Study to Evaluate ARINA-1 in the Prevention of Bronchiolitis Obliterans Progression in Participants With Bilateral Lung Transplant

The goal of this clinical trial is to compare ARINA-1 plus Standard of Care vs Standard of Care alone. The main question it aims to answer are:Evaluate the effectiveness of ARINA-1 in preventing bronchiolitis obliterans syndrome (BOS) progression in participants with a bilateral lung transplantTo evaluate the effectiveness of ARINA-1 on improving quality of life decline and preventing or delaying the use of augmented immunosuppression in participants with pre-BOS relative to SOC.Participants will have clinic visits at screening, randomization (day 1) and weeks 4, 12, 18, and 24. After week 24, participants will have clinic visits at weeks 32, 40, and 48.Participants will also have a telehealth visit on day 2 and phone calls to assess adverse events (AEs), serious adverse events (SAEs), and review patient education will occur during weeks 5, 8, 36, and 44.

Inclusion Criteria:Bilateral lung transplant >12 months from the time of Visit 1 / RandomizationAge 18-75 years old at the time of consentRoutinely followed at enrolling siteWilling and able to comply with visit schedule and at-home requirements10-20% decrease in FEV1 from the post-transplant baseline within the last 12 months.Capable of giving informed consentOn a stable maintenance regimen of azithromycin for >4 weeks prior to ScreeningOn a stable 3-agent immunosuppression regimen that includes a steroid, a calcineurin inhibitor (CNI), and cell cycle inhibitor (e.g., mycophenolate, azathioprine) >4 weeks prior to ScreeningIf a woman of childbearing potential (WOCBP), must agree to use a reliable method of birth control for the entire duration of the study.Exclusion Criteria:Positive urine pregnancy test at screening and baseline visitDiagnosis of active congestive heart failure or symptomatic coronary artery disease > grade 3 based on the New York Heart Association Functional Classification (NYHA) criteriaRestrictive allograft syndrome (RAS) defined by radiographic interstitial or alveolar opacities on chest X-ray or CT scan that are consistent with RASAdvanced BOS (BOS 1-4) defined by >20% decrease in FEV1 in post-transplant baselineA diagnosis of probable antibody-mediated rejection (AMR) <12 months prior to the baseline visitDonor-specific antibodies (DSA) identified <6 months prior to the baseline visit. *The presence of DSA >6 months from the baseline visit is acceptable for enrollment into the study.Unresolved diffuse alveolar damageReceiving mechanical ventilationChronic kidney disease stage IV or higher, including on dialysisInitiating a new maintenance therapy or changing immunosuppression maintenance therapy (e.g., changing tacrolimus to cyclosporine) <30 days prior to the baseline visit.Currently using an mTOR inhibitor or azathioprineInitiating or changing antibiotic (including azithromycin), antiviral, or antifungal therapy <14 days prior to the baseline visit.Use of alemtuzumab <6 months prior to the baseline visitUse of anti-thymocyte therapies (e.g., anti-thymocyte globulin) or photopheresis <90 days prior to the baseline visitInitiating a multivitamin or other supplement (inhaled, oral, or IV) containing vitamin C, glutathione, or N-acetylcysteine <90 days prior to the baseline visitSignificant unstable comorbidities, in the opinion of the site investigatorAllery or previous adverse reaction to azithromycinA diagnosis of dynamic collapse / tracheobrochomalacia or endobronchial stent <90 days of the baseline visit.Subjects currently participating in, or who have participated in an interventional (drug or device) clinical study <30 days of the baseline visit.Have been diagnosed with ARAD within 6 weeks of the Screening Visit.Have used belatacept <6 months prior to Clinic Visit 1