Cell transplantation as an experimental treatment for Duchenne muscular dystrophy

In vitro-generated human muscle reserve cells are heterogeneous for Pax7 with distinct molecular states and metabolic profiles

BACKGROUND

The capacity of skeletal muscles to regenerate relies on Pax7+ muscle stem cells (MuSC). While in vitro-amplified MuSC are activated and lose part of their regenerative capacity, in vitro-generated human muscle reserve cells (MuRC) are very similar to quiescent MuSC with properties required for their use in cell-based therapies.

METHODS

In the present study, we investigated the heterogeneity of human MuRC and characterized their molecular signature and metabolic profile.

RESULTS

We observed that Notch signaling is active and essential for the generation of quiescent human Pax7+ MuRC in vitro. We also revealed, by immunofluorescence and flow cytometry, two distinct subpopulations of MuRC distinguished by their relative Pax7 expression. After 48 h in differentiation medium (DM), the Pax7High subpopulation represented 35% of the total MuRC pool and this percentage increased to 61% after 96 h in DM. Transcriptomic analysis revealed that Pax7High MuRC were less primed for myogenic differentiation as compared to Pax7Low MuRC and displayed a metabolic shift from glycolysis toward fatty acid oxidation. The bioenergetic profile of human MuRC displayed a 1.5-fold decrease in glycolysis, basal respiration and ATP-linked respiration as compared to myoblasts. We also observed that AMPKα1 expression was significantly upregulated in human MuRC that correlated with an increased phosphorylation of acetyl-CoA carboxylase (ACC). Finally, we showed that fatty acid uptake was increased in MuRC as compared to myoblasts, whereas no changes were observed for glucose uptake.

CONCLUSIONS

Overall, these data reveal that the quiescent MuRC pool is heterogeneous for Pax7 with a Pax7High subpopulation being in a deeper quiescent state, less committed to differentiation and displaying a reduced metabolic activity. Altogether, our data suggest that human Pax7High MuRC may constitute an appropriate stem cell source for potential therapeutic applications in skeletal muscle diseases.

Mesenchymal Stem Cell Transplantation for the Treatment of Age-Related Musculoskeletal Frailty

Projected life expectancy continues to grow worldwide owing to the advancement of new treatments and technologies leading to rapid growth of geriatric population. Thus, age-associated diseases especially in the musculoskeletal system are becoming more common. Loss of bone (osteoporosis) and muscle (sarcopenia) mass are conditions whose prevalence is increasing because of the change in population distribution in the world towards an older mean age. The deterioration in the bone and muscle functions can cause severe disability and seriously affects the patients’ quality of life. Currently, there is no treatment to prevent and reverse age-related musculoskeletal frailty. Existing interventions are mainly to slow down and control the signs and symptoms. Mesenchymal stem cell (MSC) transplantation is a promising approach to attenuate age-related musculoskeletal frailty. This review compiles the present knowledge of the causes and changes of the musculoskeletal frailty and the potential of MSC transplantation as a regenerative therapy for age-related musculoskeletal frailty.

Co-Transplantation of Bone Marrow-MSCs and Myogenic Stem/Progenitor Cells from Adult Donors Improves Muscle Function of Patients with Duchenne Muscular Dystrophy

Duchenne muscular dystrophy (DMD) is a genetic disorder associated with a progressive deficiency of dystrophin that leads to skeletal muscle degeneration. In this study, we tested the hypothesis that a co-transplantation of two stem/progenitor cell populations, namely bone marrow-derived mesenchymal stem cells (BM-MSCs) and skeletal muscle-derived stem/progenitor cells (SM-SPCs), directly into the dystrophic muscle can improve the skeletal muscle function of DMD patients. Three patients diagnosed with DMD, confirmed by the dystrophin gene mutation, were enrolled into a study approved by the local Bioethics Committee (no. 79/2015). Stem/progenitor cells collected from bone marrow and skeletal muscles of related healthy donors, based on HLA matched antigens, were expanded in a closed MC3 cell culture system. A simultaneous co‑transplantation of BM-MSCs and SM-SPCs was performed directly into the biceps brachii (two patients) and gastrocnemius (one patient). During a six‑month follow‑up, the patients were examined with electromyography (EMG) and monitored for blood kinase creatine level. Muscle biopsies were examined with histology and assessed for dystrophin at the mRNA and protein level. A panel of 27 cytokines was analysed with multiplex ELISA. We did not observe any adverse effects after the intramuscular administration of cells. The efficacy of BM‑MSC and SM‑SPC application was confirmed through an EMG assessment by an increase in motor unit parameters, especially in terms of duration, amplitude range, area, and size index. The beneficial effect of cellular therapy was confirmed by a decrease in creatine kinase levels and a normalised profile of pro-inflammatory cytokines. BM-MSCs may support the pro-regenerative potential of SM-SPCs thanks to their trophic, paracrine, and immunomodulatory activity. Both applied cell populations may fuse with degenerating skeletal muscle fibres in situ, facilitating skeletal muscle recovery. However, further studies are required to optimise the dose and timing of stem/progenitor cell delivery.

The Importance of Biophysical and Biochemical Stimuli in Dynamic Skeletal Muscle Models

Classical approaches to engineer skeletal muscle tissue based on current regenerative and surgical procedures still do not meet the desired outcome for patient applications. Besides the evident need to create functional skeletal muscle tissue for the repair of volumetric muscle defects, there is also growing demand for platforms to study muscle-related diseases, such as muscular dystrophies or sarcopenia. Currently, numerous studies exist that have employed a variety of biomaterials, cell types and strategies for maturation of skeletal muscle tissue in 2D and 3D environments. However, researchers are just at the beginning of understanding the impact of different culture settings and their biochemical (growth factors and chemical changes) and biophysical cues (mechanical properties) on myogenesis. With this review we intend to emphasize the need for new in vitro skeletal muscle (disease) models to better recapitulate important structural and functional aspects of muscle development. We highlight the importance of choosing appropriate system components, e.g., cell and biomaterial type, structural and mechanical matrix properties or culture format, and how understanding their interplay will enable researchers to create optimized platforms to investigate myogenesis in healthy and diseased tissue. Thus, we aim to deliver guidelines for experimental designs to allow estimation of the potential influence of the selected skeletal muscle tissue engineering setup on the myogenic outcome prior to their implementation. Moreover, we offer a workflow to facilitate identifying and selecting different analytical tools to demonstrate the successful creation of functional skeletal muscle tissue. Ultimately, a refinement of existing strategies will lead to further progression in understanding important aspects of muscle diseases, muscle aging and muscle regeneration to improve quality of life of patients and enable the establishment of new treatment options.

Muscle Stem/Progenitor Cells and Mesenchymal Stem Cells of Bone Marrow Origin for Skeletal Muscle Regeneration in Muscular Dystrophies

Muscular dystrophies represent a group of diseases which may develop in several forms, and severity of the disease is usually associated with gene mutations. In skeletal muscle regeneration and in muscular dystrophies, both innate and adaptive immune responses are involved. The regenerative potential of mesenchymal stem/stromal cells (MSCs) of bone marrow origin was confirmed by the ability to differentiate into diverse tissues and by their immunomodulatory and anti-inflammatory properties by secretion of a variety of growth factors and anti-inflammatory cytokines. Skeletal muscle comprises different types of stem/progenitor cells such as satellite cells and non-satellite stem cells including MSCs, interstitial stem cells positive for stress mediator PW1 expression and negative for PAX7 called PICs (PW1⁺/PAX7⁻ interstitial cells), fibro/adipogenic progenitors/mesenchymal stem cells, muscle side population cells and muscle resident pericytes, and all of them actively participate in the muscle regeneration process. In this review, we present biological properties of MSCs of bone marrow origin and a heterogeneous population of muscle-resident stem/progenitor cells, their interaction with the inflammatory environment of dystrophic muscle and potential implications for cellular therapies for muscle regeneration. Subsequently, we propose—based on current research results, conclusions, and our own experience—hypothetical mechanisms for modulation of the complete muscle regeneration process to treat muscular dystrophies.

Hybrid Muscular Tissues: Preparation of Skeletal Muscle Cell-Incorporated Collagen Gels

We prepared three different types of hybrid muscular tissues in which C2C12 cells (skeletal muscle myoblast cell line) were incorporated in type I collagen gels and then differentiated to myotubes upon culture: a disctype, a polyester mesh-reinforced sheet-type, and a tubular type. A cold mixed solution of the cells and type I collagen was poured into three different types of molds and was kept at 37°C in an incubator to form C2C12 cell-incorporated gels. A polyester mesh was incorporated into a gel to form the sheet-type tissue. The tubular hybrid tissue was prepared by pouring a mixed solution into the interstitial space of a tubular mold consisting of an outer sheath and a mandrel and subsequently culturing after removal of the outer sheath. Hybrid tissues were incubated in a growth medium (20% fetal bovine serum medium) for the first 4 days and then in a differentiation medium (2% horse serum medium) to induce formation of myotubes. Transparent fragile gels shrank with time to form opaque gels, irrespective of type, resulting in the formation of quite dense hybrid tissues. On day 14 of incubation, myoblasts fused and differentiated to form multinucleated myotubes. For a tubular type hybrid tissue, both cells and collagen fiber bundles became circumferentially oriented with incubation time. Periodic mechanical stress loading to a mesh-reinforced hybrid tissue accelerated the cellular orientation along the axis of the stretch. The potential applications for use as living tissue substitutes in damaged and diseased skeletal and cardiac muscle and as vascular grafts are discussed.

A Potential Alternative Strategy for Myoblast Transfer Therapy: The use of Sliced Muscle Grafts

Excellent long-term survival (up to 1 yr) of donor skeletal muscle cells was demonstrated using a mouse Y-chromosome specific probe, following the transplantation of grafts of whole muscles from male “normal” C57B1/10Sn mice into dystrophic muscles of female host mice. After the transplantation of equivalent sliced muscle grafts there was extensive movement of the male donor cells and fusion with host myofibres. This contrasts with the extremely poor survival of isolated myoblasts after injection into the same mouse model for Duchenne muscular dystrophy. The use of sliced muscle grafts may therefore represent a potential alternative approach to myoblast transfer therapy.

Laminin 521 maintains differentiation potential of mouse and human satellite cell-derived myoblasts during long-term culture expansion

Background

Large-scale expansion of myogenic progenitors is necessary to support the development of high-throughput cellular assays in vitro and to advance genetic engineering approaches necessary to develop cellular therapies for rare muscle diseases. However, optimization has not been performed in order to maintain the differentiation capacity of myogenic cells undergoing long-term cell culture. Multiple extracellular matrices have been utilized for myogenic cell studies, but it remains unclear how different matrices influence long-term myogenic activity in culture. To address this challenge, we have evaluated multiple extracellular matrices in myogenic studies over long-term expansion.

Methods

We evaluated the consequence of propagating mouse and human myogenic stem cell progenitors on various extracellular matrices to determine if they could enhance long-term myogenic potential. For the first time reported, we comprehensively examine the effect of physiologically relevant laminins, laminin 211 and laminin 521, compared to traditionally utilized ECMs (e.g., laminin 111, gelatin, and Matrigel) to assess their capacity to preserve myogenic differentiation potential.

Results

Laminin 521 supported increased proliferation in early phases of expansion and was the only substrate facilitating high-level fusion following eight passages in mouse myoblast cell cultures. In human myoblast cell cultures, laminin 521 supported increased proliferation during expansion and superior differentiation with myotube hypertrophy. Counterintuitively however, laminin 211, the native laminin isoform in resting skeletal muscle, resulted in low proliferation and poor differentiation in mouse and human cultures. Matrigel performed excellent in short-term mouse studies but showed high amounts of variability following long-term expansion.

Conclusions

These results demonstrate laminin 521 is a superior substrate for both short-term and long-term myogenic cell culture applications compared to other commonly utilized substrates. Since Matrigel cannot be used for clinical applications, we propose that laminin 521 could possibly be employed in the future to provide myoblasts for cellular therapy directed clinical studies.

Electronic supplementary material

The online version of this article (doi:10.1186/s13395-016-0116-4) contains supplementary material, which is available to authorized users.

Imaging Approaches in Functional Assessment of Implantable Myogenic Biomaterials and Engineered Muscle Tissue

The fields of tissue engineering and regenerative medicine utilize implantable biomaterials and engineered tissues to regenerate damaged cells or replace lost tissues. There are distinct challenges in all facets of this research, but functional assessments and monitoring of such complex environments as muscle tissues present the current strategic priority. Many extant methods for addressing these questions result in the destruction or alteration of tissues or cell populations under investigation. Modern advances in non-invasive imaging modalities present opportunities to rethink some of the anachronistic methods, however, their standard employment may not be optimal when considering advancements in myology. New image analysis protocols and/or combinations of established modalities need to be addressed. This review focuses on efficacies and limitations of available imaging modalities to the functional assessment of implantable myogenic biomaterials and engineered muscle tissues.

Influence of immune responses in gene/stem cell therapies for muscular dystrophies

Muscular dystrophies (MDs) are a heterogeneous group of diseases, caused by mutations in different components of sarcolemma, extracellular matrix, or enzymes. Inflammation and innate or adaptive immune response activation are prominent features of MDs. Various therapies under development are directed toward rescuing the dystrophic muscle damage using gene transfer or cell therapy. Here we discussed current knowledge about involvement of immune system responses to experimental therapies in MDs.

Strategies to improve regeneration of the soft palate muscles after cleft palate repair

Children with a cleft in the soft palate have difficulties with speech, swallowing, and sucking. These patients are unable to separate the nasal from the oral cavity leading to air loss during speech. Although surgical repair ameliorates soft palate function by joining the clefted muscles of the soft palate, optimal function is often not achieved. The regeneration of muscles in the soft palate after surgery is hampered because of (1) their low intrinsic regenerative capacity, (2) the muscle properties related to clefting, and (3) the development of fibrosis. Adjuvant strategies based on tissue engineering may improve the outcome after surgery by approaching these specific issues. Therefore, this review will discuss myogenesis in the noncleft and cleft palate, the characteristics of soft palate muscles, and the process of muscle regeneration. Finally, novel therapeutic strategies based on tissue engineering to improve soft palate function after surgical repair are presented.

TGF-β1 enhances contractility in engineered skeletal muscle

Scaffoldless engineered 3D skeletal muscle tissue created from satellite cells offers the potential to replace muscle tissue that is lost due to severe trauma or disease. Transforming growth factor-beta 1 (TGF-β1) plays a vital role in mediating migration and differentiation of satellite cells during the early stages of muscle development. Additionally, TGF-β1 promotes collagen type I synthesis in the extracellular matrix (ECM) of skeletal muscle, which provides a passive elastic substrate to support myofibres and facilitate the transmission of force. To determine the role of TGF-β1 in skeletal muscle construct formation and contractile function in vitro, we created tissue-engineered 3D skeletal muscle constructs with varying levels of recombinant TGF-β1 added to the cell culture medium. Prior to the addition of TGF-β1, the primary cell population was composed of 75% Pax7-positive cells. The peak force for twitch, tetanus and spontaneous force were significantly increased in the presence of 2.0 ng/ml TGF-β1 when compared to 0, 0.5 and 1.0 ng/ml TGF-β1. Visualization of the cellular structure with H&E and with immunofluorescence staining for sarcomeric myosin heavy chains and collagen type I showed denser regions of better organized myofibres in the presence of 2.0 ng/ml TGF-β1 versus 0, 0.5 and 1.0 ng/ml. The addition of 2.0 ng/ml TGF-β1 to the culture medium of engineered 3D skeletal muscle constructs enhanced contractility and extracellular matrix organization.

Engineering skeletal muscle tissue--new perspectives in vitro and in vivo

Muscle tissue engineering (TE) has not yet been clinically applied because of several problems. However, the field of skeletal muscle TE has been developing tremendously and new approaches and techniques have emerged. This review will highlight recent developments in the field of nanotechnology, especially electrospun nanofibre matrices, as well as potential cell sources for muscle TE. Important developments in cardiac muscle TE and clinical studies on Duchenne muscular dystrophy (DMD) will be included to show their implications on skeletal muscle TE.

Advances in musculoskeletal tissue engineering: moving towards therapy

Skeletal muscle can self-repair, but is unable to restore significant tissue loss, as consequence of trauma, congenital defects, tumor ablation or denervation. Intramuscular injection of autologous or allogenic derived myogenic cells (namely satellite cells and myoblasts) did not lead to efficient regeneration because of poor cell retention and survival, as well as immunorejection. In the last decade, tissue engineering looked at overcoming these problems by investigating alternative treatment options, i.e., the suspension of myogenic precursors in temporary matrix, formed by biodegradable and biocompatible materials. This approach allows to engineer custom architectured preconditioned implants, and locally deliver paracrine factors.This article reviews current and potential strategies for the repair of damaged muscle and suggests some innovative approaches for the translation to the clinical setting.

Tissue engineering approach to repair abdominal wall defects using cell-seeded bovine tunica vaginalis in a rabbit model

The aim of this study was to engineer skeletal muscle tissue for repair abdominal wall defects. Myoblast were seeded onto the scaffolds and cultivated in vitro for 5 days. Full thickness abdominal wall defects (3 x 4 cm) were created in 18 male New Zealand white rabbits and randomly divided into two equal groups. The defects of the first group were repaired with myoblast-seeded-bovine tunica vaginalis whereas the second group repaired with non-seeded-bovine tunica vaginalis and function as a control. Three animals were sacrificed at 7th, 14th, and 30th days of post-implantation from each group and the explanted specimens were subjected to macroscopic and microscopic analysis. In every case, seeded scaffolds have better deposition of newly formed collagen with neo-vascularisation than control group. Interestingly, multinucleated myotubes and myofibers were only detected in cell-seeded group. This study demonstrated that myoblast-seeded-bovine tunica vaginalis can be used as an effective scaffold to repair severe and large abdominal wall defects with regeneration of skeletal muscle tissue.

The development of genipin-crosslinked poly(caprolactone) (PCL)/gelatin nanofibers for tissue engineering applications

Composite nanofibers of poly(caprolactone) (PCL) and gelatin crosslinked with genipin are prepared. The contact angles and mechanical properties of crosslinked PCL-gelatin nanofibers decrease as the gelatin content increases. The proliferation of myoblasts is higher in the crosslinked PCL-gelatin nanofibers than in the PCL nanofibers, and the formation of myotubes is only observed on the crosslinked PCL-gelatin nanofibers. The expression level of myogenin, myosin heavy chain, and troponin T genes is increased as the gelatin content is increased. The results suggest that PCL-gelatin nanofibers crosslinked with genipin can be used as a substrate to modulate proliferation and differentiation of myoblasts, presenting potential applications in muscle tissue engineering.

Mesenchymal stem cells as anti-inflammatories: implications for treatment of Duchenne muscular dystrophy

Duchenne muscular dystrophy (DMD) is a lethal X-linked musculodegenerative condition consisting of an underlying genetic defect whose manifestation is augmented by inflammatory mechanisms. Previous treatment approaches using gene replacement, exon-skipping or allogeneic cell therapy have been relatively unsuccessful. The only intervention to mediate improvement in survival, albeit minor, is glucocorticoid treatment. Given this modality appears to function via suppression of underlying inflammation; we focus this review on the inflammatory response as a target for mesenchymal stem cell (MSC) therapy. In contrast to other cell based therapies attempted in DMD, MSC have the advantages of (a) ability to fuse with and genetically complement dystrophic muscle; (b) possess anti-inflammatory activities; and (c) produce trophic factors that may augment activity of endogenous repair cells. We conclude by describing one practical scenario of stem cell therapy for DMD.

Development and progress of engineering of skeletal muscle tissue

Engineering skeletal muscle tissue remains still a challenge, and numerous studies have indicated that this technique may be of great importance in medicine in the near future. This article reviews some of the recent findings resulting from tissue engineering science related to the contractile behavior and the phenotypes of muscle tissue cells in different three-dimensional environment, and discusses how tissue engineering could be used to create and regenerate skeletal muscle, as well as the extended applications and the related patents concerned with engineered skeletal muscle.

Fabrication of skeletal muscle constructs by topographic activation of cell alignment

Skeletal muscle fiber construction for tissue-engineered grafts requires assembly of unidirectionally aligned juxtaposed myotubes. To construct such a tissue, a polymer microchip with linearly aligned microgrooves was fabricated that could direct myoblast adaptation under stringent conditions. The closely spaced microgrooves fabricated by a modified replica molding process guided linear cellular alignment. Examination of the myoblasts by immunofluorescence microscopy demonstrated that the microgrooves with subcellular widths and appropriate height-to-width ratios were required for practically complete linear alignment of myoblasts. The topology-dependent cell alignment encouraged differentiation of myoblasts into multinucleate, myosin heavy chain positive myotubes. The monolayer of myotubes formed on the microstructured chips allowed attachment, growth and differentiation of subsequent layers of linearly arranged myoblasts, parallel to the primary monolayer of myotubes. The consequent deposition of additional myoblasts on the previous layer of myotubes resulted in three-dimensional multi-layered structures of myotubes, typical of differentiated skeletal muscle tissue. The findings demonstrate that the on-chip device holds promise for providing an efficient means for guided muscle tissue construction.

Tissue engineering in head and neck reconstructive surgery: what type of tissue do we need?

Craniofacial tissue loss due to congenital defects, disease or injury is a major clinical problem. The head and neck region is composed of several tissues. The most prevalent method of reconstruction is autologous grafting. Often, there is insufficient host tissue for adequate repair of the defect side, and extensive donor site morbidity may result from the secondary surgical procedure. The field of tissue engineering has the potential to create functional replacements for damaged or pathologic tissues.

Craniofacial muscle engineering using a 3-dimensional phosphate glass fibre construct

The current technique to replace missing craniofacial skeletal muscle is the surgical transfer of local or free flaps. This is associated with donor site morbidity, possible tissue rejection and limited supply. The alternative is to engineer autologous skeletal muscle in vitro, which can then be re-implanted into the patient. A variety of biomaterials have been used to engineer skeletal muscle with limited success. This study investigated the use of phosphate-based glass fibres as a potential scaffold material for the in vitro engineering of craniofacial skeletal muscle. Human masseter (one of the muscles of mastication)--derived cell cultures were used to seed the glass fibres, which were arranged into various configurations. Growth factors and matrix components were to used to manipulate the in vitro environment. Outcome was determined with the aid of microscopy, time-lapse footage, immunofluorescence imaging and CyQUANT proliferation, creatine kinase and protein assays. A 3-dimensional mesh arrangement of the glass fibres was the best at encouraging cell attachment and proliferation. In addition, increasing the density of the seeded cells and using Matrigel and insulin-like growth factor I enhanced the formation of prototypic muscle fibres. In conclusion, phosphate-based glass fibres can support the in vitro engineering of human craniofacial muscle.

Skeletal muscle tissue engineering

The reconstruction of skeletal muscle tissue either lost by traumatic injury or tumor ablation or functional damage due to myopathies is hampered by the lack of availability of functional substitution of this native tissue. Until now, only few alternatives exist to provide functional restoration of damaged muscle tissues. Loss of muscle mass and their function can surgically managed in part using a variety of muscle transplantation or transposition techniques. These techniques represent a limited degree of success in attempts to restore the normal functioning, however they are not perfect solutions. A new alternative approach to addressing difficult tissue reconstruction is to engineer new tissues. Although those tissue engineering techniques attempting regeneration of human tissues and organs have recently entered into clinical practice, the engineering of skeletal muscle tissue ist still a scientific challenge. This article reviews some of the recent findings resulting from tissue engineering science related to the attempt of creation and regeneration of functional skeletal muscle tissue.

Evolving therapeutic strategies for Duchenne muscular dystrophy: targeting downstream events

Duchenne muscular dystrophy (DMD) is a progressive, lethal, muscle wasting disease that affects 1 of 3500 boys born worldwide. The disease results from mutation of the dystrophin gene that encodes a cytoskeletal protein associated with the muscle cell membrane. Although gene therapy will likely provide the cure for DMD, it remains on the distant horizon, emphasizing the need for more rapid development of palliative treatments that build on improved understanding of the complex pathology of dystrophin deficiency. In this review, we have focused on therapeutic strategies that target downstream events in the pathologic progression of DMD. Much of this work has been developed initially using the dystrophin-deficient mdx mouse to explore basic features of the pathophysiology of dystrophin deficiency and to test potential therapeutic interventions to slow, reverse, or compensate for functional losses that occur in muscular dystrophy. In some cases, the initial findings in the mdx model have led to clinical treatments for DMD boys that have produced improvements in muscle function and quality of life. Many of these investigations have concerned interventions that can affect protein balance in muscle, by inhibiting specific proteases implicated in the DMD pathology, or by providing anabolic factors or depleting catabolic factors that can contribute to muscle wasting. Other investigations have exploited the use of anti-inflammatory agents that can reduce the contribution of leukocytes to promoting secondary damage to dystrophic muscle. A third general strategy is designed to increase the regenerative capacity of dystrophic muscle and thereby help retain functional muscle mass. Each of these general approaches to slowing the pathology of dystrophin deficiency has yielded encouragement and suggests that targeting downstream events in dystrophinopathy can yield worthwhile, functional improvements in DMD.

Dystrophin expression in myofibers of Duchenne muscular dystrophy patients following intramuscular injections of normal myogenic cells

Three Duchenne muscular dystrophy (DMD) patients received injections of myogenic cells obtained from skeletal muscle biopsies of normal donors. The cells (30 x 10 (6)) were injected in 1 cm3 of the tibialis anterior by 25 parallel injections. We performed similar patterns of saline injections in the contralateral muscles as controls. The patients received tacrolimus for immunosuppression. Muscle biopsies were performed at the injected sites 4 weeks later. We observed dystrophin-positive myofibers in the cell-grafted sites amounting to 9 (patient 1), 6.8 (patient 2), and 11% (patient 3). Since patients 1 and 2 had identified dystrophin-gene deletions these results were obtained using monoclonal antibodies specific to epitopes coded by the deleted exons. Donor dystrophin was absent in the control sites. Patient 3 had exon duplication and thus specific donor-dystrophin detection was not possible. However, there were fourfold more dystrophin-positive myofibers in the cell-grafted than in the control site. Donor-dystrophin transcripts were detected by RT-PCR (using primers reacting with a sequence int eh deleted exons) only in the cell-grafted sites in patients 1 and 2. Dystrophin transcripts were more abundant in the cell-grafted than in the control site in patient 3. Therefore, significant dystrophin expression can be obtained in teh skeletal muscles of DMD patients following specific conditions of cell delivery and immunosuppression.

Engineering of muscle tissue

The loss or failure of an organ or tissue is one of the most frequent, devastating, and costly problems in health care. Tissue engineering and regenerative medicine is an emerging interdisciplinary field that applies the principles of biology and engineering to the development of viable substitutes that restore, maintain, or improve the function of human tissues and organs. Tissue engineering science has provided critical new knowledge that will deepen our understanding of the phenotype of an important category of cell types-the muscle cells-and this knowledge may enable meaningful advances in musculoskeletal tissue engineering. There are two principle strategies for the replacement of impaired muscle tissues. One approach uses the application of isolated and differentiated cells (in vivo tissue engineering), using a transport matrix for the cell delivery; the other uses in vitro-designed and pre-fabricated tissue equivalents (in vitro tissue engineering). Future developments and the decision regarding which approach is more promising depend on the elucidation of the relationships among cell growth and differentiation, the three-dimensional environment, the architecture of the cells, and gene expression of the developmental process and the survival of the cells and integration in the host in in vivo experiments. As the techniques of tissue engineering become more sophisticated and as issues such as vascularization and innervation are addressed, the usefulness of these methods for reconstructive surgery may grow significantly.

Transplantation of normal and DMD myoblasts expressing the telomerase gene in SCID mice

The limited proliferative capacity of dystrophic human myoblasts severely limits their ability to be genetically modified and used for myoblast transplantation. The forced expression of the catalytic subunit of telomerase can prevent telomere erosion and can immortalize different cell types. We thus tested the ability of telomerase to immortalize myoblasts and analyzed the effect of telomerase expression on the success of myoblast transplantation. Telomerase expression did not significantly extend the human myoblast life span. The telomerase expressing myoblasts were nonetheless competent to participate in myofiber formation after infection with the retroviral vector. Although the new fibers obtained are less numerous than after the transplantation of normal myoblasts, these results demonstrate that the forced expression of telomerase does not block the ability of normal or dystrophic myoblasts to differentiate in vivo. It will be now necessary to determine the factors that prevent telomerase from extending the life span of human myoblasts before the potential of this intervention can be fully examined.

Myoblast transplantation in whole muscle of nonhuman primates

The goal of the present study was to determine the feasibility, success, and toxicity of myoblast transplantation (MT) in the whole muscle of primates. Allogenic myoblasts transduced with the beta-galactosidase (beta-Gal) gene were transplanted in the whole Biceps brachii of 5 monkeys immunosuppressed with FK506. Myoblast injections were spaced at every 1 to 1.5 mm in 7 muscles, as well as at every 5 mm in 2 muscles. Myoblasts were resuspended in HBSS, notexin 1 microg/ml or notexin 5 microg/ml. Depending on the number of beta-Gal labeled myoblasts and the injection protocol, biopsies of transplanted muscles exhibited 7% to 74% beta-Gal+ fibers 1 month after MT. Beta-Gal+ fibers were present in muscle biopsies made 3, 8, and 12 months after MT. Myoglobinuria and hyperkalemia, the risk factors after extensive muscle damage and notexin toxicity, were not observed. The withdrawal of immunosuppression led to histological evidences of cellular rejection of the graft. We concluded that MT can be successfully performed in large primate muscles without toxicity due to muscle damage. An effective immunosuppression allowed the maintenance of beta-Gal+ fibers up to 1 year after MT. These results suggest parameters that may allow effective MT in humans.

Plasma membrane cytoskeleton of muscle: a fine structural analysis

The discovery of dystrophin and its definition as the causative molecule in Duchenne Muscular Dystrophy has led to a renewed interest in the molecular structure of the muscle fiber plasma membrane and its association with the extracellular basal lamina. The original identification of dystrophin gave credence to the possibility that the plasma membrane of the muscle fiber may be highly organized and involved in maintaining appropriate homeostasis in this actively contracting cellular system. In this review, we examine the currently known members of the muscle fiber plasma membrane cytoskeleton and the interactions that occur between the different members of this complex using histological, electron microscopic, and confocal methods. From our studies and others cited in this review, it is clear that the dystrophin cytoskeletal complex is not completely understood and component molecules continue to be discovered. Perhaps equally importantly, currently defined molecules (such as alpha-actinin or neuronal nitric oxide synthase) are being recognized as being specifically associated with the complex. What is striking from all of the studies, to date, is that while we are able to identify members of the dystrophin cytoskeletal complex and while we are able to associate mutations of individual molecules with disease(s), we are still unable to truly define the roles of each of the molecules in maintaining the normal physiology of the muscle fiber.

Progress in myoblast transplantation: a potential treatment of dystrophies

Myoblast transplantation (MT) consists of injecting normal or genetically modified myogenic cells into muscles, where they are expected to fuse and form mature fibers. As an experimental approach to treat severe genetic muscle diseases, MT was tested in dystrophic patients at the beginning of the 1990s. Although these early clinical trials were unsuccessful, MT has progressed through the research on animal models. Many factors that may condition the success of MT were identified in the last years. The present review updates our knowledge on MT and describes the different problems that have limited its success. Factors that were first underestimated, like the specific immune response after MT, are presently well characterized. Destruction of the hybrid fibers by activated T-lymphocytes and production of antibodies against the transplanted myoblasts take place after MT and are responsible for the graft rejection. The choice of the immunosuppression seems to be very important, and FK506 is the best agent known to allow the best results after MT. Under FK506 immunosuppression, very efficient MT were obtained both in mice and monkeys. Moreover, in dystrophic mice it was demonstrated that MT ameliorates some phenotypical characteristics of the disease. The improvement of the survival of the transplanted cells and the increase of their migration into the injected tissue are presently under investigation. Some of the present research is directed also to bypass the immunosuppression by using the patient's own cells for MT. In this sense, efforts are conducted to introduce the normal gene into the patient's myoblasts before MT and to improve the ability of these cells to proliferate in vitro. Micros. Res. Tech. 48:213-222, 2000.

Dynamics of myoblast transplantation reveal a discrete minority of precursors with stem cell-like properties as the myogenic source

Myoblasts, the precursors of skeletal muscle fibers, can be induced to withdraw from the cell cycle and differentiate in vitro. Recent studies have also identified undifferentiated subpopulations that can self-renew and generate myogenic cells (Baroffio, A., M. Hamann, L. Bernheim, M.-L. Bochaton-Pillat, G. Gabbiani, and C.R. Bader. 1996. Differentiation. 60:47-57; Yoshida, N., S. Yoshida, K. Koishi, K. Masuda, and Y. Nabeshima. 1998. J. Cell Sci. 111:769-779). Cultured myoblasts can also differentiate and contribute to repair and new muscle formation in vivo, a capacity exploited in attempts to develop myoblast transplantation (MT) for genetic modification of adult muscle. Our studies of the dynamics of MT demonstrate that cultures of myoblasts contain distinct subpopulations defined by their behavior in vitro and divergent responses to grafting. By comparing a genomic and a semiconserved marker, we have followed the fate of myoblasts transplanted into muscles of dystrophic mice, finding that the majority of the grafted cells quickly die and only a minority are responsible for new muscle formation. This minority is behaviorally distinct, slowly dividing in tissue culture, but rapidly proliferative after grafting, suggesting a subpopulation with stem cell-like characteristics.

Transplantation of dermal fibroblasts expressing MyoD1 in mouse muscles

Transplantation of normal myoblasts into dystrophic muscles is a potential treatment for Duchenne muscular dystrophy (DMD). However, the success of such grafts is limited by the immune system responses. To avoid rejection problems, autologous transplantation of the patient's corrected myoblasts has been proposed. Regretfully, the low proliferative capacity of DMD myoblasts in culture (due to their premature senescence) limits such procedure. On the other hand, modification of dermal fibroblasts leading to the myogenic pathway using a master regulatory gene for myogenesis is an interesting alternative approach. In this study, the retrovirally encoded MyoD1 cDNA was introduced in dermal fibroblasts of TnI LacZ mice to provoke their conversion into myoblast-like cells. In vitro and in vivo assays were done and the results were compared to those obtained with uninfected fibroblasts and myoblasts. Some MyoD1-expressing fibroblasts were able to fuse and to express beta-galactosidase (under the transcriptional control of the Troponin I promoter), dystrophin and desmin in vitro. Thirty days following implantation of these modified fibroblasts in muscles of mdx mice, an average of 7 beta-Gal+/Dys-muscle fibers were observed. No beta-Gal+ fibers were observed after the transplantation of uninfected fibroblasts. Our results indicate that the successful implantation of myoblasts obtained from genetically modified fibroblasts is indeed feasible. However, the in vitro conversion rate and the in vivo fusion of genetically modified fibroblasts must be largely increased to consider this approach as a potential therapy for DMD and other myopathies.

Successful transplantation of genetically corrected DMD myoblasts following ex vivo transduction with the dystrophin minigene

Myoblast transplantation and gene therapy are two promising therapeutical approaches for the treatment of Duchenne Muscular Dystrophy (DMD). So far, both strategies have met many hurdles, mainly because of immune reactions. In this study, we investigated a third and novel strategy based on the combination of these two basic ones, i.e., transplantation of genetically modified myoblasts. We first derived a primary culture from a muscle biopsy of a young DMD patient (3 years old). Adenoviral-mediated dystrophin gene transfer into these DMD cultures and expression of the dystrophin transgene were achieved in vitro. The transduced cultures were then transplanted the same day in immunodeficient SCID mouse muscles. Three weeks following the graft, many human dystrophin-positive fibers were observed throughout sections of the injected muscles. However, many fibers expressed human MHC antigens without expressing human dystrophin due to the low percentage of infected primary muscle cells in vitro (even when a high MOI [400] was used) and to a reduction and even to a complete loss of transgene copy number during myoblast replication. From our results, we conclude that, although not at a high proportion, (1) DMD primary myoblast cultures are infectable by adenoviruses; (2) they can be efficiently transplanted back in a muscle, leading to normal fusion of infected myoblasts with the host fibers; and (3) they can correct the dystrophin deficiency in the host fibers by the expression of a mini-dystrophin transgene.

Myoblast transplantation in non-dystrophic dog

Dog myoblasts obtained from muscle biopsies were infected in vitro with a defective retroviral vector containing a cytoplasmic beta-galactosidase (beta-Gal) gene. These myoblasts were initially transplanted in the irradiated muscles of SCID mice and beta-Gal positive muscle fibers were observed. beta-Gal myoblasts were also transplanted back either in the donor dogs (autotransplantation model) or in unrelated recipient dogs (allotransplantation model). Following these myoblast injections, a rapid inflammatory reaction developed within the muscle as indicated by an expression of P-selectin and of pro-inflammatory cytokine mRNAs (interleukin 6 (IL-6) and transforming growth factor beta (TGF-beta), and by a neutrophil infiltration. Following either auto- or allotransplantation in inadequately or non-immunosuppressed dogs, a specific immune reaction also developed within 2 weeks as indicated by the infiltration of CD4+ and of CD8+ lymphocytes, the increased expression of IL-10 and granzyme B mRNAs and the presence of antibodies reacting with the injected cells. Some dogs were immunosuppressed with several combinations of FK506, cyclosporine (CsA) and RS-61443. In dogs immunosuppressed with CsA combined with RS-61443, only a few myoblasts and myotubes expressing beta-Gal were observed 1-2 weeks after the transplantation, but no muscle fibers expressing beta-Gal were observed after 4 weeks, and antibodies against the injected cells were formed. In dogs immunosuppressed with FK506 alone, although no antibodies against the injected cells were produced, there were no small cells and no muscle fibers expressing beta-Gal 1 month after the transplantation. However, FK506 triggered diarrhea and vomiting in dogs. When the dogs were immunosuppressed with FK506 combined with CsA and RS-61443, muscle fibers expressing beta-Gal were present 4 weeks after the transplantation and no antibodies reacting with donor myoblasts were detected. These results indicate that the combination of three immunosuppressive agents (i.e., FK506, CsA and RS-61443) is effective in controlling the specific immune reactions following myoblast transplantation in dogs and they underline that the outcome of myoblast transplantation is dependent in part on an adequate immunosuppression. These results obtained here in normal dogs may justify myoblast transplantation in dystrophic dogs despite the side effects of FK506.

Prior culture with concanavalin A increases intramuscular migration of transplanted myoblast

The effect was studied of pretreatment with concanavalin A (ConA) of primary myoblast cultures on their migration when transplanted into muscles. As donors, transgenic CD1 mice in which the beta-galactosidase gene is under the control of a CMV promoter (CMVLacZ.9) were used. The myoblasts were grown with 20 microg/mL ConA during the 2 days before injecting them in the right tibialis anterior (TA) muscles of BALB/c mice and mdx mice. As a control, myoblasts from the same primary cultures were grown without ConA and injected in the left TA muscles. The host muscles were not previously irradiated or damaged by notexin injection. The recipient mice were immunosuppressed with FK506. Four days after myoblast transplantation, the area occupied by donor cells was significantly greater (more than threefold) following culture with ConA than without ConA. This result indicates that culture of myoblasts with ConA permits them to migrate farther following their transplantation in host muscles not previously damaged by notexin injection or irradiation. This suggests that pretreatment with ConA may be helpful for myoblast transplantation in humans. The mechanism of this effect still remains to be investigated.

Transplantation of myoblasts from a transgenic mouse overexpressing dystrophin prduced only a relatively small increase of dystrophin-positive membrane

Myoblast cultures from normal and Tg-MDA (transgenic mouse overexpressing dystrophin 50-fold) mice were transplanted into dystrophin-deficient mdx mouse muscles. Four weeks after transplantation, dystrophin-positive fibers were observed four times more frequently in cross sections of muscles injected with Tg-MDA. Myoblasts from Tg-MDA mice also expressing the beta-gal transgene (Tg-MDA/beta-gal) and myoblasts from beta-gal transgenic mice containing one normal dystrophin gene (normal/beta-gal) were also transplanted into mdx mouse muscles. Four weeks after transplantation, the fiber length positive for dystrophin (nuclear domain) was shorter (439 +/- 326 microm) than the beta-gal nuclear domain (1466 +/- 713 microm) of the same fiber when normal/beta-gal myoblasts were transplanted, but increased (1302 +/- 487 microm) when Tg-MDA/beta-gal myoblasts were used. These experiments show that despite the presence in Tg-MDA myoblasts of constructions which lead in vivo in transgenic mice to an overexpression of dystrophin 50-fold, the membrane area over which dystrophin was expressed was increased only threefold. This observation is also expected for vector-mediated gene therapy.

Chemotaxis of skeletal muscle satellite cells

Migration of myogenic cells occurs extensively during both embryogenesis and regeneration of skeletal muscle and is important in myoblast gene therapy, but little is known about factors that promote chemotaxis of these cells. We have used satellite cells from adult rats purified by Percoll density gradient centrifugation to test growth factors and wound fluids for chemotactic activity in blind-well Boyden chambers. Of a variety of growth factors tested only hepatocyte growth factor (HGF) and transforming growth factor-beta (TGF-beta) exhibited significant chemotactic activity. The dose-response curves for both of these factors was bell-shaped with maximum activity in the 1-10 ng/ml range. Checkerboard analysis of TGF-beta showed that chemotaxis occurred only in response to a positive concentration gradient. An extract of rat platelets also exhibited chemotactic activity for satellite cells. Half-maximal activity of this material was about 3 micrograms/ml, and there was no evidence of inhibition of migration at high concentrations. Checkerboard analysis of platelet extract exhibited evidence of both chemotaxis and chemokinesis, or increase in random motility of cells. Inhibition experiments showed that most, but not all, of the chemotactic activity in platelet extract could be blocked with a neutralizing antibody to TGF-beta. A saline extract of crushed muscle was found to contain both mitogenic and motogenic factors for satellite cells. The two activities were present in different fractions after heparin affinity chromatography. We propose that the proliferation and migration of satellite cells during regeneration is regulated by overlapping gradients of several effector molecules released at the site of muscle injury. These molecules may also be useful for enhancing the dispersion of injected myoblasts during gene therapy.

Hybrid muscular tissues: preparation of skeletal muscle cell-incorporated collagen gels

We prepared three different types of hybrid muscular tissues in which C2C12 cells (skeletal muscle myoblast cell line) were incorporated in type I collagen gels and then differentiated to myotubes upon culture: a disc-type, a polyester mesh-reinforced sheet-type, and a tubular type. A cold mixed solution of the cells and type I collagen was poured into three different types of molds and was kept at 37 degrees C in an incubator to form C2C12 cell-incorporated gels. A polyester mesh was incorporated into a gel to form the sheet-type tissue. The tubular hybrid tissue was prepared by pouring a mixed solution into the interstitial space of a tubular mold consisting of an outer sheath and a mandrel and subsequently culturing after removal of the outer sheath. Hybrid tissues were incubated in a growth medium (20% fetal bovine serum medium) for the first 4 days and then in a differentiation medium (2% horse serum medium) to induce formation of myotubes. Transparent fragile gels shrank with time to form opaque gels, irrespective of type, resulting in the formation of quite dense hybrid tissues. On day 14 of incubation, myoblasts fused and differentiated to form multinucleated myotubes. For a tubular type hybrid tissue, both cells and collagen fiber bundles became circumferentially oriented with incubation time. Periodic mechanical stress loading to a mesh-reinforced hybrid tissue accelerated the cellular orientation along the axis of the stretch. The potential applications for use as living tissue substitutes in damaged and diseased skeletal and cardiac muscle and as vascular grafts are discussed.

Objective quantification of muscle and fat in human dystrophic muscle by magnetic resonance image analysis

Information about changes in muscle composition has to date been primarily restricted to histological examination of biopsy samples or qualitative assessment of images obtained using a variety of techniques (e.g., ultrasound, CT, and MRI). We describe the development of a quantitative method for the analysis of muscle composition using MR T2 relaxation time mapping and image analysis. This approach provides an objective means of studying muscle and, when used in conjunction with force production measurements, may provide an accurate measure of response to muscle therapy.