J R Soc Med 2004;97:465-471
doi:10.1258/jrsm.97.10.465
© 2004 Royal Society of Medicine
Adult bone-marrow stem cells and their potential in medicine
H T Hassan MD PhD
M El-Sheemy MS PhD
Institute of Medical Sciences, University of Lincoln, UK
Correspondence to: Professor H T Hassan, Director, Institute of Medical
Sciences, University of Lincoln, Brayford Pool, Lincoln LN6 7TS, UKE-mail:
hhassan{at}lincoln.ac.uk
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INTRODUCTION
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An area of research that today generates great optimism is the
use of stem
cells for therapy of human diseases. Much of the
excitement centres on
embryonic stem cells, but this approach
remains controversial for ethical
reasons; moreover, routine
clinical application of this strategy is many years
away. By
contrast, haematopoietic stem cells from adult bone marrow are
well
characterized and have long been used
therapeutically.
1 An
adult weighing 70 kg has a functional haematopoietic marrow
volume of about
1.75 L and upon increased demands such as infection
or haemorrhage it can
increase
sixfold.
1,2
No moral controversy
surrounds the use of these cells since they are either
autologous
or collected from a consenting donor. The potential applications
of
adult bone marrow cells have gained momentum with discoveries
relating to the
mesenchymal stem cell.
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MESENCHYMAL STEM CELLS
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Adult bone-marrow-derived mesenchymal stem cells (MSC) are capable
of
differentiation along several lineages (
Box
1).
315
They
are positive for CD29, CD44, CD105 and CD166, have a doubling
time of
about two days, expand in culture up to sixfold and
their biological functions
are not altered by
ageing.
3,15
Box 2 lists some of the
cytokine receptors expressed by these cells
and the cytokines produced. Their
features and properties are
closely similar to those of counterpart cells
isolated from
fetal blood, liver and bone in the first and second trimesters,
from
amniotic fluid and umbilical cord blood, and from adult peripheral
blood,
compact bone and adipose
tissue.
2127
Moreover,
a CD133-positive subpopulation of these cells, which can be
expanded
under defined conditions for more than one hundred
population doublings
without telomere shortening or karyotypic
abnormality, has proved capable of
differentiation not only
into mesenchymal cell types (osteoblasts,
chondrocytes, adipocytes,
myocytes) but also into endothelium and cells with
neuroectodermal
phenotype and
function.
2830
Previously, adult marrow-derived
stem cells were believed to yield a limited
number of cell types
whereas embryonic cells were totipotent. The discovery of
these
multipotent adult stem cells has clearly narrowed the gap: they
offer a
very promising and much more abundant potential resource
for therapy of
inherited or degenerative diseases and for repair
of tissues such as
cartilage, bone and myocardium.
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Box 1. Differentiation potential of adult bone marrow mesenchymal stem
cells (from refs 3,
4,
5,
6,
7,
8,
9,
10,
11,
12,
13,
14,
15)
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ADULT STEM CELL PLASTICITY
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What is the mechanism of stem cell differentiation? When the
phenomenon was
first explored, the possibility of cell fusion
was mootedthat is,
hybridization with other cells rather
than true plasticity. Indeed, embryonic
stem cells were seen
to hybridize with brain cells to form tetraploid cells
with
pluripotent
character.
31
However,
in-vitro and
in-vivo studies
of adult bone marrow
stem cells suggest a rate of cell fusion
too low to account for the
transdifferentiation.
32
Moreover,
single euploid bone marrow MSC, never co-cultured with
tissue-specific
cells or embryonic cells, have been seen to differentiate into
cells
of the three germ
layers;
33 in
vivo, the use of bone marrow
cells selectively expressing the enhanced
green fluorescent
protein ruled out fusion as a mechanism for the generation
of
functional pancreatic islet beta
cells;
34 and
hepatocytes, cardiomyocytes,
and pancreatic and endothelial cells have been
described as
physiologically either diploid or
polyploid.
3537
Certain
cytokines, including interleukins (IL) 1, 4, and 13, tumour
necrosis
factor alpha and interferon gamma, are involved in
the generation of normal
multinucleated cells such as osteoclasts
and Langhans giant
cells;
3840
thus, observations suggesting
fusion of bone marrow cells with, for example,
Purkinje neurons,
cardiomyocytes and
hepatocytes
41 may
instead simply reflect
physiological polyploidy.
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BIOLOGY OF ADULT MARROW MESENCHYMAL STEM CELLS
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The direction in which bone marrow MSC differentiate is heavily
influenced
by cytokines (
Table 1). For
example, bone morphogenetic
protein 6 (BMP-6) not only influences
differentiation towards
chondrogenesis or osteogenesis but may also serve to
regulate
the bone marrow environment via the effects of IL-6 on haematopoiesis
and
osteogenesis.
50
Two possible mechanisms have been proposed for
a regulatory role of BMP-6 in
the human bone marrow microenvironment:
(i) it might enhance the osteoblastic
differentiation of human
MSC; or (ii) it might reduce the osteoclastic
differentiation
of haematopoietic marrow cells by decreasing interleukin-6
production
in bone marrow stroma. MSC coexpressing CD133 and fetal liver
kinase
1 generated endothelial cells in the presence of vascular endothelial
growth
factor, and functional hepatocytes in the presence of fibroblast
growth
factor-4 and hepatocyte growth
factor.
29,30
Also, MSC
coexpressing CD133, CD172 and nestin differentiated along a
neural
pathway in the presence of fibroblast growth factor or
retinoic acid plus
nerve growth
factor.
51,54
An MSC side-population
with high efflux of DNA binding dye and expressing CD90
(Thy1)
differentiated into mesangial renal
cells.
55
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MIGRATION/MOBILIZATION OF ADULT MARROW STEM CELLS
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In animal models, transplanted bone marrow cells have been detected
in
skeletal and cardiac
muscle,
5658
vascular
endothelium,
58,59
liver,
6062
lung,
gut and skin
epithelia,
62
pancreatic beta cell
islets,
34,63
renal
glomeruli,
14,55
and
neural
tissue.
33,6469
When bone-marrow-derived MSC were
injected intracerebrally in
acid-sphingomyelinase-deficient
mice, the onset of neurological abnormalities
was delayed and
the animals lifespan was
extended.
70 Local
transplantation of
such cells is also reported to have regenerated
bone
7173
and
myocardium.
74,75
It
is noteworthy that no donor-derived tumours have been seen in
these animal
modelswhereas with transplantation of undifferentiated
embryonic stem
cells teratoma development has been
reported.
76 The
results also differ from those of undifferentiated embryonic
stem cell
transplantation in that engraftment and tissue-specific
differentiation are
achieved without pretransplantation measures
to induce differentiation down
the lineage desired. The ability
of marrow-derived cells to populate numerous
body tissuesbone,
liver, cardiac muscle, colon, skinis well
shown in patients
who have received cells from gender-mismatched donors
(
Table
2).
7784
A
postmortem study revealed donor-derived neurons in the hippocampus
and
cerebral cortex of brain samples from women who had received
bone marrow
transplants from
men.
85 Deductions
from such findings
must be qualified by the observation that women who have
carried
male fetuses may show long-term mosaicism with male cells;
nevertheless,
the weight of the evidence is that donor bone-marrow-derived
cells
can migrate and give rise to tissues belonging to all three
germ-cell
layers.
7785
It is noteworthy that, in the transdifferentiation
of these adult marrow stem
cells, there was no evidence of cell
fusion.
7785
Lately,
work in mice indicated that such cells participate in skin
regeneration
and reconstitution and promote wound
healing;
8688
and
one research group reports a pilot study in three patients indicating
that
locally applied autologous bone marrow cells enhanced dermal
building and
closure of long-term non-healing
wounds.
89
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Table 2. Migration of human adult bone marrow stem cells in gender-mismatched
bone marrow transplantation patients
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CLINICAL STUDIES
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In animal models of myocardial infarction, stem cells were reported
to
participate in repair whether injected locally or stimulated
in bone marrow by
use of stem cell factor (SCF) and
G-CSF.
90 In man, a
randomized placebo-controlled study revealed increased
coronary collateral
flow in patients treated with intracoronary
GM-CSF (molgramostim) followed by
two weeks of subcutaneous
administration.
91
In the past decade the use of G-CSF (filgrastim) has transformed the
treatment of cancer by facilitating marrow reconstitution after myeloablative
therapy. We must hope for a similar breakthrough in the management of coronary
heart disease.
In allogeneic transplantation, mesenchymal stem cells in bone marrow play a
key part in immunomodulation and the induction of tolerance. MSC suppress the
proliferation of T-lymphocytes induced by cellular or non-specific mitogenic
stimuli92 and
negatively influence B-cell
lymphopoiesis.93
Allogeneic/xenogeneic MSC transplants engraft in immunocompetent sheep and
non-human
primates.9497
When a patient was treated, after myeloablation, with both haematopoietic stem
cells and cultured MSC from a mismatched donor, only grade I graft-versus-host
disease (GvHD) was
observed.98 That
MSC can not only reduce GvHD but also facilitate haematopoietic engraftment is
evidenced by the rapid haematopoietic recovery of patients with breast cancer
who received autologous blood stem cells together with culture-expanded MSC
after high-dose
chemotherapy.99 In
both clinical trials, MSC transplantation was well tolerated.
Osteogenesis imperfecta has been the focus of two studies in children.
Allogeneic MSC transplantation, leading to successful osteoblast engraftment
in 3 of 5 children with type III osteogenesis imperfecta, was associated with
a 4477% increase in bone mineral content, improved linear growth and
reduced fracture
frequency.77,100
In another cohort of 6 children with type III osteogenesis imperfecta who had
received earlier bone marrow transplantation, MSC infusions from the original
donor resulted in a 50% improvement in their growth
velocity.101
Similar improvements were observed in children with metachromatic
leukodystrophy and Hurlers syndrome after repeated allogeneic marrow
MSC
infusions.102
Ten clinical studies have been reported on the effects of autologous bone
marrow stem cell transplantation in patients with myocardial infarction or
ischaemic heart failure (Table
3).103112
In three pilot studies, two of them randomized controlled trials, bone marrow
cells infused via a coronary catheter a few days after acute myocardial
infarction led to significant improvement in coronary flow reserve and left
ventricular ejection
fraction.104,105,111
In the remaining seven, marrow cells injected directly into the myocardium of
patients with chronic ischaemic heart disease yielded benefits in ejection
fraction and also angina
score.103,106110,112
Despite the impressive safety record of all these pilot clinical trials,
the possibility of undesired differentiation into other tissues must be borne
in mind in monitoring of future studies.
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THE FUTURE
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In the next decade, the approaches discussed above will clearly
be
developed and refined. Further avenues will open up. For
example,
bone-marrow-derived cells expressing stem cell factor
have been shown to
initiate endogenous pancreatic tissue regeneration
in
mice.
113 If such
cells could be used as pancreatic beta islet
cell progenitors, there would be
scope for autologous transplantation
in patients with diabetes, avoiding the
need for the immunosuppression
necessary after allotransplantation and
circumventing the scarcity
of allogeneic material. Whereas the multipotent
adult dermal
stem cells from human scalp skin have shown mainly neural
differentiation,
suggesting a possible therapeutic role in neurodegenerative
diseases,
114,115
the
bone marrow MSC show strong orientation towards bone, cartilage,
endothelium
and cardiac muscle.
In conclusion, the existing medical uses of bone marrow are likely to
expand greatly with exploitation of the therapeutic potential of adult
mesenchymal stem cells, with their capacity for many lines of differentiation.
The next stage is to isolate the various subsets and investigate their
mechanisms of differentiation and homing to tissues. This work has vast
implications for human wellbeing, through cell and gene therapies, through
tissue engineering and through immunotherapy.
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