Clinical trial NCT01590628
Conditions: Sickle Cell Disease & Thalassemia
Keywords: Sickle Cell Disease & Thalassemia Genetic disorder
Sponsor: Gamida Cell ltd
Start date: 2012-09-01; Completion date: 2019-10-01
Enrollment: 16 participants; Allocation: NA; Intervention model: SINGLE_GROUP

Brief summary:
Allogeneic Stem Cell Transplantation of NiCord®, Umbilical Cord Blood-Derived Ex Vivo Expanded Stem and Progenitor Cells, in Patients with Hemoglobinopathies

Detailed description:
Umbilical cord blood (UCB) is an alternative stem cell source for hematopoietic stem cell transplantations (HSCT) and can be used for the treatment of various life-threatening diseases, such as hematological malignancies or genetic blood disorders, in such cases where a matched related stem cell donor is not available. However, the major drawback of using this valuable stem cells source is the limited cell dose in a single cord blood unit (CBU), which was shown to be associated with inadequate hematopoietic reconstitution and high risk of transplant-related mortality. To improve outcomes and extend applicability of UCB transplantation, one potential solution is ex vivo expansion of UCB-derived stem and progenitor cells. NiCord® is a stem/progenitor cell based product composed of ex vivo expanded allogeneic UCB cells. NiCord® is based on a novel technology for the ex vivo cell expansion of cord blood derived hematopoietic progenitor cells. By increasing the number of the short and long-term reconstitution progenitor cells transplanted, NiCord® has the potential to enable the broader application of UCB transplantation, and improve the clinical outcomes of UCB transplantation.

In Part 1 of this study, NiCord® will be administered to the patient in conjunction with a second, unmanipulated CBU. In Part 2 of this study, NiCord® will be administered to the patient without a second, unmanipulated CBU. The study duration per patient is approximately 270 days from signing of informed consent to last visit on day 180 post-transplant.

The overall study objectives of part 1 of this study are to evaluate the safety and efficacy of co-transplantation of NiCord® and an unmanipulated CBU in patients with Hemoglobinopathies (Sickle Cell Disease (SCD), or thalassemia major) following myeloablative therapy. The overall study objectives of part 2 of this study are to evaluate the safety and efficacy of transplantation of NiCord® in patients with Hemoglobinopathies (Sickle Cell Disease (SCD), or thalassemia major) following myeloablative therapy.

The study hypothesis for part 1 of this study is that the co-transplantation of NiCord® and an unmanipulated unrelated cord blood graft in patients with hemoglobinopathies (SCD, or thalassemia major) following myeloablative preparative therapy will be safe and will enable cord blood engraftment. The study hypothesis for part 2 of this study is that transplantation of NiCord® in patients with hemoglobinopathies (SCD, or thalassemia major) following myeloablative preparative therapy will be safe and will enable cord blood engraftment.

Up to fifteen (15) evaluable patients recruited for part 1 of the study and up to five (5) patients for part 2 of the study should be 2-45 years of age, at least 10 kg in weight, have symptomatic SCD or thalassemia major and should be considered as candidates for allogeneic myeloablative HSCT for the treatment of SCD.

Arms: arm 1: NiCord: NiCord® is a cell-based product composed of umbilical cord-derived ex vivo expanded stem and progenitor cells.
Interventions: intervention 1: NiCord
Intervention descriptions: intervention 1: NiCord® is a cell-based product composed of umbilical cord-derived ex vivo expanded stem and progenitor cells

Protocol documents:
Prot_SAP_000.pdf: 
 
 
GC P#02.01.020 
 
Date: December 13, 2017 (Amdt VI) 
 
NiCord® Hemoglobinopathy Protocol 
 
Page 1 
Study Title 
 
 
Allogeneic Stem Cell Transplantation of NiCord®, Umbilical Cord Blood-Derived Ex Vivo 
Expanded Stem and Progenitor Cells, in Patients with Hemoglobinopathies 
 
Clinical Phase 
 
 
Pilot Study 
 
Product: 
 
 
 
NiCord® 
 
IND Number: 
 
 
14459 
 
EudraCT Number:  
 
2014-000074-19 
 
Sponsor 
 
Gamida Cell Ltd. 
PO Box 34670 
Jerusalem 91340 
Israel 
Tel: 972-2-6595666 
Fax:  972-2-6595616 
 
Director, Medical Affairs  
 
Einat Galamidi Cohen, M.D. 
 
Protocol No.  
 
 
GC P#02.01.020  
Dated                                               
December 8, 2011 
Amendment #  
 
 
VI 
Dated  
 
 
 
December 13, 2017 
 
This clinical study will be conducted in accordance with the Sponsor's Standard Operating 
Procedures (SOPs), this protocol, current Good Clinical Practice (GCP), the Declaration of 
Helsinki, the provisions of International Conference on Harmonization (ICH) Guidelines and all 
local applicable laws and regulations. 
 
 
 
 
 
 
 
 
CONFIDENTIAL 
The information in this document is considered privileged and confidential, and may not be 
disclosed to others except to the extent necessary to obtain Institutional Review Board 
(IRB)/Ethics Committee (EC) approval, written informed consent and the approval of local 
regulatory authorities as required by local law. 
 
 


 
 
GC P#02.01.020 
 
Date: December 13, 2017 (Amdt VI) 
 
NiCord® Hemoglobinopathy Protocol 
 
Page 2 
 
TABLE OF CONTENTS 
1. 
INVESTIGATOR’S AGREEMENT ..........................................................................11 
2. 
STUDY SYNOPSIS ...................................................................................................12 
3. 
BACKGROUND AND RATIONALE .......................................................................24 
3.1. 
Overview .....................................................................................................................24 
3.2. 
Sickle cell disease morbidity and mortality ................................................................24 
3.3. 
Conventional approaches and their limitations ...........................................................25 
3.4. 
Role of Hematopoietic stem cell transplantation (HSCT) ..........................................25 
3.4.1. 
Barriers to wider applicability of HSCT for SCD ......................................................26 
3.4.2. 
Hematopoietic stem cell transplantation for patients with thalassemia ......................26 
3.4.3. 
Unrelated Umbilical Cord Blood as an alternative graft source for HSCT ................28 
3.4.4. 
UCB in hemoglobinopathies: increased graft failure – a function of lower 
cell dose ......................................................................................................................28 
3.4.5. 
Strategies to augment cell dose: use of dual UCB grafts ............................................29 
3.4.6. 
Combining 2 UCB grafts: a newly emerging and successful strategy to 
augment cell dose .......................................................................................................30 
3.5. 
Ex Vivo Expansion Of Cord Blood Cells ...................................................................30 
3.5.1. 
Ex-Vivo Expansion by Liquid Suspension Culture ....................................................31 
3.5.2. 
Gamida Cell Expansion Technology ..........................................................................32 
3.6. 
Rationale for the administration of NiCord® as a single expanded CBU ...................35 
3.7. 
Clinical Experience with NiCord® and CordIn™ ......................................................36 
3.7.1. 
NiCord® Clinical Experience in Hematological Malignancies ..................................37 
3.7.2. 
CordIn™ Clinical Experience in Hemoglobinopathies ..............................................43 
3.8. 
Rationale for Study Design & Dosages ......................................................................43 
3.8.1. 
Study Population .........................................................................................................44 
3.8.2. 
CBU Cell Dose ...........................................................................................................44 
3.8.3. 
Selection of CBUs ......................................................................................................44 
4. 
STUDY OBJECTIVES, HYPOTHESIS & STUDY ENDPOINTS ..........................45 
4.1. 
Objectives ...................................................................................................................45 
4.2. 
Hypothesis ..................................................................................................................46 
4.3. 
Definition of Study Endpoints ....................................................................................46 
4.3.1. 
Acute Toxicity ............................................................................................................46 


 
 
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Date: December 13, 2017 (Amdt VI) 
 
NiCord® Hemoglobinopathy Protocol 
 
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4.3.2. 
Neutrophil Engraftment ..............................................................................................46 
4.3.3. 
Platelet Engraftment ...................................................................................................46 
4.3.4. 
Autologous Recovery .................................................................................................46 
4.3.5. 
Transplant Related Mortality ......................................................................................47 
4.3.6. 
Acute and Chronic GvHD ..........................................................................................47 
4.3.7. 
Immune Reconstitution ...............................................................................................47 
4.3.8. 
Chimerism of the Two CBU Grafts ............................................................................47 
4.3.9. 
Life-threatening/Fatal Infection ..................................................................................47 
4.3.10. 
Regimen Related Toxicities ........................................................................................48 
5. 
STUDY POPULATION .............................................................................................49 
5.1. 
Number of Patients .....................................................................................................49 
5.2. 
Eligibility Criteria .......................................................................................................49 
5.3. 
Reproductive Restrictions ...........................................................................................53 
5.4. 
Patient Withdrawals ....................................................................................................53 
5.4.1. 
Withdrawal of Patients from the Study ......................................................................53 
5.4.2. 
Criteria for Withdrawal ...............................................................................................53 
5.4.3. 
Early Discontinuation of Follow-up ...........................................................................54 
6. 
CONCOMITANT MEDICATIONS & SUPPORTIVE CARE .................................55 
6.1. 
Previous Medications ..................................................................................................55 
6.2. 
Disallowed Concomitant Medications ........................................................................55 
6.3. 
Preparative & Conditioning Regimen ........................................................................55 
6.3.1. 
Hydroxyurea Administration ......................................................................................55 
6.3.2. 
Fludarabine Administration ........................................................................................56 
6.3.3. 
Busulfan Administration .............................................................................................56 
6.3.4. 
Cyclophosphamide (CY) Administration ...................................................................56 
6.3.5. 
Melphalan ...................................................................................................................57 
6.3.6. 
Methylprednisolone ....................................................................................................57 
6.4. 
GvHD Prophylaxis Medications .................................................................................57 
6.5. 
Acute & Chronic GvHD Treatment ............................................................................58 
6.6. 
Supportive Care ..........................................................................................................58 
6.6.1. 
Engraftment Syndrome ...............................................................................................59 
6.6.2. 
Venous Access ............................................................................................................59 


 
 
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6.6.3. 
Seizure Prophylaxis for SCD Patients ........................................................................59 
6.6.4. 
Hypertension ...............................................................................................................59 
6.6.5. 
Growth Factor .............................................................................................................59 
6.6.6. 
Blood Products ............................................................................................................59 
6.6.7. 
Infection Prophylaxis and Surveillance ......................................................................60 
6.6.8. 
Treatment of Infections ...............................................................................................61 
6.6.9. 
Discharge Instructions and Follow-up ........................................................................61 
6.6.10. 
Supportive Care Guidelines for CNS Toxicities ........................................................61 
6.6.11. 
Nutrition ......................................................................................................................62 
6.6.12. 
Guidelines for Infusing a Second Stem Cell Product or Donor Cellular 
Infusion .......................................................................................................................62 
6.7. 
Investigational Agents ................................................................................................62 
6.8. 
Other Medications ......................................................................................................62 
7. 
DETAILED STUDY PLAN .......................................................................................68 
7.1. 
Pre-Screening Activities: Search for Matching CBUs ...............................................68 
7.2. 
Informed Consent and Registration ............................................................................68 
7.2.1. 
Consent of minors .......................................................................................................69 
7.3. 
Eligibility/Screening Assessments (within 45 days prior to CBU shipment to 
the production site) .....................................................................................................69 
7.4. 
Baseline Assessments (Within 4 weeks prior to start of conditioning) ......................71 
7.5. 
CBU’s Shipment & Receipt at the Production Site and Clinical Site ........................72 
7.6. 
Preparative Phase (Day –35 to one day prior to start of conditioning 
regimen) ......................................................................................................................72 
7.7. 
Eligibility Confirmation: (one week prior to start of conditioning regimen) .............72 
7.8. 
Conditioning Phase .....................................................................................................72 
7.9. 
Pre-Transplantation Day (Day 0) ................................................................................73 
7.9.1. 
Preparation and Infusion of the Unmanipulated CBU and NiCord® ..........................73 
7.9.2. 
Evaluation and Treatment of Mycoplasma Safety Test Failure .................................76 
7.9.3. 
Post Transplantation Follow-Up (Day 0 to 1) ............................................................76 
7.10. 
Scheduled Treatment Visits (As Detailed in Table 4) ................................................76 
7.10.1. 
Scheduled Visits on Day 7/ Days (±3) 14, 21, 28, 35, 42, 70/ Day (±14) 100/ 
Day (±21) 180 .............................................................................................................76 
7.10.2. 
Evaluation and Treatment of Graft Failure .................................................................77 


 
 
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NiCord® Hemoglobinopathy Protocol 
 
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7.10.3. 
Early Discontinuation of Follow-up ...........................................................................77 
7.10.4. 
Criteria for Early Termination/Discontinuation .........................................................78 
7.11. 
Unscheduled Visit .......................................................................................................78 
7.12. 
Post-study Follow-up ..................................................................................................78 
7.13. 
Data Reporting ............................................................................................................78 
7.13.1. 
Criteria for Forms Submission ....................................................................................78 
8. 
STUDY MEDICATION .............................................................................................80 
8.1. 
Description ..................................................................................................................80 
8.1.1. 
NiCord® ......................................................................................................................80 
8.2. 
CBU Supply ................................................................................................................80 
8.3. 
Manufacturing .............................................................................................................80 
8.3.1. 
Out of Specification Results .......................................................................................82 
8.4. 
Handling of Cord Blood Unit .....................................................................................83 
8.5. 
Shipment .....................................................................................................................83 
9. 
SAFETY MONITORING ..........................................................................................85 
9.1. 
Definitions ..................................................................................................................85 
9.1.1. 
Adverse Event (AE) ....................................................................................................85 
9.1.2. 
Infusion Reaction ........................................................................................................85 
9.1.3. 
Serious Adverse Event (SAE) ....................................................................................85 
9.1.4. 
Suspected Adverse Reaction .......................................................................................86 
9.1.5. 
Causality .....................................................................................................................86 
9.1.6. 
Expectation .................................................................................................................86 
9.1.7. 
Toxicity Grading .........................................................................................................86 
9.1.8. 
Expedited Reporting ...................................................................................................86 
9.2. 
Observation, Detection and Recording of AEs and SAEs ..........................................87 
9.3. 
Follow-up of AEs and SAEs .......................................................................................88 
9.4. 
Clinical Laboratory Evaluations .................................................................................88 
9.5. 
Pregnancy ...................................................................................................................88 
9.6. 
Patient Withdrawal from Study Procedures due to Adverse Events ..........................89 
9.7. 
Medical Monitor Review ............................................................................................89 
9.8. 
Sponsor Obligations ....................................................................................................89 
9.9. 
FDA Reporting ...........................................................................................................89 


 
 
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Date: December 13, 2017 (Amdt VI) 
 
NiCord® Hemoglobinopathy Protocol 
 
Page 6 
10. 
STATISTICAL METHODOLOGY ...........................................................................90 
10.1. 
Patients & Analysis Cohorts .......................................................................................90 
10.1.1. 
Per Protocol (PP) Data Analysis Set ...........................................................................90 
10.1.2. 
Withdrawals from the Trial ........................................................................................91 
10.2. 
Sample Size ................................................................................................................91 
10.3. 
Interim Analysis & Early Stopping ............................................................................91 
10.3.1. 
Part 1 Guidelines .........................................................................................................92 
10.3.2. 
Part 2 Guidelines .........................................................................................................92 
10.4. 
Statistical Analysis ......................................................................................................93 
10.4.1. 
Primary Endpoints ......................................................................................................93 
10.4.2. 
Secondary Endpoints & Analysis ...............................................................................93 
10.4.3. 
Exploratory Endpoints & Analyses ............................................................................94 
10.4.4. 
Post Study Analysis ....................................................................................................95 
10.5. 
Safety Assessment ......................................................................................................95 
10.5.1. 
Adverse Experiences ..................................................................................................95 
10.6. 
Statistical Software .....................................................................................................95 
11. 
CLINICAL DATA MANAGEMENT ........................................................................96 
11.1. 
Data Quality Assurance ..............................................................................................96 
11.2. 
Data Collection ...........................................................................................................96 
11.3. 
Source Documents ......................................................................................................96 
11.4. 
Staff Training ..............................................................................................................97 
11.5. 
Data Monitoring ..........................................................................................................97 
11.6. 
Confidentiality ............................................................................................................97 
APPENDIX A. GVHD CLASSIFICATION ..............................................................................98 
APPENDIX B. SAFETY DATA REPORTING .......................................................................100 
APPENDIX C. PROTOCOL SPECIFIED ADVERSE EVENTS ............................................101 
APPENDIX D. COMMON TERMINOLOGY CRITERA FOR ADVERSE EVENTS 
V4.03  (CTCAE) .......................................................................................................104 
APPENDIX E. DRUG LABELS ..............................................................................................105 
REFERENCES ............................................................................................................................106 
 
List of Tables 
Table 1:  Methods of Expansion ....................................................................................................31 


 
 
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NiCord® Hemoglobinopathy Protocol 
 
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Table 2: Overview of ongoing clinical studies of NiCord® ..........................................................37 
Table 3: Overview of ongoing clinical studies of CordIn™ ..........................................................43 
Table 4: Evaluations & Examinations Flow Sheet ........................................................................63 
Table 5: Final Process Quality Control Tests and Release Criteria for NiCord® CF ....................81 
Table 6: Final Process Quality Control Tests for NiCord® NF .....................................................82 
Table 7: Final Process Quality Control Tests for the NiCord® CF/NF Thawing/Infusion 
Solution .......................................................................................................................82 
 
List of Figures 
Figure 1a:  Study Scheme (for Part 1) ...........................................................................................22 
Figure 1b:  Study Scheme (for Part 2) ...........................................................................................23 
 
 


 
 
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Date: December 13, 2017 (Amdt VI) 
 
NiCord® Hemoglobinopathy Protocol 
 
Page 8 
List of Abbreviations 
 
AE 
 
Adverse Events 
AIBW 
 
Adjusted Ideal Body Weight 
ALT 
ANC 
 
Alanine Transaminase 
Absolute Neutrophil Count 
AST 
BM 
 
Aspartate Aminotransferase 
Bone Marrow 
CBB 
 
Cord Blood Bank 
CBU 
 
Cord Blood Unit 
CF 
 
Cultured Fraction 
CFU 
 
Colony-forming Units 
CMV 
 
Cytomegalovirus 
CNS 
 
Central Nervous System 
CoA 
 
Certificate of Analysis 
CRFs 
 
Clinical Report Forms 
CRO 
CSA 
CTCAE 
 
Contract Research Organization 
Cyclosporine A 
Common Terminology Criteria for Adverse Events 
DCC 
 
Data Coordinating Center 
DLCO 
 
Diffusing Lung Capacity of Carbon Monoxide 
DMC 
 
Data Monitoring Committee  
EBV 
EC 
 
Epstein–Barr Virus 
Ethics Committee 
FPQC 
 
Final Process Quality Controls 
GCP 
 
Good Clinical Practice 
G-CSF 
 
Granulocyte Colony-Stimulating Factor 
GM-CSF 
GFR 
 
Granulocyte-Macrophage Colony-Stimulating Factor 
Glomerular Filtration Rate 
GvHD 
 
Graft-versus-host Disease 
HbS 
HCG 
HIV 
HLA 
 
Hemoglobin S 
Human Chorionic Gonadotropin 
Human Immunodeficiency Virus 
Human Leukocyte Antigen 
HPC 
HSC 
 
Hematopoietic Progenitor Cell 
Hematopoietic Stem Cells 
HSCT 
 
Hematopoietic Stem Cell Transplantation 
HTLV 
IBW 
 
Human T-Lymphotropic Virus 
Ideal Body Weight 
IC 
 
Informed Consent 
ICH 
 
International Conference on Harmonization 
IPQC 
 
In-process Quality Controls 
IRB 
 
Institutional Review Board  
ITT 
 
Intent to Treat 
IV 
LVEF 
 
Intravenous 
Left Ventricular Ejection Fraction 


 
 
GC P#02.01.020 
 
Date: December 13, 2017 (Amdt VI) 
 
NiCord® Hemoglobinopathy Protocol 
 
Page 9 
List of Abbreviations 
 
MAC 
mARTs 
 
Myeloablative conditioning 
Mono-ADP-ribosyltransferases  
MM 
 
Medical Monitor 
MMF 
 
Mycophenolate Mofetil 
MRA 
MRI 
NAD+ 
 
Magnetic Resonance Angiogram 
Magnetic Resonance Imaging 
Nicotinamide Adenine Dinucleotide  
NAM 
 
Nicotinamide 
NF 
 
Non-cultured Fraction 
NK 
 
Natural Killer 
NMDP 
OOS 
 
National Marrow Donor Program 
Out of Specification 
PARPs 
 
Poly-ADP-ribose Polymerases 
PB 
 
Peripheral Blood 
PBSC 
PCR 
 
Peripheral Blood Stem Cell 
Polymerase Chain Reaction 
PP 
 
Per Protocol 
PRBC 
QC 
 
Packed Red Blood Cells 
Quality Control 
RBC 
SAE 
 
Red Blood Cell 
Serious Adverse Event 
SC 
SCD 
 
Sickle-Hemoglobin C 
Sickle Cell Disease 
SCF 
SCT 
SLM 
 
Stem Cell Factor 
Stem Cell Transplant 
Study Logistics Manager 
SOPs 
 
Standard Operating Procedures  
SRC 
 
SCID Repopulating Cells 
SS 
TCD 
 
Sickle-Cell Anemia 
Trans-Cranial Doppler 
TPO 
TRM 
 
Thrombopoietin 
Transplant-related Mortality 
UCB 
UCBT 
 
Umbilical Cord Blood 
Umbilical Cord Blood Transplantation 


 
 
GC P#02.01.020 
 
Date: December 13, 2017 (Amdt VI) 
 
NiCord® Hemoglobinopathy Protocol 
 
Page 10 
SPONSOR PROTOCOL APPROVAL PAGE 
 
Protocol Title:  Allogeneic Stem Cell Transplantation of NiCord®, Umbilical Cord Blood-
Derived Ex Vivo Expanded Stem and Progenitor Cells, in Patients with Hemoglobinopathies 
 
 
Clinical Phase 
 
 
Pilot Study 
 
 
Protocol Number:   
 
GC P#02.01.020  
 
Amendment Number:  
 
VI 
 
Dated:  
 
 
 
December 13, 2017 
 
 
Approved by: 
 
Director, Medical Affairs  
 
Einat Galamidi Cohen, M.D. 
 
 
 
___________________________________  
___________________________ 
Signature  
 
 
 
 
 
Date 
 


 
 
GC P#02.01.020 
 
Date: December 13, 2017 (Amdt VI) 
 
NiCord® Hemoglobinopathy Protocol 
 
Page 11 
 
Protocol Title:  Allogeneic Stem Cell Transplantation of NiCord®, Umbilical Cord Blood-
Derived Ex Vivo Expanded Stem and Progenitor Cells, in Patients with Hemoglobinopathies 
 
Clinical Phase 
 
 
Pilot Study 
 
 
Protocol Number:   
 
GC P#02.01.020  
 
Amendment Number:  
 
VI 
 
Dated:  
 
 
 
December 13, 2017 
1. 
INVESTIGATOR’S AGREEMENT 
I have carefully read the foregoing protocol including all appendices and agree that it contains all 
the necessary information for conducting the study safely. 
 
I will conduct this study in strict accordance with this protocol and according to the current GCP 
regulations and will attempt to complete the study within the designated time frame. 
 
I will provide copies of the protocol and all other information relating to pre-clinical and prior 
clinical experience submitted by the Sponsor to all personnel responsible to me who participate 
in the study. I will discuss this information with them to ensure that they are adequately informed 
regarding the drug and conduct of the study. 
 
I agree to keep records on all subject information (CRFs, shipment, and all other information 
collected during the study) in accordance with the current GCP and local regulations. 
 
 
 
 
Principal Investigator’s Name 
 
 
 
 
Signature 
 
 
 
 
Date 
 
 
 
 
Institution 
 


 
 
GC P#02.01.020 
 
Date: December 13, 2017 (Amdt VI) 
 
NiCord® Hemoglobinopathy Protocol 
 
Page 12 
2. 
STUDY SYNOPSIS 
Protocol Number 
GC P#02.01.020  
 
Protocol Title  
Allogeneic Stem Cell Transplantation of NiCord®, Umbilical Cord Blood-Derived Ex Vivo 
Expanded Stem and Progenitor Cells, in Patients with Hemoglobinopathies 
 
Number of Centers and Planned Geographical Distribution 
Up to 5 centers in the U.S.  
 
Clinical Phase 
Pilot study 
 
Investigational Product    
NiCord® is a cryopreserved stem/progenitor cell-based product comprised of:  
1) Ex vivo expanded umbilical cord blood-derived hematopoietic CD34+ progenitor cells (NiCord® 
cultured fraction (CF)).  
2) The non-cultured cell fraction of the same CBU (NiCord® Non-cultured Fraction (NF)) consisting 
of mature myeloid and lymphoid cells.  
Both fractions, i.e., NiCord® CF and NiCord® NF, will be kept frozen until they are thawed and 
infused on the day of transplantation.    
 
In Part 1 of this study, NiCord® will be administered to the patient in conjunction with a second, 
unmanipulated CBU.  
 
In Part 2 of this study, NiCord® will be administered to the patient without a second, 
unmanipulated CBU.  
 
Study Duration 
Total study duration per patient is approximately 270 days from signing of informed consent to 
last visit on day 180 post-transplant. 
 
Study Objectives  
Part 1: The overall study objectives are to evaluate the safety and efficacy of co-transplantation 
of NiCord® and an unmanipulated CBU in patients with Hemoglobinopathies (Sickle Cell 
Disease (SCD), or thalassemia major) following myeloablative therapy.  
 
Part 2: The overall study objectives are to evaluate the safety and efficacy of transplantation of 
NiCord® in patients with Hemoglobinopathies (Sickle Cell Disease (SCD), or thalassemia major) 
following myeloablative therapy. 
 


 
 
GC P#02.01.020 
 
Date: December 13, 2017 (Amdt VI) 
 
NiCord® Hemoglobinopathy Protocol 
 
Page 13 
Primary Objectives 
• Assessment of the acute toxicity associated with the infusion of NiCord®, within 24 hours 
post-infusion 
• Part 1: Assessment of cumulative incidence of donor-derived neutrophil engraftment by day 
42 following co-transplantation of NiCord® and unmanipulated cord blood grafts 
• Part 2: Assessment of cumulative incidence of donor-derived neutrophil engraftment by day 
42 following transplantation of NiCord®  
Secondary Objectives 
• Proportion of transplant-related mortality at 100 days 
• Event-free survival at 100 days (death, autologous recovery, primary or secondary graft 
failure will be considered events for this endpoint) 
• Overall survival at 180 days 
Exploratory Objectives  
• Incidence of donor cell chimerism (>10%) from either donor at 100 and 180 days 
• Percentage donor chimerism in whole blood, CD3+ and myeloid (CD15+ or CD33+) 
fractions at 7, 14, 21, 28, 42, 70, 100,180 days 
• Time from infusion to neutrophil (>500/uL) and platelet (>50K/uL) engraftment 
• Incidence of platelet engraftment (>50K/uL) at 180 days 
• Incidence of acute GvHD grade II-IV and III-IV at 100 days 
• Incidence of chronic GvHD (limited or extensive) at 180 days 
• Incidence of regimen-related toxicity  
• Incidence of life-threatening and fatal infections at 180 days 
• Immune reconstitution at 100 days, and 180 days 
Post-study Analysis 
• Event-free survival at 1 year (death, autologous recovery, primary or secondary graft failure 
will be considered events for this endpoint) 
• Overall survival at 1 year 
• Percentage donor chimerism in whole blood, CD3+ and myeloid (CD15+ or CD33+) 
fractions at 1 year 
• Incidence of chronic GvHD (limited or extensive) at 1 year 
• Incidence of life-threatening and fatal infections at 1 year 
• Immune reconstitution at 1 year 
 


 
 
GC P#02.01.020 
 
Date: December 13, 2017 (Amdt VI) 
 
NiCord® Hemoglobinopathy Protocol 
 
Page 14 
Study Hypothesis 
 
Part 1: Co-transplantation of NiCord® and an unmanipulated unrelated cord blood graft in 
patients with hemoglobinopathies (SCD, or thalassemia major) following myeloablative 
preparative therapy will be safe and will enable cord blood engraftment.  
 
Part 2: Transplantation of NiCord® in patients with hemoglobinopathies (SCD, or thalassemia 
major) following myeloablative preparative therapy will be safe and will enable cord blood 
engraftment. 
 
Study Design  
This is an open-label, non-randomized, interventional, single group assignment study of NiCord® 
in patients suffering from hemoglobinopathies. In Part 1, the patients will be transplanted both 
with NiCord® and an unmanipulated CBU. In Part 2, the patients will be transplanted with 
NiCord® only. 
 
Once the best available cord blood units (CBUs) have been identified and the patient or legal 
guardian has signed the informed consent (IC), the patient will be screened for the study. The 
trial consists of four phases: 
 
(I) Eligibility/Screening Phase  
Patient clinical assessment and eligibility review: 45 days prior to CBU shipment for the start of 
manufacturing.  
The selected CBU for ex-vivo expansion will be shipped from the Cord Blood Bank (CBB) to 
the production site and received no later than two days before the start of production. 
 
 
(II) Baseline Phase  
Baseline clinical assessments: within 4 weeks prior to start of conditioning regimen. 
Confirm patient suitability for transplant: 1 week prior to start of conditioning regimen. 
 
(III) Preparative and Conditioning Phase 
Once the patient is consented to the study and found to be eligible, the patient is started on 
hydroxyurea: 30mg/kg/day orally, beginning on day -35 (may be extended if transplant is 
delayed) until one day prior to the start of conditioning.   
 
In Part 1: The unmanipulated CBU will be shipped from the CBB to the clinical site prior to the 
initiation of conditioning.  
 
 


 
 
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The myeloablative conditioning regimen will consist of: 
• Busulfan:  
o For patients <21 years old: 1mg/kg/dose IV q 6h on days -9 to -6 for 16 doses  
o For patients >21 years old:  0.8mg/kg/dose IV q 6h on days -7 to -4 for 16 
doses 
• Cyclophosphamide:  
o For patients < 21 years old: 50mg/kg/day IV on days -5 to -2  
o For patients >21 years old: 60mg/kg/day IV on days -3 and -2 
• Fludarabine:  
o For patients <21 years old: 35 mg/m2 IV daily x 5 days (days -14 through -10)  
o For patients >21 years old: 35 mg/m2 IV daily x 5 days (days -12 through -8) 
The GvHD prophylaxis regimen will be: 
• Mycophenolate Mofetil (MMF): beginning day –3 for at least 45 days  
AND  
• Cyclosporine: beginning day -3 to at least day 180 
 
(IV) Transplantation and Post Transplantation Follow-up Phase 
NiCord® CF + NF and Infusion Solutions will be shipped to the clinical site before 
transplantation. 
 
Day 0:  
Part 1: Transplantation of the unmanipulated CBU followed by NiCord® with a minimal interval 
of four hours between the infusions of the two units.  With regards to NiCord® infusion: the 
NiCord® CF will be infused first, followed by the NiCord® NF starting no later than 1 hour post 
NiCord® CF infusion. 
 
Days +1 to +180: Post-transplant supportive care and follow-up. 
 
Throughout the study, all AEs, concomitant medications and clinically significant procedures 
will be recorded in both patient’s medical charts and CRF. 
 
Post-study Follow-up 
Clinical outcomes including secondary graft failure, chronic GvHD, cardiac and pulmonary 
function tests, chimerism, Hb-electropheresis, incidence of life-threatening infections, immune 
reconstitution, routine labs, vital signs, physical exam, performance scale, and survival status 
(including causes of death), will be collected from the center at six months post study completion 
(1 year post transplantation), as per site practice.  
 


 
 
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Number of Patients  
Part 1: Up to fifteen (15) patients who are evaluable for the engraftment endpoint.  Part 1 will be 
closed to enrollment at the time that this amendment is approved. 
 
Part 2: Up to five (5) patients who are evaluable for the engraftment endpoint. 
 
Inclusion Criteria 
1. Patients must be 2 – 45 years of age and at least 10 kg 
2. Patient is a candidate for allogeneic SCT for treatment of SCD or thalassemia:  
a. Patient must have clinically severe SCD (e.g., SS, SC or SBeta0 Thal) with at least one 
of the following clinical complications: 
• Recurrent painful events (at least 3 in the 2 years prior to enrollment) that cannot be 
explained by other causes. Pain may occur in typical sites associated with vaso-
occlusive painful events and cannot be explained by causes other than SCD. Pain lasts 
at least 4 hours and requires parenteral narcotic treatment, equianalgesic dose of oral 
narcotics or parenteral nonsteroidal anti-inflammatory drugs. These painful events 
may be treated in any setting, but events managed at home will be considered only if 
there is documentation of the event in a clinical record that may be reviewed by an 
investigator.  These events must occur despite adequate supportive care measures 
(e.g., hydroxyurea therapy). 
• Acute chest syndrome (ACS) with at least two episodes with the development of a 
new infiltrate on chest radiograph and/or having a perfusion defect demonstrable on a 
lung radioisotope scan within the past two years that required hospitalization, oxygen 
therapy, and red blood cell (RBC) transfusion.  These episodes must occur despite 
adequate supportive care measures (e.g., hydroxyurea therapy).  At least one episode 
of acute chest syndrome per year while on hydroxyurea therapy unless patient is 
unable to take hydroxyurea due to toxicity. 
• Any combination of painful events and ACS episodes that total three or more events 
within the two years before transplantation 
• SCD related and clinically significant neurologic event (stroke or hemorrhage) or 
SCD related neurologic defect lasting more than 24 hours 
• Abnormal cerebral magnetic resonance imaging (MRI) and/or abnormal cerebral 
magnetic resonance angiography (MRA) 
• Abnormal Transcranial Doppler (TCD), as defined by a TCD velocity that exceeds 
200 cm/sec by the non-imaging technique (or TCD measurement of >185 cm/sec by 
the imaging technique) measured at a minimum of two separate occasions one month 
or more apart 
• Patients on chronic PRBC transfusion therapy, defined as receiving 8 or more 
transfusions per year for > 1 year to prevent vaso-occlusive clinical complications 


 
 
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(e.g., pain, stroke, and acute chest syndrome), with a history of alloimmunization 
which compromises the delivery of adequate transfusion therapy 
OR; 
b. Patients with thalassemia major requiring ≥8 (or >100 ml/kg) RBC transfusions per year 
in the two years preceding enrollment. 
3. Part 1: Patients must have two partially HLA-matched CBUs. Units must be HLA-
matched at 4-6/6 HLA class I (HLA-A & HLA-B, low resolution) and II (HLA-DRB1, 
high resolution) loci with the subject and 3-6/6 HLA-A, B, DRB1 loci with each other 
(using same resolution of typing).  Double mismatch at any one locus (A, B, or DRB1) is 
not permitted. 
 
Part 2: Patients must have one partially HLA-matched CBU. Unit must be HLA-matched 
at 4-6/6 HLA class I (HLA-A & HLA-B, low resolution) and II (HLA-DRB1, high 
resolution) loci with the subject. Double mismatch at any one locus (A, B, or DRB1) is 
not permitted. 
a. For patients weighing ≥ 25 kg, the manipulated CBU must have a pre-
cryopreserved (post processing) total nucleated cell dose of ≥1.8x109 and 
≥1.8x107cells per kg body weight.  
For patients weighing < 25 kg, the manipulated CBU must have a pre-
cryopreserved (post processing) total nucleated cell dose of ≥1.6x109.  
Part 1: The unmanipulated CBU should contain a pre-cryopreserved (post 
processing), nucleated cell dose of at least 3.5x107/kg.  The better matched unit 
will be the unmanipulated unit (as per investigator’s discretion).  
b. The manipulated CBU should contain a pre-cryopreserved (post processing), total 
CD34+ cell count of ≥ 8x106 for patients weighing ≥ 25 kg and a pre-
cryopreserved (post processing), total CD34+ cell count of ≥7x106 for patients 
weighing < 25 kg. 
c. The manipulated CBU will have undergone volume reduction (both plasma and 
red blood cell depletion) prior to cryopreservation.   
d. The CBU should be procured from a public bank that meets local applicable 
regulations.  
e.  The selected units should be typed twice (i.e., initial typing and verification 
typing). Verification typing (confirmatory typing) should be in a laboratory that is 
ASHI/EFI accredited and must come from an attached segment. 
4. Patients’ Performance score ≥70% by Lansky or Karnofsky performance status scale 
5. Patient has sufficient physiologic reserves including: 
• Cardiac: Left ventricular ejection fraction (LVEF) > 50% by echocardiogram 
radionuclide scan or cardiac MRI; or LV shortening fraction > 26% 


 
 
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• Pulmonary: Pulse oximetry with a baseline O2 saturation of ≥ 85% is required for all 
patients; DLCO > 60% of predicted for age (corrected for hemoglobin) for patients in 
whom pulmonary function testing can be performed.  cDLCO value should be from 
testing performed before the administration of a bronchodilator if applicable.  FVC 
and FEV1 > 60% of predicted for age. 
• Renal: Serum creatinine ≤ 1.5 x upper limit of normal for age and GFR > 100 
mL/min/1.73 m2.  For patients ≥16 years of age, GFR should be >70 mL/min/1.73 m2.  
Note, estimated GFR value not acceptable; nuclear GFR testing must be performed. 
• Hepatic: Serum conjugated (direct) bilirubin < 2 x upper limit of normal for age as 
per local laboratory in the absence of gall bladder disease or prior cholecystectomy; 
Hepatic transaminases (ALT and AST) < 5 x upper limit of normal range 
6. In SCD patients, HbS should be ≤ 45% within 7 days prior to initiation of conditioning 
regimen.  If the HbS level is >45% then the patient must receive RBC transfusions or 
erythrocyte exchange prior to conditioning regimen initiation. 
7. Patient must have at least one graft source as a backup in case of graft failure:  
a. Autologous stem cells harvested from bone marrow; OR 
b.  A related, haplo-identical family member who is suitable for bone marrow or 
peripheral blood stem cell donation and has agreed to do so in the event of graft 
failure; OR 
c. An additional HLA-matched CBU, or two CBUs, reserved as a backup. 
8. Females of childbearing potential, defined as any female who has experienced menarche 
and is not postmenopausal or permanently sterilized (e.g., tubal occlusion, hysterectomy, 
bilateral salpingectomy), agree to use an appropriate method of contraception from at 
least 7 days prior to Hydroxyurea administration until completion of follow-up 
procedures.  An appropriate method of contraception is defined as one that results in a 
low failure rate (i.e., less than 1 percent per year) when used consistently and correctly, 
such as implants, injectables, combined oral contraceptives, some intrauterine 
contraceptive devices (IUDs), sexual abstinence, or a vasectomized partner. 
9. Patient and/or legal guardian signs the written informed consent after being made aware 
of the nature of the patient’s disease and willingly consents to the treatment program after 
being informed of alternative treatments, potential risks, benefits, and discomforts. 
 
Exclusion Criteria 
1. Evidence of uncontrolled bacterial, viral or fungal infections or severe concomitant 
diseases, which in the judgment of the Principal Investigator, indicate that the patient 
could not tolerate transplantation. 
2. Evidence of HIV infection or HIV positive serology. 
3. Evidence of active Hepatitis B or Hepatitis C as determined by serology or PCR. 


 
 
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4. Pregnancy as indicated by a positive serum human chorionic gonadotrophin (HCG) test 
or lactation. 
5. Patients with 8/8 HLA-matched related family donor or unrelated donor able to donate. 
6. Severe alloimmunization with inability to guarantee a supply of adequate PRBC donors 
7. Evidence of donor specific anti-HLA antibodies to the selected NiCord® CBU 
(MFI>2000 to HLA A, B, C, or DRB1). 
8. Prior myeloablative allogeneic hematopoietic stem cell transplant within last 12 months 
or reduced intensity transplant within the past 6 months.  
9. Allergy to bovine products, Gentamicin, or to any product which may interfere with the 
treatment. 
10. Psychologically incapable of undergoing bone marrow transplant (BMT) with associated 
strict isolation or documented history of medical non-compliance and/or psychiatric 
illness and/or social situations that would limit compliance with study requirements. 
11. Enrolled in another clinical trial or received an investigational treatment within 30 days 
prior to CBU shipment to the production facility, unless documented approval obtained 
from Sponsor. 
 
Statistical Considerations 
 
The data from Part 1 and Part 2 will be analyzed separately.  A secondary analysis combining the 
data will be provided; this combined analysis will also present the results from each part 
separately. 
 
Primary End-point and Principal Analysis: Cumulative incidence of donor-derived neutrophil 
engraftment by day 42. Time-to-neutrophil engraftment is defined as the first of three (3) 
consecutive measurements on different days that the patient has an absolute neutrophil count 
(ANC) greater than, or equal to, 500/uL following conditioning regimen-induced nadir. The 
ANC recovery must be of donor origin documented by peripheral blood chimerism assays 
indicating: 
a. Mixed chimerism – >10% host cells and <90% host cells    
OR 
b. Donor chimerism – <10% host cells 
 
Interim Analysis and Safety Assessment Guidelines:  
Part 1: The data emerging from this study will be reviewed by an independent DMC.  In Part 1, 
this committee will review the accumulated data after 3 6 (and 10, if still recruiting) patients 
have entered the study and have been assessed at day 100 following the transplant. The 
committee will make recommendations to the Sponsor regarding early stopping or study 
modification. 
  


 
 
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Early safety assessment guidelines will be used to monitor the following events, and alert the 
DMC. The following events will prompt consideration of early stopping or modification of the 
protocol: 
• 
Serious (grade 4 or 5) acute toxicities: if ≥2 out of the first 7 or ≥3 out of the first 14 
patients experience grade 4 or 5 acute toxicity 
• 
Neutrophil engraftment: if ≥3 of the first 5 patients or ≥4 out of the first 8 patients or ≥5 
of the first 11 patients or >6 of the first 14 patients fail to achieve neutrophil engraftment 
(from either NiCord®, the unmanipulated CBU or both).  Additionally, early 
consideration will be given by the DMC if 2 out of the first 2 patients fail to engraft 
• 
Secondary graft failure: If ≥3 of the first 5 patients, ≥4 out of the first 8 patients, or ≥5 of 
the first 11 patients or >6 of the first 14 patients experience secondary graft failure, as 
defined in section 4.3.2 
• 
Treatment-related mortality at 100 days: if ≥3 out of the first 5 patients or ≥4 out of the 
first 8 patients or ≥5 out of the first 11 patients or >6 of the first 14 patients die before 
100 days from treatment-related causes 
 
Part 2:  The data emerging from Part 2 of the study will be reviewed by the DMC.  In Part 2, a 
DMC review will occur after 3 patients receive NiCord® as a standalone graft and have been 
assessed at day 100 following transplant.  Recruitment may continue during the follow-up of the 
third cryopreserved NiCord® recipient.   
 
Early safety assessment guidelines will be used to monitor the following events, and alert the 
DMC. The following events will prompt consideration of early stopping or modification of the 
protocol in Part 2: 
• 
Serious (grade 4 or 5) acute toxicities: if 1 out of the first 1, or ≥2 out of the first 5 
patients experience grade 4 or 5 acute toxicity 
• 
Neutrophil engraftment: if 2 out of the first 2, or ≥3 of the first 5 patients fail to achieve 
neutrophil engraftment.  Additionally, early consideration will be given by the DMC if 
the first patient fails to engraft 
• 
Secondary graft failure: if 2 out of the first 2, or ≥3 of the first 5 patients experience 
secondary graft failure, as defined in section 4.3.2 
• 
Treatment-related mortality at 100 days: if 2 out of the first 2, or ≥3 of the first 5 patients 
die before 100 days from treatment-related causes 
 
Statistical Notes  
The guidelines in Part 1 and 2 are formulated so that an alert will occur if the posterior 
probability is sufficiently high that the chance of an event exceeds a given threshold. 
Specifically:  
• 
Acute toxicity: posterior probability that chance of grade 4 or 5 acute toxicity is greater 
than 5% exceeds 0.95. Prior distribution: Beta (0.05, 0.95). 


 
 
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• 
Neutrophil engraftment: posterior probability that chance of no neutrophil engraftment is 
greater than 20% exceeds 0.95. Prior distribution: Beta (0.2, 0.8). 
• 
Secondary Graft Failure: posterior probability that chance of secondary graft failure is 
greater than 20% exceeds 0.95. Prior distribution: Beta (0.2, 0.8). 
• 
Treatment-related mortality: posterior probability that chance of treatment-related 
mortality within 100 days of transplant is greater than 20% exceeds 0.95. Prior 
distribution: Beta (0.2, 0.8). 
 


 
 
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3. 
BACKGROUND AND RATIONALE 
3.1. 
Overview  
Allogeneic hematopoietic stem cell transplantation (HSCT) is a potentially curative procedure 
for a number of hematologic malignancies, non-malignant hematologic diseases, bone marrow 
failure syndromes and inherited metabolic disorders. The application of allogeneic HSCT is 
limited by donor availability of suitably HLA-matched family donors. Alternative donors include 
mismatched family members or matched unrelated donors, but these approaches are often 
complicated by an increased risk of graft-versus-host disease (GvHD) or prolonged and 
cumbersome search and procurement processes. In addition, far fewer subjects of racial 
minorities find suitable HLA-matched donors. 
 
Umbilical Cord Blood (UCB) has been increasingly used as an alternative source of stem cells; 
however, in nearly every large single center or registry analysis of outcomes after umbilical cord 
blood transplantation (UCBT), cell dose is identified as an important factor influencing the 
incidence and rate of hematopoietic recovery, risk of transplant-related mortality (TRM) and 
probability of survival and therefore, is a key hurdle precluding broader use of this potentially 
beneficial stem cell source. 
 
To improve outcomes and extend applicability of UCBT, one potential solution is ex vivo 
expansion of UCB-derived stem and progenitor cells. 
 
Gamida Cell Ltd. is engaged in the development of NiCord®, an expanded hematopoietic UCB-
derived stem/progenitor cell graft, as a potential medicinal product for the treatment of subjects 
with high-risk hematological malignancies. 
 
The manufacturing of the fresh and the cryopreserved NiCord® cultured fraction is exactly the 
same apart for the re-suspension on the last manufacturing day, the cryopreservation and the 
suspension before transplantation. The cryopreservation of NiCord® allows flexibility in the 
planning and timing of transplantation, to accommodate the patient’s disease status and any 
changes required, as resulting from the patient’s medical condition. 
3.2. 
Sickle cell disease morbidity and mortality  
 
SCD is an autosomal recessive genetic disease caused by a single mutation in the beta globin 
gene, which leads to a multitude of pathophysiologic changes including sickling of hemoglobin 
and vasculopathy resulting in a clinically heterogeneous multisystem disease.1 The original case 
report of SCD was published in 1910.2 SCD was the first inherited disease attributed to a 
molecular defect – a single amino acid substitution (glutamine replaced by valine) at the sixth 
position of the β-globin chain of hemoglobin A (β6 glu  val).3 Despite being clinically identified 
more than a century ago, and being the first disease to be known to have a molecular basis, 
effective therapies based on knowledge of molecular defects are lacking.4, 5 It is one of the most 
common inherited disorders worldwide. SCD affects 1 in every 400 African-American live births 
translating into a prevalence of 70,000 in the U.S. alone, and over 50,000 in Europe. When sickle 


 
 
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hemoglobin (hemoglobin S) is deoxygenated, it aggregates into large polymers, leading to 
distortion in shape and rigidity of red cells, which in turn is responsible for vaso-occlusion, the 
hallmark of pathophysiology. Vaso-occlusion underlies the development of symptoms in various 
target organs including but not limited to the central nervous system, lungs, bones, joints, 
kidneys, and eyes. The most catastrophic clinical syndrome is the development of cerebral 
infarction. Cerebrovascular accidents, including cerebral infarction (ischemic stroke) and 
cerebral hemorrhage (hemorrhagic stroke) are a leading cause of death in children and adults 
with SCD. Nearly 10% of patients have a stroke by 20 years of age. In addition, silent stroke is 
also prevalent in 20% of patients with SCD. Once patients have an episode of stroke, recurrent 
strokes are common in two-thirds of patients without intervention. Other serious complications 
of SCD include chronic lung disease, pulmonary hypertension and cor pulmonale (as a result of 
recurrent acute chest syndromes), severe vaso-occlusive painful crises, and osteonecrosis of 
bones and joints. Children with SCD are also known to have cognitive impairments because of 
overt or often, silent strokes. These morbidities significantly decrease the quality of life and also 
predict a more severe phenotype, such as development of stroke and recurrent acute chest 
syndromes.6, 7, 8  
 
Median survival of patients with SCD in the 1970s was 14.3 years.9, 10 As a result of a number of 
clinical advances in management of SCD, such as newborn screening, early institution of 
antibiotics, immunizations, early identification of patients at risk for strokes, chronic 
transfusions, and hydroxyurea, the median survival in the 1990s had improved to 42 years and 48 
years in males and females respectively.11 While this is a significant improvement from the past, 
it still represents a decrease in life span by 2-3 decades as compared to the general population. 
Furthermore, patients often are medically and psychologically debilitated from the years of 
chronic problems occurring from childhood and frequently cannot become self-sufficient 
productive members of society as young adults. Taken together, the morbidity and mortality 
related to SCD represent a public health burden of great magnitude. 
3.3. 
Conventional approaches and their limitations 
Chronic transfusion has been shown to decrease the risk of recurrent strokes and even employed 
in primary stroke prevention.12, 13 However, despite regular chronic transfusions, approximately 
20% patients developed a second stroke in one study.14 Besides, several patients continue to have 
silent infarcts in spite of receiving chronic transfusions.15 Thus, chronic transfusion has 
limitations in treatment of SCD and is not without risks, the most well-known of which are iron 
overload, alloimmunization, allergic reactions and infections. Hydroxyurea has also been shown 
to ameliorate some disease manifestations in some patients with SCD.16 However, many patients 
do not respond to hydroxyurea and the role in stroke prevention is unclear. Thus, neither chronic 
transfusions nor hydroxyurea represent a curative therapy for sickle cell anemia.  
3.4. 
Role of Hematopoietic stem cell transplantation (HSCT) 
HSCT is the only therapy demonstrated to be curative for patients with SCD. Studies from 
Belgium, France, and the U.S. have shown that HSCT from HLA-identical or matched related 
donors (MRD), using bone marrow or cord blood as graft source, and myeloablative 
conditioning (MAC) consisting of busulfan, cyclophosphamide and ATG (Bu/Cy/ATG) is 
associated with event-free survival of 80-85% in patients with SCD.17, 18, 19, 20 Further analysis 


 
 
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of 26 long-term survivors in the American cohort with a median follow-up of 56 months 
demonstrated stabilization of underlying vasculopathy, and resolution of other complications 
related to SCD e.g., further episodes of pain, stroke, or acute chest syndrome in most patients 
who had stable engraftment.21 Thus, HSCT clearly modifies the natural course of SCD patients 
in a curative manner.  Barriers to wider applicability of HSCT for SCD patients include the lack 
of HLA-identical related donors and inherent resistance to engraftment in the setting of 
alternative donor HSCT.  
3.4.1. 
Barriers to wider applicability of HSCT for SCD  
The main barrier to wider applicability of HSCT for SCD is the lack of HLA-identical related or 
non-related donors. HLA-identical related donors are available for only 10-20% of the patients 
and there are no reports of matched unrelated donor HSCT likely because of the difficulty 
finding a suitable matched unrelated donor for SCD patients.22 Results obtained with an HLA-
matched sibling cord blood (CB) transplantation are remarkable but the chances of finding a 
related HLA-identical CB unit are no better than that of finding an HLA-matched sibling. 
Available data involving the use of mismatched unrelated CBT indicates primary graft failure 
and GvHD as a major concern.23 Patients with SCD, like other hemoglobinopathies, have an 
inherently increased risk to reject mismatched grafts and therefore, primary graft failure. This is 
because of various factors such as marrow hyperactivity attempting to compensate for the 
chronic anemia, high incidence of alloimmunization resulting from frequent exposure to packed 
red cell transfusions, and lack of exposure to prior chemotherapy leaving the patient 
immunocompetent immediately prior to transplant. Therefore, there is an urgent need to develop 
protocols that will enable successful engraftment of grafts derived from mismatched donors. If 
partially mismatched, unrelated umbilical cord blood grafts would be considered, the majority of 
the patients would have at least a 4/6 HLA-matched donor available. 
3.4.2. 
Hematopoietic stem cell transplantation for patients with thalassemia  
Allogeneic hematopoietic stem cell transplantation (HSCT) still remains the only potentially 
curative treatment for patients with thalassemia, which represents the most frequent inborn 
genetic disorder in the Mediterranean countries.24 Since the first successful allogeneic HSCT, 
performed in Seattle more than 20 years ago by Thomas and colleagues on an Italian child, 
hundreds of patients with thalassemia have been cured of their original disorder after receiving 
an allograft, in most cases from an HLA-identical family donor.25, 26, 27 In view of this result, 
allogeneic HSCT represents an attractive therapeutic alternative, especially for those patients, 
and their families, who do not accept the prospective of a lifelong disease, requiring continuing 
treatment with blood transfusion and drugs.28  
 
The extensive experience accumulated in the field of HSCT from an HLA-identical sibling for 
patients with thalassemia has allowed to identify clinical parameters influencing post-transplant 
outcome, thus permitting more refined prognostic counseling to the patients considering the 
option of HSCT or to their parents.26, 27, 28, 29, 31 In particular, the risk of dying of transplant-
related complications has been clearly shown to be mainly dependent on patient age, iron 
overload and liver viral infections. In fact, adults, especially when affected by chronic active 
hepatitis, have a worse outcome than children, the probability of survival with transfusion 
independence having been reported to be 58%;29 among children below the age of 17, three 


 
 
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classes of risk have been identified on the basis of regularity of previous iron chelation, liver 
enlargement and presence of portal fibrosis.26 In the most recent update of the Pesaro group’s 
experience, the probability of thalassemia-free survival of patients younger than 17 years at time 
of bone marrow transplantation (BMT) who received the allograft from an HLA-identical 
relative and belonging to class I and II was 87% and 85%, respectively.30. Worse results have 
been reported in pediatric patients who had low compliance with iron chelation favoring the 
occurrence of iron-induced organ damage, in whom the probability of thalassemia-free survival 
was initially reported to be 53%. Reducing the dosage of cyclophosphamide, used together with 
busulfan in the preparative regimen of these patients, it has been possible to document a lower 
incidence of transplant-related mortality for children in class III, which remained, however, in 
the order of 25%.31 A most recent survey, reporting on a limited number of class 3 patients, has 
suggested that the adoption, during the 2 months preceding HSCT, of a hypertransfusion 
regimen, intended to reduce the expansion pressure on the erythron, together with the use of 
azathioprine and hydroxyurea to suppress hematopoiesis and fludarabine for reducing the risk of 
rejection may lower the probability of treatment failures and improve post-transplant outcome 
also in this subgroup of patients.32  
 
The results obtained by the Pesaro team in patients transplanted from an HLA-compatible 
relative have been substantially reproduced by other groups, whose studies have confirmed that 
the majority of patients with thalassemia given HSCT from an HLA-identical sibling can be 
cured of their disease and that both iron overload and old age unfavorably affect post-transplant 
outcome.33, 34   
 
One impediment to the success of allogeneic HSCT for the cure of thalassemia is represented by 
graft rejection, whose incidence is considerably higher than that observed in patients transplanted 
for leukemia.30, 31 Several factors may contribute to the occurrence of this complication, 
including avoidance of any immunosuppressive or myeloablative treatment before 
transplantation, possible allo-immunization related to erythrocyte transfusions and large spleen 
size, especially in older patients. Notably, in patients transplanted from an HLA-identical sibling, 
the incidence of rejection is directly correlated with the patient’s class of risk, an incidence of 
4%, 8% and 12% being observed in patients belonging to risk class I, II and III, respectively.30, 31 
 
Stable mixed chimerism is also not uncommon among patients transplanted for thalassemia from 
a compatible sibling,35 as seen also in patients with acquired aplastic anemia following BMT.36 
Patients with thalassemia developing stable chimerism, even with a low percentage of donor 
marrow progenitors (20-30%), have been reported to experience marked enrichment for donor 
cells in the mature red blood cell compartment, which makes them transfusion-independent.35 
This observation has provided a strong biological and clinical rationale for considering the use of 
reduced-intensity preparative regimens in patients with thalassemia. Thalassemia patients with 
liver/heart damage could represent the ideal candidates for well-controlled, clinical trials of less 
toxic conditioning regimens by centers experienced in HSCT. So far, few reports have 
demonstrated the feasibility of using reduced-intensity preparative regimens (which may also 
help reduce the incidence of late effects, in particular those concerning growth and fertility, 
resulting from high-dose chemotherapy used for conventional HSCT) for successfully treating 
patients with haemoglobinopathies.37, 38, 39, 40 Although transplant-related toxicity was mild in all 


 
 
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cases reported, a significant proportion of these patients did not have sustained engraftment. This 
finding indicates that, using non-myeloablative strategies, stable donor engraftment is more 
difficult to achieve in patients with hemoglobinopathies than in adults with malignancy and it 
does not encourage the use of this approach in young and well-fitted patients, who deserve more 
intensive myeloablative treatment. 
3.4.3. 
Unrelated Umbilical Cord Blood as an alternative graft source for HSCT 
Among the most significant advances in HSCT over the past decades have been explorations into 
the use of alternate hematopoietic grafts, to include allogeneic unrelated UCB.41, 42, 43 UCB, the 
residual baby’s blood in the placenta, is a by-product from childbirth that historically had been 
discarded.  Experimental studies have demonstrated that UCB is enriched in primitive 
hematopoietic progenitors compared with adult bone marrow (BM) and mobilized peripheral 
blood stem cell grafts (PBSC).  Notably, long-term engrafting cells are almost eightfold enriched 
among UCB CD34+ cells compared to those in CD34+ cells from PBSC. These biological 
features may well explain the curious clinical finding that despite a slower pace of myeloid 
engraftment after UCB transplantation there is a higher prevalence of early progenitors in the 
marrow space in those children who were given UCB as opposed to BM transplant.44   
 
UCBT is associated with a decreased incidence as well as severity of both acute and chronic 
GvHD. There are other advantages such as easy availability and lesser chance of viral 
transmission through the product. Unrelated 4/6 HLA-matched UCBT is an acceptable stem cell 
graft for patients with hematological malignancies for whom matched related or unrelated donors 
are not available. The main drawback of UCBT result from the relatively low dose of total 
nucleated cells and CD34+ cells within an umbilical cord blood unit.  Infusion of high cell dose 
relative to the size of the patient strongly correlates with time to engraftment and probability of 
overall engraftment and thus, survival.45 Results of UCBT for hematological malignancies have 
been substantially improved in the last years and rate of successful engraftment is relatively high 
in patients transplanted with an adequate cell dose of 2.5-3x106/kg. However, delayed 
hematopoietic recovery still substantially contributes to increased morbidity and transplant-
related mortality.46 For patients without a single UCB unit with adequate cell dose, double 
UCBT is an acceptable alternative.47 Yet, the problem of delayed hematopoietic recovery 
persists and the risk of GvHD is increased.  
3.4.4. 
UCB in hemoglobinopathies: increased graft failure – a function of lower cell 
dose 
Unrelated CBT has been used in a limited number of patients with hemoglobinopathies and with 
limited success so far. Cell dose is even more critical for the successful of UCBT in SCD and 
thalassemia patients. It has been reported that cell dose of the UCB graft is an independent 
predictor of engraftment and subsequent event-free survival in hard to engraft patients. 
Combined registry data from Eurocord, CIBMTR and New York Blood Center on patients with 
hemoglobinopathies undergoing UCBT was recently published.23 Sixteen patients with SCD and 
35 patients with thalassemia were reported to have undergone an unrelated UCB transplant. 
Patients with SCD had an overall survival probability of 94%, but only 50% event-free survival. 
Seven of 16 SCD patients received a reduced-intensity conditioning. Primary graft failure was 
the predominant cause of treatment failure occurring in 7 of 16 patients with SCD and 20 of 35 


 
 
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patients with thalassemia. In multivariate analysis of the overall cohort, engraftment rate and 
EFS were higher with cell dose >5 x 107/kg. The 2-year probability of EFS was 45% in patients 
who received grafts with cell dose >5 x 107/kg and 13% with lower cell dose. These results 
highlight the critical importance of adequate cell dose in patients with hemoglobinopathies 
undergoing unrelated UCB transplants and suggest more successful results to be obtained by 
implementing new strategies that would allow adequate cell dose in the UCB graft. 
3.4.5. 
Strategies to augment cell dose: use of dual UCB grafts 
With the realization of critical importance of cell dose in engraftment and survival after single 
UCBT, and with the aim of increasing the cell dose for adults and adolescents who could not find 
a single cord with adequate cell dose, transplantation was performed in adults with hematologic 
malignancies with a combination of 2 UCB units that were partially HLA-matched with the 
recipient (4-6/6 HLA match) and with each other.56 Phase II non-comparative studies, and 
retrospective comparisons, suggest that by adding a second CBU, successful engraftment can be 
achieved at a rate that is comparable to a UCBT using a single adequately sized CBU.48 
Outcomes of single versus double cord in pediatric patients with high risk leukemia undergoing 
myeloablative conditioning demonstrated similar outcomes with no survival advantage in 
recipients of a double UCBT as compared to those transplanted with an adequately dosed single 
UCB unit.49 While recipients of two units had a higher incidence of acute GvHD, relapse risk 
was unchanged. Therefore, single UCBT was recommended as the standard approach in children 
with hematologic malignancies for whom a single unit containing ≥2.5 x 107nucleated cells/ kg 
matched at zero, one or two HLA-loci is available.  Double UCBT however remains a suitable 
alternative in the absence of an adequately dosed single UCB unit in children with hematologic 
malignancies. 
 
Importantly, despite the increased cell dose provided by DCBT, time-to-neutrophil and platelet 
engraftment (engraftment kinetics) and engraftment rates appear to be comparable between 
single and double CBT.50 Thus the use of DCBT does not appear to improve the hematopoietic 
recovery following transplantation and the risk of GvHD is increased. 
 
Another confounding topic to consider is that in DCBT usually only one of the two CBUs 
engrafts. Early after transplantation (day 21) both CBUs contribute to hematopoiesis in 40–50% 
of patients, but by day 100, one CBU predominates in the vast majority of patients51 and the 
dominant CBU cannot yet be predicted. It has been postulated that graft-versus-graft immune 
interactions are the principal mechanism promoting the engraftment of a single CBU in patients 
undergoing DCBT. Delaney et al52 have demonstrated that early CD3+ PB chimerism predicts 
the long-term engrafting CBU following myeloablative DCBT. The correlation of higher early 
post-transplant donor CD3+ PB chimerism with the dominant CBU suggests a rapid immune 
mediated response as a primary mechanism of action for long-term single donor dominance. In 
vivo53 and in vitro54 studies also suggest that the predominant CBU in the setting of double CBT 
is the CBU able to develop a prevalent cytotoxic activity directed against activated lymphocytes 
and HSC graft of the other CBU. It is therefore possible that a discordant dominance between the 
two CBUs, in terms of stem cell potency and graft-versus-graft alloreactivity, could result in 
graft failure, i.e., when the dominant CBU with respect to alloreactive capacity eradicates the 
CBU able to support a more efficient and robust hematopoietic engraftment.54  


 
 
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3.4.6. 
Combining 2 UCB grafts: a newly emerging and successful strategy to augment 
cell dose 
With the realization of critical importance of cell dose in engraftment and survival after single 
UCBT, and with the aim of increasing the cell dose for adults and adolescents who could not find 
a single cord with adequate cell dose, transplantation was performed in adults with hematologic 
malignancies at University of Minnesota with a combination of 2 UCB units that were partially 
HLA-matched with the recipient (4-6/6 HLA match) and with each other.55, 56, 57 Twenty-three 
patients with a median age of 24 years received 2 UCB units with a median infused cell dose of 
3.5 x 107/kg after TBI-based myeloablative conditioning. Engraftment was achieved in all 21 
evaluable patients at a median of 23 days. Mixed chimerism was noted in 24% of patients at day 
21, however by day 100, only one of the two units predominated. While a significantly higher 
CD3+ dose was noted in the predominating unit, this observation has not been confirmed in 
subsequent larger data from the same institution. Understanding the kinetics of engraftment with 
double UCBT is an area of active research.  Incidence of grade II GVHD was increased but not 
that of severe grades III-IV (13%). Disease-free survival was 57% at 1 year, with 72% of patients 
alive if they received transplants while in remission. With safety and feasibility of double UCBT 
demonstrated, increasing number of double UCBT have been performed at several institutions 
with similar observations – reproducible engraftment, low transplant related mortality (TRM), 
and comparable progression free survival (PFS).58, 59 A multicenter, randomized, open label 
study, comparing outcomes of single versus double cord in pediatric patients with high risk 
leukemia undergoing myeloablative conditioning, through the NHLBI/NCI-sponsored Blood and 
Marrow Transplant Clinical Trials Network (BMT CTN, Study 0501) has been completed.60 The 
study demonstrated similar outcomes with no survival advantage in recipients of a double UCB 
transplant as compared to those transplanted with an adequately dosed single UCB unit. While 
recipients of two units had a higher incidence of acute GvHD, relapse risk was unchanged. 
Therefore, single UCB transplant was recommended as the standard approach in children with 
hematologic malignancies for whom a single unit containing ≥2.5 x 107nucleated cells/ kg 
matched at zero, one or two HLA-loci is available.  Double UCB transplant however remains a 
suitable alternative in the absence of an adequately dosed single UCB unit in children with 
hematologic malignancies. 
3.5. 
Ex Vivo Expansion Of Cord Blood Cells 
Attempts to increase the UCB graft cell dose and particularly the CD34+ progenitor cell dose by 
ex-vivo expansion led to numerous clinical trials addressing the clinical implications of 
expansion of an UCB unit using various methods of expansion (Table 1). The double cord 
approach, used in those trials, serves as safe modality for evaluating the safety and potential 
efficacy of graft manipulation. 
 
Laboratory studies characterizing the expanded cell populations have shown promise and some 
of the clinical trials may suggest more rapid hematopoietic recovery in UCB recipients. 
 


 
 
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Table 1:  Methods of Expansion 
 
Summary of clinical trials evaluating UCB that has been expanded ex vivo 
3.5.1. 
Ex-Vivo Expansion by Liquid Suspension Culture 
In an effort to expand HSCs ex vivo, one method has been liquid culture, in which UCB-derived 
progenitor cells (primarily CD133+ or CD34+) are cultured with combinations of cytokines 
growth factors, serum or serum free medium in various flasks, bags or containers. In the attempts 
to stimulate the proliferation of primitive hematopoietic progenitors, various “cocktails” of 
growth factors and cytokines were tested but the proper mixture has not yet been determined. 
Pre-clinical and clinical results with cytokine only expansion cultures were not satisfactory and 
prompted attempts to further optimize ex vivo culture conditions61, 62, 63, 64, 65, 66, 67 as well as the 
development of new technologies aimed at attenuating in vitro differentiation, enhancing 
expansion of less differentiated progenitor cells and increasing the numbers of short and long 
term repopulating cells. This included the use of histone deacetylases, thought to promote HSC 
self-renewal,68 the use of glycogen synthase kinase-3 inhibitors reported to maintain the 
pluripotency of stem cells69 and the use of an immobilized, engineered form of the Notch ligand 
δ-1to stimulate ex vivo UCB expansion.70 The latter was tested on a small number of patients71 
with promising results suggesting that the expanded unit may provide short-term repopulating 
cells that may facilitate and improve speed of engraftment of the non-cultured unit. Later clinical 
studies have further supported the use of ex vivo cultured umbilical cord blood stem cells to 
shorten the time to hematopoietic recovery following myeloablative chemotherapy.72, 73 Myeloid 
engraftment occurred at a median time of about 15-16 days and platelet engraftment at a median 
of about 40-42 days. This is accomplished by increasing the frequency of lineage committed 


 
 
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short-term repopulating hematopoietic stem cells. However, the expanded cells which were 
observed as early as one week post transplantation were lost before or after engraftment. In all 
cases, the co-infused unmanipulated cord blood unit provided long-term hematopoiesis. 
 
Gamida Cell Ltd. introduced the use of tetraethylenepentamine, a copper chelator thought to 
modulate the proliferation and differentiation of primitive hematopoietic progenitors.74, 75, 76 This 
method was tested in a phase III study of 100 patients with encouraging results.77 
 
Gamida Cell Ltd. has undertaken to develop NiCord®, a novel product of ex vivo expanded CBU 
to be transplanted with or without a second, unmanipulated CBU. As discussed above, the 
incidence of neutrophil engraftment and time to engraftment following transplantation of either 
single large CB unit or double CB units are still lower and delayed compared to BM or PB 
transplantations. By increasing the number of short and long-term reconstitution progenitor cells 
transplanted, NiCord® has the potential to ameliorate this limitation, enabling broader application 
of UCBT in adults and adolescents, and improving the clinical outcomes of transplantation. 
3.5.2. 
Gamida Cell Expansion Technology 


 
 
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3.6. 
Rationale for the administration of NiCord® as a single expanded CBU 
Ideally, a successful expansion technology would obviate the need for DCBT, and in most cases 
would enable the clinician to choose a single, best HLA-matched CBU for the patient. Most ex 
vivo expansion technologies are successful in expanding a subset of hematopoietic progenitor 
cells (HPCs), which are expected to improve short-term early hematopoietic reconstitution; while 
the main concern still remains for preservation of long-term repopulating cells in ex vivo 
conditions106, 107, 108 . The concern is not only related to the persistence of such unique cells in 
culture, but also to their potential to differentiate and reconstitute all blood cell lineages 
including myeloid, T, NK and B cells, as efficiently as the long-term repopulating cells before 
expansion.109 
Until the advent of NiCord® expansion technology, ex vivo expansion studies have only been 
successful in demonstrating short-term early hematopoietic reconstitution. 
In light of the accumulated data from the ongoing NiCord® clinical program in hematologic 
malignancies, Part 2 of the study aims to assess whether UCB transplantation of a single 
expanded CBU using the NiCord® technology provides donor-derived engraftment in patients 
with hemoglobinopathies following myeloablative therapy.  
The DCBT approach adds a measure of safety to the evaluation of novel approaches to ex vivo 
expansion. However, as previously described, the drawback of this strategy is that graft-versus-
graft immune interactions lead to the engraftment of one of the two CBUs transplanted and 
therefore potentially, the most potent CBU with respect to hematopoietic reconstitution may be 
eradicated by the immunologically dominant CBU. Furthermore, the use of DCBT has not 
demonstrated any improvement in the rates or kinetics of engraftment.  Current data suggest that 
unrelated CBT with NiCord® may make it possible to choose the best CBU for the patient, 
expand it in culture and transplant it to the patient in a single CBT approach. 


 
 
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Clinical data to date demonstrate that patients with hematological malignancies treated with 
NiCord® as a standalone graft can rapidly engraft both neutrophils and platelets. Subsequently, 
patients require a substantially shorter duration of hospitalization after transplantation, which is 
consistent with more rapid recuperation. Available patient follow-up indicates a safe profile in 
terms of the robustness of engraftment, and the occurrence of GvHD, as compared to 
unmanipulated CBT despite the use of partially mismatched CBUs. Moreover, the available data 
show that patients treated with NiCord® are able to develop functional hematopoietic systems, 
with the development of myeloid and lymphoid cells, supporting immune recovery. 
 
As detailed in section  3.7.1.2, a study of NiCord® in hematological malignancies as a standalone 
graft source is ongoing (GC P#03.01.020). The dataset that served as the basis for the NiCord® 
Phase III hematological malignancies study design comprised patients aged 12-65 years old 
treated at multiple international centers between August 2013 and June 2015. Sixteen patients 
received NiCord® as a standalone graft. All 16 NiCord®-only recipients achieved neutrophil 
engraftment by day 42 with full donor chimerism. Only one patient experienced secondary graft 
failure in the year following NiCord® transplant. The median days to neutrophil engraftment in 
NiCord® -only recipients was 10 days post transplant, ranging from 6 days to 26 days.  All but 
two of these patients engrafted prior to day 18 post transplant. For NiCord®-only recipients, the 
cumulative incidence of platelet engraftment to 20k/mm3 and 50k/mm3 at 100 days post 
transplant was 75% and 64% respectively.  Among the engrafters, the median time to 
engraftment to 20k/mm3 and 50k/mm3 was 32 days and 42 days respectively. Immune 
reconstitution of CD4+, CD8+, CD19+, CD56+/16+ in NiCord®-only recipients was comparable 
to unmanipulated cord blood transplantation in historical controls. The overall survival of 
NiCord®-only recipients at 180 and 365 days was 81% and 59% respectively, and the cumulative 
incidence of non-relapse mortality at day 100 and day 180 post transplant was 12% and 19% 
respectively.  
 
Demonstration of successful, rapid and sustained engraftment of a single expanded CBU would 
obviate the need for the use of a second CBU, providing both potentially less GvHD and 
significant cost savings. NiCord® could potentially provide an accessible graft for allogeneic 
transplantation in patients with hemoglobinopathies who do not have a matched related donor 
option, thereby addressing a critical unmet need. 
3.7. 
Clinical Experience with NiCord® and CordIn™  
 


 
 
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3.7.1. 
NiCord® Clinical Experience in Hematological Malignancies 
The clinical experience with NiCord® in Hematological Malignancies is summarized in Table 2 
below. 
Table 2: Overview of ongoing clinical studies of NiCord® 
Protocol Number 
(ClinicalTrials.gov 
Number) 
Study Title 
Study Status 
Institution/Principal 
Investigator 
GC P#01.01.020 
(NCT01221857a) 
Allogeneic Stem Cell 
Transplantation of 
NiCord®, Umbilical Cord 
Blood-Derived Ex Vivo 
Expanded Stem and 
Progenitor Cells, in 
Combination With a 
Second, Unmanipulated 
Cord Blood Unit in Patients 
With Hematological 
Malignancies 
Complete  
Duke University Health System/ 
Dr. Joanne Kurtzberg and Dr. 
Mitchell Horwitz 
Cardinal Bernardin Cancer Center, 
Loyola University/ 
Dr. Patrick Stiff 


 
 
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Protocol Number 
(ClinicalTrials.gov 
Number) 
Study Title 
Study Status 
Institution/Principal 
Investigator 
GC P#03.01.020 
(NCT01816230b) 
Allogeneic Stem Cell 
Transplantation of 
NiCord®, Umbilical Cord 
Blood-derived Ex Vivo 
Expanded Stem and 
Progenitor Cells, in 
Adolescent and Adult 
Patients with 
Hematological 
Malignancies. 
Enrollment 
completed 
(estimated 
LPLV: June 
2018) 
Duke University Health System/ 
Dr. Mitchell Horwitz 
Hospital Universitario y 
Politécnico La Fe/ 
Dr. Guillermo Sanz 
Vanderbilt University Medical 
Center/ 
Dr. Madan Jagasia 
Hospital Universitari Vall 
d'Hebrón/ 
Dr. David Valcárcel 
AOU San Luigi Gonzaga/ Dr. 
Daniela Cilloni 
Universitair Medisch Centrum 
Utrecht/ Dr. Jaap Jan Boelens 
Cedars-Sinai Medical Center/ Dr. 
Yulia Linares 
Cleveland Clinic/ Dr. Rabi Hanna 
University of Minnesota/ Dr. John 
Wagner 
Cardinal Bernardin Cancer Center, 
Loyola University/ 
Dr. Patrick Stiff 
Oregon Health & Science 
University/ Dr. Richard Maziarz 
National University Hospital/ 
Liang Piu Koh 
Singapore General Hospital/ 
William Hwang 
GC 
P#04.01.020/030 
(NCT02039557c) 
 
Long Term Follow Up for 
Patients who have received 
Allogeneic Stem Cell 
Transplantation of 
NiCord®/CordIn™, 
Umbilical Cord Blood-
derived Ex Vivo Expanded 
Stem and Progenitor Cells. 
Ongoing 
Duke University Health System/ 
Dr. Mitchell Horwitz and Dr. 
Joanne Kurtzberg 
Hospital Universitario y 
Politécnico La Fe/ 
Dr. Guillermo Sanz 
Hospital Universitari Vall 
d'Hebrón/ 
Dr. David Valcárcel 


 
 
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Protocol Number 
(ClinicalTrials.gov 
Number) 
Study Title 
Study Status 
Institution/Principal 
Investigator 
GC P#05.01.020 
(NCT02730299d) 
A Multicenter, Phase III, 
Randomized Trial of 
Transplantation of 
NiCord®, Umbilical Cord 
Blood-derived Ex Vivo 
Expanded Stem and 
Progenitor Cells, versus 
Unmanipulated Umbilical 
Cord Blood for Patients 
with Hematological 
Malignancies 
Ongoing 
Duke University Health System/ 
Dr. Mitchell Horwitz 
Hospital Universitario y 
Politécnico La Fe/ 
Dr. Guillermo Sanz 
Hospital Universitari Vall 
d'Hebrón/ 
Dr. David Valcárcel 
Cleveland Clinic/ Dr. Rabi Hanna 
University of Minnesota/ Dr. John 
Wagner 
Cardinal Bernardin Cancer Center, 
Loyola University/ 
Dr. Patrick Stiff 
 Universitair Medisch Centrum 
Utrecht/ Dr. Jaap Jan Boelens 
Dana Farber Cancer Institute/ Dr. 
Corey Cutler 
University of Kansas Cancer 
Center/ Dr. Joseph McGuirk 
a http://clinicaltrials.gov/ct2/show/NCT01221857?term=nicord&rank=1. 
b https://clinicaltrials.gov/ct2/show/NCT01816230?term=nicord&rank=4 
c https://clinicaltrials.gov/ct2/show/NCT02039557?term=Gamida+Cell+ltd&rank=6 
d https://clinicaltrials.gov/ct2/show/NCT02730299?term=Gamida+Cell+ltd&rank=5 
The subsequent sections describe the clinical studies mentioned above.  
3.7.1.1. 
Study GC P#01.01.020 
A pilot clinical study of NiCord® in hematological malignancies in combination with a second, 
unmanipulated CBU was completed (GC P#01.01.020). This is a single arm pilot study to 
evaluate the safety of the co-transplantation of NiCord® and an unmanipulated CBU to patients 
with hematological malignancies following myeloablative therapy.  
 
Patients under the age of 65 years with hematological malignancies and no available matched 
sibling or matched unrelated adult donor were eligible at Duke University School of Medicine or 
Loyola University Medical Center between December 2010 and August 2012. Eligibility 
required the availability of 1 cord blood unit containing at least 2.5x107 total nucleated cells per 
kilogram of the recipient’s body weight. This unit was designated as the unmanipulated unit. The 
second unit, designated for NiCord® expansion, contained at least 1.5x107 total nucleated cells 
per kilogram of the recipient’s body weight. When 2 units with at least 2.5x107 total nucleated 
cells per kilogram of the recipient’s body weight were available, the best-matched unit was 
assigned as the unmanipulated unit. The cord blood units were required to match the recipient at 


 
 
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4 or more HLA loci by intermediate-resolution typing for HLA class I alleles (A and B) and 
high-resolution typing for HLA class II DRB1 alleles. 
 
The bone marrow conditioning regimen consisted of 1,350-cGy TBI delivered in 9 fractions on 
days –9 to –5, and fludarabine 40 mg/m2 was given on days –5 to –2 of the transplantation. An 
optional infusion of 60 mg/kg cyclophosphamide on days –4 and –3 was given at the discretion 
of the managing physician. GvHD prophylaxis was provided by Tacrolimus and Mycophenolate 
Mofetil starting 4 days before transplantation. Mycophenolate Mofetil and Tacrolimus were 
continued for a minimum of 60 days and 6 months following transplantation, respectively. 
Main results are described below and in the Clinical Study Report. 
 
Efficacy: Twelve patients were enrolled and transplanted. Eleven of the twelve transplanted 
patients achieved neutrophil engraftment with full donor chimerism (<10% host chimerism). 
Eleven of the twelve transplanted patients were evaluable (one patient received an 
unmanipulated CBU transplant instead of NiCord®). The median days to neutrophil engraftment 
in NiCord® recipients achieving engraftment was 12.5 days, ranging from 7 days to 26 days. All 
but one of the patients who engrafted did so prior to day 20 post-transplant. The median days to 
neutrophil engraftment in NiCord® recipients achieving engraftment with NiCord® as the 
predominating donor source was 10.5 days, ranging from 7 days to 18 days. In comparison, 
historical reports of unmanipulated CB transplants estimate the median days to engraftment at 
23-27 days with a range of 13-80 days.110,111,112. In a historical control group of 17 patients who 
received unmanipulated DCBT with the same conditioning regimen at the same transplant 
center, median time to engraftment was 25 days (range 13-38).113  
 
All engrafted patients maintained full donor chimerism throughout follow-up. Seven patients 
maintained predominance (>90%) of NiCord® cells, three patients maintained predominance of 
unmanipulated CBU cells (including one who did not receive NiCord®), and one patient 
exhibited mixed chimerism throughout follow-up.  
 
Platelets engraftment was achieved in nine out of eleven patients who received NiCord®. One 
patient died before achieving platelet recovery and one patient experienced primary engraftment 
failure. The median time to platelet engraftment to 20,000/mm3 was 33 days (range 26-49 days) 
for all patients transplanted with NiCord® and 30 days (range 26-41) for the 7 patients who 
demonstrated engraftment with NiCord®. The median days for platelet recovery to 50,000/mm3 
in patients achieving engraftment were 36 days. 
 
Immune reconstitution of engrafted patients was robust. Immune reconstitution analysis of the 
patients last performed at days 100, 180 and 365 post-transplantation also demonstrated the 
recovery of all blood cell lineages including CD3, CD4 and CD8 (T cells), CD19 (B cells) and 
CD56 (NK cells). Immune reconstitution was similar for patients engrafting with the NiCord® 
unit compared to those engrafting with the unmanipulated CBU.  
Safety: There was no grade 4 infusion toxicity. Three patients had a grade 3 toxicity (two with 
hypertension and one with hematuria), two patients had grade 2 toxicity, five patients had grade 
1 toxicity, and two patients had no toxicity within 24-hours post infusion.  


 
 
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One patient died from causes other than relapse within the first 100 days post-transplant. No 
NiCord® recipient developed grade III or IV GvHD. Five of eleven NiCord® recipients 
developed grade II GvHD. A total of 14 Serious Adverse Events (SAEs) were reported in eight 
of the eleven NiCord® recipients. One of the 14 SAEs (grade 3 hypertension immediately 
following infusion) was determined to be related to NiCord®. 1-year overall and progression-free 
survival rates were 82% and 73%, respectively.  
 
Conclusions: Infusion of NiCord® was well tolerated and provided rapid short-term engraftment 
as well as stable, long-term multi-lineage hematopoiesis. The results of this study warranted 
further studies of NiCord® as a solitary graft source.  
3.7.1.2. 
Study GC P#03.01.020 
A clinical study of NiCord® in hematological malignancies as a standalone graft source is 
ongoing (GC P#03.01.020). This is a single arm study to evaluate the ability of NiCord® to 
provide durable engraftment as a single graft source in patients with hematological malignancies 
following conditioning therapy.  
 
The dataset that served as the basis for the NiCord® Phase III hematological malignancies study 
design comprised patients aged 12-65 years old with hematological malignancies and no 
available matched sibling or matched unrelated adult donor that were eligible at multiple 
international centers between August 2013 and June 2015. Eligibility required the availability of 
a cord blood unit containing at least 8x106 total CD34+ cells as well as a pre-cryopreserved 
(post-processing) total nucleated cell count of ≥1.8x109, and total nucleated cell dose ≥1.5x107 
TNC/kg. The cord blood unit was required to match the recipient at 4 or more HLA loci by 
intermediate-resolution typing for HLA class I alleles (A and B) and high-resolution typing for 
HLA class II DRB1 alleles. 
 
Multiple conditioning regimens were used, including TBI/Flu/±Cy and Thiotepa/Bu/Flu.  GvHD 
prophylaxis was provided by Tacrolimus or Cyclosporine and mycophenolate Mofetil starting 
three days before transplantation. Mycophenolate Mofetil and Tacrolimus/Cyclosporine were 
continued for a minimum of 60 days and 5 months following transplantation, respectively. 
 
Main results are described below. 
 
Efficacy: Eighteen patients received NiCord® (16 NiCord®-only recipients and two patients who 
received both NiCord® and the backup CBU). All 16 NiCord®-only recipients achieved 
neutrophil engraftment by day 42 with full donor chimerism. 
 
The median days to neutrophil engraftment in NiCord® -only recipients was 10 days post 
transplant, ranging from 6 days to 26 days.  All but two of these patients engrafted prior to day 
18 post transplant.       
 
For NiCord®-only recipients, the cumulative incidence of platelet engraftment to 20k/mm3 and 
50k/mm3 at 100 days post transplant was 75% (95% CI: 43-91) and 64% (95% CI: 32-84) 
respectively .  Two patients died prior to day 100 without 20k/mm3 platelet engraftment, one 


 
 
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patient failed to engraft platelets at 20k/mm3 by day 100, two patients engrafted 20k/mm3 but not 
50k/mm3 by day 100, and one patient was pending engraftment at last follow-up of 88 days post 
transplant.  Among the engrafters, the median time to engraftment to 20k/mm3 and 50k/mm3 was 
32 days and 42 days respectively.  
 
The overall survival of NiCord®-only recipients at 180 and 365 days was 81% (95% CI: 51-93) 
and 59% (95% CI: 25-82) respectively.   
 
Immune reconstitution of CD4+, CD8+, CD19+, CD56+/16+ in NiCord®-only recipients was 
comparable to unmanipulated cord blood transplantation in historical controls. 
 
Safety: Only one patient experienced secondary graft failure in the year following NiCord® 
transplant.   
 
For NiCord® alone recipients, the cumulative incidence of non-relapse mortality at day 100 and 
day 180 post transplant was 12% (95%CI: 2-34) and 19% (95%CI: 4-42) respectively.  
 
The incidence of acute GvHD grade II-IV and III-IV at 100 days post NiCord® only transplant 
was 50% (95% CI: 23-72) and 12% (95% CI: 2-34) respectively.  Eight of the sixteen NiCord®-
only recipients experienced chronic GvHD in the year following NiCord® transplant.  One case 
of chronic GvHD was extensive while the other seven were limited. 
 
Among 18 patients receiving NiCord® (16 NiCord® only recipients and two patients who 
received both NiCord® and the backup CBU), no grade 4 infusion toxicity occurred.  One 
NiCord® recipient had a grade 3 toxicity (atrial fibrillation), eight patients had grade 2 toxicity, 
seven patients had grade 1 toxicity, and two patients had no toxicity within 24-hours post 
infusion.  Two infusion toxicities (grade 2 serious infusion related hypersensitivity and grade 2 
non-serious hypertension) were reported as related to NiCord®.   
 
Forty SAEs were reported in 15 of the 18 NiCord® recipients.  Six of the 40 SAEs reported were 
determined to be related to NiCord®.  These six related SAEs included five GvHD events and 
one grade 2 infusion-related hypersensitivity. 
 
Of the 16 NiCord®-only recipients, 14 experienced one or more post transplant grade 2 or 3 
infections.  Of the 30 reported post transplant grade 2 or 3 infections, a total of five grade 3 
infections were reported in three NiCord® only recipients; one patient with a Klebsiella infection 
at day 325 post transplant, one patient with an RSV infection at day 5 post transplant, and one 
patient with three infections (Klebsiella at day 111 post transplant, Aspergillus at day 119 post 
transplant and Cryptosporidium at day 126 post transplant). 
 
No new malignancies or autoimmune diseases were reported in any of the transplant recipients. 
 
Conclusions:  Infusion of NiCord® was well tolerated and provided rapid short term neutrophil 
engraftment as well as stable, long term multilineage hematopoiesis.  Initiation of a phase III trial 
evaluating the efficacy of NiCord® compared to unmanipulated cord blood is warranted. 


 
 
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3.7.1.3. 
Study GC P#04.01.020/030 
The study GC P#04.01.020/030 entitled: “Long Term Follow Up for Patients who have received 
Allogeneic Stem Cell Transplantation of NiCord®/CordIn™, Umbilical Cord Blood-derived Ex 
Vivo Expanded Stem and Progenitor Cells.” is an ongoing long-term observational study of 
patients who have received either a NiCord® or CordIn™ transplant.  The overall study objective 
is to describe the clinical outcomes of patients through 5 years post NiCord® or CordIn™ 
transplantation. 
3.7.1.4. 
Study GC P#05.01.020 
The study GC P#05.01.020 entitled: “A Multicenter, Phase III, Randomized Trial of 
Transplantation of NiCord®, Umbilical Cord Blood-derived Ex Vivo Expanded Stem and 
Progenitor Cells, versus Unmanipulated Umbilical Cord Blood for Patients with Hematological 
Malignancies” is an open-label study to compare the safety and efficacy of NiCord® single ex 
vivo expanded cord blood unit transplantation to unmanipulated cord blood unit transplantation 
in patients with hematological malignancies following conditioning therapy. 
3.7.2. 
CordIn™ Clinical Experience in Hemoglobinopathies 
Table 3: Overview of ongoing clinical studies of CordIn™ 
Protocol Number 
(ClinicalTrials.gov 
Number) 
Study Title 
Study 
Status 
Institution/Principal 
Investigator 
GC P#01.01.030 a 
(NCT02504619 b) 
Allogeneic Stem Cell 
Transplantation of 
CordIn™, Umbilical Cord 
Blood-Derived Ex Vivo 
Expanded Stem and 
Progenitor Cells, in Patients 
with Hemoglobinopathies  
Ongoing 
Robert Debré Hospital/ 
Dr. Jean-Hugues Dalle 
UCSF Benioff Children's 
Hospital/  
Dr. Mark Walters   
Children’s National Medical 
Center, Washington/ 
Dr. Allistair Abraham 
a IND Number: 16245 
b https://clinicaltrials.gov/ct2/show/NCT02504619?term=GC+P%2301.01.030&rank=1 
3.7.2.1. 
Study GC P#01.01.030 
The study GC P#01.01.030 entitled: “Allogeneic Stem Cell Transplantation of CordIn™, 
Umbilical Cord Blood-Derived Ex Vivo Expanded Stem and Progenitor Cells, in Patients with 
Hemoglobinopathies” is an open-label study to evaluate the safety and efficacy of CordIn™ in 
patients with Hemoglobinopathies following conditioning therapy with Busulfan, Thiotepa, and 
Fludarabine.  As of 09Oct2017, one patient has been transplanted on this protocol. 
3.8. 
Rationale for Study Design & Dosages 
For HSCT to become a realistic therapeutic option available to a majority of patients with severe 
SCD and thalassemia, effective and safe use of alternative donors such as umbilical cord blood 


 
 
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needs to be established. Given that previous attempts with UCB grafts result in too high a level 
of graft failure, this study proposes an innovative strategy for unrelated allogeneic 
transplantation of SCD patients and thalassemia patients using an ex-vivo expanded UCB graft 
utilizing a novel technology (NiCord®), with or without a second unmanipulated CBU, following 
preparative conditioning. This approach aims to address the need for improved donor access, as 
well as the CD34 cell dose limitation. We will gain information about engraftment and safety of 
unrelated UCB transplantation with NiCord® grafts, as well as additional aspects, including 
immune reconstitution and GvHD. 
3.8.1. 
Study Population 
This study will include patients who are candidates for myeloablative HSCT for treatment of 
SCD or thalassemia. As described above allogeneic HSCT with sibling donor cell engraftment 
can ameliorate SCD or thalassemia symptoms, improve quality of life, and stabilize vasculopathy 
with acceptable rates of early and late toxicities. Unfortunately, for a very large number of 
patients such a match is not available. CBUs are widely available but their limited cell dose is 
associated with limited stem/progenitor cell subpopulations and is a key hurdle precluding broader 
use of this stem cell source in this population. Therefore, the study population of SCD or thalassemia 
using expanded cord blood will be included in this study.  For ethical reasons, the study will only 
enroll patients who do not have an adequate suitably matched and readily available stem cell 
donor. 
3.8.2. 
CBU Cell Dose 
Part 1 only: as a safety precaution, the unmanipulated UCB unit is required to contain at least 
3.5x107 TNC/kg body weight.  
 
Part 1 and Part 2: 
The manipulated UCB unit is required to contain ≥1.8x109 TNC and ≥1.8x107 TNC/kg body 
weight for patients weighing ≥25kg, and TNC ≥1.6x109 for patients weighing <25kg. 
 
The manipulated CBU should contain a pre-cryopreserved (post processing), total CD34+ cell 
count of ≥ 8x106 for patients weighing ≥ 25 kg and a pre-cryopreserved (post processing), total 
CD34+ cell count of ≥7x106 for patients weighing < 25 kg.  
3.8.3. 
Selection of CBUs 
Decisions on the selection of CBUs are never arbitrary, but rather are based on specific 
histocompatibility data, cell dose, availability, and in some cases the source of the CBU. 
However, there is no clear consensus or evidence-based algorithm as to the hierarchy of these 
factors. Thus, some physicians believe cell dose is of greatest importance, some examine CD34+ 
dose, and others prioritize HLA matching. For this reason, the protocol does not specify 
prioritization rules when more than one eligible CBU is identified.  
 


 
 
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4. 
STUDY OBJECTIVES, HYPOTHESIS & STUDY ENDPOINTS 
4.1. 
Objectives   
Primary Objectives 
• Assessment of the acute toxicity associated with the infusion of NiCord®, within 24 hours 
post-infusion 
• Part 1: Assessment of cumulative incidence of donor-derived neutrophil engraftment by day 
42 following co-transplantation of NiCord® and unmanipulated cord blood grafts 
• Part 2: Assessment of cumulative incidence of donor-derived neutrophil engraftment by day 
42 following transplantation of NiCord®  
Secondary Objectives 
• Proportion of transplant-related mortality at 100 days 
• Event-free survival at 100 days (death, autologous recovery, primary or secondary graft 
failure will be considered events for this endpoint) 
• Overall survival at 180 days 
Exploratory Objectives  
• Incidence of donor cell chimerism (>10%) from either donor at 100 and 180 days 
• Percentage donor chimerism in whole blood, CD3+ and myeloid (CD15+ or CD33+) 
fractions at 7, 14, 21, 28, 42, 70, 100 and 180 days 
• Time from infusion to neutrophil (>500/uL) and platelet (>50k/uL) engraftment 
• Platelet engraftment (>50k/uL) at 180 days 
• Incidence of acute GvHD grade II-IV and III-IV at 100 days 
• Incidence of chronic GvHD (limited or extensive) at 180 days 
• Incidence of regimen-related toxicity  
• Incidence of life-threatening and fatal infections at 180 days 
• Immune reconstitution at 100 days and 180 days 
Post-study Analysis 
• Event-free survival at 1 year (death, autologous recovery, primary or secondary graft failure 
will be considered events for this endpoint) 
• Overall survival at 1 year 
• Percentage donor chimerism in whole blood, CD3+ and myeloid (CD15+ or CD33+) 
fractions at 1 year 
• Incidence of chronic GvHD (limited or extensive) at 1 year 
• Incidence of life-threatening and fatal infections at 1 year 


 
 
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• Immune reconstitution at 1 year 
4.2. 
Hypothesis 
Part 1: Co-transplantation of NiCord® and an unmanipulated unrelated cord blood graft in 
patients with hemoglobinopathies (SCD or thalassemia major) following a preparative therapy 
will be safe and will enable cord blood engraftment.  
 
Part 2: Transplantation of NiCord® in patients with hemoglobinopathies (SCD or thalassemia 
major) following myeloablative preparative therapy will be safe and will enable cord blood 
engraftment. 
4.3. 
Definition of Study Endpoints  
4.3.1. 
Acute Toxicity 
Acute toxicity will be assessed and graded as per site practice, guidelines and forms and in line 
with CTCAE v.4.03 as specified in Appendix D.  
4.3.2. 
Neutrophil Engraftment 
Neutrophil engraftment is defined as achieving an Absolute Neutrophil Count (ANC) of ≥500 
mm3 for 3 consecutive measurements on different days by day 42 inclusive (the day of 
engraftment will be defined as the first of these 3 days). The ANC recovery must be of donor 
origin documented by peripheral blood chimerism assays indicating a. Mixed chimerism - >10% 
host cells and <90% host cells or b. Donor chimerism – <10% host cells. 
  
Primary graft failure is defined as failure to achieve neutrophil engraftment by day 42 as 
described above. Death prior to day 14 will be considered insufficient follow-up to determine 
graft failure.  Infusion of a second stem cell product on or prior to Day 42 will be considered 
primary graft failure. Infusion of an additional stem cell product after documented neutrophil 
engraftment will be considered secondary graft failure, even if it occurs on or prior to Day 42.  
 
Secondary graft failure consists of documented engraftment as defined above, followed by 
neutropenia (< 500/µL for three or more consecutive laboratory values on separate days), without 
subsequent improvement occurring either spontaneously or after growth factor treatment.  
Infusion of a second stem cell product after documented neutrophil engraftment will be 
considered secondary graft failure. 
4.3.3. 
Platelet Engraftment  
Platelet engraftment is defined as the first day of a minimum of 3 consecutive measurements on 
different days such that the patient has achieved a platelet count >50x109/L with no platelet 
transfusions in the preceding 7 days (count day of engraftment as one of the preceding 7 days). 
The first day of the three measurements will be designated the day of platelet engraftment.  
4.3.4. 
Autologous Recovery 
Autologous recovery is defined in patients recovering from an aplastic phase as achieving ANC 
≥500 mm3 for 3 consecutive measurements on different days with >90% host chimerism in the 
peripheral blood or >70% Hb S level on Hemoglobin electrophoresis.   


 
 
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Autologous recovery is defined in patients who have previously recovered as presenting with 
ANC ≥500 mm3, and RBC and platelet transfusion independence in the past month with ≥90% 
host chimerism in the peripheral blood or >70% Hb S level on Hemoglobin electrophoresis. 
4.3.5. 
Transplant Related Mortality 
Transplant related mortality is defined as any death not preceded by autologous recovery.   
4.3.6. 
Acute and Chronic GvHD  
Incidence of acute GvHD grade II-IV and III-IV will be assessed based on the Consensus 
Conference on Acute GvHD grading (Appendix A) on day 100.   Chronic GvHD will be 
assessed on day 180 and will be classified as limited or extensive according to Appendix A. 
4.3.7. 
Immune Reconstitution 
The humoral system will be assessed based on levels of immunoglobulins (IgG, IgA, IgM). 
Cellular immune recovery will be assessed based on lymphocyte subset analysis to quantify the 
numbers and proportions of different lymphocyte subpopulations (CD3, CD4, CD8, CD19, 
CD16/56), as well as additional immunophenotyping as per site practice.  T-Cell Receptor 
Excision Circles (TREC) analysis will be performed. 
4.3.8. 
Chimerism of the Two CBU Grafts 
Percent engraftment of both NiCord® and the unmanipulated CBUs will be assessed by 
peripheral blood Chimerism test using RFLP or microsatellite with separate assessment of the 
lymphoid and myeloid fractions post neutrophil engraftment and optionally an assessment of 
erythroid chimerism at 180 days post-transplant in patients with mixed chimerism.  
4.3.9. 
Life-threatening/Fatal Infection 
Any infection that involves: 
• 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 
• Fungemia including Candidemia 
• Proven or probable invasive fungal infections (e.g., Aspergillus, Mucor, Fusarium, 
Scedosporium, resistant candida species) 


 
 
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• 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) 
• Severe VZV infection (coagulopathy or organ involvement) 
• CMV end-organ involvement (pneumonitis, enteritis, retinitis) 
• EBV PTLD 
• Adenovirus with end-organ involvement (except enteritis, conjunctivitis and upper 
respiratory tract) 
• Lower tract respiratory viruses 
• Any viral encephalitis or meningitis 
• CNS or other organ toxoplasmosis 
• Strongyloides hyperinfection 
• Severe sepsis without an identified organism 
4.3.10. 
Regimen Related Toxicities 
Post transplant grade 3-5 toxicities assessed using CTCAE v4.03 as specified in Appendix D. 
 


 
 
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5. 
STUDY POPULATION 
5.1. 
Number of Patients  
The sample size is up to 20 evaluable patients (up to 15 evaluable patients who enrolled and 
received NiCord® and an unmanipulated CBU plus up to 5 evaluable patients who enrolled and 
received NiCord® only).   In addition, patients must have met all of the following criteria: 
• 
Did not receive any stem cells up to day 28 except for the NiCord® and, if in Part 1, 
the unmanipulated CBU (e.g., second unmanipulated CBU) 
• 
Did not die prior to day 14 
• 
Received conditioning therapy as specified in the protocol 
• 
Did not seriously contravene the eligibility criteria specified in section 5.2 below 
• 
Did not receive a NiCord® transplant that was outside the final process quality control 
(FPQC) limits specified in section 8.3 
Enrolled patients who have received a transplant of CB cells but did not meet all of the above 
criteria will enter the main statistical analysis (ITT) but will be considered non-evaluable for the 
per protocol analysis. For completing the per protocol analysis such patients can be replaced.  
 
Any patient may be removed from the study at any time if in the judgment of the Investigator 
further treatment is not in the best interests of the patient. Patients may also withdraw themselves 
from the study at any time and for any reason. 
 
Patients will be defined as screening failures if they are withdrawn from the study before 
receiving NiCord®.  All screening failures will be replaced.  
 
Patients will be defined as early termination/discontinuation, if dropout occurs after 
transplantation of NiCord®.  
 
For early termination/discontinuation patients, termination visit should be completed. In case 
such patients did not withdraw consent, study investigator will make all efforts to gather 
information on the clinical outcomes as assessed during the usual clinical management of their 
disease over the first 180 days following transplantation and to capture this information in the 
CRF.  
5.2. 
Eligibility Criteria  
 
Inclusion Criteria 
1. Patients must be 2 – 45 years of age and at least 10 kg. 
2. Patient is a candidate for allogeneic SCT for treatment of SCD or thalassemia:  
a. Patient must have clinically severe SCD (e.g., SS, SC or SBeta0 Thal) with at least one 
of the following clinical complications: 


 
 
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• Recurrent painful events (at least 3 in the 2 years prior to enrollment) that cannot be 
explained by other causes. Pain may occur in typical sites associated with vaso-
occlusive painful events and cannot be explained by causes other than SCD. Pain lasts 
at least 4 hours and requires parenteral narcotic treatment, equianalgesic dose of oral 
narcotics or parenteral nonsteroidal anti- inflammatory drugs. These painful events 
may be treated in any setting, but events managed at home will be considered only if 
there is documentation of the event in a clinical record that may be reviewed by an 
investigator.  These events must occur despite adequate supportive care measures 
(e.g., hydroxyurea therapy) 
• Acute chest syndrome (ACS) with at least two episodes with the development of a 
new infiltrate on chest radiograph and/or having a perfusion defect demonstrable on a 
lung radioisotope scan within the past two years that required hospitalization, oxygen 
therapy, and red blood cell (RBC) transfusion.  These episodes must occur despite 
adequate supportive care measures, (e.g., hydroxyurea therapy).  At least one episode 
of acute chest syndrome per year while on hydroxyurea therapy unless patient is 
unable to take hydroxyurea due to toxicity 
• Any combination of painful events and ACS episodes that total three or more events 
within the two years before transplantation 
• SCD related and clinically significant neurologic event (stroke or hemorrhage) or 
SCD related neurologic defect lasting more than 24 hours 
• Abnormal cerebral magnetic resonance imaging (MRI) and/or abnormal cerebral 
magnetic resonance angiography (MRA) 
• Abnormal Transcranial Doppler (TCD), as defined by a TCD velocity that exceeds 
200 cm/sec by the non-imaging technique (or TCD measurement of >185 cm/sec by 
the imaging technique) measured at a minimum of two separate occasions one month 
or more apart 
• Patients on chronic PRBC transfusion therapy, defined as receiving 8 or more 
transfusions per year for > 1 year to prevent vaso-occlusive clinical complications 
(e.g., pain, stroke, and acute chest syndrome), with a history of alloimmunization 
which compromises the delivery of adequate transfusion therapy 
OR; 
b. Patients with thalassemia major requiring ≥8 (or >100 ml/kg) RBC transfusions per year 
in the two years preceding enrollment. 
3. Part1: Patients must have two partially HLA-matched CBUs. Units must be HLA-
matched at 4-6/6 HLA class I (HLA-A & HLA-B, low resolution) and II (HLA-DRB1, 
high resolution) loci with the subject and 3-6/6 HLA-A, B, DRB1 loci with each other 
(using same resolution of typing). Double mismatch at any one locus (A, B, or DRB1) is 
not permitted 
Part 2: Patients must have one partially HLA-matched CBU. Unit must be HLA-matched 
at 4-6/6 HLA class I (HLA-A & HLA-B, low resolution) and II (HLA-DRB1, high 


 
 
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resolution) loci with the subject. Double mismatch at any one locus (A, B, or DRB1) is 
not permitted 
a. For patients weighing ≥ 25 kg, the manipulated CBU must have a pre-
cryopreserved (post processing) total nucleated cell dose of ≥1.8x109 and 
≥1.8x107cells per kg body weight.  
For patients weighing < 25 kg, the manipulated CBU must have a pre-
cryopreserved (post processing) total nucleated cell dose of ≥1.6x109.  
Part 1: The unmanipulated CBU should contain a pre-cryopreserved (post 
processing), nucleated cell dose of at least 3.5x107/kg.  The better matched unit 
will be the unmanipulated unit (as per investigator’s discretion).  
b. The manipulated CBU should contain a pre-cryopreserved (post processing), total 
CD34+ cell count of ≥ 8x106 for patients weighing ≥ 25 kg and a pre-
cryopreserved (post processing), total CD34+ cell count of ≥7x106 for patients 
weighing < 25 kg.   
c. The manipulated CBU will have undergone volume reduction (both plasma and 
red blood cell depletion) prior to cryopreservation. 
d. The CBU should be procured from public banks that meet local applicable 
regulations 
e. The selected unit should be typed twice (i.e., initial typing and verification 
typing). Verification typing (confirmatory typing) should be in a laboratory that is 
ASHI/EFI accredited and must come from an attached segment  
4. Patients’ Performance score ≥70% by Lansky or Karnofsky performance status scale. 
5. Patient has sufficient physiologic reserves including: 
• Cardiac: Left ventricular ejection fraction (LVEF) > 50% by echocardiogram 
radionuclide scan or cardiac MRI; or LV shortening fraction > 26% 
• Pulmonary: Pulse oximetry with a baseline O2 saturation of ≥ 85% is required for all 
patients; DLCO > 60% of predicted for age (corrected for hemoglobin) for patients in 
whom pulmonary function testing can be performed. cDLCO value should be from 
testing performed before the administration of a bronchodilator if applicable.  FVC 
and FEV1 > 60% of predicted for age. 
• Renal: Serum creatinine ≤ 1.5 x upper limit of normal for age and GFR > 100 
mL/min/1.73 m2.  For patients ≥16 years of age, GFR should be >70 mL/min/1.73 m2.  
Note, estimated GRF value not acceptable; nuclear GFR testing must be performed. 
• Hepatic: Serum conjugated (direct) bilirubin < 2 x upper limit of normal for age as 
per local laboratory in the absence of gall bladder disease or prior cholecystectomy; 
Hepatic transaminases (ALT and AST) < 5 x upper limit of normal range 


 
 
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6. In SCD patients, HbS should be ≤ 45% within 7 days prior to initiation of the 
conditioning regimen.  If the HbS level is >45% then the patient must receive RBC 
transfusions or erythrocyte exchange prior to conditioning regimen initiation. 
7. Patient must have at least one graft source as a backup in case of graft failure:  
a. Autologous stem cells harvested from bone marrow; OR 
b. A related, haplo-identical family member who is suitable for bone marrow or 
peripheral blood stem cell donation and has agreed to do so in the event of graft 
failure; OR 
c. An additional HLA-matched CBU, or two CBUs, reserved as a backup 
8. Females of childbearing potential, defined as any female who has experienced menarche 
and is not postmenopausal or permanently sterilized (e.g., tubal occlusion, hysterectomy, 
bilateral salpingectomy), agree to use an appropriate method of contraception from at 
least 7 days prior to Hydroxyurea administration until completion of follow-up 
procedures.  An appropriate method of contraception is defined as one that results in a 
low failure rate (i.e., less than 1 percent per year) when used consistently and correctly, 
such as implants, injectables, combined oral contraceptives, some intrauterine 
contraceptive devices (IUDs), sexual abstinence, or a vasectomized partner. 
9. Patient and/or legal guardian signs the written informed consent after being made aware 
of the nature of the patient’s disease and willingly consents to the treatment program after 
being informed of alternative treatments, potential risks, benefits, and discomforts. 
Exclusion Criteria 
1. Evidence of uncontrolled bacterial, viral or fungal infections or severe concomitant 
diseases, which in the judgment of the Principal Investigator, indicate that the patient 
could not tolerate transplantation. 
2. Evidence of HIV infection or HIV positive serology. 
3. Evidence of active Hepatitis B, Hepatitis C or EBV as determined by serology or PCR. 
4. Pregnancy as indicated by a positive serum human chorionic gonadotrophin (HCG) test, 
or lactation. 
5. Patients with 8/8 HLA-matched related family donor or unrelated donor able to donate. 
6. Severe alloimmunization with inability to guarantee a supply of adequate PRBC donors. 
7. Evidence of donor specific anti-HLA antibodies to the selected NiCord® CBU 
(MFI>2000 to HLA A, B, C, or DRB1). 
8. Prior myeloablative allogeneic hematopoietic stem cell transplant within last 12 months 
or reduced intensity transplant within the past 6 months. 
9. Allergy to bovine products, Gentamicin, or to any product which may interfere with the 
treatment. 


 
 
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10. Psychologically incapable of undergoing bone marrow transplant (BMT) with associated 
strict isolation or documented history of medical non-compliance and/or psychiatric 
illness and/or social situations that would limit compliance with study requirements. 
11. Enrolled in another clinical trial or received an investigational treatment within 30 days 
prior to CBU shipment to the production facility, unless documented approval obtained 
from Sponsor. 
5.3. 
Reproductive Restrictions 
The long term effect of stem cell product on fetal development has not been studied. 
Consequently, precautions must be taken to avoid any pregnancy that could potentially occur 
during drug exposure to EITHER male OR female patients. 
 
Female patients should be either post-menopausal (amenorrhea for at least 12 consecutive 
months), surgically sterile or, if a woman of child-bearing potential (WOCP), have a negative 
urine beta human chorionic gonadotropin (HCG) pregnancy test prior to entering the study and 
agree to use acceptable methods of contraception during the study.  An acceptable method of 
contraception is defined as one that results in a failure rate less than 1 percent per year when used 
consistently and correctly, such as implants, injectables, combined oral contraceptives, some 
intrauterine contraceptive devices (IUDs), sexual abstinence, or a vasectomized partner. 
 
WOCP must be advised to use acceptable contraceptives throughout the study period. If 
hormonal contraceptives are used, they should be taken according to the package insert. WOCP 
who are not currently sexually active must agree to use acceptable contraception, as defined 
above, if they decide to become sexually active during the period of the study and for 4 weeks 
after the last dose of stem cell therapy. 
5.4. 
Patient Withdrawals 
5.4.1. 
Withdrawal of Patients from the Study 
Any patient may be removed from the study at any time if in the judgment of the Investigator 
further treatment is not in the best interests of the patient. The primary reason for withdrawal 
must be recorded in the patient’s medical record and in the CRF.  If a patient is withdrawn for 
more than one reason, each reason should be documented in the source document and the most 
medically significant reason should be entered on the CRF. 
 
Patients may also withdraw themselves from the study at any time and for any reason, without 
prejudice to their future medical care by the physician or at the institution. 
 
Patients will be defined as screening failures if they are withdrawn from the study before 
receiving NiCord®, or as early termination/discontinuation, if dropout occurs after 
transplantation of NiCord®. Screening failures can be replaced.   
5.4.2. 
Criteria for Withdrawal 
Patients who are prematurely discontinued from the study should be followed and treated by the 
Investigator according to institutional guidelines. Patients who join the study will be asked for 


 
 
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permission that their clinical investigator be allowed to transmit information to the trial center on 
the clinical outcomes as assessed during the usual clinical management of their disease over the 
first 6 months following treatment. This will allow us to continue to gather clinical information 
on patients who subsequently withdraw from active participation and did not withdraw informed 
consent, and to include them in the analyses of all clinical endpoints.  
 
A patient may withdraw or be withdrawn from the study for the following reasons: 
• Patient or legal guardian withdrew consent 
• Sponsor requested patient to be withdrawn 
• Pregnancy 
• Request of primary care physician or Investigator, based on the patient’s best interests 
• Occurrence of an AE or SAE, which, in the judgment of the investigator, justifies 
withdrawal due to its nature, severity or requirement for treatment, regardless of the 
causal relationship to the IMP 
• Non-compliance (per investigator judgment) 
• Lost to follow-up 
At least three documented attempts must be made to contact any patient lost to follow-up (e.g., 
calling the patient at last known phone number, sending a certified letter to the patient’s last 
known address). 
5.4.3. 
Early Discontinuation of Follow-up  
For early termination patients that withdraw/are withdrawn from the study post transplant, any 
assessments due at the time of withdraw (according to Table 4) are requested. 


 
 
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6. 
CONCOMITANT MEDICATIONS & SUPPORTIVE CARE 
6.1. 
Previous Medications 
All medications taken by/given to the patient, as a treatment for the primary and concomitant 
diseases within 30 days prior to screening, will be recorded in the patient files. 
6.2. 
Disallowed Concomitant Medications  
The following medications should not be given post transplant: 
• Methotrexate (unless approved in advance by Sponsor)  
• Any cytokines except G-CSF or GM-CSF should not be used (including IL-2 or others, 
unless approved by Sponsor); bio-identical substitutions are allowed.  
• The use of Bactrim is discouraged on or after day -2 and prior to engraftment as it may 
delay engraftment, and is reserved only in cases where it is assessed to be essential and 
superior to all alternative medications 
• Investigational agents, unless previously approved by the sponsor 
6.3. 
Preparative & Conditioning Regimen 
All patients will receive one of two conditioning regimens, depending on the patient’s age, as 
shown in the tables below. GvHD prophylaxis will consist of cyclosporine and mycophenolate in 
both regimens.  
 
Patients <21 years old 
Days 
Agent 
Dose 
-35 to -15 
Hydroxyurea1 
30mg/kg/day orally 
-14 to -10 
Fludarabine 
35 mg/m2 IV daily x 5 days 
-9 to -6 
Busulfan 
1mg/kg/dose IV q 6h x 16 doses 
-5 to -2  
Cyclophosphamide2 50mg/kg/day x 4 doses  
1 Hydroxyurea may be extended if transplant is delayed.  If patient is already on HU, the dose will be maintained at 
the prescribed level if it is at least 30mg./kg/day. 
2 If treatment with Cyclophosphamide is contraindicated, substitute Melphalan 45 mg/m2/day IV x 3 days (-4 to -2) 
 
Patients >21 years old 
Days 
Agent 
Dose 
-35 to -13 
Hydroxyurea1 
30mg/kg/day orally 
-12 to -8 
Fludarabine 
35 mg/m2 IV daily x 5 days 
-7 to -4 
Busulfan 
0.8 mg/kg/dose IV q 6h x 16 doses 
-3 and -2  
Cyclophosphamide 
60mg/kg/day x 2 doses  
1 Hydroxyurea may be extended if transplant is delayed.  If patient is already on HU, the dose will be maintained at 
the prescribed level if it is at least 30mg./kg/day. 
6.3.1. 
Hydroxyurea Administration 
Start at 30mg/kg/day, once daily as a liquid or capsule. Monitor CBC, ANC and LFTs weekly. 
Hold hydroxyurea for Platelets < 50,000/uL, ANC < 1000, or if AST/ALT > 4x Upper limit of 


 
 
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normal. Resume at 20% lower dose when laboratory values improve. Start no later than day -35 
and continue until one day prior to the start of conditioning.  The administration period may be 
extended if transplant is delayed. If the patient is already on a lower dose of hydroxyurea, adjust 
the dose to 30 mg/kg/day and continue.  If the patient is already on a higher dose hydroxyurea, 
no adjustment is necessary.   
 
Refer to Appendix E, ‘Drug Labels’, for risks and toxicities of Hydroxyurea administration 
6.3.2. 
Fludarabine Administration 
Fludarabine 35 mg/m2/day will be administered as a 15-30 minute IV infusion. Fludarabine will 
be dosed as per adjusted ideal body weight (see below for cyclophosphamide).   
Refer to Appendix E, ‘Drug Labels’, for risks and toxicities of Fludarabine administration. 
6.3.3. 
Busulfan Administration 
For patients <21 years old, administer 1 mg/kg/dose intravenously as a 2-hour infusion every 6 
hours for 16 doses.  For patients >21 years old, administer 0.8 mg/kg/dose intravenously as a 2-
hour infusion every 6 hours for 16 doses. Dilute in normal saline to a concentration of 0.5mg/ml.  
Busulfan pharmacokinetic sampling will be obtained after the 1st dose. Dose modification will 
target a steady state concentration (Css) of 600-900 ng/ml. 
 
Refer to Appendix E, ‘Drug Labels’, for risks and toxicities of Busulfan administration. 
6.3.4. 
Cyclophosphamide (CY) Administration 
Dose will be calculated using adjusted ideal body weight*, if actual body weight is more than 
125% of ideal body weight. For patients <21 years old, the dose is 50mg/kg/day for 4 days 
(60mg/kg/day for 2 days for patients >21 years old) diluted in normal saline and administered  
intravenously as a 60 minute infusion.  Provide adequate hydration 3000 ml/m2/day of 
appropriate maintenance IV solution during CY administration.  Mesna 50 mg/kg/day is given 
IV as a continuous infusion beginning 30 min prior to CY and continuing until 24 hours after the 
last administered CY dose. 
 
Refer to Appendix E, ‘Drug Labels’, for risks and toxicities of CY administration. 
 
* Ideal Body Weight Formulas: 
For patients 1 to 18 years of age: (ht = cm, IBW = kg) 
Less than 60 inches (152.4 cm): IBW = (ht2 x 1.65)/1000 
More than 60 inches (152.4 cm): Males IBW = 39.0 + [2.27 x (ht - 60)] 
Females IBW = 42.2 + [2.27 x (ht - 60)] 
 
For patients over 18 years old: 
Males IBW = 50 kg+2.3 kg/inch over 5 feet (or 50 kg + 0.91kg/cm over 152.4cm)  
Females IBW = 45.5 kg+2.3 kg/inch over 5 feet (or 45.5 kg + 0.91kg/cm over 152.4cm)  
 


 
 
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Adjusted Ideal Body Weight Formula for all patients:  
AIBW = IBW + [(0.25) x (ABW - IBW)] 
 
6.3.5. 
Melphalan 
If treatment with cyclophosphamide is contraindicated in patients <21 years old, substitute 
melphalan 45 mg/m2/day IV as a 15-20 minute infusion x 3 days (-4 to -2).  Melphalan must be 
infused within 60 minutes of preparation. 
 
Refer to Appendix E, ‘Drug Labels’, for risks and toxicities of Melphalan administration. 
6.3.6. 
Methylprednisolone 
If methylprednisolone is substituted for ATG, administer IV as a 1 hour infusion. 
 
Refer to Appendix E, ‘Drug Labels’, for risks and toxicities of Methylprednisolone 
administration. 
6.4. 
GvHD Prophylaxis Medications 
All patients will receive GvHD prophylaxis with two drugs as follows:  
 
Cyclosporine A (CSA) 
CSA will be administered beginning on Day –3. If administering via continuous IV infusion, it is 
recommended to target cyclosporine trough levels of 200-400 ng/mL by TDX method (or 100-
250 ng/mL by Tandem MS or equivalent level for other CSA testing methods).  For intermittent 
dosing, it is recommended to target cyclosporine trough levels of 150-300 ng/mL by TDX 
method (or equivalent level for other CSA testing methods).   
 
Dose adjustments will be made on the basis of toxicity and high or low CSA levels.  Once the 
patient can tolerate oral medications and has a normal gastro-intestinal transit time, CSA can be 
converted to an oral form at 2-3x the current IV dose. CSA dosing will be monitored and altered 
as clinically appropriate.   
 
In the absence of actual toxicity, patients will receive CSA until Day +180 or graft failure.  
Following day +180 patients will receive CSA according to institutional protocols. 
 
In the event of toxicity or GvHD, centers may switch to Tacrolimus. Dosing should be adjusted 
to maintain a tacrolimus trough blood level of 5-15 ng/mL. In the event of toxicity to 
Tacrolimus, treat per institutional practice. 
 
Refer to Appendix E, ‘Drug Labels’, for risks and toxicities of CSA administration. 
 
Mycophenolate Mofetil (MMF)  
MMF will be given at a dose of 15 mg/kg/dose IV q 8 hours beginning the morning of Day –3.  
(If renal failure and GFR < 25 mL/min do not exceed dose of 1 gm q 8 hours.  No dose 
adjustment is required for liver disease.)  MMF should be given IV until patient can tolerate oral 
medications and has a normal gastro-intestinal transit time.  Capsules/tablets or suspension may 


 
 
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be used to achieve calculated doses, and the site is allowed to round the dose up or down to 
accommodate the nearest capsule/tablet size per standard of care at the site.  MMF will be dosed 
based on the patient’s actual body weight. 
 
MMF should be continued for 45 days or 7 days after engraftment, whichever day is later, if 
acute GvHD or graft failure has not occurred.  If GvHD occurs before Day 45, treat according to 
institutional protocols. 
 
In the event of toxicity to MMF, dosing may be adjusted or discontinued per institutional 
practice. 
 
Refer to Appendix E, ‘Drug Labels’, for risks and toxicities of MMF administration. 
6.5. 
Acute & Chronic GvHD Treatment  
Management of acute and chronic GvHD will be at the Investigator's discretion and in 
accordance with the institution's guidelines. The following guidelines are suggested:  
 
• The diagnosis of acute GvHD will be made on clinical and histological grounds (see 
Appendix A for grading system).  Acute GvHD, manifest as skin rash (ranging from 
palmar erythema to bullous dermatitis), mucositis (manifest most dramatically as 
diarrhea), hepatitis, and delayed hematopoietic recovery, usually occurs within the first 
100 days but may occur later on.  Patients with grade II or greater acute GvHD may 
receive as first-line therapy methylprednisolone, 1-10 mg/kg/day (IV or PO) for 7 to 14 
days, and then tapered as clinically indicated every 5-7 days.  An alternative first-line 
regimen of methylprednisolone 500 mg/m2/dose q 12 hours x2 doses, repeated every 48-
72 hours for up to 4 courses may also be used.  If acute GvHD persists, or does not 
respond to institution of steroids, treatment should be instituted at the discretion of the 
attending physician.  
o Enrollment in phase I/II studies of novel anti-GvHD therapy is permitted per 
approval of the Sponsor. 
• Chronic GvHD, seen much more frequently in patients who have had acute GvHD, is 
manifested by sclerodermatous and atrophic skin changes, xerophthalmia, xerostomia, 
weight loss, and immunodeficiency (with particular susceptibility to sinopulmonary 
infections), and will be diagnosed by clinical and histologic criteria. Treatment with 
prednisone and cyclosporine or azathioprine or other medications per institutional 
guidelines should be instituted if systemic disease is diagnosed; this therapy may 
contribute to the susceptibility to infection.  
6.6. 
Supportive Care 
Institutional standard of care practice guidelines will be followed after transplantation for 
nutritional support, treatment of infections, and blood product support. Supportive care 
guidelines are detailed below.  


 
 
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6.6.1. 
Engraftment Syndrome 
Engraftment syndrome is a clinical diagnosis. The most frequently reported manifestations are 
transient fever, rash, and respiratory symptoms not attributable to infection or GvHD. The 
pathophysiology is poorly understood, but is thought to be multifactorial mediated by cellular, 
complement and cytokine components. 
 
Diagnostic criteria include fever (temperature >38.5° C) without an identifiable infectious cause 
prior to or with neutrophil recovery with or without an erythematous rash or capillary leak 
(weight gain, edema, ascites, effusions) or respiratory symptoms not attributable to IPS. Mild 
symptoms may not require therapy due to the self-limiting nature of this syndrome. 
Methylprednisolone should not be given as prophylaxis for engraftment syndrome prevention. 
For progressive symptoms, methylprednisolone at 2 mg/kg/day is recommended with tapering 
once response is achieved. If recurrent or prolonged, investigation for GvHD is recommended. 
6.6.2. 
Venous Access  
Recipients will have appropriate long-term central venous access placed, per institutional 
standard practice, prior to beginning the conditioning regimen. The placement of a triple lumen 
tunneled catheter is recommended. 
6.6.3. 
Seizure Prophylaxis for SCD Patients 
Prophylaxis against seizures is mandatory in all SCD patients and should be commenced at the 
start of conditioning. Suitable drugs for prophylaxis include phenytoin, clonazepam, or 
levetiracetam, and should be administered according to institution guidelines. Seizure 
prophylaxis should be continued in SCD patients until cyclosporine or any other calcineurin 
inhibitor is discontinued.  In patients with pre-existing seizures, continued prophylaxis may be 
given per standard of care. 
 
Serum magnesium level should be maintained >1.5 mg/dL in all SCD patients during the period 
of treatment with calcineurin inhibitors cyclosporine or tacrolimus to reduce the risk of seizures. 
6.6.4. 
Hypertension  
Hypertension should be strictly controlled to prevent CNS toxicity. Blood pressure should be 
monitored closely and both systolic and diastolic hypertension should be treated promptly to 
maintain blood pressure at the patient’s pre-transplant baseline ± 20%. 
6.6.5. 
Growth Factor  
G-CSF (e.g., Filgrastim, Neupogen, Granix, Zarxio) therapy will be given IV starting Day +1 at 
dose of 5 μg/kg/day (rounding to nearest vial dose). G-CSF will be continued until the absolute 
neutrophil count (ANC) is > 2,000/μL on 3 consecutive days after the nadir.  
6.6.6. 
Blood Products 
All blood products (except the unmanipulated UCB and NiCord®) must be irradiated to at least 
2500 cGy before administration to transplant recipients to reduce the risk of developing third-
party graft-versus-host disease.  
 


 
 
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In all SCD patients, the hemoglobin level must be maintained between 9.0 and 11.0 g/dL for at 
least 100 days post-transplant and platelet count > 50,000/μL post-transplant until recovered to 
avoid neurological adverse events (AEs), as described previously.114 
6.6.7. 
Infection Prophylaxis and Surveillance 
Institution guidelines will be followed to provide prophylaxis for infections. Strict guidelines for 
hygiene and care will be applied. Before starting the pre-transplant conditioning there should be 
no evidence of mucosal or cutaneous infections. All dental caries should be resolved and 
abscesses eliminated. Supervised dental prophylaxis is recommended. Oral candida prevention 
should be vigorously pursued.  
 
All patients must be nursed in a single room during neutropenia and should preferably be nursed 
in a single room during all admissions. All visitors must be free of active infections. Rigorous 
hand washing is crucial. 
6.6.7.1. 
Anti-viral Prophylaxis 
Acyclovir 400 mg PO BID is recommended for anti-viral prophylaxis with conditioning through 
the duration of neutropenia and then at 800 mg PO BID until 1year post transplant or until 6 
months after immunosupression is discontinued. If unable to tolerate PO medications, IV 
prophylaxis will be necessary.  Other anti-viral prophylaxis regimens may be administered per 
institutional guidelines, however, prophylaxis with ganciclovir or valganciclovir is strongly 
discouraged on or after day -2 until engraftment is achieved. 
6.6.7.2. 
Anti-bacterial Prophylaxis 
Anti-bacterial prophylaxis is required.  Ciprofloxacin 500 mg PO BID day 0-100 is 
recommended.  Other anti-bacterial prophylaxis regimens may be administered per institutional 
guidelines. 
6.6.7.3. 
PCP Prophylaxis 
Trimethoprim-sulfamethoxazole or an equivalent drug should be administered after engraftment 
as per institutional guidelines.  The use of Bactrim is discouraged on or after day -2 and prior to 
engraftment as it may delay engraftment, and is reserved only for cases where it is assessed to be 
essential and superior to all alternative medications.  
6.6.7.4. 
Fungal Prophylaxis 
Anti-fungal prophylaxis against Aspergillus sp. is recommended with agents such as 
itraconazole, voriconazole, or posaconazole.   
6.6.7.5. 
CMV Surveillance  
All recipients must be tested for CMV using the PCR method at least once during the 
conditioning period, at the weekly protocol specified visits up through Day 42, and then at day 
70 and day 100 or more frequently as clinically indicated. Antiviral therapy for CMV 
reactivation should commence preemptively if CMV testing reveals a high or rising viral load. If 
CMV reactivation occurs at or before engraftment, foscarnet may be considered to prevent 
marrow suppression. 


 
 
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6.6.7.6. 
Adenovirus Intervention Guideline 
Testing for adenovirus infection in the blood by PCR method is recommended in the event of 
symptoms suspicious for infection such as diarrhea, hepatic dysfunction or respiratory 
symptoms. If an active systemic infection is diagnosed, therapy should be instituted with 
cidofovir or other active agents per institution guidelines. 
6.6.7.7. 
Intravenous Immune Globulin 
Intravenous immune globulin may be administered according to institutional practice guidelines. 
Weekly IVIG infusions (500 mg/kg/dose) are recommended for immunoprophylaxis through 
Day 100 to maintain IgG levels in the normal range for age.  Alternatively, if IVIG is not given 
on a regular schedule, IgG levels should be monitored and IVIG infusions given to maintain IgG 
level in the normal range for age. 
6.6.8. 
Treatment of Infections 
Patients undergoing the myeloablation treatment outlined in this study are expected to develop 
immunodeficiency. Therefore, the approach to the diagnosis and treatment of fever in such 
patients should be an aggressive one. If any infections occur, it will be treated per institutional 
practice and will be recorded in the source documents and in the e-CRF.  
6.6.9. 
Discharge Instructions and Follow-up 
Patients and their treating physicians should be provided clear instructions at discharge that 
emphasize the importance of continued follow-up as per study protocol, including early reporting 
of infectious symptoms, medical treatments received and any other medical events to their 
clinical center. The clinical center should attempt weekly contact with patients through day 70 to 
ask about infectious symptoms and any other medical events or treatments.  Clinical centers will 
continue with monthly contact from day 70 to the completion of follow-up. 
6.6.10. 
Supportive Care Guidelines for CNS Toxicities 
Patients with SCD and cerebral vasculopathy have a high incidence of new CNS toxicities 
(seizures, labile hypertension, RPLS, PRES, intracranial hemorrhage, stroke, etc.) during the 
entire transplant process, beginning with the conditioning regimen and lasting through the time 
that immunosuppression is eventually discontinued. In order to minimize or avoid these risks, 
adherence to the following guidelines is strongly recommended for all patients: 
 
1. The baseline blood pressure in patients with SCD is often less than “normal” for age. 
Hypertension can ensue following fluid infusions, or with the use of medications such as 
corticosteroids and calcineurin inhibitors, even after short term use. Blood pressure (both 
systolic and diastolic) should be monitored closely (at least every 4 hours) and strictly 
maintained within 20% of the baseline blood pressure of the patient – aggressive (and 
often parenteral) use of anti-hypertensive drugs may be required to control hypertension. 
 
2. Seizure prophylaxis is mandatory.  Prophylaxis with phenytoin, gabapentin or 
levetiracetam should be commenced with conditioning therapy per standard guidelines 
and continued for 180 days after transplant or until cyclosporine or any other calcineurin 
inhibitor is discontinued, whichever is later.  In patients with pre-existing seizures, 
continued prophylaxis may be given per standard of care.    


 
 
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3. Platelet counts will be monitored frequently after starting the conditioning therapy and 
platelet transfusions will be administered as needed to keep levels > 50,000/μL. 
6.6.11. 
Nutrition  
All patients will be candidates for total parenteral nutrition; length of use is at the attending 
physician's discretion.   
6.6.12. 
Guidelines for Infusing a Second Stem Cell Product or Donor Cellular Infusion  
A second transplant or donor cellular infusion (DCI) should not be considered unless the patient 
has graft failure. If graft failure occurs then the patient may be treated per institutional 
guidelines. 
6.7. 
Investigational Agents 
Unless approved by the Sponsor, investigational agents should not be administered from 30 days 
prior to CBU shipment to the production facility until the end of study follow-up for all patients 
transplanted. 
6.8. 
Other Medications  
Patients should receive full supportive care according to institutions’ practice patterns and 
clinical guidance as described above, including transfusions of blood and platelets, antibiotics, 
anti-emetics, or any other supportive care according to clinical judgment. 
  
All concomitant medications administered, from time of signature on the ICF and until the end of 
the study, will be recorded in the source documents and the reason for administration should be 
clearly stated in the indications and if needed also documented as AEs. 
 
Rescue equipment (oxygen) and drugs such as hydrocortisone, epinephrine (other inotropic 
agents), and antihistamines should be available at the transplantation unit and will be 
administered at the Investigator’s discretion.


 
 
 
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Table 4: Evaluations & Examinations Flow Sheet 
 
NiCord® Study for Hemoglobinopathies - Schedule of Assessments Summary 
 
Before transplant  
Days Post-transplant 
 
 
Eligibility / 
Screening 
Phase 
 
Baseline 
Phase 
 
Preparative and  
Conditioning 
Phase 
 
Transplantation and Post Transplantation FU Phase 
Post-
Study 
FU 
Days 
Within 45 
days prior to 
CBU 
shipment 
Within 4 
weeks prior to 
start of 
conditioning1 
-35 to -15/-13 
Preparative 
 
-14/-12 to -2 
Conditioning2 
0 
1 
7 
14
±3 
21
±3 
28
±3 
35
±3 
42
±3 
70
±3 
100 
±14 
180 
±21 
365 
±21 
Part 1: Identify two UCB 
matching units 3 
Part 2: Identify one UCB 
matching unit 3 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Written Informed 
Consent4 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Backup Identification 
/BM Harvest5 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Eligibility Criteria 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
hCG Test for Pregnancy 
(if of child bearing 
potential) 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ship selected CBU for 
manipulation to arrive at 
the production site 
preferably no later than 
two days before the start 
of manufacturing 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical History 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Historical Medications 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Concomitant Medications  
X 
X 
X 
X X X X 
X 
X 
X 
X 
X 
X 
X 
X 
Karnofsky/Lansky 
performance scale 
X 
X 
 
 
 
 
 
 
X 
 
 
X 
X 
X 
X 
Confirm Eligibility within 
one week prior to 
conditioning 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
 
 
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NiCord® Study for Hemoglobinopathies - Schedule of Assessments Summary 
 
Before transplant  
Days Post-transplant 
 
 
Eligibility / 
Screening 
Phase 
 
Baseline 
Phase 
 
Preparative and  
Conditioning 
Phase 
 
Transplantation and Post Transplantation FU Phase 
Post-
Study 
FU 
Days 
Within 45 
days prior to 
CBU 
shipment 
Within 4 
weeks prior to 
start of 
conditioning1 
-35 to -15/-13 
Preparative 
 
-14/-12 to -2 
Conditioning2 
0 
1 
7 
14
±3 
21
±3 
28
±3 
35
±3 
42
±3 
70
±3 
100 
±14 
180 
±21 
365 
±21 
Physical Examination  
X 
X 
X6 
X X 
 
 
 
X 
 
 
X 
X 
X 
X 
Vital Signs7 
X8 
X8 
X6 
X X X X 
X 
X 
X 
X 
X 
X 
X 
X 
Laboratory 
CBC & Chemistry 9 
X 
X 
X6 
X X X X 
X 
X 
X 
X 
X 
X 
X 
X 
Complete urinalysis with 
microscopic examination 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CBU confirmatory HLA 
typing10 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Infectious disease 
markers11 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Viral Screening 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Radionuclide GFR12 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Anti-HLA antibodies23 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CMV PCR   
 
 
X13 
 
 
X X 
X 
X 
X 
X 
X 
X 
 
 
Immunophenotyping 
Lymphocyte subsets14, 15 
 
X 
 
 
 
 
 
 
 
 
 
 
X 
X 
X 
Immunoglobulins (IgG, 
IgA, IgM)15 
 
X 
 
 
 
 
 
 
 
 
 
 
X 
X 
X 
T-cell Receptor Excision 
Circles (TREC)15 
 
X 
 
 
 
 
 
 
 
 
 
 
X 
X 
X 
Peripheral blood baseline 
sample for Chimerism16  
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Peripheral blood 
chimerism17 
 
 
 
 
 
X X 
X 
X 
 
X 
X 
X 
X 
X 
Hb-electrophoresis18 
 
X 
 
 
 
 
 
 
 
 
 
 
 
X 
X 


 
 
 
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NiCord® Study for Hemoglobinopathies - Schedule of Assessments Summary 
 
Before transplant  
Days Post-transplant 
 
 
Eligibility / 
Screening 
Phase 
 
Baseline 
Phase 
 
Preparative and  
Conditioning 
Phase 
 
Transplantation and Post Transplantation FU Phase 
Post-
Study 
FU 
Days 
Within 45 
days prior to 
CBU 
shipment 
Within 4 
weeks prior to 
start of 
conditioning1 
-35 to -15/-13 
Preparative 
 
-14/-12 to -2 
Conditioning2 
0 
1 
7 
14
±3 
21
±3 
28
±3 
35
±3 
42
±3 
70
±3 
100 
±14 
180 
±21 
365 
±21 
Preparative and 
Conditioning regimen as 
per protocol 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
NiCord® CF, NF, and 
infusion solutions shipped 
to transplant center  
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
NiCord® CF thawing and 
infusion 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
NiCord® NF thawing and 
infusion 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
Toxicity assessment 24 
hours post infusion19 
 
 
 
X X 
 
 
 
 
 
 
 
 
 
 
GvHD prophylaxis20 
 
 
X 
X X X X 
X 
X 
X 
X 
X 
X 
X 
 
G-CSF Therapy21 
 
 
 
 
X X X 
X 
X 
X 
X 
 
 
 
 
Infection prophylaxis22 
 
 
X 
 
 
X X 
X 
X 
X 
X 
 
 
 
 
Cardiac: 
• ECG23 
• Echocardiography 
LVEF or shortening 
fraction, tricuspid 
regurgitation, and jet 
velocity (if present)24 
X 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
 
CT scan sinus, chest, 
abdomen, pelvis23 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Chest X-ray25 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
MRA/MRI26 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pulmonary Function Test 
with cDLCO, FEV1, 
FVC, O223 
X 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
 


 
 
 
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NiCord® Study for Hemoglobinopathies - Schedule of Assessments Summary 
 
Before transplant  
Days Post-transplant 
 
 
Eligibility / 
Screening 
Phase 
 
Baseline 
Phase 
 
Preparative and  
Conditioning 
Phase 
 
Transplantation and Post Transplantation FU Phase 
Post-
Study 
FU 
Days 
Within 45 
days prior to 
CBU 
shipment 
Within 4 
weeks prior to 
start of 
conditioning1 
-35 to -15/-13 
Preparative 
 
-14/-12 to -2 
Conditioning2 
0 
1 
7 
14
±3 
21
±3 
28
±3 
35
±3 
42
±3 
70
±3 
100 
±14 
180 
±21 
365 
±21 
Assess Acute GvHD27 
 
 
 
 
 
X X 
X 
X 
X 
X 
X 
X 
X 
X 
Assess Chronic GvHD 
 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
X 
Hospital Admission 
 
 
From initiation of conditioning regimen until end of study 
 
RBC and platelet 
transfusion record 
 
 
RBC and platelet transfusion recording from transplant until d180 
 
Infections 
 
 
Report all grade 2/3 infections from initiation of conditioning regimen until end of study.  
Report life threatening infections through the 6-month post study follow-up. 
Serious adverse events 
 
 
From initiation of conditioning regimen until end of study 
 
1 Baseline assessments should be completed and resulted prior to initiation of the conditioning regimen.   
2  Transition from preparative to conditioning phase is dependent on the patient’s age.  Conditioning begins at day -12 for patients ≥21 years of age whereas conditioning 
begins on day -14 for patients <21 years of age.  
3  Before signing informed consent and according to CBU matching criteria as detailed in Section 7.1 of the protocol. 
4  Signing informed consent can be done before screening, as per site practice. Signed consent is required prior to performing any protocol specific tests or procedures that are 
not part of the standard site practice. Standard of care hydroxyurea dose adjustment is permitted prior to consent if it is in the best interest of the patient regardless of the 
patient’s participation in the trial.   
5  Autologous stem cells harvested from bone marrow should be obtained, or related haploidentical donor/back-up CBU(s) to be identified (as detailed in inclusion criteria), 
in case of engraftment failure. If Autologous stem cells harvest from BM is chosen as the backup graft source, the backup BM harvest can be obtained during Baseline, but 
prior to the start of conditioning treatment, for patients who have an alternative back-up stem cell source identified. 
6    As per site practice. 
7  Temperature, blood pressure, pulse, respiratory rate; saturation (pulse oxymetry) required through the Day 42 visit. 
8  Including height, weight and BSA. 
9 CBC performed daily from Day 0 until neutrophil engraftment.  Differentials not required if WBC<0.2.  Blood chemistries include (at a minimum): serum creatinine,  
    total bilirubin, alkaline phosphatase, AST, ALT, and magnesium at screening, baseline (before start of conditioning), day -1, day 0, and then at least twice weekly until 
Day 28, and weekly after Day 28 until 12 weeks post-transplant, 6 months and 1 year post-transplant). 
10 HLA -A, -B, -C, -DRB1 must be typed at high resolution and patient must also have ABO and Rh typing performed.   
11 Infectious disease markers include: CMV, Hepatitis panel (HepB sAg, HepB Core Ab, HepC Ab), EBV Ab, herpes simplex virus, syphilis Ab (such as RPR), HIV and  
     HTLV I/II antibody, and varicella zoster. 
12 Tests from 90 days prior to screening are acceptable for eligibility, provided the patient has been asymptomatic since the time of the tests. For baseline testing, can be done 
up to 90 days prior to initiation of the conditioning regimen, provided the patient has been asymptomatic since the time of the tests. 
13 After start of chemotherapy. 
14 CD3, CD4, CD8, CD19, CD16/56 and others as per site practice. 
15  Blood sample collection may be done at any time before the start of the conditioning regimen as long as the tests are resulted before the initiation of conditioning. 
16  Sample can be collected during screening if more convenient. 


 
 
 
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17 Measured by molecular methods, in whole blood and fractionated for lymphoid and myeloid components; Bone marrow chimerism is an acceptable alternative. 
 Optional: Red cell chimerism measured after day 180 and 365 when RBC transfusion independence has been achieved for a minimum of 2 months. 
18 Hb-electrophoresis only needed pre-transplant (within 7 days prior to initiation of conditioning) in SCD non-chronically RBC transfused patients. If the HbS level is >45% 
then the patient must receive RBC transfusions or erythrocyte exchange prior to conditioning initiation. Post transplant Hb-electrophoresis at day 180 and 365 in SCD 
patients unless host reconstitution has occurred.  
19 (fever, chills, allergic reaction/hypersensitivity, anaphylaxis, sinus bradycardia, sinus tachycardia, hypertension, hypotension, nausea, vomiting, diarrhea, dyspnea, 
hypoxia, hemoglobinuria, infection, flank pain and any other skin, CNS, cardiac, pulmonary or other toxicity manifestations). 
20 GVHD prophylaxis with CSA and MMF beginning on day -3. 
21 Rounded to the nearest vial starting day +1 until the ANC is >2,000/µl x 3 consecutive days. 
22 As per site practice. 
23 Tests performed 30 days prior to screening are acceptable. 
24 It is recommended that these tests be performed ≤ 90 days prior to the initiation of conditioning regimen. However, provided the patient has been asymptomatic since the 
time of the tests, they can be done up to 6 months prior to the initiation of conditioning regimen. 
25  It is recommended that the X-ray be performed ≤ 30 days prior to the initiation of the conditioning regimen.  However, it can be done < 60 days prior to the initiation of 
the conditioning regimen, provided the patient has been asymptomatic since the time of the X-ray scan. 
26 The requirement for a baseline MRI/MRA of the brain to assess for radiologic disease applies only to the patients with SCD; it is not required for patients with 
Thalassemia. Tests from within 6 months prior to screening are acceptable, provided no clinical signs of change were observed since the time of the tests. For patients with 
a past history of CNS complications tests from up to within 30 days prior to screening are recommended. 
27 GVHD and other morbidity assessments at every visit post- transplant. 
 


 
 
 
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7. 
DETAILED STUDY PLAN 
7.1. 
Pre-Screening Activities: Search for Matching CBUs 
In Part 1: potential candidates for double CBT for whom a search yielded matched 
unmanipulated and manipulated CBUs will be identified as screen candidates for the 
study. 
 
In Part 2: potential candidates for single CBT for whom a search yielded a matched CBU 
will be identified as screen candidates for the study.  
 
Units must be HLA-matched at 4-6/6 HLA class I (HLA-A & HLA-B, low resolution) 
and II (HLA-DRB1, high resolution) loci with the patient and, for Part 1, 3-6/6 HLA-A, 
B, DRB1 loci with each other (using same resolution of typing). Double mismatch at any 
one locus (A, B, or DRB1) is not permitted. 
 
The manipulated CBU should contain a pre-cryopreserved (post-processing) total 
nucleated cell dose of ≥1.8x109 and ≥1.8x107/kg for patients weighing ≥ 25 kg or a pre-
cryopreserved (post-processing) total nucleated cell dose of ≥1.6x109 for patients 
weighing < 25kg. In Part 1: the unmanipulated CBU should contain a pre-cryopreserved 
(post-processing), nucleated cell dose of at least 3.5x107 per kilogram. The 
unmanipulated unit will be the best matched unit (as per Investigator's discretion).  
 
The manipulated CBU should contain a pre-cryopreserved (post-processing), total 
CD34+ cell count of ≥ 8x106 for patients weighing ≥ 25 kg and a pre-cryopreserved 
(post-processing), total CD34+ cell count of ≥7x106 for patients weighing < 25 kg. The 
manipulated CBU will have undergone volume reduction (both plasma and red blood cell 
depletion) prior to cryopreservation.  
 
All CBUs should be procured from public banks that meet local applicable regulations. 
Donors are screened and tested in accordance with the relevant regulatory requirements. 
The CBU should be tested for the applicable infectious diseases and be eligible. In case 
the CBU is ineligible or with unusual findings, the clinical site should fill out an urgent 
medical need document. 
 
The selected units should be typed twice (i.e., initial typing and verification typing).  
Verification (confirmatory) typing should be in a lab that is ASHI/EFI accredited and 
must come from an attached segment.  
 
An acceptable CBU (meeting CBU acceptance criteria as defined above) must be 
identified and available prior to patient’s screening. 
7.2. 
Informed Consent and Registration 
A conference will be held with the patient and family to discuss this study and alternative 
treatments available for the treatment of the underlying disease. The conference will be 
conducted by the principal investigator or by other designated qualified person 
(according to local regulations) that has been delegated by the principal investigator. 
 
Standard of care workup for transplant may be done prior to patient consent. Prior to 
performing any study activities/evaluations that are not part of the site’s routine clinical 
practices, the patient and/or his/her legal guardian must be thoroughly informed about all 
aspects of the study, including scheduled study visits and activities, and must sign the 


 
 
 
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written informed consent. Informed consent from the patient and/or his/her legal guardian 
will be obtained using a form approved by the Institutional Review Board or Ethics 
Committee of the institution enrolling the patient.  A signed copy of the written informed 
consent should be given to the patient and/or his/her legal guardian. 
 
Standard of care hydroxyurea dose adjustment is permitted prior to consent if it is in the 
best interest of the patient regardless of the patient’s participation in the trial. 
   
7.2.1. 
Consent of minors 
As a rule, a pediatric subject is legally unable to provide informed consent. Therefore, 
pediatric study participants are dependent on their parent(s)/legal guardian to assume 
responsibility for their participation in clinical studies. Fully informed consent should be 
obtained from the legal guardian in accordance with regional laws or regulations. All 
participants should be informed to the fullest extent possible about the study in language 
and terms they are able to understand. Where appropriate, participants should assent to 
enroll in a study (age of assent to be determined by IRB's/EC's or be consistent with local 
legal requirements). Participants of appropriate intellectual maturity should personally 
sign and date either a separately designed, written assent form or the written informed 
consent. In all cases, participants should be made aware of their rights to decline to 
participate or to withdraw from the study at any time. Attention should be paid to signs of 
undue distress in patients who are unable to clearly articulate their distress. Although a 
participant’s wish to withdraw from a study must be respected, there may be 
circumstances in therapeutic studies for serious or life-threatening diseases in which, in 
the opinion of the investigator and parent(s)/legal guardian, the welfare of a pediatric 
patient would be jeopardized by his or her failing to participate in the study. In this 
situation, continued parental (legal guardian) consent should be sufficient to allow 
participation in the study. Emancipated or mature minors (defined by local laws) may be 
capable of giving autonomous consent. 
7.3. 
Eligibility/Screening Assessments (within 45 days prior to CBU shipment 
to the production site) 
Tests performed during screening period according to the Centers’ routine evaluation of 
candidates for stem cell transplantation need not be repeated, provided they were 
performed recently enough, as detailed below.  
 
Patient's eligibility for the study will be assessed. The activities will be performed as 
detailed in Table 4 and will include:  
• Routine screening evaluation: 
 
Medical history including primary and concomitant disease and historical 
medications 
 
Concomitant medications will be recorded in the patient’s medical record 
 
Patients’ Performance score by Karnofsky (age ≥16) or Lansky Play-
Performance scale (age < 16) 
 
Physical examination and vital signs (including height, weight and BSA) 


 
 
 
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 
Laboratory: CBC with WBC differential  
 
Blood chemistry (serum creatinine, total bilirubin, alkaline phosphates, AST, 
ALT, and magnesium at a minimum)  
 
Serum beta hCG (females of childbearing potential)  
 
Complete urinalysis with microscopic examination 
 
Anti-HLA antibodies (tests from within 30 days prior to screening are 
acceptable) 
 
Radionuclide GFR is strongly recommended as the test of choice. Measurement 
of 24-hour urine creatinine clearance is acceptable if the former is not available. 
Estimated GFR using the serum creatinine and patient weight/age/sex is not an 
acceptable alternative.  Tests from 90 days prior to screening are acceptable for 
eligibility, provided the patient has been asymptomatic since the time of the tests 
 
Serologic infectious disease markers for: CMV, Hepatitis panel (HepB sAg, 
HepB Core Ab, HepC Ab), EBV Ab, herpes simplex virus, syphilis Ab (such as 
RPR), HIV and HTLV I/II antibody, and varicella zoster 
 
Dental Consultant (recommended, optional) 
 
Physiologic reserves assessment:  
− Pulmonary Function Tests including Carbon Monoxide Diffusing 
Capacity (DLCOc), FEV1, FVC, and oxygen saturation, if the patient is 
able to perform.  (If PFT testing included the use of bronchodilators, then 
the baseline results prior to the administration of any medications should 
be used when determining eligibility).  It is recommended that these tests 
be performed ≤ 90 days prior to initiation of the conditioning regimen. 
However, provided the patient has been asymptomatic since the time of 
the tests they can be done up to 6 months prior to initiation of the 
conditioning regimen 
− 12 lead ECG (tests performed within 30 days prior to screening are 
acceptable) 
− Baseline echocardiography for left ventricular ejection fraction (LVEF), 
left ventricular shortening fraction and presence or absence of tricuspid 
regurgitation. If present, measure jet velocity as a measure of pulmonary 
hypertension. It is recommended that these tests be performed ≤ 90 days 
prior to initiation of the conditioning regimen. However, provided the 
patient has been asymptomatic since the time of the tests, they can be done 
up to 6 months prior to initiation of the conditioning regimen 
 
Autologous stem cells harvest from BM should be obtained as per site practice, 
or related haploidentical donor/back-up CBU(s) to be identified (as detailed in 
the inclusion criteria), in case of engraftment failure. If Autologous stem cells 
harvest from BM is chosen as the backup graft source, the backup BM harvest 
can be obtained during Baseline, but prior to the start of conditioning treatment, 
for patients who have an alternative back-up stem cell source identified.  
• CBU match:  
 Patient and CBU ABO and Rh typing  
 Patient HLA class I & II high resolution typing  
 Peripheral blood baseline sample for chimerism laboratory  


 
 
 
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 
CBU HLA class I (A, B, and C) & II (DRB1) high resolution typing.  Note that 
although the matching requirement per protocol only requires low resolution A 
and B matching, high resolution DNA based typing is required for loci A, B, C as 
well as DRB1 
All above mentioned activities should be completed prior to sending the CBU to the 
production site for expansion. Sites may perform standard of care preparation for 
transplantation (i.e., hydroxyurea administration) during the eligibility/screening phase in 
order not to delay the date of transplantation. 
7.4. 
Baseline Assessments (Within 4 weeks prior to start of conditioning) 
All tests must be performed during baseline period unless exception as detailed below.  
Baseline activities will be performed as detailed in Table 4 and will include:   
• Medical history including primary and concomitant disease 
• Concomitant medications will be recorded in the patient’s medical record 
• Patients’ Performance score by Karnofsky (age ≥16) or Lansky Play-Performance 
scale (age < 16) 
• Physical examination and vital signs (including height, weight and BSA) 
• Laboratory: CBC with WBC differential, blood chemistry (serum creatinine, total 
bilirubin, alkaline phosphates, AST, ALT, and magnesium at a minimum)  
• Serum beta hCG (females)  
• Peripheral blood baseline sample for chimerism laboratory. Sample can be 
collected during screening if more convenient. 
• Radionuclide GFR is strongly recommended as the test of choice. Measurement 
of 24-hour urine creatinine clearance is acceptable if the former is not available. 
For baseline testing, can be done up to 90 days prior to initiation of the 
conditioning regimen, provided the patient has been asymptomatic since the time 
of the tests 
• Immunophenotyping – Lymphocyte subsets: CD3, CD4, CD8, CD19, CD16/56 
and additional immunophenotyping as per site practice 
• Immunoglobulin levels (IgG, IgA, IgM) 
• Blood sample for T-cell Receptor Excision Circles (TREC) 
• Chest X-ray. It is recommended that the X-ray be performed ≤ 30 days prior to 
the initiation of the conditioning regimen.  However, it can be done < 60 days 
prior to the initiation of the conditioning regimen, provided the patient has been 
asymptomatic since the time of the X-ray scan. 
• CT sinus, chest, abdomen, pelvis  (Tests performed 30 days prior to screening are 
acceptable) 
• Serologic tests for: CMV, Hepatitis panel (HepB sAg, HepB Core Ab, HepC Ab), 
EBV Ab, herpes simplex virus, syphilis Ab (such as RPR), HIV and HTLV I/II 
antibody, and varicella zoster 
• MRA/MRI of the brain to assess for radiologic disease- applies only to SCD 
patients; it is not required for patients with Thalassemia. MRA/MRI tests from 
within 6 months prior to screening are acceptable, provided no clinical signs of 
change were observed since the time of the tests. For patients with a past history 


 
 
 
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of CNS complications tests from up to within 30 days prior to screening are 
recommended.   
All above mentioned activities should be completed and resulted prior to initiation of the 
conditioning regimen. 
7.6. 
Preparative Phase (Day –35 to one day prior to start of conditioning 
regimen) 
In Part 1: Prior to the initiation of the conditioning regimen (i.e., Day -10 for patients on 
Regimen #1 or Day -15 for patients on Regimen #2), the unmanipulated CBU must be 
present at the Clinical Site. Patient's monitoring during the preparative period (including 
physical examination, vital signs, CBC and blood chemistry) will be evaluated per 
section 6.3.1.  
 
In SCD patients, Hb-electrophoresis (Hb F, Hb S, Hb A2) will be assessed within 7 days 
prior to administration of conditioning regimen.  
 
In SCD patients, in order to begin the conditioning phase, Hb S must be ≤45% or the 
patient must receive appropriate therapy calculated to reduce Hb S to ≤45%.  Viral 
screening is suggested prior to administration of the conditioning regimen to confirm 
absence of infection.  Patients with fever or suspected minor infection should await 
resolution of symptoms before starting the conditioning regimen.   
7.7. 
Eligibility Confirmation: (one week prior to start of conditioning 
regimen) 
Confirm that all previous eligibility tests are still up to date, and repeat any tests that are 
outside of the acceptable timeframe for eligibility.  Viral screening is suggested prior to 
administration of the conditioning regimen to confirm absence of infection.  At the 
investigator’s discretion, patients with fever or suspected minor infection should await 
resolution of symptoms before starting the conditioning regimen. 
7.8. 
Conditioning Phase 
The preparative & conditioning regimen will be administered as detailed in section 6.3. 
The choice of conditioning regimen will be at the Investigator’s discretion. GvHD 
prophylaxis will be administered as detailed in section 6.4
Patient monitoring during the 
conditioning phase (including physical examination, vital signs, CBC and blood 


 
 
 
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chemistry) will be evaluated as per site practice. CMV PCR is required as outlined in 
section 6.6.7.5). 
7.9. 
Pre-Transplantation Day (Day 0) 
Safety Assessment  
Prior to transplantation, the patient will be evaluated by the Investigator or designee 
including: 
• Physical Examination including weight 
• CBC, blood chemistry 
• Vital Signs: temperature, blood pressure, pulse, respiratory rate and oxygen 
saturation 
7.9.1. 
Preparation and Infusion of the Unmanipulated CBU and NiCord®  
7.9.1.1. 
Unmanipulated CBU Preparation (Part 1) 
The unmanipulated CBU should be thawed and diluted by trained personnel using 
institutional procedures.  
 
The CBU will be placed in a sterilized zip lock bag. The bag will then be submerged in a 
37°C water bath and agitated until almost all ice crystals have dissolved followed by 
volume dilution (as per institutional practice) to preserve cell viability. The thawed and 
diluted CBU should be next weighed and centrifuged, supernatant should be removed and 
the CBU pellet should be re-suspended (as per institutional practice). An aliquot from the 
unmanipulated CBU will be removed prior to infusion to measure the total number of 
nucleated cells, percent of cell viability and percentage of the CD34+ cell population. As 
per institutional practice, additional tests may include CFU, ALDHbr, 7-AAD, glyA cell 
content and FACS analysis for the percentage of the CD133+, CD45+, CD3+, CD4+, 
CD8+, CD19+, CD16+CD56+ cell populations. The CBU should be labeled with the 
patient identification information and transferred to the bedside for infusion.   
7.9.1.2. 
Preparation of NiCord® Non-cultured Fraction (NF)  
 
NiCord® NF will be kept frozen until the day of transplantation. It will be shipped to the 
clinical site, together with NiCord® CF, in a cryoshipper equipped with a calibrated data 
logger, prior to transplantation.  The SLM will fax/email the NiCord® NF final CoA to 
the clinical site. NiCord® NF will be sent with the required documentation according to 
the manufacturer's SOP.  
 
Upon arrival, NiCord® NF should be kept in a controlled Liquid Nitrogen freezer (≤ -
150°C) until transplant.  
 


 
 
 
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7.9.1.3. 
Preparation of NiCord® Cultured Fraction (CF)  
Upon completion of the manufacturing process, final QC tests of NiCord® CF are 
initiated, and NiCord® CF is labeled and cryopreserved according to the Manufacturer's 
SOPs. The QC tests performed are divided into bioassays and safety tests. The results of 
the tests should meet predefined specifications.  
 
NiCord® CF will be kept frozen until the day of transplantation.  
In parallel to product testing and prior to transplantation, NiCord® CF and NF will be 
shipped with all available CBU segments to the clinical site in a cryoshipper equipped 
with a calibrated data logger, and with any other required documentation according to the 
manufacturer's SOP. 
Upon arrival, NiCord® CF should be kept in a controlled Liquid Nitrogen freezer (≤ -
150°C). 
   


 
 
 
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7.9.1.4. 
Infusion of the Unmanipulated CBU and/or NiCord® on Day 0 
The unmanipulated CBU and/or NiCord® should not be irradiated under any 
circumstances.   
 
The immediate pre-transplant evaluation will be carried out according to the operating 
procedures of the participating institutions and should be in keeping with the data 
reporting requirements of this study.  
 
In Part 1: NiCord® and the unmanipulated CBU will be transplanted on the same day 
with a minimal interval of 4 hours between the infusions.  The unmanipulated CBU will 
be transplanted first followed by NiCord®.   
 
The unmanipulated CBU should be infused via the patient's central venous catheter using 
an in-line filter as per site practice. Rate of infusion will be according to site practice 
 
With regards to the NiCord® infusion: NiCord® CF will be infused first, followed 
immediately (up to 1 hour) by the infusion of NiCord® NF.  
 
Prior to its infusion, NiCord® must be identified at the Clinical Site according to the 
Sponsor's SOP and designated Form. The Clinical Site should check the product labels as 
well as the CoAs and will make sure that all NiCord® fractions & the infusion solutions 
were shipped in appropriate conditions and are within their shelf life time prior to 
infusing them.  NiCord® CF and NiCord® NF should be infused via the patient's central 
venous catheter as per site practice.  
 
NiCord® is intended to be given by gravity without additional support taking into account 
the overall time of infusion and the minimal infusion time according to the endotoxin 
limit. Infusion of NiCord® CF and NiCord® NF should not exceed 5 cc/kg/h. NiCord® CF 
and NiCord® NF should be infused as soon as possible after thaw.  
• Total duration of NiCord® CF infusion should target a maximum of 2 hours from 
end of thaw to end of infusion, while considering the minimal infusion time 
specified in the product's CoA.  
• Total duration of NiCord® NF infusion should not exceed 1 hour from end of 
thaw to end of infusion, while considering the minimal infusion time specified in 
the product's CoA.    
• The minimal infusion time is calculated based on the actual endotoxin test result 
and the endotoxin limit of 5 EU/Kg weight/60 minutes. 
 
If the patient develops chest tightness or other symptoms, a brief rest (1-2 minutes) may 
be required before proceeding with the remainder of the infusion.  
 
A physician or physician extender (NP or PA) must be present on the patient care unit 
during the infusions and for 1 hour afterwards. Vital signs should be monitored before 
beginning the infusion and every 30 minutes during the infusion. Pre-medication and 
hydration prior to cord blood infusion should be administered per institutional procedure. 
Rescue equipment (oxygen) and drugs such as hydrocortisone, epinephrine and 
Diphenhydramine, should be available at the bedside for emergency use if infusion 
reactions occur. Furosemide (0.5-1.0 mg/kg/dose) may be given if volume overload or 
decreased urine output occurs.  


 
 
 
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7.9.2. 
Evaluation and Treatment of Mycoplasma Safety Test Failure 
The mycoplasma safety test results may not be available at the time the patient is 
transplanted.  In the event that this test proves positive after transplantation, the clinical 
site will be notified and the following steps will be implemented:  
1. Blood cultures will be drawn 
2. Antibiotic coverage will be modified such that the known isolate will be 
adequately covered  
3. Antibiotic coverage will be discontinued if blood cultures prove negative and 
antibiotic cessation is clinically indicated 
 
The clinical site will receive a final CoA containing all test results. 
7.9.3. 
Post Transplantation Follow-Up (Day 0 to 1)  
Safety assessment including: 
• Physical Examination 
• Vital Signs: temperature, blood pressure, pulse, respiratory rate and oxygen 
saturation 30, 60 minutes and at 2, 4 and 24 hours post transplantation of the 
NiCord® NF infusion 
• CBC, blood chemistry 
• Assessment of acute toxicity: 
o Part 1:  From the start of the Unmanipulated CBU infusion up through 24 
hours post infusion of the NiCord® NF 
o Part 2: From the start of NiCord® CF infusion up through 24 hours post 
infusion of the NiCord® NF 
• Cardiac one lead monitor is optional; however, ECG twice a day will be 
mandatory in case of acute toxicity 
• AEs Reporting 
• G-CSF will be administered beginning on day +1 
• Record RBC and platelet transfusions  
7.10. 
Scheduled Treatment Visits (As Detailed in Table 4) 
7.10.1. 
Scheduled Visits on Day 7/ Days (±3) 14, 21, 28, 35, 42, 70/ Day (±14) 100/ 
Day (±21) 180  
The following assessments are mandatory: 
• AEs and concomitant medications will be recorded in the patient’s medical record 
• Vital Signs (note, pulse oximetry not required after the Day 42 visit) 
• Physical examination (days 28, 70, 100, and 180) including cardiac and 
pulmonary monitoring 
• Karnofsky/ Lansky performance status score (days 28, 70, 100, and 180) 
• CBC with WBC differential (differential not required if WBC<0.2), blood 
chemistry (serum creatinine, total bilirubin, alkaline phosphatase, AST, ALT and 
magnesium, at a minimum) 
• CMV PCR weekly at the protocol specified visits up through Day 42 and then at 
day 70and day 100or more frequently as clinically indicated  


 
 
 
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• Hb-electrophoresis: Hb F, Hb S, Hb A2 (day 180 unless host reconstitution has 
occurred)   
• Pulmonary Function Tests including Carbon Monoxide Diffusing Capacity 
(DLCOc), FEV1, and FVC if the patient is able to perform, and oxygen saturation 
(days 100 and 180) 
• 12 lead ECG (days 100 and 180) 
• Echocardiography for left ventricular ejection fraction (LVEF), left ventricular 
shortening fraction and presence or absence of tricuspid regurgitation.  If present, 
measure jet velocity as a measure of pulmonary hypertension (days 100 and 180)    
• Cyclosporine levels as per institutional guidelines to ensure blood levels are 
within target range 
• Peripheral blood collection for chimerism (days 7, 14, 21, 28, 42, 70, 100 and 180 
only). Whole blood and lineage specific (CD3 and either CD15 or CD33) 
chimerism will be performed. Optionally, red cell chimerism will be assessed 
after day 180 when RBC transfusion independence has been achieved for a 
minimum of 2 months. 
• Immunophenotyping – Lymphocyte subsets: CD3, CD4, CD8, CD19, CD16/56 
(days 100 & 180), additional immunophenotyping as per site practice  
• Immunoglobulin levels (IgG, IgA, IgM) (days 100 & 180) 
• Blood sample for T-cell Receptor Excision Circles (TREC) (days 100 & 180) 
• GvHD assessment: 
o Acute: Weekly up to 100 days (inclusive) and at 180 day visit, or more 
frequently as clinically indicated.  Acute GvHD will be assessed according to 
the Consensus Conference on Acute GvHD grading (Appendix A). 
o Chronic: day 100 and day 180 visits or more frequently as clinically indicated. 
GvHD will be assessed and classified as limited or extensive, according to 
standard criteria (Appendix A) on days 100 and 180 post-transplant, or more 
frequently as clinically indicated 
• GvHD prophylaxis as specified in section 6.4 
• Infection prophylaxis as specified in section 6.6.7 
• Hospitalization recording 
• Record RBC and platelet transfusions through Day 180 
7.10.2. 
Evaluation and Treatment of Graft Failure 
Evaluation of Graft Failure: should a patient suffer primary or secondary graft failure, an 
attempt will be made to determine the cause of failure. Evaluation will include: 
• Chimerism studies, viral/bacterial cultures including PCR analysis for Herpes 
viruses (including CMV and HHV6). Assessment should be performed between 
day 21 and 42 for primary graft failure 
Treatment of Graft Failure: If the patient meets the definition of primary or secondary 
graft failure, they will be treated at the discretion of the treating physician.  
7.10.3. 
Early Discontinuation of Follow-up  
Reasons for withdrawal of the patient prior to Day 180 must be stated in the CRF and in 
the site source documentation for all study patients who were enrolled in the study. This 


 
 
 
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includes patients who were screened and assigned a screening number but did not start 
the treatment. (Patients will be defined as screening failures when withdrawn from 
the study before receiving the NiCord® infusion). For early termination patients that 
withdraw/are withdrawn from the study post transplant, any assessments due at the 
time of withdraw (according to Table 4) are requested. 
Patients who experience graft failure or autologous recovery post transplant will continue 
to be followed for survival.  No other study related assessments are required for these 
subjects after the date of graft failure or autologous recovery. 
7.10.4. 
Criteria for Early Termination/Discontinuation 
Patients who are prematurely discontinued from the study should be followed and treated 
by the Investigator according to institutional guidelines. Patients who join the study will 
be asked for permission that their clinical investigator be allowed to transmit information 
to the trial center on the clinical outcomes as assessed during the usual clinical 
management of their disease over the first year following treatment. This will allow us to 
continue to gather clinical information on patients who subsequently withdraw from 
active participation and did not withdraw informed consent, and to include them in the 
analyses of all clinical endpoints.  
 
A patient may withdraw or be withdrawn from the study for the following reasons: 
• Patient withdrew consent 
• Sponsor requested patient to be withdrawn 
• Request of primary care physician or Investigator 
• Non-compliance (per investigator judgment) 
• Lost to follow-up 
• AE 
7.11. 
Unscheduled Visit 
An unscheduled visit may be performed at any time during the study at the patient's 
request, or as deemed necessary by the Investigator. The date and reason for the 
unscheduled visit will be recorded in the patient medical record. Vital signs, AEs and 
concomitant medications will be assessed.  
7.12. 
Post-study Follow-up 
Clinical outcomes including secondary graft failure, chronic GvHD, cardiac and 
pulmonary function tests, chimerism, Hb-electropheresis, incidence of life-threatening 
infections, immune reconstitution, routine labs, vital signs, physical exam, performance 
scale, and survival status (including causes of death), will be collected from the center at 
six months post study completion (1 year post transplantation), as per site practice. Other 
than life threatening infections and events resulting in death, SAE reporting is not 
required during post-study follow-up.  Data from the post-study follow-up period will be 
used in the post-study analysis of one year post transplant outcomes. 
7.13. 
Data Reporting  
7.13.1. 
Criteria for Forms Submission 


 
 
 
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8. 
STUDY MEDICATION  
8.1. 
Description 
8.1.1. 
NiCord® 
NiCord® is a cryopreserved cell-based product of allogeneic, ex vivo expanded, umbilical 
cord blood-derived, hematopoietic CD34+ progenitor cells (NiCord® CF) and the non-
expanded cell fraction of the same cord blood unit (NiCord® NF) consisting of mature 
myeloid and lymphoid cells. 
 
See further details on the cell expansion process in section 3.5. 
8.2. 
 CBU Supply  
All CBUs should be procured from public banks that meet local applicable regulations. If 
the optimal unit(s) for the patient was determined ineligible or with unusual findings as 
per local regulations, the unit may be used under the urgent medical need provision and 
in consultation with the sponsor. 
8.3. 
Manufacturing  
NiCord® CF, NF and infusion solution manufacturing will be performed at Gamida Cell 
manufacturing site by personnel that have been trained and qualified by the Sponsor 
according to the Sponsor's SOPs. 
 
NiCord® is manufactured in a production site, inside a laminar flow hood (class 100, ISO 
5) within a room that has been qualified as a Class 10,000 (ISO 7), in compliance with 
the production instructions and procedures as provided by the Sponsor. 
 
QC tests are performed throughout the course of the manufacturing and on the final 
product and their results are documented. The testing includes in-process quality controls 
(IPQC) and final process quality controls (FPQC) performed according to the relevant 
Manufacturer’s SOP. The IPQC and FPQC tests are performed according to written 
analytical methods either by QC employees or by trained outsourcing testing labs.  
 
IPQC samples from NiCord® are taken at different identified stages during the process.  
 
FPQC samples from NiCord® NF are taken prior to cryopreservation on day 0 of 
production. FPQC samples from NiCord® CF are taken prior to cryopreservation on the 
harvest day.  
 
All safety and some of the IPQC and FPQC bioassay tests have specifications and the 
results should be within the provided specifications. Some of the IPQC and FPQC 
bioassays do not have specifications and results are only collected and documented. 


 
 
 
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Table 7: Final Process Quality Control Tests for the NiCord® CF/NF 
Thawing/Infusion Solution 
Test 
Acceptance Criteria 
Appearance  
Clear solution, free of foreign particles 
Safety Tests 
Sterility – bacteria 
No growth 
Sterility – yeast and molds 
No growth 
Endotoxin content (EU/ml) 
≤0.5 
 
8.3.1. 
Out of Specification Results 
In case an Out of Specification (OOS) result is found, a deviation report will be filled out, 
an investigation will be conducted and completed in a timely manner and any corrective 
action suggested will be implemented promptly to avoid recurrence of the incident. The 
resulting report will be attached to the deviation report and filed in the Batch Record. 
 
NiCord® NF will be released with a final CoA specifying QC test results.   
 
The infusion solution, used to thaw and dilute the NiCord® CF and NF, will be released 
with a final CoA specifying QC test results. 


 
 
 
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8.3.1.2. 
NiCord® NF OOS 
8.4. 
Handling of Cord Blood Unit  
Packaging of NiCord® CF, NiCord® NF and the infusion solutions will be performed 
according to the Sponsor’s procedures. 
 
Labeling of NiCord® CF, NiCord® NF and the infusion solutions and will be performed 
according to the Manufacturer’s SOP. 
8.5. 
Shipment  
NiCord® CF and NF will be kept frozen at the production site until release, and then will 
be shipped together with all available CBU segments/samples to the clinical site in a 
cryoshipper equipped with a calibrated data logger and with all necessary 
documentations. The infusion solutions for NiCord® CF and NF will be shipped to the 
clinical site in parallel in a 2-8°C package equipped with a calibrated data logger. 
 
 


 
 
 
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The shipment of NiCord® will be controlled by the sponsor in order to assure that 
shipment conditions were maintained as described in the Sponsors procedures. The 
checks performed will be documented in a special form according to the Manufacturer's 
SOP. When a shipment is received, the Investigator/Coordinator will acknowledge 
receipt.  


 
 
 
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9. 
SAFETY MONITORING 
9.1. 
Definitions 
9.1.1. 
Adverse Event (AE) 
Adverse event means any untoward medical occurrence associated with the use of the 
investigational product, whether or not considered related to the investigational product. 
9.1.2. 
Infusion Reaction 
Part 1: Any adverse event that begins or worsens (i.e., increases in grade) between the 
start of the first CBU infusion and 24 hours after the end of the second CBU infusion.   
 
Part 2: Any adverse event that begins or worsens (i.e., increases in grade) between the 
start of the NiCord® infusion and 24 hours after the end of the infusion. 
9.1.3. 
Serious Adverse Event (SAE) 
An adverse event or suspected adverse reaction (see section 9.1.4) is considered “serious” 
if, in the view of either the investigator or sponsor, it fulfils one or more of the following 
criteria:  
• Results in death  
• Is life-threatening  
NOTE: An event is considered "life-threatening" if, in the view of either the 
investigator or sponsor, its occurrence places the patient or subject at immediate 
risk of death. It does not include an adverse event or suspected adverse reaction 
that, had it occurred in a more severe form, might have caused death.  CTCAE 
grade four events are not automatically defined as life threatening for SAE 
determination.  For example, a grade four increase in ALT/SGPT may or may not 
be deemed as life threatening by the investigator and/or sponsor. 
• Requires inpatient hospitalization or prolongation of existing hospitalization 
NOTE:  Complications that occur during hospitalization are AEs.  If a 
complication prolongs hospitalization or fulfills any other serious criteria, the 
event is serious.  Elective or previously scheduled hospitalizations for pre-existing 
conditions which have not worsened after initiation of treatment should not be 
classified as SAEs. Any hospitalization regardless of duration will be considered 
serious unless the hospitalization was for social or convenience reasons during 
which no untoward medical occurrence occurred.  
• Results in persistent or significant disability or incapacity 
NOTE:  The term disability is defined as a substantial disruption of the ability to 
conduct normal life functions.   This definition is not intended to include 
experiences of relatively minor medical significance, such as uncomplicated 
headache, nausea, vomiting, diarrhea, influenza, or accidental trauma (i.e., 
sprained ankle) that may interfere or prevent everyday life functions but do not 
constitute a substantial disruption.  
• Is a congenital anomaly/birth defect 
Important medical events that do not meet any of the criteria above should be considered 
serious when, based upon appropriate medical judgment, they jeopardize the patient or 
subject or require medical or surgical intervention to prevent one of the outcomes listed 
in this definition. 


 
 
 
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9.1.4. 
Suspected Adverse Reaction 
A suspected adverse reaction is considered as any adverse event for which there is a 
reasonable possibility that the study product caused the event. “Reasonable possibility” 
means there is evidence to suggest a causal relationship between the drug and adverse 
event. 
 
The Investigator must make the determination of relationship to the study product for 
each AE/SAE.  Alternative causes, such as natural history of the underlying diseases, 
concomitant therapy, other risk factors, and the temporal relationship of the event to the 
study product, will be considered and investigated. The Investigator will also consult the 
Clinical Investigator’s Brochure and/or Product Information for marketed products in the 
determination of his/her assessment. 
9.1.5. 
Causality 
The Investigator must make the determination of causal relationship to the study product 
for each AE/SAE. The Investigator should decide whether, in his or her medical 
judgment there is a reasonable possibility that the event may have been caused by the 
study product. Alternative causes, such as natural history of the underlying diseases, 
concomitant therapy, other risk factors, and the temporal relationship of the event to the 
study product, will be considered and investigated.   
9.1.6. 
Expectation 
Unexpected: An event is considered “unexpected” when it is not listed in the IB or it is 
not listed at the specificity and severity that has been observed. It also refers to AEs or 
suspected adverse reactions that are mentioned in the investigator’s brochure but are not 
specifically mentioned as occurring with the particular drug under investigation. 
9.1.7. 
Toxicity Grading 
All AEs will be graded using NCI’s CTCAE Version 4.03. An AE that is assessed as 
grade three (i.e., “severe”) should not be confused with an SAE.  Severity is a category 
used for rating the intensity of an event; both AEs and SAEs can be assessed as severe.  
An event is described as ‘serious’ when it fulfils one or more of the criteria described in 
section 9.1.3. 
9.1.8. 
Expedited Reporting 
• Grade 3-5 infusion reactions  
• Part 1: Non-engraftment at 42 days post NiCord® cultured cell and 
unmanipulated CBU infusion   
• Part 2: Non-engraftment at 42 days post NiCord® infusion 
• All serious, unexpected, suspected adverse reactions as defined in 21 CFR312.32  
After initial notification within 24 hours, a detailed summary of the events above is 
required from the Investigator within 2 working days of knowledge of the event.  The 
summary will include date of onset, peak grade, potential causes, resolution date (if 
applicable), past medical history, concomitant medications, an event narrative, and 
actions taken.  A discharge summary or hospital notes with supporting labs and 
radiologic reports should be attached as well. 
 


 
 
 
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Other SAEs that do not meet the criteria for expedited reporting should also be reported 
within 24 hours of the transplant team’s knowledge of the event. Other non serious AEs 
should be recorded in the database as outlined in Appendix B.   
Clinical centers are expected to report AEs to their IRB according to their own 
institutional guidelines. 
9.2. 
Observation, Detection and Recording of AEs and SAEs 
The Investigator and/or study personnel will enquire about the occurrence of AEs at 
every visit, after the subject has had the opportunity to spontaneously mention any 
problems.  Because of their underlying disease and toxic preparative therapy, a wide 
range of adverse events are anticipated.   
All AEs will be recorded in the source documents with sufficient detail to allow for 
grading per CTCAE v4.03, and reported on the appropriate CRF page.  
• All infections post transplant will be reported on an infection form.   
• Graft versus Host Disease (GvHD) will be reported on GvHD forms.   
• Common events post transplant (summarized in Appendix C) will be reported on 
the Toxicity Form.  For these common events, the highest grade over a given 
interval will be recorded on a Toxicity form, with the exception of some GvHD 
symptoms which will be recorded on the GvHD forms.  
• Serious Adverse Events post transplant will be reported on SAE summary forms 
• Hospital Admission reporting is due from time of the start of the conditioning 
regimen until end of study; this is reported on the Hospital Admission Summary 
form. 
Serious Adverse Events 
At all times during the transplant and post transplant follow-up phase, SAEs will be 
reported on SAE summary forms.  These events may require reporting on other forms as 
well (e.g., Death form when applicable).  SAEs must be reported within 24hrs of the 
transplant team’s knowledge of the event.   
Where possible, a diagnosis rather than a list of symptoms should be recorded. The 
investigator will attempt to establish a diagnosis of the event based on signs, symptoms, 
and/or other clinical information. In such cases, the diagnosis should be documented as 
the AE/SAE and not the individual signs/symptoms. If a diagnosis has not been made 
then each symptom should be listed individually. 


 
 
 
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9.3. 
Follow-up of AEs and SAEs 
All reported AEs and SAEs will be followed and recorded until resolution with or 
without sequelae (the patient’s health has returned to baseline status or all variables have 
returned to normal), until the condition stabilizes (the investigator does not expect any 
further improvement or worsening of the event), until an outcome is reached or the event 
is otherwise explained, or until there is agreement between the investigator and Sponsor 
that additional follow-up is not warranted. The investigator will ensure that follow-up 
includes any supplemental investigations as may be indicated to elucidate the nature 
and/or causality of the AE/SAE.  This may include additional laboratory tests or 
investigations, histopathological examinations, or consultation with other health care 
professionals. Where appropriate, medical tests and examinations will be performed to 
document resolution of the event(s).  Additional follow-up information, if required, or 
available, must be reported in the same timelines as initial information.  New or updated 
information will be recorded on the originally completed CRF, with all changes to SAEs 
signed and dated by the investigator on a source document and maintained in the site’s 
study files. 
9.4. 
Clinical Laboratory Evaluations 
All laboratory measurements will be evaluated for abnormalities.  An abnormal 
laboratory finding is not by itself considered to be an AE or SAE unless the investigator 
considers the abnormal finding to be of clinical significance.  The abnormal laboratory 
finding does not have to be associated with the use of NiCord® to be considered clinically 
significant. 
9.5. 
Pregnancy 
Investigators must inform all female subjects of child-bearing potential that it is currently 
unknown whether NiCord® poses any risk to an unborn child, and should instruct subjects 
to use appropriate methods of contraception. Subjects should also be instructed to inform 
the investigator immediately should they become pregnant during the study. The 
investigator should counsel the subject, discuss the risks of continuing with the pregnancy 
and the possible effects on the fetus. The investigator should also recommend that the 
subject be closely monitored by her personal physician until conclusion of the pregnancy, 
and once concluded, that both the subject and her infant be carefully monitored throughout 
the puerperium. Breast feeding is not recommended as there is no data regarding the safety 
of a nursing child either during or following NiCord® administration to the mother. All 
AEs will be communicated to the investigator by the subject. 
 
Pregnancy will not be considered as an AE. Any report of pregnancy recorded for any 
female study participant or a female partner of a male study participant should be reported 
immediately within 24 hours to the sponsor. 
 
The Investigator will follow the pregnant woman until completion of the pregnancy, and 
must notify the Sponsor of the outcome within 24 hours of the Investigator’s knowledge of 
the pregnancy outcome.  This notification includes pregnancies resulting in live, “normal” 
births. 


 
 
 
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If the pregnant subject experiences an SAE during pregnancy, or the outcome of the 
pregnancy meets the criteria for classification as an SAE, the Investigator should follow 
the procedures for reporting SAEs (i.e., report the event to the Sponsor within 24 hours of 
the Investigator’s knowledge of the event). 
All neonatal deaths and congenital anomalies that occur within 30 days of birth (regardless 
of causality) should be reported as SAEs to the Sponsor.  In addition, any infant death or 
congenital anomaly occurring after 8 weeks that the Investigator suspects is related to the 
in utero exposure to the study drug should also be reported to the Sponsor. 
9.6. 
Patient Withdrawal from Study Procedures due to Adverse Events 
Any patient can be removed from the study at any time if the subject experiences an AE or 
SAE, which, in the in the judgment of the Investigator, justifies withdrawal due to its 
severity, nature or requirements for treatment, regardless of the causal relationship to the 
study product. Full details of withdrawal criteria are provided in section 5.4.   
9.7. 
Medical Monitor Review 
• Grade 3-5 infusion reactions  
• Part 1: Non-engraftment at 42 days post NiCord® cultured cell and 
unmanipulated CBU infusion 
• Part 2: Non-engraftment at 42 days post NiCord® infusion   
• All serious adverse events as defined in 21 CFR312.32   
9.8. 
Sponsor Obligations 
Any concerns regarding the type or frequency of an event will be communicated to the 
DMC Chair by the sponsor.  The DMC Chair will review the adverse event materials, 
determine if the information is complete, determine if additional DMC review is required 
and make recommendations to the sponsor concerning continuation of the study. 
9.9. 
FDA Reporting 
The Sponsor is responsible for reporting all unexpected fatal or life-threatening suspected 
adverse reactions to the FDA by telephone or fax according to FDA guidelines no later 
than seven calendar days after knowledge of the event.  All grade 3-5 infusion reactions, 
non-engraftment at 42 days post NiCord® cultured cell and unmanipulated CBU infusion 
(Part 1), non-engraftment at 42 days post NiCord® infusion (Part 2), and all serious, 
unexpected, suspected adverse reactions are reported to the FDA by the Sponsor via a 
written report within fifteen days of receipt of the information (21 CFR 312.32).   
 


 
 
 
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10. 
STATISTICAL METHODOLOGY 
The study is designed as a pilot study to evaluate the safety and efficacy of 
transplantation of NiCord® with or without an unmanipulated cord blood unit to patients 
with Hemoglobinopathies following myeloablative therapy. 
 
Safety and efficacy data from all participating patients will be reviewed periodically by 
an independent Data Monitoring Committee (DMC). Interim analyses will be conducted 
to check for safety with regard to serious acute toxicity, neutrophil engraftment by day 
42, and transplant related mortality at 100 days.  
 
Eligible patients who underwent all study screening procedures, completed the 
conditioning treatment and were infused with NiCord® will be included in the statistical 
analyses. Summary data and listings of the patients who were excluded from efficacy and 
safety analyses will be appended to the clinical trial report in order to enable an 
assessment of the nature of the missing data. 
 
Final analysis will be performed when the planned 15 evaluable patients who received 
NiCord® and unmanipulated cord blood have been assessed 180 days after transplant and 
the planned 5 evaluable patients who received NiCord® without unmanipulated cord 
blood have been assessed 180 days after transplant.  If enrollment in Part 1 or Part 2 is 
closed before the maximum number of evaluable patients have been transplanted, the 
final analysis for each part will be performed after the last evaluable patient has been 
assessed after transplant.  The final analysis for Part 2 will include a secondary analysis 
in which Part 1 and Part 2 patients are evaluated together, however, the results of the 
separate analyses will be shown with the combined analysis. 
 
Interim analyses may be conducted as the study is on-going at the Sponsor’s discretion.  
There will be no adjustment to control the overall Type I error. 
10.1. 
Patients & Analysis Cohorts  
The following data analysis sets are defined for the final analysis of this study:  
Part 1 and Part 2 Primary (ITT) Data Analysis Sets consist of all patients who have 
entered the study under Part 1 or Part 2 of the protocol and have received a transplant of 
CB cells. These cohorts will serve as the principal cohorts for the primary analysis to be 
conducted at the completion of the study.  
 
In addition, an interim analysis for the DMC was conducted on the interim ITT data 
analysis set that included the first 6 patients who enrolled in Part 1 and were evaluated for 
acute toxicity, neutrophil engraftment and percent donor derived engraftment/chimerism 
(of either NiCord®, unmanipulated CBU or both) by day 42 and 100-day transplant 
related mortality. Similarly, an interim analysis for the DMC will be conducted on the 
interim ITT data analysis set that includes the first 3 patients who enroll in Part 2 and 
have been evaluated for acute toxicity, neutrophil engraftment and percent donor derived 
engraftment/chimerism by day 42 and 100-day transplant related mortality 
10.1.1. 
Per Protocol (PP) Data Analysis Set  
The two Per Protocol Data Analysis Sets will include all patients enrolled in Part 1 or 
Part 2, respectively, who actually received NiCord® with or without the unmanipulated 
CBU and who, in addition, met all of the following criteria: 
a) Did not receive any stem cells up to day 28 except for the NiCord® and, if in Part 
1, the unmanipulated CBU (e.g., second unmanipulated CBU) 
b) Did not die prior to day 14 


 
 
 
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c) Received myeloablative conditioning therapy according to or similar to that 
specified in the protocol 
d) Did not seriously contravene the eligibility criteria specified in section 5.2 
e) Did not receive a NiCord® transplant that was outside FPQC limits, as specified 
in section 8.3 
 
Patients satisfying the above criteria will be termed "evaluable". All study endpoints will 
be assessed in the PP cohorts. 
10.1.2. 
Withdrawals from the Trial 
• Patients who enter the study but do not receive a transplant of CB cells (screening 
failures) will not be included in the main statistical analysis and will be replaced.  
• Patients who join the study will be asked for permission that their clinical 
investigator be allowed to transmit information to the trial center on the clinical 
outcomes as assessed during the usual clinical management of their disease over the 
first year following treatment. This will allow us to continue to gather clinical 
information on patients who subsequently withdraw from active participation 
without withdrawal of the informed consent, and to include them in the analyses of 
all clinical endpoints 
10.2. 
Sample Size 
Up to 15 evaluable patients will be entered into the study for Part 1 and up to 5 evaluable 
patients will be entered into the study for Part 2. If patients are entered and are 
subsequently found not to have satisfied all the per protocol criteria (as specified in 
section 10.1.1), then further patients will be recruited. These sample sizes were chosen 
for this pilot study informally and were not calculated to meet any specific considerations 
of statistical power. It is however, rather typical of the size that is used in similar pilot 
studies. The number is large enough to provide reasonable experience with the practical 
issues involved in administering the treatment and small enough to allow a reasonably 
rapid progression to the next phase of the research, should the treatment appear both safe 
and promising.  
10.3. 
Interim Analysis & Early Stopping  
The data emerging from this study will be reviewed by an independent DMC. This 
committee reviewed the accumulated data after 6 patients entered Part 1 of the study and 
were assessed at day 100 following the transplant. 
 
A subsequent DMC review will occur after 3 patients have entered Part 2 of the study and 
have been assessed at Day 100 following the transplant.  At this review, the DMC will 
monitor safety data and in particular the detailed chimerism and engraftment data of the 
first 3 patients transplanted with NiCord® as a single expanded graft, including: 
• Any occurrence of primary or secondary graft failure 
• Any substantial decrease in donor chimerism (especially myeloid chimerism), 
or evidence of impending graft failure.  
 
Particular consideration will be given to cases of graft failure which can be attributed to 
post-transplant complications such as HHV6 infection, CMV infection, severe GvHD, 
prolonged ganciclovir usage, or other medicine-related, e.g., MMF, Cidofovir, etc. 
 
The committee will make recommendations to the Sponsor regarding early stopping or 
study modification. 
 


 
 
 
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Early safety assessment guidelines will be used to monitor the following events, and alert 
the DMC.  
If an alert occurs, accrual to the study will be halted. The DMC will consider the data in 
depth and make recommendations to the sponsor. It is understood that DMC 
recommendations to the sponsor are not binding and that the sponsor is the sole party 
responsible for final decisions regarding termination or continuation of the trial. 
10.3.1. 
Part 1 Guidelines  
The following events will prompt consideration of early stopping or modification of the 
protocol for Part 1. 
10.3.1.1. Serious (Grade 4+5) Acute Toxicities  
If ≥2 out of the first 7 or ≥3 out of the first 14 patients experience grade 4 or 5 acute 
toxicity  
10.3.1.2. Neutrophil Engraftment  
If ≥3 of the first 5 patients, ≥4 out of the first 8 patients, or ≥5 of the first 11 patients or 
>6 of the first 14 patients fail to achieve neutrophil engraftment by day 42 (from either 
NiCord®, the unmanipulated CBU or both), as defined in Section 4.3.2. Additionally, 
early consideration will be given by the DMC if 2 out of the first 2 patients fail to engraft. 
10.3.1.3. Secondary Graft Failure 
If ≥3 of the first 5 patients, ≥4 out of the first 8 patients, or ≥5 of the first 11 patients or 
>6 of the first 14 patients experience secondary graft failure, as defined in Section 4.3.2. 
10.3.1.4. Transplant Related Mortality At 100 Days  
If ≥3 out of the first 5 patients, ≥4 out of the first 8 patients, or ≥5 out of the first 11 
patients or >6 of the first 14 patients die before 100 days from treatment-related causes. 
 
In the case of an early stopping event, study recruitment may be renewed based on both 
the recommendation and rationale of the DMC and local IRB approval. 
 
Statistical Notes: The above guidelines are formulated so that an alert will occur if the 
posterior probability is sufficiently high that the chance of an event exceeds a given 
threshold.  
Acute Toxicity: posterior probability that chance of grade 4 or 5 toxicity is greater than 
5% exceeds 0.95. Prior distribution: beta (0.05, 0.95). 
 
Neutrophil Engraftment: posterior probability that chance of no neutrophil engraftment 
by day 42 is greater than 20% exceeds 0.95. Prior distribution: beta (0.2, 0.8). 
 
Secondary Graft Failure: posterior probability that chance of secondary graft failure is 
greater than 20% exceeds 0.95. Prior distribution: beta (0.2, 0.8). 
 
Transplant Related Mortality: posterior probability that chance of transplant related 
mortality within 100 days of transplant is greater than 20% exceeds 0.95.  Prior 
distribution: beta (0.2, 0.8). 
10.3.2. 
Part 2 Guidelines  
The following events will prompt consideration of early stopping or modification of the 
protocol for Part 2, using the same statistical considerations as provided in Part 1. 
 


 
 
 
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10.3.2.1. Serious (Grade 4+5) Acute Toxicities  
If 1 out of the first 1, or >2 out of the first 5 patients experience grade 4 or 5 acute 
toxicity  
10.3.2.2. Neutrophil Engraftment  
If 2 of the first 2 patients, or ≥3 of the first 5 patients fail to achieve neutrophil 
engraftment by day 42 as defined in Section 4.3.2.  Additionally, early consideration will 
be given by the DMC if the first patient in Part 2 fails to engraft. 
10.3.2.3. Secondary Graft Failure 
If 2 of the first 2 patients, or ≥3 of the first 5 patients experience secondary graft failure, 
as defined in Section 4.3.2. 
10.3.2.4. Transplant Related Mortality At 100 Days  
If 2 of the first 2 patients, or ≥3 of the first 5 patients die before 100 days from treatment-
related causes. 
10.4. 
Statistical Analysis  
Patients enrolled in Part 1 and Part 2 will be analyzed separately.  Data listings will be 
provided for Part 2 results, given the small sample size.  A secondary analysis will 
analyze the data from Part 1 and Part 2 patients combined, however, the results from the 
separate analyses will also be presented with the combined results.   
10.4.1. 
Primary Endpoints 
10.4.1.1. Acute Toxicity 
The proportion of patients with grade 4 or 5 toxicity will be estimated together with 95% 
confidence limits based on the binomial distribution. The proportion with toxicity grades 
1, 2, and 3 will also be estimated. 
10.4.1.2. Neutrophil Engraftment 
To assess the incidence of neutrophil engraftment post transplant, a cumulative incidence 
curve will be computed along with a 95% confidence interval at 42 days post-transplant.  
Death, autologous recovery, and second transplant prior to engraftment will be 
considered as a competing risk. 
10.4.2. 
Secondary Endpoints & Analysis  
Planned secondary endpoints are defined in Section 4 and will be analyzed as follows:  
10.4.2.1. Transplant Related Mortality  
To assess the incidence of transplant related mortality, a cumulative incidence curve of 
death occurring in a subject not preceded by autologous recovery will be computed along 
with a 95% confidence interval at 100 days post-transplant.  Autologous recovery will be 
considered as a competing risk. 
10.4.2.2. Event-free Survival  
The proportion of patients with event-free survival at 100 days post transplant will be 
estimated along with a 95% confidence interval using the Kaplan-Meier method.  Death, 
autologous recovery, primary or secondary graft failure will be considered events for this 
endpoint.   
10.4.2.3. Overall Survival  
The proportion of patients alive at 180 days post transplant will be estimated using the 
Kaplan-Meier method. 


 
 
 
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10.4.3. 
Exploratory Endpoints & Analyses  
The list of exploratory endpoints and their pre-planned analyses is as follows: 
10.4.3.1. Incidence of Donor Cell Chimerism  
The incidence of patients achieving donor chimerism (< 90% host cells), from either 
NiCord® or the unmanipulated CBU if transplanted in Part 1, at day 100 will be 
estimated.  Death, autologous recovery, and graft failure will be considered competing 
risks for this endpoint. 
10.4.3.2. Percentage Donor Chimerism in Whole Blood, CD3+ and Myeloid 
(CD15+ or CD33+) Fractions  
The chimerism proportions of the unmanipulated CBU and NiCord® will be measured on 
days 7, 14, 21, 28, 42, 70, 100 and 180 post transplant in patients with neutrophil 
engraftment before target day. The distribution of these portions (median, quartiles) will 
be estimated at each time point.  Patients who do not have neutrophil engraftment will be 
excluded from this analysis.  Patients who have secondary graft failure, autologous 
recovery, or who die before target day (14, 21, 28, 42, 70, 100 and 180 respectively) will 
be excluded from this analysis after the event.  The contribution of NiCord® alone will be 
estimated as will the total donor (NiCord® + unmanipulated CBU) contribution. 
10.4.3.3. Time from Transplantation to Neutrophil Engraftment  
Median time to neutrophil (>500/uL) engraftment will be estimated among those in 
whom engraftment is achieved. 
10.4.3.4. Time from Transplantation to Platelet Engraftment  
Median time to platelet (>50K/uL) engraftment will be estimated among those in whom 
engraftment is achieved.  
10.4.3.5. Platelet Engraftment (>50k/uL) at 180 Days  
To assess the incidence of platelet engraftment (>50k/uL) post transplant a cumulative 
incidence curve will be computed along with a 95% confidence interval at 180 days post-
transplant.  Death, autologous recovery, and second transplant prior to engraftment will 
be considered as a competing risk. 
10.4.3.6. Acute GvHD Grade II-IV and III-IV 
The cumulative incidence of patients who experience these events will be computed 
along with a 95% confidence interval at day 100. Death, autologous recovery, graft 
failure and second transplant will be counted as competing risks in the estimation.  
10.4.3.7. Chronic GvHD (Limited or Extensive) 
The cumulative incidence of patients who experience this event will be computed along 
with a 95% confidence interval at day 180. Death, autologous recovery, graft failure and 
second transplant will be counted as competing risks in the estimation.  
10.4.3.8. Regimen-related Toxicity  
The cumulative incidence of patients who experience regimen-related toxicity by day 180 
will be estimated. 
10.4.3.9. Life-threatening or Fatal Infections 
The cumulative incidence of patients who experience life-threatening or fatal infections 
by day 180 will be estimated. Death will be counted as competing risk in the estimation 


 
 
 
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10.4.3.10. Immune Reconstitution 
The distributions of total immunoglobulin levels at days 100 and 180 (mean, standard 
deviation, median, quartiles) will be estimated. The distributions of the numbers and 
proportions of different lymphocyte subpopulations at days 100 and 180 (mean, standard 
deviation, median, quartiles) will also be estimated.  The distributions of T-cell excision 
circles at days 100 and 180 (mean, standard deviation, median, quartiles) will also be 
estimated.  Patients who have graft failure, who have autologous reconstitution, or who die 
before target day (100 or 180 respectively) will be excluded from this analysis after the 
event.   
10.4.4. 
Post Study Analysis  
The following secondary, and exploratory endpoints will also be analyzed as noted in 
sections 10.4.2 and 10.4.3 above, however the timepoint of the analysis will be at 1 year 
post transplant; event-free survival, overall survival, percentage donor chimerism, 
incidence of chronic GvHD, incidence of life-threatening and fatal infections, and 
immune reconstitution. 
10.5. 
Safety Assessment  
10.5.1. 
Adverse Experiences  
The incidence and frequency of adverse experiences will be presented by System Organ 
Class and preferred terminology according to MedDRA dictionary and to NCI toxicity 
criteria. AEs will also be presented by System Organ Class, High Level Term and 
preferred terminology. Serious adverse experiences will be listed and discussed on a 
case-by-case basis.  
10.6. 
Statistical Software  
SAS® version 9.1 or higher software and R version 2.10.0 or higher will be used for 
statistical analysis and data presentation of the information collected in this study. 


 
 
 
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11. 
CLINICAL DATA MANAGEMENT 
11.1. 
Data Quality Assurance 
This study will be organized, performed, and reported in compliance with the 
Sponsor/CRO’s SOPs, protocols and working practice documents, and the requirements 
of the Declaration of Helsinki and ICH/GCP guidelines. Compliance will be achieved 
through a combination of study specific audits of investigative sites and audits at regular 
intervals of the Sponsor/CRO’s systems for data handling, analysis, and reporting. 
 
A quality assurance audit of this trial may be conducted by the sponsor or sponsor’s 
designees. The quality assurance auditor will have access to all medical records, the 
investigator’s trial-related files and correspondence, and the informed consent 
documentation that is relevant to this clinical trial. 
11.2. 
Data Collection 
Investigators or designees will enter the information required by the protocol onto the 
CRFs. Each investigative site will be visited as frequently as documented in the 
monitoring plan by the CRO on behalf of the Sponsor to review the CRFs for 
completeness and accuracy. The CRO representative will highlight any discrepancies 
found between source documents and the completed CRFs and ensure that appropriate 
site personnel address the discrepancies. When a discrepancy results in corrected CRF 
data, the correction will be reviewed again against the correct source documentation. 
Uniform procedures will be discussed at the Site Initiation Visit. 
11.3. 
Source Documents 
Source documents provide evidence for the existence of the patient and substantiate the 
integrity of the data collected. All clinical data entered onto the CRF must be supported 
by source documentation maintained at the clinical site.  Data entered in the CRFs that 
are transcribed from source documents must be consistent with the source documents or 
the discrepancies must be explained. The investigator may need to request previous 
medical records or transfer records, depending on the trial; also current medical records 
must be available.  
 
Direct access to source data - documents 
• 
The investigator / institution will permit trial-related monitoring, audits, IRB / 
IEC review and regulatory inspection, providing direct access to all related source 
data / documents. 
• 
CRFs and all source documents, including progress notes and copies of laboratory 
and medical test results must be available at all times for review by the sponsor’s 
clinical trial monitor and inspection by health authorities (e.g., MS CA/EMA). 
The Clinical Research Associate (CRA) / on site monitor may review all CRFs, 
and written informed consents. The accuracy of the data will be verified by 
reviewing the documents. 


 
 
 
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11.4. 
Staff Training 
Prior to enrollment, all clinical study personnel will be trained to ensure adherence to the 
protocol and assure the highest possible data quality. Training will be led by CRO and the 
sponsor at a central location.  Training presentations will address informed consent 
procedures, study operations and protocol requirements, data collection procedures, 
maintenance of source documentation, CRF completion and review, routine reporting 
requirements, data entry and management, and policies and procedures. 
11.5. 
Data Monitoring 
CRAs will be responsible for monitoring CRFs and source documents for accuracy, 
protocol compliance, subject safety, and adherence to guidelines in the Site Operations 
Manuals. 
 
At each site visit, the CRA will review recruitment guidelines and study eligibility 
criteria.  As the study progresses, completed data forms may be reviewed during site 
visits and compared to source documentation (medical or site records) to confirm 
accuracy. 
11.6. 
Confidentiality 
Individual names of participants will be masked by participating centers and all patients 
will be assigned a patient identifier code.  The link between the patient’s identity and the 
ID code will be kept securely at the center. Only the ID code will be used to identify the 
patient when submitting study data.  Patient identity will not be revealed in any 
presentations or publications resulting from this study. 
 


 
 
 
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APPENDIX A. 
GVHD CLASSIFICATION  
 
Acute GvHD Definition 
Acute GvHD will be assessed at every visit from transplantation (day 0) until end of 
study or more frequently as clinically indicated. GvHD will be classified according to the 
Consensus Conference on Acute GvHD grading:115  
 
 
Overall Grade 
Skin 
Liver 
Gut 
I 
Stage 1-2 
None 
None 
II 
Stage 3 or 
Stage 1 or 
Stage 1 
III 
 
Stage 2-3 or 
Stage 2-4 
IV 
Stage 4 or 
Stage 4 
 
 
*See following table for individual organ staging. The overall grade of GvHD, however, 
reflects the actual extent of disease. For each overall grade, an assessment of skin disease 
plus liver and/or gut involvement is required. 
 
Acute GvHD may be documented after day 99 (“late acute”) if according to the clinical 
judgment the investigator feels it should be classified as acute rather than chronic. 
 
Clinical Manifestations and Staging of Acute Graft-versus-Host Disease 
Organ 
Clinical Manifestations 
Staginge 
Skina 
Erythematous, maculopapular rash 
involving palms and soles; may 
become confluent 
Severe disease: bullae. 
Stage 1: <25% rash 
Stage 2: 25-50% rash 
Stage 3: generalized erythroderma 
Stage 4: bullae 
Liverb 
Painless jaundice with conjugated 
hyperbilirubinemia and increased 
alkaline phosphatase. 
Stage 1: bilirubin 2-3 mg/dL 
Stage 2: bilirubin 3.1-6 mg/dL 
Stage 3: bilirubin 6.1-15 mg/dL 
Stage 4: bilirubin >15 mg/dL 
Gastrointestinal tractc 
Upper: nausea, vomiting, anorexia. 
Lower: diarrhea, abdominal cramps, 
distention, ileus, bleeding. 
Stage 1: diarrhea >500 ml/day or 
persistent nausea, vomiting, or anorexiad 
Stage 2: diarrhea >1000 ml/day 
Stage 3: diarrhea >1500 ml/day 
Stage 4: large volume diarrhea and 
severe abdominal pain +/- ileus 
a Use ‘Rule of Nines’ or burn chart to determine extent of rash 
b  Range given as total bilirubin.  Downgrade one stage if a cause of elevated bilirubin other than GvHD has been documented. 
c  Downgrade one stage if a cause of diarrhea other than GvHD has been documented. 
d  Persistent nausea with histologic evidence of GvHD in the stomach or duodenum.  Downgrade upper GI one stage if biopsy 
result is negative, or if no biopsy done and GvHD is not an etiology, or if the biopsy is equivocal and GvHD is not an etiology. 
e Although GvHD will be assessed at every protocol-specified visit, GvHD will only be analyzed if it occurs after primary 
neutrophil engraftment.  If GvHD is not an etiology for any organ, then GvHD is downgraded to stage 0. 
 
 
 


 
 
 
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Chronic GvHD Definition 
Chronic GvHD will be assessed from day 100 until day 180 or more frequently as 
clinically indicated. Chronic GvHD will be classified as limited or extensive according to 
the following criteria. 
 
Criteria for Extent of Involvement in Chronic Graft-versus-Host Disease 
Involvement 
Clinical Criteria 
Limited 
Localized skin involvement, liver dysfunction, or both. 
Extensive 
Generalized skin involvement 
OR 
Localized skin involvement or liver dysfunction plus any one of the following: 
Chronic aggressive hepatitis, bridging necrosis, cirrhosis. 
Eye involvement (result on Schirmer test: <5 mm). 
Involvement of mucosalivary glands. 
Mucosal involvement (on lip biopsy). 
Involvement of other target organs. 
 
Chronic GvHD will also be classified as mild, moderate, or severe, according to the 
National Institute of Health consensus grading criteria51. 


 
 
 
 
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APPENDIX B. 
SAFETY DATA REPORTING 
 
 
 
< 24 hours post infusion 
 
Prior to infusion or > 24 hours post infusion 
Protocol Specifieda 
Unspecifiedb 
Non engraftment 
@ 42 days post tx 
Protocol Specifieda 
Unspecifiedb 
  Grade 3-5 
    -- Record name & grade on 
 
Infusion form  
    -- Submit SAE summary 
 
forms  
    -- Expedited report 
 
  Grade 1-2* 
    -- Capture name & grade only 
        on Infusion form  
  Grade 3-5 
    -- Submit SAE 
 
summary forms 
    -- Expedited report 
 
  Grade 1-2*   
    -- Submit AD1 
    -- Submit SAE 
 
summary forms 
   -- Expedited 
 
report 
  Grade 3-5* 
    -- Capture name and 
        grade only on 
         visit summary 
         formsc 
 
  Grade 1-2* 
    -- Not reported 
  SAE 
    -- Submit SAE 
 
summary forms 
    -- If associated w/ 
        NiCord® and un- 
        expected then 
        expedited report 
 
  Grade 3 non SAE 
    -- Submit AD1 
 
  Grade 1-2 non SAE 
    -- Not reported 
* If SAE, submit SAE summary forms.  If SAE associated with NiCord®, then submit expedited report 
a Protocol specified events and database reporting location are listed in Appendix C of this document 
b Unspecified events are events that are not listed as protocol specified events 
c Visit Summary Forms include: “Transplant Toxicity”, “Acute GvHD”, and “Follow-up GvHD” The following forms are also required when 
applicable: 
• Hospitalization Form, Death Form, Infection Form required if applicable  


 
 
 
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APPENDIX C. 
PROTOCOL SPECIFIED ADVERSE EVENTS 
 
< 24 hours post CBU or NiCord® infusion 
Event 
Database Location* 
Allergic reaction/ Hypersensitivity 
Infusion Form  
Anaphylaxis 
Infusion Form  
Diarrhea 
Infusion Form  
Dyspnea  
Infusion Form  
Fever 
Infusion Form  
Hemoglobinuria 
Infusion Form  
Hypertension  
Infusion Form  
Hypotension  
Infusion Form  
Hypoxia 
Infusion Form  
Infection 
Infusion Form and  
Infection Form  
Nausea  
Infusion Form  
Rigors, Chills 
Infusion Form  
Sinus bradycardia 
Infusion Form  
Sinus tachycardia  
Infusion Form  
Vomiting 
Infusion Form  
*Grade 3-5 events also require SAE summary forms. 
 
>24 hours post NiCord® infusion with or without unmanipulated CBU up to 100 
days post transplant 
Event 
Database Location* 
Acute chest syndrome 
Transplant Toxicity  
Alkaline phosphatase increased 
Transplant Toxicity  
ALT increased 
Transplant Toxicity  
Avascular necrosis 
Transplant Toxicity  
Bilirubin increased 
Acute GvHD Form**  
Capillary leak syndrome 
Transplant Toxicity  
Cardiac Arrhythmia 
Transplant Toxicity  
Creatinine increased 
Transplant Toxicity  
Diarrhea 
Acute GvHD Form**  
Dyspnea 
Transplant Toxicity  
Fever 
Transplant Toxicity  
Hemorrhage 
Transplant Toxicity  
HUS/TTP/Microangiopathy 
Transplant Toxicity  
Hypertension  
Transplant Toxicity  
Hypotension  
Transplant Toxicity  
Hypoxia 
Transplant Toxicity  
Infection 
Infection Form  
Intracranial Hemorrhage 
Transplant Toxicity  
Left ventricular systolic dysfunction 
Transplant Toxicity  
Maculopapular rash/ Erythroderma 
Acute GvHD Form**  
Nausea/ Vomiting/ Anorexia 
Acute GvHD Form**  
Non-infective cystitis 
Transplant Toxicity  
Oral Mucositis 
Transplant Toxicity  


 
 
 
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Event 
Database Location* 
Pericardial Effusion 
Transplant Toxicity  
Pulmonary hypertension 
 
Transplant Toxicity  
Restrictive cardiomyopathy 
Transplant Toxicity  
Rigors, Chills 
Transplant Toxicity  
RPLS- Reversible Posterior 
Leukoencephalopathy Syndrome 
Transplant Toxicity  
Seizure 
Transplant Toxicity  
Somnolence 
Transplant Toxicity  
Stroke 
Transplant Toxicity  
Thrombocytopenia 
Transplant Toxicity***  
*Grade 1-2 events are not reported.  SAEs also require SAE summary forms. 
**Note that events on the Acute GvHD form are not graded using the CTCAE 
*** Note that all post transplant related Thrombocytopenia events (grade 0-4) will be captured 
on the Transplant Toxicity form only, and will not require AE reporting unless associated with 
an SAE. 
 
101-180 days post transplant 
Event 
Database Location* 
Acute chest syndrome 
Transplant Toxicity  
Alkaline phosphatase increased 
Transplant Toxicity  
ALT increased 
Transplant Toxicity  
Avascular necrosis 
Transplant Toxicity  
Bilirubin increased 
Follow-up GvHD**  
Capillary leak syndrome 
Transplant Toxicity  
Cardiac Arrhythmia 
Transplant Toxicity  
Creatinine increased 
Transplant Toxicity  
Diarrhea 
Follow-up GvHD**  
Dry eye 
Follow-up GvHD**  
Dysphagia 
Follow-up GvHD**  
Dyspnea 
Transplant Toxicity and Follow-up 
GvHD**   
Forced expiratory volume decreased 
Follow-up GvHD**  
Fever 
Transplant Toxicity  
Hemorrhage 
Transplant Toxicity  
HUS/TTP/Microangiopathy 
Transplant Toxicity  
Hypertension  
Transplant Toxicity  
Hypotension  
Transplant Toxicity  
Hypoxia 
Transplant Toxicity and 
Follow-up GvHD **  
Infection 
Infection Form  
Intracranial Hemorrhage 
Transplant Toxicity  
Left ventricular systolic dysfunction 
Transplant Toxicity  
Malabsorption 
Follow-up GvHD**  
Myositis 
Follow-up GvHD**  
Nausea/ Vomiting/ Anorexia 
Follow-up GvHD**  
Non-infective cystitis 
Transplant Toxicity ( 
Oral Mucositis 
Transplant Toxicity and 
Follow-up GvHD** ( 
Pericardial Effusion 
Transplant Toxicity  
Pulmonary Fibrosis 
Follow-up GvHD**  


 
 
 
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Event 
Database Location* 
Pulmonary hypertension 
Transplant Toxicity  
Rash 
Follow-up GvHD**  
Restrictive cardiomyopathy 
Transplant Toxicity  
Rigors, Chills 
Transplant Toxicity  
RPLS- Reversible Posterior 
Leukoencephalopathy Syndrome 
Transplant Toxicity  
Seizure 
Transplant Toxicity  
Somnolence 
Transplant Toxicity  
Stroke 
Transplant Toxicity  
Thrombocytopenia 
Transplant Toxicity***  
Vaginal inflammation 
Follow-up GvHD**  
*Grade 1-2 events are not reported.  SAEs also require adverse event forms SAE summary 
forms. 
**Note that events on the Follow-up GvHD) form are not graded using the CTCAE 
*** Note that all post transplant related Thrombocytopenia events (grade 0-4) will be captured 
on the Transplant Toxicity form only, and will not require AE reporting unless associated with 
an SAE. 


 
 
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APPENDIX D. COMMON TERMINOLOGY CRITERA FOR 
ADVERSE EVENTS V4.03  
(CTCAE)  
 
Document available upon request. 
 
 
 


 
 
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APPENDIX E. DRUG LABELS 
 
Documents available upon request 
 


 
 
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