Immunomodulatory Effect of Vitamin D in Allogenic Post-transplant

Study Overview
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Brief Summary
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The purpose of this study is to determine whether vitamin D is effective in the prevention of graft-versus-host-disease after completion of allogeneic transplant.

Detailed Description
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The allogeneic transplant of haematopoietic cell is the only treatment option for many malignant blood diseases. Unfortunately, the progression free survival and the quality of life of transplanted patients is limited due to the development of graft-versus-host-disease (GVHD). The development of new prophylaxis strategies of GVHD based in the use of immunomodulator agents (allowing the generation of an immunotolerance state and avoiding the use of immunosuppression) is essential. The GVHD is due to the cytotoxic effect of the donor lymphocytes T against healthy organs and tissues of the receptor. Calcineurin inhibitor combined with methotrexate or antibodies anti-lymphocytes T are used as standard prophylaxis. This type of antibodies has demonstrated efficacy to reduce GVHD, but have not increased survival due to increasing the risk of relapses and serious post-transplant infections. Due to its interactions with VDR (vitamin D receptor) present in immune system cells, vitamin D is able to inhibit the activation of dendritic cells and the proliferation and production of cytokines by lymphocytes T. Based on this effect, the peri- and post- transplant administration of vitamin D might decrease the risk of GVHD in allogeneic transplanted patients, subsequently decreasing the immunosuppressant treatment requirements and improving the prognosis of those patients.

Official Title
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Immunomodulatory Effect of Vitamin D in Allogenic Post-transplant

Conditions
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Hematopoietic Stem Cell Transplantation

Intervention / Treatment
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* Drug: 1000IU/day of Vitamine D
* Drug: 5000IU/day of Vitamine D


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Age ≥ 18 years The patient should accomplish all the criteria to proceed to an allogeneic transplant The patient or their legal guardians should signed the informed consent approved by the Ethics Committees of Clinical Trials Exclusion Criteria: Hypercalcemia ≥ 10.5 mg/dl Renal insufficiency with creatinine level ≥ 2 x upper limit of normal (1,1 mg/dl) Participation in others Clinical Trials in which the intervention may affect the result of the study. Patients receiving GVHD immunoprophylaxis with thymoglobuline or GVHD prophylaxis including in vitro or in vivo lymphocytes T depletion (anti-lymphocyte T globulin, ALG) Patients receiving a transplant from an haploidentical donor

Ages Eligible for Study
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Minimum Age: 18 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: Prevention
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| No Intervention: Group 1: Control<br>Control group is composed by the first 50 patients included in the study. Those patients will not receive the treatment. Evaluations and follow-up will be the same as in the other groups. | |
| Experimental: Group 2: 1000IU/day of Vitamine D<br>It is composed by the following 50 patients joining the study. They will take 1000 IU of vitamin D once a day. | Drug: 1000IU/day of Vitamine D<br>* Administration of a specified dose of Vitamine D<br>* Other names: Vitamine D dose of 1000 international units (IU);|
| Experimental: Group 3: 5000IU/day of Vitamine D<br>It is composed by the last 50 patients joining the study. They will take 5000 IU of vitamin D once a day. | Drug: 5000IU/day of Vitamine D<br>* Administration of a specified dose of Vitamine D<br>* Other names: Vitamine D dose of 5000 international units (IU);|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Incidence/severity of Graft-Versus-Host-Disease | Number of cases of GVHD/Seriousness graded according to National Institutes of Health Consensus Development Project on Criteria for Clinical Trials in Chronic Graft-versus-Host Disease | Day +150 post-transplant | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Serum levels of Th1/Th2 cytokines | (IL-2, IL-4, IL-6, IL-10, tumor necrosis factor alfa (TNF)-α and interferon gamma (IFN-g)) are determined by flow cytometry using the BD Human Th1/Th2 Cytokine CBA | Day -5 pre-transplant and +1, +7, +21,+56 and +100 post-transplant | 
| Dendritic cells | The following markers were used to identify different subpopulations CD16-PB, CD45-V500, HLADR-FITC, BDCA-PE, CD11c-PerCP-Cy5.5, CD86-PE-Cy7, CD123-APC and CD14-APC-H7. Plasmacytoid dendritic cells: HLADR+ CD123++ CD11c- CD16- CD14- BDCA1- CD45+. Monocyte-derived dendritic cells: HLADR+ CD123+d CD11c+ CD16++ CD14-/+d BDCA- CD45+. Myeloid BDCA1 dendritic cells : HLADR+ CD123- CD11c+ CD16- CD14- BDCA+ CD45+ | Day +21,+56 and +100 post-transplant | 
| Subpopulations of lymphocytes | To be identified using the combination CD19+CD8-FITC, CD3+CD56-PE, CD4- PerCP-Cy5.5, HLADR-APC T cells: CD3+ (CD3+CD4+CD8-, CD3+CD4-CD8+, CD3+CD4+CD8+, CD3+CD4-CD8+) B cells: CD19+ HLADR+ NK cells: CD3- CD19- CD56+ CD45RA-FITC and CCR7-PE were used to distinguish the repertory of naive/effector/memory of CD4 and CD8 cells. -naive T cells: CD45RA+CCR7+ -effector T cells: CD45RA+CCR7- -central memory T cells: CD45RA-CCR7+ -Peripheral memory T cells: CD45RA-CCR7- | Day +21,+56 and +100 post-transplant | 
| Regulatory T cells | after incubation of surface antigens (CD25-FITC, CD127-PE and CD4-PerCP-Cy5.5), cells were washed in PBS and then fixed and permeabilized with FoxP3 Staining Buffer Set (eBiosciences) for FOXP3 staining. phenotype of Treg: CD4+CD25+CD127-/+wFoxP3+ | Day +21,+56 and +100 post-transplant | 
| NK markers | using the following combinations: CD94-FITC/CD56-PE/CD3-PerCP-Cy5.5/HLADR-APC CD11a-FITC/CD16-PE/CD3-PerCP-Cy5.5/CD56-APC CD158a-FITC/CD161-PE/CD3-PerCP-Cy5.5/CD56-APC CDNKB1-FITC/NKAT-PE/CD3-PerCP-Cy5.5/CD56-APC We identify NK cells with weak expression of CD56 (CD56 called  weak) and those expressing more intensely this marker CD56 bright . In addition the expression of different KIR receptor as CD158a , CD161 , and NKAT2 NKB1 were reported. | Day +21,+56 and +100 post-transplant | 
| Activation of T cells | Activation assays are performed on 500 µl of peripheral blood added in 48-well plates. Peripheral blood is stimulated or not with PMA (20µg/2ml) and ionomycin (0.91 µg/ml). | Day +21,+56 and +100 post-transplant | 
| Peak Plasma Concentration (Cmax) of Vitamin D | Peak Plasma Concentration (Cmax) | Day -5 pre-transplant and +1, +7 and +21 post-transplant | 
| Area under the plasma concentration of Vitamin D | Area under the plasma concentration versus time curve (AUC) | Day -5 pre-transplant and +1, +7 and +21 post-transplant | 
| Bone densitometry changes carried out by protocol in post-transplant period | Treatment effect in the subsequent development of osteoporosis | Day +150 post-transplant | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Graft-Versus-Host-Disease, post-allogeneic transplant, haematopoietic progenitors