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. Neurologist Departement:
1. Stroke
2. Parkinson's and Alzheimer's disease
3. Huntington’s disease
2. Surgery Departement:
1. Fracture Case
2. Burns Case
3. Repair tendon
4. Spinal cord damage
3. Internist Departement
1. Heart disease--- Miocard Infarct
2. Renal Injury
3. Diabetes Mellitus
4. Peripheral vascular ischaemia--- Ulcus Diabeticum
5. Growth hormone deficiency
4. Dermatologist Department
1. Aging (Cosmetic)
5. 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
3. Multipotent Adult Stem Cell
4. Progenitor
5. Diffrentiated Matur Cell
 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 (non-
dividing) 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:
• Immunoprivileged
Safe 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 T-
cell 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 insulin-
producing 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 SETELAH GANTI

MEDIUM MEDIUM
5th Day
THANKS YOU