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Xia Q, Zhao Y, Dong H, Mao Q, Zhu L, Xia J, Weng Z, Liao W, Hu Z, Yi J, Feng S, Jiang Y, Xin Z. Progress in the study of molecular mechanisms of intervertebral disc degeneration. Biomed Pharmacother 2024; 174:116593. [PMID: 38626521 DOI: 10.1016/j.biopha.2024.116593] [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: 02/03/2024] [Revised: 04/01/2024] [Accepted: 04/10/2024] [Indexed: 04/18/2024] Open
Abstract
Degenerative intervertebral disc disease (IVDD) is one of the main spinal surgery, conditions, which markedly increases the incidence of low back pain and deteriorates the patient's quality of life, and it imposes significant social and economic burdens. The molecular pathology of IVDD is highly complex and multilateral however still not ompletely understood. New findings indicate that IVDD is closely associated with inflammation, oxidative stress, cell injury and extracellular matrix metabolismdysregulation. Symptomatic management is the main therapeutic approach adopted for IVDD, but it fails to address the basic pathological changes and the causes of the disease. However, research is still focusing on molecular aspects in terms of gene expression, growth factors and cell signaling pathways in an attempt to identify specific molecular targets for IVDD treatment. The paper summarizes the most recent achievements in molecularunderstanding of the pathogenesis of IVDD and gives evidence-based recommendations for clinical practice.
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Affiliation(s)
- Qiuqiu Xia
- Department of Orthopedic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi Guizhou 563000, China; First School of Clinical Medicine, Zun yi Medical University, Zunyi 563000, China
| | - Yan Zhao
- Department of Orthopedic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi Guizhou 563000, China; First School of Clinical Medicine, Zun yi Medical University, Zunyi 563000, China
| | - Huaize Dong
- Department of Orthopedic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi Guizhou 563000, China; First School of Clinical Medicine, Zun yi Medical University, Zunyi 563000, China
| | - Qiming Mao
- Department of Orthopedic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi Guizhou 563000, China; First School of Clinical Medicine, Zun yi Medical University, Zunyi 563000, China
| | - Lu Zhu
- Department of Orthopedic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi Guizhou 563000, China; First School of Clinical Medicine, Zun yi Medical University, Zunyi 563000, China
| | - Jiyue Xia
- Department of Orthopedic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi Guizhou 563000, China; First School of Clinical Medicine, Zun yi Medical University, Zunyi 563000, China
| | - Zijing Weng
- Department of Orthopedic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi Guizhou 563000, China; First School of Clinical Medicine, Zun yi Medical University, Zunyi 563000, China
| | - Wenbo Liao
- Department of Orthopedic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi Guizhou 563000, China
| | - Zongyue Hu
- Department of Pain Rehabilitation, Affiliated Sinopharm Gezhouba Central Hospital, Third Clinical Medical College of Three Gorges University, Yichang, Hubei Province 443003, China
| | - Jiangbi Yi
- Department of Orthopedic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi Guizhou 563000, China; First School of Clinical Medicine, Zun yi Medical University, Zunyi 563000, China
| | - Shuai Feng
- Department of Orthopedic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi Guizhou 563000, China; First School of Clinical Medicine, Zun yi Medical University, Zunyi 563000, China
| | - Youhong Jiang
- Department of Orthopedic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi Guizhou 563000, China; First School of Clinical Medicine, Zun yi Medical University, Zunyi 563000, China
| | - Zhijun Xin
- Department of Orthopedic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi Guizhou 563000, China; Institut Curie, PSL Research University, CNRS UMR3244, Dynamics of Genetic Information, Sorbonne Université, Paris 75005, France.
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Jiang C, Liu Y, Zhao W, Yang Y, Ren Z, Wang X, Hao D, Du H, Yin S. microRNA-365 attenuated intervertebral disc degeneration through modulating nucleus pulposus cell apoptosis and extracellular matrix degradation by targeting EFNA3. J Cell Mol Med 2024; 28:e18054. [PMID: 38009813 PMCID: PMC10826450 DOI: 10.1111/jcmm.18054] [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: 04/25/2023] [Revised: 10/30/2023] [Accepted: 11/14/2023] [Indexed: 11/29/2023] Open
Abstract
This present study is aimed to investigate the role of microRNA-365 (miR-365) in the development of intervertebral disc degeneration (IDD). Nucleus pulposus (NP) cells were transfected by miR-365 mimic and miR-365 inhibitor, respectively. Concomitantly, the transfection efficiency and the expression level of miRNA were detected by quantitative reverse transcription polymerase chain reaction (qRT-PCR). Meanwhile, NP cells apoptosis was measured through propidium iodide (PI)-AnnexinV-fluorescein isothiocyanate (FITC) apoptosis detection kit. Subsequently, immunofluorescence (IF) staining was performed to assess the expression of collagen II, aggrecan and matrix metalloproteinase 13 (MMP-13). In addition, bioinformatic prediction and Luciferase reporter assay were used to reveal the target gene of miR-365. Finally, we isolated the primary NP cells from rats and injected NP-miR-365 in rat IDD models. The results showed that overexpression of miR-365 could effectively inhibit NP cells apoptosis and MMP-13 expression and upregulate the expression of collagen II and aggrecan. Conversely, suppression of miR-365 enhanced NP cell apoptosis and elevated MMP-13 expression, but decreased the expression of collagen II and aggrecan. Moreover, the further data demonstrated that miR-365 mediated NP cell degradation through targeting ephrin-A3 (EFNA3). In addition, the cells apoptosis and catabolic markers were increased in NP cells when EFNA3 upregulated. More importantly, the vivo data supported that miR-365-NP cells injection ameliorated IDD in rats models. miR-365 could alleviate the development of IDD by regulating NP cell apoptosis and ECM degradation, which is likely mediated by targeting EFNA3. Therefore, miR-365 may be a promising therapeutic avenue for treatment IDD through EFNA3.
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Affiliation(s)
- Chao Jiang
- Department of Orthopedic SurgeryThe First Affiliated Hospital of Xi'an Jiaotong UniversityXi'anChina
| | - Youjun Liu
- Department of Orthopedic SurgeryThe First Affiliated Hospital of Xi'an Jiaotong UniversityXi'anChina
| | - Weigong Zhao
- Department of Orthopedic SurgeryThe First Affiliated Hospital of Xi'an Jiaotong UniversityXi'anChina
| | - Yimin Yang
- Department of Orthopedic SurgeryThe First Affiliated Hospital of Xi'an Jiaotong UniversityXi'anChina
| | - Zhiwei Ren
- Department of Orthopedic SurgeryThe First Affiliated Hospital of Xi'an Jiaotong UniversityXi'anChina
| | - Xiaohui Wang
- Department of Orthopedic SurgeryThe First Affiliated Hospital of Xi'an Jiaotong UniversityXi'anChina
- Department of Developmental GeneticsMax Planck Institute for Heart and Lung ResearchBad NauheimGermany
| | - Dingjun Hao
- Department of Orthopedic SurgeryThe First Affiliated Hospital of Xi'an Jiaotong UniversityXi'anChina
| | - Heng Du
- Department of Orthopedic SurgeryThe First Affiliated Hospital of Xi'an Jiaotong UniversityXi'anChina
| | - Si Yin
- Department of Orthopedic SurgeryThe First Affiliated Hospital of Xi'an Jiaotong UniversityXi'anChina
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Zhu S, Wang J, Suo M, Huang H, Liu X, Wang J, Li Z. Can extracellular vesicles be considered as a potential frontier in the treatment of intervertebral disc disease? Ageing Res Rev 2023; 92:102094. [PMID: 37863436 DOI: 10.1016/j.arr.2023.102094] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 10/04/2023] [Accepted: 10/16/2023] [Indexed: 10/22/2023]
Abstract
As a global public health problem, low back pain (LBP) caused by intervertebral disc degeneration (IDD) seriously affects patients' quality of life. In addition, the prevalence of IDD tends to be younger, which brings a huge burden to individuals and society economically. Current treatments do not delay or reverse the progression of IDD. The emergence of biologic therapies has brought new hope for the treatment of IDD. Among them, extracellular vesicles (EVs), as nanoscale bioactive substances that mediate cellular communication, have now produced many surprising results in the research of the treatment of IDD. This article reviews the mechanisms and roles of EVs in delaying IDD and describes the prospects and challenges of EVs.
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Affiliation(s)
- Shengxu Zhu
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, the People's Republic of China; Key Laboratory of Molecular Mechanism for Repair and Remodeling of Orthopedic Diseases, Liaoning Province, the People's Republic of China
| | - Junlin Wang
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, the People's Republic of China
| | - Moran Suo
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, the People's Republic of China; Key Laboratory of Molecular Mechanism for Repair and Remodeling of Orthopedic Diseases, Liaoning Province, the People's Republic of China
| | - Huagui Huang
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, the People's Republic of China; Key Laboratory of Molecular Mechanism for Repair and Remodeling of Orthopedic Diseases, Liaoning Province, the People's Republic of China
| | - Xin Liu
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, the People's Republic of China; Key Laboratory of Molecular Mechanism for Repair and Remodeling of Orthopedic Diseases, Liaoning Province, the People's Republic of China
| | - Jinzuo Wang
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, the People's Republic of China; Key Laboratory of Molecular Mechanism for Repair and Remodeling of Orthopedic Diseases, Liaoning Province, the People's Republic of China
| | - Zhonghai Li
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, the People's Republic of China; Key Laboratory of Molecular Mechanism for Repair and Remodeling of Orthopedic Diseases, Liaoning Province, the People's Republic of China.
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Huang H, Liu X, Wang J, Suo M, Zhang J, Sun T, Zhang W, Li Z. Umbilical cord mesenchymal stem cells for regenerative treatment of intervertebral disc degeneration. Front Cell Dev Biol 2023; 11:1215698. [PMID: 37601097 PMCID: PMC10439242 DOI: 10.3389/fcell.2023.1215698] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 07/27/2023] [Indexed: 08/22/2023] Open
Abstract
Intervertebral disc degeneration is thought to be a major contributor to low back pain, the etiology of which is complex and not yet fully understood. To compensate for the lack of drug and surgical treatment, mesenchymal stem cells have been proposed for regenerative treatment of intervertebral discs in recent years, and encouraging results have been achieved in related trials. Mesenchymal stem cells can be derived from different parts of the body, among which mesenchymal stem cells isolated from the fetal umbilical cord have excellent performance in terms of difficulty of acquisition, differentiation potential, immunogenicity and ethical risk. This makes it possible for umbilical cord derived mesenchymal stem cells to replace the most widely used bone marrow-derived and adipose tissue derived mesenchymal stem cells as the first choice for regenerating intervertebral discs. However, the survival of umbilical cord mesenchymal stem cells within the intervertebral disc is a major factor affecting their regenerative capacity. In recent years biomaterial scaffolds in tissue engineering have aided the survival of umbilical cord mesenchymal stem cells by mimicking the natural extracellular matrix. This seems to provide a new idea for the application of umbilical cord mesenchymal stem cells. This article reviews the structure of the intervertebral disc, disc degeneration, and the strengths and weaknesses of common treatment methods. We focus on the cell source, cell characteristics, mechanism of action and related experiments to summarize the umbilical cord mesenchymal stem cells and explore the feasibility of tissue engineering technology of umbilical cord mesenchymal stem cells. Hoping to provide new ideas for the treatment of disc degeneration.
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Affiliation(s)
- Huagui Huang
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Xin Liu
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Jinzuo Wang
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Moran Suo
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Jing Zhang
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Tianze Sun
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Wentao Zhang
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Zhonghai Li
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, China
- Key Laboratory of Molecular Mechanism for Repair and Remodeling of Orthopedic Diseases, Dalian, Liaoning, China
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Zhao YD, Huang YC, Lin JL, Li WS. Intervertebral Disc Progenitors: Lessons Learned from Single-Cell RNA Sequencing and the Role in Intervertebral Disc Regeneration. Bioengineering (Basel) 2023; 10:713. [PMID: 37370644 DOI: 10.3390/bioengineering10060713] [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: 04/10/2023] [Revised: 05/28/2023] [Accepted: 05/30/2023] [Indexed: 06/29/2023] Open
Abstract
The tremendous personal and economic burden worldwide caused by low back pain (LBP) has been surging in recent years. While intervertebral disc degeneration (IVDD) is the leading cause of LBP and vast efforts have been made to develop effective therapies, this problem is far from being resolved, as most treatments, such as painkillers and surgeries, mainly focus on relieving the symptoms rather than reversing the cause of IVDD. However, as stem/progenitor cells possess the potential to regenerate IVD, a deeper understanding of the early development and role of these cells could help to improve the effectiveness of stem/progenitor cell therapy in treating LBP. Single-cell RNA sequencing results provide fresh insights into the heterogeneity and development patterns of IVD progenitors; additionally, we compare mesenchymal stromal cells and IVD progenitors to provide a clearer view of the optimal cell source proposed for IVD regeneration.
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Affiliation(s)
- Yu-Dong Zhao
- Department of Orthopaedics, Peking University Third Hospital, Beijing 100191, China
- Engineering Research Center of Bone and Joint Precision Medicine, Beijing 100191, China
- Beijing Key Laboratory of Spinal Disease Research, Beijing 100191, China
| | - Yong-Can Huang
- Shenzhen Engineering Laboratory of Orthopaedic Regenerative Technologies, Department of Spine Surgery, Peking University Shenzhen Hospital, Shenzhen 518036, China
| | - Jia-Liang Lin
- Department of Orthopaedics, Peking University Third Hospital, Beijing 100191, China
- Engineering Research Center of Bone and Joint Precision Medicine, Beijing 100191, China
- Beijing Key Laboratory of Spinal Disease Research, Beijing 100191, China
| | - Wei-Shi Li
- Department of Orthopaedics, Peking University Third Hospital, Beijing 100191, China
- Engineering Research Center of Bone and Joint Precision Medicine, Beijing 100191, China
- Beijing Key Laboratory of Spinal Disease Research, Beijing 100191, China
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Zhang X, Hu Y, Hao D, Li T, Jia Y, Hu W, Xu Z. New strategies for the treatment of intervertebral disc degeneration: cell, exosome, gene, and tissue engineering. Am J Transl Res 2022; 14:8031-8048. [PMID: 36505274 PMCID: PMC9730054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 09/19/2022] [Indexed: 12/15/2022]
Abstract
Low back pain (LBP) caused by intervertebral disc (IVD) generation (IVDD) has always been an important problem that cannot be ignored. Traditional therapies have many deep-rooted and intractable complications that promote their treatment mode transfer to new therapies. This article mainly summarizes the shortcomings of traditional treatment methods and analyzes the research status and future development direction of IVDD treatment. We outlined the most promising IVDD therapies, including cell, exosome, gene, and tissue engineering therapy, especially tissue engineering therapy, which runs through the whole process of other therapies. In addition, the article focuses on the cellular, animal, and preclinical challenges faced by each therapeutic approach, as well as their respective advantages and disadvantages, to provide better ideas for relieving the IVDD patients' pain through new treatment methods.
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Affiliation(s)
- Xiaobo Zhang
- Department of Spine Surgery, Honghui Hospital, Xi’an Jiao Tong UniversityXi’an 710054, Shaanxi, China
| | - Yicun Hu
- Department of Orthopedics, Lanzhou University Second HospitalLanzhou 730000, Gansu, China
| | - Dingjun Hao
- Department of Spine Surgery, Honghui Hospital, Xi’an Jiao Tong UniversityXi’an 710054, Shaanxi, China
| | - Tao Li
- Department of Spine Surgery, Honghui Hospital, Xi’an Jiao Tong UniversityXi’an 710054, Shaanxi, China
| | - Yuhan Jia
- Department of Spine Surgery, Honghui Hospital, Xi’an Jiao Tong UniversityXi’an 710054, Shaanxi, China
| | - Wei Hu
- Department of Spine Surgery, Honghui Hospital, Xi’an Jiao Tong UniversityXi’an 710054, Shaanxi, China
| | - Zhengwei Xu
- Department of Spine Surgery, Honghui Hospital, Xi’an Jiao Tong UniversityXi’an 710054, Shaanxi, China
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Khalid S, Ekram S, Salim A, Chaudhry GR, Khan I. Transcription regulators differentiate mesenchymal stem cells into chondroprogenitors, and their in vivo implantation regenerated the intervertebral disc degeneration. World J Stem Cells 2022; 14:163-182. [PMID: 35432734 PMCID: PMC8963382 DOI: 10.4252/wjsc.v14.i2.163] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 07/29/2021] [Accepted: 01/06/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Intervertebral disc degeneration (IVDD) is the leading cause of lower back pain. Disc degeneration is characterized by reduced cellularity and decreased production of extracellular matrix (ECM). Mesenchymal stem cells (MSCs) have been envisioned as a promising treatment for degenerative illnesses. Cell-based therapy using ECM-producing chondrogenic derivatives of MSCs has the potential to restore the functionality of the intervertebral disc (IVD).
AIM To investigate the potential of chondrogenic transcription factors to promote differentiation of human umbilical cord MSCs into chondrocytes, and to assess their therapeutic potential in IVD regeneration.
METHODS MSCs were isolated and characterized morphologically and immunologically by the expression of specific markers. MSCs were then transfected with Sox-9 and Six-1 transcription factors to direct differentiation and were assessed for chondrogenic lineage based on the expression of specific markers. These differentiated MSCs were implanted in the rat model of IVDD. The regenerative potential of transplanted cells was investigated using histochemical and molecular analyses of IVDs.
RESULTS Isolated cells showed fibroblast-like morphology and expressed CD105, CD90, CD73, CD29, and Vimentin but not CD45 antigens. Overexpression of Sox-9 and Six-1 greatly enhanced the gene expression of transforming growth factor beta-1 gene, BMP, Sox-9, Six-1, and Aggrecan, and protein expression of Sox-9 and Six-1. The implanted cells integrated, survived, and homed in the degenerated intervertebral disc. Histological grading showed that the transfected MSCs regenerated the IVD and restored normal architecture.
CONCLUSION Genetically modified MSCs accelerate cartilage regeneration, providing a unique opportunity and impetus for stem cell-based therapeutic approach for degenerative disc diseases.
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Affiliation(s)
- Shumaila Khalid
- Dr. Panjwani Center for Molecular Medicine and Drug Research, International Center for Chemical and Biological Sciences, University of Karachi, Karachi 75270, Sindh, Pakistan
| | - Sobia Ekram
- Dr. Panjwani Center for Molecular Medicine and Drug Research, International Center for Chemical and Biological Sciences, University of Karachi, Karachi 75270, Sindh, Pakistan
| | - Asmat Salim
- Dr. Panjwani Center for Molecular Medicine and Drug Research, International Center for Chemical and Biological Sciences, University of Karachi, Karachi 75270, Sindh, Pakistan
| | - G. Rasul Chaudhry
- Department of Biological Sciences, Oakland University, Rochester, MI 48309, United States
| | - Irfan Khan
- Dr. Panjwani Center for Molecular Medicine and Drug Research, International Center for Chemical and Biological Sciences, University of Karachi, Karachi 75270, Sindh, Pakistan
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Umbilical Cord Mesenchymal Stromal Cells for Cartilage Regeneration Applications. Stem Cells Int 2022; 2022:2454168. [PMID: 35035489 PMCID: PMC8758292 DOI: 10.1155/2022/2454168] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 10/13/2021] [Accepted: 11/23/2021] [Indexed: 11/30/2022] Open
Abstract
Chondropathies are increasing worldwide, but effective treatments are currently lacking. Mesenchymal stromal cell (MSCs) transplantation represents a promising approach to counteract the degenerative and inflammatory environment characterizing those pathologies, such as osteoarthritis (OA) and rheumatoid arthritis (RA). Umbilical cord- (UC-) MSCs gained increasing interest due to their multilineage differentiation potential, immunomodulatory, and anti-inflammatory properties as well as higher proliferation rates, abundant supply along with no risks for the donor compared to adult MSCs. In addition, UC-MSCs are physiologically adapted to survive in an ischemic and nutrient-poor environment as well as to produce an extracellular matrix (ECM) similar to that of the cartilage. All these characteristics make UC-MSCs a pivotal source for a stem cell-based treatment of chondropathies. In this review, the regenerative potential of UC-MSCs for the treatment of cartilage diseases will be discussed focusing on in vitro, in vivo, and clinical studies.
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Ekram S, Khalid S, Salim A, Khan I. Regulating the fate of stem cells for regenerating the intervertebral disc degeneration. World J Stem Cells 2021; 13:1881-1904. [PMID: 35069988 PMCID: PMC8727226 DOI: 10.4252/wjsc.v13.i12.1881] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 07/12/2021] [Accepted: 11/15/2021] [Indexed: 02/06/2023] Open
Abstract
Lower back pain is a leading cause of disability and is one of the reasons for the substantial socioeconomic burden. The etiology of intervertebral disc (IVD) degeneration is complicated, and its mechanism is still not completely understood. Factors such as aging, systemic inflammation, biochemical mediators, toxic environmental factors, physical injuries, and genetic factors are involved in the progression of its pathophysiology. Currently, no therapy for restoring degenerated IVD is available except pain management, reduced physical activities, and surgical intervention. Therefore, it is imperative to establish regenerative medicine-based approaches to heal and repair the injured disc, repopulate the cell types to retain water content, synthesize extracellular matrix, and strengthen the disc to restore normal spine flexion. Cellular therapy has gained attention for IVD management as an alternative therapeutic option. In this review, we present an overview of the anatomical and molecular structure and the surrounding pathophysiology of the IVD. Modern therapeutic approaches, including proteins and growth factors, cellular and gene therapy, and cell fate regulators are reviewed. Similarly, small molecules that modulate the fate of stem cells for their differentiation into chondrocytes and notochordal cell types are highlighted.
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Affiliation(s)
- Sobia Ekram
- Dr. Panjwani Center for Molecular Medicine and Drug Research, International Center for Chemical and Biological Sciences, University of Karachi, Karachi 75270, Sindh, Pakistan
| | - Shumaila Khalid
- Dr. Panjwani Center for Molecular Medicine and Drug Research, International Center for Chemical and Biological Sciences, University of Karachi, Karachi 75270, Sindh, Pakistan
| | - Asmat Salim
- Dr. Panjwani Center for Molecular Medicine and Drug Research, International Center for Chemical and Biological Sciences, University of Karachi, Karachi 75270, Sindh, Pakistan
| | - Irfan Khan
- Dr. Panjwani Center for Molecular Medicine and Drug Research, International Center for Chemical and Biological Sciences, University of Karachi, Karachi 75270, Sindh, Pakistan
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Williams RJ, Tryfonidou MA, Snuggs JW, Le Maitre CL. Cell sources proposed for nucleus pulposus regeneration. JOR Spine 2021; 4:e1175. [PMID: 35005441 PMCID: PMC8717099 DOI: 10.1002/jsp2.1175] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 10/01/2021] [Accepted: 10/20/2021] [Indexed: 12/13/2022] Open
Abstract
Lower back pain (LBP) occurs in 80% of adults in their lifetime; resulting in LBP being one of the biggest causes of disability worldwide. Chronic LBP has been linked to the degeneration of the intervertebral disc (IVD). The current treatments for chronic back pain only provide alleviation of symptoms through pain relief, tissue removal, or spinal fusion; none of which target regenerating the degenerate IVD. As nucleus pulposus (NP) degeneration is thought to represent a key initiation site of IVD degeneration, cell therapy that specifically targets the restoration of the NP has been reviewed here. A literature search to quantitatively assess all cell types used in NP regeneration was undertaken. With key cell sources: NP cells; annulus fibrosus cells; notochordal cells; chondrocytes; bone marrow mesenchymal stromal cells; adipose-derived stromal cells; and induced pluripotent stem cells extensively analyzed for their regenerative potential of the NP. This review highlights: accessibility; expansion capability in vitro; cell survival in an IVD environment; regenerative potential; and safety for these key potential cell sources. In conclusion, while several potential cell sources have been proposed, iPSC may provide the most promising regenerative potential.
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Affiliation(s)
- Rebecca J. Williams
- Biomedical Research Centre, BiosciencesSheffield Hallam UniversitySheffieldUK
| | - Marianna A. Tryfonidou
- Department of Clinical Sciences, Faculty of Veterinary MedicineUtrecht UniversityUtrechtThe Netherlands
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Zhang Z, Zhang L, Yang J, Huang J, Cai J, Zhang S, Feng X, Wang Q. Influence of extracellular nanovesicles derived from adipose-derived stem cells on nucleus pulposus cell from patients with intervertebral disc degeneration. Exp Ther Med 2021; 22:1431. [PMID: 34707712 DOI: 10.3892/etm.2021.10866] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 01/26/2021] [Indexed: 01/07/2023] Open
Abstract
An increasing number of individuals are suffering from lower back and neck pain caused by intervertebral disc degeneration each year. Although the application of mesenchymal stem cells (MSCs) has provided desirable results in the treatment of intervertebral disc degeneration, there are multiple risks associated with the directed application of MSCs. An increasing number of studies have suggested that stem cells, through the release of extracellular nanovesicles, have vital functions in tissue regeneration and repair with low risk. The present study investigated the effect of extracellular nanovesicles derived from adipose-derived stem cells (ADSCs) on nucleus pulposus (NP) cells from patients with intervertebral disc degeneration. Human NP cells were obtained from patients with intervertebral disc degeneration undergoing surgical procedures in addition to ADSCs from liposuction patients. ADSC-derived extracellular nanovesicles were isolated and characterized. The differentiation and biological activity of NP cells cultured with or without ADSC-derived extracellular nanovesicles were assessed and inflammatory factors and intervertebral disc degeneration-associated markers were also measured. The results indicated that extracellular nanovesicles derived from ADSCs increased the migration and proliferation of NP cells and inhibited inflammatory activity, suggesting their utility for the treatment of intervertebral disc degeneration.
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Affiliation(s)
- Zhiqiang Zhang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Orthopaedic Institute, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu 225001, P.R. China
| | - Liang Zhang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Orthopaedic Institute, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu 225001, P.R. China
| | - Jiandong Yang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Orthopaedic Institute, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu 225001, P.R. China
| | - Jijun Huang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Orthopaedic Institute, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu 225001, P.R. China
| | - Jun Cai
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Orthopaedic Institute, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu 225001, P.R. China
| | - Shengfei Zhang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Orthopaedic Institute, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu 225001, P.R. China
| | - Xinmin Feng
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Orthopaedic Institute, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu 225001, P.R. China
| | - Qiang Wang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Orthopaedic Institute, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu 225001, P.R. China
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12
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Zhang XB, Chen XY, Qi J, Zhou HY, Zhao XB, Hu YC, Zhang RH, Yu DC, Gao XD, Wang KP, Ma L. New hope for intervertebral disc degeneration: bone marrow mesenchymal stem cells and exosomes derived from bone marrow mesenchymal stem cell transplantation. Curr Gene Ther 2021; 22:291-302. [PMID: 34636308 DOI: 10.2174/1566523221666211012092855] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 07/30/2021] [Accepted: 09/08/2021] [Indexed: 11/22/2022]
Abstract
Bone marrow mesenchymal stem cells (BMSCs), multidirectional cells with self-renewal capacity, can differentiate into many cell types and play essential roles in tissue healing and regenerative medicine. Cell experiments and in vivo research in animal models have shown that BMSCs can repair degenerative discs by promoting cell proliferation and expressing extracellular matrix (ECM) components, such as type II collagen and protein-polysaccharides. Delaying or reversing the intervertebral disc (IVD) degeneration (IDD) process at an etiological level may be an effective strategy. However, despite increasingly in-depth research, some deficiencies in cell transplantation timing and strategy remain, preventing the clinical application of cell transplantation. Exosomes exhibit the characteristics of the mother cells from which they were secreted and can inhibit nucleus pulposus (NP) cell (NPC) apoptosis and delay IDD through intercellular communication. Furthermore, the use of exosomes effectively avoids problems associated with cell transplantation, such as immune rejection. This manuscript introduces almost all of the BMSCs and exosomes derived from BMSCs (BMSCs-Exos) described in the IDD literature. Many challenges regarding the use of cell transplantation and therapeutic exosome intervention for IDD remain to be overcome.
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Affiliation(s)
- Xiao-Bo Zhang
- Department of Orthopedics, Honghui Hospital, Xi'an Jiaotong University, Shanxi 710000. China
| | - Xiang-Yi Chen
- Department of Orthopedics, Lanzhou University Second Hospital, Gansu 730000. China
| | - Jin Qi
- Department of Orthopedics, Lanzhou University Second Hospital, Gansu 730000. China
| | - Hai-Yu Zhou
- Department of Orthopedics, Lanzhou University Second Hospital, Gansu 730000. China
| | - Xiao-Bing Zhao
- Department of Orthopedics, Lanzhou University Second Hospital, Gansu 730000. China
| | - Yi-Cun Hu
- Department of Orthopedics, Lanzhou University Second Hospital, Gansu 730000. China
| | - Rui-Hao Zhang
- Department of Orthopedics, Lanzhou University Second Hospital, Gansu 730000. China
| | - De-Chen Yu
- Department of Orthopedics, Lanzhou University Second Hospital, Gansu 730000. China
| | - Xi-Dan Gao
- Department of Orthopedics, Lanzhou University Second Hospital, Gansu 730000. China
| | - Ke-Ping Wang
- Department of Orthopedics, Lanzhou University Second Hospital, Gansu 730000. China
| | - Lin Ma
- Department of Orthopedics, Lanzhou University Second Hospital, Gansu 730000. China
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13
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Huang G, Sun Y, Li J, Xie Z, Tong X. Therapeutic Effects of Microsurgical Clipping at Different Time Points on Intracranial Aneurysm and Prognostic Factors. Artery Res 2021. [DOI: 10.1007/s44200-021-00001-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Abstract
Background
Microsurgical clipping is effective for treating early rupture hemorrhage in intracranial aneurysm (IA) patients. We aimed to evaluate the therapeutic effects of microsurgical clipping at different time points on IA and to explore prognostic factors.
Methods
A total of 102 eligible patients were divided into good prognosis group (n = 87) and poor prognosis group (n = 15) according to Glasgow Outcome Scale (GOS) scores at discharge. The effects of microsurgical clipping at different time points (within 24 h, 48 h and 72 h) were compared. The incidence rates of postoperative complications in patients with different Hunt–Hess grades were compared. Prognostic factors were determined by multivariate logistic regression analysis. The nomogram prediction model was established based on independent risk factors and validated.
Results
The good recovery and success rates of complete aneurysm clipping were significantly higher in patients undergoing surgery within 24 h after rupture. The incidence rate of complications was significantly higher in patients with Hunt–Hess grade IV. Good and poor prognosis groups had significantly different age, history of hypertension, preoperative intracranial hematoma volume, aneurysm size, preoperative Hunt–Hess grade, later surgery, postoperative complications and National Institute of Health Stroke Scale (NIHSS) score, as independent risk factors for prognosis. The nomogram model predicted that poor prognosis rate was 14.71%.
Conclusion
Timing (within 24 h after rupture) microsurgical clipping benefits the prognosis of IA patients. Age, history of hypertension, preoperative intracranial hematoma volume, aneurysm size, preoperative Hunt–Hess grade, later surgery, postoperative complications and NIHSS score are independent risk factors for poor prognosis.
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14
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Brown C, McKee C, Halassy S, Kojan S, Feinstein DL, Chaudhry GR. Neural stem cells derived from primitive mesenchymal stem cells reversed disease symptoms and promoted neurogenesis in an experimental autoimmune encephalomyelitis mouse model of multiple sclerosis. Stem Cell Res Ther 2021; 12:499. [PMID: 34503569 PMCID: PMC8427882 DOI: 10.1186/s13287-021-02563-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 08/23/2021] [Indexed: 02/06/2023] Open
Abstract
Background Multiple sclerosis (MS) is an autoimmune inflammatory disease of the central nervous system (CNS). MS affects millions of people and causes a great economic and societal burden. There is no cure for MS. We used a novel approach to investigate the therapeutic potential of neural stem cells (NSCs) derived from human primitive mesenchymal stem cells (MSCs) in an experimental autoimmune encephalomyelitis (EAE) mouse model of MS. Methods MSCs were differentiated into NSCs, labeled with PKH26, and injected into the tail vein of EAE mice. Neurobehavioral changes in the mice assessed the effect of transplanted cells on the disease process. The animals were sacrificed two weeks following cell transplantation to collect blood, lymphatic, and CNS tissues for analysis. Transplanted cells were tracked in various tissues by flow cytometry. Immune infiltrates were determined and characterized by H&E and immunohistochemical staining, respectively. Levels of immune regulatory cells, Treg and Th17, were analyzed by flow cytometry. Myelination was determined by Luxol fast blue staining and immunostaining. In vivo fate of transplanted cells and expression of inflammation, astrogliosis, myelination, neural, neuroprotection, and neurogenesis markers were investigated by using immunohistochemical and qRT-PCR analysis.
Results MSC-derived NSCs expressed specific neural markers, NESTIN, TUJ1, VIMENTIN, and PAX6. NSCs improved EAE symptoms more than MSCs when transplanted in EAE mice. Post-transplantation analyses also showed homing of MSCs and NSCs into the CNS with concomitant induction of an anti-inflammatory response, resulting in reducing immune infiltrates. NSCs also modulated Treg and Th17 cell levels in EAE mice comparable to healthy controls. Luxol fast blue staining showed significant improvement in myelination in treated mice. Further analysis showed that NSCs upregulated genes involved in myelination and neuroprotection but downregulated inflammatory and astrogliosis genes more significantly than MSCs. Importantly, NSCs differentiated into neural derivatives and promoted neurogenesis, possibly by modulating BDNF and FGF signaling pathways. Conclusions NSC transplantation reversed the disease process by inducing an anti-inflammatory response and promoting myelination, neuroprotection, and neurogenesis in EAE disease animals. These promising results provide a basis for clinical studies to treat MS using NSCs derived from primitive MSCs. Supplementary Information The online version contains supplementary material available at 10.1186/s13287-021-02563-8.
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Affiliation(s)
- Christina Brown
- Department of Biological Sciences, Oakland University, Rochester, MI, 48309, USA.,OU-WB Institute for Stem Cell and Regenerative Medicine, Rochester, MI, 48309, USA
| | - Christina McKee
- Department of Biological Sciences, Oakland University, Rochester, MI, 48309, USA.,OU-WB Institute for Stem Cell and Regenerative Medicine, Rochester, MI, 48309, USA
| | - Sophia Halassy
- Ascension Providence Hospital, Southfield, MI, 48075, USA
| | - Suleiman Kojan
- Department of Neuroscience, OUWB School of Medicine, Oakland University, Rochester, MI, 48309, USA
| | - Doug L Feinstein
- Department of Anesthesiology, The University of Illinois at Chicago, Chicago, IL, 60607, USA.,Department of Veterans Affairs, Jesse Brown VA Medical Center, Chicago, IL, 60612, USA
| | - G Rasul Chaudhry
- Department of Biological Sciences, Oakland University, Rochester, MI, 48309, USA. .,OU-WB Institute for Stem Cell and Regenerative Medicine, Rochester, MI, 48309, USA.
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15
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Merimi M, El-Majzoub R, Lagneaux L, Moussa Agha D, Bouhtit F, Meuleman N, Fahmi H, Lewalle P, Fayyad-Kazan M, Najar M. The Therapeutic Potential of Mesenchymal Stromal Cells for Regenerative Medicine: Current Knowledge and Future Understandings. Front Cell Dev Biol 2021; 9:661532. [PMID: 34490235 PMCID: PMC8416483 DOI: 10.3389/fcell.2021.661532] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 05/28/2021] [Indexed: 12/11/2022] Open
Abstract
In recent decades, research on the therapeutic potential of progenitor cells has advanced considerably. Among progenitor cells, mesenchymal stromal cells (MSCs) have attracted significant interest and have proven to be a promising tool for regenerative medicine. MSCs are isolated from various anatomical sites, including bone marrow, adipose tissue, and umbilical cord. Advances in separation, culture, and expansion techniques for MSCs have enabled their large-scale therapeutic application. This progress accompanied by the rapid improvement of transplantation practices has enhanced the utilization of MSCs in regenerative medicine. During tissue healing, MSCs may exhibit several therapeutic functions to support the repair and regeneration of injured tissue. The process underlying these effects likely involves the migration and homing of MSCs, as well as their immunotropic functions. The direct differentiation of MSCs as a cell replacement therapeutic mechanism is discussed. The fate and behavior of MSCs are further regulated by their microenvironment, which may consequently influence their repair potential. A paracrine pathway based on the release of different messengers, including regulatory factors, chemokines, cytokines, growth factors, and nucleic acids that can be secreted or packaged into extracellular vesicles, is also implicated in the therapeutic properties of MSCs. In this review, we will discuss relevant outcomes regarding the properties and roles of MSCs during tissue repair and regeneration. We will critically examine the influence of the local microenvironment, especially immunological and inflammatory signals, as well as the mechanisms underlying these therapeutic effects. Importantly, we will describe the interactions of local progenitor and immune cells with MSCs and their modulation during tissue injury. We will also highlight the crucial role of paracrine pathways, including the role of extracellular vesicles, in this healing process. Moreover, we will discuss the therapeutic potential of MSCs and MSC-derived extracellular vesicles in the treatment of COVID-19 (coronavirus disease 2019) patients. Overall, this review will provide a better understanding of MSC-based therapies as a novel immunoregenerative strategy.
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Affiliation(s)
- Makram Merimi
- Laboratory of Experimental Hematology, Institut Jules Bordet, Université Libre de Bruxelles (ULB), Bruxelles, Belgium.,LBBES Laboratory, Genetics and Immune-Cell Therapy Unit, Faculty of Sciences, University Mohammed Premier, Oujda, Morocco
| | - Rania El-Majzoub
- Department of Biomedical Sciences, School of Pharmacy, Lebanese International University, Beirut, Lebanon.,Laboratory of Cancer Biology and Molecular Immunology, Faculty of Sciences-I, Lebanese University, Beirut, Lebanon
| | - Laurence Lagneaux
- Laboratory of Clinical Cell Therapy, Institut Jules Bordet, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Douâa Moussa Agha
- Laboratory of Experimental Hematology, Institut Jules Bordet, Université Libre de Bruxelles (ULB), Bruxelles, Belgium
| | - Fatima Bouhtit
- Laboratory of Experimental Hematology, Institut Jules Bordet, Université Libre de Bruxelles (ULB), Bruxelles, Belgium.,LBBES Laboratory, Genetics and Immune-Cell Therapy Unit, Faculty of Sciences, University Mohammed Premier, Oujda, Morocco
| | - Nathalie Meuleman
- Laboratory of Experimental Hematology, Institut Jules Bordet, Université Libre de Bruxelles (ULB), Bruxelles, Belgium
| | - Hassan Fahmi
- Osteoarthritis Research Unit, University of Montreal Hospital Research Center (CRCHUM), Montreal, QC, Canada
| | - Philippe Lewalle
- Laboratory of Experimental Hematology, Institut Jules Bordet, Université Libre de Bruxelles (ULB), Bruxelles, Belgium
| | - Mohammad Fayyad-Kazan
- Laboratory of Cancer Biology and Molecular Immunology, Faculty of Sciences-I, Lebanese University, Beirut, Lebanon.,Department of Natural Sciences, School of Arts and Sciences, Lebanese American University, Beirut, Lebanon
| | - Mehdi Najar
- Laboratory of Clinical Cell Therapy, Institut Jules Bordet, Université Libre de Bruxelles (ULB), Brussels, Belgium.,Osteoarthritis Research Unit, University of Montreal Hospital Research Center (CRCHUM), Montreal, QC, Canada
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16
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Ekram S, Khalid S, Bashir I, Salim A, Khan I. Human umbilical cord-derived mesenchymal stem cells and their chondroprogenitor derivatives reduced pain and inflammation signaling and promote regeneration in a rat intervertebral disc degeneration model. Mol Cell Biochem 2021; 476:3191-3205. [PMID: 33864569 DOI: 10.1007/s11010-021-04155-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 04/02/2021] [Indexed: 12/21/2022]
Abstract
Intervertebral disc (IVD) degeneration is an asymptomatic pathophysiological condition and a strong causative factor of low back pain. There is no cure available except spinal fusion and pain management. Stem cell-based regenerative medicine is being considered as an alternative approach to treat disc diseases. The current study aimed to differentiate human umbilical cord-mesenchymal stem cells (hUC-MSCs) into chondrocyte-like cells and to elucidate their feasibility and efficacy in the degenerated IVD rat model. Chondrogenic induction medium was used to differentiate hUC-MSCs into chondroprogenitors. Rat tail IVD model was established with three consecutive coccygeal discs. qPCR was performed to quantify the molecular markers of pain and inflammation. Histological staining was performed to evaluate the degree of regeneration. Induced chondroprogenitors showed the expression of chondrogenic genes, SOX9, TGF-β1, ACAN, BMP2, and GDF5. Immunocytochemical staining showed positive expression of chondrogenic proteins SOX9, TGF-β1, TGF-β2, and Collagen 2. In in vivo study, transplanted chondroprogenitors showed better survival, homing, and distribution in IVD as compared to normal MSCs. Expression of pain and inflammatory genes at day 5 of cell transplantation modulated immune response significantly. The transplanted labeled MSCs and induced chondroprogenitors differentiated into functional nucleus pulposus (NP) cells as evident from co-localization of red (DiI) and green fluorescence for SOX9, TGF-β1, and TGF-β2. Alcian blue and H & E staining showed standard histological features, indicating better preservation of the NP structure and cellularity than degenerated discs. hUC-MSCs-derived chondroprogenitors showed better regeneration potential as compared to normal MSCs. The pain and inflammation genes were downregulated in the treated group as compared to the degenerated IVD.
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Affiliation(s)
- Sobia Ekram
- Dr. Panjwani Center for Molecular Medicine and Drug Research, International Center for Chemical and Biological Sciences, University of Karachi, Karachi, 75270, Pakistan
| | - Shumaila Khalid
- Dr. Panjwani Center for Molecular Medicine and Drug Research, International Center for Chemical and Biological Sciences, University of Karachi, Karachi, 75270, Pakistan
| | - Imtiaz Bashir
- Zainab Panjwani Memorial Hospital, Mohammadali Habib Road, Numaish Karachi, 74800, Pakistan
| | - Asmat Salim
- Dr. Panjwani Center for Molecular Medicine and Drug Research, International Center for Chemical and Biological Sciences, University of Karachi, Karachi, 75270, Pakistan
| | - Irfan Khan
- Dr. Panjwani Center for Molecular Medicine and Drug Research, International Center for Chemical and Biological Sciences, University of Karachi, Karachi, 75270, Pakistan.
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17
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Zhang Y, Zhang Z, Chen P, Ma CY, Li C, Au TYK, Tam V, Peng Y, Wu R, Cheung KMC, Sham PC, Tse HF, Chan D, Leung VY, Cheah KSE, Lian Q. Directed Differentiation of Notochord-like and Nucleus Pulposus-like Cells Using Human Pluripotent Stem Cells. Cell Rep 2021; 30:2791-2806.e5. [PMID: 32101752 DOI: 10.1016/j.celrep.2020.01.100] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 10/15/2019] [Accepted: 01/28/2020] [Indexed: 12/26/2022] Open
Abstract
Intervertebral disc degeneration might be amenable to stem cell therapy, but the required cells are scarce. Here, we report the development of a protocol for directed in vitro differentiation of human pluripotent stem cells (hPSCs) into notochord-like and nucleus pulposus (NP)-like cells of the disc. The first step combines enhancement of ACTIVIN/NODAL and WNT and inhibition of BMP pathways. By day 5 of differentiation, hPSC-derived cells express notochordal cell characteristic genes. After activating the TGF-β pathway for an additional 15 days, qPCR, immunostaining, and transcriptome data show that a wide array of NP markers are expressed. Transcriptomically, the in vitro-derived cells become more like in vivo adolescent human NP cells, driven by a set of influential genes enriched with motifs bound by BRACHYURY and FOXA2, consistent with an NP cell-like identity. Transplantation of these NP-like cells attenuates fibrotic changes in a rat disc injury model of disc degeneration.
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Affiliation(s)
- Yuelin Zhang
- Department of Medicine, Li Ka Shing Faculty of Medicine, the University of Hong Kong, Hong Kong; Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, Guangzhou, Guangdong 510080, China
| | - Zhao Zhang
- Department of Medicine, Li Ka Shing Faculty of Medicine, the University of Hong Kong, Hong Kong; Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, Guangzhou, Guangdong 510080, China
| | - Peikai Chen
- School of Biomedical Sciences, Li Ka Shing Faculty of Medicine, the University of Hong Kong, Hong Kong
| | - Chui Yan Ma
- Department of Medicine, Li Ka Shing Faculty of Medicine, the University of Hong Kong, Hong Kong
| | - Cheng Li
- Department of Medicine, Li Ka Shing Faculty of Medicine, the University of Hong Kong, Hong Kong
| | - Tiffany Y K Au
- School of Biomedical Sciences, Li Ka Shing Faculty of Medicine, the University of Hong Kong, Hong Kong
| | - Vivian Tam
- School of Biomedical Sciences, Li Ka Shing Faculty of Medicine, the University of Hong Kong, Hong Kong
| | - Yan Peng
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, the University of Hong Kong, Hong Kong
| | - Ron Wu
- School of Biomedical Sciences, Li Ka Shing Faculty of Medicine, the University of Hong Kong, Hong Kong
| | - Kenneth Man Chee Cheung
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, the University of Hong Kong, Hong Kong
| | - Pak C Sham
- Centre for PanorOmic Sciences, Li Ka Shing Faculty of Medicine, the University of Hong Kong, Hong Kong
| | - Hung-Fat Tse
- Department of Medicine, Li Ka Shing Faculty of Medicine, the University of Hong Kong, Hong Kong
| | - Danny Chan
- School of Biomedical Sciences, Li Ka Shing Faculty of Medicine, the University of Hong Kong, Hong Kong
| | - Victor Y Leung
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, the University of Hong Kong, Hong Kong
| | - Kathryn S E Cheah
- School of Biomedical Sciences, Li Ka Shing Faculty of Medicine, the University of Hong Kong, Hong Kong.
| | - Qizhou Lian
- Department of Medicine, Li Ka Shing Faculty of Medicine, the University of Hong Kong, Hong Kong; Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, Guangzhou, Guangdong 510080, China; The State Key Laboratory of Pharmaceutical Biotechnology, the University of Hong Kong, Hong Kong.
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18
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Hei L, Ge Z, Yuan W, Suo L, Suo Z, Lin L, Ding H, Qiu Y. Evaluation of a rabbit model of adjacent intervertebral disc degeneration after fixation and fusion and maintenance in an upright feeding cage. Neurol Res 2021; 43:447-457. [PMID: 33455565 DOI: 10.1080/01616412.2020.1866804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Purpose: To establish an animal model of adjacent intervertebral disc degeneration by performing spinal fixation and fusion after percutaneous needle puncture and removal of the intervertebral disc or percutaneous needling of the vertebral body without removal of the intervertebral disc. Methods: We established a model of adjacent intervertebral disc degeneration after spinal fixation and fusion of rabbits maintained in upright feeding cages. Twenty-five healthy New Zealand rabbits were used. In the experimental group, the L3-4 intervertebral disc was percutaneously punctured with an 18-G needle under fluoroscopic guidance. Once degeneration occurred, the L3-4 disc was excised, and interbody fusion was performed. The changes in the adjacent intervertebral discs were observed periodically via X-ray and MRI. In the control group, the L3 vertebral body was percutaneously needled with an 18-G needle under fluoroscopic guidance. The changes in the adjacent intervertebral discs were observed on X-ray and MRI at 4, 8, and 12 weeks after puncture in both groups. At 12 weeks postoperatively, the animals were euthanized, and the histopathologic changes of the adjacent intervertebral discs were assessed using hematoxylin-eosin and TdT-mediated dUTP nick end labeling (TUNEL) staining. The mRNA and protein expressions of aggrecanase-1 were measured by real-time quantitative PCR and Western blot analysis. The product of aggrecan degradation, Aggrecan ARGxx, was measured by Western blot analysis. Results: The degeneration of the intervertebral discs in the adjacent segments in the experimental group increased over time. The mRNA and protein expressions of aggrecanase-1 and the expression of Aggrecan ARGxx in the experimental group were significantly increased after puncture, fixation, and fusion (P<0.05). The adjacent intervertebral disc sections had a significantly lower cell density and significantly higher TUNEL-positive cell rate in the experimental group than the control group (P<0.05). Conclusion: The results suggest that the occurrence of intervertebral disc degeneration in adjacent segments may begin with the degeneration of the punctured intervertebral disc.
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Affiliation(s)
- Long Hei
- Department of Orthopedics, The First Affiliated Hospital of Xi' an Jiaotong University, Xi' An, China.,Department of Spine Surgery, The General Hospital of Ningxia Medical University
| | - Zhaohui Ge
- Department of Orthopedics, The First Affiliated Hospital of Xi' an Jiaotong University, Xi' An, China.,Department of Spine Surgery, The General Hospital of Ningxia Medical University
| | - Wenqi Yuan
- Department of Spine Surgery, The General Hospital of Ningxia Medical University
| | - Ling Suo
- Fourth Clinical Department, Minkang Hospital of Ningxia Hui Autonomous Region, Yinchuan, China
| | - Zhigang Suo
- Department of Spine Surgery, The General Hospital of Ningxia Medical University
| | - Leilei Lin
- Department of Spine Surgery, The General Hospital of Ningxia Medical University
| | - Huiqiang Ding
- Department of Spine Surgery, The General Hospital of Ningxia Medical University
| | - Yusheng Qiu
- Department of Orthopedics, The First Affiliated Hospital of Xi' an Jiaotong University, Xi' An, China
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19
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Li Z, Chen S, Ma K, He R, Xiong L, Hu Y, Deng X, Yang A, Ma X, Shao Z. Comparison of different methods for the isolation and purification of rat nucleus pulposus-derived mesenchymal stem cells. Connect Tissue Res 2020; 61:426-434. [PMID: 31203667 DOI: 10.1080/03008207.2019.1611793] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE Recently, nucleus pulposus-derived mesenchymal stem cells (NPMSCs) have been identified and have shown good prospects for the repair of degenerative intervertebral discs. However, there is no consensus about the methods for the isolation and purification of NPMSCs. Therefore, a reliable and efficient isolation and purification method is potentially needed. We aimed to compare different methods and to identify an optimal method for isolating and purifying NPMSCs. METHODS NPMSCs were isolated and purified using two common methods (a low-density culture (LD) method and a mesenchymal stem cell complete medium culture (MSC-CM) method) and two novel methods (a cloning cylinder (CC) method and a combination of the CC and MSC-CM methods (MSC-CM+CC)). The morphology, MSC-specific surface markers (CD44, CD73, CD90, CD105, CD34 and HLA-DR), multiple-lineage differentiation potential, colony formation ability, and stemness gene (Oct4, Nanog, and Sox2) expression were evaluated and compared. RESULTS NPMSCs isolated from nucleus pulposus (NP) tissues via the four methods met the criteria stated by the International Society of Cell Therapy (ISCT) for MSCs, including adherent growth ability, MSC-specific surface antigen expression, and multi-lineage differentiation potential. In particular, the MSC-CM+CC method yielded a relatively higher quality of NPMSCs in terms of cell surface markers, multiple-lineage differentiation potential, colony formation ability, and stemness gene expression. CONCLUSIONS Our results indicated that NPMSCs can be obtained via all four methods and that the MSC-CM+CC method is more reliable and efficient than the other three methods. The findings from this study provide an alternative option for isolating and purifying NPMSCs.
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Affiliation(s)
- Zhiliang Li
- Department of Orthopedics, Renmin Hospital of Wuhan University , Wuhan, China
| | - Sheng Chen
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology , Wuhan, China
| | - Kaige Ma
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology , Wuhan, China
| | - Ruijun He
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology , Wuhan, China
| | - Liming Xiong
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology , Wuhan, China
| | - Yiqiang Hu
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology , Wuhan, China
| | - Xiangyu Deng
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology , Wuhan, China
| | - Aoxue Yang
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology , Wuhan, China
| | - Xuan Ma
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology , Wuhan, China
| | - Zengwu Shao
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology , Wuhan, China
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20
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Autologous fibroblasts induce fibrosis of the nucleus pulposus to maintain the stability of degenerative intervertebral discs. Bone Res 2020; 8:7. [PMID: 32128275 PMCID: PMC7015945 DOI: 10.1038/s41413-019-0082-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 10/04/2019] [Accepted: 11/01/2019] [Indexed: 01/06/2023] Open
Abstract
Lumbar degenerative disc diseases cause low back pain (LBP). The maintenance of the height and stability of the intervertebral disc (IVD) space is an effective treatment for LBP. The following study evaluated the effects of fibroblast injection on intervertebral disc degeneration (IDD) in a preclinical setting. Compared with the IDD group, the fibroblast treatment group demonstrated effective maintenance of IVD height, reduced endplate degeneration, and improved nuclear magnetic resonance signals and overall histological structure. In doing so, fibrotic IVDs maintained the stability and biomechanics of the vertebra. This finding is in agreement with clinical findings that human nucleus pulposus (NP) fibrosis is essential for the maintenance of IVD height and mechanical properties in patients following percutaneous endoscopic lumbar discectomy (PELD). Mechanistically, we demonstrated that injected fibroblasts not only proliferated but also induced NP cells to adopt a fibrotic phenotype via the secretion of TGF-β. Finally, to better mimic human conditions, the efficacy of autologous fibroblast injection in the treatment of IDD was further examined in a nonhuman primate cynomolgus monkey model due to their capacity for upright posture. We showed that the injection of fibroblasts could maintain the IVD height and rescue IVD signals in cynomolgus monkeys. Taken together, the results of our study reveal that autologous fibroblast injection can enhance the natural process of fibrosis during acute and subacute stages of stress-induced IDD. Fibrotic IVDs can maintain the stability, biological activity, and mechanical properties of the intervertebral space, thus providing a new direction for the treatment of intervertebral space-derived lumbar degenerative diseases.
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21
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Urits I, Capuco A, Sharma M, Kaye AD, Viswanath O, Cornett EM, Orhurhu V. Stem Cell Therapies for Treatment of Discogenic Low Back Pain: a Comprehensive Review. Curr Pain Headache Rep 2019; 23:65. [PMID: 31359164 DOI: 10.1007/s11916-019-0804-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Discogenic low back pain (DLBP) stems from pathology in one or more intervertebral discs identified as the root cause of the pain. It is the most common type of chronic low back pain (LBP), representing 26-42% of attributable cases. RECENT FINDINGS The clinical presentation of DLBP includes increased pain when sitting, coughing, or sneezing, and experiencing relief when standing or ambulating. Dermatomal radiation of pain to the lower extremity and neurological symptoms including numbness, motor weakness, and urinary or fecal incontinence are signs of advanced disease with disc prolapse, nerve root compression, or spinal stenosis. Degenerative disc disease is caused by both a decrease in disc nutrient supply causing decreased oxygen, lowered pH, and lessened ability of the intervertebral disc (IVD) to respond to increased load or injury; moreover, changes in the extracellular matrix composition cause weakening of the tissue and skewing the extracellular matrix's (ECM) harmonious balance between catabolic and anabolic factors for cell turnover in favor of catabolism. Thus, the degeneration of the disc causes a shift from type II to type I collagen expression by NP cells and a decrease in aggrecan synthesis leads to dehydrated matrix cells ultimately with loss of swelling pressure needed for mechanical support. Cell-based therapies such as autologous nucleus pulposus cell re-implantation have in animal models and human trials shown improvements in LBP score, retention of hydration in IVD, and increased disc height. Percutaneously delivered multipotent mesenchymal stem cell (MSC) therapy has been proposed as a potential means to uniquely ameliorate discogenic LBP holistically through three mechanisms: mitigation of primary nociceptive disc pain, slow or reversal of the catabolic metabolism, and restoration of disc tissue. Embryonic stem cells (ESCs) can differentiate into cells of all three germ layers in vitro, but their use is hindered related to ethical concerns, potential for immune rejection after transplantation, disease, and teratoma formation. Another similar approach to treating back pain is transplantation of the nucleus pulposus, which, like stem cell therapy, seeks to address the underlying cause of intervertebral disc degeneration by aiming to reverse the destructive inflammatory process and regenerate the proteoglycans and collagen found in healthy disc tissue. Preliminary animal models and clinical studies have shown mesenchymal stem cell implantation as a potential therapy for IVD regeneration and ECM restoration via a shift towards favorable anabolic balance and reduction of pain.
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Affiliation(s)
- Ivan Urits
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA.
| | | | - Medha Sharma
- University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Omar Viswanath
- Valley Anesthesiology and Pain Consultants, Phoenix, AZ, USA
- Department of Anesthesiology, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
- Department of Anesthesiology, School of Medicine, Creighton University, Omaha, NE, USA
| | - Elyse M Cornett
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA, USA
| | - Vwaire Orhurhu
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
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22
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Brown C, McKee C, Bakshi S, Walker K, Hakman E, Halassy S, Svinarich D, Dodds R, Govind CK, Chaudhry GR. Mesenchymal stem cells: Cell therapy and regeneration potential. J Tissue Eng Regen Med 2019; 13:1738-1755. [PMID: 31216380 DOI: 10.1002/term.2914] [Citation(s) in RCA: 319] [Impact Index Per Article: 63.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 05/15/2019] [Accepted: 06/07/2019] [Indexed: 12/12/2022]
Abstract
Rapid advances in the isolation of multipotent progenitor cells, routinely called mesenchymal stromal/stem cells (MSCs), from various human tissues and organs have provided impetus to the field of cell therapy and regenerative medicine. The most widely studied sources of MSCs include bone marrow, adipose, muscle, peripheral blood, umbilical cord, placenta, fetal tissue, and amniotic fluid. According to the standard definition of MSCs, these clonal cells adhere to plastic, express cluster of differentiation (CD) markers such as CD73, CD90, and CD105 markers, and can differentiate into adipogenic, chondrogenic, and osteogenic lineages in vitro. However, isolated MSCs have been reported to vary in their potency and self-renewal potential. As a result, the MSCs used for clinical applications often lead to variable or even conflicting results. The lack of uniform characterization methods both in vitro and in vivo also contributes to this confusion. Therefore, the name "MSCs" itself has been increasingly questioned lately. As the use of MSCs is expanding rapidly, there is an increasing need to understand the potential sources and specific potencies of MSCs. This review discusses and compares the characteristics of MSCs and suggests that the variations in their distinctive features are dependent on the source and method of isolation as well as epigenetic changes during maintenance and growth. We also discuss the potential opportunities and challenges of MSC research with the hope to stimulate their use for therapeutic and regenerative medicine.
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Affiliation(s)
- Christina Brown
- Department of Biological Sciences, Oakland University, Rochester, MI, USA.,OU-WB Institute for Stem Cell and Regenerative Medicine, Oakland University, Rochester, MI, USA
| | - Christina McKee
- Department of Biological Sciences, Oakland University, Rochester, MI, USA.,OU-WB Institute for Stem Cell and Regenerative Medicine, Oakland University, Rochester, MI, USA
| | - Shreeya Bakshi
- Department of Biological Sciences, Oakland University, Rochester, MI, USA.,OU-WB Institute for Stem Cell and Regenerative Medicine, Oakland University, Rochester, MI, USA
| | - Keegan Walker
- Department of Biological Sciences, Oakland University, Rochester, MI, USA.,OU-WB Institute for Stem Cell and Regenerative Medicine, Oakland University, Rochester, MI, USA
| | - Eryk Hakman
- Department of Obstetrics and Gynecology, Ascension Providence Hospital, Southfield, MI, USA
| | - Sophia Halassy
- Department of Obstetrics and Gynecology, Ascension Providence Hospital, Southfield, MI, USA
| | - David Svinarich
- Department of Obstetrics and Gynecology, Ascension Providence Hospital, Southfield, MI, USA.,Ascension Providence Hospital, Southfield, MI, USA
| | - Robert Dodds
- Department of Obstetrics and Gynecology, Ascension Providence Hospital, Southfield, MI, USA
| | - Chhabi K Govind
- Department of Biological Sciences, Oakland University, Rochester, MI, USA.,OU-WB Institute for Stem Cell and Regenerative Medicine, Oakland University, Rochester, MI, USA
| | - G Rasul Chaudhry
- Department of Biological Sciences, Oakland University, Rochester, MI, USA.,OU-WB Institute for Stem Cell and Regenerative Medicine, Oakland University, Rochester, MI, USA
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23
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Yang SH, Yang KC, Chen CW, Huang TC, Sun YH, Hu MH. Comparison of Transforming Growth Factor-Beta1 and Lovastatin on Differentiating Mesenchymal Stem Cells toward Nucleus Pulposus-like Phenotype: An In Vitro Cell Culture Study. Asian Spine J 2019; 13:705-712. [PMID: 31079432 PMCID: PMC6773984 DOI: 10.31616/asj.2018.0257] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Accepted: 12/30/2018] [Indexed: 01/08/2023] Open
Abstract
Study Design In Vitro cell culture study. Purpose This study aims to investigate the impact of transforming growth factor-beta1 (TGF-β1) and lovastatin on differentiating human mesenchymal stem cells (MSCs) toward nucleus pulposus (NP)-like phenotype. Overview of Literature MSCs offer a cell source to the cell-based therapy for intervertebral disc degeneration. TGF-β1 is used to induce MSCs to differentiate into NP-like cells; however, an undesired expression of collagen type I has been reported. Statins reportedly stimulate expression of bone morphogenetic protein-2 (BMP-2) and promote the chondrogenic phenotype to NP cells. However, the effects of statins with or without TGF-β1 on the differentiation of MSCs into NP-like cells remain unclear. Methods Human MSCs were treated with TGF-β1 alone, lovastatin alone, and simultaneous or sequential treatment with TGF-β1 and lovastatin. After the proposed stimulation, the total RNA was extracted to assess the expression profile of NP cells-specific genes. Hematoxylin–eosin staining was used for examining the microscopic morphology. Furthermore, we detected the syntheses of S-100 protein, aggrecan, and collagen type II in the extracellular matrix using immunohistochemical staining. Results Simultaneous or sequential treatment of TGF-β1 and lovastatin could further augment the BMP-2 overexpression compared with lovastatin-alone treatment. However, the mRNA expression of aggrecan and collagen type II was not compatible with the expression level of BMP-2. Immunohistochemical studies revealed compatible production of aggrecan, collagen type II, and S-100 protein in all three groups treated with lovastatin. Cells in groups treated with lovastatin were less populated than that in the group treated with TGF-β1 alone. Conclusions This study demonstrates a promising role of lovastatin in inducing human MSCs into NP-like cells. However, further optimization of cell density before lovastatin treatment, treatment duration, and combination with TGF-β1 are warranted to attain better stimulatory effects.
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Affiliation(s)
- Shu-Hua Yang
- Department of Orthopedics, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Kai-Chiang Yang
- Department of Dental Technology, College of Oral Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chih-Wei Chen
- Department of Orthopedics, National Taiwan University Hospital Hsin Chu Branch, Hsin Chu, Taiwan
| | - Ting-Chun Huang
- Department of Orthopedics, National Taiwan University Hospital Chu Tung Branch, Hsin Chu, Taiwan
| | - Yuan-Hui Sun
- Department of Orthopedics, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ming-Hsiao Hu
- Department of Orthopedics, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
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