Multi-Drug Desensitization Protocol for Heart Transplant Candidates

Inclusion Criteria:

• 1. Voluntary signed informed consent before performance of any study-related procedure not part of normal medical care, with the understanding that consent may be withdrawn by the subject at any time without prejudice to future medical care.

  2.Female subject is either post-menopausal or surgically sterilized, or willing to use two acceptable methods of birth control for the duration of the study and for up to 2 months after the last dose of study medication.

  3.Male subject agrees to use an acceptable method for contraception for the duration of the study.

  4.Patient is greater than or equal to 18 years of age but less than 70 years old (inclusive).

  5.Patients with a Calculated Panel Reactive Antibody (CPRA) of ≥ 50% by Luminex Single Antigen Flow Bead (SAFB) testing (LABScreen®, Canoga Park, CA), where a Mean Fluorescence Intensity (MFI) of 1000 is the positive threshold.

  6.Patient is considered compliant and intends to be available for follow-up study period of 1 year.

  7.Patient must have no known hypersensitivity to treatment with bortezomib, boron, or mannitol.

  8.Patient must have no hypersensitivity to rituximab. 9.Patient must have no history of allergy or anaphylaxis to rabbit proteins or to any product excipients, or have active acute or chronic infections which contraindicate additional immunosuppression.

  10.Patient must have no history of an anaphylactic or severe systemic response to Immune Globulin (Human). Individuals with selective IgA deficiencies who have antibody against IgA (anti-IgA antibody) should not receive IVIG since these patients may experience severe reactions to the IgA which may be present.

  11.Patients without an AICD implanted will need to consent to wear a Zoll LifeVest Wearable Defibrillator.

Exclusion Criteria:

1. Women who are pregnant, breastfeeding, or have a positive pregnancy test on enrollment. If the patient becomes pregnant during the study, she must be removed from the study before receiving any additional study drug.
2. History of hepatitis C virus (HCV) positivity (by polymerase chain reaction, PCR)
3. Patients who are human immunodeficiency virus (HIV)-positive, or hepatitis B surface antigen (HBsAg)-positive.
4. Patient is deemed likely to have a second solid organ transplant or cell transplant (e.g. kidney or islet cell) in next 3 years.

5. Patient at risk for tuberculosis (TB):

   1. Current clinical, radiographic, or laboratory evidence of active or latent TB as determined by local standard of care
   2. History of active TB:
   3. Within the last 2 years, even if treated
   4. Greater than 2 years ago, unless there is documentation of adequate treatment according to locally accepted clinical practice
   5. Patient at risk of reactivation of TB precludes administration of conventional immunosuppression (as determined by investigator and based upon appropriate evaluation)
6. Patient with active peptic ulcer disease (PUD), chronic diarrhea, or gastrointestinal malabsorption
7. Patient with a history of hypercoaguable state
8. Patient with hemoglobin < 7 g/dL, white blood cell (WBC) count < 2000/mm3 (3 x 109/L) or platelet count < 30,000 /mm3 prior to transplant
9. Receipt of a live vaccine within 4 weeks prior to study entry
10. Patient treated with immunosuppressive therapy (e.g. methotrexate, abatacept, etc) for indications such as autoimmune disease, or patient with comorbidity to a degree that treatment with such agents is likely during the trial in the opinion of the investigator
11. Patients with current or recent severe systemic infections within 2 weeks of medication start
12. Evidence of severe liver disease with abnormal liver profile (aspartate aminotransferase [AST], alanine aminotransferase [ALT] or total bilirubin > 1.5 times upper limit of normal (ULN) at screening.)
13. Patient has ≥ Grade 2 peripheral neuropathy within 14 days of medication start
14. History of malignancy within the past 5 years that is not considered to be cured, with the exception of localized basal cell carcinoma of the skin (excised ≥ 2 years prior to study initiation)
15. Prisoner or patient compulsorily detained (involuntarily incarcerated) for treatment of either a psychiatric or physical (e.g. infectious disease) illness
16. Patient with a history of substance abuse (drugs or alcohol) within the past 6 months, or psychotic disorders that are not compatible with adequate study follow-up
17. Patient with a history of amiodarone exposure within three months.
18. Patient with a previous heart or other transplant