3D bioprinting of liver models: A systematic scoping review of methods, bioinks, and reporting quality

Background

Effective communication is crucial for broad acceptance and applicability of alternative methods in 3R biomedical research and preclinical testing. 3D bioprinting is used to construct intricate biological structures towards functional liver models, specifically engineered for deployment as alternative models in drug screening, toxicological investigations, and tissue engineering. Despite a growing number of reviews in this emerging field, a comprehensive study, systematically assessing practices and reporting quality for bioprinted liver models is missing.

Methods

In this systematic scoping review we systematically searched MEDLINE (Ovid), EMBASE (Ovid) and BioRxiv for studies published prior to June 2nd, 2022. We extracted data on methodological conduct, applied bioinks, the composition of the printed model, performed experiments and model applications. Records were screened for eligibility and data were extracted from included articles by two independent reviewers from a panel of seven domain experts specializing in bioprinting and liver biology. We used RAYYAN for the screening process and SyRF for data extraction. We used R for data analysis, and R and Graphpad PRISM for visualization.

Results

Through our systematic database search we identified 1042 records, from which 63 met the eligibility criteria for inclusion in this systematic scoping review. Our findings revealed that extrusion-based printing, in conjunction with bioinks composed of natural components, emerged as the predominant printing technique in the bioprinting of liver models. Notably, the HepG2 hepatoma cell line was the most frequently employed liver cell type, despite acknowledged limitations. Furthermore, 51% of the printed models featured co-cultures with non-parenchymal cells to enhance their complexity. The included studies offered a variety of techniques for characterizing these liver models, with their primary application predominantly focused on toxicity testing. Among the frequently analyzed liver markers, albumin and urea stood out. Additionally, Cytochrome P450 (CYP) isoforms, primarily CYP3A and CYP1A, were assessed, and select studies employed nuclear receptor agonists to induce CYP activity.

Conclusion

Our systematic scoping review offers an evidence-based overview and evaluation of the current state of research on bioprinted liver models, representing a promising and innovative technology for creating alternative organ models. We conducted a thorough examination of both the methodological and technical facets of model development and scrutinized the reporting quality within the realm of bioprinted liver models. This systematic scoping review can serve as a valuable template for systematically evaluating the progress of organ model development in various other domains. The transparently derived evidence presented here can provide essential support to the research community, facilitating the adaptation of technological advancements, the establishment of standards, and the enhancement of model robustness. This is particularly crucial as we work toward the long-term objective of establishing new approach methods as reliable alternatives to animal testing, with extensive and versatile applications.

Stem Cell-Based Strategies: The Future Direction of Bioartificial Liver Development

Acute liver failure (ALF) results from severe liver damage or end-stage liver disease. It is extremely fatal and causes serious health and economic burdens worldwide. Once ALF occurs, liver transplantation (LT) is the only definitive and recommended treatment; however, LT is limited by the scarcity of liver grafts. Consequently, the clinical use of bioartificial liver (BAL) has been proposed as a treatment strategy for ALF. Human primary hepatocytes are an ideal cell source for these methods. However, their high demand and superior viability prevent their widespread use. Hence, finding alternatives that meet the seed cell quality and quantity requirements is imperative. Stem cells with self-renewing, immunogenic, and differentiative capacities are potential cell sources. MSCs and its secretomes encompass a spectrum of beneficial properties, such as anti-inflammatory, immunomodulatory, anti-ROS (reactive oxygen species), anti-apoptotic, pro-metabolomic, anti-fibrogenesis, and pro-regenerative attributes. This review focused on the recent status and future directions of stem cell-based strategies in BAL for ALF. Additionally, we discussed the opportunities and challenges associated with promoting such strategies for clinical applications.

Three dimensional (bio)printing of blood vessels: from vascularized tissues to functional arteries

Tissue engineering has emerged as a strategy for producing functional tissues and organs to treat diseases and injuries. Many chronic conditions directly or indirectly affect normal blood vessel functioning, necessary for material exchange and transport through the body and within tissue-engineered constructs. The interest in vascular tissue engineering is due to two reasons: (1) functional grafts can be used to replace diseased blood vessels, and (2) engineering effective vasculature within other engineered tissues enables connection with the host's circulatory system, supporting their survival. Among various practices, (bio)printing has emerged as a powerful tool to engineer biomimetic constructs. This has been made possible with precise control of cell deposition and matrix environment along with the advancements in biomaterials. (Bio)printing has been used for both engineering stand-alone vascular grafts as well as vasculature within engineered tissues for regenerative applications. In this review article, we discuss various conditions associated with blood vessels, the need for artificial blood vessels, the anatomy and physiology of different blood vessels, available 3D (bio)printing techniques to fabricate tissue-engineered vascular grafts and vasculature in scaffolds, and the comparison among the different techniques. We conclude our review with a brief discussion about future opportunities in the area of blood vessel tissue engineering.

Three Dimensional Bioprinting for Hepatic Tissue Engineering: From In Vitro Models to Clinical Applications

Fabrication of functional organs is the holy grail of tissue engineering and the possibilities of repairing a partial or complete liver to treat chronic liver disorders are discussed in this review. Liver is the largest gland in the human body and plays a responsible role in majority of metabolic function and processes. Chronic liver disease is one of the leading causes of death globally and the current treatment strategy of organ transplantation holds its own demerits. Hence there is a need to develop an in vitro liver model that mimics the native microenvironment. The developed model should be a reliable to understand the pathogenesis, screen drugs and assist to repair and replace the damaged liver. The three-dimensional bioprinting is a promising technology that recreates in vivo alike in vitro model for transplantation, which is the goal of tissue engineers. The technology has great potential due to its precise control and its ability to homogeneously distribute cells on all layers in a complex structure. This review gives an overview of liver tissue engineering with a special focus on 3D bioprinting and bioinks for liver disease modelling and drug screening.

Application of 3D Bioprinting in Liver Diseases

Liver diseases are the primary reason for morbidity and mortality in the world. Owing to a shortage of organ donors and postoperative immune rejection, patients routinely suffer from liver failure. Unlike 2D cell models, animal models, and organoids, 3D bioprinting can be successfully employed to print living tissues and organs that contain blood vessels, bone, and kidney, heart, and liver tissues and so on. 3D bioprinting is mainly classified into four types: inkjet 3D bioprinting, extrusion-based 3D bioprinting, laser-assisted bioprinting (LAB), and vat photopolymerization. Bioinks for 3D bioprinting are composed of hydrogels and cells. For liver 3D bioprinting, hepatic parenchymal cells (hepatocytes) and liver nonparenchymal cells (hepatic stellate cells, hepatic sinusoidal endothelial cells, and Kupffer cells) are commonly used. Compared to conventional scaffold-based approaches, marked by limited functionality and complexity, 3D bioprinting can achieve accurate cell settlement, a high resolution, and more efficient usage of biomaterials, better mimicking the complex microstructures of native tissues. This method will make contributions to disease modeling, drug discovery, and even regenerative medicine. However, the limitations and challenges of this method cannot be ignored. Limitation include the requirement of diverse fabrication technologies, observation of drug dynamic response under perfusion culture, the resolution to reproduce complex hepatic microenvironment, and so on. Despite this, 3D bioprinting is still a promising and innovative biofabrication strategy for the creation of artificial multi-cellular tissues/organs.

Mimicking Native Liver Lobule Microarchitecture In Vitro with Parenchymal and Non-parenchymal Cells Using 3D Bioprinting for Drug Toxicity and Drug Screening Applications

Bioengineering an in vitro liver model recapitulating the native liver microarchitecture consisting of parenchymal and non-parenchymal cells is crucial in achieving cellular crosstalk and hepatic metabolic functions for accurate hepatotoxicity prediction. Bioprinting holds the promise of engineering constructs with precise control over the spatial distribution of multiple cells. Two distinct tissue-specific liver extracellular matrix (ECM)-based bioinks with excellent printability and rheological attributes are formulated for supporting parenchymal and non-parenchymal cells. A physiologically relevant human vascularized liver model is bioprinted with a novel liver ECM-based bioink laden with human adipose mesenchymal stem cell-derived hepatocyte-like cells (HLCs), human umbilical vein endothelial cells (HUVECs), and human hepatic stellate cells (HHSCs) using an extrusion-based bioprinting approach and validated for hepatotoxicity assessment. The HLC/HUVEC/HHSC-laden liver model resembles native alternate cords of hepatocytes with a functional sinusoidal lumen-like network in both horizontal and vertical directions, demonstrating enhanced albumin production, urea synthesis, and cytochrome P450 (CPR) activity. Furthermore, the liver model is evaluated for drug toxicity assessment following 24 h exposure to different concentrations of (i) non-hepatotoxicants aspirin and dexamethasone, (ii) idiosyncratic hepatotoxicant trovafloxacin mesylate, and (iii) clinical hepatotoxicant acetaminophen and troglitazone. A follow-up cell viability and metabolic competence evaluation by estimating DNA concentration, lactate dehydrogenase activity, and CPR activity revealed a dose-dependent clinically relevant hepatotoxic response. These results corroborated that the developed clinically relevant vascularized liver model is affordable and would aid pharmaceutical companies in speeding up the drug development and provide a robust platform for hepatotoxicity screening.

Polymeric Bioinks for 3D Hepatic Printing

Three-dimensional (3D) printing techniques have revolutionized the field of tissue engineering. This is especially favorable to construct intricate tissues such as liver, as 3D printing allows for the precise delivery of biomaterials, cells and bioactive molecules in complex geometries. Bioinks made of polymers, of both natural and synthetic origin, have been very beneficial to printing soft tissues such as liver. Using polymeric bioinks, 3D hepatic structures are printed with or without cells and biomolecules, and have been used for different tissue engineering applications. In this review, with the introduction to basic 3D printing techniques, we discuss different natural and synthetic polymers including decellularized matrices that have been employed for the 3D bioprinting of hepatic structures. Finally, we focus on recent advances in polymeric bioinks for 3D hepatic printing and their applications. The studies indicate that much work has been devoted to improvising the design, stability and longevity of the printed structures. Others focus on the printing of tissue engineered hepatic structures for applications in drug screening, regenerative medicine and disease models. More attention must now be diverted to developing personalized structures and stem cell differentiation to hepatic lineage.

Current Advances on 3D-Bioprinted Liver Tissue Models

The liver, the largest gland in the human body, plays a key role in metabolism, bile production, detoxification, and water and electrolyte regulation. The toxins or drugs that the gastrointestinal system absorbs reach the liver first before entering the bloodstream. Liver disease is one of the leading causes of death worldwide. Therefore, an in vitro liver tissue model that reproduces the main functions of the liver can be a reliable platform for investigating liver diseases and developing new drugs. In addition, the limitations in traditional, planar monolayer cell cultures and animal tests for evaluating the toxicity and efficacy of drug candidates can be overcome. Currently, the newly emerging 3D bioprinting technologies have the ability to construct in vitro liver tissue models both in static scaffolds and dynamic liver-on-chip manners. This review mainly focuses on the construction and applications of liver tissue models based on 3D bioprinting. Special attention is given to 3D bioprinting strategies and bioinks for constructing liver tissue models including the cell sources and hydrogel selection. In addition, the main advantages and limitations and the major challenges and future perspectives are discussed, paving the way for the next generation of in vitro liver tissue models.

Review fantastic medical implications of 3D-printing in liver surgeries, liver regeneration, liver transplantation and drug hepatotoxicity testing: A review

The epidemiological trend in liver diseases becomes more serious worldwide. Several recent articles published by International Journal of Surgery in 2018 particularly emphasized the encouraging clinical benefits of hepatectomy, liver regeneration and liver transplantation, however, there are still many technical bottlenecks underlying these therapeutic approaches. Remarkably, a few preliminary studies have shown some clues to the role of three-dimensional (3D) printing in improving traditional therapy for liver diseases. Here, we concisely elucidated the curative applications of 3D-printing (no cells) and 3D Bio-printing (with hepatic cells), such as 3D-printed patient-specific liver models and devices for medical education, surgical simulation, hepatectomy and liver transplantation, 3D Bio-printed hepatic constructs for liver regeneration and artificial liver, 3D-printed liver tissues for evaluating drug's hepatotoxicity, and so on. Briefly, 3D-printed liver models and bioactive tissues may facilitate a lot of key steps to cure liver disorders, predictably bringing promising clinical benefits. This work further provides novel insights into facilitating treatment of hepatic carcinoma, promoting liver regeneration both in vivo and in vitro, expanding transplantable liver resources, maximizing therapeutic efficacy as well as minimizing surgical complications, medical hepatotoxicity, operational time, economic costs, etc.

3D Miniaturization of Human Organs for Drug Discovery

"Engineered human organs" hold promises for predicting the effectiveness and accuracy of drug responses while reducing cost, time, and failure rates in clinical trials. Multiorgan human models utilize many aspects of currently available technologies including self-organized spherical 3D human organoids, microfabricated 3D human organ chips, and 3D bioprinted human organ constructs to mimic key structural and functional properties of human organs. They enable precise control of multicellular activities, extracellular matrix (ECM) compositions, spatial distributions of cells, architectural organizations of ECM, and environmental cues. Thus, engineered human organs can provide the microstructures and biological functions of target organs and advantageously substitute multiscaled drug-testing platforms including the current in vitro molecular assays, cell platforms, and in vivo models. This review provides an overview of advanced innovative designs based on the three main technologies used for organ construction leading to single and multiorgan systems useable for drug development. Current technological challenges and future perspectives are also discussed.