Kein Folientitel

1
Stem Cells and Autoimmune Disease
Prof Alan TyndallDept of RheumatologyUniversity
of Basel On behalf of the EBMT and EULAR
2
What is a stem cell? On division, one daughter
cell replenishes a whole compartment, and the
other remains fully stem.
3
What types of stem cells are there?
Mouse ? man
4
Embryonal pluripotent Stem Cells
NB early differentiation into a tissue type
e.g.heart muscle cell is not the same as complete
functioning organ. Embryonal stem cells
often give rise to tumors.
5
Adult multipotent stem cells
NB Most adult stem cells only replenish one
tissue type successfully e.g. blood stem cells
supply all the types of blood cells in the body
life long.
6
Examples of adult stem cells
7
Speculation
multipotent
8
Speculation
9

• Issues
• Scientific
• Ethical
• Theological
• Cultural
• Commercial
• Public education

10
Pluripotent Embryonal stem cell
Pluripotent stem cells
Totipotent stem cells
Somatic stem cell
Germ stem cell
Somatic Cell
Primitive germ cell
Endoderm Ectoderm Mesoderm
Adult Multipotent stem cell
Liver Intestine Pancreas
Skin Hair Nerves
Blood Muscle Bone Cartilage
Gametes
Courtesy of Dr F. Prosper Cardoso.
11
Blood stem cell transplantation

• Over 30 years experience.
• Saving many lives from e.g. leukemia.
• Eradicate good and bad cells then replace the
  blood system.
• Originally bone marrow transplant, now peripheral
  blood derived stem cells.

12
Hematopoietic and Mesenchymal Stem Cells
13
How is it done?
(Sykes et al , Nature Med 2005)
14
Haematopoietic stem cell transplantation (HSCT)
for severe autoimmune disease

• Concept
• Intensive immunosuppression with haematopoietic
  stem cell rescue
• Resetting of autoimmunity?

15
Resetting the Immune system
16
HSCT for autoimmune disease

• Animal models (van Bekkum)
• Tolerance induction in an autologous arthritis
  rat model
• Coincidental cases for malignant disease
• Allogeneic
• Autologous

17

• To establish through prospective randomised
  clinical trials the role of HSCT in treating
  autoimmune disease
• To study immune reconstitution

18
Autoimmune Disease Working Party (ADWP) EBMT/EULAR
19
Autoimmune diseases pts 803Disease
classification
VASCULITIS 28 Behcets
6 Wegeners 7 Takayasu 2
Microscopic polyarteritis nodosa 2
Classical polyarteritis nodosa 1
Churg-Strauss 1 Other 9
OTHER NEUROLOGICAL 15 Myasthenia gravis
2 Other
13 INFLAMMATORY BOWEL 12 Crohn's disease
6 Ulcerative colitis 2 Other
4 OTHER AD 21

• MULTIPLE SCLEROSIS 281
• CONNECTIVE TISSUE D. 232
• SSc 136
• SLE 78
• PM/DM 8
• Sjoegren 1
• Other/Unknown 12
• ARTHRITIS 147
• Rheumatoid arthritis 93
• Juvenile chronic arthritis
• - Systemic JIA 32
• - Other JIA 12
• - Polyarticular JIA 5
• Psoriatic arthritis 2
• Other 3
• HAEMATOLOGICAL 54

Lyon, March 2007
20
Systemic sclerosis (SSc)
21
. Clinical outcome in 57 systemic sclerosis
patients followed up to 60 months post
transplant.
Farge et al , Ann Rheum Dis 2004
22
Patient selection is critical Early SSc
23
Patients with severe systemic sclerosis
Immunoablation SCT 1. Mobilisation (CYC 2x2
g/m2, G-CSF 10 mg/kg) 2. Leukapheresis/CD34
selection 3. Conditioning (CYC 200 mg/kg,rabbit
ATG 7.5 mg/kg) 4. Reinfusion CD34 cells
Control treatment 12x monthly iv pulse CYC 750
mg/m2
CYC Cyclophosphamide
Study Administration Office Jaap van Laar
(Leiden)Study coordinators Jaap van Laar
(Leiden), Dominique Farge (Paris), Alan Tyndall
(Basel)Project manager Ingeborg de Jonge
(Leiden)Statistician Jaap Sont (Leiden)
24
ASTIS trial March 2001 July 2007 98 patients
randomised 46 SCT 52 controls in 20 centres
no graft failures or unexpected toxicities
1x probable TRM
Leeds (3)
Amsterdam (6)
Herne-Bochum (3)
Leiden (20)
Frankfurt (1)
Nijmegen (7)
Tübingen (2)
Paris (18)
Würzburg (1)
Strassbourg (1)
Freiburg (1)
Basel-Bern (5)
Bordeaux (1)
Vienna (3)
Clerm Ferr (1)
Grenoble (1)
Florence (10)
Toulouse (2)
Thessaloniki (1)
Marseille (1)
includes Martignique, Poitiers
25
(No Transcript)
26
SCOT (
Scleroderma Cyclophophamide Or Transplant)
Patients with severe systemic sclerosis
Immunoablation SCT 1. Mobilisation (CYC 2x2
g/m2, G-CSF 10 mg/kg) 2. Leukapheresis/CD34
selection 3. Conditioning (CYC 200 mg/kg,equine
ATG 90 mg/kg), Radiation 4. Reinfusion CD34 cells
Control treatment 12x monthly iv pulse CYC 750
mg/m2
CYC Cyclophosphamide
Principle investigator KeithSullivanStudy
coordinators Dan Furst, Peter McSweeneySponsor
NIH/NIAMS ( Linda Griffith)
27
Mesenchymal stem cell transplantation for severe
autoimmune disease

• Concept
• Homing to inflammed tissue then antiinflammatory
  effect
• Repair of damaged tissue??

28
Hematopoietic and Mesenchymal Stem Cells
29
MSCs
Courtesy of F. Dazzi
30
Immunomodulation in-vivo models

• Baboon skin graft - yes
  ( Bartholemew et al , Exp
  Hematol, 2002)
• Mouse MS model (EAE) yes
  (Uccelli A et al, Blood
  20051061755-61)
• Mouse MS model (EAE) yes
  (Zhang J et al, Exp Neurol
  200519516-26))
• Mouse RA model CIA worse. TNF? effect?
  (Jorgensen J, Arthritis Rheum 2005,
  521595-603)
  - yes
  ( Pennesi
  et al , Arthritis Rheum in press )
• Mouse acute GvHD model yes
  
  (Dazzi F et al)
• Other e.g. SLE, colitis , CIA etc

31
Tissue injury in-vivo models

• Rat kidney ischaemia/reperfusion renal failure
  model protects pre and 12 hours
• (Togel F et al, Kidney Int
  200567(5)1772-1784)
• Mouse bleomycin lung fibrosis model
• Home to affected lung
• Reduce inflammation and fibrosis
• Most effective immediately after injury
• (Ortiz L et al, Proc Natl Acad Sci U S A
  2003100(14)8407-8411)
• Carbon tetrachloride hepatic fibrosis mouse
• Protect immediately, not one week later
• Some transdifferentiation to epthelium
• (Fang B et al, Transplantation
  200478(1)83-88)

32
Immunomodulation clinical

• Acute GvHD stage IV (9-year-old boy, leukaemia)
  
• MSCs (expanded ex vivo from mother)
• Arrested gut, skin and liver acute GvHD
  (Le Blanc K et al, Lancet
  2004363(9419)1439-1441)
• 52 GvHD patients stage III/IV from 4 centres -
  sibs, haploidentical, HLA mismatched 3rd party
• - median 1 X 106 / Kg body weight - CR
  73 , PR 9, NR 17, relapse 9, alive 45,
  chronic GvHD 18
• 
  (Ball et al personal communication)
• Standardisation of definition and expansion of
  MSCs - EBMT Stem Cell Subcommittee
• - International Society of Cellular Therapies
  (ISCT)

33
(No Transcript)
34
Mechanisms of Immunomodulation ?

• Soluble factorsTGFb, IL-10, HGF (Di Nicola M et
  al, Blood 200299(10)3838-3843)
• 
  
• Indoleamine 2,3 deoxygenase (Meisel et al,
  Blood 2004103(12)4619-4621)
• Classical anergy IL- 2 reversible (Zappia
  E et al, Blood 20051061755-61)
• Cell cycle arrest irreversible (Glennie S
  et al, Blood 2005105(7)2821-2827)
• Apoptosis activated T cells (Plumas J et
  al, Leukemia 2005191597-1604)
• Nitric oxide reduces Stat5 phosphorylation (
  murine) ( Sato et al, Blood 2006)
• Interleukin 1 receptor antagonist ( Ortiz et al,
  PNAS 2007)

35
Residual proliferation()of allogeneic and
autologous blood lymphocytes in presence of 5 AD
BM-MSC
(Bocelli-Tyndall C et al Rheumatology 2006)
36
MSC and Autoimmune Diseases Genoa, Italy.
October 26th/ 27th/28th, 2007EULAR, ISNI, and
EBMT Development Committee
37
The Future make haste slowly.
A perfection of means, and confusion of aims,
seems to be our main problem.
Albert Einstein
Any man who can drive safely while kissing a
pretty girl is simply not giving the kiss the
attention it deserves.
Albert Einstein ( in a lighter mood)