The document discusses hematopoietic stem cell transplantation (HSCT), including opportunities and challenges. It covers various diseases treatable with HSCT, sources of stem cells, factors influencing transplant success, and challenges in finding HLA-matched unrelated donors due to extensive HLA diversity. It proposes establishing stem cell banks with HLA-homozygous embryonic stem cell lines to increase donor availability and success rates for patients requiring HSCT.

1. Prof. Narinder K Mehra Dept of Transplant Immunology & Immunogenetics AIIMS, New Delhi [email_address] Hematopoietic Stem Cell Transplantation : Opportunities and challenges

3. Bone Marrow Peripheral Blood Stem Cells (PBSC) Cord Blood Sources of Hematopoietic Stem Cells NKM / AIIMS

5. Chromosome 6 Gene map of the HLA region Class II Class III Class I 1.8 Mb 40 % of which have assumed immune functions tel. Long arm cen. short arm tel. 6p 21.3 HLA region Bf DP DM DQ DR C4 C2Hsp70TNF B C E A G F 128 functional genes Most polymorphic Ag presentation, crucial in organ and HSCT

6. Compatible Donor Search - Matching HLA Family- ¼ chance Unrelated – 1/500 - 0/10 million chance of match 70% patients do not have family donor

7. Extraordinary polymorphism in HLA Number Class I Antigens Class I Alleles Class II Antigens Class II Alleles

8. Multiple DNA Based HLA Technologies SSP SSOP Reverse SSOP SBT Luminex (Flow) DNA extraction (optimum quality, quantity, contamination free) is critical

9. DNA vs Serology: Example of a CML patient HLA Pt (P)/ Serology PCR based DNA typing Cousin Donor (CD) Low Resolution High Resolution A P 34, 2 3401, 02 3401, 0207 CD 34, 2 3402, 02 3402, 0211 B P 8, 40 0802, 4003 0802, 4003 CD 8, 40 0801, 4007 0801, 4007 Cw P 4, - 07, 04 0704, 04 CD 4, 7 07 , 0501 07(01-03), 0501 DR P 4, 2 15, 04 1501, 0405 CD 4, 2 15, 04 1502, 0404 DQB1 P 3, 1 03, 01 0301, 0601 CD 3, 1 03, 01 0302, 0602 Match Full Partial Major Grade Match Mismatch Mismatches NKM / AIIMS

12. North Indians Diversity of HLA-A2 Caucasians Japanese Gambian Tissue Antigens 57, 502-507, 2001. Hungarian Gypsies

13. Caucasoids Japanese B*2705 B*2702 Blacks B*2705 B*2703 B*2705 B*2704 Thai B*2705 B*2704 B*2706 B*2707 Azores B*2705 B*2702 B*2703 B*2708 B*2707 AIIMS / NKM Asian Indians B*2707 ( 11% ) B*2704 ( 29% ) B*2702 ( 1.6%) B*2714 ( 0.01% ) B*2705 (57% )

14. * Multiple HLA-DR3 haplotypes Caucasians Indians A1-B8-DR3 (AH8.1) A26-B8-DR3 (AH8.2*) Unique A24-B8-DR3 A2-B8-DR3 Chinese Indians A33-B58-DR3 (AH58.1) A33-B58-DR3 Indians ???? A2-B50-DR3 Unique *Witt , Mehra, Kaur,….et al Tissue Antigens 2002

15. What if an HLA-A,-B,-DR compatible sibling is not available in the family ? OPTIONS Extended family search Partially HLA compatible donors Ante Natal HLA typing Unrelated Donors through registry NKM / AIIMS

17. HLA Matching Siblings Leukemias Thal. M. Identical 177 42 Haploidentical 143 87 Unidentical 21 31 Donor Selection : AIIMS Experience (1998 – Feb 2003) NKM / AIIMS * CVS typing reconfirmed after birth in 3 cases * Out of these, two were transplanted CVS* N+ = 33 14 (42.4%) 12 (36.4%) 7 (21.2%)

18. Unrelated Donor Tx : Thalassemia Major Pt: S W A26 A26 B8 B8 DR3 DR3 A26 A33 B8 B35 DR3 DRx AH A26 A11 B8 B35 DR3 DR15 A26 A11 B8 B35 DR3 DR15 AH I Pt: S Ch A26 A11 B8 B8 DR3 DR3 AH AH A1 A11 B52 B8 DR3 DR3 A26 A26 B8 B8 DR3 DR3 II Ancestral Haplotypes Conserved in the race ?

20. Balancing Act – Strategy to Reduce One Complication May Increase Another T Cell Depletion Reduce GvHD Decrease engraftment Increase infection Increase risk relapse

21. Bone Marrow Donors Worldwide 13.8M Donors Jan, 2010 B.M.Donors = 13.8 M CBUs = 176,779 75 Registries 37 CB Banks BMDW France Greffe de Moelle 125,843 Austrian Bone Marrow Donors 52,029 National Marrow Donor Program 3,927,577 Anthony Nolan Research Center 358,285 Australian Bone Marrow Donor Registry 162,450 German Registry of Bone Marrow Donors 2,299,322 Asian Indian Donor Marrow Registry 3,630 1994

23. 311,311 277,081 62,841 1205 BMDW- Asian Component Total : 12.34M, July,2008 95% 5% No of Donors

24. ASIAN REGISTRIES Country Registry Year of Estb No of Donors MUD Tx JAPAN Japan Marrow Donor Program 1991 300,000 >8000 CHINA Chinese Marrow Donor Program 1992 950,000 >1117 SINGAPORE Bone Marrow Donor Program 1993 44,000 >215 TAIWAN Budhist Tzu Chi Marrow Donor Registry 1993 319,000 >1800 KOREA Korea Marrow Donor Program 1994 144,970 >1477 THAILAND Thai Stem Cell Donor Registry

28. Donor Centres AIDMR-National Network Transplant Centres AIIMS, SGPGI, IIH, CMC, PGI NBU, GSBTM AIIMS, N Delhi AHRR, N Delhi CMC, Vellore TMH, Mumbai SGPGI, Lucknow Apollo, Chennai PGI, Chd KEM, Mumbai

29. 1. Patient Diagnosis 2. Family Screening for HLA Id sib- best option 3. If not-available Family in distress 4. Search for options : a) extended family search: not always rewarding except in consanginous marriages b) Prenatal genetic testing & HLA analysis- useful in disease like thalassemia major unrelated HSCT c) Search in national registry- donor pool too small d) Search in international registry: BMDW, WMDA, ANT etc STEPS INVOLVED IN MUD TRANSPLANTATION

31. Ottinger et al, Blood 2003 MFD, early disease MUD, early disease ISD, early disease ISD, advanced disease MUD, advanced disease MFD, advanced disease Overall Survival after allo HSCT from ISDs, MFDs and MUDs Years after Transplantation

32. Risk of acGvHD after HSCT from ISDs, MFDs and MUDs MFD MUD ISD Ottinger et al, Blood 2003

33. MFD , MM2 MFD , MM1 MUD ISD MFD , MMO Impact of mismatched HLA Loci on the risk of Ac GvHD Days after Transplantation p Ottinger et al, Blood 2003

35. Probability of survival after Allogeneic Stem Cell Transplant Hows et al, BMT 2006

40. Source of Somatic Cells Collborative study between AIIMS and NIRRH Fetal fibroblasts Human fetal fibroblasts already being successfully grown at the NIRRH by Dr Deepa Bhartiya Aneuploid cases from a Cytogenetics lab (n= 10) Adult fibroblasts Selection of HLA Homozygous individuals positive for Ancestral Haplotype , AH8.2 by the AIIMS Group of Prof N.K. Mehra Adult skin biopsies, Cytogenetics lab (n=2)

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45. AIIMS – TII GROUP

46. Derivation and Characterization of two genetically unique huESC lines on in-house derived human feeders (Stem cells and development 2008)

48. Project with a Strong Basic Research Component as well as a Future Translational Goal in the Area of Stem Cell Research Establishing the Technology to Derive Human Embryonic Stem Cell Lines by Somatic Cell Nuclear Transfer and Parthenogenesis NIRRH, Mumbai - Deepa Bhartiya and group AIIMS, New Delhi – Narinder Mehra, Gurvinder Kaur Other collaboators…….

50. Survival among HLA-A,B and DRB1 allele matched pairs by number of mismatched class I loci Years after Transplant 1 Mismatch (n=317) 0 Mismatches (n=791) 2 Mismatches (n=117) Flomenberg et al, Blood 2004