Regenerative Medicine: From Autologous Platelet Derived Growth Factors (PRP) to Stem Cells

This conference is an opportunity for practitioners to present experiences they are having daily in their practices using cell medicine. The International Cell Medicine Society has organized all of these doctors, researchers and other interested scientists.

Henry Young, PhD

Adult Stem Cell Overview

Stem cells progress from totipotent stem cells, pluripotent stem cells and germ layer lineage stem cells to progenitor stem cells. Stem cells are found in every tissue in the body except one. These cells are isolated, frozen and sorted.

Christopher Centeno, MD

Overview of the ICMS Lab, Clinical Guidelines and Re-Implant Registry (www.cellmedicinesociety.org)

The International Cell Medicine Society (ICMS) has developed safety guidelines for clinics and laboratories. The goal is to develop basics for safe stem cells now. The strategy includes limiting the types of cells and limiting changes to cells. Stem cell types include induced pluripotent stem cells, embryonic stem cells, cord stem cells, allogeneic stem cells and your own- autologous stem cells. All cells except autologous are too risky at this point. Autologous are important candidates for early use and safest with the least number of side effects. However, with stem cells you can do long term culture, insert genes, expose the stem cells to exotic growth factors, mimic the physiologics of the body and short term culture. The only safe approach is to mimic the body and do short term culture.

Lab guidelines have been developed by ICMS. The closest analog for physicians would be fertility labs, credentialed through the College of American Pathologists (CAP) and use a 3-5 day blastocyte procedure. Accreditation for stem cell labs would be Reglera and the therapies would follow procedures similar to Good Tissue Practices on autologous stem cells with minimal expansions. Drug production, which is under the authority of the FDA, is dealing with mass production that could affect thousands of people. Autologous stem cells deal with only one person from whom the stem cells came from making this a medical procedure. The state medical boards monitor all medical procedures when there is a one on one patient risk and would monitor autologous stem cell therapies.

Lab guidelines for stem cells address contamination, cross contamination protection and culturing stem cell issues. Culturing is not always necessary, as in bone marrow aspirates, but sometimes is needed to get therapeutic effect. Most animal researchers have used culture expansion. It is believed that the critical dose will require expansion. In expansion, the biological potency of cells decreases with time and the likelihood if adverse changes to the cell increase. For this reason, minimal expansion is preferred. The growth medium is important and can use autologous serum can be used. This process includes manipulation, centrifugation and using human reagents, only exposing the autologous stem cells to physiological mediums.

Practice guidelines are carefully thought out by ICMS and thoroughly covered in the clinical guideline procedures . The third facet of the ICMS plan is the patient registry. In this way, early patient work can be closely monitored. The hope of the ICMS approach is to treat more patients, move from research to treating patients without restrictions. All of these steps are put in place for stem cell lines.

Business plans keep companies from sharing. Amgen, Osiris, Geron don't share, keeping their research secret until patents are filed. This reduces what is available to patients. The Patient Registry takes down the walls by encouraging physicians to share their results, thus getting clinical solutions for physicians.

A cardiologist can go to the technology provider through the ICMS to learn what is necessary for a successful treatment. ICMS will have live physician mentoring, training and certification, lab staff training and certification, live lab staff mentoring live collection mentoring and collection training and certification. ICMS wants to allow physicians to use autologous stem cells therapies in a safe manner and to move the science forward.

Alan Harris, MD, PhD

Autologous Banking and Cellular Therapies

Dr. Harris is from Neostem, Inc. in New York. His presentation dealt with very-small embryonic-like stem cells (VSELS) with myocardial infarction, stroke, in aging and cosmetic uses. Neostem, Inc. uses apheresis to harvesting autologous stem cells and banks them. The targeted applications are for wound care, rejuvenation, musculoskeletal and orthopedic applications. They have a patented exclusive on autologous VSELs which have no risk of rejection. Sixteen stem cells have been identified and by 2017 will be used in 1.9 million procedures annually for autoimmune, diabetes, cardiovascular and orthopedic procedures. To date 2600 adult clinical trials have been done. It is forecasted that by 2012 autologous adult stem cells will be a $20 billion dollar business.

Stem cells are the cornerstone of regenerative medicine. Stem cells are unique as they can differentiate into daughter cells and self replicate as well. They make ectodermal, mesodermal and endodermal cells beginning as a zygote, develop to a blastocyst, then a gastrula and finally organ tissue. Each person has primitive embryonic stem cells called VSELs and can be taken from bone, cord blood and blood and be stored for therapeutic use. The broad potential use is for heart attack, dermatologic applications, autoimmune diseases and macular degeneration etc. Very-small embryonic-like stem cells (VSELs) have been identified in adult bone marrow. They are deposited early on in the bone marrow and are candidates for pluripotent stem cells. There are 17 publications regarding VSELs. Signals are given by the body that includes the activation of epigenetic modifiers which regulate these stem cells. They leave the bone marrow and circulate in the blood to the heart, liver, muscle and brain and then back to the bone marrow.

Research shows VSELs are at the highest point in the blood at 24 hours after a myocardial infarct and then still high five days later. The damage signal goes to bone marrow and the stem cells differentiate into cardiac muscle cells in the blood as early as 12 hours and then lodge in the heart. Stroke has had similar findings: stroke triggers the mobilization of the VSELs.

Research shows VSELs will regenerate macular cells in the eyes, rejuvenate tissues, play important roles in tissue and organ regeneration with pathologies. Epigenetic mechanisms control the pluripotency and quiescence of adult bone marrow derived stem cells.

Michael West, PhD

Opportunities in the Treatment of Age-Related Degenerative Disease

There are two lines of cells, germ cell lines and somatic cell lines. Germ cell lines are immortal as they have telomerase which allows the cell to live forever. We are made up of some cells which are the result of all the previous generations of humans on Earth. At a certain point the germ cell line becomes somatic cells where there is no telomerase so over time the telomeres at the end of the DNA chain become shorter and shorter as the cell replicates and ultimately ends up in cell death. The reason for this process of becoming somatic is to control against cancer, but the cost creates aging. West believes that in the future we can reverse the aging clock by the use of telomerase technology. The safety and efficacy of this heterochronic cell implantation has not been determined.

Christopher Centeno, MD

Clinical Experience with Adult Mesenchymal Stem Cells in Orthopedics

Centeno reported on clinical experiences with autologous adult stem cells, mesenchymal stem cells (MSCs) from the bone marrow, in orthopedic applications. There are 9682 published papers on MSCs. They manage the repair response. If using allogeneic cells the genes of the donor cells remain active in the host, there can be rejection issues and genetic disease can be transmitted creating some risk. In delivery there is a pulmonary first pass effect where the MSCs get trapped in the lungs. About 10 in one million ended up in the brain so it is a very large block of larger stem cell types. However, very small embryonic-like stem cells (VSELs) may avoid the obstacle of the lung.

MSCs are rare, accounting for only 1 in 10,000 in the bone marrow. Using Bone Marrow Aspirate Concentrate (BMAC) from the bone marrow is not a good option for orthopedic applications because the density of MSCs is not adequate. Orthopedic therapies need 5-50 million cells and 60 ml of bone marrow only gives 90,0000 cells. As a result, it is necessary to expand the stem cells harvested. There is a huge difference in how individual's stem cells will expand in culture. They have found that there are common characteristics of individuals whose stem cells don't expand well; premenopausal women and individuals on prescription drugs including statin drugs and ace inhibitors.

Centeno has had four years of clinical experience harvesting autologous adult stem cells from synovial fluid and MSCs from bone marrow. Allopathic treatment to date concentrates on the quick fix application through surgery. However, to accomplish long lasting healing it is important to first determine what caused the issue with the joint, looking at stability, neurology, alignment, articulation and the use of 3.0 Tesla MRI. Addressing this and using autologous stem cells can be a long lasting answer.

Yael Porat, PhD

Developing new adult stem/progenitor cell lines

Stem cells exhibit plasticity: the ability of cells from one lineage to give rise to cells in another lineage. This is true for cells from almost any tissue in the body. Cells from one organ, injected into another, can give rise to new tissue in the second organ. Researchers can take adult stem cells and re-inject them into an early blastocyst. The cells will differentiate into the new cell line. Human hair follicle stem cells have differentiated into neural and muscle cell lines. Dr. Porat works with stem cells from blood. From this you are getting a mixture of cells and she has found interactions of these cells contribute to good final results. She believes in having scientific data and patient follow up. In addition, she believes that clear regulation and ethics codes are critical. This will result in trust and reliability for physicians and patients. ISSCR, ICMS. Rejuvenare and others are addressing this already. Good regulations include Good Manufacturing Practice and Good Tissue Practice are necessary. The protocols must have regulations to protect against contamination. Products need high viability, proliferation capacity, differentiation, homing, induction of regenerative factors and capacity to generate cytokines that recruit stem cells from the bone marrow. The process she outlined includes blood collection, stem cell harvesting, directing the cell populations and use in treatment.

Christine Humphrey, Esq

Regulatory Issues in Autologous Adult Stem Cell Use

The Food Drug Cosmetic Act (FDCA) 1938 and Public Health and Safety Act (PHSA) 1944 give certain over sight to the Food and Drug Association (FDA). Nothing in these acts gives the FDA jurisdiction to practice medicine. Existing case law as recent as 2006 confirms this. Investigational New Drug (IND) and Biologics Licensed Application (BLA) are a part of the FDA process. The FDA has created definitions for areas of jurisdiction including the definition of tissue and stem cells (HCT/Ps). Currently the FDA in 21 CFR part 1271, which is the definition of HCT/Ps clarifies that tissue is not subject to IND/BLA requirements if the use is homologous and minimally manipulated. However, in 2005 the FDA changed the definition of HCT/Ps without public commentary. The original definition pertained to tissue “infused from one individual into another individual”. The new definition was changed to simply “into a human recipient”. This change brought autologous adult stem cells under the authorization of the FDA and in this case control over this area of the practice of medicine. According to Congressional legislation, there is supposed to be a rigid wall between the FDA and the practice of medicine which makes this issue one to be questioned.

John Schultz, MD, DABPM

Clinical Experiences with Adult MSC's in Degenerative Disc Disease

Physicians must look at the patient as a whole and not emphasize a quick fix. If surgery is opted instead there is morbidity and surgical consequences. These therapies often advance the degenerative cascade. It is imperative to ask how the body got into the condition that needs attention and how do we optimize function. It is important to look at stability, articulation, alignment and neurology. Mesenchymal stem cells (MSC) differentiate into muscle, cartilage and tendon. In initial trials, Schultz used bone marrow aspirate BMA. The trials failed and no one got better. It was determined the treatment didn't offer a sufficient number of cells for repair. As a result, Schultz went back to the drawing board, got IRB approval within new the criteria guidelines: treating with autologous, conditioned MSC's which had been expanded in vitro and implanted into the posterior annulus along with platelet derived supernatant. Data collection included laboratory, imaging with the 3.0 Tesla MRI, FRI and VAS. Images were taken before the procedure, at one month and three months. Success was accomplished with the new protocol.

Alejandro Mesples, MD; Buenos Aires, Argentina

Treatment of Type 1 Diabetes using Autologous Bone Marrow

Research was done on chronic diabetic type 1 patients with the disease for two plus years. This was done in Argentina with all necessary approvals at the Universidad de Moron. Dr. Mesples is a cardiologist. Type 1 diabetes is the focus of the research because it affects up to 10 percent of the population. It is an autoimmune , chronic and degenerative disease. With diabetes, organ function can be measured with a C peptide. Preclinical evidence showed that bone marrow mesenchymal stem cells (MSC) can treat B-cell regeneration and medicate the immune response causing diabetes. Also this treatment can stop the onset of the disease. Adult stem cells can migrate by chemokines, differentiate, are safe and there is no ethical issue. Patients with bone marrow transplants in malignant blood diseases, ischemic heart disease, lower limb arterial disease, corneal injury, bone injury suffered no adverse issues.

In this study, the hypothesis was that injection of autologous stem cells into the pancreas would regenerate the organ. The hopeful endpoint was a 50 percent reduction in insulin use and other parameters would improve. All participants in the study were negative for auto reactive antibodies. Results: 45% of patients stopped insulin usage after 6-36 months; 30% normalized Hb; 80% increased the C peptides. Forty five percent of the participants were off insulin for at least 6 months; A1C improved in the responders; C peptide increased as well. Overall in the study 45 patients improved substantially, 30 had reduced insulin use and symptoms and 25 percent had no response. The only adverse responses included bone pain in the bone marrow harvesting and a few bruises at the injection site. It appeared the autologous stem cells contributed to systemic immune suppression, encouraged neovacularization and organ regeneration and function . There is another study being developed that will determine if they can get longer lasting results, confirm the results can be repeated and determine if autologous adult stem cell can affect type 2 diabetes. It is hoped this therapy for diabetes can become available throughout Latin America. www.stematix.com.

Jorge Tuma-Mubarak, MD

Terminal Heart Failure improvement with Minimal Invasive Delivery of Autologous Bone Marrow Mononuclear cells and long term follow up

Congestive heart failure is increasing and we aren't reducing mortality and morbidity. Orthotropic cardiac transplant is difficult. Over the last nine years there have been lots of published papers, randomized and nonrandomized, reporting on more than 10,000 patients. Outcome showed safety, improved function and improvement of ejection fraction. Delivery techniques vary including IM intracoronary, retro grade technique into the coronary veins which is the best for retention.

Endpoints safety retrograde injection via coronary veins in pats with left ventricular dysfunction less than 25%. Ejection fraction.

The study did typical labs, cardiac catheterization, 1-2 year follow up. The technique involved 800 patients, bone marrow aspiration of 450 ml with local anesthesia. The results included improvement in systolic volume; the ejection fraction improved from 19% to 29%. In non-ischemic patients the ejection fraction went from 24% to 44%. Most patients were class 4 heart disease in the beginning of the study and were class 2 afterwards. In general there were no complications, no enzyme elevations, improvement was evident in 90% of the patients within 21 days.

In a second case the ischemic patient had an ejection fraction of 18% and had class 4 heart disease prior to treatment. After treatment the ejection fraction increased to 28% and after two years was at 52% . At that point the patient has class 1 heart disease. Dr. Tuma shared that this treatment is not the cure but is an excellent avenue to improve the quality of life for the patient. He believes it is the medicine of the future.

Augusto Brazzini, MD; San Marin University, Lima, Peru

Endovascular Implant of Adult Stem Cells for Parkinson's disease

Always work with a doctor who has a specialty in the area of the disease to be treated. In Parkinson's disease there is neuron death. If the neurons are stimulated they can renew. In 1942 Rita Levi-Montalcini recognized this and called it nerve growth factor . Others also have shown that adult stem cells can regenerate neurons in the brain. Stem cells pass through the blood brain barrier due to a chemical reaction. Dr. Brazzini removes 350cc of the bone marrow. There is purification and concentration of stem cells, selective endovascular implant to regions near the affected area via super selective catheterization. The catheter can be used to deliver stem cells to the brain via the arteries and vessels in the neck.

Prior to any procedures, the doctor looks at the history and clinical examination, MRI and nuclear medicine to rule out other brain diseases, laboratory tests, surgical risk, psychiatric evaluations, photos and recordings and includes informed consent. There are exclusions for this procedure including patients older than 80 years old and those with cancer or cardiovascular disease. Results are good to excellent; 15% to 80%. Results differ because some patients with lesser results had prior treatment with medications. Many people are treated with medications that really don't have Parkinson's. The best results are experienced at four months and then level out. 15% of the patients, after one year, feel they do not have Parkinson's anymore. The conclusion of the study was that Parkinson's cannot be cured but the technique can reduce the functional limitations and improve quality of life to a great degree. This treatment also shows promise for brain infarct and hypoxia.

Tamara Jorquiera, MC

Endovascular Implant of Adult Stem Cells for Advanced Peripheral Vascular Disease

Peripheral vascular disease (PVD) is a very common disease in people 65 years and older including 12-20% of the population. Only 25% of those suffering PVD have a good treatment. Risk factors are smoking and diabetes. Half of the people with PVD will need amputation. In the United States 10-20 million dollars a year is spent to treat PVD. Stem cell therapy is used when the limb is not viable and there is no other option but amputation. However, it would be better to get to the patient while the limb is still viable. The therapy improves blood circulation and regenerates the tissue. Two processes take place- angiogenesis: making new vessels from existing cells and vasculogenesis: the creation of new vessels that were not there originally. Patients were excluded if they had cancer or infections in the bone.

Evaluations were made, consent forms signed, bone marrow was extracted, endovascular implantation and follow up. Infusion is by catheter to get as close to the obstruction as possible. This also gets the autologous stem cells to the capillary bed for vasculorgenesis. The cases presented were remarkable. Within one year the patients were able to walk again and no longer had pain. They went from a stage 4 to a stage 1. The study showed safety and effectiveness. It is good to bring this to the world. It is not a cure but it totally improves the quality of life for these patients.

Michael Freeman, PhD

Overview of the ICMS Research Methodology and Re-implantation Registry

The purpose behind the registry is to have a clearing house for treatments. What will dictate the future are regulatory forces, observational issues and entrepreneurial facets. We are looking at replacing very expensive therapies with less expensive options. The goal is to look closer at observational issues and what is happening in the field. There could be problems if we let the regulatory forces or the entrepreneurial facet rule the day. Epidemiologic study is the answer. The registry is there for safety and efficacy. ICMS has an IRB to have safe practices and oversight. It has a built in system to look for complications at 3,6,12 months and up to 20 years by phone, email or mail. There is data already on over 430 patients. The process is consistent with the Department of Health Services. All complications are looked into. If there is a problem it goes to the committee and then to the IRB. If it is a cell line then use can be stopped or restricted and all members will receive instant notification. There are a huge variety of outcome measures that are considered. Critical components are HIPPA compliant so the patient's identity is protected. Procedure data is identified: diagnosis, procedure type, protocol and post procedural assessment. All this will be put into a form that is publication friendly.

For more information visit the International Cell Medicine Society website.