Donor-Alloantigen-Reactive Regulatory T Cell (darTregs) in Liver Transplantation

Study Overview
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Brief Summary
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The purpose of this study is look at the safety of: Taking a specific combination of immunosuppressant drugs after liver transplantation Receiving one of three different doses of donor-alloantigen-reactive regulatory T cells (darTregs) while taking this specific combination of drugs

Detailed Description
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After liver transplantation, immunosuppressants must be taken every day to prevent the body from injuring the transplanted liver by a process called rejection. People who take these drugs may experience side effects. Studies show that some of body's cells, called T regulatory cells (Tregs), may play a part in accepting the transplanted liver. The investigators are learning about whether scientists can take Tregs from the blood of a liver transplant recipient and teach them to protect the transplanted liver from rejection. In the laboratory, the recipient Tregs are exposed to cells from the liver donor. Research data suggests that giving these donor reactive Tregs back to the transplant recipient might allow a liver transplant recipient to take lower doses of immunosuppressants, or perhaps to stop them altogether, without rejecting the liver.

Official Title
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Donor-Alloantigen-Reactive Regulatory T Cell (darTreg) Therapy in Liver Transplantation (RTB-002)

Conditions
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Liver Transplantation

Intervention / Treatment
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* Biological: Anti-Thymocyte Globulin - Rabbit
* Biological: darTreg Infusion
* Drug: Everolimus
* Drug: Tacrolimus
* Drug: Mycophenolate mofetil
* Drug: Prednisone
* Drug: Acetaminophen
* Drug: Diphenhydramine
* Drug: Anti-Infective Prophylaxis
* Procedure: Leukapheresis
* Procedure: Blood draws
* Procedure: Liver biopsies
* Procedure: Liver transplantation


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Subjects who meet all of the following criteria are eligible for enrollment as study participants: Able to understand and provide informed consent End-stage liver disease and listed for primary solitary liver transplant Have a calculated Model for End Stage Liver Disease (MELD) score ≤ 25 at the time of study entry/consent Female and male subjects with reproductive potential must agree to use effective methods of birth control for the duration of the study. If history of Hepatitis C Virus (HCV), have completed or are in current treatment for HCV AND have no detectable HCV RNA. Subjects with HCC meeting Milan criteria. Exclusion Criteria: Below are exclusion criteria to be assessed at study enrollment, prior to Stage 1 study procedures. Subjects who meet any of these criteria are not eligible for Stage 1 study procedures. Note that subjects in Cohort 1a or 1b will NOT undergo leukapheresis regardless of eligibility. End stage liver disease secondary to autoimmune etiology (autoimmune hepatitis, primary biliary cirrhosis, or primary sclerosing cholangitis) History of less than 5 years remission of malignancy, except for 1) HCC or 2) history of adequately treated in-situ cervical carcinoma, or adequately treated basal or squamous cell carcinoma of the skin. History of previous organ, tissue or cell transplant Serologic evidence of human immunodeficiency (HIV) 1 or -2 infection Epstein-Barr Virus (EBV) or cytomegalovirus (CMV) sero-negativity (EBV or CMV naïve candidates) Chronic use of systemic glucocorticoids or other Immunosuppression (IS), or biologic immunomodulators Chronic condition requiring anti-coagulation after liver transplantation Any chronic illness or prior treatment which, in the opinion of the investigator, precludes study participation Participation in any other studies that involved investigational drugs or regimens in the preceding year Received any vaccination within 28 days prior to leukapheresis or blood collection for Treg manufacture Hemoglobin <9.0 g/dL within 10 days prior to screening Neutrophils <1,500/μL within 10 days prior to screening Platelets <40,000/μL within 10 days prior to screening Thymoglobulin Exclusion Criteria B (Stage 2): Below are exclusion criteria to be assessed prior to administration of Thymoglobulin®. Subjects who meet any of these criteria should not receive Thymoglobulin®: Calculated Model for End Stage Liver Disease (MELD) score >25 at the time of deceased donor liver transplant Last alpha-fetoprotein (AFP) obtained prior to liver transplantation >400 μg/L for candidates with Hepatocellular Carcinoma (HCC) Unacceptable Peripheral Blood Mononuclear Cells (PBMC) product for participants enrolled in Cohorts 2, 3, or 4 per the UCSF The Human Islet and Cellular Transplant Facility (HICTF) manufacturing specifications Absence of donor spleen for any participants Human leukocyte antigen (HLA)-DR (DR is one of class II antigens) matched to donor at both loci Subject is < 21 or >70 years of age at the time of transplantation Located in the intensive care unit 72 hours after transplantation Hemoglobin <8.0 g/dL Absolute neutrophil count <1,200/μL Platelets <40,000/μL Positive pregnancy test for females of child bearing potential Unexpected histopathology on back table liver biopsy that contraindicates the initiation of Treg supportive IS regimen. Development of a condition requiring chronic anti-coagulation. Hypersensitivity to rabbit proteins or any excipient in Thymoglobulin®. Detectable HCV RNA or less than six months after end of treatment for HCV at the time of transplantation (i.e., does not meet criteria for SVR). Below are exclusion criteria to be assessed prior to conversion to Everolimus (EVR)-based IS regimen. (Assessed at day 30-44 after transplantation for continuation in the trial) All subjects regardless of eligibility for EVR conversion, with any of the following will not receive darTregs and will move into safety follow up: Explanted liver with evidence of increased risk of recurrent cancer risk (hepatocellular (HCC) tumor burden exceeding the Milan criteria; presence of vascular invasion; cholangiocarcinoma morphology) Insufficient depletion of recipient T cells, defined as a nadir CD3 count ≥50 cells μ/L (50 cells /mcL) or total lymphocyte count ≥ 0.1x 109/L if CD3 count is unavailable Development of a condition requiring chronic anti-coagulation. Clinical evidence of biliary obstruction Alanine Aminotransferase (ALT) >2.0 x upper limit of normal (ULN) Inability to taper off corticosteroids by 44 days (+/- 2 days) after transplant Detectable circulating HCV RNA. Everolimus Conversion Criteria C2 (assessed prior to conversion to EVR based IS regimen; EVR cannot be initiated prior to 30 days after liver transplantation). Subjects with any of the following will remain on TAC-based IS regimen. Evidence of hepatic artery stenosis or thrombosis by Doppler examination or angiography within 7 days prior to conversion Urine protein/creatinine ratio >1.0 within 7 days prior to conversion Calculated GFR less than 30 ml/min per MDRD4 (Modification of Diet in Renal Disease Study) equation within 7 days prior to conversion Physical examination documentation of abnormal wound healing or uncontrolled wound infection Hemoglobin <8.0 g/dL within 7 days prior to conversion Absolute neutrophil count <1,200/μL within 7 days prior to conversion Platelets <50,000/μL within 7 days prior to conversion *Below are exclusion criteria to be assessed prior to darTreg infusion for subjects in Cohorts 2, 3, and 4 only. Subjects in Cohort 2, 3, or 4 who meet any of these criteria should not receive a darTreg-infusion: Inability or unwillingness of participant to give additional written informed consent Unacceptable darTreg product Detectible circulating Epstein-Barr Virus (EBV) or cytomegalovirus (CMV) DNA within 10 days prior to darTreg infusion Detectible Hepatitis B Virus (HBV) DNA within 10 days prior to darTreg infusion Detectable circulating HCV RNA within 10 days prior to darTreg infusion. Alanine Aminotransferase (ALT) >1.5x upper limit of normal within 10 days of darTreg infusion Most recent, but not greater than 10 days prior to darTreg infusion,12 hour TAC trough levels of > 8 μg/L for all subjects Most recent, but not greater than 10 days prior to darTreg infusion,12 hour EVR trough levels of < 5 μg/L for subjects on EVR For subjects on EVR-based IS, received Mycophenolate Mofetil (MMF) within 10 days prior to darTreg infusion Evidence of acute rejection or chronic rejection according to Banff criteria on protocol allograft biopsy based on local assessment Received any vaccination within 14 days prior to darTreg infusion Positive pregnancy test for females of child bearing potential Inability or unwillingness of participant to comply with study protocol or procedures. Calculated glomerular filtration rate (eGFR) less than 40 ml/min per MDRD4 equation within 10 days prior to infusion.

Ages Eligible for Study
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Minimum Age: 21 Years
Maximum Age: 70 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Non-Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Cohort 1 - Treg-supportive IS only<br>3 subjects (Cohort 1a) at site 1 (UCSF) and 3 subjects (Cohort 1b) from site 2 (Mayo Rochester) will receive Treg-Supportive immunosuppression (IS) regimen and will not receive Donor-Alloantigen-Reactive T Regulatory Cells (darTregs). Progression from one cohort to the next will depend on the cumulative incidence of sentinel adverse events. | Biological: Anti-Thymocyte Globulin - Rabbit<br>* Liver transplantation/Treg-supportive immunosuppression (IS) treatment. Subjects will be given a dose range of 3.0-4.5 mg/kg total, in divided doses of 1.5 mg/kg/day. Subjects who meet eligibility criteria for Thymoglobulin® administration will be given 1.5 mg/kg intravenously (IV) on post-operative day 3, within 72 hours of transplantation. Additional doses of 1.5 mg/kg IV will be administered until CD3 count is <50/mm^3 or when the maximal dose of 4.5/mg/kg has been given.<br>* Other names: Thymoglobulin®;Drug: Everolimus<br>* Liver transplantation/Treg-supportive immunosuppression (IS) treatment. Subjects meeting eligibility criteria for Treg-supportive IS regimen will begin EVR no sooner than 30 days after liver transplantation and no later than 44 days after transplantation; with target trough levels of 6-8 μg/L.EVR target trough levels will be further reduced to 4-6 μg/L 24 - 26 weeks after transplantation.<br>* Other names: Zortress®;Drug: Tacrolimus<br>* Liver transplantation/Treg-supportive immunosuppression (IS) treatment. Between 30 and 44 days following transplant: Subjects who are not eliminated by Exclusion Criteria C1 (Protocol Section 14.3.1) will proceed in the study and receive either TAC-based or EVR- based IS, based on eligibility Criteria C2 (Section 4.3.4 ) TAC-based IS: reduce TAC trough level to 3-8 μg/dL; continue MMF EVR-based IS: reduce TAC trough level to 3-8 μg/dL; EVR target trough level of 6-8 μg/dL; decrease then discontinue MMF<br>* Other names: Prograf®;Drug: Mycophenolate mofetil<br>* Liver transplantation/Treg-supportive immunosuppression (IS) treatment. 1000 mg total daily dose. MMF will be initiated within 24 hours of transplantation. MMF must be discontinued as soon as target EVR trough levels have been achieved.<br>* Other names: Myfortic;Drug: Prednisone<br>* Liver transplantation/Treg-supportive immunosuppression (IS) treatment. Solumedrol 500 mg will be given IV on the day of transplantation. Additional Solumedrol will be prescribed according to site-specific standard of care. Oral prednisone should be initiated once oral medication is tolerated.<br>* Other names: Solumedrol;Drug: Anti-Infective Prophylaxis<br>* Intravenous ganciclovir and/or oral Valcyte will be administered for the prophylaxis of cytomegalovirus (CMV) and Epstein-Barr Virus (EBV) for at least six months after liver transplantation.<br>* Other names: Valcyte;Procedure: Blood draws<br>* Blood draws are necessary to carefully and frequently evaluate allograft function after liver transplantation and treatment with Treg-supportive IS as well as after darTreg infusion. Peripheral blood samples will be collected and analyzed per protocol throughout subject participation in this study.<br>* Other names: Phlebotomy;Procedure: Liver biopsies<br>* Subjects will have a liver biopsy for this study 12-14 weeks after transplantation. For subjects receiving darTregs, a second biopsy will be performed 7-10 days after darTregs infusion.<br>* Other names: Liver biopsy samples;Procedure: Liver transplantation<br>* Inclusion in this trial is in the setting of subjects defined as having end-stage liver disease and listed for primary solitary liver transplant.<br>* Other names: Liver transplant;|
| Experimental: Cohort 2 - darTreg infusion,50 million(range 25 to 60 million)<br>At least 3 subjects will receive a single infusion of 50 million darTregs. Progression from one cohort to the next will depend on the cumulative incidence of sentinel adverse events. | Biological: Anti-Thymocyte Globulin - Rabbit<br>* Liver transplantation/Treg-supportive immunosuppression (IS) treatment. Subjects will be given a dose range of 3.0-4.5 mg/kg total, in divided doses of 1.5 mg/kg/day. Subjects who meet eligibility criteria for Thymoglobulin® administration will be given 1.5 mg/kg intravenously (IV) on post-operative day 3, within 72 hours of transplantation. Additional doses of 1.5 mg/kg IV will be administered until CD3 count is <50/mm^3 or when the maximal dose of 4.5/mg/kg has been given.<br>* Other names: Thymoglobulin®;Biological: darTreg Infusion<br>* A single dose darTreg infusion (Cohorts 2 - 4) will be received as per protocol.<br>* Other names: Donor-Alloantigen-Reactive Regulatory T Cell Infusion;Drug: Everolimus<br>* Liver transplantation/Treg-supportive immunosuppression (IS) treatment. Subjects meeting eligibility criteria for Treg-supportive IS regimen will begin EVR no sooner than 30 days after liver transplantation and no later than 44 days after transplantation; with target trough levels of 6-8 μg/L.EVR target trough levels will be further reduced to 4-6 μg/L 24 - 26 weeks after transplantation.<br>* Other names: Zortress®;Drug: Tacrolimus<br>* Liver transplantation/Treg-supportive immunosuppression (IS) treatment. Between 30 and 44 days following transplant: Subjects who are not eliminated by Exclusion Criteria C1 (Protocol Section 14.3.1) will proceed in the study and receive either TAC-based or EVR- based IS, based on eligibility Criteria C2 (Section 4.3.4 ) TAC-based IS: reduce TAC trough level to 3-8 μg/dL; continue MMF EVR-based IS: reduce TAC trough level to 3-8 μg/dL; EVR target trough level of 6-8 μg/dL; decrease then discontinue MMF<br>* Other names: Prograf®;Drug: Mycophenolate mofetil<br>* Liver transplantation/Treg-supportive immunosuppression (IS) treatment. 1000 mg total daily dose. MMF will be initiated within 24 hours of transplantation. MMF must be discontinued as soon as target EVR trough levels have been achieved.<br>* Other names: Myfortic;Drug: Prednisone<br>* Liver transplantation/Treg-supportive immunosuppression (IS) treatment. Solumedrol 500 mg will be given IV on the day of transplantation. Additional Solumedrol will be prescribed according to site-specific standard of care. Oral prednisone should be initiated once oral medication is tolerated.<br>* Other names: Solumedrol;Drug: Acetaminophen<br>* Pre-medication for single dose darTreg infusion (Cohorts 2 - 4). 650mg of acetaminophen will be administered intravenously or by mouth 30-60 minutes prior to the darTreg infusion.<br>* Other names: Tylenol®;Drug: Diphenhydramine<br>* Pre-medication for single dose darTreg infusion (Cohorts 2 - 4). 25-50mg of diphenhydramine will be administered intravenously or by mouth 30-60 minutes prior to the darTreg infusion.<br>* Other names: Diphenhydramine Hydrochloride;Drug: Anti-Infective Prophylaxis<br>* Intravenous ganciclovir and/or oral Valcyte will be administered for the prophylaxis of cytomegalovirus (CMV) and Epstein-Barr Virus (EBV) for at least six months after liver transplantation.<br>* Other names: Valcyte;Procedure: Leukapheresis<br>* Leukapheresis is necessary to ensure collection of adequate numbers of autologous Tregs to support ex vivo expansion of darTregs for infusion after liver transplantation. Participants enrolled in Cohorts 3 and 4 will undergo leukapheresis. Participants enrolled in Cohort 2 will have either whole blood collection or leukapheresis for the purpose of isolating autologous Tregs for later manufacture. If a cohort 2 subject has a hemoglobin level >/=10.5 gm/dL, he or she will undergo phlebotomy. If the patient has a hemoglobin level </=10.5 gm/dL and remains eligible for the study, the patient will undergo leukapheresis.<br>* Other names: Leukocytapheresis;Procedure: Blood draws<br>* Blood draws are necessary to carefully and frequently evaluate allograft function after liver transplantation and treatment with Treg-supportive IS as well as after darTreg infusion. Peripheral blood samples will be collected and analyzed per protocol throughout subject participation in this study.<br>* Other names: Phlebotomy;Procedure: Liver biopsies<br>* Subjects will have a liver biopsy for this study 12-14 weeks after transplantation. For subjects receiving darTregs, a second biopsy will be performed 7-10 days after darTregs infusion.<br>* Other names: Liver biopsy samples;Procedure: Liver transplantation<br>* Inclusion in this trial is in the setting of subjects defined as having end-stage liver disease and listed for primary solitary liver transplant.<br>* Other names: Liver transplant;|
| Experimental: Cohort 3 - darTreg infusion,200 million(range100-240 million)<br>At least 3 subjects will receive a single infusion dose of 200 million darTregs. Progression from one cohort to the next will depend on the cumulative incidence of sentinel adverse events. | Biological: Anti-Thymocyte Globulin - Rabbit<br>* Liver transplantation/Treg-supportive immunosuppression (IS) treatment. Subjects will be given a dose range of 3.0-4.5 mg/kg total, in divided doses of 1.5 mg/kg/day. Subjects who meet eligibility criteria for Thymoglobulin® administration will be given 1.5 mg/kg intravenously (IV) on post-operative day 3, within 72 hours of transplantation. Additional doses of 1.5 mg/kg IV will be administered until CD3 count is <50/mm^3 or when the maximal dose of 4.5/mg/kg has been given.<br>* Other names: Thymoglobulin®;Biological: darTreg Infusion<br>* A single dose darTreg infusion (Cohorts 2 - 4) will be received as per protocol.<br>* Other names: Donor-Alloantigen-Reactive Regulatory T Cell Infusion;Drug: Everolimus<br>* Liver transplantation/Treg-supportive immunosuppression (IS) treatment. Subjects meeting eligibility criteria for Treg-supportive IS regimen will begin EVR no sooner than 30 days after liver transplantation and no later than 44 days after transplantation; with target trough levels of 6-8 μg/L.EVR target trough levels will be further reduced to 4-6 μg/L 24 - 26 weeks after transplantation.<br>* Other names: Zortress®;Drug: Tacrolimus<br>* Liver transplantation/Treg-supportive immunosuppression (IS) treatment. Between 30 and 44 days following transplant: Subjects who are not eliminated by Exclusion Criteria C1 (Protocol Section 14.3.1) will proceed in the study and receive either TAC-based or EVR- based IS, based on eligibility Criteria C2 (Section 4.3.4 ) TAC-based IS: reduce TAC trough level to 3-8 μg/dL; continue MMF EVR-based IS: reduce TAC trough level to 3-8 μg/dL; EVR target trough level of 6-8 μg/dL; decrease then discontinue MMF<br>* Other names: Prograf®;Drug: Mycophenolate mofetil<br>* Liver transplantation/Treg-supportive immunosuppression (IS) treatment. 1000 mg total daily dose. MMF will be initiated within 24 hours of transplantation. MMF must be discontinued as soon as target EVR trough levels have been achieved.<br>* Other names: Myfortic;Drug: Prednisone<br>* Liver transplantation/Treg-supportive immunosuppression (IS) treatment. Solumedrol 500 mg will be given IV on the day of transplantation. Additional Solumedrol will be prescribed according to site-specific standard of care. Oral prednisone should be initiated once oral medication is tolerated.<br>* Other names: Solumedrol;Drug: Acetaminophen<br>* Pre-medication for single dose darTreg infusion (Cohorts 2 - 4). 650mg of acetaminophen will be administered intravenously or by mouth 30-60 minutes prior to the darTreg infusion.<br>* Other names: Tylenol®;Drug: Diphenhydramine<br>* Pre-medication for single dose darTreg infusion (Cohorts 2 - 4). 25-50mg of diphenhydramine will be administered intravenously or by mouth 30-60 minutes prior to the darTreg infusion.<br>* Other names: Diphenhydramine Hydrochloride;Drug: Anti-Infective Prophylaxis<br>* Intravenous ganciclovir and/or oral Valcyte will be administered for the prophylaxis of cytomegalovirus (CMV) and Epstein-Barr Virus (EBV) for at least six months after liver transplantation.<br>* Other names: Valcyte;Procedure: Leukapheresis<br>* Leukapheresis is necessary to ensure collection of adequate numbers of autologous Tregs to support ex vivo expansion of darTregs for infusion after liver transplantation. Participants enrolled in Cohorts 3 and 4 will undergo leukapheresis. Participants enrolled in Cohort 2 will have either whole blood collection or leukapheresis for the purpose of isolating autologous Tregs for later manufacture. If a cohort 2 subject has a hemoglobin level >/=10.5 gm/dL, he or she will undergo phlebotomy. If the patient has a hemoglobin level </=10.5 gm/dL and remains eligible for the study, the patient will undergo leukapheresis.<br>* Other names: Leukocytapheresis;Procedure: Blood draws<br>* Blood draws are necessary to carefully and frequently evaluate allograft function after liver transplantation and treatment with Treg-supportive IS as well as after darTreg infusion. Peripheral blood samples will be collected and analyzed per protocol throughout subject participation in this study.<br>* Other names: Phlebotomy;Procedure: Liver biopsies<br>* Subjects will have a liver biopsy for this study 12-14 weeks after transplantation. For subjects receiving darTregs, a second biopsy will be performed 7-10 days after darTregs infusion.<br>* Other names: Liver biopsy samples;Procedure: Liver transplantation<br>* Inclusion in this trial is in the setting of subjects defined as having end-stage liver disease and listed for primary solitary liver transplant.<br>* Other names: Liver transplant;|
| Experimental: Cohort 4 - darTreg infusion,800 million(range 400-960 million)<br>Six subjects will receive a single infusion of 800 million darTregs. | Biological: Anti-Thymocyte Globulin - Rabbit<br>* Liver transplantation/Treg-supportive immunosuppression (IS) treatment. Subjects will be given a dose range of 3.0-4.5 mg/kg total, in divided doses of 1.5 mg/kg/day. Subjects who meet eligibility criteria for Thymoglobulin® administration will be given 1.5 mg/kg intravenously (IV) on post-operative day 3, within 72 hours of transplantation. Additional doses of 1.5 mg/kg IV will be administered until CD3 count is <50/mm^3 or when the maximal dose of 4.5/mg/kg has been given.<br>* Other names: Thymoglobulin®;Biological: darTreg Infusion<br>* A single dose darTreg infusion (Cohorts 2 - 4) will be received as per protocol.<br>* Other names: Donor-Alloantigen-Reactive Regulatory T Cell Infusion;Drug: Everolimus<br>* Liver transplantation/Treg-supportive immunosuppression (IS) treatment. Subjects meeting eligibility criteria for Treg-supportive IS regimen will begin EVR no sooner than 30 days after liver transplantation and no later than 44 days after transplantation; with target trough levels of 6-8 μg/L.EVR target trough levels will be further reduced to 4-6 μg/L 24 - 26 weeks after transplantation.<br>* Other names: Zortress®;Drug: Tacrolimus<br>* Liver transplantation/Treg-supportive immunosuppression (IS) treatment. Between 30 and 44 days following transplant: Subjects who are not eliminated by Exclusion Criteria C1 (Protocol Section 14.3.1) will proceed in the study and receive either TAC-based or EVR- based IS, based on eligibility Criteria C2 (Section 4.3.4 ) TAC-based IS: reduce TAC trough level to 3-8 μg/dL; continue MMF EVR-based IS: reduce TAC trough level to 3-8 μg/dL; EVR target trough level of 6-8 μg/dL; decrease then discontinue MMF<br>* Other names: Prograf®;Drug: Mycophenolate mofetil<br>* Liver transplantation/Treg-supportive immunosuppression (IS) treatment. 1000 mg total daily dose. MMF will be initiated within 24 hours of transplantation. MMF must be discontinued as soon as target EVR trough levels have been achieved.<br>* Other names: Myfortic;Drug: Prednisone<br>* Liver transplantation/Treg-supportive immunosuppression (IS) treatment. Solumedrol 500 mg will be given IV on the day of transplantation. Additional Solumedrol will be prescribed according to site-specific standard of care. Oral prednisone should be initiated once oral medication is tolerated.<br>* Other names: Solumedrol;Drug: Acetaminophen<br>* Pre-medication for single dose darTreg infusion (Cohorts 2 - 4). 650mg of acetaminophen will be administered intravenously or by mouth 30-60 minutes prior to the darTreg infusion.<br>* Other names: Tylenol®;Drug: Diphenhydramine<br>* Pre-medication for single dose darTreg infusion (Cohorts 2 - 4). 25-50mg of diphenhydramine will be administered intravenously or by mouth 30-60 minutes prior to the darTreg infusion.<br>* Other names: Diphenhydramine Hydrochloride;Drug: Anti-Infective Prophylaxis<br>* Intravenous ganciclovir and/or oral Valcyte will be administered for the prophylaxis of cytomegalovirus (CMV) and Epstein-Barr Virus (EBV) for at least six months after liver transplantation.<br>* Other names: Valcyte;Procedure: Leukapheresis<br>* Leukapheresis is necessary to ensure collection of adequate numbers of autologous Tregs to support ex vivo expansion of darTregs for infusion after liver transplantation. Participants enrolled in Cohorts 3 and 4 will undergo leukapheresis. Participants enrolled in Cohort 2 will have either whole blood collection or leukapheresis for the purpose of isolating autologous Tregs for later manufacture. If a cohort 2 subject has a hemoglobin level >/=10.5 gm/dL, he or she will undergo phlebotomy. If the patient has a hemoglobin level </=10.5 gm/dL and remains eligible for the study, the patient will undergo leukapheresis.<br>* Other names: Leukocytapheresis;Procedure: Blood draws<br>* Blood draws are necessary to carefully and frequently evaluate allograft function after liver transplantation and treatment with Treg-supportive IS as well as after darTreg infusion. Peripheral blood samples will be collected and analyzed per protocol throughout subject participation in this study.<br>* Other names: Phlebotomy;Procedure: Liver biopsies<br>* Subjects will have a liver biopsy for this study 12-14 weeks after transplantation. For subjects receiving darTregs, a second biopsy will be performed 7-10 days after darTregs infusion.<br>* Other names: Liver biopsy samples;Procedure: Liver transplantation<br>* Inclusion in this trial is in the setting of subjects defined as having end-stage liver disease and listed for primary solitary liver transplant.<br>* Other names: Liver transplant;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Percent of Participants With Biopsy-Proven Acute and/or Chronic Rejection | Biopsy-proven acute rejection graded as Mild, Moderate or Severe, per 1997 Banff classification. Chronic Rejection graded using Banff 2000 classification. References: 1.) Banff Schema for Grading Liver Allograft Rejection: An International Consensus Document developed by an international panel of experts in liver transplantation pathology, hepatology, and surgery (Hepatology 1997; 25(3): 658-663). 2.) Update of the International Banff Schema for Liver Allograft Rejection: Working Recommendations for the Histopathologic Staging and Reporting of Chronic Rejection (Hepatology 2000; 31(3): 792-799). | Transplantation to 40 Weeks Post Transplantation | 
| Percent of Participants With Grade 3 or Higher Infectious Adverse Event(s) | The severity of infectious adverse events (AEs) was classified into grades as follows: Grade 1 = asymptomatic; clinical or diagnostic observation only; intervention with oral antibiotic, antifungal, or antiviral agent only; no invasive intervention required Grade 2 = symptomatic; intervention with intravenous antibiotic, antifungal, or antiviral agent; invasive intervention may be required Grade 3 = any infection associated with hemodynamic compromise requiring pressors; any infection necessitating intensive care unit level of care; any infection necessitating operative intervention; any infection involving the central nervous system; any infection with a positive fungal blood culture; any proven or probable aspergillus infection; any tissue invasive fungal infection; any pneumocystis jiroveci infection Grade 4 = life-threatening infection Grade 5 = death resulting from infection | Transplantation to 40 Weeks Post Transplantation | 
| Percent of Participants With Grade 3 or Higher Wound Complication(s) Adverse Event(s) | The severity of adverse events (AEs) was classified into grades using the National Cancer Institute Common Terminology Criteria for Adverse Events (NCI-CTCAE) version 4.0 (4/28/2009): Grade 3 wound complications are defined as Hernia without evidence of strangulation; fascial disruption/dehiscence; primary wound closure or revision by operative intervention indicated Grade 4 complications are defined as Hernia with evidence of strangulation; major reconstruction flap, grafting, resection, or amputation indicated | Transplantation to 40 Weeks Post Transplantation | 
| Percent of Participants With Grade 2 or Higher Hematologic Adverse Events (AEs) of Anemia, Neutropenia, and/or Thrombocytopenia | The severity of adverse events (AEs) was classified into grades using the National Cancer Institute Common Terminology Criteria for Adverse Events (NCI-CTCAE) version 4.0 (4/28/2009): Grade 1 = mild AE Grade 2 = moderate AE Grade 3 = severe and undesirable AE Grade 4 = life-threatening or disabling AE Grade 5 = death | Transplantation to 40 Weeks Post Transplantation | 
| Percent of Participants With Adverse Events (AEs) Attributable to the Donor Alloantigen Reactive Tregs (darTregs) Infusion | AEs classified by the site investigator/clinician as possibly or definitely related to the study treatment, the Donor Alloantigen Reactive Tregs (darTregs) infusion. These AEs include: infusion reaction Grade 3 or higher cytokine release syndrome (Reference: National Cancer Institute Common Terminology Criteria for Adverse Events (NCI-CTCAE) version 4.0 (4/28/2009) grading criteria malignant cellular transformation. | Transplantation to 40 Weeks Post Transplantation | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Donor-Alloantigen-Reactive Regulatory T Cell Therapy, Tregs, Cell- and Tissue-Based Therapy, Immunotherapy, Adoptive, Liver Transplantation