Bone Marrow or Umbilical Cord Stem Cells Treat Refractory Lupus-Related Kidney Disease

Autoimmune diseases are those diseases in which the patient’s own immune system attacks his or her own tissues. the treatment of such diseases requires giving patients drugs that suppress the immune system. Such drugs have potent side effects and taking such drugs long-term can also predispose patients to cancers and other types of inimical conditions.

One particular type of autoimmune disease, Systemic Lupus Erythematosis, otherwise known as SLE or just Lupus, results from an immune response against components inside our cells. The recognition of these proteins and other substances by our immune system causes massive cell damage and death. However, lupus is a very individual disease. In some patients, the disease manifests by producing butterfly-like lesions on the face.

Lupus butterfly rash (from
Lupus butterfly rash (from

In others, a severe arthritis in several joints results. In other lupus patients, the liver undergoes progressive degradation and scarring. Still others have severe heart problems, and others have scarring and progressive damage to the kidneys. In other patients a combination of symptoms and organs are affected. Some cases of lupus are sporadic and mild, but others are fulminant and relentless. The particular disease a person shows is completely individual.

In some lupus patients, the kidneys experience lupus nephritis (LN), which is inflammation of the tissues of the kidney. In some patients, drug treatments with corticosteroid drugs like prednisone, or other drugs like hydroxychloroquine (Plaquenil), also can help control lupus. Other drugs include powerful immune suppressants such as cyclophosphamide (Cytoxan), azathioprine (Imuran, Azasan), mycophenolate (Cellcept), leflunomide (Arava) and methotrexate (Trexall), all of which have lists of side effects that include increased risk of infection, liver damage, decreased fertility and an increased risk of cancer. However in a percentage of LN patients, drug treatments simply do not work, and these conditions are known as refractory LN.

A new clinical trial has examined the ability of mesenchymal stem cells from bone marrow or umbilical cord tissue to treat refractory LN. This Chinese study examined 81 patients with active refractory LN. The mesenchymal stem cells (MSCs) used in this study were “allogeneic,” which means that they were taken from someone other than the patient. Such treatments have been shown to successfully treat patients with other types of autoimmune diseases (see Figueroa FE, et al., Biol Res. 2012;45(3):269-77).

In this single-center clinical trial, Fei Gu and Dandan Wang and others from the Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China enrolled 81 Chinese patients with active and refractory LN from 2007 to 2010. These patients received by intravenous administration either allogeneic bone marrow- or umbilical cord-derived MSCs at a dose of 1 million cells per kilogram of bodyweight. All 81 patients were then monitored over the course of one year with periodic follow-up visits to evaluate kidney function and to determine if the patients were experiencing any adverse events from the stem cell treatments.

During the year-long follow-up, 77 of the 81 patients survived ( survival rate of 95%) and 49/81 patients (60.5%) achieved remission. Eleven of 49 (22.4 %) patients showed a “renal flare,” which means that their symptoms and kidney inflammation returned by the end of 12 months after having previously experienced complete remission.

Kidney function jumped during this time. The main measure of kidney function is a test called the glomerular filtration rate or GFR. This measures how well the kidney filters materials per unit time. GFR in these patients improved significantly 12 months after the stem cell treatment (mean ± SD, from 58.55 ± 19.16 to 69.51 ± 27.93 mL/min). Two other measures used to determine the severity of lupus in a patient (Systemic Lupus Erythematosus Disease Activity Index or SLEDAI score), and the activity of lupus within the kidney (British Isles Lupus Assessment Group or BILAG scores) also decreased consistently, showing that the severity of the disease decreased and the severity of the disease within the kidney also decreased after the stem cell treatment (BILAG scores – 4.48 ± 2.60 at baseline to 1.09 ± 0.83 at 12 month and the SLEDAI scores – 13.11 ± 4.20 at baseline to 5.48 ± 2.77 at 12 months).

If that is not convincing, get this: the doses of prednisone and immunosuppressive drugs required by these patients were tapered. In other words, patients were able to eventually get off their drugs sometime within this year-long period. Is that cool or what!! No transplantation-related adverse events were observed.

Thus, the authors conclude, “Allogeneic MSCT resulted in renal remission for active LN patients within 12-month visit, confirming its use as a potential therapy for refractory LN.”

Now this treatment is NOT a cure. Several patients still experienced renal flares one year after treatment, and not all the patients experienced remission. Therefore, this is not a treatment for everyone. Identifying which patients will be helped by these treatments might require microarray analyses, but the bottom line is clear – some patients are definitely helped by MSC treatments.

Granted this is a small study and it is not a controlled study – these stem cell-treated patients were not compared to anything else. However it is a very hopeful beginning. There were no adverse side effects and 60% of the patients experienced remission, and that is definitely good news

New US Phase IIa Trial and Phase III Trial in Kazakhstan Examine CardioCell’s itMSC Therapy to Treat Heart Attack Patients

The regenerative medicine company CardioCell LLC has announced two new clinical trials in two different countries that utilize its allogeneic stem-cell therapy to treat subjects with acute myocardial infarction (AMI), which is a problem that faces more than 1.26 million Americans annually. The United States-based trial is a Phase IIa AMI clinical trial that is designed to evaluate the clinical safety and efficacy of the CardioCell Ischemia-Tolerant Mesenchymal Stem Cells or itMSCs. The second clinical trial in collaboration with the Ministry of Health in Kazakhstan is a Phase III AMI clinical trial on the intravenous administration of CardioCell’s itMSCs. This clinical trial is proceeding on the strength of the efficacy and safety of itMSCs showed in previous Phase II clinical trials.

CardioCell’s itMSCs are exclusively licensed from CardioCell’s parent company Stemedica Cell Technologies Inc. Normally, when mesenchymal stem cells from fat, bone marrow, or some other tissue source are grown in the laboratory, the cells are provided with normal concentrations of oxygen. However, CardioCell itMSCs are grown under low oxygen or hypoxic conditions. Such growth conditions more closely mimic the environment in which these stem cells normally live in the body. By growing these MSCs under these low-oxygen conditions, the cells become tolerant to low-oxygen conditions (ischemia-tolerant), and if transplanted into other low-oxygen environments, they will flourish rather than die.

Another advantage of itMSCs for regenerative treatments over other types of MSCs is that itMSCs secrete higher levels of growth factors that induce the formation of new blood vessels and promote tissue healing. These clinical trials have been designed to help determine if CardioCell’s itMSC-based therapies stimulate a regenerative response in acute heart attack patients.

“CardioCell’s new Phase IIa AMI study is built on the excellent safety data reported in previous Phase I clinical trials using our unique, hypoxically grown stem cells,” says Dr. Sergey Sikora, Ph.D., CardioCell’s president and CEO. “We are also pleased to report that the Ministry of Health in Kazakhstan is proceeding with a Phase III CardioCell-therapy study following its Phase II study that was highly promising in terms of efficacy and safety. Our studies target AMI patients who have depressed left ventricular ejection fraction (LVEF), which makes them prone to developing extensive scarring and therefore to the development of chronic heart failure. CardioCell hopes our itMSC therapies will inhibit the development of extensive scarring and, thus, the occurrence of chronic heart failure in these patients.”

The United States-based Phase IIa clinical trial will take place at Emory University, Sanford Health and Mercy Gilbert Medical Center. The CardioCell Phase IIa AMI trial is a double-blinded, multicenter, randomized study designed to assess the safety, tolerability and preliminary clinical efficacy of a single, intravenous dose of allogeneic mesenchymal bone-marrow cells infused into subjects with ST segment-elevation myocardial infarction (STEMI).

“While stem-cell therapy for cardiovascular disease is nothing new, CardioCell is bringing to the field a new, unique type of stem-cell technology that has the possibility of being more effective than other AMI treatments,” says MedStar Heart Institute’s Director of Translational and Vascular Biology Research and CardioCell’s Scientific Advisory Board Chair Dr. Stephen Epstein. “Evidence exists demonstrating that MSCs grown under hypoxic conditions express higher levels of molecules associated with angiogenesis and healing processes. There is also evidence indicating they migrate with greater avidity to various cytokines and growth factors and, most importantly, home more robustly to ischemic tissue. Studies like those underway using CardioCell’s technology are designed to determine if we can evoke a more potent healing response that will reduce the extent of myocardial cell death occurring during AMI and thereby decrease the amount of scar tissue resulting from the infarct. A therapy that could achieve this would have a major beneficial impact in reducing the occurrence of chronic heart failure.”

Kazakhstan’s National Scientific Medical Center is conducting a Phase III AMI clinical trial using CardioCell’s itMSCs, which are sponsored by local licensee Altaco. This clinical trial is entitled, “Intravenous Administration of itMSCs for AMI Patients,” and is proceeding based on a completed Phase II efficacy and safety study. However, the results of this previous Phase II study are preliminary because the sample group was so small. Despite these limitations, the findings demonstrated statistically significant elevation (more than 12 percent over the control group) in the ejection fraction of the left ventricle of the heart in patients who had received itMSCs. Also, a significant reduction in inflammation was also observed, as ascertained by lower CRP (C-reactive protein) levels in the blood of treated patients in comparison to control groups. Thus, Dr. Daniyar Jumaniyazov, M.D., Ph.D., principal investigator in Kazakhstan clinical trials states: “In our clinical Phase II trial for patients with AMI, treatment using itMSCs improved global and local myocardial function and normalized systolic and diastolic left ventricular filling, as compared to the control group. We are encouraged by these results and look forward to confirming them in a Phase III study.”

CardioCell’s treatment is the first to apply itMSC therapies for cardiovascular indications like AMI, chronic heart failure and peripheral artery disease. Manufactured by CardioCell’s parent company Stemedica and approved for use in clinical trials, itMSCs are manufactured under Stemedica’s patented, continuous-low-oxygen conditions and proprietary media, which provide itMSCs’ unique benefits: increased potency, safety and scalability. itMSCs differ from competing MSCs in two key areas. itMSCs demonstrate increased migratory ability towards the place of injury, and they show increased secretion of growth and transcription factors (e.g., VEGF, FGF and HIF-1), as demonstrated in a peer-reviewed publication (Vertelov et al., 2013). This can potentially lead to improved regenerative abilities of itMSCs. In addition, itMSCs have significantly fewer HLA-DR receptors on the cell surface than normal MSCs, which might reduce the propensity to cause immune responses. As another benefit, itMSCs are highly scalable. A single donor specimen can currently yield about 1 million patient treatments, and this number is expected to grow to 10 million once full robotization of Stemedica’s facility is complete.

The Benefits of Repeated Mesenchymal Stem Cell Treatments to the Heart

Mesenchymal stem cells have the ability to improve the heart after a heart attack. However can repeated administrations of mesenchymal stem cells cause an increased benefit to the heart after a heart attack?

A collaborative research project between the Royal Adelaide Hospital, the University of Adelaide in South Australia, and the Mayo Clinic in Rochester, Minnesota has administered mesenchymal stem cells multiple times to rodents after a heart attack to determine if administering these stem cells multiple times after a heart attack increases the performance of the heart.

The experimental procedure was relatively straight-forward. Three groups of mice were evaluated by means of cardiac magnetic resonance imaging (MRI). Then all three were given heart attacks by tying off the left anterior descending artery. Immediately after the heart attack, two groups were injected with one million mesenchymal stem cells into the heart. The third group was injected with ProFreeze (a cryopreservation solution). One week later, a second set of heart MRIs were taken, and the first and third group of mice received injections of ProFreeze and the third group received another one million mesenchymal stem cells. All animals were given two more heart MRIs one week later and two weeks after that. One month after the initial heart attacks, the mice were euthanized and their hearts were sectioned and examined.

Those mice that did not receive injections of mesenchymal stem cells showed a precipitous drop in their heart performance. The ejection fraction (average percent of blood pumped from the heart) dropped from around 60% to about 20% and then stayed there. Those mice treated with one round of mesenchymal stem cells (MSCs) after their ejection fractions drop from 60% to about 35% after one week, and then stayed there. Those animals that received two shots of MSCs have their ejection fractions drop from around 60% to about 41%. Thus the administration of a second round of MSCs did significantly increase the performance of the heart.

The heart also shows tremendous structural improvements as a result of MSC transplantation. These improvements are even more dramatic in those mice that received two doses of MSCs. The mass of the heart and the thickness of the walls of the heart are greater in those animals that received two MSC doses, than those that received only one dose. Secondly, the size of the heart scar is smallest in those animals that received two doses of MSCs. Third, the density of blood vessels was MUCH higher in the animals that received two MSC doses. Also, the tissue far from the infarction in those animals that had received two doses of MSCs showed twice the density of blood vessels per cubic millimeter of heart tissue than those animals that had only received one injection of MSCs. Therefore, additional transplantations of MSCs increase blood vessel density, decrease the size of the heart scar and increase the thickness of the walls of the heart.

MSCs have the capacity to heal the heart after a heart attack. The degree to which they heal the heart differs from patient to patient, but additional treatments have the capacity to augment the healing capacities of these cells.  Also, in this experiment, the mice received someone else’s MSCs.  This is known as “allogeneic” transplantation, and it is an important concept, since older patients, diabetic patients, or those who have had a heart attack typically have MSCs that do not perform well.  Therefore to receive MSCs from a donor is a way around this problem.

The problem with this experiment is that it was done in mice, and they were injected directly into the heart tissue. Such a procedure is almost certainly impractical for human patients. Instead, intracoronary delivery is probably more practical, but here again, repeated releasing cells into the coronary arteries increases the risk of clogging them. Therefore, it is probably necessary to administer the second dose of MSCs some time after the first dose. To calibrate when to administer the second dose, large animal experiments will be required.

Thus, while this experiment looks interesting and hopeful, more work is required to make this usable in humans.  It does, however, establish the efficacy of repeated allogeneic MSC transplantations, which is an important feature of these experiments.

Mesenchymal Stem Cell Transplantation Improves Heart Remodeling After a Heart Attack

Stem cell scientists from the University of Maryland, Baltimore have used bone marrow mesenchymal stem cells (MSCs) to treat sheep that had suffered a heart attack. They found that the injected stem cells prevented the heart from deteriorating.

This work was a collaboration between the laboratories of Mark Pittenger, ZhonGjun Wu and Bartley Griffith from the Department of Surgery and the Artificial Organ Laboratory.

After a heart attack, the region of the heart that was deprived of oxygen undergoes cell death and is replaced by a heart scar. However, the region next to the dead cells also undergo problematic changes. The cells in these regions adjacent to dead region must contract more forcibly in order to compensate for the noncontracting dead region. These cells enlarge, but some undergo cell death due to inadequate blood supply. There are other changes that can occur, such as abnormalities in Calcium ion handling and poor contractability.

Thus, the problems that result from a heart attack can spread throughout the heart and cause heart failure. In this experiment, the U of Maryland scientists injected MSCs into the sheep hearts four hours after a heart attack to determine if the stem cells could prevent the region adjacent to the dead heart cells from deteriorating.

In this experiment, bone marrow MSCs were isolated from sheep bone marrow and put through a battery of tests to ensure that they could differentiate into bone, cartilage, and fat. Once the researchers were satisfied that the MSCs were proper MSCs, they induced heart attacks in the sheep, and then injected ~200 million MSCs into the area right next to the region of the heart that died.

After 12 weeks, tissue biopsies from these sheep hearts were taken and examined. Also, the sheep hearts were measured for their heart function and structure.

The sheep that did not receive any MSC injections continued to deteriorate and showed signs of stress. The cells adjacent to the dead region expressed a cadre of genes associated with increased cell stress. Furthermore, there was increased cell death and evidence of scarring in the region adjacent to the death region. There was also evidence of Calcium ion-handling problems in the adjacent tissue and increased cell death.

On the other hand, the hearts of the sheep that had received injections of MSCs into the area adjacent to the dead region showed a reduced expression of those genes associated with increased cell stress. Also, these hearts contracted better than those that had not received stem cell injections. There was also less cell death, less scarring, and no evidence of Calcium ion-handling problems.

Changes that occur in the heart after a heart attack are collectively referred to as “remodeling.” Remodeling begins regionally, in those areas near the dead heart cells, but these deleterious changes spread to the rest of the heart, resulting in heart failure. The injections of MSCs into the area next to the dead region clearly prevented remodeling from occurring.

This pre-clinical study is a remarkable study for another reason: the MSCs used in this study were allogeneic. Allogeneic is a fancy way of saying that they did not come from the same animal that suffered the heart attack, but from some other healthy animal. Therefore, the delivery of a donor’s MSCs into the heart of a heart attack patient could potentially prevent heart remodeling.

The main problem with this experiment is that the MSCs were injected directly into the heart muscle. In humans, such a procedure requires special equipment and carries potential risks that include perforation of the heart wall, rupture of the heart wall, or further damaging the heart muscle. Therefore, if such a technology could be adapted to a more practical delivery system in humans, then certainly human clinical trials should be forthcoming.

See Yunshan Zhao, et al., “Mesenchymal stem cell transplantation improves regional cardiac remodeling following ovine infarction.” Stem Cells Translational Medicine 2012;1:685-95.