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) • Heterogeneous population of precursor cells • Multiple sources of MSC Le Blanc K & Mougiakakos. Nature reviews 2012

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 Clinical trial CD362+ MSC Mechanism of action

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 Tregs ê MSC T cells é TH1 é • Multifactorial- TH17 é genetic and environmental factors • Complex disease pathogenesis Macrophages é Webb GJ et al. Annu Rev Pathol Mech Dis 2018

Studies • Experimental Ø In vivo studies in 3 murine models: UC-MSC effect on hepatic inflammatory activity (ALT and CD45) and T cell infiltration Ø In 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 (CCL 4 ) • Chronic Mdr2 KO/FVB mouse model : Model of sclerosing cholangitis

US: Unselected MSC UC- Umbilical cord Hepatic CD45 ALT Human CD362+ UC-MSC reduce inflammation in 3 mouse % area of CD45+ cells in liver I n U j n u i r e n 0 2 4 6 8 j d u M r e d d r F 2 K V B O / F V B c o n Mdr2 -/- t U r S o l U models of inflammatory livery injury C M C S D C 3 2 6 5 2 + 0 k U ** C M S C 2 5 0 k No MSC ALT level ( IU/L) 100 200 300 400 500 0 Ova bil 10 M (OT-1 & OT-2) Ova-Bil US UC MSC CD362+ UC MSC * MSC Data from V Wigneswara & M Alfaifi ALT level ( IU/L) 100000 150000 200000 50000 100 150 200 50 Control 0 0 M.O US UC MSC 250K CCL4 US UC MSC 1M CCL4 * CD362+ UC MSC 250K CD362+ UC MSC CCl 4 CD45 Heat inactivated MSC * * CD362+ UC MSC 1M

Infusion of CD362+ UC-MSC reduce hepatic CD3 + , CD4 + & CD8 + T cell infiltration in the chronic model of sclerosing cholangitis * (p=0.0255) * (p=0.0426) * (p=0.0200) * (p=0.0375) * (p=0.0264) 20000 * (p=0.0255) 60000 60000 CD8 + cells /g 15000 CD4 + cells /g CD3 + cells /g 40000 40000 10000 20000 5000 20000 0 0 0 Control US-UC MSC 250k CD362+ UC-MSC 250k Control US-UC MSC 250k CD362+ UC-MSC 250k Control US-UC MSC 250k CD362+ UC-MSC 250k * p < 0·05 Data from V Vigneswara

Infusion of CD362+ UC-MSC induces CD4 + CD25 + Foxp3 + Tregs ** (p=0.0021 ) ** (p=0.0044 ) CD25 high FOXP3 + cells (%) 20 15 CD3 + CD4 + 10 5 0 Control US-UC MSC 250k CD362+ UC-MSC 250k Data from V Vigneswara * p < 0·05

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 **** **** **** **** **** **** 100 100 % CD4+ proliferation % CD8+ proliferation 80 60 50 40 20 0 0 m 1 4 6 4 6 1 4 6 4 6 m : : 1 6 5 : : 1 6 5 i 1 1 1 1 : : 2 i : : 2 t 1 1 t 1 1 S : : S 1 1 MSC:PBMC MSC:PBMC Key Stim: stimulated PBMC only **** p≤0.0001

%CD4 + TNF α + expressing cells UC-MSC reduce peripheral blood CD4 + T 100 50 0 S t i m * 1 : 1 1 TNFα MSC:PBMC TNFα : 4 1 : 1 6 1 : 6 4 1 : 2 5 6 cell activation %CD4 + IFN γ + expressing cells 100 * p< 0.05 20 40 60 80 0 S t i m * 1 *p ≤ 0.05 IFN γ : 1 * MSC:PBMC 1 : 4 1 : 1 6 1 : 6 4 1 : 2 5 6 %CD4 + IL-2 + expressing cells 100 20 40 60 80 0 S t i m 1 : 1 1 MSC:PBMC : 4 IL2 1 : 1 6 1 : 6 4 1 : 2 5 6

UC-MSC suppress Intrahepatic CD4 + and CD8 + T cell proliferation from patients with PSC * ** ** * 100 100 % CD8+ proliferation % CD4+ proliferation 80 80 60 60 40 40 20 20 0 0 1 4 6 4 6 1 4 6 4 6 m m : : 1 6 5 : : 1 6 5 1 1 1 1 i : : 2 : : 2 i t 1 1 t 1 1 : : S S 1 1 MSC:CD4+ T cell MSC:CD8+ T cell

UC-MSC reduce intrahepatic CD4 + T cell activation from patients with PSC TNFα IFN γ IL2 * ** ** ** %CD4 + TNF α + expressing cells %CD4+IL2 expressing cells 100 * * 100 * %CD4 + IFN γ + expressing cells 50 80 80 40 60 60 30 40 40 20 20 20 10 0 0 0 1 4 6 4 6 Stim 1:1 1:4 1:16 1:64 1:256 Stim 1:1 1:4 1:16 1:64 1:256 m : : 1 6 5 1 1 : : 2 i t 1 1 : S 1 MSC:CD4+ T cell MSC:CD4+ T cell MSC:CD4+ T cell

Summary of MSC actions CD4 CD3 CD8 Hepatic Tregs inflammation Reduction TNFα CD4 CD8 IFNγ CD362+ UC-MSC Proliferation and Activation Biliary epithelial cell inflammation and death

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 Williams R et al. Lancet 2018 AIH • Prevalence 16-18 cases per 100,000 inhabitants • 10-20% patients are treatment intolerant or unresponsive • Therapies limited by side-effects & limited 2 nd line options

Unmet needs of patients with PSC and AIH Patients with AIH Patients with PSC • Higher mortality risk for AIH patients Mean transplant-free survival = 14.5 years • compared to matched general population Weismüller & Trivedi et al. Gastro 2017 Groenbark et al. J Hep 2014

PSC Bucket trial concept AIH 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 Inclusion criteria Patients with AIH Patients with PSC Patients refractory to treatment Serum ALP ≥ 1.5 ULN at Serum ALT ≥ 1.5 ULN at screening visit screening visit STAGE 1 STAGE 2 Determine: Safety at a higher dose Determine: EFFICACY and safety Safe Safe 2.5 X 10 6 cells/kg 1.0 X 10 6 cells/kg Stage 2 n=3 n=3 Safety: Assessed by dose limiting toxicity (DLT) Chief Investigator: Prof Gideon Hirschfield and adverse events Co-CI: Prof Philip Newsome

Patient pathway in the trial MSC infusion Initial f/u Long term safety f/u Screening Pre-treatment Treatment Visit 1 Visit 2 Visit 3 Visit 7 Visit 8 Visit 5 Registration SD -28 SD -7 SD 0 SD 14 SD 28 SD 56 D180 D270 D360 D720 D540 End of DLT reporting Significant clinical events period (stage 1) and serious adverse events will be captured Primary efficacy outcome measures Secondary efficacy outcome measures Change in ALP (PSC)/ALT (AIH) from baseline 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 Collaborators Dan Hollyman Trial Co-ordinator Prof Gideon Hirschfield & Steve Elliman Jon Smythe Darren Barton Prof Philip Newsome Martin Hoogdjuin Rebecca Storey Vasanthy Vigneswara Carla Baan Mohammed Alfaifi Debashish Roy Trial Statistician Nguyet-Thin Luu Daniel Slade Evaggelia Liaskou Christina Yap