Sccr Institute-risa-2017.pptx

THE ART OF STEM CELL From Basic To Clinical Application DR.dr.Agung Putra, Msi,Med

For The Beginning of Formation of SCCR-Institute

The very first idea was created in 2012, inspired by Dr.dr. Agung Putra MSi Med’s reasearch on “Isolating of the Stem Cell Cancer” in Stem Cell Institute, Kalbe Farme. Jakarta”

• To cultivate “a moleculer research-culture” , concerning STEM CELL and CANCER. • Starting to collect information from SCI and fellow research colleagues abroad (Calgary Canada) who have more advanced experience in stem-cell and cancer research. • We finally made it to build our laboratory in end of 2013.

•Located at the heart of Sultan Agung Islamic Hospital, •Our laboratory is made to be accessible for anyone who wants to do the research

• We also have stemcell workshop for fellow doctors and specialists.

Workshop Stem Cell Part I

Prof Dr Harold E. Varmus: • Nobel Prize for medicine : Genetic basis of cancer • Director of the U.S. NCI ( National Cancer Institute)

Prof. DR Jaap Jan Boelens : Stem cell engenering/ Oncologist/ Immunology/---Untrecht Nederland

INTRODUCTION • Severe Organ Damage – Organ transplantation

• Autoimune Disease –Incurable disease

• Degenerative Disease – Incurable disease

Disavantage Of Organ Transplantation 1. The rate of organ donation: 1. 1200 organ/per year---- Much lower than that of the potential recipients 2. Not be possible to meet the need of the new cases arising each year -----around 2.000 and 3.500 2. Neurodegenerative diseases 1. around 100.000 for Parkinson’s disease 2. 600.000 for Alzheimer’s with 8.000 and 6.000 new cases respectively each year. 3. Heart disease : the presence of a new pacemaker could give rise to arrhythmias 4. Complecity process

NEED FOR THERAPEUTIC ALTERNATIVES

STEM CELL Potential source for regenerative medicine and tissue replacement after injury or disease

THE FUTURE OF STEM CELL “ Stem cell therapy is one of the most promising future techniques in the medical arsenal for the repair of damaged or destroyed tissue”

BENEFIT STEM CELL THERAPY 1. Easier to carry out 2. Does not require such a complex surgical procedure 3. Could reach a much wider population.

TARGET STEM CELL THERAPY 1.

2.

3.

4. 5.

Neurologist Departement: 1. Stroke 2. Parkinson's and Alzheimer's disease 3. Huntington’s disease Surgery Departement: 1. Fracture Case 2. Burns Case 3. Repair tendon 4. Spinal cord damage Internist Departement 1. Heart disease--- Miocard Infarct 2. Renal Injury 3. Diabetes Mellitus 4. Peripheral vascular ischaemia--- Ulcus Diabeticum 5. Growth hormone deficiency Dermatologist Department 1. Aging (Cosmetic) Opthalmologist Therapy 1. Lesions in the cornea 2. Retinophaty Diabetica

WHY ?? AND HOW

THE POTENTIAL OF CELL “ Everycell have the potential to develop theirself into some or many different cell types in the body “

CELL TYPE

THE HIGHEST POTENT OF CELL • Stem Cell • Matur Cell / No

DIFFERENTIATED CELL • The vast majority of cells in the body (somatic cells) fall into specific classes or types, such as: – Muscle, – Bone, – Neurons etc • Not interchangeable (a muscle cell cannot become a neuron) • Lost the ability to create new cells. • Have finite lifespans

THE POTENCY OF CELL 1. Totipotent Embrionic Stem Cell 2. Pluripotent Adult Stem Cell 3. Multipotent 4. Progenitor Matur Cell 5. Diffrentiated

The Classification of stem cell 1. Embryonic stem cells--- Pluripotent 2. Adult Stem Cell (Tissue resident stem cells)---Multipotent 1. Hematopoietic stem cells

2. Mesenchymal stromal cells (MSCs) 3. Induced pluripotent stem cells (iPS cells)

4. Cancer stem cells

CANCER STEM CELL

COLABARATION CSC-MACROPHAGE

EMBRIONIC STEM CELL

THE CHARACTERISTIC OF STEM CELL

Tissue damage • Progenitor cells can be activated in: –Tissue injury –Tissue damaged –Dead cells • 2 substances that trigger the progenitors to mobilize toward the damaged tissue. 1. Growth factors 2. Cytokines

“Stem cell niche" “

a specific area of each tissue where they may remain quiescent (nondividing) for many years until they are activated by disease or tissue

injury” ---- “Microenvironment”

Stem cell niche

Homing “ The progenitor could move through the body and migrate towards the tissue where they are needed”.

--- Home sweet home

No Rejection: Safe • Immunoprivileged

as – Do not express HLA class II, CD40, CD80 and CD86 molecules [5]. Furthermore – Express low levels of HLA class I – Not lysed by NK cells and cytotoxic T lymphocytes [17].

• In the absence of costimulation – T-cell engagement can results in anergy • that would contribute to MSC tolerance seen in patients [18].

• Did not induce humoral alloresponse in hematopoietic stem cell transplantation (HSCT) recipients [19],

• Safe therapy

•

Suppression of the immune function by MSC, through – –

• •

Soluble factors Cell–cell contact,

Inhibit the proliferation and the function of immune cells : T and B cells, NK cells and dendritic cells. Recruit - induce T regulatory cells that are involved in immunosuppression.

• Immunosuppressive factors in MSC-mediated Tcell suppression: – IL-10 – IDO – PGE2 – TGF-b – Hepatocyte growth factor (HGF) – Nitric oxide [20].

Paracrine/autocrine mechanisms in stem cell signaling .

Massimiliao Gnecchi et al. Circulation Research. 2008;103:1204-1219

Copyright © American Heart Association, Inc. All rights reserved.

Producing and releasing soluble mediators with known cytoprotective properties.

Mechanisms involved in Neovascularization.

Cardiac Regeneration.

STROKE DESEASE

Neurological scores [National Institutes of Health Stroke Scale (NIHSS) • Assessed on admission – just prior to cell infusion, – immediately after cell infusion, 1, 2, 4, 7 and 14 days, 1, 3 and 6 months -1 year by neurosurgeons and neurologists

• Modified Rankin scores – Parentheses after NIHSS scores, so that a patient with an NIHSS score of 5 and a modified Rankin score of 3 on a given day is presented as having scores of 5

MRI • Brain MRI and MRA (1.5 Tesla, GE) were performed in all patients before and after infusion • brain 3D CT angiography (Toshiba) was carried out in some patients. • MRIs were targeted for admission – 1–2 days prior to cell infusion, – Immediately after cell infusion – 1 and 2 days, – 1 and 2 weeks, – 1, 3 and 6 months – 1 year post-infusion Interpreted by unblinded radiologists.

• This 52-year-old male, with a history of premature ventricular contractions/diabetes mellitus/hypertension, sustained an atherosclerotic stroke due to right internal carotid artery occlusion

• MRI demonstrated infarction of white matter in the right frontal lobe and adjacent basal ganglia • The patient displayed left hemiparesis.

• The patient received an intravenous infusion of 1.6 X 108 autologous human MSCs

NIHSS/Rankin scores Forty-three days after the stroke • • • • • • •

8(4) on Day 28 5(4) on Day 0--- immediately prior to cell infusion. Treatment 3(3) on Day 7, 1(2) on Day 14, 1(2) on Day 30 0(1) on Day 90

NO SIDE AFFECT • There were no major cell injection-related adverse events except slight itching on the hand, face • MRIs following Cell injection showed no tumour or abnormal cell growth over 1 year

MRI – 0 Day: demonstrated lesion volume 21.67 cm3 immediately prior to cell infusion – 7 day post-infusion : 14.61 cm3, without new lesions (Fig. 3C).

MRI Perfusion • Analysis showed increased cerebral blood flow 7 days after injection .

Diabetes Type II

Clinical assessment and follow-up • • • •

Time: first, third, and sixth month. Age and Gender Diabetes duration Medications – Weight, – Height – BMI were recorded. • Laboratory – Fasting plasma glucose (FPG) – Postprandial blood glucose (PBG) – HbA1c – C-peptide

RESULTS • Baseline clinical characteristics between the efficacy and inefficacy groups were not statistically different (p > 0.05). • Treatment: – FBG and PBG: significantly reduced (p < 0.05) – Plasma C-peptide levels and regulatory T (Treg) cell number : numerically higher • however, the difference : did not reach significance (p > 0.05). • During the treatment course – 4 out of 18 patients (22.2%) had slight transient fever. – Up to 6 months: feeling of well-being and were physically more active

CONCLUSIONS • UMSC transfusion – Safe and Well tolerated – Effectively alleviates blood glucose – Increases • The generation of C-peptide • The levelsTregs in a subgroup of T2DM patients.

Diabetes Type I

Treatment for T1DM The insulin injection – Achieve adequate glycemic control, but it is • Inconvenient for the patient and • Does not completely prevent the development of diabetic complications. Other treatments: islet transplantation – have many limitations, • The shortage of donors • Lifetime taken of immunosuppressive agents.

Previous Researche Stem Cell • Had been successfully induced to differentiate into insulinproducing cells in vitro [5-8] – Embryonic stem cells (ESCs) – Umbilical cord blood stem cells – Induced pluripotent stem cells (iPS) – Mesenchymal stem cells (MSCs)

Advantage of MSC • Have potent immunoregulatory capacity both in vitro and in vivo, • modulate many functions of immune cells including T cells, B cells, dendritic cells and NK [9-11]. • Have been tried in [14-16] – Preclinical animal studies – Clinical trials in treatment of • GVHD [12, 13] • Autoimmune diseases: – Multiple sclerosis – systemic lupus erythematosus – Crohn’s disease.

Wharton’s Jelly -Derived MSCs (WJ-MSCs) • Becoming a viable option because a – high yield of young cells

• can be harvested from the umbilical cord without any additional surgery [25].

Clinical assessment and follow-up • All patients received extensive physical and laboratory examinations, – Dose of insulin used – Whole blood cell counts – Liver and renal function tests – Cardiac enzyme and Cardiac troponin – Serum electrolytes – Serum lipids – Blood coagulation function – Microalbuminuria, – Cancer screening test – Glutamic acid decarboxylase antibody (GADA) test---at baseline • Followed up – at monthly intervals for the first 3 months – and then every 3 months for the next 21 months

Insulin requirements Group I

• The dosage of insulin per day: progressively reduced • At the end of the follow-up period, – in 3/15 patients insulin was discontinued – in 8 of the remaining 12 patients: the daily insulin dosage was reduced by more than 50% of the baseline; – in 1 of the remaining 3 patients, the daily insulin dosage was reduced by 15-50% – while there were 2 patients whose insulin dosage was maintained

Insulin requirements Group II

• The dose of insulin per day increased gradually • In 7/14 patients, insulin was increased by more than 50% of the baseline • In the 7 remaining patients, insulin was slightly increased by about 15-45%. • The difference between the two groups was significant (P < 0.001), and the serial changes in the mean doses of insulin required are shown in

HEART ATTACK

Acute Myocardial Infarction (AMI) • Major advances in treatment , still represents a significant cause of mortality and morbidity • Cardiomyocytes begin to die--- if blood supply is not quickly restored ----Undergoes Necrosis or Apoptosis, leading to: – Ischemic cardiomyopathy – Congestive heart failure. • The endogenous regenerative capacity: unable to replenish a significant loss of tissue.

Cirrhosis Hepatis

Osteoatritis

Before Treatment

20h After Treatment

The source of HSC 1. Adult bone marrow 2. Growth-factor mobilized peripheral blood 3. Umbilical Cord Blood (UCB)

Primary Culture Umbilical cord tissue on 1 day

Primary Culture Umbilical cord tissue on 2 day

Primary Culture Umbilical cord tissue on 3 day

Primary Culture Umbilical cord tissue on 5 day

Primary Culture Umbilical cord tissue on 9 day

TENDON

1st Day

2nd Day

3RD DAY

SEBELUM GANTI MEDIUM

SETELAH GANTI MEDIUM

5th Day

THANKS YOU