This is a 50 patient, Phase 1/2a multi-center pilot study to test the safety and to describe the preliminary efficacy of intravenous administration of allogenic human cord tissue mesenchymal stromal cells (hCT-MSC) as an investigational agent, under U.S. INDs 19968 (Duke) and 19937 (U Miami) to patients with acute respiratory distress syndrome (ARDS) due to COVID-19 infection (COVID-ARDS). The first 10 consecutive patients will receive investigational MSCs manufactured by Duke. In the second phase of the study, 40 additional patients will be randomized to receive placebo or investigational MSCs manufactured by Duke or University of Miami. Patients will be eligible for infusion of 3 daily consecutive doses of hCT-MSC or placebo if they have a confirmed diagnosis of COVID-19 and meet clinical and radiographic criteria for ARDS. Results from the first 10 patients will be compared with concurrent outcomes utilizing standard of care treatments in participating hospitals and in published reports in the medical literature. Results from the additional 40 patients will be combined with the first 10 and analyzed. The trial is relying on focused eligibility of the participants (patients with ARDS), single cohort with short trial time (4 weeks), and simple assessment of clinical outcome (survival, improvement of ARDS). This is a sequential design in the sense that after the first 10 patients are evaluated a decision will be made by the PIs and the Data Safety Monitoring Board whether to proceed with the exploratory randomized portion of the study.
This is a 50 patient, Phase 1/2a multi-center pilot study to test the safety and to describe
the preliminary efficacy of intravenous administration of allogenic human cord tissue
mesenchymal stromal cells (hCT- MSC) as an investigational agent, under U.S. INDs 19968
(Duke) and 19937 (U Miami) to patients with acute respiratory distress syndrome (ARDS) due to
COVID-19 infection (COVID-ARDS). Patients will be eligible for treatment with 3 daily
consecutive doses of hCT-MSC at 1 million cells/kg (max dose 100 million cells) in the phase
1 portion of the study or a fixed dose of 100 million cells daily x 3 days, 12-36 hours apart
in the phase 2 portion of the study, if they have a confirmed diagnosis of COVID-19 and meet
clinical and radiographic criteria for ARDS. The primary endpoint is short-term safety of
hCT-MSC infusions given on this schedule. The key secondary endpoints are 28 day survival, an
increase in PaO2/FiO2 ratio by 50% at 96 hours, days to hospital discharge to home or rehab,
and number of days requiring mechanical or non-invasive ventilation or high flow nasal
cannula.
The study will be executed in two phases. The first 10 consecutive patients will all receive
investigational product. The second part of the study is a randomized, controlled trial in 40
additional patients. The overall aim of the study is to establish safety and to gain critical
information as to whether patients with COVID-ARDS will benefit from MSC infusions. Results
from the first 10 patients will be compared with concurrent outcomes utilizing standard of
care treatments in participating hospitals and in published reports in the medical
literature. Results from the additional 40 patients will be analyzed as a randomized placebo
control trial. The trial is relying on focused eligibility of the participants (patients with
ARDS), single cohort with short trial time (4 weeks), and simple assessment of clinical
outcome (survival, improvement of ARDS). This is a sequential design in the sense that after
the first 10 patients are evaluated a decision will be made by the PIs and the Data Safety
Monitoring Board whether to proceed with the exploratory randomized portion of the study.
The MSCs are manufactured from allogeneic cord tissue donated to the Carolinas Cord Blood
Bank (CCBB) at Duke University. The CCBB is an FDA licensed public cord blood bank (licensed
name DUCORD). Cord tissue is donated by mothers delivering healthy term male babies by
Cesarean section, after written informed consent from the newborn infant's mother. Full donor
screening and testing is performed in accordance with regulatory requirements (21CFR 1271).
The hCT-MSCs will be manufactured in the Marcus Center for Cellular Cures in the Robertson
GMP Cell Manufacturing Laboratory and the Clinical Research Cell Manufacturing Program
(CRCMP) laboratory, Interdisciplinary Stem Cell Institute (ISCI), Miller School of Medicine,
University of Miami. These hCT-MSCs are already being utilized in clinical trials to treat
pediatric patients with autism spectrum disorder (IND 17313), cerebral palsy (IND 17921),
hypoxic ischemic encephalopathy (IND 17313) and adults with osteoarthritis of the knee
(IND18414). To date, over 210 doses of cells have been delivered to patients on these
clinical trials with an excellent safety profile. At University of Miami, hCT-MSCs are used
in the clinical trial to evaluate cytokine suppression in patients with chronic inflammation
due to metabolic syndrome (IND 17324), 12 subjects in the pilot phase of the study had
completed the dose without any treatment emergence SAE.
The rationale for using this approach for patients infected with COVID-19 is that ARDS, the
rate-limiting complication impacting survival, is caused, at least in part, by a cytokine
release syndrome (CRS) which results is severe immune dysregulation. Involved cytokines
include IL-6, IL-8, IL-10, THP-1M, TNF-alpha, and others. MSCs have strong anti-inflammatory
and immune-modulatory activities without apparent toxicity or further immunosuppression.
Approximately 3-5 % of patients with COVID-19 develop ARDS which carries a very high
mortality rate (30-60%) due to multi-system organ failure. Effective treatment of ARDS, the
most feared complication of COVID-19, may convert the COVID-19 pandemic into a more
manageable "flu-like" illness that every American is expected to experience, and most will
survive, on an annual basis.
Biological: Human cord tissue mesenchymal stromal cells (hCT-MSC) manufactured by Duke University.
Human cord tissue mesenchymal stromal cells (hCT-MSC) manufactured by Duke University or University of Miami.
Other Name: hCT-MSC
Other: Placebo
Placebo will be comprised of 40-80 mL of Plasmalyte-A + 1% Human Serum Albumin (HAS) prepared in an identical container to the one used for cell administration. The placebo product will undergo the same process of sterility testing including release inspection, transport and product custodian.
Inclusion Criteria:
1. The patient or legally authorized representative (LAR) must have the ability to
understand and the willingness to provide a signed and dated informed consent form.
2. Age 18 years and over
3. The patient agrees to use adequate contraception for the duration of the treatment
protocol and for 6 months post treatment.
4. Positive RT- PCR testing for COVID-19 nucleic acid using nasopharyngeal swabbing or
any other site
5. Patient meets ARDS criteria and is on non-invasive or mechanical ventilation or high
flow nasal cannula
1. bilateral opacities on chest imaging consistent with pulmonary edema
2. A need for positive pressure ventilation or high flow nasal cannula
3. PaO2/FiO2 ratio ≤ 300 mmHg by arterial blood gas or SpO2/FiO2 imputation.
4. Infiltrates not fully explained by cardiac failure or fluid overload in the
physician's best clinical judgement
6. Subjects requiring dialysis as a result of a COVID-19 infection will not be excluded.
Exclusion Criteria:
1. Evidence of multiorgan failure involving one or more organs, excluding the lungs as
defined below:
1. Presence of shock, defined as MAP < 65 mmHg with signs of peripheral
hypoperfusion, or continuous infusion of 2 or more vasopressor or inotrope agents
to maintain MAP ≥ 65 mmHg.
2. Serum bilirubin > 10 mg/dl
3. Platelet count < 50,000/ml
4. Subjects requiring dialysis as a result of anything other than a COVID-19
infection will be excluded
2. Evidence of acquired or congenital immunodeficiency (due to immunosuppressive therapy
excluding steroid use for treatment of COVID-19 acute respiratory failure, HIV,
previous treatment for cancer, etc.)
3. History of metastatic cancer diagnosis or treatment in the past 1 year
4. History of previous treatments with MSCs or other cell therapies
5. Patient is co-enrolled in any other IND-sponsored clinical trials for COVID-19 or
ARDs. Drugs that are administered under emergency use authorizations (EUA) by the FDA
are permitted.
6. Evidence of pregnancy or lactation
7. Moribund patient not expected to survive >24 hours
8. Unable/unwilling to deliver lung protective ventilation
9. Patient is receiving Extracorporeal Membrane Oxygenation (ECMO)
Boca Raton Regional Hospital
Boca Raton, Florida, United States
Jackson Memorial Hospital
Miami, Florida, United States
University of Miami Hospital
Miami, Florida, United States
New York Medical College
Valhalla, New York, United States
Duke Hospital
Durham, North Carolina, United States