Cell based therapy in inflammatory liver disease- the MERLIN trial - - PowerPoint PPT Presentation

Cell based therapy in inflammatory liver disease- the MERLIN trial

Dr Ashnila Janmohamed Clinical research fellow in Hepatology Birmingham Rare Disease Symposium 18 May 2018

Mesenchymal stromal cells (MSC)

Le Blanc K & Mougiakakos. Nature reviews 2012

• Heterogeneous

population of precursor cells

• Multiple sources of MSC

Potential applications of MSC in liver disease

Forbes & Newsome. J Hep 2012

MSC have a pleiotropy of action on the immune system

Alfaifi M et al. J Hep 2018

MERLIN programme: MEsenchymal stromal cells to Reduce Liver INflammation

Pintail Orbsen UoB NHSBT UNIPD Efficacy Mechanism

• f action

Clinical trial

CD362+ MSC

Immune-mediated liver disease

Webb GJ et al. Annu Rev Pathol Mech Dis 2018

Primary sclerosing cholangitis (PSC) and autoimmune hepatitis (AIH) share the same immune-pathogenesis

• Multifactorial-

genetic and environmental factors

• Complex disease

pathogenesis

MSC

Webb GJ et al. Annu Rev Pathol Mech Dis 2018

Tregs ê T cells é TH1é TH17 é Macrophages é

Studies

• Experimental

ØIn vivo studies in 3 murine models: UC-MSC effect on hepatic inflammatory activity (ALT and CD45) and T cell infiltration ØIn vitro studies: UC-MSC effect on T cell proliferation and activation using tissues from patients with PSC

• Clinical trial

Ø Safety and efficacy of UC-MSC in patients with PSC and AIH

In vivo models of inflammatory liver injury

• Ovalbumin (Ova)- Bil mouse model: Transgenic

mouse model of immune-mediated hepatobiliary injury

• C57BL/6 mice: Carbon-tetrachloride-induced liver

injury (CCL4)

• Chronic Mdr2 KO/FVB mouse model: Model of

sclerosing cholangitis

Human CD362+ UC-MSC reduce inflammation in 3 mouse models of inflammatory livery injury

U n i n j u r e d F V B I n j u r e d M d r 2 K O / F V B c

• n

t r

• l

U S U C M S C 2 5 k C D 3 6 2 + U C M S C 2 5 k 2 4 6 8

% area of CD45+ cells in liver

**

Mdr2-/- ALT Hepatic CD45

UC- Umbilical cord US: Unselected MSC Data from V Wigneswara & M Alfaifi

Ova bil 10 M (OT-1 & OT-2) US UC MSC CD362+ UC MSC 100 200 300 400 500

ALT level ( IU/L) *

Ova-Bil No MSC MSC

Control CCL4 US UC MSC 250K US UC MSC 1M CD362+ UC MSC 250K CD362+ UC MSC 1M 50 100 150 200

ALT level ( IU/L) * * M.O CCL4 CD362+ UC MSC Heat inactivated MSC 50000 100000 150000 200000

CD45

*

CCl4

Infusion of CD362+ UC-MSC reduce hepatic CD3+, CD4+ & CD8+ T cell infiltration in the chronic model of sclerosing cholangitis

*p < 0·05

Control US-UC MSC 250k CD362+ UC-MSC 250k 5000 10000 15000 20000 CD8+ cells /g * (p=0.0255) * (p=0.0255) Control US-UC MSC 250k CD362+ UC-MSC 250k 20000 40000 60000 CD4+ cells /g * (p=0.0264) * (p=0.0200) Control US-UC MSC 250k CD362+ UC-MSC 250k 20000 40000 60000 CD3+ cells /g * (p=0.0426) * (p=0.0375)

Data from V Vigneswara

Infusion of CD362+ UC-MSC induces CD4+CD25+Foxp3+ Tregs

*p < 0·05 Data from V Vigneswara

Control US-UC MSC 250k CD362+ UC-MSC 250k

5 10 15 20

CD3+CD4+ CD25highFOXP3+ cells (%) ** (p=0.0021) ** (p=0.0044)

In-vitro assessment of efficacy of UC- MSC in patients with PSC

Ø Effect of UC-MSC on CD4+ and CD8+ T cell proliferation and activation

T cell proliferation and activation

UC-MSC suppress peripheral blood CD4+ and CD8+ T cell proliferation from patients with PSC

Key Stim: stimulated PBMC only **** p≤0.0001

S t i m 1 : 1 1 : 4 1 : 1 6 1 : 6 4 1 : 2 5 6 20 40 60 80 100

MSC:PBMC % CD4+ proliferation **** **** ****

S t i m 1 : 1 1 : 4 1 : 1 6 1 : 6 4 1 : 2 5 6 50 100

MSC:PBMC % CD8+ proliferation **** **** ****

UC-MSC reduce peripheral blood CD4+ T cell activation

TNFα

* p< 0.05

*p ≤ 0.05

S t i m 1 : 1 1 : 4 1 : 1 6 1 : 6 4 1 : 2 5 6 20 40 60 80 100

MSC:PBMC %CD4+IFNγ+ expressing cells * *

S t i m 1 : 1 1 : 4 1 : 1 6 1 : 6 4 1 : 2 5 6 20 40 60 80 100

MSC:PBMC %CD4+ IL-2+ expressing cells

S t i m 1 : 1 1 : 4 1 : 1 6 1 : 6 4 1 : 2 5 6 50 100

MSC:PBMC %CD4+TNFα+ expressing cells *

TNFα IFN γ IL2

UC-MSC suppress Intrahepatic CD4+ and CD8+ T cell proliferation from patients with PSC

S t i m 1 : 1 1 : 4 1 : 1 6 1 : 6 4 1 : 2 5 6 20 40 60 80 100

MSC:CD4+ T cell % CD4+ proliferation * ** *

S t i m 1 : 1 1 : 4 1 : 1 6 1 : 6 4 1 : 2 5 6 20 40 60 80 100

MSC:CD8+ T cell % CD8+ proliferation **

UC-MSC reduce intrahepatic CD4+ T cell activation from patients with PSC

S t i m 1 : 1 1 : 4 1 : 1 6 1 : 6 4 1 : 2 5 6 20 40 60 80 100

MSC:CD4+ T cell %CD4+TNFα+ expressing cells ** * *

Stim 1:1 1:4 1:16 1:64 1:256 10 20 30 40 50

MSC:CD4+ T cell %CD4+IFNγ+ expressing cells ** * Stim 1:1 1:4 1:16 1:64 1:256 20 40 60 80 100

MSC:CD4+ T cell %CD4+IL2 expressing cells * **

TNFα IFN γ IL2

CD362+ UC-MSC

Summary of MSC actions

CD3 CD4 CD8 Tregs Hepatic inflammation Biliary epithelial cell inflammation and death

Reduction

CD8 CD4 Proliferation and Activation TNFα IFNγ

MSC clinical trials in liver disease

• MSC therapy has been used in a number of clinical

studies to treat liver disease (n=300)

• Found to be safe
• Variability in efficacy
• Most studies have short follow-ups so long-term efficacy

data is lacking

Primary sclerosing cholangitis (PSC) and autoimmune hepatitis (AIH)

PSC

• Prevalence 16.2 per 100,000

inhabitants

• Affects young patients
• No licensed effective therapies

AIH

• Prevalence 16-18 cases per 100,000 inhabitants
• 10-20% patients are treatment intolerant or unresponsive
• Therapies limited by side-effects & limited 2nd line options

Williams R et al. Lancet 2018

Unmet needs of patients with PSC and AIH

Patients with PSC

Weismüller & Trivedi et al. Gastro 2017

• Mean transplant-free survival = 14.5 years

Groenbark et al. J Hep 2014

• Higher mortality risk for AIH patients

compared to matched general population

Patients with AIH

AIH PSCBucket trial concept

Common mechanistic and clinical primary end point

Primary Outcome measures

• Safety and Feasibility
• Disease end-point

Ø Change in serum ALP (PSC) and ALT (AIH) from baseline

• Mechanistic end-point

Ø Increase in circulating Tregs

Trial design

Safety: Assessed by dose limiting toxicity (DLT) and adverse events

Inclusion criteria Patients with PSC Serum ALP ≥ 1.5 ULN at screening visit Patients with AIH Patients refractory to treatment Serum ALT ≥ 1.5 ULN at screening visit

STAGE 1

Determine: Safety at a higher dose

STAGE 2

Determine: EFFICACY and safety

2.5 X 106 cells/kg n=3 Safe 1.0 X 106 cells/kg n=3 Safe

Stage 2 Chief Investigator: Prof Gideon Hirschfield Co-CI: Prof Philip Newsome

Screening Visit 1

SD -28

Pre-treatment Visit 2

SD -7

Registration Treatment Visit 3

SD 0

MSC infusion

SD 28

Primary efficacy

• utcome measures

Change in ALP (PSC)/ALT (AIH) from baseline Visit 7 Visit 8

SD 56

Initial f/u

SD 14

End of DLT reporting period (stage 1) Secondary efficacy

• utcome measures

Long term safety f/u

D720 D360 D180 D540 D270

Significant clinical events and serious adverse events will be captured Visit 5

Patient pathway in the trial

SD= study day

Clinical trial progress

• Ethical and regulatory approval (MHRA) obtained- April

2017

• Substantial amendment to MHRA submitted- April

2018

• Aim to recruit 19 patients per cohort

Acknowledgements

Prof Gideon Hirschfield & Prof Philip Newsome Vasanthy Vigneswara Mohammed Alfaifi Nguyet-Thin Luu Evaggelia Liaskou Collaborators Steve Elliman Martin Hoogdjuin Carla Baan Debashish Roy Dan Hollyman Jon Smythe Trial Co-ordinator Darren Barton Rebecca Storey Trial Statistician Daniel Slade Christina Yap