aplikasi terapi stem cell (25/4/2010)

8/8/2019 Aplikasi Terapi Stem Cell (25/4/2010)

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AG. SoemantriAG. Soemantri

BAGIAN ILMU KESEHATAN ANAKBAGIAN ILMU KESEHATAN ANAKFAKULTAS KEDOKTERAN UNDIP / RSUP DR KARIADIFAKULTAS KEDOKTERAN UNDIP / RSUP DR KARIADI

SEMARANGSEMARANG

APLIKASI TERAPIAPLIKASI TERAPISTEM CELLSTEM CELL


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PENDAHULUAN (1)PENDAHULUAN (1)

UU RI No. 36 tahun 2009 tentang kesehatan,UU RI No. 36 tahun 2009 tentang kesehatan,

yang menyangkut masalah transplantasiyang menyangkut masalah transplantasi

Pasal 64 ayat 1, ayat 2, ayat 3Pasal 64 ayat 1, ayat 2, ayat 3


Pasal 66Pasal 66



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1.1. FrischzellenthherapeuticaFrischzellenthherapeutica (i.e. cell (i.e. cellxenotransplants) are outside of regulatoryxenotransplants) are outside of regulatory

controls of the State because they are neithercontrols of the State because they are neither

drugs nor (therapeutica, (drugs nor (therapeutica, (arzneimittelarzneimittel in in

German), but are another form of medication,German), but are another form of medication,individually prepared by a physician, for hisindividually prepared by a physician, for his

specific patient, by agreement with his patient,specific patient, by agreement with his patient,

confirmed by the signed informed consentconfirmed by the signed informed consent

prescribed by lawprescribed by law (February, 16, 2000)(February, 16, 2000)

2.2. They are prepared for one time use onlyThey are prepared for one time use only


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3.3. They have no shelfThey have no shelf--lifelife

4.4. They are not distributed through theThey are not distributed through theusual channels, i.e. through pharmaciesusual channels, i.e. through pharmacies

5.5. They have to be implanted on a dateThey have to be implanted on a dateset prior to the start of their preparationset prior to the start of their preparation

6.6. Their implantation has to be carried outTheir implantation has to be carried out

by the same physician who wrote aby the same physician who wrote aprescription for the stem cellprescription for the stem cellxenotransplants for the named patient.xenotransplants for the named patient.


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BUNDESVERFASSUNGSGERICHTBUNDESVERFASSUNGSGERICHT

Der Bund ist nach Art. 74 Abs. 1 Nr. 19 GG nichtDer Bund ist nach Art. 74 Abs. 1 Nr. 19 GG nichtbefugt, die Herstellung solcher Arzneimittel zubefugt, die Herstellung solcher Arzneimittel zu

regeln, die der Arzt zur Anendung bei eigenenregeln, die der Arzt zur Anendung bei eigenenPatienten herstelltPatienten herstellt (February, 16, 2000)(February, 16, 2000)

The International XenotransplantationThe International XenotransplantationAssociation Consensus Statement on ConditionsAssociation Consensus Statement on Conditions

for Undertaking Clinical Trials of Porcine Isletfor Undertaking Clinical Trials of Porcine IsletProducts in Type 1 DiabetesProducts in Type 1 Diabetes (July, 27, 2009)(July, 27, 2009)


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DEFINISI STEM CELLDEFINISI STEM CELL

(SEL PUNCA)(SEL PUNCA)

Stem Cell adalah sel yang mampu memperbanyak diriStem Cell adalah sel yang mampu memperbanyak diri

dalam waktu yang lama dan dapat berkembang menjadidalam waktu yang lama dan dapat berkembang menjadi

berbagai sel khusus / spesifik yang membentuk jaringan.berbagai sel khusus / spesifik yang membentuk jaringan.

PotencyPotencykemampuan berdeferensiasi kearah sel tertentukemampuan berdeferensiasi kearah sel tertentu

SelfSelf--renewalrenewal

kemampuan memperbanyak melalui siklus darikemampuan memperbanyak melalui siklus dari

pembelahan sel sambil mempertahankan kondisipembelahan sel sambil mempertahankan kondisiundifferentiatedundifferentiated


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KRITERIA STEM CELLKRITERIA STEM CELL

( SEL PUNCA )( SEL PUNCA )

1.1. Belum mempunyai fungsiBelum mempunyai fungsi

2.2. Kemampuan untuk berproliferasi menjadi selKemampuan untuk berproliferasi menjadi sel

yang identik dengan sel asalnyayang identik dengan sel asalnya3.3. Berubah menjadi sel tipe lain dengan fungsiBerubah menjadi sel tipe lain dengan fungsi

yang spesifikyang spesifik


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1.1. GENERAL ISSUESGENERAL ISSUES

-- Stem Cell BiologyStem Cell Biology-- Differentiated parental DNA Chain causesDifferentiated parental DNA Chain causes

stem cell pattern of cellstem cell pattern of cell--type switching intype switching in

Schizosaccharomyces pombeSchizosaccharomyces pombe

-- On equivalence groups and the Notch/LINOn equivalence groups and the Notch/LIN--1212-- Cell Cycle Control, Cheekpoints, and StemCell Cycle Control, Cheekpoints, and Stem

Cell BiologyCell Biology

-- Senescence ofD

ividing Somatic CellsSenescence ofD

ividing Somatic Cells-- Repopulating Patterns of Primitive HematoRepopulating Patterns of Primitive Hemato

poietic Stem Cellpoietic Stem Cell


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2.2. EARLY DEVELOPMENTEARLY DEVELOPMENT

-- The Drosophila Ovary : An in vivo stem cellThe Drosophila Ovary : An in vivo stem cellsystemsystem

-- Male GermMale Germ--line stem cellline stem cell

-- Primordial Germ cells as stem cellPrimordial Germ cells as stem cell-- Embryonic stem cellsEmbryonic stem cells

-- Embryonal Carcinoma cells as embryonicEmbryonal Carcinoma cells as embryonic

stem cellsstem cells

-- Trophoblast stem cellsTrophoblast stem cells


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3.3. MESODERMMESODERM-- Hematopoietic stem cell : molecularHematopoietic stem cell : molecular

diversification and developmentaldiversification and developmental

irrelationshipsirrelationships

-- Hematopoietic stem cell : Lymphopoiesis andHematopoietic stem cell : Lymphopoiesis andthe problem of commitment versus plasticitythe problem of commitment versus plasticity

-- The hemangioblastThe hemangioblast

-- Mesenchymal stem cells of human adultMesenchymal stem cells of human adult

bone marrowbone marrow

-- Fate mapping of stem cellFate mapping of stem cell


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4. ECTODERM4. ECTODERM

-- Stem cell and neurogenesisStem cell and neurogenesis-- Epidermal stem cellEpidermal stem cell

5. ENDODERM5. ENDODERM-- Liver stem cellLiver stem cell

-- Pancreatic stem cellPancreatic stem cell

-- Stem cells in the Epithelium of the smallStem cells in the Epithelium of the small

intestine and colonintestine and colon


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BASIC CONCEPT OFBASIC CONCEPT OF

CELLULAR ANDCELLULAR ANDMOLECULAR BIOLOGYMOLECULAR BIOLOGY


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Mathematical Biosciences Institute (Ohio State Univ), 2 October 2003

RNA

Protein

DNADOGMA CENTRAL


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3 MOLECULES OF LIFE3 MOLECULES OF LIFE

All life depends on three critical molecules:All life depends on three critical molecules:DNAsDNAs

Hold information on how cell worksHold information on how cell works

RNAsRNAs

Act to transfer short pieces of information toAct to transfer short pieces of information todifferent parts of celldifferent parts of cell

Provide templates to synthesize into proteinProvide templates to synthesize into protein

ProteinsProteins Form enzymes that send signals to other cellsForm enzymes that send signals to other cells

and regulate gene activityand regulate gene activity

Form bodys major components (e.g. hair, skin,Form bodys major components (e.g. hair, skin,

etc.)etc.)


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ANOTHER VIEW OF CENTRAL DOGMAANOTHER VIEW OF CENTRAL DOGMA

A gene is expressed in 3 steps:

1) Transcription: RNA synthesis

2) Splicing: removal of intron sequence from RNA

3) Translation: Protein synthesis


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TRANSCRIPTIONTRANSCRIPTION

Transcription is initiated by a complex of

transcription factors binding to the

promoter site located upstream of the gene

An enzyme, RNA polymerase II, travels

along the gradually unzipped DNA template

and polymerizes nucleotides into an RNA.

The sequence of nucleotides on DNA

template determines the sequence on RNA

by following the rule of base-pair

complementarity, i.e., A U, T- A, C G, G

C.

Transcription continues until entire gene is

copied to RNA.

Source of diagram: http://ghs.gresham.k12.or.us/science/ps/sci/ibbio/chem/nucleicAnimation


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SPLICINGSPLICING

pre mRNA

Exon 1 Exon 2 Exon 3Intron 1 Intron 2

mature mRNA


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TRANSLATION (1)TRANSLATION (1) By translation, the

nucleotide sequence onmRNA

determines the amino acid

sequence by genetic code.

Genetic code: three base

pairs of RNA (called a codon)

determine one amino acid

based on a fixed table.

Translation always starts at

AUG (start codon), and ends

with any of UAA, UAG, or

UGA (stop codon)


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TRANSLATION (2)TRANSLATION (2)

Transfer RNAs (tRNAs)Transfer RNAs (tRNAs): small: smallRNA molecules. Most of theRNA molecules. Most of thetRNAs function as carriers oftRNAs function as carriers ofamino acids and participate inamino acids and participate inprotein synthesis.protein synthesis.

For example, the tRNA with theFor example, the tRNA with theanticodon CGG correspondsanticodon CGG correspondswith the codon GCC andwith the codon GCC andattaches alanine amino acidattaches alanine amino acid

onto the peptide chain.onto the peptide chain.

RibosomeRibosome: a complex of: a complex ofprotein and rRNAprotein and rRNA

Animation

Source of diagram: http://www.wiley.com/legacy/college/boyer/0470003790/structure/tRNA/


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MODERN TECHNOLOGY IN MEDICINEMODERN TECHNOLOGY IN MEDICINE

Human genomeHuman genome::

Gene ther. in 2010Gene ther. in 2010

Individualized Ther.Individualized Ther.

New hopesNew hopes::

CancerCancer

Vascular/Heart dis.Vascular/Heart dis.

DiabetesDiabetes

AlzheimersAlzheimers

ParkinsonParkinson

Modern technologyModern technology::

DiagnosticDiagnostic

Early ScreeningEarly Screening

PrognosticPrognostic

Follow upFollow up

Stem cellStem cell

AntisenseAntisense

Biomedical EngineeringBiomedical Engineering

New approachesNew approaches::

Genome Analysis:Genome Analysis:

Expression geneExpression gene

analysisanalysis

Micro ArrayMicro Array

Protein analysisProtein analysis


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HOW MUCH DNA DO WE HAVE?HOW MUCH DNA DO WE HAVE?

humans have 2 x 23humans have 2 x 23chromosomeschromosomes

EACH cells contains 6EACH cells contains 6billion bases DNAbillion bases DNA

that is 1 meter of DNAthat is 1 meter of DNA

a human being hasa human being has>100.000.000.000.000>100.000.000.000.000cellscells

that is 100 billion km ofthat is 100 billion km ofDNADNA


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CELLCELL CELLCELL

COMMUNICAT

IONCOMMUNICAT

IONReceptorsReceptors

Signal transductionsSignal transductions

Second messengers moleculesSecond messengers moleculesNuclear transcription factorsNuclear transcription factors

Gene activationsGene activations

ProteinProtein ResponsRespons


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CELLS CAN WITHDRAW FROM THE CELL CYCLECELLS CAN WITHDRAW FROM THE CELL CYCLE

AND DISMANTLE THE REGULATORY MACHINERYAND DISMANTLE THE REGULATORY MACHINERY

GG00 is a quiescent stateis a quiescent state

Cdks and cyclins disappearCdks and cyclins disappear

Some cells enter GSome cells enter G00

temporarily and dividetemporarily and divideinfrequenty (I.e.infrequenty (I.e.hepatocytes)hepatocytes)

Other differentiated cellOther differentiated celltypes (neurons) spend theirtypes (neurons) spend their

life in Glife in G00


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CellsCellsCell division increasesCell division increases

the number ofthe number ofsomaticsomatic(body)(body) cellscells, and consists, and consistsof:of:

MitosisMitosis (division of(division ofnucleus)nucleus)

CytokinesisCytokinesis (division of(division ofcytoplasm)cytoplasm)

ApoptosisApoptosis (cell death)(cell death)decreases the number ofdecreases the number ofcells.cells.

Both cell division andBoth cell division andapoptosis occur duringapoptosis occur duringnormal development andnormal development andgrowth.growth.


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Start checkpoint

Controls G1/S transitionCommits cell to another

round of cell division

G2/M checkpoint

Checks that DNA is fullyreplicated

M checkpoint

IsD

NA division(chromosome segregation)

progressing correctly?


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CHROMOSOMESCHROMOSOMES

genomic DNA is very longhumans, 6 x 109 bp

~1.8 meters total length

total length reduced via

associates with proteins individual DNA molecules

condensed into

chromosomes

humans have 22 pairs +X/X or X/Y (ie, diploid)


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553

3

exon exonintronupstream downstream

Initiation codon termination codon


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CENTRAL DOGMA OF MOLECULARCENTRAL DOGMA OF MOLECULAR

BIOLOGYBIOLOGY

Adapted from http://www.bioinfbook.org/

DNA Sequence

(splited by

genes)

RNA phenotypeproteinAmino

Acid

sequence


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CENTRAL DOGMACENTRAL DOGMA

Gene

RNA

Protein

Transcription

Translation

Genome

Transcriptome

Proteome


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A process by hich signals rom outside the cell are trans erred inside

the cell through cascade o proteins interaction. Involved in all cellular

activities (death, gro th, di erentiation, etc.)

egulate by protein phosphorylation.

Cellular signal transduction


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REGULATORS : PROLIFERATION,REGULATORS : PROLIFERATION,

DIFFERENTIATION, APOPTOSIS, REPAIRDIFFERENTIATION, APOPTOSIS, REPAIR

Genome :Genome :

Genes :Genes :

Cell cycleCell cycle DifferentiatiDifferentiati

oo

ApoptosisApoptosis

RepairRepair MetabolismMetabolism

etcetc

ProteomeProteome

Protein:Protein:

cyclin, CD

K,CD

KIcyclin, CD

K,CD

KI GF : GMGF : GM--CSF, FGFCSF, FGF

BclBcl--2, p53,2, p53,

caspasecaspase

Gadd, enzymGadd, enzymrepairrepair

dlldll

Transcriptome

RNARNA

RNA

RNA

RNA

RNA


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HOW TO UNDERSTOOD ??HOW TO UNDERSTOOD ??

GENE:GENE:

CytogeneticsCytogenetics

FISHFISH

DNA analysisDNA analysis

Southern blotSouthern blot

+/+/--

PCRPCR

specificspecific

MLPAMLPA

Sequencing :Sequencing :

SSCPSSCP

Gene activ:

RNA

Northern blot

RT- PCR

RNA-se protection

Assay

Micro array

R-ISH

Gene active :

Protein

Western BlotSDS-PAGE

ELISA

FISH


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APLIKASI STEM CELL (SEL PUNCA)APLIKASI STEM CELL (SEL PUNCA)

Tidak semua dibicarakan satu persatu tentangTidak semua dibicarakan satu persatu tentang

aplikasiaplikasi

Yang disinggung yang pernah dijalankan olehYang disinggung yang pernah dijalankan oleh

RSUP Dr Kariadi / FK UNDIPRSUP Dr Kariadi / FK UNDIP


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BERDASAR ASAL SEL YANG DIPAKAI

Autotransplantasi

Dari satu bagian tubuh ke bagian tubuh yang

lain pada individu yang sama

Allotransplantasi

Antar individu pada spesies yang sama

XenotransplantasiAntar spesies yang berbeda


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MESODERMMESODERM

Sel yang berasal dari Mesoderm ini yaituSel yang berasal dari Mesoderm ini yaitu

Mesenchymal Stem Cells of HumanMesenchymal Stem Cells of Human

Adult Bone Marrow, yang digunakan untukAdult Bone Marrow, yang digunakan untuk

cangkok sumsum tulangcangkok sumsum tulang

-- Metoda AllologMetoda Allolog

-- Metoda AutologMetoda Autolog


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Cangkok Sumsum Tulang telah dilaksanakan diCangkok Sumsum Tulang telah dilaksanakan di

RSUP Dr. Kariadi tahun 1987, 2 kasus denganRSUP Dr. Kariadi tahun 1987, 2 kasus denganautolog untuk penderita dengan diagnosis AMLautolog untuk penderita dengan diagnosis AML

M(2)M(2)

Salah satu sudah lulus Sarjana Kedokteran danSalah satu sudah lulus Sarjana Kedokteran dan

EkonomiEkonomi

Satu kasus dengan metoda allolo untukSatu kasus dengan metoda allolo untuk

penderitapenderita thallasemia homo zygotethallasemia homo zygote


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Cangkok hati dilaksanakan di RSUP Dr KariadiCangkok hati dilaksanakan di RSUP Dr Kariadi

pada tanggal 1 Oktober 2006 dengan atresiapada tanggal 1 Oktober 2006 dengan atresia

billier, anak U lakibillier, anak U laki--laki umur 15 bulan denganlaki umur 15 bulan dengan

donor dari ibu kandungnya.donor dari ibu kandungnya.Cangkok hati II dilaksanakan di RSUP DrCangkok hati II dilaksanakan di RSUP Dr

Kariadi pada Juni 2009 dengan AllagileKariadi pada Juni 2009 dengan Allagile

Syndrome, anak A lakiSyndrome, anak A laki--laki umur 7 tahunlaki umur 7 tahun

dengan donor sukarela.dengan donor sukarela.

ENDODERMENDODERM


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XENOTRANSPLANTASIXENOTRANSPLANTASI pp

AMANKAH ??AMANKAH ??

Legalitas (+)Legalitas (+)

Keputusan MA German No 1 BvR420/97, EuropeanKeputusan MA German No 1 BvR420/97, EuropeanCommunity Council directive 2001/83/EC, UUCommunity Council directive 2001/83/EC, UU

seluruh negara Uni eropaseluruh negara Uni eropaJaminan keamanan (+)Jaminan keamanan (+)

Hewan yang dipakai (kelinci) memenuhi persyaratanHewan yang dipakai (kelinci) memenuhi persyaratanyang dikeluarkan oleh : Guidelines on Infectiousyang dikeluarkan oleh : Guidelines on InfectiousDisease Issues in XenotransplantasiDisease Issues in Xenotransplantasi

Merupakan hewan dari galur tertutup yang diisolasiMerupakan hewan dari galur tertutup yang diisolasidan diawasi dari kemungkinan tertular penyakitdan diawasi dari kemungkinan tertular penyakit(diawasi 7 turunan )(diawasi 7 turunan )


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EVIDENBASEDEVIDENBASED

HASIL PENELITIAN TERAPI CANGKOK STEM CELLHASIL PENELITIAN TERAPI CANGKOK STEM CELL

3000 penderita SD yang diterapi3000 penderita SD yang diterapi pp 25% bisa sekolah secara25% bisa sekolah secara

normalnormal

Outcome terapi : terjadi peningkatan TB, LK, IQ, indeksOutcome terapi : terjadi peningkatan TB, LK, IQ, indeks

volume otak, perkembangan mental, perkembangan motorikvolume otak, perkembangan mental, perkembangan motorik

Evaluasi mental dan psikologis 83 penderita SD yang diterapiEvaluasi mental dan psikologis 83 penderita SD yang diterapi

: terjadi penurunan hiperaktivitas, peningkatan konsentrasi: terjadi penurunan hiperaktivitas, peningkatan konsentrasi

dan peningkatan kemampuan bahasa ekspresifdan peningkatan kemampuan bahasa ekspresif

Evaluasi imunologis : terjadi peningkatan IgA dan penurunanEvaluasi imunologis : terjadi peningkatan IgA dan penurunan

IgGIgGpp Menurunnya frekuensi dan beratnya infeksi bakteriMenurunnya frekuensi dan beratnya infeksi bakteri


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EVIDENCE BASEDEVIDENCE BASED

Pada Cangkok Stem Cell (CST) usia Pada Cangkok Stem Cell (CST) usia 3 tahun3 tahun

kenaikan MDI > 50 point terjadi pada :kenaikan MDI > 50 point terjadi pada :

17 % bila tidak di CST17 % bila tidak di CST

58 % pada CST I58 % pada CST I

71 % pada CST II71 % pada CST II

Pada usia 4Pada usia 4--9 tahun9 tahunkenaikan 25kenaikan 25--49 point49 point


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Figure 2. Phosphorylation targets of DYRK1A. The Hsa21-encoded kinase

DYRK1A has been shown to phosphorylate a multitude of targets, which

have been implicated in a number of biological processes and DS-

associated phenotypes, including endocytosis and AD.


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RINGKASANRINGKASAN

Telah diutarakan konsep dasar biomolekuler,Telah diutarakan konsep dasar biomolekuler,

siklus selsiklus sel

Definisi dan jenisDefinisi dan jenis--jenis, kriteria stem cell (seljenis, kriteria stem cell (sel

punca)punca)

Dasar hukumDasar hukum

Dasar keberhasilan asosiasi stem cellDasar keberhasilan asosiasi stem cell

Aplikasi yang pernah dilakukan di RSUP DrAplikasi yang pernah dilakukan di RSUP DrKariadi/FK UNDIP : cangkok sumsum tulang,Kariadi/FK UNDIP : cangkok sumsum tulang,

cangkok hati, cangkok stem cellcangkok hati, cangkok stem cell


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aplikasi terapi stem cell (25/4/2010)

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