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Journal of Cellular Immunotherapy 2 (2016) 3e20
http://www.elsevier.com/locate/jocit

Mesenchymal stem cells: Immunomodulatory capability and clinical

potential in immune diseases
Qinjun Zhao a, Hongying Ren b, Zhongchao Han a,b,*
a
National Engineering Research Center of Cell Products/AmCellgene Co. Ltd, Tianjin, China
b
State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking
Union of Medical College, Tianjin, China
Received 13 August 2014; revised 29 November 2014; accepted 15 December 2014
Available online 24 February 2015

Abstract

Mesenchymal stem cells (MSCs) represent a heterogenous population of adult, fibroblast-like multi-potent cells. MSCs have drawn much
attention during the last decade in the field of regenerative medicine, mainly due to their capacity to differentiate into specific cell types,
abundant production of soluble growth factors and cytokines, and hematopoiesis supporting properties. In addition, MSCs can migrate to the
sites of inflammation and hold potent of immunomodulatory and anti-inflammatory effects through cell and cell interactions between MSCs and
lymphocytes or production of soluble factors. Therefore, the application of MSCs in many disease situations is full of possibilities for future
clinical treatment. Phase III clinical trials have been run using MSCs for treatment of Graft versus Host Disease (GVHD), and MSCs product
approval has been achieved for pediatric GVHD treatment in Canada and New Zealand (Prochymal®; Osiris Therapeutics). In addition, hundreds
of clinical trials are being run using MSCs for treatment of several immune mediated diseases, including GVHD, aplastic anemia (AA), Crohn's
disease (CD), rheumatoid arthritis (RA), and multiple sclerosis (MS). In this review we mainly focus on immunomodulation potential of MSCs
and promising therapeutic application of MSCs in immune mediated diseases. Furthermore, we emphasize that biological effectiveness of MSCs
will be one of most important standards to determine the dose of MSCs infusion.
Copyright © 2015, Shanghai Hengrun Biomedical Technology Research Institute. Publishing Services By Elsevier B.V. This is an open access
article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Keywords: MSCs; Immunomodulatory; Cell infusion; Biological effectiveness

1. Introduction
Friedenstein was the first person to describe the isolation of
clonogenic, proliferating fibroblastic MSCs from rat bone
marrow (BM). And they showed that colony-forming unit fi-
broblasts (CFU-Fs) derived stromal cells can serve as feeder
layers for the culture of heamatopoietic stem cells (HSCs) and
can differentiate into osteocytes, chondricytes and adipocytes
[1,2]. Besides BM, MSCs can also be isolated from adipose
* Corresponding author. Institute of Hematology Chinese Academy of
Medical Sciences and Peking Union of Medical College, 288 Nan Jing Road,
300020, Tianjin, China. Fax: þ86 22 27317273.
E-mail address: hanzhongchao@hotmail.com (Z. Han).
Peer review under responsibility of Shanghai Hengrun Biomedical Tech-
nology Research Institute.
tissues [3], fetal liver [4], cord blood and mobilized peripheral
blood [5], fetal lung [6], placenta [7], umbilical cord [8,9],
dental pulp [10], synovial membrane [11], periodontal liga-
ment [12], endometrium [13], trabecular and compact bone
[14,15] (Fig. 1).
Increased evidences have shown that under appropriate
culture conditions, MSCs are capable of differentiating into
mesodermal, endodermal and even ectodermal cells. MSCs are
capable of secreting growth factors and immunoprotective
cytokines which have been used in the field of cell and organ
transplantation. Most importantly, MSCs are safe, do not form
teratoma, and can be used for tissue regeneration and repair
[16,17]. And easy isolation, large quantity expansion and
multipotential differentiation of MSCs make them ideal
candidate for stem cell-based therapy and their application as

http://dx.doi.org/10.1016/j.jocit.2014.12.001
2352-1775/Copyright © 2015, Shanghai Hengrun Biomedical Technology Research Institute. Publishing Services By Elsevier B.V. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
4 Q. Zhao et al. / Journal of Cellular Immunotherapy 2 (2016) 3e20

Fig. 1. The tissue source and multipotential differentiation of MSCs. MSCs are multipotent cells that can be isolated from various human tissues including BM,
adipose tissues, fetal liver, mobilized peripheral blood, cord blood, fetal lung, placenta， umbilical cord, dental pulp, synovial membrane, periodontal ligament,
endometrium, trabecular and compact bone. MSCs have the capacity to differentiate into mesenchymal tissues both in vitro and in vivo, including osteoblast,
condrocyte, adipocyte, tendon, skeletal muscle cells, cardiomyocyte and haematopoietic supporting stroma cells. In addition, MSCs can differentiate into tissues of
ectodermal, including skin, neurons. Furthermore, MSCs can differentiate into tissues of endodermal including lung, hepatocytes, renal, and pancreatic b-cells,
endothelial cells.

gene carriers. Another intriguing feature of MSCs is that they
are able to escape immune recognition and inhibit immune
responses. Therefore, MSCs will be a very promising tool for
immunomodulatory cell therapy in immune mediated diseases.
At the time of writing, there are currently 423 clinical trials
using MSCs registered at clinical-trials.gov. The clinical trials
have been run for tissue repair including cardiac ischemia,
limb ischemia, amyotrophic lateral sclerosis, diabetes,
ischemic stroke, osteoarthritis, liver cirrhosis, and liver failure
and so on. More clinical trials have been run for immune
mediated diseases including GVHD, CD, MS, respiratory
distress syndrome, AA, and RA (www.clinicaltrials.gov). In
fact, immune mediated diseases are actually the largest kind of
diseases to be clinically studied now. In addition, the biolog-
ical effectiveness maybe one of important factors to determine
the cell dose for infusion. The biological effectiveness always
different in different tissue derived MSCs or different MSCs
subpopulation. In other words, the treatment of various disease
maybe will need different MSCs subpopulation and MSCs
dose. And, for the same disease, MSCs dose is also variable
for different tissue derived MSCs.
2. Definition of MSCs
Pittenger et al. firstly defined MSCs by their ability to
proliferate in culture with an attached fibroblast-like
morphology, by the presence of a consistent set of cell sur-
face protein markers, and by their extensive consistent dif-
ferentiation to multiple lineages mesenchymal tissue under
certain controlled in vitro conditions [18]. However, to date
because there is no specific or unique cell surface marker, so
the definition of MSCs was always controversy. Therefore,
currently MSCs have been defined by using a combination of
cell surface phenotypic protein markers, plastic adherent
fibroblast-like growth and functional properties. It is generally
agreed that adult human MSCs express Stro-1 [19], CD105
(SH2) [20], CD73 (SH3/4) [21], CD44, CD71 (transferring
receptor), CD90 (THY1), the ganglioside GD2 [22,23] and
CD271 (low-affinity nerve growth factor receptor), as well as
some cell adhesion molecules including intercellular adhesion
molecule-1,-2 (ICAM-1,-2), integrins (a1, a2, a3, a5, a6, aV,
b1, b3, b4) [24], activated leukocyte-cell adhesion molecule
(ALCAM), lymphocyte function-associated antigen 3 (LFA-
 Q. Zhao et al. / Journal of Cellular Immunotherapy 2 (2016) 3e20
3), vascular cell adhesion molecule-1 (VCAM-1), and CD72
[18,25]. They also express human leukocyte antigen (HLA)
class I but not class II molecules on cell surface [26,27].
Additionally, MSCs lack the expression of typical hemato-
poietic antigens CD11a, CD14, CD31, CD34 and CD45
[9,18], Or co-stimulatory molecules CD40, CD80, and CD86
[28,29]. The International Society for Cellular Therapy (ISCT)
has offered several minimal criteria to identify MSCs which
are listed as: 1) Plastic adherent fibroblast-like growth while
maintaining these cells in standard conditions. 2) Expression
of CD73, CD90 and CD105 markers in at least 95% of cell
population and lack expression of CD34, CD45, CD14,
CD11b, CD19 or CD79a and HLA-II markers as measured by
flow cytometry. 3) Differentiation capability into adipogenic,
osteogenic and chondrogenic lineage cells in vitro [30]. Some
markers, including GD2, nestin and CD271, have been used to
investigate the function of certain tissue derived MSCs or
different MSCs subpopulation [22,23,31,32]. For example,
GD2þ umbilical cord derived MSCs are a subpopulation of
MSCs with feature of primitive precursor cells and most
multipotential cells [23]. And CD106þ placenta derived
MSCs are the more mature and biological functional MSCs
with feature of stronger immunomodulatory capability [33]
and angiogenic potential (not published).
Numbers studies also showed that the MSCs have the ca-
pacity to differentiate into multiple mesenchymal tissues both
in vitro and in vivo, including osteoblast [25,34], condrocyte
[35,36], adipocyte [37,38], tendon [39,40], skeletal muscle
cells [39], cardiomyocyte [41,42] and hematopoietic support-
ing stroma cells [43]. In addition, MSCs also have capability
for differentiating into tissues of ectodermal, including skin
[44], neurons [45]. Furthermore, MSCs can differentiate into
tissues of endodermal including lung [46,47], hepatocytes
[27,48], renal [49,50], and pancreatic b-cells [51,52], endo-
thelial cells [53,54] (Fig. 1). Actually, the tissue repair capa-
bility of MSCs is mainly base on their multi-lineage
differentiation potential.
3. The safety of MSCs in clinical application
MSCs have been used in several approaches for regenera-
tive cell therapy, as well as in the perspective of modulating
immune response. Therefore, the biosafety features of MSCs
need to be carefully investigated to exclude the occurrence of
functional or genetic alterations before their release for clin-
ical use. Bernardo et al. show that human BM-derived MSCs
can be cultured long-term in vitro, without losing their
morphologic, phenotypical, and functional characteristics.
Moreover, MSCs propagated in culture continuously for up to
44 weeks maintained a normal karyotype [55]. Meza-zepeda
et al. also report that adipose derived MSCs do not bypass
senescence even after two months of post-senescence culture.
MSCs show no evidence of transformation in vitro on the basis
of re-entry into the cell cycle, mitotic index, acquisition of a
rounded phenotype and loss of anchorage-dependence [56]. In
addition, Poloni et al. show that human MSCs from BM,
chorionic villi and amniotic fluid are not susceptible to
5
transformation after extensive in vitro expansion [57]. Chen
et al. reported that human umbilical cord MSCs (hUC-MSCs)
maintain their biological character and function after long-
term in vitro culturing (P15). Since hUC-MSCs can be
safely expanded in vitro and are not susceptible to malignant
transformation in serum-free medium [58]. Therefore, basi-
cally MSCs can maintain a stable immunophenotype and
chromosome structure and will not be malignant trans-
formation after long term in vitro culture expansion.
At the same time, increased evidences show that MSCs is
also safe in vivo normal animal or animal disease model cell
infusion therapy. Wang et al. evaluate the overall toxicology of
hUC-MSCs in cynomolgus monkeys with repeated adminis-
trations and show that transplantation of hUC-MSCs did not
affect the general health of cynomolgus monkeys [16]. Feng
et al. evaluated the safety of human MSCs transplanted in
cerebrum of Macaca fascicularis. Their results show that the
transplantation of human MSCs in monkeys did not affect total
IgM, IgG, CD3, CD4, or CD8 values. And transplantation of
hMSCs to the cerebrum represents a safe alternative for clin-
ical application of neurological disorders [59]. Francois et al.
infused intravenously human MSCs to NOD/SCID mice with
total body irradiation or local abdominal or leg irradiation and
investigated the long term side-effect. Their results demon-
strated that no tissue abnormality or abnormal human MSCs
proliferation was observed at 120 days after irradiation.
Meanwhile, These results showed that MSCs injection is safe
and efficient for long-term treatment of severe complications
after radiotherapy for patients refractory to conventional
treatments [60].
Finally, human MSCs is also safe according to numerous
clinical trial reports. Shi et al. assessed the safety and initial
efficacy of UC-MSCs transfusions for acute-on-chronic liver
failure (ACLF) patients associated with hepatitis B virus
(HBV) infection. Their results suggest that UC-MSCs trans-
fusions are safe in the clinic and may serve as a novel thera-
peutic approach for HBV-associated ACLF patients [61].
Wang et al. assess the safety and efficacy of human UC-MSCs
in the treatment of rheumatoid arthritis (RA). Their results
show that no serious adverse effects were observed during or
after infusion. Furthermore, the treatment of UC-MSCs
induced a significant remission of disease according to the
28-joint disease activity score [62]. Rodrigo et al. evaluates the
safety and feasibility of intramyocardial MSCs injection in
nine patients, shortly after AMI during short-term and 5-year
follow-up. Their results suggest that intramyocardial injec-
tion of MSCs in patients shortly after AMI is feasible and safe
up to 5-year follow-up [63]. Gupta et al. conducted a pro-
spective double blind randomized placebo controlled multi-
center study to determine the safety of BM-MSCs in pa-
tients with critical limb ischemia. Their results show that BM-
MSCs are also safe when injected intramuscularly at a dose of
2 million cells/kg body weight [64]. In addition, Lee et al.
performed a randomized pilot study to investigate the safety
and efficacy of MSCs in patients with AMI. Their results
showed that there was no treatment-related toxicity during
intracoronary administration of MSCs. Meanwhile, no
6 Q. Zhao et al. / Journal of Cellular Immunotherapy 2 (2016) 3e20
significant adverse cardiovascular events occurred during
follow-up [65]. Futhermore，Pak et al. evaluate the safety of
adipose tissue derived MSCs (AT-MSCs) that was used for
patients suffering from orthopedic conditions. Ninety one
patients suffering from orthopedic conditions were treated
with autologous AT-MSCs. AT-MSCs were injected with PRP
into various joints (n ¼ 100). No neoplastic complications
were detected at any AT-MSCs implantation sites. Based on
longitudinal cohort, the autologous and uncultured ADSCs/
PRP therapy could be considered to be safe when used as
percutaneous local injections [66]. Till now, scientists evaluate
the safety of MSCs through three different level including
in vitro culture expansion, animal disease model and clinical
trials and get a conclusion that MSCs is safe cell. In addition,
MSCs preparation and production must be manipulated in
GMP or GTP laboratory and only qualified MSCs can be used
for clinical application for safety and achieving ideal clinical
effect.
4. Interaction between MSCs and immune cells
MSCs have also been shown to possess broad immunoreg-
ulatory capabilities and are capable of influencing both adap-
tive and innate immune responses. MSCs inhibit immune cells
proliferation and maturation and suppress immune reactions
both in vitro and in vivo in a non-MHC restricted manner [67].
Therefore, MSCs are considered to be hypoimmunogenic,
displaying low expression levels of HLA class I, no expression
of HLA class Ⅱ, and no expression of costimulatory molecules,
including CD40, CD80, and CD86 [28,68]. Basically, MSCs
could exert widespread immunomodulatory effects on cells of
both the innate and adaptive immune system. Ex-vivo
expanded MSCs have also been showed to suppress the activ-
ity of a broad range of immune cells, including T cells, natural
killer T (NKT) cells, dendritic cells (DCs), B cells, neutrophils,
monocytes, macrophages and so on.
4.1. MSCs inhibit T cells proliferation and suppress
allogeneic T-cell response
The main features of the T cell response is cell proliferation
and cytokines secretion. Inhibit T cell proliferation is the most
significant effect for MSCs. In vitro, MSCs are capable of
suppressing T lymphocyte proliferation induced by mitogens
[67,69,70], alloantigens [67,68,71,72], as well as activation of
T cells by CD3 and CD28 antibodies [68]. Suppression of T
cell proliferation by MSCs has no immunological restriction,
similar suppressive effects being observed with cells that were
autologous or allogeneic to the responder cells [28,67,72].
MSCs also modulate immune responses through the induction
of regulatory T cells which are important in maintaining im-
mune homeostasis and self-tolerance. MSCs have been re-
ported to induce formation of regulatory T cells that were
responsible for inhibition of allogeneic lymphocyte prolifera-
tion [70]. In addition, an increase in the population of regu-
latory T (Treg) cells has been demonstrated in mitogen-
stimulated peripheral blood mononuclear cell (PBMCs)
cultures in the presence of MSCs [73,74]. Yan et al. reported
that MSC-exposed Treg cells are capable of more immuno-
suppressive than Tregs without coculturing with MSCs. And
their results showed that programmed cell death 1 receptor/
B7-H1 interactions and IL-10 might be responsible for the
enhanced suppressive capability of MSC-exposed regulatory T
cells [75]. However, depletion of regulatory T cells had no
effect on the suppression of T cell proliferation by MSCs, and
MSCs physically hinder T cells from the contact with antigen
presenting cells (APCs) in a noncognate fashion [76]. Human
adipocyte-MSCs undergo different modes of activation, when
they were treated with mouse splenic T cell culture superna-
tant, compared to when they were stimulated with human
PBMC supernatant. However, they still exerted an anti-
proliferative effect on mouse splenic T cells in vitro, primar-
ily through COX-2 expression [77]. Human adipose-AT-MSCs
obtained from kidney donors induced a 2$1-fold increase in
the percentage of CD25(þ) CD127() FoxP3(þ) cells within
the CD4(þ) T cell population from allostimulated CD25()
cells. And AT-MSCs induced Treg cells inhibited effector cell
proliferation as effectively as natural regulatory T cells. The
vast majority of cells within the induced Treg fraction had a
methylated FOXP3 gene Treg-specific demethylated region
indicating that they were not of natural regulatory T cells
origin [78].
Although the exact mechanism underlying the immuno-
suppressive effects of MSCs is still not clear, most evidences
supported that soluble factors are involved. These factors
include prostaglandin E2 (PGE2) [73,79e81], indoleamine
2,3-dioxygenase (IDO) [82,83], hepatocyte growth factor
(HGF) [84,85] and transforming growth factor (TGF)-b 1
[69,86]. Additionally, it is well-established that IFN-g plays an
important role in the enhancement of MSCs suppressive ac-
tivity [82]. Furthermore, increased evidences support that
MSCs inhibit the proliferation and/or functions of CD4þ Th1
and Th17 cells, CD8þ T cells, and natural killer cells pre-
dominantly via the secretion of soluble factors including TGF-
b1 and HGF [87e90]. In addition, MSCs play a key role in
cytotoxic CD8þ T cells against intracellular pathogens.
Schurch et al. reported that IFN-g can promote the release of
hematopoietic cytokines, including IL-6 from MSCs, which in
turn reduced the expression of the transcription factors Runx-1
and Cebpa in early hematopoietic progenitor cells and
increased myeloid differentiation and triggered the temporary
activation of emergency myelopoiesis and promote clearance
of the infection [91] (Fig. 2).
4.2. MSCs block natural killer T (NKT) cells
proliferation and cytotoxicity
NKT cells are part of the innate immune system, and bridge
the adaptive immune system with the innate immune system.
Once activated, these cells can perform functions ascribed to
both Th and Tc cells, involving the enhance of cell mediated
immune response [92]. In addition, NKT cells play a key role
in the elimination of virus infected cells and tumor cells.
MSCs alter the phenotype of NKT cells and suppress
 Q. Zhao et al. / Journal of Cellular Immunotherapy 2 (2016) 3e20 7

Fig. 2. The MSCs exert their immune suppressive potential by cell to cell contact and by secretion of immune regulatory molecules. MSCs display broad
immunomodulatory properties, MSCs can inhibit the proliferation and function of T cells, Natural killer T (NKT) cells, T regulatory cells， B cells and dendritic
cells (DCs). However, MSCs secrete IL-6 and preserve neutrophils viability by inhibiting apoptosis. Several soluble factors have been shown to play a major role in
the immunosuppressive effects of MSCs, including prostaglandin E2 (PGE2), transforming growth factor (TGF)-b1, indoleamine 2,3-dioxygenase (IDO), nitric
oxide, hepatocyte growth factor (HGF), interleukin (IL)-6 and IL-10.

proliferation, cytokine secretion, and cytotoxicity against
HLA-class I-expressing targets. Some of these effects require
cell-to-cell contact, whereas others are mediated by soluble
factors, including TGF-b1 and PGE2, suggesting the existence
of diverse mechanisms for MSC-mediated NKT-cell suppres-
sion [84]. Spaggiari et al. also showed that MSCs can inhibit
the IL-2-induced proliferation of unactivated NKT cells [93].
In addition, the results reported by Selmani et al. showed that
MSCs inhibited iNKT (Va24(þ)Vb11(þ)) and gd T (Vd2(þ))
cell expansion from PBMC in both cell-to-cell contact and
transwell systems. MSCs, through HLA-G5, affect innate
immunity by inhibiting both NKT cell-mediated cytolysis and
IFN-g secretion [94]. Furthermore, Prigione et al. reported that
MSCs inhibited IFN-g production by activated Va24(þ)
Vb11(þ) and impaired CD3-mediated proliferation of acti-
vated Va24(þ)Vb11(þ) and Vd2(þ) T cells, without affecting
their cytotoxic potential [95]. Therefore, MSCs achieve inhi-
bition of the NKT cells proliferation and immune regulatory
function by involving of multiple cytokines and signal
pathway (Fig. 2).
4.3. MSCs affect B cells proliferation and maturation
B cells are a type of lymphocyte in the humoral immunity
of the adaptive immune system specialized in antigen pre-
sentation and antibody production. Recent studies also showed
that MSCs can inhibit several functions of B cells, Corcione
et al. showed that B-cell proliferation was inhibited by MSCs
through an arrest in the G0/G1 phase of the cell cycle. A major
mechanism of B-cell suppression was soluble factors of MSCs
production [96]. Furthermore, MSCs inhibited B-cell differ-
entiation because IgM, IgG, and IgA production was signifi-
cantly impaired. And CXCR4, CXCR5, and CCR7 in B-cell
expression, as well as chemotaxis to CXCL12, the CXCR4
ligand, and CXCL13, the CXCR5 ligand, were significantly
down-regulated by MSCs, suggesting that these cells affect
chemotactic properties of B cells. In addition, MSCs also
affect migrate to inflammatory regions under the guidance of
cell adhesion molecules and receptors for inflammatory che-
mokines [97]. One recent study by Lee et al. showed that the
conditioned medium of MSCs infected with a mycoplasma
strain, Mycoplasma arginini, has marked inhibitory effects on
Ig production by lipopolysaccharide/interleukin-4-induced B
cells compared with mycoplasma-free MSC-CM [98]. Yan
et al. found that BAFF in MSCs was expressed at a higher
level after TLR4-priming, indicating that TLR4 and a down-
stream pathway play a role in BAFF secretion and thus exert
an important function in B lymphocyte-related immune
regulation [99]. Another recent study highlighted galectin-9
(Gal-9) strongly upregulated upon activation of the cells by
IFN-g. And their results showed that Gal-9 is a major mediator
of the anti-proliferative and functional effects of MSCs not
8 Q. Zhao et al. / Journal of Cellular Immunotherapy 2 (2016) 3e20
only on T cells but also on B cells. Moreover, Gal-9 and
activated MSCs contribute to the suppression of antigen trig-
gered immunoglobulin release [100]. By contrast, Rosado
et al. reported that BM-MSCs are able to promote in vitro
proliferation and differentiation of transitional and naive B
cells isolated from both healthy donors (HDs) and pediatric
patients with Systemic Lupus Erythematosus (SLE) upon
stimulation with CpG, soluble CD40L, anti-Ig antibodies and
IL-2 [101]. Meanwhile, the results by our group show that
treatment with UC-MSCs resulted in an increase of prolifer-
ation, differentiation of B cells into plasma cells and produc-
tion of antibodies in vitro. And our results also showed that
PGE2 partially mediated the immunosuppressive activity of
MSC [102]. These conflicting results hinted that it is important
to distinguish the direct action of MSCs on B cells from in-
direct effects mediated by other cell types contained in the
different culture conditions.
4.4. MSCs modulate dendritic cells (DCs) generation
and maturation
DCs are the main APCs in the mammalian immune system.
Their main function is to present antigen material on the cell
surface to the T cells. DCs affect significantly the balance
between helper and regulatory T cell and establish tolerance to
self antigen [103]. The presence of MSCs blocked the differ-
entiation of peripheral and umbilical cord blood derived
CD14 þ CD1a  precursors into dermal/interstitial DCs
[104]. Coculture of MSCs with DCs resulted in reduced
expression of CCR7 by DCs following stimulation. Likewise,
DCs matured in the presence of MSCs, showed significantly
less migration to CCL19 [105]. Zhang et al. showed that
MSCs inhibit the up-regulation of CD1a, CD40, CD80, CD86,
and HLA-DR during DCs differentiation and prevent an in-
crease of CD40, CD86, and CD83 expression during DCs
maturation [80]. In addition, Jiang et al. also showed that
MSCs coculture could strongly inhibit the initial differentia-
tion of monocytes to DCs. In addition, mature DCs treated
with MSCs were significantly reduced in the expression of
CD83, suggesting their skew to immature status. Meanwhile,
decreased expression of presentation molecules (HLA-DR and
CD1a) and costimulatory molecules (CD80 and CD86) and
down-regulated IL-12 secretion were also observed [106].
Moreover, the differentiation of BM progenitors into DCs
cultured with conditioned supernatants from MSCs was partly
inhibited through the secretion of IL-6 [107]. Furthermore,
MSCs secreted PGE2 plays a major role in MSC-mediated
inhibition of DCs maturation, and inhibitory effect on DCs
maturation by acting early, during the progression from
monocytes to iDCs induced by GM-CSF and IL-4, although
they do not interfere with LPSeinduced iDC differentiation
into mDCs [108]. Additionally, MSCs inhibit in vitro DCs
effector properties, including antigen processing and presen-
tation to T cells through the inhibition of the activation of
mitogen-activated protein kinases (MAPKs) occurring upon
TLR4 stimulation. In addition, in vitro exposure of DCs to
MSCs as well as in vivo intravenous administration of MSCs
results in a significant down-regulation of CCR7 and CD49d,
two molecules involved in DCs homing to lymphoid organs.
This event leads to inhibition of migration to the draining
lymph nodes and subsequent impairment of priming of
antigen-specific naive T cells [109] (Fig. 2).
4.5. MSCs preserve neutrophils viability and function
Neutrophils form an essential part of the innate immune
system. They are differentiated from HSC in the BM. Neutro-
phil progenitors have a quite high proliferation rate and mature
neutrophils have a very short lifespan. Neutrophils are one type
of phagocytes and are found in the peripheral blood, tissues and
BM. Neutrophils possess the capability of chemotaxis,
phagocytosis and bactericide. During the beginning phase of
inflammation, neutrophils are one of the first-responders of
inflammatory cells to migrate towards the site of inflammation.
MSCs inhibit in vitro apoptosis of resting and IL-8-activated
neutrophils and reduce N-formyl-l-methionin-l-leucyl-L-
phenylalanine (f-MLP)-induced respiratory burst while not
affecting phagocytosis, expression of adhesion molecules, or
the migration capability of neutrophils in response to classic
stimuli. And further research showed that MSCs rescued neu-
trophils from apoptosis by constitutive release of IL-6 [110].
Cassatella et al. reported that MSCs, upon TLR activation, may
sustain and amplify the functions of neutropils. Their results
showed that TLR3-activated MSCs are powerful in preserving
neutropils viability and function, and a concerted action of
endogenously produced IL-6, IFN-b, and GM-CSF determines
most of the modulatory effects exerted on PMN by TLR3-
activated MSC [111]. The results reported by Maqbool et al.
also indicated MSCs rescue neutrophils from nutrient- or
serum-deprived cell death [112] (Fig. 2). Therefore, neutrophils
may be one of most important immune cells mediated the
forward immunomodulatory of MSCs.
4.6. MSCs induces macrophage M1/M2 phenotype
transformation
Macrophages are differentiated from monocytes residing in
tissues. Macrophages play a key role in innate immune system.
They are highly specialized in removal of dying or dead cells and
cellular debris. And macrophage also is important immune
effector cell involving cell mediated immune response.
Increasing evidences have demonstrated that MSCs-mediated
regulation of macrophages is critical for inflammation response
and tissue injury repair. Nemeth et al. reported that injection of
BM-MSCs can beneficially modulate the response of the host
immune system to sepsis and significantly improve animal sur-
vival [113]. And their results suggest that the injected MSCs
interact with circulating and tissue monocytes and macrophages
and reprogram them. Treated monocytes and macrophages pro-
duce large amounts of IL-10, and the treatment decreases the
amounts of circulating TNF-a and IL-6. Cao et al. transplanted
mouse MSCs into the pancreas of the streptozotocin-treated
hyperglycemic isogeneic mice, resulting in a decrease in blood
glucose due to a recovery in b cell mass. Their analysis suggest
 Q. Zhao et al. / Journal of Cellular Immunotherapy 2 (2016) 3e20
that the grafted MSCs recruited M2 macrophages in a stromal
cell-derived factor 1 (SDF-1)-dependent manner, which activates
Wnt/b-catenin signaling in pancreatic bcells to promote b cell
replication [114]. Another recent study demonstrated that mouse
MSCs skewed macrophages towards an M2 phenotype in a cell
contact-independent manner. MSCs exerted this effect through
the inhibition of NF-kB p65 and the activation of STAT3
pathways [115]. In addition, preferential shift of the macrophage
phenotype from M1 to M2 may be related to the immune-
modulating characteristics of MSCs [116,117] (Fig. 3). There-
fore, the discovery of monocytes and M1 macrophage trans-
forming into M2 macrophage in presence of MSCs may be quite
significant for inflammatory biology development and inflam-
matory disease treatment in future.
4.7. MSCs inhibit immune cells in vivo
The immunomodulatory capacity of MSCs has also been
evaluated in vivo. First, in vivo administration of MSCs pro-
longed the survival of skin graft [72]. In addition, results
demonstrated that MSCs do ameliorate mice experimental
autoimmune encephalomyelitis (EAE) [90]. Allogeneic MSCs
improve the survival of corneal allografts without engraftment
and primarily by secreting TSG-6 that acts by aborting early
inflammatory responses [118]. AT-MSCs therapy efficiently
ameliorates autoimmune diabetes pathogenesis in diabetic
NOD/SCID mice by attenuating the Th1 immune response
concomitant with the expansion/proliferation of Treg cells,
thereby contributing to the maintenance of functional b-cells
[119]. In established chronic colitis, therapeutic injection of
activated macrophages by coculture with AT-MSCs alleviated
its progression and avoided disease recurrence. And AT-MSCs
protected from severe sepsis by reducing the infiltration of in-
flammatory cells into various organs and by downregulating the
production of several inflammatory mediators, where AT-MSCs
mediated macrophages derived IL-10 played a critical role
[120]. In addition, administration of MSCs isolated from human
BM, umbilical cord, or adipose tissue provoked a pronounced
Fig. 3. MSCs promote the survival of monocytes and induce differentiation
toward macrophage M2 anti-inflammatory phenotype that express CD206 and
CD163. In addition, activated MSCs secrete prostaglandin E2 (PGE2) that
drives resident macrophages with an M1 proinflammatory phenotype toward to
an M2 anti-inflammatory phenotype.
9
increase in alveolar macrophages and inhibited hallmark fea-
tures of asthma, including airway hyperresponsiveness, eosin-
ophilic accumulation, and Th2 cytokine production.
Importantly, selective depletion of this macrophage compart-
ment reversed the therapeutic benefit of MSCs treatment on
airway hyperresponsiveness [121]. Lee et al. established one
humanized mouse model by injecting isolated hUCB-derived
CD34 þ cells intravenously into immunocompromised NOD/
SCID IL2g null mice. After repeated intravenous injection of
hPBMSCs or MRC5 cells into these mice, immunological al-
terations including T cell proliferation and increased IFN-g,
TNF-a, and human IgG levels, were observed. In contrast,
hUCB-MSCs injection did not elicit these responses [122].
Meanwhile, Zanotti et al. reported that the use of encapsulated
cells unequivocally demonstrates that MSCs do not require
homing to specific organs or cellecell contacts to control
inflammation and their immunosuppressive action is based on
the release of soluble factors that may act systemically [123]. In
addition, anti-inflammatory is another important capability of
MSCs and was confirmed in vivo too. Nemeth et al. showed that
an intravenous injection of MSCs can beneficially modulate the
response of the host immune system to sepsis and improve
survival. And their results suggested that the injected MSCs
interact with monocytes and macrophages in circulating and
tissue and reprogram them. Treated monocytes and macro-
phages produce large amounts of IL-10, and the treatment de-
creases the amounts of circulating TNF-a and IL-6 [113]. This
reduces harm caused by unbridled immune responses to the host
tissues. Another recent study showed that systemic infusion of
MSCs significantly ameliorated the clinical and histopatholog-
ical severity of colitis, abrogating weight loss, diarrhea and
inflammation, and increasing survival. And their results
demonstrated that the therapeutic effect was associated with
downregulation of the Th1-driven inflammatory responses.
MSCs decreased a wide panel of inflammatory cytokines and
chemokines and increased IL10, acting on macrophages [124].
Furthermore, systemic infusion of AT-MSCs on the activation
state of macrophages inhibited colitis in mice, reducing mor-
tality and weight loss while lowering the colonic and systemic
levels of inflammatory cytokines [120]. However, ambiguous
results were reported that intravenously infused C57BL/6 green
fluorescent protein (GFP) MSCs home to the lungs in C57BL/6
recipient mice and induce an inflammatory response. This
response was characterized by increased mRNA expression of
monocyte chemoattractant protein-1 (MCP1), IL1-b, and TNF-
a and an increase in macrophages in lung tissue after MSCs
infusion [125]. These results of pre-clinical studies showed that
MSCs possess broad immunomodulatory and anti-
inflammatory activity in disease animal model in vivo and hin-
ted us MSCs may be a promising candidate for potential clinical
application in treating immune-based disorders in future.
4.8. Factors affecting the immunomodulatory activity of
MSCs
Evidences showed that inflammation environment can
change the immunomodulation activity of MSCs. Inflamed
10 Q. Zhao et al. / Journal of Cellular Immunotherapy 2 (2016) 3e20
periodontal ligament stem cells showed significantly dimin-
ished inhibition of T-cell proliferation. In cocultures, stimu-
lated PBMSCs showed significantly less induction of
CD4þCD25 þ FOXP3þ regulatory T cells and IL-10 secre-
tion in the presence of inflamed compared with healthy peri-
odontal ligament stem cells. Furthermore, suppression of Th17
differentiation and IL-17 production by inflamed periodontal
ligament stem cells was significantly lesser than by healthy
cells [126]. Waterman et al. have suggested that MSCs may
polarize into two distinctly acting phenotypes following spe-
cific TLR stimulation, resulting in different immune modula-
tory effects and distinct secretomes. The TLR4-primed MSCs
population exhibits a proinflammatory profile (MSC1) and the
TLR3-primed MSCs population delivers anti-inflammatory
signals (MSC2) [127]. Furthermore, Micro RNA expression
level also is another important factor affect the immunomo-
dulation capability. Reported results showed that miR-181a
[128] and miR-155 [129] reduces the immunosuppressive
capacity of inflammatory cytokine-activated MSCs. In addi-
tion, Evidence had also shown that different cell subsets show
different immunomodulation activity. Yang et al. reported
CD106þ chorionic villi(CV)-MSCs possess high immunomo-
dulation activity, whereas CD106- CV-MSCs possess high
colony formation capacity. In addition, the immunosuppres-
sive activity of MSCs is highly related to their ability for the
secretion of immunoregulatory cytokines and PGE2. In
CD106þ MSCs, a list of genes was up regulated, including
COX-2, IL-1a, IL-1b, IL-6 and IL-8 [33]. Recently, chemical
that can correct the MSCs biological function was also re-
ported. The research by Ma et al. showed that Immunomod-
ulatory agent thalidomide corrects impaired MSCs function in
inducing tolerogenic DCs in patients with immune thrombo-
cytopenia. The thalidomide modulated MSCs from ITP pa-
tients induced mature DCs to become tolerogenic DCs. And
the induction of tolerogenicity in DCs by MSCs was depen-
dent on the expression of TIEG1 in DCs [130]. Furthermore,
recent experiments clearly documented the inhibitory effect of
gamma irradiation on proliferation of MSCs, but does not
impair the immunosuppressive capacity of BM-MSCs in vitro
and thus might increase the safety of MSC-based cell products
in clinical applications [131]. Zhang et al. reported that MSCs
from late passage displayed a stronger immunosuppressive
activities. And their results also showed that increased
interleukin-6 production may be a possible underlying mech-
anism for enhanced immunomodulatory ability of MSCs
[132]. These results hinted that some growth factors, cytokines
and chemicals may be used for correcting impaired MSCs
function to benefit patients with MSCs deficiency in future.
4.9. The effect of immune cells against MSCs
The interaction between MSC and immune cells is usually
bidirectional. Sotiropoulou tested the ability of different cyto-
kines to induce NK cytotoxicity against MSCs, their results
show that NK cells cultured for 4 days in IL-15esupplemented
medium could effectively lyse MSCs. In addition, IL-2 and the
combinations of IL-12/IL-15 and IL-12/IL-18 also resulted in
induction of lytic activity against MSCs [84]. Another study by
Spaggiari et al. indicated that the activated NK cells by IL-2
explosion, but not freshly isolated NK cells, displayed strong
cytolytic activity. Meanwhile, their investigation showed that the
expression of NKp30, NKG2D and DNAM-1 in NK cells
involved in the lysis of MSCs [93]. In addition, Eugela et al.
investigated the effect of Tregs against MSCs. Their results
showed that kidney perirenal AT-MSCs and originating Tregs
from healthy donors do not impair each other's suppressive effect
on allo-reactivity [133]. Actually, There are still lots of work to
do to clear the effect on MSCs by other immune cells now.
5. Therapeutic application of MSCs for immune diseases
Currently, there are many promising clinical trials using
MSCs in cell-based therapies of numerous diseases. MSCs
suppress T-cells, B cells and DCs function and represent a
promising strategy for cell therapy of immune-mediated dis-
eases. The immunomodulatory activities of MSCs provide a
rational basis for their application in the treatment of immune-
mediated diseases. Our analysis below will include the most
frequently studied immune mediated diseases: GVHD, AA,
MS, RA, CD and SLE.
5.1. MSCs and GVHD
GVHD is a difficult and potentially lethal complication of
hematopoietic stem cell transplantation (HSCT). This can
occur in up to 30e50% of patients for HLA matched sibling
transplant and even more frequently in HLA-mismatched un-
related donor transplants (60e80%) [134]. GVHD is normally
treated with corticosteroid and other immunosuppressive
therapy [135,136]. However, response of GVHD to steroid
therapy is between 20% and 40%, mortality of GVHD with
refractory to steroid therapy approaches 80% [137]. MSCs can
be expanded in culture and possess complex and diverse
immunomodulatory activity. Moreover, human MSCs carry
low levels of class 1 and no class 2 HLA antigens, making
them immunoprivileged and able to be used without HLA
matching. Increased evidences have shown that MSCs may be
promising cell product for GVHD treatment (Table 1). First
clinical trial displayed that BM-MSCs have a potent immu-
nosuppressive effect in vivo, and induced complete response
(CR) of aGVHD that is refractory to conventional immuno-
suppressive therapy [138]. A later phase II clinical study from
the same group involved 55 steroid-resistant patients with
severe aGVHD. Treatment with HLA-identical and hap-
loidentical sibling donor BM or third-party mismatched BM-
MSCs induced a 70% initial response rate that was not
related to age or HLA match. None of the patients had side
effects either during or immediately after the MSCs infusion
[139]. Ringden et al. injected MSCs to eight patients with
steroid-refractory grades IIIeIV GVHD. GVHD disappeared
completely in six of eight patients. Two died soon after MSCs
treatment with no obvious response. Five patients are still alive
3 years post MSCs transplantation. Their survival rate was
significantly better than that of 16 patients with steroid-
 Q. Zhao et al. / Journal of Cellular Immunotherapy 2 (2016) 3e20 11

resistant biopsy-proven gastrointestinal GVHD, not treated

MSC, mesenchymal stem cell; BM, bone marrow; aGVHD: acute graft versus host disease; cGVHD: chronic graft versus host disease; CR: complete response; PR: partial response; NR: no response; FP: follow up
(Herrmann et al., 2012)
(Herrmann et al., 2012)
(Le Blanc et al., 2004)

(Le Blanc et al., 2008)

(Ringden et al., 2006)

(Ringden et al., 2013)

with MSCs during the same period (P ¼ 0.03) [140]. Herr-

(Muroi et al., 2013)

(Ball et al., 2013)
mann et al. also undertook a phase I trial in patients suffer
from steroid-refractory aGVHD and cGVHD utilizing BM-
References

MSCs. The response rate overall for aGVHD was complete

in seven, partial in four and no response in one patient. Two
patients with cGVHD achieved CR with two partial responses
(PR) and three with no response (NR). The survival for those
Improved
Improved
Improved

Improved
Improved
Improved
Improved
Improved
Outcome

with aGVHD who achieved a complete response compared

with those who did not was significant (p ¼ 0.03) [141].
Further research showed that MSCs infusions are safe and
effective for children with steroid-refractory aGVHD, espe-
21 Months
12 months

30 months
30 months

96 weeks
2.9 years

cially when applied early in the disease course [142]. In

3 years
2 years

addition, Muroi et al. conducted a multicenter phase I/II study

FP

using BM-MSCs manufactured from healthy unrelated vol-

unteers to treat steroid-refractory aGVHD. By week 4, 13 of
NR（%）

14 patients (92.9%) had responded to MSCs therapy with a CR

(n ¼ 8) or PR (n ¼ 5). At 24 weeks, 11 patients (10 with CR
29.1

42.9
13.5
8.3

7.1
25

25
e

and 1 with PR) were alive. At 96 weeks, 8 patients were alive

in CR. Their results showed that third party-derived BM-
PR（%）

MSCs may be safe and effective for patients with steroid-

16.4

33.3
28.5
21.6

35.7

refractory GVHD [143]. Meanwhile, Ringden et al. tested

50
e
e

placenta derived MSCs (PDMSCs) for treatment of steroid-

CR（%）

refractory aGVHD. Nine patients who had undergone HSCT

and who had developed steroid-refractory grade IIIeIV
54.5

58.3
28.5

57.1
100
75

65
25

aGVHD were treated by PDMSCs infusion. Their results

showed that there was an overall response rate of 75% [144].
Side effect

The results by Ringden et al. showed that MSCs derived from

1 seizurs
(patient)

other tissue also can be tried to treat GVHD.

There have been several studies using MSCs as prophylaxis
e
e
e

e
e
e

to prevent GVHD and promote HSCs engraftment and ob-

Infusions

tained useful and inspiring results (Table 2). In phase I studies,

2e19
2e11
1e13

8e16
1e5

Lazarus et al. estimated the feasibility of transplanting autol-

15
1
1

ogous or allogeneic MSCs to improve engraftment of HSCs, as

well as to reduce GVHD [145,146]. Kuzmina et al. accom-
(1.3e2.7)  106/kg
(1.3e2.7)  106/kg

(0.9e2.8)  106/kg
(0.7e9)  106/kg
(0.4e9)  106/kg

(0.9e3)  106/kg

plished a Phase II clinical trial and investigated that the pro-

phylaxis of MSCs for aGVHD. Their results showed that the
2  106/kg

2  106/kg

patients with BM-MSCs infusion have significant lower rate of

grade II-IV aGVHD (5.3%) compared with patients without
Dose

BM-MSCs infusion (38.9%) of patients (P ¼ 0.002) [147].

Several researches have shown that MSCs from amnion,
Sibling, haploidentical
Donor source of MSC

placenta, and umbilical cord can be potentially used for

Allogeneic placenta
and third-party BM
Haploidentical BM

substituting BM-MSC in several therapeutic applications,

Clinical trials of using MSCs treatment for GVHD.

third-party BM

third-party BM
third-party BM
third-party BM

including the treatment of GVHD [9,79,148]. Therefore, our

group tested to cotransplant the culture-expanded UC-MSCs
in 50 people with refractory/relapsed hematologic malignancy
BM

undergoing haplo-HSCT with myeloablative conditioning.

Grade II-IV aGVHD was observed in 12 of 50 (24.0%) pa-
GVHD grade

tients. cGVHD was observed in 17 of 45 (37.7%) patients and

was extensive in 3 patients. The probability that patients
IIIeIV

IIIeIV
ⅢeⅣ
ⅡeIV

ⅡeIV

ⅡeIII

would attain progression-free survival at 2 years was 66.0%.

period; -: not observed.
IV

Our research indicated that MSCs cotransplantation with

HSCs is effective in improving donor engraftment and
No. of patients

reducing severe GVHD [149]. Meanwhile, our group observed

12 aGVHD

that Patients with severe AA (n ¼ 17) received haploidentical

7 cGVHD
Table 1

HSCT plus MSCs infusion. The 3-month and 6-month survival

55

37

14

rates for all patients were 88.2% and 76.5%, respectively;

1
8

9
12 Q. Zhao et al. / Journal of Cellular Immunotherapy 2 (2016) 3e20

mean survival time was 56.5 months. Therefore, our results

MSC, mesenchymal stem cell; AA: aplastic anemia; BM, bone marrow; aGVHD: acute graft versus host disease; cGVHD: chronic graft versus host disease; PBS: Phosphate Buffer solution; FP: follow up period;
(Kuzmina et al., 2012)
(Lazarus et al., 2005)
showed that Combined transplantation of haploidentical HSCs

(Wu et al., 2013)

(Wu et al., 2014)
(Li et al., 2014)
and MSCs on severe AA without an HLA-identical sibling
donor was safe, effectively reduced the incidence of severe
References

GVHD, and improved patient survival [150]. Then another

clinical trial of AA investigated by our group and suggested
that the modified conditioning regimen without high-dose
immunosuppressive agents was sufficient to achieve sus-
Improved

Improved
Improved
Improved
Improved
Outcome

tained donor engraftment in which the third-party donor-

derived UC-MSCs may play an important role [151]. Although
cell dose is much less in our clinical trial (5  105/kg) than in
clinical trial (14  105) run by Le Blanc K et al., our clinical
32 months

58 months
78 months
2 years

3 years

trial also achieved ideal therapeutic effect. This is also

consistent to our recent data that show that PGE2 which plays
FP

a key role in immunomodulation was secreted much more in

cGVHD（%）

UC-MSCs than BM-MSCs. Therefore, PGE2 maybe can be

MSC:21.05

using as a biological effectiveness to evaluate immunomodu-

PBS: 31.6

lation potency of MSCs (not published). These results showed

14.2%

that MSCs derived from kinds of tissue may be safe and

61

32
35

effective for prevention of GVHD.

aGVHD（%）
Grade IIIeIV

5.2. MSC and acquired AA

PBS: 5.26
MSC: 0

23.5%
23.8

AA is mostly considered an immune-mediated BM failure

28

14

syndrome, characterized by hypoplasia and pancytopenia with

fatty BM and reduced angiogenesis. Previous investigations
aGVHD（%）

have demonstrated that acquired AA is manifested as abnor-

PBS: 47.36
MSC: 31.6
Grade ⅠeⅡ

malities of HSCs/HPCs and hematopoietic microenvironment

[152]. Lots of evidences have hinted that AA might be a
33.3
35.2
28
e

syndrome characterized by stem/progenitor-cell disorders

including HSCs/HPCs and BM-MSCs. BM-MSCs support
(2.87e10)  106/kg
(0.9e1.3)  106/kg

hematopoiesis and regulate almost overall immune cells

(1e5)  106/kg

function to maintain the hematopoietic and immune homeo-

5.0  105/kg
5.0  105/kg

stasis [97,139]. BM-MSCs can modulate the major immune

cell functions including T cells, B cells, monocytes, DCs,
Dose

NKTs and neutrophils [153,154]. BM-MSCs possess remark-

able immunosuppressive properties on Th1, Th17 and CTLs.
Allogeneic unbilical cord
Allogeneic unbilical cord
Allogeneic unbilical cord

BM-MSCs inhibit the proliferation of T cells, IFN-g and TNF-

Donor source of MSC

a secretion by Th1 cells while promoting IL-10 production by

Th2 cells and the expansion of Treg cells. However, recent
researches showed that BM-MSCs from AA patients had poor
proliferation and deficient immune suppression of MLR, PHA-
Clinical trials of using MSCs prophylaxis for GVHD.

induced T cell activation and IFN-g release [155,156]. Our

BM
BM

recent study showed that BM-MSCs from AA patients were

reduced in suppressing the proliferation and clonogenic po-
No. of patients

tential of CD4þ T cells while promoting Treg cells expansion.

BM-MSCs were also defective to suppress the production of
TNF-a and IFN-g by CD4þ cells. However, there was no
significant difference in regulating the production of IL-4, IL-
46
37

50
21
17

10 and IL-17 [157]. In addition, our research also showed that

hematologic malignancy
hematologic malignancy

hematologic malignancy

BM-MSCs from AA patients showed aberrant morphology,

decreased proliferation and clonogenic potential and increased
apoptosis than BM-MSCs from healthy controls. BM-MSCs
-: not observed.

from AA patients were susceptible to be induced to differen-

tiate into adipocytes but more difficult to differentiate into
Disease
Table 2

osteoblasts. Consistent with abnormal biological features, a

AA
AA

large number of genes implicated in cell cycle, cell division,

 Q. Zhao et al. / Journal of Cellular Immunotherapy 2 (2016) 3e20
proliferation, chemotaxis and hematopoietic cell lineage
showed markedly decreased expression in BM-MSCs from
AA patients. Conversely, more related genes with apoptosis,
adipogenesis and immune response showed increased
expression in BM-MSCs from AA patients. The gene
expression profile of BM-MSCs further confirmed the
abnormal biological properties and provided significant evi-
dence for the possible mechanism of the destruction of the BM
microenvironment in AA [158].
MSCs may be a promising therapeutic candidate as a
treatment for AA due to following two quite important facts,
① hematopoiesis supporting and potent immunosuppressive
capability of MSC and ② biological characteristical difference
and functional capability deficiency of BM-MSCs derived
from patients with AA. However, till today there is just one
clinical trials using MSCs alone was accomplished by Xiao
et al. Xiao et al. investigated that the safety and efficacy post
intravenous administration of MSCs to 18 patients with AA.
BM-MSCs ((5.0e7.1)  105/kg body weight) were injected
intravenously to 18 patients, including 14 patients with non-
severe AA and four patients with severe AA who were re-
fractory to prior immunosuppressive treatment. Two patients
had injection-related adverse events, including transient fever
and headache. No major adverse events were reported during
the follow-up period. An immunological analysis revealed an
increased proportion of CD4(þ)CD25(þ) FOXP3(þ) regula-
tory T cells [159]. Therefore, their results showed that MSCs
are safety and efficacy for AA treatment. In another recent
study, Ozdogu H et al. summarized that the result of post-
transplant treatment with MSCs of a 26-year-old patient
with AA complicated by invasive sino-orbital aspergillosis.
The patient was treated with MSCs to benefit from the dual
effects of MSCs in immune reconstitution: suppression against
alloreactive T cells and facilitation of the re-engraftment
process. The patient did not develop acute or chronic
GVHD. And the aspergillus infection healed completely. The
engraftment failure was also ended without any complications
[160]. In addition, there are several reports pointed that the
patients achieved rapid hematopoietic engraftment of donor
origin and lower rate of acute or chronic GVHD was observed
post cotransplantation MSCs with HSCs [161,162]. BM-MSCs
in patients with AA are abnormal. However, allogenic MSCs
will be eliminated soon after transplantation. The efficacy of
MSCs was mainly achieved through the secretion of couples
of immune factors. Abnormal MSCs would not be replaced.
So it is totally possible the efficacy of MSCs in clinical
treatment is transient. Therefore, according to our under-
standing MSCs should be applied for couple of times to
maintain the therapeutic effect. However, it is still need to be
clear according to the controlled pilot or clinical trial.
5.3. MSCs and MS
MS is the most common neurological disease in young
adults, affecting approximately two million people worldwide.
MS is an autoimmune disorder of the central nervous system
where myelin and oligodendrocytes are targeted by cell
13
mediated and humoral immunity [163]. Currently there is still
no effective choice for MS treatment. Given MSCs putative
roles in immunosuppression and neural repair, they have also
recently been proposed as treatment for MS. In addition, the
results showed that patient MSCs exhibited phenotypic
changes, distinct transcriptional profile and functional defects
implicated in MSC immunomodulatory and immunosuppres-
sive activity [164]. Currently, close to 17 clinical trials are
registered to use MSCs therapy for the treatment of MS (http://
www.clinicaltrials.gov/). MSCs have well been tolerated and
were safe in patients with early phase clinical studies. Autol-
ogous MSCs were safely given to patients with secondary
progressive MS. The efficacy results demonstrated the evi-
dence of structural, functional, and physiological improvement
after treatment in some visual endpoints is suggestive of
neuroprotection [165]. Mohajeri et al. investigated the mo-
lecular mechanism of MSCs infusion for MS treatment. They
found that the expression of FoxP3 after intrathecal injection
of MSCs was significantly higher than the levels prior to
treatment. Such significant enhanced expression of FoxP3
associated with clinical stability [166]. Findings from this pilot
study further support the potential of MSCs for treatment of
MS patients. A patient with MS was transplanted with mul-
tiple allogeneic hUC-MSC. The results also showed allogeneic
hUC-MSC may be a safe, effective, and more practical source
of stem cells for the treatment of MS [167]. However, obvi-
ously lots of effective trials still will be needed before MSCs
can be used for MS clinical treatment in future.
5.4. MSCs and RA
RA is the commonest autoimmune joint disease that has
achieved significant therapeutic advances in the past decades,
but remains difficult to treat in a subset of cases. Therefore,
Wang et al. firstly tried to treat RA by using MSCs infusion. In
a clinical trial for RA treatment by Wang, 172 patients with
active RA who had inadequate responses to traditional medi-
cation were enrolled. Patients were divided into two groups for
different treatment: disease-modifying anti-rheumatic drugs
(DMARDs) plus medium without UC-MSCs, or DMARDs
plus UC-MSCs group (4  107 cells per time) via intravenous
injection. Their results showed that no serious adverse effects
were observed during or after infusion. The serum levels of
TGF-а and IL-6 decreased after the first UC-MSCs treatment
(P < 0.05). The percentage of CD4(þ)CD25(þ)Foxp3(þ)
regulatory T cells of peripheral blood was increased
(P < 0.05). The therapeutic effects maintained for 3e6 months
without continuous administration, correlating with the
increased percentage of Treg cells of peripheral blood.
Repeated infusion after this period can enhance the therapeutic
efficacy. Therefore, treatment with DMARDs plus UC-MSCs
may provide safe, significant, and persistent clinical benefits
for patients with active RA [62]. In another recent phase I
clinical trial by Liang et al., four patients with persistently
active RA underwent MSCs transplantation. Three of four
patients received a reduction in erythrocyte sedimentation rate,
DAS-28, and visual analog scale pain score at 1 and 6 months
14 Q. Zhao et al. / Journal of Cellular Immunotherapy 2 (2016) 3e20
after transplantation. No one had achieved the DAS-28-defined
remission in the follow-up period. No serious adverse events
were reported. Their results demonstrated that allogeneic
MSCT is a one of safe treatment choice for severe and resis-
tant RA [168].
5.5. MSCs and CD
CD is a chronic inflammatory bowel disease characterized
by a relapsing-remitting clinical behavior. The main feature of
CD is intestinal inflammation. In recent years several groups
tried to use MSCs to treat CD and obtained some promising
results. The results of a phase I study showed that adminis-
tration of autologous BM-MSCs appears safe and feasible in
the treatment of refractory CD [169]. Ciccocioppo et al.
enrolled 12 consecutive outpatients with CD refractory or
unsuitable for current available therapies. Ten patients (two
refused) received intrafistular MSCs injections. All patients
who underwent MSCs infusion sustained complete closure
(seven cases) or incomplete closure (3 cases) of fistula tracks
with a parallel reduction of CD and perianal disease activity
indexes, and rectal mucosal healing were induced by treat-
ment. In addition, the percentage of mucosal and circulating
Treg cells significantly increased during the treatment and
remained stable until the end of follow up [170]. The results
from two phase I/IIa clinical trial demonstrated that allogeneic
AT-MSCs also is a simple, safe, and beneficial therapy for
perianal fistula in CD patients [171,172]. In another phase 2
study, administration of allogeneic MSCs reduced CD activity
index and CD endoscopic index of severity scores in patients
with CD luminal refractory to biologic therapy [173].
5.6. MSCs and SLE
SLE is a common and potentially fatal autoimmune disease
characterized by autoantibodies associated with multiorgan
injury, including the renal, cardiovascular, neural, musculoskel-
etal and cutaneous systems. Although disease severity and organ
involvement vary significantly among SLE patients, abnormal-
ities of T and B lymphocytes are universal [174,175]. Conven-
tional immunosuppressive therapies, such as cyclophosphamide
and mycophenolate mofetil can control disease in most, but not
all, patients with lupus nephritis. There is a subset of lupus
nephritis patients whose disease either does not respond or re-
lapses, and their prognosis remains poor. In addition, progressive
immunosuppressive therapy may lead to the development of
serious infection, cumulative drug toxicity, and an increased risk
of cardiovascular disease and malignancy [176]. Recent research
showed that there were abnormalities in actin cytoskeleton, cell
cycling regulation, BMP/TGF-b, and MAPK signaling pathways
in BM-MSCs from SLE patients [177]. Tang et al. found that
activated NF-kB pathway in SLE derived BM-MSCs inhibits the
BMP-2-induced osteoblastic differentiation through BMP/Smad
signaling pathway, suggesting that the impaired osteoblastic
differentiation may participate in the pathology of osteoporosis in
SLE patients [178]. Another research also found that BM-MSCs
from SLE patients exhibited senescent behavior and are involved
in the pathogenesis of SLE. And numerous studies have shown
that p16 [179], Wnt/b-catenin and p53/p21 pathway plays critical
role in the senescent of SLE BM-MSCs [180e182]. A pilot
single-center clinical studies reported the safety and efficacy of
allogeneic BM-MSCs and UC-MSCs in treating drug-resistant
SLE patients, and the clinical results have been encouraging
[183]. In addition, Li et al. investigated that the roles of MSCs
transplantation in SLE patients with refractory cytopenia. Thirty-
five SLE patients with refractory cytopenia were enrolled in a
MSCs transplantation trial. The results suggested that MSCs
transplantation could reverse hematological aberration in SLE
patients with refractory cytopenia, which might be associated
with reconstitution of Treg and Th17 cells [184]. Wang et al.
observed the long-term safety and efficacy of allogeneic MSCs
transplantation in treatment-resistant SLE patients. Eighty-seven
patients with persistently active SLE who were refractory to
standard treatment or had life-threatening visceral involvement
were enrolled. Allogeneic BM-MSCs and UC-MSCs were
intravenously. These results showed that allogeneic MSCs
transplantation resulted in the induction of clinical remission and
improvement in organ dysfunction in drug-resistant SLE patients
[185]. A recent multicenter clinical study by Wang et al. found
that intravenous UC-MSCs transplantation resulted in clinical
disease remission and systemic amelioration in lupus patients
who are refractory to other. However, some patients had disease
relapses after 6 months; therefore, they suggested that a repeated
MSCs infusion is feasible and necessary after 6 months to avoid
disease relapse [186].
5.7. MSCs and inflammatory disease
MSCs are also used in human clinical trials for the treat-
ment of inflammatory. MSCs modulate inflammation by
decreasing the immune cells and products of the inflammatory
response [187]. Skrahin et al. accomplished an open-label
phase 1 safety trial. They infused autologous MSCs as
adjunct treatment in patients with multidrug and extensively
drug-resistant tuberculosis. Their results showed that MSCs as
an adjunct therapy are safe and can now be explored further
for the treatment of patients with MDR or XDR tuberculosis in
combination with standard drug regimens [188].
5.8. MSCs and other immune disease
Report showed that UC-MSCs could restore behavioral
functions and attenuate the histopathological deficits of
experimental autoimmune encephalomyelitis over the long
term (i.e., 50 days) by suppression of perivascular immune cell
infiltrations and reduction in both demyelination and axonal
injury in the spinal cord [189]. Zhang et al. tried to infuse UC-
MSCs to treat patients with HIV-1-infected immunological
nonresponders (INRs). Their results showed that all patients
tolerated the UC-MSCs transfusions well throughout the trial.
The UC-MSCs transfusions preferentially increased circulating
naive and central memory CD4 T-cell counts and restored HIV-
1-specific IFN-g and IL-2 production in the INRs. These en-
hancements in immune reconstitution were also associated
 Q. Zhao et al. / Journal of Cellular Immunotherapy 2 (2016) 3e20
with the reduction of systemic immune activation and inflam-
mation in vivo. The data suggested that MSCs transplantation
may be used as a novel immunotherapeutic approach to
reversing immune deficiency in HIV-1-infected INRs [190].
6. Perspective
MSCs have become a subject of clinical research interest
due to their easy isolation and in vitro large scale cultivated
amplification, attractive potential for multi-lineage differenti-
ation and hematopiesis supporting, growth factors production
and cytokines secretion, and potential immunomodulatory
capacity. In addition, MSCs is definitely safe and well-toler-
ated for use in cell therapy, which provide a striking candidate
for degenerative diseases and immune mediated diseases.
Increased clinical evidence suggests that MSCs may have
great potential in the treatment and prevention of GVHD, AA,
MS, CD, SLE and some other immune mediated diseases.
Nevertheless, clinical trials yielded ambiguous results on the
effects of MSCs. These ambiguous findings might result from
insufficient standardization during the MSCs extraction,
expansion and administration procedures and interindividual
MSCs donor differences. Therefore, to obtain maximal clinical
benefit, lots of problems, including tissue sources, numbers of
cells, the optimal passage time in culture before use, cell
subpopulation and standardized process of cell production,
need to be solved before MSCs as a medicine applied widely
to treat patients. In addition, it is absolutely important to
optimize process of treatment and be able to effectively
monitor and communicate the benefits and risks of a cell
therapy to a patient. Furthermore, a clear and rigorous phar-
macokinetics and pharmacodynamics model of the mechanism
of action of transient cell therapies is absolutely necessary.
Expanding our understanding of the molecular mechanisms
governing immunomodulatory properties of MSCs will enable
us to greatly improve their clinical efficacy. Most importantly,
further well-designed, randomized and controlled clinical tri-
als should be designed for better understanding of the under-
lying biology and utilizing MSCs therapy for immune
mediated disease in the future. In addition, the cell dose that
was using in clinical treatment is still totally different in
different group study. We suggest that we should determine the
MSCs cell dose according to the biological effectiveness of the
MSCs. Meanwhile, it is really urgent to develop the biological
effectiveness of various MSCs biological functions.
Conflict of interst
The authors wish to confirm that there are no conflicts of
interest associated with this publication and there has been no
significant financial support for this work that could have
influenced its outcome.
Acknowledgments
This work was supported by The National Basic Research
Program of China (973 Program) (2011CB964802), National
15
Natural Science Foundation of China (81000196 and
81330015) and Tianjin Research Program of Application
Foundation and Advanced Technology (12JCZDJC25000).
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