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Li C, Zhou L, Sun H, Yang MM. Age-Related Macular Degeneration: A Disease of Cellular Senescence and Dysregulated Immune Homeostasis. Clin Interv Aging 2024; 19:939-951. [PMID: 38807637 PMCID: PMC11130992 DOI: 10.2147/cia.s463297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 05/11/2024] [Indexed: 05/30/2024] Open
Abstract
Age-related macular degeneration (AMD) is a degenerative ocular disease primarily affecting central vision in the elderly. Its pathogenesis is complex, involving cellular senescence and immune homeostasis dysregulation. This review investigates the interaction between these two critical biological processes in AMD pathogenesis and their impact on disease progression. Initially, cellular senescence is analyzed, with particular emphasis on retinal damage induced by senescent retinal pigment epithelial cells. Subsequently, the occurrence of immune homeostasis dysregulation within the retina and its mechanistic role in AMD areis explored. Furthermore, the paper also discusses in detail the interplay between cellular senescence and immune responses, forming a vicious cycle that exacerbates retinal damage and may influence treatment outcomes. In summary, a deeper understanding of the interrelation between cellular senescence and immune dysregulation is vital for the developing innovative therapeutic strategies for AMD.
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Affiliation(s)
- Cunzi Li
- The Second Clinical Medical College of Jinan University (Shenzhen People’s Hospital), Shenzhen, 518020, People’s Republic of China
| | - Lan Zhou
- Department of Ophthalmology, Shenzhen People’s Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, 518020, People’s Republic of China
- Post-Doctoral Scientific Research Station of Basic Medicine, Jinan University, Guangzhou, 510632, People’s Republic of China
| | - Hongyan Sun
- Department of Ophthalmology, Shenzhen People’s Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, 518020, People’s Republic of China
| | - Ming Ming Yang
- Department of Ophthalmology, Shenzhen People’s Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, 518020, People’s Republic of China
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Bang E, Hwangbo H, Kim MY, Ji SY, Kim DH, Shim JH, Moon SK, Kim GY, Cheong J, Choi YH. Urban aerosol particulate matter promotes mitochondrial oxidative stress-induced cellular senescence in human retinal pigment epithelial ARPE-19 cells. ENVIRONMENTAL TOXICOLOGY AND PHARMACOLOGY 2023; 102:104211. [PMID: 37423393 DOI: 10.1016/j.etap.2023.104211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/27/2023] [Accepted: 07/03/2023] [Indexed: 07/11/2023]
Abstract
Environmental exposure to urban particulate matter (UPM) is a serious health concern worldwide. Although several studies have linked UPM to ocular diseases, no study has reported effects of UPM exposure on senescence in retinal cells. Therefore, this study aimed to investigate the effects of UPM on senescence and regulatory signaling in human retinal pigment epithelial ARPE-19 cells. Our study demonstrated that UPM significantly promoted senescence, with increased senescence-associated β-galactosidase activity. Moreover, both mRNA and protein levels of senescence markers (p16 and p21) and the senescence-associated secretory phenotype, including IL-1β, matrix metalloproteinase-1, and -3 were upregulated. Notably, UPM increased mitochondrial reactive oxygen species-dependent nuclear factor-kappa B (NF-κB) activation during senescence. In contrast, use of NF-κB inhibitor Bay 11-7082 reduced the level of senescence markers. Taken together, our results provide the first in vitro preliminary evidence that UPM induces senescence by promoting mitochondrial oxidative stress-mediated NF-κB activation in ARPE-19 cells.
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Affiliation(s)
- EunJin Bang
- Anti-Aging Research Center, Dong-eui University, Busan 47227, Republic of Korea; Department of Biochemistry, Dong-eui University College of Korean Medicine, Busan 47227, Republic of Korea
| | - Hyun Hwangbo
- Anti-Aging Research Center, Dong-eui University, Busan 47227, Republic of Korea; Department of Biochemistry, Dong-eui University College of Korean Medicine, Busan 47227, Republic of Korea
| | - Min Yeong Kim
- Anti-Aging Research Center, Dong-eui University, Busan 47227, Republic of Korea; Department of Biochemistry, Dong-eui University College of Korean Medicine, Busan 47227, Republic of Korea
| | - Seon Yeong Ji
- Anti-Aging Research Center, Dong-eui University, Busan 47227, Republic of Korea; Department of Biochemistry, Dong-eui University College of Korean Medicine, Busan 47227, Republic of Korea
| | - Da Hye Kim
- Anti-Aging Research Center, Dong-eui University, Busan 47227, Republic of Korea; Department of Molecular Biology, Pusan National University, Busan 46241, Republic of Korea
| | - Jung-Hyun Shim
- Department of Pharmacy, College of Pharmacy, Mokpo National University, Muan 58554, Republic of Korea
| | - Sung-Kwon Moon
- Department of Food and Nutrition, Chung-Ang University, Ansung 17546, Republic of Korea
| | - Gi-Young Kim
- Department of Marine Life Science, Jeju National University, Jeju 63243, Republic of Korea
| | - Jaehun Cheong
- Department of Molecular Biology, Pusan National University, Busan 46241, Republic of Korea
| | - Yung Hyun Choi
- Anti-Aging Research Center, Dong-eui University, Busan 47227, Republic of Korea; Department of Biochemistry, Dong-eui University College of Korean Medicine, Busan 47227, Republic of Korea.
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Konar G, Flickinger Z, Sharma S, Vallone K, Lyon C, Doshier C, Lyon W, Patton JG. Damage-induced senescent immune cells regulate regeneration of the zebrafish retina. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.01.16.524296. [PMID: 36711649 PMCID: PMC9882244 DOI: 10.1101/2023.01.16.524296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Zebrafish spontaneously regenerate their retina in response to damage through the action of Müller glia. Even though Müller glia (MG) are conserved in higher vertebrates, the capacity to regenerate retinal damage is lost. Recent work has focused on the regulation of inflammation during tissue regeneration with precise temporal roles for macrophages and microglia. Senescent cells that have withdrawn from the cell cycle have mostly been implicated in aging, but are still metabolically active, releasing proinflammatory signaling molecules as part of the Senescence Associated Secretory Phenotype (SASP). Here, we discover that in response to retinal damage, a subset of cells expressing markers of microglia/macrophages also express markers of senescence. These cells display a temporal pattern of appearance and clearance during retina regeneration. Premature removal of senescent cells by senolytic treatment led to a decrease in proliferation and incomplete repair of the ganglion cell layer after NMDA damage. Our results demonstrate a role for modulation of senescent cell responses to balance inflammation, regeneration, plasticity, and repair as opposed to fibrosis and scarring.
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Affiliation(s)
| | | | - Shivani Sharma
- Department of Biological Sciences, Vanderbilt University, Nashville TN, USA
| | - Kyle Vallone
- Department of Biological Sciences, Vanderbilt University, Nashville TN, USA
| | - Charles Lyon
- Department of Biological Sciences, Vanderbilt University, Nashville TN, USA
| | - Claire Doshier
- Department of Biological Sciences, Vanderbilt University, Nashville TN, USA
| | - William Lyon
- Department of Biological Sciences, Vanderbilt University, Nashville TN, USA
| | - James G. Patton
- Department of Biological Sciences, Vanderbilt University, Nashville TN, USA
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Oxidative stress in retinal pigment epithelium impairs stem cells: a vicious cycle in age-related macular degeneration. Mol Cell Biochem 2021; 477:67-77. [PMID: 34535868 DOI: 10.1007/s11010-021-04258-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 09/02/2021] [Indexed: 10/20/2022]
Abstract
Aging, chronic oxidative stress, and inflammation are major pathogenic factors in the development and progression of age-related macular degeneration (AMD) with the loss of retinal pigment epithelium (RPE). The human RPE contains a subpopulation of progenitors (i.e., RPE stem cells-RPESCs) whose role in the RPE homeostasis is under investigation. We evaluated the paracrine effects of mature RPE cells exposed to oxidative stress (H2O2) on RPESCs behavior through co-cultural, morphofunctional, and bioinformatic approaches. RPESCs showed a decline in proliferation, an increase of the senescence-associated β-galactosidase activity, the acquisition of a senescent-like secretory phenotype (SASP), and the reduction of their stemness and differentiation competencies. IL-6 and Superoxide Dismutase 2 (SOD2) seem to be key molecules in RPESCs response to oxidative stress. Our results get insight into stress-induced senescent-associated molecular mechanisms implicated in AMD pathogenesis. The presence of chronic oxidative stress in the microenvironment reduces the RPESCs abilities, inducing and/or maintaining a pro-inflammatory retinal milieu that in turn could affect AMD onset and progression.
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Lee KS, Lin S, Copland DA, Dick AD, Liu J. Cellular senescence in the aging retina and developments of senotherapies for age-related macular degeneration. J Neuroinflammation 2021; 18:32. [PMID: 33482879 PMCID: PMC7821689 DOI: 10.1186/s12974-021-02088-0] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 01/15/2021] [Indexed: 12/16/2022] Open
Abstract
Age-related macular degeneration (AMD), a degenerative disease in the central macula area of the neuroretina and the supporting retinal pigment epithelium, is the most common cause of vision loss in the elderly. Although advances have been made, treatment to prevent the progressive degeneration is lacking. Besides the association of innate immune pathway genes with AMD susceptibility, environmental stress- and cellular senescence-induced alterations in pathways such as metabolic functions and inflammatory responses are also implicated in the pathophysiology of AMD. Cellular senescence is an adaptive cell process in response to noxious stimuli in both mitotic and postmitotic cells, activated by tumor suppressor proteins and prosecuted via an inflammatory secretome. In addition to physiological roles in embryogenesis and tissue regeneration, cellular senescence is augmented with age and contributes to a variety of age-related chronic conditions. Accumulation of senescent cells accompanied by an impairment in the immune-mediated elimination mechanisms results in increased frequency of senescent cells, termed “chronic” senescence. Age-associated senescent cells exhibit abnormal metabolism, increased generation of reactive oxygen species, and a heightened senescence-associated secretory phenotype that nurture a proinflammatory milieu detrimental to neighboring cells. Senescent changes in various retinal and choroidal tissue cells including the retinal pigment epithelium, microglia, neurons, and endothelial cells, contemporaneous with systemic immune aging in both innate and adaptive cells, have emerged as important contributors to the onset and development of AMD. The repertoire of senotherapeutic strategies such as senolytics, senomorphics, cell cycle regulation, and restoring cell homeostasis targeted both at tissue and systemic levels is expanding with the potential to treat a spectrum of age-related diseases, including AMD.
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Affiliation(s)
- Keng Siang Lee
- Bristol Medical School, Translational Health Sciences, University of Bristol, Bristol, BS8 1TD, UK
| | - Shuxiao Lin
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, BS8 1TD, UK
| | - David A Copland
- Bristol Medical School, Translational Health Sciences, University of Bristol, Bristol, BS8 1TD, UK
| | - Andrew D Dick
- Bristol Medical School, Translational Health Sciences, University of Bristol, Bristol, BS8 1TD, UK. .,Institute of Ophthalmology, University College London, London, EC1V 9EL, UK. .,National Institute for Health Research Biomedical Research Centre, Moorfields Eye Hospital, London, EC1V 2QH, UK.
| | - Jian Liu
- Bristol Medical School, Translational Health Sciences, University of Bristol, Bristol, BS8 1TD, UK.
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Crosstalk between Long-Term Sublethal Oxidative Stress and Detrimental Inflammation as Potential Drivers for Age-Related Retinal Degeneration. Antioxidants (Basel) 2020; 10:antiox10010025. [PMID: 33383836 PMCID: PMC7823845 DOI: 10.3390/antiox10010025] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 12/23/2020] [Accepted: 12/25/2020] [Indexed: 12/16/2022] Open
Abstract
Age-related retinal degenerations, including age-related macular degeneration (AMD), are caused by the loss of retinal pigmented epithelial (RPE) cells and photoreceptors. The pathogenesis of AMD, deeply linked to the aging process, also involves oxidative stress and inflammatory responses. However, the molecular mechanisms contributing to the shift from healthy aging to AMD are still poorly understood. Since RPE cells in the retina are chronically exposed to a pro-oxidant microenvironment throughout life, we simulated in vivo conditions by growing ARPE-19 cells in the presence of 10 μM H2O2 for several passages. This long-term oxidative insult induced senescence in ARPE-19 cells without affecting cell proliferation. Global proteomic analysis revealed a dysregulated expression in proteins involved in antioxidant response, mitochondrial homeostasis, and extracellular matrix organization. The analyses of mitochondrial functionality showed increased mitochondrial biogenesis and ATP generation and improved response to oxidative stress. The latter, however, was linked to nuclear factor-κB (NF-κB) rather than nuclear factor erythroid 2–related factor 2 (Nrf2) activation. NF-κB hyperactivation also resulted in increased pro-inflammatory cytokines expression and inflammasome activation. Moreover, in response to additional pro-inflammatory insults, senescent ARPE-19 cells underwent an exaggerated inflammatory reaction. Our results indicate senescence as an important link between chronic oxidative insult and detrimental chronic inflammation, with possible future repercussions for therapeutic interventions.
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Emri E, Kortvely E, Dammeier S, Klose F, Simpson D, den Hollander AI, Ueffing M, Lengyel I. A Multi-Omics Approach Identifies Key Regulatory Pathways Induced by Long-Term Zinc Supplementation in Human Primary Retinal Pigment Epithelium. Nutrients 2020; 12:nu12103051. [PMID: 33036197 PMCID: PMC7601425 DOI: 10.3390/nu12103051] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 10/01/2020] [Accepted: 10/01/2020] [Indexed: 12/14/2022] Open
Abstract
In age-related macular degeneration (AMD), both systemic and local zinc levels decline. Elevation of zinc in clinical studies delayed the progression to end-stage AMD. However, the molecular pathways underpinning this beneficial effect are not yet identified. In this study, we used differentiated primary human fetal retinal pigment epithelium (RPE) cultures and long-term zinc supplementation to carry out a combined transcriptome, proteome and secretome analysis from three genetically different human donors. After combining significant differences, we identified the complex molecular networks using Database for Annotation, Visualization and Integrated Discovery (DAVID) and Ingenuity Pathway Analysis (IPA). The cell cultures from the three donors showed extensive pigmentation, development of microvilli and basal infoldings and responded to zinc supplementation with an increase in transepithelial electrical resistance (TEER) (apical supplementation: 443.2 ± 79.3%, basal supplementation: 424.9 ± 116.8%, compared to control: 317.5 ± 98.2%). Significant changes were observed in the expression of 1044 genes, 151 cellular proteins and 124 secreted proteins. Gene set enrichment analysis revealed changes in specific molecular pathways related to cell adhesion/polarity, extracellular matrix organization, protein processing/transport, and oxidative stress response by zinc and identified a key upstream regulator effect similar to that of TGFB1.
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Affiliation(s)
- Eszter Emri
- Wellcome Wolfson Institute for Experimental Medicine, Queen’s University of Belfast, Belfast BT97BL, Northern Ireland, UK; (E.E.); (D.S.)
- Roche Pharma Research and Early Development, Immunology, Infectious Diseases and Ophthalmology (I2O) Discovery and Translational Area, Roche Innovation Center Basel, F. Hoffmann-La Roche Ltd., 4070 Basel, Switzerland;
| | - Elod Kortvely
- Roche Pharma Research and Early Development, Immunology, Infectious Diseases and Ophthalmology (I2O) Discovery and Translational Area, Roche Innovation Center Basel, F. Hoffmann-La Roche Ltd., 4070 Basel, Switzerland;
- Institute for Ophthalmic Research, University of Tubingen, D-72076 Tubingen, Germany; (S.D.); (F.K.); (M.U.)
| | - Sascha Dammeier
- Institute for Ophthalmic Research, University of Tubingen, D-72076 Tubingen, Germany; (S.D.); (F.K.); (M.U.)
| | - Franziska Klose
- Institute for Ophthalmic Research, University of Tubingen, D-72076 Tubingen, Germany; (S.D.); (F.K.); (M.U.)
| | - David Simpson
- Wellcome Wolfson Institute for Experimental Medicine, Queen’s University of Belfast, Belfast BT97BL, Northern Ireland, UK; (E.E.); (D.S.)
| | | | - Anneke I. den Hollander
- Departments of Ophthalmology and Genetics, Radboud University Medical Center, 6525EX Nijmegen, The Netherlands;
| | - Marius Ueffing
- Institute for Ophthalmic Research, University of Tubingen, D-72076 Tubingen, Germany; (S.D.); (F.K.); (M.U.)
| | - Imre Lengyel
- Wellcome Wolfson Institute for Experimental Medicine, Queen’s University of Belfast, Belfast BT97BL, Northern Ireland, UK; (E.E.); (D.S.)
- Correspondence: ; Tel.: +44-(0)-28-9097-6027
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Blasiak J. Senescence in the pathogenesis of age-related macular degeneration. Cell Mol Life Sci 2020; 77:789-805. [PMID: 31897543 PMCID: PMC11105088 DOI: 10.1007/s00018-019-03420-x] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 12/06/2019] [Accepted: 12/10/2019] [Indexed: 01/07/2023]
Abstract
Age-related macular degeneration (AMD) is a complex eye disease underlined by the death of photoreceptors and degeneration of retinal pigment epithelium (RPE) and choriocapillaris (CC). The mechanism(s) responsible for massive and progressive retinal degeneration is not completely known. Senescence, a state of permanent inhibition of cell growth, may be induced by many factors important for AMD pathogenesis and results in senescence-associated secretory phenotype (SASP) that releases growth factors, cytokines, chemokines, proteases and other molecules inducing inflammation and other AMD-related effects. These effects can be induced in the affected cell and neighboring cells, leading to progression of AMD phenotype. Senescent cells also release reactive oxygen species that increase SASP propagation. Many other pathways of senescence-related AMD pathogenesis, including autophagy, the cGAS-STING signaling, degeneration of CC by membrane attack complex, can be considered. A2E, a fluorophore present in lipofuscin, amyloid-beta peptide and humanin, a mitochondria-derived peptide, may link AMD with senescence. Further studies on senescence in AMD pathogenesis to check the possibility of opening a perspective of the use of drugs killing senescent cells (senolytics) and terminating SASP bystander effects (senostatics) might be beneficial for AMD that at present is an incurable disease.
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Affiliation(s)
- Janusz Blasiak
- Department of Molecular Genetics, Faculty of Biology and Environmental Protection, University of Lodz, Pomorska 141/143, Lodz, Poland.
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Age-related macular degeneration: A two-level model hypothesis. Prog Retin Eye Res 2019; 76:100825. [PMID: 31899290 DOI: 10.1016/j.preteyeres.2019.100825] [Citation(s) in RCA: 103] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 12/19/2019] [Accepted: 12/26/2019] [Indexed: 02/08/2023]
Abstract
Age-related diseases, including age-related macular degeneration (AMD), are of growing importance in a world where population ageing has become a dominant global trend. Although a wide variety of risk factors for AMD have been identified, age itself remains by far the most important risk factor, making it an urgent priority to understand the connections between underlying ageing mechanisms and pathophysiology of AMD. Ageing is both multicausal and variable, so that differences between individuals in biological ageing processes are the focus of a growing number of pathophysiological studies seeking to explain how ageing contributes to chronic, age-related conditions. The aim of this review is to integrate the available knowledge on the pathophysiology of AMD within the framework of the biology of ageing. One highly significant feature of biological ageing is systemic inflammation, which arises as a second-level response to a first level of molecular damage involving oxidative stress, mutations etc. Combining these insights, the various co-existing pathophysiological explanations in AMD arrange themselves according to a two-level hypothesis. Accordingly, we describe how AMD can be considered the consequence of age-related random accumulation of molecular damage at the ocular level and the subsequent systemic inflammatory host response thereof. We summarize evidence and provide original data to enlighten where evidence is lacking. Finally, we discuss how this two-level hypothesis provides a foundation for thoughts and future studies in prevention, prognosis, and intervention.
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Fafián-Labora JA, Morente-López M, Arufe MC. Effect of aging on behaviour of mesenchymal stem cells. World J Stem Cells 2019; 11:337-346. [PMID: 31293716 PMCID: PMC6600848 DOI: 10.4252/wjsc.v11.i6.337] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 04/03/2019] [Accepted: 05/06/2019] [Indexed: 02/06/2023] Open
Abstract
Organs whose source is the mesoderm lineage contain a subpopulation of stem cells that are able to differentiate among mesodermal derivatives (chondrocytes, osteocytes, adipocytes). This subpopulation of adult stem cells, called “mesenchymal stem cells” or “mesenchymal stromal cells (MSCs)”, contributes directly to the homeostatic maintenance of their organs; hence, their senescence could be very deleterious for human bodily functions. MSCs are easily isolated and amenable their expansion in vitro because of the research demanding to test them in many diverse clinical indications. All of these works are shown by the rapidly expanding literature that includes many in vivo animal models. We do not have an in-depth understanding of mechanisms that induce cellular senescence, and to further clarify the consequences of the senescence process in MSCs, some hints may be derived from the study of cellular behaviour in vivo and in vitro, autophagy, mitochondrial stress and exosomal activity. In this particular work, we decided to review these biological features in the literature on MSC senescence over the last three years.
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Affiliation(s)
- Juan Antonio Fafián-Labora
- Grupo de Terapia Celular y Medicina Regenerativa, Departamento de Fisioterapia, Ciencias Biomédicas y Medicina, Universidade da Coruña, A Coruña 15006, Spain
| | - Miriam Morente-López
- Grupo de Terapia Celular y Medicina Regenerativa, Departamento de Fisioterapia, Ciencias Biomédicas y Medicina, Universidade da Coruña, A Coruña 15006, Spain
| | - María C Arufe
- Grupo de Terapia Celular y Medicina Regenerativa, Departamento de Fisioterapia, Ciencias Biomédicas y Medicina, Universidade da Coruña, A Coruña 15006, Spain
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