A Prospective, Single-arm Clinical Trial of Prevention of Severe Acute Graft-versus-host Disease After Pediatric Patients Receiving Allogeneic Hematopoietic Stem Cell Transplantation Using a daGOAT Model
Phase: PHASE2
Conditions: Transplant-Related Disorder
Sponsor: Institute of Hematology & Blood Diseases Hospital, China

 
Clinical study protocol 
Title: 
A prospective, single-arm clinical trial of prevention of severe acute 
graft-versus-host disease after pediatric patients receiving 
allogeneic hematopoietic stem cell transplantation using a daGOAT 
model 
Portocol 
number: 
daGOAT-child-001 
Research 
unit： 
Institute of Hematology & Blood Diseases Hospital, Chinese 
Academy of Medical Sciences & Peking Union Medical College. 
Address： 
Nanjing Road, Heping district, Tianjin, China 
Version： 
4.0 
Version date： March 6, 2023 
 
 
Declaration of Secrecy 
 
This document is confidential information of Institute of Hematology & Blood Diseases Hospital, 
Chinese Academy of Medical Sciences & Peking Union Medical College (Tianjin, China) and is only 
used for the purpose of this clinical study. It shall not be disclosed to anyone other than the 
participating researchers and members of the institutional review board. This information cannot be 
used for any purpose other than the evaluation or implementation of clinical studies without the prior 
written consent of Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical 
Sciences & Peking Union Medical College. 
 
 

 
 
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1. 
Abstract 
 
Title 
A prospective, single-arm clinical trial of prevention of severe acute 
graft-versus-host disease after pediatric patients receiving allogeneic 
hematopoietic stem cell transplantation using the daGOAT model 
Study 
objective 
To evaluate the efficacy and safety of ruxolitinib for prophylactic 
therapy of pediatric patients who are predicted to have a high risk for 
developing severe acute graft-versus-host disease (aGVHD) by the 
daGOAT model. 
Study design This is a prospective single-arm historical-control clinical trial. ≥ 40 
pediatric patients receiving HLA-mismatched allogeneic 
hematopoietic stem cell transplantation (allo-HSCT) will be enrolled 
after October 1, 2022.  
Study 
population 
Pediatric patients receiving HLA-mismatched allo-HSCT. 
Inclusion 
criteria 
1. Patients must be ≤ 16 years of age; 
2. Patients receiving human leukocyte antigen (HLA)-mismatched 
and non-cord blood allo-HSCT; 
3. Patients who can take oral medication; 
4. Patients or their guardians have to sign an informed consent form 
before the start of the research procedure. 
Exclusion 
criteria 
1. Tandem transplantation or multiple transplantations; 
2. Patients who are allergic to or cannot tolerate ruxolitinib; 
3. Mental or other medical conditions that make the patients unable 
to comply with the research treatment and monitoring 
requirements; 
4. Patients who are pregnant or cannot take appropriate contraceptive 
measures during treatment; 
5. Patients who are ineligible for the study due to other factors, or 
will bear great risk if participating in the study. 
Sample size 
The incidence rate of severe aGVHD within 100 days of previous 
pediatric transplant patients at the Institute of Hematology & Blood 
Diseases Hospital, Chinese Academy of Medical Sciences & Peking 
Union Medical College (IHCAMS) was 26% during 1 December 
2020–13 January 2022. The incidence rate after using the daGOAT 
model will fall to 8% per the researchers’ estimation. To attain a 0.05 

 
 
2 
significance level, a 0.8 power at a presumed 5% dropout rate, ≥ 
40 participants will need to be enrolled. 
Dosage 
regimen 
 Model-predicted high-risk patients: weight ≤ 25 kg, ruxolitinib, 
2.5mg bid po until at least day 60 post-transplant and terminated 
after day 100; weight > 25 kg, ruxolitinib, 5mg bid po until at 
least day 60 post-transplant and terminated after day 100. If 
‘azoles’ are taken concomitantly, ruxolitinib will start at half 
dose. If the patient tolerates ruxolitinib, the dose can be increased 
to 10mg bid po. 
 
 Model-predicted low risk: regular aGVHD prophylactic 
regimens. 
Study 
endpoints 
Primary endpoint: incidence of severe aGVHD after transplantation 
within 100 days. 
Secondary endpoints: incidence of aGVHD (any grade) in various 
target organs, overall survival after transplantation, relapse-free 
survival rate, relapse rate, incidence of severe infections, safety of 
treatment, and total cost of treatment. 
Safety 
evaluation 
Encompassing physical examination, vital signs, adverse events, 
concomitant therapy, and abnormal results of laboratory tests. 
Statistical 
analysis 
SAS and R statistical analysis software will be used to conduct the 
statistical analysis tailored to data properties. Efficacy and safety 
variables will be compared with the predefined target value. All 
comparison tests will be two-sided, and statistical significance will be 
defined as P < 0.05 in all the analyses. 

 
 
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2. 
Research background 
At present, there are about 40,000 new allogeneic hematopoietic stem cell 
transplantation (allo-HSCT) cases every year in the world [1, 2], among which 
about a quarter occur in China. Allo-HSCT has become the primary treatment 
method for some hematological diseases such as refractory and relapsed acute 
leukemia and bone marrow failure. The individuals are affected by dynamic and 
static multi-dimensional parameters as well as post-transplant immune 
reconstitution. The use of machine learning to integrate big data for predicting 
severe aGVHD (grade III–IV) may provide a new path towards understanding 
immune complications after transplantation. 
 
Previous foundation of research 
The researchers have compiled the postoperative clinical data of the patients who 
received HLA-mismatched allogeneic hematopoietic stem cell transplantation 
(allo-HSCT) at the IHCAMS from 2012 to 2021—named the ‘aGOAT dataset’, 
which contained 194 dynamic variables of 584 adult patients and 159 dynamic 
variables of 45 pediatric patients, including complete blood counts, blood 
biochemistry, electrolytes, cytokines, flow cytometry, antibody, fluid 
inflow/outflow, and vital signs. Severe aGVHD occurred within 100 days in 16% 
of the adult patients and 24% of the pediatric patients. A dynamic forecasting 
model for severe aGVHD, termed the ‘daGOAT model’, was constructed, 
achieving an AUROC score of more than 0.78. This result has been published in 
Nature Computational Science in 2022.[3] 
 
This study aims to prospectively evaluate the use of the daGOAT model in real-world 
clinical settings at the IHCAMS. 
 
1. 
Gratwohl, A., et al., One million haemopoietic stem-cell transplants: a retrospective observational study. 
Lancet Haematol, 2015. 2(3): p. e91-100. 

 
 
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2. 
Xu, L.P., et al., A review of hematopoietic cell transplantation in China: data and trends during 2008-
2016. Bone Marrow Transplant, 2017. 52(11): p. 1512-1518. 
3. 
Liu, X., et al. Dynamic forecasting of severe acute graft-versus-host disease after transplantation. Nat 
Comput Sci , 2022.2: p. 153-159. 
 
3. 
Study objective 
To evaluate the efficacy and safety of ruxolitinib for prophylactic therapy of pediatric 
patients who are predicted to have a high risk for developing severe aGVHD 
according to the daGOAT model. 
 
4. 
Study design 
This is a prospective single-arm historical-control clinical trial. Pediatric patients 
receiving HLA-mismatched allogeneic hematopoietic stem cell transplantation (allo-
HSCT) at the IHCAMS will be enrolled after October 1, 2022. 
The daGOAT model will dynamically predict the risk for severe aGVHD daily from 
day 7 to day 12 after transplantation, and medication will be adjusted according to the 
predicted risk.  
The study flowchart is shown in Figure 1 (LR, low risk; HR, high risk). 
 

 
 
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Figure 1. Study flowchart 
 
 
5. 
Study population 
Pediatric patients receiving HLA-mismatched allo-HSCT from the IHCAMS. 
 
5.1 Inclusion criteria 
1) 
Patients must be ≤ 16 years of age; 
2) 
Patients receiving HLA-mismatched and non-cord blood allo-HSCT; 

 
 
6 
3) 
Patients who can take oral medication; 
4) 
Patients or their guardians have to sign an informed consent form before 
the start of the research procedure. 
5.2 Exclusion criteria 
Patients who meet any of the following criteria will not be enrolled in the study: 
1) 
Tandem transplantation or multiple transplantations; 
2) 
Patients who are allergic or intolerable to ruxolitinib; 
3) 
Suffering from mental or other medical conditions that make the patient 
unable to comply with the research treatment and monitoring requirements; 
4) 
Patients who are pregnant or cannot take appropriate contraceptive 
measures during treatment; 
5) 
Patients who are ineligible for the study due to other factors, or will bear 
great risk if participating in the study. 
5.3 Drop-out and withdrawal criteria 
1) 
Failure of neutrophil engraftment within 30 days of transplantation; 
2) 
A patient may withdraw from the study if he/she does not wish to continue 
participating in the study, and the date and reason for withdrawal shall be 
recorded. The investigator may also decide to discontinue a patient from 
the clinical study if there is an unacceptable risk. 
 
6. 
Dosage regimen 
1) Model-predicted high-risk patients: weight ≤ 25 kg, ruxolitinib 2.5mg bid 
po until at least day 60 post-transplant and terminated after day 100; 
weight > 25 kg, ruxolitinib 5mg bid po until at least day 60 post-transplant 
and terminated after day 100. If ‘azoles’ are taken concomitantly, 
ruxolitinib will start at half dose. If the patient tolerates ruxolitinib, the 
dose can be increased to 10mg bid po. 
2) 
Model-predicted low risk: regular aGVHD prophylactic regiments. 
 

 
 
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7. 
Study assessment and follow-up 
7.1. Medical history 
Medical history (previous treatments, including chemotherapy). 
7.2. Physical examination 
Physical examination before transplantation, including body height, body 
weight, body surface area, the Eastern Cooperative Oncology Group score. 
7.3. Laboratory tests  
Laboratory tests performed at diagnosis and before and after transplantation at 
various time points. 
1) 
Blood routine: Red blood cell count, hemoglobin, platelet count, white 
blood cell count, white blood cell classification count, etc. 
2) 
Urine routine: specific gravity, pH, urine sugar, urine protein, 
urobilinogen, ketone bodies, microscopic red blood cells, urine white 
blood cells, bacteria, crystals, tube type, etc. 
3) 
Coagulation function tests: activated partial thromboplastin time, plasma 
prothrombin time, international normalized ratio of prothrombin time, 
thrombin time, plasma fibrinogen, and plasma D-dimer. 
4) 
Bone marrow:  
 
Smear or biopsy analysis; 
 
Immunophenotype analysis by flow cytometry; 
 
Chromosome karyotype; 
 
Gene mutation analysis. 
5) 
Blood biochemistry. 
 
Electrolyte includes sodium, potassium, chlorine, calcium and 
phosphorus, etc. 
 
Liver function tests include alanine aminotransferase, aspartate 
aminotransferase, alkaline phosphatase, γ-glutamyltransferase, lactate 
dehydrogenase, total protein, albumin, total bilirubin, direct bilirubin, 
total cholesterol, triglyceride, etc. 

 
 
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 
Renal function tests include blood urea nitrogen, uric acid and 
creatinine, etc. 
6) 
Immune cell subset analysis by flow cytometry. 
7.4. Other examinations. 
1) 
12-lead electrocardiogram; 
2) 
Chest computed tomography; 
3) 
Abdominal ultrasound and abdominal CT when necessary; 
4) 
Echocardiography when necessary. 
5) 
Other examinations that the investigators consider appropriate. 
7.5. Follow-up. 
Patients will be followed up at days 14, 28, 42, 60, 90, 180, 270, 360 and 540 
after transplantation; data on infection, relapse, survival, and quality of life will 
be collected. 
 
8. 
Study endpoints 
8.1  Primary endpoint 
Incidence of severe aGVHD after transplantation within 100 days. 
8.2  Secondary endpoints 
Incidence of aGVHD (any grade) in various target organs, overall survival 
after transplantation, relapse-free survival rate, relapse rate, incidence of 
severe infections, safety of treatment, and total cost of treatment. 
 
9. 
Adverse event and severe adverse event 
Starting from the date of signing the informed consent form to the last visit, all 
adverse events will be evaluated and recorded according to the Common Terminology 
Criteria for Adverse Events version 5.0. 
 

 
 
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10. Sample size calculation 
The incidence rate of severe aGVHD within 100 days of previous pediatric patients at 
the IHCAMS was 26% during 1 December 2020 ¬ 13 January 2022. The incidence 
rate after using the daGOAT model will fall to 8% per the researchers’ estimation. To 
attain a 0.05 significance level, a 0.8 power at a presumed 5% dropout rate, ≥ 40 
participants will need to be enrolled. 
 
11. Statistical analysis 
SAS and R statistical analysis software will be used to conduct the statistical analysis 
tailored to data properties. Efficacy and safety variables will be compared with the 
predefined target value. All comparison tests will be two-sided, and statistical 
significance will be defined as P < 0.05 in all the analyses. 
 
12. Ethical review 
The study will be conducted in accordance with the Declaration of Helsinki (2013), 
relevant regulations issued by the government of the People’s Republic of China, and 
additional precautions required by the ethics review committee at the IHCAMS. 
Before the study, the investigator will obtain approvals from the ethics review 
committee at the IHCAMS regarding the study protocol data sheet, informed consent 
form, subject enrollment form, and other relevant information to be provided to the 
subject before enrollment. During the study, if there is any amendment to the study 
protocol data sheet, informed consent form, subject enrollment form, and other 
relevant information to be provided to the subject before enrollment, renewed 
approvals shall be obtained before continuation of the study. 
 

 
 
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13. Preservation of research data 
All data of this study will be stored at the IHCAMS. Data sharing among the 
researchers will abide by the regulations of the People’s Republic of China regarding 
desensitization.