Diabetes

Coding Dimension ID: 
289
Coding Dimension path name: 
Diabetes
Funding Type: 
SEED Grant
Grant Number: 
RS1-00308
Investigator: 
ICOC Funds Committed: 
$635 242
Disease Focus: 
Diabetes
Stem Cell Use: 
Embryonic Stem Cell
oldStatus: 
Closed
Public Abstract: 
The goals of this proposal are to investigate endodermal differentiation and proliferation in human ES cell cultures. Endodermal cells give rise to the epithelial lining of the respiratory and digestive tract as well as to the liver and pancreas. The future treatment of diseases such as type I diabetes using stem cell therapy relies on our ability to differentiate stem cells into endoderm, a prerequisite step to forming pancreatic beta cells. In 2005, D’Amour et al. reported the efficient differentiation of human ES cells into endoderm. This report provides a potentially effective protocol that needs to be further evaluated (specific aim 1). In addition, given that the success of stem-cell therapy depends on our ability to generate large numbers of differentiated cells (e.g. 200-700 million beta cells per patient are currently being used in the Edmonton protocol), we will investigate the ability of the endodermal generated in specific aim 1 cells to proliferate in culture (specific aim 2).
Statement of Benefit to California: 
Stem cell therapy relies on the development of efficient and reproducible protocols to differentiate stem cells into various cell types such as pancreatic beta cells. The first step to making pancreatic beta cells is the differentiation of stem cells into so-called endodermal cells, one of the 3 basic cell types of the body. In addition, in order to make stem cell therapy a viable option, one needs to be able to generate large numbers of differentiated cells from stem cells. Our proposal aims to establish such protocols. The health of California and its citizens will ultimately benefit from this research as it will help develop stem cell therapies.
Progress Report: 
  • The goals of this proposal are to investigate endodermal differentiation and proliferation of human ES cells in culture. Endodermal differentiation is a necessary step towards making pancreatic beta cells, as well as other endodermal cells such as liver cells. Pancreatic beta cells generated from human ES cells could be used to treat type I diabetics. In the past two years, we have incorporated human ES cell culture technology into our laboratory and have been able to replicate data obtained by other research groups. While several other research groups and companies around the world are focused on making pancreatic beta cells as quickly as possible, we strongly believe that a more detailed understanding of the biology of human ES cell differentiation into endoderm will help the optimization of this protocol. Therefore, we have focused our efforts on testing a number of variables in the initial step of creating definitive endoderm. We have found that different human ES cell lines have very different capacity to differentiate into endoderm under the same culture conditions. In addition, we have recently focused our research effort on the post-translational modifications of key regulators of endoderm differentiation, and found a critical role for a poorly appreciated modification, namely a sugar modification called GlcNAcylation. In summary, developing a reproducible and efficient way to differentiate human ES cells into endoderm, as well as a thorough understanding of this key step, will allow us and others to elucidate the detailed set of molecular and biochemical events underlying this critical differentiation step, and will improve differentiation protocols.
  • The goals of this proposal are to investigate endodermal differentiation and proliferation of human ES cells in culture. Endodermal differentiation is a necessary step towards making pancreatic beta cells, as well as other endodermal cells, such as liver cells. Pancreatic beta cells generated from human ES cells could be used to treat type I diabetes. In the past two years, we have incorporated human ES cell culture technology into our laboratory and have been able to replicate data obtained by other research groups. While several other research groups and companies around the world are focused on making pancreatic beta cells as quickly as possible, we strongly believe that a more detailed understanding of the biology of human eS cell differentiation into endoderm will help the optimization of this protocol. Therefore, we have focused our efforts on testing a number of variables in the initial step of creating definitive endoderm. We have found that different human ES cell lines have very different capacity to differentiate into endoderm under the same culture conditions. IN addition, we have recently focused our research effort on the post-translational modifications of key regulators of endoderm differentiation, and found a critical role for a poorly appreciated modification—namely a sugar modification called GlcNAcylation. In summary, developing a reproducible and efficient way to differentiate human ES cells into endoderm, as well as thorough understanding of this key step, will allow us and others to elucidate the detailed set of molecular and biochemical events underlying this critical differentiation step, and will improve differentiation protocols.
  • We initiated a project on the role of post-translational modifications during hES cell differentiation into endodermal lineages, specifically on the GlcNAcylation sugar modification. We found that this modification appears to be important for endoderm formation in hES cell cultures. Identification of modified proteins is an important next step in understanding the mechanisms of this phenomenon and may ultimately provide a basis to develop assays for screening drugs that enhance endoderm/beta-cell formation.
Funding Type: 
Disease Team Research I
Grant Number: 
DR1-01423
Investigator: 
Institution: 
Type: 
PI
Type: 
Co-PI
ICOC Funds Committed: 
$22 999 937
Disease Focus: 
Diabetes
Collaborative Funder: 
JDRF
Stem Cell Use: 
Embryonic Stem Cell
Cell Line Generation: 
Embryonic Stem Cell
oldStatus: 
Active
Public Abstract: 
Diabetes exacts a tremendous toll on patients, their families, and society in general. Autoimmune Type 1 diabetes, often called juvenile-onset diabetes, is caused by a person’s own immune system mistakenly destroying their insulin-producing cells in the pancreas, known as beta cells. When those beta cells are lost, the ability to produce insulin in response to food intake is lost, and blood sugar can increase to toxic levels. Although not due to autoimmunity, Type 2 diabetics often lose their ability to produce insulin as well. While pharmaceutical insulin is commonly used to control both types of diabetes, it does not sufficiently replace beta cells, and the adverse short- and long-term effects of diabetes remain, including dangerous episodes of low blood sugar, nerve damage, blindness, kidney damage, foot ulcers leading to amputations, and cardiovascular disease. Ideally, one would like to replace lost beta cells, and attempts to do so have included the use of pancreatic transplants, beta cell (islet) transplants, and transplants of animal cells or tissues. Unfortunately, those approaches are hindered by 1) the limited amount of donor tissue available, and 2) issues regarding immunological complications between donors and recipients. To solve the first problem, the Diabetes Disease Team applying for this CIRM award has developed methods to make replacement beta cells from human embryonic stem cells (hESC), which can be reliably grown in large-scale batches. The hESC-derived beta cells have been shown to cure experimental diabetes in mice and rats. Regarding the issue of donor-recipient compatibility, the Team has had initial success with several strategies, including administering the cells inside a simple device, implantable under the skin, as well as next-generation pharmaceuticals that enable transplantation between unmatched individuals without major side effects. With the critical proof-of-concept milestones behind us, the Team now needs to perform all of the manufacturing and laboratory testing required to assure reliable production of a safe and effective product, thereby generating the data needed to seek FDA approval to test the product in humans. The project engages over 30 scientists and physicians, as well as numerous associates and technicians, whose expertise covers all of the critical areas from process development and manufacturing to clinical testing of novel biomedical products. The proposal includes active project management, and regulatory and ethical oversight. The Team has well defined time lines and milestones to advance the candidate product to an FDA submission. If successful, testing in diabetic patients could begin as early as 3 years from the project initiation.
Statement of Benefit to California: 
Diabetes mellitus currently afflicts more than 250 million people worldwide, with projections of 380 million by the year 2030 (source: International Diabetes Federation). In 2007, there were an estimated 2.7 million Californians with diabetes (source: California Diabetes Program, California Department of Public Health). Further, the disease disproportionately affects certain minority groups and the elderly. Despite the use of insulin and advances in its delivery, the human cost of diabetes is underscored by the financial costs to society: tens of billions of dollars each year in California alone. The primary cause of Type 1 diabetes, and contributing significantly to Type 2 diabetes as well, is the loss of insulin-producing pancreatic beta cells. The proposed Disease Team will develop a beta cell replacement therapy for diabetes. If successful, the therapy will go beyond insulin function, and will perform the full array of normal beta cell functions, including responding in a more physiological manner than manual or mechanized insulin administration. Because they will be more physiological, the replacement cells should also reduce the long-term effects of diabetes. Moreover, the cell therapy will alleviate patients of the constant monitoring of blood glucose and painful insulin injections. For these reasons, it is possible that the product could transform the diabetes treatment landscape and replace pharmaceutical insulin in the market. This product will be available in California first, through clinical trials, and if approved by the FDA for commercial production, could eventually help hundreds of thousands of diabetic Californians. The product will substantially increase quality of life for diabetics and significantly reduce the health care burden in the state. The Team will employ various Californian physicians and scientists, and success of the Team will generate positive recognition for the state. Lastly, once commercially marketed, the product will yield additional jobs in manufacturing, sales, and related industries, and generate revenue for California. Given the market need and the clear feasibility, the product could become the most significant stem cell-based medical treatment of the coming decade, and that would be a great achievement for California, its taxpayers, and CIRM.
Progress Report: 
  • The CIRM Diabetes Disease Team is developing a cell therapy to treat insulin-dependent diabetes. The ultimate goal under CIRM Award DR1-01423 is to file an IND with the FDA to allow first-in-human clinical testing of the cell therapy product. To reach that goal, numerous research and development activities need to be successfully executed in parallel, and the project requires careful planning and agile management. This is particularly critical because the planned product is complex and, as a cutting-edge technology, extends into new regulatory territory. In Year 1 of this Award, virtually all aspects of the project remained on track and the 4-year time line to filing an IND remains the same.
  • The planned product is a combination therapy that is expected to alleviate a diabetic’s need to perform frequent blood monitoring and insulin injections. It will essentially replace or provide needed support to the endocrine pancreas that is lost or damaged in diabetes. The product consists of a human pancreatic progenitor cell population administered in a durable delivery device. Following administration, the progenitor cells mature into human pancreatic islets including functional insulin-producing glucose-responsive beta cells. Prototypes of the product have been tested in hundreds of rodents, and in proof-of-concept studies, this cell-device combination has cured rodents of drug-induced diabetes.
  • The pancreatic progenitor cells are manufactured from human embryonic stem (ES) cells through a series of precise steps in cell culture. Using ES cells as starting material allows for the mass production of progenitor cells that will be required if the product is successful, as ES cells are remarkably proliferative while still remaining stable. In Year 1 of the Disease Team Award, frozen cell banks of ES cells were manufactured under Current Good Manufacturing Practice (cGMP), as required to clinically test and commercialize a cell therapy. Additionally in Year 1, the specific details of the pancreatic progenitor cell manufacturing process were finalized, and documentation was put in place to allow cGMP manufacture of pancreatic progenitor cells for future animal and human studies.
  • The cell delivery device is a small flat sealed chamber made from a semi-permeable membrane. The device serves multiple purposes. It is intended to protect the cells from the patient’s immune system, which is particularly important in autoimmune (Type 1) diabetes. It retains the cells at the site of administration for ease of monitoring and possible removal if necessary. Importantly, while cells cannot pass through it, the semi-permeable membrane allows sugars, oxygen, and other nutrients in, to sustain and regulate the islet cells, and allows insulin and other endocrine proteins out, to regulate blood sugar and other metabolic physiology. In Year 1, numerous prototype configurations of the delivery device were tested in animals, and a final configuration was determined. A device manufacturing facility was designed and built. Manufacturing and testing equipment was installed, and documentation put in place for production of clinically compliant devices. As with cell manufacturing described above, device manufacturing can now proceed at a scale and level of quality that will facilitate pre-clinical and clinical testing of the combination product.
  • It is possible that the device alone will not be sufficient to protect the cells from a diabetic patient’s immune system. In anticipation of this possibility, the Diabetes Disease Team includes world-renowned immunologists who are establishing animal models to test and address this question accordingly. Fortunately, there are many pharmaceutical options, including cutting-edge technologies, that have proven effective in protecting transplanted human islets from immune rejection, and those might be applied to administration of this cell therapy product as well. The Disease Team’s clinical group is developing plans for the first-in-human testing and will incorporate a regimen of immune modulation as appropriate. In Year 1, the animal models to test the requirement for immune modulation and various regimens were established. In Year 2, these models will be used to investigate these questions.
  • The CIRM Diabetes Disease Team is developing a cell therapy to treat insulin-dependent diabetes. The ultimate goal under CIRM Award DR1-01423 is to file an IND with the FDA to allow first-in-human clinical testing of the cell therapy product. To reach that goal, numerous research and development activities need to be successfully executed in parallel, and the project requires careful planning and agile management. This is particularly critical because the planned product is complex and, as a cutting-edge technology, extends into new regulatory territory. In Year 2 of this Award, virtually all aspects of the project remained on track and the 4-year time line to filing an IND remains the same.
  • The planned product is a combination therapy that is expected to alleviate diabetes patients’ need to perform frequent blood monitoring and insulin injections. It will essentially replace or provide needed support to the endocrine pancreas that is lost or damaged in diabetes. The product consists of a human pancreatic progenitor cell population administered in a durable delivery device. Following administration, the progenitor cells mature into human pancreatic islets including functional insulin-producing glucose-responsive beta cells. Prototypes of the product have been tested in hundreds of rodents, and in proof-of-concept studies this cell-device combination has cured rodents of drug-induced diabetes.
  • The pancreatic progenitor cells are manufactured from human embryonic stem (ES) cells through a series of precise steps in cell culture. Using ES cells as starting material allows for the mass production of progenitor cells that will be required if the product is successful, as ES cells are remarkably proliferative while still remaining stable. In Year 1 of the Disease Team Award, frozen cell banks of ES cells were manufactured under Current Good Manufacturing Practice (cGMP), as required to clinically test and commercialize a cell therapy. In Year 2, these cGMP ES cell banks were tested to confirm that they performed similarly to previous banks. The cell manufacturing protocol was finalized and several batches of progenitor cells were manufactured to demonstrate the reliability of the protocol, in particular, with the new cGMP ES cells.
  • The cell delivery device is a small flat sealed chamber made from a semi-permeable membrane. The device serves multiple purposes. It is intended to protect the cells from the patient’s immune system, which is particularly important in autoimmune (Type 1) diabetes. It retains the cells at the site of administration for ease of monitoring and possible removal if necessary. Importantly, while cells cannot pass through it, the semi-permeable membrane allows sugars, oxygen, and other nutrients in, to sustain and regulate the islet cells, and allows insulin and other endocrine proteins out, to regulate blood sugar and other metabolic physiology. In Year 1, numerous prototype configurations of the delivery device were tested in animals, and a final configuration was determined. A device manufacturing facility was designed and built. Manufacturing and testing equipment was installed, and documentation put in place for production of clinically compliant devices. In Year 2, several batches of delivery devices were manufactured and tested under development phase-appropriate Quality Systems Regulations. A Good Laboratory Practice (GLP) study of the combination product, comprised of cells and devices manufactured with the newly developed systems, was performed to establish safety and efficacy in mice, prior to human testing. The results of the GLP study were favorable, suggesting the combination product will likely be safe and effective in the clinic.
  • It is possible that the device alone will not be sufficient to protect the cells from a patient’s immune system. In anticipation of this possibility, the Diabetes Disease Team includes world-renowned immunologists who are establishing animal models to test and address this question accordingly. In Year 2, preliminary data were collected using these animal models. The preliminary data suggest that the device will protect cells from autoimmunity.
  • In Year 3, the clinical protocol will be drafted, further refinements to product manufacturing including device loading will be established, and further pre-clinical testing will be performed. The Team plans to present the candidate product and development plans to regulatory agencies in order to obtain valuable feedback. The goal is to establish sufficient pre-clinical assurance to facilitate clinical testing at the end of the 4-year award period.
  • The CIRM Diabetes Disease Team is developing a stem cell-derived cell therapy to treat insulin-dependent diabetes. The ultimate goal under the 4-year CIRM Award DR1-01423 is to file an IND (Investigational New Drug application) with the FDA to allow first-in-human clinical testing of the cell therapy product. To reach this goal, numerous research and development activities need to be successfully executed in parallel. The project requires careful planning and agile management particularly because the planned product is complex and, as a cutting-edge technology, extends into new territory from a regulatory perspective. In Year 3 of this Award, all aspects of the project remained close to the original schedule. One study report from an external Contract Research Organization (CRO) was delivered two months later than planned, which delayed a meeting with the FDA and subsequent downstream activities. Accordingly, two months has been added to the original 4-year time line to filing an IND. The new target for IND filing is March 2014.
  • The planned product is a combination therapy that is expected to alleviate diabetes patients’ need to perform frequent blood monitoring and insulin injections. It will essentially replace or provide needed support to the endocrine pancreas that is lost or damaged in diabetes. The product consists of a human cell population containing pancreatic progenitors administered subcutaneously in a durable delivery device. Following administration, the progenitor cells mature into human pancreatic islet-like tissue including functional insulin-producing, glucose-responsive beta cells while in the device. Prototypes of the product have been tested in hundreds of rodents, and in proof-of-concept studies this cell-device combination has cured rodents of chemically-induced diabetes.
  • The pancreatic cells are manufactured from human embryonic stem (ES) cells through a series of precise steps in cell culture. In Year 3, a Cell Manufacturing Cleanroom was built and commissioned in preparation for manufacturing cells for clinical testing. Two new cell manufacturing formats, both amenable to the scale-up that will be required for commercial manufacturing, were also developed. At the end of Year 3, a Pilot Plant was established for process development and technology transfer of the cell manufacturing protocol.
  • The cell delivery device is essentially a small sealed envelope made from a semi-permeable membrane. It is expected to protect the cells from the patient’s immune system and retain the cells at the site of administration. At the same time it will allow sugars, oxygen, and other nutrients in, to sustain and regulate the islet-like tissue, and allow insulin and other endocrine proteins out, to regulate blood sugar and other metabolic physiology. In Years 1-2, prototype (‘animal-sized’) devices were produced and tested, the configuration was finalized, and a Device Manufacturing Facility with equipment for quality control testing was built. In Year 3, the clinical (‘human-sized’) device was designed and built. Also in Year 3, all ISO10993 (safety standards for medical devices from the International Organization for Standardization) testing was completed, establishing that the device and its component materials will be safe for human use. A prototype system to load the progenitor cells into the device was designed and built in Year 3. The Team established and staffed a Combination Product Group.
  • In Year 3, a GLP (good laboratory practice) study of the combination product to test safety and efficacy in mice, prior to human testing, was completed by an independent CRO. The results were favorable, providing further rationale for advancement of the product into clinical testing.
  • To evaluate the potential of the device to protect the implanted cells from a patient’s immune system, the Diabetes Disease Team includes world-renowned immunologists who are establishing animal models to test and address this question. In Year 3, animal studies demonstrated that the device indeed protects animal cells from allo-immunity (addressing differences between donor and recipient tissues), suggesting the human pancreatic cells will also be protected in the product planned for human use.
  • In Year 3, the Team met with the FDA in a Pre-IND meeting. This meeting was informative and provided clarity on the remaining activities before an IND can be submitted and a clinical trial initiated.
  • During Years 1-3, the clinical protocol was drafted, and in Year 4 it will be finalized while the clinical sites are prepared. Also in Year 4, refinements to product manufacturing including device loading will be established, and additional pre-clinical testing will be performed to further assure safety of all aspects of the clinical plan. The goal is to establish a body of pre-clinical data that supports clinical testing at the end of the 4-year award period.
  • In the years just prior to the establishment of the CIRM Diabetes Disease Team, scientists at ViaCyte (then known as Novocell) clearly demonstrated in mice the great promise of using pancreatic progenitor cells as a potential cell replacement therapy for type 1 diabetes.
  • In type 1 diabetes, the insulin-producing cells of the pancreas are lost to autoimmunity. ViaCyte has shown that human pancreatic progenitors, derived from human embryonic stem cells (hESC) in culture, will further mature to human pancreatic islet cells including glucose-responsive insulin-producing cells after implantation, and that these cells can rescue or protect mice from experimentally induced diabetes [Kroon et al., 2008, Nature Biotechnology, 26(4): 443-452]. Further, the group demonstrated that the pancreatic progenitor cells could effectively protect mice from experimental diabetes when implanted in a “macro-encapsulation” device, which is designed to protect the cells from allo- and auto-immunity.
  • In short, the ViaCyte team developed a procedure and a strategy to replace the insulin-producing cells lost in type 1 diabetes, leveraging the great potential of hESC as an approach to large-scale production of replacement cells, and macro-encapsulation as a way to avoid immunosuppressant drugs typically needed in same-species cell and organ transplantation. The next crucial steps were to translate this promising research into a clinically acceptable process, assure the safety and efficacy of the approach in independent animal studies, establish a plan to test in patients with type 1 diabetes, and submit the complete data package to the regulatory authorities, including the FDA, in order to allow clinical trials to commence.
  • Over the past four and half years, the CIRM Diabetes Disease Team achieved the goals and milestones that it proposed at its inception in 2009. Substantial progress was made in advancing the stem cell-derived cell therapy and delivery device combination product from research phase to clinical development, including initiation of a Phase 1/2 clinical trial upon completion of this work.
  • In cell product development, the achievements included manufacture of Master and Working Cell Banks of the specific hESC starting material under Good Manufacturing Practices (GMP), development of a robust, reliable, scalable manufacturing process for differentiation of hESC into pancreatic progenitor cells (PEC-01™ cells), and development of cryopreservation and thawing and recovery methods for preparation of PEC-01 cells prior to loading into macro-encapsulation (Encaptra®) devices.
  • In device development, achievements included assessing and establishing materials and methods, and formalizing procedures for manufacturing Encaptra devices. Devices and their materials were thoroughly tested for biocompatibility and safety under ISO 10993 regulations. Custom manufacturing and testing methods and protocols were established.
  • In parallel with cell and device development, the team established custom materials and methods for combining these two main components into the product candidate (VC-01™ product). This included aseptic processes for loading cells into devices, sealing the devices, and placing them into custom packaging for delivery to the clinic.
  • Extensive Quality Control and Quality Assurance (QC/QA) systems were designed and implemented to assure standardized, reliable, safe and efficacious VC-01 product would be produced for clinical research. As biologicals (the cells) and devices fall under different regulations, the team needed to develop a custom hybrid quality management system that addressed both sets of regulations.
  • Numerous pre-clinical studies were performed in preparation for clinical testing, including three safety and efficacy studies of the VC-01 combination product under Good Laboratory Practices (GLP) at independent contract research organizations. Scientists in the immunology laboratories at University of California, San Francisco, and the La Jolla Institute for Allergy and Immunology further examined and demonstrated the utility of macro-encapsulation to protect implanted cells from allo- and auto-immunity in several animal models. The pre-clinical studies collectively indicated that proceeding to human testing was warranted and appropriate.
  • In the final years of the project, a Phase 1/2 first-in-human clinical trial was prepared. The trial is designed to provide critical insights into safety and the potential efficacy of the product concept. Lastly, the team had successful interactions with regulatory authorities, including a pre-IND submission and meeting with the FDA, and as a culmination of all of the work, a device master file (MAF) and investigational new drug application (IND) were submitted to the FDA. In the last month of the project the regulatory documents were accepted by the FDA, and the path was set to commence clinical testing of the product in patients with type 1 diabetes.

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