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Experimental Physiology 90.6 pp 799-806
DOI: 10.1113/expphysiol.2005.031377
© The Physiological Society 2005
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Pfizer Lecture in Human Physiology

New dimensions in tissue engineering: possible models for human physiology

Keith Baar1

1 Division of Molecular Physiology, University of Dundee, MSI/WTB Dow Street, Dundee DD1 5EH, UK

Abstract

Tissue engineering is a discipline of great promise. In some areas, such as the cornea, tissues engineered in the laboratory are already in clinical use. In other areas, where the tissue architecture is more complex, there are a number of obstacles to manoeuvre before clinically relevant tissues can be produced. However, even in areas where clinically relevant tissues are decades away, the tissues being produced at the moment provide powerful new models to aid the understanding of complex physiological processes. This article provides a personal view of the role of tissue engineering in advancing our understanding of physiology, with specific attention being paid to musculoskeletal tissues.

(Received 19 June 2005; accepted after revision 3 August 2005; first published online 9 August 2005)
Corresponding author K. Baar: Division of Molecular Physiology, University of Dundee, MSI/WTB Dow Street, Dundee DD1 5EH, UK. Email: k.baar{at}dundee.ac.uk

The goal of tissue engineering is to use scaffolding materials and multipotent stem cells to produce tissue replacements (Vunjak-Novakovic et al. 2004). While great progress has been made towards this goal, a number of obstacles remain, including: (1) vascularization of the engineered tissues; (2) maturation of the tissues, since most are developmentally arrested; (3) transdifferentiation of the donor stem cells to simultaneously produce all of the cells required to form a complete tissue; and (4) creation of effective interfaces between biological and artificial materials.

While these limitations currently prevent large-scale growth of tissues for use in regenerative medicine, the tissues that are currently being made are potentially powerful tools for studying tissue physiology in a controlled environment.

Need for multiple models to enable understanding of tissue physiology

Our understanding of human physiology has benefited greatly from a reductionist approach. Use of model organisms, such as non-human primates, pigs, rats, mice and flies, has given physiologists a degree of control that would never be possible in human experiments. Further reduction, studying isolated cells in culture, has given even more control by allowing us to look at the response of an individual cell type to a physiological intervention. As with all models, none of these is a true representation of what occurs in vivo within the intact human body, but they provide a great deal of initial information about the basic mechanisms underlying human physiology.

The goal of any model is to have distinct experimental advantages while remaining as close as possible to the physiological reality. This is especially important in musculoskeletal tissues. Tissues such as muscle, tendon, ligament and bone are distinct from many other tissues in the body in that their function is largely mechanical. Bone provides the rigid scaffold that gives our bodies shape and provides the levers that allow movement. Tendons and ligaments are mechanical interfaces between tissues, functioning to absorb and return force. Muscles, whether smooth, cardiac or skeletal, produce the forces required to pass foodstuffs, circulate the blood and allow us to breathe and move. Surrogate measures of function have been created for these tissues so that in vitro experiments can be linked to the physiological function. For bone, mitrogen activated protein (MAP) kinase activation, prostaglandin production or nitric oxide synthesis symbolize the adaptation to loading (Smalt et al. 1997). In tendon and ligament, collagen synthesis is correlated to functional changes (Banes et al. 1999). In skeletal muscle, protein-to-DNA ratio is used to note hypertrophy or atrophy, and this in turn is correlated to force (Rommel et al. 2001). In cardiac muscle, the expression of neonatal genes and elevation of protein synthesis are markers for growth (Boluyt et al. 1997). While these markers have their roles, what we as physiologists want to know is whether the bone is stronger, whether the tendon is stiffer or whether the muscle produces more force. To answer these questions, traditional cell culture models are insufficient.

One new model that will allow physiologists to make these determinations in vitro is three-dimensional (3D) tissue engineering. Three-dimensional tissue engineering involves isolating or transdifferentiating the desired cell type and then either providing a 3D scaffold (Radisic et al. 2004) or promoting the reorganization of a monolayer of cells into a self-organized 3D engineered tissue (Baar et al. 2005). Following the formation of the 3D construct, a variety of physiological parameters can be determined. For muscle, force production, time to peak tension, half-relaxation time and excitability (chronaxie and rheobase) can be measured by electrically stimulating the constructs while attached to a force transducer (Dennis & Kosnik, 2000; Dennis et al. 2001; Kosnik et al. 2001; Dennis & Kosnik, 2002) For tendon, tangent stiffness, ultimate tensile strain and stored energy can be measured during a stress–strain test (Garvin et al. 2003; Calve et al. 2004). For bone, tests for compression stiffness, three- or four-point bending and tensile strength are possible (Thomson et al. 1995). Using these tests it is possible to determine the effect of altered genetics or chemical or mechanical stimuli on the physiological function of the tissue. The other distinct advantage of 3D engineered tissues is that the cells can be allowed to proliferate for a short period without losing the unique mechanical properties of the cell (Hecker et al. 2005). This means that tissue from a single biopsy can be expanded to produce 30–60 genetically identical 3D engineered tissues (Huang et al. 2005). This is especially important in human experiments, where the starting material is extremely valuble. To illustrate the utility of these tools, the early results of studies from our laboratory as well as others will be discussed below.

Engineering adult skeletal muscle: role of electrical stimulation

Chronic low-frequency electrical stimulation (CLFS) was originally used to test whether motor neurone-specific impulse patterns could affect the contractile speed of skeletal muscles (Salmons & Vrbova, 1967). A tonic stimulus that mimicked the impulse pattern of a slow motor neurone was found to slow the speed of both contraction and relaxation in fast-twitch muscles. The importance of electrical activity on the phenotype of skeletal muscle was reinforced when Salmons and Sréter showed that the slow-to-fast muscle transition following cross-reinnervation of the soleus with the peroneal nerve could be reversed by CLFS (Salmons & Sreter, 1976). This experiment showed conclusively that the role of the nerve in determining muscle phenotype was largely dependent on electrical, not chemical input. Since that time, the CLFS-induced fast-to-slow transition has been shown to be the result of a change in the isoforms of the contractile proteins (myosin heavy chain, Brown et al. 1983), regulatory proteins (myosin light chain, Sreter et al. 1973; tropomyosin, Roy et al. 1979; and troponin, Hartner & Pette, 1990) and calcium-sequestering proteins (parvalbumin, Green et al. 1984; and sarco/endoplasmic reticulum Ca-ATPase (SERCA), Ohlendieck et al. 1991). The shift in protein isoforms, as well as the concomitant mitochondrial biogenesis (Takahashi & Hood, 1993), results in a fatigue-resistant muscle with an improved duty cycle.

While these in vivo experiments have given us great insight into the phenotype resulting from electrical stimulation, they are limited as to determining the molecular mechanisms underlying this change. The most promising molecular candidate underlying the fast-to-slow shift in muscle phenotype is the calcium-dependent phosphatase, calcineurin. Overexpression of calcineurin induces a fast-to-slow fibre transformation (Chin et al. 1998), and electrical stimulation is thought to activate calcineurin (Dunn et al. 2001; Kubis et al. 2002). However, in vivo it is difficult to determine whether the effects of electrical stimulation require calcineurin activation or whether electrical stimulation and calcineurin activate distinct molecular pathways that have a similar effect on muscle phenotype. To address this question directly, we have recently undertaken experiments using 3D engineered muscles treated with 2 weeks of CLFS, cyclosporin A (CsA, to block calcineurin), or both interventions together, in order to determine the effects on force production and contraction and relaxation time. To perform these experiments we formed 3D engineered muscles from primary rat soleus muscle cells and a fibrin gel scaffold (Huang et al. 2005). These constructs were either electrically stimulated with 5–20 Hz pulses every 4 s, treated with 500 ng ml–1 CsA, or given both interventions. Cyclosporin A treatment decreased the time-to-peak tension (TPT) without significantly affecting half-relaxation time (1/2RT, Fig. 1, Y. C. Huang, R. G. Dennis & K. Baar, unpublished observations). Slow electrical stimulation did not affect either the TPT or the 1/2RT of the constructs. Interestingly, both CLFS and CsA increased force production in the constructs. When the two stimuli were added together the TPT remained faster and the force produced by the constructs was 3.4-fold higher than in controls (Fig. 1). These results suggest three important things about the mechanism of CLFS/calcineurin induced changes in muscle phenotype. First, cyclosporin A treatment increases the rate of skeletal muscle contraction, probably through modulation of myosin heavy chain expression. Second, cyclosporin A treatment alone has no effect on the rate of skeletal muscle relaxation, suggesting that a permissive level of another factor is required for the shift in calcium sequestration. Lastly, inhibition of calcineurin and electrical stimulation has independent and additive effects on muscle force production, suggesting that the two stimuli use distinct anabolic mechanisms. These observations are consistent with observations by Zádor and colleagues that neither innervation nor calcineurin directly controls the expression of SERCA2a (Zador & Wuytack, 2003; Zador et al. 2005).



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Figure 1.  Representative plot from engineered muscles stimulated to perform a 10 ms twitch
Engineered muscle constructs were stimulated for 2 weeks with CLFS (slow stimulation), cyclosporin A (CsA), or both interventions (slow stimulation + CsA). Graph represents the force produced by the constructs over a 250 ms time period following stimulation (Y. C. Huang, R. G. Dennis & K. Baar, unpublished observations).

 
Engineered tendon and cardiac muscle: the importance of stretch/loading

Mechanical loading is one of the most potent stimulators of musculoskeletal growth and adaptation (Benjamin & Hillen, 2003). A number of in vitro models have been developed to test the effect of stretch on a variety of cell types in two dimensions. Most of these techniques have stretched a monolayer of cells using flexible-bottomed culture dishes that were placed under static load (Vandenburgh & Kaufman, 1979) or dynamically loaded using either a screw-driven piston (Vandenburgh et al. 1995) or a vacuum-based loading device (Banes et al. 1985). These experiments have provided valuable information; however, as discussed above, the functional changes that result are much less well understood. More recently, stretch has been used on 3D engineered musculoskeletal tissues and the functional consequences of the stretch described.

Eschenhagen and his group (Eschenhagen et al. 1997) have used mechanical loading to improve the function of their 3D engineered heart tissues (EHT). These tissues are created by a gelation process in which neonatal rat hearts are dissociated, the cardiomyocytes are mixed with a solution containing collagen I and matrigel, and then pipetted into molds of various sizes and shapes (Eschenhagen et al. 1997; Fink et al. 2000; Zimmermann et al. 2000, 2002a,b). The original description of the effect of stretch on these tissues used rectangular molds containing a piece of silicone tubing covered with Velcro® at each end to promote adhesion with the collagen gel. After 4 days in culture, the constructs were placed in a bioreactor, a device that controls the chemical, mechanical and electrical environment of the constructs, and a unidirectional stretch of between 1 and 20% was applied at a frequency of 2 Hz. The mechanical stretch induced a 40% increase in cardiomyocyte cross-sectional area and a two- to fourfold increase in force production (Fig. 2). This finding is extremely interesting since it suggests that the cardiomyocyte growth observed was compensatory and not decompensatory hypertrophy. The initial phase of heart muscle hypertrophy, in response to increased load, results in an increase force production to maintain wall stress (Frey & Olson, 2003). Prolonged strain results in a further increase in the size of the cardiomyocytes without a concomitant increase in force production. This switch, from compensatory to decompensatory growth, is a hallmark of disease progression (Czubryt & Olson, 2004). Since the best determinant of this shift is decreased coupling of cell size and force production it has been difficult to model in vitro. However, stretch of 3D engineered cardiac tissue provides a culture model that may allow identification of the molecular mechanism underlying the shift towards decompensatory growth and heart failure.



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Figure 2.  Effect of 6 days of stretch on engineered heart tissue protein content and force production
Cardiac cells within a matrigel scaffold were stretched by 20% of resting length at 1.5 Hz for 4 days and protein content (brown bars) and force production (grey bars) were determined. * indicates significance with P < 0.05. Reproduced with permission from Fink et al. (2000).

 
Stretch has also been used to study the functional response of engineered tendons to chronic loading. Garvin et al. (2003) engineered tendons by incubating avian tendon fibroblasts and a collagen gel matrix in a vacuum mold. Once the constructs had formed, they underwent a uniaxial cyclic stretching programme consisting of 1 Hz cycles of 1% elongation for 1 h per day for 7 days. At the end of the 7 day stretching period, the stiffness and ultimate tensile strength were determined. Seven days of stretch resulted in a 3.7-fold increase in stiffness and a 2.9-fold increase in ultimate tensile strength. We have since shown that a similar stretching protocol results in a 2.4-fold increase in collagen synthesis (J. J. Andrick, K. Mundy & K. Baar, unpublished observations). This increase in collagen synthesis is accompanied by the activation of a number of kinases that may be important in the response of tendon cells to stretch. Engineered tendons provide an ideal model for determining the signal transduction pathway responsible for the adaptation of tendon to activity. These experiments would be extremely difficult to perform in vivo because of the density of the extracellular matrix, the paucity of cells and the difficulty in targeting drugs or genes specifically to the tendon. In a 3D engineered model of tendon, the number of cells and the density of the matrix are controlled by the investigator, inhibitors or specific transgenes can be freely added and the effects of these interventions on tendon function can be rapidly determined.

Engineered skeletal muscle with improved fatigue resistance (overexpression studies)

One of the strengths of using engineered tissues lies in the ability to transfect the composite cells and rapidly determine the functional importance of overexpressing or knocking down specific proteins within the cells. We have used this technique in our engineered muscles to determine the effects of a coordinator of mitochondrial biogenesis, PPAR{gamma} coactivator (PGC-1{alpha}), on muscle function. Myoblasts were transfected with the PGC-1{alpha} cDNA, driven by the myosin light chain 2 slow promoter to achieve muscle-specific expression of the cDNA. Constructs were then engineered from the transfected cells and fatigue resistance was determined using a 5 min contraction protocol consisting of a single 1 s tetanus every 5 s for 5 min. Overexpression of PGC-1{alpha} resulted in a 2.75-fold increase in force at the end of the 5 min contraction period (Fig. 3). This finding mimics quite closely what is seen in mice overexpressing PGC-1{alpha} in muscle (Lin et al. 2002). Muscles from these mice showed an ~2.7-fold increase in their fatigue index compared to littermate controls. The close approximation of the effect of transfection in engineered muscle with the physiological effects of overexpression in transgenic animals provides validation for using engineered muscle as a functional model of in vivo physiology. Furthermore, when knocking out a gene of interest produces embryonic lethality in mice, knockdown experiments in engineered tissues provide a possible alternative to tissue-specific knockouts for determining the functional effects of a specific protein.



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Figure 3.  Representative trace from control and PGC-1{alpha} transfected engineered muscles
Muscles were engineered from myoblasts transfected with PGC-1{alpha} and force was determined during a 5 min contraction protocol consisting of one 1 s contraction every 5 s for 5 min. At the end of the contraction protocol, the engineered muscle transfected with PGC-1{alpha} had fatigued less than the control muscle, producing a greater percentage of its maximal force.

 
Future areas of study

Promoting increased size of engineered tissues (perfusion/vascularization).  The primary limitation to the development of large well-organized 3D engineered tissues is the delivery of nutrients and oxygen to the cells at the core of the construct. In all cases for non-perfused engineered tissues, there is a depth limit from the surface of the construct beyond which the cells will fail to survive. We term this the ‘viable radius’. When the radius of the tissue construct exceeds the viable radius for that tissue, necrosis is readily visible in the core. The viable radius of tissue constructs varies with the construction and the metabolic rate of the cells. In self-organizing cardiac tissues the viable radius appears to be in the range of 40–50 µm (Baar et al. 2005), whereas in skeletal muscle and tendon constructs it is 150–200 µm (Dennis & Kosnik, 2000; Calve et al. 2004). The gelation technique has overcome this limitation to some degree by promoting the formation of strands of cells within the scaffolding material (Zimmermann et al. 2002b). However, this has the undesirable side-effect of decreasing the function of the construct (i.e. the specific force produced). The Vunjak-Novakovic (Carrier et al. 2002a,b) and Vandenburgh laboratories (Chromiak et al. 1998) have reported temporary solutions. Both groups have successfully grown bigger constructs using a low shear stress mass perfusion apparatus (Carrier et al. 2002a,b). By mass perfusing a dense scaffolding material containing neonatal cardiac muscle cells with a flow rate from 0.6 to 3 ml min–1, Carrier et al. (2002a) were able to increase the number of cells deep within the matrix. They report that a flow rate of 0.6 ml min–1 produces a uniform cell density up to ~1 mm deep.

While experiments using perfusion can slightly increase some metabolic parameters and construct size, new methods will be required to provide the level of circulating nutrients and oxygen required for the formation of larger tissues. The most frequent method of clinical neovascularization uses an extrinsic blood supply (Cassell et al. 2002). Here, an avascular structure is implanted into an animal or human near a rich vascular bed, such as a subcutaneous region, in the mesentery, or in the omentum. Vascularization of the implanted tissue occurs as a result of the inflammatory wound healing process in response to the surgery. Implantation of 3D muscle tissues is known to result in a high degree of vascularization (Okano & Matsuda, 1998; Li et al. 1999; van Wachem et al. 1999; Leor et al. 2000; Sakai et al. 2001; Eschenhagen et al. 2002; Zimmermann et al. 2002a); however, it is unclear whether the new vascular tissue allows the constructs to grow larger upon the return to cell culture or aids in the development of a more mature phenotype.

Another possible technique that can be completed in vitro involves co-culturing the engineered tissues with embryoid bodies (Wartenberg et al. 2001). Embryoid bodies are grown from pluripotent embryonic stem cells that aggregate to form 200–400 µm balls of cells. These cells can differentiate into cells of any of the three germ layers. When embryoid bodies were cultured in contact with tumour spheroids where central necrosis was apparent, within 5 days a branched network of capillary-like structures sprouted (Wartenberg et al. 2001). This neovascularization resulted in a decrease in central necrosis and a 557% increase in the size of the tumour spheroid.

Engineering physiologically relevant tissue interfaces.  The most extreme difference between engineered tissues and in vivo tissues is at the interfaces (Fig. 4). In vivo, the transition from muscle to bone is seamless. The regional variability of tendon allows it to transfer mechanical force and power from the compliant muscle to the stiff bone with high fidelity (E. M. Arruda, S. Calve, R. G. Dennis, K. Mundy & K. Baar, unpublished observations). This natural transition prevents impedance mismatching and therefore decreases the likelihood of injury at the transition. While this aspect of physiology is essential to protecting muscle and allowing the transfer of force and power, it is very poorly understood. In fact, while 13 genes are known to be involved in determining muscle attachment in Drosophila melanogaster, no genes are known to play this role in mammals. Tendons initially develop independently from muscle in the limb bud mesoderm (Edom-Vovard & Duprez, 2004). The tendon cells only contact the somatically derived muscle cells later in development. Once linked, the presence of gradients of fibroblast growth factors, such as FGF-4 and FGF-8 (Edom-Vovard et al. 2001, 2002), and growth and differentiation factors (Wolfman et al. 1997; Aspenberg & Forslund, 1999; Lou et al. 2001; Rickert et al. 2001) are believed to give cues that are important for the formation of the tissue interface. This type of tissue development is well suited for tissue engineering. Gradients of growth factors can be immobilized on the semisolid scaffolds that form the muscle anchors (DeLong et al. 2005). Preloading the scaffolds with fibroblasts and then placing them in a muscle cell culture would recapitulate much of the developmental biology involved in tendon formation. However, whether this technique is sufficient to produce a graded non-elastic tissue like tendon has yet to be determined.



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Figure 4.  Paralympian Marlon Shirley prepares for the 200 m sprint final
The limitations in our understanding of how to engineer transitions between tissues can be easily seen by contrasting the large bolts that serve as the attachment of Mr Shirley's Ossur Flex-Foot® CheetahTM prosthetic and the intricate transition between the gastrocnemius muscle and calcaneus of his biological limb. (Brian Bahr, Getty Images).

 
Prospects for the interplay between physiology and tissue engineering.  While a great deal of progress has been made in the last 10 years, there remain numerous areas where rapid advancements can be made. New bioreactors for the development, manipulation and testing of 3D engineered muscle tissue constructs have given us the tools to improve the quality of the tissues being generated and to assess their function during culture. However, the corresponding biological effects are not being determined. Engineers have long realized that the advancement of tissue engineering depends largely on collaboration with developmental biologists and physiologists. Physiologists are only now realizing that 3D engineered tissues provide a unique model for testing physiological theories.

A number of physiological issues must be addressed in order to ensure the future development of 3D engineered musculoskeletal tissues. (1) The developmental state of the cells within the 3D constructs needs to be determined. The force of contraction, time to peak tension and half-relaxation time of muscle are determined by the isoform of myosin, calcium-handling machinery and regulatory proteins that are expressed. There are no reports in the literature on 3D skeletal muscles, and very little information in the literature on cardiac tissues, that focuses on the expression pattern of these proteins in engineered tissue. (2) Mechanisms for shifting the phenotype of the 3D engineered tissues to that of the mature tissue need to be developed. This would include: in muscle, the expression of adult contractile proteins (mature myosin heavy chain (MHC)), the proper regulatory proteins (in heart, cardiac-specific tropomyosin and troponins) and mature calcium-handling machinery (in heart, SERCA2a and phospholamban), and the desired functional architecture, such as pennation angle and fibre length; in tendon and ligament, the type of collagen and proteoglycans expressed and the regional mechanical variability of the tissue. (3) Novel techniques need to be developed to make it possible to engineer suitable tissue-to-tissue interfaces, such as the myotendonous junction. This is essential in order to provide mechanical impedance matching and to create the complex structures that are involved in the transduction of mechanical signals.

If we can answer these difficult questions, not only will we have developed functionally important engineered tissues, but we will also have greatly advanced our understanding of physiology.

Footnotes

The Pfizer Lecture in Human Physiology was given at the Physiological Society Meeting at Kings College London 18th December 2004.

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Acknowledgements

I would like to thank R. G. Dennis and Y. C. Huang for outstanding support and assistance. This work was supported by a grant from the defense advanced research projects agency (Navy) contract no. N66001 [GenBank] –02-C-8034.




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