Pluristem to take part in EU stem cell study

(Shiri Habib-Valdhorn, Globes [online], Israel business news) Broadly speaking there are two types of adult stem cell therapies: Those that involve the use of the patient’s own stem cells, called autologous, and those that involve use of another patient’s cells, called allogeneic. There are pros and cons to both approaches.

In the autologous approach the main advantage is that because the cells come from the same patient, there is no issue of immunological rejection or fear of contamination from another person’s infectious agents. The drawbacks with autologous approaches include: a) the fact that stem cell extraction, manipulation, and re-administration requires expensive and laborious procedures, as well as the need for equipment that is not commonly available at most hospitals; b) patients with a variety of disease conditions often have defective stem cells that work suboptimally as compared to stem cells from healthy patients; and c) many times the procedure for extracting the patient’s own stem cells involves painful procedures such as bone marrow aspiration, or potentially dangerous procedures such as stem cell mobilization. This allows the procedure to be performed only for a limited number of times.

The allogeneic stem cell therapy approach has the advantage of using cells that have been generated in large quantities for a specific function and biological activity. This means that the cells used are of a certain quality standard. Additionally, the allogeneic approach does not require complex cell manipulation procedures since the cells are shipped frozen to the point of care. Allogeneic cells can be administered on multiple occasions to the patient if needed. The downside of allogeneic cell therapy is the potential for immunological rejection, as well as patient sensitization. The sensitization of the patient to allogeneic cells may not allow for future use of the stem cells, as well as preclude the patient from bone marrow transplantation.

Pluristem Therapeutics Ltd. (Nasdaq:PSTI; DAX: PJT) is an Israeli company that trades on NASDAQ which is focused on generating allogeneic, “off the shelf” cellular products from placental cells using a proprietary bioreactor device. Originally Pluristem was working on using these stem cells to accelerate bone marrow engraftment after transplantation.

The process of bone marrow transplantation involves administration of chemotherapy and/or radiation to patients with blood malignancies in order to destroy the abnormal cells of the recipient, followed by injection of healthy donor blood making cells (hematopoietic stem cells) in order to provide to the recipient a new immune system. While this procedure has saved thousands of lives, one of the major drawbacks is that the donor cells sometimes take weeks, if not months, to start producing new blood cells. The use of donor cord blood has also been tried in this context experimentally, however, cord blood takes even longer than bone marrow to “engraft” in the recipient. Pluristem believed that its cells produce various growth factors that accelerate the process of engraftment.

In 2009 Pluristem began using its cells for the treatment of critical limb ischemia. This disease is a manifestation of advanced peripheral artery disease characterized by non-ceasing pain, ulcers, and a high rate of amputation. Given that the Pluristem cells produce high amounts of various growth factors, the concept is that administration of these cells into the muscles of patients with critical limb ischemia will result in production of new blood vessels, which will provide increased circulation to the legs of these patients. Other companies such as Medistem Inc are also using allogeneic cells, albeit from different sources (menstrual blood endometrial regenerative cells), for the treatment of this condition.

Recently Pluristem was chosen as one of 19 companies from 12 countries that will participate in a placenta stem cell study financed by EU Seventh Framework Progamme for Research and Development.

The study will be conducted concurrently at 12 European medical centers to examine the effect of placenta stem cell treatments on several kinds of heart cells that are damaged by high blood glucose levels caused by diabetes. The study will examine whether placenta stem cell-based anti-inflammatory agents can prevent or delay the onset of diastolic heart failure (DHF) among diabetics.

This is a new indication for Pluristem’s PLX (PLacental eXpanded) cell therapy product. The company will be allotted $150,000 from the Seventh Framework Progamme for R&D to cover the cost of the research and to develop the stem cells for the program.

Pluristem chairman and CEO Zami Aberman said, “There has been a growing interest in the potential of PLX cells to treat a variety of clinical indications following the release of the PLX-PAD clinical study interim results, which demonstrated safety and shows a trend of efficacy. The decision to use our PLX cells in this DHF study is further verification of the uniqueness of Pluristem’s PLX cells as an off-the-shelf product that requires no tissue matching prior to administration. There is a significant unmet medical need for the treatment of DHF, not only in Europe but also globally, and Pluristem’s placenta-derived cell therapy may provide patients and physicians with an effective and safe treatment option for this disease.”

The use of mesenchymal stem cells for treatment of cardiac diseases has previously been reported by Medistem Inc and Osiris Therapeutics.

Pluristem’s Off-The-Shelf Placenta-Derived Cell Therapies

Pluristem announced that its "off the shelf" placental stem
cells will be the focus of upcoming talking at investor and medical
conferences. The company Pluristem is currently in Phase I trials assessing its
unique bio-reactor expanded placental stem cells for the treatment of critical
limb ischemia. In contrast to other therapies that use the patient’s own stem
cells (called autologous), the advantage of the "universal donor" or
"allogeneic" approach is that large numbers of cells can be generated according
to defined conditions. Additionally, universal donor cells can be administered
several times at a number that is limited only by the desire of the physician to
escalate the dose. In the autologous situation stem cells are usually taken
from the bone marrow, making it difficult to perform multiple extractions.

Pluristem will present at the International Society for
Cellular Therapy’s (ISCT) 16th Annual Meeting in Philadelphia some updates on
its ongoing programs.

"We recently reported interim top-line results from our
Phase I clinical trials demonstrating that PLX-PAD is safe, well tolerated and
had improved the quality of life of CLI patients in the studies," said Zami
Aberman, Pluristem’s chairman and CEO. "With PLX-PAD, we have the unique
opportunity to utilize a single source of cells, the placenta, to treat an
unlimited number of CLI patients. Our presentations at the ISCT Annual Meeting
and other conferences will highlight the potential of PLX-PAD as well as our
core technology that enables the cost-effective development of cell therapies
derived from the human placenta."

There are several other companies pursuing "universal
donor" stem cells. Medistem, the licensor of technologies used by Cellmedicine
has developed such a cell from the endometrium, called "Endometrial Regenerative
Cells" that are currently subject of an IND application for use in critical limb
ischemia. Athersys is using bone marrow derived universal donor stem cells for
treatment of heart failure. The most advancement in this area comes from the
company Osiris Therapeutics which also uses bone marrow derived cells to treat a
variety of conditions, although all are still in clinical trials.

In
the majority of cases universal donor cells are related directly or indirectly
to mesenchymal stem cells. These cells, originally discovered by Dr. Arnold
Caplan, express low levels of proteins that are seen by the immune system, thus
allowing them to be transplanted without matching. Additionally, they also
produce proteins that actively suppress the immune system from killing them. In
diseases associated with abnormal immunity mesenchymal stem cells have shown
promise. Cellmedicine has published on use of mesenchymal stem cells in
treatment of multiple sclerosis

Success Stems From Adult Cells

The use of adult stem cells for conditions besides bone marrow transplant is most prevalent in the area of heart failure. Since the original study of Strauer et al in 2001 in which a 46-year old patient was administered bone marrow stem cells after a heart attack and experienced a profound improvement in cardiac function, more than a thousand patients have received adult stem cells for cardiac-associated conditions.

Today the story of Eddie Floyd, a small business owner from Austin, Texas was highlighted in an article describing his presentation to the Texas Alliance for Life. Mr. Floyed suffered a heart attack three years ago. The heart attack caused profound damage so as to make him eligible to participate in a clinical trial being conducted at the Texas Heart Institute using his own bone marrow stem cells. The trial involves administration of the stem cells using a special catheter to the blood vessels supplying the heart muscle.

Three years later, Mr Floyd is happy with the results. He explains that he has been able to resume normal daily activities. "There really isn’t anything that I can’t do because of my heart, that I’m aware of. [But] there are a few things I can’t do because of my belly…,"

Since the stem cells are from the patient’s own body, there is no possibility of rejection. He stated "They did not cause any kind of rejection, so I didn’t have to have any rejection-preventive medicine or anything like that…They were just generic stem cells that became heart."

In his talk Mr. Floyd explained that despite all of the media publicity and controversy around embryonic stem cells, these cells produced no benefit to patients like himself. There was one clinical trial in embryonic stem cells that was approved, which was Geron’s spinal cord injury protocol. The approval, however, was retracted before any patients were treated.

In contrast, adult stem cells such as the ones derived from the bone marrow have been used successfully not only in the treatment of heart failure, but other diseases such as liver failure, type 2 diabetes, and prevention of amputation in patients having poor circulation in the legs.

Currently adult stem cells are in clinical trials in the US and Western Europe. The most advanced adult stem cell types are in Phase III of trials, meaning that
if successful they will be sold as a drug within the next 1-3 years. Because Phase III trials have a placebo control arm, some patients do not want the risk
of being in a placebo group and therefore choose to go to clinics outside the US that offer this treatment. Once such clinic, Cellmedicine, has published
results on patients, such as a recent heart failure patient who underwent a profound recovery in heart function after treatment. The patient is described
in the peer reviewed journal International Archives of Medicine which is freely accessible at
www.intarchmed.com/content/pdf/1755-7682-3-5.pdf.

Stem Cells Have GPS to Generate Proper Nerve Cells

One of the main questions in stem cell therapy is how the
injected cells "know" to find their way into the specific parts of the body
where they are needed. The most common example of stem cells homing is during
bone marrow transplant. In this situation donor stem cells are administered to
the recipient intravenously, but somehow they find their way to the bone marrow
of recipient, and once in the bone marrow start producing new blood cells. It
was discovered that specific cells in the bone produce a chemical signal called
stromal derived factor (SDF)-1 that acts as a homing beacon for the stem cells,
causing them to be localized in the bone marrow regardless of where they are
injected. This is explained in the video
www.youtube.com/watch?v=VJaQkYWdJ8w.

By knowing the signals involved in keeping stem cells in
the bone marrow, drugs have been made that can temporarily release them from the
bone into circulation. One example of such a drug made by Genzyme called
Mozibil. This is a small molecule that has been synthesized to act as an agent
that blocks the interaction between SDF-1 and its receptor. By blocking this
interaction, stem cells are "mobilized" to exit the bone marrow and enter
systemic circulation. Once the drug exits circulation by normal metabolism, the
stem cells home back to the bone marrow, or if there is injury in the body, some
of them localize to the damaged area.

Mozibil and similar agents are useful in situations where
one wants to collect patient stem cells without having to perform a bone marrow
aspiration, which is a painful procedure involving drilling numerous holes in
the bone of the donor. Another use of such "mobilizers" is to increase the
number of stem cells in circulation, to accelerate recovery in conditions such
as stroke or heart attack. In both of these conditions an increase in
circulating stem cells is associated with better recovery. Thus if one
artificially increases the number of stem cells in circulation by administering
agents such as Mozibil, it may be possible to see a therapeutic benefit.

While the control of stem cell homing for the bone marrow
is relatively well-known, the brain is a completely different matter. A
previously unknown factor that regulates how stem cells produce different types
of cells in different parts of the nervous system has been discovered by Stefan
Thor, professor of Developmental Biology, and graduate students Daniel Karlsson
and Magnus Baumgardt, at Linköping University in Sweden.

The scientists studied a specific stem cell in the nervous
system of the fruit fly. This stem cell is present in all segments of the
nervous system, but outside of the nervous system it is found only in the
thorax. To investigate why this cell type is not created in the stomach or head
region they manipulated the Hox genes’ activity in the fly embryo. The
investigators found out that the Hox genes in the stomach region stop stem cells
from splitting before the specific cells are produced. In contrast, the specific
nerve cells are actually produced in the head region, but the Hox genes turn
them into another, unknown, type of cell. Hox genes can thus exert their
influence both on the genes that control stem cell division behaviour and on the
genes that control the type of nerve cells that are created.

"We constantly find new regulating mechanisms, and it is
probably more difficult than previously thought to routinely use stem cells in
treating diseases and repairing organs, especially in the nervous system", says
Thor.

The regulation of stem cell homing by Hox genes has previously been demonstrated in
other systems, however this is the first time that it was found in relation to
development of the nervous system. These findings may lead to strategies for
"rewiring" neurons after injury has occurred in situations such as cerebral
palsy or stroke.

Stem Cells Don’t have to be Alive to Be Beneficial

The use of stem cells in patients who have poor circulation
is well-known.  In fact, the first use of stem cells for conditions other than
blood disorders was in patients who were undergoing bypass surgery.  Usually
patients undergo bypass because of advanced atherosclerosis that is inhibiting
the flow of blood to the heart muscle.  Despite success of bypass surgery, the
underlying problem of thickened blood vessels remains.  Japanese scientists (Hamano
et al. Local implantation of autologous bone marrow cells for therapeutic
angiogenesis in patients with ischemic heart disease: clinical trial and
preliminary results. Jpn Circ J. 2001 Sep;65(9):845-7
) in 1999 treated 5
patients with ischemic heart disease with their own bone marrow cells injected
into the heart muscle during bypass.  Of these 5 patients, 3 demonstrated
increased blood flow at the area where the stem cells were injected.  Subsequent
to this numerous clinical trials have been conducted using bone marrow stem
cells for increasing circulation both to the heart and also to legs that lack
proper blood flow (particularly in patients with critical limb ischemia see
video

http://www.youtube.com/watch?v=dcCwZ4CsiKc
). 

One of the major questions has always been how the injected
stem cells improve circulation.  Originally the idea was that the stem cells
become new blood vessels, and that these new blood vessels take over the
function of the older blood vessels.  However, recent data suggests that the
stem cells injected actually collaborate with the stem cells that are already in
the patient.  For example, it was demonstrated that in patients lacking oxygen
in their legs who receive bone marrow stem cell therapy, the responders actually
have increased levels of their own circulating stem cells.  Here is a video
describing this

http://www.youtube.com/watch?v=OwIOL13vXQ4
.

It is believed that bone marrow stem cells, particularly
mesenchymal stem cells, are capable of producing proteins that stimulate the
body’s own stem cells into making new blood vessels.  These proteins include
IGF-1, VEGF, and HGF. 

A recent study from Stanford University (Hoffmann et al.
Angiogenic Effects Despite Limited Cell Survival of Bone Marrow-Derived
Mesenchymal Stem Cells under Ischemia. Thorac Cardiovasc Surg. 2010
Apr;58(3):136-142
) should to investigate the cellular and molecular
interactions which are associated with formation of new blood vessels after
administration of bone marrow mesenchymal stem cells.

The investigators first began by assessing production of
the protein VEGF from bone marrow mesenchymal stem cells under conditions of
normal oxygen, and under reduced oxygen conditions.  The idea being that if
mesenchymal stem cells are responsible for producing growth factors, then it
would make sense that production of these factors would increase in response to
needs of the body (eg reduced oxygen).  As a control, fibroblast cells were
assessed side by side with the mesenchymal stem cells.  It was found using in
vitro experiments that mesenchymal stem cells produced much higher levels of
VEGF under hypoxia as compared to fibroblasts, however, mesenchymal stem cells
died faster than fibroblasts in response to hypoxia.

To determine whether mesenchymal stem cells or fibroblasts
cause formation of new blood vessels in animals, a model of critical limb
ischemia was developed in which the artery feeding the leg of mice was ligated. 

One week after induction of ischemia in the leg, 1 million
mesenchymal stem cells, or fibroblasts were injected into the muscles of the
animals.  The cells were labeled genetically so that the injected cells could be
distinguished from the endogenous cells. 

Substantially elevated levels of new blood vessels, and
improved circulation, was observed in the mice that received mesenchymal stem
cells as compared to fibroblasts.  Interestingly, at 3 weeks after
administration, despite improved circulation, the mice receiving mesenchymal
stem cells had much lower numbers of injected cells as compared to mice that
received fibroblasts.

This study suggests that mesenchymal stem cells seem to use
the natural mechanisms of the body in order to generate new blood vessels. 
Something else of interest from this study is that fibroblasts live longer in
hypoxia as compared to mesenchymal stem cells.  Hypothetically it may be
possible to transfect fibroblasts with genes that stimulate production of new
blood vessels.  Unfortunately, the proper combination of growth factors and
concentration are still not known for creation of new blood vessels.