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1. Manifestation of Novel Social Challenges of the European Unionin the Teaching Material ofMedical Biotechnology Master’s Programmesat theUniversity of Pécs and at the University of Debrecen Identificationnumber: TÁMOP-4.1.2-08/1/A-2009-0011

2. Manifestation of Novel Social Challenges of the European Unionin the Teaching Material ofMedical Biotechnology Master’s Programmesat theUniversity of Pécs and at the University of Debrecen Identification number: TÁMOP-4.1.2-08/1/A-2009-0011 Dr. Judit Pongrácz Threedimensionaltissuecultures and tissueengineering – Lecture 21 Commercialproducts(1)

3. Organfailure • Organ failure is organ dysfunction to such a degree that normalhomeostasiscannot be maintained without external clinical intervention. • Recently, a curativetherapyfororganfailures is onlyorgantransplantation • Regenerativemedicineoffersthesolutiontoavoidgraftrejection, the most commoncomplication of transplantation

4. Regenerativemedicine • Regenerative medicine is the process of creating living, functional tissues to repair or replace tissue or organ function lost due to damage, or congenital defects. • Ithas the potentialtosolvetheproblemsof: • the shortage of organs available for donation compared to the number of patients that require life-saving organ transplantation • organtransplantrejection, since the organ's cells will match that of the patient

5. Commercialization of tissueengineering • Rapid development of tissue engineering allows the commercialization of several products • Cellular therapies offer therapeutic solutions for serious diseases like organ failure • More and more products are approved for regular clinical use

6. Cardiovasculardiseases Heartvalves Pulmonaryvalve Aorticvalve Leftcoronary artery Right coronary artery Tricuspidvalve Bicuspidvalve

7. Artificial heart valves • Mechanical heart valves are made of biocompatible metal alloys and plastics • Durable structure, may last for many years • The non-biological surface of implants may cause blood clotting disturbances • Bacterial infection is a serious risk

8. Biological heart valves • Valves of animals, like pigs, which undergo a decellularization procedure in order to make them suitable for implantation in the human heart. • Other types of biological valves (made from decellularized equine or bovine pericardium) are sewn to a frame • They are less durable than mechanical valves

9. Tissue engineered heart valves • Scaffolds seeded with endothelial cells • Perspective: • Enhanced durability • No clotting disorders • No increased infection risk • Similar mechanical properties to that of native valves • BMMC seeded TE heart valves are available but only for the pulmonary circulation (right heart side)

10. Replacement of blood vessels • Arterial „organ failure” occurs mainly as a result of atherosclerosis • Venous „organ failure” occurs most frequently in venous varicosity • Replacement of damaged organs: only arteries • Autografts, xenografts, artificial stents or blood vessels

11. Vascular tissue engineering • Xenografts: decellularized veins, ureters or intestinal submucosa from animals (canine, porcine, rabbit origin mainly) • Recently, human allografts are used also • PCLA-PGA copolymer heart valve constructs seeded with BMSC in paediatric patients

12. Developments in vascular TE • Tissue printing of a blood vessel: • Cells: mixture of smooth muscle and endothelium • Spontaneous structure will form

13. Vascular grafts • Vascular grafting in surgery uses mainly autografts: the patient’s own veins or arteries are used to bridge closures on blood vessels. • Example: CABG surgery • Vascular stenting: Percutaneous Coronary Intervention (PCI), Abdominal Aortic Aneurysm treatment • Artificial blood vessel: Aortofemoral bypass

14. Vascular tissue engineering • Xenografts: decellularized veins, ureters or intestinal submucosa from animals (canine, porcine, rabbit origin mainly) • Recently, human allografts are used also • PCLA-PGA copolymer heart valve constructs seeded with BMSC in paediatric patients

15. Tissue engineered blood vessel • TE bloodvesselsareusedonlyinlowpressurepulmonarycirculation • Thesegraftsarenotdurableenoughtowithstandhigharterialpressure Cellisolation Cellexpansion Small-vein harvest Cellseeding onpolymer Tissue-engineeredgraft

16. TEBV production • HUVEC and SMC were grown in conventional tissue culture flasks to form a monolayer which could be peeled off • Monolayers were wrapped around inert tubular supports to form concentric layers • Inner membrane: dehydrated fibroblast sheet • Smooth muscle cells formed the second sheet • Fibroblast sheet was rolled on to form an adventitia • Endothelial cells were seeded on the inner surface

17. Cartilage injury and regeneration • Cartilage injury: acute or chronic • Acute injury: mainly traumatic • Chronic injury: inflammation/degeneration • Arthritis/Arthrosis • Regeneration is slow and in case of massive damage or chronic disease, degeneration occurs • Heavily effects life quality and frequently occurs in the developed world

18. Challenges for cartilage TE Hyalinous cartilage, not fibrous cartilage needed Avascular tissue, chondrocytes have low metabolic rate Mechanical stimulation of engineered construct is necessary for good results

19. Autologouschondrocyteimplantation(ACI) I 200-300 mg cartilage is harvested by arthroscopically from a less weight bearing area (intercondylar notch superior ridge of the medial or lateral femoral condyle) The matrix is digested enzymatically,chondrocytes are isolated Chondrocytes are cultured in vitro for approximately four to six weeks

20. Autologouschondrocyteimplantation(ACI) II • Cultured chondrocytes are applied on the damaged area during an open-knee surgery (also called arthrotomy). These autologous cells should adapt themselves to their new environment by forming new cartilage. • During the implantation, chondrocytes are applied on the damaged area in combination with a membrane (tibialperiosteum or biomembrane) or pre-seeded in a scaffold matrix.

21. Autologouschondrocyteimplantation(ACI)III Tissuecultureof isolatedchondrocytes Biopsyof healthycartilage Culturedchondrocytes injectedunder patch Damagedcartilage (Lesion) Periosteal patch harvestedfromtibia

22. Commercialproductsfor ACI Carticel® service: Genzyme Harvestedcartilage is senttoGenzyme Release of chondrocytes, culturing and proliferation of chondrocytesareperformedbythefirm The surgeonreceivestheready-to-implantdifferentiatedcells

23. Matrix-induced ACI (MACI) • Harvested chondrocytes are expanded on hyalin or collagen matrices • No significant difference in the clinical outcome between ACI and MACI • Use of MSCs in MACI are in trial currently • Main challenge: differentiation towards hyalin cartilage instead of fibrous cartilage • Many different matrices are used

24. Manifestation of Novel Social Challenges of the European Unionin the Teaching Material ofMedical Biotechnology Master’s Programmesat theUniversity of Pécs and at the University of Debrecen Identification number: TÁMOP-4.1.2-08/1/A-2009-0011 Dr. Judit Pongrácz Threedimensionaltissuecultures and tissueengineering – Lecture 22 Commercialproducts(2)

25. Bioartificial liver Assist Device • Liver has remarkable regeneration capacity on its own • Liver replacement treatments are applied in both acute and chronic liver failure • Bridges the time until a suitable donor is found • Support until the transplanted liver starts working • Treatment option for acute-on-chronic liver failure • Treatment in acute liver failure: replacing liver detoxification function until the patient’s own liver regenerated on its own

26. Liver dialysis • Dialysis-like solutions • No living cells used • Ammonia causes encephalopathia • Extracorporeal detoxification

27. Bioartificialliver Oxygen Plasma filter Bioreactor PKM-19 Livercells Patient’s plasma

28. ELAD®bioartificialliver Incubator ELADTM Heparin infusion Bloodpump ELADTM Ultrafiltrate pump Plasma filter Pumping system ELADTM ELADTM Oxygenator Cell filter Recirculation pump Bloodcircuit Ultrafiltratecircuit Glucose Reservoir Glucose infusionpump Priming infusion line

29. Cell-free ELAD: MARS Bloodcircuit Mars-Albumincircuit Dialysatecircuit MarsFluxDialyzer diaMarsFlux Adsorptioncolumns diaFlux Dialyzer Blood pump Anion exchange resin Activated charcoal Albumin pump

30. Skin grafting and replacement • Burn injuries • Chronic wounds, e.g. diabetic or PAD ulcers • Cosmetic surgery

31. Hair Erector pili muscle Sebaceous gland Epidermis Dermis Sweat gland Fat Structure of theskin

32. Purpose of skingrafting • Restorethebarrierfunction→keratinocytes • Recently no nerve, vascular, sweatglandsorhairfolliclescan be includedintotheskin

33. Split-thicknessgrafts • Full thickness burns → dermis AND epidermis are both lost • Partial thickness burns →epidermis is largely intact • If more, than 30-40% body surface is burnt, TE products are welcome by surgeons • Smaller surface burns may be cured with split thickness autografts

34. Autologousskingrafts Skin is meshedto covera largewound Grafttakenfrom patient’s healthyskin Wound

35. Integra®skinreplacement 1. A patch of syntheticskin is placedon top of damagedtissue 2. The patch containschemicalsthattriggergrowth of newbloodvessels and proteinsforskinregeneration 3. The bloodvesselsrestartblood flow tothearea and thesiliconemembrane is removed Undamageddermis Undamagedepidermis Siliconemembrane Bloodvesselsforming Restartedblood flow Underlyingtissue Syntheticskinpatch withsiliconemembrane 7 daysafterapplication 14+ daysafterapplication 4. A smallgraft of thepatient’sownskinreplacesthesiliconemembrane 5. The skingrafteventuallycreates a smoothsurface of regeneratedskin Meshedskingraft Regeneratedskin 14+ daysafterapplication 35+ daysafterapplication

36. CulturedEpithelialAllograft(CEA) • CEA alone • Integracombinedwith CEA