Overall, kidney graft survival markedly improved over the past decades, mainly as a result of improvement of first-year graft survival. Long-term graft survival, however, has remained in essence unaltered over the past 2 decades. This has been attributed to graft loss from interstitial fibrosis (IF) and tubular atrophy (TA).1 The mechanism for the development of IF/TA includes both alloimmunity and nonimmunologic causes such as drug toxicity (eg, calcineurin inhibitors [CNI]), (viral) infections and recurrent renal disease.2 In addition, long-term nonspecific immunosuppression results in life-threatening complications including infections and malignancies.3,4 Therefore, there is an unmet need to develop novel therapy to modulate the immune system and to induce repair and to govern the balance between overimmunosuppression and underimmunosuppression.
Mesenchymal stromal cell (MSC) therapy has been put forward as a possible strategy because MSCs potentially affect immunologic, inflammatory, vascular, and regenerative pathways.5,6 In vitro studies demonstrate that MSCs play a role in modulation of immune responses, and beneficial immunomodulatory and regenerative effects of MSCs have been shown in experimental transplant models.7-13 In clinical kidney transplantation, initial trials have focused mainly on safety and feasibility of MSC treatment, whereas follow-up studies have been initiated with the desired clinical efficacy to reduce ischemia-reperfusion injury (IRI), to prevent/reverse acute transplant rejection, and to improve long-term transplant survival with minimization of immunosuppression.8 Here, we summarize the current state-of-the-art of MSCs in kidney transplantation, and we discuss lessons learned from the initial clinical trials for the design of future studies.
Immune Modulating and Reparative Capacities of MSCs
MSCs are nonhematopoietic progenitor cells that can differentiate into several mesenchymal tissues, including osteoblasts, adipocytes, and chondrocyte progenitors. MSCs can be isolated from various tissues including bone marrow (BM), adipose tissue (AT), and umbilical cord. In the BM, MSCs control hematopoietic stem cell homeostasis in the endosteal and the perivascular niche.14 In addition, perivascular stromal cells (PSCs) which share characteristics with BM MSCs can be identified within several different organs.15,16 These PSCs may also possess tissue-specific properties and play a role in local tissue homeostasis.17 Indeed, for example, human PSCs isolated from the kidney show distinct functional properties with respect to epithelial wound healing, interstitial integration, and amelioration of kidney injury.18
Although several attempts have been made to select a homogeneous MSC population, no unique phenotype has been identified that allows the reproducible isolation of MSC precursors, and functional characterization still relies primarily on their ability to adhere to plastic and their differentiation potential. The International Society of Cellular Therapy stated that MSCs should bear at least the stromal markers, CD73, CD90, and CD105, and be negative for hematopoietic markers, CD14, CD34, and CD45.19 Of importance for clinical application is that MSCs are easily isolated and that they are capable of substantial proliferation and expansion in culture.20
Immune Modulating Properties
Several studies demonstrated that MSCs play a role in the modulation of immune responses,21,22 and a myriad of mechanisms has been suggested, as extensively reviewed.5,8 MSCs can downregulate the effector function of immune cells including T cells, B cells, macrophages, dendritic cells (DCs), and can promote the conversion into regulatory cells.5,8,23-26
MSCs have intrinsic hypoimmunogenicity properties. Indeed, they express a low-intermediate HLA class I and lymphocyte function-associated antigen-3 and do not express costimulatory molecules, such as B7-1, B7-2, CD40, and CD40L.5,21,27 MSCs have a clear effect on the function of T cells. They suppress the proliferation of CD4+ and CD8+ T cells22,28-30 which was shown to be dependent on a cell-cycle arrest in G0/G1 phase.31 In addition, MSCs can prevent T cells from activation-induced cell death.32 In an inflammatory microenvironment, MSCs could promote a Th1 to Th2 shift by affecting IFN-γ secretion from Th1 and IL-17 release by CD4+ Th17 and IL-4 secretion from Th2 cells. MSCs could also inhibit the cytolytic potential of cytotoxic lymphocytes.33 MSC-mediated effects on T cells were shown to be mediated by varipous cell membrane-associated and soluble molecules including prostaglandin E2 (PGE2), TGF-β, indoleamine 2,3-dioxygenase, soluble HLA-G, nitric oxide, hepatocyte growth factor, IL-10, programmed death-ligand 1, Jagged-1, and B7-H1.5,6,34
MSCs can also influence regulatory T (Treg) cells. Indeed, they can induce regulatory FoxP3+Treg cells, Treg 1 cells IL10+-producing cells and Th3 TGF B+ Treg cells.26 Moreover, MSCs have profound effects on the antigen-presenting cells and on B cells. IL-2– and IL-15–driven natural killer cell proliferation and IFN-γ production are impaired by MSCs,21,35-37 as well as generation of DCs from peripheral blood monocytes in vitro.38-40 In addition, MSCs have been shown to mediate a switch to alternatively activated M2 macrophages, which possess anti-inflammatory activities.23,24 MSCs promote the survival of resting B cells but can inhibit the differentiation and activation of B cells.41 B-cell function is thought to be affected by cell-cell contact and soluble factors synthesized by MSCs, including IFN-γ. MSCs were also shown to have a direct effect on B cells by inhibiting plasmablast differentiation and induction of IL-10–producing regulatory B cells.42
The immunomodulatory properties make MSCs especially attractive for potential use in treating immune-mediated diseases.5,6,43-45 A large number of experimental models have been used to evaluate the in vivo MSC immunoregulatory properties related to alloreactive responses in solid organ transplantation.8,10,44-48 Most studies focused their endpoints on efficacy, including prolonged graft survival and inhibition of the rejection process.8,11-13,49,50
Different experimental studies have demonstrated that the majority of MSCs get entrapped in the lung and do not migrate to peripheral organs.51 It is assumed that the entrapped MSCs cause a systemic immune response which is responsible for the beneficial effects. Indeed, in this way, MSCs could attenuate sepsis via PGE2-dependent reprogramming of host macrophages.51
It is important to note that the mechanisms of MSCs are largely independent of cognate MSC-T cell interaction. Therefore, the same regulatory mechanisms will be applicable to autologous as well as allogenic or third-party MSC. The different functions of MSCs, including hypoimmunogenicity, modulation of immune cell function (including DC and T-cell function), as well as the creation of a suppressive microenvironment, are all mechanisms of MSCs to avoid deletion by the host.
Immune Milieu Influences the Therapeutic Efficacy of MSCs
Both inflammatory cytokines and Toll-like receptor ligands have been shown to enhance the regulatory mechanisms of MSCs.52 This so-called licensing is an essential requirement for MSC activity, implying that the immune milieu influences therapeutic efficacy. Indeed, in vivo studies demonstrated that IFN-γ activation of MSCs increases their therapeutic efficacy.53,54 Like IFN-γ, TNF-α has been observed to induce immunosuppressive activity by MSCs through the production of prostaglandin PGE2 and cyclo-oxygenase-2.55 In a humanized mouse allograft rejection model, alloreactivity was marked by pronounced CD45+ T cell infiltrates consisting of CD4+ and CD8+ T cells and increased IFN-γ expression in the skin grafts, which were all significantly inhibited by both BM MSC and AT MSC.53 Of interest, Casiraghi et al13 demonstrated that pretransplant infusion of MSCs prolonged the survival of semiallogeneic (B6C3 in B6) murine heart transplants through the generation of Treg cells. In this model, pretransplant infusion of MSCs of recipient origin was as effective in inducing long-term acceptance of cardiac allografts as donor-derived MSCs. A single recipient-derived MSC infusion given peritransplant was marginally effective, and a single MSC dose given 1 day after transplantation was not effective at all. Interestingly, in a murine kidney transplant model, posttransplant syngeneic MSC infusion caused premature graft dysfunction and failed to prolong graft survival.50 In contrast, pretransplant syngeneic MSC infusion induced a significant prolongation of kidney graft survival by inducing Treg cells.50 Thus, the therapeutic use of the immunomodulatory properties of MSCs depend on the timing of their infusion,56 which is probably related to the necessity for the appropriate microenvironment to allow MSCs to acquire their immunosuppressive properties.
It is however important to note that, like many immune cells, MSCs do not always have an antiinflammatory response. Indeed, in the presence of low IFN-γ levels MSCs express MHC-class II molecules and acquire phagocytic function and antigen presentation activity to CD4+ T cells.57,58 These findings should be taken into account when designing clinical MSC studies.
MSCs are believed to have critical roles in repairing damaged tissues. Different studies have suggested that the ability of MSCs to produce paracrine factors, rather than their transdifferentiation, plays a prominent role in affecting tissue repair.6,59 In animal models, MSC therapy decreased fibrosis in the heart60 and other organs, such as the lung, liver, and kidney.7,61,62 Different cytokines have been shown to mediate the antifibrotic properties, including bone morphogenic proteinin-763 and hepatocyte growth factor.64 After kidney transplantation, MSCs could attenuate the progression of IF/TA when this process was already in progress.7 Besides a reduction in IF/TA, MSC-treated animals demonstrated also less macrophages infiltrating the parenchyma and reduced expression of inflammatory cytokines while increasing the expression of antiinflammatory factors.7
Of importance, MSCs may not only be antifibrotic but may also contribute to fibrosis. Humphreys et al65 showed, with lineage tracing studies of FoxD1+ pericytes, that PSCs can transform into myofibroblasts upon severe kidney injury and contribute to renal fibrosis as a last resort repair mechanism. In the allograft, inhibition of endothelial cell injury and stabilization of the microvasculature lead to physiological remodelling and restoration of the allograft tissue.66,67 Therefore, protecting the vasculature can prevent tissue fibrosis. In this respect, MSCs might play an important role, as they are closely related to endothelial cells both in the BM, where they control the vascular niche, as in the peripheral tissue where they stabilize the microvascular architecture.68-70
In different models, it was shown that MSC-derived exosomes have functions similar to those of MSCs, such as repairing tissue damage and modulating the immune system.71 Administration of exosomes might be a controllable, manageable, and feasible approach in future studies. However, their possible mechanisms and exact compositions need further investigation.
Clinical Trials With MSCs in Renal Transplantation
Both autologous and allogenic MSC transplantation have been used clinically for the treatment of a wide variety of diseases. Indeed, MSCs are being used for the treatment of many inflammatory disorders, including inflammatory bowel disease, rheumatoid arthritis, diabetes mellitus, and graft versus host disease (GvHD).48 Research appears to support their therapeutic value in various inflammatory diseases; however, despite this progress, there are still many challenges to be considered including further unravelling of the mechanisms of action, choosing the best design and the emerging regulatory frameworks.48 In renal transplantation, a few clinical trials with MSCs have been finished, which mainly focused on safety and feasibility. Currently, there are ongoing clinical trials with the aim to promote tolerance and to improve graft survival with minimization of immunosuppression (Table 1 for published clinical trials; Figure 1 for practical issues, goals, challenges and evaluation of MSC treatment).
Different Challenges in Clinical Trials: Source, Dose, Route, Timing, and Concomitant Immunosuppression
MSCs for clinical applications are classified as advanced therapy medicinal products (ATMP) and should be manufactured in full compliance with Good Manufacturing Practice guidelines to ensure quality and reproducibility. Despite these demands, protocols are not uniform yet. MSCs may be derived from different starting materials (mainly BM, AT, or cord blood), and different media might be used for culturing the cells. MSCs require an approved and well-defined panel of assays to be released for clinical use. Because MSCs need to be cultured under Good Manufacturing Practice conditions, it is a costly therapy. Centralization of MSC production (with sharing of procedures and protocols) at specialized laboratories might reduce costs and promote standardization of the MSC product. Once the efficacy of MSC therapy has become clear, a cost-effect analysis is of major importance.
In renal transplantation, so far the published studies use BM-derived cells. The BM contains only a very low percentage (0.001%-0.01%) of primary MSCs, and therefore expansion of MSCs ex vivo is necessary. To culture and differentiate MSCs, an optimal combination of several factors, including cytokines, growth factors, and serum supplements is essential. Clinical trials so far have mainly used fetal calf serum–expanded cells; however, studies are currently investigating animal serum-free culture conditions.72 These animal-free additives include platelet lysate/platelet-rich plasma, cytokines and growth factors and human serum. The culture process takes approximately 4 to 6 weeks, which makes applications for acute indications a logistic challenge. Currently, more efficient methods for manufacturing of clinical MSCs is being developed, including bioreactor systems, which are specifically suited for MSC expansion.
Until now, no large-dose finding studies are performed, and in most studies, the dose and frequency of MSCs is chosen empiric. A potency assay which can guide us in the best dosage and frequency of administration would be of interest, but is a challenge to develop. Doses of MSC are chosen above what is considered the minimal effective dose and below a potential toxic dose. The studies in renal transplantation administered 0.5 × 106 to 5.0 × 106 MSCs per kilogram, however, in other studies, including GvHD higher amounts (0.4 to 9.0 × 106) were administered.73 The frequency of 2 infusions might be preferable compared with 1 infusion. A long-lasting response was hardly observed in patients with steroid-resistant GvHD who received 1 infusion, whereas most responders had 2 or more infusions.74 So far, intravenous infusion has been the route of administration for most clinical studies, including in renal transplantation and has been shown to be safe. MSCs can also be injected directly into the kidney or underneath the kidney capsula with the advantage of direct homing and no entrapment in the lungs. However, the development of embolisms could be one of the side effects.
It is of importance that an optimal concurrent immunosuppressive regimen is chosen in which drugs have no negative impact on MSC function and vice versa.75 Different in vitro studies75 and a few animal studies have elucidated the interaction of MSCs with concurrent immunosuppression.76-79 The combination of MSCs with mycophenolate mofetil (MMF) was shown to significantly prolong survival of allografts compared with MSCs alone.77 Of interest, it was also found that MSC monotherapy inhibited acute graft rejection and in combination with rapamycin induced donor-specific allograft tolerance. In tolerant recipients, MSCs migrated to the transplanted heart and various lymphoid organs, and a high frequency of Tol-DCs and CD4+CD25+Foxp3+ T cells was found.78 The results support the clinical applicability of MSCs in combination with a mammalian target of rapamycin inhibitor or MMF in clinical transplantation.
Autologous BM MSCs
A few studies have focused on the role of MSCs in the early induction phase in renal transplant recipients. In a pilot study of safety and clinical feasibility, autologous MSC infusion was shown to be feasible, allowing an increase of Treg cells in the peripheral blood and control of memory CD8+ T-cell function.80 In these patients, as seen in the experimental studies, timing of the infusion seemed of major importance, because MSC therapy early after transplantation negatively affected kidney graft function, which was not the case when MSCs were given before transplantation.81 In a trial among 159 patients undergoing renal transplantation, the use of autologous MSCs compared with anti-IL-2 receptor antibody induction therapy resulted in lower incidence of acute rejection, decreased risk of opportunistic infection, and better estimated renal function at 1 year.82 In a study by Mudrabettu et al,83 in living kidney transplantation, safety and feasibility was demonstrated in 4 patients who were treated with autologous BM MSCs 1 day before and 1 month after transplantation. In this study, no early or late kidney dysfunction or viral infections were reported.
In a phase 1 clinical study, we tested safety and feasibility of autologous MSC therapy in HLA-DR mismatched patients with subclinical rejection in their renal biopsy at 4 or 24 weeks after renal transplantation.84 MSCs were infused in 6 patients, and the therapy was feasible and well tolerated without adverse events related to the treatment itself. In addition, initial results suggested immunosuppression after MSC therapy. The MSC-treated patients demonstrated a profound reduction in donor-specific peripheral blood mononuclear cells (PBMC) proliferation 12 weeks after MSC infusion, whereas the response to third-party PBMCs was more variable. Three patients developed opportunistic viral infections, which was likely to be related to the MSC treatment. In 2 patients with allograft rejection, the infiltrate had disappeared after the MSC infusion (Figure 2). In a follow-up study of 70 renal transplant recipients, the hypothesis that MSCs in combination with everolimus can facilitate tacrolimus withdrawal and reduce fibrosis is currently tested.85
Allogeneic MSCs offer the advantage of immediate availability for clinical use which is of major importance in indications where treatment is needed without delay, such as allograft rejection or CNI toxicity. However, allogeneic MSCs could possibly elicit an antidonor immunoresponse, which may increase the incidence of rejection and impact the allograft survival in the long term. Within the transplant setting, there are conflicting preclinical results regarding allogeneic MSCs. Some preclinical studies showed an accelerated graft rejection after allogeneic MSC administration,86-89 whereas others showed that allogeneic MSCs promote graft survival.77,78,87 One clinical study investigated allogeneic donor-derived MSCs combined with low-dose tacrolimus in 6 renal transplant recipients. They could give a 50% reduction of tacrolimus dose in the MSC group; however, long-term data have not been reported, and it was not determined whether HLA-specific antibodies were produced.90
In another study, donor-derived BM MSCs combined with a sparing dose of tacrolimus (0.04-0.05 mg/kg per day) were administered to 16 de novo living-related kidney transplant recipients; 16 other patients received a standard dose of tacrolimus (0.07-0.08 mg/kg per day). The safety of MSC infusion, acute rejection, graft function, graft survival, and patient survival were evaluated over 24 months or longer after kidney transplantation. All patients survived and had stable renal function at the 24-month follow-up. The combination of low-dose tacrolimus and MSCs was as effective as standard-dose tacrolimus in maintaining graft survival at least 2 years after transplantation.91 A recent study has analyzed the immunosuppressive effects of MSC (1.5-3.0 × 106/kg) infusion, planned 3 to 5 days after transplantation in 5 patients, who were prospectively screened for anti-HLA antibodies at months 1, 3, and 6. So far, 2 patients developed anti-HLA antibodies against shared kidney/MSC mismatch, and 1 patient developed 2 specific antibodies against MSC at month 6. All antibodies were anti-HLA class I except for 1.92 In our current clinical study (the Neptune study), allogeneic MSCs are infused at a timepoint where immunosuppression is lowered and the kidney is at increased risk for developing immune-mediated injury.88 Primary endpoints of this study include allograft rejection and graft loss. Secondary end points, all measured before and after MSC infusions, include de novo HLA antibody development and extensive immune monitoring.
To minimize the chance of development of antidonor immune responses and thus rejection, selected allogeneic MSCs are given in which MSCs have no similarity with the HLA mismatches between the kidney graft and the recipient and the recipient should have no HLA antibodies directed to the MSCs. In addition, in another clinical study, third-party allogeneic MSC will be tested as a strategy to induce tolerance in kidney transplant recipients (clinical trials, NCT02565459). It is expected that these studies will provide insight into the optimal strategy and risks of allogeneic MSCs in the transplant setting.
Safety Aspects in Clinical Trials With MSCs
Because transplant recipients have already an increased risk of (opportunistic) infections and malignancies due to the concomitant immunotherapy, it is difficult to determine additional risks of MSC infusions. All clinical studies should be ethically approved and both serious adverse events as well as suspected unexpected serious adverse reactions should be carefully recorded and reported to the proper authorities. Careful assessment of both short- and long-term effects of MSC treatment is of major importance. For MSC treatment a scoring system, the so-called MiSOT-1 score was designed to evaluate safety of intravenous and intraportal infusion stem cell products after liver transplantations93 with the aim to identify very serious adverse events. There is no uniform score yet, which also identifies less severe adverse events and which can be used to assess safety in cell-based trials in renal transplantation.
Important potential risks in solid organ transplant recipients include direct toxicity related to MSC infusion, malignancies, risks for overimmunosuppression and immunogenicity, as also extensively reviewed elsewhere.45,94,95 To date, no direct toxicity related to the infusion itself or immediate adverse effects have been describedin the numerous clinical trials with MSCs for clinical indications.6 In humans, quite a large cohort of patients is exposed to MSC therapy, and no new malignancies have been reported so far. However, most clinical trials have a short follow-up period, and the inclusion of ill patients with poor prognosis could have biased the outcomes as well. In transplant recipients, it will be anyway a difficult task to link the development of malignancies to the use of MSC therapy, because there is already an increased risk for malignancies in this population. Because MSCs are particularly known for their immunosuppressive functions, a potential side effect of MSC therapy would be overimmunosuppression. In the study of Tan et al,82 a significant decrease in opportunistic infections was seen with MSC induction. However, the majority of patients in this study (151 of 154) had a cytomegalovirus (CMV) negative serological status, probably explaining the low incidence of CMV infections. In our phase I trial in renal transplant recipients, 3 of 6 patients developed opportunistic virus infections after MSC infusions that are typically associated with too much immunosuppression, including BK nephropathy and CMV infections.84 Clinical trials in the context of GvHD or hematopoietic stem cell transplantation also showed a trend to more infections after MSC therapy.96,97 Clearly, frequent and accurate monitoring of infectious complications remains essential in cell based therapy.
It is important to realize that many topics still need to be addressed. There is, for example, little known about the influencing factors, timing, dosage, route of administration, and frequency of MSC administration in renal recipients. These issues are challenging to study in a clinical setting because of the regulatory, logistic, and financial issues, where large numbers of included patients are mostly not available.
In the setting of renal transplantation, a number of different endpoints are used to measure clinical efficacy and to obtain mechanistic insight. The criterion standard clinical endpoint in renal transplantation is graft failure and death. However, substantial improvements in 1-year patient and kidney survival have shifted the endpoint to biopsy-proven acute rejection (BPAR), which is identified as a marker for chronic rejection and long-term graft survival. Declining rates of rejection have further shifted the endpoint to alternative surrogate markers, including renal function, histological findings, and immunological (bio)markers to measure efficacy and to provide mechanistic insight. Hence, it is important to evaluate short-term endpoint markers, which can predict potentially poorer long-term graft survival and BPAR. However, at the same time, this is a great challenge, because most surrogate endpoints are not adequate validated and only partly predict long-term graft survival.
According to the different indication of MSC therapy, the focus of the various endpoints might differ. For example, when assessing IRI, short-term endpoints, such as renal function and BPAR, will provide the most insight in efficacy. On the other hand, when assessing chronic allograft injury, the endpoints will be more focused on long-term outcomes and will include patient and graft survivals, histology, and renal function. Other endpoints, including immune monitoring and biomarker studies, will apply for all studies, although the focus on the markers chosen may vary between trials. Therefore, it is of importance to establish the rationale first, and the most relevant efficacy endpoints should then be determined accordingly.
Both gene expression profiling and detailed subset analysis of immune cells have identified potential fingerprints of immunoregulation. Interestingly, in these studies, not only T-cell subsets (CD4, CD8, effector, memory or Treg cells) but also other lineages, such as B cell, monocytes, and natural killer cells showed to be of importance. In the study of Perico et al,80 a progressive increase of the percentage of CD4+CD25highFoxP3+CD127− Treg cells and a marked inhibition of memory CD45 RO+RA−CD8+ T-cell expansion was observed posttransplant after MSC treatment. In the study by Mudrabettu et al,83 MSC infusion was also associated with expansion of Treg cells, and a reduced ex vivo proliferation of T cells was found in response to polyclonal stimuli. In our study, no differences in immune profiles were observed which might be due to a different timing of infusion and a short follow-up of immune monitoring.84 In addition, only a small number of patients were included in the different trials.
Recently, the ONE study consortium has developed an immune monitoring strategy to compare the efficacy of different cell therapies, including procedures for whole blood leukocyte subset profiling by flow cytometry. This standardized method, which includes 6 panels to analyze the immune response, facilitates fair and meaningful comparisons between trials, such as MSC therapy.98 Moreover, functional assays, such as the mixed lymphocyte reaction and measurements of different cytokines, should be performed to analyze donor-specific lymphocyte proliferation after MSC treatment. In general, sharing of procedures and protocols for safety and efficacy endpoints will allow for more reliable comparisons between the different clinical trials.
What Is the Future of MSCs in Transplantation
Preclinical and early clinical results of MSCs in solid organ transplantation seem promising. However, to further promote wider application of MSC in renal transplantation, it is of importance to increase the understanding of the mechanism of action, to develop tools to identify eligible patients, and to determine efficacy. Results from the currently enrolled studies are awaited in the near future and will provide us with additional information regarding the risks and benefits of MSCs. In addition, we currently face challenges with clinical implementation of cell therapy which include uncertainties of technological, financial, regulatory, and strategic nature. Identifying opportunities to address these challenges may accelerate the development and increase the impact of novel MSC therapy in the transplant setting.
1. Lamb KE, Lodhi S, Meier-Kriesche HU. Long-term renal allograft survival in the United States: a critical reappraisal. Am J Transplant
2. Pascual M, Theruvath T, Kawai T, et al. Strategies to improve long-term outcomes after renal transplantation. N Engl J Med
3. Rama I, Grinyo JM. Malignancy after renal transplantation: the role of immunosuppression. Nat Rev Nephrol
4. Kotton CN, Fishman JA. Viral infection in the renal transplant recipient. J Am Soc Nephrol
5. English K, French A, Wood KJ. Mesenchymal stromal cells: facilitators of successful transplantation? Cell Stem Cell
6. Tolar J, Le Blanc K, Keating A, et al. Concise review: hitting the right spot with mesenchymal stromal cells. Stem Cells
7. Franquesa M, Herrero E, Torras J, et al. Mesenchymal stem cell therapy prevents interstitial fibrosis and tubular atrophy in a rat kidney allograft model. Stem Cells Dev
8. Casiraghi F, Perico N, Cortinovis M, et al. Mesenchymal stromal cells in renal transplantation: opportunities and challenges. Nat Rev Nephrol
9. Bank JR, Rabelink TJ, de Fijter JW, et al. Safety and efficacy endpoints for mesenchymal stromal cell therapy in renal transplant recipients. J Immunol Res
10. Chabannes D, Hill M, Merieau E, et al. A role for heme oxygenase-1 in the immunosuppressive effect of adult rat and human mesenchymal stem cells. Blood
11. Zhou HP, Yi DH, Yu SQ, et al. Administration of donor-derived mesenchymal stem cells can prolong the survival of rat cardiac allograft. Transplant Proc
12. Bartholomew A, Sturgeon C, Siatskas M, et al. Mesenchymal stem cells suppress lymphocyte proliferation in vitro and prolong skin graft survival in vivo. Exp Hematol
13. Casiraghi F, Azzollini N, Cassis P, et al. Pretransplant infusion of mesenchymal stem cells prolongs the survival of a semiallogeneic heart transplant through the generation of regulatory T cells. J Immunol
14. Kiel MJ, Morrison SJ. Uncertainty in the niches that maintain haematopoietic stem cells. Nat Rev Immunol
15. Crisan M, Corselli M, Chen WC, et al. Perivascular cells for regenerative medicine. J Cell Mol Med
16. Crisan M, Yap S, Casteilla L, et al. A perivascular origin for mesenchymal stem cells in multiple human organs. Cell Stem Cell
17. da Silva Meirelles L, Chagastelles PC, Nardi NB. Mesenchymal stem cells reside in virtually all post-natal organs and tissues. J Cell Sci
. 2006;119(Pt 11):2204–2213.
18. Leuning DG, Reinders ME, Li J, et al. Clinical-grade isolated human kidney perivascular stromal cells as an organotypic cell source for kidney regenerative medicine. Stem Cells Transl Med
19. Dominici M, Le Blanc K, Mueller I, et al. Minimal criteria for defining multipotent mesenchymal stromal cells. The International Society for Cellular Therapy position statement. Cytotherapy
20. Pittenger MF, Mackay AM, Beck SC, et al. Multilineage potential of adult human mesenchymal stem cells. Science
21. Aggarwal S, Pittenger MF. Human mesenchymal stem cells modulate allogeneic immune cell responses. Blood
22. Krampera M, Glennie S, Dyson J, et al. Bone marrow mesenchymal stem cells inhibit the response of naive and memory antigen-specific T cells to their cognate peptide. Blood
23. Mannon RB. Macrophages: contributors to allograft dysfunction, repair, or innocent bystanders? Curr Opin Organ Transplant
24. Kim J, Hematti P. Mesenchymal stem cell-educated macrophages: a novel type of alternatively activated macrophages. Exp Hematol
25. Franquesa M, Hoogduijn MJ, Bestard O, et al. Immunomodulatory effect of mesenchymal stem cells on B cells. Front Immunol
26. Di Ianni M, Del Papa B, De Ioanni M, et al. Mesenchymal cells recruit and regulate T regulatory cells. Exp Hematol
27. Nauta AJ, Fibbe WE. Immunomodulatory properties of mesenchymal stromal cells. Blood
28. Di Nicola M, Carlo-Stella C, Magni M, et al. Human bone marrow stromal cells suppress T-lymphocyte proliferation induced by cellular or nonspecific mitogenic stimuli. Blood
29. Tse WT, Pendleton JD, Beyer WM, et al. Suppression of allogeneic T-cell proliferation by human marrow stromal cells: implications in transplantation. Transplantation
30. Le Blanc K, Tammik L, Sundberg B, et al. Mesenchymal stem cells inhibit and stimulate mixed lymphocyte cultures and mitogenic responses independently of the major histocompatibility complex. Scand J Immunol
31. Glennie S, Soeiro I, Dyson PJ, et al. Bone marrow mesenchymal stem cells induce division arrest anergy of activated T cells. Blood
32. Benvenuto F, Ferrari S, Gerdoni E, et al. Human mesenchymal stem cells promote survival of T cells in a quiescent state. Stem Cells
33. Duffy MM, Ritter T, Ceredig R, et al. Mesenchymal stem cell effects on T-cell effector pathways. Stem Cell Res Ther
34. Franquesa M, Hoogduijn MJ, Baan CC. The impact of mesenchymal stem cell therapy in transplant rejection and tolerance. Curr Opin Organ Transplant
35. Spaggiari GM, Capobianco A, Abdelrazik H, et al. Mesenchymal stem cells inhibit natural killer-cell proliferation, cytotoxicity, and cytokine production: role of indoleamine 2,3-dioxygenase and prostaglandin E2. Blood
36. Spaggiari GM, Capobianco A, Becchetti S, et al. Mesenchymal stem cell-natural killer cell interactions: evidence that activated NK cells are capable of killing MSCs, whereas MSCs can inhibit IL-2-induced NK-cell proliferation. Blood
37. Sotiropoulou PA, Perez SA, Gritzapis AD, et al. Interactions between human mesenchymal stem cells and natural killer cells. Stem Cells
38. Jiang XX, Zhang Y, Liu B, et al. Human mesenchymal stem cells inhibit differentiation and function of monocyte-derived dendritic cells. Blood
39. Nauta AJ, Kruisselbrink AB, Lurvink E, et al. Mesenchymal stem cells inhibit generation and function of both CD34 + −derived and monocyte-derived dendritic cells. J Immunol
40. Zhang W, Ge W, Li C, et al. Effects of mesenchymal stem cells on differentiation, maturation, and function of human monocyte-derived dendritic cells. Stem Cells Dev
41. Schena F, Gambini C, Gregorio A, et al. Interferon-γ-dependent inhibition of B cell activation by bone marrow-derived mesenchymal stem cells in a murine model of systemic lupus erythematosus. Arthritis Rheum
42. Franquesa M, Mensah FK, Huizinga R, et al. Human adipose tissue-derived mesenchymal stem cells abrogate plasmablast formation and induce regulatory B cells independently of T helper cells. Stem Cells
43. Salem HK, Thiemermann C. Mesenchymal stromal cells: current understanding and clinical status. Stem Cells
44. Hoogduijn MJ, Popp FC, Grohnert A, et al. Advancement of mesenchymal stem cell therapy in solid organ transplantation (MISOT). Transplantation
45. Franquesa M, Hoogduijn MJ, Reinders ME, et al. Mesenchymal stem cells in solid organ Transplantation (MiSOT) fourth meeting: lessons learned from first clinical trials. Transplantation
46. Reinders ME, Fibbe WE, Rabelink TJ. Multipotent mesenchymal stromal cell therapy in renal disease and kidney transplantation. Nephrol Dial Transplant
47. Reinders ME, Rabelink TJ, de Fijter JW. The role of mesenchymal stromal cells in chronic transplant rejection after solid organ transplantation. Curr Opin Organ Transplant
48. Griffin MD, Elliman SJ, Cahill E, et al. Concise review: adult mesenchymal stromal cell therapy for inflammatory diseases: how well are we joining the dots? Stem Cells
49. Wang Y, Zhang A, Ye Z, et al. Bone marrow-derived mesenchymal stem cells inhibit acute rejection of rat liver allografts in association with regulatory T-cell expansion. Transplant Proc
50. Casiraghi F, Azzollini N, Todeschini M, et al. Localization of mesenchymal stromal cells dictates their immune or proinflammatory effects in kidney transplantation. Am J Transplant
51. Nemeth K, Leelahavanichkul A, Yuen PS, et al. Bone marrow stromal cells attenuate sepsis via prostaglandin E(2)-dependent reprogramming of host macrophages to increase their interleukin-10 production. Nat Med
52. Pevsner-Fischer M, Morad V, Cohen-Sfady M, et al. Toll-like receptors and their ligands control mesenchymal stem cell functions. Blood
53. Roemeling-van Rhijn M, Khairoun M, Korevaar SS, et al. Human bone marrow- and adipose tissue-derived mesenchymal stromal cells are immunosuppressive in vitro and in a humanized allograft rejection model. J Stem Cell Res Ther
. 2014;(Suppl 6):20780.
54. Roemeling-van Rhijn M, Reinders ME, Franquesa M, et al. Human allogeneic bone marrow and adipose tissue derived mesenchymal stromal cells induce CD8+ cytotoxic T cell reactivity. J Stem Cell Res Ther
. 2014;3(Suppl 6):004.
55. English K, Barry FP, Field-Corbett CP, et al. IFN-gamma and TNF-alpha differentially regulate immunomodulation by murine mesenchymal stem cells. Immunol Lett
56. Bernardo ME, Fibbe WE. Mesenchymal stromal cells: sensors and switchers of inflammation. Cell Stem Cell
57. Chan JL, Tang KC, Patel AP, et al. Antigen-presenting property of mesenchymal stem cells occurs during a narrow window at low levels of interferon-gamma. Blood
58. Stagg J. Immune regulation by mesenchymal stem cells: two sides to the coin. Tissue Antigens
59. Prodromidi EI, Poulsom R, Jeffery R, et al. Bone marrow-derived cells contribute to podocyte regeneration and amelioration of renal disease in a mouse model of Alport syndrome. Stem Cells
60. Ohnishi S, Sumiyoshi H, Kitamura S, et al. Mesenchymal stem cells attenuate cardiac fibroblast proliferation and collagen synthesis through paracrine actions. FEBS Lett
61. Reinders ME, de Fijter JW, Rabelink TJ. Mesenchymal stromal cells to prevent fibrosis in kidney transplantation. Curr Opin Organ Transplant
62. Souidi N, Stolk M, Seifert M. Ischemia-reperfusion injury: beneficial effects of mesenchymal stromal cells. Curr Opin Organ Transplant
63. Ninichuk V, Gross O, Segerer S, et al. Multipotent mesenchymal stem cells reduce interstitial fibrosis but do not delay progression of chronic kidney disease in collagen4A3-deficient mice. Kidney Int
64. Li L, Zhang Y, Li Y, et al. Mesenchymal stem cell transplantation attenuates cardiac fibrosis associated with isoproterenol-induced global heart failure. Transpl Int
65. Humphreys BD, Lin SL, Kobayashi A, et al. Fate tracing reveals the pericyte and not epithelial origin of myofibroblasts in kidney fibrosis. Am J Pathol
66. Babu AN, Murakawa T, Thurman JM, et al. Microvascular destruction identifies murine allografts that cannot be rescued from airway fibrosis. J Clin Invest
67. Contreras AG, Briscoe DM. Every allograft needs a silver lining. J Clin Invest
68. Khairoun M, van der Pol P, de Vries DK, et al. Renal ischemia/reperfusion induces a dysbalance of angiopoietins, accompanied by proliferation of pericytes and fibrosis. Am J Physiol Renal Physiol
69. Chen J, Park HC, Addabbo F, et al. Kidney-derived mesenchymal stem cells contribute to vasculogenesis, angiogenesis and endothelial repair. Kidney Int
70. Zacharek A, Chen J, Cui X, et al. Angiopoietin1/Tie2 and VEGF/Flk1 induced by MSC treatment amplifies angiogenesis and vascular stabilization after stroke. J Cereb Blood Flow Metab
71. Tomasoni S, Longaretti L, Rota C, et al. Transfer of growth factor receptor mRNA via exosomes unravels the regenerative effect of mesenchymal stem cells. Stem Cells Dev
72. Schallmoser K, Bartmann C, Rohde E, et al. Human platelet lysate can replace fetal bovine serum for clinical-scale expansion of functional mesenchymal stromal cells. Transfusion
73. Le Blanc K, Frassoni F, Ball L, et al. Mesenchymal stem cells for treatment of steroid-resistant, severe, acute graft-versus-host disease: a phase II study. Lancet
74. Ball LM, Bernardo ME, Roelofs H, et al. Multiple infusions of mesenchymal stromal cells induce sustained remission in children with steroid-refractory, grade III-IV acute graft-versus-host disease. Br J Haematol
75. Hoogduijn MJ, Crop MJ, Korevaar SS, et al. Susceptibility of human mesenchymal stem cells to tacrolimus, mycophenolic acid, and rapamycin. Transplantation
76. Eggenhofer E, Renner P, Soeder Y, et al. Features of synergism between mesenchymal stem cells and immunosuppressive drugs in a murine heart transplantation model. Transpl Immunol
77. Eggenhofer E, Steinmann JF, Renner P, et al. Mesenchymal stem cells together with mycophenolate mofetil inhibit antigen presenting cell and T cell infiltration into allogeneic heart grafts. Transpl Immunol
78. Ge W, Jiang J, Baroja ML, et al. Infusion of mesenchymal stem cells and rapamycin synergize to attenuate alloimmune responses and promote cardiac allograft tolerance. Am J Transplant
79. Zhang W, Qin C, Zhou ZM. Mesenchymal stem cells modulate immune responses combined with cyclosporine in a rat renal transplantation model. Transplant Proc
80. Perico N, Casiraghi F, Introna M, et al. Autologous mesenchymal stromal cells and kidney transplantation: a pilot study of safety and clinical feasibility. Clin J Am Soc Nephrol
81. Perico N, Casiraghi F, Gotti E, et al. Mesenchymal stromal cells and kidney transplantation: pretransplant infusion protects from graft dysfunction while fostering immunoregulation. Transpl Int
82. Tan J, Wu W, Xu X, et al. Induction therapy with autologous mesenchymal stem cells in living-related kidney transplants: a randomized controlled trial. JAMA
83. Mudrabettu C, Kumar V, Rakha A, et al. Safety and efficacy of autologous mesenchymal stromal cells transplantation in patients undergoing living donor kidney transplantation: a pilot study. Nephrology (Carlton)
84. Reinders ME, de Fijter JW, Roelofs H, et al. Autologous bone marrow-derived mesenchymal stromal cells for the treatment of allograft rejection after renal transplantation: results of a phase I study. Stem Cells Transl Med
85. Reinders ME, Bank JR, Dreyer GJ, et al. Autologous bone marrow derived mesenchymal stromal cell therapy in combination with everolimus to preserve renal structure and function in renal transplant recipients. J Transl Med
86. Inoue S, Popp FC, Koehl GE, et al. Immunomodulatory effects of mesenchymal stem cells in a rat organ transplant model. Transplantation
87. Griffin MD, Ryan AE, Alagesan S, et al. Anti-donor immune responses elicited by allogeneic mesenchymal stem cells: what have we learned so far? Immunol Cell Biol
88. Reinders ME, Dreyer GJ, Bank JR, et al. Safety of allogeneic bone marrow derived mesenchymal stromal cell therapy in renal transplant recipients: the neptune study. J Transl Med
89. English K, Wood KJ. Mesenchymal stromal cells in transplantation rejection and tolerance. Cold Spring Harb Perspect Med
90. Peng Y, Ke M, Xu L, et al. Donor-derived mesenchymal stem cells combined with low-dose tacrolimus prevent acute rejection after renal transplantation: a clinical pilot study. Transplantation
91. Pan GH, Chen Z, Xu L, et al. Low-dose tacrolimus combined with donor-derived mesenchymal stem cells after renal transplantation: a prospective, non-randomized study. Oncotarget
92. Rowart P, Erpicum P, Detry O, et al. Mesenchymal stromal cell therapy in ischemia/reperfusion injury. J Immunol Res
93. Dillmann J, Popp FC, Fillenberg B, et al. Treatment-emergent adverse events after infusion of adherent stem cells: the MiSOT-I score for solid organ transplantation. Trials
94. Reinders ME, Leuning DG, de Fijter JW, et al. Mesenchymal stromal cell therapy for cardio renal disorders. Curr Pharm Des
95. Casiraghi F, Remuzzi G, Abbate M, et al. Multipotent mesenchymal stromal cell therapy and risk of malignancies. Stem Cell Rev
96. von Bahr L, Batsis I, Moll G, et al. Analysis of tissues following mesenchymal stromal cell therapy in humans indicates limited long-term engraftment and no ectopic tissue formation. Stem Cells
97. Moermans C, Lechanteur C, Baudoux E, et al. Impact of cotransplantation of mesenchymal stem cells on lung function after unrelated allogeneic hematopoietic stem cell transplantation following non-myeloablative conditioning. Transplantation
98. Streitz M, Miloud T, Kapinsky M, et al. Standardization of whole blood immune phenotype monitoring for clinical trials: panels and methods from the ONE study. Transplant Res