Module 1 Objectives Regenerative Cell Therapy. Module 1. Why Use Regenerative Cell Therapy? What is Regenerative Medicine? Regenerative Therapy Goals

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1 Module 1 Principles of Regenerative Medicine Module 1 Objectives Regenerative Cell Therapy Learn why to use regenerative cells Learn what they are Learn the relevant mechanisms of action Learn why adipose is a rich source Learn the basics of collection and use 1 2 What is Regenerative Medicine? You are ALIVE because you continuously renew (rejuvenate) various tissues/organs. In every tissue in which this rejuvenation process occurs, a source exists which gives rise to these differentiated cells. The source is called a STEM CELL. - Arnold Caplan, PhD Lack of satisfactory therapy for degenerative disease Osteoarthritis Autoimmune diseases Poor healing Why Use Regenerative Cell Therapy? Non-union fractures Tendon/ligament injuries Wounds Case Western Reserve University Father of the Mesenchymal Stem Cell 3 4 Regenerative Therapy Goals Maximize Strength Range of Motion Performance Reduce Doesn t Matter Your Job Title! Scars Pain Future Disease 5 6

2 7 8 What are Stem Cells? Stem Cells are Primitive cells present in almost every tissue Able to become different types of tissue: Tendon Bone Ligament Self-renewing Trophic Factories Courtesy, NIH Stem Cell website Embryonic vs Adult Stem Cells Embryonic Stem Cells Source: inner cell mass of embryo Intended to form a whole animal - not for repair Gruen L and Grabel L, Concise Review: Scientific and Ethical Roadblocks to Human Embryonic Stem Cell Therapy. Stem Cell 2006;24; Embryonic vs Adult Stem Cells Embryonic Stem Cells Source: inner cell mass of embryo Intended to form a whole animal - not for repair Form Teratomas in-vivo UNPREDICTABLE Rejected due to foreign genotype Embryonic vs Adult Stem Cells Adult Stem Cells Source: most adult tissues contain them Ability to differentiate into many tissues (multi-potent) Do not form teratomas except in extreme in-vitro If autologous, no chance for rejection Gruen L and Grabel L, Concise Review: Scientific and Ethical Roadblocks to Human Embryonic Stem Cell Therapy. Stem Cell 2006;24;

3 DR. HELEN BLAU, Stanford University School of Medicine: Adult stem cells, until recently, were thought to be tissue-specific. That is the skin had its own stem cells, and the liver had its own stem cells, and muscle. And now stem cells have been considered something broader in the adult, and this was quite unexpected. July 14, Xenogeneic Donor Cell Sources Definition: Tissues from a different species Example: Pig heart valves, porcine hepatocytes Allogeneic Definition: Tissues from same species different individual Example: Bone marrow transplant, heart transplant Autologous Definition: Recipient supplies tissue for own transplant Example: Blood bank before surgery, skin transplant, tendon relocation Adult Stem Cell Sources Bone Marrow Adipose Muscle Skin Brain Nasal Nerve Many others Trophic support - growth factors and cytokines 2. Anti-inflammatory 3. Differentiation into tissue 4. Homing to injury site 5. Immune System Modulation 1. Trophic support growth factors and cytokines a. Anti-scarring b. Angiogenic (VEGF) c. Anti-apototic (block cell death after injury) d. Stimulation of resident tissue stem cells Caplan and Dennis, J Cell Biochem,

4 Ischemia Model Adipose Cell Therapy 7 Days post ischemia Saline Control DR. JAMES WILLERSON, University of Texas Health Science Center: The patients that were treated had better blood flow to their hearts and better local function of their heart where we'd injected the cells and better overall function of their heart. And they'd also improved symptomatically, so much so that at least two or three of the original 14 not only could do more, but they were now jogging on the beach. Adipose Stem Cell Treated Laser Doppler Blood Flow Miranville, Circulation, Factors Secreted by Mesenchymal Stem Cells* Interleukins IL-3, IL-6, IL-7, IL-8,IL-11, IL-12, IL-14, IL-15 Neurotrophic Factors NGF, BDNF, GDNF 2. Anti-inflammatory Decrease pro-inflammatory mediators Increase anti-inflammatory mediators Growth Factors and Cytokines LIF, VEGF, HGF, SDF, SCF, M-CSF, bfgf, IGFBP, Oncostatin M, MIP1-, TIMP-1, TIMP-2, TGF-1, TGF-2, PDGF, EGF, KGF * Rehman et al, Circulation 2004, 109: Nakagami et al, J Atheroscler Thromb 2006, Apr 13(2): Tholpady et al, Clin Plastic Surg, Differentiation into tissue Osteogenic Assay: Alkaline Phosphatase and Von Kossa Staining of Differentiated ASCs Cardiac Muscle Liver Control Wells Nerve Fat-derived Stem Cells Angiogensis/ Anti-apoptosis No bone formation Bone Cartilage Gene Therapy Fat Tholpady et al, Clin Plastic Surg, 2006 (Photo courtesy Cytori Therapeutics) 23 Test Wells Equine ADAS cells Vet-Stem data 24 Bone formation

5 Human Therapy 4. Homing to injury site Journal of Cranio-Maxillofacial Surgery (2004) 32, European Association for Cranio-Maxillofacial Surgery Damaged cartilage Autologous stem cells (adipose) and fibrin glue used to treat widespread traumatic calvarial defects: case report MSCs Photo Courtesy Cognate Therapeutics Human Therapy Osiris Therapeutics Announces Positive Results in Groundbreaking Stem Cell Trial to Treat Heart Disease-Intravenous Therapy Resulted in Statistically Significant Improvement Over Placebo in Multiple Safety and Efficacy Endpoints Baltimore, Mar 25, Immune System Modulation Texas Heart Institute at St. Luke s Episcopal Hospital Leads World s First Adult Stem Cell Study Using Patient s Own Fat Tissue Groh et al, Expt Hemat, Human Therapy Osiris Therapeutics Reports Positive Phase II Results Using PROCHYMAL(TM) for the Treatment of Acute Graft vs. Host Disease-Stem Cell Therapy Resulted in a 74% Complete Response Rate in a Life Threatening Disease That Currently Has No Approved Treatment BALTIMORE, Nov 09,

6 The Injury Response Cascade Stem Cells in Injury Response Inflammation Magnitude Regeneration Fibrosis Magnitude Inflammation Regeneration Acute Injury QUICK FIX Time Scar Complete Acute Injury Time Fibrosis Scar Absent 31 Courtesy, Arnold Caplan, Case Western Reserve 32 Courtesy, Arnold Caplan, Case Western Reserve REGENERATIVE MEDICINE REGENERATE TISSUES TROPHIC BIOACTIVE FACTORS TURNOVER/ IMMUNO- MAINTAINANCE SUPRESSIVE MICROENVIRONMENT/ Courtesy, Arnold Caplan, MILEAU 33 Case Western Reserve Roles / Functions Stem cells are injury-specific, perfectly choreographed pharmaceutical factories Dr. Arnold Caplan Case Western Reserve Influence by injury micro-environment 34 PubMed Literature Search Last year 219 Last 5 years 600 Total Hits 1,

7 Why Adipose? Why Adipose? High healing cell count No culturing required Family of healing cells Easy to access Renewable resource Rapid autologous source Autologous Adipose Characteristics FDA no regulation of autologous cells if minimally manipulated Safety low rejection risk Disease transmission very low Rapid Turnaround no wait for culturing What Cells Do We Use?* How do we characterize? Regenerative (progenitor-type) Cells 63.3% Adipose-derived Stem Cell Types 34.6% Endothelial Types (vascular progenitor) 12.2% Vascular Smooth Muscle + Pericyte 10.3% Hematopoetic Stem Cell Type 6.2% Other Tissue Cells 22.5% Leukocytes 14.2% TOTAL 100.0% RESEARCH Visual (cytospin, morphology) Flow Cytometry CD Markers Growth rate, morphology CFU-F Assays (adherence) Differentiation Assays Osteo, Chondro *Varma et al, Stem Cells and Development 2007: (freshly isolated human adipose) How do we characterize? COMMERCIAL RELEASE Cell counts (yield) Visual quality assessment Viability (trypan blue exclusion) Sample weight Sample temperature 41 42

8 Service Overview Adipose Tissue Harvest Inguinal Approach 43 Alternate Sites: Thoracic Approach, Falciform fat, or any other subcutaneous fat location 44 Adipose Tissue Harvest Thoracic Approach Vet-Stem Adipose Collection Kit Alternate Site: Falciform fat 1. Sterile Collection tubes 2. Cryo-block 3. Submission form 4. Owner Consent form Vet-Stem Laboratory San Diego Vet-Stem Adipose Processing Lab 47 48

9 Cell Count and Viability Assessment Complete Injections while holding needle in place Stem Cell Banking Excess cells can be banked Storage is in liquid nitrogen Cell viability +14 years* * Spurr et al, Cryobiology, 2002 (human stem cells) Summary of Principles of Regenerative Medicine Adipose derived cells are a mix of stem and multipotent progenitors Adult sources avoid many pitfalls of embryonic Adipose is a rich source of stem and regenerative cells that can be easily collected, concentrated and utilized Summary of Principles of Regenerative Medicine Regenerative cells function by Trophic actions Anti-inflammatory regulation Differentiation into needed tissues Homing to injury Immune modulation 53