Allogeneic Mesenchymal Precursor Cells (MPC) in Diabetic Nephropathy: A Randomized, Placebo-controlled, Dose Escalation Study
David K Packham, Ian R Fraser, Peter G Kerr, Karen R Segal, David K Packham, Ian R Fraser, Peter G Kerr, Karen R Segal
Abstract
Background: Diabetic nephropathy is the most common cause of end stage renal failure. We assessed the safety, tolerability, and explored therapeutic effects of adult allogeneic bone-marrow derived mesenchymal precursor cells (MPC) in patients with moderate to severe diabetic nephropathy.
Methods: Multicenter, randomized, double-blind, dose-escalating, sequential, placebo-controlled trial assessing a single intravenous (IV) infusion of allogeneic MPC (United States adopted name: rexlemestrocel-L) 150×106 (n=10), 300×106 (n=10) or placebo (n=10) in adults with diabetic nephropathy with an estimated glomerular filtration rate (eGFR) 20-50ml/min/1.73m2. Thirty patients at three Australian centers were enrolled between July 2013 and June 2014 and randomized 2:1, in two sequential dose cohorts, to receive rexlemestrocel-L or placebo. Study duration was 60weeks. Primary endpoint was safety and tolerability. Primary exploratory efficacy endpoint was change from baseline in eGFR and directly measured GFR by 99Tc-DTPA plasma clearance (mGFR) at 12weeks post-infusion. The trial was registered on ClinicalTrials.gov (NCT01843387).
Findings: All patients completed the study and were included in analyses applied to the intention to treat population. There were no acute adverse events (AEs) associated with infusion and no treatment-related AEs or serious AEs were deemed treatment-related by investigators. No patients developed persistent donor specific anti-HLA antibodies. Relative to placebo, a single IV rexlemestrocel-L infusion showed trends of stabilizing or improving eGFR and mGFR at week 12. The adjusted least squares mean (LSM±SE) differences from placebo in changes from baseline at 12weeks in the rexlemestrocel-L groups were 4.4±2.16 and 1.6±2.15ml/min/1.73m2 for eGFR and 4.1±2.75 and 3.9±2.75 for mGFR for the 150×106 and 300×106 cell groups, respectively.
Interpretation: This study demonstrates the safety of rexlemestrocel-L in diabetic nephropathy with suggestive effects on renal function to be confirmed in larger, appropriately powered trials.
Keywords: Diabetic nephropathy; Glomerular filtration rate; Inflammation; Mesenchymal precursor cells; Stem cell.
Copyright © 2016 The Authors. Published by Elsevier B.V. All rights reserved.
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References
- Brenner B.M., Cooper M.E., de Zeeuw D. Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. NEJM. 2001;345:861–869.
- Cantaluppi V., Biancone L., Quercia A., Deregibus M.C., Segoloni G., Camussi G. Rationale of mesenchymal stem cell therapy in kidney injury. Am. J. Kidney Dis. 2013;61:300–309.
- Gronthos S., Fitter S., Diamond P., Simmons P., Itescu S., Zannettino A.C.W. A novel monoclonal antibody (STRO-3) identifies an isoform of tissue non-specific alkaline phosphatase expressed by multipotential bone marrow stromal stem cells. Stem Cells Dev. 2007;16:1–11.
- Hickson L.J., Eirin A., Lerman L.O. Challenges and opportunities for stem cell therapy in patients with chronic kidney disease. Kidney Int. 2016;89:767–778.
- Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int. Suppl. 2013;3:1–150.
- Kim J., Hematti P. Mesenchymal stem cell-educated macrophages: a novel type of alternatively activated macrophages. Exp. Hematol. 2009;37:1445–1453.
- Levey A.S., Bosch J.P., Lewis J.B., Greene T., Rogers N., Roth D. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group. Ann. Intern. Med. 1999;130(6):461–470. (Mar. 16)
- Levey A.S., Stevens L.A., Schmid C.H., Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) A new equation to estimate glomerular filtration rate. Ann. Intern. Med. 2009;150(9):604–612.
- Lewis E.J., Hunsicker L.G., Clarke W.R. Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes. NEJM. 2001;345:851–860.
- Lim A.K., Tesch G.H. Inflammation in diabetic nephropathy. Mediat. Inflamm. 2012;2012:146–154.
- Maggini J., Mirkin G., Bognanni I. Mouse bone marrow-derived mesenchymal stromal cells turn activated macrophages into a regulatory-like profile. PLoS One. 2010;5(2)
- Meirelles Lda S., Fontes A.M., Covas D.T., Caplan A.I. Mechanisms involved in the therapeutic properties of mesenchymal stem cells. Cytokine Growth Factor Rev. 2009;20:419–427.
- Navarro-Gonzalez J.F., Mora-Fernandez C. Inflammatory pathways. Contrib. Nephrol. 2011;170:113–123.
- Papazova D.A., Oosterhuis N.R., Gremmels H., van Koppen A., Joles J.A., Verhaar M.C. Cell-based therapies for experimental chronic kidney disease: a systematic review and meta-analysis. Dis. Model. Mech. 2015;8(3):281–293.
- Pergola P.E., Krauth M., Huff J.W. Effect of bardoxolone methyl on kidney function in patients with T2D and Stage 3b-4 CKD. Am. J. Nephrol. 2011;33:469–476.
- Prockop D.J., Oh J.Y. Mesenchymal stem/stromal cells (MSCs): role as guardians of inflammation. Mol. Ther. 2012;20:14–20.
- Psaltis P.J., Paton S., See F. Enrichment for stro-1 expression enhances the cardiovascular paracrine activity of human bone marrow-derived mesenchymal cell populations. J. Cell. Physiol. 2010;223:530–540.
- Ruilope L.M., Agarwal R., Chan J.C. Rationale, design, and baseline characteristics of ARTS-DN: a randomized study to assess the safety and efficacy of finerenone in patients with type 2 diabetes mellitus and a clinical diagnosis of diabetic nephropathy. Am. J. Nephrol. 2014;40:572–581.
- See F., Seki T., Psaltis P.J. Therapeutic effects of human stro-3-selected mesenchymal precursor cells and their soluble factors in experimental myocardial ischemia. J. Cell. Mol. Med. 2011;15:2117–2129.
- Simmons P.J., Torok-Storb B. Identification of stromal cell precursors in human bone marrow by a novel monoclonal antibody, STRO-1. Blood. 1991;78:55–62.
- Singer N.G., Caplan A.I. Mesenchymal stem cells: mechanisms of inflammation. Annu. Rev. Pathol. 2011;6:457–478.
- Skyler J.S., Fonseca V.A., Segal K.R., Rosenstock J. Allogeneic mesenchymal precursor cells in type 2 diabetes: a randomized, placebo-controlled, dose-escalation safety and tolerability pilot study. Diabetes Care. 2015;38:1742–1749.
- Togel F., Westenfelder C. The role of multipotent marrow stromal cells (MSCs) in tissue regeneration. Organogenesis. 2011;7:96–100.
- Tuttle K.R., Bakris G.L., Bilous R.W. Diabetic kidney disease: a report from an ADA consensus conference. Diabetes Care. 2014;37:2864–2883.
- United States Department of Health and Human Services . 2010. The Common Terminology Criteria for Adverse Events Version 4.0.3. (June 14)
- von Bahr L., Batsis I., Moll G. Analysis of tissues following mesenchymal stromal cell therapy in humans indicates limited long-term engraftment and no ectopic tissue formation. Stem Cells. 2012;30:1575–1578.
- Wada J., Makino H. Inflammation and the pathogenesis of diabetic nephropathy. Clin. Sci. (Lond.) 2013;124:139–152.
Source: PubMed