A Study of CyBorD (Cyclophosphamide, Bortezomib, Dexamethasone) Plus Daratumumab in People With Monoclonal Gammopathy of Renal Significance (MGRS)

Eligibility Criteria

• * Subjects must have a confirmed diagnosis of NDMM as per standard IMWG criteria
• * Subjects must have measurable disease, defined as meeting at least 1 of the following criteria ≤ 14 days prior to registration:
• * A monoclonal Immunoglobulin (M-protein) concentration on serum protein electrophoresis (SPEP) of ≥ 0.5 g/dL.
• * Measurable urinary light chain secretion by quantitative analysis using urine protein electrophoresis (UPEP) of ≥ 200 mg/24 hours.
• * Involved serum free light chain (FLC) level ≥ 10 mg/dL, provided the serum FLC ratio is abnormal.
• * eGFR must be \<40 ml/min/1.73m2
• * Subjects must have histologically confirmed diagnosis of monoclonal gammopathy associated CN by kidney biopsy OR If a kidney biopsy is not available, a percentage of urine albumin excretion (%UAE) \< 25 % AND FLC \> 50 mg/dL
• * Histologically confirmed diagnosis of MGRS-associated renal disease by kidney biopsy
• * Presence of monoclonal gammopathy by serum protein electrophoresis, Immunofixation, or Free Light Chain Assay
• * Evidence of plasma cell dyscrasia by bone marrow biopsy confirming clonal plasma cell population
• * eGFR \<40 ml/min/1.73m2 or 24h urine total protein \> 1gm
• * Subjects must be ≥ 18 years of age at time of registration.
• * Subjects must have an Eastern Cooperative Oncology Group (ECOG) performance status of 0, 1, or 2 ≤ 14 days prior to registration.
• * No evidence of unequivocal recent nephrotoxic exposure (NSAIDs, radiocontrast...)
• * No evidence of obstructive nephropathy by ultrasound
• * Subjects must have adequate hematology laboratory values within 14 days prior to registration defined by the following:
• * Neutrophils ≥ 1.0 × 10\^9 /L (Patients cannot have received G-CSF or GM-CSF within 1 week of screening or pegfilgrastim within 2 weeks of screening to meet eligibility).
• * Platelets ≥ 100 × 10\^9 /L for run-in and 75 × 10\^9 /L for phase II (Note: Platelet support is not permitted to help participants meet eligibility criteria).
• * hemoglobin ≥ 7.5 g/dL without prior red blood cells \[RBC\] transfusion within 7 days before the laboratory test; recombinant human erythropoietin use is permitted.
• * Subjects must have adequate hepatic function laboratory values ≤ 14 days prior to registration:
• * Aspartate aminotransferase (AST), alkaline phosphatase (AP) or alanine aminotransferase (ALT) ≤ 3 × the upper limit of normal (ULN)
• * Total bilirubin ≤ 1.5 x ULN except for patients with a history of elevated total bilirubin, such as in Gilbert's.
• * Hepatic Child-Pugh score at worse A (patients are eligible for the phase 2 part but not for the Run-in-Period of the trial).
• * Female patients will have to satisfy the following criteria:
• * Be postmenopausal for at least 1 year Prior to registration visit, OR
• * Be surgically sterile, OR
• * If of childbearing potential, agree to practice 2 effective methods of contraception, at the same time, from the time of signing the informed consent form through 90 days after the last dose of study drug, OR
• * Agree to practice true abstinence when this is in line with the preferred and usual lifestyle of the subject. (Periodic abstinence \[e.g., calendar, ovulation, symptothermal, post-ovulation methods\] and withdrawal are not acceptable methods of contraception). If patient is female and of childbearing potential, she must have a negative serum beta human chorionic gonadotropin (β-HCG) test \< 14 days prior to registration and consent to ongoing pregnancy testing during the course of the study.
• * Male patients, even if surgically sterilized (i.e., status post-vasectomy), must agree to one of the following
• * Practice effective barrier contraception during the entire study treatment period and through 90 days after the last dose of study drug, OR
• * Practice true abstinence when this is in line with the preferred and usual lifestyle of he subject. (Periodic abstinence \[e.g., calendar, ovulation, symptothermal, postovulation methods\] and withdrawal are not acceptable methods of contraception).
• * Subjects must have the willingness and ability to comply with scheduled visits, treatment plan, laboratory tests, study procedures, and research procedures.
• * MGRS associated with diseases other than plasma cell dyscrasia (e.g. CLL, B-cell neoplasm, Waldenstrom's macroglobulinemia...)
• * Plasma cell leukemia, AL amyloidosis, or POEMS syndrome.
• * Treatment with prior drugs aimed at the plasma cell dyscrasia.
• * Treatment with prior or concurrent investigational agents aimed at the plasma cell dyscrasia.
• * Female patients who are lactating or have a positive serum pregnancy test during the screening period.
• * Major surgery ≤ 14 days before registration.
• * Focal radiation therapy within 14 days prior to registration with the exception of palliative- radiotherapy for symptomatic management but not on measurable extramedullary plasmacytoma.
• * Disease-related central nervous system involvement.
• * The subject has uncontrolled significant intercurrent illness including, but not limited to, ongoing or active infection.
• * Clinically significant cardiac disease, including:
• * Myocardial infarction within 6 months before randomization, or unstable or uncontrolled disease/condition related to or affection cardiac function (e.g., unstable angina, congestive heart failure, New York Heart Association Class III-IV)
• * Uncontrolled cardiac arrhythmia
• * Any serious medical or psychiatric illness that could, in the investigator's opinion, potentially interfere with the completion of treatment according to this protocol.
• * Known allergy to any of the study medications, their analogues, or excipients in the various formulations of any agent.
• * Concurrent malignancy except for treated non-melanoma skin cancer, cervical carcinoma in situ and low-risk prostate CA being monitored without treatment.
• * Grade 2 or higher peripheral neuropathy on clinical examination during the screening period.
• * Chemotherapy ≤ 14 days of registration.
• * Exposure to an investigational drug (including investigational vaccine) or invasive investigational medical device for any indication within 4 weeks or 5 pharmacokinetic halflives, whichever is longer.
• * Patients with known chronic obstructive pulmonary disease (COPD) with a forced expiratory volume in 1 second (FEV1) \<50% of predicted normal; moderate or severe persistent asthma within the past 2 years. Note that FEV1 testing is required for participants suspected of having COPD and participants must be excluded if FEV1 is \<50% of predicted normal
• * Moderate or severe persistent asthma within the past 2 years, or uncontrolled asthma of any classification. Note that participants who currently have controlled intermittent asthma or controlled mild persistent asthma are allowed to participate.
• * Patients who have a contraindication to the use of any form of anticoagulation or antiplatelet agents.
• * The use of strong CYP3A4 and CYP1A2 inducers or inhibitors will not be allowed while patients are treated on this study.
• * Patients with Hepatic Child-Pugh score B and C. Note that patients with Hepatic Child-Pugh score A are excluded from the Run-in-Period of the trial
• * Patient is:
• * Known history of human immunodeficiency virus (HIV) and those who are seropositive for HIV.
• * Seropositive for hepatitis B (defined by a positive test for hepatitis B surface antigen \[HBsAg\]). Subjects with resolved infection (ie, subjects who are HBsAg negative but positive for antibodies to hepatitis B core antigen \[anti-HBc\] and/or antibodies to hepatitis B surface antigen \[anti-HBs\]) must be screened using real-time polymerase chain reaction (PCR) measurement of hepatitis B virus (HBV) DNA levels. Those who are PCR positive will be excluded. EXCEPTION: Subjects with serologic findings suggestive of HBV vaccination (anti-HBs positivity as the only serologic marker) AND a known history of prior HBV vaccination, do not need to be tested for HBV DNA by PCR.
• * Seropositive for hepatitis C (except in the setting of a sustained virologic response \[SVR\], defined as aviremia at least 12 weeks after completion of antiviral therapy).
• * Vaccination with live attenuated vaccines within 4 weeks of first study agent administration.
• * Plasmapheresis within 28 days before randomization.