Patent Application
20120269779
The present invention generally relates to mesenchymal stromal cell populations, methods of isolating these populations and methods for treating organ dysfunction, multi-organ failure, cerebral dysfunction and renal dysfunction, including, but not limited to stroke, acute renal failure (also known as acute kidney injury), transplant associated acute renal failure, graft versus host disease, chronic renal failure, and wound healing.
Stroke or cerebral vascular accident (CVA) is a clinical term for a rapidly developing loss of brain function, due to lack of blood supply. The reason for this disturbed perfusion of the brain can be thrombosis, embolism or hemorrhage. Stroke is a medical emergency and the third leading cause of death in Western countries. It is predicted that stroke will be the leading cause of death by the middle of this century. Risk factors for stroke include advanced age, previous stroke or ischemic attack, high blood pressure, diabetes, mellitus high cholesterol, cigarette smoking and cardiac arrhythmia with atrial fibrillation. Therefore, a great need exists to provide a treatment for stroke.
Multi-organ failure (MOF) also remains a major unresolved medical problem. MOF develops in the most severely ill patients who have sepsis, particularly when the latter develops after major surgery or trauma. It occurs also with greater frequency and severity in elderly patients, those with diabetes mellitus, underlying cardiovascular and renal disease and impaired immune defenses. MOF is characterized by shock, acute renal failure (ARF), leaky cell membranes, dysfunction of the lungs, liver, heart, blood vessels and other organs. Mortality due to MOF approaches 100% despite the utilization of the most aggressive forms of therapy, including intubation and ventilatory support, administration of vasopressors, antibiotics, steroids, hemodialysis and parenteral nutrition. Many of these patients have serious impairment of the healing of surgical or trauma wound, and, when infected, these wounds further contribute to recurrent infections, morbidity and death.
ARF is defined as an acute deterioration in renal excretory function within hours or days, resulting in the accumulation of “uremic toxins,” and, importantly, a rise in the blood levels of potassium, hydrogen and other ions, all of which contribute to life threatening multisystem complications such as bleeding, seizures, cardiac arrhythmias or arrest, and possible volume overload with pulmonary congestion and poor oxygen uptake. The most common cause of ARF is an ischemic insult of the kidney resulting in injury of renal tubular and postglomerular vascular endothelial cells. The principal etiologies for this ischemic form of ARF include intravascular volume contraction, resulting from bleeding, thrombotic events, shock, sepsis, major cardiovascular surgery, arterial stenosis, and others. Nephrotoxic forms of ARF can be caused by radiocontrast agents, significant numbers of frequently used medications such as radiocontrast agents, chemotherapeutic drugs, antibiotics and certain immunosuppressants such as cyclosporine. Patients most at risk for all forms of ARF include diabetics, those with underlying kidney, liver, cardiovascular disease, the elderly, recipients of a bone marrow transplant, and those with cancer or other debilitating disorders.
Both ischemic and nephrotoxic forms of ARF result in dysfunction and death of renal tubular and microvascular endothelial cells. Sublethally injured tubular cells dedifferentiate, lose their polarity and express vimentin, a mesenchymal cell marker, and Pax-2, a transcription factor that is normally only expressed in the process of mesenchymal-epithelial transition in the embryonic kidney. Injured endothelial cells also exhibit characteristic changes.
The kidney, even after severe acute insults, has the remarkable capacity of self-regeneration and consequent re-establishment of nearly normal function. It is thought that the regeneration of injured nephron segments is the result of migration, proliferation and differentiation of surviving tubular and endothelial cells. However, the self-regeneration capacity of surviving tubular and vascular endothelial cells may be exceeded in severe ARF. Patients with isolated ARF from any cause, i.e., ARF that occurs without MOF, continue to have mortality in excess of 50%. This dismal prognosis has not improved despite intensive care support, hemodialysis, and the recent use of atrial natriuretic peptide, Insulin-like Growth Factor-1 (IGF-1), more biocompatible dialysis membranes, continuous hemodialysis, and other interventions. An urgent need exists to enhance the kidney's self-defense and autoregenerative capacity after severe injury.
Another acute form of renal failure, transplant-associated acute renal failure (TA-ARE), also termed early graft dysfunction (EGD), commonly develops upon kidney transplantation, mainly in patients receiving transplants from cadaveric donors, although TA-ARF may also occur in patients receiving a living related donor kidney. Up to 50% of currently performed kidney transplants utilize cadaveric donors. Kidney recipients who develop significant TA-ARF require treatment with hemodialysis until graft function recovers. The risk of TA-ARF is increased with elderly donors and recipients, marginal graft quality, significant comorbidities and prior transplants in the recipient, and an extended period of time between harvest of the donor kidney from a cadaveric donor and its implantation into the recipient, known as “cold ischemia time.” Early graft dysfunction or TA-ARF has serious long term consequences, including accelerated graft loss due to progressive, irreversible loss in kidney function that is initiated by TA-ARF, and an increased incidence of acute rejection episodes leading to premature loss of the kidney graft. Therefore, a great need exists to provide a treatment for early graft dysfunction due to TA-ARF or Delayed Graft Function (DGF).
Chronic renal failure (CRF) or Chronic Kidney Disease (CKD) is the progressive loss of nephrons and consequent loss of renal function, resulting in End Stage Renal Disease (ESRD), at which time patient survival depends on dialysis support or kidney transplantation. The progressive loss of nephrons, i.e., glomeruli, tubuli and microvasculature, appears to result from self-perpetuating fibrotic, inflammatory and sclerosing processes, most prominently manifested in the glomeruli and renal interstitium. The loss of nephrons is most commonly initiated by diabetic nephropathy, glomerulonephritides, many proteinuric disorders, hypertension, vasculitic, inflammatory and other injuries to the kidney. Currently available forms of therapy, such as the administration of angiotensin converting enzyme inhibitors, angiotensin receptor blockers, other anti-hypertensive and anti-inflammatory drugs such as steroids, cyclosporine and others, lipid lowering agents, omega-3 fatty acids, a low protein diet, and optimal weight, blood pressure and blood sugar control, particularly in diabetics, can significantly slow and occasionally arrest the progressive loss of kidney function in the above conditions. The development of ESRD can be prevented in some compliant patients and delayed in others. Despite these successes, the annual growth of patient numbers with ESRD, requiring chronic dialysis or transplantation, remains at 6-9%, representing a continuously growing medical and financial burden. There exists an urgent need for the development of new interventions for the effective treatment of CRF or CKD and thereby ESRD, to treat patients who fail to respond to conventional therapy, i.e., whose renal function continues to deteriorate. Stem cell treatment will be provided to arrest/reverse the fibrotic processes in the kidney.
Taken together, therapies that are currently utilized in the treatment of stroke, ARF, the treatment of established ARF of native kidneys per se or as part of MOF, and ARF of the transplanted kidney, and organ failure in general have not succeeded to significantly improve morbidity and mortality in this large group of patients. Consequently, there exists an urgent need for the improved treatment of MOF, renal dysfunction, and organ failure.
Very promising pre-clinical studies in animals and a few early phase clinical trials administer bone marrow-derived hematopoietic stromal cells for the repair or protection of one specific organ such as the heart, small blood vessels, brain, spinal cord, liver and others. These treatments have generally used only a single population of bone-marrow stem cells, either Hematopoietic (HSC) or Mesenchymal stromal cells (MSC), and obtained results are very encouraging in experimental stroke, spinal cord injury, and myocardial infarction. The intracoronary administration of stem cells in humans with myocardial infarction or coronary artery disease has most recently been reported to result in significant adverse events such as acute myocardial infarction, ventricular fibrillation and other complications and death. Peripheral administration of stem cells or the direct injection into the injured myocardium showed more favorable results both in animal and in Phase I trials. MSC have been infused into patients either simultaneously or a few weeks after they first received a bone marrow transplant in the treatment of cancers, leukemias, osteogenesis imperfecta, and Hurler's syndrome to accelerate reconstitution of adequate hematopoiesis. Effective treatment of osteogenesis imperfecta and Hurler's syndrome has been shown using MSC. Importantly, administration of a mixture of HSC and MSC, known to physiologically cooperate in the maintenance of hematopoiesis in the bone marrow, has, until now (see below) not been utilized for the treatment of any of the above listed renal disorders, MOF or wound healing.
The invention encompasses mesenchymal stromal cells that are isolated from bone marrow and methods of producing these mesenchymal stromal cells. The bone marrow is cultured on tissue culture plates for 1-4 days. After this period, non-adherent cells are removed and the remaining adherent cells are cultured for an additional 7-15 days in human platelet lysate (PL)-supplemented media. In some embodiments, when the cells reach 70-90% confluence, the cells are removed from the tissue culture plates. These cells are between 85 and 95% MSC. The cells are then suspended in physiologically acceptable solution with approximately 5% serum albumin and 10% DMSO and frozen at rate of 1° C. per minute temperature decrease using a controlled rate freezer.
The invention also encompasses mesenchymal stromal cells that have been cultured in platelet lysate supplemented culture media and wherein the population of mesenchymal stromal cells expresses Prickle1 at a higher degree than mesenchymal stromal cells that have been cultured in fetal calf serum supplemented culture media. In some embodiments, the mesenchymal stromal cells of the invention are less immunogenic than mesenchymal stromal cells that have been cultured in fetal calf serum supplemented culture media.
The invention also encompasses mesenchymal stromal cells that express the antigens CD105, CD90, CD73 and CD44 on their surfaces. In some embodiments, the mesenchymal stromal cells of the invention do not express proteins selected from the group consisting of CD45, CD34 and CD14 and MHC II on their surfaces.
The invention also provides methods of using the MSC of the invention, cultured in PL-supplemented media. These methods include administering the MSC of the invention to subjects for the treatment of neurological, inflammatory or renal disorders. These disorders include stroke, acute renal failure, transplant associated acute renal failure, graft versus host disease, chronic renal failure, and wound healing. The MSC are thawed in a step-wise manner, if frozen and the DMSO is diluted from the MSC. The MSC are administered intra-arterially to the supra-renal aorta generally by way of the femoral artery. The catheter used to administer the cells, is generally relatively small to minimize damage to the vasculature of the subject. Also, the MSC of the invention are administered at 25-50% higher pressure than that in the aorta. The MSC are administered at a dose of approximately between 105 and 101° cells per kg body weight of the subject. Preferably the MSC are administered at a dose of approximately between 106 and 108 per kg body weight of the subject. These doses of MSC are suspended in greater than 40 mL of physiologically acceptable carrier (PlasmaLyte APlasmaLyte A with 5% of serum albumin. The volume and serum albumin prevent the MSC from clumping when they are administered which could lead to side effects in the subject. The cells are administered through the catheter at a rate of about 1 mL of cells per second. Single or multiple administrations of MSC are used to provide therapeutic effects.
The invention also encompasses methods of isolating a population of MSC from whole bone marrow; culturing the bone marrow on tissue culture plates in culture media between 2 and 10 days; removing or washing off non-adherent cells; culturing the adherent cells between 9 and 20 days in PL-supplemented media; and harvesting or detaching the adherent cells from the tissue culture plates; thereby obtaining a population of mesenchymal stromal cells. In certain embodiments, the mesenchymal stromal cells are mammalian. In some embodiments, the mammalian mesenchymal stromal cells are human. In some specific embodiments, the platelet lysate is present in the culture media at about 20 μl of platelet lysate per 1 ml of culture media. In other specific embodiments, the platelet lysate is made up of pooled thrombocyte concentrates or pooled buffy coats after centrifugation.
The invention also provides a method of treating or decreasing the likelihood of onset of a renal disorder associated with surgery in a subject in need by administering a therapeutically effective dose of a population of mesenchymal stromal cells (MSC) isolated by the method comprising providing bone marrow; culturing the bone marrow on tissue culture plates in culture media between 2 and 10 days; removing or washing off non-adherent cells; culturing the adherent cells between 9 and 20 days in platelet lysate supplemented media; and harvesting or detaching or enzymatically detaching the adherent cells from the tissue culture plates; thereby treating or decreasing the likelihood of onset of the renal disorder associated with surgery in the subject.
In one embodiment, the surgery is coronary artery bypass surgery. In another embodiment, the renal disorder is selected from the group consisting of acute renal failure, chronic renal failure or chronic kidney disease. In another embodiment, the therapeutically effective dose is between about 7.0×105 and 7.0×106 MSC per kg. In another embodiment, the MSC are administered intravenously. More specifically, the MSC are administered into the suprarenal aorta.
In another embodiment, the subject is a mammal. More specifically, the mammal is a human.
In another embodiment, the MSC are allogeneic.
The invention also provides a method of treating or decreasing the likelihood of onset of a renal disorder associated with surgery in a subject in need by administering a therapeutically effective dose of a population of allogeneic mesenchymal stromal cells (MSC); thereby decreasing the likelihood of onset of the renal disorder associated with surgery in the subject.
In one embodiment, the surgery is coronary artery bypass surgery. In another embodiment, the renal disorder is selected from the group consisting of acute renal failure, chronic renal failure or chronic kidney disease. In another embodiment, the therapeutically effective dose is between about 7.0×105 and 7.0×106 MSC per kg. In another embodiment, the MSC are administered intravenously. More specifically, the MSC are administered into the suprarenal aorta.
In another embodiment, the subject is a mammal. More specifically, the mammal is a human.
The present invention provides mesenchymal stromal cells (MSC) with unique properties beneficial for their use to treat neurological or kidney pathology. The present invention also provides methods of producing MSC with unique properties beneficial for their use to treat stroke and kidney pathology. The present invention also provides methods of using MSC with unique properties beneficial for their use to treat stroke and kidney pathology.
Mesenchymal Stromal Cells Cultured in Platelet Lysate (PL) Supplemented Media
The invention provides mesenchymal stromal cells (MSC) with unique properties that make them particularly beneficial for use in the treatment of neurological or kidney pathology. The MSC of the invention are grown in media containing platelet lysate (PL), as described in greater detail below. The culturing of MSC in PL-supplemented media creates MSC that are more protective against ischemia-reperfusion damage than MSC grown in fetal calf serum (FCS)-supplemented media.
The MSC of the invention, cultured in PL-supplemented media constitute a population with (i) surface expression of the antigens CD105, CD90, CD73 and CD44, but lacking hematopoietic markers CD45, CD34 and CD14 and MHC II; (ii) preservation of the multipotent trilineage (osteoblasts, adipocytes and chondrocytes) differentiation capability after expansion with PL, however the adipogenic differentiation was delayed and needed longer times of induction. This decreased adipogenic/lipogenic ability is a favorable property because in mice the intraarterial injection of MSC for treatment of chronic kidney injury has resulted in formation of adipocytes (Kunter U, Rong S, Boor P, et al. Mesenchymal stromal cells prevent progressive experimental renal failure but maldifferentiate into glomerular adipocytes. J Am Soc Nephrol 2007 Jun;18(6):1754-64). These results are reflected in the gene expression profile of PL-generated cells revealing a downregulation of genes involved in fatty acid metabolism, described in greater detail below.
The MSC of the invention, cultured in PL-supplemented media have been described to act immunomodulatory by impairing T-cell activation without inducing anergy. There is a dilution of this effect in vitro in mixed lymphocyte cultures (MLC) leading eventually to an activation of T-cells if decreasing amounts of MSC, not cultured in PL-supplemented media, are added to the MLC reaction. This activation process is not observed when PL-generated MSC are used in the MLC as third party, as shown in greater detail below. We conclude that the MSC of the invention, cultured in PL-supplemented media are less immunogenic and that growing MSC in FCS-supplemented media may act as a strong antigen or at least express an adjuvant function in T-cell stimulation. This result again is reflected in differential gene expression showing a downregulation of MHC II compounds verifying the decreased/or absent DR immunostimulation by MSC, as shown below.
Moroever, the MSC of the invention, cultured in PL-supplemented media show upregulation of genes involved in the cell cycle (e.g. cyclins and cyclin dependent kinases) and in DNA replication and purine metabolism when compared to MSC cultured in FCS-supplemented media. On the other hand, genes functionally active in cell adhesion/extracellular matrix (ECM)-receptor interaction, differentiation/development, TGF-β signaling and TSP-1 induced apoptosis were shown to be downregulated in the MSC of the invention, cultured in PL-supplemented media when compared to MSC cultured in FCS-supplemented media, again supporting the results of faster growth and accelerated expansion.
The MSC of the invention, cultured in PL-supplemented media when intraaterially administered lead to improvement of regeneration of hypoxic tissue by interfering with the local inflammation, apoptosis and by delivering growth factors needed for the repair of damaged cells. Hypoxic cells secrete SDF1 (stromal cell derived factor 1) which attracts MSC express the CXCR4, receptor for the chemokine SDF-1. The MSC of the invention, cultured in PL-supplemented media are particularly good candidates for regenerative therapy in CNS damage. They express the gene Prickle1 gene involved in neuroregeneration at eight-fold higher level when compared to MSC cultured in FCS-supplemented media. Mouse Prickle1 and Prickle2 genes are expressed in postmitotic neurons and promote neurite outgrowth (Okuda H, Miyata S, Mori Y, Tohyama M. FEBS Lett. 2007 Oct 2;581(24):4754-60). Furthermore, MAG (Myelin-associated glycoprotein) is expressed at 13-fold lower level in the MSC of the invention when, cultured in PL-supplemented media. MAG is a cell membrane glycoprotein and may be involved in myelination during nerve regeneration. The lack of recovery after central nervous system injury is caused, in part, by myelin inhibitors including MAG. MAG acts as a neurite outgrowth inhibitor for most neurons tested but stimulates neurite outgrowth in immature dorsal root ganglion neurons (Vyas A A, Patel H V, Fromholt S E, Heffer-Lauc M, Vyas K A, Dang J, Schachner M, Schnaar R L. Gangliosides are functional nerve cell ligands for MAG, an inhibitor of nerve regeneration. Proc Natl Acad Sci USA, 2002;99(12):8412-7). These differentially regulated genes would favor the use of PL cultured MSC for regeneration of neuronal injury.
Additionally, the expression of RAR-responsive (TIG1) (retinoid acid (RA) receptor-responsive 1 gene, shows 12 fold higher expression in the MSC of the invention, cultured in PL-supplemented media) (Liang et al. The quantitative trait gene latexin influences the size of the hematopoietic stromal cell population in mice. Nature Genetics 2007;39(2):178-188), Keratin 18 (9 fold higher expression in the MSC of the invention, cultured in PL-supplemented media) (Bühler H, Schaller G. Transfection of keratin 18 gene in human breast cancer cells causes induction of adhesion proteins and dramatic regression of malignancy in vitro and in vivo. Mol Cancer Res. 2005;3(7):365-71), CRBP1 (cellular retinol binding protein 1, 5.7 fold higher expression in the MSC of the invention, shows cultured in PL-supplemented media) (Roberts D, Williams S J, Cvetkovic D, Weinstein J K, Godwin A K, Johnson S W, Hamilton T C. Decreased expression of retinol-binding proteins is associated with malignant transformation of the ovarian surface epithelium. (DNA Cell Biol. 2002;21(1):11-9.) and Prickle1 suggest a less tumorigenic phenotype of the MSC of the invention, cultured in PL-supplemented media.
Furthermore, we show evidence below that MSC grown in PL-supplemented medium are more protective against ischemia-reperfusion damage than MSC grown in FCS-supplemented medium.
Methods of Producing Mesenchymal Stromal Cells
The mesenchymal stromal cells (MSC) of the invention are cultured in media supplemented with platelet lysate (PL) as opposed to fetal calf serum (FCS). In one embodiment of the method of producing MSC of the invention, the starting material for the MSC is bone marrow isolated from healthy donors. Preferably, these donors are mammals. More preferably, these mammals are humans. In one embodiment of the method of producing MSC of the invention, the bone marrow is cultured in tissue culture flasks between 2 and 10 days prior to washing non-adherent cells from the flask. Optionally, the number of days of culture of bone marrow cells prior to washing non-adherent cells is 2 to 3 days. Preferably the bone marrow is cultured in platelet lysate (PL) containing media. For example, 300 μl of bone marrow is cultured in 15 ml of PL supplemented medium in T75 or other adequate tissue culture vessels.
After washing away the non-adherent cells, the adherent cells are also cultured in media that has been supplemented with platelet lysate (PL). Thrombocytes are a well characterized human product which a is widely used in clinics for patients in need of blood supplement. Thrombocytes are known to produce a wide variety of factors, e.g. PDGF-BB, TGF-β, IGF-1, and VEGF. In one embodiment of the method of producing MSC of the invention, an optimized preparation of PL is used. This optimized preparation of PL is made up of pooled platelet rich plasmas (PRPs) from at least 10 donors (to equalize for differences in cytokine concentrations) with a minimal concentration of 3×109 thrombocytes/ml.
According to preferred embodiments of the method of producing MSC of the invention, PL was prepared either from pooled thrombocyte concentrates designed for human use (produced as TK5F from the blood bank at the University Clinic UKE Hamburg-Eppendorf, pooled from 5 donors) or from 7-13 pooled buffy coats after centrifugation with 200×g for 20 min. Preferably, the PRP was aliquoted into small portions, frozen at −80° C., and thawed immediately before use to produce PL. PL-containing medium was prepared freshly for each cell feeding. In a preferred embodiment, medium contained αMEM as basic medium supplemented with 5 IU Heparin/ml medium and 5% of freshly thawed PL. The method of producing MSC of the invention uses a method to prepare PL that differs from others according to the thrombocyte concentration and centrifugation forces. The composition of this PL is described in greater detail, below.
In one embodiment of the method of producing MSC of the invention, the adherent cells are cultured in PL-supplemented media at 37° C. with approximately 5% CO2 under hypoxic conditions. Preferably, the hypoxic conditions are an atmosphere of 5% O2. In some situations hypoxic culture conditions allow MSC to grow more quickly. This allows for a reduction of days needed to grow the cells to 90-95% confluence. Generally, it reduces the growing time by three days. In another embodiment of the method of producing MSC of the invention, the adherent cells are cultured in PL-supplemented media at 37° C. with approximately 5% CO2 under normoxic conditions, i.e. wherein the O2 concentration is the same as atmospheric O2 approximately 20.9%. Preferably, the adherent cells are cultured between 9 and 12 day; being fed every 4 days with PL-supplemented media. In one embodiment of the method of producing MSC of the invention, the adherent cells are grown to between 70 and 90% confluence. Preferably, once this level of confluence is reached, the cells are enzymatically detached using trypsin.
In certain embodiments, the population of cells that is isolated from the plate is between 85-95% MSC. In other embodiments, the MSC are greater than 95% of the isolated cell population.
In another embodiment of the method of producing MSC of the invention, the cells are frozen after they are released from the tissue culture plate. Freezing is performed in a step-wise manner in a physiologically acceptable carrier, 5-10% human serum albumin and 10% DMSO. Thawing is also performed in a step-wise manner. Preferably, when thawed, the frozen MSC of the invention are diluted 4:1 to reduce the DMSO concentration especially when the MSC are to be administered intra-arterially. In this case, frozen MSC of the invention are thawed quickly at 37° C. and administered intravenously without any dilution or washings. Optionally the cells are administered following any protocol that is adequate for the transplantation of hematopoietic stromal cells (HSCs). Preferably, the serum albumin is human serum albumin.
In another embodiment of the method of producing MSC of the invention, the cells are frozen in aliquots of 106-108 cells in 50 mL of physiologically acceptable carrier and serum albumin (HSA). In another embodiment of the method of producing MSC of the invention, the cells arc frozen in aliquots of 106-108 cells per kg of subject body weight, in 50 mL of physiologically acceptable carrier and human serum albumin (HSA). In one aspect of these embodiments, when a therapeutic dose is being prepared, the appropriate number of cryovials is thawed in order to provide the appropriate number of cells for the therapeutic dose. Preferably, after DMSO is diluted from the thawed cells, the number of cryovials chosen is placed in a sterile infusion bag with 5% human serum albumin. Once in the bag, the MSC do not aggregate and viability remains greater than 95% for at least 6 hours even when the MSC are stored at room temperature. This provides ample time to administer the MSC of the invention to a patient in an operating room, Optionally, the physiologically acceptable carrier is PlasmaLyte A Preferably the albumin is present at a concentration of 5% w/v. Suspending 106−108 MSC of the invention in greater than 40 mL of physiological carrier is critical to their biological activity. If the cells are suspended in lower volumes, the cells are prone to aggregation. Administration of aggregated MSC to mammalian subjects has resulted in cardiac infarction. Thus, it is crucial that non-aggregated MSC be administered according to the methods of the invention. The presence of albumin is also critical because it prevents aggregation of the MSC and also prevents the cells from sticking to plastic containers the cells pass through when administered to subjects.
In another embodiment of the method of producing MSC of the invention, a closed system is used for generating and expanding the MSC of the invention from bone marrow of normal donors. This closed system is a device to functionally expand cells ex vivo. In one specific embodiment, the closed system includes: 1. a central expansion unit preferably constructed similarly to bioreactors with compressed (within a small unit), but extended growth surfaces; 2. media bags which can be sterilely connected to the expansion unit (e.g. by welding tubes between the unit and the bags) for cell feeding; and 3. electronic devices to operate automatically the medium exchange, gas supply and temperature.
The advantages of the closed system in comparison to conventional flask tissue culture are the construction of a functionally closed system, i.e. the cell input and media bags are sterile welded to the system. This minimizes the risk of contamination with external pathogens and therefore may be highly suitable for clinical applications. Furthermore, this system can be constructed in a compressed form with consistently smaller cell culture volumes but preserved growth area. The smaller volumes allow the cells to interact more directly with each other which creates a culture environment that is more comparable to the in vivo situation of the bone marrow niche. Also the closed system saves costs for the media and the whole expansion process.
The construction of the closed system may involve two sides: the cells are grown inside of multiple fibers with a small medium volume. In some embodiments, the culture media contains growth factors for growth stimulation, and medium without expensive supplements is passed outside the fibers. The fibers are designed to contain nanopores for a constant removal of potentially growth-inhibiting metabolites while important growth-promoting factors are retained in the growth compartment.
In certain embodiments of the method of producing MSC of the invention, the closed system is used in conjunction with a medium for expansion of MSC which does not contain any animal proteins, e.g. fetal calf serum (FCS). FCS has been connected with adverse effects after in vivo application of FCS-expanded cells, e.g. formation of anti-FCS antibodies, anaphylactic or arthus-like immune reactions or arrhythmias after cellular cardioplasty. FCS may introduce unwanted animal xenogeneic antigens, viral, prion and zoonose contaminations into cell preparations making new alternatives necessary.
Methods of Using Mesenchymal stromal cells
The MSC of the invention are used to treat or ameliorate conditions including, but not limited to, stroke, multi-organ failure (MOF), acute renal failure (ARF) of native kidneys, ARF of native kidneys in multi-organ failure, ARF in transplanted kidneys, kidney dysfunction, acute kidney injury (AKI), chronic kidney disease (CKD), AKI, ARF or CKD associated with heart surgery, organ dysfunction and wound repair refer to conditions known to one of skill in the art. Descriptions of these conditions may be found in medical texts, such as The Kidney, by Barry M. Brenner and Floyd C. Rector, Jr., W B Saunders Co., Philadelphia, last edition, 2001, which is incorporated herein in its entirety by reference.
Stroke or cerebral vascular accident (CVA) is a clinical term for a rapidly developing loss of brain function, due to lack of blood supply. The reason for this disturbed perfusion of the brain can be thrombosis, embolism or hemorrhage. Stroke is a medical emergency and the third leading cause of death in Western countries. It is predicted that stroke will be the leading cause of death by the middle of this century. These factors for stroke include advanced age, previous stroke or ischemic attack, high blood pressure, diabetes, mellitus high cholesterol, cigarette smoking and cardiac arrhythmia with atrial fibrillation. Therefore, a great need exists to provide a treatment for stroke patients.
ARF is defined as an acute deterioration in renal excretory function within hours or days. In severe ARF, the urine output is absent or very low. As a consequence of this abrupt loss in function, azotemia develops, defined as a rise of serum creatinine levels and blood urea nitrogen levels. Serum creatinine and blood urea nitrogen levels are measured. When these levels have increased to approximately 10 fold their normal concentration, this corresponds with the development of uremic manifestations due to the parallel accumulation of uremic toxins in the blood. The accumulation of uremic toxins causes bleeding from the intestines, neurological manifestations most seriously affecting the brain, leading, unless treated, to coma, seizures and death. A normal serum creatinine level is about 1.0 mg/dL, a normal blood urea nitrogen level is about 20 mg/dL. In addition, acid (hydrogen ions) and potassium levels rise rapidly and dangerously, resulting in cardiac arrhythmias and possible cardiac standstill (arrest) and death. If fluid intake continues in the absence of urine output, the patient becomes fluid overloaded, resulting in a congested circulation, pulmonary edema and low blood oxygenation, thereby also threatening the patient's life. One of skill in the art interprets these physical and laboratory abnormalities, and bases the needed therapy on these findings.
MOF is a condition in which kidneys, lungs, liver and heart functions are generally impaired simultaneously or successively, resulting in mortality rates as high as 100% despite the conventional therapies utilized to treat ARF. These patients frequently require intubation and respirator support because their lungs develop Adult Respiratory Distress Syndrome (ARDS), resulting in inadequate oxygen uptake and CO2 elimination. MOF patients also depend on hemodynamic support, vasopressor drugs, and occasionally, an intra-aortic balloon pump, to maintain adequate blood pressures since these patients are usually in shock and suffer from heart failure. There is no specific therapy for liver failure which results in bleeding and accumulation of toxins that impair mental functions. Patients may need blood transfusions and clotting factors to prevent or stop bleeding. MOF patients will be given stem cell therapy when the physician determines that therapy is needed based on assessment of the patient.
Delayed Graft Function (DGF) or transplant associated-acute renal failure (TA-ARF) is ARF that affects the transplanted kidney in the first few days after implantation. The more severe TA-ARF, the more likely it is that patients will suffer from the same complications as those who have ARF in their native kidneys, as above. The severity of TA-ARF is also a determinant of enhanced graft loss due to rejection(s) in the subsequent years. These are two strong indications for the prompt treatment of TA-ARF with the stem cells of the present invention.
Chronic renal failure (CRF) or Chronic Kidney Disease (CKD) is the progressive loss of nephrons and consequent loss of renal function, resulting in End Stage Renal Disease (ESRD), at which time patient survival depends on dialysis support or kidney transplantation. The need for stem cell therapy of the present invention will be determined on the basis of physical and laboratory abnormalities described above.
In some embodiments of methods of use of MSC of the invention, the MSC of the invention are administered to patients in need thereof when one of skill in the art determines that conventional therapy fails. Conventional therapy includes hemodialysis, antibiotics, blood pressure medication, blood transfusions, intravenous nutrition and in some cases, ventilation on a respirator in the ICU. Hemodialysis is used to remove uremic toxins, improve azotemia, correct high acid and potassium levels, and eliminate excess fluid. In other embodiments of methods of use of MSC of the invention, the MSC of the invention are administered as a first line therapy. The methods of use of MSC of the present invention is not limited to treatment once conventional therapy fails and may also be given immediately upon developing an injury or together with conventional therapy.
In certain embodiments, the MSC of the invention are administered to a subject once. This one dose is sufficient treatment in some embodiments. In other embodiments the MSC of the invention are administered 2, 3, 4, 5, 6, 7, 8, 9 or 10 times in order to attain a therapeutic effect.
Monitoring patients for a therapeutic effect of administered stem cells delivered and assessing further treatment will be accomplished by techniques known to one of skill in the art. For example, renal function will be monitored by determination of blood creatinine and blood urea nitrogen (BUN) levels, serum electrolytes, measurement of renal blood flow (ultrasonic method), creatinine and inulin clearances and urine output. A positive response to therapy for ARF includes return of excretory kidney function, normalization of urine output, blood chemistries and electrolytes, repair of the organ and survival. For MOF, positive responses also include improvement in blood pressure and improvement in functions of one or all organs.
In other embodiments the MSC of the invention are used to effectively repopulate dead or dysfunctional kidney cells in subjects that are suffering from chronic renal pathology including chronic renal failure because of the “plasticity” of the MSC populations. The term “plasticity” refers to the phenotypically broad differentiation potential of cells that originate from a defined stem cell population. MSC plasticity can include differentiation of stem cells derived from one organ into cell types of another organ. “Transdifferentiation” refers to the ability of a fully differentiated cell, derived from one germinal cell layer, to differentiate into a cell type that is derived from another germinal cell layer.
It was assumed, until recently, that stem cells gradually lose their pluripotency and thus their differentiation potential during organogensis. It was thought that the differentiation potential of somatic cells was restricted to cell types of the organ from which respective stem cells originate. This differentiation process was thought to be unidirectional and irreversible. However, recent studies have shown that somatic stem cells maintain some of their differentiation potential. For example, hematopoietic stromal cells may be able to transdifferentiate into muscle, neurons, liver, myocardial cells, and kidney. It is possible that as yet undefined signals that originate from injured and not from intact tissue act as transdifferentiation signals.
In certain embodiments, a therapeutically effective dose of MSC is delivered to the patient. An effective dose for treatment will be determined by the body weight of the patient receiving treatment, and may be further modified, for example, based on the severity or phase of the stroke, kidney or other organ dysfunction, for example the severity of ARF, the phase of ARF in which therapy is initiated, and the simultaneous presence or absence of MOF. In some embodiments of the methods of use of the MSC of the invention, from about 1×105 to about 1×101° MSC per kilogram of recipient body weight are administered in a therapeutic dose. Preferably from about 1×105 to about 1×108 MSC per kilogram of recipient body weight is administered in a therapeutic dose. More preferably from about 7×105 to about 5×101° MSC per kilogram of recipient body weight is administered in a therapeutic dose. More preferably from about 1×106 to about 1×108 MSC per kilogram of recipient body weight is administered in a therapeutic dose. More preferably from about 7×105 to about 5×106 MSC per kilogram of recipient body weight is administered in a therapeutic dose. More preferably from about 7×105 to about 7×106 MSC per kilogram of recipient body weight is administered in a therapeutic dose. More preferably about 2×106 MSC per kilogram of recipient body weight is administered in a therapeutic dose. The number of cells used will depend on the weight and condition of the recipient, the number of or frequency of administrations, and other variables known to those of skill in the art. For example, a therapeutic dose may be one or more administrations of the therapy.
In certain embodiments, MSC are administered to treat or decrease the likelihood of onset of AKI, ARF and/or CKD in a subject who receives heart surgery. This surgery includes coronary artery bypass surgery. In another preferred embodiment, the MSC are administered through intravenous injection. More preferably, the MSC are injected into the suprarenal aorta. In another preferred embodiment, the MSC are allogeneic.
The therapeutic dose of stem cells is administered in a suitable solution for injection. Solutions are those that are biologically and physiologically compatible with the cells and with the recipient, such as buffered saline solution, PlasmaLyte A or other suitable excipients, known to one of skill in the art.
In certain embodiments of the MSC of the invention are administered to a subject at a rate between approximately 0.5 and 1.5 mL of MSC in physiologically compatible solution per second. Preferably, the MSC of the invention are administered to a subject at a rate between approximately 0.83 and 10 mL per second. More preferably, the MSC are suspended in approximately 50 mL of physiologically compatible solution and is completely injected into a subject between approximately one and three minutes. More preferably the 50 mL of MSC in physiologically compatible solution is completely injected in approximately one minute.
In other embodiments, the MSC are used in trauma or surgical patients scheduled to undergo high risk surgery such as the repair of an aortic aneurysm. MSC of the invention can be administered to these patients for prophylactic therapy and preparation prior to major surgery. In the case of poor outcome, including infected and non-healing wounds, development of MOF post-surgery, the patient's own MSC, prepared according to the methods of the invention, that are cryopreserved may be thawed out and administered as detailed above. Patients with severe ARF affecting a transplanted kidney may either be treated with MSC, prepared according to the methods of the invention, from the donor of the transplanted kidney (allogeneic) or with cells from the recipient (autologous). Allogeneic or autologous MSC, prepared according to the methods of the invention, are an immediate treatment option in patients with TA-ARF and for the same reasons as described in patients with ARF of their native kidneys.
In certain embodiments, the MSC of the invention are administered to the patient by infusion intravenously (large central vein such vena cava) or intra-arterially (via femoral artery into supra-renal aorta). Preferably, the MSC of the invention are administered via the supra-renal aorta. In certain embodiments, the MSC of the invention are administered through a catheter that is inserted into the femoral artery at the groin. Preferably, the catheter has the same diameter as a 12-18 gauge needle. More preferably, the catheter has the same diameter as a 15 gauge needle. The diameter is relatively small to minimize damage to the skin and blood vessels of the subject during MSC administration. Preferably, the MSC of the invention are administered at a pressure that is approximately 50% greater than the pressure of the subject's aorta. More preferably, the MSC of the invention are administered at a pressure of between about 120 and 160 psi. The shear stress created by the pressure of administration does not cause injury to the MSC of the invention. Generally, at least 95% of the MSC of the invention survive injection into the subject. Moreover, the MSC are generally suspended in a physiologically acceptable carrier containing about 5% HSA. The HSA, along with the concentration of the cells prevents the MSC from sticking to the catheter or the syringe, which also insures a high (i.e. greater than 95%) rate of survival of the MSC when they are administered to a subject. The catheter is advanced into the supra-renal aorta to a point approximately 20 cm above the renal arteries. Preferably, blood is aspirated to verify the intravascular placement and to flush the catheter. More preferably, the position of the catheter is confirmed through a radiographic or sound based method. Preferably the method is transesophageal echocardiography (TEE). The MSC of the invention are then transferred to a syringe which is connected to the femoral catheter. The MSC, suspended in the physiologically compatible solution are then injected over approximately one to three minutes into the patient. Preferably, after injection of the MSC of the invention, the femoral catheter is flushed with normal saline. Optionally, the pulse of the subject found in the feet is monitored, before, during and after administration of the MSC of the invention. The pulse is monitored to ensure that the MSC do not clump during administration. Clumping of the MSC will lead to a decrease or loss of small pulses in the feet of the subject being administered MSC.
A MSC expansion medium containing platelet lysate (PL) was developed as an alternative to FCS. PL isolated from platelet rich plasma (PRP) were analyzed with either Human 27-plex (from BIO-RAD) or ELISA to show that inflammatory and anti-inflammatory cytokines as well as a variety of mitogenic factors are contained in PL, as shown below in Table 1. The human-plex method presented the concentration in [pg/ml] from undiluted PL while in the ELISA the PL was diluted to a thrombocyte concentration of 1×109/ml and used as 5% in medium (the values therefore have to be multiplied by at least 20).<: below the detection limit. Values with a black background are anti-inflammatory cytokines and cells with a gray background are inflammatory cytokines.
For effective expansion of MSC, an optimized preparation of PL is needed. The protocol includes pooling PRPs from at least 10 donors (to equalize for differences in cytokine concentrations) with a minimal concentration of 3×109 thrombocytes/ml.
PL was prepared either from pooled thrombocyte concentrates designed for human use (produced as TK5F from the blood bank at the University Clinic UKE Hamburg-Eppendorf, pooled from 5 donors) or from 7-13 pooled buffy coats after centrifugation at 200×g for 20 min. Platelet rich plasma (PRP) was aliquoted into small portions, frozen at—80° C., thus producing PL which is thawed immediately before use. PL-containing medium was prepared fresh for each cell feeding. Medium contained αMEM as basic medium supplemented with 5 IU Heparin/ml medium (source: Ratiopharm) and 5% of freshly thawed PL (Tab. 2).
Bone marrow was collected from non-mobilized healthy donors. White blood cells (WBC) concentrations and CFU-F from bone marrows isolated from different donors varied. This is summarized in Table 3, below.
Once the bone marrow was received, a sample was removed and sent for infectious agent testing. Testing includes human immunodeficiency virus, type 1 and 2 (HIV I/II), human T cell lymphotrophic virus, type I and II (HTLV I/II), hepatitis B virus (HBV), hepatitis C virus (HCV), Treponema pallidum (syphilis) and cytomegalovirus (CMV).
Reagents used are shown in Table 4, below.
300 μl of whole bone marrow was plated in 15 ml of αMEM media containing 5% PL in tissue culture flask with 75 cm2 of growth area or in larger vessels for 2-10 days to allow the mesenchymal stromal cells (MSC) to adhere. Residual non-adherent cells were washed from the flask. αMEM media containing 5% platelet-rich plasma was added to the flask. Cells were allowed to grow until 70%-100% confluency (approximately 3-4 days). Cells were then trypsinized and re-plated into a Nunc Cell Factory™. Cells remained in the Cell Factory™ for approximately 6-8 days days for expansion with media exchanges every 4 days.
Cells were harvested by first washing in phosphate buffered saline (PBS), treating with trypsin and washing with αMEM and then cryopreserved in 10% DMSO, 5% HSA in PlasmaLyte APlasmaLyte A A using controlled-rate freezing. When the cells were required for infusion, they were thawed, washed free of DMSO and resuspended to the desired concentration in PlasmaLyte APlasmaLyte A A containing 5% HSA.
The final cell product consisted of approximately 106-108 cells per kg of weight of the subject (depending on the dose schedule) suspended in 50 ml PlasmaLyte A with 5% HSA. No growth factors, antibodies, stimulants, or any other substances were added to the product at any time during manufacturing. The final concentration was adjusted to provide the required dose such that the volume of product that is returned to the patient remained constant.
The expansion of MSC from bone marrow (BM) has been shown to be more effective with PL- compared to FCS-supplemented media. The size, (
MSC were isolated by plating 5×105 mononuclear cells/well in 3 ml.
Also, MSC cultured in PL-supplemented media are less adipogenic in character when compared to MSC cultured in FCS-supplemented media.
MSC have been described to act immunomodulatory by impairing T-cell activation without inducing anergy. A dilution of this effect has been shown in vitro in mixed lymphocyte cultures (MLC) leading eventually to an activation of T-cells if decreasing amounts of MSC are added to the MLC reaction. This activation process is not observed when PL-generated MSC are used in the MLC as third party.
Additional data from differential gene expression analysis of PL-generated compared to FCS-generated MSC showed an upregulation of genes involved in the cell cycle (e.g. cyclins and cyclin dependent kinases) and the DNA replication and purine metabolism. On the other hand, genes functionally active in cell adhesion/extracellular matrix (ECM)-receptor interaction (
Furthermore, we show evidence that MSC grown in PL-supplemented medium are more protective against ischemia-reperfusion damage than MSC grown in FCS-supplemented medium. Human kidney proximal tubular cells (HK-2) were forced to start apoptotic events by incubation with antimycin A, 2-deoxyclucose and calcium ionophore A23187 (Lee H T, Emala C W 2002, J Am Soc Nephrol 13, 2753-2761; Xie J, Guo Q 2006, J Am Soc Nephrol 17, 3336-3346). This treatment chemically mimics an ischemic event. Reperfusion was simulated by refeeding the HK-2 cells with rescue media consisting of conditioned medium incubated for 24h on confluent layers of MSC grown with either alphaMEM+10% FCS or alphaMEM+5% PL.
The obtained results show that supernatants from MSC grown in PL-containing medium are more effective to reduce HK-2 cell death after chemically simulated ischemia/reperfusion than supernatants from MSC grown in FCS-supplemented medium (
A parallel FACS assay detecting annexin V which binds to apoptotic cells showed similar results. The proportion of viable cells (=annexin V negative) was highest in the HK-2 cells rescued with MSC-conditioned PL medium (85.7%, as compared to 78.0% in MSC-conditioned FCS medium,
Cryospreservation Protocol for Human Mesenchymal Stromal Cells (hMSC).
Mesenchymal stromal cells were cryopreserved in a DMSO solution, at a final concentration of 10%, for long-term storage in vapor phase liquid nitrogen (LN2, <−150° C.). The viability and functionality of hMSC in prolonged storage has been demonstrated and there is currently no recognized expiration of products that remain in continuous LN2 storage.
hMSC were derived from human bone marrow.
Reagents, Standards, Media, And Special Supplies Required:
Instrumentation:
A. Calculate the number of cyrovials needed to freeze the hMSC product
For example, 3.71×108 =24.7ml.
For example: 24 ml=6, 4 ml cyrovials
B. Calculate the total freeze volume
Total freeze volume consisted of 10% DMSO by volume, 20% albumin by volume, and the remaining volume PlasmaLyte A (70%).
For example: Total Freeze Volume=24 ml DMSO=2.4 ml Albumin=4.8 ml PlasmaLyte A=16.8 ml
C. Prepare freeze mix
a. e.g. 6ml of DMSO, 6 ml of PlasmaLyte A
D. Prepare Sample For Freezing
E. Freezing
a. For example, the volume of DMSO+the volume of already added PlasmaLyte A+the volume of albumin+cell pellet volume minus the total freeze volume equals amount of PlasmaLyte A needed.
F. Expected Ranges for MSC Thawed after Being Frozen According to Protocol:
a. CD 105 (≧90%)
b. CD 73 (≧90%)
c. CD 90 (≧90%)
d. CD 44 (≧90%)
e. CD 34 (<10%)
f. CD 45 (<10%)
g. HLA-DR (<10%)
Thawing Protocol for Human Mesenchymal Stromal Cells (hMSC).
Stored human Mesenchymal stromal cells (hMSC) are cryopreserved using DMSO as a cell cryoprotectant. When thawed, DMSO creates a hypertonic environment which leads to sudden fluid shifts and cell death. To limit this effect, the product was washed with a hypertonic solution ameliorating DMSO's unfavorable effects. Post-thaw product release testing was done to ensure processing was performed so as to prevent contamination or cross-contamination.
Reagents, Standards, Media, And Special Supplies Required:
Instrumentation
A. Wash Solution Preparation
a. Volume of product, multiplied times 4 in addition to 80 mls for cell resuspension and testing
b. Wash Solution=20% by volume stock albumin (25% Human, USP, 12. 5 g/50 ml), 80% PlasmaLyte A
B. Thawing and Washing
a. The wash solution was slowly added drop wise to the thawed product. The wash solution was gradually introduced to the cells while gently rinsing the product to allow the cells to adjust to normal osmotic conditions. Slow addition of wash solution with gentle agitation prevents cell membrane rupture from osmotic shock during thaw.
b. 1 ml of the wash solution was used to rinse the cryovial.
c. The rinse was added to the product conical tube.
a. For higher doses the volume was split in half, with one half of the volume thawed in one 250 ml conical tube and the other half in the other 250 ml conical tube.
a. For higher doses
15-30% of patients who undergo coronary bypass surgery develop acute kidney injury (AKI) as defined by the RIFLE criteria. The mortality for coronary bypass surgery associated AKI is between 5 and 20%.
16 patients needing on-pump cardiac surgery (CABG, valve) who are at risk for post-operation AKI were selected. Many of these patients had underlying kidney disease (chronic kidney disease (CKD) stages 1-4), were more than 65 years of age, had congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and/or hypertension (HT), and had a cardiopulmonary bypass (CPB) time of more than 2 hours. At the end of the surgery, between 1 and 24 hours after AKI, patients received between 7.0×105, 2.0×106 or 7.0×106 allogeneic mesenchymal stromal cells (MSC) administered into the suprarenal aorta. Follow ups were performed of the patients at 6 months and 3 years.
No adverse events or serious adverse events associated with the MSC were reported for any patientsMSC. Moreover, a preliminary analysis shows patients injected with MSC showed improvements in several clinical criteria when compared to historically matched case controlsMSC For example, as shown in
Further, all patients who received MSC showed better results in the RIFLE criteria used to measure AKI. As shown in
This application claims priority from U.S. Provisional Application No. 61/256,674, filed on Oct. 30, 2009, which is incorporated herein in its entirety.
| Filing Document | Filing Date | Country | Kind | 371c Date |
|---|---|---|---|---|
| PCT/US10/54852 | 10/29/2010 | WO | 00 | 7/11/2012 |
| Number | Date | Country | |
|---|---|---|---|
| 61256674 | Oct 2009 | US |
