Allogeneic Cell Combination Therapy Ameliorates Chronic Kidney Disease-Induced Heart Failure with Preserved Ejection Fraction

Abstract

Background: Left ventricular hypertrophy and heart failure with preserved ejection fraction (HFpEF) are primary manifestations of the cardiorenal syndrome in patients with chronic kidney disease (CKD). Therapies that improve morbidity and mortality in HFpEF are lacking. Cell-based therapies promote cardiac repair in ischemic and non-ischemic cardiomyopathies. We hypothesized that cell-based therapy ameliorates CKD-induced HFpEF.

Methods and results: Yorkshire pigs (n = 26) underwent 5/6 embolization-mediated nephrectomy. CKD was confirmed by increased creatinine and decreased glomerular filtration rate (GFR). Mean arterial pressure (MAP) was not different between groups from baseline to 4 weeks. HFpEF was evident at 4 weeks by increased LV mass, relative wall thickening, end-diastolic pressure, and end-diastolic pressure-volume relationship, with no change in ejection fraction (EF). Four weeks post-embolization, allogeneic (allo) bone marrow-derived mesenchymal stem cells (MSC; 1 × 107 cells), allo-kidney-derived stem cells (KSC; 1 × 107 cells), allo-cell combination therapy (ACCT; MSC + KSC; 1:1 ratio; total = 1 × 107 cells), or placebo (Plasma-Lyte) was delivered via intra-renal artery. Eight weeks post-treatment, there was a significant increase in MAP in the placebo group (21.89 ± 6.05 mmHg) compared to the ACCT group. GFR significantly improved in the ACCT group. EF, relative wall thickness, and LV mass did not differ between groups at 12 weeks. EDPVR improved in the ACCT group, indicating decreased ventricular stiffness.

Conclusions: Intra-renal artery allogeneic cell therapy was safe in a CKD swine model manifesting the characteristics of HFpEF. The beneficial effect on renal function and ventricular compliance in the ACCT group supports further research of cell therapy for cardiorenal syndrome.

Keywords: allogeneic cell combination therapy; cardiorenal; cell-based therapy; chronic kidney disease (CKD); heart failure with preserved ejection fraction (HFpEF); kidney-derived stem cells (KSCs); mesenchymal stem cells (MSCs).

Graphical Abstract

This study describes the development of a novel large animal model of chronic kidney disease (CKD)-induced heart failure with preserved ejection fraction (HFpEF). Renal intra-arterial delivery of allogeneic MSCs and KSCs improved glomerular filtration rate (GFR). RNA-Seq data showed decreased podocyte apoptosis, reactive oxygen species, inflammatory pathways, and renin-angiotensin system activation. Allogeneic cell combination therapy (ACCT) restored diastolic function toward normal and decreased titin protein markers of stiffness. Cell therapy also prevented the increase in blood pressure over time.

Figure 1.

Development of chronic kidney disease (CKD) after embolization. The CKD model was validated from baseline (N = 26) to 4 weeks by an increased (A) creatinine (P < .0001) and (B) blood urea nitrogen (BUN, P < .0001) and decreased (C) glomerular filtration rate (GFR) (P < .0001) and (D) renal perfusion (P < .0001). (E) Urine protein/creatinine ratio and (F) mean arterial pressure (MAP) did not change over time.

Figure 2.

Signs of CKD-induced heart failure with preserved ejection fraction (HFpEF). HFpEF was demonstrated at 4 weeks by increases in (A) left ventricular (LV) mass (P < .0001), (B) relative wall thickness (P < .0001) as evaluated by MRI (N = 26), (C) end-diastolic pressure (EDP; P = .045), and (D) end-diastolic pressure-volume relationship (EDPVR; P = .0002) as evaluated by pressure-volume (PV) loops (N = 13).

Figure 3.

Safety of allogeneic cell single and combination therapy. The absence of immune response to allogeneic cell therapy. (A) Allogeneic MSCs, KSCs, or combination cell therapy did not elicit an acute immune response, evaluated by mixed lymphocyte reaction (n = 26). Positive control used was phytohemagglutinin (PHA). (B) Evidence of cell localization in the cortex of the remnant kidney 24 hours after cell delivery.

Figure 4.

Renal functional improvement in response to allogeneic cell single and combination therapy. Improvement in blood pressure and kidney function. (A) There was a significant difference in MAP between groups (P = .04), with an increase in the placebo group (P < .0001). (B) GFR had the greatest improvement in the combination group (P = .002). (C) Urine protein/creatinine ratio and (D) total kidney volumes did not change significantly in any group after cell delivery. (E) Glomerular area in the placebo group was higher, albeit not significantly, than other groups without compensation of renal function. Abbreviations: MSC, allogeneic mesenchymal stem cells; KSC, allogeneic kidney-derived stem cells; ACCT (MSCs + KSCs), allogeneic cell combination therapy.

Figure 5.

RNA data showing decreased inflammatory markers, oxidative stress, and renin-angiotensin signaling system in allogeneic cell combination therapy (ACCT) compared to placebo. RNA-Seq analysis: (A) Heat map showing the top 50 differentially expressed genes between placebo, to the left, and ACCT groups, to the right. (B) Pathways involving extracellular matrix disassembly (q < 10⁻⁶, NES = −2.20) and an increase in oxidative respiration (q < 10⁻⁶, NES = 3.45) are downregulated in the ACCT group compared to placebo. (C) Kidney RNA-Seq analysis of the placebo and combination groups showed that ACCT downregulated genes related to podocyte apoptosis. Importantly, the ACCT group downregulated renin-angiotensin signaling (P = .024) related to blood pressure and cardiac hypertrophy (D).

Figure 6.

Allogeneic cell combination therapy (ACCT) restores diastolic dysfunction. Improvement in diastolic dysfunction. (A) Left ventricular end-diastolic (LVED) mass and (B) end-diastolic pressure (EDP) did not change significantly at 12 weeks. However, (C) ACCT improved EDPVR significantly (ΔEDPVR; P = .003). (D) Molecular analyses demonstrated the changes in titin phosphorylation in the placebo- compared to the MSC-treated group. (E) Cardiomyocyte area did not differ between groups. Cardiomyocytes (n = 50 per sample) were evaluated by WGA rhodamine immunofluorescent staining (n = 5 per group). (F) Capillary density showed a trend toward higher capillary density in the ACCT group; however, there was no significant difference between groups. Three random areas were evaluated by Alexa Fluor 488 isolectin immunofluorescent staining (N = 5 per group). Abbreviations: MSC, allogeneic mesenchymal stem cells; KSC, allogeneic kidney-derived stem cells; ACCT (MSCs + KSCs), allogeneic cell combination therapy.