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Atukorala I, Hannan N, Hui L. Immersed in a reservoir of potential: amniotic fluid-derived extracellular vesicles. J Transl Med 2024; 22:348. [PMID: 38609955 PMCID: PMC11010396 DOI: 10.1186/s12967-024-05154-2] [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: 11/08/2023] [Accepted: 04/02/2024] [Indexed: 04/14/2024] Open
Abstract
This review aims to encapsulate the current knowledge in extracellular vesicles extracted from amniotic fluid and amniotic fluid derived stem/stromal cells. Amniotic fluid (AF) bathes the developing fetus, providing nutrients and protection from biological and mechanical dangers. In addition to containing a myriad of proteins, immunoglobulins and growth factors, AF is a rich source of extracellular vesicles (EVs). These vesicles originate from cells in the fetoplacental unit. They are biological messengers carrying an active cargo enveloped within the lipid bilayer. EVs in reproduction are known to play key roles in all stages of pregnancy, starting from fertilisation through to parturition. The intriguing biology of AF-derived EVs (AF-EVs) in pregnancy and their untapped potential as biomarkers is currently gaining attention. EV studies in numerous animal and human disease models have raised expectations of their utility as therapeutics. Amniotic fluid stem cell and mesenchymal stromal cell-derived EVs (AFSC-EVs) provide an established supply of laboratory-made EVs. This cell-free mode of therapy is popular as an alternative to stem cell therapy, revealing similar, if not better therapeutic outcomes. Research has demonstrated the successful application of AF-EVs and AFSC-EVs in therapy, harnessing their anti-inflammatory, angiogenic and regenerative properties. This review provides an overview of such studies and discusses concerns in this emerging field of research.
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Affiliation(s)
- Ishara Atukorala
- Department of Obstetrics, Gynaecology & Newborn Health, Melbourne Medical School, The University of Melbourne, Mercy Hospital for Women, 163 Studley Road, Heidelberg, VIC, 3084, Australia.
- Department of Obstetrics, Gynaecology & Newborn Health, The Northern Centre for Health Education and Research, Northern Health, Epping, VIC, Australia.
| | - Natalie Hannan
- Department of Obstetrics, Gynaecology & Newborn Health, Melbourne Medical School, The University of Melbourne, Mercy Hospital for Women, 163 Studley Road, Heidelberg, VIC, 3084, Australia
- Department of Obstetrics, Gynaecology & Newborn Health, The Northern Centre for Health Education and Research, Northern Health, Epping, VIC, Australia
| | - Lisa Hui
- Department of Obstetrics, Gynaecology & Newborn Health, Melbourne Medical School, The University of Melbourne, Mercy Hospital for Women, 163 Studley Road, Heidelberg, VIC, 3084, Australia
- Department of Obstetrics, Gynaecology & Newborn Health, The Northern Centre for Health Education and Research, Northern Health, Epping, VIC, Australia
- Department of Perinatal Medicine, Mercy Hospital for Women, Mercy Health, Heidelberg, VIC, Australia
- Reproductive Epidemiology Group, Murdoch Children's Research Institute, Parkville, VIC, Australia
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Tonna JE, Pierce J, Brintz BJ, Bardsley T, Hatton N, Lewis G, Phillips JD, Skidmore CR, Selzman CH. A randomized, double-blinded, placebo-controlled clinical trial of sterile filtered human amniotic fluid for treatment of COVID-19. BMC Infect Dis 2023; 23:864. [PMID: 38066442 PMCID: PMC10704623 DOI: 10.1186/s12879-023-08856-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 11/30/2023] [Indexed: 12/18/2023] Open
Abstract
IMPORTANCE Acellular human amniotic fluid (hAF) is an antimicrobial and anti-inflammatory fluid that has been used to treat various pro-inflammatory conditions. In a feasibility study, we have previously demonstrated that hAF could be safely administered to severely ill patients with coronavirus disease-19 (COVID-19). The impact of acellular hAF on markers of systemic inflammation and clinical outcomes during COVID-19 infection remain unknown. OBJECTIVE To determine the safety and efficacy of acellular, sterile processed intravenously administered hAF on markers of systemic inflammation during COVID-19. DESIGN, SETTINGS AND PARTICIPANTS This single-center Phase I/II randomized, placebo controlled clinical trial enrolled adult (age ≥ 18 years) patients hospitalized for respiratory symptoms of COVID-19, including hypoxemia, tachypnea or dyspnea. The study was powered for outcomes with an anticipated enrollment of 60 patients. From 09/28/2020 to 02/04/2022 we enrolled and randomized 47 (of an anticipated 60) patients hospitalized due to COVID-19. One patient withdrew consent after randomization but prior to treatment. Safety outcomes to 30 days were collected through hospital discharge and were complete by the end of screening on 6/30/2022. INTERVENTIONS Intravenous administration of 10 cc sterile processed acellular hAF once daily for up to 5 days vs placebo. MAIN OUTCOME AND MEASURES Blood biomarkers of inflammation, including C-Reactive protein (CRP), lactate dehydrogenase, D-dimer, and interleukin-6 (IL-6), as well as safety outcomes. RESULTS Patients who were randomized to hAF (n = 23) were no more likely to have improvements in CRP from baseline to Day 6 than patients who were randomized to placebo (n = 24) hAF: -5.9 [IQR -8.2, -0.6] vs placebo: -5.9 [-9.4, -2.05]; p = 0.6077). There were no significant differences in safety outcomes or adverse events. Secondary measures of inflammation including lactate dehydrogenase, D-dimer and IL-6 were not statistically different from baseline to day 6. CONCLUSIONS AND RELEVANCE In this randomized clinical trial involving hospitalized patients with COVID-19, the intravenous administration of 10 cc of hAF daily for 5 days did not result in statistically significant differences in either safety or markers of systemic inflammation compared to placebo, though we did not achieve our enrollment target of 60 patients. TRIAL REGISTRATION This trial was registered at ClinicalTrials.gov as #NCT04497389 on 04/08/2020.
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Affiliation(s)
- Joseph E Tonna
- Department of Surgery, Division of Cardiothoracic Surgery, University of Utah Health, Salt Lake City, UT, USA
- Department of Emergency Medicine, University of Utah Health, Salt Lake City, UT, USA
| | - Jan Pierce
- Department of Medicine, Division of Hematology, Cell Therapy and Regenerative Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Benjamin J Brintz
- Department of Medicine, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Tyler Bardsley
- Department of Medicine, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Nathan Hatton
- Department of Medicine, Division of Pulmonary Medicine, University of Utah Health, Salt Lake City, UT, USA
| | - Giavonni Lewis
- Department of Surgery, Division of General Surgery, University of Utah Health, Salt Lake City, UT, USA
| | - John D Phillips
- Department of Medicine, Division of Hematology, Cell Therapy and Regenerative Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Chloe R Skidmore
- Department of Surgery, Division of Cardiothoracic Surgery, University of Utah Health, Salt Lake City, UT, USA
| | - Craig H Selzman
- Department of Surgery, Division of Cardiothoracic Surgery, University of Utah Health, Salt Lake City, UT, USA.
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Bowen CM, Ditmars FS, Gupta A, Reems JA, Fagg WS. Cell-Free Amniotic Fluid and Regenerative Medicine: Current Applications and Future Opportunities. Biomedicines 2022; 10:biomedicines10112960. [PMID: 36428527 PMCID: PMC9687956 DOI: 10.3390/biomedicines10112960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/09/2022] [Accepted: 11/15/2022] [Indexed: 11/19/2022] Open
Abstract
Amniotic fluid (AF) provides critical biological and physical support for the developing fetus. While AF is an excellent source of progenitor cells with regenerative properties, recent investigations indicate that cell-free AF (cfAF), which consists of its soluble components and extracellular vesicles, can also stimulate regenerative and reparative activities. This review summarizes published fundamental, translational, and clinical investigations into the biological activity and potential use of cfAF as a therapeutic agent. Recurring themes emerge from these studies, which indicate that cfAF can confer immunomodulatory, anti-inflammatory, and pro-growth characteristics to the target cells/tissue with which they come into contact. Another common observation is that cfAF seems to promote a return of cells/tissue to a homeostatic resting state when applied to a model of cell stress or disease. The precise mechanisms through which these effects are mediated have not been entirely defined, but it is clear that cfAF can safely and effectively treat cutaneous wounds and perhaps orthopedic degenerative conditions. Additional applications are currently being investigated, but require further study to dissect the fundamental mechanisms through which its regenerative effects are mediated. By doing so, rational design can be used to fully unlock its potential in the biotechnology lab and in the clinic.
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Affiliation(s)
- Charles M. Bowen
- Department of Surgery, The University of Texas Medical Branch at Galveston, Galveston, TX 77555, USA
- John Sealy School of Medicine, The University of Texas Medical Branch at Galveston, Galveston, TX 77555, USA
| | - Frederick S. Ditmars
- Department of Surgery, The University of Texas Medical Branch at Galveston, Galveston, TX 77555, USA
- John Sealy School of Medicine, The University of Texas Medical Branch at Galveston, Galveston, TX 77555, USA
| | - Ashim Gupta
- Future Biologics, Lawrenceville, GA 30043, USA
- BioIntegrate, Lawrenceville, GA 30043, USA
- South Texas Orthopaedic Research Institute (STORI Inc.), Laredo, TX 78045, USA
- Regenerative Orthopaedics, Noida 201301, UP, India
| | - Jo-Anna Reems
- Merakris Therapeutics, RTP Frontier 800 Park Offices Dr. Suite 3322, Research Triangle Park, NC 27709, USA
- Department of Engineering, University of Utah, Salt Lake City, UT 84112, USA
| | - William Samuel Fagg
- Department of Surgery, The University of Texas Medical Branch at Galveston, Galveston, TX 77555, USA
- Regenerative Orthopaedics, Noida 201301, UP, India
- Department of Biochemistry and Molecular Biology, The University of Texas Medical Branch at Galveston, Galveston, TX 77555, USA
- Correspondence:
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Liu N, Bowen CM, Shoja MM, Castro de Pereira KL, Dongur LP, Saad A, Russell WK, Broderick TC, Fair JH, Fagg WS. Comparative Analysis of Co-Cultured Amniotic Cell-Conditioned Media with Cell-Free Amniotic Fluid Reveals Differential Effects on Epithelial–Mesenchymal Transition and Myofibroblast Activation. Biomedicines 2022; 10:biomedicines10092189. [PMID: 36140291 PMCID: PMC9495976 DOI: 10.3390/biomedicines10092189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 08/31/2022] [Accepted: 09/01/2022] [Indexed: 11/16/2022] Open
Abstract
Myofibroblast activation is a cellular response elicited by a variety of physiological or pathological insults whereby cells initiate a coordinated response intended to eradicate the insult and then revert back to a basal state. However, an underlying theme in various disease states is persistent myofibroblast activation that fails to resolve. Based on multiple observations, we hypothesized that the secreted factors harvested from co-culturing amniotic stem cells might mimic the anti-inflammatory state that cell-free amniotic fluid (AF) elicits. We optimized an amnion epithelial and amniotic fluid cell co-culture system, and tested this hypothesis in the context of myofibroblast activation. However, we discovered that co-cultured amniotic cell conditioned media (coACCM) and AF have opposing effects on myofibroblast activation: coACCM activates the epithelial–mesenchymal transition (EMT) and stimulates gene expression patterns associated with myofibroblast activation, while AF does the opposite. Intriguingly, extracellular vesicles (EVs) purified from AF are necessary and sufficient to activate EMT and inflammatory gene expression patterns, while the EV-depleted AF potently represses these responses. In summary, these data indicate that coACCM stimulates myofibroblast activation, while AF represses it. We interpret these findings to suggest that coACCM, AF, and fractionated AF represent unique biologics that elicit different cellular responses that are correlated with a wide variety of pathological states, and therefore could have broad utility in the clinic and the lab.
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Affiliation(s)
- Naiyou Liu
- Division of Transplant, Department of Surgery, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Charles M. Bowen
- Division of Transplant, Department of Surgery, University of Texas Medical Branch, Galveston, TX 77555, USA
- John Sealy School of Medicine, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Mohammadali M. Shoja
- Division of Transplant, Department of Surgery, University of Texas Medical Branch, Galveston, TX 77555, USA
| | | | - Laxmi Priya Dongur
- Division of Transplant, Department of Surgery, University of Texas Medical Branch, Galveston, TX 77555, USA
- John Sealy School of Medicine, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Antonio Saad
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - William K. Russell
- Department of Biochemistry and Molecular Biology, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Thomas Christopher Broderick
- Merakris Therapeutics, RTP Frontier, Research Triangle Park, NC 27709, USA
- Golden LEAF Biomanufacturing Training and Education Center, North Carolina State University, Raleigh, NC 27606, USA
| | - Jeffrey H. Fair
- Division of Transplant, Department of Surgery, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - William Samuel Fagg
- Division of Transplant, Department of Surgery, University of Texas Medical Branch, Galveston, TX 77555, USA
- Department of Biochemistry and Molecular Biology, University of Texas Medical Branch, Galveston, TX 77555, USA
- Merakris Therapeutics, RTP Frontier, Research Triangle Park, NC 27709, USA
- Correspondence: ; Tel.: +1-(409)-772-2412; Fax: +1-(409)-747-7364
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Lee YS, Javan H, Reems JA, Li L, Lusty Beech J, Schaaf CI, Pierce J, Phillips JD, Selzman CH. Acellular human amniotic fluid protects the ischemic/reperfused rat myocardium. Am J Physiol Heart Circ Physiol 2022; 322:H406-H416. [DOI: 10.1152/ajpheart.00331.2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Amniotic products are potent immunomodulators utilized clinically to repair tissue injury. Little information exists regarding the potential of cell-free human amniotic fluid (hAF) to treat cardiovascular disease. Herein, we sought to determine the influence and efficacy of acellular hAF on myocardial ischemia/reperfusion injury. Processed hAF was obtained from volunteer donors at the time of elective caesarean section and manufactured using proprietary methods. Left anterior descending coronary artery ligation was performed on rats for 60 minutes. Thirty minutes after release and reperfusion, either saline or hAF was injected intramyocardially. Serial echocardiography revealed that compared to saline injected rats, hAF animals maintained their ejection fraction and did not adversely remodel through the 4-week period. This preserved ventricular function correlated with decreased infarct size, less fibrosis, and reduced expression of cytokines and infiltrating inflammatory cells. Comparative arrays of different donor hAF lots confirmed the presence of a wide array of immunomodulatory and host-defense proteins. The observed functional cardioprotection was furthermore evident when given intravenously and across multiple hAF donors. In conclusion, our data demonstrate, for the first time, the cardioprotective effect of acellular hAF on myocardial injury. These observations spanned across diverse donors and likely result from the mixture of a plethora of naturally produced cytokines, chemokines, and immune-modulating proteins rather than a single, defined mechanistic culprit. The ubiquitous availability of hAF as a cell-free solution further suggests its potential for widespread adoption as a therapy for myocardial ischemia/reperfusion injury.
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Affiliation(s)
- Young Sook Lee
- Division of Cardiothoracic Surgery, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Hadi Javan
- Division of Cardiothoracic Surgery, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Jo-Anna Reems
- Cell Therapy and Regenerative Medicine Program, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Ling Li
- Division of Cardiothoracic Surgery, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Jessica Lusty Beech
- Division of Cardiothoracic Surgery, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Christine I. Schaaf
- Division of Cardiothoracic Surgery, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Jan Pierce
- Cell Therapy and Regenerative Medicine Program, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - John D. Phillips
- Cell Therapy and Regenerative Medicine Program, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Craig H. Selzman
- Division of Cardiothoracic Surgery, University of Utah School of Medicine, Salt Lake City, UT, United States
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