1. Manifestation of Novel Social Challenges of the European Union in the Teaching Material of Medical Biotechnology Master’s Programmes at the University of Pécs and at the University of Debrecen Identification number: TÁMOP-4.1.2-08/1/A-2009-0011

2. COMMERCIAL PRODUCTS (1) Dr. Judit Pongrácz Three dimensional tissue cultures and tissue engineering – Lecture 21 Manifestation of Novel Social Challenges of the European Union in the Teaching Material of Medical Biotechnology Master’s Programmes at the University of Pécs and at the University of Debrecen Identification number: TÁMOP-4.1.2-08/1/A-2009-0011

3. TÁMOP-4.1.2-08/1/A-2009-0011 Organ failure Organ failure Organ failure is organ dysfunction to such a degree that normal homeostasis cannot be maintained without external clinical intervention. Recently, a curative therapy for organ failures is only organ transplantation Regenerative medicine offers the solution to avoid graft rejection, the most common complication of transplantation

4. TÁMOP-4.1.2-08/1/A-2009-0011 Regenerative medicine Regenerative medicine 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. It has the potential to solve the problems of: the shortage of organs available for donation compared to the number of patients that require life-saving organ transplantation organ transplant rejection, since the organ's cells will match that of the patient

5. TÁMOP-4.1.2-08/1/A-2009-0011 Commercialization of tissue engineering 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. TÁMOP-4.1.2-08/1/A-2009-0011 Cardiovascular diseases Aortic valve Tricuspid valve Bicuspid valve Pulmonary valve Right coronary artery Left coronary artery Heart valves

7. TÁMOP-4.1.2-08/1/A-2009-0011 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. TÁMOP-4.1.2-08/1/A-2009-0011 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. TÁMOP-4.1.2-08/1/A-2009-0011 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. TÁMOP-4.1.2-08/1/A-2009-0011 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. TÁMOP-4.1.2-08/1/A-2009-0011 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. TÁMOP-4.1.2-08/1/A-2009-0011 Developments in vascular TE Tissue printing of a blood vessel: Cells: mixture of smooth muscle and endothelium Spontaneous structure will form

13. TÁMOP-4.1.2-08/1/A-2009-0011 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. TÁMOP-4.1.2-08/1/A-2009-0011 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. TÁMOP-4.1.2-08/1/A-2009-0011 Tissue engineered blood vessel TE blood vessels are used only in low pressure pulmonary circulation These grafts are not durable enough to withstand high arterial pressure Small-veinharvest Cell seeding on polymer Cell isolation Cell expansion Tissue-engineered graft

16. TÁMOP-4.1.2-08/1/A-2009-0011 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. TÁMOP-4.1.2-08/1/A-2009-0011 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. TÁMOP-4.1.2-08/1/A-2009-0011 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. TÁMOP-4.1.2-08/1/A-2009-0011 I Autologous chondrocyte implantation (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. TÁMOP-4.1.2-08/1/A-2009-0011 II Autologous chondrocyte implantation (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 (tibial periosteum or biomembrane) or pre- seeded in a scaffold matrix.

21. TÁMOP-4.1.2-08/1/A-2009-0011 III Autologous chondrocyte implantation (ACI) III Biopsy of healthy cartilage Cultured chondrocytes injected under patch Periosteal patch harvested from tibia Damaged cartilage (Lesion) Tissue culture of isolated chondrocytes

22. TÁMOP-4.1.2-08/1/A-2009-0011 Commercial products for ACI Carticel® service: Genzyme Harvested cartilage is sent to Genzyme Release of chondrocytes, culturing and proliferation of chondrocytes are performed by the firm The surgeon receives the ready-to- implant differentiated cells

23. TÁMOP-4.1.2-08/1/A-2009-0011 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. COMMERCIAL PRODUCTS (2) Dr. Judit Pongrácz Three dimensional tissue cultures and tissue engineering – Lecture 22 Manifestation of Novel Social Challenges of the European Union in the Teaching Material of Medical Biotechnology Master’s Programmes at the University of Pécs and at the University of Debrecen Identification number: TÁMOP-4.1.2-08/1/A-2009-0011

25. TÁMOP-4.1.2-08/1/A-2009-0011 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. TÁMOP-4.1.2-08/1/A-2009-0011 Liver dialysis Dialysis-like solutions No living cells used Ammonia causes encephalopathia Extracorporeal detoxification

27. TÁMOP-4.1.2-08/1/A-2009-0011 Bioartificial liver Patient’splasma Oxygen PKM-19 Liver cells PlasmafilterBioreactor

28. TÁMOP-4.1.2-08/1/A-2009-0011 ELAD ® bioartificial liver Blood circuit Ultrafiltrate circuit Glucose ELAD TM Plasma filter Oxygenator Pumping system Reservoir Blood pump Ultrafiltrate pump Recirculation pump Glucose infusion pump Priming infusion line Heparin infusion Incubator Cell filter

29. TÁMOP-4.1.2-08/1/A-2009-0011 Cell-free ELAD: MARS MarsFlux Dialyzer diaMarsFlux Adsorption columns diaFlux Dialyzer Blood circuit Mars-Albumin circuit Dialysate circuit Blood pump Albumin pump Activated charcoal Anion exchange resin

30. TÁMOP-4.1.2-08/1/A-2009-0011 Skin grafting and replacement Burn injuries Chronic wounds, e.g. diabetic or PAD ulcers Cosmetic surgery

31. TÁMOP-4.1.2-08/1/A-2009-0011 Structure of the skin Epidermis Dermis Fat Sweat gland Erector pili muscle Hair Sebaceous gland

32. TÁMOP-4.1.2-08/1/A-2009-0011 Purpose of skin grafting Restore the barrier function → keratinocytes Recently no nerve, vascular, sweat glands or hair follicles can be included into the skin

33. TÁMOP-4.1.2-08/1/A-2009-0011 Split-thickness grafts 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. TÁMOP-4.1.2-08/1/A-2009-0011 Autologous skin grafts Skin is meshed to cover a large wound Graft taken from patient’s healthy skin Wound

35. TÁMOP-4.1.2-08/1/A-2009-0011 Integra ® skin replacement 1. A patch of synthetic skin is placed on top of damaged tissue Undamaged dermis Silicone membrane Undamaged epidermis Underlyin g tissue Synthetic skin patch with silicone membrane Blood vessels forming 3. The blood vessels restart blood flow to the area and the silicone membrane is removed 2. The patch contains chemicals that trigger growth of new blood vessels and proteins for skin regeneration 7 days after application 14+ days after application 4. A small graft of the patient’s own skin replaces the silicone membrane Meshed skin graft 14+ days after application 5. The skin graft eventually creates a smooth surface of regenerated skin Regenerat ed skin 35+ days after application Restarted blood flow

36. TÁMOP-4.1.2-08/1/A-2009-0011 Cultured Epithelial Allograft (CEA) CEA alone Integra combined with CEA