Human Genome,

Gene Targeted Therapy

&
Stem Cell
Mohammad Saifur Rohman, MD. PhD.
Interventional Cardiologist

Department of Cardiology and Vascular Medicine

Faculty of Medicine, Brawijaya University/dr. Saiful Anwar
Hospital, Malang
 Outlines
• Human Genome
• Genomic to Clinical Practice
• Gene targeted Therapy
• Stem cell
 The genome is our Genetic Blueprint

• Nearly every human

cell contains 23 pairs of
chromosomes
– 1 - 22 and XY or XX
• XY = Male
• XX = Female

• Length of chr 1-22, X, Y

together is ~3.2 billion
bases (about 2 meters
diploid)
 The Genome is
Who We Are on the inside!
• Chromosomes consist Information coded in
DNA
of DNA
– molecular strings of A,
C, G, & T
– base pairs, A-T, C-G
• Genes
– DNA sequences that
encode proteins
– less than 3% of human
genome
 The Completion of the Human Genome
Sequence
• June 2000 White House
announcement that the majority
of the human genome (80%)
had been sequenced (working
draft).
• Working draft made available
on the web July 2000 at
genome.ucsc.edu.
• Publication of 90 percent of the
sequence in the February 2001
issue of the journal Nature.
• Completion of 99.99% of the
genome as finished sequence on
July 2003.
 The Project is not Done…
• Next there is the Annotation:
The sequence is like a topographical map, the
annotation would include cities, towns,
schools, libraries and coffee shops!
So, where are the genes?
How do genes work?
And, how do scientists use this
information for scientific
understanding and to benefit
us?
 What do genes do anyway?
• We only have ~27,000 genes, so that means that each
gene has to do a lot.
• Genes make proteins that make up nearly all we are
(muscles, hair, eyes).
• Almost everything that happens in our bodies happens
because of proteins (walking, digestion, fighting disease).

OR
OR

Eye Color and Hair Color

are determined by genes
 Genes are important
• By selecting different pieces of a gene, your body
can make many kinds of proteins. (This process is
called alternative splicing.)
• If a gene is “expressed” that means it is turned on
and it will make proteins.
 What we’ve learned from our genome so
far…
• There are a relatively small number of human genes,
less than 30,000, but they have a complex architecture
that we are only beginning to understand and
appreciate.
-We know where 85% of genes are in the sequence.
-We don’t know where the other 15% are because
we haven’t seen them “on” (they may only be expressed
during fetal development).
-We only know what about 20% of our genes do so
far.
• So it is relatively easy to locate genes in the genome,
but it is hard to figure out what they do.
 Finding the genes that contribute to
common conditions like cancer, diabetes,
congestive heart failure, Parkinson’s
disease, schizophrenia, autism, stroke,
and osteoporosis is critically important.

But until now, terribly difficult.

Applications of Genomics to Clinical Practice

• Molecular diagnosis
– $1000 for human genome sequence

• Prediction of a healthy person’s risk of disease

– Including cancer, cardiovascular disease, diabetes,
etc.

• Evaluation of responses to drugs and environmental

agents
– Pharmacogenomics
 Where do clinicians begin?
• Begin with assessment of family history

“Even when an individual’s genome can be

displayed on a personal microchip, interpreting
that information will depend in large part, on
the biological and environmental contexts in
which the genome is expressed, and the family
milieu is as good a guide as any.”

Pyeritz RE. JAMA 278:235. 1997

 Family Health History
• Is an important risk factor for chronic diseases
that reflects
– Inherited genetic susceptibility
– Shared environment risk factors (diet)
– Cultural factors (religious practices)
– Common behaviors (smoking, physical activity)

• Prior to offering any genetic susceptibility testing,

a clinician needs to assess the family history of
disease
– Who should be tested?
– What genes should be tested?
 Family History of Diabetes
• T2D is an independent risk factor for the disease

• 88-95% have affected 1st degree relatives

– 70-77% have affected 2nd degree relative

• Individuals with a positive family history are about 2-6 times

more likely to develop T2D than those with a negative family
history
– Risk ~40% if 1 T2D parent; ~80% if 2 T2D parents
 Family History of Diabetes
• FH identifies a group of high risk individuals
– Using a simple and inexpensive approach
– Who may benefit from early detection
– To develop personal and family-based risk factor
modification strategies
– In the future, may benefit from genetic testing

• Has been difficult to find genes for T2D

– Late age at onset
– Polygenic inheritance
• Multiple genes with small effects
– Multifactorial inheritance
 Core Competencies
Represents minimum knowledge, skills and attitudes
necessary for health professionals in all disciplines to
provide patient care that involves awareness of
genetic issues and concerns
– Medicine - Dentistry
– Nursing - Psychology
– Public Health - Social work
Collecting Family History Information in
Clinical Practice

• Other barriers
– Lack of time
– Lack of reimbursement for collecting the
information
– Concerns about insurance / employment
discrimination
– Lack of convenient tools / software for data
collection
Prevention Strategies for High Risk Families

• Targeted lifestyle changes such as diet, exercise and stopping

smoking

• Screening at earlier ages, more frequently and with more

intensive methods than might be used of average risk
individuals

• Use of chemoprevention approaches

– Aspirin

• Referral to a generalist or specialist

Prevention Strategies for High Risk Families

• Will identification of high risk families lead to behavior

change?
– Positive and negative studies

• Consider the tool used for data collection

– Interactive vs. web-based tools
• Complete at home, with input from family members
• In clinician’s office
– Personal digital assistants (PDAs)
• With evidence-based guidelines, monitoring and
feedback options
 Evaluation of Family History Tools
• Before family history is accepted as a screening tool, must
evaluate
– Accuracy and reliability
– Effectiveness of risk stratification on early detection
and prevention

• 4 components of evaluation
– Analytical validity
– Clinical validity
– Clinical utility
– Ethical, legal and social issues

• Same issues would need to be addressed before genetic

testing could be used as a screening tool
Gleevec™ – Specifically Targets
An Abnormal Protein, Blocking
Its Ability To Cause Chronic Myeloid Leukemia
Chromosome 9;22
translocation
Bcr-Abl fusion protein Bcr-Abl fusion protein

Gleevec™

CML Normal
 Cost-Effective?
• Gleevec as 1st line therapy for CML
• 6 years increased survival over interferon-
alpha therapy
• $43,100/per life-year saved

Reed et al, Cancer 101:2574-83, 2004

 PKU Screening
• All published studies show that PKU
screening and treatment represent a net
direct cost savings to society

Phenylketonuria: Screening and Management

NIH Consensus Statement Online 2000
 Uterine
Cancer
48

Colon Colon
Cancer Cancer
51 56

Hereditary NonPolyposis Colon Cancer

(HNPCC)
 Uterine
Cancer
48

Colon Colon
Cancer Cancer
51 56

Identifying Those At Risk

 HNPCC Screening – is it cost-
effective? Need to know…
• Sensitivity, specificity, and timing of genetic
test
• Genotype-phenotype association
• Prevalence of genetic mutations
• Clinical outcome and severity
• Interventions available for mutation carriers
• Effectiveness of interventions
 Genomic Medicine:

Predictive, personalized, and pre-

emptive
 The potential benefits of identifying
genes/variations
involved in disease
Predisposition

 Improve the understanding of disease Targeted screening

etiology and mechanism
Prevention

 Early disease risk assessment

Diagnosis
 Discover new drug targets
Therapy

 Disease prevention

 population or ethnic group variability Predictive

medicine
 Pharmacogenomics:
The Promise of Personalized Medicine
 Disease with Genetic Component
Accelerated by
Human Genome
Project and
HapMap
Identify Genetic Defect(s)

Diagnostics
Pharmacogenomics
Therapeutic
Preventive Developments
Time
Medicine • Gene Therapy
• Drug Therapy
 Genes
• Are carried on a chromosome

• The basic unit of heredity

• Encode how to make a protein

– DNARNA proteins

• Proteins carry out most of life’s function.

• When altered causes dysfunction of a protein

• When there is a mutation in the gene, then it will change the codon, which will
change which amino acid is called for which will change the conformation of the
protein which will change the function of the protein. Genetic disorders result
from mutations in the genome.
 What is Gene Therapy

• It is a technique for correcting defective genes that are

responsible for disease development
• There are four approaches:
1. A normal gene inserted to compensate for a nonfunctional
gene.
2. An abnormal gene traded for a normal gene
3. An abnormal gene repaired through selective reverse
mutation
4. Change the regulation of gene pairs
 The First Case
• The first gene therapy was performed on
September 14th, 1990
– Ashanti DeSilva was treated for SCID
• Sever combined immunodeficiency
– Doctors removed her white blood cells, inserted
the missing gene into the WBC, and then put
them back into her blood stream.
– This strengthened her immune system
– Only worked for a few months 
 How It Works
• A vector delivers the therapeutic gene into a
patient’s target cell
• The target cells become infected with the viral
vector
• The vector’s genetic material is inserted into
the target cell
• Functional proteins are created from the
therapeutic gene causing the cell to return to
a normal state
 Picture 

http://encarta.msn.com/media_461561269/Gene_Therapy.html
 Viruses
• Replicate by inserting their DNA into a host
cell
• Gene therapy can use this to insert genes that
encode for a desired protein to create the
desired trait
• Four different types
 Adenovirus cont.

http://en.wikipedia.org/wiki/Gene_therapy
 Non-viral Options
• Direct introduction of therapeutic DNA
– But only with certain tissue
– Requires a lot of DNA
• Creation of artificial lipid sphere with aqueous core,
liposome
– Carries therapeutic DNA through membrane
• Chemically linking DNA to molecule that will bind to special
cell receptors
– DNA is engulfed by cell membrane
– Less effective 
• Trying to introduce a 47th chromosome
– Exist alongside the 46 others
– Could carry a lot of information
– But how to get the big molecule through membranes?
 Problems with Gene Therapy
• Short Lived
– Hard to rapidly integrate therapeutic DNA into genome and
rapidly dividing nature of cells prevent gene therapy from long
time
– Would have to have multiple rounds of therapy
• Immune Response
– new things introduced leads to immune response
– increased response when a repeat offender enters
• Viral Vectors
– patient could have toxic, immune, inflammatory response
– also may cause disease once inside
• Multigene Disorders
– Heart disease, high blood pressure, Alzheimer’s, arthritis and
diabetes are hard to treat because you need to introduce more
than one gene
• May induce a tumor if integrated in a tumor suppressor gene
because insertional mutagenesis
 Unsuccessful Gene therapies
• Jesse Gelsinger, a gene therapy patient who lacked ornithine
transcarbamylase activity, died in 1999.

• Within hours after doctors shot the normal OTC gene attached to a
therapeutic virus into his liver, Jesse developed a high fever. His
immune system began raging out of control, his blood began
clotting, ammonia levels climbed, his liver hemorrhaged and a flood
of white blood cells shut down his lungs.

• One problem with gene therapy is that one does not have control
over where the gene will be inserted into the genome. The location
of a gene in the genome is of importance for the degree of
expression of the gene and for the regulation of the gene (the so-
called "position effect"), and thus the gene regulatory aspects are
always uncertain after gene therapy
Successful Gene Therapy for Severe Combine
Immunodeficiency

• Infants with severe combined immunodeficiency are unable

to mount an adaptive immune response, because they have a
profound deficiency of lymphocytes.

• severe combined immunodeficiency is inherited as an X-linked

recessive disease, which for all practical purposes affects only
boys. In the other half of the patients with severe combined
immunodeficiency, the inheritance is autosomal recessive —
and there are several abnormalities in the immune system
when the defective gene is encoded on an autosome.
 Severe Combine Immunodeficiency
Continued
• A previous attempt at gene therapy for immunodeficiency
was successful in children with severe combined
immunodeficiency due to a deficiency of adenosine
deaminase. In these patients, peripheral T cells were
transduced with a vector bearing the gene for adenosine
deaminase. The experiment was extremely labor intensive,
because mature peripheral-blood T cells were modified
rather than stem cells, and the procedure therefore had to
be repeated many times to achieve success.
 Successful One Year Gene Therapy Trial
For Parkinson's Disease

• Neurologix a biotech company announced that they have

successfully completed its landmark Phase I trial of gene
therapy for Parkinson's Disease.

• This was a 12 patient study with four patients in each of three

dose escalating cohorts. All procedures were performed under
local anesthesia and all 12 patients were discharged from the
hospital within 48 hours of the procedure, and followed for 12
months. Primary outcomes of the study design, safety and
tolerability, were successfully met. There were no adverse
events reported relating to the treatment.
 Recent Developments

• Genes get into brain using liposomes coated in polymer call

polyethylene glycol
– potential for treating Parkinson’s disease
• RNA interference or gene silencing to treat Huntington’s
– siRNAs used to degrade RNA of particular sequence
– abnormal protein wont be produced
• Create tiny liposomes that can carry therapeutic DNA through
pores of nuclear membrane
• Sickle cell successfully treated in mice
 Current Status
• FDA hasn’t approved any human gene therapy product for
sale
Reasons:
• In 1999, 18-year-old Jesse Gelsinger died from multiple organ
failure 4 days after treatment for omithine transcarboxylase
deficiency.
– Death was triggered by severe immune response to
adenovirus carrier
• January 2003, halt to using retrovirus vectors in blood stem
cells because children developed leukemia-like condition after
successful treatment for X-linked severe combined
immunodeficiency disease
Gene Therapy vs. Cell Therapy
• Genetic mutation Gene Therapy

• Protein dysfunction

• Cell dysfunction Cell Therapy

• Tissue Dysfunction From Stem Cell

• Organ Dysfunction
 Mammalian development
Oocyte Zygote Developmental
potential

Sperm Totipotent

Trophoblast
(extraembryonic)

Inner cell Embryonic

mass Blastocyst Pluripotent
Stem cells
(in vitro)

Epiblast

Primitive Multipotent

Primitive streak

Endoderm Mesoderm Ectoderm

(lung, liver, (blood, heart, bone, (central and peripheral
pancreas, etc.) skeletal muscle, etc.) nervous system,
epidermis, etc.)

48
Emerging Technol Platform for SCs, 2010.-
 Embryonic Stem Cell Pathway

Germ layers & Embryonic Reprogrammed

Tissue stem cells
Adult stem cells
differentiation
Tissue stem cells
Mesoderm Ectoderm

Endoderm

Tissue
stem cells
Neurones
Muscle
Blood cells
Lung/Gut/Liver

DNA
Tissue
transfection
Engineering

Cell Transplantation

e.g., Neuronal bundles or

Gene Therapy Pancreatic Islets, etc.

49
SC Technol, Basic Applic 2010.-
 Embryonic and Adult Stem Cells

totipotent

Loose definition
Strict definition pluripotent

23/05/2010, Seminar Univ

Boenjamin Setiawan, dr.,PhD
Brawijaya
 There are two main types of Stem Cells—
Adult & Embryonic Stem Cells

• Adult stem cells

– found in adult tissue
– can self-renew many times
– are multipotent – they can differentiate to become only the
types of cells in the tissue they come from.
• hematopoietic stem cells – give rise to blood cells
• mesenchymal stem cells – give rise to cells of
connective tissues and bones
• umbilical cord stem cells – a rich source of
hematopoietic stem cells
• stem cells found in amniotic fluid – might be more
flexible than adult stem cells

23/05/2010, Seminar Univ

Boenjamin Setiawan, dr.,PhD
Brawijaya
 Where are adult stem cells found and what do
they normally do?

• An adult stem cell is an undifferentiated cell

found among differentiated cells in a tissue or
organ, can renew itself, and can differentiate to
yield the major specialized cell types of the tissue
or organ.

23/05/2010, Seminar Univ

Boenjamin Setiawan, dr.,PhD
Brawijaya
 Where adult stem cells are found?
Adult stem cells have been identified in many organs and tissues.
However, there are a very small number of stem cells in each
tissue.

• Stem cells are thought to reside in a specific area of each tissue

where they may remain quiescent (non-dividing, STEM CELL
NICHE) for many years until they are activated by disease or
tissue injury.

• The adult tissues reported to contain stem cells include Brain,

Bone marrow, Peripheral blood, Blood vessels, Skeletal muscle,
Skin, hUCB, Umbilical Cord, Amniotic liquid, Adipose Tissue, liver
etc.

23/05/2010, Seminar Univ

Boenjamin Setiawan, dr.,PhD
Brawijaya
 Adult Stem Cells
1. Isolation: umbilical cord, blood,
adipocytes, skin, dental pulp…

2. Expansion in vitro

3. Exposure to chemical cocktails

4. Injection in blood or tissues

5. iPSC (induced pluripotent SC) Cell lineages

6. Mobilization
Cellular
Plasticity
• The discovery of mammalian cellular plasticity
raises the possibility of reprogramming restricted
cell fate, & may provide an alternative to many of
the obstacles associated with using embryonic &
adult stem cells in clinical applications.-
• With a safe & efficient dedifferentiation process,
healthy, abundant & easily accesible adult cells
from a given individual could be used to generate
different functional cell types to repair damaged
tissues & organ.-
Lyssiatis et al, Emmerging Techno Platform for SCs, 2009.- 56
Examples of transcription factor over expression or
ablation experiments that result in cell fate changes

57
Nature 2009.-
Methods Used to
Cellular Reprogramming

• Nuclear Transplantation.-
Somatic Cell Nuclear Transfer (SCNT)
• Cell Fusion.-
• Culture Mediated.-
• Genetic Approach.-
• Small Molecule.-

Pollyana et al, SC Technol 2010.- 58

 Induced Pluripotent
Stem (iPS) Cells

• Yamanaka could produce cell lines with

some of the properties of ES cells by
introducing just four transcription factors
associated with pluripotency – Oct3/4,
Sox2, c-Myc & Klf4 – into mouse skin
fibroblast then selecting cells that
expressed a marker of pluripotency, Fbx15,
in response to these factors, these cells
were called iPS cells.-

Rossant, Nature 2007.-

 Hypothetical strategy for using iPS cells in
cell-based therapies

Nature Med 2007.-

 iPS cells generation in patient fibroblasts
 Parkinson’s disease (Wernig and Jaenisch, 2008, Maehr and Melton PNAS 2009).
 Amyopathic Lateral Sclerosis, (Dimos and Eggan Science 2008)
 Type I diabetes (Maehr and Melton PNAS 2009)
 ADA-SCID, SBDS, Gaucher disease, Duchenne and Becker Muscular dystrophin,
Parkinson’s disease, Huntington disease, JDM, Down syndrome, Lesch-Nyhan
syndrome. (Park and Daley Cell 2008).

iPS cells generation from other cell types

• Blood cells (Loh and Daley 2009). B-cells (Hanna and Jaenisch Cell 2008)
• Blood stem cells (Emiinli and Hochedlinger Nat Genet 2009)
• Pancreatic b-cells (Stadtfeld and Hochedlinger Cell Stem Cell2008)
• Hepatic and gastric endoderm (Aoi and Yamanaka Science 2008)
• Neural stem cells (Kim and Scholar, Nature 2008)
23/05/2010, Seminar Univ
Boenjamin Setiawan, dr.,PhD 61
Brawijaya
Chemical Approach to
Stem Cells & Regenerative Medicine
• Chemical approaches are starting to have an
increasingly important role in this young field.-
• Attention has focused on chemical approaches
that allow the precise manipulation of cells in
vitro to obtain homogeneous cell types for cell-
based therapies.-
• Such approach with biological & chemical
therapeutics to stimulate endogenous cells to
regenerate, & can act on target cells or their
niches in vivo to promote cell survival
proliferation, differentiation, reprogramming &
homing.-
Xu et al, Nature 2008.-
Other Therapeutic Strategy for
Regenerative Medicine

• Small Molecules
Small molecules can target stem cells
or progenitor cells for self-renewal or
differentiation.-
(example : retinoic acid, cytidine
analogues)
63
Small
Molecules
• Selected chemical compounds that regulate
cell fate : synthetic small molecules &
natural products that bind to nuclear
receptors ( all – trans retinoic acid &
dexamethasone), histone & DNA modifing
enzymes (trichostatin A, BIX01294, 5-
azacytidine) protein kinase & signaling
molecules (reversin, purmorphamine,
forskolin, QSII, B10, cyclopamin,
pluripotin & Y-27632).-

Xu et al, Nature 2008.-

 Chemical Reprogramming
Osteoblasts

Lineage-specific
differentiation
conditions
Small molecule
induced
Myoblasts multipotency
(a) Adipocytes
Osteoblast,
adipocytes Fibroblast

C2C12 Osteoblasts,
myoblasts Myogenic cells
HN O

N N
N

N
N N
H
Osteoblasts, H
3TE1
adipocytes Reversine osteoblast

Adipocytes
(b) Skeletal
myoblasts
O O
OH
Oligodendrocytes

HDAC
inhibitors Neural
Stem-like
cell
Astrocytes
Oligodendrocyte
Precursor cells
(c) Neurons
65
Emerging Technol Platform for SCs, 2010.-
 Therapeutic strategies for regenerative
medicine
Terminally differentiated cells
Terminally differentiated cells
A B
Bone marrow

Progenitor c
cell

Hematopoietic Precursor Progenitor

stem cell cell cell
b c
a d
e Drug targeting
endogenous stem
Osteoblast Extracellular cells or progenitor cells
matrix

66
Nature 2008.-
The Use of Stem Cells in Medicine:
Which type of cells used ?

Hematopoietic stem cells :

Cardiovascular Disease
Mesenchymal stem cells:
Metabolic Disease
Umbilical cord stem cells
Cancer stem Cells
 Stem Cells
for
Cardiovascular Disease

Saifur MS Literature review, 2009

 Background
• The paradigm that the heart is a postmitotic organ
incapable of regenerating parenchymal cells was
established in the 1970s1

• This dogma has profoundly conditioned basic and clinical

research in cardiology for the last 3 decades2

• The only response of cardiomyocytes to stress is

hypertrophy and/or death3

1. Nadal-Ginard B, Mahdavi V. J Clin Invest 1989;84:1693–1700.

2. Chien KR. Nature 2004;428:607– 608.
3. Anversa P, Kajstura J, Leri A, Bolli R. Circulation 2006;113;1451-1463
 New Insight

• Beltrami group in 1998 : Evidence of myocytes

proliferation in cardiomyopathy1

• More myocytes reenter cell cycle after infarction2

• From circulating or resident stem cells ?2

• On going reparative mechanism mediated by circulating

stem cells3

• Artificially amplify by locally applying stem cells

1. Kajstura J, Beltrami CA, et al. Proc Natl Acad Sci USA 1998; 95: 8801-8805.
2. Beltrami AP, et al. N Engl J Med 2001; 344: 1750-1757
3. Quaini F, et al. N Engl J Med 2002;346:5–15
Factors affecting regeneration

Segers VF, Lee RT. Nature 2008; 451: 937-942.

 Various questions remain:
• The identification of those patients who benefit most from
cell therapy

• The optimal cell type and number for patient with acute
and chronic diseases

• The best time and way of cell delivery, and the

mechanisms of action by which cells exhibit beneficial
effects

• Although no major safety concerns were raised during the

initial clinical trials, several potential side effects need to
be carefully monitored

Arterioscler Thromb Vasc Biol. 2008;28:208-216

Stem Cells for AMI: Mainly MNC

Wollert KC, Drexler H. Circ Res 2005; 96:151-163

 No Revascularization Option:
MNN by Transendocardial Delivery

Wollert KC, Drexler H. Circ Res 2005; 96:151-163

Myoblast: Transepicardial Delivery

Wollert KC, Drexler H. Circ Res 2005; 96:151-163

Clinical Trials : Cell Preparation

Dimmeler S, Burchfield J, Zeiher AM. Arterioscler Thromb Vasc Biol 2008; 28:208-216.
Clinical Trials: Cell Preparation

Dimmeler S, Burchfield J, Zeiher AM. Arterioscler Thromb Vasc Biol 2008; 28:208-216.
Mechanism of Actions

Wollert KC, Drexler H. Circ Res 2005; 96:151-163

 Results of Clinical Trials
• Overall, the intracoronary infusion of autologous BMC is safe
and feasible in patients with acute myocardial infarction

• Improvement in global LV ejection fraction by an absolute 6

to 9 percentage point, reduced end-systolic LV volumes, and
improved perfusion in the infarcted area 4 to 6 months after
cell transplantation.

• Janssens did not reveal a significant effect on global ejection

fraction, but showed an improvement in regional ejection
fraction and a reduction of the infarct size in the BMC group.

Dimmeler S, Burchfield J, Zeiher AM. Arterioscler Thromb Vasc Biol 2008; 28:208-216.
 The proper time ?

• Patients with a lower baseline ejection fraction showed a

significant 3-fold higher recovery in global ejection
fraction indicating that patients with more severe
myocardial infarction profit most from BMC therapy

• Patients being treated up to 4 days after the myocardial

infarction showed no benefit, whereas later treatment
(day 4 to 8) provided an enhanced improvement of
ejection fraction during follow-up

Dimmeler S, Burchfield J, Zeiher AM. Arterioscler Thromb Vasc Biol 2008; 28:208-216.
Myoblast, CD133 and mesenchymal cells
• The Myoblast Autologous Grafting in Ischemic Cardiomyopathy
(MAGIC) trial was a randomized, placebo-controlled, 3-arm,
double-blind trial. Myoblast transfer did not improve regional or
global LV function beyond that seen in control patients.
• A higher number of arrhythmic events in the myoblast-treated
patients. Another study of CAuSMIC also used myoblast showing
improvement QOL

• Intracoronary administration of enriched CD133+ cells is feasible

but was associated with increased incidence of coronary events

• Another study used adipose tissue-derived mesenchymal cells

using NOGA (PRECISE Trial)

Menasché P, Alfieri O, Janssens S, McKenna W, et al.Circulation.2008;117:1189-1200.

 Bone marrow–derived
stem cells

• They have a role in promoting angiogenesis1

• The physical incorporation of progenitor cells into new

capillaries or by perivascular accumulation of cells1

• Provide paracrine survival signals to cardiomyocytes2

• Protect from apoptotic and modulate inflammation2

1. Urbich C, Dimmeler S. Circ Res 2004; 95: 343–353.

2. Gnecchi M, et al. Nat Med 2005;11: 367–368.
 Embryonic Stem Cells

• Clonality, self renewal and multipotentiality

• Immunological rejection
• Propensity of ES cells to form teratomas
• To limit teratoma : differentiate on of ES cells invitro
• Differentiated ES cells can survive and improve myocardial
function if delivered to the myocardium in a rich
prosurvival cocktail

Segers VF, Lee RT. Nature 2008; 451: 937-942.

 Future Direction
• Cell enhancement strategies
• Specific attention should be given to the processing of the
cells before initiating their clinical application
• Progression to widespread clinical application must be
balanced against the inherent risk of testing a novel
therapy
• Proceed in controlled trials with the utmost rigorous
scientific and ethical standards, extensive in vitro and
animal studies
• The promise of functional cardiac regeneration by cell-
based therapies offers novel opportunities to address the
large unmet clinical need of treating patients with severe
cardiac dysfunction

Dimmeler S, Burchfield J, Zeiher AM. Arterioscler Thromb Vasc Biol 2008; 28:208-216.
 Therapeutic strategy
• Preactivation of Cells

• Treatment of the Target Tissue to Improve Homing and

Engraftment

• Modulation of Common Endogenous Modifiers of Stem

Cell Exhaustion and Organism Aging

Dimmeler S, Leri A. Circ Res 2008; 102; 1319-1330

 Preactivation of Cells

Bone-marrow-derived stem/progenitor cells:

Hematopoietic stem cells Tissue-derived stem/progenitor cells:
Endothelial progenitor cells Cardiac stem cells
Mesenchymal stem cells Adipose-tissue derived cells
SP Cells

Pretreament to improve
Survival
Homing
Functional engrafment
Functional activity

Dimmeler S, Leri A.
Circ Res 2008; 102; 1319-1330
 Current Clinical Uses of Adult Stem Cells

 Cancers—Lymphomas, multiple myeloma, leukemias, breast

cancer, neuroblastoma, renal cell carcinoma, ovarian cancer
 Autoimmune diseases — multiple sclerosis, systemic lupus,
rheumatoid arthritis, scleroderma, scleromyxedema, Crohn’s
disease
 Anemias (incl. sickle cell anemia)
 Immunodeficiencies—including human gene therapy
 Bone/cartilage deformities — children with osteogenesis
imperfecta
 Corneal scarring – generation of new corneas to restore sight
 Stroke—neural cell implants in clinical trials
 Current Clinical Uses of Adult Stem Cells

 Repairing cardiac tissue after heart attack — bone marrow or

muscle stem cells from patient
 Parkinson’s—retinal stem cells, patient’s own neural stem
cells, injected growth factors
 Growth of new blood vessels — e.g., preventing gangrene
 Gastrointestinal epithelia — regenerate damaged ulcerous
tissue
 Skin — grafts grown from hair follicle stem cells, after
plucking a few hairs from patient
 Wound healing — bone marrow stem cells stimulated skin
healing
 Spinal cord injury — clinical trials currently in Portugal, Italy,
S. Korea
 Liver failure — clinical trials in U.K.
Thank You