**4. Conclusion**

204 Liver Regeneration

regarding whether reduction in HLA-I expression by HCMV US proteins renders infected cells more susceptible to NK killing [217, 218], we next examined whether forced expression of US6 or US11 predisposed MSC to NK lysis. To our surprise, expression of US6 or US11 protein did not increase the ability of NK cells to target MSC. Moreover, expression of US11 actually protected MSC from NK cytotoxic effects [219]. Based on these promising *in vitro* results, we transplanted MSC-US6, MSC-US11 and MSC-E (control cell line transduced with the empty vector) into fetal sheep recipients by IP injection. Tissues were collected at 60 days posttransplant and analyzed for engraftment and hepatocytic differentiation of the transplanted cells. Using both quantitative PCR and immunofluorescence, we determined that expression of either the US6 or the US11 HCMV protein on the transplanted MSC led to significantly enhanced levels of liver engraftment compared to those seen with MSC-E. However, although the increased levels of engrafted cells translated into increased levels of cells expressing HEPAR-I, many of these did not express albumin or Ov-6 [220]. This suggests that the hepatocytes generated by transplantation of these genetically modified cells were of a broad range of differentiation, not immature and not completely mature at the time of tissue collection. These results clearly show that by enhancing the immuno-evasive MSC properties, the levels of engraftment and hepatocyte generation can be significantly increased to provide a more successful regenerative therapy, even in the context of a fetal recipient whose immune

Despite the promising results obtained in animal models, the use of MSC to treat liver diseases is still in its infancy, and very few clinical trials using these cells have been performed. Several concerns still exist over this therapy regarding the best administration route, and the possibility of cellular fusion, with the inherent risks that may accompany the presence of hepatocytes that are potentially genetically unstable within the environment of a diseased liver. In 2007, Mohamadnejad *et al*. reported that infusion of BM-derived MSC via a peripheral vein was found to be well tolerated and to have a definite therapeutic effect, since the quality of life of all 4 transplanted patients was improved by 12 months post-infusion, and the model for end-stage liver disease (MELD) scores for 2 of the 4 patients improved

Another 8 patients with end-stage liver disease due to different etiologies received 30-50 million BM-derived MSC injected into a peripheral vein or the portal vein. Treatment was well tolerated by all patients, and liver function improved as verified by MELD scores. However, both of these trials lacked a control arm, and the number of patients was very small. Another study examining the safety and efficacy of umbilical cord-derived MSC (UC-MSC) in 45 patients with decompensated liver cirrhosis demonstrated that both patients that received UC-MSC and those in the control arm that received saline suffered no significant side-effects or complications. However, in patients treated with UC-MSC there was a significant reduction in the volume of ascites when compared with control. Also, UC-MSC therapy significantly improved liver function, as evidenced by the increase of serum albumin levels, decrease in total serum bilirubin levels, and decrease in the sodium model for end-stage liver disease scores [151]. Forty patients with end-stage liver failure due to chronic hepatitis C were selected for a controlled study in which 10 received autologous

system is presumed to be largely immature.

significantly during the course of the trial.

**3. Clinical trials** 

Presently, chronic liver disease constitutes one of the leading worldwide causes of death. It can be triggered by a wide array of insults, including, but not limited to hepatitis infection, alcohol consumption, exposure to toxic chemicals, and congenital defects. Currently, the only definitive treatment for chronic liver disease is whole or partial liver transplantation. Due to the limited availability of donor livers and the severe morbidity and mortality associated with this treatment, there is an urgent need for new therapeutic approaches. While hepatocyte transplantation represents an option, the limited availability of donor livers and the inability to maintain and expand hepatocytes in culture precludes this option from becoming a clinically viable treatment option. MSC offer several advantages such as: extensive expansion in vitro, multipotent differentiative capacity, the ability to selectively and efficiently migrate to sites of injury following systemic infusion, their potent immunomodulatory and trophic properties, and the ease with which they can be genetically modified, making it possible to use autologous cells, even in the case of underlying genetic disease. MSC can be isolated from a wide range of human tissues and, despite subtle differences, they all share the same beneficial characteristics, making MSC transplantation a promising approach for liver repair/regeneration. However, in order to maximize MSC capabilities for improving/recovering the liver mass and/or function depending on the particular disease/injury, several issues must still be resolved: selection of the most therapeutic MSC source; standardization of the protocols for unequivocally isolating the desired MSC population from each tissue; more complete *in vitro* and *in vivo* characterization of the differentiative potential of the cells; and further optimization of the route, cell dose, timing, and degree of desired MSC differentiation. Once these questions have been answered, the knowledge gained during *in vitro* and *in vivo* studies in animal models could be safely and efficiently translated into humans to develop an appropriate and successful therapy for chronic liver disease.

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#### **5. Acknowledgement**

This work was supported by National Institutes of Health (Bethesda, MD, USA) grants HL73737 and HL97623.

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**12** 

*India* 

**Cell Based Therapy for Chronic Liver** 

Chaturvedula Tripura1, Aleem Khan2 and Gopal Pande1,\* *1CSIR- Centre for Cellular and Molecular Biology, Hyderabad, 2Centre for Liver Research and Diagnostics, Deccan Medical College,* 

**in Restoration of the Liver Cell Functions** 

Liver is the largest organ in the human body and it functions like a metabolic factory. Disruption of its anatomical structure, which is often caused by excessive fibrosis of the extracellular matrix (ECM), when left unattended, can lead to cirrhosis of the liver and cause permanent and irreversible damage to its organization and function, with fatal consequences. Liver cirrhosis, which is generally the end result of chronic liver disease (CLD), can be caused due to many etiological reasons including (a) long term infections with hepatitis B and C viruses, (b) uncontrolled alcohol abuse, (c) excessive exposure to metabolic products of metals like iron and copper (d) autoimmune inflammation of the liver (e) nonalcoholic fatty liver disease (NAFLD) and (f) nonalcoholic steatohepatitis (NASH) (reviewed in [1]). Histo-pathologically, a hallmark of liver cirrhosis is the abnormal production and storage of collagen molecules in the ECM, formation of a scar tissue that replaces normal parenchyma and blockage of the portal flow of blood through the organ, thus affecting normal hepatocellular activity and ultimately total loss of liver functions [2, 3]. Cirrhosis of the liver in early stages is largely asymptomatic, therefore remains undetected by physical examination and other available tests. Diagnosis of fibrosis at early stages and prevention of its progression to cirrhosis is a very important factor in the management of the disease. Among the different options available for treatment, this review would focus on cell based therapy for liver cirrhosis with a special attention on the challenges and procedures of using human fetal liver cells. Methods to improve the clinical application of cell and tissue imaging of liver in the management of cirrhosis would also be

The established choices of treatment for cirrhosis are very limited and in most cases withdrawl of the underlying causative agent is used as the first line of treatment. Anti-viral

**1. Introduction** 

discussed, briefly.

\* Corresponding Author

**2. Treatment options for liver cirrhosis** 

**Disease: Role of Fetal Liver Cells** 

*Owaisi Hospital, Kanchan Bagh, Hyderabad,* 

