Taking advantage of the potential of mesenchymal stromal cells in liver regeneration: Cells and extracellular vesicles as therapeutic strategies

Table 1 Mesenchymal stem/stromal cells clinical trials for liver diseases

Ref.	Etiology or disease	Cell source/origen	Study design (n; groups)	Cell administration condition			Phase	Results	Follow up	Side effects
				Dose	P value	Route
Mohamadnejad et al[14] 2007	Cirrhosis	BM/Auto	n = 4	1, 0.6 × 107	2-4	IV	I	MELD ↓	12 mo	None
Kharaziha et al[15] 2009	Cirrhosis	BM/Auto	n = 8; 4 HBV 1 HCV 1 Alcohol 2 Control	3.5 × 107	3-4	PV/IV	I/II	MELD ↓	24 wk	None
El-Ansary et al[16] 2010	Cirrhosis	BM/Auto	n = 12	10 × 106	1	IS/IV	I	MELD ↓; no differences between IS vs IV	6 mo	NA
Peng et al[29] 2011	Cirrhosis (HBV)	BM/Auto	n = 158; 53 MSC 105 Control	3.4-3.8 × 108	3	HA	I/II	ALB ↑, MELD ↓	48 mo	None
Amer et al[34] 2011	Cirrhosis (HCV)	BM/Auto	n = 40; 20 MSC 20 Control	2 × 107	NA	IS/IH	I/II	ALB ↑, C.P ↓, MELD ↓	6 mo	Fever (50%), transient shivering (15%)
El-Ansary et al[17] 2012	Cirrhosis (HCV)	BM/Auto	n = 25; 9 MSC 6 Hep. Diff. 10 Control	1 × 106/kg MSC or 40% HLCs and 60% MSCs	5	IV	II	ALB↑, MELD ↓, no differences between HLCs vs MSCs.	6 mo	NA
Zhang et al[18] 2012	Cirrhosis (HBV)	UC/Allo	n = 45; 30 MSC 15 Control	0.5 × 106/kg every 4 wk, 3 times	3-4	IV	I/II	ALB ↑, MELD↓, ascites ↓	48 wk	None
Shi et al[19] 2012	Acute-on-chronic Liver failure (HBV cirrhosis)	UC/Allo	n = 43; 34 MSC 9 Control	0.5 × 106/kg every 4 wk, 3 times	3-4	IV	I/II	ALB ↑, PT ↑, MELD ↓, SR↑	72 wk	None
Mohamadnejad et al[20] 2013	Cirrhosis	BM/Auto	n = 25; 14 MSC 11 Control	2 × 108	3-4	IV	II	No beneficial effect	12 mo	None
Wang et al[21] 2013	UDCA-resistant PBC	UC/Allo	n = 7	0.5 × 106/kg every 4 wk, 3 times	4	IV	I/II	ALP↓, γ-GT ↓, quality of life↑ (fatigue↓, pruritus↓)	48 wk	None
Amin et al[35] 2013	Cirrhosis	BM/Auto	n = 20	10 × 106	2	IS	I/II	ALT ↓,AST ↓,BIL ↓, PT ↓, ALB↑, PT↑	24 wk	None
Jang et al[30] 2014	Cirrhosis	BM/Auto	n = 11	5 × 107 every 4 wk, 2 times	4-5	HA	II	C.P ↓, TGF-β ↓, αSMA ↓, collagen1 ↓, fibrosis ↓,	20 wk	None
Wang et al[18] 2014	UDCA-resistant PBC	BM/Allo	n = 10	3-5 × 105/kg	3-5	IV	I/II	ALT ↓, AST ↓, γGT, BIL ↓, IgM ↓, Tregs ↑, IL-10↑, CD8+T cells↓	12 mo	None
Salama et al[23] 2014	Cirrhosis	BM/Auto	n = 40; 20 MSC 20 Control	1 × 106/kg	0	IV	II	ALT↓, AST↓,BIL↓, ALB↑, PT↑, C.P↓, ascites ↓	26 wk	NA
Xu et al[31] 2014	Cirrhosis	BM/Auto	n = 56; 27 MSC 29 Control	0.75 × 106/kg	NA	HA	II/III	ALB↑, MELD↓, ↑ Tregs/Th17 cell ratio, IL-17↓, TNFα↓, IL-6↓, TGF-β ↑	24 wk	NA
Suk et al[32] 2016	Cirrhosis	BM/Auto	n = 55; 18 MSC (× 1 d) 19 MSC (× 2 d) 18 Control	5 × 107 (1 mo post BM asp.) /5 × 107 (1 and 2 m post BM asp.)	4-5	HA	II	C.P ↓, fibrosis ↓	12 mo	None
Zhang et al[24] 2017	Ischemic-type biliary lesions	UC/Allo	n = 82; 12 MSC 70 Control	1 × 106/kg; week 1, 2, 4, 8, 12 and 16	4	IV	II/III	BIL↓,ALP↓, γGT ↓, graft survival ↑	24 mo	None
Detry et al[25] 2017	Liver transplantation	BM/Allo	n = 20; 10 MSC 10 Control	1.5-3 × 106/kg; day 3 post-transplant	2-3	IV	I/II	No beneficial effect	6 mo	None
Sakai et al[33] 2017	Cirrhosis	AT/Auto	n = 4	6.6 × 105/kg	0	HA	I	ALB ↑, PT↓	1 mo	None
Shi et al[26] 2017	Liver transplantation	UC/Allo	n = 20; 14 MSC 13 Control	1 × 106/kg; every 4 wk, 3 times	3-4	IV	I	ALT↓, AST↓, BIL ↓, improve liver allograft histology, acute rejection↓ (↑ peripheral Tregs, ↑ Tregs/Th17 cell ratio).	12 wk	None
Hartleif et al[27] 2017	Pediatric liver transplantation	BM/Allo	n = 7	1 × 106/kg; day 0 and day 2 post-transplantation	2-3	PV/IV	I	NA	24 mo	None
Lin et al[28] 2017	Acute-on-chronic Cirrhosis (HBV)	BM/Allo	n = 110; 56 MSC 54 Control	1-10 × 105 cells/kg; 1/wk, 4 wk	5-6	IV	I/II	MELD↓, SR↑, infections↓	24 wk	None

P: Passage; BM: Bone Marrow; Allo: Allogeneic; Auto: Autologous; IV: Intravenous Infusion; MELD: Model for end-stage Liver Disease; HBV: Hepatitis B Virus; HCV: Hepatitis C Virus; IS: Intrasplenic; IH: Intrahepatic; NA: Not available; HA: Hepatic artery; CP: Child-Pugh score; HLC: Hepatocyte-like cells; UC: Umbilical cord; SR: Survival rate; Cr: Creatinine; BIL: Bilirubin; PBC: Primary biliary cirrhosis; UDCA: Ursodeoxycholic acid; Hep. Diff.: Hepatocyte differentiated; PT: Prothrombin time; ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; ALP: Alkaline phosphatase; γ-GT: γ-glutamyltranspeptidase; Asp: Aspiration.

Table 2 Mesenchymal stem/stromal cells-derived extracellular vesicles in experimental models of liver disease

Ref.	EVs Isolation/characteristics	Experimental model	Protocol	Biological effects
Haga et al[98] 2016	Ultracentrifugation Size: 46-116 nm Alix+ CD9+, CD81+	C57Bl mice. ALF, i.p. 20 mg/body DGalNAc + 0,3 mg/body TNF-α	2 × 108 to 2 × 1010 i.p./i.v.	↑ Survival, ↑ F4/80, ↑ inhibitor MMP-1 and IL-6, ↓ inflammation and apoptosis, ↓ ALT/AST, ↓ ALP, ↓ EGF, SCF, IFN-γ, IP-10, IL-1α, MIP3, MCP-1/3
Yan et al[100] 2016	Ultracentrifugation Size: 30-100 nm CD9+, CD61+, CD63+	BALB/c-nu/nu mice, i.p. CCL4induced ALF, 0.15-0.35 mL/kg	8, 16, and 32 mg/kg i.v./oral	↓ Oxidative stress and apoptosis Induces ERK1/2 phosphorylation and Bcl2 expression Inhibits IKKB/NFκB/casp9/3 pathway
Tan et al[99] 2014	TFF, 100.kDa MWCO filter Size: 55-100 nm	C57BL/6 mice. CCL4-induced ALF, i.p. 0.05 mL CCL4/kg	0.4 μg (100 μL) i.s.	↑ Cell viability: TAMH, THLE-2, and Huh-7 ↑ Hepatocytes proliferation ↓ ALT/AST ↓ Casp 3/7 ↑ antiapoptoticBcl-xL
Chen et al[97] 2017	Centrifugation and Exoquick-TC Size: 30-100 nm CD63+ and tsg101+	C57BL/6 mice. ALF, i.p. D-GalNAc 800 mg/kg and LPS 50 μg/kg	1 μg/μL i.v.	↑ Liver function and survival ↓ Apoptosis ↓ TNF-α, IL-6 and IL-1 ↓ Casp-3 ↓ Necrosis and inflammation
Nong et al[101] 2016	Ultracentrifugation and ultrafiltration Size: 50-60 nm CD9+, CD63+ and CD81+	Rats I/R injury	600 μg suspended in 400 μL of PBS i.v.	↑ GSH, GSH-PX and SOD ↓ AST/ALT ↓ TNF-α, IL-6 and HMGB1 ↓ Casp-3 and Bax
Du et al[93] 2017	Centrifugation and filtered by 0, 45-μm PVDF filter ExoQuick Size: 100-200 nm Alix+, CD63+ and CD81+	C57 mice I/R injury	2.5 × 1012 particles in 500 μL of PBS i.v.	↑ Hepatocytes proliferation ↑ SK activity and S1P formation. Hepatoprotective and proliferative effect abolished by the inhibition of SK or S1P receptor 1

i.p.: Intraperitoneal injection; i.v.: Intravenous injection; i.s.: Intrasplenic; MMP: Metalloproteinases; CCL₄: Corbon tetrachloride; D-GalNAc: N Acetylgalactosamine; IL: Interleukins; ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; ALP: Alkaline phosphatase; EGF: Epidermal growth factor; SCF: Stem cell factor; TNF: Tumor necrosis factor; IFN: Interferon; IP: Inducible protein; MIP: Macrophage inflammatory protein; MCP: Monocyte chemotactic protein; ERK: Extracellular signal-regulated kinase; Bcl: B-cell lymphoma; TFF: Tangential flow filtration; MWCO: Molecular weight cut-off; ALF: Acute liver failure; TAMH: Transgenic mouse hepatocyte; THLE: T-antigen immortalized human liver epithelial; Casp: Caspase; GSH: Glutathione; GSH-PX: Glutathione peroxidase; SOD: Superoxide dismutase; HMGB: High mobility group box; PBS: Phosphate-buffered saline; SK: Sphingosine kinase; S1P: Sphingosine 1-phosphate.