Stem cell therapy: facts and myths Giuseppe Remuzzi Lyon, September 12, 2008

1. Stem cell therapy: facts and myths Giuseppe Remuzzi Lyon, September 12, 2008

3. CASE REPORT - 1 A 46-year-old man had an acute anterior myocardial infarction He had a revascularization procedure, but more than 12 h post the beginning of symptoms The occluded vessel was reopened, but the myocardial tissue was irremediably damaged

4. CASE REPORT - 2 Because of irreversible myocardial damage he will have a diminished quality of life He is a modern individual, who is well informed about novel alternative options

5. What options?

7. Adult stem cells couldn’t do much more than regenerate cell types of origin

9. Embryonic stem cells have the ability to self-renew and to differentiate into all three embryonic germ layers

10. ADULT STEM CELLS FOR CARDIAC REPAIR Heart Cardiac stem cells Remodelling Angiogenesis Endogenous stem cells activation Differentiation into other cell types Paracrine effects Fat Mesenchymal stem cells Bone marrow Endothelial progenitor cells Blood

12. Bone marrow mononuclear cells Circulating progenitor cells Skeletal myoblasts Mesenchymal stem cells TEIM: TransEndocardial IntraMyocardial injection

13. Challenges

14. Issues such as purity of cells, number and whether they have to be differentiated into cardiomyocytes before transplantation have never been addressed

15. Is this procedure safe in the long term? To which extent these cells are retained into myocardial tissue? Is spatial distribution important?

16. Many scientists say that they are reluctant to undertake further clinical trials until they hear more definitive answers about the risks and benefits of adult stem cell therapies

17. The NEW ENGLAND JOURNAL of MEDICINE, SEPTEMBER 21, 2006 EDITORIAL Cardiac Cell Therapy - Mixed Results from Mixed Cells Anthony Rosenzwieg, M.D. Corriere della Sera, GIOVEDI’, 4 APRILE 2002

18. In a mouse model of myocardial infarction, infused bone marrow stem cells differentiated only into blood cells, not cardiac myocytes, and they failed to contribute to myocardial regeneration The results of all studies do not promote the use of intracoronary infusions of autologous bone marrow to improve ventricular function Schwartz, N Engl J Med, 2006

19. ACUTE KIDNEY INJURY - Cysplatin Mesenchymal stem cell injection 100 * * 80 Saline 60 BUN(mg/dl) 40 20 MSC 0 0 1 4 5 7 11 29 days Imberti et al., J Am Soc Nephrol, 2007

20. 4d 1000X MESENCHYMAL STEM CELL ENGRAFT THE KIDNEY AND DIFFERENTIATE TO TUBULAR EPITHELIAL CELLS AT LOW EXTENT Cisplatin female mouse + male MSC

21. MESENCHYMAL STEM CELLS ACCELERATE TUBULAR CELL REGENERATION AFTER CISPLATIN Cisplatin + saline Cisplatin + MSC 35 30 25 * * 20 Ki 67 positive nuclei / HPF 15 10 5 0 4 11 4 11 29 days 29 Ki 67: nuclear proliferation marker Imberti et al., J Am Soc Nephrol, 2007

22. 160 120 BUN (mg/dl) 80 40 0 cispl+ saline cispl+ si-irrel MSC cispl+ si-IGF-1 MSC INSULIN-LIKE GROWTH FACTOR-1 SUSTAINS STEM CELL-MEDIATED RENAL REPAIR Imberti et al., J Am Soc Nephrol, 2007

23. EFFECT OF HUMAN STEM CELL TREATMENT ON CISPLATIN-INDUCED ACUTE KIDNEY INJURY IN NOD/SCID MICE Stem cell types Renal function Renal histology Survival at 7 days Bone marrow Cord blood Amniotic fluid Protected Protected Preserved Preserved 50 % 86 % Currently testing None of the untreated mice survived cisplatinum at 7 days Morigi et al., Stem Cells, 2008

24. THE HUMAN PILOT STUDY This is a pilot, explorative study to test the feasibility and safety of systemic infusion of donor ex-vivo expanded MSCs to repair the kidney and improve function in patients with solid organ cancers who develop acute renal failure after chemotherapy with cisplatin Primary aim To evaluate the rate of renal function loss up to 15 days post-MSC infusion, as assessed by serial measurements of serum creatinine concentration (primary outcome variable) and of glomerular filtration rate (GFR) estimated by prediction equation Patients Start with 3 patients: (5 x 106 MSC, 10 x 106 MSC, 15 x 106 MSC) If safe and successful: upgrade the number to 8 patients

25. Frozen-thawed donated human embryos produced by in vitro fertilization were cultured to the blastocyst stage Inner cell masses were isolated by immunosurgery and plated on irradiated mouse embryonic fibroblast feeder After 9 to 15 days, inner cell mass-derived outgrowth was dissociated to obtain embryonic stem cell clumps that were replated on fibroblast feeder

26. Circulatory system Immune system Nervous system

27. A lot of people think that scientists do not respect ethical and human values and consider science as something in conflict with faith

29. NATURE, 11 september 2003 Science and the ethics of science are two sides of the same coin Scientists must take the lead in ensuring the the progress of science is both ethical and as free from political intervention as possible, if for no other reason than that only they can do so

30. The NEW ENGLAND JOURNAL of MEDICINE

31. In his veto message, the President explained that “stem cells… can be drawn from children, adults, and the blood in umbilical cords with no harm to the donor, and these stem cells are currently being used in medical treatments

32. According to the New York Times, Karl Rowe, head of the White House’s Office of Political Affairs, has declared that embryonic stem cells aren’t required because there is “far more promise from adult stem cells”

34. It seems that the White House received this idea from David Prentice, a senior fellow for life sciences at the Family Research Council and an advisor to Republican members of Congress In a report of the President’s Council on Bioethics, Prentice claimed that adult stem cells can effectively treat more that 65 diseases

35. Not only this assertion is patently false, but the information purveyed on the Family Research Council’s Web site is pure hokum Schwartz, N Engl J Med, 2006

36. “DE HUMANI CORPORIS FABRICA” Andrea Vesalius, 1543 When Andrea Vesalius first published his radical De Humani Corporis Fabrica, the ancient texts of Aristotle and Galen were still judged authoritative in the medical school of Europe By performing his own dissections, Vesalius discovered errors in the ancient author’s teachings The De Humani Corporis Fabrica, which drew attention to these flaws, initially threatened the academic medical establishment but ultimately won Vesalius admiration and a post as court physician to Charles V

37. STEM CELLS, MIRACLE OR CURE? Disease FDA approved Effects/limitations Parkinson’s disease Spinal cord injury Amyotrophic lateral sclerosis Multiple sclerosis Rheumatoid arthritis Corneal regeneration Osteogenesis imperfecta Thalassemia major NO NO NO NO NO NO NO YES No benefit No rigorous study Safe Feasible No or low effects chemotherapy side effects Modest effect Concern of durability of the effects Partial improvement of vision Feasible Lack of long term data Improvement of symtpoms Efficacious (n = 2 patients) ANTONIO MISSIERI Smith et al., Science, 2006

38. To support the inclusion of Parkinson’s disease on his list, Prentice cites congressional testimony by a patient and a physician, a meeting abstract by the same physician, and two publications that have nothing to do with stem cell therapy for Parkinson’s disease In fact, there is currently no FDA-approved adult stem cell treatments - and non cure of any kind - for Parkinson’s disease

39. For spinal cord injury, Prentice cites personal opinions expressed in Congressional testimony by one physician and two patients There is currently no FDA-approved adult stem cell treatment or cure for spinal cord injury

40. By promoting the falsehood that adult stem cell treatments are already in general use for 65 diseases and injuries those who repeat his claims mislead laypeople and cruelly deceive patients Smith et al., Science, 2006

42. Washingtonpost.com 04 September 2008 Injections of hope Doctors Promote Offshore Stem Cell Shots, but Some Patients Cry Foul Brain-damaged three-year-old patient was treated in a clinic of Bahamas with fetal stem cells for 25,000$ When he returned home the child began have seizures and was still unable to walk and talk Desperate patients, spending high amount of money, risk their life with offshore stem cell injections provided by doctors promising false hopes

43. Credit: iStockphoto

44. The use of human embryonic stem cells in cell replacement therapies has been limited due to several technical and ethical issues There has been an extensive debate about the benefits and drawbacks of adult vs embryonic stem cell use in therapies

45. MAJOR CONCERNS - 1 The way they are - derived - characterized - established - maintained In vitro differentiation

46. MAJOR CONCERNS - 2 Epigenetic profiles Chromosomal aberrations Risk of tumors Genetic instability

47. DISEASE MODELS WHERE HUMAN EMBRYONIC STEM CELLS HAVE BEEN SHOWN TO BE EFFECTIVE (mainly SCID mice) Cell type developed Animal model Reference Oligodendrocyte progenitors Cardiomyocytes Hepatocytes Chondrocytes Endothelial cells Neural precursors Pancreatic cells Neuroepithelial precursors and dopaminergic neurons Human embryonic stem cells Spinal cord injury Myocardial infarction Toxic-liver injury Spinal fusion Surgical induction of hind limb ischemia Quinolinic acid-induced Huntington Streptozotocin diabetes Parkinson Open neural tube defect Keirstead et al., 2005 Nakamura et al., 2005 Laflamme et al., 2007 Leor et al., 1996 Kehat et al., 2004 Caspi et al, 2007 Seo et al., 2005 Muschler et al., 2003 Cho eet al., 2007 Song et al., 2007 Shim et al., 2007 Sontag et al., 2007 Ben-Hur et al., 2004 Lee et al., 2006

48. Immune-rejection

49. Generation of patient specific human nuclear transfer embryonic stem cells lines may circumvent the problem of immuno-rejection, the greatest challenge in cell replacement therapy