Open access

Treatment of the end Stage Liver Cirrhosis by Human Umbilical Cord Blood Stem Cells: Preliminary Results

Written By

Jong Yoon Bahk, Zhengfu Piao, Jae Hun Jung and Hoon Han

Published: 23 August 2011

DOI: 10.5772/22684

From the Edited Volume

Stem Cells in Clinic and Research

Edited by Ali Gholamrezanezhad

Chapter metrics overview

4,442 Chapter Downloads

View Full Metrics

1. Introduction

The liver is a vital organ essential for life of vertebrates and other animals and plays a variety of metabolic functions, including glycogen storage, detoxification, plasma protein synthesis, the production of biochemicals for digestion and other roles. In the normal liver, hepatocytes physiologically renewed at very slow tempo. However, when injured by acute damage or drug intoxications, dormant hepatocytes re-enter the cell cycle and hepatic progenitor cells (HPCs) or oval cells are also thought to differentiate into hepatocytes, resulting in restoration of the structure and functions of the liver parenchyma [1-2]: thus the liver has regenerative capacity. In severely overwhelmed cases, mature hepatocytes seemed to be blocked their proliferation activity, but HPCs are thought to be profoundly activated and play an important role in compensation of liver function [3, 4]. When liver injury and inflammation occur chronically, normal liver tissue is replaced by fibrosis, scare tissue, diffuse necrosis and regenerative nodules [5], thus resulting in an irreversible chronic inflammation loss of liver function at the final stage: liver cirrhosis (LC) [6, 7, 8, 9]. Regardless of its underlying causes, the morphologic figures and complications caused by LC are similar and as disease progresses, complications develop. They include portal hypertension, varix, ascities, hepatic encephalopathy, idiopathic peritonitis and hepatic coma. The classification of LC is based on the etiology, such as alcoholics, post-hepatitic, biliary, cardiac, metabolic, inherited and drug induced cirrhosis. Incidence of the specific types of liver cirrhosis is different from area to areas. Alcoholic cirrhosis is the most common type in North America, Western Europe and South America. Abstinence from alcohol would prevent the complicating liver cirrhosis [10]. One-fourth of the patients with repeated liver injuries and three fourth of post-hepatitic cirrhosis has the history of viral hepatitis (hepatitis B or hepatitis C). Post-hepatitic cirrhosis induced by those viruses is the most common cirrhosis found in South Eastern Asia and China including Korea, and second most common in America and Western Europe. In America, over 20% of patients infected chronically with HCV for more than 20 years were reported to develop post-hepatitic cirrhosis [11]. Biliary cirrhosis also occurs in association with injury of the biliary system or its prolonged impairment, which destroys liver parenchyme with progressive fibrosis. Billary, cardiac, metabolic, inherited and drug induced liver cirrhosis are much less common than alcoholic or posthepatitic cirrhosis [12]. Avoidance of causative drugs, excessive protein intake and anti-infectious medicine were usually used as a first choice of treatment. Overall, about 75% of patients have progression and die within 5 years after the findings of the disease. Immune system is also deeply involved in the magnitude of cirrhosis. For example, in some instances cirrhosis can cause immune system dysfunction, leading to high susceptibility to infections or in other cases, autoimmune responses caused by the immunologic damage to the liver causing inflammation and eventually scaring and cirrhosis.

Until now, no simple hematologic diagnostic test for the LC has been developed [13]. LC is diagnosed by clinical findings, such as chronic liver disease, reduced platelet count, esophageal varix, ascitis, portal hypertension symptoms, splenomegaly and changes in hematologic parameters [14]. For the definite diagnosis, the liver biopsy is used, although invasive.

LC is the common end feature of an excessive and persistent scaring resulted from secondary fibrotic tissue remodeling followed by liver injuries and is regarded as irreversible disease.

In the rodents, both findings that carbon tetrachloride (CCl4) treatment and bile duct ligation injury were reported to induce fibrogenesis [15], and spontaneous recovery from once established liver fibrosis [16-17], suggest that the hepatic fibrosis is a dynamic bi-directional event, and highlighted that the liver fibrosis is potentially reversible by antifibrotic therapy [18].

After hepatic injury, the hepatic stellate cells (HSCs), positioned in the center of the ongoing fibrogenesis of liver [19], are activated to proliferate and to produce contractile elements such as α smooth muscle actin (α-sma), a major determinant of sinusoidal portal hypertension [27], and collagens (mainly type I and III) [21]. This process is most likely mediated through the stimulation of cytokines, such as transforming growth factor-β (TGF-β), platelet-derived growth factor (PDGF), and endothelin (ET-1) [20], that are produced in a synergistic fashion of paracrine and autocrine from injured hepatic cells and inflammatory cells. The positive feedback loops between extracellular matrix and produced cytokines may also play an important roles in the acceleration of fibrosis [22].

Among them, TGF-β1 is thought to be the most significant factor for HSCs, because it upregulates the expression of its receptor [23, 32], leading to raising the susceptibility to other mitogens such as PDGF, thrombin and angiotensin-II, etc. and eventually inducing proliferation of HSCs. It also accelerated the accumulation of HSCs in response to migration stimuli such as PDGF, vasoactive substance ET-1, and monocyte chemotatic protein [24]. Extracellular matrix (ECM) modulates HSC functions by interacting it with PDGF, fibroblast growth factor (FGF), TGF-β, and matrix metalloproteinases (MMPs) that present in the space of Disse [25]. Integrins expressed on HSCs play important roles in cell-matrix interactions for activation of latent TGF-β1 that modifies fibrogenesis.

In contrast, basement membrane tends to suppress the proliferation activity of HSCs and their collagen synthesis [26]. The cirrhotic liver overexpressed the ET-1 [28], a stimulant of nitric oxide production from HSCs and autocrine, that plays important roles for their own proliferation. HSCs also secrete neutrophil and monocyte chemoattractants, such as colony stimulating factors (CSF), MCP-1, and IL-8 that amplify the hepatic inflammatory response (31). Matrix synthesis is highly dependent on TGF β-1 and liver cirrhosis is closely related with ECM alteration in quantity and quality. Hepatic fibrosis is enhanced by synthesis of the neomatrix with type-1 collagen and the neomatrix degradation is inhibited by TIMPs (tissue inhibitor of metalloproteinases, TIMPs) [33]. Thus activated HSCs are responsible for hepatic fibrosis. TIMP-1 inhibits apoptosis of HSCs [33] and induced promotion of perpetuation in hepatic fibrosis [34].

Prevention of the unnecessary medication is important for maintaining physiological conditions of the liver because it is very sensitive to medicines as well as microbial infection. The principle of treatment in LC is to remove such potential risk factors, and to correct the underlying invasive causes. Currently, treatments are focused on preventing complications such as ascites, esophageal varix and hepatic encephalopathy etc. Detection of serological changes at the early stage and regular follow up studies of those features are important for reducing the risky liver diseases such as LC. Usually, diet, bed rest, fluid restriction and diuretics, paracentesis and the liver transplantation are included in the treatment of the LC [35-36]. For the treatment of decompensated LC, orthotopic liver transplantation is regarded as the only definitive therapeutic option [36]. Several factors such as lack of available donors, combined with operative risks, complications associated with rejection, usage of immunosuppressive agents and cost-intensiveness make this strategy available to only a few people [37, 41]. Those problems inherent in the liver transplantation have prompted the search for alternative therapeutic methods for intractable liver diseases [42]. Due to these problems, many LC patients die from life-threatening complications at relatively early age. Recently, along with the development of regenerative medicine, the use of pluripotent stem cells are proposed for recovering from the disease states as an alternative therapy [38]. Fetal liver derived stem cells transplanted showed some improvement for conservative management in the end stage liver diseases [39]. In clinical cell therapy, highly enriched cell numbers and the high repopulation potential are essential [40].

Liver cells obtained from the post-mortem have been also used for transplantation as the promising alternative [43-46]. The liver cell transplantation is regarded as a less invasive, less expensive, and can alleviate the problem of organ shortage. Although there are some advantages in the liver cell transplantation over the orthotopic liver transplantation, long-term observation seems to be important for the evaluation.

Reversal of hepatic fibrosis and cirrhosis may be achieved by resolution of liver fibrosis, an increase of apoptosis of activated HSCs and collagenolysis [47]. In the CCl4 rat model, the removal of CCl4 increased the apoptosis of HSCs: 50% decrease in cell numbers at 72 hours post-removal. And antifibrotic therapy with NO donor decreased the HSCs number to 50% at 18 hours after the treatment [48]. Induction of HSCs apoptosis degraded the matrix and recovered from the liver fibrogenetic conditions by removing the source of fibrotic neomatrix and TIMPs. [49-50] Biliary fibrosis was reversed after decompression of the bile duct ligation [51]. Apoptosis of HSCs induces pro-MMP-2 activation [52] suggesting matrix remodeling, because MMPs specifically degrade collagens and non-collagenous substrates in matrix. The matrix degradation seems a pivotal initial step in the processes of liver fibrosis resolution. The most important event is the action of the interstitial collagenases, MMP-1, which cleaves the collagen-1 molecule [53]. Collagenase activity resulted from the gap between activated MMPs to TIMPs. Increase of TIMP-1 expression occurs in parallel with progressive fibrosis. Sustained TIMP-1 expression means the failure in degradation of fibrosis and there is intrinsic link between HSC apoptosis and matrix degradation [47]. This suggests that the proteolysis facilitates the resolution and repair of the injured liver [54]. The failure of degradation of fibrosis by collagenase impairs HSC apoptosis to induce the delaying or blocking the hepatocyte regenerative response [54].

Recovery from the hepatic fibrosis has been reported in animal models after removal of CCl4, which is used for induction of acute hepatitis [55-61] and clinical patients [62-66]. Hepatic fibrosis, induced by several toxins [57-59] or ligation of bile duct [60], was reversed after the removal of the causes. In human, reversal of the hepatic fibrosis was reported in patients with alcoholic liver disease, hemochromatosis and other liver diseases [62-64]. Reversal of the posthepatitic cirrhosis was also noted after improvement from the hepatitis B infection [65]. Moreover, posthepatitic cirrhosis due to hepatitis C infection responded to the interferon treatment. [66]

Due to the limitation of the donor livers, the stem cell-based therapy has been suggested as a possible alternative therapy [67]. Plasticity (trans-differentiation) and fusion activities inherent in stem cells are important for the development, regeneration and repair of liver organs [68-70, 72]. The stem cells produce various humoral substances (cytokines, growth factors) and factors for homing or migration, also. Those characteristics of stem cells are also important for the therapy [71]. Recently, mesenchymal stem cell (MSC) derived from umbilical cord (UC) is regarded as a promising form for cell therapy because of their easy accessibility, MSC is much primitive than other tissue sources and do not express the major histocompatibility complex (MHC) class II (HLA-DR) antigens [74]. Previous studies have shown that

UCMSC are still viable and not rejected at 4 months after xenografts, without the need for immune suppression, suggesting that they are a favorable cell source for transplantation [75-77]. UCMSC are able to differentiate into adipocytes, osteocytes, chondrocytes [78,79], neurons [80,81], cardiomyocytes [78,82] and renal tubule epithelial cells [83] upon cultured in induction media.

Initially, stem cell was isolated from bone marrow and characterized as plastic adherent fibroblastoid cell which has the capacity to generate some tissues [84]. As study on stem cell has progressed, the stem cells were also found in the many other adult organs. The discovery of trans-differentiation potential [85] led us to use them in currently incurable or intractable diseases. Stem cells are used for two purposes: one is the trans-differentiation of stem cells into the specific cell types to replace the damaged or destroyed cells or tissues, and the other is the stimulation of the pre-existing native cellular repair mechanism in damaged organs, which may contain resident dormant stem cells. Currently, stem cell-based cell therapy is increasingly applied to the variety of diseases including cardiovascular issues [86], diabetes [87], musculoskeletal disorders [88], renal problems [89], impotence [90] and hepatic cirrhosis [91]. Stem cells can also be used for cytokine producer. Stem and other cells, which are genetically engineered for the production of cytokines, are also used as a vehicle of cytokines for targeting injury or disease sites, such as cancer sites [92]. Stem cells, in particular committed to hepatocytes, can also be used for screening of drug toxicity [93].

Stem cells are classified into three, according to the differences in sources; embryonal stem cell (ESC), adult stem cell (ASC) and induced pluripotent stem (iPS) cell. ESC was developed by Thomson in Wisconsin [94]. Fetal stem cells and amniotic stem cells may belong to this category. The differentiation potential of ESCs is great but the clinical use has been strictly limited due to the ethical problem and the tumorigenesis. The iPS cells were generated from mouse fibroblasts in 2006 by Yamanaka [95], with introduction of four genes; Oct 3/4, Sox2, c-Myc, and Klf 4. The potentiality of iPS cells seems appears to be unlimited for clinical applications, but the bio-characterization of iPS cells has not established yet, although they are under intensive study. The origin of ASCs first discovered is bone marrows (BMSC), and then, the ASCs were discovered from the many mature organs [96-100]. Among these, bone marrow, adipose tissues (ADSC) and umbilical cord blood (UCBSC) derived stem cells are currently available for cell-based clinical therapies. BMSCs were actively applied for the treatment of hematologic diseases, already. The spectrum of clinical application of BMSCs continues to expand with the time. UCBSCs are collected from venous blood of the cord, but the cell number collected is not great. The UCBSC was applied for Fanconi's anemia [101] in 1986 between siblings. UCBSC seems to contain the most immature form of ASCs that have few chances to contact with environmental antigens, immunologically immature [102]. The UCBSCs do not raises any ethical concern at umbilical cord blood collection issues and collection can be processed without invasiveness for donors. The regenerative capabilities of UCBSC are similar to other types of ASC [103]. Adipose tissue derived stem cell (ADSC) was first described by plastic surgeons [104]. The procedure harvesting adipose tissue is a common work among plastic surgeons for cosmetic or regenerative purposes, although it is somewhat invasive. The processed lipoaspirated tissues harbor abundant multipotent stem cells, which have similar potential with BMSC or UCBSC [103]. ADSCs are permitted for autologous cell-based therapy in many countries.

The angiogenic, neurogenic and trans-differentiation potential of stem cells are the principal targets in stem cell based treatment [105-110]. Vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), platelet derived growth factor AB (PDGF-AB), transforming growth factor-β (TGF-β), and integrin β are stem cell angiogenic factors [111,112]. Brain-derived neurotrophic factors, and neurotrophin-4/5 (NT4/5) [113,114] are stem cell neurotrophic factors. Reports on the effects of stem cells for improvement of vascular insufficiencies [115-118] and neuropathies [119-121] are accumulating these days.

Liver cirrhosis has been thought to be an irreversible disease. However, recent studies on cirrhosis of animals and humans suggest that liver cirrhosis is a potentially reversible disease. Stem cells, which are of anti-fibrotic and trans-differential potential, raised the possibility of their??? use for the treatment of liver fibrosis and cirrhosis as an alternative treatment replacing for liver transplantation.

In the present study we report our pre-clinical and clinical experiences of umbilical cord blood derived stem cell treatment for end stage liver cirrhosis, and discuss on the stem cell therapy in liver cirrhosis.

Advertisement

2. Materials and methods

2.1. Preclinical study

For the evaluation of the stem cell effect, we prepared the rat liver cirrhosis model with carbon tetrachloride (CCl4). Male Sprague-Dawley rats (6weeks old, 180–-200g) were used. The rats were grouped into 3, one control group (A) and two experimental groups, CCl4 treated group (B) and CCl4 treatment plus stem cell treated group (C). Cirrhosis was induced by intraperitoneal administration of CCl4 (4:1 olive oil) at a dose of 0.1 mL/100 g body weights, three times a week. The same volume of olive oil only was intraperitoneally infused for control. For cirrhosis induction, CCl4 was infused for 8 weeks. Human umbilical cord blood stem cells were infused at a dose of 1x106 cells in 0.2 mL through the tail vein, and saline of same volume for control and CCl4 only group. Rats were sacrificed at one, two and four weeks and one pathologist evaluated the pathologic changes of liver. For pathologic evaluation, sections of approximately 4 μm thick were made and stained with haematoxylin and eosin (H&E) staining for routine histology, and Masson’s trichrome (MT) staining for collagen.

2.2. Clinical study

Total 51 patients were participated in this treatment. The exclusion criteria for patient recruitment in stem cell treatment with liver cirrhosis were age limitation, over 70, and cancer. Among them, 46 patients (male 27 and 19 female) were classified as the Child-Pugh (CP) class C liver cirrhosis and 5 (four male and one female) were classified as the CP class B, finally, although they were classified as the class C from the other hospital, at the time of initiation. All participants are randomly involved in this treatment after reviewed the medical records of patients whose life expectancy were less than 6 months, evaluated by doctors in charge before involved in these treatments. 43 patients graduated from the college or upper rank school. The cause of cirrhosis was alcholic in 18 and posthepatitic in 36. Although 17 had the heart problem, it was not definite whether cardiac problem was the solitary cause of the cirrhosis or not, except two. The common clinical complications for portal hypertension were varix [41] and ascitis [34]. For all patients, the explanation was made on the treatments rationale and material, and informed consents were obtained. All patients understood the treatment and no body has the opinion on baseline studies (Table 1). All participating patients were negative on cancer especially at baseline studies. They had specific conditions that could be related with liver cirrhosis and had the several complications induced from portal hypertension (Table 2).

ImagingUltrasound Exam. on Heart, Liver, Kidney
CT on Abdomen
EndoscopicGastroscopy, Esophagoscopy
Blood & SerologyCBC, Serologic series 12
UrineUA, Microscopic Examination
Cancer MarkerAFP, CEA
OthersVDRL, AIDS, Hepatitis B Ag/Ab, Hepatitis C AG/Ab.,
Electrolyte, C-reactive protein, ASO titer, EKG, ESR, RA factor
Coagulation PT (INR)

Table 1.

Base line studies.

The human umbilical cord blood stem cells (hUCBSC) were supplied by Histostem Co. Ltd. (Seoul, Korea) that was permitted for clinical use from the Korean government (KFDA).

The supplied stem cells were ABO, HLA-ABC, DR and sex matched for each patient, and the donor of each stem cell unit does not have any specific familial medical history. The stem cell markers of hUCBSCs were studies by flow cytometry. Total cell numbers that infused for each patient were around 1.5 x 107. hUCBSCs were infused percutaneous directly into liver parenchyma using needle under the ultrosonographic guide. All patients were informed for usual life after one-day bed rest. Patients were followed every month from treatment at least for 6 times. At follow up check, patients were evaluated for prothrombin time, albumin, ascities and encephalopathy before and after each month from the stem cell therapy. Patients were evaluated for serological results, ascities and encephalopathy before and after each month from the stem cell therapy. The final survival was checked at November 30, 2010, 7 to 75 months from the initiation of the stem cell therapy.

Conditions manifested
at initial visit
Positive Patients
Number
Negative
Patients Number
Alcohol Intoxication1833
Hepatitis History3615
Heart Problem1734
GB Problem051
Varix4110
Ascitis3417
Hepatic
encephalopathy
1932
Peritonitis150

Table 2.

Patient condition at presentation.

Study ItemsNormal ValueNormal
Patients
Range of Measure value
Patients Number
Total Protein6.3 - 8.2 g/dL1239
Albumin3.5 - 5.1
g/dL
51.0 - 2.02.1 - 3.0"/>3.1
17263
ALP38 – 1261338
sGOT5 – 40 IU/L249
sGPT5 – 35 IU/L150
Total Bilirubin0.2 - 1.3
mg/dL
14<2mg/dL2-3mg/dL"/>3mg/dL
18163
Direct
Bilirubin
0 - 0.3
mg/dL
1734
PT (INR)<1.718<1.71.7 - 2.3"/>2.3
182211

Table 3.

The results of serologic test before stem cell treatment.

Advertisement

3. Results

3.1. Stem cells

The flow cytometric results (Figure 1) of hUCBSCs were CD13(+), CD14(-), CD29(+),CD31(-), CD34(-), CD44(+), CD45(-), CD49e(+), CD54(+), CD90(+), CD106(-), AMSA(+), SH2(+), SH3(+), HLA-ABC(+) and HLA-DR(-).

Figure 1.

Flow cytometric findings of the surface markers in hUCBSCs.

3.2. Preclinical study

The gross finding of the liver was examined (Figure 2) at 12 weeks after the starting the infusion of CCl4. Compared to the control which have normal hepatic configuration (A), the CCl4 infused rats (B) without stem cell treatment showed nodular surfaced distorted liver but CCl4 infusion with stem cell treatment rat (C) showed recovered from the distorted nodular liver but much distorted compared with control (A).

The microscopic study (Figure 3), with haematoxylin and eosin (H&E) staining for routine histology and Masson’s trichrome (MT) staining for collagen, were done on liver section at 1, 2 and 4 weeks after CCl4 injection for 8 weeks. The control group showed normal

Figure 2.

Gross findings of the liver at 12 weeks after initiation of the CCl4 intraperitoneal injections. A is control, B is CCl4 intraperitoneal injection and C is CCl4 intraperitoneal injection plus hUCBSC treated rat.

architecture at all livers (A). At 1 week after CCl4 injection for 8 weeks, the experimental group showed the cirrhosis was induced in both without (B1) and with stem cell treatment group (C1), the fibrosis and deposition of collagen, separating liver parenchyma into large lobules. At 2 week after CCl4 injection for 8 weeks, there was definite difference between without stem cell treatment group and with stem cell group. The without stem cell treatment group (B2) showed increased septa composed of fibrosis and collagen. Compared to without stem cell group, with stem cell group (C2) showed reduced septa than first week after CCl4 injection for 8 weeks. At 4 week after CCl4 injection for 8 weeks, the without stem cell treatment group (B3) showed much increased septa composed of fibrosis and collagen and there is new fine septa were appeared within large lobules. In with stem cell treatment group (C3), the septa composed of fibrosis and collagen were reduced and the lobules are closely approximated each other. In these pathologic findings, experimental group without stem cell therapy induced the extensive fibrosis / cirrhosis and the fibrosis was progressed as the time passing (B). These CCl4 induced fibrosis / cirrhosis was proved by disruption of liver parenchyma architecture, extension of fibers, large fibrous septa formation, pseudolobe separation and collagen accumulation. These alterations were progressed and increased in fibrosis and collagen deposition with time passing. The histopathological findings confirmed that the cirrhosis was significantly reduced by stem cell infusion.

Figure 3.

Microscopic findings of the rat liver in control and experimental rats. A from control rat, B from CCl4 intraperitoneal injection only rat and C from CCl4 intraperitoneal injection with hUCBSC therapy rat. 1 at 9 week from CCl4 intraperitoneal injection, 2 at 10 weeks and 3 at 12 weeks.

3.3. Clinical study

The participants’ age ranged from 49 to 68 years old (mean 54.7 years). The mean age of the CP class C were 56.2 and class B were 48.9. After the stem cell therapy, there was no death within 6 months from the initiation of the stem cell therapy. There were 9 deaths from 7 months within 12 months, 19 deaths from 13 months within 2 years, 13 deaths over 2 year within 3 years, 3 deaths over 3 years within 5 years. 7 are living now, from 11 to 75 months from stem cell therapy, and among them, two are living over 5 year. During the procedure (Figure 4), the bleeding from the liver was not remarkable. Clinically, ascitis was improved in 21 and 5 did not show any ascitis within 6 months. Among 5, 2 are alive more than 5 years (Figure 5). In hepatic encephalopathy, all patients showed improvement in symptom.

Figure 4.

Laparascopic view of percutaneous injection of the stem cells into liver. The needle is inserted into the nodular surfaced liver.

Figure 5.

CT findings from the patient who is living more than 5 years. A is CT taken just before (Feb. 21, 2005) stem cell therapy and B is CT taken was after 5 months (July 23, 2005). The measured liver size was increased from 689.98 CC to 915.36 CC and hepatic density is lowered suggesting release of fibrosis.

But there is no patient who lived more than 30 months. Serologic follow up check was done in all patients (Table 3 and 4). In serologic test, although there were some changes in the results, it was impossible to get the uniform information in trends of change. Among 39, those who had abnormal protein level, total protein level was normalized at 6, but among 39, only 2 were normalized in albumin. In these 2, one had normalization of total protein level but one did not, meaning some difference in improvements among sub-group.

Study ItemsNormal ValueNormal
Patients
Range of Measure value
Patients Number
Total Protein6.3 - 8.218(+6)33(-6)
Albumin3.5 - 5.17(+2)1.0 - 2.02.1 - 3.0"/>3.1
12(-5)25(-1)7(+4)
ALP38 - 12617(+4)34(-4)
sGOTM: 17 - 59
F: 14 - 36
9(+7)42(-7)
sGPTM: 21 - 72
F: 9 - 52
12(+11)39(-11)
Total Bilirubin0.2 - 1.316((+2)<2mg/dL2-3mg/dL"/>3mg/dL
21(+3)14(-2)0(-3)
Direct Bilirubin0 - 0.318(+1)33(-1)
PT (INR)<1.723(+5)<1.71.7 - 2.3"/>2.3
23226

Table 4.

Serologic test results at post stem cell treatment 6 months.

Advertisement

4. Discussion

Most of the chronic liver injuries, regardless of their causes, progress to liver fibrosis and eventually result in cirrhosis that is thought to be irreversible, and the liver cirrhosis (LC) results in impairment of the hepatic function becoming a massive health care burden worldwide. LC is induced by many different causes, such as chronic viral hepatitis, toxic damage including alcohol, parasitic disease, inborn errors of metabolism, and non-alcoholic fatty liver disease etc. The cause of LC has a wide geographic variation. Alcohol is the most common cause in western countries [122] and liver disease is the 5th most common cause of death in the United Kingdom [123]. Recent reports on pre-clinical and clinical studies suggested that LC could be reversible. HSCs activated upon liver injury are thought to be responsible for collagenogenesis and fibrosis in extracelluar matrix [124, 125]. Modulation of HSC activity [126], promotion of HSC apoptosis [127], blocking of matrix formation [128] or anti-proliferation measures on matrix fibrogenic and contractile response to HSC and degradation of established matrix [125,129] could be taken as potent strategies for reversal of LC. In addition to these strategies, stem cell therapy with multiple cytokine production and trans-differentiation potential would be a new option [130] for reversal of established LC.

HSCs are responsible for the production of extracellular matrix at the center of LC. Therefore, the inhibition of the activation of HSCs [131-133] or promotion of HSC apoptosis [134-135] would be an eradicating measure for fibrogenesis. The platelet-derived growth factor (PDGF) is the most potent mitogen for HSCs, thereby inhibitors against PDGF have been tried [136-138]. For the patients whose fibrosis is progressing, the matrix formation blockers [139] or anti-proliferation measures to matrix fibrogenesis [140] would be another measure for the reduction of LC. HSCs contribute to portal hypertension through multiple mechanisms including collagen deposition, vasoconstriction, and regulation of sinusoidal structure. So, the reduction of contractile response to HSC [141] would be a measure reducing critical complications induced by portal hypertension. Increasing the degradation of established matrix [125,142,142] would be an ideal strategy for reversal of LC.

Recently developed stem cell therapy [143-144] may be a promising strategy for LC, because we can expect them to trans-differentiate into hepatocytes and to stimulate the differentiation of hepatocytes from the dormant stem cells remaining in injured host liver and stem cells in bone marrow through cytokine production [145]. BMSC, ADSC, and UCBSC are currently used for stem cells therapy. Unseparated bone marrow cells and purified BMSCs have been used for the treatment of the hematopoietic diseases for more than 50 years. Their application fields are expanding day by day. For advanced liver diseases such as cirrhosis, stem cell engraftment can be most promising strategy after the organ transplantation [146]. In animals treated with CCl4 intraperitoneal infusion, the percentage of lin- Sca-1+ cells in the bone marrow and peripheral blood increases twofold at twenty-four hours later [147] and this increase peaks at day one in the bone marrow and day two in the peripheral blood [147]. This finding suggests that bone stem cells started to proliferate and migrate to the periphery [147]. Requirement of engraftment of stem cells into the patients with the severe liver diseases are increasing. For BMSC therapy, bone marrow aspiration is inevitable and bone marrow aspiration is a invasive procedure. Differentiation potential, and maximal life span of BMSC decrease with increasing age [148-149]. In post-hepatitic LC patients, the autologous BMSCs are not suitable for the treatment, because their proliferation capacity is restricted significantly in the tissue environment of end stage of the disease [150]

ADSCs were relatively recently found. Their easy isolation [151] and high differentiation potential [152] may be attractive as alternative promising stem cells in place of BMSCs. In the meantime, UCBSCs has been used for several diseases. UCBSCs have advantages over other types of stem cells, because umbilical cord blood (UCB) can be obtained without invasiveness or harm to donor. Cells from UCB have many advantages because of the immaturity of stem cells compared to other types. Moreover, UCBSCs provide no ethical barriers for basic and clinical applications [153-154]. Recently, UCB banking for transplantation of haematopoietic stem cells is increasingly in many institutions [155] due to their easy availability and the ready on shelf system. All clinical papers are of autologous or allogenic stem cell therapy. Among the adult stem cells, UCBSCs are youngest stem cells and they had only few chances to contact with environmental antigens. UCBSCs have higher proliferative potential than BMSC and higher expression of the endothelial-specific markers following endothelial differentiation [156].

When we decided to attempt to treat with UCBSCs for some diseases, we carefully consider suitable cell (origin) for target organs, cell numbers, route for administration, supplementation of growth factors and post-treatment cares. In spite of increasing requirement of stem cell treatment, the protocol for stem cell treatment has not established until now. Because the preparation of the stem cells for enough quantity that has the identical or similar biology is not easy, we should consider the measure to secure the enough number of stem cells, culture or mixing of different donors. Although many trials with stem cell were done, most of them are autologous rather than allogenic. Basically, many diseases caused by different pathogenesis, it needs different treatment. In case of LC, bone marrow stem cells from liver cirrhotic caused by chronic hepatitis B infection showed significantly lower S-phase fractions and growth factor (IGF-1, PDGF α, PDGF β) receptor expression than normal people [157]. It indicates that allogenic stem cell therapy is better than autologous in LC. We suppose that allogenic stem cell therapy would be reasonable in case of the hereditary or genetic disease. The number of stem cells in specific treatment has not decided yet, too. Moriya et al. [158] used 1x105 embryonal stem cells in animal study model (mice). Liu et al.[159] used 5x105 endothelial precusor cells in 150 g animal study model(rat). Yan et al. [160] infuse 3x106 hunman UCBSCs in mice. Although these reports are animal study, when we calculate the cell number in weight to weight (animal to human) base, the cell number for human treatment should be over 1x108 cells. But Mohamadnejad et al. [161] infused 31.73 x 106 autologous bone marrow mesenchymal stem cells for four liver cirrhotic patients via peripheral vein. So, the cell number for treatment of disease should be standardized according to the disease, although there should be many trials for standardization.

In introduction part of this chapter, we mentioned on the characteristics of stem cells, homing or migration (someone uses ‘targeting’). Homing in stem cell biology means stem cell moving toward injury site along the some chemotactic signal [162]. So, many animal experiments localized the targeted stem cells, which were infused via tail vein [260-164] or intraperitoneal infusion[165] and sometimes via specific route such as portal vein[166]. And in case of cellular cardioplasty for myocardiac infarction model, several different infusion has been used, direct intracoronary [167], intravenous with homing[168] and mobilization with homing from bone marrow or peripheral blood[169]. In cellular cardiomyoplasty, according to the cell delivery system, the results are different. Least effective method is mobilization from peripheral blood or bone marrow[170-171] and most effective method is intracoronary infusion [172-173]. And in case of intravenous infusion, according to the blood flow, all blood in body has to pass the lung and some proportion of infused stem cells are trapped at the lung [174-175]. Some are trapped at other organs[176].

There are many growth factors which support or enhancing stem cell activities. The supplement of growth factors into stem cell culture media or coupled treatment of stem cell with growth factors was reported in vitro and in vivo, already. Supplement of growth factors in culture system has been done from long ago in culturing technique and sometimes essential job for culture, but the coupled clinical treatment of stem cell with growth factors [177-178] are in different conditions [177-178]. Although we use the various growth factors for in vitro culture system, there are a few growth factors which are permitted to use for human from the health concerning governmental bureau. So, it is not easy to search the simultaneous application of the growth factor as an auxiliary measure for stem cell therapy [178-180].

Post-treatment care are difficult to mention at present time because there is no report for large sized world wide data related on the stem cell treatment on specific disease until now. Although the data on the post-treatment care for better maintenance of end result of stem cell therapy are needed, it is not proposed yet. As in the material and method, we had the clinical treatment for end-stage LC whose survival was expected to be less than 6 months. The result showed that the all patients had improved survival although their initial life expectancy was based on the doctor's experiences. Other laboratory data had some differences among patient to patient, but most of the patients who had the hepatic encephalopathy and more than half of the ascitic patient had the improved symptoms.

In author's stem cell treatment for LC, we used umbilical cord blood stem cells (UCBSCs), only. UCBSCs produce and secrete various humoral factors (cytokine or growth factors)(261-262). They are stem cell factor (SCF), macrophage colony stimulating factor (M-CSF), granulocyte macrophage colony stimulating factor (GM-CSF), vascular endothelial growth factor (VEGF), interleukin 1β (IL-1β), IL-6, IL-8, IL-11, IL-12, IL-15, stromal cell-derived factor 1α (SDF-1α), hepatocyte growth factor (HGF), epitehlial cell-derived protein 78 (ENA-78), Growth-related oncogene (GRO), oncostain M (OSM), monocyte chemoattractant protein-1 (MCP-1), fibroblast growth factor 4 (FGF-4), FGF-7, FGF-9, granulocyte chemotactic protein 2 (GCP-2), Insulin like growth factor (IGF), Insulin-like growth factor binding protein 1 (IGFBP-1), IGFBP-2, IGFBP-3, IGFBP-4, Interferon-gamma-inducible protein 10 (IP-10), Leukemia inhibitory factor (LIF), migration inhibitory factor (MIF), macrophage inflammatory protein 3α (MIP-3alpha), osteoprotegerin, (OPG), pulmonary and activation-regulated chemokine (PARC), Placenta growth factor (PIGF), transforming growth factor β1(TGF-β1), TGF-β2, TGF-β3, tissue inhibitors of matrix metalloproteinases 1 (TIMP-1) and TIMP-2.

Among these cytokines, some of them are favorable for antifibrosis and some are prone to enhance the fibrosis in liver. The results of balance between favorable and unfavorable effects among the various cytokines secreted from the UCBSC would predict treatment or aggravation of LC. Among above cytokines that UCBSCs secrete, HGF, IGF-1, IGFBP and interferon would be closely related with fibrolysis of liver but TGF-β1 and TIMP will promote hepatic fibrosis. Although the results of UCBSC treatment on LC patient showed much improvement on symptoms and liver function related laboratory data, we do not know the interaction between those cytokines, which has some antagonistic effects.

We injected stem cells into liver parenchyme directly under the ultrasound guide. Total cell numbers were around 1.5 x 107 hUCBSCs in each patient. Until now, there are many trials with animal model of LC but no author has presented the proper cell number for stem cell treatment on LC. Around 1 x 106 cells were infused intravascularly in rat or mouse liver cirrhosis model and they showed improvement in hepatic functions. Although the most of patients in our treatment group showed favorable effects on LC after stem cell therapy, the role of cell number in LC treatment was not definite. We infused the stem cells directly into the target organ, liver, the cell number that authors used were much less than animal experiments. In spite of our small numbered stem cells, there was some improvement in data for hepatic function.

As mentioned before, we infused the stem cells directly into the liver parenchyma. The infusion route would be closely related with results of the stem cell treatment. In systemic intravenous administration would be the easiest method in stem cell treatment but the trapping of stem cell by lung or some reticuloendothelial system, during circulation before homing, would lessen the treatment effects. Although there are several data related with homing after intravenous infusion of stem cells, it is unclear that how many portions of infused cells are homed. To increase the homed stem cells in target organ, some therapies try to infuse the stem cells via selective artery, although it is invasive. More invasive therapy would be the orthotopic infusion/transplantation of stem cells under direct of indirect visualization. Surgically exposed target lesion would be treated with high accuracy and possibly permit reduced numbered stem cell implantation with same effects. Modern developed imaging modalities enabled us target the lesions with very high accuracy with less damage. The choice of the route for best effective targeting the lesion would be depend on the imaging modality and technique of operator.

Average life expectancy of the LC patients chose randomly by authors is expected to no more than 6 months. After stem cell therapy, no body had gone within 6 month and two of 51 patients survived more than 5 years. There would be many causes contributing to the improvement of patients' survival. Among them, the role of stem cell for improvement of survival and laboratory data should get attention. Although Kögler and Liu reported the various cytokines, which they detected from UCBSCs, there would be many unknown cytokines (humoral factors), which is secreted by the UCBSCs. We do not know the mechanisms that improved survival and laboratory data in liver function, but the HGF, INF and IGF and IGFBP would be closely related with fibrolysis and collagenolysis.

Originally HGF has mitogenic, motogenic, morphogenic and anti-cell death activities [181], and identified and cloned as a mitogen protein for hepatocyte [182-183]. HGF stimulates expression and activity of proteases involved in breakdown of ECM proteins, including urokinase-type plasminogen activator and matrix metalloproteinases. In LC, HGF suppress the proliferation while promoting apoptosis of α-SMA-positive cells in the liver, that histological resolution from liver cirrhosis.[181] Growth inhibition and promotion of apoptosis in portal myofibroblasts by HGF would be an ancillary resolution for liver fibrosis/cirrhosis.[184] Mesenchymal stem cells (MSCs) can prevent the development of liver fibrosis, and hepatocyte growth factor (HGF) can also attenuate liver cirrhosis. [185] HGF/MSCs significantly inhibit the formation of liver fibrosis in rats, while MSCs and HGF had synergistic effects in the process. The antifibrosis effect of HGF/MSCs may have contributed in modulating the activation and apoptosis of HSCs, elevating the rHGF expression level, and decreasing the TGF-beta 1 secretion of activated HSCs.[185]. In CCl4-induced liver cirrhosis rat model, hBMSCs treatment results were induced by two mechanisms that work together: the differentiation of transplanted hBMSCs into liver cells that are able to restore normal liver functions, and expression by production of MMP by hBMSCs which is involved in the repair of liver fibrosis. [186].

In interferon, there are many subtypes but only a few of them are reported to be produced from the UCBSCs. Among them, interferon alpha (IFN-α) suppress the progression of hepatic fibrosis [187], and lowers fibrosis scores, tissue hydroxyproline levels, liver TIMP-1 and elevate MMP-13 levels. IFN-α has role to increases HSC apoptosis, too[188]. TIMP is the representative fibrosis favoring molecule and MMP is the representative molecule for fibrolysis. IFNγ have the hepatic protective effect by inhibition of adenosine A2A receptor function in hepatic stellate cells [191]. Among those cytokines, M-CSF promotes the interferone production.

Insulin-like growth factor-1 (IGF-1) and major portion of the circulating IGF-1 synthesized in the liver are hepatic origin in normal state, but in LC the plasma levels are diminished [190-191]. When the deficient IGF-1 in LC was replaced by daily administration of recombinant IGF-1, it induces a significant improvement of liver function [192]. In liver, the expression of IGF-1 receptor is poor [193-194] and it seems that IGF-I acts on nonparenchymal cells. IGF-1 improves the liver structures and function through the activation of tissue-repair mechanism at non-parenchyma. It seems that there is an amplification loop which are favoring the efficacy of the therapy because the IGF-1 upregulate the IGF-1R in hepatic septa [195]. In liver cirrhosis, the supplementation of IGF-1 induces the antifibrogenic and hepatoprotective effects. [196] Aside from the antifibrogenic effects, patients treated with stem cell showed improved serum albumin and enzyme levels indicating liver functions and these results are supposed due to IGF effects.

This discussion reviewed the mechanism that stem cell have favoring results related with LC. But it would not be the total mechanisms that explain the favoring effect of stem cells on LC. Among the above mentioned cytokines produced by UCBSCs, there are reports for characterization of cytokins, such as SDF-1[197] IL-8 [198] M-CSF [199], RANTES [200], MIP-1α [201], IP-10 [202] and EGF [203], but the most of them are not directly related with improvement of LC.

Until now, there are several clinical papers, around 10, on the results of autologous stem cell treatments, either autologous bone marrow derived stem cells or mobilized stem cells and fetal stem cell for the end stage liver cirrhotic patients. All of them are backing further clinical application of stem cell on liver cirrhosis. Most of the reports were related with the treatment with small number of patients, less than 10 patients, except for India [204]. And the routes of stem cell infusion, aside from the mobilized hepatopoietic stem cells, are portal vein or hepatic artery with a few intravenous infusions. With these data, it is practically difficult to compare the superiority of the route of stem cell infusion due to small patient number in each case. Although there are common findings are improvement of hepatic conditions.

In the clinical data that we introduced in this chapter, all patients were supposed to be gone within 6 months before they were involved in stem cell therapy, meaning terminal state LC patients. Two third in 51 had the ascitis and more than one third had the hepatic encephalopathy. After single stem cell therapy using UCBSC, most of the hepatic encephalopathy patients and more than two third of ascitic patients were improved in symptom or responded to medical therapy who were refractory to previous therapy. But other data for liver function, albumin, aminotransferases, bilirubin or prothrombin time has irregular responses. About half of patients of ascites who had the improved symptoms showed improved albumin values but difficult to pull out any reproducible protocol, requiring further study. Because we choose the patients randomly in loose exclusion criteria, it would be difficult to get the objectively reproducible data from our experience for base of any protocol in stem cell therapy. But we can get some idea of trends of stem cell therapy for LC, although we had a single treatment. The stem cell therapy improves the ascitis and hepatic encephalopathy definitely in some group of patient, although we do not characterized this group, yet. In case of hepatic encephalopathy, the most of patients showed objectively improved symptom but we do not presume the mechanism, too. At the point of patient survival, all patients survived more than 6 months, although it would be difficult to believe the patients’ initial life expectancy as the objective data. The patients' survival would not be related with liver function only but would be the summation of the various indexes of life signs. The most common side reaction that related with the stem cell treatment was pain, experiencing during stem cell infusion procedures. As mentioned before, much of the stem cell biology including producing cytokines has been proven already but it would be a tip of iceberg. We treated the patients who were regarded as the hopeless condition in point of survival improvement based on the reasonable solid animal study results of stem cell therapy, but they lack objective clinical efficacy aside from trend of stem cell therapy. So, to get the further acquisition of objective clinical effects and base on proper protocol, large multicenter trial on stem cell therapy for liver cirrhosis would be needed.

Advertisement

5. Conclusion

The conclusion of our review and experience is that there are lots of beneficial effects of stem cells on end stage liver cirrhosis and stem cell therapy serves for prolongation of the life and improvement of quality of life. The analysis of author’s experience lacks objectivity. And if there is the more systemic multicenter large numbered study, we can make the proper guideline for stem cell therapy on liver cirrhosis.

References

  1. 1. HeimD.WegeH.2009Hepatic stem and progenitor cells in liver diseases and hepatocarcinogenesis. Minerva Gastroenterol Dietol. 5521112101827-1642
  2. 2. Kung JW, Forbes SJ.2009Stem cells and liver repair. Curr Opin Biotechnol. 205568740958-1669
  3. 3. BirdT. G.LorenziniS.ForbesS. J.2008Activation of stem cells in hepatic diseases. Cell Tissue Res. 33112833000030-2766X.
  4. 4. HeimD.WegeH.2009Hepatic stem and progenitor cells in liver diseases and hepatocarcinogenesis. Minerva Gastroenterol Dietol. 5521111210112-1421X.
  5. 5. ManuelpillaiU.TchongueJ.LourenszD.VaghjianiV.SamuelC. S.LiuA.WilliamsE. D.SievertW.2010Transplantation of Human Amnion Epithelial Cells Reduces Hepatic Fibrosis in Immunocompetent CCl Treated Mice. Cell Transplant. 1991157680963-6897
  6. 6. FriedmanS. L.2003Liver fibrosis- from bench to bedside. J. Hepatol. 38(Suppl. 1):S38S53, 0168-8278
  7. 7. TasciI.MasM. R.VuralS. A.ComertB.AlcigirG.SerdarM.MasN.IsikA. T.AtesY.2006Rat liver fibrosis regresses better with pegylated interferon alpha2b and ursodeoxycholic acid treatments than spontaneous recovery. Liver Int. 2622612681478-3223
  8. 8. LeftonH. B.RosaA.CohenM.2009Diagnosis and epidemiology of cirrhosis. Med Clin North Am. Jul;93478799vii, 0025-7125
  9. 9. FernándezM.SemelaD.BruixJ.ColleI.PinzaniM.BoschJ.2009Angiogenesis in liver disease. J Hepatol. 503604200168-8278
  10. 10. SandahlT. D.JepsenP.ThomsenK. L.VilstrupH.Incidence and mortality of alcoholic hepatitis in Denmark 1999-2008: A nationwide population based cohort study. J Hepatol. 2011Apr;5447607640168-8278
  11. 11. Seeff LB.2002Natural history of chronic hepatitis C. Hepatology 36(5 suppl 1):S35S46, 0270-9139
  12. 12. WallaertB.BonniereP.PrinL.CortotA.TonnelA. B.VoisinC.1986Primary biliary cirrhosis. Subclinical inflammatory alveolitis in patients with normal chest roentgenograms. Chest. 90684280012-3692
  13. 13. OhS.AfdhalN. H.2001Hepatic fibrosis: are any of the serum markers useful? Curr Gastroenterol Rep. 3112181522-8037
  14. 14. LuL. G.MDZengMao. Y. M.LiJ. Q.QiuD. K.FangJ. Y.CaoA. P.WanM. B.LiC. Z.YeJ.CaiX.ChenC. W.WangJ. Y.WuS. M.ZhuJ. S.ZhouX. Q.2003Relationship between clinical and pathologic findings in patients with chronic liver diseases. World J Gastroenterol. 912279628001007-9327
  15. 15. Chang ML, Yeh CT, Chang PY, Chen JC.2005Comparison of murine cirrhosis models induced by hepatotoxin administration and common bile duct ligation. World J Gastroenterol. 21;11274167721007-9327
  16. 16. IssaR.WilliamsE.TrimN.KendallT.MJArthurReichen. J.BenyonR. C.IredaleJ. P.2001Apoptosis of hepatic stellate cells: involvement in resolution of biliary fibrosis and regulation by soluble growth factors. Gut. 484548570017-5749
  17. 17. IssaR.ZhouX.ConstandinouC. M.FallowfieldJ.Millward-SadlerH.MDGacaSands. E.SulimanI.TrimN.KnorrA.MJArthurBenyon. R. C.IredaleJ. P.2004Spontaneous recovery from micronodular cirrhosis: evidence for incomplete resolution associated with matrix cross-linking. Gastroenterology. 1267179518080016-5085
  18. 18. TasciI.MasM. R.VuralS. A.DeveciS.ComertB.AlcigirG.MasN.AkayC.BozdayiM.YurdaydinC.BozkayaH.UzunalimogluO.IsikA. T.SaidH. M.2007Pegylated interferon-alpha plus taurine in treatment of rat liver fibrosis. World J Gastroenterol. 21;13233237441007-9327
  19. 19. FriedmanS. L.1993Seminar in medicine of the Beth Islael Hospital, Boston. The cellular basis of hepatic fibrosis. Mechanisms and treatment strategies. N Engl J Med 328182818350028-4793
  20. 20. GeremiasA. T.MACarvalhoBorojevic. R.MonteiroA. N.2004TGF beta1 and PDGF AA override collagen type I inhibition of proliferation in human liver connective tissue cells. BMC Gastroenterol. Dec 3;4:30. 0147-12301471230X.
  21. 21. Kharbanda KK, Rogers DD 2nd, Wyatt TA, Sorrell MF, Tuma DJ.2004Transforming growth factor-beta induces contraction of activated hepatic stellate cells. J Hepatol. 4116060168-8278
  22. 22. ParsonsC. J.TakashimaM.RippeR. A.2007Molecular mechanisms of hepatic fibrogenesis. J Gastroenterol Hepatol. 22 Suppl 1:S79840815-9319
  23. 23. DooleyS.DelvouxB.LahmeB.Mangasser-StephanK.GressnerA. M.2000Modulation of transforming growth factor beta response and signaling during transdifferentiation of rat hepatic stellate cells to myofibroblasts. Hepatology. 31510941060270-9139
  24. 24. ChangY. Z.YangL.YangC. Q.2008Migration of hepatic stellate cells in fibrotic microenvironment of diseased liver model. Hepatobiliary Pancreat Dis Int. 7440151499-3872
  25. 25. Friedman SL.2003Liver fibrosis- from bench to bedside. J Hepatol 38:S38530168-8278
  26. 26. JesnowskiR.FürstD.RingelJ.ChenY.SchrödelA.KleeffJ.KolbA.SchareckW. D.LöhrM.2005Immortalization of pancreatic stellate cells as an in vitro model of pancreatic fibrosis: deactivation is induced by matrigel and N-acetylcysteine. Lab Invest. 85101276910023-6837
  27. 27. Rockey DC.2001Hepatic blood flow regulation by stellate cells in normal and injured liver. Semin Liver Dis. 213337490272-8087
  28. 28. PinzaniM.MilaniS.De FrancoR.GrapponeC.CaligiuriA.GentiliniA.Tosti-GuerraC.MaggiM.FailliP.RuoccoC.GentiliniP.1996Endothelin 1 is overexpressed in human cirrhotic liver and exerts multiple effects on activated hepatic stellate cells. Gastroenterology. 1102534480016-5085
  29. 29. Rockey DC, Chung JJ.1998Reduced nitric oxide production by endothelial cells in cirrhotic rat liver: endothelial dysfunction in portal hypertension. Gastroenterology. 1142344510016-5085
  30. 30. PinzaniM.MarraF.2001Cytokine receptors and signaling in hepatic stellate cells. Semin Liver Dis. 2133974160272-8087
  31. 31. MarraF.1999Hepatic stellate cells and the regulation of liver inflammation. J Hepatol. 3161120300168-8278
  32. 32. Friedman SL.2000Molecular regulation of hepatic fibrosis, an integrated cellular response to tissue injury. J Biol Chem. 27542247500021-9258
  33. 33. IredaleJ. P.BenyonR. C.MJArthurFerris. W. F.AlcoladoR.WinwoodP. J.ClarkN.MurphyG.1996Tissue inhibitor of metalloproteinase-1 messenger RNA expression is enhanced relative to interstitial collagenase messenger RNA in experimental liver injury and fibrosis. Hepatology. 241176840270-9139
  34. 34. MurphyF. R.IssaR.ZhouX.RatnarajahS.NagaseH.MJArthurBenyon. C.IredaleJ. P.2002Inhibition of apoptosis of activated hepatic stellate cells by tissue inhibitor of metalloproteinase-1 is mediated via effects on matrix metalloproteinase inhibition: implications for reversibility of liver fibrosis. J Biol Chem. 29;2771311069760021-9258
  35. 35. SchoutenJ.MichielsenP. P.2007Treatment of cirrhotic ascites. Acta Gastroenterol Belg. 702217220001-5644
  36. 36. HeidelbaughJ. J.SherbondyM.2006Cirrhosis and chronic liver failure: part II. Complications and treatment. Am Fam Physician. 74(5):767 EOF76 EOFX.
  37. 37. ZhaoQ.RenH.ZhuD.HanZ.2009Stem/progenitor cells in liver injury repair and regeneration. Biol Cell. 10110557710248-4900
  38. 38. KharazihaP.HellströmP. M.NoorinayerB.FarzanehF.AghajaniK.JafariF.TelkabadiM.AtashiA.HonardoostM.ZaliM. R.SoleimaniM.2009Improvement of liver function in liver cirrhosis patients after autologous mesenchymal stem cell injection: a phase I-II clinical trial. Eur J Gastroenterol Hepatol. 211011992050095-4691X
  39. 39. AAKhanShaik. M. V.ParveenN.RajendraprasadA.MAAleemHabeeb.MASrinivasG.RajT. A.TiwariS. K.KumaresanK.VenkateswarluJ.PandeG.HabibullahC. M.2010Human fetal liver-derived stem cell transplantation as supportive modality in the management of end-stage decompensated liver cirrhosis. Cell Transplant. 194409180963-6897
  40. 40. OertelM.MenthenaA.ChenY. Q.TeisnerB.JensenC. H.ShafritzD. A.2008Purification of fetal liver stem/progenitor cells containing all the repopulation potential for normal adult rat liver. Gastroenterology. 1343823320016-5085
  41. 41. AbbasogluO.2008Liver transplantation: yesterday, today and tomorrow. World J Gastroenterol. 14203117221007-9327
  42. 42. GaudioE.CarpinoG.CardinaleV.FranchittoA.OnoriP.AlvaroD.2009New insights into liver stem cells. Dig Liver Dis. 417455621590-8658
  43. 43. StromS. C.Roy-ChowdhuryJ.FoxI. J.1999Hepatocyte transplantation for the treatment of human disease. Sem Liver Dis 19390272-8087
  44. 44. AllenK. J.SorianoH.2001Liver cell transplantation: The road to clinical application. J Lab Clin Med 1382983120038-2299
  45. 45. NajimiM.SokalE.2004Update on liver cell transplantation. J Pediatr Gastroenterol Nutr 393113190277-2116
  46. 46. DhawanA.MitryR. R.HughesR. D.2006Hepatocyte transplantation for liver-based metabolic disorders. J Inherit Metab Dis 294310141-8955
  47. 47. IredaleJ. P.BenyonR. C.PickeringJ.Mc CullenM.NorthropM.PawleyS.HovellC.MJArthur1998Mechanisms of spontaneous resolution of rat liver fibrosis. Hepatic stellate cell apoptosis and reduced hepatic expression of metalloproteinase inhibitors. J Clin Invest. 10235385490021-9738
  48. 48. DaiL.JiH.KongX. W.ZhangY. H.2010Antifibrotic effects of ZK14, a novel nitric oxide-donating biphenyldicarboxylate derivative, on rat HSC-T6 cells and CCl4-induced hepatic fibrosis. Acta Pharmacol Sin. 31127341671-4083
  49. 49. IredaleJ. P.BenyonR. C.PickeringJ.Mc CullenM.NorthropM.PawleyS.HovellC.MJArthur1998Mechanisms of spontaneous resolution of rat liver fibrosis. Hepatic stellate cell apoptosis and reduced hepatic expression of metalloproteinase inhibitors. J Clin Invest. 10235385490021-9738
  50. 50. WrightM. C.IssaR.SmartD. E.TrimN.MurrayG. I.PrimroseJ. N.MJArthurIredale. J. P.MannD. A.2001Gliotoxin stimulates the apoptosis of human and rat hepatic stellate cells and enhances the resolution of liver fibrosis in rats. Gastroenterology. 12136856980016-5085
  51. 51. IssaR.WilliamsE.TrimN.KendallT.MJArthurReichen. J.BenyonR. C.IredaleJ. P.2001Apoptosis of hepatic stellate cells: involvement in resolution of biliary fibrosis and regulation by soluble growth factors. Gut. 4845485570017-5749
  52. 52. HartlandS. N.MurphyF.AucottR. L.AbergelA.ZhouX.WaungJ.PatelN.BradshawC.CollinsJ.MannD.BenyonR. C.IredaleJ. P.2009Active matrix metalloproteinase-2 promotes apoptosis of hepatic stellate cells via the cleavage of cellular N-cadherin. Liver Int. 297966781478-3223
  53. 53. LeroyV.MonierF.BottariS.TrocmeC.SturmN.HilleretM. N.MorelF.ZarskiJ. P.2004Circulating matrix metalloproteinases 1, 2, 9 and their inhibitors TIMP-1 and TIMP-2 as serum markers of liver fibrosis in patients with chronic hepatitis C: comparison with PIIINP and hyaluronic acid. Am J Gastroenterol. 99227190002-9270
  54. 54. IssaR.ZhouX.TrimN.Millward-SadlerH.KraneS.BenyonC.IredaleJ.2003Mutation in collagen-1 that confers resistance to the action of collagenase results in failure of recovery from CCl4-induced liver fibrosis, persistence of activated hepatic stellate cells, and diminished hepatocyte regeneration. FASEB J. 1714790892-6638
  55. 55. CameronG. R.KarunaratneW. A. E.1936Carbon tetrachloride cirrhosis in relation to liver regeneration. J Path Bact 42: 1-21, 0368-3494.
  56. 56. QuinnP. S.HigginsonJ.1965Reversible and irreversible changes in experimental cirrhosis. Am J Pathol 473533690002-9440
  57. 57. MorrioneT. G.LevineJ.Collagenolyticactivity.collagenresorption.inexperimental.cirrhosisArch Pathol 196759 EOF63 EOF
  58. 58. HuttererF.RubinE.PopperH.1964Mechanism of collagen resorption in reversible hepatic fibrosis. Exp Mol Pathol 862152230014-4800
  59. 59. TakadaA.PortaE. A.HartroftW. S.1967The recovery of experimental dietary cirrhosis. Am J Pathol 51: 929 EOF57 EOF
  60. 60. Jacques WE, McAdams AI.1957Reversible biliary cirrhosis in rat after partial ligation of common bile duct. AMA Arch Path 631491530096-6711
  61. 61. OkazakiI.OdaM.MaruyamaK.Funatsueversible.biliarycirrhosis.inrat.afterpartial.ligationof.commonbile.ductA. M.AMA Arch Path 63149153K, Matsuzaki S, Kamegaya K, Tsuchiya M. (1974Mechanism of collagen resorption in experimental hepatic fibrosis with special reference to the activity of lysosomal enzymes. Biochem Exp Biol 11: 15-28, 0366-0060.
  62. 62. RubinE.HuttererF.Hepaticfibrosis.1967Studies in the formation and resorption. In: Wagner BM, Smith DE, eds, The Connective Tissue, Baltimore, Williams and Wilkins, 142160
  63. 63. Perez-TamayoR.1965Some aspects of connective tissue of the liver. In: Popper H, Schaffner F, eds, Progress in Liver Diseases 2, New York, Grune & Stratton, 192210
  64. 64. RojkindM.MADunn1979Hepatic fibrosis. Gastroenterology 768498630016-5085
  65. 65. MaruyamaK.OkazakiI.KashiwazakiK.OdaM.IshiiH.TsuchiyaM.1981A case of subacute hepatitis with reversible liver fibrosis. Gastroenterol Jpn 166116150435-1339
  66. 66. AraiM.NiiokaM.MaruyamaK.WadaN.FujimotoN.NomiyamaT.TanakaS.OkazakiI.1996Changes in serum levels of metalloproteinases and their inhibitors by treatment of chronic hepatitis C with interferon. Dig Dis Sci 4199510000163-2116
  67. 67. GuettierC.2005Which stem cells for adult liver? Ann Pathol. 2513344ISSM 0242-6498.
  68. 68. ShackelN.RockeyD. .2005In pursuit of the ‘‘Holy Grail’’-stem cells, hepatic injury, fibrogenesis and repair. Hepatology 4116180270-9139
  69. 69. Vieyra DS, Jackson KA, Goodell MA. (2005Plasticity and tissue regenerative potential of bone marrow-derived cells. Stem Cell Rev. 165691550-8943
  70. 70. FilipS.EnglishD.MokryJ.2004Issues in stem cell plasticity. J. Cell. Mol. Med. 857271582-1838
  71. 71. SmartN.RileyP. R.2008The stem cell movement. Circ Res. 102101155680009-7330
  72. 72. Eckersley-Maslin MA, Warner FJ, Grzelak CA, McCaughan GW, Shackel NA.2009Bone marrow stem cells and the liver: are they relevant? J Gastroenterol Hepatol. 24101608160815-9316
  73. 73. OertelM.MenthenaA.ChenY. Q.TeisnerB.JensenC. H.ShafritzD. A.2008Purification of fetal liver stem/progenitor cells containing all the repopulation potential for normal adult rat liver. Gastroenterology. 13438238320016-5085
  74. 74. ZhaoQ.RenH.LiX.ChenZ.ZhangX.GongW.LiuY.PangT.HanZ. C.2009Differentiation of human umbilical cord mesenchymal stromal cells into low immunogenic hepatocyte-like cells. Cytotherapy 1144144261465-3249
  75. 75. WeissM. L.MedicettyS.BledsoeA. R.RachakatlaR. S.ChoiM.MerchavS.LuoY.MSRaoVelagaleti. G.TroyerD.2006Human umbilical cord matrix stem cells: preliminary characterization and effect of transplantation in a rodent model of Parkinson’s disease. Stem Cells 24781920250-6793
  76. 76. MedicettyS.BledsoeA. R.FahrenholtzC. B.TroyerD.WeissM. L.2004Transplantation of pig stem cells into rat brain: proliferation during the first 8 weeks. Exp Neurol 19032410014-4886
  77. 77. FuY. S.ChengY. C.LinM. Y.ChengH.ChuP. M.ChouS. C.ShihY. H.KoM. H.MSSung2006Conversion of human umbilical cord mesenchymal stem cells in Wharton’s jelly to dopaminergic neurons in vitro : potential therapeutic application for parkinsonism. Stem Cells 241151240250-6793
  78. 78. KöglerG.SenskenS.AireyJ. A.TrappT.MüschenM.FeldhahnN.LiedtkeS.SorgR. V.FischerJ.RosenbaumC.GreschatS.KnipperA.BenderJ.DegistiriciO.GaoJ.CaplanA. I.CollettiE. J.Almeida-PoradaG.MüllerH. W.ZanjaniE.WernetP.2004A new human somatic stem cell from placental cord blood with intrinsic pluripotent differentiation potential. J Exp Med 2001231350022-1007
  79. 79. StrauerB. E.BrehmM.ZeusT.BartschT.SchannwellC.AntkeC.SorgR. V.KöglerG.WernetP.MüllerH. W.KösteringM.2005Regeneration of human infarcted heart muscle by intracoronary autologous bone marrow cell transplantation in chronic coronary artery disease: IACT study. J Am Coll Cardiol 46165116580735-1097
  80. 80. YooK. J.LiR. K.WeiselR. D.MickleD. A.JiaZ. Q.KimE. J.TomitaS.YauT. M.2000Heart cell transplantation improves heart function in dilated cardiomyopathic hamsters. Circulation 102:III204III209, 0009-7322
  81. 81. KimS. W.HanH.ChaeG. T.LeeS. H.BoS.YoonJ. H.LeeY. S.LeeK. S.ParkH. K.KangK. S.2006Successful stem cell therapy using umbilical cord blood-derived multipotent stem cells for Bueger’s disease and ischemic limb disease animal model. Stem Cells 24162016260250-6793
  82. 82. Lim JH, Byeon YE, Ryu HH, Jeong YH, Lee YW, Kim WH, Kang KS, Kweon OK.2007Transplantation of canine umbilical cord blood-derived mesenchymal stem cells in experimentally induced spinal cord injured dogs. J Vet Sci 82752820122-9845X
  83. 83. MinJ. Y.YangY.SullivanM. F.KeQ.ConversoK. L.ChenY.MorganJ. P.XiaoY. F.2003Long-term improvement of cardiac function in rats after infarction by transplantation of embryonic stem cells. Thorac Cardiovasc Surg 1253613690022-5223
  84. 84. Gordon MY, Gordon-Smith EC.1981Bone marrow fibroblastoid colony-forming cells (F-CFC) in aplastic anaemia: colony growth and stimulation of granulocyte-macrophage colony-forming cells (GM-CFC). Br J Haematol. 493465770006-0291
  85. 85. KadivarM.KhatamiS.MortazaviY.MAShokrgozarTaghikhani. M.SoleimaniM.2006In vitro cardiomyogenic potential of human umbilical vein-derived mesenchymal stem cells. Biochem Biophys Res Commun. 3402639470000-6291X
  86. 86. ReineckeH.MinamiE.ZhuW. Z.MALaflamme2008Cardiogenic differentiation and transdifferentiation of progenitor cells. Circ Res. 103101058710009-7330
  87. 87. Mishra PK, Singh SR, Joshua IG, Tyagi SC.2010Stem cells as a therapeutic target for diabetes. Front Biosci. 15461771945-0494
  88. 88. ToyodaM.CuiCh.UmezawaA.2007Myogenic transdifferentiation of menstrual blood-derived cells. Acta Myol. 2631761781128-2460
  89. 89. BussolatiB.CamussiG.2007Stem cells in acute kidney injury. Contrib Nephrol. 1562502580302-5114
  90. 90. BahkJ. Y.JungJ. H.HanH.MinS. K.LeeY. S.2010Treatment of diabetic impotence with umbilical cord blood stem cell intracavernosal transplant: preliminary report of 7 cases. Exp Clin Transplant. 82150601304-0855
  91. 91. NikeghbalianS.PournasrB.AghdamiN.RasekhiA.GeramizadehB.HosseiniAsl. S. M.RamziM.KakaeiF.NamiriM.MalekzadehR.VosoughDizaj. A.Malek-HosseiniS. A.BaharvandH.2011Autologous transplantation of bone marrow-derived mononuclear and CD133(+) cells in patients with decompensated cirrhosis. Arch Iran Med. 1411271029-2977
  92. 92. RenC.KumarS.ChandaD.KallmanL.ChenJ.JDMountzPonnazhagan. S.2008Cancer gene therapy using mesenchymal stem cells expressing interferon-beta in a mouse prostate cancer lung metastasis model. Gene Ther. 15211446530969-7128
  93. 93. Dan YY, Yeoh GC.2008Liver stem cells: a scientific and clinical perspective. J Gastroenterol Hepatol. 2356876980815-9319
  94. 94. ThomsonJ. A.KalishmanJ.GolosT. G.DurningM.CPHarrisBecker. R. A.HearnJ. P.1995Isolation of a primate embryonic stem cell line. Proc Natl Acad Sci U S A. 9217784480027-8424
  95. 95. TakahashiK.YamanakaS.2006Induction of pluripotent stem cells from mouse embryonic and adult fibroblast cultures by defined factors. Cell. 1264663760062-8674
  96. 96. YoshimuraK.SatoK.AoiN.KuritaM.InoueK.SugaH.EtoH.KatoH.HirohiT.HariiK.2008Cell-assisted lipotransfer for facial lipoatrophy: efficacy of clinical use of adipose-derived stem cells. Dermatol Surg. 3491178851076-0512
  97. 97. Alvarez-BuyllaA.LoisC.1995Neuronal stem cells in the brain of adult vertebrates. Stem Cells. 133263720250-6793
  98. 98. OhyamaM.2007Hair follicle bulge: A fascinating reservoir of epithelial stem cells. J Dermatol Sci 4681890923-1811
  99. 99. CriglerL.KazhanieA.YoonT. J.ZakhariJ.AndersJ.TaylorB.ViradorV. M.2007Isolation of a mesenchymal cell population from murine dermis that contains progenitors of multiple cell lineages. FASEB J. 21(9): 2050--2063, 0892-6638
  100. 100. van der BogtK. E. A.SheikhA. Y.SchrepferS.HoytG.CaoF.RansohoffK. J.SwijnenburgJ.PearlJ.LeeA.FischbeinM.ContagC. H.RobbinsR. C.WuJ. C.2008Comparison of Different Adult Stem Cell Types for Treatment of Myocardial Ischemia. Circulation 118;S121S129, 0009-7322
  101. 101. GluckmanE.BroxmeyerH. A.AuerbachA. D.FriedmanH. S.DouglasG. W.DevergieA.EsperouH.ThierryD.SocieG.LehnP.1989Hematopoietic reconstitutions in a patient with fanconi’’s anemia by means of umbilical-cord blood fro an HLA identical sibling. N. Engl. J. Med., 321(17), 1174-1178, 0028-4793
  102. 102. Bradley MB, Cairo MS.2005Cord blood immunology and stem cell transplantation. Hum Immunol. 665431460198-8859
  103. 103. BiebackK.KernS.KocaömerA.FerlikK.BugertP.2008Comparing mesenchymal stromal cells from different human tissues: bone marrow, adipose tissue and umbilical cord blood. Biomed Mater Eng. 18(1 Suppl):S7160959-2989
  104. 104. Tholpady SS, Katz AJ, Ogle RC.2003Mesenchymal stem cells from rat visceral fat exhibit multipotential differentiation in vitro. Anat Rec A Discov Mol Cell Evol Biol. May;27213984021552-4884
  105. 105. EscolarM. L.MDPoeProvenzale. J. M.RichardsK. C.AllisonJ.WoodS.WengerD. A.PietrygaD.WallD.ChampagneM.MorseR.KrivitW.KurtzbergJ.2005Transplantation of umbilical-cord blood in babies with infantile Krabbe’s disease. N Engl J Med 352: 2069. 0028-4793
  106. 106. ReffelmannT.KoenemannS.KlonerR. A.2009Promise of blood-and bone marrow-derived stem cell transplantation for functional cardiac repair: putting it in perspective with existing therapy. J Am coll Cardiool 53: 305, 0735-1097
  107. 107. LimJ. H.ByeonE.RyuH. H.JeongY. H.LeeY. W.KimW. H.et al.2007Transplantation of canine umbilical cord blood-derived mesenchymal stem cells in experimentally induced spinal cord injured dogs. J Vet Sci 8: 275, 0122-98451229845X.
  108. 108. Zhang QH, She MP.2007Biological behaviour and role of endothelial progenitor cells in vascular diseases. Chin Med J (Engl). 120:2297, 0366-6999
  109. 109. KimKim. S. W.HanH.ChaeG. T.LeeS. H.BoS.YoonJ. H.LeeY. S.LeeK. S.ParkH. K.KangK. S.2006Successful stem cell therapy using umbilical cord blood-derived multipotent stem cells for Bueger’s disease and ischemic limb disease animal model. Stem Cells 24: 1620. 0250-679302506793
  110. 110. Savitz SI, Rosenbaum DM, Dinsmore JH, Wechsler LR, Caplan LR.2002Cell Transplantation for Stroke. Ann Neurol 52: 266, 0364-5134
  111. 111. Gomes ME, Bossano CM, Johnston CM, Reis RL, Mikos AG.2006In vitro localization of bone growth factors in constructs of biodegradable scaffolds seeded with marrow stromal cells and cultured in a flow perfusion bioreactor. Tissue Eng. 121177881076-3279
  112. 112. Lee MY, Huang JP, Chen YY, Aplin JD, Wu YH, Chen CY, Chen PC, Chen CP.2009Angiogenesis in differentiated placental multipotent mesenchymal stromal cells is dependent on integrin alpha5beta1. PLoS One. 22;4(10):e6913, 1392-6203
  113. 113. Fan CG, Zhang QJ, Tang FW, Han ZB, Wang GS, Han ZC.2005Human umbilical cord blood cells express neurotrophic factors. Neurosci Lett. 3;380332250304-3940
  114. 114. YoussoufianM.WalmsleyB.2007Brain-derived neurotrophic factor modulates cell excitability in the mouse medial nucleus of the trapezoid body. Eur J Neurosci. 2561647520095-3816X.
  115. 115. EtonD.YuH.2010Enhanced cell therapy strategy to treat chronic limb-threatening ischemia. J Vasc Surg. 5211992040741-5214
  116. 116. ChangS. A.KangH. J.LeeH. Y.KimK. H.HurJ.HanK. S.ParkY. B.KimH. S.2009Peripheral blood stem cell mobilisation by granulocyte-colony stimulating factor in patients with acute and old myocardial infarction for intracoronary cell infusion. Heart. 95161326301355-6037
  117. 117. Kang HJ, Kim HS.2008G-CSF- and erythropoietin-based cell therapy: a promising strategy for angiomyogenesis in myocardial infarction. Expert Rev Cardiovasc Ther. 65703131477-9072
  118. 118. SavitzS. I.ChoppM.DeansR.CarmichaelS. T.PhinneyD.WechslerL.2011Stem Cell Therapy as an Emerging Paradigm for Stroke (STEPS) II. Stroke. 42382590039-2499
  119. 119. UrbaniakHunter. K.YarbroughC.CiacciJ.2010Gene- and cell-based approaches for neurodegenerative disease. Adv Exp Med Biol. 671117300065-2598
  120. 120. LeeH. J.LeeJ. K.LeeH.ShinJ. W.CarterJ. E.SakamotoT.JinH. K.BaeJ. S.2010The therapeutic potential of human umbilical cord blood-derived mesenchymal stem cells in Alzheimer’s disease. Neurosci Lett. 30;48113050304-3940
  121. 121. FornaiF.MeiningerV.SilaniV.2011Future therapeutical strategies dictated by pre-clinical evidence in ALS. Arch Ital Biol. 1491169740003-9829
  122. 122. RamachandranP.IredaleJ. P.2009Reversibility of liver fibrosis. Ann Hepatol. 84283911665-2681
  123. 123. DuranteA. J.StLouis. T.MeekJ. I.NavarroV. J.SofairA. N.2008The mortality burden of chronic liver disease may be substantially underestimated in the United States. Conn Med. 727389920011-6178
  124. 124. Hui AY, Friedman SL.2003Molecular basis of hepatic fibrosis. Expert Rev Mol Med. 551231462-3994
  125. 125. LiJ. T.LiaoZ. X.PingJ.XuD.WangH.2008Molecular mechanism of hepatic stellate cell activation and antifibrotic therapeutic strategies. J Gastroenterol. 436419280944-1774
  126. 126. Friedman SL.1999Cytokines and fibrogenesis. Semin Liver Dis. 192129400272-8087
  127. 127. Han YP.2006Matrix metalloproteinases, the pros and cons, in liver fibrosis. J Gastroenterol Hepatol. 21 Suppl 3:S88910815-9319
  128. 128. HartlandS. N.MurphyF.AucottR. L.AbergelA.ZhouX.WaungJ.PatelN.BradshawC.CollinsJ.MannD.BenyonR. C.IredaleJ. P.2009Active matrix metalloproteinase-2 promotes apoptosis of hepatic stellate cells via the cleavage of cellular N-cadherin. Liver Int. 297966781478-3223
  129. 129. PoveroD.BuslettaC.NovoE.di BonzoL. V.CannitoS.PaternostroC.ParolaM.2010Liver fibrosis: a dynamic and potentially reversible process. Histol Histopathol. 2581075910213-3911
  130. 130. CantzT.SharmaA. D.Jochheim-RichterA.ArsenievL.KleinC.MannsM. P.OttM.2004Reevaluation of bone marrow-derived cells as a source for hepatocyte regeneration. Cell Transplant. 136659660963-6897
  131. 131. Friedman SL.1999Cytokines and fibrogenesis. Semin Liver Dis. 192129400272-8087
  132. 132. JiangJ. X.VenugopalS.SerizawaN.ChenX.ScottF.LiY.AdamsonR.DevarajS.ShahV.MEGershwinFriedman. S. L.TörökN. J.2010Reduced nicotinamide adenine dinucleotide phosphate oxidase 2 plays a key role in stellate cell activation and liver fibrogenesis in vivo. Gastroenterology. 1394137584
  133. 133. Myung SJ, Yoon JH, Kim BH, Lee JH, Jung EU, Lee HS.2009Heat shock protein 90 inhibitor induces apoptosis and attenuates activation of hepatic stellate cells. J Pharmacol Exp Ther. 33012762820022-3565
  134. 134. Han YP.2006Matrix metalloproteinases, the pros and cons, in liver fibrosis. J Gastroenterol Hepatol. 21 Suppl 3:S88910815-9319
  135. 135. LangerD. A.DasA.SemelaD.Kang-DeckerN.HendricksonH.BronkS. F.KatusicZ. S.GoresG. J.ShahV. H.2008Nitric oxide promotes caspase-independent hepatic stellate cell apoptosis through the generation of reactive oxygen species. Hepatology. 4761983930270-9139
  136. 136. LiuY.WenX. M.LuiE. L.FriedmanS. L.CuiW.HoN. P.LiL.YeT.FanS. T.ZhangH.2009Therapeutic targeting of the PDGF and TGF-beta-signaling pathways in hepatic stellate cells by PTK787/ZK22258. Lab Invest. 89101152600023-6837
  137. 137. GonzaloT.BeljaarsL.van de BovenkampM.TemmingK.van LoenenA. M.Reker-SmitC.MeijerD. K.LacombeM.OpdamF.KériG.OrfiL.PoelstraK.KokR. J.2007Local inhibition of liver fibrosis by specific delivery of a platelet-derived growth factor kinase inhibitor to hepatic stellate cells. J Pharmacol Exp Ther. 3213856650022-3565
  138. 138. YoshijiH.NoguchiR.KuriyamaS.IkenakaY.YoshiiJ.YanaseK.NamisakiT.KitadeM.MasakiT.FukuiH.2005Imatinib mesylate (STI-571) attenuates liver fibrosis development in rats. Am J Physiol Gastrointest Liver Physiol. 288(5):G907130193-1857
  139. 139. HartlandS. N.MurphyF.AucottR. L.AbergelA.ZhouX.WaungJ.PatelN.BradshawC.CollinsJ.MannD.BenyonR. C.IredaleJ. P.2009Active matrix metalloproteinase-2 promotes apoptosis of hepatic stellate cells via the cleavage of cellular N-cadherin. Liver Int. 297966781478-3223
  140. 140. WangY.GaoJ.ZhangD.ZhangJ.MaJiangJ.H.2010New insights into the antifibrotic effects of sorafenib on hepatic stellate cells and liver fibrosis. J Hepatol. 5311321440168-8278
  141. 141. TaoJ.MallatA.GalloisC.BelmadaniS.MéryP. F.NhieuJ. T.PavoineC.LotersztajnS.1999Biological effects of C-type natriuretic peptide in human myofibroblastic hepatic stellate cells. J Biol Chem. 20;274342376190021-9258
  142. 142. PoveroD.BuslettaC.NovoE.di BonzoL. V.CannitoS.PaternostroC.ParolaM.2010Liver fibrosis: a dynamic and potentially reversible process. Histol Histopathol. 2581075910213-3911
  143. 143. CantzT.SharmaA. D.Jochheim-RichterA.ArsenievL.KleinC.MannsM. P.OttM.2004Reevaluation of bone marrow-derived cells as a source for hepatocyte regeneration. Cell Transplant. 136659660963-6897
  144. 144. KharazihaP.HellstroemP. M.NoorinayerbB.FarzanehdF.AghajanibK.JafaribF.TelkabadibM.AtashidA.HonardoostdM.ZalicM. R.SoleimanieM.2009Improvement of liver function in liver cirrhosis patients after autologous mesenchymal stem cell injection: a phase I--II clinical trial. Eur J Gastroenterol Hepatol 21:1199--1205, 0095-46910954691X
  145. 145. ShackelN.RockeyD.2005In pursuit of the ‘‘Holy Grail’’--stem cells, hepatic injury, fibrogenesis and repair. Hepatology 4116180279-9139
  146. 146. JensenC. H.JauhoE. I.Santoni-RugiuE.HolmskovU.TeisnerB.TygstrupN.BisgaardH. C.2004Transit-amplifying ductular (oval) cells and their hepatocytic progeny are characterized by a novel and distinctive expression of delta-like protein/ preadipocyte factor 1/fetal antigen 1. Am. J. Pathol. 164: 1347--1359. 0002-9440
  147. 147. KhuranaS.MukhopadhyayA.2007Characterization of the potential subpopulation of bone marrow cells involved in the repair of injured liver tissue. Stem Cells 25: 1439--47, 0250-6793
  148. 148. StenderupK.JustesenJ.ClausenC.KassemM.2003Aging is associated with decreased maximal life span and accelerated senescence of bone marrow stromal cells. Bone. 33919268756-3282
  149. 149. MuellerS. M.GlowackiJ.2001Age-related decline in the osteogenic potential of human bone marrow cells cultured in three-dimensional collagen sponges. J Cell Biochem. 82583900730-2312
  150. 150. ZhongY. S.LinN.DengM. H.ZhangF. C.TangZ. F.XuR. Y.2010Deficient proliferation of bone marrow-derived mesenchymal stem cells in patients with chronic hepatitis B viral infections and cirrhosis of the liver. Dig Dis Sci. 552438450163-2116
  151. 151. ZukP. A.ZhuM.MizunoH.HuangJ.FutrellJ. W.KatzA. J.BenhaimP.LorenzH. P.HedrickM. H.2001Multilineage cells from human adipose tissue: Implications for cell-based therapies. Tissue Eng 72112281937-3341
  152. 152. LeeR. H.KimB.ChoiI.KimH.ChoiH. S.SuhK.BaeY. C.JungJ. S.2004Characterization and expression analysis of mesenchymal stem cells from human bone marrow and adipose tissue. Cell Physiol Biochem 143113241015-8987
  153. 153. GluckmanE.RochaV.Boyer-ChammardA.LocatelliF.ArceseW.PasquiniR.OrtegaJ.SouilletG.FerreiraE.LaporteJ. P.FernandezM.ChastangC.1997Outcome of cord-blood transplantation from related and unrelated donors. Eurocord Transplant Group and the European Blood and Marrow Transplantation Group. N Engl J Med. 337373810028-4793
  154. 154. Grewal SS, Barker JN, Davies SM, Wagner JE.2003Unrelated donor hematopoietic cell transplantation: marrow or umbilical cord blood. Blood. 1014233440006-4971
  155. 155. Warkentin PI.2003Foundation for the Accreditation of Cellular Therapy Voluntary accreditation of cellular therapies: Foundation for the Accreditation of Cellular Therapy (FACT) Cytotherapy. 52993051465-3249
  156. 156. ChenM. Y.LieP. C.LiZ. L.WeiX.2009Endothelial differentiation of Wharton’s jelly-derived mesenchymal stem cells in comparison with bone marrow-derived mesenchymal stem cells. Exp Hematol. 375629400030-1482X.
  157. 157. ZhongY. S.LinN.DengM. H.ZhangF. C.TangZ. F.XuR. Y.2010Deficient proliferation of bone marrow-derived mesenchymal stem cells in patients with chronic hepatitis B viral infections and cirrhosis of the liver. Dig Dis Sci. 552438450163-2116
  158. 158. MoriyaK.YoshikawaM.OujiY.SaitoK.NishiofukuM.MatsudaR.IshizakaS.FukuiH.2008Embryonic stem cells reduce liver fibrosis in CCl4-treated mice. Int J Exp Pathol. 89640190959-9673
  159. 159. LiuP.LiuZ. D.WuN.congX.FeiR.ChenH. S.WeiL.2009Transplanted Endothelial Progenitor Cells Ameliorate Carbon Tetrachloride-.Induced Liver Cirrhosis in Rats. Liver Transpl 15109211001527-6465
  160. 160. YanY.XuW.QianH.SiY.ZhuW.CaoH.ZhouH.MaoF.2009Mesenchymal stem cells from human umbilical cords ameliorate mouse hepatic injury in vivo. Liver Int. 293356651478-4223
  161. 161. MohamadnejadM.AlimoghaddamK.Mohyeddin-BonabM.BagheriM.BashtarM.GhanaatiH.BaharvandH.GhavamzadehA.MalekzadehR.2007Phase 1 trial of autologous bone marrow mesenchymal stem cell transplantation in patients with decompensated liver cirrhosis. Arch Iran Med. 104459661029-2977
  162. 162. LiM.YuJ.LiY.LiD.YanD.QuZ.RuanQ.2010CXCR4 positive bone mesenchymal stem cells migrate to human endothelial cell stimulated by ox-LDL via SDF-1alpha/CXCR4 signaling axis. Exp Mol Pathol. 88225050014-4800
  163. 163. MagnascoA.CorselliM.BertelliR.IbaticiA.PeresiM.GaggeroG.CappielloV.ChiavarinaB.MattioliG.GusmanoR.RavettiJ. L.FrassoniF.GhiggeriG. M.2008Mesenchymal stem cells protective effect in adriamycin model of nephropathy. Cell Transplant. 17(10-11):1157-67, 0963-6897
  164. 164. ZhaoX.HuangL.YinY.FangY.ZhouY.2007Autologous endothelial progenitor cells transplantation promoting endothelial recovery in mice. Transpl Int. 208712210943-0874
  165. 165. Di CampliC.PiscagliaA. C.RutellaS.BonannoG.VecchioF. M.MAZoccoMonego. G.MichettiF.MancusoS.PolaP.LeoneG.GasbarriniG.GasbarriniA.2005Improvement of mortality rate and decrease in histologic hepatic injury after human cord blood stem cell infusion in a murine model of hepatotoxicity. Transplant Proc. 3762707100041-1345
  166. 166. OkuraH.SagaA.FumimotoY.SoedaM.MoriyamaM.MoriyamaH.NagaiK.LeeC. M.YamashitaS.IchinoseA.HayakawaT.MatsuyamaA.2011Transplantation of human adipose tissue-derived multilineage progenitor cells reduces serum cholesterol in hyperlipidemic watanabe rabbits. Tissue Eng Part C Methods. 172145541937-3384
  167. 167. Kang HJ, Kim MK, Kim MG, Choi DJ, Yoon JH, Park YB, Kim HS.2011A multicenter, prospective, randomized, controlled trial evaluating the safety and efficacy of intracoronary cell infusion mobilized with granulocyte colony-stimulating factor and darbepoetin after acute myocardial infarction: study design and rationale of the ‘MAGIC cell-5combination cytokine trial’. Trials. 7;12(1):33, 1745-6215
  168. 168. HareJ. M.TraverseJ. H.HenryT. D.DibN.StrumpfR. K.SchulmanS. P.GerstenblithG.De MariaA. N.DenktasA. E.GammonR. S.HermillerJ. B.MAJr ReismanSchaer. G. L.ShermanW.2009A randomized, double-blind, placebo-controlled, dose-escalation study of intravenous adult human mesenchymal stem cells (prochymal) after acute myocardial infarction. J Am Coll Cardiol. 54242277860735-1097
  169. 169. ChangS. A.KangH. J.LeeH. Y.KimK. H.HurJ.HanK. S.ParkY. B.KimH. S.2009Peripheral blood stem cell mobilisation by granulocyte-colony stimulating factor in patients with acute and old myocardial infarction for intracoronary cell infusion. Heart. 95161326301335-6037
  170. 170. ZohlnhöferD.DibraA.KopparaT.de WahaA.RipaR. S.KastrupJ.ValgimigliM.SchömigA.KastratiA.2008Stem cell mobilization by granulocyte colony-stimulating factor for myocardial recovery after acute myocardial infarction: a meta-analysis. J Am Coll Cardiol. 51151429370735-1097
  171. 171. FanL.ChenL.ChenX.FuF.2008A meta-analysis of stem cell mobilization by granulocyte colony-stimulating factor in the treatment of acute myocardial infarction. Cardiovasc Drugs Ther. 22145540920-3206
  172. 172. ZhangS.SunA.XuD.YaoK.HuangZ.JinH.WangK.ZouY.GeJ.2009Impact of timing on efficacy and safetyof intracoronary autologous bone marrow stem cells transplantation in acute myocardial infarction: a pooled subgroup analysis of randomized controlled trials. Clin Cardiol. 328458660160-9289
  173. 173. SunL.ZhangT.LanX.DuG.2010Effects of stem cell therapy on left ventricular remodeling after acute myocardial infarction: a meta-analysis. Clin Cardiol. 3352963020160-9289
  174. 174. PendharkarA. V.ChuaJ. Y.AndresR. H.WangN.GaetaX.WangH.De ChoiA.ChenR.RuttS.GambhirB. K.GuzmanS. S.R.2010Biodistribution of neural stem cells after intravascular therapy for hypoxic-ischemia. Stroke. 4192064700093-2499
  175. 175. HartingM. T.JimenezF.XueH.FischerU. M.BaumgartnerJ.DashP. K.CoxC. S.2009Intravenous mesenchymal stem cell therapy for traumatic brain injury. J Neurosurg. 11061189970022-3085
  176. 176. FengQ.ChowP. K.FrassoniF.PhuaC. M.TanP. K.PrasathA.KheeHwang. W. Y.2008Nonhuman primate allogeneic hematopoietic stem cell transplantation by intraosseus vs intravenous injection: Engraftment, donor cell distribution, and mechanistic basis. Exp Hematol. 36111556660030-1472X.
  177. 177. HohensteinB.KuoM. C.AddabboF.YasudaK.RatliffB.SchwarzenbergerC.EckardtK. U.CPHugoGoligorsky.MS2010Enhanced progenitor cell recruitment and endothelial repair after selective endothelial injury of the mouse kidney. Am J Physiol Renal Physiol. 298(6):F1504140193-1857X.
  178. 178. HerrmannJ. L.AbarbanellA. M.WeilB. R.WangY.PoynterJ. A.ManukyanM. C.MeldrumD. R.2010Postinfarct intramyocardial injection of mesenchymal stem cells pretreated with TGF-alpha improves acute myocardial function. Am J Physiol Regul Integr Comp Physiol. 299(1):R37180363-6119
  179. 179. KöglerG.RadkeT. F.LefortA.SenskenS.FischerJ.SorgR. V.WernetP.2005Cytokine production and hematopoiesis supporting activity of cord blood-derived unrestricted somatic stem cells. Exp Hematol. 3355735830030-1472X.
  180. 180. Liu CH, Hwang SM.2005Cytokine interactions in mesenchymal stem cells from cord blood. Cytokine. 3262702791014-4666
  181. 181. GakE.TaylorW. G.ChanA. M.RubinJ. S.1992Processing of hepatocyte growth factor to the heterodimeric form is required for biological activity. FEBS Lett. 311117210014-5793
  182. 182. NakamuraT.NawaK.IchiharaA.1984Partial purification and characterization of hepatocyte growth factor from serum of hepatectomized rats. Biochem Biophys Res Commun 122145014590000-6291X.
  183. 183. NakamuraT.NishizawaT.HagiyaM.SekiT.ShimonishiM.SugimuraA.TashiroK.ShimizuS.1989Molecular cloning and expression of human hepatocyte growth factor. Nature 3424404430028-0836
  184. 184. KimW. H.MatsumotoK.BesshoK.NakamuraT.2005Growth inhibition and apoptosis in liver myofibrolasts promoted by hepatocyte growth factor leads to resolution from liver cirrhosis. Am J Pathol 16101710280002-9440
  185. 185. YuY.LuL.QianX.ChenN.YaoA.PuL.ZhangF.LiX.KongL.SunB.WangX.2010Antifibrotic effect of hepatocyte growth factor-expressing mesenchymal stem cells in small-for-size liver transplant rats. Stem Cells Dev. 196903141547-3287
  186. 186. Chang YJ, Liu JW, Lin PC, Sun LY, Peng CW, Luo GH, Chen TM, Lee RP, Lin SZ, Harn HJ, Chiou TW.2009Mesenchymal stem cells facilitate recovery from chemically induced liver damage and decrease liver fibrosis. Life Sci. 85(13-14):517-25, 0024-3205
  187. 187. TanabeJ.IzawaA.TakemiN.MiyauchiY.ToriiY.TsuchiyamaH.SuzukiT.SoneS.AndoK.2007Interferon-beta reduces the mouse liver fibrosis induced by repeated administration of concanavalin A via the direct and indirect effects. Immunology. 1224562700019-2805
  188. 188. TasciI.MasM. R.VuralS. A.ComertB.AlcigirG.SerdarM.MasN.IsikA. T.AtesY.2006Rat liver fibrosis regresses better with pegylated interferon alpha2b and ursodeoxycholic acid treatments than spontaneous recovery. Liver Int 262612681478-3223
  189. 189. Block ET, Cronstein BN.2010Interferon-gamma inhibits adenosine A2A receptor function in hepatic stellate cells by STAT1-mediated repression of adenylyl cyclase. Int J Infereron Cytokine Mediator Res. 201021131260117-9139X.
  190. 190. Jones JI, Clemmons DR.1995Insulin-like growth factors and their binding proteins: biological actions. Endocr Rev. 163320016-3769X
  191. 191. Clemmons DR, Van Wyk JJ.1984Factors controlling blood concentration of somatomedin C. Clin Endocrinol Metab 13113430030-0595X.
  192. 192. ConchilloM.de KnegtR. J.PayerasM.QuirogaJ.SangroB.HerreroJ. I.Castilla-CortazarI.FrystykJ.FlyvbjergA.YoshizawaC.JansenP. L.ScharschmidtB.PrietoJ.2005Insulin-like growth factor I(IGF-1) replacement therapy increases albumin concentration in liver cirrhosis: results of a pilot randomized controlled clinical trial. J Hepatol 436306360168-8278
  193. 193. CaroJ. F.PoulosJ.IttoopO.PoriesW. J.FlickingerE. G.SinhaM. K.1988Insulin like growth factor I binding in hepatocytes from human liver, heman hepatoma, and normal, regenerating, and fetal rat liver. J Clin Invest 81;9769810021-9738
  194. 194. ScharfJ. G.KnittelT.DombrowskiF.MüllerL.SaileB.BraulkeT.HartmannH.RamadoriG.1998Characterization of the IGF axis components in isolate rat hepatic stellate cells. Hepatology 27127512840270-9139
  195. 195. SobrevalsL.RodriguezC.Romero-TrevejoJ. L.GondiG.MonrealI.PañedaA.JuanarenaN.ArcelusS.RazquinN.GuembeL.González-AseguinolazaG.PrietoJ.FortesP.2010Insulin-like growth factor I gene transfer to cirrhotic liver induces fibrolysis and reduces fibrogenesis leading to cirrhosis reversion in rats. Hepatology. 513912210270-9139
  196. 196. TutauF.Rodríguez-OrtigosaC.PucheJ. E.JuanarenaN.MonrealI.GarcíaFernández. M.ClavijoE.CastillaA.Castilla-CortázarI.2009Enhanced actions of insulin-like growth factor-I and interferon-alpha co-administration in experimental cirrhosis. Liver Int. 29137461478-3223
  197. 197. Gilchrist ES, Plevris JN.2010Bone Marrow-Derived Stem Cells in Liver Repair: 10 Years Down the Line. Liver Transpl 161181291527-6465
  198. 198. KöglerG.RadkeT. F.LefortA.SenskenS.FischerJ.SorgR. V.WernetP.2005Cytokine production and hematopoiesis supporting activity of cord blood-derived unrestricted somatic stem cells. Exp Hematol. 335573830030-1472X
  199. 199. Schibler KR, Liechty KW, White WL, Christensen RD.1993Production of granulocyte colony-stimulating factor in vitro by monocytes from preterm and term neonates. Blood. 8282478840006-4971
  200. 200. JenhaniF.DurandV.BenAzouna. N.ThalletS.BenOthmen. T.BejaouiM.DomenechJ.2011Human cytokine expression profile in various conditioned media for in vitro expansion bone marrow and umbilical cord blood immunophenotyped mesenchymal stem cells. Transplant Proc. 432639430041-1345
  201. 201. SuehiroY.MutaK.UmemuraT.AbeY.NishimuraJ.NawataH.1999Macrophage inflammatory protein 1alpha enhances in a different manner adhesion of hematopoietic progenitor cells from bone marrow, cord blood, and mobilized peripheral blood. Exp Hematol. 27111637450030-1472X.
  202. 202. Liu CH, Hwang SM.2005Cytokine interactions in mesenchymal stem cells from cord blood. Cytokine. 32627091043-4666
  203. 203. GangE. J.JeongJ. A.HanS.YanQ.JeonC. J.KimH.2006In vitro endothelial potential of human UC blood-derived mesenchymal stem cells. Cytotherapy. 83215271465-3249
  204. 204. AAKhanShaik. M. V.ParveenN.RajendraprasadA.MAAleemHabeeb.MASrinivasG.RajT. A.TiwariS. K.KumaresanK.VenkateswarluJ.PandeG.HabibullahC. M.2010Human fetal liver derived stem cell transplantation as supportive modalitity in the management of end-stage decompensated liver cirrhosis. Cell Transplant 1944094180963-6897

Notes

Written By

Jong Yoon Bahk, Zhengfu Piao, Jae Hun Jung and Hoon Han

Published: 23 August 2011