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Iworima DG, Baker RK, Ellis C, Sherwood C, Zhan L, Rezania A, Piret JM, Kieffer TJ. Metabolic switching, growth kinetics and cell yields in the scalable manufacture of stem cell-derived insulin-producing cells. Stem Cell Res Ther 2024; 15:1. [PMID: 38167219 PMCID: PMC10762849 DOI: 10.1186/s13287-023-03574-3] [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: 04/26/2023] [Accepted: 11/16/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Diabetes is a disease affecting over 500 million people globally due to insulin insufficiency or insensitivity. For individuals with type 1 diabetes, pancreatic islet transplantation can help regulate their blood glucose levels. However, the scarcity of cadaveric donor islets limits the number of people that could receive this therapy. To address this issue, human pluripotent stem cells offer a potentially unlimited source for generating insulin-producing cells through directed differentiation. Several protocols have been developed to make stem cell-derived insulin-producing cells. However, there is a lack of knowledge regarding the bioprocess parameters associated with these differentiation protocols and how they can be utilized to increase the cell yield. METHODS We investigated various bioprocess parameters and quality target product profiles that may influence the differentiation pipeline using a seven-stage protocol in a scalable manner with CellSTACKs and vertical wheel bioreactors (PBS-Minis). RESULTS Cells maintained > 80% viability through all stages of differentiation and appropriately expressed stage-specific markers. During the initial four stages leading up to the development of pancreatic progenitors, there was an increase in cell numbers. Following pancreatic progenitor stage, there was a gradual decrease in the percentage of proliferative cells, as determined by Ki67 positivity, and a significant loss of cells during the period of endocrine differentiation. By minimizing the occurrence of aggregate fusion, we were able to enhance cell yield during the later stages of differentiation. We suggest that glucose utilization and lactate production are cell quality attributes that should be considered during the characterization of insulin-producing cells derived from stem cells. Our findings also revealed a gradual metabolic shift from glycolysis, during the initial four stages of pancreatic progenitor formation, to oxidative phosphorylation later on during endocrine differentiation. Furthermore, the resulting insulin-producing cells exhibited a response to several secretagogues, including high glucose. CONCLUSION This study demonstrates process parameters such as glucose consumption and lactate production rates that may be used to facilitate the scalable manufacture of stem cell-derived insulin-producing cells.
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Affiliation(s)
- Diepiriye G Iworima
- Department of Cellular and Physiological Sciences, Life Sciences Institute, The University of British Columbia, Vancouver, BC, Canada
- School of Biomedical Engineering, The University of British Columbia, Vancouver, BC, Canada
| | - Robert K Baker
- Department of Cellular and Physiological Sciences, Life Sciences Institute, The University of British Columbia, Vancouver, BC, Canada
| | - Cara Ellis
- Department of Cellular and Physiological Sciences, Life Sciences Institute, The University of British Columbia, Vancouver, BC, Canada
| | - Chris Sherwood
- Michael Smith Laboratories, The University of British Columbia, Vancouver, BC, Canada
| | - Lisa Zhan
- Department of Cellular and Physiological Sciences, Life Sciences Institute, The University of British Columbia, Vancouver, BC, Canada
| | | | - James M Piret
- School of Biomedical Engineering, The University of British Columbia, Vancouver, BC, Canada
- Michael Smith Laboratories, The University of British Columbia, Vancouver, BC, Canada
- Department of Chemical and Biological Engineering, The University of British Columbia, Vancouver, BC, Canada
| | - Timothy J Kieffer
- Department of Cellular and Physiological Sciences, Life Sciences Institute, The University of British Columbia, Vancouver, BC, Canada.
- School of Biomedical Engineering, The University of British Columbia, Vancouver, BC, Canada.
- Department of Surgery, The University of British Columbia, Vancouver, BC, Canada.
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Krishtul S, Skitel Moshe M, Kovrigina I, Baruch L, Machluf M. ECM-based bioactive microencapsulation significantly improves islet function and graft performance. Acta Biomater 2023; 171:249-260. [PMID: 37708927 DOI: 10.1016/j.actbio.2023.09.009] [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: 01/01/2023] [Revised: 08/17/2023] [Accepted: 09/07/2023] [Indexed: 09/16/2023]
Abstract
Microencapsulation is a promising strategy to prolong the survival and function of transplanted pancreatic islets for diabetes therapy, albeit its translation has been impeded by incoherent graft performance. The use of decellularized ECM has lately gained substantial research momentum due to its innate capacity to augment the function of cells originating from the same tissue type. In the present study, the advantages of both these approaches are leveraged in a porcine pancreatic ECM (pECM)-based microencapsulation platform, thus significantly enhancing murine pancreatic islet performance. pECM-encapsulated islets sustain high insulin secretion levels in vitro, surpassing those of islets encapsulated in conventional alginate microcapsules. Moreover, pECM-encapsulated islet cells proliferate and produce an enriched intra-islet ECM framework, displaying a distinctive structural rearrangement. The beneficial effect of pECM encapsulation is further reinforced by the temporary protection against cytokine-induced cytotoxicity. In-vivo, this platform significantly improves glucose tolerance and achieves glycemic correction in 100% of immunocompetent diabetic mice without any immunosuppression, compared to only 50% mice achieved glycemic correction by alginate encapsulation. Altogether, the results presented herein reveal that pECM-based microencapsulation offers a natural pancreatic niche that can restore the function of isolated pancreatic islets and deliver them safely, avoiding the need for immunosuppression. STATEMENT OF SIGNIFICANCE: Aiming to improve pancreatic islet transplantation outcomes in diabetic patients, we developed a microencapsulation platform based on pancreatic extracellular matrix (pECM). In these microcapsules the islets are entrapped within a pECM hydrogel that mimics the natural pancreatic microenvironment. We show that pECM encapsulation supports the islets' viability and function in culture, and provides temporal protection against cytokine-induced stress. In a diabetic mouse model, pECM encapsulation significantly improved glucose tolerance and achieved glycemic correction without any immunosuppression. These results reveal the potential of pECM encapsulation as a viable treatment for diabetes, providing a solid scientific basis for more advanced preclinical studies.
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Affiliation(s)
- Stasia Krishtul
- Faculty of Biotechnology & Food Engineering, Technion - Israel Institute of Technology, Haifa 3200003, Israel
| | - Michal Skitel Moshe
- Faculty of Biotechnology & Food Engineering, Technion - Israel Institute of Technology, Haifa 3200003, Israel
| | - Inna Kovrigina
- Faculty of Biotechnology & Food Engineering, Technion - Israel Institute of Technology, Haifa 3200003, Israel
| | - Limor Baruch
- Faculty of Biotechnology & Food Engineering, Technion - Israel Institute of Technology, Haifa 3200003, Israel
| | - Marcelle Machluf
- Faculty of Biotechnology & Food Engineering, Technion - Israel Institute of Technology, Haifa 3200003, Israel.
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Urbanczyk M, Zbinden A, Schenke-Layland K. Organ-specific endothelial cell heterogenicity and its impact on regenerative medicine and biomedical engineering applications. Adv Drug Deliv Rev 2022; 186:114323. [PMID: 35568103 DOI: 10.1016/j.addr.2022.114323] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 04/23/2022] [Accepted: 05/05/2022] [Indexed: 02/08/2023]
Abstract
Endothelial cells (ECs) are a key cellular component of the vascular system as they form the inner lining of the blood vessels. Recent findings highlight that ECs express extensive phenotypic heterogenicity when following the vascular tree from the major vasculature down to the organ capillaries. However, in vitro models, used for drug development and testing, or to study the role of ECs in health and disease, rarely acknowledge this EC heterogenicity. In this review, we highlight the main differences between different EC types, briefly summarize their different characteristics and focus on the use of ECs in in vitro models. We introduce different approaches on how ECs can be utilized in co-culture test systems in the field of brain, pancreas, and liver research to study the role of the endothelium in health and disease. Finally, we discuss potential improvements to current state-of-the-art in vitro models and future directions.
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4
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Taguchi T, Duan W, Wolfson W, Duhon B, Halphen EG, Lopez MJ. Feline Adipose Derived Multipotent Stromal Cell Transdifferentiation Into Functional Insulin Producing Cell Clusters. Front Bioeng Biotechnol 2022; 10:904519. [PMID: 35769100 PMCID: PMC9234738 DOI: 10.3389/fbioe.2022.904519] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 05/10/2022] [Indexed: 11/22/2022] Open
Abstract
Diabetes mellitus (DM) is one of the most prevalent feline endocrinopathies, affecting up to 1% of pet cats. De novo generation of functional insulin producing cell (IPC) clusters via transdifferentiation of feline adipose-derived multipotent stromal cells (ASCs) may not only provide a viable, functional cell therapy for feline DM, but may also serve as a platform for developing a comparable human treatment given feline and human DM similarities. Cells were induced to form IPCs with a novel, three-stage culture process with stromal or differentiation medium under static and dynamic conditions. Clusters were evaluated for intracellular zinc, viability, intracellular insulin, glucagon, and somatostatin, ultrastructure, glucose stimulated insulin secretion in the presence or absence of theophylline, and protein and gene expression. Isolated cells were multipotent, and cell clusters cultured in both media had robust cell viability. Those cultured in differentiation medium contained zinc and mono- or polyhormonal α-, β-, and δ-like cells based on immunohistochemical labeling and Mallory-Heidenhan Azan-Gomori’s staining. Ultrastructurally, cell clusters cultured in differentiation medium contained insulin granules within vesicles, and clusters had a concentration-dependent insulin response to glucose in the presence and absence of theophylline which increased both insulin secretion and intracellular content. Expression of NK6.1, Pax6, Isl1, Glut2, RAB3A, glucagon, insulin, and somatostatin increased with differentiation stage for both sexes, and expression of nestin at stages 1 and 2 and Neurod1 at stage 2 was higher in cells from female donors. The cluster insulin secretion responses and endocrine and oncogene gene expression profiles were inconsistent with insulinoma characteristics. A total of 180 proteins were upregulated in differentiated clusters, and the majority were associated with biological regulation, metabolic processes, or stimulus response. Dynamic culture of IPC clusters resulted in clusters composed of cells primarily expressing insulin that released higher insulin with glucose stimulation than those in static culture. Collectively, the results of this study support generation of functional IPC clusters using feline ASCs isolated from tissues removed during routine sterilization. Further, cluster functionality is enhanced with dynamic, motion-driven shear stress. This work establishes a foundation for development of strategies for IPC therapy for short or long-term diabetes treatment and may represent an option to study prevention and treatment of diabetes across species.
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Affiliation(s)
- Takashi Taguchi
- Laboratory for Equine and Comparative Orthopedic Research, Department of Veterinary Clinical Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, LA, United States
| | - Wei Duan
- Laboratory for Equine and Comparative Orthopedic Research, Department of Veterinary Clinical Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, LA, United States
| | - Wendy Wolfson
- Department of Veterinary Clinical Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, LA, United States
| | - Brandy Duhon
- Department of Veterinary Clinical Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, LA, United States
| | - Emily G. Halphen
- Laboratory for Equine and Comparative Orthopedic Research, Department of Veterinary Clinical Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, LA, United States
| | - Mandi J. Lopez
- Laboratory for Equine and Comparative Orthopedic Research, Department of Veterinary Clinical Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, LA, United States
- *Correspondence: Mandi J. Lopez,
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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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Tonti OR, Larson H, Lipp SN, Luetkemeyer CM, Makam M, Vargas D, Wilcox SM, Calve S. Tissue-specific parameters for the design of ECM-mimetic biomaterials. Acta Biomater 2021; 132:83-102. [PMID: 33878474 PMCID: PMC8434955 DOI: 10.1016/j.actbio.2021.04.017] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 03/18/2021] [Accepted: 04/08/2021] [Indexed: 02/06/2023]
Abstract
The extracellular matrix (ECM) is a complex network of biomolecules that mechanically and biochemically directs cell behavior and is crucial for maintaining tissue function and health. The heterogeneous organization and composition of the ECM varies within and between tissue types, directing mechanics, aiding in cell-cell communication, and facilitating tissue assembly and reassembly during development, injury and disease. As technologies like 3D printing rapidly advance, researchers are better able to recapitulate in vivo tissue properties in vitro; however, tissue-specific variations in ECM composition and organization are not given enough consideration. This is in part due to a lack of information regarding how the ECM of many tissues varies in both homeostatic and diseased states. To address this gap, we describe the components and organization of the ECM, and provide examples for different tissues at various states of disease. While many aspects of ECM biology remain unknown, our goal is to highlight the complexity of various tissues and inspire engineers to incorporate unique components of the native ECM into in vitro platform design and fabrication. Ultimately, we anticipate that the use of biomaterials that incorporate key tissue-specific ECM will lead to in vitro models that better emulate human pathologies. STATEMENT OF SIGNIFICANCE: Biomaterial development primarily emphasizes the engineering of new materials and therapies at the expense of identifying key parameters of the tissue that is being emulated. This can be partially attributed to the difficulty in defining the 3D composition, organization, and mechanics of the ECM within different tissues and how these material properties vary as a function of homeostasis and disease. In this review, we highlight a range of tissues throughout the body and describe how ECM content, cell diversity, and mechanical properties change in diseased tissues and influence cellular behavior. Accurately mimicking the tissue of interest in vitro by using ECM specific to the appropriate state of homeostasis or pathology in vivo will yield results more translatable to humans.
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Affiliation(s)
- Olivia R Tonti
- Paul M. Rady Department of Mechanical Engineering, University of Colorado - Boulder, 1111 Engineering Center, 427 UCB, Boulder, CO 80309, United States
| | - Hannah Larson
- Paul M. Rady Department of Mechanical Engineering, University of Colorado - Boulder, 1111 Engineering Center, 427 UCB, Boulder, CO 80309, United States
| | - Sarah N Lipp
- Paul M. Rady Department of Mechanical Engineering, University of Colorado - Boulder, 1111 Engineering Center, 427 UCB, Boulder, CO 80309, United States
| | - Callan M Luetkemeyer
- Paul M. Rady Department of Mechanical Engineering, University of Colorado - Boulder, 1111 Engineering Center, 427 UCB, Boulder, CO 80309, United States
| | - Megan Makam
- Paul M. Rady Department of Mechanical Engineering, University of Colorado - Boulder, 1111 Engineering Center, 427 UCB, Boulder, CO 80309, United States
| | - Diego Vargas
- Paul M. Rady Department of Mechanical Engineering, University of Colorado - Boulder, 1111 Engineering Center, 427 UCB, Boulder, CO 80309, United States
| | - Sean M Wilcox
- Paul M. Rady Department of Mechanical Engineering, University of Colorado - Boulder, 1111 Engineering Center, 427 UCB, Boulder, CO 80309, United States
| | - Sarah Calve
- Paul M. Rady Department of Mechanical Engineering, University of Colorado - Boulder, 1111 Engineering Center, 427 UCB, Boulder, CO 80309, United States.
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Goddi A, Schroedl L, Brey EM, Cohen RN. Laminins in metabolic tissues. Metabolism 2021; 120:154775. [PMID: 33857525 DOI: 10.1016/j.metabol.2021.154775] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 03/13/2021] [Accepted: 04/08/2021] [Indexed: 12/16/2022]
Abstract
Laminins are extracellular matrix proteins that reside in the basement membrane and provide structural support in addition to promoting cellular adhesion and migration. Through interactions with cell surface receptors, laminins stimulate intracellular signaling cascades which direct specific survival and differentiation outcomes. In metabolic tissues such as the pancreas, adipose, muscle, and liver, laminin isoforms are expressed in discrete temporal and spatial patterns suggesting that certain isoforms may support the development and function of particular metabolic cell types. This review focuses on the research to date detailing the expression of laminin isoforms, their potential function, as well as known pathways involved in laminin signaling in metabolic tissues. We will also discuss the current biomedical therapies involving laminins in these tissues in addition to prospective applications, with the goal being to encourage future investigation of laminins in the context of metabolic disease.
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Affiliation(s)
- Anna Goddi
- Committee on Molecular Metabolism and Nutrition, The University of Chicago, 900 East 57th St, Chicago, IL 60637, USA
| | - Liesl Schroedl
- Pritzker School of Medicine, The University of Chicago, 924 E 57th St, Chicago, IL 60637, USA
| | - Eric M Brey
- Department of Biomedical Engineering and Chemical Engineering, The University of Texas at San Antonio, One UTSA Circle, San Antonio, TX 78249, USA
| | - Ronald N Cohen
- Committee on Molecular Metabolism and Nutrition, The University of Chicago, 900 East 57th St, Chicago, IL 60637, USA; Section of Endocrinology, Diabetes, and Metabolism, The University of Chicago, 5841 South Maryland Ave, Chicago, IL 60637, USA.
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MacFarlane EM, Bruin JE. Human Pluripotent Stem Cells: A Unique Tool for Toxicity Testing in Pancreatic Progenitor and Endocrine Cells. Front Endocrinol (Lausanne) 2021; 11:604998. [PMID: 33542706 PMCID: PMC7851047 DOI: 10.3389/fendo.2020.604998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 11/27/2020] [Indexed: 12/18/2022] Open
Abstract
Diabetes prevalence is increasing worldwide, and epidemiological studies report an association between diabetes incidence and environmental pollutant exposure. There are >84,000 chemicals in commerce, many of which are released into the environment without a clear understanding of potential adverse health consequences. While in vivo rodent studies remain an important tool for testing chemical toxicity systemically, we urgently need high-throughput screening platforms in biologically relevant models to efficiently prioritize chemicals for in depth toxicity analysis. Given the increasing global burden of obesity and diabetes, identifying chemicals that disrupt metabolism should be a high priority. Pancreatic endocrine cells are key regulators of systemic metabolism, yet often overlooked as a target tissue in toxicology studies. Immortalized β-cell lines and primary human, porcine, and rodent islets are widely used for studying the endocrine pancreas in vitro, but each have important limitations in terms of scalability, lifespan, and/or biological relevance. Human pluripotent stem cell (hPSC) culture is a powerful tool for in vitro toxicity testing that addresses many of the limitations with other β-cell models. Current in vitro differentiation protocols can efficiently generate glucose-responsive insulin-secreting β-like cells that are not fully mature, but still valuable for high-throughput toxicity screening in vitro. Furthermore, hPSCs can be applied as a model of developing pancreatic endocrine cells to screen for chemicals that influence endocrine cell formation during critical windows of differentiation. Given their versatility, we recommend using hPSCs to identify potential β-cell toxins, which can then be prioritized as chemicals of concern for metabolic disruption.
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Affiliation(s)
| | - Jennifer E. Bruin
- Department of Biology & Institute of Biochemistry, Carleton University, Ottawa, ON, Canada
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Yap L, Wang JW, Moreno-Moral A, Chong LY, Sun Y, Harmston N, Wang X, Chong SY, Vanezis K, Öhman MK, Wei H, Bunte R, Gosh S, Cook S, Hovatta O, de Kleijn DPV, Petretto E, Tryggvason K. In Vivo Generation of Post-infarct Human Cardiac Muscle by Laminin-Promoted Cardiovascular Progenitors. Cell Rep 2020; 26:3231-3245.e9. [PMID: 30893597 DOI: 10.1016/j.celrep.2019.02.083] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 01/15/2019] [Accepted: 02/21/2019] [Indexed: 12/25/2022] Open
Abstract
Regeneration of injured human heart muscle is limited and an unmet clinical need. There are no methods for the reproducible generation of clinical-quality stem cell-derived cardiovascular progenitors (CVPs). We identified laminin-221 (LN-221) as the most likely expressed cardiac laminin. We produced it as human recombinant protein and showed that LN-221 promotes differentiation of pluripotent human embryonic stem cells (hESCs) toward cardiomyocyte lineage and downregulates pluripotency and teratoma-associated genes. We developed a chemically defined, xeno-free laminin-based differentiation protocol to generate CVPs. We show high reproducibility of the differentiation protocol using time-course bulk RNA sequencing developed from different hESC lines. Single-cell RNA sequencing of CVPs derived from hESC lines supported reproducibility and identified three main progenitor subpopulations. These CVPs were transplanted into myocardial infarction mice, where heart function was measured by echocardiogram and human heart muscle bundle formation was identified histologically. This method may provide clinical-quality cells for use in regenerative cardiology.
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Affiliation(s)
- Lynn Yap
- Cardiovascular & Metabolic Disorders Program, Duke-NUS Medical School, National University of Singapore, Singapore 169857, Singapore
| | - Jiong-Wei Wang
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore; Department of Physiology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117593, Singapore; Cardiovascular Research Institute, National University Heart Centre, Singapore 117599, Singapore
| | - Aida Moreno-Moral
- Cardiovascular & Metabolic Disorders Program, Duke-NUS Medical School, National University of Singapore, Singapore 169857, Singapore
| | - Li Yen Chong
- Cardiovascular & Metabolic Disorders Program, Duke-NUS Medical School, National University of Singapore, Singapore 169857, Singapore
| | - Yi Sun
- BioLamina AB, Löfströms Allé 5A, Sundbyberg 17266, Sweden
| | - Nathan Harmston
- Cardiovascular & Metabolic Disorders Program, Duke-NUS Medical School, National University of Singapore, Singapore 169857, Singapore
| | - Xiaoyuan Wang
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore; Cardiovascular Research Institute, National University Heart Centre, Singapore 117599, Singapore
| | - Suet Yen Chong
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore; Cardiovascular Research Institute, National University Heart Centre, Singapore 117599, Singapore
| | - Konstantinos Vanezis
- Cardiovascular Genetics and Genomics Group MRC London Institute of Medical Sciences, Imperial Centre for Translational and Experimental Medicine, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK
| | - Miina K Öhman
- Cardiovascular & Metabolic Disorders Program, Duke-NUS Medical School, National University of Singapore, Singapore 169857, Singapore
| | - Heming Wei
- Cardiovascular & Metabolic Disorders Program, Duke-NUS Medical School, National University of Singapore, Singapore 169857, Singapore; National Heart Research Institute Singapore, National Heart Centre Singapore, Singapore 169609, Singapore
| | - Ralph Bunte
- Cardiovascular & Metabolic Disorders Program, Duke-NUS Medical School, National University of Singapore, Singapore 169857, Singapore
| | - Sujoy Gosh
- Cardiovascular & Metabolic Disorders Program, Duke-NUS Medical School, National University of Singapore, Singapore 169857, Singapore
| | - Stuart Cook
- Cardiovascular & Metabolic Disorders Program, Duke-NUS Medical School, National University of Singapore, Singapore 169857, Singapore; National Heart Research Institute Singapore, National Heart Centre Singapore, Singapore 169609, Singapore; National Heart & Lung Institute, Imperial College London, Cale Street, London SW3 6LY, UK
| | - Outi Hovatta
- Division of Obstetrics and Gynecology, Department of Clinical Sciences, Intervention and Technology, Karolinska Institute and Karolinska University Hospital, Huddinge, Stockholm 141 86, Sweden
| | - Dominique P V de Kleijn
- Cardiovascular Research Institute, National University Heart Centre, Singapore 117599, Singapore; University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | - Enrico Petretto
- Cardiovascular & Metabolic Disorders Program, Duke-NUS Medical School, National University of Singapore, Singapore 169857, Singapore
| | - Karl Tryggvason
- Cardiovascular & Metabolic Disorders Program, Duke-NUS Medical School, National University of Singapore, Singapore 169857, Singapore; Department of Medical Biochemistry and Biophysics, Karolinska Institute, 171 77 Stockholm, Sweden.
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Nilsson J, Fardoos R, Hansen L, Lövkvist H, Pietras K, Holmberg D, Schmidt-Christensen A. Recruited fibroblasts reconstitute the peri-islet membrane: a longitudinal imaging study of human islet grafting and revascularisation. Diabetologia 2020; 63:137-148. [PMID: 31701200 PMCID: PMC6890581 DOI: 10.1007/s00125-019-05018-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Accepted: 08/22/2019] [Indexed: 12/18/2022]
Abstract
AIMS/HYPOTHESIS Rapid and adequate islet revascularisation and restoration of the islet-extracellular matrix (ECM) interaction are significant factors influencing islet survival and function of the transplanted islets in individuals with type 1 diabetes. Because the ECM encapsulating the islets is degraded during islet isolation, understanding the process of revascularisation and engraftment after transplantation is essential and needs further investigation. METHODS Here we apply a longitudinal and high-resolution imaging approach to investigate the dynamics of the pancreatic islet engraftment process up to 11 months after transplantation. Human and mouse islet grafts were inserted into the anterior chamber of the mouse eye, using a NOD.ROSA-tomato.Rag2-/- or B6.ROSA-tomato host allowing the investigation of the expansion of host vs donor cells and the contribution of host cells to aspects such as promoting the encapsulation and vascularisation of the graft. RESULTS A fibroblast-like stromal cell population of host origin rapidly migrates to ensheath the transplanted islet and aid in the formation of a basement membrane-like structure. Moreover, we show that the vessel network, while reconstituted by host endothelial cells, still retains the overall architecture of the donor islets. CONCLUSIONS/INTERPRETATION In this transplantation situation the fibroblast-like stromal cells appear to take over as main producers of ECM or act as a scaffold for other ECM-producing cells to reconstitute a peri-islet-like basement membrane. This may have implications for our understanding of long-term graft rejection and for the design of novel strategies to interfere with this process.
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Affiliation(s)
- Julia Nilsson
- Department of Experimental Medical Science, Lund University, 221 84, Lund, Sweden
- Lund University Diabetes Centre, Malmö, Sweden
| | - Rabiah Fardoos
- Department of Experimental Medical Science, Lund University, 221 84, Lund, Sweden
| | - Lisbeth Hansen
- Department of Experimental Medical Science, Lund University, 221 84, Lund, Sweden
| | - Håkan Lövkvist
- Department of Clinical Sciences, Lund, Neurology, Lund University, Lund, Sweden
- Clinical Studies Sweden - Forum South, Unit for Medical Statistics and Epidemiology, Skåne University Hospital, Lund, Sweden
| | - Kristian Pietras
- Division of Translational Cancer Research, Department of Laboratory Medicine, BioCARE, Lund University, Lund, Sweden
| | - Dan Holmberg
- Department of Experimental Medical Science, Lund University, 221 84, Lund, Sweden
- Lund University Diabetes Centre, Malmö, Sweden
| | - Anja Schmidt-Christensen
- Department of Experimental Medical Science, Lund University, 221 84, Lund, Sweden.
- Lund University Diabetes Centre, Malmö, Sweden.
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Yap L, Tay HG, Nguyen MT, Tjin MS, Tryggvason K. Laminins in Cellular Differentiation. Trends Cell Biol 2019; 29:987-1000. [DOI: 10.1016/j.tcb.2019.10.001] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 10/01/2019] [Accepted: 10/04/2019] [Indexed: 12/21/2022]
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Lammert E, Thorn P. The Role of the Islet Niche on Beta Cell Structure and Function. J Mol Biol 2019; 432:1407-1418. [PMID: 31711959 DOI: 10.1016/j.jmb.2019.10.032] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 10/25/2019] [Accepted: 10/29/2019] [Indexed: 01/15/2023]
Abstract
The islets of Langerhans or pancreatic islets are pivotal in the control of blood glucose and are complex microorgans embedded within the larger volume of the exocrine pancreas. Humans can have ~3.2 million islets [1] which, to our current knowledge, function in a similar manner to sense circulating blood glucose levels and respond with the secretion of a mix of different hormones that act to maintain glucose concentrations around a specific set point [2]. At a cellular level, the control of hormone secretion by glucose and other secretagogues is well-understood [3]. The key signal cascades have been identified and many details of the secretory process are known. However, if we shift focus from single cells and consider cells within intact islets, we do not have a comprehensive model as to how the islet environment influences cell function and how the islets work as a whole. This is important because there is overwhelming evidence that the structure and function of the individual endocrine cells are dramatically affected by the islet environment [4,5]. Uncovering the influence of this islet niche might drive future progress in treatments for Type 2 diabetes [6] and cell replacement therapies for Type 1 diabetes [7]. In this review, we focus on the insulin secreting beta cells and their interactions with the immediate environment that surrounds them including endocrine-endocrine interactions and contacts with capillaries.
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Affiliation(s)
- Eckhard Lammert
- Institute of Metabolic Physiology, Heinrich Heine University, Düsseldorf, Germany; Institute for Vascular and Islet Cell Biology, German Diabetes Center, Leibniz Center for Diabetes Research, Heinrich Heine University, Düsseldorf, Germany; German Center for Diabetes Research (DZD e.V.), Neuherberg, Germany
| | - Peter Thorn
- Charles Perkins Centre, School of Medical Sciences, University of Sydney, Camperdown, NSW 2006, Australia.
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Chen Y, Nguyen DT, Kokil GR, Wong YX, Dang TT. Microencapsulated islet-like microtissues with toroid geometry for enhanced cellular viability. Acta Biomater 2019; 97:260-271. [PMID: 31404714 DOI: 10.1016/j.actbio.2019.08.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 08/08/2019] [Accepted: 08/08/2019] [Indexed: 12/27/2022]
Abstract
Transplantation of immuno-isolated islets is a promising strategy to restore insulin-secreting function in patients with Type 1 diabetes. However, the clinical translation of this treatment approach remains elusive due to the loss of islet viability resulting from hypoxia at the avascular transplantation site. To address this challenge, we designed non-spherical islet-like microtissues and investigated the effect of their geometries on cellular viability. Insulin-secreting microtissues with different shapes were fabricated by assembly of monodispersed rat insulinoma beta cells on micromolded nonadhesive hydrogels. Our study quantitatively demonstrated that toroid microtissues exhibited enhanced cellular viability and metabolic activity compared to rod and spheroid microtissues with the same volume. At a similar level of cellular viability, toroid geometry facilitated efficient packing of more cells into each microtissue than rod and spheroid geometries. In addition, toroid microtissues maintained the characteristic glucose-responsive insulin secretion of rat insulinoma beta cells. Furthermore, toroid microtissues preserved their geometry and structural integrity following their microencapsulation in immuno-isolatory alginate hydrogel. Our study suggests that adopting toroid geometry in designing therapeutic microtissues potentially reduces mass loss of cellular grafts and thereby may improve the performance of transplanted islets towards a clinically viable cure for Type 1 diabetes. STATEMENT OF SIGNIFICANCE: Transplantation of therapeutic cells is a promising strategy for the treatment of a wide range of hormone or protein-deficiency diseases. However, the clinical application of this approach is hindered by the loss of cell viability and function at the avascular transplantation site. To address this challenge, we fabricated hydrogel-encapsulated islet-like microtissues with non-spheroidal geometry and optimal surface-to-volume ratio. This study demonstrated that the viability of therapeutic cells can be significantly increased solely by redesigning the microtissue configuration without requiring any additional biochemical or operational accessories. This study suggests that the adoption of toroid geometry provides a possible avenue to improve the long-term survival of transplanted therapeutic cells and expedite the translation of cell-based therapy towards clinical application.
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Affiliation(s)
- Yang Chen
- School of Chemical and Biomedical Engineering, Nanyang Technological University, Singapore 637459, Singapore
| | - Dang T Nguyen
- School of Chemical and Biomedical Engineering, Nanyang Technological University, Singapore 637459, Singapore
| | - Ganesh R Kokil
- School of Chemical and Biomedical Engineering, Nanyang Technological University, Singapore 637459, Singapore
| | - Yun Xuan Wong
- School of Chemical and Biomedical Engineering, Nanyang Technological University, Singapore 637459, Singapore
| | - Tram T Dang
- School of Chemical and Biomedical Engineering, Nanyang Technological University, Singapore 637459, Singapore.
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14
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Delsing L, Kallur T, Zetterberg H, Hicks R, Synnergren J. Enhanced xeno-free differentiation of hiPSC-derived astroglia applied in a blood-brain barrier model. Fluids Barriers CNS 2019; 16:27. [PMID: 31462266 PMCID: PMC6714544 DOI: 10.1186/s12987-019-0147-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Accepted: 07/30/2019] [Indexed: 12/20/2022] Open
Abstract
Background Human induced pluripotent stem cells (hiPSC) hold great promise for use in cell therapy applications and for improved in vitro models of human disease. So far, most hiPSC differentiation protocols to astroglia use undefined, animal-containing culture matrices. Laminins, which play an essential role in the regulation of cell behavior, offer a source of defined, animal-free culture matrix. Methods In order to understand how laminins affect astroglia differentiation, recombinant human laminin-521 (LN521), was compared to a murine Engelbreth-Holm-Swarm sarcoma derived laminin (L2020). Astroglia expression of protein and mRNA together with glutamate uptake and protein secretion function, were evaluated. Finally, these astroglia were evaluated in a coculture model of the blood–brain barrier (BBB). Results Astroglia of good quality were generated from hiPSC on both LN521 and L2020. However, astroglia differentiated on human LN521 showed higher expression of several astroglia specific mRNAs and proteins such as GFAP, S100B, Angiopoietin-1, and EAAT1, compared to astroglia differentiated on murine L2020. In addition, glutamate uptake and ability to induce expression of junction proteins in endothelial cells were affected by the culture matrix for differentiation. Conclusion Our results suggest that astroglia differentiated on LN521 display an improved phenotype and are suitable for coculture in a hiPSC-derived BBB model. This provides a starting point for a more defined and robust derivation of astroglia for use in BBB coculture models. Electronic supplementary material The online version of this article (10.1186/s12987-019-0147-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Louise Delsing
- Department of Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Göteborg, Sweden. .,Systems Biology Research Center, School of Bioscience, University of Skövde, Högskolevägen, Box 408, 541 28, Skövde, Sweden. .,Discovery Biology, Discovery Sciences, R&D, AstraZeneca, Mölndal, Sweden.
| | | | - Henrik Zetterberg
- Department of Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Göteborg, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK.,UK Dementia Research Institute at UCL, London, UK
| | - Ryan Hicks
- Discovery Biology, Discovery Sciences, R&D, AstraZeneca, Mölndal, Sweden
| | - Jane Synnergren
- Systems Biology Research Center, School of Bioscience, University of Skövde, Högskolevägen, Box 408, 541 28, Skövde, Sweden
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Townsend SE, Gannon M. Extracellular Matrix-Associated Factors Play Critical Roles in Regulating Pancreatic β-Cell Proliferation and Survival. Endocrinology 2019; 160:1885-1894. [PMID: 31271410 PMCID: PMC6656423 DOI: 10.1210/en.2019-00206] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 06/27/2019] [Indexed: 12/27/2022]
Abstract
This review describes formation of the islet basement membrane and the function of extracellular matrix (ECM) components in β-cell proliferation and survival. Implications for islet transplantation are discussed. The insulin-producing β-cell is key for maintaining glucose homeostasis. The islet microenvironment greatly influences β-cell survival and proliferation. Within the islet, β-cells contact the ECM, which is deposited primarily by intraislet endothelial cells, and this interaction has been shown to modulate proliferation and survival. ECM-localized growth factors, such as vascular endothelial growth factor and cellular communication network 2, signal through specific receptors and integrins on the β-cell surface. Further understanding of how the ECM functions to influence β-cell proliferation and survival will provide targets for enhancing functional β-cell mass for the treatment of diabetes.
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Affiliation(s)
- Shannon E Townsend
- Department of Molecular Physiology and Biophysics, Vanderbilt University, Nashville, Tennessee
| | - Maureen Gannon
- Department of Molecular Physiology and Biophysics, Vanderbilt University, Nashville, Tennessee
- Department of Veterans Affairs, Tennessee Valley Health Authority, Nashville, Tennessee
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Cell and Developmental Biology, Vanderbilt University, Nashville, Tennessee
- Correspondence: Maureen Gannon, PhD, Vanderbilt University Medical Center, 2213 Garland Avenue, MRB IV 7465, Nashville, Tennessee 37232. E-mail:
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Zbinden A, Marzi J, Schlünder K, Probst C, Urbanczyk M, Black S, Brauchle EM, Layland SL, Kraushaar U, Duffy G, Schenke-Layland K, Loskill P. Non-invasive marker-independent high content analysis of a microphysiological human pancreas-on-a-chip model. Matrix Biol 2019; 85-86:205-220. [PMID: 31238092 DOI: 10.1016/j.matbio.2019.06.008] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 06/20/2019] [Accepted: 06/20/2019] [Indexed: 12/15/2022]
Abstract
The increasing prevalence of diabetes, its heterogeneity, and the limited number of treatment options drive the need for physiologically relevant assay platforms with human genetic background that have the potential to improve mechanistic understanding and e\xpedite diabetes-related research and treatment. In this study, we developed an endocrine pancreas-on-a-chip model based on a tailored microfluidic platform, which enables self-guided trapping of single human pseudo-islets. Continuous, low-shear perfusion provides a physiologically relevant microenvironment especially important for modeling and monitoring of the endocrine function as well as sufficient supply with nutrients and oxygen. Human pseudo-islets, generated from the conditionally immortalized EndoC-βH3 cell line, were successfully injected by hydrostatic pressure-driven flow without altered viability. To track insulin secretion kinetics in response to glucose stimulation in a time-resolved manner, dynamic sampling of the supernatant as well as non-invasive real-time monitoring using Raman microspectroscopy was established on-chip. Dynamic sampling indicated a biphasic glucose-stimulated insulin response. Raman microspectroscopy allowed to trace glucose responsiveness in situ and to visualize different molecular structures such as lipids, mitochondria and nuclei. In-depth spectral analyses demonstrated a glucose stimulation-dependent, increased mitochondrial activity, and a switch in lipid composition of insulin secreting vesicles, supporting the high performance of our pancreas-on-a-chip model.
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Affiliation(s)
- Aline Zbinden
- Dept. of Women's Health, Research Institute of Women's Health, Eberhard Karls University Tübingen, Germany
| | - Julia Marzi
- Dept. of Women's Health, Research Institute of Women's Health, Eberhard Karls University Tübingen, Germany; The Natural and Medical Sciences Institute (NMI) at the University of Tübingen, Reutlingen, Germany
| | - Katharina Schlünder
- Fraunhofer Institute for Interfacial Engineering and Biotechnology (IGB), Stuttgart, Germany
| | - Christopher Probst
- Fraunhofer Institute for Interfacial Engineering and Biotechnology (IGB), Stuttgart, Germany
| | - Max Urbanczyk
- Dept. of Women's Health, Research Institute of Women's Health, Eberhard Karls University Tübingen, Germany
| | - Scott Black
- The Natural and Medical Sciences Institute (NMI) at the University of Tübingen, Reutlingen, Germany
| | - Eva M Brauchle
- Dept. of Women's Health, Research Institute of Women's Health, Eberhard Karls University Tübingen, Germany; The Natural and Medical Sciences Institute (NMI) at the University of Tübingen, Reutlingen, Germany
| | - Shannon L Layland
- Dept. of Women's Health, Research Institute of Women's Health, Eberhard Karls University Tübingen, Germany
| | - Udo Kraushaar
- The Natural and Medical Sciences Institute (NMI) at the University of Tübingen, Reutlingen, Germany
| | - Garry Duffy
- Discipline of Anatomy and the Regenerative Medicine Institute, School of Medicine, College of Medicine Nursing and Health Sciences, National University of Ireland Galway, Ireland; Science Foundation Ireland (SFI), Centre for Research in Advanced Materials for Biomedical Engineering (AMBER), Trinity College Dublin, National University of Ireland Galway, Galway, Ireland
| | - Katja Schenke-Layland
- Dept. of Women's Health, Research Institute of Women's Health, Eberhard Karls University Tübingen, Germany; The Natural and Medical Sciences Institute (NMI) at the University of Tübingen, Reutlingen, Germany; Dept. of Medicine/Cardiology, University of California Los Angeles (UCLA), Los Angeles, CA, USA.
| | - Peter Loskill
- Dept. of Women's Health, Research Institute of Women's Health, Eberhard Karls University Tübingen, Germany; Fraunhofer Institute for Interfacial Engineering and Biotechnology (IGB), Stuttgart, Germany.
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Xu L, Guo Y, Huang Y, Xu Y, Lu Y, Wang Z. Hydrogel materials for the application of islet transplantation. J Biomater Appl 2019; 33:1252-1264. [PMID: 30791850 DOI: 10.1177/0885328219831391] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Type 1 diabetes mellitus is a serious disease comprising approximately 10% of all diabetes cases, and the global incidence of type 1 diabetes mellitus is steadily rising without any promise of a cure in the near future. Although islet transplantation has proven to be an effective means of treating type 1 diabetes mellitus and promoting insulin independence in patients, its widespread implementation has been severely constrained by instances of post-transplantation islet cell death, rejection, and severe adverse immune responses. Islet encapsulation is an active area of research aimed at shielding implanted islets from immunological rejection and inflammation while still allowing for effective insulin and nutrient exchange with donor cells. Given their promising physical and chemical properties, hydrogels have been a major subject of focus in the field of islet transplantation and encapsulation technology, offering promising advances towards immunologically privileged islet implants. The present review therefore summarizes the current state of research regarding the use of hydrogels in the context of islet transplantation, including both natural molecular hydrogels and artificial polymer hydrogels, with the goal of understanding the current strengths and weaknesses of this treatment strategy.
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Affiliation(s)
- Liancheng Xu
- Suqian First Hospital, Suqian, Jiangsu, China
- Department of General Surgery, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China
| | - Yibing Guo
- Research center of clinical medicine, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China
| | - Yan Huang
- Department of General Surgery, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China
- Research center of clinical medicine, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China
| | - Yang Xu
- Research center of clinical medicine, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China
| | - Yuhua Lu
- Department of General Surgery, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China
- Research center of clinical medicine, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China
| | - Zhiwei Wang
- Department of General Surgery, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China
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