Histocompatibility Matching for Hematopoietic Stem Cell Transplant: Can we Close the Gaps? Michael Aubrey, CHS

Transcription

1 Histocompatibility Matching for Hematopoietic Stem Cell Transplant: Can we Close the Gaps? Michael Aubrey, CHS

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3 HLA Matching Is Like ABO Matching (but Much More Difficult) ABO Types HLA Types Billions and billions But the consequences of imperfect matching are similar: Product might not take The recipient might have a bad reaction

4 Chromosome 6: The Home of HLA ß2M DP DQ DR B C A 400kb 50kb 1100kb 100kb 1270kb B1 A1 B1 A1 B1 B3 A B4 B5 Classical Class II Haplotype (not to scale) Classical Class I

5 Haplotypes a b A1 B8 DR17 A11 B60 DR15 A2 B7 DR15 A33 B44 DR7 c d Homozygous A1 B8 DR17 A1 B8 DR17 A11 B60 DR15 A11 B60 DR15 A2 B7 DR15 a/c Recipient or genotypically identical A33 B44 DR7 a/d Sibling haploidentical A2 B7 DR15 b/c Sibling haploidentical A33 B44 DR7 b/d Sibling Non-identical HLA is inherited in blocks called haplotypes HLA protein products are co-dominant The chance of a two haplotype match amongst two true siblings is ~25%

6 Role of HLA: Advertise Self vs. Non-Self From Jan Klein and Akie Sato, NEJM, Vol 343, 2000.

7 Role of HLA From Jan Klein and Akie Sato, NEJM, Vol 343, NATURE VOL JUNE 2012

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9 Path to a Donor Matched Related Donor (MRD) Matched Unrelated Donor (MUD) -Mismatched Related or Unrelated -Cord Blood Unit (CBU) -Haplomatched Donor A V A I L A B I L I T Y ~30% Dependent on family size, health and availability 20-80% of the remaining dependent on HLA type >90% of the remaining dependent on transplant center expertise and recipient antibodies Recipient: A*,A* B*,B* C*,C* DRB1*,DRB1* DQB1*,DQB1* MRD/MUD: A*,A* B*,B* C*,C* DRB1*,DRB1* DQB1*,DQB1* CBU: A,A B,B DRB1*,DRB1* Haplomatched: A*,A* B*,B C*,C DRB1*,DRB1* DQB1*,DQB1*

10 Polygenism & Polymorphism DRB1*01:01 DRB1*07:01 DRB1*01:03 DRB1*10:01 DRB1*11:04 DRB1*16:02 DRB1*09:01:02 DRB1*14:03 A* B* C* DRB1* DRB3/4/5* DQA1* DQB1* DPA1* DPB1* Gene April 2012 HLA Allele Count Number Alleles Proteins Null Alleles HLA-A HLA-B HLA-C HLA-DRA HLA-DRB HLA-DRB3/4/ HLA-DQA HLA-DQB HLA-DPA HLA-DPB

11 How Many Alleles in a Population of 7 Billion? ~350,000 Tissue Antigens 77, (2011) Source:

12 EUR API NMDP Data 2008

13 Worldwide Unrelated Donor Search BMDW Registries 2010: Korea, Noted on BMDW but not officially listed

14 Matching Odds By Race NMDP Data 2010

15 HLA Matching Matters (disease state and stem cell source are major influences) Early Disease (NMDP, 2007) Gap 1: Technical and biological aspects of SCT Gap 2:Room for matching improvements Gap 3: Established HLA Effect

16 HLA Matching Matters (disease state and stem cell source are major influences) Advanced Disease (NMDP, 2007) Gap 1: Technical and biological aspects of SCT Gap 2:Room for matching improvements Gap 3: Established HLA Effect

17 HLA Matching Matters (disease state and stem cell source are major influences) Arora Petersdorf, CML, 2009 Gap 1: Technical and biological aspects of SCT Gap 2:Room for matching improvements Gap 3: Established HLA Effect

18 HLA Typing Is Based On Incomplete Information All clinical HLA typings are based on incomplete information. It is possible that what we do not know could alter the expression of an HLA allele: -Mutations in the membrane proximal, trans-membrane, and cytosolic domains (limited sequencing) -Mutations in introns (not sequenced) -Mutations in promoter regions (not sequenced) -Mutations in alpha chains of class II proteins. DRA1, DQA1 and DPA1 are not routinely sequenced for clinical typings.

19 HLA Typing Is Based On Incomplete Information BLOOD, 4 OCTOBER 2012 VOLUME 120, NUMBER 14

20 MHC Polymorphism Correlates with Peptide and TcR Binding region Polymorphism of class I and II: Red>Blue>Green>Yellow Immunobiology of the Human MHC, 2006

21 Complete Matching Is Elusive! Known Mismatched Donors Used in Certain Scenarios! 9/10 matched siblings, parents or children! 9/10 (7/8) MUD donors! 5/10 haplomatched donors! Cord bloods routinely matched at 4/6-6/6 HLA-A,B,DRB1. However, these units may be as low as 2/10 at the allele level! 10/10 Matched Donors May be Mismatched at Other Loci: HLA- DRB3/4/5, DQA1, DPA1, or DPB1! >4% of matched siblings are DPB1 mismatched (Transplantation, Volume 77(7), 15 April 2004, pp )! Of 1775 MUD transplant pairs, 648 matched at HLA- A,B,C,DRB1,DQA1,DQB1. Of these, only 107 matched for DPB1 (Human Immunology 68, 30 40, 2007) Conclusion: Excluding two haplotype matched siblings, most donors will be mismatched at one or more traditional HLA loci

22 MHC Matching Across Megabases BLOOD, 4 OCTOBER 2012 VOLUME 120, NUMBER 14

23 MHC Haplotype Matching (Gap 2 Strategy) Study Participants Patients were eligible if they received a myeloablative conditioning regimen and T cell replete HCT with bone marrow or growth-factor-mobilized blood cells from an HLA-A, -B, -C, -DRB1, - DQB1 allele-identical unrelated donor for treatment of a blood disorder, and cyclosporine and methotrexate for post-grafting immunosuppression. Haplotyping to Determine Linkage of HLA-A, -B, and -DRB1 Alleles We previously described a novel DNA microarray method to determine the physical linkage of HLA-A, -B, and DRB1 alleles when family study is not available. Genomic DNA was extracted from lymphoblastoid cell lines under conditions that minimize shearing and then hybridized to arrays containing two oligonucleotide probes, each specific for the two HLA-B alleles in the sample. The linked HLA-A and -DRB1 alleles on the captured HLA-B allele-specific strands were then genotyped by using oligonucleotide probes. Petersdorf EW, Malkki M, Gooley TA, Martin PJ, Guo Z (2007) MHC haplotype matching for unrelated hematopoietic cell transplantation.plos Med 4(1): e8.

24 MHC Haplotype Matching HaploType Freq as percents A*01:01 A*03:01 B*07:02 B*08:01 DRB1*03:01 DRB1*15:01 EUR AFA API HIS NAM #1 A*01:01-B*07:02-DRB1*03: #2 A*03:01-B*08:01-DRB1*15: #3 A*01:01-B*08:01-DRB1*15: #4 A*03:01-B*07:02-DRB1*03: #5 A*03:01-B*07:02-DRB1*15: #6 A*01:01-B*08:01-DRB1*03: #7 A*03:01-B*08:01-DRB1*03: #8 A*01:01-B*07:02-DRB1*15: X/Million (std estimate): EUR Haplotype % 0.0% 0.4% 98.7% 0.9% Petersdorf EW, Malkki M, Gooley TA, Martin PJ, Guo Z (2007) MHC haplotype matching for unrelated hematopoietic cell transplantation.plos Med 4(1): e8.

25 MHC Haplotype Matching: Grades III-IV GvHD Petersdorf EW, Malkki M, Gooley TA, Martin PJ, Guo Z (2007) MHC haplotype matching for unrelated hematopoietic cell transplantation.plos Med 4(1): e8.

26 MHC Haplotype Matching: Recurrent Malignancy Petersdorf EW, Malkki M, Gooley TA, Martin PJ, Guo Z (2007) MHC haplotype matching for unrelated hematopoietic cell transplantation.plos Med 4(1): e8.

27 MHC Haplotype Matching: Overall Survival Petersdorf EW, Malkki M, Gooley TA, Martin PJ, Guo Z (2007) MHC haplotype matching for unrelated hematopoietic cell transplantation.plos Med 4(1): e8.

28 HLA Mismatches Outside of the T Cell Binding Domain (Gap 3 Strategy) www-ermm.cbcu.cam.ac.uk Groove (T Cell Binding) Domain CD3 CD4 CD8 TM Cytoplasmic Tail Class I Class II 1 Exon 2 Exon 3 Exon Exon 2 Exon

29 HLA Mismatches Outside of the Antigen Recognition Site (ARS) Commonly Observed Allele Pairs that Differ Outside the T cell Binding Region (more common allele in bold) DRB1*14:01 vs. DRB1*14:54 β2 A*23:01 vs. A*23:17 TM B*07:05 vs. B*07:06 TM C*07:01 vs. C*07:06 vs. C*07:18 TM and/or CT DQB1*02:01 vs. DQB1*02:02 β2 but always differ at DQA1 DQB1*03:01 vs. DQB1*03:19 β2 DPB1*04:02 vs. DPB1*105:01 β2

30 HLA Mismatches Outside of the Antigen Recognition Site (ARS) Not DIRECTLY recognized by the T cell Negative MLC between DRB1*14:01 and DRB1:14:54 C*03:03 and C*03:04 not associated with severe agvhd in Japanese study (this difference is within ARS but on a loop not touched by TcR) Different alleles are surrogate markers for different HAPLOTYPES. For example, DRB3*02:01-DRB1*14:01 vs. DRB3*02:02-DRB1*14:54 Could affect CD3/CD4/CD8 binding or HLA signal transduction Theoretically, HLA allelic differences can activate the immune system through indirect recognition

31 HLA Mismatches Outside of the ARS: DRB1*14:01 vs. DRB1*14:54 Daunting Statistics: Based on a 9% expected difference in survival between a 7/8 vs. an 8/8 match Power: 80% P-Value: <0.05 Number of Necessary Transplant Pairs: 88,000

32 HLA Mismatches Outside of the ARS: DRB1*14:01 vs. DRB1*14:54

33 Mismatched Donors (Gap 3)

34 Mismatched Donors (Gap 3)

35 HLA Permissive/Non-Permissive MM (2007) HR for severe agvhd Marrow Tx, , facilitated by JMDP HLA-C Allele MM Special Case: C*0303-C ( ) C*0304-C ( ) Differ at position 91, not thought to interact with peptide or TCR A high proportion of HLA-C allele MM will be this combination Takakazu Kawase, et al, Japan Marrow Donor Program, Published in Blood 2007

36 The final study population consisted of 2107 patients with good or intermediate risk hematological malignancies who underwent allogeneic HCT from HLA matched or single HLA class I allele or Ag-mismatched unrelated donors. Good risk was defined as AML and ALL in first CR, CML in first chronic phase, and myelodysplastic syndrome subtype refractory anemia. Intermediate risk was defined as AML and ALL in second or subsequent CR or in first relapse, and CML in accelerated phase or second chronic phase. Patients with high-risk disease were excluded from the analysis in order to better examine the relationship between amino acid substitutions and survival To avoid confounding effects of HLA mismatches in the graft-vs-host and host-vs-graft directions, donors and recipients that were homozygous at an HLA class I locus (n=91) were excluded from analysis. Donor recipient pairs with more than one mismatch in HLA- A, B, C and DRB1 or those mismatched at HLA-DRB1 were also excluded. There were 1507 donor recipient pairs who were matched at HLA-A, B, C and DRB1 (referred to as the matched. group) and 600 donor recipient pairs with only one allele or Ag mismatch at HLA-A, B or C (referred to as the mismatched group).

37 Class I Amino Acid Mismatches Fewer HLA-B positions significant; therefore, a higher likelihood of HLA-B permissive MM

38 Class I Amino Acid Mismatches

39 Example Class I Mismatches Observed at ClinImmune (9/10 Overall Matched Pairs) A Antigen A Allele B Antigen B Allele C Antigen C Allele Allele Mismatches Patient Donor Narrative A*02:01 A*02:06 Non permissive A*02:01 A*02:07 Permissive A*02:05 A*02:01 Non permissive A*24:02 A*24:30 Permissive B*07:04 B*07:02 Permissive B*35:01 B*35:03 Non permissive B*35:01 B*35:03 Non permissive B*35:03 B*35:08 Non permissive B*35:03 B*35:08 Non permissive B*35:57 B*35:01 Outside ARS, presumed permissive B*35:57 B*35:01 Outside ARS, presumed permissive B*39:06 B*39:01 Non permissive C*03:04 C*03:03 Permissive C*07:01 C*07:02 Non permissive C*07:01 C*07:02 Non permissive C*07:01 C*07:02 Non permissive C*07:0101 C*07:0202 Non permissive i C*07:02 C*07:01 Non permissive C*07:02 C*07:01 Non permissive C*07:02 C*07:01 Non permissive C*07:02 C*07:01 Non permissive C*07:02 C*07:01 Non permissive C*07:18 C*07:01 Outside ARS, presumed permissive C*08:02 C*08:12 Permissive

40 HLA-DPB1 (Gap 2,3 Optimization) Classic HLA Class II molecule: Alpha chain and Beta chain First reported in 1980 Identified by lymphocyte cellular assays Lower surface expression than other HLA s Clinical importance is still being debated Antibodies Cellular response (Rejection, GVH)

41 Importance of DPB1 for BMT? Pawelec G, et al, 1987 Transplant Proc : strong implication is that HLA-DP is of little prognostic consequence for avoiding GVHD Petersdorf EW, et al, 1993 Blood: recipient incompatibility for DPB1 alleles does not detectably influence the risk of acute GVHD Varney MD, et al, 1999 Human Immunology: There was a significant association of increased freqency of severe GVHD compared to mild GVHD with DPB1 mismatched transplants compared to DPB1 matched transplants

42 Importance of DPB1 for BMT? Loiseau, et al, 2002 Bone Marrow Transplant: DPB1 disparities contribute to severe GVHD and reduced patient survival after unrelated bone marrow transplantation. Lee, S et al, 2007 Blood: There was no association of HLA-DP mis-matching with survival. There was an association with increased acute GVHD

43 Likelihood of Matching? 10/10 Matched Sibling Donor: ~96% 10/10 Matched Unrelated Donor: ~20% 0 MM ~55% 1 MM ~25% 2 MM Why? Recombination Hot Spot leads to poor association with the other HLA molecules BLOOD, 4 OCTOBER 2012 VOLUME 120, NUMBER 14

44 HLA Allo-Antibodies Develop in Response to NonSelf HLA Molecules! Blood products Antibody Persistence! Allograft! Pregnancies! Natural HLA Antibodies (crossreactions with ingested allergens or microorganisms)?

45 Antibody Compatibility in Well-Matched Unrelated Donors Stefan O. Ciurea, et al. Donor-specific anti-hla antibodies and graft failure in matched unrelated donor hematopoietic stem cell transplantation, Blood, 2011 The presence of anti-hla antibodies pre-transplant was determined prospectively in 592 MUD transplant recipients Anti-HLA antibodies were detected in 116 patients (19.6%) 20 patients (3.4%) with anti-dpb1 antibodies. Overall, graft failure occurred in 19 of 592 transplants (3.2%) compared to 3/8 (37.5%) patients with DSA (p=0.0014). In multivariate analysis, DSA was the only factor highly associated with graft failure (p=0.0001, OR 21.3).

46 Number of HLA-DP alleles

47 HLA-DPB1 Matching: How Often Do We Have The Luxury of Multiple 10/10 s? N=235 Searches at ClinImmune Labs, compiled

48 HLA-DPB1 Matching: Acute GvHD Study Population The 5930 patient/donor pairs who were included in this analysis were contributed by the IHWG in HCT All were required to have four-digit typing results for six HLA loci (HLA-A, -B, -C, -DRB1, -DQB1, -DPB1), as well as demographic and clinical follow-up data available When considering the matching status for the other five HLA loci (HLA-A, -B, -C, -DRB1, -DQB1), 2705 (46%) pairs were matched for 10/10 alleles, with the remainder having one or more mismatch for any of these loci. In those pairs matched for 10/10 alleles the incidence of matching for DPB1 was 17%, while this was 12% in those pairs where one or more additional HLA mismatch was found. Shaw, et al (2007). Clinical importance of HLA-DPB1 in haematopoietic cell Transplantation. Tissue Antigens: 69 supplement 1.

49 HLA-DPB1 Matching: Acute GvHD The incidence of grades II IV and grades III IV agvhd in the group overall was 2918/5622 (52%) and 1738/5622 (31%), respectively. There was a significantly higher risk of both grades II IV agvhd [hazard ratio (HR): 1.33; P-value <= ] and grades III IV agvhd (HR: 1.26; P-value <= ) in those pairs that were mismatched for DPB1 compared with those that were matched. These results remained highly significant when adjusted regression models were applied. Shaw, et al (2007). Clinical importance of HLA-DPB1 in haematopoietic cell Transplantation. Tissue Antigens: 69 supplement 1.

50 HLA-DPB1 Matching: Relapse Shaw, et al (2007). Clinical importance of HLA-DPB1 in haematopoietic cell Transplantation. Tissue Antigens: 69 supplement 1.

51 HLA-DPB1 Matching: Survival Shaw, et al (2007). Clinical importance of HLA-DPB1 in haematopoietic cell Transplantation. Tissue Antigens: 69 supplement 1.

52 HLA-DPB1 Matching: Relapse in Japan Patients This study was conducted using clinical data that were collected prospectively at transplant centers participating in the Japan Marrow Donor Program. Patients who received a first transplant of T cell replete marrow for a hematologic malignancy from a serologically HLA-A, -B, and DR antigen-matched unrelated donor between January 1993 and December 2005 through the Japan Marrow Donor Program (n =4643) were registered. Kawase, et al (2009). HLA mismatch combinations associated with decreased risk of relapse: implications for the molecular mechanism. Blood113:

53 HLA-DPB1 Matching: Relapse in Japan Kawase, et al (2009). HLA mismatch combinations associated with decreased risk of relapse: implications for the molecular mechanism. Blood113:

54 HLA-DPB1 Matching: Alleles Associated with Decreased Relapse Kawase, et al (2009). HLA mismatch combinations associated with decreased risk of relapse: implications for the molecular mechanism. Blood113:

55 Important Epitopes in T-cell Responses Nicholson, et al Human Immunology:163. Alloresponses to HLA-DP detected in the primary MLRcorrelation with a single amino acid difference. Glutamic acid positive at position 69 (69E+) Correlated with the ex vivo MLR test but NOT in vivo response Zino, E, et al Blood: A T-cell epitope encoded by a subset of HLA-DPB1 alleles determines nonpermissive mismatches for hematologic stem cell transplantation.

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57 HLA-DP Allele Immunogenicity Groups Zino, E, et al Blood: Recall the DPB1 antigenic epitopes: 56A, 56E, 85-87EAV, 85-87GPM The most reactive DPB1 TCE are all 56E and 85-87EAV

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59 T Cell Epitope Groups TCE Group TCE Group 1 Part of DP3 epitope TCE Group 2 Part of DP3 epitope TCE Group 3 Alleles 09:01 10:01 17:01 (4% of DPB1 alleles) 03:01 14:01 45:01 86:01 (11% of DPB1 alleles) All others (85% of DPB1 alleles) Modified from Crociollo, et.al., Nonpermissive HLA- DPB1 disparity is a significant independent risk factor for mortality aber unrelated hematopoieec stem cell transplantaeon. Blood (2009) 114:

60 Scoring Permissive vs. Non-Permissive Modified from Crociollo, et.al., Nonpermissive HLA- DPB1 disparity is a significant independent risk factor for mortality aber unrelated hematopoieec stem cell transplantaeon. Blood (2009) 114:

61 Findings Overall mortality Non-relapse mortality Relapse Grade 3-4 agvhd You can down modulate the risk of relapse by choosing a permissive DPB1 mismatch without increasing the overall mortality. However, if relapse is low-risk it is better to choose a DPB1 match. A non-permissive mismatch increases negative sequelae (agvh, NRM, OS).

62 Findings Overall mortality Non-relapse mortality Relapse Grade 3-4 agvhd In a 9/10 match DPB1 matched and DPB1 permissive mismatch appear to provide essentially equivalent outcomes. A non-permissive mismatch increases negative sequelae (agvh, NRM, OS).

63 10/10 Matched Survival Time after HSC transplantation (years)

64 10/10 Non-relapse Mortality Time after HSC transplantation (years)

65 10/10 Relapse

66 DPB1 in Clinical Practice DPB1 influences GVH and GVL as supported by large international studies When multiple donors are available type for DPB1: Achieve antibody compatibility (no DSA) Then: Allele matched/tce Permissive mismatches Better than: TCE Non-Permissive mismatches

67 Putting It All Together: Choosing a Donor Matched Sibling 1. Preferred donor 2. Avoid DSA (mainly at DPB1, ~4%) MUD 1. Avoid DSA 2. Strive for 10/10 or accept 8/8 with DQB1 mismatch 3. For HLA-A,B,C,DRB1 mismatches: A. Avoid DRB1 allele or antigen and C antigen mismatches B. Consider: Maximizing outcomes based on permissive DPB1 mismatching C. Consider: Maximizing outcomes based on avoiding detrimental class I amino acid mismatches Non-HLA Factors for All Donors Age, sex, ABO, CMV, health, availability CBU 1. Avoid DSA 2. Maximize TNC within an HLA match group 3. Avoid two antigen (HLA-A,B) or allele (HLA-DRB1) mismatches at one locus 4. Prefer C,DRB1 matching 5. Minimize HLA mismatches in the rejection direction 6. CBU-Specific Non-HLA factors: TNC, RBC depletion and ABO, CD34, bank reputation Haplomatched 1. Avoid DSA 2. Prefer 5/10 matched donor over better matched donor 3. Strive to determine haplotypes within family