Abstract
Bone regeneration and repair are crucial to ambulation and quality of life. Factors such as poor general health, serious medical comorbidities, chronic inflammation, and ageing can lead to delayed healing and nonunion of fractures, and persistent bone defects. Bioengineering strategies to heal bone often involve grafting of autologous bone marrow aspirate concentrate (BMAC) or mesenchymal stem cells (MSCs) with biocompatible scaffolds. While BMAC shows promise, variability in its efficacy exists due to discrepancies in MSC concentration and robustness, and immune cell composition. Understanding the mechanisms by which macrophages and lymphocytes – the main cellular components in BMAC – interact with MSCs could suggest novel strategies to enhance bone healing. Macrophages are polarized into pro-inflammatory (M1) or anti-inflammatory (M2) phenotypes, and influence cell metabolism and tissue regeneration via the secretion of cytokines and other factors. T cells, especially helper T1 (Th1) and Th17, promote inflammation and osteoclastogenesis, whereas Th2 and regulatory T (Treg) cells have anti-inflammatory pro-reconstructive effects, thereby supporting osteogenesis. Crosstalk among macrophages, T cells, and MSCs affects the bone microenvironment and regulates the local immune response. Manipulating the proportion and interactions of these cells presents an opportunity to alter the local regenerative capacity of bone, which potentially could enhance clinical outcomes.
Cite this article: Bone Joint Res 2024;13(9):462–473.
Keywords: Bone regeneration, Bone marrow aspirate concentrate therapy, Cell-based therapy, Immunomodulatory therapy, Stem cells, lymphocytes, macrophages, mesenchymal stem cells (MSCs), cytokines, osteogenesis, bone marrow aspirate concentrate (BMAC), secretion, inflammation, nonunion of fractures
Article focus
Investigating the interactions of macrophages, lymphocytes, and mesenchymal stem cells (MSCs) in bone regeneration.
Exploring how the immune cells influence the osteogenic potential of MSCs and bone healing.
Evaluating potential strategies for optimizing cell-based therapies for bone regeneration by utilizing specific interactions among immune cell interactions with MSCs.
Key messages
Macrophages and lymphocytes play critical roles in bone regeneration, with different subtypes promoting either bone formation or resorption. Their interaction with MSCs is crucial for effective bone healing.
The balance between pro-inflammatory and anti-inflammatory immune cells significantly influences the osteogenic potential of MSCs, with M2 macrophages, helper T2 (Th2) and regulatory T (Treg) cells being particularly supportive of bone formation.
Enhancing the regenerative capacity of bone marrow aspirate concentrate (BMAC) by modulating immune cell composition and interactions offers a promising means to improve clinical outcomes in bone repair and regeneration.
Strengths and limitations
This study provides a comprehensive overview of the crosstalk between immune cells and MSCs, highlighting the potential for targeted immunomodulation to promote bone regeneration.
The manuscript identifies specific immune cell subtypes that can be targeted to improve the efficacy of BMAC-based therapies for bone healing, and provides practical insights for clinical applications.
The variability in outcomes due to differences in MSC concentration and immune cell composition in BMAC highlights the challenge of achieving consistent results, necessitating further research to standardize therapeutic approaches.
Introduction
Compromised bone healing often affects a patient’s function, potential for ambulation, and quality of life. Factors that could lead to undesirable clinical outcomes include: poor overall health; serious medical comorbidities such as diabetes and chronic renal disease; obesity; medications; and ageing.1,2 Chronic inflammation is present in many of these scenarios,3 and is associated with several commonly observed conditions including corticosteroid-induced osteonecrosis, fracture nonunions,4-6 and persistent bone defects.
Recently, bioengineering strategies have been developed for augmenting bone regeneration and repair. One approach includes grafting of reparative cells and a biocompatible scaffold. The most common source of cellular components is autologous bone marrow aspirate concentrate (BMAC), which fulfills the principle of “minimal manipulation” mandated by the USA Food and Drug Administration (FDA).7 Another strategy is the use of stem cell therapy, which is permissible by regulatory bodies in some countries despite these cells undergoing more than “minimal manipulation”.
BMAC is an autologous, safe, and reliable source of cells that has demonstrated a solid foundation with sufficient biological basis for bone regeneration. Some applications of BMAC include the enhancement of healing of osteonecrotic lesions during core decompression8,9 and healing of long bone fractures in pre-clinical animal studies, as well as in clinical trials.10
However, the outcomes of BMAC use are not uniformly positive. In a study by Cuomo et al,11 neither bone marrow aspirate (BMA) nor mesenchymal stem cell (MSC)-enriched BMA mixed with demineralized bone matrix resulted in reliable healing of a 6 mm critical-sized bone defect in the rat femur. The authors suggested that the number of MSCs, the presence of an enhanced osteoinductive signal (e.g. bone morphogenic protein-2 (BMP-2)), or the variability of the carrier are among many contributing factors to deficiency of bone formation in this model.
Clinical grafting of progenitor cells for fracture nonunion is safe and effective. In one study, the radiological outcome evaluated by preoperative and four-month postoperative CT scans, for the treatment of nonunions, was dependent on the percentage of progenitor cells present.12 BMAC contains a mean MSC concentration of 0.001% detected by flow cytometry; thus, the quality of the BMAC is an important factor when considering cell-based therapy.13 Furthermore, a recent meta-analysis of the use of BMAC for the treatment of small non-critical size fracture nonunions reported a healing rate of only 71% to 77%. Although there are reports that MSCs alone can promote bone formation,14,15 bone union was achieved in only 4% to 59% of cases using MSCs alone without immune cells.16 These healing rates in small defects suggest that substantially worse results are anticipated for larger critical-size bone defects. These results also highlight the importance of immune cells as a source of osteoinductive paracrine signals. Not only are immune cells involved, but the presence of endocrine/metabolic pathways and environmental factors also influence the process of bone formation.
Current clinical and pre-clinical reports together advocate for further opportunities for the optimization of BMAC as a cell-based therapy. The strategy could encompass specific targeting of the deficiencies of BMAC including the low progenitor cell number, suboptimal immune cell composition, or the variability of the delivery biomaterial. The purpose of this review was to summarize the roles of major immune cell components, including macrophages and lymphocytes (T cells) in BMAC, in terms of their effects on osteogenesis, and to identify the knowledge gap and potential opportunities to enhance osteogenesis by a minimal manipulative cytotherapeutic approach.
Major cellular components of the bone marrow
MSCs have self-renewal and multipotent differentiation capabilities, and are able to differentiate into various cell types such as osteoblasts, adipocytes, chondrocytes, myotubes, fibroblasts, and more. Currently, MSCs find broad applications in cell-based therapies owing to their immunomodulatory properties and regenerative potential. In the bone marrow, MSCs constitute a very small fraction, ranging from 0.001% to 0.01% of nucleated cells, while macrophages (granulocytic lineage) account for 40% to 55%, and T cells account for up to 25%.17 However, in addition to the potential differentiation into osteoblasts, MSCs influence macrophages and T cells by secreting paracrine factors and extracellular vesicles (EVs), thereby contributing to bone formation. The relevance of macrophages and T cells interacting with MSCs in facilitating bone formation and remodelling is briefly outlined below. Nonetheless, other immune cells also play important roles in regulating bone generation, including neutrophils and mast cells in tandem with MSCs, macrophages, and T cells; these interactions will also be briefly discussed.
Macrophages
Macrophages are members of the monocyte/macrophage/foreign body giant cell/osteoclast/dendritic cell lineage. Macrophages are present in most tissues, where they play crucial immunomodulatory roles by recognizing, engulfing, and degrading cellular debris and pathogens. In the non-stromal cell population of the bone marrow, 50% of cells are white blood cells (WBCs), i.e. monocytes/macrophages, polymorphonuclear leucocytes, mast cells, and their precursors; 25% are in the erythropoietic lineage; and the balance, about 25%, are in the T cells lineage.18 Macrophages present antigens to T cells and induce the expression of co-stimulatory molecules on antigen-presenting cells. Macrophages can alter their polarization phenotype in response to local environmental cues.19 Activated macrophages are typically classified into two general phenotypes: the pro-inflammatory (M1) and anti-inflammatory (M2) macrophage phenotypes.20,21 M1 macrophages are induced by inflammatory cytokines such as tumour necrosis factor-alpha (TNF-α) and interferon-gamma (IFN-γ) from helper T1 (Th1) cells, as well as inflammatory stimuli like bacterial lipopolysaccharide (LPS).22 M1 macrophages release high levels of pro-inflammatory cytokines such as interleukin-1-beta (IL-1β), IL-6, TNF-α, and IFN-γ.23 Conversely, M2 macrophages are induced by Th2 cytokines such as IL-4 and IL-13, and they secrete anti-inflammatory cytokines like IL-10 and transforming growth factor-beta (TGF-β).
Macrophages can differentiate into osteoclasts involved in bone resorption and metabolism.24 Furthermore, it has been reported that M1 macrophages are more prone to differentiate into osteoclasts rather than naïve or M2 macrophages.25 Osteoclasts are particularly involved in bone resorption and are promoted in inflammatory environments. Inflammatory cytokines such as IL-1 and TNF-α secreted by M1 macrophages enhance the production of receptor activator of nuclear factor kappa-B ligand (RANKL), which promotes osteoclast formation and activity. Furthermore, inflammatory cytokines IFN-γ and TNF-α induce apoptosis in bone marrow mesenchymal stem cells (BMMSCs), inhibit collagen and proteoglycan synthesis, and thereby impede bone formation.26,27 Consequently, during inflammation, the bone resorptive activity of osteoclasts can outpace the bone-forming ability of osteoblasts, greatly contributing to inflammatory bone loss. Therefore, the balance between M1 and M2 phenotypes plays a crucial role in various microenvironments including bone.28 This suggests a potential for immunomodulation at target sites by adjusting this macrophage balance, for the purpose of bone regeneration.
T cells
T cells comprise approximately 25% of the non-stromal cells in the bone marrow. They originate from haematopoietic stem cells in the bone marrow and mature in the thymus. T cells are further divided into αβ and γδ T cells; αβ T cells consist of CD4+ Th cells and CD8+ cytotoxic T cells. CD4+ Th cells are the most extensively studied subset. CD4+ Th cells interact with other immune cells via surface receptors and modulate activation states by secreting cytokines.29 CD8+ cytotoxic T cells play a crucial role in eliminating intracellular pathogens and emerging neoplasms.
CD4+ Th cells can be subdivided into different subsets based on their cytokine expression profiles, such as Th1, Th2, Th17, and regulatory T (Treg) cells. Th1 cells are polarized by IL-12, produce IFN-γ and TNF-α, induce cell-mediated immune responses, and regulate the activation of M1 pro-inflammatory macrophages and inflammatory reactions.30,31 Th2 cells, stimulated by IL-2 and IL-4, secrete IL-4, IL-5, IL-10, and IL-13 and regulate immune responses such as activation of B lymphocytes, eosinophils, and M2 macrophages.32,33 Th17 cells are stimulated by cytokines like IL-6 and IL-23, secrete IL-17 and IL-22, and participate in inflammatory and autoimmune responses.34,35 Treg cells, induced by cytokines such as TGF-β, IL-2, and IL-10, are involved in suppressing autoimmune responses and inflammation.
Generally, cytokines produced by Th1 and Th17 cells exhibit pro-inflammatory properties, while those from Th2 and Treg cells demonstrate anti-inflammatory effects. The inflammatory microenvironment has secondary effects on both osteoclasts and osteoblasts; thus, the balance between Th1/Th2 cells and Th17/Treg cells has great relevance to the homeostatic equilibrium between bone resorption and formation.
T cells are believed to play important roles in coordinating metabolism and assist in the process of tissue regeneration. For example, conditioned medium from human CD4+ T cells has been shown to statistically significantly upregulate the expression of Runt-related transcription factor 2 (Runx2), osteocalcin, alkaline phosphatase (ALP), and bone sialoprotein in allogenic MSCs, enhancing mineralization of bone in culture of MSCs.36 Therefore, it is important to delineate the roles of macrophages and T cells, and their crosstalk with stromal cells from BMA, in order to exploit their unique characteristics and enlist them as supporting factors for bone regeneration.
Neutrophils
Neutrophils are a subset of granulocytes derived from the haematopoietic stem cell lineages and are part of the innate immune system; neutrophils exhibit chemotaxis, phagocytosis, and bactericidal activity.37,38 Neutrophils are the first inflammatory cells to migrate to the injury site in response to chemotactic stimuli from resident macrophages, and participate in the clearance of bacteria, dead cells, and debris.39 Additionally, neutrophils secrete inflammatory and chemotactic mediators such as IL-6 and CCL2, which recruit monocytes/macrophages.40,41 These recruited monocytes/macrophages influence MSC migration and osteogenic differentiation.42 However, excessive and continued neutrophil-induced inflammation may contribute to impaired fracture healing, by heralding a state of chronic inflammation.3,43
Mast cells
Mast cells (MCs), derived from the haematopoietic stem cell lineage, are tissue-resident immune cells well known for promoting allergic reactions.44 Like neutrophils, MCs are part of the innate immune system and are capable of phagocytosis. They regulate vascular permeability and blood flow to initiate the rapid recruitment of effector cells such as neutrophils, eosinophils, and natural killer cells.45 MCs store and newly synthesize mediators, including cytokines and enzymes, which can be rapidly released in response to stimuli in acute inflammation or allergic reactions.46 These mediators include histamine, IL-6, and TNF-α, which promote osteoclast formation, and IL-1 and TNF-α, which inhibit osteoblast activity, thereby promoting bone resorption and inhibiting bone formation. Conversely, MCs can promote bone formation through TGF-β and potentially reduce osteoclast formation and bone resorption via IL-12. MCs also enhance MSC proliferation and migration.47 However, the effects on bone metabolism remain unclear, as studies using MC-deficient mice have shown contradictory results depending on the mouse model used.
Crosstalk between major cell types
MSCs and macrophages
MSCs and macrophages mutually influence each other, promoting osteogenesis. Studies using human buffy coats showed that factors secreted by pro-inflammatory macrophages statistically significantly increased MSC adhesion and migration, whereas factors from anti-inflammatory macrophages enhanced MSC osteogenic activity and cell migration.48 However, research utilizing human inflammatory synovium revealed that only the conditioned medium from anti-inflammatory macrophages enhanced MSC migration, with no statistically significant impact observed with pro-inflammatory macrophage-conditioned medium.49
In studies involving direct co-culture of MSCs and macrophages, it has been reported that the initial inflammatory phase regulated by M1 macrophages promotes osteogenesis by MSCs via the COX-2-PGE2 pathway.50 Macrophages derived from human monocytic leukaemia THP-1 cell line secrete IL-23 in the inflammatory environment, which activates the signal transducer and activator of transcription 3 (STAT3) and β-catenin pathways, thereby enhancing expression of markers of bone formation and osteogenic differentiation by MSCs.51 Moreover, bone formation was enhanced by promoting the differentiation of inflammatory M1 macrophages into anti-inflammatory M2 macrophages 72 hours after the initial inflammatory phase,52,53 emphasizing the importance of M1 macrophages initially and the early inflammatory environment in bone formation.42 Furthermore, recent studies have revealed that EVs, containing proteins and microRNAs and other molecules, are endocytosed by target cells, where they exert their functional influence.54 Enrichment of miR-155 in the EVs of M1 macrophages decreased osteogenic differentiation of MSCs, while treatment of MSCs with miR-378a, enriched in the EVs of M2 macrophages, increased MSC osteoinductive gene expression.55 Additionally, polarized M2 macrophages release TGF-β, promoting osteogenesis by MSCs;56 BMP-2 secreted by M2 macrophages also enhances bone differentiation,57,58 suggesting that macrophages in the M2 polarized phenotype may have a greater impact on MSC osteogenesis compared to M1 macrophages. MSCs have also been shown to possess anti-inflammatory properties and immunomodulatory functions. MSCs were shown to regulate macrophage polarization, phagocytosis, and metabolism.59 In one study, naïve macrophages cultured with MSCs promoted the secretion of the proinflammatory cytokines TNF-α and IL-12. In contrast, M1 macrophages cultured with MSCs shifted towards an M2 macrophage phenotype.60 One of the MSC-derived EVs, miR-181c, has been found to inhibit the expression of Toll-like receptor 4 (TL4) and reduce the expression of inflammatory factors such as TNF-α and IL-1β.61 Furthermore, MSC-derived EVs promoted polarization towards the M2 phenotype, leading to enhanced expression of anti-inflammatory cytokines.62,63 Additionally, it has been observed that the polarization effect of MSC-derived EVs towards the M2 phenotype is more pronounced when MSCs are pre-treated with pro-inflammatory substances or cytokines, such as LPS or elevated reactive oxygen species (ROS).64-66 MSC-derived EVs regulate macrophage polarization toward anti-inflammatory M2 macrophage subtypes, especially when inflammatory cytokines are present. In summary, the interaction between MSCs and macrophages influences the process of osteogenesis (Figure 1). The presence of macrophages was generally shown to enhance osteogenesis of MSCs alone, with M2 macrophages showing a greater beneficial effect on bone formation compared to the M1 phenotype.
MSCs and T cells
The absence of T cells in mice has been identified as a determinant for decreased differentiation and proliferation of MSCs, emphasizing the substantial crosstalk between T cells and MSCs.67 Focusing on the relationship between MSCs and cytokine-releasing CD4+ Th cells, the impact of T cells on MSCs is summarized below.
Activated T cells promoted the secretion of BMP-2 by MSCs, leading to enhanced bone formation.68 Additionally, conditioned media from human CD4+ T cells, but not CD8+ T cells, promoted bone formation in allogenic MSCs.36 CD4+ T cells consist of subsets with inflammatory Th1, Th17, and anti-inflammatory Th2, Treg characteristics. High levels of Th1 cytokines, such as IFN-γ and TNF-α, were correlated with decreased new bone formation.27 Furthermore, Th1 cells, which promote inflammation, inhibit osteoprotegerin (OPG) expression via IFN-γ production, leading to an increase in the RANKL/OPG ratio and promotion of osteoclast formation.69 Conversely, Th2 cytokines, such as IL-4 and IL-13, suppress RANKL expression by osteoblasts, enhance OPG expression, and decrease the overall RANKL/OPG ratio. These results suggest that Th2 cytokines decrease osteoclast formation and promote osteoblast activity.70-72
Treg cells can inhibit osteoclast formation through direct contact with high expression of cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) by Treg cells and cytokine-dependent mechanisms.73,74 Treg cells promote the proliferation and differentiation of osteoblasts by activating intracellular effectors such as mitogen-activated protein kinases (MAPKs) and Smad-related proteins, which induce differentiation of MSCs to osteoblasts through the secretion of TGF-β.69,75,76 Furthermore, treatment of MSCs with dihydroepiandosterone (DHEA) in a mouse model increased the proportion of Tregs, and resulted in increased osteoblastogenesis and osteogenesis.77 Additionally, Tregs have been shown to enhance the immunomodulatory properties of MSCs through the secretion of anti-inflammatory factors such as IL-10.78-80
Unlike Treg cells, Th17 cells can promote osteoclast formation through both direct and indirect mechanisms. Th17 cells directly express RANKL on their surface, stimulating the proliferation and differentiation of osteoclast precursors.81,82 IL-17 secreted by Th17 cells indirectly induced the expression of macrophage colony-stimulating factor (M-CSF) and RANKL on the surface of MSCs, promoting osteoclast formation.81,83,84 Furthermore, many cytokines produced by Th17 cells induced the production of inflammatory factors, enhanced the expression of NF-κB, and further promoted RANKL expression. IL-17 is also associated with migration and motility of MSCs.4 Additionally, a study using mouse bone marrow MSCs found that IL-17 enhances MSCs’ immunosuppressive function by increasing the expression of inducible nitric oxide synthase (iNOS) and subsequent production of nitric oxide (NO).85 Similarly, Th1 cells have also been found to enhance the immunomodulatory functions of MSCs through the secretion of proinflammatory cytokines.86,87
In summary, anti-inflammatory Th2 and Treg cells are involved in bone formation, while pro-inflammatory Th1 and Th17 cells are implicated in osteoclast formation, thereby promoting bone resorption.
Regarding the impact of MSCs on T cells, co-culture of murine T cells and MSCs led to a decrease in the levels of TNF-alpha and IFN-gamma, suggesting that MSCs exert anti-inflammatory effects.88 One of the key mechanisms through which MSCs attenuate the immune response is through modulation of the Th1/Th2 cell and Th17/Treg cell balance.78,89 MSCs are involved in shifting the Th1/Th2 balance towards Th2 cells, demonstrating their anti-inflammatory effects.90-94
Treg cells have potent and well-established anti-inflammatory effects.95-97 Numerous studies have indicated that MSCs are involved in the proliferation and differentiation of Tregs, via different pathways including the Notch signalling pathway, the Fas/Fas ligand signalling pathway, and the mTOR signalling pathway.78,98-101
Th17 cells are pro-inflammatory cells that exert their effects through the secretion of pro-inflammatory cytokines including IL-17.102,103 Multiple studies suggest that MSCs are involved in the inhibition of Th17 cells and their ability to secrete IL-17. MSC-dependent suppression of Th17 cells involves many cells and pathways including the IL-10 signalling pathway, the prostaglandin E2 (PGE2) signalling pathway, the CCL2 signalling pathway, and the PD-1/PDL1 signalling pathway.104-110 These pathways have been shown to be context-dependent. For example, PGE2 signalling by MSCs can stimulate or downregulate Th17 cells under different conditions, depending on cell maturity and the local microenvironment.105,110,111
In summary, MSCs generally promote the differentiation of T cells to anti-inflammatory Th2 and Treg cell phenotype, particularly in inflammatory environments, leading to anti-inflammatory effects (Figure 2). Conversely, Th2 and Treg cells enhance osteoblastogenesis and bone formation. Therefore, it is suggested that the interactions between MSCs and T cells are mostly skewed towards the anti-inflammatory side where MSCs, Th2, and Treg are promoting one another toward resolving the acute inflammatory response, decreasing the secretion of pro-inflammatory cytokines, and increasing the secretion of anti-inflammatory cytokines, thus enhancing bone regeneration.
Macrophages and T cells
When murine macrophages were co-cultured with Th1 cells to simulate inflammatory bowel disease (IBD), M1 polarization of macrophages was found to be promoted through STAT3 signalling.21 It was suggested that Th1 cells may play a causative role in the immune response and pathology in IBD patients, and perhaps other inflammatory disorders. The polarization pathway is dependent on the helper T cells’ phenotypes. Unlike Th1 cells, Th2 cells produce IL-4 to activate the M2 macrophage phenotype while simultaneously suppressing polarization of the M1 macrophage phenotype (Figure 3).112 Similarly, αβ T cells inhibit the inflammatory response by promoting M2 macrophage proliferation. One study found that knocking out αβ T cells led to increased polarization toward the M1 state, and decreased polarization toward the M2 state. This is a role that is also shared by Treg cells, which secrete cytokines to induce a shift towards M2 polarization, consistent with their anti-inflammatory function.67,113,114 This induction is associated with increased IL-10 production, and decreased major histocompatibility complex (MHC)-class II molecule expression. Subsequently, there is a decrease in MHC-related co-stimulation, which appears to control inflammatory processes such as Th17 cell expansion and promote immune tolerance.115 In tumours, Treg cells induce the release of IL-10 and IL-6 by macrophages, which subsequently promote tumour cell survival and Treg function.116 There is also modulation of the macrophage signalling pathway via microRNAs. Wu et al117 found that the release of IFN-γ by T cells primed the activation of macrophages, which was associated with a decrease in levels of miR-3473b. Indeed, restoration of miR-3473b levels reversed macrophage activation, suggesting a regulatory role of the microRNA in this inflammatory pathway.117 Understanding the downstream effects of these T cell/macrophage interactions, as well as potential modulators, can facilitate the identification of novel targets for immunotherapies and bone metabolism.
T cell activation requires antigen presentation via major MHC molecules. This is accomplished by different immune cells, including macrophages. Macrophages can present antigens via MHC class I or class II proteins. Macrophages also function as phagocytic cells and will digest foreign molecules and present subsequent antigens to activate T cells.118 Depending on the co-stimulatory molecules, these interactions can lead to variable T cell fates. The B7-1 ligand on macrophages can activate or inhibit T cell proliferation by binding to the CD28 receptor or cytotoxic T-lymphocyte associated protein 4 (CTLA-4) receptor on the T cell surface, respectively.119,120 One study found that the B7-CD28 interaction was synergistically acted upon by IL-12 secretion by macrophages, leading to enhanced T cell activation. These results suggest that IL-12 serves as a soluble signalling component in the T cell regulation pathway seen in macrophages.121 Another study found that administration of anti-B7 antibodies to macrophages diminished T cell responses, further underscoring the role of macrophages in early T cell activation.122
Cytokines released by macrophages also serve as a mechanism for regulating naïve T cell differentiation. Macrophages can secrete IL-12 and IFN-γ to induce Th1 proliferation. Acting in a cyclic manner, these Th1 effector cells will subsequently produce IFN-γ and TNF to upregulate macrophage phagocytosis. Another study found that synovial macrophages release IL-2 to induce Th1 differentiation. Th2 differentiation is induced by IL-4 secretion by macrophages, ultimately enhancing the anti-parasitic response. Egan et al123 showed that synovial macrophages release IL-1B, IL-6, and IL-23 to induce Th17 differentiation. Macrophages can also release TGF-β, which polarizes Treg cells and generates a phenotype characterized by immunosuppression.124 The delivery of TGF-β by M2 macrophages was found to induce the expression of CTLA-4 and other Treg-associated molecules on naïve CD4 T cells.125 MSCs secrete TGF-β, which can induce macrophages to secrete IL-10 and CCL-18. These factors subsequently stimulate Treg growth.126 Together, these findings suggest the potential of utilizing macrophages as a mechanism for controlling inflammation following surgery or as a therapy to target the immune disorders. For example, tumour-associated macrophages have been shown to suppress T cell proliferation through expression of programmed cell death ligand 1 (PD-L1) and secretion of IL-10, an anti-inflammatory cytokine. The immunosuppressive effect is also achieved by recruiting Treg cell migration to carcinomas via CCL22 signalling.127 However, this tumour-induced T cell proliferation can be reversed to target tumour growth. Macrophage-induced T cell stimulation in tumours was restored via inhibition of B7-H4 expression on tumour macrophages, highlighting a mechanism for how the macrophage–T cell axis can be regulated in various microenvironments.128 Given the key role that macrophages and T cells play in the immune and healing responses, manipulating immune cell subpopulations to optimize recovery in the clinical context should be explored. Future research should investigate how impacting the sub-composition of the immune microenvironment can improve the efficacy of immunotherapeutics and ultimately enhance clinical outcomes.
In summary, the results from crosstalk among various cell types (Figure 4) suggest opportunities to manipulate BMAC in terms of the composition or the proportions of macrophages, T cells, and MSCs so that bone regeneration can be optimized. MSCs have immunomodulatory effects. When they are co-cultured with macrophages, the macrophages would preferentially differentiate into the M2 phenotype, and these differentiated M2 macrophages promote osteoblast differentiation and bone formation. Additionally, when CD4+ T cells are added, MSCs and M2 macrophages will promote CD4+ T cells to differentiate into Th2 or Treg cells, the anti-inflammatory phenotypes. The increase in Th2 and Treg cells would further promote the polarization of macrophages into M2. Additionally, promoting anti-inflammatory M2 macrophages and Th2/Treg cells, rather than pro-inflammatory M1, Th1, and Th17 cells, reduces osteoclast formation. In other words, Th2 cells, Treg cells, and M2 macrophages are believed to not only enhance bone formation by MSCs, but also promote bone formation by inhibiting bone resorption. Therefore, the simultaneous presence of macrophages, CD4+ T cells, and MSCs is important for successful coordinated bone repair and regeneration. Understanding the optimal ratios of these cells could further enhance the bone-forming effects of BMAC, offering promising prospects for future treatments.
However, in some patients, secretion of inflammatory cytokines due to senescense-associated secretory phenotypes (SASP) from senescent cells in ageing,129 decreased oestrogen levels in postmenopausal osteoporosis,130 sustained hyperglycaemia in diabetes,131,132 and chronic inflammatory conditions like rheumatoid arthritis may alter the functions of these cells.26
Conclusion
In the context of osteogenesis, co-culture of MSCs with macrophages has been demonstrated to enhance bone formation.50,57,133 This may be attributed to the potential of M2 EVs to promote MSC-associated osteogenesis and the capacity of MSCs to differentiate from an M1 to M2 phenotype. Elevated levels of inflammatory cytokines, including M1 cytokines such as IFN-γ and TNF-α, are associated not only with a deficiency in new bone formation but also with promoting osteoclast formation, thereby enhancing bone resorption.27 Co-culturing MSCs with T cells decreases the levels of TNF-α and IFN-γ in the co-culture medium, suggesting an anti-inflammatory effect of the MSCs,88 which could influence bone formation. Furthermore, activated CD4+ T cells produce soluble factors that contribute to osteoblastic differentiation of human MSCs.84 In macrophages and T cells, Th1 and Th17 promote the pro-inflammatory M1 phenotype,21 whereas Th2 and Treg cells promote the anti-inflammatory M2 phenotype.114,115 Additionally, M1 macrophages induce the proliferation of Th1 and Th17 cells, whereas M2 induces proliferation of Th2 and Treg cells. These findings suggest the potential for promoting bone formation by co-culturing MSCs, macrophages, and T cells together, highlighting the importance of understanding the roles of these cells. These findings have major implications for future therapies for immunomodulation of bone to enhance fracture healing and repair bone defects.
Author contributions
M. Murayama: Conceptualization, Data curation, Resources, Visualization, Writing – original draft, Writing – review & editing
S. K. Chow: Conceptualization, Formal analysis, Writing – original draft, Writing – review & editing
M. L. Lee: Writing – original draft, Writing – review & editing
B. Young: Writing – original draft, Writing – review & editing
Y. S. Ergul: Writing – review & editing
I. Shinohara: Writing – review & editing
Y. Susuki: Writing – review & editing
M. Toya: Writing – review & editing
Q. Gao: Writing – review & editing
S. B. Goodman: Conceptualization, Formal analysis, Writing – review & editing
Funding statement
The authors disclose receipt of the following financial or material support for the research, authorship, and/or publication of this article: this project was partially funded by S. B. Goodman's position as the Robert L. and Mary Ellenburg Professor of Surgery, Stanford University.
ICMJE COI statement
S. B. Goodman reports partial funding from his position as Robert L. and Mary Ellenburg Professor of Surgery, Stanford University, related to this study.
Data sharing
The data that support the findings for this study are available to other researchers from the corresponding author upon reasonable request.
© 2024 Murayama et al. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (CC BY-NC-ND 4.0) licence, which permits the copying and redistribution of the work only, and provided the original author and source are credited. See https://creativecommons.org/licenses/by-nc-nd/4.0/
Contributor Information
Masatoshi Murayama, Email: muramasa@stanford.edu, muramasa218@gmail.com.
Simon K. Chow, Email: skhchow@stanford.edu, skhchow@ort.cuhk.edu.hk.
Max L. Lee, Email: maxlee12@stanford.edu.
Bill Young, Email: younbil@stanford.edu.
Yasemin S. Ergul, Email: yaseminsudeergul@gmail.com.
Issei Shinohara, Email: issei27@stanford.edu.
Yosuke Susuki, Email: susuki10@stanford.edu.
Masakazu Toya, Email: mtoyaorthop@gmail.com.
Qi Gao, Email: qigao7@stanford.edu.
Stuart B. Goodman, Email: goodbone@stanford.edu.
Data Availability
The data that support the findings for this study are available to other researchers from the corresponding author upon reasonable request.
References
- 1. Chow SKH, Chim YN, Wang JY, Wong RMY, Choy VMH, Cheung WH. Inflammatory response in postmenopausal osteoporotic fracture healing. Bone Joint Res. 2020;9(7):368–385. doi: 10.1302/2046-3758.97.BJR-2019-0300.R2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Kushioka J, Chow SK-H, Toya M, et al. Bone regeneration in inflammation with aging and cell-based immunomodulatory therapy. Inflamm Regen. 2023;43(1):29. doi: 10.1186/s41232-023-00279-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3. Bastian O, Pillay J, Alblas J, Leenen L, Koenderman L, Blokhuis T. Systemic inflammation and fracture healing. J Leukoc Biol. 2011;89(5):669–673. doi: 10.1189/jlb.0810446. [DOI] [PubMed] [Google Scholar]
- 4. Fong K, Truong V, Foote CJ, et al. Predictors of nonunion and reoperation in patients with fractures of the tibia: an observational study. BMC Musculoskelet Disord. 2013;14(1):103. doi: 10.1186/1471-2474-14-103. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5. Bishop JA, Palanca AA, Bellino MJ, Lowenberg DW. Assessment of compromised fracture healing. J Am Acad Orthop Surg. 2012;20(5):273–282. doi: 10.5435/JAAOS-20-05-273. [DOI] [PubMed] [Google Scholar]
- 6. Calori GM, Albisetti W, Agus A, Iori S, Tagliabue L. Risk factors contributing to fracture non-unions. Injury. 2007;38:S11–8. doi: 10.1016/s0020-1383(07)80004-0. [DOI] [PubMed] [Google Scholar]
- 7.No authors listed Regulatory Considerations for Human Cells, Tissues, and Cellular and Tissue-Based Products: Minimal Manipulation and Homologous Use: Guidance for Industry and Food and Drug Administration Staff. Food and Drug Administration (FDA) 2020. [21 August 2024]. https://www.fda.gov/media/109176/download#:~:text=Under%20the%20regulatory%20framework%20for,1271.3 date last. accessed.
- 8. Goodman SB. The biological basis for concentrated iliac crest aspirate to enhance core decompression in the treatment of osteonecrosis. Int Orthop. 2018;42(7):1705–1709. doi: 10.1007/s00264-018-3830-1. [DOI] [PubMed] [Google Scholar]
- 9. Maruyama M, Lin T, Kaminow NI, et al. The efficacy of core decompression for steroid-associated osteonecrosis of the femoral head in rabbits. J Orthop Res. 2021;39(7):1441–1451. doi: 10.1002/jor.24888. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10. Gianakos A, Ni A, Zambrana L, Kennedy JG, Lane JM. Bone marrow aspirate concentrate in animal long bone healing: an analysis of basic science evidence. J Orthop Trauma. 2016;30(1):1–9. doi: 10.1097/BOT.0000000000000453. [DOI] [PubMed] [Google Scholar]
- 11. Cuomo AV, Virk M, Petrigliano F, Morgan EF, Lieberman JR. Mesenchymal stem cell concentration and bone repair: potential pitfalls from bench to bedside. J Bone Joint Surg Am. 2009;91-A(5):1073–1083. doi: 10.2106/JBJS.H.00303. [DOI] [PubMed] [Google Scholar]
- 12. Hernigou P, Poignard A, Beaujean F, Rouard H. Percutaneous autologous bone-marrow grafting for nonunions. Influence of the number and concentration of progenitor cells. J Bone Joint Surg Am. 2005;87-A(7):1430–1437. doi: 10.2106/JBJS.D.02215. [DOI] [PubMed] [Google Scholar]
- 13. Brozovich A, Sinicrope BJ, Bauza G, et al. High variability of mesenchymal stem cells obtained via bone marrow aspirate concentrate compared with traditional bone marrow aspiration technique. Orthop J Sports Med. 2021;9(12):23259671211058459. doi: 10.1177/23259671211058459. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14. Xu C, Liu Y. Osteosarcoma cells/cell lines are not appropriate for studies on bone regeneration in vitro. Bone Joint Res. 2023;12(5):311–312. doi: 10.1302/2046-3758.125.BJR-2023-0088.R1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15. Gómez-Barrena E, Padilla-Eguiluz N-G, López-Marfil M, Ruiz de la Reina R, REBORNE Consortium Volume and location of bone regeneration after autologous expanded mesenchymal stromal cells in hip osteonecrosis: a pilot study. Bone Joint Res. 2022;11(12):881–889. doi: 10.1302/2046-3758.1112.BJR-2022-0152.R1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16. Palombella S, Lopa S, Gianola S, Zagra L, Moretti M, Lovati AB. Bone marrow-derived cell therapies to heal long-bone nonunions: a systematic review and meta-analysis - which is the best available treatment? Stem Cells Int. 2019;2019:3715964. doi: 10.1155/2019/3715964. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17. Hulme CH, Perry J, McCarthy HS, et al. Cell therapy for cartilage repair. Emerg Top Life Sci. 2021;5(4):575–589. doi: 10.1042/ETLS20210015. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18. Goodman SB, Zwingenberger S. Concentrated autologous bone marrow aspirate is not “stem cell” therapy in the repair of nonunions and bone defects. Biomater Biosyst. 2021;2:100017. doi: 10.1016/j.bbiosy.2021.100017. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19. Ferrante CJ, Leibovich SJ. Regulation of macrophage polarization and wound healing. Adv Wound Care (New Rochelle) 2012;1(1):10–16. doi: 10.1089/wound.2011.0307. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20. Gordon S, Martinez FO. Alternative activation of macrophages: mechanism and functions. Immunity. 2010;32(5):593–604. doi: 10.1016/j.immuni.2010.05.007. [DOI] [PubMed] [Google Scholar]
- 21. Ruan S, Xu L, Sheng Y, et al. Th1 promotes M1 polarization of intestinal macrophages to regulate colitis-related mucosal barrier damage. Aging (Albany NY) 2023;15(14):6721–6735. doi: 10.18632/aging.204629. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22. Awad F, Assrawi E, Jumeau C, et al. Impact of human monocyte and macrophage polarization on NLR expression and NLRP3 inflammasome activation. PLoS One. 2017;12(4):e0175336. doi: 10.1371/journal.pone.0175336. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23. Thomas L, Rao Z, Gerstmeier J, et al. Selective upregulation of TNFα expression in classically-activated human monocyte-derived macrophages (M1) through pharmacological interference with V-ATPase. Biochem Pharmacol. 2017;130:71–82. doi: 10.1016/j.bcp.2017.02.004. [DOI] [PubMed] [Google Scholar]
- 24. Yao Y, Cai X, Ren F, et al. The macrophage-osteoclast axis in osteoimmunity and osteo-related diseases. Front Immunol. 2021;12:664871. doi: 10.3389/fimmu.2021.664871. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25. Liang B, Wang H, Wu D, Wang Z. Macrophage M1/M2 polarization dynamically adapts to changes in microenvironment and modulates alveolar bone remodeling after dental implantation. J Leukoc Biol. 2021;110(3):433–447. doi: 10.1002/JLB.1MA0121-001R. [DOI] [PubMed] [Google Scholar]
- 26. Goldring SR. Pathogenesis of bone and cartilage destruction in rheumatoid arthritis. Rheumatology (Oxford) 2003;42(90002):ii11–6. doi: 10.1093/rheumatology/keg327. [DOI] [PubMed] [Google Scholar]
- 27. Liu Y, Wang L, Kikuiri T, et al. Mesenchymal stem cell-based tissue regeneration is governed by recipient T lymphocytes via IFN-γ and TNF-α. Nat Med. 2011;17(12):1594–1601. doi: 10.1038/nm.2542. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28. Muñoz J, Akhavan NS, Mullins AP, Arjmandi BH. Macrophage polarization and osteoporosis: a review. Nutrients. 2020;12(10):2999. doi: 10.3390/nu12102999. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29. Ziemkiewicz N, Hilliard G, Pullen NA, Garg K. The role of innate and adaptive immune cells in skeletal muscle regeneration. Int J Mol Sci. 2021;22(6):3265. doi: 10.3390/ijms22063265. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30. Szabo SJ, Sullivan BM, Stemmann C, Satoskar AR, Sleckman BP, Glimcher LH. Distinct effects of T-bet in TH1 lineage commitment and IFN-gamma production in CD4 and CD8 T cells. Science. 2002;295(5553):338–342. doi: 10.1126/science.1065543. [DOI] [PubMed] [Google Scholar]
- 31. Hölscher C. The power of combinatorial immunology: IL-12 and IL-12-related dimeric cytokines in infectious diseases. Med Microbiol Immunol. 2004;193(1):1–17. doi: 10.1007/s00430-003-0186-x. [DOI] [PubMed] [Google Scholar]
- 32. Zhu J, Min B, Hu-Li J, et al. Conditional deletion of Gata3 shows its essential function in T(H)1-T(H)2 responses. Nat Immunol. 2004;5(11):1157–1165. doi: 10.1038/ni1128. [DOI] [PubMed] [Google Scholar]
- 33. Gordon S. Alternative activation of macrophages. Nat Rev Immunol. 2003;3(1):23–35. doi: 10.1038/nri978. [DOI] [PubMed] [Google Scholar]
- 34. Guo K, Zhang X. Cytokines that modulate the differentiation of Th17 cells in autoimmune uveitis. J Immunol Res. 2021;2021:6693542. doi: 10.1155/2021/6693542. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35. Liang SC, Tan X-Y, Luxenberg DP, et al. Interleukin (IL)-22 and IL-17 are coexpressed by Th17 cells and cooperatively enhance expression of antimicrobial peptides. J Exp Med. 2006;203(10):2271–2279. doi: 10.1084/jem.20061308. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36. Grassi F, Cattini L, Gambari L, et al. T cell subsets differently regulate osteogenic differentiation of human mesenchymal stromal cells in vitro. J Tissue Eng Regen Med. 2016;10(4):305–314. doi: 10.1002/term.1727. [DOI] [PubMed] [Google Scholar]
- 37. Deng Z, Zhang Q, Zhao Z, et al. Crosstalk between immune cells and bone cells or chondrocytes. Int Immunopharmacol. 2021;101(Pt A):108179. doi: 10.1016/j.intimp.2021.108179. [DOI] [PubMed] [Google Scholar]
- 38. Teng T-S, Ji A-L, Ji X-Y, Li Y-Z. Neutrophils and immunity: from bactericidal action to being conquered. 2017. J Immunol Res. 2017;2017:9671604. doi: 10.1155/2017/9671604. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 39. Loi F, Córdova LA, Pajarinen J, Lin T, Yao Z, Goodman SB. Inflammation, fracture and bone repair. Bone. 2016;86:119–130. doi: 10.1016/j.bone.2016.02.020. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 40. Hurst SM, Wilkinson TS, McLoughlin RM, et al. IL-6 and its soluble receptor orchestrate a temporal switch in the pattern of leukocyte recruitment seen during acute inflammation. Immunity. 2001;14(6):705–714. doi: 10.1016/s1074-7613(01)00151-0. [DOI] [PubMed] [Google Scholar]
- 41. Xing Z, Lu C, Hu D, et al. Multiple roles for CCR2 during fracture healing. Dis Model Mech. 2010;3(7–8):451–458. doi: 10.1242/dmm.003186. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 42. Omar OM, Granéli C, Ekström K, et al. The stimulation of an osteogenic response by classical monocyte activation. Biomaterials. 2011;32(32):8190–8204. doi: 10.1016/j.biomaterials.2011.07.055. [DOI] [PubMed] [Google Scholar]
- 43. Gibon E, Lu LY, Nathan K, Goodman SB. Inflammation, ageing, and bone regeneration. J Orthop Translat. 2017;10:28–35. doi: 10.1016/j.jot.2017.04.002. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 44. Galli SJ, Tsai M. IgE and mast cells in allergic disease. Nat Med. 2012;18(5):693–704. doi: 10.1038/nm.2755. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 45. Ragipoglu D, Dudeck A, Haffner-Luntzer M, et al. The role of mast cells in bone metabolism and bone disorders. Front Immunol. 2020;11:163. doi: 10.3389/fimmu.2020.00163. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 46. Wernersson S, Pejler G. Mast cell secretory granules: armed for battle. Nat Rev Immunol. 2014;14(7):478–494. doi: 10.1038/nri3690. [DOI] [PubMed] [Google Scholar]
- 47. Nazari M, Ni NC, Lüdke A, et al. Mast cells promote proliferation and migration and inhibit differentiation of mesenchymal stem cells through PDGF. J Mol Cell Cardiol. 2016;94:32–42. doi: 10.1016/j.yjmcc.2016.03.007. [DOI] [PubMed] [Google Scholar]
- 48. Vallés G, Bensiamar F, Maestro-Paramio L, García-Rey E, Vilaboa N, Saldaña L. Influence of inflammatory conditions provided by macrophages on osteogenic ability of mesenchymal stem cells. Stem Cell Res Ther. 2020;11(1):57. doi: 10.1186/s13287-020-1578-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 49. Wesdorp MA, Bastiaansen-Jenniskens YM, Capar S, Verhaar JAN, Narcisi R, Van Osch G. Modulation of inflamed synovium improves migration of mesenchymal stromal cells in vitro through anti-inflammatory macrophages. Van Cartilage. 2022;13(1):19476035221085136. doi: 10.1177/19476035221085136. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 50. Lu LY, Loi F, Nathan K, et al. Pro-inflammatory M1 macrophages promote osteogenesis by mesenchymal stem cells via the COX-2-prostaglandin E2 pathway. J Orthop Res. 2017;35(11):2378–2385. doi: 10.1002/jor.23553. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 51. Tu B, Liu S, Liu G, et al. Macrophages derived from THP-1 promote the osteogenic differentiation of mesenchymal stem cells through the IL-23/IL-23R/β-catenin pathway. Exp Cell Res. 2015;339(1):81–89. doi: 10.1016/j.yexcr.2015.10.015. [DOI] [PubMed] [Google Scholar]
- 52. Loi F, Córdova LA, Zhang R, et al. The effects of immunomodulation by macrophage subsets on osteogenesis in vitro. Stem Cell Res Ther. 2016;7:15. doi: 10.1186/s13287-016-0276-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 53. Nathan K, Lu LY, Lin T, et al. Precise immunomodulation of the M1 to M2 macrophage transition enhances mesenchymal stem cell osteogenesis and differs by sex. Bone Joint Res. 2019;8(10):481–488. doi: 10.1302/2046-3758.810.BJR-2018-0231.R2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 54. Kalluri R, LeBleu VS. The biology, function, and biomedical applications of exosomes. Science. 2020;367(6478):eaau6977. doi: 10.1126/science.aau6977. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 55. Kang M, Huang C-C, Lu Y, et al. Bone regeneration is mediated by macrophage extracellular vesicles. Bone. 2020;141:115627. doi: 10.1016/j.bone.2020.115627. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 56. Liu H, Wu Q, Liu S, et al. The role of integrin αvβ3 in biphasic calcium phosphate ceramics mediated M2 macrophage polarization and the resultant osteoinduction. Biomaterials. 2024;304:122406. doi: 10.1016/j.biomaterials.2023.122406. [DOI] [PubMed] [Google Scholar]
- 57. Zhang Y, Böse T, Unger RE, Jansen JA, Kirkpatrick CJ, van den Beucken JJJP. Macrophage type modulates osteogenic differentiation of adipose tissue MSCs. Cell Tissue Res. 2017;369(2):273–286. doi: 10.1007/s00441-017-2598-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 58. Jiang F, Qi X, Wu X, et al. Regulating macrophage-MSC interaction to optimize BMP-2-induced osteogenesis in the local microenvironment. Bioact Mater. 2023;25:307–318. doi: 10.1016/j.bioactmat.2023.02.001. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 59. Lu D, Xu Y, Liu Q, Zhang Q. Mesenchymal stem cell-macrophage crosstalk and maintenance of inflammatory microenvironment homeostasis. Front Cell Dev Biol. 2021;9:681171. doi: 10.3389/fcell.2021.681171. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 60. Vasandan AB, Jahnavi S, Shashank C, Prasad P, Kumar A, Prasanna SJ. Human mesenchymal stem cells program macrophage plasticity by altering their metabolic status via a PGE2-dependent mechanism. Sci Rep. 2016;6:38308. doi: 10.1038/srep38308. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 61. Li X, Liu L, Yang J, et al. Exosome derived from human umbilical cord mesenchymal stem cell mediates MiR-181c attenuating burn-induced excessive inflammation. EBioMedicine. 2016;8:72–82. doi: 10.1016/j.ebiom.2016.04.030. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 62. Li J, Xue H, Li T, et al. Exosomes derived from mesenchymal stem cells attenuate the progression of atherosclerosis in ApoE−/- mice via miR-let7 mediated infiltration and polarization of M2 macrophage. Biochem Biophys Res Commun. 2019;510(4):565–572. doi: 10.1016/j.bbrc.2019.02.005. [DOI] [PubMed] [Google Scholar]
- 63. Li K, Yan G, Huang H, et al. Anti-inflammatory and immunomodulatory effects of the extracellular vesicles derived from human umbilical cord mesenchymal stem cells on osteoarthritis via M2 macrophages. J Nanobiotechnology. 2022;20(1):38. doi: 10.1186/s12951-021-01236-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 64. An JH, Li Q, Bhang DH, Song WJ, Youn HY. TNF-α and INF-γ primed canine stem cell-derived extracellular vesicles alleviate experimental murine colitis. Sci Rep. 2020;10(1):2115. doi: 10.1038/s41598-020-58909-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 65. Ti D, Hao H, Tong C, et al. LPS-preconditioned mesenchymal stromal cells modify macrophage polarization for resolution of chronic inflammation via exosome-shuttled let-7b. J Transl Med. 2015;13:308. doi: 10.1186/s12967-015-0642-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 66. Lo Sicco C, Reverberi D, Balbi C, et al. Mesenchymal stem cell-derived extracellular vesicles as mediators of anti-inflammatory effects: endorsement of macrophage polarization. Stem Cells Transl Med. 2017;6(3):1018–1028. doi: 10.1002/sctm.16-0363. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 67. Avery D, Morandini L, Gabriec M, et al. Contribution of αβ T cells to macrophage polarization and MSC recruitment and proliferation on titanium implants. Acta Biomater. 2023;169:605–624. doi: 10.1016/j.actbio.2023.07.052. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 68. Rifas L. T-cell cytokine induction of BMP-2 regulates human mesenchymal stromal cell differentiation and mineralization. J Cell Biochem. 2006;98(4):706–714. doi: 10.1002/jcb.20933. [DOI] [PubMed] [Google Scholar]
- 69. Tanaka Y. Clinical immunity in bone and joints. J Bone Miner Metab. 2019;37(1):2–8. doi: 10.1007/s00774-018-0965-5. [DOI] [PubMed] [Google Scholar]
- 70. Young N, Mikhalkevich N, Yan Y, Chen D, Zheng W. Differential regulation of osteoblast activity by Th cell subsets mediated by parathyroid hormone and IFN-gamma. J Immunol. 2005;175(12):8287–8295. doi: 10.4049/jimmunol.175.12.8287. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 71. Lubberts E, Joosten LA, Chabaud M, et al. IL-4 gene therapy for collagen arthritis suppresses synovial IL-17 and osteoprotegerin ligand and prevents bone erosion. J Clin Invest. 2000;105(12):1697–1710. doi: 10.1172/JCI7739. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 72. Onoe Y, Miyaura C, Kaminakayashiki T, et al. IL-13 and IL-4 inhibit bone resorption by suppressing cyclooxygenase-2-dependent prostaglandin synthesis in osteoblasts. J Immunol. 1996;156(2):758–764. doi: 10.4049/jimmunol.156.2.758. [DOI] [PubMed] [Google Scholar]
- 73. Zaiss MM, Axmann R, Zwerina J, et al. Treg cells suppress osteoclast formation: a new link between the immune system and bone. Arthritis Rheum. 2007;56(12):4104–4112. doi: 10.1002/art.23138. [DOI] [PubMed] [Google Scholar]
- 74. Rossi M, Rana I, Buonuomo PS, et al. Stimulation of Treg cells to inhibit osteoclastogenesis in Gorham-Stout disease. Front Cell Dev Biol. 2021;9:706596. doi: 10.3389/fcell.2021.706596. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 75. Runyan CE, Liu Z, Schnaper HW. Phosphatidylinositol 3-kinase and Rab5 GTPase inversely regulate the Smad anchor for receptor activation (SARA) protein independently of transforming growth factor-β1. J Biol Chem. 2012;287(43):35815–35824. doi: 10.1074/jbc.M112.380493. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 76. Zhu L, Hua F, Ding W, Ding K, Zhang Y, Xu C. The correlation between the Th17/Treg cell balance and bone health. Immun Ageing. 2020;17(1):30. doi: 10.1186/s12979-020-00202-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 77. Qiu X, Gui Y, Xu Y, Li D, Wang L. DHEA promotes osteoblast differentiation by regulating the expression of osteoblast-related genes and Foxp3(+) regulatory T cells. Biosci Trends. 2015;9(5):307–314. doi: 10.5582/bst.2015.01073. [DOI] [PubMed] [Google Scholar]
- 78. Chen Q-H, Wu F, Liu L, et al. Mesenchymal stem cells regulate the Th17/Treg cell balance partly through hepatocyte growth factor in vitro. Stem Cell Res Ther. 2020;11(1):91. doi: 10.1186/s13287-020-01612-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 79. Vasilev G, Ivanova M, Ivanova-Todorova E, et al. Secretory factors produced by adipose mesenchymal stem cells downregulate Th17 and increase Treg cells in peripheral blood mononuclear cells from rheumatoid arthritis patients. Rheumatol Int. 2019;39(5):819–826. doi: 10.1007/s00296-019-04296-7. [DOI] [PubMed] [Google Scholar]
- 80. Lim J-Y, Im K-I, Lee E-S, et al. Enhanced immunoregulation of mesenchymal stem cells by IL-10-producing type 1 regulatory T cells in collagen-induced arthritis. Sci Rep. 2016;6:26851. doi: 10.1038/srep26851. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 81. Huang H, Kim HJ, Chang E-J, et al. IL-17 stimulates the proliferation and differentiation of human mesenchymal stem cells: implications for bone remodeling. Cell Death Differ. 2009;16(10):1332–1343. doi: 10.1038/cdd.2009.74. [DOI] [PubMed] [Google Scholar]
- 82. Sato K, Suematsu A, Okamoto K, et al. Th17 functions as an osteoclastogenic helper T cell subset that links T cell activation and bone destruction. J Exp Med. 2006;203(12):2673–2682. doi: 10.1084/jem.20061775. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 83. Kotake S, Udagawa N, Takahashi N, et al. IL-17 in synovial fluids from patients with rheumatoid arthritis is a potent stimulator of osteoclastogenesis. J Clin Invest. 1999;103(9):1345–1352. doi: 10.1172/JCI5703. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 84. Croes M, Öner FC, van Neerven D, et al. Proinflammatory T cells and IL-17 stimulate osteoblast differentiation. Bone. 2016;84:262–270. doi: 10.1016/j.bone.2016.01.010. [DOI] [PubMed] [Google Scholar]
- 85. Han X, Yang Q, Lin L, et al. Interleukin-17 enhances immunosuppression by mesenchymal stem cells. Cell Death Differ. 2014;21(11):1758–1768. doi: 10.1038/cdd.2014.85. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 86. Cassano JM, Schnabel LV, Goodale MB, Fortier LA. Inflammatory licensed equine MSCs are chondroprotective and exhibit enhanced immunomodulation in an inflammatory environment. Stem Cell Res Ther. 2018;9(1):82. doi: 10.1186/s13287-018-0840-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 87. Han Y, Yang J, Fang J, et al. The secretion profile of mesenchymal stem cells and potential applications in treating human diseases. Signal Transduct Target Ther. 2022;7(1):92. doi: 10.1038/s41392-022-00932-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 88. Sui B-D, Chen J, Zhang X-Y, et al. Gender-independent efficacy of mesenchymal stem cell therapy in sex hormone-deficient bone loss via immunosuppression and resident stem cell recovery. Exp Mol Med. 2018;50(12):1–14. doi: 10.1038/s12276-018-0192-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 89. Wang K, Shi Y-J, Song Z-L, et al. Regulatory effect of rat bone marrow mesenchymal stem cells on Treg/Th17 immune balance invitro. Mol Med Rep. 2020;21(5):2123–2130. doi: 10.3892/mmr.2020.11019. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 90. Salek Farrokhi A, Zarnani AH, Moazzeni SM. Mesenchymal stem cells therapy protects fetuses from resorption and induces Th2 type cytokines profile in abortion prone mouse model. Transpl Immunol. 2018;47:26–31. doi: 10.1016/j.trim.2018.01.002. [DOI] [PubMed] [Google Scholar]
- 91. Weiss ARR, Dahlke MH. Immunomodulation by mesenchymal stem cells (MSCs): mechanisms of action of living, apoptotic, and dead MSCs. Front Immunol. 2019;10:1191. doi: 10.3389/fimmu.2019.01191. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 92. Ge W, Jiang J, Arp J, Liu W, Garcia B, Wang H. Regulatory T-cell generation and kidney allograft tolerance induced by mesenchymal stem cells associated with indoleamine 2,3-dioxygenase expression. Transplantation. 2010;90(12):1312–1320. doi: 10.1097/TP.0b013e3181fed001. [DOI] [PubMed] [Google Scholar]
- 93. Wang Q, Sun B, Wang D, et al. Murine bone marrow mesenchymal stem cells cause mature dendritic cells to promote T-cell tolerance. Scand J Immunol. 2008;68(6):607–615. doi: 10.1111/j.1365-3083.2008.02180.x. [DOI] [PubMed] [Google Scholar]
- 94. Bai L, Lennon DP, Eaton V, et al. Human bone marrow-derived mesenchymal stem cells induce Th2-polarized immune response and promote endogenous repair in animal models of multiple sclerosis. Glia. 2009;57(11):1192–1203. doi: 10.1002/glia.20841. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 95. van der Veeken J, Gonzalez AJ, Cho H, et al. Memory of inflammation in regulatory T cells. Cell. 2016;166(4):977–990. doi: 10.1016/j.cell.2016.07.006. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 96. Rocamora-Reverte L, Melzer FL, Würzner R, Weinberger B. The complex role of regulatory T cells in immunity and aging. Front Immunol. 2020;11:616949. doi: 10.3389/fimmu.2020.616949. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 97. Lei H, Schmidt-Bleek K, Dienelt A, Reinke P, Volk H-D. Regulatory T cell-mediated anti-inflammatory effects promote successful tissue repair in both indirect and direct manners. Front Pharmacol. 2015;6:184. doi: 10.3389/fphar.2015.00184. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 98. Akiyama K, Chen C, Wang D, et al. Mesenchymal-stem-cell-induced immunoregulation involves FAS-ligand-/FAS-mediated T cell apoptosis. Cell Stem Cell. 2012;10(5):544–555. doi: 10.1016/j.stem.2012.03.007. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 99. Rashedi I, Gómez-Aristizábal A, Wang XH, Viswanathan S, Keating A. TLR3 or TLR4 activation enhances mesenchymal stromal cell-mediated Treg induction via notch signaling. Stem Cells. 2017;35(1):265–275. doi: 10.1002/stem.2485. [DOI] [PubMed] [Google Scholar]
- 100. Abe Y, Ochiai D, Taguchi M, et al. Human amniotic fluid stem cells ameliorate thioglycollate-induced peritonitis by increasing Tregs in mice. Int J Mol Sci. 2022;23(12):6433. doi: 10.3390/ijms23126433. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 101. Luo Y, Guo J, Zhang P, et al. Mesenchymal stem cell protects injured renal tubular epithelial cells by regulating mTOR-mediated Th17/Treg axis. Front Immunol. 2021;12:684197. doi: 10.3389/fimmu.2021.684197. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 102. Tesmer LA, Lundy SK, Sarkar S, Fox DA. Th17 cells in human disease. Immunol Rev. 2008;223:87–113. doi: 10.1111/j.1600-065X.2008.00628.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 103. Singh RP, Hasan S, Sharma S, et al. Th17 cells in inflammation and autoimmunity. Autoimmun Rev. 2014;13(12):1174–1181. doi: 10.1016/j.autrev.2014.08.019. [DOI] [PubMed] [Google Scholar]
- 104. Luz-Crawford P, Hernandez J, Djouad F, et al. Mesenchymal stem cell repression of Th17 cells is triggered by mitochondrial transfer. Stem Cell Res Ther. 2019;10(1):232. doi: 10.1186/s13287-019-1307-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 105. Terraza-Aguirre C, Campos-Mora M, Elizondo-Vega R, et al. Mechanisms behind the immunoregulatory dialogue between mesenchymal stem cells and Th17 cells. Cells. 2020;9(7):1660. doi: 10.3390/cells9071660. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 106. Rafei M, Campeau PM, Aguilar-Mahecha A, et al. Mesenchymal stromal cells ameliorate experimental autoimmune encephalomyelitis by inhibiting CD4 Th17 T cells in a CC chemokine ligand 2-dependent manner. J Immunol. 2009;182(10):5994–6002. doi: 10.4049/jimmunol.0803962. [DOI] [PubMed] [Google Scholar]
- 107. Glenn JD, Smith MD, Kirby LA, Baxi EG, Whartenby KA. Disparate effects of mesenchymal stem cells in experimental autoimmune encephalomyelitis and cuprizone-induced demyelination. PLoS One. 2015;10(9):e0139008. doi: 10.1371/journal.pone.0139008. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 108. Luz-Crawford P, Noël D, Fernandez X, et al. Mesenchymal stem cells repress Th17 molecular program through the PD-1 pathway. PLoS One. 2012;7(9):e45272. doi: 10.1371/journal.pone.0045272. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 109. Qu X, Liu X, Cheng K, Yang R, Zhao RCH. Mesenchymal stem cells inhibit Th17 cell differentiation by IL-10 secretion. Exp Hematol. 2012;40(9):761–770. doi: 10.1016/j.exphem.2012.05.006. [DOI] [PubMed] [Google Scholar]
- 110. Wang D, Huang S, Yuan X, et al. The regulation of the Treg/Th17 balance by mesenchymal stem cells in human systemic lupus erythematosus. Cell Mol Immunol. 2017;14(5):423–431. doi: 10.1038/cmi.2015.89. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 111. Rozenberg A, Rezk A, Boivin M-N, et al. Human mesenchymal stem cells impact Th17 and Th1 responses through a prostaglandin E2 and myeloid-dependent mechanism. Stem Cells Transl Med. 2016;5(11):1506–1514. doi: 10.5966/sctm.2015-0243. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 112. DeNardo DG, Barreto JB, Andreu P, et al. CD4(+) T cells regulate pulmonary metastasis of mammary carcinomas by enhancing protumor properties of macrophages. Cancer Cell. 2009;16(2):91–102. doi: 10.1016/j.ccr.2009.06.018. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 113. Collison LW, Workman CJ, Kuo TT, et al. The inhibitory cytokine IL-35 contributes to regulatory T-cell function. Nature. 2007;450(7169):566–569. doi: 10.1038/nature06306. [DOI] [PubMed] [Google Scholar]
- 114. Tiemessen MM, Jagger AL, Evans HG, van Herwijnen MJC, John S, Taams LS. CD4+CD25+Foxp3+ regulatory T cells induce alternative activation of human monocytes/macrophages. Proc Natl Acad Sci U S A. 2007;104(49):19446–19451. doi: 10.1073/pnas.0706832104. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 115. Romano M, Fanelli G, Tan N, et al. Expanded regulatory T cells induce alternatively activated monocytes with a reduced capacity to expand T helper-17 cells. Front Immunol. 2018;9:1625. doi: 10.3389/fimmu.2018.01625. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 116. Kryczek I, Wei S, Zhu G, et al. Relationship between B7-H4, regulatory T cells, and patient outcome in human ovarian carcinoma. Cancer Res. 2007;67(18):8900–8905. doi: 10.1158/0008-5472.CAN-07-1866. [DOI] [PubMed] [Google Scholar]
- 117. Wu C, Xue Y, Wang P, et al. IFN-γ primes macrophage activation by increasing phosphatase and tensin homolog via downregulation of miR-3473b. J Immunol. 2014;193(6):3036–3044. doi: 10.4049/jimmunol.1302379. [DOI] [PubMed] [Google Scholar]
- 118. Unanue ER. Antigen-presenting function of the macrophage. Annu Rev Immunol. 1984;2:395–428. doi: 10.1146/annurev.iy.02.040184.002143. [DOI] [PubMed] [Google Scholar]
- 119. Greenwald RJ, Freeman GJ, Sharpe AH. The B7 family revisited. Annu Rev Immunol. 2005;23:515–548. doi: 10.1146/annurev.immunol.23.021704.115611. [DOI] [PubMed] [Google Scholar]
- 120. Sharpe AH, Pauken KE. The diverse functions of the PD1 inhibitory pathway. Nat Rev Immunol. 2018;18(3):153–167. doi: 10.1038/nri.2017.108. [DOI] [PubMed] [Google Scholar]
- 121. Kubin M, Kamoun M, Trinchieri G. Interleukin 12 synergizes with B7/CD28 interaction in inducing efficient proliferation and cytokine production of human T cells. J Exp Med. 1994;180(1):211–222. doi: 10.1084/jem.180.1.211. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 122. Powers GD, Faherty DA, Connaughton SE, et al. Expression and functional analysis of murine B7 delineated by a novel monoclonal antibody. Cell Immunol. 1994;153(2):298–311. doi: 10.1006/cimm.1994.1030. [DOI] [PubMed] [Google Scholar]
- 123. Egan PJ, van Nieuwenhuijze A, Campbell IK, Wicks IP. Promotion of the local differentiation of murine Th17 cells by synovial macrophages during acute inflammatory arthritis. Arthritis Rheum. 2008;58(12):3720–3729. doi: 10.1002/art.24075. [DOI] [PubMed] [Google Scholar]
- 124. Swain SL, McKinstry KK, Strutt TM. Expanding roles for CD4. Nat Rev Immunol. 2012;12(2):136–148. doi: 10.1038/nri3152. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 125. Schmidt A, Zhang X-M, Joshi RN, et al. Human macrophages induce CD4(+)Foxp3(+) regulatory T cells via binding and re-release of TGF-β. Immunol Cell Biol. 2016;94(8):747–762. doi: 10.1038/icb.2016.34. [DOI] [PubMed] [Google Scholar]
- 126. Melief SM, Schrama E, Brugman MH, et al. Multipotent stromal cells induce human regulatory T cells through a novel pathway involving skewing of monocytes toward anti-inflammatory macrophages. Stem Cells. 2013;31(9):1980–1991. doi: 10.1002/stem.1432. [DOI] [PubMed] [Google Scholar]
- 127. DeNardo DG, Ruffell B. Macrophages as regulators of tumour immunity and immunotherapy. Nat Rev Immunol. 2019;19(6):369–382. doi: 10.1038/s41577-019-0127-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 128. Kryczek I, Zou L, Rodriguez P, et al. B7-H4 expression identifies a novel suppressive macrophage population in human ovarian carcinoma. J Exp Med. 2006;203(4):871–881. doi: 10.1084/jem.20050930. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 129. Franceschi C, Bonafè M, Valensin S, et al. Inflamm-aging. An evolutionary perspective on immunosenescence. Ann N Y Acad Sci. 2000;908:244–254. doi: 10.1111/j.1749-6632.2000.tb06651.x. [DOI] [PubMed] [Google Scholar]
- 130. Fischer V, Haffner-Luntzer M. Interaction between bone and immune cells: Implications for postmenopausal osteoporosis. Semin Cell Dev Biol. 2022;123:14–21. doi: 10.1016/j.semcdb.2021.05.014. [DOI] [PubMed] [Google Scholar]
- 131. Li Z, Zhang B, Shang J, et al. Diabetic and nondiabetic BMSC–derived exosomes affect bone regeneration via regulating miR-17-5p/SMAD7 axis. Int Immunopharmacol. 2023;125:111190. doi: 10.1016/j.intimp.2023.111190. [DOI] [PubMed] [Google Scholar]
- 132. Tang Y, Zheng L, Zhou J, et al. miR‑203‑3p participates in the suppression of diabetes‑associated osteogenesis in the jaw bone through targeting Smad1. Int J Mol Med. 2018;41(3):1595–1607. doi: 10.3892/ijmm.2018.3373. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 133. Romero-López M, Li Z, Rhee C, et al. Macrophage effects on mesenchymal stem cell osteogenesis in a three-dimensional in vitro bone model. Tissue Eng Part A. 2020;26(19–20):1099–1111. doi: 10.1089/ten.TEA.2020.0041. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings for this study are available to other researchers from the corresponding author upon reasonable request.