Controlled Inhibition of the Mesenchymal Stromal Cell Pro-inflammatory Secretome via Microparticle Engineering

Role of secretomes in cell-free therapeutic strategies in regenerative medicine

After an injury, peripheral nervous system neurons have the potential to rebuild their axons by generating a complicated activation response. Signals from the damaged axon are required for this genetic transition to occur. Schwann cells (SCs) near a damaged nerve's distal stump also play a role in the local modulation of axonal programs, not only via cell-to-cell contacts but also through secreted signals (the secretome). The secretome is made up of all the proteins that the cell produces, such as cytokines, growth factors, and extracellular vesicles. The released vesicles may carry signaling proteins as well as coding and regulatory RNAs, allowing for multilayer communication. The secretome of SCs is now well understood as being critical for both orchestrating Wallerian degeneration and maintaining axonal regeneration. As a consequence, secretome has emerged as a feasible tissue regeneration alternative to cell therapy. Separate SC secretome components have been used extensively in the lab to promote peripheral nerve regeneration after injury. However, in neurological therapies, the secretome generated by mesenchymal (MSC) or other derived stem cells has been the most often used. In fact, the advantages of cell treatment have been connected to the release of bioactive chemicals and extracellular vesicles, which make up MSCs' secretome.

Impacts of priming on distinct immunosuppressive mechanisms of mesenchymal stromal cells under translationally relevant conditions

BACKGROUND

The multimodal properties of mesenchymal stromal cells (MSCs), particularly their ability to modulate immune responses is of high interest in translational research. Pro-inflammatory, hypoxic, and 3D culture priming are promising and often used strategies to improve the immunosuppressive potency of MSCs, but the underlying mechanisms are not well understood. Therefore, the aims of this study were (i) to compare the effects of pro-inflammatory, hypoxic, and 3D culture priming on the in vitro immunosuppressive potential of MSCs, (ii) to assess if immunosuppressive priming effects are temporally preserved under standard and translationally relevant culture conditions, and (iii) to investigate if the three priming strategies engage the same immunosuppressive mechanisms.

METHODS

Functional in vitro T cell suppressive potency measurements were conducted to assess the impact of pro-inflammatory, hypoxic, and 3D culture priming on the immunosuppressive potential of human bone marrow-derived MSCs. Primed MSCs were either cultured under standard cell culture conditions or translationally relevant culture conditions, and their transcriptomic adaptations were monitored over time. Next-generation sequencing was performed to assess if different priming strategies activate distinct immunosuppressive mechanisms.

RESULTS

(i) Pro-inflammatory, hypoxic, and 3D culture priming induced profound transcriptomic changes in MSCs resulting in a significantly enhanced T cell suppressive potential of pro-inflammatory and 3D culture primed MSCs. (ii) Priming effects rapidly faded under standard cell culture conditions but were partially preserved under translationally relevant conditions. Interestingly, continuous 3D culture priming of MSCs maintained the immunosuppressive potency of MSCs. (iii) Next-generation sequencing revealed that priming strategy-specific differentially expressed genes are involved in the T cell suppressive capacity of MSCs, indicating that different priming strategies engage distinct immunosuppressive mechanisms.

CONCLUSION

Priming can be a useful approach to improve the immunosuppressive potency of MSCs. However, future studies involving primed MSCs should carefully consider the significant impact of translationally relevant conditions on the preservation of priming effects. Continuous 3D culture could act as a functionalized formulation, supporting the administration of MSC spheroids for a sustainably improved immunosuppressive potency.

Mesenchymal Stem Cell-Derived Exosomal microRNAs in Cardiac Regeneration

Mesenchymal stem cell (MSC)-based therapy is one of the most promising modalities for cardiac repair. Accumulated evidence suggests that the therapeutic value of MSCs is mainly attributable to exosomes. MSC-derived exosomes (MSC-Exos) replicate the beneficial effects of MSCs by regulating various cellular responses and signaling pathways implicated in cardiac regeneration and repair. miRNAs constitute an important fraction of exosome content and are key contributors to the biological function of MSC-Exo. MSC-Exo carrying specific miRNAs provides anti-apoptotic, anti-inflammatory, anti-fibrotic, and angiogenic effects within the infarcted heart. Studying exosomal miRNAs will provide an important insight into the molecular mechanisms of MSC-Exo in cardiac regeneration and repair. This significant information can help optimize cell-free treatment and overcome the challenges associated with MSC-Exo therapeutic application. In this review, we summarize the characteristics and the potential mechanisms of MSC-derived exosomal miRNAs in cardiac repair and regeneration.

Fusogenic liposome-coated nanoparticles for rapid internalization into donor corneal endothelial tissue to enable prophylaxis before transplantation

Cold stress (hypothermia) during storage and cytokine stress due to acute allograft rejection adversely affect the donor corneal endothelium in the short term. Pharmacological pre-treatment (before transplantation) of the donor corneal endothelium or cells (propagated in vitro for cell injection therapy) with microtubule stabilizers, cold stress protectants, and other molecules is an attractive strategy to tackle damage caused by hypothermia and cytokine stress. These molecules can be delivered intracellularly to the donor corneal endothelium or cells at controlled rates for desired periods and with one-time administration using nanoparticles. However, the death-to-preservation time of donor corneas of more than 4 to 6 h significantly decreases endothelial cell density and increases the risk of microbial contamination. Therefore, we have developed fusogenic liposome-coated nanoparticles for rapid internalization of nanoparticles into cultured corneal endothelial cells and ex vivo corneal endothelial tissue. Here, we have shown that the fusogenic liposome-coated nanoparticles have the intrinsic ability to efficiently and rapidly internalize into cultured corneal endothelial cells and ex vivo corneal tissue within 3 h by possibly fusing with the cell membrane and bypassing the endocytic pathway. Lactate dehydrogenase assay showed that the internalized fusogenic liposome-coated nanoparticles did not cause cytotoxicity in endothelial cells associated with the ex vivo cornea for at least up to 2 days. Thus, fusogenic liposome-coated nanoparticles have great potential as a platform for engineering cells and endothelial tissue of donor corneas to facilitate prophylactic drug delivery during storage and after transplantation.

Barium sulphate microparticles are taken up by three different cell types: HeLa, THP-1, and hMSC

Cytotoxicity and cellular uptake of spherical barium sulphate microparticles (diameter 1 µm) were studied with three different cell lines, i.e. THP-1 cells (monocytes; model for a phagocytosing cell line), HeLa cells (epithelial cells; model for a non-phagocytosing cell line), and human mesenchymal stem cells (hMSCs; model for non-phagocytosing primary cells). Barium sulphate is a chemically and biologically inert solid which allows to distinguish two different processes, e.g. the particle uptake and potential adverse biological reactions. Barium sulphate microparticles were surface-coated by carboxymethylcellulose (CMC) which gave the particles a negative charge. Fluorescence was added by conjugating 6-aminofluorescein to CMC. The cytotoxicity of these microparticles was studied by the MTT test and a live/dead assay. The uptake was visualized by confocal laser scanning microscopy (CLSM) and scanning electron microscopy (SEM). The particle uptake mechanism was quantified by flow cytometry with different endocytosis inhibitors in THP-1 and HeLa cells. The microparticles were easily taken up by all cell types, mostly by phagocytosis and micropinocytosis, within a few hours. STATEMENT OF SIGNIFICANCE: The interaction of particles and cells is of primary importance in nanomedicine, drug delivery, and nanotoxicology. It is commonly assumed that cells take up only nanoparticles unless they are able to phagocytosis. Here, we demonstrate with chemically and biologically inert microparticles of barium sulphate that even non-phagocytosing cells like HeLa and hMSCs take up microparticles to a considerable degree. This has considerable implication in biomaterials science, e.g. in case of abrasive debris and particulate degradation products from implants like endoprostheses.

Microtubule Stabilization Protects Hypothermia-Induced Damage to the Cytoskeleton and Barrier Integrity of the Corneal Endothelial Cells

Purpose: To determine the impact of hypothermia on the barrier function of donor corneal endothelium, thereby enhancing the success of corneal transplantation. Methods: Primary cultures of porcine endothelial cells were subjected to hypothermia (15 h; 4°C). The impact on microtubule assembly, peri-junctional actomyosin ring (PAMR), and ZO-1 was assessed by immunocytochemistry with and without pretreatment with a microtubule-stabilizing agent (Epothilone B; EpoB; 100 nM) and a p38 MAP kinase inhibitor (SB-203580; 20 μM). In addition, EpoB-loaded PLGA nanoparticles (ENPs) prepared by nanoprecipitation technique and coated with poly-L-lysine (PLL-ENPs) were administered one-time for sustained intracellular delivery of EpoB. Results: Exposure to hypothermia led to microtubule disassembly concomitant with the destruction of PAMR and the displacement of ZO-1 at the cellular periphery, suggesting a loss in barrier integrity. These adverse effects were attenuated by pretreatment with EpoB or SB-203580. PLL-ENPs possessed a zeta potential of ∼26 mV and a size of ∼110 nm. Drug loading and entrapment efficiency were 5% (w/w) and ∼87%, respectively, and PLL-ENPs showed a biphasic release in vitro: burst phase (1 day), followed by a sustained phase (∼4 weeks). Pretreatment with PLL-ENPs (0.4 mg/mL) for 24 h stabilized the microtubules and opposed the hypothermia-induced damage to PAMR and the redistribution of ZO-1. Conclusions: Hypothermia induces microtubule disassembly via activation of p38 MAP kinase and subsequently breaks down the barrier function of the endothelium. Sustained intracellular delivery of EpoB using nanoparticles has the potential to overcome endothelial barrier failure during prolonged cold storage of donor cornea.

Engineering the MSC Secretome: A Hydrogel Focused Approach

The therapeutic benefits of exogenously delivered mesenchymal stromal/stem cells (MSCs) have been largely attributed to their secretory properties. However, clinical translation of MSC-based therapies is hindered due to loss of MSC regenerative properties during large-scale expansion and low survival/retention post-delivery. These limitations might be overcome by designing hydrogel culture platforms to modulate the MSC microenvironment. Hydrogel systems could be engineered to i) promote MSC proliferation and maintain regenerative properties (i.e., stemness and secretion) during ex vivo expansion, ii) improve MSC survival, retention, and engraftment in vivo, and/or iii) direct the MSC secretory profile using tailored biochemical and biophysical cues. Herein, it is reviewed how hydrogel material properties (i.e., matrix modulus, viscoelasticity, dimensionality, cell adhesion, and porosity) influence MSC secretion, mediated through cell-matrix and cell-cell interactions. In addition, it is highlighted how biochemical cues (i.e., small molecules, peptides, and proteins) can improve and direct the MSC secretory profile. Last, the authors' perspective is provided on future work toward the understanding of how microenvironmental cues influence the MSC secretome, and designing the next generation of biomaterials, with optimized biophysical and biochemical cues, to direct the MSC secretory profile for improved clinical translation outcomes.

Strategies to Potentiate Paracrine Therapeutic Efficacy of Mesenchymal Stem Cells in Inflammatory Diseases

Mesenchymal stem cells (MSCs) have been developed as cell therapeutics for various immune disorders using their immunoregulatory properties mainly exerted by their paracrine functions. However, variation among cells from different donors, as well as rapid clearance after transplantation have impaired the uniform efficacy of MSCs and limited their application. Recently, several strategies to overcome this limitation have been suggested and proven in pre-clinical settings. Therefore, in this review article, we will update the knowledge on bioengineering strategies to improve the immunomodulatory functions of MSCs, including genetic modification and physical engineering.

Age-Related Changes in the Inflammatory Status of Human Mesenchymal Stem Cells: Implications for Cell Therapy

Human mesenchymal stem/stromal cell (hMSC)-based cell therapies are promising for treating a variety of diseases. The unique immunomodulatory properties of hMSCs have extended their therapeutic potential beyond tissue regeneration. However, extensive pre-clinical culture expansion inevitably drives cells toward replicative “aging” and a consequent decline in quality. These “in vitro-aged” hMSCs resemble biologically aged cells, which have been reported to show senescence signatures, diminished immunosuppressive capacity, and weakened regenerative potential as well as pro-inflammatory features. In this review, we have surveyed the literature to explore the intimate relationship between the inflammatory status of hMSCs and their in vitro aging process. We posit that a shift from an anti-inflammatory to a pro-inflammatory phenotype of culture-expanded hMSCs contributes to a deterioration in their therapeutic efficacy. Potential molecular and cellular mechanisms underpinning this phenomenon have been discussed. We have also highlighted studies that leverage these mechanisms to make culture-expanded hMSCs more amenable for clinical use.

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Aged MSCs have reduced immunosuppressive potential

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Chronic inflammatory microenvironments can exacerbate MSC senescence and aging

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The immunomodulatory potential of MSCs should be assessed prior to clinical use

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MSC immunomodulatory properties may be modified in vitro by bioengineering means

A cell-based drug delivery platform for treating central nervous system inflammation

Mesenchymal stem cells (MSCs) are promising candidates for the development of cell-based drug delivery systems for autoimmune inflammatory diseases, such as multiple sclerosis (MS). Here, we investigated the effect of Ro-31-8425, an ATP-competitive kinase inhibitor, on the therapeutic properties of MSCs. Upon a simple pretreatment procedure, MSCs spontaneously took up and then gradually released significant amounts of Ro-31-8425. Ro-31-8425 (free or released by MSCs) suppressed the proliferation of CD4⁺ T cells in vitro following polyclonal and antigen-specific stimulation. Systemic administration of Ro-31-8425-loaded MSCs ameliorated the clinical course of experimental autoimmune encephalomyelitis (EAE), a murine model of MS, displaying a stronger suppressive effect on EAE than control MSCs or free Ro-31-8425. Ro-31-8425-MSC administration resulted in sustained levels of Ro-31-8425 in the serum of EAE mice, modulating immune cell trafficking and the autoimmune response during EAE. Collectively, these results identify MSC-based drug delivery as a potential therapeutic strategy for the treatment of autoimmune diseases. KEY MESSAGES: MSCs can spontaneously take up the ATP-competitive kinase inhibitor Ro-31-8425. Ro-31-8425-loaded MSCs gradually release Ro-31-8425 and exhibit sustained suppression of T cells. Ro-31-8425-loaded MSCs have more sustained serum levels of Ro-31-8425 than free Ro-31-8425. Ro-31-8425-loaded MSCs are more effective than MSCs and free Ro-31-8425 for EAE therapy.

Emergence of the Stem Cell Secretome in Regenerative Engineering

The secretome is defined as the set of molecules and biological factors that are secreted by cells into the extracellular space. In the past decade, secretome-based therapies have emerged as a promising approach to overcome the limitations associated with cell-based therapies for tissue and organ regeneration. Considering the growing number of recent publications related to secretome-based therapies, this review takes a step-by-step engineering approach to evaluate the role of the stem cell secretome in regenerative engineering. We discuss the functional benefits of the secretome, the techniques used to engineer the secretome and tailor its therapeutic effects, and the delivery systems and strategies that have been developed to use the secretome for tissue regeneration.

Immunosuppressive Effects of Mesenchymal Stem Cells-derived Exosomes

Mesenchymal stem cells (MSCs) have become important seed cells in therapy because of their immunosuppressive function and anti-inflammatory effects. MSCs exert immunosuppressive effects through direct contact or paracrine action. The paracrine functions of MSCs are at least partially mediated by exosomes, which are membrane vesicles, carrying abundant proteins, nucleic acids and other active molecules. MSC-exos have heterogeneity. The exosomes from different donors, tissues generations of MSCs carry different bioactive molecules. These cargos are transferred to recipient cells by endocytosis or binding to proteins on the receptor surface to mediate intercellular communication between different cell types and affect the functions of the recipient cells. Exosomes play an important role in the regulation of the immune system. Exosomes derived from MSCs (MSC-exos) carry immunomodulatory effectors or transmit active signal molecules to regulate the biological activities of immune cells and thus mediating immune suppression, especially on macrophages and T cells. Mitochondria and autophagy-related pathways are also associated with MSC-exos immunosuppressive effects. Graphical Abstract.

Shattering barriers toward clinically meaningful MSC therapies

More than 1050 clinical trials are registered at FDA.gov that explore multipotent mesenchymal stromal cells (MSCs) for nearly every clinical application imaginable, including neurodegenerative and cardiac disorders, perianal fistulas, graft-versus-host disease, COVID-19, and cancer. Several companies have or are in the process of commercializing MSC-based therapies. However, most of the clinical-stage MSC therapies have been unable to meet primary efficacy end points. The innate therapeutic functions of MSCs administered to humans are not as robust as demonstrated in preclinical studies, and in general, the translation of cell-based therapy is impaired by a myriad of steps that introduce heterogeneity. In this review, we discuss the major clinical challenges with MSC therapies, the details of these challenges, and the potential bioengineering approaches that leverage the unique biology of MSCs to overcome the challenges and achieve more potent and versatile therapies.

Conditioned medium of adipose derived Mesenchymal Stem Cells reverse insulin resistance through downregulation of stress induced serine kinases

Insulin resistance (IR) is a constituent part of Type 2 Diabetes Mellitus (T2DM). Conditioned medium from Adipose derived Mesenchymal Stem Cells (ADMSCs-CM) has been shown to reverse IR. However, its effect on cellular stress is not well established. The objective of this study was to explore the effect of ADMSCs-CM on reactive oxygen species, mitochondrial membrane potential (ΔΨm), endoplasmic reticulum (ER) stress and expression of oxidative and inflammatory stress induced serine kinases (SISK) which are pathophysiologically linked to IR. In insulin resistant, 3T3-L1 adipocytes and C2C12 myoblast cell culture models, glucose uptake was assayed by 2-NBDG uptake. Immunomodulatory cytokines, intracellular reactive oxygen species generation, ΔΨm and protein expression of JNK1, IKKβ and phospho-IRS1 (307) were analyzed using FACS. mRNA expression of ER stress markers (CHOP1 and IRE1) and SISK (JNK1, IKKβ, ERK1 and S6K1) were analyzed using RT-PCR. ADMSCs-CM effectively improve glucose uptake as evidenced by 2-NBDG uptake assay. FACS analysis showed that ADMSCs-CM possessed significantly higher levels of IL-6 and IL-10. ADMSCs-CM decreased intracellular generation of reactive oxygen species where it restored ΔΨm in C2C12 cells. ADMSCs-CM mediated reduction in ER stress was confirmed by down-regulation in CHOP1 and IRE1 mRNA expression. ADMSCs-CM treatment showed significant down-regulation of SISK mRNA expression including IKKβ, JNK, ERK and S6K1. Our results unequivocally demonstrate for the first time the mechanism of action of ADMSCs-CM in amelioration IR by reducing oxidative and inflammatory cellular stress. This study identifies SISK as potential therapeutic targets for T2DM therapy.

Aggregation of Human Mesenchymal Stromal Cells Eliminates Their Ability to Suppress Human T Cells

Mesenchymal stromal cells (MSCs) are administered locally to treat sites of inflammation. Local delivery is known to cause MSCs to aggregate into “spheroids,” which alters gene expression and phenotype. While adherent MSCs are highly efficient in their inhibition of T cells, whether or not this property is altered upon MSC aggregation has not been thoroughly determined. In this study, we discovered that aggregation of MSCs into spheroids causes them to lose their T cell-suppressive abilities. Interestingly, adding budesonide, a topical glucocorticoid steroid, alongside spheroids partially restored MSC suppression of T cell proliferation. Through a series of inhibition and add-back studies, we determined budesonide acts synergistically with spheroid MSC-produced PGE2 to suppress T cell proliferation through the PGE2 receptors EP2 and EP4. These findings highlight critical differences between adherent and spheroid MSC interactions with human immune cells that have significant translational consequences. In addition, we uncovered a mechanism through which spheroid MSC suppression of T cells can be partly restored. By understanding the phenotypic changes that occur upon MSC aggregation and the impact of MSC drug interactions, improved immunosuppressive MSC therapies for localized delivery can be designed.

Bioconjugated Carbon Dots for Delivery of siTnfα to Enhance Chondrogenesis of Mesenchymal Stem Cells by Suppression of Inflammation

Although a promising strategy, the mesenchymal stem cell (MSC)‐based therapy of cartilage defects is sometimes accompanied with chronic inflammation during the remodeling status, which may hinder cartilage regeneration. During this process, the inflammatory cytokine tumor necrosis factor α (TNFα) plays an important role and may be a potential target. In this study, we investigated the effect of Tnfα RNA interference by introducing a functional and highly safe carbon dot (CD)‐SMCC nanovector synthesized by bioconjugation of CDs with a protein crosslinker, sulfosuccinimidyl‐4‐(N‐maleimidomethyl) cyclohexane‐1‐carboxylate (sulfo‐SMCC), as the vehicle of the silenced TNFα (siTnfα) on chondrogenesis of MSCs. The results showed that CD‐SMCC displayed intense fluorescence with well‐dispersed and positively charged properties, which favored effective binding and delivering of siTnfα into the MSCs. CD‐SMCC‐siTnfα nanoformula also exhibited considerably high transfection efficiency and nearly no cytotoxicity, which is preferred over commercial polyethyleneimine. Interference of Tnfα by CD‐SMCC‐siTnfα markedly promoted the chondrogenesis of MSCs, as indicated by upregulating cartilage‐specific markers. Furthermore, in vivo exploration indicated that CD‐SMCC‐siTnfα transfected MSCs accelerated cartilage regeneration. In conclusion, this study demonstrated that in combination with the novel CD‐SMCC nanovector, targeting Tnfα may facilitate stem cell‐based therapy of cartilage defects. stem cells translational medicine2019;8:724&736

Fra-2 Expression in Osteoblasts Regulates Systemic Inflammation and Lung Injury through Osteopontin

Inflammatory responses require mobilization of innate immune cells from the bone marrow. The functionality of this process depends on the state of the bone marrow microenvironment. We therefore hypothesized that molecular changes in osteoblasts, which are essential stromal cells of the bone marrow microenvironment, influence the inflammatory response. Here, we show that osteoblast-specific expression of the AP-1 transcription factor Fra-2 (Fra-2^Ob-tet) induced a systemic inflammatory state with infiltration of neutrophils and proinflammatory macrophages into the spleen and liver as well as increased levels of proinflammatory cytokines, such as interleukin-1β (IL-1β), IL-6, and granulocyte-macrophage colony-stimulating factor (GM-CSF). By in vivo inhibition of osteopontin (OPN) in Fra-2^Ob-tet mice, we demonstrated that this process was dependent on OPN expression, which mediates alterations of the bone marrow niche. OPN expression was transcriptionally enhanced by Fra-2 and stimulated mesenchymal stem cell (MSC) expansion. Furthermore, in a murine lung injury model, Fra-2^Ob-tet mice showed increased inflammatory responses and more severe disease features via an enhanced and sustained inflammatory response to lipopolysaccharide (LPS). Our findings demonstrate for the first time that molecular changes in osteoblasts influence the susceptibility to inflammation by altering evasion of innate immune cells from the bone marrow space.

Bioengineered cellular and cell membrane-derived vehicles for actively targeted drug delivery: So near and yet so far

Cellular carriers for drug delivery are attractive alternatives to synthetic nanoparticles owing to their innate homing/targeting abilities. Here, we review molecular interactions involved in the homing of Mesenchymal stem cells (MSCs) and other cell types to understand the process of designing and engineering highly efficient, actively targeting cellular vehicles. In addition, we comprehensively discuss various genetic and non-genetic strategies and propose futuristic approaches of engineering MSC homing using micro/nanotechnology and high throughput small molecule screening. Most of the targeting abilities of a cell come from its plasma membrane, thus, efforts to harness cell membranes as drug delivery vehicles are gaining importance and are highlighted here. We also recognize and report the lack of detailed characterization of cell membranes in terms of safety, structural integrity, targeting functionality, and drug transport. Finally, we provide insights on future development of bioengineered cellular and cell membrane-derived vesicles for successful clinical translation.

Mesenchymal Stem Cell Secretome: Toward Cell-Free Therapeutic Strategies in Regenerative Medicine

Earlier research primarily attributed the effects of mesenchymal stem cell (MSC) therapies to their capacity for local engrafting and differentiating into multiple tissue types. However, recent studies have revealed that implanted cells do not survive for long, and that the benefits of MSC therapy could be due to the vast array of bioactive factors they produce, which play an important role in the regulation of key biologic processes. Secretome derivatives, such as conditioned media or exosomes, may present considerable advantages over cells for manufacturing, storage, handling, product shelf life and their potential as a ready-to-go biologic product. Nevertheless, regulatory requirements for manufacturing and quality control will be necessary to establish the safety and efficacy profile of these products. Among MSCs, human uterine cervical stem cells (hUCESCs) may be a good candidate for obtaining secretome-derived products. hUCESCs are obtained by Pap cervical smear, which is a less invasive and painful method than those used for obtaining other MSCs (for example, from bone marrow or adipose tissue). Moreover, due to easy isolation and a high proliferative rate, it is possible to obtain large amounts of hUCESCs or secretome-derived products for research and clinical use.