single-arm open label interventional phase
8 schedule of patient activities

Scheduled evaluations after screening and until engraftment may be performed +/-3 days from the targeted date; assessments performed after engraftment and through day 100 may be done +/-7 days of the targeted date. After day 100 assessments may be done +/- 30 days of the targeted date. In addition, targeted days may be altered as clinically appropriate (e.g., intercurrent illness, maximum blood volume for clinical care preventing research lab testing, patient refusal).  
| Schedule of Assessments - Standard of Care Study Phase Screening Conditioning 24 MGTA456                                               | Follow up                                       |          |      |      |    |    |     |     |             |    |     |     |        |
|-----------------------------------------------|-------------------------------------------------|----------|------|------|----|----|-----|-----|-------------|----|-----|-----|--------|
| Study Day(s)                                  | -60 to -10                                      | -8 to -1 | 0    | 7    | 14 | 21 | 28  | 35  | 42          | 60 | 100 | 180 | 360±30 |
| ±3                                            | ±3                                              | ±3       | ±3   | ±3   | ±3 | ±3 | ±10 | ±30 | and  720±30 |    |     |     |        |
| Informed                                      | X                                               |          |      |      |    |    |     |     |             |    |     |     |        |
| Consent                                       | SCRF                                            |          |      |      |    |    |     |     |             |    |     |     |        |
| Pregnancy test1                               | X                                               |          |      |      |    |    |     |     |             |    |     |     |        |
| SCRF                                          | X                                               |          |      |      |    |    |     |     |             |    |     |     |        |
| (at 360  only)                                |                                                 |          |      |      |    |    |     |     |             |    |     |     |        |
| Medical  history/current  medical  conditions | OCRF                                            |          |      |      |    |    |     |     |             |    |     |     |        |
| At every visit with a medical provider        |                                                 |          |      |      |    |    |     |     |             |    |     |     |        |
| Concomitant  therapies                        | Reviewed at every visit with a medical provider |          |      |      |    |    |     |     |             |    |     |     |        |
| Body height                                   | X                                               |          |      |      |    |    |     |     |             |    |     |     |        |
| SCRF                                          |                                                 |          |      |      |    |    |     |     |             |    |     |     |        |
| Vital signs2                                  | X                                               | X        |      |      |    |    |     |     |             |    |     |     |        |
| SCRF                                          | ICRF                                            |          |      |      |    |    |     |     |             |    |     |     |        |
| Physical                                      | X                                               |          |      |      |    |    |     |     |             |    |     |     |        |
| examination                                   | OCRF                                            |          |      |      |    |    |     |     |             |    |     |     |        |
| At every visit with a medical provider        |                                                 |          |      |      |    |    |     |     |             |    |     |     |        |
| Karnofsky /  Lansky  Performance  status      | X                                               | X        | X    | X    | X  |    |     |     |             |    |     |     |        |
| SCRF                                          | OCRF                                            | OCRF     | OCRF | OCRF |    |    |     |     |             |    |     |     |        |
| Echocardiogra m ECHO or  MUGA                 | X                                               | X        |      |      |    |    |     |     |             |    |     |     |        |
| SCRF                                          | OCRF                                            |          |      |      |    |    |     |     |             |    |     |     |        |
| Adults: chest xray/ chest CT Peds: chest CT                                               | X                                               |          |      |      |    |    |     |     |             |    |     |     |        |
| SCRF                                          |                                                 |          |      |      |    |    |     |     |             |    |     |     |        |
| PFT (if capable)                              | X                                               | X        |      |      |    |    |     |     |             |    |     |     |        |
| otherwise S02                                 | SCRF                                            | OCRF     |      |      |    |    |     |     |             |    |     |     |        |
| GFR or  creatinine clearance                  | X                                               |          |      |      |    |    |     |     |             |    |     |     |        |
| SCRF                                          |                                                 |          |      |      |    |    |     |     |             |    |     |     |        |
| Hematology3                                   | X                                               | X Daily  | X    | X    | X  | X  | X   | X   | X           | X  | X   | X   |        |
| SCRF                                          |                                                 |          |      |      |    |    |     |     |             |    |     |     |        |
| Blood                                         | X                                               |          |      |      |    |    |     |     |             |    |     |     |        |
| SCRF                                          | X                                               |          |      |      |    |    |     |     |             |    |     |     |        |
| chemistries                                   |                                                 |          |      |      |    |    |     |     |             |    |     |     |        |  
| Study Phase                | Screening   | Conditioning 24   | MGTA456      | Follow up   |      |      |      |      |             |    |     |     |        |
|----------------------------|-------------|-------------------|------|-------------|------|------|------|------|-------------|----|-----|-----|--------|
| Study Day(s)               | -60 to -10  | -8 to -1          | 0    | 7           | 14   | 21   | 28   | 35   | 42          | 60 | 100 | 180 | 360±30 |
| ±3                         | ±3          | ±3                | ±3   | ±3          | ±3   | ±3   | ±10  | ±30  | and  720±30 |    |     |     |        |
| Immunoglobulin             | X           | X                 | X    | X           | X    | X    |      |      |             |    |     |     |        |
| levels                     | OCRF        | OCRF              | OCRF | OCRF        | OCRF | OCRF |      |      |             |    |     |     |        |
| Viral screen4              | X           |                   |      |             |      |      |      |      |             |    |     |     |        |
| SCRF                       |             |                   |      |             |      |      |      |      |             |    |     |     |        |
| CMV and EBV                | X           | X                 | X    | X           | X    | X    | X    | X    | X           |    |     |     |        |
| surveillance               | SCRF        | OCRF              | OCRF | OCRF        | OCRF | OCRF | OCRF | OCRF | OCRF        |    |     |     |        |
| HHV6  surveillance  (pcr)  | X           | X                 | X    | X           | X    | X    | X    |      |             |    |     |     |        |
| SCRF                       | OCRF        | OCRF              | OCRF | OCRF        | OCRF | OCRF |      |      |             |    |     |     |        |
| Anti-HLA                   | X           |                   |      |             |      |      |      |      |             |    |     |     |        |
| antibody                   | SCRF        |                   |      |             |      |      |      |      |             |    |     |     |        |
| GVHD score5                | X           | X                 | X    | X           | X    | X    | X    | X    | X           | X  |     |     |        |
| OCRF                       | OCRF        | OCRF              |      |             |      |      |      |      |             |    |     |     |        |
| Adverse  events6           | SAEs only   | X                 |      |             |      |      |      |      |             |    |     |     |        |
| Disease Status             | X           | X                 | X    | X           |      |      |      |      |             |    |     |     |        |
| Assessments                | SCRF        | OCRF              | OCRF | OCRF        |      |      |      |      |             |    |     |     |        |
| Chimerism7 (CD3,  CD33/66) | X           | X                 | X    | X           | X    |      |      |      |             |    |     |     |        |
| OCRF                       | OCRF        | OCRF              | OCRF | OCRF        |      |      |      |      |             |    |     |     |        |
| T-cell subsets             | X           | X                 | X    | X           | X    |      |      |      |             |    |     |     |        |
| OCRF                       | OCRF        | OCRF              | OCRF | OCRF        |      |      |      |      |             |    |     |     |        |  
Abbreviations: LTFU=long term follow-up; ECHO=echocardiogram; MUGA=multigated acquisition; PFT=pulmonary function tests; GFR=glomerular filtration rate; CMV=cytomegalovirus;HHV6=human herpes virus 6; GVHD=graft-versus-host disease; SAE=severe adverse event; SCRF=result recorded in a screening case report form; OCRF=result recorded in outcomes case report form; ICRF=result recorded in infusion case report form; x=result retained in electronic medical record with specific results eg days to ANC and platelet recovery, retained in the BMT database. Dates of transfusions, resource utilization and costs will be obtained from the electronic medical record and Fairview Health System after day 100 with summary files maintained in the BMT database. 1 For females of child bearing potential (post-menarche), serum pregnancy testing is required at screening and 1 year visits. If not done within 7 days of Day -9, pregnancy test must be repeated prior to initiating conditioning.  
2 Vital signs include body weight, body temperature, blood pressure, pulse, and pulse oximetry. Vital signs will be checked before and every 15 minutes during the infusion, at the completion of the infusion, and one hour post infusion per institutional guidelines. More frequent vital signs may be required depending on reactions to the product infusion. Weight will be collected at pre-infusion only. The highest temperature recorded within 24 hr period will be reported.  
3 Hematology will need to be repeated daily during inpatient hospitalization, then at every scheduled visit. The patient will remain hospitalized until neutrophil engraftment is achieved.  
4 All patients will be screened for hepatitis B surface antigen (HBsAg), hepatitis B core antibody (HBcAb), hepatitis C virus (HCV), herpes simplex virus (HSV),
cytomegalovirus, (CMV), Epstein-Barr virus (EBV), and human T cell lymphotropic virus 1/2 (HTLV1/2). After Screening, infection surveillance will include human herpesvirus 6 (HHV-6) (to be tested weekly through Day 42), and CMV and EBV (to be tested weekly through Day 100).  
5 Weekly assessments for GVHD is collected starting at Day 7 until hospital discharge, and then at every scheduled visit. aGVHD will be collected until Day 100 and cGVHD will be collected starting at Day 100 and then at Day 180 and 360/EOS
6 AEs must be reported starting from the day of transplant Day 0 and per the timeline specified in Section 9. SAEs will be collected from the time conditioning is initiated at Day -9 and per the timeframe specified in Section 9.  
7 Chimerism will be assessed by sorting for 4 subsets - CD3 T cells, CD33/66 myeloid cells, CD19 B cells and CD56 NK cells. Evaluation of CD3 and CD33/66 subsets is considered SOC assessments on days 21, 28, 35, 42, 60, 100, 180, 360 and 720. Blood volume limits will be monitored for all patients; if the blood volume for SOC blood work exceeds the maximum allowable, research blood samples will either be cancelled or delayed until a date and time it is considered appropriate based on institutional criteria.  
| Study Phase                                                                | Screening   | Conditioning   | MGTA456      | Follow up   |      |      |      |     |     |             |     |      |     |        |
|----------------------------------------------------------------------------|-------------|----------------|------|-------------|------|------|------|-----|-----|-------------|-----|------|-----|--------|
| Study Day(s)                                                               | -60 to -10  | -8 to -1       | 0    | 7           | 14   | 21   | 28   | 35  | 42  | 60          | 100 | 1206 | 180 | 360±30 |
| ±3                                                                         | ±3          | ±3             | ±3   | ±3          | ±3   | ±3   | ±10  | ±10 | ±30 | and  720±30 |     |      |     |        |
| MGTA-456                                                                   | X           |                |      |             |      |      |      |     |     |             |     |      |     |        |
| Infusion1,2                                                                | OCRF        |                |      |             |      |      |      |     |     |             |     |      |     |        |
| Chimerism3, 8  (CD19/20)  (CD16/56)                                        | X           | X              | X    | X           | X    | X    | X    |     |     |             |     |      |     |        |
| OCRF                                                                       | OCRF        | OCRF           | OCRF | OCRF        | OCRF | OCRF | OCRF |     |     |             |     |      |     |        |
| X                                                                          |             |                |      |             |      |      |      |     |     |             |     |      |     |        |
| Chimerism3, 8                                                              | X           | X              |      |             |      |      |      |     |     |             |     |      |     |        |
| (CD3, CD33/66)                                                             | OCRF        | OCRF           | X    | X           |      |      |      |     |     |             |     |      |     |        |
| OCRF                                                                       | OCRF        | OCRF           |      |             |      |      |      |     |     |             |     |      |     |        |
| X                                                                          |             |                |      |             |      |      |      |     |     |             |     |      |     |        |
| Cellular immune                                                            | X           | X              | X    | X           | X    | X    | X    |     |     |             |     |      |     |        |
| reconstitution4                                                            | OCRF        | OCRF           | OCRF | OCRF        | OCRF | OCRF | OCRF |     |     |             |     |      |     |        |
| T cell repertoire4                                                         | X           | X              | X    | X           | X    | X    | X    |     |     |             |     |      |     |        |
| OCRF3                                                                      | OCRF        | OCRF           | OCRF | OCRF        | OCRF | OCRF |      |     |     |             |     |      |     |        |
| TREC5                                                                      | X           | X              | X    | X           | X    | X    |      |     |     |             |     |      |     |        |
| OCRF                                                                       | OCRF        | OCRF           | OCRF | OCRF        | OCRF |      |      |     |     |             |     |      |     |        |
| Serologies: Hep B,  polio, pertussis,  diphtheria,  tetanus,  pneumococcal | X           | X              | X    |             |      |      |      |     |     |             |     |      |     |        |
| OCRF                                                                       | X           |                |      |             |      |      |      |     |     |             |     |      |     |        |
| OCRF                                                                       | OCRF        | OCRF           |      |             |      |      |      |     |     |             |     |      |     |        |
| X                                                                          |             |                |      |             |      |      |      |     |     |             |     |      |     |        |
| Pediarix and  Pneumovax  vaccines9                                         | X           | X              |      |             |      |      |      |     |     |             |     |      |     |        |
| OCRF                                                                       | OCRF        | OCRF           |      |             |      |      |      |     |     |             |     |      |     |        |
| X                                                                          |             |                |      |             |      |      |      |     |     |             |     |      |     |        |
single-arm open label interventional phase
schedule of assessments - research

Abbreviations: OCRF=result recorded in outcomes case report form 1 Two therapeutic cell preparations will be infused sequentially in the following order. First= a target cell dose is >10 x 106 CD34/kg. However, if the cell dose is <
the target of 10 x 106 CD34/kg, it may be infused as long as it exceeds 1x106 CD34+/kg BW cells will be administered. With regard to TNC, the maximum cell dose is 2.7 x 108/kg for children (<18 years) and 8.1 × 108 cells/kg for adults [expanded product only] based on the highest cell dose windows evaluated in prior studies. There is no lower limit for TNC dose, only a lower limit for CD34 dose.. The exact dose level achieved after stem cell expansion should be recorded. Second = CD34- negative fraction from the same UCB unit. All available CD34-negative cells will be administered.  
2.Graft Evaluation. The total number of CD3+ and CD34+ cells and methylcellulose colony-forming cells will be enumerated for all UCB grafts beinfused into the patient regardless prior processing (standard of care). Proportions of CD34+CD133+CD90+ cells and T cell subsets will also be determined (research).  
3.Chimerism will be assessed by sorting for 4 subsets - CD3 T cells, CD33/66 myeloid cells, CD19 B cells and CD56 NK cells. Evaluation of CD19 and CD56 is research at all time points; evaluation of CD3 and CD33/66 subsets is research on days 7 and 14 but not for other time points, as this would be considered SOC assessments on days 21, 28, 35, 42, 60, 100, 180, 360 and 720. Blood volume limits will be monitored for all patients; if the blood volume for SOC blood work exceeds the maximum allowable, research blood samples will either be cancelled or delayed until a date and time it is considered appropriate based on institutional criteria.  
4 Immune Reconstitution. Patients will also have an extensive evaluation of immune reconstitution, including NK and B cell subset but particular emphasis on T
cell subsets, ie TCR rearrangement excision circles (TREC) and naïve (CD45RA+/CD27+), central memory (CD45RA+CD27-), effector memory (CD45RACD27-) and stem/memory (Tsm, CD8/45RA/62L/95/CCR7+) populations, as well as TCR repertoire diversity. In addition, Quantitative recovery of immunoglobulin synthesis and functional T and B cell generation and antigen driven responses in response to immunizations will be evaluated. For adult patients, six 10 mL green heparin tubes and one 10 mL red top tube at each time point. For pediatric patients, two 10 mL green heparin tubes and one 5 mL red top tube (not to exceed 2 mL/kg in patients ≤ 40kg ) per time point 5 Frozen cells (no extra blood) 6 At subject's home clinic/provider 7 Diphtheria and tetanus ab panel(lab 792) 0.8 ml-2 ml red top; polio antibody (lab 653) 0.6 ml-2.0 ml red top; hepatitis B surface antibody (lab 6383) 1.2 ml-2 ml red top; B. pertussis lab 6759 0.8-2 ml red top; pneumo 7 (lab 5896) 0.7-3 ml red top.  
8 If at any time point WBC < 500, do not draw sample for chimerism 9 Unless there is active acute or chronic GVHD. Missed immunizations will not be considered study deviations.
single-arm open label interventional phase
9 adverse event monitoring recording

Toxicity and adverse events will be classified according to NCI's Common Terminology Criteria for Adverse Events V 5.0 (CTCAE) and reported on the schedule below. A copy of the CTCAE events can be downloaded from http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm\#ctc_50
single-arm open label interventional phase
9.1definitions

The following definitions are based on the Code of Federal Regulations Title 21 Part 312.32
(21CFR312.32(a)).  
Adverse Event: Any untoward medical occurrence associated with the use of a drug in humans, whether or not considered drug related.  
Suspected Adverse Reaction: Any adverse event for which there is a reasonable possibility that the drug caused the adverse event.  
Treatment-Emergent Adverse Event: Any event not present prior to the initiation of the treatment or any event already present that worsens in either intensity or frequency following exposure to the treatment. A treatment emergent AE refers to an event temporally related to the study treatment regardless of the causality assessment by the investigator.
single-arm open label interventional phase
life-threatening adverse event or life-threatening

adverse event or suspected adverse reaction 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. Note: a life-threatening event does not necessarily equate to a CTCAE grade 4.  
Serious Adverse Event Or Serious Suspected Adverse Reaction: An adverse event or suspected adverse reaction is considered "serious" if, in the view of either the investigator or sponsor, it results in any of the following outcomes:
- Death
- A life-threatening adverse event
- Inpatient hospitalization or prolongation of existing hospitalization
- A persistent or significant incapacity or substantial disruption of the ability to conduct normal life functions
- A congenital anomaly/birth defect.
Important medical events that may not result in death, be life-threatening, or require hospitalization may be considered serious when, based upon appropriate medical judgment, they may jeopardize the patient or subject and may require medical or surgical intervention to prevent one of the outcomes listed in this definition.
single-arm open label interventional phase
unexpected adverse event or unexpected

or suspected adverse reaction is considered "unexpected" if it is not listed in the investigator brochure or is not listed at the specificity or severity that has been observed; or, if an investigator brochure is not required or available, is not consistent with the risk information described in the general investigational plan or elsewhere in the current application, as amended. Thus, as defined by the FDA adverse events that occur as part of the disease process or underlying medical conditions are considered *unexpected;* however, for the purposes of this study they will not be documented or reported.
single-arm open label interventional phase
9.2adverse event monitoring recording and

Monitoring for adverse events will begin with MGTA infusion and continue through 2 year post-transplant anniversary visit.
single-arm open label interventional phase
9.2.2 event recording/documentation

Due to the intentional use of chemotherapy and radiation to eliminate residual leukemia and provide adequate immune suppression to reduce the risk of graft rejection, numerous toxicities are anticipated in this patient population as detailed in section 7. Therefore, adverse event documentation in OnCore for the purposes of this study will focus on:  
- All grade 4 or 5 non-hematologic adverse events through neutrophil engraftment or Day 42, whichever is shorter
- All serious unexpected suspected adverse reactions after Day 42 (or engraftment) through 2 years post-transplant upon knowledge
- Targeted toxicities (appendix V) for all patients at the following time points:
o Prior to the MGTA infusion o 4 hours (+/- 1 hour) post UCB infusion o 24 hours (+/- 1 hour) post UCB infusion o 48 hours (+/- 1 hour) post UCB infusion
Transplant related outcomes will be collected as routine by the BMT Database.
single-arm open label interventional phase
9.2.3 event reporting to the

Certain events will require prompt reporting according to the table below:  
| Agency                                                                                                                                                                                                                                                                                                                             | Criteria for reporting                 | Timeframe   | Form to   | Submission  information   | Copy to:   |
|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|----------------------------------------|-------------|-----------|---------------------------|------------|
| Use                                                                                                                                                                                                                                                                                                                                |                                        |             |           |                           |            |
| Events requiring prompt reporting  including, but not limited to  unanticipated death of a locally enrolled  subject(s); new or increased risk; any  adverse event that require a change to  the protocol or consent form or any  protocol deviation that resulting in harm  refer to  http://www.research.umn.edu/irb/forms. html | within 5  business  days of  discovery | Report      | irb@      | SAE                       |            |
| Form                                                                                                                                                                                                                                                                                                                               | umn.edu                                | Coordinator mccsaes@umn. edu             |           |                           |            |
| IRB                                                                                                                                                                                                                                                                                                                                |                                        |             |           |                           |            |
| Masonic Cancer  Center SAE  Coordinator Events that meet the definition of dose                                                                                                                                                                                                                                                    | reporting                              | Event Form  | mccsaes@u |                           |            |
| At time of                                                                                                                                                                                                                                                                                                                         |                                        |             |           |                           |            |
| limiting toxicity or an early study stopping                                                                                                                                                                                                                                                                                       | mn.edu                                 |             |           |                           |            |
| rule                                                                                                                                                                                                                                                                                                                               |                                        |             |           |                           |            |  
| Unexpected fatal or unexpected life                                                                                                                                                                       | As soon as                                                                |                          |              |
|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------|--------------------------|--------------|
| threatening suspected adverse reaction                                                                                                                                                                    | possible but  no later than  7 calendardays                                                                           | Institution al SAE  form | Submit as an |
| 1) Serious and unexpected suspected                                                                                                                                                                       | amendment                                                                 |                          |              |
| adverse reaction or                                                                                                                                                                                       | to IND                                                                    |                          |              |
| 2) increased occurrence of serious  suspected adverse reactions over that  listed in the protocol or investigator brochure or 3) findings from other sources (other  studies, animal or in vitro testing) |                                                                           |                          |              |
| FDA                                                                                                                                                                                                       | As soon as  possible but  no later than  15 calendardays                                                                           |                          |              |
| Note: Events due to the disease under treatment or an preexisting medical condition will not  require expedited reporting to the FDA for the purposes of this study                                       |                                                                           |                          |              |
| Magenta                                                                                                                                                                                                   | 1) Product manufacturing failures 2) Failure of hematopoietic engraftment |                          |              |  
At the time of continuing review/IND annual report, relevant events recorded in OnCore will be reported in summary format by those persons responsible for such reporting.
single-arm open label interventional phase
9.3monitoring for stopping rule events

In addition to the event monitoring and reporting described in the previous section, the following events will be considered excess toxicity and be reported using the Event Form found in OnCore:  
- Excess graft failure at day 42
- Excess TRM at day 100
- Excess grade III-IV acute GVHD
A copy of the completed Event Form must be sent to the SAE Coordinator (mccsaes@umn.edu) at the time it is submitted to the study statistician.  
As these events are outcomes of the treatment, not toxicity as found in CTCAE, they should only be recorded/reported as an AE, if they meet the criteria found in section 9.2
single-arm open label interventional phase
10 study data collection and

This study will collect regulatory and clinical data using University of Minnesota CTSI's instance of OnCore® (Online Enterprise Research Management Environment).  
The Oncore database resides on dedicated secure and PHI compliant hardware consisting of 3 physical servers: dev, DR, and production. The dev server is located in the University of Minnesota (UMN) datacenter (WBOB) and houses six database instances (test, train, sandbox, mcc reports, oncdm, and vendor) that are backed up locally because the data is refreshed from Oncore production data. The production server is located in the UMN datacenter (WBOB). All the data servers are managed by the Academic Health Center - Information Systems (AHC-IS) virtual servers which utilize clustered infrastructure to provide real-time failover of virtual servers. This real-time clustering is physically limited to the UMN data center. All relevant AHC IS procedures related for PHI compliant servers (as required by the Center of Excellence for HIPAA
Data) apply to Oncore databases.  
The integrated data will be stored in PHI compliant servers managed by AHC IS with access given to those authorized users in the Clinical and Translation Science Institute Informatics team (CTSI BPIC and MCC CISS). The data will be integrated and extracted to researchers through the CTSI Informatics team and will be delivered through secure and compliant mechanisms (e.g. AHC IE data shelter, BOX, sftp, etc). If data deidentification is needed, then compliant AHC IE data de-identification tools will be used.  
The informatics team will grant the IRB approved study team members access to data. Additional data about correlative laboratory samples generated by the Masonic Cancer Center Translational Therapy Laboratory (TTL) from the protocol-directed correlative research samples is stored in their Laboratory Information Management System
(LIMS).The LIMS database application is also stored on a production server located in the UMN datacenter (WBOB) and is managed by the Academic Health Center Key study personnel are trained on the use of OnCore and will comply with protocol specific instructions embedded within the OnCore.
single-arm open label interventional phase
10.2 case report forms

Participant data will be collected using protocol specific CRFs developed within OnCore, based on its library of standardized forms. The CRFs will be approved by the study's Principal Investigator and the Biostatistician prior to release for use. There is a screening case report form (SCRF) which the Study Coordinator or designee will use to register the patient into OnCore at time of study entry. An infusion case report form (ICRF) will be used to document adverse events during the infusion of MGTA-456
(expanded product and CD34 depleted product) and outcomes case report form (OCRF) will record specific outcomes data for submission to the BMT Database. As medications, blood product administration, provider examinations and laboratory/radiographic data are accessible to the BMT Database through a Data Sharing Agreement, CRFs will only be needed for specific data collection.
single-arm open label interventional phase
10.3 data and safety monitoring

The study's Data and Safety Monitoring Plan will be in compliance with the University of Minnesota Masonic Cancer Center's Data & Safety Monitoring Plan (DSMP), which can be accessed at http://z.umn.edu/dmsp For the purposes of data and safety monitoring, this study is classified as high risk
(under a locally held IND). Therefore the following requirements will be fulfilled:  
The Masonic Cancer Center Data and Safety Monitoring Council (DSMC) will review the study's progress at least quarterly with the understanding the Cancer Protocol Review Committee (CPRC) may require more frequent reporting.  
The PI will comply with at least twice yearly monitoring of the project by the Masonic Cancer Center monitoring services.  
The PI will oversee the submission of all reportable adverse events per the definition of reportable in section 9.2.3 to the Masonic Cancer Center's SAE Coordinator, the University of Minnesota IRB, and the FDA.
In addition, at the time of the continuing review with the University of Minnesota IRB, a copy of the report with any attachments will be submitted to the CPRC.
single-arm open label interventional phase
10.4 ind annual reports

In accordance with regulation 21 CFR § 312.33, the sponsor-investigator with assistance from the MCC Clinical Trials Office (CTO) will submit a progress report annually. The report will be submitted within 60 days of the anniversary date that the IND went into effect.
single-arm open label interventional phase
10.5 data sharing with magenta

Only data related to MGTA-456 product manufacturing data and product failures (lot release, failure to engraft) will be shared with Magenta.
single-arm open label interventional phase
10.6 monitoring

The investigator will permit study-related monitoring, audits, and inspections by the IRB,
government regulatory bodies, and University of Minnesota compliance groups. The investigator will make available all study related documents (e.g. source documents, regulatory documents, data collection instruments, study data, etc.). The investigator will ensure the capability for inspections of applicable study-related facilities (e.g. pharmacy, diagnostic laboratory, etc.) will be available for trial related monitoring, audits, or regulatory inspections.
single-arm open label interventional phase
10.7 study record retention

The investigator will retain study records including source data, copies of case report form, consent forms, HIPAA authorizations, and all study correspondence in a secured facility for at 6 years after the study file is closed with the IRB and FDA.  
In addition, the CTO will keep a master log of all patients participating in the study with sufficient information to allow retrieval of the medical records for that patient.  
Please contact the CTO before destroying any study related records.
single-arm open label interventional phase
11 definition of study endpoints

All patients will have daily complete blood counts beginning on day +1 with white blood cell differential assessments beginning when the total WBC ≥0.5 x 109/L. The day of neutrophil recovery will be the first of three consecutive days when the ANC is ≥0.5 x 109/L.
single-arm open label interventional phase
11.2 platelet recovery

The frequency of platelet count assessments will vary over the course of the transplant period. During the firsts 100 days after transplant, all patients will have at least weekly platelet counts. The day of platelet recovery will be the first of three consecutive measurements when the platelet count is ≥20,000 x 109/L without a platelet transfusion in the prior 7 days.
single-arm open label interventional phase
11.3 engraftment

Engraftment is determined by neutrophil recovery with hematopoietic cells of donor origin
(chimerism). Complete chimerism is defined as 90-100% of marrow cells or CD33/66+ peripheral blood cells of donor origin. Partial chimerism is defined as 10-90% donor cells and autologous recovery is defined as 0-10% donor cells.
single-arm open label interventional phase
11.4 graft failure

Graft failure is the absence of neutrophil recovery or lack of chimerism from any etiology.  
- **Primary Graft Failure** is defined by the absence of neutrophil recovery by day 42 after UCBT or absence of chimerism before day 42. Note: Patients surviving ≥14 days will be considered evaluable and patients receiving a 'back-up' unmanipulated graft within 5 days of the transplant, as a result of bioassays outside the specification limits for MGTA-456, will not be considered evaluable
- **Secondary Graft Failure** is defined by a recurrence of neutropenia (ANC <0.5 x 109/L
lasting >7 days) or autologous recovery after prior engraftment.
single-arm open label interventional phase
11.5 graft-versus-host disease

GVHD is the immune response of donor cells directed against host tissues. There are two distinct forms - acute and chronic.  
- Acute **GVHD** is syndrome that typically occurs in the first 100 days after transplant and is characterized by abdominal pain or cramps, nausea, vomiting, and diarrhea, jaundice or other liver function abnormalities, and skin rash. The diagnosis is based on the presence of one or more of these symptoms without other etiology and often supported by tissue biopsy. Patients will be assigned an overall GVHD score based on extent of skin rash, volume of diarrhea and maximum bilirubin level. At day 100, the maximum severity will be determined using the NIH Consensus Criteria.  
- **Chronic GVHD** is a syndrome that typically occurs 3 months or more after transplant and is characterized by dry eyes or vision changes, dry mouth with increased sensitivity to foods, fatigue, muscle weakness, arthralgias, arthritis, contractures, skin rash, hyper and hypopigmentation, scleroderma, obliterative bronchiolitis, steatorrhea, weight loss. The diagnosis is based on the presence of one or more of these symptoms without other etiology and often supported by tissue biopsy.
single-arm open label interventional phase
11.7 relapse

Relapse is the recurrence of the underlying disease for which the transplant was performed. The diagnosis of relapse is based on morphological evidence supported by cytogenetic and/or molecular testing consistent with disease characteristics noted at diagnosis or a relapse prior to transplant.
single-arm open label interventional phase
11.8 non-catheter associated bacterial infection

All blood or invasive bacterial infections (i.e. excluding surveillance cultures of the nose, throat, stool and urine; catheter infections) which are not considered to be a central lineassociated infection (CLABSI) based on published criteria from the U.S. Centers for Disease Control, will be considered an event. A second positive bacterial culture with the same organism from the same site will not be considered a new event unless symptoms resolved after treatment and negative cultures were documented for at least one week.
single-arm open label interventional phase
11.9 event free survival (efs)

EFS is the patient's status of being alive with sustained engraftment and in continuous complete remission.
single-arm open label interventional phase
12 statistical considerations 12.1 study

The principal objective of this phase II trial is to determine if transplantation of MGTA456 significantly reduces the expected duration of neutropenia relative to that estimated in recipients of an unmanipulated single UCB unit transplantation receiving the same conditioning and GVHD immunoprophylaxis for hematological malignancy. The primary endpoint of engraftment will be evaluated using a two stage enrollment procedure, while TRM, graft failure, and excessive acute GVHD will be monitored using continual stopping boundaries. Stage 1 will enroll 18 patients. If 4 or more demonstrate engraftment by day 14, an additional 22 patients will be enrolled in stage 2 for a maximum total of 40 enrolled patients. If 9 or more demonstrate engraftment in both stages combined, the treatment will be considered a success.  
The aim is to evaluate the impact of MGTA-456 containing >10 x 106 CD34 cells/kg.  
Patients may still receive MGTA-456 at lower cell doses (<10 x 106 CD34 cells/kg but >2 x 106 CD34 cells/kg) but endpoints and stopping rules will be evaluated separately by study design.  
12.1.1 **Primary Endpoint**
- Incidence of neutrophil recovery by day 14 after transplantation
single-arm open label interventional phase
12.1.3 exploratory endpoints

- Description of immunological recovery
- Incidence of absolute CD4 T cell ≥0.2 x 109/L by day 100 - Incidence of opportunistic infection (viral / fungal) by day 100
- Description of hospital costs by day 100
- Description of number of red cell and platelet transfusions by day 100.  
- Assess B and T cell immune reconstitution as well as functional responses at day 100 and day 180.
single-arm open label interventional phase
12.2 statistical analysis

Our primary hypothesis is that subjects transplanted with MGTA-456 will demonstrate neutrophil recovery by day 14 at a substantially higher frequency relative to the historical estimate for identically treated patients transplanted with unmanipulated UCB.  
Neutrophil engraftment by day 14 will be estimated with simple proportions. Given our experience from historical data as well as the pilot data for MGTA-456, it is unlikely that there will be any deaths without engraftment prior to day 14. If such a scenario arises, however, neutrophil engraftment will be estimated by cumulative incidence, treating nonevent death as a competing risk [41]. Cumulative incidence will also be used to estimate platelet recovery, TRM, GVHD, relapse and infection treating non-event deaths or relapse in the case of TRM as a competing risk. Simple proportions will be used to estimate secondary graft failure among engrafted patients only. Overall survival and EFS will be estimated with Kaplan-Meier curves [43]. If assumptions are satisfied, a sample mean along with a 95% confidence interval will be used to assess the number of surviving discharged days from the hospital prior to day 100 post-transplant. In addition, a one-sample t-test will be run to compare the study group average to a null hypothesis estimate of 60 days. If assumptions are not satisfied, descriptive statistics such as medians, ranges and interquartile ranges will be used. These will similarly be used for the endpoints of immune reconstitution and hospital costs. Descriptive endpoints may also be summarized with boxplots and dot plots. No specific hypothesis tests will be
single-arm open label interventional phase
12.1.2 secondary and transplant related

- Number of days alive without hospitalization between days 0 and 100 after transplantation
- Incidence of secondary graft failure
- Incidence of platelet recovery at day 60
- Incidence of TRM at 6 months
- Incidence of grades II-IV and III-IV acute GVHD at day 100
- Incidence of chronic GVHD at 1 year
- Incidence of relapse at 2 years
- Incidence of non-catheter associated bacterial infections by day 100 - Probability of overall survival and event-free survival at 2 years used to investigate B and T cell immune reconstitution or functional response. Descriptive statistics such as medians and ranges at days 100 and 180 along with descriptive plots will be used to assess these parameters.
single-arm open label interventional phase
12.3 rationale for sample size

Although the primary endpoint is the incidence of patients reaching neutrophil recovery by day 14, the sample size is based on the more restrictive test for the number of surviving hospital-free days prior to day 100. We want to detect a minimum 10 day improvement in the average number of days surviving outside of the hospital. Based on the historical estimate of 60 days and using a standard deviation of 25.0 from pilot data, a sample size of 40 patients will provide 80% power to detect a minimum improvement of 10 days over the null hypothesis of 60 days. This power estimate uses a one-sided one-sample t-test. In the assessment of our primary endpoint, historical data show that the standard control populations have an estimated neutrophil engraftment of 13% by day 14 post-HSCT. Pilot data among patients receiving the expanded MGTA-456 unit potentially show engraftment of 60% by day 14. We want to detect a minimum improvement of 20% (from 13% to 33%). Based on a Simon's optimal two stage design with a type I error of 5%, 40 patients will provide power of 87% [48].
single-arm open label interventional phase
12.4 monitoring guidelines

Early stopping rules for excess graft failure, TRM and grade III-IV acute GVHD will be in place to monitor safety. In the event that a monitoring boundary is triggered, study enrollment will be suspended and the PI, IRB and the Cancer Center's DSMC will be notified.  
The stopping rules were developed using an adaptation of Pocock stopping boundaries
[44].  
- Graft Failure by day 42: We will construct a boundary such that the probability of early stopping is at most 5% if the graft failure rate is equal to 5%. The monitoring boundary for the MGTA-456 patients will be 2/4, 3/12, 4/21, 5/31 or 6 graft failures out of 40 patients. The probability of stopping early if the actual probability of graft failure is 20% is 88%.  
- TRM by 6 months: We will construct a boundary such that the probability of early stopping is at most 5% if the TRM rate is equal to 20%. The monitoring boundary for the MGTA-456 patients will be 3/3, 4/5, 5/8, 6/11, 7/14, 8/17, 9/21, 10/24, 11/28, 12/31, 13/35, 14/38 or 15 deaths out of 40 patients. The probability of stopping early if the actual probability of TRM is 40% is 80%.  
- Grade III-IV Acute GVHD day 100: We will construct a boundary such that the probability of early stopping is at most 5% if the GVHD rate is equal to 15%. The monitoring boundary for the MGTA-456 patients will be 3/4, 4/7, 5/10, 6/14, 7/18, 8/22, 9/27, 10/32, 11/36 or 12 events out 40 patients. The probability of stopping early if the actual probability of TRM is 30% is 66%. Operating characteristics are calculated using software available at www.bios.unc.edu/∼qaqish/software.  
- We understand that inclusion of the stopping rules may slightly reduce the overall power of our study.
single-arm open label interventional phase
12.5 gender and ethnicities statement

This study is open to both males and females and to all racial/ethnic groups. The patient enrollment pattern is expected to be similar to that of other hematological malignancy studies. It is not anticipated that the outcome will be affected by either race or gender.  
The study will not have separate accrual targets for different subgroups.
single-arm open label interventional phase
13 conduct of the study

The study will be conducted in accordance with the appropriate regulatory requirement(s). Essential clinical documents will be maintained to demonstrate the validity of the study and the integrity of the data collected. Master files will be established at the beginning of the study, maintained for the duration of the study and retained in a centralized file within the Clinical Trials Office of the Masonic Cancer Center according to the appropriate regulations.
single-arm open label interventional phase
13.2 ethical considerations

The study will be conducted in accordance with ethical principles founded in the Declaration of Helsinki. The IRB will review all appropriate study documentation in order to safeguard the rights, safety and well-being of the patients. The study will only be conducted at sites where IRB approval has been obtained. The protocol, consent, written information given to the patients, safety updates, annual progress reports, and any revisions to these documents will be provided to the IRB by the investigator.
single-arm open label interventional phase
13.3 informed consent

All potential study participants will be given a copy of the IRB-approved consent to review. The investigator or designee will explain all aspects of the study in lay language and answer all questions regarding the study. If the participant decides to participate in the study, he/she will be asked to sign and date the consent document. Patients who refuse to participate or who withdraw from the study will be treated without prejudice.
single-arm open label interventional phase
14 references

1) Cheuk DKL. Optimal stem cell source for allogeneic stem cell transplantation for hematological malignancies. World. J. Transplant. 2013; 3 (4): 99-112.  
2) Eapen M, Rocha V. Principles and analysis of hematopoietic stem cell transplantation outcomes: the physician's perspective. Lifetime Data Anal 2008; 14: 379-88.  
3) Gragert L, Eapen M, Williams E, Freeman J, Spellman S, Baitty R, Hartzman R, Rizzo JD,
Horowitz M, Confer D, Maiers M. HLA match likelihoods for hematopoietic stem-cell grafts in the U.S. Registry. New Engl J Med 2014;371: 339-348.  
4) Ballen KK, Gluckman E, Broxmeyer HE. Umbilical cord blood transplantation: the first 25 years and beyond. Blood. 2013; 122 (4): 491-498.  
5) Smith AR, Wagner JE. Alternative hematopoietic stem cell sources for transplantation:
place of umbilical cord blood. Br. J. Haematol. 2009; 147 (2): 246-61.  
6) Wagner JE, Kernan NA, Steinbuch M, Broxmeyer HE, Gluckman E. Allogeneic sibling umbilical-cord-blood transplantation in children with malignant and non-malignant disease.  
Lancet. 1995;346:214-219.  
7) Gluckman E, Rocha V, Boyer-Chammard A, et al. Outcome of cord-blood transplantation from related and unrelated donors. Eurocord Transplant Group and the European Blood and Marrow Transplantation Group. N Engl J Med. 1997;337:373-381.  
8) Rubinstein P, Adamson JW, Stevens C. The placental/umbilcal cord blood program of the New York BloodCenter: a progress report. Ann NY Acad Sci. 2006;872:328–35.  
9) Hackenberg P, Kögler G, Wernet P. NETCORD: a cord blood allocation network. Bone Marrow Transplant. 1998;22:S17– 8.  
10) Lazzari L, Corsini C, Curioni C, Lecchi L, Scalamogna M, Rebulla P, et al. The Milan Cord Blood Bank the Italian Cord Blood Network. J Hematother. 1996;5:117–22.  
11) Barker JN. Umbilical cord blood (UCB) transplantation: an alternative to the use of unrelated volunteer donors? Hematology (Am Soc Hematol Educ Program) 2007; 2007:55-61 12) Brunstein CG, Gutman JA, Weisdorf DJ, Woolfrey AE, Defor TE, Gooley TA, et al.  
Allogeneic hematopoietic cell transplantation for hematological malignancy: Relative risks and benefits of double umbilical cord blood. Blood. 2010;116:4693-9 13) Verneris MR, Brunstein CG, Barker J, et al. Relapse risk after umbilical cord blood transplantation: enhanced graft-versus-leukemia effect in recipients of 2 units. Blood.  
2009;114:4293-4299.  
14) Rocha V, Labopin M, Mohty M, et al. Outcomes after double unit unrelated cord blood transplantation compared to single UCBT in adults with acute leukemia in remission: An Eurocord ELWP Collaboration Study. Blood. 2010;116:401 15) Showel M, Fuchs EJ. Recent developments in HLA-haploidentical transplantations. Best Pract Res Clin Haematol 2015; 28: 141-6.  
16) Kasamon YL, Bolaños-Meade J, Prince GT, et al. Outcomes of nonmyeloablative HLAhaploidentical blood or marrow transplantation with high-dose post-transplantation cyclophosphamide in older adults. J Clin Oncol 2015; 33: 3152-61.  
17) Shaw BE. Related haploidentical donors are a better choice than matched unrelated donors: Counterpoint. Blood Advances 2017; 1: 401-406.  
18) Wagner JE, Barker JN, DeFor TE, Baker KS, Blazar BR, Eide C, Goldman A, Kersey J,
Krivit W, MacMillan ML, Orchard PJ, Peters C, Weisdorf DJ, Ramsay NK, Davies SM.  
Transplantation of unrelated donor umbilical cord blood in 102 patients with malignant and nonmalignant diseases: influence of CD34 cell dose and HLA disparity on treatmentrelated mortality and survival. Blood 2002;100: 1611-8.  
19) Kurtzberg J, Prasad VK, Carter SL, Wagner JE, Baxter-Lowe LA, Wall D, et al. Results of the Cord Blood Transplantation Study (COBLT): clinical outcomes of unrelated donor umbilical cord blood transplantation in pediatric patients with hematologic malignancies. Blood. 2008;112:4318-27.  
20) Barker JN, Weisdorf DJ, DeFor TE, Blazar BR, Miller JS, Wagner JE. Transplantation of two partially HLA matched umbilical cord blood units to enhance engraftment in adults with hematological malignancy. *Blood*. 2005; 105 (3): 1343-7.  
21) Brunstein CG, Barker JN, Weisdorf DJ, DeFor TE, Miller JS, Blazar BR, McGlave PB,
Wagner JE. Umbilical cord blood transplantation after nonmyeloablative conditioning:
impact on transplantation outcomes in 110 adults with hematological disease. *Blood*. 2007; 110 (8): 3064-70.  
22) Wagner JE, Jr., Eapen M, Carter S, Wang Y, Schultz KR, Wall DA, et al. One-unit versus two-unit cord-blood transplantation for hematologic cancers. N Engl J Med. 2014; 371: 1685-94.  
23) Eapen M, Kurtzberg J, Zhang M-J, Hattersely G, Fei M, Mendizabal A, Chan KW, De Oliveira S, Schultz KR, Wall D, Horowitz MM, Wagner JE. Umbilical Cord Blood Transplantation in Children with Acute Leukemia: Impact of Conditioning on Transplantation Outcomes. Biol Blood Marrow Transplant 2017; 23: 1714–1721.  
24) Wagner JE, Brunstein CG, Boitano AE, DeFor TE, McKenna D, Sumstad D, Blazar BR,
Tolar J, Le C, Jones J, Cooke CP, Bleul CC. Safety and efficacy of StemRegenin-1 expanded umbilical cord blood hematopoietic cells after myeloablative conditioning. Cell Stem Cell 2016;18:144-55.  
25) Boitano, A. E.,Wang, J.,Romeo, R.,Bouchez, L. C.,Parker, A. E.,Sutton, S. E.,Walker, J.  
R.,Flaveny, C. A.,Perdew, G. H.,Denison, M. S.,Schultz, P. G.,Cooke, M. P. Aryl hydrocarbon receptor antagonists promote the expansion of human hematopoietic stem cells. Science 2010, 329 (5997), 1345-8.  
26) de Lima M, McMannis J, Gee A, Komanduri K, Couriel D, Andersson BS, Hosing C,
Khouri I, Jones R, Champlin R, et. al. Transplantation of ex vivo expanded cord blood cells using the copper chelator tetraethylenepentamine: a phase I/II clinical trial. Bone Marrow Transplant. 2008; 41 (9): 771-8.  
27) Delaney C, Heimfeld S, Brashem-Stein C, Voorhies H, Manger RI, Bernstein ID. Notchmediated expansion of human cord blood progenitor cells capable of rapid myeloid reconstitution. Nat. Med. 2010; 16 (2): 232-6.  
28) de Lima M, McNiece I, Robinson SN, Munsell M, Eapen M, Horowitz M, Alousi A, Saliba R, McMannis JD, Kaur I, et.al. Cord-blood engraftment with ex vivo mesenchymal-cell culture. New Engl. J. Med. 2012; 367 (24): 2305-15.  
29) Horwitz ME, Chao NJ, Rizzieri DA, Long GD, Sullivan KM, Gasparetto C, Chute JP, Morris A, McDonald C, Waters-Pick B, et. al. Umbilical cord blood expansion with nicotinamide provides long-term multi-lineage engraftment. J. Clin. Invest. 2014; 124 (4): 3121-8.  
30) Radtke S, Gorgens A, Kordelas L, Schmidt M, Kimmig KR, Koninger A, Horn PA, Giebel B. CD133 allows elaborated discrimination and quantification of haematopoietic progenitor subsets in human haematopoietic stem cell transplants. Brit J Haematol 2015; 169: 868-878.  
31) Wong WM, Sigvardsson M, Astrand-Grundstom I, Hogge D, Larsson J, Qian H, Ekblom M.  
Expression of integrin α2 receptor in human cord blood CD34+CD38-CD90+ stem cells engrafting long-term in NOD/SCID-IL2Rc null mice. Stem Cells 2013; 31:360-371.  
32) Gutman JA, Turtle CJ, Manley TJ, Heimfeld S, Riddell SR, Delaney C. Single-unit dominance after double-unit umbilical cord blood transplantation coincides with a specific CD8+ T-cell response against the nonengrafted unit. Blood. 2010; 115 (4): 757-785.  
33) Ramirez P, Wagner JE, DeFor TE, Blazar BR, Verneris MR, Miller JS, McKenna DH,
Weisdorf DJ, McGlave PB, Brunstein CG. Factors predicting single-unit predominance after double umbilical cord blood transplantation. Bone Marrow Transplant. 2012; 47 (6):
799-803.  
34) Lund TC, Boitano AE, Delaney CS, Shpall EJ, Wagner JE. Advances in umbilical cord blood manipulation-from niche to bedside. Nat Rev Clin Oncol. 2015;12:163-74.  
35) Yahata T, Ando K, Miyatake H, Uno T, Sato T, Ito M, Kato S, Hotta T. Competitive repopulation assay of two gene-marked cord blood units in NOD/SCID/gammac(null) mice. Mol Ther 2004; 10: 882-91.  
36) Shu Z, Heimfeld S, Gao D. Hematopoietic SCT with cryopreserved grafts: adverse reactions after transplantion and cryoprotectant removal before infusion, Bone Marrow Transplant 2014; 49: 469-476.  
37) Konuma T, Ooi J, Takahashi S, Tomonari A, Tsukada N, Kobayashi T, Sata A, Kato S,
Kasahara S, Ebihara Y, Nagamura-Inoue T, Tsuji K, Tojo A, Asano S. Cardiovascular toxicity of cryopreserved cord blood cell infusion, Bone Marrow Transplant 2008; 41: 861865.  
38) Regan DM, Wofford JD, Wall DA. Comparison of cord blood thawing methods on cell recovery, potency, and infusion. Transfusion. 2010; 50:2670-75.  
39) Kharbanda S, Smith AR, Hutchinson SK, McKenna DH, Ball JB, Lamb LS, Agarwal R,
Weinberg KI, Wagner JE. Unrelated donor allogeneic hematopoietic stem cell transplantation for patients with hemoglobinopathies using a reduced- intensity conditioning regimen and third-party mesenchymal stromal cells. Biol Blood Marrow Transplant.2014; 20:581-586.  
40) Martín-Henao GA, Resano PM, Villegas JM, Manero PP, Sánchez JM, Bosch MP, Codins AE, Bruguera MS, Infante LR, Oyarzabal AP, Soldevila RN, Caiz DC, Bosch LM, Barbeta EC, Ronda JR. Adverse reactions during transfusion of thawed haematopoietic progenitor cells from apheresis are closely related to the number of granulocyte cells in the leukapheresis product. Vox Sang. 2010; 99:267-73.  
41) Lin, DY. Non-parametric inference for cumulative incidence functions in competing risks studies. Statistics in Medicine 1997, 16 (8), 901-10.  
42) Gray RJ. A class of K-sample tests for comparing the cumulative incidence of a competing risk. Ann Stat. 1988;16:1141-54.  
43) Kaplan EL, Meier P. Nonparametric estimation from incomplete observations. J Am Stat Assoc. 1958;53:457-81.  
44) Ivanova A, Qaqish B, Schell M. Continuous toxicity monitoring in phase II trials in oncology. Biometrics. 2005 61:540-, 2005.  
45) Park BG, Park CJ, Jang S, et al. Reconstitution of lymphocyte subpopulations after hematopoietic stem cell transplantation: comparison of hematologic malignancies and donor types in event-free patients. Leuk Res. 2015;39(12):1334-1341.  
46) Abdel-Azim H, Elshoury A, Mahadeo KM, Parkman R, Kapoor N. Humoral Immune Reconstitution Kinetics after Allogeneic Hematopoietic Stem Cell Transplantation in Children: A Maturation Block of IgM Memory B Cells May Lead to Impaired Antibody Immune Reconstitution. Biol Blood Marrow Transplant. 2017;23(9):1437-1446.  
47) Wagner JE, Brunstein C, McKenna D, et al. StemRegenin-1 (SR1) Expansion Culture Abrogates the Engraftment Barrier Associated with Umbilical Cord Blood Transplantation
(UCBT). Vol. 124; 2014.  
48) Simon R. Optimal two-stage designs for Phase II Clinical Trials. Controlled Clinical Trials 1989;10:1-10.
single-arm open label interventional phase
appendix i - karnofsky and

| Karnofsky Scale (recipient age ≥ 16 years)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  | Lansky Scale (recipient age <16 years)                                |
|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------|
| Able to carry on normal activity; no special care is needed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 | Able to carry on normal activity; no special care  is needed          |
| 100 Normal, no complaints, no evidence of disease                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           | 100 Fully active                                                      |
| 90 Able to carry on normal activity                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         | 90 Minor restriction in physically strenuous play                     |
| 80 Normal activity with effort                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              | 80 Restricted in strenuous play, tires more easily,  otherwise active |
| Unable to work, able to live at home cares for most  personal needs, a varying amount of assistance is needed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               | Mild to moderate restriction                                          |
| 70 Cares for self, unable to carry on normal activity or to do                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              | 70 Both greater restrictions of, and less time spent in               |
| active work                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 | active play                                                           |
| 60 Requires occasional assistance but is able to care for most  60 Ambulatory up to 50% of time, limited active play  needs  with assistance/supervision 50 Requires considerable assistance and frequent medical  50 Considerable assistance required for any active  care  play, fully able to engage in quiet play Unable to care for self, requires equivalent of institutional  or hospital care, disease may be progressing rapidly Moderate to severe restriction 40 Disabled, requires special care and assistance 40 Able to initiate quite activities  30 Severely disabled, hospitalization indicated, although death  not imminent 30 Needs considerable assistance for quiet activity 20 Very sick, hospitalization necessary 20 Limited to very passive activity initiated by others  (e.g., TV) 10 Moribund, fatal process progressing rapidly 10 Completely disabled, not even passive play |                                                                       |  
https://www.cibmtr.org/manuals/fim/1/en/topic/appendix-l-karnofsky-lansky-performance-status Lansky scale above will only be applied to children aged 2-15 years, inclusive. For children <2 years, scores will be severe, mild to moderate or no restrictions: Levels of Restriction:  
Severe All activities require more than any age appropriate assistance Mild to moderate Some activities require more than age appropriate assistance None All activities require assistance that is age appropriate
single-arm open label interventional phase
appendix ii - recommended tbi

Fractionated Total Body Irradiation (In Lateral Position):
1320 cGy administered in an 8 fractions of 165 cGy each with 2 fractions being given each day.  
Total body irradiation is given at a dose rate of 10-19 cGy/minute prescribed to the midplane of the patient at the level of the umbilicus.  
The total body irradiation will be delivered with right and left lateral fields, with the patient supine on a specially designed couch.  
Based on measurements of transverse thicknesses, aluminum compensators will be used to ensure that the dose homogeneity across the field is within 10 % of the prescribed dose. Usually head/neck, leg and lung compensators are used (although based on calculated mid-mediastinal doses, lung compensators are often not needed).  
Total body irradiation will be delivered with a linear accelerator using 6, 10, and 18 MeV X-rays.  
The energy used will be based on the calculated dose to the midline at points up and down the patient's torso. The lowest energy that gives 90-100% of the prescription point dose will be used.  
A beam "spoiler" will be used to ensure a full skin dose.  
Half value layer lung and kidney blocks will not be utilized. Testicular boosts should be used for all males with ALL (and according to institutional practice for other diseases). The testicular boost is given in a single 400 cGy fraction with either electrons prescribed to Dmax or photons prescribed to the midplane of the scrotum. If electrons are used, the energy for the testicular boost depends on the thickness of the testicles and is chosen so that the D90 corresponds > to the posterior surface of the scrotum.
single-arm open label interventional phase
appendix iii - busulfan dose

This protocol will use once daily (every 24 hour) intravenous BU dosing. Four (4) total doses of BU will be given over 4 days in the preparative regimen. AUC determination after each of the first 3 doses will be performed (AUC1, AUC2, and AUC3 following Doses \#1, \#2 and \#3, respectively). For all patients, each busulfan dose will be administered over 3 hours by central venous line per University of Minnesota BMT Program standard guidelines..  
THE TOTAL regimen busulfan AUC (AUCcum) targeted will be = **14,080-16,400 (µM·Min)/L [57.7-** 67.2 (mg · h)/L] with ideal target AUCcum **of 15,200 (µM·Min)/L [62 (mg · h)/L]** in order to best optimize engraftment while minimizing toxicity. If at any time upon interim analysis and review of patients transplanted on this protocol with the principal investigators and pharmacy team, the subsequent busulfan levels (following doses \#2 and \#3) are deemed reasonable and consistent, the decision may be made to only do kinetics with the first dose for all remaining patients treated on this protocol. In that event, kinetics for a subsequent dose (i.e. AUC monitoring) may be performed whenever a dose change is required but will not be mandatory. These protocol changes (if enacted) will not require a treatment deviation or protocol amendment.
single-arm open label interventional phase
steady state concentration (css) equivalent

The initial empiric busulfan dosing (Dose \#1) for ALL patients will be determined as follows:
a. For patients weighing <12 kg: initial dose will be based on the formula according to the population PK model developed by Long-Boyle.  
b. For patients weighing ≥12kg and <66 kg: initial dose will be determined by the nomogram adapted from Bartelink.  
c. For patients weighing ≥66kg: initial busulfan dose = 3 mg/kg IV Once Daily
single-arm open label interventional phase
1. for patients <12 kg

- Use the Dosing Calculator (Long-Boyle Busulfan 1st Dose) on the BMT website to determine the precise dose for the patient;
- Age: enter the age in years (to the hundredths place) by dividing the patient's age in days by 365
- Weight: enter the weight in kg (to the tenths place)
- The Calculator is constructed using the following function:
o Dose (mg) = AUC(target) x CLi o AUC(target) = 15.6 mg·hr·L-1 (equivalent to 3800 μM·min∙L-1)
o CLi is a function of weight and age CLi = 2.3 L/h x (Matmag + (1- Matmag) x [1-e(-age x Kmat)]) x (weight/8 kg)0.75 Maturation magnitude (Matmag) = 0.46; Maturation rate constant
(kmat) = 1.4
- See Table A-1 below for EXAMPLE first Busulfan doses for hypothetical children under 12 kg; this table can be used to ensure your patient's calculator output does not carry significant error. However, the patient's first dose should be determined directly from the calculator.  
Table A-1: Sample First Busulfan Doses for Various Ages and Weights Using the Long-Boyle Method for Determination of First Busulfan Dose for patients < 12 kg & for ideal target AUCcum of 15,200 (µM·Min)/L [62 (mg · h)/L. Use this table to check against error from the calculator.  
| Sample Age             | Sample Weight (kg)   | 1st Busulfan Dose Per   |
|------------------------|----------------------|-------------------------|
| Long-Boyle Method (mg) |                      |                         |
| 1 month                | 4                    | 11                      |
| (0.08 years)           | 4.4                  | 11.9                    |
| 5                      | 13                   |                         |
| 3 months               | 5.8                  | 17.4                    |
| (0.25 years)           | 6.4                  | 18.7                    |
| 6.8                    | 19.6                 |                         |
| 6 months               | 7.2                  | 24.1                    |
| (0.50 years)           | 7.8                  | 25.5                    |
| 8.4                    | 27                   |                         |
| 9 months               | 8.2                  | 29.4                    |
| (0.75 years)           | 9                    | 31.6                    |
| 9.6                    | 33.1                 |                         |
| 12 months              | 9.6                  | 35.4                    |
| (1 years)              | 10.2                 | 37.1                    |
| 11                     | 39.2                 |                         |
| 15 months              | 10.2                 | 38.8                    |
| (1.25 years)           | 11                   | 41                      |
| 11.8                   | 43.3                 |                         |  
2. **For patients >/= 12 kg to <66 kg:** the first busulfan dose will be according to weightbased dosing nomogram developed by Bartelink, which determines the first dose as a function of **weight** only.  
- Determine the first dose directly from the nomogram chart (no calculator is used)
- Round the patient's weight to the nearest kg. For weights in kg ending in "x.5",
round UP to the nearest kg. For instance, for a weight of 43.5 kg, use 44 kg to determine the first busulfan dose from the nomogram.  
- See Table A-2 for nomogram Table A-2: Nomogram for the Determination of First Busulfan Dose for Patients ≥ 12 kg and < 66kg for ideal target AUCcum of 15,200 (µM·Min)/L [62 (mg · h)/L. (Adapted from Bartelink). Round the patient's weight to the nearest kg in order to determine the first busulfan dose from this nomogram  
| Weight   | Dose   | Weight   | Dose   | Weight   | Dose   | Weight   | Dose   | Weight   | Dose   | Weight   | Dose   |
|----------|--------|----------|--------|----------|--------|----------|--------|----------|--------|----------|--------|
| (kg)     | (mg)   | (kg)     | (mg)   | (kg)     | (mg)   | (kg)     | (mg)   | (kg)     | (mg)   | (kg)     | (mg)   |
| 20       | 64.7   | 30       | 86.3   | 40       | 103.5  | 50       | 117.8  | 60       | 130.5  |          |        |
| 21       | 67.1   | 31       | 88.2   | 41       | 105    | 51       | 119.1  | 61       | 131.6  |          |        |
| 12       | 41.8   | 22       | 69.5   | 32       | 90.2   | 42       | 106.5  | 52       | 120.5  | 62       | 132.6  |
| 13       | 45     | 23       | 71.9   | 33       | 92.1   | 43       | 108    | 53       | 121.8  | 63       | 133.7  |
| 14       | 48.2   | 24       | 74.3   | 34       | 94.1   | 44       | 109.5  | 54       | 123.2  | 64       | 134.7  |
| 15       | 51.2   | 25       | 76.5   | 35       | 96     | 45       | 111    | 55       | 124.5  | 65       | 135.8  |
| 16       | 54     | 26       | 78.5   | 36       | 97.5   | 46       | 112.4  | 56       | 125.7  |          |        |
| 17       | 56.8   | 27       | 80.4   | 37       | 99     | 47       | 113.7  | 57       | 126.9  |          |        |
| 18       | 59.5   | 28       | 82.4   | 38       | 100.5  | 48       | 115.1  | 58       | 128.1  |          |        |
| 19       | 62.2   | 29       | 84.3   | 39       | 102    | 49       | 116.4  | 59       | 129.3  |          |        |  
3. **For patients weighing ≥ 66kg:** first busulfan dose = 3 mg/kg IV.
single-arm open label interventional phase
busulfan therapeutic drug monitoring (tdm)

Area under the curve (AUC) analyses will be calculated in-house per University of Minnesota BMT standard guidelines for all patients. The AUC will be calculated for each dose using serum busulfan concentrations (in ng/ml) performed by the University of Minnesota Medical Center Drug Analysis Lab and obtained at the following time-points:
- Immediately prior to busulfan infusion (*ONLY to be drawn if obtaining levels with doses 2, 3 or 4)
- Immediately after the end of the busulfan infusion - 15 minutes after the end of the busulfan infusion - 1 hour after the end of the busulfan infusion
- 3 hours after the end of the busulfan infusion - 5 hours after the end of the busulfan infusion
- 7 hours after the end of the busulfan infusion
* "trough" or pre-dose serum busulfan level will only be obtained when performing AUC on 2nd or higher doses, as serum busulfan level prior to dose \#1 is assumed to be zero.  
After determination of the patient's clearance and AUC, subsequent doses will be calculated linearly to achieve a goal cumulative AUC exposure. For patients receiving 4 total busulfan doses the goal AUCcum **= 14,080-16,400**
(µM·Min)/L [57.7-67.7 (mg · h)/L] with ideal target AUCcum of 15,200 (µM·Min)/L [62 (mg
· h)/L]
single-arm open label interventional phase
guidelines for changing subsequent busulfan

Subsequent busulfan dose changes will be made according to the following guidelines:
1. The **goal cumulative AUC range** (AUCcum for the entire 4-dose course) will be 14,080-16,400 (µM·Min)/L [57.7-67.7 (mg · h)/L] **with ideal target AUCcum** of 15,200 (µM·Min)/L [62 (mg · h)/L]
2. Cumulative AUC is defined as the sum of each individual dose AUC:
AUCcum = AUC1 + AUC2 + AUC3 + AUC4 3. Patients will undergo Dose \#1 AUC analysis (AUC1), Dose \#2 AUC analysis
(AUC2) and Dose \#3 AUC analysis (AUC3).  
4. Changes will be made to subsequent doses only if the **projected AUCcum** falls outside of the goal range a. After the first busulfan dose, **projected AUCcum** = AUC1 x 4 b. After the second busulfan dose, **projected AUCcum** = AUC1 + [AUC2 x 3]
c. After the third busulfan dose, **projected AUCcum** = AUC1 + AUC2 +
[AUC3 x 2]
5. If dose adjustment is necessary, new doses will be calculated based on an ideal target AUCcum of exactly 15,200 μM·min∙L**-1 [62 (mg · h)/L].**
single-arm open label interventional phase
references

1) Bartelink IH. Body weight-dependent pharmacokinetics of busulfan in paediatric haematopoietic stem cell transplantation patients: towards individualized dosing. Clin Pharmacokinet. 2012;51:331-45.  
2) Bartelink IH, van Kesteren C, Boelens JJ, Egberts TC, Bierings MB, Cuvelier GD, Wynn RF,
Slatter MA, Chiesa R, Danhof M, Knibbe CA. Predictive performance of a busulfan pharmacokinetic model in children and young adults. Ther Drug Monit. 2012;34:574-83.  
3) Savic RM, Cowan MJ, Dvorak CC, Pai SY, Pereira L, Bartelink IH, Boelens JJ, Bredius RGM,
Wynn RF, Cuvelier GDE, Shaw PJ, Slatter MA, Long-Boyle J. Effect of weight and maturation on busulfan clearance in infants and small children undergoing hematopoietic cell transplantation. Biol Blood Marrow Transplant. 2013;19:1608-1614.
single-arm open label interventional phase
appendix iv - gvhd scoring

Organ involvement will be staged using the criteria outlined in the table below. Biopsy of each organ site at diagnosis or major change in disease activity will be performed unless clinical circumstances make it impossible. Consensus Clinical Stage and Grade of Acute GVHD (Przepiorka *et al*, 1995)  
| Stage        | Skin                                                                | Liver                                    | Lower  Gastrointestinal  Tract                                                       | Upper  Gastrointestinal  Tract   |
|--------------|---------------------------------------------------------------------|------------------------------------------|--------------------------------------------------------------------------------------|----------------------------------|
| 1            | Maculopapular rash  <25% of body  surface                           | Bilirubin 2.0 - 3.0                      | Diarrhea 500 - 1000                                                                  |                                  |
| mg/dl        | mL/day or 280 - 555  mL/m2                                          | No protracted  nausea and  vomiting      |                                                                                      |                                  |
| 2            | Maculopapular rash  25-50% body  surface                            | Bilirubin 3.1 - 6.0                      | Diarrhea 1001 - 1500                                                                 |                                  |
| mg/dl        | mL/day or 556 - 833  mL/m2                                          | Persistent nausea,  vomiting or anorexia |                                                                                      |                                  |
| 3            | Generalized                                                         | Bilirubin 6.1 - 15.0                     | Diarrhea >1500  mL/day or >833 mL/m2                                                 |                                  |
| erythroderma | mg/dl                                                               |                                          |                                                                                      |                                  |
| 4            | Generalized  erythroderma with  bullous formation  and desquamation | Bilirubin > 15 mg/dl                     | Severe abdominal  pain, with or without  ileus, or stool with  frank blood or melena |                                  |
single-arm open label interventional phase
grading for treatment criteria

Mild GVHD Skin stage I-II only (Equivalent to Seattle Grade I).  
Moderate GVHD Skin stage I-III and/or liver I-IV and/or Gastrointestinal tract (GI) I-III and/or Upper GI (UGI). (Equivalent to Seattle Grade II, III).  
Severe GVHD Any stage IV along with severe clinical illness.
single-arm open label interventional phase
late acute and chronic gvhd

Late acute and chronic GVHD will be assessed using the National Institutes of Health (NIH)
Consensus Criteria.
single-arm open label interventional phase
appendix v - targeted toxicities

| MT2018-06                                        | Refer to section 9.2.2 for time points                                   |                                                                                                                                                                                                      |                                                                                                                                                                                                                                                                                                                                                       |                                                                                                                                                                                                                         |                                                                                                                                                                                             |
|--------------------------------------------------|--------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Patient Initials: _______                        | Date of Assessment: _________                                            | Assessment Time Point: _________                                                                                                                                                                     |                                                                                                                                                                                                                                                                                                                                                       |                                                                                                                                                                                                                         |                                                                                                                                                                                             |
| Toxicity                                         | Grade 0                                                                  | Grade 1                                                                                                                                                                                              | Grade 2                                                                                                                                                                                                                                                                                                                                               | Grade 3                                                                                                                                                                                                                 | Grade 4                                                                                                                                                                                     |
| Infusion Related                                 | None                                                                     | Mild transient reaction;                                                                                                                                                                             |                                                                                                                                                                                                                                                                                                                                                       |                                                                                                                                                                                                                         |                                                                                                                                                                                             |
| Reaction                                         | infusion interruption not  indicated; intervention not  indicated        | Therapy or infusion interruption  indicated but responds promptly to  symptomatic treatment (e.g.,  antihistamines, NSAIDS, narcotics,  IV fluids); prophylactic medications  indicated for < 24 hrs | Prolonged (e.g., not rapidly responsive  to symptomatic medication and/or brief  interruption of infusion); recurrence of  symptoms following initial  improvement; prolongation of  hospitalization for clinical sequelae                                                                                                                            | Life-threatening  consequences; urgent  intervention indicated                                                                                                                                                          |                                                                                                                                                                                             |
| Bronchospasm                                     | None                                                                     | Mild symptoms; intervention                                                                                                                                                                          | Symptomatic; medical intervention                                                                                                                                                                                                                                                                                                                     |                                                                                                                                                                                                                         |                                                                                                                                                                                             |
| not indicated                                    | indicated; limiting instrumental  ADL                                    | Limiting self-care ADL; oxygen                                                                                                                                                                       | Life-threatening respiratory                                                                                                                                                                                                                                                                                                                          |                                                                                                                                                                                                                         |                                                                                                                                                                                             |
| saturation decreased                             | or hemodynamic  compromise; intubation or  urgent intervention indicated |                                                                                                                                                                                                      |                                                                                                                                                                                                                                                                                                                                                       |                                                                                                                                                                                                                         |                                                                                                                                                                                             |
| Dyspnea/                                         | None                                                                     | Shortness of breath with                                                                                                                                                                             | Shortness of breath with minimal                                                                                                                                                                                                                                                                                                                      | Shortness of breath at rest; limiting                                                                                                                                                                                   | Life-threatening                                                                                                                                                                            |
| Wheezing                                         | moderate exertion                                                        | exertion; limiting instrumental ADL                                                                                                                                                                  | self- care ADL                                                                                                                                                                                                                                                                                                                                        | consequences; urgent  intervention indicated                                                                                                                                                                            |                                                                                                                                                                                             |
| Hypoxia                                          | None                                                                     | Decreased oxygen  saturation with exercise  (e.g., pulse oximeter <  88%); intermittent  supplemental oxygen                                                                                         | Decreased oxygen saturation at  rest (e.g., pulse oximeter < 88% or                                                                                                                                                                                                                                                                                   | Life-threatening airway compromise;                                                                                                                                                                                     |                                                                                                                                                                                             |
| PaO2 < =55 mm Hg)                                | urgent intervention indicated (e.g.,  tracheotomy or intubation          | Life-threatening airway  compromise; urgent  intervention indicated (e.g.,  tracheotomy or intubation                                                                                                |                                                                                                                                                                                                                                                                                                                                                       |                                                                                                                                                                                                                         |                                                                                                                                                                                             |
| Fever                                            | None                                                                     | 38.0 - 39.0 degrees C                                                                                                                                                                                | >39.0 - 40.0 degrees C (102.3 -                                                                                                                                                                                                                                                                                                                       | >40.0 degrees C (>104.0 degrees F)                                                                                                                                                                                      | >40.0 degrees C (>104.0                                                                                                                                                                     |
| (100.4 - 102.2 degrees F)                        | 104.0 degrees F)                                                         | for < 24 hrs                                                                                                                                                                                         | degrees F) for >24 hrs                                                                                                                                                                                                                                                                                                                                |                                                                                                                                                                                                                         |                                                                                                                                                                                             |
| Chills                                           | None                                                                     | Mild sensation of cold;                                                                                                                                                                              | Moderate tremor of the entire                                                                                                                                                                                                                                                                                                                         | Severe or prolonged, not responsive                                                                                                                                                                                     | Life Threatening                                                                                                                                                                            |
| shivering; chattering of teeth                   | body; narcotics indicated                                                | to narcotics                                                                                                                                                                                         |                                                                                                                                                                                                                                                                                                                                                       |                                                                                                                                                                                                                         |                                                                                                                                                                                             |
| Hypertension                                     | None                                                                     | Prehypertension (systolic  BP 120 - 139 mm Hg or  diastolic BP 80 - 89 mm Hg)                                                                                                                        | Stage 1 hypertension (systolic BP  140 - 159 mm Hg or diastolic BP  90 -99 mm Hg); medical  intervention indicated; recurrent or  persistent (>24 hrs); symptomatic  increase by >20 mm Hg (diastolic)  or to >140/90 mm Hg if previously  WNL; monotherapy indicated;  Pediatric: recurrent or persistent  (>24 hrs) BP >ULN; monotherapy  indicated | Stage 2 hypertension (systolic BP >=  160 mm Hg or diastolic BP >=100 mm  Hg); medical intervention indicated;  more than one drug or more intensive  therapy than previously used  indicated; Pediatric: Same as adult | Life-threatening  consequences (e.g.  malignant hypertension,  transient or permanent  neurologic deficit,  hypertensive crisis); urgent  intervention indicated;  Pediatric: Same as adult |
| Hypotension                                      | None                                                                     | Asymptomatic, intervention                                                                                                                                                                           | Non-urgent medical intervention                                                                                                                                                                                                                                                                                                                       | Medical intervention or hospitalization                                                                                                                                                                                 | Life-threatening and urgent                                                                                                                                                                 |
| not indicated                                    | indicated                                                                | indicated                                                                                                                                                                                            | intervention indicated                                                                                                                                                                                                                                                                                                                                |                                                                                                                                                                                                                         |                                                                                                                                                                                             |
| Sinus                                            | None                                                                     | Asymptomatic, intervention                                                                                                                                                                           | Symptomatic, medical intervention                                                                                                                                                                                                                                                                                                                     | Severe, medically significant, medical                                                                                                                                                                                  | Life-threatening                                                                                                                                                                            |
| Bradycardia                                      | not indicated                                                            | indicated                                                                                                                                                                                            | intervention indicated                                                                                                                                                                                                                                                                                                                                | consequences; urgent  intervention indicated                                                                                                                                                                            |                                                                                                                                                                                             |
| Sinus                                            | None                                                                     | Asymptomatic, intervention                                                                                                                                                                           | Symptomatic; non-urgent medical                                                                                                                                                                                                                                                                                                                       | Urgent medical intervention indicated                                                                                                                                                                                   | Life Threatening                                                                                                                                                                            |
| Tachycardia                                      | not indicated                                                            | intervention indicated                                                                                                                                                                               |                                                                                                                                                                                                                                                                                                                                                       |                                                                                                                                                                                                                         |                                                                                                                                                                                             |
| Vomiting                                         | None                                                                     | 1 - 2 episodes (separated by                                                                                                                                                                         | 3 - 5 episodes (separated by 5                                                                                                                                                                                                                                                                                                                        | >6 episodes (separated by 5 minutes)                                                                                                                                                                                    |                                                                                                                                                                                             |
| 5 minutes) in 24 hrs                             | minutes) in 24 hrs                                                       | in 24 hrs; tube feeding, TPN or  hospitalization indicated                                                                                                                                           | Life-threatening  consequences; urgent  intervention indicated                                                                                                                                                                                                                                                                                        |                                                                                                                                                                                                                         |                                                                                                                                                                                             |
| Creatinine                                       | Normal                                                                   | >1-1.5x baseline; >1.5 x LN                                                                                                                                                                          | >1.5 - 3.0x baseline; >1.5-3.0x LN                                                                                                                                                                                                                                                                                                                    | >3.0 baseline; > 3.0 - 6.0 x ULN                                                                                                                                                                                        | >6.0 x ULN                                                                                                                                                                                  |
| Rash                                             | None                                                                     | Macules/papules covering <  10% BSA with or without  symptoms (e.g., pruritus,  burning, tightness)                                                                                                  | Macules/papules covering 10-30%  BSA with or without symptoms;  limiting instrumental ADL                                                                                                                                                                                                                                                             | Macules/papules covering >30% BSA  with or without associated symptoms;  limiting self-care ADL                                                                                                                         | Life Threatening                                                                                                                                                                            |
| Chest Pain                                       | None                                                                     | Mild pain                                                                                                                                                                                            | Moderate pain; limiting                                                                                                                                                                                                                                                                                                                               | Pain at rest; limiting self-care ADL                                                                                                                                                                                    | Life Threatening                                                                                                                                                                            |
| instrumental ADL                                 |                                                                          |                                                                                                                                                                                                      |                                                                                                                                                                                                                                                                                                                                                       |                                                                                                                                                                                                                         |                                                                                                                                                                                             |
| Back/Flank Pain                                  | None                                                                     | Mild pain                                                                                                                                                                                            | Moderate pain; limiting                                                                                                                                                                                                                                                                                                                               | Pain at rest; limiting self-care ADL                                                                                                                                                                                    | Life Threatening                                                                                                                                                                            |
| instrumental ADL                                 |                                                                          |                                                                                                                                                                                                      |                                                                                                                                                                                                                                                                                                                                                       |                                                                                                                                                                                                                         |                                                                                                                                                                                             |
| Flushing                                         | None                                                                     | Asymptomatic; clinical or  diagnostic observations  only; intervention not  indicated                                                                                                                | Moderate symptoms; medical  intervention indicated; limiting  instrumental ADL                                                                                                                                                                                                                                                                        | Symptomatic, associated with  hypotension and/or tachycardia;  limiting self-care ADL                                                                                                                                   | --------------------                                                                                                                                                                        |
| Urticaria(Hives)                                 | None                                                                     | Urticarial lesions covering <  10% BSA; topical  intervention indicated                                                                                                                              | Urticarial lesions covering 10 - 30% BSA; oral intervention  indicated                                                                                                                                                                                                                                                                                | Urticarial lesions covering >30% BSA;                                                                                                                                                                                   | Life Threatening                                                                                                                                                                            |
| IV intervention indicated                        |                                                                          |                                                                                                                                                                                                      |                                                                                                                                                                                                                                                                                                                                                       |                                                                                                                                                                                                                         |                                                                                                                                                                                             |
| Neurologic-                                      | None                                                                     | Mild                                                                                                                                                                                                 | Moderate                                                                                                                                                                                                                                                                                                                                              | Severe                                                                                                                                                                                                                  | Life Threatening                                                                                                                                                                            |
| Other-Specify                                    | None                                                                     | Mild                                                                                                                                                                                                 | Moderate                                                                                                                                                                                                                                                                                                                                              | Severe                                                                                                                                                                                                                  | Life Threatening                                                                                                                                                                            |
| Person Completing Form:                          | ADL = activities of daily living                                         |                                                                                                                                                                                                      |                                                                                                                                                                                                                                                                                                                                                       |                                                                                                                                                                                                                         |                                                                                                                                                                                             |
| All Events are Expected and Attributable Except: |                                                                          |                                                                                                                                                                                                      |                                                                                                                                                                                                                                                                                                                                                       |                                                                                                                                                                                                                         |                                                                                                                                                                                             |