Clinical trial NCT04167514
Conditions: Graft Versus Host Disease (GVHD)
Sponsor: CSL Behring
Start date: 2020-01-09; Completion date: 2024-06-26
Enrollment: 136 participants; Allocation: RANDOMIZED; Intervention model: PARALLEL

Brief summary:
Study CSL964\_5001 will investigate the efficacy of AAT with corticosteroids compared with corticosteroids alone as first line therapy for patients with high-risk acute GVHD

Detailed description:

Arms: arm 1: Alpha-1 antitrypsin (AAT) is a lyophilized powder for intravenous administration arm 2: Albumin solution administered intravenously
Interventions: intervention 1: Alpha-1 antitrypsin (AAT) intervention 2: Placebo
Intervention descriptions: intervention 1: AAT is a lyophilized product for intravenous administration intervention 2: Albumin solution administered intravenously

Protocol documents:
SAP_002.pdf: 
 
 
 
 
A Randomized, Double-Blind, Placebo-Controlled Multicenter Phase III Trial of 
Alpha 1 – Antitrypsin (AAT) Combined with Corticosteroids vs 
Corticosteroids Alone for the Treatment of High Risk Acute Graft-versus-Host 
Disease (GVHD) Following Allogeneic Hematopoietic Stem Cell Transplant 
 
BMT CTN 1705/CSL964_5001 
IND#: 18195 
NCT#: 04167514 
 
STATISTICAL ANALYSIS PLAN 
Version 3.0 
November 30, 2023 
 
 
Effective by: December 7, 2023 
 
 
 
 
 
 
 
 
 
 
 
 


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VERSION HISTORY 
Version numbers will always be whole numbers and any changes to the document require up-
versioning. 
Version 
# 
Creation/ 
Revision 
Date 
(DDMMMYYYY) 
Approved 
By 
Effective Date 
(DDMMMYYYY) 
Reason for Change 
1.0 
24FEB2022 
11MAR2022 
Initial document 
2.0 
04JUL2022 
14JUL2022 
Protocol Amendment 
3.0 
30NOV2023 
07DEC2023 
Protocol Amendment 
PPD
PPD
PPD


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TABLE OF CONTENTS 
1 INTRODUCTION ....................................................................................................... 1 
2 STUDY SCHEMA AND PATIENT ASSESSMENT SCHEDULE ............................... 1 
2.1 
Study Schema .......................................................................................................... 1 
2.2 
Schedule of Assessments ......................................................................................... 2 
3 STUDY OBJECTIVES AND DESIGN ........................................................................ 4 
3.1 
Study Objective ........................................................................................................ 4 
3.2 
Primary Objective ..................................................................................................... 4 
3.3 
Secondary Objectives ............................................................................................... 4 
3.4 
Exploratory Objectives .............................................................................................. 4 
3.5 
Study Design ............................................................................................................ 5 
3.6 
Randomization .......................................................................................................... 6 
4 SAMPLE SIZE AND POWER CONSIDERATIONS .................................................. 7 
4.1 
Historical Data .......................................................................................................... 7 
4.2 
Statistical Design and Sample Size Determination.................................................... 8 
4.3 
Simulation Study ....................................................................................................... 9 
5 ANALYSIS POPULATION ...................................................................................... 10 
5.1 
Intention to Treat Population ....................................................................................10 
5.2 
Modified Intention to Treat Population......................................................................10 
5.3 
Safety Analysis Population ......................................................................................10 
5.4 
Pharmacokinetic Analysis Population ......................................................................10 
6 ANALYSIS VARIABLES ......................................................................................... 10 
6.1 
Acute GVHD Response Definitions ......................................................................10 
6.2 
Primary Endpoint – Overall Response at Day 28 .................................................12 
6.3 
Secondary Endpoints ...........................................................................................13 
6.3.1 
Duration of Response (DOR) ...............................................................................13 
6.3.2 
Non-Relapse Mortality (NRM) ..............................................................................13 
6.3.3 
Overall Survival (OS) ...........................................................................................14 
6.3.4 
Progression Free Survival (PFS) ..........................................................................14 
6.3.5 
GVHD-Free Survival ............................................................................................17 
6.3.6 
Acute GVHD Response to AAT/PTM ...................................................................17 
6.3.7 
Acute GVHD Response Allowing for Approved Next-Line Therapy ......................17 
6.3.8 
Systemic Infections ..............................................................................................18 


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6.3.9 
Adverse Events ....................................................................................................19 
6.3.10 
Chronic GVHD .....................................................................................................19 
6.3.11 
Relapse/Progression of the Primary Disease .......................................................19 
6.4 
Exploratory Endpoints ..........................................................................................20 
6.4.1 
Serum AAT Levels ...............................................................................................20 
6.4.2 
Stool AAT Levels .................................................................................................20 
6.4.3 
Immune Cell Subsets ...........................................................................................20 
6.4.4 
Inflammatory Cytokines and GVHD Biomarkers ...................................................20 
6.4.5 
Overall and Organ Specific Response Rates by GVHD and Biomarker-Based  
Risk Classifications ..............................................................................................20 
6.4.6 
Systemic Corticosteroid Dose ..............................................................................21 
6.4.7 
CMV Reactivation ................................................................................................21 
6.4.8 
Patient Reported Outcomes .................................................................................22 
6.5 
Safety Variables ...................................................................................................22 
7 STATISTICAL METHODOLOGY ............................................................................ 24 
7.1 
General Guidelines ..................................................................................................24 
7.2 
Demographics and Disposition ................................................................................25 
7.2.1 
Demographics and Baseline Characteristics ........................................................25 
7.2.2 
Participant Disposition .........................................................................................26 
7.2.3 
Protocol Deviations ..............................................................................................26 
7.3 
Study Treatment ......................................................................................................27 
7.4 
Analysis of Primary Endpoint – Overall Response at Day 28 ...................................27 
7.4.1 
Analysis Strategy .................................................................................................27 
7.4.2 
Interim Futility Analysis ........................................................................................30 
7.4.2.1 Primary Analysis ..................................................................................................30 
7.4.2.2 Sensitivity Analysis ..............................................................................................30 
7.4.2.3 Decision Criterion ................................................................................................30 
7.4.3 
Final Analysis.......................................................................................................30 
7.4.3.1 Pivotal Analysis ....................................................................................................30 
7.4.3.2 Sensitivity Analysis Regarding Potential Unblinding Incident (SA1) .....................31 
7.4.3.3 Sensitivity Analysis Regarding January 2021 Study Drug Supply Disruption  
(SA2) ...................................................................................................................31 
7.4.3.4 Supplementary Analyses .....................................................................................31 
7.4.3.5 Decision Criterion ................................................................................................32 


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7.5 
Analysis of Secondary Endpoints .............................................................................32 
7.5.1 
Duration of Response (DOR) ...............................................................................32 
7.5.2 
Non-Relapse Mortality (NRM) ..............................................................................33 
7.5.3 
Overall Survival (OS) ...........................................................................................34 
7.5.4 
Progression-Free Survival (PFS) .........................................................................35 
7.5.5 
GVHD-Free Survival ............................................................................................36 
7.5.6 
Acute GVHD Response to AAT/PTM ...................................................................37 
7.5.7 
Acute GVHD Response Allowing for Approved Next-Line Therapy ......................37 
7.5.8 
Systemic Infections ..............................................................................................38 
7.5.9 
Adverse Events (AEs) ..........................................................................................38 
7.5.10 
Chronic GVHD .....................................................................................................38 
7.5.11 
Relapse/Progression of Primary Disease .............................................................38 
7.6 
Analysis of Exploratory Endpoints ............................................................................39 
7.6.1 
Serum AAT Levels ...............................................................................................39 
7.6.2 
Stool AAT Levels .................................................................................................39 
7.6.3 
Immune Cell Subsets ...........................................................................................39 
7.6.4 
Inflammatory Cytokines and GVHD Biomarkers ...................................................39 
7.6.5 
Overall and Organ-Specific Response Rates by GVHD and Biomarkers  
Based Risk Classifications ...................................................................................40 
7.6.6 
Systemic Corticosteroid Dose ..............................................................................40 
7.6.7 
CMV Reactivation ................................................................................................40 
7.6.8 
Patient Reported Outcomes .................................................................................40 
7.7 
Interim Analyses ......................................................................................................41 
7.7.1 
Futility Analysis of Primary Endpoint ....................................................................41 
7.7.2 
Analysis for 6-Month Clinical Study Report ..........................................................41 
7.8 
Safety Analysis ........................................................................................................41 
7.8.1 
Data and Safety Monitoring Board .......................................................................41 
7.8.2 
Statistical Monitoring Rules ..................................................................................42 
7.8.3 
Safety Event Summaries for Analysis Reports .....................................................42 
7.9 
Missing Data and Sensitivity Analysis ......................................................................42 
7.10 
Assessment of Impact of COVID-19 on Trial Results ...............................................42 
7.10.1 
COVID-19 Related Modifications to Data Collection.............................................42 
7.10.2 
COVID-19 Related Events and Visit Disruptions ..................................................43 
7.10.3 
Sensitivity Analysis of the Primary Endpoint ........................................................43 


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7.11 
Changes to Protocol-Specified Analysis ..................................................................43 
8 REFERENCES ........................................................................................................ 44 
APPENDIX A: STATISTICAL ANALYSIS PLAN APPROVAL SIGNATURE PAGE ... 46 
APPENDIX B: INTERIM ANALYSIS FOR FUTILITY: DSMB DATA  
                        PRESENTATION PLAN ........................................................................ 47 
 
 


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LIST OF ABBREVIATIONS 
Abbreviations  
Description of Abbreviations 
aGVHD 
Acute Graft-Versus-Host Disease 
AAT 
Alpha 1 - Antitrypsin 
AE 
Adverse Event 
AESI 
Adverse Event of Special Interest 
ALT 
Alanine Aminotransferase 
AREG 
Amphiregulin 
AST 
Aspartate Aminotransferase 
BMT 
Blood and Marrow Transplant 
BMT CTN 
Blood and Marrow Transplant Clinical Trials Network 
BSA 
Body Surface Area 
Cmax 
Maximum Concentration 
Ctrough 
Trough Concentration 
CBC 
Complete Blood Count 
CI 
Confidence Interval 
CLL 
Chronic Lymphocytic Leukemia 
CMV 
Cytomegalovirus 
COVID-19 
Coronavirus Disease 2019 
CR 
Complete Response 
CRF 
Case Report Form 
CS 
Corticosteroids 
CT 
Computerized Tomography 
CTCAE  
Common Terminology Criteria for Adverse Events 
DOR 
Duration of Response 
DSMB  
Data and Safety Monitoring Board 
EOT 
End of Therapy 
FDG 
Fluoro-Deoxyglucose 
GI 
Gastrointestinal 
GVHD 
Graft-Versus-Host Disease 
HSCT 
Hematopoietic Stem Cell Transplantation 
HQL 
Health Quality of Life 
IL 
Interleukin 
IMP 
Investigational Medicinal Product 
IND 
Investigational New Drug 
IRT 
Interactive Response Technology 
ITT 
Intention-to-Treat 
IV 
Intravenous 
mITT 
Modified Intention-to-Treat 
MAGIC 
Mount Sinai Acute GVHD International Consortium 
MDASI 
MD Anderson Symptom Inventory 


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Abbreviations  
Description of Abbreviations 
MDS 
Myelodysplastic Syndromes 
MN 
Refined Minnesota Risk 
MOP 
Manual of Procedures 
MP 
Methylprednisolone 
MR 
Mixed Response 
NCT 
National Clinical Trial 
NHLBI 
National Heart, Lung, and Blood Institute 
NIH 
National Institutes of Health 
NK 
Natural Killer 
NR 
No Response 
NRM 
Non-Relapse Mortality 
ORR 
Overall Response Rate 
OS 
Overall Survival 
PCR 
Polymerase Chain Reaction 
PET 
Positron Emission Tomography 
PFS 
Progression-Free Survival 
PK 
Pharmacokinetics 
PR 
Partial Response 
PROMIS 
Patient-Reported Outcomes Measurement Information System 
PTM 
Placebo to Match 
REG3α 
Regenerating Family Member 3 Alpha 
SAE 
Serious Adverse Events 
SAP 
Statistical Analysis Plan 
ST2 
Suppression of Tumorigenicity 2 
TD 
Treatment Discontinuation 
Teff 
T Effector Cell 
TF 
Treatment Failure 
TLFs 
Tables, Listings, and Figures 
TNFα 
Tumor Necrosis Factor Alpha 
Treg 
T Regulatory Cell 
VGPR 
Very Good Partial Response 


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INTRODUCTION 
This Statistical Analysis Plan (SAP) elaborates upon the analysis strategy introduced in the study 
protocol and includes detailed procedures for completing the statistical analysis of efficacy and 
safety endpoints.  
The content herein is based on BMT CTN Protocol 1705 version 5.0.  In order to prevent bias from 
arising in the analysis, Versions 1.0 and 2.0 of the SAP were finalized and signed before the first 
analysis of study data at the planned interim analysis.  If required, further revisions to the approved 
SAP may be made prior to the database hard lock.  Future revisions will be version controlled. 
This statistical analysis is coordinated by the responsible biostatistician at Emmes.  Any changes 
to the analyses described in the SAP will be detailed and justified in the final analysis report. 
2 
STUDY SCHEMA AND PATIENT ASSESSMENT SCHEDULE 
2.1 STUDY SCHEMA 
* IMP and CS dosing is the 
same for adolescent and 
adult patients. 


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2.2 SCHEDULE OF ASSESSMENTS 
Table 1: Required Assessments Post-Enrollment 
Notes: 
*      +/- 3 days from the target day to allow for scheduling flexibility, holidays, etc.   
**    +/- 14 days from the target day to allow for scheduling flexibility 
***  +/- 28 days to allow for scheduling flexibility 
**** 60 days to allow for scheduling flexibility 
1 
Pre-therapy assessments preferably should be performed prior to enrollment; however, up to 36 hours post-enrollment is allowed. 
2 
End of Treatment assessments (except specimen collection) for patients that terminate treatment early will be done 30 days after the last dose of study drug. A 
+/-  3-day window is allowed. 
3      Pregnancy test (by blood) for females of childbearing potential within 30 days prior to enrollment. Serum or urine test on Day 28 and Day 56. 
4 
Includes anti-viral prophylaxis 
5      AEs and SAEs will be reported from randomization until 30 days post last dose. Beginning at 31 days from the last dose of study drug through the end of study 
follow-up, SAEs deemed to be related to the study drug require reporting, and any unanticipated SAE regardless of relationship to study drug require reporting. 
6 
Only English- and Spanish-speaking patients are eligible to participate in the Health Quality of Life (HQL) component of this trial. MDASI surveys to be completed 
by both English- and Spanish-speaking patients. PROMIS surveys to be completed by English speaking patients only. Surveys may not be completed by 
surrogates. 
7 
The Chronic GVHD Provider Survey is due at each Chronic GVHD evaluation and will record GVHD symptoms present in the last week and must be completed 
by a clinician on the day of the assessment. 
 
Days 
 
 
Pre-
Enrollment  
Pre-
Therapy1 
7* 
14* 
21* 
28* 
35* 
42* 
49* 
56 *  
86 
(3 mos)** 
120** 6 mos*** 
EOT2 
(+ 30 
days) 
12 mos**** 
History, physical exam, weight and height 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Karnofsky/Lansky Performance Status  
X 
 
 
 
 
X 
 
 
 
X 
X 
 
X 
 
X 
Pregnancy test if applicable3 
X 
 
 
 
 
X 
 
 
 
X 
 
 
 
 
 
Acute GVHD evaluation 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
X 
 
X 
Liver Function Tests (alkaline phosphatase, 
bilirubin, AST, ALT) 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
X 
 
X 
CBC with differential, platelet count 
X 
 
 
X 
 
X 
 
 
 
X 
X 
 
 
 
 
Immunosuppressive drug monitoring (e.g., 
sirolimus, tacrolimus, cyclosporine) 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
X 
X 
X 
Determination of corticosteroid dose, including 
administered dose and patient weight 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
X 
X 
X 
Chronic GVHD evaluation7 
 
 
 
 
 
X 
 
 
 
X 
X 
 
X 
 
X 
Toxicity assessment 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
 
 
Infection monitoring4 
 
Reporting of infections at time of occurrence from time of enrollment through 3 months 
 
 
AE/SAE assessments5 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
X5 
X5 
X5 
Patient-reported outcomes6: MDASI, PROMIS 
 
X 
 
 
 
X 
 
 
 
X 
 
 
X 
 
 


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Table 2: Required and Optional Assessments Post-Treatment Initiation 
Type 
Purpose 
Day 
Pre-Therapy2 
0 
8 
16 
24 
28 
56 
TD3 
Required 
Study drug levels1 
X 
X 
X 
X 
X 
X 
X 
 
Serum Inflammatory Cytokines and GVHD 
Biomarkers4 
X 
 
X 
 
 
X 
X 
X 
Flow Cytometry4 
X 
 
 
X 
 
X 
X 
X 
Optional (at select centers) 
Stool research samples5 
X 
 
X 
 
 
X 
 
X 
Notes: Enrollment is Day 0. First dose of study drug must occur within 12 hours after enrollment and may fall on Day 0 or Day 1. 
1   Samples should be drawn just prior to each study drug infusion (and also within 15 to 45 minutes post-end of infusion for the Day 0, 16, 28, and 
56 samples). 
2 Collect sample prior to administering study drug. 
3 The sample should be collected at treatment discontinuation (TD) if that occurs prior to Day 28 (stool)/56 (blood). (Note: This is at the time that 
patient discontinues the study drug.) 
4 The collection of required research blood samples for serum biomarkers and flow cytometry studies should be coordinated with the collection of 
the pre-drug infusion blood samples for AAT level measurements. If the study drug is administered before or after the indicated day, but within 
the treatment window (Section 2.5.1.7), the timing of the research sample collection can be adjusted accordingly. If not possible for some reason 
to not coordinate the research sample collection, the window of collection for research blood samples are ± 3 day. 
5 Stool samples being collected from consenting patients at selected centers with active Microbiome laboratories should be collected if possible, 
on the target visit day indicated or within ± 3 days of the scheduled visit.


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STUDY OBJECTIVES AND DESIGN 
3.1 STUDY OBJECTIVE 
BMT CTN protocol #1705 a phase III, multicenter, double-blinded, randomized, placebo-
controlled trial designed to compare AAT and corticosteroids (CS) to matched placebo/PTM 
and CS as first-line therapy for patients with high-risk acute GVHD. 
3.2 PRIMARY OBJECTIVE 
The primary objective of this trial is to compare the rate of overall (complete or partial) 
response on Day 28 post-randomization between AAT and CS versus placebo to match 
(PTM) and CS in patients with high-risk acute GVHD. 
3.3 SECONDARY OBJECTIVES 
Secondary objectives of the study are to assess the following: 
1. Duration of response at 6 and 12 months post-randomization. 
2. Cumulative incidence of non-relapse mortality (NRM) at 6 and 12 months post-
randomization. 
3. Overall survival (OS) and progression-free survival (PFS) at 6 and 12 months post-
randomization. 
4. GVHD-free survival at Day 56 post-randomization. 
5. Proportions of complete response (CR), very good partial response (VGPR), partial 
response (PR), and treatment failure (TF) at Days 7, 14, 21, 28, 56, and 86 post-
randomization. 
6. Proportions of CR, very good partial response (VGPR), PR, and treatment failure (TF) 
at Days 7, 14, 21, 28, 56, and 86 post-randomization for patients who receive 
Ruxolitinib or other second line therapies approved by the protocol Chairs as next-line 
therapy and remain on AAT/PTM. 
7. Incidence of systemic infections to assess safety. 
8. Incidence of adverse events (AEs) at 30 days post last dose of the drug to assess 
safety.  
9. Incidence of chronic GVHD at 6 and 12 months post-randomization. 
10. Incidence of disease relapse at 6 and 12 months post-randomization. 
3.4 EXPLORATORY OBJECTIVES 
The exploratory objectives of the study are to assess the following:   
1. AAT levels in serum at Days 0, 8, 16, 24, 28, and 56 post-treatment initiation. 
2. Stool concentrations of AAT at baseline and at Days 8 and 28 post-treatment initiation. 
3. Blood ratios of T regulatory to T effector cells (Treg/Teff), Natural Killer (NK) cells, and 
cellular immune subsets at baseline and at Days 16, 28, and 56 post-treatment 
initiation. 


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4. Serum levels of inflammatory cytokines and biomarkers at baseline and at Days 8, 28, 
and 56 post-treatment initiation. 
5. Overall and organ-specific response rates comparison based on Refined Minnesota 
(MN) risk groups (Revised Minnesota high vs. standard) and organ-specific response 
rates comparison based on biomarker-based risk groups. 
6. Corticosteroid-dose at baseline, Days 7, 14, 21, 28, 56, 86, 6 months and 12 months 
post-randomization. 
7. CMV reactivation requiring therapy by Day 56 post-randomization. 
8. Change in patient-reported outcomes from baseline to Days 28, 56 and 6 months post-
randomization.  
3.5 STUDY DESIGN 
This study is a phase III, multicenter, double-blinded, randomized, placebo-controlled trial 
designed to compare AAT and CS to PTM and CS as first-line therapy for patients with 
high-risk acute GVHD.  The targeted enrollment is 136 patients, accrued over three years 
from approximately 25 treatment centers with patients randomly allocated at a 1:1 ratio to 
treatment arms (68 patients per arm).  Patients will be followed for one year following 
enrollment. 
The primary endpoint is the overall (complete or partial) response to acute GVHD treatment 
at Day 28 post-randomization.  Patients without a Day 28 response assessment will be 
considered failures.  Acute GVHD will be graded and assessed for response based on 
Mount Sinai Acute GVHD International Consortium (MAGIC) Criteria (Harris et al. 2016). 
The primary hypothesis is that the overall (CR+PR) response rate of high risk acute GVHD 
will be improved under treatment by AAT and CS compared to PTM and CS.  Statistically, 
this will be evaluated by testing the null hypothesis that the odds ratio of overall response 
for the AAT+CS versus PTM+CS treatment arms is equal to 1 versus the alternative 
hypothesis that the odds ratio is greater than 1 after adjustment for the treatment center-
group (see definition in Section 7.4.1) and Minnesota (MN) risk category (high vs. 
standard).  An odds ratio greater than 1 indicates that the response rate is higher in the 
AAT+CS group compared with the PTM+CS group. This null hypothesis will be tested using 
a one-sided significance level of 2.5%. 
One interim analysis for futility is included, to be performed once 76 patients become 
evaluable for the primary endpoint. There will be no early stopping for efficacy based on 
the interim analysis results. 
To be eligible for this study, a patient must be experiencing an initial, clinically diagnosed 
presentation of acute GVHD after allogeneic transplant that requires systemic therapy with 
CS. Moreover, the acute GVHD must exhibit one of the following clinical features within 72 
hours prior to enrollment: (A) high risk by Refined Minnesota Criteria (Macmillan et al. 2015, 
defined below) or (B) isolated stage 2 involvement of the lower gastrointestinal (GI) tract or 
stage 1 lower GI tract disease with skin involvement.  


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High-risk by Refined Minnesota Criteria (any one below): 
• Single organ involvement 
a. 
Stage 4 skin 
b. 
Stage 3-4 lower GI 
c. 
Stage 1-4 liver 
• Multiple organ involvement  
a. Stage 1-2 lower GI plus any liver 
b. Stage 2 lower GI plus any skin 
c. Stage 3-4 lower GI plus any liver or skin 
d. Any three-organ involvement 
Under Versions 1.0 - 3.0 of the protocol, patients 18 years of age or older at enrollment 
were eligible for this study. Following release of Version 4.0, patients 12 years or older are 
eligible for this study. 
Other inclusion/exclusion criteria can be found in section 2.4 of the study protocol. 
Study drug (AAT/PTM) must be initiated as soon as possible after enrollment and no longer 
than 12 hours after enrollment.  Each dose of study drug will be 120 mg/kg (actual weight) 
based on the patient’s weight recorded at enrollment. Subsequent doses should be given 
on Days 4, 8, 12, 16, 20, 24, and 28.  The patient’s weight recorded at enrollment will be 
used to determine the dose for all infusions (i.e., dose adjustments for changes in weight 
during the treatment period will not be made).  Responding patients (CR/PR at Day 28), 
compared to maximum GVHD organ staging within 72 hours prior to enrollment, that are 
receiving study drug alone or study drug plus Ruxolitinib or other approved next-line therapy 
will continue to receive treatment at a dose of 120mg/kg (actual weight) on Days 35, 42, 
49, and 56.  Patients who are not in CR/PR at Day 28 will not continue to receive the study 
drug.  Responding patients at Day 28 who progress after Day 28 may continue to receive 
weekly doses through Day 56.  Patients that receive next-line therapy other than ruxolitinib 
may not continue receiving study drug unless approval is granted by the BMT CTN 1705 
Protocol Chairs.  All treatments will have a window of +/- 3 days to allow for efficient 
scheduling of patients for holidays/weekends/etc. 
3.6 RANDOMIZATION 
Participants will be randomized at a 1:1 ratio between the AAT and PTM treatment arms 
using permuted blocks of random sizes.  Randomization will be stratified by treatment 
center.  Randomization will be conducted in the Suvoda IRT system after enrollment has 
been completed in Advantage eClinical.  


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SAMPLE SIZE AND POWER CONSIDERATIONS 
4.1 HISTORICAL DATA 
The high risk acute GVHD patients included in the study population include patients with 
Minnesota (MN) high risk classification per the Refined Minnesota criteria, MN standard 
risk patients with isolated stage 2 involvement of the lower GI tract or stage 1 lower GI tract 
disease with skin involvement.  To determine the appropriate sample size for this study, 
historical data were used to determine the Day 28 overall response rate expected in this 
population under CS treatment.  In developing the Refined Minnesota risk criteria, 
Macmillan et al. 2015 used acute GVHD data collected from 1723 patients across multiple 
centers to estimate GVHD response rates in their acute GVHD risk classification of 
Minnesota (MN) high vs. standard risk.  Among MN high risk patients in this cohort, the Day 
28 overall response rate was 43% (Figure 1). 
Additionally, data from patients presenting with lower GI acute GVHD in the BMT CTN 0302 
and 0802 acute GVHD treatment trials and at MD Anderson Cancer Center during 2009-
2012 were examined.  Among these patients, those with isolated stage 2 lower GI or stage 
1 lower GI and skin involvement had observed Day 28 overall response rates of 50-57% 
(highlighted rows in Table 3), indicating a similar level of risk as to the MN high risk category 
despite being classified as “standard risk” per these criteria.  Therefore, they are included 
in the study population to increase the set of study eligible patients that may benefit from 
AAT+CS treatment.  As a whole, these historical control data suggest a Day 28 overall 
response rate of approximately 50% for the study population. 
Figure 1: Comparison of Day 28 Overall Response (CR+PR) Rates in MN Standard 
vs. High Risk acute GVHD patients (Macmillan et al. 2015). 
 
 


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Table 3: Observed Day 28 Response Rates for Patients with Lower GI GVHD from 
BMT CTN 0302/0802 Trials and MD Anderson Cancer Center 
 
MD Anderson Cancer 
Center 
BMT CTN 0302/0802 
Trials 
Organ Involvement 
N 
Day 28 CR/PR Rate 
N 
Day 28 CR/PR Rate 
Isolated Lower GI: 
 
 
 
 
Stage 1 
37 
73% 
8 
75% 
Stage 2 
14 
50% 
9 
56% 
Stage 3-4 
23 
48% 
15 
67% 
Lower GI + any liver: 
 
 
 
 
Stage 1 
9 
56% 
7 
43% 
Stage 2 
5 
40% 
8 
50% 
Stage 3-4 
12 
17% 
5 
0% 
Lower GI + any skin: 
 
 
 
 
Stage 1 
19 
53% 
30 
57% 
Stage 2 
10 
50% 
17 
41% 
Stage 3-4 
17 
35% 
17 
41% 
* Highlighted rows show Minnesota standard risk subgroups that were selected for inclusion in BMT 
CTN 1705 based in similar observed CR/PR rates to Minnesota high risk patients 
4.2 STATISTICAL DESIGN AND SAMPLE SIZE DETERMINATION 
The primary hypothesis is that the odds ratio for the overall response (CR+PR) at Day 28 
between the treatment groups, adjusted for treatment center and GVHD risk (MN high vs. 
standard risk), is greater than 1 (AAT+CS versus PTM+CS).  The primary analysis will be 
based on a Wald test from a logistic mixed model with the overall response as the 
outcomes, testing the odds ratio of treatment assignment, as described in section 6.4.1.1.  
The required sample size for this study is approximated using a two-sample Z-test of the 
difference in response rates.  Historical control data indicate that the overall response rate 
at Day 28 for high risk acute GVHD is approximately 50%.  We anticipate that AAT+CS 
treatment will increase the Day 28 overall response rate to 75%, corresponding to a 25% 
effect size.  To perform a one-sided test of the superiority of AAT+CS over PTM+CS with 
one interim analysis for futility, we use a two-stage design with one interim analysis for 
futility based on a Gamma family error spending function with 𝛾𝛾= −8.  The interim futility 
analysis was chosen to occur after 76 patients are evaluable for Day 28 response, at a 56% 
information fraction.  This design specification and the two-sample Z-test sample size 
calculation imply that a sample size of 136 patients (68 per arm) is required to sufficiently 
maintain a one-sided type I error of 2.5% while providing 86% statistical power for a one-
sided test to detect a 25% effect size.  
Operating characteristics of this sequential design with a two-sample Z-test of response 
rates are shown in Table 4 as an approximation to the operating characteristics provided 
by a logistic mixed model in this setting.  Kahan and Morris 2012 demonstrated that a 
stratified analysis improves statistical power for a specific set of analysis techniques.  
Based on their findings, we expect that the power provided by an unadjusted analysis via 
a two-sample Z-test comparing proportions is a lower bound to the power provided by the 
specified logistic mixed model.   


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Table 4: Group Sequential Design Stopping Thresholds for Z-test of Proportions 
with One-Sided Type I Error 2.5%, Power 86% and an Effect Size of 25% 
 
 
 
Futility Boundary Scales 
Probability of 
Stopping Early for 
Futility 
Info. 
Fraction 
Sample 
Size 
Nominal 
Cumulative 
Type II Error 
Rate 
Difference in 
Proportions 
Z-
Statistic 
Conditional 
Power at 
Alternative 
Under 
Null 
Under 
Alternative 
0.56 
76 
0.004 
-0.034 
-0.31 
0.089 
0.378 
0.004 
1.00 
136 
0.139 
0.163 
1.96 
- 
- 
- 
4.3 SIMULATION STUDY 
A simulation study was conducted to evaluate the power provided by a logistic mixed model 
in this sequential design.  Randomized treatment assignments were generated for each 
simulated trial using stratified randomized block design at a 1:1 ratio with permuted blocks 
of size 6, with center accrual numbers obtained from those observed in participating centers 
of the BMT CTN 1501 study.  Centers with fewer than 10 patients were combined, resulting 
in 6 center-groups of size 23, 19, 17, 15, 14, and 48.  We assumed these groups’ random 
effects are a random sample from a zero-mean normal distribution.  Additionally, we 
estimated that 65% of the patients would be classified as Refined Minnesota high risk, with 
GVHD risk (MN high vs. standard) included as a fixed effect in the logistic model for all 
simulations.  We considered possible effect sizes of 10%, 15%, 20%, and 25% and 
standard deviations for the random effects of 0.05, 0.60, and 1.00, with 1000 replicated 
trials simulated for each scenario. 
Simulation results in Table 5 indicate that, in the near absence of a random effect (i.e., 
when the standard deviation of the random effect is close to zero), the statistical power is 
at least 94.2% to detect an odds ratio of 3.0, corresponding to an effect size of 25%.  
Further, when the random effect is present (standard deviation of 0.6 or 1.0), statistical 
power is at least 92% and 90% to detect an odds ratio of 3.0.  For any other given effect 
size, the power levels are similar regardless of the variability of the random effects.  These 
results support the ability of the logistic mixed model to provide at least 86% power in this 
group sequential design. 
Table 5: Empirical Power for Logistic Mixed Model (1000 simulations per scenario) 
Effect Size (AAT vs. PTM) 
Power (%) 
Standard Deviation of Random Effects 
Difference in Day 28 CR/PR 
Odds Ratio 
0.05 
0.60 
1.00 
10% 
1.500 
25.5 
24.2 
20.8 
15% 
1.857 
53.8 
51.3 
48.4 
20% 
2.500 
85.0 
83.4 
79.6 
25% 
3.000 
94.2 
92.9 
90.1 


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5 
ANALYSIS POPULATION 
5.1 INTENTION TO TREAT POPULATION 
The intention-to-treat (ITT) population consists of all randomized subjects, classified 
according to their randomized treatment assignments.  All randomized subjects are 
included, regardless of whether the assigned study treatment was truly administered.  This 
population comprises the primary efficacy analysis population for the study. 
5.2 MODIFIED INTENTION TO TREAT POPULATION 
The modified intention-to-treat (mITT) population consists of all subjects from the intention-
to-treat population who initiate their randomized treatment. 
5.3 SAFETY ANALYSIS POPULATION 
The safety analysis population will include all randomized subjects who received at least 
one dose of study treatment.  Subjects will be classified according to the study treatment 
received. If a patient receives a dose of the incorrect study treatment (study treatment 
mismatched to the randomized assignment), they will be classified as follows: 
• 
If incorrect study treatment is received for the entire treatment period, the patient will be included 
in the treatment group corresponding to the study treatment received. 
• 
If incorrect study treatment is received for only one dose and the correct treatment is received 
for all other doses, the patient will be included in the correct treatment group with a narrative 
provided for any events occurring during the period for which the subject is incorrectly dosed. 
• 
If incorrect study treatment is received for more than one dose and the correct treatment is 
received for at least one other dose, the patient will be included in group corresponding to the 
majority of received doses; if equal numbers of doses of both treatments were received, they 
will be classified by their randomized assignment.  A narrative will be provided for any events 
occurring during periods for which the subject was incorrectly dosed. 
5.4 PHARMACOKINETIC ANALYSIS POPULATION 
The pharmacokinetic (PK) analysis population will include all subjects who received at least 
one dose of study treatment and with at least 1 quantifiable serum AAT antigen 
concentration or serum AAT concentration with functional activity. This population will be 
analyzed using the treatment the subject actually received.  
6 
ANALYSIS VARIABLES 
6.1 ACUTE GVHD RESPONSE DEFINITIONS 
The response of acute GVHD to study treatment is evaluated by comparing the organ 
staging at the assessment time to the maximum GVHD organ staging within 72 hours prior 
to enrollment.  Organ staging is performed in the acute GVHD target organs skin, upper GI, 
lower GI, and liver according to MAGIC criteria (Harris et al. 2016), which are shown in 
Table 6. 
 


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Table 6: Acute GVHD Organ Staging per MAGIC Criteria (Harris et al. 2016) 
Stage 
Skin  
Lower GI  
Upper GI  
Liver 
0 
No active (erythematous) 
GVHD rash 
Adult: Diarrhea 0-499mL/day or 0-3 
episodes/day 
Child: 
0.0-9.9mL/kg/day 
or 
0-4 
episodes/day 
No or intermittent 
nausea, vomiting, 
or anorexia 
Bilirubin 
< 2.0 mg/dL 
1 
Maculopapular rash 
< 25% BSA 
Adult: Diarrhea 500-999mL/day or 3-4 
episodes/day 
Child: 
10.0-19.9mL/kg/day 
or 
4-6 
episodes/day 
Persistent nausea, 
vomiting, 
or 
anorexia 
Bilirubin 
2.0-3.0 
mg/dL 
2 
Maculopapular rash 
25-50% BSA 
Adult: Diarrhea 1000-1500mL/day or 5-7 
episodes/day 
Child: 
20.0-30.0mL/kg/day 
or 
7-10 
episodes/day 
--- 
Bilirubin 
3.1-6.0 
mg/dL 
3 
Maculopapular rash 
> 50% BSA 
Adult: Diarrhea > 1500mL/day or > 7 
episodes/day 
Child: 
> 
30.0mL/kg/day 
or 
> 
10 
episodes/day 
--- 
Bilirubin 
6.1-15.0 
mg/dL 
4 
Generalized erythroderma 
(> 50% BSA) plus bullous 
formation 
and 
desquamation > 5% BSA 
Severe abdominal pain with or without 
ileus or grossly bloody stool (regardless 
of stool volume) 
--- 
Bilirubin 
>15.0 
mg/dL 
 
Response Definitions: 
• 
Complete response (CR) is defined as having a stage of 0 in all evaluable organs.  
• 
Very good partial response (VGPR) is defined as a quantitative and functional response that 
closely approximates CR.  Patients must have all of the following clinical features: 
o No rash or rash involving <25% of body surface area (BSA) without bullae (residual faint 
erythema and hyperpigmentation do not count) 
o Serum bilirubin <2mg/dl or <25% of baseline at enrollment 
o Ability to tolerate food or enteral feedings with predominantly formed stool (no overt GI 
bleeding or cramping and no more than occasional nausea or vomiting) 
• 
Partial response (PR) is defined as improvement in one or more acute GVHD target organs 
without progression in others.  Note that VGPR is a subset of PR. 
• 
Mixed response (MR) is defined as improvement in one or more organs with deterioration in 
another organ manifesting acute GVHD symptoms or development of acute GVHD symptoms 
in a new organ. 
• 
No response (NR) is defined as the absence of improvement or progression in any organ. 
• 
Progression is defined as deterioration in at least one organ without any improvement in others. 
Patients who die will be classified as non-responders (NR).  Patients who have an 
escalation of prednisone-equivalent steroid dose to 2.5mg/kg/day or higher will be 
classified as NR with the following exception: if a patient received a prednisone-equivalent 
dose of 2.5mg/kg/day or more on the randomization day, maintaining this starting dose is 
not automatically considered an NR, but escalation to a dose higher than the starting one 


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is an NR; moreover, if their dose is tapered below 2.5 mg/kg/day and later re-escalated to 
2.5 mg/kg/day or above, they will be classified as an NR. 
The receipt of next-line GVHD therapy also may impact how a patient is classified for GVHD 
response.  This affects the following endpoints as described: 
• 
Overall Response at Day 28, Duration of Response, Acute GVHD Response to 
AAT/PTM, Overall and Organ Specific Response Rate by GVHD and Biomarker-based 
risk Classifications: If a patient receives next-line GVHD therapy prior to a GVHD 
assessment visit, they will be classified as a non-responder (NR) for that assessment time. 
• 
Acute GVHD Response Allowing for Approved Next Line Therapy: If a patient receives 
next-line GVHD therapy that is not approved by the protocol chairs prior to a GVHD assessment 
visit, they will be classified as a non-responder (NR) for that assessment time.  However, the 
receipt of protocol chair-approved next-line therapy has no impact on the grading of GVHD 
response for this endpoint. 
• 
GVHD-free Survival: If a patient receives next-line GVHD therapy while being event-free, they 
will be classified as an event at the time point of the therapy’s initiation. 
6.2 PRIMARY ENDPOINT – OVERALL RESPONSE AT DAY 28 
Overall response at Day 28 is defined as having a complete or partial response at Day 28, 
i.e. having partial or complete resolution of acute GVHD symptoms in some organ(s) 
without worsening in any other(s) along with being alive, free of any next-line GVHD 
therapy, and free of escalation of prednisone-equivalent steroid dose to 2.5mg/kg/day or 
more.  Patients who have an escalation of prednisone-equivalent steroid dose to 
2.5mg/kg/day or higher will be classified as NR with the following exception: if a patient 
received a prednisone-equivalent dose of 2.5mg/kg/day or more on the randomization day, 
maintaining this starting dose is not automatically considered an NR, but escalation to a 
dose higher than the starting one is an NR; moreover, if their dose is tapered below 2.5 
mg/kg/day and later re-escalated to 2.5 mg/kg/day or above, they will be classified as an 
NR. 
Organ staging is performed by MAGIC criteria, shown in Table 6.  Patients with a missing 
Day 28 acute GVHD assessment will be classified as non-responders (NR).  A Day 28 
acute GVHD assessment conducted out of window (refer to Section 7.1 for visit window 
definition) will be considered as missing. 
A supplementary analysis described in Section 7.4.3.4 will include adjustment for the 
refined Minnesota risk category and the MAGIC biomarker risk score (Srinagesh et al. 
2019).  The MAGIC biomarker risk score will be computed from baseline levels of ST2 and 
REG3α per the following algorithm: 
• For each patient, compute their estimated 6 month non-relapse mortality risk 𝑝𝑝̂ 
according to 
𝑙𝑙𝑙𝑙𝑙𝑙൫−𝑙𝑙𝑙𝑙𝑙𝑙(1 −𝑝𝑝̂)൯= −11.263 + 1.844 𝑙𝑙𝑙𝑙𝑙𝑙10 𝑆𝑆𝑆𝑆2 + 0.577 𝑙𝑙𝑙𝑙𝑙𝑙10 𝑅𝑅𝑅𝑅𝑅𝑅3𝛼𝛼 
• If 𝑝𝑝̂ < 14.1%, biomarker score = 1; else if 𝑝𝑝̂ > 29.0%, biomarker score = 3; else, 
biomarker score = 2 


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6.3 SECONDARY ENDPOINTS 
For any time-to-event outcomes that follow, the analysis cutoff date will be defined as the 
date upon which a data freeze is performed for an analysis.  
6.3.1 
DURATION OF RESPONSE (DOR) 
DOR is defined as the time from Day 28 response (CR or PR) until the first of the following 
events occurs: progression of acute GVHD, death, any next-line GVHD therapy, or 
escalation of prednisone-equivalent steroid dose to 2.5mg/kg/day or more.  DOR will be 
evaluated in the set of patients that attain a response (CR or PR) on Day 28.  Progression 
is defined as the worsening by one stage or more from nadir in any acute GVHD target 
organ without improvement in other organs in comparison with the prior response.  In the 
DOR context, the prior response refers to Day 28 response (CR or PR); nadir in an organ 
refers to Day 28 stage of this organ.  For a patient in CR at Day 28, nadir is stage 0 in all 
target organs.   
DOR, in days, is calculated as (Date of acute GVHD progression, death, next-line acute 
GVHD therapy, escalation of prednisone-equivalent steroid dose to 2.5mg/kg/day or more, 
or last known to be alive) – (Date of Day 28 Response) +1. 
Table 7: DOR Definition 
Situation  
Date of Event or 
Censoring 
Outcome 
Death, acute GVHD progression, next-line acute 
GVHD therapy initiation, or steroid dose escalation 
≥ 2.5mg/kg/day before or on analysis cutoff date  
Date of event 
DOR event 
Death, acute GVHD progression, next-line acute 
GVHD therapy initiation, or steroid dose escalation 
≥ 2.5mg/kg/day; all events happened after analysis 
cutoff date  
Analysis cutoff date 
Censored 
No event occurred, last known date alive is before 
or on analysis cutoff date  
Last known date alive 
Censored 
No event occurred; last known date alive is after 
analysis cutoff date  
Analysis cutoff date 
Censored 
DOR = Date of Event or Censoring – Date of Day 28 Response + 1 
6.3.2 
NON-RELAPSE MORTALITY (NRM) 
NRM is defined as death without prior relapse/progression for the primary disease.  
Relapse/progression is treated as a competing risk for NRM and defined in section 6.3.4.  
The NRM time is defined as the time from the date of randomization until the documented 
date of relapse/progression or death from any cause, whichever happens first.  The 
outcome type is defined as shown in Table 8.  All relapses/progressions and deaths 
occurring on or after the randomization date will be included.  Patients who are event-free 
at the time of analysis will be censored at the last day known to be alive or at the analysis 
data freeze date, whichever is earlier.  Patients experiencing event(s) after the analysis cut-
off date will be censored at the analysis cut-off date. 


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Table 8: NRM and Relapse/progression Competing Risks Definition 
Situation  
Date of Event or Censoring Outcome 
Relapse/progression occurred before or on 
analysis cutoff date 
Date of relapse/progression 
Relapse/ 
progression 
Death 
without 
prior 
relapse/progression 
occurred before or on analysis cutoff date 
Date of death 
NRM 
Death and/or relapse/progression occurred, all 
events happened after analysis cutoff date 
Analysis cutoff date 
Censored 
No death or relapse/progression occurred, last 
known date alive is before or on cutoff date 
Last known date alive 
Censored 
No death or relapse/progression occurred; last 
known date alive is after the cutoff date 
Analysis cutoff date 
Censored 
Time of NRM = Date of Event or Censoring – Date of Randomization + 1 
6.3.3 
OVERALL SURVIVAL (OS) 
OS is defined as the absence of death; failures for OS include deaths from any causes.  
The OS time is defined as the time from the date of randomization until the documented 
date of death from any cause.  All deaths occurring on or after the randomization date will 
be included.  Patients who are still alive at the time of analysis will be censored at the last 
day known to be alive or at the analysis data freeze date, whichever is earlier.  Patients 
who died after the analysis cut-off date will be censored at the analysis cut-off date. 
Time of OS, in days, is calculated as (Date of death or last known to be alive) – (Date of 
Randomization) +1. 
Table 9: OS Definition 
Situation  
Date of Event or Censoring Outcome 
Death before or on analysis cutoff date  
Date of death  
Death 
Death after analysis cutoff date  
Analysis cutoff date  
Censored 
Last known date alive is before or on cutoff date  
Last known date alive 
Censored 
Last known date alive is after the cutoff date  
Analysis cutoff date  
Censored 
Time of OS = Date of Event or Censoring – Date of Randomization + 1 
6.3.4 
PROGRESSION FREE SURVIVAL (PFS) 
PFS is defined as being alive and free of relapse/progression of the primary disease.  
Failures for PFS include death from any cause and disease relapse/progression.  The PFS 
time is defined as the time from the date of randomization until the documented date of 
disease relapse/progression or death from any cause, whichever happens first. 
Malignancy Relapse/progression Definition:  
A subject’s underlying disease (i.e., malignancy) relapse/progression information is 
collected in the case report form. Relapse is defined by either morphological or cytogenetic 
evidence of acute leukemia or myelodysplastic syndrome (MDS), consistent with pre-


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transplant features, or radiologic evidence of lymphoma, documented or not by biopsy.  
Progression of disease applies to patients with lymphoproliferative diseases (lymphoma or 
chronic lymphocytic leukemia) not in remission prior to transplantation.  The event is 
defined as an increase in the size of prior sites of disease or evidence of new sites of 
disease, documented or not by biopsy.  In addition, the institution of any therapy to treat 
persistent, 
progressive, 
or 
relapsed 
malignancy, 
including 
the 
withdrawal 
of 
immunosuppressive therapy or donor lymphocyte infusion, will be considered evidence of 
relapse/progression regardless of whether the criteria described above were met. 
• Acute Leukemia: Relapse will be diagnosed when there is: 
o Reappearance of leukemia blast cells in the peripheral blood; or 
o > 5% blasts in the bone marrow not attributable to another cause (e.g. bone 
marrow regeneration) 
o The development of extramedullary leukemia or leukemic cells in the cerebral 
spinal fluid 
• MDS: Relapse will be diagnosed when there is: 
o Satisfaction of criteria for evolution into acute myeloid leukemia (blasts greater 
than 20%), or 
o Reappearance of pre-transplant morphological abnormalities detected in bone 
marrow specimens combined with a decrease in PB chimerism, OR 
o Reappearance of pre-transplant cytogenetic abnormality in at least one metaphase 
by routine metaphase cytogenetics or a positive test by FISH on each of two 
separate consecutive examinations at least one month apart, regardless of the 
number of metaphases analyzed 
o For patients with: 
 Less than 5% blasts: greater or equal to 50% increase in blasts to greater or 
equal to 5% blasts confirmed by flow cytometry  
 5%-10% blasts:  greater or equal to 50% increase to greater or equal to 10% 
blasts confirmed by flow cytometry  
Lymphoproliferative Diseases: Relapse or progression will be diagnosed when there is: 
o The appearance of any new lesion more than 1.5 cm in any axis during or at the 
end of therapy, even if other lesions are decreasing in size.  Increased fluoro-
deoxyglucose (FDG) uptake in a previously unaffected site will only be considered 
relapsed or progressive disease after confirmation with other modalities.  In 
patients with no prior history of pulmonary lymphoma, new lung nodules identified 
by CT are mostly benign.  Thus, a therapeutic decision should not be made solely 
based on the positron emission tomography (PET) without histologic confirmation. 


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o At least a 50% increase from the nadir in the sum of the product diameters of any 
previously involved nodes, or in a single involved node, or the size of other lesions 
(e.g., splenic or hepatic nodules).  To be considered a progressive disease, a 
lymph node with a diameter of the short axis of less than 1.0 cm must increase by 
≥ 50% and to a size of 1.5 x 1.5 cm or more than 1.5 cm in the long axis.  
o Lesions should be PET positive if observed in a typical FDG-avid lymphoma or the 
lesion was PET positive before therapy unless the lesion is too small to be 
detected with current PET systems (<1.5 cm in its long axis by CT). 
o In addition to the criteria above, patients with chronic lymphocytic leukemia (CLL) 
who present in complete remission prior to transplantation may fulfill the relapse 
definition if there is a reappearance of circulating malignant cells that are 
phenotypically characteristic of CLL.  
• Other Malignant Diseases: Probable or definitive evidence of progression must be 
documented by biopsy, imaging, or peripheral blood findings that are diagnostic or 
otherwise consistent with that disease state. 
Non-malignant Diseases: Patients with non-malignant diseases will be considered to 
have a transplant status of persistent/active disease.  Graft failures will be considered a 
relapse of the disease. 
All relapses/progressions and deaths occurring on or after the randomization date will be 
included.  Patients who are still alive and free of relapse/progression at the time of analysis 
will be censored at the last day known to be alive and progression-free or at the analysis 
data freeze date, whichever is earlier.  Patients experiencing relapse/progression or death 
after the analysis cut-off date will be censored at the analysis cut-off date. 
Time of PFS, in days, is calculated as (Date of relapse/progression, death, or last known 
to be alive) – (Date of Randomization) +1. 
Table 10: PFS Definition 
 
Situation  
Date of Event or Censoring Outcome 
Death or relapse/progression occurred before or 
on analysis cutoff date  
Date of relapse/progression 
or death  
PFS event 
Death and/or relapse/progression occurred, all 
events happened after analysis cutoff date 
Analysis cutoff date  
Censored 
No death or relapse/progression occurred, last 
known date alive is before or on analysis cutoff 
date 
Last known date alive 
Censored 
No death or relapse/progression occurred; last 
known date alive is after analysis cutoff date 
Analysis cutoff date  
Censored 
Time of PFS = Date of Event or Censoring – Date of Randomization + 1 


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6.3.5 
GVHD-FREE SURVIVAL 
GVHD-free survival is defined as being alive, free of active acute and chronic GVHD, free 
of any next-line GVHD therapy, and free of escalation of prednisone-equivalent steroid 
dose to 2.5mg/kg/day or more.  The following exception is permitted for steroid escalation: 
if a patient received a prednisone-equivalent dose of 2.5mg/kg/day or more on the 
randomization day, maintaining this starting dose is not automatically considered a failure, 
but escalation to a dose higher than the starting one is a failure; moreover, if their dose is 
tapered below 2.5 mg/kg/day and later re-escalated to 2.5 mg/kg/day or above, they will be 
classified as a failure.  Acute GVHD is defined per the MAGIC criteria (Harris et al. 2016) 
with grade 0 referring to no acute GVHD. Chronic GVHD is defined per the 2014 NIH 
Consensus Criteria.  The proportion of patients with GVHD-free survival will be evaluated 
at Day 56 post-randomization.  For the analysis of GVHD-free survival, a patient with a 
missing acute or chronic GVHD assessment will be considered to be a failure at the 
corresponding GVHD assessment Day.  An acute or chronic GVHD assessment conducted 
out of window (refer to Section 7.1 for visit window definition) will be considered as missing. 
6.3.6 
ACUTE GVHD RESPONSE TO AAT/PTM 
This endpoint focuses specifically upon the effect of the randomized treatment (AAT or 
PTM) alone on acute GVHD response, following a similar approach as for the primary 
endpoint at Day 28.  The proportions of patients with CR, PR (including the subset with 
VGPR), and treatment failure (TF) will be described at Days 7, 14, 21, 28, 56, and 86 post-
randomizations.  The designation of TF consists of patients with NR, MR, and acute GVHD 
progression.  The Day 86 response will be summarized only in patients remaining on study 
maintenance treatment (AAT/PTM) after Day 28.  Patients who die, initiate either approved 
or unapproved next-line GVHD therapy, or have escalation of prednisone-equivalent 
steroid dose to 2.5mg/kg/day or more prior to an acute GVHD assessment will be classified 
as non-responders (NR) at the corresponding Day with the following exception: if a patient 
received a prednisone-equivalent dose of 2.5mg/kg/day or more on the randomization day, 
maintaining this starting dose is not automatically considered an NR, but escalation to a 
dose higher than the starting one is an NR; moreover, if their dose is tapered below 2.5 
mg/kg/day and later re-escalated to 2.5 mg/kg/day or above, they will be classified as an 
NR.  Patients with a missing acute GVHD assessment will be classified as non-responders 
(NR) at the corresponding Day.  An acute GVHD assessment conducted out of window 
(refer to Section 7.1 for visit window definition) will be considered as missing. 
6.3.7 
ACUTE GVHD RESPONSE ALLOWING FOR APPROVED NEXT-LINE 
THERAPY 
This endpoint focuses upon the effect of the randomized treatment (AAT or PTM) on acute 
GVHD response, possibly in conjunction with an approved next-line therapy.  The 
proportions of patients with CR, PR (including the subset with VGPR), and treatment failure 
(TF) will be described at Days 7, 14, 21, 28, 56, and 86 post-randomization.  The 
designation of TF consists of patients with NR, MR, and acute GVHD progression.  The 
Day 86 response will be summarized only in patients remaining on study maintenance 
treatment (AAT/PTM) after Day 28.  Patients who die, initiate next-line GVHD therapy that 
is not approved by the protocol chairs, or have escalation of prednisone-equivalent steroid 


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dose to 2.5mg/kg/day or more prior to an acute GVHD assessment will be classified as 
non-responders (NR) at the corresponding Day with the following exception: if a patient 
received a prednisone-equivalent dose of 2.5mg/kg/day or more on the randomization day, 
maintaining this starting dose is not automatically considered an NR, but escalation to a 
dose higher than the starting one is an NR; moreover, if their dose is tapered below 2.5 
mg/kg/day and later re-escalated to 2.5 mg/kg/day or above, they will be classified as an 
NR.  Patients with a missing acute GVHD assessment will be classified as non-responders 
(NR) at the corresponding Day.  The acute GVHD assessment conducted out of window 
(refer to Section 7.1 for visit window definition) will be considered as missing. 
Note that this endpoint uses the same ITT population for analysis as the secondary 
endpoint defined in section 6.3.6, while the categorization of response for patients who 
receive a protocol chair approved next-line therapy differs between these two endpoints.  
The receipt of an approved next-line therapy will be categorized as a failure (NR) for the 
endpoint in 6.3.6, while for this secondary endpoint 6.3.7 the receipt of an approved next-
line GVHD therapy is not automatically considered a failure (NR) and, consequently, such 
a patient is still assessed for GVHD response as specified in Section 6.1. 
6.3.8 
SYSTEMIC INFECTIONS 
The incidence of Grade 2 to 3 systemic infections occurring from randomization until 30 
days after the last dose of the study drug (AAT or PTM) will be described.  Grade 2 to 3 
systemic infections are defined according to BMT CTN Manual of Procedures (MOP).  
Death before infection will be treated as a competing risk.  Infection time is defined as the 
time from the date of randomization until the documented date of infection onset or death 
from any cause, whichever happens first.  The outcome type is defined as shown in Table 
11.  All infections and deaths occurring on or after the randomization date will be included.  
Patients who are alive and free of infection onset at the time of analysis will be censored at 
the last day known to be alive or at the analysis data freeze date, whichever is earlier.  
Patients experiencing event(s) after the analysis cut-off date will be censored at the 
analysis cut-off date. 
Table 11: Systemic Infections Competing Risks Definition 
Situation  
Date of Event or Censoring Outcome 
Infection occurred before or on analysis cutoff 
date 
Date of infection onset 
Infection 
Death without prior infection onset occurred 
before or on analysis cutoff date 
Date of death 
Death 
Death and/or infection onset occurred, all events 
happened after analysis cutoff date 
Analysis cutoff date 
Censored 
No death or infection onset occurred, last known 
date alive is before or on analysis cutoff date 
Last known date alive 
Censored 
No death or infection onset occurred; last known 
date alive is after analysis cutoff date 
Analysis cutoff date 
Censored 
Time of Infection = Date of Event or Censoring – Date of Randomization + 1 


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6.3.9 
ADVERSE EVENTS 
The incidence of Grade 3-5 treatment-emergent adverse events occurring from 
randomization until 30 days after the last dose of study drug (AAT or PTM) will be described, 
where the grade is defined per Common Terminology Criteria for Adverse Events (CTCAE) 
Version 5.0. 
6.3.10 CHRONIC GVHD 
Chronic GVHD is defined per the 2014 NIH Consensus Criteria (Jagasia et al. 2015), with 
death before chronic GVHD treated as a competing risk.  Chronic GVHD time is defined as 
the time from the date of randomization until the documented date of chronic GVHD onset 
of any severity (mild, moderate, severe, or unknown) or death from any cause, whichever 
happens first.  All chronic GVHD onsets and deaths occurring on or after the randomization 
date will be included.  Patients who are event-free at the time of analysis will be censored 
at the last day known to be alive or at the analysis data freeze date, whichever is earlier.  
Patients experiencing event(s) after the analysis cut-off date will be censored at the 
analysis cut-off date. 
Table 12: Chronic GVHD Competing Risks Definition 
Situation  
Date of Event or Censoring Outcome 
Chronic GVHD onset occurred before or on 
analysis cutoff date 
Date of chronic GVHD onset 
Chronic 
GVHD 
Death without prior chronic GVHD onset 
occurred before or on analysis cutoff date 
Date of death 
Death 
Death and/or chronic GVHD onset occurred, all 
events happened after analysis cutoff date 
Analysis cutoff date 
Censored 
No death or chronic GVHD onset occurred, last 
known date alive is before or on analysis cutoff 
date 
Last known date alive 
Censored 
No death or chronic GVHD onset occurred, last 
known date alive is after analysis cutoff date 
Analysis cutoff date 
Censored 
Time of chronic GVHD = Date of Event or Censoring – Date of Randomization + 1 
6.3.11 RELAPSE/PROGRESSION OF THE PRIMARY DISEASE 
A relapse/progression of the primary disease is defined as in section 6.3.4.  Death without 
prior relapse/progression is treated as a competing risk for relapse/progression.  
Relapse/progression time is defined similarly as PFS time in section 6.3.4, with the outcome 
type defined as shown in Table 8.  All relapses/progressions and deaths occurring on or 
after the randomization date will be included.  Patients who are event-free at the time of 
analysis will be censored at the last day known to be alive or at the analysis data freeze 
date, whichever is earlier.  Patients experiencing event(s) after the analysis cut-off date will 
be censored at the analysis cut-off date. 


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6.4 EXPLORATORY ENDPOINTS 
6.4.1 
SERUM AAT LEVELS 
AAT levels will be assessed using measurements of serum antigen concentration and 
serum AAT concentration with functional activity (functional AAT concentration) just prior 
to infusion and 30 min (+/- 15 min) post-end of infusion on Day 0 and on Days 16, 28, and 
56 post-treatment initiation; these levels will also be assessed prior to infusion on Days 8 
and 24 post-treatment initiation.  Ctrough value is the serum AAT concentration of the 
sample collected prior to drug infusion and Cmax value is the serum AAT concentration of 
the sample collected within 15 to 45 minutes post-end of infusion.  Post-infusion 
measurements are limited to subjects receiving a dose of AAT/PTM.  
6.4.2 
STOOL AAT LEVELS 
Stool concentrations of AAT at baseline and at Days 8 and 28 post-initiation of treatment 
(or at treatment discontinuation (TD) if before Day 28) will be collected at a subset of centers 
for a limited cohort of patients. 
6.4.3 
IMMUNE CELL SUBSETS 
Peripheral blood ratios of T regulatory to T effector (Treg/Teff) cells and Natural Killer (NK) 
cell populations will be assessed at baseline and on Days 16, 28, and 56 post-treatment 
initiation (or at treatment discontinuation (TD) if before Day 56).  
6.4.4 
INFLAMMATORY CYTOKINES AND GVHD BIOMARKERS 
Serum levels of IL-1β, IL-6, IL-10, TNFα, amphiregulin (AREG), heparin sulfate, ST2, and 
REG3α will be evaluated at baseline and at Days 8, 28, and 56 post-treatment initiation (or 
at treatment discontinuation (TD) if prior to Day 56). 
6.4.5 
OVERALL AND ORGAN SPECIFIC RESPONSE RATES BY GVHD AND 
BIOMARKER-BASED RISK CLASSIFICATIONS 
The proportions of patients with an overall response (complete or partial) at Day 28 post-
randomization will be described by the MN risk category (high vs. standard) and by Ann 
Arbor biomarker risk score (1 vs. 2 vs. 3).  Additionally, the response rate of each GVHD 
target organ will be described on Day 28 by treatment arm, MN risk and Ann Arbor 
biomarker risk.  An organ overall response is defined as a decrease in its staging from 
baseline, along with being alive, free of any next-line GVHD therapy, and free of escalation 
of prednisone-equivalent steroid dose to 2.5mg/kg/day or more. The baseline staging refers 
to the maximum GVHD organ staging within 72 hours prior to enrollment. Patients who 
have an escalation of prednisone-equivalent steroid dose to 2.5mg/kg/day or higher will be 
classified as a non-responder with the following exception:  if a patient received a 
prednisone-equivalent dose of 2.5mg/kg/day or more on the randomization day, 
maintaining this starting dose is not automatically considered a non-response, but 
escalation to a dose higher than the starting one is an non-response; moreover, if their 
dose is tapered below 2.5 mg/kg/day and later re-escalated to 2.5 mg/kg/day or above, 
they will be classified as an non-response.  Patients will be classified as responders or non-
responders for each target organ accordingly.  Organ staging is performed by MAGIC 
criteria, shown in Table 6.  Patients with a missing Day 28 acute GVHD assessment will be 
classified as non-responders for all organs.  The Day 28 acute GVHD assessment 


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conducted out of window (refer to Section 7.1 for visit window definition) will be considered 
as missing.  The organ-specific response rate will be evaluated only using patients with a 
staging greater than 0 in the corresponding organ at baseline. 
The Ann Arbor biomarker risk score (Levine et al. 2015) will be computed from baseline 
levels of TNFR1, ST2, and REG3α.  The algorithm is as follows: 
• For each patient, compute their estimated 6 month non-relapse mortality risk 𝑝𝑝̂ 
according to 
𝑙𝑙𝑙𝑙𝑙𝑙൫−𝑙𝑙𝑙𝑙𝑙𝑙(1 −𝑝𝑝̂)൯= −9.169 + 0.598 𝑙𝑙𝑙𝑙𝑙𝑙2 𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇1 −0.028 𝑙𝑙𝑙𝑙𝑙𝑙2 𝑅𝑅𝑅𝑅𝑅𝑅3𝛼𝛼+ 0.189 𝑙𝑙𝑙𝑙𝑙𝑙2 𝑆𝑆𝑆𝑆2 
• If 𝑝𝑝̂ ≤10%, biomarker score = 1; else if 𝑝𝑝̂ ≥40%, biomarker score = 3; else, 
biomarker score = 2 
6.4.6 
SYSTEMIC CORTICOSTEROID DOSE 
The prednisone-equivalent corticosteroid dose will be evaluated at baseline; on Days 7, 14, 
21, 28, 56, 86; and at 6 and 12 months post-randomization.  Methylprednisolone doses will 
be converted to prednisone-equivalent doses through multiplication by a factor of 1.25.  
Dexamethasone will be converted to prednisone-equivalent doses through multiplication 
by a factor of 6.67. 
6.4.7 
CMV REACTIVATION 
Cytomegalovirus (CMV) reactivations to be assessed include those requiring new systemic 
treatment for a CMV PCR level per institutional practice (patients receiving only standard 
of care viral prophylaxis will not be included in this assessment).  Death prior to CMV 
reactivation will be treated as a competing risk.  CMV reactivation time is defined as the 
time from the date of randomization until the documented date of CMV reactivation or death 
from any cause, whichever happens first.  All CMV reactivations and deaths occurring on 
or after the randomization date will be included.  Patients who are alive and free of CMV 
reactivation at the time of analysis will be censored at the last day known to be alive or at 
the analysis data freeze date, whichever is earlier.  Patients experiencing event(s) after the 
analysis cut-off date will be censored at the analysis cut-off date.   
Table 13: CMV Reactivation Competing Risks Definition 
Situation  
Date of Event or Censoring Outcome 
CMV reactivation occurred before or on analysis 
cutoff date 
Date of CMV reactivation 
CMV 
reactivation 
Death without prior CMV reactivation occurred 
before or on analysis cutoff date 
Date of death 
Death 
Death and/or CMV reactivation occurred, all 
events happened after analysis cutoff date 
Analysis cutoff date 
Censored 
No death or CMV reactivation occurred, last 
known date alive is before or on analysis cutoff 
date 
Last known date alive 
Censored 
No death or CMV reactivation occurred, last 
known date alive is after analysis cutoff date 
Analysis cutoff date 
Censored 
Time of CMV reactivation = Date of Event or Censoring – Date of Randomization + 1 


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6.4.8 
PATIENT REPORTED OUTCOMES  
Patient self-reported measures for both adolescents (participants age 12.00 - 17.99 years 
at enrollment) and adults (age 18.00 or older) will be assessed at baseline, Days 28, 56, 
and 6 months post-randomization using the MD Anderson Symptom Inventory (MDASI) 
and selected PROMIS subscales assessing the domains of GI symptoms, physical 
function, and satisfaction with participation in social roles.  Adolescent versions of these 
assessments will be completed by adolescents. 
6.5 SAFETY VARIABLES 
Safety outcomes of interest include adverse events (AEs), serious adverse events 
(SAEs), and deaths.  SAEs are defined as AEs that resulted in one of the following 
outcomes: death, a threat to life, requiring or prolonging inpatient hospitalization, causing 
persistent or significant disability, causing a congenital anomaly or birth defect, are 
assessed as important medical events, or requiring intervention to prevent any of the 
aforementioned outcomes.  Treatment-emergent adverse events (TEAEs) are defined as 
AEs starting on or after the first infusion date of study drug. 
An AE/SAE can be classified as anticipated or unanticipated: 
• 
Anticipated AEs/SAEs are those that have been previously identified as resulting from the 
underlying disease, the HSCT, or acute GVHD and are not related to the study drug. 
• 
Unanticipated AEs/SAEs are those that vary in nature, intensity, or frequency from information 
in the current anticipated event list, the Investigator’s Brochure, the package insert, or when it 
is not included in the informed consent document as a potential risk.  Unanticipated events 
would also include those that have not been previously described as a result of the underlying 
disease requiring HSCT, the HSCT, or acute GVHD. 
*  The following are anticipated adverse events and do NOT require reporting as an 
AE/SAE: 
o Disease progression of primary malignancy 
o GVHD and symptoms of GVHD (these are recorded in acute and chronic GVHD eCRFs) 
o Infections 
o Graft failure 
o Medical or surgical procedures (condition that leads to the procedure is the AE) 
o Situations where an untoward medical occurrence has not taken place. For example: 
 
Planned hospitalizations due to pre-existing conditions, which have not worsened (e.g. 
HSCT) 
 
Hospitalizations that occur for procedures not due to an AE (e.g. cosmetic surgery) 
 
Hospitalizations for a diagnostic procedure where the hospital stay is less than 24 hours 
in duration or for normal management procedures (e.g. chemotherapy) 


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 
Overdose of AAT or any concomitant therapy that does not result in any adverse signs 
or symptoms 
* Laboratory findings do NOT need to be reported as AEs in the following cases: 
o Laboratory parameters already beyond the reference range at screening, unless a further 
increase/decrease can be considered an exacerbation of a pre-existing condition. 
o Abnormal hematological laboratory parameters considered anticipated due to myeloablative 
conditioning regimen, or other permitted chemotherapy treatments are not considered AEs. 
o An abnormal laboratory value that cannot be confirmed after repeat analysis, preferably in 
the same laboratory (i.e., the previous result could be marked as not valid and should not 
necessarily be reported as an AE). 
AEs and SAEs will be classified per CTCAE v5.0.  All non-serious adverse events will be 
reported from the time of randomization until 30 days after the last dose of study drug 
(AAT/PTM).  Anticipated non-serious adverse events will be collected on calendar- or 
event-driven forms.  All SAEs are required to be reported from the time of randomization 
until 30 days following the last dose of study drug.  In addition, any SAEs occurring after 
that 30-day period and assessed as unanticipated or related to the investigational product 
must be reported.  All SAEs are to be followed up until resolved, judged to be no longer 
clinically significant, or until they become chronic to the extent that they can be fully 
characterized. 
Any unanticipated SAEs from time of enrollment through the study defined follow up are 
required to be reported following the BMT CTN Administrative MOP Chapter 6.  
Additionally, any grade 4 anticipated AE not collected on the calendar-driven toxicity or a 
specified event-driven form must also be reported through the expedited AE reporting 
system in Advantage eClinical. 
Additionally, CSL Behring has a list of events classified as Adverse Events of Special 
Interest (AESI).  These include “anaphylactic infusional reaction” and “suspected 
transmission of a viral agent via a medicinal product.”  Both of these events must be 
reported through the expedited AE reporting system via Advantage eClinical and must be 
reported within 24 hours of knowledge of the event even if it does not meet the serious 
criteria. 
Toxicities are a subset of anticipated adverse events determined to be from the underlying 
disease process, HSCT, GVHD prophylaxis, or corticosteroid use, and generally, are not 
considered to be related to the study product.  The toxicities listed in Appendix E of the 
study protocol were pre-determined by the Protocol Team.  Once the participant has 
reached 31 days from the last dose of study drug, toxicities listed in Protocol Appendix E 
should be reported at the specified time points on the Toxicity CRF.  
The primary cause of death will be described for patients that expired on the study.  


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7 
STATISTICAL METHODOLOGY 
7.1 GENERAL GUIDELINES 
Counts and percentages will be used to describe categorical variables, while the number 
of subjects (N), median, mean, standard deviation, interquartile range and range will be 
used to summarize continuous variables. 
The study day for most efficacy and safety assessments will be computed in reference to 
the date of randomization, with the date of randomization defined as Study Day 0 for each 
patient.  For all assessments, the (Study) Day will be calculated as (assessment date – 
randomization date).  Unless otherwise specified, the visit window will be defined similarly 
to those specified in the protocol with the target day calculated in reference to the date of 
randomization.  For outcomes where data are summarized in reference to a different date, 
such as treatment initiation, the assessment time point is clarified explicitly. 
For each patient-reported outcome, the baseline value is defined as the outcome score 
assessed at the Pre-Therapy visit on the schedule of assessments (Section 2.2). For all 
other variables, unless otherwise specified, the baseline value is defined as the last 
available measurement prior to the first infusion of study drug if the measurement time was 
collected and the last available measurement before or on the date of the first infusion of 
study drug if the measurement time was not collected. 
Hypothesis testing for the primary endpoint’s analysis is one-sided, evaluating the 
superiority of AAT to PTM for Day 28 overall response, at a 2.5% significance level.  The 
testing for secondary endpoints will be two-sided at a 5% significance level and is 
equivalent to assessment by two one-sided tests, each at a 2.5% level.  Testing of 
exploratory endpoints will be two-sided at a 1% significance level.  Table 14 summarizes 
the endpoints to be analyzed for each analysis population. 
A hierarchical testing procedure will be employed to ensure control of the familywise type I 
error rate at a one-sided, 2.5% level when evaluating the primary and key secondary 
endpoints of interest.  A gatekeeping approach will be used with the following tests of 
superiority of AAT to PTM for the corresponding endpoints: 
1. Overall Response at Day 28: The Wald test from the primary analysis as specified 
in Section 7.4.3.1 (one-sided at 2.5% level) 
2. Duration of Response, Primary Definition: The log-rank test for comparing the DOR 
from Day 28 to 12 months post-randomization from the primary analysis as specified 
in Section 7.5.1 (two-sided at 5% level) 
3. Duration of Response, Supplementary Definition: The log-rank test for comparing 
the DOR from Day 28 to 12 months post-randomization from the supplementary 
analysis as specified in Section 7.5.1 (two-sided at 5% level) 
4. Non-relapse Mortality: The Gray’s test for comparing the cumulative incidence of 
NRM from randomization to 12 months post-randomization as specified in Section 
7.5.2 (two-sided at 5% level) 
5. Overall Survival: The log-rank test for comparing the OS from randomization to 12 
months post-randomization from the primary analysis as specified in Section 7.5.3 
(two-sided at 5% level) 


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6. Progression-free Survival: The log-rank test for comparing the PFS from 
randomization to 12 months post-randomization from the primary analysis as 
specified in Section 7.5.4 (two-sided at 5% level) 
7. GVHD-free Survival at Day 56: The Wald test from the logistic mixed model as 
specified in Section 7.5.5 (two-sided at 5% level) 
The gatekeeping procedure evaluates the endpoints sequentially in the order displayed and 
ends if the one-sided test or two-sided test for an endpoint fails to find a significant result 
showing superiority of AAT to PTM, precluding further testing of any remaining endpoints 
in the hierarchy.  This strategy ensures control of the one-sided familywise type I error rate 
at 2.5% and permits claims of confirmatory benefit for any endpoint(s) where superiority of 
AAT is demonstrated.  Any hypothesis testing performed outside the hierarchy is deemed 
descriptive in this study. 
Analyses for several endpoints involve adjustment for center effects through regression 
modeling.  Because the average number of patients enrolled per center is expected to be 
small (136/25 ≈ 5.5), centers will be combined into center-groups for these analyses to 
ensure the stability of the models.  This will be done by including the top 5 enrolling centers 
each as a separate group and combining all other centers into a sixth catchall group. 
All efficacy analyses will be conducted using the ITT population unless otherwise specified. 
Table 14: Endpoints for Analysis Under Each Analysis Population 
Analysis Population 
Primary 
Endpoint 
Secondary 
Efficacy 
Endpoints 
Exploratory 
Endpoints* 
except 
Serum AAT 
Levels 
Serum AAT 
Levels 
Safety 
Endpoints 
Intention-to-Treat (ITT) 
X 
X 
X 
 
 
Modified ITT 
X 
 
 
 
 
Pharmacokinetic 
 
 
 
X 
 
Safety 
 
 
 
 
X 
* The analysis populations related with biomarkers and stool AAT levels, if different from ITT population, will 
be defined and presented in a separate document depending on the data availability.  
All data processing, summarization, and analyses will be performed using SAS Version 9.4 
or higher and R version 3.5 or higher.  Specifications for the table, figure, and data listing 
formats can be found in the supplementary TLF shell document for this SAP. 
7.2 DEMOGRAPHICS AND DISPOSITION 
7.2.1 
DEMOGRAPHICS AND BASELINE CHARACTERISTICS 
Demographic and baseline characteristics will be summarized using descriptive statistics 
for the ITT population.   
Categorical variables to be examined include age at randomization (less than 18 years vs. 
18 - <55 years vs. 55 - <60 years vs. 60 years or older), gender, race, ethnicity, pre-
transplant Karnofsky/Lansky performance status (<90 vs. >=90), pre-transplant primary 
disease, pre-transplant disease type (malignant vs. non-malignant), pre-enrollment MAGIC 


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acute GVHD grade (I vs. II vs. III vs. IV), pre-enrollment MAGIC acute GVHD skin stage (0 
vs. 1 vs. 2 vs. 3 vs. 4), pre-enrollment MAGIC acute GVHD upper GI stage (0 vs. 1), pre-
enrollment MAGIC acute GVHD lower GI stage (0 vs. 1 vs. 2 vs. 3 vs. 4), pre-enrollment 
MAGIC acute GVHD liver stage (0 vs. 1 vs. 2 vs. 3 vs. 4), pre-enrollment refined MN risk 
classification (high vs. standard), acute GVHD eligibility criterion, graft source (bone 
marrow vs. peripheral blood vs. umbilical cord), donor sex, donor relatedness (biologically 
related vs. not biologically related), baseline Ann Arbor biomarker risk score (1 vs. 2 vs. 3), 
baseline MAGIC biomarker risk score (1 vs. 2 vs. 3), pre-enrollment GVHD prophylaxis, 
and conditioning regimen at transplant.  If and only if a categorical variable has missing 
data for some patient(s), a “Missing” category will be included as well for that variable with 
its frequency and percentage. Descriptive statistics for the baseline Ann Arbor biomarker 
risk score and the baseline MAGIC biomarker risk score may be provided in a separate 
report depending on the biomarker data availability. 
Continuous characteristics considered include age at randomization, time from steroid 
initiation to randomization, time from disease diagnosis to transplant, time from transplant 
to enrollment, height at transplant, weight at enrollment and body mass index at enrollment.  
Descriptive statistics will summarize values among non-missing observations. 
7.2.2 
PARTICIPANT DISPOSITION 
The number and percentage of patients experiencing the following events on study will be 
described: 
• 
Enrollment 
• 
Initiating study treatment (AAT or PTM) 
• 
Initiating next-line therapy (before Day 28, at/after Day 28) 
• 
Completing study treatment up to Day 28 
• 
Completing maintenance study treatment up to Day 56 
• 
Completing planned study follow-up alive (i.e., initiate study treatment and complete 1 year 
of follow-up alive) 
• 
Completing planned study follow-up (i.e. initiate study treatment and either die within 1 year 
and did not terminate study prior to the death or complete 1 year of follow-up alive) 
In addition, the reasons for patients failing to initiate study treatment, discontinuing study 
treatment after initiation, and withdrawing from the study will be tabulated. 
7.2.3 
PROTOCOL DEVIATIONS 
The number and percentage of patients in the ITT population with any major protocol 
deviation will be tabulated by the deviation type.  A listing of all protocol deviations for 
patients in the ITT population will be provided. 


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7.3 STUDY TREATMENT  
Compliance with protocol-prescribed usage of study treatment will be described based on 
the Safety population.  The recommended schedule for study treatment includes infusion 
at a dose of 120 mg/kg on Day 0, 4, 8, 12, 16, 20, 24, and 28.  The patient’s weight recorded 
at enrollment will determine the dose for all infusions. 
Responding patients (CR/PR) will continue to receive study treatment at a dose of 120 
mg/kg on Day 35, 42, 49, and 56. 
All subsequent treatments will have a window of ± 3 days to allow for efficient scheduling 
of patients for holidays/weekends/etc. 
An infusion may be held for the following reasons: 
• 
CTCAE Grade 3+ adverse event that is not attributable to an anticipated post-transplant event 
• 
Severe infection resulting in hemodynamic instability requiring the use of vasopressor 
medication 
• 
At the treating physician’s discretion 
Additionally, an infusion should be discontinued immediately if anaphylactic or severe 
anaphylactoid reactions occur. 
Study drug shall be discontinued and not re-instituted if any one of the following criteria is 
met: 
• 
The patient does not receive study medication for 3 consecutive doses or 4 doses in total for 
any reason, including toxicity 
• 
The patient receives next line therapy other than Ruxolitinib that is not approved by the Study 
Chairs 
• 
Relapse or progression of underlying malignancy 
• 
Pregnancy or initiation of breastfeeding during the study 
• 
Withdrawal of consent from study and/or study drug 
The number and percentage of patients who received all planned infusions overall and 
through Day 28 will be tabulated.  Additionally, treatment compliance will be summarized 
overall and through Day 28.  The number of patients who receive Ruxolitinib or other 
approved next-line therapies will be tabulated. 
7.4 ANALYSIS OF PRIMARY ENDPOINT – OVERALL RESPONSE AT DAY 28 
7.4.1 
ANALYSIS STRATEGY 
The primary objective of this study is to evaluate whether AAT treatment provides a superior 
Day 28 overall response (CR+PR) rate in contrast to placebo-to-match (PTM).  The overall 
response rate is suspected to differ by treatment center and Minnesota (MN) risk category 
(high vs. standard).  Because the average number of patients enrolled per center is 


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expected to be small (136/25 ≈ 5.5), centers will be combined into center-groups for these 
analyses to ensure the stability of the models.  This will be done by including the top 5 
enrolling centers each as a separate group and combining all other centers into a sixth 
catchall group. 
A logistic mixed model will be used to evaluate the effect of study treatment on Day 28 
overall response while accounting for these factors, with center-group included as a random 
effect and treatment arm (AAT vs. PTM) and MN risk as fixed effects. 
The primary hypothesis is that the Day 28 overall response rate under AAT treatment 
exceeds this proportion under PTM after adjusting for center and MN risk.  No interactions 
of center or MN risk with treatment assignments are expected.  Therefore, the null and 
alternative hypotheses for this comparison are: 
• 
H0: Adjusted odds ratio of response for AAT vs. PTM ≤ 1 
• 
HA: Adjusted odds ratio of response for AAT vs. PTM > 1 
This odds ratio will be evaluated in the logistic mixed model using a one-sided, group 
sequential test with an overall type I error rate controlled at 2.5%.  The standardized log 
odds ratio estimate from this model will be used as the test statistic (Z-statistic) at each 
stage. Positive values of the Z-statistic correspond to higher estimated odds of overall 
response for the AAT group compared to PTM.  
Sequential testing of the treatment effect of AAT relative to PTM will be performed using a 
two-stage design with one interim analysis for futility based on a Gamma family error 
spending function from Hwang et al. 1990 with 𝛾𝛾= −8.  The interim futility analysis will 
occur after 76 patients are evaluable for Day 28 response and the final analysis will happen 
after the total study population becomes evaluable. 
The primary analysis of Day 28 response will use the efficacy and futility boundaries 
displayed in Table 15, with efficacy/futility indicated if the Z-statistic falls above/below the 
respective boundary values.  Note that the futility boundary is non-binding in that the overall 
type I error rate will not be inflated beyond 2.5% if the trial continues after the futility 
boundary is reached.  The estimand for this primary analysis is specified in Table 16. The 
clinical question of interest is: what is the difference in overall response rate on Day 28 
post-randomization between AAT combined with corticosteroids versus PTM combined 
with corticosteroids in patients with high risk acute GVHD following allogeneic 
hematopoietic stem cell transplant (HSCT), regardless of discontinuation of study 
treatment? 
Table 15: Group Sequential Design Stopping Thresholds for Primary Endpoint: 
Primary Analysis Approach 
Analysis 
Information 
Fraction 
Sample 
Size 
Futility Boundary 
for Z-Statistic* 
Efficacy Boundary 
for Z-Statistic* 
Interim 
0.56 
76 
-0.31 
- 
Final 
1.00 
136 
- 
1.96 
* Positive values of the Z-statistic correspond to higher estimated odds of overall response for the AAT 
arm compared to placebo. 
Table 16: Estimand for Primary Endpoint - Day 28 Overall Response 


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Estimand Attribute 
Definition 
Variable 
Day 28 Overall Response, refer to Section 6.2 for details 
Treatment 
AAT (+corticosteroids) or PTM (+corticosteroids), refer to Section 2.1 
for details 
Population 
Patients with high risk acute GVHD following allogeneic HSCT 
Intercurrent Events 
Event 
Strategy 
Description 
1. Death before 
Day 28 visit 
Composite strategy 
Classified as a non-
response 
2. Initiation of 
additional systemic 
aGVHD treatment1 
before Day 28 visit 
Composite strategy 
Classified as a non-
response 
3. Discontinuation 
of study treatment 
Treatment policy 
No effect on determination 
of overall response status 
Population-level 
Summary 
Proportions and 95% CIs for each arm; adjusted odds ratio from logistic 
mixed model and its 95% CI 
1 Includes next-line GVHD therapy and escalation of prednisone-equivalent steroid dose to 2.5mg/kg/day or 
more. 
Due to a process error that has been corrected, there is a small chance that the treatment 
assignments of some participants were unblinded to their treatment center staff.  A 
maximum of 14 participants could have been affected.  To assess the robustness of the 
primary analysis results in consideration of this: 
1) In the event that the primary analysis reaches its futility boundary at the interim analysis, 
a sensitivity analysis would be conducted where these 14 participants will be omitted 
from the ITT analysis population; and 
2) At the final analysis, a sensitivity analysis will be conducted where these 14 participants 
will be omitted from the ITT analysis population. 
The sensitivity analyses would include 62 participants at interim and 122 at the final 
analysis. These analyses would be conducted using the ITT population and a similar 
estimand as in Table 16, with the only modification being the exclusion of the 14 potentially 
affected patients from the ITT population.  The efficacy and futility boundaries for the 
sensitivity analyses are displayed in Table 17. 
Table 17: Group Sequential Design Stopping Thresholds for Primary Endpoint: 
Sensitivity Analysis Approach 
Analysis 
Information 
Fraction 
Sample 
Size 
Futility Boundary 
for Z-Statistic* 
Efficacy Boundary 
for Z-Statistic* 
Interim 
0.51 
62 
-0.61 
- 
Final 
1.00 
122 
- 
1.96 
* Positive values of the Z-statistic correspond to higher estimated odds of overall response for the AAT 
arm compared to placebo. 


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Details on the conduct of the primary and sensitivity analyses of the Day 28 response rate 
and decisions on futility and/or efficacy to be made based on their findings are described 
in the subsequent sections. 
7.4.2 
INTERIM FUTILITY ANALYSIS 
7.4.2.1 PRIMARY ANALYSIS 
The interim futility analysis will be performed after 76 patients become evaluable for Day 
28 response.  The primary analysis approach will use the ITT population.  A logistic mixed 
model will be used to evaluate the effect of study treatment on Day 28 overall response 
while accounting for treatment center and MN risk category (high vs. standard), with center-
group included as a random effect and treatment arm and MN risk as fixed effects.  The 
standardized log odds ratio estimate for treatment arm from this model will be used as the 
test statistic (Z-statistic) and will be compared to the futility boundary in Table 15.  
7.4.2.2 SENSITIVITY ANALYSIS 
If the Z-statistic from the primary analysis is less than or equal to the futility boundary, a 
sensitivity analysis will be conducted that excludes from the ITT population the 14 
participants who could have potentially been affected by unblinding.  This analysis would 
use a logistic mixed model with treatment arm, MN risk, and treatment center-group 
included as covariates.  The standardized log odds ratio estimate for treatment arm would 
be used as the test statistic and compared to the futility boundary in Table 17.  
7.4.2.3 DECISION CRITERION 
If both the primary and sensitivity analysis results meet their corresponding futility 
boundaries, the trial will be stopped.  Otherwise, if one or both of the analyses do not meet 
their futility boundaries, the trial will continue. 
7.4.3 
FINAL ANALYSIS 
7.4.3.1 PIVOTAL ANALYSIS 
The final analysis will be performed after 136 patients become evaluable for Day 28 
response.  The primary analysis approach will use the ITT population.  A logistic mixed 
model will be used to evaluate the effect of study treatment on Day 28 overall response 
while accounting for treatment center-group and MN risk category (high vs. standard), with 
center-group included as a random effect and treatment arm and MN risk as fixed effects.  
The standardized log odds ratio estimate for treatment arm from this model will be used as 
the test statistic (Z-statistic) and will be compared to the efficacy boundary in Table 15.  
The proportion of patients with ORR at Day 28 will be described by treatment arm using 
sample proportions and 95% Wilson score CIs.  Adjusted odds ratio estimates from the 
logistic mixed model of Day 28 overall response will be summarized in a regression table. 


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7.4.3.2 SENSITIVITY ANALYSIS REGARDING POTENTIAL UNBLINDING INCIDENT 
(SA1) 
A sensitivity analysis will also be conducted that excludes from the ITT population the 14 
participants who could have potentially been affected by unblinding.  This analysis will use 
a logistic mixed model with treatment arm, MN risk, and treatment center-group included 
as covariates.  The standardized log odds ratio estimate for treatment arm would be used 
as the test statistic and compared to the efficacy boundary in Table 17.  The proportion of 
patients with ORR at Day 28 will be described by treatment arm using sample proportions 
and 95% Wilson score CIs.  Adjusted odds ratio estimates from the logistic mixed model of 
Day 28 overall response will be summarized in a regression table. 
7.4.3.3 SENSITIVITY ANALYSIS REGARDING JANUARY 2021 STUDY DRUG SUPPLY 
DISRUPTION (SA2) 
Due to a quality control error during the manufacturing process of the study drug, the study 
drug was recalled, and enrollment was put on hold in January 2021. This hold was lifted in 
May 2021 with release of version 3.0 of the protocol. 
The course of treatment was disrupted for two patients who were still receiving study drug 
at the time of the drug recall. To evaluate the sensitivity of analysis results to this disruption, 
we will conduct a sensitivity analysis of the primary endpoint according to the same 
procedure in Section 7.4.3.1 where any patients whose treatment courses were disrupted 
by the drug recall are excluded from the ITT analysis population.  This analysis would be 
conducted using the ITT population and a similar estimand as in Table 16, with the only 
modification being the exclusion of the 2 patients affected by the supply disruption from the 
ITT population. 
7.4.3.4 SUPPLEMENTARY ANALYSES 
Two supplementary analyses will investigate the potential influence of other variables on 
the primary analysis’ outcome in the ITT population.  Two logistic mixed models will be 
fitted with Day 28 overall response as the outcome.  One model will have fixed effects of 
treatment arm, MN risk, age (under 18 years vs. 18 years or older), and disease type 
(malignant vs. non-malignant) and a random effect of center-group; the second will also 
include these covariates in addition to the MAGIC biomarker risk score (1 vs. 2 vs. 3).  If 
no patients under 18 years old are enrolled and randomized, the fixed effect for age will be 
omitted from the model. The results from the second model may be presented in a separate 
report depending on the biomarker data availability. 
In addition to these protocol-specified supplementary analyses, an additional 
supplementary analysis will assess Day 28 overall response in comparison to the aGVHD 
organ staging at initiation of AAT/PTM (i.e., aGVHD organ staging collected at pre-therapy 
visit if available, and the maximum GVHD organ staging within 72 hours prior to enrollment 
if not available).  The analysis population will include the mITT patients, i.e., those who 
initiate their assigned study therapy.  A logistic mixed model will evaluate the effect of 
treatment arm on Day 28 overall response with adjustment for treatment center and MN 
risk as specified in Section 7.4.1.1. 


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Moreover, the effects of duration from the initiation of corticosteroid to the initiation of IMP 
(<= 24 hours vs. 24-48 hours vs. 48-72 hours vs. 72 hours or more) and dose of 
corticosteroid on Day 28 post-randomization (>= 2mg/kg/day vs. 1.00-1.99 mg/kg/day vs. 
0.26-1.00 mg/kg/day vs. 0.25 mg/kg/day or less, prednisone-equivalent) on Day 28 overall 
response will be evaluated using logistic mixed models that adjust for treatment center-
group and MN risk.  These analyses will use the mITT population. 
7.4.3.5 DECISION CRITERION 
The findings from the primary analysis alone will be used to judge efficacy of AAT in 
comparison to PTM for the primary endpoint at the final analysis.  If the primary analysis 
test statistic falls above the efficacy boundary, the study team will conclude that significant 
evidence of efficacy has been demonstrated; otherwise, the conclusion is that insufficient 
evidence of efficacy exists. 
7.5 ANALYSIS OF SECONDARY ENDPOINTS 
7.5.1 
DURATION OF RESPONSE (DOR) 
DOR will be evaluated in the set of patients in the ITT population who achieve a response 
(CR/PR) at Day 28.  DOR will be estimated using the Kaplan-Meier estimator, with the 
probability of having a durable response, i.e. retaining the CR/PR, evaluated at 6 and 12 
months post-randomization.  Estimates and 95% CIs for the median and quartiles of the 
DOR will be obtained from the Kaplan-Meier estimator using the inverse Kaplan-Meier 
method described in Andersen et al. 1993.  DOR will be compared from Day 28 to 12 
months post-randomization between arms using a log rank test.  DOR will also be displayed 
graphically using Kaplan-Meier curves with numbers of subjects at risk at specific time 
points presented for each treatment group. 
Primary and supplementary analyses will be performed.  In the primary analysis, DOR is 
defined as stated in section 6.3.1, as the time from Day 28 response to progression of acute 
GVHD, any next-line GVHD therapy, escalation of prednisone-equivalent steroid dose to 
2.5mg/kg/day or more, or death from any cause.  Its estimand is displayed in Table 18. The 
clinical question of interest is: what is the difference in duration of response between AAT 
combined with corticosteroids versus PTM combined with corticosteroids in patients with 
high risk acute GVHD following allogeneic HSCT who attain a Day 28 overall response, 
regardless of discontinuation of study treatment? 
Table 18: Estimand for Duration of Response - Primary Analysis 
Estimand Attribute 
Definition 
Variable 
Duration of Response; refer to Sections 6.3.1 and 7.9, and above for 
details 
Treatment 
AAT (+corticosteroids) or PTM (+corticosteroids), refer to Section 2.1 
for details 
Population 
Patients with high risk acute GVHD following allogeneic HSCT who 
attain a Day 28 overall response 
Intercurrent Events 
Event 
Strategy 
Description 


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Estimand Attribute 
Definition 
1. Acute GVHD 
progression 
Composite strategy 
Classified as an event 
2. Death 
Composite strategy 
Classified as an event 
3. Initiation of 
additional systemic 
aGVHD treatment1 
Composite strategy 
Classified as an event 
4. Discontinuation 
of study treatment 
Treatment policy 
No effect on variable 
Population-level 
Summary 
Median and quartiles with 95% CIs for each arm; probabilities of durable 
response at 6 and 12 months by arm; log rank test p-value comparing 
arms from Day 28 to 12 months post-randomization 
1 Includes next-line GVHD therapy and escalation of prednisone-equivalent steroid dose to 2.5mg/kg/day or 
more. 
For the supplementary analysis, DOR is defined as the time from Day 28 response to any 
next-line GVHD therapy, escalation of prednisone-equivalent steroid dose to 2.5mg/kg/day 
or more, or death from any cause; the corresponding estimand is shown in Table 19. The 
clinical question of interest is similar to the one for the primary analysis of DOR with the 
only difference being the definition of DOR.  
Table 19: Estimand for Duration of Response - Supplementary Analysis 
Estimand Attribute 
Definition 
Variable 
Duration of Response, refer to Sections 6.3.1 and 7.9, and above for 
details 
Treatment 
AAT (+corticosteroids) or PTM (+corticosteroids), refer to Section 2.1 
for details 
Population 
Patients in Intention-to-treat Population who attain a Day 28 overall 
response 
Intercurrent Events 
Event 
Strategy 
Description 
1. Acute GVHD 
progression 
Treatment policy 
No effect on variable 
2. Death 
Composite strategy 
Classified as an event 
3. Initiation of 
additional systemic 
aGVHD treatment1 
Composite strategy 
Classified as an event 
4. Discontinuation 
of study treatment 
Treatment policy 
No effect on variable 
Population-level 
Summary 
Median and quartiles with 95% CIs for each arm; probabilities of durable 
response at 6 and 12 months by arm; log rank test p-value comparing 
arms from Day 28 to 12 months post-randomization 
1 Includes next-line GVHD therapy and escalation of prednisone-equivalent steroid dose to 2.5mg/kg/day or 
more. 
7.5.2 
NON-RELAPSE MORTALITY (NRM) 
The time from randomization until NRM will be described in the ITT population graphically 
for each treatment arm using the Aalen-Johansen estimator (Aalen and Johansen 1978), 
with numbers of subjects at risk at specific time points presented for each treatment group 


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and relapse/progression of the primary disease treated as a competing risk.  Estimates of 
the cumulative incidence of NRM will be provided at 6 and 12 months post-randomization 
along with 95% CIs computed using the complementary log-log transformation.  Gray’s test 
will be used to compare the cumulative incidence of NRM within 12 months post-
randomization between arms as the primary analysis.  The estimand for NRM is presented 
in Table 20. The clinical question of interest is: what is the difference in cumulative 
incidence of NRM between AAT combined with corticosteroids versus PTM combined with 
corticosteroids in patients with high risk acute GVHD following allogeneic HSCT, regardless 
of discontinuation of study treatment? 
Table 20: Estimand for Non-relapse Mortality 
Estimand Attribute 
Definition 
Variable 
Non-relapse Mortality, refer to Sections 6.3.2 and 7.9 for details  
Treatment 
AAT(+corticosteroids) or PTM (+corticosteroids), refer to Section 2.1 for 
details 
Population 
Patients with high risk acute GVHD following allogeneic HSCT 
Intercurrent Events 
Event 
Strategy 
Description 
1. Death 
Composite strategy 
Classified as an event 
2. Relapse / 
progression 
Composite strategy 
Classified as a non-event 
(competing risk) 
3. Discontinuation 
of study treatment 
Treatment policy 
No effect on variable 
Population-level 
Summary 
Cumulative incidence of NRM at 6 and 12 months with 95% CIs for each 
arm; Gray’s test p-value comparing arms from randomization to 12 
months post-randomization 
In a supplementary analysis, a Cox proportional hazards model with mixed effects will be 
used to compare the cause-specific hazards of NRM between treatment arms while 
adjusting for an MN risk fixed effect and center-group lognormal frailties.  The Cox 
regression model will be used to evaluate the adjusted hazard ratio of treatment (AAT vs. 
PTM) using a point estimate and a 95% CI. 
7.5.3 
OVERALL SURVIVAL (OS) 
The time from randomization until death from any cause will be described in the ITT 
population graphically for each treatment arm using the Kaplan-Meier estimator, with 
numbers of subjects at risk at specific time points presented for each treatment group. 
Estimates of OS at 6 and 12 months post-randomization will be provided along with 95% 
CIs computed using the complementary log-log transformation as detailed in Kalbfleisch 
and Prentice 1980.  For the primary analysis, the log-rank test will be used to compare OS 
within 12 months of randomization between arms as the primary analysis.  The estimand 
for OS is shown in Table 21. The clinical question of interest is: what is the difference in 
overall survival between AAT combined with corticosteroids versus PTM combined with 
corticosteroids in patients with high risk acute GVHD following allogeneic HSCT, regardless 
of discontinuation of study treatment? 
 


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Table 21: Estimand for Overall Survival 
Estimand Attribute 
Definition 
Variable 
Overall Survival, refer to Sections 6.3.3 and 7.9 for details 
Treatment 
AAT (+corticosteroids) or PTM (+corticosteroids), refer to Section 2.1 
for details 
Population 
Patients with high risk acute GVHD following allogeneic HSCT 
Intercurrent Events 
Event 
Strategy 
Description 
1. Death 
Composite strategy 
Classified as an event 
2. Discontinuation 
of study treatment 
Treatment policy 
No effect on variable 
Population-level 
Summary 
OS probabilities at 6 and 12 months with 95% CIs for each arm; log rank 
test p-value comparing arms from randomization to 12 months post-
randomization 
In a supplementary analysis, a Cox proportional hazards model with mixed effects will be 
used to compare OS between treatment arms while adjusting for an MN risk fixed effect 
and center-group lognormal frailties.  The Cox regression model will be used to evaluate 
the adjusted hazard ratio of treatment (AAT vs. PTM) using a point estimate and a 95% CI. 
7.5.4 
PROGRESSION-FREE SURVIVAL (PFS) 
PFS is defined as being alive and free of relapse/progression of the primary disease.  The 
time from randomization until PFS failure will be described in the ITT population graphically 
for each treatment arm using the Kaplan-Meier estimator, with numbers of subjects at risk 
at specific time points presented for each treatment group.  Estimates of PFS at 6 and 12 
months post-randomization will be provided along with 95% CIs computed using the 
complementary log-log transformation as detailed in Kalbfleisch and Prentice 1980.  For 
the primary analysis, the log-rank test will be used to compare PFS within 12 months post-
randomization between arms as the primary analysis.  Table 22 shows the estimand for 
PFS. The clinical question of interest is: what is the difference in PFS between AAT 
combined with corticosteroids versus PTM combined with corticosteroids in patients with 
high risk acute GVHD following allogeneic HSCT, regardless of discontinuation of study 
treatment? 
Table 22: Estimand for Progression-free Survival 
Estimand Attribute 
Definition 
Variable 
Progression-free Survival, refer to Sections 6.3.4 and 7.9 for details 
Treatment 
AAT (+corticosteroids) or PTM (+corticosteroids), refer to Section 2.1 
for details 
Population 
Patients with high risk acute GVHD following allogeneic HSCT 
Intercurrent Events 
Event 
Strategy 
Description 
1. Death 
Composite strategy 
Classified as an event 
2. Relapse / 
progression 
Composite strategy 
Classified as an event 
3. Discontinuation 
of study treatment 
Treatment policy 
No effect on variable 


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Estimand Attribute 
Definition 
Population-level 
Summary 
PFS probabilities at 6 and 12 months with CIs for each arm; log rank test 
p-value comparing arms from randomization to 12 months post-
randomization 
In a supplementary analysis, a Cox proportional hazards model with mixed effects will be 
used to compare PFS between treatment arms while adjusting for an MN risk fixed effect 
and center-group lognormal frailties.  The Cox regression model will be used to evaluate 
the adjusted hazard ratio of treatment (AAT vs. PTM) using a point estimate and a 95% CI. 
7.5.5 
GVHD-FREE SURVIVAL 
GVHD-free survival is defined as being alive, free of active acute or chronic GVHD, free of 
any next-line GVHD therapy, and free of escalation of prednisone-equivalent steroid dose 
to 2.5mg/kg/day or more.  The GVHD-free survival at Day 56 will be computed as a binary 
outcome. The proportion of patients in the ITT population with GVHD-free survival at Day 
56 will be evaluated by the treatment arm.  These proportions will be described by sample 
proportions and 95% Wilson score CIs.  A logistic mixed model will be used to evaluate the 
effect of study treatment on Day 56 GVHD-free survival while accounting for center-group 
and MN risk, with center-group included as a random effect and treatment arm and MN risk 
as fixed effects.  Table 23 contains the estimand for GVHD-free survival. The clinical 
question of interest is: what is the difference in Day 56 GVHD-free survival between AAT 
combined with corticosteroids versus PTM combined with corticosteroids in patients with 
high risk acute GVHD following allogeneic HSCT, regardless of discontinuation of study 
treatment? 
Table 23: Estimand for GVHD-free Survival 
Estimand Attribute 
Definition 
Variable 
Day 56 GVHD-free Survival, refer to Sections 6.3.5 and 7.9 for details 
Treatment 
AAT(+corticosteroids) or PTM (+corticosteroids), refer to Section 2.1 for 
details 
Population 
Patients with high risk acute GVHD following allogeneic HSCT 
Intercurrent Events 
Event 
Strategy 
Description 
1. Death before 
Day 56 
Composite strategy 
Classified as a failure 
2. Development of 
aGVHD or cGVHD 
before Day 56 
Composite strategy 
Classified as a failure 
2. Initiation of 
additional systemic 
aGVHD treatment1 
before Day 56 
Composite strategy 
Classified as a failure 
3. Discontinuation 
of study therapy 
Treatment policy 
No effect on variable 
Population-level 
Summary 
Proportion of patients with GVHD-free at Day 56 with 95% CIs for each 
arm; adjusted odds ratio from logistic mixed model with 95% CI and p 
value 


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1 Includes next-line GVHD therapy and escalation of prednisone-equivalent steroid dose to 2.5mg/kg/day or 
more. 
7.5.6 
ACUTE GVHD RESPONSE TO AAT/PTM 
The proportions of patients with CR, PR, and TF will be tabulated by treatment arm at Days 
7, 14, 21, 28, and 56 for all patients in the ITT population and at Day 86 for the subset of 
patients that remained on study maintenance treatment after Day 28.  Goodman 
simultaneous 95% CIs (Goodman 1965) will be provided for the response category 
proportions.  These proportions will be compared between treatment arms using Fisher’s 
exact test.  If a patient does not complete the acute GVHD assessment on an evaluation 
day for any reason (e.g. missed visit, withdrawal from the study, loss to follow-up), they will 
be assigned as a TF on that Day. Moreover, patients who die, initiate either approved or 
unapproved next-line GVHD therapy, or have escalation of prednisone-equivalent steroid 
dose to 2.5mg/kg/day or more prior to an acute GVHD assessment will be classified as 
non-responders (NR) at the corresponding Day. 
7.5.7 
ACUTE GVHD RESPONSE ALLOWING FOR APPROVED NEXT-LINE 
THERAPY 
The proportions of patients with CR, PR, and TF will be tabulated by treatment arm at Days 
7, 14, 21, 28, and 56 for all patients in the ITT population and at Day 86 for the subset of 
patients that remained on study maintenance treatment after Day 28.  Goodman 
simultaneous 95% CIs (Goodman 1965) will be provided for the response category 
proportions.  These proportions will be compared between treatment arms using Fisher’s 
exact test.  If a patient does not complete the acute GVHD assessment on an evaluation 
day for any reason (e.g. missed visit, withdrawal from the study, loss to follow-up), they will 
be assigned as a TF on that Day. Moreover, patients who die, initiate next-line GVHD 
therapy that is not approved by the protocol chairs, or have escalation of prednisone-
equivalent steroid dose to 2.5mg/kg/day or more prior to an acute GVHD assessment will 
be classified as non-responders (NR) at the corresponding Day. 
The overall response (CR+PR) rate at Day 28 allowing for approved next-line treatments 
will be compared between treatment arms.  A logistic mixed model will be used to evaluate 
the effect of study treatment on Day 28 overall response with adjustment for treatment 
center-group and MN risk category (high vs. standard), with center-group (defined in 
section 7.1) included as a random effect and treatment arm and MN risk as fixed effects.  
This analysis will use the ITT population.  A two-sided Wald test of the treatment arm odds 
ratio in the logistic mixed model will be performed at a significance level of 5%.  The 
standardized log odds ratio estimate from this model will be used as the test statistic (Z-
statistic).  The proportion of patients with an overall response at Day 28 will be described 
by treatment arm by sample proportions and 95% Wilson score CIs.  Adjusted odds ratio 
estimates from the logistic mixed model of Day 28 overall response will be summarized in 
a regression table. 


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7.5.8 
SYSTEMIC INFECTIONS 
The frequency of Grade 2-3 infections occurring from randomization until 30 days post-last 
dose of AAT/PTM will be tabulated in the safety population by treatment arm, disease site, 
date of onset, and severity, with Grade defined per the BMT CTN Technical MOP. 
The time from randomization until the first Grade 2-3 infection will be described graphically 
using the Aalen-Johansen estimator, with death before infection treated as a competing 
risk.  Estimates of the cumulative incidence of Grade 2-3 infection will be provided at 3 
months post-randomization along with 95% CIs computed using the complementary log-
log transformation.  Gray’s test will be used to compare the cumulative incidence of Grade 
2-3 infection within 3 months of randomization between arms. 
7.5.9 
ADVERSE EVENTS (AES) 
The frequency of Grade 3-5 TEAEs per CTCAE version 5.0 occurring from randomization 
until 30 days post-last dose will be tabulated by the organ system for each treatment arm 
in the safety population. 
The proportions of patients experiencing a Grade 3-5 TEAE will be described by arm using 
95% Wilson score CIs and compared between treatment arms using Barnard’s exact test. 
7.5.10 CHRONIC GVHD 
The time from randomization until the onset of chronic GVHD of any severity (mild, 
moderate, or severe per 2014 NIH Consensus Criteria) will be described in the ITT 
population graphically using the Aalen-Johansen estimator, with death prior to chronic 
GVHD onset treated as a competing risk.  Estimates of the cumulative incidence of chronic 
GVHD will be provided at 6 and 12 months post-randomization along with 95% CIs 
computed using the complementary log-log transformation.  Gray’s test will be used to 
compare the cumulative incidence of chronic GVHD within 12 months of randomization 
between arms as the primary analysis. 
In a supplementary analysis, a Cox proportional hazards model with mixed effects will be 
used to compare the cause-specific hazards of chronic GVHD between treatment arms 
while adjusting for an MN risk fixed effect and center-group lognormal frailties.  The Cox 
regression model will be used to evaluate the adjusted hazard ratio of treatment (AAT vs. 
PTM) using a point estimate and a 95% CI. 
The maximum severity of chronic GVHD through 12 months post-randomization will be 
tabulated by treatment arm. 
7.5.11 RELAPSE/PROGRESSION OF PRIMARY DISEASE 
The time from randomization until relapse/progression of the primary disease will be 
described in the ITT population graphically for each treatment arm using the Aalen-
Johansen estimator, with death prior to relapse/progression treated as a competing risk.  
Estimates of the cumulative incidence of relapse/progression will be provided at 6 and 12 
months post-randomization along with 95% CIs computed using the complementary log-


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log transformation.  Gray’s test will be used to compare the cumulative incidence of 
relapse/progression within 12 months of randomization between arms as the primary 
analysis. 
In a supplementary analysis, a Cox proportional hazards model with mixed effects will be 
used to compare the cause-specific hazards of relapse/progression between treatment 
arms while adjusting for an MN risk fixed effect and center-group lognormal frailties.  The 
Cox regression model will be used to evaluate the adjusted hazard ratio of treatment (AAT 
vs. PTM) using a point estimate and a 95% CI. 
7.6 ANALYSIS OF EXPLORATORY ENDPOINTS 
7.6.1 
SERUM AAT LEVELS 
The 
pharmacokinetic 
parameters maximum 
concentration 
(Cmax) 
and 
trough 
concentration (Ctrough) for serum antigen AAT concentrations and serum functional AAT 
concentrations (AAT concentrations with functional activity) will be reported and 
summarized in the PK population at Days 0, 16, 28, and 56 post-treatment initiation by 
treatment arm using the n, mean, standard deviation (SD), coefficient of variation (CV%), 
median, range, geometric mean, and geometric CV%.  Ctrough will also be summarized 
on Days 8 and 24. 
7.6.2 
STOOL AAT LEVELS 
The stool concentration of AAT may be summarized at baseline and at Days 8 and 28 post-
treatment initiation by treatment arm using the mean, median, quartiles, and range.  The 
detailed analysis of this endpoint may be described in a separate document when data 
become available. 
7.6.3 
IMMUNE CELL SUBSETS 
Peripheral blood ratios of T regulatory to T effector (Treg/Teff) cells and Natural Killer (NK) 
cell populations may be described by treatment arm using the sample mean, median, 
range, and quartiles at baseline and Days 16, 28, and 56 post-treatment initiation in tables 
of summary statistics and displayed graphically using box plots.  Changes in levels from 
baseline to each subsequent assessment time may be described similarly in summary 
tables and compared between treatment arms using Wilcoxon rank sum tests.  The detailed 
analysis of this endpoint may be described in a separate document when data become 
available. 
7.6.4 
INFLAMMATORY CYTOKINES AND GVHD BIOMARKERS 
Serum levels of IL-1β, IL-6, IL-10, TNFα, amphiregulin (AREG), heparin sulfate, ST2, and 
REG3α may be described by treatment arm using the sample mean, median, range, and 
quartiles baseline and at Days 8, 28, and 56 post-treatment initiation in tables of summary 
statistics and displayed graphically using box plots.   Changes in levels from baseline to 
each subsequent assessment time may be described similarly in summary tables and 
compared between treatment arms using Wilcoxon rank sum tests.  The detailed analysis 
of this endpoint may be described in a separate document when data become available. 


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7.6.5 
OVERALL AND ORGAN-SPECIFIC RESPONSE RATES BY GVHD AND 
BIOMARKERS BASED RISK CLASSIFICATIONS 
The proportions of patients with an overall response (complete or partial) and the response 
rate of each GVHD target organ at Day 28 will be described in the ITT population by MN 
risk (high vs. standard) and by Ann Arbor biomarker risk score (1, 2, or 3) using sample 
proportions and 95% Wilson score CIs and compared on each factor using Fisher's exact 
test. 
In addition, a subgroup analysis of overall response by treatment arm will be conducted.  
Response rates for each arm within levels of MN risk and Ann Arbor biomarker score will 
be described using sample proportions and 95% Clopper-Pearson CIs.  Potential 
differential treatment effects between subgroups will be evaluated using logistic regression 
models with treatment arm, risk classification, and an interaction of the two included as 
effects. Wald test p-values of the interaction terms will be reported to assess the presence 
of differential effects across subgroups.  The results from the analysis by Ann Arbor 
biomarker risk score may be presented in a separate report depending on the biomarker 
data availability. 
7.6.6 
SYSTEMIC CORTICOSTEROID DOSE 
The prednisone-equivalent corticosteroid dose being administered (measured in 
prednisone equivalent) will be described at baseline, at Days 7, 14, 21, 28, 56, and 86 and 
at 6 and 12 months post-randomization by treatment arm in the ITT population using the 
sample mean, median, range, and quartiles in a table of summary statistics and displayed 
graphically using box plots.  Changes in levels from baseline to each subsequent 
assessment time will be described similarly in summary tables and compared between 
treatment arms using Wilcoxon rank sum tests. 
7.6.7 
CMV REACTIVATION 
Among patients who were CMV positive at transplant, the cumulative incidence of initiation 
of systemic treatment for CMV reactivation will be described in the safety population 
graphically using the Aalen-Johansen estimator, with death treated as a competing risk.  
Estimates of the cumulative incidence of CMV reactivation will be provided at Day 56 for 
each arm along with 95% CIs computed using the complementary log-log transformation.  
Gray’s test will be used to compare the cumulative incidence of CMV reactivation within 56 
days post-randomization between arms. 
7.6.8 
PATIENT REPORTED OUTCOMES 
Patient self-reported measures will be assessed at baseline, Days 28 and 56, and 6 months 
post-randomization using the MD Anderson Symptom Inventory (MDASI) and selected 
PROMIS subscales.  The core symptom severity and mean interference subscales of the 
MDASI and the PROMIS domains will be scored according to the recommendations of the 
developers. 
For each subscale/domain considered, scores at baseline, Days 28 and 56, and 6 months 
post-randomization will be described in the ITT population by treatment arm using the 


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sample mean, median, range, and quartiles in tables of summary statistics and displayed 
graphically using box plots.  Linear regression models will be used to compare trajectories 
in scores over time between treatment arms while adjusting for baseline score; model 
effects will include treatment assignment, baseline score, and post-randomization 
assessment time (Day 28, Day 56, or 6 months). 
Provided that at least 10 adolescent participants are enrolled, separate analyses of patient 
reported outcomes will be conducted for adolescents and adults.  Otherwise, their data will 
be aggregated for one common analysis. 
7.7 INTERIM ANALYSES 
7.7.1 
FUTILITY ANALYSIS OF PRIMARY ENDPOINT 
This trial includes one formal interim analysis for futility, to occur once 76 patients are 
evaluable for the primary endpoint.  The existence of a futility signal will be determined as 
specified in Section 7.4.1.  Note that this is non-binding futility stopping rule, in that the type 
I error rate will not exceed 2.5% if the DSMB chooses not to stop the trial in the presence 
of a futility signal. 
7.7.2 
ANALYSIS FOR 6-MONTH CLINICAL STUDY REPORT 
To expedite the evaluation of the primary endpoint and to support a potential regulatory 
submission, a clinical study report will be drafted once all enrolled participants complete 6 
months of follow-up in the study.  This report will include efficacy, safety, and PK data 
collected through the data cut-off date.  Analysis included in this report will consist of 
descriptive statistics on baseline characteristics and outcomes as well as formal treatment 
comparison for the primary endpoint Day 28 overall response via hypothesis testing. The p 
value from the test of superiority of AAT to PTM will be calculated via a logistic mixed model 
for GVHD-free survival at Day 56. This p value is considered descriptive in the 6-month 
report and will not be formally evaluated for efficacy of AAT until all the testing entailed in 
the hierarchical testing procedure is completed at the end of the study. The analysis will be 
performed using the statistical methods detailed in Sections 7.4-7.6.   
A detailed account of which TLFs will be included in the 6-month clinical study report is 
provided in the supplementary TLF shell document for this SAP. 
7.8 SAFETY ANALYSIS 
7.8.1 
DATA AND SAFETY MONITORING BOARD 
The policies and composition of the Data and Safety Monitoring Board (DSMB) are 
described in the BMT CTN MOP.  The DSMB performs a review of key efficacy and safety 
data at least once a year at regularly scheduled meetings.  Additional reviews may occur 
on an ad-hoc basis by request of the DSMB.  The content of the data reports provided for 
DSMB reviews is not specified by this SAP. 


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7.8.2 
STATISTICAL MONITORING RULES 
The rate of non-relapse mortality occurring by Day 56 will be monitored monthly for each 
treatment arm.  If either rate significantly exceeds pre-set thresholds, the NHLBI will be 
notified so that the DSMB can be advised.  These stopping guidelines serve as triggers for 
consultation with the DSMB for guidance and are not formal “stopping rules” that would 
mandate automatic closure of study enrollment.  The monitoring scheme is detailed in 
section 5.3.4 of the study protocol. 
7.8.3 
SAFETY EVENT SUMMARIES FOR ANALYSIS REPORTS 
All safety analyses will be conducted using the safety population.  All AEs and SAEs 
reported on the study will be categorized by MedDRA preferred terms using MedDRA 
version 23.0 and higher.  The number of each type of event and number of patients affected 
will be described during two study periods: from randomization until 30 days following the 
last dose of study drug (AAT/PTM), and from 30 days following the last dose until 12 months 
post-randomization.  These events will be reported using the safety analysis population. 
In addition, AEs and SAEs will be described in the same manner for the set of patients who 
received Ruxolitinib or other approved next-line therapy and those who did not. Causes of 
death for expired participants will be tabulated.  
7.9 MISSING DATA AND SENSITIVITY ANALYSIS 
Regarding endpoints involving acute GVHD response to study treatment (overall response, 
DOR, GVHD-free survival, acute GVHD response, organ-specific response), any patient 
with a missing acute GVHD assessment at the evaluation day will be classified as a non-
responder (NR) at that time point. 
For the duration of response (DOR), a patient with a missing acute GVHD assessment will 
be considered as a failure at that time point. 
For GVHD-free survival, a patient with either a missing acute or chronic GVHD assessment 
will be considered as a failure at that time point. 
For time-to-event outcomes other than DOR and GVHD-free survival (NRM, OS, PFS, 
chronic GVHD, relapse/progression), patients that withdraw or are lost to follow-up are 
assumed to be censored at random. 
For other endpoints, the occurrence of missing data, whether due to the patient’s missing 
assessment(s) or withdrawal from the study, is assumed to occur randomly. 
7.10 ASSESSMENT OF IMPACT OF COVID-19 ON TRIAL RESULTS 
7.10.1 COVID-19 RELATED MODIFICATIONS TO DATA COLLECTION 
The BMT CTN considers the COVID-19 era to have potentially impacted its trials effective 
March 10, 2020 unless otherwise specified.  Data collection was adjusted, and guidance 
was given to centers to track the impact of COVID-19.  Specifically, the following 
modifications were made: 


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• 
Impact of COVID-19 on scheduled visits: Collection of information about whether visits were 
missed or scheduled out of the assessment window; the type of visit (clinic visit, telemedicine 
visit, phone contact, or combination); and if the visit was missed, what the reason for the missed 
visit was (which included COVID-19 as an option) 
• 
COVID-19 infections: Guidance on the collection of COVID-19 infection occurrences was 
incorporated into the infection data collection form 
• 
COVID-19 related deaths: Addition of COVID-19 as a potential primary cause of death 
7.10.2 COVID-19 RELATED EVENTS AND VISIT DISRUPTIONS 
Frequencies and percentages will be provided on the number of missed visits, out of 
window visits, type of visits, and reasons for missed visits, summarized overall and by 
treatment arm.  The number of deaths attributed to COVID-19 and the number of COVID-
19 infections will also be described by treatment arm. 
7.10.3 SENSITIVITY ANALYSIS OF THE PRIMARY ENDPOINT 
The primary endpoint of this study is overall response (CR+PR) at Day 28 post-
randomization.  To assess the impact of COVID-19 on the trial’s pivotal analysis, the 
following COVID-19 sensitivity analyses (CA) are proposed. 
• 
CA1: Exclude patients from the analysis who have missing Day 28 GVHD assessments 
attributed to a COVID-19 related event or for those who have a telemedicine or phone contact 
visit only 
• 
CA2: Exclude patients from the analysis who had a COVID-19 infection or death attributed to 
COVID-19 before or on Day 28 
• 
CA3: Exclude all patients who are excluded from analysis in CA1 and/or CA2 
For each sensitivity analysis, the primary endpoint will be analyzed as described in Section 
7.4.3.1 according to the ITT principle.  The purpose of the sensitivity analyses is to assess 
the robustness of the pivotal analysis results.  The impact of sensitivity analysis populations 
on the number of responses and widths of the confidence intervals should be considered 
in interpreting these analyses.   
If thought to be important based on the results, similar sensitivity analyses of secondary 
endpoints may also be conducted. 
7.11 CHANGES TO PROTOCOL-SPECIFIED ANALYSIS 
The current SAP elaborates on the protocol-specified analysis.  The sole change in the 
SAP from the protocol-specified analysis is that the significance level of the two-sided 
testing of exploratory endpoints is planned to change from 5% to 1%.  Any future revisions 
to the SAP that constitute changes from the protocol-specified analysis, and the justification 
for these changes, will be documented here. 


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8 
REFERENCES 
1. Aalen, O. O. and S. Johansen (1978). An empirical transition matrix for non-
homogeneous Markov chains based on censored observations. Scand J Stat 141-150. 
2. Andersen, P. K., O. Borgan, R. D. Gill, and N. Keiding (1993). Statistical Models Based 
on Counting Processes. Springer Ser. Statist., Springer. 
3. Goodman, L. A. (1965). On Simultaneous Confidence Intervals for Multinomial 
Proportions. Technometrics 7(2): 247-254. 
4. Harris, A. C., R. Young, S. Devine, W. J. Hogan, F. Ayuk, U. Bunworasate, C. 
Chanswangphuwana, Y. A. Efebera, E. Holler, M. Litzow, R. Ordemann, M. Qayed, A. 
S. Renteria, R. Reshef, M. Wolfl, Y. B. Chen, S. Goldstein, M. Jagasia, F. Locatelli, S. 
Mielke, D. Porter, T. Schechter, Z. Shekhovtsova, J. L. Ferrara and J. E. Levine (2016). 
"International, Multicenter Standardization of Acute Graft-versus-Host Disease Clinical 
Data Collection: A Report from the Mount Sinai Acute GVHD International Consortium." 
Biol Blood Marrow Transplant 22(1): 4-10. 
5. Jagasia, M. H., H. T. Greinix, M. Arora, K. M. Williams, D. Wolff, E. W. Cowen, J. Palmer, 
D. Weisdorf, N. S. Treister, G. S. Cheng, H. Kerr, P. Stratton, R. F. Duarte, G. B. 
McDonald, Y. Inamoto, A. Vigorito, S. Arai, M. B. Datiles, D. Jacobsohn, T. Heller, C. L. 
Kitko, S. A. Mitchell, P. J. Martin, H. Shulman, R. S. Wu, C. S. Cutler, G. B. Vogelsang, 
S. J. Lee, S. Z. Pavletic and M. E. Flowers (2015). National Institutes of Health 
Consensus Development Project on Criteria for Clinical Trials in Chronic Graft-versus-
Host Disease: I. The 2014 Diagnosis and Staging Working Group report. Biol Blood 
Marrow Transplant 21(3): 389-401 e381. 
6. Kahan, B. C., & Morris, T. P. (2012). Improper analysis of trials randomised using 
stratified blocks or minimisation. Stat Med, 31(4), 328-340. 
7. Kalbfleisch, J. D. and Prentice, R. L. (1980). The Statistical Analysis of Failure Time 
Data. New York: John Wiley & Sons. 
8. Hwang, I. K., Shih W. J., and De Cani J. S. (1990). Group sequential designs using a 
family of type I error probability spending functions. Stat Med, 9(12), 1439-1445. 
9. Levine, J. E., Braun T. M., Harris A. C., Holler E., Taylor A., Miller H., Magenau J., 
Weisdorf D. J., Ho V. T., Bolanos-Meade J., Alousi A. M., and Ferrara J. L. M. (2015) A 
prognostic score for acute graft-versus-host disease based on biomarkers: a multicentre 
study. Lancet Haematology, 2(1):e21-29. 
10. MacMillan, M. L., Robin, M., Harris, A. C., DeFor, T. E., Martin, P. J., Alousi, A., Ho, 
V.T., Bolaños-Meade, J., Ferrara, J. L., Jones, R. and Arora, M. (2015). A refined risk 
score for acute graft-versus-host disease that predicts response to initial therapy, 
survival, and transplant-related mortality. Biol Blood Marrow Transplant 21(4), 761-767. 
11. Srinagesh, H. K., Özbek, U., Kapoor, U., Ayuk, F., Aziz, M., Ben-David, K., Choe, H. K., 
DeFilipp, Z., Etra, A., Grupp, S. A., Hartwell, M. J., Hexner, E. O., Hogan, W. J., Karol, 
A. B., Kasikis, S., Kitko, C. L., Kowalyk, S., Lin, J.-Y., Major-Monfried, H., Mielke, S., 
Merli, P., Morales, G., Ordemann, R., Pulsipher, M. A., Qayed, M., Reddy, P., Reshef, 
R., Rosler, W., Sandhu, K. S., Schechter, T., Shah, J., Sigel, K., Weber, D., Wolfl, M., 
Wudhikarn, K., Young, R., Levine, J. E., and Ferrara, J. L. M. (2019) The MAGIC 


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algorithm probability is a validated response biomarker of treatment of acute graft-
versus-host disease. Blood Advances 3(23):4034-42. 
12. Wilson, E. B. (1927). Probable inference, the law of succession, and statistical 
inference. J Am Stat Assoc 22: 209-212.


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APPENDIX B: INTERIM ANALYSIS FOR FUTILITY: DSMB DATA PRESENTATION 
PLAN 
Protocol and Primary Endpoint 
The primary endpoint for the protocol BMT CTN 1705 “A Randomized, Double-Blind, Placebo-
Controlled Multicenter Phase III Trial of Alpha 1 – Antitrypsin (AAT) Combined with Corticosteroids 
vs Corticosteroids Alone for the Treatment of High-Risk Acute Graft-versus-Host Disease (GVHD) 
Following Allogeneic Hematopoietic Stem Cell Transplant” is overall response at Day 28. Overall 
response at Day 28 is defined as having a complete or partial response (CR or PR) at Day 28, i.e. 
having partial or complete resolution of acute GVHD symptoms in some organ(s) without worsening 
in any other(s) along with being alive, free of any next-line GVHD therapy, and free of escalation of 
prednisone-equivalent steroid dose to 2.5mg/kg/day or more.  Acute GVHD organ staging at Day 
28 is compared to maximum GVHD organ staging within 72 hours prior to enrollment to determine 
whether a complete or partial resolution has occurred.  Organ staging is performed according to 
MAGIC criteria (Harris et al. 2016).  Patients with a missing Day 28 acute GVHD assessment will 
be classified as non-responders (NR). 
Study Design on Interim Analysis 
This trial includes one formal interim analysis for futility, to occur once 76 patients are evaluable for 
the primary endpoint. The primary analysis will be done using the intention-to-treat (ITT) population. 
The intention-to-treat (ITT) population consists of all randomized subjects, classified according to 
their randomized treatment assignments.  
A logistic mixed model will be used to evaluate the effect of study treatment on Day 28 overall 
response while accounting for treatment center and MN risk category (high vs. standard), with 
center-group included as a random effect and treatment arm and MN risk as fixed effects.  The top 
5 enrolling centers each will count as a separate group and all other centers will be combined into 
a sixth catchall group. So there will be a total of 6 center groups.  
The standardized log odds ratio estimate for treatment arm from this model will be used as the test 
statistic (Z-statistic) and will be compared to the futility boundary in Table 1. The futility boundaries 
were obtained from the Gamma family spending function with shape parameters of -8. 
Futility Interim Analysis Stopping Boundary 
Table 1: Group Sequential Design Stopping Thresholds for Primary Endpoint: Primary 
Analysis Approach 
Analysis 
Information 
Fraction 
Sample 
Size 
Futility Boundary 
for Z-Statistic 
Efficacy Boundary 
for Z-Statistic 
Interim 
0.56 
76 
-0.31 
- 
Final 
1.00 
136 
- 
1.96 
 
Sensitivity Analysis for Interim Analysis  
A sensitivity analysis will be conducted ONLY IN THE EVENT that the primary analysis reaches its 
futility boundary at the interim analysis as above mentioned in Table 1. 


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The sensitivity analyses would include 62 participants at interim analysis.  Due to a process error 
that has been corrected, there is a small chance that the treatment assignments of some 
participants were unblinded to their treatment center staff.  A maximum of 14 participants could 
have been affected.  To assess the robustness of the primary analysis results in consideration of 
this, a sensitivity analysis will be conducted where these 14 participants will be omitted from the ITT 
analysis population.  Therefore, the sensitivity analysis will include 62 subjects (76 randomized – 
14 randomized subjects potentially affected)  
The efficacy and futility boundaries for the sensitivity analyses are displayed in Table 2. Again, the 
futility boundaries were obtained from the Gamma family spending function with shape parameters 
of -8. 
Table 2: Group Sequential Design Stopping Thresholds for Primary Endpoint: Sensitivity 
Analysis Approach 
Analysis 
Information 
Fraction 
Sample 
Size 
Futility Boundary 
for Z-Statistic 
Efficacy Boundary 
for Z-Statistic 
Interim 
0.51 
62 
-0.61 
- 
Final 
1.00 
122 
- 
1.96 
If the Z-statistic from the primary analysis is less than or equal to the futility boundary, a sensitivity 
analysis will be conducted that excludes from the ITT population the 14 participants who could have 
potentially been affected by unblinding.  Similarly, this analysis would use a logistic mixed model 
and the standardized log odds ratio estimate for treatment arm would be used as the test statistic 
and compared to the futility boundary in Table 2. 
Results and Data Presentation to DSMB  
Primary results for the interim analysis will be presented as below: 
Analysis 
Information 
Fraction 
Sample 
Size 
(#Patient 
Included) 
Test Statistic 
Reach Futility 
Boundary for Z-
Statistic (Yes or 
No) 
Interim 
0.56 
76 
 
 
Sensitivity analysis results for the interim analysis will be presented as below: 
Analysis 
Information 
Fraction 
Sample 
Size 
(#Patient 
Included) 
Test Statistic 
Reach Futility 
Boundary for Z-
Statistic (Yes or 
No) 
Interim 
0.51 
62 
 
 
If both the primary and sensitivity analysis results meet their corresponding futility boundaries, the 
study team recommends closure of the trial.  Otherwise, if one or both of the analyses do not meet 
their futility boundaries, the team recommends that the trial continue. 
Besides the interim analysis results, below exhibits will also be included in the DSMB report to 
facilitate the review, and these are usually included in the regular DSMB closed data review. All 
data will be presented in Closed session by the Unblinded STAT lead. 


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Exhibit R1: Participant disposition table 
 
Numbers of patients that were randomized, received study treatment, completed study treatment, 
stopped study treatment early, withdrew by treatment arm I and II 
Exhibit R2: Overall response  
(A) 
Overall response by Day 56 in Arm I 
(B) 
Overall response by Day 56 in Arm II  
Overall (complete + partial) response summarized at Days 14, 28, and 56 
Timing of Interim Analysis 
From operation perspective, DCC is monitoring the data submission for the enrolled patients to 
ensure we have 76 randomized patients with Day 28 evaluation for the primary endpoint for this 
interim analysis. A nightly monitoring is put in place and will send an automatic email alert to the 
STAT team when the time is approaching to see the data submission for the primary endpoint for 
the first 76 patients. Patient who would expire prior to Day 28 will be included in the ITT population 
for the primary endpoint. DCC will plan a data freeze for DSMB review when 76 patients reach 28 
days follow up.  
 


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Prot_000.pdf: 
 
 
A Randomized, Double-Blind, Placebo-Controlled Multicenter Phase III Trial 
of Alpha 1 – Antitrypsin (AAT) Combined with Corticosteroids vs 
Corticosteroids Alone for the Treatment of High Risk Acute Graft-versus-Host 
Disease (GVHD) Following Allogeneic Hematopoietic Stem Cell Transplant 
BMT CTN PROTOCOL 1705 
CSL BEHRING PROTOCOL CSL964_5001 
Version 5.0 
Sponsored by the National Institutes of Health 
National Heart, Lung, and Blood Institute 
National Cancer Institute 
CSL Behring 
IND# 18195 
1MD Anderson Cancer Center 
2University of Michigan 
3CSL Behring 
4Levine Cancer Institute 
5Fred Hutchinson Cancer Research Center 
6National Heart, Lung, and Blood Institute 
7Center for International Blood and Marrow Transplant 
Research, Medical College of Wisconsin 
 
8Emmes  
9Cleveland Clinic  
10Baylor College of Medicine 
11Dana-Farber Cancer Institute 
12H. Lee Moffitt Cancer Institute 
13Memorial Sloan-Kettering Cancer Center 
14Children’s Healthcare of Atlanta 
15Washington University in St. Louis 
16National Cancer Institute 
 
 
PPD
PPD
PPD


Blood and Marrow Transplant Clinical Trials Network  
 
BMT CTN 1705 – HR aGVHD AAT 
 
Version 5.0, August 14, 2023 
 
 
1-1 
PROTOCOL SYNOPSIS 
A Randomized, Double-Blind, Placebo-Controlled Multicenter Phase III Trial of Alpha 1 – 
Antitrypsin (AAT) Combined with Corticosteroids vs Corticosteroids Alone for the Treatment 
of High-Risk Acute Graft-versus-Host Disease (GVHD) Following Allogeneic Hematopoietic 
Stem Cell Transplant 
 
Co-Chairs: 
 
 
Study Design: 
This study is a phase III, multicenter, double-blinded, 
randomized, placebo-controlled trial designed to compare AAT 
and corticosteroids (CS) to placebo and CS as first line therapy 
for patients with high-risk acute GVHD. 
 
Primary Objective: 
The primary objective of this trial is to compare the rate of 
complete response (CR) and partial response (PR) on Day 28 
post-randomization between AAT and CS versus placebo to 
match (PTM) and CS in patients with high-risk acute GVHD. 
 
Secondary Objectives: 
Secondary objectives are to assess the following: 
1. Duration of response at 6- and 12-months post-
randomization. 
2. Cumulative incidence of non-relapse mortality (NRM) at 6- 
and 12-months post-randomization. 
3. Overall survival (OS) and progression free survival (PFS) at 
6- and 12-months post-randomization. 
4. GVHD-free survival at Day 56 post-randomization. 
5. Proportions of CR, very good partial response (VGPR), PR, 
and treatment failure (TF) at Days 7, 14, 21, 28, 56, and 86 
post-randomizations. 
6. Proportion of patients with CR, PR (including subset with 
VGPR), and treatment failure (TF) at Days 7, 14, 21, 28, 56, 
and 86 post-randomization who receive ruxolitinib or other 
second line therapies approved by the protocol Chairs as 
next-line therapy and remain on AAT/PTM. 
7. Incidence of systemic infections to assess safety. 
8. Incidence of Adverse Events (AEs) at 30 days post last dose 
of drug to assess safety.  
9. Incidence of chronic GVHD at 6- and 12-months post-
randomization.  
10. Incidence of disease relapse at 6- and 12-months post-
randomization. 
 
PPD


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Exploratory Objectives: 
Exploratory objectives are as follows: 
1. AAT levels in serum at Days 1, 8, 16, 24, 28, and 56 post-
treatment initiation. 
2. Stool concentrations of AAT at baseline and at Days 8 
and 28 post-treatment initiation. 
3. Blood ratios of T regulatory to T effector cells (Treg/Teff), 
Natural Killer (NK) cells and cellular immune subsets at 
baseline and at Days 14, 28, and 56 post-treatment initiation. 
4. Serum levels of inflammatory cytokines and biomarkers at 
baseline and at Days 8, 28 and 56 post-treatment initiation. 
5. Overall and organ-specific response rates comparison based 
on Minnesota (MN) risk groups (Revised Minnesota High vs 
Standard) and organ-specific response rates comparison 
based on biomarker-based risk groups. 
6. Corticosteroid dose at baseline, Days 7, 14, 21, 28, 56, 86, 
6 months and 12 months post-randomization. 
7. CMV reactivation requiring therapy by Day 56 post-
randomization. 
8. Change in patient-reported outcomes from baseline to 
Day 28, Day 56, and 6-months post-randomization. 
 
Inclusion Criteria: 
Patients meeting the eligibility criteria should be enrolled as soon 
as possible after the start of CS, but no more than 72 hours 
afterwards.   
1. Patients experiencing their initial presentation of acute 
GVHD requiring systemic therapy after allogeneic 
transplant for any malignant or non-malignant indication. 
2. The clinical diagnosis of acute GVHD requiring systemic 
therapy with CS. Patients can be enrolled with only a 
clinically established diagnosis. Biopsy of involved organs 
with acute GVHD is encouraged but is not required and 
should not delay study entry. Enrollment/randomization 
includes commitment to continue steroids with PTM or AAT 
as specified in the protocol, as well as the required follow-up 
observations. If, according to institutional practice, the 
intention to treat is dependent upon biopsy results, the 
patient should not complete enrollment on the BMT CTN 
1705 study until the biopsy results are available.  
3. Acute GVHD must meet one (either A or B) of following 
clinical features within 72 hours prior to enrollment:  
(A) High-risk by Refined Minnesota Criteria (any one 
below): 
Single organ involvement 
a. Stage 4 skin 
b. Stage 3-4 lower GI 
c. Stage 1-4 liver 


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Multiple organ involvement  
a. Stage 1-2 lower GI plus any liver 
b. Stage 2 lower GI plus any skin 
c. Stage 3-4 lower GI plus any liver or skin 
d. Any three organ involvement 
OR:  
(B) Either of the below: 
1. Isolated stage 2 involvement of the lower GI 
tract   
2. Stage 1 lower GI tract disease with skin 
involvement 
4. Acute GVHD developing after allogeneic hematopoietic cell 
transplantation using any graft or donor source or 
conditioning intensity.  
5. Patients should not have received systemic immune 
suppressive therapy for treatment of active GVHD except for 
a maximum of 72 hours of prior CS therapy prior to 
enrollment. Topical skin and GI CS (such as budesonide and 
oral beclomethasone diproprionate) are allowed.  
6. Patients 12 years of age or older at time of enrollment.  
7. Ability to provide written informed consent from patient, 
parent or legal guardian, and assent if applicable. 
Exclusion Criteria  
1. Patients with prior exogenous AAT exposure for GVHD 
prophylaxis.  
2. Relapsed, progressing or persistent malignancy 
3. Evidence of minimal residual disease (MRD) requiring 
withdrawal of systemic immune suppression.  
4. Patients with acute GVHD developing after administration 
of a donor lymphocyte infusion (DLI) for relapse / 
progression of disease. Patients with acute GVHD after 
planned donor lymphocyte infusion or planned T cell or NK 
cell add back are eligible. 
5. Patients with uncontrolled infections will be excluded. 
Infections are considered controlled if appropriate therapy 
has been instituted and, at the time of enrollment, no signs 
of progression are present. Progression of infection is 
defined as hemodynamic instability attributable to sepsis, 
new symptoms, worsening physical signs or radiographic 
findings attributable to infection. Persisting fever without 
other signs or symptoms will not be interpreted as 
progressing infection. 


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6. A clinical presentation resembling de novo chronic GVHD 
or overlap syndrome (as defined in Appendix C) developing 
before or present at the time of enrollment.  
7. Patients receiving other drugs for the treatment of GVHD. 
Note, GVHD prophylaxis agents (e.g., calcineurin 
inhibitors) may be continued at local Investigator’s 
discretion. 
8. Patients receiving systemic CS for any indication within 
7 days before enrollment, except the following:  
a. CS administered as premedication for supportive care 
(such as before transfusion of blood products or before 
intravenous medications to prevent infusion reactions, 
fever, etc.).  
b. If steroid therapy has been administered for treatment 
of a non-GVHD related condition and tapered to 
< 0.6 mg/kg/day 
prednisone 
(0.5 
mg/kg/day 
methylprednisolone) for 7 or more days prior to 
enrollment. 
c. Treatment of active GVHD with CS is allowed for up to 
72 hours prior to enrollment. 
9. Patients who are pregnant or breastfeeding.  
10. Females of childbearing potential (FCBP) or males who can 
get a FCBP pregnant and have sexual contact with FCBP and 
are unwilling to use 2 effective forms of birth control or 
abstinence from the start of study drug treatment through 
30 days after the last dose of study drug, Effective forms of 
birth control are listed in Appendix D.  
11. Patients on renal replacement therapy.  
12. Patients 
requiring 
continuous 
supplemental 
oxygen 
(O2 requirement > 2L/min to maintain peripheral O2 
saturation [SpO2] > 90%). 
13. Patients with active hepatic sinusoidal obstructive syndrome 
(SOS) and/or clinical evidence of impaired hepatic function 
(ascites or encephalopathy related to liver disease) who in 
the judgment of the treating physician are not expected to 
have normalized bilirubin by Day 56 after enrollment. 
14. Patients with a history of hypersensitivity to AAT or any 
component of the investigational product or PTM (albumin), 
including 
congenitally 
IgA-deficient 
patients 
with 
antibodies to IgA or PTM. 
15. Patients unlikely to be adherent to study specific assessments 
at the transplant center. 
 
Treatment Description: 
All patients will receive prednisone 2 mg/kg/day PO 
(or methylprednisolone (MP) at 1.6 mg/kg/day IV) divided into 
1-2 daily doses for at least 72 hours after enrollment. CS may be 


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tapered as tolerated according to institutional practice. However, 
corticosteroid taper may not start sooner than 3 days after 
enrollment and the prednisone dose cannot be less than 
0.25 mg/kg/day prednisone (MP 0.2 mg/kg/day) at Day 28 
post-enrollment. 
 
 
 
Patients will be randomized 1:1 to receive AAT or PTM. 
Patients will receive AAT/PTM on Days 0 or 1, 4, 8, 12, 16, 20, 
24, and 28. Responding patients will continue to receive 
AAT/PTM on Days 35, 42, 49, and 56. 
Accrual Objective: 
136 total patients will be enrolled and randomized 1:1 to AAT 
vs PTM. 
Accrual Period: 
The estimated accrual period is 3 years. 
Study Duration: 
Patients will be followed for 12 months following 
randomization. 
Interim Analysis: 
The study will consist of one interim analysis for futility after 
76 patients are evaluable, at a time coincident with a regularly 
scheduled meeting of the National Heart, Lung, and Blood 
Institute (NHLBI)-appointed Data and Safety Monitoring Board 
(DSMB) review, then a 12-month analysis after accrual and all 
patients follow up is complete. An additional analysis will be 
conducted after all randomized patients complete 6 months of 
follow-up. Multiplicity adjustment is not needed for this analysis 
as all the patients would have completed the primary endpoint 
visit at Day 28 by the time of analysis. Policies and composition 
of the DSMB are described in the BMT CTN Manual of 
Procedures. 
Stopping Guidelines: 
The stopping guidelines serve as a trigger for consultation with 
the DSMB for additional review and are not formal “stopping 
rules” that would mandate automatic closure of study 
enrollment. Safety monitoring will be based on Day 56 NRM. 
Toxicity, adverse events, and other safety endpoints will be 
monitored regularly and reported to the DSMB at each meeting. 
 
 


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STUDY SCHEMA 
 
                                 
 
 
IMP and CS dosing is the same for adolescent and adult patients. 


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TABLE OF CONTENTS 
PROTOCOL SYNOPSIS .......................................................................................................... 1-1 
STUDY SCHEMA ..................................................................................................................... 1-6 
LIST OF TABLES ................................................................................................................... 1-11 
LIST OF FIGURES ................................................................................................................. 1-11 
1 
BACKGROUND AND RATIONALE .............................................................................. 1-1 
1.1 
Introduction ...................................................................................................................... 1-1 
1.2 
Results of Previous Acute GVHD Therapy Trials ........................................................... 1-1 
1.3 
Risk Stratification of Acute GVHD ................................................................................. 1-1 
1.3.1 
Risk Stratification by Clinical Grading using Onset Organ Severity ......................... 1-2 
1.3.2 
Risk Stratification by Blood Biomarkers .................................................................... 1-2 
1.3.3 
Impact of Lower GI GVHD on NRM: Further Refinement of the Revised Minnesota 
Prognostic ................................................................................................................... 1-3 
1.4 
Study Hypothesis and Design .......................................................................................... 1-5 
1.5 
Alpha 1-Antitrypsin (AAT) ............................................................................................. 1-6 
1.5.1 
Alpha 1-Antitrypsin (AAT) as an Immunomodulatory .............................................. 1-6 
1.5.2 
Alpha-1 Antitrypsin in Pre-Clinical Models of GVHD .............................................. 1-8 
1.5.3 
Safety and Efficacy of AAT in Patients with Steroid-Refractory Acute GVHD ....... 1-9 
1.5.4 
Clinical Efficacy, Safety and Pharmacokinetic Data with AAT in Humans ............ 1-10 
1.6 
Dose Rationale for Planned Study ................................................................................. 1-11 
1.6.1 
Acute Phase Reactant Properties of AAT ................................................................. 1-12 
1.6.2 
Pre-Clinical Experience with AAT ........................................................................... 1-12 
1.6.3 
Clinical Experience with AAT in HCT Setting ........................................................ 1-12 
1.6.4 
Clinical Experience with AAT in Adolescents ......................................................... 1-13 
1.6.5 
AAT Target Level for Proposed Dose in Treatment of GVHD................................ 1-13 
1.6.6 
Ruxolitinib for the Treatment of Steroid-Refractory Acute GVHD ......................... 1-14 
2 
STUDY DESIGN ................................................................................................................ 2-1 
2.1 
Study Overview................................................................................................................ 2-1 
2.2 
Hypothesis and Specific Objectives ................................................................................. 2-1 
2.2.1 
Primary Hypothesis ..................................................................................................... 2-1 
2.3 
Study Objectives .............................................................................................................. 2-1 
2.3.1 
Primary Objective ....................................................................................................... 2-1 
2.3.2 
Secondary Objectives.................................................................................................. 2-1 
2.3.3 
Exploratory Objectives ............................................................................................... 2-1 
2.4 
Patient Eligibility ............................................................................................................. 2-2 
2.4.1 
Inclusion Criteria ........................................................................................................ 2-2 


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2.4.2 
Exclusion Criteria ....................................................................................................... 2-3 
2.4.3 
Adolescent Population ................................................................................................ 2-4 
2.5 
Treatment Plan ................................................................................................................. 2-4 
2.5.1 
Alpha 1 – Antitrypsin (AAT) ...................................................................................... 2-4 
2.5.2 
Corticosteroids (CS).................................................................................................... 2-8 
2.5.3 
Supportive Care .......................................................................................................... 2-9 
2.6 
Study Unblinding ........................................................................................................... 2-11 
2.7 
Study Conduct ................................................................................................................ 2-11 
2.8 
Study Termination.......................................................................................................... 2-12 
3 
STUDY ENDPOINTS ........................................................................................................ 3-1 
3.1 
Primary Endpoint ............................................................................................................. 3-1 
3.1.1 
Response Definitions .................................................................................................. 3-1 
3.2 
Secondary Endpoints........................................................................................................ 3-1 
3.2.1 
Duration of Response (DOR)...................................................................................... 3-1 
3.2.2 
Non-Relapse Mortality (NRM) ................................................................................... 3-2 
3.2.3 
Overall Survival (OS) and Progression-Free Survival (PFS) ..................................... 3-2 
3.2.4 
GVHD-Free Survival .................................................................................................. 3-2 
3.2.5 
Proportion of Response ............................................................................................... 3-2 
3.2.6 
Proportion of Response (Next-Line Therapy) ............................................................ 3-2 
3.2.7 
Systemic Infections ..................................................................................................... 3-2 
3.2.8 
Adverse Events ........................................................................................................... 3-3 
3.2.9 
Chronic GVHD ........................................................................................................... 3-3 
3.2.10 
Disease Relapse .......................................................................................................... 3-3 
3.3 
Exploratory Endpoints ..................................................................................................... 3-4 
3.3.1 
AAT Levels ................................................................................................................. 3-4 
3.3.2 
Stool AAT, Microbiome, and Metabolome ................................................................ 3-4 
3.3.3 
Immune Subsets .......................................................................................................... 3-5 
3.3.4 
Inflammatory Cytokines and GVHD Biomarkers ...................................................... 3-5 
3.3.5 
Overall and Organ-Specific Response Rates by Refined Minnesota Risk and 
Biomarker-Based Risk Classifications ....................................................................... 3-5 
3.3.6 
Systemic Corticosteroid Dose ..................................................................................... 3-5 
3.3.7 
CMV-Reactivation ...................................................................................................... 3-5 
3.3.8 
Patient-Reported Outcomes ........................................................................................ 3-5 
4 
PATIENT ENROLLMENT AND EVALUATION ......................................................... 4-1 
4.1 
Approaching Patients, Eligibility Screening and Obtaining Consent .............................. 4-1 
4.2 
Enrollment and Randomization ....................................................................................... 4-1 


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4.3 
Study Monitoring ............................................................................................................. 4-2 
4.3.1 
Follow-Up Schedule ................................................................................................... 4-2 
4.3.2 
Assessments ................................................................................................................ 4-2 
4.4 
Adverse Event Reporting ................................................................................................. 4-7 
4.4.1 
Definitions................................................................................................................... 4-7 
4.4.2 
Classification of Adverse Events by Severity ............................................................. 4-9 
4.4.3 
Classification of Adverse Events by Relationship to Investigational Product ........... 4-9 
4.4.4 
Required Adverse Event Reporting ............................................................................ 4-9 
4.4.5 
Pregnancy .................................................................................................................. 4-10 
5 
STATISTICAL CONSIDERATIONS .............................................................................. 5-1 
5.1 
Study Design .................................................................................................................... 5-1 
5.1.1 
Accrual ........................................................................................................................ 5-1 
5.1.2 
Randomization ............................................................................................................ 5-1 
5.1.3 
Primary Endpoint ........................................................................................................ 5-1 
5.1.4 
Primary Hypothesis ..................................................................................................... 5-2 
5.2 
Sample Size and Power Calculations ............................................................................... 5-2 
5.3 
Study Analysis Schedule and Safety Stopping Guidelines .............................................. 5-2 
5.3.1 
Interim Analysis for Futility ....................................................................................... 5-2 
5.3.2 
Operating Characteristics of the Design ..................................................................... 5-3 
5.3.3 
6 Month Analysis for Clinical Study Report .............................................................. 5-4 
5.3.4 
Guidelines for Safety Monitoring ............................................................................... 5-5 
5.3.5 
Safety Analysis ........................................................................................................... 5-6 
5.4 
Demographic and Baseline Characteristics...................................................................... 5-6 
5.5 
Analysis Populations ........................................................................................................ 5-7 
5.5.1 
Primary Analysis Population ...................................................................................... 5-7 
5.5.2 
Safety Analysis Populations ....................................................................................... 5-7 
5.5.3 
General Analysis Guidelines ....................................................................................... 5-7 
5.6 
Analysis of Primary Endpoint .......................................................................................... 5-7 
5.7 
Analysis of Secondary Endpoints .................................................................................... 5-8 
5.7.1 
Duration of Response .................................................................................................. 5-8 
5.7.2 
Non-relapse Mortality ................................................................................................. 5-8 
5.7.3 
Overall Survival and Progression-Free Survival ........................................................ 5-8 
5.7.4 
GVHD-Free Survival .................................................................................................. 5-8 
5.7.5 
Proportion of Response ............................................................................................... 5-9 
5.7.6 
Proportion of Response (Next-Line Therapy) ............................................................ 5-9 
5.7.7 
Systemic Infections ..................................................................................................... 5-9 


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5.7.8 
Adverse Events ........................................................................................................... 5-9 
5.7.9 
Chronic GVHD ........................................................................................................... 5-9 
5.7.10 
Disease Relapse .......................................................................................................... 5-9 
5.8 
Analysis of Exploratory Endpoints ................................................................................ 5-10 
5.8.1 
AAT Levels ............................................................................................................... 5-10 
5.8.2 
Stool AAT, Microbiome and Metabolome ............................................................... 5-10 
5.8.3 
Immune Subsets ........................................................................................................ 5-10 
5.8.4 
Inflammatory Cytokines and GVHD Biomarkers .................................................... 5-10 
5.8.5 
Overall and Organ-Specific Response Rates by Refined Minnesota Risk and 
Biomarker-Based Risk Classifications ..................................................................... 5-10 
5.8.6 
Systemic Corticosteroid Dose ................................................................................... 5-10 
5.8.7 
CMV-Reactivation .................................................................................................... 5-11 
5.8.8 
Patient-Reported Outcomes ...................................................................................... 5-11 
APPENDIX A HUMAN SUBJECTS ...................................................................................... A-1 
APPENDIX B LABORATORY PROCEDURES ...................................................................B-1 
APPENDIX C DIAGNOSIS AND SEVERITY SCORING FOR ACUTE AND CHRONIC 
GVHD ............................................................................................................. C-1 
APPENDIX D LIFESTYLE RESTRICTIONS ..................................................................... D-1 
APPENDIX E ANTICIPATED TOXICITIES .......................................................................E-1 
APPENDIX F PATIENT REPORTED OUTCOMES MEASUREMENT INFORMATION 
SYSTEM (PROMIS) ...................................................................................... F-1 
APPENDIX G BMT CTN SEVERITY GRADING TABLE AND RECURRENCE 
INTERVAL DEFINITIONS......................................................................... G-1 
APPENDIX H ABBREVIATIONS ......................................................................................... H-1 
APPENDIX I REFERENCES .................................................................................................. I-1 
 
 
 


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LIST OF TABLES 
Table 1-1 
Day 28 Response Rate for Patients with Lower GI GVHD.................................... 1-5 
Table 1-2 
Selected In Vivo Biological Activities of AAT44 ................................................... 1-7 
Table 1-3 
Selected In Vitro Biological Activities of AAT44 ................................................... 1-8 
Table 1-4 
Clinical Studies Conducted in Subjects with A1-PI Deficiency and/or Subjects with 
Emphysema ........................................................................................................... 1-10 
Table 2-1 
Study Drug Schedule .............................................................................................. 2-6 
Table 2-2 
Suggested Steroid Taper for Responding Patients .................................................. 2-8 
Table 2-3 
Timeline for Declaring Patient as having Acute GVHD Progression or No Response 
Categories ............................................................................................................. 2-10 
Table 4-1 
Required Assessments Post- Enrollment ................................................................ 4-5 
Table 4-2 
Required and Optional Research Assessments Post-Initiation of Treatment (see 
APPENDIX B for further details) ........................................................................... 4-6 
Table 5-1 
Single Boundary Non-Binding Futility Stopping Thresholds with One-Sided Type I 
Error 2.5%, Power 86% and an Effect Size of 25% ............................................... 5-3 
Table 5-2 
Summary of Operating Characteristics ................................................................... 5-4 
Table 5-3 
Stratified Mixed Effects Logistic Model with 1000 Simulations of Size 136 ........ 5-4 
Table 5-4 
Sequential Monitoring Plan for 68 Subjects per Arm (α = 0.065, β = 0.10, p0 ≤ 0.20, 
p1 ≥ 0.40) ................................................................................................................. 5-5 
Table 5-5 
Operating Characteristics of the Sequential Probability Ratio Test for Day 56 NRM 
with 100,000 Simulation Replicates ....................................................................... 5-6 
  
 
LIST OF FIGURES 
Figure 1-1 
Comparison of Day 28 CR/PR in MN Standard vs High Risk aGVHD patients ... 1-2 
Figure 1-2 
Comparison of Day 28 CR/PR in AA1, AA2, and AA3 biomarker-based risk 
stratified patients ..................................................................................................... 1-2 
Figure 5-1 
Stopping Boundary on Difference in Proportions Scale ......................................... 5-3 
Figure 5-2 
Acceptance and Rejection Boundaries for Safety Monitoring ............................... 5-6 
 


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CHAPTER 1 
1 
BACKGROUND AND RATIONALE  
1.1 
Introduction 
Acute graft-versus-host disease (GVHD) is a frequent complication of allogeneic hematopoietic 
cell transplantation (HCT) involving activation of donor T-lymphocytes against host tissues1. 
Despite immune suppression prophylaxis, up to 30-50% of HCT recipients will experience acute 
GVHD of varying severity1-3. The syndrome of acute GVHD involves multiple target organs, 
including the skin (presenting most frequently as a maculopapular rash), intestinal tract 
(presenting as nausea/vomiting and/or diarrhea), and liver (presenting as cholestatic liver injury 
with or without transaminase elevation). 
The mainstay of treatment of acute GVHD is high dose corticosteroids (CS), typically initially 
dosed at the prednisone equivalent of 1-2 mg/kg per day4. High dose CS have several 
shortcomings, including both limited efficacy as well as toxicity including infections, 
hyperglycemia, hypertension, hyperlipidemia, osteoporosis and osteonecrosis. Approximately 
50% of patients respond to CS, while only 30% have a durable response5-7. Despite these 
limitations, no prospective study has demonstrated an advantage in response rate or survival for 
the addition of a second agent to CS for the treatment of steroid naïve acute GVHD8-13. 
1.2 
Results of Previous Acute GVHD Therapy Trials 
To date, two multicenter acute GVHD treatment trials have been conducted in the Blood and 
Marrow Transplant Clinical Trials Network (BMT CTN). The first, BMT CTN 0302, was a 
multicenter, randomized, four-arm phase II trial that was designed to identify the agent most 
promising for use in addition to CS for the front-line therapy of acute GVHD8. Patients with a 
new diagnosis of acute GVHD were randomized to receive either etanercept, mycophenolate 
mofetil (MMF), denileukin diftitox, or pentostatin in additional to high dose CS. The proportion 
of Day 28 CR/PR was highest in the MMF arm at 60%. Thus, MMF was selected for a randomized 
phase III trial of MMF versus placebo in addition to CS for first-line therapy of acute GVHD in 
the subsequent study, BMT CTN 080213. In BMT CTN 0802, MMF did not meet the primary 
endpoint of extending GVHD-free survival at Day 56 at a planned interim analysis of 235 patients, 
and the trial was terminated for futility.  
It has been suggested that the enrollment of all newly diagnosed cases without regard to the 
likelihood of response to steroids alone or GVHD severity diminished the ability of these trials to 
show improvement beyond standard therapy. Neither BMT CTN 0302 nor 0802 was risk-
stratified according to clinical or biomarker-based strategies (nor any such trial published to date). 
To that end, application of risk-adaptive approaches targeting patients who have a lower 
likelihood of responding to steroids alone and; accordingly, a high-risk for non-relapse mortality 
(NRM), may identify cohorts capable of benefiting from intensification of immune suppression. 
1.3 
Risk Stratification of Acute GVHD 
Identifying which patients are at increased risk of becoming steroid-refractory may help to better 
test novel agents in combination with CS or perhaps even alone. Different approaches to risk 
stratify patients with acute GVHD have been recently developed and refined. These strategies 
include models built upon initial clinical staging of acute GVHD target organs (e.g., skin, 
intestinal tract, and liver) and serum biomarker-based approaches. Both of these strategies hold 


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value in identifying patients who are likely to respond well (i.e., demonstrate a complete response 
[CR] or partial response [PR]) to CS and thus less likely to die due to complications of the 
transplant (NRM)14-16. 
1.3.1 Risk Stratification by Clinical Grading using Onset Organ Severity 
In 1990, Weisdorf et al. identified in multivariate analyses that 
overall stage score (sum of each acute GVHD organ stage 0-4, plus 
1 point for upper GI, for a maximum score of 13) was strongly 
associated with likelihood of CR17. Based upon this initial 
observation that single organ involvement was more likely to 
achieve a CR than multi-organ involvement, the GVHD Risk 
Score was subsequently developed by the Minnesota group18. 
Multivariate analysis of the outcomes of 864 consecutive patients 
from 1990-2007 yielded the following high-risk organ stages: skin 
stage 4, lower gastrointestinal stage 3/4, liver stage 3/4, or skin 
stage 3 plus lower gastrointestinal or liver stage > 2 GVHD. 
The GVHD Risk Score has recently been refined using data from 
multiple centers with a total of 1,723 patients used in modeling – 
the largest acute GVHD cohort analyzed for their characteristics 
and outcomes to date19. Developed using clinical grouping and 
recursive 
partitioning, 
this 
new 
Risk 
Score 
(http://z.umn.edu/MNAcuteGVHDRiskScore) [referred to as 
Minnesota (MN) Risk Scores] can classify patients into high-risk 
(HR) or standard risk at the onset of acute GVHD symptoms. In 
this model, 84% of patients are classified as standard risk, defined 
as single organ involvement (stage 1-3 skin or stage 1-2 GI) or two 
organ involvement (stage 1-3 skin plus stage 1 GI; or stage 1-3 
skin plus stage 1-4 liver), with a Day 28 CR/PR rate of 69% 
(Figure 1-1). All others are considered HR, with a Day 28 CR/PR 
rate of 43%. This model can be used in real time at the time of 
acute GVHD diagnosis, making it practical for stratification in 
clinical trials. Similarly, this model predicted for 6-month NRM 
(Standard risk 22% vs High risk 44%, p-0.001). 
1.3.2 Risk Stratification by Blood Biomarkers 
Development of risk profiles for patients with newly diagnosed acute GVHD that are predictive 
of outcomes independent of clinical staging have been a major advancement in acute GVHD 
research. Serum proteomic patterns associated with acute GVHD were first published 
approximately a decade ago20, 21. The University of Michigan group has significantly expanded 
the proteomic profiling of patients with acute GVHD in recent years by developing a 3-level risk 
stratification system, Ann Arbor 1 (AA1) low-risk acute GVHD, Ann Arbor 2 (AA2) 
intermediate-risk acute GVHD, and Ann Arbor 3 (AA3) high-risk acute GVHD. The Ann Arbor 
score is based upon serum or plasma levels of tumor necrosis factor receptor-1 (TNFR1), 
regenerating islet-derived 3-alpha (REG3α), and suppression of tumorigenicity 2 (ST2) measured 
at diagnosis of GVHD, regardless of clinical severity (grades I-IV). Each Ann Arbor score 
corresponds to a distinct risk of six-month NRM, such that AA1 GVHD has < 10% NRM, AA2 
GVHD ~25% NRM, and AA3 GVHD has > 40% NRM. The scoring algorithm was validated in 
Figure 1-1 
Comparison 
of 
Day 28 CR/PR in MN Standard vs 
High Risk aGVHD patients 
Figure 1-2 
Comparison 
of 
Day 28 CR/PR in AA1, AA2, and 
AA3 
biomarker-based 
risk 
stratified patients 


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an independent test set of patients with acute GVHD from the University of Michigan and the 
University of Regensberg, and in a separate validation set from the BMT CTN acute GVHD 
treatment trials 0302 and 08027. Relapse rates do not differ between Ann Arbor scores and thus 
the differences in NRM translate into significant differences in survival. Differences in response 
to treatment account for the vast majority of differences in NRM. Patients with AA1 demonstrate 
81% CR/PR at Day 28 and AA2 patients demonstrate 68% CR/PR at Day 28 (Figure 1-1 and 
Figure 1-2). In contrast, high risk AA3 patients demonstrate 46% CR/PR at Day 28. Furthermore, 
treatment responses for patients with AA3 GVHD are significantly less likely to be durable 
compared to AA1 and AA2 patients with only 21% of AA3 patients remaining in a CR without a 
flare at six months from diagnosis compared to 47% of AA1/2 patients (p < 0.001). Importantly, 
similar proportions of patients are assigned to each Ann Arbor score in each of the three standard 
groupings of Glucksberg grades (I vs II vs III/IV). Thus, approximately 20% of all newly 
diagnosed GVHD cases have a high-risk biomarker profile and have lower likelihood of response 
to primary treatment and experience high NRM even when the clinical presentation is not severe, 
such as a < 50% skin rash (grade 1 acute GVHD). Further, patients who present with a limited 
skin rash yet have a high-risk biomarker panel (AA3) have been shown to have high NRM due to 
subsequent development of steroid-refractory lower GI GVHD. As such, the biomarker panel 
appears to identify patients who have or will develop high risk lower GI GVHD. More recently, 
the same group has validated these results using two of the original three biomarkers (ST2 and 
REG3α)22. While promising to date, biomarker-based risk stratification has heretofore not been 
prospectively validated for determining eligibility in the context of a large multi-center GVHD 
treatment trial. 
1.3.3 Impact of Lower GI GVHD on NRM: Further Refinement of the Revised Minnesota 
Prognostic 
As confirmed by the Minnesota grading system, isolated acute GVHD of the skin is generally not 
life-threatening with the majority of patients responding to topical and/or systemic steroids. 
On the other end of the spectrum, patients who19, 23 experience advanced stage 3-4 acute GVHD 
of liver (peak total serum bilirubin > 6 mg/dL) have poor outcomes but represent only 2% of the 
current transplant population19, 24. While the incidence of severe gastrointestinal GVHD 
(stage 3-4, or peak diarrheal volumes over 1.5 liters per day) has also decreased during the past 
decade, treatment remains unsuccessful in most cases, and the gastrointestinal tract is involved in 
virtually all fatal cases of acute GVHD24. Accordingly, reducing acute GVHD mortality is 
contingent upon improving responses in patients with lower GI GVHD. 
Two distinct phenotypes of gut GVHD can be identified—upper gut (limited to stage 1) and 
mid-lower gut—that differ in presentation, natural history, response to therapy, and risk of 
mortality. The upper gut phenotype generally does not progress to the mid-lower gut phenotype 
and has been shown not to impact NRM25, 26. In contrast, the mid-lower gut phenotype of GVHD 
presents with secretory, protein-rich diarrhea27, 28. In severe cases, the entire small intestine and 
colon are edematous and inflamed, with diarrheal volumes in excess of 1.5 liters per day often 
associated with mucosal ulceration, sloughing and bleeding and severe abdominal pain. 
Most patients with severe mid-lower gut GVHD require prolonged hospitalization for supportive 
care including total parenteral nutrition and pain control. Although outcomes are typically poor, 
the standard initial therapy remains prednisone at 2 mg/kg/day, with addition of other immune 
suppressive therapies only when treatment with prednisone fails to control the disease. Despite 
this approach, outcomes are poor in the approximately 50% of patients who do not respond to 
high dose CS due to a high likelihood for treatment resistance to additional lines of immune 
suppression, infection, and considerable NRM. While de novo development of stage 3-4 lower 


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GI GVHD clearly represents high risk acute GVHD, only a small percent (8%) of patients present 
with this stage, with the vast majority developing advanced organ stage later in their disease 
course while already on primary treatment (termed steroid-refractory)19. Taking this into 
consideration, targeting any patient who presents with diarrhea (regardless of volume) for clinical 
trials would be one strategy to reduce GI GVHD-related mortality. Unfortunately, amongst 
patients who present with any lower GI tract involvement, a sizable fraction may do well with a 
steroid-alone approach, thereby diminishing the ability to detect a meaningful effect of 
investigational therapy.  
Recently, a database of 309 consecutive patients with GI GVHD was analyzed from 
The University of Texas, MD Anderson Cancer Center between the years of 2009-201229. 
Roughly half of the patients presented with isolated upper GI GVHD with minimal (< 500 cc in 
24 hours) stool output. An analysis of all the remaining patients with stage 1 or higher lower GI 
GVHD (either isolated or combined with another organ) is shown in Table 1-1. From this analysis, 
patients with isolated lower GI stage 1 GVHD appear to have a higher Day 28 response rate with 
roughly 3/4 of the patients responding to first-line therapy. Similar results were seen for patients 
enrolled onto two consecutive acute GVHD trials within the Blood and Marrow Transplant 
Clinical Trials Network (BMT CTN 0302 and 0802 trials) with a 75% Day 28 response rate to 
first-line therapy for those presenting with isolated stage 1 lower GI GVHD (Table 1-1). 
However, from these datasets, patients with isolated lower GI stage 2 or stage 1 lower GI plus 
skin have a Day 28 response rate of 50-57% and despite being otherwise “standard risk” per the 
Minnesota Clinical Staging system define a population at risk for treatment resistance who may 
potentially benefit from a high-risk treatment protocol. Importantly, combining these subsets of 
GI GVHD with the Minnesota HR groups would increase study eligible patients from roughly 
15% to 25-30%. 
 


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Table 1-1 
Day 28 Response Rate for Patients with Lower GI GVHD 
MD Anderson Cancer Center 
 
N 
Day 28 CR/PR (%) 
6-month NRM (95% Confidence Interval) 
Isolated Lower GI 
Stage 1 
Stage 2* 
Stage 3 - 4 
Lower GI + any liver 
Stage 1 
Stage 2 
Stage 3 - 4 
Lower GI + any skin 
Stage 1* 
Stage 2 
Stage 3 – 4 
 
37 
14 
23 
 
9 
5 
12 
 
19 
10 
17 
 
27 (73%) 
7 (50%) 
11 (48%) 
 
5 (56%) 
2 (40%) 
2 (17%) 
 
10 (53%) 
5 (50%) 
6 (35%) 
 
33% (21-53) 
29% (12-65) 
39% (23-65) 
 
56% (31-99) 
40% (14-100) 
58% (36-94) 
 
33% (16-68) 
20% (6-69) 
53% (34-83) 
BMT CTN 0302 / 0802 Trials 
 
N 
Day 28 CR/PR (%) 
6-month NRM (95% Confidence Interval) 
Isolated Lower GI 
Stage 1 
Stage 2* 
Stage 3 - 4 
Lower GI + any liver 
Stage 1 
Stage 2 
Stage 3 - 4 
Lower GI + any skin 
Stage 1* 
Stage 2 
Stage 3 - 4 
 
8 
9 
15 
 
7 
8 
5 
 
30 
17 
17 
 
75% 
56% 
67% 
 
43% 
50% 
0% 
 
57% 
41% 
41% 
 
25% 
44% 
27% 
 
43% 
37.5% 
80% 
 
30% 
41% 
41% 
*Patients designated as Minnesota Standard Risk considered appropriate for High-Risk Trial 
1.4 
Study Hypothesis and Design 
Identification and novel treatment strategies for patients at risk for steroid resistance remains a 
major unmet clinical need. In this context it is hypothesized that administration of additional 
immune suppression capable of increasing response rates without toxicity will limit further 
progression of GVHD and improve outcomes. Reflective of the above advancements in risk 
stratification for patients with newly diagnosed acute GVHD, we propose enrolling patients with 
newly-diagnosed Minnesota HR, isolated lower GI Stage 2 or Lower GI stage 1 plus any skin 
onto a prospective, double-blind, randomized, phase III trial of prednisone at a dose of 
2 mg/kg/day (or methylprednisolone- equivalent) plus α1- Antitrypsin (AAT) or placebo. 
Our hypothesis is that the addition of the AAT, Zemaira®, a therapy with a demonstrated safety 
record as well as pre-clinical and clinical data in the setting of acute GVHD, will improve Day 28 
acute GVHD response when added to CS in patients with newly diagnosed, HR acute GVHD. 
Patients who achieve a CR or PR to GVHD treatment at Day 28 have improved long-term 
outcomes (survival and NRM) when compared to non-responders and serves as a validated 
primary endpoint for acute GVHD trials. 


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1.5 
Alpha 1-Antitrypsin (AAT) 
Alpha 1-Antitrypsin (AAT) is a naturally occurring 52-kDa circulating protease inhibitor 
produced by the liver that inactivates several serine proteases from neutrophils and macrophages 
and protects tissues from proteolytic degradation. Serum AAT concentrations in healthy 
individuals range from 1.5 to 2.5 mg/ml and can increase twofold during inflammation, coinciding 
with AAT’s role as an acute phase reactant30. Congenital deficiency in AAT results in emphysema 
and cirrhosis of the liver31, 32. In addition, AAT deficiency has been associated with the 
development of various autoimmune diseases including necrotizing panniculitis, vasculitis, 
inflammatory bowel disease and glomerulonephritis33. AAT is licensed for long-term 
augmentation and maintenance therapy in adults with severe hereditary deficiency of AAT with 
clinically evident emphysema. Consistent safety of the investigational product when administered 
intravenously (IV) for AAT deficiency has been observed in more than 14 years of use, with 
833,197.22 standard doses sold worldwide for the period between 01 July 2003 and 20 August 
2017, corresponding to 16,023 patient-years. Post-marketing surveillance has shown that AAT is 
safe and well tolerated when used at the recommended dosage with no association with increased 
risk of infection. Recent research has elucidated immune regulatory roles of AAT, independent 
of protease inhibition, leading to growing interest in this therapy across various inflammatory and 
immune-mediated conditions. 
1.5.1 Alpha 1-Antitrypsin (AAT) as an Immunomodulatory 
A growing body of evidence has demonstrated AAT to not only possess the ability to inhibit 
serine proteases, such as elastase and proteinase-3, but also exert anti-inflammatory and tissue 
protective effects independent of protease inhibition. AAT appears to effectively interfere with 
inflammatory responses and protect from cell death in a large number of in vivo and in vitro 
experimental models reviewed in Table 1-2 and Table 1-3. A noteworthy example includes the 
blockade of inflammatory cytokine release from human peripheral blood mononuclear cells34. 
Specifically, AAT decreases the production of important inflammatory cytokines such as tumor 
necrosis factor alpha (TNF-α) and IL-1β, two prototypical upstream mediators of inflammation. 
AAT also lowers the levels of chemokines IL-8 and monocyte chemotactic protein (MCP)-1, two 
major cytokines important in the trafficking of inflammatory cells. While the activity of 
proinflammatory cytokines appears to consistently diminish in the presence of AAT, the release 
of anti-inflammatory mediators increases. For example, the endogenous inhibitor of IL-1 activity, 
IL-1 receptor antagonist, is upregulated by AAT in human blood cells35. Similarly, IL-10 levels 
have been shown to increase by AAT in various experimental conditions34, 36-39. An examination 
of the cellular targets of AAT, demonstrates it to be specific for members of the innate immune 
system, such as macrophages and neutrophils, as well as B-lymphocytes and dendritic cells. 
In contrast, responses of purified T-lymphocytes are consistently unaffected37, 38, 40-43, allowing 
for a variety of responses to concanavalin A and anti-CD3/CD28 stimulation to persist. 
This cell-specific discretion, together with the ability to protect tissues from injury, sets AAT in 
a unique niche among modulators of the immune system and distinguishes it from classic 
immunosuppressants. 
 
 


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Table 1-2 
Selected In Vivo Biological Activities of AAT44 
 
In vivo model 
Outcome 
Reference 
Modulation of 
adaptive 
immunity 
 
Islet allograft immune 
response 
Graft survival prolonged, immune cell infiltration 
reduced, intragraft insulin content increased, 
intragraft vascular endothelial growth factor 
(VEGF) transcript levels elevated 
Grafts accepted, immune tolerance achieved, 
Tregs localized at graft sites, systemic and local 
IL-1RA elevated. 
40 
 
 
 
 
38 
Islet autoimmune 
response 
Islet function preserved, immune tolerance 
achieved, auto-and alloreactive grafts accepted. 
37, 45-47 
Cell allograft immune 
response 
Day 1-5 immune cell infiltration reduced, 
including macrophages, neutrophils, T cells and 
NK cells 
40 
 
Collagen-induced arthritis 
Delayed disease onset, lower disease score 
48, 49 
Experimental 
autoimmune 
encephalomyelitis 
Decreased disease incidence, lower disease 
scores, Increased Treg proportions in lymphoid 
compartments 
36 
GVHD (major 
histocompatibility 
complex [MHC] disparate 
bone marrow 
transplantation) 
Attenuation (posttreatment) and prevention 
(pretreatment) of GVHD, reduced expansion of 
alloreactive T cells, enhanced recovery of Tregs, 
reduced serum levels of proinflammatory 
cytokines and superior survival 
41, 42 
In vivo 
leukocyte 
infiltration 
 
Thioglycolate-elicited 
peritoneal infiltration 
Infiltrating macrophages and neutrophils 
diminished 
40 
Acute myocardial 
infarction 
Myocardial leukocyte infiltration diminished 
50 
Experimental 
autoimmune 
encephalomyelitis 
Decreased Spinal leukocyte infiltration 
36 
In vivo innate 
responses 
 
Systemic 
lipopolysaccharide (LPS) 
challenge (mice) 
Anti-inflammatory serum cytokine profile 
including elevated IL-1Ra and IL-10 and greater 
levels of Foxp3FOXP3 Tregs 
38 
Lung LPS challenge 
(rabbits) 
Lung Function and arterial blood gas improved, 
bronchoalveolar neutrophil elastase, TNF-α and 
IL-8 reduced 
51 
In vivo cell 
injury 
 
Toxic β-cell injury 
48-h cell death reduced, insulin release preserved 
40, 52 
Acute myocardial injury 
after Left anterior 
descending occlusion and 
myocardial infarction 
Reduced infarct size, decreased caspase-1 tissue 
levels, reduced post-infarct remodeling 
50 
 
 


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Table 1-3 
Selected In Vitro Biological Activities of AAT44 
In vitro assay 
Cellular targets 
Outcomes 
Reference 
Cell function 
Glucose-stimulated 
insulin secretion 
• 
Mouse islets 
 
• 
Human Islets 
• 
Cytokine-dampened insulin 
release restored 
• 
Impure islet culture insulin 
release improved 
40 
 
53 
Collagen 1 production 
during wound healing 
• 
Β-cell lines 
• 
Skin Fibroblasts 
• 
Insulin release improved 
• 
Production increased 
54 
55 
Cell survival 
Proinflammatory 
cytokine toxicity 
• 
Primary mouse islets 
• 
Rat INS-1 cell line 
• 
Lactate dehydrogenase (LDH) 
release diminished 
• 
Cell death reduced 
40 
 
54 
Β-cell-specific toxin 
(steptozotocin) 
• 
Murine MIN-6 cell line 
• 
Apoptosis reduced 
 
52 
Casapase-3-induced 
apoptosis 
• 
Primary lung alveolar 
endothelial cells 
• 
Apoptosis reduced 
56 
LPS and ischemia-
induced injury 
• 
Adult cardiac myocyte 
cell line HL-1 
• 
Cell death reduced 
 
50 
Immune cell cytokine production 
LPS stimulation 
• 
Human peripheral 
blood mononuclear 
cells (PBMC) 
• 
Reduced proinflammatory 
cytokine release 
57 
Heat-inactivated S. epi 
stimulation 
• 
Human PBMC 
• 
Reduced proinflammatory 
cytokine release 
34 
Steady-state 
• 
Nonstimulated murine 
B cell 
• 
Human neutrophils 
• 
Steady-state B cell activating 
factor production decreased 
• 
Reduced TNF-α release 
48 
 
58 
LPS stimulation 
• 
Human PBMC 
• 
Reduced IL-32 
41 
Mixed lymphocyte 
reaction 
• 
Murine OT-II T cells 
and ovalbumin 
(OVA-)-loaded 
Dendritic cell 
• 
Reduced IL-6, elevated IL-2 and 
elevated IL-10 
39 
Immune cells not directly targeted by AAT 
• 
In vitro 
immunization 
• 
Concanavalin A 
stimulation 
• 
CD3/CD28 
stimulation 
• 
Mouse splenocytes 
• 
Mouse splenocytes 
• 
Purified mouse T cells 
All 3 models: 
• 
Intact T-cell clumping, 
proliferation, response to IL-2 
and IFNγ release 
48 
 
40 
 
37, 42 
1.5.2 Alpha-1 Antitrypsin in Pre-Clinical Models of GVHD 
It is believed that AAT acts as an immunomodulator59, allowing for expression of regulatory 
T-cell repertoires that support chimerism, immune tolerance, and protection of allografts. AAT 
was shown to inhibit cytokine release in a mouse model and is likely to have an important 
protective role against inflammatory responses in GVHD due to its function as an acute-phase 
reactant. 


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Studies suggest that inflammatory cytokines play a key role in the pathogenesis of GVHD60-62. 
Inflammatory cytokines promote end organ damage and so their suppression should be beneficial 
to patients at GVHD symptom onset. In multiple experimental models of allogeneic HCT, the 
administration of AAT appears to have a number of effects: induction of anti-inflammatory 
cytokines and suppression of anti-inflammatory cytokines; indirectly altering the in vivo ratios of 
donor effector T-cells (Teff) to donor regulatory T-cells (Tregs); interference with activation of 
dendritic cells; and suppression of the development of GVHD42, 63, 64. In three independent 
laboratories using several different murine models of GVHD, administration of AAT improved 
survival and GVHD-severity scores when compared to mice treated with control, human albumin. 
Despite altering these ratios, AAT exposure did not impact T-cell function (either Tcon or Treg) 
in vitro and in minimal residual disease (leukemia) models, AAT exposure did not appear to 
inhibit the graft-versus-leukemic effect. The impact of AAT on T-cell ratios was determined to 
result from the suppression of pro-inflammatory cytokine secretion, namely, TNF-α, IL-1β and 
IL-6 and increased secretion of anti-inflammatory cytokines IL-10 and IL-6 via inhibition of 
NF-κβ in dendritic cells. 
More recently, the mechanisms through which excessive inflammatory responses contribute to 
the pathophysiology of GVHD have been studied and suggest that AAT may be able to attenuate 
immune responses amplified by tissue injury. Detection of tissue damage by innate immune cells 
using pattern-recognition receptors (PRRs) that sense noninfectious molecular signatures [called 
danger-associated molecular patterns (DAMPs)] is known to augment adaptive immunity65. 
Murine models have demonstrated that one such DAMP, heparan sulfate (HS), an extracellular 
matrix component, activates Toll-like receptor 4 on dendritic cells in vitro, leading to the 
enhancement of dendritic cell maturation and alloreactive T-cell responses. In addition, it was 
demonstrated that serum HS levels were acutely elevated at the onset of clinical GVHD in mice 
after allo-HSCT and treatment of mice with AAT decreased serum levels of HS, leading to a 
reduction in alloreactive T-cell responses and GVHD severity63. Conversely, an HS mimetic that 
increased serum HS levels accelerated GVHD. Further, in patients undergoing allo-HSCT for 
hematologic malignancies, serum HS levels were found to be elevated and correlated with the 
severity of GVHD. These results identify a critical role for HS, and more broadly DAMPs, in 
promoting acute GVHD after allogeneic HSCT and suggest that modulation of these 
inflammatory stimuli may have therapeutic potential for the control of clinical GVHD.  
1.5.3 Safety and Efficacy of AAT in Patients with Steroid-Refractory Acute GVHD 
An investigator-initiated phase 2 open-label study with Zemaira® was conducted in 
40 steroid-refractory acute GVHD patients (median age 50 years, range 18-70) at a dose of 
60 mg/kg twice weekly for 4 weeks66. One third of the patients had lower GI GVHD; all stage 
3 or 4, while a quarter had liver-involvement (all stage 3/4). The overall response rate and 
complete response rate by Day 28 was 65% and 35%, respectively, and included responses in all 
GVHD target organs. At Day 60, responses were sustained in 73% of patients without intervening 
immunosuppression. Organ-specific responses were seen in skin, GI and liver. Importantly, 50% 
of patients with steroid-resistant lower GI GVHD achieved a Day 28 CR. The treatment was well 
tolerated, with no infusion reactions or drug-related Grade 3/4 adverse events. A total of 7 patients 
died within 30 days of the last infusion of AAT with 5/7 of these patients having progressive 
acute GVHD, 1 patient dying from gram negative sepsis and 1 patient from interstitial pneumonia 
syndrome. 6-month overall survival was 45% [95% confidence interval (CI), 32-63%]. 
In a second study, an open-label phase 1/2 clinical trial of Glassia® (Baxalta/Kamada) for 
steroid-refractory acute GVHD was undertaken in 12 patients following HCT67. Patients received 


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AAT over a 15-day course: In Cohort 1, the loading dose of AAT was 90 mg/kg IV on Day 1, 
followed by maintenance doses of 30 mg/kg/day IV on Days 3, 5, 7, 9, 11, 13, and 15. In Cohort 
2, the loading dose was 90 mg/kg IV on Day 1, followed by 7 maintenance doses of 60 mg/kg/day 
IV on the same schedule (total weekly dosage of 270 mg/kg). Eight of the 12 subjects included in 
the study, who had received allogeneic HCT, showed improvement in GVHD manifestations, 
with four showing complete improvement. Treatment response was particularly apparent in terms 
of sigmoidoscopic appearance of the GI tract and GI-related symptoms. Survival at the last 
follow-up (> 104 to > 820 days) was 50%. In this study, no clinically relevant signs of toxicity 
attributable to treatment with AAT were reported. 
1.5.4 Clinical Efficacy, Safety and Pharmacokinetic Data with AAT in Humans 
Clinical efficacy, safety, and pharmacokinetic (PK) data are available for the investigational 
product from 6 completed studies in subjects with Alpha 1-antitrypsin (also called 
Alpha1-Proteinase Inhibitor (A1-PI)) deficiency and/or subjects with emphysema. The results of 
these studies are presented in this section. Summaries of the studies are provided in Table 1-4. 
Table 1-4 Clinical Studies Conducted in Subjects with A1-PI Deficiency and/or Subjects 
with Emphysema 
Study Number 
No. of 
subjects 
enrolled 
Route, 
regimen, 
duration 
Dose 
(mg/kg/body 
weight) 
Results 
RPR118635-101 
(phase 1) 
19 
IV, single-dose 
15 
30 
60 
120 
The terminal half-life of AAT was 
estimated to be approximately 5 days, 
independent of dose. Concentrations of 
antigenic AAT in epithelial lining fluid 
were approximately 10% of the serum 
AAT concentrations and demonstrated 
diffusion into the lung. 
There were no clinically relevant safety 
findings 
that 
could 
be 
directly 
attributed to AAT. 
RPR118635-201 
(phase 2/3) 
9 
IV, weekly for 
6 months, 
3-5 months of 
compassionate 
use 
60 
Weekly serum AAT measurements 
showed that AAT was successful in 
maintaining 
trough 
serum 
concentrations well above the threshold 
of 0.6 mg/mL. 
AAT was safe and well tolerated. 
CE1226/2-1002 
(phase 1b)  
vs Prolastin 
18 
IV, single dose 
60 
Non-inferiority of AAT to Prolastin in 
bioavailability was shown, as measured 
by area under the curve of functional 
AAT after a dose of 60 mg/kg body 
weight functionally active AAT. AAT 
was well tolerated and similar to 
Prolastin with respect to the incidence 
and severity of AEs. 
 
 


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Study Number 
No. of 
subjects 
enrolled 
Route, 
regimen, 
duration 
Dose 
(mg/kg/body 
weight) 
Results 
CE1226/2-2002 
(phase 3) 
vs Prolastin 
44 
IV, weekly for 6 
months 
60 
Mean steady-state trough concentration 
of serum antigenic AAT was shown to 
be non-inferior to that achieved with 
Prolastin and was above the threshold 
of 0.6 mg/mL. Antigenic assays also 
demonstrated that AAT was delivered 
to the lower lung and was able to 
complex with its substrate, neutrophil 
elastase. 
AAT was safe and well tolerated. 
CE1226_4001 
(phase 3/4) 
vs placebo 
180 
IV, weekly for 
up to 24 months 
60 
The rate of change in lung density, 
measured as computer tomography-
measured lung volume adjusted 15th 
percentile of the lung density (Adjusted 
P15), consistently showed a slower 
decline in subjects treated with AAT, 
relative to placebo. AAT was safe and 
well tolerated. 
CE1226_3001 
(phase 3, open 
label extension 
study to 
CE1226_4001) 
Delayed Start vs 
Early Start 
groupa 
140 
IV, weekly for 
up to 24 months 
60 
The rate of change in lung density, 
measured as computer tomography-
measured Adjusted P15, consistently 
demonstrated: 
• A continued slower decline across 4 
years for the Early Start group  
• A consistent advantage favoring the 
Early Start group over the Delayed 
Start group at all time points from 
baseline to Month 48, i.e., the lung 
tissue loss during the first 2 years of 
placebo exposure in the Delayed 
Start group was permanent 
• A statistically significant change in 
the rate of annual lung density 
decline 
temporal 
to 
the 
administration of AAT in the 
Delayed Start group 
• Modest, statistically significant 4-year 
correlations between annual lung 
density decline rates and FEV1, 
FEV1%, and FVC were established 
• Lower rates and proportions of fast 
decliners temporal to administration 
of drug 
AAT = alpha-1 antitrypsin; Adjusted P15 = measured lung volume-adjusted 15th percentile of the lung density; AE = adverse 
event; FEV1 = Forced expiratory volume in 1 second; FVC = Forced vital capacity 
a Subjects receiving AAT throughout the treatment period of studies CE1226_4001 and CE1226_3001 are termed “Early Start” 
subjects, whilst those who received placebo during study CE1226_4001 and were then reallocated to AAT in the open-label 
extension study CE1226_3001 are termed “Delayed Start” subjects. 
1.6 
Dose Rationale for Planned Study 
In this trial we propose administration of AAT at a dose of 120 mg/kg twice weekly through 
Day 28. Responding patients (CR/PR) will continue to receive a once weekly dose of 120 mg/kg 
through Day 56. As is detailed below, there is a strong rationale for studying this dose in adults 
and adolescents for this disease population. 


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1.6.1 Acute Phase Reactant Properties of AAT 
AAT is the most abundant, endogenous serine protease inhibitor in the circulation 30, 68, 69. 
Serum AAT concentrations in healthy individuals range from 1.5 to 2.5 mg/mL and levels have 
been shown to further increase in inflammatory states 30, 70. Similar to C-reactive protein (CRP), 
AAT is a known acute-phase reactant whose serum levels rise in response to injury, inflammation, 
or infection71. High levels of AAT are commonly seen in various physiologic or disease states 
including: patients with colorectal cancer (mean 206 mg/dL, range 459 mg/dL), pregnancy (mean 
427 mg/dL; range 316–582 mg/dL), and pregnancy in diabetic women (mean, 786 mg/dL; range 
523-1255 mg/dL) 72-74. 
1.6.2 Pre-Clinical Experience with AAT 
Multiple experimental models of allogeneic HCT have shown that administration of AAT both 
reduces the development of, as well, as provides effective therapy for established GVHD. 
These models implicate a reduction of inflammatory cytokines and an induction of 
anti-inflammatory cytokines as being integral to AAT’s efficacy42, 63, 64. Additional models 
suggest that AAT’s effect on cytokines may occur in a dose-response fashion. For example, in a 
human pulmonary cell culture model simulating ischemia- reperfusion processes in lung 
transplantation, AAT significantly inhibited cell death and inflammatory cytokine release in a 
dose-dependent fashion in vitro, with maximal cell viability observed at concentration of 
5mg/ml75. In addition, ex vivo assays performed on fresh whole blood from adult subjects with 
new-onset type 1 diabetes, AAT suppressed expression of IL-6 and IL-1β dose-dependently, with 
> 50% inhibition achieved in the range of 2.5 -5 mg/mL AAT76. Based on the totality of the 
evidence available, it is hypothesized that targeting AAT peak levels above the normal range or 
≥ 2.5 mg/mL should down-regulate inflammatory cytokines and therefore provide protection 
against cytokine-mediated damage. 
1.6.3 Clinical Experience with AAT in HCT Setting 
Clearance of AAT as a result of stool losses has been used as a diagnostic tool in patients with 
protein-losing enteropathies including inflammatory bowel disease and GI malignancies77. 
Not surprisingly, patients with lower GI GVHD (also a protein-losing enteropathy) have been 
found to have increased clearance (via stool losses) of AAT. The first report detailing the 
measurement of levels of AAT in stool in allogeneic HCT recipients was by Weisdorf and 
colleagues in 1983 where it was demonstrated that patients receiving conditioning chemotherapy 
for transplant experience increased clearance of AAT as a result of higher (than normal) stool 
concentrations of AAT78. Serial measurements of stool AAT showed that patients who did not go 
on to develop GI GVHD had a return to baseline levels whereas those who developed lower GI 
GVHD had a marked and persistent increased clearance of AAT. These finds were subsequently 
reproduced in two additional reports with one demonstrating that stool AAT levels at the time of 
GI GVHD onset could serve as an independent- predictor of GVHD response to therapy79, 80. 
Based on these reports, accounting for increased stool losses of AAT in patients with lower GI 
GVHD requires consideration when dosing this agent for this study population. 
In additional support for a higher dosing regimen of AAT, a prospective analysis by Marcondes 
and colleagues showed an inverse relationship between donor AAT levels and the occurrence of 
GVHD in matched sibling allogeneic HCT recipients, with average donor endogenous AAT 
levels of approximately 4 mg/mL reported to result in no incidence of GVHD64. Further, in an 
open-label, single-center, phase 1/2 study of AAT in 12 heavily-treated patients with 


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steroid-refractory acute GVHD of the GI tract, an overall response rate of 66%, and complete 
response rate of 33% was seen67. In this study, a cumulative weekly dose of 270 mg/kg/week was 
shown to be safe. Based on PK measurements, the authors concluded that higher plasma levels 
for AAT via more extended/repeated courses of AAT and a longer maintenance regimen (beyond 
15 days as was used in this study) may be necessary to allow for complete suppression of GVHD. 
In contrast, a second study of AAT for patients with newly diagnosed, steroid-refractory acute 
GVHD, AAT dosed at 60 mg/kg twice weekly resulted in a 65% overall response rate at Day 2866. 
In this study, although AAT trough levels increased relative to study entry AAT levels, these 
trough levels were still within the normal range at 4 weeks (2.15 mg/mL) suggesting that 
60 mg/kg twice weekly (120 mg total weekly dose) did not reach the optimal levels reflected in 
the above cited pre-clinical models. 
1.6.4 Clinical Experience with AAT in Adolescents 
Similar to adults, adolescent children are at significant risk for mortality from GVHD and thus 
may derive potential benefit from equal access to promising investigational therapies. 
Efficacy and safety of AAT in pediatric populations have been explored in several published 
studies of its use in type 1 diabetes (T1DM), where doses of either 180 mg/kg/week  or up to 
90 mg/kg/week were administered with no concerning adverse events (AEs) reported (Gottlieb et 
al81 (AAT product not specified), 2014; Rachmiel et al82 (Glassia®), 2016; Brener et al83 
(Glassia®), 2018; Weir et al84 (Aralast NP®), 2018). In these studies, AAT therapy was reported 
to be safe and well tolerated in children (Rachmiel et al82, 2016), including out to 5 years of 
surveillance (Brener et al83, 2018), and no safety differences were reported between adult and 
pediatric patients (Gottlieb et al81, 2014; Weir et al84, 2018).  Presently, there is no data on the use 
of AAT treatment in acute GVHD or emphysema conditions in pediatric populations. As an 
endogenous protein with proposed weight-based dosing and without evidence of differential 
pharmacokinetics between adults and children where studied, no differential safety profile is 
anticipated with its use in treatment of aGVHD. Due to these considerations, a stepwise plan was 
developed by the sponsor and protocol team (approved by FDA) whereby adolescent patients 
would be enrolled only after first observing no adverse safety signals after enrolling the first 
40 patients.  
1.6.5 AAT Target Level for Proposed Dose in Treatment of GVHD 
It is hypothesized that during acute GVHD, AAT may attenuate inflammation, inhibit 
development of T-memory cells and enhance Tregs and protect against damage and 
down-regulate inflammatory cytokines. The target level of AAT, based on both in vitro and 
clinical data suggest that targeting a level above the upper limit of normal values may provide the 
optimal regulation of T cells and cytokines to ameliorate GVHD symptoms. This target level of 
AAT is likely to provide sustained AAT levels, thereby enhancing Tregs and reducing the 
pro-inflammatory cytokines.  
A PK model of 1000 subjects has been used to simulate a variety of AAT doses and dose 
regimens, with the intent to identify those which result in mean AAT peak level estimates around 
or above the upper limit of normal, i.e., ≥ 2.5 mg/mL. The simulated concentration–time profiles 
generated using AATD PK estimates was validated with data in GVHD patients from the 
literature and multiple doses were modeled. 
Based on this simulation, the dose of 120 mg/kg twice weekly for 4 weeks achieved median trough 
levels above the upper limit of normal (ULN) and provided sufficient separation in median AAT 
levels when compared with a dose 60 mg/kg twice weekly. In addition, this dosing regimen shows 


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that > 50% of the simulated GVHD subjects at this dose regimen achieve serum AAT levels above 
normal physiologic levels almost immediately after initiation of treatment, and levels are 
maintained throughout the 28-day treatment period. The cumulative weekly dose 
(240 mg/kg/week) is similar to the dose regimen of 270 mg/kg/week shown to be safe in 
Marcondes et al trial67.  
1.6.6 Ruxolitinib for the Treatment of Steroid-Refractory Acute GVHD 
The Janus kinase (JAK) and signal transducers and activators of transcription (STAT) signaling 
pathways play an important role in immune-cell activation and tissue inflammation during acute 
GVHD.  Ruxolitinib is an oral selective inhibitor of JAK1 and JAK2 that reduces the incidence 
and severity of GVHD in vivo while preserving graft-versus-leukemia effects in preclinical 
models.  Recently, ruxolitinib was granted FDA approval in the United States for patients 12 years 
and older who develop steroid-refractory or dependent acute GVHD grade II-IV based on the 
results of a prospective phase 2 trial (REACH1).  At a protocol-specified dose of 10mg twice 
daily, 54.9% of the 36 enrolled patients achieved a response on Day 28 without additional therapy. 
Simultaneously, an open-label, phase 3 trial (based on the same study criteria) was performed 
outside of the United States with patients randomized to ruxolitinib 10mg twice daily versus best 
available therapy (BAT).  The results on this study were recently published and showed a higher 
Day 28 and Day 56 response rate in the ruxolitinib arm when compared to BAT (62% vs. 39%; 
odds ratio, 2.64; 95% C.I. 1.43 to 3.94; P< 0.001) and (40% vs. 22%; odds ratio 2.38; 95% C.I. 
1.43 to 3.94; P< 0.001), respectively.  Adverse events were not significantly different between 
the study arms with thrombocytopenia, anemia and CMV infection being most common.   
The availability of an FDA-approved agent for patients enrolled onto this trial may affect the 
frequency and timing of use of next-line therapy.  Importantly, while the results of the REACH 1 
and 2 trials are encouraging, a majority of patients will not achieve or maintain a response through 
Day 56 of treatment with ruxolitinib and outcomes remain poor for patients with 
steroid-refractory acute GVHD.   In an effort to improve upon the outcomes seen thus far with 
ruxolitinib in a steroid-refractory setting, patients that progress or are non-responders on the 
current trial will have the option to stay on AAT/PTM when next-line therapy with ruxolitinib is 
initiated. These patients will be followed for secondary endpoints (while being considered a 
failure for the primary endpoint).  Importantly, the wealth of experience with AAT outside of the 
study indication would suggest that AAT is unlikely to have drug interaction with ruxolitinib nor 
contribute additional safety concerns.   
 


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CHAPTER 2 
2 
STUDY DESIGN 
2.1 
Study Overview 
This study is a phase III, multicenter, double-blinded, randomized, placebo-controlled trial 
designed to compare AAT and CS to PTM and CS as first-line therapy for patients with high-risk 
acute GVHD. 
2.2 
Hypothesis and Specific Objectives 
2.2.1 Primary Hypothesis 
The primary hypothesis is that the addition of AAT to standard therapy with CS will improve the 
Day 28 post-randomization complete response (CR)/partial response (PR) rate in patients with 
newly diagnosed high-risk acute GVHD. 
2.3 
Study Objectives 
2.3.1 Primary Objective 
The primary objective of this trial is to compare the rate of CR and PR on Day 28 
post-randomization between AAT and CS versus PTM and CS in patients with high-risk acute 
GVHD. 
2.3.2 Secondary Objectives 
1. Evaluate the duration of response at 6- and 12-months post-randomization. 
2. Cumulative incidence of non-relapse mortality at 6- and 12-months post-randomization. 
3. Overall survival and progression-free survival at 6- and 12-months post-randomization. 
4. GVHD-free survival at Day 56 post-randomization. 
5. Proportions of CR, very good partial response (VGPR), PR, and treatment failure (TF) at 
Days 7, 14, 21, 28, 56, and 86 post-randomization. 
6. Proportions of CR, very good partial response (VGPR), PR, and treatment failure (TF) at 
Days 7, 14, 21, 28, 56, and 86 post-randomization for patients who receive ruxolitinib or 
other second line therapies approved by the protocol Chairs as next-line therapy and 
remain on AAT/PTM. 
7. Incidence of systemic infections to assess safety. 
8. Incidence of Adverse Events at 30 days post last dose of drug to assess safety.  
9. Incidence of chronic GVHD at 6- and 12-months post-randomization. 
10. Incidence of disease relapse at 6- and 12-months post-randomization. 
2.3.3 Exploratory Objectives 
1. AAT levels in serum at Days 0, 8, 16, 24, 28, and 56 post-treatment initiation. 
2. Stool concentrations of AAT at baseline and at Days 8 and 28 post-treatment initiation. 


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3. Blood ratios of T regulatory to T effector cells (Treg/Teff), Natural Killer (NK) cells and 
cellular immune subsets at baseline and at Days 16, 28, and 56 post-treatment initiation. 
4. Serum levels of inflammatory cytokines and biomarkers at baseline and at Days 8, 28 and 
56 post-treatment initiation. 
5. Overall and organ-specific response rates comparison based on Minnesota (MN) risk 
groups (Revised Minnesota High vs Standard) and organ-specific response rates 
comparison based on biomarker-based risk groups. 
6. Corticosteroid dose at baseline, Days 7, 14, 21, 28, 56, 86, 6 months and 12 months 
post-randomization. 
7. CMV reactivation requiring therapy by Day 56 post-randomization. 
8. Change in patient-reported outcomes from baseline to Day 28, Day 56, and 6-months 
post-randomization. 
a. MD Anderson Symptom Inventory (MDASI) 
b. Patient-Reported Outcome Measurements Information System (PROMIS) 
2.4 
Patient Eligibility  
Patients meeting the eligibility criteria should be enrolled as soon as possible after the start of CS, 
but no more than 72 hours afterwards. 
2.4.1 Inclusion Criteria 
1. Patients experiencing their initial presentation of acute GVHD requiring systemic therapy 
after allogeneic transplant for any malignant or non-malignant indication. 
2. The clinical diagnosis of acute GVHD requiring systemic therapy with CS. Patients can 
be enrolled with only a clinically established diagnosis. Biopsy of involved organs with 
acute GVHD is encouraged but is not required and should not delay study entry. 
Enrollment and randomization include a commitment to continue steroids with PTM or 
AAT as specified in the protocol, as well as the required follow-up observations. 
If, according to institutional practice, the intention to treat is dependent upon biopsy 
results, the patient should not complete enrollment on the BMT CTN 1705 study until the 
biopsy results are available.  
3. Acute GVHD must meet one (either A or B) of following clinical features within 72 hours 
prior to enrollment:  
A. High-risk by Refined Minnesota Criteria (any one below): 
Single organ involvement 
a. 
Stage 4 skin 
b. 
Stage 3-4 lower GI 
c. 
Stage 1-4 liver 
Multiple organ involvement  
a. 
Stage 1-2 lower GI plus any liver 
b. 
Stage 2 lower GI plus any skin 
c. 
Stage 3-4 lower GI plus any liver or skin 
d. 
Any three organ involvement 


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OR:  
B. Either of the below: 
1. Isolated stage 2 involvement of the lower GI tract   
2. Stage 1 lower GI tract disease with skin involvement 
4. Acute GVHD developing after allogeneic hematopoietic cell transplantation using any 
graft or donor source or conditioning intensity.  
5. Patients should not have received systemic immune suppressive therapy for treatment of 
active GVHD except for a maximum of 72 hours of prior CS therapy prior to enrollment. 
Topical skin and GI CS (such as budesonide and oral beclomethasone diproprionate) are 
allowed.  
6. Patients 12 years of age or older at time of enrollment.  
7. Ability to provide written informed consent from patient, parent or legal guardian, and 
assent if applicable. 
2.4.2 Exclusion Criteria  
1. Patients with prior exogenous AAT exposure for GVHD prophylaxis.  
2. Relapsed, progressing or persistent malignancy 
3. Evidence of minimal residual disease (MRD) requiring withdrawal of systemic immune 
suppression.  
4. Patients with acute GVHD developing after administration of a donor lymphocyte 
infusion (DLI) for relapse / progression of disease. Patients with acute GVHD after 
planned donor lymphocyte infusion or planned T cell or NK cell add back are eligible. 
5. Patients with uncontrolled infections will be excluded. Infections are considered 
controlled if appropriate therapy has been instituted and, at the time of enrollment, no 
signs of progression are present. Progression of infection is defined as hemodynamic 
instability attributable to sepsis, new symptoms, worsening physical signs or radiographic 
findings attributable to infection. Persisting fever without other signs or symptoms will 
not be interpreted as progressing infection. 
6. A clinical presentation resembling de novo chronic GVHD or overlap syndrome 
(as defined in APPENDIX C) developing before or present at the time of enrollment.  
7. Patients receiving other drugs for the treatment of GVHD. Note, GVHD prophylaxis 
agents (e.g., calcineurin inhibitors) may be continued at local Investigator’s discretion. 
8. Patients receiving systemic CS for any indication within 7 days before enrollment, except 
the following:  
a. CS administered as premedication for supportive care (such as before transfusion 
of blood products or before intravenous medications to prevent infusion reactions, 
fever, etc.).  
b. If steroid therapy has been administered for treatment of a non-GVHD related 
condition and tapered to < 0.6 mg/kg/day prednisone (0.5 mg/kg/day 
methylprednisolone) for 7 or more days prior to enrollment.  


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c. Treatment of active GVHD with CS is allowed for up to 72 hours prior to 
enrollment. 
9. Patients who are pregnant or breastfeeding.  
10. Females of childbearing potential (FCBP) or males who can get a FCBP pregnant and 
have sexual contact with FCBP and are unwilling to use 2 effective forms of birth control 
or abstinence from the start of study drug treatment through 30 days after the last dose of 
study drug, Effective forms of birth control are listed in APPENDIX D.  
11. Patients on renal replacement therapy.  
12. Patients requiring continuous supplemental oxygen (O2 requirement > 2L/min to maintain 
peripheral O2 saturation [SpO2] > 90%). 
13. Patients with active hepatic sinusoidal obstructive syndrome (SOS) and/or clinical 
evidence of impaired hepatic function (ascites or encephalopathy related to liver disease) 
who in the judgment of the treating physician are not expected to have normalized 
bilirubin by Day 56 after enrollment. 
14. Patients with a history of hypersensitivity to AAT or any component of the investigational 
product or PTM (albumin), including congenitally IgA-deficient patients with antibodies 
to IgA or PTM. 
15. Patients unlikely to be adherent to study specific assessments at the transplant center. 
2.4.3 Adolescent Population  
The protocol was amended (v4.0), after DSMB review and approval, to include patients between 
the ages of 12 to 17.99 years after 40 adult patients had been enrolled onto the trial and completed 
the Day 56 follow-up assessment for safety. 
2.5 
Treatment Plan 
2.5.1 Alpha 1 – Antitrypsin (AAT) 
2.5.1.1 
Drug Information – AAT 
AAT is a lyophilized product for IV administration. Each product package contains 1 single-use 
vial of lyophilized powder and 1 single use vial of sterile water for injection. 
AAT will be manufactured by CSL Behring (CSLB) in accordance with International Conference 
on Harmonisation (ICH) Good Manufacturing Practice (GMP) guidelines and local regulatory 
requirements. 
Information on the preparation and administration of AAT is provided in the Investigational 
Medicinal Product (IMP) Handling Instructions. 
2.5.1.2 
Drug Information – PTM 
The PTM solution will be a commercial albumin product (5% Alburex) diluted in 5% dextrose to 
a visual match to reconstituted AAT solution of 50 mg/mL. An unblinded pharmacist or designee 
will prepare the AAT solution or PTM solution. Once prepared, the solutions are a visual match, 
allowing the study team to be blinded to the assigned treatment.  


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Instructions for preparation of PTM by an unblinded pharmacist or designee are presented in the 
Investigational Medicinal Product Handling Instructions. 
2.5.1.3 
Packaging and Labeling 
The investigational products will be packaged and labeled according to current ICH GMP and 
Good Clinical Practice (GCP) guidelines, and national legal requirements. 
Investigational products will be packaged in an unblinded manner and prepared at the site by an 
unblinded pharmacist or designee. 
2.5.1.4 
Supply and Storage 
Investigational products will be supplied to the study sites by CSLB or delegate. 
AAT must be stored under temperature-controlled and monitored conditions at the predefined 
temperature range in a secure storage area as specified in the Investigational Medicinal Product 
Handling Instructions. 
PTM must be stored under temperature-controlled conditions between 2-8° C. 
2.5.1.5 
Drug Accountability and Destruction 
1. Investigational products must be used only as directed in the clinical study protocol. 
2. The unblinded pharmacist or designee must provide reasons for any discrepancies in drug 
accountability. 
3. All investigational products must be accounted for throughout the study. 
4. Records for the delivery of investigational products to the study site, the inventory at the 
study site, the dispensing and the destruction of investigational product to CSLB / 
designee must be maintained by the unblinded pharmacist or designee as described in the 
IMP Handling Instructions. Administration of investigational products is recorded in the 
electronic case report forms (eCRF). 
5. Any unused, partially used, or empty vials of investigational product should be retained, 
if possible. On-site destruction must be in compliance with applicable local & national 
regulations and per site’s SOPs. 
6. All drug accountability records must be stored in the Suvoda Interactive Response 
Technology system (IRT) and site file and must be readily available for inspection by the 
unblinded study monitor and / or auditor, and open to regulatory inspection at any time. 
7. The Investigator (and/or hospital pharmacist) will ensure that all study drug is stored in 
a secured area under required storage conditions and is dispensed by qualified staff 
members. All study drug will be accounted for in the Suvoda IRT system. 
8. The Investigator is responsible for maintaining drug accountability records. 
Drug accountability records will be reviewed during monitoring visits. Study drug must 
be administered only to patients enrolled in this study as per the protocol. 
9. The unblinded study monitor will be allowed at intervals, and upon request during the 
study, to check unused supplies. Accounting for the use of supplies will be by reference 


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to each center's record of supplies received, the dispensing records for the total number 
of patients enrolled at each center and the unused and returned supplies. 
10. Further details regarding accountability and destruction of investigational product are 
provided in the IMP Handling Instructions and the Suvoda IRT Manual. 
2.5.1.6 
Reconstitution/Preparation of AAT (Zemaira®)/PTM 
Details with regard to preparation and distribution of the study drug can be found within the IMP 
Handling Instructions. AAT/PTM should be administered within 24 hours of preparation. 
2.5.1.7 
Dose and Administration 
The first dose of study drug (AAT/PTM) must be initiated as soon as possible after enrollment 
and must be within 12 hours of enrollment. Each dose of study drug will be 120 mg/kg (actual 
weight) based on the patient’s weight recorded at enrollment. Subsequent doses should be given 
on Days 4, 8, 12, 16, 20, 24, 28 (Table 2-1). The patient’s weight recorded at enrollment will 
be used to determine the dose for all infusions (i.e., dose adjustments for changes in weight 
during the treatment period will not be made). 
Patients that are non-responders or progress will be considered to be steroid-refractory (SR) and 
may start next-line therapy as described in section 2.5.3.3. Ruxolitinib is recommended for next-
line therapy as it is an FDA-approved treatment for SR-GVHD.   
Responding patients (CR/PR) at Day 28, compared to maximum GVHD organ staging within 
72 hours prior to enrollment, that are receiving study drug alone, or study drug plus ruxolitinib, 
should continue to receive treatment at a dose of 120 mg/kg (actual weight) on Days 35, 42, 49, 
and 56 (Table 2-1). Patients who are not in CR/PR at Day 28 will not continue to receive study 
drug. Responding patients at Day 28 who progress after Day 28 may continue to receive weekly 
doses through Day 56. 
Patients that receive next-line therapy other than ruxolitinib may not continue receiving study 
drug unless approval is granted by the BMT CTN 1705 Protocol Chairs. 
Table 2-1 
Study Drug Schedule 
 
Day 
01 
4 
8 
12 
16 
20 
24 
28 
35 
42 
49 
56 
All patients 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
 
CR/PR (VGPR) patients only 
 
 
 
 
 
 
 
 
X 
X 
X 
X 
1 Enrollment is Day 0, First dose of study drug must occur within 12 hours after enrollment and may fall on Day 0 
or Day 1. 
Patients can receive study drug (AAT/PTM) as either an inpatient or outpatient. All subsequent 
treatments will have a window of ± 3 days to allow for efficient scheduling of patients for 
holidays/weekends/etc. Following administration of the first or second dose, adjusting future 
infusions to accommodate a Monday/Thursday or Tuesday/Friday schedule is encouraged. 
Infusion Rate: AAT/ PTM should be administered at a rate not exceeding 0.08 mL/kg body 
weight/minute. If adverse events occur, the rate should be reduced, or the infusion interrupted 
until the symptoms subside. The infusion may then be resumed at a rate tolerated by the subject. 


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Monitoring: Vital signs (temperature, heart rate, blood pressure, respiratory rate) should be 
recorded at a minimum: pre-infusion, approximately 10 minutes into the infusion and 
approximately 20 minutes after completion of the infusion. It should be noted that infusion 
reactions during and following AAT administration have been reported but are rare. 
These include: 
• Uncommon (≥ 1/1,000 to < 1/100): hypersensitivity reactions (including tachycardia, 
hypotension, confusion, syncope, oxygen consumption decreased and pharyngeal 
oedema), flushing, infusion-site reactions (including infusion site hematoma) 
• Very rare (< 1/10,000): anaphylactic reactions 
If anaphylactic or severe anaphylactoid reactions occur, the infusion should be discontinued 
immediately. Epinephrine and other supportive therapy should be available for the treatment of 
any acute anaphylactic or anaphylactoid reaction. 
2.5.1.8 
Dose Interruptions 
Study drug (AAT or PTM) may be held at the discretion of the treating physician and resumed at 
their discretion. Rationale for missed doses should be recorded. Patients that do not receive study 
medication for 3 consecutive doses or miss 4 doses in total will be removed from further study 
treatment. 
Infections 
Patients with severe infections resulting in hemodynamic instability requiring use of vasopressor 
medication may have study drug held at the discretion of the treating physician. 
2.5.1.9 
Adverse Events Related to Study Drug (AAT or PTM) 
Adverse Events of Study Drug (AAT or PTM) 
Patients with a non-hematologic grade 3 or higher adverse event which is not attributable to an 
anticipated post-transplant event may have their study drug held at the attending physician’s 
discretion. Anticipated post-transplant events include GVHD and chemotherapy toxicities 
(see Appendix E and Section 2.5.2.2 respectively.). Study drug should be restarted after recovery 
of related toxicities to grade 2 or lower or identification of an alternative cause for these toxicities. 
Observed adverse reactions as identified from clinical studies in AAT-deficient subjects and 
during post marketing use of AAT can be found in the Investigator Brochure AAT CSL964. 
Adverse Events related to PTM (Alburex) 
Adverse reactions to albumin 5% are rare, although nausea, fever, chills or urticaria may 
occasionally occur. 
 
2.5.1.10 Study Drug Discontinuation Criteria 
Patients that progress or are non-responders and receive ruxolitinib as next-line therapy are 
encouraged to continue study drug (AAT/PTM).   
Study drug shall be discontinued and not re-instituted if any one of the following criteria is met: 


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• Patient does not receive study medication for 3 consecutive doses or 4 doses in total for 
any reason, including toxicity. 
• Patients that receive next-line therapy other than ruxolitinib not approved by the BMT 
CTN 1705 Protocol Chairs. 
• Relapse or progression of underlying malignancy. 
• Pregnancy or initiation of breastfeeding during the study; refer to Section 4.4.5. 
• Withdrawal of consent from study and/or study drug 
The reason for discontinuation of study drug must be documented by the study team. 
All randomized patients, including those that did not receive any study drug, discontinued 
study drug and/or failed treatment, are evaluable for all endpoints of the study and should 
continue with protocol-specific follow-up and data collection unless the patient has 
specifically withdrawn consent to provide data. 
2.5.2 Corticosteroids (CS) 
2.5.2.1 CS Dosing and Taper 
All patients enrolled on this trial must receive CS at a minimum dose of prednisone 
2 mg/kg/day PO (or methylprednisolone 1.6 mg/kg/day IV) divided into 1-2 daily doses as 
therapy for acute GVHD for at least 72 hours post enrollment. For patients that weigh over 
100 kg, maximal starting dose of prednisone will be 200 mg (or methylprednisolone-equivalent). 
For calculation of subsequent CS doses/kg on subsequent measures, the modified starting weight 
of 100 kg will be used. For patients less than 100 kg, dosing of steroids may follow institutional 
practices (with respect to actual versus adjusted weight). Daily dose per kg is based on the weight 
of the patient at time of enrollment. 
For responding patients with evidence of improvement in signs and symptoms of acute GVHD 
after treatment initiation, a suggested CS taper is provided below or may follow institutional 
practice. However, taper must not start sooner than 72 hours after enrollment and the CS dose 
must not be tapered to less than 0.25 mg/kg/day prednisone-equivalent (or 0.2 mg/kg/day 
methylprednisolone) before Day 29. A suggested taper schedule is provided below. 
Table 2-2 
Suggested Steroid Taper for Responding Patients 
Suggested taper for responders 
(Prednisone/Methylprednisolone) 
Days 1-5 
2 mg/kg/day (please note that taper cannot start until 3 days after 
enrollment) 
Days 6-10 
1.5 mg/kg/day 
Day 11-15 
1.0 mg/kg/day 
Days 16-20 
0.5 mg/kg/day 
Days 21-28* 
0.25 mg/kg/day 
Days 29-56 
Gradual further taper with a goal of reaching < 0.2 mg/kg/day of 
prednisone (or < 0.16 mg/kg/day of methylprednisolone) by Day 56. 
*Do NOT taper below 0.25mg/kg/day prednisone (or 0.2 mg/kg/day methylprednisolone) before 
Day 29. 
 


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2.5.2.2 
Adverse Events Related to CS 
The side effects of prednisone are broad and well recognized. They include: 
• Cardiac and vascular: hypertension  
• Cutaneous: impaired wound healing, skin fragility, erythema, acne 
• Endocrine: cushingoid state, growth suppression (pediatric), secondary adrenocortical and 
HPA (hypothalamic pituitary adrenal)-axis suppression, diabetes mellitus, hypokalemia, 
body fluid retention, weight gain 
• Gastrointestinal: peptic ulcers, esophagitis, pancreatitis, gastrointestinal perforation 
gastrointestinal hemorrhage 
• General: edema, increased appetite 
• Hematologic: leukocytosis (transient), lymphopenia  
• Musculoskeletal: myopathy, osteoporosis, tendon rupture, bone fractures, avascular 
necrosis of bones 
• Neurologic: Increased intracranial pressure, convulsions, headache, increased intraocular 
pressure, glaucoma, mood swings, restlessness, insomnia, personality changes, seizure, 
severe depression, or frank psychotic manifestations 
• 
Miscellaneous: increased risk of infection 
2.5.3 Supportive Care 
2.5.3.1 
GVHD Prophylaxis Medications 
Non-investigational medications such as cyclosporine, tacrolimus, mycophenolate mofetil 
(MMF), sirolimus (if used as GVHD prophylaxis prior to the development of acute GVHD) may 
be continued, resumed, or increased to therapeutic doses per provider discretion, and 
adjusted/discontinued as necessary for renal, central nervous system (CNS) or other toxicity using 
institutional management guidelines. Resumption of a GVHD prophylaxis agent is not considered 
the addition of a next-line agent. Changing prophylactic agents within a drug class or to similar 
agents due to toxicity would not represent new therapy or treatment failure. 
2.5.3.2 
Topical and Ancillary GVHD Therapies 
Topical therapy for acute GVHD is allowed and should be used according to institutional 
practices. Topical therapy including corticosteroid creams, topical tacrolimus, oral 
beclomethasone or budesonide, topical azathioprine, and ophthalmic glucocorticoids, is not 
considered as secondary systemic therapy. 
Ancillary/supportive care measures for acute GVHD such as the use of anti-motility agents for 
diarrhea, including octreotide, is allowed at the discretion of the treating physician. Use of 
ursodiol to prevent/reduce gall bladder sludging or prevent hepatic transplant complications is 
also allowed according to institutional guidelines. 
2.5.3.3 
Acute GVHD Progression or Non-response 
Acute GVHD Progression (see Section 3.1.1 Response Definition for Progression): 
A patient cannot be declared as having progression in acute GVHD before 72 hours from the 
time of study randomization. Patients should receive at least 2 doses of AAT/PTM before being 
declared as having acute GVHD progression (and starting next-line therapy).  Patients receiving 


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ruxolitinib are encouraged to continue study drug (AAT/PTM), however, study treatment may be 
discontinued at the discretion of the treating physician.  
Acute GVHD No Response (see Section 3.1.1 Response Definitions for No Response): 
An additional line of therapy (for non-response) must not be started before Day 7. A patient should 
receive at least 3 doses of study drug (AAT/PTM) before starting next line therapy for 
non-response.  
Ruxolitinib is recommended for next-line therapy as it is an FDA-approved treatment for 
SR-GVHD. Patients receiving ruxolitinib are encouraged to continue study drug (AAT/PTM) to 
determine if the continuation of AAT can improve outcomes. Patients that are non-responders 
and receive next-line therapy other than ruxolitinib may not continue study drug (AAT or PTM) 
unless approval is granted by the BMT CTN 1705 Protocol Chairs.   
Patients who receive a non-protocol approved therapy for treatment of acute GVHD will be 
considered as treatment failure and study drug must be discontinued. 
Table 2-3 
Timeline for Declaring Patient as having Acute GVHD Progression or No 
Response Categories 
Response 
Definition 
 Minimum Number 
of Doses of AAT/ 
PTM Before Starting 
Next Line Therapy 
Mandated Minimum 
Time from Enrollment 
Before Starting Next 
Line Therapy 
Progression 
2 doses 
72 hours 
No Response 
3 doses 
7 days 
 
2.5.3.4 
Acute GVHD Flare 
A flare is defined as any progression of acute GVHD after an initial response (i.e., earlier CR or 
PR) that requires re-escalation of steroid dosing, or initiation of additional topical or systemic 
therapy. 
If acute GVHD flares during taper of CS, the dose of steroids may be increased at the discretion 
of the treating physician as long as this increase is to less than 2.5 mg/kg/day of prednisone 
(or methylprednisolone equivalent of 2 mg/kg/day). Doses otherwise above these parameters will 
be considered as a “new agent” and the patient will be scored as a failure. Other Supportive Care 
Guidelines 
In addition to prescribed study drug plus CS, all patients should receive the following per 
institutional practice: 
• Transfusion support  
• Anti-infective prophylaxis against herpes viruses, Pneumocystis jiroveci, bacterial and 
fungal infections. 
• Routine CMV antigenemia/viral load testing by hybrid capture or PCR-based methods 
(with preemptive therapy in patients who develop a positive assay). CMV testing is 
recommended weekly through at least Day 100 post-transplant. Prophylaxis against CMV 
is allowed. 


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• Co-enrollment onto supportive care and infectious disease protocols will be allowed on 
case-by-case basis and requires approval by study chairs and sponsor.  
2.6 
Study Unblinding 
Subjects and all personnel involved with the conduct and interpretation of the study will be 
blinded to the study treatment except for the investigational pharmacy staff involved in study drug 
preparation. In addition, CSL’s Clinical Trial Supply team, CSL’s IRT team, and the Suvoda IRT 
team and system are unblinded. Unblinding of the study drug should only be considered for 
participant safety contingent upon knowing the blinded study drug assignment. In situations that 
satisfy these criteria, the Investigator may break the blind per the processes laid out in the BMT 
CTN 1705 Unblinding Procedures. The reason for unblinding must be fully documented. 
Any unblinding by the investigational staff must be reported immediately as outlined in the BMT 
CTN 1705 Unblinding Procedures and must include an explanation of why the study medication 
was unblinded. If possible, CSL Behring should be consulted prior to unblinding of the study 
drug. The Sponsor may break the treatment code for participants who experience a suspected 
unexpected serious adverse reaction (SUSAR), to determine if the individual case or a group of 
cases requires expedited regulatory reporting. 
2.7 
Study Conduct 
This study will be conducted in accordance with the protocol, the IMP Manual, the Suvoda IRT 
system, the BMT CTN Administrative MOP, and the following: 
• Consensus ethical principles derived from international guidelines including the 
Declaration of Helsinki 
• Applicable ICH Good Clinical Practice (GCP) Guidelines 
• Applicable laws and regulations 
 
The National Marrow Donor Program (NMDP) single Institutional Review Board (IRB) of 
Record will oversee this study and conduct the study-specific reviews as required by federal 
regulations and per the NMDP IRB Standard Operating Procedures (SOPs). 
Site personnel will enter enrollment data and post randomization data in the electronic case report 
forms (eCRFs) in Advantage eClinical as described in the BMT CTN 1705 Forms Guide. 
Randomization will be conducted in the Suvoda IRT system after enrollment has been completed 
in Advantage eClinical. Source documentation should be made available for monitoring visits, 
audits, and regulatory inspections as described in the BMT CTN Administrative MOP.  
Participating Principal Investigators bear ultimate responsibility for training of site staff as well 
as the scientific, technical, and administrative aspects of conduct of the protocol, even when 
certain tasks have been delegated to coinvestigators, sub-investigators, or staff.  The PIs have a 
responsibility to protect the rights and welfare of participants and comply with all requirements 
regarding the clinical obligations and all other pertinent requirements in 21 CFR part 312. 
In addition to following applicable federal, state, and local regulations, investigators are expected 
to follow ethical principles and standards and receive training in GCP every three years and 
human subjects training within the past 3 years and thereafter as per institutional requirements. 


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2.8 
Study Termination 
Regulatory agencies have the right to terminate the study at any time in case of safety concerns 
or if special circumstances concerning the study drug or the company itself occur, making further 
treatment of patients impossible. The study sponsor also has the right to terminate the study. 
In this event, the Investigator(s) and relevant authorities will be informed of the reason for study 
termination. 
CSLB reserves the right to prematurely discontinue or suspend the study either at a particular site 
or at all study sites at any time and for any reason. If such action is taken, the Study Monitor 
(or delegate) will discuss this with the Investigator at each study site at that time and notify the 
Investigators in writing. If the study is suspended or terminated for safety reasons, all 
Investigators and the relevant regulatory agencies will be immediately notified of the action as 
well as the reason for the suspension/termination. The Investigator at each study site will advise 
their local Institutional Review Board (IRB) / Institutional Ethics Committee (IEC). The BMT 
CTN DCC will notify the NMDP single IRB of Record overseeing the study of the suspension/ 
termination. 
 


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CHAPTER 3 
3 
STUDY ENDPOINTS 
3.1 
Primary Endpoint  
The primary endpoint is the proportion of participants with an overall (complete or partial) 
response to acute GVHD treatment at Day 28 post-randomization, compared to maximum GVHD 
organ staging within 72 hours prior to enrollment. Patients without a Day 28 response assessment 
will be considered failures. Acute GVHD will be graded and assessed for response based on Harris 
(Mount Sinai Acute GVHD International Consortium [MAGIC]) Criteria (refer to APPENDIX C). 
3.1.1 Response Definitions 
Response definitions are listed below:  
1. Complete Response (CR) is defined as a score of 0 for the GVHD staging in all evaluable 
organs.  
2. Partial response (PR) is defined as improvement in one or more organs involved with 
GVHD symptoms without progression in others. 
a. Very good partial response (VGPR) is defined as a quantitative and functional 
response that closely approximates CR. Patients must have all of the following 
clinical features. i.e., (1) no rash or rash involving < 25% of body surface area 
(BSA) without bullae (residual faint erythema and hyperpigmentation do not 
count), (2) serum bilirubin < 2mg/dl or < 25% of baseline at enrollment and 
(3) ability to tolerate food or enteral feedings with predominantly formed stool 
(no overt GI bleeding or cramping and no more than occasional nausea or 
vomiting). 
3. Mixed response (MR) is defined as improvement in one or more organs with deterioration 
in another organ manifesting symptoms of GVHD or development of symptoms of GVHD 
in a new organ. 
4. No Response (NR) is defined as absence of any improvement or progression as defined.  
5. Progression is defined as deterioration in at least one organ without any improvement in 
others.  
Patients who receive next-line systemic GVHD therapy (or escalation of steroids to 
≥ 2.5 mg/kg/day of prednisone [or methylprednisolone equivalent of 2 mg/kg/day]) before Day 28 
will be classified as NR. Responses categorized as NR, MR and progression will be treated as 
a failure for the primary endpoint. 
3.2 
Secondary Endpoints  
3.2.1 Duration of Response (DOR) 
The duration of response (DOR) is defined as time from the Day 28 response (CR or PR) to any 
of the following events: recurrence/progression of acute GVHD, new systemic salvage therapy for 


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acute GVHD, re-escalation of steroids to greater or equal to 2.5 mg/kg prednisone or equivalent, 
or death from any cause. Patients without any of these events will censored at last follow up. DOR 
will be evaluated at 6- and 12-months post-randomization. 
3.2.2 Non-Relapse Mortality (NRM)  
An event for non-relapse mortality (NRM) is death without prior evidence of relapse/progression 
of the primary disease, where relapse/progression is treated as a competing risk. The cumulative 
incidence of NRM at 6 months and 12 months post-randomization will be evaluated.  
3.2.3 Overall Survival (OS) and Progression-Free Survival (PFS)  
Overall survival (OS) and progression-free survival (PFS) will be evaluated at 6 months and 
12 months post-randomization. An event for OS is death from any cause, while an event for PFS 
is death from any cause or relapse/progression of the primary disease. 
3.2.4 GVHD-Free Survival 
Patients alive, free of active acute or chronic GVHD, and without other systemic agents 
(or escalation of steroids to ≥ 2.5 mg/kg/day of prednisone [or methylprednisolone equivalent of 
2 mg/kg/day]) added for treatment of GVHD will be considered successes for this endpoint. 
The proportion of participants with GVHD-free survival at Day 56 post-randomization will be 
evaluated.  
3.2.5 Proportion of Response 
The proportion of patients with CR, PR (including subset with VGPR), and treatment failure (TF) 
will be described at Days 7, 14, 21, 28, 56 and 86 post-randomization. The Day 86 response will 
be assessed in patients remaining on maintenance treatment after Day 28. The designation of TF 
will consist of patients with NR, MR, progression or initiation of additional systemic (next-line) 
GVHD therapies (or escalation of steroids to ≥ 2.5 mg/kg/day of prednisone 
[or methylprednisolone equivalent of 2 mg/kg/day]). Death from any cause will also be considered 
a TF. 
3.2.6 Proportion of Response (Next-Line Therapy) 
The proportions of patients with CR, PR (including subset with VGPR), and treatment failure (TF) 
at Days 7, 14, 21, 28, 56, and 86 post-randomization for patients who receive ruxolitinib or other 
next-line therapies approved by the protocol Chairs as next-line therapy and remain on AAT/PTM. 
3.2.7 Systemic Infections 
The incidence of Grade 2 to 3 systemic infections, as defined in Appendix G, occurring from 
randomization until 30 days after last dose of study drug (AAT or PTM) will be described. 
Infections developing after randomization will be recorded by site of disease, date of onset, and 
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3.2.8 Adverse Events 
The incidence of Grade 3-5 treatment-emergent adverse events (per Common Terminology 
Criteria for Adverse Events [CTCAE] Version 5.0) that occur from randomization until 30 days 
after last dose of study drug (AAT or PTM) will be described.  
3.2.9 Chronic GVHD 
The cumulative incidence of chronic GVHD will be evaluated at 6- and 12-months 
post-randomization, where death is treated as a competing risk. Chronic GVHD is defined per 
National Institutes of Health (NIH) Consensus Criteria (see APPENDIX C). Diagnosis of chronic 
GVHD of any severity (mild, moderate, or severe) is considered an event for this endpoint. 
Organ involvement and maximum severity will also be described at 6 and 12 months. 
3.2.10 Disease Relapse 
The cumulative incidence of relapse/progression of the primary disease will be evaluated at 6- and 
12-months post-randomization, with death prior to relapse/progression treated as a competing risk.  
Malignancy relapse is defined as follows:  
Relapse is defined by either morphological or cytogenetic evidence of acute leukemia or 
myelodysplastic syndrome (MDS) consistent with pre-transplant features, or radiologic evidence 
of lymphoma, documented or not by biopsy. Progression of disease applies to patients with 
lymphoproliferative diseases (lymphoma or chronic lymphocytic leukemia) not in remission prior 
to transplantation. The event is defined as increase in size of prior sites of disease or evidence of 
new sites of disease, documented or not by biopsy.  
Acute leukemia– Relapse will be diagnosed when there is: 
- 
Reappearance of leukemia blast cells in the peripheral blood; or, 
- 
> 5% blasts in the bone marrow, not attributable to another cause (e.g., bone marrow 
regeneration) 
- 
The development of extramedullary leukemia or leukemic cells in the cerebral spinal fluid  
Myelodysplastic Syndrome (MDS) – Relapse will be diagnosed when there is: 
- 
Satisfying criteria for evolution into acute myeloid leukemia (blasts greater than 20%), OR 
- 
Reappearance of pre-transplant morphological abnormalities detected in bone marrow 
specimens combined with a decrease in PB chimerism; OR 
- 
Reappearance of pre-transplant cytogenetic abnormality in at least one metaphase by 
routine metaphase cytogenetics or a positive test by FISH on each of two separate 
consecutive examinations at least one month apart, regardless of the number of metaphases 
analyzed 
- 
For patients with: 
o Less than 5% blasts: greater or equal to 50% increase in blasts to greater or equal to 
5% blasts confirmed by flow cytometry  
o 5%-10% blasts:  greater or equal to 50% increase to greater or equal to 10% blasts 
confirmed by flow cytometry  


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Lymphoproliferative Diseases – Relapse or progression will be diagnosed when there is: 
- 
Appearance of any new lesion more than 1.5 cm in any axis during or at the end of therapy, 
even if other lesions are decreasing in size. Increased fluorodeoxyglucose (FDG) uptake in 
a previously unaffected site will only be considered relapsed or progressive disease after 
confirmation with other modalities. In patients with no prior history of pulmonary 
lymphoma, new lung nodules identified by CT are mostly benign. Thus, a therapeutic 
decision should not be made solely on the basis of the PET without histologic confirmation. 
- 
At least a 50% increase from nadir in the sum of the product diameters of any previously 
involved nodes, or in a single involved node, or the size of other lesions (e.g., splenic or 
hepatic nodules). To be considered progressive disease, a lymph node with a diameter of 
the short axis of less than 1.0 cm must increase by > 50% and to a size of 1.5 x 1.5 cm or 
more than 1.5 cm in the long axis.  
- 
Lesions should be PET positive if observed in a typical FDG-avid lymphoma or the lesion 
was PET positive before therapy unless the lesion is too small to be detected with current 
PET systems (< 1.5 cm in its long axis by CT). 
- 
In addition to the criteria above, patients with chronic lymphocytic leukemia (CLL) who 
present in complete remission prior to transplantation may fulfill the relapse definition if 
there is reappearance of circulating malignant cells that are phenotypically characteristic 
of CLL.  
For other diseases not listed probable or definitive evidence of progression must be documented 
by biopsy, imaging, or peripheral blood findings that are diagnostic or otherwise consistent with 
that disease state. 
*Institution of any therapy to treat persistent, progressive or relapsed malignancy, including 
the withdrawal of immunosuppressive therapy, or donor lymphocyte infusion, will be 
considered evidence of relapse/progression regardless of whether the criteria described 
above were met. 
Non-malignant Diseases:  
Non-malignant diseases will be considered to have a transplant status of persistent/active disease. 
Graft failures will be considered recurrence. 
3.3 
Exploratory Endpoints 
3.3.1 AAT Levels 
AAT levels will be assessed using measurements of serum antigen concentration and functional 
activity just prior to infusion and 30 min (+/- 15 min) post-end of infusion on Day 0, and on 
Days 16, 28, and 56 post-initiation of treatment. Post-infusion measurements are limited to 
subjects receiving a dose of AAT/PTM. AAT levels will be measured only prior to infusion on 
Days 8 and 24 post-initiation of treatment.  
3.3.2 Stool AAT, Microbiome, and Metabolome 
Stool concentrations of AAT at baseline and at Days 8 and 28 post-initiation of treatment (or at 
treatment discontinuation (TD) if prior to Day 28) at a subset of centers for a limited cohort of 


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patients. Samples will be stored for future analysis of the stool microbiome, metabolome, and 
biomarkers.  
3.3.3 Immune Subsets  
The changes in peripheral blood ratios of T regulatory to T effector (Treg/Teff) cells and Natural 
Killer (NK) cells and other relevant immune subsets at baseline and at Days 16, 28, and 
56 post-initiation of treatment (or at treatment discontinuation (TD) if prior to Day 56).  
3.3.4 Inflammatory Cytokines and GVHD Biomarkers  
Serum levels of IL-1β, IL-6, IL-10, TNFα, amphiregulin (AREG), HS, ST2, and REG3α will be 
evaluated at baseline and at Days 8, 28, and 56 post-initiation of treatment (or at treatment 
discontinuation (TD) if prior to Day 56). Remaining samples will be retained for analysis of 
additional relevant cytokines, DAMPs and GVHD biomarkers. 
3.3.5 Overall and Organ-Specific Response Rates by Refined Minnesota Risk and 
Biomarker-Based Risk Classifications 
The proportions of patients with an overall response (complete or partial) at Day 28 
post-randomization will be described by Refined Minnesota risk category (high or standard risk) 
and by Ann Arbor biomarker risk score (1, 2, or 3). Additionally, the response rate of each GVHD 
target organ will be described at Day 28 by Refined Minnesota risk and Ann Arbor biomarker risk. 
An organ response is defined as a decrease in staging of that organ from baseline. 
The organ-specific response rate will be evaluated only using patients with a staging greater than 
0 in the corresponding organ at baseline. 
3.3.6 Systemic Corticosteroid Dose 
The systemic corticosteroid dose will be evaluated at baseline and on Days 7, 14, 21, 28, 56, 86, 
6 months and 12 months post-randomization.  
3.3.7 CMV-Reactivation 
The proportion of patients requiring new systemic treatment for an increasing CMV PCR level per 
institutional practice for CMV-reactivation will be evaluated at Day 56 post-randomization. 
Patients receiving only standard of care viral prophylaxis will not be included in this assessment 
3.3.8 Patient-Reported Outcomes 
Patient-reported outcomes for both adolescents and adults will be assessed at baseline, Days 28, 
56 and 180 post-randomization by the MD Anderson Symptom Inventory85 (MDASI), and selected 
Patient-Reported Outcome Measurements Information System (PROMIS) subscales for 
gastrointestinal symptoms, physical function and satisfaction with participation in social roles. 
Adolescent versions should be completed by patients who are less than 18 years of age at the time 
of enrollment. The instruments will be scored according to the recommendations of the developers. 
Patient-reported outcomes (PRO) data will be collected electronically. The MDASI instrument 
will only be offered to English- and Spanish-speaking patients. The PROMIS instrument will only 
be offered to English-speaking patients. The instruments cannot be completed by surrogates.  


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CHAPTER 4 
4 
PATIENT ENROLLMENT AND EVALUATION 
4.1 
Approaching Patients, Eligibility Screening and Obtaining Consent 
Patients with previously untreated, acute GVHD meeting eligibility criteria will be approached as 
soon as possible after diagnosis. Patients willing to participate in the trial will sign a NMDP 
IRB-approved consent or assent form, and eligibility for enrollment will be further evaluated. 
4.2 
Enrollment and Randomization 
Patients will be (1) enrolled using the BMT CTN Advantage eClinical system and then 
(2) randomized in the Suvoda Interactive Response Technology (IRT) system. The IRT system 
will also provide the study drug supply management. Patients will be randomized to AAT versus 
PTM in a 1:1 ratio. The following procedures shall be followed: 
Patients must be enrolled in Advantage eClinical prior to randomization in the Suvoda IRT 
System. 
1. An authorized user at the clinical center completes the initial screening by entering patient 
demographics, eligibility information (consent date, inclusion/exclusion criteria) and 
patient’s weight on the Enrollment Form in Advantage eClinical. 
2. If the patient is eligible, “successful enrollment’ is displayed along with a patient study 
ID# number and patient’s weight. Information regarding participant’s log-in information 
for the ePRO system is also included. The coordinator should print two copies of the 
screen: one for the patient’s chart and one for the study participant. 
3. Immediately after the patient is successfully enrolled/ deemed eligible in Advantage 
eClinical, the authorized user must register the patient in the Suvoda IRT system for 
randomization to occur. The user enters the Patient ID# assigned in eClinical, 
demographics (year of birth, age, and sex) and weight at time of enrollment. 
4. The Suvoda IRT system will determine the patient’s randomization assignment and 
automatically email the site’s investigational pharmacist on record with the following 
information: Patient ID #, Visit # and the specific kits to be used to prepare the patient’s 
assigned treatment. 
5. A visit schedule based on enrollment date is displayed in Advantage eClinical for printing. 
If a connection is interrupted during an enrollment session in Advantage eClinical, the process is 
completely canceled and logged. A backup manual enrollment system will also be available to 
provide for short-term system failure or unavailability. If the Suvoda IRT system is interrupted or 
down, the Suvoda Help Desk must be notified.  
A patient is considered on the study once randomization in the IRT system is complete.  
Patient must begin study drug (AAT or PTM) within 12 hours of enrollment in Advantage 
eClinical. 


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4.3 
Study Monitoring 
4.3.1 Follow-Up Schedule 
The Follow-up Schedule for scheduled study visits is outlined in Table 4-1. The timing of 
follow-up visits is based on the date of enrollment. A detailed description of each of the forms 
and the procedures required for forms completion and submission can be found in the Data 
Management Handbook and User’s Guide. 
Criteria for Forms Submission: Criteria for timeliness of submission for all study forms are 
detailed in the BMT CTN 1705 Forms Guide. Forms that are not entered in Advantage eClinical 
within the specified time will be considered delinquent. Transplant Centers can view past due 
forms via Advantage eClinical. A missing form will continue to appear until the form is entered 
into Advantage eClinical, or until an exception is granted and entered into the Missing Form 
Exception File, as detailed in the Forms Guide. 
Reporting Patient Deaths: The Recipient Death Information must be entered into the web-based 
data entry system within 24 hours of knowledge of a patient’s death even if the cause of death is 
unknown at that time. Once the cause of death is determined, the form must be updated. 
Center for International Blood and Marrow Transplant Research (CIBMTR) Data 
Reporting: Centers participating in BMT CTN trials must register pre- and post-transplant 
outcomes on all consecutive hematopoietic stem cell transplants done at their institution during 
their time of participation to the CIBMTR. Registration is done using procedures and forms of 
the Stem Cell Transplant Outcomes Database (SCTOD). (Note: Federal legislation requires 
submission of these forms for all US allotransplant recipients.) CIBMTR post- transplant Report 
Forms must continue to be submitted for all patients enrolled on this trial. Additionally, CIBMTR 
pre- and post- transplant Report Forms must also be submitted for all patients enrolled on this 
trial according to the randomization assigned to the patient at the time of initial registration with 
the CIBMTR. Long-term follow-up of patients on this study will continue through routine 
CIBMTR mechanisms. 
4.3.2 Assessments 
Assessment and/or reporting of the following is required for patients enrolled on this study. 
All assessments are considered standard of care unless identified below by “*”. 
Pre-Enrollment  
1. Performance status (Karnofsky for patients age 16 and older; Lansky for patients age 
12-15.99 at the time of enrollment), history and physical exam including height and 
weight within 7 days prior to enrollment. 
2. Complete acute GVHD staging and grading information including assessments of rash, 
diarrhea, nausea/vomiting, and liver abnormalities prior to enrollment. 
3. Corticosteroid start date and dose (including administered dose and patient weight) prior 
to enrollment. 
4. Liver function tests (bilirubin, alkaline phosphatase, AST, ALT) within 48 hours prior to 
enrollment. 


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5. Complete blood count (CBC) with differential and platelet count within 48 hours prior to 
enrollment. 
6. Pregnancy test (by blood) for females of childbearing potential within 30 days prior to 
enrollment. 
Post- Randomization (Prior to initiation of Study Drug (AAT/PTM)) 
1. Baseline patient-reported outcome measures prior to initiation of AAT/PTM. 
Only English- and Spanish-speaking patients may participate in the MDASI Health 
Quality of Life (HQL) component of this trial; only English-speaking patients may 
participate in the PROMIS HQL component. Adolescent versions should be completed by 
patients who are less than 18 years of age at the time of enrollment. Surveys may not be 
completed by surrogates.* 
2. GVHD prophylaxis medication and complete acute GVHD staging and grading 
information including assessments of rash, diarrhea, nausea/vomiting, and liver 
abnormalities prior to initiation of AAT/PTM. 
3. Blood research samples for serum AAT levels in peripheral blood collected pre-treatment 
(just prior to first dose of study drug) Note: samples will also be collected 15-45 minutes 
post-end of infusion.* 
4. Blood research samples collected pre-treatment for serum inflammatory cytokines, 
GVHD biomarkers and flow cytometry.* 
5. Optional stool research sample pre-treatment from consenting patients (select centers 
only).* 
Post- Randomization (Treatment and Post-Treatment Follow-Up) 
1. Performance status (Karnofsky for patients age 16 and older; Lansky for patients age 
12-15.99) at Days 28 and 56, and at 3 months, 6 months, and 12 months.  
2. Complete acute GVHD staging and grading information including assessments of rash, 
diarrhea, nausea/vomiting, weight and liver function tests weekly until Day 56, and 3, 6, 
and 12 months. Days 28 and 56 scoring must be performed by direct observation at the 
Transplant Center. Evaluations at other time points may be performed by clinicians 
familiar with assessing GVHD other than at the Transplant Center but the Transplant 
Center is responsible for collecting all required data. All GVHD treatment decisions must 
be made by the physician at the Transplant Center. 
3. Liver function tests (bilirubin, alkaline phosphatase, AST, ALT) weekly until Day 56, and 
at 3 months, 6 months, and 12 months. 
4. Chronic GVHD assessment at Days 28 and 56, and months 3, 6 and 12. 
5. GVHD prophylaxis medication (if available) weekly through Day 28. 
6. CBC with differential, platelet count on Days 14, 28, 56, and 86.  
7. Toxicities at Day 120, 6 months and end of treatment (EOT). 
8. Infections up to 3 months are reported on the event driven infection forms. Per protocol 
section 4.4.1 infections are anticipated events and do not require reporting as an AE/SAE. 
9. Corticosteroid dose (including administered dose and patient weight) weekly until Day 
56, and at months 3, 6 and 12 and/or EOT. 


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10. Second-line immune suppressive therapy weekly until Day 56 and at months 3, 6 and 12 
and/or EOT. 
11. Patient-reported outcome measures at Day 28, Day 56, and 6 months. Only English- and 
Spanish-speaking patients may participate in the MDASI HQL component of this trial; 
only English-speaking patients may participate in the PROMIS HQL component of the 
trial.  Adolescent versions should be completed by patients who are less than 18 years of 
age at the time of enrollment Surveys may not be completed by surrogates.* 
12. Blood research samples for serum AAT levels in peripheral blood in peripheral blood at 
Days 0, 8, 16, 24, 28, and 56. Samples should be drawn just prior to each study drug 
infusion (and within 15-45 minutes post-end of infusion for the Day 16, 28, and 
56 samples). See APPENDIX B for further details.* 
13. Blood research samples at Days 8, 16, 28, and 56 (or treatment discontinuation [TD] if 
prior to Day 56) for serum inflammatory cytokines, GVHD biomarkers and flow 
cytometry. The collection of required research blood samples should be coordinated with 
the collection of the pre-infusion blood samples for AAT level measurements. If study 
drug is administered before or after the indicated day, but within the treatment window 
(Section 2.5.1.7), the timing of the research sample can be adjusted accordingly. If it is 
not possible to coordinate the research sample collection, the window of collection for 
research blood samples is ± 3 days.* 
14. Optional stool research samples at Days 8 and 28 (or within +/- 3 days of treatment 
discontinuation [TD]). Stool samples from consenting patients should be collected if 
possible, on the target visit day indicated or within +/- 3 days of the scheduled visit. (Select 
centers only)* 


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Table 4-1 
Required Assessments Post- Enrollment 
* 
± 3 days from the target day to allow for scheduling flexibility, holidays, etc. 
** 
± 14 days from the target day to allow for scheduling flexibility 
*** ± 28 days to allow for scheduling flexibility 
**** 60 days to allow for scheduling flexibility 
1 
Pre-therapy assessments preferably should be performed prior to enrollment, however, up to 36 hours post- enrollment is allowed. 
2 
End of Treatment assessments (except specimen collection) for patients that terminate treatment early will be done 30 days after the last dose of study drug. A ± 3-day window is allowed. 
3 
Pregnancy test (by blood) for females of childbearing potential within 30 days prior to enrollment. Serum or urine test on Day 28 and Day 56. 
4 
Includes anti-viral prophylaxis 
5 
AEs and SAEs will be reported from randomization until 30 days post last dose.  Beginning at 31 days from the last dose of study drug through the end of study follow-up, SAEs deemed to be 
related to the study drug require reporting, and any unanticipated SAE regardless of relationship to study drug require reporting. 
6 
Only English- and Spanish-speaking patients are eligible to participate in the Health Quality of Life (HQL) component of this trial. MDASI surveys to be completed by both English- and Spanish-
speaking patients. PROMIS surveys to be completed by English speaking patients only. Surveys may not be completed by surrogates. 
7 
The Chronic GVHD Provider Survey is due at each Chronic GVHD evaluation and will record GVHD symptoms present in the last week and must be completed by a clinician on the day of the 
assessment. 
 
Days 
 
Pre-
Enrollment  
Pre-Therapy1 
7* 
14* 21* 28* 35* 42* 49* 56 *  
86 
(3 mos)** 
120** 
180 (6 
mos)*** 
EOT2 
(+ 30 
days) 
365 (12 
mos)**** 
History, physical exam, weight and 
height 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Karnofsky/Lansky Performance 
Status  
X 
 
 
 
 
X 
 
 
 
X 
X 
 
X 
 
X 
Pregnancy test if applicable3 
X 
 
 
 
 
X 
 
 
 
X 
 
 
 
 
 
 Acute GVHD evaluation 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
X 
 
X 
Liver 
Function 
Tests 
(alkaline 
phosphatase, bilirubin, AST, ALT) 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
X 
 
X 
CBC with differential, platelet count 
X 
 
 
X 
 
X 
 
 
 
X 
X 
 
 
 
 
Immunosuppressive drug monitoring 
(eg, sirolimus, tacrolimus, 
cyclosporine) 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
X 
X 
X 
Determination of corticosteroid dose, 
including administered dose and 
patient weight 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
X 
X 
X 
Chronic GVHD evaluation7 
 
 
 
 
 
X 
 
 
 
X 
X 
 
X 
 
X 
Toxicity assessment 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
 
 
Infection monitoring4 
 
Reporting of infections at time of occurrence from time of enrollment through 3 months 
 
 
AE/SAE assessments5 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
X5 
X5 
X5 
Patient-reported outcomes6:  
MDASI, PROMIS 
 
X 
 
 
 
X 
 
 
 
X 
 
 
X 
 
 


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Table 4-2 
Required and Optional Research Assessments Post-Initiation of Treatment (see APPENDIX B for further details) 
Type 
Purpose 
Day 
Pre-Therapy2 
0 
8 
16 
24 
28 
56 
TD3 
Required 
Study drug levels1 
X 
X 
X 
X 
X 
X 
X 
 
Serum Inflammatory Cytokines and 
GVHD Biomarkers4 
X 
 
X 
 
 
X 
X 
X 
Flow Cytometry4 
X 
 
 
X 
 
X 
X 
X 
Optional (at select centers) 
Stool research samples5 
X 
 
X 
 
 
X 
 
X 
NOTE: Enrollment is Day 0. First dose of study drug must occur within 12 hours after enrollment and may fall on Day 0 or Day 1. 
1 
Samples should be drawn just prior to each study drug infusion (and also within 15 to 45 minutes post-end of infusion for the Day 0, 16, 28, and 56 samples). 
2 
Collect sample prior to administering study drug. 
3 
Sample should be collected at treatment discontinuation (TD) if that occurs prior to Day 28 (stool)/56 (blood). (Note: This is at the time that patient discontinues the study drug.) 
4 
The collection of required research blood samples for serum biomarkers and flow cytometry studies should be coordinated with the collection of the pre-drug infusion blood 
samples for AAT level measurements. If study drug is administered before or after the indicated day but within the treatment window (Section 2.5.1.7), the timing of the research 
sample collection can be adjusted accordingly. If not possible for some reason to not coordinate the research sample collection, the window of collection for research blood 
samples are ± 3 day. 
5 
Stool samples being collected from consenting patients at selected centers with active Microbiome laboratories should be collected if possible on the target visit day indicated or 
within ± 3 days of the scheduled visit. 


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4.4 
Adverse Event Reporting 
Adverse event (AE) reporting is summarized below with the specific requirements described 
under Section 4.4.4.  
4.4.1 Definitions 
Adverse Event: Any untoward medical occurrence in a patient or clinical investigation subject 
administered a pharmaceutical product and which does not necessarily have a causal relationship 
with this treatment. An adverse event (AE) therefore is any unfavorable and unintended sign 
(including an abnormal laboratory finding), symptom, or disease temporally associated with the 
use of a medicinal (investigational) product, whether related or not related to the IMP/PTM 
medicinal (investigational) product. 
An adverse event can be Anticipated or Unanticipated 
• Anticipated adverse events are those that have been previously identified as resulting 
from the underlying disease, the HCT, or acute GVHD and not related to study drug. 
Investigator should refer to the anticipated event list (see Appendix E) to assess whether 
or not an event is anticipated. Anticipated events will be collected in the data capture 
system through calendar-driven forms (Toxicity, GVHD, etc.) and event-driven forms 
(Death, Infection, etc.). Events that meet serious criteria should be reported as detailed in 
Section 4.4.4.2. 
• Unanticipated adverse events are those that vary in nature, intensity, or frequency from 
information in the current anticipated event list, the Investigator’s Brochure, the package 
insert, or when it is not included in the informed consent document as a potential risk. 
Unanticipated events would also include those that have not been previously described as 
a result of the underlying disease requiring HCT, the HCT or acute GVHD. 
The following are anticipated adverse events and do NOT require reporting as an AE/SAE: 
• Disease progression of primary malignancy 
• GVHD and symptoms of GVHD (these are recorded in acute and chronic GVHD eCRFs) 
• Infections 
• Graft failure 
• Medical or surgical procedures (the condition that leads to the procedure is the AE) 
• Situations where an untoward medical occurrence has not taken place. For example: 
o Planned hospitalizations due to pre-existing conditions, which have not worsened 
(e.g., HCT) 
o Hospitalizations that occur for procedures not due to an AE (e.g., cosmetic surgery) 
o Hospitalizations for a diagnostic procedure where the hospital stay is less than 
24 hours in duration or for normal management procedures (e.g., chemotherapy) 
o Overdose of AAT or any concomitant therapy that does not result in any adverse signs 
or symptoms.  (An overdose is a dose higher than the dose established in the 
protocol.  For this study, the protocol dose is 120 mg/kg.  There is a 5% variance that 
is allowed due to the rounding permitted in the preparation of the IMP. Therefore, an 


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AAT dose ≥1.06% of 120 mg/kg (i.e., 126 mg/kg) that does not result in any adverse 
signs or symptoms would not require reporting as an AE/SAE.) 
 
Laboratory findings do NOT need to be reported as AEs in the following cases: 
• Laboratory parameters already beyond the reference range at screening, unless a further 
increase / decrease can be considered an exacerbation of a pre-existing condition. 
• Abnormal hematological laboratory parameters considered anticipated due to 
myeloablative conditioning regimen or other permitted chemotherapy treatments are not 
considered AEs. 
• An abnormal laboratory value that cannot be confirmed after repeat analysis, preferably 
in the same laboratory (i.e., the previous result could be marked as not valid and should 
not necessarily be reported as an AE). 
Serious Adverse Event: A serious adverse event (SAE), as defined by per 21 CFR 312.32, is any 
adverse event that results in one of the following outcomes, regardless of causality, anticipation, 
and/or expectedness:  
• Results in death 
• Is life-threatening. Life-threatening means that the person was at immediate risk of death 
from the reaction as it occurred, i.e., it does not include a reaction which hypothetically 
might have caused death had it occurred in a more severe form. 
• Requires or prolongs inpatient hospitalization (i.e., the event required at least a 24-hour 
hospitalization or prolonged a hospitalization beyond the expected length of stay). 
Hospitalization admissions and/or surgical operations scheduled to occur during the study 
period but planned prior to study entry are not considered SAEs if the illness or disease 
existed before the person was enrolled in the trial, provided that it did not deteriorate in 
an unexpected manner during the trial (e.g., surgery performed earlier than planned). 
• Results in persistent or significant disability/incapacity. Disability is defined as a 
substantial disruption of a person’s ability to conduct normal life functions. 
• Is a congenital anomaly or birth defect; or 
• Is an important medical event when, based upon appropriate medical judgment, it may 
jeopardize the participant and require medical or surgical intervention to prevent one of 
the outcomes listed above. Examples of such medical events include allergic 
bronchospasm requiring intensive treatment in an emergency room or at home; blood 
dyscrasias or convulsions that do not result in inpatient hospitalization, or the development 
of drug dependency or drug abuse. 
Medical and scientific judgment should be exercised in deciding whether reporting is also 
appropriate in situations other than those listed above. For example, important medical events 
may not be immediately life threatening or result in death or hospitalization but may jeopardize 
the subject or may require intervention to prevent one of the outcomes listed in the definition 
above (e.g., suspected transmission of an infectious agent by a medicinal product is considered a 


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Serious Adverse Event). Any event is considered a Serious Adverse Event if it is associated with 
clinical signs or symptoms judged by the Investigator to have a significant clinical impact.  
4.4.2 Classification of Adverse Events by Severity 
The severity refers to the intensity of the reported event. The Investigator must categorize the 
severity of each SAE according to the National Cancer Institute (NCI) CTCAE Version 5.0. 
CTCAE 
guidelines 
can 
be 
referenced 
at 
the 
following 
website: 
https://ctep.cancer.gov/protocoldevelopment/electronic_applications/docs/CTCAE_v5_Quick_
Reference_5x7.pdf. For any term that is not specifically listed in the CTCAE scale, intensity will 
be assigned a grade of one through five using the following CTCAE guidelines: 
• Grade 1: Mild; asymptomatic or mild symptoms, clinical or diagnostic observations only; 
intervention not indicated 
• Grade 2: Moderate; minimal, local or noninvasive intervention indicated; limiting 
age-appropriate instrumental activities of daily living 
• Grade 3: Severe or medically significant but not immediately life-threatening; 
hospitalization or prolongation of hospitalization indicated; disabling; limiting self-care 
activities of daily living 
• Grade 4: Life-threatening consequences; urgent intervention indicated 
• Grade 5: Death related to AE 
4.4.3 Classification of Adverse Events by Relationship to Investigational Product 
The relationship of each reported event to the study therapy will be assessed by the Investigator; 
after careful consideration of all relevant factors such as (but not limited to) the underlying study 
indication, coexisting disease, concomitant medication, relevant history, pattern of the SAE, 
temporal relationship to any study therapy interventions and dechallenge or rechallenge according 
to the following guidelines: 
• Possibly, Probably, or Definitely Related: there is a reasonable possibility that the study 
therapy caused the event. A relationship of possibly, probably, or definitely related to the 
investigational product is considered related for the purposes of regulatory authority 
reporting. 
• Unlikely, or Not Related: There is no reasonable possibility that the investigational 
product caused the event. An unlikely or not related relationship to the investigational 
product is considered not related for the purposes of regulatory authority reporting.  
4.4.4 Required Adverse Event Reporting 
4.4.4.1 
Non-Serious Adverse Events 
All non-serious adverse events will be reported from randomization until 30 days after the last 
dose of study drug (AAT/PTM). Some anticipated non-serious events will be collected on 
calendar-driven forms or event-driven forms (Infection, GVHD, Graft Failure, Readmission/ 
Hospitalization, and Progression/Relapse).  


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4.4.4.2 
Serious Adverse Events (SAE) 
All SAEs will be reported from randomization until 30 days after the last dose of study drug 
(AAT/PTM). In addition, any SAE assessed as related to the investigational product that occurs 
after the 30-day follow-up period must be reported. Any unanticipated SAE from 31 days after 
the last dose of study drug through the study defined follow up (1-year post enrollment) are 
required to be reported through the expedited AE reporting system in Advantage 
eClinical. Additionally, any grade 4 anticipated event not collected on the calendar-driven 
toxicity or specified event-driven form must also be reported through the expedited AE 
reporting system in Advantage eClinical. For this study, the reporting will be based on 
unanticipated in place of the MOP definition of unexpected. 
All reported SAEs are to be followed up until resolved, the Investigator judges an event as no 
longer clinically significant, or until the event stabilizes/becomes chronic to the extent that the 
event can be fully characterized.  
Serious adverse events (SAEs) will be reported through an expedited AE reporting system via 
electronic data capture. Life-threatening and fatal SAEs must be reported within 24 hours of 
knowledge of the event. All other SAEs must be reported within 1 business day of knowledge of 
the event. Events entered in the EDC will be reported using NCI’s CTCAE Version 5.0. 
The Data and Safety Monitoring Board will receive reports of all unanticipated/unexpected SAEs 
upon review by the BMT CTN Medical Monitor and CSLB. Summary reports for all reported 
SAEs will be reviewed by the DSMB on at least an annual basis. 
4.4.4.3 
Adverse Events of Special Interest (AESI) 
The Sponsor has a list of events classified as Adverse Events of Special Interest (AESI). 
These include ‘anaphylactic infusional reaction’ and ‘suspected transmission of a viral agent via 
a medicinal product.’ Both events must be reported through the expedited AE reporting system 
via Advantage eClinical and must be reported within 24 hours of knowledge of the event even if 
it does not meet serious criteria. 
4.4.4.4 
Toxicity Reporting 
Toxicities are a subset of anticipated adverse events determined to be from the underlying disease 
process, HCT, GVHD prophylaxis, or corticosteroid use, and generally are not considered to be 
related to the study product. The toxicities listed in APPENDIX E were pre-determined by the 
Protocol Team. 
Once the participant has reached 31 days from last dose of study drug, toxicities listed in 
APPENDIX E should be reported at the specified time points on the Toxicity CRF. If an event 
listed is determined to be serious and related to AAT, it should be reported via the expedited 
reporting process on the AE/SAE case report form (CRF). 
4.4.5 Pregnancy  
A female subject or female partner of a male subject who becomes pregnant from randomization 
up to and including 30 days after the last dose of study drug, must notify the Investigator 
immediately. CSLB must be notified within 5 days of the Investigator becoming aware of the 
pregnancy. 


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If a female subject becomes pregnant, she must discontinue treatment with the study drug but may 
continue other study procedures at the discretion of the Investigator.  
Whenever possible, a pregnancy in a subject or in a female partner of a male subject exposed to 
study drug should be followed to term to assess any potential occurrence of congenital anomalies 
or birth defects. Any follow-up information, including premature termination and the status of the 
mother and child after delivery, should be reported by the Investigator through the expedited AE 
reporting system in Advantage eClinical.  All abnormal pregnancies and neonatal outcomes 
(e.g., spontaneous abortion, stillbirth, neonatal death, or congenital anomaly) will meet the criteria 
for SAE classification. The Investigator should follow the procedure for reporting these events as 
SAEs.


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CHAPTER 5 
5 
STATISTICAL CONSIDERATIONS 
5.1 
Study Design 
This study is a phase III, multicenter, double-blinded, randomized, placebo-controlled trial 
designed to compare AAT and corticosteroids (CS) to placebo-to-match (PTM) and CS as 
first-line therapy for patients with high-risk acute GVHD.  
The study consists of an interim analysis for futility and a 12-month analysis at the end of the 
study. An additional analysis will be conducted after all randomized patients in the study complete 
6 months of follow-up. Multiplicity adjustment is not needed for this analysis as all the patients 
would have completed the Day 28 primary endpoint visit by the time of analysis.   
The target enrollment is 136 patients from approximately 25 centers with 68 patients assigned to 
each arm.  
5.1.1 Accrual 
It is estimated that an accrual period of 36 months (assuming a steady state of 4 patients per month 
after ramp up) will be necessary to enroll the target sample size. Accrual will be reported by race, 
ethnicity, gender, and age. 
5.1.2 Randomization 
Following enrollment, patients will be stratified by centers and randomized within each center in 
a 1:1 ratio using permuted blocks of random sizes for the two treatment arms. 
Treatment practices differ considerably by centers. This includes the time to declare a patient 
refractory to steroids and potentially initiate next-line therapy. The variability by center may 
produce greater differences in treatment groups compared with age (adolescent vs adult), GHVD 
risk or disease. Additionally, the pathobiology of GVHD in both adolescent and adult and in 
malignant and non-malignant disease patient populations are similar. Therefore, since the 
presentation of GVHD and the anticipated response to treatment are expected to be similar, center 
was prioritized as the primary stratification variable.  
5.1.3 Primary Endpoint 
The primary endpoint is the proportion of participants with an overall (complete or partial) 
response to acute GVHD treatment at Day 28 post-randomization. Patients without a Day 28 
response assessment will be considered failures. Acute GVHD will be graded and assessed for 
response based on Harris Criteria (refer to APPENDIX C). Patients who receive next-line 
systemic GVHD therapy (or escalation of steroids to ≥ 2.5 mg/kg/day of prednisone 
[or methylprednisolone equivalent of 2 mg/kg/day]) before Day 28 will be classified as NR. 
Responses categorized as NR, MR and progression will be treated as a failure for the primary 
endpoint. The primary analysis will be performed using the intent-to-treat principle. Therefore, 
all randomized patients will be included in the primary analyses. 


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5.1.4 Primary Hypothesis 
The primary null hypothesis is that the odds ratio for response (CR/PR) at Day 28 between the 
treatment groups, adjusted for center, is equal to 1 versus the alternative hypothesis that the odds 
ratio is greater than 1 (AAT+CS versus PTM+CS). Therefore, an odds ratio greater than one 
means the response rate is higher in the AAT+CS group compared with the PTM+CS group. 
This null hypothesis will be tested using a one-sided significance level of 2.5%.  
5.2 
Sample Size and Power Calculations 
The primary analysis will be based on a Wald test from a mixed effects logistic regression to test 
the odds ratio for response between the groups, adjusted for center and GVHD risk (Group A vs 
Group B; see Section 2.4.1, #3) as described in Section 5.6. We approximate the sample size and 
power requirements for this study based on a two-sample Z test of response rates. Historical 
control data indicates that the overall response rate (CR/PR) at Day 28 for high risk acute GVHD 
is approximately 50%. We further anticipate that the treatment will increase response rate to 75%. 
We planned a single boundary (nonbinding futility) design for testing a one-sided hypothesis with 
one interim analysis for futility, when 56% of the information is evaluable (76 patients or 38 per 
arm), and a 12-month analysis using a design based on the Gamma family spending function with 
parameter γ = -8. Therefore, a sample size of 136 patients (68 per arm) is required to sufficiently 
maintain a one-sided type I error of 2.5% while providing 86% statistical power for a one-sided 
test to detect an effect size of 25%. All statistical analyses will be done using SAS Version 9.4 or 
higher or R Version 3.4.4 or higher. 
5.3 
Study Analysis Schedule and Safety Stopping Guidelines 
The study will consist of an interim analysis for futility after 56% of the patients (n=76) are 
evaluable, at a time coincident with a regularly scheduled meeting of the NHLBI-appointed 
DSMB, and a 12-month analysis after accrual and follow up for the primary endpoint is complete. 
An additional analysis will be conducted after all the randomized patients in the study complete 
6 months of follow-up post-randomization. This analysis is conducted to expedite the primary 
endpoint evaluation for potential regulatory submission. Multiplicity adjustment is not needed for 
this analysis as all the patients would have completed the Day 28 primary endpoint visit by the 
time of analysis. The details for this 6-month analysis, including the data to be included, will be 
specified in the statistical analysis plan.   
Policies and composition of the DSMB are described in the BMT CTN’s Manual of Procedures. 
The stopping guidelines serve as a trigger for consultation with the DSMB for additional review 
and are not formal “stopping rules” that would mandate automatic closure of study enrollment. 
Toxicity, adverse events, and other safety endpoints will be monitored regularly and reported to 
the DSMB at each meeting.  
5.3.1 Interim Analysis for Futility 
Analyses will be performed as described below in Section 5.6 for the primary endpoint. At the 
interim analysis time point, a Wald test for testing whether the odds ratio is equal to 1 in a mixed 
effects logistic regression model will be compared to the critical values shown in Table 5-1. 
All patients with at least 28 days of follow-up post randomization prior to the time of the interim 
analyses will be used to compute this statistic. Therefore, if the response rate in the placebo group 


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is at least 0.034 or higher than the AAT group, the DSMB will make a recommendation regarding 
termination or continuation of the trial. 
Non-binding futility stopping rules—maintaining type I error control even if not followed 
exactly—were obtained from the Gamma family spending function with shape parameters γ = -
8. This boundary corresponds to a conditional power of 8.9% under the alternative. This would 
also correspond approximately to an effect size (on a difference in response rates scale) less than 
-0.034 (Figure 5-1) or a Z statistic less than -0.31. In other words, if we were to observe a test 
statistic of -0.31 or smaller at the interim analysis, there is only an 8.9% chance that the study 
would be statistically significant at the 12-month analysis, under the alternative hypothesis.  
Table 5-1 
Single Boundary Non-Binding Futility Stopping Thresholds with One-Sided 
Type I Error 2.5%, Power 86% and an Effect Size of 25% 
Info. 
Fraction 
Sample 
Size 
Nominal 
Cumulative 
Type II 
Error Rate 
Futility Boundary Scales 
Probability of 
Stopping Early 
for Futility 
 
 
 
Difference in 
Proportions 
Z-Statistic 
Conditional 
Power Under 
Alternative 
Under 
Null 
Under Alternative 
0.56 
76 
0.004 
-0.034 
-0.31 
0.089 
0.378 
0.004 
1.0 
136 
0.139 
0.163 
1.96 
 
 
 
 
Figure 5-1 
Stopping Boundary on Difference in Proportions Scale 
 
 
5.3.2 Operating Characteristics of the Design 
The statistical power to reject the null hypothesis under various treatment effect sizes using the Z 
test for comparing binomial proportions is shown in Table 5-2 as an approximation to the power 
using the primary analysis of mixed effects logistic regression. Kahan and Morris (2012) showed 
that a stratified analysis improves statistical power. Therefore, the unadjusted power analysis is a 
conservative estimate of the actual power. Also shown are the stopping probabilities for futility 


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at each effect size for the interim and 12-month analysis. This table shows that the target sample 
size of 136 patients has 86% power to detect a 25% difference in the response rate and is based 
on a simulation study with 10,000 simulated datasets. 
Table 5-2 
Summary of Operating Characteristics 
Effect Size 
Expected Sample 
Size 
Overall  
Cumulative Power 
Probability of 
Stopping Early 
0.00 
114 
2.3% 
0.360 
0.10 
129 
21.24% 
0.110 
0.15 
133 
41.9% 
0.046 
0.20 
135 
65.2% 
0.015 
0.25 
136 
85.9% 
0.003 
 
5.3.2.1 Stratified Mixed Effects Logistic Simulation 
We simulated a stratified randomized block design using blocks of size 6, based on the 
distribution of patients observed in each center of the BMT CTN 1501 study. Centers with fewer 
than 10 patients were combined resulting in a total of 6 centers of size 23, 19, 17, 15, 14 and 48. 
We assumed these centers are a random sample from a larger population with standard deviations 
0.05, 0.6 and 1.0. Additionally, we estimated that 35% of the patients will be classified as “high 
risk”; a covariate that we adjust for in all the simulations done 
Simulation results indicate that in the absence of a random effect (i.e., when the standard deviation 
of the random effect is close to zero) our statistical power is at least 94.2% to detect an odds ratio 
of 3. Further, when the random effect is present (std. dev. of 0.6 and 1.0) statistical power is at 
least 92.9% and 90.1% to detect an odds ratio of 3 as shown in Table 5-3. We also obtain statistical 
power ranging from 20.8% to 25.5% when the odds ratio is 1.5 regardless of the variability 
between centers. 
Table 5-3 
Stratified Mixed Effects Logistic Model with 1000 Simulations of Size 136 
Effect Size 
Power (%) 
Variance of Random Effects 
AAT - PTM 
Odds Ratio 
Coef. 
0.0025 
0.36 
1.0 
10% 
1.500 
0.406 
25.5 
24.2 
20.8 
15% 
1.857 
0.619 
53.8 
51.3 
48.4 
20% 
2.500 
0.916 
85.0 
83.4 
79.6 
25% 
3.000 
1.099 
94.2 
92.9 
90.1 
 
5.3.3 6 Month Analysis for Clinical Study Report  
A clinical study report for potential regulatory submission will be prepared after all randomized 
subjects have completed at least 6 months of follow-up post-randomization. The database will be 
locked to support this clinical study report. Data transfer and unblinding will follow the study’s 
Blinding Management Plan. This report will include descriptive statistics based on available data 
at time of the analysis as well as formal hypothesis testing / treatment comparisons for the primary 
Day 28 overall response rate (CR/PR) endpoint and secondary endpoints including GVHD-free 


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survival, proportion of response, proportion of response allowing for next-line therapy, and 
systemic infections.  
The BMT CTN 1705 Statistical Analysis Plan (SAP) will elaborate further on the contents of the 
6-month report. 
5.3.4 Guidelines for Safety Monitoring 
Monitoring of a key safety endpoint will be conducted monthly, and if rates significantly exceed 
pre-set thresholds, the NHLBI will be notified in order that the DSMB can be advised. 
Policies and composition of the DSMB are described in the BMT CTN's Manual of Procedures. 
The stopping guideline serves as a trigger for consultation with the DSMB for additional review. 
Safety monitoring will be based on Day 56 NRM. The proportion of NRM based on historical 
controls is estimated to be 20% versus an alternative hypothesis of 40%. This outcome will be 
monitored up to 56 days post-randomization, separately in each treatment arm, using a truncated 
Sequential Probability Ratio Test (SPRT) for binary data resulting in decision boundaries with a 
common slope of 0.293 and an upper intercept of 2.679 with nominal type I and type II error rates 
of, 0.065 and 0.10, respectively.  
This sequential testing procedure conserves type I error at 5% across all the monthly 
examinations. The SPRT can be represented graphically. At each monthly examination, the 
number of evaluable patients is plotted against the cumulative sum of the endpoint of interest. 
The continuation region of the SPRT is defined by two parallel lines. Only the upper boundary 
will be used for monitoring to protect against excessive Day 56 NRM. If the cumulative sum of 
the endpoint falls above the upper boundary, the SPRT rejects the null hypothesis, and concludes 
that there are more events than predicted by the observed number of patients evaluable. 
Otherwise, the SPRT continues until enrollment reaches the target sample size of 68 patients per 
arm. Table 5-4 and Figure 5-2 gives the rejection boundaries for the number of events for Day 56 
NRM corresponding to the number of evaluable patients. As an example, if there are 15 evaluable 
patients with the number of Day 56 NRM being 8 or more, then this would trigger a review by 
the DSMB. Note that, at least four events must be observed to trigger review.  
Table 5-4 
Sequential Monitoring Plan for 68 Subjects per Arm (α = 0.065, β = 0.10, 
p0 ≤ 0.20, p1 ≥ 0.40) 
Number of 
Evaluable 
Patients 
Rejection 
Boundary for 
the Null for the 
No. of Day 56 
NRM  
Number of 
Evaluable 
Patients 
Rejection 
Boundary for 
the Null for the 
No. of Day 56 
NRM 
Number of 
Evaluable 
Patients 
Rejection 
Boundary for the 
Null for the No. 
of Day 56 NRM 
1-3 
 
22-24 
10 
46-48 
17 
4 
4 
25-27 
11 
49-52 
18 
5-7 
5 
29-31 
12 
53-55 
19 
8-11 
6 
32-35 
13 
56-59 
20 
12-14 
7 
36-38 
14 
60-62 
21 
15-18 
8 
39-42 
15 
63-65 
22 
19-21 
9 
43-45 
16 
66-68 
23 
 


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Figure 5-2 Acceptance and Rejection Boundaries for Safety Monitoring 
 
 
The actual operating characteristics of the SPRT, shown in Table 5-5, were determined in a 
simulation study that assumed a uniform accrual of 68 patients to each arm over a 36-month 
accrual period. 
Table 5-5 
Operating Characteristics of the Sequential Probability Ratio Test for Day 56 
NRM with 100,000 Simulation Replicates 
True Day 56 NRM Rate 
20% 
25% 
30% 
35% 
40% 
Probability Reject Null 
0.051 
0.200 
0.481 
0.768 
0.935 
Mean No. of Day 56 NRMs 
13.1 
15.0 
14.9 
12.9 
10.5 
Mean No. of Patients Enrolled 
66 
60 
50 
37 
26 
Mean No. of Months 
36 
33 
27 
20 
15 
 
For example, the testing procedure rejects the null hypothesis in favor of the alternative 5.1%% 
of the time when the true Day 56 rate is 20% and 93.5% of the time when the rate is 40%. 
When the true Day 56 NRM rate is 40%, a review will be triggered when 10.5 events have been 
observed in 26 patients over a 15-month period. 
5.3.5 Safety Analysis 
The reporting of serious adverse events is described in detail in Section 4.4.4.2. All reported 
serious adverse events potentially associated with study drug will be carefully examined with 
respect to the severity and relationship to study drug. The type and severity of adverse events will 
be described. 
5.4 
Demographic and Baseline Characteristics 
Demographics and baseline characteristics will be summarized for all patients. Characteristics to 
be examined are: age, gender, race/ethnicity, performance status, primary disease, time from 
steroid initiation to randomization, acute GVHD grade at enrollment, MN classification, graft 


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source, GVHD prophylaxis, conditioning regimen, time from disease diagnosis to transplant, time 
from GVHD onset to randomization. 
5.5 
Analysis Populations 
5.5.1 Primary Analysis Population  
The intention-to-treat population will serve as the population for the primary analysis. 
All randomized subjects will be included in this population. Subjects will be included in the 
treatment group to which they are randomized. Intention-to-treat population consists of all 
randomized subjects whether or not treatment was administered. Any subject who receives a 
treatment randomization assignment will be considered to have been randomized. Analyses for 
the primary and secondary endpoints will use the primary analysis population. 
5.5.2 Safety Analysis Populations 
The safety analysis population in this study will comprise of all patients “as treated” in the study. 
This population will be used for the analysis of safety data. The “as treated” population consists 
of all randomized subjects who received at least one dose of study treatment. Subjects will be 
included in the treatment group corresponding to the study treatment they received for the analysis 
of safety data using the “as treated” population. For most subjects this will be the treatment group 
to which they are randomized. Subjects who take incorrect study treatment for the entire treatment 
period will be included in the treatment group corresponding to the study treatment received. 
Any subject who receives the incorrect study medication for one cycle but receives the correct 
treatment for all other cycles will be analyzed according to the correct treatment group and a 
narrative will be provided for any events that occur during the cycle for which the subject is 
incorrectly dosed. 
5.5.3 General Analysis Guidelines 
Primary analyses for the primary, secondary, and exploratory endpoints will use the primary 
analysis population except when otherwise specified. Analyses of each endpoint in each 
population will follow the analysis plans as described below in Sections 5.6, 5.7, and 5.8. 
We expect minimal missing data (< 5%) for the primary endpoint and secondary endpoints based 
on the past experience with a large phase III aGVHD treatment trial (BMT CTN protocol #0802. 
All secondary and exploratory analyses will use a two-sided significance level of 5%. 
5.6 
Analysis of Primary Endpoint 
The response rate (CR/PR) at Day 28, compared to maximum GVHD organ staging within 
72 hours prior to enrollment, is expected to be different by centers and GVHD risk (Group A vs 
Group B; see Section 2.4.1, #3). Therefore, we will fit a generalized linear mixed model with the 
response rate (CR/PR) at Day 28 as the outcome, treatment group as the main effect, and adjusted 
for GVHD risk fixed effect and center-specific random effects. A one-sided significance level of 
2.5% will be used. The response rate (CR/PR) at Day 28 will be estimated using frequencies in 
each group along with corresponding 95% confidence intervals.  
We plan on conducting two sensitivity analyses to assess the robustness of our findings. 
First, using the above generalized linear mixed model we will adjust for GVHD risk, age 
(adolescent vs adults) and disease (malignant vs non-malignant) all as main effects, in addition to 


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center specific random effects. The second analysis will include all the covariates from the first 
analysis in addition to the Mount Sinai Acute GVHD International Consortium (MAGIC) 
biomarker score. These two models will be compared to the primary analysis model in order to 
assess the impact on the main effect estimate. 
5.7 
Analysis of Secondary Endpoints 
5.7.1 Duration of Response 
Duration of response will be evaluated at 6- and 12-months post-randomization in the cohort of 
patients who achieve a Day 28 response. There will be a primary and secondary analyses of DOR. 
In the primary analysis, DOR is defined as the time from Day 28 response to progression, new 
salvage therapy for acute GVHD, death from any cause, or re-escalation of steroids to ≥ 2.5 mg/kg 
prednisone or equivalent. Patients without any of these events will censored at last follow up. 
For the secondary analysis, DOR will be defined as time from Day 28 response to death from any 
cause or new salvage therapy. Otherwise, patients are censored. For each definition, the 
probabilities of DOR will be estimated using the Kaplan-Meier method and compared between 
treatment arms using the log-rank test. 
5.7.2 Non-relapse Mortality 
Non-relapse mortality at 6 months and 12 months post-randomization will be estimated using the 
cumulative incidence function, treating relapse as a competing risk. The cumulative incidence 
curves for non-relapse mortality will be compared between the treatment groups using Gray’s 
test. A Cox proportional hazards regression model with mixed effects will be used to compare the 
cause specific hazards of NRM between treatment groups adjusting for GVHD risk with 
center-specific log-normal frailties. 
5.7.3 Overall Survival and Progression-Free Survival 
Progression-free survival (PFS) at 6- and 12-months post-randomization will be estimated using 
the Kaplan-Meier method, treating death or relapse of malignancy as events in patients with 
malignancies. Overall Survival (OS) at 6 and 12 months will also be estimated using the 
Kaplan-Meier method. These endpoints will be compared between the treatment groups using the 
log-rank test. A Cox proportional hazards regression model with mixed effects will be used to 
compare PFS and OS between treatment groups adjusting for GVHD risk with center-specific 
log-normal frailties. 
5.7.4 GVHD-Free Survival 
The proportion of patients surviving at Day 56 after randomization without acute or chronic 
GVHD and without other systemic agents (or escalation of steroids to ≥ 2.5 mg/kg/day of 
prednisone [or methylprednisolone equivalent of 2 mg/kg/day]) added for treatment of GVHD 
will be evaluated. Provided there is no censoring prior to 56 days, this endpoint we will be 
computed as a binary outcome and summarized using frequencies/proportions. GVHD-Free 
survival will be compared by treatment adjusting for GVHD risk and center-specific random 
effects using a generalized linear mixed model. Additionally, treatment groups will be compared 
using difference in proportions, relative risk and an odds ratio estimate along with corresponding 


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confidence intervals. Censoring before 56 days is highly unlikely; and should this occur we 
anticipate this will be minimal. 
5.7.5 Proportion of Response 
The proportions of patients with Complete Response (CR), Partial Response (PR) (including 
subset with “Very Good Partial Response” [VGPR]), and Treatment Failure (TF) at Days 7, 14, 
21, 28, 56 and 86 post-randomization will be described and compared between the treatment 
groups using the chi-square test or Fisher’s exact test as appropriate. 
5.7.6 Proportion of Response (Next-Line Therapy) 
The proportions of patients with CR, PR (including subset with VGPR), and treatment failure 
(TF) at Days 7, 14, 21, 28, 56, and 86 post-randomization who receive ruxolitinib or other 
next-line therapies approved by the protocol Chairs as next-line therapy and remain on AAT/PTM 
will be described and compared between the treatment groups, to evaluate any differences in 
safety and efficacy, using the chi-square test or Fisher’s exact test as appropriate. The proportion 
of AE/SAE will be described in these patient populations. 
5.7.7 Systemic Infections  
Frequencies of grade 2 or 3 infections occurring from randomization until 30 days after last study 
drug or placebo treatment will be tabulated by site of disease, date of onset, and severity. The time 
to first serious (grade 2 or 3) infection will be described using the cumulative incidence function 
and compared between treatment groups using Gray’s test, with death treated as a competing risk. 
5.7.8 Adverse Events 
Frequencies of grade 3-5 adverse events (per CTCAE Version 5.0) that occur from randomization 
through 30 days after completing study drug or placebo treatment will be tabulated using the 
Safety Population. The proportion of patients experiencing grade 3-5 adverse events will be 
compared between the treatment groups using an odds ratio estimate with confidence interval. 
5.7.9 Chronic GVHD  
The incidence of chronic GVHD will be computed at 6- and 12-months post- randomization using 
the cumulative incidence method, treating death prior to chronic GVHD as a competing risk. 
Diagnosis of chronic GVHD of any severity (mild, moderate, or severe) per NIH Consensus 
Criteria (see APPENDIX C) is considered an event for this endpoint. Cumulative incidence will 
be compared between treatment groups using Gray’s test. Cause specific hazard for chronic 
GVHD will be compared by treatment adjusting for GVHD risk and center-specific random 
effects using a generalized linear mixed model. 
5.7.10 Disease Relapse 
Disease relapse will be summarized at 6- and 12-months post-randomization using the cumulative 
incidence function with death as a competing risk. Cumulative incidence will be compared 
between treatment groups using Gray’s test. Cause specific hazards for disease relapse will be 
compared by treatment adjusting for GVHD risk and center-specific random effects using a Cox 
proportional hazards model with center specific log-normal random effects. 


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5.8 
Analysis of Exploratory Endpoints 
5.8.1 AAT Levels 
The pharmacokinetics parameters maximum (Cmax) and trough (Ctrough) serum antigen 
concentration of AAT will be measured and summarized using descriptive statistics at Days 0, 8, 
16, 24, 28 and 56 post-treatment initiation. 
5.8.2 Stool AAT, Microbiome and Metabolome 
Stool concentrations of AAT will be measured and summarized using descriptive statistics at 
baseline and Days 8 and 28 post-treatment initiation.  
5.8.3 Immune Subsets 
The changes in peripheral blood ratios of T regulatory to T effector (Treg/Teff) cells, Natural 
Killer (NK) cells and other cellular immune subsets from baseline to Days 16, 28, and 
56 post-treatment initiation will be summarized using descriptive statistics at each time point and 
compared between treatment groups using Mann-Whitney nonparametric tests. Select immune 
subsets may also be analyzed using a linear mixed model adjusting for baseline value, time and 
treatment, as well as a treatment by time interaction term. 
5.8.4 Inflammatory Cytokines and GVHD Biomarkers 
Serum levels of inflammatory cytokines (e.g., IL-1β, IL-6, IL-10, TNFα), damage associated 
molecular patterns (e.g., heparan sulfate) and select GVHD biomarkers (eg, ST2, REG3α) at 
baseline and at Days 8, 28, and 56 post-treatment initiation will be summarized using descriptive 
statistics at each time point and compared between treatment groups using Mann-Whitney 
nonparametric tests. Select measurements may also be analyzed using a linear mixed model 
adjusting for baseline value, time, and treatment, as well as a treatment by time interaction term. 
5.8.5 Overall and Organ-Specific Response Rates by Refined Minnesota Risk and 
Biomarker-Based Risk Classifications 
The proportions of patients with an overall response (complete or partial) and response rate of 
each GVHD target organ at Day 28 post-randomization will be described by Refined Minnesota 
risk category (A vs B; see Section 2.4.1, #3) and by Ann Arbor biomarker risk score (1, 2, or 3) 
using sample proportions and confidence intervals and compared on each factor using the 
chi-square test or Fisher's exact test as appropriate.  
5.8.6 Systemic Corticosteroid Dose 
The systemic corticosteroid-dose (measured as prednisone-equivalent) will be summarized at 
baseline and at Days 7, 14, 21, 28, 56, 86, 6 months and 12 months post-randomization using 
descriptive statistics at each time point and compared between treatment groups using 
Mann-Whitney nonparametric tests.  


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5.8.7 CMV-Reactivation 
The proportions of patients requiring new systemic treatment for CMV-reactivation by Day 56 
post-randomization will be compared between the treatment groups using a chi-square test or 
Fisher’s exact test as appropriate. 
5.8.8 Patient-Reported Outcomes 
Participant self-reported measures for both adolescents and adults will be assessed at baseline, 
Days 28, 56 and 180 post-randomization by MDASI, and selected PROMIS subscales for 
gastrointestinal symptoms, physical function and satisfaction with participation in social roles. 
These instruments will be scored according to the recommendations of the developers. The scores 
will be examined using the medians, means, ranges, and standard deviations. Linear regression 
models for the Day 28, Day 56 and 6-month score adjusting for baseline score and other covariates 
will be used to explore differences between treatment arms and changes in outcomes over time. 
Provided there is sufficient data, separate analyses will be conducted for adolescent and adult 
patients. Otherwise, their data will be combined/aggregated. 


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APPENDIX A 
 
HUMAN SUBJECTS 
1. Subject Consent 
 
Candidates for the study will be identified as described in Chapter 4 of the protocol. The Principal 
Investigator or his/her designee at each transplant center will contact the candidates, provide the 
patient with information about the purpose of the study, and obtain consent or assent. The BMT 
CTN DCC will provide a template of the consent and assent forms to each center. Each center 
will customize the templates according to their local requirements and submit for review by the 
DCC for adequacy prior to submitting to the NMDP IRB of Record. Each center must provide 
evidence of IRB approval to the DCC. 
2. Confidentiality 
Confidentiality will be maintained by individual names being masked and assigned a patient 
identifier code. The code relaying the patient’s identity with the ID code will be kept separately 
at the center. The ID code will be generated by and kept on file at the BMT CTN Data and 
Coordinating Center upon enrollment. 
3. Participation of Adolescents 
The protocol was amended (v4.0), after DSMB review and approval, to include adolescents ages 
12 - 17.99 after 40 adult patients were enrolled onto the trial and completed the Day 56 follow-up 
assessment for safety. 
4. Participation of Women and Minorities 
Women, ethnic minorities, and other populations will be included in this study. Accrual of women 
and minorities at each center will be monitored to determine whether their rates of enrollment are 
reflective of the distribution of potentially eligible women and minorities expected from data 
reported to the CIBMTR and from published data on incidence of high risk acute GVHD in these 
groups. Centers will be notified if their rates differ significantly from those expected and asked 
to develop appropriate recruitment reports. 
5. GCP 
This study will be conducted in accordance with standards of Good Clinical Practice (as defined 
by the International Council for Harmonization) and all applicable national and local regulations. 


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APPENDIX B 
 
LABORATORY PROCEDURES 
Research Samples for Protocol-Defined and Ancillary Correlative Laboratory Studies  
This protocol involves collection of required and optional research samples for patients 
consenting to the BMT CTN 1705 study. The objectives are based on the current understanding 
of AAT biology informed by preclinical and clinical studies available at the time of protocol 
development. These studies will explore the impact of AAT administration on serum levels of 
AAT, key cellular immune subsets, inflammatory markers and GVHD biomarkers.  
Required peripheral blood samples will be collected at calendar driven time points that are 
required to support study-specific secondary and exploratory endpoints that are summarized in 
the table below. Additionally, stool losses of AAT and changes in gut microbiome are known to 
occur during the development of GVHD. Stool samples, which are optional for patients at selected 
centers associated with active microbiome laboratories, will be collected for planned exploratory 
analysis of stool AAT levels and correlation with serum cytokines and/or validated proteomic 
GVHD related biomarkers. Remaining stool and serum biospecimens will be made available for 
future research of microbiome, microbial metabolome and correlative laboratory studies with 
potential to advance findings of the current trial. Sample collection, processing and shipping 
procedures are detailed in the BMT CTN 1705 Research Sample Information Guide. 
Enrollment is Day 0 and the first dose of study drug must occur within 12 hours after enrollment. 
Therefore, the first dose may fall on Day 0 or Day 1 in the tables below. 
 


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Subjects 
Sample Type 
Sample 
Collection 
Time Points 
Sample 
Collection and 
Sample 
Processing 
Summary 
Shipping 
Specifications 
Shipping 
and Testing 
Location 
All 
Patients 
(Required) 
Peripheral 
Blood 
(SST Clot 
Tube) 
 
5 mL 
 
Serum 
AAT Levels 
Prior to study 
drug infusion and 
15-45 min post-
infusion 
• 
Day 0 
(baseline) 
• 
Day 16 
• 
Day 28 
• 
Day 56 
 
Prior to study 
drug infusion 
only 
• 
Day 8 
• 
Day 24 
 
Note: Collection 
of blood samples 
for AAT levels are 
limited to subjects 
still receiving 
assigned study 
treatment. 
 
Collect the blood 
sample and place 
5 mL in SST 
Vacutainer tube 
containing no 
anticoagulant. 
Allow blood 
samples to clot 
upright for 30-60 
minutes in a tube 
rack prior to 
centrifugation and 
serum aliquot 
storage at -80⁰C.  
Refer to the BMT 
CTN 1705 
Research 
Specimen 
Information 
Guide for details 
related to sample 
processing, 
aliquot labeling, 
storing and 
shipping. 
Frozen serum 
sample aliquots 
will be 
periodically 
batched-
shipped to the 
BMT CTN 
Biorepository 
by priority 
overnight 
FedEx® 
delivery. 
BMT 
CTN 
Biorepository 
All 
Patients 
(Required) 
Peripheral 
Blood 
(SST Clot 
Tube) 
 
6 mL 
 
Serum 
Inflammatory 
Cytokines 
and GVHD 
Biomarkers 
 
Prior to study 
drug infusion on: 
• 
Day 0 
(baseline) 
Prior to study 
drug infusion, on 
Days: 8, 28 and 56 
(or TD if prior to 
Day 56) 
 
Coordinate the 
collection with the 
pre-drug infusion 
blood samples for 
AAT level 
measurements. If 
not possible in rare 
circumstances, the 
window of 
collection for 
research blood 
samples is ± 3 
days. 
Collect the blood 
sample and place 
5 mL in SST 
Vacutainer tube 
containing no 
anticoagulant. 
Allow blood 
samples to clot 
upright for 30-60 
minutes in a tube 
rack prior to 
centrifugation and 
serum aliquot 
storage at -80⁰C.  
Refer to the BMT 
CTN 1705 
Research 
Specimen 
Information 
Guide for details 
related to sample 
processing, 
aliquot labeling, 
storing and 
shipping. 
Frozen serum 
sample aliquots 
will be 
periodically 
batched-
shipped to the 
BMT CTN 
Biorepository 
by priority 
overnight 
FedEx® 
delivery. 
BMT CTN 
Biorepository 


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Subjects 
Sample Type 
Sample 
Collection 
Time Points 
Sample 
Collection and 
Sample 
Processing 
Summary 
Shipping 
Specifications 
Shipping 
and Testing 
Location 
All 
Patients 
(Required) 
Peripheral 
Blood 
(sodium 
heparin) 
 
10 mL 
 
Flow 
Cytometry (T 
regulatory, T 
effector and 
NK cell 
subsets) 
Prior to study 
drug infusion on: 
• 
Day 0 
(baseline) 
Prior to study 
drug infusion, on 
Days: 16, 28 and 
56 (or TD if prior 
to Day 56) 
 
Coordinate the 
collection with the 
pre-drug infusion 
blood samples for 
AAT level 
measurements. If 
not possible in rare 
circumstances, the 
window of 
collection for 
research blood 
samples are ± 3 
days.  
Collect the blood 
sample and place 
10 mL in 
Vacutainer tube 
containing sodium 
heparin 
anticoagulant. 
Gently mix 
sample by 
inversion 8-10 
times to mix 
sample well with 
anticoagulant. 
Blood sample 
tube will be 
shipped at 
ambient 
temperature, on 
the day of 
collection, to 
project 
laboratory by 
priority 
overnight 
FedEx® 
delivery. 
RPCI Project 
Laboratory 
Stool Samples for Patients Enrolled at Selected Centers with Participating Microbiome Labs 


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Subjects 
Sample Type 
Sample 
Collection 
Time Points 
Sample 
Collection and 
Sample 
Processing 
Summary 
Shipping 
Specifications 
Shipping 
and Testing 
Location 
Patients at 
a Subset of 
Centers 
(Optional) 
Stool 
 
10-20 mL 
 
Stool AAT, 
Microbiome, 
and 
Metabolome 
Studies 
 
 
Prior to study 
drug infusion on: 
• 
Day 0 
(baseline) 
Prior to study 
drug infusion, on 
Days: 8 and 28 (or 
TD if prior to Day 
28) 
 
Stool samples 
should be 
collected if 
possible, on the 
target visit day 
indicated or within 
± 3 days of the 
scheduled visit. 
Collect stool 
samples according 
to applicable 
inpatient or 
outpatient 
procedures 
described in the 
Research Sample 
Information 
Guide. 
Transfer a 10-20 
mL stool sample 
to a sterile 
specimen 
transport 
container. Also 
transfer a small 
amount of stool 
sample to the 
OMNIgene Gut 
stool stabilization 
tube provided by 
the BMT CTN.  
Refer to the BMT 
CTN 1705 
Research 
Specimen 
Information 
Guide for details 
related to sample 
requirements, 
OMNIgene Gut 
tube 
sampling/mixing 
procedures, 
sample labeling 
and transport to 
center’s 
Microbiome 
laboratory for 
further process 
and temporary 
frozen storage. 
Frozen stool 
sample aliquots 
processed by 
the center’s 
Microbiome 
Laboratory will 
be periodically 
batched-
shipped to the 
BMT CTN 
Biorepository 
by priority 
overnight 
FedEx® 
delivery. 
BMT CTN 
Biorepository 
 
 
 


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APPENDIX C 
 
DIAGNOSIS AND SEVERITY SCORING FOR ACUTE AND CHRONIC GVHD 
1. (2014 NIH Consensus Criteria87) 
 
 
Organ scoring of chronic GVHD. ECOG indicates Eastern Cooperative Oncology Group; KPS, Karnofsky 
Performance Status, Lansky Performance Status; BSA, body surface area; ADL, activities of daily living; LFTs, liver 
function tests; AP, alkaline phosphatase; ALT, alanine aminotransferase; ULN, normal upper limit. *Weight loss 
within 3 months. Skin scoring should use both percentage of BSA involved by disease signs and the cutaneous 
features scales. When a discrepancy exists between the percentage of total body surface (BSA) score and the skin 
feature score, OR if superficial sclerotic features are present (Score 2), but there is impaired mobility or ulceration 
(Score 3), the higher level should be used for the final skin scoring. To be completed by specialist or trained medical 
providers. **Lung scoring should be performed using both the symptoms and FEV1 scores whenever possible. FEV1 
should be used in the final lung scoring where there is discrepancy between symptoms and FEV1 scores. 


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C-4 
Chronic GVHD Grading according to the NIH Consensus Criteria chronic GVHD severity 
scale 
 


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C-5 
2. Harris (MAGIC) Criteria 
 
3. Categories of Acute and Chronic GVHD 
 
Categories of Acute and Chronic GVHD 
Category 
Time of 
Symptoms 
after HCT 
Presence of 
Acute 
GVHD 
Features 
Presence of 
Chronic GVHD 
Features 
Acute GVHD 
Classic acute GVHD 
≤ 100 d 
Yes 
No 
Late-onset acute GVHD 
> 100 d 
Yes 
No 
Chronic GVHD 
Classic chronic GVHD 
No time 
limit 
No 
Yes 
Overlap syndrome 
No time 
limit 
Yes 
Yes 


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D-1 
APPENDIX D 
 
LIFESTYLE RESTRICTIONS 
Female subjects of childbearing potential and all male subjects must use medically reliable 
methods of contraception from the first dose of investigational product until 1 month after the last 
dose of investigational product. 
Childbearing potential is assumed in all female subjects except: 
• Female subjects aged > 60 years. 
• Female subjects aged 45 to 60 years (inclusive) with amenorrhea for ≥ 1 year. 
• Female subjects who are surgically sterile for at least 3 months before providing informed 
consent. 
Acceptable methods of contraception are:  
• Abstinence, where abstinence is the preferred and usual lifestyle of the subject, including 
refraining from heterosexual intercourse during the entire period of risk associated with the 
investigational product. Periodic abstinence (calendar, symptothermal, postovulation 
methods), withdrawal (coitus interruptus), spermicides only, and lactational amenorrhoea 
method are not acceptable definitions of abstinence. 
• Hormonal methods: acceptable hormonal methods include oral contraceptives, contraceptive 
medication patch, contraceptive medication injection, estrogen/progestin vaginal ring, or 
contraceptive medication implant. 
• 2 barrier methods; acceptable barrier methods include: female or male condoms, with 
spermicidal foam or spermicidal jelly, or diaphragm, with spermicidal foam or spermicidal 
jelly. The female condom and male condom should not be used together. 
• Use of intrauterine device (placed more than 3 months before providing informed consent). 
• Surgical sterilization (more than 3 months before providing informed consent) of subject or 
subject's partner.


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E-1 
APPENDIX E 
 
ANTICIPATED TOXICITIES 
The purpose of this appendix is to outline those AEs that commonly occur in the study population. 
The following is a list of events that the Sponsor considers to be common toxicities for agents 
used in HCT conditioning and GVHD prophylaxis regimens. The events listed below require 
reporting via the Toxicity CRF in Advantage eClinical and do NOT change the reporting 
obligations, timelines or prevent the need to report an AE meeting the definition of an SAE. 
 
If aggregate analysis of these events indicates they occur more frequently with study drug, an 
expedited safety report may be submitted to regulatory agencies. 
 
Lack of relationship to the investigational product is not automatically assumed; therefore, an 
assessment is required by the Investigator for any events specified below. The Sponsor will also 
perform the causality assessment on a case-by-case basis and expedite reporting to regulatory 
agencies when applicable. 
 
General Disorders 
Fever 
 
Immune System Disorders 
Allergic reaction 
 
GI Disorders 
Mucositis 
Nausea 
Vomiting 
Gastric ulcer 
Esophagitis 
Pancreatitis 
GI perforation 
Increased appetite 
Anorexia 
 
Renal Disorders 
Cystitis noninfective 
Acute kidney injury 
Chronic kidney injury 
 
Hemorrhagic Disorders 
Hemorrhage 
 
Blood & Lymphatic Disorders 
Leukocytosis 
Anemia 
Thrombotic thrombocytopenic 
purpura/Thrombotic microangiopathy 
Hemolytic Uremic Syndrome 
 
Vascular Disorders 
Thromboembolic event 
 
Respiratory Disorders 
Hypoxia 
Dyspnea 
 
Investigations 
Neutrophil count decreased 
Platelet count decreased 
ALT 
AST 
Bilirubin 
Alkaline phosphatase 
Hyperglycemia 
Hypokalemia 
Weight gain 
 


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E-2 
Cardiac Disorders 
Hypotension 
Hypertension 
Cardiac arrhythmia 
Left ventricular systolic dysfunction 
Pericardial effusion 
Restrictive cardiomyopathy 
 
Nervous System Disorders 
Restlessness 
Insomnia 
Glaucoma 
Headache 
Somnolence 
Seizure 
Musculoskeletal Disorders 
Myopathy 
Tendon rupture 
Bone fracture 
Avascular necrosis 
Osteoporosis 
Arthralgia 
 
Skin Disorders 
Erythema 
Rash acneiform 
 
Endocrine/Metabolic Disorders 
Cushingoid 
Adrenal insufficiency 
Edema 


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F-1 
APPENDIX F 
 
PATIENT REPORTED OUTCOMES MEASUREMENT INFORMATION SYSTEM 
(PROMIS) 
1. In general, would you say your health is…. 
a. Poor 
b. Fair 
c. Good 
d. Very good 
e. Excellent 
 
2. In the past 7 days, how often did you have nausea—that is, a feeling like you could vomit?  
a. Never (skip next question) 
b. Rarely 
c. Sometimes 
d. Often 
e. Always 
 
3. In the past 7 days, how often did you know that you would have nausea before it happened?  
a. Never  
b. Rarely 
c. Sometimes 
d. Often 
e. Always 
 
4. In the past 7 days, how often did you have a poor appetite? 
a. Never  
b. Rarely 
c. Sometimes 
d. Often 
e. Always 
 
5. In the past 7 days, how often did you throw up or vomit? 
a. Never 
b. One day 
c. 2-6 days 
d. Once a day 
e. More than once a day 


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F-2 
6. In the past 7 days, how often did you have belly pain? 
a. No days 
b. One day 
c. 2-6 days 
d. Once a day 
e. More than once a day 
 
7. In the past 7 days, how many days did you have loose or watery stools?  
a. No days 
b. One day 
c. Two days 
d. 3-5 days 
e. 6-7 days 
 
8. In the past 7 days, how often did you feel like you needed to empty your bowels right away 
or else you would have an accident?  
a. Never 
b. One time during the past 7 days 
c. 2-6 days during the past 7 days 
d. Often once a day 
e. More than once a day 
 
9. In the past 7 days, how often did you have bowel incontinence—that is, have an accident 
because you could not make it to the bathroom in time?  
a. No days 
b. One day 
c. 2-3 days 
d. 4-5days 
e. 6-7 days 
 
10. Are you able to dress yourself, including tying shoelaces and buttoning your clothes?  
a. Without any difficulty 
b. With a little difficulty 
c. With some difficulty 
d. With much difficulty 
e. Unable to do 


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F-3 
11. Are you able to get out of bed into a chair?  
a. Without any difficulty 
b. With a little difficulty 
c. With some difficulty 
d. With much difficulty 
e. Unable to do 
 
12. Are you able to go for a walk of at least 15 minutes? 
a. Without any difficulty 
b. With a little difficulty 
c. With some difficulty 
d. With much difficulty 
e. Unable to do 
 
13. Are you able to go up and down stairs at a normal pace?  
a. Without any difficulty 
b. With a little difficulty 
c. With some difficulty 
d. With much difficulty 
e. Unable to do 
 
14. In the past 7 days, I feel fatigued 
a. Not at all 
b. A little bit 
c. Somewhat 
d. Quite a bit 
e. Very much 
 
15. In the past 7 days, I have trouble starting things because I am tired 
a. Not at all 
b. A little bit 
c. Somewhat 
d. Quite a bit 
e. Very much 
 
16. In the past 7 days, how run-down did you feel on average? 
a. Not at all 
b. A little bit 
c. Somewhat 
d. Quite a bit 
e. Very much 


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F-4 
17. In the past 7 days, how fatigued were you on average? 
a. Not at all 
b. A little bit 
c. Somewhat 
d. Quite a bit 
e. Very much 
 
18. In the past 7 days, how much did pain interfere with your day to day activities? 
a. Not at all 
b. A little bit 
c. Somewhat 
d. Quite a bit 
e. Very much 
 
19. In the past 7 days, how much did pain interfere with your enjoyment of life?  
a. Not at all 
b. A little bit 
c. Somewhat 
d. Quite a bit 
e. Very much 
 
20. In the past 7 days, how would you rate your pain on average? 
a. No pain 0 
b. 1 
c. 2 
d. 3 
e. 4 
f. 5 
g. 6 
h. 7 
i. 8 
j. 9 
k. Worst imaginable pain, 10 
 
21. In the past 7 days, how bothered were you by sores on your skin? 
a. Not at all 
b. Slightly 
c. Moderately 
d. Quite a bit 
e. Extremely 
 


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F-5 
22. In the past 7 days, how intense was your itch in general? 
a. Had no itch 
b. Mild 
c. Moderate 
d. Severe 
e. Very severe 
 
23. In the past 7 days, I felt worthless 
a. Never 
b. Rarely 
c. Sometimes 
d. Often 
e. Always 
 
24. In the past 7 days, I felt helpless 
a. Never 
b. Rarely 
c. Sometimes 
d. Often 
e. Always 
 
25. In the past 7 days, I felt depressed 
a. Never 
b. Rarely 
c. Sometimes 
d. Often 
e. Always 
 
26. In the past 7 days, I felt hopeless 
a. Never 
b. Rarely 
c. Sometimes 
d. Often 
e. Always 
 
27. In the past 7 days, my sleep quality was… 
a. Very poor 
b. Poor 
c. Fair 
d. Good  
e. Very good 


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F-6 
28. In the past 7 days, my sleep was refreshing 
a. Not at all 
b. A little bit 
c. Somewhat 
d. Quite a bit 
e. Very much 
 
29. In the past 7 days, I had a problem with my sleep 
a. Not at all 
b. A little bit 
c. Somewhat 
d. Quite a bit 
e. Very much 
 
30. In the past 7 days, I had difficulty falling asleep 
a. Not at all 
b. A little bit 
c. Somewhat 
d. Quite a bit 
e. Very much 


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G-1 
APPENDIX G 
 
BMT CTN SEVERITY GRADING TABLE AND RECURRENCE INTERVAL 
DEFINITIONS 
 
Type of Infection/ 
Severity Grade 
Grade 1 
Grade 2 
Grade 3 
Bacterial infections 
 
Bacterial focus NOS 
requiring no more than 14 
days of therapy for 
treatment (e.g., urinary tract 
infection)  
 
Coag Neg Staph (S. epi), 
Corynebacterium, or 
Proprioniobacterium 
bacteremia 
 
 
Cellulitis responding to 
initial therapy within 14 
days 
 
 
 
 
 
 
 
 
 
 
 
C. Difficile toxin positive 
stool with diarrhea < 
1L without abdominal pain 
(child < 20 mL/kg) 
Bacteremia (except CoNS) 
without severe sepsis *** 
 
 
 
Bacterial focus with 
persistent signs, symptoms 
or persistent positive cultures 
requiring greater than 14 
days of therapy  
 
Cellulitis requiring a change  
in therapy d/t progression  
Localized or diffuse 
infections requiring incision 
with or without drain 
placement  
 
Any pneumonia documented 
or presumed to be bacterial 
 
 
 
 
C. Difficile toxin positive 
stool with diarrhea > 1L 
(child > 20 mL/kg) or with 
abdominal pain   
Bacteremia with deep organ 
involvement (e.g., with new 
or worsening pulmonary 
infiltrates; endocarditis) 
 
Severe sepsis with 
bacteremia. 
 
 
 
 
Fasciitis requiring 
debridement  
 
 
 
 
 
Pneumonia requiring 
intubation 
 
Brain abscess or meningitis 
without bacteremia 
 
C. Difficile toxin positive 
stool with toxic dilatation or 
renal insufficiency 
with/without diarrhea 
 
 
 
 


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G-2 
Type of Infection/ 
Severity Grade 
Grade 1 
Grade 2 
Grade 3 
Fungal infections 
 
 
 
 
 
 
 
 
 
 
 
 
 
Fungal 
infections 
continued 
 
Superficial candida 
infection (e.g., oral thrush, 
vaginal candidiasis) 
 
Candida esophagitis (biopsy 
proven). 
 
Proven or probable fungal 
sinusistis confirmed 
radiologically without 
orbital, brain or bone 
involvement. 
 
Fungemia including 
Candidemia 
 
Proven or probable invasive 
fungal infections (e.g., 
Aspergillus, Mucor, 
Fusarium, Scedosporium). 
 
 
 
Disseminated infections 
(defined as multifocal 
pneumonia, presence of 
urinary or blood antigen, 
and/or CNS involvement) 
with Histoplasmosis, 
Blastomycosis, 
Coccidiomycosis, or 
Cryptococcus. 
 
Pneumocystis jiroveci 
pneumonia (regardless of 
PaO2 level) 
Viral infections 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mucous HSV infection 
 
Dermatomal Zoster 
 
 
 
Asymptomatic CMV 
viremia untreated or a 
CMV viremia with viral 
load decline by at least 2/3 
of the baseline value after 2 
weeks of therapy 
 
 
EBV reactivation not 
treated with rituximab 
 
 
Adenoviral conjunctivitis 
asymptomatic viruria, 
asymptomatic stool 
shedding and viremia not 
requiring treatment   
 
Asymptomatic HHV-6 
viremia untreated or an 
HHV-6 viremia with a viral 
load decline by at least 0.5 
log after 2 weeks of 
therapy 
 
 
VZV infection with 3 or 
more  dermatomes  
 
 
Clinically active CMV 
infection (e.g. symptoms, 
cytopenias) 
or CMV Viremia not 
decreasing by at least 2/3 of 
the baseline value after 2 
weeks of therapy 
 
EBV reactivation requiring 
institution of therapy with 
rituximab 
 
Adenoviral upper respiratory 
infection, viremia, or 
symptomatic viruria 
requiring treatment 
 
 
Clinically active HHV-6 
infection (e.g., symptoms, 
cytopenias) or HHV-6 
viremia without viral load 
decline 0.5 log after 2 weeks 
of therapy 
 
 
Severe VZV infection 
(coagulopathy or organ 
involvement) 
 
CMV end-organ 
involvement (pneumonitis, 
enteritis, retinitis) 
 
 
 
 
 
EBV PTLD 
 
 
 
Adenovirus with end-organ 
involvement (except 
conjunctivitis and upper 
respiratory tract) 
 
 
 
 
 
 
 
 


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G-3 
Type of Infection/ 
Severity Grade 
Grade 1 
Grade 2 
Grade 3 
 
 
 
 
 
 
Viral infections 
continued 
 
 
 
BK viremia or viruria with 
cystitis not requiring 
intervention 
 
 
 
 
 
 
 
 
Viremia (virus not 
otherwise specified) not 
requiring therapy 
 
BK viremia or viruria with 
clinical consequence  
requiring prolonged therapy 
and/or surgical intervention 
 
Enterocolitis with enteric 
viruses  
 
Symptomatic upper tract 
respiratory virus 
 
Any viremia (virus not 
otherwise specified) 
requiring therapy  
 
 
 
 
 
 
 
 
 
 
Lower tract respiratory 
viruses 
 
 
 
 
 
Any viral encephalitis or 
meningitis 
Parasitic infections 
 
 
 
CNS or other organ 
toxoplasmosis 
 
Strongyloides hyperinfection 
Nonmicrobiologically 
defined infections 
 
Uncomplicated fever with 
negative cultures 
responding within 14 days 
 
Clinically documented 
infection not requiring 
inpatient management 
 
 
 
 
Pneumonia or 
bronchopneumonia not 
requiring mechanical 
ventilation 
 
Typhlitis 
 
 
 
 
Any acute pneumonia 
requiring mechanical 
ventilation  
 
 
 
 
Severe sepsis*** without an 
identified organism 
    *Concomitant or multimicrobial infections are graded according to the grade of the infection 
with the higher grade of severity. 
  **Therapy includes both PO and IV formulations 
***Severe Sepsis:   
Adults: 
Hypotension 
-A systolic blood pressure of <90 mm Hg or a reduction of >40 mm hg from baseline in the 
absence of other causes for hypotension 


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G-4 
Multiple Organ Dysfunction Syndrome 
-2 or more of the following: Renal failure requiring dialysis, respiratory failure requiring bipap 
or intubation, heart failure requiring pressors, liver failure 
Pediatrics: 
-Pediatric SIRS definition and suspected or proven infection and cardiovascular dysfunction 
or ARDS or TWO or MORE other organ dysfunctions 
 
Pediatric SIRS definition: 
Two or more of the following, one of which must be abnormal temperature or leukocyte count 
1) Core temperature >38.5C or < 36C 
2) Tachycardia, otherwise unexplained persistent in absence of external stimulus, chronic 
drugs or painful stimuli. or bradycardia, in < 1 year old, otherwise unexplained persistent. 
3) Tachypnea or mechanical ventilation for an acute process not related to underlying 
neuromuscular disease or general anesthesia 
4) Leukocytosis or leukopenia for age (not secondary to chemotherapy) or >10% bands 
 
Pediatric organ dysfunction criteria: 
 
Cardiovascular: despite administration of fluid bolus >40 ml/kg in 1 hour: 
• Hypotension <5th percentile for age (or per Table 1)  
• Pressors at any dose  
• Two of the following:  
o Capillary refill > 5 secs  
o Core to peripheral temperature gap > 3oC  
o Urine output < 0.5 mL/kg/hr  
o Unexplained metabolic acidosis (Base deficit > 5.0 mEq/L)  
o Blood lactate > 2 x ULN  
 
Respiratory: 
• ARDS or  
• Intubated or  
• >50% FiO2 to maintain SaO2 > 92%  
 
Neurological: 
• Glasgow Coma Score < 11 or  
• Acute change in mental status with a decrease in GSC >3 pts from abnormal baseline  
 
Renal: 
• Serum creatinine > 2 x ULN for age or 2-fold increase in baseline creatinine  
 
Hepatic: 
• Total bilirubin >4 mg/dL or  
• ALT >2 x ULN for age  
 


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G-5 
 
TABLE 1: FOUR AGE GROUPS RELEVANT TO HCT: 
Age 
Tachycardia 
(bpm) 
Bradycardia 
(bpm) 
Tachypnea 
(breaths/min) 
Leukocytosis / 
Leukopenia 
(WBC) 
Hypotension 
Systolic BP 
mmHg 
1 mo to 1 yr 
>180 
<90 
>34 
>17.5 to <5.0 
<100 
2 yr to 5 yr 
>140 
NA 
>22 
>15.5 to <6.0 
<94 
6 yr to 12 yr 
>130 
NA 
>18 
>13.5 to <4.5 
<105 
13 yr to < 18 yr 
>110 
NA 
>14 
>11 to <4.5 
<117 
 
Disseminated Infections:  
1. Two or more non-contiguous sites with the SAME organism 
2. A disseminated infection can occur at any level of severity, but most will be grade 2 or 3. 
 
Recurrence Intervals to Determine Whether an Infection is the Same or New: 
1. CMV, HSV, EBV, HHV6: 2 months (< 60 days) 
2. VZV, HZV: 2 weeks (< 14 days) 
3. Bacterial, non-C. difficile: 1 week (< 7 days) 
4. Bacterial, C. difficile: 1 month (< 30 days) 
5. Yeast: 2 weeks (< 14 days) 
6. Molds: 3 months (< 90 days) 
7. Helicobacter: 1 year (< 365 days) 
8. Adenovirus, Enterovirus, Influenza, RSV, Parainfluenza, Rhinovirus: 2 weeks (< 14 days) 
9. Polyomavirus (BK virus): 2 months (< 60 days) 
 
For infections coded as “Disseminated” per the Infection Form, any previous infection with the 
same organism but different site within the recurrence interval for that organism will be counted 
as part of the disseminated infection. 
 
 
 


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H-1 
APPENDIX H 
 
ABBREVIATIONS 
A1-PI: Alpha1-Proteinase Inhibitor 
AA1: Ann Arbor 1 
AA2: Ann Arbor 2 
AA3: Ann Arbor 3 
AAT: Alpha 1 – Antitrypsin 
ADL: Activities of Daily Living 
AE: Adverse Event 
ALT: Alanine Transaminase 
AP: Alkaline Phosphatase 
AREG: Amphiregulin 
AST: Aspartate Transaminase 
BLA: Biologics License Application 
BMT CTN: Blood and Marrow Transplant 
Clinical Trials Network 
BSA: Body Surface Area 
CBC: Complete Blood Count 
CD: Cluster of Differentiation 3 
CI: Confidence Interval 
CIBMTR: Center for International Blood and 
Marrow Transplant Research 
CLL: Chronic Lymphocytic Leukemia 
CMV: Cytomegalovirus 
CNS: Central Nervous System 
CR: Complete Response 
CRF: Case Report Form 
CRP: C-Reactive Protein 
CS: Corticosteroids 
CSLB: CSL Behring 
CT: Computed Tomography 
CTCAE: Common Terminology Criteria for 
Adverse Events 
DAMP: Danger-Associated Molecular Pattern 
DCC: Data Coordinating Center 
DLI: Donor Lymphocyte Infusion 
DOR: Duration of Response 
DSMB: Data and Safety Monitoring Board 
ECOG: Eastern Cooperative Oncology Group 
eCRF: Electronic Case Report Form 
EDC: Electronic Data Capture 
EOT: End of Therapy 
FCBP: Females of Childbearing Potential 
FDG: Fluorodeoxyglucose 
FEV1: Forced Expiratory Volume in 1 Second 
FOXP3: Forkhead Box Protein P3 
FVC: Forced Vital Capacity 
GCP: Good Clinical Practice 
GI: Gastrointestinal 
GMP: Good Manufacturing Practice 
IRT: Suvoda Interactive Response Technology 
IV: Intravenous 
KPS: Karnofsky Performance Status 
LDH: Lactate Dehydrogenase 
LFT: Liver Function Test 
LPS: Lipopolysaccharide  
MAGIC: Mount Sinai Acute GVHD International 
Consortium 
MCP-1: Monocyte Chemotactic Protein-1 
MDASI: MD Anderson Symptom Inventory 
MDS: Myelodysplastic Syndrome 
MHC: Major Histocompatibility Complex 
MIN-6: Mouse Insulinoma 6 
MMF: Mycophenolate Mofetil 
MN: Minnesota 
MOP: Manual of Procedures 
MP: Methylprednisolone 
MR: Mixed Response 
MRD: Minimal Residual Disease 
NCI: National Cancer Institute 
NF-κβ: 
Nuclear 
Factor 
Kappa-Light-Chain-
Enhancer of Activated B Cells 
NHLBI: National Heart, Lung, and Blood Institute 
NIH: National Institutes of Health 
NK: Natural Killer 
NMDP: National Marrow Donor Program 
NR: No Response 
NRM: Non-Relapse Mortality 
OS: Overall Survival 
OT-II: Ovalbumin-Specific, MHC Class II-
Restricted αβ T Cell Receptor 
OVA: Ovalbumin 
PBMC: Peripheral Blood Mononuclear Cells 
PCR: Polymerase Chain Reaction 
PET: Positron Emission Tomography 
PFS: Progression-Free Survival 
PK: Pharmacokinetic 
PO: Per Os 
PR: Partial Response 
PRO: Patient-Reported Outcomes 
PROMIS: Patient-Reported Outcome 
Measurements Information System 
PRR: Pattern-Recognition Receptor 
PTM: Placebo To Match 
REG3α: Regenerating Islet-Derived 3-alpha 
SAE: Serious Adverse Event 
SCTOD: Stem Cell Transplant Outcomes Database 
SOS: Sinusoidal Obstruction Syndrome 


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H-2 
GVHD: Graft Versus Host Disease 
HCT: Hematopoietic Cell Transplant 
HL-1: Cardiac Muscle Cell Line Designated 
“HL-1” 
HPA: Hypothalamic Pituitary Adrenal 
HQL: Health Quality of Life 
HR: High Risk 
HS: Heparan Sulfate 
HSCT: Hematopoietic Stem Cell Transplant 
ICH: International Conference on Harmonisation 
ID: Identification 
IEC: Institutional Ethics Committee 
IFNγ: Interferon Gamma 
IgA: Immunoglobulin A 
IL: Interleukin 
IL-1RA: Interleukin 1 Receptor Antagonist 
IMP: Investigational Medicinal Product 
INS-1: Insulinoma 1 
IRB: Institutional Review Board 
SpO2: Peripheral O2 Saturation 
SPRT: Sequential Probability Ratio Test 
SR: Steroid Refractory 
SST: Serum Separator Tube 
ST2: Suppression of Tumorigenicity 2 
SUSAR: Suspected Unexpected Serious Adverse 
Reaction 
Tcon: Conventional T Cells 
TD: Treatment Discontinuation 
Teff: Donor Effector T Cells 
TF: Treatment Failure 
TNFR1: Tumor Necrosis Factor Receptor-1 
TNF-α: Tumor Necrosis Factor Alpha 
Tregs: Donor Regulatory T Cells 
ULN: Upper Limit of Normal 
VEGF: Vascular Endothelial Growth Factor 
VGPR: Very Good Partial Response 


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I-1 
APPENDIX I 
 
REFERENCES 
1. 
Jacobsohn, D.A. and G.B. Vogelsang, Acute graft versus host disease. Orphanet J Rare 
Dis, 2007. 2: p. 35. 
2. 
Jagasia, M., et al., Risk factors for acute GVHD and survival after hematopoietic cell 
transplantation. Blood, 2012. 119(1): p. 296-307. 
3. 
Lee, S.E., et al., Risk and prognostic factors for acute GVHD based on NIH consensus 
criteria. Bone Marrow Transplant, 2013. 48(4): p. 587-92. 
4. 
Martin, P.J., et al., First- and second-line systemic treatment of acute graft-versus-host 
disease: recommendations of the American Society of Blood and Marrow 
Transplantation. Biol Blood Marrow Transplant, 2012. 18(8): p. 1150-63. 
5. 
Przepiorka, D., et al., 1994 Consensus Conference on Acute GVHD Grading. Bone 
Marrow Transplant, 1995. 15(6): p. 825-8. 
6. 
MacMillan, M.L., et al., Response of 443 patients to steroids as primary therapy for acute 
graft-versus-host disease: comparison of grading systems. Biol Blood Marrow 
Transplant, 2002. 8(7): p. 387-94. 
7. 
Levine, J.E., et al., A prognostic score for acute graft-versus-host disease based on 
biomarkers: a multicentre study. Lancet Haematol, 2015. 2(1): p. e21-9. 
8. 
Alousi, A.M., et al., Etanercept, mycophenolate, denileukin, or pentostatin plus 
corticosteroids for acute graft-versus-host disease: a randomized phase 2 trial from the 
Blood and Marrow Transplant Clinical Trials Network. Blood, 2009. 114(3): p. 511-7. 
9. 
Couriel, D.R., et al., A phase III study of infliximab and corticosteroids for the initial 
treatment of acute graft-versus-host disease. Biol Blood Marrow Transplant, 2009. 
15(12): p. 1555-62. 
10. 
Cragg, L., et al., A randomized trial comparing prednisone with antithymocyte 
globulin/prednisone as an initial systemic therapy for moderately severe acute graft-
versus-host disease. Biol Blood Marrow Transplant, 2000. 6(4a): p. 441-7. 
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