Mesenchymal Stem Cell for Acute Respiratory Distress Syndrome Due for COVID-19

Acute Respiratory Distress Syndrome (ARDS) is the main cause of death from COVID-19. One of
the main mechanisms for ARDS is the storm of cytokines and chemokines, which cause
uncontrolled fatal systemic inflammation. The SARS-CoV-2 virus infects cells that express the
angiotensin II converting enzyme receptor (ACE2). This receptor is widely distributed on the
surface of type II alveolar cells (AT2) and on the capillary endothelium. This is why the
cytokine storm will trigger a violent attack by the immune system on the body, cause ARDS and
multiple organ failure, and can ultimately lead to death. Mortality in cases of severe SIRA
caused by COVID 19 varies significantly between 50 and 90%, basically depending on the age of
the patient and the presence of comorbidities.

The plasticity of Mesenchymal Stem Cell (MSC) regulates inflammation and immunity. MSC can
promote and inhibit an immune response, depending on the dynamics of inflammation and
depending on the activation force of the immune system, the types of inflammatory cytokines
present, and the effects of immunosuppressants. Essentially, the state of inflammation
determines the immunoregulatory fate of MSC. Thus, IV application of MSC has been shown to
control the inflammatory response in various diseases, such as the graft-versus-host reaction
and the ARDS caused by H5NI.

MSC are negative for ACE2, therefore they have been used to decrease the cytokine storm
present in COVID-19.

Two recent studies in China have used human allogeneic MSC to treat COVID-19 pneumonia. Both
studies reveal a marked reversal of symptoms, even in critically serious cases. Lung function
improved two days after MSC application and 10 days later they were discharged. Lymphocytes
increased, PCR decreased, and cytokine-producing immune cells disappeared within 3 to 6 days.
Regulatory immune cells increased. TNF alpha factor decreased and IL10 increased.

Taking into account the previous concepts together with the current global pandemic, and the
high mortality existing among patients with bilateral pneumonia caused by COVID-19 and severe
ARDS, the investigators propose intravenous infusion of mesenchymal stem cells from bank
laboratory, with the purpose partially proven to decrease the systemic inflammatory process,
offering it as a salvage treatment.

Five patients, of either sex, over 18 years of age, with bilateral pneumonia caused by
COVID-19 and severe ARDS that has not improved in relation to the following parameters: a)
Persistent PaO2 / FiO2 less than 150, b) persistent fever, c ) D-dimer increase of at least
50% of baseline and / or ferritin greater than 1000, after 48 h of hospital stay receiving
the standard management measures used at that time in the care center, will be included in
the study. Covid pneumonia should be confirmed by chest CT and RNA detection by positive
SARS-Cov2 PCR. This treatment will be administered after discussing it with the relatives
that it is a procedure considered as rescue and will be carried out with informed consent.

Their follow-up will be daily while they are hospitalized in the Intensive Care Unit and / or
hospitalized, until their discharge from the hospital or until the third week after surgery.
If the patient has already been discharged from the hospital, his last evaluation will be in
the third week.

The main objective of this protocol is: To describe the clinical changes secondary to IV
administration of MSC, in patients with bilateral COVID-19 pneumonia complicated by severe
ARDS, with the evaluation of the PaO2 / FiO2 ratio, heart rate and respiratory rate, as well
as of the fever curve daily.

The secondary objectives are:

a) To assess the effect of the proposed treatment on the general biochemical indicators
(Leukocytes, absolute lymphocytes, absolute neutrophils, absolute monocytes, absolute
eosinophils, absolute basophils, erythrocytes, hemoglobin, platelets, total bilirubin,
albumin, amino-aspartate transferase, fibrinogen, procalcitonin, glomerular filtration,
myoglobin, troponin, ferritin and D-dimer. Daily.

b. To assess the anti-inflammatory effect of the proposed treatment with assessment of the
levels of cytokines, and C-reactive protein, TNFa, IL10, IL1, IL6, IL17, VEGF in plasma.
These variables will be evaluated before treatment, upon discharge from the ICU, and / or
from the Hospital.

c. Assess the radiological evolution of the proposed treatment through simple chest CT. These
variables will be evaluated before treatment, upon discharge from the ICU, and / or from the
Hospital.

d. Evaluate immune system improvement with mass cytometry to analyze patients' immune cells:
regulatory T cells (CXCR3-), dendritic cells (DC, CXCR3-), CXCR3 + CD4 + T, CXCR3 + CD + T,
and CXCRT3 + NK. These variables will be evaluated before treatment, upon discharge from the
ICU, and / or from the Hospital.

e) Assess the safety of the proposed treatment (allergic reactions and / or infection) F. To
assess the negativization of the RNA detection test by SARS-Cov2 PCR. These variables will be
evaluated before treatment, upon discharge from the ICU, and / or from the Hospital.

The inclusion criteria are:

1. Comply with the informed consent procedure and sign the informed consent form.

2. Over 18 years

3. Of any gender

4. With SARS-Cov2 PCR RNA detection test, positive

5. With bilateral pneumonia caused by COVID-19

6. Severe ARDS with PaO2 / FiO2 less than 150

7. That it has not improved in relation to: a) Persistent PaO2 / FiO2 less than 150, b)
persistent fever, c) increase in D-dimer at least 50% of the baseline and / or ferritin
greater than 1000, after 48 hrs hospital stay receiving the standard management measures
used at that time in the care center.

8. Lymphopenia less than 800 total lymphocytes

9. Increased D-dimer (> 1200 mg / dl)

10. CT compatible with bilateral pneumonia

11. SOFA under 11 With knowledge of the patient and / or their responsible relatives that it
is a rescue treatment, in an experimental phase.

The bank mesenchymal cells will be donated by the CBCells Bio Technology Laboratory, at no
cost to the patient or INCMNSZ.

1x106 x Kg of weight, diluted in 100 ml of saline, will be infused intravenously, to pass in
40 minutes. It will be monitored with monitors, Pao2 / Fio2, FC, FR, ECG. Additionally, fever
and muscle contractures will be monitored, which will be recorded every hour for 24 hours and
every 24 hours thereafter, up to three weeks after the application of MSC. The patient should
continue with their indicated medical treatments, such as antibiotics and specific treatments
in case of comorbidities.

The results will be compared with the historical controls attended at INCMNSZ Thus, the
results obtained will give information to calculate the sample size in subsequent studies in
which the usefulness of the procedure will be evaluated.