Is Aging a Treatable Disease inthe 21st Century? Doris A. Taylor Director, Center for Cardiovascular Repair University Of Minnesota firstname.lastname@example.orgWhat is a stem cell? Differentiates – becomes different tissues Self renews – makes more of itself why do we care?
Aging and its diseases are a failure of stem cells Endogenous repair of our organs is the norm … Because we have stem cells in virtually every organ or in bone marrow. With chronic diseases or aging (maybe the same thing), stem cells: - Decrease in number - Decrease in function With injury our body ramps up (inflammatory) signals to recruit more cells… Heart disease/ Inflammation Diabetes etc. Cells and tissues But prevent the Our goal: (exogenous therapy to) Increase stem cell number down side … cancer Increase function Increase survival under stressDisease is a failure of the balance between injury and repair Inflammation Injury Repair (atherosclerosis, Protective Cells heart attack, high blood pressure) Tissue integrity Stem cells: self-renew and differentiate into multiple tissues self-
The major diseases of aging and possible cell therapies Heart Disease – cells to grow new muscle, new hearts Diabetes – islet transplant and new pancreati Stroke – cell therapy to repair brain damage Cancer – halting stem cell proliferation Memory Loss – new cells for vascular and neural circuit repair An Example of Treating Aging with Stem Cells: Heart Disease PREVENTION (hardening of the arteries) ◦ Preventing and reversing atherosclerosis by giving stem/progenitor cells ◦ Diagnosing/predicting disease by measuring cells in blood TREATMENT (heart attack, heart failure) ◦ Repairing the damage after a heart attack ◦ Finding new better cells – we found heart stem cells ◦ Finding new molecules that are better than cells CURE (heart failure, diabetes, kidney disease etc.) ◦ Building new organs – heart, kidney, lung, pancreas etc.
Atherosclerosis (hardening of the arteries)causes narrowing of blood vessels due to a build up of cholesterol and fat Foam Fatty Intermediate Fibrous Complicated Cells Streak Lesion Atheroma Plaque Lesion/Rupture Endothelial Dysfunction From First Decade From Third Decade From Fourth Decade Smooth Growth of the Lipid Core Thrombosis Muscle and (Clot) Collagen Butler R, et al. Eur Heart J 1998;19:1617-1627. Preventing heart disease In animals preventing or reversing the atherosclerosis (hardening of the arteries and plaque) that leads to heart attack and stroke – is possible by injecting stem cells from bone marrow into the blood stream intravenously.
Ruptured plaque causes heart attack Atherosclerosis or hardening of the arteries causes narrowing of blood vessels and inflammation. Ultimately a plaque can “rupture” or burst and as occurs with any wound, a blood clot forms. Unfortunately these clots are inside blood vessels and they clog the vessel leading to a heart attack. Can we PREVENT coronary artery disease with stem cell therapy? Intravenous young bone marrow “stem” cells Atherosclerosis 4 months (hardening of the arteries)ApoE -/- mice with hardening of the arteries
No Treatment Plaque Innominate Aortic Artery Root Cell Treated Rauscher FM, et al. Circulation. 2003;108:457-463. No treatment Stem cell treatedRauscher FM, et al. Circulation. 2003;108:457-463. BM stem cell infusion can prevent atherogenesis in young animals but can it reverse plaque deposition in older animals?
Can we reverse plaque formation in older animals? Positive stem cells go down with aging - disease happens By delivering BM cells, reversing disease in animals is possible; Female cells were more beneficial than male cells Delivering cells changed the type of SCs in bone marrow. Is it clinically relevant? Nelson, Zenovich, …Taylor Zenovich, Circ Res 2007 We measure stem cells in bone marrow and blood to diagnose heart and vascular disease and predict if treatments are working “Biorepository” Blood drawn for PC and cytokine Center for measurements Cardiovascular Repair Confidential and PrivilegedWhen a patient University of Minnesota Shipments Date Web Interfaceenters a clinical trial Entered into Sends an e-mail Arrival Logged to Coordinator in Web Interface Web Interface and Technician to expect shipped samples Samples are Prepared FACS Stem cells Results Entered into Web Interface Real time status and tracking Cytokines Report generation Blinded data analysis Inflammation Easy data sharing Regulatory compliance Reduced work load Functional Effect Measurements
“Positive” and “negative” PCs differ inblood of men and women. Disease progression Positive PC # Data from Lerman et al Mayo ClinicWe can predict disease progression and response to treatment From Idea to Clinical Test Ideas ◦ biomarkers for failing endogenous repair ◦ Predict risk for disease progression ◦ Predict ability to respond positively to treatment ◦ Provide mechanistic insight into therapies Translation ◦ From small animal studies to clinical trials ◦ (CAD/PVD and BM-MNCs; ICDs and failed repair) ◦ Complementary/alternative therapies (nutra- ceuticals, exercise, stress reduction, acupuncture…)
Developing Biorepositories Doris Taylor on behalf of the NHLBI Cardiovascular Cell Therapy Research Network NHLBI PO: S Skarlatos PhD NHLBI Chair: R Simari MD Mayo Network Chair Steering Committee PRC UTSPH DSMB Data Coordinating Center PI L Moye Skills Skills Development Development CCF Center UF Center Core THI Center VU Center Core UM Center PI S Ellis PI C Pepine PI J Willerson PI D Vaughan PI T Henry Cell processing Cell processing Cell processing Cell processing Cell processing Biorepository Biorepository Creating a Biorepository Blood drawn “Biorepository” for PC and cytokine Center for Cardiovascular Repair measurements University of Minnesota Confidential and PrivilegedWhen a patient enters Web Interface Shipments Datea clinical trial Entered into Sends an e-mail Arrival Logged to Coordinator in Web Interface Web Interface and Technician to expect shipped samples Samples are Prepared FACS Stem cells Results Entered into Web Interface Real time status and tracking Cytokines Report generation Blinded data analysis Inflammation Easy data sharing Regulatory compliance Reduced work load Functional Effect Measurements
HypothesisBone marrow composition (progenitor cellnumber/function) changes temporally afteracute myocardial infarction.Thus, the active agent in bone marrow cell therapytrials may differ depending on the time of BM harvest.These changes likely differ by sex and with age Progenitor cell profiling
Patient Sex and Age distribution # Age (years) TIME females 2 (6.7%) 49-52 TIME males 28 (92.3) 38-81 Late-TIME females 3 (15.8%) 58-83 Late-TIME males 16 (84.2) 31-74 FOCUS females 1 (4%) 84 FOCUS males 24 (96) 46-81 Probably don’t have enough females or age variation to test hypothesisMonocyte Chemoattractant Protein - 1 CD45+, CD19+ 12 10 %of lymphocytes 8 Males 6 Females 4 2 0
Progenitor Cell Profiles in Bone Marrow changewith time after AMI CD45+31low CD45+31bright Progenitor Cell Profiles in Bone Marrow at increasing Times after AMI CD19+CXCR4
Age and sex-related differences in:- disease onset/progression- stem cell number- capacity for endogenous repair- response to diseaseBuild new test bedsBegin to examine differencesTest a Hypothesis:Stem Cells Fail Earlier in MenThis begins to explain the sex differences in onset and progression of CVD
Sex comparison of age‐ and disease matched cells in human peripheral bloodResponse to disease differsSex differences in “stem” cells in human PBUMN/Mayo project (Lerman Taylor)
Implications for clinical trials? Most clinical cell therapy studies have occurred in males Emerging negative cell therapy data could be related to donor and or recipient sex Autologous cells may not be ideal Evaluating the “active agent” is criticalCurrent studies at UMN-CCVRMild, moderate and severe endothelial dysfunction (Lerman - Mayo) Gene therapy for PVD (Henry) Cell therapy for AMI and chronic LV dysfunction (Traverse, Henry) ICD implantation (Ouyang/Tomaselli - Hopkins) CAV, PH (Colvin-Adams) Hypertension undergoing Meditation vs. Lifestyle education (Dusek) or Acupuncture (Bairey-Merz Cedars Sinai)
A putative predictive population of progenitor cells based on disease state or time after AMIControl End dys PVD AMI AMI AMI Chronic CAV Treated 3-5d 7-9d 14-21d LV PVD dysfxn Status of cell profiling Beginning to define sex differences in response to vascular injury and repair Defining composition of active agent in human clinical trials Beginning to predict responders and non- responders – testing our model Need better cell options for clinical repair of failing heart…
Treating heart disease What is a heart attack? The plaque in a blood vessel “ruptures” or bursts and causes loss of oxygen to the cells downstream. Those cells die and the heart cant replace them – a scar forms…and often heart failure happens Can we treat it? Can we replace the underlying loss of blood vessels and muscle cells that occur after a heart attack by transplanting your own (autologous) stem cells from muscle, bone marrow, blood, fat, or even heart Acute Myocardial Infarction University of Minnesota The Problem: 500,000 new cases of AMI /yr Approximately 200/yr at FUMC 10% develop Shock 10%(additional) have an EF < 30% i.e.HF Total eligible for cell therapy = 30-40/Yr Southdale as a partner = 70-80/yrHeart disease now surpasses the other 5 leading causes of illness combined worldwide
TREATING heart attack and heart failure The Past: Approximately 80% of people die within 5 years Today: Better devices, better medicines; ~50% die within 5 years The Future: Cell and gene therapy to treat the underlying loss of cells The Future at CCVR: Better cells, better delivery options, new organs Treating heart disease with cells: Our role... FIRST transplantation of cells into heart to try to improve pumping capacity after a heart attack – Taylor et al., Nature Medicine 1998 If no benefit – STOP If so, figure out why and how Optimize it Try with different cells 2001 - Menasche The Lancet 2001 1998 - Taylor et al Nature Med 1998
How do we treatdamaged heart with yourown stemcells? Take a muscle or bone marrow biopsy Grow the cells Deliver cells to injured myocardium & measure the effect. Send cells to Clinical trials are cardiologist or surgeon underway Exposure of the Intramyocardial Infarcted Area Injections of Cells (inferior aspect of the heart) Menasche et al The Lancet 2001
Initial Human Experiences withIntramyocardial Transplantation of AutologousMyoblasts LVEF(%) Cells into revascularized region . Journal of the American College of Cardiology. Volume 41, Issue 7. April 2003, Pages 1078-1083. Dr. Felipe Prosper, University of Navarra. Originally Cells into non- non- presented at 2004 TCT. revascularized regionEF and symptoms improve in HF patients aftercatheter-based transplantation of autologous myoblasts Average 6.7 years after EF (%) AMI 3.0 2.7 2.5Journal of the American College of Cardiology, ClassVol. 42, No. 12, 2003, Smits, Serruys et al. Patient 2.2Study. 2.0 2.0 1.9 Sole therapy 1.5 1.7 Baseline 1-Mo 3-Mo 6-Mo 12-Mo
Myoblasts engrafted throughout scar New muscle cells and blood vessels can grow informerly scarred myocardium (Atkins et al Ann Thoracic Surg. 2000) new blood new muscle vessel scar Rabbit cryoinfarction Cells injected 2 weeks post injury Function 1 mo post cells
Serial Sections of Myoblasts in HumanHeartConfocal images of myosin staining incell transplanted heart Hagege et al The Lancet 361: 2003
1 mo post injury 2 months post cells % Chg in LVSD % Change in LVDDTreated (n=4) -13.2 ± 33.8% -10.1 ± 32.2%Control (n=4) +47.2 ± 33.0% +36.9 ± 14.3% p Value <0.05 <0.05 Other stem cell types used for heart repair early after heart attack Bone marrow Blood Umbilical Cord Blood Fat …
Acute MI: University of Frankfurt 20 pts 3-6 days post MI TOPCARE-AMI 9 pts: Bone marrow 11 pts: 250 cc peripheral aspiration blood drawn Mononuclear cells Ex vivo EPC expansion isolated in cell culture (3 days) Intracoronary Infusion Assmus et al, Circulation 2002;106:3009-17Summary of clinical bone marrow cell therapy data Baseline EF Follow up EF # Dose Contr Cell Contr Cell Pts (x10E6) ol Tx ol TxMEAN 692 47.6 47.4 49.9 53.4 595SEM 422 1.6 1.7 2.0 2.2
Summary of BM MNC Clinical Data BM MNCs can: Be delivered early in disease process Be delivered via the circulation Engraft in scar Improve perfusion and wall motion Possibly secrete GF that impact surrounding scar, remainder of myocardium Generate period of angiogenesis; effect seems to persist for 6-12 months but may not persist... Cells are ill-defined, vary widely from study to study, may home to wrong sites Treating AMI with cell therapy Clinical Stages Coronary AMI Post-AMI HF Post- End-Stage HF End- Atherosclerosis Refractory Angina ISCHEMIC H E A R T DISEASE Cell type BMNCs BMNCs BMNCs BMNCs administered MSCs SKMBs SKMBs EPCs MSCs CPCs Across CHD Continuummoderately + trials 2 8 7 7 24 - trials 0 2 0 1 3 mixed 0 3 0 2 5
Are the current cells good enough? Arm and leg muscle cells and bone marrow cells aren’t exactly like heart cells. A 5-7% improvement in pumping isn’t a home run Can we find some other stem cells that are more like heart and blood vessel cells? Where should we look? Treating heart disease with cells: Our continued role... day 11 DISCOVERY of new stem cells from adult heart – Taylor group, 2007 day 1
Cells… Adult stem or progenitor cells exist in almost every organ or tissue including heart Smooth muscle cells Endothelial cells Adult rat heart derived SSEA-1+ cells can be proliferated to large numbers and give rise to defined cardiac precursors c-kit sca-1From Ott et al, 2007 Nature Clinical Practice Cardiovascular Medicine
These adult stem cells isolated from heart can also make the components of blood vessels Smooth muscle cells So we have all the components we need to Endothelial cells make new blood vessels and new beating heart cellsUndifferentatied SSEA‐1+ cells can differentiate into beating cardiocyte‐like cells and vascular cells and improve cardiac performance S c a r V o lu m e (% LV ) 0 .2 8 0 .2 6 0 .2 4 scar volume 0 .2 2 0 .2 0 0 .1 8 0 .1 6 0 .1 4 0 .1 2 c o n tro l c ell tre a te d d p /d t m a x 8000 7000 In Vivo 6000 dp/dt max 5000 4000 GFP VWF 3000 2000 1000 c o n tro l c e ll tre a te d E F % S im p s o n 70 60 50 EF% 40 30 20 b a s e lin e 1 w eek 3 w eeks 5 w eeks c o n tro l c e ll tre a te d
Why not Embryonic SCs?ESCs can form spontaneouslybeating cardiocytes;Are easy to grow in a dish In undifferentiated state cannot easily be controlled (form tumors called teratomas); Require an allogeneic (non-self derived) source of cells May be rejected if differentiated and are tumorigenic if undifferentiated. We are developing new methods to deliver cells in high risk patients FIRST Robot Cell Delivery Ott HC… Taylor DA. Journal of Thoracic and HC… Cardiovascular Surgery, 2006
Treating Heart Failure 22 Million people living with heart failure >250,000 deaths/year Number One (hospital) Diagnosis Number One Cause of Readmission Cell therapy may not be enough…for end-stage HF What are the options?Acknowledgements Current Lab Members Marj Carlson Jessica Dries Stefan Kren Linell Grzesik Greg Kolb Brent Bjorkland Dusty Moore Mike Jacobs Abhijna Vedula Teague O’Meara Jacob Radkey Victor Piazza Nicole Plourde Katrina Rhett Claudia Zierold
Thank you• NIH NHLBI- CCTRN• AHA Jon Holden DeHaan Cardiac Myogenesis Research Award Excel Bank Foundation Medtronic Foundation Minnesota Medical Foundation UMN Office of Technology Commercialization