¿Cómo buscar un donante no emparentado y que características

debe tener el mejor donante

¿Cómo buscar un donante no emparentado y que características

debe tener el mejor donante

Dr. Enric Carreras

Aula Interactiva Hematología

3 de Febrero de 2010

Expressed on the surface of most

nucleated cells

(except red cells

and CNS cells)

Expressed on the surface of cellsof the

immunesystem

(dendritic, LB, LT activated, macrophages)

HLA Molecules

DP DQ DR B C A

HLA class II HLA class I

B1 A1 B1 A1 B1 A1B3B4B5

The HLA System

B1 B3 B4 B5 A1

HLA Polymorphism

4631249 853

HLA-CHLA-BHLA-A

1359989659

DPB1DQB1DRB2-9DRB1

January 2010

HLA Typing and Nomenclature

B62 (15)

Protein

*Not required

(Broad specificity)*

Serologic type in order discovered

Typing by SerologyRequires live lymphocytes from fresh bloodTests patient cells surface HLA antigensagainst serologic reagents (anti-bodies)

Requires live lymphocytes from fresh bloodTests patient cells surface HLA antigensagainst serologic reagents (anti-bodies)

A2 A203#, A210#A9 A23, A24, A2403#A10 A25, A26, A34, A66A19 A29, A30, A31, A32, A33, A74A24 A2403#A28 A68, A69B5 B51, B52, B5102#, B5103#B7 B703#B12 B44, B45B14 B64, B65B15 B62, B63, B75, B76, B77B16 B38, B39,B3901#,B3902#B17 B57, B58B21 B49, B50, B4005#B22 B54, B55, B56B27 B2708#B39 B3901#, B3902#B40 B60, B61B51 B5101#, B5103#B70 B71, B72

Broad, Splits and Associated Ag

http://www.anthonynolan.com/HIG/lists/broad.html

Broad Split and associated # Ag

Uses DNA from cell nucleusDoes not require live cellsSamples can be stored and typed laterVariety of methods are used

Uses DNA from cell nucleusDoes not require live cellsSamples can be stored and typed laterVariety of methods are used

HLA Typing and Nomenclature

DNA based techniques

Gene *

B*1501

Antigen group (based on similarity and/or serology)

Allele number in order discovered

ReportTyping Level What does it tell

Low ResolutionSerology or DNA Typing (Ag level)

which antigen or allele is present

B62 B*15XX

High ResolutionDNA Typing (Allele Level)

which allele is present B*1501

Intermediate ResolutionDNA Typing

which alleles may be present out of all the alleles

of within an antigen B*15ADE

Different Levels of HLA Typing

1501150215031504150515061601160316051607

ADE =

Intermediate Resolution DNA Typing

http://www.nmdpresearch.org/HLA/alpha.html

Multiple allele code lists, provided by the National Marrow Donor Program

WHO HLA nomenclatureB*150101 (same protein but differ at DNA level)B*15010102(<> allele outside protein coding region)B*15010102N(no protein expression on cell surface)A*24020102L(low expression at cell surface)B*44020102S(protein secreted but not at cell surface)

HLA typing: Methods & Resolution

Treat as absent

Treat as absent

Use only 4 digits

Use only 4 digits

Use only 4 digits

New HLA nomenclature

A*01:01:01:01 A*02:01:01:02L A*26:01:01 A*33:01 B*08:08N C*01:03 C*07:02:01:01

A*01010101A*02010102LA*260101A*3301B*0808N Cw*0103Cw*07020101

After April 2010Today

HLA types and definition of "Match"

Match level Donor Patient

A*2301 A*2301Allele (or High-level) Match

A*2402 A*2401Allele (or High-level) Mismatch

* Potential allelic match

Antigen (or Low-level) Match * A23 A23

A*23 A*23Antigen (or Low-level) Match *

A*24

A24Antigen (or Low-level) Mismatch

A*23

A23

Antigen (or Low-level) Mismatch

1) HLA compatible sibling?

- Test A, B, DR loci (low resolution) to prevent 2-2.5% of recombination

- If >1 match sibling → analyze minor locus (as DPB1) to find the best donor

Donor Search: the first three steps

NO?

2) Test parents and patient’s children

To analyse family haplotypes →

- impact on search strategy, and

- detection of typing mistakes

Donor Search: the first three steps

Start the search

The Search

± (useful)DQB1

(DRB1 association)

NODR3-9DQA1DPA1DPB1

National Registry

International Network

MinimumA*2301B*0701C*0201

DRB1*0301

Match donor

3) If the patient has a very frequent haplotype (>1%)

HLA-A*29, B*44, DRB1*07HLA-A*01, B*08, DRB1*03HLA-A*30, B*18, DRB1*03HLA-A*02, B*07, DRB1*15HLA-A*02, B*44, DRB1*13HLA-A*02, B*51, DRB1*04HLA-A*33, B*14, DRB1*01HLA-A*30, B*13, DRB1*07(www.ashi-hla.org)

Type 2nd line family members (uncles,

cousins) from the side of the family that

contribute with the less frequent haplotype

Donor Search: the first three steps

A B C DR DQ DPGenotypicallyid. sibling

a a a a a a

a a a aa a a

10/109/108 / 8

a= identical at allele level

Unrelated Matched Donor Definition

7/8

Minimum requirement

a a a a aa a a a/b

Recommended

a

a a a a a a

b

NMDP(2004)

FHCRC(2001)

DQDRCBA

Effect of a single mismatch on survival in occidental patients

FHCRC(2004)

CIBMTR(EBMT’09)

YesYes

Yes Yes Yes NoYes

Yes Yes Yes Yes*Yes

Yes Yes Yes NoYes

Effect of Mismatching on Survival

No----RECNo--Si (A)EICH crónica

Si (A, C, DRB1)----SLESi (A, C, DRB1)Si#SiTRM

Si--Si (A)EICH agudaNo--Si (C**)FI

Impacto de un MM sobre:SiSiSi- Peor > 1 MM?

No (Si en C)NoSi- Peor MM Ag que alélico? Impacto sobre la SRV:

38579481874Pacientes analizadosCIBMTR ‘09Seattle ‘04NMDP ‘04

MM= mismatch. ** significación indiciaria;

0,0

0,1

0,2

0,3

0,4

0,5

0,6

0,7

0,8

0,9

1,0

0 12 24 36 48 60

Survival

Probability of Overall Survival by HLA Matching for Early Disease Stage

Log-rank p-value = < 0.0001

8/8 HLA Matched (n=835)

7/8 HLA Matched (n=379)

Months after transplant

6/8 HLA Matched (n=241)

50%

39%

28%

Single MM → 8 - 12% survival at 5 y.

Any additional MM → 8 - 12% survival

Single MM → 8 - 12% survival at 5 y.

Any additional MM → 8 - 12% survival

courtesy of M Horowitz

0,0

0,1

0,2

0,3

0,4

0,5

0,6

0,7

0,8

0,9

1,0

0 12 24 36 48 60

Survival

Probability of Overall Survival by HLA Matching for

Early Disease Stage

Log-rank p-value = < 0.0001

8/8 HLA Matched (n=835)

7/8 HLA Matched (n=379)

0,0

0,1

0,2

0,3

0,4

0,5

0,6

0,7

0,8

0,9

1,0

0 12 24 36 48 60

Survival

Advanced Disease Stage

8/8 HLA Matched (n=327)7/8 HLA Matched (n=195)

Months after transplant

courtesy of M. Horowitz

Single mismatch

Petersdorf et al., Blood 2004

CIBMTR, EBMT 2006

Acceptable in Acceptable in some patientssome patients

Our goal must be

To find a donorA, B, C, DRB1 (±DQB1)identical at allele level

Spanish ExperienceUD-SCT in CM L 1stCP - Spanish experience

HLA typing

0 12 24 36 48 60 72 84 96

Months

0,0

0,2

0,4

0,6

0,8

1,0Pr

obab

ility

of S

urvi

val

10/10 at allele level (n= 12)

9/10 at allele level (n= 9)

8/8 at allele level (n= 4)

identity A, B +/- C (serologic) + DRB1 (DNA) (n= 17)

identity A, B +/- C (serologic) + DRB1 + DQB1 (DNA) (n= 40)

1 o 2 diferences in A, B o C (serologic) o in DRB1 o DQB1 (DNA) (n= 10)

Carreras et al, BMT 2006

Yahoub-Agha et al., JCO 2006

OS

DFS

TRM

10/10 URD-HSCT vs HLA-id sibling

IdentityA, B, C,

DRB1, DQB1at allele level

Otros aspectos a considerar

Dirección alo-reactividad

Presencia de anticuerpos anti-HLA

Alo-reactividad KIR

Identidad haplotípica

Antígenos maternos heredados

Tiempo disponible

Características del donante

Presencia de anticuerpos anti-HLA

Si TPH con incompatibilidades D-R ⇒

- Test de citotoxicidad ¿Ac. citotóxicos?

- Si Panel Reactive Antibody (PRA) >10% ⇒

- estudio confirmatorio para detectar

frente a que Ac. HLA se ha producido la

sensibilización

Allo-reactivity direction

A*2401A*2401← GvHDA*0201

A*2401

A*0201A*2401Rejection →A*0201

A*0201

A*0302A*2401Rejection ↔ GvHDEj: A*0201

A*2401

DonorEfectPatient

Farag et al, Blood 2002

KIR alloreactivity

MatchMismatch

Farag et al, Blood 2002

KIR alloreactivity

MatchMismatch

Perugia results AML advanced phasesno allo-KIR allo-KIR

Graft failure 14% 2% ⇓GvHD 13% 4% ⇓Relapse 55% 0% ⇓DFS 10% 58% ⇑

Velardi et al., 2003

Perugia Perugia resultsresults AML AML advancedadvanced phasesphasesno no alloallo--KIR KIR alloallo--KIRKIR

GraftGraft failurefailure 14%14% 2% 2% ⇓⇓GvHDGvHD 13%13% 4% 4% ⇓⇓RelapseRelapse 55%55% 0% 0% ⇓⇓DFSDFS 10%10% 58% 58% ⇑⇑

Velardi et al., 2003

KIR Allo-reactivity

NoBw4/Bw6NoC1/C2

NoBw6/Bw6NoC2/C2 Bw4/Bw6

NoBw4/Bw4

C1/C2

NoC1/C1

SiBw4/Bw6SiC1/C2

NoBw6/Bw6NoC2/C2 Bw6/Bw6

SiBw4/Bw4

C2/C2

SiC1/C1

SiBw4/Bw6SiC1/C2

SiBw6/Bw6SiC2/C2 Bw4/Bw4

NoBw4/Bw4

C1/C1

NoC1/C1

RecipientAlloKIR

DonorRecipientAlloKIR

Donor

Farag et al., BB&MT 2006

KIR allo-reactivityin URD-HSCT

1571 UND SCT1004 match A, B, C, DRB1

137 GvH KIR MM170 HvG KIR MM

260 B or C MM but KIR M survival in myeloid malignancies

Haplotype matching for URD-HSCT

Patient DonorMatch

DonorHaplo-MM

GvHD III-IV

Petersdorf et al., PLoS Med 2007

Non-inhered maternal antigens (NIMA)Haploidentical SCT

Cord blood

Van Rood et al, PNAS 2009

GvHD II-IV GvHD III-IV

IPA

IPA

NIMANIMA

Ichinohe et al, Blood 2004

Timing for SCT

o Patients requiring allo-HSCT are not equal

o Each disease & disease status ⇒ ideal timing

CML / CLL RA/RSALPD / PCDSAA Cong. Dis.

AML / ALL- high risk- 1st relapseRAEBCongenital diseases

AML / ALL- resistant- early relapseRAEB-t

Diseases /status

>3 months<3 monthsasapIntervalDx-Tx

1. URD

2. CBT

3. Haplo

1. CBT

2. URD

3. Haplo

4. Auto ⇒

1. CBT

2. Haplo

3. Auto ⇒

Therapeutic

options

>3 months<3 monthsasapInterval

Dx-Tx

Auto ⇒ Auto-HSCT while waiting a donor for an allo-RIC

46%Spain

2.5%Germany

% CBT2008 data

Timing for SCT

Bone Marrow vs Peripheral blood vsCord Blood Transplantation

MO 41%SP 39%SC 33%

MO 22%*SP 24%*SC 37%*

MO 41%*SP 54%*SC 27%*

MO 38%SP 47%*SC 30%*

MO 92%SP 96%SC 80%

MO 330SP 630SC 165

CIBMTR 2009

SLEMRTEICH crónica

EICH aII-IV

>500 μLneutrófilos

NúmeroTPH

Grupo

MO= Medula ósea match alta resolución SP= sangre periférica match alta resolución; SCU= sangre cordón umbilical

* Diferencias estadísticamente significativas entre MO vs SCU y/o SP vs SCU

Similar SLE entre los tres tipos de trasplantes

Cortesía de V. Rocha ALWP Barcelona 2009

If we have more than one match donor

Donor age (younger)

CMV (match)

Gender (male)

Parity (never pregnant)

ABO (compatible)

Body size (larger)

Which one to choose?

Kollman et al., Blood, 2001

Impact of Donor age

Impact of Age of DonorUD-SCT in CML 1s tCP / Spanish Experience

Age of donor

0 12 24 36 48 60 72 84 96

Months

0,2

0,4

0,6

0,8

1,0C

umul

ativ

e Pr

opor

tion

Surv

ivin

g

p=0,05

Donor < 35 years

Donor >=35 years

Carreras et al. BMT 2005

p= .006

Donor CMV(+)

Donor CMV (-)

CMV (+) patientsCMV (-) patients

Donor CMV(+)

Donor CMV (-)

p= .04

Nicholson et al., 2002 Ljungman et al., 2003

Impact CMV Serological Status

CMV + ⇒ +match - ⇒ -

Donor and recipient sex and parity

No impact in acute GvHD, relapse, TRM and survival

Male donor

Nulliparous female

Parous female

1.261.330.84Par ♀Recip.

1.581.020.75Null♀Recip.

1.561.441.00♂Recip.

Par

♀ D

Null

♀ D♂

Don.

Chr.GVHD

Loren et al., BB&MT, 2006

Chronic GvHD

Recommended search strategy

A, B, C, DRB1 high resolution typing (patient)

Simultaneous search of compatible donor & CBU

DonorRegistries

CBBanks

< 9/10 or not enough time

CBT

HLA 10/10 o 9/8

URD-HSCT

TNC >2x107/kgHLA id. ≥4/6

requiredrecommended

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