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Bioreactor Systems for Tissue Engineering II

January 2010
Advances in Biochemical Engineering/biotechnology 123:55-105

January 2010
123:55-105

DOI:10.1007/10_2009_24

Source
PubMed

Authors:

Birgit Weyand

Hannover Medical School

Christine Radtke

Hannover Medical School

Peter Maria Vogt

Hannover Medical School

Show all 6 authorsHide

While bone marrow-derived mesenchymal stem cells are known and have been investigated for a long time, mesenchymal stem cells derived from the adipose tissue were identified as such by Zuk et al. in 2001. However, as subcutaneous fat tissue is a rich source which is much more easily accessible than bone marrow and thus can be reached by less invasive procedures, adipose-derived stem cells have moved into the research spotlight over the last 8 years. Isolation of stromal cell fractions involves centrifugation, digestion, and filtration, resulting in an adherent cell population containing mesenchymal stem cells; these can be subdivided by cell sorting and cultured under common conditions. They seem to have comparable properties to bone marrow-derived mesenchymal stem cells in their differentiation abilities as well as a favorable angiogenic and anti-inflammatory cytokine secretion profile and therefore have become widely used in tissue engineering and clinical regenerative medicine.

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123

Advances in Biochemical

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Advances in Biochemical Engineering/Biotechnology

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With contributions by

P. Adamietz W. Brehm J. Burk R. Cancedda T. Cantz 

Y.-H. Choi P. Czermak U. Delling E. Dohle 

R. M. El Backly M. A. Esteban D. Freimark S. Fuchs 

C. Geißler P. Geigle C. Gittel C. Goepfert M. Griensven 

R. Grillari-Voglauer R. Hass T. Hatlapatka H. Ju

¨lke 

C. Kasper C. J. Kirkpatrick K. Klose M. Kolbe 

J. W. Kuhbier A. Lavrentieva I. Majore D. Marten 

U. Martin P. Moretti D. Pei A. Peterbauer-Scherb 

P. Pino-Grace R. Poertner S. Pohl R. Po

¨rtner K. Reimers 

I. Ribitsch A. F. Schilling A. Slobodianski C. Stamm 

H.-F. Tse P. M. Vogt C. Wallrapp C. Weber 

B. Weyand S. Wolbank J. Xu Q. Zhuang

Editors

PD Dr. Cornelia Kasper

Universita

¨t Hannover

Inst. Technische Chemie

Callinstr. 3

30167 Hannover

Germany

kasper@iftc.uni-hannover.de

Prof. Dr. Ralf Po

¨rtner

TU Hamburg-Harburg

Inst.Biotechnologie u.

Verfahrenstechnik

Denickestr. 15

21073 Hamburg

Germany

poertner@tuhh.de

Prof. Martijn van Griensven

Ludwig Boltzmann Institut fu

¨r

Klinische und Experimentelle

Traumatologie

Donaueschingenstr. 13

1200 Wien

Austria

Martijn.van.Griensven@LBITRAUMA.ORG

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¨rtner

TU Hamburg-Harburg

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Ludwig Boltzmann Institut fu

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Klinische und Experimentelle

Traumatologie

Donaueschingenstr. 13

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Austria

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Chemical Engineering

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Preface

First of all, the editors of this special volume would like to thank all the authors for

their excellent contributions. We would also like to thank Prof. Dr. Thomas Scheper

as well as Dr. Marion Hertel and Ingrid Samide from Springer for providing the oppor-

tunity to compose this volume and Springer for organizational and technical support.

Tissue engineering represents one of the major emerging ﬁelds in modern bio-

technology. Tissue engineering combines different disciplines ranging from bio-

logical and material sciences to engineering and clinical disciplines. The aim of

tissue engineering is the development of therapeutic approaches to substitute

diseased organs or tissues or improve their function. Stem cells are early progeni-

tors that may substitute diseased tissues or provide cues for endogenous healing.

Stem cells are present in virtually all tissues. The ﬁrst chapters describe different

sources of stem cells including isolation and expansion. The use of fetal tissues

and umbilical cord is discussed as they come from immunoprivileged sites and

are considered to be early stem cells. The use of adipose-derived stem cells is dis-

cussed as a readily available autologous source. Subsequently, newer techniques for

“manufacturing” stem cells from somatic cells using “induced pluripotent stem cell”

technology are discussed and described in two chapters. The following chapter deals

with bioreactor cultivation of stem cells. Speciﬁc tissues such as cartilage and

endothelial precursors built the bridge to the last chapters. In those chapters, clinical

applications are the focus of interest. It covers a wide range of clinical applications

from veterinary orthopedics and human bone diseases until cardiologic applications.

This small overview indicates that we have tried to cover the area of stem cells

from isolation, expansion up to clinical applications. The road has been walked

already for a substantial distance. However, we are still at the beginning of this

exciting new technology.

We hope that this state-of-the-art book is helpful to your research. Please enjoy

reading it, as much as we enjoyed preparing it.

Summer 2010 Cornelia Kasper

Ralf Po

¨rtner

Martijn van Griensven

Contents

Alternative Sources of Adult Stem Cells: Human Amniotic Membrane .... 1

Susanne Wolbank, Martijn van Griensven, Regina Grillari-Voglauer,

and Anja Peterbauer-Scherb

Mesenchymal Stromal Cells Derived from Human Umbilical Cord

Tissues: Primitive Cells with Potential for Clinical and Tissue

Engineering Applications ..................................................... 29

Pierre Moretti, Tim Hatlapatka, Dana Marten, Antonina Lavrentieva,

Ingrida Majore, Ralf Hass, and Cornelia Kasper

Isolation, Characterization, Differentiation, and Application

of Adipose-Derived Stem Cells ............................................... 55

¨rn W. Kuhbier, Birgit Weyand, Christine Radtke, Peter M. Vogt,

Cornelia Kasper, and Kerstin Reimers

Induced Pluripotent Stem Cells: Characteristics and Perspectives ...... 107

Tobias Cantz and Ulrich Martin

Induced Pluripotent Stem Cell Technology in Regenerative

Medicine and Biology ........................................................ 127

Duanqing Pei, Jianyong Xu, Qiang Zhuang, Hung-Fat Tse,

and Miguel A. Esteban

Production Process for Stem Cell Based Therapeutic Implants:

Expansion of the Production Cell Line and Cultivation

of Encapsulated Cells ........................................................ 143

C. Weber, S. Pohl, R. Poertner, Pablo Pino-Grace, D. Freimark,

C. Wallrapp, P. Geigle, and P. Czermak

Cartilage Engineering from Mesenchymal Stem Cells .................... 163

C. Goepfert, A. Slobodianski, A.F. Schilling, P. Adamietz, and R. Po

¨rtner

xiii

Outgrowth Endothelial Cells: Sources, Characteristics and Potential

Applications in Tissue Engineering and Regenerative Medicine ......... 201

Sabine Fuchs, Eva Dohle, Marlen Kolbe, and Charles James Kirkpatrick

Basic Science and Clinical Application of Stem Cells

in Veterinary Medicine ...................................................... 219

I. Ribitsch, J. Burk, U. Delling, C. Geißler, C. Gittel, H. Ju

¨lke, and W. Brehm

Bone Marrow Stem Cells in Clinical Application: Harnessing

Paracrine Roles and Niche Mechanisms ................................... 265

Rania M. El Backly and Ranieri Cancedda

Clinical Application of Stem Cells in the Cardiovascular System ....... 293

Christof Stamm, Kristin Klose, and Yeong-Hoon Choi

Index .......................................................................... 319

xiv Contents

Adv Biochem Engin/Biotechnol (2010) 123: 1–27

DOI: 10.1007/10_2010_71

#Springer-Verlag Berlin Heidelberg 2010

Published online: 17 March 2010

Alternative Sources of Adult Stem Cells:

Human Amniotic Membrane

Susanne Wolbank, Martijn van Griensven, Regina Grillari-Voglauer,

and Anja Peterbauer-Scherb

Abstract Human amniotic membrane is a highly promising cell source for tissue

engineering. The cells thereof, human amniotic epithelial cells (hAEC) and human

amniotic mesenchymal stromal cells (hAMSC), may be immunoprivileged, they

represent an early developmental status, and their application is ethically uncontro-

versial. Cell banking strategies may use freshly isolated cells or involve in vitro

expansion to increase cell numbers. Therefore, we have thoroughly characterized

the effect of in vitro cultivation on both phenotype and differentiation potential of

hAEC. Moreover, we present different strategies to improve expansion including

replacement of animal-derived supplements by human platelet products or the

introduction of the catalytic subunit of human telomerase to extend the in vitro

lifespan of amniotic cells. Characterization of the resulting cultures includes phe-

notype, growth characteristics, and differentiation potential, as well as immuno-

genic and immunomodulatory properties.

Keywords Adipogenesis, Expansion, hTERT, Human amniotic cells, Immor-

talization, Immunomodulation, Immunophenotype, Mesenchymal markers,

Osteogenesis, Platelet lysate, Stem cell markers, Telomerase

S. Wolbank, M. van Griensven (*)

Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Donaueschingenstraße

13, 1200 Vienna, Austria

Austrian Cluster for Tissue Regeneration, Vienna, Austria

e-mail: Martijn.van.Griensven@trauma.lbg.ac.at

A. Peterbauer-Scherb

Red Cross Blood Transfusion Service of Upper Austria, Krankenhausstrasse 7, 4020 Linz, Austria

R. Grillari-Voglauer

Department of Biotechnology, Institute of Applied Microbiology, University of Natural Resources

and Applied Life Sciences, Muthgasse 18, 1190 Vienna, Austria

Contents

1 Introduction . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

1.1 Stem Cell Characteristics of Amnion-Derived Cells .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

1.2 Expansion and Cryoconservation of Amnion-Derived Cell: Towards Cell Banking . . 4

2 Stem Cell Characteristics and Immunomodulatory Potential of Human

Amnion-Derived Stem Cells . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . 7

2.1 Isolation of Separate Populations of hAEC and hAMSC . . . . . . . . . . . . . . . . .. . . . . . . . . . . . 7

2.2 Stem Cell Characteristics and Immunomodulation of hAEC and hAMSC . . . . . . . . . . . 8

3 Phenotypic Shift and Reduced Osteogenesis During In Vitro Expansion

of Human Amnion Epithelial Cells . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . 10

3.1 Shift in Surface Antigen Expression During Cultivation of hAEC . . . . . . . . . . . . . . . . . 10

3.2 Osteogenic Differentiation Potential of hAEC Decreases

upon In Vitro Cultivation ..................................................... 12

4 Platelet Lysate for FCS-Free Expansion and Cryoconservation of Amnion-Derived Cells . .. 12

5 hTERT Induced Extension of In Vitro Life Span of Amnion-Derived Stem Cells . . . . . . . 14

6 Discussion . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . 19

6.1 Stem Cell Characteristics and Immunomodulatory Potential of Human

Amnion-Derived Stem Cells . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . 19

6.2 Phenotypic Shift and Reduced Osteogenesis During In Vitro Expansion of

Human Amnion Epithelial Cells .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . 20

6.3 Platelet Lysate for FCS-Free Expansion and Cryoconservation of

Amnion-Derived Cells ...... ................................................... 22

6.4 hTERT Induced Extension of In Vitro Life Span of Amnion-Derived Stem Cells . . . 22

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Abbreviations

7-AAD 7-Amino-actinomycin D

ALPL Alkaline phosphatase gene

AP Alkaline phosphatase

AR Alizarin red

ASC Adipose-derived stem cells

BGLAP Bone gamma-carboxyglutamate protein

BMPR1B Bone morphogenetic protein receptor 1B

BMPR2 Bone morphogenetic protein receptor 2

BMSC Bone marrow mesenchymal stem cells

BrdU 5-Bromo-2-deoxy uridine

CBFA1 Core binding factor alpha

DMSO Dimethylsulfoxide

EDTA Ethylenediaminetetraacetic acid

ELISA Enzyme-linked immunosorbent asssay

FCS Fetal calf serum

FOI Fold of induction

hAEC Human amniotic epithelial cells

hAMSC Human amniotic mesenchymal stromal cells

2 S. Wolbank et al.

HPRT Hypoxanthine-guanine phosphoribosyltransferase

hTERT Human telomerase reverse transcriptase

Lep Leptin

MLR Mixed lymphocyte reaction

MSC Mesenchymal stem cells

O-Kit Mesenchymal stem cell osteogenic stimulatory kit

OO Oil red O

PBMC Peripheral blood mononuclear cells

PBS Phosphate buffered saline

PCR Polymerase chain reaction

PD Population doubling

PDpT Population doubling post transduction

PHA Phytohemagglutinin

PL Platelet lysate

PPARgPeroxisome proliferator-activated receptor gamma

PRP Platelet-rich plasma

pT Post transduction

RT-PCR Reverse transcriptase polymerase chain reaction

SA-b-gal Senescence associated b-galactosidase

SC Stem cells

TA Telomerase activity

TGF-bTransforming growth factor beta

TRAP Telomeric repeat ampliﬁcation protocol

vK von Kossa

1 Introduction

Various cell sources have been proposed for regenerative medicine, each having

their advantages and drawbacks. Since mature cell types are rarely available in

sufﬁcient quality and amounts, research has focused on undifferentiated stem cells.

Embryonic stem cells are characterized by pluripotency and an unlimited self-

renewal capacity [1]. The major drawback of these cells is their high tumorigenic

potential. Additionally, their generation is associated with major ethical concerns.

In contrast, recovery of adult stem cells is not ethically restricted, tumorigenic

conversion was observed only in sparse cases [2], and autologous application is

possible. In 1999, Pittenger found that bone marrow not only contained hemato-

poietic stem cells but also mesenchymal stem cells (MSC) [3]. However, important

limitations of bone marrow mesenchymal stem cells (BMSC) are their limited

proliferation capacities, their low frequency, and donor site morbidity. Further-

more, decreased differentiation potential with donor age has been reported [4].

During recent years, human adult MSC from various sources including adipose

tissue, muscle, connective tissue, skin, placenta, blood, cord blood, synovium,

Alternative Sources of Adult Stem Cells: Human Amniotic Membrane 3

periosteum, and perichondrium have been established as promising tools in regen-

erative medicine [5–11]. The ﬁrst successful cell based therapies for diseases such

as myocardial infarction, multiple sclerosis, amyotrophic lateral sclerosis, graft-

versus-host-disease, osteogenesis imperfecta, and Crohn’s ﬁstula have been con-

ducted [12–17].

1.1 Stem Cell Characteristics of Amnion-Derived Cells

Placenta derived cells, in particular those from amniotic membrane, have been

described to combine qualities from both embryonic and adult stem cells, with a

differentiation capacity to derivatives of all three germ layers, and a lack of

tumorigenicity [18,19]. Amniotic membrane is the innermost of the fetal mem-

branes and consists of a single layer of epithelial cells residing on a basement

membrane, overlying a stromal layer. Human amniotic epithelial cells (hAEC) and

human amniotic mesenchymal stromal cells (hAMSC), respectively, can be released

separately from these two layers by differential enzymatic digestion [19–21]. Both

of these cell types have been described to express markers of mesenchymal

and embryonic stem cells [18,19,22–25]. What makes these cells especially

attractive is that large amounts can be isolated from an uncontroversial material

that is usually discarded after birth. Most importantly, immunosuppressive char-

acteristics of amniotic cells might render allogeneic application possible [19,24,

26]. Furthermore, their fetal origin may provide amniotic cells not only with stem

cell potential but also with an immunoprivileged status [27]. Human amnion is

widely used in surgery and wound treatment for burned skin, decubitus ulcers, and

in ophthalmology [28,29]. When transplanting amniotic membrane intracorneally

or under the kidney capsule, no rejection but only a mild cell-mediated reaction was

observed [27].

All these characteristics would make amniotic cells ideal candidates for tissue

engineering and their application in regenerative medicine. For this purpose, cells

can theoretically be used directly after isolation, or after in vitro cultivation, the

latter of which permits a gain in cell numbers, but important disadvantages are

increases in the risk of contamination with pathogens, accumulation of mutations,

and loss of differentiation potential and functionality.

1.2 Expansion and Cryoconservation of Amnion-Derived

Cell: Towards Cell Banking

To clarify the effect of in vitro culture on the quality of amnion-derived cells, a

thorough characterization comparing these cells before and after cultivation has

been performed.

4 S. Wolbank et al.

Applicability of these cells for allogeneic transplantation and stem cell based

therapies could further be boosted by standardized collection, quality control, and

careful selection of functional and safe cell banking products. However, in order to

provide sufﬁcient stem cell numbers for cell banking and cell based therapies, their

limited replicative potential has to be overcome. Regarding this aim, we followed

two strategies: (1) optimization of the expansion medium using human derived

growth supplements instead of fetal calf serum (FCS) and (2) introduction of the

catalytic subunit of human telomerase.

1.2.1 Effect of In Vitro Expansion on Amnion-Derived Stem Cells

As a consequence of the adaptation processes to the artiﬁcial cell culture environ-

ment and/or the possible enrichment of clones that have a growth advantage

in vitro, the phenotype of cells may change during cultivation. Such alterations

during in vitro cultivation have been described for BMSC [3] and in detail for

adipose-derived stem cells (ASC) [30–32].

We systematically analyzed the surface antigen expression proﬁle of hAEC

directly after isolation and in the course of in vitro cultivation, with a focus on

mesenchymal and embryonic stem cell markers and investigated possible func-

tional consequences of in vitro cultivation regarding their osteogenic and adipo-

genic differentiation potential.

1.2.2 Strategies to Circumvent Growth Limitation In Vitro: Use of Platelet

Lysate During Expansion and Cryopreservation

Culturing mammalian cells usually involves expansion in cell culture medium

supplemented with FCS. Furthermore, FCS is also a crucial component of cryo-

preservation media. While FCS is the golden standard to supplement research cell

culture media, its application for cell based therapies should be minimized as it

bares the risk for transmission of pathogens including prions, viruses and zoonoses

[33]. Immunological in vitro reactions to FCS after cultivation have already been

demonstrated [34,35]. In addition to the reported disadvantages of FCS there is a

predicted shortage in FCS in the next few years resulting in 50% increased purchase

prices [36].

Hence, well-screened human sources for growth factors would be favorable for

cell therapy. As such, platelets may offer a viable alternative to FCS. They contain

in their a-granules growth factors including platelet derived growth factor, basic

ﬁbroblast growth factor, insulin-like growth factor, and transforming growth factor

beta (TGF-b)[33] whereby TGF-b1 is the most abundant [37]. These growth

factors play important roles during wound healing by exerting above all mitogenic

activity.

Platelet derived products – such as platelet lysate (PL) or platelet-rich plasma

(PRP) – have already been proposed as culture supplement for several cell types

Alternative Sources of Adult Stem Cells: Human Amniotic Membrane 5

including BMSC [33,37–47], umbilical cord blood MSC [48], ASC [43,49], and

stromal cells from dental pulp and trabecular bone [43] showing increased clono-

genic efﬁciency and proliferative capacity compared to standard FCS culture. PL

also stimulates proliferation and collagen production of human tenocytes and

increases the gene expression of matrix-degrading enzymes and angiogenic growth

factors [50]. Furthermore, myelomas, hybridomas, hepatocytes, ﬁbroblasts, and

epithelial cells have already been evaluated using PL with regard to cell growth,

viability, and production efﬁciency [51]. Growth stimulation upon PL treatment

was also demonstrated for primary chondrocytes. However, PL failed to support a

chondrogenic phenotype [52–54] in contrast to BMSC cultures showing increased

chondrogenic marker genes in presence of PRP [55]. Primary human skeletal

muscle cells showed decreased differentiation capacity into myotubes and impaired

functionality [56]. Proliferation of primary human osteoblasts was not affected by

addition of PRP to the culture medium [57]. For human dermal and gingival

ﬁbroblasts, contradicting results were obtained for platelet derived products as

culture supplements ranging from growth suppression [58] to growth promotion

[59,60]. Using ASC, Davenport et al. showed that PL only initially supported cell

proliferation but led to growth arrest shortly after ﬁrst subcultivation [61]. In

contrast, addition of thrombin activated PRP to the culture medium increased

ASC proliferation and retained their differentiation capacity during long-term

culture [49].

Moreover, platelet derived products and BMSC have already been used clini-

cally both to treat distraction osteogenesis of the lower extremity in patients with

achondroplasia and hypochondroplasia yielding accelerated bone regeneration [62]

and also to treat successfully a patient with severe radiation burn [63].

However, the inﬂuence of platelet derived products for the cultivation of cells

isolated from amniotic membrane has not been addressed before.

1.2.3 Strategies to Circumvent Growth Limitation In Vitro:

Introduction of hTERT

Stem cells needed at therapeutic doses, especially in adults, may require extensive

in vitro expansion. In this regard, one major drawback of these cells is their low

proliferative capacity and limited in vitro life span before reaching an irreversible

growth arrest also termed replicative senescence [19]. Additionally, long-term

cultures of human MSC may show altered or reduced responsiveness to differenti-

ation signals [64].

One strategy to circumvent these limitations is the introduction of the catalytic

subunit of human telomerase reverse transcriptase (hTERT) which has been

reported to extend the cellular life span of numerous cell types including normal

ﬁbroblasts, endothelial or epithelial cells [65–67], in vitro propagated tumor cells

[68–70], and also of stem cells [71,72]. It has been shown that hTERT immorta-

lized human MSC originating from sources such as bone marrow and adipose tissue

maintain their differentiation potency [72–74]. We report in this section the

6 S. Wolbank et al.

establishment and the characterization of the ﬁrst hTERT immortalized hAMSC

lines including their immunomodulatory functions, a crucial factor for using these

cell lines in allogeneic cell therapies [75]. Therefore, if cell banking is intended, it is

important to monitor the cells’ ability to alloactivate peripheral blood mononuclear

cells (PBMC) as well as to modulate the proliferation of activated PBMC.

2 Stem Cell Characteristics and Immunomodulatory Potential

of Human Amnion-Derived Stem Cells

2.1 Isolation of Separate Populations of hAEC and hAMSC

Placentae were collected from Cesarean sections after obtaining informed consent

of the mothers according to the approval of the local ethical committee. Amnion

was peeled off the placenta, washed extensively with phosphate buffered saline

(PBS) at 4C, and dissected in 2–3 cm

pieces. Half of these were digested for

320 min with 0.05% trypsin/EDTA (PAA, Austria), the other half for 2 h with

1 mg/mL collagenase I (Biochrom, Austria) for isolation of hAEC and hAMSC,

respectively. Hematoxylin/eosin staining of parafﬁn embedded sections of amnion

demonstrates that digestion of amniotic membrane with trypsin and collagenase left

an essentially intact mesenchymal and epithelial layer (Fig. 1a).

After addition of ice-cold PBS, cell suspensions were ﬁltered through a 100-mm

cell strainer, centrifuged, and seeded in culture ﬂasks at a density of 7 10

cells/cm

for hAMSC and 14 10

–21 10

cells/cm

for hAEC in EGM-2

Fig. 1 Isolation of pure fractions of hAEC and hAMSC. (a) Hematoxylin and eosin stain of fresh

amnion (undigested) and after digestion with trypsin and collagenase, as performed for isolation of

hAEC and hAMSC, respectively. (b) Epithelial and mesenchymal morphology of hAEC and

hAMSC, respectively

Alternative Sources of Adult Stem Cells: Human Amniotic Membrane 7

(Lonza, Belgium). The resulting cultures are composed of pure populations with a

clearly distinguishable epithelial and mesenchymal morphology, respectively

(Fig. 1b).

2.2 Stem Cell Characteristics and Immunomodulation

of hAEC and hAMSC

Both amniotic cell populations are routinely characterized by a common surface

marker expression proﬁle including the presence of CD73, CD90, CD105, and

MHC I, and the concomitant absence or low levels of CD34, CD45, and MHC II,

analyzed by ﬂow cytometry. Purity of amniotic subpopulations could be determined

by CD49d (a4-integrin) expression which was 2 2.4% in the hAEC and

96 3.9% in the hAMSC population.

To evaluate the reproducibility of differentiation of hAEC and hAMSC,

osteogenic differentiation was induced 24 h after seeding by changing the medium

to Mesenchymal Stem Cell Osteogenic Stimulatory Kit (O-Kit, Stemcell Tech-

nologies, Canada) and maintaining these cultures for 21 days. Adipogenic dif-

ferentiation was performed according to Portmann-Lanz et al. [23]. Osteogenic

differentiation was demonstrated by spectrophotometric assessment of Alizarin red

(AR). Typically, osteogenic differentiation of both cell types, hAEC (at P1 or P2)

and hAMSC (at P2), was successfully induced in three of four cases. Adipogenic

differentiation was evident for two of four hAMSC isolations, while, in contrast to

published data [22,23], hAEC did not differentiate along the adipogenic lineage in

our hands (data not shown).

For investigating immunomodulation in vitro, amnion-derived cells were cocul-

tured with PBMC, isolated from whole blood as in mixed lymphocyte reactions

(MLRs). For this, 5 10

cells of two different allogeneic PBMC populations

were cocultured in 100 mL PBMC medium/well (RPMI1640, 9% FCS, 2 mM

L-glutamine, 100 U/mL penicillin G, and 0.1 mg/mL streptomycin) in triplicates

in 96-well ﬂat bottom plates. Amnion-derived cells were seeded in the wells and

allowed to adhere before adding PBMC. The stem cells (SC) were added at

SC/PBMC ratios of 1:1 (5 10

SC), 1:2, 1:4, 1:8, and 1:16. On day 5, 10 mM

5-bromo-2-deoxyuridine (BrdU) was added and BrdU ELISA (Roche) was per-

formed on day 6 according to the manufacturer’s instructions. Similarly, for

phytohemagglutinin (PHA) activation assay, 5 10

PBMC were activated by

5mg/mL PHA (Sigma) on day 3 of the culture. To examine interaction between

allogeneic SC and unstimulated PBMC, SC were cocultured with unstimulated

PBMC at 1:1 (5 10

SC), 1:2, 1:4, 1:8, and 1:16 ratios in 100 mL. On day 4,

10 mM BrdU was added. The inhibitory effect of SC was calculated as PBMC

proliferation (%) = (E

STIM+SC

E

STIM

)100. E

STIM+SC

= mean absorption of

stimulated PBMC cocultured with allogeneic SC; E

STIM

= mean absorption of

stimulated PBMC. Data were analyzed by one-way ANOVA and Tukey’s multiple

8 S. Wolbank et al.

comparison test. Data sets of cells at low vs high population doublings (PDs) were

compared by two-tailed Student’s t-test. A p-value less than 0.05 was considered as

signiﬁcant.

hAMSC and hAEC inhibited proliferation of activated PBMC in a dose-depen-

dent manner as demonstrated by a decrease in proliferation with increasing stem

cell amounts. SC were most effective when added in equal cell numbers compared

to PBMC, signiﬁcantly reducing PBMC proliferation in MLR experiments to a level

of 34% (range 3–73%) in the case of hAMSC (Fig. 2a) and 23% (range 0–72%) in

the case of hAEC (Fig. 2b). When PBMC were activated by PHA, similar inhibition

was reached, in detail 33% (range 12–66%) for hAMSC (Fig. 3a), and 28% (range

0–60%) for hAEC (Fig. 3b). The lowest SC dose resulting in signiﬁcant inhibition

of lymphocyte response was 25%, in single cases even 12.5%.

200

180

160

140

120

100

12.5 25

hAMSC added (%)

PBMC proliferation (%)

50 100

200

180

160

140

120

100

12.5 25

hAEC added (%)

PBMC proliferation (%)

50 100

Fig. 2 hAMSC and hAEC inhibit MLR-activated PBMC in a cell dose-dependent manner. PBMC

were cocultured with equal amounts of allogeneic PBMC and different amounts of third party (a)

hAMSC (n¼12), (b) hAEC (n¼9). Median Q1 and Q3 are depicted

200

180

160

140

120

100

12.5 25

hAMSC added (%)

PBMC proliferation (%)

50 100

200

180

160

140

120

100

12.5 25

hAEC added (%)

PBMC proliferation (%)

50 100

Fig. 3 hAMSC and hAEC inhibit PHA-activated lymphocyte proliferation in a cell dose-depen-

dent manner. PBMC were cocultured with (a) hAMSC (n¼12), (b) hAEC (n¼8). Median 

Q1 and Q3 are depicted

Alternative Sources of Adult Stem Cells: Human Amniotic Membrane 9

3 Phenotypic Shift and Reduced Osteogenesis During In Vitro

Expansion of Human Amnion Epithelial Cells

For tissue engineering purposes, cells may be applied either directly after isolation

from the tissue or after a period of in vitro expansion to obtain higher cell numbers.

In order to investigate the advantages and drawbacks of these strategies we com-

pared freshly isolated and cultivated hAEC regarding their surface antigen expres-

sion proﬁle and their osteogenic differentiation capacity.

3.1 Shift in Surface Antigen Expression During

Cultivation of hAEC

To investigate the impact of in vitro expansion on the immunophenotype of cells

with potential for regenerative medicine, we carefully characterized the surface

antigen proﬁle of hAEC directly after isolation and during cultivation by ﬂow

cytometry. We focused on hAEC, as recovery of primary hAMSC is usually too

low for thorough analysis. For this purpose, freshly isolated cells and cells during

culture were immunostained for CD14, CD34, CD45, CD13, CD29, CD44, CD49c,

CD49d, CD49e, CD54, CD73, CD90, CD166, Ki67 (BD, Austria), CD105 (Abcam)

and SSEA-4, TRA-1-60, TRA-1-81 (Chemicon), by 7-AAD (BD) for dead cells and

measured by ﬂow cytometry.

Surface antigens were clustered into four groups, according to their expression

patterns (representative histograms are depicted in Fig. 4a, summarized in Fig. 4b).

The ﬁrst group comprises CD49d (integrin a4; used to differentiate hAEC from

hAMSC) and the hematopoietic markers CD14, CD34, and CD45. These antigens

are hardly detectable on freshly isolated hAEC (preP0) and remain at similar levels

during passaging.

The surface antigens of the second group are uniformly expressed at high levels,

both in primary isolates (preP0) and after further cultivation. This group comprises

the stromal cell markers CD29 (integrin b1), CD49c (integrin a3), CD73 (ecto-50-

nucleotidase), and CD166 (ALCAM), and the embryonic stem cell marker SSEA-4.

Group 3 consists of the stromal cell associated markers CD13 (aminopeptidase

N), CD44 (HCAM), CD49e (integrin a5), CD54 (ICAM-1), CD90 (Thy-1), and

CD105 (endoglin), which are low (medium to undetectable) directly after isolation

(preP0) and are rapidly increased during in vitro cultivation.

Two additional embryonic stem cells markers, TRA-1-60 and TRA-1-81 (group

4), are characterized by medium expression in preP0 cells, which decreases upon

cultivation.

As in vivo, amniotic cells reside within a tissue that remains of approximately

the same size during the last weeks of pregnancy, these cells would probably be in a

quiescent state directly after isolation, but start dividing upon transfer into tissue

culture medium. Therefore, we tested the hypothesis that upregulation of group 3

antigens might be associated with re-entry of the cells into the cell cycle. Only

10 S. Wolbank et al.

2–6% of freshly isolated hAEC (preP0) were stained for the proliferation marker

Ki67, which is expressed in all phases of the cell cycle but not in G0. After a few

days in culture, Ki67 expression increased dramatically (Fig. 4a, b), concomitant

with the observed upregulation of group 3 antigens. However, expression of group 3

antigens is not dependent on proliferation of hAEC, as expression remained high

Fig. 4 Surface antigen expression of four freshly isolated (preP0) hAEC strains and during

cultivation at various passages (P0–P3) by ﬂow cytometry. (a) Antigens were grouped according

to their expression proﬁle during cultivation (see text) and representative histograms of one

member of each group are shown. Gray peaks represent unspeciﬁc isotype controls, solid lines

represent the speciﬁc antibodies. (b) Summary: shown are means and corresponding standard

deviations, calculated from the data of all antigens of each group of all four hAEC isolations

(hAEC 87, 88, 90, and 91) at the indicated passages

Alternative Sources of Adult Stem Cells: Human Amniotic Membrane 11

when proliferation slowed down after several passages in vitro, concomitant with a

drastic decrease in Ki67 staining (Fig. 4a, b).

3.2 Osteogenic Differentiation Potential of hAEC Decreases

upon In Vitro Cultivation

We addressed the question as to whether the observed shift in mesenchymal and

embryonic stem cell markers during cultivation of hAEC (Fig. 4) is associated with

alterations of their functional phenotype, i.e., their capacity to differentiate along

the adipogenic and osteogenic lineages. Therefore, adipogenic and osteogenic

conditions (as described in Sect. 2.1) were applied to different hAEC isolations

seeded directly after isolation (P0) and after cultivation (P2 or P3). In addition to

mineralization, quantitative real time PCR was performed analyzing expression of

RUNX2/CBFA1 (core binding factor alpha), alkaline phosphatase (ALPL), bone

gamma-carboxyglutamate protein (BGLAP, osteocalcin), bone morphogenetic pro-

tein receptor 1B (BMPR1B), and bone morphogenetic protein receptor 2 (BMPR2)

using a light cycler TM480 (Roche) and Taqman gene expression assays (Applied

Biosystems). Expression values were normalized to the housekeeping gene hypo-

xanthine-guanine phosphoribosyltransferase (HPRT).

Similar to passaged hAEC, no adipogenic differentiation was observed using

four strains of freshly isolated hAEC (data not shown). In contrast, the same strains

showed predominantly stronger mineralization ability at P0 (in three out of four

cases) when compared to passaged cells (P2–P3). Interestingly, preliminary results

with hAMSC suggest similar mineralization and lipid accumulation after induction

of P0 vs P2 cells (data not shown). We conﬁrmed mineralization by analysis of

mRNA levels of selected genes involved in osteogenesis. In freshly isolated hAEC

(P0) all osteogenic markers were upregulated upon cultivation in O-Kit for 14 and

21 days (Fig. 5). In cultivated hAEC (P1), RUNX2 and ALPL were also increased

under osteogenic conditions whereas virtually no alteration in transcription of

BGLAP, BMPR1B, and BMPR2 was observed.

4 Platelet Lysate for FCS-Free Expansion and

Cryoconservation of Amnion-Derived Cells

For producing PL, platelet concentrates from 36 healthy donors that could no longer

be used for patients were pooled, frozen at 80C, and thawed quickly in a water

bath at 37C, resulting in growth factor release from bursting platelets. Platelet

debris was removed by centrifugation at 2,000g for 10 min while the PL was

ﬁltered using a 0.22-mm ﬁlter, aliquoted, and stored until application at 80C.

For determining growth kinetics, cells were isolated from three donors as

described in Sect. 2.1, and 2.5 10

cells were seeded in T-25 ﬂasks and cultured

12 S. Wolbank et al.

for about 100 days in PL expansion medium (DMEM-LG & Ham’s F12, 5% PL,

2mML-glutamine, 100 U/mL Penicillin, 0.1 mg/mL Streptomycin (PAA), 2 U/mL

Heparin (Biochrom)) at 37C, 5% CO

, and 95% humidity. PD was calculated at

each subcultivation using the formula: SLN (cells harvested/cells seeded)/LN(2).

hAMSC from all three donors cultured in PL showed between 21 and 32 PD

without growth arrest whereas control hAMSC cultured in EGM-2 (Lonza), a

commercially available medium containing 2% FCS, showed only 5 PD before

proliferation totally ceased (Fig. 6a).

Not only during expansion but also during cryopreservation, substitution of FCS

would be favorable for establishing cell banks. In preliminary experiments, several

media containing PL (5%, 90% PL) were compared to standard FCS media (10%,

90% FCS) as well as a serum-free medium (CryoSFM, PromoCell) for cryopreser-

vation of hAMSC. Then 1 10

P1 cells were resuspended in the respective

medium and frozen at a freezing rate of 1C/min. From these preliminary data,

the best conditions, namely 5% PL medium (5% PL, 10% dimethylsulfoxide

(DMSO), 85% DMEM-LG), 90% FCS medium (90% FCS, 10% DMSO), and

CryoSFM were chosen for further investigation.

After thawing, cell viability was assessed by trypanblue exclusion assay. Addi-

tionally, growth kinetic studies were performed to evaluate characteristics of

hAMSC before and after cryopreservation. Cells cryopreserved in PL showed

RUNX2 ALPL BGLAP BMPR1B BMPR2

P 0

P 1

d14

fold expression compared to d0

d21 d14 d21 d14 d21 d14 d21 d14 d21

Fig. 5 Osteogenic differentiation of hAEC isolations seeded directly after isolation (P0) and after

cultivation (P1). Expression levels of selected genes implicated in osteogenesis, determined using

quantitative real-time PCR. Expression levels after cultivation in O-Kit for 14 and 21 days (d14

and d21) were normalized to the levels before induction (d0). Shown are means and standard

deviations of three measurements from two individual donors

Alternative Sources of Adult Stem Cells: Human Amniotic Membrane 13

lower cell viability after thawing when compared to those stored in FCS medium or

serum-free CryoSFM (Fig. 7). While growth kinetics after thawing seemed to be

unaffected by the cryopreservation medium applied, strong impact of the donors on

PD was evident (Fig. 6b–d). An observed phenomenon was the low attachment

capacity of hAMSC cryopreserved in 5% PL. Hence, coating experiments with

gelatine (1% in PBS) or “Coating matrix Kit” (Invitrogen) were performed but

attachment of cells to the culture vessel surface could not be substantially improved

(data not shown).

5 hTERT Induced Extension of In Vitro Life Span

of Amnion-Derived Stem Cells

For introduction of hTERT a retroviral transfection system was chosen. Therefore,

the cDNA of hTERT (kindly provided by Geron Corp.) was inserted into the

retroviral vector pLXSN (Clontech Laboratories Inc.) and retroviral particles

praecryo

donor 3 - after cryo

donor 1 - after cryo

donor 2 - after cryo

days in culture

PDs

PDs PDs

days in culture days in culture

days in culture

10 10

15 15

20 20

25 25

30 30

35 35

40 40

20 20

40 40

60 60

80 80

100 100

100

120

5% PL

donor 3 - EGM-2

donor 3 - PL

donor 2 - PL

donor 1 - PL

5% PL

5% PL praecryo 5% PL praecryo

5% PL praecryo

cryo-SFM cryo-SFM

cryo-SFM

90% FCS 90% FCS

90% FCS

Fig. 6 Growth characteristics of hAMSC from three donors before (a) and after cryopreservation

(b–d) cultivated in medium supplemented with either 5% PL or EGM-2 and cryopreserved in FCS,

PL containing media or serum-free Cryomedium (CryoSFM). PDs cumulative population

doublings

14 S. Wolbank et al.

were generated as described previously [70]. Gene transfer was performed at early

PD (<PD8) according to the manufacturer’s instructions (Clontech Laboratories

Inc.). Then 24 h post transduction transfectants were selected using 200 mg/mL

Geneticin Sulfate G418 and arising cell clones were grown as mass culture. PD of

transduced cell lines were calculated starting with the ﬁrst passage post transduc-

tion (PDpT) using the formula stated in Sect. 4. Telomerase activity (TA) was

determined using a modiﬁcation of the real-time telomeric repeat ampliﬁcation

protocol (TRAP) assay as described in detail previously [70] and calculated relative

to that of HEK293 cells (positive control). For determination of senescence,

associated b-galactosidase (SA-b-gal) activity cells were ﬁxed with 3% formalde-

hyde and stained as described in detail previously [76]. For characterizing pheno-

type, differentiation potential, and immunomodulatory properties, protocols

according to Sect. 2.2 were performed. For quantitative evaluation, AR was

measured after extraction using 20% methanol/10% acetic acid at 450 nm. For

quantiﬁcation of intracellular alkaline phosphatase (AP) activity, washed cells were

frozen and thereafter incubated in 0.5% Triton X-100. After incubation with

4-nitrophenolphosphate, samples were measured at 405/620 nm. In addition to

osteogenic marker genes peroxisome proliferator-activated receptor gamma

(PPARg) and leptin (Lep) were evaluated as adipogenic marker genes by quantita-

tive RT-PCR as described in Sect. 3.2.

Immortalized stem cell lines (originating from the mesenchymal layer of the two

amniotic membrane donors hAMSC76 and hAMSC83) were established by over-

expression of hTERT. Human stem cells were isolated from amnion and propagated

in vitro until they reached replicative senescence. Representative growth curves of

hAMSC76 are shown in Fig. 8a. Senescence was evidenced by growth arrest, large

and ﬂat cell morphology (Fig. 8b), and SA-b-gal activity (Fig. 8c). Upon ectopic

expression of hTERT stem cell populations were immortalized (so far expanded

to at least PD60 with no signs of growth retardation; Fig. 9a). Furthermore,

hTERT overexpression maintained many characteristics of the original cellular

phenotype. Figure 9b demonstrates ﬁbroblastoid morphology of transduced cells

(hAMSC76telo-PD78pT, hAMSC83telo-PD43pT) comparable to early passage

100

90%FCS

cryomedium

viability (%)

Cryo SFM

hAMSC1

hAMSC2

hAMSC3

5%PL

Fig. 7 Cell viability of

hAMSC from three donors

after cryopreservation in PL,

FCS containing media or

serum-free Cryomedium

(CryoSFM) and thawing as

determined by trypanblue

exclusion assay. Data are

presented in % of viability at

freezing

Alternative Sources of Adult Stem Cells: Human Amniotic Membrane 15

parental counterparts. Telomerase activity after transduction was veriﬁed by TRAP

assay (Fig. 9c). In contrast to empty vector control cells (hAMSCneo), hTERT-

transduced cell lines expressed signiﬁcant telomerase activity at early as well as

higher PDpT (at least PD38pT) when compared to HEK293 control cells (49–72%

of HEK293).

Expression of selected hematopoietic (CD14, CD34, and CD45 negative) and

mesenchymal markers (CD73, CD90, and CD105 positive) on hTERT-transduced

cell lines were similar to their parental cultures, also after prolonged in vitro

propagation (hAMSC76telo-PD84pT, hAMSC83telo-55pT; Table 1). Interest-

ingly, the major population of hTERT-transduced hAMSC lost expression of the

mesenchymal marker CD90. Therefore, hAMSC83telo were characterized in more

detail, i.e., at several PD and for additional antigens (Table 2). At early PD after

Fig. 8 Growth characteristics and morphology of hAMSC. (a) Cells were grown in vitro until

replicative senescence. Representative growth curve of hAMSC76 is shown. (b) Phase contrast

microscopy and (c) staining for SA-b-galactosidase activity of early and late passage cells.

Magniﬁcation in b, c: 100

Fig. 9 Growth potential and morphological characteristics of hTERT-transduced hAMSC. (a)

Growth curves of hTERT-transduced cell lines. (b) Phase contrast microscopy of hTERT-transduced

immortalized cell lines. (c) TRAP assays at two different PDs post transduction (PDpT) demonstrate

telomerase activity in cell lines. neo Vector control, telo hTERT-transduced; in b: 100

16 S. Wolbank et al.

transduction, hAMSC83telo were still homogenously positive for CD90; however

at PD55pT, only 8.7% of the cells expressed this marker. This subpopulation

remained detectable after a further 41 PDs (PD96pT). With the exception of

SSEA-4, the expression of which increased after hTERT transduction, all other

Table 1 Surface antigen expression of nontransduced (normal) and hTERT-transduced (telo)

hAMSC. hAMSC76 and hAMSC83 were analyzed at PD6 and 5, their hTERT-transduced

counterparts at population doubling 84 and 55 post transduction, respectively

Antigen hAMSC76 hAMSC83

Normal Telo Normal Telo

CD14 0.5 7.0 2.6 10.5

CD34 0.0 0.1 0.1 0.1

CD45 0.0 11.6 0.0 2.0

CD73 96.0 100.0 99.9 100.0

CD90 100.0 53.3 100.0 8.7

CD105 95.7 99.8 92.5 99.9

HLA ABC 98.9 99.8 99.4 99.7

HLA DR 0.5 2.6 0.2 2.3

Table 2 Detailed ﬂow cytometric characterization of hTERT-transduced

hAMSC83telo during prolonged in vitro cultivation, compared to the nontrans-

duced counterpart. Additional antibodies were purchased from BD (CD13,

CD29, CD44, CD49c CD49d CD49e, CD54, CD166), Chemicon (SSEA-4,

TRA-1-60, TRA-1-81 and Oct-4), Santa Cruz Biotechnology (Vimentin)

Antigen Normal Telo

PD3 PD26pT PD55pT PD96pT

CD13 100.0 100.0 99.7 99.8

CD14 5.1 2.1 10.5 6.4

CD29 99.9 n.d. 99.6 99.8

CD34 0.4 0.1 0.1 0.2

CD44 100.0 n.d. 99.4 99.9

CD45 2.7 0.1 2.0 4.8

CD49c 100.0 n.d. 99.8 99.8

CD49d 98.2 n.d. 99.7 99.9

CD49e 100.0 n.d. 99.7 99.9

CD54 72.0 n.d. 89.0 98.7

CD73 100.0 76.6 100.0 100.0

CD90 100.0 100.0 8.7 22.8

CD105 98.5 95.8 99.9 99.8

CD166 100.0 n.d. 99.8 99.8

HLA ABC 100.0 100.0 99.7 99.9

HLA DR 7.2 0.7 2.3 5.2

SSEA-4 26.6 81.7 99.6 85.6

TRA-1-60 6.4 n.d. 3.4 0.9

TRA-1-81 6.1 n.d. 6.4 0.5

Oct-4 62.1 n.d. 72.9 89.2

Vimentin 100.0 n.d. 100.0 n.d.

n.d. Not determined; PD population doubling; pT post transduction

Alternative Sources of Adult Stem Cells: Human Amniotic Membrane 17

antigens tested showed no alteration. Analysis of the cellular karyotype revealed

that hTERT transduction did not induce abnormalities in chromosomal number or

structure since both, nontransduced stem cells and the hTERT cell lines showed a

normal karyotype. Additionally, soft agar assays showed no indication for a tumor-

igenic conversion upon hTERT transduction (data not shown).

After introduction of hTERT, amnion-derived stem cell lines showed a similar

differentiation potential towards the adipogenic and osteogenic lineage when

compared to the nontransduced counterparts. hAMSC generally show a low differ-

entiation potential towards the adipogenic lineage as demonstrated by OO staining.

Although singular hAMSC76telo cells gained the capacity for lipid accumulation,

these rare events were not quantiﬁable (data not shown). On the level of adipogenic

marker genes, quantitative real-time PCR revealed low levels of PPARgexpression

and induction of leptin transcription in hAMSC (Fig. 10). When testing for osteo-

genic differentiation, signiﬁcant mineral deposition of all hAMSC lines was

observed, as analyzed by quantiﬁcation of AR staining (Fig. 11a). Also, a low

but signiﬁcant increase of AP activity (Fig. 11b) as well as induction of mRNA

levels of AP at very low levels was seen (Fig. 12a). Osteocalcin mRNA was

induced in all hAMSC during differentiation (Fig. 12b). In order to test immuno-

modulation of the hTERT immortalized stem cell lines, their suppressive effect

on MLR- or PHA-activated lymphocyte proliferation was analyzed (Fig. 13).

The tested cells inhibited MLR-activated PBMC proliferation in a cell dose-

dependent manner. hTERT-transduced hAMSC inhibited signiﬁcantly at a 1:8

SC/PBMC ratio (Fig. 13a), parental hAMSC even at 1:16. Similarly, when stem

cells were cocultured with PHA-activated PBMC, the inhibitory potency of

hAMSC was unaltered after hTERT overexpression, inhibiting signiﬁcantly at a

ratio of 1:8 (Fig. 13b).

1000

hAMSC76

hAMSC83

hAMSC83telo

hAMSC76telo

100

0.1

induction factor

PPAR

LEP

Fig. 10 Adipogenic differentiation potential of nontransduced and hTERT-transduced hAMSC

3 weeks after induction. Relative expression of peroxisome proliferator-activated receptor gamma

(PPARg) and leptin 2 weeks after adipogenic induction of nontransduced and hTERT-transduced

hAMSC. Expression levels are normalized to HPRT and presented relative to d0 cultures (set to 1).

Means and SDs of two individual experiments are displayed

18 S. Wolbank et al.

6 Discussion

6.1 Stem Cell Characteristics and Immunomodulatory Potential

of Human Amnion-Derived Stem Cells

Taken together, our data clearly show a cell dose dependency of the immuno-

modulatory effect of amnion-derived stem cells, which corroborates published results

for MSC from adipose tissue or bone marrow [77–81]. Furthermore, we demonstrate

cell dose-dependent immunosuppression for the two distinct amniotic stem cell types

which were characterized by differential expression of a4-integrin. Interestingly,

0.2 140

120

100

***

AR AP

0.16

0.12

0.08

OD 450nm

0.04

hAMSC76 hAMSC83 hAMSC83telo

hAMSC76telo hAMSC76

pNPP μM

hAMSC83 hAMSC83telo

hAMSC76telo

Fig. 11 Osteogenic differentiation potential of nontransduced and hTERT-transduced hAMSC

3 weeks after induction. Osteogenic differentiation demonstrated by Alizarin red (AR) quantiﬁca-

tion (a) and alkaline phosphatase (AP) (b) of hAMSC. Differences between control cultures (CM)

and osteogenic differentiation cultures (OM) with p<0.05 were regarded as signiﬁcant

0.20

0.15

0.10

normalized gene expression

0.05

0.00

hAMSC76 hAMSC83 hAMSC83telo

hAMSC76telo

5.0

4.0

3.0

normalized gene expression

2.0

0.0

1.0

hAMSC76 hAMSC83 hAMSC83telo

hAMSC76telo

*CM

Fig. 12 Expression levels of alkaline phosphatase (AP) (a) and osteocalcin (OC) (b) 2 weeks after

osteogenic induction of nontransduced and hTERT-transduced hAMSC. Expression levels in

osteogenic medium (OM) and control medium (CM) are presented normalized to HPRT. Means

and SDs of three individual experiments are displayed. Differences between control cultures (CM)

and osteogenic differentiation cultures (OM) with p<0.05 were regarded as signiﬁcant

Alternative Sources of Adult Stem Cells: Human Amniotic Membrane 19

although epithelial and mesenchymal fractions show distinct morphology and marker

expression, they have similar potency to modulate immunoreactions in vitro.

6.2 Phenotypic Shift and Reduced Osteogenesis During In Vitro

Expansion of Human Amnion Epithelial Cells

We show here that differentiation of amniotic cells strongly depends on the donor.

Hence, three of four hAEC and hAMSC strains at P2 clearly showed positive

differentiation. Adipogenic differentiation of hAMSC was less reproducible, with

two positive cases of four. Strikingly, none of the six hAEC strains tested during this

study showed evidence of adipogenic differentiation, which seems to be in contra-

diction to recent reports [8,22,23]. In ’t Anker et al. published adipogenic differen-

tiation of a stem cell population derived from mechanical disaggregation of the whole

amniotic membrane and selection by completely different culture conditions com-

pared to ours [8]. Portmann-Lanz et al. reported a transient growth retardation during

which morphology changed from typically epithelial, cobblestone-like to a ﬁbroblast-

like morphology [23]. In our study, hAEC isolations with noticeable change of

morphology towards the ﬁbroblast-like phenotype were excluded to allow separate

analysis of mesenchymal and epithelial cells. Discrepancies with published reports

may be due to the use of different cell populations with different differentiation

potential or the application of different culture conditions [8,22,23].

100

PBMC proliferation (%)

1:16 1:8 1:4 1:2 1:1

hAMSC

hAMSC telo

100

PBMC proliferation (%)

1:16 1:8 1:4 1:2 1:1

hAMSC

hAMSC telo

Fig. 13 Immunomodulation of nontransduced and hTERT-transduced hAMSC. (a) hAMSC (76

n=4,83n= 3) inhibit mixed lymphocyte reaction (MLR) in a cell dose-dependent manner. (b)

hAMSC (76 n=4,83n= 4) inhibit phytohemagglutinin-activated lymphocyte proliferation in a

cell dose-dependent manner. PBMC proliferation is calculated as percentage of uninhibited

proliferation. p<0.05 was regarded as signiﬁcant inhibition. Median Q1 and Q3 are depicted.

Asterisk indicates signiﬁcant inhibition of proliferation

20 S. Wolbank et al.

We further focused on a detailed characterization of the surface antigen expres-

sion proﬁle of freshly isolated amniotic cells and its alteration during in vitro

cultivation using hAEC. We demonstrate that hAEC undergo profound changes

during the ﬁrst days in culture, concomitant with, but not dependent on entry into

the cell cycle. Intriguingly, several markers associated with MSC, such as CD90

and CD105, are expressed at low levels or not at all on primary isolates and are

upregulated only after cultivation. This is of major importance considering possible

immunoisolation methods of noncultured cells for stem cell enrichment, which has

been established for CD105

bone marrow derived stem cells [8].

The observed alteration of the phenotype may be explained by several mechan-

isms. First, cells with the “altered” phenotype might be present in the primary

isolate as a minor population and overgrow the main population due to a growth

advantage in vitro; this explanation is highly implausible, as the change in surface

antigen expression occurs very rapidly and hAEC have low growth rates in vitro.

Second, the immunophenotype of the entire population might shift during cultiva-

tion or, third, only a subpopulation of the isolated cells might adapt to the culture

conditions by changing its phenotype and become enriched by passaging. Directly

after isolation, the population is heterogeneous with e.g., 20–50% being CD13-

positive and the remaining 50–80% CD13-negative cells. We estimate that about

two thirds of isolated hAEC become adherent during the ﬁrst 3 days in culture, after

which we usually remove the cells of the supernatant. Interestingly, preliminary

results suggest that these nonadherent cells differ from their adherent counterparts,

e.g., in reduced CD44 and increased CD54 expression (G. Stadler, unpublished

observation). However, adherence to plastic does not trigger the full spectrum of

alterations noticed after three passages, as expression of group 3 antigens is still

rather low at day 3 (d3), when cells have just adhered to the culture dish (in Fig. 1d,

CD105 and CD49e are shown as representative examples for group 3 antigen

expression). Thus, we hypothesize that, as a ﬁrst selection step, only part of the

primarily isolated heterogeneous cell population adheres to plastic, concomitant

with a partial upregulation of group 3 antigens that are further upregulated during

continued in vitro cultivation to result in a homogeneous population with high

expression of mesenchymal stem cell markers.

Finally, we have addressed the crucial question regarding the consequences of

the phenotypic shift during cultivation in terms of differentiation capacity, which

has to be answered before applying cultivated stem cells for tissue engineering. We

found that osteogenic differentiation was reduced after cultivation for two passages,

at a time point at which group 3 antigens were homogeneously and highly

expressed and embryonic TRA-antigens (group 4) were reduced to undetectable

levels. Functional impairment through cultivation has also been shown for primary

murine BMSC, which lost their homing ability in vitro [82].

In conclusion, our results suggest that freshly isolated hAEC have a superior

differentiation potential compared to hAEC cultivated under standard conditions

and therefore we are currently aiming to develop culture conditions allowing

maintenance of the original phenotype and differentiation capacity.

Alternative Sources of Adult Stem Cells: Human Amniotic Membrane 21

6.3 Platelet Lysate for FCS-Free Expansion and

Cryoconservation of Amnion-Derived Cells

PL is an interesting alternative to FCS during expansion and cryopreservation of

cells intended for application in humans. Expansion of hAMSC in a PL containing

medium is superior to a medium containing FCS. However, cryopreservation in

PL decreases cell viability after thawing. For future cell banking attempts, a

combination of expansion in PL medium and cryopreservation in serum free

cryomedium may allow for animal free strategy for expansion, cultivation and

banking of hAMSC. However, some pitfalls including low attachment capacity of

PL-expanded hAMSC have to be overcome.

6.4 hTERT Induced Extension of In Vitro Life Span

of Amnion-Derived Stem Cells

The applied strategy was successful in creating immortalized cell lines with largely

retained characteristics of the parental cells with regard to morphology, surface

marker proﬁle, and immunosuppressive capacity and showed similar or improved

differentiation potential. However, one of two hAMSCtelo lines resulted in a

signiﬁcantly higher immunogenicity compared to the nontransduced controls,

although the surface marker proﬁle currently regarded as most important for

human MSC characterization did not differ from the parental cells. This suggests

that yet unknown markers will have to be identiﬁed in order to predict immunoge-

nicity of the cells. In summary, the novel cell lines give proof of principle that

hTERT is a promising tool to generate sufﬁcient material for stem cell banking and

tissue engineering, but concomitantly emphasize the need for careful and standar-

dized characterization.

Stem cell characteristics of the newly established cell lines, especially their

differentiation and immunogenicity, were variable. Concerning typical surface

marker proﬁles, hAMSC lost the mesenchymal marker CD90 in a subpopulation

of telomerized cells during prolonged in vitro propagation. It has recently been

published that, upon cultivation in EGM-2 (also used in our study for hAMSC), a

subpopulation of CD90 negative human BMSC evolved after prolonged culture,

probably due to angiogenic growth factors in the medium [83]. The decrease in

CD90 expression and concomitant increase of the embryonic stem cell marker

SSEA-4 found in our immortalized hAMSC lines suggests an alteration of the

phenotype during long-term culture in EGM-2.

Both parental hAMSC isolates possessed low adipogenic differentiation poten-

tial which has been described before [68,69]. However, hTERT transduction led to

increased lipid accumulation of hAMSC76 under adipogenic conditions. This is in

contrast to the ﬁnding that mesenchymal stromal cells from chorion cotransduced

22 S. Wolbank et al.

with hTERT and Bmi-1 showed minimal adipogenic differentiation that even

decreased with time in culture [84].

We observed immunosuppression of activated PBMC by our immortalized cell

lines, the exception being hAMSC76telo. Since the cell surface marker proﬁles of

hAMSCtelo lines analyzed here were identical, we propose that a marker as

predictor for immunogenicity remains to be identiﬁed and included in routine

surface marker proﬁling.

In conclusion, the immortalized stem cell lines established in this study can be

seen as a ﬁrst step to a proof of principle for their applicability in cell based therapy

approaches. Since obvious donor and cell line speciﬁc differences exist, stem cell

material for cell banks will have to be routinely tested. Speciﬁcally, their differen-

tiation potential and immunosuppressive effects are of major importance. However,

additional caveats that limit the use are controversially discussed in the literature. In

particular, the tumorigenic potential of stem cells in general and hTERT-transduced

cells speciﬁcally is a matter of debate. Most reports ﬁnd that stem cells retain their

differentiation potential, contact inhibition properties, stable karyotype, and do not

show tumorigenic potential even after extensive in vitro expansion. In other studies,

spontaneous transformation of human ASC after 4–5 months in culture and a high

rate of tumorigenicity evolving as a consequence of hTERT introduction in human

MSC after approximately 3 years in culture were reported [2,85]. Hence, it can be

expected that given a high quality of starting material concerning stem cell char-

acteristics and genetic stability and by use of a reasonable culture time in vitro

suitable stem cell material can be made available for cell banking by careful

monitoring and characterization.

Acknowledgments This work was partially supported by the European STREP Project HIPPO-

CRATES (NMP3-CT-2003-505758), the Austrian Science Fund (FWF) project NRN-S093-06, the

“Herzfeldersche Familienstiftung”, and the Lorenz Boehler Fonds. Parts of this work were carried

out under the scope of the European NoE “EXPERTISSUES” (NMP3-CT-2004-500283).

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Alternative Sources of Adult Stem Cells: Human Amniotic Membrane 27

Adv Biochem Engin/Biotechnol (2010) 123: 29–54

DOI: 10.1007/10_2009_15

#Springer-Verlag Berlin Heidelberg 2009

Published online: 12 December 2009

Mesenchymal Stromal Cells Derived from

Human Umbilical Cord Tissues: Primitive

Cells with Potential for Clinical and Tissue

Engineering Applications

Pierre Moretti*, Tim Hatlapatka*, Dana Marten, Antonina Lavrentieva,

Ingrida Majore, Ralf Hass, and Cornelia Kasper

Abstract Mesenchymal stem or stromal cells (MSCs) have a high potential for

cell-based therapies as well as for tissue engineering applications. Since Friedenstein

ﬁrst isolated stem or precursor cells from the human bone marrow (BM) stroma that

were capable of osteogenesis, BM is currently the most common source for MSCs.

However, BM presents several disadvantages, namely low frequency of MSCs,

high donor-dependent variations in quality, and painful invasive intervention. Thus,

tremendous research efforts have been observed during recent years to ﬁnd alterna-

tive sources for MSCs.

In this context, the human umbilical cord (UC) has gained more and more

attention. Since the UC is discarded after birth, the cells are easily accessible

without ethical concerns. This postnatal organ was found to be rich in primitive

stromal cells showing typical characteristics of bone-marrow MSCs (BMSCs), e.g.,

they grow as plastic-adherent cells with a ﬁbroblastic morphology, express a set of

typical surface markers, and can be directly differentiated at least along mesoder-

mal lineages. Compared to BM, the UC tissue bears a higher frequency of stromal

cells with a higher in vitro expansion potential. Furthermore, immune-privileged

and immune-modulatory properties are reported for UC-derived cells, which open

highly interesting perspectives for clinical applications.

P. Moretti, T. Hatlapatka, D. Marten, A. Lavrentieva, I. Majore, and C. Kasper (*)

Institut fu

¨r Technische Chemie, Leibniz Universita

¨t Hannover, Callinstraße, 5, 30167, Hannover,

Germany

e-mail: Moretti@iftc.uni-hannover.de, Hatlapatka@iftc.uni-hannover.de, Marten@iftc.uni-hannover.

de, Lavrentieva@iftc.uni-hannover.de, Majore@iftc.uni-hannover.de, Kasper@iftc.uni-hannover.de

R. Hass

AG Biochemie und Tumorbiologie, Klinik fu

¨r Frauenheilkunde und Geburtshilfe, Medizinische

Hochschule Hannover, Carl-Neuberg-Str.1, 30625, Hannover, Germany

e‐mail: hass.ralf@mh‐hannover.de

*Equal Contributors

Keywords Counterﬂow centrifugal elutriation, Mesenchymal stem cell, Mesen-

chymal stromal cell, MSC, Umbilical cord

Contents

1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

2 The Human Umbilical Cord: A Source of MSCs . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . 31

3 Isolation of MSCs from the Umbilical Cord. . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . 33

4 Characterization of UC-Derived MSCs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . 35

5 In Vitro Differentiation Potential . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

6 Immune Properties of MSCs and In Vivo Applications . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . 44

7 Future Perspectives . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 46

References .......................................................................................48

Abbreviations

ALP Alkaline phosphatase

b-FGF Basic ﬁbroblast growth factor

BM Bone marrow

BrdU 5-Bromo-2-deoxyuridine

CCE Counterﬂow centrifugal elutriation

CD Cluster of differentiation

CFSE Carboxyﬂuorescein diacetate succinimidyl ester

CFU-F Colony forming unit-ﬁbroblast

DAPI 40,6-Diamidino-2-phenylindole

ESC Embryonic stem cell

GMP Good manufacturing practice

GvHD Graft-versus-host disease

HA Hyaluronic acid

HLA Human leukozyte antigen

HUCPVC Human umbilical cord perivascular cells

ISCT International Society for Cellular Therapy

MLC Mixed lymphocyte culture

MSC Mesenchymal stromal cell

MTT 3-(4,5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide

PBL Peripheral blood lymphocytes

PBMC Peripheral blood mononuclear cell

PBS Phosphate buffered saline

UC Umbilical cord

UCB Umbilical cord blood

UCMS Umbilical cord matrix cells

VEGF Vascular endothelial growth factor

WJ Wharton’s jelly

WJC Wharton’s jelly cell

30 P. Moretti et al.

1 Introduction

The engineering of stem cells to restore defect functions in human tissues is an

exciting challenge in the ﬁeld of regenerative medicine. Embryonic stem cells

(ESC) have a great potential for this purpose due to their pluripotent differentiation

capability, but their use is limited by serious ethical considerations. Recent ﬁndings

evidencing the reprogramming of somatic cells to pluripotent stem cells (termed

IPS cells) [1] open ethically acceptable perspectives. However the concern remains

that undifferentiated IPS cells as well as ESC may form teratomas after transplan-

tation in the body.

Adult mesenchymal stem or stromal cells (MSCs) are considered a valuable

alternative to these cells. Since their discovery in bone marrow (BM) by Frieden-

stein et al. [2], BMSCs have been extensively investigated and their use in animal

studies as well as in clinical trials showed encouraging results (reviewed in [3]).

Today BM-MSCs are still considered as the “gold standard” for the use of adult

MSCs. Nevertheless BM as a source for MSCs presents several disadvantages.

Besides the invasive and painful collecting procedure, in BM-aspirates MSCs are

present at very low frequency (approximately 0.001–0.01% [4]) and their quality

varies with the age of the donor. The low frequency implies that an extensive

in vitro expansion of the cells will be required to deliver clinical doses to a patient,

which enhances the risk of epigenetic damages as well as viral and bacterial

contaminations. For these reasons, alternative sources of MSCs are needed.

In this context, the human umbilical cord (UC) gained more and more attention

during the last decade (see Fig. 1). The UC is a non-controversial and accessible

source of autologous cells, which can be easily processed after birth. It has been

demonstrated that MSCs are found both in the blood (UCB) [5] and in the tissues of

UC. However, UCB-derived MSCs may have a limited technological potential

because their frequency seems even lower than in BM (range 0.001–0.000001%

[6]) and their isolation is hardly reproducible [7,8], whereby UCB contains larger

amounts of other tissue stem cell populations including CD133

cells or hemato-

poietic stem cells (CD34

). In contrast, the frequency of MSCs in UC-tissues is

believed to be much higher. Thus, using robust isolation procedures, a large number

of multipotent primitive stromal cells with high proliferation capacity can be

isolated. All these features open interesting perspectives for the scalable production

and engineering of UC-derived cells for clinical applications. Here, we give an

overview of the scientiﬁc evidences collected during the recent years that human

UC may be a valuable cell source for cell-based therapies.

2 The Human Umbilical Cord: A Source of MSCs

The human UC is the lifeline between the fetus and the placenta. It is formed

during the ﬁfth week of embryogenesis and grows to a ﬁnal length of approximately

60–65 cm, weighs about 40 g, and has a mean diameter of 1.5 cm in normal

Mesenchymal Stromal Cells Derived from Human Umbilical Cord Tissues 31

pregnancies [9,10]. UC usually comprises two arteries and a vein, which are

immersed within the so-called Wharton’s jelly (WJ) and enclosed by a simple

amniotic epithelium (see Fig. 2a). WJ is a mucoid connective tissue rich in

proteoglycans and hyaluronic acid (HA), which insulates and protects umbilical

vessels from torsion, compression, or bending and therefore ensures a constant

blood ﬂow between fetus and placenta.

Fig. 2 Cross section of an umbilical cord. (a) UC consists of two arteries and one vein embedded

in the Wharton’s jelly and surrounded by an amniotic epithelium (modiﬁed from [95]). (b) Four

separate compartments within the umbilical cord have been shown to comprise mesenchymal

stromal cells

350

300

Cumulative number of publications

250

200

150

100

222223 4612

128

191

293

349

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Fig. 1 Cumulative number of publications over the last 15 years dealing with UC-derived MSCs

(entries by PubMed with the terms “mesenchymal stem cells” and “umbilical cord” till July

2009)

32 P. Moretti et al.

In recent years, several studies described at least four separate regions (see

Fig. 2b) of the UC containing MSCs. The term “MSC” has been related to several

deﬁnitions. In this chapter we use “MSC” as an acronym for mesenchymal stromal

cell (discussed in Sect. 4). MSCs could successfully be isolated from UCB [7,11–15],

the umbilical vein subendothelium [16–18], the intervascular region [19–29], the

perivascular region [30,31], or from whole UC tissue [32,33]. UC-derived MSCs

meet the basic deﬁnition of multipotent MSCs as postulated by the International

Society for Cellular Therapy (ISCT) (see Sect. 4).

Thus, this chapter will focus on MSCs derived from UC tissue, but not from

UCB (see Fig. 2b, region 2–4).

3 Isolation of MSCs from the Umbilical Cord

In recent years, several investigators published protocols for isolating MSCs from

the UC tissue. Depending on from which part of the cord the cells should be

isolated, protocols have been adopted and modiﬁed. A schematic overview of

applied isolation protocols is given in Fig. 3. Basically, the isolation procedure

starts with the removal of umbilical vessels. The cord is then cut down to smaller

segments or chopped into small pieces which are subsequently enzymatically

digested [22,23,29]. Alternative isolation methods without removal of vessels

[34,35] and without enzymatic digestions [26,34] or explant cultures [33,36] have

also been described. To isolate cells from the perivascular tissue or the subendothe-

lium of the umbilical vein, further methods have been established [16–18,30,31].

We have used a protocol without enzymatic digestion and without removal of

umbilical vessels to isolate MSC-like cells from whole UC tissue in an explant

culture approach. Therefore, human UCs were obtained from patients with written

consent delivering full-term (38–40 weeks) infants by cesarean section. The use of

this material has been approved by the Institutional Review Board, project #3037 in

an extended permission on June 17, 2006.

First, blood from arteries and the vein was removed by ﬂushing phosphate

buffered saline (PBS) through the vessels using a sterile syringe and blunt needles.

Thereafter,UCwasstoredinanappropriate transfer medium (PBS) enriched with

5g L

1

glucose, 50 mgmL

1

gentamicin, 2.5 mgmL

1

amphotericin B, 100 U.mL

1

penicillin, and 100 mgmL

1

streptomycin), to minimize the risk of contaminations.

The UC was ﬁrst cut into 10–15 cm long segments which were subsequently cut into

approximately 0.5 cm

large pieces. During the isolation procedure, transfer medium

was used to keep the cord and the minced piecesmoist.Finally,thesmallpieceswere

transferred to cell culture ﬂaks (Fig. 4a) and incubated in aMEM supplemented with

15% of allogous human serum and 50 mgm

1

gentamicin at 37C in a humidiﬁed

atmosphere with 5% CO

. The medium was changed every second day. An outgrowth

of adherent cells from single tissue pieces could be observed after approximately

10 days (Fig. 4b). After 2 weeks the UC tissue was removed and the adherent cells

(Fig. 4c) were harvested by enzymatic treatment. The obtained cell suspension was

Mesenchymal Stromal Cells Derived from Human Umbilical Cord Tissues 33

centrifuged at 200 g for 5 min and the cells were resuspended in aMEM supplemented

with 10% human serum and 50 mgmL

1

gentamicin and subcultured at a density of

4000 cells cm

2

. These culture conditions have demonstrated to support an optimal

growth of the cells.

The isolated cells exhibited a high proliferation potential. Cell population

doubling times ranged from 27.5 1.6 h (passage 2) to 78.9 6.3 h (passage 17).

Fig. 4 Isolation of mesenchymal stem cell-like cells from umbilical cord. (a) Explant culture of

minced UC tissue. (b) After approximately 10 days of culture cells start to grow out of the small

UC segments. (c) Adherent growing monolayer of ﬁbroblast-shaped cells after 2 weeks of culture

Fig. 3 Schematic overview of applied isolation protocols. Various approaches have been used to

isolate mesenchymal stromal cells from the umbilical cord tissue. Basically, the isolation proce-

dure includes steps of removing umbilical vessels, tissue chopping and enzymatic digestion

(indicated by bold arrows), but several alterations of protocols have been described

34 P. Moretti et al.

At our culture conditions, the cells could be expanded without loss of proliferative

activity and viability at least for 20 population doublings. After approximately 50

population doublings the cells entered a phase of replicative senescence. High

proliferation potential and expansion capacity are common features for UC-derived

stromal cells, which were described by several other groups [20,26,29,30,34,35,

37,38]. Furthermore, UC-derived cells could be efﬁciently cryopreserved and

revitalized. We used a cryo-medium containing 80% human serum, 10% culture

medium, and 10 % DMSO. The cells were gradually frozen at a rate of 1C min

1

and ﬁnally stored at 196C. At these conditions cell survival rate after rapid

thawing at 37C reached 75 12.8%.

To date, it still remains to be further investigated whether cells isolated from

different compartments or derived by different isolation procedures share the same

stem cell characteristics, e.g., proliferation and differentiation potential and immu-

nologic properties (see below).

4 Characterization of UC-Derived MSCs

The acronym “MSC” has been widely used in the literature for “mesenchymal

stromal cell” as well as for “mesenchymal stem cell” to denominate plastic-adherent

ﬁbroblast-like cultures isolated from different adult or extra-embryonic tissues.

Because there is currently no consensus set of markers allowing the identiﬁcation

of MSCs and considering the fact the deﬁnition criteria for stem cell is not

unanimously accepted [39], it appeared unwise to apply the term “stem cell” for

mesenchymal cell population. In this context, ISCT proposed to term plastic-

adherent ﬁbroblast cultures “multipotent mesenchymal stromal cells” (MSC) [40]

and published in 2006 the minimal criteria deﬁning these cells [41].

UC-derived stromal cells meet the basic criteria deﬁned by the ISCT, namely the

adherence to plastic, the expression of a set of speciﬁc surface antigens (see below),

and a multipotent differentiation potential (discussed in paragraph 5 Differentiation

Potential).

Histologically, cells freshly isolated from the UC are mainly ﬁbroblastic in

appearance (see Fig. 5a). However, some groups reported more than one phenotype

in UC-derived MSC cultures [23,29,31,36] and noticed changes in the distribution

of the phenotype after several passages [23,36]. Our group observed for instance a

broad cell size distribution and marked morphological differences in isolated UC-

MSCs cultures (see Fig. 5b). After fractionation of different populations via coun-

terﬂow centrifugal elutriation (CCE) according to the size of the cells, we obtained

two sub-populations with signiﬁcant differences in cell size, growth properties, and

biochemical markers expression. Whereas small-sized subpopulation exhibited the

highest proliferative capacity and the most pronounced expression of MSC mar-

kers, large-sized cells were identiﬁed as senescent via b-galactosidase staining (see

Fig. 6)[36]. These ﬁndings may be of importance in order to deliver high quality

cells for clinical applications.

Mesenchymal Stromal Cells Derived from Human Umbilical Cord Tissues 35

Fig. 5 Morphology of UC-derived stroma cells. (a) UC MSC show predominantly ﬁbroblastic

morphology. The cytoplasm of cells was visualized via Calcein-AM stain (100magniﬁcation).

(b) Cells with marked morphological differences can be rather observed in the cultures collected

from UC. The image presents large cells (a, white arrows) surrounded by small cells (b, black

arrows), which show increased nucleus-to-cytoplasm ratio. For the visualization of cell nuclei

DAPI staining was performed (200magniﬁcation)

100

∗

∗p< 0,01

∗∗p< 0,001

∗∗

UC-derived

prinary cells

Subpopulation of

small-sized cells

Subpo pulation of

large-sized cells

Persentage of senescent cells (%)

Fig. 6 Senescence staining in sub-population of UC-derived primary cell cultures [36]. (a) UC-

derived primary cell population. (b) CCE-derived subpopulation of small-sized cells. (c) CCE-

derived subpopulation of large-sized cells. (d) Comparison of the senescence level in the

CCE-derived fractions. Cells were cultured for 6 days after elutriation. Following subculture, the

cells were seeded at a density of 6000 cells cm

2

and cultured for further 48 h in complete medium.

A relative high portion of multi-nucleated cells (arrows) were detectable in the subpopulation of

the large-sized cells. Student’s t-tests were performed for the recognition of the signiﬁcant

differences (marked with asterisks) in comparison to UC-derived primary cell population

36 P. Moretti et al.

An additional feature of MSCs is their clonogenicity. A single cell is able to rise

to a ﬁbroblastic colony in a so-called colony forming unit ﬁbroblast (CFU-F) assay.

Historically, this characterization parameter is linked to the pioneer work of

Friedenstein et al., who ﬁrst isolated stromal cells from BM according to their

capability to form ﬁbroblastic colonies and demonstrated their osteogenic potential

in vitro [2]. The CFU-F assay gives the frequency of ﬁbroblast-like cells within a

population liable to extensive proliferation and to rise to a colony (see Fig. 7).

This approach is commonly used to enumerate MSCs in a particular tissue [4].

For instance, Lu et al. recently evaluated the frequency at 1 CFU-F per 1609

mononuclear cells (MNCs) in whole UC tissues [35]. More speciﬁcally, 1 CFU-F

per 333 MNCs was reported in cells isolated from perivascular tissues of the UC

vein [31]. In comparison, the isolation frequency of CFU-F from BM is estimated in

a range of 1–10 CFU-F per 10

MNCs [4] and only 1 CFU-F per 10

MNCs [7]to

1–3 CFU-F per 10

MNCs are reported in UCB [42,43]. According to these data,

the human UC is considered to harbor a higher number of MSCs than found in BM

or UCB. The results of the CFU-F assay, however, depend on different parameter

such as the isolation method, culture conditions, as well as the cell seeding density.

This leads to a high degree of variability in the results and makes the comparison of

the published data difﬁcult. Analysis of speciﬁc molecule expression at the single

cell level via ﬂow cytometry is strongly advisable to identify MSCs within a mixed

cell population.

In contrast to other progenitor cell populations, such as, for instance, hemato-

poeitic stem cells, there is currently no speciﬁc marker available deﬁning human

MSCs. The expression of a set of markers combined with the demonstration of

in vitro multi-lineage differentiation potential is necessary to identify MSCs in UC-

derived cell populations. Table 1summarizes extracellular and intracellular mole-

cules expressed by UC-MSCs reported in the literature up to July 2009.

Fig. 7 CFU-F assay of UC-derived stromal cells

Mesenchymal Stromal Cells Derived from Human Umbilical Cord Tissues 37

Table 1 Reported intra- and extra-cellular markers of UC-derived MSCs till July 2009

Marker Expression References

CD10 + [24,29]

CD13 + [24,29,35,54,96–101]

CD14 [23,24,29,35,97,102,103]

CD29 (integrin b1) + [28,29,35,54,55,66,100,102–106]

CD31 (PECAM) [29,30,35,54,66,100,105]

CD33 [29,60]

CD34 [20,23,24,28–31,35,36,54,55,60,66,97,

98,100–103,105,106]

CD38 [20,100,106]

CD44 + [23,24,28,29,31,35,36,54,60,66,98,100,

101,103,105,106]

CD45 [20,23,24,28–31,35,36,54,60,66,98,100,

101,103,105]

CD49b (integrin a2) + [29,98]

CD49c (integrin a4) + [29]

CD49d (integrin a3) + [29]

CD49e + [29,30]

CD51 (integrin a5) + [21,28,29]

CD54 (ICAM-1) /+

[20,98,105]

CD56 [29]

CD71 /+ [103,106]

CD73 (SH3) + [21,23,24,28,31,35,36,45,55,66,101–105]

CD90 (Thy-1) + [20,24,29–31,35,36,45,54,55,60,66,98,

101,103,104]

CD105 (endoglin, SH2) + [20,21,23,24,28,29,31,35,36,45,60,66,

97,98,100,102,105]

CD106 (VCAM-1) /+

[31,35,54,56,98,107]

CD117 (c-kit) /+

[24,26,30,31,45,54,60,98,103,104]

CD123 (IL-3 receptor) [31]

CD133 [29]

CD146 + [30,56,108]

CD166 (ALCAM) + [35,45,101,102,104,105,109]

CD235a (glycophorin A) [31]

CD271 ND

Bmi-1 + [89,106]

Esrrb [89]

GD2 + [47]

HLA-1 + [20,29,48,106]

HLA-DR (MHC class II) [24,29,31,33,35,54,55,66,98,100,101,

104,106,107]

HLA-DP (MHC class II) [24,31,100,103]

HLA-DQ (MHC class II) [24,31,103]

HLA-A, B, C (MHC class I) + [24,31,35,54,98,101–104]

HLA-G (MHC class I) /+

[31,34,82]

Hoxb-4 [89]

MSCA-1 n.d.

Nanog + [29,45,47,48,89,110]

Nucleostemin + [89,106,110]

Oct-3/4 /+

[34,45,47,48,89,110,111]

Rex-1 + [45]

Sox-2 + [29,45,47,110]

(continued)

38 P. Moretti et al.

The surface antigen SH2 (CD105), SH3 (CD73), and Thy-1 (CD90) are widely

used for the identiﬁcation of UC-derived stromal cells (see Table 1), as these

markers are proposed by the ISCT as positive markers for human MSCs [41].

However, these epitopes are also expressed on hematopoietic and endothelial

cells, which are two potential contaminants in UC-derived cell populations. Conse-

quently, it is necessary to carefully exclude cells from hematopoietic or endothelial

origin using surface marker such as CD45, CD34, or CD31. HA receptor CD44 is

also a commonly accepted marker, as the extracellular matrix of the UC is one of

the highest HA-containing tissue in humans [44]. Figure 8exemplarily illustrates

the immunophenotype of a stromal cell population isolated from whole UC tissue

by our group. Additionally, like MSCs isolated from other tissues, UC-derived

stroma cells do not express the human leukocyte antigen HLA-DR but express

HLA-I. However, Sarugaser et al. reported that the expression of the latter marker

may be manipulated in vitro, which may be very promising in term of allogenic

transplantations [31].

Table 1 (continued)

Marker Expression References

SSEA-3 /+

[45,89]

SSEA-4 /+

[31,45,47,66,89]

STRO-1 /+

[30,31,48]

Tbx-3 [89]

TCL-1 [89]

Tra-1-60 /+

[45,89]

Tra-1-81 /+

[45,89]

ZFX + [89]

Zic-3 [89]

Discrepancy among the published results

Fig. 8 Flow cytometric analysis of UC-derived stroma cells

Mesenchymal Stromal Cells Derived from Human Umbilical Cord Tissues 39

UC-derived stroma cells were found positive for pluripotency markers usually

expressed by ESCs such as Oct-3/4, Nanog, Sox-2, or SSEA-4 (see Table 1), which

underlines their primitive nature. The primitive character of the UC-derived cells is

also illustrated by their high proliferation and expansion capacity. UC-derived

stroma cells have shorter doubling times compared to adult BM-MSCs [30,35,

37,38], exhibit telomerase activity [23,26,45], and could be expanded in vitro to a

number of population doublings ranging from 20 to 80 without evidences of

senescence or abnormal karyotype [20,26,29,34]. It was ﬁrst unclear whether

UC-derived stroma cells were homogenous regarding their primitiveness or if UC-

derived stroma populations rather harbor a subset of primitive MSCs [46]. For

instance, population doubling times estimated between 60 and 85 h for freshly

isolated UC-cells rapidly decrease within 2–3 passages to approximately 25 h [23,

31], which may indicate the presence of a fast growing sub-population of more

primitive cells overgrowing the initial population. This hypothesis was further

strengthened by recent works demonstrating via ﬂow cytometry a subset of cells

expressing pluripotency markers [47,48]. Zhang et al., for instance, reported that

approximately 20% of stroma cells isolated from perivascular tissues of the umbili-

cal arteria express Oct-3/4 and Nanog [48].

With growing evidence that MSC-like cell population isolated from UC tissues

are rather heterogeneous, at least in regard to primitive marker expression, the

identiﬁcation of a universal marker deﬁning primitive human MSCs remains

challenging. Several cell surface molecules were recently proposed for the identiﬁ-

cation and isolation of MSCs in BM aspirates such as CD271 [49,50], MSCA-1

[50], SSEA-4 [51], and the neural ganglioside GD2 [52,53]. To our knowledge,

CD271 and MSCA-1 expressions have not been reported yet in UC-derived stroma

cell populations. Xu et al. recently isolated a subset of GD2

cells exhibiting a high

clonogenicity as well as proliferation capacity but also a signiﬁcantly stronger

multi-differentiation potential than GD2



cells. According to these results, GD2

may be a useful marker to isolate multipotent MSCs from UC-tissues, but further

studies are needed to verify these ﬁndings.

The most convincing biological property for the identiﬁcation of MSCs remains

the capability to differentiate into mesodermal lineages. In the next section the

in vitro differentiation potential of UC-derived stromal cells will be discussed.

5 In Vitro Differentiation Potential

The differentiation repertoire of stroma cells derived from UC tissue reported in the

literature till July 2009 is summarized in Table 2.

The potential of UC stroma cells to differentiate into adipocytes, chondrocytes,

and osteocytes has been widely investigated and well established by several groups.

According tothe minimal deﬁnition criteria proposedby the ISCT, UC-derived stroma

cells are considered multipotent MSCs [41]. Successful adipogenic, chondrogenic,

and osteogenic differentiation of UC-derived MSCs are presented in Fig. 9.

40 P. Moretti et al.

Adipogenic potential is usually demonstrated by the apparition of cells exhibit-

ing intracellular lipid droplets (Fig. 9a). The capacity to form chondroblasts is

evidenced by the formation of shiny cell-spheres with type II collagen expression in

the extracellular matrix in droplet cultures (Fig. 9b). Enhanced ALP expression and

mineralization assayed by von Kossa or alizarin red staining demonstrate osteo-

genic potency (Fig. 9d, e). It should also be mentioned that sub-populations of cells

spontaneously exhibiting a functional osteogenic potential with mineralized bone

nodules can be observed in UC-MSCs cultures [31]. Such bone nodules are

presented exemplary in Fig. 10.

In addition, it has been shown that UC-MSCs can successfully differentiate to

endothelial cells after addition of VEGF and b-FGF [54,55] and can form vessel-

like structures in matrigel cultures [37,55]. Furthermore, some UC-derived cell

populations also seem to be able to differentiate to muscle cells. For instance, WJ

cells (WJCs) could be induced to skeletal myocytes when placed in myogenic

medium [20]. Differentiation to cardiomyocytes was also reported but remains

controversial. Whang et al. demonstrated for instance that WJCs could be induced

to cells exhibiting cardiomyocyte morphology and expressing speciﬁc markers

(N-cadherin and cardiac troponin) using 5-azacytidine or cardiomyocyte-

conditioned medium [28]. Kadivar et al. observed cardiomyocyte like cells expres-

sing cardiac speciﬁc genes after 5-azacytidine induction of UC-MSCs isolated from

the endothelium/subendothelium layer of the UC vein. In contrast to these results,

Martin-Rendon et al. could not detect cardiac markers expression after in vitro

induction of MSCs isolated from the WJs and perivascular tissues [56]. Furthermore,

differentiated in vitro cultures of functional cardiomyocytes presenting beating

clusters are poorly or not demonstrated. To our knowledge, only one group reported

differentiated cells exhibiting slight spontaneous beating after 21 days of induction;

however no quantitative data are presented in this study [57].

Recent ﬁndings suggest that UC-MSCs can differentiate into endodermal

lineages. Campard et al. reported that UC-matrix cells constitutively expressed

Table 2 Differentiation potential of stroma cells derived from human umbilical cord tissue

reported in the literature till July 2009

Cell type References

Mesodermal lineage Adipocyte [16,17,20,23,28,30,34,35,37,45,48,54–56,60,

63,67,102,103,105–108,112,113]

Chondrocyte [17,19,23,28,30,37,45,48,55,56,60,63,67,

102,103,108,112]

Osteocyte

[16–18,20,23,28,30,31,34–37,45,48,54–56,60,

63,66,67,102,103,105–108,112–115]

Cardiomyocyte

[28,56,57,105]

Skeletal myocyte [20]

Endothelial cells [37,54,55]

Ectodermal lineage Neuronal cells [21–23,25,26,35,60–62]

Endodermal lineage Islet-like cells [38,59]

Immature

hepatocyte

[58]

Discrepancy among the published results

Mesenchymal Stromal Cells Derived from Human Umbilical Cord Tissues 41

markers of hepatic lineage, such as albumin, alpha-fetoprotein, cytokeratin-19,

connexin-32, and dipeptidyl peptidase IV. After in vitro hepatic induction, cells

exhibiting a hepatocyte-like morphology with hepatic features such as speciﬁc

markers up-regulation and urea production were observed. However, the authors

pointed out that their cells lack important characteristics of functional liver cells

and thus conclude that UC-matrix cells can be differentiated at least to immature

hepatocytes [58]. Chao et al. were also able to induce WJCs using a four stage

Fig. 9 Adipogenic, chondrogenic and osteogenic potential of UC-derived MSCs. (a) Formation of

lipid droplets stained with oil red O in Wharton’s jelly cells after adipogenic induction, scale bar ¼

20 mm (modiﬁed from [23]), (b) cell sphere obtained in droplet culture of chondrogenically

induced UC-MSCs (scale bar ¼500 mm) with abundant type II collagen expression (in c, scale

bar ¼50 mm) (modiﬁed from [23]), (d) ALP expression after osteogenic differentiation of

umbilical vein derived MSCs (modiﬁed from [17]). (e) Mineralization of osteogenically induced

culture of umbilical vein derived MSCs evidenced by von Kossa staining (modiﬁed from [17])

42 P. Moretti et al.

differentiation protocol to form islet-like clusters expressing pancreatic related

genes and secreting insulin in response to glucose concentrations [59]. Recent

results from Wu et al., who successfully differentiated WJCs to pancreatic cells

and observed higher differentiation potential compared to BM-MSCs [38], further

reinforce these ﬁndings.

Finally, several groups observed the differentiation of WJCs to cells exhibiting

morphological and biochemical characteristics of neural cells, suggesting that UC-

MSCs are able to differentiate to a certain state of maturation along the neuronal

lineage [21–23,25,26,35,60–62]. Mitchell et al. were the ﬁrst to observe neuronal

differentiation of WJCs after stimulation with b-FGF and other neuronal differenti-

ation reagents [26]. The differentiation was attested according to morphological

changes and expression of neuron-speciﬁc enolase, bIII-tubulin, neuroﬁlament M

and tyrosin hydroxylase [26]. The differentiation potential was then conﬁrmed by

several other groups [21,23,25,60]. Figure 11 shows exemplary neuronal cells

obtained by Karahuseyinoglu et al. after neuronal induction of a sub-population of

WJCs [23]. Interestingly, it also seems possible to generate some sub-types of

neurones as demonstrated by Fu et al., who were able to obtain dopaminergic

neurones from WJCs [21].

Summarizing the published data, we ﬁnd strong evidence to suggest that the

human UC is a source of multipotent stroma cells which are capable of differentiat-

ing into mesodermal and non-mesodermal lineages. It remains unclear whether the

differentiation potential of the UC-derived MSCs depends on their location in the

UC-tissues. For instance, Suzdal’tseva et al. reported that only a few cells isolated

from the cord vein subendothelial tissue were able to differentiate to osteoblasts

[63]. In contrast, cells isolated from perivascular tissues of the umbilical vein

showed a high osteogenic potential with spontaneous formation of bone nodules

[31], which was even evaluated higher than the potential of bone-marrow MSCs in

a comparative study [30]. Recently, two sub-populations were evidenced in cultures

of WJ-derived MSCs with regard to the expression of vimentin and pan-cytokeratin

ﬁlaments [23]. Interestingly, cells expressing cytokeratin, predominantly located

in the perivascular tissue of the cord, did not differentiate into neurones in vitro.

These ﬁndings are consistent with the results of Sarugaser et al., who showed

that perivascular UC-cells could not be induced to the neuronal lineage [31].

Fig. 10 Mineralized bone nodule in UC-MSCs culture. (a) Phase contrast microscopy picture of a

bone nodule, (b) alkaline phosphatase (violet dark cells) and alizarin red staining of a nodule

(arrow), (c) alkaline phosphatase (violet dark cells) and von Kossa staining of a nodule (arrow)

Mesenchymal Stromal Cells Derived from Human Umbilical Cord Tissues 43

The hypothesis of a location-dependent differentiation potential of UC-derived

stroma cells is also supported by the fact that a gradient of cell maturity was observed

within the UC tissues [64]. According to the cytoskeletal complexity, the most

immature cells are located in subamniotic and intervascular regions, whereas cells

of perivascular regions may represent a more differentiated state [64,65].

Many groups most likely investigate mixed populations of UC-MSCs, particu-

larly if the cells are derived from whole UC or from the WJ. Thus, the results of

studies comparing the differentiation potential of UC-derived MSCs with other

sources (for example BM) should be carefully interpreted [17,56,66,67]. More

work is needed to attest whether cells isolated from a deﬁned compartment of the

UC is more suitable for a speciﬁc differentiation lineage. This information would be

of tremendous importance for clinical applications of UC-derived MSCs.

6 Immune Properties of MSCs and In Vivo Applications

Besides their multi-lineage differentiation potential, BM-derived MSCs have

been shown to exhibit immune-privileged and immune-modulatory properties,

which predestine them as ideal candidates for cell-based therapies. They fail to

Fig. 11 Neuronal differentiation of WJCs, modiﬁed from [23]. (a)b-III Tubulin expression, (b)

Nestin expression located in the perinuclear cytoplasm in particular (b0), (c) neuroﬁlament-160

(NF-M), (d) neuron-speciﬁc nuclear protein expression (Neu-N) restricted to the nucleus, (e)

neuron-speciﬁc enolase (NSE), (f) microtubule-associated protein-2 (MAP2) detected as disconti-

nuities along the cells. (g) MAP2 distribution in cell–cell contact. Scale bars ¼10 mm(b0), 20 mm

(b,c), 50 mm(e), 100 mm(a,c,d)

44 P. Moretti et al.

induce proliferation of allogeneic lymphocytes in vitro and do not induce an

immune response when used in allogenic mismatched animal experimental models

[68–70]. Furthermore, they have regulatory effects on several cells of the immune

system (e.g., T, B, dendritic, and natural killer cells) [71–77], prolong skin graft

survival [78], and have been used in clinical applications to reduce acute and

chronic graft-versus-host disease (GvHD) [79,80]. Currently, three groups have

investigated the in vitro immune properties of UC-derived MSCs and observed

similar immunologic phenotypes to that of BM-MSCs. Ennis et al. [81] used cells

isolated from the perivascular tissue of the UC [human UC perivascular cells

(HUCPVC)] in one- and two-way mixed lymphocyte cultures (MLC) with resting

or activated peripheral blood lymphocytes (PBL) to examine whether HUCPVCs

induce or modulate proliferation of immune cells. Proliferation of PBLs was

determined by measurement of 5-bromo-2-deoxyuridine (BrdU) or tritiated thymi-

dine [

H] incorporation. They could show that HUCPVCs did not induce allogenic

lymphocyte proliferation but reduced the proliferation of alloreactive PBLs in a

dose-dependent way. Weiss et al. [82] describe similar observations using WJ-

derived cells termed UC matrix stroma (UCMS) cells. In co-culture experiments

they could show that UCMS cells not only suppressed the proliferation of Con-A-

stimulated rat splenocytes [measured by live cell counting, 3-(4,5-dimethylthiazol-2-yl)-

2,5-diphenyltetrazolium bromide (MTT)-assay and carboxyﬂuorescein diacetate

succinimidyl ester (CFSE)-assay] and activated human peripheral blood mononu-

clear cells (PBMCs) or puriﬁed T cells (measured by tritiated thymidine

[

H] incorporation) but also did not induce any proliferation of resting immune

cells. Furthermore, ﬂow cytometric analysis revealed the absence of the immune

response-related surface antigens CD40, CD80, and CD86. Yoo et al. [83] com-

pared the immune-suppressive effect of BM-MSCs and WJ-derived MSCs on

phytohemagglutinin-induced T cell proliferation and report that both BM-MSCs

and WJ-MSCs effectively reduced the proliferation of immune cells.

In vivo applications of UC-MSCs revealed further interesting attributes similar

to BM-MSCs. Regarding their potential for cell-based therapy applications, UC-

derived mesenchymal cells seem to support tissue repair by stimulating and mod-

ulating tissue-speciﬁc cells rather than differentiating into specialized cells. Yang

et al. [84] reported a positive modulation of microglia and reactive astrocytes

activities by UC-MSCs when transplanted into rats after complete transection of

the spinal cord. They detected an elevated production of various cytokines around

the lesion promoting spinal cord repair. Similar to these ﬁndings, Weiss et al. [29]

hypothesized a supportive function of UC-MSCs mediated by various secreted

trophic factors when used in a rodent model of Parkinson’s disease. Referring to

their preliminary work on porcine UC-derived MSCs, which were successfully

transplanted into rat brains without triggering an immune response or being rejected

[85], they then transplanted human UC-MSCs into brains of Parkinson’s disease

model rats without any immune-suppression. The transplanted cells did not produce

brain tumors or a frank host immune rejection response. Furthermore, they signiﬁ-

cantly mitigated induced motor deﬁcits [29]. Liao et al. [86] used UC-derived

MSCs in a rodent stroke model and observed that the cells, injected into the rat

Mesenchymal Stromal Cells Derived from Human Umbilical Cord Tissues 45

brain, survived for at least 5 weeks and reduced injury volume and neurologic

functional deﬁcits of rats after stroke. They assume angiogenesis-promoting prop-

erties of the cells by producing angiogenic cytokines. Koh et al. [87] also applied

a rodent stroke model. They used MSCs isolated from the umbilical vein sub-

endothelium and induced differentiation of the cells into neuron-like cells, as

indicated by morphology, expression of neuronal cell markers, and secretion of

neurotrophic factors, before transplantation into rats. Since the UC-MSCs were

both morphologically differentiated into neuronal cells and able to produce neuro-

trophic factors, but had not become functionally active neuronal cells, the authors

hypothesize that the observed improvement in neurobehavioral function might be

related to the neuroprotective effects of UC-MSCs rather than to the formation of a

new network between host neurons and the implanted cells. Analogical ﬁndings

were reported by Lund et al. [24]. They suggested a supportive behavior of MSCs in

a rodent model of retinal disease when UC-MSCs were shown to contribute to

photoreceptor rescue. The cells did not transform into neurons but more likely

secreted neurotrophic factors, as indicated by higher expression levels of these

factors in vitro.

Besides their supporting properties, UC-MSCs were also shown to be easily

genetically manipulated. Friedman et al. [88] and Kermani et al. [89] both trans-

fected UC-tissue derived MSCs with a GFP-reporter gene and created a stable cell

line. Considering the immune-privileged and immune-modulatory properties, the

cytokine production and supportive functions in vivo and the ability to be easily

transfected, UC-derived mesenchymal cells are promising candidates for cell-based

therapies and clinical applications. Currently, there are ﬁrst clinical trials aiming

to demonstrate if human UC-MSC have in vivo immune-suppressive effects and

can be used for GVHD treatment [“Allogeneic Mesenchymal Stem Cell for

Graft-Versus-Host Disease Treatment (MSCGVHD)”; ClinicalTrials.gov Identiﬁer:

NCT00749164; www.ClinicalTrials.gov].

7 Future Perspectives

In terms of cell engineering, the human UC is a very advantageous source of MSCs.

Cells from UC are easily accessible, may be processed under GMP conditions, and

the isolation of a high number of MSCs can be rapidly achieved in a reproducible

manner. Particularly interesting features of UC-MSCs were evidenced in recent

years. Due to their youth, UC-derived MSCs exhibit a high proliferation capacity

and expansion potential. Thus, compared to other MSC-sources, for UC-derived

MSCs no extensive expansion is required to obtain clinical doses, thereby reducing

the risk of possible epigenetic damages occurring during the in vitro expansion

process. Because one of the challenges of the bioprocesses will be the generation of

clinical grade MSCs in disposable reactors, the monitoring of the cultures will be

46 P. Moretti et al.

essential to control cell quality. The development of adequate in situ sensors for the

monitoring of the cultures will be of great interest [90]. Furthermore, it has been

shown that UC-MSCs can be frozen and thawed efﬁciently, which makes them

suitable for their use in clinical cell banking. The therapeutic use of MSCs will

require storage prior to clinical applications. In this regard, it appears worthwhile

that UC-cells isolated at birth, may be safely stored and delivered decades later to a

patient. Nevertheless, additional studies may be necessary to attest the stability of

long term cryopreserved cells.

The clinical potential of MSCs is primary dependent on their differentiation

potential. Like BM stromal cells, UC-derived MSCs were demonstrated to be

multipotent. Interestingly, their differentiation repertoire does not seem to be

restricted to the mesodermal lineages, since the cells could be successfully induced

to neurones, liver, and pancreatic cells. A growing body of evidences suggests,

however, that UC-MSC populations are rather heterogeneous, harboring a subset of

primitive cells. The next generation of studies should focus on the identiﬁcation and

characterization of these sub-populations. In particular, the question of whether the

differentiation potential of the isolated populations is dependent on their location in

the UC-tissues is of great interest for clinical application. Newly described MSCs

markers may be helpful in this regard.

Additionally, ﬁrst in vitro and in vivo animal studies evidenced immune-

privileged and immune-modulatory properties of UC-derived MSCs. Low levels

of rejection were observed in all reports of in vivo transplantation experiments and

encouraging results in tissue repairs were observed. In particular, supportive func-

tion through paracrine effects seems to be involved. The next generation of studies

and ﬁrst clinical trials will clarify whether the beneﬁt of UC-derived MSCs after

transplantation experiments relies on supportive effects and/or on differentiation

in vivo.

One of the ambitious aims of regenerative medicine is the engineering of tissue

in vitro. Few but very promising applications of UC-derived MSCs have been

reported in this ﬁeld. For instance, UC-MSCs are believed to have a high potential

in cardiovascular tissue engineering [91]. They grew very well on bio-degradable

polymer for the elaboration of cardiovascular constructs [33] and could be used for

the construction of human pulmonary conduits [92], for the engineering of biologi-

cally active living heart valve leaﬂets [27], and for the elaboration of living patches

with potential for pediatric cardiovascular tissue engineering [93]. The use of newly

developed scaffolds, mechanical strain approaches, or 3D bioreactors for tissue

generation, which were successfully applied with MSCs from other sources [94],

will also be a highly interesting issue.

Considering the very encouraging results obtained in recent years, it may only be

a question of time until UC-derived MSCs will be routinely used for clinical and

tissue engineering applications.

Acknowledgments The authors are grateful to Martina Weiss for her support with the production

of the ﬁgures and to Stefanie Boehm for the critical reading of this work.

Mesenchymal Stromal Cells Derived from Human Umbilical Cord Tissues 47

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DOI: 10.1007/10_2009_24

#Springer-Verlag Berlin Heidelberg 2010

Published online: 21 January 2010

Isolation, Characterization, Differentiation,

and Application of Adipose-Derived Stem Cells

Jo¨rn W. Kuhbier, Birgit Weyand, Christine Radtke, Peter M. Vogt,

Cornelia Kasper, and Kerstin Reimers

Abstract While bone marrow-derived mesenchymal stem cells are known and

have been investigated for a long time, mesenchymal stem cells derived from the

adipose tissue were identiﬁed as such by Zuk et al. in 2001. However, as subcuta-

neous fat tissue is a rich source which is much more easily accessible than bone

marrow and thus can be reached by less invasive procedures, adipose-derived stem

cells have moved into the research spotlight over the last 8 years.

Isolation of stromal cell fractions involves centrifugation, digestion, and ﬁltra-

tion, resulting in an adherent cell population containing mesenchymal stem cells;

these can be subdivided by cell sorting and cultured under common conditions.

They seem to have comparable properties to bone marrow-derived mesenchymal

stem cells in their differentiation abilities as well as a favorable angiogenic and

anti-inﬂammatory cytokine secretion proﬁle and therefore have become widely

used in tissue engineering and clinical regenerative medicine.

Keywords Adipose-derived stem cells, ASC, Fat harvesting, Isolation protocoll,

Stem cell application

Contents

1 Introduction .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

2 Isolation of ASC . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

2.1 Inﬂuence of Donor Site and Age . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . 58

2.2 Techniques of Harvesting Fat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . 60

2.3 Isolation of ASC from Fat Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . 62

J.W. Kuhbier (*)

Department of Plastic, Hand and Reconstructive Surgery, Podbielskistrasse 380, 30659 Hannover,

Germany

e-mail: joernkuhbier@gmx.de

B. Weyand, C. Radtke, P.M. Vogt, C. Kasper, and K. Reimers

Department of Plastic, Hand and Reconstructive Surgery, Medical School Hannover, Podbielski-

strasse 380, 30659 Hannover, Germany

3 Characterization of ASC . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . 65

3.1 Characterization via Surface Marker and Gene Expression . . . . . . . . . . . . . . . . . . . . . . . . .. 65

4 Differentiation of ASC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

4.1 Adipogenic Differentiation . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

4.2 Osteogenic Differentiation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . 72

4.3 Chondrogenic Differentiation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . 73

5 In Vivo Applications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

5.1 Cytokine Proﬁle Secreted by ASC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . 74

5.2 Angiogenesis and Functional Improvement of Ischemic Muscle Tissue . . . . . . . . . . . .. 76

5.3 Neurological and Skeletal Application of ASC . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . 80

5.4 ASC for Enhancement and Acceleration of Wound Healing . . . . . . . . . . . . . . . . . . . . . . . . 83

5.5 Immunomodulatory Effect of ASC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . 86

5.6 Other Purposes in Current In Vivo Application . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . 89

6 Tissue Engineering Applications . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

6.1 Adipose Tissue . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . 91

6.2 Bone Tissue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92

6.3 Cartilage Tissue . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

7 Summary ................................................................................... 93

References ......................................................................................94

1 Introduction

Despite bone marrow being the primary and best studied source of stem cell

populations, multilineage progenitor cells with the potential to differentiate into

multiple cell lines have been found in the heart [1,2], muscle [3,4], lung [5,6],

intestine [7], kidney [8], liver [9], pancreas [10], skin [11], and even in the brain

[12,13]. These tissue-resident stem cells seem to posses certain repair functions in

their native tissue, but also have potential for and might contribute to tissue

regeneration processes in regions other than their origin [14,15].

Due to their many advantages, several recent studies favor adipose-tissue

derived mesenchymal stem cells for their study purposes. A multilineage stem

cell population that was derived from the stroma of adipose tissue was ﬁrst

described by Zuk et al. in 2001 [16], who used the term “processed lipoaspirate”,

as they isolated the cells from an aspirate of a liposuction. Since the lipoaspirate is

composed of several cell types, it requires processing by stepwise centrifugation in

order to isolate the stem cell fraction.

Fat tissue is composed mainly of mature adipocytes which are aligned in lobules

and surrounded by connective tissue. Within the connective tissue, a vascular network

allows nutrition and also transportation of endocrine mediators produced by adipose

tissue, especially leptin and adiponectin, an insulin-sensitizing hormone [17,18]. In

speciﬁc anatomical locations, such as the abdominal wall, the fat layer is divided by a

thin facia, so-called Scarpa’s facia, into a superﬁcial and a deeper layer of fat tissue.

After centrifugation of the lipoaspirate, the most voluminous fraction contains

adipocytes, which may burst and die during processing. Alongside, another

56 J.W. Kuhbier et al.

centrifugation fraction is the so-called “stromal-vascular fraction” (SVF), as the

stromal and vascular tissues show nearly identical centrifugation properties. The

SVF contains a heterogenous cell population composed of circulating blood cells,

ﬁbroblasts, pericytes, endothelial cells, and multipotent stem cells.

Over the past few years, several nomenclatures for these multipotent cells have

been used, e.g., processed lipoaspirate, adipose tissue-derived stromal cells, or

adipose-derived mesenchymal stem cells, but in this chapter we will use the term

“adipose-derived stem cells” (ASC), based on a consensus reached by the Second

Annual Meeting of the International Fat Applied Technology Society in Pittsburgh,

PA, in 2004, and which is also favored in the literature.

In recent years, research interest in plastic and reconstructive surgery has focused

on characterization and tissue engineering approaches of ASC, since these cells are

easily and frequently harvested during lipoforming procedures [19–21]. In the

following chapter on ASC we would like to deﬁne the term “ASC” and its origin.

Furthermore, we want to cover the surgical procedures and isolation techniques for

ASC from fat tissue. In addition, we want to display the characterization of ASC via

surface markers and their differentiation capabilities into different cell lines, e.g.,

adipocytes, chondrocytes, osteoblasts, myocytes [16], endothelial cells [22], neuron-

like cells [23–26], hepatocytes [27,28], pancreatic cells [29], and hematopoietic

supporting cells [30,31], together with the underlying signal cascades. This will be

followed by a short overview of the application of ASC in tissue engineering and in

clinical medicine, using the angiogenic, antiapoptotic, hematopoietic, and anti-

inﬂammatory cytokine proﬁle secreted by ASC [31,32].

2 Isolation of ASC

Due to the easy accessible anatomical location and the abundant existence of

subcutaneous adipose tissue, ASC hold the advantage of a simple and above all

less invasive harvesting technique. Thus, adipose tissue might be considered as a

rich source of stem cells, especially with the increased incidence of obesity in

modern populations. In general, adipose tissue can be harvested by liposuction,

lipoplasty, or lipectomy procedures. Minimal-invasive procedures such as liposuc-

tion or lipoplasty have the advantage of a reduced patient discomfort and lower

donor site morbidity compared to lipectomy.

To avoid risks of general anesthesia, small amounts of adipose tissue (100–

200 mL) can be obtained under local anesthesia by liposuction procedures. Note-

worthy, these “small amounts” are still bigger volumes than those yielded by bone

marrow aspiration. In comparison, 1 g of adipose tissue yields approximately

510

stem cells [33], which is 500-fold greater than the number of MSCs in

1 g of bone marrow [34].

For a complete overview of the harvesting and isolation process, see Fig. 1.

Isolation, Characterization, Differentiation, and Application of Adipose-Derived Stem Cells 57

2.1 Inﬂuence of Donor Site and Age

Several studies have compared the impact of the isolation procedure via aspiration

liposuction, ultrasound-assisted liposuction, or lipectomy on the yield of ASC.

Fig. 1 Flowchart of fat harvesting and ASC isolation process. Note the different cannulas used for

the different techniques of fat harvesting

58 J.W. Kuhbier et al.

Furthermore, different donor sites such as fat derived from abdominal tissue, hips,

or thighs have been compared regarding cell yield, cell viability, and cell dif-

ferentiating capacity. Interestingly, neither the type of surgical procedure nor the

anatomical site of the adipose tissue affects the total number of viable cells that can

be obtained from the stromal-vascular cell fraction [33,34]. However, there is

increasing evidence that both the cellular composition and the differentiation

capacity display heterogeneity according to the localization of the adipose tissue,

at least in the murine model [35].

Since different anatomical localizations of fat tissues have their own metabolic

characteristics, such as lipolytic activity, fatty acid composition, and gene expres-

sion proﬁle, the source of subcutaneous adipose tissue grafts might inﬂuence the

long-term characteristics of the fat graft. In rabbits, the osteogenic potential of ASC

from the visceral adipose tissue is described to be more effective than those of the

subcutaneous adipose tissue [36].

In humans, data from literature are ambivalent; whilst most studies show no

difference in the proliferation rate, i.e., the culture doubling time [37–43], there is

one study that measured faster proliferation rates in preadipocytes from subcuta-

neous vs omental adipose tissue (doubling time 4 1daysvs51days)[44].

This study also found a higher number of endothelial cells in the harvested SVF

in agreement with the ﬁnding that endothelial cells from adipose tissue were

recentlydescribedtopromotepreadipocyte proliferation [45]. Another study

describes differences in the frequency of ASC in the adipose tissue from abdomi-

nal subcutaneous tissue and from the hip/thigh region with abdominal tissue

having superior frequencies, though the absolute cell number was the same

[46]. While few studies found attachment and proliferation ratios to be more

pronounced in ASC derived from younger donors compared with older donors

[40], others found no difference in proliferative capacity concerning the age [41,

42,44,45,47,48].

Noteworthy, in the study by Zhu et al. [43], though the authors stated ACS from

younger donors to be faster proliferating, the difference between young and old

donors was slight and not statistically signiﬁcant.

In addition, the studies mentioned above also examined the differentiation

capacity of ASC. Whereas one study examined the adipogenic and osteogenic

potential [24], others focused merely on the adipogenic [8,40,41,44,49]or

osteogenic capacity [42,47,48,50]. Interestingly, while some studies found no

difference in adipogenesis with regard either to the region [40,44] or to the age

[41], other studies found the potential for adipogenic differentiation elevated in

older donors [40,43].

In contrast, in two studies, differences related to the donor site could be found

regarding the adipogenic capacity [8,49]. Tchkonia et al. compared the differenti-

ation into adipocytes of ASC harvested in abdominal subcutaneous, mesenteric, and

omental adipose tissue and observed the highest adipogenic capacity in abdominal

subcutaneous adipose tissue, followed by intermediate capacity in mesenteric

adipose tissue, and lowest capacity in omental adipose tissue [51]. Hauner and

Entenmann found a signiﬁcantly higher metabolic activity in differentiated

Isolation, Characterization, Differentiation, and Application of Adipose-Derived Stem Cells 59

adipocytes derived from ASC, which were harvested from the abdominal subcuta-

neous adipose tissue compared to ASC obtained from the femoral adipose tissue in

obese women [52].

Concerning osteogenesis, the ﬁndings were also ambivalent; some studies found

no difference in osteogenic capacity [41,47,48,50], others found higher osteogenic

differentiation rates in younger donors [43]. The ﬁnding that osteogenic capacity is

preserved during aging stands in contrast to current clinical experience, where time

for fracture healing is enhanced in the elderly or osteoporotic bones compared to the

skeleton of younger people. Hence, Khan et al. concede that the donors examined in

their study were in their later life (ranging from 57–86) and suffered from osteoar-

thritis [47].

In summary, general scientiﬁc opinion negates any age-dependant effect on ASC

proliferation, whereas the inﬂuence of age on the differentiation capacity of ASC

remains debatable.

2.2 Techniques of Harvesting Fat

Techniques of fat harvesting include direct excision such as dermolipectomy,

abdominoplasty, or removal by less or minimal-invasive procedures, such as

liposuction. Dermolipectomy comprises the surgical removal of excessive skin

and fat tissue from various body locations. The different techniques of abdomino-

plasty originated from variation in abdominal wall incision for repair of large

umbilical hernias in the early 1900s [53]. The modern abdominoplasty as a distinct

procedure with umbilical transposition and musculoaponeurotic plication was

described by Vernon in the early 1960s and was further reﬁned by others such as

Pitanguy, Regnault, and Psillakis [54–59].

After preparation of a whole ﬂap of skin and fat, fat lobules of approximately

0.5–1 cm

are separated from the dermo-epidermal layer and minced by repeated

cutting with scissors until reaching a paste-like/mushy/pappy appearance. Here-

after, the processing is the same as in liposuction.

Independent of or in combination with an abdominoplasty, the body shape can

be modeled by liposuction. Technical aspects of liposuction/lipoplasty include

different cannula sizes and shapes, and the use of a wetting tumescent solution,

which can drastically reduce blood loss compared to the original dry techniques or

ultrasound-assisted devices, which can be advantageous by removing fat tissue

from ﬁbrous or scarred areas. Besides ultra-sound-assisted liposuction, which offers

very good results concerning body sculpturing but should not be used for harvesting

fat due to poor yields of viable cells [60], there are currently four common methods

in use for liposuction/lipoﬁlling purposes: conventional liposuction, the method

described by Coleman, [61–64], the alternative method developed by Jackson et al.

[65,66], and the LipiVage

syringe combination.

Whereas liposuction intends to remove fat tissue, devices for lipoﬁlling combine

gentle removal of fat with internal processing for reinjection of a viable cell fraction

60 J.W. Kuhbier et al.

with the Coleman method being the ﬁrst and probably best described technique, the

Jackson method as a mostly experimentally used technique, and the LipiVage

syringe combination as the newest technique.

Conventional liposuction, also called suction-assisted lipectomy, is performed as

follows. The patient is brought to a supine position and local, regional, epidural, or

general anesthesia is used, depending on the patient’s preference or anesthetic risk.

A small skin incision with a length of approximately 1 cm is made in the lower

abdomen to inﬁltrate a mixed solution with a blunt Lamis inﬁltrator. For local

anesthesia, the solution contains lactated Ringer’s solution with 0.5% lidocaine

with 1:200,000 of epinephrine for local hemostasis via vasoconstriction. During

epidural or general anesthesia, 1:400,000 epinephrine in Ringer’s lactate helps to

maintain hemostasis. By using epinephrine, blood loss and contamination of the

harvested fat with blood cells is minimized. The solutions are inﬁltrated at a ratio of

1 cc of solution per cubic centimeter of fat graft to be harvested. An aspiration

cannula, 3–4 mm in diameter and 15 or 23 cm in length with a hollow blunt tip, is

then connected to a liposuction machine with the negative pressure of the machine

being set up at a pressure no greater than 20 cm H

O (Fig. 1). Fat is harvested

through the same incision previously made for inﬁltration, moving the cannula

forward and backwards, disrupting adipose cells mechanically from the surround-

ing tissue. The adipose aspirate is collected in a sterile bottle; further processing is

identical to those of the other methods.

Conventional liposuction is well-tried for the aspiration of fat in the sense of not

processing or injecting it thereafter. Many adipocytes are destroyed due to rough

mechanical disruption, indicating that other cell types like stromal cells and ASC

are also damaged. Thus, the more gentle technique developed by Coleman is widely

used for fat transplantation purposes, e.g., body sculpturing or rejuvenation tech-

niques, which is well described and standardized [61–64,67].

The anesthesia and inﬁltration technique is the same as described above while,

for the harvesting, a different cannula is used. Though it is also 3 mm in diameter

and 15 or 23 cm in length, the blunt tip is slightly different. The two distal openings

positioned extremely close to the end give the tip a shape reminiscent of a bucket

handle (Fig. 1). Also, the harvesting cannula is connected to a 10-cc Luer-Lok

syringe instead of using a high-pressure vacuum suction machine. Gently pulling

back the plunger of a 10-cc syringe provides a light negative pressure while the

cannula is advanced and retracted through the harvest site. Alternative devices that

lock the plunger of syringes into place should be avoided, as they can create higher

negative pressures that may damage the fragile tissue.

For the technique by Jackson et al. [65,66], a ﬁne needle apparatus is used

together with a 20-cc syringe. The needle for harvest is that used by veterinarians to

inject antibiotics into the udders of cows, and it is ﬁtted to a 20-cc syringe. With a

diameter of 2 mm and a length of 7 cm, it has a wide bore with a blunt tip and

several side holes (Fig. 1). Harvesting is performed as in the other two techniques

with forward and backwards motion and intermittent aspiration.

According to recent studies, the technique by Jackson should be favored, as it

was superior to the Coleman method in the yield of viable cells in total and ASC in

Isolation, Characterization, Differentiation, and Application of Adipose-Derived Stem Cells 61

particular [65], while, in the study by Pu et al. [64], the Coleman method was

superior to conventional liposuction although only the yield of adipocytes was

measured. Declaring adipocyte viability as a marker for general cellular viability

in a fat graft, the chemical effect of epinephrine/lidocaine inﬁltration remains

unnoteworthy, because studies done in the 1990s showed that no chemical damage

occurred during liposuction concerning viability of adipocytes [60,68,69]. At least,

investigations about the inﬂuence of inﬁltration on ASC yield are lacking as yet.

Another promising technique is the LipiVage

-System, quite a new fat harvest,

wash, and transfer system which also uses very slight negative pressure, though

connected to a vacuum system [49]. While ﬁrst results revealed superior numbers of

viable adipocytes, no data exist for the harvest of ASC at present [49].

In summary, for fat grafting, no matter if intended either for fat transplantation

or yield of ASC, conventional liposuction should not be used due to the harsh

movements that cause damage to the cells. In contrast, one of the gentle liposuction

methods is recommended for harvesting since it has the advantage of a less invasive

procedure compared to an abdominoplasty, but regarding the yield of adipocytes,

no difference has been found so far between the described techniques [35].

2.3 Isolation of ASC from Fat Grafts

As mentioned before, the isolation processing for the yield of ASC from fat grafts is

identical for abdominoplasty- or liposuction-harvested grafts. Most publications

use the protocol by Zuk et al. [16], though actually Rodbell pioneered in centrifu-

gation and digestion of fat to identify different fractions in 1966 [70–72]. However,

the identiﬁcation of the SVF was just a secondary product of his work focusing on

the metabolism of isolated fat cells, and therefore Zuk et al. are usually referred to

as the prime investigators.

After transferring the lipoaspirate or the dissected lobules into a laboratory under

sterile conditions following good manufacturing practice (GMP), they are exten-

sively washed in equal volumes of sterile phosphate-buffered saline (PBS). The

extracellular matrix (ECM) is digested at 37C for 30 min with 0.075% collagenase

in PBS [73] under permanent shaking. Thereafter, enzyme activity is neutralized

with Dulbecco’s modiﬁed Eagle’s medium (DMEM), containing 10% fetal bovine

serum (FBS) and centrifuged at 1,200gfor 10 min to obtain a high-density pellet

of the SVF. The pellet is resuspended in 160 mM NH

Cl and incubated at

room temperature for 10 min to lyse contaminating red blood cells. The SVF was

collected by centrifugation, as detailed above, ﬁltered through a 100-mm nylon

mesh to remove cellular debris and incubated overnight at 37C/5% CO

at a

density of approximately 150,000 cm



in control medium (DMEM containing

10% FBS and 1% antibiotic/antimycotic solution, for example penicillin/strepto-

mycin). Following incubation, the plates were washed extensively with PBS to

remove residual nonadherent blood cells. Further cultivation can be done for up to

15 passages before cells become senescent if cells are separated at approximately

62 J.W. Kuhbier et al.

60–70% conﬂuence to avoid differentiation due to contact inhibition. A remarkable

ﬁnding was described by Zhu et al. who passaged ASC cultures up to 25 passages

and studied the growth kinetics and differentiation potential [74]. Interestingly,

ASC showed several logarithmic growth periods, e.g., the ﬁrst between the 4th and

7th day of culture, the second between 9th and 10th day, though they allowed cells

to reach 90% conﬂuence. While morphology and surface marker did not change

between earlier passages and the 25th, multilineage differentiation potential was

declined in the 25th passage [75].

Lee et al. observed the greatest numbers of cells obtained from cultures plated

at low density [76], so not more than 4 10

cells cm

2

should be plated per

passage. However, before the next passage, a phenotype characterization, for best

results with a ﬂow cytometry cell sorter, should follow to cultivate as pure cultures

of ASC as possible. Handling these small numbers of cells while culturing, it is

noteworthy that cryopreservation is also suitable [77]. ASC appear to be ﬁbro-

blast-like shaped, expand easily in even FBS-free culture media [78]andcanbe

passaged with Trypsin/ethylene-di-amine-tetra-acetic acid (EDTA) (Fig. 2). The

medium should be changed every 2 or 3 days, and passage time is usually about

1 week, depending on the density of plated cells.

Fig. 2 Isolated ASC in

monolayer culture. (a) The

cells (Passage 0) are seeded

to allow cell–cell contacts.

Magniﬁcation 100, scale bar

represents 100 mm. (b)Ata

higher density the cells begin to

form characteristic structures.

Magniﬁcation 40, scale bar

represents 200 mm

Isolation, Characterization, Differentiation, and Application of Adipose-Derived Stem Cells 63

There are slight differences in the isolation process of some authors, mostly

concerning the concentration of collagenase or the buffer used [15,65,74,79,80].

Here, some authors favor longer digestion periods ranging from 30–90 min

[15], higher collagenase concentration ranging from 0.05 to 0.15% [15,77,79,

80], different collagenases, e.g., collagenase H (1 mg mL

1

+ 2% bovine serum

albumin (BSA)) [65], a different buffer for dissolving the collagenase, e.g., Krebs–

Ringer solution (pH 7.4) buffered with 25 mM hydroxyehtyl-piperazine-ethane-

sulfonic acid (HEPES) containing 20 mg mL

1

BSA [15], or addition of BSA

(1–2%) [48,74]. If dissected lobules instead of lipoaspirates were harvested,

Zhu et al. preferred Hank’s buffer instead of PBS for washing, while their digestion

buffer comprised 0.1% collagenase and 0.25% trypsin in Hank’s buffer [74].

Galie

´et al. compared different centrifugation speeds concerning the yield of

ASC and found the best results at 1,200g[81], like in the original protocol. Kim

et al. ﬁltered the supernatant through a 70-mm nylon mesh [82–86], while Martinez-

Lorenzo et al. preferred the use of ﬁrst a 100-mm and then a 40-mm nylon mesh [87];

the group around Gonzalez used just a 40-mm nylon mesh [88,89].

After ﬁltering, Kim et al. used histopaque-1077 as Ficoll gradient in centrifu-

gation [78,79,90,91]. Histopaque-1077 is an inexpensive polysaccharide solu-

tion mixed with a radiopaque contrast medium with a density if 1.077 g mL

1

which forms a distinct opaque layer. Thus, different fractions of a lipoaspirate can

be identiﬁed very easily. However, since most other research groups performed

isolation of ASC lacking this solution, it may not be necessary for identifying

the SVF.

Nagakami et al. used another slightly different protocol [92,93] developed

in 1978 by Bjo

¨rntorp et al. [94], which used a digesting solution containing 0.1 M

(HEPES) buffer, 0.12 M NaCl, 0.05 M KCl, 0.001 M CaCl

, 0.005 M glucose,

and 1.5% (w/v) BSA with 0.2% (w/v) collagenase at a pH of 7.4 and a tempera-

ture of 37C for 30 min. Filtration was with a 250-mm nylon mesh and after that

fat cells were allowed to ﬂoat to the surface for 15 min. The infranatant was

aspired and ﬁltered through a 25-mm nylon mesh and the passing cells were

cultured.

Recent studies showed that the growth kinetics of ASC can be inﬂuenced by

several exogenous supplements. Iwashima et al. displayed that addition of ﬁbro-

blast growth factor 2 (FGF2) signiﬁcantly increased proliferation speed of ASC via

the FGF-receptor 2 compared with nonsupplemented control medium [95], but

FGF-2 also increases chondrogenic differentiation [96].

Proliferation can also be stimulated by exogenous supplementation of sphingo-

sylphosphorylcholine via the activation of c-jun N-terminal kinase (JNK), platelet-

derived growth factor (PDGF) via JNK-activation, and oncostatin N via activation

of the microtubule-associated protein kinase (MEK)/extracellular signal-regulated

kinase (ERK) and the JAK3/STAT1-pathway [97–99].

We would recommend use of the original protocol and modiﬁcation of

some parameters by demand to improve ASC yield. To stimulate proliferation,

it may be advisable to add FGF-2 or one of the other mentioned exogenous

supplements.

64 J.W. Kuhbier et al.

3 Characterization of ASC

Due to the fact that during the isolation process of ASC by stepwise centrifugation

and digestion only the SVF can be obtained and this fraction contains a mixture of

several cell types, there is a need for further characterization of ASC. In early

studies ASC were deﬁned by their ability to differentiate into the adipogenic,

osteogenic, and chondrogenic pathway. Nowadays the populations of ASC can be

further characterized and sorted by their surface markers using ﬂow cytometry,

which is an elegant way to derive pure cell populations from a cell mixture.

Thus, several surface markers have been described to characterize whether a cell

is an ASC or not, while some markers have also been found just in subpopulations

of ASC.

In the next paragraphs, ﬁrst speciﬁc surface markers are displayed and also gene

expression patterns of several proteins typical for ASC are listed. Second, we are

going to explain, differentiation pathways and mechanisms of ASC as far as they

are revealed.

3.1 Characterization via Surface Marker and Gene Expression

The ﬁrst publication by Zuk et al. deﬁned the stem cell characteristics of ASC by

their ability to differentiate into several mesenchymal cell lineages, such as the

adipogenic, osterogenic, chondrogenic, and myogenic lineage [16].

With the following lineage-speciﬁc determinants and the matching histological

and immunohistochemical assays, the differentiation was proven: Adipogenic differ-

entiation was deﬁned by lipid accumulation (monitored with Oil Red-O stain),

osteogenic differentiation by alkaline phosphatase (AP) activity (AP-stain) and calci-

ﬁed matrix production (Von Kossa stain), chondrogenic differentiation by sulfated

proteoglycan-rich matrix (Alcian Blue (pH 1.0) stain) and Collagen II synthesis

(Collagen II-speciﬁc monoclonal antibody), and myogenic differentiation by multi-

nucleation (phase contrast microscopy) and skeletal muscle myosin heavy-chain and

MyoD1 expression (Myosin- and MyoD1-speciﬁc monoclonal antibodies (Fig. 3).

One year later, the same working group published another study in which they

characterized ASC by ﬂow cytometry analysis and made a comparison with BSC

[21]. Both populations expressed CD13, CD29, CD44, CD71, CD90, and CD105/

SH2 and SH3, which together with SH2 is considered a marker for MSCs [100]. In

addition, both ASC and BSC expressed STRO-1, a marker for multilineage pro-

genitors from bone marrow [101]. In contrast, no expression of the hematopoietic

lineage markers CD31, CD34, and CD45 as well as absence of CD14, CD16, CD56,

CD61, CD62E, and CD104 were observed in either of the cultures. Interestingly,

there was a difference between both stem cell lines for the expression of CD49d,

which was expressed by ASC but not BSC, and CD106 for which it was vice versa.

A recent study by McIntosh et al. investigated the temporal changes of marker

expression on ASC [102]. Hence, markers seem to underlie progression or depression

Isolation, Characterization, Differentiation, and Application of Adipose-Derived Stem Cells 65

by ongoing passaging, showing a passage-dependent decrease of CD11a, CD13,

CD45, CD86, and histocompatibility locus of antigen (HLA)-DR. Instead, CD40,

CD54, and HLA-ABC increased during passaging, while CD80 showed growing

expression until passage 1 and 2, and then decreased.

Fig. 3 Histologic staining of

differentiated ASC. (a)

Adipogenic lineage stained

with Oil Red-O staining. (b)

Osteogenic lineage stained with

Von Kossa staining. (c)

Chondrogenic lineage stained

with Alcian blue staining. For

(a) magniﬁcation 200, scale

bar represents 50 mm, for (b,c)

magniﬁcation 100, scale bar

represents 100 mm

66 J.W. Kuhbier et al.

In their excellent review, Scha

¨fﬂer and Bu

¨chler deﬁned positive and nega-

tive markers and genes for ASC with regard to the literature [15]. Thus, ASC are

positive for CD9, CD10, CD13, CD29, CD44, CD49d, CD49e, CD54, CD55,

CD59, CD73, CD90, CD105, CD106, CD146, CD166, HLA I, Fibronectin,

Endomucin, smooth muscle cell-speciﬁc alpha actin, Vimentin, and Collagen-I.

They are negative for CD11b, CD14, CD19, CD31, CD34, CD45, CD79a, CD80,

CD117, CD133, CD144, HLA-DR, c-kit, MyD88, STRO-1, Lin, and HLA II.

Even more extensive is the study by Katz et al. [103], who analyzed the trans-

criptome of ASC using a microarray technique (Table 1). Though their results

demonstrated uniformity in some gene and surface marker expression considering

different isolation and cultivation protocols, there seem to be time-dependent

changes already seen in short-term culture with decrease of certain surface markers

as well as differences in individual gene expression proﬁles with a 66% consistency

in gene expression comparing samples of three persons with gene arrays and seven

persons in ﬂow cytometrie [103].

Comparing partly contrary data from different research laboratories, it appears

difﬁcult to determine a deﬁnitive immunophenotype. Until now, there has been no

deﬁnitive immunophenotype of ASC as surface markers do change expression

during passaging. According to results of different studies, one can agree upon a

selected surface maker expression proﬁle as a basic prerequisite in order to deﬁne

the adipose mesenchymal stem cell: This proﬁle should comprise positivity for

mesenchymal stem cell markers such as CD105, CD73, and CD90 as well as lack of

the hematopoietic lineage markers c-kit, CD14, CD11b, CD34, CD45, CD79a,

CD19, and HLA-DR [78].

Another interesting investigation was carried out by Gonzalez et al. who studied

the inhibition of inﬂammatory and autoimmune responses by undifferentiated ASC

[88]. They found not only expression of surface receptors chemokine (C-C motif)

receptor 1 (CCR1), CCR2, CCR4, CCR7, CCR9, chemokine (C-X-C motif) recep-

tor 1 (CXCR1), and CXCR5, but also proof for their functionality because ASC

migrated in response to chemokine (C-C motif) ligand 5 (CCL5), CCL22, CCL19,

CCL25, chemokine (C-X-C motif) ligand 8 (CXCL8), and CXCL13 activation.

This would suggest anti-inﬂammatory properties as well as immunosuppressive

properties mediated by ASC, conﬁrmed by more recent studies which are displayed

in the paragraph below regarding immunomodulation by ASC.

4 Differentiation of ASC

The perception of adipose tissue has undergone a radical change over the past

10 years. From a special type of connective tissue with the function to store excess

energy as triglycerides, new functions have been assigned to adipose tissue during

the past 10 years. Adipose tissue has been described as a real endocrinic organ

between neuroendocrine and metabolic signaling [104]. Furthermore, it has been

identiﬁed as a rich source of multipotent stem cells.

Isolation, Characterization, Differentiation, and Application of Adipose-Derived Stem Cells 67

Table 1 Transcription proﬁle of extracellular matrix and angiogenesis-related genes in early-

passage, undifferentiated human ASC [103]

Cell adhesion molecules

Integrins

Integrin a1 CD49a/VLA-1

Integrin a2 CD49b

Integrin a2b CD41b

Integrin a3 CD49c

Integrin a4 CD49d

Integrin a5 CD49e/VLA-5

Integrin a6 CD49f/VLA-6

Integrin a7

Integrin a8

Integrin a9

Integrin a11

Integrin aV CD51

Integrin aX CD11c

Integrin b1 CD29

Integrin b2 CD18

Integrin b3 CD61

Integrin b4

Integrin b5

Integrin b8

Cadherins and catenins

Cadherin 1 type 1

Cadherin 5 CD144

Catenin b1

Catenin d1

Catenin d2

Catenin a1

Catenin a-like 1

Other cell adhesion molecules

GPIV CD36

H-CAM CD44

CEACAM-5 CD66e

ELAM-1 CD62e

ICAM-1 CD54

PECAM-1 CD31

VCAM-1 CD106

DCC

NCAM-1 CD56

Contactin 1

NRCAM

Matrix proteins

Caveolin 1

Collagen type IV a2

Collagen type 18 a

Collagen a1

Extracellular matrix protein 1

Fibrinogen B

Fibronectin 1

Laminin g1

Osteonectin

(continued)

68 J.W. Kuhbier et al.

Table 1 (continued)

Osteopontin

Thrombospondin 1

Thrombospondin 2

Thrombospondin 3

Thrombospondin 4

Endoglin CD105

F2, Human prothrombin

Restin (RSN)

Vitronectin

Laminin b1 chain

MICA

Proteases

Matrix metalloproteinases

Metalloproteinase/METH 1

Matrix metalloproteinase 2 (MMP2)

Matrix metalloproteinase 10 (MMP10)

Membrane-type matrix metalloproteinase 1 (MMP14)

Matrix metalloproteinase 17 (MMP17)

Matrix metalloproteinase 26 (MMP26)

Human stromelysin-3 (MMP11)

Matrix metalloproteinase 9 (MMP9)

Matrix metalloproteinase 20 (MMP20)

Disintegrin-like metalloproteinase

Matrix metalloproteinase 1 (MMP1)

Matrix metalloproteinase 3 (MMP3)

Matrix metalloproteinase 7 (MMP7)

Matrix metalloproteinase 8 (MMP8)

Matrix metalloproteinase 12 (MMP12)

Matrix metalloproteinase 13 (MMP13)

Matrix metalloproteinase 15 (MMP15)

Matrix metalloproteinase 16 (MMP16)

Matrix metalloproteinase 24 (MMP24)

Other proteases

Cystatin C

Cathepsin B

Cathepsin C

Heparinase

Macrophage scavenger receptor 1 (MSR 1) CD204

Plasminogen activator, urokinase

Prostaglandin-endoperoxide synthase 1 (COX1)

Prostaglandin-endoperoxide synthase 2 (COX2)

Urokinase-type plasminogen activator receptor

Transmembrane protease serine 4

Cathepsin L

Caspase 8

Meningioma expressed antigen 5 (hyaluronidase)

Plasminogen activator

Cathepsin G

Protease inhibitors

Plasminogen activator inhibitor, type I

Plasminogen activator inhibitor, type II

Protease inhibitor 5

(continued)

Isolation, Characterization, Differentiation, and Application of Adipose-Derived Stem Cells 69

Table 1 (continued)

Pigment epithelium derived factor

Tissue inhibitor of metalloproteinase 1

Tissue inhibitor of metalloproteinase 2

Tissue inhibitor of metalloproteinase 3

Growth factors and receptors

Ephrin family

Ephrin-A2

Ephrin-B2

Ephrin-A5

Ephrin-B5

Fibroblast growth factors and receptors

Fibroblast growth factor 1 (acidic)

Fibroblast growth factor 2 (basic)

Fibroblast growth factor 4

Fibroblast growth factor 6

Fibroblast growth factor 8 (keratinocyte growth factor)

Fibroblast growth factor receptor 1

Fibroblast growth factor receptor 2

Fibroblast growth factor receptor 3

Fibroblast growth factor receptor 4

Platelet-derived growth factors and receptors

Platelet-derived growth factor a

Platelet-derived growth factor-BB

Platelet-derived growth factor receptor aCD 140a

Platelet-derived growth factor receptor bCD140b

Platelet factor 4

Transforming growth factors and receptors

Transforming growth factor a

Transforming growth factor b1

Transforming growth factor b3

Transforming growth factor breceptor 1

Transforming growth factor breceptor 2

Transforming growth factor breceptor 3

Transforming growth factor b2

Vascular endothelial growth factors and receptors

Vascular endothelial growth factor D

Placental growth factor

Vascular endothelial growth factor

Vascular endothelial growth factor B

Kinase insert domain receptor

Tyrosine kinase, endothelial

Tyrosine kinase with immunoglobulin and EGF homology domains

Vascular endothelial growth factor C

Vascular endothelial growth factor receptor

Other growth factors and receptors

Angiogenin

Angiopoietin-1

Angiopoietin-2

Angiostatin binding protein 1

Chromogranin A (parathyroid secretory protein 1, precursor for vasostatin)

Epidermal growth factor receptor

Hepatocyte growth factor

(continued)

70 J.W. Kuhbier et al.

Although there has been some theoretical discussion about the origin of stem

cells as true residents of fat tissue or as migratory mesenchymal stem cells passing

through, there is a broad consensus that fat tissue is a rich source of multipotent

cells which can be differentiated into adipogenic, osteogenic, and chondrogenic

lineages. Myogenic and neurogenic differentiation potential has also been

described [105,106], as well as single reports about hepatic differentiation [27]

and differentiation into endothelial cells which is under current debate [107].

4.1 Adipogenic Differentiation

The multipotent stem cells residing in the vascular stroma of adipose tissue give rise

to adipocytes in a highly regulated way characterized by uniform steps starting with

Table 1 (continued)

Insulin-like growth factor 1

Melanoma growth stimulator activity a

Nitric oxide synthase 3

Endothelial differentiation sphingolipid G-protein-coupled receptor 1

Epidermal growth factor

Cytokines and chemokines

Interferon b1

Interferon g

Interleukin 8

Interleukin 10

Interleukin 12A

Midkine (neurite growth-promoting factor 2)

Neuropilin

Prolactin

Tumor Necrosis Factor a

Vascular endothelial cell growth inhibitor

Colony stimulating factor 3 (granulocyte)

Interferon a1

Pleiotrophin (heparin binding growth factor 8/neurite growth-promoting

factor 1)

Small inducible cytokine A2

Transcription factors

DNA-binding protein inhibitor

Inhibitor of DNA binding 3 (dominant negative helix-loop-helix protein)

Mothers against decapentaplegic, Drosophila homolog 1

V-ets avian erythroblastosis virus E26 oncogene homolog 1

Hypoxia-inducible factor 1 (basic helix-loop-helix transcription factor)

V-erb-b2 avian erythroblastic leukemia viral oncogene homolog 2

H-CAM Homing-associated cell adhesion molecule, CEACAM Carcinoembryogenic antigen-

related cellular adhesion molecule, ELAM-1 Endothelial leukocyte adhesion molecule1, ICAM-1

Intercellular adhesion molecule 1, PECAM-1 Platelet/endothelial cell adhesion molecule 1,

VCAM-1 Vascular cell adhesion molecule 1, DCC Deleted in colorectal carcinoma, NCAM-1

Neural cell adhesion molecule 1, NRCAM Neuronal cell adhesion molecule, MICA MHC class I

chain-related protein A

Isolation, Characterization, Differentiation, and Application of Adipose-Derived Stem Cells 71

an initial commitment, in which cells are determined in the adipogenic lineage

without yet expressing markers of terminal differentiation. Although the molecular

trigger which converts the multipotent stem cells into preadipocytes has not been

identiﬁed, it was demonstrated that treatment with bone morphogenic protein 4

(BMP4) induces adipocyte commitment of the multipotent stem cell line C3H10T1/

2 via an activation of the Smad signaling pathway by phosphorylation [108]. An

identiﬁcation of the transcription factors controlled by this signaling pathway might

help one to understand the factors necessary for adipogenic determination [109].

Recent studies suggest that regulation of the Wnt pathway is important in adipo-

genesis [110]; further evidence is given by the fact that expression of Dickkopf

(Dkk)1 and secreted frizzled-related protein (sFRP) is necessary for differentiation

of ASC [111]. Characteristic genes of adipogenic differentiation include peroxi-

some proliferator-activated receptor-g(PPARg), lipoprotein lipase (LPL), glycerol-

3-phosphate dehydrogenase (GAPDH), and glucose transporter 4 (Glut4), whereas

adipogenic inhibitory genes like preadipocyte factor-1 (Pref-1) are repressed [112].

A high cellular density [113] and a subsequent growth arrest at the G0/G1

boundary are important prerequisites for preadipocyte differentiation [114]. FGF2

enhances adipogenic differentiation in ASC which in turn is [113] stimulated by

3-isobutyl-1-methylxanthine (IBMX), dexamethasone, insulin, and indomethacin

[115]. Thiazolidinediones like trogitazone, pioglitazone, and rosiglitazone are con-

sidered to be strong inducers of adipogenic differentiation by binding to PPARs

[116]. Hong et al. achieved an improvement of adipogenic differentiation in vitro

by supplementation with 17-bestradiol [117] consistent with the regulative inﬂu-

ence of sexual steroid hormones on adipocyte development [118].

4.2 Osteogenic Differentiation

Since their ﬁrst description by Urist [119], the osteo-inductive potential of bone

morphogenetic proteins (BMPs) has been well studied. The transcriptional activator

Runx2/Cbfa1 acts downstream of the BMP signaling pathway on the expression of

osteogenic genes including osteopontin (OPN) and Collagen type 1 subtype A1

(COL1A1) [120].

Medium formulas which have been shown to induce osteogenic phenotypes of

ASC include supplementation with dexamethasone, b-glycerolphsphate, and 1,25-

dihydroxyvitamin D

Mischen et al. examined the osteogenic differentiation capacity under different

growth conditions with variable supply of oxygen and nutrients [121]. They demon-

strated a dependence of osteogenic differentiation on sufﬁcient availability of glucose

and/or oxygen with concentration ranging from physiologically normal to high. From

these results the authors concluded that therapeutic use of ASC in an hypoxic

environment, e.g., ischemic osseous defects, require supraphysiologic concentration

of glucose and glutamine to compensate for the lack of oxygen. Knippenberg et al.

combined stimulation by 1,25-dihydroxyvitamin D

and ﬂuid shear stress to induce

72 J.W. Kuhbier et al.

osteogenic differentiation, demonstrating that the mechanosensitivity in these cells

leads to increased expression of marker genes for bone cell development [121]. It has

been assumed that mechanical loading increases gene expression of spermidine/

spermine N1-acetyltransferase (SSAT), a regulator of polyamine catabolism, which

in turn modulates nitric oxide (NO) production and cyclooxygenase 2 (COX2) gene

expression, which indicates a bone-cell like response to mechanical stimulation[122].

Several groups induced osteogenic differentiation by genetic manipulation of

ASC. Stimulation with osteogenic protein -1 (OP-1) induced osteopontin secretion

and the production of mineralized nodules in murine ASC [123]. Dragoo et al.

demonstrated that adenoviral transmitted transfection of ASC with BMP-2 led to

bone induction comparable to cells treated with recombinant BMP-2 [79]. Rat ASC

transduced with human BMP-7 gene differentiated in vitro into osteoblasts, pro-

ducing osteocalcin and a mineralized matrix [124]. Transduction of ASC with the

osteogenic transactivator Runx2 by adenoviral gene delivery induced osteoblastic

gene expression [125] equally successfully, which means that the implementation

of effectors downstream of BMP are also suited for the induction of osteogenic

differentiation in ASC. The idea to integrate tissue engineering approaches into

single surgical procedures prompted Helder et al. to investigate the possibility of

short term stimulations to induce osteogenic differentiation. In their study, ASC

have been stimulated for 15 min with BMP-2 and BMP-7. While BMP-7 induced a

more chondrogenic phenotype, a short-term stimulation with BMP-2 resulted in an

increase of Runx-2 and osteopontin gene expression in the stimulated cultures after

4 days; gene expression, however, decreased to control values in 14-day-old

cultures [126]. So principally short inductions may be effective but other supporting

schemes have to be implemented to achieve a stable osteogenic phenotype.

4.3 Chondrogenic Differentiation

The chondrogenic potential of ASC has been described as somewhat impaired

compared to bone marrow derived stem cells which might depend on higher

expression rates of Integral membrane protein 2A (ITM2A) [127]. Culture medium

should contain tissue growth factor b1, ascorbate-2-phosphate, and dexamethasone

[128]. The regulative pathways leading to chondrogenic differentiation of ASC are

less well characterized than the pathways for adipose and bone differentiation but it

has been found that BMP-4, TGF b3, as well as the Smad 1, 2 and 6 are involved.

The growth and differentiation factor-5 (GDF5), which is an important factor in

chondrogenesis [129], is also able to promote chondrogenic differentiation in ASC

transduced with an adenovirus carrying gdf5 [130].

Chondrogenic differentiation depends on a sufﬁcient supply of oxygen and

nutrients [131]. A high cellular density is also a prerequisite for chondrogenic

differentiation [132]. The working group of M. Longaker achieved chondrogenic

differentiation in a 3D micromass culture system [133]. Additional information was

provided by Lu et al. based on their ﬁndings that ASC culture in collagen II

Isolation, Characterization, Differentiation, and Application of Adipose-Derived Stem Cells 73

enhanced chondrogenic gene expression. The authors could correlate this with a

downregulation of Rock 2 gene expression and assume that the differences

observed result from a more rounded cell shape associated with culture in collagen

II gels under a b1 integrin-Rho A/Rock signaling pathway [134]. Controlled release

of TGF-b1 from gelatine-chitosan microspheres resulted in enhanced expression of

the chondrogenic marker proteins collagen II and aggrecan when compared to

controls treated with gelatine microspheres [135].

Chondrogenesis was enhanced by stimulation with FGF-2 [96]. It was reported

that extended passaging (P4–P9) resulted in enhanced expression of aggrecan in

ASC stimulated with BMP-6 [136] which is a potent inducer of chondrogenic

differentiation [91].

5 In Vivo Applications

Since several studies have been carried out concerning the application of bone-

marrow derived mesenchymal stem cells (BSC), studies concerning the application

of ASC display a rapidly growing ﬁeld in cell therapy. Because of their differentia-

tion potential and easy-to-obtain location, ASC display at least an equivalent, but

probably a superior, alternative. Due to the more comfortable yield and higher cell

numbers, they seem to be more practical in use than BSC [33,34].

As previously reported, ASC secrete a favorable cytokine proﬁle for biological

applications [31,32,137]. This proﬁle is certainly one reason for the impressive

biochemical properties of those cells.

5.1 Cytokine Proﬁle Secreted by ASC

A review of the literature regarding clinical applications of ASC reveals outstand-

ing properties of these cells, mainly caused by secretion of a very favorable mixture

of cytokines, which is not only angiogenic, but also immunosuppressive and

antioxidative [138].

Rehmann and coworkers analyzed the cytokine proﬁle of ASC in 2004 and

found large amounts of vascular endothelial growth factor (VEGF; 1203 254

pg 10

6

cells), hepatocyte growth factor (HGF; 12,280 2944 pg 10

6

cells), and

tissue growth factor-b(TGF-b; 1247 346 pg 10

6

cells), but only small amounts

of granulocyte/monocyte-colony stimulating factor (GM-CSF; 84 15 pg 10

6

cells) or basic ﬁbroblast growth factor (bFGF; 124 13 pg 10

6

cells). Strikingly,

when cultured in hypoxic medium containing just 1% O

instead of 21% O

VEGF secretion increased nearly ﬁvefold (from 1203 254 pg 10

6

cells to

5980 1066 pg 10

6

cells), which is consistent with other studies implying

hypoxia as a signiﬁcant stimulus for angiogenesis at least for ASC [32].

In a study by Kilroy et al., HGF secretion could be induced by treatment of bFGF

or epidermal growth factor (EGF) [31]. Additions of 10 ng mL

1

of either bFGF or

74 J.W. Kuhbier et al.

EGF resulted in a 2- to 20-fold increase of baseline secretion of HGF, while the

presence of ascorbat-2-phosphate additionally to bFGF or EGF, respectively,

increased HGF secretion even more. Together, ascorbat-2-phosphate and bFGF or

EGF ampliﬁed HGF secretion to the 2.0- or 6.3-fold of just the growth factor alone.

Interestingly, neither one of those factors alone nor coaddition with ascorbat-2-

phosphate enhanced secretion in differentiated adipocytes. In that study, it was also

found that secretion of proinﬂammatory factors can be induced by treatment of

ASC with lipopolysaccharide (LPS), probably due the presence of toll-like recep-

tors in ASC [139]. Using enzyme linked immuno-sorbent assay (ELISA), the

concentration of different cytokines was analyzed for time dependence.

Thus, exposure to LPS for 24 h increased the secretion levels of proinﬂammatory

cytokines, though they show different temporal secretion levels. While interleukin

(IL)-6 and IL-8 exhibited their maximal mean level of 7845 pg mL

1

or 6506 pg mL

1

ASC-CM respectively, tumor necrosis factor a(TNF a) reached its peak (maximal

mean level of 112 pg mL

1

) after 8 h of LPS exposition and declined after 24 h. The

hematopoietic, but also proinﬂammatory cytokines macrophage-colony stimulating

factor (M-CSF) and GM-CSF were also induced to a peak of 976 and 52 pg mL

1

respectively, after 24 h induction. The levels of the B-cell inductive factor IL-7 and of

the proinﬂammatory cytokine IL-11 were low, but displayed signiﬁcant induction of

LPS after 24 h, reaching maximal mean levels of 3.4 and 12.7 pg mL

1

,respectively,

while neither IL-1a,IL-1b, nor IL-12 were detectable in the ASC conditioned medium

(ASC-CM). While ASC were not as effective as marrow-derived stroma (MdS) in

supporting formation of clonogenic myeloid cells (CMC) out of CD34

CD38

neg

Lin

neg

cells (64.1 11 CMC out of 100 CD34

CD38

neg

Lin

neg

cells for MdS vs 24.7 9

CMC for ASC), they can actually be stated as hematopoietic effective.

In a study by Bhang et al., inﬂuence of hypoxia, addition of FGF-2, and addi-

tional supplement of FGF-2 in hypoxic conditions were investigated [140].

While hypoxia and exogenous FGF-2 each elevated VEGF, endogenous FGF-2,

and hypoxia-inducible factor (HIF)-1a, but not HGF secretion, supplementation of

both together led to further increase of VEGF, endogenous FGF-2, HIF-1a, and

HGF secretion.

The ﬁndings of the cytokine proﬁle ASC were quite similar in a study by

Kim et al. which revealed the following cytokine levels in ASC-CM cultivated

for 72 h [85]: platelet-derived growth factor (PDGF; 44.41 2.56 pg mL

1

placenta-derived growth factor (PlGF; 37.87 1.69 pg mL

1

), bFGF (131.35 

30.31 pg mL

1

), keratinocyte growth factor (KGF; 86.28 20.33 pg mL

1

TGF-b1 and -b2 (103.33 1.70 and 75.42 95.98 pg mL

1

), HGF (670.94 

86.92 pg mL

1

), and VEGF (809.53 95.98 pg mL

1

). In addition, the values

of type I collagen and ﬁbronectin were measured, showing interestingly large

amounts, containing more than 1000-fold the values of cytokines (921.47 49.65

ng mL for collagen I and 1466.48 460.21 ng mL

1

for ﬁbronectin).

In a study by Wei et al. that researched the application of ASC-CM in a mouse

model of hypoxic brain injury (see Sect. 4.3 for further details), contents of brain-

derived neurotrophic factor (BDNF) and insulin-like growth factor (IGF)-1 were

detected, suggesting also neuroprotective properties of ASC [141].

Isolation, Characterization, Differentiation, and Application of Adipose-Derived Stem Cells 75

Additionally, angiogenic matrix metalloproteinases (MMP), MMP-3 and MMP-

9 in particular, were detected in ASC-CM in higher amounts than BSC conditioned

medium [137]. In this study, amounts of MMP-1, MMP-2, tissue inhibitor of matrix

metalloproteinase (TIMP)-1, TIMP-2, TIMP-3, monocyte-chemoattractant protein

(MCP)-1, MCP-2, and granulocyte chemotactic peptide (GCP)-2 were also detect-

able in ASC-CM, though in low amounts, which could be slightly increased by

culturing in endothelial growth medium for microvascular cells (EGM-MV).

Proteomic analysis for antioxidants in ASC-CM revealed the presence of the

precursors of insulin-like growth factor-binding protein (IGFBP)-3, IGFBP-4,

IGFBP-5, IGFBP-6, IGFBP-7, IL-6, IL-8, latent transforming growth factor beta

binding protein (LTBP)-1, LTBP-2, pigment epithelium-derived factor, superoxide

dismutase (SOD)-2, SOD-3, and glutathione peroxidase [82].

A study by Kang et al. investigated the mRNA-expression of different immuno-

modulatory cytokines, revealing a superior expression of immunosuppressive fac-

tors [142]. Constitutive expression was measured for TGF-b, IL-6, IL-8, CCL2,

CCL5, VEGF, HGF, COX2, TIMP-1, and TIMP-2, but not for IL-4, IL-10, IL-13,

IL-17A, Interferon (IFN)-g, and GM-CSF. Moreover, TNF-aproduction of leuko-

cytes cocultured with ASC decreased signiﬁcantly, whereas TGF-b, IL-6 and IFN-g

production signiﬁcantly increased in ASC when cocultured with leukocytes. Immu-

nomodulatory factors of ASC, such as TGF-b, HGF, prostaglandin E2 (PGE2), and

indoleamine-2,3-dioxygenase (IDO) increased signiﬁcantly in an ASC/leukocyte

coculture.

Taken together, the mixture of constitutively or inducibly expressed angiogenic,

hematopoietic, and immunomodulatory mediators secreted by ASC suggest a major

inﬂuence of ASC on other cell types.

Several studies provided evidence for a humoral effect of ASC on other cells by

in vitro tests, in which direct cell–cell contacts were avoided by trans-well assays or

by addition of ASC-conditioned medium. Further in vitro and in vivo analysis

conﬁrmed (see following paragraphs for further details) that no direct contact of

ASC to tissue resident cells is required to achieve the desired effect.

5.2 Angiogenesis and Functional Improvement of Ischemic

Muscle Tissue

The cytokine proﬁle mentioned above is surely the main reason for the impressive

angiogenetic capacity, i.e., the induction of tissue neovascularisation. This capacity

is perhaps the most inﬂuential property of the ASC when it comes to regeneration

because sufﬁcient nutrition and oxygenation is the basic principle for functional

tissue regeneration.

Neels et al. studied adipose tissue formation, e.g., a fat pad, from ASC in vivo

[143]. For that purpose, they injected 3T3-F442A preadipocytes subcutaneously

into nude mice. Surprisingly, they found not just mature adipocytes, but also blood

vessel formation in the derived fat pad. To investigate whether these vessels were

76 J.W. Kuhbier et al.

derived from the implanted cells or host, they prestained 3T3-F442A cells with

ﬂuorescent green cell tracer and afterwards stained the specimen with ﬂuorescent

endothelial cell-speciﬁc lectin. By this method they could demonstrate that the new

vascularization was derived from host cells. New vessel formation by host cells was

found in the pads explanted after 1, 2, 3, and 4 weeks, suggesting a common origin

of early and late neovascularization. Interestingly, vessel invasion occurred only at

speciﬁc points in the fat pads, probably due to the fascia surrounding the fat pad.

Thus, vascularization displayed as sprouting from larger vessels that were sur-

rounded by nerve bundles that resided just outside the fascia.

Similar ﬁndings were observed by Nakagami et al. who applied ASC in an

ischemic hindlimb model in vivo ﬁrst [92].

In preliminary in vitro studies, they found an increase of endothelial cell (EC)

viability, migration and tube formation in coculture with ASC, mainly through

secretion of VEGF and HGF. The inﬂuence of both of these factors was conﬁrmed

by antibody blocking, either of one factor alone or of both together. This also

revealed synergistic effects as blocking of one factor inhibited EC viability by 25%

(VEGF) or 23% (HGF), respectively, and EC migration by 48% (VEGF) or 26%

(HGF), respectively, while blocking of both of them returned EC viability and

migration to the baseline level.

The in vivo model of hindlimb ischemia was achieved by ligation of the distal

potions of the femoral artery and saphenous vein as wells as dissection of the side

branches. ASC were harvested from the inguinal adipose tissue of the same mice,

and the mice were divided into three groups. In one group, just PBS was injected

into the ischemic hindlimb 10 days after ischemia generation, in the second and in

the third, each 1 10

ASC in endothelial growth medium (EGM) either enriched

with or without growth-factors were injected. Then, 2 and 4 weeks after implanta-

tion, blood ﬂow was evaluated by laser Doppler imaging, which showed enhanced

recovery in the ASC application group compared to the control group and further

improvement in the group with application of ASC combined with growth-factor

riched EGM.

Histological analysis of the thigh adductor muscle revealed capillary density

depending on change in the blood ﬂow level with the capillaries being positive for

von Willebrand factor as endothelial marker. Interestingly, the injected ACS did not

show any positive immunoﬂuorescence staining for von Willebrand factor. Thus,

they stimulated capillary ingrowth without endothelial differentiation of themselves.

In 2006, Moon et al. studied dose and time dependency of ASC injection in the

hindlimb ischemia model by ligation of the femoral blood vessels. He assessed

blood ﬂow by laser Doppler ﬂowmetry and muscle necrosis by histological and

immunohistological analysis [144].

Ischemic hindlimbs in the ASC group showed normal appearance while mice

receiving just PBS injection experienced severe ischemic damage with limb con-

tracture and a 60% incidence of autoamputation after 28 days. The blood ﬂow in the

ASC treated group was signiﬁcantly higher than in the PBS-treated control group,

actually nearly comparable to the nonischemic control mice. Histological observa-

tion showed functional muscle ﬁber arrangement vs muscle necrosis in the control

Isolation, Characterization, Differentiation, and Application of Adipose-Derived Stem Cells 77

group, while immunostaining with von Willebrand-factor antibody also revealed

intact blood vessels vs blood vessel necrosis in the control group. These ﬁnding

were dose-dependent, as ASC injections with cell numbers ranging from 10

to 10

cells resulted in better clinical and histological outcomes in the higher cell numbers.

Surprisingly, the time-dependence of ASC injection after vessel ligation resulted in

better endpoints of blood ﬂow in delayed application of ASC 7 days after vessel

ligation compared to application of ASC 24 h after the start of ischemia. The

authors explained these ﬁndings to be related to better cell survival by subsidence

of inﬂammatory responses in the hindlimb. Due to the high cell numbers required

for cell transplantation, especially when they should be yielded from small amounts

of tissue, a later injection is also favorable to expand ASC before transplantation.

The same workgroup found an essential role of MMP for vessel formation in an

additional study in 2007 [145]. Especially MMP-3 and -9 seem to have outstanding

importance for the formation as inhibition by GM6001 decreased in vitro endothe-

lial tube formation of ASC. The same effect could be observed by transfection of

ASC with silencer RNA for MMP-3 and -9 in vitro, which was conﬁrmed in vivo in

a similar mice model. Mice transplanted with MMP-3 or -9 silencer RNA (siRNA)

oligonucleotides-transfected ASC showed lower blood ﬂow recovery and higher

tissue injury compared to mice transplanted with ASC which were transfected with

control oligonucleotides. Comparison of injection of ASC or BSC demonstrated

improved recovery from hindlimb ischemia in the ASC group. This ﬁnding suggest

a role of MMP-dependent angiogenesis as BSC displayed lower MMP expression

rates in RT-PCR analysis compared to ASC.

Furthermore, Fang et al. found an important therapeutic role for stromal cell-

derived factor 1 (SDF-1), a factor which mobilizes endothelial progenitor cells from

the bone marrow. In this study, intraperitoneal injection of a neutralizing anti-SDF-

1 antibody in an ischemic hindlimb model resulted in smaller numbers of circulat-

ing EPC and less therapeutic efﬁcacy of ASC [146]. A positive correlation between

ASC injection and increase of SDF-1 from the ischemic tissue was found, causing

higher numbers of circulating EPC. These results suggest SDF-1 being one of the

main factors responsible for the neovascularisation of ischemic tissue mediated by

ASC implantation. Interestingly, VEGF gene expression was not detected in ische-

mic tissue, but in ASC, which implicates a complex orchestration of growth factors

by implanted ASC.

Hypoxia has recently been shown to increase angiogenic growth factor secre-

tion, e.g., VEGF and HGF, which suggests an essential role for ASC in tissue

recovery after injury, usually leaving tissue regions with suboptimal nutrition [140].

The same effect, i.e., local increase of angiogenic growth factors can be achieved by

supplementation of FGF-2, which also supported local survival of ASC and neo-

vascularisation in an ischemic hindlimb model.

Functional improvement of ischemic muscle tissue by ASC transfer was also

observed in a myocardial infarction model by Wang et al. [147]. ASC were labeled

before implantation with superparamagnetic iron oxide (SPIO) and Lenti-GFP-

vectors. One week after ligation of the left anterior descending coronary artery

(LAD), ASC were implanted and rats were allowed to recover for 4 weeks. Left

78 J.W. Kuhbier et al.

ventricular (LV) function and thickness of the myocardial wall were monitored

with magnetic resonance (MR) imaging. ASC implanted animals showed signiﬁ-

cantly higher LV ejection fractions than control groups as well as a thicker LV

formation and smaller ischemic size in the infarct area, which was approved by

histological analysis. Indeed, SPIO-containing GFP-labeled ASC were found in

the infarct rim and infarct core, indicating direct involvement of ASC in infarct

remodeling.

The purpose of another study by Schenke-Layland was to investigate the effect

of freshly isolated ASC on engraftment, LV-function, and remodeling of myocar-

dial tissue [148].

Myocardial infarction (MI) was created by ligation of the LAD for 45 min,

followed by a stabilizing phase of 15 min and then injection of ASC harvested from

GFP-expressing rats in the chambers of the ischemic LV of Lewis rats. Functional

assessment was revealed by echocardiography (ECG) prior to MI as well as 6 and

12 weeks after MI. ECG-evaluated ejection fractions, stroke volumes, and cardiac

outputs were compared to the preinfarction values, which displayed a signiﬁcantly

better LV function of the ASC-treated group vs the saline-treated control group.

While no signiﬁcant engraftment of the infracted area could be found, remodel-

ing was effectively prevented by ASC treatment, demonstrated by histological

examination.

In most recent studies, heart failure caused by myocardial infarction was also

treated with ASC injection. Recovery of heart function was monitored with MR and

ECG [147,149]. In the study by Wang et al., improved heart function and increased

capillary density was observed though only 0.5% of the implanted cells differen-

tiated to cardiomyoblast-like cells (CLC). These ﬁndings were supported in a study

by Okura et al. in a coronary ligated mouse model in which one group of human

ASC were differentiated to CLC prior to transplantation by induction with 0.1%

dimethyl sulfoxide for 48 h, while another group of ASC remained undifferentiated.

Cell incubation at 20C for 20 min achieved spontaneous detachment as mono-

layers, and transplantation of these monolayer-patches was performed directly into

the infracted area of the heart. CLC differentiation was conﬁrmed by evidence of

the cardiac enzymes alpha-cardiac actin, myosin light chain, and myosin heavy

chain. Although patch-transplantation resulted in short-term improvement evalu-

ated by ECG, long-term improvement was only obtained in the CLC-transplanted

group. Histological analysis revealed engraftment of CLC to the scarred areas, but

not of ASC. CLC also differentiated into human cardiac troponin I-producing cells,

and thus resulted in recovery of cardiac function and improvement of the long-term

survival.

These ﬁndings are supported by results of a study by van der Bogt et al. in

which no long-term improvement of heart function could be found after trans-

plantation of neither ASC nor BSC. No ASC were found to be present in the heart

after 4 weeks of implantation, which was monitoredbyinvivobioluminescence

measurement after injection of D-luciferin [150].Whilethisisincontrasttothe

results of most other studies, the study mentioned beforehand could explain these

ﬁndings [149].

Isolation, Characterization, Differentiation, and Application of Adipose-Derived Stem Cells 79

In most studies, the main reason for improvement of ischemic myocardium is

mediated by neoangiogenesis, derived by growth factors secreted by ASC, while a

study by Okura et al. showed that just a very small percentage of undifferentiated

ASC stay resident in the infarction area of the heart, in contradiction to the study of

van der Bogt et al. [149,150]. In this context, an in vivo detection of biolumines-

cence of predifferentiated CLC implanted to the infracted region of the heart could

lead to further understanding of repair mechanisms by ASC.

ASC also display homing properties, i.e., trafﬁcking to ischemic tissues if

injected intravenously, for which a study by Bailey et al. offers an explanation

[151]. In an agent-based computer-simulation, based on 150 rules formulated after

an extensive literature review, the adhesion molecule selectin and its cell receptor

CD24 was identiﬁed as responsible for leukocyte-like “rolling”-properties of ASC,

meaning endothelial adhesion-mediated slowing of circulating cells in the blood

ﬂow. In this manner, adhesion and extravasation of ASC were also mediated, which

could be conﬁrmed in an in vitro model, showing that only a subpopulation of ASC

that expressed CD24 slowed down on an immobilized P-selectin coated surface.

With the knowledge of those underlying mechanisms, further studies concerning

the guidance of endothelial P-selectin expression in ischemic tissue should be done

to uncover the homing processes in vivo.

5.3 Neurological and Skeletal Application of ASC

Interestingly, neuronal recovery is also possible after transplantation of ASC, as the

ﬁrst studies by Kang et al. showed, probably due to the homing to ischemic tissues

[152]. Murine ASC were treated with azacytidine to induce neural differentiation,

which was conﬁrmed by expression of microtubule-associated protein 2 (MAP2)

and glial ﬁbrillary acidic protein (GFAP) as neuron-resident. After transfection with

Lac-Z to visualize migration patterns, ASC were transplanted to the lateral ventricle

of the brain of a rat model. Though ASC migrated to various parts of the brain,

ischemic brain injury induced by middle cerebral artery occlusion (MCAO)

increased migration to the injured cortex signiﬁcantly. While functional deﬁcits

showed recovery after transplantation of differentiated ASC, transfection of ASC

with the gene of BDNF improved motor recovery of the deﬁciency.

In addition to Kang’s results, Lee and Yoon used human ASC instead of murine

stem cells in a similar study design. They monitored the neurological recovery by

histological analysis and also performed behavioral tests for which animals were

trained 3 days prior to infarction [153]. They found ASC being located in several

brain areas but mainly on the borders between infarcted and adjacent (healthy)

tissue. Behavioral tests revealed signiﬁcant improvement of motor function in the

ASC transplanted group compared to the control groups which obtained either no or

sham injection with PBS after MCAO.

The same migration properties were shown by SPIO labeling of ASC prior

to transplantation, monitored via MR imaging [154]. ASC transplantation was

80 J.W. Kuhbier et al.

followed by stereotactic imaging directly into areas adjacent to the infarcted tissue,

which was veriﬁed by postmortem histological analysis 24 h onwards.

Even merely conditioned medium of ASC with the secreted growth factors

should beware of long-term tissue loss after hypoxic brain injury, as could be

shown in a study by Wei and colleagues [141]. ASC-CM was applied via the

jugular vein of neonatal Sprague-Dawley rats that were subjected to brain ischemia

1 h or 24 h after injury. Morphometric analysis was performed 1 week after and

behavioral tests and histological analysis 2 months after transplantation. The ASC-

CM treated groups displayed less hippocampal and cortical volume loss as well as

signiﬁcantly better results in the behavioral tests. Histological examination also

revealed less neuronal loss. In ASC-CM, several neurotrophic factors, IGF-1 and

BDNF in particular, were identiﬁed as probably responsible for these impressive

ﬁndings.

ASC transplantation was also beneﬁcial in brain recovery after hemorrhagic

stroke induced by intracerebral stereotactic infusion of collagenase and followed by

ASC application 24 h afterwards [137]. Cell numbers positively stained for terminal

transferase dUTP nick end labeling (TUNEL), myeloperoxidase (MPO), or OX-42,

and brain water content were checked 3 days post transplantation as markers for

acute brain inﬂammation, hemispheric atrophy, and perihematomal glial thickness.

Additionally, behavioral scores were evaluated 6 weeks afterwards. All markers

together with brain atrophy were signiﬁcantly less in the treatment groups com-

pared to the controls, but strikingly, histological analysis revealed ASC in the

perihematomal areas that were stained positive for endothelial markers, i.e., von

Willebrand factor and endothelial barrier antigen, but not for neuronal or glial

markers, suggesting differentiation into endothelial but not neuronal cells.

In neurotoxic brain damage too, ASC application was successful in recent

studies, whether if the cause was glutamate-induction [155] or 3-nitroproprionic

acid [156]. In both studies, transplantation of ASC [155]orjustinjectionof

BDNF-containing ASC-CM [156] showed signiﬁcant improvement of neurologi-

cal functions.

Furthermore, in other locations of the central nervous system, like in spinal cord

injury, ASC transplantation led to efﬁcient migration of approximately 35% of the

transplanted cells to the site of the injury, followed by signiﬁcant recovery of motor

function in a rat model [157].

Lately, another promising application was the transplantation of a large amount

of ASC (approximately 25 million cells) in three cases of multiple sclerosis in a

clinical phase I trial [158]. Though MR revealed no signiﬁcant changes at the lesion

sites, subjective and functional improvement appeared in all three cases. Pharma-

ceutical medication could be drastically reduced while neurological tests had

signiﬁcantly better results than before treatment. These impressive results have

been achieved without further treatment.

Besides the neurological, cardial, and muscular applications, ASC have also

been used in regeneration purposes of the skeletal system.

Thus, the ﬁrst application in skeletal tissue engineering using ASC was an

extended traumatic calvarial defect, where ﬁbrin glue was used as carrier and

Isolation, Characterization, Differentiation, and Application of Adipose-Derived Stem Cells 81

scaffold for the ASC [159]. In this case report, a 7-year-old girl was suffering from a

closed, multifragment calvarial fracture after a fall. Conditions were complicated as

a bilateral decompressive craniectomy had to be performed because of refractory

intracranial hypertension. After secondary replantation of the calvarial fragments

with titanium miniplates, progressive and disseminated calvarial bone resorption

occurred over several months, probably due to insufﬁcient ﬁxation. Loosening of

almost all osteosynthesis plates and chronic infection with accompanying signiﬁ-

cant bone resorption resulted in an unstable skull. Following resection of the

unstable osteosynthesis and scar tissue, an imprint template of the defects was

made and two macroporous sheets were manufactured with the imprint. In the

sheets, bone was taken from the ilium, milled, and applied to the sheets. In addition,

ASC were derived from the subcutaneous adipose tissue, processed, and injected

into the sheets. To keep the cells in place, autologous ﬁbrin glue yielded from

peripheral blood of the patient 2 days prior was sprayed with a spray adapter into

the sheet. A cranial computer-tomography showed marked ossiﬁcation in the defect

areas, depicting that healing processes have been occurred, though it remains

questionable how much of the effect was due to conventional bone transplantation

and what inﬂuence ASC transplantation had.

These ﬁndings could be approved by Cowan et al. who used a calvarial defect in

a mouse model [160], though they used allogenic cells for regeneration. In their

study they also compared ASC with BSC, calvarial-derived osteoblasts, and dura

mater-derived cells as well as all of these cell types derived from either juvenile or

adult donor mice.

Actually, they found ASC resulting in higher mineralization and metabolization

rates and thus bone of higher quality than in the other groups and juvenile cells

promoting better outcomes than adult cells. However, bone regeneration occurred

in all cell types with BSC rebuilding bone faster than osteoblasts and osteoblasts

faster than dura mater-derived cells.

Hattori et al. compared bone formation by allogenic ASC and BSC seeded on b-

tricalcium-phosphate (b-TCP) scaffolds that were implanted subcutaneously in the

backs of nude mice [75]. While they found no signiﬁcant morphological differences

in scanning electron microcopy, histology, and immunohistology as well as the

protein amount of secreted osteocalcin between ASC and BSC, implantation of the

b-TCP-scaffold alone gave poor results. Noteworthy, only few cells were stained

positive for antimouse osteocalcin while most cells were positive for antihuman

osteocalcin. As the authors yielded ASC from humans and purchased human BSC,

these results indicate that the new built bone was mostly of stem cell origin.

In contrast to these ﬁndings, Follmar et al. prepared bone allografts in a rabbit

model by rinsing the bone marrow out, drilling cortical holes in the surface, and

cutting the ends off, thus manufacturing 2.5-cm bone tubes [161]. Those tubes were

either implanted into rabbits subcutaneously without further modiﬁcation, ﬁlled

with ﬁbrin glue, ﬁlled with ﬁbrin glue containing undifferentiated ASC, or ﬁlled

with ﬁbrin glue containing predifferentiated ASC. Six weeks after implantation,

tubes were explanted and examined histologically. In the bone tubes without any

supplement, a foreign body reaction, i.e., ﬁbrous encapsulation, could be observed.

82 J.W. Kuhbier et al.

The ﬁbrin glue tube revealed a mild inﬂammation reaction, especially at the cortical

perforations, indicating that ﬁbrin glue provokes an immune response. A mild

inﬂammation can also be observed in the ASC groups as well as acellular blebs,

apparently remnants of dead cells. Since lack of oxygen and nutrient supply can be

one of the causes for cell death, the ﬁbrin glue envelope around the ASC might have

acted as a barrier instead of being a matrix for binding and storage of growth factors

secreted by ASC. This hypothesis might have served as motivation for Lendeckel

et al. to spray ﬁbrin glue onto the cell-seeded sheets.

Another study by Peterson et al. found poor bone formation by ASC-seeded

collagen-ceramic scaffolds implanted in femoral defects of nude mice comparable

to unseeded control scaffolds [162]. Results were assessed by radiography, his-

tology, and mechanical testing. However, when ASC were transfected with human

BMP-2-carrying adenoviruses, bone regeneration improved dramatically. In

mechanical testing, regenerated bones were inferior to undamaged control femurs.

Reviewing the literature for in vivo implantation of ASC to treat cartilage

defects, we found two studies using an experimental rabbit model with intraarti-

cular application of ASC seeded on a carrier matrix, i.e., ﬁbrin glue [90]or

alginate [163]. In both studies, a deﬁned cartilage defect was created artiﬁcially

in the knee joint of the animals using a dermal biopsy punch [90]orasmallimpact

machine [163]. Dragoo et al. applied ASC to these chondral defects in a ﬁbrin

glue scaffold while Zhang et al. used calcium-alginate as carrier matrix. Prior to

application, Dragoo et al. transfected ASC with Lac-Z gene to determine the fate

of the transplanted ASC. Results were evaluated by morphological and histologi-

cal assessment [163] and further on protein and gene level by Western Blot and

PCR [90].

In all experiments, ASC groups showed superior results to those of the control

group. Zhang et al. found proper chondral tissue in histological analysis as well as

in macroscopic inspection, revealing chondrocyte-like cells, thick matrix, and

cartilage-like lacunas after 8 weeks and tissue adjacent to native cartilage after

12 weeks, respectively, in the ASC-treated group. In the study by Dragoo et al., all

12 experimental defects showed complete healing, 10 of 12 scaffolds had seamless

annealing to the native cartilage. Aggrecan, a superﬁcial zone protein of cartilage,

collagen type II messenger ribonucleic acid, and beta-galactosidase as Lac-Z gene

product were identiﬁed in all 12 experimental specimens, which exhibited a colla-

gen type II:I ratio similar to that of normal rabbit cartilage. Quantitative histologic

analysis that evaluated nature, surface thickness, integrity, bonding, and absence of

degenerative changes resulted in an average score of 18.2 of 21 in the experimental

group, compared with 10.0 in the controls [90].

5.4 ASC for Enhancement and Acceleration of Wound Healing

In recent years, the potential of ASC for wound healing has also been discovered

and is currently further tested for future therapeutic options. In 2005, Rigotti et al.

Isolation, Characterization, Differentiation, and Application of Adipose-Derived Stem Cells 83

published a ﬁrst clinical trial concerning wound healing of chronic radiation wound

defects in a small patient collective of 20 patients [164]. Caused by external

oncologic radiation therapy, lesions may spontaneously appear after no or minor

trauma and may rapidly proceed in size in irradiated tissue with former healthy

appearance even years after end of the therapy. The most frequent presentation is

radiodermatitis with erythema, desquamation, and edema, which evolves over time

in subcutaneous ﬁbrosis and, in most critical cases, toward radionecrosis. There are

hypotheses that identify vessel hyperpermeability and altered blood ﬂow causing a

chronic ischemic status as reason for the tissue damage [165]. Nevertheless,

ultrastructural analysis by Rigotti et al. revealed capillary vessels reduced in

number with duplication of the basal membrane and ectatic lumina [164]. Treated

patients were suffering on progressive tissue lesions, i.e., grade 3 (several symp-

toms) and grade 4 (irreversible functional damage) according to the LENT-SOMA

scale for classiﬁcation of late radiation morbidity. Puriﬁed lipoaspirates taken from

a healthy donor site were administered by repeated computer-assisted injection, and

therapy outcomes were assessed as downgrading in the LENT-SOMA scale after

18–33 months.

Except for one patient, a signiﬁcant increase in the scale could be observed,

ranging from complete remission to slight improvement, e.g., downgrading from

grade 4 (irreversible functional damage) to grade 3 (several symptoms). The authors

hypothesized neoangiogenesis in the ischemic tissues as cause for improvement of

tissue structure, afﬁrmed by ultrastructural analysis of biopsies from the treated tissue.

Parker et al. described accelerated wound healing in a murine model of impaired

wound healing with diabetic db/db mice by injection of allogenic ASC, resulting in

wound closure of 92% after 12 days vs 49% in the controls and complete wound

closure in the treatment group 1 week sooner than in the controls [166].

These ﬁndings could be conﬁrmed by two studies implemented by Nambu et al.

dealing either with impaired wound healing caused by topical application of the

antimitogenic mitomycin C or in diabetic db/db mice as well [167,168], though

ASC were seeded on an atelocollagen carrier scaffold.

Mitomycin C inhibits proliferation of various cells, including ﬁbroblasts, kera-

tinocytes, and endothelial cells, most likely through inhibition of DNA, RNA, and/

or protein synthesis, and thus is suitable for a model of local full-thickness wound

healing disorders. Strikingly, enhancement of granulation tissue formation, i.e.,

thicker granulation tissue and higher numbers of capillaries, by ASC application

was statistically signiﬁcant in the mitomycin C-treated wounds but not in the

control wounds [167].

Using diabetic mice displayed similar results, i.e., epithelization rates of 87.3%

in the ASC group vs 57.8% in the control group and more than double numbers of

capillaries as well as more than double thickness of the granulation tissue.

A study series by Kim et al. on wound healing of skin defects by local applica-

tion of ASC demonstrated improved and faster wound healing, prevention of photo-

aging, and antiwrinkle effect in the ASC-treated groups [82–86]. Kim’s ﬁrst study

in 2007 measured the effect of secretory factors on human dermal ﬁbroblasts (HDF)

[85]. Enhancement of HDF proliferation and migration was promoted by direct

84 J.W. Kuhbier et al.

contact with ASC and also by indirect contact through ASC-CM, i.e., serum-free

DMEM/F12-medium in which ASC were cultured for 72 h. Growth factors and

ECM secreted by ASC were measured with ELISA as well as collagen I, III,

ﬁbronectin, and MMP-1 secretion by HDF following induction by ASC-CM. In

addition, the therapeutic effect of ASC application in a collagen gel into 7-mm

experimental wounds of nude mice was investigated.

Proliferation and migration was signiﬁcantly higher by culture with ASC and

ASC-CM compared to controls. Interestingly, the secretion of collagen I and

ﬁbronectin were much higher than those of growth factors with an amount of

921.47 49.65 ng mL

1

for collagen I and 1466.48 460.21 ng mL

1

for

ﬁbronectin, respectively. HDF-production of collagen I, III, and ﬁbronectin was

upregulated by induction with ASC-CM while MMP-1 was downregulated. In vivo

wound closure after 7 days was also signiﬁcantly faster in ASC-treated wounds.

In another study in 2008, Kim et al. found evidence for antioxidant action and thus

a protecting function of ASC [82]. Actually, ASC-CM had an antioxidant potential

comparable to ascorbic acid, measured by an antioxidant assay kit containing the

enzymes superoxide dismutase (SOD), catalase, and glutathione peroxidase (GPx),

the macromolecules albumin and ferritin as well as an array of small molecules

including ascorbic acid, a-tocopherol, b-carotine, reduced glutathione, uric acid, and

bilirubin. Furthermore, proteomic analysis of ASC-CM demonstrated increased

SOD- and GPx-activity in HDF cultured in ASC-CM after tert-butyl-hydroperoxide

(tbOOH)-exposure, which causes dose-dependent oxidative injury, as well as

increased caspase-3 activity as indicator for apoptosis following tbOOH-exposure.

For results of proteomic analysis, see Sect. 4.1. Though comparable in their

antioxidant activity, ASC-CM exhibited a more potent protective effect on HDF

than ascorbic acid, probably by scavenging free radicals. ASC-CM increased SOD-

activity 1.37-fold and GPx-activity 2.5-fold while ascorbic acid did not change

SOD-activity and increased GPx-activity 1.5-fold. The percentage of apoptotic

HDF incubated for 24 h with ASC-CM were 8.4 vs 5.1% in controls, 2.8-fold

increase in caspase-3 activity after tbOOH-exposure was reversed by ASC-CM

(decrease of 2.1-fold compared to controls).

Another factor secreted by ASC, TGF-b1, is responsible for inhibition of

melanin synthesis, related to another study by Kim et al. in 2008 [86].

In 2009, Kim et al. could show the antiwrinkle effect of intradermal injection of

ASC [83]. An artiﬁcial photo-aging mouse model, induced by deﬁned amounts of

UVB-radiation, displayed not only dose-dependent reduction of skin wrinkles,

afﬁrmed by an optical scoring scale. Dermal thickness increased after mid-level-

and high-level-administration of ASC, i.e., injection of 10

or 10

ASC (16 and

28%, respectively). In addition, UVB-radiation decreased proliferation of HDF, but

this effect was altered by pretreatment of HDF with ASC-CM which showed a

protective effect on HDF-proliferation.

ASC could be found in skin biopsies 2 weeks after injection, which also resulted

in elevated levels of collagen ﬁbers in the dermis.

In 2009, Kim also reported a case report with a single female patient who

received two successive intradermal injections into the periorbital region at

Isolation, Characterization, Differentiation, and Application of Adipose-Derived Stem Cells 85

2-week-intervals [84]. Two months after the second injection, she showed improve-

ment of general skin texture and wrinkles as well as a slight increase of dermal

thickness (2.054 mm before vs 2.317 mm after treatment).

Strikingly, a most recent study by Kim et al. in 2009 could show that VEGF- and

bFGF-secretion of ASC is dependent on the oxygen concentration of the culture

medium with preference to hypoxic medium [169]. To conﬁrm these ﬁndings,

experimental wound healing was observed after application of a collagen gel

containing ASC-CM after incubation either in hypoxia (2% O

, 20% CO

, and

balanced N

) or in normoxia (20% O

,5%CO

), resulting in faster wound closure

in hypoxia-conditioned medium.

These latest ﬁndings suggest that ASC play an important role in tissue repair

after injury. Capillary damage in the wound bed leads to lack of oxygenation and

nutrient supply resulting in a hypoxic environment. Therefore, cells that can

promote wound healing under hypoxic conditions are most favored, indicating

that MSC in general and ASC in particular may represent the body’s own potential

source for tissue regeneration.

5.5 Immunomodulatory Effect of ASC

The ﬁrst study concerning the immunomodulatory effects of ASC was published in

2005 by Puissant et al. [170]; this study as well as the one by Keyser et al. [171] and

Kang et al. [142] are mentioned here, though they were in vitro studies, due to direct

clinical connection.

Puissant et al. tested the response of activated or nonactivated lymphocytes

to ASC and BSC to ﬁnd out either if stem cells would trigger a lymphocyte

reaction or if they have an inﬂuence on triggered lymphocytes. They found

ASC and BSC to be nonimmunogenic while they appeared to be immunosup-

pressive to activated lymphocytes. This modulatory effect on lymphocytes was

obviouslymediatedbycytokinesasitalsoappearedinatranswellassay,

in which ASC and lymphocytes were separated from each other by a porous

membrane. Strikingly, these cytokines seem to be induced by lymphocytes as

a kind of secretory response, as only a mild immunosuppressive effect was

measured when lymphocytes were incubated with ASC-CM, indicating the

need for presence of both cell types together to initiate the immunosuppressive

reaction.

These ﬁndings were approved by Keyser et al. who compared the reduction of

T-cell activation by MSC from different tissues [171]. Either Concavalin A or

allogenic T-cells were used to induce activation of another population of T-cells.

Noteworthy, suppression of T-cell response was most pronounced in MSC from

adipose tissue, suggesting them as salvage therapy for suppression of graft-versus-

host disease (GVHD).

In 2007, Yanez et al. performed a methodical study to investigate exactly this

purpose [172]. Beside in vitro studies, they also implanted bone marrow from

86 J.W. Kuhbier et al.

C57Bl/6 mice to B6D2F1 mice irradiated beforehand and compared ASC-injection

0, 7, and 14 days vs 14, 21, and 28 days post implantation.

The remarkable ﬁnding was that the early implanted animals had signiﬁcantly

higher survival rates due to GVHD than the later implanted animals.

In contrast to the just mild suppression of ASC-CM alone, Kang et al. found the

supernatant of ASC-CM derived from beagle dogs culture to suppress leukocyte

proliferation that was stimulated before with Concovalin A, pokeweed mitogen,

and LPS [142]. For more detailed consideration of the immunomodulatory cytokine

proﬁle of these canine ASC, see the paragraph above concerning cytokine proﬁles

of ASC.

In 2004, LeBlanc et al. reported a case of severe therapy-resistant GVHD of the

gut and the liver, which improved rapidly after injection of ASC, which displayed

the ﬁrst use of ASC in clinical medicine [173].

From 2006 on, Fang et al. published a series of studies dealing with the clinical

application of ASC for the suppression of GVHD [46,174–178]. In their study from

2006, they reported a case of a patient who suffered from severe GVHD after stem

cell transplantation, which also manifested mainly in the gut and the liver, proven

by coloscopy and elevated liver enzymes [178].

After ASC-transplantation from an allogenic donor, symptoms vanished in a few

days, indicating immunosuppression.

Another case report referred to a woman with an acute hepatic GVHD caused

by hematopoietic stem cell transplantation, who failed conventional immu-

nosuppressive therapy, e.g., cyclosporine and prednisone [177]. Thus, she was

treated with tacrolimus, which was discontinued because of deterioration of

renal function. As a salvage therapy, she was than treated with ASC, which

resulted in rapid and complete resolution of hepatic GVHD as well as renal

toxicity.

Similar ﬁnding were published, when two pediatric patients suffered from

Philadelphia chromosome-positive acute lymphatic leukemia (ALL) or acute mye-

loic leukemia (AML), respectively [176]. The child with ALL displayed a gastro-

intestinal manifestation with severe, partly bloody diarrhea, signiﬁcant loss of

weight, and deterioration of general condition 89 days after hematopoietic cord

blood transplantation although adequate pharmaceutical immunosuppression was

administered.

AML in the other patient was treated with peripheral blood stem cell transplan-

tation and an adequate pharmaceutical therapy regime as well. After 62 days, a

strong involvement of the liver in GVHD was observed by elevation of the liver

enzymes.

Both patients showed rapid remission of symptoms after injection of allogenic

ASC without side effects, which lasted at least for the follow-up of 374 days or

2 years after ASC-injection, respectively.

Comparable success was noticed in six patients in another study suffering from

steroid-refractory GVHD after hematopoietic stem cell transplantation because

of leukemia [175]. Here different regimes of immunosuppressive therapy were

also followed to protect the patients from GVHD, but their condition deteriorated.

Isolation, Characterization, Differentiation, and Application of Adipose-Derived Stem Cells 87

Following ASC transplantation, four of the patients kept remission-free for the

duration of the follow-up, which ranged between 18 and 90 months. Two of the

patients died – one with no obvious response to AMC transplantation of multi-

organ failure and one of a relapse of leukemia. However, the patient mentioned

ﬁnally showed a good response to ASC-therapy while the relapse was 16 month

after the ASC-infusion; thus the proven response rate can be stated as ﬁve of six

patients.

The two studies published lately were case reports of the treatment of either

refractory pure red cell aplasia (PRCA) after major ABO-incompatible stem

cell transfusion or refractory chronic autoimmune thrombocytopenic purpura

[46,174].

PRCA occurred in two patients in the ﬁrst mentioned study due to donor-

recipient incompatibility, which here was HLA- but not ABO-matched. Although

a conditioning therapy with Busulfan and cyclophosphamide was performed in

both cases, the clinical appearance of PRCA, i.e., principally reticulocytopenia

and thus erythrocytopenia, could not be avoided. Both patients needed a red

blood cell transfusion weekly with no beneﬁcialeffectfromerythropoietin

administration.

In the second case, one patient was diagnosed with autoimmune thrombocyto-

penic purpura, a disorder wherein autoantibodies are directed against platelet

surface glycoprotein (GPs), usually GPIIb/IIIa or GPIb/IX. Hereby, splenic platelet

destruction is induced and platelet production inhibited, leading to lack of platelets

and extended clotting time.

As in the previously described cases, ASC transplantation led to remission,

which is continuing up to the publishing date.

In four studies carried out by the work-group around Gonzalez, ASC were also

shown to suppress inﬂammative diseases [88,89,179,180]. Two studies concerned

the treatment of inﬂammative bowel diseases, induced by tri-nitro-benzene sulfonic

acid, and sepsis, the two other studies concerned the treatment of an experimental

arthritis, induced by immunization against collagen. All of the studies were per-

formed in vitro as well as in vivo in a murine model.

The authors’ interesting thesis is that ASC intervene in the regulation of Th1-

cells, the key effectors of autoimmune disorders like Crohn’s disease or rheumatoid

arthritis, by inﬂuencing regulatory T-cells which can be considered as inﬂuential

mediators of regulating the inﬂammatory response.

Actually, they found downregulation of both Th1-driven autoimmune and

inﬂammatory responses, resulting in amelioration of the clinical and histopatholo-

gical severity, abrogating body weight loss, diarrhea, and overall survival in the

colitis/sepsis studies and joint inﬂammation in the arthritis studies.

These ﬁndings were mediated by suppression of Th1-cells as wells as augmen-

tation of IL-10-producing T-cells, a cytokine responsible for inhibition of T-cell-

response.

Also, ASC impaired Th1 cell expansion by direct cell-to-cell contacts and,

additionally induced a population of CD4(+)CD25(+)FoxP3(+) regulatory T cells

with suppressive capacity on Th1 effector responses in vitro and in vivo.

88 J.W. Kuhbier et al.

Taking these ﬁndings together, ASC have a great immunomodulatory inﬂuence

as they are effective suppressors of immune system responses, in particular T cell

responses which mediate GVHD as well as autoimmune inﬂammatory reactions. In

the mentioned pioneering clinical studies, they acted as salvage therapy for cases

that were refractory to conventional therapy.

Therefore, they may play a bigger role in future directions of immunologic and

hematologic therapy as well as in transplantation medicine due to their properties

with seemingly lack of side effects.

5.6 Other Purposes in Current In Vivo Application

A quite interesting clinical application for ASC was published by Garcia-Olmo

et al. in 2003 describing a case report, in which they used autologous ASC in a

ﬁstula in Crohn’s disease [181]. Beside the characteristic diarrhea caused by

transmural inﬂammation of the intestine wall, enterocutaneous, rectovaginal, and

perianal ﬁstulas display a frequent and often stigmatizing complication of Crohn’s

disease with an incidence ranging between 17 and 50%, depending on the source. In

particular, secreting processes, e.g., vaginal ﬂatus or fetal incontinence in rectova-

ginal ﬁstulas or secretion of intestinal content through enterocutaneous ﬁstulas, are

extremely unpleasant for the patient.

In the reported case, the patient had a history of disease for 11 years prior to the

study and had already received several therapeutic trials including surgical treat-

ment, which resulted in remission.

Garcia-Olmo and coworker harvested the SVF via liposuction from subcutane-

ous fat, processed it, and injected puriﬁed ASC superﬁcial into the wall of the

ﬁstula. A vaginal ﬂap covered the resected posterior vaginal wall while ﬁbrin glue

sealed the perineal hole. After 1 week, the ﬁstula had completely closed, demon-

strating epithelization. Due to this, a clinical phase I study was initiated including

ﬁve patients suffering from Crohn’s ﬁstulas that were also treated at least twice

medically and surgically [182]. Here, in 75% of the cases, a closure and epitheli-

zation of the ﬁstula, stated as healing, occurred. Nevertheless, it is worth mention-

ing that they found no relationship between the numbers of cells injected and the

success of the procedure as well as between the age or gender of the patient and the

success.

Two other studies followed, the ﬁrst being a clinical phase II trial including 35

patients suffering from complex perianal ﬁstulas, and other than Crohn’s ﬁstulas,

which resulted as well in a healing in 71% of the patients [183]. In the second, the

effectiveness of injection of either the SVF or puriﬁed and expanded ASC was

tested with much better results for the expanded ASC, i.e., healing in 75% of the

ﬁstulas vs 25% of the ﬁstulas with the SVF. Obviously, this is due to the content of

just 2–5% ASC in the SVF without processing [184].

The same work-group around Garcia-Olmo also used a similar technique for

successful treatment of a tracheomediastinal ﬁstula [185]. The patient had

Isolation, Characterization, Differentiation, and Application of Adipose-Derived Stem Cells 89

received treatment with Nd-YAG laser resulting in progressive necrosis which led

to formation of a ﬁstula with a diameter of 10 mm. Within 3 h of general

anesthesia, a lipoaspirate was harvested, centrifuged, puriﬁed, and resuspended

inﬁbringluefollowedbyabronchoscopyinwhichtheﬁbringluewiththeASC

was injected into the cavity of the ﬁstula. General examination concerning

clinical symptoms was performed weekly for the ﬁrst month; ﬂexible bronchos-

copywasdoneevery3months,whichrevealedlackofsymptomsaswellas

mayor reepithelization and complete closure of the ﬁstula, leaving only a small

depression in the tracheal wall.

Another application already used in clinical medicine is the so-called cell-

assisted lipotransfer by the work-group around Yoshimura [186–188], though the

ﬁrst description of implantation of ASC for soft tissue augmentation was by Cho

et al. [139]. Either in ASC pretreated in conditioned medium or undifferentiated

ASC were implanted subcutaneously in athymic mice, each group supplemented

with or without bFGF. Six weeks after implantation, they found not just newly

formed adipose tissue but also neovascularisation of this tissue with both prediffer-

entiation and bFGF enhanced these effects.

These ﬁnding were approved by Matsumoto et al. who used merely centrifu-

gation to yield human SVF, which was mixed 1:1 with aspirated fat to obtain

fat with a high ASC concentration (cell-assisted lipotransfer; CAL), labeled with

CM.DiI and transplanted it also subcutaneously to severe combined immune

deﬁciency mice [186]. The CAL fat survival was better than the pure fat controls,

resulting in 35% larger specimen derived after transplantation, with SVF-cells

stained DiI-positive found between adipocytes and connective tissue. Some of

these cells were also positive for von Willebrand factor, suggesting endothelial

differentiation.

CAL transplantation in Green ﬂuorescent protein rats also showed neoangiogen-

esis by SVF-cells in the acute phase of transplantation, indicating CAL as

promising tool for long-time survival of fat transplantation.

Actually, this work-group performed two clinical trials, one dealing with facial

lipoatrophy and one with breast augmentation, which could prove the success of

CAL [187,188].

In the lipoatrophy treatment study, six patients received autologous SVF from

the abdomen which resulted in an average volumetric augmentation between 60 and

80% in the 10 month follow-up examination [188]. As facial lipoatrophy is very

stigmatizing because patients can hardly hide it, those improvements display a

satisfying result, though reﬁnements should always be aimed for.

The second study examined breast augmentation by CAL in 40 cases. Although,

the technique displayed long-term survival and safety, two cases with small cyst

formation and microcalciﬁcation were detected by mammography at 24 months

[187]. Less fat atrophy was observed and the augmented breasts looked more

natural than those with artiﬁcial implants, which also generally appeared to be

harder than the CAL-augmented ones.

Although those ﬁndings are impressive, they still raise the question whether

CAL is really superior to (pure) fat transfer by methods of proven quality and by an

90 J.W. Kuhbier et al.

experienced surgeon. With a careful, gentle, and tissue-conserving technique dur-

ing liposuction, comparable and repeatable results can usually be achieved, as was

reviewed recently in the literature [67,189].

6 Tissue Engineering Applications

As a general deﬁnition, tissue engineering combines the principles of bioengineer-

ing, biomaterial engineering, and cell transplantations to generate bio-artiﬁcial

tissues and organs, thus stimulating the self-regeneration of damaged tissues after

the in vivo transfer. Artiﬁcial ECM is provided to allow for cell proliferation and

differentiation in a three-dimensional cell scaffold. Generally, two classes of

biomaterials are used for tissue engineering purposes naturally derived and

synthetic materials; the decision usually depends on the physiological and mechan-

ical requirements as well as the biodegradability.

6.1 Adipose Tissue

In an early approach, Patrick et al. seeded preadipocytes on poly DL-lactic-co-

glycolic acid (PLGA) scaffolds where they differentiated into mature adipocytes,

although they did not reach the size of natural mature adipocytes isolated from

epididymal adipose tissue [190].

Adipogenic differentiated rat ASC were seeded on polyglycolic acid (PGA) ﬁbers

and implanted subcutaneously onto the heads of rats. Intracellular lipid vacuoles

could be demonstrated histologically inthe grafts explanted after 4 and 8 weeks [191].

In the study of von Heimburg et al., human preadipocytes were seeded on

different biodegradable carriers like HYAFF 11 sponge and collagen sponges.

The HYAFF 11 sponges turned out to have a higher cell density than the collagen

matrices used [192]. Further modiﬁcations including pore size and coating with

glycosaminoglycan hyaluronic acid improved cell penetration and vascularization

in an in vivo approach [193]. Collagen sponges were also used by Huss et al. for

coculture assay with human mammary epithelial cells and preadipocytes. They

found lipid-containing cells clustered around ductal structures [194].

Gelatin sponges seeded with human ASC have soft tissue-like mechanical pro-

perties which is generally preferable compared to more rigid structures [195].

Hyaluronic acid (HA)-based materials have been used in a variety of tissue engi-

neering purposes and clinical applications [196,197]. An HA-based scaffold has

also been used as a scaffold for adipocyte precursor cells. Full maturation into

adipocytes was achieved with an even cell distribution [198].

In a unique approach, in 2008 Valle

´e et al. [199] completely renounced the

substitution of exogenous matrix materials, resulting in three-dimensional cell

sheets of adipogenic stimulated cells.

Isolation, Characterization, Differentiation, and Application of Adipose-Derived Stem Cells 91

6.2 Bone Tissue

Three dimensional culture has a favorable effect on expression of osteogenic marker

genes compared to monolayer culture when ASC are cultured in osteogenic

medium [200]. The use of stromal vascular fractions of adipose tissue has been

considered advantageous since it enables direct three-dimensional seeding without

two-dimensional culture steps for cell expansion [201]. ASC seeded on biomater-

ials of clinical relevance in the treatment of bone defects like hydroxyapatite,

cancellous human bone fragments, deproteinized bovine bone granules, and tita-

nium produce more calciﬁed matrix than cells in monolayers [202].

After 2 weeks of differentiation in porous PLGA foams, mineralized nodular

structures were shown [203]. In their rat transplantation model, Lee et al. demon-

strated that predifferentiated grafts did not show bone formation but stained posi-

tively for osteocalcin after 4 weeks [191]. After 8 weeks, osteocalcin expression

was still detectable and, additionally, bone formation was shown in histological

analysis.

In their study with electrospun composite scaffolds consisting of beta-tricalcium

phosphate (TCP) crystals and poly L-lactic acid (PLA), McCullen et al. provided

another indication that matrix properties are important in the differentiation process

as alkaline phosphatase activity and mineralization were shown to depend on ﬁber

diameter and TCP content [204].

Shen et al. used a three-dimensional sintered microsphere matrix of poly(lactide-

co-glycolide) and differentiated using recombinant GDF-5 as an alternative matrix

material for bone tissue engineering [205].

Combinations of ECM components are often used to enhance the cell adhesion

on hydrophobic synthetic polymers [206].

Beside the administration of modifying substances like growth factors or the

transduction with genes of the osteogenic signaling pathway, an optimized dif-

ferentiation of the ASC is largely inﬂuenced by the used scaffold material and

stimulation exerted by mechanical forces. Honeycomb-shaped atellocollagen

sponges seeded with ASC were successfully used for bone formation in 3D

cultures in vitro and in vivo [207]. Osteoinductive materials like b-TCP have

been shown to induce osteogenic differentiation [208]. In a comparative study

between akermanite ceramics and b-TCP an even higher osteoinductivity was

found for the akermanite ceramics [209]. Peterson et al. demonstrated in a

combined approach that BMP-2 transfected ASC together with collagen-ceramic

carriers resulted in healing of a critical size femoral defect when applied to nude

mice [162].

In their approach dealing with the induction of osteogenesis by mechanical

forces, van Griensven et al. showed that bone tissue constructs were achieved by

seeding adult stem cells derived from bone marrow and adipose tissue seeded on

Sponceram matrices in a rotating bed bioreactor [210].

In a combined assay with human ASC seeded on a composite BMP-2 loaded

PLGA/hydoxyapatite scaffold were implanted subcutaneously on the backs of

92 J.W. Kuhbier et al.

athymic mice without any predifferentiation. After explantation, expression of

human-speciﬁc osteoblastic genes was found [211].

6.3 Cartilage Tissue

PLGA is a scaffold commonly used in cartilage tissue engineering based on

differentiated ASC [212–214]. In their study, Jin et al. combined cellular tranduc-

tion with human TGF b2 and cultivation on a three-dimensional PLGA/alginate

compound to produce cartilage formation efﬁciently in vitro and in vivo [215].

While copolymers of PLGA is a common substrate in cartilage tissue engineering

due to advantageous mechanical properties, successful cell seeding is often ham-

pered by its hydrophobicity [216]; the authors circumvented this problem by

choosing aliginate as a cell carrier.

In another approach ASC were encapsulated in aliginate microbeads together with

a chimeric RGD-protein. The parameters analyzed included chondrogenic differen-

tiation after TGFb3 dependent induction. An increased expression of chondrogenic

genes was observed which dependent on a b1 integrin mediated signaling [217].

Cheng et al. worked without stimulation with exogenous growth factors when

they seeded ASC on scaffolds derived from porcine articular cartilage. After a

cultivation period between 4 and 6 weeks, expression of chondrogenic genes was

observed [218]. These ﬁnding stress the importance of three-dimensional structures

in the chondrogenic differentiation for which there is a broad consensus in the

published literature [132–134,217,218]. Also mechanical forces like hydrostatic

pressure have been found to be important for chondrogenesis and have been implied

by Ogawa et al. in their study on ASC seeded in three-dimensional collagen

matrices. Cyclic hydrostatic pressure conditions caused an increase in chondro-

genic gene expression in TGFb1 stimulated cultures.

Another possibility for cartilage tissue engineering was described by Hildner

et al. when they demonstrated that cocultivation of human articular chondrocytes

together with ASC resulted in increased collagen type IX expression, indicating a

long-term stability of cartilage [219].

7 Summary

Stem cells derived from adipose tissue represent an enormous potential for medical

therapeutic applications. Their versatile properties range from promotion of cell

proliferation, differentiation, and migration over immunomodulatory functions,

e.g., in GVHD and regeneration to facilitate tissue repair and neovascularization

in injury and ischemia. A major advantage for clinical application of ASC is based

upon easy harvesting techniques with sufﬁcient yields, vast availability, and low

donor site morbidity compared to stem cells obtained from bone marrow or

Isolation, Characterization, Differentiation, and Application of Adipose-Derived Stem Cells 93

peripheral blood. The fast expanding ﬁeld of basic and clinical research in ASC

biology, pathophysiology, and their potential therapeutic applications promises

further exciting discoveries in the near future.

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DOI: 10.1007/10_2010_74

#Springer-Verlag Berlin Heidelberg 2010

Published online: 10 June 2010

Induced Pluripotent Stem Cells: Characteristics

and Perspectives

Tobias Cantz and Ulrich Martin

Abstract The induction of pluripotency in somatic cells is widely considered as a

major breakthrough in regenerative medicine, because this approach provides the

basis for individualized stem cell-based therapies. Moreover, with respect to cell

transplantation and tissue engineering, expertise from bioengineering to transplan-

tation medicine is now meeting basic research of stem cell biology.

In this chapter, we discuss techniques, potential and possible risks of induced

pluripotent stem (iPS) cells in the light of needs for patient-derived pluripotent stem

cells. To this end, we compare these cells with other sources of pluripotent cells and

discuss the ﬁrst encouraging results of iPS cells in pharmacological research,

disease modeling and cell transplantation, providing fascinating perspectives for

future developments in biotechnology and regenerative medicine.

Keywords Cell transplantation, Differentiation, Induced pluripotent stem cells

(iPS cells), Reprogramming, Tissue engineering

Contents

1 Introduction .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108

2 Needs for Patient-Derived Expandable Cell Sources . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . 108

3 Induction of Pluripotency and Reprogramming . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110

4 Technologies for Generation of Induced Pluripotent Stem Cells . . . . . . . . . . . . . . . . . . . . . . . . . 112

5 Induced Pluripotent Stem Cells: Risks and Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . 113

T. Cantz

Junior Research Group Stem Cell Biology, Excellence Cluster REBIRTH, Hannover Medical

School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany

e-mail: cantz.tobias@mh-hannover.de

U. Martin (*)

Leibniz Research Laboratories for Biotechnology and Artiﬁcial Organs LEBAO, Excellence

Cluster REBIRTH, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany

e-mail: martin.ulrich@mh-hannover.de

6 Induced Pluripotent Stem Cells for Drug Screening and Safety Pharmacology . . . . . . . . . . 114

7 Induced Pluripotent Stem Cells for Disease Modeling . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . 116

8 Induced Pluripotent Stem Cells for Cell-Based Therapies .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118

9 Perspectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120

1 Introduction

The isolation and characterization of embryonic stem (ES) cells from mouse

blastocysts by Evans and Kaufman in the early 1980s [1] represents a hallmark in

stem cell research. Widespread belief was maintained that isolation of ES cells was

only possible from certain mouse inbred strains, and isolation of ES cells from other

species may not be possible at all due to lack of comparable inbred strains in other

species. Just 15 years later, Thomson et al. contradicted this hypothesis by estab-

lishing nonhuman primate (NHP) ES cell cultures from rhesus monkey (Macaca

mulatta)[2], common marmoset (Callithrix jacchus)[3], and ﬁnally ES cells from

humans [4]. Although the ultimate proof of pluripotency by generation of chimeric

animals is still pending in these animals, and due to ethical reasons almost impos-

sible in humans, primate ES cells are now generally considered pluripotent based

on their ability to form teratomas and to differentiate in vitro into cells of all three

germ layers. Even redifferentiation into trophoectoderm has been demonstrated [5].

Despite their unlimited potential for differentiation and expansion, the use of

human ES cells in research, pharmascreening and cellular therapies is ethically

controversial due to their isolation from human embryos and the unavailability of

patient-speciﬁc cells.

Consequently, a lot of effort was invested into research aiming for generating

pluripotent human cells from other sources than preimplantation embryos, which

ﬁnally led to the induction of pluripotency in “terminally differentiated” cells as

demonstrated by Shinya Yamanaka in his groundbreaking Cell paper. This particu-

lar study and his subsequent work were a major stimulus to stem cell research,

because the two major obstacles to clinical application associated with ES cells

were overcome – destruction of human embryos and allogeneic immune rejection

[6–8].

2 Needs for Patient-Derived Expandable Cell Sources

In regenerative medicine, several concepts focus on individualized therapies which

take advantage of cell-based tissue repair or tissue engineering applications. The

use of patient-derived cells will circumvent immunologic issues like rejection of the

transplants, but is limited by the availability of suitable (tissue-speciﬁc) stem cells

108 T. Cantz and U. Martin

and, in the case of genetic mutations, by gene correction strategies which can

be applied to the patients’ cells. Moreover, patient-derived cells, which mimic

the diseased phenotype, may allow the ex vivo exploration of new therapeutic

approaches. However, besides the hematopoietic system hardly any other organ is

as well understood and, therefore, little is known about progenitor cell types within

the cellular hierarchy during organ development which can be expanded in vitro for

future applications.

For instance, the liver is an ideal target organ for cell-based therapy as demon-

strated by the application of hepatocyte transplantation in a number of patients with

hereditary metabolic liver disease and acute liver failure [9–13]. In these ﬁrst

clinical studies, hepatocyte transplantation has been considered either as a full

treatment option, or in more severe situations, as a bridge to transplantation [14].

In some patients, transplanted hepatocytes are able to engraft, repopulate the liver,

and restore the deﬁcient hepatic function for up to 18 months post-transplantation

[15,16] and, meanwhile, more than 20 such patients have been reported in recent

years [17]. However, hepatocytes prepared from donor organs can only be provided

for a small number of patients and other cell sources are urgently needed. Another

example is the engineering of bioartiﬁcial cardiac muscle which may allow replace-

ment of infarcted heart tissue. Cardiac tissue engineering is hampered by the fact that

adult cardiomyocytes (CMs) have almost no potential for proliferation [18]. In

conclusion, for the majority of tissue types, including liver and heart, the lack of

suitable cell sources represents one of the major hurdles to be overcome prior to

clinical application of novel regenerative therapies.

With respect to adult stem cell sources, recent research suggests strong limita-

tions of adult cell sources with regard to differentiation and expansion potential (see

for instance [19–23]), despite a variety of earlier reports suggesting a virtually

unlimited plasticity. Consequently, different adult stem cells appear to be useful for

therapeutic regeneration of those tissue types, which show a high natural capacity

for regeneration, for example, bone or skin. In case of tissue and organs with rather

limited natural regeneration potential, for instance the heart, it is still controversial

whether adult stem and progenitor cells can prevent loss of function or reconstruc-

tion of injured tissue [20–23]. Furthermore, although not proven to the extend, there

is a general impression that in older (and diseased) patients, there are less stem and

progenitor cells of superior function than in younger donors, which might be due to

telomere dysfunctions in aged or stressed cells [24].

In contrast to adult stem cells, pluripotent stem cells, such as ES cells, are

characterized by their unlimited potential to grow in vitro and to develop into virtually

any cell type. As outlined above, pluripotent cells can be isolated from early embryos

by collecting blastomeres or by isolating the inner cell mass of blastocysts and

subsequent cultivation in appropriate cell culture conditions. Interestingly, these

conditions differ distinctly between various mammalian species and to date we are

still not able to derive true ES cells from species other than mice [1], NHPs [2,3],

humans [4], and rats [25]. However, various issues need to be considered with respect

to application of human ES cells for clinical therapies. Besides strong ethical concerns

on destructive use of human embryos, the major limitation for clinical use may be an

Induced Pluripotent Stem Cells: Characteristics and Perspectives 109

immunologic rejection of allogeneic ES cell-derived grafts, which accounts for recent

efforts to explore patient-derived pluripotent stem cells.

Recently, it has been demonstrated that pluripotent stem cells can also be

derived from embryonic/fetal and adult germ cells. Accordingly, in males, testis-

derived cells could serve as an alternative source for autologous pluripotent stem

cells [26–31]. In females, pluripotent (embryonic) stem cells can be generated by

parthenogenetic activation of oocytes, as demonstrated in mice and NHPs [32].

More recently, mouse parthenogenetic pluripotent stem cell lines were thoroughly

described by Kitai Kim [33]. Interestingly, the human stem cell line which was

reported by the Korean scientist Woo-Suk Hwang as somatic nuclear transfer

(SCNT)-derived cell line was actually a pluripotent stem cell line which has

emerged after parthenogenetic activation of an oocyte [33]. The latter two are

both germ line-derived pluripotent stem cells, in theory, could be derived from

patients, but are not very likely to become an easily applicable cell source for

regenerative medicine due to the invasiveness during their isolation procedure.

Finally, pluripotent stem cells can be generated through artiﬁcial reprogramming

of somatic cells, as described in detail below.

3 Induction of Pluripotency and Reprogramming

Using the technique of SCNT, pioneered by John Gurdon [34], the birth of the

sheep Dolly in 1996 was the ultimate proof that mammalian cells can be repro-

grammed establishing a fully totipotent state. Hereby a somatic nucleus is intro-

duced into an enucleated oocyte arrested at metaphase II stage. These entities are

considered to share the same developmental potential with fertilized eggs and can

give rise to viable offspring [35]. Other concepts of nuclear reprogramming include

the use of ES cells’ protein extracts [36], which are able to reprogramme nuclei of

ﬁbroblasts into pluripotent cells, or the use of ES cells in fusion approaches

resulting in heterokaryons of ES cell and somatic cell origin, whereas the somatic

nucleus gains a pluripotency-related gene expression proﬁle [37–39]. Cells gener-

ated by these two latter approaches are considered to be pluripotent but not

totipotent, mainly because these cells were generated using ES cells.

In 2006, Shinya Yamanaka presented a new concept of reprogramming using

retroviral expression of key transcription factors which invalidate with the original

transcriptional network of the somatic cells [7]. This pioneering work has been

further reﬁned and adopted to the generation of human pluripotent stem cells in

recent years [6,8], and has shown great promise in regenerative medicine (Fig. 1).

Even if these iPS cells are considered to share most – if not all – of their molecular

characteristics with ES cells, we are still far from providing a concise concept of

how reprogramming using the Yamanaka factors (Oct4, Sox2, Klf4, c-Myc) or the

Thomson factors (Oct4, Sox2, Nanog, Lin28) works and how this approach can be

explained describing the molecular mechanisms.

110 T. Cantz and U. Martin

The generation of iPS with doxycycline (dox)-inducible reprogramming vectors

from murine embryonic ﬁbroblasts (MEFs) carrying an Oct4-GFP reporter gene

knock-in allele enabled ﬁrst insights into this process [40]. An exposure of dox for at

least 8 days was necessary to obtain iPS cell colonies as analyzed after 20 days. The

number of iPS cell colonies was higher after admission of dox for 10, 11, 12, and 13

days, respectively. Interestingly, during 12 days of dox-induction, the expression of

the ﬁbroblast marker Thy1 was decreasing, while the murine pluripotency-asso-

ciated marker SSEA1 was increasing. The expression of SSEA1 was detectable

earlier than the expression of the canonical pluripotency factors like Oct4 and Sox2

[40]. In a more advanced system, so-called dox-inducible secondary iPS cells were

investigated by generating chimeric mice from dox-inducible iPS which carry a

puromycin resistance [41]. MEFs from these chimeric mice were selected with

puromycin, resulting in a MEF population which originated from one primary iPS

cell line. Adding dox to these MEFs resulted in the generation of secondary iPS with

a much higher efﬁciency, namely 4% compared to 0.1% in primary iPS cells.

However, the efﬁciency was far from reaching 100% as one could assume from the

experimental outline. Two reasons for this discrepancy can be discussed as outlined

by a recent comment of Yamanaka [42]. First, an elite cell population (such as a rare

stem/progenitor cell) is more susceptible to iPS reprogramming and, therefore only a

small subset of cells can be successfully reprogrammed into a pluripotent state.

Second, stochastic genetic and epigenetic changes are mandatory for successful

reprogramming, and this might only happen in a subset of cells. Based on recent

literature, Yamanaka favored the latter explanation, which is further strengthened by

Fig. 1 Generation of patient-speciﬁc iPS cells. Patients’ ﬁbroblasts were cultivated and transduced

with lenti- or retroviral vectors encoding the four reprogramming factors Oct4, Sox2, Klf4, and

c-Myc. With a limited efﬁciency, few ﬁbroblasts change their cellular fate and acquire an induced

pluripotent stem cell phenotype. Applying in vitro differentiation protocols, cell derivatives of all

three germ layers (like neurons, cardiomyocytes, and hepatocytes) can be generated. Those cells

might resemble the patient’s diseased cell phenotype and allow studies on new drug targets or

pathophysiological mechanisms and may be used for tissue engineering or cell transplantation

approaches

Induced Pluripotent Stem Cells: Characteristics and Perspectives 111

an elegant recent study: Hanna et al. utilized the dox-induction system for secondary

iPS cells, but started with clonal pre-B-cells as a more homogenous starting popula-

tion than MEFs [43]. Initially, only 3–5% of the cells gave rise to iPS colonies within

2 weeks. But eventually almost all of the cells committed to iPS colonies with

latency times up to 18 weeks. These differences in latency were not predictable by

any experimental parameter which is highly consistent with the necessity of yet

unknown stochastic events during iPS cell reprogramming.

4 Technologies for Generation of Induced Pluripotent

Stem Cells

The recent reprogramming of somatic cells into pluripotent ES-like cells [6,7]is

generally considered as a revolutionary breakthrough for the development of novel

regenerative therapies. However, the initial technique was very inefﬁcient and

restricted to embryonic and adult ﬁbroblasts as cell source. With respect to genera-

tion of clinically applicable cells, the classical technology based on retroviral

overexpression of several reprogramming factors poses risks including the potential

for insertional mutagenesis [44] and malignant transformation resulting from acti-

vation of oncogenic transgenes.

First reports on the induction of murine and human iPS cells reported repro-

gramming efﬁciencies of about 0.01–0.1%, resulting in relatively few fully repro-

grammed cell clones. In the meantime, major improvements in reprogramming

efﬁciencies have been achieved.

Recent results demonstrated reprogramming of a variety of cell types (for example,

[45,46]) including clinically easily accessible cell types such as keratinocytes, hair

cells [47], and blood cells [48–51]. These results suggest that the majority of somatic

cell types if not all cells can be reprogrammed. Efﬁciency of reprogramming could be

dramatically increased up to 2% for human cells [52] and up to 28% for secondary

mouse iPS cells in an inducible transgenic mouse model [48]. In addition, it has been

shown that depending on the cell type, and although very inefﬁcient, iPS cells can be

generated using only two [46] and even one reprogramming factor [53,54].

These remarkable improvements have been achieved mainly through optimized

reprogramming protocols, the use of siRNAs/shRNAs against p53/p21/UTF-1/

DNA methyltransferase [55–57] and application of different small molecules for

inhibition or activation of different factors and pathways (for review, [58]is

recommended). These include inhibitors of histone deacetylase [59], the G9a

histone methyltransferase [60], the TGFß- and MEK-ERK pathways [52], and an

agonist of L-type calcium channels [61]. Inhibitors of GSK-3 [62,63], MAP Kinase

[63], and TGF-ß [64,65] have been used to replace KLF4 [66] or SOX-2 (and

c-Myc) [60,63,65]. Micro RNA (miR)-based approaches may represent another

way to replace integrating vectors and recent publications indicated the usefulness

of miR-302 and of the miR-290 cluster, the latter being downstream effectors of

c-Myc, for reprogramming of somatic cells [67,68].

112 T. Cantz and U. Martin

Since most of the typically applied reprogramming factors including OCT4,

SOX2, KLF4, MYC, NANOG, and LIN28 can be considered as oncogenes and may

lead to malignant transformation of iPS-derivatives, permanent presence of those

transgenes in the reprogrammed cells should be avoided and the development of

transgene-free iPS cells is mandatory. In addition, insertional mutagenesis asso-

ciated with integrating vectors may result in malignant transformation and loss of

function. Thus, alternative approaches are desired for production of clinically

applicable iPS cells, and very recent studies have already demonstrated the possibil-

ity of using conventional plasmids [69], nonintegrating adenoviral [70] and episomal

vectors [71], as well as protein transduction [72,73], instead of integrating vectors.

Very recently, another paper demonstrated the generation of transgene-free human

iPS cells by means of a vector system based on Sendai virus, an RNA virus without

DNA state [74].

Although alternative approaches to induce pluripotent stem cells that avoid

integration of transgenes into the host genome have now been demonstrated

generally feasible, those methods are currently largely far from being technically

mature: episomal approaches are extremely inefﬁcient, genomic integration is not

excluded, and oncogenes such as MYC and large T-antigen are required [71].

Protein transduction is also yet extremely inefﬁcient and, importantly, requires

huge amounts of recombinant proteins [72,75].

Clearly, the above techniques are extremely promising; nevertheless, further

signiﬁcant improvement and development of novel and modiﬁed techniques is

required.

5 Induced Pluripotent Stem Cells: Risks and Limitations

Although it is now generally accepted that iPS cells are pluripotent, it has been

observed that individual iPS clones show considerable variation in their potential

for differentiation. Whereas such variations can also be observed between different

ES cell lines, variations between individual iPS cells clones may be even higher,

especially due to incomplete transgene silencing, which apparently leads to delayed

and less efﬁcient differentiation [76]. Thomson et al. very recently reported a lower

neural differentiation efﬁciency of a series of human iPS cell clones compared to

several established ES cell lines [77]. Interestingly, this was also observed for

transgene-free iPS cell clones generated by means of episomal vectors, thereby

arguing for further reasons underlying the observed variations in differentiation

behavior. Clearly, further work is needed to clarify whether iPS cells hold similar

differentiation potential to ES cells and how the best iPS cell clones for a certain

purpose can be identiﬁed.

Of major importance for future clinical application of iPS cells is to overcome

current limitations such as lack of large scale culture technologies and inefﬁcient

speciﬁc differentiation, and to assess iPS cell related risks. As in case of ES cells,

there are issues of teratoma formation after transplantation of iPS-cell derivatives

Induced Pluripotent Stem Cells: Characteristics and Perspectives 113

and of chromosomal abnormalities that could arise during stem cell expansion [78–

82]. Whereas teratoma formation is considered to be manageable through suitable

rigorous cell puriﬁcation approaches and genetic systems enabling the ablation of

contaminating cell grafts [83,84], it is currently unknown whether and how

chromosomal abnormalities which may result in malignant transformation can be

avoided during extended cell expansion.

Another critical point is the use of oncogenic transgenes, such as MYC, for

reprogramming and the risk of insertional mutagenesis due to the use of retroviruses

to induce pluripotency. As discussed above, alternative technologies for generation

of transgene-free iPS cells are thus crucial for clinical application of iPS-based cell

and tissue transplants.

Another aspect regarding the production of clinically useful iPS cells concerns

the quality of iPS cells derived from somatic cells of aged individuals. Although

mammalian species differ dramatically with respect to their maximum life span and

the incidence of spontaneously occurring tumors, a common observation from

mouse to man is that the risk of cancer increases exponentially during the later

stages of life [85,86]. In general, epigenetic [87] and genetic modiﬁcations, includ-

ing telomere shortening and spontaneous mutations, are considered as underlying

causes. For example, somatic mutations of the epidermal growth factor receptor

have been shown to lead to the development of non-small-cell lung cancer [88].

On the other hand, mitochondrial mutations typically have effects on catabolism

and cell function. Normal mitochondria help to remove free radicals, but somatic

mutations of the mitochondrial DNA over time make them less effective and, thus,

may contribute to the advancement of aging and/or cancer [89].

Whereas epigenetic changes and loss of telomerase activity in cells of aging

individuals may be reversed during induction of pluripotent stem cells [90],

acquired chromosomal abnormalities and/or point mutations are not corrected

during reprogramming and may lead to iPS-derivatives with reduced functionality.

In addition, somatic cell clones with acquired mutations that result in higher

reprogramming efﬁciency and increased proliferation rates are likely to become

enriched during expansion of the primary cell source. This is further enhanced

during the reprogramming and proliferation of the resultant iPS cells, thereby

supporting an increased cancer risk.

As a consequence, one should consider the use of “young” cell sources such as

cord blood [49] for derivation of clinically useful iPS cells.

6 Induced Pluripotent Stem Cells for Drug Screening

and Safety Pharmacology

Pluripotent stem cells, with theoretically unlimited potential for proliferation and

differentiation, may not only represent a cell source for basic biomedical research

and clinical cell transplantation, but are rather considered as the most important

114 T. Cantz and U. Martin

prerequisite for the development of novel, high-throughput assays for drug screen-

ing and pharmacology studies.

During the ﬁrst phase of drug development, the most potent compounds are

identiﬁed among several hundred thousands of candidates, followed by the detailed

characterization of selected compounds (several hundred to several thousand) in

primary and secondary pharmacology studies. Finally, safety pharmacology studies

focus on identifying adverse effects on physiological functions.

The cost-effective and available high-throughput assays used in the early phases

of drug screening do not always meet the data quality requirements for detailed

characterization of pharmacodynamic properties and potential of undesired side

effects. Indeed, data of higher quality can be generated only through the use of

sophisticated, costly, and labor-intensive in vitro assays or by in vivo experiments,

for example telemetry studies. Due to high costs of animal experiments, safety

pharmacology studies, required by law, are usually completed in the ﬁnal phases of

drug development. As non-mammalians and rodents poorly reﬂect speciﬁc aspects

of human physiology and immunology, large animals such as dogs and NHPs are

commonly used in the last phase of preclinical pharmacology studies and safety

pharmacology.

In contrast, over the past few years, safety pharmacology studies have been

initiated earlier in drug discovery as a way to reduce the rate of failure and thereby

costs. However, to further support this process, as well as to reduce the number of

ethically problematic animal experiments, it is now required to develop cost-

effective in vitro assays producing higher quality data than currently available.

Current assays for cardiac safety pharmacology represent a common example for

pharmacological screening systems. Available assays for cardiac safety pharma-

cology can be separated into three classes: (1) relatively cost-effective assays more

or less suitable for automated high-throughput screening, but with limited predic-

tive value, for example, the dofetilide binding assay or rubidium efﬂux assay;

(2) labor (and cost) intensive in vitro assays with higher predictivity, such as

Langendorf heart and patch clamp; and (3) most expensive, animal experiments

in dogs or monkeys, but with the highest predictive value.

One major problem of all cardiac in vitro assays is the cell source. Human CMs

would be optimal; however, these are not available as myocyte-derived tumor cell

lines and adult primary CMs lose proliferation potential. As an alternative, existing

assays use Xenopus oocytes or human tumor cell lines genetically modiﬁed to

express hERG channels [91], or primary CMs prepared from hearts of other species,

for example dogs. However, the phenotype of these cell sources is far from being

able to mirror closely the function of human CMs.

The availability of ES cells and iPS cells from humans with their high expansion

capacities now offers the possibility to generate almost unlimited numbers of

functional CMs [49] as the perfect tool for the development of novel high-through-

put pharmacological screening systems. Such assays can be based not only on

electrophysiological detection of prolongation of QT-intervals, but also on detec-

tion of Ca

-transients or the biochemical/biophysical analysis of speciﬁc ion

channels. Furthermore, the inﬂuence of drugs on cardiovascular differentiation and

Induced Pluripotent Stem Cells: Characteristics and Perspectives 115

development [92] can be tested by means of pluripotent stem cell lines, transgenic

for ﬂuorescent reporter genes under control of speciﬁc promoters.

In case of screening for prolongation of the QT-interval [93], pluripotent stem

cell-derived CMs are probably better qualiﬁed than adult CMs, from a functional

point of view, as they represent embryonic CMs with a typical reduced repolariza-

tion reserve similar to CMs of diseased hearts. Therefore, prolongation effects on

repolarization can be detected at much lower concentrations as compared with cells

from healthy adult tissue. This may even be an advantage over animal experiments

and ﬁrst stages of clinical studies where as, in these cases, usually healthy individuals

are tested.

In addition to iPS-derived CMs from healthy individuals, iPS-derived CMs from

patients with genetically based diseases, for instance from long QT patients, may be

highly useful for drug screening purposes. Although not shown so far for iPS-

derived CMs from long QT patients, it is supposed that such cells are more sensitive

to certain QT-interval prolonging drugs than control cells.

Similar to cardiac drug screening, the cell source represents one if not the

bottleneck for development of novel in vitro assays in other ﬁelds, for instance,

safety screening for hepatotoxicity. So far, only limited numbers of human hepa-

tocytes have been available from donor organs that are unsuitable for clinical organ

transplantation, and unlimited supply with iPS cell-derived functional hepatic cells

would overcome the major bottleneck of in vitro drug evaluation of hepatotoxicity.

Recently, two groups described successful adaption of human ES cell differentia-

tion protocols to human iPS cell lines, which give rise to hepatic cells exhibiting all

major metabolic liver functions [94,95].

7 Induced Pluripotent Stem Cells for Disease Modeling

The generation of human iPS cells from various types of somatic cells provides

improved iPS cell generation strategies for adequate patient-speciﬁc cell culture

models for a variety of diseases and disorders, including hematopoietic disorders,

neurological disorders, arrhythmic heart disorders, pulmonary diseases, and meta-

bolic liver diseases (Fig. 1). Implications of the genetic defect during the speciﬁca-

tion of the affected cell type can be investigated and the severity of the defect can be

correlated to the individual course of the disease. Most importantly, derivatives of

disease-speciﬁc iPS offer an unlimited cell resource for in vitro studies allowing not

only advanced studies on the pathophysiology of such diseases but also evaluation

of future therapeutic interventions, including gene therapeutic approaches.

With respect to patients suffering from myeloproliferative disorders (MPDs),

studying disease-speciﬁc iPS cells might be of particular interest if the disease was

caused by a speciﬁc genetic mutation. Ye and colleagues recently described the

generation of iPS cells from patients’ CD34-positive blood cells that carry the

JAK2-V617F mutation leading to MPD [96]. These MDP-iPS were morphological

undistinguishable from normal human iPS cells and did not show alterations with

116 T. Cantz and U. Martin

respect to their pluripotent phenotype. Nevertheless, in vitro differentiation into blood

cells demonstrated an increased erythropoiesis, resembling the primary disease of the

patients [96]. In a recent letter, a Chinese group reports on the generation of iPS cells

from patients suffering from b-thalassemia, which is an inherited disease character-

ized by reduced synthesis of hemoglobin beta subunit [97], but the authors did not

provide analyses of the diseased phenotype after in vitro erythropoiesis.

Aiming at neurological disorders, numerous groups are interested in studying

iPS from patients, who suffer from an inherited form of amytrophic lateral sclerosis

(ALS). One future goal might be to generate patient-derived transplantable motor

neurons but today’s efforts focus on modeling the disease phenotype by analyzing

and inﬂuencing the motor neuron destruction. The ﬁrst crucial step for those studies

has already been achieved by generating ALS-speciﬁc iPS cell lines that were

differentiated into motor neurons in vitro [98].

Spinal muscular atrophy is a genetic disease affecting motor neurons, which, in

contrast to ALS, leads to symptoms in early childhood. In an elegant study, Ebert

et al. described the generation of disease-speciﬁc iPS cells from patients’ skin

ﬁbroblast and compared these cells with iPS cells derived from ﬁbroblasts of the

unaffected mothers [99]. Importantly, the authors were able to demonstrate that the

patient iPS cell-derived motor neurons showed selective deﬁcits and, thereby,

maintained the disease phenotype.

One pitfall of using iPS cells for disease modeling might be that the cells acquire

mutations in relevant pathways due to insertional mutagenesis caused by the

retroviral delivery of the reprogramming factors. This issue is addressed in one

study on iPS cells that were derived from ﬁve individual patients suffering from

Parkinsons disease [100]. Using Cre-excisable reprogramming factors, the authors

generated factor-free iPS cell lines that were a superior source of cells for studying

iPS cell-derived dopaminergic neurons. A very rare disease of the peripheral

nervous system was studied using iPS cells derived from patients’ ﬁbroblasts

suffering from familial dysautonomia, FD [101]. A point mutation in the IKBKAP

gene results in mis-splicing, but to date little is known about the detailed mecha-

nism of the loss of autonomic and sensory neurons in the peripheral nervous system.

FD-derived iPS cells could be differentiated into peripheral neurons, which mimic

the underlying disease phenotype by showing alterations in the levels of normal

IKBKAP transcripts and marked defects in neurogenic differentiation and migra-

tion behavior. Moreover, FD-iPS cells were used to evaluate candidate drugs such

as kinetin, epigallocatechin gallate, and tocotrienol.

Besides hematologic and neurologic disorders, iPS cells were also generated to

study metabolic diseases, such as type 1 diabetes mellitus. In recent years intense

basic science has led to improved protocols to differentiate human ES cells into

insulin-producing b-cells [102,103] but still more insights with respect to the (auto-)

immunologic reactions causing the loss of b-cells are desired. The lack of available

patient-derived type 1 diabetes (T1D)-speciﬁc b-cells is regarded as one of the

major obstacles that limit the current knowledge of the disease mechanism. Maehr

and colleagues from Doug Melton’s lab were demonstrating that T1D-iPS could be

generated for various patients and could be differentiated into insulin-producing

Induced Pluripotent Stem Cells: Characteristics and Perspectives 117

cells [104] and, thus, might be the long sought source not only for T1D disease

modeling but also for future cell replacement therapies.

8 Induced Pluripotent Stem Cells for Cell-Based Therapies

The above-mentioned iPS cells from T1D provide a good example for the two

aspects of iPS cell research in regenerative medicine. Besides indirect use of iPS-

cell derivatives to study pathophysiology and new pharmacotherapeutic strategies

of the respective disorder, patient-speciﬁc iPS cells would be a unique resource as

therapeutic cell transplants if mature and functional cell derivatives were obtainable

by in vitro differentiation. According to the efforts of various laboratories as well as

of the company Novocell Inc., it might well be that b-cells from diabetic patients’

iPS cells are the ﬁrst autologous iPS-derivatives to be used in clinical applications.

Hereby, one major concern reﬂects autoimmunologic depletion of the patients’ iPS

cell-derived cell transplant, which might be overcome by encapsulation of the

transplanted cells into alginate-based matrices [105].

Again, the ﬁrst proof-of-principle for iPS cell-based therapies was given in the

ﬁeld of hematology using a humanized sickle cell anemia mouse model. After

generation of iPS cells from these mice, the autologous iPS cells could be geneti-

cally repaired by correction of the human sickle hemoglobin allele applying gene-

speciﬁc targeting. Moreover, by in vitro differentiation, disease-free hematopoietic

progenitor cells could be obtained, which were able to ameliorate the phenotype

after transplantation into the diseased mice [106].

Even if therapeutic applications with human iPS cells need to overcome various

technical and safety issues, a lot of other diseases could be candidates for iPS-

derived cell therapies. However, besides safety issues while generating iPS cells,

one might also take into account that some genetic disorders will require genetic

correction of the primary donor cells prior to iPS reprogramming. This was the case

when Raya and colleagues from Belmonte’s lab [107] were attempting to generate

iPS cells from patients suffering from Fanconi anemia (FA). Due to the chromo-

somal instability of the primary FA-ﬁbroblasts the authors were unsuccessful in

generating FA-speciﬁc iPS cells. Only cells that were corrected using a normal

copy of the FANCA gene gave rise to iPS cell lines that could be expanded and pass

all criteria for human pluripotent stem cells. Furthermore, these cells did not show

major abnormalities during in vitro hematopoiesis, suggesting their future use in

therapeutic applications once the above-mentioned safety issued are sufﬁciently

resolved.

As mentioned above, human iPS cell-derived hepatic cells can be obtained if

suitable differentiation protocols are applied [94,95]. Besides their use for pharma-

cologic applications such as drug screening and toxicological analyses, hepatic iPS-

cell derivatives might become a valuable autologous source for cell therapies of

acute liver failure or of metabolic liver diseases. However, reﬁned differentiation

protocols need to be established that result in a more mature hepatic phenotype,

118 T. Cantz and U. Martin

which can efﬁciently engraft and repopulate diseased livers. As pointed out in a

recent study taking advantage of a murine competitive liver repopulation assay,

human ES cell-derived hepatic cells failed to give rise to a detectable amount of

hepatic cells in this xeno-transplantation model [108].

Innovative concepts in treating retinal degeneration focus on stem cell-derived

photoreceptor progenitor cells or retinal pigmented epithelial cells. In a recent

study, Osakada et al. describe the generation of retinal progenitor cells from both

human ES cells and human iPS cells, using a small molecule-based differentiation

protocol that avoids cross-species contaminations as observed if bacterial or animal

products were used [109]. Such xeno-free iPS cell-derived retinal progenitors may

be highly useful for clinical translation of therapeutic concepts as developed by

Lamba and colleagues, who transplanted human iPS-derived retinal epithelial cells

into mice and were able to demonstrate engraftment of human cells in the mouse

retina and show expression of photoreceptor markers [110].

Whether ﬁnally patient-speciﬁc iPS cells or allogeneic iPS will be clinically

applied is not clear at present. Certainly, autologous cells are advantageous since

pharmacological immunosuppression is not required. However, if patient-speciﬁc

iPS-derivatives are applied, the required time frame for isolation and culture of

primary cells, reprogramming, selection of suitable clones, expansion, differentia-

tion, enrichment, and optionally tissue engineering has to be considered and will

exclude treatment of acute diseases and injuries. Maybe worldwide banking of

allogeneic iPS(-derivatives) may provide the required cells at least for the majority

of patients. Other possibilities are the engineering of genetically modiﬁed “univer-

sal” cell lines or the development of clinically applicable iPS-based tolerance

induction protocols. In both cases, cell production would be possible on an indus-

trial scale, thereby leading to dramatically reduced costs compared to autologous

cell therapy.

9 Perspectives

The generation of human iPS cells [6,8,111], together with the latest developments

showing production of iPS cells without integrating vectors [69–71,75], create new

opportunities for the establishment of clinically useful autologous stem cell lines

(Fig. 1).

After these pioneering developments, four major issues need to be addressed. First,

it is now crucial to develop technologies that enable selection of the “best” ones from

the large number of iPS clones that usually result from one reprogramming experi-

ment: besides culture characteristics, the potential for teratoma formation and poten-

tial predetermination to differentiate in the desired lineage(s) are critical for clinical

application. Second, it is mandatory to improve the efﬁciency and speciﬁcity of

in vitro differentiation in order to obtain iPS-cell derivatives that are mature enough

to mimic the targeted (diseased) cell type during drug screening and toxicology

analyses. Third, besides differentiation strategies, functional engraftment capabilities

Induced Pluripotent Stem Cells: Characteristics and Perspectives 119

of transplanted human iPS-cell derivatives need to be addressed. Finally, and

probably most critical, several safety issues need to be resolved, because the iPS

cells themselves and their differentiated derivatives might harbor various genetic

and epigenetic abnormalities, which could be acquired just during the reprogram-

ming process or selected during expansion of the (most proliferative) cell clones.

In conclusion, iPS cell biology is a young ﬁeld within stem cell research that

covers various important and attractive scientiﬁc areas, ranging from basic under-

standing of (epi-)genetics during nuclear reprogramming, over applied sciences

with respect to stem cell expansion and differentiation, to translational research on

clinical applications in (large) animal models in preparation for future phase-I

clinical trials.

Acknowledgments We are very grateful to the members of our labs for providing intensive

discussions and a lot of critical input, which contributed to this review. Both authors are group

leaders within the cluster of excellence REBIRTH (REgenerative BIology and Reconstructive

THerapy), which is funded by the German Research Foundation (DFG; EXC 62/1). Further

funding is provided by the DFG (MA 2331/6-1, SCHO 340/4-1), the Federal Ministry of Education

and Research through grants 0313926A, 01GN0812, 01GN0816 and 01GM0854, 01GN0958 and

0315493, as well as by the Jose

´Carreras leukemia foundation (DJCLS R09/01).

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Adv Biochem Engin/Biotechnol (2010) 123: 127–141

DOI: 10.1007/10_2010_72

#Springer-Verlag Berlin Heidelberg 2010

Published online: 10 June 2010

Induced Pluripotent Stem Cell Technology

in Regenerative Medicine and Biology

Duanqing Pei, Jianyong Xu, Qiang Zhuang, Hung-Fat Tse,

and Miguel A. Esteban

Abstract The potential of human embryonic stem cells (ESCs) for regenerative

medicine is unquestionable, but practical and ethical considerations have ham-

pered clinical application and research. In an attempt to overcome these issues, the

conversion of somatic cells into pluripotent stem cells similar to ESCs, commonly

termed nuclear reprogramming, has been a top objective of contemporary biology.

More than 40 years ago, King, Briggs, and Gurdon pioneered somatic cell nuclear

reprogramming in frogs, and in 1981 Evans successfully isolated mouse ESCs.

In 1997 Wilmut and collaborators produced the ﬁrst cloned mammal using

nuclear transfer, and then Thomson obtained human ESCs from in vitro fertilized

blastocysts in 1998. Over the last 2 decades we have also seen remarkable ﬁndings

regarding how ESC behavior is controlled, the importance of which should not be

underestimated. This knowledge allowed the laboratory of Shinya Yamanaka to

overcome brilliantly conceptual and technical barriers in 2006 and generate

induced pluripotent stem cells (iPSCs) from mouse ﬁbroblasts by overexpressing

deﬁned combinations of ESC-enriched transcription factors. Here, we discuss

some important implications of human iPSCs for biology and medicine and also

point to possible future directions.

Keywords Disease modeling, Embryonic stem cells, Induced pluripotent stem

cells, Regenerative medicine, Reprogramming

D. Pei (*), J. Xu, Q. Zhuang, and M.A. Esteban (*)

Stem Cell and Cancer Biology Group, Key Laboratory of Regenerative Biology, South China

Institute for Stem Cell Biology and Regenerative Medicine, Guangzhou Institutes of Biomedicine

and Health, Chinese Academy of Sciences, Guangzhou 510530, China

e-mail: esteban@gibh.org, pei_duanqing@gibh.ac.cn

H.-F. Tse

Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong, China

Contents

1 Pluripotency and Induced Pluripotency .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . 128

1.1 Embryonic Stem Cells . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . 128

1.2 Pluripotency and Its Regulators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . 130

1.3 Induced Pluripotent Stem Cells . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132

2 Conclusions .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138

Abbreviations

bFGF Basic ﬁbroblast growth factor

BMP Bone morphogenetic protein

EpiSCs Epiblast stem cells

ERK Extracellular signal-regulated kinase-1

ESCs Embryonic stem cells

GFP Green ﬂuorescent protein

GSK3B Glycogen synthase kinase 3 beta

ICM Inner cell mass

iPSCs Induced pluripotent stem cells

LIF Leukemia inhibitory factor

Oct4 Octamer-4

POU5F1 POU class 5 homeobox 1

SCNT Somatic cell nuclear transfer

SKOM Sox2, Klf4, Oct4, c-Myc

SKONL Sox2, Klf4, Oct4, Nanog, Lin28

STAT Signal transducer and activator of transcription

Tgfb Transforming growth factor beta

1 Pluripotency and Induced Pluripotency

1.1 Embryonic Stem Cells

After fertilization the mammalian zygote undergoes a series of quick symmetric

cell divisions to reach the morula stage. Soon afterwards the ﬁrst differentiation

event produces the blastocyst, which is composed of an outer layer or trophecto-

derm and the inner cell mass (ICM) [1] (Fig. 1). The blastocyst stage embryo

implants into the receptive uterine wall and then the trophectoderm transforms into

the placenta, which connects the developing fetus to the maternal uterine wall and is

responsible for the exchange of nutrients and oxygen. The ICM transform into the

128 M.A. Esteban et al.

epiblast, which later differentiates into the three germ layers (ectoderm, mesoderm,

and endoderm) through a process known as gastrulation, and these three lineages

form all the tissues of the newborn individual [2]. Embryonic stem cell (ESC) lines

are considered in vitro representations of the ICM, and they are derived from

preimplantation blastocysts once these are broken and the cells cultured in speciﬁc

tissue culture conditions [3,4]. Human ESCs are phenotypically and functionally

very distinct from mouse ESCs; for example, they are ﬂat and require basic

ﬁbroblast growth factor (bFGF) and Activin A/transforming growth factor beta

(Tgfb) signaling to maintain their pluripotent state, whereas mouse ESCs are tightly

clustered and require leukemia inhibiting factor (LIF)/Stat3 and Bmp4 signaling

[5–7]. Human ESCs also differ epigenetically from mouse ESCs by several criteria

such as X chromosome inactivation, their pattern of gene expression, and pluripo-

tency factor promoter occupancy across the genome [8]. A different type of stem

cells termed epiblast stem cells or EpiSCs can also be derived from the postimplan-

tation mouse epiblast, and these cells share many characteristics with human ESCs

including the ﬂat morphology and tissue culture requirements [9,10]. EpiSCs have

a very restricted developmental potential but they can produce teratomas composed

of the three germ layers. Interestingly, they can be reversed into bona ﬁde ESCs by

manipulating the culture conditions or using chemical inhibitors [8,11]. Altogether

these ﬁndings have provoked questions concerning the true identity of human ESCs

and whether they can also be reset to a mouse ESC-like status. In mouse,

Fig. 1 Schematic representation of embryonic stem cell differentiation and reprogramming

Induced Pluripotent Stem Cell Technology in Regenerative Medicine and Biology 129

pluripotency is routinely tested by injecting cells into blastocysts of a mouse strain

with different coat color, but this approach cannot be used in humans and thus many

questions remain. The failure to isolate true ESCs from other relevant mammalian

species like ungulates (e.g., pig) [12] and even from many (deﬁned as non-

permissive) mouse strains [8] has also been a major roadblock in making cross-

comparisons. Nevertheless, given their ability to differentiate into all possible

lineages of the body, human ESCs have longbeenviewedasapotential “fountain

of youth” for regenerative medicine purposes and a major scientiﬁc advance [13]

(Fig. 1). Adult stem cells of mesenchymal originhavealsoraisedmuchinterest

for transplantation purposes and are poorly immunogenic, but they have a rather

limited differentiation potential and are difﬁcult to expand ex vivo [14].

1.2 Pluripotency and Its Regulators

Despite the immense potential of human ESCs, the use of human embryos, even if

from in vitro fertilization, remains controversial, and the problem of immune

rejection following transplantation in patients is difﬁcult to solve [15]. This has

stimulated scientists to ﬁnd alternative ways to produce pluripotent cells in vitro by

resetting the nuclei of somatic cells to an embryonic-like stage. These methods are

generically termed nuclear reprogramming or reprogramming, and the two most

extended variants are somatic cell nuclear transfer (SCNT) [16] and direct repro-

gramming using exogenous factors [17,18]. Pioneer studies by King, Briggs, and

Gurdon had shown decades earlier that when an undifferentiated [19] or a somatic

nucleus [20] is transferred to a frog egg deprived of its own nucleus, the egg bearing

the exogenous DNA can produce a normal tadpole. This was proof of concept that

developmental fates are not a ﬁxed state and suggested that somatic cells contain all

the necessary information to direct the development of a new individual. The

successful cloning of Dolly in 1997 proved this idea and made human SCNT a

top scientiﬁc objective for producing patient speciﬁc human ESC-like pluripotent

cell lines. But even though SCNT was successful in a number of other species

including non-human primates [21,22], many technical challenges persist in

humans and early reports turned out to be fraudulent. After this, thanks at least in

part to improved technologies for high throughput functional screening, studies

worldwide progressively narrowed into the identiﬁcation of key transcriptional

networks that govern ESC function [23,24]. Given the existing restrictions in

many countries, most of these analyses were done with mouse ESCs, but the

existing paradigms apply to a great extent in humans and possibly other mammals

as well. Among other key transcription factors, Octamer-4 (Oct4), identiﬁed by

Austin Smith and collaborators [25], and Nanog, identiﬁed by Austin Smith [26]

and Shinya Yamanaka [27], are essential regulators of pluripotency. For example,

levels of the homeobox-containing protein Oct4 (also termed POU5F1) only 50%

higher than normal induce mesodermal differentiation, while if 50% lower ESC

fate is shifted towards the trophectoderm. Likewise, knock-down of Oct4 prevents

130 M.A. Esteban et al.

proliferation of ICM cells and induces differentiation into trophectoderm in mouse

embryos [25]. In contrast, the homeodomain containing protein Nanog is not

absolutely required to sustain mouse ESC characteristics [28], but its overexpres-

sion renders them resistant to differentiation upon LIF withdrawal [26–28]. Oct4,

Nanog, and other ESC transcription factors coordinately bind to DNA-binding sites

in target promoters along the genome [24], and act as gene activators or repressors

depending on the identity of extra proteins that are recruited to these promoters; for

example, recruitment of the transactivator P300 associates with active transcription,

and proteins of the Polycomb group with repression [29,30] (Fig. 2). This duality

has the purpose of coordinating the activation of pluripotency genes with the

silencing of others that are involved in lineage differentiation programs, and is

tightly related to the nature of the concomitant histone modiﬁcations (e.g., acetyla-

tion, methylation) [31]. In addition, ESC transcription factors usually bind to their

own promoters in an autoregulatory loop, and can induce the transcription of

each other [24]. The accessible amount of information regarding ESC pluripotency

is nowadays impressive, and although knowledge is not yet fully digested, it was

determinant to allow Takahashi and Yamanaka to generate induced pluripotent stem

cells (iPSCs) from mouse somatic cells in 2006 [17], an outstanding achievement.

Fig. 2 Schematic representation of the transcriptional networks controlling ESC pluripotency and

how this knowledge was employed to discover iPSCs

Induced Pluripotent Stem Cell Technology in Regenerative Medicine and Biology 131

1.3 Induced Pluripotent Stem Cells

Takahashi and Yamanaka had a simple yet sophisticated approach to nuclear

reprogramming: they ﬁrst selected a combination of transcription factors and

other proteins with well established roles in ESC behavior, which were delivered

as a pool into mouse ﬁbroblasts by means of retroviral vectors (Fig. 2). The

transduced cells were cultured in conditions similar to mouse ESCs and after

approximately 15 days colonies with mouse ESC characteristics formed; then the

exogenous factors were eliminated one by one until it appeared that the SKOM

(Sox2, Klf4, Oct4, and c-Myc) cocktail was necessary and sufﬁcient (Fig. 2)[17].

The ﬁrst generation iPSCs formed teratomas but had a different global gene

expression pattern from ESCs and failed to produce adult chimeric mice. The use

of genetically engineered knock in mice with reporter systems (green ﬂuorescent

protein, GFP) and resistance to antibiotics inserted into the promoter of key ESC

pluripotent regulators (e.g., Nanog) allowed the generation of chimera competent

iPSCs with germ line transmission by the Yamanaka and Jaenisch labs [32,33], and

ever since the ﬁeld has been an explosion of remarkable achievements one after the

other. In particular, the Yamanaka and Thomson laboratories were the ﬁrst to

produce human iPSCs using retroviral or vectors and SKOM [34] or SKONL (NL

stands for Nanog and Lin28) factor combinations [35].

1.3.1 Delivery Methods

Methods for generating iPSCs are evolving very quickly and the choice is very

varied but can basically be divided into integrating and non-integrating approaches.

The initial experiments by Takahashi and Yamanaka used retroviral vectors [17],

and this turned out to be particularly useful given that ESCs have self defense

mechanisms (DNA methylation of the integrated virus) against invading genomes

such as retroviruses. Accordingly, silencing of the exogenous retroviral vectors

was established as a relevant criterion to discern fully reprogrammed from partially

reprogrammed colonies [17]. iPSCs have also been generated with lentiviruses,

which have a less reliable degree of silencing in ESCs/iPSCs but can be com-

bined with an inducible doxycycline-dependent system. Retroviral and lentiviral

approaches, although robust and reproducible, have the problem of possible reacti-

vation of the viral vector, in particular after transplantation, and for example mice

generated with SKOM retroviruses had a high frequency of tumors and other

abnormalities [32]. This is possibly related to c-Myc and over time the need for

this oncogene (and other factors as well) in the cocktail has been bypassed [36,37],

but we should not forget that in some instances Klf4 has also been regarded as an

oncogene and overexpression of Oct4 in adult tissues can cause dysplasia [38,39].

To avoid this problem, Jaenisch and collaborators induced iPSCs using a polycy-

stronic cassette that could be removed by adding CRE recombinase [40]. Interest-

ingly, the authors found a change in gene expression in iPSC cell lines before and

132 M.A. Esteban et al.

after excision with the recombinase, which points to minor presence of the viral

transcripts having a substantial impact on gene expression. Nevertheless, this

approach, although appealing, leaves a genetic scar after the excision and still

does not preclude the risk of insertional mutation. Hochedlindger and collaborators

also made mouse iPSCs using adenoviruses [41] and afterwards this was achieved

in human cells [42]. More recently human iPSCs were produced by Yu et al. using

episomal vectors [43], and mouse and human iPSCs by Zhou et al. and Kim et al.

using proteins [44,45]. These non-integrating approaches have very low efﬁciency

compared to retroviruses/lentiviruses and the challenge is to improve the reproduc-

ibility of existing protocols. The addition of compounds such as the histone

deacetylase inhibitor valproic acid [46], vitamin C [47], or chemical inhibitors of

Tgfb receptors [48–50], and a careful donor cell selection will deﬁnitely facilitate

this objective. The number of cell types that can be used to generate iPSCs is

growing steadily [51–56]. So far, superior cell sources are deﬁned mainly on the

basis of such a weak criterion as human ESC-like morphology and alkaline

phosphatase staining, but this may be misleading and it is important to evaluate

the epigenetic reprogramming and safety of the resulting colonies using more

accurate methods (see Sect. 1.3.3 below). Understanding why some cells are

more amenable to reprogramming than others and how these compounds work

will also shed light into the reprogramming.

1.3.2 Modeling Human Disease with iPSCs

Mouse transgenic and knock out models are extremely valuable for studying human

disease but in many cases the parallelism between both species does not exist due to

differences in animal physiology or in gene function. This has made it increasingly

necessary to develop more accurate human disease models for mechanistic studies

and drug discovery. One possible way to do this is using in vitro fertilized ovules

after the corresponding preimplantation genetic diagnosis. This has produced

human ESCs from diseases such as cystic ﬁbrosis [57] or Huntington disease

[58], but is severely constrained by ethical considerations and the diseases that

are routinely screened. Another option is to modify genetically existing human ESC

cell lines by means of homologous gene recombination, but apart from ethical

concerns this area of research has been largely stalled due to technical difﬁculty in

achieving DNA recombination compared to mouse ESCs [59,60]. In this regard, if

the targeting efﬁciency is low for knocking out one gene, it is almost negligible for

eliminating the two. This approach may still be feasible for X chromosome-linked

syndromes, in which only one allele needs to be abrogated, for example Lesch–

Nyhan disease [61], but among other considerations the selection procedure may

alter the epigenetic state and quality of the resulting ESC cell lines. More recently,

successful homozygous gene disruption in human ESCs using zinc-ﬁnger nuclease-

mediated genome editing [62] or a bacterial artiﬁcial chromosome (BAC)-based

targeting approach has also been reported [63]. Regarding the zinc-ﬁnger nuclease

Induced Pluripotent Stem Cell Technology in Regenerative Medicine and Biology 133

technology, not every gene is susceptible and the DNA-binding speciﬁcity of the

designed zinc-ﬁnger proteins remains to be validated with vigorous genomic

analysis. The generation of iPSCs from individuals with genetic diseases could

solve these problems but caution is needed as there are also potential caveats [59,

60]. One fundamental consideration is that many diseases have a late onset and the

neurons or other progeny derived from iPSCs may not reproduce the age related

phenotype. In addition, some diseases are non-cell autonomous and require not only

time to develop but also the existence of a body context (e.g., neurons affected by

secretions of glia cells). Another perhaps more incapacitating problem is that

differentiation protocols are still inefﬁcient and the lack of a homogeneous popula-

tion can be a major problem for detecting biomarkers and performing drug screen-

ing or transcriptomic/proteomics analysis. Nevertheless, recent reports have

succeeded in ﬁnding either an in vitro phenotype or using patient-speciﬁc iPSC

cell line generation to shed light onto the reprogramming. For example, Ebert et al.

produced iPSCs from spinal muscular atrophia [64], Lee et al. from familial

dysautonomia [65], and Agarwal et al. from dyskeratosis congenita [66], and this

list is likely to increase steadily. Although setting up meaningful in vitro models

will likely take several years and for many diseases it may never be achieved, this

research will revitalize the interest on rare human conditions touching essential

aspects of human physiology (e.g., DNA repair) for which the availability of

patients (not to mention the tissue) is reduced.

1.3.3 Accuracy of the Epigenetic Reprogramming

iPSCs have been repeatedly described as identical or almost identical to ESCs but

the initial comparisons were too vague for a matter of such importance and deﬁning

the epigenetic identity of iPSCs compared to ESCs is now a very active aspect of

research. Among other major questions (Fig. 3) that are steadily discussed in all

forums we have: is the epigenetic reprogramming of iPSCs complete or only an

effective makeup? If it is only a makeup, then – as long as it works and is safe –

does it matter? Also, is there any epigenetic memory from the tissue of origin and

does this memory have any functional implications? Related to the latter, an

interesting possibility is that the existence of a tissue-speciﬁc epigenetic memory

confers an advantage rather than being negative, which could thus be exploited to

develop iPSCs that retain a relevant functional ability. On the other hand, it could

happen that the abnormal epigenetic reprogramming (either epigenetic memory or

of a different kind) is a requisite for generating iPSCs. As was discussed above, in

the mouse it is easy to test for the acquisition of pluripotency and recently adult

animals were produced entirely from mouse iPSCs by means of tetraploid comple-

mentation [67–69]. This suggests that mouse ESCs and iPSCs are either epigeneti-

cally identical or that putative abnormally reprogrammed genes are not functionally

relevant. However, this procedure still has a very poor success rate and it remains to

be found whether these animals or their progeny are exempt of any physiological

abnormalities. In this regard, for example, mice produced by SCNT are more prone

134 M.A. Esteban et al.

to disease and can have developmental abnormalities [70,71]. In the case of human

iPSCs, epigenetic reprogramming is normally deﬁned by complete DNA demeth-

ylation of selected regions of Oct4 and Nanog promoters and by hybridization

arrays that compare the gene expression proﬁle (DNA or microRNA microarrays)

and the pattern of histone modiﬁcations (mainly histone methylation). Interestingly,

a recent meta-analysis of published DNA microarrays by Chin et al. showed that

mouse and human iPSCs retain a common gene expression signature especially

during the ﬁrst passages [72], and Ghosh et al. showed the retention in iPSCs from

different tissues of patterns of gene expression reminiscent of the tissue of origin

[73]. Both studies have compared iPSCs generated by different methods in different

laboratories and although the conclusions are attractive their analysis is not exempt

of problems. For example, Chin et al. deﬁned abnormal reprogramming as those

genes changed more than 1.5-fold between the average of a panel of iPSCs and a

panel of ESCs [72], which can be misleading because gene expression of ESCs is

known to differ between cell lines and so is expected of iPSCs. Besides, although

they identiﬁed up-regulated genes that belong to developmental pathways, this

could be a consequence of partial differentiation in the borders of some colonies,

which for example is not infrequent during the ﬁrst passages of freshly isolated

human iPSCs. Ghosh et al. also stated that the retention of a footprint from the

tissue of origin could be due to those iPSC cell lines being a heterogeneous

population of both reprogrammed and partially reprogrammed cells [73]. In any

case, DNA arrays have limitations, and a rather more accurate comparison should

require digital sequencing technologies: deep transcriptomic sequencing, and

whole genome ChIP-on-Chip sequencing and DNA bisulfate sequencing for asses-

sing DNA methylation. The latter was recently achieved with human ESCs and

these available data are a powerful resource for future comparisons with human

iPSCs [74]. On the other hand, Doi et al. also used comprehensive high throughput

Fig. 3 Possibilities regarding the extent of the epigenetic reprogramming in iPSCs

Induced Pluripotent Stem Cell Technology in Regenerative Medicine and Biology 135

array-based relative methylation (CHARM) to identify in a more restricted part of

the genome series of differentially methylated regions (DMRs) between multiple

ESCs and human iPSCs and their respective donor cells [75]. Pick et al. also

described the inadequate maintenance of imprinted genes, which was demonstrated

by abnormal DNA methylation of their respective promoters, between donor cells

and some of the resulting human iPSCs cell lines [76].

1.3.4 iPSCs from Other Species

After the existing technical hurdles and safety concerns are solved, the jump of

human iPSCs to the ﬁrst clinical trials will be a monumental step that cannot be

made without prior animal validation. Given its ease and reproducibility, mouse

iPSCs are unquestionably the preferred tool for mechanistic studies and technical

innovations that subsequently become validated in the human model. Besides,

proof of the principle that iPSCs have huge therapeutic potential was achieved

early by the Jaenisch laboratory, which showed that mouse iPSCs from a mouse

with sickle cell anemia can be used to correct the mutation using homologous

differentiation followed by hematopoietic progenitor differentiation and transplan-

tation [77]. However, in general the differences in size, physiology, and life span

between mice and humans are too big for valuable comparisons. For example, the

heart beat frequency in mice is several hundred per minute compared to around 70

in humans, challenging if not invaliding any possible conclusions made after iPSC

derived-cardiomyocytes transplantation. This has encouraged researchers to

develop iPSCs from other mammalian species, speciﬁcally the rat, monkey, and

pig in this order. Rat iPSCs were generated by two independent groups [78,79]

following the successful isolation of rat ESCs using extracellular signal-regulated

kinase-1 (ERK) and glycogen synthase kinase 3 beta (GSK3B) inhibitors by Smith

and Ying [80,81]. Li et al. used ﬁbroblasts and SKOM retroviruses [78], while Liao

et al. used ﬁbroblasts and bone marrow mesenchymal cells infected with inducible

lentiviruses [79]. In both studies, rat iPSC pluripotency was demonstrated by

teratomas, and the formation of chimeric animals (without germ line transmission)

was only reported by Li et al. [78]. Rats are larger than mice and, although their life

span and physiology also differ from humans, they are excellent laboratory animals

for a wide range of diseases. Monkey iPSCs were then produced from Rhesus

monkey (Macaca mulatta) skin ﬁbroblasts using SKOM retroviruses by Deng and

collaborators, whose pluripotency was judged on the base of teratoma formation

[82]. A problem of monkeys is that their close phylogenetic relationship with

humans still raises ethical concerns and, besides, in most countries there is no

easy access to these animals. Aiming to develop a large animal model which is

exempt of these problems, Esteban et al. [83] and later on Wu et al. [84] and Ezashi

et al. [85] reported the generation of porcine iPSCs using retroviruses or lentiviruses

and ﬁbroblasts or bone marrow mesenchymal stem cells from Tibetan mini-pig and

farm pig (Sus scrofa). Although chimeric animals were not presented, pluripotency

was demonstrated by teratoma formation. Notably, reliable teratomas had not been

136 M.A. Esteban et al.

shown in numerous previous attempts to isolate pig ESCs [86]. Given that the

porcine physiology is strikingly similar to humans and their maintenance is easy

and relatively inexpensive, the pig stands arguably as the best model for preclinical

trials using iPSCs [87]. Difﬁculties of this model include the mentioned lack of

bona ﬁde porcine ESCs with which to establish comparisons, the incomplete

sequencing and annotation of the pig genome, and the limited availability of tested

reagents, speciﬁcally antibodies, that can assist with the characterization of these

iPSCs or their derivatives [87]. Besides, in all three studies either the transgenes

were not properly silenced [83,85] or if doxycline was removed the cells differ-

entiated [84], which raises important questions as to whether the reprogramming

was indeed complete. Nevertheless, improvement of the current derivation proto-

cols is expected soon and pig iPSCs could play a major role in accelerating the

clinical application of human iPSCs.

2 Conclusions

Two major trends have arisen after roughly 4 years of intense iPSC research: the

possibility of personalized stem cell therapies using human iPSCs and the creation

of in vitro models of human disease. At the current pace of discovery these two

types of research may progressively divert and their respective standards could be

different. For clinical application iPSC cell lines will have to meet the most

stringent criteria of quality and be exempt of transgene insertions. Analyzing the

extent of the epigenetic reprogramming in human iPSCs will almost inevitably

involve the next generation sequencing technologies. But the analysis of multiple

iPSCs is not enough and this will need to be contrasted with ESCs from different

sources in order to exclude differences related to the genetic background. This will

raise the costs considerably, at least with currently available technologies, and

reinforces the idea that further research on human ESCs is important to understand

iPSCs, which would surely ﬁnd many detractors [88]. Altogether this may imply

that the long awaited objective of having patient speciﬁc pluripotent stem cells is

not feasible or at least will take longer than expected. Potential solutions include

the creation of a bank of iPSCs matching as many haplotypes as possible, or the

production of iPSCs engineered to have low immunogenicity. In both cases the use

of fetal sources (e.g., cord blood [54,55] and umbilical cord matrix mesenchymal

cells [89]) should be preferred as these cells do not have the risk of incorporated

mutations that is omnipresent in more aged tissues (especially skin cells). By

creating iPSC banks, only those iPSC cell lines of the highest quality would be

selected, further expanded in the absence of animal products or xenobiotics, and

scrupulously tested before clinical trials are approved. Besides, any abnormalities

happening afterwards would be immediately noticed and recorded. On the other

hand, for modeling genetic diseases in vitro, safety and near perfect epigenetic

reprogramming is a priori less of a concern and this parallel ﬁeld may thus move

quicker and face less criticisms. Of course, genetic and epigenetic abnormalities

Induced Pluripotent Stem Cell Technology in Regenerative Medicine and Biology 137

can also have an impact on the phenotype and be seriously misleading but this

problem can be solved by analyzing iPSCs from different affected individuals as

well as unaffected controls (ideally from the same family to eliminate the effects of

a different genetic background). It is also remarkable that, following the success of

iPSC derivation, cells resembling neurons have been produced directly from mouse

ﬁbroblasts by overexpressing neural enriched transcription factors [90]. These

neurons display electrical activity and can form synapses, but it is unclear yet

whether they bear extensive neuron-like epigenetic remodeling and the ﬁbroblast

genetic program has been effectively shut down. In the near future we may see other

examples of direct transdifferentiation (Fig. 1), and if the transformation is accurate

this may end up being more practical than the uphill differentiation into iPSCs and

then downhill into speciﬁc lineages. In any case, this experiment is a clear indica-

tion that iPSC technology is forcing us to think of cell fate as a navigable condition

rather than a ﬁxed state, and this directly or indirectly will likely inﬂuence how we

perceive human physiology and disease.

Acknowledgments Work in the authors’ laboratories, Chinese Academy of Sciences, National

Natural Science Foundation of China, Ministry of Science and Technology 973 program, National

High Technology Research and Development Program of China, Bureau of Science and Technol-

ogy of Guangzhou Municipality.

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Induced Pluripotent Stem Cell Technology in Regenerative Medicine and Biology 141

Adv Biochem Engin/Biotechnol (2010) 123: 143–162

DOI: 10.1007/10_2009_25

#Springer-Verlag Berlin Heidelberg 2010

Published online: 21 January 2010

Production Process for Stem Cell

Based Therapeutic Implants: Expansion

of the Production Cell Line and Cultivation

of Encapsulated Cells

C. Weber, S. Pohl, R. Poertner, Pablo Pino-Grace, D. Freimark,

C. Wallrapp, P. Geigle, and P. Czermak

Abstract Cell based therapy promises the treatment of many diseases like diabetes

mellitus, Parkinson disease or stroke. Microencapsulation of the cells protects them

against host-vs-graft reactions and thus enables the usage of allogenic cell lines for

the manufacturing of cell therapeutic implants. The production process of such

implants consists mainly of the three steps expansion of the cells,encapsulation of

the cells, and cultivation of the encapsulated cells in order to increase their vitality

and thus quality. This chapter deals with the development of ﬁxed-bed bioreactor-

based cultivation procedures used in the ﬁrst and third step of production. The

bioreactor system for the expansion of the stem cell line (hMSC-TERT) is based on

non-porous glass spheres, which support cell growth and harvesting with high yield

and vitality. The cultivation process for the spherical cell based implants leads to an

increase of vitality and additionally enables the application of a medium-based

differentiation protocol.

Keywords Cell therapy, Mesenchymal stem cells, Encapsulation, Fixed bed

bioreactor, Glass carrier

C. Weber, S. Pohl, P. Pino-Grace, D. Freimark, and P. Czermak

Institute of Biopharmaceutical Technology, University of Applied Sciences Giessen-Friedberg,

Giessen, Germany

R. Poertner

Institute of Bioprocess and Biosystem Technology, University of Hamburg-Harburg, Hamburg,

Germany

C. Wallrapp and P. Geigle

CellMed AG, Alzenau, Germany

P. Czermak (*)

Department of Chemical Engineering, Kansas State University, Manhattan, KS, USA

e-mail: peter.czermak@tg.fh-giessen.de

Contents

1 Introduction .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144

2 Expansion of hMSC-TERT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146

2.1 Reactor System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146

2.2 Expansion of hMSC-TERT on a Laboratory Scale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149

2.3 Theoretical Scale Up of the hMSC-TERT Expansion Process . . . . . . .. . . . . . . . . . . . . . . 156

3 Cultivation of Encapsulated Cells . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . 157

3.1 The Reactor System . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157

3.2 Cultivation of Encapsulated Cells . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . 158

3.3 Theoretical Scale Up of the Cell Bead Cultivation Process . . . . . . . . . . . . . . . . . . . . . . . . . 160

3.4 Conclusion and Outlook . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161

1 Introduction

Cell based therapy can be deﬁned as the implantation of autologous, allogenic, or

xenogenic cells for the replacement of damaged cells or organ functions. Either the

implanted cells are able to assume this function by themselves or they stimulate

other cells, which then can cause a regeneration of the tissue or organ function.

Examples are the treatment of diabetes mellitus with insulin- and GLP-1-secreting

cells or Parkinson disease with dopamine-secreting cells as well as the implantation

of mesenchymal stem cells for regeneration of heart, cartilage, or bone tissue [1–6].

The implantation of allogenic (or xenogenic) cells demands a protection against

host-vs-graft reactions which can be achieved by a suppression of the recipient’s

immune system or by an encapsulation of the transplanted cells.

Promising, for the treatment of many endocrine or degenerative diseases are

microencapsulated stem cells, for example the CellBead

system developed by the

CellMed AG (Alzenau, Germany). These cell beads consist of an inner cell contain-

ing core which is surrounded by an alginate capsule (Fig. 1). Each cell bead

contains about 2,000–3,000 cells in a non-proliferating state. The diameter of the

cell containing core bead is about 400 mm and the diameter of the alginate capsule

between 500 and 600 mm.

Core bead: 2000 – 3000 cells

Alginate capsule

Fig. 1 Light-microscopic image of cell beads

144 C. Weber et al.

The allogenic production cell line is based on human mesenchymal stem cells,

which are transfected with the gene of the catalytic subunit of human telomerase.

The telomerase activity counteracts the shortening of the telomeres after each cell

cycle, which indicates a transformation of the cells to a permanent cell line [7].

Dependent on the designated use the cells are genetically modiﬁed with additional

therapeutic genes.

The cell beads can be implanted by injection using a sterile syringe. At the

implantation site the cells are providedwith nutrients bydiffusion through the capsule

and in turn release therapeutic molecules. Antigens and components of the host

immune system cannot penetrate through the capsule (Fig. 2). The advantages of

this therapeutical system are a continuous drug delivery and, due to the local applica-

tion, high drug concentrations at the point of implantation. Furthermore, a production

in stock is possible since a cell line is used.

The implantation of this cell therapeutic system behind the blood-brain barrier

makes them suitable for the treatment of, e.g., stroke. Clinical phase 1 studies with

GLP-1-transfected cells revealed a reduced loss of neuronal cells in a controlled

cortical impact rat model due to the implantation of GLP-1 secreting cell beads

[8]. Originally, intestinal cells secrete GLP-1in response to food intake. GLP-1

enhances insulin secretion of beta-cells as well as promoting insulin sensitivity.

Since GLP-1 receptors are also expressed throughout the mammalian brain, the

implantation of GLP-1 secreting cell beads into the brain may cause neurotrophic

and neuroprotective effects.

The production process of cell based implants consists of three steps, whereas

this chapter is focused on the ﬁrst and third production steps (Fig. 3).

Due to the fact that the cells themselves are the product, the requirements of the

stem cell expansion process differ from a common mammalian cell culture where,

for example, a virus or protein is the product.

The cultivation and harvesting procedure for the expansion of the stem cell

based production cell line should be very gentle in order to obtain high yields and

vitalities of harvested cells. The used carrier should be non-porous which eases the

separation of detached cells from the carrier.

The cell bead cultivation process aims to increase the vitality of the encapsulated

cells. A decrease of the cell vitality of the implants may be caused by the harvesting

Nutrients, oxygen,

therapeutic molecules

Antibodies, complement,

Macrophages, ...

Antigens

Alginate capsule

Core bead

Fig. 2 The alginate capsule of a cell bead acts as a semipermeable membrane

Production Process for Stem Cell Based Therapeutic Implants 145

and encapsulation procedure. Apoptotic cells will be decomposed during this

cultivation.

An optional differentiation of the cell beads may support cell survival at the

transplantation place. Furthermore, a differentiation may induce the expression of

therapeutic molecules.

Here we introduce two ﬁxed-bed bioreactor systems, one for the expansion of

the adherent production cell line and the other for the cultivation of the cell beads.

As an example, the application of an adipogenic differentiation protocol was

investigated.

Both ﬁxed-bed systems have to be transferred into a GMP-process. Therefore

some requirements are addressed to the reactor systems. For maintaining sterility

during the process they have to be designed as a closed system with the possibility

of online monitoring. Furthermore, automation of the process should be enabled to

reduce human error and labor input. A simple design of the reactor system and its

peripheral components beneﬁts the manufacturing of disposables, which reduces

extensive cleaning procedures and documentation effort. Figure 3gives an over-

view about the cell bead production process and its requirements.

2 Expansion of hMSC-TERT

2.1 Reactor System

Many disposable reactor systems used in the cultivation of adherent animal cells

like T-ﬂasks, roller bottles, wave reactors, stirred-tank reactors, or spinner ﬂasks are

established, but they show more or less drawbacks. T-ﬂasks and their cognate

1. Expansion of hMSC-TERT

2. Encapsulation of the cells

3. Cultivation of the CellBeads®

– Gentle cultivation and

harvesting procedure

High vitality

– Increasing of the vitality

– Differentiation of the cells

Transfer into GMP process

Closed systems

Online monitoring

Automation

Disposable

Fig. 3 Steps and requirements of the cell bead production process

146 C. Weber et al.

systems are labor consuming in operation, or intricate in automation. Suspension

reactors in combination with a microcarrier have the drawback that a special system

for the separation of the enzymatically detached cells from the carrier is necessary.

This counteracts a simple design which is demanded for manufacturing as a

disposable. Therefore a ﬁxed-bed bioreactor system was developed, which is

based on a non-porous carrier. The advantage of a non-porous carrier is that the

adherent cells, located on the carrier surface, can be easily ﬂushed out of the reactor

with the medium ﬂow after enzymatic detachment. A carrier screening has revealed

that non-porous borosilicate glass spheres (BSGS) are most suitable with respect to

the growth behavior, cell harvest, and nutrient supply.

Figure 4shows a prototype of the ﬁxed-bed reactor. It consists of a glass

cylinder with a stainless steel lid and bottom plate, which are equipped with

hose connectors for the medium inlet and outlet. A funnel shaped insert leads to a

nearly uniform inﬂow. The periphery of the ﬁxed bed consists of some ﬂasks that

act as conditioning, collecting, waste, and storage vessels, the tubing, some pinch

valves, two peristaltic pumps, single use noninvasive oxygen sensors (PreSens –

Precision Sensing GmbH, Regensburg, Germany) for process monitoring, and

sterile air ﬁlters for adjustment of the vessel pressure. All parts except the valves

and the pumps can be designed for production as a disposable, or they are already

available as commercial single use items. A further advantage of this system is a

Conditioning

vessel

Collecting

vessel

Enzyme

solution

IPO2

IPO2 Incubator

37°C

5% CO2

Waste

Medium PBS Inoculum

4°C

Fig. 4 Fixed-bed reactor system for the expansion of hMSC-TERT

Production Process for Stem Cell Based Therapeutic Implants 147

comfortable automation of the process including the inoculation, culturing, and

harvesting procedures.

The oxygen supply can be provided by surface aeration or in larger systems with

a single use membrane oxygenator. Bubble aeration would have the drawbacks of

foam forming when serum containing medium is used.

The reactor system can be operated in a humidiﬁed incubator at 37C and 5%

. Larger scales demand special heating strategies for the ﬁxed bed and the

conditioning vessel. Furthermore, a gas mix station is demanded when the medium

is aerated by using membrane oxygenators in order to enrich the feed air with CO

which is necessary for a pH adjustment of sodium bicarbonate buffered medium.

For determination of growth and consumption kinetics and for scale up calcu-

lations a mathematical model was used that is shown here in a simpliﬁed form

(Fig. 5).

The system is mainly composed of the interacting compartments, the ﬁxed bed,

and the conditioning vessel. The concentration cof any nutrient component in the

ﬁxed bed depends on time and axial position zand can be expressed by the

convection-consumption equation

edc

dt¼vdc

dzqXFBðtÞ(1)

with the superﬁcial velocity, v, which is deﬁned as the ﬂow velocity in the reactor

tube without the packed bed, the cell speciﬁc consumption rate qof the regarded

nutrient component, the time dependent and volume speciﬁc cell density

XFBðtÞ¼X0

FB emt(2)

()

vqXt

d d

×=-×-×× z

(, )

Fixed bed Conditioning

vessel

cftz=()

cft=

Effectiveness

factor

Consumption

rate

Cell densitySuperficial velocity

Porosity

Oxygen supply

Vdt

Vc×

Fig. 5 Simpliﬁed illustration of the mass balances of the ﬁxed-bed reactor and its associated

conditioning vessel

148 C. Weber et al.

and the effectiveness factor , that considers mass transfer resistance [9–14]. The

growth rate mand the glucose consumption rate qGlc can be described by Monod

kinetics:

m¼mmax cGlc

cGlc þkM;m

(3)

qGlc ¼qGlc;max cGlc

cGlc þkM;qGlc

(4)

with the Monod constants kM;qGlc and kM;mwhereas the oxygen consumption rate qOx

is assumed to be concentration independent:

qOx ¼const:(5)

For the concentration cCV in the conditioning vessel only time dependence is

assumed. It can be described by balancing the nutrient in- and outﬂow:

VdcCV

dt¼

VcCV þ

VcFB (6)

with the concentration at the reactor outlet cFB , the medium volume V;and the

volume ﬂow

V. In the case of an oxygen balance, 6) has to be extended by the

oxygen transfer rate OTR:

VdcCV;Ox

dt¼

VcCV;Ox þ

VcFB;Ox þOTR (7)

2.2 Expansion of hMSC-TERT on a Laboratory Scale

Fixed-bed cultivations of hMSC-TERT were performed in scales up to a bed

volume of 300 cm

. With these cultivations several process relevant problems

could be investigated (Fig. 6).

Acarrier screening was performed to ﬁnd a suitable carrier regarding growth

and harvesting behavior of the hMSC-TERT.

Inoculation and harvesting procedures were developed, which can be automated

and lead to high yields of adhered or detached cells, respectively. Furthermore, the

harvesting procedure has to result in a high vitality of the detached cells.

The laboratory scale bioreactor system for the cell expansion has to be scaled up

to the production scale. Therefore a maximal superﬁcial velocity has to be deﬁned in

order to avoid negative effects on the cell growth caused by shear stress. Model

parameters like growth and consumption rates, which are necessary for scale up

calculations, were determined by ﬁtting them to the experimental data.

Production Process for Stem Cell Based Therapeutic Implants 149

2.2.1 Carrier Screening

Non-porous BSGS of 1, 2, and 3 mm diameter as well as ﬁbrous macroporous

polyethylene terephthalate based carrier (BioNoc II™, Cesco Bioengineering Co,

Taichung, Taiwan) were investigated and compared.

Therefore, reactors were ﬁlled with 60 cm

carrier and inoculated with a cell

number corresponding to 5,000 cells per cm

. During the 4 h inoculation procedure

without perfusion of the ﬁxed bed, the reactors were manually turned around 180

after 10, 40, 130, and 240 min in order to return sedimented and non-attached

cells into the ﬁxed bed. After the inoculation procedure, the cultivation was started

by perfusion of the system with EMEM (Eagle’s Minimal Essential Medium)

supplemented with 10% fetal calf serum (FCS). Table 1gives more detail to the

cultivations. The ﬁnal cell numbers at the end of the cultivations were determined

by counting of crystal violet stained nuclei after lysis of the cells with citric acid

[15].

The results of the cultivations (Fig. 7) are summarized in Table 2. The highest

growth rate as well as the highest cell density after 160 h was reached with 2 mm

BSGS. The lowest number of attached cells after the inoculation procedure was

Table 1 Cultivations of hMSC-TERT in 60-cm

ﬁxed-bed reactors aimed at ﬁnding suitable

carrier

Carrier Sphere diameter

(mm)

Growth surface per 60 cm

ﬁxed bed A (cm

)

Medium

volume V(ml)

Superﬁcial velocity

v(m s

1

)

BioNoc II™– 9,600 1,000 1.5 10

4

Borosilicate

glass

spheres

1 2,196 500 3.0 10

4

2 1,098 500 3.0 10

4

3 732 500 3.0 10

4

Exeperimental scales: 15 – 300 cm3

– Carrier screening

– Inoculation procedure

– Determination of the maximal

superficial velocity

Harvesting procedure

Consumption and growth kinetics

Theoretical scale up

Mathematical model

Fig. 6 Overview of performed lab scale experiments for the development of a ﬁxed bed based

expansion process for hMSC-TERT

150 C. Weber et al.

obtained with BioNoc II™. Channeling was detected by using of BSGS with a dia-

meter of 1 mm, which means a non-optimal nutrient supply and thus limitations of the

cells.

Beside the growth behavior, the yield after a harvesting procedure was used

for an evaluation of the carrier. Therefore ﬁxed beds, which consisted of 2-mm

glass spheres or BioNoc II™, were cyclically perfused with Accutase™or Trypsin

solution for 20 min at a superﬁcial velocity of 1.3 10

4

1

Accutase™was more effective regarding the yield of detached cells than

Trypsin (Fig. 8). The highest yield of 92% was obtained with 2-mm glass spheres

and Accutase™.

0 20 40 60 80 100 120 140 160 180

100

O2-Saturation,

inlet

O2-Saturation,

outlet

0 25 50 75 100 125 150 175 200

100

0 25 50 75 100 125 150 175

100

BioNoc IITM

3mm BSGS

2mm BSGS

0 25 50 75 100 125 150 175 200

100

1mm BSGS

0.0

5.0x105

1.0x106

1.5x106

2.0x106

2.5x106

Cell density XFB [1/cm3]

Concentration ccv [mg/ml]

Oxygen saturation [%]

0.0

5.0x105

1.0x106

1.5x106

2.0x106

2.5x106

0.0

5.0x105

1.0x106

1.5x106

2.0x106

2.5x106

0.0

0.5

1.0

1.5

0.0

0.5

1.0

1.5

0.0

0.5

1.0

1.5

0.0

0.5

1.0

1.5

Glucose cCV,Glc

Laktat cCV,Lac

0.0

5.0x10

1.0x10

1.5x10

2.0x10

2.5x10

XFB, Counting of nuclei

XFB, Calculated from

O2- consumption

Time [h]

Fig. 7 Cultivations of hMSC-TERT in 60-cm

ﬁxed-bed reactors on non-porous borosilicate glass

spheres (BSGS) and macroporous BioNoc II™carrier. Red curves (2-mm BSGS) were simulated

using the model. BSGS borosilicate glass spheres

Production Process for Stem Cell Based Therapeutic Implants 151

Table 2 Results of the comparative cultivations of hMSC-TERT in 60-cm

ﬁxed-bed reactors on different carrier. The mean growth rates mmand the cell densities

XFB after the inoculation procedures were obtained by ﬁtting of 2) to the experimental data. BSGS: borosilicate glass spheres

Units 1 mm BSGS

2 mm BSGS 3 mm BSGS BioNoc II™

Cultivation time (h) 192 168 192 168

Mean growth rate mm(1 d

1

) 0.307 0.062 0.487 0.042 0.372 0.063 0.391 0.034

Cell density at the end of cultivation XFB (1 cm

2

) 6.69 10

9.64 10

1.32 10

1.54 10

(1 cm

3

) 2.45 10

1.75 10

1.61 10

5.63 10

Cell density after 160 h XFB (1 cm

2

) (5.11 2.20) 10

(9.32 2.55) 10

(7.92 3.60) 10

(1.31 0.29) 10

(1 cm

3

) (1.66 0.72) 10

(1.71 0.47) 10

(9.50 4.31) 10

(2.01 0.46) 10

Cell density after the inoculation

procedure X0

(1 cm

2

) (6.58 2.84) 10

(3.68 0.99) 10

(6.63 3.01) 10

(9.68 2.10) 10

(1 cm

3

) (2.14 0.92) 10

(6.63 1.81) 10

(7.96 3.61) 10

(1.55 0.34) 10

(–) 0.946 0.998 0.932 0.986

Channeling

152 C. Weber et al.

Considering the previous facts, BSGS with a diameter of 2 mm are most suitable

for the cultivation and harvesting procedure of hMSC-TERT. The next steps

including the development of automatable inoculation and harvesting procedures

as well as the determination of kinetic parameters for scale up calculations were

performed with 2-mm BSGS.

2.2.2 Inoculation Procedure

The main problem by inoculation of the ﬁxed bed was that non-adherend cells

sedimented and did not get the chance to adhere to the carrier when the system is

ﬁlled with cell suspension and incubated without perfusion. This yielded a small

amount of adhered cells and an axial cell density proﬁle. Therefore, perfusion steps

should be included in the inoculation procedure.

Figure 9shows an inoculation procedure with intermittent perfusion intervals. The

yield, which is deﬁned as the ratio of adherend cells to the inoculated cell number,

could be increased from 30%, without perfusion, to about 50%, with perfusion.

2.2.3 Determination of the Maximal Superﬁcial Velocity

Due to the non-porosity of the glass carrier, the cells are totally exposed to the shear

stress caused by the medium ﬂow, which requires a deﬁnition of a maximal

superﬁcial velocity. For this purpose, hMSC-TERT were cultured in 25-cm

ﬁxed

beds at different superﬁcial velocities. The growth rate was used as an evaluation

parameter. A reference culture in six-well cell culture plates was performed to get

the maximal growth rate at v ¼0.

100

BioNoc IITM

Trypsin

Yield [%]

BioNoc IITM,

AccutaseTM

BSGS,

Trypsin

BSGS,

AccutaseTM

Fig. 8 Preliminary harvesting experiments in ﬁxed-bed reactors containing 2-mm borosilicate

glass spheres or BioNoc II™, respectively. The beds were cyclic perfused with enzyme solution

for 20 min. The data represent the mean standard deviation of four experiments

Production Process for Stem Cell Based Therapeutic Implants 153

The growth rate starts to decrease at about 3.0 10

4

1

(Fig. 10). This

velocity was used for scale up calculations and experimental determinations of

growth and consumption kinetics in ﬁxed-bed reactors.

2.2.4 Cultivation in Different Scales: Consumption and Growth Kinetics

Cultivations were performed in scales from 15 to 300 cm

. Growth, oxygen, and

glucose consumption kinetics were determined by ﬁtting the model parameters to

the experimental data. Glutamine wasn’t considered since it is an unimportant

energy source for hMSC [16]. The modeled curves for a 60-cm

scale are exem-

plarily shown in Fig. 7.

30 min x min cultivation30 min 30 min 30 min

No perfusion

v = 0

x min x min x min

Perfusion

v = 0.72 [cm/min]

x = hFB / v [min]

Fig. 9 Scheme of the inoculation procedure. Repeated perfusion steps enhance the number of

attached cells and thus the yield of the inoculation procedure

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

Growth rate [1/d]

Superficial velocity [m/s]

0 3 x 10–4 8 x 10–4 2 x 10–3

Fig. 10 Growth rates of hMSC-TERT in a ﬁxed bed consisting of non-porous borosilicate glass

spheres with a diameter of 2 mm at different superﬁcial velocities. The data represent the mean 

standard deviation of four cultivations

154 C. Weber et al.

Table 3shows the ﬁtted model parameters. The growth and consumption rates

are comparable to those reported in the literature. Glucose consumption and

growth rates of human mesenchymal stem cells are reported to be (0.23 –

1.22) 10

7

mg h

1

cell

1

[17,18] and 0.33 – 0.94 1 d

1

[15,16,19–22],

respectively. Oxygen consumption rates of (1.22 – 3.20) 10

8

mg h

1

cell

1

are reported for various human cell types [23–27].

Most important for scale up considerations is the oxygen consumption rate.

2.2.5 Harvesting Procedure

A drawback of the preliminary harvesting procedure used for the carrier screening

was that, due to the cyclic perfusion of the enzyme solution, already detached cell

were repeatedly passed through the reactor system. This caused shear stress which

led to a decrease in vitality to values below 90% (data not shown). Therefore, a

harvesting procedure was developed in which the cell suspension will be directly

connected to the collecting vessel (Fig. 11).

In the ﬁrst step, cells become detached by perfusion of the ﬁxed bed for 10 min

with Accutase™solution at a superﬁcial velocity of 1.8 10

4

1

. After this

the cells get ﬂushed out by perfusion with medium at a superﬁcial velocity of

3.2 10

3

1

for 2 min. This harvesting procedure resulted in a yield of

detached and separated cells of approximately 82% and a vitality of about 96%.

The advantages of this procedure are the comfortable automation and separation

of the detached cells without any further system components or process steps.

Table 3 Consumption and growth kinetics of hMSC-TERT cultured on 2-mm borosilicate glass

spheres in ﬁxed-bed reactors at 15, 60, and 300 cm

scales. The data were obtained by ﬁtting the

model parameters to the experimental data

Maximal growth rate mmax 0.55 – 0.69 (1 day

1

)

Monod constant kM;m0.135 – 0.160 (mg mL

1

)

Maximal glucose consumption rate qGlc;max (8.0 – 11.8) 10

8

(mg h

1

cell

1

)

Monod constant kM;qGlc 0.10 – 0.16 (mg mL

1

)

Oxygen consumption rate qOx (0.98 – 2.14) 10

8

(mg h

1

cell

1

)

1.Perfusion with AccutaseTM

10 min

v = 1.8 x 10–4 [m/s]

v = 3.2 x 10–3 [m/s]

2. Perfusion with medium

2 min

Cell detachment

Separation of the cells

from the carrier

Fig. 11 Harvesting of hMSC-TERT in ﬁxed-bed reactors based on non-porous borosilicate glass

spheres

Production Process for Stem Cell Based Therapeutic Implants 155

2.3 Theoretical Scale Up of the hMSC-TERT Expansion Process

For scale up calculations of the ﬁxed bed, it is mainly the dissolved oxygen

concentration that has to be considered, since it is magnitudes lower than other

limiting medium components such as glucose. The oxygen concentration or satura-

tion, respectively, decreases in axial direction that demands a deﬁnition of a

maximal ﬁxed-bed height hFB (Fig.12).

The maximal ﬁxed-bed height depends, assuming a 100% air saturated inﬂow

concentration and a constant inﬂow velocity (3.0 10

4

1

), on the maximal

cell density and the minimal oxygen concentration in the ﬁxed bed, which can be

found at the outﬂow region. This maximal bed height can be calculated by using the

previously described model:

hFB ¼fðXFB;cOx;out Þ(8)

Using the maximal bed height, a calculation of the maximal volume VFB of a

single ﬁxed bed as a function of the thickness ratio TR and with it a calculation of

the needed number nFB of parallel operated ﬁxed-bed reactors for the cultivation of

a certain target cell number NXis possible:

VFB ¼hFB phFB

TR 2



(9)

nFB ¼NX

XFB VFB

(10)

z= hFB

cOx,in= 100% air saturation

v = 3 x 10–4 m/s

XFB = 9 x 105 cells/cm3

XFB = 2 x 106 cells/cm3

XFB = 3 x 106 cells/cm3

XFB = 4 x 106 cells/cm3

qOx x XFB

cOx,out

Fig. 12 Dependency of the bed height on the outlet oxygen saturation and target cell density

calculated using the model of the cultivation process and the maximal oxygen consumption rate

(Table 3)

156 C. Weber et al.

The reactor system was scaled exemplarily for the cultivation of a target cell

number of 20 billion cells that is sufﬁcient for approximately 200 single doses of

cell beads with a volume of about 5 mL per dose (Table 4).

The volume of a single ﬁxed bed decreases with increasing cell number,

thickness ratio, and outlet oxygen saturation. Small reactor volumes means a

large number of parallel operated ﬁxed-bed reactors, but this is very intricate and

non-practical regarding the handling and operation of the bioreactor system. There-

fore a reduction of the target cell density, as well as a reduction of the thickness

ratio and the outlet oxygen saturation, is recommended. As a result of this, small

numbers of parallel operated reactors which can be handled and operated more

easily are obtained. The oxygen outlet concentration, of course, can only be

decreased to an uncritical value.

3 Cultivation of Encapsulated Cells

3.1 The Reactor System

The cell bead cultivation system is based on single use plastic syringes in which the

cell beads themselves form the bed. The original piston is replaced by a custom

made insert, which enables perfusion of the ﬁxed bed (Fig. 13).

Beside the cultivation on a single dose level, the advantages of this bioreactor

system are a cryopreservation of the cell beads by direct freezing of the syringe and

post-thaw an implantation of the cell beads using this syringe. This avoids contam-

ination risky transfer steps. For this purpose, the insert can be designed in such a

manner that it can act as the original syringe piston.

The reactor periphery is similar to that of the hMSC-TERT expansion system.

Furthermore, the previously described mathematical model can be used as well for

the simulation of the cell bead cultivation process.

Table 4 Numbers and volumes of parallel operated ﬁxed beds needed for the cultivation of

210

cells as a function of thickness ratio, target cell density, and outlet oxygen saturation

Thickness ratio ¼1 Thickness ratio ¼2

Target cell

density (cm

3

)

Fixed-bed

volume

(L)

Number of

ﬁxed beds

Fixed-bed

volume

(L)

Number of

ﬁxed beds

Total

ﬁxed-bed

volume (L)

Outlet oxygen saturation: 20%

110

20 1.1 5.2 4.2 21.9

210

2.3 4.8 0.6 19.1 10.9

410

0.3 18.3 0.07 73.1 5.5

Outlet oxygen saturation: 30%

110

13.4 1.6 3.4 6.5 21.9

210

1.5 7.3 0.4 29.0 10.9

410

0.2 27.8 0.05 111.4 5.5

Production Process for Stem Cell Based Therapeutic Implants 157

3.2 Cultivation of Encapsulated Cells

Cultivations of cell beads were exemplarily performed under adipogenic conditions

on a 1-cm

scale (data not shown). Induction medium was applied for 3 days

followed by 4 days cultivation with maintenance medium (Table 5). This cycle

was repeated three times [14]. Medium, 50 mL per cycle, was perfused at a

superﬁcial velocity of 1.28 10

4

1

, that is below the ﬂuidization point.

Reference cultures were performed in 25-cm

T-ﬂasks using the same protocol.

Vitality was determined after 0, 100, 200, and 500 h with the Trypan blue

exclusion method after lysis of the cell beads using EDTA [28].

The vitality increased with advancing cultivation time, whereas the cell number

decreased (Fig. 14). This is explainable by decomposition of apoptotic cells.

Apoptosis may be triggered by the harvesting or the encapsulation process, or

Incubator

37°C

5% CO2

Conditioning

vessel

Waste

Medium Cryopro-

tective

medium

Inoculum

(cell beads)

4°C

IPO2

Fig. 13 System for the cultivation of cell beads in syringe based ﬁxed reactors

Table 5 Composition of media for the adipogenic cultivation of cell beads [28]

Induction medium Maintenance medium

DMEM þ10% FCS DMEM þ10% FCS

100 U mL

1

penicillin 100 U mL

1

penicillin

0.1 mg mL

1

streptomycin 0.1 mg mL

1

streptomycin

0.01 mg mL

1

insulin 0.01 mg mL

1

insulin

0.5 mM 3-isobutyl-1-methyl-xanthin –

0.2 mM indomethacin –

1mM dexamethason –

158 C. Weber et al.

dominant in this case, by the cryopreservation of the cell beads prior to the

cultivation. It could be shown that the vitality, and thus the quality of the beads,

is gradable during the cultivation process.

As an example, an adipogenic differentiation protocol was applied, whereby the

differentiation to adipocytes was veriﬁed by staining with the lipophilic ﬂuorescence

dye Nile red (Fig. 15)[28]. Adipogenic cultured cell beads showed higher ﬂuores-

cence intensity and thus are interpreted to be differentiated to adipocytes. No differ-

ences between the ﬁxed-bed culture and the reference culture in T-ﬂasks are detectable.

Table 6 shows the kinetics obtained by ﬁtting the model parameter to the

experimental data which were used for a theoretical scale up of the system.

100

Fixed bed

Reference (T25-Flask)

Vitality [%]

Cell number Nx [-]

2x106

4x106

6x106

8x106

1x107

Time [h]

500

200

1000

Time [h]

500

200

Fig. 14 Time dependent vitality and cell number of cell beads cultured in ﬁxed-bed reactors and in

T-ﬂasks (reference)

Adipogenic

cultivation

Non-adipogenic

cultivation

T25-Flask

(Reference)

Fixed bed

Fig. 15 Nile red staining of cell beads which were cultured under adipogenic and non-adipogenic

conditions in ﬁxed-bed reactors or T25-ﬂasks

Production Process for Stem Cell Based Therapeutic Implants 159

3.3 Theoretical Scale Up of the Cell Bead Cultivation Process

A calculational scale up was carried out for a cultivation of 200 single doses of cell

beads each of 5 mL (Fig. 16). The inlet oxygen concentration was assumed to be air

saturated. This can be realized, for example, by using membrane oxygenators.

For a calculation of the oxygen or glucose concentration proﬁle in the cell bead,

the following diffusion and diffusion-reaction equations were used:

DCC d2cCC

dr2þ2

rdcCC



¼qXCC (11)

DAC d2cAC

dr2þ2

rdcAC



¼0 (12)

Table 6 Consumption kinetics of encapsulated hMSC-TERT (cell beads) which were obtained

by ﬁtting of model parameters to the experimental data of the adipogenic cultivation in a 1-cm

ﬁxed-bed scale (Fig. 14)

Growth rate mmax 0 (1 day

1

)

Maximal glucose consumption rate qGlc;max (7.3 – 9.4) 10

8

(mg h

1

cell

1

)

Monod constant kM;qGlc 0.06 (mg mL

1

)

Oxygen consumption rate qOx 5.5 10

9

(mg h

1

cell

1

)

Glucose concentration

cell bead center [mg/ml]

Glucose concentration

in medium [mg/ml]

10 20 30 40 50 60

Oxygen saturation

cell bead center [%]

Oxygen saturation

in medium [%]

012345

0 100 200 300 400 500

inlet outlet

Glucose concentration

in medium [mg/ml]

Time [h]

100

outlet

inlet

Oxygen saturation

in medium [%]

Fig. 16 Simulated adipogenic cultivation of 200 single doses (5 cm

) of cell beads as well as the

glucose and oxygen proﬁle at the cell bead center. Medium volume per cycle: 40 L, superﬁcial

velocity: 2.5 10

4

1

160 C. Weber et al.

with the concentration in the cell containing core bead cCC as well as in the cell free

alginate capsule cAC, the effective diffusion coefﬁcient in the core bead DCC and

alginate capsule DAC;and the cell density of the core bead XCC.

It could be shown that an oxygen saturation in the medium of 40% leads to an

oxygen saturation at the center of approximately 22% (Fig. 16). The differences in

glucose between the medium and the cell bead center is negligible. Thus, it can be

assumed that no limitations of the cells at the center of a cell bead are expectable.

3.4 Conclusion and Outlook

Two ﬁxed-bed reactor systems for the production of stem cell based therapeutic

implants were introduced. One system was developed for the expansion of the

production cell line (hMSC-TERT) and a second for the cultivation of encapsulated

cells in order to increase their vitality and thus the quality of the implants.

The ﬁxed-bed system for the expansion of the production cell line is based on

non-porous BSGS. Cells can be cultured and harvested with high yield and vitality.

The separation of the cells from the carrier can easily be performed by ﬂushing

them out with the medium ﬂow. This saves additional process steps.

The ﬁxed-bed system for the cultivation of encapsulated cells is based on commer-

cially available syringes in which the cell beads represent the bed. The advantage of

this system is that it can be used as an implantation tool after the cultivation procedure.

It could be shown that the vitality is gradable by the cultivation process. Furthermore,

the application of an adipogenic differentiation protocol could be demonstrated.

Both systems can be automated and produced as disposable items due to their

simple design.

The next steps will concern the development of a GMP-conform cryopreser-

vation procedure for the cell beads and the implementation of the cultivation

systems to the overall GMP-process of cell bead production.

Acknowledgements The authors would like to thank the Federal Ministry of Economics and

Technology for ﬁnancial support as well as the CellMed AG for providing the production cell line

hMSC-TERT and the CellBeads1.

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Adv Biochem Engin/Biotechnol (2010) 123: 163–200

DOI: 10.1007/10_2010_67

#Springer-Verlag Berlin Heidelberg 2010

Published online: 4 May 2010

Cartilage Engineering from Mesenchymal

Stem Cells

C. Goepfert, A. Slobodianski, A.F. Schilling, P. Adamietz, and R. Po¨ rtner

Abstract Mesenchymal progenitor cells known as multipotent mesenchymal stro-

mal cells or mesenchymal stem cells (MSC) have been isolated from various

tissues. Since they are able to differentiate along the mesenchymal lineages of

cartilage and bone, they are regarded as promising sources for the treatment of

skeletal defects. Tissue regeneration in the adult organism and in vitro engineering

of tissues is hypothesized to follow the principles of embryogenesis. The embryonic

development of the skeleton has been studied extensively with respect to the

regulatory mechanisms governing morphogenesis, differentiation, and tissue for-

mation. Various concepts have been designed for engineering tissues in vitro based

on these developmental principles, most of them involving regulatory molecules

such as growth factors or cytokines known to be the key regulators in developmen-

tal processes. Growth factors most commonly used for in vitro cultivation of

cartilage tissue belong to the ﬁbroblast growth factor (FGF) family, the transform-

ing growth factor-beta (TGF-b) super-family, and the insulin-like growth factor

(IGF) family. In this chapter, in vivo actions of members of these growth factors

described in the literature are compared with in vitro concepts of cartilage

engineering making use of these growth factors.

C. Goepfert (*) and R. Po

¨rtner

Institute of Bioprocess and Biosystems Engineering, Hamburg University of Technology,

Hamburg, Germany

e-mail: c.goepfert@tuhh.de

A. Slobodianski

Kompetenzzentrum Tissue Engineering, Universita

¨tzuLu

¨beck, Lu

¨beck, Germany

P. Adamietz

Department of Biochemistry and Molecular Biology II: Molecular Cell Biology, University

Medical Center Hamburg-Eppendorf, Hamburg, Germany

A.F. Schilling

Biomechanics Section, Hamburg University of Technology, Hamburg, Germany

Keywords Bone morphogenetic protein (BMP), Cartilage, Chondrocytes, Differ-

entiation, Fibroblast growth factor (FGF), Growth factors, Indian hedgehog (Ihh),

Insulin like growth factor (IGF), Mesenchymal stem cells (MSC), Multipotent

mesenchymal stromal cells (MSC), PTH related peptide (PTHrP), Sonic hedgehog

(Shh), Transforming growth factor-beta (TGF)

Contents

1 Introduction .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165

1.1 The Term “Mesenchymal Stem Cells” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165

1.2 Concepts for Cartilage Cultivation In Vitro .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167

2 Development of Cartilage Tissue In Vivo . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168

2.1 Migration and Proliferation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . 178

2.2 Cell Condensation . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . 178

2.3 Chondrogenic Differentiation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . 178

2.4 Endochondral Ossiﬁcation . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179

3 The Inﬂuence of Growth Factors on Cartilage

Development In Vivo . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . 180

3.1 Fibroblast Growth Factors in Early Skeletal Development . . . . . . . . . . . . . . . . . . . . . . . . . 180

3.2 The TGF-bSuperfamily of Growth and Differentiation Factors . . . . . . . . . . . . . . . . . . . . 181

3.3 The Role of IGFs in the Development of Cartilage Tissue . . . . . . . . . . . . . . . . . . . . . . . . . 182

3.4 Terminal Differentiation or Development of Articular Cartilage . . . . . . . . . . . . . . . . . . . 182

4 Growth Factors in Adult Cartilage Tissue . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183

4.1 The Role of FGF in Adult Articular Cartilage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183

4.2 Members of the TGF-bSuperfamily in Adult Articular Cartilage . . . . . . . . . . . . . . . . . . 184

4.3 The Role of IGF in Adult Articular Cartilage . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . 184

5 Engineering of Cartilage Tissue In Vitro . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185

5.1 Expansion of Progenitor Cells . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . 185

5.2 Chondrogenic Differentiation In Vitro . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . 186

5.3 Maintenance of the Hyaline Phenotype in Cultivated Cartilage Tissue .. . . . . . . . . . . . 188

6 Conclusion .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189

Abbreviations

AER Apical ectodermal ridge

BMP Bone morphogenetic protein

ECM Extracellular matrix

FGF Fibroblast growth factor

FGFR FGF receptor

GF Growth factor

HA Hyaluronic acid

IGF Insulin-like growth factor

IGFBP IGF binding protein

IGFR IGF receptor

Ihh Indian hedgehog

164 C. Goepfert et al.

MSC Mesenchymal stem cells

OA Osteoarthritis

PTHrP PTH related peptide

RA Rheumatoid arthritis

Shh Sonic hedgehog

TGF-bTransforming growth factor-b

ZPA Zone of polarizing activity

1 Introduction

1.1 The Term “Mesenchymal Stem Cells”

For cartilage regeneration in vitro and in vivo, various strategies have been pursued

regarding the appropriate cell source, chemical and physical factors, and culture

conditions. It is widely agreed that tissue regeneration from autologous cells can be

achieved taking advantage of the natural course and progression of embryonic

development [1–4]. Therefore, autologous mesenchymal stem cells (MSCs) are

extensively investigated for their ability to regenerate articular cartilage tissue in

situ or in vitro.

Tissues forming the skeleton of the limbs originate from stem cells of the lateral

plate and the somitic mesenchyme [2]. These embryonal MSCs undergo a series of

differentiation steps, ﬁnally producing differentiated skeletal tissues such as bone

and cartilage. In the adult organism, there are a limited number of mesenchymal

progenitor cells residing in the bone marrow which give rise to the repair of

damaged tissue, for instance bone, and which can easily be obtained by marrow

aspiration and selected by their ability to adhere to culture vessels. To date, it is not

clear whether they represent cells remaining from the embryonic mesenchyme or

whether they are a heterogenous population of mesenchymal precursor cells [4,5],

possibly originating from the invading blood vessels populating the newly formed

bone marrow space during endochondral ossiﬁcation [6].

First evidence for a precursor pool within the bone marrow was given by Frieden-

stein et al. [7], who described ectopic osteogenic differentiation originating from

whole bone marrow. Based on these results, they hypothesized a population of cells

occurring in the bone marrow which are able to differentiate along the osteogenic

lineage. These cells were characterized in vitro as colony forming ﬁbroblastic cells

(CFU-f), isolated by their adherence to culture vessels [8]. MSC were hypothesized

as progenitor cells of mesenchymal tissues residing in the bone marrow and perios-

teum, persisting throughout lifetime as a pool for tissue regeneration, and which

might be isolated, expanded, and used for autologous treatment of damaged tissues

[9]. In 1999, Pittenger et al. [10] demonstrated the ability of clonally expanded human

bone marrow cells to differentiate towards the osteogenic, chondrogenic, and adipo-

genic lineages and thereby making it possible to develop treatments with human

Cartilage Engineering from Mesenchymal Stem Cells 165

autologous cells for the repair of mesenchymal tissues such as bone, cartilage and

adipose tissue. Since that time, these so-called MSCs have been isolated from various

tissues including adipose tissue [11], muscle and brain [12], bone [13], synovium [14,

15], umbilical cord [16], and blood [17]. Cells with even higher differentiation

potential have been isolated from cord blood [18,19] and from bone marrow [20].

In order to characterize the MSCs, several markers have been described, but none

of them proved to be unique and exclusively present on MSCs. Enrichment of MSCs

has been carried out using the Stro-1 monoclonal antibody [21,22]. The resulting cell

population was shown to be able to differentiate into the mesenchymal lineages of

osteoblasts, chondrocytes, adipocytes, and stromal cells supporting hematopoiesis

[23]. Other antigens speciﬁc for undifferentiated precursor cells and absent on

differentiated cells have been identiﬁed using the monoclonal antibodies SH-2 (endo-

glin, co-receptor for TGF-b3) [24], SH-3, and SH-4, respectively [25]. But there are

no unique surface antigens so far deﬁning “the” MSC.

Clonally derived MSCs have been extensively analyzed for their ability to

proliferate in vitro, retaining their multi-lineage differentiation potential upon

prolonged cultivation. It was shown that these clonally derived cells lost their

multi-lineage potential upon extended cultivation in vitro and thus behave like

plastic progenitor cells rather than stem cells [5,26–28]. On the other hand, Jiang

et al. [20] were able to describe a subset of pluripotent cells in the mouse and the rat

bone marrow, virtually proliferating for up to 60 passages without losing their

characteristic growth rates and their potential even to transdifferentiate into the

endodermal and ectodermal lineages displaying some features of hepatocytes or

neuronal cell types [20,29]. Thus it is likely that MSCs are a heterogenous

population of rare cells in the bone marrow compartment and other tissues, dis-

playing various stages of predifferentiation. Due to the heterogeneity of the cell

preparations commonly referred to as MSCs, Dominici et al. deﬁned mesenchymal

stem cells as plastic adherent cells positive for CD105, CD73, CD90 lacking the

expression of hematopoetic markers CD45, CD34, CD14 or CD11, CD79 alpha or

CD19 and HLA-DR surface markers [30]. Finally, according to this deﬁnition,

MSCs must be shown to differentiate into osteoblasts, adipocytes and chondrocytes

in vitro. According to Horwitz et al. [31], ﬁbroblast-like plastic adherent mesen-

chymal progenitor cells isolated from various tissues are termed multipotent mes-

enchymal stromal cells (also referred to as MSCs).

Recently, it has been proposed to deﬁne “stemness” as a state of cells which are

able to differentiate into various cell types rather than the cells themselves [32].

According to this view, plasticity would be the most prominent characteristic of

stem cells whereas self-renewal and hierarchical differentiation are regarded as

subordinate features of these cell populations. Therefore, dedifferentiated cells

capable of differentiating into more than their original cell type could also be

regarded as stem cells. Since in vitro-expanded and thus dedifferentiated articular

chondrocytes were shown to differentiate similarly to MSCs along the mesenchy-

mal lineages into osteoblasts, chondrocytes, including hypertrophic chondrocytes,

and adipocytes [33,34], the term “secondary progenitor cells” could be appropriate

for dedifferentiated chondrocytes [35].

166 C. Goepfert et al.

1.2 Concepts for Cartilage Cultivation In Vitro

The regeneration of damaged tissues in the adult organism as well as in vitro

engineering of tissues is hypothesized to follow the principles of embryogenesis

[1–4]. Therefore it is assumed that cartilage formation by means of cell therapy or

tissue engineering is bound to recapitulate, at least in several aspects, the stages of

in vivo development. The development of the appendicular skeleton is initiated by

migration of the early mesenchymal progenitors of the skeletal tissue towards the

prospective limb regions and by proliferation of these undifferentiated progenitors.

The accumulation of high cell densities is the prerequisite of cell condensation as

the key event of cartilage tissue formation. Thus, the factors governing the migra-

tion and proliferation of the undifferentiated mesenchymal cells hold potential for

the expansion of undifferentiated precursor cells in vitro.

The morphogenesis of skeletal elements requires precartilage condensation

leading to chondrogenic differentiation and thus to the formation of cartilaginous

models of the skeletal elements. During chondrogenic differentiation, the cells

adopt a rounded morphology and start to synthesize cartilage speciﬁc matrix

molecules. Further shaping of the skeletal primordia involves the separation of

the digital rows by apoptosis of the cells within the interdigital mesenchyme. The

concomitant formation of the joints requires dedifferentiation of the cells in the

prospective joint regions transiently leading to high cell densities and ﬁnally to

apoptotic cell death and the development of the joint cavity.

Since the precursor cells are usually expanded in 2D systems in vitro where they

display a ﬂattened spindle-shaped morphology, 3D culture systems are supposed to

be appropriate for chondrogenic differentiation. The naturally occurring events are

mimicked by cell–cell-contacts established in high density pellet culture [36]by

cultivation in hydrogels [37–41] or 3D matrices of biocompatible materials [42,43].

A comparison between the in vivo stages of cartilage development and the strate-

gies used for transferring these stages into in vitro concepts and the inherent

challenges is given in Table 1.

Usually these culture systems taken alone are not sufﬁcient to induce chondro-

genesis of precursor cells. Therefore, growth factors are included into the culture

medium and combined with physical factors such as reduction of oxygen supply

Table 1 Strategies for transferring in vivo development into in vitro concepts

In vivo development of cartilage tissue In vitro cultivation of cartilage tissue

Migration and proliferation Expansion of MSC in vitro (2D cultivation)

Prechondrogenic condensation 3D aggregate culture imitating cellular condensation

Chondrogenic differentiation Cultivation in 3D biomaterials mimicking the 3D

structure of the ECM

Transient growth plate cartilage:

hypertrophy and apoptosis

Permanent articular cartilage: no

hypertrophy, no apoptosis

Prevention of hypertrophy and apoptosis in articular

cartilage regeneration

Cartilage Engineering from Mesenchymal Stem Cells 167

which occurs naturally by exclusion of the blood vessels from forming limb buds.

Chondrogenic differentiation in vitro is achieved after cultivation for several weeks

resulting in the formation of collagen type II and proteoglycans along with other

cartilage speciﬁc tissue components.

In vivo, the articular cartilage is maintained in a stage in which progression

towards hypertrophy naturally occurring in the growth plate is prevented by deﬁned

mechanisms. In the growth plate, hypertrophy and calciﬁcation of the cartilage

tissue precede vascular invasion, ﬁnally leading to tissue replacement by bone. The

inactivation of the differentiation program towards hypertrophy is particularly

important for in vitro cultivation of cartilage tissue when MSCs are used as the

cell source since terminally differentiated cells will undergo apoptosis. Unlike

MSCs, articular chondrocytes usually do not undergo lineage progression upon

extended cultivation [44] or when implanted into ectopic sites [45]. Maintenance of

the phenotype of articular cartilage therefore comprises the inactivation of the

developmental pathway leading to terminal differentiation, and a switch to sus-

tained maintenance of functional extracellular matrix. For this reason, the appro-

priate stage of in vitro cultivated cartilage tissue needs to be carefully evaluated

regarding the state of cellular phenotype of chondrocytes and the characteristics of

the extracellular matrix formed.

In this overview, regimes of growth factor treatments currently applied in

cartilage tissue engineering in vitro are compared to stage speciﬁc actions of growth

factors in vivo during cartilage differentiation. Since growth factors of the ﬁbroblast

growth factor (FGF)-family, transforming growth factor-b(TGF-b) superfamily

and the insulin-like growth factor (IGF) family are widely used in cartilage engi-

neering in vitro, the overview will be narrowed to these major groups of growth

factors. An overview of in vivo actions with in vitro applications of growth factors

is given in Table 2.

2 Development of Cartilage Tissue In Vivo

The development of the skeleton in vivo is a multistep process tightly regulated

regarding the temporal and spatial distribution of the appropriate signals. Morpho-

genesis is evoked by gradients of speciﬁc signaling molecules along the axes of the

developing limbs. Following steps are triggered by the achievement of distinct

differentiation stages of the cells and by stage speciﬁc extracellular matrix synthe-

sis. Regulatory mechanisms such as feedback terminate a distinct developmental

stage and allow for further differentiation. Thus, tissue development depends on the

differentiation stage of the cells as well as on signals provided by paracrine,

autocrine or systemic factors, and the extracellular matrix (Fig. 1).

Taking into account the multi-stage process leading to functional tissues in vivo,

histogenesis in vitro also needs to be tightly regulated regarding the time sequence

of induction and the resulting consecutive stages of extracellular matrix synthesis

(Fig. 2).

168 C. Goepfert et al.

Table 2 Occurrence and actions of growth factors in developing and mature cartilage, diseased cartilage tissue, and applications in cartilage cultivation

in vitro

Growth factor/

receptor

Role in the development of

cartilage tissue in vivo

Role in adult cartilage tissue Role in cartilage lesions or in

articular cartilage disease

In vitro applications and functions

FGF family

FGF-2 Present in the AER Bound to heparan sulfate in

the ECM, possible role in

mechanotransduction

[97–99]

Recruitment of MSCs to

cartilage defects

Stimulation of proliferation of

MSC in vitro [146]

Stimulation of Tenascin synthesis

in mesenchymal

condensations [147]

– Induction of MMP-13 [101] and

noggin [104]

Maintenance of differentiation

potential of MSCs [126,127]

Stimulation of tenascin and

syndecan synthesis in

condensations limiting size of

condensations [64]

– Increased production in RA

[148]

Increased integrin alpha10-

expression on cultured MSCs

in vitro [128]

Activation by endothelial

proteases in endochondral

ossiﬁcation [149]

– – Maintenance of differentiation

potential of mammalian

chondrocytes in vitro [123]

– – – “Dedifferentiation” of

chondrocytes [33]

FGF-4 Occurrence in the AER,

chemoattractant for limb bud

mesenchymal cells [46]

–– –

Occurrence in the ZPA, role in

AP axis formation, controls

the formation of gap junctions

[150,151]

–– –

FGF-8 Expression in the AER,

maintenance of fgf-10

expression in the underlying

mesenchyme

[47,75,77]

–– –

(continued)

Cartilage Engineering from Mesenchymal Stem Cells 169

Table 2 (continued)

Growth factor/

receptor

Role in the development of

cartilage tissue in vivo

Role in adult cartilage tissue Role in cartilage lesions or in

articular cartilage disease

In vitro applications and functions

FGF-10 Lateral plate mesenchyme: – – –

Proliferation, migration [73,77]– – –

Expression in blastemas of

regenerating limbs of

amphibia [78]

–– –

FGF-18 Role in endochondral ossiﬁcation,

coordination of

chondrogenesis and

osteogenesis [152,153]

–– –

Signaling via FGFR3, promotion

of chondrogenesis [154]

–– –

FGF receptors

FGFRI Mesenchymal cells of the limb

bud prior to condensation

[155,156]

– – Expression in proliferating cells

of mesenchymal lineage

in vitro [157]

Absence of FGFR1 causes

apoptosis in limb buds [158]

– – Expression prior to differentiation

[130,131]

– – – Expression in hypertrophic

cultures of MSCs [130,131]

FGFRII Mesenchymal condensations

[156], essential for limb

outgrowth [74]

Adult articular cartilage

[130]

– Expression in condensations of

mesenchymal micromass

cultures [157]

Expression in limb bud

ectodermal epithelium [155]

– – Expression during condensation

in vitro [131]

Ectodermal FGF-2 and

FGF-8 inhibit chondrogenesis

through FGFRII signaling

[159]

– – Down regulation during

differentiation in vitro [130]

In prechondrocytic cells prior to

condensation [155]

–– –

170 C. Goepfert et al.

FGFRIII Growth plate chondrocytes [155,

160]

– – Prior to calciﬁcation of

mesenchymal micromass

cultures [157]

TGF-bsuperfamily

TGF-b1 Expression in condensations,

stimulates synthesis of

ﬁbronectin Tenascin, N-

CAM, N-cadherin [50,64,65]

Present in adult cartilage,

bound to cartilage matrix

[107]

Induction of OA-like changes

upon overexpression [111]

Induction of chondrogenesis of

bone marrow MSC [133] and

synovium derived MSC [137]

Fn positive areas precede

chondrogenic differentiation

[86]

Stimulation of ﬁbronectin

synthesis in cartilage

explants [161]

Stimulation of proteoglycan

synthesis by OA

chondrocytes [162,163]

Inhibitory effect on primary

chondrocytes [164,165]

Inhibition of terminal

differentiation of epiphyseal

chondrocytes [166]

TGF binding domain in

Procollagen type IIA [167]

– Upregulation of TGF-b

expression in OA [168]

–

Storage in growth plate matrix

bound to LTBP, activation by

matrix vesicles [107,108]

–– –

Stimulation of PTHrP synthesis in

epiphyseal chondrocytes

[169]

–– –

Proliferation of undifferentiated

mesenchymal cells [79]

–– –

TGF-b2 Condensations Present in adult cartilage Proliferation Induction of matrix synthesis,

Endogenous synthesis by

ATDC-5 aggregate cultures

[170]

– – – Inhibitory effect on proliferation

of MSCs [146]

(continued)

Cartilage Engineering from Mesenchymal Stem Cells 171

Table 2 (continued)

Growth factor/

receptor

Role in the development of

cartilage tissue in vivo

Role in adult cartilage tissue Role in cartilage lesions or in

articular cartilage disease

In vitro applications and functions

TGF-b3 – – Proliferation, stimulation of

matrix synthesis

Chondrogenic differentiation of

MSCs [10,36]

– – Induction by IL-1 [112]–

BMP (general) Negative regulators of the AER

[81]

– – ATDC5 cell line: stage speciﬁc

expression of BMP-2, -4, -6,

-7 [171]

Feedback inhibition by Noggin

[172]

–– –

BMP signaling required for

maintenance of differentiated

phenotype, cell proliferation

and hypertrophy [173]

–– –

Inhibition of BMP signaling by

noggin inhibits condensation

and differentiation [91]

–– –

BMPs act as heterodimers [82]– – –

Co-localization of BMPs [174]– – –

Feedback inhibition of BMP

signaling by noggin [175]

–– –

BMP-2 Expression in the AER and ZPA – – Stimulation of N-cadherin

synthesis and chondrogenesis

in C3H10T1/2 cells [176]

Induction of collagen type X

synthesis and alkaline

phosphatase expression in

growth plate chondrocytes

[177]

– – Induction of chondrogenesis of

bone marrow MSC [178] and

synovium derived MSC [15]

and synovial explants [137]

172 C. Goepfert et al.

BMP-4 Induction of collagen type X

synthesis and alkaline

phosphatase expression in

growth plate chondrocytes

[177]

–– –

BMP-6 Transient expression in

prehypertrophic chondrocytes

[179,180]

– – Chondrogenic differentiation of

MSCs, synthesis by

prehypertrophic cells in vitro

[171]

BMP-7

(OP-1)

Expression during

chondrogenesis

Synovial ﬂuid, cartilage

tissue

Reduced expression in aged

cartilage tissue [113]

Synthesis of collagen type II,

aggrecan, GAG

Induction of collagen type X

synthesis and alkaline

phosphatase expression in

growth plate chondrocytes

[177]

– – Induction of chondrogenesis in

ATDC5 cell line [181]

– – – Induction of chondrogenesis of

synovial explants [137]

– – – Redifferentiation of articular

chondrocytes [182,183]

BMP receptors BMPRIB expression preﬁgures

the cartilage primordia [184]

–– –

BMPRIB present on

chondrogenic cells,

stimulation of BMPRIB

expression by TGF-b[65,

185]

–– –

Inhibition of BMPRIB expression

by FGF causes apoptosis [80]

–– –

GDFs Formation of joints and joint

spaces [186,187]

–– –

(continued)

Cartilage Engineering from Mesenchymal Stem Cells 173

Table 2 (continued)

Growth factor/

receptor

Role in the development of

cartilage tissue in vivo

Role in adult cartilage tissue Role in cartilage lesions or in

articular cartilage disease

In vitro applications and functions

IGF family

IGF-I IGF promotes limb bud

outgrowth [188–190]

IGF-I is detected in articular

cartilage [115] and in

synovial ﬂuid [191]

Increased synthesis of IGF-I and

IGFBP-3 in OA [192–194]

and RA [194]

Chondrogenic effect on MSCs in

the absence of insulin [195]

Co-expression of IGF-I and

IGFBP-2 in condensing

mesenchyme [196]

Autocrine effect [197]– –

Stimulation of IGF synthesis in

growth plate by growth

hormone [116]

–– –

Expression mainly in

proliferating chondrocytes of

the growth plate [121]

–– –

IGF-II Expression in chondrocyte

precursors, co-expression

with both types of IGF

receptors [95]

Autocrine effect [197]– –

IGF binding proteins

IGFBP-3 Perichondrium [94] Transport of IGF-I Inhibits of IGF-I induced matrix

synthesis

Antiproliferative effect of

IGFBP-3 on RCJ3.1C5.18 cell

line [198]

– – Increased in synovial ﬂuid of

OA and RA [194]

–

– – Increased synthesis in OA [192,

193]

–

IGFBP-4 Developing cartilage [95]– – –

IGFBP-5 Mesenchymal condensations [95]– – –

IGFBP-6 Mesenchymal condensations [95]– – –

IGF receptors – – Increased number of binding

sites in OA chondrocytes,

decreased responsiveness to

IGF [192]

–

174 C. Goepfert et al.

PTHrP

PTHrP Synthesis in epiphyseal

chondrocytes [67,169]

– Prevention of collagen type X

synthesis by MSC of OA

donors [144]

Prevention of collagen type X

synthesis by bone marrow

MSC [143,144] and by

adipose tissue derived MSC

[143]

Hedgehog proteins

Ihh Production by prehypertrophic

chondrocytes, induction of

PTHrP in epiphyseal cartilage

[68,69]

–– –

Shh Expression in the ZPA, role in AP

axis formation [89,199]

–– –

Growth factor interactions

FGF/TGF Stimulation of TGF synthesis by

FGF in progress zone =>

promotes transition of

precursor cells towards

differentiation [46]

– – FGF suppresses senescence

induced by TGF-b2[129]

– – – “Secondary progenitor cells”

from human articular

chondrocytes [35]

– – – Stimulation of chondrocyte

growth in vitro [203]

– – – Synergistic effect on chondrocyte

proliferation together with

PDGF-BB [124]

FGF/BMP FGF and BMP have opposite

effects on limb outgrowth

[208]

–– –

FGF and BMP interact to induce

apoptosis of the interdigital

mesenchyme [80]

–– –

IGF/TGF – – – Additive effect on chondrogenesis

of MSC [138]andon

synovium derived MSC [200]

(continued)

Cartilage Engineering from Mesenchymal Stem Cells 175

Table 2 (continued)

Growth factor/

receptor

Role in the development of

cartilage tissue in vivo

Role in adult cartilage tissue Role in cartilage lesions or in

articular cartilage disease

In vitro applications and functions

– – – Enhanced chondrogenesis of

periosteal explants [201]

– – – Synergistic effect of IGF-I and

TGF-bon redifferentiation of

human articular chondrocytes

[202]

IGF/BMP – – Synergistic effect on matrix

synthesis in OA

chondrocytes [204]

Synergistic effect on matrix

synthesis [204,206]

– – Inhibitory effect on MMP-13

expression [205]

IGF/TGF/FGF – – – Enhance proliferation of

synovium derived stem cells

[200]

IGF/BMP/FGF – – – Inhibition of anabolic effects of

IGF-I and BMP-7 on

chondrocytes by FGF [105]

TGF/BMP – – – Induction of chondrogenesis of

adipose-derived stem cells

by TGF-b3 combined with

BMP-6 [135]

– – – Induction of chondrogenesis of

bone marrow and adipose

tissue derived MSC by

TGF-b2 in combination with

BMP-7 [136]

– – – Synergistic effect of TGF-b1 and

BMP-2 on the chondrogenesis

of bone marrow MSC [207]

176 C. Goepfert et al.

mesenchymal stem cells promotion of

lineage progression

differentiated cells

paracrine / autocrine

growth factors

extracellular

matrix

release of growth

factors from ECM

binding of growth

factors to ECM

proliferating /

differentiating cells

stage specific

synthesis of paracrine /

autocrine GF

GF promoting

lineage progression

stage specific

synthesis / remodelling

of ECM

feedback via

cell surface receptors

Fig. 1 Interaction of cellular differentiation, growth and differentiation factors, and speciﬁc

matrix molecules during histogenesis. Morphogenesis and histogenesis result from the interaction

of speciﬁc growth and differentiation factors acting in a stage dependent manner. Growth factor

actions are modulated by binding to ECM molecules and the expression of their receptors

depending on the developmental stage of the cells

proliferation and

differentiation

terminal

differentiation

calcification /

vascularization

ossificationproliferation

and migration

FGF-10

FGF-2,4,8

FGFR1

condensation

TGF-ß

FGF-2

shh

FGF-2/FGFR2

IGF-II

BMP-2,4,7

FGF-18/FGFR3

PTHrP

BMP-2,7

FGF-2/FGFR1

BMP-2,7

collagen I

collagen IIA collagen IIB collagen X collagen I

diaphysis

epiphysis

perichondral

bone collar

fibronectin

blood vessel

cartilaginous

model

N-

cadherin

aggrecan

tenascin

hyaluronan

growth

plate

Fig. 2 Development of the long bones under the control of growth factors. The different develop-

mental stages of the skeletal primordia are shown together with the speciﬁc growth and differenti-

ation factors (above the arrows) which promote the stage speciﬁc synthesis of matrix molecules

(below)[6,144]

Cartilage Engineering from Mesenchymal Stem Cells 177

2.1 Migration and Proliferation

In the initial phase of limb development, mesenchymal cells of the lateral plate

mesenchyme and of the somitic mesenchyme migrate towards the limb ﬁeld [2].

The ectodermal cells are induced by the mesoderm to form a specialized epithelial

structure termed the apical ectodermal ridge (AER). The AER supports migration

and proliferation of the mesenchymal cells providing the cell mass for the forma-

tion of precartilage condensations [46,47].

2.2 Cell Condensation

Cell condensation is characterized as a transient stage during the early morphogen-

esis which can be detected by PNA (peanut agglutinin) staining [48,49]. During

cell condensation, cell density in the prospective limb regions is increased leading

to cell–cell contacts mediated by cell adhesion molecules such as N-cadherin and

N-CAM [50–52] and the formation of gap junctions [53,54]. Cell adhesion

molecules are expressed speciﬁcally during the condensation phase and down

regulated subsequently upon chondrogenic differentiation of the prechondrogenic

cells. Prior to cell condensation, the extracellular matrix in the prospective limb

regions contains high amounts of collagen type I and hyaluronan [55,56]. Hyaluronan

is supposed to prevent cell–cell interactions prior to the condensation phase [56].

During the condensation phase, hyaluronidase activity is detected, suggesting that

matrix remodeling takes place allowing for cell–cell interaction. During the con-

densation phase, a speciﬁc splice variant of ﬁbronectin, FnEIIIA, is detected

throughout the condensations [57,58]. Fibronectin was shown to be essential

for condensation and subsequent chondrogenesis. Furthermore, ﬁbronectin distri-

bution during the condensation phase indicates the localization of skeletal elements

formed later on [55].

2.3 Chondrogenic Differentiation

Cellular differentiation is characterized by the increased synthesis of transcription

factors sox-5 and sox-6, and the appearance of the cartilage speciﬁc transcription

factor sox-9 [59–61]. Collagen type I and ﬁbronectin are synthesized in the ECM

prior to condensation and reach a maximum density at the time of cellular differen-

tiation [55]. Chondrogenic differentiation of the condensing cells is characterized

by the appearance of collagen types II, IX, and XI, the characteristic components of

collagenous network of cartilage tissue. As a result of chondrogenic differentiation,

178 C. Goepfert et al.

remodeling of the extracellular matrix towards the cartilaginous composition of the

tissue takes place. Collagen type I consequently disappears from the tissue [55].

In adult articular cartilage, ﬁbronectin is detected predominantly in the pericellular

area [62]. Collagen type I is usually not detected in articular cartilage unless repair

tissue is formed originating from the bone marrow. Mixed collagen type I and type

II formation resulting in mechanically inferior ﬁbrocartilage is assumed to be an

intrinsic property of MSCs which cannot be avoided in mesenchymal cartilage

repair [63].

During cell differentiation, tenascin is transiently up-regulated in the developing

tissue. Tenascin and its receptor syndecan prevent further interaction of N-CAM

with ﬁbronectin and thus terminate the condensation phase, allowing for further

progression of cellular differentiation [64].

Along with cellular differentiation and cartilage tissue formation, the skeletal

elements of the limbs are shaped into the precursors of the future skeleton. Joint

formation and the organization of the digital rows involve apoptosis of the cell

groups in the joint space and the interdigital regions. Therefore, the mesenchy-

mal cells of the limb bud either undergo chondrogenic differentiation or apo-

ptosis [65].

2.4 Endochondral Ossiﬁcation

During the development of the appendicular skeleton in vivo, the cartilaginous

models of the long bones are replaced by bone tissue. Thus, lineage progression

towards terminal differentiation is an intrinsic program of the mesenchymal cells.

Articular cartilage, however, does not undergo the process of terminal differ-

entiation unless there are pathological conditions such as osteoarthritis (OA). In

OA, lineage progression is resumed leading to the formation of collagen type X

as a hypertrophy marker [66] and ﬁnally to abnormal calciﬁcation patterns of

the cartilage matrix. The mechanisms preventing the chondrocytes of the peri-

articular region from terminal differentiation and maintaining the cartilaginous

phenotype of articular cartilage are extensively studied in vivo [67–69]. In the

growth plate, chondrocytes resume proliferation leading to columnar cartilage

which represents the growth zone of the long bones in the embryo and the

juvenile organism. Chondrocytes leaving the growth zone start synthesizing

collagen type X which is the hallmark of hypertrophy. Morphologically, the

chondrocytes swell and adopt the hypertrophic phenotype. The hypertrophic

cartilagetissueiserodedbyinvadingcellsandreplacedbybonemarrowandin

the end by bone. Hypertrophic chondrocytes also secrete matrix degrading

enzymes such as MMP-13 which cleaves speciﬁcally collagen type II and thus

contributes to remodeling of the extracellular matrix. Hypertrophic chondrocytes

ﬁnally undergo apoptosis.

Cartilage Engineering from Mesenchymal Stem Cells 179

3 The Inﬂuence of Growth Factors on Cartilage

Development In Vivo

An overview of the occurrence and actions of growth factors in developing and

mature cartilage tissue is given in Table 2.

3.1 Fibroblast Growth Factors in Early Skeletal Development

The members of the FGF family share a homologous central core but differ in

their carboxyterminal and N-terminal regions due to alternative splicing [70]. The

FGFs are known as mitogens for mesodermal and neuroectodermal cell types.

They induce chemotaxis and angiogenesis [71] and bind to heparan sulfate with

high afﬁnity [72]. Members of the FGF family of growth factors play a crucial

role in the development and morphogenesis of the appendical skeleton. They

are involved in all stages of tissue development as well as in the signal transduc-

tion during mechanical loading. FGFs are also involved in the remodeling and

degradation of articular cartilage matrix taking place in inﬂammatory joint

diseases.

FGFs are indispensable for outgrowth of limb buds preceding the development

of the appendical skeleton [47,73]. The initial steps involve epithelial to mesen-

chymal interactions mediated by members of the FGF-family. Mesenchymal FGF-10

and ectodermal FGF-8 are the earliest factors involved in limb bud outgrowth. FGF-

10 is synthesized by the mesenchymal cells and induces the expression of FGF-

8 within the AER. The proximo-distal axis of the developing limb is established via

this feedback loop [74] which results in accumulation of proliferating cells in the

region of the prospective limb bud [46]. A speciﬁc splice variant of CD44 with the

ability to speciﬁcally bind FGF-8 mediates the presentation and thus the stimulation

of mesenchymal cells by FGF-8 [75]. FGF-4 and FGF-2 are co-expressed in the

AER [74,76,77]. Knowledge about these events arises from regeneration of limbs

in amphibians [78] and knockout models in mice [74]. Signal transduction is

mediated by FGFR2 [74].

During morphogenesis of the limb skeleton, the members of the FGF family of

growth factors interact with other growth and differentiation factors. After the

onset of condensation in the proximal region, a growth zone is formed between the

AER and the condensing cell mass, termed the progress zone (PZ). The dynamic

structure of the PZ results from the interaction of members of the FGF family with

TGF-b. Proliferating cells move away from the AER and leave the zone governed

by the growth promoting FGFs. Further proximally, members of the TGF-b

superfamily are expressed within the condensing region of the limb bud. TGF-b

promotes chondrogenic differentiation of the cells leading to the expression of

cartilage matrix genes. Whereas TGF-bacts as growth stimulus in undifferentiated

mesenchymal cells [79], it stimulates the formation of N-cadherin and N-CAM and

180 C. Goepfert et al.

the synthesis of ﬁbronectin and tenascin in the condensing regions, thereby

promoting the progression of mesenchymal cells towards chondrogenic differenti-

ation [50].

When limb outgrowth is completed, growth stimulation by the FGFs is

terminated by regression of the AER induced by members of the BMP family

[80,81].

3.2 The TGF-bSuperfamily of Growth and Differentiation

Factors

The TGF-bsuperfamily of growth factors comprises a number of growth and

differentiation factors characterized by their dimeric structure. Growth factors

belonging to the TGF-bsuperfamily are the transforming growth factors TGF-b1,

b2 and b3, the bone morphogenetic proteins (BMP-2–BMP-15), growth and differ-

entiation factors (GDF), activin and inhibin, and Mu

¨llerian inhibitory substance.

BMPs often act as heterodimers which are known to have higher afﬁnities for their

receptors [82]. Members of the TGF-bsuperfamily are involved in embryonic

development as well as in repair responses to tissue injuries, but also in pathological

tissue responses such as scarring and ﬁbrosis [83].

Among the members of the TGF-bsuperfamily TGF-b1 to TGF-b3, BMP-2, -4,

and -7, as well as GDF-5 and GDF-6, play crucial roles during skeletal development.

After the establishment of the AER, TGF-b1 is expressed in the condensing

regions of the limb buds. It plays a crucial role in co-stimulating HA synthesis in the

sub-epidermal layer of the limb bud [84]. TGF-balso induces the synthesis of cell

adhesion molecules involved in prechondrogenic cell–cell interactions, N-CAM,

and N-cadherin, which are prerequisite for the induction of chondrogenic differen-

tiation [50,85].

In the early phase of condensation, members of the TGF-bfamily stimulate the

synthesis of ﬁbronectin [86] which is necessary for the condensation and differen-

tiation of the mesenchymal cells. Furthermore, members of the TGF-bfamily up-

regulate the synthesis of tenascin and collagen type I which is transiently expressed

during the early phase of condensation [50]. TGF-bis known to induce the

synthesis of the transcription factor sox-9 which is the key regulator of chondro-

genesis [87]. The expression of Sox-9 is regulated by other paracrine factors such as

FGF [88].

BMPs are co-expressed with FGFs in the AER but act as negative regulators of

the AER [81] and as morphogenic factors involved in the antero-posterior axis

formation induced by the zone of polarizing activity (ZPA) [89,90]. BMPs origi-

nating from the AER are involved in shaping the autopod by inducing apoptosis in

the interdigital mesenchyme acting through the BMP receptor BMPR1A which is

expressed throughout the limb buds. In the digital elements, TGF-b1 induces the

synthesis of BMPR1B which allows for chondrogenic differentiation of the

Cartilage Engineering from Mesenchymal Stem Cells 181

condensing cells mediated by BMP. BMPR1B expression is inhibited in the inter-

digital mesenchyme by FGFs secreted by the AER [80].

BMP-2, -4, and -7 were shown to be co-expressed throughout the limb bud. They

are required during the condensation stage and later on for the induction of chondro-

genic differentiation. Inhibition of BMP signaling by misexpression of noggin causes

complete inhibition of prechondrogenic condensation [91]. After chondrogenic dif-

ferentiation, BMP actions in the limb cartilages are regulated by their endogenous

inhibitor noggin [91]. BMPs stimulate the synthesis of noggin and thus induces

limitation of the chondrogenic regions in the limb. At the same time, BMP expression

persists in the perichondrium and stimulates recruitment of mesenchymal cells for

chondrogenic differentiation [91]. Thus, TGF and BMP pathways interact in the

context of chondrogenic differentiation of mesenchymal cells.

3.3 The Role of IGFs in the Development of Cartilage Tissue

During embryogenesis, both isoforms of the IGF family, IGF-I and IGF-II, are

present in the skeletal system. Absence of IGF signalling exerted by knockout of

IGF receptor genes leads to severe skeletal defects [92]. Both receptors, IGFR1 and

IGFR2, are expressed in all stages of limb bud development [93]. The IGF actions

in the skeletal system are modulated by the IGF binding proteins (IGFBP) by

reducing or enhancing the bioavailability of the IGFs. IGF-I and IGF-II and the

IGFBP exhibit a speciﬁc pattern in the developing limb buds, suggesting a speciﬁc

role during chondrogenesis [94]. In prechondrogenic condensations, IGF-II is found

to be co-expressed with IGFBP-5 and IGFBP-6 [95]. During digit formation, IGFs

are also present in the interdigital mesenchyme undergoing apoptosis instead of

chondrogenic differentiation. IGFBP-2, -4, and -5 are found in the interdigital zone

whereas IGFBP-3, -4, and -5 are detected in the phalangeal joint areas [94] at the

time of joint formation. Components of the IGF-system are also detected in the

AER (IGFBP-2 and -4) and in the ZPA (IGF-I and IGFBP-4) [94].

3.4 Terminal Differentiation or Development of

Articular Cartilage

During further progression of skeletal development, two divergent lineages of

chondrocytic phenotypes emerge from the cartilaginous models of the skeleton.

Periarticular cartilage is prevented from terminal differentiation and develops into

hyaline articular cartilage. Cartilaginous tissue of the growth plate on the other hand

progresses towards terminal differentiation and is ﬁnally replaced by bone. The

regulation of terminal differentiation vs maintenance of epiphyseal cartilage has

been extensively studied in vivo. Vortkamp et al. have established a model of

182 C. Goepfert et al.

interdependent regulation by a negative feedback loop between the growth zone

and the epiphysis [69]. Prehypertrophic chondrocytes synthesize Ihh, which

induces PTHrP in epiphyseal chondrocytes. It is assumed that PTHrP is a key factor

preventing hypertrophy and terminal differentiation of the epiphyseal chondro-

cytes. TGF-b2 was shown to stimulate the synthesis of PTHrP in the perichondrium

of organ cultures of developing bones. TGF-bexpression was induced by

Hedgehog proteins [96]. BMP acts independently of PTHrP on terminal differenti-

ation by delaying this process [68].

4 Growth Factors in Adult Cartilage Tissue

Growth and differentiation factors are also present in adult articular cartilage

performing distinct functions in tissue maintenance, transduction of mechanical

stimuli, and regeneration. Since these functions differ from the actions exerted

during development, the availability of growth factors is adjusted by speciﬁc binding

factors and antagonists, and by their afﬁnity to extracellular matrix molecules such

as heparan sulfate, collagen, and ﬁbronectin. These mechanisms make sure that the

growth factors are available to regulate the natural turnover of cartilage matrix or

induce tissue repair in cartilage injury for example caused by traumatic tissue

damage and disease.

4.1 The Role of FGF in Adult Articular Cartilage

Besides their role in the development of the skeleton, the FGFs are also detected in

hyaline articular cartilage. FGF-2 was found to be entrapped within the pericellular

matrix bound to heparan sulfate side chains of perlecan [97]. Perlecan was detected

in the pericellular matrix of the chondrocytes rich in collagen type VI. FGF-2 has

been demonstrated to exert signiﬁcant functions during mechanical loading of

articular cartilage [98] and mediate the immediate response of articular cartilage

to mechanical injury [99]. Its role in cartilage injury and repair is still controversial,

since FGF-2 is known to have anabolic as well as catabolic effects. It was shown

that FGF-2 inhibited aggrecanolysis by ADAMTS, which is regarded as an initial

and still reversible step of matrix degradation in OA and rheumatoid arthritis (RA)

[100]. On the other hand, FGF-2 is known to induce matrix metalloproteinases

MMP-1 and MMP-3 and tissue inhibitor of metalloproteinase TIMP-1 [99]. FGF-2

stimulates the synthesis of MMP-13 [101], the major collagen type II degrading

enzyme which is found to be present in excess in OA and RA, but also plays a role

in tissue remodeling during skeletogenesis [102,103]. Furthermore, FGF-2 induces

chondrocyte proliferation and thus might contribute to cluster formation in affected

cartilage tissue. Nucleus pulposus cells up-regulate the synthesis of noggin upon

stimulation with FGF-2, which might contribute to the reduced sensitivity to

Cartilage Engineering from Mesenchymal Stem Cells 183

BMP-7 observed in diseased tissue [104,105]. Increased synthesis of FGF-2 by

cells of the synovial tissue contributes to the altered growth factor environment in

cartilage disease [103]. The multi-facetted actions of FGF-2 in healthy hyaline

cartilage and in trauma and disease demonstrate the imperative of tight regulation

of the availability of growth factors in the adult cartilage tissue.

4.2 Members of the TGF-bSuperfamily in Adult

Articular Cartilage

TGF-bis secreted together with its propeptide (latency associated peptide, LAP),

which binds with high afﬁnity to TGF-band thus limits its bioavailability. Further-

more, there are several members of LTBP proteins which bind to TGF-band form

large latent complexes (LLCs). LTBPs contain binding domains for extracellular

matrix proteins such as collagen and ﬁbronectin. LTBP-3 knockout mice show

skeletal abnormities which are due to impaired TGF-bsignaling leading to early

OA [106]. Thus LTBP-3 is assumed to have a regulatory function in articular

cartilage. LTBP-1 plays a major role in the growth plate during endochondral

ossiﬁcation [107,108]. These observations indicate that local concentrations of

TGF-bare tightly regulated by binding factors and that sequestered growth factors

might be released upon demand [109]. TGF-bitself is known to be essential for the

homeostasis of adult articular cartilage, because the phenotype of TGF-breceptor

type II knockout mice displays signs of OA and impaired cartilage repair [110]. On

the other hand, overexpression TGF-bin mice leads to the formation of osteophytes

similar to osteophyte formation in OA [111]. Inﬂammatory cytokines such as IL-1

induce the synthesis of TGF-b3 in articular chondrocytes [112].

The role of BMPs is largely investigated during development of the skeleton

and well established in cell differentiation, histogenesis, and morphogenesis.

BMPs are also known to be present in synovial ﬂuid and mature articular cartilage

tissue [113]. BMP signaling is known to be strictly regulated by negative feed-

back, for example by noggin, which is induced by various isoforms of BMP. BMP

overexpression leads to progression of differentiation and to matrix calciﬁcation,

even in articular cartilage. Therefore it can be hypothesized that there are mechan-

isms to limit BMP signaling in the adult articular cartilage tissue. TGF-bs are

known to inhibit partially excess BMP action, but the interactions of TGF-band

BMP during development and in mature articular cartilage tissue have not been

fully elucidated.

4.3 The Role of IGF in Adult Articular Cartilage

IGF was ﬁrst described to stimulate proteoglycan synthesis [114] and to maintain a

steady state of proteoglycan synthesis in articular cartilage explants [115]. In the

184 C. Goepfert et al.

growth plate, IGF was shown to be the local mediator of growth hormone action on

proliferative chondrocytes and thus to contribute to the longitudinal growth of the

long bones [116,117]. The IGFs are found as complexes with their speciﬁc binding

proteins, themselves exerting distinct functions promoting or inhibiting IGF signal-

ing. Endocrine IGF-I in the bloodstream is complexed by IGFBP-3 as a carrier

protein. In articular cartilage, IGFBP-3, -4, and -5 were detected [118]. IGFBPs are

known to play signiﬁcant roles in IGF transport in the articular cartilage [119] and

in transduction of mechanical stimulation [120]. IGFBPs bound to extracellular

matrix might represent a reservoir for IGF within the cartilage tissue. IGFBP-3 was

shown to bind to ﬁbronectin of the pericellular matrix, but neither IGFBP-4 nor

IGFBP-5 were associated with these extracellular matrix components [118]. On the

other hand, in OA, IGF-signaling and thus matrix synthesis are impaired by the

increased levels of inhibitory IGFBP-3 in the synovial ﬂuid [121]. Although IGF-I

is synthesized in the diseased articular cartilage at higher rates compared to healthy

cartilage tissue, the stimulatory effect on matrix synthesis is reduced compared to

normal articular cartilage tissue [122].

5 Engineering of Cartilage Tissue In Vitro

An overview of the applications and actions of growth factors in cartilage cultiva-

tion in vitro is given in Table 2.

5.1 Expansion of Progenitor Cells

For the expansion of chondrocytes or MSCs, various growth factors have been used

in order to optimize cell growth starting with a limited number of primary cells. The

expansion of chondrocytes usually implies a process of dedifferentiation, meaning

that matrix synthesis is down-regulated when chondrocytes are isolated from their

natural environment. Growth factor treatment stimulates the growth of chondro-

cytes in vitro, but also contributes to dedifferentiation [33].

Among the members of the FGF family, FGF-2 is the factor most studied in

cartilage tissue engineering. Treatment with FGF-2, which is a strong mitogen for

various mesenchymal cell types, leads to a rapid loss of collagen type II synthesis

during cell expansion. On the other hand, FGF-2 inhibits the formation of stress

ﬁbers and the typical collagen type I expression of dedifferentiated articular

chondrocytes [123]. Furthermore, chondrocytes expanded in the presence of

FGF-2 are able to produce higher amounts of matrix constituents when culture

conditions permissive for redifferentiation are applied [123]. Various growth

factor regimes have been suggested for the expansion of articular chondrocytes,

most of them comprising the application of FGF-2, which allows for the expansion

of adult articular chondrocytes and at the same time priming the cells for

Cartilage Engineering from Mesenchymal Stem Cells 185

optimized redifferentiation. FGF-2 is also used in combination with TGF-b[35]or

TGF-band PDGF-BB [124].

FGF-2 together with TGF-band PDGF-BB was also shown to promote dediffer-

entiation towards the “mesenchymal” phenotype, thus leading to increased synthesis

of cartilage matrix components upon the application of differentiating conditions

[33]. This beneﬁcial effect on chondrocytes is contributed to the maintenance of sox-

9 expression during expansion of articular chondrocytes and MSCs in vitro [88].

For mesenchymal progenitor cells, FGF-2 is a very powerful growth stimulating

factor, extending the life span of bone marrow MSC [125], but also helping to

maintain the multipotential properties of the precursor cells during prolonged

cultivation in vitro. This has been shown for the osteogenic [126] and for the

chondrogenic potential of bone marrow MSC [127]. The mechanism by which

treatment with FGF maintains the differentiation potential of MSCs and improves

the matrix synthesis of dedifferentiated chondrocytes is not yet clear. Varas et al.

have shown that treatment with FGF-2 during extended expansion of MSCs leads to

up-regulation of the cartilage speciﬁc integrin alpha10 while reducing the expres-

sion of integrin alpha 11 characteristic for ﬁbroblasts [128]. FGF-2 was also shown

to slow down senescence of MSCs during expansion in vitro by inhibiting TGF-b2

expression [129].

In chondrogenic cultures of MSCs, FGF receptors are expressed in a similar

manner as in vivo during chondrogenesis. FGFR1 was detected in MSCs prior to

chondrogenic differentiation and later on in hypertrophic constructs derived from

pellet cultures of human MSCs [130,131]. On the mRNA level, FGFR2 and FGFR3

expression was shown to increase over time after the onset of chondrogenic

differentiation [131], whereas on the protein level, FGFR2 and FGFR3 were not

detected in collagen type II synthesizing tissue or in articular cartilage at all. The

three types of FGF receptors were detected on the protein level in pellet cultures of

adult human MSCs, indicating a role for FGF during the late phase of cartilage

differentiation in vitro [130]. Hypertrophy and calciﬁcation were accompanied by

expression of MMP-13 and decreasing levels of proteoglycan and collagen content,

indicating that matrix degradation takes place in a way comparable to the in vivo

situation in the growth plate [131].

5.2 Chondrogenic Differentiation In Vitro

Chicken limb bud mesenchymal cells, long established as in vitro model of

chondrogenic differentiation, demonstrate the ability of mesenchymal cells to

undergo reversibly differentiation, terminal differentiation, and dedifferentiation

[28]. Suspension cultures of these mesenchymal cells undergo spontaneous

chondrogenesis and start collagen type II synthesis in vitro induced by cell–cell

contacts upon aggregation. The differentiating cells in aggregate cultures were

shown to proceed towards terminal differentiation and synthesize collagen type

186 C. Goepfert et al.

X[132]. On the other hand, chicken limb bud cells adopt a ﬁbroblastic morphology

and synthesize collagen type I when transferred to monolayer culture at low cell

densities.

For chondrogenic induction of adult MSCs, high cell densities in pellet culture

or in appropriate 3D biomaterials in combination with growth factors are required.

Growth factors currently used for chondrogenic differentiation of MSCs belong to

the TGF-bsuperfamily. TGF-band BMPs are well established in redifferentiation

of culture expanded chondrocytes [33,123,124]. The protocols for chondrogenic

differentiation of bone marrow MSCs make use of TGF-b1[133], TGF-b3

[10,36] BMP-2, -4, -6, and -7, or combinations of these growth factors. Most of

these protocols use serum free conditions and include dexamethasone and ITS

(insulin, transferrin, and selenite) supplement in the culture medium [10]. Since

MSCs can be isolated from different tissues, the growth factors used for chondro-

genic induction are adapted to the different requirements. For the chondrogenic

differentiation of bone marrow MSCs, BMP-2 was most effective in comparison

with BMP-4 and BMP-6 [134].

Compared to bone marrow MSCs, adipose tissue-derived MSCs have a reduced

chondrogenic potential. In this cell culture system, the combined action of TGF-b

and BMP-6 was most effective in inducing chondrogenesis. This was due to

upregulation of the TGF-breceptor-1 (TbRI) by BMP-6. TbRI is usually absent

from a adipose tissue-derived MSCs [135]. A combination of TGF-b2 and BMP-7

also effectively induced chondrogenesis of adipose tissue-derived MSCs [136].

Bovine synovium derived MSCs cultivated in alginate gel underwent chondro-

genic differentiation upon treatment with BMP-2 but not in response to TGF-b

[15]. Micromass cultures of synovium derived cells and explants of the synovial

membrane were differentiated towards the chondrogenic lineage using TGF-b,

BMP-2, or BMP-7, in the absence of dexamethasone. These growth factors

induced different types of cartilaginous tissue, all showing synthesis of cartilage

matrix proteoglycans. Collagen type II was only obtained by treatment with

BMPs, but not with TGF-b[137]. Morphologically, BMP driven chondrogenesis

resulted in cartilage-like appearance of chondrocytes within lacunae, but similar to

hypertrophic cartilage, which was conﬁrmed by expression analysis of collagen

type X. On the other hand, TGF-b1 failed to induce collagen type II synthesis and

showed lower levels of collagen type X. Morphologically, lacunae within the

tissue were not apparent.

Members of the IGF family have also been used in protocols for chondrogenic

induction of MSCs. Martin et al. have shown that IGF-I and -II stimulate the growth

of marrow derived cells in vitro, but have no inﬂuence on subsequent chondrogenic

or osteogenic differentiation [126]. In vitro induction of chondrogenesis usually is

carried out under serum free conditions using a pre-mix of ITS (insulin, transferrin,

selenite). Longobardi et al. pointed out [138] that high concentrations of insulin in

the culture medium might obscure the effect of IGF-I on chondrogenic differentia-

tion of MSCs since insulin also binds to IGF receptors, although with much lower

afﬁnity. In the absence of insulin, IGF-I stimulated cell proliferation as well as

chondrogenesis of MSCs and induced Sox-9 and collagen type II expression and

Cartilage Engineering from Mesenchymal Stem Cells 187

proteoglycan synthesis in a way that was comparable to TGF-b. Effects of IGF-I

and TGF-bwere additive. In contrast to IGF-I, TGF-binduced condensation as

shown by PNA staining and the expression of cell adhesion molecules mediating

cell–cell contacts such as N-cadherin. Although IGF-I induced the synthesis of

chondrogenic markers, this was carried out in a way that was independent of cell

condensation [138].

5.3 Maintenance of the Hyaline Phenotype in Cultivated

Cartilage Tissue

For future clinical applications of MSCs for the treatment of articular cartilage

defects, the characterization of cellular differentiation and the composition of the

resulting cartilage tissue are essential in order to make sure that implanted tissue

will meet the biochemical and biomechanical requirements. To date there are major

problems related to the characterization of the developmental stage of the resulting

tissue. In chondrogenic cultures of MSCs, collagen type I is usually expressed along

with collagen type II indicating a ﬁbrocartilaginous phenotype of the cells in vitro

[139,140]. Fibrocartilage is biomechanically inferior to hyaline cartilage and thus

the implantation of ﬁbrocartilaginous tissue might lead to failure of the graft [63].

Another concern is the synthesis of collagen type X and the progression towards

terminal differentiation observed in cartilaginous tissue derived from various

sources of MSCs. Terminal differentiation might lead to calciﬁcation and invasion

of blood vessels and thus to the loss of the implanted tissue [45,139,140]. Early

induction of collagen type X was observed upon chondrogenic induction of MSCs,

even before the onset of collagen type II synthesis [141,142]. In order to overcome

this problem, PTHrP was applied in chondrogenic cultures to prevent terminal

differentiation. In the presence of PTHrP, collagen type X expression was sup-

pressed and alkaline phosphatase activity was reduced in comparison with control

cultures [143] even when derived from OA patients [144].

6 Conclusion

The development of the limbs is one of the most studied models for the investiga-

tion of the mechanisms controlling morphogenesis and regeneration in vivo. In

vitro culture models have been derived from cell cultures of the limb mesenchyme

to explore the developmental mechanisms under deﬁned conditions and knockout

mice have been generated to study in detail the factors contributing to tissue

development and morphogenesis.

In vitro synthesis of cartilage tissue, mainly driven by the emerging concepts of

regenerative medicine, relies on experimental approaches involving biomaterials

188 C. Goepfert et al.

and growth factors known to support chondrogenesis in vivo. Besides the actions

of growth factors, there are signiﬁcant inﬂuences of the ECM components on

cartilage differentiation which might have a major impact on the design of new

biomimetic scaffolds. These effects mediated by the cooperation of growth

factors and their speciﬁc receptors with integrins and other cell surface receptors

were shown to play a major role in modulating growth factor actions during

differentiation.

Regarding future clinical applications of cartilage engineering from MSCs, there

are still important questions to be answered regarding the differences between

permanent articular cartilage and the transient cartilage of the growth plate. Knowledge

about the mechanisms deﬁning the type of cartilage formed in vivo might lead to

improved protocols for cartilage production in vitro.

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Adv Biochem Engin/Biotechnol (2010) 123: 201–217

DOI: 10.1007/10_2009_65

#Springer-Verlag Berlin Heidelberg 2010

Published online: 18 February 2010

Outgrowth Endothelial Cells: Sources,

Characteristics and Potential Applications in

Tissue Engineering and Regenerative Medicine

Sabine Fuchs, Eva Dohle, Marlen Kolbe, and Charles James Kirkpatrick

Abstract Endothelial progenitor cells from peripheral blood or cord blood are

attracting increasing interest as a potential cell source for cellular therapies aiming

to enhance the neovascularization of tissue engineered constructs or ischemic

tissues. The present review focus on a speciﬁc population contained in endothelial

progenitor cell cultures designated as outgrowth endothelial cells (OEC) or endo-

thelial colony forming cells from peripheral blood or cord blood. Special attention

will be paid to what is currently known in terms of the origin and the cell biological

or functional characteristics of OEC. Furthermore, we will discuss current concepts,

how OEC might be integrated in complex tissue engineered constructs based on

biomaterial or co-cultures, with special emphasis on their potential application in

bone tissue engineering and related vascularization strategies.

Keywords Bone tissue engineering, Co-culture models, Endothelial progenitor

cells, Vascularization

Contents

1 Introduction . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . 202

2 Endothelial Progenitor Cells in the Neovascularization Process ............................. 202

3 Diversity of Endothelial Progenitor Cell Populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203

4 Origin of OEC and Enrichment Strategies . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205

5 In Vivo Evaluations of Angiogenic Potential of OEC . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . 208

6 OEC for Vascularization of Complex Tissue Engineered Constructs . . . . . . . . . . . . . . . .. . . . . 209

7 Self-Endothelialization Strategies . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 212

8 Conclusions . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . 213

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213

S. Fuchs (*), E. Dohle, M. Kolbe, and C.J. Kirkpatrick

Institute of Pathology, Universita

¨tsmedizin der Johannes Gutenberg-Universita

¨t, Langenbeck-

strasse 1, Mainz, Germany

e-mail: fuchss@uni-mainz.de

1 Introduction

The creation of adequate tissue equivalents and other therapeutical products in tissue

engineering and regenerative medicine is, for several reasons, a highly challenging

task. First of all, tissues reveal a highly complex structure, usually consisting of more

than a single cell type and a cellular organization in an individual, tissue speciﬁc

manner. In addition, tissue function is regulated by a close interaction of the individ-

ual cell types controlled via matrix components and cell to cell communication

mechanisms also underlying the control through physiological conditions such as

oxygen tension, state of inﬂammation, or mechanical stimulation. Last but not least,

tissues are integrated into the body and linked to central body functions, such as

vascularization, ensuring the supply with oxygen and nutrients, as well as the removal

of waste products. Furthermore, adequate vascularization is an essential prerequisite

allowing stem cells to approach the sites of tissue repair [1–4]. The development of

new therapies leading to a fast and successful vascularization is therefore one of the

most central and highly discussed subjects in tissue engineering and regenerative

medicine. In this context, the use of endothelial progenitor cells for proangiogenic

cell therapies has been proposed as a potential means to overcome the current

problems in the neovascularization of bioengineered or harmed tissues [4,5]. Despite

high expectations, the use of endothelial progenitor cells is currently not yet feasible

for broad clinical applications, due to a series of open questions regarding the

deﬁnition of the relevant cell types and the transfer into practicable approaches,

which meet the clinical requirements.

2 Endothelial Progenitor Cells in the Neovascularization Process

For many years angiogenesis, the generation of blood vessels from the existing

vasculature through activation of proliferation and sprouting mechanisms in adult

endothelial cells, was considered as the exclusive pathway for blood vessel forma-

tion in an adult organism.

The understanding of blood vessel formation has changed in recent years,

mainly due to the discovery of so-called endothelial progenitor cells by Asahara

et al. [6]. They postulated that in the adult organism endothelial progenitor cells

contribute to de novo formation of blood vessels in a process described as vascu-

logenesis. Since then, vasculogenesis, the contribution of stem cells or endothelial

progenitor cells to de novo vascularization, has been discussed as a collateral

mechanism in neovascularization. Although the deﬁnition clearly differentiates

the two processes in the academic sense, both mechanisms seem to work hand

in hand in blood vessel formation and remodeling. Both pathways are coupled

through a series of mostly unknown signaling mechanisms guiding endothe-

lial progenitor cells to the sites of repair and inducing their differentiation and

functional integration into the vasculature [7].

202 S. Fuchs et al.

A signiﬁcant number of studies on endothelial progenitor cells have been

published over the last decade, deﬁning endothelial progenitor cells by surface

markerssuchasCD133andCD34[8–10], and a series of other characteristics

such as low density lipoprotein (LDL)-uptake [4] and binding of ulex europaeus

agglutinin (UEA) [6,11]. The ability to form vascular structures in proangiogenic

matrices in vitro, as well as the potential to contribute to the vascularization

in vivo have been deﬁned as functional key elements of endothelial progenitor

cells. Several sources, isolation procedures, and suggested marker proﬁles for

endothelial progenitor cells have been described, although there is still a lack of

consensus on which cell type would resemble the “true endothelial progenitor

cell” or might be preferred in terms of a therapeutical application. From a

practical point of view, suchacellwouldhavetofulﬁllaseriesofprerequisites

including: (1) origin from an easy obtainablesourceinconnectionwithaminimal

invasive procedure and (2) a good expansion capability not interfering with the

therapeutical potential. According to these requirements, endothelial progenitor

cells, in particular from peripheral blood or cord blood, have raised signiﬁcant

interest.

3 Diversity of Endothelial Progenitor Cell Populations

Experimental evidence from studies by Lin [12], Gulati [13], Hur [14], and

Ingram [15] suggested that endothelial progenitor cells from the peripheral

blood are a heterogeneous population of cells. Endothelial progenitor cells

from peripheral blood were classiﬁed by several groups according to their

order of appearance and morphological characteristics in early or late endothe-

lial progenitor cells [14]. Other synonyms for late endothelial progenitor

cells include outgrowth endothelial cells (OEC) [12], late OEC, blood OEC,

and endothelial colony forming endothelial cells. Although the isolation proce-

dure or the nomination of these subsets differs slightly amongst the individual

studies, the phenotypic and functional key features described for those cells are

more or less identical and are summarized in Table 1. This rather simple classiﬁ-

cation was at least a basis for the deﬁnition of blood derived endothelial progenitor

cells for subsequent studies using these cells for applications in tissue engineering

and regenerative medicine as described in this review.

The isolation of mononuclear cells from the blood by ﬁcoll gradient centrifuga-

tion followed by culture in a commercial available cell culture medium resulted in

cellular colonies with cobble stone-like morphology showing remarkable simila-

rities to endothelial cells in terms of the marker proﬁle and functional key elements

(Table 1).

Those cells appear at relatively low frequency in the peripheral blood [15,27,

28]. In contrast to these cells, so-called early endothelial progenitor cells make up

the majority of mononuclear cells derived from the peripheral blood and show a

more or less rounded to ﬁbroblast-like morphology. Although they express to some

Outgrowth Endothelial Cells: Sources, Characteristics and Potential Applications 203

Table 1 Overview of characteristics and functions

EPC OEC

Morphology Spindle shaped morphology [12,16,17]Cobblestone-like morphology [13,15,18,19]

Order of appearance After 7 days in culture [14,16] After 2–3 weeks in culture [12–14]

Marker proﬁle CD31+ [6,11,17]

CD45+ [17,20]

CD34+ [6,11,16]

CD14+ [13,16,17]

CD146[21]

CD133+ [8,9,22]

Flt-1 [14]

eNos[14]

vWF [14,19,23]

VE-Cadherin [11,14,17]

KDR [11,14,23]

CD36+ [12]

Tie2+ [6,13]

CD31+ [13,19,24]

CD45[20]

CD34+ [8,16,20]

CD14[13,16]

CD146+ [21,24]

CD133[20]

Flt-1 [14]

eNos [13,14]

vWF [14,19,24]

VE-Cadherin [12,14,24]

KDR [14,16,20]

CD36+ [12]

Tie-2+ [13]

Caveolin-1 [13,24]

Characteristics

In vitro Low proliferative potential [14,16,17]

No tube formation on matrigel [16,25]

High proliferative potential [14,16]

Tube formation on matrigel [16,25]

In vivo Vasculogenic potential through paracrine mechanisms [13]

Secretion of proangiogenic molecules [16]

High vasculogenic potential [13,14,26]

204 S. Fuchs et al.

extent relevant endothelial markers such as CD31 (compare Table 1), these cells do

not show the full marker proﬁle of endothelial markers or the functional features

typical for endothelial cells. Most of these cells still carry hematopoietic markers

such as CD45 (compare Table 1). Different studies have compared the early vs late

endothelial progenitor cells in terms of their characteristics. The isolation of OEC

has been reported from different sources such as human cord blood as well as adult

peripheral blood or from different species such as porcine [29], murine [30], and

canine [31].

Surprisingly, although only OEC showed the characteristics and angiogenic

potential of endothelial cells in vitro, both cell types contributed to the de novo

vascularization in vivo [14]. In a following study the same group provided addi-

tional data potentially explaining the discrepancies in the angiogenic potential of

early EPC in vitro and in vivo. In this study early EPC supported the angiogenic

activity of OEC in vitro [16] probably through paracrine mechanisms based on the

production of IL-8 and VEGF by early EPC. This cytokine production improved the

angiogenic activity of OEC in vitro. In addition, the invasion of OEC into angio-

genic matrices in vitro was positively inﬂuenced when both cell types were applied

mediated through activation of matrix metalloproteinases such as MMP-2 in OEC

and MMP-9 in early EPC. In the same study a synergistic effect was also docu-

mented for the neovascularization process in vivo by the application of both

populations in a hindlimb model. Subsequently, data from these studies are ques-

tioning the contribution of early endothelial progenitor cells to the neovasculariza-

tion process as a result of a true progenitor function in a strict sense including the

differentiation towards mature endothelial cells. It seems to be more adequate to

assume that only a small subset contained within this mixed population constitutes a

true endothelial stem progenitor cell with the ability to differentiate towards an

endothelial cell. On the other hand, the improvement of the vascularization pro-

cess by so-called early endothelial progenitor cells seems to be mainly the result of

other mechanisms such as the support of mature endothelial cells or true stem

cells by paracrine factors and other mechanisms which still need to be deﬁned

further.

4 Origin of OEC and Enrichment Strategies

Although it has been widely accepted that peripheral blood contains stem cells with

the potential to differentiate towards cells with endothelial phenotype there are still

a series of difﬁculties identifying their distinct origin. Several markers have been

suggested in attempts to deﬁne the origin of OEC or to isolate them in a more

speciﬁc manner from diverse mononuclear cell fractions. Nevertheless, most of

these surface markers result only in an enrichment of cell populations containing

OEC. In addition, some of these applied surface markers are not suitable to

distinguish progenitor derived endothelial cells from mature endothelial cells

circulating in the blood stream, as discussed in the following section.

Outgrowth Endothelial Cells: Sources, Characteristics and Potential Applications 205

Gulati et al. [13] isolated and identiﬁed OEC from the CD 14 negative fraction of

mononuclear cells from the peripheral blood. Other approaches used CD146 to isolate

cells with the characteristics of OEC from the cord blood and adult peripheral blood

[12,21]. The adhesion molecule CD146 is expressed in different types of endothelial

cells throughout the vascularization and is often used to identify circulating mature

endothelial cells (CEC) [32]. Delorme et al. used a combination of an adhesion step

in order to separate mature endothelial cells from the mononuclear fraction followed

by a magnetic separation step for CD146 positive cells. Using this approach they

identiﬁed two distinct populations in cord blood and in peripheral blood forming OEC

in culture CD146 positive EPC (CD146+, CD34+, CD45+, CD133+, or CD117+)

and CD146 CEC (CD146+, CD34+, CD45, CD133,orCD117).

The complexity of the problem of how to differentiate between endothelial cells

from the circulation and from cells which have been mobilized from the bone

marrow was highlighted by a study of Lin et al. [12]. This group investigated

OEC from recipients of gender-mismatched bone marrow transplantations. By in

situ hybridization, Lin et al. were able to identify endothelial cells from the

recipient making up the majority of endothelial cells in the early phases of the

culture. On the other hand, the donor derived endothelial cells constitute the major

population after 1 month of the cultures which was due to their high expansion

capacity (over 1,000-fold over 2 months). It was not possible to distinguish donor or

recipient derived OEC on the basis of a marker proﬁle, whereas the capability of

expansion was one of the remarkable differences of the two endothelial cell

populations found in the peripheral blood. Both endothelial cell types were positive

for CD36, indicating their microvascular endothelial phenotype. This microvascu-

lar phenotype of OEC was also supported by ﬁndings from other groups. Microvas-

cular characteristics of OEC were recently also supported by microarray data,

indicating that OEC are different from macrovascular cells, share similarities

with microvascular cells or might be even considered as an individual subclass of

endothelial cells [33].

Although CD133 is one of the markers suggested for endothelial progenitor

groups, cell sorting experiments provided evidence that OEC are not derived from

CD133 or CD45 positive cells but seem to be enriched in the CD34 positive, CD45

negative fraction [20].

Besides these surface marker based isolation strategies, another approach to

enrich OEC from the mononuclear fraction has been described recently [28]. By

including a passaging step (Fig. 1a) in the early phase of the culture of mononuclear

cells, the formation of OEC colonies was signiﬁcantly improved in one group of

cultures classiﬁed as high colony forming cultures. This simple protocol modiﬁca-

tion resulted in a signiﬁcant enrichment of OEC (Fig. 1b) and in a higher number of

OEC gained per individual donor. Although the reason for this effect has to be

further deﬁned, the protocol modiﬁcation might exert a positive effect, speciﬁcally

on such OEC with a high clonogenic potential, which have been described by

several groups as stated above.

Other groups modiﬁed the isolation protocols by using full blood preparations

omitting widely used centrifugation steps which resulted in an improved OEC

206 S. Fuchs et al.

colony formation. For the further expansion of these cells the same group estab-

lished culture conditions designed for a potential therapeutical use of OEC in

humans [34].

Isolation of OEC

blood plasma

Centrifugation Standard protocol

Ficoll

erythrocytes

Mononuclear cells

p1 p2… px

Appearance

of OEC Expansion

day 0 7x28

Discard non-

adherent cells

Mononuclear cells

Modified protocol Passaging step

Passaging step

Standard protocol Modified protocol

*of seeded MNC

generate OEC

colonies

0,0131 %*

Low colony-

forming culture1

High colony-

forming culture2

0,0010 %*0,0014 %*0,0024 %*

Low colony-

forming culture1

High colony-

forming culture2

1Low colony-forming culture: < 0,004 %

of seeded MNC generate OEC colonies in

culture with passa

step (n = 23)

2High colony-forming culture: > 0,004 %

of seeded MNC generate OEC colonies in

culture with passa

step (n = 23)

Fig. 1 (a) Schematic overview of the standard and the modiﬁed culture protocol according to

Kolbe et al. (b) Schematic overview on the effects of protocol modiﬁcation on the enrichment of

OEC from adult peripheral blood

Outgrowth Endothelial Cells: Sources, Characteristics and Potential Applications 207

Nevertheless, despite the advances in the understanding of endothelial progeni-

tor cell biology, the identiﬁcation and speciﬁc isolation of OEC from heterogeneous

peripheral blood cell populations remains also a technical problem due to their very

low frequencies in heterogeneous cell populations isolated from the peripheral

blood. Steurer et al. [35] recently compared real time PCR and ﬂow cytometry to

detect circulating endothelial cells and endothelial progenitor cells. Using deﬁned

numbers of circulating endothelial cells added to heterogeneous blood mononuclear

cells, detection limits were in the range of 0.001% for quantitative real time PCR or

0.01% for ﬂow cytometry. Despite the ten-times higher sensitivity of real time

PCR, the speciﬁcity of the real time PCR was lower due to the methodological

problems associated with this technology also due to the lack of markers exclu-

sively expressed on the relevant cell types.

5 In Vivo Evaluations of Angiogenic Potential of OEC

A series of studies investigated the in vivo potential of OEC for vascularization

strategies in tissue engineering and regenerative medicine. From these studies we

have learned that the successful formation of blood vessels depends strongly on the

experimental settings and the source of OEC as described in the following section.

Melero-Martin et al. [36] co-implanted OEC from the cord blood or adult peripheral

blood together with smooth muscle cells in matrigel plugs. Only in co-implantion

approaches blood vessel formation by OEC was observed, reﬂecting an active role

of the smooth muscle cells in the blood vessel formation or stabilization. The

angiogenic activity of the blood derived cells reduced with increasing numbers of

passages that the cells underwent during their expansion in vitro. Consistent with

the ﬁnding that the therapeutical potential correlates with cellular aging, cord blood

derived endothelial cells had a higher angiogenic potential then those derived from

adult blood. This observation was also conﬁrmed by Au et al. [37] although this

group used different experimental settings and co-implanted the endothelial cells

with 10T1/2 mouse embryonic ﬁbroblasts as stabilizing perivascular-like cells in

collagen gels. In this study, co-implantation with other cell types such as 10T1/2 had

no effect on the blood vessel formation itself. Nevertheless, the stability of newly

formed blood vessels formed by adult peripheral blood derived cells was relatively

impaired, so that these vessels regressed within the 3 weeks. Compared to this cord

blood cell derived vessels revealed a stability lasting over months. In another study

by Au et al. the critical role of stabilizing cells for the in vivo outcome of

transplanted endothelial cells was proven in another experimental set up based on

HUVEC as endothelial cell source and on bone marrow mesenchymal stem cells

functioning as cells with perivascular potential. Using collagen gels based

approaches, the blood vessel formation without mesenchymal cells (MSCs) was

negligible whereas the addition of those or of 10T1/2 ﬁbroblasts leaded to blood

vessels with a long-term stability [38].

208 S. Fuchs et al.

6 OEC for Vascularization of Complex Tissue Engineered

Constructs

Successful regeneration or replacement of complex tissues combines challenges in

biomaterial design, evaluation of therapeutically relevant cell populations, as well

as an improved knowledge of cellular and molecular mechanisms involved in tissue

repair. A fast and successful vascularization of such complex constructs is essential

for the tissue survival but still associated with severe problems especially in term of

larger or highly vascularized tissues such as bone or muscle. To overcome these

limitations in tissue engineering, different strategies have been developed, includ-

ing diverse delivery systems for angiogenic growth factors [39–41], as well as the

generation of prevascularized tissues by incorporation of endothelial cells [42–45]

or endothelial progenitor cells, recently also reviewed by [46]. Prevascularization

and anastomosis of bioengineered vascular structures with those in the peri-implant

tissue might be a suitable therapeutic approach to enhance or to accelerate the

vascularization as recently shown by Levenberg et al. for a muscle construct [47].

Although OEC seem to possess a promising angiogenic potential, the question,

how OEC could be applied for complex and properly vascularized tissue constructs,

has to be addressed from case to case depending on the ﬁeld of application. OEC

have been used to generate vascular network in skin substitutes based on decel-

lularized dermis [48,49] leading to the active perfusion of the skin constructs by

OEC derived blood vessels. Another potential application of outgrowth endothelial

lies in the generation of artiﬁcial blood vessels. Several groups have shown that the

coverage of artiﬁcial blood vessels with OEC seems to be an effective way to

overcome problems associated with thrombogenicity [50,51].

In other approaches, OEC have been combined with biomaterials serving as

scaffolds to deliver them to the site of the action. The bio-functionality of such

constructs has been assessed in vitro and in vivo. In a recent study the alginate

based delivery of OEC from human cord blood has been compared with the

application of OEC by bolus injection in an ischemic hindlimb model. Bolus

injection of OEC showed no therapeutical effect and resulted in necrosis and

foot loss. In contrast, the material based approach successfully induced the vascu-

lar reperfusion to normal levels within 40 days and prevented tissue necrosis [52].

This study showed a signiﬁcant advantage of material based delivery of OEC for

therapeutical applications.

Most of the studies described above were performed in matrigel or other gel-like

matrices; nevertheless the use of biomaterials depends on the ﬁeld of application

and is another critical element for successful vascularization strategies. In bone

tissue engineering, mechanical stability of scaffolding materials is considered as

one of the key features. Such scaffolding materials have to support the ingrowth of

vessels from the peri-implant tissue and should not interfere with the angiogenic

potential of endothelial cells included in the construct.

Furthermore, a series of studies emphasized the close association of bone devel-

opment and angiogenesis including a mutual information exchange of osteoblasts

Outgrowth Endothelial Cells: Sources, Characteristics and Potential Applications 209

and endothelial cells or their respective precursors [53–56] and a beneﬁcial effect in

bone formation by strategies improving the vascularization process in general.

Although the detailed mechanisms are still unclear, it seems that the co-culture

with the primary osteoblasts (pOB) or MSCs provides both a proangiogenic matrix

based on components such as collagen and the supply with angiogenic growth

factors such as VEGF leading to an angiogenic activation of endothelial cells

[57,58], as well as the inclusion of control mechanisms based on intercellular

communication [59–61]. These ﬁndings will probably result in new concepts in

tissue engineering, such as prevascularization strategies based on the natural inter-

action of cells as recently addressed by several authors [46,62–64]. From this point

of view, OEC might serve as a potential source of autologous endothelial cells in

applications in tissue engineering and regenerative medicine.

At present there are several arguments supporting the potential of OEC for bone

tissue engineering applications. First, OEC grow according to our experience on

any type of scaffolding materials, which supports the growth and the functionality

of endothelial cells in general, so that they could be applied to a series of biomater-

ials developed for bone tissue engineering. Furthermore, co-cultures of OEC with

primary human osteoblasts induce the organization of OEC into prevascular struc-

tures characterized by a deﬁned vascular lumen [65] also depicted in Fig. 2.This

beneﬁcial effect on the angiogenic activity of OEC in co-cultures with osteoblasts

can also be transferred to biomaterial based tissue engineering approaches proven at

both levels of investigation in vitro [66] and in vivo [67].

In addition, subcutaneous co-implantation of both cell types, OEC and primary

human osteoblasts in a matrigel plugs, improvedtheformationofactivelyper-

fused blood vessels by OEC compared to controls implanting OEC alone [67].

These ﬁndings can also be conﬁrmed in applicationsbasedonscaffolding mate-

rials such as starch polycaprolactone (SPCL) ﬁber meshes after subcutaneous

implantation [67].

Although the detailed mechanisms are still unclear, it seems that the co-culture

with the pOB provides both a proangiogenic matrix based on components such as

collagen [66] and the supply with angiogenic growth factors such as VEGF and

angiopoietin-1 [68], leading to an angiogenic activation of OEC. Another potential

effect in co-cultures of endothelial cells and other cells is the stabilization of

vascular structures mediated by the matrix components enabling the organization

of endothelial cells into matured tube-like structures with the basement proteins

collagen type-4 and laminin (Fig. 2), as has been shown before for co-cultures of

endothelial cells with ﬁbroblasts [69], smooth muscle cells [36,42], and MSCs [38].

Similar co-culture approaches by other groups using canine derived OEC and

mesenchymal stem cells co-implanted subcutaneously on collagen ﬁber mesh

scaffolds in a nude mouse showed both, a positive effect on the vascularization

process as well as on bone formation [70]. Although in this study no direct inﬂuence

of EPC on the osteogenic differentiation in terms of alkaline phosphatase activity

was observed, the improved vascularization per se seems to have a beneﬁcial effect

on the bone formation process.

210 S. Fuchs et al.

Fig. 2 Co-cultures consisting of outgrowth endothelial cells (OEC) and primary osteoblasts (pOB)

stained immunohistochemical for endothelial cell speciﬁc marker CD31 after 1 week: (a) cross

section of constructs derived from rotating cell culture vessels as described in Fuchs et al. 2007 and

after 3 weeks, (b) two-dimensional culture of co-cultivation. (c–f) Frozen sections of three-

dimensional co-cultures generated in a rotating cell culture vessel system for 3 weeks and stained

for laminin (c,d;green) and collagen IV (e,f;green). The endothelial marker vWF is stained in

red (c,e). Cell nuclei are counterstained with Hoechst (blue). Scale bars (a–f)=75mM

Outgrowth Endothelial Cells: Sources, Characteristics and Potential Applications 211

Nevertheless, despite their promising outcome, the above-mentioned studies

have to be considered as proof of principle studies. Many more studies are

needed, focusing on the underlying mechanisms of repair processes and the

reﬁnement of protocols to optimize cell isolation efﬁcacies and implantation

strategies before these approaches might be applied in clinical practice. In this

context, there is also an increasing demand for advanced test systems taking into

account the complexity of physiological processes during tissue regeneration.

Therefore, a series of co-culture models have been developed over recent years,

serving as therapeutical tools, but also as advanced in vitro models to mimic ways

of cellular interaction during the repair process and to identify potential targets

for therapeutical intervention.

The currently existing concept in tissue engineering is based on the compo-

nents scaffolds, cells, and growth factors to enhance and accelerate the repair

process. Some growth factors are already known as potential candidates for

a therapeutical intervention, other potential therapeutical options still have to

be identiﬁed, for instance by investigation of developmental processes often

recapitulated in repair processes in adult life [71–73]. Potential signaling path-

ways of interest in bone repair are wnt signaling pathways [74,75] mediating

developmental processes by secreted morphogens, as well hedgehog mediated

pathways [74] which is involved in the two fundamental processes in bone repair

angiogenesis [76] and osteogenesis [77–79]. Sonic hedgehog enhances both

processes simultaneously as it has been recently shown in co-cultures of OEC

and pOB [68].

7 Self-Endothelialization Strategies

For all the applications based on complex constructs as described above, OEC

have to be isolated and expanded in vitro. This is associated with certain risks

such as karyotype aberrations during the expansion of OEC [80] in vitro. Last, but

not least, in vitro expansion of OEC is time and cost consuming and often

incompatible with acute cell therapy of ischemic tissues. Therefore, other strate-

gies aim at a self-endothelialization of functionalized biomaterial surfaces by

attracting endothelial progenitor cells from the peripheral bloodstream as recently

reviewed in [81]. These approaches include the application of RGD sequences,

antibodies, etc. to generate artiﬁcial surfaces with a selective afﬁnity for circulat-

ing cells with endothelial capacity. Using phage display technologies to identify

peptide ligands that bind to OEC but not to human umbilical vein endothelial cells

[82], new potential approaches for material modiﬁcation have been suggested

[83]. Other groups used aptamers, single stranded nucleic acids identiﬁed by

systematic evolution of ligands by exponential enrichment (SELEX) with a high

afﬁnity to circulating CD31 positive cells to promote adhesion of cells with

endothelial characteristics [84].

212 S. Fuchs et al.

8 Conclusions

Endothelial progenitor cells and OEC in particular have raised new hopes as cell

sources for proangiogenic therapies. In recent years the picture of therapeutical

relevant cell types contained in heterogeneous endothelial progenitor cell cultures

became more evident. Nevertheless, although initial ideas concerning a potential

application in tissue engineering and regenerative medicine have been developed, a

lot of questions need to be answered. These includes aspects of basic endothelial

progenitor cell biology as well as the development of new therapeutical concepts by

the integration of multidisciplinary research areas.

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DOI: 10.1007/10_2010_66

#Springer-Verlag Berlin Heidelberg 2010

Published online: 23 March 2010

Basic Science and Clinical Application

of Stem Cells in Veterinary Medicine

I. Ribitsch, J. Burk, U. Delling, C. Geißler, C. Gittel,

H. Ju

¨lke, and W. Brehm

Abstract Stem cells play an important role in veterinary medicine in different ways.

Currently several stem cell therapies for animal patients are being developed and

some, like the treatment of equine tendinopathies with mesenchymal stem cells

(MSCs), have already successfully entered the market. Moreover, animal models are

widely used to study the properties and potential of stem cells for possible future

applications in human medicine. Therefore, in the young and emerging ﬁeld of stem

cell research, human and veterinary medicine are intrinsically tied to one another.

Many of the pioneering innovations in the ﬁeld of stem cell research are achieved by

cooperating teams of human and veterinary medical scientists.

Embryonic stem (ES) cell research, for instance, is mainly performed in animals.

Key feature of ES cells is their potential to contribute to any tissue type of the body

(Reed and Johnson, J Cell Physiol 215:329–336, 2008). ES cells are capable of self-

renewal and thus have the inherent potential for exceptionally prolonged culture (up

to 1–2 years). So far, ES cells have been recovered and maintained from non-human

primate, mouse (Fortier, Vet Surg 34:415–423, 2005) and horse blastocysts (Guest

and Allen, Stem Cells Dev 16:789–796, 2007). In addition, bovine ES cells have

been grown in primary culture and there are several reports of ES cells derived from

mink, rat, rabbit, chicken and pigs (Fortier, Vet Surg 34:415–423, 2005). However,

clinical applications of ES cells are not possible yet, due to their in vivo teratogenic

degeneration. The potential to form a teratoma consisting of tissues from all three

germ lines even serves as a deﬁnitive in vivo test for ES cells.

Stem cells obtained from any postnatal organism are deﬁned as adult stem cells.

Adult haematopoietic and MSCs, which can easily be recovered from extra embryonic

or adult tissues, possess a more limited plasticity than their embryonic counterparts

(Reed and Johnson, J Cell Physiol 215:329–336, 2008). It is believed that these

I. Ribitsch (*), J. Burk, U. Delling, C. Geißler, and H. Ju

¨lke

Translational Centre for Regenerative Medicine, Leipzig, Germany

e-mail: iribitsch@trm.uni-leipzig.de

U. Delling, C. Gittel, and W. Brehm

Large Animal Clinic for Surgery, Faculty of Veterinary Medicine, Leipzig, Germany

stem cells serve as cell source to maintain tissue and organ mass during normal cell

turnover in adult individuals. Therefore, the focus of attention in veterinary science

is currently drawn to adult stem cells and their potential in regenerative medicine.

Also experience gained from the treatment of animal patients provides valuable

information for human medicine and serves as precursor to future stem cell use in

human medicine.

Compared to human medicine, haematopoietic stem cells only play a minor role

in veterinary medicine because medical conditions requiring myeloablative chemo-

therapy followed by haematopoietic stem cell induced recovery of the immune

system are relatively rare and usually not being treated for monetary as well as

animal welfare reasons.

In contrast, regenerative medicine utilising MSCs for the treatment of acute

injuries as well as chronic disorders is gradually turning into clinical routine.

Therefore, MSCs from either extra embryonic or adult tissues are in the focus of

attention in veterinary medicine and research. Hence the purpose of this chapter is

to offer an overview on basic science and clinical application of MSCs in veterinary

medicine.

Keywords Animal models, Clinical stem cell applications, Embryonic stem cells,

Immunogenicity, Induced pluripotent stem cells, Mesenchymal stem cells, Regen-

erative medicine, Stem cell sources, Veterinary medicine

Contents

1 Basic Research: Origin, Functionality and Capacities of Mesenchymal Stem Cells . . . . . . 221

2 Stem Cell Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222

2.1 Bone Marrow . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222

2.2 Peripheral Blood .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . 224

2.3 Umbilical Cord Blood . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225

2.4 Stem Cell Recovery from Solid Mesenchymal Tissues . . . . . . . . . . . . . . . . . . . . . . . . . . . 226

2.5 Adipose Tissue . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . 227

2.6 Umbilical Cord . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . 228

2.7 Synovial Membrane . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . 230

2.8 Periodontal Ligament . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . 231

2.9 Skin ............................................................................... 232

2.10 Other Potential MSC Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . 233

3 Immunogenicity . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . 233

4 Clinical Applications of Stem Cells in Veterinary Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234

4.1 Tendon Injuries . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236

4.2 Osteoarthritis . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242

4.3 MSCs in Bone Regeneration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . 247

4.4 Spinal Cord Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250

4.5 Liver Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . 252

5 Future Prospects and Outlook . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253

6 Embryonic Stem Cells and Induced Pluripotent Stem Cells . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254

7 Animal Models . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . 255

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256

220 I. Ribitsch et al.

1 Basic Research: Origin, Functionality and Capacities

of Mesenchymal Stem Cells

Mesenchymal stem cells (MSCs) are a population of undifferentiated multipotent

cells isolated from adult tissue (e.g. bone marrow or fat), with the capacity to

differentiate into mesodermal lineages such as bone, cartilage, fat, and muscle

tissue [1–4] and the ability of self-renewal through replication [5].

MSCs participate in tissue regeneration by two distinct mechanisms. They

directly contribute to tissue repair by differentiating into speciﬁc cellular pheno-

types such as tendon or ligament ﬁbroblasts. Of equal importance to the direct

differentiation and production of matrix is the production of bioactive proteins by

adult stem cells. These factors include various growth factors, anti-apoptotic factors

and chemotactic agents that have profound effects on the local cellular dynamics,

producing anabolic effects, stimulating neovascularisation, and recruiting addi-

tional stem cells to the site of injury. Recruited stem cells may in turn differentiate

and/or produce additional biologically active peptides [6].

MSCs can be isolated and expanded with high efﬁciency (Fig. 1) and induced to

differentiate into multiple lineages under deﬁned culture conditions in vitro [2,7].

MSCs are typically spindle shaped resembling ﬁbroblasts [8].

Due to the lack of speciﬁc MSC markers which would allow an exclusive

deﬁnition of cells as completely undifferentiated stem cells or as lineage committed

cells [5], MSCs are identiﬁed through their ability to differentiate into multiple

lineages, their property to adhere to plastic in vitro and, in human medicine, through

a combination of positive expression (CD 105, CD 73, CD 90) or distinct lack (CD

34, CD 45) of typical cell surface markers [9]. However, in veterinary medicine the

characterization of stem cells is a bit more difﬁcult because most of the commonly

available cell surface markers do not cross react with the animal cells. Thus it is not

clear if results indicating a lack of speciﬁc surface markers are based on a true lack

of these markers or if the human directed markers simply do not cross-react with

animal cells [10]. Currently, adherence to plastic and trilineage differentiation

potential are the only way to identify MSCs in veterinary medicine [11].

Within the last few years the name “mesenchymal stem cells” has been used

very generally for any sort of mesenchymal progenitor cells. Recently the term

“mesenchymal stem cells” has been reviewed by the International Society of

Cellular Therapy who suggested to rather use the name “multipotent mesenchymal

stromal cells” in order to ensure an accurate denomination in scientiﬁc literature.

The term “mesenchymal stem cells” should be exclusively used for cells with

proven in vivo potential of long-term survival with self-renewal ability and the

capacity to repopulate multilineage tissue. A precise nomenclature of cell popula-

tions will enable a much more accurate comparison of results from different

investigators [11]. This is of particular importance in veterinary medicine since

differences between species always need to be considered. However, this distinc-

tion has not yet been generally accepted and therefore the term used by each author

has been maintained in this article.

Basic Science and Clinical Application of Stem Cells in Veterinary Medicine 221

2 Stem Cell Sources

In animals, and in humans, a lot of different tissues representing potential sources of

adult stem cells have been identiﬁed. Currently, bone marrow (BM) is certainly the

best researched source. Even though a lot of alternative sources of MSCs have been

described and investigated, bone marrow is still the most commonly used source to

recover stem cells [12,13].

In veterinary medicine not only the potential stem cell yield is important for the

deﬁnition of a good cell source but also species speciﬁc difﬁculties regarding

the process of stem cell recovery and the associated costs certainly need to be

taken into consideration. Therefore, the practicability of different stem cell sources

in veterinary clinical practice does not always correlate with the theoretically best

source from a cell yield and quality perspective. Nevertheless it has repeatedly been

described that there are signiﬁcant differences in MSCs from different tissue sources

and that ﬁndings from one species cannot necessarily be extrapolated to another [14].

In future the identiﬁcation of the optimal mesenchymal tissue as a source of

MSCs depending on the intended use and the animal species will play an important

role. Also the cell source to treat best a particular clinical condition is yet to be

discovered.

Until proven otherwise, bone marrow remains the most reliable source of

progenitor cells in veterinary medicine [15].

2.1 Bone Marrow

Isolation of bone marrow derived MSCs, also known as marrow stromal cells or

mesenchymal stromal cells [16,17], has been described in several animal species

[18] such as rabbits, mice and rats, horses [3], dogs [9,19], cats [20], pigs [21] and

cattle [22].

Bone marrow contains not only mesenchymal ﬁbroblast-like stem cells but also

a high amount of haematopoietic stem cells. The MSCs can easily be separated

from the haematopoietic cell fraction by culture and adherence to plastic dishes.

Fig. 1 Different stages of MSC culture (immediately after seeding, 30%, 70% and 100% con-

ﬂuency)

222 I. Ribitsch et al.

Primary bone marrow derived nucleated cells vary in morphology and include large

widespread, occasionally multi-nucleated cells and spindle shaped mononuclear

cells. With subsequent passages this degree of heterogeneity decreases and the

small spindle shaped ﬁbroblast like cells predominate [16]. In contrast, Giovannini

et al. [18] reported that MSCs obtained from equine bone marrow always display

the same ﬁbroblastic morphology.

Opinions regarding the quality of bone marrow as MSC source are controversial,

as there seem to be signiﬁcant differences between different species.

Even though it is reported that in mature individuals bone marrow is generally

the richest source of stem cells presently known in humans as well as animals [15],

Yoshimura et al. [14] found that the colony formation rate of primary bone marrow

derived MSCs in rats and humans seems to be lower than that of MSC derived from

other mesenchymal tissues. The number of primary colonies per nucleated cell from

synovium, periosteum, adipose and muscle tissue seems to be much higher [14].

An advantage of bone marrow derived stem cells is that they can easily be

passaged many times and over long time periods [15,23]. They also show good

differentiation potential. However, Vidal et al. [16] showed that adipogenesis of

equine bone marrow MSC is satisfying only after adding 5% rabbit serum to the

culture medium.

In bone marrow the achievable MSC yield also varies between different species:

canine and feline BM-derived MSC frequency, for example, is about 1 in 2.5 10

and 1 in 3.8 10

respectively, whereas in murine bone marrow MSC frequencies

range between 1 in 10.8 10

and 1 in 3.45 10

. In horses an MSC frequency of

1 in 4.2 10

is reported [16].

Ultimately, bone marrow is not an optimal source for MSC, because the collec-

tion procedure is painful and contains a non-negligible risk of haemorrhage and

infection as well as sepsis [18]. Additionally, in veterinary medicine there is a

relatively high safety risk for the veterinarian due to the collection modality in

particular collecting bone marrow from horses, which is either performed from the

patient’s sternum or tuber coxae (Fig. 2and 3).

Fig. 2 Bone marrow

collection from a horse’s

sternum

Basic Science and Clinical Application of Stem Cells in Veterinary Medicine 223

Bone marrow collection in a horse is usually conducted under standing sedation.

If bone marrow is collected from the tuber coxae the veterinarian is standing right

next to the patients hind leg and can easily be kicked. If the bone marrow is

aspirated from the horse’s sternum the operating veterinarian is kneeling under

the sedated horse and can therefore easily be kicked as well. Some horses also tend

to fall down either due to the relatively heavy sedation or in an attempt to hinder the

veterinarian from puncturing their sternum. This is associated with some risk for the

veterinarian (who might get caught underneath the horse) and the patient itself,

because the needle might be pushed further into the sternum when the horse’s chest

touches the ground.

In rodents, who play a major role in animal experiments, using MSCs we are

facing a different problem, as the collection and isolation of sufﬁcient amounts of

bone marrow MSCs is quite difﬁcult due to the small body size of the animals,

resulting in a limitation of the feasible number of in vivo experiments [14].

2.2 Peripheral Blood

Peripheral blood (PB) compared to bone marrow and solid tissue displays a safe and

virtually pain-free source for stem cell recovery.

Unfortunately, isolation and proliferation of ﬁbroblast like cells from PB

requires very sophisticated techniques. Only in mice, guinea pigs and rabbits can

standard isolation protocols as known for bone marrow derived MSCs be used [15].

In horses, Smith et al. [24] processed blood samples using a slightly modiﬁed

method as for equine bone marrow, but were not able to isolate ﬁbroblastoid cells.

This is in agreement with data obtained in human medicine and in canines,

where it was reported that the isolation and propagation of PB derived ﬁbroblast

like cells from mature individuals is difﬁcult [25]. A study on equine PB derived

stem cells performed by Koerner et al. [15] revealed that only 36.4% of the samples

Fig. 3 Bone marrow

collection from a horse’s

tuber coxae

224 I. Ribitsch et al.

gave rise to ﬁbroblastoid cells. In these samples only 1–5 cell colonies were

observed after 14 days. Giovannini et al. [18] used more sophisticated isolation

techniques and were able to isolate successfully ﬁbroblast like cells from 8 out of 12

PB samples (75% success rate).

Both Giovannini et al. [18] and Koerner et al. [15] found cells of different

morphologies in the initial culture. One group of colony forming units (CFUs)

consisted of cells with a more ﬁbroblastic shape whereas other cells in other CFUs

showed a more distinct polygonal morphology. Nonetheless, similar to bone mar-

row, the morphologic differences observed in the initial culture were lost after the

ﬁrst passage [18].

Another interesting ﬁnding was that, as a consequence of continued passaging,

equine PB derived stem cells either stopped proliferating or grew in a side by side

primary structure and a net-shaped secondary structure. After about ﬁve passages

the proliferation capacities of PB progenitors seem to cease [15].

In addition, the differentiation potential of blood derived MSCs seems to be

inferior compared to other stem cell sources as Koerner et al. [15] were not able to

induce chondrogenic differentiation. In contrast, Giovannini et al. [18] were able to

show that equine PB derived ﬁbroblast like cells do have the potential to differenti-

ate into the three common mesodermal lineages but only under specially optimised

differentiation conditions.

Moreover, equine PB progenitor cells proved very sensitive to trypsinisation as

well as cryostorage in liquid nitrogen and thawing [15], which signiﬁcantly alters

their usefulness in regenerative medicine in the long run. In addition, the limited

differentiation potential observed by Koerner et al. [15] as well as the slower

differentiation response towards cartilage and bone observed by Giovannini et al.

[18] indicate that PB derived ﬁbroblastoid cells might not be the same cells as bone

marrow MSCs.

2.3 Umbilical Cord Blood

Compared to human medicine, umbilical cord blood (UCB) collection has only

recently moved into the focus of interest in veterinary medicine. Therefore, experi-

ence in this ﬁeld is still very limited and mainly restricted to the horse. According to

our knowledge, UCB banking is only commercially available for horses.

In equine medicine it was shown that UCB can be collected without complica-

tions for either the foal or the mare at the time of foaling (Fig. 4a, b, c). The only

downside is that UCB can only be collected if a veterinarian or somebody else who

is capable of drawing blood is present at the birth, which often is not the case.

UCB stem cells show slightly different characteristics when compared to other

adult stem cells. They are proven to differentiate into cell types characteristic for

mesodermal and endodermal origins. Their ability to form hepatocytes suggests

that UCB derived cells may be more plastic than MSCs derived from other adult

Basic Science and Clinical Application of Stem Cells in Veterinary Medicine 225

tissues. In addition, Oct4 – a characteristic embryonic stem (ES) cell marker protein –

was identiﬁed in over 90% of the cell nuclei of equine UCB derived cells [26].

Compared to other cell sources like bone marrow and fat, the achievable MSC

yield from UCB is relatively low. Only in four out of seven UCB samples could

colonies with MSC morphology be detected. Additionally, and similar to humans,

the achievable number of primary cultures (between one and ﬁve) is relatively low

[13]. This was also conﬁrmed by Reed and Johnson [26] who reported that the yield

of adherent cells was poor.

Similar to PB and bone marrow, the morphology of cultured UCB cells varies

[13,26]. The recovered cell population was heterogeneous with typical slender and

elongated spindle shaped cells and cell clusters of cuboidal cells with shorter

cytoplasmatic extensions. It is not yet clear why undifferentiated cells show differ-

ent morphology and if they display different stem cell phenotypes [13,26].

Equine UCB derived MSCs can be successfully differentiated towards the

osteogenic, chondrogenic and adipogenic cell fate [13,26]. However, formation

of adipogenic [13,26] and muscle cells was not efﬁcient [26]. It was only possible

to induce adipogenic differentiation after adding rabbit serum to the culture

media [13].

In contrast to PB derived MSCs, it was reported that cryo preservation, thawing

and post thawing expansion had no negative inﬂuence on either cell morphology,

proliferation potential or differentiation capacity of UCB derived MSCs [13].

Based on that knowledge, and similar to human medicine, commercial storage of

equine UCB derived stem cells for later use for autologous stem cell transplantation

is available and might offer the same potential as in humans [13].

2.4 Stem Cell Recovery from Solid Mesenchymal Tissues

Sakaguchi et al. [27] reported that the colony forming efﬁciency of suspended cells

from solid mesenchymal tissues following collagenase digestion is about 100-fold

higher than that of bone marrow. This was conﬁrmed by Yoshimura et al. [14] who

reported that the yield and proliferation capacity of MSCs from solid tissues was

much better than from bone marrow.

Fig. 4 (a, b, c): Collection of equine umbilical cord blood

226 I. Ribitsch et al.

2.5 Adipose Tissue

Together with bone marrow, fat, which is more abundant and more easily accessible

than bone marrow [28] (Fig. 5), is the most frequently used stem cell source in

veterinary medicine. Unfortunately, evidence that fat derived stem cells are quali-

tatively and quantitatively comparable to bone marrow derived stem cells is still

missing. Regardless of that, stem cell therapies for animals (dogs and horses) using

fat derived cells for the treatment of osteoarthritis (OA) as well as tendon and

ligament injuries are already on the market. However, commercially available

“stem cell therapies” using fat derived stem cells cannot always be referred to as

real stem cell therapy. The MSC rate in the nucleated cell fraction of fat is very low

and only culture puriﬁcation and expansion leads to a sufﬁcient MSC yield. Hence

the application of the nucleated cell fraction without prior cell puriﬁcation and

expansion cannot be referred to as true stem cell therapy.

However, fat might be a useful alternative to bone marrow because it can easily

be obtained from subcutaneous tissue which is less invasive than a bone marrow

aspiration [13] and therefore associated with less risk and pain to the patient. In

addition it is usually available in large amounts [29].

Recently studies comparing MSCs from fat and bone marrow regarding their

quality and quantity performing FACS- and PCR-analysis as well as differentiation

and proliferation experiments were carried out in horses. It was conﬁrmed that the

differentiation potential of fat derived stem cells is similar to bone marrow derived

MSCs [30,31]. Comparing the yield of adherent cells, growth kinetics, cell

senescence and efﬁciency of gene transduction between MSCs from bone marrow

and MSCs from adipose tissue, it has been reported that there is no difference

between the cells derived from these two sources [32]. Interestingly, more recently

Conrad et al. [30] and Mundle et al. [31] in contrast demonstrated that MSCs

derived from fat show a twofold faster proliferation compared to bone marrow

MSCs in vitro. This was lately conﬁrmed by Dahlgren [6] who reported about a

higher frequency of stem cells in fat compared to bone marrow (2% vs 0.002%)

with an average cell yield of 450.000 per gram of fat and a higher proliferation rate.

Also Reich et al. [28] found a shorter population doubling time and faster migration

into an artiﬁcial wound area when comparing fat with bone marrow derived stem

cells.

Interestingly, this seems to be in contrast to humans as Sakaguchi et al. [27]

reported that MSCs derived from human adipose tissue had a lower proliferation

potential than other mesenchymal tissue derived MSCs. On the other hand, Kern

et al. [33] demonstrated a higher proliferation potential of human adipose tissue

derived MSCs. Regarding the number of colony-forming units [33] and population

doublings [29], fat is reported to be a better source of progenitor cells as well.

Comparing the MSC differentiation potential from different sources in vitro and

in vivo, MSCs from adipose tissue of rodents seem to have the lowest chondrogenic

potential [14,34] based on their reduced expression of bone morphogenetic protein

(BMP)-2, -4, -6 and lack of TGF-breceptors, which was also found in human adipose

Basic Science and Clinical Application of Stem Cells in Veterinary Medicine 227

tissue [35]. Also, canine adipose derived MSCs seem to have a lower chondrogenic

differentiation potential compared to bone marrow MSCs whereas the osteogenic

potential appeared to be comparable [28].

As expected, the adipogenic differentiation potential is obviously higher in

adipose derived MSCs than in MSCs from other sources [14].

2.6 Umbilical Cord

The umbilical cord (UC) matrix or Wharton’s jelly of humans and animals is

reported to be a particularly rich source of very young MSCs with high proliferation

ability (Fig. 6). The gelatinous connective tissue of the umbilical cord consists of

myoﬁbroblast like stromal cells, collagen ﬁbres and proteoglycans [10,36].

Umbilical cord MSCs have so far only played a minor role in veterinary science

and no clinical applications are known to date. However, promising results in

human medicine are already available and have prompted the ﬁrst veterinary

medical in vitro studies (mainly in equine medicine), which might serve as basis

for future studies and possible ﬁrst clinical applications.

Stem cell isolation from umbilical cord tissue (Wharton’s jelly) is easy and

practicable as a simple collagenase digestion of small, blood vessel free matrix

pieces is performed [36]. The average number of cells and CFUs calculated at the

end of the primary culture and the population doubling as well as fold increase of

umbilical cord derived stem cells are reasonably high [36].

In addition, they can be cryogenically stored and brought back into culturewithout

obvious changes regarding their growth or phenotypic characteristics [10,36].

Umbilical cord matrix cells show functional similarities to MSCs from other

sources [10,36]: It could be shown that the ﬁbroblast like cells can differentiate into

the three major mesenchymal lineages bone, cartilage and fat [36]. Interestingly,

again three morphological types of cells in the primary culture were observed

Fig. 5 Fat recovery location

in horses [145]

228 I. Ribitsch et al.

(Fig. 7): Large and occasionally multi-nucleated cells, small, spindle-shaped,

mononucleated cells and stellate cells. The large and occasionally multi-nucleated

cells disappeared after the ﬁrst passage and the small, spindle-shaped ﬁbroblastoid

cells predominated [36].

It was reported that UC MSCs express embryonic marker proteins like Oct-4,

SSEA-4 and c-Kit [10,36]. Therefore, it is hypothesised that they represent a

primitive phenotype between embryonic and adult stem cells [10,36]. This hypothesis

was supported by the ﬁndings of Mitchell et al. [37] who demonstrated that cells

isolated from porcine umbilical cord matrix are able to differentiate into cells that

morphologically resemble neurons and express proteins speciﬁc for neurons and

glia cells. In addition, Weiss et al. [38] showed that porcine umbilical cord matrix

cells express markers of mature neurons when transplanted into rat brain. Rat

umbilical cord matrix cells show similar properties and equine umbilical cord

matrix cells were also demonstrated to adopt a morphology typical for neurons

with axon and dendrite like processes upon culture in the right medium [10]. These

ﬁndings conﬁrm that MSCs from extraembryonic tissues are able to differentiate

Fig. 6 Isolation of MSC from

umbilical cord tissue via

migration onto culture dish

Fig. 7 Different MSC

morphology in primary

culture

Basic Science and Clinical Application of Stem Cells in Veterinary Medicine 229

into cells from distinct germ layers like mesoderm and ectoderm. Another indica-

tion is that a large subset of the cultured umbilical cord matrix cells remain in the

quiescent state which is related to self renewal ability [10].

Stem cells from extraembryonic tissues are furthermore expected to express low

immunogenicity and may, therefore, potentially serve as allogeneic donor cells in

thefuture[10]. However, trials proving the allogeneic applicability of extra-embryonic

tissue derived stem cells in regenerative medicine are still missing. Hoynowski

et al. [10] evaluated the expression of markers related to immunogenicity such as

HLA-ABC, HLA-1AG and MHC-11. Unfortunately, they were unable to conﬁrm

whether the lack of signiﬁcant expression was truly negative or if equine cells

simply do not cross react with the reagents developed for human cells.

All these ﬁndings indicate that the umbilical cord matrix seems to be a good

alternative to bone marrow. MSCs from the umbilical cord can be collected in a

non-invasive manner at birth and stored for future use [10,36]. The only downside

is that the maternal perineum and the delivery environment are certainly not sterile

[36], particularly referring to animals. Therefore, a sterile collection is challenging

and only samples cultured in a medium containing a relatively high amount of

antibiotics can be considered suitable for experiments and clinical applications.

2.7 Synovial Membrane

The synovial membrane (synovium) lines the inside of joint cavities, bursae and

tendon sheaths and regulates the content of the synovial ﬂuid which is contained in

these cavities. The ﬁrst successful extraction of MSCs from the synovium was

performed in humans by De Bari et al. [39]. According to Fan et al. [12] and

Yoshimura et al. [14], stem cells from the synovial membrane of humans and rats

excel other sources of MSCs in higher ability of proliferation and superiority in

chondrogenesis and adipogenesis. The achievable colony number per nucleated

cells was reported to be 100-fold higher than that of bone marrow derived rat MSCs.

Compared to other MSC sources, synovium-derived stem cells were also highest in

colony forming efﬁciency, fold increase and growth kinetics [14]. On the other

hand, they seem to be inferior in osteogenic capability compared to periosteal-

derived MSCs and bone marrow derived, but still superior in comparison to fat and

muscle derived stem cells [12,27].

In addition to the in vitro results, multiple reasons why it is assumed that

synovium derived MSCs are especially superior in chondrogenesis compared to

MSCs from other sources were reported.

Synovium derived MSC have a higher hyaluronan receptor expression and

express enzymes involved in hyaluronan synthesis, the synovial membrane is further

believed to contribute to repair of partial thickness cartilage defects [12] and

cartilage can be formed in pathological synovial tissue (synovial chondromatosis)

and synovial pannus of rheumatoid arthritic knee joints [12,14].

230 I. Ribitsch et al.

Moreover, synovium and cartilage originate from a common source of progeni-

tor cells and synovial tissue expresses a variety of cartilage speciﬁc markers [12].

A very interesting ﬁnding in particular for the treatment of tendon injuries is that

synovium derived MSCs can serve as hyaluronic acid blasters, avoiding adhesion, a

common complication in tendon injuries that can lead to scar tissue formation [12].

Although they can also be extracted from pathological synovium [12] and only a

minimal amount of synovial tissue is necessary for the extraction of a reportedly

high amount of MSCs, and in spite of the high regeneration rate of the synovium

which leads one to expect few complications at the donor site [12,27], the cell

recovery process by arthroscopy requires general anaesthesia and is therefore

associated with a relatively high risk for the patient, especially in large animals.

Furthermore, it would also be expensive. In addition, preparation of the synovial

tissue for stem cell extraction is not easy. It was reported that the separation of the

subsynovial tissue from the synovial tissue – which is required in order to obtain

homogenous cell culture – is difﬁcult. Another question regarding the quality of

MSCs from the synovium that needs to be addressed is the fact that some of them

seem to retain their ﬁbroblastic characteristics even after differentiation induction

[12]. Therefore, synovium might be a practicable MSC source in human but not

necessarily in veterinary medicine.

2.8 Periodontal Ligament

In equine orthopaedics, MSCs have attracted much notice because of promising

results of MSC treatments of superﬁcial digital ﬂexor tendonitis. However, recov-

ered tendons have inferior biomechanical properties compared to healthy tendons.

Consequently, a source of MSCs is needed which guarantees a high tenogenic

differentiation capacity. In this regard, the periodontal ligament (PDL) earns much

attention. Under physiological conditions, the equine PDL combines two remark-

able characteristics. It withstands high biomechanical strains presenting character-

istics similar to a tendon, and at the same time it possesses a high regenerative

capacity [40].

The periodontial ligament is situated between the tooth and the jaw bone and is

part of the complex that keeps a tooth in place in its alveolar cavity. In veterinary

medicine the PDL as source for MSCs was only described in rodents and horses.

In order to compensate for rapid surface attrition the hypsodont equine cheek

tooth erupts continuously which is inevitably associated with permanent remodel-

ling of the periodontium. Therefore, the periodontium shows a rapid cell turnover

compared to other soft connective tissues. The equine PDL for example shows a

proliferation index of 1–3% [41]. In addition, the functional requirements of the

PDL depend on ample capacity for dynamic changes regarding tissue synthesis

remodelling and repair. This is only possible because of the inherent capacity of the

periodontial cells to differentiate into osteoblasts, collagen-forming ﬁbroblasts or

cementoblast [42,43].

Basic Science and Clinical Application of Stem Cells in Veterinary Medicine 231

It has been proposed that the periodontium comprises a population of undiffer-

entiated progenitor cells which migrate either towards the cementum to differenti-

ate into cementoblasts or towards the alveolar bone to become osteoblasts [41].

Gould [44] and McCulloch [42] showed typical characteristics of these cells in mice

which strongly indicate that they indeed are stem cells. A population of progenitor

cells which may be stem cells was also found in the paravascular sites of the mouse

molar PDL [42].

Only recently these suggestions were conﬁrmed. MSCs in the periodontial

ligament of sheep and pigs – which were able to differentiate into a large variety

of cell lineages in vitro – were detected [45,46]. At the same time it was shown that

there seems to be a considerable difference between PDL derived and bone marrow

derived MSCs based on their higher expression of tenocyte speciﬁc transcription

factors [47]. Periodontal cells also showed signiﬁcantly higher capacities for self-

regeneration, i.e. number of CFUs, than cells from the subcutis, whereas the

population doubling time of subcutaneous cells seems to be signiﬁcantly faster

than those of PDL cells. All cells showed osteogenic and adipogenic differentiation.

Marker mRNA for chondrogenic differentiation (Aggrecan, Collagen 2, COMP)

was highly expressed by cells from the middle and apical areas of the PDL. In

contrast, in subcutaneous cells and PDL cells from the subgingival area the expres-

sion of chondrogenic marker mRNA was limited to Aggrecan and COMP. The

equine PDL contains cell populations that exhibit typical properties deﬁned for

MSCs. Cells from the apical and the middle areas showed higher differentiation

capacities than subgingival cells and subcutaneous cells [40].

Equine PDL cells might be a promising source for MSC-therapies in equine

musculoskeletal disorders [40]. However, the PDL contains only a small number of

progenitor cells [44], suggesting that the role as practicable MSC source in regen-

erative medicine needs to be questioned.

2.9 Skin

MSC derived from skin would be very easily accessible (regardless of the species)

with low costs and a low risk for both the patient and the veterinarian.

In juvenile and adult rodents it was shown that stem cells can be isolated from

the dermis. Interestingly, these cells seem to be able to differentiate into neuroec-

todermal and mesenchymal lineages, including neurons, glia, smooth muscle cells

and adipocytes. Based on these ﬁndings, rodent dermis derived stem cells are

distinct from MSCs. They can be passaged for at least one year without losing

their differentiation capacity and therefore probably represent a novel multipotent

adult stem cell type. They also clearly differ from adherent bone marrow derived

stem cells in the way that they require different growth factors to proliferate and

their selective ability to express proteins typical for neuronal precursors, as well as

their morphology and habit to grow in spheres. It is suggested that these precursor

cells represent a novel multipotent adult stem cell capable of generating cells from

232 I. Ribitsch et al.

more than one embryonic lineage [48]. However, further investigations will be

necessary to conﬁrm these ﬁndings.

2.10 Other Potential MSC Sources

Other potential sources of MSCs are muscle, brain [15,49], synovial ﬂuid [50],

tendon [51] or periosteum [14]. Although rodent models for these tissues exist, the

practicable isolation of these cells as a common stem cell type used in regenerative

medicine is doubtful.

Regarding the differentiation ability, it is remarkable that MSCs derived from

muscle produce only tiny pellets after chondrogenic differentiation [34]. However,

they show a good calciﬁcation potential after osteogenic differentiation [14] as well

as an easy differentiation to adipocytes [52]. According to Koga et al. [34] muscle-

derived MSCs have a higher proliferation potential than other stem cells [34].

Although the isolation of brain-derived MSCs after enzymatic digestion of the

whole brain is not a practicable way to harvest MSCs for tissue engineering

purposes, it is interesting to see that this stem cell type has a less efﬁcient adipogenic

proliferation potential [52].

MSCs isolated from the cambium layer of the periosteum have a high chondro-

genic proliferation potential which results in a greater production of cartilage

matrix. Regarding the calciﬁcation ability, it is not surprising that the periosteum-

derived MSCs have a high osteogenic proliferation potential [14].

3 Immunogenicity

The immunogenicity of adult MSCs is not completely understood. MSCs are said

to be hypo-immunogenic and to suppress T-cell activity and dendritic cell function

[8,11] in humans and animal models [8].

Normally, allogeneic cells would be rejected by immune response. Surprisingly,

immunologists found that MSCs do not seem to obey the normal rules of allogeneic

rejection. Evidence indicates that the use of mismatched MSCs does not provoke a

proliferative T-cell response, thus suggesting an immunosuppressive potential [8].

Krampera et al. [53] found that murine MSCs lack MHC class II and inhibit

T-cell activity. Furthermore, Tse et al. [54] showed in humans that MSCs do not

elicit allogeneic T-cell response even when MHC class II was upregulated. It was

also reported that allogeneic baboon MSCs suppress lymphocyte activity in vitro

and prolong graft survival, indicating the anti inﬂammatory and pro healing effect

of MSCs which was later conﬁrmed by Di Nicola et al. [55], Tse et al. [54] and

Krampera et al. [53].

MSCs appear to evade allogeneic rejection by being hypoimmunogenic, inter-

fering with maturation and function of dendritic cells, modulating CD4 and CD8

Basic Science and Clinical Application of Stem Cells in Veterinary Medicine 233

T-cell phenotype and response as well as natural killer cell activity and creating an

immunosuppressive milieu based on secretion of a variety of soluble factors [8].

Recently, allogeneic MSC transplantations were carried out in rabbits and

horses, showing no signiﬁcant difference compared to autologous transplants.

Autologous and allogeneic bone marrow derived MSCs in a ﬁbrin carrier were

implanted into rabbit Achilles tendons. In accordance with Guest et al. [56] it was

found that the distribution of inﬂammatory cells was similar in the allogeneic and

the autologous group. No apparent immune reaction such as lymphocyte inﬁltration

associated with the allogeneic transplantation was observed. Viable allogeneic

MSCs were detectable at 8 weeks post implantation [57].

In another study, autologous and allogeneic green ﬂuorescent protein (GFP)

labelled mesenchymal progenitor cells (MPCs) were injected into artiﬁcially cre-

ated superﬁcial digital ﬂexor tendon (SDFT) lesions in horses. A very interesting

ﬁnding was that no differences in either the number or distribution of autologous

and allogeneic cells as well as in the density of leukocytes at the respective injection

sites were observed. Injection of allogeneic MSCs did not lead to any immune

response from the host. Neither external nor histological signs of increased inﬂam-

mation were found compared to the autologous injection site [56].

Therefore, MSCs really seem to be immunoprivileged and one could possibly

provide a readily available source of allogeneic MSCs for regenerative medicine

purposes at least in veterinary medicine. What needs to be kept in mind, though, is

the inherent risk of disease transmission from donor to recipient [5]. However,

some day regenerative veterinary medicine might be able to rely on allogeneic cells

to repair or replace tissue [8].

4 Clinical Applications of Stem Cells in Veterinary Medicine

Stem cell therapy in veterinary medicine is gradually turning into clinical reality.

Especially in equine orthopaedics and small animals stem cell treatments are being

commercially offered (Fig. 8).

It was demonstrated that special chemokine receptors enable MSCs to respond to

signals produced by damaged tissues [56]. As a response to these signals MSCs

migrate into the damaged tissue and seem to induce regeneration of the respective

tissue. Therefore, a lot of hope and research emphasis is put into the newly evolving

ﬁeld of human as well as veterinary regenerative medicine.

However, not every treatment that is being advertised as stem cell therapy is

actually what it promises to be.

In many cases direct injection of crude bone marrow or nucleated cells isolated

from fat without further culture expansion is performed. This treatment is often

wrongly referred to as stem cell therapy, which might lead to misunderstandings [58].

As a matter of fact the transplant mainly consists of nucleated cells rather than

actual stem cells.

234 I. Ribitsch et al.

Herthel [59] for example reported that direct bone marrow injection for the

treatment of suspensory ligament (SL) injuries led to signiﬁcantly better results and

a decreased reinjury rate 92% of the bone marrow treated horses went back to

work compared to 84.8% that did not become sound or did not go back to work that

had received conventional treatment.

For multiple reasons the success of this treatment is questionable.

First of all, bone marrow contains only a small number of actual stem cells.

Therefore, the treatment cannot be referred to as actual stem cell treatment [5,24,

58]. Convincing studies show that only about 0.001–0.01% of mononuclear cells

isolated from bone marrow aspirate using Ficoll density gradient are MSCs. Hence

the number of MSCs in crude bone marrow would actually be even less than 0.001–

0.01%. In horses under 5 years of age it was shown that only 1–2 10

adherent

cells can be obtained from 10 mL of bone marrow aspirate after 3 days in culture [5].

Second, crude bone marrow might contain bone spicules and fat cells which can

be deleterious to tissue regeneration [24].

In contrast, injection of in vitro expanded MSCs provides a larger number of MSCs

than endogenously available or delivered by direct bone marrow injection and addi-

tionally avoids the risk of adverse effects of other bone marrow constituents [24].

Therefore, it is important to interpret cautiously results from studies using stem

cell treatment because the term “stem cell therapy” is not always used in the correct

way and might be misleading.

Passaging and

further

expansion

Stem cell isolation

Proliferation

Cell

har-

vest

Biopsy

MSCs

Genetic Engineering

Tissue Engineering

Implantation

Adherent cells

Fig. 8 MSC therapy principle

Basic Science and Clinical Application of Stem Cells in Veterinary Medicine 235

4.1 Tendon Injuries

In addition to in vitro studies and small animal experiments, it is certainly the horse

that veterinary research is focussed on concerning stem cell treatment of tendon

injuries.

Tendon injuries are a frequently occurring problem in the equine athlete (Fig. 9).

Due to the equine quadruped-speciﬁc anatomy characterised by the proximally

located muscles and the distally located long SDFT, deep digital ﬂexor tendon

(DDFT) and SL in combination with the hyper-extended metacarpophalangeal

joint, equine tendons and ligaments are exposed to enormous forces during athletic

workout. Maximal strains in the SDFT are reported to be at 16%, which comes up to

the functional limit, during galloping in thoroughbreds [60].

After suffering a clinical injury, a short inﬂammatory phase is observed in the

tendon, followed by the creation of ﬁbrous scar tissue. This scar tissue lacks

elasticity compared to healthy tendon and therefore the risk of re-injury is high

[61]. Outcomes following conventional treatment regimes unfortunately are rather

poor [62]. As stem cell therapy encourages the regeneration of functional tendon

tissue rather than scar tissue, it is expected to reduce re-injury rates [56]. Two

possible theories regarding the effect of stem cells are discussed. One possibility is

that they differentiate into tenocytes within the tendon environment and support

healing via collagen production and remodelling activities. The second possibility

is that the injected cells supply growth factors rather than differentiate terminally

into the required tissue [57,60].

It is proposed that the introduction of MSCs into the tissue which contains the

required cell type, in addition to the adequate mechanical environment, provides the

best stimulus for appropriate differentiation [24]. In case of stem cell treatments for

tendon or ligament lesions it is suggested that tensional mechanical load is neces-

sary for an optimal formation of organised tendon and ligament matrix [63].

Therefore, equine tendinopathy, with its typical centrally-positioned damage

surrounded by relatively intact tendon tissue or at least the thick paratenon offers

Fig. 9 Equine tendinitis of

the SDFT (courtesy of Dr.

Johannes Edinger)

236 I. Ribitsch et al.

perfect conditions for stem cell applications (Fig. 10, 11 and 12). Abundant growth

factors are also involved in early tendon healing and provide a perfect graft bed for

the injected MSCs. However, treatments of other forms of injuries are more

problematic mainly because accurate placement of the cells and cell retention is

more difﬁcult [24].

In many cases direct intratendinous injection of crude bone marrow to support

tendon healing is performed, which was ﬁrst reported by Herthel [59]. Although the

results of this study were favourable compared to conventional treatment, the

success of this technique is questionable for multiple reasons which have already

been discussed above. In addition, injection of large volumes of bone marrow might

even exacerbate the tendon injury, due to disruption of remaining intact tendon

tissue [24].

There are two different approaches of stem cell therapy that are clinically used

for the treatment of equine tendon disease: one is to apply isolated and expanded

bone marrow-derived MSCs, the other is to implant adipose-derived nucleated cell

(ADNC) fractions [60] or adipose derived expanded MSC.

The latter technique was tested in a small controlled experimental study with

eight horses suffering from collagenase-induced tendinitis. Five days after creation

of the SDFT lesions, adipose tissue was harvested from the paraxial caudodorsal

gluteal region under standing sedation and local anaesthesia. Collagenase digestion

and serial centrifugation was used to isolate and purify the ADNC fractions which

were then resuspended in phosphate buffered saline (PBS) solution, in order to be

injected only 2 days after adipose tissue harvest and 7 days after the lesions were

created. Four horses obtained ADNC-treatment, the others served as control.

Ultrasonographic and, 6 weeks later, gross and histologic examination revealed

an improvement in structural organisation and a reduction of inﬂammation in the

ADNC-treated tendons compared to the controls. Gene expression for COMP was

also signiﬁcantly increased (concentrations of COMP, a noncollagenous glycopro-

tein, are positively correlated with ultimate tensile strength and stiffness in equine

tendons). However, analysis of collagen revealed no signiﬁcant differences

between the two groups [64]. Unfortunately, although this technique is widely

Fig. 10 Core lesion in an

equine SDFT

Basic Science and Clinical Application of Stem Cells in Veterinary Medicine 237

used in the USA, there seems to be little information concerning the clinical

outcomes available so far. Dahlgren [6] reported that a total of 78% of sport horses

have returned to their previous level of performance and 69% of race horses have

returned to race more than once. Also Leppa

¨nen et al. [65] showed some promising

results after the application of enriched adipose derived stem cells in treatment of

equine tendon and ligament injuries. Signiﬁcant improvement in ultrasonographic

ﬁbre alignment scores and echogenicity scores were found during the follow-ups at

1, 3 and 6 months after the treatment. After a year from the injury 85% of the horses

in the recovery population (n¼31) were back to competing and 75.9% of all

patient owners included in a survey (n¼44) reported excellent or good satisfac-

tion, no signiﬁcant adverse effects being reported [65].

These results are promising indications of good clinical success using the

procedure. The full potential of adipose-derived adult stem cell technology will

become evident in the coming years [6].

The major advantage of using ADNCs would be the immense reduction of the

interval from tissue harvest until cell application which minimises the cost and

simpliﬁes laboratory procedures. Studies have revealed that approximately 80% of

the cells isolated from human lipid aspirates are multipotent MSCs [64]. However,

this has not yet been conﬁrmed for the horse, and therefore this kind of treatment

should not be referred to as stem cell therapy in the narrow sense.

Another approach, using BM-derived MSCs, is performed according to a tech-

nique reported in [24]. By now, some aspects of this technique have been modiﬁed.

To name the most considerable ones, ﬁrst the number of injected cells rose from

500,000 cells mentioned by [24] to approximately 10 10

cells [61,66,67].

Pacini et al. [66] observed that a cell number of less than 1 10

was insufﬁcient

for tendon healing. Second, while Smith et al. [24] used fresh autologous plasma to

resuspend the cells before injection, nowadays citrated bone marrow supernatant is

applied, which has stimulatory effects on the injected cells and, due to the diffusion

of the citrate, clots after injection [68]. Nevertheless, there are also other

approaches, such as using PBS [67], autologous serum [66] or ﬁbrinogen [69].

Fig. 11 Sonography of a core lesion in an equine SDFT. (a) Transversal view. (b) Longitudinal

view (courtesy of Prof. Roger Smith)

238 I. Ribitsch et al.

In a more recent study, eight horses with naturally occurring SDFT injury were

used. Autologous bone marrow derived MSCs were expanded in vitro, suspended in

citrated bone marrow supernatant and 1 10

implanted into the damaged SDFT

of four horses under ultrasound guidance. Saline was injected into four controls.

Horses received controlled exercise and were euthanised after 6 months. However

markers of regeneration in tendon were not identiﬁed but a normalisation of

biomechanical (reduced stiffness), histological (lower scores) and compositional

parameters (lower GAG content) towards those levels in normal (or less injured)

tendon could be considerable surrogate markers of regeneration. MSC implantation

results in a tissue more like normal matrix rather than ﬁbrous scar tissue formed

after natural repair (Fig. 12a, b). MSC-treated SDFT had greater elasticity than

saline-treated SDFT ( p<0.05). Cross-sectional area of MSC-treated tendons was

lower than saline-treated tendons ( p<0.05). Histologically, MSC-treated tendons

had improved cellularity and organisation scores at the injured site and were

comparable to uninjured sites of the treated tendon. In the MSC-treated SDFT,

collagen-linked ﬂuorescence was higher and DNA content lower than the saline-

treated SDFT (p<0.05). Collagen and GAG content was lower in MSC-treated

SDFT but not signiﬁcantly. The evidence of optimised healing seen experimentally

is supported clinically where a reduction in re-injury rate was found [70].

To date, initial reports describing long-term results of stem cell treatment of

tendinous lesions in horses as clinical patients have been published [61,66]. Results

are favourable. Pacini et al. [66] reported a success rate of 90% following MSC

treatment of SDFT lesions in 10 race horses, showing that horses successfully

returned to their previous level of competition without re-injuring for more than

2 years, while in the non-MSC-treated control group, re-injury occurred in all

horses after a median time of 7 months [66]. The biggest clinical trial – with 500

cases of MSC-treated SDFT lesions involved, with long-term follow-up in 82 race

horses and in 24 other sports horses – was presented by Smith [61]. Investigating

re-injury rates after a 48-week rehabilitation, only 13–36% of the horses re-injured,

Fig. 12 (a) Equine tendon after conservative treatment – obvious scar tissue formation. (b) Equine

tendon after MSC therapy – no scar tissue formation (courtesy of Prof. Roger Smith)

Basic Science and Clinical Application of Stem Cells in Veterinary Medicine 239

including injuries to the contralateral untreated limbs. These results were compared

to success rates of 23–66% in all horses after more than 2 years of full work

following conventional treatment, published by Dyson [71] and Smith [61]. Own

experiences with MSC-treatment of equine tendinous lesions are based on 120

cases, whereof 35% had SDFT lesions and 56% were affected in the SL; success

rates for the ﬁrst group were nearly 80% and over 70% for the second group, these

being horses that had returned to their previous level of performance and horses that

were in full training [72].

Considering these promising results, it is important to point out that the time of

cell injection plays an important role in the success of the treatment. Based on

clinical experience, it is suggested that the optimal time for implantation of MSCs is

1–2 months after injury, when a suitable granulation bed has formed and before

ﬁbrosis is dominating [68].

Besides the encouraging clinical outcome, the ultrasonographic and post mortem

examinations of either clinical [61,73] or experimental studies [56,64,67,69] also

provide promising results. In most cases, ultrasonography revealed that MSC-

treated lesions ﬁlled in more quickly [73] and showed a linear striated pattern in

the longitudinal view [61]. However, Schnabel et al. [67] could not ﬁnd any

signiﬁcant differences between the treated and their control groups.

Histological ﬁndings showed that treated lesions appear to heal excellently and

organised collagen ﬁbres in a crimp pattern were found [61,67] (Fig. 13a, b, c, d).

In the study conducted by Schnabel et al. [67], the effect of Insulin-Like Growth

factor I gene transfer to the MSCs was tested additionally, but no signiﬁcant

differences between tendons treated with IGF-I gene enhanced MSCs (AdIGF-

MSCs) and unmodiﬁed MSCs could be detected. Schnabel et al. [67] also examined

mechanical properties, anabolic and catabolic gene expressions, as well as DNA,

glycosaminoglycan and total collagen content. Although the treated tendons were

stiffer than the controls, and AdIGF-MSC-treated tendons showed an increased

gene expression of the catabolic MMP-13, there were no signiﬁcant differences in

all of these parameters. These results suggest that the predominant effect of MSCs

on tendon healing is administered through structural organisation.

Another interesting study investigated the possibility of allogeneic MSC appli-

cation. Autologous and allogeneic GFP labelled MPCs, isolated from bone marrow,

were injected separately into SDFT lesions which had been artiﬁcially created using

a synovial resector blade. At 10 and 34 days after the treatment, no gross and

histological qualitative differences between the control lesions and those treated

with MPCs could be found in post mortem examinations, which might be due to the

short period of time after cell injection. In both cases large aggregations of

disorganised cells as well as completely acellular areas within the lesions were

detected with haematoxilin and eosin staining. Most labelled cells were located

within the MPC-treated lesions, and some were well integrated into the crimp

pattern of adjacent healthy tendon areas. A very interesting ﬁnding was that

no differences in either the number or distribution of autologous and allogeneic

cells as well as in the density of leukocytes observed at the respective injection sites

were observed, and neither external nor other histological signs of increased

240 I. Ribitsch et al.

inﬂammation were found compared to the autologous injection site. This indicates

that injection of allogeneic MSCs did not lead to any immune response from the

host [56].

In a similar small animal study, autologous and allogeneic bone marrow derived

MSCs in a ﬁbrin carrier were implanted into rabbit Achilles tendons. In accordance

with Guest et al. [56] it was found that the distribution of inﬂammatory cells was

similar in the allogeneic and the autologous group. No apparent immune reaction

such as lymphocyte inﬁltration associated with the allogeneic transplantation was

observed. This seems to conﬁrm that MSCs do not cause alloresponses due to

attributed mechanisms such as hypoimmunogenicity and the prevention of normal

T-cell responses. Viable allogeneic MSCs were detectable at 8 weeks post implan-

tation. At 3 and 6 weeks following implantation, the cells were shown to migrate

around the repair site but in contrast to Guest et al. [56] no migration into the

proximal or distal normal tendon was found. Collagen ﬁbres seemed more orga-

nised with denser collagen I structures and better biomechanical properties in early

tendon healing. At 6 and 12 weeks, however, no differences were detected com-

pared to the group treated with the ﬁbrin carrier alone [57].

Crovace et al. [74] also evaluated the efﬁcacy of local injection of allogenic

MSC but in an ovine Achilles tendinitis model. The tendons injected with

Fig. 13 (a, c) Histology of an MSC treated tendon. (b, d) Histology of a normal tendon

Basic Science and Clinical Application of Stem Cells in Veterinary Medicine 241

allogeneic red ﬂuorescent protein labelled stem cells in ﬁbrin glue showed better

architecture of collagen ﬁbres and higher expression of Collagen I compared to

control tendons. Moreover, no red ﬂuorescent protein labelled cells were detected

in control tendons [74].

As in the studies mentioned above, current investigations of tissue engineered

tendons are based on histological and mechanical properties (Fig. 14a, b), due to a

lack of speciﬁc markers that characterise tendon ﬁbroblasts. A recent study is now

analysing a panel of marker genes, which are, in combination, characteristic for

adult tendon tissue. Suggested markers are COL1A2, scleraxis and tenascin-C,

whereof low expression of tenascin-C and high expression of the former ones

distinguish tendon tissue from bone or cartilage [75].

Based on this knowledge, it might be possible to evaluate objectively tendon

neogenesis after stem cell application. Further controlled studies will reveal the

treatment success with different progenitor cell types, with or without modiﬁcation,

so that optimal tendon tissue promoting MSCs can be identiﬁed.

4.2 Osteoarthritis

Osteoarthritis (OA) is a degenerative joint disease with intermittent inﬂammatory

episodes. It is induced by mechanical and biological factors interfering with the

normal balance between cartilage synthesis and degradation. These factors,

together with inﬂammatory episodes, lead to softening, ﬁbrillation and degradation

of the cartilage surface, as well as to a loss of articular cartilage and sclerosis of the

subchondral bone in conjunction with osteophyte formation [146] (Fig. 15a, b, c).

The disease can be inherited or induced by one major trauma, several microtraumas

or strenuous exercise [76], and leads to pain and decreased range of motion.

OA is the most common human and animal joint disease encountered world-

wide. Therefore, MSC therapy for OA is of interest for both human and veterinary

medicine and results obtained from research in animals will serve as baseline for

clinical trials in humans. Unfortunately, no experimental models that really resem-

ble the pathology of spontaneous OA are available.

However, for single site cartilage defects, several animal models are available.

Fig. 14 (a) Core lesion in an equine SDFT – typical haemorrhage. (b) Normal equine SDFT

242 I. Ribitsch et al.

When choosing a certain species for an OA research study one needs to consider

anatomical, physiological and biomechanical aspects as well as availability,

handling, ethical concerns and, last but not least, economic aspects.

Rodents are rarely used for cartilage defect models, due to their knee joint size

and physiology (growth plates do not close). Rabbits are a useful species for early

cartilage defect research; however, important differences in size and physiology

minimise their applicability (spontaneous cartilage regeneration in young indivi-

duals). Furthermore, dogs can be used for OA research, since they can have defects

exclusively involving cartilage tissue (without damaging the subchondral plate),

second look arthroscopy can be performed and anatomy and weight bearing is

similar to human conditions. But relatively small defect volumes and ethical issues

make the dog a less often used species. Small ruminants (sheep and goat) are more

commonly employed for preclinical studies as joint anatomy and biomechanical

aspects resemble the human situation. A debatable issue is the sheep’s variable

cartilage thickness (0.4–1.68 mm in different studies) that can produce variable

results within the same study. Cartilage thickness seems to be less variable in goats,

allowing partial and complete thickness defects. Pigs are a seldom used species for

research, due to difﬁculties with handling and behaviour. The horse represents the

largest available animal model and probably the species with most anatomical

similarities to humans [77]. Comparable to humans, horses tend to develop sponta-

neous joint disorders. This is an essential aspect for clinically relevant OA as there

might be differences between spontaneous long-lasting and experimentally induced

development of OA [78]. Furthermore, cartilage thickness in the equine stiﬂe joint

approximates 1.75–2 mm and is therefore comparable to cartilage thickness in the

knee of humans, which approximates 2.2 mm. Nevertheless, the differences in

human and equine body weights might result in different weight bearings and

biomechanical properties within the knee joints [77]. Frisbie et al. [76] compared

different animal models with regard to cartilage thickness in the knee joint and

observed that the horse is most similar to the human, followed by goat, sheep, dog

and ﬁnally rabbit.

Fig. 15 Extensive cartilage

defect (courtesy of

Dr. Johannes Edinger)

Basic Science and Clinical Application of Stem Cells in Veterinary Medicine 243

In veterinary orthopaedics in general, but especially in horses and dogs, joint

disease plays a major role. Joint diseases are the most prevalent causes of lameness

in horses [79,80]. Degenerative forms of arthritis constitute approximately one

third of all equine lameness, and OA is certainly the most important one [81]. The

reasons for the development of OA are not yet fully understood. It is assumed that

injury, age and genetics are some of the risk factors [82].

Several epidemiologic studies have shown that lameness due to joint disease is

the most signiﬁcant factor responsible for inability to race and loss of performance

in horses [83]. Thus, OA not only has a major impact on equine performance [84,

85], causing morbidity and pain, but is also a major cause of economic loss [86].

Unfortunately, articular cartilage shows only minimal regeneration potential as

there is a limited response of cartilage to tissue damage and an inability of natural

repair response from adjacent tissues to produce cartilage tissue with morphologic,

biochemical and biomechanical properties of healthy articular cartilage. Current

treatments include a wide range of non-pharmacological, pharmacological and

surgical modalities. Evidence to support the effectiveness of individual treatments,

however, is variable [87]. Therefore, the prognosis for patients suffering from OA is

still poor. The goals of contemporary management of the OA patient remain control

of pain and improvement of joint function as well as of quality of life. However,

there are no effective pharmacological therapies available that alter the pathobio-

logic course of the disease [88]. Therefore, major attempts have been made during

recent years to assess the efﬁcacy of regenerative treatments for OA.

For cartilage repair, chondrocytes seem to be the preferred cell type. It is

possible to harvest cartilage, isolate the chondrocytes and expand them in vitro.

These cells can later be transplanted as fresh or cryopreserved cells. Seddighi et al.

[89] found that cartilage engineered with fresh chondrocytes contains more cells

and extracellular matrix than constructs engineered with cryopreserved cells. The

chondrocytes can be implanted into an existing cartilage defect under a periosteal

covering graft [90] or seeded on a collagen membrane which is then transplanted

into the cartilage defect [91]. Litzke et al. [92] performed autologous chondrocyte

transplantation (ACT) in an equine large animal model. They could show that in

comparison to untreated defects, ACT-treated defects had a signiﬁcantly improved

defect ﬁlling with well integrated neocartilage.

However, because of the limited cell amount in donors, terminated life span and

possible de-differentiation of chondrocytes during the culture period, alternative

cell types with chondrogenic potential need to be found.

Currently, adult MSCs are being evaluated for various therapeutic approaches in

OA treatment [1,93].

Well known and practicable sources for MSCs with promising chondrogenic

potential are bone marrow [3] and UCB [13,18]. PB was also used but, in compari-

son to the other sources, yields were much lower and chondrogenic differentiation

was difﬁcult to achieve [15].

It has been shown that MSCs in general – when exposed to TGF ß (Transforming

growth factor) – are capable of chondrogenic differentiation and production of

collagen type 2 and proteoglycan – two major factors needed for cartilage repair

244 I. Ribitsch et al.

[1,3,4]. Furthermore, Hegewald et al. [94] found that hyaluronic acid and autolo-

gous synovial ﬂuid induce chondrogenic differentiation and collagen type 2-produc-

tion of equine MSCs. Chondrogenic differentiation is also supported by bone

morphogenetic protein-4 (BMP-4). In a study conducted by Kuroda et al. [95],

muscle derived stem cells, transduced to express BMP-4, were mixed with ﬁbrin

glue and implanted into cartilage defects. The results of this treatment showed

improvement of cartilage repair up to 24 weeks after transplantation. All these

ﬁndings suggest that MSCs may be used as a therapeutic agent in OA.

Currently, different techniques exist for the transplantation of MSCs into carti-

lage defects.

There is the possibility of transplanting differentiated [96] or undifferentiated

MSCs, with or without a scaffold. For the implantation without a scaffold, cells can

be suspended in various ﬂuids and injected blindly or arthroscopically. Further-

more, they can be ﬁxed with ﬁbrin glue to a certain location. Scaffolds consist of

natural or synthetic materials and are usually ﬁxed onto the defect site by suturing,

press-ﬁt and/or ﬁbrin glue. MSCs are loaded onto the scaffold either before or

immediately after the implantation into the defect and are supposed to expand,

differentiate, and produce cartilage matrix.

Nowadays, the intra-articular injection of suspended cells is the most practicable

way and therefore most common cell application mode for veterinarians. Agung

et al. [1] injected ﬂuorescent-labelled MSCs into rat knee joints with multiple

injured tissues (anterior cruciate ligament, medial meniscus and articular cartilage

of the femural condyles). Four weeks after injection, they found that MSCs mobi-

lised into some or even all injured tissues depending on the initial number of

injected cells. When 1 10

MSCs were injected cells migrated only into the

injured anterior cruciate ligament (ACL). When 1 10

MSCs were injected, cells

Fig. 16 (a) Naturally occurring osteoarthritis – extensive cartilage degeneration with typical

wearlines. (b) Naturally occurring osteoarthritis – extensive cartilage degeneration with typical

wearlines after Indian ink staining

Basic Science and Clinical Application of Stem Cells in Veterinary Medicine 245

were also found in the injured meniscus and articular cartilage, with extracellular

matrix present adjacent to the injected MSCs. However, it was shown that injection

of larger numbers of MSCs led to the formation of free scar tissue within the joint,

which might have adverse effects on cartilage regeneration. Therefore, determining

the optimal number of cells to be injected is essential to minimise problems

resulting from unrequested tissues. Regardless of the questions that still need to

be solved, Ferris et al. [97] reported about their results of a clinical evaluation of

bone marrow derived MSCs in naturally occurring joint disease in horses. Of the 40

horses integrated in the study, 72% returned to work. About half of them returned to

or even exceeded their previous level of work. They also found that age, sex, breed

and discipline were not signiﬁcantly associated with outcome. Only the severity of

the injury, as classiﬁed by the attending veterinarian, was signiﬁcantly associated

with a return to work as four horses who had severe cartilage damage were unable

to return to performance. This study conﬁrms anecdotal reports of good clinical

outcome post MSC treatment for joint related lesions. Results of this study support

future controlled trials to be undertaken for the use of MSCs in horses [97]. Also

dogs suffering from OA in their elbow and hip joints were treated with adipose

tissue derived cells resulting in an overall clinical improvement of the patients [147,

148]. However, in an equine OA model no difference in lameness improvement

between horses treated with MSCs from bone marrow and nucleated cells from

adipose tissue [98] was found.

Oshima et al. [99] transplanted undifferentiated green ﬂuorescence protein-

marked mesenchymal cells (MCs) rigidly into an osteochondral defect in rats

using ﬁbrin glue. It was shown that there were still some marked MSCs in the

defect for as long as 24 weeks after transplantation. Also the defects showed better

repaired with hyaline-like cartilage than untreated defects.

Wilke et al. [100] implanted undifferentiated MSCs arthroscopically in a self-

polymerising autologous ﬁbrin vehicle. The advantage of this technique is the one-

step surgical procedure, requiring only one arthroscopy under general anaesthesia.

They observed that MSC grafts in horses did improve early healing (1 month) of

full thickness cartilage lesions, but the long-term healing (8 months) did not

improve compared to untreated defects.

Recently, another new technique of transplanting cells into rabbit cartilage

defects, called local adherent technique, was described [34]. Undifferentiated

MSCs in suspension were directly placed on the cartilage defect. The defect

is pointing upwards and is held stationary for approximately 10 min to allow

cell adherence. This easy technique can also be performed via minimal invasive

surgery.

Although some studies have provided promising results [1,93,101], the efﬁcacy

of MSCs in the treatment of OA is still controversial.

To date it is unknown whether tissue regeneration after MSC transplantation

originates from the transplanted cells themselves, or whether the transplanted

MSCs initiate and support local cells in regenerating the damaged tissue [102].

Another important factor which might contribute to therapeutic success is the anti-

inﬂammatory function assigned to MSCs [103].

246 I. Ribitsch et al.

4.3 MSCs in Bone Regeneration

The natural repair process of fractured bone occurs via primary and secondary bone

union. It is a complex process in which local MSCs generate various essential

progenies: chondroblasts, chondrocytes, ﬁbroblasts and osteoblasts forming a frac-

ture callus. Cellular events during regeneration include MSC chemoattraction,

migration, proliferation and differentiation into osteoblastic, chondroblasic or

ﬁbroblastic lineages depending on the local fracture environment [104]. New

extracellular matrix (ECM) is formed and comprises osteoids and cartilage that

undergo enchondral ossiﬁcation and bone formation until the fracture gap is

bridged [105].

This natural repair process is efﬁcient for most fractures since the mechanical

environment is maintained or created by internal ﬁxation or adjustment. However,

speciﬁc situations such as tumour resection, trauma, arthrodesis, spinal fusions,

metabolic disease or insufﬁcient healing capacities lead to substantial loss of bone.

They require augmentation of the natural healing process to regenerate larger

quantities of bone. The tissue engineering process of osseous tissue delivers some

or all elements required for the natural repair process directly to the site of the large

defect. Based on that, three general approaches have been applied to the art of tissue

engineering of bone: matrix based therapies that use scaffolding implants to replace

the missing bone, factor based therapies that directly provide osteoinductive stimuli

such as the family of BMPs and cell based therapies that transfer cells with

osteogenic potential directly to the repair site [106]. The latter is based on the

implantation of unfractionated fresh bone marrow, culture expanded MSCs, MSCs

differentiated towards osteoblastic and chondrogenic lineages or cells that have

been modiﬁed genetically to express a rhBMP [106]. In general, less differentiated

cells are easier to expand in vitro due to their high proliferation rate, while

differentiated cells are more effective in vivo due to their higher and rapid produc-

tion of mineralised ECM.

For both humans and animals, expanded MSCs derived from various tissues

(e.g. bone marrow, adipose tissue, periosteum, skeletal muscle) are conﬁrmed to

possess osteogenic potential after culture in the presence of dexamethasone, ascor-

bic acid and glycerophosphate in vitro [15,18,107,108]. Among all adult stem

cells, bone marrow-derived stem cells remain the most commonly used cell source

for bone regeneration and repair in studies using different animal models [109].

After in vitro ﬁndings, the ﬁrst animal studies were conducted and indicated that

MSCs maintain their osteogenic capacity in vivo. Therefore, isolated and expanded

MSCs were loaded into porous scaffold matrices and implanted into the subcutane-

ous tissue of athymic murine hosts where the cells induced the formation of

vascularised bone [19]. Next steps comprised the implantation of expanded MSCs

and scaffolds into segmental defects in the femur of small animal models (e.g. rats)

as shown by Kadiyala and coworkers [19]. By 8 weeks, substantial new bone

formation occurred at the interface between the host tissue and the implant, leading

to a continuous span of bone across the defect. Furthermore, Richards and

Basic Science and Clinical Application of Stem Cells in Veterinary Medicine 247

coworkers injected murine MSCs into distracted femoral bones of rats. After

5 weeks they observed signiﬁcant increase of new bone volume, formation of

new trabecular bone with marked osteoblastic activity and osteoid production

[110]. These studies established the proof of principle for MSC based tissue

regeneration therapy in bone.

So far, the bone regeneration capacity of MSCs to repair various damaged bone

tissues such as long bones, cranial bone, mandibular bone and alveolar bone as well

as for the enhancement of spinal fusion was examined.

For large segment defects of long bones, Bruder et al. [111] studied the healing

of critical-sized osteoperiosteal defects using porous ceramic implants loaded with

expanded MSCs. At 16 weeks, radiographic union was established at the interface

between the host bone and the implants in samples that had been loaded with MSCs.

Signiﬁcantly more bone was found in the pores of the implants loaded with MSCs

than in the cell free implants. In addition, a large bone collar formed around the

MSC loaded implants which became integrated and contiguous with callus that

formed in the region of the periosteum of the host bone [111]. Other investigators

used sheep as alternative species for the segmental bone defect model and con-

ﬁrmed that, after a 2 months period, MSC loaded implants resulted in increased

bone formation and accelerated repair compared to unloaded scaffolds [112].

The group of Cui applied adipose derived stem cells and coral scaffolds to

repair a cranial bone defect in a canine model. Three-dimensional CT scans after

12 weeks showed that MSC loading of the scaffold resulted in new bone formation

while unloaded scaffolds were found partially degraded. Furthermore, radiographic

analysis after 24 weeks showed that MSC loaded scaffolds led to more than

threefold higher percentages of repair volume than unloaded scaffolds. This study

substantiates the potency to apply MSCs and coral scaffold for cranial bone

regeneration [113].

In terms of mandibular regeneration, Yuan and coworkers seeded osteogenically

induced bone marrow derived MSCs onto a porous beta-TCP scaffold. The cell-

scaffold-construct was implanted into critical-sized mandibular bone defects in

dogs. New bone formation was observed from 4 weeks after implantation and

bony union was achieved after 32 weeks. More importantly, the engineered bone

achieved a satisfactory biomechanical property in terms of bending load strength,

bending displacement and bending stress [114].

Alveolar bone resorption that is caused by periodontal disease is another ﬁeld of

interest for the application of MSCs in bone regeneration. Weng and coworkers

mixed osteogenically induced bone marrow derived MSCs with calcium alginate to

create a cell-scaffold-construct in gel form. Those were implanted into alveolar

defects in dogs. After 4 weeks bone nodule structures were observed via histology

in the tissue. The engineered bone became more mature over 12 weeks, which was

similar to normal bone. At 24 weeks the repair level of the alveolus reached nearly

half of the height of the normal alveolus showing the applicability of MSCs for

alveolar bone regeneration [115].

Next to the described treatments for acute fractures, fracture nonunions and bone

defects, MSCs can further be used to achieve therapeutic arthrodesis as necessary

248 I. Ribitsch et al.

for spinal fusions. Muschler and coworkers developed a rapid, simple and effective

method to prepare cellular grafts containing enriched populations of bone marrow-

derived MSCs in an implantable matrix of demineralised cortical bone powder.

Afterwards, the MSCs enriched cellular graft was implanted into an established

canine spinal fusion model. The study showed that a simple aspirate of bone

marrow plus demineralised cortical bone powder resulted in an improvement in

bone union score, fusion area, and fusion volume compared to matrix alone and

matrix with pure bone marrow [116].

Crovace [117] also reported about enhanced bone healing using a resorbable

bioceramic based on silicon stabilised tricalcium phosphate and bone marrow

mononuclear cells, in a sheep model with a large-sized (4.8 cm), experimentally

induced defect in a weight-bearing long bone.

Gardel et al. [118] and McDuffee [119] on the other hand used MSCs which had

been differentiated into osteoblasts prior to direct injection into the fracture site in

canine patients and a horse model. The former successfully implanted osteoblasts

resuspended in PBS into a tibial fracture of a cat. The osteogenic behaviour of the

implanted cells was shown by the increased activity of serum ALP after the ﬁrst and

second week of cell application and was in good agreement with the excellent

regeneration and bone healing characteristics of the fracture site. Based on the

results, MSC application may be considered a possible adjuvant therapy for a quick

and successful treatment of long-bone fracture in orthopaedic surgery of small

animals but requires further investigation [118].

According to McDuffee [119], periosteal tissue turned out to be the tissue of

choice to be used in the in vivo study in a large animal fracture model. Twenty

million labelled cells, stimulated to differentiate into osteoprogenitors, combined

with a ﬁbrin glue were transplanted into the treatment limb. Fibrin glue alone

served as control. Results form ﬁve horses demonstrated enhanced bone formation

in simulated fractures which received the osteoprogenitor cell-based therapy.

Radiographic data showed an increase ( p<0.05) in the bone density and histolog-

ical data a greater percentage of bone area in the limbs which received osteopro-

genitor cells compared to control limbs [119].

Another possible indication for the application of MSCs in bone regeneration is

Legg–Calve

´–Perthe

´s disease in dogs. Legg–Calve

´–Perthe

´s syndrome, also known

as aseptic necrosis of the femoral head, is a degenerative disease of the hip joint,

characterised by loss of bone mass which may lead to a deformity of the femur head

and the surface of the hip socket. The disease is characterised by idiopathic

avascular osteonecrosis of the capital femoral epiphysis of the femoral head leading

to an interruption of the blood supply of the head of the femur close to the hip joint.

Small breeds are typically affected. Clinical symptoms are usually seen at a young

age (6–8 months). Radiographically the patients show increased opacity and focal

lysis in the head of the femur and, later in the disease, collapse and fracture of the

neck of the femur. The recommended treatment is surgical removal of the femur

head.

Lately Crovace and coworkers reported about the implantation of autologous bone

marrow mononuclear cells as a minimal invasive therapy of Legg–Calve

´–Perthe

´s

Basic Science and Clinical Application of Stem Cells in Veterinary Medicine 249

disease in dogs. Prior to implantation the cells were suspended in ﬁbrin glue. Implan-

tation was performed by transcutaneous injection, under CT or radiographic guide,

using a Jamshidi needle inserted through the femoral head and neck starting at the base

of the trochanter major.

In nine of the treated dogs the disappearance of pain was observed after about

3–4 weeks following cell administration. This also became obvious by a gradual

weightbearingontheaffectedlimbuptoacomplete remission of the symptomatology.

In the other two cases a femoral head and neck ostectomy was performed because

the recovery proceeded too slowly. Histological and immunohistochemical studies

were performed on these samples and showed new formation of cartilage and

subchondral bone in the implantation area. Therefore cell therapy seems to be an

effective and minimal invasive therapeutic approach for the treatment of Legg–

Calve

´–Perthe

´s disease. The efﬁcacy is considered to be due to the osteogenetic as

well as anti-inﬂammatory capacity of the stromal cells which may ﬁrst lead to pain

relieve and then to reparative activity within the bone causing a better sclerosis of

the femoral head [120].

Regardless of the clinical application, all mentioned studies share the common

observation of improved bone tissue formation upon local MSC application as an

essential part of the tissue engineering process. However, the application of MSCs

for bone repair in the veterinary implementation does not predominantly aim at the

clinical treatment of animal patients. More often, animals are used as appropriate

models to conduct preclinical studies before advancing to human clinical trials.

Still, the principles tested in a species like the dog can directly be clinically

translated in the patient of the respective species.

4.4 Spinal Cord Injuries

Acute spinal cord injuries affect many dogs and cats. It has been reported that about

1–2% of all dogs admitted to animal hospitals suffer from injuries to the spinal cord

only due to intervertebral disc disease. Clearly there are many other conditions that

can lead to compression, concussion or laceration of the spinal cord [121].

Traumatic spinal cord injury causes loss of tissue, including myelinated ﬁbre

tracts responsible for carrying descending motor and ascending sensory informa-

tion. Reduced myelination could be due to either loss of myelinated cells or reduced

oligodendrocyte myelin synthesis [122].

Although animals tend to recover a substantial amount of locomotor ability after

spinal cord injury, the natural CNS capacity to recover from injury is unfortunately

limited. Neuroanatomical differences between species may also be an important

factor that needs to be considered in the assessment of the recovery of spinal cord

injuries [121].

After spinal cord injury, massive oligodendrocyte death attributed to apoptosis

occurs. It seems that a complete restoration of the lost myelin in the injury zone

by endogenous oligodendrocytes is not possible. Therefore transplantation of cells

250 I. Ribitsch et al.

with the ability to differentiate into oligodendrocytes may be a feasible method for

myelin replacement. It was reported that stem cells implanted into spinal cord

lesions not only differentiate into astrocytes and oligodendrocytes but also integrate

into axonal pathways and thus regenerate injured axons [122].

At the moment lots of different sources of cells for neurotransplantation are

being evaluated, e.g. embryonic, bone marrow, adipose and UCB stem cells. The

cells obtained from these sources can migrate and differentiate into neural pheno-

types in the damaged brain and spinal cord [123].

Jeffery et al. [124] showed that recovery of locomotor activity of dogs with

spinal cord injuries following autologous olfactory glial cell transplantation

appeared to be considerably faster than reported in historical cases.

Adel and Gabr [125] reported signiﬁcant improvement in the motor power of six

dogs compared to the control group, based on intrathecal transplantation of autolo-

gous bone marrow derived MSCs 1 week after spinal cord injury.

It was also shown that allogeneic UCB derived MSC transplantation is feasible

to induce neuroregeneration using UCB MSCs derived from canine foetuses. UCB

contains more mesenchymal progenitor cells and is more pluripotent and geneti-

cally ﬂexible than bone marrow derived stem cells. Based on the fact that they are

less mature than other adult stem cells they may not elicit alloreactive responses

that modulate the immune system.

Dogs included in the study had more than 75% of their spinal canal occluded

over a 12-h period. This resulted in a manifest lesion with histologically severe

haemorrhage and vacuole formation. The dogs showed paraplegia and were not

expected to regain a normal gait. In the group with UCB MSC treatment the gait

improved from 2 weeks and the weight bearing of the pelvic limbs improved from

10% to 50% of the time. Therefore, the group with UBC MSC treatment appeared

to have improved spinal cord function after the experimentally induced spinal cord

injury. It is concluded that MSCs might improve the functional outcome by creating

new neuronal pathways in the ﬁbrous scar tissue. They have been observed to

integrate into the lesion in the central nervous tissue and a smaller percentage of

cavity formation was observed following UCB MSC injection. However, 8 weeks

after stem cell implantation magnetic resonance imaging and histology showed no

convincing evidence of spinal cord regeneration. Based on somatosensory evoked

potentials it was also demonstrated that the nerve conduction velocity was signiﬁ-

cantly improved. In addition a distinct structural consistency of the nerve cell

bodies was observed in lesions treated with MSCs [123].

After human UCB stem cell implantation following spinal cord injury in rats,

locomotor function was signiﬁcantly enhanced within 14 days after transplantation

as compared to the non-treated group. In contrast to the non-treated group, consis-

tent plantar stepping, forelimb-hindlimb coordination and no toe drag during

walking were observed. Findings demonstrated that hUCB stem cells differentiate

into oligodendrocytes and neurons in vivo and lead to improved locomotor function

[122]. Moreover, Dasari et al. [122] showed that the number of oligodendrocytes

as well as of myelinated axons was elevated in the treatment group compared to the

control group and that neuroptropins (NT3 and BDNF) secreted by these

Basic Science and Clinical Application of Stem Cells in Veterinary Medicine 251

oligodendrocytes in turn enhanced myelinogenesis as well as proliferation and

survival of oligodendrocyte precursors. Furthermore, hUCB stem cells producing

these neurotropins seem to promote neuritogenesis and axon myelination. Morpho-

logically normal appearing sheaths around the axons in the injured areas were found

as well, which was consistent with the observed rapid locomotor improvement.

These results are consistent with the hypothesised migration of stem cells to lesion

sites and their participation in healing of neurological defects caused by traumatic

injury. In the non-injured areas of the spinal cord no hUCB derived cells were

detectable [122].

First results from studies in primates (Rhesus monkeys) using bone marrow

derived MSCs were promising as well.

Corticosomatosensory evoked potential signals recovered signiﬁcantly 3 months

after MSC injection whereas in control animals the signals remained ﬂattened. The

same was observed for motorevoked potential. Healing and regeneration of the

spinal cords in animals transplanted with MSC derived cells was shown by H&E

staining. In contrast, the injured tissue of the control animals showed obvious

degeneration with the appearance of many holes and abundant dissolution of neural

tissue and cells. Re-establishment of the axon pathway across the contusive injury of

the spinal cord was evaluated by application of labelled cells that were later observed

in the rostral thoracic spinal cord, red nucleus and sensory motor cortex [126].

It is not clear, however, whether the therapeutic potential of stem cells is based

on their attributed inherent ability to replace injured tissues or if they repair

damaged tissue through the induction of neural protection and secretion of neuro-

trophic factors by various cell types within the graft. More precisely, stem cells

could either promote axonal regeneration by constituting a connection through a

lesion site which in turn supports axonal attachment or secrete certain growth

factors to attract injured axons. It also still needs to be determined if the enhanced

functional recovery is based on re-myelination of demyelinated axons or by trophic

support to prevent degeneration of the white matter [122].

MSCs have been shown to differentiate into neurons via ex vivo induction as

well as following in vivo transplantation. However, compared with native MSCs,

neural induced MSCs display a higher survival rate and support better functional

recovery after transplantation in rat models. As the microenvironment of acute

injury does not favour de novo neurogenesis, the brief induction of MSCs prior to

implantation might have a beneﬁcial effect on their in vivo differentiation [126].

4.5 Liver Disease

Also so-called liver progenitor cells (LPC) are hoped to be able to support liver

regeneration. LPCs, undifferentiated epithelial cells lying at the interface of the

hepatic cords and the biliary tree, offer a promising target for therapeutic interven-

tion in severe liver diseases [127]. They are bipotential cells who express hepato-

cytic, biliary and progenitor cell markers and can also be isolated from the smallest

252 I. Ribitsch et al.

and most peripheral branches of the biliary tree (Hering canals) [128,129]. These

cells are deﬁned as side population. Side populations were identiﬁed in multiple

tissues and display an enriched population of authentic or potential tissue stem

cells. In vitro they show a greatly enriched haematopoietic stem cell potential

whereas in vivo they show haematopoietic reconstitution activity. In healthy livers,

LPCs remain in a quiescent stadium [129] and their presence is low, but they

proliferate and invade the liver parenchyma in several pathologic conditions

[128]. LPCs are only activated during liver regeneration when hepatocyte prolifer-

ation is insufﬁcient [127]. Activated LPCs can either differentiate into haemato-

poietic lineages [129] or mature hepatocytes as well as cholangiocytes in order to

regenerate the pathological changes in the liver [128].

In animal models it was shown that MSCs induced to adopt a hepatocytic

phenotype as well as BM mononuclear MSC subpopulations contribute to a histo-

logic decrease in hepatic ﬁbrosis and a rise in serum albumin level when infused

early enough after injury onset [130].

The results of the study performed by Arends et al. [129] provide a new option of

treatment approach in currently untreatable canine liver diseases. It is hypothesised

that liver reconstitution can be stimulated by injection of progenitor cells into

diseased livers or via stimulation of the endogenous progenitor cells. The potential

use of these cells for the treatment of naturally occurring liver disease in dogs is also

of interest for human medicine, as a high homology with human liver diseases at the

molecular as well as pathological level is described [128].

Another approach to achieve liver regeneration might be using bone marrow.

Bone marrow comprises hepatic stellate cells and myoﬁbroblasts, which were

showntobeofMSCorigin[131]. Based on these ﬁndings it is hypothesised that

some hepatocyte regeneration may be achieved through bone marrow MSC

transplantation and might induce measurable improvements in hepatic function

after damage. Whether engraftment and origin restitution continues in the long

term has not been described yet. Another possible explanation for the reduced

ﬁbrosis is that hepatocyte proliferation and suppression of ﬁbrogenesis are

induced by critical growth factors and cytokines supplied by migrating bone

marrow cells [130].

5 Future Prospects and Outlook

Based on all these reports it is obvious that regenerative medicine in the ﬁeld of

veterinary medicine is making great steps to become clinical reality but it is also

shown that several important questions still remain to be answered. One of the

fundamental questions is the adequate number of cells that would need to be

implanted in order to achieve optimal results. Proving that the effect of cell based

treatment regimes is in fact caused by the administered stem cells and not by any

other cells or biological factors applied simultaneously is still outstanding as well [11].

It also needs to be answered whether stem cells really functionally incorporate into

Basic Science and Clinical Application of Stem Cells in Veterinary Medicine 253

the tissue that requires regeneration or whether they excite a conducting role

recruiting and controlling resident cells to regenerate the respective tissue [11].

Maybe they rather synthesise and secrete growth factors which in turn promote

tissue function [5].

Considering all the aspects discussed above, it also seems that MSCs obtained

from different sources may have different properties and it will be necessary to

deﬁne the best source depending on the intended treatment.

6 Embryonic Stem Cells and Induced Pluripotent Stem Cells

Embryonic stem (ES) cells are pluripotent stem cells obtained from the inner cell

mass of the blastocyst – an early-stage embryo. In humans, for example, embryos

reach the blastocyst stage about 4–5 days post fertilisation. ES cells are capable of

self-renewal and thus have the inherent potential for exceptionally prolonged

culture (up to 1–2 years). So far ES cells have been recovered and maintained

from non-human primate, mouse [5] and horse blastocysts [132]. In addition,

bovine ES cells have been grown in primary culture and there are several reports

of ES cells derived from mink, rat, rabbit, chicken and pigs [5]. Advances in the

laboratory have led to development of feeder and animal-sera – free cells lines.

However, clinical application of ES cells remains faced with practical and ethical

concerns [133]. Their potential for uncontrolled proliferation and immune rejection

[133] as well as their tendency towards teratogenic degeneration in vivo remain

major obstacles. The potential to form teratoma consisting of tissues from all three

germ lines even serves as a deﬁnitive in vivo test for ES cells.

Recently veterinary scientists started to develop several equine ES cells lines so

that they can be genetically matched to patients to eliminate immune rejection

[133]. Horse ES cells were found to express ES cell marker genes that differ from

both human and mouse ES cells, but that reﬂects the expression of these genes in the

inner cell mass of horse blastocysts. Therefore it may be concluded that species

differences exist even at this early stage of development and that horse ES cells may

provide a better tool to study early horse development than extrapolating data from

other species. Equine ES cells are able to generate derivatives of all three germ

layers upon differentiation in vitro. Interestingly, they seem not to generate terato-

mas upon implantation into severe combined immune deﬁcient (SCID) mice. This,

combined with a lack of expression of MHC class II antigens, may make horse ES

cells more suitable for use in cell transplantation therapies [134] than ES cells from

other species. Based on that, at least two companies are currently developing equine

ES cells and pilot studies are being performed to determine the efﬁcacy of equine

ES cells for tendon regeneration [133]. In addition, ES cells certainly remain an

important model system for studying cellular differentiation in relationship to

development and oncogenesis [133].

A major breakthrough in the ﬁeld of stem cell research was achieved in 2006,

when it was shown that induced pluripotent stem (IPS) cells could be obtained from

254 I. Ribitsch et al.

adult somatic cells through expression of a set of transcription factors such as Oct4,

Sox2, Klf4, c-Myc, NANOG and Lin28 [133]. Also IPS cells are capable of

differentiating into all three embryonic germ layers and, because of this, they

have enormous potential for biomedical research and regenerative therapy. These

ES-like cells have been generated from rodent, human and porcine somatic cells by

forcing the ectopic expression of four transcription factors, Oct4, Sox2, Klf4 and

cMyc. These IPS cells may have a great potential in medicine because they can be

produced in a patient-speciﬁc manner [135]. Generation of IPS cells allows for

development of patient-speciﬁc cell populations without the ethical controversy of

ES cells. Prior to clinical application, an important next step will be to identify ways

of assessing which IPS cell lines are sufﬁciently reprogrammed and safe for

therapeutic applications [133]. In addition it will again be necessary to overcome

their potential to form teratoma in vivo.

A species, other than humans, that is likely to beneﬁt from this potential is the

horse, particularly in regard to the treatment of musculoskeletal injuries. First

studies attempting to derive IPS cells from equine somatic cells have begun.

Putative equine IPS colonies were identiﬁed that tested positive for ALP and

Nanog. Clonal populations have continued to expand while maintaining their ES-

like morphology over several passages. Current efforts are focused on deﬁnitely

establishing the pluripotency of these cell lines, including their potential for

differentiation into cells of all three embryonic germ layers. Initial results are

very encouraging for the eventual generation of IPS cell lines that may have great

potential for equine regenerative medicine [135]. However, it was shown that age,

origin and cell type have a deep impact on the reprogramming efﬁciency [136] and

most likely also the quality of the obtained IPS cells. IPS cells obtained from

somatic cells of adult patients are IPS cells with the biological age of the donor.

Therefore, recently a study on the generation of IPS cells from human cord blood

was carried out in order to obtain IPS cells from young cells which can be expected

to carry minimal somatic mutations and the immunological immaturity of newborn

cells [136]. This might offer major advantages for the future use of IPS cells.

In summary, it can clearly be said that in the future a lot of effort still needs to be

put into all ﬁelds of stem cell research and veterinary medicine will also play an

important role because animals may serve as models for human medicine.

7 Animal Models

Cell therapy with adult pluripotent MSCs may revolutionise the treatment of a large

variety of diseases in veterinary as well as in human medicine in the future [7].

Veterinary medicine in the form of animal trials plays a major role in preclinical

and ﬁrst clinical phases of human medical trials. In animal studies MSCs seem to

provide disease-ameliorating effects in conditions like Alzheimer’s disease [137],

Huntington’s disease [138], amyotrophic lateral sclerosis [139], spinal cord injury

[122,140–142] and myocardial infarction [143,144].

Basic Science and Clinical Application of Stem Cells in Veterinary Medicine 255

Also, the effect of MSCs in orthopaedic disorders like OA and tendon injuries is

being studied using animal models.

In general, it is important to deﬁne the questions and goals of a preclinical

animal study before the required species is chosen. However, successful laboratory

studies provide valuable proof of principal demonstrating statistical differences in

outcome between small groups of treated and control animals with highly uniform

injuries, but translational studies aiming to determine whether MSC transplantation

provides a medically useful effect in large patient populations that have some

variability in the degree of injury severity still need to be carried out [124].

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Basic Science and Clinical Application of Stem Cells in Veterinary Medicine 263

Adv Biochem Engin/Biotechnol (2010) 123: 265–292

DOI: 10.1007/10_2010_78

#Springer‐Verlag Berlin Heidelberg 2009

Published online: 27 August 2010

Bone Marrow Stem Cells in Clinical

Application: Harnessing Paracrine Roles

and Niche Mechanisms

Rania M. El Backly and Ranieri Cancedda

Abstract The being of any individual throughout life is a dynamic process relying

on the capacity to retain processes of self-renewal and differentiation, both of which

are hallmarks of stem cells. Although limited in the adult human organism, regen-

eration and repair do take place in virtue of the presence of adult stem cells. In the

bone marrow, two major populations of stem cells govern the dynamic equilibrium

of both hemopoiesis and skeletal homeostasis; the hematopoietic and the mesen-

chymal stem cells. Recent cell based clinical trials utilizing bone marrow-derived

stem cells as therapeutic agents have revealed promising results, while others have

failed to display as such. It is therefore imperative to strive to understand the

mechanisms by which these cells function in vivo, how their properties can be

maintained ex-vivo, and to explore further their recently highlighted immunomod-

ulatory and trophic effects.

Keywords Bone marrow stem cells, Homing and recruitment, Paracrine roles,

Regenerative medicine, Stem cell niche

Contents

1 Bone Marrow Stem Cell Based Clinical Trials: Lessons Learned . . . . . . . . . . . . . . . . . . . . . . . . 266

1.1 Stem Cell Based Therapies for Cardiovascular Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266

1.2 Diligent Candidates for Treatment of a Multitude

of Systemic Diseases . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268

R. Cancedda (*)

Istituto Nazionale per la Ricerca sul Cancro, and Dipartimento di Oncologia, Biologia e Genetica

dell’Universita’ di Genova, Genova, Italy

e-mail: ranieri.cancedda@unige.it

R.M. El Backly

Istituto Nazionale per la Ricerca sul Cancro, and Dipartimento di Oncologia, Biologia e Genetica

dell’Universita’ di Genova, Genova, Italy

Dentistry, Alexandria University, Alexandria, Egypt

1.3 From Tissue Engineering to Regenerative Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 270

2 Redeﬁning the Bone Marrow Niche: Implications for Clinical Application . . . . . . . . . . . . . . 271

2.1 The Bone Marrow Niche: An Orchestra of Cells and Signals . . . . . . . . . . . . . . . . . . . . . . 272

2.2 Niche Mechanisms and Bases for Stem Cell Homing and Recruitment . . . . . . . . . . . . 276

3 Immunomodulation, Trophic Effects, and Angiogenic Supporting Role of Bone Marrow

Derived Stem Cells . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . 282

4 Concluding Remarks . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . 284

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285

Abbreviations

BM-MSCs Bone marrow derived mesenchymal stem cells

BMSCs Bone marrow derived stem cells

HSCs Hematopoietic stem cells

MSCs Mesenchymal stem cells

1 Bone Marrow Stem Cell Based Clinical Trials: Lessons

Learned

Innovative in-depth research in the ﬁeld of stem cell biology has paved the way for

the initiation of numerous clinical trials using bone marrow stem cells as therapeu-

tic agents, many of which are already in phases II and III. Currently more than 1,280

clinical trials involving the use of bone marrow stem cells are listed under service of

the US National Institutes of Health alone (www.clinicaltrials.gov). Clinical studies

published in the past couple of years showed promising results and offered hope for

major leaps, particularly in the treatment of cardiovascular disease [1,2]. However,

it is difﬁcult to extract information from many of these trials due to the small

number of cases and varying beneﬁts to the patients [3–5]. Perhaps the most

limiting factors seem to be the lack of protocol standardization and the shortage

of in vivo tracking assays, which make understanding the mechanisms by which

these effects are brought about difﬁcult to analyze in human subjects.

1.1 Stem Cell Based Therapies for Cardiovascular Disease

In spite of some inconsistencies, the fact that some beneﬁcial outcomes were noted

cannot be ignored. Acute myocardial infarction (AMI) has probably received the

most attention of clinically based studies using bone marrow stem cell based

therapies [6]. A clinical study conducted on AMI in 60 patients receiving intracor-

onary injections of autologous mononuclear bone marrow stem cells revealed

improvement of both systolic and diastolic left ventricular functions after 6 months.

266 R.M. El Backly and R. Cancedda

The injected cells were phenotypically characterized, the majority of those trans-

planted being CD34+ cells and a smaller fraction CD133+ cells. In contrast to other

studies which have shown minimal improvements, the conductors of this study

relate positive alleviation of symptoms to several points: the method of introduction

of the cells which in this case was intracoronary, the high number of cells used in

this study including a major fraction of CD34+ cells, and the elevated initial

severity of the condition. However, the number of patients was too low to extrapo-

late sufﬁcient clinical data [5]. The route of cell-delivery appears as a determining

factor in interpreting beneﬁcial results. Preclinical studies indicated that direct

intramyocardial cell injection could provide higher efﬁcacy [7] and a recently

conducted phase I clinical trial displayed substantial patient improvement up to

12 months post-injection [8]. However, the lack of sham controls and placebos

leave unanswered questions, such as to what extent the observed improvement is

due to the injected cells.

The time-line over which some of these studies have been conducted also

appears to have an effect on the extent of improvements witnessed. While short-

term studies have advocated the therapeutic regimen and report signiﬁcant effects,

it has been suggested that multiple injections could be required [9,10]. Some

longer-term studies varying from 18 month to 3 year follow-up of patients who

received transplants showed disparate results [2,4,11]. However, results of the

REPAIR-AMI trial have dissected the processes by which left ventricular remodel-

ing took place within 4 months after injection and have revealed that bone marrow

cell injection resulted in earlier remodeling after AMI compared to the placebo

group [12]. In these patients, adverse cardiovascular events were signiﬁcantly

reduced and functional improvements persisted for at least 2 years. Most beneﬁts

appeared for patients who had presented with a more severe initial status [2].

A meta-analysis conducted over seven controlled clinical studies on patients

with AMI revealed that bone marrow stem cell administration signiﬁcantly

enhanced left ventricular functions although two of these studies reported no effect

[13]. Although inclusion and exclusion criteria were met, mild variations between

these studies did exist, such as differences in cell fraction isolation techniques as

well as in the time of bone marrow stem cell administration, number of cells given,

methods of evaluation, and follow-up intervals.

Based on recent evidence of the importance of CXCR12/CXCR4 interactions in

homing and recruitment, the REGENT clinical trial was conducted using CD34(+)

CXCR4(+) bone marrow cells vs an unselected and control group, respectively [3].

After 6 months, the differences in left ventricular function, however, were not

signiﬁcant between the groups, although in patients with more severe illness, results

were better in the cell therapy group. In another study, an antagonist of CXCR4

systemically injected in patients with AMI displayed an enhanced capacity of

mobilizing CD133+ cells [14]. These effects were observed following a single

injection as compared to the need for multiple injections of G-CSF, and did not

cause systemic activation of inﬂammation.

Other approaches have involved the use of precultured allogeneic bone

marrow mesenchymal stem cells. A phase I clinical trial using allogeneic BMScs

Bone Marrow Stem Cells in Clinical Application: Harnessing Paracrine Roles 267

(prochymal) in patients with AMI has shown a signiﬁcant increase in ejection

fraction that was sustained up to 6 months [1]. The use of more sensitive analytical

techniques, such as the cardiac MRI, revealed that some improvements maintained

up to 12 months could only be seen in the groups that had received the hBMSCs.

Reverse remodeling was also noted in the cell-therapy group, as compared to the

placebo group which showed a continuous chamber enlargement; however, these

effects were nonsigniﬁcant. Although the cells were apparently not retained at

the site of damage for prolonged periods of time, the therapeutic effects appeared

to be most important in the early post-injury period.

It is highly probable that the paracrine and immunomodulatory effects elicited

by these cells could be as important as the exact number of cells engrafted, and

whether or not these cells directly contribute to tissue remodeling remains to be

seen. A signiﬁcant improvement of cardiac function has been shown in a rat model

of myocardial infarction, whereas the number of cells found in the ischemic heart

decreased after 60 min of inoculation and most of the cells were entrapped in the

lungs [15]. However, homing was more efﬁcient in ischemic rat hearts as compared

to the sham-operated controls. This in fact could be attributed to changes in the

local microenvironment and the interaction with the cells which are then capable of

activating and recruiting other cells as well as secreting biochemical factors and

providing cardioprotective functions. Studies on mice using allogeneic bone mar-

row stem cells have shown similar detainment times of both syngeneic and alloge-

neic cells emphasizing the immunomodulatory properties of mesenchymal stem

cells and that cell number reduction was not due to immune rejection [16].

Clinical trials using stem cell therapy in AMI have been categorized according to

three general approaches; direct injection, indirect cell mobilization using G-CSF,

or a combinational approach by ﬁrst mobilizing the cells and then performing a

direct cell injection [6]. In light of the moderate improvements shown from trials

using the ﬁrst and second approaches, the combinational approach has gained favor.

This technique may overcome the hurdle of myocardial homing of small numbers

of cells by indirect mobilization through the introduction of a successive stem cell

injection, thereby enhancing chances of engraftment [17]. A multitude of factors

still need to be addressed, such as mechanism of action, lineage of the stem cells

and characterization, number of cells, time and method of delivery, homing, follow-

up, and imaging of biologic effects [6]. Other applications of stem cell based

cardiac therapy are also currently targeting nonischemic dilated cardiomyopathy

[18], peripheral arterial disease [19], and ischemic heart failure [20].

1.2 Diligent Candidates for Treatment of a Multitude

of Systemic Diseases

Stem cell based clinical trials are also underway for the treatment of a substantially

diverse group of systemic diseases ranging from neurodegenerative disorders,

stroke, graft-versus-host disease (GVHD), and lately to diabetes mellitus [21].

268 R.M. El Backly and R. Cancedda

This is in addition to the use of allogeneic MSCs in the treatment of osteogenesis

imperfecta and ankle arthritis [22].

It has been proposed that bone marrow stem cells can be used in the treatment of

acute GVHD [23]. Allogeneic mesenchymal stem cells have been shown to

enhance engraftment of cotransplanted hematopoietic stem cells in leukemia

patients presenting with GVHD as a consequence of a previous MSC injection

which resulted in hematopoietic recovery of patients [24]. In a clinical trial involv-

ing a group of patients with steroid resistant acute GVHD, half of the patients were

found responsive to at least a single injection of bone marrow stem cells. The cells

appeared to have a multiorgan effect on reversing GVHD perhaps by suppression of

donor T-cell responses to recipient alloantigen [23].

Chronic obstructive pulmonary disease (COPD) and Crohn’s disease have also

been addressed by stem cell based approaches and are just embarking on the clinical

trial phase [25]. Autoimmune diseases such as systemic lupus erythematosus (SLE)

may also beneﬁt from allogeneic bone marrow stem cell therapy. SLE has been

shown in mice to be associated with osteoblastic niche deﬁciency which is thereby

detrimental to maintenance of the hematopoietic stem cell niche and may contribute

to the pathology of SLE [26]. Allogeneic MSCs may act by reestablishing the

osteoblastic niche, recovering Foxp3+ cells, and down-regulating Th17 cell levels

which are important entities in combating autoimmune diseases. Based on these

conclusions, a patient based study was conducted revealing improvements of SLE

symptoms upon short-term follow-up [26]. Similar results were displayed in

patients with systemic sclerosis receiving autologous hematopoietic stem cell

transplantation (HSCT) [27].

The emergence of clinical studies directed towards treatment of neurodegenera-

tive diseases using stem cell based therapy has launched aspiration for many

patients. A study on seven patients with Parkinson’s disease receiving autologous

BM-MSCs has indicated subjective improvements in some symptoms [28]. These

are initial results that cannot be generalized at this time but offer immense hope for

the future. Other areas include targeting amytrophic lateral sclerosis [29] and stroke

[30,31].

Treatment of diabetes mellitus has lately acquired recognition as a substantial

goal of bone marrow stem cell based therapies using different approaches. Type I

diabetes mellitus has been shown to be reversible following nonmyeloablative

HSCT. The majority of the patients in this study could remain insulin-free for

periods as long as 4 years. C-peptide levels were elevated and, even though patients

had to resume insulin treatments, this could account for a decreased rate of future

complications from diabetes mellitus [32]. Autologous nonmyeloablative HSCT

currently appears to be the sole modality capable of reversing insulin dependent

diabetes. Consistent positive effects were noted as well in type II diabetic patients

[33]. Local cell therapies aiming towards the treatment of chronic diabetic ulcers

revealed an improved healing in response to the autologous BM-MSC application

in conjunction with wound dressings although biochemical parameters remained

unaltered [34].

Bone Marrow Stem Cells in Clinical Application: Harnessing Paracrine Roles 269

1.3 From Tissue Engineering to Regenerative Medicine

In the context of tissue engineering approaches, clinical trials utilizing bone

marrow derived stem cell/scaffold based strategies are lacking. The bone tissue

engineering category, which has been the pioneer ﬁeld explored, is evidently

lagging behind [35]. This can probably be accounted for by several reasons

including, but not limited to, the absence of a general consensus on (1) the type

of scaffold to be used for distinct bone defects, (2) the type of cell(s) providing

optimum bone regeneration in the shortest time, (3) the appropriate biomolecule

cocktails, including their time and mode of delivery, the capacity to overcome the

revascularization hurdle met with especially in large defects, (4) optimal high-

resolution noninvasive method(s) for the evaluation of the implant results, and

(5) clinically feasible, safe, and efﬁcient protocol(s) that will result in fully func-

tional dynamic tissues mimicking those of developmental origin.

Long-term follow up of successful reconstruction of challenging long bone

defects was documented in four patients who received macroporous bioceramic

scaffolds implanted with autologous BM-MSCs [36,37]. The 6- to 7-year outcome

of these patients revealed good integration with complete bone healing and evi-

dence of revascularization in the graft area yet, the scaffolds remained unresorbed.

This could later compromise the biomechanical integrity of the regenerated tissue

in addition to hindering objective follow-up of the healing process. However,

recently a modiﬁed silicon stabilized tricalcium phosphate based scaffold has

been introduced to address these limitations [38,39].

Subsequent to these studies, there has been an array of isolated clinical case

reports in different application areas. Some aimed to enhance the functionality of

allogenic bone grafts by incorporating bone marrow mononuclear cells [40], while

others have reported successful long-term results using a combination of bone

marrow derived stromal cells and platelet rich plasma as injectable tissue engi-

neered bone for maxillary sinus augmentation [41]. In the latter, alveolar bone

height showed consistent increase over 24 months compared to baseline values,

although no controls were incorporated in this study.

A similar study showed that bone marrow derived stem cells delivered on a

biphasic hydroxyapatite–tricalcium phosphate (HA/TCP) material successfully

elevated the sinus compared to initial bone heights and facilitated implant place-

ment in six patients [42]. However in a second study by the same group, little bone

formation was seen when BMSCs were combined with a conventional bone substi-

tute in alveolar clefts [43]. It is the recommendation by the investigators that the use

of human serum rather than conventional fetal calf serum could have hindered the

ability of the BM-MSCs to form bone. Transfer of the cells to the graft substitute as

well as the difﬁculty in establishing bone continuity could be hindering parameters

in alveolar cleft regeneration by MSCs based modalities.

A major drawback in these studies is the absence of control patients. Of course,

this is not an easy task in a clinical set-up which again reemphasizes the need for

controlled clinical trials mimicking the same parameters applied in successful case

270 R.M. El Backly and R. Cancedda

reports. Only then can an objective unbiased evaluation be made. Another impor-

tant setback is the use of heterogeneous populations of stem cells that did not go

through in vitro characterization before patient testing [41–43].

A more insightful clinical study investigating the use of autologous BM-MSCs

in conjunction with a hydroxyapatite based scaffold for regenerating osseous jaw

bone defects prior to dental implant placement documented de novo bone formation

in only one of six patients after 4 months [44]. At the same time, a set of

synchronized experiments were performed implanting cells from each patient in

immunodeﬁcient mice. These revealed ectopic bone formation with cells from all

patients;, however, the failure to conﬁrm this clinically was explained by a lack of

sufﬁcient vascular supply leading to immediate death of the cells following trans-

plantation. It is hence plausible that bone marrow stem cell–scaffold based strate-

gies need to address the issue of reconstituting a developmentally conductive

“niche” which would ensure establishment of a vascular network while maintaining

a bed of self-renewing stem cells ensuring dynamic turnover of the tissue [45].

It is apparent that stem cell based clinical therapy is steadfastly gaining momen-

tum yet, until stringent parameters are applied and generalized, a standard clinical

application will remain far-fetched. On this basis, more in-depth basic studies have

resurfaced, aiming to arrive at more comprehensive explanations for clinical

observations.

2 Redeﬁning the Bone Marrow Niche: Implications

for Clinical Application

A clinically appealing concept for the use of stem cells is one that allows manipula-

tion of these cells in vivo rather than relying solely on the cumbersome process of

ex vivo culture and expansion. These newly founded methodologies would thereby

be capable of triggering in-house recruitment and expansion of stem cell populations

in a way that would boost the body’s own regenerative capacity. This entails a deeper

probing of the bone marrow stem cell microenvironment (the bone marrow niche).

A niche is a local microenvironment within which one or more stem cells are

housed and maintained. Initially, the niche concept was deﬁned by Grinnell and it

was introduced in mammals by Schoﬁeld to delineate a microenvironment capable

of supporting hematopoiesis [46,47]. An ideal niche is one that, after a complete

elimination of its host stem cell population, could retake a new stem cell and in turn

maintain it. Hence, a niche is difﬁcult to replicate in in vitro cultures since these

newly introduced environments can alter the patterning of the cells and modify their

behavior later in vivo. The existence of facultative niches is a facilitating mecha-

nism to allow homing of stem cells in response to stress or injury. Indeed, signaling

proﬁles of stem cells vary according to the neighboring cells and the physical

environment, which further complicates the identiﬁcation and puriﬁcation of a

purely genuine stem cell [48].

Bone Marrow Stem Cells in Clinical Application: Harnessing Paracrine Roles 271

The existence of stem cell niches in the organism is a vital prerequisite to

maintaining a constant supply of naı

¨ve, undifferentiated stem cells while maintain-

ing lineage development required for the individual’s long-term survival. For

successful cell based therapy, transplanted stem cells must be capable of homing

to appropriate niches, thereby maintaining their lineage development potential and

at the same time a constant supply of native cells. In a tissue engineering approach,

the ultimate goal would be to engineer an appealing niche within the scaffold,

thereby creating a suitable microenvironment for the delivered cells which can be

sustained in vivo [49].

2.1 The Bone Marrow Niche: An Orchestra of Cells and Signals

Although stem cell niches should by concept exist in all organs and tissues, little

information exists on the nature and mechanism that control these niches. So far,

most studies have been concerned with the bone marrow stem cell niche. This is the

particular niche within the bone marrow representing a harmonious microenviron-

ment whereby the coexistence of hematopoietic stem cells within their physical

microenvironment with bone marrow derived mesenchymal stem cells brings about

this balance. In the following section, we will present available information on the

bone marrow niche as well as a paradigm of other stem cell niches. Indeed the stem

cell niche represents the physical 3D microenvironment within which stem cells are

either maintained in a quiescent state, protecting the stem cell reservoir from

exhaustion, or under triggering circumstances are prompted to enter the cell cycle

and proliferate, mature, or differentiate. From a bone engineering perspective,

recreating the stem cell niche is required if a truly hematopoiesis supporting stroma

is to be developed within the newly regenerating bone [50–52].

Mesenchymal stem cells have been redeﬁned on a more precise basis as being

cells that display plastic adherence, express CD105, CD90, and CD73 in greater

than 95% of the culture, and display a lack of expression of markers including

CD34, CD45, CD14 or CD11b, CD79a or CD19, and HLA-DR in greater than 95%

of the culture, in addition to their capacity to differentiate into bone, fat and

cartilage [53].

Hematopoietic stem cells are cells capable of self-renewal and giving rise to a

cascade of differentiation leading to the creation of all types of blood cells [48].

Hematopoietic stem cells found in adult bone marrow develop from preexisting

hematopoietic stem cells that emerged early in ontogenesis, when the bone

marrow had not yet formed. In mouse bone marrow, genuine hematopoietic

stem cells appear in the bone marrow only after 4–5 days of birth, meaning that

they are not responsible for the initial establishment of hematopoiesis but play a

major role in its long-term sustenance [54]. During human embryonic develop-

ment, hematopoiesis sequentially includes the yolk sac, an area surrounding the

dorsal aorta termed the aorta–gonad mesonephros (AGM) region, the fetal liver,

the bone marrow, and the placenta. However, the properties of hematopoietic

272 R.M. El Backly and R. Cancedda

stem cells differ in each of these sites, shining additional evidence on the

inﬂuential effects of various niches [55].

Within adult bone marrow, hematopoietic stem cells can be more precisely

described as groups of cells with varying developmental potentials depending

upon signals derived from their cellular niches. It is within this microenvironment

that they receive prompting “instructions” either towards blood lineage develop-

ment or maintenance of self-renewal, i.e., there is a presence of a continuous pool of

undifferentiated cells [55].

Identiﬁcation of hematopoietic stem cells within their niches has been facilitated

by the evolution of SLAM family proteins [48,56]. The identiﬁcation of SLAM

family receptors, including CD150, CD244, and CD48 on the cell surface allowed

the deﬁnition of the majority of hematopoietic stem cells as related to endothelial

cells in vivo [46].

Four possible models of a bone marrow stem cell niche have been depicted:

(1) the ﬁrst relies on adherence of HSCs to perivascular cells and is inﬂuenced by

nearby endosteal cells; (2) according to the second model stem cells may reside in

endosteal niches but can migrate and are subsequently controlled in the perivascular

microenvironment by perivascular cells; (3) in the third, stem cells reside in

spatially distinct endosteal and perivascular niches; (4) in the last model the stem

cells exist in a niche with equal contributions from endosteal and perivascular

cells [48].

A positive role of osteoblasts (osteogenic endosteal lining cells) has been

depicted using constitutively active PPR (col1-caPPR) under the control of the

a1 (I) collagen promoter active in osteoblastic cells in a transgenic mouse. These

mice, which had an increased number of trabeculae and trabecular osteoblasts,

presented a signiﬁcantly higher stem-cell-enriched lineage negative (Lin



) Sca-1

c-Kit

subpopulation of cells as compared to the wild type animals. This increase

was found to be stroma-determined, yet the number of cells in G0 vs G1 was not

different between the two types. Furthermore, the PPR activation on the osteoblasts

increased the overall production of Jag1 thereby activating Notch signals which led

to the expansion of the stem cell fraction [57].

Furthermore, it has been shown that cell-to-cell contact between osteoblasts and

hematopoietic stem cells ensures hemopoietic stem cell survival. The physical

adjacency of CD34+ bone marrow cells to the osteoblasts triggers the release of

several cytokines such as interleukin (IL)-6, leukemia inhibitory factor (LIF),

transforming growth factor-b1 (TGF-b1), macrophage inhibitory protein-1a,

hepatocyte growth factor (HGF), CXCL12, and IL-7. It has been suggested that

quiescent hematopoietic stem cells are maintained by close contact with osteoblasts

while their proliferation and differentiation is a function of endothelial cells [46].

Quiescent long-term populating hematopoietic stem cells (LT-HSCs) were

found to express Tie 2 tyrosine kinase receptor that interacts with Angiopoietin-1

(Ang)-1 secreted by osteoblasts [58]. They have also been found to be attached to

N-cadherin osteoblasts where increased numbers of LT-HSCs were found to be

associated with an increase of CD45



N-cadherin

osteoblastic cells presenting

evidence for the role of N-cadherin in supporting HSCs [59]. However, others have

Bone Marrow Stem Cells in Clinical Application: Harnessing Paracrine Roles 273

shown that N-cadherin is not essential for proper hematopoiesis. Through genetic

deletion of N-cadherin from HSCs in adult Mx-1



Cre

N-cadherin

ﬂ/

mice, no

effects on hematopoietic stem cell maintenance were found. It remains possible that

the effect of N-cadherin deﬁciency acts indirectly or that a subset of HSCs do not

rely on N-cadherin to localize to the endosteum, and again raises the possibility of

perivascular niches [60,61]. Supportive facts seem to point to hematopoietic stem

cell localization to different niches with diverse effects on their properties.

Further evidence for the role of osteoblasts in preserving the quiescent state of

HSCs comes from models aiming to devise the osteoblastic niche in vitro. By

coculturing osteoblastically differentiated human mesenchymal stem cells with

megakaryocytes in the presence of hypoxia, maturation and differentiation of

megakaryoctyes into proplatelets was prevented. At the same time, this dynamic

interaction led to the deposition of more regularly oriented ﬁbrillar collagen by the

human osteoblasts. This in turn led to a feedback inhibitory effect on proplatelet

formation mediated through a binding with the integrin a2b1 receptors [62].

In considering the role played by the cells of the osteoblastic cell lineage in the

HSC niche, one should notice the major role which is apparently played by stromal

preosteoblast cells rather than mature osteoblasts [63]. This sheds light on the rather

crucial role that bone marrow mesenchymal stem cells play in regulatory mechan-

isms of the hematopoietic stem cell niche.

The endochondral ossiﬁcation route to bone formation also provides additional

evidence for modulator functions within the hematopoietic stem cell niche where

the formation of a hematopoietic territory appears to take place only via endochon-

dral ossiﬁcation [16]. Upon ectopic transplantation of mesenchymal stem cells,

only CD105

Thy1



mesenchymal stem cells were found to reconstitute both bone

and marrow, i.e., they reconstituted a niche generating environment. This was

explained by the fact that CD105

Thy1



formed bone through a cartilage interme-

diate whereas CD105

Thy1

cells did not. Expression of osteoblastic markers was

found to be ﬁvefold higher for the latter cells. The mechanism of niche generation

was initiated by formation of donor-derived chondrocytes which then recruited

host-derived vasculature into the center of the developing graft. As endochondral

ossiﬁcation progressed, hematopoietic centers began to appear ﬁrst by appearance

of erythroid and myeloid, followed by c-kit

progenitors, and ﬁnally the HSCs [16].

This evidence also poses questions as to the optimal differentiation route

required to optimize bone engineering in a bone marrow mesenchymal stem cell

based approach in vivo [64–67]. This is of the utmost clinical relevance and should

be used in the future to develop more targeted strategies for tissue engineering, in

particular by providing enhanced vascularization. Prepriming of bone marrow

mesenchymal stem cells for bone engineering is a rapidly evolving issue for clinical

exploitation but it is beyond the scope of this review.

Cross-talk between hematopoietic stem cells and various niche cells has also

been demonstrated through other models [62,68]. Ex vivo real time imaging of

stem cells has shown dynamic interaction between HSCs and the bone marrow

upon their transplantation in irradiated mice. The HSCs preferentially homed to the

endosteal region, yet this preference disappeared in the absence of bone marrow

274 R.M. El Backly and R. Cancedda

damage. A mechanism was proposed through expression of SDF-1(CXCL12)

which had an increased expression in the trabecular bone area in response to

irradiation. In the central marrow zone, vascular signals appear to predominate

and the presence of bone marrow damage may give rise to a transient stimulatory

environment where osteoblastic signals are reduced and vascular signals are

enhanced [60].

The correlation between HSCs and MSCs has likewise been studied. The spatial

relationships within the niche through cell-to-cell contacts studied in a three-com-

partment coculture system of HSCs and MSCs provide insight into their behavioral

interconnectivity. Within this system, the cellular localization of HSCs in relation to

MSCs affected their expansion. HSCs that had migrated beneath the MSCs retained

their stem cell characteristics and proliferated more slowly. b1 integrins and the

SDF-1/CXCR4 axis were involved in their migration beneath the feeder layer of

MSCs [69]. It has also been shown that contact with MSCs alters the migratory

behavior and genetic proﬁles of CD133+ HSCs ex vivo [70]. Others showed the

importance of MSCs in maintaining the hematopoietic environment [71].

Nonetheless, the intricate bond between HSCs and MSCs seems to rely on

more than just their physical coexistence. Cotransplantation of HSCs with naı

¨ve

MSCs alone did not seem to support their self-renewal whereas b-catenin-acti-

vated MSCs gave rise to a 4.5-fold increase in the frequency of competitive

repopulating units (CRUs) while bone marrow cellularity remained normal.

This implies activation of Wnt/b-catenin signals, a concept which may be

employed to enhance engraftment of allogeneic transplanted HSCs for patient

therapy. It also denotes that successful engraftment may require the preexistence

of an activated niche environment [72].

Furthermore, three-dimensional spheroidal culture encompassing noninduced

and 1-week osteoblastic induced human bone marrow stromal cells were con-

structed. In this model, hematopoietic CD34+ cells were seen to migrate freely

and lodge to and from the spheroids and could maintain a hematopoietic conductive

environment; however,the osteo-induced BM-MSCs displayed more strained

migration. Speciﬁc localization of the CD34+ cells was shown only in mixed

spheroids containing both BM-MSCs and osteo-induced BMSCs, showing that

both BM-MSCs and active osteoblasts are required for an informative microenvi-

ronment. CXCL12 expression increased in the BM-MSCs in the presence of

hypoxia [73].

Recent relevance has been given to oxygen levels in the niche microenvironment

with discernible proof of the detrimental effects of high oxygen levels on self-

renewal of HSCs. Engraftment potential and primitive phenotypes of HSCs appear

to be maintained in a hypoxic environment [58]. Slow-cycling HSCs appear to exist

in hypoxic zones close to the bone surface and distant from capillaries [74]. SDF-1,

which has been shown to be important for HSC homing, is induced by hypoxia

inducible factor-1 (HIF-1) and has been found to be abundantly expressed in

hypoxic areas of the bone marrow [75].

It is possible that a hypoxic environment functions as a protective mechanism to

maintain a pool of quiescent stem cells [58,62]. This knowledge can again be

Bone Marrow Stem Cells in Clinical Application: Harnessing Paracrine Roles 275

tailored to clinical application as many of the diseases showing beneﬁcial effects

with bone marrow stem cell therapy share a common phenomenon of oxygen

deprivation. Creation of hypoxic zones could provide an effective method of

enhancing stem cell recruitment to ischemic tissues and improving repair capabil-

ities. However, the exact oxygen concentration and its duration are not irrefutable and

require additional studies, although MSCs cultured in 1% O

appear to have reduced

proliferation in culture supplemented with platelet lysate over prolonged durations

and this appears to be a protective mechanism against DNA damage that may arise

with successive replications as well as from free oxygen radical species [76].

Concomitantly shown is the fact that the alterations in the bone marrow micro-

environment may be a causative factor in the development of diseases with osteo-

lytic bone lesions such as multiple myeloma. However, repair of these bone lesions,

that should operate through mesenchymal stem cells, does not occur in these

patients [77]. Similar observations on disease associated changes of the bone

marrow niche have been reﬂected through the altered colony forming efﬁciency

(CFE) of bone marrow stromal cells in a multitude of metabolic, skeletal, and

hematological pathologies [78].

As for the long-standing debate as to the location and origin of the bone marrow

mesenchymal stem cell and, in turn, the deﬁnition of its niche, the European

GENOSTEM consortium has recently published an extensive report. They accu-

rately deﬁne native bone marrow mesenchymal stem cells to be located on the

abluminal side of endothelial cells in sinusoids and that they are the same entity as

the stromal cells forming the hematopoietic stem cell niche [79]. It has also been

demonstrated by others that mesenchymal stem cells may have originated from the

pericytes. Isolated puriﬁed pericytes display multipotency and secretion of multiple

growth factors similar to those secreted by MSCs. They also express all commonly

accepted MSC markers, including CD44, CD73, CD90, and CD105. This could

explain the continued presence of progenitor cells with multilineage potential found

in virtually all organs. They go further as to illuminate the possibility of the

existence of an even more primitive stem cell in human vascular structures [80,81].

Based on the GENOSTEM experience, they deduce that bone marrow mesen-

chymal stem cells may in the future be selected using markers of marrow mural/

pericyte cells as they have been shown to be multipotential yet preferentially

primed to differentiate along mesenchymal and vascular smooth muscle lineages.

They also conclude that bona ﬁde stem cells are in fact those that represent clonal

highly proliferative culture expandable cells [79].

2.2 Niche Mechanisms and Bases for Stem Cell Homing

and Recruitment

Migration, homing, and recruitment of bone marrow stem cells are reliant on their

respective niches and their interaction mechanisms. In the previous sections, cell–

cell communications within the niche have been discussed with some clariﬁcations

276 R.M. El Backly and R. Cancedda

as regards mechanisms controlling these interactions, yet stem cell trafﬁcking is a

whole new face of the coin.

It has been shown from a number of clinical trials that bone marrow derived stem

cell therapy may provide an efﬁcient means of reconstituting host bone marrow.

This may occur through mechanisms involving the recapitulation of signals

required to reestablish an appealing host niche, as successful engraftment relies

on the availability of open niches with low turnover rates that will support self-

renewal, maturation, and differentiation (Fig. 1). Homing is essentially a multi-

cascade process that involves intravascular dissemination of stem cells coupled

with active migration occurring both before and after the dissemination step. For

efﬁcient homing to take place, the cells arriving at the target site must distinguish

target-speciﬁc signals and enter into a multistep adhesion cascade to adhere to

vessel walls in the target organ. Interstitial migration, which is another trafﬁcking

mechanism, differs from homing in that it does not require blood ﬂow yet necessi-

tates active ameboid movement of the cells [82].

CXCL12 and angiopoietin-1 expression has been found in endosteal as well as

perivascular cells and are thought to be important regulators important for their

maintenance [50]. Notch and Wnt signaling have also been suggested although they

Fig. 1 Schematic diagram depicting some of the numerous stem cell niche interactions and

speciﬁc roles within played by hematopoietic and mesenchymal stem cells during homeostasis

and injury

Bone Marrow Stem Cells in Clinical Application: Harnessing Paracrine Roles 277

may not be necessary for adult HSC maintenance in stable conditions but rather

upon stress induction. Coordinated processes of symmetric and asymmetric divi-

sion could also contribute to maintenance of HSCs [48].

A concise review has summed up the major cell-extrinsic factors within the bone

marrow microenvironment that are mostly responsible for hematopoietic stem cell

regulation. The CXCL12/CXCR4 axis is important for controlling retention of

HSCs within the bone marrow as well as the presence of calcium sensing receptors

on the surface of HSCs, and a lack of osteopontin may lead to increase in the HSC

pool. N-Cadherin appears to play a role although it continues to be controversial

and so does the role of Jagged-1 in the activation of Notch1 pathways. On the other

hand, maintenance of a quiescent population of HSCs appears to be clearly linked to

stem cell factor (SCF), Ang-1, and thrombopoietin [63]. These are in addition to

Annexin II, very late antigen-4 (VLA-4)/ﬁbronectin (FN) or vascular cell adhesion

molecule-1 (VCAM-1) and leukocyte function associated antigen-1 (LFA-1)/inter-

cellular adhesion molecule-1 (ICAM-1) [46].

Some cell intrinsic factors have also been identiﬁed. Profound exploration of

intercellular signals reveals molecular mechanisms involved in cellular crosstalk

in the bone marrow niche. Upon hematopoietic progenitor and osteoblast cell

contact, intercellular transfer takes place. Parts of the hematopoietic progenitor

cell membrane are endocytosed at the interface by osteoblasts and delivered to

SARA (Smad Anchor for Receptor Activation) – positive signaling endosomes.

SARA endosomes specialize in the propagation of extracellular signals such as

TGFb3 and are known to signal through SMAD activation. In response to intercel-

lular transfer, the osteoblasts exhibit greater production of SDF-1 as consequence of

a decreased SMAD signaling. This probably occurs because the transferred material

in the SARA endosomes sequesters SARA away from its cofactor function in

SMAD activation leading to increased SDF-1 production. The cumulative result

of these events may inﬂuence migration, homing and function of hematopoietic

progenitors [83].

Microvesicles (MVs) which are vehicles for mRNA transport have been incri-

minated in intracellular niche communications as well. They interact with cells

through speciﬁc receptor ligand interactions leading to direct cell stimulation or by

cell surface receptor transfer. Endothelial stem cells (ESCs) are an ample source of

MVs and ESC derived MVs can reprogram hematopoietic progenitors by a hori-

zontal transfer of mRNA and protein delivery. The ESC derived MVs can shuttle a

speciﬁc subset of cellular mRNA such as that associated with eNOS and P13K/

AKT pathways [84].

Hematopoietic stem cell homing and migration show a strong involvement of

CD41/integrinab2 during mouse embryogenesis stem cell trafﬁcking. CXCR7 may

also be involved. A switch from rapid proliferation to quiescence takes place

shortly after HSC homing to bone marrow. The Egr1 transcription factor is the

direct molecular link between HSC proliferation and in vivo localization [69,82].

In addition, CCR2 has been identiﬁed as a possible player during hematopoietic

stem cell recruitment to the damaged liver in mice, as active recruitment occurred

only in wild type mice and not in CCR2

/

mice [85].

278 R.M. El Backly and R. Cancedda

For hematopoietic stem cell reengraftment in the host bone marrow, it is likely

that preexisting pathways normally used to support HSC physiological circulation

to maintain hematopoiesis are also involved to guide efﬁcient engraftment. In vivo

stem cell homing and migration patterns, however, vary between stem cell lineages

and rely to a great extent on how they normally interact with their niches. By

understanding these innate migratory mechanisms, stem cells may be exploited as

clinical drug or gene delivery vehicles with precise aiming properties [82].

A unique multistep adhesion cascade for HSC homing involves, ﬁrst, free-

ﬂowing HSCs being tethered to the vessel by the vascular selectins, E- and

P-selectin, which bind to sialyl-Lewis-like carbohydrate ligands that are associated

with PSGL-1 and CD44 on HSCs. Selectin binding, together with engagement of

endothelial VCAM-1 with the integrin VLA-4 (a4b1), mediates HSC rolling in

marrow sinusoids. The rolling HSCs are then activated by the chemokine CXCL12,

which binds to the G protein-coupled receptor, CXCR4. The chemokine signal is

thought to induce a rapid conformational change in the VLA-4 heterodimer (VLA-4)

that results in increased afﬁnity for VCAM-1 and permits the rolling cells to arrest.

Adherent HSCs then migrate into the extravascular bone marrow compartment.

Some blood-borne HSCs exit the blood in various peripheral organs where they

spend almost 36 h before entering the draining lymphatics. While in peripheral

tissues, HSCs can divide and differentiate, presumably to replenish tissue-resident

myeloid cells. Through this mechanism, migratory HSCs contribute to immune

surveillance by the innate immune system [82].

Hematopoietic stem and progenitor cells (HSPCs) apparently also follow extra-

medullary trafﬁc routes shown by the presence of clonogenic HSPCs in mouse

thoracic duct lymph, which are capable of short and long-term multilineage recon-

stitution. HSPCs travel to extramedullary sites where they remain for 2 days before

they enter the draining lymphatics and return to the blood. The release of tissue-

residing HSPCs into lymphatics seems to occur in response to a lipid S1P gradient

which in a similar way regulates the egress of lymphocytes from thymus, spleen,

and lymph nodes. This mechanism may serve as part of the innate immune system

by which quiescent HPSCs which express TLRs (TLRs recognize foreign mole-

cules such as the bacterial outer membrane component LPS) are forced to enter the

cell cycle of myeloid differentiation upon TLR-LPS binding to provide large

numbers of cells to boost the number of innate immune effector cells in response

to infection or damage [86].

As for migratory mechanisms invoked by mesenchymal stem cells injected in

AMI, these maybe confronted with those utilized by leucocytes in response to

inﬂammation. Inﬂammation-released chemokines trigger an intense release of

integrins which propagate ﬁrm adhesion to extracellular components followed by

their migration from the endothelium through the extracellular matrix (ECM) via

the action of ECM degrading matrix metalloproteinases (MMPs). Of these MMPs,

MT1-MMP appears to control human MSC collagenolysis and invasion as well as

controlling MSC differentiation in 3D in a speciﬁc fashion [87]. The adhesion

cascade constitutes several steps which start with tethering and rolling, followed

by a chemotactic/activating stimulus provided by soluble or surface-bound

Bone Marrow Stem Cells in Clinical Application: Harnessing Paracrine Roles 279

chemoattractants, and ﬁnally sticking. Both selectin and integrin mediation appear

crucial for adhesion [82,88,89].

Integrin-mediated adhesion is mandatory if the cells are to cope with shear

stresses encountered associated with transendothelial migration. Yet although this

maybe the probable mechanism, critical chemokines speciﬁcally responsible for

MSC migration remain under speculation. It is factual that MSCs have been shown

to express various adhesion molecules including CD106 (VCAM-1), CD54

(ICAM-1), CD50 (ICAM-3), CD166 (ALCAM), CD44, and integrins including

a1, a2, a3, a4, a5, av, b1, b3, and b4, many of which are thought to be involved in

migration. In particular, high levels of expression of CD44 by MSCs may be

directly responsible as blocking CD44 expression markedly reduces the migration

of MSCs to damaged kidneys in mice. Signal transduction pathways have gained

less attention although Wnt signaling has lately been pinpointed as vital for

migration, yet may negatively affect self-renewal properties [88,89].

In animal models of AMI, myocardial ischemia is found to be responsible for

the release of CCL2 (MCP-1), CCL3 (MIP-1a/), CCL4 (MIP-1b), CXCL8 (IL-8),

CXCL10 (IP-10), and CXCL12 (SDF-1). At the same time, MSCs have been found

to express CXCR4 which allow them to migrate in response to CXCL12. However,

their expression of CXCR4 appears to be reduced with ex vivo expansion, yet can

be enhanced by stimulation with cytokines Flt-3 ligand, SCF, interleukin (IL)-6,

HGF, and IL-3. Electin-mediated adhesion has also been suggested to be involved

despite the presence of fucosyl transferase in MSCs; an enzyme necessary to

generate functional P and E-selectin receptors, remains contradictory in the sense

that some researchers have found that MScs have fucosyl transferase (necessary for

functional P and E selectin binding) while others (discussed in this reference) have

found that they DO NOT have the enzyme and so doubt the involvment of P and E

selectin adhesion in MSc migration [88].

High mobility group box 1 (HMGB-1) as well as SDF-1aact as strong chemoat-

tractants for a variety of cell types including stem cells. HMGB-1 is a chemoattractant

released during inﬂammation and cell necrosis and may be involved in recruitment.

Furthermore, Rho GTPases which function during adhesion and migration events

through actin cytoskeletal regulation have been investigated in trafﬁcking of MSCs.

However, neither the Rho nor the Rho effector Rho kinase (ROCK) were found

crucial for migration of MSCs in a 3D model. Although others have shown that Rho

inhibition induced cytoskeletal reorganization in MSCs, rendering them more sus-

ceptible to induction of migration, data remain inconclusive. On the other hand,

enhanced migration velocity of MSCs in response to PDGF-B activated ﬁbroblasts

points to a positive role of growth factor (bFGF) and epithelial neutrophil activating

peptide-78 (ENA-78 or CXCL5) in mediating MSC trafﬁcking. Blocking both bFGF

and CXCL5 inhibited both trafﬁcking and differentiation of MSCs while invasion

and migration were enhanced when these factors were added exogenously [89].

The SDF-1/CXCR4 axis has repeatedly been shown to play a major role

in migration and homing of both mesenchymal and hematopoietic stem cells

[82,90–93]. Hematopoietic stem cells are retained within the bone marrow in a

quiescent state by virtue of the SDF-1a/CXCR4 axis, and their mobilization may be

280 R.M. El Backly and R. Cancedda

effectively brought about by CXCR4 antagonist coupled with G-CSF treatment,

while this same regimen did not effectively mobilize endothelial or stromal pro-

genitor cells. However, when pretreatment with VEGF was administered, hemato-

poietic stem cell mobilization was suppressed while the mobilization of endothelial

progenitor cells was enhanced. Exogenous VEGF stimulated the hematopoietic

stem cells to enter into the cell cycle, thereby hindering their migration afﬁnity,

whereas it had no effect on endothelial or stromal progenitor cells that retained their

ability to migrate in response to administration of CXCR4 antagonist. The effect is

only noticed after a few days of pretreatment with VEGF as acute administration

did not interfere with endothelial progenitor cell mobilization [91]. Such selective

recruitment patterns raise questions as to the therapeutic implications of clinically

established protocols and may offer some explanation for some of the disappointing

results obtained from some clinical trials.

SDF-1 is up-regulated at sites of bone injury and partakes in endochondral bone

repair. Using live and dead bone graft models, SDF-1 expression was shown to be

increased markedly in the acute phase of repair in only the live graft periosteum,

certifying its role for successful bone healing. Intravenous injection of BMSCs leads

to their rapid recruitment to the live graft lesion while blocking CXCR4 using an

antagonist inhibited their migration. CXCR4

+/

and SDF-1

+/

mice show marked

reduction in callus formation and exchanging live grafts between CXCR4

+/

and

SDF-1

+/

mice revealed that, while live bone grafts from CXCR4

+/

into SDF-1

+/

mice could restore decreased bone formation by as much as 52%, the opposite had no

such effect [92].

Also worth noting is the migration of osteogenic bone marrow MSCs during the

bone remodeling cycle to sites where bone resorption is underway to start a coupling

process between bone resorption and formation. Active TGFb1 is released from the

bone matrix in response to osteoclastic bone resorption which induces migration of

BMSCs through SMAD family transduction proteins. Depletion of TGF-b1 in mice

resulted in massive trabecular bone volume loss, and when these mice received

BMSC transplants the cells failed to migrate to the bone surface, showing the

essential role of TGF-b1 in inducing migration [94]. From the clinical perspective,

the use of bone marrow derived mesenchymal stem cells as a therapy approach for

skeletal diseases such as osteoporosis, arthritis, infantile hypo-phosphasia, and

osteogenesis imperfecta may be useful, whether these cells are to be exploited by

virtue of their capacity to enhance bone repair and regeneration directly or indi-

rectly, or by their spectrum of trophic and immunomodulatory functions [95].

Mechanisms of mobilization and homing/recruitment are vital if stem cells are to

be therapeutically used in the clinic. When the mode of delivery is systemic,

homing/recruitment mechanisms are the main mechanisms that must be optimized

if the cells are to reach the target organs in high enough levels to bring about the

desired effect. However, when stem cells are to be utilized as local delivery

systems, the need for recruitment signals is surmounted by the need to sustain

survival, differentiation, and proliferation if these cells are to contribute directly to

local tissue repair. Whether the positive effects brought about by the cells are due

to a direct contribution to local tissue repair is uncertain as extensive evidence

Bone Marrow Stem Cells in Clinical Application: Harnessing Paracrine Roles 281

seems to point strongly to the paracrine role of injected MSCs as the main reason

for the therapeutic effects noticed.

3 Immunomodulation, Trophic Effects, and Angiogenic

Supporting Role of Bone Marrow Derived Stem Cells

The trophic effects of mesenchymal stem cells are portrayed by their ability to home

to injured tissues and secrete an array of bioactive macromolecules or paracrine

factors that are both immunoregulatory as well as regenerative. These capacities lie

at the very heart of what is regenerative medicine. It is possible that human MSCs

undergoing logarithmic growth are comparable to those that arrive in vivo to sites of

injury or ischemia aiming to recuperate lost tissue, since 24 h of MSC culture under

osteogenic (+dex, +ascorbate) or stromagenic conditions (+IL-1a) yields

conditioned medium with a variety of secreted bioactive molecules such as G-

CSF, GM-CSF, M-CSF, LIF, IL-6, IL-11, SCF, IL-3, TGFb2, and OSM [96].

MSCs have been described to have strong immunosuppressive effects displayed

through their ability to inhibit TNFaand INFgsecretion, thus increasing IL-10

secretion, thereby inhibiting T-cell response. This has been supported by the positive

effects of allogeneic MSC transplantation to combat GVHD. However, the behavior

of MSCs towards the immune system is context sensitive. Low doses of INFgcause

MSCs to express class II major histocompatibility complex (MHC) causing them to

behave as antigen presenting cells, while high doses decrease the surface expression

of class II MHC and lead to secretion of antiinﬂammatory factors [96,97]. The

presence of proinﬂammatory cytokines is necessary to trigger the immunosuppres-

sive function of MSCs [98]. Several reports have noted the need for INFgto promote

the immunosuppressive effects of MSCs; however, others have shown that INFg

alone is insufﬁcient and that the costimulatory activity of either TNFaor IL-1 is

required. Nitric oxide (NO) appears to mediate this function. Inducible nitric oxide

synthase (iNOS) is upregulated in MSCs stimulated by inﬂammatory cytokines and

the immunosuppressive properties of MSCs are not observed in iNOS deﬁcient mice.

The inherent secretory active nature of MSCs allows them to render a regenera-

tive microenvironment at the site of tissue injury or destruction. This has been duly

shown in models of myocardial ischemia whereby the trophic effects of MSCs

served to inhibit apoptosis and scarring, stimulated angiogenesis, as well as induced

mitosis of tissue residing stem or progenitor cells [96]. Activation of the paracrine

pathway of autologous transplanted BMSCs has been achieved in a pig model

with acute myocardial ischemia upon the coimplantation of a (bFGF)-incorporated

degradable stent (TMDRSI). This method enhanced survival and differentiation of

transplanted cells, thereby augmenting their effects on myocardial remodeling [99].

In a similar manner, speciﬁc populations of bone marrow derived mesen-

chymal stem cells have been shown to have superior paracrine effects. Stro-1

mesenchymal precursor cells isolated from BM have a tenfold enhanced clonogenic

efﬁciency compared to their plastic adherence selected counterparts. This speciﬁc

282 R.M. El Backly and R. Cancedda

subpopulation has enhanced paracrine effects as conditioned media from these cells

have a much higher capacity to induceendothelial cell migration and endothelial tube

formation in vitro as well as superior effects on target cardiac muscle cells [100].

Trophic effects of bone marrow derived mesenchymal stem cells can also be

harnessed to promote evolution of noninvasive myocardial stem therapy regimens.

Available data from several reports supports the contribution of injected cells,

mainly through their paracrine effects [101,102]. Intramuscular injection of

BMSCs and BMSC-conditioned media in a hamster model of heart failure showed

that, although the cells appeared to be trapped in the muscle, they were capable of

bringing about a multitude of effects that ultimately stimulated active heart regen-

eration. Myocyte regeneration was evident by the expression of cell cycle markers.

Circulating levels of HGF, LIF, and macrophage colony-stimulating factor were

associated with the mobilization of c-Kit-positive, CD31-positive, and CD133-

positive progenitor cells and with the subsequent increase in myocardial c Kit-

positive cells. These should be c-Kit

, CD31

, CD133

. Trophic effects of BMSCs

further activated the expression of HGF, IGF-II, and VEGF in the myocardium,

emphasizing the precise molecular cross-talks that took place between the injected

BMSCs and the host bone marrow compartment and heart. Hopefully, by accurately

evaluating effectiveness of this regimen, in the future one may overcome present

clinical drawbacks of intramyocardial or intracoronary injection [102].

Such intricate cross-talks can also be displayed in ectopic mouse models of bone

regeneration. It has been reported that most of the bone marrow derived sheep

mesenchymal stem cells incorporated within ceramic scaffolds disappeared shortly

after implantation, and that within 48 h a large percentage of apoptotic cells could

be observed [103]. In spite of this fact, bone regeneration still occurred in the

ectopic implants as possibly due to the presence of a small number of apoptosis-

resistant BMSCs capable of surviving and regaining their proliferative nature.

However, mouse BMSCs implanted in ceramic scaffolds into syngeneic mice

gave rise to bone of host origin [104,105]. Host cells recruited to the implants at

7 days were shown to be a CD31+ enriched population while 11 days after implan-

tation a CD146+ enriched population could be recovered. The latter was dependent

on the preoccurrence of the ﬁrst wave of recruited endothelial progenitor rich

population. It was proposed that the exogenous BMSCs release numerous factors

in the immediate implant vicinity, thus creating a likable microenvironment to

support recruitment of host cells. This fact, combined with newly formed vascular

networks, can facilitate the cellular cross-talk between the implant milieu and the

host circulation system facilitating the recruitment process. The strong trophic

effects noticed in this work with the formation of bone from host origin may be

attributed to the implantation of less committed MSCs that are capable of boosting

the host response to trigger intrinsic repair as opposed to a more osteogenic com-

mitted phenotype that would be tempted to initiate a bone formation cascade.

In addition to the previously mentioned effects, MSC conditioned media has also

been found to stimulate differentiation processes of certain cell types such as from

neural progenitor cells to oligodendricytes. Therefore, the trophic effects of MSCs

can be summed up into antiapoptotic, supportive (stimulate mitosis, proliferation,

and differentiation), and angiogenic [96,97].

Bone Marrow Stem Cells in Clinical Application: Harnessing Paracrine Roles 283

The antiapoptotic effects of MSCs are a function of increased levels of vascular

endothelial growth factor (VEGF), insulin-like growth factor 1 (IGF-1), and HGF

all of which enhance endothelial cell growth and survival. Secretion of GM-CSF,

bFGF, and TGF-bhas also been reported. Hypoxic culture conditions increase the

production of these growth factors, hence explaining antiapoptotic roles of MSCs

aiming to minimize cell death as hypoxia occurs in the early stages of injury. bFGF

and HGF also contribute to the anti-scaring effects of MSCs by reducing ﬁbrosis,

while VEGF, bFGF, placental growth factor (PlGF), and MCP-1 secretion enhance

angiogenesis. The secretion of SDF-1 by MSCs aims to retain a pool of quiescent

hematopoietic stem cells while the secretion of a larger spectrum of chemoattrac-

tant chemokines accounts for the MSC involvement in homing and recruitment

mechanisms of a variety of cell types [97].

A major trophic effect of bone marrow derived stem cells deals with their direct

and indirect involvement in angiogenesis. Cotransplantation of human bone marrow

derived hematopoietic and mesenchymal stem cells in an ectopic model of bone

regeneration has been shown to enhance angiogenesis in the implants. The human

hematopoietic cells formed stable anastomosis with host vasculature enlightening

vascular signaling provided by transplanted cells [52]. When VEGF was added to this

model, vessel number and diameter increased; however, bone regeneration capacity

wasreduced.ThisispossibleasVEGFstimulates endothelial differentiation of CD34+

hematopoietic stem cells which have been previously shown to contribute themselves

to osteocalcin expression and engraft at fracture healing sites [106].

In a novel 3D coculture system, BM-MSCs were cultured with human umbilical

vein endothelial cells (HUVECs). In this model, 3D lawns of ﬁbroblasts (multi-

layers) were ﬁrst created, then on top of these lawns HUVECs were seeded in

conjunction with BMSCs. The incorporation of BM-MSCs along with HUVECs led

to development and stabilization of tube-like vascular structures in vitro. Further-

more, a subset of the BMSCs was closely coaligned with the newly formed vascular

structures [107]. In parallel studies, coculturing BM-MSCs with endothelial cells

elicited a time- and dose-dependent increase in vessel formation. The number of

sable vessels formed increased when higher proportions of BM-MSCs were used

and with longer culture times [108]. As strategies aiming to enhance angiogenesis

are at the core of regenerative medicine, discovering the active contribution of bone

marrow derived stem cells to angiogenesis is of major interest in the ﬁeld.

4 Concluding Remarks

The various effects of bone marrow stem cells make them likely candidates for the

leap into clinical regenerative medicine and tissue engineering (Fig. 2). The appli-

cations are innumerable and will be surpassed only by the further discovery of

additional roles for BMSCs in development, disease, and tissue repair [109].

To arrive at deﬁned clinical applications of bone marrow stem cell therapy,

meticulous reappraisal appears necessary and the lack of wider scale standardized

284 R.M. El Backly and R. Cancedda

clinical trials makes it a difﬁcult task. The exact mechanisms by which these cells

function in vivo after transplantation remain highly enigmatic. Data from clinical

trials show that there are undoubted beneﬁts and the safety of the procedures has

been well established, yet, a more profound understanding of the multidimensional

aspects of bone marrow stem cell homing, recruitment, and engraftment in vivo is

mandatory. More stringent parameters need to be applied to isolate, expand, and

characterize these cells if these methods are to move forward as established

therapeutic regimens suitable for clinical use. Regenerative medicine has evolved

as a growing ﬁeld aiming to harness the body’s innate capacity for regeneration;

yet, the comprehensive understanding of these processes still requires delving deep

into the basic blocks of developmental biology.

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292 R.M. El Backly and R. Cancedda

Adv Biochem Engin/Biotechnol (2010) 123: 293–317

DOI: 10.1007/10_2010_77

#Springer-Verlag Berlin Heidelberg 2010

Published online: 27 August 2010

Clinical Application of Stem Cells

in the Cardiovascular System

Christof Stamm, Kristin Klose, and Yeong-Hoon Choi

Abstract Regenerative medicine encompasses “tissue engineering” – the in vitro

fabrication of tissues and/or organs using scaffold material and viable cells – and

“cell therapy” – the transplantation or manipulation of cells in diseased tissue

in vivo. In the cardiovascular system, tissue engineering strategies are being

pursued for the development of viable replacement blood vessels, heart valves,

patch material, cardiac pacemakers and contractile myocardium. Anecdotal clinical

applications of such vessels, valves and patches have been described, but informa-

tion on systematic studies of the performance of such implants is not available, yet.

Cell therapy for cardiovascular regeneration, however, has been performed in large

series of patients, and numerous clinical studies have produced sometimes

conﬂicting results. The purpose of this chapter is to summarize the clinical experi-

ence with cell therapy for diseases of the cardiovascular system, and to analyse

possible factors that may inﬂuence its outcome.

Keywords Cell therapy, Heart, Regeneration, Stem cells

C. Stamm (*)

Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Augusten-

burger Platz 1, 13352 Berlin, Germany

Berlin-Brandenburg Center for Regenerative Therapies, Berlin, Germany

e-mail: stamm@dhzb.de

K. Klose

Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Augusten-

burger Platz 1, 13352 Berlin, Germany

Y.-H. Choi

Department of Cardiothoracic Surgery, Heart Center and Center of Molecular Medicine Cologne,

University of Cologne, Cologne, Germany

Contents

1 Clinical Background . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . 294

2 Myocardial Regeneration Concepts .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . 295

2.1 Direct Regeneration . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295

2.2 Intrinsic Cardiac Regeneration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . 297

2.3 Indirect Regeneration . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . 297

3 The Development of Cardiac Cell Therapy .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . 297

4 Clinical Cardiovascular Cell Therapy . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298

4.1 Skeletal Myoblasts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298

4.2 Bone Marrow Mononuclear Cells in Acute Infarction .. . . . . . . . . . . . . . . . . . . . . . . . . . 299

4.3 MNC in Chronic Ischaemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . 299

4.4 MNC in Non-Ischaemic Heart Disease . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . 301

4.5 Puriﬁed Stem Cell Products . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301

4.6 Cytokine-Induced Bone Marrow Cell Mobilization .. . . . . . . . . . . . . . . . . . . . . . . . . . . . 302

4.7 Second Generation Clinical Cell Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . 303

4.8 Combination Treatments . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . 304

4.9 Foetal or Neonatal Stem Cells . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305

4.10 Paediatric Heart Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . 305

5 Clinical Translation Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . 306

5.1 Patient Selection . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . 306

5.2 Cell Delivery . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . 306

5.3 Timing . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307

5.4 Cell Survival . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . 307

5.5 Dose .............................................................................. 307

5.6 Age ............................................................................... 308

5.7 Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308

5.8 Legal Framework . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308

6 Future Clinical Cell Therapy Studies . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310

1 Clinical Background

Heart failure is not a uniform disease but has a variety of causes. Quantitatively, the

most important is clearly ischaemic heart disease, i.e. coronary artery disease.

Occlusion of a coronary vessel results in irreversible necrosis of the downstream

myocardium unless the vessel can be reopened within a few hours. Tissue remodel-

ling processes later lead to ﬁbrotic scar formation in the infarct area, but can also

affect neighbouring areas of still viable myocardium and may further impair

contractile function of the heart. The other causes of heart failure are usually

grouped together as “non-ischaemic” and include genetic predisposition, inﬂam-

matory heart disease (viral myocarditis, Chagas disease), toxic myocardial damage

(doxorubicin, alcohol, cocaine) and structural defects such as valvar disease or

congenital abnormalities. Often, however, the underlying cause cannot be clearly

established, and the term “idiopathic dilated cardiomyopathy” is used. If the onset

294 C. Stamm et al.

of heart failure is sudden and neither the heart itself nor the other organ systems

have had time to adjust to the reduced cardiac output, cardiogenic shock results.

The symptoms of this life-threatening situation are mainly the result of a reduced

blood ﬂow from the heart (low cardiac output). If heart failure develops more

gradually and allows the organism to exert compensatory mechanisms, symptoms

are often those of a reduced blood ﬂow to the heart (“congestive heart failure”).

According to Neumann et al., the incidence of heart failure requiring hospitalization

in Germany exceeds 300 per 100,000 population, and it is currently the most

frequent reason for hospital admission [1]. Predominantly older patients are at

risk of developing heart failure, and its prevalence among octogenarians is in the

range of 10–20%. Heart failure, chronic ischaemic heart disease and acute myo-

cardial infarction are the three most common causes of death, and the costs to the

German public health system amount to several billion Euros per year. According

to population-based studies, mortality within the ﬁrst year after diagnosis of heart

failure is nearly 40%, followed by an annual death rate of 10% in subsequent years.

For several decades, organ transplantation was the only solution for patients with

end-stage heart failure but, mainly due to the increasing donor shortage, it is

accessible only for a small proportion of patients. In addition, the side-effects of

life-long immunosuppression and transplant vasculopathy limit quality of life and

long-term graft function. More recently, mechanical assist device therapy is per-

formed not only as a bridge-to-transplantation, but also as the deﬁnitive therapy for

elderly patients, or patients who have comorbidities that preclude heart transplan-

tation. The design of such assist devices is constantly being improved, but antic-

oagulation management and infections of power supply lines traversing the skin

remain signiﬁcant problems [2]. Taken together, the current treatment options for

the vast majority of patients with heart failure are palliative, because the underlying

cause, a net loss of contractile cell mass, cannot be reversed with current therapeutic

means.

2 Myocardial Regeneration Concepts

Given the limited efﬁcacy of today’s palliative treatment options, the concept of

regenerating the diseased myocardium, i.e. improving its functional capacity by

restoring the normal tissue composition, is clearly intriguing. For a better under-

standing of the wide range of “regenerative” therapeutic concepts, a systematic

approach may be helpful (Figs. 1and 2).

2.1 Direct Regeneration

Actual de novo regeneration of contractile cells within the human heart requires the

transplantation of cardiomyocytes or their progenitors derived from pluripotent

Clinical Application of Stem Cells in the Cardiovascular System 295

stem cells. A large amount of experimental data exists for embryonic stem cells

(ESC), which can effectively re-generate myocardium but provoke ethical contro-

versies, a risk of teratoma formation and immunologic problems when used in

humans [3,4]. However, the possibility of producing pluripotent stem cells by

genetic reprogramming of somatic cells (induced pluripotent stem cells, iPSC) has

recently opened up exiting new possibilities [5].

Mechanism

Angiogenesis (growth of new blood vessels from pre-existing vessels)

• Vasculogenesis (spontaneous blood-vessel formation) and

• Intussusception (blood vessel formation by branching of existing vessels)

Arteriogenesis (increase in the diameter of existing arterial vessels)

Direct suppport of ischemic end-organ cells/tissues

Immunomodulation

Therapeutic

compounds

Physcial stimuli (hypoxia, hyperoxygenation, heat, ultrasound etc.)

Growth factors (gene therapy, protein delivery)

Cytokines

Somatic stem cells (HSC, MSC, Myoendothelial cells)

Endothelial progenitor cells

Cells overexpressing growth factors and/or cytokines)

Vasculature

Fig. 2 Regeneration of the vascular system. Here, the systematic approach shown for myocardial

regeneration is not applicable. The concepts shown are not only valid for the vasculature of the

heart, but also that of any other ischaemic tissue

Angiogenesis

Extracellular matrix

Protection of ischemic

cardiomyocytes

Immunomodulation

Contractile cell

replacement

Increased number of

functional

cardiomyocytes

Cardiomyocytes

proliferation

Activation and

differentiation of

resident CPC

Mechanism

Myocardium

ESC

iPS-derived

cardiomyocytes

Somatic stem cells /

progenitor cells

Growth factors

Laser revascularization

etc.

Genetic cell cycle

manipulation (Cyclins)

CPC activation

Therapeutic

compounds

Direct regenerationIndirect regeneration Intrinsic regeneration

Angiogenesis

Extracellular matrix

Protection of ischemic

cardiomyocytes

Immunomodulation

Contractile cell

replacement

Increased number of

functional

cardiomyocytes

Cardiomyocytes

proliferation

Activation and

differentiation of

resident CPC

Mechanism

ESC

iPS-derived

cardiomyocytes

Somatic stem cells /

progenitor cells

Growth factors

Laser revascularization

etc.

Genetic cell cycle

manipulation (Cyclins)

CPC activation

Therapeutic

compounds

Fig. 1 Systematic representation of myocardial regeneration strategies. Examples of the proposed

mechanism, its biological mediators, and the respective therapeutic compounds are listed

296 C. Stamm et al.

2.2 Intrinsic Cardiac Regeneration

Speciﬁc progenitor cells that reside in the heart (i.e. cardiac stem cells, cardiac

progenitor cells) may possess a therapeutically exploitable cardiomyogenic poten-

tial [6–8]. Alternatively, mature cardiomyocytes, which are terminally differen-

tiated and do not proliferate, might be forced to leave the G

resting phase and

re-enter the S-phase (DNA synthesis) of the cell cycle [9,10]. However, DNA

synthesis does not necessarily result in genome duplication, and genome duplica-

tion does not necessarily result in cytokinesis – division of the cell [9,11]

2.3 Indirect Regeneration

Somatic human stem cell and progenitor cell products cannot compensate for a loss

of contractile tissue in terms of de novo formation of cardiomyocytes [12]. They

are, however, able to exert a number of indirect beneﬁcial effects on the diseased

myocardium, including the support of angiogenesis and arteriogenesis, modulation

of extracellular matrix composition and manipulation of local immune processes

[13–16]. Moreover, somatic stem cells seem to be able to protect directly ischaemic

cardiomyocytes cell death and/or loss-of-function, but it is unclear whether this

phenomenon is clinically relevant [17,18].

3 The Development of Cardiac Cell Therapy

The goal of cardiovascular regenerative medicine is to restore heart function

primarily by biologic means such as the support of intrinsic regeneration processes

or the transplantation of exogenous cells. In the 1990s, the concept of cell trans-

plantation for heart failure evolved [19–21]. Initially, myocyte cultures and neona-

tal rodent cardiomyocytes were used for transplantation in animal hearts [22–25],

and the ﬁnding that transplanted contractile cells are able to incorporate in postnatal

myocardium was ground-breaking. Later, those cells were applied to experimental

models of myocardial infarction or non-ischaemic cryolesions, and it was shown

that there may indeed be a beneﬁt in terms of contractile function. However,

transplanted cardiomyocytes may not be able to survive in terminally ischaemic

infarcted tissue [26]. Skeletal muscle progenitor cells (satellite cells, skeletal

myoblasts), however, have a very high tolerance to ischemia, the capacity to

maintain contractile work even through prolonged periods of anaerobic metabo-

lism, and were shown to form contractile neo-tissue even in scar tissue after

myocardial infarction [20,27]. Indeed, skeletal myoblasts were the ﬁrst cells to

be used for clinical cell therapy, but they were found not to integrate into recipient

myocardium and the functional beneﬁt was very limited (see below).

Clinical Application of Stem Cells in the Cardiovascular System 297

In parallel to the transplantation of contractile cells, marrow-derived cells of

haematopoietic–pre-endothelial lineage were shown to be useful for the induc-

tion of angiogenesis in the ischaemic heart. The potent pro-angiogenic capacity

of marrow-derived cells was initially shown in the mouse hindlimb ischaemia

model, and Kocher and colleagues successfully used human CD34+ cells in a rat

model of myocardial infarction [13]. Here, the increased growth of small blood

vessels in the infarcted heart was associated with a marked improvement of

contractility. In large animals, however, the impact of neo-angiogenesis on

contractility is less pronounced, while in humans it is often negligible. The

most signiﬁcant – apparent – breakthrough, however, was reported in 2001

when C-kit+ lincells were isolated from the bone marrow of GFP expressing

transgenic mice and implanted in the infarcted myocardium of non-GFP-expressing

animals, and indeed both GFP+ blood vessels and contractile cells were visualized

[28]. The conclusion was that adult bone marrow stem cells can differentiate

into both endothelial cells and cardiomyocytes, driven by factors present in the

surrounding infarcted host myocardium. This report led to clinical pilot studies, in

which mainly autologous bone marrow mononuclear cells were delivered to the

hearts of patients with myocardial infarction. Other investigators doubted the

surprising plasticity of unmodiﬁed adult bone marrow stem cells, and reports

were published that, using state-of-the-art methods, failed to detect relevant

cardiomyocyte differentiation of murine bone marrow stem cells in vivo [29].

Controversy on this issue remains and variations in the technical details of the

various experiments are used to help explain the different outcomes. However,

even if some haematopoietic stem cells can be driven to express myocyte-speciﬁc

markers, the frequency of such events in humans is surely too small to produce

a signiﬁcant clinical effect [30]. Mesenchymal stem cells (MSC) from rodents

appear to have a greater myogenic potential, provided they are manipulated

genetically and/or epigenetically, but only a few studies have provided evidence

of functioning cardiomyocytes produced from human MSC in vitro [31–33]. In

addition, multipotent cells have been described that seem to belong to none of the

typical bone marrow cell compartments but do have a strong regenerative impact

on the heart [34]. It is, however, unclear whether such “stemness” characteristics

are true features of primary cells or have been induced by long-term cell culture.

4 Clinical Cardiovascular Cell Therapy

4.1 Skeletal Myoblasts

Clinical myoblast transplantation as part of a cardiac surgical procedure was ﬁrst

performed in 2001 [35]. Initial safety and feasibility studies were successful and

laid the foundation for the avalanche of cell therapy studies that were to come later

[36]. Once a large number of patients had undergone CABG and myoblast

298 C. Stamm et al.

transplantation, however, problems with ventricular arrhythmia were noted. It soon

became clear that skeletal myoblasts lack the capacity to couple electrically with

surrounding cardiomyocytes because they do not express the intercellular commu-

nication protein connexin 43 and thus do not form “connexon” ion channels that are

part of the gap junction typical for cardiomyocytes [37]. Several clinical trials using

skeletal myoblasts and catheter-based delivery devices are still ongoing [38–40],

but the majority of clinicians have abandoned skeletal myoblasts for treatment of

heart failure.

4.2 Bone Marrow Mononuclear Cells in Acute Infarction

In theory, no potentially important cell population is missed by transplanting the

entirety of nucleated marrow cells into the heart. On the other hand, vast numbers of

leukocyte progenitor cells are being delivered in addition to the actual stem cells,

and some have argued that more inﬂammation than regeneration is induced in

the myocardium. A clinically very relevant argument in favour of mononuclear

cells (MNCs) is their simple and speedy preparation. Traditionally, density gradient

centrifugation is used to separate bone marrow mononuclear cells (MNCs) from

other marrow components, and industry has developed several easy-to-use devices

for one-step preparation of MNC products in closed systems. Bone marrow

MNCs were the ﬁrst cell products to be used in patients with acute myocardial

infarction, where they are injected into the infarct vessel that has before been

reopened by percutaneous balloon dilation and stent placement (Fig. 3). Following

several small-scale pilot trails [41,42], the ﬁrst randomized, placebo-controlled

study comparing intracoronary MNC injection with standard treatment of acute

myocardial infarction was the Hannover BOOST trial [43–45]. At 6 month follow-

up, cell-treated patients had a signiﬁcantly higher left ventricular ejection fraction

than control patients. Subsequently, a number of similar studies were conducted by

other groups, including a multicenter study that enrolled 200 patients [46–51].

Some of those trials clearly produced a negative result in that there was no

difference in outcome between cell-treated and placebo-treated patients [52,53].

In the multicenter trial coordinated by the Frankfurt group, LVEF rose by 5.5% in

cell-treated patients, and by 3.0% in the placebo-treated control group [54]. The

difference proved statistically signiﬁcant, but it remains controversial whether such

a small effect will translate into a relevant clinical beneﬁt. Other reports focused on

clinical exercise tolerance and quality-of-life data, and again there seems to be a

slight advantage for patients who have received cell therapy [55].

4.3 MNC in Chronic Ischaemia

Patients with chronic myocardial ischaemia have also been treated with bone marrow

MNC products in several clinical studies. Again, some trials on catheter-based

Clinical Application of Stem Cells in the Cardiovascular System 299

delivery of MNCs have shown a modest beneﬁt, while others have produced an

essentially negative result [56–58]. The same must be said regarding surgical injec-

tion of MNCs in conjunction with bypass surgery. In early pilot studies, an improve-

ment of regional ventricular wall motion in cell-treated areas was observed, but this

did not lead to better global heart function as compared with routine bypass surgery

[59]. Our own experience was very similar. We treated 14 patients undergoing bypass

surgery for chronic ischaemic heart disease and compared their outcome with that of

ten patients who had a standard CABG operation. Using a novel echocardiographic

analysis tool (ventricular wall strain imaging), we were able to detect improved

myocardial function in cell-treated segments (Fig. 4). However, this did not result

in better global ventricular function as assessed by LV ejection fraction [60]. In a very

recent elegant study, Galinanes and colleagues directly compared intracoronary and

intramyocardial injection of MNCs in CABG patients by injecting into the heart

muscle or into the bypass graft [61]. Again, they found no relevant beneﬁt of either

delivery technique over placebo treatment.

Fig. 3 Delivery of regenerative cell products to the heart. The most frequently used approach has

so far been intracoronary injection. Surgical trans-epicardial injection is usually performed

together with other cardiac surgical procedures, but stand-alone injection via a mini-thoracotomy

is also possible. Catheter-based trans-endocardial injection into the myocardium usually requires

complex realtime imaging techniques, and cell delivery is less reliable

300 C. Stamm et al.

4.4 MNC in Non-Ischaemic Heart Disease

Initial experimental and clinical cardiac cell therapy studies focussed on ischaemic

heart disease, but more recently the potential therapeutic usefulness of cell

transplantation for other types of heart failure has been investigated [62–64]. In

the recent trial by the Frankfurt group, the effects of selective intracoronary

bone marrow cell infusion in 33 patients with non-ischaemic dilated cardiomyo-

pathy were studied. Overall, microvascular function in the coronary system was

improved, and the increase of regional contractile function correlated with the

functionality of the infused cells as measured by their colony-forming capacity

[65]. A decrease in brain natriuretic peptide (NT-proBNP) serum levels also

suggested a beneﬁcial effect on left ventricular remodelling processes, and con-

trolled studies are planned to validate these ﬁndings.

4.5 Puriﬁed Stem Cell Products

Progenitor cell products can be prepared using clinical-grade immunomagnetic selec-

tion for either CD34 or CD133, and negative selection for CD45 is also possible.

Human bone marrow stem cells of haematopoietic-endothelial lineage, progeny of the

primitive haemangioblast, the common precursor of blood and blood vessel-forming

cells, can be isolated for clinical use based on the expression of CD34 and CD133 [66,

67]. Theoretically, these cells are potent supporters of angiogenesis processes

and hence may be useful for the relief of myocardial ischaemia. Another strategy

is the in vitro expansion of bone marrow mononuclear cells, with or without addition

of differentiation-inducing or differentiation-suppressing substances. Alternatively,

SEPT

ANT_SEPT

3–6

–9

–22

–13

–20

–17

–12

–17

–22

–13

–11

–11–16

–19 –18

–2

–11

–14

–15

–11

–6

–9 –8

–7

–13

–9 –16

ANT_SEPT

ANT ANTSEPT

LAT LATINF INF

POST POST

Fig. 4 Two-dimensional longitudinal strain echocardiography analysis of regional left ventricular

contractile performance, depicted as “bull’s eye view”. Preoperatively (a) the strain data are

inhomogenous, with impaired myocardial motion shown inblue. After bypass surgery and bone

marrow cell injection (b), performance has largely normalized

Clinical Application of Stem Cells in the Cardiovascular System 301

progenitor cells can be identiﬁed based on intracellular enzyme activities, such as

aldehyde dehydrogenase (ALDH) activity. ALHD+ cell products from peripheral

blood and bone marrow correlate closely with those enriched for CD34 or CD133

but may have superior functional characteristics [68]. Few investigators have used

puriﬁed haematopoietic stem cell products for the treatment of acute or subacute

myocardial infarction. In one such study, concerns were raised about a higher rate of

stent occlusion following intracoronary injection of CD133+ cells. Notably, Hofmann

et al. studied the cardiac retention of bone marrow cells after intracoronary injection

using radioactively labelled cells [69]. When mononuclear marrow cells were used,

approximately 2% of the activity was retained in the heart, while the vast majority of

the cells accumulated in liver and spleen. However, when CD34 selected cells were

used, cardiac cell retention was between 14% and 39%. In chronic ischaemia,

however, CD34 or CD133 enriched cells products have found more widespread

application [70,71]. In conjunction with CABG surgery, intramyocardial injection

of CD34+ bone marrow cells resulted in nearly 10% higher LV ejection fraction than

CABG surgery alone [67]. Our group has focussed on CD133+ cells given during

CABG surgery, because they are believed to contain a subpopulation of cells that are

even more immature than CD34+ cells. In 2001, we started a feasibility and safety

study in ten patients, and no procedure-related adverse events were observed [72,73].

Subsequently, we conducted a controlled study in 40 patients. Here, CABG and

CD133+ cell injection led to a signiﬁcantly higher LVEF at 6 month follow-up than

CABG surgery alone [66]. A pronounced effect on the blood supply to the ischaemic

myocardium was evident in numerous patients, indicating the potent angiogenesis

support of CD133+ cells (Fig. 5). Other groups have isolated CD133 cells for surgical

delivery from peripheral blood, following mobilization from the marrow with G-CSF

[74,75]. This procedure yields a substantially higher cell dose but requires several

days for cell preparation. Enriched bone marrow stem cell products (here CD34

cells)

have also been administered by intramuscular injection using catheter-based systems.

In a phase I/II pilot trial, this procedure has been shown to be safe, and preliminary

data indicate an improvement of LV function over placebo treatment [76].

4.6 Cytokine-Induced Bone Marrow Cell Mobilization

Another strategy aims at circumventing any mechanically invasive procedure for

cell delivery and minimizing the interval between the onset of myocardial infarc-

tion and cell therapy by mobilizing marrow cells using granulocyte stimulating

factor (G-CSF). The idea is that stem/progenitor cells mobilized from marrow will

be attracted to the ischaemic heart and initiate regeneration processes [77]. That the

number of circulating progenitor cells can be greatly enhanced by G-CSF stimula-

tion has been well established [78]. However, the number of mature leukocytes

also rises markedly, and this has raised concerns regarding the safety of C-CSF

treatment. In patients with myocardial infarction treated with G-CSF a high rate

302 C. Stamm et al.

of in-stent restenosis has been observed. Moreover, incidences such as acute

re-infarction and sudden death have occurred in other studies [79]. A number of

controlled clinical efﬁcacy studies have subsequently been performed, but the

outcome data in terms of heart function improvement are rather disappointing.

4.7 Second Generation Clinical Cell Products

Given the modest improvement of heart function after intracardiac delivery of

unmodiﬁed bone marrow cells, clinical studies are currently being conducted

with cell products that have been subjected to in vitro modiﬁcations or have been

isolated from alternative sources. Among those are mononuclear cells conditioned

and expanded in speciﬁc bioreactor systems where, theoretically, cells with greater

stemness are enriched and their secretory activity is augmented [80,81]. The

frequency of CD34

or CD133

cells that are not committed towards a leukocyte

phenotype (CD45



) is very low in adult human bone marrow [82,83], but expan-

sion of haematopoietic stem cells in vitro induces spontaneous differentiation and

impairs stem cell function [84]. Bioreactor systems that may be able to suppress

stem cell differentiation during proliferation have been developed, but their clinical

use in cardiovascular medicine has been limited [85,86]. The second cellular

compartment within the bone marrow, the stroma, contains stem cells that are

easier to handle and to manipulate. Multipotent stromal cells, a.k.a. MSC, make

Fig. 5 Perfusion scans of the heart of a patient who had myocardial infarction of the inferior wall

of the left ventricle (arrow). Preoperatively (a), perfusion is several impaired. Two weeks after

bypass grafting and transplantation of CD133+ cells in the infarct area, there is no obvious change

in blood supply (b). Six months later, however, perfusion is effectively restored (c), probably via a

pro-angiogenic effect of the cell transplantation. This effect is maintained at 1 year follow-up (d)

Clinical Application of Stem Cells in the Cardiovascular System 303

up only 0.01% of the nucleated bone marrow cells but are important supporters of

haematopoiesis and act as an independent stem cell pool involved in the mainte-

nance of tissues derived from the embryonic mesenchyme [87]. Moreover, they

have been shown to be able to trans-differentiate across lineage boundaries in

experimental models, and possess potent immuno-modulatory properties that may

also be useful for cardiovascular regenerative medicine [88–91]. Several clinical

pilot studies have evaluated the effect of autologous bone marrow MSC in patients

with heart disease, but results have been equivocal [92,93]. Allogeneic donor MSC

are also being used in patients with heart disease [94]. They can escape detection

and elimination by the immune system, because they express no MHC class II, low

levels of MHC class I, and none of the T cell co-stimulatory antigens CD40, CD80

or CD86. Deﬁnitive clinical efﬁcacy data, however, are not available yet. MSC

from non-marrow tissues are also being evaluated in clinical pilot studies in both

autologous and allogeneic fashion. Autologous MSC from adipose tissue can be

isolated by plastic adherence in cell culture before they are injected into the heart,

while in other trials cells are freshly obtained from a large volume of lipo-aspirate

by digestion, washing and centrifugation, and injected intramyocardially without

prior cell cultivation [95].

Another interesting development that may help optimize the clinical usefulness

of MSC-like cells is the identiﬁcation of perivascular cells that co-express myo-

genic and endothelial cell markers and have a robust myocyte differentiation

capacity (myoendothelial cells). They are believed to represent the solid-organ

reservoir of tissue-speciﬁc MSC [96,97], and have been shown to be very efﬁcient

for myocardial regeneration in experimental models.

4.8 Combination Treatments

Numerous strategies to enhance the regenerative capacity of adult stem cells in the

heart have been developed. For instance, genetic manipulation of mesenchymal

stem cells inducing overexpression of anti-apoptotic proteins such as AKT or Bcl-2,

or cytokines such as HGF, IGF or VEGF, not only leads to a marked improvement

of MSC survival following transplantation into the heart, but also has beneﬁcial

effects on the surrounding host myocardium that comes in contact with secreted

anti-apoptotic factors [98,99]. However, due to patient safety concerns and regu-

latory restrictions, genetically modiﬁed adult stem cells have not yet been tested in

the clinical setting. Clinically better applicable strategies to improve cell therapy in

the heart are, for instance, hypoxic preconditioning, heat shock treatment or stimu-

lation of cells with cytokines [100,101], which increase both cellular resilience and

paracrine activity. Alternatively, pre-treatment of cells with pharmaceutical agents

such as erythropoietin, parathyroid hormone, statins or nitric oxide synthase enhan-

cers has also been applied [102–104]. For both approaches, clinical trials have been

initiated. The same is the case for the combination of cell therapy and ultrasound

304 C. Stamm et al.

shock wave treatment [105], which was shown to increase the functional capacity

of bone marrow and endothelial progenitor cells [106]. Transplanted cells may

survive and function better when they are embedded in an adequate extracellular

matrix (ECM) [107], and a clinical trial has been set up where bone marrow cells

are mixed with collagen-rich semi-liquid hydrogel prior to implantation in the

heart [108]. In this context, the recent development of decellularized cardiac

ECM should also be mentioned, which can not only be used as a scaffold for

myocardial tissue engineering but will also help understand the interactions

between cardiac ECM and transplanted cells [109]. Finally, the combination of

transmural laser revascularization (TMLR) and cell therapy deserves to be noted,

TMLR is believed to induce a local inﬂammatory stimulus that supports marrow

cells injected into the heart. Again, clinical studies are in progress [110].

4.9 Foetal or Neonatal Stem Cells

The use of juvenile stem cells for cardiac regeneration may solve the problem of age-

related and disease-related impairment of stem cell function, and experimental

studies have been conducted with cells derived from cord blood, umbilical cord

or placenta [5,111]. However, autologous cells will only be available for patients

who had cord blood (or other cells) banked at the time of birth, and large-scale cord

blood banking for autologous use has just begun. Some stem cell types from neonatal

tissues, however, may have a sufﬁciently immature immunophenotype to allow

allogeneic application [112,113]. For instance, a clinical trial of allogeneic placenta

MSC in patients with severe limb ischaemia is currently going on in our institution

[114]. Therapeutic applications for heart disease have not yet been described.

4.10 Paediatric Heart Disease

For children with structural congenital heart disease, tissue engineering may offer

new therapeutic options in the future, including the implantation of viable, auto-

logous valves and blood vessels. A number of children, however, suffer from

acquired or congenital heart failure without structural defects, and require assist

device support and/or heart transplantation. Several cases of cell therapy for

myocardial regeneration in children have been reported [115,116]. Some of these

reports were very encouraging, and it has been speculated that the young myocar-

dium may have a greater regenerative potential, and that juvenile stem cells possess

greater plasticity and proliferative capacity. Systematic studies, however, have not

been performed so far.

Clinical Application of Stem Cells in the Cardiovascular System 305

5 Clinical Translation Problems

Attention usually focuses on the cell product, but there are many other factors

that need to be considered to maximize the likelihood of successful cell-based

myocardial regeneration.

5.1 Patient Selection

Every novel therapeutic approach is best evaluated in a uniform cohort of patients

with well-deﬁned patient-related and disease-related characteristics. Regarding cell

therapy for heart disease, however, this is more difﬁcult than it ﬁrst seems. In the

majority of patients, myocardial cell therapy has been performed within several

days after the onset of myocardial infarction symptoms, when patients cannot be

selected according to their pre-treatment heart function [43,47,53,54]. Conse-

quently, such patient cohorts cover a wide range of left ventricular contractility at

baseline, impeding data analysis and interpretation. In patients with chronic myo-

cardial ischaemia, the degree of contractile dysfunction is usually better deﬁned

[66,67,74]. Patients with non-ischaemic heart disease have also been subject to cell

therapy approaches, although the body of preclinical data is much smaller than for

ischaemic heart disease [117]. Here, one problem is the diversity of underlying

aetiologies for non-ischaemic heart failure, including inﬂammatory processes,

genetic diseases and a large group of “idiopathic” cases where no cause can be

established.

5.2 Cell Delivery

Injection into the coronary arteries requires transmigration of cells through the

vascular wall into the myocardium. Catheter-based direct intramyocardial cell

delivery is also possible, often combined with intracardiac NOGA mapping of the

left ventricle to identify the area of interest (Fig. 3)[56]. A needle-tipped catheter

can also be guided into the epicardial veins for injection into the myocardium

(reviewed in [118]). For cell delivery under direct vision using surgical techniques,

any commercially available syringe and needle system can be used, but industry has

also developed special cell injection systems with side-holes. In some trials, cells

are being delivered by peripheral venous injection, relying on myocardial chemo-

kines to attract cells to the heart, but the majority undergo ﬁrst-pass trapping in the

lung or are eliminated by the reticuloendothelial system [119]. Each of these cell

delivery techniques involves biologic processes that are incompletely understood

but probably have a major impact on the therapeutic efﬁcacy.

306 C. Stamm et al.

5.3 Timing

It is not known whether there is an ideal time point for cell therapy in patients with

ischaemic heart disease. Emergency treatment of acute infarction is usually done by

the interventional cardiologist, who may also decide to perform intracoronary injec-

tion of a rapidly available cell product. The situation in chronic ischaemic heart

disease is very different. In the post-infarct or chronically ischaemic myocardium, a

substantial net loss of contractile tissue mass has occurred and there is diffuse or

localized scar formation. Intuitively, the longer the interval between myocardial

infarction and cell treatment, the smaller the chance to achieve a beneﬁcial effect

becomes. This notion, however, is presently not supported by solid data.

5.4 Cell Survival

When cells are injected into diseased myocardium, most of them do not survive.

The magnitude of cell death upon intramyocardial transplantation is difﬁcult to

measure, but the suggested survival rate ranges between 0.1 and 10% [26,120].

The ischaemic heart is a hostile environment, due to local hypoxia, acidosis, lack

of substrates and accumulation of metabolites. Moreover, it is inﬁltrated by

phagocytic cells that remove cell debris, and many transplanted cells are probably

lost in this “clean-up” process. Third, the mechanic forces in the myocardium are

substantial. Transmural pressure is high during systole, there are shear forces

between contracting myoﬁbers and layers, and a marrow cell is not well equipped

to withstand such stress. However, the rate of cell death can be slowed. Transfec-

tion of marrow stromal cells with genes encoding for the anti-apototic proteins

AKT or Bcl-2 has been shown to improve greatly cell survival and regenerative

capacity [98,99]. Pre-treatment of endothelial progenitor cells with eNOS-

enhancing substances also appears to have a beneﬁcial effect [102], similar to

the effects observed with statins [103]. Hypoxic preconditioning or heat shock

prior to cell injection might also help, since both activate anti-apoptotic and

NO-related signalling pathways [100].

5.5 Dose

The normal adult heart weighs 250–350 g, and around 80% of the myocardial mass

consists of approximately 10 10

cardiomyocytes [121]. Assuming that 20% of

the cardiomyocytes are lost following myocardial infarction, one would ultimately

need 2 10

surviving neo-myocytes weighing nearly 50 g to reconstitute the

myocardium completely. Given the high rate of cell death upon transplantation into

the heart and the presumably very low number of adult stem cells that actually

differentiate into myocytes, it becomes clear that, with currently available cell

products, we are far from being able to replace all lost heart muscle tissue.

Clinical Application of Stem Cells in the Cardiovascular System 307

5.6 Age

Theoretically, stem cells constantly renew themselves, but it has become clear that

bone marrow stem cells undergo ageing processes and are affected by remote

diseases [122]. Ageing may not just be imposed on marrow cells by external and

internal stressors, but seems to be an active process that helps protect the organism.

For instance, upregulation of cell cycle inhibitors of the cip/kip and the INK4a/ARF

family reduces the risk of malignancy in the ageing organism. On the other hand,

this protective mechanism reduces the stem cell’s capacity for self-renewal and

proliferation. Indeed, when the cyclin-dependent kinase inhibitor p16INK4a, which

accumulates with age, is knocked out in ageing mice, tissue regeneration processes

involving haematopoietic stem cells are much improved, but the animals also

develop various kinds of malignancies [123]. In essence, the organism sacriﬁces

its regenerative capacity in order to counteract the increasing tendency to develop

cancer.

5.7 Disease

It has been well established that ischaemic heart disease is associated with impaired

endothelial progenitor cell number and function [124], but it remains unclear

whether progenitor cell dysfunction is a cause or an effect of heart disease. On

the other hand, exercise has beneﬁcial effects on the somatic stem cell pool. It may

be argued that the attempt to repair heart failure with autologous cells that are

affected by age and disease is a futile undertaking. The use of allogenic, juvenile

stem cells from healthy individuals may be an elegant solution and is propagated by

those involved in cell banking activities. However, disease processes in the recipi-

ent organism may inﬂuence even the behaviour of healthy allogenic cells. Humoral

factors in the serum of patients with heart failure have been shown to impair the

in vitro proliferation of allogenic bone marrow MSC [125]. Our group has studied

the effect of heart failure patient serum on neonatal cord blood mesenchymal stem

cells, and we found that, in some patients, MSC proliferation is accelerated, while

in others it is severely impaired (Fig. 6). The identiﬁcation of patients who are

likely to beneﬁt from cell therapy and those who will probably not respond is still a

largely neglected ﬁeld of research. Given the biologic complexity of viable cells as

therapeutic compounds as well as the organism’s response to those clearly requires

an individualized approach to maximize the efﬁcacy of cardiac cell therapy

5.8 Legal Framework

Today, the legal situation regarding the production and the therapeutic use of viable

cells and related products has been clariﬁed in many countries. Within the EU, this

308 C. Stamm et al.

was completed with the Regulation on Advanced Therapies No 1394/2007, and the

situation is similar in North America. Cells used for tissue regeneration are now

considered medicinal products. Hence, their production and clinical application

must comply with Good Manufacturing (GMP) and Good Clinical Practice (GCP).

Essentially, the same rules are applied that were originally designed to supervise

the development in production processing of pharmaceutical compounds. One

exception is when autologous cells are harvested and implanted within the same

surgical procedure, as is sometimes done in bedside bone marrow or adipose tissue

cell transplantation. However, even such “bedside cell therapy products” may be

considered medicinal products if the cells undergo more-than-minimal manipula-

tion or their use is non-homologous (meaning the cells are meant to behave in a way

that differs from their original function). This regulatory framework has greatly

helped optimize the safety of patients who are subjected to still experimental

cellular therapies. On the other hand, it has signiﬁcantly slowed down the clinical

translation process.

6 Future Clinical Cell Therapy Studies

Previous and ongoing clinical studies using somatic cells from marrow, adipose

tissue and other sources were relatively easy to conduct in accordance with the cell

therapy-speciﬁc regulations and the standards of evidence-based medicine. The

0.1

0.2

0.3

0.4

0.5

0123456

time [days]

Viable cells (MTS test)

0.1

0.2

0.3

0.4

0.5

0123456

time [days]

Viable cells (MTS test)

Fig. 6 Serum of patient with heart failure inﬂuences stem cell behaviour. (a) The in vitro

proliferation rate of neonatal cord blood mesenchymal stem cells from a healthy donor, in the

presence (black) and absence (grey) of serum from a patient with ischaemic heart failure.

Compared to the standard medium (foetal calf serum), cell proliferation and viability is much

reduced. On the other hand, (b) shows the in vitro proliferation rate of the same cell type, in the

presence of serum from a patient who underwent surgery for ischaemic heart disease (black),

compared to that of a healthy individual (grey). Here, the patient serum clearly has activating

effects

Clinical Application of Stem Cells in the Cardiovascular System 309

majority of these approaches were shown to be safe, albeit also with limited

efﬁcacy, because they mainly induce indirect regeneration and do not directly

interfere with genomic integrity and cardiomyocyte biology. The clinical evalua-

tion of stem cell-derived contractile cells for direct regeneration, however, carries

much greater risks and needs a different approach. Because of the tumour and

arrhythmia risk when, for instance, iPS cell-derived myocytes are transplanted, we

feel that feasibility and safety studies should initially be performed in no-option

patients who have or require a mechanical ventricular assist device (VAD).

Here, ventricular arrhythmia is usually not life-threatening, and myocardium for

histology studies can be collected upon VAD explanation or heart transplantation.

Cell therapy has led to a new level of complexity in both experimental cardio-

vascular research and clinical practice. The successful use of viable cells for

regeneration of diseased tissue requires a completely novel scientiﬁc and clinical

armamentarium, and it cannot be foreseen whether the efforts will be ultimately

rewarded by efﬁcacious and safe regenerative therapies.

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Index

Activin, 181

Activin A/transforming growth factor

beta (Tgfb), 129

Acute myocardial infarction (AMI), 266

Adipogenesis, 1

Adipose tissue, 91, 227

Adipose-derived stem cells (ASC), 5, 55, 57

Alginate capsules, 145

Aminopeptidase, 10

Amnion-derived cells, 4

Amytrophic lateral sclerosis (ALS), 117

Angiogenesis, 76, 202

Angiopoietin-1, 277

Animal models, 220

Basic ﬁbroblast growth factor (bFGF), 129

Blood vessel formation, 202

Bone marrow, collection, 223

mononuclear cells, 299

stem cells, 265, 271, 285

Bone marrow mesenchymal stem cells

(BMSC), 3, 31

Bone morphogenetic proteins (BMP),

72, 163, 181

receptors, 12

Bone tissue engineering, 92, 201

Brain, 233

Brain-derived neurotrophic factor

(BDNF), 75

Cadherins, 68

Cardiac cell therapy, 297

Cardiomyoblast-like cells (CLC), 79

Cardiomyocytes (CMs), 109

Cardiomyopathy, 294

Cardiovascular disease, 266

Cartilage, 163

cultivation, 167

repair, 244

tissue, 93

engineering, 185

Caveolin, 68

Cell-assisted lipotransfer (CAL), 90

Cell beads, 144

Cell condensation, PNA (peanut agglutinin)

staining, 178

Cell delivery, coronary arteries, 306

Cell survival, 307

Cell therapy, 143, 293

Cell transplantation, 107

Cholangiocytes, 253

Chondroblasts, 41

Chondrocytes, 163

Chondrogenesis, 73

Chondrogenic differentiation, 178, 186

Chronic obstructive pulmonary disease

(COPD), 269

Clinical stem cell applications, 220

Clonogenic myeloid cells (CMC), 75

Co-culture models, 201

Collagen, 68

319

Collagen type 1 subtype A1 (COL1A1), 72

Combination treatments, 304

Counterﬂow centrifugal elutriation (CCE),

29, 35

Crohn’s disease, 89, 269

CXCL12, 277

Cytokines, 74

Delivery methods, 132

Dexamethasone, 72

Diabetes, 117, 144, 268

Differentiation, 107, 163

Disease modeling, 116, 127, 133

DNA methylation, 135

Dofetilide, 115

Doxycycline, 111

Embryonic stem cells, 31, 128, 220

Encapsulated cells, cultivation, 157

Encapsulation, 143

Endochondral ossiﬁcation, 179

Endothelial progenitor cells, 201, 202

Endothelial stem cells (ESCs), 278

Epigenetic reprogramming, 134

Equine orthopaedics, 234

Estradiol, 72

Expansion, 1

Extracellular matrix (ECM), 247

Extracellular signal-regulated kinase-1

(ERK), 136

Fanconi anemia (FA), 118

Fat harvesting, 55, 60

Fibrin glue, 82

Fibroblast growth factors (FGF), 263, 180

Fibronectin, 68, 178

Fixed bed bioreactor, 143

Glass carrier, 143

Glial ﬁbrillary acidic protein (GFAP), 80

GLP-1, 144

Glucose transporter 4, 72

Glycerol-3-phosphate dehydrogenase

(GAPDH), 72

Glycogen synthase kinase 3 beta (GSK3B)

inhibitors, 136

Good Clinical Practice (GCP), 309

Graft-versus-host disease, 45, 86, 268

Granulocyte stimulating factor

(G-CSF), 302

Growth and differentiation factors

(GDF), 181

Growth factors, 163

Heart, 109, 293

Heart disease, 308

paediatric, 305

Heart failure, 79, 294

Hematopoietic stem and progenitor cells

(HSPCs), 279

Hematopoietic stem cell transplantation

(HSCT), 269

Hepatocytes, 252

High mobility group box 1 (HMGB-1), 280

Homing and recruitment, 265

Human amniotic cells, 1

Human amniotic epithelial cells (hAEC), 4

Human amniotic mesenchymal stromal cells

(hAMSC), 4

Human telomerase reverse transcriptase

(hTERT), 1, 6

Human umbilical vein endothelial cells

(HUVECs), 284

Hyaline phenotype, 188

Hyaluronan, 178

Hyaluronic acid (HA), 32

Hypoxia, 284, 307

Hypoxia-inducible factor (HIF), 75

Immortalization, 1

Immunogenicity, 220, 233

Immunomodulation, 1, 8, 44, 86, 282

Immunophenotype, 1

In vitro differentiation, 40

Indian hedgehog (Ihh), 163

Indomethacin, 72

Induced pluripotent stem cells (iPS), 107,

127, 220

320 Index

Inhibin, 181

Insulin, 72

Insulin-like growth factor (IGF), 75, 163,

168, 182, 284

Integral membrane protein 2A (ITM2A), 73

Integrins, 68

Intervertebral disc disease, 250

Ischaemia, myocardial, 299

Ischemic muscle tissue, 76

Isobutyl-1-methylxanthine (IBMX), 72

Isolation protocol, 55

Juvenile stem cells, cardiac regeneration,

305

Laminin, 68

Leukemia, 87, 129, 269

Leukemia inhibiting factor (LIF), 129, 273

Lipectomy, 58

Lipoatrophy, 90

Lipoprotein lipase, 72

Liposuction, 58

Liver disease, 109, 116, 252

Liver progenitor cells (LPC), 252

Marmoset (Callithrix jacchus), 108

Marrow-derived stroma (MdS), 75

Matrix metalloproteinases (MMPs), 76, 279

Mesenchymal markers, 1

Mesenchymal stem cells (MSC), 29, 143,

163, 165, 220

Mesenchymal stromal cell, 29, 163

Microtubule-associated protein

2 (MAP2), 80

Microvesicles (MVs), 278

Middle cerebral artery occlusion

(MCAO), 80

Mononuclear cells, 299

MSC, 29, 143, 163, 165, 220

¨llerian inhibitory substance, 181

Multipotency, 163

Murine embryonic ﬁbroblasts (MEFs), 111

Myelination, 250

Myeloperoxidase (MPO), 81

Myeloproliferative disorders (MPDs), 116

Myocardial infarction (MI), 79

Myocardial regeneration, 295

Natriuretic peptide, 301

Neovascularization, 202

Neuroptropins, 251

Nitric oxide, 73, 282

Nonhuman primate (NHP) ES cell

cultures, 108

Osteoarthritis (OA), 179, 242

Osteogenesis, 1, 10, 212

Osteonectin, 68

Osteopontin (OPN), 72

Outgrowth endothelial cells (OEC), 203

OX-42, 81

Paediatric heart disease, 305

Paracrine roles, 265

Parkinsons disease, 117, 144, 269

Patient-derived expandable cells, 108

Periodontal ligament (PDL), 231

Periosteum, 233

Peripheral blood, 224

mononuclear cells (PBMC), 7

Photoreceptor progenitor cells, 119

Pioglitazone, 72

Placental growth factor (PlGF), 284

Platelet lysate, 1, 12

Pluripotency induction, 110

Proliferator-activated receptor, 72

PTH related peptide (PTHrP), 163

PTHrP, 183

Pure red cell aplasia (PRCA), 88

Regeneration, 293

Regenerative medicine, 127, 220, 265, 270

Reprogramming, 107, 110, 127, 134

Rhesus monkey (Macaca mulatta), 108, 136

Rosiglitazone, 72

Index 321

Scarpa’s facia, 56

Secreted frizzled-related protein (sFRP), 72

Self-endothelialization, 212

Sickle cell anemia, 118

Skeletal myoblasts, 298

Skin, 232

SKOM, 132

Somatic cell nuclear transfer (SCNT), 130

Sonic hedgehog (Shh), 163

Spermidine/spermine N1-acetyltransferase

(SSAT), 73

Spinal cord injuries, 250

Stem cells, application, 55

homing, 276

markers, 1

niche, 265

sources, 220

Steroid hormones, 72

Stromal cell-derived factor 1 (SDF-1), 78

Stromal-vascular fraction (SVF), 57

Superﬁcial digital ﬂexor tendonitis, 231

Superparamagnetic iron oxide (SPIO), 78

Synovial ﬂuid, 233

Synovial membrane, 230

Telomerase, 1, 15, 40, 145

Tenascin, 179

Tendon, 233

injuries, 236

Thiazolidinediones, 72

Thomson factors, 110

Thrombopoietin, 278

Tissue engineering, 91, 107, 270, 293

TNF a,75

Transferase dUTP nick end labeling

(TUNEL), 81

Transforming growth factor (TGF), 163,

168, 181

Transmural laser revascularization (TMLR),

305

Trogitazone, 72

Umbilical cord, 29, 228

blood (UCB), 225

Vascularization, 201

Vasculogenesis, 202

VEGF, 75, 77, 284

Veterinary medicine, 220, 234

Wharton’s jelly (WJ), 32

Yamanaka factors, 110

Zone of polarizing activity (ZPA), 181

322 Index

Influence of Tamoxifen on Different Biological Pathways in Tumorigenesis and Transformation in Adipose-Derived Stem Cells, Mammary Cells and Mammary Carcinoma Cell Lines- An In Vitro Study

Article

Full-text available

Sep 2022

Breast carcinoma is one of the most common malignant tumors in women. In cases of hormone-sensitive cells, tamoxifen as an anti-estrogenic substance is a first line medication in the adjuvant setting. The spectrum of autologous breast reconstructions ranges from fat infiltrations to complex microsurgical procedures. The influence of adipose-derived stem cells (ASC) on the tumor bed and a possibly increased recurrence rate as a result are critically discussed. In addition, there is currently no conclusive recommendation regarding tamoxifen-treated patients and autologous fat infiltrations. The aim of the present study was to investigate the effect of tamoxifen on the gene expression of a variety of genes involved in tumorigenesis, cell growth and transformation. Mam-mary epithelial cell line and mammary carcinoma cell lines were treated with tamoxifen in vitro as well as co-cultured with ASC. Gene expression was quantified by PCR arrays and showed increased expression in the mammary carcinoma cell lines with increasing time of treatment and concentration of tamoxifen. The data presented can be considered as an addition to the controversial discussion on the relationship between ASC and breast carcinoma cells. Further studies are needed to quantify the in vivo interaction of ASC and mammary carcinoma cells and to conclusively assess the impact of tamoxifen in reconstructive cases with fat grafting.

ADSC-Based Cell Therapies for Musculoskeletal Disorders: A Review of Recent Clinical Trials

Article

Full-text available

Sep 2021
INT J MOL SCI

Recently published clinical trials involving the use of adipose-derived stem cells (ADSCs) indicated that approximately one-third of the studies were conducted on musculoskeletal disorders (MSD). MSD refers to a wide range of degenerative conditions of joints, bones, and muscles, and these conditions are the most common causes of chronic disability worldwide, being a major burden to the society. Conventional treatment modalities for MSD are not sufficient to correct the underlying structural abnormalities. Hence, ADSC-based cell therapies are being tested as a form of alternative, yet more effective, therapies in the management of MSDs. Therefore, in this review, MSDs subjected to the ADSC-based therapy were further categorized as arthritis, craniomaxillofacial defects, tendon/ligament related disorders, and spine disorders, and their brief characterization as well as the corresponding conventional therapeutic approaches with possible mechanisms with which ADSCs produce regenerative effects in disease-specific microenvironments were discussed to provide an overview of under which circumstances and on what bases the ADSC-based cell therapy was implemented. Providing an overview of the current status of ADSC-based cell therapy on MSDs can help to develop better and optimized strategies of ADSC-based therapeutics for MSDs as well as help to find novel clinical applications of ADSCs in the near future.

Editorial: Therapeutic potential of mesenchymal stem cells in organ and tissue regeneration

Article

Full-text available

Nov 2023

Tumorigenic effects of human mesenchymal stromal cells and fibroblasts on bladder cancer cells

Article

Full-text available

Sep 2023

Background Patients with muscle-invasive bladder cancer face a poor prognosis due to rapid disease progression and chemoresistance. Thus, there is an urgent need for a new therapeutic treatment. The tumor microenvironment (TME) has crucial roles in tumor development, growth, progression, and therapy resistance. TME cells may also survive standard treatment of care and fire up disease recurrence. However, whether specific TME components have tumor-promoting or tumor-inhibitory properties depends on cell type and cancer entity. Thus, a deeper understanding of the interaction mechanisms between the TME and cancer cells is needed to develop new cancer treatment approaches that overcome therapy resistance. Little is known about the function and interaction between mesenchymal stromal cells (MSC) or fibroblasts (FB) as TME components and bladder cancer cells. Methods We investigated the functional impact of conditioned media (CM) from primary cultures of different donors of MSC or FB on urothelial carcinoma cell lines (UCC) representing advanced disease stages, namely, BFTC-905, VMCUB-1, and UMUC-3. Underlying mechanisms were identified by RNA sequencing and protein analyses of cancer cells and of conditioned media by oncoarrays. Results Both FB- and MSC-CM had tumor-promoting effects on UCC. In some experiments, the impact of MSC-CM was more pronounced. CM augmented the aggressive phenotype of UCC, particularly of those with epithelial phenotype. Proliferation and migratory and invasive capacity were significantly increased; cisplatin sensitivity was reduced. RNA sequencing identified underlying mechanisms and molecules contributing to the observed phenotype changes. NRF2 and NF-κB signaling was affected, contributing to improved cisplatin detoxification. Likewise, interferon type I signaling was downregulated and regulators of epithelial mesenchymal transition (EMT) were increased. Altered protein abundance of CXCR4, hyaluronan receptor CD44, or TGFβ-signaling was induced by CM in cancer cells and may contribute to phenotypical changes. CM contained high levels of CCL2/MCP-1, MMPs, and interleukins which are well known for their impact on other cancer entities. Conclusions The CM of two different TME components had overlapping tumor-promoting effects and increased chemoresistance. We identified underlying mechanisms and molecules contributing to the aggressiveness of bladder cancer cells. These need to be further investigated for targeting the TME to improve cancer therapy.

Enhanced Repaired Enthesis Using Tenogenically Differentiated Adipose-Derived Stem Cells in a Murine Rotator Cuff Injury Model

Article

Full-text available

May 2022

Rotator cuff tear (RCT) is among the most common shoulder injuries and is prone to rerupture after surgery. Selecting suitable subpopulations of stem cells as a new specific cell type of mesenchymal stem cells has been increasingly used as a potential therapeutic tool in regenerative medicine. In this study, murine adipose-derived SSEA-4+CD90+PDGFRA+ subpopulation cells were successfully sorted, extracted, and identified. These cells showed good proliferation and differentiation potential, especially in the direction of tendon differentiation, as evidenced by qRT-PCR and immunofluorescence. Subsequently, we established a murine rotator cuff injury model and repaired it with subpopulation cells. Our results showed that the subpopulation cells embedded in a fibrin sealant significantly improved the histological score, as well as the biomechanical strength of the repaired tendon enthesis at four weeks after surgery, compared with the other groups. Hence, these findings indicated that the subpopulation of cells could augment the repaired enthesis and lead to better outcomes, thereby reducing the retear rate after rotator cuff repair. Our study provides a potential therapeutic strategy for rotator cuff healing in the future.

Rebuilding hippocampus neural circuit with hADSC-derived neuron cells for treating ischemic stroke

Article

Full-text available

Apr 2022

Background: Human adipose-derived stem cells (hADSCs) have been demonstrated to be a promising autologous stem cell source for treating various neuronal diseases. Our study indicated that hADSCs could be induced into neuron-like cells in a stepwise manner that are characterized by the positive expression of MAP2, SYNAPSIN 1/2, NF-200, and vGLUT and electrophysiological activity. We first primed hADSCs into neuron-like cells (hADSC-NCs) and then intracerebrally transplanted them into MCAO reperfusion mice to further explore their in vivo survival, migration, integration, fate commitment and involvement in neural circuit rebuilding. Results: The hADSC-NCs survived well and transformed into MAP2-positive, Iba1- or GFAP-negative cells in vivo while maintaining some proliferative ability, indicated by positive Ki67 staining after 4 weeks. hADSC-NCs could migrate to multiple brain regions, including the cortex, hippocampus, striatum, and hypothalamus, and further differentiate into mature neurons, as confirmed by action potential elicitation and postsynaptic currents. With the aid of a cell suicide system, hADSC-NCs were proven to have functionally integrated into the hippocampal memory circuit, where they contributed to spatial learning and memory rescue, as indicated by LTP improvement and subsequent GCV-induced relapse. In addition to infarction size shrinkage and movement improvement, MCAO-reperfused mice showed bidirectional immune modulation, including inhibition of the local proinflammatory factors IL-1α, IL-1β, IL-2, MIP-1β and promotion proinflammatory IP-10, MCP-1, and enhancement of the anti-inflammatory factors IL-15. Conclusion: Overall, hADSC-NCs used as an intermediate autologous cell source for treating stroke can rebuild hippocampus neuronal circuits through cell replacement.

Stem Cell Therapy: From Idea to Clinical Practice

Article

Full-text available

Mar 2022
INT J MOL SCI

Regenerative medicine is a new and promising mode of therapy for patients who have limited or no other options for the treatment of their illness. Due to their pleotropic therapeutic potential through the inhibition of inflammation or apoptosis, cell recruitment, stimulation of angiogenesis, and differentiation, stem cells present a novel and effective approach to several challenging human diseases. In recent years, encouraging findings in preclinical studies have paved the way for many clinical trials using stem cells for the treatment of various diseases. The translation of these new therapeutic products from the laboratory to the market is conducted under highly defined regulations and directives provided by competent regulatory authorities. This review seeks to familiarize the reader with the process of translation from an idea to clinical practice, in the context of stem cell products. We address some required guidelines for clinical trial approval, including regulations and directives presented by the Food and Drug Administration (FDA) of the United States, as well as those of the European Medicine Agency (EMA). Moreover, we review, summarize, and discuss regenerative medicine clinical trial studies registered on the Clinicaltrials.gov website.

Research progress in cell therapy for oral diseases: focus on cell sources and strategies to optimize cell function

Article

Full-text available

Mar 2024

In recent years, cell therapy has come to play an important therapeutic role in oral diseases. This paper reviews the active role of mesenchymal stem cells, immune cell sources, and other cells in oral disorders, and presents data supporting the role of cell therapy in oral disorders, including bone and tooth regeneration, oral mucosal disorders, oral soft tissue defects, salivary gland dysfunction, and orthodontic tooth movement. The paper will first review the progress of cell optimization strategies for oral diseases, including the use of hormones in combination with stem cells, gene-modified regulatory cells, epigenetic regulation of cells, drug regulation of cells, cell sheets/aggregates, cell-binding scaffold materials and hydrogels, nanotechnology, and 3D bioprinting of cells. In summary, we will focus on the therapeutic exploration of these different cell sources in oral diseases and the active application of the latest cell optimization strategies.

Emerging Trends in Mesenchymal Stem Cells Applications for Cardiac Regenerative Therapy: Current Status and Advances

Article

Full-text available

Jun 2022

Irreversible myocardium infarction is one of the leading causes of cardiovascular disease (CVD) related death and its quantum is expected to grow in coming years. Pharmacological intervention has been at the forefront to ameliorate injury-related morbidity and mortality. However, its outcomes are highly skewed. As an alternative, stem cell-based tissue engineering/regenerative medicine has been explored quite extensively to regenerate the damaged myocardium. The therapeutic modality that has been most widely studied both preclinically and clinically is based on adult multipotent mesenchymal stem cells (MSC) delivered to the injured heart. However, there is debate over the mechanistic therapeutic role of MSC in generating functional beating cardiomyocytes. This review intends to emphasize the role and use of MSC in cardiac regenerative therapy (CRT). We have elucidated in detail, the various aspects related to the history and progress of MSC use in cardiac tissue engineering and its multiple strategies to drive cardiomyogenesis. We have further discussed with a focus on the various therapeutic mechanism uncovered in recent times that has a significant role in ameliorating heart-related problems. We reviewed recent and advanced technologies using MSC to develop/create tissue construct for use in cardiac regenerative therapy. Finally, we have provided the latest update on the usage of MSC in clinical trials and discussed the outcome of such studies in realizing the full potential of MSC use in clinical management of cardiac injury as a cellular therapy module. Graphical abstract

Mesenchymal stem/stromal cells in cancer therapy

Article

Full-text available

Nov 2021
J HEMATOL ONCOL

The multipotent mesenchymal stem/stromal cells (MSCs), initially discovered from bone marrow in 1976, have been identified in nearly all tissues of human body now. The multipotency of MSCs allows them to give rise to osteocytes, chondrocytes, adipocytes, and other lineages. Moreover, armed with the immunomodulation capacity and tumor-homing property, MSCs are of special relevance for cell-based therapies in the treatment of cancer. However, hampered by lack of knowledge about the controversial roles that MSC plays in the crosstalk with tumors, limited progress has been made with regard to translational medicine. Therefore, in this review, we discuss the prospects of MSC-associated anticancer strategies in light of therapeutic mechanisms and signal transduction pathways. In addition, the clinical trials designed to appraise the efficacy and safety of MSC-based anticancer therapies will be assessed according to published data.

The Metabolism of Isolated Fat Cells

Article

Full-text available

Sep 1966

Martin Rodbell

Proteins of fat cells, isolated from rat epididymal fat pads, were labeled with ¹⁴C-histidine or ¹⁴C-leucine. The fate of the labeled protein was examined after subsequent treatment of the cells with hormones. Release of labeled proteins was stimulated by lipolytic hormones (adrenocorticotropic hormone, glucagon, and epinephrine) and by theophylline. Proteolysis, as measured by the appearance in the medium of trichloracetic acid-soluble radioactivity, occurred to a small extent but was not influenced by lipolytic hormones. Release of such nonparticulate enzymes as malic dehydrogenase, glucose 6-phosphate dehydrogenase, lactic dehydrogenase, and hexokinase was also enhanced by lipolytic hormones. In intact adipose tissue, lipolytic hormones had the same effect on release of enzymes as observed with isolated fat cells. Release of protein was secondary to the rise in intracellular concentration of fatty acids in response to lipolytic hormones. Fatty acids, not their peroxides, were responsible for the release of protein. Isolated fat cells released protein after albumin in the medium became saturated with fatty acids. Intact adipose tissue released enzymes in response to lipolytic hormones when the concentration of fatty acids in the tissue reached approximately 16 µeq per g. With isolated fat cells, accumulation of intracellular fatty acids and protein release were prevented by either providing an excess of albumin in the medium or supplying glucose to the cells, especially in the presence of insulin, which accelerated re-esterification of intracellular fatty acids. It is suggested that the metabolic capacity of adipose tissue, in vitro and in vivo, is regulated in part by the release of cellular protein mediated through the intracellular concentration of fatty acids which is the product of the opposing actions of insulin and lipolytic hormones.

Metabolism of Isolated Fat Cells

Article

Full-text available

Jan 1966

Martin Rodbell

Phospholipase C (α toxin of Clostridium perfringens) has been found to cause, at relative high concentrations, the lysis of fat cells isolated from rat epididymal adipose tissue. Lysis of the fat cells resulted in the loss of insulin response in proportion to the amount of cells broken. It is suggested that the effects of insulin on glucose metabolism by the fat cell are dependent on the presence of an intact cell membrane. The level of flexokinase activity in the fat cell was not affected by insulin or phospholipase C; sufficient hexokinase was present to account for all the glucose phosphorylated by fat cells in response to insulin. Evidence is presented that glucose is transported in the fat cell by a carrier-mediated, stereospecific process. Insulin and treatment of fat cells with phospholipase C under conditions that did not cause lysis, stimulated the transport of glucose. Anabolic processes, such as fatty acid synthesis from glucose and amino acid incorporation into protein, were also stimulated by insulin and phospholipase C. The action of phospholipase C on glucose transport and amino acid utilization was a function of enzyme concentration, suggesting that the amount of cellular phospholipid hydrolyzed by the enzyme determined the amount of solute entering the cell. Phospholipids appear, therefore, to be linked to transport processes. The common effects of insulin and phospholipase C on the fat cell suggests that the same parameter in the cell is affected by these substances. It is hypothesized that insulin and phospholipase C act on the plasma membrane to alter the configuration of its lipoproteins from a laminated to a micellar or globular form. The latter configuration of the membrane lipoproteins might have interstices that permit the carrier-mediated passage of solutes into the cell.

Metabolism of Isolated Fat Cells

Article

Full-text available

Jan 1966

A study was made of the effects of phospholipase C (Clostridium perfringens α toxin) and of insulin on lipolysis by fat cells isolated from epididymal adipose tissue of the rat. Both insulin and phospholipase C inhibited, in the absence of glucose in the incubation medium, the release of fatty acids and glycerol that was stimulated by submaximal concentrations of adrenocorticotropic hormone, epinephrine, glucagon, and theophylline. Both substances failed to inhibit the lipolytic action of high concentrations of adrenocorticotropic hormone and theophylline. The similar inhibitory action of phospholipase C and of insulin on lipolysis, an action that is independent of their stimulatory effects on glucose transport, provides additional evidence that both may be acting on a common parameter, possibly the plasma membrane, of the fat cell.

Plastic Surgery of the Abdomen with Improvement in the Body Contour

Article

Jul 1984
CLIN PLAST SURG

Jorge M. Psillakis

The author presents the evolution of his technique of undermining the major oblique musculature to reduce the diameter of the waist and also reduce the diameter of the superior abdomen by resecting cartilage from the seventh and eighth ribs when the anterior projection is exaggerated. Treatment of the aponeurotic muscle wall plays an important role in obtaining good aesthetic results because this wall will serve as a base for the cutaneous tegument upon healing.

Structural Fat Grafts

Article

Jan 2001
CLIN PLAST SURG

Sydney R. Coleman

Since the nineteenth century, physicians have experimented with injections of a wide variety of substances to alter the surface contours of human faces. The ideal substance still eludes us, but fat grafting through a blunt cannula seems to be the safest of all the fillers used, and in skilled hands, can give long lasting results. A technique of harvesting, refining, and infiltrating fat is presented, along with a discussion of the qualities of this transplanted fat that make it one of the most ideal fillers available.

Facial Recontouring with Lipostructure

Article

Apr 1997
CLIN PLAST SURG

Sydney R. Coleman

This article presents a specific method of autologous fatty tissue transplantation, Lipostructure, which incorporates the technique of syringe liposuction with an intricate layering of autologous fatty tissue. The presented methods of infiltration of fatty tissue allow precise control over the contours of the face to replace atrophied or missing structures and enhance facial contours. Autologous fatty tissue harvested, refined, and placed in the specific fashion described is presented as an exemplary agent for augmentation in soft-tissue facial recontouring.

Understanding Adipocyte Differentiation

Article

Jan 1998

Gregoire, Francine M., Cynthia M. Smas, and Hei Sook Sul. Understanding Adipocyte Differentiation. Physiol. Rev. 78: 783–809, 1998. — The adipocyte plays a critical role in energy balance. Adipose tissue growth involves an increase in adipocyte size and the formation of new adipocytes from precursor cells. For the last 20 years, the cellular and molecular mechanisms of adipocyte differentiation have been extensively studied using preadipocyte culture systems. Committed preadipocytes undergo growth arrest and subsequent terminal differentiation into adipocytes. This is accompanied by a dramatic increase in expression of adipocyte genes including adipocyte fatty acid binding protein and lipid-metabolizing enzymes. Characterization of regulatory regions of adipose-specific genes has led to the identification of the transcription factors peroxisome proliferator-activated receptor-γ (PPAR-γ) and CCAAT/enhancer binding protein (C/EBP), which play a key role in the complex transcriptional cascade during adipocyte differentiation. Growth and differentiation of preadipocytes is controlled by communication between individual cells or between cells and the extracellular environment. Various hormones and growth factors that affect adipocyte differentiation in a positive or negative manner have been identified. In addition, components involved in cell-cell or cell-matrix interactions such as preadipocyte factor-1 and extracellular matrix proteins are also pivotal in regulating the differentiation process. Identification of these molecules has yielded clues to the biochemical pathways that ultimately result in transcriptional activation via PPAR-γ and C/EBP. Studies on the regulation of the these transcription factors and the mode of action of various agents that influence adipocyte differentiation will reveal the physiological and pathophysiological mechanisms underlying adipose tissue development.

Comparison of proliferation and differentiation capacity of human adipocyte precursor cells from the omental and subcutaneous adipose tissue depot of obese subjects

Article

Sep 2003

Upper body obesity is characterized by an expansion of visceral adipose tissue and associated with an increased susceptibility for diabetes and cardiovascular disease. To get a better understanding of the regulation of body fat distribution, adipocyte development was compared between the omental and subcutaneous adipose tissue region in 29 obese subjects. Therefore, the proliferation and differentiation capacity in primary cultures of adipose tissue-derived stromal cells were studied. Differentiation of preadipocytes was assessed by morphological criteria and determination of glycerol-3-phosphate dehydrogenase after stimulation by standardized adipogenic conditions. Proliferation was stimulated using fetal calf serum and assessed by counting the cell number in the culture dishes. Stromal cells of the subcutaneous region proliferated faster than those of the omental region, whereas there was no regional difference in adipose differentiation with any of the adipogenic media. There were more endothelial cells in the cultures from the omental than from the subcutaneous tissue, but there was no correlation between endothelial cell contamination and proliferation capacity, suggesting that the regional difference in proliferation capacity was not due to regional differences in the amount of endothelial cells. There was a negative correlation between donor age and proliferation of subcutaneous cells but not of omental cells, possibly explaining the greater capacity for adipose tissue growth in the omental as compared to the subcutaneous depot with aging. In conclusion, there may exist regional differences in adipose tissue growth with regard to proliferation capacity, whereas there are apparently no differences in differentiation capacity between subcutaneous and omental preadipocytes.

Cell-Assisted Lipotransfer: Supportive Use of Human Adipose-Derived Cells for Soft Tissue Augmentation with Lipoinjection

Article