Jennifer Hui-Chun Ho, MD, PhD Center for Stem Cell Research, Wan Fang Medical Center, Taipei Medical University, Taipei, Taiwan

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1 : ISCT Jennifer Hui-Chun Ho, MD, PhD Center for Stem Cell Research, Wan Fang Medical Center, Taipei Medical University, Taipei, Taiwan

2 Introduction --Acute Respiratory Distress Syndrome (ARDS) 1. Acute respiratory distress syndrome (ARDS) is the major reason of morbidity and mortality in critically ill patients (Mendez JL and Hubmayr RD. Curr Opin Crit Care 2005; Rubenfeld GD,et al. N Engl J Med 2005). 2. Pathomechanism: severe acute lung inflammation (Ware LB and Matthay MA. N Engl J Med 2000). 3. Clinical management: supportive care (Cepkova M and Matthay MA. J Intensive Care Med 2006). 4. Goal of a successful treatment: facilitating tissue repair without fibrotic change by attenuating local inflammatory (Rocco PR and Pelosi P. Curr Opin Crit Care 2008). A therapeutic strategy that specifically decreases local inflammation and promotes lung tissue repair would be highly valuable in treating ARDS.

3 Introduction --Stem Cell Transplantation 1. Therapeutic potential of stem cells for tissue regeneration: self-renewal, multipotency, and a paracrine capacity (He S, et al. Annu Rev Cell Dev Biol 2009). 2. Bone marrow-derived mesenchymal stem cells (BM-MSCs) are known to be potent immune modulators (Le Blanc K and Ringden O. J Intern Med 2007), and these cells improve the survival rate after acute lung injury (ALI) by decreasing systemic as well as local inflammatory response, and bronchial epithelial cell differentiation. (Gupta N, et al. J Immunol 2007; Xu J, et al. Am J Physiol Lung Cell Mol Physiol 2007; Yamada M, et al. J Immunol 2004; Mei SH, et al. PLoS Med 2007). 3. For clinical consideration, bone marrow aspiration is a moderate-risk procedure (Bosi A and Bartolozzi B. Transplant Proc 2010). Alternately, adipose tissue is an abundant source of MSCs (Zuk PA, et al. Mol Biol Cell 2002).

4 Introduction --Orbital fat-derived stem cells (OFSCs) A platform technology has been established to isolate multipotent stem cells from a minimal volume (0.5 1 ml) of human orbital adipose tissue. (Ho JH, et al. Tissue Eng Part A 2011 ) OFSCs BM-MSCs (Ho JH, et al. Tissue Eng, 2011) (Ho JH, et al. J Ortho Res 2010)

5 To investigate therapeutic effect of OFSCs in acute lung injury in an animal model

6 Growth kinetics and tri-lineage differentiation ability of OFSCs Growth curve Chondrogenic differentiation OFSCs BM-MSCs Safranin-O staining (21 days) Osteogenic differentiation OFSCs BM-MSCs Adipogenic differentiation OFSCs BM-MSCs phase ALP (2 wks) Von Kossa(2 wks) Phase (3 wks) Oil Red O (3 wks) (Ho JH, et al. Tissue Eng 2011; Lee KD, et al. Hepatology 2004)

7 Surface phenotype of OFSCs and BM-MSCs OFSCs (selected) BM-MSCs (selected) (Ho JH, et al. Tissue Eng 2011) (Lee OK, et al. Hepatology 2004) OFSCs BM-MSCs CD CD CD CD CD CD49b + + CD49d CD49e + + CD CD CD CD CD CD CD CD CD CD HLA-ABC + + HLA-DR - - Surface phenotype on OFSCs and BM-MSCs are identical under 260 surface antigen screening using BD lyoplate.

8 OFSCs exhibited potential of epithelial cell differentiation in vitro G H Q-dot: quantum dot HCE-T cells: human corneal epithelial cells ESA: epithelial specific antigen ZO-1: zonal occludin-1 (Ho JH, et al. Tissue Eng 2011)

9 Animal model and OFSC transplantation --Lipopolysaccharide (LPS)-induced ALI Experimental administration of LPS via intravenous (IV) or intratracheal (IT) injection is used to create acute lung inflammation in animal models (Altemeier WA, et al. J Immunol 2005; Gharib SA, et al. Am J Respir Crit Care Med 2006; Rojas M, et al. Am J Physiol Lung Cell Mol Physiol 2005; Matute-Bello G, et al. Clin Diagn Lab Immunol 2004). Intratracheal (IT) injection with LPS (25 μg in 50 μl sterile saline/mice) 8-10 w/o male Bulb/c Mice OFSCs (3 x 10 5 /mice) OFSCs protect mice survival from LPSinduced ALI in the first 3 days. (n=10)

10 Evaluation of OFSCs transplantation During the first 3 days: 1. Antigenicity of OFSCs 2. Systemic inflammatory cytokine analysis On day 3 before sacrifice: 1. Bronchoalveolar lavage 2. Systemic inflammatory cytokine analysis 3. Circulation neutrophil and monocyte count and T-lymphocyte After sacrifice: 1. Lung wet/dry weight ratio analysis 2. H&E staining and histopathological scoring 3. Immunohistochemistric and fluorescent staining 4. Western blot analysis

11 OFSCs ameliorated LPS-induced acute lung injury The severity of LPS-induced ALI was determined according to : 1) alveolar congestion; 2) hemorrhage; 3) Infiltration or aggregation of neutrophils in airspaces or vessel walls; 4) thickness of alveolar wall/hyaline membrane formation. Each criterion was graded according to a 5-point scale (Takao Y, et al. Anesth Analg 2005). (Ho JH, et al. Cri Car Med 2012)

12 OFSCs reduced LPS-induced acute lung inflammation and endothelial/epithelial permeability A B CD68: macrophage marker Ly6G: neutrophil marker Lung W/D ratio: weight of wet v.s. dry lung tissue BAL: bronchoalveolar lavage (Student t test, * p< 0.05) C D E (two-way analysis of variance with a Bonferroni test at 95% of confidence interval, ns: nonsignificance; * p<0.05, n=5) (Ho JH, et al. Cri Car Med 2012)

13 LPS triggers innate immunity through activation of Toll-like receptor 4 (TLR4)/CD14 signaling pathway (Sly LM et al. Exp Hematol. 2003)

14 OFSCs inhibited the activation of macrophage as well as TLR4/CD14 signaling pathway in lung parenchyma inos: inducible nitrioxide synthetase TGF- β: tissue growth fact-beta (Student t test, * p< 0.05) (Ho JH, et al. Cri Car Med 2012)

15 OFSCs reduced systemic pro-inflammatory cytokines and further T-lymphocyte recruitment OFSCs significantly decreased the serum level of macrophage inflammatory protein-1 (MIP-1) (D) but increased the interleukin-6 (IL-6) level (B) and soluble TNF receptor II (stnf RII)(D) after lipopolysaccharide (LPS) treatment for 6 hrs. After LPS treatment for 72 hrs, OFSCs significantly decreased circulation B-lymphocyte chemoattractant (BLC)(E) and IL-12 (F) level. CD11 b: neutrophil and monocyte marker CD4: T lymphocyte marker (I, J: ANOVA with Tukey s post hoc test at 95 confidence intervals; different letters represent different levels of significance, n=5) (A-H: Student t test, * p< 0.05) (Ho JH, et al. Cri Car Med 2012)

16 OFSCs were tolerated in xenotransplant model TNF- α : tissue necrosis factor-alpha INF- γ : interferon-gamma (ANOVA with Tukey s post hoc test at 95 confidence intervals; different letters represent different levels of significance, n=5) (Ho JH, et al. Cri Car Med 2012)

17 Only few OFSCs existed in damaged lung tissue after three days of transplantation mouse 1 mouse 2 mouse 3 CMFDA: 5-chloromethylfluorescein diacetate DAPI: 4,6-diamidino-2-phenylindole OFSCs labeled with CMFDA Nuclei labeled with DAPI Few CMFDA (+) cells (< 1%) can be found in lung tissue 3 days after LPS injection. (Ho JH, et al. Cri Car Med 2012)

18 Discussion-1 1. In LPS-induced ALI, macrophages and neutrophils infiltrations enhance pulmonary endothelial and epithelial permeability (Chignard M and Balloy V. Am J Physiol Lung Cell Mol Physiol 2000). 2. LPS triggers macrophage activation through binding to TLR4/CD14 to mediate inflammatory protein release including two critical cytokines in the pathogenesis of ALI, i.e. a. inos cytotoxic oxidant production (Baumgarten G, et al. Eur J Anaesthesiol 2006; Kristof AS, et al. Am J Respir Crit Care Med 1998; Numata M, et al. J Immunol 1998) b. TGF- β- increase in pulmonary endothelial and epithelial permeability (Zhang X, et al. World J Gastroenterol 2004; Haddad IY, et al. J Clin Invest 1994; Wesselkamper SC, et al. Am J Respir Crit Care Med 2005;) 3. OFSCs, stem cells derived from human orbital fat tissue, possess a powerful anti-inflammation ability in vivo and abrogate LPS-induced acute lung injury.

19 Discussion-2 4. During early stage of ALI, serum level of pro-inflammatory cytokines such as MIP-1, BLC and IL-12 are elevated. (Jeyaseelan S, et l. Infect Immun 2004; Heremans H, et al. Am J Respir Crit Care Med 2000) a. MIP-1: Macrophage inflammatory protein-1, secreted by macrophages, induces the chemotaxis of CD4 T lymphocytes and neutrophils (Didon L, et al. Am J Respir Crit Care Med 2011; Mohamadzadeh M, et al. J Immunol 1996). b: BLC: B-lymphocyte chemoattractant, secreted by monocytes, lymphocytes, and dendritic cells and detectable in serum when tissue inflammation occurs, is a potent chemokine to attract B and T lymphocytes to the areas of infection and inflammation (Vissers JL, et al. Eur J Immunol 2001; Carlsen HS, et al. Blood 2004; Horwitz EM, et al. Proc Nat Acad Sci U S A 2002; Breitfeld D, et al. J Exp Med 2000). c. IL-12: Interleukin-12, secreted by monocytes, macrophages, and neutrophils, is a critical regulatory cytokine that stimulates type 1 helper T cells (Th1) to release IFN-γ in response to bacterial products (Heremans H, et al. Am J Respir Crit Care Med 2000; Dobashi K, et al. Clin Exp Immunol 2001; Gately MK, et al. Annu Rev Immunol 1998). 5. Systemic OFSC transplantation not only reduces serum levels of MIP-1, BLC and IL-12, but also inhibits subsequent T cells recruitment, indicating that OFSCs ameliorate further lung injury from T cell-related complications.

20 Discussion-3 6. In murine models of LPS-induced ALI, systemic BM-MSCs transplantation reduces the inflammatory response; however, the engraftment rate was extremely low during the first 2 weeks (0.1% to 9%) (Xu J, et al. Am J Physiol Lung Cell Mol Physiol 2007; Mei SH, et al. PLoS Med 2007; Xu J, et al. J Pathol 2008). 7. Similarly, we observed a small percentage of OFSCs were found (1%) in lung parenchyma in the first 3 days. Despite the low engraftment rate, OFSC administration led to a dramatic improvement in lung condition, suggesting that therapeutic effect of OFSCs may be primarily from their paracrine effects. 8. OFSCs are advantageous over BMMSCs because they can be isolated from a minimal volume (0.5 1 ml) of orbital fat tissues via a low-risk procedure. 9. In murine model of LPS-induced ALI, the circulation cytokine profile altered by systemic transplantation of OFSCs is different from BM-MSCs reported in the literatures, showing that the underlying molecular mechanisms between OFSCs and BM-MSCs in regulation of LPS-induced immune response are not the same.

21 Conclusion 1. OFSCs are of low immunogenicity and tolerated in a xenotransplant model. 2. Systemic administration of OFSCs diminishs acute LPS-induced lung inflammation by inhibiting macrophage and neutrophil-associated inflammatory responses. 3. OFSCs transplantation provides a novel therapeutic strategy for extensive acute lung injury or acute respiratory dystress syndrome.

22 ACKNOWLEDGMENTS Department of Respiratory Therapy, Taipei Medical University, Taipei, Taiwan Mauo-Ying Bien, PhD You-Lan Yang, PhD Genomics Research Center, Academia Sinica, Taipei, Taiwan Michael Hsiao, PhD Department of Pathology, Wan Fang Hospital-TMU, Taipei, Taiwan Chi-Long Chen, MD, PhD Center for Stem Cell Research, Wan Fang Hospital-TMU, Taipei, Taiwan Ming-Hsien Chien, PhD Chia-Chi Ku, MS Yun-Chuang Chang, MS Hsiang-Yin Pao, MS

23 Thank you for your attention!

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