Regenerative Medicine for Severe Heart Failure

The World’s First Allogeneic iPS-derived Retina Cell Transplant

Our aim is to develop outer retinal cell therapy using iPS cells. The first in man application of autologous iPS cell-derived RPE (iPSC-RPE) cells started in 2013, targeted age-related macular degeneration (AMD). We proceeded to clinical research using HLA matched allogeneic iPSC-derived RPE cells. Immune responses to transplanted allogeneic cells could be suppressed by topical steroid administration without systemic immunosuppressant. Safety was confirmed one year after transplantation of HLA 6 loci matched allogeneic iPSC-RPE transplantation. So far 6 patients have received autologous and allogeneic iPS-derived retinal pigment epithelial cell transplantation. The grafted cells survive without any harm in all the patients.

The next challenge is photoreceptor replacement. We proved that grafted photoreceptor cells formed synapses only when they were transplanted in the form of organoids. They showed the functional recovery in the completely photoreceptor degenerated blind mice after transplantation. With those findings as POC, we are performing clinical study using retinal organoid for retinitis pigmentosa. 

Recent advances in cellular therapy for hematologic malignancies

In 2019, two novel treatment strategies against hematologic malignancies such as leukemia, lymphoma, and myeloma have been approved in Japan; one utilizes patient’ own immune cells and the other uses family member’s immune cells. Chimeric antigen receptor T cells (CAR-T) are patient’ s T cells that have been genetically engineered to attack own cancer cells. CAR-T can cure B-cell leukemia and lymphoma that had been resistant to cancer chemotherapies. Allogeneic hematopoietic cell transplantation (HCT) has been curative treatment for hematologic malignancies but required an HLA-identical donor. However, birthrate is declining in most counties and therefore bone marrow banking is required. We developed HLA-haploidentical HCT in Japan. The donor is typically a family member who shares only one of the 2 HLA haplotypes. Now all the patients who requires HCT to fight cancer can have a donor in their own family, eliminate the needs of bone marrow banking. These two strategies provide chance of cure in patients with hematologic malignancies that are refractory to standard treatments. 

Regenerative medicine for the treatment of osteoarthritis of the knee

Osteoarthritis of the knee (OAK) is a progressive and debilitating disease affecting millions, however, effective treatment to reverse joint damage and to restore articular cartilage is still in development. We completed the clinical study of autologous chondrocyte sheets transplantation to the patients of OAK, and reported safety and efficacy associated with this study. The ministry of Health Labour and Welfare approved this treatment as the Advanced Medical Care which provide patients with adaptation of national health insurance in Japan. Patients can be treated with autologous chondrocyte sheets transplantation if patients pay extra cost. On the other hand, the most useful characteristic of cartilage is immunotolerance, so the use of allogeneic chondrocyte sheets derived from surgical sample of polydactyly patients is in a rational manner. We are currently conducting a clinical study involving the allogeneic transplantation of polydactyly-derived chondrocyte sheets with the aim of treating patients with OAK. In my presentation, I will introduce our project to overcome OAK using regenerative medicine.  

Mesenchymal Stem Cell Therapies for Liver Cirrhosis

Cirrhosis is a chronic condition that can lead to liver failure. Currently, the only available option for decreasing mortality is liver transplantation. However, liver transplantation is highly invasive. Therefore, stem cell therapy has been expected as an alternative. Previously, we performed autologous bone marrow cell infusion therapy (ABMi) which we started in 2003 and found that ameliorating liver fibrosis with inducing liver regeneration. Now, majority of trials focus on low-immunogenicity Mesenchymal Stem Cell (MSCs) appropriate for allogeneic administration. We started clinical trial of allogenic adipose tissue derived MSC therapy for liver cirrhosis from 2017. Now Phase I has finished and now do Phase II clinical trial. From basic study we show that MSCs act as “conducting cells” and regulate host cells including macrophages via extracellular vesicles (EVs) signal leading to ameliorate liver fibrosis and promote regeneration. Based on the experience of clinical trial for liver cirrhosis we also started clinical trial of MSC therapy for severe cases of COVID-19 in 2020.

Allogeneic MSC therapy is attractive therapy that can be applied into a variety of diseases and patients and expand the field of regenerative medicine.

Human iPS cell-derived dopaminergic neurons function in a primate Parkinson's disease model

Human induced pluripotent stem cells (iPSCs) can provide a promising source of midbrain dopaminergic (DA) neurons for cell replacement therapy for Parkinson’s disease (PD). Towards clinical application of iPSCs, we have developed a method for 1) scalable DA neuron induction on human laminin fragment and 2) sorting DA progenitor cells using a floor plate marker, CORIN. The grafted CORIN+ cells survived well and functioned as midbrain DA neurons in the 6-OHDA-lesioned rats, and showed the minimal risk of tumor formation. In addition, we performed a preclinical study using primate PD models. Regarding efficacy, human iPSC-derived DA progenitor cells survived and functioned as midbrain DA neurons in MPTP-treated monkeys. Regarding safety, cells sorted by CORIN did not form any tumors in the brains for at least two years. Based on these results, we have started a clinical trial to treat PD patients at Kyoto University Hospital in Kyoto, Japan, in 2018. The trial evaluates the safety and efficacy of transplanting human iPS cell-derived DA progenitors into PD patients' putamen. We implant approximately 5 million cells to each of 7 patients and observe for 2 years. By showing these results, I will discuss how we can cross the valley of death.

Cell Therapy for Spinal Cord Injury using Induced Pluripotent Stem Cells

Spinal cord injuries (SCI) result in devastating loss of function, because spinal cord of human beings never regenerates after injury. People believed in this dogma for a long time. There is an emerging hope for regeneration-based therapy of the damaged spinal cord due to the progress of neuroscience and regenerative medicine including stem cell biology. Stimulated by the 2012 Nobel Prize in Physiology or Medicine awarded for Shinya Yamanaka and Sir John Gurdon, there is an increasing interest in the iPS cells (iPSCs) and reprogramming technologies in medical science. While iPS cells are expected to open new era providing enormous opportunities in the biomedical sciences in terms of cell therapies for regenerative medicine, safety-related concerns for iPS cell-based cell therapy should be resolved prior to the clinical application of iPSCs. Especially, some previous reports indicated risk factors for the use of iPSCs, such as genetic and epigenetic abnormalities that could take place during reprogramming or maintenance in subsequent cell culture. Of particular relevance is the potential tumorigenicity and immunogenicity associated with iPSC-based cell therapy. In this symposium, I would like to summarize previous efforts in the field as well as the current status of iPSC-based cell therapy for repair of the damaged central nervous system, with a special emphasis on SCI. Furthermore, I would like to explain our upcoming clinical trial of iPSC-derived neural stem cell transplantation for sub-acute SCI patients.

Reprogrammed’ stem cells to treat spinal-cord injuries for the first time

Spinal cord injury (SCI) is a devastating injury, resulting in permanent neurological impairment and attendant social and economic losses. In our previous preclinical studies, we showed transplantation of neural stem progenitor cells (NS/PCs) can result in successful functional recovery. We found that long-term restoration of motor function was induced without tumorigenicity, by selecting suitable hiPSCs-lines, when NS/PCs-derived from human induced pluripotent stem cells (hiPSCs) were transplanted into mouse or non-human primate SCI models. Based on these findings, we are establishing production and selection method of clinical grade NS/PCs stocks-derived from human iPSC stocks generated from HLA-homozygous super-donors by CiRA. In this clinical trial, SCI patients with ASIA impairment scale A are the target subjects for our clinical study, and 2 × 106 hiPSC-NS/PCs will be transplanted at 14–28 days after injury. The patients will be followed-up for one year, undergoing neurological and imaging evaluations and rehabilitation.

Generation of hepato-biliary-pancreatic organoid from human pluripotent stem cells

Organoids are multicellular structures that can be derived from adult organs or pluripotent stem cells. Early versions of organoids range from simple epithelial structures to complex, disorganized tissues with large cellular diversity. The current challenge is to engineer cellular complexity into organoids in a controlled manner that results in organized assembly and acquisition of tissue function. These efforts have relied on studies of organ assembly during embryonic development and have resulted in development of organoids with multilayer tissue complexity and higher order functions. For example, we show that antero-posterior interactions recapitulate the foregut and the midgut boundary in vitro, modeling the inter-coordinated specification and invagination of the human hepato-biliary-pancreatic system from human pluripotent stem cells. Coupled with patient-derived stem cells, my group studied the mechanisms of human hepatic diseases that includes viral hepatitis, steatohepatitis, recently extended to drug induced liver injury, wherein organoid modelled remarkable correlation between the clinical phenotype and genotype. Here I will summarize the frontiers of organoid research, and discuss its promise and impact to elucidate personalized disease mechanisms and understand drug reactions in humans, realizing “My Medicine” applications.

Generation of cytotoxic T lymphocytes from iPS cells: Development of “off-the-shelf T cells” for cell therapy targeting cancer and viral infection

We have proposed a strategy to use the iPSC technology for expansion of antigen specific cytotoxic T lymphocytes (CTLs); iPSCs produced from T cells (T-iPSCs) inherit rearranged T cell receptor (TCR) genes, and thus all regenerated T cells from T-iPSCs express the same TCR. Based on this idea, we previously succeeded in regenerating tumor antigen-specific CTLs (Cell Stem Cell, 2013). To apply this approach in allogeneic setting, we developed a method in which non-T cell derived iPSCs are transduced with exogenous TCR genes (TCR-iPSCs) (PCT/JP2015/070623). We used HLA-haplotype homo semi-universal iPSCs and WT1-specific TCR that had been clinically tested in Japan. The regenerated WT1-CTLs showed cytotoxicity against renal cell carcinoma cells in patient-derived xenograft model (iScience, 2020). We are now preparing for clinical trial to be realized in 3-4 years in Kyoto University Hospital, in which acute myeloid leukemia patients will be treated by the regenerated WT1-CTLs. Since 2020, the whole world has been hit by a pandemic of COVID-19. To fight against this disease, we have started to develop off-the-shelf T cell medicine, and have started to clone corona-specific TCRs. We propose that this strategy can be applied to other viral infections, such as MERS or Ebora hemorrhage fever, etc. (201 words).

Quality and Quantity-Cultured Human Mononuclear Cells Improve the Human Fat raft Vascularization and Survival in an In Vivo Murine Experimental Model

We have recently disclosed a newly developed ex vivo expansion system of peripheral blood mononuclear cells (PbMNC) to generate assembly of cells including endothelial progenitor cells (EPCs) and macrophages and regulatory T cells for enhanced vasculogenesis and wound healing. For the first time, this methodology will allow us to transplant highly vasculogenic peripheral blood cells from only 100 mL of blood draw. After finishing pre-clinical study and safety tests, we have performed a physician-based phase I clinical trial for treating non-healing ischemic limb ulcers from January 2015 to March 2018 and demonstrated its safety and efficacy in patients. Industrial clinical trial is prepared to be staring in 2021 FY. Herein, we will introduce challenges and future perspective of world`s first non-invasive and effective peripheral blood vascular stem cell therapy for limb salvage.

iPSC technology-based regenerative therapy for diabetes

Diabetes is caused by an absolute or relative insufficiency of insulin which is secreted from pancreatic β-cells, resulting in impaired glucose metabolism in entire body. The supplementation of β-cell function is an effective therapeutic strategy, but the insufficient cell supply is a major obstacle to this intervention. Regenerative medicine strategies using human induced pluripotent stem cells (iPSCs) are among the candidate approaches to solve the problems. Based on the knowledge of developmental biology, the stepwise differentiation strategy by mimicking pancreatic development has been adopted. Our group developed the directed differentiation methods to generate transplantable pancreatic lineage cells from human iPSCs. In addition, we are examining the therapeutic potential of human iPSC-derived pancreatic cells by transplantation into diabetes mouse models, and recent results indicate therapeutic effectiveness. Further elucidation of the mechanisms of pancreatic development and establishing the efficient differentiation methods from human iPSCs into pancreatic lineage cells will be required for the development of regenerative medicine strategies for diabetes, such as cell transplantation therapy and new drug discovery. In this presentation, I would like to summarize the current status of pancreatic regeneration researches using human iPSCs including our results and discuss the future perspective of iPSC technology-based regenerative treatment of diabetes.

Flexible endoscopic surgery 2021

Recently marked advancement of technology allows completing conventional surgery using flexible endoscopy. Laparoscopic Heller-Dor surgery can be done now by transoral flexible endoscopic surgery. This is POEM (Peroral endoscopic myotomy) for esophageal achalasia.

World first case was done in 2008, more than 2200 consecutive cases received POEM in our hospital. As offshoots of POEM, POET (Peroral endoscopic tumor resection), G-POEM (Gastric POEM) for gastroparesis, Z-POEM (Zenker POEM) were developed and clinically well accepted. In these procedures, submucosal tunnel is commonly created and then each surgical procedure is completed. Like this way, flexible endoscopic surgery brings us minimally invasive surgery with no visible scar on our skin. In this lecture we would like to show you a clinical series of flexible endoscopic surgery and discuss future of it.

Real-time endoscopic diagnosis using deep learning technology and ESD for lower GI neoplasms

Image-enhance endoscopy (IEE) assists in the early detection of flat and depressed neoplasia, differentiation between non-neoplastic and neoplastic lesions, and the characterization of early colorectal cancers.  The Japan NBI Expert Team (JNET) was organized in 2011 to develop a universal magnifying NBI classification system. Consensus on JNET classification was reached based on univariate and multivariate analysis using a modified Delphi method on June 6, 2014.

In the western countries, however, magnified endoscopic diagnosis is not yet widely adopted. There is immense variability in the diagnostic ability of flat and depressed neoplasia among endoscopists, and solutions are critically needed.

An AI using a deep learning system that automatically detect pre-cancerous lesion and diagnose the estimated histology during colonoscopy is currently available.

As for therapeutic procedures, lesions smaller than 2cm are generally treated with endoscopic mucosal resection (EMR). In case of lesions larger than 2cm, piecemeal EMR is inevitable. The main advantage of endoscopic submucosal dissection (ESD) over EMR is completeness of resection as it enables en bloc removal of lesions irrespective of lesion size. This allows a definitive histological diagnosis and staging of superficially invasive cancers which is significantly superior to piecemeal EMR providing a treatment alternative to surgery for early colorectal cancer with no risk of lymph-node metastasis.

Colorectal ESD has gained acceptance as a safe and effective therapeutic option not only in Japan but also in western countries and is considered as the mainstream treatment for some neoplastic lesions with distinctive features.

Up-to-date advanced endoscopy of upper GI neoplasm

Advanced diagnostic and therapeutic endoscopy is developed and widely accepted in Japan. Endoscopic submucosal dissection (ESD) is technically more demanding than endoscopic mucosal resection (EMR). However, it allows for en bloc resection regardless of lesion size and location. Some adverse events have been resolved by the development of novel devices, techniques, and prophylactic procedures. Moreover, several papers reported excellent short and long-term ESD outcomes for superficial esophageal squamous cell carcinoma and early gastric cancer. ESD is now acceptable minimally invasive treatment options, and some Japanese guidelines were published and revised.

Moreover, the ESD technique consisting of mucosal incision and submucosal dissection has been utilized for more advanced surgical resection, such as laparoscopic and endoscopic cooperative surgery (LECS) for gastric submucosal tumor and hybrid endoscopy-assisted larynx preserving esophagectomy for cervical esophageal cancer.

This lecture will overview the up-to-date advanced endoscopy for upper GI neoplasms.

Telemedicine in Asia and beyond: Possible expansion to UAE

With the tight restriction of physical movement, COVID-19 drastically changed our life-style and forced us to communicate online all over the world. People felt inconvenience without direct human touch, but at the same time, we have re-recognized the efficiency of remote communications. We started remote medical education in 2002 with the development of new telemedicine system which could preserve the quality of transmitted images without any costly special videoconferencing equipment. It rapidly expanded in Asia as well as other parts of the world, having collaborated with 1028 institutions in 75 countries and organized over 1200 programs so far in 39 medical fields such as endoscopy and surgery. Now UAE is one of our top priorities of activity expansion and we would like to discuss how we can achieve it.

Mitochondrial Augmentation Therapy Restoring Cellular Bioenergetics in Dysfunctional or Damaged Tissues and Organs

Development of innovative therapy with low-intensity pulsed ultrasound for angina pectoris and dementia

Although the numbers of patients with severe angina pectoris and those with dementia have been rapidly increasing in the current super-aging society, effective therapies still remain to be developed.  In 2004, we succeeded in developing low-intensity shock wave therapy that enhances angiogenesis and improves myocardial ischemia in patients with severe angina pectoris.  Then, we aimed to develop innovative therapy with ultrasound, which should be safer and time-saving than shock wave therapy.  In 2013, we found that low-intensity pulsed ultrasound (LIPUS) exerts almost the same effects as shock wave therapy and this LIPUS therapy ameliorated myocardial ischemia in a porcine model of angina.  Based on these findings, we started investigator-initiated clinical trial of the LIPUS therapy for angina pectoris with 60 patients.  The results will be available in 2021.  Then, we hypothesized that this LIPUS therapy may also be effective for dementia.  In mouse models of Alzheimer disease and vascular dementia, we confirmed that the LUPUS therapy is effective and safe.  Based on these findings, we started investigator-initiated clinical trial of the LIPUS therapy for Alzheimer disease.  We already have confirmed its safety in those patients in the exploratory trial and have started subsequent confirmatory trial with 40 patient

Introduction of BNCT and its future possibility

Boron neutron capture therapy (BNCT) is new radiotherapy to treat intractable cancers based on the external radation of neutron, in vivo nuclear reaction of 10B (n, α)7Li and high cancer cell killing effect of α and 7Li particles, and an evaluation of 10B concentration in target tumor and surrounding normal issue with a PET/CT. The BNCT was initially conducted by means of nuclear reactor as neutron source. It is now possible to employ an in-house accelerator in a hospital. The BNCT required cancer cell specific delivery of 10B, and 10B boronophenylalanine (BPA: INN : Borofolan (10B)) was developed as 10B carrier agent. The PET tracer of 18F-FBPA was developed to estimate BPA concentration in tumors and normal issue in a patient before the BNCT. For Unresectable, locally advanced or locally recurrent – head and neck cancer, the Phase II clinical trial was completed. The objective response rate was 71%, and overall survival at 2 years was 85%. The BNCT accelerator and Borofalan (10B) WERE APPROVED BY Ministry of Health, Labour, and Welfare, Japan. In order to extend an application of BNCT, the clinical trials for recurrent glioblastoma multiforme, recurrent malignant meningioma, malignant melanoma, and angiosarcoma are now on-going by means of BNCT accelerator and Borofalan (10B) in Japan. (206 words)

Tele-ICU and the integration of AI technologies

While the number of critically ill patients with underlying diseases is rapidly increasing in super aging society, medical resources in acute care settings, especially intensivists and ICU beds, are limited. In our hospital research in 2019, 61% of ICU incidents were attributed to communication errors. Moreover, today’s COVID-19 pandemic redefines many clinical activities because of the restriction of face-to-face interaction. In this session, we will explain a new approach to intensive care using ICT and AI, and introduce examples of utilization and research of ICT (Tele-ICU) and AI at our hospital.

Tele-ICU and the integration of AI technologies

While the number of critically ill patients with underlying diseases is rapidly increasing in super aging society, medical resources in acute care settings, especially intensivists and ICU beds, are limited. In our hospital research in 2019, 61% of ICU incidents were attributed to communication errors. Moreover, today’s COVID-19 pandemic redefines many clinical activities because of the restriction of face-to-face interaction. In this session, we will explain a new approach to intensive care using ICT and AI, and introduce examples of utilization and research of ICT (Tele-ICU) and AI at our hospital.

Electronic Clinical Pathway to be used in Learning Health System

Real-world evidence is defined as clinical evidence about the usage and potential benefits or risks of a medical product derived from analyses of real-world data (RWD). Standardization and structuring of data are necessary for analysis of RWD collected from different institutions to use medical purpose level. However, electronic medical record is not a good data source of RWD for achievement high quality data analysis, because of difficulty of standardization and filled by unstructured data

About 2,000 of Japanese hospitals are using clinical pathway system (scheduled procedures are planned by diagnosis basis) in electronic medical record system, but not standardized. We have lead the ePath project which determined the outcome-oriented standard structure of data, electronic message and repository for analysis of high quality medical RWD collected from multiple medical institutes, and conducted a verification study with 4 top vendors of electronic medical record with 4 hospitals.

In the data structure, we have three layers with an outcome (layer 1), assessments (layer 2, multiple), and tasks (layer 3, same number to layer 2, linked as 1: N: N), and named as "OAT unit" as a basic unit in medical process. Now, we can describe all processes of inpatient clinical course by series of OAT unit on clinical pathway system in main diseases. We are analyzing medical process RWD like a Toyota automobile factory, improving by medical PDCA cycle 'Kaizen' to form a multi-institutional Learning Health System.

Development of new robot-assisted surgical system suitable for the tele-surgery

Japan is experiencing a super-aging society both in rural and urban areas. A medical care service has become complicated and specialized every year.  Therefore, it is difficult that all doctors handle all diseases. Thus, a chronic manpower shortage is one of main problem in medical issue. However, tele-surgery is not an applicable in clinical condition since it have some problems for realization. The significant problem is the network latency. In Japan, some companies including robotic companies, network operators, and research institutes cooperate and start an experimental study to establish a tele-surgery. We want to introduce practical realization of telesurgery, establishing a reasonable guideline for regulatory. As a basic study, we are investigating the impact of communication delay on the surgical technique. We will elucidate which techniques has problems by the communication delay and clarify the limit of communication delay. Next step is the experimental study for tele-surgery. We will start the tele-surgery between university hospital and area hospital using open network system in at least three area. Efficacy and safety will be confirmed in the experimental study. We will ultimately develop the next generation Japanese surgeon assist robot suitable for tele-surgery. 

Development of oligonucleotide therapeutics gene by gene

Luxna Biotech has developed antisense drug discovery platform based on the bridged nucleic acid technology originate from Prof. Satoshi Obika group of Osaka University. Luxna also has been collaborating with pharmaceutical companies for novel targets including spinal cord injury and small cell lung cancer from academic research.

Today, we’d like to introduce our most advanced project, spinal cord injury treatment antisense drug development. The glial and fibrotic scars form a physical and chemical barrier to axon growth after spinal cord injury (SCI) and chondroitin sulfate (CS) is presumed to play a pivotal role for the neuronal regeneration. Our strategy is the inhibition of biosynthesis of CS with antisense oligonucleotide (ASO).

ASOs were designed with our proprietary nucleic acids to match both of mice and human CSGalNAcT1 mRNA sequences. It was found that some ASOs demonstrated efficacy in mice SCI model with minimal in vitro hepatotoxicity and cytotoxicity. There was no adverse event occurred in normal Cynomolgus monkey safety study. Non-clinical GLP studies are planned to start in late 2021.