High-Dose Stem Cell Treatments in Chronic Heart Patients Increases Survival Rates

The DanCell clinical trial was conducted about seven years ago at the Odense University Hospital, Odense, Denmark by a clinical research team led by Axel Diederichsen. The DanCell study examined 32 patients with severe ischemic heart failure who had received two rounds of bone marrow stem cell treatments.

The DanCell study was small and uncontrolled. However, because the vast majority of stem cell-based clinical trials have examined the efficacy of stem cell treatments in patients who have recently experienced a heart attack, this study was one of the few that examined patients with chronic heart failure.

In this study, patients had an average ejection fraction of 33 ± 9%, which is in the cellar – normal ejection fractions in healthy patients are in the 50s-60s. Therefore, these are patients with distinctly “bad tickers.” All 32 patients received two repeated infusions (4 months apart) of their own bone marrow stem cells, but these stem cell infusions were quantitated to determine the number of “CD34+” cells and the number of “CD133+” cells. CD34 is a cell surface protein found on bone marrow hematopoietic stem cells, but it by no means exclusive to HSCs. CD133 is also a cell surface protein found, although not exclusively, on the surfaces of cells that form blood vessels and blood vessels cells as well.

Initially, patients showed no improvements in heart function after 12 months. However, when patients were classified according to those who received the most or the least number of CD34+ cells, a curious thing emerged: those who received more CD34+ cells had a better chance of surviving than those who received fewer CD34+ cells.

Is this a fluke? To determine if it was, Diederichsen and his colleagues followed these patients for 7 years after the bone marrow infusion. When Diederichsen and his colleague recorded the number of deaths and compared them with the number of CD34+ cells infused, the pattern once again held true. The CD34+ cell count and CD133+ cell count did not significantly correlate with survival, but the CD34+ cell count alone was significantly associated with survival. In the authors own words: “decreasing the injected CD34 cell count by 10[6] increases the mortality risk by 10%.”

The conclusions of this small and admittedly uncontrolled study: “patients might benefit from intracoronary stem cell injections in terms of long-term clinical outcome.”

Three things to consider: Patients with heart conditions have poorer quality bone marrow stem cell numbers. Therefore, allogeneic stem cells might be a better way to go with this patient group. Secondly, the Danish group used Lymphoprep to prepare their bone marrow stem cells, which has been used in other failed studies, and the stem cell quality was almost certainly an issue in these cases (see the heart chapter in my book The Stem Cell Epistles for more information). Therefore, independent tests of the bone marrow quality are probably necessary as well or a different isolation technique in general. Also, a controlled trial must be run in order to confirm the efficacy of bone marrow stem cell infusions for patients with chronic ischemic heart disease. Until them, all we can conclude is that intracoronary injections of a high number of CD34+ cells may have a beneficial effect on chronic ischemic heart failure in terms of long-term survival.

New Model for Kidney Regeneration

Harvard Stem Cell Institute Kidney Diseases Program Leader Benjamin Humphreys has examined tissue regeneration in the kidney. His interest in kidney regeneration has occupied a major part of his career, but some of his more recent work resulted from his skepticism of a particular theory of kidney regeneration.

The kidney stem cell repair model postulates that scattered throughout the kidney are small stem cell populations and are activated after the kidney is injured to repair it. This theory, however, conflicts with another view of kidney regeneration. Namely that after injury, the cells of the kidney dedifferentiate into more primordial versions of themselves and proliferate, after which they differentiate into the various tissues of the kidney.

Humphreys and his colleagues now have evidence that strongly suggests that all the cells of the kidney have the capacity to divide after injury and contribute to kidney regeneration.

Their evidence comes in the form of experiments in mice in which the cells of the kidney were genetically tagged, and then the kidneys were injured to determine what cells contributed to the regeneration of the kidney.

The tagging in this experiment is complicated, but quite technically brilliant. The kidney is composed of myriads of tiny functional units called nephrons. Each nephron is fed by a tiny knot of blood vessels called a glomerulus.  The structure of a nephron is shown below.  


The blood supply to the kidney comes from branches off the descending aorta knows as renal arteries.  After entering the kidneys, the renal arteries branch multiple times until they become tiny vessels that feed into each nephron known as afferent arterioles.  The afferent arterioles forms a dense network of knot-like vessels that form the glomerulus and the portion of the nephron that interacts with the glomerulus is known as the Bowman’s capsule..  The blood vessels of the glomerulus are very special because they are exceptionally porous.  However, the Bowman’s capsule has a series of cells with foot-like extensions that coat the glomerulus called “podocytes.”  An especially beautiful picture of podocytes wrapped around a glomerular vessel is shown below.


The podocytes cover the pores of the glomerulus and only allows water and things dissolved in water through the pores.  Proteins do not make it through – they are too heavily charged.  Cells also do not make it through – they are too big.  But water, sodium ions, potassium ions, hydrogen ions, some drugs, metabolites, waste products, and things like that all make it through the podocyte-guarded pores.  For this reason, if you have excessive protein or some blood cells in your urine, it is usually an indication that something is wrong.  

Now, rest of the tubing attached to the nephron serve to reabsorb all the things you do not want to get rid of and not absorb all the things you do want to get rid of.  The amount of water you eliminate depends on your degree of hydration and is controlled by a hormone called antidiuretic hormone, which is release by the posterior lobe of your pituitary gland when you are dehydrated.  In the presence of ADH, the posterior tubing reabsorbs more water, and in lower concentrations of this hormone, it reabsorbs far less.  

Now that we know something about the kidney, here’s how Humphreys and others genetically marked the kidneys of their mice.  The sodium-dependent inorganic phosphate transporter (SLC34a1) is only expressed in mature proximal tubule cells.  Tetsuro Kusaba, the first author on this paper, and his colleagues inserted a CreERT2 cassette into this gene.  If you are lost at this point all you need to remember is this: the CreERT2 cassette is inserted into a gene that is ONLY expressed in specific kidney cells.  The Cre gene encodes a recombinase that clips out specific bits of DNA from a chromosome.  Kusaba and others crossed these engineered mice with another strain of mice that had the gene for a bright red dye inserted into another gene, but this dye could not be expressed because another piece of DNA was in the way.  When these hybrid mice were fed a drug called tamoxifen, it activated the expression of the Cre protein, but only in the proximal tubule cells of the kidney and this Cre protein clipped out the piece of DNA that was preventing the red dye gene from being expressed.  Therefore, these mice had a particular part of their nephrons, the proximal tubules glowing bright red.  This is a stroke of shear genius and it genetically marks these cells specifically and strongly.  

Next, Kusaba and colleagues used unilateral ischemia reperfusion injury (IRI) to damage the kidneys.  In IRI, the blood supply is stopped to one kidney but not the other for a short period of time (26 minutes).  This causes cell death and kidney damage.  The other kidney is not damaged and serves as a control for the experiment.  

Examination of the damaged kidneys showed that  red-glowing cells were found in areas other than the proximal tubules.  The only way these cells could have ended up in these places was if the differentiated cells divided and helped repair the damaged parts of the nephrons.  

Other research groups have seen similar results, but interpreted them as evidence of stem cell populations in the kidney.  However, Humphreys groups discovered something even more fascinating.  These “stem cell-markers” in the kidney are actually markers of kidney damage and regeneration and all cells in the kidney express them.  In Humphreys words, “What was really interesting is when we looked at the appearance and expression patterns of these differentiated cells, we found that they expressed the exact same ‘stem cell markers’ that these other groups claimed to find in their stem cell populations.  And so, if a differentiated cell is able to express a ‘stem cell marker’ after injury, then what our work shows is that that’s an injury marker – is doesn’t define a stem cell.”  

Indeed, several genes that have been taken to be signs of a kidney stem cell population (CD133, CD24, vimentin, and KIM-1) were expressed in red-glowing cells.  A stem cell population should not be fully differentiated and therefore, should not be able to express the red dye.  However, red-glowing cells clearly expressed these found genes after injury.  This rather definitely shows that it is the fully differentiated cells that are doing the regeneration in the kidney and not a resident stem cell population.  This does not prove that there is no resident stem cell population in the kidney, but only that the lion’s share of the regeneration is done by differentiated cells, and that under these conditions, no stem cell population was detected.  

This new interpretation of kidney repair suggests that cells can reprogram themselves in a way that resembles the way mature cells are chemically manipulated to revert to an induced pluripotent state.  

See Tetsuro Kusaba, Matthew Lalli, Rafael Kramann, Akio Kobayashi, and Benjamin D. Humphreys. Differentiated kidney epithelial cells repair injured proximal tubule. PNAS (October 14, 2013); doi:10.1073/pnas.1310653110.  

Adult Stem Cells Help Build Human Blood Vessels in Engineered Tissues

University of Illinois researchers have identified a protein expressed by human bone marrow stem cells that guides and stimulates the construction of blood vessels.

Jalees Rehman, associate professor of cardiology and pharmacology at the University of Illinois at Chicago College of Medicine and lead author of this paper, said: “Some stem cells actually have multiple jobs.”

As an example, stem cells from bone marrow known as mesenchymal stem cells can form bone, cartilage, or fat, but they also have a secondary role in that they support other cells in bone marrow.

Rehman and others have worked on developing engineered tissues for use in cardiac patients, and they noticed that mesenchymal stem cells were crucial for organizing other cells into functional stem cells.

Workers from Rehman’s laboratory mixed mesenchymal stem cells from human bone marrow with endothelial cells that line the inside of blood vessels. The mesenchymal stem cells elongated and formed a kind of scaffold upon which the endothelial cells adhered and organized to form tubes.

“But without the stem cells, the endothelial cells just sat there,” said Rehman.

When the cell mixtures were implanted into mice, blood vessels formed that were able to support the flow of blood. Then Rehman and his colleagues examined the genes expressed when their stem cells and endothelial cells were combined. They were aided in this venture by two different bone marrow stem cell lines, one of which supported the formation of blood vessels, and the other of which did.

Their microarray experiments showed that the vessel-supporting mesenchymal stem cells expressed high levels of the SLIT3 protein. SLIT3 is a blood vessel-guidance protein that directs blood vessel-making cells to particular places and induces them to make blood vessels. The cell line that do not stimulate blood vessel production made little to no SLIT3.

Rehman commented, “This means that not all stem cells are created alike in terms of their SLIT3 production and their ability to encourage blood vessel formation.”

Rehman continued: “While using a person’s own stem cells for making blood vessels is ideal because it eliminates the problem of immune rejection, it might be a good idea to test a patient’s stem cells to make sure they are good producers of SLIT3. If they aren’t, the engineered vessels may not thrive or even fail to grow.

Mesenchymal stem cells injections are being evaluated in clinical trials to see if their can help grow blood vessels and improve heart function in patients who have suffered heart attacks.

So far, the benefits of stem cell injection have been modest, according to Rehman. Evaluating the gene and protein signatures of stem cells from each patient may allow for a more individualized approach so that every patient receives mesenchymal stem cells that are most likely to promote blood vessel growth and cardiac repair. Such pre-testing might substantially improve the efficacy of stem cell treatments for heart patients.

Directly Programming Skin Cells to Become Blood-Making Stem Cells

Within our bones lies a spongy, ribbon-like material called bone marrow.  Bone marrow is home to several different populations of stem cells, but the star of the stem cell show in the bone marrow are the hematopoietic stem cells or blood-making stem cells.   When a patient receives a bone marrow transplant these are the stem cells that are transferred, take up residence in the new bone marrow, and begin making new red and white blood cells for the patient.  Because bone marrow is such a precious commodity from a clinical standpoint, finding a way to make more of it is essential.

Hematopoiesis from Pluripotent Stem Cell

A new report from scientists at Mt Sinai Hospital in New York suggest that the transfer of specific genes into skin fibroblasts can reprogram mature, adult cells into hematopoietic stem cells that look and function exactly like the ones normally found within our bone marrow.

A research team at the Icahn School of Medicine at Mount Sinai led by Kateri Moore screen a panel of 18 different genes for their ability to induce blood-forming activity when transfected into fibroblasts. Kateri and others discovered that a combination four different genes (GATA2, GFI1B, cFOS, and ETV6) is sufficient to generate blood vessel precursors with the subsequent appearance of hematopoietic stem cells. These cells expressed several known hematopoietic stem cell surface proteins (CD34, Sca1 and Prominin1/CD133).

Reprogramming of fibroblasts to HSCs

“The cells that we grew in a Petri dish are identical in gene expression to those found in the mouse embryo and could eventually generate colonies of mature blood cells,” said Carlos Filipe Pereira, first author of this paper and a postdoctoral research fellow in Moore’s laboratory.

The combination of gene factors that we used was not composed of the most obvious or expected proteins,” said Ihor Lemischka, a colleague of Dr. Moore at Mt. Sinai Hospital.  “Many investigators have been trying to grow hematopoietic stem cells from embryonic stem cells, but this process has been problematic.  Instead, we used mature mouse fibroblasts, pick the right combination of proteins, and it worked.”

According to Pereira, there is a rather critical shortage of suitable donors for blood stem cells transplants.  Bone marrow donors are currently necessary to meet the needs of patients suffering from blood diseases such as leukemia, aplastic anemia, lymphomas, multiple myeloma and immune deficiency disorders.  “Programming of hematopoietic stem cells represents an exciting alternative,” said Pereira.

“Dr. Lemischka and I have been working together for over 20 years in the fields of hematopoiesis and stem cell biology,” said Kateri Moore.  “It is truly exciting to be able to grow these blood forming cells in a culture dish and learn so much from them.  We have already started applying this new approach to human cells and anticipate similar success.”