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Paul PK, Das R, Drow TJ, de Souza AH, Balamurugan AN, Belt Davis D, Galipeau J. OUP accepted manuscript. Stem Cells Transl Med 2022; 11:630-643. [PMID: 35438788 PMCID: PMC9216495 DOI: 10.1093/stcltm/szac018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 02/04/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Pradyut K Paul
- Department of Medicine, University of Wisconsin-Madison, Madison, WI, USA
| | - Rahul Das
- Department of Medicine, University of Wisconsin-Madison, Madison, WI, USA
| | - Travis J Drow
- Department of Biochemistry, University of Wisconsin-Madison, Madison, WI, USA
| | - Arnaldo H de Souza
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, University of Wisconsin-Madison, Madison, WI, USA
| | - Appakalai N Balamurugan
- Clinical Islet Cell Laboratory, Center for Clinical and Translational Research, Abigail Wexner Research Institute, Nationwide Children’s Hospital, Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Dawn Belt Davis
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, University of Wisconsin-Madison, Madison, WI, USA
- William S. Middleton Memorial Veterans Hospital, Madison, WI, USA
| | - Jacques Galipeau
- Corresponding author: Jacques Galipeau, Don and Marilyn Anderson Professor in Oncology, University of Wisconsin School of Medicine and Public Health, University of Wisconsin in Madison, WI, USA. Tel: +1 608-263-0078;
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Rambøl MH, Han E, Niklason LE. Microvessel Network Formation and Interactions with Pancreatic Islets in Three-Dimensional Chip Cultures. Tissue Eng Part A 2020; 26:556-568. [PMID: 31724494 PMCID: PMC7249478 DOI: 10.1089/ten.tea.2019.0186] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 11/01/2019] [Indexed: 12/13/2022] Open
Abstract
The pancreatic islet is a highly vascularized micro-organ, and rapid revascularization postislet transplantation is important for islet survival and function. However, the various mechanisms involved in islet revascularization are not fully understood, and we currently lack good in vitro platforms to explore this. Our aim for this study was to generate perfusable microvascular networks in a microfluidic chip device, in which islets could be easily integrated, to establish an in vitro platform for investigations on islet-microvasculature interactions. We compared the ability of mesenchymal stem cells (MSCs) and fibroblasts to support microvascular network formation by human umbilical vein endothelial cells (HUVECs) and human induced pluripotent stem cell-derived endothelial colony-forming cell in two-dimensional and three-dimensional models of angiogenesis, and tested the effect of different culture media on microvessel formation. HUVECs that were supported by MSCs formed patent and perfusable networks in a fibrin gel, whereas networks supported by fibroblasts rapidly regressed. Network morphology could be controlled by adjusting relative cell numbers and densities. Incorporation of isolated rat islets demonstrated that islets recruit local microvasculature in vitro, but that the microvessels did not invade islets, at least during the course of these studies. This in vitro microvascularization platform can provide a useful tool to study how various parameters affect islet integration with microvascular networks and could also be utilized for studies of vascularization of other organ systems. Impact statement To improve pancreatic islet graft survival and function posttransplantation, rapid and adequate revascularization is critical. Efforts to improve islet revascularization are demanding due to an insufficient understanding of the mechanisms involved in the process. We have applied a microfluidics platform to generate microvascular networks, and by incorporating pancreatic islets, we were able to study microvasculature-islet interactions in real time. This platform can provide a useful tool to study islet integration with microvascular networks, and could be utilized for studies of vascularization of other organ systems. Moreover, this work may be adapted toward developing a prevascularized islet construct for transplantation.
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Affiliation(s)
- Mia H. Rambøl
- Department of Molecular Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Edward Han
- Department of Biomedical Engineering and Yale University, New Haven, Connecticut, USA
- Department of Anesthesiology, Yale University, New Haven, Connecticut, USA
| | - Laura E. Niklason
- Department of Biomedical Engineering and Yale University, New Haven, Connecticut, USA
- Department of Anesthesiology, Yale University, New Haven, Connecticut, USA
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3
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de Souza BM, Rodrigues M, de Oliveira FS, da Silva LPA, Bouças AP, Portinho CP, Dos Santos BP, Camassola M, Rocha D, Lysakowski S, Martini J, Leitão CB, Nardi NB, Bauer AC, Crispim D. Improvement of human pancreatic islet quality after co-culture with human adipose-derived stem cells. Mol Cell Endocrinol 2020; 505:110729. [PMID: 31972330 DOI: 10.1016/j.mce.2020.110729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 12/30/2019] [Accepted: 01/17/2020] [Indexed: 01/08/2023]
Abstract
The aim of this study was to investigate whether co-culture of human islets with adipose-derived stem cells (ASCs) can improve islet quality and to evaluate which factors play a role in the protective effect of ASCs against islet dysfunction. Islets and ASCs were cultured in three experimental groups for 24 h, 48 h, and 72 h: 1) indirect co-culture of islets with ASC monolayer (Islets/ASCs); 2) islets alone; and 3) ASCs alone. Co-culture with ASCs improved islet viability and function in all culture time-points analyzed. VEGFA, HGF, IL6, IL8, IL10, CCL2, IL1B, and TNF protein levels were increased in supernatants of islet/ASC group compared to islets alone, mainly after 24 h. Moreover, VEGFA, IL6, CCL2, HIF1A, XIAP, CHOP, and NFKBIA genes were differentially expressed in islets from the co-culture condition compared to islets alone. In conclusion, co-culture of islets with ASCs promotes improvements in islet quality.
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Affiliation(s)
- Bianca M de Souza
- Laboratory of Human Pancreatic Islet Biology, Endocrine Division, Hospital de Clınicas de Porto Alegre, Porto Alegre, Rio Grande do Sul (RS), Brazil; Universidade Federal do Rio Grande do Sul, Faculty of Medicine, Department of Internal Medicine, Graduate Program in Medical Sciences: Endocrinology, Porto Alegre, RS, Brazil.
| | - Michelle Rodrigues
- Laboratory of Human Pancreatic Islet Biology, Endocrine Division, Hospital de Clınicas de Porto Alegre, Porto Alegre, Rio Grande do Sul (RS), Brazil
| | - Fernanda S de Oliveira
- Laboratory of Cell Differentiation, Experimental Research Center, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
| | - Liana P A da Silva
- Laboratory of Human Pancreatic Islet Biology, Endocrine Division, Hospital de Clınicas de Porto Alegre, Porto Alegre, Rio Grande do Sul (RS), Brazil
| | - Ana P Bouças
- Laboratory of Human Pancreatic Islet Biology, Endocrine Division, Hospital de Clınicas de Porto Alegre, Porto Alegre, Rio Grande do Sul (RS), Brazil; Universidade Federal do Rio Grande do Sul, Faculty of Medicine, Department of Internal Medicine, Graduate Program in Medical Sciences: Endocrinology, Porto Alegre, RS, Brazil
| | - Ciro P Portinho
- Laboratory of Human Pancreatic Islet Biology, Endocrine Division, Hospital de Clınicas de Porto Alegre, Porto Alegre, Rio Grande do Sul (RS), Brazil
| | - Bruno P Dos Santos
- Laboratory for Tissue Bioengineering (BioTis), Inserm U1026, University of Bordeaux, Bordeaux, France
| | - Melissa Camassola
- Laboratory for Stem Cells and Tissue Engineering, Post-Graduation Program in Cellular and Molecular Biology Applied to Health, Universidade Luterana do Brasil, Canoas, RS, Brazil
| | - Dagoberto Rocha
- Post-Graduation Program in Health Sciences, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil
| | - Simone Lysakowski
- Organ Procurement Organization, Santa Casa de Misericórdia de Porto Alegre. Porto Alegre, RS, Brazil
| | - Juliano Martini
- Transplant Center, Surgery Department, Hospital Dom Vicente Scherer, Santa Casa de Misericórdia de Porto Alegre. Porto Alegre, RS, Brazil
| | - Cristiane B Leitão
- Laboratory of Human Pancreatic Islet Biology, Endocrine Division, Hospital de Clınicas de Porto Alegre, Porto Alegre, Rio Grande do Sul (RS), Brazil; Universidade Federal do Rio Grande do Sul, Faculty of Medicine, Department of Internal Medicine, Graduate Program in Medical Sciences: Endocrinology, Porto Alegre, RS, Brazil
| | - Nance B Nardi
- Laboratory for Stem Cells and Tissue Engineering, Post-Graduation Program in Cellular and Molecular Biology Applied to Health, Universidade Luterana do Brasil, Canoas, RS, Brazil
| | - Andrea C Bauer
- Laboratory of Human Pancreatic Islet Biology, Endocrine Division, Hospital de Clınicas de Porto Alegre, Porto Alegre, Rio Grande do Sul (RS), Brazil; Universidade Federal do Rio Grande do Sul, Faculty of Medicine, Department of Internal Medicine, Graduate Program in Medical Sciences: Endocrinology, Porto Alegre, RS, Brazil
| | - Daisy Crispim
- Laboratory of Human Pancreatic Islet Biology, Endocrine Division, Hospital de Clınicas de Porto Alegre, Porto Alegre, Rio Grande do Sul (RS), Brazil; Universidade Federal do Rio Grande do Sul, Faculty of Medicine, Department of Internal Medicine, Graduate Program in Medical Sciences: Endocrinology, Porto Alegre, RS, Brazil
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4
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Choi B, Kim SH. Regulatory T Cells Promote Pancreatic Islet Function and Viability via TGF-β1 in vitro and in vivo. KOREAN JOURNAL OF CLINICAL LABORATORY SCIENCE 2018. [DOI: 10.15324/kjcls.2018.50.3.304] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Bongkum Choi
- Transplantation Research Center, Clinical Research Institute, Samsung Biomedical Research Institute, Seoul, Korea
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sa-Hyun Kim
- Department of Clinical Laboratory Science, Semyung University, Jecheon, Korea
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Navaei-Nigjeh M, Moloudizargari M, Baeeri M, Gholami M, Lotfibakhshaiesh N, Soleimani M, Vasheghani-Farahani E, Ai J, Abdollahi M. Reduction of marginal mass required for successful islet transplantation in a diabetic rat model using adipose tissue-derived mesenchymal stromal cells. Cytotherapy 2018; 20:1124-1142. [PMID: 30068495 DOI: 10.1016/j.jcyt.2018.06.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 05/10/2018] [Accepted: 06/06/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND AIMS Adipose tissue-derived mesenchymal stromal cells (AT-MSCs), widely known as multipotent progenitors, release several cytokines that support cell survival and repair. There are in vitro and in vivo studies reporting the regenerative role of AT-MSCs possibly mediated by their protective effects on functional islet cells as well as their capacity to differentiate into insulin-producing cells (IPCs). METHODS On such a basis, our goal in the present study was to use three different models including direct and indirect co-cultures and islet-derived conditioned medium (CM) to differentiate AT-MSCs into IPCs and to illuminate the molecular mechanisms of the beneficial impact of AT-MSCs on pancreatic islet functionality. Furthermore, we combined in vitro co-culture of islets and AT-MSCs with in vivo assessment of islet graft function to assess whether co-transplantation of islets with AT-MSCs can reduce marginal mass required for successful islet transplantation and prolong graft function in a diabetic rat model. RESULTS Our findings demonstrated that AT-MSCs are suitable for creating a microenvironment favorable for the repair and longevity of the pancreas β cells through the improvement of islet survival and maintenance of cell morphology and insulin secretion due to their potent properties in differentiation. Most importantly, hybrid transplantation of islets with AT-MSCs significantly promoted survival, engraftment and insulin-producing function of the graft and reduced the islet mass required for reversal of diabetes. CONCLUSIONS This strategy might be of therapeutic potential solving the problem of donor islet material loss that currently limits the application of allogeneic islet transplantation as a more widespread therapy for type 1 diabetes.
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Affiliation(s)
- Mona Navaei-Nigjeh
- Department of Tissue Engineering and Applied Cell Sciences, School of Advanced Technologies in Medicine, Tehran University of Medical Sciences, Tehran, Iran; Toxicology and Diseases Group, The Institute of Pharmaceutical Sciences (TIPS), Tehran University of Medical Science, Tehran, Iran
| | - Milad Moloudizargari
- Student Research Committee, Department of Immunology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Maryam Baeeri
- Toxicology and Diseases Group, The Institute of Pharmaceutical Sciences (TIPS), Tehran University of Medical Science, Tehran, Iran
| | - Mahdi Gholami
- Toxicology and Diseases Group, The Institute of Pharmaceutical Sciences (TIPS), Tehran University of Medical Science, Tehran, Iran
| | - Nasrin Lotfibakhshaiesh
- Department of Tissue Engineering and Applied Cell Sciences, School of Advanced Technologies in Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Masoud Soleimani
- Department of Hematology, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | | | - Jafar Ai
- Department of Tissue Engineering and Applied Cell Sciences, School of Advanced Technologies in Medicine, Tehran University of Medical Sciences, Tehran, Iran.
| | - Mohammad Abdollahi
- Toxicology and Diseases Group, The Institute of Pharmaceutical Sciences (TIPS), Tehran University of Medical Science, Tehran, Iran; Department of Toxicology and Pharmacology, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran.
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Rawal S, Williams SJ, Ramachandran K, Stehno-Bittel L. Integration of mesenchymal stem cells into islet cell spheroids improves long-term viability, but not islet function. Islets 2017; 9:87-98. [PMID: 28662368 PMCID: PMC5624285 DOI: 10.1080/19382014.2017.1341455] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Pancreatic islets, especially the large islets (> 150µm in diameter) have poor survival rates in culture. Co-culturing with mesenchymal stem cells (MSCs) has been shown to improve islet survival and function. However, most co-culture studies have been comprised of MSC surrounding islets in the media. The purpose of this study was to determine whether islet survival and function was improved when the 2 populations of cells were intermingled with each other in a defined geometry. Hybrid spheroids containing 25, 50 or 75 or 90% islets cells with appropriate numbers of MSCs were created along with spheroids comprised of only islet cells or only MSCs. Spheroids were tested for yield, viability, diameter, cellular composition, and glucose-stimulated insulin secretion. The 25% islet/75% MSC group created the fewest spheroids, with the poorest survival and insulin secretion and the largest diameter. The remaining groups were highly viable with average diameters under 80µm at formation. However, the hybrid spheroid groups preferred to cluster in islet-only spheroids. The 50, 75 and 90% islet cell groups had excellent long-term survival with 90-95% viability at 2 weeks in culture, compared with the islet only group that were below 80% viability. The glucose-stimulated insulin secretion was not statistically different for the 50, 75, or 90 groups when exposed to 2.4, 16.8, or 22.4 mM glucose. Only the spheroids with 25% islet cells had a statistically lower levels of insulin release, and the 100% had statistically higher levels at 22.4 mM glucose and in response to secretagogue. Thus, imbedded co-culture improved long-term viability, but failed to enhance glucose-stimulated insulin secretion in vitro.
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Affiliation(s)
- Sonia Rawal
- Department of Physical Therapy and Rehabilitation Sciences, University of Kansas Medical Center, Kansas City, KS, USA
| | - S. Janette Williams
- Department of Physical Therapy and Rehabilitation Sciences, University of Kansas Medical Center, Kansas City, KS, USA
- Likarda LLC, Kansas City, KS, USA
| | | | - Lisa Stehno-Bittel
- Department of Physical Therapy and Rehabilitation Sciences, University of Kansas Medical Center, Kansas City, KS, USA
- Likarda LLC, Kansas City, KS, USA
- CONTACT Lisa Stehno-Bittel Department of Physical Therapy and Rehabilitation Science, University of Kansas Medical Center, 3901 Rainbow Blvd, MS 2002, Kansas City, KS 66160, USA
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de Souza BM, Bouças AP, de Oliveira FDS, Reis KP, Ziegelmann P, Bauer AC, Crispim D. Effect of co-culture of mesenchymal stem/stromal cells with pancreatic islets on viability and function outcomes: a systematic review and meta-analysis. Islets 2017; 9:30-42. [PMID: 28151049 PMCID: PMC5345749 DOI: 10.1080/19382014.2017.1286434] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 01/05/2017] [Accepted: 01/20/2017] [Indexed: 12/12/2022] Open
Abstract
The maintenance of viable and functional pancreatic islets is crucial for successful islet transplantation from brain-dead donors. To overcome islet quality loss during culture, some studies have co-cultured islets with mesenchymal stem/stromal cells (MSC). However, it is still uncertain if MSC-secreted factors are enough to improve islet quality or if a physical contact between MSCs and islets is needed. Therefore, we performed a systematic review and meta-analysis to clarify the effect of different culture contact systems of islets with MSCs on viability and insulin secretion outcomes. Pubmed and Embase were searched. Twenty studies fulfilled the eligibility criteria and were included in the qualitative synthesis and/or meta-analysis. For both outcomes, pooled weighted mean differences (WMD) between islet cultured alone (control group) and the co-culture condition were calculated. Viability mean was higher in islets co-cultured with MSCs compared with islet cultured alone [WMD = 18.08 (95% CI 12.59-23.57)]. The improvement in viability was higher in islets co-cultured in indirect or mixed contact with MSCs than in direct physical contact (P <0.001). Moreover, the mean of insulin stimulation index (ISI) was higher in islets from co-culture condition compared with islet cultured alone [WMD = 0.83 (95% CI 0.54-1.13)], independently of contact system. Results from the studies that were analyzed only qualitatively are in accordance with meta-analysis data. Co-culture of islets with MSCs has the potential for protecting islets from injury during culture period. Moreover, culture time appears to influence the beneficial effect of different methods of co-culture on viability and function of islets.
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Affiliation(s)
- Bianca Marmontel de Souza
- Laboratory of Human Pancreatic Islet Biology, Endocrine Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
- Postgraduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Ana Paula Bouças
- Laboratory of Human Pancreatic Islet Biology, Endocrine Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
- Postgraduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Fernanda dos Santos de Oliveira
- Laboratory of Cell Differentiation, Experimental Research Center, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Karina Pires Reis
- Laboratory of Human Pancreatic Islet Biology, Endocrine Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Patrícia Ziegelmann
- Statistics Department and Post-Graduation Program in Epidemiology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Andrea Carla Bauer
- Laboratory of Human Pancreatic Islet Biology, Endocrine Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
- Postgraduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Daisy Crispim
- Laboratory of Human Pancreatic Islet Biology, Endocrine Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
- Postgraduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
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8
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Qujeq D, Abedian Z. Viability and functional recovery of pancreatic islet cells co-cultured with liver, salivary glands and intestine cells. Process Biochem 2016. [DOI: 10.1016/j.procbio.2016.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Dietrich I, Crescenzi A, Chaib E, D'Albuquerque LAC. Trophic effects of adipose derived stem cells on Langerhans islets viability--Review. Transplant Rev (Orlando) 2015; 29:121-6. [PMID: 26002997 DOI: 10.1016/j.trre.2015.04.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Revised: 04/14/2015] [Accepted: 04/30/2015] [Indexed: 12/18/2022]
Abstract
Langerhans islets transplantation has been proposed to provide an endogenous source of insulin in Type I diabetes. However, the hypoxic stress and the receptor's immune reaction suffered by the implants cause them to fail in sustaining the insulin production along the time. Experimental studies have shown that adipose derived stem cells (ADSCs) can secrete cytokines that activate free radical scavengers, antioxidants and chaperone heat/shock proteins leading to reduction of apoptosis in damaged tissues. Therefore, using the PubMed database, we reviewed the experimental studies that investigated the trophic effects of ADSCs on Langerhans islets viability, in vitro and in vivo, from 2009 to 2014. We excluded articles that investigated the effects of other types of mesenchymal stem cells on β-cell survival as well articles that worked in the differentiation of ADSCs into insulin producing cells. The analysis of the experiments revealed that exposure of islets to ADSCs in vitro, even for a short period of time, can enhance islet cell viability and function. In vivo studies also corroborated the trophic effects of ADSCs leading to the improvement of islet function and reduction of the number of the islets required for controlling the receptor's glucose levels. This review can contribute to guide future experiments looking for a long term diabetes treatment employing ADSC trophic effects for the enhancement of transplanted Langerhans islet viability and functioning.
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Affiliation(s)
- Isa Dietrich
- Department of Gastroenterology, Liver and Pancreas Transplantation-Surgery Unit, São Paulo University Medical School, São Paulo 05403090 Brazil.
| | - Alessandra Crescenzi
- Department of Gastroenterology, Liver and Pancreas Transplantation-Surgery Unit, São Paulo University Medical School, São Paulo 05403090 Brazil
| | - Elezar Chaib
- Department of Gastroenterology, Liver and Pancreas Transplantation-Surgery Unit, São Paulo University Medical School, São Paulo 05403090 Brazil
| | - Luiz Augusto Carneiro D'Albuquerque
- Department of Gastroenterology, Liver and Pancreas Transplantation-Surgery Unit, São Paulo University Medical School, São Paulo 05403090 Brazil
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10
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Jun Y, Kang AR, Lee JS, Park SJ, Lee DY, Moon SH, Lee SH. Microchip-based engineering of super-pancreatic islets supported by adipose-derived stem cells. Biomaterials 2014; 35:4815-26. [PMID: 24636217 DOI: 10.1016/j.biomaterials.2014.02.045] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Accepted: 02/23/2014] [Indexed: 12/13/2022]
Abstract
Type 1 diabetes mellitus (T1DM) is a chronic disorder characterized by targeted autoimmune-mediated destruction of the β cells of Langerhans within pancreatic islets. Currently, islet transplantation is the only curative therapy; however, donor shortages and cellular damage during the isolation process critically limit the use of this approach. Here, we describe a method for creating viable and functionally potent islets for successful transplantation by co-culturing single primary islet cells with adipose-derived stem cells (ADSCs) in concave microwells. We observed that the ADSCs segregated from the islet cells, eventually yielding purified islet spheroids in the three-dimensional environment. Thereafter, the ADSC-exposed islet spheroids showed significantly different ultrastructural morphologies, higher viability, and enhanced insulin secretion compared to mono-cultured islet spheroids. This suggests that ADSCs may have a significant potential to protect islet cells from damage during culture, and may be employed to improve islet cell survival and function prior to transplantation. In vivo experiments involving xenotransplantation of microfiber-encapsulated spheroids into a mouse model of diabetes revealed that co-culture-transplanted mice maintained their blood glucose levels longer than mono-culture-transplanted mice, and required less islet mass to reverse diabetes. This method for culturing islet spheroids could potentially help overcome the cell shortages that have limited clinical applications and could possibly be developed into a bioartificial pancreas.
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Affiliation(s)
- Yesl Jun
- Biotechnology-Medical Science, KU-KIST Graduate School of Converging Science and Technology, Korea University, Seoul 136-701, Republic of Korea
| | - Ah Ran Kang
- Biotechnology-Medical Science, KU-KIST Graduate School of Converging Science and Technology, Korea University, Seoul 136-701, Republic of Korea
| | - Jae Seo Lee
- Biotechnology-Medical Science, KU-KIST Graduate School of Converging Science and Technology, Korea University, Seoul 136-701, Republic of Korea
| | - Soon-Jung Park
- Department of Stem Cell Biology, School of Medicine, Konkuk University, Seoul 143-701, Republic of Korea
| | - Dong Yun Lee
- Department of Bioengineering, College of Engineering, Hanyang University, Seoul 133-791, Republic of Korea
| | - Sung-Hwan Moon
- Department of Stem Cell Biology, School of Medicine, Konkuk University, Seoul 143-701, Republic of Korea
| | - Sang-Hoon Lee
- Biotechnology-Medical Science, KU-KIST Graduate School of Converging Science and Technology, Korea University, Seoul 136-701, Republic of Korea; Department of Biomedical Engineering, College of Health Science, Korea University, Seoul 136-703, Republic of Korea.
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11
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Ju MK, Jeong JH, Lee JI, Kim YS, Kim MS. Proliferation and functional assessment of pseudo-islets with the use of pancreatic endocrine cells. Transplant Proc 2014; 45:1885-8. [PMID: 23769063 DOI: 10.1016/j.transproceed.2012.12.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Accepted: 12/31/2012] [Indexed: 11/26/2022]
Abstract
Many obstacles beset islet transplantation, particularly insufficient tissue mass. Previously, we reported production of pseudo-islets. In addition, there have been reports in which coculture with pancreatic islet and bone marrow mesenchymal stem cells (BMSCs) demonstrated positive effects on pancreatic islet function. The purpose of this study was to perform morphologic and functional evaluations of pancreatic pseudo-islets cocultured with BMSCs. Pancreatic endocrine cells (PECs) were collected with a previously reported method; bone marrow was aspirated from the rat femur. Subsequently, PECs and BMSCs cocultured at high density on low-cell-binding culture dishes kept suspended by shaking. The functionality and characteristics of the mixed cell complexes were evaluated by glucose challenge, insulin enzyme-linked immunosorbent assay, reverse-transcription polymerase chain reaction, and immunohistochemistry. Through expansion for 2 weeks in continuous culture passages, ∼1 million PECs were recovered after aggregation. They presented spherical shapes and sizes similar to naïve islets, according to phase-contrast microscopy. The spheroid aggregates of pancreatic islet cells and BMSCs showed fortified functions and maintained viability. In conclusion, PECs served as a cell source for pseudo-islets, which were both morphologically and genetically similar to naïve islets. We also suggest a manufacturing method for mixed cellular complexes from 2 different origins that can improve secretion ability and cell differentiation.
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Affiliation(s)
- M K Ju
- Research Institute for Transplantation, Yonsei University Health System, Seoul, South Korea; Department of Transplantation Surgery, Yonsei University Health System, Seoul, South Korea
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12
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Wu H, Ye Z, Mahato RI. Genetically modified mesenchymal stem cells for improved islet transplantation. Mol Pharm 2011; 8:1458-70. [PMID: 21707070 DOI: 10.1021/mp200135e] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The use of adult stem cells for therapeutic purposes has met with great success in recent years. Among several types of adult stem cells, mesenchymal stem cells (MSCs) derived from bone marrow (BM) and other sources have gained popularity for basic research and clinical applications because of their therapeutic potential in treating a variety of diseases. Because of their tissue regeneration potential and immune modulation effect, MSCs were recently used as cell-based therapy to promote revascularization, increase pancreatic β-cell proliferation, and avoid allograft rejection in islet transplantation. Taking advantage of the recent progress in gene therapy, genetically modified MSCs can further enhance and expand the therapeutic benefit of primary MSCs while retaining their stem-cell-like properties. This review aims to gain a thorough understanding of the current obstacles to successful islet transplantation and discusses the potential role of primary MSCs before or after genetic modification in islet transplantation.
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Affiliation(s)
- Hao Wu
- Department of Pharmaceutical Sciences, University of Tennessee Health Science Center, Memphis, Tennessee, United States
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13
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Sakai T, Xu Y. Stem cells decreased neuronal cell death after hypoxic stress in primary fetal rat neurons in vitro. Cell Transplant 2011; 21:355-64. [PMID: 21669034 DOI: 10.3727/096368911x580545] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
To explore stem cell-mediated neuronal protection through extracellular signaling pathways by transplanted stem cells, we sought to identify potential candidate molecules responsible for neuronal protection using an in vitro coculture system. Primary fetal rat hippocampal neurons underwent hypoxia (≤1% oxygen) for 96 h nad then were returned to a normoxic condition. The study group then received rat umbilical cord matrix-derived stem cells, while the control group received fresh media only. The experimental group showed decreased neuronal apoptosis compared to the control group [44.5 ± 1.6% vs. 71.0 ± 4.2% (mean ± SD, p = 0.0005) on day 5] and higher neuronal survival (4.9 ± 1.2 cells/100× field vs. 2.2 ± 0.3, p = 0.02 on day 5). Among 90 proteins evaluated using a protein array, stem cell coculture media showed increased protein secretion of TIMP-1 (5.61-fold), TIMP-2 (4.88), CNTF-Rα (3.42), activin A (2.20), fractalkine (2.04), CCR4 (2.02), and decreased secretion in MIP-2 (0.30-fold), AMPK α1 (0.43), TROY (0.48), and TIMP-3 (0.50). This study demonstrated that coculturing stem cells with primary neurons in vitro decreased neuronal cell death after hypoxia with significantly altered protein secretion. The results suggest that stem cells may offer neuronal protection through extracellular signaling.
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Affiliation(s)
- Tetsuro Sakai
- Department of Anesthesiology, The McGowan Institute for Regenerative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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14
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Fan CG, Zhang QJ, Zhou JR. Therapeutic potentials of mesenchymal stem cells derived from human umbilical cord. Stem Cell Rev Rep 2011; 7:195-207. [PMID: 20676943 DOI: 10.1007/s12015-010-9168-8] [Citation(s) in RCA: 137] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Human umbilical cord-derived mesenchymal stem cells (hUC-MSCs), isolated from discarded extra-embryonic tissue after birth, are promising candidate source of mesenchymal stem cells (MSCs). Apart from their prominent advantages in abundant supply, painless collection, and faster self-renewal, hUC-MSCs have shown the potencies to differentiate into a variety of cells of three germ layers (such as bone, cartilage, adipose, skeletal muscle, cardiomyocyte, endothelium, hepatocyte-like cluster, islet-like cluster, neuron, astrocyte and oligodendrocyte), to synthesize and secret a set of trophic factors and cytokines, to support the expansion and function of other cells (like hematopoietic stem cells, embryonic stem cells, natural killer cells, islet-like cell clusters, neurons and glial cells), to migrate toward and home to pathological areas, and to be readily transfected with conventional methods. Two excellent previous reviews documenting the characteristics of this cell population with special emphasis on its niche, isolation, surface markers and primitive properties have been published recently. In this review, we will firstly give a brief introduction of this cell population, and subsequently dwell on the findings of differential capacities with emphasis on its therapeutic potentials.
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Affiliation(s)
- Cun-Gang Fan
- Neurosurgical Department of Peking University People's Hospital, Beijing, China
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15
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Jung EJ, Kim SC, Wee YM, Kim YH, Choi MY, Jeong SH, Lee J, Lim DG, Han DJ. Bone marrow-derived mesenchymal stromal cells support rat pancreatic islet survival and insulin secretory function in vitro. Cytotherapy 2011; 13:19-29. [PMID: 21142900 DOI: 10.3109/14653249.2010.518608] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND AIMS Recent evidence has suggested that transplanted bone marrow (BM)-derived mesenchymal stromal cells (MSC) are able to engraft and repair non-hematopoietic tissues successfully, including central nervous system, renal, pulmonary and skin tissue, and may possibly contribute to tissue regeneration. We examined the cytoprotective effect of BM MSC on co-cultured, isolated pancreatic islets. METHODS Pancreatic islets and MSC isolated from Lewis rats were divided into four experimental groups: (a) islets cultured alone (islet control); (b) islets cultured in direct contact with MSC (IM-C); (c) islets co-cultured with MSC in a Transwell system, which allows indirect cell contact through diffusible media components (IM-I); and (d) MSC cultured alone (MSC control). The survival and function of islets were measured morphologically and by analyzing insulin secretion in response to glucose challenge. Cytokine profiles were determined using a cytokine array and enzyme-linked immunosorbent assays. RESULTS Islets contact-cultured with MSC (IM-C) showed sustained survival and retention of glucose-induced insulin secretory function. In addition, the levels of monocyte chemoattractant protein-1 (MCP-1) and tumor necrosis factor-α (TNF-α) were decreased, and tissue inhibitor of metalloproteinases-1 (TIMP-1) and vascular endothelial growth factor (VEGF) levels were increased at 4 weeks in both the IM-C and IM-I groups. CONCLUSIONS These results indicate that contact co-culture is a major factor that contributes to islet survival, maintenance of cell morphology and insulin function. There might also be a synergic effect resulting from the regulation of inflammatory cytokine production. We propose that BM MSC are suitable for generating a microenvironment favorable for the repair and longevity of pancreatic islets.
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Affiliation(s)
- Eun-Jung Jung
- Asan Institute for Life Science, Asan Medical Center, Seoul, Republic of Korea
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16
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Eve DJ, Fillmore RW, Borlongan CV, Sanberg PR. Stem cell research in cell transplantation: sources, geopolitical influence, and transplantation. Cell Transplant 2010; 19:1493-509. [PMID: 21054954 DOI: 10.3727/096368910x540612] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
If the rapidly progressing field of stem cell research reaches its full potential, successful treatments and enhanced understanding of many diseases are the likely results. However, the full potential of stem cell science will only be reached if all possible avenues can be explored and on a worldwide scale. Until 2009, the US had a highly restrictive policy on obtaining cells from human embryos and fetal tissue, a policy that pushed research toward the use of adult-derived cells. Currently, US policy is still in flux, and retrospective analysis does show the US lagging behind the rest of the world in the proportional increase in embryonic/fetal stem cell research. The majority of US studies being on either a limited number of cell lines, or on cells derived elsewhere (or funded by other sources than Federal) rather than on freshly isolated embryonic or fetal material. Neural, mesenchymal, and the mixed stem cell mononuclear fraction are the most commonly investigated types, which can generally be classified as adult-derived stem cells, although roughly half of the neural stem cells are fetal derived. Other types, such as embryonic and fat-derived stem cells, are increasing in their prominence, suggesting that new types of stem cells are still being pursued. Sixty percent of the reported stem cell studies involved transplantation, of which over three quarters were allogeneic transplants. A high proportion of the cardiovascular systems articles were on allogeneic transplants in a number of different species, including several autologous studies. A number of pharmaceutical grade stem cell products have also recently been tested and reported on. Stem cell research shows considerable promise for the treatment of a number of disorders, some of which have entered clinical trials; over the next few years it will be interesting to see how these treatments progress in the clinic.
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Affiliation(s)
- David J Eve
- Center of Excellence for Aging & Brain Repair, Department of Neurosurgery and Brain Repair, University of South Florida College of Medicine, Tampa, FL 33612, USA.
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17
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Wang HS, Shyu JF, Shen WS, Hsu HC, Chi TC, Chen CP, Huang SW, Shyr YM, Tang KT, Chen TH. Transplantation of insulin-producing cells derived from umbilical cord stromal mesenchymal stem cells to treat NOD mice. Cell Transplant 2010; 20:455-66. [PMID: 20719086 DOI: 10.3727/096368910x522270] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Diabetes mellitus can be treated with islet transplantation, although there is a scarcity of donors. This study investigated whether human mesenchymal stem cells (MSCs) from umbilical cord stroma could be induced to differentiate into insulin-producing cells and the effects of retro-orbital injection of human insulin-producing cells for the treatment of nonobese diabetic (NOD) mice. MSCs were isolated from human umbilical cord stroma and induced to differentiate into insulin-producing cells using differentiation medium. Differentiated cells were evaluated by immunocytochemistry, RT-PCR, and real-time PCR. C-peptide release, both spontaneous and after glucose challenge, was measured by ELISA. Insulin-producing cells were then transplanted into NOD mice. Blood glucose levels and body weights were monitored weekly. Human nuclei and C-peptide were detected in mouse livers by immunohistochemistry. Pancreatic β-cell development-related genes were expressed in the differentiated insulin-producing cells. Differentiated cells' C-peptide release in vitro increased after glucose challenge. Further, in vivo glucose tolerance tests showed that blood sugar levels decreased after the cells' transplantation into NOD mice. After transplantation, insulin-producing cells containing human C-peptide and human nuclei were located in the liver. Thus, we demonstrated that differentiated insulin-producing cells from human umbilical cord stromal MSCs transplanted into NOD mice could alleviate hyperglycemia in diabetic mice.
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Affiliation(s)
- Hwai-Shi Wang
- Institute of Anatomy and Cell Biology, School of Medicine, National Yang Ming University, Taipei, Taiwan, ROC
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18
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Ciceri F, Piemonti L. Bone marrow and pancreatic islets: an old story with new perspectives. Cell Transplant 2010; 19:1511-22. [PMID: 20719074 DOI: 10.3727/096368910x514279] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
In the past years, in the field of β-cell replacement for diabetes therapy, the easy availability of bone marrow (BM) and the widely consolidated clinical experience in the field of hematology have contributed to the development of strategy to achieve donor-specific transplantation tolerance. Recently, the potential role of BM in diabetes therapy has been reassessed from a different point of view. Diverse groups investigated the contribution of BM cells to β-cell replacement as direct differentiation into insulin-producing cells. More importantly, while direct differentiation is highly unlikely, a wide array of experimental evidences indicates that cells of BM origin are capable of facilitating the survival or the endogenous regeneration of β-cells through an as yet well-defined regeneration process. These new experimental in vitro and in vivo data will expand in the near future the clinical trials involving BM or BM-derived cells to cure both type 1 and type 2 diabetes in humans. In this review we recapitulate the history of use of BM in diabetes therapy and we provide clinically relevant actual information about the participation of BM and BM-derived stem cells in islet cell regeneration processes. Furthermore, new aspects such as employing BM as "feeder tissue" for pancreatic islets and new clinical use of BM in diabetes therapy are discussed.
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Affiliation(s)
- Fabio Ciceri
- Haematology and BMT Unit, San Raffaele Scientific Institute, Via Olgettina 60, Milan, Italy
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19
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Sordi V, Piemonti L. Mesenchymal stem cells as feeder cells for pancreatic islet transplants. Rev Diabet Stud 2010; 7:132-43. [PMID: 21060972 DOI: 10.1900/rds.2010.7.132] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Allogeneic islet transplantation serves as a source of insulin-secreting beta-cells for the maintenance of normal glucose levels and treatment of diabetes. However, limited availability of islets, high rates of islet graft failure, and the need for life-long non-specific immunosuppressive therapy are major obstacles to the widespread application of this therapeutic approach. To overcome these problems, pancreatic islet transplantation was recently suggested as a potential target of the "therapeutic plasticity" of adult stem cells. In fact, new results suggest that stem/precursor cells, and mesenchymal stem cells in particular, co-transplanted with islets can promote tissue engraftment and beta-cell survival via bystander mechanisms, mainly exerted by creating a milieu of cytoprotective and immunomodulatory molecules. This evidence consistently challenges the limited view that stem/precursor cells work exclusively through beta-cell replacement in diabetes therapy. It proposes that stem cells also act as "feeder" cells for islets, and supporter of graft protection, tissue revascularization, and immune acceptance. This article reviews the experience of using stem cell co-transplantation as strategy to improve islet transplantation. It highlights that comprehension of the mechanisms involved will help to identify new molecular targets and promote development of new pharmacological strategies to treat type 1 and type 2 diabetes patients.
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Affiliation(s)
- Valeria Sordi
- San Raffaele Diabetes Research Institute (HSR-DRI), Division of Immunology, Transplantation and Infectious Disease, San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy.
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20
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Karaoz E, Genç ZS, Demircan PÇ, Aksoy A, Duruksu G. Protection of rat pancreatic islet function and viability by coculture with rat bone marrow-derived mesenchymal stem cells. Cell Death Dis 2010; 1:e36. [PMID: 21364643 PMCID: PMC3032304 DOI: 10.1038/cddis.2010.14] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2010] [Revised: 03/10/2010] [Accepted: 03/18/2010] [Indexed: 02/06/2023]
Abstract
The maintenance of viable and functional islets is critical in successful pancreatic islet transplantation from cadaveric sources. During the isolation procedure, islets are exposed to a number of insults including ischemia, oxidative stress and cytokine injury that cause a reduction in the recovered viable islet mass. A novel approach was designed in which streptozotocin (STZ)-damaged rat pancreatic islets (rPIs) were indirectly cocultured with rat bone marrow-derived mesenchymal stem cells (rBM-MSCs) to maintain survival of the cultured rPIs. The results indicated that islets cocultured with rBM-MSCs secreted an increased level of insulin after 14 days, whereas non-cocultured islets gradually deteriorated and cell death occurred. The cocultivation of rBM-MSCs with islets and STZ-damaged islets showed the expression of IL6 and transforming growth factor-β1 in the culture medium, besides the expression of the antiapoptotic genes (Mapkapk2, Tnip1 and Bcl3), implying the cytoprotective, anti-inflammatory and antiapoptotic effects of rBM-SCs through paracrine actions.
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Affiliation(s)
- E Karaoz
- Stem Cell and Gene Therapy Research and Application Center, Kocaeli University, Kocaeli, Turkey.
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21
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Fu RH, Liu SP, Ou CW, Yu HH, Li KW, Tsai CH, Shyu WC, Lin SZ. Alternative Splicing Modulates Stem Cell Differentiation. Cell Transplant 2009; 18:1029-38. [PMID: 19523332 DOI: 10.3727/096368909x471260] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Stem cells have the surprising potential to develop into many different cell types. Therefore, major research efforts have focused on transplantation of stem cells and/or derived progenitors for restoring depleted diseased cells in degenerative disorders. Understanding the molecular controls, including alternative splicing, that arise during lineage differentiation of stem cells is crucial for developing stem cell therapeutic approaches in regeneration medicine. Alternative splicing to allow a single gene to encode multiple transcripts with different protein coding sequences and RNA regulatory elements increases genomic complexities. Utilizing differences in alternative splicing as a molecular marker may be more sensitive than simply gene expression in various degrees of stem cell differentiation. Moreover, alternative splicing maybe provide a new concept to acquire induced pluripotent stem cells or promote cell–cell transdifferentiation for restorative therapies and basic medicine researches. In this review, we highlight the recent advances of alternative splicing regulation in stem cells and their progenitors. It will hopefully provide much needed knowledge into realizing stem cell biology and related applications.
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Affiliation(s)
- Ru-Huei Fu
- Center for Neuropsychiatry, China Medical University Hospital, Taichung, Taiwan
- Graduate Institute of Immunology, China Medical University, Taichung, Taiwan
| | - Shih-Ping Liu
- Center for Neuropsychiatry, China Medical University Hospital, Taichung, Taiwan
- Graduate Institute of Basic Medical Science, China Medical University, Taichung, Taiwan
| | - Chen-Wei Ou
- Graduate Institute of Immunology, China Medical University, Taichung, Taiwan
| | - Hsiu-Hui Yu
- Center for Neuropsychiatry, China Medical University Hospital, Taichung, Taiwan
| | - Kuo-Wei Li
- Center for Neuropsychiatry, China Medical University Hospital, Taichung, Taiwan
| | - Chang-Hai Tsai
- Department of Pediatrics, China Medical University Hospital, Taichung, Taiwan
- Department of Healthcare Administration, Asia University, Taichung, Taiwan
| | - Woei-Cherng Shyu
- Center for Neuropsychiatry, China Medical University Hospital, Taichung, Taiwan
- Graduate Institute of Immunology, China Medical University, Taichung, Taiwan
| | - Shinn-Zong Lin
- Center for Neuropsychiatry, China Medical University Hospital, Taichung, Taiwan
- Graduate Institute of Immunology, China Medical University, Taichung, Taiwan
- China Medical University Beigang Hospital, Yunlin, Taiwan
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