Public and Private Cord Blood Banking: United We Stand!

cordbloodunit

The recent years have been witness to revolutions in the medical fields in many aspects, and more specifically in the development of applications in regenerative medicine. One of the most promising and fastest growing fields of regenerative medicine is cellular therapy for both personalized and generalized treatments. Indeed, incredibly innovative approaches have been and are being developed to treat degeneration of tissues and organs due to aging or damage using stem and progenitor cells. This led to an increase in cell therapy revenues from $410M in 2008 to $5.4B in 2012, truly marking our entry into the age of the cell and making cell-based therapeutics the next pillar of medicine; virtually every branch of medicine will see direct application of cell therapies.

Stem and progenitor cells are undifferentiated cells, which, under the right conditions, can differentiate to become virtually any type of cell that makes up the tissues and organs in the body. This ability makes stem and progenitor cells ideal for use in proven and novel clinical therapies to replace defective or damaged cells resulting from a variety of disorders and injuries as well as for use in research. Stem and progenitor cells provide the foundation for cell therapies and, amongst the different types of stem and progenitor cells, none has been more researched, funded and commercialized than mesenchymal and hematopoietic stem and progenitor cells (MSPC’s & HSPC’s respectively) typically found in bone marrow in large quantities.

Recent data show however that umbilical cord blood obtained from the umbilical cord and placenta is a rich source of MSPC’s and HSPC’s; the latter can be used for transplantation to treat a range of malignant, genetic, metabolic, and immune disorders. In fact, it was shown that cord blood HSPC’s are more proliferative and have a greater chance of matching family members than stem cells from bone marrow. Additionally, cord blood is not only widely available and easily accessible—collection is relatively non-invasive, safe and painless—but its derived HSPC’s can even be safely infused when they are an incomplete match for the recipient due to their immunologically naïve quality. In spite of this, cord blood is still routinely discarded as hospital waste along with the umbilical cord and placenta following birth when it should be collected, processed, tested and banked for future therapeutic use, especially since, until now, 50 percent of all patients seeking a transplant cannot find a match.

There have been more than 30,000 transplants worldwide using cord blood derived HSPC’s and the demand is still growing fast. Indeed, the National Marrow Donor Program estimates that by the year 2015, there will be 10,000 cord blood transplants worldwide per year as opposed to 3,000 per year in 2010. From 23 active cord bloods as of 2005, the Bone Marrow Donors Worldwide (BMDW) currently list 44 public cord banks from 26 different countries and there are approximately 225 private cord blood banks worldwide. That is an eleven fold increase (1,100 percent) in the companies involved in the industry over only a seven year period, and yet, the market is far from being saturated as the offer still cannot meet the demand—both in number and quality.

There are two main types of cord blood banks: licensed public banks, which ask mothers to donate their umbilical cord blood—only the umbilical cord blood—for future use by anyone who may be a potential match, and private or family banks, which will store cord blood, tissue and/or MSPC’s from either or both the umbilical cord and placenta for future use by the donor or matching family members for an average fee of $1,600 per item plus an annual storage fee of around $100 per item. Historically, public banks have been not-for-profit while private or family banks have been for-profit enterprises. The private cord blood industry has been criticized by a number of professional bodies including the EU ethics Committee and the Royal College of Pediatrics because the medical utility of private cord blood banks is believed to be more potential than actual and, thus, private cord blood banks threaten the supply of cord blood units to the public system which is based on actual needs and not potential ones.

It is important nonetheless to point out that the private banks are founded on the autologous (cells derived or transferred from the same individual’s body) business model, where cells are harvested from the patient to be treated in a facility before being shipped back to the physician for delivery into the same patient, who is thus both the donor and recipient. The allogeneic (cells derived from separate individuals of the same species) business model on the other hand is based on mass production of aliquots of cells from a single healthy donor to be shipped to the physicians for subsequent delivery into the patient—the allogeneic model being the preferred one by the big biopharmaceuticals companies of course. Against common belief, the autologous business model is far from being unsupported or unsound since there are currently over 650 FDA clinical trials involving autologous and allogeneic applications of MSPC’s and HSPC’s with a clear bias to autologous approaches as they don’t provoke an immunological response by the patient. In fact, recent data have shown that, in reality, it is not autologous vs. allogeneic but autologous and allogeneic as there is room for both therapies in treating patients, even within a single diagnosis.

Until recently, only one alternative existed to both the public donation and private storage: directed donation of cord blood donated to public banks to siblings who have an existing condition that may in the future require an allogeneic transplant. This alternative nonetheless was simply not good enough for parents who wanted to take a form of biological insurance to safeguard their children’s future and who understood the potential of autologous therapies and the advantages early-stage stem cells as opposed to adult stem cells—many studies showed greater proliferative capacity and greater plasticity of newborn stem cells as opposed to same types of stem cells harvested from adults. Furthermore, with the growing awareness of parents of stem cell therapeutics, a deeper commitment to research and development of stem cell therapeutics by the banks was expected: regenerative medicine is to be included in the world of tomorrow today. This situation gave rise to new kinds of umbilical cord blood banks—hybrid models that combine aspects of both the public and private systems with a clear commitment to research and development in the field of stem cell therapeutics.

The hybrid models can be classified into two broad categories: the cord blood banks that offer both options, either private storage or public donation, and the cord blood banks that make the privately stored cord blood available to the public system. The first category is the most prominent one in North America and Belgium and keeps gaining popularity with the recent announcement that the major public banks have agreed to expand their services to offer private storage. The second category is the most popular one in Spain, Turkey, the U.K. and Germany, each with its own characteristics. Indeed, In the Turkish model, according to government legislation, 25 percent of all privately stored cord blood is donated to the public system. In the Spanish model, cord blood stored in a private bank is registered on the Official Spanish Register of Bone Marrow Donors and should a patient in need of a transplant find a match in a private bank, parents are obliged to donate said cord blood and the storage fee is reimbursed. In the U.K., the Virgin model comes to mind where 80 percent of the privately stored cord blood is donated to the public system for allogeneic transplantation. And finally, in Germany, should a patient needing a transplant find a match in a private bank, the bank asks for permission to the parents for release, however, as opposed to the Spanish system, the parents are under no obligation to accept.

No matter the outcome of which hybrid model is the best, both public and private cord blood banks are now working together to implement new stem cell therapeutics and allow for a greater number of patients needing a transplant to actually find a matched donor.

Y.S.H.

Stemness, Neural Stem Cells and their Applications to Treat Neurodegenerative Disorders!

neural stem cells

The last decade has seen scientist progress from isolating pluripotent stem cells from early embryos and growing them in the laboratory to being able to generate them from terminally differentiated adult cells using viral insertion of key transcription factors. These remarkable advancements opened the doors, in theory, to a vast array of applications in cell therapy, gene therapy and disease modeling to treat and/or study numerous degenerative illnesses that had remained elusive until now. More specifically, these recent discoveries finally opened the door to potential cures to neurodegenerative disorders, such as ALS, Parkinson’s disease, Alzheimer’s disease, Huntington’s disease, or even Schizophrenia and Bipolar disorder, and even spinal cord injuries using neural stem cells therapies—by directly injecting them into the patient at specific locations for example. However, before I embark on the nature of neural stem cells and the current ongoing clinical trials to determine the extent of their applications, it might be wise to first remind ourselves of what we understand today to be a stem cell, or even what stemness means. Indeed, as our understanding of the biology and unique properties of stem cells grow, so must we refine the scope of what it is we are studying!

Our initial understanding of all stem cells is based on their functionality, as having three characteristics that set them apart from other cells: they are unspecified, they can divide and renew themselves for very long periods of time, and they can be induced, under certain conditions, to become differentiated cells with specialized functions. This definition seems simple and broad enough to encompass all stem cells you say? Well, not exactly.  Indeed, this definition only works for embryonic or fetal stem cells that are only present for a short period in the lifetime of an organism. This definition can no longer be used when we try to separate transient progenitor cells from adult stem cells (or somatic stem cells). Efforts have thus been put in to refine this definition to adult stem cells that self-renew for the entire life span of an organism. However, this, also, wasn’t enough to take into account the different differentiating characteristics of adult stem cells: potency. Is a somatic stem cell that can only differentiate into one type of differentiated cell (unipotent) really a stem cell? Maybe a stem cell should be set apart based on its gene regulations, but again, this characteristic is not unique to stem cells. This makes you wonder about induced pluripotent stem cells doesn’t it? Are they really stem cells or simply pluripotent cells? Some scientists even define stemness as a system-level property as the environment has been shown to play a direct role in defining the nature of the stem cell (the niche makes the stem cell!). This subject is so complex that the majority of scientists decided to agree on a working definition for a stem cell, to be a clonal, self-renewing entity that is multipotent and thus can generate several differentiated cell types, while preserving numerical homeostasis—even though this definition is not applicable in all instances!

The origin of stem cells itself remains to be elucidated—not embryonic stem cells of course, which are derived from the inner cell mass of the blastocysts, but somatic stem cells. Everything gets complicated at the gastrulation event, after fertilization of the egg and the implantation of the zygote in the uterine wall. During gastrulation every cell in the embryo changes its position to become committed to one of the three germ layers, which themselves become properly positioned with respect to another within the context of the embryo. It is possible, thanks to numerous fate mapping studies, to determine what cells in various regions of the embryo will become. Remember that the three germ layers are the ectoderm, on the outside of the embryo, the endoderm, on the inside of the embryo and the mesoderm, in the middle, and that, after gastrulation, once a cell is committed to a germ layer, it will no longer form structures based on its location. Now, back to the origin of somatic stem cells dilemma; the common understanding is that development is achieved essentially through successive cell fate restrictions controlled by both intrinsic and extrinsic factors after gastrulation, and, thus, stem cells occur right after the formation of germ layers, restricted to their respective lineage by said germ layer. A second major theory implies that stem cells follow a similar developmental path as primordial germ cells, in that they avoid completely lineage commitment during gastrulation and migrate subsequently to specific tissues and organ niches. This matter remains to be elucidated and is actively researched by scientists all over the globe—it is an important matter and does imply determination of biomarkers of the different types of stem cells.

To get back to the subject at hand, and since we are not going to answer the question on the origin of somatic stem cells in this article, the common understanding on the development of neural stem cells (NSCs) is that it begins with the formation of nervous tissue from the ectoderm after gastrulation. It was observed that appearance of NSCs coincides with the induction of the neural plate and the appearance of restricted progenitor cells. It was also observed that developing and adult NSCs seem to acquire temporal and positional information, i.e. they give rise to region-appropriate progeny and earlier NSCs gives rise more frequently to neurons than glia compared to more mature NSCs. It is important to note that it was observed that NSCs for the most part do not give rise to all the neurons types in the adult brain. Indeed, they were found to be mostly limited to the production of GABA and glutamate neurons. The subject of NSCs is still relatively new, since they were first isolated in the early 1990s in the adult rodent striatum. Since then, many NSCs have been isolated from adult animals from a variety of locations in the central nervous system (CNS), including the spinal cord, the hippocampus, and the neocortex, as well as the striatum, and the search for NSCs’ new niches is still ongoing!

Despite having discovered so many endogenous NSCs in mammals, it was observed that their potential in “self-repair” after injury was not met because of, it is believed, constrains due to their environment, their restricted mobility and their limited numbers. Thus, the logical hypothesis followed: if NSCs were expanded ex vivo and implanted into regions needing repair, overcoming the in vivo limitations, the true potential of NSCs would be unlocked. Extensive research and experimentations were conducted based on this assumption, and are still conducted today with astonishing results and even more surprising discoveries about the properties of NSCs. For example, it was observed that exogenous NSCs are capable of sensing, homing in on, and responding adequately to neurogenic signals produced during degenerative processes in order to resume development. Additionally, it was observed that NSCs not only differentiate very efficiently into neural cells but also evade most of the obstacles that must be overcome by other gene or cellular therapies, i.e. NSCs can cross the blood-brain barrier. NSCs seem to be the answer scientists have been waiting for to treat extensive neurodegenerative processes as was previously said, dementia conditions, as well as spinal contusion and cerebellar degeneration, and many more. What are we waiting for to get these therapies up and running you ask? Nothing; scientists have been working hard at them for years, ever since they discovered the different NSCs’ niches!

Just to cite the pioneer in the field, Neuralstem, using its patented technology for “isolation and expansion of human neural stem cells from each of the NSCs niche regions of the developing central nervous system in virtually unlimited numbers from a single donated tissue,” is currently in phase II to treat ALS after having successfully demonstrated the safety of its procedure on 18 patients in phase I—using its patented world’s first intraspinal surgical device for the delivery of neural stem cells. From what I was able to gather, there were observations in several of the patients of slowed progression of lower extremity weakness, and one patient may have even improved just from the first intervention! Neuralstem is also in phase I/II to treat ischemic stroke and spinal cord injury, and is in pre-clinical phase to treat glioblastoma, multiple sclerosis, optic neuritis, Alzheimer’s disease, traumatic brain injury, peripheral nerve injury, diabetic neuropathy, lysosomal disease, Parkinson’s disease, cerebral palsy, and ischemic spastic paraplegia! As you might have guessed, one of the major difficulties lies in getting the right NSCs to the site of repair in order to produce only the right kind of neural cell types. At least, that is until we find the sacred grail of NSCs: a multipotent NSC that can produce all the different kinds of neural cells at the right time and place…or maybe not. A very recent paper, published by researchers at the Stanford University School of Medicine on April 14th, inspired by Shinya Yamanaka’s Nobel prize winning work, shows successful transformation of skin cells directly into oligodendrocyte precursor cells (direct lineage reprogramming !), the cells that wrap nerve cells in the insulating myelin sheaths that help nerve signals propagate. Could Shinya Yamanaka’s work on human induced pluripotent stem cells have opened the way to tomorrow’s neural stem cell (and stem cell in general) therapies? Many seem to think so; what about you?

Y.S.H.

Induced Oligodendrocyte Precursor Cells

Researchers at the Stanford University School of Medicine, inspired by the work of Shinya Yamanaka, have succeeded in transforming skin cells directly into oligodendrocyte precursor cells (direct lineage reprogramming!), the cells that wrap nerve cells in the insulating myelin sheaths that help nerve signals propagate. This could lead, in principle, to cell therapies for diseases like inherited leukodystrophies and multiple sclerosis, as well as spinal cord injuries and disease modeling.

You can read the full article in Nature Biotechnology here or the Science Daily article here.

Adult Stem Cells Isolated from Human Intestinal Tissue

Scientists at the University of North Carolina at Chapel Hill (UNC) report that for the first time adult stem cells from human intestinal tissue have been isolated. The accomplishment provides a much-needed resource for scientists eager to uncover the true mechanisms of human stem cell biology, they say. It also enables researchers to explore new tactics to treat inflammatory bowel disease or to ameliorate the side effects of chemotherapy and radiation, which often damage the gut.

Full article here

Study of Human Central Nervous System Stem Cells (HuCNS-SC) in Patients With Thoracic Spinal Cord Injury

StemCells Inc. is conducting a Phase I/II clinical trial of human central nervous system stem cells (HuCNS-SC) therapy in Switzerland, at the Balgrist University Hospital, University of Zurich, in order to determine if the single dose intramedullary transplantation of HuCNS-SC cells in the thoracic spinal cord is both safe and efficient in treating patients with sub-acute spinal cord injury.

This study will enroll 12 patients between the age of 18 years and 60 years, who suffered the injury at least 6 weeks prior to screening for inclusion in this study—based on the American Spinal Injury Association (ASIA) level determination assessed by the principal investigator: Dr. Armin Curt, MD.

The main endpoint being to assess safety and efficiency of one dose, the number of patient seems right since age, gender, duration of injury and ethnic backgrounds are not real variables—making the results of this study statistically significant. However, it is a single group experiment with open label, which means that the placebo effect is not taken into account (I guess it is appropriate in this case?). It is good to remember that this study is very preliminary.

Furthermore, the study subjects will receive immunosuppression for nine months following transplantation in order to minimize rejection and will be followed for one year following transplantation and then will be enrolled in a separate long-term follow-up study for an additional four years. There are further safety issues for the patients that the researchers might want to include in their study, the environment the patients will be in for the duration of receiving immunosuppressants; it could affect results.

This study is very promising and might open new doors to treating spinal cord injury–I am impatient to find out what happens.

Stem Cells from Fat Show Promise in Treatment of Brain Cancer

Very interesting article from JHU hub:

Cells may give clinicians new way to chase migrating cancer, Johns Hopkins researchers say. Johns Hopkins researchers have found that stem cells from a patient’s own fat may be able to deliver new treatments directly into the brain after removal of the most common and aggressive form of brain tumor.

The stem cells, called mesenchymal stem cells (MSCs), have the ability to seek out damaged cells, investigators say, such as those involved in cancer, and may provide clinicians a new tool for accessing difficult-to-reach parts of the brain where cancer cells can hide and proliferate. Harvesting these stem cells from fat is less invasive and less expensive than getting them from bone marrow, a more commonly studied method, researchers say.

Results of the laboratory study are described online in the journal PLOS ONE.

“The biggest challenge in brain cancer is the migration of cancer cells,” says study leader Alfredo Quinones-Hinojosa, professor of neurosurgery, oncology, and neuroscience at the Johns Hopkins University School of Medicine. “Even when we remove the tumor, some of the cells have already slipped away and are causing damage somewhere else. Building off our findings, we may be able to find a way to arm a patient’s own healthy cells with the treatment needed to chase down those cancer cells and destroy them. It’s truly personalized medicine.”

 Currently, standard treatments for glioblastoma, the most common and aggressive form of brain tumor, are chemotherapy, radiation, and surgery, but even a combination of all three rarely leads to more than 18 months of survival after diagnosis. Glioblastoma tumor cells are particularly nimble, migrating across the entire brain and establishing new tumors. This migratory capability is thought to be a key reason for the low cure rate of this tumor type.

“Essentially these MSCs are like a ‘smart’ device that can track cancer cells,” Quinones-Hinojosa says.