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Marquez-Curtis LA, Elliott JAW. Mesenchymal stromal cells derived from various tissues: Biological, clinical and cryopreservation aspects: Update from 2015 review. Cryobiology 2024; 115:104856. [PMID: 38340887 DOI: 10.1016/j.cryobiol.2024.104856] [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: 11/28/2023] [Revised: 01/26/2024] [Accepted: 01/30/2024] [Indexed: 02/12/2024]
Abstract
Mesenchymal stromal cells (MSCs) have become one of the most investigated and applied cells for cellular therapy and regenerative medicine. In this update of our review published in 2015, we show that studies continue to abound regarding the characterization of MSCs to distinguish them from other similar cell types, the discovery of new tissue sources of MSCs, and the confirmation of their properties and functions that render them suitable as a therapeutic. Because cryopreservation is widely recognized as the only technology that would enable the on-demand availability of MSCs, here we show that although the traditional method of cryopreserving cells by slow cooling in the presence of 10% dimethyl sulfoxide (Me2SO) continues to be used by many, several novel MSC cryopreservation approaches have emerged. As in our previous review, we conclude from these recent reports that viable and functional MSCs from diverse tissues can be recovered after cryopreservation using a variety of cryoprotectants, freezing protocols, storage temperatures, and periods of storage. We also show that for logistical reasons there are now more studies devoted to the cryopreservation of tissues from which MSCs are derived. A new topic included in this review covers the application in COVID-19 of MSCs arising from their immunomodulatory and antiviral properties. Due to the inherent heterogeneity in MSC populations from different sources there is still no standardized procedure for their isolation, identification, functional characterization, cryopreservation, and route of administration, and not likely to be a "one-size-fits-all" approach in their applications in cell-based therapy and regenerative medicine.
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Affiliation(s)
- Leah A Marquez-Curtis
- Department of Chemical and Materials Engineering, University of Alberta, Edmonton, AB, Canada, T6G 1H9; Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada, T6G 1C9
| | - Janet A W Elliott
- Department of Chemical and Materials Engineering, University of Alberta, Edmonton, AB, Canada, T6G 1H9; Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada, T6G 1C9.
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Silva PL, Scharffenberg M, Rocco PRM. Understanding the mechanisms of ventilator-induced lung injury using animal models. Intensive Care Med Exp 2023; 11:82. [PMID: 38010595 PMCID: PMC10682329 DOI: 10.1186/s40635-023-00569-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 11/17/2023] [Indexed: 11/29/2023] Open
Abstract
Mechanical ventilation is a life-saving therapy in several clinical situations, promoting gas exchange and providing rest to the respiratory muscles. However, mechanical ventilation may cause hemodynamic instability and pulmonary structural damage, which is known as ventilator-induced lung injury (VILI). The four main injury mechanisms associated with VILI are as follows: barotrauma/volutrauma caused by overstretching the lung tissues; atelectrauma, caused by repeated opening and closing of the alveoli resulting in shear stress; and biotrauma, the resulting biological response to tissue damage, which leads to lung and multi-organ failure. This narrative review elucidates the mechanisms underlying the pathogenesis, progression, and resolution of VILI and discusses the strategies that can mitigate VILI. Different static variables (peak, plateau, and driving pressures, positive end-expiratory pressure, and tidal volume) and dynamic variables (respiratory rate, airflow amplitude, and inspiratory time fraction) can contribute to VILI. Moreover, the potential for lung injury depends on tissue vulnerability, mechanical power (energy applied per unit of time), and the duration of that exposure. According to the current evidence based on models of acute respiratory distress syndrome and VILI, the following strategies are proposed to provide lung protection: keep the lungs partially collapsed (SaO2 > 88%), avoid opening and closing of collapsed alveoli, and gently ventilate aerated regions while keeping collapsed and consolidated areas at rest. Additional mechanisms, such as subject-ventilator asynchrony, cumulative power, and intensity, as well as the damaging threshold (stress-strain level at which tidal damage is initiated), are under experimental investigation and may enhance the understanding of VILI.
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Affiliation(s)
- Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G-014, Ilha Do Fundão, Rio de Janeiro, RJ, 21941-902, Brazil
| | - Martin Scharffenberg
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus at Technische Universität Dresden, Dresden, Germany
| | - Patricia Rieken Macedo Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G-014, Ilha Do Fundão, Rio de Janeiro, RJ, 21941-902, Brazil.
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Battaglini D, Iavarone IG, Al-Husinat L, Ball L, Robba C, Silva PL, Cruz FF, Rocco PR. Anti-inflammatory therapies for acute respiratory distress syndrome. Expert Opin Investig Drugs 2023; 32:1143-1155. [PMID: 37996088 DOI: 10.1080/13543784.2023.2288080] [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: 09/17/2023] [Accepted: 11/22/2023] [Indexed: 11/25/2023]
Abstract
INTRODUCTION Treatments for the acute respiratory distress syndrome (ARDS) are mainly supportive, and ventilatory management represents a key approach in these patients. Despite progress in pharmacotherapy, anti-inflammatory strategies for the treatment of ARDS have shown controversial results. Positive outcomes with pharmacologic and nonpharmacologic treatments have been found in two different biological subphenotypes of ARDS, suggesting that, with a personalized medicine approach, pharmacotherapy for ARDS can be effective. AREAS COVERED This article reviews the literature concerning anti-inflammatory therapies for ARDS, focusing on pharmacological and stem-cell therapies, including extracellular vesicles. EXPERT OPINION Despite advances, ARDS treatments remain primarily supportive. Ventilatory and fluid management are important strategies in these patients that have demonstrated significant impacts on outcome. Anti-inflammatory drugs have shown some benefits, primarily in preclinical research and in specific clinical scenarios, but no recommendations are available from guidelines to support their use in patients with ARDS, except in particular settings such as different subphenotypes, specific etiologies, or clinical trials. Personalized medicine seems promising insofar as it may identify specific subgroups of patients with ARDS who may benefit from anti-inflammatory treatment. However, additional efforts are needed to move subphenotype characterization from bench to bedside.
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Affiliation(s)
- Denise Battaglini
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Ida Giorgia Iavarone
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Lou'i Al-Husinat
- Department of Clinical Medical Sciences, Faculty of Medicine, Yarmouk University, Irbid, Jordan
| | - Lorenzo Ball
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Chiara Robba
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Fernanda F Cruz
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Patricia Rm Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- National Institute of Science and Technology for Regenerative Medicine, Rio de Janeiro, Brazil
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Wang L, Feng M, Zhao Y, Chen B, Zhao Y, Dai J. Biomimetic scaffold-based stem cell transplantation promotes lung regeneration. Bioeng Transl Med 2023; 8:e10535. [PMID: 37476061 PMCID: PMC10354774 DOI: 10.1002/btm2.10535] [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: 11/20/2022] [Revised: 04/04/2023] [Accepted: 04/16/2023] [Indexed: 07/22/2023] Open
Abstract
Therapeutic options are limited for severe lung injury and disease as the spontaneous regeneration of functional alveolar is terminated owing to the weakness of the inherent stem cells and the dyscrasia of the niche. Umbilical cord mesenchymal-derived stem cells (UC-MSCs) have been applied to clinical trials to promote lung repair through stem cell niche restruction. However, the application of UC-MSCs is hampered by the effectiveness of cell transplantation with few cells homing to the injury sites and poor retention, survival, and proliferation in vivo. In this study, we constructed an artificial three-dimensional (3D) biomimetic scaffold-based MSCs implant to establish a beneficial regeneration niche for endogenous stem cells in situ lung regeneration. The therapeutic potential of 3D biomimetic scaffold-based MSCs implants was evaluated by 3D culture in vitro. And RNA sequencing (RNA-Seq) was mapped to explore the gene expression involved in the niche improvement. Next, a model of partial lung resection was established in rats, and the implants were implanted into the operative region. Effects of the implants on rat resected lung injury repair were detected. The results revealed that UC-MSCs loaded on biomimetic scaffolds exerted strong paracrine effects and some UC-MSCs migrated to the lung from scaffolds and had long-term retention to suppress inflammation and fibrosis in residual lungs and promoted vascular endothelial cells and alveolar type II epithelial cells to enter the scaffolds. Then, under the guidance of the ECM-mimicking structures of scaffolds and the stimulation of the remaining UC-MSCs, vascular and alveolar-like structures were formed in the scaffold region. Moreover, the general morphology of the operative lung was also restored. Taken together, the artificial 3D biomimetic scaffold-based MSCs implants induce in situ lung regeneration and recovery after lung destruction, providing a promising direction for tissue engineering and stem cell strategies in lung regeneration.
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Affiliation(s)
- Linjie Wang
- Center for Disease Control and Prevention of People's Liberation ArmyBeijingChina
| | - Meng Feng
- Institute of Combined Injury, State Key Laboratory of Trauma, Burns and Combined Injury, Chongqing Engineering Research Center for Nanomedicine, College of Preventive Medicine, Chongqing Engineering Research Center for Biomaterials and Regenerative MedicineArmy Medical University, Third Military Medical UniversityChongqingChina
| | - Yazhen Zhao
- Institute of Combined Injury, State Key Laboratory of Trauma, Burns and Combined Injury, Chongqing Engineering Research Center for Nanomedicine, College of Preventive Medicine, Chongqing Engineering Research Center for Biomaterials and Regenerative MedicineArmy Medical University, Third Military Medical UniversityChongqingChina
| | - Bing Chen
- State Key Laboratory of Molecular Developmental BiologyInstitute of Genetics and Developmental Biology, Chinese Academy of SciencesBeijingChina
| | - Yannan Zhao
- State Key Laboratory of Molecular Developmental BiologyInstitute of Genetics and Developmental Biology, Chinese Academy of SciencesBeijingChina
| | - Jianwu Dai
- State Key Laboratory of Molecular Developmental BiologyInstitute of Genetics and Developmental Biology, Chinese Academy of SciencesBeijingChina
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Wang Z, Hu Y, Wang X, Chen Y, Wu D, Ji H, Yu C, Fang J, Pan C, Wang L, Wang S, Guo Y, Lu Y, Wu D, Ren F, Zhu H, Shi Y. Comparative Analysis of the Therapeutic Effects of Fresh and Cryopreserved Human Umbilical Cord Derived Mesenchymal Stem Cells in the Treatment of Psoriasis. Stem Cell Rev Rep 2023:10.1007/s12015-023-10556-8. [PMID: 37199874 DOI: 10.1007/s12015-023-10556-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2023] [Indexed: 05/19/2023]
Abstract
Psoriasis, an inflammatory autoimmune skin disease, is characterized by scaly white or erythematous plaques, which severely influence patients' quality of life and social activities. Mesenchymal stem cells derived from the human umbilical cord (UCMSCs) represent a promising therapeutic approach for psoriasis because of its unique superiority in ethical agreeableness, abundant source, high proliferation capacity, and immunosuppression. Although cryopreservation provided multiple benefits to the cell therapy, it also greatly compromised clinical benefits of MSCs due to impaired cell functions. The current study aims to evaluate the therapeutic efficacy of cryopreserved UCMSCs in a mouse model of psoriasis as well as in patients with psoriasis. Our results showed that cryopreserved and fresh UCMSCs have comparable effects on the suppression of psoriasis-like symptoms such as thickening, erythema, and scaling, and serum IL-17 A secretion in mice model of psoriasis. Moreover, psoriatic patients injected with cryopreserved UCMSCs had a significant improvement in the Psoriasis Area and Severity Index (PASI), Physician Global Assessment (PGA), and Patient Global Assessments (PtGAs) scores compared to baseline values. Mechanically, cryopreserved UCMSCs markedly inhibit the proliferation of PHA-activated PBMCs, type 1 T helper (Th1) and type 17 T helper (Th17) cell differentiation and secretion of inflammatory cytokines including IFN-γ, TNF-a and IL-17 A in PBMCs stimulated by anti-CD3/CD28 beads. Taken together, these data indicated that cryopreserved UCMSCs exhibited great beneficial effect on psoriasis. Thus, cryopreserved UCMSCs can be systemically administered as ''off-the-shelf'' cell product for psoriasis therapy. Trial Registration ChiCTR1800019509. Registered on November 15, 2018-Retrospectively registered, http://www.chictr.org.cn/ .
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Affiliation(s)
- Zhifeng Wang
- Department of Dermatology, Shanghai Skin Disease Hospital, Tongji University School of Medicine, Shanghai, 200443, China.
- Sinoneural Cell Engineering Group Holdings Co., Ltd, No. 1188, Lianhang Road, Shanghai, 201100, China.
| | - Yifan Hu
- Department of Dermatology, Shanghai Skin Disease Hospital, Tongji University School of Medicine, Shanghai, 200443, China
- Institute of Psoriasis, Tongji University School of Medicine, Shanghai, 200443, China
| | - Xiaoyu Wang
- Sinoneural Cell Engineering Group Holdings Co., Ltd, No. 1188, Lianhang Road, Shanghai, 201100, China
| | - Youdong Chen
- Department of Dermatology, Shanghai Skin Disease Hospital, Tongji University School of Medicine, Shanghai, 200443, China
- Institute of Psoriasis, Tongji University School of Medicine, Shanghai, 200443, China
| | - Danfeng Wu
- Sinoneural Cell Engineering Group Holdings Co., Ltd, No. 1188, Lianhang Road, Shanghai, 201100, China
| | - Houli Ji
- Sinoneural Cell Engineering Group Holdings Co., Ltd, No. 1188, Lianhang Road, Shanghai, 201100, China
| | - Cuicui Yu
- Sinoneural Cell Engineering Group Holdings Co., Ltd, No. 1188, Lianhang Road, Shanghai, 201100, China
| | - Jingmeng Fang
- Sinoneural Cell Engineering Group Holdings Co., Ltd, No. 1188, Lianhang Road, Shanghai, 201100, China
| | - Chunrong Pan
- Sinoneural Cell Engineering Group Holdings Co., Ltd, No. 1188, Lianhang Road, Shanghai, 201100, China
| | - Lianjian Wang
- Sinoneural Cell Engineering Group Holdings Co., Ltd, No. 1188, Lianhang Road, Shanghai, 201100, China
| | - Shouxin Wang
- Sinoneural Cell Engineering Group Holdings Co., Ltd, No. 1188, Lianhang Road, Shanghai, 201100, China
| | - Yinhong Guo
- Sinoneural Cell Engineering Group Holdings Co., Ltd, No. 1188, Lianhang Road, Shanghai, 201100, China
| | - Yi Lu
- Sinoneural Cell Engineering Group Holdings Co., Ltd, No. 1188, Lianhang Road, Shanghai, 201100, China
| | - Di Wu
- Sinoneural Cell Engineering Group Holdings Co., Ltd, No. 1188, Lianhang Road, Shanghai, 201100, China
| | - Fangfang Ren
- Sinoneural Cell Engineering Group Holdings Co., Ltd, No. 1188, Lianhang Road, Shanghai, 201100, China
| | - Hao Zhu
- Sinoneural Cell Engineering Group Holdings Co., Ltd, No. 1188, Lianhang Road, Shanghai, 201100, China.
| | - Yuling Shi
- Department of Dermatology, Shanghai Skin Disease Hospital, Tongji University School of Medicine, Shanghai, 200443, China.
- Institute of Psoriasis, Tongji University School of Medicine, Shanghai, 200443, China.
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Li CH, Zhao J, Zhang HY, Wang B. Banking of perinatal mesenchymal stem/stromal cells for stem cell-based personalized medicine over lifetime: Matters arising. World J Stem Cells 2023; 15:105-119. [PMID: 37181005 PMCID: PMC10173813 DOI: 10.4252/wjsc.v15.i4.105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 01/07/2023] [Accepted: 03/22/2023] [Indexed: 04/26/2023] Open
Abstract
Mesenchymal stromal/stem cells (MSCs) are currently applied in regenerative medicine and tissue engineering. Numerous clinical studies have indicated that MSCs from different tissue sources can provide therapeutic benefits for patients. MSCs derived from either human adult or perinatal tissues have their own unique advantages in their medical practices. Usually, clinical studies are conducted by using of cultured MSCs after thawing or short-term cryopreserved-then-thawed MSCs prior to administration for the treatment of a wide range of diseases and medical disorders. Currently, cryogenically banking perinatal MSCs for potential personalized medicine for later use in lifetime has raised growing interest in China as well as in many other countries. Meanwhile, this has led to questions regarding the availability, stability, consistency, multipotency, and therapeutic efficiency of the potential perinatal MSC-derived therapeutic products after long-term cryostorage. This opinion review does not minimize any therapeutic benefit of perinatal MSCs in many diseases after short-term cryopreservation. This article mainly describes what is known about banking perinatal MSCs in China and, importantly, it is to recognize the limitation and uncertainty of the perinatal MSCs stored in cryobanks for stem cell medical treatments in whole life. This article also provides several recommendations for banking of perinatal MSCs for potentially future personalized medicine, albeit it is impossible to anticipate whether the donor will benefit from banked MSCs during her/his lifetime.
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Affiliation(s)
- Cheng-Hai Li
- Stem Cell Program of Clinical Research Center, People's Hospital of Zhengzhou University and Henan Provincial People's Hospital, Zhengzhou 450003, Henan Province, China
| | - Jing Zhao
- Department of Clinical Laboratory, People's Hospital of Zhengzhou University and Henan Provincial People's Hospital, Zhengzhou 450003, Henan Province, China
| | - Hong-Yan Zhang
- Department of Pharmacy, Fuwai Central China Cardiovascular Hospital, Zhengzhou 450000, Henan Province, China
| | - Bin Wang
- Department of Neurosurgery, People's Hospital of Zhengzhou University and Henan Provincial People's Hospital, Zhengzhou 450003, Henan Province, China.
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Singh K. Prenatal Interventions for the Treatment of Congenital Disorders. Regen Med 2023. [DOI: 10.1007/978-981-19-6008-6_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
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Dave C, Mei SHJ, McRae A, Hum C, Sullivan KJ, Champagne J, Ramsay T, McIntyre L. Comparison of freshly cultured versus cryopreserved mesenchymal stem cells in animal models of inflammation: A pre-clinical systematic review. eLife 2022; 11:75053. [PMID: 35838024 PMCID: PMC9286731 DOI: 10.7554/elife.75053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 06/05/2022] [Indexed: 12/09/2022] Open
Abstract
Background: Mesenchymal stem cells (MSCs) are multipotent cells that demonstrate therapeutic potential for the treatment of acute and chronic inflammatory-mediated conditions. Although controversial, some studies suggest that MSCs may lose their functionality with cryopreservation which could render them non-efficacious. Hence, we conducted a systematic review of comparative pre-clinical models of inflammation to determine if there are differences in in vivo measures of pre-clinical efficacy (primary outcomes) and in vitro potency (secondary outcomes) between freshly cultured and cryopreserved MSCs. Methods: A systematic search on OvidMEDLINE, EMBASE, BIOSIS, and Web of Science (until January 13, 2022) was conducted. The primary outcome included measures of in vivo pre-clinical efficacy; secondary outcomes included measures of in vitro MSC potency. Risk of bias was assessed by the SYRCLE ‘Risk of Bias’ assessment tool for pre-clinical studies. Results: Eighteen studies were included. A total of 257 in vivo pre-clinical efficacy experiments represented 101 distinct outcome measures. Of these outcomes, 2.3% (6/257) were significantly different at the 0.05 level or less; 2 favoured freshly cultured and 4 favoured cryopreserved MSCs. A total of 68 in vitro experiments represented 32 different potency measures; 13% (9/68) of the experiments were significantly different at the 0.05 level or less, with seven experiments favouring freshly cultured MSC and two favouring cryopreserved MSCs. Conclusions: The majority of preclinical primary in vivo efficacy and secondary in vitro potency outcomes were not significantly different (p<0.05) between freshly cultured and cryopreserved MSCs. Our systematic summary of the current evidence base may provide MSC basic and clinical research scientists additional rationale for considering a cryopreserved MSC product in their pre-clinical studies and clinical trials as well as help identify research gaps and guide future related research. Funding: Ontario Institute for Regenerative Medicine
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Affiliation(s)
- Chintan Dave
- Division of Critical Care Medicine, Department of Medicine, Western University, London, Canada
| | - Shirley H J Mei
- Regenerative Medicine Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Andrea McRae
- Regenerative Medicine Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Christine Hum
- Knowledge Synthesis Group, Ottawa Hospital Research Institute, Ottawa, Canada.,University of Ottawa, Ottawa, Canada
| | - Katrina J Sullivan
- Knowledge Synthesis Group, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Josee Champagne
- Knowledge Synthesis Group, Ottawa Hospital Research Institute, Ottawa, Canada.,Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Tim Ramsay
- Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Lauralyn McIntyre
- Knowledge Synthesis Group, Ottawa Hospital Research Institute, Ottawa, Canada.,Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Canada
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