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Ran R, Zhang SB, Shi YQ, Dong H, Song W, Dong YB, Zhou KS, Zhang HH. Spotlight on necroptosis: Role in pathogenesis and therapeutic potential of intervertebral disc degeneration. Int Immunopharmacol 2024; 138:112616. [PMID: 38959544 DOI: 10.1016/j.intimp.2024.112616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Revised: 06/19/2024] [Accepted: 06/30/2024] [Indexed: 07/05/2024]
Abstract
Intervertebral disc degeneration (IDD) is the leading cause of low back pain, which is one of the major factors leading to disability and severe economic burden. Necroptosis is an important form of programmed cell death (PCD), a highly regulated caspase-independent type of cell death that is regulated by receptor-interacting protein kinase 1 (RIPK1), RIPK3 and mixed lineage kinase domain-like protein (MLKL)-mediated, play a key role in the pathophysiology of various inflammatory, infectious and degenerative diseases. Recent studies have shown that necroptosis plays an important role in the occurrence and development of IDD. In this review, we provide an overview of the initiation and execution of necroptosis and explore in depth its potential mechanisms of action in IDD. The analysis focuses on the connection between NP cell necroptosis and mitochondrial dysfunction-oxidative stress pathway, inflammation, endoplasmic reticulum stress, apoptosis, and autophagy. Finally, we evaluated the possibility of treating IDD by inhibiting necroptosis, and believed that targeting necroptosis may be a new strategy to alleviate the symptoms of IDD.
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Affiliation(s)
- Rui Ran
- Lanzhou University Second Hospital, 82 Cuiying Men, Lanzhou 730000, PR China; Orthopedics Key Laboratory of Gansu Province, Lanzhou 730000, PR China
| | - Shun-Bai Zhang
- Lanzhou University Second Hospital, 82 Cuiying Men, Lanzhou 730000, PR China; Orthopedics Key Laboratory of Gansu Province, Lanzhou 730000, PR China
| | - Yong-Qiang Shi
- Lanzhou University Second Hospital, 82 Cuiying Men, Lanzhou 730000, PR China; Orthopedics Key Laboratory of Gansu Province, Lanzhou 730000, PR China
| | - Hao Dong
- Lanzhou University Second Hospital, 82 Cuiying Men, Lanzhou 730000, PR China; Orthopedics Key Laboratory of Gansu Province, Lanzhou 730000, PR China
| | - Wei Song
- Lanzhou University Second Hospital, 82 Cuiying Men, Lanzhou 730000, PR China; Orthopedics Key Laboratory of Gansu Province, Lanzhou 730000, PR China
| | - Yan-Bo Dong
- Lanzhou University Second Hospital, 82 Cuiying Men, Lanzhou 730000, PR China; Orthopedics Key Laboratory of Gansu Province, Lanzhou 730000, PR China
| | - Kai-Sheng Zhou
- Lanzhou University Second Hospital, 82 Cuiying Men, Lanzhou 730000, PR China; Orthopedics Key Laboratory of Gansu Province, Lanzhou 730000, PR China
| | - Hai-Hong Zhang
- Lanzhou University Second Hospital, 82 Cuiying Men, Lanzhou 730000, PR China; Orthopedics Key Laboratory of Gansu Province, Lanzhou 730000, PR China.
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Rudnitsky E, Braiman A, Wolfson M, Muradian KK, Gorbunova V, Turgeman G, Fraifeld VE. Stem cell-derived extracellular vesicles as senotherapeutics. Ageing Res Rev 2024; 99:102391. [PMID: 38914266 DOI: 10.1016/j.arr.2024.102391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2024] [Revised: 06/13/2024] [Accepted: 06/19/2024] [Indexed: 06/26/2024]
Abstract
Cellular senescence (CS) is recognized as one of the hallmarks of aging, and an important player in a variety of age-related pathologies. Accumulation of senescent cells can promote a pro-inflammatory and pro-cancerogenic microenvironment. Among potential senotherapeutics are extracellular vesicles (EVs) (40-1000 nm), including exosomes (40-150 nm), that play an important role in cell-cell communications. Here, we review the most recent studies on the impact of EVs derived from stem cells (MSCs, ESCs, iPSCs) as well as non-stem cells of various types on CS and discuss potential mechanisms responsible for the senotherapeutic effects of EVs. The analysis revealed that (i) EVs derived from stem cells, pluripotent (ESCs, iPSCs) or multipotent (MSCs of various origin), can mitigate the cellular senescence phenotype both in vitro and in vivo; (ii) this effect is presumably senomorphic; (iii) EVs display cross-species activity, without apparent immunogenic responses. In summary, stem cell-derived EVs appear to be promising senotherapeutics, with a feasible application in humans.
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Affiliation(s)
- Ekaterina Rudnitsky
- The Shraga Segal Department of Microbiology, Immunology and Genetics, Faculty of Health Sciences, Center for Multidisciplinary Research on Aging, Ben-Gurion University of the Negev, Beer-Sheva 8410501, Israel
| | - Alex Braiman
- The Shraga Segal Department of Microbiology, Immunology and Genetics, Faculty of Health Sciences, Center for Multidisciplinary Research on Aging, Ben-Gurion University of the Negev, Beer-Sheva 8410501, Israel
| | - Marina Wolfson
- The Shraga Segal Department of Microbiology, Immunology and Genetics, Faculty of Health Sciences, Center for Multidisciplinary Research on Aging, Ben-Gurion University of the Negev, Beer-Sheva 8410501, Israel
| | - Khachik K Muradian
- Department of Biology of Aging and Experimental Life Span Extension, State Institute of Gerontology of National Academy of Medical Sciences of Ukraine, Kiev 4114, Ukraine
| | - Vera Gorbunova
- Department of Biology, Rochester Aging Research Center, University of Rochester, Rochester, NY 14627, USA
| | - Gadi Turgeman
- Department of Molecular Biology, Faculty of Natural Sciences and Medical School, Ariel University, Ariel 40700, Israel.
| | - Vadim E Fraifeld
- The Shraga Segal Department of Microbiology, Immunology and Genetics, Faculty of Health Sciences, Center for Multidisciplinary Research on Aging, Ben-Gurion University of the Negev, Beer-Sheva 8410501, Israel.
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Fan MH, Pi JK, Zou CY, Jiang YL, Li QJ, Zhang XZ, Xing F, Nie R, Han C, Xie HQ. Hydrogel-exosome system in tissue engineering: A promising therapeutic strategy. Bioact Mater 2024; 38:1-30. [PMID: 38699243 PMCID: PMC11061651 DOI: 10.1016/j.bioactmat.2024.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 03/24/2024] [Accepted: 04/08/2024] [Indexed: 05/05/2024] Open
Abstract
Characterized by their pivotal roles in cell-to-cell communication, cell proliferation, and immune regulation during tissue repair, exosomes have emerged as a promising avenue for "cell-free therapy" in clinical applications. Hydrogels, possessing commendable biocompatibility, degradability, adjustability, and physical properties akin to biological tissues, have also found extensive utility in tissue engineering and regenerative repair. The synergistic combination of exosomes and hydrogels holds the potential not only to enhance the efficiency of exosomes but also to collaboratively advance the tissue repair process. This review has summarized the advancements made over the past decade in the research of hydrogel-exosome systems for regenerating various tissues including skin, bone, cartilage, nerves and tendons, with a focus on the methods for encapsulating and releasing exosomes within the hydrogels. It has also critically examined the gaps and limitations in current research, whilst proposed future directions and potential applications of this innovative approach.
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Affiliation(s)
- Ming-Hui Fan
- Department of Orthopedic Surgery and Orthopedic Research Institute, Laboratory of Stem Cell and Tissue Engineering, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, PR China
| | - Jin-Kui Pi
- Core Facilities, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, PR China
| | - Chen-Yu Zou
- Department of Orthopedic Surgery and Orthopedic Research Institute, Laboratory of Stem Cell and Tissue Engineering, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, PR China
| | - Yan-Lin Jiang
- Department of Orthopedic Surgery and Orthopedic Research Institute, Laboratory of Stem Cell and Tissue Engineering, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, PR China
| | - Qian-Jin Li
- Department of Orthopedic Surgery and Orthopedic Research Institute, Laboratory of Stem Cell and Tissue Engineering, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, PR China
| | - Xiu-Zhen Zhang
- Department of Orthopedic Surgery and Orthopedic Research Institute, Laboratory of Stem Cell and Tissue Engineering, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, PR China
| | - Fei Xing
- Department of Orthopedic Surgery and Orthopedic Research Institute, Laboratory of Stem Cell and Tissue Engineering, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, PR China
| | - Rong Nie
- Department of Orthopedic Surgery and Orthopedic Research Institute, Laboratory of Stem Cell and Tissue Engineering, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, PR China
| | - Chen Han
- Department of Orthopedic Surgery and Orthopedic Research Institute, Laboratory of Stem Cell and Tissue Engineering, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, PR China
| | - Hui-Qi Xie
- Department of Orthopedic Surgery and Orthopedic Research Institute, Laboratory of Stem Cell and Tissue Engineering, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, PR China
- Frontier Medical Center, Tianfu Jincheng Laboratory, Chengdu, Sichuan, 610212, PR China
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Sun L, Xiao M, Chen L, Ni L, Chen X, Zhang L, Yao J, Shao Z, Zhao B, Chen X, Liu Y. Enhanced Tissue Regeneration Through Immunomodulatory Extracellular Vesicles Encapsulated in Diversified Silk-Based Injectable Hydrogels. Adv Healthc Mater 2024:e2401460. [PMID: 39011805 DOI: 10.1002/adhm.202401460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Revised: 06/26/2024] [Indexed: 07/17/2024]
Abstract
Mesenchymal stem cells (MSCs) immunologically trained using lipopolysaccharide (LPS) display enhanced immunomodulatory capabilities. Extracellular vesicles (EVs) derived from MSCs are widely used in regenerative medicine owing to their bioactive properties without the drawbacks of cell therapy. However, it remains unclear whether EVs derived from LPS-stimulated (trained) MSCs (L-EVs) inherit the enhanced reparative potential from their parent cells. Thus, this study first aims to explore the effect of immunological training on the bioactivity of L-EVs. LPS-trained bone marrow-derived MSCs (BMSCs) secrete more EVs, and these EVs significantly promote M2 macrophage polarization. Subsequently, hydrogel systems based on thixotropic injectable silk fibroin are prepared for in vivo EV delivery. These hydrogels have controllable gelation time and exhibit outstanding reparative effects on rat skin wounds and alveolar bone defects. Finally, it is revealed that L-EVs promote M2 macrophage polarization by inhibiting the nuclear translocation of PKM2. Overall, this study shows that the immunological training of BMSCs effectively improves the therapeutic effects of their EVs and provides a convenient and diversified EV delivery strategy using an injectable silk fibroin hydrogel. This strategy has broad clinical application prospects for tissue regeneration.
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Affiliation(s)
- Liangyan Sun
- Department of Orthodontics, Department of Macromolecular Science, Multidisciplinary Consultant Center, Shanghai Stomatological Hospital & School of Stomatology, Fudan University, Shanghai, 200001, China
- Shanghai Key Laboratory of Craniomaxillofacial Development and Diseases, Fudan University, Shanghai, 200001, China
| | - Menglin Xiao
- Department of Orthodontics, Department of Macromolecular Science, Multidisciplinary Consultant Center, Shanghai Stomatological Hospital & School of Stomatology, Fudan University, Shanghai, 200001, China
- State Key Laboratory of Molecular Engineering of Polymers, Laboratory of Advanced Materials, Fudan University, Shanghai, 200433, China
| | - Ling Chen
- Department of Orthodontics, Department of Macromolecular Science, Multidisciplinary Consultant Center, Shanghai Stomatological Hospital & School of Stomatology, Fudan University, Shanghai, 200001, China
- State Key Laboratory of Molecular Engineering of Polymers, Laboratory of Advanced Materials, Fudan University, Shanghai, 200433, China
| | - Lingyue Ni
- Department of Orthodontics, Department of Macromolecular Science, Multidisciplinary Consultant Center, Shanghai Stomatological Hospital & School of Stomatology, Fudan University, Shanghai, 200001, China
- Shanghai Key Laboratory of Craniomaxillofacial Development and Diseases, Fudan University, Shanghai, 200001, China
| | - Xiaoxuan Chen
- Department of Orthodontics, Department of Macromolecular Science, Multidisciplinary Consultant Center, Shanghai Stomatological Hospital & School of Stomatology, Fudan University, Shanghai, 200001, China
- Shanghai Key Laboratory of Craniomaxillofacial Development and Diseases, Fudan University, Shanghai, 200001, China
| | - Lina Zhang
- Department of Biostatistics, Clinical Research Institute, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Jinrong Yao
- Department of Orthodontics, Department of Macromolecular Science, Multidisciplinary Consultant Center, Shanghai Stomatological Hospital & School of Stomatology, Fudan University, Shanghai, 200001, China
- State Key Laboratory of Molecular Engineering of Polymers, Laboratory of Advanced Materials, Fudan University, Shanghai, 200433, China
| | - Zhengzhong Shao
- Department of Orthodontics, Department of Macromolecular Science, Multidisciplinary Consultant Center, Shanghai Stomatological Hospital & School of Stomatology, Fudan University, Shanghai, 200001, China
- State Key Laboratory of Molecular Engineering of Polymers, Laboratory of Advanced Materials, Fudan University, Shanghai, 200433, China
| | - Bingjiao Zhao
- Department of Orthodontics, Department of Macromolecular Science, Multidisciplinary Consultant Center, Shanghai Stomatological Hospital & School of Stomatology, Fudan University, Shanghai, 200001, China
- Shanghai Key Laboratory of Craniomaxillofacial Development and Diseases, Fudan University, Shanghai, 200001, China
| | - Xin Chen
- Department of Orthodontics, Department of Macromolecular Science, Multidisciplinary Consultant Center, Shanghai Stomatological Hospital & School of Stomatology, Fudan University, Shanghai, 200001, China
- State Key Laboratory of Molecular Engineering of Polymers, Laboratory of Advanced Materials, Fudan University, Shanghai, 200433, China
| | - Yuehua Liu
- Department of Orthodontics, Department of Macromolecular Science, Multidisciplinary Consultant Center, Shanghai Stomatological Hospital & School of Stomatology, Fudan University, Shanghai, 200001, China
- Shanghai Key Laboratory of Craniomaxillofacial Development and Diseases, Fudan University, Shanghai, 200001, China
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Liu S, Li K, He Y, Chen S, Yang W, Chen X, Feng S, Xiong L, Peng Y, Shao Z. PGC1α-Inducing Senomorphic Nanotherapeutics Functionalized with NKG2D-Overexpressing Cell Membranes for Intervertebral Disc Degeneration. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2024; 11:e2400749. [PMID: 38554394 PMCID: PMC11165536 DOI: 10.1002/advs.202400749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 03/07/2024] [Indexed: 04/01/2024]
Abstract
Cellular senescence is a significant contributor to intervertebral disc aging and degeneration. However, the application of senotherapies, such as senomorphics targeting senescence markers and the senescence-associated secretory phenotype (SASP), remains limited due to challenges in precise delivery. Given that the natural killer group 2D (NKG2D) ligands are increased on the surface of senescent nucleus pulposus (NP) cells, the NKG2D-overexpressing NP cell membranes (NNPm) are constructed, which is expected to achieve a dual targeting effect toward senescent NP cells based on homologous membrane fusion and the NKG2D-mediated immunosurveillance mechanism. Then, mesoporous silica nanoparticles carrying a peroxisome proliferator-activated receptor-ɣ coactivator 1α (PGC1α)inducer (SP) are coated with NNPm (SP@NNPm) and it is found that SP@NNPm selectively targets senescent NP cells, and the SP cores exhibit pH-responsive drug release. Moreover, SP@NNPm effectively induces PGC1α-mediated mitochondrial biogenesis and mitigates senescence-associated markers induced by oxidative stress and the SASP, thereby alleviating puncture-induced senescence and disc degeneration. This dual-targeting nanotherapeutic system represents a novel approach to delivery senomorphics for disc degeneration treatment.
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Affiliation(s)
- Sheng Liu
- Department of OrthopedicsUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022China
| | - Kanglu Li
- Department of OrthopedicsUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022China
| | - Yuxin He
- Department of OrthopedicsUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022China
| | - Sheng Chen
- Department of OrthopedicsUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022China
| | - Wenbo Yang
- Department of OrthopedicsUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022China
| | - Xuanzuo Chen
- Department of OrthopedicsUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022China
| | - Shiqing Feng
- The Second Hospital of Shandong UniversityCheeloo College of MedicineShandong UniversityJinan250033China
- Department of OrthopedicsQilu Hospital of Shandong UniversityCheeloo College of MedicineShandong UniversityJinan250012China
- Department of OrthopedicsTianjin Medical University General HospitalTianjin Medical UniversityTianjin300052China
| | - Liming Xiong
- Department of OrthopedicsUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022China
| | - Yizhong Peng
- Department of OrthopedicsUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022China
| | - Zengwu Shao
- Department of OrthopedicsUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022China
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Jiang H, Qin H, Yang Q, Huang L, Liang X, Wang C, Moro A, Xu S, Wei Q. Effective delivery of miR-150-5p with nucleus pulposus cell-specific nanoparticles attenuates intervertebral disc degeneration. J Nanobiotechnology 2024; 22:292. [PMID: 38802882 PMCID: PMC11129471 DOI: 10.1186/s12951-024-02561-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 05/16/2024] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND The use of gene therapy to deliver microRNAs (miRNAs) has gradually translated to preclinical application for the treatment of intervertebral disc degeneration (IDD). However, the effects of miRNAs are hindered by the short half-life time and the poor cellular uptake, owing to the lack of efficient delivery systems. Here, we investigated nucleus pulposus cell (NPC) specific aptamer-decorated polymeric nanoparticles that can load miR-150-5p for IDD treatment. METHODS The role of miR-150-5p during disc development and degeneration was examined by miR-150-5p knockout (KO) mice. Histological analysis was undertaken in disc specimens. The functional mechanism of miR-150-5p in IDD development was investigated by qRT-PCR assay, Western blot, coimmunoprecipitation and immunofluorescence. NPC specific aptamer-decorated nanoparticles was designed, and its penetration, stability and safety were evaluated. IDD progression was assessed by radiological analysis including X-ray and MRI, after the annulus fibrosus needle puncture surgery with miR-150-5p manipulation by intradiscal injection of nanoparticles. The investigations into the interaction between aptamer and receptor were conducted using mass spectrometry, molecular docking and molecular dynamics simulations. RESULTS We investigated NPC-specific aptamer-decorated polymeric nanoparticles that can bind to miR-150-5p for IDD treatment. Furthermore, we detected that nanoparticle-loaded miR-150-5p inhibitors alleviated NPC senescence in vitro, and the effects of the nanoparticles were sustained for more than 3 months in vivo. The microenvironment of NPCs improves the endo/lysosomal escape of miRNAs, greatly inhibiting the secretion of senescence-associated factors and the subsequent degeneration of NPCs. Importantly, nanoparticles delivering miR-150-5p inhibitors attenuated needle puncture-induced IDD in mouse models by targeting FBXW11 and inhibiting TAK1 ubiquitination, resulting in the downregulation of NF-kB signaling pathway activity. CONCLUSIONS NPC-targeting nanoparticles delivering miR-150-5p show favorable therapeutic efficacy and safety and may constitute a promising treatment for IDD.
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Affiliation(s)
- Hua Jiang
- Department of Spine Surgery, The First Affiliated Hospital of Guangxi Medical University, 6 Shuangyong Road, Nanning, 530021, Guangxi Zhuang Autonomous Region, People's Republic of China.
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Guangxi Medical University, 6 Shuangyong Road, Nanning, 530021, Guangxi Zhuang Autonomous Region, People's Republic of China.
| | - Hongyu Qin
- Department of Spine Surgery, The First Affiliated Hospital of Guangxi Medical University, 6 Shuangyong Road, Nanning, 530021, Guangxi Zhuang Autonomous Region, People's Republic of China
| | - Qinghua Yang
- Department of Spine Surgery, The First Affiliated Hospital of Guangxi Medical University, 6 Shuangyong Road, Nanning, 530021, Guangxi Zhuang Autonomous Region, People's Republic of China
| | - Longao Huang
- Department of Spine Surgery, The First Affiliated Hospital of Guangxi Medical University, 6 Shuangyong Road, Nanning, 530021, Guangxi Zhuang Autonomous Region, People's Republic of China
| | - Xiao Liang
- Department of Spine Surgery, The First Affiliated Hospital of Guangxi Medical University, 6 Shuangyong Road, Nanning, 530021, Guangxi Zhuang Autonomous Region, People's Republic of China
| | - Congyang Wang
- Department of Spine Surgery, The First Affiliated Hospital of Guangxi Medical University, 6 Shuangyong Road, Nanning, 530021, Guangxi Zhuang Autonomous Region, People's Republic of China
| | - Abu Moro
- Department of Spine Surgery, The First Affiliated Hospital of Guangxi Medical University, 6 Shuangyong Road, Nanning, 530021, Guangxi Zhuang Autonomous Region, People's Republic of China
| | - Sheng Xu
- Research Centre for Regenerative Medicine, Guangxi Engineering Center in Biomedical Material for Tissue and Organ Regeneration, Guangxi Medical University, 22 Shuangyong Road, Nanning, 530021, Guangxi Zhuang Autonomous Region, People's Republic of China
| | - Qingjun Wei
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Guangxi Medical University, 6 Shuangyong Road, Nanning, 530021, Guangxi Zhuang Autonomous Region, People's Republic of China.
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Genedy HH, Humbert P, Laoulaou B, Le Moal B, Fusellier M, Passirani C, Le Visage C, Guicheux J, Lepeltier É, Clouet J. MicroRNA-targeting nanomedicines for the treatment of intervertebral disc degeneration. Adv Drug Deliv Rev 2024; 207:115214. [PMID: 38395361 DOI: 10.1016/j.addr.2024.115214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 02/09/2024] [Accepted: 02/14/2024] [Indexed: 02/25/2024]
Abstract
Low back pain stands as a pervasive global health concern, afflicting almost 80% of adults at some point in their lives with nearly 40% attributable to intervertebral disc degeneration (IVDD). As only symptomatic relief can be offered to patients there is a dire need for innovative treatments.Given the accumulating evidence that multiple microRNAs (miRs) are dysregulated during IVDD, they could have a huge potential against this debilitating condition. The way miRs can profoundly modulate signaling pathways and influence several cellular processes at once is particularly exciting to tackle this multifaceted disorder. However, miR delivery encounters extracellular and intracellular biological barriers. A promising technology to address this challenge is the vectorization of miRs within nanoparticles, providing both protection and enhancing their uptake within the scarce target cells of the degenerated IVD. This comprehensive review presents the diverse spectrum of miRs' connection with IVDD and demonstrates their therapeutic potential when vectorized in nanomedicines.
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Affiliation(s)
- Hussein H Genedy
- Nantes Université, Oniris, CHU Nantes, INSERM, Regenerative Medicine and Skeleton, RMeS, UMR1229, Nantes, France; Univ Angers, INSERM, CNRS, MINT, SFR ICAT, F-49000 Angers, France
| | - Paul Humbert
- Nantes Université, Oniris, CHU Nantes, INSERM, Regenerative Medicine and Skeleton, RMeS, UMR1229, Nantes, France
| | - Bilel Laoulaou
- Nantes Université, Oniris, CHU Nantes, INSERM, Regenerative Medicine and Skeleton, RMeS, UMR1229, Nantes, France; Univ Angers, INSERM, CNRS, MINT, SFR ICAT, F-49000 Angers, France
| | - Brian Le Moal
- Nantes Université, Oniris, CHU Nantes, INSERM, Regenerative Medicine and Skeleton, RMeS, UMR1229, Nantes, France; Univ Angers, INSERM, CNRS, MINT, SFR ICAT, F-49000 Angers, France
| | - Marion Fusellier
- Nantes Université, Oniris, CHU Nantes, INSERM, Regenerative Medicine and Skeleton, RMeS, UMR1229, Nantes, France; Department of Diagnostic Imaging, CRIP, ONIRIS, College of Veterinary Medicine, Food Science and Engineering, Nantes F-44307, France
| | | | - Catherine Le Visage
- Nantes Université, Oniris, CHU Nantes, INSERM, Regenerative Medicine and Skeleton, RMeS, UMR1229, Nantes, France
| | - Jérôme Guicheux
- Nantes Université, Oniris, CHU Nantes, INSERM, Regenerative Medicine and Skeleton, RMeS, UMR1229, Nantes, France
| | - Élise Lepeltier
- Univ Angers, INSERM, CNRS, MINT, SFR ICAT, F-49000 Angers, France; Institut Universitaire de France (IUF), France.
| | - Johann Clouet
- Nantes Université, Oniris, CHU Nantes, INSERM, Regenerative Medicine and Skeleton, RMeS, UMR1229, Nantes, France
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Zhao Y, Dong H, Xia Q, Wang Y, Zhu L, Hu Z, Xia J, Mao Q, Weng Z, Yi J, Feng S, Jiang Y, Liao W, Xin Z. A new strategy for intervertebral disc regeneration: The synergistic potential of mesenchymal stem cells and their extracellular vesicles with hydrogel scaffolds. Biomed Pharmacother 2024; 172:116238. [PMID: 38308965 DOI: 10.1016/j.biopha.2024.116238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 01/28/2024] [Accepted: 01/30/2024] [Indexed: 02/05/2024] Open
Abstract
Intervertebral disc degeneration (IDD) is a disease that severely affects spinal health and is prevalent worldwide. Mesenchymal stem cells (MSCs) and their derived extracellular vesicles (EVs) have regenerative potential and have emerged as promising therapeutic tools for treating degenerative discs. However, challenges such as the harsh microenvironment of degenerated intervertebral discs and EVs' limited stability and efficacy have hindered their clinical application. In recent years, hydrogels have attracted much attention in the field of IDD therapy because they can mimic the physiologic microenvironment of the disc and provide a potential solution by providing a suitable growth environment for MSCs and EVs. This review introduced the biological properties of MSCs and their derived EVs, summarized the research on the application of MSCs and EVs in IDD, summarized the current clinical trial studies of MSCs and EVs, and also explored the mechanism of action of MSCs and EVs in intervertebral discs. In addition, plenty of research elaborated on the mechanism of action of different classified hydrogels in tissue engineering, the synergistic effect of MSCs and EVs in promoting intervertebral disc regeneration, and their wide application in treating IDD. Finally, the challenges and problems still faced by hydrogel-loaded MSCs and EVs in the treatment of IDD are summarized, and potential solutions are proposed. This paper outlines the synergistic effects of MSCs and EVs in treating IDD in combination with hydrogels and aims to provide theoretical references for future related studies.
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Affiliation(s)
- Yan Zhao
- Department of Orthopedic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou, China
| | - Huaize Dong
- Department of Orthopedic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou, China
| | - Qiuqiu Xia
- Department of Orthopedic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou, China
| | - Yanyang Wang
- Department of Cell Engineering Laboratory, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, China
| | - Lu Zhu
- Department of Orthopedic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou, China
| | - Zongyue Hu
- Department of Pain Rehabilitation, Affiliated Sinopharm Gezhouba Central Hospital, Third Clinical Medical College of Three Gorges University, Yichang 443003, Hubei, China
| | - Jiyue Xia
- Department of Orthopedic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou, China
| | - Qiming Mao
- Department of Orthopedic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou, China
| | - Zijing Weng
- Department of Orthopedic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou, China
| | - Jiangbi Yi
- Department of Orthopedic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou, China
| | - Shuai Feng
- Department of Orthopedic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou, China
| | - Youhong Jiang
- Department of Orthopedic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou, China
| | - Wenbo Liao
- Department of Orthopedic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou, China
| | - Zhijun Xin
- Department of Orthopedic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou, China; Institut Curie, PSL Research University, CNRS UMR3244, Dynamics of Genetic Information, Sorbonne Université, 75005 Paris, France.
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9
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Du S, Zhou X, Zheng B. Beyond Traditional Medicine: EVs-Loaded Hydrogels as a Game Changer in Disease Therapeutics. Gels 2024; 10:162. [PMID: 38534580 DOI: 10.3390/gels10030162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 01/29/2024] [Accepted: 02/06/2024] [Indexed: 03/28/2024] Open
Abstract
Extracellular vesicles (EVs), especially exosomes, have shown great therapeutic potential in the treatment of diseases, as they can target cells or tissues. However, the therapeutic effect of EVs is limited due to the susceptibility of EVs to immune system clearance during transport in vivo. Hydrogels have become an ideal delivery platform for EVs due to their good biocompatibility and porous structure. This article reviews the preparation and application of EVs-loaded hydrogels as a cell-free therapy strategy in the treatment of diseases. The article also discusses the challenges and future outlook of EVs-loaded hydrogels.
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Affiliation(s)
- Shutong Du
- Institute for Cell Analysis, Shenzhen Bay Laboratory, Shenzhen 518132, China
| | - Xiaohu Zhou
- Institute for Cell Analysis, Shenzhen Bay Laboratory, Shenzhen 518132, China
| | - Bo Zheng
- Institute for Cell Analysis, Shenzhen Bay Laboratory, Shenzhen 518132, China
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10
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Muir VG, Fainor M, Orozco BS, Hilliard RL, Boyes M, Smith HE, Mauck RL, Schaer TP, Burdick JA, Gullbrand SE. Injectable Radiopaque Hyaluronic Acid Granular Hydrogels for Intervertebral Disc Repair. Adv Healthc Mater 2023:e2303326. [PMID: 38142300 PMCID: PMC11193841 DOI: 10.1002/adhm.202303326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 12/10/2023] [Indexed: 12/25/2023]
Abstract
Injectable hydrogels offer minimally-invasive treatment options for degenerative disc disease, a prevalent condition affecting millions annually. Many hydrogels explored for intervertebral disc (IVD) repair suffer from weak mechanical integrity, migration issues, and expulsion. To overcome these limitations, an injectable and radiopaque hyaluronic acid granular hydrogel is developed. The granular structure provides easy injectability and low extrusion forces, while the radiopacity enables direct visualization during injection into the disc and non-invasive monitoring after injection. The radiopaque granular hydrogel is injected into rabbit disc explants to investigate restoration of healthy disc mechanics following needle puncture injury ex vivo and then delivered in a minimally-invasive manner into the intradiscal space in a clinically-relevant in vivo large animal goat model of IVD degeneration initiated through degradation by chondroitinase. The radiopaque granular hydrogel successfully halted loss of disc height due to degeneration. Further, the hydrogel not only enhanced proteoglycan content and reduced collagen content in the nucleus pulposus (NP) region compared to degenerative discs, but also helped to maintain the structural integrity of the disc and promote healthy segregation of the NP and annulus fibrosus regions. Overall, this study demonstrates the great potential of an injectable radiopaque granular hydrogel for treatment of degenerative disc disease.
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Affiliation(s)
- Victoria G Muir
- Department of Bioengineering, School of Engineering and Applied Sciences, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Matthew Fainor
- Department of Orthopaedic Surgery, McKay Orthopaedic Research Laboratory, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
- Translational Musculoskeletal Research Center, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, 19104, USA
| | - Brianna S Orozco
- Department of Orthopaedic Surgery, McKay Orthopaedic Research Laboratory, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
- Translational Musculoskeletal Research Center, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, 19104, USA
| | - Rachel L Hilliard
- Department of Clinical Studies, New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Madeline Boyes
- Department of Clinical Studies, New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Harvey E Smith
- Department of Orthopaedic Surgery, McKay Orthopaedic Research Laboratory, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
- Translational Musculoskeletal Research Center, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, 19104, USA
| | - Robert L Mauck
- Department of Bioengineering, School of Engineering and Applied Sciences, University of Pennsylvania, Philadelphia, PA, 19104, USA
- Department of Orthopaedic Surgery, McKay Orthopaedic Research Laboratory, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
- Translational Musculoskeletal Research Center, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, 19104, USA
| | - Thomas P Schaer
- Department of Clinical Studies, New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Jason A Burdick
- Department of Bioengineering, School of Engineering and Applied Sciences, University of Pennsylvania, Philadelphia, PA, 19104, USA
- BioFrontiers Institute, University of Colorado Boulder, Boulder, CO, 80303, USA
- Department of Chemical and Biological Engineering, College of Engineering and Applied Science, University of Colorado Boulder, Boulder, CO, 80303, USA
| | - Sarah E Gullbrand
- Department of Orthopaedic Surgery, McKay Orthopaedic Research Laboratory, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
- Translational Musculoskeletal Research Center, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, 19104, USA
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11
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Wang N, Mi Z, Chen S, Fang X, Xi Z, Xu W, Xie L. Analysis of global research hotspots and trends in immune cells in intervertebral disc degeneration: A bibliometric study. Hum Vaccin Immunother 2023; 19:2274220. [PMID: 37941392 PMCID: PMC10760394 DOI: 10.1080/21645515.2023.2274220] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 10/19/2023] [Indexed: 11/10/2023] Open
Abstract
Intervertebral disc degeneration is an important pathological basis for spinal degenerative diseases. The imbalance of the immune microenvironment and the involvement of immune cells has been shown to lead to nucleus pulposus cells death. This article presents a bibliometric analysis of studies on immune cells in IDD in order to clarify the current status and hotspots. We searched the WOSCC, Scopus and PubMed databases from 01/01/2001 to 08/03/2023. We analyzed and visualized the content using software such as Citespace, Vosviewer and the bibliometrix. This study found that the number of annual publications is increasing year on year. The journal study found that Spine had the highest number of articles and citations. The country/regions analysis showed that China had the highest number of publications, the USA had the highest number of citations and total link strength. The institutional analysis found that Shanghai Jiao Tong University and Huazhong University of Science Technology had the highest number of publications, Tokai University had the highest citations, and the University of Bern had the highest total link strength. Sakai D and Risbud MV had the highest number of publications. Sakai D had the highest total link strength, and Risbud MV had the highest number of citations. The results of the keyword analysis suggested that the current research hotspots and future directions continue to be the study of the mechanisms of immune cells in IDD, the therapeutic role of immune cells in IDD and the role of immune cells in tissue engineering for IDD.
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Affiliation(s)
- Nan Wang
- Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, Jiangsu, P.R. China
| | - Zehua Mi
- Hospital for Skin Diseases, Institute of Dermatology Chinese Academy of Medical Sciences, Peking Union Medical College, Nanjing, China
| | - Shuang Chen
- Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, Jiangsu, P.R. China
| | - Xiaoyang Fang
- Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, Jiangsu, P.R. China
| | - Zhipeng Xi
- Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, Jiangsu, P.R. China
| | - Wenqiang Xu
- Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, Jiangsu, P.R. China
| | - Lin Xie
- Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, Jiangsu, P.R. China
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12
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Zhu S, Wang J, Suo M, Huang H, Liu X, Wang J, Li Z. Can extracellular vesicles be considered as a potential frontier in the treatment of intervertebral disc disease? Ageing Res Rev 2023; 92:102094. [PMID: 37863436 DOI: 10.1016/j.arr.2023.102094] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 10/04/2023] [Accepted: 10/16/2023] [Indexed: 10/22/2023]
Abstract
As a global public health problem, low back pain (LBP) caused by intervertebral disc degeneration (IDD) seriously affects patients' quality of life. In addition, the prevalence of IDD tends to be younger, which brings a huge burden to individuals and society economically. Current treatments do not delay or reverse the progression of IDD. The emergence of biologic therapies has brought new hope for the treatment of IDD. Among them, extracellular vesicles (EVs), as nanoscale bioactive substances that mediate cellular communication, have now produced many surprising results in the research of the treatment of IDD. This article reviews the mechanisms and roles of EVs in delaying IDD and describes the prospects and challenges of EVs.
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Affiliation(s)
- Shengxu Zhu
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, the People's Republic of China; Key Laboratory of Molecular Mechanism for Repair and Remodeling of Orthopedic Diseases, Liaoning Province, the People's Republic of China
| | - Junlin Wang
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, the People's Republic of China
| | - Moran Suo
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, the People's Republic of China; Key Laboratory of Molecular Mechanism for Repair and Remodeling of Orthopedic Diseases, Liaoning Province, the People's Republic of China
| | - Huagui Huang
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, the People's Republic of China; Key Laboratory of Molecular Mechanism for Repair and Remodeling of Orthopedic Diseases, Liaoning Province, the People's Republic of China
| | - Xin Liu
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, the People's Republic of China; Key Laboratory of Molecular Mechanism for Repair and Remodeling of Orthopedic Diseases, Liaoning Province, the People's Republic of China
| | - Jinzuo Wang
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, the People's Republic of China; Key Laboratory of Molecular Mechanism for Repair and Remodeling of Orthopedic Diseases, Liaoning Province, the People's Republic of China
| | - Zhonghai Li
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, the People's Republic of China; Key Laboratory of Molecular Mechanism for Repair and Remodeling of Orthopedic Diseases, Liaoning Province, the People's Republic of China.
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13
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Lu G, Zhang C, Li K, Gao K, Fu M, Lyu C, Quan Z. Sinomenine Ameliorates IL-1β-Induced Intervertebral Disc Degeneration in Rats Through Suppressing Inflammation and Oxidative Stress via Keap1/Nrf2/NF-κB Signaling Pathways. J Inflamm Res 2023; 16:4777-4791. [PMID: 37881650 PMCID: PMC10596063 DOI: 10.2147/jir.s430423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 10/17/2023] [Indexed: 10/27/2023] Open
Abstract
Purpose To investigate the molecular mechanism underlying the inhibitory effect of sinomenine (SN) on interleukin-1β (IL-1β)-induced apoptosis in nucleus pulposus cells (NPCs), and to evaluate the potential role of SN in preventing intervertebral disk degeneration (IDD). Methods The Rat NPCs were cultured in vitro and identified using Hematoxylin-Eosin (HE) staining, toluidine blue staining, and immunofluorescence analysis. NPCs were pretreated with or without SN, then induced with IL-1β to assess cell viability, ROS levels, apoptotic rates, and wound healing ability. Relevant protein expression was detected using Elisa, qPCR and Western Blot techniques. NPCs were pretreated with SN, either alone or in combination with Nrf2-IN-1 or SC, before being induced to undergo apoptosis by IL-1β. Apoptosis was detected using Hoechst staining, while qPCR and Western Blot techniques assessed protein expression. Rat caudal intervertebral discs were induced with IDD, with or without SN injection, and then co-injected with IL-1β. The levels of IDD were evaluated using HE staining and modified saffron-O-fix green cartilage staining. Relevant protein expression was detected using Elisa, qPCR, and Western Blot techniques. Results IL-1β significantly reduced NPC activity, induced ROS accumulation and apoptosis, decreased cell healing rate, promoted the expression and secretion of inflammatory factors, and inhibited extracellular matrix synthesis. However, pretreatment with SN effectively reversed these effects. Inhibition of the Keap1/Nrf2 signaling pathway or activation of the NF-κB signaling pathway significantly attenuated the cytoprotective effects of SN and increased apoptosis. Acupuncture combined with IL-1β injection markedly induced intervertebral disc degeneration in rat caudal spine, upregulated inflammatory factors expression and secretion, and downregulated extracellular matrix synthesis. SN intervention notably enhanced antioxidant enzyme expression and reversed these outcomes. Conclusion SN can prevent IL-1β-induced apoptosis of NPCs and ameliorate IDD by activating the Keap1/Nrf2 pathway and inhibiting the NF-κB signaling pathway.
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Affiliation(s)
- Gongbiao Lu
- Department of Spine Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400042, People’s Republic of China
- Department of Spine Surgery, Jining No.1 People’s Hospital, Jining, 272011, People’s Republic of China
| | - Cunxin Zhang
- Department of Spine Surgery, Jining No.1 People’s Hospital, Jining, 272011, People’s Republic of China
| | - Kang Li
- Department of Spine Surgery, Jining No.1 People’s Hospital, Jining, 272011, People’s Republic of China
| | - Kai Gao
- Department of Orthopaedics, Jining No.1 People’s Hospital, Jining, 272011, People’s Republic of China
| | - Maoqing Fu
- Department of Spine Surgery, Jining No.1 People’s Hospital, Jining, 272011, People’s Republic of China
| | - Chaoliang Lyu
- Department of Spine Surgery, Jining No.1 People’s Hospital, Jining, 272011, People’s Republic of China
| | - Zhengxue Quan
- Department of Spine Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400042, People’s Republic of China
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