# Patent

## Title
Use of the cathelicidin LL-37 and derivatives thereof for wound healing

## Abstract

Use of the antimicrobial cathelicidin peptide II-37, N-terminal fragments of LL-37 or extended sequences of LL-37 having 1-3 amino acids in the C-terminal end, for stimulating proliferation of epithelial and stromal cells and thereby healing of wounds, such as chronic ulcers. The cytotoxic effect of LL-37 may be reduced by including a bilayer-forming polar lipid, especially a digalactosyldiacylglycerol, in pharmaceutical compositions and growth media comprising LL-37.

## Background
RELATED APPLICATIONS
This application is a continuation of application Ser. No. 13/938,120 filed Jul. 9, 2013, which is a divisional of co-pending application Ser. No. 13/193,131 filed on Jul. 28, 2011, now U.S. Pat. No. 8,506,994, which is a divisional of to application Ser. No. 12/232,215, filed on Sep. 12, 2008, now U.S. Pat. No. 8,012,933 B2, which issued on Sep. 6, 2011. Application Ser. No. 12/232,215 is a divisional of application Ser. No. 10/543,659 filed on Jul. 28, 2005, now U.S. Pat. No. 7,452,864, which issued on Nov. 18, 2008. Application Ser. No. 10/543,659 is the national stage of PCT International Application No. PCT/SE2004/000111 filed Jan. 28, 2004, which claims the benefit of priority of Application No. SE 0300207-8 filed in Sweden on Jan. 29, 2003 and U.S. Application No. 60/444,964 filed on Feb. 5, 2003. The entire contents of each of these applications are hereby incorporated by reference.


TECHNICAL FIELD
The present invention refers to the peptide LL-37 and N-terminal fragments, as well as functional derivatives thereof, which peptides can be used for cell proliferation, epithelial repair, and wound healing, and to a pharmaceutical composition comprising one or more of said peptides.
BACKGROUND OF THE INVENTION
Epithelia constitute the primary barrier between host and the potentially harmful environment, and therefore the protection of this interface is vital. A wound represents a broken barrier and immediately sets in motion a series of tightly orchestrated events with the purpose to promptly reinstate the integrity of the barrier. Urgent wound closure has evolved in higher organisms, diverging from the time-consuming process of complete regeneration of tissue seen in lower species. Impaired wound healing represents a major challenge in clinical medicine ranging from the relative delay in “normal” healing seen with increasing age to pathologic non-healing ulcers.
Chronic ulcers constitute a major clinical problem and although our understanding of the physiologic wound process has increased over the past decades only minor
Chronic ulcers constitute a major clinical problem and although our understanding of the physiologic wound process has increased over the past decades only minor therapeutic improvements have been attained. Distinct etiologies may underlie the development of ulcerations in different clinical conditions but, whatever the cause, non-healing ulcers are characterized by an inability of the epithelium to migrate, proliferate and close the barrier defect. The most common type of chronic skin ulcers is leg ulcers due to venous insufficiency. These patients develop peripheral venous oedema with subsequent ulceration of the skin, whereas the arterial circulation is intact. Leg and foot ulcers due to arteriosclerotic deficiencies are less common.
In addition, skin ulcers develop in association with immune diseases such as pyoderma gangrenosum and vasculitis. Current treatment includes long-term systemic immunosuppression and is not always effective. Epithelial defects and ulcers in the oral, genital and gastrointestinal mucous membranes are common and cause much distress. The underlying pathomechanisms are not always clear, such as in aphtae and erosive lichen and treatment is poor.
Traditional wound care involves removal, mechanically or enzymatically, of necrotic debris to allow formation of granulation tissue. Wounds that are heavily colonized with bacteria may require antiseptic treatment to prevent invasive infection. Numerous topical anti-microbial agents are used, such as iodine, chlorhexidine, hydrogen peroxide, silver and antibiotics, but the risk of toxic effects of these agents on the matrix and the neoepidermis must be considered. Once the wound is clean of necrotic tissue, dressings should be used to promote granulation tissue formation. A large variety of such dressings are available and numerous animal studies and clinical trials have demonstrated their beneficial effect on wound healing.
A certain proportion of wounds remain therapy-resistant and there is need for additional treatment. During the past decade there has been much focus on the potential use of growth factors to accelerate wound repair. Growth factors are molecules, which control cellular processes that are critical in tissue repair, including cell migration, proliferation, angiogenesis and de novo synthesis of extracellular matrix. The beneficial effect of such growth factors has been suggested in a wide variety of trials (Scharffetter-Kochanek et al., Basic Res Cardiol 93:1-3, 1999). However, to date growth factor treatment of chronic ulcers has been largely disappointing in clinical practice. At present becaplermin (Regranex®), licensed in U.S. and Europe but not in Sweden, is the only growth factor for use, preferentially in diabetic foot ulcers. The reasons for clinical failure of growth factors in the treatment of chronic ulcers are thought to involve delivery problems and rapid degradation.
In parallel, there has been development of tissue therapies using auto-logous and allogenic materials in bioengineered human skin equivalents. Cultured epidermal keratinocytes constitute a functioning treatment for coverage of large areas of injured skin in e.g. burn patients, but is expensive, time consuming and requires laboratory facilities. To provide a dermal substrate multiple strategies have been used such as acellular human cadaver and bovine collagen with or without cells. All methods available have considerable disadvantages such as potential transmission of disease and high costs and are hardly suited for basic wound care.
Antimicrobial peptides are effector molecules of the innate immune system, which serve to protect the host against potentially harmful microorganisms. They are conserved through evolution and are widespread in nature. In human, only a handful has been identified so far; among which the defensins and the human cathelicidin antimicrobial peptide hCAP18 have been implicated in epithelial defense (Selsted et al., J Biol Chem 258:14485-14489, 1983).
WO 96/08508 relates to the human polypeptide FALL-39, as well as to pharmaceutical compositions containing said peptide and having an antimicrobial activity against bacteria. The peptide was named FALL-39 after the first four amino acid residues and consisted of the 39 amino acid C-terminal part of a proprotein concomitantly identified by three separate groups (Cowland et al., FEBS, 1995; Agerberth et al., Proc Natl Acad Sci USA 1995; Larrick et al., FEBS Letters 1996). The peptide was shown to have potent antimicrobial activity against both gram-positive and gram-negative bacteria. Further characterization of the C-terminal peptide demonstrated a shorter sequence comprising 37 amino acids excluding the first two (FA) resulting in LL-37, which is the accepted current designation (Gudmundsson et al., Eur J Biochem 238:325-332, 1996).
The proprotein was named hCAP18, human cationic anti-microbial protein, and is a member of the cathelicidin family of proteins consisting of cathelin, which has been conserved through evolution and a C-terminal part, variable in different species. In man, hCAP18 is the only member of this protein family, whereas in other species, such as mouse and pig, there are several members. The C-terminal peptide LL-37 is thought to function extracellularly and there is no evidence for intracellular cleavage of the proprotein. hCAP18/LL-37 is present in leukocytes and in barrier organs such as skin, mucous membranes, respiratory epithelium and reproductive organs. The localization of hCAP18/LL-37 to barrier epithelia seems to be consistent with a protective role for the peptide in preventing local infection and systemic microbial invasion. LL-37 is described as a cysteine-free peptide that can adopt an amphiphatic, or in other words amphiphilic, α-helical conformation. A high cationicity in combination with a stabilized amphiphatic α-helical structure seems to be required for the anti-microbial effect of such peptides against gram-positive bacteria and fungi, as has been shown experimentally (Gianga-spero et al., Eur J Biochem 268:5589-5600, 2001). The amphiphatic and α-helical structure seems to be less critical for killing of gram-negative bacteria. In association with inflammation hCAP18/LL-37 is upregulated in skin epithelium (Frohm et al., J Biol Chem 272:15258-15263, 1997) and mucous membranes (Frohm Nilsson et al., Infect Immun 67:2561-2566, 1999).
PRIOR ART
Dorschner et al., J Invest Dermatol 117:91-97, 2001, demonstrated that the expression of cathelicidins was increased in human and murine skin after incision, and that lack of the murine homologue cathelicidin gene fails to protect against invasion of Group A streptococci in such mice.
WO 96/09322, Children's Medical Center Corporation, discloses that the antibacterial peptide PR-39 possesses syndecan-1 and -4 inductive activity and therefore simultaneously could reduce infection and, as a synducin, influence the action of growth factors, matrix components, and other cellular effectors involved in tissue repair. The synducins could be administered in a pharmaceutical carrier, such as conventional liposomes.
EP 0 935 965 A1, Toray Industries, Inc., refers to an antipylori agent containing an anti-microbial peptide, such as the porcine peptide PR-39, as an active agent. It is concluded that exogeneous administration of PR-39 has anti-microbial activity against Helicobacter pylori and accelerates healing of gastric ulcers in rat. FALL39 is mentioned as one of the members of the cathelin family.
U.S. Pat. No. 6,255,282, Helix Biomedix, Inc., discloses novel synthetic lytic peptides sharing structural and functional properties of different known lytic peptides. Especially a peptide of 18 to about 40 amino acids and having an α-helical conformation is described. The lytic cathelicidin peptides, however, are not mentioned.
Frohm Nilsson, Thesis, Karolinska Institutet, Stockholm 2001, concomitantly demonstrated that human cathelicidin anti-microbial protein, hCAP 18, is induced in human skin wounding, with high levels and release of active C-terminal peptide, LL-37, in physiological healing but not in chronic non-healing ulcers. hCAP18 was detected in the wound bed and in the epithelium during normal wound healing but was absent in the epithelium of chronic leg ulcers and was detected only in the wound bed and stroma. It was speculated that low levels of hCAP18 and the lack thereof in the epithelium of chronic ulcers contribute to impaired healing.
Zasloff, Nature 415:389-395, 2002, in a review of anti-microbial peptides discusses the diverse applications, which have been demonstrated for said peptides as anti-infective agents, and anti-microbial peptides in pharmaceutical development are described.
EP 1 358 888 A1, Bals et al., having a date of publication of Nov. 5, 2003, relates to the use of the peptide LL-37 for prevention or treatment of a disease caused by reduced blood flow and arteriosclerosis and for treatment of wounds due to reduced arterial blood supply. The ability of LL-37 to induce formation of new blood vessels and to stimulate proliferation of endothelial cells is shown. The invention relates entirely to the angiogenetic effect and there is no mentioning of epithelia.
Although a therapeutic use of anti-microbial peptides, in particular LL-37, has been suggested, this has so far not been realized. At high concentrations of the peptide, LL-37 exerts a cytotoxic effect. The potential cytotoxic effects exerted by LL-37 are, however, inhibited in the presence of serum, but pharmaceutical formulations containing serum should be avoided due to risk for transmitting diseases, restricted accessibility and high costs.
SUMMARY OF THE INVENTION
The human anti-microbial peptide hCAP18 is up-regulated in skin epithelium as a normal response to injury. However, in chronic non-healing leg ulcers only low levels of hCAP18 were found. Notably, in the chronic leg ulcers, hCAP18 and LL-37 were entirely absent in the epithelium but present in the inflammatory infiltrate in the wound bed and in the stroma. We have now shown that hCAP18 is induced during re-epithelialization of organ-cultured skin wounds, and that this re-epithelialization was inhibited by antibodies against LL-37 in a concentration-dependant manner. These findings suggest that LL-37 plays a crucial role in wound closure, functioning as a growth factor. The invention concerns the use of LL-37 or a new synthetic peptide derived from LL-37 or a functional derivative thereof, to compensate for the lack of natural LL-37 produced in vivo.
It was also shown that up-regulation of hCAP18 and/or adding LL-37 peptide stimulate proliferation of normal epithelial and stromal cells, suggesting that normal wound healing and epithelial regeneration could also be enhanced.
It was also found that the cytotoxicity of LL-37 could be reduced in a composition comprising certain lipids.



BRIEF DESCRIPTION OF THE DRAWINGS
FIG. 1 is a schematic drawing of the 18 kDa hCAP18 protein consisting of a signal peptide, S.P., the conserved cathelin part, and the anti-microbial peptide LL-37, which is enzymatically cut off in vivo.
FIG. 2 is a schematic drawing of the cathelicidin protein family, illustrating the diversity of C-terminal peptides in different species.
FIGS. 3A, 3B, and 3C show the cDNA sequence (SEQ ID NO: 21) of the pIRES2-EGFP vector including the coding sequence for hCAP18, used for transgenic expression of hCAP 18.



DESCRIPTION OF THE INVENTION
The present invention refers to a peptide having a sequence of at least 20 amino acids of the N-terminal fragment of LL-37, with the proviso that LL-37 is excluded, as well as to pharmaceutically acceptable salts and derivatives thereof. LL-37 has the amino acid sequence SEQ ID NO 1:

    
    
        H-Leu-Leu-Gly-Asp-Phe-Phe-Arg-Lys-Ser-Lys-Glu-Lys-Ile-Gly-Lys-Glu-Phe-Lys-Arg-Ile-Val-Gln-Arg-Ile-Lys-Asp-Phe-Leu-Arg-Asn-Leu-Val-Pro-Arg-Thr-Glu-Ser-OH.
    
    


The N-terminal sequence of LL-37 refers to a sequence beginning with the amino acid residue number 1 of leucine, Leu.
Pharmaceutically acceptable salts contain for instance the counterions acetate, carbonate, phosphate, sulphate, trifluoroacetate, and chloride. A preferred salt is the acetate. Esters and amides are examples of pharmaceutically acceptable derivatives.
The peptide of the invention should have an amino acid chain of no more that 40 amino acids. The invention refers to a peptide having the sequence of LL-37 to which 1-3 amino acids have been added in the C-terminal end. Any amino acid selected from Ala, Arg, Asn, Asp, Cys, Gln, Glu, Gly, His, Ile, Leu, Lys, Met, Phe, Pro, Ser, Thr, Trp, Tyr, Val, as well as derivatives thereof can be added. An example of a peptide having 38 amino acids, LL-38, SEQ ID NO 19, has the sequence of LL-37 to which serine has been added in the C-terminal end.
The invention especially refers to a peptide having a sequence of at least 20 amino acids and selected from the group consisting of LL-36, LL-35, LL-34, LL-33, LL-32, LL-31, LL-30, LL-29, LL-28, LL-27, LL-26, LL-25, LL-24, LL-23, LL-22, LL-21 and LL-20, having the sequence SEQ ID NO 2, SEQ ID NO 3, SEQ ID NO 4, SEQ ID NO 5, SEQ ID NO 6, SEQ ID NO 7, SEQ ID NO 8, SEQ ID NO 9, SEQ ID NO 10, SEQ ID NO 11, SEQ ID NO 12, SEQ ID NO 13, SEQ ID NO 14, SEQ ID NO 15, SEQ ID NO 16, SEQ ID NO 17, and SEQ ID NO 18, respectively.
Preferred peptides are selected from the groups consisting of LL-36, LL-35, LL-34, LL-33, LL-32, LL-31, LL-30, LL-29, LL-28, LL-27, LL-26, and LL-25.
The amino acid sequences of the peptides of the invention are given in the following table.












SEQ ID
Pep-



NO
tide
Amino Acid Sequence

















1
LL-
LLGDFFRKSKEKIGKEFKRIVQRIKDFLRNLVPRTES



37



 


2
LL-
LLGDFFRKSKEKIGKEFKRIVQRIKDFLRNLVPRTE



36



 


3
LL-
LLGDFFRKSKEKIGKEFKRIVQRIKDFLRNLVPRT



35



 


4
LL-
LLGDFFRKSKEKIGKEFKRIVQRIKDFLRNLVPR



34



 


5
LL-
LLGDFFRKSKEKIGKEFKRIVQRIKDFLRNLVP



33



 


6
LL-
LLGDFFRKSKEKIGKEFKRIVQRIKDFLRNLV



32



 


7
LL-
LLGDFFRKSKEKIGKEFKRIVQRIKDFLRNL



31



 


8
LL-
LLGDFFRKSKEKIGKEFKRIVQRIKDFLRN



30



 


9
LL-
LLGDFFRKSKEKIGKEFKRIVQRIKDFLR



29



 


10
LL-
LLGDFFRKSKEKIGKEFKRIVQRIKDFL



28



 


11
LL-
LLGDFFRKSKEKIGKEFKRIVQRIKDF



27



 


12
LL-
LLGDFFRKSKEKIGKEFKRIVQRIKD



26



 


13
LL-
LLGDFFRKSKEKIGKEFKRIVQRIK



25



 


14
LL-
LLGDFFRKSKEKIGKEFKRIVQRI



24



 


15
LL-
LLGDFFRKSKEKIGKEFKRIVQR



23



 


16
LL-
LLGDFFRKSKEKIGKEFKRIVQ



22



 


17
LL-
LLGDFFRKSKEKIGKEFKRIV



21



 


18
LL-
LLGDFFRKSKEKIGKEFKRI



20



 


19
LL-
LLGDFFRKSKEKIGKEFKRIVQRIKDFLRNLVPRTESS



38









The new peptides can be used as a medicament for cell proliferation, epithelial regeneration, healing of normal or chronic wounds, and as antimicrobial agents.
The new peptides are believed to have the potential to form an α-helical structure at physiological conditions.
According to another aspect the invention refers to the use of a peptide having an amino acid sequence selected from the group consisting of

    
    
        a) SEQ ID NO 1;
        b) a sequence containing at least 20 amino acids of the N-terminal fragment of SEQ ID NO 1;

and pharmaceutically acceptable salts or derivatives thereof, which peptide enhances proliferation of epithelial and/or stromal cells through a non-lytic mechanism, for the preparation of a medicament for epithelial regeneration, and healing of wound epithelium and stroma.

    
    


The present invention especially refers to the use of the peptide LL-37 having the amino acid sequence SEQ ID NO 1, in the form of a salt, preferably an acetate salt.
The invention also refers to the use of a peptide, selected from the group consisting of LL-20 to LL-36, as stated above.
LL-37, as well as LL-25 to LL-36, possesses a net positive charge (+5-+7) at neutral pH due to the cationic amino acid residues of lysine and arginine in the primary structure. Especially LL-34 and LL-35 have net positive charge of 7. The other amino acid residues are nonpolar/hydrophobic or polar and neutral, or, to a less extent, polar and negatively charged, which makes the whole peptide molecule amphiphatic. Peptides of this type interact electrostatically with the negatively charged phospholipid microbial cell walls inserting the hydrophobic face into the bilayer. A reduction of either hydrophobicity and/or charge reduces the anti-microbial effect of the peptides. The cytotoxic effect exerted by the peptides against host cells, often assessed as hemolytic activity, is shown to correlate with their anti-microbial effects (Chen et al., FEBS Lett 236:462-466, 1988). Various studies have confirmed that this is true also for other amphiphatic α-helical anti-microbial peptides.
Studies of the C-terminal peptide, having a length of 37 amino acids, of rabbit CAP18 (Cap18106-142) show that broad-spectrum antibacterial activity is retained in the highly basic 20 residue N-terminal sequence, but not if the N-terminus is truncated (Larrick et al., Antimicrob Agents Chemother 37:2534-2539, 1993).
LL-37, as well as the new peptides LL-20 to LL-36, can be synthesized using an automatic peptide synthesizer and standard methods for peptide syntheses.
The invention especially refers to the use of the LL-37 peptide or anyone of the peptides LL-20 to LL-36 for the preparation of a medicament for treatment of chronic ulcers. Said chronic ulcers can be due to venous insufficiency, such as leg ulcers, metabolic dysfunction, such as diabetes, or immunological diseases, such as vasculites, and pyoderma gangrenosum. The peptides of the invention can also be used for treatment of wounds due to trauma or burns. The described peptides can especially be used for regeneration of epithelial tissue, and to enhance epidermal regeneration following microdermabrasion.
In addition to being toxic to the cell, LL-37 is rapidly degraded in the wound environment. Serine proteinase 3 was recently shown to be responsible for extracellular cleavage of hCAP18 (Sorensen et al., Blood 97:3951-3959, 2001).
In order to prevent decomposition of the peptide and also for reducing the intrinsic cytotoxicity, the peptide can be formulated with a polar lipid carrier. Said formulation should facilitate the administration of the peptide to the wound and will in addition provide a sustained release of the peptide after administration. The stability of the peptide will be improved both in vivo and in vitro.
Another object of the invention is thus a pharmaceutical composition comprising an anti-microbial cathelicidin peptide in the form of pharmaceutically acceptable salts or derivatives thereof in combination with a carrier consisting of a bilayer-forming polar lipid and an aqueous solution.
The cathelicidin peptide can, in addition to LL-37 in human, be derived from different animal species, and is for example SC5 from sheep, Bac5 from cow, PR-39 from pig, CRAMP from mouse, and p15 from rabbit, see FIG. 2.
A bilayer normally refers to the lamellar arrangements of polar lipids in water. The acyl chains form the internal hydrophobic part and the polar head-groups the hydrophilic part of the bilayer. As examples of such polar bilayer-forming lipids, either of natural or synthetic origin, can be mentioned phosphatidylcholine, phosphatidylglycerol, digalactosyldiacylglycerol, sphingomyelin and the like. Depending on the concentration of said polar lipids in polar solvents, such as water, liposomes or viscous gels of the lamellar liquid crystalline type may be formed.
The pharmaceutical composition especially comprises a peptide having an amino acid sequence selected from the group consisting of

    
    
        a) SEQ ID NO 1;
        b) a sequence containing at least 20 amino acids of the N-terminal fragment of SEQ ID NO 1;

in the form of pharmaceutically acceptable salts or derivatives thereof in combination with a carrier consisting of a bilayer-forming polar lipid and an aqueous solution.

    
    


Preferred bilayer-forming polar lipids to be mixed or formulated with the peptide are those, which are neutral in charge. Especially useful are the digalactosyldiacylglycerols, and other glycolipids, such as the glycosyl ceramides, either natural or synthetic, in which a non-ionic carbohydrate moiety constitutes the polar head-group. Less preferred, but still useful, are those polar lipids, which are zwitterionic and neutral at physiological conditions, such as phosphatidylcholine, phosphatidylethanolamine, and sphingomyelin. Least preferred are those polar lipids, which are negatively charged and thus form strong complexes with the positively charged peptide.
According to the invention said bilayer-forming polar lipid carrier is preferably selected from the group consisting of phospholipids, galactolipids and sphingolipids.
An especially preferred bilayer-forming polar lipid is digalactosyldiacylglycerol or polar lipid mixtures rich in digalactosyldiacylglycerols due to the extremely good cutaneous tolerability of this class of polar lipids. Digalactosyldiacylglycerol is a class of lipids belonging to the glycolipid family, well known constituents of plant cell membranes. One of the most abundant classes contains two galactose units, and the commonly used nomenclature and abbreviation of this is digalactosyldiacylglycerol, DGDG, sometimes referred to as galactolipids. Galactolipids, primarily DGDG and DGDG-rich materials have been investigated and found to be surface active material of interest in industrial applications such as food, cosmetics, and pharmaceutical products. WO 95/20944 describes the use of DGDG-rich material, a “galactolipid material”, as a bilayer-forming material in polar solvents for pharmaceutical, nutritional and cosmetic use. Said application does not disclose the use of galactolipids in combination with peptides and proteins in general, particularly not a peptide of the present invention.
According to a preferred aspect the invention refers to a pharmaceutical composition wherein the bilayer-forming polar lipid carrier is a polar lipid mixture rich in digalactosyldiacylglycerols.
Another preferred aspect of the invention is a pharmaceutical composition wherein the peptide is in the form of acetate. A preferred peptide is LL-37 in the form of an acetate salt. Especially preferred is a pharmaceutical composition comprising a combination of an acetate of LL-37 and CPL-Galactolipid as the bilayer-forming lipid carrier. CPL-Galactolipid is a trademark for a galactolipid fraction consisting of 50-70% by weight of digalactosyldiacylglycerols and 30-50% or other polar lipids.
The ratio between the peptide in the form of a salt and a galactolipid carrier in the pharmaceutical composition should preferably be 1:5 to 1:50, especially 1:10-1:25 by weight.
In addition to the bilayer-forming lipid the carrier also contains an aqueous solution. An aqueous solution refers to a solution having physiologically or pharmaceutically acceptable properties regarding pH, ionic strength, isotonicity etc. As examples can be mentioned isotonic solutions of water and other biocompatible solvents, aqueous solutions, such as saline and glucose solutions, and hydrogel-forming materials. The aqueous solution can be buffered, such as phosphate-buffered saline, PBS.
The pharmaceutical composition can in addition comprise pharmaceutically acceptable excipients, such as a preservative to prevent microbial growth in the composition, antioxidants, isotonicity agents, colouring agents and the like. In aqueous suspensions the compositions can be combined with suspending and stabilising agents.
The colloidal nature of the composition makes it possible to prepare the composition aseptically by using a final sterile filtration step.
In order to form a gel the peptide can be preferably formulated with a hydrogel-forming material. Examples of hydrogel-forming materials are synthetic polymers, such as polyvinylalcohol, polyvinylpyrolidone, polyacrylic acid, polyethylene glycol, poloxamer block copolymers and the like; semi-synthetic polymers, such as cellulose ethers, including carboxymethylcellulose, hydroxyethylcellulose, hydroxy-propylcellulose, methylcellulose, methylhydroxypropylcellulose and ethylhydroxy-ethylcellulose, and the like; natural gums, such as acacia, carragenan, chitosan, pectin, starch, xanthan gum and the like.
It is advantageous to use a hydrogel which is muco-adhesive. In that respect it is particularly useful to use hyaluronic acid and derivatives thereof, cross-linked polyacrylic acids of the carbomer and polycarbophil types, polymers that readily form gels, which are known to adhere strongly to mucous membranes.
It is also advantageous to use block copolymers of the poloxamer type, i.e. polymers consisting of polyethylene glycol and polypropylene glycol blocks. Certain poloxamers dispersed in water are thermoreversible: at room temperature they are low viscous but exhibit a marked viscosity increase at elevated temperatures, resulting in a gel formation at body temperature. Thereby the contact time of a pharmaceutical formulation administered to the relatively warm wound may be prolonged and thus the efficacy of the incorporated peptide may be improved.
The pharmaceutical composition of the invention can be formulated for topical or enteral, that is oral, buccal, sublingual, mucosal, nasal, bronchial, rectal, and vaginal administration.
Non-limiting examples of pharmaceutical compositions for topical administration are solutions, sprays, suspensions, emulsions, gels, and membranes. If desired, a bandage or a band aid or plaster can be used, to which the pharmaceutical composition has been added. Tablets, capsules, solutions or suspensions can be used for enteral administration.
According to another aspect the invention refers to the use of a peptide having an amino acid sequence selected from the group consisting of

    
    
        a) SEQ ID NO 1;
        b) a sequence containing at least 20 amino acids of the N-terminal fragment of SEQ ID NO 1;

in the form of pharmaceutically acceptable salts or derivatives thereof for proliferation of epithelial and/or stromal cells in vitro through a non-lytic mechanism.

    
    


Said proliferation can especially be used for proliferation of human autologous epithelial and stromal cells in vitro.
The invention also refers to a growth medium for culturing eukaryotic cells, such as epithelial and/or stromal cells, which comprises LL-37 or a peptide as described in combination with a basal medium. A cytotoxicity reducing agent can be added, such as serum. Apolipoprotein A-I (apoA-I) has been found to be the main LL-37 binding protein in human plasma and works as a scavenger of LL-37 (Wang et al, J Biol Chem 273:33115-33118, 1998; Sorensen et al, J Biol Chem 274:22445-22451, 1999), suggesting a mechanism involved in the regulation of a cathelicidin peptide. The cytotoxicity reducing agent can also be a bilayer-forming polar lipid, such as a lipid selected from the group consisting of phospholipids, galactolipids and sphingolipids, as described above.
The basal medium of the growth medium of the invention is based on double-distilled water, and a number of the following ingredients: inorganic salts, phenol red, glucose, thymidine, hypoxanthinine, HEPES, sodium pyruvate, aminopterin, amino acids and vitamins. For culturing of epithelial cells, such as e.g. keratinocytes, in vitro the growth medium can consist of basal medium and a growth promoting kit including a) LL-37 peptide in a salt solution, b) penicillin+streptomycin, c) insulin, d) transferrin, e) triiodotyronine, f) hydrocortisone, g) choleratoxin, and a selected cytotoxicity reducing agent, such as serum or a polar lipid. For culturing of stromal cells, such as e.g. fibro-blasts, in vitro, a growth medium can consist of basal medium and a growth promoting kit including a) LL-37 peptide in a salt solution, b) penicillin+streptomycin, and a selected cytotoxicity reducing agent, such as serum or a polar lipid.
Another object of the invention is a method of enhancing the expansion of human autologous epithelial and stromal cells in vitro for cell transplantation in vivo, wherein cells are isolated from an excised piece of healthy skin, said isolated cells are cultivated in vitro in a growth medium according to the invention, and the cultivated cells are subsequently harvested and used for treatment of wounds, such as burn injuries and ulcers.
The invention also refers to a growth promoting kit comprising the LL-37 peptide or a peptide as described, and a cytotoxicity reducing bilayer-forming polar lipid, optionally in combination with antibiotics, basal media, and other conventional additives in separate containers.
According to still another aspect the invention refers to transfection of a full-length hCAP 18 cDNA construct into autologous human keratinocytes for cell transplantation of ulcers and burns. The cDNA construct is designed to allow regulation of hCAP18 gene expression by a switch mechanism (Resnitzky et al., Mol Cell Biol 14:1669-1679, 1994). Autologous human keratinocytes are obtained from a healthy skin piece excised from the patient. The keratinocytes are isolated and expanded in cell culture as described. The cDNA construct is transfected into keratinocytes. The transfected keratinocytes are further expanded in vitro and given back to the patient.
The invention especially refers to the use of a gene construct comprising the complete cDNA sequence of hCAP18 having the sequence SEQ ID NO 20 for transfection of epithelial and/or stromal cells in order to enhance proliferation of said cells.
EXAMPLES
Example 1
Preparation of Synthetic Peptides
The LL-37 peptide was synthesized according to solid phase synthesis with the 9-fluorenylmethoxycarbonyl/tert-butyl strategy. The crude peptide, as the trifluoroacetate salt, was purified with HPLC and finally isolated by lyophilization (lot 971/26, from PolyPeptide Laboratories A/S, HiHerod, Denmark). The purity was determined by means of HPLC and area integration and was found to be 99%. The molecular weight was analyzed using mass spectrometry and corresponded to the theoretical value of 4493 g/mol as the free base. Analysis of composition of amino acids showed that the relative amounts of each amino acid corresponded with the theoretical values for LL-37. The peptide content was calculated from the results from the amino acid analysis and found to be 73%, the remainder being counterions and residual solvent.
Several batches of LL-37 were synthesized, and the LL-37 peptide used in the following Examples 2 and 5 was in the form of the acetate salt.
The peptides LL-36 and LL-38 were synthesized correspondingly, in the form of acetate.
The different peptides used in the following examples and tests were as follows.



















Purity
Peptide content

Manufact.


Peptide
Counterion
Lot
area-%
% (w/w)
Used in
Year







LL-37
Trifluoroacetate
YS 5253
98

Ex. 3, 4, 6, 7
1997







Test 3


LL-37
Trifluoroacetate
971/26
99
73
Test 5
2002


LL-37
Acetate
990/37/A
99
83
Ex. 2, 5
2003







Test 4


LL-38
Acetate
990/38


Test 4
2003


LL-36
Acetate
990/39


Test 4
2003









Example 2
Preparation of a Pharmaceutical Composition Comprising a Mixture of LL-37 Peptide and Lipid Carrier
A pharmaceutical composition was prepared using the following ingredients:














Ingredient
Concentration









LL-37
100 ppm*



CPL-Galactolipid
0.20%



2.6% Glycerol in sterile
ad 100%



water







*ppm = parts per million (by weight)






The peptide LL-37, as the acetate salt (lot 990/37/A), and the lipid carrier, CPL-Galactolipid, obtained from Lipocore Holding AB, a lipid material rich in digalactosyl-diacylglycerols and prepared from oats, were weighed in a 50 ml glass flask. The two ingredients were gently mixed and then the glycerol solution was added. The mixture was shaken vigorously for 120 min and then allowed to stand for 1 h. The resulting composition was a fine, homogenous dispersion. It was kept refrigerated until use.

Example 3
Preparation of Aqueous Mixtures Comprising the LL-37 Peptide and a Lipid Carrier
Mixtures of LL-37, as the trifluoroacetate salt (lot 971/26) and a polar, bilayer-forming lipid carrier were prepared using the following ingredients (percentages in weight by weight):













TABLE 1





Ingredient
A1
A2
B1
B2
C1
C2







LL-37
100 ppm
—
90
—
92
—


CPL-Galactolipid
0.19%
0.20%
—
—
—
—


Epikuron 200
—
—
0.19%
0.19%
—
—


CPL-Sphingomyelin
—
—
—
—
0.19%
0.19%


DMEM
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CPL-Galactolipid, obtained from Lipocore Holding AB, is a chromatographically purified galactolipid fraction from oats, Epikuron 200, obtained from Lucas Meyer GmbH, is phosphatidylcholine from soybean, and CPL-Sphingomyelin, obtained from Lipocore Holding AB, is chromatographically purified sphingomyelin from bovine milk. DMEM, Dulbecco's Modified Eagle Medium, from Invitrogen Corp. is an aqueous solution containing inorganic salts, glucose, phenol red, amino acids and vitamins
The peptide LL-37 and the lipid carrier were weighed in a glass flask and then DMEM was added. The resulting dispersions were vigorously shaken, using a Heidolph Promax mixer at a frequency of 200/min for 1.5 h, and allowed to equilibrate and settle for about 3 h at room temperature. A visual assessment was then made and the following results were obtained: All samples were turbid dispersions and there were no differences in turbidity between any of the samples B1, B2, C1, and C2. The only observed difference was between samples A1 and A2: the former, containing the peptide, was significantly less turbid than the latter, without the peptide. Sample A2 was slightly less turbid than, in turn, samples B1, B2, C1, and C2. These observations indicate a stronger interaction between the two components in sample A1, which results in a smaller average particle size of the dispersion, compared to the peptide-free sample A2, but also compared to the rest of the corresponding samples. After one day of storage at room temperature samples A1 and A2 were unchanged, i.e. both were homogeneous dispersions and A1 less turbid than A2, whereas the four other samples had considerable sediments on the bottom of the glass flasks.
All three mixtures of peptide and polar lipid carrier are useful for various purposes, e.g. as delivery systems and for tests in cell cultures; however, since the shelf-life of the mixtures of peptide and galactolipid is considerably longer (no sediment-ation) than that of the others, said mixtures are the most preferred for practical use.
Example 4
Preparation of Aqueous Mixtures Comprising a Mixture of LL-37 Peptide and Lipid Carrier
Samples of LL-37 as trifluoroacetate (lot 971/26) and a polar, bilayer-forming lipid carrier were prepared using the following ingredients (percentages in weight by weight):














TABLE 2





Ingredient
Sample D
Sample E
Sample F
Sample G
Sample H
Sample I
Sample J







LL-37
96 ppm
100 ppm
100 ppm
103 ppm
100 ppm
100 ppm
100 ppm


CPL-Galactolipid
0.21%
—
—
—
0.20%
—
—


PC from soybean, 40%
—
0.21%
—
—
—
—
—


PC from egg yolk, 60%
—
—
0.21%
—
—
—


DOPC, 99%
—
—
—
0.20%
—
—
—


PC from soybean, 70%
—
—
—
—
—
0.20%
—


PC from soybean, 94%
—
—
—
—
—

0.20%


PBS
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CPL-Galactolipid, manufactured by LTP Lipid Technologies Provider AB, is a chromatographically purified galactolipid fraction from oats. The various phospholipids used were phosphatidylcholine (PC) from soybean, approximately 40% (Sigma; P-3644); PC from dried egg yolk, approximately 60% (Sigma; P-5394); synthetic dioleylphosphatidylcholine (DOPC), approximately 99% (Sigma; P-6354); PC from soybean, approximately 70% (Lipoid S75); and PC from soybean, approximately 94% (Lipoid S100). PBS is phosphate-buffered saline from Invitrogen Corp. (Dulbecco's; cat. no. 14190-094).
All the investigated polar lipids have chain melting phase transition temperatures well below 0° C., i.e., in the range of −10 to −15° C., when fully hydrated.
The peptide LL-37 and the lipid carrier were weighed in a 100 ml glass flask and then PBS was added. The total volume was about 30 ml. The samples were vigorously shaken, using an ST mixer (type B1, E. Bilchler, Tübingen) set at 5.5 (corresponding to an approximate frequency of 150/min) for 2 h, and allowed to equilibrate and settle for about 30 min at room temperature. The turbidity of the resulting dispersions was then recorded at 400-800 nm on a Shimadzu UV-VIS Spectrophoto-meter UV-160A. The measurements were made against pure water at room tempera-ture using a 10 mm cuvette cell. Turbidity data in Table 3 are presented as % trans-mission at 600 nm. Visual assessments of the dispersions were also made. Turbidity measurements were repeated after one and two days of storage at room temperature of the dispersions.







TABLE 3







Turbidity Data














Turbidity









(λ = 600 nm)
Sample D
Sample E
Sample F
Sample G
Sample H
Sample I
Sample J





30 min
64.1%
70.9%
5.1%
1.7%
68.6%
18.6%
1.4%


 1 day
57.3%
65.6%
—
—
67.0%
19.8%
—


 2 days
57.2%
65.5%
—
—
66.9%
20.5%
—









From the visual assessments it was concluded that all mixtures formed more or less turbid dispersions; samples D, E, H, and I formed the least turbid dispersions, manifested in the highest transmission of light in Table 3, whereas samples F, G, and J formed the most turbid dispersions and consequently gave rise to the lowest trans-mission of light detected by the spectrophotometer. After one day of storage at room temperature, samples F, G, and J with the initially high turbidity (low transmission) had all sedimented and were not measured. Samples D, E, H, and I were all stable dispersions and resulted in reproducible turbidity data, after one and two days after preparation.
Samples D and H are duplicates, both containing CPL-Galactolipid but sample H had a slightly higher weight ratio of peptide to galactolipid. This resulted in a slightly lower turbidity (higher transmission) in sample H suggesting that the interaction between peptide and lipid in this sample is stronger than that in sample D, leading to smaller complexes/aggregates which give rise to lower turbidity.
Samples D, E, H, and I were further monitored with respect to colloidal stability at 2-8° C. for 2 months.







TABLE 4







Stability data









Sample
Appearance
Stability





D
fine turbid dispersion, slight sedimentation, easy
acceptable



to redisperse sediment


E
turbid dispersion, slight sedimentation; microbial
not



growth
acceptable


H
fine turbid dispersion, slight sedimentation, easy
acceptable



to redisperse sediment


I
turbid dispersion, slight sedimentation; microbial
not



growth
acceptable









These data and observations show that two mixtures of peptide and polar lipid carrier are better than the rest of the tested mixtures. The carriers containing CPL-Galactolipid (sample D and H) and PC from soybean, ca 40% (sample E) gave rise to the most finely dispersed systems with the longest colloidal stability; however, it is only CPL-Galactolipid which is acceptable for pharmaceutical use, since the phospholipid material with only 40% phosphatidylcholine may be used for technical applications only. These data again demonstrate the usefulness of the galactolipid material in various pharmaceutical applications, e.g. as a carrier system for peptides.
Example 5
Preparation of Aqueous Mixtures Comprising Varying Contents of LL-37 Peptide and Varying Contents of Galactolipid
A stock solution of LL-37 peptide (acetate salt; lot 990/37/A) in PBS, 995 ppm, and a stock solution of CPL-Galactolipid, 1.00%, in PBS were prepared. Aliquots of the stock solutions plus additional PBS were mixed in 20 ml glass vials with rubber stoppers and aluminum caps. The compositions of the mixtures are presented in Table 5. After equilibration at room temperature for 1 h, the vials were shaken in horizontal position on an ST mixer (type B1, E. Büehler, Tübingen), set at 7.5 (corresponding to an approximate frequency of 190/min), for 1 h. The mixtures were then allowed to equilibrate and settle over night at room temperature. The appearances of the mixtures after one and five days a 4° C. were evaluated as: clear colloidal, slightly turbid, turbid, milky, and the results are summarized in Table 5.












TABLE 5








Peptide:




Sample
LL-37
Galacto-
Lipid
Appearance after
Appearance after


number
(ppm)
lipid (%)
(w/w)
1 Day
5 Days




















01
247
0.135
1:5.5
turbid dispersion,
turbid dispersion,






sediment
sediment


02
181
0.133
1:7.4
clear colloidal solution
clear colloidal solution,







slight sediment


03
116
0.133
1:11
clear colloidal solution
clear colloidal solution


04
50.5
0.135
1:27
clear colloidal solution
clear colloidal solution


05
16.5
0.133
1:81
slightly turbid
slightly turbid






dispersion,
dispersion,






homogeneous
homogeneous


06
8.2
0.135
1:165
turbid dispersion,
turbid dispersion,






homogeneous
homogeneous


07
—
0.133
—
turbid dispersion,
turbid dispersion,






homogeneous
homogeneous


08
248
0.266
1:11
clear colloidal solution
clear colloidal solution,







slight sediment


09
182
0.267
1:15
clear colloidal solution
clear colloidal solution


10
116
0.266
1:23
clear colloidal solution
clear colloidal solution


11
49.8
0.268
1:54
slightly turbid
slightly turbid






dispersion,
dispersion,






homogeneous
homogeneous


12
17.1
0.266
1:156
slightly turbid
slightly turbid






dispersion,
dispersion,






homogeneous
homogeneous


13
8.9
0.265
1:298
slightly turbid
slightly turbid






dispersion,
dispersion,






homogeneous
homogeneous


14
—
0.265
—
slightly turbid
slightly turbid






dispersion,
dispersion,






homogeneous
homogeneous


15
247
0.532
1:22
clear colloidal solution
clear colloidal solution


16
182
0.532
1:29
slightly turbid
slightly turbid






dispersion,
dispersion,






homogeneous
homogeneous


17
116
0.533
1:46
turbid dispersion,
turbid dispersion,






homogeneous
homogeneous


18
49.2
0.533
1:108
turbid dispersion,
turbid dispersion,






homogeneous
homogeneous


19
16.5
0.534
1:324
turbid dispersion,
turbid dispersion,






homogeneous
homogeneous


20
8.2
0.532
1:649
turbid dispersion,
turbid dispersion,






homogeneous
homogeneous


21
—
0.533
—
turbid dispersion,
turbid dispersion,






homogeneous
homogeneous


22
248
0.799
1:32
turbid dispersion,
turbid dispersion,






homogeneous
slight sediment


23
182
0.802
1:44
milky dispersion,
milky dispersion,






homogeneous
slight sediment


24
115
0.801
1:70
milky dispersion,
milky dispersion,






homogeneous
slight sediment


25
50.1
0.799
1:159
milky dispersion,
milky dispersion,






homogeneous
slight sediment


26
16.8
0.799
1:476
milky dispersion,
milky dispersion,






homogeneous
slight sediment


27
8.6
0.798
1:928
milky dispersion,
milky dispersion,






homogeneous
slight sediment


28
—
0.798
—
milky dispersion,
milky dispersion,






homogeneous
slight sediment









It is clear that certain ratios of LL-37 peptide and galactolipid give rise to an appearance in solution, which indicate the presence of small complexes, smaller in size than particles of the corresponding samples without LL-37. A clear solution indicates a superior colloidal stability.
Example 6
Conformational Measurements
Measurements of circular dichroism (CD) of LL-37 in solution may reveal information about conformational changes. The antibacterial activity of LL-37 is dependent on the conformation: a high content of helical content results in a strong antibacterial action and a high cytotoxic activity (Johansson et al., J Biol Chem 273:3718-3724, 1998). It has been found that the α-helical conformation of LL-37 is dependent on the counterion, the pH, and the peptide concentration (Johansson et al., J Biol Chem 273:3718-3724, 1998). It is also known that a certain fraction of the peptide has an α-helical structure in aqueous solution and that this structure may be promoted by the presence of additives such as lipids, transforming it from a random coil to an α-helix (Turner et al., Antimicrob Agents Chemother 42:2206-2214, 1998).
Samples for circular dichroism (CD) measurements were prepared in 10 mM aqueous phosphate buffer solution, pH 7.0, containing 200 ppm LL-37 (as the trifluoroacetate, lot 971/26), with and without 0.40% CPL-Galactolipid. The samples, 20 ml in 50 ml glass flasks, were vigorously shaken with an ST mixer (type B1, E. Büchler, Tübingen) set at 7.5 (corresponding to an approximate frequency of 220/min) for 2 h. They were then allowed to equilibrate and settle over night at 2-8° C.
CD spectra were recorded on a Jasco J-720 (Jasco Inc.) spectropolari-meter. The sample compartment with the cuvette cell (1 mm path length) was placed near the photomultiplier, in order to reduce effects of light scattering from the disper-sions. The samples were measured at room temperature and scanned from 280 to 200 nm at a rate of 20 nm/min, with a resolution of 1 nm and 3 accumulations per run. The results are expressed as the mean residue ellipticity, [θ], and the percentage of α-helical conformation at 222 nm is estimated by the following formula: ([θ]222+3900)·100/41900.
The CD measurements on 200 ppm LL-37 in 10 mM phosphate buffer solution, pH 7.0, revealed an α-helical secondary structure by double dichroic minima at 208 and 222 nm. The minimum at 222 nm was used to calculate the percentage α-helical structure, which was found to be about 63%. When the galactolipid was added at a concentration of 0.40% (w/w) in the same buffer solution the α-helical structure of LL-37 was practically unaffected, with an approximate α-helical structure of 64%.
Enhanced helical conformation is related to increased antibacterial activity. It is speculated that the secondary structure is also relevant for the wound healing capacity of LL-37, where a high percentage of α-helical structure means enhanced activity. In an aqueous buffer solution this also means high cytotoxicity, but in the presence of galactolipid the secondary structure is retained, and thus the activity is unaffected, whereas the cytotoxicity is diminished.
An anionic synthetic phospholipid, palmitoyl-oleoyl-phosphatidylglycerol (POPG; Sigma-Aldrich, P6956) was used as a reference and tested using the same experimental conditions as described above. A lower percentage of α-helical structure, 58%, was found when this lipid was present, indicating that the conformation and thus activity of LL-37 is more influenced by the negatively charged phospholipid than by the neutral galactolipid. However, more importantly, after one month of storage at 4° C. the sample had partially separated, with sediments on the bottom of the container. Gentle shaking resulted in a coarse dispersion. At the same time-point, sediments were also observed in the corresponding sample based on galactolipid, but to a lesser extent, which could be redispersed to a fine dispersion by gentle agitation.
Example 7
Cytotoxicity Tests
In vitro cytotoxicity assays are valuable for the evaluation of the toxicity of materials, which come into close contact with living tissues.
Selected formulations were tested for in vitro cytotoxicity in cultured mammalian cells (L 929 mouse fibroblasts). The test design was based on the US Pharmacopeia 26th edition, Method <87> and the ISO 10993-5 standard.
Formulations D and E (see Example 4, Table 2) were mixed with complete cell culture medium (HAM F12 medium with 10% foetal bovine serum) at concentrations of 10, 2, 0.4 and 0.08% (v/v). These test solutions were used to treat triplicate cell cultures for 24 h. Triplicate untreated cultures, negative controls (treated with an extract of polypropylene) and positive controls (treated with an extract of tin-stabilised polyvinyl chloride) were included.
Both formulations showed no to slight toxicity (cytotoxicity grade 0-1) when tested at 10% (v/v) and no toxicity (cytotoxicity grade 0) at 2%, 0.4% and 0.08% (v/v).
Cytotoxicity test with a positive control solution containing 100 ppm LL-37 in PBS caused mild toxicity (cytotoxicity grade 2) at all four concentrations tested (10, 2, 0.4 and 0.08% mixtures of the solution with cell culture medium). This level of toxicity is defined as 20-50% of the cells being dead or showing morphological signs of toxicity. The scale has a range of 0 to 4 and when test extracts of medical devices are tested, grades 3 and 4 fail the test. This positive control solution is considerably more toxic than formulation D and E which showed no or just slight toxicity.
BIOLOGICAL EXPERIMENTS
Based on our recent findings that

    
    
        hCAP18/LL-37 is induced in skin and mucous membranes in association with inflammation and wounding, and
        hCAP18/LL-37 is lacking in chronic ulcer epithelium despite massive inflammation,

we hypothesized that hCAP18/LL-37 is involved in the regenerative capacity of skin epithelium. The following experiments were performed to test this hypothesis.

    
    


Test 1. Investigation of the Expression Pattern of hCAP18/LL-37 in Non-Inflammatory Human Wound Healing
Tissue Samples
Human skin was obtained from routine abdominal or breast reduction surgery. Under sterile conditions, full-thickness wounds were made, on the epidermal side, with a 3-mm biopsy punch. These ex vivo wounds were excised with a 6-mm biopsy punch and subsequently transferred to 24-well plates and covered with 2 ml of medium. Such wounds reproducibly re-epithelialize within 4-7 days (Kratz et al. Scand J Plast Reconstr Surg Hand Surg 28:107-112, 1994; Inoue et al., J Invest Dermatol 104:479-483, 1995; Kratz et al., Microsc Res Tech 42:345-350, 1998). Medium, DMEM (Dulbecco's modified Eagle's medium, GIBCO) containing 10% fetal calf serum (FCS) and antibiotics (PEST=penicillin 50 U/ml and streptomycin 50 mg/ml), was changed every third day. Wounds were harvested at different time-points, by 2, 4 and 7 days post-wounding and snap frozen. In total, the experiment was repeated four times. Four different donors were used and triplicate wounds were made for each condition in every experiment. In each experiment, only skin from a single donor was used.
Preparation of RNA Probes
To detect mRNA for the hCAP18 gene and immunoreactivity for hCAP18/LL-37 we performed in situ hybridization and immunohisto-chemistry on samples of wounds representing all time-points of sequential re-epithelialization. For in situ hybridization we used 35S-labeled antisense and sense RNA probes and the experiment was performed as described (Frohm Nilsson et al., Infect Immun 67:2561-2566, 1999).
Preparation of LL-37 Antibody
For immunohistochemistry we raised and prepared a polyclonal LL-37 antibody as follows: LL-37 peptide (lot YS 5253, EuroDiagnostica AB, Malmo, Sweden) was prepared as a trifluoroacetate salt according to Fmoc-strategy using solid phase synthesis (Fields and Noble, 1990) and purified by HPLC to a purity of 98%. Biological activity of the peptide was confirmed in an antibacterial assay. The peptide was used for immunization of three rabbits according to a standard protocol (AgriSera, Vannas, Sweden). Polyclonal antiserum was affinity-purified using synthetic LL-37 peptide and the purified antiserum was assessed with ELISA. IgG concentration of the immune serum was diluted to 0.5 mg/ml. Pre-immune serum was collected from each rabbit and the IgG concentration was 2 mg/ml.
Immunohistochemistry
All biopsies were snap frozen and handled identically. In short, 6-7 μm thick cryostat sections were incubated with the LL-37 antibody at dilutions 1:1000 and 1:2000 and stained according to the indirect peroxidase method using a Vectastain kit (Vector Laboratories, Burlingame, USA) and following the manufacturer's instructions. Sections were counterstained with Mayer's hematoxyline solution. All experiments were repeated minimum three times to ensure reproducability. As controls, serial tissue sections were processed in parallel without adding primary antibody and using pre-immune rabbit IgG (DAKO, Glostrup, Denmark) as primary antibody.
Results
At time-point 0 h there was moderate expression of hCAP18 mRNA and LL-37 protein in the basal layer of the epidermis throughout the tissue consistent with our previous findings of a constitutive hCAP18 expression in basal epidermis. Wounds harvested at different time-points during re-epithelialization demonstrated a distinct signal for hCAP18 mRNA and LL-37 protein in the epithelium migrating to cover the wounded surface. No cells in the underlying dermal matrix were positive for hCAP18/LL-37. These results indicate that de novo synthesis of hCAP18 occurs in keratinocytes during re-epithelialization without inflammation and support our hypothesis that hCAP18 may be linked to epithelial regeneration.
Test 2. Inhibition of Re-Epithelializing of Human Skin Wounds Ex Vivo with LL-37 Antibody
LL-37 antibody, prepared in Test 1, was added in 2 ml medium per well (DMEM, +10% FCS and PEST) to a final antibody dilution of 1:10, 1:100 and 1:1000. As control we used the corresponding pre-immune serum at a final IgG concentration equal to the 1:10 dilution of the LL-37 antiserum and a set of wounds treated only with medium. Each experimental condition was made in triplicates and repeated twice. The media were changed every third day and LL-37 antibody or pre-immune serum was added as described above. The ex vivo wounds were harvested 2, 4 and 7 days post-wounding. All specimens were snap frozen, sectioned in completion and mounted on Superfrost Plus slides prior to staining with hematoxylin-eosine. Sections representing maximal re-epithelialization in the center of the wounds were selected for evaluation. The proliferative capacity of keratinocytes was investigated through immunohisto-chemistry with the proliferation marker Ki67 (mouse monoclonal Ki67 antiserum (DAKO, Glostrup, Denmark) at 1:25 dilution) in wounds representing all treatment conditions.
Results
Treatment with LL-37 antibody produced a concentration-dependant inhibition of re-epithelialization. All wounds treated with the highest LL-37 antibody concentration (1:10) failed to re-epithelialize. In these wounds only single keratinocytes with a fragile flattened appearance had migrated from each wound edge. The wounds treated with LL-37 at medium concentration (1:100) showed delayed re-epithelialization, these wounds were mostly healed by day 7 but not by day 4. Moreover, the epithelium was thinner and the keratinocytes had a fragile appearance. Wounds treated with LL-37 antibody at the lowest concentration (1:1000) did not differ from control wounds, which had all healed by day 4 with a 2-3 layer robust epithelium. Control wounds treated with only medium and control IgG antibody healed equally. In the control wounds the majority of cells in the re-epithelializing tongue were positive for the proliferation marker Ki67, whereas there were no Ki67 positive cells in the wounds treated with LL-37 at 1:10. We concluded from this experiment that LL-37 may be critically involved in skin re-epithelialization and that the proliferative capacity seemed preferentially affected, since blocking with LL-37 antibody allowed the initial migration of single cells from the wound edge, but effectively prevented further proliferation of the keratinocytes.
Test 3. Proliferation of HaCat Cells by Treatment with Synthetic, Biologically Active LL-37 Peptide Per Se and in Combination with a Polar Lipid Carrier
HaCat cells were used for these experiments. HaCat cells are an immortalized human keratinocyte cell line (Boukamp et al., J Cell Biol 106:761-771, 1988), which is suitable for experimental keratinocyte research. HaCat cells were cultured in medium (DMEM, +10% FCS and PEST). Both types of cell cultures were treated with synthetic, bioactive LL-37 (lot YS 5253). In addition a mixture of LL-37 (114 μg/ml) and CPL-Galactolipid (0.2%) in medium containing serum at either 2 or 10% was added to evaluate the capacity to increase proliferation and inhibit cytotoxicity. Cells were harvested at different time-points (24 h, 48 h, 72 h and 96 h) and counted by flowcytometry (Becton-Dickinson) and stained by Trypan-Blue to evaluate viability. Positivity for Trypan-Blue indicates that the cell membrane has been damaged. Proliferation and viability were also ascertained by measuring mitochondrial activity (WST-1, Roche, Cook et al. Anal Biochem 179:1-7, 1989).







TABLE 6







Proliferation of HaCat cells at 96 h Assessed by Flowcytometry.














Serum
Number
Trypan
Increased


EGF
LL-37
Conc.
of Cells
Blue+
Proliferation


(nM)
(μg/ml)
(%)
(Mean)
(%)
(%)















—
—
10
32270
<1
0


1.7
—
10
42000
<1
30


—
25
10
36470
<1
13


—
50
10
40950
<1
27


—
100
10
66430
<1
100


—
25
2
32130
<1
0


—
50
2
53620
30-50
Not relevant







Cytotoxic effect


—
100
2
15120
100
Not relevant







Cytotoxic effect





Increase in cell proliferation is calculated in comparison with baseline (−EGF). Mean values from triplicate samples/condition in three separate experiments are presented













TABLE 7







Proliferation and Viability of HaCat Cells at 48


h Measured by Mitochondrial Activity (WST-1).














Serum

Trypan
Increased


EGF
LL-37
Conc.

Blue+
Proliferation


(nM)
(μg/ml)
(%)
Absorbance
(%)
(%)















—
—
10
0.622
<1
0


1.7
—
10
1.107
<1
77


—
100
10
1.110
<1
78





Increase in cell proliferation is calculated in comparison with baseline (−EGF). Mean values from 6 samples/condition in one experiment are presented













TABLE 8







Proliferation of HaCat Cells at 72 h Assessed by Flowcytometry













EGF
LL-37
Lipid
Serum
Number of
Trypan Blue +
Increased


(nM)
(μg/ml)
(0.2%)
Conc. (%)
Cells (Mean)
(%)
Proliferation (%)
















—
—
−
10
55207
<1
 0


1.7
—
−
10
85050
<1
54


1.7
—
+
10
87640
<1
58


—
100
−
10
88853
<1
61


—
100
+
10
91980
<1
66


—
100
−
2
150500
100
Not relevant








Cytotoxic effect


—
100
+
2
87360
<1
58





Increase in proliferation is calculated in comparison with baseline (-EGF). Mean valued from triplicate samples/condition in one experiment are presented.






Results
The treatment of HaCat cells with LL-37 peptide resulted in a concentration-dependant increase in proliferation. This indicates that LL-37 peptide has the capacity to stimulate the proliferation of keratinocytes to a level that equals or surpasses that of EGF, the golden standard for epithelial cell proliferation. We have used EGF at 1.7 nM since this has been established as optimal to stimulate proliferation of keratinocytes in culture and has become a standard culture condition (Cohen et al., Dev Biol 12:394-407, 1965). HaCat cells are highly proliferating epithelial cells and it is interesting that LL-37 can increase the proliferation of these cells even further. The cytotoxic effect induced by LL-37 at 100 μg/ml, in 2% serum was completely abolished when lipid was added to the mixture, indicating that the lipid is able to substitute for serum in this experimental condition.
The test has shown that synthetic, bioactive LL-37 (25-100 μg/ml) added to cell cultures of HaCat cells, in media with 10% Fetal Calf Serum (FCS), increases proliferation in a concentration-dependent manner. However, if the peptide (100 μg/ml) was added to a keratinocyte culture in a medium containing 2% FCS, all of the keratinocytes became positive with Trypan Blue staining, indicating a cytotoxic effect on these cells.
The cytotoxic activity of cathelicidin is inhibited by the presence of serum, a mechanism thought to protect the host cells from potentially harmful effects. Our data confirms that the cytotoxic effect of LL-37 is inhibited in the presence of serum (10%). In addition, the mixture of LL-37 (25 μM) and polar lipid carrier (0.2%), in medium containing the lower serum concentration (2% FCS), inhibits the cytotoxic effect and increases the proliferation. These data suggest that the polar lipid carrier has similar protecting capacity as serum, without interfering with the LL-37 bioactivity.
Primary data show that human keratinocytes are proliferated in the same way as HaCat cells.
Test 4. Proliferation of HaCat Cells by Treatment with the Synthetic Peptides LL-36, LL-37 and LL-38
HaCat cells were cultured in medium (DMEM, +10% FCS and PEST). HaCaT cells were plated in 96 well plates (Falcon, USA) at the concentration of 2000 cells per well. Cells were plated at −48 hours and stimulated with different concen-trations of synthetic LL-37, LL-36, and LL-38 peptide by hour 0 and after 48 hours.
The testing was done in one experiment with 6 wells in each condition. 1 Ci/mmol of 3H-Thymidine (THYMIDINE, [METHYL-3H]-740.0 GBq/mmol (20.00 Ci/mmol) 1.0 ml of Ethanol:Water, 7:3, Perkin Elmer Life Sciences Inc. Boston Mass., USA) was added to each well and incubated for 12-17 hours. Proliferation was evaluated by 3H-Thymidine incorporation a liquid scintilator (MicroBeta Perkin Elmer Life Sciences Inc. Boston Mass., USA) after 72 and 96 hours.







TABLE 9







Proliferation of HaCat Cells by LL-37 at 96 h Assessed


by 3H-Thymidine Incorporation after 72 and 96 Hours.












Serum
Counts Per
Standard
Increased


LL-37
Conc.
Minute
Deviation
Proliferation


(μg/ml)
(%)
(Mean)
(+/−)
(%)














0
10
52774
11639
0


1.00
10
75445
32827
43


5.00
10
102353
33808
94


10.00
10
73548
8424
39


25.00
10
76510
10550
45


50.00
10
65119
8565
23





Increase in cell proliferation (Proliferation Index) is calculated in comparison with baseline (Control = 0 μg/ml). Mean values from four samples per condition in one experiment are presented.













TABLE 10







HaCat cells stimulated by LL-36 peptide. Proliferation


Assessed by 3H-Thymidine Incorporation after 96 Hours.












Serum
Counts Per
Standard
Increased


LL-36
Conc.
Minute
Deviation
Proliferation


(μg/ml)
(%)
(Mean)
(+/−)
(%)














0
10
69323
7511
0


1.00
10
86253
10770
24


5.00
10
116381
14570
68


10.00
10
70157
3660
1


25.00
10
72674
7965
5


50.00
10
68560
11699
−1





Increase in cell proliferation (Proliferation Index) is calculated in comparison with baseline (Control = 0 μg/ml). Mean values from four samples per condition in one experiment are presented.













TABLE 11







HaCat Cells Stimulated by LL-38 Peptide. Proliferation


Assessed by 3H-Thymidine Incorporation after 96 Hours.












Serum
Counts Per
Standard
Increased


LL-38
Conc.
Minute
Deviation
Proliferation


(μg/ml)
(%)
(Mean)
(+/−)
(%)














0
10
79191
15277
0


1.00
10
82008
7911
4


5.00
10
68694
16599
−13


10.00
10
57293
8512
−28


25.00
10
54294
14335
−31


50.00
10
48701
6080
−39





Increase in cell proliferation (Proliferation Index) is calculated in comparison with baseline (Control = 0 μg/ml). Mean values from four samples per condition in one experiment are presented.






Test 5. Proliferation of Human Fibroblasts by Treatment with LL-37 Peptide
The peptide LL-37 used in this and following tests was as described in Example 1 (lot 971/26). The fibroblasts, a type of stromal cells, were obtained from injured and uninjured skin in patients with chronic leg ulcers due to venous insufficiency. Punch-biopsies (4-mm) were taken from the wound margin including 50% of the epithelialized area and from uninjured skin in the knee region. Individuals with a history of diabetes mellitus, arterial insufficiency or chronic inflammatory disease were excluded. Patients with signs of eczema in the ulcer margin, clinical signs of infection or undergoing systemic or topical antibiotic treatment at the time for biopsy were also excluded. Patients included were all treated with inert local dressings and standard compression bandaging.
Fibroblast were put in culture using explant technique (Hehenberger et al., Cell Biochem Funct 15:197-201, 1997). Fibroblasts were plated in 96 well plates (Falcon, USA) at the concentration of 2000 cells per well. Cells were plated at −48 hours and stimulated with different concentrations of synthetic LL-37 peptide by hour 0. The testing was done in one experiment with 6 wells in each condition. Proliferation and viability were ascertained by measuring mitochondrial activity (WST-1, Roche) after 24 h and 48 h. See Table 12 and Table 13 below. Increase in cell proliferation (Proliferation Index) is calculated in comparison with baseline (Control=0 μg/ml). Mean values from six samples per condition in one experiment are presented.







TABLE 12







Human Wound Fibroblast Stimulated by LL-37. Proliferation


and Viability of Human Fibroblasts Measured by Mitochondrial


Activity (WST-1) at 48 Hours.














Serum

Standard
Increased


LL-37
Lipid
Conc.

Deviation
Proliferation


(μg/ml)
(0.2%)
(%)
Absorbance
(+/−)
(%)















—
−
10
0.785
0.020
0


25
−
10
1.171
0.242
49


50
−
10
1.073
0.199
37


100
−
10
0.955
0.187
22


100
+
2
0.960
0.122
22
















TABLE 13







Human Normal Fibroblast Stimulated by LL-37 Peptide.


Proliferation and Viability of Human Fibroblasts Measured


by Mitochondrial Activity (WST-1) at 48 Hours












Serum

Standard
Increased


LL-37
Conc.

Deviation
Proliferation


(μg/ml)
(%)
Absorbance
(+/−)
(%)














—
10
0.560
0.019
0


25
10
0.597
0.067
7


50
10
0.626
0.076
12


100
10
0.669
0.051
19









Test 6. Transgenic Expression of hCAP18 in HEK293 Cells and Proliferation of HEK293-hCAP18 Cells
A Bfa1 fragment from Image clone 3057931 (ref) containing the entire coding sequence for hCAP18 including the 16 by of the 5′-untranslated region, was subcloned into the Sma1-site of the bycistronic vector pIRES2-EGFP (BD Biosciences, Bedford, Mass.). Human embryonic kidney cells, HEK293, were transfected using Fugene (Roche Diagnostics, Indianapolis, Ind.) under standard conditions, and selected for two weeks with 400 ng/ml G418 antibioticum (Invitrogen, Paisley, UK). The cells were sorted for EGFP expression with a MoFlo® high speed cell sorting flow cytometer (DakoCytomation, Fort Collins, Colo.) using SummitTM software for data analysis, and their expression of CAP18 was quantified by immunoblotting. Control cell lines were similarly established by transfection with the vector only expressing EGFP.
For proliferation assay, cell lines were harvested at 70% confluence and seeded in 24-well plates. After 24 hours, medium was changed and cells were cultured in 2 ml of medium (OPTIMEM, Gibco BRL, Life Technologies, Scotland) supplemented with 5% FCS and PEST. All conditions were performed in triplicates. Medium was changed every second day. Cell lines were then harvested at day 6 and counted by Flow Cytometry. Cell viability was measured with Trypan Blue; under all conditions <5% of the cells were Trypan Blue positive. Increase in cell proliferation (Proliferation Index) is calculated in comparison with baseline (HEK293-EGFP). Mean values from triplicate samples per condition in one experiment are presented.







TABLE 14







Proliferation of HEK293-hCAP-18 Cells at


144 Hours Assessed by Flow-Cytometry.












Serum

Standard
Increased


Cell
Conc.
Number of
Deviation
Proliferation


Type
(%)
Cells (Mean)
(+/−)
(%)














HEK293-EGFP
5
169063
63726
0


HEK293-hCAP18
5
485884
88168
187









The proliferation of the HEK293-hCAP18 cells was also assessed by incorporation of 3H-thymidine and the results obtained are presented in Table 15 below. The increase in cell proliferation (Proliferation Index) is calculated in comparison with baseline (HEK293-EGFP). Mean values from four samples per condition in one experiment are presented.







TABLE 15







Proliferation of HEK293-hCAP-18 Cells at 144 Hours Assessed


by 3H-Thymidine Incorporation after 96 Hours.












Serum
Counts Per
Standard
Increased


Cell
Conc.
Minute
Deviation
Proliferation


Type
(%)
(Mean)
(+/−)
(%)














HEK293-EGFP
0.1
364
118
0


HEK293-hCAP18
0.1
796
206
111


HEK293-EGFP
0.5
811
459
0


HEK293-hCAP18
0.5
2271
792
180


HEK293-EGFP
1
744
433
0


HEK293-hCAP18
1
2303
359
209


HEK293-EGFP
2
767
334
0


HEK293-hCAP18
2
3483
771
354


HEK293-EGFP
5
958
414
0


HEK293-hCAP18
5
6088
1783
534


HEK293-EGFP
10
1806
664
0


HEK293-hCAP18
10
6541
2827
262









Test 7. Culturing of Human Cells for Transplantation in Different Growth Media
Culture of Epithelial Cells
A piece of skin, 1×1 cm, is excised from healthy skin of the patient. The skin is minced and treated with trypsin/EDTA (0.05/0.01%) and 2-5×106 of the recruited keratinocytes are added to 1.5×106 mitomycin-pretreated (4 μg/ml, 2 h) 3T3 cells in 75 cm2 culture flasks. Growth medium A containing LL-37 peptide is added. Cells are harvested by trypsination as sheets and transplanted onto the patient.
Growth Medium A is used for culture of epithelial cells such as e.g. keratinocytes in vitro and consists of Basal Medium and a growth promoting kit (GPK) including a) LL-37 peptide in a salt solution, b) penicillin+streptomycin, c) insulin, d) transferring, e) triiodotyronine, f) hydrocortisone, g) choleratoxin, and a selected cytoxicity reducing agent, such as serum or a polar lipid.
Culture of Stromal Cells
Stromal cells are obtained from a 4 mm skin biopsy, cleaned from subcutaneous tissue and plated in cell culture dishes using the explant technique to obtain primary fibroblasts. Growth medium B is used for culturing the biopsy. Cells are harvested by trypsination and given back to the patient.
Growth Medium B is used for culture of stromal cells such as e.g. fibroblasts in vitro and consists of Basal medium and a growth promoting kit including a) LL-37 peptide in a salt solution, b) penicillin+streptomycin, and a selected cytotoxicity reducing agent, such as serum or a polar lipid.
Basal medium is based on double-distilled water containing inorganic salts, phenol red, glucose, thymidine, hypoxanthinine, HEPES, sodium pyruvate, aminopterin, amino acids and vitamins
SUMMARY OF THE EXPERIMENTS
In summary, it has been demonstrated that LL-37 is produced in skin epithelium during normal wound healing and that LL-37 is required for re-epithelializa-tion to occur. We have also shown that endogenous LL-37 is lacking in chronic ulcer epithelium. We therefore propose that treatment with LL-37, as well as with N-terminal fragments of said peptide, and functional derivates thereof provides a rational strategy to promote healing of such ulcers. Furthermore, addition of LL-37 and transgenic expression of hCAP18/LL-37 also stimulates proliferation of healthy cells indicating that LL-37 can be used to enhance both normal and deficient epithelial repair in vivo and proliferation of epithelial cells in vitro for autologous cell transplantation. We have also identified a suitable carrier and delivery system that reduces cytotoxicity and has the potential to protect from rapid degradation in vivo of LL-37 and other cathelicidin peptides.

## Claims

1. A method for stimulating proliferation of epithelial cells in a chronic ulcer due to diabetes, comprising administering an effective amount of a peptide LL-37 (SEQ ID NO: 1) or a pharmaceutically acceptable salt thereof to a subject in need of such treatment.

2. The method according to claim 1, wherein said peptide LL-37 (SEQ ID NO: 1) is in the form of the acetate salt.

3. The method of claim 1 wherein the peptide LL-37 (SEQ ID NO: 1) is administered topically to the chronic ulcer.

4. A method for stimulating epithelial regeneration in a chronic ulcer due to diabetes, comprising administering an effective amount of a peptide LL-37 (SEQ ID NO: 1) or a pharmaceutically acceptable salt thereof to a subject in need of such treatment.

5. The method according to claim 4, wherein said peptide LL-37 (SEQ ID NO: 1) is in the form of the acetate salt.

6. The method of claim 4 wherein the peptide LL-37 (SEQ ID NO: 1) is administered topically to the chronic ulcer.

7. A method for stimulating re-epithelialization in a chronic ulcer due to diabetes, comprising administering an effective amount of a peptide LL-37 (SEQ ID NO: 1) or a pharmaceutically acceptable salt thereof to a subject in need of such treatment.

8. The method according to claim 7, wherein said peptide LL-37 (SEQ ID NO: 1) is in the form of the acetate salt.

9. The method of claim 7 wherein the peptide LL-37 (SEQ ID NO: 1) is administered topically to the chronic ulcer.