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Hagenstein J, Burkhardt S, Sprezyna P, Tasika E, Tiegs G, Diehl L. CD44 expression on murine hepatic stellate cells promotes the induction of monocytic and polymorphonuclear myeloid-derived suppressor cells. J Leukoc Biol 2024; 116:177-185. [PMID: 38484149 DOI: 10.1093/jleuko/qiae053] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 01/31/2024] [Accepted: 02/22/2024] [Indexed: 06/30/2024] Open
Abstract
In chronic inflammation, regulatory immune cells, such as regulatory T cells and myeloid-derived suppressor cells, can develop. Local signals in the inflamed tissue, such as cytokines and eicosanoids, but also contact-dependent signals, can promote myeloid-derived suppressor cell development. In the liver, hepatic stellate cells may provide such signals via the expression of CD44. Myeloid-derived suppressor cells generated in the presence of hepatic stellate cells and anti-CD44 antibodies were functionally and phenotypically analyzed. We found that both monocytic and polymorphonuclear myeloid-derived suppressor cells generated in the presence of αCD44 antibodies were less suppressive toward T cells as measured by T-cell proliferation and cytokine production. Moreover, both monocytic and polymorphonuclear myeloid-derived suppressor cells were phenotypically altered. Monocytic myeloid-derived suppressor cells mainly changed their expression of CD80 and CD39, and polymorphonuclear myeloid-derived suppressor cells showed altered expression of CD80/86, PD-L1, and CCR2. Moreover, both polymorphonuclear and monocytic myeloid-derived suppressor cells lost expression of Nos2 messenger RNA, whereas monocytic myeloid-derived suppressor cells showed reduced expression of TGFb messenger RNA and polymorphonuclear myeloid-derived suppressor cells reduced expression of Il10 messenger RNA. In summary, the presence of CD44 in hepatic stellate cells promotes the induction of both monocytic and polymorphonuclear myeloid-derived suppressor cells, although the mechanisms by which these myeloid-derived suppressor cells may increase suppressive function due to interaction with CD44 are only partially overlapping.
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Affiliation(s)
- Julia Hagenstein
- Institute of Experimental Immunology and Hepatology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
- Hamburg Center of Translational Immunology (HCTI), University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Simon Burkhardt
- Institute of Experimental Immunology and Hepatology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
- Hamburg Center of Translational Immunology (HCTI), University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Paulina Sprezyna
- Institute of Experimental Immunology and Hepatology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
- Hamburg Center of Translational Immunology (HCTI), University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Elena Tasika
- Institute of Experimental Immunology and Hepatology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
- Hamburg Center of Translational Immunology (HCTI), University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Gisa Tiegs
- Institute of Experimental Immunology and Hepatology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
- Hamburg Center of Translational Immunology (HCTI), University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Linda Diehl
- Institute of Experimental Immunology and Hepatology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
- Hamburg Center of Translational Immunology (HCTI), University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
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Asgari R, Mehran YZ, Weber HM, Weber M, Golestanha SA, Hosseini Kazerouni SM, Panahi F, Mohammadi P, Mansouri K. Management of oxidative stress for cell therapy through combinational approaches of stem cells, antioxidants, and photobiomodulation. Eur J Pharm Sci 2024; 196:106715. [PMID: 38301971 DOI: 10.1016/j.ejps.2024.106715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 01/05/2024] [Accepted: 01/29/2024] [Indexed: 02/03/2024]
Abstract
Over the recent decades, stem cell-based therapies have been considered as a beneficial approach for the treatment of various diseases. In these types of therapies, the stem cells and their products are used as treating agents. Despite the helpful efficacy of stem cell-based therapies, there may be challenges. Oxidative stress (OS) is one of these challenges that can affect the therapeutic properties of stem cells. Therefore, it seems that employing strategies for the reduction of OS in combination with stem cell therapy can lead to better results of these therapies. Based on the available evidence, antioxidant therapy and photobiomodulation (PBM) are strategies that can regulate the OS in the cells. Antioxidant therapy is a method in which various antioxidants are used in the therapeutic processes. PBM is also the clinical application of light that gained importance in medicine. Antioxidants and PBM can regulate OS by the effect on mitochondria as an important source of OS in the cells. Considering the importance of OS in pathologic pathways and its effect on the treatment outcomes of stem cells, in the present review first the stem cell therapy and effects of OS on this type of therapy are summarized. Then, antioxidant therapy and PBM as approaches for reducing OS with a focus on mitochondrial function are discussed. Also, a novel combination treatment with the hope of achieving better and more stable outcomes in the treatment process of diseases is proposed.
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Affiliation(s)
- Rezvan Asgari
- Medical Biology Research Center, Health Technology Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Yasaman Zandi Mehran
- Department of Biomedical Engineering, Science and Research Branch, Islamic Azad University, Tehran, Iran
| | - Hans Michael Weber
- International Society of Medical Laser Applications, Lauenfoerde, Germany
| | | | | | | | - Farzad Panahi
- Medical Biology Research Center, Health Technology Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Pantea Mohammadi
- Medical Biology Research Center, Health Technology Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Kamran Mansouri
- Medical Biology Research Center, Health Technology Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran.
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Sun H, Xiao D, Liu W, Li X, Lin Z, Li Y, Ding Y. Well-known polypeptides of deer antler velvet with key actives: modern pharmacological advances. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2024; 397:15-31. [PMID: 37555852 DOI: 10.1007/s00210-023-02642-y] [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: 06/25/2023] [Accepted: 07/20/2023] [Indexed: 08/10/2023]
Abstract
Deer antler velvet, with kidney tonifying, promoting the production of essence and blood, strengthening tendons and bones, not only has a thousand-year medicinal history but also its modern pharmacology mainly focuses on its active polypeptides on motor, nerve, and immune systems. The purpose of this report is to fill the gap in the comprehensive, systematic, and detailed review of polypeptides during the recent 30 years (1992-2023). The research method was to review 53 pharmacological articles from the Public Medicine, Web of science, ACS, and Science Direct database sources by searching the keywords "pilose antler," "deer velvet," "Pilose Antler Peptide (PAP) and Velvet Antler Polypeptide (VAP)." The results showed that deer antler polypeptides (DAPs), by regulating EGF, EGFR, MAPK, P38, ERK, NF-κB, Wnt, PI3K, Akt, MMP, AMPK, Stir1, NLRP3, HO-1, Nrf, Rho, TLR, TGF-β, Smad, Ang II, etc., revealed their effects on seven system-related diseases and their mechanisms, including osteoarthritis, intervertebral disc degeneration, osteoporosis, Alzheimer's, Parkinson's, triple-negative breast cancer, liver injury, liver fibrosis, cardiovascular disease, acute lung injury, and late-onset hypogonadism. In conclusion, DAPs have good effects on motor and other system-related diseases, but the secondary and tertiary structures of DAPs (0.5-1800 KDa) need to be further elucidated, and the structure-activity relationship study is still unavailable and needs to be covered. It is expected that this review may provide the necessary literature support for further research. The activities and mechanisms of polypeptides from the past 30 years (1992-2023) are summarized covering seven systems, related diseases, and its regulatory genes and proteins.
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Affiliation(s)
- He Sun
- School of Pharmaceutical Sciences, Changchun University of Chinese Medicine, Changchun, 130117, Jilin, China
| | - Dandan Xiao
- School of Pharmaceutical Sciences, Changchun University of Chinese Medicine, Changchun, 130117, Jilin, China
| | - Wei Liu
- School of Pharmaceutical Sciences, Changchun University of Chinese Medicine, Changchun, 130117, Jilin, China
| | - Xue Li
- School of Pharmaceutical Sciences, Changchun University of Chinese Medicine, Changchun, 130117, Jilin, China
| | - Zhe Lin
- School of Pharmaceutical Sciences, Changchun University of Chinese Medicine, Changchun, 130117, Jilin, China
| | - Yong Li
- School of Pharmaceutical Sciences, Changchun University of Chinese Medicine, Changchun, 130117, Jilin, China.
| | - Yuling Ding
- School of Pharmaceutical Sciences, Changchun University of Chinese Medicine, Changchun, 130117, Jilin, China.
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Wu D, Wu J, Liu H, Shi S, Wang L, Huang Y, Yu X, Lei Z, Ouyang T, Shen J, Wu G, Wang S. A biomimetic renal fibrosis progression model on-chip evaluates anti-fibrotic effects longitudinally in a dynamic fibrogenic niche. LAB ON A CHIP 2023; 23:4708-4725. [PMID: 37840380 DOI: 10.1039/d3lc00393k] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2023]
Abstract
Although renal fibrosis can advance chronic kidney disease and progressively lead to end-stage renal failure, no effective anti-fibrotic drugs have been clinically approved. To aid drug development, we developed a biomimetic renal fibrosis progression model on-chip to evaluate anti-fibrotic effects of natural killer cell-derived extracellular vesicles and pirfenidone (PFD) across different fibrotic stages. First, the dynamic interplay between fibroblasts and kidney-derived extracellular matrix (ECM) resembling the fibrogenic niche on-chip demonstrated that myofibroblasts induced by stiff ECM in 3 days were reversed to fibroblasts by switching to soft ECM, which was within 2, but not 7 days. Second, PFD significantly down-regulated the expression of α-SMA in NRK-49F in medium ECM, as opposed to stiff ECM. Third, a study in rats showed that early administration of PFD significantly inhibited renal fibrosis in terms of the expression levels of α-SMA and YAP. Taken together, both on-chip and animal models indicate the importance of early anti-fibrotic intervention for checking the progression of renal fibrosis. Therefore, this renal fibrosis progression on-chip with a feature of recapitulating dynamic biochemical and biophysical cues can be readily used to assess anti-fibrotic candidates and to explore the tipping point when the fibrotic fate can be rescued for better medical intervention.
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Affiliation(s)
- Di Wu
- Institute for Translational Medicine, School of Medicine, Zhejiang University, Hangzhou, 310029, China
- Henan Key Laboratory of Rare Diseases, Endocrinology and Metabolism Center, The First Affiliated Hospital, and, College of Clinical Medicine of Henan University of Science and Technology, Luoyang, 471003, China
- Tianfu Jincheng Laboratory, City of Future Medicine, Chengdu, 641400, China
| | - Jianguo Wu
- Institute for Translational Medicine, School of Medicine, Zhejiang University, Hangzhou, 310029, China
| | - Hui Liu
- Institute for Translational Medicine, School of Medicine, Zhejiang University, Hangzhou, 310029, China
- National Engineering Research Center for Biomaterials, Sichuan University, Chengdu, 610065, China
- Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu, 610065, China
| | - Shengyu Shi
- Institute for Translational Medicine, School of Medicine, Zhejiang University, Hangzhou, 310029, China
| | - Liangwen Wang
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Yixiao Huang
- National Engineering Research Center for Biomaterials, Sichuan University, Chengdu, 610065, China
- Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu, 610065, China
| | - Xiaorui Yu
- National Engineering Research Center for Biomaterials, Sichuan University, Chengdu, 610065, China
- Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu, 610065, China
| | - Zhuoyue Lei
- National Engineering Research Center for Biomaterials, Sichuan University, Chengdu, 610065, China
- Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu, 610065, China
| | - Tanliang Ouyang
- National Engineering Research Center for Biomaterials, Sichuan University, Chengdu, 610065, China
- Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu, 610065, China
| | - Jia Shen
- Kidney Disease Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310029, China
| | - Guohua Wu
- Henan Key Laboratory of Rare Diseases, Endocrinology and Metabolism Center, The First Affiliated Hospital, and, College of Clinical Medicine of Henan University of Science and Technology, Luoyang, 471003, China
- National Engineering Research Center for Biomaterials, Sichuan University, Chengdu, 610065, China
- Tianfu Jincheng Laboratory, City of Future Medicine, Chengdu, 641400, China
| | - Shuqi Wang
- Institute for Translational Medicine, School of Medicine, Zhejiang University, Hangzhou, 310029, China
- National Engineering Research Center for Biomaterials, Sichuan University, Chengdu, 610065, China
- Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu, 610065, China
- Tianfu Jincheng Laboratory, City of Future Medicine, Chengdu, 641400, China
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Pei Q, Yi Q, Tang L. Liver Fibrosis Resolution: From Molecular Mechanisms to Therapeutic Opportunities. Int J Mol Sci 2023; 24:ijms24119671. [PMID: 37298621 DOI: 10.3390/ijms24119671] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 05/25/2023] [Accepted: 05/30/2023] [Indexed: 06/12/2023] Open
Abstract
The liver is a critical system for metabolism in human beings, which plays an essential role in an abundance of physiological processes and is vulnerable to endogenous or exogenous injuries. After the damage to the liver, a type of aberrant wound healing response known as liver fibrosis may happen, which can result in an excessive accumulation of extracellular matrix (ECM) and then cause cirrhosis or hepatocellular carcinoma (HCC), seriously endangering human health and causing a great economic burden. However, few effective anti-fibrotic medications are clinically available to treat liver fibrosis. The most efficient approach to liver fibrosis prevention and treatment currently is to eliminate its causes, but this approach's efficiency is too slow, or some causes cannot be fully eliminated, which causes liver fibrosis to worsen. In cases of advanced fibrosis, the only available treatment is liver transplantation. Therefore, new treatments or therapeutic agents need to be explored to stop the further development of early liver fibrosis or to reverse the fibrosis process to achieve liver fibrosis resolution. Understanding the mechanisms that lead to the development of liver fibrosis is necessary to find new therapeutic targets and drugs. The complex process of liver fibrosis is regulated by a variety of cells and cytokines, among which hepatic stellate cells (HSCs) are the essential cells, and their continued activation will lead to further progression of liver fibrosis. It has been found that inhibiting HSC activation, or inducing apoptosis, and inactivating activated hepatic stellate cells (aHSCs) can reverse fibrosis and thus achieve liver fibrosis regression. Hence, this review will concentrate on how HSCs become activated during liver fibrosis, including intercellular interactions and related signaling pathways, as well as targeting HSCs or liver fibrosis signaling pathways to achieve the resolution of liver fibrosis. Finally, new therapeutic compounds targeting liver fibrosis are summarized to provide more options for the therapy of liver fibrosis.
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Affiliation(s)
- Qiying Pei
- Key Laboratory of Biorheological Science and Technology, Ministry of Education, College of Bioengineering, Chongqing University, Chongqing 400044, China
| | - Qian Yi
- Department of Physiology, School of Basic Medical Science, Southwest Medical University, Luzhou 646000, China
| | - Liling Tang
- Key Laboratory of Biorheological Science and Technology, Ministry of Education, College of Bioengineering, Chongqing University, Chongqing 400044, China
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Lu X, Guo H, Wei X, Lu D, Shu W, Song Y, Qiu N, Xu X. Current Status and Prospect of Delivery Vehicle Based on Mesenchymal Stem Cell-Derived Exosomes in Liver Diseases. Int J Nanomedicine 2023; 18:2873-2890. [PMID: 37283714 PMCID: PMC10239634 DOI: 10.2147/ijn.s404925] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 05/10/2023] [Indexed: 06/08/2023] Open
Abstract
With the improvement of the average life expectancy and increasing incidence of obesity, the burden of liver disease is increasing. Liver disease is a serious threat to human health. Currently, liver transplantation is the only effective treatment for end-stage liver disease. However, liver transplantation still faces unavoidable difficulties. Mesenchymal stem cells (MSCs) can be used as an alternative therapy for liver disease, especially liver cirrhosis, liver failure, and liver transplantation complications. However, MSCs may have potential tumorigenic effects. Exosomes derived from MSCs (MSC-Exos), as the important intercellular communication mode of MSCs, contain various proteins, nucleic acids, and DNA. MSC-Exos can be used as a delivery system to treat liver diseases through immune regulation, apoptosis inhibition, regeneration promotion, drug delivery, and other ways. Good histocompatibility and material exchangeability make MSC-Exos a new treatment for liver diseases. This review summarizes the latest research on MSC-Exos as delivery vehicles in different liver diseases, including liver injury, liver failure, liver fibrosis, hepatocellular carcinoma (HCC), and ischemia and reperfusion injury. In addition, we discuss the advantages, disadvantages, and clinical application prospects of MSC-Exos-based delivery vectors in the treatment of liver diseases.
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Affiliation(s)
- Xinfeng Lu
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, 310000, People’s Republic of China
- Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province, Hangzhou, 310006, People’s Republic of China
| | - Haijun Guo
- Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province, Hangzhou, 310006, People’s Republic of China
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, People’s Republic of China
| | - Xuyong Wei
- Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province, Hangzhou, 310006, People’s Republic of China
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, People’s Republic of China
| | - Di Lu
- Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province, Hangzhou, 310006, People’s Republic of China
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, People’s Republic of China
| | - Wenzhi Shu
- Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province, Hangzhou, 310006, People’s Republic of China
- Zhejiang University School of Medicine, Hangzhou, 310058, People’s Republic of China
| | - Yisu Song
- Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province, Hangzhou, 310006, People’s Republic of China
- Zhejiang University School of Medicine, Hangzhou, 310058, People’s Republic of China
| | - Nasha Qiu
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, 310000, People’s Republic of China
- Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province, Hangzhou, 310006, People’s Republic of China
| | - Xiao Xu
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, 310000, People’s Republic of China
- Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province, Hangzhou, 310006, People’s Republic of China
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, People’s Republic of China
- Zhejiang University School of Medicine, Hangzhou, 310058, People’s Republic of China
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Saravanan PB, Kalivarathan J, Khan F, Shah R, Levy MF, Kanak MA. Exosomes in transplantation: Role in allograft rejection, diagnostic biomarker, and therapeutic potential. Life Sci 2023; 324:121722. [PMID: 37100379 DOI: 10.1016/j.lfs.2023.121722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 04/10/2023] [Accepted: 04/19/2023] [Indexed: 04/28/2023]
Abstract
Exosomes are 50-200 nm-sized extracellular vesicles that are secreted by cells to transfer signals and communicate with other cells. Recent research has revealed that allograft-specific exosomes containing proteins, lipids, and genetic materials are released into circulation post-transplantation which are powerful indicators of graft failure in solid-organ and tissue transplantations. The macromolecular content of exosomes released by the allograft and the immune cells serve as potential biomarkers for assessing the function and the acceptance/rejection status of the transplanted grafts. Identifying these biomarkers could aid in the development of therapeutic strategies to improve graft longevity. Exosomes can be used to deliver therapeutic agonists/antagonists to grafts and prevent rejection. Inducing long-term graft tolerance has been demonstrated in many studies using exosomes from immunomodulatory cells such as immature DCs, T regulatory cells, and MSCs. The use of graft-specific exosomes for targeted drug therapy has the potential to reduce the unwanted side effects of immunosuppressive drugs. Overall, in this review, we have explored the critical role of exosomes in the recognition and cross-presentation of donor organ-specific antigens during allograft rejection. Additionally, we have discussed the potential of exosomes as a biomarker for monitoring graft function and damage, as well as their potential therapeutic applications in mitigating allograft rejection.
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Affiliation(s)
| | - Jagan Kalivarathan
- VCU Hume-Lee Transplant Institute, VCU health system, Richmond, VA, United States of America
| | - Faizaan Khan
- Department of Surgery, School of Medicine, VCU, Richmond, VA, United States of America
| | - Rashi Shah
- Department of Surgery, School of Medicine, VCU, Richmond, VA, United States of America
| | - Marlon F Levy
- VCU Hume-Lee Transplant Institute, VCU health system, Richmond, VA, United States of America; Department of Surgery, School of Medicine, VCU, Richmond, VA, United States of America
| | - Mazhar A Kanak
- VCU Hume-Lee Transplant Institute, VCU health system, Richmond, VA, United States of America; Department of Surgery, School of Medicine, VCU, Richmond, VA, United States of America
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