Interstitial Cystitis

STEM CELLS FOR IC/PBS
Millions of patients suffer from interstitial cystitis/painful bladder syndrome. This severe and debilitating condition has historically been confused with other bladder pathology which must be ruled out, making IC difficult to diagnose. Currently, IC/PBS is defined as “an unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder, associated with lower urinary tract symptoms of more than 6 weeks duration, in the absence of infection or other identifiable
causes.” (2009 new American IC/BPS Guidelines). Although there are several theories to explain IC, the exact cause remains unclear. Many patients with IC have the biomarker APF (antiproliferative factor) in their urine which inhibits bladder cell proliferation, making healing of the bladder lining much more difficult (1). Recent research indicates IC may be related to systemic neurosensitization and neuroinflammation that occurs within the bladder and also some other organ systems (2). Regardless of the cause, the end result of IC is damage to urothelium and bladder muscle that can run the spectrum from mild mucosal irritation to deep Hunner’s ulcers.

Adipose derived adult (non-embryonic) mesenchymal stem cells are currently being investigated for use in degenerative conditions that result in damage to various organs and systems.  These cells have the ability to seek out areas of injury and regeneration and assist in the repair of nerves, blood vessels, muscle, fat, cartilage, bone, and many other structures. These cells are naturally recruited by cytokines (SDF-1 stromal derived factor one, HGF hepatocyte growth factor, and platelets), to sites of inflammation, ischemia, hypoxia, or injury and they assist in the healing process either by directly forming needed cells or secreting chemical messengers that promote healing. Stem cells are mobilized naturally from bone marrow when the body is healing but they are also found dormant but available in human adipose tissue. These stem cells from fat are abundant in levels up to 2500 times greater than those found in bone marrow and research indicates that the fat derived stem cells have equivalent regeneration potential to the bone marrow cells (3).  Also, stem cell treatment success appears to relate to the number of cells used and this gives adipose cells a significant potential advantage to regenerate human tissues. Mesenchymal stem cells have been used extensively around the world in the successful treatment of orthopedic, cardiac, pulmonary, and neurologic disease in both humans and veterinary models. We have evidence that adipose derived stem cells can differentiate into functional smooth muscle cells (4,5) and we think therefore, that bladder repair by stem cells may be possible in IC patients. A recent study in mice with bladder outlet obstruction demonstrated that florescent protein labeled MSC’s (mesenchymal stem cells) injected intravenously into test subjects incorporated into bladder muscle resulting in decreased hypoxia, hypertrophy, and fibrosis and increased blood flow. Nine out
of ten mice who received MSC’s had improved bladder compliance (6).

We know that patients with IC demonstrate abnormal cell signaling and cytokine release (7). For this reason, we believe that stem cell treatment may be helpful for interstitial cystitis patients who exhibit mucosal and smooth muscular damage. We have developed a protocol to treat patients with IC of various stages with adipose derived stem cells. Our protocol uses high doses of stem cells injected intravenously and also intra-vesically (directly into the bladder lumen) and in some cases directly into trigger points in the pelvic floor. We have evidence that intravesical instillation of adipose derived stem cells into mice effectively shows morphological and phenotypic evidence of smooth muscle incorporation into the bladder wall three months after instillation (8).

Phoenix Stem Cell Treatment Center is using high dose autologous adipose derived stem cells for the investigational treatment of various degenerative diseases. The use of autologous cells ensures that the patients receive cells from only their own bodies. The technology to isolate the adipose derived stem cells has been obtained from Korea and is state of the art. All PSCTC studies are patient funded and not approved by the FDA. We have initiated a pilot study to investigate the effectiveness of high dose adipose derived stem cells on interstitial cystitis. Only adult adipose derived stem cells are used at the Phoenix Stem Cell Treatment Center since embryonic stem cells have the potential to form rare tumors and have ethical considerations. At Phoenix Stem Cell Treatment Center, the stem cells are obtained from a “mini” liposuction-like procedure performed under local anesthetic. Stem cells are isolated on site from the patient’s own fat and then deployed in our facility within 90 minutes. Regenerative healing naturally takes time and we do not expect immediate improvement in symptoms. Patients will be followed closely through our research registry and data collected carefully to help establish effectiveness of our treatment protocols.

1.  Proc Natl Acad Sci U S A.
2004 Aug 10;101(32):11803-8. Epub 2004 Jul 28.

An antiproliferative factor from interstitial cystitis patients is a frizzled 8 protein-related sialoglycopeptide.

Keay SKSzekely ZConrads TPVeenstra TDBarchi JJ JrZhang COKoch KRMichejda CJ.

Division of Infectious Diseases, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
skeay@medicine.umaryland.edu

Comment in:

J Urol. 2005 Mar;173(3):909-10.

Abstract

Approximately 1 million people in the United States suffer from interstitial cystitis, a chronic painful urinary bladder disorder
characterized by thinning or ulceration of the bladder epithelial lining; its etiology is unknown. We have identified a glycosylated frizzled-related peptide inhibitor of cell proliferation that is secreted specifically by bladder epithelial cells from patients with this disorder. This antiproliferative factor (APF) profoundly inhibits bladder cell proliferation by means of regulation of cell adhesion protein and growth factor production. The structure of APF was deduced by using ion trap mass spectrometry (MS), enzymatic
digestion, lectin affinity chromatography, and total synthesis, and confirmed by coelution of native and synthetic APF derivatives on microcapillary reversed-phase liquid chromatography (microRPLC)/MS. APF was determined to be an acidic, heat-stable sialoglycopeptide whose peptide chain has 100% homology to the putative sixth transmembrane domain of frizzled 8. Both synthetic and native APF had identical biological activity in normal bladder epithelial cells and T24 bladder cancer cells. Northern blot analysis indicated binding of a probe containing the sequence for the frizzled 8 segment with mRNA extracted from cells of patients with interstitial cystitis but not controls. APF is therefore a frizzled-related peptide growth inhibitor shown to contain
exclusively a transmembrane segment of a frizzled protein and is a potential biomarker for interstitial cystitis.

PMID: 15282374 [PubMed - indexed for MEDLINE]

2.  “What causes IC?”  www.ic-Network.com

3.   MolBiol Cell. 2010 Jun;21(11):1783-7. Epub 2010 Apr 7.

The adipose-derived stem cell: looking back and looking ahead.

Zuk PA.

Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA. pzuk@mednet.ucla.edu

Abstract

In 2002, researchers at UCLA published a manuscript in Molecular Biology of the Cell describing a novel adult stem cell population isolated from adipose tissue-the adipose-derived stem cell (ASC). Since that time, the ASC has gone on to be one of the most popular adult stem cell populations currently being used in the stem cell field. With multilineage mesodermal potential and possible ectodermal and endodermal potentials also, the ASC could conceivably be an alternate to pluripotent ES cells in both the lab and in the clinic. In this retrospective article, a historical perspective on the ASC is given together with exciting new applications for the stem cell being considered today.

PMID: 20375149 [PubMed - indexed for MEDLINE]

4.  Proc Natl Acad Sci U S A.
2006 Aug 8;103(32):12167-72. Epub 2006 Jul 31.

Clonogenic multipotent stem cells in human adipose tissue differentiate into functional smooth muscle cells.

Rodríguez LVAlfonso ZZhang RLeung JWu BIgnarro LJ.

Department of Urology, University of California School of Medicine, Los Angeles, CA 90024, USA. lrodriguez@mednet.ucla.edu

Abstract

Smooth muscle is a major component of human tissues and is essential for the normal function of a multitude of organs including the intestine, urinary tract and the vascular system. The use of stem cells for cell-based tissue engineering and regeneration strategies represents a promising alternative for smooth muscle repair. For such strategies to succeed, a reliable source of smooth muscle precursor cells must be identified. Adipose tissue provides an abundant source of multipotent cells. In this study, the
capacity of processed lipoaspirate (PLA) and adipose-derived stem cells to differentiate into phenotypic and functional smooth muscle cells was evaluated.  To induce differentiation, PLA cells were cultured in smooth muscle differentiation medium. Smooth muscle differentiation of PLA cells induced genetic expression of all smooth muscle markers and further confirmed by increased protein expression of smooth muscle cell-specific alpha actin (ASMA), calponin, caldesmon, SM22, myosin heavy chain (MHC), and smoothelin. Clonal studies of adipose derived multipotent cells demonstrated differentiation of these cells into smooth muscle cells in addition to trilineage differentiation capacity.  Importantly, smooth muscle-differentiated cells, but not their precursors,
exhibit the functional ability to contract and relax in direct response to pharmacologic agents. In conclusion, adipose-derived cells have the potential to differentiate into functional smooth muscle cells and, thus, adipose tissue can be a useful source of cells for treatment of injured tissues where smooth muscle plays an important role.

PMID: 16880387 [PubMed - indexed for MEDLINE]

5.  Tissue Eng Part A. 2010 Apr;16(4):1201-13.

Differentiation of adipose-derived stem cells into contractile smooth muscle cells induced by transforming growth factor-beta1 and bone morphogenetic protein-4.

Wang CYin SCen LLiu QLiu WCao YCui L.

Department of Plastic and Reconstructive Surgery,
Shanghai Jiao Tong University School of Medicine , Shanghai, People’s Republic
of China .

Abstract

Smooth muscle cells (SMCs) play an essential role in maintaining the structural and functional integrity of blood vessel and thus is
a critical element for blood vessel construction via tissue engineering approach. Adipose-derived stem cells (ASCs) represent a reliable source of mesenchymal stem cells with multidifferentiation potential. In this study, the feasibility of differentiation of human ASCs (hASCs) into cells with phenotypic and functional properties of SMCs was explored. hASCs isolated from human
lipoaspirate were expanded to passage 5 and then induced with administration of transforming growth factor-beta1 (TGF-beta1) and bone morphogenetic protein-4 (BMP4) either alone or in combination with culture medium. Expression of SMC-related markers including alpha-SM actin (alpha-SMA, SM22alpha, calponin, and SM myosin heavy chain) were detected by immunofluorescent staining, reverse transcription (RT)-polymerase chain reaction, and western blot analysis. It was found that only under the circumstance of a combined stimulation with TGF-beta1 and BMP4, both early and mid markers (alpha-SMA, SM22alpha, calponin) as well as a late marker (SM myosin heavy chain) of SMC differentiation were identified to similar levels as those in human umbilical artery SMCs. More importantly, these SM differentiated cells showed the function of contracting collagen matrix lattice when they were entrapped inside. The contractile function of differentiated hASCs was further enhanced by direct exposure to 60 mM KCl, consistent with what occurred in human umbilical artery SMCs. These results provide evidence that ASCs possess the potential to differentiate into contractile SM-like cells when stimulated by TGF-beta1 and BMP4 together. SMCs
differentiated from hASCs may provide an abundant source as seed cells for blood vessel engineering.

PMID: 19895205 [PubMed - indexed for MEDLINE]

6.  J Urol.
2011 Mar;185(3):1132-8. Epub 2011 Jan 21.

Mesenchymal stem cell recruitment and improved bladder function after bladder outlet obstruction: preliminary data.

Woo LLTanaka STAnumanthan GPope JC 4thThomas JCAdams MCBrock JW 3rdBhowmick NA.

Abstract

PURPOSE: Mesenchymal stem cells have various therapeutic benefits in various organ injury models. Bladder outlet obstruction causes smooth muscle hypertrophy and fibrosis, leading to lowered compliance, increased storage pressures and renal injury. Decreased blood flow and hypoxia may contribute to obstruction related bladder decompensation. We used a mouse model to determine whether mesenchymal stem cell recruitment occurred after bladder outlet obstruction and whether this was associated with changes in bladder hypoxia, histology and function. We also identified potential chemokines involved in mesenchymal stem cell recruitment.

MATERIALS AND METHODS: A total of 20 female mice underwent bladder outlet obstruction. Three days later 2 million green fluorescent protein labeled mesenchymal stem cells were intravenously administered. After 4 weeks urodynamic and histological
evaluation was performed. Quantitative reverse transcriptase-polymerase chain reaction was done to determine relative expression of the chemokines CCL2, CCL20, CCL25, CXCL9 and CXCL16. We simultaneously studied mice with bladder outlet obstruction only without mesenchymal stem cell injection and a control group.

RESULTS: In 10 of 15 surviving mesenchymal stem cell injected mice mesenchymal stem cells were identified in the detrusor, and decreased hypoxia, hypertrophy and fibrosis was seen. Nine of 10 mice with mesenchymal stem cell engraftment had improved compliance compared to those without engraftment (mean ± SD 9.6 ± 5.1 vs 3.9 ± 2.6 μl/cm H(2)O, p = 0.012). Polymerase chain reaction revealed a 2-fold increase in CCL2 expression but there were no significant changes in other chemokine levels.

CONCLUSIONS: Mesenchymal stem cell recruitment to the bladder after bladder outlet obstruction appears to be associated with increased blood flow and decreased tissue hypoxia, which may contribute to improvement in histopathological and functional parameters.  Mesenchymal stem cell recruitment may be related to CCL2 over expression.  Additional studies in larger samples are needed but these initial results suggest a potential role for mesenchymal stem cell based therapy for bladder
outlet obstruction related bladder injury.

Copyright © 2011 American Urological Association
Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

PMID: 21255803 [PubMed - in process]

7.  Cell Signal.
2008 Dec;20(12):2174-9. Epub 2008 Jun 19.

Cell signaling in interstitial cystitis/painful bladder syndrome.

Keay S.

Department of Medicine, University of Maryland School of Medicine and Veterans Administration Maryland Health Care System, Baltimore, Maryland, United States. skeay@medicine.umaryland.edu

Abstract

Evidence for several types of cell signaling abnormalities has been presented for patients with interstitial cystitis/painful bladder syndrome (IC/PBS), a poorly understood chronic painful bladder disorder for which currently there is no reliable effective therapy.
Increases or decreases in various urine cytokines and growth factors have been found in patient specimens, along with abnormal expression of epithelial differentiation markers, growth factors, cell membrane proteins, neurotransmitters, and other cytokines in tissue biopsies and/or explanted bladder cells from IC/PBS patients. Some of the abnormalities found in bladder epithelial cells from IC/PBS patients have been shown to be induced in normal cells by an antiproliferative factor from IC/PBS bladder epithelial cells that binds to a functional cell membrane receptor (CKAP4/p63). Greater understanding of cell signaling events associate with this debilitating disorder may lead to the development of more effective therapies.

PMID: 18602988 [PubMed - indexed for MEDLINE]

8.  Urol. 2005 Nov;174(5):2041-5.

Processed lipoaspirate cells for tissue engineering of the lower urinary tract: implications for the treatment of stress urinary incontinence and bladder reconstruction.

Jack GSAlmeida FGZhang RAlfonso ZCZuk PARodríguez LV.

Department of Urology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA.

Abstract

PURPOSE: We performed a pilot study to investigate the ability of human adipose derived, multipotent stem cells to be delivered to and survive within bladder and urethral smooth muscle.

MATERIALS AND METHODS: Lipoaspirate was acquired from female patients undergoing liposuction. The lipoaspirate was
processed to yield a pluripotent population of processed lipoaspirate (PLA) cells. For tissue delivery PLA cells were fluorescent labeled and suspended in Hanks’ balanced salt solution (Sigma Chemical Co., St. Louis, Missouri). To assess PLA viability in multiple animal models 8 Rnu athymic rats (Charles River, Wilmington, Massachusetts) and 6 SCID mice (Taconic Farms, Oxnard, California) underwent laparotomy and injection of PLA cells into the bladder and urethra. An additional 8 rats underwent sham injection of Hanks’ balanced salt solution alone. Experimental and control animals were sacrificed 2, 4, 8 and 12 weeks after injection, and the bladders and urethras were analyzed.

RESULTS: Self-regenerating, pluripotent PLA cells were easily isolated from human adipose tissue. Evaluation 2, 4, 8 and 12 weeks after injection demonstrated PLA cell viability and incorporation into the recipient smooth muscle. Eight weeks following
injection PLA cells demonstrated in vivo expression of alpha-smooth muscle actin, an early marker of smooth muscle differentiation.

CONCLUSIONS: PLA cells are an easily accessible source of pluripotent cells, making them ideal for tissue regeneration. PLA cells remain viable up to 12 weeks in the lower urinary tract. Human PLA cells injected into the urinary tract show morphological and
phenotypic evidence of smooth muscle incorporation and differentiation with time. PLA cells may provide a feasible and cost effective cell source for urinary tract reconstruction.

PMID: 16217390 [PubMed - indexed for MEDLINE]