JSRM: an exclusive and free online journal is the official organ of
|Vol.IV Issue: I: (JSRM code: 004010200002)|
Cell Therapy for Acute Liver Failure - Ideal source of cell
Khan AA1, Parveen N1, Aejaz Habeeb M1, Paspala S1, Rajendraprasad A1, Mahaboob Vali S1, Khaja MN1, Lakshmi N 2, Pramila R2, Habibullah CM1,2
1 Centre for Liver Research and diagnostics, Deccan College of Medical Sciences, Owaisi Hospital and research center, Hyderabad, 2 Department of Biotechnology,JNTU, Hyderabad
Liver is the central metabolic organ that regulates bodyfs energy supply, secretes several essential compounds and clears substances by several methods, including recycling, inactivation andexcretion. Global loss of the liver function results in profound metabolic instability and disruption of essential functions such as acid-base balance and thermoregulation leading to acute liver failure (ALF).If this is not rapidly reversed, complications such as uncontrolled bleeding occur, and dependent organs such as brain and kidneys begin to fail, reducing the chance of recovery even further. Acute liver failure (ALF) carries high morbidity and mortality (>80%) even in the best centres.
Presently, orthotopic liver transplantation (OLTx) is the only treatment that improves the survival rate in patients with ALF. Advent of various immunosuppressive agents has improved the success rate of this procedure by preventing rejection. Non availability of donor organs however remained a major limitation.
Two approaches viz., (i) hepatocyte transplantation (ii) extracorporeal liver support system, have been attempted to provide temporary liver support to failing liver till a suitable organ becomes available. These approaches have demonstrated their efficacy in the pre-clinical and clinical studies.
Preclinical studies- Hepatocyte transplantation in experimental models of Acute Liver Failure
Clinical studies- Hepatocyte transplantation in patients with acute and chronic liver failure
Very recently we have demonstrated the efficacy of the hepatic progenitors transplantation managing hyperbilirubinemia in the treatment of crigler-najjar syndrome type 1 by hepatic progenitor cell transplantation26. Patient reporting the confirmed case of Criggler Najar syndrome type 1 of age 2 year female with unconjugated hyperbilirubinemia and bilirubin of >30mg/dl was treated with hepatic progenitor cell infusion through hepatic artery. No procedure related complications encountered. No kernicterus was observed. Total Bilirubin started falling 10 days after cell infusion. After 2 month of cell infusion, bilirubin starts decreasing from 29.0mg/dl to 16 mg/dl, conjugated bilirubin increasing approximately 5 fold, unconjugated bilirubin decreasing nearly 2 fold and SGPT also decreasing from 210 U/L to 64 U/L. This study demonstrates the efficacy of hepatic progenitor cell in management of hyperbilirubinemia in these patients. As the procedure is very simple and the patient has tolerated the cell therapy, infusion can be repeated as an when require to manage hyperbilrubinemia which often cause lethal kernicterus. This study was developed to assess safely, feasibility and efficacy of hepatic progenitor cell transplantation in a child of Criggler-Najjar Syndrome type-I.
Autologous bone marrow stem cell transplantation in chronic liver disease (liver cirrhosis)
Autologous bone marrow derived stem cells also provide important source of cells for treatment of liver diseases. In our centre we have demonstrated the safety and tolerability of injecting autologous bone marrow stem cells (CD34+) in four patients with liver insufficiency. The study was based on the hypothesis that the CD34+ cell population in G-CSF mobilized blood and autologous bone marrow contains a subpopulation of cells with the potential for regenerating damaged tissue. We separated CD34+ stem cell population from the bone marrow. The potential of the bone marrow cells to differentiate into hepatocytes and other cell lineages is already reported. Besides this, several reports demonstrated the plasticity of the hematopoietic stem cells to differentiate into hepatocytes. Recently Sakaida demonstrated the reduction of fibrosis in chemically induced liver cirrhosis following bone marrow stem cell transplantation. From therapeutic point of view chronic liver cirrhosis is one of the targets where BMC transplantation can be employed. In this condition, there is excessive deposition of extracellular matrix and necrosis of hepatocytes. Encouraged by this evidence that the CD34+ cell population contains cells with the potential to form hepatocyte-like cells, four patients with liver insufficiency were given G-CSF to mobilise their stem cells. 0.1X108 CD34+ cells were injected into the hepatic artery. No complications or specific side effects related to the procedure were observed. All the four patients showed improvement in serum albumin, bilirubin, ALT after first month of cell infusion.25
Xenogenic liver cells: Alternative source of cells for treatment of acute liver failure
Use of freshly isolated hepatocytes seems to be a practical approach for obtaining a large number of viable cells. Primary human hepatocytes can be harvested for surgical samples, biopsies, or from liver grafts; however, their availability is limited. To obtain a large number of hepatocytes, several sources have been tried, viz., transformed hepatocyte cell lines, cultured hepatocytes and freshly isolated hepatocytes. Cell line has the advantage of ability to sustain cell growth indefinitely, which is not possible with primary hepatocyte culture; however, alteration of gene expression under culture conditions may pose a problem. 28
Thus, most groups have used hepatocytes from other species, more often of porcine, goat and rabbit origin. Metabolic, detoxification and synthetic functions of porcine hepatocytes have been studied extensively.
Extracorporeal bioartificial liver support system (BALSS) for the management of Acute liver Failure
Hepatocytes are major component for the development of any BALSS. Approximately 25 x 109 hepatocytes are needed to provide adequate artificial liver support system for patients with ALF 29.
Immunomodulation of hepatocytes
Microencapsulation of goat cells for the development BAL
Encapsulation of the hepatocytes in alginate poly-l-lysine membrane has been shown to provide protection against such damage30. Hence the use of microencapsulated hepatocytes in bioreactor module provides a way for using xenogenic hepatocytes.
In our study, goat hepatocytes were encapsulated in alginate poly-L-lysine- with the ultimate goal of developing an ideal BAL device and reconfirmed the immunoisolation provided by the encapsulation of hepatocytes and have also evaluated a hollow bioreactor module using these encapsulated hepatocytes and shown its ability to detoxify ammonia to urea 31 .(fig 1)
Xenogenic transplantation of microencapsulated rat hepatocytes in ALF
Xenotransplantation of UV-B irradiated hepatocytes in ALF animal model
Role of xenoantibodies against galactosyl (alphagal) epitope in (HAR)
Longterm survival of intraperitoneal transplanted TGP immobilized cells in acute liver failure rat animal model
Hepatocytes are anchorage dependent for their long-term survival and functions. Various techniques are being used successfully for providing a substratum for long-term survival of the transplanted cells such as microcarriers, microencapsulation, extracellular matrices but these are derived from animal source. Hence not appropriate for clinical use. There is a need of chemically synthesized biocompatible polymer for clinical application.
Mebiol Gel, an aqueous solution of thermo reversible gelation polymer (TGP) which is a biocompatible polymer. The intraperitoneal transplantation of hepatocytes embedded in TGP (Mebiol Gel) resulted in prolonged survival and function of the cells and was able to support acute liver failure in animal models thus giving a hope that when applied in humans, it could successfully provide liver support in severe acute liver failure when transplanted intraperitoneally 32 Fig (2 )
2. Zenoroli MI. Hepatic encephalopathy. Experimental studies in a
3. Blitzer BJ, Waggoner JG, Jones EA. A model of fulminant hepatic failure in the rabbit. Gastroenterology 1978; 74 : 664-71.
4. Traber PG, Ganger DR, Blei AT. Brain edema in rabbits with galactosamine induced fulminant hepatitis. Gastroenterology 1986; 92 : 1347-56.
5. McClung HJ, Sloan HR, Powers P. Early changes in the permeability of the blood brain barrier produced by toxins associated with liver failure. Ped Res 1990; 28 : 327-31.
6. Dixit V, Chang TMS. Brain edema and the blood brain barrier in galactosamine-induced fulminant hepatic failure rats. An animal model for evaluation of liver support
7. Zimmerman C, Ferenci P, Pifi C. Hepatic encephalopathy in thiocetamide-induced acute liver failure in rats: characterization of an improved model and study of
8. Peeling J, Schoemaker L, Gauthier T. Cerebral metabolic and histologic effects of thiocetamide-induced liver failure. Am J Physiol 1993; 265 : G572-8.
9. Hilgier JW, Haugvicova R, Albgrecht J. Decreased potassium stimulated release of [3H] D aspartate from hippocampal slices distinguishes encephalopathy related
10. Yurdaydin C, Hortnagl H, Steindl P. Increase serotoninergic and noradrnergic activity in hepatic encephalopathy in rats with thioacetamid-induced acute liver
11. Gammal SH, Basile AS, Geller D. Reversal of the behavioral and electrophysiological abnormalities of an animal model of hepatic encephalopathy by benzodiazepine receptor ligands. Hepatology 1990; 11 : 371-8.
12. Sutherland DER, Numata M, Matas AJ. Hepatocellular transplantation in acute liver failure. Surgery 1977; 82 : 124-32.
13. Sommer BG, Sutherland DER, Matas AJ. Hepatocellular transplantation for treatment of D-galactosamine-induced acute liver failure in rats. Transplantation 1979; 11 : 578-84.
14. Makowka I, Falk RE, Rotstein LE. Cellular transplantation in the treatment of experimental hepatic failure. Science 1980; 210 : 901-3.
15. Bamgartner D, La Plante-OfNeill PM, Sutherland DET. Effects of intrasplenic injection of hepatocytes, hepatocytes fragments and hepatocytes culture supernatants on Dgalactosamine- induced liver failure on rats. Eur Surg Res 1983; 15 : 129-35.
16. Habibullah CM, Ayesha Q, Khan AA, Naithani R, Lahiri S. Xenotransplantation of UV-B irradiated hepatocytes survival and immune response. Transplantation 1995; 59 : 1495-7.
17. Mito M, Kusano M. Hepatocyte transplantation in man. Cell Transplant 1993; 2 : 65-74
18. Habibullah CM, Syed IH, Qamar A, Taher-Uz Z. Human fetal hepatocyte transplantation in patients with fulminant hepatic failure. Transplantation 1994; 58 : 951-2.
19. Storm SC, Fisher RA, Thompson MT, Sanyal AJ, Cole PE, Ham JM. Hepatocyte transplantation as a bridge to orthotopic liver transplantation in terminal liver failure.
20. Sorino HE, Wood RP, Kang DC. Hepatocellular transplantation (HCT) in children with fulminant hepatic failure. Hepatology 1997; 26 : 239A.
21. Bilir B, Durham JD, Kristal J. Transjugular intraportal transplantation of cryopreserved human hepatocytes in a patient with acute liver failure. Hepatology 1996; 24 : 728.
22. Fox IJ, Roy Chowdhary J, Kauffman SS. Treatment of the Crigler-Najjar syndrome type I with hepatocyte transplantation. N Engl J Med 1998; 338 : 1422-6.
23. Sokal EM, Smets F, Bourgos A, Van Maldergem L, Buls JP, Reding R. Hepatocyte transplantation in a 4-year girl with peroxisomal biogenesis disease: technique, safety
24. Khan AA, Habeeb A, Parveen N, Naseem B, Babu RP, Capoor AK, et al. Peritoneal transplantation of human fetal hepatocytes for the treatment of acute fatty liver pregnancy; a case report. Trop Gastroenterol 2004; 25 : 141-3.
25. Aleem A khan Parveen N, Mahaboob vali S, RajendraPrasad A, Ravindraprakash, Venkateswarlu, SGA Rao , M Lakshmi Narusu , M N Khaja, R.Pramila, Aejaz Habeeb ,C.M.Habibullah. safety and efficacy of autologous bone marrow stem cell transplantation through hepatic artery for the treatment of chronic liver failure-a preliminary study. Transplantation Proceedings (In Press)
26. Aleem A khan, Parveen N, Mahaboob vali S, RajendraPrasad A, Ravindraprakash, Venkateswarlu J, Pratap Rao, Gopal Pande, Aejaz Habeeb, C.M.Habibullah. treatment of crigler-najjar syndrome type 1 by hepatic progenitor cell transplantation: a simple procedure for management of hyperbilirubinemia. Transplantation Proceedings (In Press)
27 . Aleem A khan, Parveen N, Mahaboob vali S, RajendraPrasad A, Ravindraprakash, Venkateswarlu J, Pratap Rao, Gopal Pande , M Lakshmi Narusu , M N Khaja, R.Pramila, Aejaz Habeeb, C.M.Habibullah, management of hyperbilirubenemia in biliary atresia by hepatic progenitor cell transplantation through hepatic artery. Transplantation Proceedings ( In Press)
28 Nagaki M, Kim YI, Miki K. Development and characterization of hybrid bioartificial liver using primary hepatocytes entrapped in a basement membrane matrix.
29 Sielaff TD, Hu My, Amiot B. Gel-entrapment bioartificial liver therapy in galactosamine hepatitis. J Surg Res 1995; 59 : 179-84.
30 Khan AA, Capoor A, Habibullah CM. In vitro assessment for microencapsulation providing immunoprotection against antibody mediated cell lysis. Acta Medica et Biologica 1999; 47 : 97-102
31 Khan AA, Capoor A, Parveen N, Naseem S, Vijaylakshmi V, Habibullah CM. In vitro studies on bioreactor module containing encapsulated goat hepatocytes for the development of bioartificial liver. Indian J Gastroenterol 2002; 21 : 55-8.
32 Parveen Nyamathulla, Aleem Ahmed Khan, S. Baskar, M .A Habeeb
33.Galili U, Macher BA, Beuhler J, Shohet SB. Human natural anti-alpha galactosyl IgG: II. The specific recognition of alpha (1-3) -linked galactose residues. J Exp Med 1985; 162 : 573-82.
34. Galili U, Buehler J, Shohet SB, Macher BA. The human natural anti-Gal IgG. III. The subtley of immune tolerance in man as demonstrated by cross reactivity between natural anti-Gal and anti-B antibodies. J Exp Med 1987; 165 : 693-704.
35. Galili U, Shohet SB, Kobrin E, Stults CLM, Macher BA. Man, apes and old world monkeys differ from other mammals in the expression of alpha galactosyl epitopes on nucleated cells. J Biol Chem 1988; 263 : 17755-62.
36. Sandrin MS, Kenzie IF. Gal Alpha (1,3) Gal, the major xeno antigen (s) recognized in pigs by human natural antibodies. Immunol Rev 1995; 141 : 169-90.
Correspondign Author: Dr. C.M Habibullah, Director, Centre for Liver Research and diagnostics, Deccan College of Medical Sciences, Owaisi Hospital and research center, Kanchanbagh, Hyderabad. Tele/Fax +91- 40-24342954 Email: firstname.lastname@example.org
This is an open-access article distributed under the terms of the Creative Commons 3.0 Unported (CC BY 3.0) Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Copyright © Journal of Stem Cells & Regenerative Medicine. All rights reserved.