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Fakharian F, Sadeghi A, Pouresmaeili F, Soleimani N, Yadegar A. Anti-inflammatory effects of extracellular vesicles and cell-free supernatant derived from Lactobacillus crispatus strain RIGLD-1 on Helicobacter pylori-induced inflammatory response in gastric epithelial cells in vitro. Folia Microbiol (Praha) 2024:10.1007/s12223-024-01138-3. [PMID: 38308067 DOI: 10.1007/s12223-024-01138-3] [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: 07/23/2023] [Accepted: 01/15/2024] [Indexed: 02/04/2024]
Abstract
Helicobacter pylori infection is the major risk factor associated with the development of gastric cancer. Currently, administration of standard antibiotic therapy combined with probiotics and postbiotics has gained significant attention in the management of H. pylori infection. In this work, the immunomodulatory effects of Lactobacillus crispatus-derived extracellular vesicles (EVs) and cell-free supernatant (CFS) were investigated on H. pylori-induced inflammatory response in human gastric adenocarcinoma (AGS) cells. L. crispatus-derived EVs were isolated by ultracentrifugation and physically characterized by dynamic light scattering (DLS), transmission electron microscopy (TEM), and scanning electron microscopy (SEM). Furthermore, the protein content of L. crispatus-derived EVs was also evaluated by SDS-PAGE. Cell viability of AGS cells exposed to varying concentrations of EVs and CFS was assessed by MTT assay. The mRNA expression of IL-1β, IL-6, IL-8, TNF-α, IL-10, and TGF-ß genes was determined by RT-qPCR. ELISA was used for the measurement of IL-8 production in AGS cells. In addition, EVs (50 μg/mL) and CFS modulated the H. pylori-induced inflammation by downregulating the mRNA expression of IL-1β, IL-6, IL-8, and TNF-α, and upregulating the expression of IL-10, and TGF-ß genes in AGS cells. Furthermore, H. pylori-induced IL-8 production was dramatically decreased after treatment with L. crispatus-derived EVs and CFS. In conclusion, our observation suggests for the first time that EVs released by L. crispatus strain RIGLD-1 and its CFS could be recommended as potential therapeutic agents against H. pylori-triggered inflammation.
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Affiliation(s)
- Farzaneh Fakharian
- Department of Microbiology, Faculty of Biological Sciences and Technology, Shahid Beheshti University, Tehran, Iran
| | - Amir Sadeghi
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farkhondeh Pouresmaeili
- Department of Medical Genetics, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Neda Soleimani
- Department of Microbiology, Faculty of Biological Sciences and Technology, Shahid Beheshti University, Tehran, Iran
| | - Abbas Yadegar
- Foodborne and Waterborne Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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YAMASAKI-YASHIKI S, SAKAMOTO Y, NISHIMURA K, SAIKA A, ITO T, KUNISAWA J, KATAKURA Y. High productivity of immunostimulatory membrane vesicles of Limosilactobacillus antri using glycine. BIOSCIENCE OF MICROBIOTA, FOOD AND HEALTH 2023; 43:55-63. [PMID: 38188665 PMCID: PMC10767322 DOI: 10.12938/bmfh.2023-029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 08/27/2023] [Indexed: 01/09/2024]
Abstract
Nanosized membrane vesicles (MVs) released by bacteria play important roles in both bacteria-bacteria and bacteria-host interactions. Some gram-positive lactic acid bacteria produce MVs exhibiting immunoregulatory activity in the host. We found that both bacterial cells and MVs of Limosilactobacillus antri JCM 15950, isolated from the human stomach mucosa, enhance immunoglobulin A production by murine Peyer's patch cells. However, the thick cell walls of gram-positive bacteria resulted in low MV production, limiting experiments and applications using MVs. In this study, we evaluated the effects of glycine, which inhibits cell wall synthesis, on the immunostimulatory MV productivity of L. antri. Glycine inhibited bacterial growth while increasing MV production, with 20 g/L glycine increasing MV production approximately 12-fold. Glycine was most effective at increasing MV production when added in the early exponential phase, which indicated that cell division in the presence of glycine increased MV production. Finally, glycine increased MV productivity approximately 16-fold. Furthermore, glycine-induced MVs promoted interleukin-6 production by macrophage-like J774.1 cells, and the immunostimulatory activity was comparable to that of spontaneously produced MVs. Our results indicate that glycine is an effective agent for improving the production of MVs with immunostimulatory activity in gram-positive lactic acid bacteria, which can be applied as mucosal adjuvants and functional foods.
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Affiliation(s)
- Shino YAMASAKI-YASHIKI
- Department of Life Science and Biotechnology, Faculty of
Chemistry, Materials and Bioengineering, Kansai University, 3-3-35 Yamate-cho, Suita-shi,
Osaka 564-8680, Japan
- Laboratory of Vaccine Materials and Laboratory of Gut
Environmental System, Microbial Research Center for Health and Medicine, National
Institutes of Biomedical Innovation, Health and Nutrition (NIBIOHN), 7-6-8 Saito-Asagi,
Ibaraki-shi, Osaka 567-0085, Japan
| | - Yu SAKAMOTO
- Department of Life Science and Biotechnology, Faculty of
Chemistry, Materials and Bioengineering, Kansai University, 3-3-35 Yamate-cho, Suita-shi,
Osaka 564-8680, Japan
| | - Keiko NISHIMURA
- Department of Life Science and Biotechnology, Faculty of
Chemistry, Materials and Bioengineering, Kansai University, 3-3-35 Yamate-cho, Suita-shi,
Osaka 564-8680, Japan
| | - Azusa SAIKA
- Laboratory of Vaccine Materials and Laboratory of Gut
Environmental System, Microbial Research Center for Health and Medicine, National
Institutes of Biomedical Innovation, Health and Nutrition (NIBIOHN), 7-6-8 Saito-Asagi,
Ibaraki-shi, Osaka 567-0085, Japan
| | - Takeshi ITO
- Department of Mechanical Engineering, Faculty of Engineering
Science, Kansai University, 3-3-35 Yamate-cho, Suita-shi, Osaka 564-8680, Japan
| | - Jun KUNISAWA
- Laboratory of Vaccine Materials and Laboratory of Gut
Environmental System, Microbial Research Center for Health and Medicine, National
Institutes of Biomedical Innovation, Health and Nutrition (NIBIOHN), 7-6-8 Saito-Asagi,
Ibaraki-shi, Osaka 567-0085, Japan
| | - Yoshio KATAKURA
- Department of Life Science and Biotechnology, Faculty of
Chemistry, Materials and Bioengineering, Kansai University, 3-3-35 Yamate-cho, Suita-shi,
Osaka 564-8680, Japan
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Kurata A, Takeuchi S, Fujiwara R, Tamura K, Imai T, Yamasaki-Yashiki S, Onuma H, Fukuta Y, Shirasaka N, Uegaki K. Activation of the toll-like receptor 2 signaling pathway by GAPDH from bacterial strain RD055328. Biosci Biotechnol Biochem 2023; 87:907-915. [PMID: 37169920 DOI: 10.1093/bbb/zbad059] [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: 11/07/2022] [Accepted: 05/02/2023] [Indexed: 05/13/2023]
Abstract
We characterized the membrane vesicle fraction (RD-MV fraction) from bacterial strain RD055328, which is related to members of the genus Companilactobacillus and Lactiplantibacillus plantarum. RD-MVs and glyceraldehyde 3-phosphate dehydrogenase (GAPDH) were detected in the RD-MV fraction. Immunoglobulin A (IgA) was produced by Peyer's patch cells following the addition of the RD-MV fraction. In the presence of the RD-MV fraction, RAW264 cells produced the pro-inflammatory cytokine IL-6. Recombinant GAPDH probably induced the production of IL-6 by RAW264 cells via superficial toll-like receptor 2 (TLR2) recognition. A confocal laser scanning microscopy image analysis indicated that RD-MVs and GAPDH were taken up by RAW264 cells. GAPDH wrapped around RAW264 cells. We suggest that GAPDH from strain RD055328 enhanced the production of IgA by acquired immune cells via the production of IL-6 by innate immune cells through TLR2 signal transduction.
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Affiliation(s)
- Atsushi Kurata
- Department of Applied Biological Chemistry, Faculty of Agriculture, Kindai University, Nakamachi, Nara, Japan
| | - Shimpei Takeuchi
- Department of Applied Biological Chemistry, Faculty of Agriculture, Kindai University, Nakamachi, Nara, Japan
| | - Ryo Fujiwara
- Department of Applied Biological Chemistry, Faculty of Agriculture, Kindai University, Nakamachi, Nara, Japan
| | - Kento Tamura
- Department of Applied Biological Chemistry, Faculty of Agriculture, Kindai University, Nakamachi, Nara, Japan
| | - Tomoya Imai
- Research Institute for Sustainable Humanosphere, Kyoto University, Uji, Kyoto, Japan
| | - Shino Yamasaki-Yashiki
- Department of Life Science and Biotechnology, Faculty of Chemistry, Materials and Bioengineering, Kansai University, Suita, Osaka, Japan
| | - Hiroki Onuma
- Department of Applied Biological Chemistry, Faculty of Agriculture, Kindai University, Nakamachi, Nara, Japan
| | - Yasuhisa Fukuta
- Department of Applied Biological Chemistry, Faculty of Agriculture, Kindai University, Nakamachi, Nara, Japan
| | - Norifumi Shirasaka
- Department of Applied Biological Chemistry, Faculty of Agriculture, Kindai University, Nakamachi, Nara, Japan
| | - Koichi Uegaki
- Department of Applied Biological Chemistry, Faculty of Agriculture, Kindai University, Nakamachi, Nara, Japan
- Agricultural Technology and Innovation Research Institute, Kindai University, Nakamachi, Nara, Japan
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Taitz JJ, Tan JK, Potier-Villette C, Ni D, King NJ, Nanan R, Macia L. Diet, commensal microbiota-derived extracellular vesicles, and host immunity. Eur J Immunol 2023; 53:e2250163. [PMID: 37137164 DOI: 10.1002/eji.202250163] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 04/04/2023] [Accepted: 05/02/2023] [Indexed: 05/05/2023]
Abstract
The gut microbiota has co-evolved with its host, and commensal bacteria can influence both the host's immune development and function. Recently, a role has emerged for bacterial extracellular vesicles (BEVs) as potent immune modulators. BEVs are nanosized membrane vesicles produced by all bacteria, possessing the membrane characteristics of the originating bacterium and carrying an internal cargo that may include nucleic acid, proteins, lipids, and metabolites. Thus, BEVs possess multiple avenues for regulating immune processes, and have been implicated in allergic, autoimmune, and metabolic diseases. BEVs are biodistributed locally in the gut, and also systemically, and thus have the potential to affect both the local and systemic immune responses. The production of gut microbiota-derived BEVs is regulated by host factors such as diet and antibiotic usage. Specifically, all aspects of nutrition, including macronutrients (protein, carbohydrates, and fat), micronutrients (vitamins and minerals), and food additives (the antimicrobial sodium benzoate), can regulate BEV production. This review summarizes current knowledge of the powerful links between nutrition, antibiotics, gut microbiota-derived BEV, and their effects on immunity and disease development. It highlights the potential of targeting or utilizing gut microbiota-derived BEV as a therapeutic intervention.
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Affiliation(s)
- Jemma J Taitz
- Charles Perkins Centre, University of Sydney, Sydney, NSW, Australia
- School of Medical Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Jian K Tan
- Charles Perkins Centre, University of Sydney, Sydney, NSW, Australia
- School of Medical Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Camille Potier-Villette
- Charles Perkins Centre, University of Sydney, Sydney, NSW, Australia
- School of Medical Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Duan Ni
- Charles Perkins Centre, University of Sydney, Sydney, NSW, Australia
- School of Medical Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Nicholas Jc King
- Charles Perkins Centre, University of Sydney, Sydney, NSW, Australia
- School of Medical Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Ralph Nanan
- Charles Perkins Centre, University of Sydney, Sydney, NSW, Australia
- Nepean Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Laurence Macia
- Charles Perkins Centre, University of Sydney, Sydney, NSW, Australia
- School of Medical Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Sydney Cytometry, University of Sydney and Centenary Institute, Sydney, NSW, Australia
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Krzyżek P, Marinacci B, Vitale I, Grande R. Extracellular Vesicles of Probiotics: Shedding Light on the Biological Activity and Future Applications. Pharmaceutics 2023; 15:522. [PMID: 36839844 PMCID: PMC9967243 DOI: 10.3390/pharmaceutics15020522] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/20/2023] [Accepted: 02/01/2023] [Indexed: 02/08/2023] Open
Abstract
For many decades, the proper functioning of the human body has become a leading scientific topic. In the course of numerous experiments, a striking impact of probiotics on the human body has been documented, including maintaining the physiological balance of endogenous microorganisms, regulating the functioning of the immune system, enhancing the digestive properties of the host, and preventing or alleviating the course of many diseases. Recent research, especially from the last decade, shows that this health-benefiting activity of probiotics is largely conditioned by the production of extracellular vesicles. Although the importance of extracellular vesicles in the virulence of many live-threatening pathogens is widely described in the literature, much less is known with respect to the health-promoting effect of extracellular vesicles secreted by non-pathogenic microorganisms, including probiotics. Based on this, in the current review article, we decided to collect the latest literature data on the health-inducing properties of extracellular vesicles secreted by probiotics. The characteristics of probiotics' extracellular vesicles will be extended by the description of their physicochemical properties and the proteome in connection with the biological activities exhibited by these structures.
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Affiliation(s)
- Paweł Krzyżek
- Department of Microbiology, Faculty of Medicine, Wroclaw Medical University, 50-368 Wroclaw, Poland
| | - Beatrice Marinacci
- Department of Pharmacy, University “G. d’Annunzio” of Chieti-Pescara, Via dei Vestini, 31, 66100 Chieti, Italy
- Department of Innovative Technologies in Medicine & Dentistry, University “Gabriele d’Annunzio”, Chieti-Pescara, 66100 Chieti, Italy
| | - Irene Vitale
- Department of Pharmacy, University “G. d’Annunzio” of Chieti-Pescara, Via dei Vestini, 31, 66100 Chieti, Italy
| | - Rossella Grande
- Department of Pharmacy, University “G. d’Annunzio” of Chieti-Pescara, Via dei Vestini, 31, 66100 Chieti, Italy
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Kurata A, Yamasaki-Yashiki S, Imai T, Miyazaki A, Watanabe K, Uegaki K. Enhancement of IgA production by membrane vesicles derived from Bifidobacterium longum subsp. infantis. Biosci Biotechnol Biochem 2022; 87:119-128. [PMID: 36331264 DOI: 10.1093/bbb/zbac172] [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: 08/29/2022] [Accepted: 10/28/2022] [Indexed: 11/06/2022]
Abstract
Immunoglobulin A (IgA) is involved in the maintenance of gut homeostasis. Although the oral administration of bifidobacteria increases the amount of fecal IgA, the effects of bifidobacteria on intestinal immunity remain unclear. We found and characterized membrane vesicles (MVs) derived from Bifidobacterium longum subsp. infantis toward host immune cells. Bifidobacterium infantis MVs consisted of a cytoplasmic membrane, and extracellular solute-binding protein (ESBP) was specifically detected. In the presence of B. infantis MVs or recombinant ESBP, RAW264 cells produced the pro-inflammatory cytokine IL-6. IgA was produced by Peyer's patches cells following the addition of B. infantis MVs. Therefore, ESBP of B. infantis MVs is involved in the production of IgA by acquired immune cells via the production of IL-6 by innate immune cells.
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Affiliation(s)
- Atsushi Kurata
- Department of Applied Biological Chemistry, Faculty of Agriculture, Kindai University, 204-3327 Nakamachi, Nara, Japan
| | - Shino Yamasaki-Yashiki
- Department of Life Science and Biotechnology, Faculty of Chemistry, Materials and Bioengineering, Kansai University, 3-3-35 Yamate-cho, Suita, Osaka, Japan
| | - Tomoya Imai
- Research Institute for Sustainable Humanosphere, Kyoto University, Uji, Kyoto, Japan
| | - Ayano Miyazaki
- Department of Applied Biological Chemistry, Faculty of Agriculture, Kindai University, 204-3327 Nakamachi, Nara, Japan
| | - Keito Watanabe
- Department of Applied Biological Chemistry, Faculty of Agriculture, Kindai University, 204-3327 Nakamachi, Nara, Japan
| | - Koichi Uegaki
- Department of Applied Biological Chemistry, Faculty of Agriculture, Kindai University, 204-3327 Nakamachi, Nara, Japan.,Agricultural Technology and Innovation Research Institute, Kindai University, 204-3327 Nakamachi, Nara, Japan
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Novel Horizons in Postbiotics: Lactobacillaceae Extracellular Vesicles and Their Applications in Health and Disease. Nutrients 2022; 14:nu14245296. [PMID: 36558455 PMCID: PMC9782203 DOI: 10.3390/nu14245296] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 12/07/2022] [Accepted: 12/09/2022] [Indexed: 12/14/2022] Open
Abstract
Lactobacillus probiotics contained in dietary supplements or functional foods are well-known for their beneficial properties exerted on host health and diverse pathological situations. Their capacity to improve inflammatory bowel disease (IBD) and regulate the immune system is especially remarkable. Although bacteria-host interactions have been thought to occur directly, the key role that extracellular vesicles (EVs) derived from probiotics play on this point is being unveiled. EVs are lipid bilayer-enclosed particles that carry a wide range of cargo compounds and act in different signalling pathways. Notably, these EVs have been recently proposed as a safe alternative to the utilisation of live bacteria since they can avoid the possible risks that probiotics may entail in vulnerable cases such as immunocompromised patients. Therefore, this review aims to give an updated overview of the existing knowledge about EVs from different Lactobacillus strains, their mechanisms and effects in host health and different pathological conditions. All of the information collected suggests that EVs could be considered as potential tools for the development of future novel therapeutic approaches.
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Characterization of extracellular vesicles from Lactiplantibacillus plantarum. Sci Rep 2022; 12:13330. [PMID: 35941134 PMCID: PMC9360025 DOI: 10.1038/s41598-022-17629-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 07/28/2022] [Indexed: 11/08/2022] Open
Abstract
We investigated the characteristics and functionalities of extracellular vesicles (EVs) from Lactiplantibacillus plantarum (previously Lactobacillus plantarum) towards host immune cells. L. plantarum produces EVs that have a cytoplasmic membrane and contain cytoplasmic metabolites, membrane and cytoplasmic proteins, and small RNAs, but not bacterial cell wall components, namely, lipoteichoic acid and peptidoglycan. In the presence of L. plantarum EVs, Raw264 cells inducibly produced the pro-inflammatory cytokines IL-1β and IL-6, the anti-inflammatory cytokine IL-10, and IF-γ and IL-12, which are involved in the differentiation of naive T-helper cells into T-helper type 1 cells. IgA was produced by PP cells following the addition of EVs. Therefore, L. plantarum EVs activated innate and acquired immune responses. L. plantarum EVs are recognized by Toll-like receptor 2 (TLR2), which activates NF-κB, but not by other TLRs or NOD-like receptors. N-acylated peptides from lipoprotein19180 (Lp19180) in L. plantarum EVs were identified as novel TLR2 ligands. Therefore, L. plantarum induces an immunostimulation though the TLR2 recognition of the N-acylated amino acid moiety of Lp19180 in EVs. Additionally, we detected a large amount of EVs in the rat gastrointestinal tract for the first time, suggesting that EVs released by probiotics function as a modulator of intestinal immunity.
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Yang J, Shin TS, Kim JS, Jee YK, Kim YK. A new horizon of precision medicine: combination of the microbiome and extracellular vesicles. Exp Mol Med 2022; 54:466-482. [PMID: 35459887 PMCID: PMC9028892 DOI: 10.1038/s12276-022-00748-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 12/09/2021] [Accepted: 12/23/2021] [Indexed: 11/10/2022] Open
Abstract
Over several decades, the disease pattern of intractable disease has changed from acute infection to chronic disease accompanied by immune and metabolic dysfunction. In addition, scientific evidence has shown that humans are holobionts; of the DNA in humans, 1% is derived from the human genome, and 99% is derived from microbial genomes (the microbiome). Extracellular vesicles (EVs) are lipid bilayer-delimited nanoparticles and key messengers in cell-to-cell communication. Many publications indicate that microbial EVs are both positively and negatively involved in the pathogenesis of various intractable diseases, including inflammatory diseases, metabolic disorders, and cancers. Microbial EVs in feces, blood, and urine show significant differences in their profiles between patients with a particular disease and healthy subjects, demonstrating the potential of microbial EVs as biomarkers for disease diagnosis, especially for assessing disease risk. Furthermore, microbial EV therapy offers a variety of advantages over live biotherapeutics and human cell EV (or exosome) therapy for the treatment of intractable diseases. In summary, microbial EVs are a new tool in medicine, and microbial EV technology might provide us with innovative diagnostic and therapeutic solutions in precision medicine. The tiny membrane-bound vesicles containing various biomolecules that the organisms comprising our microbiome release could offer a powerful tool for precision medicine. Our bodies are home to trillions of microbes, which interact closely with our tissues to maintain a healthy physiological environment. Yoon-Keun Kim of the Institute of MD Healthcare, Seoul, South Korea, and colleagues have reviewed current research into the extracellular vesicles that these microbes use to communicate with other microbes and their human hosts. The authors note that these vesicles affect tissues throughout the body, and their activities have been linked to various disorders including asthma, Crohn’s disease and cancer. A deeper understanding of how these vesicles prevent or accelerate various conditions in different individuals could yield useful new diagnostic biomarkers and provide the foundation for interventions that are optimized for each patient.
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Affiliation(s)
- Jinho Yang
- Institute of MD Healthcare Inc., Seoul, Republic of Korea
| | - Tae-Seop Shin
- Institute of MD Healthcare Inc., Seoul, Republic of Korea
| | - Jong Seong Kim
- Institute of MD Healthcare Inc., Seoul, Republic of Korea
| | - Young-Koo Jee
- Department of Internal Medicine, Dankook University College of Medicine, Cheonan, Republic of Korea
| | - Yoon-Keun Kim
- Institute of MD Healthcare Inc., Seoul, Republic of Korea.
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