Stem cells therapies in basic science and translational medicine: current status and treatment monitoring strategies

Stem-cell technology is a major area within cell therapy that promises significant therapeutic outcome. The plasticity and self-renewal capabilities of stem cells make them valuable tools for potential application in regenerative medicine and tissue replacement following injury or disease. Here, we discuss the different types of stem cells currently used in research, preclinical and early clinical development, their potential therapeutic and diagnostic applications, and current barriers to translating basic research into clinical therapies. Biomedical imaging is increasingly being used to monitor the fate of transplanted stem cells, including their survival, proliferation, differentiation and homing to targeted organs and tissues. We discuss different imaging modalities currently utilized to track stem calls, the advantages and challenges, and future implications in clinical applications.     

Cell-based treatments for diabetes

In Type 1 diabetes mellitus the insulin-secreting beta-cells in pancreatic islets of Langerhans are selectively destroyed by autoimmune assault. Because diabetes is caused by the loss of a single cell type it is amenable to treatment by cell replacement therapy. Advances in islet transplantation procedures have demonstrated that people with Type 1 diabetes can be cured by human islet transplantation, but the severely limited availability of donor islets has restricted the widespread application of this approach, and driven the search for substitute transplant tissues. Recent experimental studies suggest that three separate sources of tissue show therapeutic potential - xenografts from other species, tissue stem cells and embryonic stem cells. Of these, xenografts are closest to clinical application but there are still major obstacles to be overcome. Insulin-expressing cells have been derived from a number of different stem cell populations but embryonic stem cells offer the major advantage of being able, in principle, to provide the vast numbers of cells required for transplantation therapy.     

Amniotic fluid stem cells: a promising therapeutic resource for cell-based regenerative therapy

Stem cells have been proposed as a powerful tool in the treatment of several human diseases, both for their ability to represent a source of new cells to replace those lost due to tissue injuries or degenerative diseases, and for the ability of produce trophic molecules able to minimize damage and promote recovery in the injured tissue. Different cell types, such as embryonic, fetal or adult stem cells, human fetal tissues and genetically engineered cell lines, have been tested for their ability to replace damaged cells and to restore the tissue function after transplantation. Amniotic fluid -derived Stem cells (AFS) are considered a novel resource for cell transplantation therapy, due to their high renewal capacity, the "in vitro" expression of embryonic cell lineage markers, and the ability to differentiate in tissues derived from all the three embryonic layers. Moreover, AFS do not produce teratomas when transplanted into animals and are characterized by a low antigenicity, which could represent an advantage for cell transplantation or cell replacement therapy. The present review focuses on the biological features of AFS, and on their potential use in the treatment of pathological conditions such as ischemic brain injury and bone damages.     

Mesenchymal stem cells: cell biology and potential use in therapy

Mesenchymal stem cells are clonogenic, non-haematopoietic stem cells present in the bone marrow and are able to differentiate into multiple mesoderm-type cell lineages e.g. osteoblasts, chondrocytes, endothelial-cells and also non-mesoderm-type lineages e.g. neuronal-like cells. Several methods are currently available for isolation of the mesenchymal stem cells based on their physical and immunological characteristics. Because of the ease of their isolation and their extensive differentiation potential, mesenchymal stem cells are among the first stem cell types to be introduced in the clinic. Recent studies have demonstrated that the life span of mesenchymal stem cells in vitro can be extended by increasing the levels of telomerase expression in the cells and thus allowing culture of large number of cells needed for therapy. In addition, it has been shown that it is possible to culture the cells in xeno-free environment without affecting their growth or differentiation potential. Finally, the mesenchymal stem cells seems to be hypoimmunogenic and thus allogenic mesenchymal stem cells transplantation is possible. It is envisaged that mesenchymal stem cells can be used in systemic transplantation for generalized diseases, local implantation for local tissue defects, as a vehicle for genes in gene therapy protocols or to generate transplantable tissues and organs in tissue engineering protocols. The results of these initial trials are very encouraging and several clinical trials are under way to study the efficacy and long-term safety of therapeutics based on mesenchymal stem cells.     

Combining polymeric devices and stem cells for the treatment of neurological disorders: a promising therapeutic approach

Cell therapy will probably become a major therapeutic strategy for neuronal disorders in the coming years. Nevertheless, due to poor survival of grafted cells and limited differentiation and integration in the host tissue, certain ameliorations must be envisaged. To address these difficulties, several strategies have been developed and among them, two methods seem particularly promising : in situ controlled drug delivery and implantation of cells adhered on biomaterial-based scaffolds. Indeed, the ability of drugs, such as growth factors, to regulate neuronal survival and/or plasticity infers the use of these molecules to treat neurodegeneration associated with human diseases. Moreover, the synthesis of cell scaffolds which mimic the extra-cellular matrix can help guide morphogenesis and tissue repair. Furthermore, cells can be cultivated on these matrices that may eventually make graft therapy a more practical approach for the treatment of neurological diseases. Nevertheless, for those two encouraging approaches multiple parameters have to be considered, such as the drug targeting strategy, but also the physical and morphological characteristics of the scaffold and the type of cells to be conveyed. This review thus focuses on those two promising strategies and also on their possible association to improve stem cell therapy of neurodegenerative disorders. Indeed, tissue replacement by grafting cells within or adhered onto drug delivering biomaterial-based devices, has recently been reported and seems to be very promising.     

Combining stem cells and tissue engineering in cardiovascular repair -- a step forward to derivation of novel implants with enhanced function and self-renewal characteristics

The use of stem and progenitor cells in cardiovascular therapy has been proposed as a feasible option to promote repair of tissue damage by ischemia, or to devise definitive artificial tissue replacements (valves, vessels, myocardium) to be surgically implanted in patients. Whereas in other medical branches such as dermatology and ophthalmology the use of ex vivo grown tissues is already accessible to a large degree, the use of bio-artificial implants in cardiovascular surgery is still marginal. This represents a major limitation in cardiovascular medicine at present. In fact, the limited durability and the lack of full compatibility of current implantable devices or tissues prevent a long-term resolution of symptoms and often require re-intervention thereby further increasing the economic burden of the cardiovascular disease. Stem cell technology can be of help to derive tissues with improved physiologic function and permanent durability. Specifically, the intrinsic ability of stem cells to produce tissue-specific "niches", where immature cells are perpetuated while differentiated progenitors are continuously produced, makes them an ideal resource for bioengineering approaches. Furthermore, recent advancements in biocompatible material science, designing of complex artificial scaffolds and generation of animal or human-derived natural substrates have made it feasible to have ex vivo reproduction of complex cell environment interactions - a process necessary to improve stem cells biological activity. This review focuses on current understanding of cardiovascular stem cell biology as well as tissue engineering and explores their interdisciplinary approach. By reviewing the relevant recent patents which have enabled this field to advance, it concentrates on various design substrates and scaffolds that grow stem cells in order to materialize the production of cardiovascular implants with enhanced functional and self-renewal characteristics.     

Embryonic stem cell-derived hematopoietic stem cells: challenges in development, differentiation, and immunogenicity

Embryonic stem cells (ESC) can potentially be manipulated in vitro to differentiate into cells and tissues of all three germ layers. This pluripotent feature is being exploited to use ESC-derived tissues as therapies for degenerative diseases and replacement of damaged organs. Although their potential is great, the promise of ESC-derived therapies will be unfulfilled unless several challenges are overcome. For example, inefficient production of ESC-derived tissues before transplantation, inability of ESC-derived tissues to integrate well into the adult microenvironments due to developmental stage incompatibility, or active immune rejection of the ESC-derived graft are all potential challenges to successful ESC-derived therapies. One way to induce immunological tolerance to allogeneic tissues is via the establishment of mixed hematopoietic chimerism in which the host and donor cells are educated to recognize each other as "self". Proof of principle that in vitro cultured ESC-derived hematopoietic progenitors can be transplanted and induce immunological tolerance to allogeneic tissues exists in mouse models. In this review, we discuss the challenges to in vitro development of a bona fide ESC-derived hematopoietic stem cell and their differentiation fate in vivo, and provide suggestions to predict the immunogenicity of specific ESC-derived hematopoietic populations before transplantation that could be used to prevent their rejection after transplantation into an adult host.     

Stem cell transplantation for neurometabolic and neurodegenerative diseases

Over the last decade, the potential for therapeutic use of stem cell transplantation for cell replacement or as cellular vectors for gene delivery for neurometabolic and neurodegenerative diseases has received a great deal of interest. There has been substantial progress in our understanding of stem cell biology. Potential applications of cell-mediated therapy include direct cell replacement or protection and repair of the host nervous system. Given the complexities of the cellular organization of the nervous system, especially in diseased states, it seems that using stem cells as cellular vectors to prevent or ameliorate neurological disorders rather than cell replacement and the regrowth of damaged circuitry is more likely to succeed in the near term. Recent success in the treatment of lysosomal storage diseases with genetically modified stem cells support this notion. In Alzheimer's and Parkinson's diseases, stem cell therapy is at its early stages and data generated in animal models and clinical trials using other cell types suggest that a combination of gene and stem cell therapy may be an optimal therapeutic paradigm.     

Stem cell transplantation as an approach to brain repair

Disease of the nervous system causes considerable suffering, places a large economic burden on society and, to date, remains relatively untapped by pharmaceutical and biotechnology companies. The burgeoning field of stem cell biology promises to revolutionise and expand the use of cell therapy in the treatment of nervous system disease. By virtue of their multipotentiality stem cells are ideally suited to replace diverse neural and glial populations lost to disease or injury, and thereby functionally reconstruct neural circuits. The ease with which they can be genetically modified also makes them appealing vectors for ex vivo gene therapy in a multitude of conditions. This article reviews the approaches used to obtain large numbers of stem cells for such applications, including stem cells derived from neural tissue and propagated using either genetic or epigenetic means, totipotential embryonic stem cells and stem cells isolated from other tissues. The evidence for the efficacy of neural stem cell therapy in prototypical animal models of disease is then reviewed.     

Mesenchymal stem cells: isolation, in vitro expansion and characterization

Mesenchymal stem cells (MSC), one type of adult stem cell, are easy to isolate, culture, and manipulate in ex vivo culture. These cells have great plasticity and the potential for therapeutic applications, but their properties are poorly understood. MSCs can be found in bone marrow and in many other tissues, and these cells are generally identified through a combination of poorly defined physical, phenotypic, and functional properties; consequently, multiple names have been given to these cell populations. Murine MSCs have been directly applied to a wide range of murine models of diseases, where they can act as therapeutic agents per se, or as vehicles for the delivery of therapeutic genes. In addition to their systemic engraftment capabilities, MSCs show great potential for the replacement of damaged tissues such as bone, cartilage, tendon, and ligament. Their pharmacological importance is related to four points: MSCs secrete biologically important molecules, express specific receptors, can be genetically manipulated, and are susceptible to molecules that modify their natural behavior. Due to their low frequency and the lack of knowledge on cell surface markers and their location of origin, most information concerning MSCs is derived from in vitro studies. The search for the identity of the mesenchymal stem cell has depended mainly on three culture systems: the CFU-F assay, the analysis of bone marrow stroma, and the cultivation of mesenchymal stem cell lines. Other cell populations, more or less related to the MSC, have also been described. Isolation and culture conditions used to expand these cells rely on the ability of MSCs, although variable, to adhere to plastic surfaces. Whether these conditions selectively favor the expansion of different bone marrow precursors or cause similar cell populations to acquire different phenotypes is not clear. The cell populations could also represent different points of a hierarchy or a continuum of differentiation. These issues reinforce the urgent need for a more comprehensive view of the mesenchymal stem cell identity and characteristics.     

Therapeutic modulation of growth factors and cytokines in regenerative medicine

Regeneration that takes place in the human body is limited throughout life. Therefore, when organs are irreparably damaged, they are usually replaced with an artificial device or donor organ. The term "regenerative medicine" covers the restoration or replacement of cells, tissues, and organs. Stem cells play a major role in regenerative medicine by providing the way to repopulate organs damaged by disease. Stem cells have the ability to self renew and to regenerate cells of diverse lineages within the tissue in which they reside. Stem cells could originate from embryos or adult tissues. Growth factors are proteins that may act locally or systemically to affect the growth of cells in several ways. Various cell activities, including division, are influenced by growth factors. Cytokines are a family of low-molecular-weight proteins that are produced by numerous cell types and are responsible for regulating the immune response, inflammation, tissue remodeling and cellular differentiation. Target cells of growth factors and cytokines are mesenchymal, epithelial and endothelial cells. These molecules frequently have overlapping activities and can act in an autocrine or paracrine fashion. A complex network of growth factors and cytokines guides cellular differentiation and regeneration in all organs and tissues. The aim of this paper is to review the role of growth factors and cytokines in different organs or systems and explore their therapeutic application in regenerative medicine. The role of stem cells combined with growth factors and cytokines in the regeneration of vascular and hematopoietic, neural, skeletal, pancreatic, periodontal, and mucosal tissue is reviewed. There is evidence that supports the use of growth factors and cytokines in the treatment of neurological diseases, diabetes, cardiovascular disease, periodontal disease, cancer and its complication, oral mucositis. After solving the ethical issues and establishing clear and reasonable regulations, regenerative medicine through stem cell application combined with specific growth factors and cytokines will have great potential in curing a variety of human diseases.     

Apoptosis and cancer stem cells: Implications for apoptosis targeted therapy

Evidence is accumulating showing that cancer stem cells or tumor-initiating cells are key drivers of tumor formation and progression. Successful therapy must therefore eliminate these cells, which is hampered by their high resistance to commonly used treatment modalities. Thus far, only a limited number of studies have addressed the cancer stem cell killing potential of apoptosis targeted therapies and mechanisms of apoptosis resistance in these cells. Apoptosis resistance may involve inherent cellular mechanisms that may change depending on the differentiations status of stem cells and, on the other hand, extrinsic factors provided by the microenvironment such as secreted survival factors, adhesion-mediated apoptosis resistance and hypoxic conditions. In order to metastasize, cancer stem cells from solid tumors have to break free from their primary epithelial sites and resist cell death activation after detachment (anoikis). The induction of an embryonic genetic program causing the transition from an epithelial to a mesenchymal state (EMT) has been implicated in enhanced migration and metastatic spread of tumor cells and may contribute to apoptosis and anoikis resistance. Considering the plasticity of cancer stem cells the question arises whether a particular apoptosis-inducing strategy will be sufficient for eliminating all the cellular appearances of these cells, also taking into account a varying microenvironment. Here, the different mechanisms of apoptosis resistance that may be encountered in the context of cancer stem cell plasticity described thus far are discussed in relation to the efficacy of apoptosis therapies, such as TRAIL, BCL-2 family and XIAP targeted therapies.     

Beta-cell replacement for insulin-dependent diabetes mellitus

Beta-cell replacement is considered the optimal treatment for type 1 diabetes, however, it is hindered by a shortage of human organ donors. Given the difficulty of expanding adult beta cells in vitro, stem/progenitor cells, which can be expanded in tissue culture and induced to differentiate into multiple cell types, represent an attractive source for generation of cells with beta-cell properties. In the absence of well-characterized human pancreas progenitor cells, investigators are exploring the use of embryonic stem cells and stem/progenitor cells from other tissues. Once abundant surrogate beta cells are available, the challenge will be to protect them from recurring autoimmunity.     

Therapeutic potential of stem cells in diabetes

Stem cells possess the ability to self-renew by symmetric divisions and, under certain circumstances, differentiate to a committed lineage by asymmetric cell divisions. Depending on the origin, stem cells are classified as either embryonic or adult. Embryonic stem cells are obtained from the inner cell mass of the blastocyst, a structure that appears during embryonic development at day 6 in humans and day 3.5 in mice. Adult stem cells are present within tissues of adult organisms and are responsible for cell turnover or repopulation of tissues under normal or exceptional circumstances. Taken together, stem cells might represent a potential source of tissues for cell therapy protocols, and diabetes is a candidate disease that may benefit from cell replacement protocols. The pathology of type 1 diabetes is caused by the autoimmune destruction or malfunction of pancreatic beta cells, and consequently, a lack of insulin. The absence of insulin is life-threatening, thus requiring diabetic patients to take daily hormone injections from exogenous sources; however, insulin injections do not adequately mimic beta cell function. This results in the development of diabetic complications such as neuropathy, nephropathy, retinopathy and diverse cardiovascular disorders. This chapter intends to summarize the possibilities opened by embryonic and adult stem cells in regenerative medicine for the cure of diabetes.     

New Insights into the Pathogenesis and Treatment of Idiopathic Pulmonary Fibrosis: A Potential Role for Stem Cells in the Lung Parenchyma and Implications for Therapy

Idiopathic Pulmonary Fibrosis (IPF) is a chronic, progressive, and often fatal form of interstitial lung disease. It is characterized by injury with loss of lung epithelial cells and abnormal tissue repair, resulting in replacement of normal functional tissue, abnormal accumulation of fibroblasts and myofibroblasts, deposition of extracellular matrix, and distortion of lung architecture which results in respiratory failure. Despite improvements in the diagnostic approach to IPF and active research in recent years, the molecular mechanisms of the disease remain poorly understood. This highly lethal lung disorder continues to pose major clinical challenges since an effective therapeutic regimen has yet to be identified and developed. For example, a treatment modality has been based on the assumption that IPF is a chronic inflammatory disease, yet most available anti-inflammatory drugs are not effective in treating it. Hence researchers are now focusing on understanding alternative underlying mechanisms involved in the pathogenesis of IPF in the hope of discovering potentially new pharmaceutical targets. This paper will focus on lung tissue repair, regeneration, remodeling, and cell types that may be important to consider in therapeutic interventions and includes a more detailed discussion of the potential targets of current therapeutic attack in pulmonary fibrosis. The discovery that adult bone marrow stem cells can contribute to the formation of differentiated cell types in other tissues, especially after injury, implies that they have the potential to participate in tissue remodeling, and perhaps regeneration. The current promise of the use of adult stem cells for tissue regeneration, and the belief that once irreversibly damaged tissue could be restored to a normal functional capacity using stem cell-based therapy, suggests a novel approach for treatment of diverse chronic diseases. However this optimism is tempered by current evidence that the pathogenesis of pulmonary fibrosis may involve the recruitment of bone marrow-derived fibroblasts, which are the key contributors to the pathogenesis of this chronic progressive disorder. Nevertheless, stem cell-related therapies are widely viewed as promising treatment options for patients suffering from various types of pulmonary diseases. Gender mismatched bone marrow or lung transplant recipients serve as natural populations in which to study the role of bone marrow-derived stem cells in recovery from pulmonary diseases. Understanding the mechanism of recruitment of stem cells to sites of injury, and their involvement in tissue repair, regeneration, and remodeling may offer a novel therapeutic target for developing more effective treatments against this fatal disorder. This article reviews the new concepts in the pathogenesis, current and future treatment options of pulmonary fibrosis, and the recent advances regarding the roles of stem cells in lung tissue repair, regeneration, and remodeling.     

Stem cell transplantation therapy: controversy over ethical issues and clinical relevance

The possibility of regenerating tissues would provide an effective therapeutic tool for the treatment of many pathological conditions, including neurological diseases, spinal cord injuries, cardiopathies, diabetes, hematological illnesses and genetic disorders. While stem cells may have the potential of regenerating a variety of tissues, as indicated by a number of groundbreaking but preliminary reports, ethical issues and safety considerations seem to preclude the use of human embryonic stem cells in the clinical setting. Adult stem cells might circumvent the issues posed by embryonic stem cells, although the potential plasticity of adult stem cells is under scrutiny because of many conflicting and contradictory reports in the field of stem cell research. Indeed, many aspects of the biology of stem cells are still not known. In this respect, stem cell biologists have to address several pressing issues. A better understanding of stem cell biology would almost certainly allow for the establishment of efficient and reliable cell transplantation experimental programs in the clinic.     

Trends in the development of microfluidic cell biochips for in vitro hepatotoxicity.

Current developments in the technological fields of liver tissue engineering, bioengineering, biomechanics, microfabrication and microfluidics have lead to highly complex and pertinent new tools called "cell biochips" for in vitro toxicology. The purpose of "cell biochips" is to mimic organ tissues in vitro in order to partially reduce the amount of in vivo testing. These "cell biochips" consist of microchambers containing engineered tissue and living cell cultures interconnected by a microfluidic network, which allows the control of microfluidic flows for dynamic cultures, by continuous feeding of nutrients to cultured cells and waste removal. Cell biochips also allow the control of physiological contact times of diluted molecules with the tissues and cells, for rapid testing of sample preparations or specific addressing. Cell biochips can be situated between in vitro and in vivo testing. These types of systems can enhance functionality of cells by mimicking the tissue architecture complexities when compared to in vitro analysis but at the same time present a more rapid and simple process when compared to in vivo testing procedures. In this paper, we first introduce the concepts of microfluidic and biochip systems based on recent progress in microfabrication techniques used to mimic liver tissue in vitro. This includes progress and understanding in biomaterials science (cell culture substrate), biomechanics (dynamic cultures conditions) and biology (tissue engineering). The development of new "cell biochips" for chronic toxicology analysis of engineered tissues can be achieved through the combination of these research domains. Combining these advanced research domains, we then present "cell biochips" that allow liver chronic toxicity analysis in vitro on engineered tissues. An extension of the "cell biochip" idea has also allowed "organ interactions on chip", which can be considered as a first step towards the replacement of animal testing using a combined liver/lung organ model.     

Regenerative and immunomodulatory potential of mesenchymal stem cells

In the past few years, mesenchymal stem cells (MSCs) have come into the limelight because of their multi-lineage stem cell potential, which retains some aspects of embryonic stem cells, and because of their characteristic immunoregulatory functions exerted on different immune effector cells. The regenerative and immunomodulatory potential of MSCs has been used to support hemopoietic stem cell engraftment; to repair or regenerate damaged or mutated tissues, such as bone, cartilage, myocardial or hepatic tissues; to interfere with neoplastic cell growth by transfecting MSCs with anti-neoplastic molecules; and to modulate autoimmune reactions such as collagenopathies, multiple sclerosis and graft versus host disease. Thus, MSCs appear to be a very promising tool for regenerative and immunoregulatory cell therapy.