Are All MSC's Created Equal? - Choose the Best Source of Stem Cells for Your Patients

Hi, this is Dr. Joy Kong. I'm a practicing physician at Thea center for Regenerative Medicine in Los Angeles, California. I'm also the founder and CEO of Chowro Biologics and the president of American Academy of Integrative Cell Therapy. And the topic I'd like to discuss here with you today is about how to pick the most effective stem cell source to help your patients. Specifically, we're going to talk about MSCs, the mesenchymal stem cells. These are the conductor in the symphony of regeneration. So let's take a look.

One thing we all want is to provide our patients with the best kind of stem cells for therapeutic use. So we all know MSCs are crucial and is the most important cells in the process of, of regeneration. So are MSCs from different tissue sources the same? This talk is about the comparisons of the mscs from different tissue sources, so you can make an educated decision about what may be the best type of mscs to give your patients. So first of all, what are MSCs? Well, in 1980s and early 1990s, what's interesting is that it was still believed that the only type of stem cells that still exist in the adult body were actually hematopoietic stem cells. It's only in early 1990s that MSCs were found. And they represent a class of cells that have the in vitro capacity to differentiate into mesodermal tissues such as bone, cartilage or fat. They have many names, such as merostromo cells, multipotent stromal cells, mesodermal stem cells, or mesenchymal stromal cells. So all kinds of combinations, but all shortened as MSCS. And the father of MSCS, Dr. Arnold Kaplan, who discovered MSCS, actually has been proposing to rename these cells as medicinal signaling cells. And the reason he's proposing that is because these cells function less as a typical stem cell, which is to differentiate and become a tissue specific cell. But they function more as a cell that orchestrate the regenerative process by sending out various relevant signals. So he feels that it will be misrepresenting really the type of function that these cells have by keeping calling them stem cells. He thinks that these should be categorized as medicinal signaling cells. These cells are derived from pericytes, so the perivascular cells. So they are huddling around the blood vessels and they can be isolated from every vascularized tissue in our body. Then what's interesting is every tissue specific stem cell is sitting next to and in communication with the parasite or mse that's sitting on the blood vessel. There's a constant crosstalk between the local STEM cells and MSCs. Now let's talk in greater details about why the MSCs are so important. So first of all, they have what's called trophic effects, so they're also called the paracrine effect. What these cells can do is to home into areas of inflammation and injury because of the chemical signals secreted by these areas. And once the cells get there, they can induce changes in the neighboring cells, including the resident stem cells. They do so by secreting cytokines and growth factors to induce such cellular changes. And the MSCs also have powerful anti inflammatory effects, so they can secrete anti inflammatory cytokines in response to inflammation. And we all know that inflammation has such a fundamental role in all the modern chronic conditions. And next, the MSCs have profound immunomodulatory effects, so they're able to regulate the immune functions. They're able to facilitate a T1 to T2 dominant immune response, especially in autoimmune disorders. And MICs also have anti apoptotic effects, so they're able to rescue apoptotic cells that may be induced by trauma, hypoxia or mechanical damages, et cetera. And it will prevent these cells from going down the path of programmed cells death. You can imagine in cases like stroke, the neighboring cells that has not died were sent out receive signals from the dying cells that they should die as well. But MSCs can come in and give them the just right signal to tell them that they don't have to die. That's preserving more tissue. And next, these MSCs also have antimicrobial properties, so they have been shown to be effective against acute or chronic infections. They're actually able to secrete antimicrobial peptides and they can be effective against bacteria, viruses or protozoa parasites. And lastly, it has been found that these mics have antifibrotic effects and they can assist in the breaking down of scar tissue that can be very helpful in cases such as liver cirrhosis or post myocardial infarction scarring. So now we know MSCs are everywhere in every vascularized tissue in our body. So are they all functionally equivalent? So let's take a look. So initially, MSCs were found from bone marrow. So bone marrow does contain MSCs. About one in every 100,000 cells is an MSC in the bone marrow. Of course, that varies with age. It drastically declines as a person gets older, down to about 1 in 2 million. When a person reaches 80 years old and the other source is liposuction is from fat. So that has become increasingly popular. And what happens with fat aspirate is that they spin them down to obtain the stromovascular fraction and within that pellet contain the adipose derived stem cells. And a lot of them are MSCs and you can infuse the MSE or you can expand them and infuse them. So, so the question is, does age matter? So we can get these mics out of people from various tissues, will age play a factor? So the fact that mics do stay in a person's body for a lifetime, that does make them more susceptible to accumulations of various cellular changes. That kind of cellular change can lead to cell death, senescence, loss of regenerative function or even neoplastic transformation. But then when you look at neonatal MSCs such as ones from Orton's jelly, they are spared from such pro aging factors. So let's look at some evidence regarding whether or not age matters. Here's one study. They looked at adipose derived mics from an aged person and they found out that these mics are significantly compromised in their ability to support vascular network formation and they're unable to rescue age related impairment in wound healing. And here's another study, they looked at bone marrow derived MSCs and they found out that comparing to developmentally early MSCs, they have less myogenic potential or engraftment properties, so they're less likely to stay after transplanted and they have less potential to regenerate muscle cells. Here's another study that looked at bone marrow stem cells and they found that these cells exhibit age related decline in inflammatory response in the cytokine chemokine receptor expression that's important for the MIC migration and activation and also impair their immune modulatory activities. Now let's look at some more evidence. So this study looked at gene expression that's related to senescence. So they looked at adipose derived stem cells, what happened when they age and they found out these senescent genes actually get expressed more and more. Here's another study that looked at the effect of aging on the availability of adipose derived stem cells and their angiogenic properties and found out that as they age, these properties continue to decline. And another study looked at the levels of reactive oxygen species in aging bone marrow stem cells. So the more they age, the higher the level of reactive oxygen species there are. And we all know that reactive auction species is a crucial factor in causing cellular damage and decline they also found out, a different study found out that older adipose derived stem cells actually are more sensitive to these reactive oxygen species. Not only do they have more that's inside of them, but they also are more susceptible to them and that impair their therapeutic effectiveness. Now let's look at some more evidence about why age matter. So this study looked at young MSCs from someone between age 1 to 5. And these young MSCs actually outperformed older MSCs from somebody that's 50 to 70 years of age in their ability to improve cardiac parameters after myocardial infarction. So they're therapeutically more effective. Here's another study that showed that mics from young individuals can still undergo neuroectodermal differentiation in vitro, but the bone marrow derived mics from elderly patients can't do that anymore. Here's another study that looked at certain factors that we're exposed to in our lifetime and such as something as simple as NSAIDs that anti inflammatories that everybody takes so liberally. But these anti inflammatory drugs can inhibit MIC's ability to differentiate into cartilage and bone. So the question is, do we even look at these factors when we are extracting the stem cells from a patient's own body? Here's some more evidence. One thing is that we also have failed to look at lifestyle factors. But this study is trying to figure out what's the effect of diet. So they looked at high fat diet on mice. So when they feed the mice high fat diet and get their adipose derived stem cells, they found that these cells have higher potential to differentiate into fat cells and but lower potential to differentiate into endothelial cells, which can be extremely helpful when it comes to tissue regeneration. And here's another study that look at cells obtained from obese patients. So they found that the osteogenic potential of these cells from obese patients actually are impaired. So the mineralization nodules they were forming were less in number and smaller in size. And so many people suffer from diabetes. And they realize this study found out that metabolic diseases like diabetes can affect the environment that these stem cells are in. So diabetes can diminish the cell's ability to establish vascular network both in vitro and in vivo. And one thing we know is how prevalent obesity is and how many people are overweight. So according to world health organizations, 35% of adults in the world are are overweight and 11% are obese and 8% have diabetes. So are we looking at these factors when we're about to give someone cell therapy Using their own cells. So another source of stem cells is perinatal source. So here is the perinatal tissue. So you got the placenta, and that's composed of the placenta, the umbilical cord and the amniotic membrane. And here's a cross section of the human umbilical cord. So you can see the two arteries and one vein. And they're enveloped in this gelatinous material that's called Wharton's jelly. So they serve to cushion and protect and probably much more that we don't quite understand yet in this Wharton's jelly. It's full of MSCs. So what are the functions of these MSCs in Wharton's jelly? So that's a question to be answered. And Wharton's jelly is enveloped in the amniotic membrane. So that's the structure. And what are the dominant cell types in either the Wharton's jelly that's composed of most of the cork tissue or the cord blood. In cord tissue, the dominant cell type is mesenchymal stem cells, whereas in cord blood the dominant cell type is hematopoietic stem cells. There are actually some direct comparative studies and in this particular study they looked at this particular topic in detail. So they compared umbilical Cord blood derived mics with bone marrow and adipose derived MSCs. So they looked at different parameters such as the growth profile, the cellular senescence and anti inflammatory properties. So let's go over them when it comes to growth profiles. First they looked at the proliferative capacity. So bone marrow and adipose derived MSCs actually stop growing at passage 11 to 12. But the umbilical cord blood derived mics, they don't stop growing until passage 14 to 18. So it's almost like they've got more life in them to keep going. What about the rate of growth? This is measured by population doubling time. The rate of growth is highest in umbilical cord blood derived mics and lowest in adipose derived MSCs. And then they looked at the clonogenicity, so ability to form clones, so multiplying, forming this colony. And again you can see umbilical cord blood derived mics actually has the highest capability to form these clones. And adipose derived mscs has the lowest. And next let's look at cellular senescence. So cells, the process of cells getting older. They looked at a particular marker for cell aging. So using what's called gall staining. And they detected that these staining results showing senescence, A passage six, there was positive senescence in bone marrow and adipose derived stem cells, but not in umbilical cord blood derived stem cells. So they haven't manifested these signs of aging. And from passage 9 to 12, the gall expression increased dramatically for all three types. But still the umbilical cord blood derived MSCs have the lowest expression of this particular marker. And then they look at other markers. So some other senescence related proteins such as P53, P21 and P16 during progressive passages. And again, umbilical cord blood derived MSEs only weakly express these markers, whereas bone marrow adipose derived mics strongly express these markers. Now let's take a look at the anti inflammatory properties when you compare these three tissue sources. So what they found out is that comparing to bone marrow and adipose derived MSCs, umbilical cord blood derived MSCs significantly downregulate inflammatory cytokines. And they also secrete much higher level of anti inflammatory protein ANGK1, which is closely associated with upregulation of anti inflammatory factors. So not only they downregulate the inflammatory factors, they also upregulate the anti inflammatory factors. So the umbilical Cord blood derived MSCs are more effective when it comes to the anti inflammatory properties. And there are also other comparisons done in various studies, so I'm gonna present them by various categories. So when it comes to orthopedics, there's some studies that compared various tissue source MSCs. So this study compared the umbilical cord MSCs to bone marrow MSCs in their ability to produce collagens. And they found out umbilical cord MSEs produce three times as much collagen. And another study showed that in these MSE's ability to form bone or cartilage, the umbilical cord derived MSCs have greater potential to form bone and cartilage comparing to bone marrow derived MSCs. Another category that's looked at is cancer. So what's the effect of these mesenchymal stem cells on cancer? So this study is very interesting. They actually looked at effects of umbilical cord blood derived MSCs versus adipose derived MSCs on glioblastoma. So both in vitro and in vivo, the umbilical Cord blood derived mics inhibited the glioblastoma growth, whereas adipose derived MSCs promoted the glioblastoma growth. This is a very powerful study. They also found out that the umbilical cord blood derived MSEs is able to induce apoptosis through this particular factor called trail. It's a tumor necrosis factor related apoptosis inducing ligand. So the TRAIL is much more strongly expressed by umbilical cord blood derived MSEs than by adipose derived MSEs. And they think this contributes to why they can fight off the cancer so much more effectively. And here's another study and what's shown is that Wharton's jelly MSCs do not induce teratoma and they do not induce tumors. And they're also not associated with enhancing the growth of solid tumors and can even fight off certain solid tumors. And they found such evidence in breast adenocarcinoma, ovarian carcinoma and osteocarcinoma. Very fascinating information. Here's another category that some studies have looked at, its ability to generate blood vessels. And they found that Wharton's jelly derived MSCs have stronger expressions of angiogenic factors and immunomodulatory molecules. And certain angiogenic factors also are known to have antifibrotic properties and that could be used to reduce or even prevent fibrosis and scarring. So this is, you know, what we talked about earlier on the anti fibrotic effects of MSCs. And Wharton's jelly MSCs of course have stronger ability to do so. And here is looking at the ability of MSCs to induce endothelial cells to migrate to certain areas to help generate blood vessels and, and warts. And jelly MSCs are better at doing this than bone marrow derived MSCs. And here's another category, neuroprotection. And a study found out that Word's jelly derived mics actually secrete factors that have better neuroprotective effects than the factors from bone marrow derived MSCs. And they can more effectively decrease cell death in apoptosis. The same study found that gene expressions in these various kinds of MSCs have different properties. So Wharton's jelly derived MSCs, their genes that are active include genes related to cellular proliferation, neurogenesis, nervous system development and blood vessel development. Whereas bone marrow derived MSEs are more tailored toward ossification and skeletal development. So this gives you a clue about the profound differences between these two kinds of MSCs. They're all MSCs. But the Wharton's jelly derived MSCs have so much more potential than the bone marrow derived MSCs. And I want to talk a little bit more about umbilical cord MSCs. So when you talk about umbilical cord MSCs, so that includes MSCs from the Orton's jelly vein arteries, the umbilical cord lining membrane and perivascular region. So the primitivity, they measure that by gene expression. So they found out that Wharton's jelly derived MSCs actually have high expression of embryonic genes. And the Wharton's jelly is a very primitive source of MSCs. It's actually somewhere between the embryonic stem cells and the mature adult stem cell. And looking at the differentiation potential of umbilical cord derived MSEs. So when they looked at the osteogenic differentiation potentials, Wharton Jelly Derived MSEs or Whole Cord Derived MSCs are the best at differentiating into bone, comparing to umbilical cord, artery and vein and lining MSEs. And they found out that wardens jelly MSEs can differentiate into all these other kinds of cells, cardiomyocytes, neurons, glia, oligodendrocytes and hepatocytes, in addition to the typical osteocyte, chondrocytes and adipocyte that we know about. And what about gene expression? So what's interesting is that in different compartments of the umbilical cord, the genes that are upregulated are different. So even though they're all umbilical cord derived MSEs, because they're in different sections, the more prominent genes are different. So when you look at amnion, so that's the fetal facing membrane, the amnionic membrane derived MSEs are more tailored towards cellular growth proliferation, whereas the chorion membrane, so the chorion is maternal facing. And MSEs in the chorion tend to be more tailored toward cardiovascular and hematopoietic system development, whereas umbilical cord MSEs. So mostly Wharton's jelly and that has more gene expressions in the nervous system and behavioral system development. So, so even though they're all umbilical cord MSCs, they have different niches. So I want to talk about the various stem cell transplants. Of course the majority of stem cell transplants done these days are still autologous. So using a patient's own either bone marrow or adipose or blood derived. So they're various forms, but it comes from a patient's own body. So what are the advantages of these autologous transplant? So first of all, it is perfect HLA match. So it's true that you know it's from the same individual. Another one is that because they're perfect match, there's a higher chance of long term engraftment. So that being said, we now know that that the way mscs function is really not through engraftment and differentiation. So what we know that even if you transplant a person's own mscs, very little engraftment actually occurs. So the majority of the function of these cells perform is through paroquin effects is by sending out signals to neighboring cells and signaling our native stem cells, the resident stem cells, to differentiate rather than them differentiating themselves. What about disadvantages of autologous stem cell transplants? First of all, you do have to get the cells and that can be an invasive procedure and can be pretty inconvenient, leading to pain, scarring, and there's a risk of infection. And procedure can require hours. And the other thing is that the quality control is more difficult because patients are getting these done in a physician's office. And physician's offices are not laboratories. They're not equipped or trained to do that. What they have is a machine that they purchased and they may have taken the course learning how to operate the machine. But there's so many variables in various physician's offices, the quality control becomes quite difficult. And also we know that when the patient ages or when they have a disease, the quantity and quality of their stem cells do decline. One thing we know is that when we were born, one out of every 10,000 cells in our body is a stem cell, is a mesenchymal stem cell. When we reach teenage years, that number becomes 1 in 100,000. So that has drastically declined. And when the person reaches age 40, that number becomes 1 in 400,000 cells. And then when we reach 80, it becomes 1 in 2 million. So the quantity drastically declines as we age. And then for example, in bone marrow, they've seen that red bone marrow are gradually changed to yellow bone marrow as we age. And there's also toxic buildup in adipose tissue. Another disadvantage is that these cells are less potent, they have shorter telomeres, they're just less versatile. So they have less differentiation potential as we've seen. And they secrete less anti inflammatory factors, less growth factors, they senesce more quickly and they're less neuroprotective. And also from the products obtained from the patient themselves, there's also less number and concentration of growth factors. Ch just because as we age we have less of them. And if you are giving these cells iv, which a lot of doctors do, what happens to these cells when they're given an iv? They are attracted to areas inflammation injury. And you had just caused an injury by obtaining the cells. So that would be the first place the cells want to go is to fix that injury you just caused. Caused. Not to mention that you are depleting your own stem cell pool by taking the cells out and reinjecting them. Because most of these cells, after you process them and re inject them, they will eventually die. So very few actually engraft like I said. And lastly, pretty difficult to achieve frequent and regular dosing. So if you want to treat certain conditions, you may want to, they may require regular dosing because a lot of times from the studies that have shown the stem cell effects on various diseases, a lot of times you will see that repeat document dosing may be needed in six to nine months. So are you going to subject a person to another procedure to obtain these autologous cell source? So these are some of the disadvantages. And let's take a look at perinatal allogeneic stem cell transplant. What are the disadvantages? So first of all, yes, there's possible immune response. These cells contain some HLA1 markers and these are important and they are marking the cells as human. So it prevents a human immune system to attack. They have very little HLA2 markers and these are the immunogenic markers. And what's the other disadvantage? They are less likely to engraft. As we talked about. But we also talked about, the main mechanism is not through engraftment but through paracrine effect. Whether you give autologous or allogenic stem cells, there's very little engraftment. So that's not their main mechanism. What are the advantages? We know that these cells are more precise, primitive, they proliferate faster, they have more differentiation potentials and also they have longer telomeres, so they have more generations left. They senesce lower and they have less accumulated genetic changes, so they're healthier. And they also contain pluripotent stem cell populations. Very interesting. And they have more embryonic characteristics, yet without the risk of teratoma. So it's like having the best of both worlds. They have embryonic properties, but they don't have the risk of the cells go haywire and forming teratoma. Another advantage is that they have abundant growth factors and proteins associated with youth. And the perinatal source cells are more potent. So we've seen they have higher anti inflammatory effects, more neuroprotective, they secrete more growth factors and we saw their ability to differentiate into bone, cartilage, etc. They're also easy to obtain, they're very convenient and they allow for frequent and regular dosing. And lastly they are abundant. So these cells, you know, are obtained from healthy life births and there is no ethical controversy because without being utilized they're just going to be thrown away as, as biological waste. And what is special about umbilical cord tissue? So we talked about perinatal cell Sources. So there's cord blood and cort tissue. What's special about cord tissue? First of all, they have very high MSE content. When you look at umbilical cord, up to 1 in 300 cells in the perivascular region is an MSC versus in cord blood is 1 in 2 million cells. So in the entire cord blood unit, which is about on average 100cc's there are only 1000 to 5000 MSC total. So there are just not very many MSCs at all. But for umbilical cord tissue, these MSEs not only are abundant, but they're also more primitive. So they were sequestered early in embryogenesis. So they're even more primitive than MSCs in umbilical cord blood. And they also contain more plural pluripotent markers. So those are the markers that were only manifest in very, very early cells, some of these embryonic markers. And they're also more able to develop into cardiomyocytes and neurons, and they're more neuroprotective and angiogenic. So, so I want to show you the tissue source comparison of cells from different tissue. So from placenta, you can see that's amniotic fluid and amniotic membrane. And from umbilical cord, it can be either umbilical cord blood or umbilical cord tissue. And autologous, you know, people use prp, use bone marrow or adipose. So you can look at the cytokine profile, the growth factor profile, and the total cell count, the percentage of MSCs and whether or not they're biologically young, that's more potent. When you consider all these factors, it looks like the more optimal sources will be the umbilical cord matrix and the amniotic membrane. Umbilical cord blood also has more cells, but unfortunately has much less MSCs. And another thing I want to talk about is native versus expanded MSCs. So a lot of clinics around the world actually get people cultured stem cells. And of course, that is not allowed to be used in the US Unless it's under a clinical study, because the FDA considers cultural expansion as manipulation, that they cannot be used without being under a drug study. So a lot of Americans actually go overseas to receive stem cell treatment of these expanded MSCs. And does that mean they're better because there's so much more of them? Well, Oxocell actually studied this. This was presented at the Perinatal Stem Cell Conference in Salt Lake City in March 2018. So they were looking at the potency of these MSCs. So the effect they're able to exert at 10,000 neurot native MSCs, they saw a certain clinical effect. When they increase the number to 100,000, so 10 times that of native MSCs, they see an increase in response, you can see in the third bar, so that's a dose dependent response. Then they give 10 times even that number. But using expanded MSCs and they want to see does that make them more effective. So at 1 million expanded mics, the clinical effectiveness is actually lower than 100,000 native mics. So they actually lost some potency. So that's a really dramatic demonstration of the quality of the expanded MSCs. And I can say that this kind of correlates with what I see clinically. There's one autistic child who went to Panama to receive the expanded MSCs, and some months later the parents could not bring the child back to Panama. So the child received products that contain native MSCs at probably one tenth the number of what he received overseas. And what's interesting is that the parents said that the child did much better on the lower number of native MSEs comparing to the massive number of the expanded MSCs. So that is very interesting to observe clinically. So in conclusion, what we all want is to give the best cells to our patients so that we can maximize their treatment results. And I hope this presentation has given you some insight and tools in making that decision so that you can provide the most helpful treatment for your patients.