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Rahman AA, Ohkura T, Bhave S, Pan W, Ohishi K, Ott L, Han C, Leavitt A, Stavely R, Burns AJ, Goldstein AM, Hotta R. Enteric neural stem cell transplant restores gut motility in mice with Hirschsprung disease. JCI Insight 2024; 9:e179755. [PMID: 39042470 PMCID: PMC11385093 DOI: 10.1172/jci.insight.179755] [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: 01/26/2024] [Accepted: 07/18/2024] [Indexed: 07/25/2024] Open
Abstract
The goal of this study was to determine if transplantation of enteric neural stem cells (ENSCs) can rescue the enteric nervous system, restore gut motility, reduce colonic inflammation, and improve survival in the Ednrb-KO mouse model of Hirschsprung disease (HSCR). ENSCs were isolated from mouse intestine, expanded to form neurospheres, and microinjected into the colons of recipient Ednrb-KO mice. Transplanted ENSCs were identified in recipient colons as cell clusters in "neo-ganglia." Immunohistochemical evaluation demonstrated extensive cell migration away from the sites of cell delivery and across the muscle layers. Electrical field stimulation and optogenetics showed significantly enhanced contractile activity of aganglionic colonic smooth muscle following ENSC transplantation and confirmed functional neuromuscular integration of the transplanted ENSC-derived neurons. ENSC injection also partially restored the colonic migrating motor complex. Histological examination revealed a significant reduction in inflammation in ENSC-transplanted aganglionic recipient colon compared with that of sham-operated mice. Interestingly, mice that received cell transplant also had prolonged survival compared with controls. This study demonstrates that ENSC transplantation can improve outcomes in HSCR by restoring gut motility and reducing the severity of Hirschsprung-associated enterocolitis, the leading cause of death in human HSCR.
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Affiliation(s)
- Ahmed A Rahman
- Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Takahiro Ohkura
- Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sukhada Bhave
- Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Weikang Pan
- Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kensuke Ohishi
- Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Drug Discovery Laboratory, Wakunaga Pharmaceutical Co. Ltd., Hiroshima, Japan
| | - Leah Ott
- Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher Han
- Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Abigail Leavitt
- Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Rhian Stavely
- Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Alan J Burns
- Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Stem Cells and Regenerative Medicine, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Allan M Goldstein
- Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ryo Hotta
- Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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2
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Alhawaj AF. Stem cell-based therapy for hirschsprung disease, do we have the guts to treat? Gene Ther 2022; 29:578-587. [PMID: 34121091 PMCID: PMC9684071 DOI: 10.1038/s41434-021-00268-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 04/26/2021] [Accepted: 05/27/2021] [Indexed: 01/09/2023]
Abstract
Hirschsprung disease (HSCR) is a congenital anomaly of the colon that results from failure of enteric nervous system formation, leading to a constricted dysfunctional segment of the colon with variable lengths, and necessitating surgical intervention. The underlying pathophysiology includes a defect in neural crest cells migration, proliferation and differentiation, which are partially explained by identified genetic and epigenetic alterations. Despite the high success rate of the curative surgeries, they are associated with significant adverse outcomes such as enterocolitis, fecal soiling, and chronic constipation. In addition, some patients suffer from extensive lethal variants of the disease, all of which justify the need for an alternative cure. During the last 5 years, there has been considerable progress in HSCR stem cell-based therapy research. However, many major issues remain unsolved. This review will provide concise background information on HSCR, outline the future approaches of stem cell-based HSCR therapy, review recent key publications, discuss technical and ethical challenges the field faces prior to clinical translation, and tackle such challenges by proposing solutions and evaluating existing approaches to progress further.
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Affiliation(s)
- Ali Fouad Alhawaj
- Department of Haematology, UCL Cancer Institute, University College London, London, WC1E 6DD, United Kingdom.
- Department of Physiology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia.
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3
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Jevans B, James ND, Burnside E, McCann CJ, Thapar N, Bradbury EJ, Burns AJ. Combined treatment with enteric neural stem cells and chondroitinase ABC reduces spinal cord lesion pathology. Stem Cell Res Ther 2021; 12:10. [PMID: 33407795 PMCID: PMC7789480 DOI: 10.1186/s13287-020-02031-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 11/16/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Spinal cord injury (SCI) presents a significant challenge for the field of neurotherapeutics. Stem cells have shown promise in replenishing the cells lost to the injury process, but the release of axon growth-inhibitory molecules such as chondroitin sulfate proteoglycans (CSPGs) by activated cells within the injury site hinders the integration of transplanted cells. We hypothesised that simultaneous application of enteric neural stem cells (ENSCs) isolated from the gastrointestinal tract, with a lentivirus (LV) containing the enzyme chondroitinase ABC (ChABC), would enhance the regenerative potential of ENSCs after transplantation into the injured spinal cord. METHODS ENSCs were harvested from the GI tract of p7 rats, expanded in vitro and characterised. Adult rats bearing a contusion injury were randomly assigned to one of four groups: no treatment, LV-ChABC injection only, ENSC transplantation only or ENSC transplantation+LV-ChABC injection. After 16 weeks, rats were sacrificed and the harvested spinal cords examined for evidence of repair. RESULTS ENSC cultures contained a variety of neuronal subtypes suitable for replenishing cells lost through SCI. Following injury, transplanted ENSC-derived cells survived and ChABC successfully degraded CSPGs. We observed significant reductions in the injured tissue and cavity area, with the greatest improvements seen in the combined treatment group. ENSC-derived cells extended projections across the injury site into both the rostral and caudal host spinal cord, and ENSC transplantation significantly increased the number of cells extending axons across the injury site. Furthermore, the combined treatment resulted in a modest, but significant functional improvement by week 16, and we found no evidence of the spread of transplanted cells to ectopic locations or formation of tumours. CONCLUSIONS Regenerative effects of a combined treatment with ENSCs and ChABC surpassed either treatment alone, highlighting the importance of further research into combinatorial therapies for SCI. Our work provides evidence that stem cells taken from the adult gastrointestinal tract, an easily accessible source for autologous transplantation, could be strongly considered for the repair of central nervous system disorders.
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Affiliation(s)
- Benjamin Jevans
- Stem Cells and Regenerative Medicine, UCL Great Ormond Street Institute of Child Health, London, UK
- Present Address: German Centre for Neurodegenerative diseases (DZNE), Bonn, Germany
| | - Nicholas D James
- Regeneration Group, The Wolfson Centre for Age-Related Diseases, Institute of Psychiatry, Psychology & Neuroscience, King's College London, Guy's Campus, London, UK
| | - Emily Burnside
- Regeneration Group, The Wolfson Centre for Age-Related Diseases, Institute of Psychiatry, Psychology & Neuroscience, King's College London, Guy's Campus, London, UK
| | - Conor J McCann
- Stem Cells and Regenerative Medicine, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Nikhil Thapar
- Stem Cells and Regenerative Medicine, UCL Great Ormond Street Institute of Child Health, London, UK
- Neurogastroenterology and Motility Unit, Department of Gastroenterology, Great Ormond Street Hospital, London, UK
- Present Address: Department of Paediatric Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, Brisbane, Australia
| | - Elizabeth J Bradbury
- Regeneration Group, The Wolfson Centre for Age-Related Diseases, Institute of Psychiatry, Psychology & Neuroscience, King's College London, Guy's Campus, London, UK
| | - Alan J Burns
- Stem Cells and Regenerative Medicine, UCL Great Ormond Street Institute of Child Health, London, UK.
- Department of Clinical Genetics, Erasmus Medical Center, Rotterdam, The Netherlands.
- Present Address: Gastrointestinal Drug Discovery Unit, Takeda Pharmaceuticals International, Cambridge, USA.
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4
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Zhao Y, Ge X, Yu H, Kuil LE, Alves MM, Tian D, Huang Q, Chen X, Hofstra RMW, Gao Y. Inhibition of ROCK signaling pathway accelerates enteric neural crest cell-based therapy after transplantation in a rat hypoganglionic model. Neurogastroenterol Motil 2020; 32:e13895. [PMID: 32515097 DOI: 10.1111/nmo.13895] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 04/23/2020] [Accepted: 05/05/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Hirschsprung's disease (HSCR) is a congenital gastrointestinal disorder, characterized by enteric ganglia absence in part or entire of the colon, due to abnormal colonization and migration of enteric neural crest cells (ENCCs) during development. Currently, besides surgery which is the main therapy for HSCR, the potential of stem cell-based transplantation was investigated as an alternative option. Although promising, it has limitations, including poor survival, differentiation, and migration of the grafted cells. We hypothesized that modulation of extracellular factors during transplantation could promote ENCCs proliferation and migration, leading to increased transplantation efficiency. Considering that the RhoA/ROCK pathway is highly involved in cytoskeletal dynamics and neurite growth, our study explored the effect of inhibition of this pathway to improve the success of ENCCs transplantation. METHODS Enteric neural crest cells were isolated from rat embryos and labeled with a GFP-tag. Cell viability, apoptosis, differentiation, and migration assays were performed with and without RhoA/ROCK inhibition. Labeled ENCCs were transplanted into the muscle layer of an induced hypoganglionic rat model followed by intraperitoneal injections of ROCK inhibitor. The transplanted segments were collected 3 weeks after for histological analysis. KEY RESULTS Our results showed that inhibition of ROCK increased viable cell number, differentiation, and migration of ENCCs in vitro. Moreover, transplantation of labeled ENCCs into the hypoganglionic model showed enhanced distribution of grafted ENCCs, upon treatment with ROCK inhibitor. CONCLUSIONS AND INFERENCES ROCK inhibitors influence ENCCs growth and migration in vitro and in vivo, and should be considered to improve the efficiency of ENCCs transplantation.
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Affiliation(s)
- Yuying Zhao
- Department of Pediatric Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.,Department of Clinical Genetics, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Xin Ge
- Department of Pediatric Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Hui Yu
- Department of Pediatric Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Laura E Kuil
- Department of Clinical Genetics, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Maria M Alves
- Department of Clinical Genetics, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Donghao Tian
- Department of Pediatric Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Qiang Huang
- Department of Pediatric Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Xinlin Chen
- Institute of Neurobiology, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, China
| | - Robert M W Hofstra
- Department of Clinical Genetics, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ya Gao
- Department of Pediatric Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
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5
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Intravital three-dimensional bioprinting. Nat Biomed Eng 2020; 4:901-915. [DOI: 10.1038/s41551-020-0568-z] [Citation(s) in RCA: 78] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 05/08/2020] [Indexed: 01/14/2023]
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6
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Dubois VP, Zotova D, Parkins KM, Swick C, Hamilton AM, Kelly JJ, Ronald JA. Safe Harbor Targeted CRISPR-Cas9 Tools for Molecular-Genetic Imaging of Cells in Living Subjects. CRISPR J 2018; 1:440-449. [PMID: 31021241 DOI: 10.1089/crispr.2018.0030] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Noninvasive molecular-genetic imaging of cells expressing imaging reporter genes is an invaluable approach for longitudinal monitoring of the biodistribution and viability of cancer cells and cell-based therapies in preclinical models and patients. However, labeling cells with reporter genes often relies on using gene transfer methods that randomly integrate the reporter genes into the genome, which may cause unwanted and serious detrimental effects. To overcome this, we have developed CRISPR-Cas9 tools to edit cells at the adeno-associated virus site 1 (AAVS1) safe harbour with a large donor construct (∼6.3 kilobases) encoding an antibiotic resistance gene and reporter genes for bioluminescence (BLI) and fluorescence imaging. HEK293T cells were transfected with a dual plasmid system encoding the Cas9 endonuclease and an AAVS1-targeted guide RNA in one plasmid, and a donor plasmid encoding a puromycin resistance gene, tdTomato and firefly luciferase flanked by AAVS1 homology arms. Puromycin-resistant clonal cells were isolated and AAVS1 integration was confirmed via PCR and sequencing of the PCR product. In vitro BLI signal correlated well to cell number (R2 = 0.9988; p < 0.05) and was stable over multiple passages. Engineered cells (2.5 × 106) were injected into the left hind flank of nude mice and in vivo BLI was performed on days 0, 7, 14, 21, and 28. BLI signal trended down from day 0 to day 7, but significantly increased by day 28 due to cell growth (p < 0.05). This describes the first CRISPR-Cas9 system for AAVS1 integration of large gene constructs for molecular-genetic imaging of cells in vivo. With further development, including improving editing efficiency, use of clinically relevant reporters, and evaluation in other cell populations that can be readily expanded in culture (e.g., immortalized cells or T cells), this CRISPR-Cas9 reporter gene system could be broadly applied to a number of in vivo cell tracking studies.
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Affiliation(s)
- Veronica P Dubois
- 1 Department of Medical Biophysics, Western University , London, Ontario, Canada.,2 Imaging Research Laboratories, Robarts Research Institute , London, Ontario, Canada
| | - Darya Zotova
- 2 Imaging Research Laboratories, Robarts Research Institute , London, Ontario, Canada
| | - Katie M Parkins
- 1 Department of Medical Biophysics, Western University , London, Ontario, Canada
| | - Connor Swick
- 2 Imaging Research Laboratories, Robarts Research Institute , London, Ontario, Canada
| | - Amanda M Hamilton
- 2 Imaging Research Laboratories, Robarts Research Institute , London, Ontario, Canada
| | - John J Kelly
- 2 Imaging Research Laboratories, Robarts Research Institute , London, Ontario, Canada
| | - John A Ronald
- 1 Department of Medical Biophysics, Western University , London, Ontario, Canada.,2 Imaging Research Laboratories, Robarts Research Institute , London, Ontario, Canada.,3 Lawson Health Research Institute, London, Ontario, Canada
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7
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Jevans B, McCann CJ, Thapar N, Burns AJ. Transplanted enteric neural stem cells integrate within the developing chick spinal cord: implications for spinal cord repair. J Anat 2018; 233:592-606. [PMID: 30191559 DOI: 10.1111/joa.12880] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2018] [Indexed: 12/27/2022] Open
Abstract
Spinal cord injury (SCI) causes paralysis, multisystem impairment and reduced life expectancy, as yet with no cure. Stem cell therapy can potentially replace lost neurons, promote axonal regeneration and limit scar formation, but an optimal stem cell source has yet to be found. Enteric neural stem cells (ENSC) isolated from the enteric nervous system (ENS) of the gastrointestinal (GI) tract are an attractive source. Here, we used the chick embryo to assess the potential of ENSC to integrate within the developing spinal cord. In vitro, isolated ENSC formed extensive cell connections when co-cultured with spinal cord (SC)-derived cells. Further, qRT-PCR analysis revealed the presence of TuJ1+ neurons, S100+ glia and Sox10+ stem cells within ENSC neurospheres, as well as expression of key neuronal subtype genes, at levels comparable to SC tissue. Following ENSC transplantation to an ablated region of chick embryo SC, donor neurons were found up to 12 days later. These neurons formed bridging connections within the SC injury zone, aligned along the anterior/posterior axis, and were immunopositive for TuJ1. These data provide early proof of principle support for the use of ENSCs for SCI, and encourage further research into their potential for repair.
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Affiliation(s)
- Benjamin Jevans
- Stem Cells and Regenerative Medicine, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Conor J McCann
- Stem Cells and Regenerative Medicine, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Nikhil Thapar
- Stem Cells and Regenerative Medicine, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Alan J Burns
- Stem Cells and Regenerative Medicine, UCL Great Ormond Street Institute of Child Health, London, UK.,Department of Clinical Genetics, Erasmus Medical Center, Rotterdam, The Netherlands.,Gastrointestinal Drug Discovery Unit, Takeda Pharmaceuticals International, Cambridge, MA, USA
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8
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Gurung S, Deane JA, Darzi S, Werkmeister JA, Gargett CE. In Vivo Survival of Human Endometrial Mesenchymal Stem Cells Transplanted Under the Kidney Capsule of Immunocompromised Mice. Stem Cells Dev 2018; 27:35-43. [DOI: 10.1089/scd.2017.0177] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
- Shanti Gurung
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - James A. Deane
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Saeedeh Darzi
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Jerome A. Werkmeister
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
- CSIRO Manufacturing, Clayton South, Victoria, Australia
| | - Caroline E. Gargett
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
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9
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Boesmans W, Hao MM, Vanden Berghe P. Optogenetic and chemogenetic techniques for neurogastroenterology. Nat Rev Gastroenterol Hepatol 2018; 15:21-38. [PMID: 29184183 DOI: 10.1038/nrgastro.2017.151] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Optogenetics and chemogenetics comprise a wide variety of applications in which genetically encoded actuators and indicators are used to modulate and monitor activity with high cellular specificity. Over the past 10 years, development of these genetically encoded tools has contributed tremendously to our understanding of integrated physiology. In concert with the continued refinement of probes, strategies to target transgene expression to specific cell types have also made much progress in the past 20 years. In addition, the successful implementation of optogenetic and chemogenetic techniques thrives thanks to ongoing advances in live imaging microscopy and optical technology. Although innovation of optogenetic and chemogenetic methods has been primarily driven by researchers studying the central nervous system, these techniques also hold great promise to boost research in neurogastroenterology. In this Review, we describe the different classes of tools that are currently available and give an overview of the strategies to target them to specific cell types in the gut wall. We discuss the possibilities and limitations of optogenetic and chemogenetic technology in the gut and provide an overview of their current use, with a focus on the enteric nervous system. Furthermore, we suggest some experiments that can advance our understanding of how the intrinsic and extrinsic neural networks of the gut control gastrointestinal function.
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Affiliation(s)
- Werend Boesmans
- Laboratory for Enteric Neuroscience (LENS), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Herestraat 49, O&N 1 Box 701, 3000 Leuven, Belgium.,Department of Pathology, Maastricht University Medical Center, P. Debeijelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Marlene M Hao
- Laboratory for Enteric Neuroscience (LENS), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Herestraat 49, O&N 1 Box 701, 3000 Leuven, Belgium.,Department of Anatomy and Neuroscience, University of Melbourne, Parkville, Victoria 3010, Australia
| | - Pieter Vanden Berghe
- Laboratory for Enteric Neuroscience (LENS), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Herestraat 49, O&N 1 Box 701, 3000 Leuven, Belgium
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10
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Stamp LA, Gwynne RM, Foong JPP, Lomax AE, Hao MM, Kaplan DI, Reid CA, Petrou S, Allen AM, Bornstein JC, Young HM. Optogenetic Demonstration of Functional Innervation of Mouse Colon by Neurons Derived From Transplanted Neural Cells. Gastroenterology 2017; 152:1407-1418. [PMID: 28115057 DOI: 10.1053/j.gastro.2017.01.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 12/21/2016] [Accepted: 01/09/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND & AIMS Cell therapy offers the potential to treat gastrointestinal motility disorders caused by diseased or absent enteric neurons. We examined whether neurons generated from transplanted enteric neural cells provide a functional innervation of bowel smooth muscle in mice. METHODS Enteric neural cells expressing the light-sensitive ion channel, channelrhodopsin, were isolated from the fetal or postnatal mouse bowel and transplanted into the distal colon of 3- to 4-week-old wild-type recipient mice. Intracellular electrophysiological recordings of responses to light stimulation of the transplanted cells were made from colonic smooth muscle cells in recipient mice. Electrical stimulation of endogenous enteric neurons was used as a control. RESULTS The axons of graft-derived neurons formed a plexus in the circular muscle layer. Selective stimulation of graft-derived cells by light resulted in excitatory and inhibitory junction potentials, the electrical events underlying contraction and relaxation, respectively, in colonic muscle cells. Graft-derived excitatory and inhibitory motor neurons released the same neurotransmitters as endogenous motor neurons-acetylcholine and a combination of adenosine triphosphate and nitric oxide, respectively. Graft-derived neurons also included interneurons that provided synaptic inputs to motor neurons, but the pharmacologic properties of interneurons varied with the age of the donors from which enteric neural cells were obtained. CONCLUSIONS Enteric neural cells transplanted into the bowel give rise to multiple functional types of neurons that integrate and provide a functional innervation of the smooth muscle of the bowel wall. Circuits composed of both motor neurons and interneurons were established, but the age at which cells are isolated influences the neurotransmitter phenotype of interneurons that are generated.
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Affiliation(s)
- Lincon A Stamp
- Department of Anatomy and Neuroscience, University of Melbourne, Melbourne, Victoria, Australia
| | - Rachel M Gwynne
- Department of Anatomy and Neuroscience, University of Melbourne, Melbourne, Victoria, Australia
| | - Jaime P P Foong
- Department of Physiology, University of Melbourne, Melbourne, Victoria, Australia
| | - Alan E Lomax
- Gastrointestinal Diseases Research Unit, Queen's University, Kingston, Ontario, Canada
| | - Marlene M Hao
- Department of Anatomy and Neuroscience, University of Melbourne, Melbourne, Victoria, Australia
| | - David I Kaplan
- The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Christopher A Reid
- The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Steven Petrou
- The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Andrew M Allen
- Department of Physiology, University of Melbourne, Melbourne, Victoria, Australia
| | - Joel C Bornstein
- Department of Physiology, University of Melbourne, Melbourne, Victoria, Australia
| | - Heather M Young
- Department of Anatomy and Neuroscience, University of Melbourne, Melbourne, Victoria, Australia.
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11
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Cooper JE, Natarajan D, McCann CJ, Choudhury S, Godwin H, Burns AJ, Thapar N. In vivo transplantation of fetal human gut-derived enteric neural crest cells. Neurogastroenterol Motil 2017; 29:e12900. [PMID: 27380932 PMCID: PMC5215633 DOI: 10.1111/nmo.12900] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 06/07/2016] [Indexed: 12/12/2022]
Abstract
The prospect of using neural cell replacement for the treatment of severe enteric neuropathies has seen significant progress in the last decade. The ability to harvest and transplant enteric neural crest cells (ENCCs) that functionally integrate within recipient intestine has recently been confirmed by in vivo murine studies. Although similar cells can be harvested from human fetal and postnatal gut, no studies have as yet verified their functional viability upon in vivo transplantation. We sought to determine whether ENCCs harvested from human fetal bowel are capable of engraftment and functional integration within recipient intestine following in vivo transplantation into postnatal murine colon. Enteric neural crest cells selected and harvested from fetal human gut using the neurotrophin receptor p75NTR were lentivirally labeled with either GFP or calcium-sensitive GCaMP and transplanted into the hindgut of Rag2- /γc- /C5- -immunodeficient mice at postnatal day 21. Transplanted intestines were assessed immunohistochemically for engraftment and differentiation of donor cells. Functional viability and integration with host neuromusculature was assessed using calcium imaging. Transplanted human fetal gut-derived ENCC showed engraftment within the recipient postnatal colon in 8/15 mice (53.3%). At 4 weeks posttransplantation, donor cells had spread from the site of transplantation and extended projections over distances of 1.2 ± 0.6 mm (n = 5), and differentiated into enteric nervous system (ENS) appropriate neurons and glia. These cells formed branching networks located with the myenteric plexus. Calcium transients (change in intensity F/F0 = 1.25 ± 0.03; 15 cells) were recorded in transplanted cells upon stimulation of the recipient endogenous ENS demonstrating their viability and establishment of functional connections.
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Affiliation(s)
- J. E. Cooper
- Stem Cells and Regenerative MedicineUCL Institute of Child HealthLondonUK
| | - D. Natarajan
- Stem Cells and Regenerative MedicineUCL Institute of Child HealthLondonUK
| | - C. J. McCann
- Stem Cells and Regenerative MedicineUCL Institute of Child HealthLondonUK
| | - S. Choudhury
- Stem Cells and Regenerative MedicineUCL Institute of Child HealthLondonUK
| | - H. Godwin
- Department of GastroenterologyGreat Ormond Street Hospital NHS Foundation TrustLondonUK
| | - A. J. Burns
- Stem Cells and Regenerative MedicineUCL Institute of Child HealthLondonUK,Department of Clinical GeneticsErasmus MCRotterdamThe Netherlands
| | - N. Thapar
- Stem Cells and Regenerative MedicineUCL Institute of Child HealthLondonUK,Department of GastroenterologyGreat Ormond Street Hospital NHS Foundation TrustLondonUK
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12
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Stamp LA, Young HM. Recent advances in regenerative medicine to treat enteric neuropathies: use of human cells. Neurogastroenterol Motil 2017; 29. [PMID: 28028898 DOI: 10.1111/nmo.12993] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 10/18/2016] [Indexed: 12/21/2022]
Abstract
As current options for treating most enteric neuropathies are either non-effective or associated with significant ongoing problems, cell therapy is a potential attractive possibility to treat congenital and acquired neuropathies. Studies using animal models have shown that following transplantation of enteric neural progenitors into the bowel of recipients, the transplanted cells migrate, proliferate, and generate neurons that are electrically active and receive synaptic inputs. Recent studies have transplanted human enteric neural progenitors into the mouse colon and shown engraftment. In this article, we summarize the significance of these recent advances and discuss priorities for future research that might lead to the use of regenerative medicine to treat enteric neuropathies in the clinic.
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Affiliation(s)
- L A Stamp
- Department of Anatomy & Neuroscience, University of Melbourne, Parkville, Vic., Australia
| | - H M Young
- Department of Anatomy & Neuroscience, University of Melbourne, Parkville, Vic., Australia
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13
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Buckinx R, Timmermans JP. Targeting the gastrointestinal tract with viral vectors: state of the art and possible applications in research and therapy. Histochem Cell Biol 2016; 146:709-720. [PMID: 27665281 DOI: 10.1007/s00418-016-1496-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2016] [Indexed: 12/11/2022]
Abstract
While there is a large body of preclinical data on the use of viral vectors in gene transfer, relatively little is known about viral gene transfer in the gastrointestinal tract. Viral vector technology is especially underused in the field of neurogastroenterology when compared to brain research. This review provides an overview of the studies employing viral vectors-in particular retroviruses, adenoviruses and adeno-associated viruses-to transduce different cell types in the intestine. Early work mainly focused on mucosal transduction, but had limited success due to the harsh luminal conditions in the gastrointestinal tract and the high turnover rate of enterocytes. More recently, several studies have successfully employed viral gene transfer to target the enteric nervous system and its progenitors. Although several hurdles still need to be overcome, in particular on how to augment transduction efficiency and specific cell targeting, viral vector technology holds strong potential not only as a valid research tool in fundamental gastroenterological research but also as a therapeutic agent in translational (bio)medical research.
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Affiliation(s)
- Roeland Buckinx
- Laboratory of Cell Biology and Histology, Department of Veterinary Sciences, University of Antwerp, Antwerp, Belgium
| | - Jean-Pierre Timmermans
- Laboratory of Cell Biology and Histology, Department of Veterinary Sciences, University of Antwerp, Antwerp, Belgium.
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14
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Detection of autophagy in Hirschsprung's disease: implication for its role in aganglionosis. Neuroreport 2016; 26:1044-50. [PMID: 26509546 DOI: 10.1097/wnr.0000000000000465] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Hirschsprung's disease (HD) is a common congenital gastrointestinal malformation, characterized by the lack of ganglion cells from the distal rectum to the proximal bowel, but the pathogenesis is not well understood. This paper evaluates the effects of autophagy in HD. Using electron microscopy, the autophagosomes were detected in three segments: narrow segment (NS), transitional segment (TS), and dilated segment (DS). Typical autophagosome structures are found in the Auerbach plexus of both NS and TS. Real-time PCR results showed that Beclin1 (NS vs. TS, P<0.01) and LC3 (NS vs. TS, P<0.05) mRNA were the highest in the NS, but p75 (NS vs. TS, P<0.01) was the highest in the DS. Correlation analysis results showed a positive correlation between Beclin1 and LC3 mRNA levels (R=0.736, P=0.000), whereas inverse correlations were found between p75 and Beclin1/LC3 mRNA levels (p75 vs. Beclin1: R=-0.714, P=0.000; p75 vs. LC3: R=-0.619, P=0.000). Immunohistochemistry analyses indicated a consistent result with mRNA levels, by increased Beclin1-positive and LC3-positive neurons, but reduced p75-positive neurons in the Auerbach plexus of TS compared with DS. These findings indicated that autophagy exists in the bowel of patients with HD. On the basis of the detection of the highest expression of the autophagy genes in NS, autophagy may additionally cause the lack of neurons.
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15
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Nontoxicity of lentiviral vector infection to viability, migration, apoptosis, and differentiation of postnatal rat enteric neural crest-derived cells. Neuroreport 2016; 26:883-9. [PMID: 26308553 DOI: 10.1097/wnr.0000000000000441] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Lentiviral vector infection of enhanced green fluorescent protein fluorescence reporter genes in enteric neural crest-derived cells maintained efficient, stable, long-term labeling and the infected enteric neural crest-derived cells could survive, proliferate, and express fluorescent reporter genes. However, the method does not show whether there is some defined or undefined toxicity to the enteric neural crest-derived cells, which may affect enteric neural crest-derived cells' properties. Here, we evaluated the enteric neural crest-derived cells properties under the influence of lentivirus infection of enhanced green fluorescent protein fluorescence reporter genes. This study used the cell count kit-8 for measurement of vitality, transwell for cell migration, immunocytochemistry for cell count and identification, and tested the apoptosis of the enteric neural crest-derived cells with flow cytometry. The enteric neural crest-derived cells with or without lentivirus and their derivative enteric neural crest-derived cells could form characteristic neurospheres, and maintain their level of fluorescent label steady. When cultured under inducing conditions, enteric neural crest-derived cells differentiated into neurons and glia. The results showed that the enteric neural crest-derived cells with or without lentivirus showed no significant difference in viability, migration, apoptosis, neuronal, and glial ratio. The study identified that lentivirus can be used in a nontoxic manner for infection of enhanced green fluorescent protein fluorescence reporter genes into enteric neural crest-derived cells.
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16
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Burns AJ, Goldstein AM, Newgreen DF, Stamp L, Schäfer KH, Metzger M, Hotta R, Young HM, Andrews PW, Thapar N, Belkind-Gerson J, Bondurand N, Bornstein JC, Chan WY, Cheah K, Gershon MD, Heuckeroth RO, Hofstra RMW, Just L, Kapur RP, King SK, McCann CJ, Nagy N, Ngan E, Obermayr F, Pachnis V, Pasricha PJ, Sham MH, Tam P, Vanden Berghe P. White paper on guidelines concerning enteric nervous system stem cell therapy for enteric neuropathies. Dev Biol 2016; 417:229-51. [PMID: 27059883 DOI: 10.1016/j.ydbio.2016.04.001] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 03/29/2016] [Accepted: 04/02/2016] [Indexed: 12/22/2022]
Abstract
Over the last 20 years, there has been increasing focus on the development of novel stem cell based therapies for the treatment of disorders and diseases affecting the enteric nervous system (ENS) of the gastrointestinal tract (so-called enteric neuropathies). Here, the idea is that ENS progenitor/stem cells could be transplanted into the gut wall to replace the damaged or absent neurons and glia of the ENS. This White Paper sets out experts' views on the commonly used methods and approaches to identify, isolate, purify, expand and optimize ENS stem cells, transplant them into the bowel, and assess transplant success, including restoration of gut function. We also highlight obstacles that must be overcome in order to progress from successful preclinical studies in animal models to ENS stem cell therapies in the clinic.
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Affiliation(s)
- Alan J Burns
- Stem Cells and Regenerative Medicine, UCL Great Ormond Street Institute of Child Health, London, UK; Department of Clinical Genetics, Erasmus Medical Center, Rotterdam, The Netherlands.
| | - Allan M Goldstein
- Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Donald F Newgreen
- Murdoch Childrens Research Institute, Royal Children's Hospital, Parkville 3052, Victoria, Australia
| | - Lincon Stamp
- Department of Anatomy and Neuroscience, University of Melbourne, Parkville, Victoria 3010, Australia
| | - Karl-Herbert Schäfer
- University of Applied Sciences, Kaiserlautern, Germany; Clinic of Pediatric Surgery, University Hospital Mannheim, University Heidelberg, Germany
| | - Marco Metzger
- Fraunhofer-Institute Interfacial Engineering and Biotechnology IGB Translational Centre - Würzburg branch and University Hospital Würzburg - Tissue Engineering and Regenerative Medicine (TERM), Würzburg, Germany
| | - Ryo Hotta
- Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Heather M Young
- Department of Anatomy and Neuroscience, University of Melbourne, Parkville, Victoria 3010, Australia
| | - Peter W Andrews
- Centre for Stem Cell Biology, Department of Biomedical Science, University of Sheffield, Sheffield, UK
| | - Nikhil Thapar
- Stem Cells and Regenerative Medicine, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Jaime Belkind-Gerson
- Division of Gastroenterology, Hepatology and Nutrition, Massachusetts General Hospital for Children, Harvard Medical School, Boston, USA
| | - Nadege Bondurand
- INSERM U955, 51 Avenue du Maréchal de Lattre de Tassigny, F-94000 Créteil, France; Université Paris-Est, UPEC, F-94000 Créteil, France
| | - Joel C Bornstein
- Department of Physiology, University of Melbourne, Parkville, Victoria 3010, Australia
| | - Wood Yee Chan
- School of Biomedical Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
| | - Kathryn Cheah
- School of Biomedical Sciences, The University of Hong Kong, Hong Kong
| | - Michael D Gershon
- Department of Pathology and Cell Biology, Columbia University, New York 10032, USA
| | - Robert O Heuckeroth
- Department of Pediatrics, The Children's Hospital of Philadelphia Research Institute, Philadelphia, PA 19104, USA; Perelman School of Medicine at the University of Pennsylvania, Abramson Research Center, Philadelphia, PA 19104, USA
| | - Robert M W Hofstra
- Stem Cells and Regenerative Medicine, UCL Great Ormond Street Institute of Child Health, London, UK; Department of Clinical Genetics, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Lothar Just
- Institute of Clinical Anatomy and Cell Analysis, University of Tübingen, Germany
| | - Raj P Kapur
- Department of Pathology, University of Washington and Seattle Children's Hospital, Seattle, WA, USA
| | - Sebastian K King
- Department of Paediatric and Neonatal Surgery, The Royal Children's Hospital, Melbourne, Australia
| | - Conor J McCann
- Stem Cells and Regenerative Medicine, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Nandor Nagy
- Department of Anatomy, Histology and Embryology, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Elly Ngan
- Department of Surgery, The University of Hong Kong, Hong Kong
| | - Florian Obermayr
- Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital Tübingen, D-72076 Tübingen, Germany
| | | | | | - Mai Har Sham
- Department of Biochemistry, The University of Hong Kong, Hong Kong
| | - Paul Tam
- Department of Surgery, The University of Hong Kong, Hong Kong
| | - Pieter Vanden Berghe
- Laboratory for Enteric NeuroScience (LENS), TARGID, University of Leuven, Belgium
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17
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Hotta R, Cheng L, Graham H, Pan W, Nagy N, Belkind-Gerson J, Goldstein AM. Isogenic enteric neural progenitor cells can replace missing neurons and glia in mice with Hirschsprung disease. Neurogastroenterol Motil 2016; 28:498-512. [PMID: 26685978 PMCID: PMC4808355 DOI: 10.1111/nmo.12744] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 11/04/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND Transplanting autologous patient-derived enteric neuronal stem/progenitor cells (ENSCs) is an innovative approach to replacing missing enteric neurons in patients with Hirschsprung disease (HSCR). Using autologous cells eliminates immunologic and ethical concerns raised by other cell sources. However, whether postnatal aganglionic bowel is permissive for transplanted ENSCs and whether ENSCs from HSCR patients can be successfully isolated, cultured, and transplanted in vivo remains unknown. METHODS ENSCs isolated from the ganglionic intestine of Ednrb(-/-) mice (HSCR-ENSCs) were characterized immunohistochemically and evaluated for their capacity to proliferate and differentiate in vitro. Fluorescently labeled ENSCs were co-cultured ex vivo with aganglionic Ednrb(-/-) colon. For in vivo transplantation, HSCR-ENSCs were labeled with lentivirus expressing green fluorescent protein (GFP) and implanted into aganglionic embryonic chick gut in ovo and postnatal aganglionic Ednrb(-/-) rectum in vivo. KEY RESULTS HSCR-ENSCs maintain normal capacity self-renewal and neuronal differentiation. Moreover, the Ednrb(-/-) aganglionic environment is permissive to engraftment by wild-type ENSCs ex vivo and supports migratrion and neuroglial differentiation of these cells following transplantation in vivo. Lentiviral GFP-labeled HSCR-ENSCs populated embryonic chick hindgut and postnatal colon of Ednrb(-/-) HSCR, with cells populating the intermuscular layer and forming enteric neurons and glia. CONCLUSIONS & INFERENCES ENSCs can be isolated and cultured from mice with HSCR, and transplanted into the aganglionic bowel of HSCR littermates to generate enteric neuronal networks. These results in an isogenic model establish the potential of using autologous-derived stem cells to treat HSCR and other intestinal neuropathies.
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Affiliation(s)
| | | | | | | | | | | | - Allan M. Goldstein
- ,Corresponding Author: Allan M. Goldstein, Massachusetts General Hospital, Warren 1153, Boston, MA 02114, Tel: 617-726-0270, Fax: 617-726-2167,
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18
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Hotta R, Cheng L, Graham HK, Nagy N, Belkind-Gerson J, Mattheolabakis G, Amiji MM, Goldstein AM. Delivery of enteric neural progenitors with 5-HT4 agonist-loaded nanoparticles and thermosensitive hydrogel enhances cell proliferation and differentiation following transplantation in vivo. Biomaterials 2016; 88:1-11. [PMID: 26922325 DOI: 10.1016/j.biomaterials.2016.02.016] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 02/12/2016] [Accepted: 02/15/2016] [Indexed: 12/29/2022]
Abstract
Cell therapy offers an innovative approach for treating enteric neuropathies. Postnatal gut-derived enteric neural stem/progenitor cells (ENSCs) represent a potential autologous source, but have a limited capacity for proliferation and neuronal differentiation. Since serotonin (5-HT) promotes enteric neuronal growth during embryonic development, we hypothesized that serotonin receptor agonism would augment growth of neurons from transplanted ENSCs. Postnatal ENSCs were isolated from 2 to 4 week-old mouse colon and cultured with 5-HT4 receptor agonist (RS67506)-loaded liposomal nanoparticles. ENSCs were co-cultured with mouse colon explants in the presence of RS67506-loaded (n = 3) or empty nanoparticles (n = 3). ENSCs were also transplanted into mouse rectum in vivo with RS67506-loaded (n = 8) or blank nanoparticles (n = 4) confined in a thermosensitive hydrogel, Pluronic F-127. Neuronal density and proliferation were analyzed immunohistochemically. Cultured ENSCs gave rise to significantly more neurons in the presence of RS67506-loaded nanoparticles. Similarly, colon explants had significantly increased neuronal density when RS67506-loaded nanoparticles were present. Finally, following in vivo cell delivery, co-transplantation of ENSCs with 5-HT4 receptor agonist-loaded nanoparticles led to significantly increased neuronal density and proliferation. We conclude that optimization of postnatal ENSCs can support their use in cell-based therapies for neurointestinal diseases.
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Affiliation(s)
- Ryo Hotta
- Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Lily Cheng
- Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Hannah K Graham
- Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Nandor Nagy
- Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Department of Human Morphology and Developmental Biology, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Jaime Belkind-Gerson
- Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - George Mattheolabakis
- Department of Pharmaceutical Sciences, School of Pharmacy, Bouve College of Health Sciences, Northeastern University, MA, USA
| | - Mansoor M Amiji
- Department of Pharmaceutical Sciences, School of Pharmacy, Bouve College of Health Sciences, Northeastern University, MA, USA
| | - Allan M Goldstein
- Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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