Bone Marrow Transplantation (2003) 32, S23S24 & 2003 Nature Publishing Group All rights reserved 0268-3369/03

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Adult stem cells and tissue repair

M Ko rbling1, Z Estrov2 and R Champlin1
1 Department of Blood and Marrow Transplantation, The University of Texas M. D. Anderson Cancer Center, Houston, TX, USA; and 2Department of Bioimmunotherapy, The University of Texas M. D. Anderson Cancer Center, Houston, TX, USA

Summary: Recently, adult stem cells originating from bone marrow or peripheral blood have been suggested to contribute to repair and genesis of cells specic for liver, cardiac and skeletal muscle, gut, and brain tissue. The mechanism involved has been termed transdifferentiation, although other explanations including cell fusion have been postulated. Using adult stem cells to generate or repair solid organ tissue obviates the immunologic, ethical, and teratogenic issues that accompany embryonic stem cells. Bone Marrow Transplantation (2003) 32, S23S24. doi:10.1038/sj.bmt.1703939 Keywords: adult stem cells; developmental stem cell plasticity; stem cell transdifferentiation; regenerative medicine

cell transplantation model using the Y chromosome as a marker. However, if stringent criteria are used to judge reports that stem cells deviate from their predetermined differentiation pathway to generate cells outside their own tissue, only a few reports published so far can stand up to critical review.1,2 The ndings of those studies fulll at least in part the following criteria: 1. the source of the stem cells must be clearly identied (eg, Y chromosome, green uorescence protein, etc); 2. transdifferentiated cells must become an integral part of the surrounding tissue; 3. transdifferentiated cells must function in the same way as the surrounding organ-specic cells do. As shown by Krause et al1 transplantation of a single hematopoietic stem cell with self-renewal capacity resulted in not only complete and permanent reconstitution of hematopoietic tissue but also generation of epithelial cells in the liver, lungs, gastrointestinal tract, and skin. Lagasse et al2 transplanted 501000 hematopoietic stem cells into mice with a fumarylacetoacetate hydrolase deciency to show that, besides hematopoietic reconstitution, biochemical liver function was restored. Although the latter experimental design provided evidence of the function of transdifferentiated cells, the clonal origin of those cells was not clearly established. However, in a follow-up study, Wagers et al group recently reported little evidence of any developmental plasticity of adult hematopoietic stem cells tested on a clonal level.3 The stem cell transdifferentiation model is only one of several differentiation models that may explain why donorderived bone marrow (BM) or peripheral blood (PB) cells are found in recipient solid organ-specic tissue. It is also conceivable that each solid organ tissue has its own circulating stem cells (eg, hematopoietic stem cells, angioblasts, mesenchymal stem cells). Jiang et al4 identied and isolated a BM-derived multipotent adult progenitor cells capable of differentiating in vivo into the hematopoietic lineage and into the epithelium of the liver, lung, and gut when transplanted.4 Another possible explanation for lineage plasticity is the de-differentiation of terminally differentiated cells to regain stem-like characteristics before the cells differentiate into another lineage.5 The stem cell transdifferentiation model has also been challenged. Cell fusion bypassing stem cell differentiation has been postulated as an alternative mechanism to explain the presence of BM-derived cells in solid organ-specic tissue. In two separate studies, BM and brain cells have

Stem cells are dened as being clonogenic, having selfrenewal capacity throughout lifetime and giving rise to terminally differentiated cells of various cell lineages. Their differentiation pathway is unidirectional, passing through the stage of lineage commitment and nally generating terminally differentiated cells. Adult stem cell differentiation is traditionally believed to be restricted to the tissue in which the stem cells reside (eg, hematopoietic stem cells generate blood cells, liver progenitor cells (oval cells) produce hepatocytes and cholangiocytes). Hematopoietic stem cells are the most thoroughly characterized adult progenitor cells, mostly because of their easy accessibility and more than 30 years of experience with their clinical use for transplantation to treat malignant disease.

Transdifferentiation of adult hematopoietic stem cells

The concept of adult stem cells being restricted to their own tissue has been challenged over the past 5 years by numerous reports that adult stem cells can jump lineage barriers and differentiate into cells outside their own tissue, a process called stem cell transdifferentiation. Many such studies are based on a sex-mismatched hematopoietic stem

Correspondence: Dr M Ko rbling, Department of Blood and Marrow Transplantation, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 423, Houston, TX 77030, USA

Adult stem cells and tissue repair M Ko rbling et al

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been shown to fuse spontaneously with embryonic stem cells in vitro to adopt subsequently the phenotype of the recipient cells.6,7 However, the in vitro culture conditions to which those cells were exposed were far from being physiologic. Fused hybrid cells are characterized by hyperdiploid DNA content, which is not regularly seen in stem cell differentiation experiments. Finally, the frequency of cell fusion is very rare, approximately 3 logs less than the frequency of donor-derived BM or PB cells appearing in solid organ-specic tissue. Another mechanism refers to horizontal DNA transfer originating from apoptotic cells that could result in the appearance of donor-derived DNA fragments in solid organ tissue.8 On a clinical level, study designs are obviously much more restricted in their ability to provide proof of stem cells originating from hematopoietic tissue and differentiating into nonlymphohematopoietic tissue. In an allogeneic sex-mismatched transplant setting, BM-derived cells were found to contribute to hepatocyte and cholangiocyte formation at frequencies of up to 43 and 38%, respectively.9 Alisons group reported similar ndings although at somewhat lower frequencies.10 Since PB is the only link between BM-derived cells and solid organ-specic tissue, it was a logical further step to investigate the possibility of PB-derived cells generating nonlymphohematopoietic tissue. Orlics group successfully demonstrated the repair of infarcted heart tissue in a mouse model by an increase in the concentration of circulating stem cells.11 In a clinical setting, we recently reported the presence of XY-positive hepatocytes and epithelial cells of the skin and gastrointestinal tract in ve female recipients of rhG-CSF-mobilized, PB stem cell allografts from male donors. Donor-derived, nonlymphohematopoietic cells were identied at frequencies ranging from 0 to 7% in the skin, gut, and liver of all ve stem cell recipients. XY probepositive cells were detected in liver tissue in these female recipients as early as day 13 and as late as day 354 after transplantation. Engraftment of nonlymphohematopoietic cells did not seem to depend on tissue damage induced by graft-versus-host disease.12 In a similar experimental setting, donor-derived Y chromosome-positive and cytokeratin-positive keratinocytes were found at frequencies ranging from 3.7 to 14.8% in six patients who underwent sex-mismatched PB stem cell transplantation. However, when the same epidermal skin cells were cultured over 1832 days through multiple passages to eliminate any contaminating lymphohematopoietic cells, donor-derived Y chromosome-specic sequences could not be detected using the polymerase chain reaction method. One may speculate that the Y chromosome-specic sequences had been lost after several culture passages or that the donor cells had no or reduced proliferative capability in vitro.13 Based on the morphological identication of XY chromosome containing BM- or PB-derived solid organspecic cells, the frequency of those nonlymphohematopoietic cells is in the range of 10% or less. It is hypothesized that tissue damage may trigger BM- or PB-derived cells to undergo differentiation into solid organ-specic tissue. The distribution pattern of those cells seems to be random, although small clusters are sometimes found.

Therapeutic strategies involving the differentiation potential of BM- or PB-derived stem cells to generate solid organspecic tissue are hypothetical. One may speculate that solid organ tissue damage triggers endogenous stem cells (eg, oval cells, intestinal crypt cells) to undergo differentiation as the rst line of defense. In case the tissue-intrinsic stem cell pool is exhausted as a result of more extensive tissue damage, exogenous and circulating stem cells are recruited as a backup system to support local tissue repair. Two mechanisms may act as triggers for cellular repair: (1) the microenvironment at the site of tissue damage by releasing adhesion molecules and cytokines, and (2) an increase in the concentration of stem cells at the site of tissue damage.

Conclusion
We are conrming initial observations of developmental stem cell plasticity or stem cell differentiation mechanisms. Currently the frequency of BM- or PB-derived nonlymphohematopoietic cells in solid organ tissue is too low to have any clinical impact. Only after stem cell differentiation mechanisms are fully understood can promising treatment strategies be designed to redirect BM or PB stem cells to generate solid organ tissue in a clinically relevant manner.

References
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