Republic of Turkey Ministry of Health Clinical Research Project

Immunosuppressive Effects of Mesenchymal Stromal Cell Infusion in Small Intestinal Transplant Patients

Republic of Turkey Ministry of Health Clinical Research Projects

Intestinal transplantation is used more frequently for irreversible gastrointestinal failure patients who no longer can be maintained on TPN (Total Parenteral Nutrtion) or effectively treated for complex abdominal pathology. Short bowel syndromes, gut dysmotility, gasstrointestinal neoplastic syndromes and enterocyte dysfunction are the leading causes of gut failure and indications for transplantation (1). Furthermore, the survival advantages of the procedure have significantly improved over the last 5 years, because of novel immunosuppressive protocols, better postoperative management, and new surgical innovations (2). Stem cell plasticity refers to the ability of organ-specific stem cells from one tissue to produce cells of a different lineage and tissue. For example, adult bone marrow cells may be able to engraft into other tissues and differentiate into cell types specific to that organ, such as hepatocytes, skeletal myocytes or small intestine(LGR5+) (3). There is increasing evidence to support this hypothesis, especially from observations that Y-chromosome containing cells can be seen in the tissues of female recipients of bone marrow from male donors (4). Although it has been argued that this may represent cell fusion rather than stem cell plasticity.(5)

In the small and large intestine, bone marrow engraftment and differentiation into mesenchymal cells have been demonstrated in humans and mice. The possibility that bone marrow derived cells could be used to populate and regenerate intestinal mucosais clearly exciting and of particular relevance to the field of tissue engineering.(6)

SBS (small bowell syndrome) is the most common indication for intestineonly transplantation. Congenital disorders such as gastroschisis, volvulus, and atresia are the leading causes in children. In adults, the main causes are visceral ischemia, Crohn’s disease, trauma, mesenteric desmoid tumor, and surgical adhesions (7). Intestinal morphology reflects its role as an absorptive surface and a barrier against luminal contents. Small intestinal surface area is increased about 600-fold by a combination of micro- and macroscopic features (8). Both small and large intestinal mucosal surfaces are rapidly replaced as a result of the activity of stem cells found in the intestinal crypts (9). Understanding of stem cell dynamics and signaling has increased rapidly in recent years (10). Tissue engineering of intestinal mucosa has been performed in animal models and offers the possibility of a novel therapy for patients with short bowel syndrome (7). The morphology of the intestine reflects its two principle roles: the digestion and absorption of nutrients, and the maintenance of a barrier against the external environment. The basic macroscopic and microscopic structure of the small and large intestine and will review current understanding of the role of stem cells in intestinal regeneration.(11) An improved knowledge of stem cell biology has led to the production of tissue engineered intestine and progress in this exciting field will be explored.

There are five main epithelial cell lineages, all of which are derived from stem cells in the intestinal crypts. The most plentiful cells in the mucosal epithelium are columnar enterocytes, which make up the absorptive surface of the intestine. The apical surface of these cells consists of a layer of densely packed microvilli, visible with electron microscopy. Each enterocyte has about 3,000 microvilli on its apical surface and their presence increases small intestinal surface area about 20- fold. Intestinal enterocytes contain numerous transport proteins in their apical and basal membranes, which allow active and passive transport of nutrients from the gut (12). In addition, several digestive enzymes, such as disaccharidases, are bound to the enterocyte microvilli. Paneth cells, unlike the other epithelial cell lines, are found at the crypt bases. They are characterised by granules containing lysozyme, tumour necrosis factor-α and defensins, and are believed to play an antibacterial role. Finally, M cells are believed to be involved in antigen sampling and transportation (13). The lamina propria contains a wide range of cell types including smooth muscle cells, vascular endothelial cells and fibroblasts.(7)

There is a particular interest on the intestinal subepithelial myofibroblasts. These cells are located in proximity to the mucosal epithelium and are believed to produce growth factors, including hepatocyte growth factor, which promote proliferation of the intestinal epithelial stem cells (12).

In the immunsuppressive era, immunomodulatory strategies in the form of graft or donor pretreatment were already used in intestinal transplant recipeints, in an attempt to prolong graft survival (14). The Pittsburgh group and, later, the Miami group continued to give unmodified donor bone marrow infusions for about a decade but this strategy failed to significantly improve outcome (15-17).

Specifically, clinical results failed to show that bone marrow augmentation reduced the incidence of acute or chronic rejection; the question of whether chimerism plays a role in the development and maintenance of tolerance has not been conclusively answered (27-29). Intestinal transplantation will be more broadly applied only if immunosuppressive or immunodulatory stragtegies are developed that diminish or eliminate the rate of severe, exfoliative rejection with its associated risks of graft loss and recipient death.

Over the last decade, there has been a rising interest in the use of mesenchymal stem cells (MSCs) for clinical applications.(18-20). There is a lot of study about using LGR5+ stem cell and rejenerative medicine in the small intestine transplantation (21). Despite recent clinical trials investigating the use of MSCs in treating immune-mediated disease (22). their applicability in solid-organ transplantation is still unknown (23-24). Whereas, from other clinical studies, it would appear that administration of MSCs is safe, issues like dosing, timing, route of administration, and in particular the use of autologous or donor-derived MSCs may be of crucial importance for the functional outcome of MSCs treatment in organ transplantation. (25-28) In this study we try to show the high selective immunsuppressive effects of autologous or/and allogenic LGR5+ MSCs treatment in small bowel transplantation in humans.


  1. Abu- Elmagd K, Reyes J, Todo S, et al. Clinical intestinal transplantation: new perspectives and immunologic considerations. J Am Coll Surg 1998;186:512- 525.
  2. Abu – Elmagd K. Intestinal transplantation for short gut syndrome and gut failure: Rewarding outcomes and current consensus. Gastro 2006;130:!32-137
  3. C. A. Gregory, D. J. Prockop, J.L. Spees Non-hematopoietic bone marrow stem cells: Molecular control of expansion and differentiation, Experimental Cell Research 2005; 306: 330-335
  4. Pittenger MF, Mackay AM, Beck SC, et al. Multilineage potential of adult human mesenchymal stem cells. Science1999; 284: 143
  5. Brittan M, Hunt T, Jeffery R , et al. Bone marrow derivation of pericryptal myofibroblasts in the Mouse and human small intestine and colon. Gut 2002;50:752-757
  6. Ando W, Tateishi K, Hart DA, et al. Cartilage repair using an in vitro generated scaffold-free tissue engineered construct derived from porcine synovial mesenchymal stem cells. Biomaterials 2007; 28: 5462.
  7. Langnas, O. Goulet, E.M.M. Quigley and K. A. Tappenden Intestinal Failure: Diagnosis, Management and Transplantation. © 2008 Blackwell Publishing. ISBN: 978-1-405-14637-1
  8. Abu- Elmagd K, Bond G, Matarese L., et a. Gut rehabilitation and intestinal transplantation. Therapy 2005;2:853-864
  9. Bond G, Costa G, Mazariegos G, et al. Intestinal failure and viscerak transplantation: a new era of colossal achievement. In: Matarese L, Steiger E, D L Steinder, eds. Intestinal Failure and Rehabilitation: A Clinical Guide. New York: CRC Press, Boca Raton, 2004;295-319
  10. Conget PA, Minguell JJ. Phenotypical and functional properties of human bone marrow mesenchymal progenitor cells. J Cell Physiol 1999; 181: 67.
  11. R. M. Day, Epithelial stem cells and tissue engineered intestine, Current Stem Cell Research & Therapy, 2006;1:113-120
  12. Powell DW, Mifflin RC, Valentich JD, et al. Myofibroblasts II. İntestinal subepithelial myofibroblasts. Am J physiol 1999;277:C183-C201.
  13. A. J. Oullette, Mucosal Immunity and inflammation IV. Paneth cell antimicrobial peptides and the biology of the mucosal barrier, Am J Physiol Gastrointest Liver Physiol 1999; 277: 6257-6261
  14. Klyushnenkova E, Mosca JD, Zernetkina V, et al. T cell responses to allogeneic human mesenchymal stem cells:immunogenicity, tolerance, and suppression. J Biomed Sci 2005; 12: 47.
  15. Pirenne J, Gruessner AC, Benedetti E, et al. Donor specific unmodified bone marrow transfusion does not facilitate intestinal engrafment after bowel transplantation in a porcine model. Surgery 1997;121:79-88 A.N.
  16. Le Blanc K, Tammik C, Rosendahl K, Zetterberg E, Ringden O. HLA expression and immunologic properties of differentiated and undifferentiated mesenchymal stem cells. Exp Hematol 2003; 31: 890.
  17. Maccario R, Moretta A, Cometa A, et al. Human mesen- chymal stem cells and cyclosporin a exert a synergistic suppressive effect on in vitro activation of alloantigen specific cytotoxic lymphocytes. Biol Blood Marrow Trans- plant 2005; 11: 1031.
  18. Tse WT, Pendleton JD, Beyer WM, Egalka MC, Guinan EC. Suppression of allogeneic T-cell proliferation by human marrow stromal cells: implications in transplantation. Transplantation 2003; 75: 389.
  19. Fang D, Seo BM, Liu Y, et al. Transplantation of mesenchymal stem cells is an optimal approach for plastic surgery. Stem Cells. 2007;25: 1021–1028.
  20. Le Blanc K, Samuelsson H, Gustafsson B, et al. Transplantation of mesenchymal stem cells to enhance engraftment of hematopoietic stem cells. Leukemia. 2007;21:1733–1738.
  21. G. Sucak, Y. Koç, M. Arat, A.Ünal, A.Tanyeli, M.Ertürk, S.B. Omay, E.ovalı; V.Ulusal Kemik İliği Transplantasyonu ve Kök Hücre Tedavileri Kongresi GVHD Kontrolünde Otolog Mezenkimal Hücrenin Olası Rolü; Poster No: 0012, 2008;197-198.
  22. Tian H, Biehs B, Warming S, Leong K. G., Langell L, Klein O D, de Sauvage F. J., A reserve stem cell population in small intestine renders LGR5 positive cells dispensable, Nature, 2011 Sep 18; 478 (7368): 255-9: doi:10.1038/nature 10408
  23. Nasef A, Mathieu N, Chapel A, et al. Immunosuppressive effects of mesenchymal stem cells: involvement of HLA- G. Transplantation 2007; 84: 231.
  24. Selmani Z, Naji A, Zidi I, et al. Human leukocyte antigen-G5 secretion by human mesenchymal stem cells is required to suppress T lymphocyte and natural killer function and to induce CD4+CD25highFOXP3+ regulatory T cells. Stem Cells 2008; 26: 212.
  25. Koc ON, Day J, Nieder M, Gerson SL, Lazarus HM, Krivit W. Allogeneic mesenchymal stem cell infusion for treatment of metachromatic leukodystrophy (MLD) and Hurler syndrome (MPS-IH). Bone Marrow Transplant2002; 30: 215
  26. Horwitz EM, Prockop DJ, Fitzpatrick LA, et al. Transplantability and therapeutic effects of bone marrow derived mesenchymal cells in children with osteogenesis imperfecta. Nat Med 1999; 5: 309.
  27. Lazarus HM, Haynesworth SE, Gerson SL, Rosenthal NS, Caplan AI. Ex vivo expansion and subsequent infusion of human bone marrow-derived stromal progenitor cells (mesenchymal progenitor cells): implications for thera- peutic use. Bone Marrow Transplant 1995; 16: 557.
  28. Rasmusson I, Uhlin M, Le Blanc K, Levitsky V. Mesenchymal stem cells fail to trigger effector functions of cytotoxic T lymphocytes. J Leukoc Biol 2007; 82: 887.