Regenerative Medicine PDF

Regenerative Medicine SOPHIE H. BOGERS, BVSC, MVSC, PHD, DACVS-LA [email protected] College of Copyright 2019 Virginia Tech All Rights Reserved LEARNING OBJECTIVES Name the 3 components of regenerative medicine for tissue engineering and describe what properties they add to the therapy Understand the p...

Regenerative Medicine SOPHIE H. BOGERS, BVSC, MVSC, PHD, DACVS-LA [email protected] College of Copyright 2019 Virginia Tech All Rights Reserved LEARNING OBJECTIVES Name the 3 components of regenerative medicine for tissue engineering and describe what properties they add to the therapy Understand the process to get stem cells and blood-derived orthobiologics Describe why regenerative therapies are not currently marketed or sold as drugs Integrate regenerative medicine therapies into a treatment plan LECTURE OUTLINE OBJECTIVE 1 The tissue engineering triad OBJECTIVE 2 Rules and Regulations OBJECTIVE 3 Types of regenerative therapies OBJECTIVE 4 Integration into common injury types 01 The tissue engineering triad WHAT WE CAN DO IS SO COOL! https://www.google.com/search?q=regenerative+medicine+growing+organs+hear t&sca_esv=2e3dfea029773cf5&bih=716&biw=1309&hl=en&tbm=vid&sxsrf=ACQV n0_8T8yLqKttcOu4SfgZSQDGveVU3A%3A1708292115052&ei=E3jSZY7qAtbSp84Pu eutgAc&ved=0ahUKEwjOv8KF7LWEAxVW6ckDHbl1C3AQ4dUDCA0&uact=5&oq=re generative+medicine+growing+organs+heart&gs_lp=Eg1nd3Mtd2l6LXZpZGVvIipyZ WdlbmVyYXRpdmUgbWVkaWNpbmUgZ3Jvd2luZyBvcmdhbnMgaGVhcnQyBRAhG KABMgUQIRigATIFECEYoAEyBRAhGJ8FMgUQIRifBUjAFVDMDliwE3AAeACQAQCYAb gBoAHwB6oBAzAuN7gBA8gBAPgBAYgGAQ&sclient=gws-wizvideo#fpstate=ive&vld=cid:68d37f7a,vid:8l6ib9HitJ0,st:0 Watch 2.10-3.20 TAKE HOME MESSAGES OBJECTIVE 1 § Regenerative medicine relies or biological products to make tissue out of: § Cells, scaffold, bioactive factors § Stem cells have different capabilities of turning into other cell types § We most commonly use mesenchymal cells that are multipotent in veterinary medicine § Genetic engineering has enabled us to change the differentiation potential of cells § E.g. we can make them into cells that can become lots of different cell types 02 Rules and Regulation https://www.fda.gov/media/88925/download Classification of Autologous Cell-Based Products Type I products Type II products More than minimal manipulation (e.g. cells grown Minimal manipulation (e.g. centrifugation) or differentiated, additional factors added) Homologous use (e.g. cartilage cells put back into Non-homologous (e.g. cells do not usually a cartilage defect) perform the same job you are using them for) Non-food animals Used in a food-producing animal Not combined with anything except water/ Effect dependent on metabolic activity of the cells crystalloid/ sterilizing/ preserving agent that There is noraise requirement for Manufacture involves combination of cells with doesn’t safety concerns kits to combined be approved other agents (e.g. BMSC with hydroxyapatite) Not with (blood another drug of device The cells are combined with another drug or products) device Investigational New Animal Drug = https://www.fda.gov/animal-veterinary/development-approval-process/new-animal-drugapplications CHALLENGES FOR EQUINE ORTHOBIOLOGICS AS DRUGS THE CONCLUSION TAKE HOME MESSAGES OBJECTIVE 2 § Drugs cannot be marketed as such if they have not undergone FDA approval § Anything can be used without marketing § Kits can be marketed without approval § It is up to you to know and communicate the risks (and know the background information for efficacy/literature) § If you do this and you have client approval these are worthwhile products to use J 03 Types of Regenerative Therapies MESENCHYMAL STEM CELL § Mesenchymal stem cells (MSC) are multipotent § MSC from bone marrow/adipose à cartilage, bone, adipose (trilineage potential) § Autologous (own cell in own body) is safest § Allogeneic (another’s cell in own body) is available § Immune response may occur – concern for repeat injection § Xenogeneic (another specie’s cell in own body) – avoid § Remember these are whole cells! MESENCHYMAL STEM CELL PRODUCTION NOT MESENCHYMAL STEM CELLS Bone marrow aspirate concentrate (BMAC) Adipose derived stromal vascular fraction (ADSF) 0.001-0.01% MSC 1.72% CFU Fibroblasts (MSC-like) BONE MARROW COLLECTION § Bone marrow § 5th sternebra 4-5cm deep1 § Best for middle-age to old horses2 § Sequential advancement best for BMAC3 § Ileum (option for young horse)4 § 10-11g Jamshidi needle1 § First 5mL most important1,4 § Remember to heparinize syringe and needle 1. Kasashima 2011, 2. Delling 2012, 3. Peters 2016, 4. Lombana 2015 ADIPOSE TISSUE COLLECTION § Sterile surgical procedure § 10cm lateral to tail-head § Inverted L- or U- block § 10cm linear incision § Remove enough for laboratory (~30-50mL) § Close skin 2-0 nylon simple interrupted § https://www.youtube.com/watch?v=dwylSbXcqQ0 1. Rich 2014 BLOOD-DERIVED PRODUCTS White blood cells Source of cytokines Inflammatory IL-1b, TNF a Anti-inflammatory IL-1Ra, IL-10 and IL-4 Platelets Source of growth factors Anabolism PDGF, TGF- b1, VEGF, IGF-1 Autologous conditioned serum - Leukocytes interact with borosilicate glass - IRAP, IRAP II Autologous protein solution - Leukocytes concentrated (~12x) - Platelets concentrated (~2x) - Pro-Stride Leukocyte rich PRP - Platelets (3-5x) - High leukocytes Pure PRP - Platelets (3-5x) - Low leukocytes HOW VETERINARIANS CHOOSE A BLOOD-DERIVED PRODUCT § There are no blood-derived products that have FDA approval1 § Practicality and expense § Stall-side vs. send to laboratory, purchase of adjunctive equipment, speed § Biologic activity based on composition § Leukocyte content may be related to increased cytokines and potential for transient joint inflammation2,3 § Consider how many anti-inflammatory cytokines vs. inflammatory cytokines § IRAP II has higher IL-1Ra: IL-1b4 § Some studies do not publish inflammatory cytokine content § Other therapeutic desires e.g. clot formation, high growth factor content 1. FDA, 2018, 2. Bertone 2014, 3. Kisiday 2012, 4. Hraha 2012 Platelets/μL (foldΔ) Leukocyte/μL (foldΔ) Reference V-Care E-Pet 542,000 (3.2) 533,300 (3.8) 13,000 (1.9) 11,000 (1.8) Textor 2013 Hessel 2015 Harvest SmartPrep2 513,000 (5.54) 725,000 (4.2) 6,910 (NC) 14,800 (~2) McCarrel 2009 Kisiday 2012 Arthrex ACP 276,000 (1.6) 183,000 (1.3) 40/uL 60 (0.1) Kisiday 2012 Hessel 2015 Arthrex Angel 320,300 (2.3) 9,100 (1.5) Hessel 2015 Pall corp. V-Pet 550,000 (~4) ? Mirza 2016 Biomet GPS III 761,000 (5.4) 40,600 (6.7) Hessel 2015 Values compared to whole blood, NC = no change 1. Franklin 2015, 2. Boswell 2014, 3. Bakker 2001, 4. Rios 2015, 5. Carmona 2016 Growth factor content proportional to platelet content1 Benefit of platelets plateau (~3 fold?)2 What is the level needed for joints? Very high levels may be detrimental to a joint3 Cytokine content related to WBC content Higher catabolism at high WBC2 Could reduce effect by lowering PRP concentration4,5 TAKE HOME MESSAGES OBJECTIVE 3 § Products can be made from blood, bone marrow or adipose tissue § Products vary in if they contain cells, scaffold or bio-active factors § Some contain all 3, some contain some not all, products have been combined or rely on the body to give missing components § Ask critical questions about new products that hit the market § Are they safe? § Where is the evidence? 04 Integration into common injuries CLINICAL PROBLEM: DEBRIDEMENT OF OSTEOCHONDROSIS THE SOLUTION: CARTILAGE RESURFACING § Exogenous products onto debrided site improve initial healing response1,2 § BMSCs in fibrin scaffold1,2 § Bone formation due to dose?2 § BMAC3 § Fibrin PRP4 § Injected post-op improve long-term tissue quality § MSCs5 1. Wilke 2007, 2. Goodrich 2013, 3. Fortier 2010, 4. Goodrich 2016, 5. McIlwraith 2011, 6. Chu 2018 THE PROBLEM: INTRA-ARTICULAR SOFT TISSUE INJURY § Most common in the stifle § Meniscal tear § Meniscotibial ligament tear § Cruciate ligament tear § Lameness and osteoarthritis § Destabilization § Source of inflammation 1. Frisbie 2014, 2. Barrett 2012 THE SOLUTION: POST-OP MSC INJECTION MSC + Scaffold § MSCs from bone marrow and adipose tissue heal menisci with fibrocartilage1 § BMSCs improve outcomes for meniscal injury after stifle arthroscopy2 § BMSCs I.A. 30 days post-op § 75% return to work compared to ~60% without 1. Gonzalez-Fernandez 2016, 2. Ferris 2014 Control THE PROBLEM: TENDINITIS § Healed tissue is not as strong as original tissue § High chance of injury recurrence § Racehorses ~50% recurr THE SOLUTION: INTRALESIONAL INJECTION THE SOLUTION: INTRALESIONAL INJECTION OF MSC § MSC treated horses had a higher odds of returning to racing (~3 times) compared to a controlled exercise alone § The controlled exercise is still important! § MSC reduced the re-injury rate of racehorses from 50% down to 25% § Meta-analysis has not shown definitive evidence for the benefit of intra-lesional PRP therapy TAKE HOME MESSAGES OBJECTIVE 4 § Regenerative therapies are being used in clinical cases § Show promise to aid healing vs. conservative management § Evidence-based medicine is needed to use correctly Questions? [email protected]