Positive Results from Mesoblast’s Phase 2 Trial of Cell Therapy in Diabetic Kidney Disease


Mesoblast Limited has announced results from its Phase 2 clinical Trial that evaluated their Mesenchymal Precursor Cell (MPC) product, known as MPC-300-IV, in patients who suffer from diabetic kidney disease. In short, their cell product was shown to be both safe and effective. The results of their trial were published in the peer-reviewed journal EBioMedicine.  Researchers from the University of Melbourne, Epworth Medical Centre and Monash Medical Centre in Australia participated in this study.

The paper describes a randomized, placebo-controlled, and dose-escalation study that administered to patients with type 2 diabetic nephropathy either a single intravenous infusion of MPC-300-IV or a placebo.

All patients suffered from moderate to severe renal impairment (stage 3b-4 chronic kidney disease for those who are interested).  All patients were taking standard pharmacological agents that are typically prescribed to patients with diabetic nephropathy.  Such drugs include angiotensin-converting enzyme inhibitors (e.g., lisinopril, captopril, ramipril, enalapril, fosinopril, ect.) or angiotensin II receptor blockers (e.g., irbesartan, telmisartan, losartan, valsartan, candesartan, etc.).  A total of 30 patients were randomized to receive either a single infusion of 150 million MPCs, or 300 million MPCs, or saline control in addition to maximal therapy.

Since this was a phase 2 clinical trial, the objectives of the study were to evaluate the safety of this treatment and to examine the efficacy of MPC-300-IV treatment on renal function.  For kidney function, a physiological parameter called the “glomerular filtration rate” or GFR is a crucial indicator of kidney health.  The GFR essentially indicates how well the individual functional units within the kidney, known as “nephrons,” are working.  The GFR indicates how well the blood is filtered by the kidneys, which is one way to measure remaining kidney function.  The decline or change in glomerular filtration rate (GFR) is thought to be an adequate indicator of kidney function, according to the 2012 joint workshop held by the United States Food and Drug Administration and the National Kidney Foundation.

nephronanatomy

Diabetic nephropathy is an important disease for global health, since it is the single leading cause of end-stage kidney disease.  Diabetic nephropathy accounts for almost half of all end-stage kidney disease cases in the United States and over 40% of new patients entering dialysis treatment.  For example, there are almost 2 million cases of moderate to severe diabetic nephropathy in 2013.

Diabetic nephropathy can even occur in patients whose diabetes is well controlled – those patients who manage to keep their blood glucose levels at a reasonable level.  In the case of diabetic nephropathy, chronic infiltration of the kidneys by inflammatory monocytes that secrete pro-inflammatory cytokines causes endothelial dysfunction and fibrosis in the kidney.

Staging of chronic kidney disease (CKD) is based on GFR levels.  GFR decline typically defines the progression to kidney failure (for example, stage 5, GFR<15ml/min/1.73m2).  The current standard of care (renin-angiotensin system inhibition with angiotensin converting enzyme inhibitors or angiotensin II receptor blockers) only delays the progression to kidney failure by 16-25%, which leaves a large residual risk for end-stage kidney disease.  For patients with end-stage kidney disease, the only treatment option is renal replacement (dialysis or kidney transplantation), which incurs high medical costs and substantial disruptions to a normal lifestyle.  Due to a severe shortage of kidneys, in 2012 approximately 92,000 persons in the United States died while on the transplant list.  For those on dialysis, the mortality rate is high with an approximately 40% fatality rate within two years.

The main results of this clinical trial were that the safety profile for MPC-300-IV treatment was similar to placebo.  There were no treatment-related adverse events.  Secondly, patients who received a single MPC infusion at either dose had improved renal function compared to placebo, as defined by preservation or improvement in GFR 12 weeks after treatment.  Third, the rate of decline in estimated GFR at 12 weeks was significantly reduced in those patients who received a single dose of 150 million MPCs relative to the placebo group (p=0.05).  Finally, there was a trend toward more pronounced treatment effects relative to placebo in a pre-specified subgroup of patients whose GFRs were lower than 30 ml/min/1.73m2 at baseline (p=0.07).  In other words, the worse the patients were at the start of the trial, the better they responded to the treatment.

The lead author of this publication, Dr David Packham, Associate Professor in the Department of Medicine at the University of Melbourne and Director of the Melbourne Renal Research Group, said: “The efficacy signal observed with respect to preservation or improvement in GFR is exciting, especially given that this trial was not powered to show statistical significance. Patients receiving a single infusion of MPC-300-IV showed no evidence of developing an immune response to the administered cells, suggesting that repeat administration is feasible and may in the longer term be able to halt or even reverse progressive chronic kidney disease. I hope that this very promising investigational therapy will be advanced to rigorous Phase 3 clinical trials to test this hypothesis as soon as possible.”

Patients who received s single IV infusion of MPC-300-IV cells showed no evidence of developing an immune response to the administered cells.  This suggests that repeated administration of MPCs is feasible and might even have the ability to halt, or even reverse progressive chronic kidney disease.

Packham and his colleagues hope that this cell-based therapy can be advanced to a rigorous Phase 3 clinical trial to further test this treatment.

Autologous Stem Cell Transplantation With Complete Ablation of Bone Marrow Delays Progression of Multiple Sclerosis in Small Phase 2 Trial


Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system. Around 2 million people, worldwide, suffer from MS. MS results from the patient’s immune system attacking the myelin sheath that surrounds nerve axons. These constant and relentless attacks upon the myelin sheath causes “demyelination,” resulting in loss of the sensory and motor function.

Treatment usually required the use of drugs that suppress the immune response. Some of these drugs work better than others, while other patients have forms of MS that do not respond to common MS treatment.

A new report published in the Lancet, has shown that chemotherapy followed by autologous hematopoietic stem cell transplantation (aHSCT) can completely halt clinical relapses of MS and prevent the development of new brain lesions in 23 of 24 MS patients. Patients who participated in this study experienced a prolonged period without the need for ongoing medication. Eight of the 23 patients had a sustained improvement in their disability 7.5 years after treatment. This is the first treatment to produce this level of disease control or neurological recovery from MS, but, unfortunately, treatment related risks limit its widespread use.

There are a few specialist centers that offer MS patients aHSCT. This treatment involves harvesting bone marrow stem cells from the patient, and then employing chemotherapy to suppress the patient’s immune system and essentially partially wipe it out. The isolated bone marrow is then reintroduced into the blood stream to “reset” the immune system and stop it attacking the body. However, a respectable percentage of MS patients relapse after these treatments. Therefore, these treatments must be refined and tweaked to improve their efficacy.

Drs Harold L Atkins and Mark S Freedman from The Ottawa Hospital and the University of Ottawa, Ottawa, Canada, respectively, and their colleagues, tested if complete destruction, rather than suppression, of the immune system during aHSCT could reduce the relapse rate in patients and increase the long-term rates of disease remission. They enrolled 24 patients aged 18-50 from three Canadian hospitals. All of these subjects had previously undergone standard immunosuppressive therapy, but these treatments had failed to control their MS. These patients all had poor prognosis and their disability ranged from moderate to requiring a walking aid to walk 100 meters (according to their Expanded Disability Status Scale or EDSS score).

Adkins and Freeman and their coworkers used a chemotherapy regimen of busulfan, cyclophosphamide and rabbit anti-thymocyte globulin to wipe out the patient’s bone marrow. Atkins explained that this treatment is “similar to that used in other trials, except our protocol uses stronger chemotherapy and removes immune cells from the stem cell graft product. The chemotherapy we use is very effective at crossing the blood-brain barrier and this could help eliminate the damaging immune cells from the central nervous system.” After being treated with chemotherapy regimen, the patients’ bone marrow was reconstituted with their previously isolated bone marrow.

This study’s primary outcome was activity-free survival at 3 years, using EDSS scores as the means of measuring MS progression, in addition to scanning for brain lesions, and assessing MS symptoms.

Of the 24 patients enrolled, one (4%) died from liver failure and sepsis caused by the chemotherapy. In the 23 surviving patients, prior to treatment, patients experienced 1.2 relapses per year on average, but after aHSCT, no relapses occurred during the follow-up period (between 4 and 13 years). These clinical outcomes were nicely complemented by an absence of newly detected brain lesions (as assessed by MRI images taken after the treatment). Initially, 24 MRI scans of the brains of all 24 subjects revealed 93 brain lesions, and after the treatment only one of the 327 scans showed a new lesion.

Despite the exciting success of this clinical trial, Freedman emphasized the need to interpret these results with caution: “The sample size of 24 patients is very small, and no control group was used for comparison with the treatment group. Larger clinical trials will be important to confirm these results. Since this is an aggressive treatment, the potential benefits should be weighed against the risks of serious complications associated with aHSCT, and this treatment should only be offered in specialist centers experienced both in multiple sclerosis treatment and stem cell therapy, or as part of a clinical trial. Future research will be directed at reducing the risks of this treatment as well as understanding which patients would best benefit from the treatment.”

Dr Jan Dörr, from the NeuroCure Clinical Research Center, Charité-Universitätsmedizin, Berlin, Germany, made this comment about this clinical trial: “These results are impressive and seem to outbalance any other available treatment for multiple sclerosis. This trial is the first to show complete suppression of any inflammatory disease activity in every patient for a long period…However, aHSCT has a poor safety profile, especially with regards to treatment-related mortality.”

He added: “So, will this study change our approach to treatment of multiple sclerosis? Probably not in the short-term, mainly because the mortality rate will still be considered unacceptably high. Over the longer term (and) in view of the increasing popularity of using early aggressive treatment, there may be support for considering aHSCT less as a rescue therapy and more as a general treatment option, provided the different protocols are harmonized and optimized, the tolerability and safety profile can be further improved, and prognostic markers become available to identify patients at risk of poor prognosis in whom a potentially more hazardous treatment might be justified.”

Bone Marrow Stem Cells and Tissue Engineering Give a Woman a New Smile


Massive injuries to the face can cause bone loss and “tooth avulsion.” Medically speaking, avulsion simply refers to the detachment of a body structure from its normal location by means of surgery or trauma. Dental implants and help with lost teeth, but if the facial bone has suffered so much loss that you cannot place implants in them, then you are out of luck. Dental prostheses can help, but these do not always fit very well.

Darnell Kaigler and his group at the University of Michigan Center for Oral Health wanted to help a 45-year-old woman who had lost seven teeth and a good portion of her upper jaw bone (maxilla) as a result of massive trauma to the face. This poor lady had some dentures that did not fit well and a mouth that did not work well.

Bone can be grown from stem cells, but getting those stem cells to survive and do what you want them to do is the challenge of regenerative medicine. Therefore, Dr. Kraigler and his group used a new technique to help this young lady, and their results are reported in the December 2014 issue of the journal Stem Cells Translational Medicine.

First, Kraigler and his co-workers extracted bone marrow stem cells from a bone marrow aspiration that was taken from the upper part of the hip bone (the posterior crest of the ilium for those who are interested).  They used a product called ixmyelocel-T from Aastrom Biosciences in Ann Arbor , MI. This product is a patient-specific, expanded multicellular therapy, cell-processing system that selectively expands mesenchymal cells, monocytes and alternatively activated macrophages, up to several hundred times more than the number found in the patient’s bone marrow, while retaining many of the hematopoietic cells collected from only a small sample (50ml) of the patient’s bone marrow. Thus, the healing cells from the bone marrow are grown and made healthy, after which the cells were bagged and frozen for later use.

ixmyelocel-T

Then the patient was readied for the procedure by having the gum tissue cut and lifted as a flap of tissue (under anesthesia, or course). Then four holes were drilled into the bone and setting screws were inserted. This is an important procedure, because implanted stem cells will not survive unless they have blood vessels that can bring them oxygen and nutrients. By drilling these holes, the tissue responds by making new blood vessels. To this exposed surface, the bone marrow-derived stem cells were applied with a tricalcium phosphate (TCP). TCP is a salt that will induce mesenchymal stem cells to form bone. Once the TCP + stem cell mixture was applied to the gum, a collagen membrane was placed over it, and the gum was then sewn shut with sutures.

Cell transplantation procedure. Front view (A) and top view (B) of the initial clinical presentation showing severe hard and soft tissue alveolar ridge defects of the upper jaw. Following elevation of a full-thickness gingival flap, the images show front view (C) and top view (D) of the severely deficient alveolar ridge, clinically measuring a width of only 2–4 mm. Front view (E) and top view (F) of the placement of “tenting” screws in preparation of the bony site to receive the graft. Placement of the β-tricalcium phosphate (seeded with the cells 30 minutes prior to placement at room temperature) into the defect (G), with additional application of the cell suspension following placement of the graft in the recipient site (H). Placement of a resorbable barrier membrane (I) to stabilize and contain the graft within the recipient site, and top view (J) of primary closure of the flap.
Cell transplantation procedure. Front view (A) and top view (B) of the initial clinical presentation showing severe hard and soft tissue alveolar ridge defects of the upper jaw. Following elevation of a full-thickness gingival flap, the images show front view (C) and top view (D) of the severely deficient alveolar ridge, clinically measuring a width of only 2–4 mm. Front view (E) and top view (F) of the placement of “tenting” screws in preparation of the bony site to receive the graft. Placement of the β-tricalcium phosphate (seeded with the cells 30 minutes prior to placement at room temperature) into the defect (G), with additional application of the cell suspension following placement of the graft in the recipient site (H). Placement of a resorbable barrier membrane (I) to stabilize and contain the graft within the recipient site, and top view (J) of primary closure of the flap.

Four months later, the patient underwent a cone-beam computed tomography (CBCT) scan. The bone regrowth can be seen in the figure below.

Cone-beam computed tomography (CBCT) scans. CBCT scans were used to render three-dimensional reconstructions of the anterior segment of the upper jaw and cross-sectional (top view) radiographic images to show volumetric changes of the upper jaw at three time points. (A, B): The initial clinical presentation shows 75% jawbone width deficiency. (C, D): Immediately following cell therapy grafting, there is full restoration of jawbone width. (E, F): Images show 25% resorption of graft at 4 months and overall net 80% regeneration of the original ridge-width deficiency.
Cone-beam computed tomography (CBCT) scans. CBCT scans were used to render three-dimensional reconstructions of the anterior segment of the upper jaw and cross-sectional (top view) radiographic images to show volumetric changes of the upper jaw at three time points. (A, B): The initial clinical presentation shows 75% jawbone width deficiency. (C, D): Immediately following cell therapy grafting, there is full restoration of jawbone width. (E, F): Images show 25% resorption of graft at 4 months and overall net 80% regeneration of the original ridge-width deficiency.

According to the paper, there was an “80% regeneration of the original jawbone.”

Into this newly regenerated bone, permanent dental implants were placed. The results are shown below.

Complete oral rehabilitation. Clinical presentation of the patient prior to initiation of treatment (A) and following completed oral reconstruction (B). (C): Periapical radiographs of oral implants showing osseointegration of implants and stable bone levels at the time of placement, 6 months following placement, and 6 months following functional restoration and biomechanical loading of implants with a dental prosthesis.
Complete oral rehabilitation. Clinical presentation of the patient prior to initiation of treatment (A) and following completed oral reconstruction (B). (C): Periapical radiographs of oral implants showing osseointegration of implants and stable bone levels at the time of placement, 6 months following placement, and 6 months following functional restoration and biomechanical loading of implants with a dental prosthesis.

Pardon me, but permit me an unprofessional moment when I say that this is really cool.  Of course, this patient will need to be observed over the next several years to determine the longevity of her bone regeneration, but the initial result is certainly something to be excited about.

Tricalcium phosphate or TCP has been used to induce the bone-making activities of mesenchymal stem cells.  It has also been used in several animal studies as a delivery vehicle for mesenchymal stem cells (for example, see Rai B, et al., Biomaterials 2010, 31:79607970; Krebsbach PH, et al., Transplantation 1997, 63:10591069; Zhou J, et al., Biomaterials 2010, 31:11711179).  TCP also seems to support stem cell proliferation, survival, and differentiation into bone.  Kresbach and others showed that TCP most consistently yielded bone formation when used as a delivery vehicle for mesenchymal stem cells compared to other biomaterials commonly used, such as gelatin sponges and demineralized bone matrix.  However, there are no studies that have ascertained how well stem cells attach to TCP, and this attachment is an important factor in determining how many stem cells reach the site of injury.  This study by Kaigler and his group (A. Rajan and others) showed that a 30-minute incubation of the cells with TCP gave sufficient attachment of the cells to the TCP for clinical use.  The efficiency of this incubation period was also not affected by the temperature.  

The other exciting features of this paper, is that most of the materials used in this study were commercially available.  The bone marrow stem cell isolation technique was pioneered by Dennis JE, and others in their 2007 article in the journal Stem Cells (25:25752582).  Effective commercialization of this technique has shown the efficacy of this procedure for clinical use.  This paper also shows the clinical feasibility of using TCP as a delivery vehicle for mesenchymal stem cell-based bone treatments.

In conclusion, I will quote the authors: “Cell survival and seeding efficiency in the context of tissue engineering and cell-therapy strategies are critical parameters for success that have not been rigorously examined in a clinical context. This study defined optimized conditions for these parameters using an autologous stem cell therapy to successfully treat a patient who had a debilitating craniofacial traumatic deficiency. To our knowledge, there have been no other clinical reports of cell therapy for the treatment of craniofacial trauma defects. This clinical report serves as solid foundation on which to develop more expanded studies using this approach for the treatment of larger numbers of patients with other debilitating conditions (e.g., congenital disorders) to further evaluate efficacy and feasibility.”

Mesenchymal Stem Cells Repair Cartilage Defects in Cynomolgus Monkeys


Repairing cartilage defects in the knee represents one of the primary goals of orthopedic regenerative medicine. Cartilage that covers the joints, otherwise known as articular cartilage, has a limited capacity for repair, which leads to further degeneration of the cartilage when it is damaged if it remains untreated. A number of surgical options for treating cartilage defects include microfracture, osteochondral grafting, and cell-based techniques such as autologous chondrocyte implantation (ACI). Each of these procedures have been used in clinical settings. Unfortunately cartilage injuries treated with microfracturing deteriorate with time, since the cartilage made by microfracturing has a high proportion of softer. less durable fibrocartilage.  Also osteochondral grafting suffers from a lack of lateral integration between host and donor cartilage.

Alternatively, tissue engineering has shown some promise when it comes to the healing of cartilage defects.  Mesenchymal stem cells (MSCs) are multipotent progenitor cells that have the ability to differentiate into several different cell lineages including cartilage-making chondrocytes.  MSCs have theoretical advantages over implanted chondrocytes when it come to healing potential.  MSCs have the ability to proliferate without losing their ability to differentiate into mature chondrocytes and produce collagen II and aggrecan. In the short-term, bone marrow-derived MSCs combined with scaffolds have been successful in cartilage repair using animal models such as rabbits (Dashtdar H, et al., J Orthop Res 2011; 29: 1336-42) sheep (Zscharnack M, et al., Am J Sports Med 2010; 38: 185769) and horses (Wilke MM, et al.,l J Orthop Res 2007; 25: 9132).  

In a recent study, Kazumasa Ogasawara and Yoshitaka Matsusue and their colleagues from Shiga University of Medical Science in Shiga, Japan, tested the ability of expanded bone marrow-derived MSCs that had been placed in a collagen scaffold to improve healing of cartilage defects in cynomolgus macaques (type of monkey).  Before this study, there were no previous studies using MSCs from primates for cartilage repair.  The monkey MSCs were shown to properly differentiate into fat, bone, or cartilage in culture, and then were transplanted into the injured cartilage in the cynomolgus macaque.  The efficacy of these cells were ascertained at 6, 12, and 24 weeks after transplantation.

In culture, the cynomolgus MSCs were able to differentiate into fat, bone, and cartilage.

Characteristics of bone marrow-derived MSCs. Panel (a) demonstrates the colony-forming properties of MSCs isolated from bone marrow of cynomolgus macaques using the present protocol (arrows). Bar: 1 cm. Panel (b) shows the adipogenetic properties of MSC-derived cells from staining of lipid droplets with oil red O (arrowheads). Bar: 20 μm. Panel (c) confirms the osteoblastic properties of MSC-derived cells with alkaline phosphatase staining (arrowheads). Bar: 30 μm. Panel (d) confirms the chondrogenetic properties from immunostaining of type-II collagen. Type-II collagen-positive matrix is stained red. Bar: 0.5 mm. Read More: http://informahealthcare.com/doi/full/10.3109/17453674.2014.958807.
Characteristics of bone marrow-derived MSCs. Panel (a) demonstrates the colony-forming properties of MSCs isolated from bone marrow of cynomolgus macaques using the present protocol (arrows). Bar: 1 cm. Panel (b) shows the adipogenetic properties of MSC-derived cells from staining of lipid droplets with oil red O (arrowheads). Bar: 20 μm. Panel (c) confirms the osteoblastic properties of MSC-derived cells with alkaline phosphatase staining (arrowheads). Bar: 30 μm. Panel (d) confirms the chondrogenetic properties from immunostaining of type-II collagen. Type-II collagen-positive matrix is stained red. Bar: 0.5 mm.
Read More: http://informahealthcare.com/doi/full/10.3109/17453674.2014.958807.

Upon transplantation into cartilage defects in the knee cartilage of cynomolgus monkeys, MSCs were compared with collagen gel devoid of MSCs.  The knees that received the transplantations did not show any signs of irritation, bone spurs or infection.  All of the animals had so-called “full-thickness cartilage defects,” and those in the non-treated group showed cartilage defects that did not change all that much.  The cartilage defects of the gel group had sharp edges at 6 weeks that were thinly covered with reparative tissue by 12 weeks, and at 24 weeks, the defect was covered with thick tissue, but the central region of the defects often remained uncovered, with a hollow-like deformity.  In the cartilage defects of those animals treated with MSCs plus the collagen gel, the sharp edges of the defects were visible at 6 weeks after the operation, but at 12 weeks, the defects were evenly covered with yellowish reparative tissue.  At 24 weeks, the defects were covered with watery hyaline cartilage-like tissue that was very similar to the neighboring naïve cartilage.

Macroscopic observations of the repaired defects in the 3 groups at 6 weeks (a, d, g), 12 weeks (b, e, h), and 24 weeks (c, f, i) after implantation. Scale bar: 5 mm. Arrow in (d): the sharp edge of the defect is visible at 6 weeks in the gel group. Arrow in (f): a hollow-like deformity remains in the central region of the defect, despite thick coverage by the reparative tissue. Arrow in (g): the sharp edge of the defect is also visible in the MSC group at 6 weeks. Read More: http://informahealthcare.com/doi/full/10.3109/17453674.2014.958807.
Macroscopic observations of the repaired defects in the 3 groups at 6 weeks (a, d, g), 12 weeks (b, e, h), and 24 weeks (c, f, i) after implantation. Scale bar: 5 mm. Arrow in (d): the sharp edge of the defect is visible at 6 weeks in the gel group. Arrow in (f): a hollow-like deformity remains in the central region of the defect, despite thick coverage by the reparative tissue. Arrow in (g): the sharp edge of the defect is also visible in the MSC group at 6 weeks.
Read More: http://informahealthcare.com/doi/full/10.3109/17453674.2014.958807.

When evaluated at the tissue level, Ogasawara and Matsusue and others used a stain called toluidine blue to visualize the amount of cartilage made by each treatment.  As you can see in the picture below, the non-treated group didn’t do so well.  In the full-thickness defect the region below the cartilage was filled with amorphous stuff 6 weeks after the procedure, and at 12 weeks, amorphous stuff faintly stained with toluidine blue, which reflects the conversion of the amorphous stuff into bone.  At 24 weeks, bone tissue reappeared below the cartilage zone, even though the bone did not look all that normal (no trabecular structure but woven bone-like structure).

In the gel group, cartilage-like tissue is seen at 6 weeks, and at 12 weeks, the faintly stained layer covered the cartilage defect. At 24 weeks, the defect was covered with the cartilage-like stuff, even though the central region had only a little cartilage, as ascertained by toluidine blue staining.  The bone underneath the cartilage looked crummy and there was excessive growth of cartilage into the region underneath the cartilage layer.

In the MSC group, the bone underneath the cartilage healed normally, and at 12 weeks, the boundary between the articular cartilage and the bone layer beneath it had reappeared.  At 24 weeks, the thickness of the toluidine blue-stained cartilage layer was comparable to that of the neighboring naïve cartilage.

Even though the gel group showed most cartilage-rich tissue covering the defect, this was due to the formation of excessive cartilage extruding through the abnormal lower bone layer.  Despite the lower amount of new cartilage produced, the MSC group showed better-quality cartilage with a regular surface, seamless integration with neighboring naïve cartilage, and reconstruction of the bone underneath the cartilage layer.

Histological findings after toluidine blue staining in the 3 groups at 6 weeks (a, d, g), 12 weeks (b, e, h), and 24 weeks (c, f, i) after implantation. Scale bar: 2 mm. Dotted line in (a): amorphous reparative tissue filling the subchondral region. Arrowheads in (b): faint toluidine blue staining that reflects involvement of endochondral ossification. Arrowhead in (c): toluidine blue-negative reparative tissue covering the defect. Dotted line in (c): reconstructed subchondral bone consisting of woven bone-like structure. Arrowhead in (d): toluidine blue-positive cartilaginous tissue. Arrowhead in (e): thin faintly toluidine blue-positive layer covering the defect. Arrowhead in (f): the unstained central region of the cartilaginous layer covering the defect. Arrow in (f): excessive cartilage extruding through the deficient tidemark. Dotted line in (g): woven bone-like subchondral bone already re-appearing at 6 weeks. Arrowhead in (h): reconstructed tidemark distinctly discriminating the articular cartilage from the subchondral bone.
Histological findings after toluidine blue staining in the 3 groups at 6 weeks (a, d, g), 12 weeks (b, e, h), and 24 weeks (c, f, i) after implantation. Scale bar: 2 mm. Dotted line in (a): amorphous reparative tissue filling the subchondral region. Arrowheads in (b): faint toluidine blue staining that reflects involvement of endochondral ossification. Arrowhead in (c): toluidine blue-negative reparative tissue covering the defect. Dotted line in (c): reconstructed subchondral bone consisting of woven bone-like structure. Arrowhead in (d): toluidine blue-positive cartilaginous tissue. Arrowhead in (e): thin faintly toluidine blue-positive layer covering the defect. Arrowhead in (f): the unstained central region of the cartilaginous layer covering the defect. Arrow in (f): excessive cartilage extruding through the deficient tidemark. Dotted line in (g): woven bone-like subchondral bone already re-appearing at 6 weeks. Arrowhead in (h): reconstructed tidemark distinctly discriminating the articular cartilage from the subchondral bone.

This protocol has been nicely optimized by Ogasawara and Matsusue and their research team.  From these data, they conclude:  “Application in larger defects is certainly in line with future clinical use. If MSCs—under optimized conditions—turn out to be superior to chondrocyte implantation in experimental cartilage repair, the procedure should be introduced to clinical practice after well-controlled randomized clinical trials.”  Hopefully, clinical trials will commence before long.  This procedure uses a patient’s own MSCs, and if such a procedure could reduce or delay the number of knee replacements, then it would surely be a godsend to clinicians and patients alike.

Human Menstrual Blood Stem Cells Treat Premature Ovarian Failure in Mice


Premature ovarian failure (POF) or primary ovarian insufficiency is a condition characterized by loss of normal ovarian function before age 40. POF causes low levels of the hormone estrogen and irregular ovulation (release of eggs). POF causes infertility.

Some medical professional call POF premature menopause, even though these two conditions are not exactly the same. Women with POF may have irregular or occasional menstrual cycles for years and may even become pregnant. However, women with premature menopause cease having periods and can’t become pregnant.

The symptoms of POF are similar to those of menopause: irregular or skipped periods (amenorrhea), which may be present for years or may develop after a pregnancy or after stopping birth control pills; hot flashes, night sweats, vaginal dryness, irritability or difficulty concentrating, and decreased sexual desire.

In women with POF, infertility is very hard to treat, but restoring estrogen levels can avert many of the complications.

There are several causes of POF. Particular chromosomal defects such as Turner’s syndrome, in which a woman has only one X chromosome instead of the usual two, and fragile X syndrome, a major cause of intellectual disability can cause POF. Likewise, exposure to various toxins can also cause POF. Chemotherapy and radiation therapy are probably the most common causes of toxin-induced POF. Other toxins such as cigarette smoke, industrial chemicals, pesticides and viruses may also hasten POF. If the immune system mounts an immune response to ovarian tissue (autoimmune disease), then it might produce antibodies against the woman’s own ovarian tissue. Such antibodies will harm the egg-containing follicles and damage the egg. What triggers the immune response is unclear, but exposure to certain viruses is one possibility. Also various sundry unknown factors may also contribute to it.

There are no treatments for POF that restore the ovaries. For this reason a recent paper in the journal Stem Cells and Development represents a great advance in POF treatment.

Te Liu from the Shanghai Institute of Chinese Medicine and colleagues have used stem cells isolated from human menstrual blood to treat toxin-induced POF in mice.

Human endometrial stem cells exhibit stem cell properties in culture. These human endometrial stem cells are easily isolated from human menstrual blood. Other laboratories have even used them to treat heart conditions in clinical trials.

In this present study, Liu and colleagues treated female mice with the anti-cancer/anti-organ rejection drug cyclophosphamide. This drug pushed the mice into POF. Then one group of mice had human menstrual stem cells injected into their ovaries whereas another group received an injection of phosphate-buffered saline.

After 14 days, ovaries from those mice injected with human menstrual stem cells expressed higher levels of ovarian-specific proteins. Also, the blood levels of estrogen of the stem cell-injected mice were also higher. Postmortem examination also showed that the average ovarian weight of the stem cell-injected mice was much higher, as was the number of normal follicles. Follicles contain eggs surrounded with follicle cells and their absence is indicative of an ovary from a woman who is in menopause. That fact that the stem cell-treated POF mice had normal follicles and more of them suggests that the injected stem cells beefed up the supply of existing eggs and helped them survive and flourish.

These results suggest that these human menstrual stem cells, which are derived from the endometrium, can survive when introduced into a living organism and promote the regeneration of ovaries. There is no evidence that these cells differentiate into eggs, but instead they probably create an environment where the existing moribund eggs are rejuvenated and revitalized. This treatment for POF might be a viable option for human patients; all without destroying human embryos.

Adult Stem Cells Used for Spinal Disc Repair


The Australian regenerative medicine company Mesoblast Limited announced the results of their 12-month clinical trial that examined the use of their “off-the-shelf” product to treat patients with disc-related low back pain.

This phase 2 clinical trial enrolled 100 patients with chronic moderate to severe “discogenic low back pain” and tested the ability of “mesenchymal precursor cells” to shore up degenerating intervertebral discs.

Intervertebral discs

Intervertebral discs sit between each vertebra and act as shock absorbers. Each disc consist of an outer layer called the “annulus fibrosus.” The annulus fibrosus consists of several layers of fibrocartilage. The annulus fibrosus surrounds an inner layer called the nucleus pulposus, which contains loose fibers suspended in a mucoprotein gel with the consistency of jelly. This jelly-like center distributes pressure evenly across the disc. These discs absorb the impact of the body’s daily activities and keep the two vertebrae separated. The development of a prolapsed disc results when the jelly in the nucleus pulposus is forced out of the doughnut/disc, which may put pressure on the nerve located near the disc.

Intervertebral structure

More than six million people in the United States alone deal with chronic back pain that has persisted for at least three months, and 3.5 million people are affected by moderate or severe degenerative intervertebral disc disease.

In this clinical trial, Mesoblast Limited injected their mesenchymal precursor cells (MPCs) into the degenerating intervertebral discs of patients suffering from moderate to severe back pain. When compared with a control group, patients who received the MPC injections used less pain killers, went through fewer surgeries and non-surgical interventions, and had greater disc stability as ascertained by X-rays. MPC injections also were well tolerated and produced few side effects.

This phase 2 clinical trial extends earlier observations by Mesoblast Limited on laboratory animals. In preclinical trials, purified MPCs increased the quality of the jelly content of the nucleus pulposus and improved disc structure in sheep.

This present study enrolled 100 patients at 13 different sites across Australia and the United States with early disc degeneration and randomly assigned the subjects to one of four groups: 1) those who received saline injections; 2) those who received hyaluronic acid injections; 3) those who received low-dose MPCs in hyaluronic acid; and 4) those who received high-dose injections of MPCs in hyaluronic acid.

All patients received their injections in an outpatient procedure, and are being evaluated for safety and efficacy to evaluate long-term treatment effects.

At 12 months, the key findings were improvement in chronic low back pain, function, and disc stability. Also, no safety concerns emerged as a result of the treatment.

As this trial proceeds, more data should be forthcoming.

A Patient’s Own Bone Marrow Stem Cells Defeat Drug-Resistant Tuberculosis


People infected with multidrug-resistant forms of tuberculosis could, potentially, be treated with stem cells from their own bone marrow. Even though this treatment is in the early stage of its development, the results of an early-stage trial of the technique show immense promise.

British and Swedish scientists have tested this procedure, which could introduce a new treatment strategy for the estimated 450,000 people worldwide who have multi drug-resistant (MDR) or extensively drug-resistant (XDR) TB.

This study, which was published in the medical journal, The Lancet, showed that over half of 30 drug-resistant TB patients treated with a transfusion of their own bone marrow stem cells were cured of the disease after six months.

“The results … show that the current challenges and difficulties of treating MDR-TB are not insurmountable, and they bring a unique opportunity with a fresh solution to treat hundreds of thousands of people who die unnecessarily,” said TB expert Alimuddin Zumla at University College London, who co-led the study.

TB initially infects the lungs but can rapidly spread from one person to another through coughing and sneezing. Despite its modern-day resurgence, TB is often regarded as a disease of the past. However, recently, drug-resistant strains of Mycobacterium tuberculosis, the microorganism that causes TB, have spread globally, rendering standard anti-TB drug treatments obsolete.

The World Health Organisation (WHO) estimates that in Eastern Europe, Asia and South Africa 450,000 people have MDR-TB, and close to half of these cases will fail to respond to existing treatments.

Mycobacterium tuberculosis, otherwise known as the “tubercle bacillus, trigger a characteristic inflammatory response (granulomatous response) in the surrounding lung tissue that elicits tissue damage (caseation necrosis).

Bone-marrow stem cells are known to migrate to areas of lung injury and inflammation. Upon arrival, they initiate the repair of damaged tissues. Since bone marrow stem cells also they also modify the body’s immune response, they can augment the clearance of tubercle bacilli from the body. Therefore, Zumla and his colleague, Markus Maeurer from Stockholm’s Karolinska University Hospital, wanted to test bone marrow stem cell infusions in patients with MDR-TB.

In a phase 1 trial, 30 patients with either MDR or XDR TB aged between 21 and 65 who were receiving standard TB antibiotic treatment were also given an infusion of around 10 million of their own bone marrow-derived stem cells.

The cells were obtained from the patient’s own bone marrow by means of a bone marrow aspiration, and then grown into large numbers in the laboratory before being re-transfused into the same patient.

During six months of follow-up, Zumla and his team found that the infusion treatment was generally safe and well tolerated, and no serious side effects were observed. The most common non-serious side effects were high cholesterol levels, nausea, low white blood cell counts and diarrhea.

Although a phase 1 trial is primarily designed only to test a treatment’s safety, the scientists said further analyses of the results showed that 16 patients treated with stem cells were deemed cured at 18 months compared with only five of 30 TB patients not treated with their own stem cells.

Maeurer stressed that further trials with more patients and longer follow-up were needed to better establish how safe and effective the stem cell treatment was.

But if future tests were successful, he said, this could become a viable extra new treatment for patients with MDR-TB who do not respond to conventional drug treatment or for those patients with severe lung damage.