Cell Based Therapies: What Do They Do and Will They Work in CLI? None Financial Disclosures Michael P. Murphy, MD The Vascular and Cardiac Adult Stem Cell Therapy Center Indiana University School of Medicine Concept of Cell Mediated Angiogenesis Bone Marrow Mononuclear Cells Population of Endothelial Progenitor Cells isolated by Asahara 1997 EPCs originate in the bone marrow Participate in blood vessel repair and development Asahara T, Murohara T, Sullivan A, et al. Isolation of putative progenitor cells for angiogenesis. Science 1997. VEG-F Concentration (pg/ml) Heterogenous mixture of cells Lymphoid progenitors: T cells, B cells Endothelial Progenitor Cells Mesenchymal Stromal Cells Secrete angiogenic growth factors 5000 4000 3000 2000 1000 0 VEGF PMSC ASC HGF Concentration (pg/ml) 3000 2500 2000 1500 1000 500 0 HGF Avg PMSC Avg ASC ANG-1 Concentration (pg/ml) 5000 4000 3000 2000 1000 0 Ang-1 AVG PMSC AVG ASC 1
Clinical Trials for CLI: United States G-CSF Mobilized CD34+ Cells Bone Marrow Derived Aldehyde Dehydrogenase Bright Cells in CLI RESTORE-CLI Pluristem Placenta Progenitor Cell BMAC- Harvest Trial MarrowStim Trial Completed Phase I/II Trials in the US MarrowStim (Biomet): 2004-2009 Phase I/II: 29 patients 30 limbs, one year Open label, non- randomized single center RESTORE-CLI (Aastrom) 2007-2010 Tissue Repair Cells (TRCs-Autologous Bone Marrow Cells) in Patients with Peripheral Arterial Disease to Treat Critical Limb Ischemia Phase I/II double blinded, placebo control Randomization: 2 (TRC);1 (control) 33 twelve month, 13 six month follow up Asymptomatic Critical Limb Ischemia (CLI) Rest Pain Claudication No Option CLI 40-50% Major Amputation at 12 months Critical Limb Ischemia Tissue Loss 1. 18-90 years Enrollment Criteria 2. Rest pain or ulceration 3. Evidence of malperfusion MarrowStim: ABI < 0.55, TBI < 0.40 RESTORE-CLI: Toe SBP < 50mmHg, Ankle SBP < 70mmHg 4. Cannot be candidate for bypass or PTA 5. Absence of significant organ dysfunction and infection 2
MarrowStim RESTORE-CLI 50 ml. Bone Marrow Aastrom TRC Bioreactor x 12 days Cell Dose and Delivery MarrowStim: 2.9 x10 9 MNCs 35-40 injections RESTORE-CLI: 136 +41 x10 6 TRCs 20 injections MarrowStim: Results at One Year with 24 limbs Major Amputations: 12.5% (3/24) Deaths: 2 Amputation Free Survival: 86.3% Complete wound healing: 44% (4/9) 3
10.2 ± 6.2 mmhg 0.11 ± 0.04 mmhg Results After ABMNC Therapy P = 0.02 P= 0.02 A Right Left Pre-Therapy Study R/L BP Index = 0.38 First Toe Pressure Toe-Brachial Index B Right Left 0.08 ± 0.04 mmhg P = 0.12 Post-Therapy Study R/L BP Index = 0.54 Ankle-Brachial Index Radiolabeled H 2 O 15 Positron Emission Tomogaphy-CT Scan. A representative image of blood perfusion ( BP) with H 2 O 15 before ABMC injection (A) and after (B). A BP index comparing flow in the treated to the untreated leg was calculated. BP in the treated leg increased by 42%. Correlation Between Progenitor Cell Populations and Outcome Amputation Free Survival at 5 years 74% (95% CI: 0.53-0.86) * Expected from TASC untreated data 4
RESTORE-CLI Time to Treatment Failure RESTORE-CLI Amputation Free Survival at 6 months Treatment Failure: major amputation, death, doubling of wound size, de novo gangrene 6 month group: Control: 43% TRC: 19%, P=.14 Conclusions Cell therapy for CLI is safe Evidence of efficacy in preventing major amputation Efficacy is durable: AFS improved at 5 years Mechanism: paracrine No significant difference in IA vs. IM delivery MarrowStim Phase III Multicenter Trial 158 patients at 25 US centers Began enrollment 2010: 49 patients Primary outcome: Amputation Free Survival at One Year Randomized: 3 treatment:1 placebo Double blinded: - Evaluating physician - Patient 5
Cardiovascular Cell Therapy Research Network Clinical and Histological Analysis of Mesenchymal Stromal Cells in AmPutations (CHAMP Trial) 90 degrees to skin 1.5 Collect MSCs at 1,3,7 days postinjection Collect injection sites if revise to AKA Gender mismatched MSCs Adult ECFC Microvascular Networks Anti-CD31 staining Fluorescent In Situ Hybridization for sex chromosomes Anti human CD31(brown) staining shows mouse RBC(arrow) flowing through human vessel 6
ECFCs only MSCs only MSC + ECFC Division of Vascular Surgery The Vascular and Cardiac Adult Stem Cell Therapy Center Indiana University School of Medicine Michael C Dalsing, MD Gary W. Lemmon MD Alan Sawchuk MD Raghu Motaghnahalli MD Dolores Cikrit MD George Akingba MD PhD Andres Fajardo MD Janet Klein, RN Keith March, MD PhD Reza Saadatzadeh Pat G sell, RN Brian Johnstone, PhD Mathias Clauss, PhD Merv Yoder, MD Dave Ingram. MD 7