle, review the trial data once a month to
ensure internal consistency.
2 Sending Reminder Messages to Subjects
Automated reminder messages will be sent to subjects in advance
via WeChat groups, text messages, or phone calls to minimize sample

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loss caused by loss to follow-up and/or withdrawal.
5.4Technical Route Chart
Figure 2 Technical Roadmap
6.Observation Items and Testing Time Points
6.1Primary Observation Endpoints
Safety is defined as the primary evaluation index of the study,
including the type and incidence of dose-limiting toxicity (DLT) within
28 days and 3 months after a single CAR-T infusion, as well as the type
and incidence of adverse events (AEs) within 12 months.
6.1.1Dose-Limiting Toxicity (DLT)
1
Definition: The DLT evaluated in this study is assessed within
two time windows: 28 days (Day 0 to Day 28) and 3 months (Day 28 to
Month 3) after CAR-T cell infusion. These time windows are selected
based on the typical timeline of CAR-T cell expansion, activity, and

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potential occurrence of major toxicities in vivo.
The determination of DLT must meet all the following criteria:

DLT must be an adverse event judged by the investigator as
probably or definitely related to CAR-T cell infusion, and cannot
be attributed to underlying diseases, comorbidities, or toxicities
from concomitant medications;

The adverse event must reach a severity grade of ≥Grade 3 (per
CTCAE v5.0) or ≥Grade 3 specific toxicity grading criteria
(e.g., IEC-HS grading).
2
For AEs occurring within 28 days and 3 months, DLT is
defined if any of the following conditions are met:

Uncontrolled Grade 3 or ≥Grade 4 cytokine release syndrome
(CRS);

Uncontrolled Grade 3 or ≥Grade 4 immune effector
cell-associated neurotoxicity syndrome (ICANS);

Death caused by CRS or ICANS of any grade;

Any ≥Grade 3 non-hematological toxicity, including but not
limited to: Grade 3 or higher cardiac toxicity (myocarditis, heart
failure), pulmonary toxicity (acute respiratory distress syndrome),
hepatotoxicity, nephrotoxicity (acute kidney injury), allergic
reactions, etc.;

Persistent ≥Grade 4 cytopenia lasting more than 28 days,

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excluding other causes such as disease progression or bone
marrow involvement. Examples include: white blood cells (WBC)
< 1.0×10⁹/L; neutrophils (NEU) < 0.5×10⁹/L, etc.;

Any fatal adverse event related to CAR-T therapy;

Any CAR-T-related ≥Grade 3 toxicity that cannot resolve or be
controlled within 28 days;

Any other severe toxicity deemed clinically significant by the
investigator or sponsor, which would be sufficient to limit dose
escalation in the future.
3
Toxicities that are expected in the study and easily manageable
(even if reaching Grade 3 or higher) will not be defined as DLT. Excluded
toxic events include:

Controlled Grade 3 CRS: effectively controlled and reduced to ≤
Grade 2 within 72 hours with standard supportive therapy
(tocilizumab and/or corticosteroids);

Controlled Grade 3 ICANS: effectively controlled and reduced to
≤Grade 2 within 72 hours with standard supportive therapy
(corticosteroids);

Transient and easily manageable laboratory abnormalities that
resolve or are effectively controlled to ≤Grade 2 within 28 days
after treatment, such as transient Grade 3 cytopenia.
6.1.2 Adverse Events (AEs)

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Severity grading is based on the Common Terminology Criteria for
Adverse Events (CTCAE) v5.0:
Grade 1: Mild; asymptomatic or mild symptoms; only clinically or
diagnostically detectable; no treatment required.
Grade 2: Moderate; requires minor, local, or non-invasive treatment;
limitation in age-appropriate instrumental activities of daily living.
Grade 3: Severe or medically significant but not immediately
life-threatening; results in hospitalization or prolongation of existing
hospitalization; disabling; limitation in self-care activities of daily living.
Grade 4: Life-threatening; requires urgent treatment.
Grade 5: Death related to complications.
6.2.Secondary Endpoints
Secondary endpoints focus on efficacy evaluation, including the
status of refractory membranous nephropathy (rMN) such as complete
remission (CR), partial remission (PR), no remission (NR), or recurrence;
the proportion of subjects maintaining CR or PR after cell infusion,
duration of remission, and recurrence; as well as changes in renal
function, immune characteristics, and cellular dynamics: proteinuria,
estimated
glomerular
filtration
rate
(eGFR),
serum
anti-PLA2R
antibodies, infection markers, complements, immunoglobulins, cytokine
levels, blood cells, changes in peripheral blood immune cell subsets, and
the expression level of CD19 on the surface of peripheral blood B cell

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subsets, etc.
6.2.1Remission or recurrence of rMN
The proportion of subjects with maintained remission, partial
remission, or no remission of rMN after cell infusion, the duration of
rMN remission, and the recurrence of rMN.
1
Definition of rMN CR: Disappearance of the patient’s clinical
symptoms and signs; urine protein reduced to <0.3 g/day or UACR <300
mg/g; with normal levels of serum albumin (ALB) and serum creatinine
(Scr).
2
Definition of rMN PR: Improvement in clinical symptoms and
signs; urine protein decreased by more than 50% compared with baseline,
and reduced to 0.3–3.5 g/day or UACR 300–3500 mg/g.
3
Definition of rMN immunological remission: PLA2R antibody
titer below the ELISA detection threshold (2 RU/mL) or negative result in
indirect immunofluorescence assay.
4
Definition of rMN NR: Insufficient reduction or persistently
high proteinuria, or deterioration of renal function, failing to meet the
criteria for remission, partial remission, or immunological remission as
mentioned above.
5
Definition of rMN recurrence: After NR or PR, the patient’s
urine protein rises again to >3.5 g/day or UACR >3500 mg/g; frequent
recurrence is defined as more than 2 recurrences within 6 months or more

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than 4 recurrences within 12 months.
6.2.2 Changes in renal function, immune characteristics, and
cellular dynamics
Changes in the subjects' serum urea (BUN), serum creatinine
(Scr), cystatin C (CysC), estimated glomerular filtration rate (eGFR),
urine protein, urine microalbumin/creatinine ratio (UACR), serum
anti-PLA2R antibodies, complements, immunoglobulins, cytokine
levels, blood cells, C-reactive protein (CRP), CAR copy parameters,
peripheral blood immune cell subsets, and the expression level of
CD19 on the surface of peripheral blood B cell subsets during the
study period.
6.2.3 Testing Time Points
The testing time points for primary and secondary endpoints
during the study are shown in Tables 3 and 4, respectively.
Table 3. Testing Time Points for Primary Endpoints (Safety)
Outcome Measurement
Measurement Description
Time Frame
Type and incidence of DLT in
rMN subjects after a single
infusion of CD19 CAR-T cells
Refer to the definition of DLT
in the study protocol
28 days and 3 months after
infusion
Type and incidence of AE in
rMN subjects after a single
infusion of CD19 CAR-T cells
Severity graded according to
CTCAE V5.0
12 months after infusion
Table 4. Testing Time Points for Secondary Endpoints (Efficacy)
Outcome Measurement
Measurement Description
Time Frame
Overall response rate
(CR+PR) in rMN subjects
after cell infusion
CR+PR
Week 2, Month 1, Month 2,
Month 3, Month 6, Month 9,
Month 12, Month 18 (if
applicable), Month 24 (if

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applicable) after infusion
Proportion of rMN subjects
achieving CR after cell
infusion
Refer to the CR definition in
the protocol
Week 2, Month 1, Month 2,
Month 3, Month 6, Month 9,
Month 12, Month 18 (if
applicable), Month 24 (if
applicable) after infusion
Proportion of rMN subjects
achieving PR after cell
infusion
Refer to the PR definition in
the protocol
Week 2, Month 1, Month 2,
Month 3, Month 6, Month 9,
Month 12, Month 18 (if
applicable), Month 24 (if
applicable) after infusion
Proportion, frequency, and
time of disease recurrence in
rMN subjects after cell
infusion
Refer to the recurrence
definition in the protocol
Week 2, Month 1, Month 2,
Month 3, Month 6, Month 9,
Month 12, Month 18 (if
applicable), Month 24 (if
applicable) after infusion
Change in eGFR from baseline
in rMN subjects after a single
infusion of CD19 CAR-T cells
Estimated glomerular filtration
rate, calculated using the
CKD-EPI 2021 formula
Week 2, Month 1, Month 2,
Month 3, Month 6, Month 9,
Month 12, Month 18 (if
applicable), Month 24 (if
applicable) after infusion
Change in urine protein from
baseline in rMN subjects after
a single infusion of CD19
CAR-T cells
24-hour urine protein
quantification
Week 2, Month 1, Month 2,
Month 3, Month 6, Month 9,
Month 12, Month 18 (if
applicable), Month 24 (if
applicable) after infusion
Change in UACR from
baseline in rMN subjects after
a single infusion of CD19
CAR-T cells
Random urine
Week 2, Month 1, Month 2,
Month 3, Month 6, Month 9,
Month
12,
Month
18
(if
applicable),
Month
24
(if
applicable) after infusion
Change in serum anti-PLA2R
antibody from baseline in rMN
subjects after a single infusion
of CD19 CAR-T cells
Venous blood
Week 2, Month 1, Month 2,
Month 3, Month 6, Month 9,
Month
12,
Month
18
(if
applicable),
Month
24
(if
applicable) after infusion
Change in serum renal
function from baseline in rMN
subjects after a single infusion
of CD19 CAR-T cells
Venous blood, Scr, CysC
Week 2, Month 1, Month 2,
Month 3, Month 6, Month 9,
Month
12,
Month
18
(if
applicable),
Month
24
(if
applicable) after infusion
Change in blood cells in rMN
subjects after a single infusion
of CD19 CAR-T cells
Venous blood, routine blood
test
Week 2, Month 1, Month 2,
Month 3, Month 6, Month 9,
Month
12,
Month
18
(if

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applicable),
Month
24
(if
applicable) after infusion
Change in CRP in rMN
subjects after a single infusion
of CD19 CAR-T cells
Venous blood
Day 2, Day 7, Day 10 or 14,
Day 21, Day 28 (1 month)
after infusion
Change in complements in
rMN subjects after a single
infusion of CD19 CAR-T cells
Serum complements C3, C4
Week 2, Month 1, Month 2,
Month 3, Month 6, Month 9,
Month
12,
Month
18
(if
applicable),
Month
24
(if
applicable) after infusion
Change in immunoglobulins in
rMN subjects after a single
infusion of CD19 CAR-T cells
IgE、IgA、IgG、IgM
Week 2, Month 1, Month 2,
Month 3, Month 6, Month 9,
Month
12,
Month
18
(if
applicable),
Month
24
(if
applicable) after infusion
Change in CAR copy
parameters in rMN subjects
after a single infusion of CD19
CAR-T cells
Parameters related to CAR
copy number
Day 2, Day 5, Day 7, Day 10
or 14, Day 21, Day 28 (1
month), Month 2, Month 3,
Month 6, Month 9, Month 12,
Month
18
(if
applicable),
Month 24 (if applicable) after
infusion
Change in ferritin in rMN
subjects after a single infusion
of CD19 CAR-T cells
Ferritin level
Day 2, Day 7, Day 10 or 14,
Day 21, Day 28 (1 month)
after infusion
Change in cytokines in rMN
subjects after a single infusion
of CD19 CAR-T cells
Cytokine panel
Day 2, Day 7, Day 10 or 14,
Day 21, Day 28 (1 month)
after infusion
Change in peripheral blood
lymphocyte subsets in rMN
subjects after a single infusion
of CD19 CAR-T cells
Peripheral blood lymphocyte
subset count
Day 2, Day 5, Day 7, Day 10
or 14, Day 21, Day 28 (1
month) after infusion
Expression level of CD19 on
the surface of peripheral blood
B cell subsets in rMN subjects
after a single infusion of CD19
CAR-T cells
Using flow cytometry method
Day 2, Day 5, Day 7, Day 10
or 14, Day 21, Day 28 (1
month) after infusion
7.Observation and Management of Adverse Events
7.1 Lymphodepletion Period
Lymphodepleting
pretreatment
(hereinafter
referred
to
as
"lymphodepletion") is required before CAR-T cell infusion to create a

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favorable immune environment for CAR-T cells, enhance their expansion,
persistence, and clinical activity, while reducing anti-CAR immune
responses.
Potential
complications
of
lymphodepletion
include
pancytopenia, immunosuppression, infection, hemorrhagic cystitis, liver
and kidney injury, etc. During this period, the subject’s vital signs and
24-hour fluid intake/output will be monitored daily, and complete blood
count, liver and kidney function, etc., will be monitored every 1–2 days.
7.2 After CAR-T Cell Infusion
After CAR-T cell infusion, patients require close clinical monitoring
to evaluate the efficacy and safety of treatment. Common adverse
reactions associated with CAR-T cell therapy include cytokine release
syndrome
(CRS),
immune
effector
cell-associated
neurotoxicity
syndrome (ICANS), tumor lysis syndrome (TLS), hemophagocytic
lymphohistiocytosis/macrophage
activation
syndrome
(HLH/MAS),
CAR-T
cell-associated
anaphylaxis
(CARAC),
immune
complex-associated hemolytic transfusion (ICAHT), B-cell aplasia,
hypogammaglobulinemia, infection, allergic reactions, and abnormal
proliferation of CAR-T cells, etc. This study refers to the CSCO
Guidelines for CAR-T Cell Therapy in Hematologic Malignancies (2024
Edition) and the Chinese Expert Consensus on Chimeric Antigen
Receptor T-Cell Therapy for Refractory Autoimmune Neurological
Diseases (2025 Edition) to assess potential CAR-T cell therapy-related

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DLTs and AEs during the study, and formulate corresponding clinical
prevention and management protocols.
7.2.1Cytokine Release Syndrome (CRS)
The possibility of CRS should be considered if any of the following
4 symptoms or signs appear: (1) Fever, with a body temperature ≥38°
C; (2) Hypotension, with a systolic blood pressure <90 mmHg (1 mmHg
= 0.133 kPa); (3) Arterial oxygen saturation <90%; (4) Presence of organ
toxicity. For specific grading, refer to the CRS grading method of the
American Society for Transplantation and Cellular Therapy [21].
Table 5. Grading of CRS
Parameter
Grade 1
Grade 2
Grade 3
Grade 4
Fever
Temperature
≥38°C
Temperature
≥38°C
Temperature
≥38°C
Temperature
≥38°C
Hypotension
None
Present, no
vasopressor
needed
Vasopressor ±
vasopressin
needed
Multiple
vasopressors
needed
(excluding
vasopressin)
Hypoxemia
None
Present,
low-flow nasal
cannula
oxygen
required
High-flow
nasal cannula,
face mask, or
Venturi mask
oxygen
required
Positive-pressure
ventilation
needed (e.g.,
CPAP, BiPAP,
intubation, or
mechanical
ventilation)
Note: CRS-related organ toxicity can be graded according to CTCAE v5.0 but
does not affect CRS grading. Fever is defined as a body temperature ≥38°C and not
attributed to any other causes. For CRS patients receiving antipyretic therapy or
anti-cytokine treatments such as tocilizumab or steroids, subsequent CRS severity
grading no longer requires the presence of fever. Low-flow nasal cannula oxygen: ≤6
L/min; high-flow nasal cannula oxygen: >6 L/min.
Table 6. Management Measures for CRS

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Grade
Symptom or
Sign
Management
1
Fever (body
temperature
≥38°C)
• Fluid replacement
• Symptomatic antipyretic therapy: physical cooling, drugs
such as acetaminophen or ibuprofen
• Rule out infection: blood/urine culture, chest imaging, etc.
• If the patient has neutropenia, prophylactic antibiotics are
given; G-CSF can be used, GM-CSF is contraindicated
• If fever persists (>3 days) or is refractory, tocilizumab
(8mg/kg) can be administered; if symptoms do not improve,
it can be repeated after 8 hours (no more than 3 times
recommended)
• If CRS does not improve after 24 hours of treatment,
dexamethasone 5~10mg qd can be administered or upgraded
to Grade 2 management
2
Hypotension
or
hypoxemia
• Fluid replacement, anti-infection
• If tocilizumab has not been used, it can be administered
(same as Grade 1 usage)
• If 1~2 doses of tocilizumab do not improve CRS,
dexamethasone 10mg q12h or qd for 1~3 days, reduce the
dose as soon as possible after symptom improvement
• If no improvement after 24 hours of dexamethasone
treatment, manage as Grade 3
• Low-flow oxygen inhalation (if needed)
• Anti-infection treatment
3
Hypotension
or
hypoxemia
• Consider transfer to ICU
• Fluid replacement, potent anti-infection
• Vasopressors (if needed)
• If tocilizumab has not been used previously, it can be
administered (8mg/kg, same as Grade 1 usage)
• Dexamethasone 10~20mg q.6h. for 1~3 days, reduce the
dose as soon as possible after symptom improvement
• High-flow oxygen inhalation (if needed)
4
Hypotension
or
hypoxemia
• Transfer to ICU
• High-flow oxygen or mechanical ventilation
• Fluid replacement, potent anti-infection
• Multiple vasopressors (if needed)
• High-dose glucocorticoid therapy (e.g., methylprednisolone
1g/d × 3 days, gradually reduce the dose)
• Tocilizumab (if applicable)
• Continuous monitoring and supportive treatment
Note: The maximum single dose of tocilizumab is 800 mg, and repeat
administration is allowed. If CRS does not improve or even worsens within 24 hours

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after treatment, the management measures should be escalated to the next grade. Early
intervention with tocilizumab and steroids will not affect the expansion and efficacy
of CD19 CAR-T cells in vivo.
7.2.2Immune
Effector
Cell-Associated
Neurotoxicity
Syndrome
(ICANS)
ICANS
presents
with
diverse
clinical
manifestations.
Early
symptoms often include decreased attention, language impairment, and
reduced writing ability, among which testing writing ability is a relatively
simple and sensitive method to assess ICANS progression. Most patients
experience reversible ICANS symptoms, while a few may develop severe
clinical manifestations such as seizures, confusion, and increased
intracranial pressure. In the most severe cases, it can progress to acute
cerebral edema, where patients may deteriorate from mild lethargy to
unconsciousness within hours, and further progression can lead to death.
For specific grading, refer to the ICANS grading method of the American
Society for Transplantation and Cellular Therapy [21].
Symptoms and signs of ICANS typically appear 3 – 6 days after
CAR-T cell infusion, peak on days 7 – 8, and gradually improve over
time, with complete resolution within 2–3 weeks [22]. In this study, in
addition to closely monitoring the patient ’ s blood routine, blood
biochemistry, coagulation function, ferritin, and cytokine levels, once
investigators
or
clinicians
suspect
ICANS,
cerebrospinal
fluid
examination,
cranial
CT/MRI,
and
electroencephalogram
will
be

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performed
based
on
the
subject ’ s
condition
after
excluding
contraindications.
Table 7. Grading of ICANS
Parame
ter
Grade 1
Grade 2
Grade 3
Grade 4
ICE
Score*
7-9
3-6
0-2
0 (Patient is unarousable and
unable to undergo ICE
scoring)
Altered
Level
of
Conscio
usness†
Awakens
spontane
ously
Awakens
to voice
Awakens only to
tactile stimulation
Unarousable or requires
vigorous/repeated
stimulation; coma
Seizure
‡
N/A
N/A
Focal/generalized
seizure with rapid
resolution; or
non-convulsive
seizure (EEG) with
resolution after
intervention
Sustained seizure (>5
minutes) or recurrent seizures
without return to baseline
Motor
Impair
ment
N/A
N/A
N/A
Deep focal motor weakness
(e.g., hemiparesis, paresis)
Increas
ed
Intracr
anial
Pressur
e/Cereb
ral
Edema§
N/A
N/A
Focal/local edema
on neuroimaging
Diffuse cerebral edema;
decorticate/decerebrate state;
cranial nerve VI palsy;
papilledema; Cushing’s triad
Note: ICANS grading is determined by the most severe event not attributed to
any other causes. Baseline ICE levels should be considered and scored before CAR-T
infusion.
*Patients with an Immune Effector Cell-Associated Encephalopathy (ICE) score
of 0 who have complete aphasia while awake are classified as Grade 3 ICANS,
whereas patients with an ICE score of 0 who are unarousable are classified as Grade 4
ICANS. Detailed scoring criteria: Orientation (4 points): year, month, city, hospital;

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Naming (3 points): 3 objects (e.g., clock, pen, button); Following commands (1 point):
e.g., extending two fingers, closing eyes, and sticking out tongue; Writing (1 point):
ability to write a standard sentence (e.g., "Our national flag is the Five-Star Red
Flag"); Attention (1 point): counting backward from 100 by 10s.
†No other causes (e.g., no use of sedative drugs).
‡Tremors and myoclonus related to immune effector cell therapy can be graded
according to CTCAE v5.0 but do not affect the score.
§Intracranial hemorrhage or cerebral infarction with or without edema is not
considered a feature of neurotoxicity and is excluded from ICANS grading. It can be
graded according to CTCAE v5.0.
Table 8. Management Measures for ICANS
Grade
Recommended Management Measures
1
• When swallowing function is impaired: switch oral medications and
nutrition to intravenous infusion
• For agitated patients: low-dose lorazepam or haloperidol for sedation
• Neurology consultation
• Funduscopic examination (to assess papilledema)
• Cranial imaging (enhanced MRI/CT)
• Optional lumbar puncture (to detect intracranial pressure, cytokines, CAR-T
cell count)
• Electroencephalogram (EEG) examination
• Preventive treatment:
- Dexamethasone 5-10mg (if likely to progress to severe neurotoxicity)
- Levetiracetam (for seizure prevention)
• When complicated with CRS: tocilizumab 8mg/kg (for those not previously
treated with anti-IL-6 therapy), can be repeated after 8 hours (total ≤2-3
doses)
2
• Same symptomatic treatment and examinations as Grade 1
• When complicated with CRS: tocilizumab used as in Grade 1
• When anti-IL-6 is ineffective or not complicated with CRS:
- Dexamethasone 10mg q6-12h or
- Methylprednisolone 1mg/kg q12h (rapid dose reduction after symptoms
decrease to Grade 1)
• When complicated with ≥Grade 2 CRS: recommend transfer to ICU•
Imaging examination: repeat every 2-3 days
3
• Same symptomatic treatment and examinations as Grade 1
• Immediately transfer to ICU with mechanical ventilation support•
High-dose steroid therapy:
- Methylprednisolone 1g/d × 3 days →gradual dose reduction (250mg q12h

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× 2 days →125mg q12h × 2 days →60mg q12h × 2 days)
• Anti-IL-6 treatment principle same as Grade 3
• When glucocorticoids are unresponsive: consider anakinra (IL-1 receptor
antagonist)
Note: Since tocilizumab binds to the IL-6 receptor, it causes an increase in serum
free IL-6 levels and further elevates IL-6 concentration in the cerebrospinal fluid,
which may exacerbate neurotoxicity. In the management of ICANS, the use of
glucocorticoids is more important than that of tocilizumab.
7.2.3Immune
Effector
Cell-Associated
Hemophagocytic
Lymphohistiocytosis-like Syndrome (IEC-HS)
IEC-HS
is
a
syndrome
of
pathological
and
biochemical
hyperinflammatory
responses
independent
of
CRS
and
ICANS,
characterized by the following features:
(1) Manifesting characteristics of macrophage activation syndrome
(MAS)/hemophagocytic lymphohistiocytosis (HLH);
(2) Attributed to immune effector cell therapy;
Exacerbated
or
new-onset
cytopenia,
hyperferritinemia,
coagulopathy
with
hypofibrinogenemia,
and/or
transaminase
abnormalities. Additionally, IEC-HS is generally considered a delayed
manifestation following the management of CRS.
IEC-HS is defined as a syndrome based on pathological and
biochemical hyperinflammatory states occurring after immune effector
cell therapy, specifically macrophage activation syndrome (MAS) or
hemophagocytic lymphohistiocytosis (HLH). The occurrence of IEC-HS
is independent of CRS and ICANS, accompanied by new-onset or

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exacerbated
cytopenia,
hyperferritinemia,
coagulopathy
with
hypofibrinogenemia, and elevated transaminases, among other features.
Furthermore, IEC-HS is generally regarded as a delayed manifestation
following the management of CRS.
Table 9. Diagnostic Criteria for IEC-HS*
Common
Findings†
• Elevated ferritin (>2×ULN or baseline at infusion) and/or rapidly rising
(clinical assessment)
• Exacerbated inflammatory response after initial improvement or
resolution of CRS treatment
• Elevated liver transaminases (>5×ULN with normal
baseline)<sup>§</sup> or >5×baseline (with abnormal baseline)‡
• Hypofibrinogenemia (<150mg/dl or <LLN)#
• Hemophagocytosis in bone marrow or other tissues#
• New-onset, exacerbated, or refractory grade 4 cytopenia in ≥1 cell line&
Other
Findings
• Elevated lactate dehydrogenase (>ULN)
• Coagulation abnormalities (e.g., elevated PT/APTT)
• Elevated direct bilirubin
• New-onset splenomegaly
• Fever（new-onset※or persistent#）
• Central nervous system toxicity
• Pulmonary manifestations (hypoxia, pulmonary infiltration, pulmonary
edema)
• New-onset renal insufficiency
• Hypertriglyceridemia (fasting >265mg/dl)#
Note: ULN: upper limit of normal; LLN: lower limit of normal.
*Diagnosis is only made if it cannot be attributed to other etiologies (including
CRS, infection, and/or disease progression).
†Refers to a cluster of symptoms occurring concurrently (e.g., all symptoms
appear within 72 hours).
‡Although most IEC-HS cases are associated with CRS, this is not absolute.
§Meets the criteria for Grade 3 transaminase elevation in CTCAE v5.0.
#Refer to HLH-2004.
&Usually refers to Grade 4 cytopenia in at least one blood cell line (platelets,
neutrophils, hemoglobin).

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※Differentiate from initial onset or recurrence of CRS.
Table 10. Grading of IEC-HS
Grade
Severity of Symptoms and Intervention Measures
1
Asymptomatic or mild symptoms
• Only observation and clinical assessment required
• Continuous clinical monitoring
2
Mild to moderate symptoms
• Medical intervention required (e.g.:
- Immunosuppressive therapy (for IEC-HS)
- Transfusion support for asymptomatic hypofibrinogenemia)
3
Severe symptoms (not immediately life-threatening)
• Aggressive treatment required (e.g.:
- Hemorrhagic coagulopathy requiring transfusion support
- Hospitalization required due to new-onset acute renal
injury/hypotension/respiratory distress)
4
Life-threatening symptoms requiring urgent intervention (e.g.:
life-threatening bleeding or hypotension, respiratory distress requiring
intubation, or acute renal injury requiring dialysis)
5
Death
Table 11. Management Measures for IEC-HS
Treatment
Level
Recommended Regimen
First-line
Treatment
• Anakinra (200–800mg/day)
• With and/or glucocorticoids:
- Dexamethasone 10–40mg/day
- Or methylprednisolone 1000mg/day
Second-line
Treatment
• If no remission within 48 hours:
- Increase the dose of first-line drugs
- Adopt dual-drug therapy (anakinra + glucocorticoid)
- May add JAK-2 inhibitor (e.g., ruxolitinib 5–10mg/day)
Third-line
Treatment
• Add JAK-2 inhibitor
• May consider:
- γ-interferon monoclonal antibody (emapalumab)
- CTLA-4 agonist (e.g., abatacept)
- CD52 antibody (alemtuzumab)
• Etoposide (50–100mg/m²) is applicable for primary HLH and
secondary HLH
Rescue
Treatment
Rapidly progressive/life-threatening high-grade IEC-HS:
- After failure of first/second-line treatment
- May consider TKI (e.g., dasatinib) as a third-line option
Note: Due to the lack of prospective studies and data on IEC-HS treatment
methods, treatment considerations are derived from expert consensus opinions. The

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consensus mentions that there are currently multiple options for third-line and
subsequent
treatment
regimens.
Therefore,
if
IEC-HS
occurs
in
the
study,
investigators or clinicians will adopt corresponding treatment methods based on the
patient’s specific conditions.
Table 12. Supportive Therapy for IEC-HS
Treatment
Type
Recommended Management Measures
Monitoring
• Daily monitoring:
- Complete blood count, coagulation function, fibrinogen
- Routine assessment for patients with abnormal liver and kidney
function
• Infection monitoring:
- Blood/urine/sputum cultures (bacteria, viruses, fungi)
- Detection of other infection sources (e.g., bronchoalveolar lavage
fluid, cerebrospinal fluid)
• HLH-related parameters:
- Soluble CD25, NK cell function, triglycerides
- Bone marrow smear, IFN-γ, CXCL9/CXCL10, IL-10/IL-18
Cytopenia
• Maintain hemoglobin >7g/dl
• Maintain platelets >50×10⁹/L (in case of active bleeding or
coagulation dysfunction)
• Consider G-CSF when ANC <0.5×10⁹/L (controversial)
• Patients with menorrhagia are recommended to consult gynecology
Coagulation
Dysfunction
• Maintain fibrinogen:
- >100mg/dl (without bleeding)
- >150mg/dl (with bleeding)
• Supplement vitamin K when INR >1.5
• Administer cryoprecipitate and FFP when INR >2
• Use venous thromboembolism prophylaxis drugs with caution
Infection
Management
• Empirical anti-infective therapy
• Rule out infectious causes of sHLH
• Prophylactic anti-infective therapy is required during
immunosuppressive treatment
• Regular infection monitoring
7.2.4 CAR-T-Associated Coagulopathy (CARAC)
CRS can cause coagulation dysfunction in patients. The principles of
management include early identification, accurate assessment, removal of
inducing factors, and stratified intervention based on CRS grading. The

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reference management methods for CARAC are as shown in the
following table.
Table 13. Management Measures for CARAC
CRS
Gra
de
CARAC Management
Preventiv
e and
Supportiv
e
Treatmen
t
Preventiv
e/Anti-inf
ective
Treatmen
t
Anti-infla
mmatory
and
Hepatopr
otective
Treatmen
t
Promote
Platelet
Productio
n
1
• Assess coagulation
indicators: If normal:
Observe.
If abnormal:
1 Increase the
frequency of coagulation
indicator monitoring
2 WHO bleeding
score③Closely monitor
CRS
√
√
√
√
2
• Assess coagulation
indicators: If improved:
Observe.
If not improved:
1 Increase monitoring
frequency②WHO
bleeding score + DIC
score
2 Control CRS
(cytokine antagonists +
glucocorticoids)
④Alternative and
anticoagulant treatment
√
√
√
√
3
• Assess coagulation
indicators: If improved:
Observe.
If not improved:
①Increase monitoring
frequency
②WHO bleeding score
+ DIC score
③Strengthen CRS
√
√
√
√

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control (increase
glucocorticoid
dose/frequency)
④Focus on alternative
treatment
⑤Adjust the plan in a
timely manner
4
• Assess coagulation
indicators: If improved:
Observe
If not improved:
①Increase the
monitoring frequency
②WHO bleeding score
+ DIC score
③Strengthen CRS
control (combination of
multiple methods)
④Replacement therapy
+ plasma exchange
√
√
√
√
7.2.5 Immune Effector Cell-Associated Hematotoxicity (ICAHT)
Some patients may experience pancytopenia, which can persist for
half a year or even longer. Close attention should be paid to the increased
risk
of
infection
during
the
period
of
cytopenia.
If
necessary,
hematopoietic stimulating factors should be administered, and blood
products such as packed red blood cells and platelets should be
transfused.
Table 14. Grading Criteria for ICAHT
Grading
Grade I
Grade II
Grade III
Grade IV
Early ICAHT ≤30 days
ANC ≤500/μl
<7 days
>7–13
days
≥14 days
Never > 500/μl
ANC ≤100/μl
—
—
≥7 days
≥14 days
Late ICAHT > 30 days
ANC ≤1 500/μl
√
ANC ≤1 000/μl
√

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ANC ≤500/μl
√
ANC ≤100/μl
√
Note: ANC, absolute neutrophil count, measured multiple times, not transient
reduction.
Table 15. Risk Stratification Score for CAR-HEMATOTOX
Assessment
Indicator
0 Point
1 Point
2 Points
Platelet Count
>175×109/L
75-175×109/L
<75×109/L
Absolute
Neutrophil Count
>1.2×109/L
<1.2×109/L
—
Hemoglobin
>90g/L
<90g/L
—
C-Reactive Protein
<30mg/L
≥30mg/L
—
Ferritin
<650ng/ml
650-2,000ng/ml
>2,000ng/ml
Note: Low risk: 0–1 point; High risk: >2 points. Assess the incidence of
hematotoxicity and infection based on results before lymphodepletion (–5 days, with a
3-day grace period). The incidence of hematotoxicity and infection is significantly
increased in high-risk patients.
Table 16. Management Methods for Short-Term ICAHT Management
Managemen
t Measure
Time
Method
Precautions
Remarks
Infusion of
Packed Red
Blood Cells
(pRBC) or
Platelets
Based
on
the
patient’s
specific
cytopenia
risk
profile
For
pRBC,
consider
using
one
product
each
time
to
reduce
iron
overload
Irradiate blood
products
or
filter out white
blood
cells;
start
7
days
before
apheresis
and
continue
until
at least 90 days
after
CAR-T
administration
Flu may affect
irradiated blood
products
Prophylactic
Use of
G-CSF
High-risk
ICAHT
patients should
use
prophylacticall
y on Day +2
G-CSF 5μg/kg
qd
Low-risk
ICAHT
patients
may
not
need
G-CSF
Reduce the risk
of
febrile
neutropenia
(without
increasing
the
risk of ≥Grade
3
CRS
or
ICANS)
Intermittent
When ANC <
5
μg/kg
qd,
-
Neutropenic

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Use of
G-CSF
500/μl
consider
10
μg/kg
if
no
response
patients
with
intermittent
recovery
respond
rapidly,
while
aplastic
patients
have
no response
Bacterial
Prophylaxis
Consider
prophylactic
treatment when
ANC < 500/μl
G-
bacteria:
third/fourth
generation
cephalosporins,
enzyme
inhibitors;
G+
bacteria:
vancomycin,
teicoplanin,
etc.
Pay attention to
colonization of
pathogens such
as
MRD
and
CRE
Adjust
according
to
the
bacterial
epidemiology
of the medical
center and the
patient's
place
of residence
Viral
Prophylaxis
From the start
of
lymphodepletio
n
conditioning
until
1
year
after
CAR-T
and/or CD4⁺ >
0.2×10⁹/L
Valacyclovir
500mg bid or
Acyclovir
800mg bid
-
-
Pneumocysti
s
Prophylaxis
From the start
of
lymphodepletio
n
conditioning
until
1
year
after
CAR-T
and/or CD4 >
0.2×10⁹/L
Cotrimoxazole
480mg
qd
or
960mg tiw
For
allergic
patients,
pentamidine,
dapsone
or
atovaquone can
be selected
-
Fungal
Prophylaxis
Neutropenia
lasting
1-3
months
Posaconazole
300mg/d
or
Caspofungin
500mg i.v./d
Prophylaxis
is
recommended
for
patients
with a history
of
invasive
aspergillosis or
long-term
use
of
corticosteroids
-
Note: Subjects with baseline cytopenia, occurrence of grade >3 CRS or ICANS,

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long-term use of glucocorticoids, and high-risk CAR-HEMATOTOX score may have
a higher risk of infection.
7.2.6 B-cell Deficiency / Hypogammaglobulinemia
B-cell aplasia is defined as a disease caused by depletion or absence
of B cells. The mechanism of CAR-T-induced B-cell aplasia is the
on-target off-tumor effect and off-target effects of CD19-targeted CAR-T
cell therapy. Usually, it is because the target is a shared target, which is
also expressed in normal tissues and will be recognized and attacked by
CAR-T, resulting in toxicity. This type of toxic side effect is relatively
common in CAR-T, and its severity is related to the expression of the
target in normal tissues and the criticality of its function. It can reduce
B-cell count and the level of gamma immunoglobulins.
Currently, there are not many reported cases of off-target toxicity in
CAR-T clinical practice. The possible reason is that most single-chain
antibodies (scFv) used in CARs are high-affinity monoclonal antibodies,
and many antibody drugs themselves have been used clinically, proving
good safety, thus ensuring the safety of CAR-T. However, attention still
needs to be paid to its off-target effects after CAR-T cell infusion. Studies
have shown that hypogammaglobulinemia may occur at different time
periods after CAR-T infusion, with an incidence of about 67% after 90
days, and a few patients even have it for several years. The main clinical
manifestation is frequent infection.
(1) Calculation method of absolute B-cell count: Absolute B-cell

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count = Total white blood cell count ×
Lymphocyte percentage ×
(CD19+ or CD20+) percentage.
Definition / Range: Absolute B-cell count < 61 cells/ml; IgG ≤
400 mg/dl.
(2)
Management
strategy:
Intravenous
infusion
of
human
immunoglobulin (5g
×
3 days, intravenous drip) for replacement
therapy.
(3) Infusion frequency: Once a month after CAR-T infusion until B
cells return to the normal range or 6 months after CAR-T infusion;
high-risk populations continue once a month until high-risk factors are
eliminated and globulin levels return to normal. For high-risk populations
with IgG ≤
400 mg/dl accompanied by severe infection, persistent
infection, or recurrent infection, pay attention to regular monitoring of
serum IgG, IgM, IgA, and the number of (CD19+ or CD20+) B cells in
peripheral blood, etc.
Table 17. Grading and Management Measures for B-cell Deficiency /
Hypogammaglobulinemia
Grading
Management Measures
Any Grade
• It is recommended to receive influenza and COVID-19
vaccines
• Viral prophylaxis and PCP prophylaxis (continue until 6-12
months after CAR-T infusion and/or CD4 cell count > 200/μl)
• High-risk patients* consider antifungal prophylaxis (such as
posaconazole), including those receiving corticosteroid therapy
for CRS/ICANS
Grade
1(Asymptomatic)
• No special intervention required
• Symptomatic supportive treatment
Grade
• Consider IVIG replacement therapy when IgG ≤400mg/dL

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2(Symptomatic,
Non-urgent)
• Targeted anti-infection treatment in case of infection
Grade 3(Requires
Urgent
Intervention)
Grade
4(Life-threatening)
*High-risk criteria for fungal infection (meeting ≥2 items): ANC ≤0.5×10⁹/L
before infusion, CAR-T dose > 2×10⁷/kg.
7.2.7 Infection
The incidence of various types of infections after CAR-T cell
therapy is approximately 55%, among which severe infections of
grade >3 account for about 33%. Most infections occur within 1 to 2
years after CAR-T cell therapy, with the incidence reaching as high as
40% within 1 month after treatment. Depending on the infection site,
non-specific
symptoms
such
as
fever,
cough,
expectoration,
and
hypotension may occur after CAR-T therapy; in severe cases, systemic
symptoms like hypotension and hypoxia can develop.The increased risk
of infection is associated with the following factors: number of previous
treatments, infections within the recent 100 days, use of glucocorticoids
or tocilizumab, febrile neutropenia, CD22-targeted CAR-T cell therapy,
and hypogammaglobulinemia. Other potential risk factors for early severe
infections include ICANS, as well as the use of tocilizumab and
corticosteroids.
（1）Infection Screening
Table 18. Infection Screening to Be Completed Before Subject Enrollment /
CAR-T Cell Infusion

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Items
Routine
Examination
Medical history inquiry and physical examination, infectious diseases
(invasive fungal disease, hepatitis, syphilis, AIDS, tuberculosis), and
other important disease histories
Laboratory
Examination
Routine blood, urine, and stool tests, ESR, liver and kidney functions,
electrolytes,
immunoglobulins,
procalcitonin,
C-reactive
protein,
detection of cytokines such as IL-6 (baseline)
Etiological
Examination
HCV, HBV, HIV, TP, EBV, CMV, COVID-19 detection; add
HSV/VZV, JCV, respiratory-related viruses, mycoplasma, G/GM
test, Mycobacterium tuberculosis when necessary based on the
patient's condition
Imaging
Examination
High-resolution
chest
CT,
abdominal
ultrasound
or
CT,
echocardiogram, cranial MRI (when necessary)
（2）Infection Prevention
The peak period of infection generally occurs within 8 weeks after
CAR-T cell infusion, decreases with time, and can last for 1 to 2 years
after treatment. The mortality rate of concurrent infection during the CRS
phase is high; therefore, infection prevention and control is a top priority
in CAR-T cell therapy.
The management of infections in subjects during this study mainly
refers to the Chinese Expert Consensus on Prevention, Diagnosis, and
Treatment of Infections Related to Chimeric Antigen Receptor T-Cell
Therapy (2022 Edition). Acyclovir or valacyclovir is administered at the
start of lymphodepletion, and the duration of medication is determined
according to the recovery of immune function. From CAR-T cell infusion
until
granulocyte
recovery,
norfloxacin,
triazole
antifungals,
and
compound sulfamethoxazole tablets are given for infection prophylaxis
(for patients allergic to quinolones, sulfonamides, etc., they can be
replaced with penicillins, cephalosporins, or macrolide antibiotics).

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Table 19. Infection Prophylaxis Regimen During CAR-T Therapy
Infection
Type
Drugs and Dosage
Duration of
Medication
Note
Bacterial
-
-
There is currently
no
evidence-based
medicine to support
routine
bacterial
prophylaxis during
immunotherapy
Viral*
•
Acyclovir
400mg
q12h
orally
•Or
5mg/kg
q12h
intravenously
From the start of
lymphodepletion
conditioning until
6
months
after
CAR-T infusion;
high-risk
patients†
extend
to 1 year
•Routine
prophylaxis
•Strengthen
monitoring
for
high-risk patients
Invasive
Fungal
• Fluconazole 400mg qd
•Filamentous
fungal
prophylaxis:
– Posaconazole
200mg
tid
p.o. (suspension)
–Or 300mg qd p.o. (tablet, bid
on the first day)
– Micafungin 50mg qd i.v.
Until
neutrophil
count returns to
normal
•
All
patients:
Fluconazole
prophylaxis
•High-risk
patients:Add
filamentous
fungal
prophylaxis
Pneumoc
ystis
•First choice: Cotrimoxazole
(TMP/SMX 160/800mg) bid
twice a week
•Alternative:
Pentamidine
300mg
nebulized
once
a
month
Start
1
week
before
infusion
until
CD4
cell
count > 200/μl
All
patients
need
prophylaxis
*Monitoring of CMV and EBV: For patients with CMV and EBV serological
IgG+, IgM-, viral PCR monitoring should be performed every 1-3 months during
treatment. Patients with chronic HBV or HCV infection should be managed jointly
with hepatologists to develop a reasonable management process.
†Recently received steroid/tocilizumab treatment.
（3）Infection Management
1
Principles for managing infections during treatment.
Table 20. Principles for Managing Infections During CAR-T Therapy

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Grading
Management Measures
Any Grade
•
Prophylactic
antiviral
and
Pneumocystis
pneumonia
prophylaxis (continue until 6-12 months after CAR-T infusion
and/or CD4 cell count > 200/μl)
•High-risk patients consider antifungal prophylaxis
•G-CSF can be used in patients with neutropenia lasting >7
days after CRS
Grade 1(Mild
Infection)
• Supportive treatment
• Empirical anti-infection therapy when febrile:
- Antibacterial: e.g., levofloxacin/ciprofloxacin
- Antifungal: e.g., fluconazole
- Antiviral: e.g., valacyclovir/acyclovir
Grade 2(Requires
Oral Antibiotics)
• Oral antibacterial drugs for the full course of treatment
Grade 3(Severe
Infection)
• Intravenous use of antibacterial drugs
• Systemic anti-infection treatment
Grade
4(Life-threatening)
• Intensive care support
2
Management of Infections Under Special Conditions During
Treatment
a.Differentiation Between CRS and Infection
The two conditions share similar clinical manifestations, but there
are currently no specific biomarkers to clearly distinguish them.
Concurrent CRS and infection may also occur, so predicting their
occurrence and development and grasping the timing of intervention are
crucial. No significant differences in cytokine levels have been observed
between CRS grades and infection severity. When CRS is complicated by
severe infection, a secondary elevation in IL-6 levels may occur.
Cytokines such as IL-8, IL-1 β , and IFN can be used to attempt
differentiation, but sufficient clinical data and evidence are still lacking.
If the two cannot be clearly distinguished, the guiding principle is

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prophylactic anti-infection combined with CRS grade-based treatment.
b.Monitoring of Special Infections
Infections include tuberculosis, histoplasmosis, listeriosis, and
nocardiosis. Investigators and clinicians should pay attention to medical
history inquiry, especially when conventional anti-infection therapy is
ineffective, and consider the possibility of infection with such special
pathogens.
c.Patients Diagnosed with COVID-19
If a patient develops COVID-19 from enrollment to CAR-T cell
infusion, CAR-T cell therapy should be postponed. For asymptomatic
patients, CAR-T infusion should be postponed for ≥14 days from the
date of the first positive nucleic acid test. For patients with mild
symptoms, CAR-T infusion should be postponed for ≥14 days starting
from the time when symptoms improve and fever resolves for at least 24
hours without the use of antipyretic drugs. If the patient has persistent
positive nucleic acid tests, unrelieved or progressively worsening
symptoms, they should withdraw from the study after evaluation by the
research team.
7.2.8 Allergic Reactions
Allergic reactions usually present as rashes within 2 weeks after cell
infusion, which fade when pressed and can resolve spontaneously in 3-5
days. In addition to allergies, the causes may include increased capillary

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endothelial fragility induced by cytokine release, with or without
thrombocytopenia, which requires comprehensive evaluation based on
multiple indicators. Drug allergies may result from components of in
vitro culture reagents during CAR-T production, viral vector impurities,
or T cell activation caused by unresolved inflammatory background
before CAR-T infusion.
Management measures for CAR-T-related allergic reactions during
the study mainly include: excluding patients with hypersensitivity or
allergic reactions at enrollment; strictly controlling procedures and
reagents
during
CAR-T
cell
manufacturing;
prophylactic
use
of
anti-allergic drugs (such as diphenhydramine or promethazine); and close
monitoring of patients' vital signs and symptoms within 14 days after
CAR-T cell infusion.
7.2.9 Abnormal Proliferation of CAR-T Cells
Within 28 days after CAR-T cell infusion, the in vivo expansion of
CAR-T cells in peripheral blood will be monitored. Blood samples will
be collected every 2-3 days in the first week and then once a week.
Specific time points are: Day 2, Day 5, Day 7, Day 10 or 14, Day 21, and
Day 28 after infusion.
Diagnostic criteria for abnormal proliferation of CAR-T cells:
peripheral
blood
white
blood
cell
count
>10×10⁹/L;
lymphocyte
percentage in white blood cells ≥70%; absolute count of CAR-T

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cells >600/μl.
When abnormal proliferation of CAR-T cells is suspected in a
patient,
glucocorticoids
and
other
immunosuppressants
(such
as
antithymocyte globulin or anti-CD52 antibody) should be administered.
Patients with severe conditions may be treated with a combination of two
or more immunosuppressants.
8.Quality Control and Quality Assurance of the Study
Investigators
will
be
responsible
for
screening
subjects
in
accordance with inclusion and exclusion criteria, recording study data in
the Case Report Form (CRF), and entering study data into the electronic
database. At the same time, they will maintain close contact with subjects
in strict accordance with time nodes to avoid enrolling ineligible subjects,
spontaneous withdrawal of subjects, or subjects not receiving treatment at
all. Specialized personnel will independently conduct study monitoring,
data management, safety monitoring, and statistical analysis. Once the
quality assurance procedures are completed, the database will be locked.
9.Statistical Analysis
All statistical analyses will not consider factors such as poor subject
compliance, premature withdrawal, or loss to follow-up. Due to the small
sample size of this study, all data will be presented as individual values.
Descriptive statistical methods will be used to report specific parameters
at
baseline
and
during
follow-up.
Statistical
analyses
and
data

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visualization will be performed using SPSS 27.0 and GraphPad Prism
9.0.
Baseline characteristics will be listed case by case by individual ID,
including age, gender, pathological classification, baseline urinary protein,
anti-PLA2R antibody level, etc.
Changes in continuous variables (e.g., laboratory indicators) will be
recorded in individual follow-up value tables by subject ID and/or
displayed as multi-time point line graphs (timeline graphs [from infusion
day to D+n days]). Categorical variables will be labeled according to
individual status (e.g., CR/PR/NR). Safety events will be listed by
individual,
including
toxicity
type,
grade,
onset
time,
duration,
intervention measures, and outcome.
Since the sample size is only 5 cases, all findings are descriptive and
do not represent generalizable inferences.
10.Ethics of Clinical Research
This clinical research will adhere to relevant regulations such as the
World Medical Association's Declaration of Helsinki. Before the
initiation of the study, the trial protocol must be approved by the Ethics
Committee before the clinical research can be conducted. Prior to each
subject's enrollment in this study, investigators are obligated to fully and
comprehensively inform the subject or their legal representative of the
purpose, procedures, potential benefits, and risks of the study, and obtain

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a written informed consent form. Subjects should be made aware that
they have the right to withdraw from the study at any time. The informed
consent form shall be retained as a clinical research document for future
reference. During the study, the personal privacy and data confidentiality
of subjects will be protected.
11. Study Schedule
August 1, 2025–October 31, 2025: Preliminary preparation, study
protocol design, investigator meeting, ethics committee review, and trial
registration.
November 1, 2025 – March 31, 2026: Trial initiation, patient
enrollment and follow-up, monitor visits, data collection, management of
blood samples and adverse adverse events.
April 1, 2026 – July 31, 2028: Data aggregation, data storage,
statistical analysis and processing, manuscript writing and publication,
and result reporting.
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