Mesenchymal Stem Cell Derived-Exosomes: A Modern Approach in Translational Medicine

Nikfarjam
et al. J Transl Med (2020) 18:449

https://doi.org/10.1186/s12967-020-02622-3 Journal of
Translational Medicine
REVIEW Open Access
Mesenchymal stem cell derived‑exosomes:

a modern approach in translational medicine
Sepideh Nikfarjam1, Jafar Rezaie2, Naime Majidi Zolbanin3 and Reza Jafari2*
Abstract
Mesenchymal stem cells (MSCs) have captured great attention in regenerative medicine for over a few decades by
virtue of their differentiation capacity, potent immunomodulatory properties, and their ability to be favorably cultured
and manipulated. Recent investigations implied that the pleiotropic effects of MSCs is not associated to their ability of
differentiation, but rather is mediated by the secretion of soluble paracrine factors. Exosomes, nanoscale extracellular
vesicles, are one of these paracrine mediators. Exosomes transfer functional cargos like miRNA and mRNA molecules,
peptides, proteins, cytokines and lipids from MSCs to the recipient cells. Exosomes participate in intercellular com-
munication events and contribute to the healing of injured or diseased tissues and organs. Studies reported that
exosomes alone are responsible for the therapeutic effects of MSCs in numerous experimental models. Therefore,
MSC-derived exosomes can be manipulated and applied to establish a novel cell-free therapeutic approach for treat-
ment of a variety of diseases including heart, kidney, liver, immune and neurological diseases, and cutaneous wound
healing. In comparison with their donor cells, MSC-derived exosomes offer more stable entities and diminished safety
risks regarding the administration of live cells, e.g. microvasculature occlusion risk. This review discusses the exosome
isolation methods invented and utilized in the clinical setting thus far and presents a summary of current information
on MSC exosomes in translational medicine.
Keywords: Mesenchymal stem cell, Exosome, Extracellular vesicle, Exosome isolation, Regenerative medicine
Background [1, 3]. MSCs are known for their ability of differentia-
Mesenchymal stem/stromal cells (MSCs) are multipo- tion, self-renewal and colony formation [4]. The unique
tent nonhematopoietic adult cells initially discovered by capacity of MSCs to proliferate in vitro and differenti-
Alexander Friedenstein while studying the bone marrow. ate into various cellular phenotypes represented a great
MSCs, possibly originated from the mesoderm, were opportunity for their recruitment as therapeutic agents
reported to express CD73, CD90 and CD105 plasma to heal necrotic or apoptotic cells of the connective tis-
membrane markers while not expressing CD14, CD34 sue. In fact, MSCs can differentiate into different lineages
and CD45 molecules [1, 2]. In addition to the bone of mesenchymal origin including adipocytes, endothe-
marrow, MSCs can be isolated from other adult tissues lial cells, cardiomyocytes, chondrocytes and osteoblasts
including adipose tissue, amniotic fluid, dental pulp, pla- as well as numerous nonmesenchymal lineages such as
centa, umbilical cord blood, Wharton’s jelly and even the hepatocytes and neuron-like cells [5, 6]. The differentia-
brain, kidney, liver, lung, spleen, pancreas and thymus tion of MSCs into functional nonmesodermal cells casted
doubt on the conventional paradigm that adult stem
cells only differentiate from their corresponding germ
*Correspondence: Jafari.reza@umsu.ac.ir
2
Solid Tumor Research Center, Cellular and Molecular Medicine Research
layer [7]. While subsequent investigations attributed this
Institute, Urmia University of Medical Sciences, Shafa St, Ershad Blvd, P.O. cross-germ line differentiation to cell fusion events or
BoX: 1138, 57147 Urmia, Iran methodology limitations [8, 9], the mechanism of tissue
Full list of author information is available at the end of the article
© The Author(s) 2020. This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing,
adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and
the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material
in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material
is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds
the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://crea-
tivecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdo-
main/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
Nikfarjam et al. J Transl Med (2020) 18:449 Page 2 of 21
repair by MSCs particularly in nonmesodermal tissues nonhaematopoietic cell types including reticulocytes, B
remained to be unraveled. and T lymphocytes, platelets, mast cells, intestinal epi-
It was originally assumed that upon in vivo injection, thelial cells, dendritic cells, neoplastic cell lines, and the
MSCs start to regenerate the damaged/diseased sites by immune cells of the nervous system, i.e. microglia and
travelling to the respective locations, engraftment, and neurons [16–18]. Accumulating knowledge has revealed
subsequent differentiation into mature functional cells. that exosomes play significant role in a variety of cell-
However, this classic hypothesis was later challenged by to-cell interaction pathways associated with numerous
findings from numerous animal and human studies per- physiological and pathological functions.
formed during the last decades. To our surprise, it was According to their molecular composition and mor-
demonstrated that MSCs neither engraft in large quanti- phology, there are different populations of MVBs and
ties nor for time spans long enough to explain the tissue thus different populations of exosomes within a cell.
replacement process [10]. According to a more contem- However, not all MVBs are destined for extracellular
porary hypothesis, MSCs employ alternate modes of tis- release. For instance, it was shown that only MVBs con-
sue repair and affect their neighboring cells by inducing taining higher proportion of cholesterol could fuse with
cell viability, proliferation and differentiation, decreas- the cellular membrane of B lymphocytes and secrete
ing cell apoptosis and fibrosis, stimulating extracellular exosomes [19]. More interestingly, multiple researches
matrix remodeling, and sometimes adjusting the local have shown that exosomes secreted from the apical
immune system responses to inhibit inflammation. These and basolateral sides of polarized cells have different
alternate strategies involve paracrine signaling between molecular compositions [20]. However, the content of
MSCs and the adjacent cells, which is facilitated by pro- exosomes partly reflects the content of their parent cells
ducing and releasing certain trophic factors, cytokines, [21]. Exosomes contain a wide variety of cytoplasmic and
chemokines and hormones, intercellular interactions membrane proteins including receptors, enzymes, tran-
facilitated by tunneling nanotubes, and secreting extra- scription factors, extracellular matrix proteins, nucleic
cellular vesicles (EVs) like exosomes [3]. Exosomes acids (mtDNA, ssDNA, dsDNA, mRNA and miRNA)
derived from MSCs represent biological functions simi- and lipids [18]. Investigations of the exosomal protein
lar to these cells by contributing to tissue regeneration content have revealed that some of these proteins are
through enclosing and conveying active biomolecules restricted to certain cell/tissue types, but others are com-
such as peptides, proteins and RNA species to the dis- mon among all exosomes. While cell adhesion molecules
eased cells/tissues [11]. In this article, we overview cur- (CAMs), integrins, tetraspanins and major histocompati-
rent available exosome isolation methods intended for bility complex (MHC) I/II proteins are common amongst
therapeutic application, and then summarize recent all exosomes, a number of fusion and transferring pro-
important achievements regarding the therapeutic imple- teins like Rab2, Rab7, annexins, flotillin, heat shock and
mentation of MSC-derived exosomes in regenerative cytoskeleton proteins, and MVB-generating proteins like
medicine in both experimental models and clinical trials. Alix (ALG2-interacting protein X) are considered non-
specific exosomal proteins [22, 23].
Exosomes Unlike proteins, exosomal lipid content is usually con-
Exosomes (30–150 nm in diameter) are classified as one served and cell type-specific. Lipids play pivotal roles
of the three subpopulations of EVs. The other two sub- in forming and protecting exosomal structure, vesicle
populations include microvesicles/shedding particles and biogenesis and regulation of homeostasis in their target
apoptotic bodies (both larger than 100 nm). Exosomes cells [24]. For instance, enhanced concentrations of lyso-
are formed by sprouting as intraluminal vesicles (ILVs) bisphosphatidic acid in the inner phospholipid layer of
within the luminal space of late endosomes or so-called MVB membrane in cooperation with Alix enable inward
multivesicular bodies (MVBs) [12]. The ILVs are then sprouting of MVBs and thereby exosome formation [25].
secreted as exosomes once MVBs incorporate to the Exosomes also regulate the homeostasis of their target
cellular membrane. Exosomes were initially detected cells by altering their lipid composition particularly in
by Rose Johnstone and colleagues in 1983 as the vesi- cholesterol and sphingomyelin [25].
cles involved in mammalian reticulocyte differentiation
and maturation [13]. Johnstone selected the term “exo-
some” because “the process seemed to be akin to reverse Methods of exosome isolation for therapeutic application
endocytosis, with internal vesicular contents released in In the following section, we will discuss the two most
contrast to external molecules internalized in membrane- frequently utilized methods, i.e. ultracentrifugation
bound structures” [14, 15]. Exosomes are constantly pro- (UC)-based techniques and ultrafiltration (UF), for isola-
duced and released by numerous haematopoietic and tion of exosomes for therapeutic application. Schematic
representation of the isolation methods is depicted enrichment of exosomes. In fact, the final preparation is
in Fig. 1 and both methods are compared in detail in somewhat low in exosome recovery and often includes
Table 1. other particles such as serum lipoparticles [29]. If the
secretory autophagy pathway is induced, lipid droplets
Ultracentrifugation‑based techniques originated from autophagosomes can also be co-isolated
When a suspension is centrifuged, its constituents will be with exosomes [30]. The presence of large quantities of
separated on the basis of their physical features such as cholesteryl ester or triacylglycerol in the final preparation
size, shape and density, the exerted centrifugal force, and is defined as an index of impurity which is caused by lipo-
the viscosity of the solvent. In ultracentrifugation (UC), proteins or lipid droplets [31]. Therefore, it was proposed
extremely high centrifugal forces (up to 1,000,000 g) are that the outcome of the 100,000 g pellet should be con-
applied to particulate components of a sample. UC meth- sidered “small EVs”, not ‘exosomes’ [32]. In an attempt to
ods are generally divided into analytical and preparative increase the exosomal yield obtained by DUC, UC dura-
techniques. In the field of exosome isolation, preparation was increased to 4 h which led to serious physical
tive UC methods are considered the gold standard and damage to the exosomes, not to mention the higher con-
account for approximately 56% of all methods employed tamination levels of soluble proteins [33]. DUC is labori-
by researchers [26]. In the following section, we will ous and time-consuming, however, it is generally appli-
discuss two types of common preparative UC-based cable to large sample volumes [34], making its scalability
approaches for isolation of exosomes. feasible for clinical purposes [29]. Another drawback of
DUC method is that its outcome is restricted by rotor
Differential ultracentrifugation The successive steps of capacity. Nevertheless, DUC technique requires little
centrifugation and debris removal is referred to as dif- methodological expertise and almost no sample pretreat-
ferential ultracentrifugation (DUC), which is the first and ment [33]. Additionally, DUC is cost-effective over time
still most frequent method implemented for isolation of and is widely utilized for isolation of exosomes in the clin-
EVs. Prior to isolation, sample is cleaned from large bio- ical setting [35–38].
components and protease inhibitors are used to prevent
degradation of exosomal proteins [27]. DUC consists of Density gradient ultracentrifugation In density gradi-
two to three successive low-speed (500 g) centrifugation ent ultracentrifugation (DGUC), a density gradient is
steps to pellet out cells, microvesicles and other parti- usually constructed using iodoxinol, CsCl, or sucrose in
cles of the extracellular matrix. Further purification is a centrifuge tube before the separation takes place [39].
then performed by 0.22 microfiltration and elimination DGUC was reported to efficiently separate exosomes
of apoptotic bodies through centrifugation at 10,000 g. from soluble cellular components and protein aggregates,
Finally, exosomes are retrieved by UC at approximately and resulted in the purest exosome recovery in compari-
100,000–120,000 g for 60–120 min and subsequent wash- son with DUC and precipitation-based techniques [40].
ing in a proper medium like phosphate buffered saline DGUC methods generally include rate-zonal ultracentrif-
(PBS) [28]. Since the size and density of most EVs and ugation and isopycnic ultracentrifugation. Several inves-
other cellular components overlap to some extent, DUC tigations have combined DGUC methods with DUC and
does not yield pure exosomes, but rather results in an reported that the purity of the separated exosomes were
(See figure on next page.)

Fig. 1 Schematic representation of most frequently utilized exosome isolation methods for therapeutic purpose. a Differential ultracentrifugation
(DUC): Sample is subjected to 2‒3 steps of low-speed (500 g) centrifugation to pellet out cells, microvesicles (MVs), extracellular matrix (ECM)
components, and cellular debris. The supernatant is then centrifuged at 10,000 g for removal of apoptotic bodies (ABs) and contaminating
proteins. Finally, exosomes are retrievd by a long (60–120 min) ultracentrifugation (UC) step at 100,000–200,000 g and subsequent washing of
the pellet in PBS; b rate-zonal ultracentrifugation (RZUC): RZUC is a type of density gradient UC (DGUC) where sample is placed at the surface of
a gradient density medium such as sucrose, and following a step of UC at 100,000 g, sample components migrate through the gradient density
and separate according to their size and shape; c isopycnic ultracentrifugation (IPUC): IPUC is another type of DGUC that separates particles based
on their density. Sample is usually mixed with a self-generating gradient substance such as CsCl, and is then subjected to a long UC step. In the
end, distributed components form bands, so-called the isopycnic position, where the buoyant density of the collected particles matches with
the gradient density of the surrounding solution. The banded exosomes can be retrieved from the density zone between 1.10 and 1.21 g/mL by
fractionation; d sequential filtration (SF): Sample is first subjected to a 100-nm dead-end (normal) filteration process to separate cells and larger
particles. Then, contaminating proteins are excluded via tangential flow filtration using a 500-kDa MWCO membrane. Lastly, the filtrate is once more
passed through a track-etch membrane filter (with pore size of 100 nm) at very low pressure in order to inhibit passing of flexible nonexosomal EVs
into the filtrate while allowing for passage of exosomes
drastically improved. However, the gradient construction exosome preparation for clinical purposes [41]. Neverthe-
in this strategy was extremely time-consuming and fur- less, several studies have successfully combined sucrose/
ther precaution was required to inhibit the gradient dam- deuterium oxide (D2O) DGUC with UC for isolation of
age during acceleration and deceleration step [28]. DGUC exosomes for clinical use [42, 43].
usually leads to a relatively low exosomal yield and is not Rate-zonal ultracentrifugation: In rate-zonal ultracen-
capable of discriminating different populations of EVs trifugation (RZUC), the sample is located in a thin zone
[32], which generally limits its application to large-scale at the surface of a shallow gradient density medium,
Table 1 Comparison of two most frequently utilized exosome isolation methods for clinical utility
DUC UF
Mechanism of exosome separation Physical features of exosomes (size, shape and density), the exerted Particle size and MWCO
centrifugal force, and the viscosity of the solvent of the utilized filter
membrane
Recovery I H
Purity H L
Specificity I L
Sample volume I H
Efficiency I I
Time H H
Cost L I
Complexity I L
Functionality of exosomes I I
Scalability I H
Advanced equipment I L
References [113–117] [118–121]
L low, I intermediate, H high
Recovery: exosomal yield; purity: the ability of isolating exosomes with minimum contamination; specificity: the ability to separate exosomes from nonexosomal
content; sample volume: the required amount of starting material; efficiency: sample processing with high quality; time: the ability to isolate exosomes in a short
amount of time; cost: the required amount of money; complexity: the need for training before use; functionality of exosomes: the use of isolated exosomes for
downstream functional analysis without changing their efficacy; scalability: the ability to isolate exosomes from large sample volumes without overly increasing time,
cost, or personnel required; advanced equipment: the need for expensive equipment and device
which possesses a lower density than that of any of the centrifugation, a steep density gradient is created in the
sample particles [41]. Then the intended centrifugal force centrifuge tube [46]. As components distribute, they
is exercised and the sample components start to travel form bands (so-called the isopycnic position) where the
through the gradient density, which gradually grows from buoyant density of the collected particles matches with
the top to the bottom of the tube, and the particles are the gradient density of the surrounding solution. The
finally separated into various zones of the tube. Since the separation of exosomes into a distinct region merely
sample particles are denser than the gradient medium, depends on their density difference from all other com-
RZUC separates components primarily based on their ponents if a sufficient time of centrifugation is applied
size and shape rather than by density [44]. The larger [41]. The banded exosomes are retrieved from the density
components and also the more spherically symmetrical zone between 1.10 and 1.21 g/mL by fractionation, which
particles migrate more rapidly through the gradient [44]. is performed either by removing certain amounts of frac-
The duration of the centrifugation phase is of significant tions from the top of the tube or by draining particles
importance, and if not properly optimized, all particles with a long-needle syringe. The concentrated exosome
will finally copellet at the bottom of the tube since they aliquot is then subjected to a short UC at ∼100,000 g and
are all denser than the gradient [28]. To avoid exosome resuspended in PBS for further analysis [41]. IPUC is a
sedimentation, a high-density cushion is typically applied very precise technique with the ability of differentiating
to layer the bottom of the centrifuge tube [41]. The capac- exosomes from other vesicles like apoptotic bodies and
ity of RZUC is limited due to small loading region of the microvesicles as well as soluble proteins [28]. However, it
centrifuge tube which presents an obstacle for large-scale is not generally applicable to clinical-scale exosome prep-
exosome preparations of clinical relevance [44]. arations [46].
Isopycnic ultracentrifugation: Isopycnic ultracentrifu-
gation (IPUC) (also known as buoyant DUC or equi- Ultrafiltration
librium DGUC) recruits the concept of buoyancy for As is the case with any other conventional membrane
separating particles based on their density. The sample filtration, ultrafiltration (UF) separates exosomes on the
density should be between the lowest and highest den- basis of their size and molecular weight cut-off (MWCO)
sity range of the gradient [45]. In IPUC, the sample is of the utilized membrane filter. MWCO is an arbitrary
located in a dense medium at the bottom of the gradient unit representative of membrane pore size, which is uti-
or uniformly mixed with a self-generating gradient sub- lized for characterizing UF membranes. UF membranes
stance such as CsCl [41]. Following a long high-speed were initially used to purify biological fluids for retaining
macromolecules particularly peptides and globular pro- MSCs (hBM-MSCs). Intramyocardial injection of
teins. Since biological macromolecules are described by exosomes was reported to improve cardiac indices such as
their molecular weight, the ability of UF membranes to cardiac systolic and diastolic performances and blood flow
retain these macromolecules is defined by their molecu- [50]. MSC exosomes were also able to exert therapeu-
lar weight. MWCO is described as the molecular weight tic effects by reducing vascular remodeling and hypoxic
where 90% of the macromolecular component is rejected pulmonary hypertension in mice. These outcomes were
by the membrane. Exosomes larger than pores of the mediated by inactivation of signal transducer and acti-
membrane are held by it and smaller components are vator of transcription 3 (STAT3) pathway and upregula-
transited through the membrane. One major drawback tion of miR-204 in the lung cells [51]. Exosomes released
of UF is the trapping and clogging of exosomes on mem- from genetically modified rat BM-MSCs overexpressing
brane filter. Thus, they cannot be recovered for down- CXCR4 (ExoCR4) were reported to enhance the levels of
stream analysis [39]. However, the isolation efficiency can insulin-like growth factor 1α (IGF1α) and pAkt, inhibit
be improved by starting the process with large MWCO caspase 3, and promote vascular endothelial growth factor
membranes and then shifting to smaller ones [39]. UF (VEGF) upregulation and tubulogenesis in cultured car-
is simpler and faster than UC, does not involve any spe- diomyocytes. Moreover, when ExoCR4-pretreated MSC-
cial equipment, and can be easily scaled up and applied sheet was engrafted into the damaged myocardium of a
to the clinical field of exosomes [36, 47]. However, UF rat MI model, the infarct size remarkably decreased and
may sometimes result in exosomal damage because of angiogenesis was triggered [52]. In another study, BM-
the implemented shear force, which can be minimized MSC exosomes promoted tube formation by endothelial
through careful regulation of the pressure exerted on the cells as well as T cell inhibition, reduction of the infarct
membrane [33]. size, and recovery of cardiac systolic and diastolic per-
Sequential filtration (SF) is a UF technique used for formances [53, 54]. Investigation of the role of exosomal
isolation of exosomes by successive steps of filtration. miRNA molecules demonstrated that miR-22-enriched
First, the biosample is loaded on a 100-nm filter, which exosomes were notably successful in decreasing the
sieves out cells and large rigid cellular components and infarct size and cardiac fibrosis in a murine post-MI
debris by dead-end (normal) filtration. Although their model via targeting MECP2 (methyl-CpG-binding protein
diameter is larger than 100 nm, different EV populations 2) [55]. BM-MSC exosomes carrying miR-221 exhibited
pass through this filter since they are flexible and soft anti-apoptotic and cardioprotective effects by downregu-
[48]. The remaining contaminants like soluble proteins lating PUMA (p53 upregulated modulator of apoptosis)
are then eliminated by tangential flow filtration using a expression in vitro [56]. Another work performed by the
500-kDa MWCO membrane and the biosample is further same team revealed that exosomal miR-19a could reduce
concentrated. The filtrate is once more passed through the infarct size and restore cardiac function through
a membrane filter, so-called track-etch membrane, with downregulating phosphatase and tensin homolog (PTEN)
defined pore sizes (100 nm) at very low pressure in order and triggering the Akt and ERK signaling pathways in an
to inhibit passing of flexible nonexosomal EVs into the acute MI rat model [57]. Additionally, exosomal miR-210
filtrate while allowing for passage of exosomes. SF is one were shown to promote angiogenesis and retain cardiac
of the most efficient methods which is performed within function both ex vivo and in vivo [58]. In an attempt to
a day. The process is automation-friendly and due to low explore the cardioprotective effects of endometrium-
manipulation forces, results in intact high-purity func- derived MSC exosomes, exosome-mediated shuttling of
tional exosomes. Additionally, SF is capable of isolating miR-21 was attributed to the suppression of PTEN, stimu-
exosomes from large sample volumes (up to 1 L) [34], lation of Akt, and upregulation of Bcl-2 and VEGF. As a
which has been implemented in clinical trials [49]. result, cardiac function was restored and the infarct size
was diminished [59]. Notable results were also found by
Application of mesenchymal stem cell‑derived exosomes Zhang et al. when cardiac stem cells were preconditioned
in regenerative medicine with BM-MSC exosomes and administered to a rat model
The therapeutic effects of MSC exosomes in preclinical of MI [60]. Here, cardiac fibrosis was reduced and survival
studies are depicted in Fig. 2 and the details are summa- and capillary density were drastically improved.
rized in Table 2.
Kidney diseases
Cardiovascular diseases In order to investigate the renoprotective effects of
The cardioprotective effects of exosomes secreted from BM-MSC exosomes, Bruno et al. found that exosomal
MSCs was investigated in a rat myocardial infarction (MI) mRNAs encoding CDC6, CDK8 and CCNB1 along with
model using vesicles from human bone marrow-derived exosomal hepatocyte growth factor (HGF) and IGF1
Fig. 2 Regenerative effects of mesenchymal stem cell-derived exosomes in different diseases in preclinical experimental models
mediated cell cycle entry and subsequent proliferation nitrogen (BUN) and improved renal function via down-
of tubular epithelial cells while blocking apoptosis [61]. regulating pro-inflammatory cytokines and Smad3 and
The renoprotective effects of AD-MSC exosomes over- TGFβ fibrotic proteins as well as enhancing anti-apop-
expressing glial cell line-derived neurotrophic factor totic proteins and angiogenic biomarkers [66]. In a gen-
(GDNF) was investigated on renal injury using a ure- tamycin-induced AKI model, administration of BM-MSC
teral obstruction murine model. Here, exosomes could exosomes remarkably reduced inflammation by upregu-
decrease peritubular capillary rarefaction and renal fibro- lating IL10 and downregulating TNFα and IL6 expression
sis. Moreover, they stimulated angiogenesis, cell migra- [67]. In an attempt to explore the antioxidant effects of
tion, sirtuin 1 signaling pathway as well as conferring MSC exosomes in the kidney tissue, it was revealed that
apoptosis resistance [62]. In a rat model of ischemia–rep- exosomes derived from human Wharton’s jelly MSCs
erfusion injury (IRI), BM-MSC exosome administration (hWJ-MSCs) could repress NADPH oxidase (NOX) and
was associated with improved tubular epithelial cell pro- reactive oxygen species [68] while triggering Nrf2/antiox-
liferation and survival [63], most probably via exosomal idant response element [69], which led to improved renal
miRNA and mRNA molecules mediating renoprotective function and apoptosis inhibition. In a cisplatin-induced
signaling pathways [64]. Exosomes released form kidney- AKI model, hWJ-MSC exosomes were reported to stimu-
derived MSCs were also recently reported to induce angi- late autophagy by upregulating autophagy-related genes
ogenesis in the renal tissue by harboring pro-angiogenic such as ATG5, ATG-7, and LC3B [70]. Exosomes released
mRNA molecules encoding basic fibroblast growth factor by hWJ-MSCs were also reported to successfully decrease
(bFGF), IGF1 and VEGF [65]. In another study on a rat BUN and creatinine levels, necrosis of proximal kidney
model of renal IRI, adipocyte-derived MSC (AD-MSC) tubules, and production of tubular protein casts through
exosomes reduced the levels of creatinine and blood urea anti-oxidative and anti-apoptosis pathways [71]. Further
Table 2 Therapeutic effects of mesenchymal stem cell-derived exosomes in different diseases in preclinical experimental models
Condition/ Exosome source Experimental model Target mechanism(s) Therapeutic effect(s) Ref
disease
Cardiovascular hBM-MSC HUVEC cell Improved proliferation, migration, and tube formation of endothe- Promoted neoangiogenesis in vitro and in vivo [50]
diseases Rat MI lial cells in vitro Improved cardiac indices, i.e. cardiac systolic/diastolic perfor-
mance and blood flow
Reduced infarct size in vivo
Nikfarjam et al. J Transl Med
mBM-MSC Mouse HPH Inactivated STAT3 pathway Reduced vascular remodeling and HPH [51]
Decreased the levels of miR-17 superfamily
Increased miR-204 levels in lung cells
Repressed the hypoxic pulmonary influx of macrophages and the
induction of MCP1 and HIMF
(2020) 18:449
rBM-MSC overexpressing CXCR4 Neonatal CM Upregulated IGF1α and pAkt levels, inhibited caspase 3, and Increased angiogenesis [52]
Rat MI promote VEGF expression and tubulogenesis in vitro Reduced infarct size
Improved cardiac remodeling
rBM-MSC HUVEC cell Enhanced tube formation by HUVEC cells Decreased infarct size; preserved cardiac systolic and diastolic [53]
Rat MI Compromised T cell function by impeding cell proliferation in vitro performance; enhanced the density of new functional capil-
lary and blood flow recovery in vivo
mBM-MSC Mouse MI miR-22-enriched exosomes were secreted after MI which reduced Reduced infarct size and cardiac fibrosis in vivo [55]
cardiomyocyte apoptosis by direct targeting of Mecp2
rBM-MSC overexpressing GATA-4 Neonatal rat CM miR-221-enriched exosomes reduced the expression of p53 while [56]
upregulating PUMA
Expression of PUMA was greatly declined in CM cocultured with
MSC
rBM-MSC overexpressing GATA-4 Neonatal rat CM Increased CM survival, reduced CM apoptosis, and preserved Exosomal miR-19a could restore cardiac contractile function [57]
mitochondrial membrane potential in vitro and decreased infarct size in vivo
Rat MI Exosomal miR-19a downregulated PTEN and triggered the Akt and
ERK signaling pathways
mBM-MSC HUVEC cell Enhanced the proliferation, migration and tube formation in vitro Promoted angiogenesis and cardiac function in vivo [58]
Mouse MI The pro-angiogenic effect of exosomes is probably associated with
a miR-210-Efna3 dependent mechanism
hEn-MSC Neonatal CM Overexpression and shuttling of exosomal miR-21 was attributed Restored cardiac function and reduced infarct size [59]
HUVEC cell to suppression of PTEN, stimulation of Akt, along with Bcl-2 and
VEGF upregulation
Rat MI
rBM-MSC Cardiac stem cell Triggered proliferation, migration, and angiotube formation in vitro Reduced cardiac fibrosis in vivo [60]
Rat MI probably mediated by a set of microRNAs Enhanced capillary density
Restored long‐term cardiac function
Kidney diseases hBM-MSC mTEC Exosomal mRNAs encoding CDC6, CDK8 and CCNB1 influenced Improved renal function and morphology [61]
cell cycle entry
Mouse AKI Exosomal miRNAs regulated proliferative/anti-apoptotic pathways
and growth factors (HGF and IGF1) that led to renal tubular cell
proliferation
Page 8 of 21
Table 2 (continued)
disease
hAD-MSC overexpressing GDNF HUVEC cell Triggered migration and angiogenesis in vitro Reduced peritubular capillary rarefaction and renal fibrosis [62]
scores in vivo
Mouse ureteral obstruction Conferred apoptosis resistance
Enhanced Sirtuin 1 signaling and p-eNOS levels

hBM-MSC Rat IRI Enhanced TEC proliferation and survival possibly via exosomal [63]
miRNA and mRNA molecules regulating renoprotective signal-
ing routes
Gl-MSC Mouse IRI Activated TEC proliferation Ameliorated kidney function [64]
Reduced the ischemic damage post IRI
(2020) 18:449
mK-MSC HUVEC cell Promoted cell proliferation in vitro and in vivo Selective engraftment in ischemic tissues and significant [65]
Mouse IRI Improved endothelial tube formation on growth factor reduced improvement of renal function
Matrigel
Expressed pro-angiogenic mRNA molecules encoding bFGF, IGF1
and VEGF
rAD-MSC Rat IRI Decreased expression of TNFα, NF-κB, IL1β, MIF, PAI1, Cox2 pro- Reduced creatinine and BUN level, and improved renal func- [66]
inflammatory molecules tion
Reduced the levels of NOX1, NOX2, and oxidized protein
Downregulated Smad3 and TGFβ fibrotic proteins
Enhanced Smad1/5 and BMP2 anti-apoptotic proteins
Upregulated CD31, vWF, and angiopoietin angiogenic biomarkers
Enhanced mito-Cyt C levels
rBM-MSC Rat AKI Enhanced IL10 levels Decreased creatinine, urea, FENa, necrosis, apoptosis [67]
Downregulated TNFα and IL6 expression
Increased cell proliferation
hWJ-MSC HUVEC cell Repressed NOX2 and ROS Reduced fibrosis [68, 69]
NRK-52E cell Decreased apoptosis and sNGAL levels Improved renal function
Rat IRI Enhanced cell proliferation. Upregulated Nrf2/antioxidant response
element and HO1 in vitro and in vivo
hWJ-MSC NRK-52E cell Upregulated autophagy-related genes such as ATG5, -7, and LC3B Improved renal function in vivo [70]
in vitro and in vivo
Rat AKI Induced mitochondrial apoptosis
Inhibited secretion of TNFα, IL1β, and IL6 pro-inflammatory
cytokines in vitro
hWJ-MSC NRK-52E cell Reduced apoptosis and necrosis of proximal kidney tubules Decreased BUN and creatinine levels [71]
Rat AKI Decreased production of tubular protein casts through anti-
oxidation and anti-apoptosis pathways in vitro and in vivo
Promoted cell proliferation by activating the ERK1/2 pathway
hBM-MSC PTEC cell Promoted cell proliferation by carrying IGF1 receptor mRNA, but [72]
not IGF1 mRNA
Page 9 of 21
disease
Liver diseases hWJ-MSC HL7702 cell Suppressing epithelial-to-mesenchymal transition in vitro and Reduced LF [73]
in vivo
Mouse LF Inactivated the TGFβ1/SMAD2 pathway

Alleviated hepatic inflammation and collagen deposition
Recovered serum AST function
Reduced collagen type I and III
hESC-MSC TAMH, THLE-2, and HuH-7 Upregulated PCNA and Cyclin D1 cell cycle proteins and anti- Recovered ALI [74]
(2020) 18:449
cells apoptotic Bcl-xL gene
Mouse ALI
hCP-MSC Rat LF Exosomal miR-125b blocked Smo production and inactivated Reduced expansion of progenitors and regressed LF [75]
Hedgehog signaling mode
MiR‐122‐modified-hAD-MSC Mouse LF Exosomal miR-122 regulated the expression of IGF1R, Cyclin G1 Suppressed LF development [76]
(CCNG1) and P4HA1, which suppress HSC activation and col-
lagen maturation Reduced the serum levels of HA, P‐III‐P, ALT, AST and liver
hydroxyproline content
mBM-MSC Mouse ALI Reduced pro-inflammatory cytokines and apoptosis Decreased the serum levels of ALT and liver necrotic areas [77]
Upregulated anti-inflammatory cytokines
Triggered the number of Tregs
hWJ-MSC Mouse ALI Exosomal GPX1 cleared H2O2 and reduced apoptosis Treated liver failure [78]
h/mBM-MSC Mouse LI Exosomal Y-RNA-1 modulated cytokine expression and reduced Reduced hepatic injury and increased survival [79]
peripheral inflammatory responses and apoptosis
Neurological hBM-MSC Mouse stroke Enhanced angioneurogenesis Recovered postischemic neurological injury [80]
diseases
Attenuated postischemic immunosuppression (i.e., B cell, NK cell Presented long term neuroprotection. Reduced motor coordi-
and T cell lymphopenia) in the peripheral blood nation impairment
rBM-MSC Rat stroke Increased synaptophysin-positive regions in the ischemic bound- Promoted neurovascular remodeling, axonal density and [81]
ary zone functional recovery
Enhanced the number of newly formed doublecortin and vW
rBM-MSC Rat stroke Exosomal miR-133b decreased the expression of connective tissue Resulted in neurite remodeling and stroke recovery [82]
growth factor and ras homolog gene family member A
rBM-MSC overexpressing miR- Rat stroke Inhibited PTEN and activated the downstream proteins, protein Improved neurogenesis, neurite remodeling/neuronal den- [83]
17–92 cluster kinase B and glycogen synthase kinase 3β drite plasticity and oligodendrogenesis
Page 10 of 21
disease
hBM-MSC Rat BI Attenuated inflammation-induced neuronal cellular degeneration Improved long-lasting cognitive functions [84]
Decreased microgliosis and prevented reactive astrogliosis

Restored short term myelination deficits and long term microstruc-

tural abnormalities of the white matter
hBM-MSC Ewe BI Reduced the neurological sequelae Promoted brain function via decreasing the total number and [85]
duration of seizures
Did not affect cerebral inflammation Preserved baroreceptor reflex sensitivity
rBM-MSC Rat TBI Enhanced angiogenesis, the number of newborn immature and Improvement of spatial learning [86]
(2020) 18:449
mature neurons, and decreased neuroinflammation Recovered sensorimotor function

rB-MSCs Mouse TBI Suppressed the expression of pro-apoptotic Bcl-2-associated X Reduced the lesion size and recovering neurobehavioral [87]
protein, TNFα and IL1β performance
Upregulated anti-apoptotic protein B-cell lymphoma 2
Modulated microglia/macrophage polarization
rBM-MSC Rat SCI Regulated macrophage function by targeting M2-type mac- [88]
rophages in the injured sites
rBM-MSC Rat SCI Reduced the proportion of A1 astrocytes via blocking the nuclear Reduced lesion area [89]
translocation of the NF-κB p65
Reduced the percentage of p65 positive nuclei in astrocytes and
TUNEL-positive cells in the ventral horn
Downregulated IL1α, IL1β and TNFα
Increased the expression of myelin basic protein, synaptophysin
and neuronal nuclei
hBM-MSC Rat SCI Showed anti-inflammatory responses in the damaged tissue and Improved locomotor activity [90]
disorganization of astrocytes and microglia
mBM-MSC Mouse AD Normoxic MSC exosomes: Decreased plaque deposition and Aβ Normoxic MSC exosomes: Recovered cognition and memory [91]
levels impairment
Reduced the activation of astrocytes and microglia Preconditioned MSC exosomes: Improved learning and
Downregulated TNFα and IL1β and upregulated IL4 and IL10 memory capabilities
Deactivated STAT3 and NF-κB

Preconditioned MSC exosomes: Reduced plaque deposition and
Aβ levels
Upregulated growth-associated protein 43, synapsin 1, and IL10
Decreased the levels of glial fibrillary acidic protein, ionized
calcium-binding adaptor molecule 1, TNFα, IL1β
Deactivated STAT3 and NF-κB
Enhanced miR-21 levels
hAD-MSC Mouse N2a cell Exosomes carried enzymatically active neprilysin and decreased [92]
both secreted and intracellular Aβ levels
Page 11 of 21
disease
hDP-MSC ReNcell VM human neural Rescued dopaminergic neurons from apoptosis via inducing [93]
stem cell 6-hydroxy-dopamine
Wound healing hWJ-MSC EA.hy926 and HFL1 cells Triggered propagation, migration, and tube formation in vitro Improved wound healing in vivo [94]
Rat skin burn Stimulated β-catenin nuclear translocation

Upregulated proliferating cell nuclear antigen, cyclin D3,
N-cadherin, and β-catenin
Downregulated E-cadherin
hWJ-MSC Dermal fibroblast and Exosomal miR-21, ‐23a, ‐125b, and ‐145 inhibited scar forma- [95]
HEK293T cell tion and myofibroblast accumulation through TGFβ2/SMAD2
(2020) 18:449
Mouse skin-defect pathway blockade and reduction of collagen deposition in vitro

and in vivo
hiPSC-MSC HUVEC cell Upregulated angiogenesis-related biomolecules Increased microvessel density and blood perfusion [96]
Mouse femoral artery
excision
hWJ-MSC Rat skin burn Upregulated collagen I, PCNA and CK19 Resulted in rapid in vivo re-epithelialization [97]
Exosomal Wnt4 contributed to β-catenin nuclear translocation and
promotion of skin cell propagation and migration
Activated AKT pathway which reduced heat stress-induced
apoptosis in vivo
hWJ-MSC Rat skin burn Decreased TNFα and IL1β levels and increased IL10 levels [98]
Exosomal miR-181c decreased inflammation via suppressing the
TLR4 signaling route
hAD-MSC HUVEC cell Promoted angiogenesis in vitro and in vivo [99]
Immunodeficient mouse Exosomal miR-125a acted as a pro-angiogenic factor by down-
regulating DLL4 and regulating the generation of endothelial
tip cells
hiPSC-MSC HUVEC cell and dermal Promoted collagen maturity and neoangiogenesis Enhanced re-epithelialization [100]
fibroblast
Rat skin wound Triggered cell proliferation and migration in vitro Decreased scar size
Increased type I, III collagen and elastin mRNA expression and
secretion and tube formation in vitro
hBM-MSC Diabetic wound and normal Promoted fibroblast propagation and migration [101]
fibroblasts Enhanced tube formation
Triggered Akt, ERK, and STAT3 signaling pathways
Upregulated HGF, IGF1, NGF and SDF1
Page 12 of 21
disease
Other diseases hWJ-MSC and hBM-MSC Mouse BPD Triggered pleiotropic effects on gene expression related with Relieving BPD, hyperoxia-associated inflammation, fibrosis, [102]
(2020) 18:449
hyperoxia -induced inflammation pulmonary hypertension and pulmonary vascular remod-

eling in the lung tissue
Modulated the macrophage phenotype fulcrum, repressing the
M1 state and promoting a M2-like state
hAD-MSC Mouse atopic dermatitis Decreased the levels of eosinophils, IgE, CD86+ and C
D206+ cells, Ameliorated atopic dermatitis in vivo [103]
and infiltrated mast cells
hBM-MSC C2C12 and HUVEC cells Exosomal miR-494 improved angiogenesis and myogenesis in vitro Resulted in muscle regeneration [104]
and in vivo
Mouse muscle injury
hBM-MSC and hWJ-MSC hPBMC Enhanced the number of Tregs in vitro Decreased educed the mean clinical score of EAE mice [105]
Mouse EAE Decreased PBMC proliferation and levels of pro-inflammatory Th1 Decreased demyelination and neuroinflammation
and Th17 cytokines inclusive of IL6, IL12p70, IL17AF, and IL22
Enhanced levels of indoleamine 2,3-dioxygenase
Aβ amyloid β peptide, AD Alzheimer’s disease, AKI acute kidney injury, ALI acute liver injury, ALT alanine aminotransferase, AST aspartate aminotransferase, bFGF basic fibroblast growth factor, BPD: bronchopulmonary
dysplasia, BMP2 bone morphogenetic protein 2, BUN blood urea nitrogen, CM cardiomyocyte, Cox-2 cyclooxygenase 2, DLL4 angiogenic inhibitor delta-like 4, DP-MSC dental pulp-derived MSC, EAE experimental
autoimmune encephalomyelitis, ERK extracellular-signal-regulated kinase, FENa fractional excretion of sodium, GDNF glial cell line-derived neurotrophic factor, Gl-MSC glomeroli MSC, GPX1 glutathione peroxidase 1, HA
hyaluronic acid, hCP-MSC human chorionic plate-derived MSC, hEn-MSC human endometrium-derived MSC, hESC-MSC human emberyonic stem cell-derived MSC, HGF hepatocyte growth factor, HIMF hypoxia-inducible
mitogenic factor, hiPSC-MSC human induced pluripotent stem cell-derived MSC, HO1 heme oxygenase 1, hPBMC human peripheral blood mononuclear cell, HPH hypoxic pulmonary hypertension, HSC hepatic stellate cell,
HUVEC human umbilical vein endothelial cell, IGF1α insulin-like growth factor 1α, IL1β interleukin 1β, IRI ischemia reperfusion injury, LF liver fibrosis, MCP1 monocyte chemoattractant protein 1, Mecp2 methyl CpG binding
protein 2, MI myocardial infarction, MIF macrophage migration inhibitor factor, mito-Cyt C mitochondrial cytochrome C, mK-MSC mouse kidney-derived MSC, mTEC murine tubular epithelial cells, NF-κB nuclear factor
κB protein, NGF nerve growth factor, NOX NADPH oxidase, P4HA1 prolyl-4-hydroxylase α1, PAI-1 protein expression of plasminogen activator inhibitor 1, PCNA proliferating cell nuclear antigen, p-eNOS phosphorylated
endothelial nitric oxide synthase, P‐III‐P procollagen III‐N‐peptide, PTEC proximal tubular epithelial cell, PTEN phosphatase and tensin homolog, PUMA p53 upregulated modulator of apoptosis, rAD-MSC rat adipocyte-
derived MSC, rB-MSC rat bone-derived MSCs, ROS reactive oxygen specie, SCI spinal cord injury, SDF1 stromal cell-derived factor 1, sNGAL serum neutrophil gelatinase-associated lipocalin, STAT3 signal transducer and
activator of transcription 3, TBI traumatic brain injury, TGFβ transforming growth factor β, TNFα tumor necrosis factor α, Treg regulatory T cell, VEGF vascular endothelial growth factor, vWF von Willebrand factor
Page 13 of 21
studies have shown that when BM-MSC exosomes were murine stroke model [80]. When BM-MSC exosomes
co-incubated with cisplatin-injured proximal tubular epi- were administered intravenously to a rat stroke model,
thelial cells, they were capable of promoting cell prolif- neurovascular plasticity was promoted and axonal den-
eration by conveying IGF1 receptor mRNA [72]. sity and synaptophysin-positive regions were improved
in the ischemic margin zone of striatum and cortex [81].
Liver diseases Further investigations regarding BM-MSC exosomes
Exosomes secreted by MSCs were also utilized in numer- showed that they contain miR-133b, which contributes to
ous studies for exploring their therapeutic effects in neurite remodeling and consequent stroke recovery upon
liver diseases. Transplantation of hWJ-MSC exosomes delivery to astrocytes and neurons [82]. Additionally, it
in a carbon tetrachloride (CCl4)-induced liver injury was revealed that these exosomes carry the miR-17–92
(LI) murine model was shown to limit liver fibrosis (LF) cluster, which mediates neurogenesis, neural remod-
and protect hepatocytes by suppressing epithelial-to- eling and oligodendrogenesis in the ischemic bound-
mesenchymal transition and inactivating the transform- ary region [83]. Here, it was further demonstrated that
ing growth factor β1 (TGFβ1)/SMAD2 pathway [73]. miR-17-92 cluster-enriched exosomes have the potential
Hepatoprotective effects of exosomes isolated from of inhibiting PTEN (a confirmed target gene of miR-17-
human embryonic stem cell-derived MSCs (hESC-MSCs) 92 cluster) and consequently activating the downstream
were explored in an in vitro model of acetaminophen/ proteins, protein kinase B (mechanistic target of rapa-
H2O2-induced LI and a murine model of CCl4-induced mycin) and glycogen synthase kinase 3β. In a laboratory
acute LI, and it was revealed that these exosomes con- model of inflammation-induced preterm brain injury,
tributed to tissue regeneration through upregulating the BM-MSC exosomes were reported to impede neural
expression of PCNA and Cyclin D1 cell cycle regulators degeneration, microgliosis and inhibit reactive astroglio-
and anti-apoptotic Bcl-xL gene [74]. In a separate study sis [84]. In another study, a reduction of the neurologi-
using a mouse model of CCl4-induced LF, it was revealed cal sequelae and recovery of brain function was shown
that exosomes released by chorionic plate-derived MSCs upon injection of BM-MSC exosomes [85]. While explor-
harbored miR-125b that demonstrated hepatoprotec- ing the neuroprotective effects of BM-MSC exosomes
tive effect by blocking Smo production and thus inacti- in traumatic brain injury (TBI), researchers found that
vating Hedgehog signaling route [75]. Furthermore, it exosomes resulted in the promotion of angiogenesis and
was revealed that AD-MSC exosomes shuttle miR-122 neuronal growth rate along with reduction of inflam-
to hepatic stellate cells (HSCs) and regulate the expres- mation in lesion boundary zone and dentate gyrus after
sion of miR-122 target genes including IGF1R, Cyclin G1 TBI [86]. In a separate TBI study, exosomes isolated from
(CCNG1) and prolyl-4-hydroxylase α1 (P4HA1), which bone-derived MSCs (B-MSCs) exhibited neuroprotec-
affect cell proliferation and collagen maturation in HSCs tive effects by reducing the lesion size and recovering
[76]. The application of BM-MSC exosomes in a conca- neurobehavioral performance. These outcomes were
navalin A-induced LI (a case of immune-induced LI) mediated by suppressing the expression of pro-apoptotic
could decrease the serum levels of alanine aminotrans- Bcl-2-associated X protein, TNFα and IL1β, upregulation
ferase (ALT) and pro-inflammatory cytokines while of anti-apoptotic protein B-cell lymphoma 2, and modu-
enhancing the expression of anti-inflammatory cytokines lating microglia/macrophage polarization [87]. In spinal
and regulatory T cell (Treg) activity [77]. In another work, cord injuries (SCIs), intravenously-delivered exosomes
a single administration of hWJ-MSC exosomes harboring were shown to regulate macrophage functions by tar-
glutathione peroxidase 1 (GPX1), a vital human anti-oxi- geting M2-type macrophages in the injured sites [88].
dant, in a murine acute LI model could treat the disease Intravenous injection of BM-MSC exosomes was also
via clearing hydrogen peroxide and relieving oxidative reported to diminish the proportion of SCI-induced A1
stress and cell death [78]. Exosomal Y-RNA-1 molecules astrocytes, the percentage of p65 positive nuclei in astro-
were demonstrated to recover LI and increase survival cytes, and the expression of IL1α, IL1β and TNFα. These
by adjusting peripheral inflammatory responses and trig- mechanisms were ascribed to nuclear translocation of
gering anti-apoptosis effects in a lethal murine model of the NF-κB p65 [89]. Similar results were reported when
D-galactosamine/TNFα-induced liver failure [79]. systemic administration of BM-MSC exosomes showed
anti-inflammatory responses in the damaged cord tissue
Neurological diseases and improved locomotor activity via disorganization of
Exosomes released from BM-MSCs were reported to astrocytes and microglia [90]. Exosomes isolated from
exhibit therapeutic effects as they recover post-ischemic hypoxia-preconditioned BM-MSCs could rescue synaptic
neurological injuries, enhance angioneurogenesis, and dysfunction and promote anti-inflammatory effects in an
represent long-term neuroprotective functions in a APP/PS1 murine model of Alzheimer’s disease (AD) [91].
In another study of AD, it was shown that AD-MSCs Other diseases

secrete exosomes containing an abundance of neprilysin, In the lung, exosomes isolated from WJ-MSCs dem-
the most utilized enzyme for degradation of β-amyloid onstrated remarkable therapeutic effects by relieving
peptides in the brain tissue. The levels of secreted and bronchopulmonary dysplasia, hyperoxia-associated inf
intracellular β-amyloid peptides were decreased when lammation, fibrosis, pulmonary hypertension and pul-
these exosomes were transferred into neuroblastoma monary vascular remodeling through adjusting the
cells [92]. In a separate study, exosomes released from phenotype of lung macrophages [102]. In a murine atopic
dental pulp MSCs (DP-MSCs) were reported to res- dermatitis model, AD-MSC exosomes could decrease the
cue dopaminergic neurons from apoptosis via inducing D86+ and C
levels of eosinophils, IgE, C D206+ cells, and
6-hydroxy-dopamine in a 3D culture [93]. the infiltrated mast cells [103]. Exosomal miR-494 con-
tributed to muscle regeneration via improving angiogen-
Wound healing esis and myogenesis [104]. Study of BM-MSC exosomes
Exosomes secreted from hWJ-MSCs contribute to in an experimental autoimmune encephalomyelitis
wound healing process via transferring Wnt4 and acti- model of multiple sclerosis revealed that they were capa-
[94]. Exosomal miRNAs including miR-21, ‐23a, ‐125b,

vating β-catenin, which leads to angiogenesis in vivo ble of downregulating pro-inflammatory cytokines and
and ‐145 from hWJ-MSCs were reported to impede

inducing Tregs [105].
scar formation and myofibroblast accumulation through Mesenchymal stem cell‑derived exosomes in clinical trials
TGFβ2/SMAD2 pathway blockade and reduction of col- Preclinical data have proven the safety of exosome
lagen deposition [95]. MSC exosomes were also able to therapy and scalability of their isolation methods from
trigger the expression of angiogenesis-related biomol- MSCs for clinical application. However, the use of MSC
ecules and increase microvessel density and blood per- exosomes in clinical setting is limited due to the lack of
fusion in the ischemic limbs of a murine model [96]. established cell culture conditions and optimal proto-
Wounds treated with hWJ-MSC exosomes demonstrated cols for production, isolation and storage of exosomes,
rapid in vivo re-epithelialization as well as upregulating optimal therapeutic dose and administration schedule,
the expression of collagen I, PCNA and CK19. Further- and reliable potency assays to evaluate the efficacy of
more, these exosomes harbored Wnt4 that contributed exosome therapy [106–108]. There are numerous stud-
to β-catenin nuclear translocation and promotion of ies investigating the efficiency of MSC exosomes in the
skin cell propagation and migration [97]. MSC exosomes clinical settings. Although most of the clinical trials
were also reported to ameliorate burn-induced inflam- are in the recruitment and active phases, some of them
mation in cutaneous wound healing. For example, hWJ- have completed without publishing their results. Korde-
MSC exosomes exhibited anti-inflammatory effects via las et al. tested the therapeutic effects of BM-MSCs in
reducing mRNA levels of pro-inflammatory cytokines patients with steroid refractory graft-versus-host dis-
such as IL1β and TNFα while increasing IL10 levels [98]. ease and found that the secretion of IL1β, TNFα, and
In another study, it was shown that AD-MSC exosomes IFNγ by PBMCs were remarkably reduced following the
were enriched in miR-125a that acted as a pro-angio- third exosome application [109]. In line with the ame-
genic factor by downregulating the angiogenic inhibitor liorated pro-inflammatory response of the PBMCs, the
delta-like 4 (DLL4) expression and modulating the gen- disease symptoms improved significantly shortly after
eration of endothelial tip cells [99]. Transplantation of the MSC exosome therapy started. In another study,
exosomes derived from human induced pluripotent stem Nassar et al. showed that the application of UC-MSC
cell-derived mesenchymal stem cells (hiPSC-MSCs) to exosomes led to overall improvement in renal function in
the wound sites in a rat model led to rapid re-epithelial- patients suffering from grade III-IV chronic kidney dis-
ization, promoted collagen maturity, and decreased the ease [110]. Here, exosome therapy resulted in remarkable
scar size. Additionally, these vesicles triggered cell pro- improvement of plasma creatinine level, estimated glo-
liferation and migration and increased the secretion of merular filtration rate, blood urea and urinary albumin
type I, III collagen and elastin in a dose-dependent man- creatinine ratio. Furthermore, serum levels of IL10 and
ner in vitro [100]. Exosomal miR-181c contributed to the TGFβ1 were increased while serum levels of TNFα were
suppression of TLR4 signaling route. Here, exosomes decreased. There are also other ongoing trials performed
derived from BM-MSCs could dose-dependently pro- to determine the safety and effectiveness of human MSC
mote fibroblast propagation and migration, tube forma- exosomes in treatment of tissue injuries which are sum-
tion, trigger Akt, ERK, and STAT3 signaling pathways, marized in Table 3.
and upregulate HGF, IGF1, nerve growth factor (NGF)
and stromal cell-derived factor 1 (SDF1) expression [101].
Table 3 Mesenchymal stem cell-derived exosomes in clinical trials (https://www.clinicaltrials.gov/)

Organ Condition/disease Trial ID/Ref Phase Status Source Dose/frequency/route Location
of exosomes
Lung Healthy NCT04313647 I Recruiting AD-MSC 1× level: 2.0 × 108/3 ml China

2× level: 4.0 × 108/3 ml
4× level: 8.0 × 108/3 ml
6× level: 12.0 × 108/3 ml
8× level: 16.0 × 108/3 ml
10× level: 20.0 × 108/3 ml
All experiments: once;
aerosol inhalation
SARS-CoV-2 pneu- NCT04276987 I Completed AD-MSC 2.0 × 108/3 ml China
monia Once a day during 5 days
Aerosol inhalation
NCT04491240 I, II Enrolling by invitation MSC Procedure 1: Russia
0.5–2 × 1010/3 ml
Procedure 2:
0.5–2 × 1010/3 ml
All experiments: twice a day
during 10 days; inhalation
Bronchopulmonary NCT03857841 I Recruiting BM-MSC 20 pmol phospholid/kg
dysplasia 60 pmol phospholid/kg
200 pmol phospholid/kg
All experiments: intravenous
injection
Skin Dystrophic epider- NCT04173650 I, II Not yet recruiting BM-MSC AGLE-102 exosomes USA
molysis bullosa Once a day during 60 days
Applied topically to the
entire body
Chronic ulcer NCT04134676 I Completed WJ-MSC Conditioned medium gel Indonesia
Every week for 2 weeks
Applied topically to the
wound
Brain Acute ischemic stroke NCT03384433 I, II Completed BM-MSC 200 µg total protein of miR- Iran
124-loaded exosomes
One month after attack
Stereotactic guidance
Alzheimer’s disease NCT04388982 I, II Not yet recruiting AD-MSC Low dosage group: 5 μg China
exosome/1 ml
Mild dosage group: 10 μg
exosome/1 ml
High dosage group: 20 μg
exosome/1 ml
All experiments: twice a
week during 12 weeks;
nasal drip
Eye Macular holes NCT03437759 Early phase I Recruiting UC-MSC 20–50 µg exosome/10 μl China
Single dose
Directly injected around
macular hole area
Dry eye NCT04213248 I, II Recruiting UC-MSC 10 µg exosome/drop China
4 times a day during 14 days
Eye drops
Organ Condition/disease Trial ID/Ref Phase Status Source Dose/frequency/route Location
of exosomes
Other Multiple organ failure NCT04356300 Not applicable Not yet recruiting UC-MSC 150 mg exosome China
organs/
tissues Once a day during 14 days
Intravenous injection
Diabetes mellitus NCT02138331 II, III Unknown UC-MSC First dose: Intravenous injec- Egypt
type 1 tion of exosomes isolated
from the supernatant
produced from 1.22–
1.51 × 106 MSCs/kg
Second dose: 7 days after
the first dose; intravenous
injection of MVs isolated
from the supernatant
produced from the same
dose of MSCs utilized in
the first injection
Osteoarthritis NCT04223622 I Not yet recruiting AD-MSC Osteochondral explants Italy
from arthroplasty
patients treated with
AD-MSC secretome (either
complete conditioned
medium or EVs)
Graft-versus-host [109] – Concluded BM-MSC 1.3–3.5 × 1010 exosome/unit; Germany
disease 0.5–1.6 mg/unit (The yield
of an EV fraction isolated
from supernatants of
4 × 107 MSCs was defined
as one unit.)
First dose: a tenth of a unit
Second dose: 2 days
after the first dose, unit
amounts were progres-
sively enhanced and
administered every
2–3 days until 4 doses
Chronic kidney [110] II, III Concluded UC-MSC 100 μg of total EV protein/ Egypt
disease kg
2 doses (1 week apart)
First dose: intravenous
injection
Second dose: infused into
the renal artery
Concluding remarks the recipient cells. Exploiting these immunomodulatory

Exosomes secreted by MSCs are now being extensively effects allows for the use of MSC-derived exosomes to
exploited to develop novel regenerative strategies for treat different inflammatory and autoimmune diseases.
numerous diseases since they convey most of the thera- The function of exosomes can be readily adjusted via
peutic properties of MSCs. Exosomes offer a possibility preconditioning of MSC culture, for instance by addi-
of cell-free therapy, which minimizes safety concerns tion of chemical factors or cytokines, exerting hypoxic
regarding the administration of viable cells. In many conditions, and introducing gene modifications such
cases, the regenerative effect of MSC exosomes has as the CRISPR/Cas9 technology [111]. However, details
been ascribed to their anti-inflammatory function in about the functional mechanisms of exosomes in MSCs
and their target cells continue to be elucidated. Moreo- Availability of data and materials
Not applicable.
ver, there are still a few unresolved concerns before
bringing MSC-derived exosomes into the clinical setting. Ethics approval and consent to participate
Standards and guidelines should be established for vesi- Not applicable.
cle size, purity, expression of certain surface biomarkers Consent for publication
(e.g. CD9, CD63, CD81), and acceptable contamination Not applicable.
levels for identification and quality control of the iso-
Competing interests
lated exosomes. It was confirmed that the physiological The authors declare that they have no competing interests.
state of MSCs influence the therapeutic efficiency of iso-
lated exosomes [108]. This issue can be partly resolved Author details
1
Department of Medical Biotechnology, Faculty of Advanced Medical
by MSC preconditioning or extracting exosomes from Sciences, Tabriz University of Medical Sciences, Tabriz, Iran. 2 Solid Tumor
induced pluripotent stem cells or embryonic stem cells Research Center, Cellular and Molecular Medicine Research Institute,
[112] in order to diminish the lot-to-lot variation regard- Urmia University of Medical Sciences, Shafa St, Ershad Blvd, P.O. BoX: 1138,
57147 Urmia, Iran. 3 Department of Pharmacology and Toxicology, Faculty
ing primary naive MSCs. In summary, findings from vari- of Pharmacy, Urmia University of Medical Sciences, Urmia, Iran.
ous research works imply that MSC-derived exosomes
possess promising therapeutic capacity for treatment of Received: 12 August 2020 Accepted: 18 November 2020
a variety of diseases. Efforts directed toward determin-
ing standards on the therapy efficacy and safety issues
will speed up clinical implementation of MSC-derived
exosomes as regenerative agents. References
1. Teixeira FG, Carvalho MM, Sousa N, Salgado AJ. Mesenchymal stem cells
secretome: a new paradigm for central nervous system regeneration?
Cell Mol Life Sci. 2013;70(20):3871–82.
Abbreviations 2. Akbari A, Jabbari N, Sharifi R, Ahmadi M, Vahhabi A, Seyedzadeh SJ, et al.
AD: Alzheimer’s disease; AD-MSC: Adipocyte-derived mesenchymal stem Free and hydrogel encapsulated exosome-based therapies in regenera-
cell; AKI: Acute kidney injury; Alix: ALG2-interacting protein X; bFGF: Basic tive medicine. Life Sci. 2020;249:117447.
fibroblast growth factor; B-MSC: Bone-derived mesenchymal stem cell; CAM: 3. Lai RC, Yeo RW, Lim SK. Mesenchymal stem cell exosomes. Semin Cell
Cell adhesion molecule; CCl4: Carbon tetrachloride; CRISPR: Clustered regularly Dev Biol. 2015;40:82–8.
interspaced short palindromic repeats; DLL4: Delta-like 4 protein; DGUC: 4. Smirnov SV, Harbacheuski R, Lewis-Antes A, Zhu H, Rameshwar P,
Density gradient ultracentrifugation; DP-MSC: Dental pulp-derived mesen- Kotenko SV. Bone-marrow-derived mesenchymal stem cells as a target
chymal stem cell; DUC: Differential ultracentrifugation; EV: Extracellular vesicle; for cytomegalovirus infection: implications for hematopoiesis, self-
GPX1: Glutathione peroxidase 1; hBM-MSC: Human bone marrow-derived renewal and differentiation potential. Virology. 2007;360(1):6–16.
mesenchymal stem cell; hESC-MSC: Human embryonic stem cell-derived mes- 5. Crapnell K, Blaesius R, Hastings A, Lennon DP, Caplan AI, Bruder SP.
enchymal stem cell; HGF: Hepatocyte growth factor; HSC: Hepatic stellate cell; Growth, differentiation capacity, and function of mesenchymal stem
hUC-MSC: Human umbilical cord blood-derived mesenchymal stem cell; hWJ- cells expanded in serum-free medium developed via combinatorial
MSC: Human Wharton’s jelly (umbilical cord matrix)-derived mesenchymal screening. Exp Cell Res. 2013;319(10):1409–18.
stem cell; IgE: Immunoglobulin E; IGF1α: Insulin-like growth factor 1α; IL1β: 6. Krause DS, Theise ND, Collector MI, Henegariu O, Hwang S, Gardner
Interleukin 1β; ILV: Intraluminal vesicle; IPUC: Isopycnic ultracentrifugation; IRI: R, et al. Multi-organ, multi-lineage engraftment by a single bone
Ischemia–reperfusion injury; K-MSC: Kidney-derived mesenchymal stem cell; marrow-derived stem cell. Cell. 2001;105(3):369–77.
LF: Liver fibrosis; LI: Liver injury; MECP2: Methyl-CpG-binding protein 2; MHC: 7. Wagers AJ, Weissman IL. Plasticity of adult stem cells. Cell.
Major histocompatibility complex; MI: Myocardial infarction; MSC: Mesenchy- 2004;116(5):639–48.
mal stem/stromal cell; MVB: Multivesicular body; MWCO: Molecular weight 8. Prockop DJ, Oh JY. Medical therapies with adult stem/progenitor cells
cut-off; NADPH: Nicotinamide adenine dinucleotide phosphate; NGF: Nerve (MSCs): a backward journey from dramatic results in vivo to the cel-
growth factor; P4HA1: Prolyl-4-hydroxylase α1; PBS: Phosphate buffered saline; lular and molecular explanations. J Cell Biochem. 2012;113(5):1460–9.
PTEN: Phosphatase and tensin homolog; PUMA: P53 upregulated modulator 9. Theise ND. On experimental design and discourse in plasticity
of apoptosis; RBC: Red blood cell; RZUC: Rate-zonal ultracentrifugation; SCI: research. Stem Cell Rev. 2005;1(1):9–13.
Spinal cord injury; SDF1: Stromal cell-derived factor 1; SF: Sequential filtration; 10. Iso Y, Spees JL, Serrano C, Bakondi B, Pochampally R, Song YH, et al.
STAT3: Signal transducer and activator of transcription 3; TBI: Traumatic brain Multipotent human stromal cells improve cardiac function after myo-
injury; TGFβ1: Transforming growth factor β1; TNFα: Tumor necrosis factor α; cardial infarction in mice without long-term engraftment. Biochem
UF: Ultrafiltration; UC: Ultracentrifugation; VEGF: Vascular endothelial growth Biophys Res Commun. 2007;354(3):700–6.
factor. 11. Rani S, Ryan AE, Griffin MD, Ritter T. Mesenchymal stem cell-derived
extracellular vesicles: toward cell-free therapeutic applications. Mol
Acknowledgements Ther. 2015;23(5):812–23.
Not applicable. 12. Rezaie J, Ajezi S, Avci ÇB, Karimipour M, Geranmayeh MH,
Nourazarian A, et al. Exosomes and their application in biomedical
Authors’ contributions field: difficulties and advantages. Mol Neurobiol. 2018;55(4):3372–93.
Conception and manuscript design: RJ. Collection of data: SN, JR, NMJ and 13. Pan BT, Johnstone RM. Fate of the transferrin receptor during matura-
RJ. Manuscript writing: SN, JR, NMJ and RJ. Made important revisions and tion of sheep reticulocytes in vitro: selective externalization of the
confirmed final revision: RJ. All authors reviewed the final version of the manu- receptor. Cell. 1983;33(3):967–78.
script. All authors read and approved the final manuscript. 14. Johnstone RM, Adam M, Hammond J, Orr L, Turbide C. Vesicle
formation during reticulocyte maturation. Association of plasma
Funding membrane activities with released vesicles (exosomes). J Biol Chem.
Not applicable. 1987;262(19):9412–20.
15. Johnstone RM. Revisiting the road to the discovery of exosomes. (DC) derived-exosomes: results of thefirst phase I clinical trial. J Transl
Blood Cells Mol Dis. 2005;34(3):214–9. Med. 2005a;3(1):10.
16. Trams EG, Lauter CJ, Salem JN, Heine U. Exfoliation of membrane 38. Lamparski HG, Metha-Damani A, Yao JY, Patel S, Hsu DH, Ruegg C, et al.
ecto-enzymes in the form of micro-vesicles. Biochimica et Biophysica Production and characterization of clinical grade exosomes derived
Acta (BBA). 1981;645(1):63–70. from dendritic cells. J Immunol Methods. 2002;270(2):211–26.
17. Potolicchio I, Carven GJ, Xu X, Stipp C, Riese RJ, Stern LJ, et al. 39. Zhang M, Jin K, Gao L, Zhang Z, Li F, Zhou F, et al. Methods and tech-
Proteomic analysis of microglia-derived exosomes: metabolic role of nologies for exosome isolation and characterization. Small Methods.
the aminopeptidase CD13 in neuropeptide catabolism. J Immunol. 2018;2(9):1800021.
2005;175(4):2237–43. 40. Van Deun J, Mestdagh P, Sormunen R, Cocquyt V, Vermaelen K,
18. Février B, Raposo G. Exosomes: endosomal-derived vesicles shipping Vandesompele J, et al. The impact of disparate isolation methods for
extracellular messages. Curr Opin Cell Biol. 2004;16(4):415–21. extracellular vesicles on downstream RNA profiling. J Extracell Vesicles.
19. Möbius W, Ohno-Iwashita Y, Donselaar EGV, Oorschot VM, Shimada 2014;3(1):24858.
Y, Fujimoto T, et al. Immunoelectron microscopic localization of 41. Li P, Kaslan M, Lee SH, Yao J, Gao Z. Progress in exosome isolation tech-
cholesterol using biotinylated and non-cytolytic perfringolysin O. J niques. Theranostics. 2017;7(3):789–804.
Histochem Cytochem. 2002;50(1):43–55. 42. Dai S, Wei D, Wu Z, Zhou X, Wei X, Huang H, et al. Phase I clinical trial
20. Chen Q, Takada R, Noda C, Kobayashi S, Takada S. Different popula- of autologous ascites-derived exosomes combined with GM-CSF for
tions of Wnt-containing vesicles are individually released from polar- colorectal cancer. Mol Ther. 2008;16(4):782–90.
ized epithelial cells. Sci Rep. 2016;6(1):35562. 43. Morse MA, Garst J, Osada T, Khan S, Hobeika A, Clay TM, et al. A phase
21. Valadi H, Ekström K, Bossios A, Sjöstrand M, Lee JJ, Lötvall JO. I study of dexosome immunotherapy in patients with advanced non-
Exosome-mediated transfer of mRNAs and microRNAs is a novel small cell lung cancer. J Transl Med. 2005;3(1):9.
mechanism of genetic exchange between cells. Nat Cell Biol. 44. Serwer P. Bacteriophages: separation of. In: Wilson ID, editor. Encyclope-
2007;9(6):654–9. dia of Separation Science. Oxford: Academic Press; 2000. p. 2102–9.
22. Van Niel G, Porto-Carreiro I, Simoes S, Raposo G. Exosomes: 45. Hameed BS, Bhatt CS, Nagaraj B, Suresh AK. Chapter 19—chromatog-
a common pathway for a specialized function. J Biochem. raphy as an efficient technique for the separation of diversified nano-
2006;140(1):13–21. particles. In: Hussain CM, editor. Nanomaterials in chromatography.
23. Poliakov A, Spilman M, Dokland T, Amling CL, Mobley JA. Structural Amsterdam: Elsevier; 2018. p. 503–18.
heterogeneity and protein composition of exosome-like vesicles (pros- 46. Carmignac DF. Biological centrifugation. Cell Biochem Func.
tasomes) in human semen. Prostate. 2009;69(2):159–67. 2002;20(4):357.
24. Minciacchi VR, Freeman MR, Di Vizio D. Extracellular vesicles in cancer: 47. Besse B, Charrier M, Lapierre V, Dansin E, Lantz O, Planchard D,
exosomes, microvesicles and the emerging role of large oncosomes. et al. Dendritic cell-derived exosomes as maintenance immuno-
Semin Cell Dev Biol. 2015;40:41–51. therapy after first line chemotherapy in NSCLC. Oncoimmunology.
25. Mashouri L, Yousefi H, Aref AR, Ahadi AM, Molaei F, Alahari SK. 2016;5(4):e1071008.
Exosomes: composition, biogenesis, and mechanisms in cancer metas- 48. Heinemann ML, Ilmer M, Silva LP, Hawke DH, Recio A, Vorontsova MA,
tasis and drug resistance. Mol Cancer. 2019;18(1):75. et al. Benchtop isolation and characterization of functional exosomes
26. Zarovni N, Corrado A, Guazzi P, Zocco D, Lari E, Radano G, et al. Inte- by sequential filtration. J Chromatogr A. 2014;1371:125–35.
grated isolation and quantitative analysis of exosome shuttled proteins 49. Escudier B, Dorval T, Chaput N, André F, Caby M-P, Novault S, et al. Vacci-
and nucleic acids using immunocapture approaches. Methods. nation of metastatic melanoma patients with autologous dendritic cell
2015;87:46–58. (DC) derived-exosomes: results of the first phase I clinical trial. J Transl
27. Rechavi O, Erlich Y, Amram H, Flomenblit L, Karginov FV, Goldstein I, Med. 2005b;3(1):10.
et al. Cell contact-dependent acquisition of cellular and viral nonau- 50. Bian S, Zhang L, Duan L, Wang X, Min Y, Yu H. Extracellular vesicles
tonomously encoded small RNAs. Genes Dev. 2009;23(16):1971–9. derived from human bone marrow mesenchymal stem cells pro-
28. Doyle LM, Wang MZ. Overview of extracellular vesicles, their origin, mote angiogenesis in a rat myocardial infarction model. J Mol Med.
composition, purpose, and methods for exosome isolation and analysis. 2014;92(4):387–97.
Cells. 2019;8(7):727. 51. Lee C, Mitsialis SA, Aslam M, Vitali SH, Vergadi E, Konstantinou G,
29. Zaborowski MP, Balaj L, Breakefield XO, Lai CP. Extracellular vesicles: et al. Exosomes mediate the cytoprotective action of mesenchymal
composition, biological relevance, and methods of study. Bioscience. stromal cells on hypoxia-induced pulmonary hypertension. Circulation.
2015;65(8):783–97. 2012;126(22):2601–11.
30. Hessvik NP, Øverbye A, Brech A, Torgersen ML, Jakobsen IS, Sandvig K, 52. Kang K, Ma R, Cai W, Huang W, Paul C, Liang J, et al. Exosomes secreted
et al. PIKfyve inhibition increases exosome release and induces secre- from CXCR4 overexpressing mesenchymal stem cells promote cardio-
tory autophagy. Cell Mol Life Sci. 2016;73(24):4717–37. protection via Akt signaling pathway following myocardial infarction.
31. Skotland T, Sandvig K, Llorente A. Lipids in exosomes: current knowl- Stem Cells Int. 2015;2015:659890.
edge and the way forward. Prog Lipid Res. 2017;66:30–41. 53. Teng X, Chen L, Chen W, Yang J, Yang Z, Shen Z. Mesenchymal stem
32. Kowal J, Arras G, Colombo M, Jouve M, Morath JP, Primdal-Bengtson cell-derived exosomes improve the microenvironment of infarcted
B, et al. Proteomic comparison defines novel markers to characterize myocardium contributing to angiogenesis and anti-inflammation. Cell
heterogeneous populations of extracellular vesicle subtypes. Proc Natl Physiol Biochem. 2015;37(6):2415–24.
Acad Sci. 2016;113(8):E968–77. 54. Rezaie J, Rahbarghazi R, Pezeshki M, Mazhar M, Yekani F, Khaksar M,
33. Zeringer E, Barta T, Li M, Vlassov AV. Strategies for isolation of exosomes. et al. Cardioprotective role of extracellular vesicles: a highlight on
Cold Spring Harbor Protoc. 2015;2015(4):074476. exosome beneficial effects in cardiovascular diseases. J Cell Physiol.
34. Busatto S, Vilanilam G, Ticer T, Lin WL, Dickson DW, Shapiro S, et al. Tan- 2019;234(12):21732–45.
gential flow filtration for highly efficient concentration of extracellular 55. Feng Y, Huang W, Wani M, Yu X, Ashraf M. Ischemic preconditioning
vesicles from large volumes of fluid. Cells. 2018;7(12):273. potentiates the protective effect of stem cells through secretion of
35. Pachler K, Lener T, Streif D, Dunai ZA, Desgeorges A, Feichtner M, et al. exosomes by targeting Mecp2 via miR-22. PLoS ONE. 2014;9(2):e88685.
A Good Manufacturing Practice-grade standard protocol for exclusively 56. Yu B, Gong M, Wang Y, Millard RW, Pasha Z, Yang Y, et al. Cardiomyocyte
human mesenchymal stromal cell-derived extracellular vesicles. Cyto- protection by GATA-4 gene engineered mesenchymal stem cells is
therapy. 2017;19(4):458–72. partially mediated by translocation of miR-221 in microvesicles. PLoS
36. Andriolo G, Provasi E, Lo Cicero V, Brambilla A, Soncin S, Torre T, et al. ONE. 2013;8(8):e73304.
Exosomes from human cardiac progenitor cells for therapeutic applica- 57. Yu B, Kim HW, Gong M, Wang J, Millard RW, Wang Y, et al. Exosomes
tions: development of a GMP-Grade Manufacturing Method. Front secreted from GATA-4 overexpressing mesenchymal stem cells serve
Physiol. 2018;9:1169. as a reservoir of anti-apoptotic microRNAs for cardioprotection. Int J
37. Escudier B, Dorval T, Chaput N, André F, Caby M-P, Novault S, et al. Vacci- Cardiol. 2015;182:349–60.
nation of metastatic melanoma patients with autologous dendritic cell
58. Wang N, Chen C, Yang D, Liao Q, Luo H, Wang X, et al. Mesenchymal 77. Tamura R, Uemoto S, Tabata Y. Immunosuppressive effect of mesen-
stem cells-derived extracellular vesicles, via miR-210, improve infarcted chymal stem cell-derived exosomes on a concanavalin A-induced liver
cardiac function by promotion of angiogenesis. Biochim Biophys Acta. injury model. Inflamm Regen. 2016;36:26.
2017;1863(8):2085–92. 78. Yan Y, Jiang W, Tan Y, Zou S, Zhang H, Mao F, et al. hucMSC exosome-
59. Wang K, Jiang Z, Webster KA, Chen J, Hu H, Zhou Y, et al. Enhanced car- derived GPX1 is required for the recovery of hepatic oxidant injury. Mol
dioprotection by human endometrium mesenchymal stem cells driven Ther. 2017;25(2):465–79.
by exosomal microRNA-21. Stem Cells Transl Med. 2017;6(1):209–22. 79. Haga H, Yan IK, Takahashi K, Matsuda A, Patel T. Extracellular vesi-
60. Zhang Z, Yang J, Yan W, Li Y, Shen Z, Asahara T. Pretreatment of Cardiac cles from bone marrow-derived mesenchymal stem cells improve
Stem Cells With Exosomes Derived From Mesenchymal Stem Cells survival from lethal hepatic failure in mice. Stem Cells Transl Med.
Enhances Myocardial Repair. J Am Heart Assoc. 2016;5(1):28565. 2017;6(4):1262–72.
61. Bruno S, Tapparo M, Collino F, Chiabotto G, Deregibus MC, Soares 80. Doeppner TR, Herz J, Görgens A, Schlechter J, Ludwig A-K, Radtke S,
Lindoso R, et al. Renal regenerative potential of different extracellular et al. Extracellular vesicles improve post-stroke neuroregeneration
vesicle populations derived from bone marrow mesenchymal stromal and prevent postischemic immunosuppression. Stem Cell Transl Med.
cells. Tissue Eng Part A. 2017;23(21–22):1262–73. 2015;4(10):1131–43.
62. Chen L, Wang Y, Li S, Zuo B, Zhang X, Wang F, et al. Exosomes derived 81. Xin H, Li Y, Cui Y, Yang JJ, Zhang ZG, Chopp M. Systemic administration
from GDNF-modified human adipose mesenchymal stem cells amelio- of exosomes released from mesenchymal stromal cells promote func-
rate peritubular capillary loss in tubulointerstitial fibrosis by activating tional recovery and neurovascular plasticity after stroke in rats. J Cereb
the SIRT1/eNOS signaling pathway. Theranostics. 2020;10(20):9425–42. Blood Flow Metab. 2013;33(11):1711–5.
63. Gatti S, Bruno S, Deregibus MC, Sordi A, Cantaluppi V, Tetta C, et al. 82. Xin H, Li Y, Liu Z, Wang X, Shang X, Cui Y, et al. MiR-133b promotes
Microvesicles derived from human adult mesenchymal stem cells pro- neural plasticity and functional recovery after treatment of stroke with
tect against ischaemia–reperfusion-induced acute and chronic kidney multipotent mesenchymal stromal cells in rats via transfer of exosome-
injury. Nephrol Dial Transpl. 2011;26(5):1474–83. enriched extracellular particles. Stem Cells. 2013;31(12):2737–46.
64. Ranghino A, Bruno S, Bussolati B, Moggio A, Dimuccio V, Tapparo M, 83. Xin H, Katakowski M, Wang F, Qian JY, Liu XS, Ali MM, et al. MicroRNA
et al. The effects of glomerular and tubular renal progenitors and cluster miR-17-92 cluster in exosomes enhance neuroplasticity and
derived extracellular vesicles on recovery from acute kidney injury. functional recovery after stroke in rats. Stroke. 2017;48(3):747–53.
Stem Cell Res Ther. 2017;8(1):24. 84. Drommelschmidt K, Serdar M, Bendix I, Herz J, Bertling F, Prager S,
65. Choi HY, Moon SJ, Ratliff BB, Ahn SH, Jung A, Lee M, et al. Microparticles et al. Mesenchymal stem cell-derived extracellular vesicles ameliorate
from kidney-derived mesenchymal stem cells act as carriers of proan- inflammation-induced preterm brain injury. Brain Behav Immun.
giogenic signals and contribute to recovery from acute kidney injury. 2017;60:220–32.
PLoS ONE. 2014;9(2):e87853. 85. Ophelders DRMG, Wolfs TGAM, Jellema RK, Zwanenburg A, Andries-
66. Lin KC, Yip HK, Shao PL, Wu SC, Chen KH, Chen YT, et al. Combination sen P, Delhaas T, et al. Mesenchymal stromal cell-derived extracellular
of adipose-derived mesenchymal stem cells (ADMSC) and ADMSC- vesicles protect the fetal brain after hypoxia-ischemia. Stem Cells Transl
derived exosomes for protecting kidney from acute ischemia-reperfu- Med. 2016;5(6):754–63.
sion injury. Int J Cardiol. 2016;216:173–85. 86. Zhang Y, Chopp M, Meng Y, Katakowski M, Xin H, Mahmood A, et al.
67. Reis LA, Borges FT, Simões MJ, Borges AA, Sinigaglia-Coimbra R, Schor Effect of exosomes derived from multipluripotent mesenchymal
N. Bone marrow-derived mesenchymal stem cells repaired but did not stromal cells on functional recovery and neurovascular plasticity in rats
prevent gentamicin-induced acute kidney injury through paracrine after traumatic brain injury. J Neurosurg. 2015;122(4):856–67.
effects in rats. PLoS ONE. 2012;7(9):e44092. 87. Ni H, Yang S, Siaw-Debrah F, Hu J, Wu K, He Z, et al. Exosomes derived
68. Zhang G, Zou X, Miao S, Chen J, Du T, Zhong L, et al. The anti-oxidative from bone mesenchymal stem cells ameliorate early inflammatory
role of micro-vesicles derived from human Wharton-Jelly mesenchymal responses following traumatic brain injury. Front Neurosci. 2019;13:14.
stromal cells through NOX2/gp91(phox) suppression in alleviating renal 88. Lankford KL, Arroyo EJ, Nazimek K, Bryniarski K, Askenase PW, Kocsis
ischemia-reperfusion injury in rats. PLoS ONE. 2014;9(3):e92129. JD. Intravenously delivered mesenchymal stem cell-derived exosomes
69. Zhang G, Zou X, Huang Y, Wang F, Miao S, Liu G, et al. Mesenchymal target M2-type macrophages in the injured spinal cord. PLoS ONE.
stromal cell-derived extracellular vesicles protect against acute kidney 2018;13(1):e0190358.
injury through anti-oxidation by enhancing Nrf2/ARE activation in rats. 89. Wang L, Pei S, Han L, Guo B, Li Y, Duan R, et al. Mesenchymal stem
Kidney Blood Press Res. 2016;41(2):119–28. cell-derived exosomes reduce A1 astrocytes via downregulation of
70. Wang B, Jia H, Zhang B, Wang J, Ji C, Zhu X, et al. Pre-incubation with phosphorylated NFκB P65 subunit in spinal cord injury. Cell Physiol
hucMSC-exosomes prevents cisplatin-induced nephrotoxicity by Biochem. 2018;50(4):1535–59.
activating autophagy. Stem Cell Res Ther. 2017;8(1):75. 90. Ruppert KA, Nguyen TT, Prabhakara KS, Toledano Furman NE, Srivastava
71. Zhou Y, Xu H, Xu W, Wang B, Wu H, Tao Y, et al. Exosomes released AK, Harting MT, et al. Human mesenchymal Stromal cell-derived
by human umbilical cord mesenchymal stem cells protect against extracellular vesicles modify microglial response and improve clinical
cisplatin-induced renal oxidative stress and apoptosis in vivo and outcomes in experimental spinal cord injury. Sci Rep. 2018;8(1):480.
in vitro. Stem Cell Res Ther. 2013;4(2):34. 91. Cui GH, Wu J, Mou FF, Xie WH, Wang FB, Wang QL, et al. Exosomes
72. Tomasoni S, Longaretti L, Rota C, Morigi M, Conti S, Gotti E, et al. derived from hypoxia-preconditioned mesenchymal stromal cells
Transfer of growth factor receptor mRNA via exosomes unravels ameliorate cognitive decline by rescuing synaptic dysfunction
the regenerative effect of mesenchymal stem cells. Stem Cells Dev. and regulating inflammatory responses in APP/PS1 mice. FASEB J.
2013;22(5):772–80. 2018;32(2):654–68.
73. Li T, Yan Y, Wang B, Qian H, Zhang X, Shen L, et al. Exosomes derived 92. Katsuda T, Tsuchiya R, Kosaka N, Yoshioka Y, Takagaki K, Oki K, et al.
from human umbilical cord mesenchymal stem cells alleviate liver Human adipose tissue-derived mesenchymal stem cells secrete func-
fibrosis. Stem Cells Dev. 2013;22(6):845–54. tional neprilysin-bound exosomes. Sci Rep. 2013;3:1197.
74. Tan CY, Lai RC, Wong W, Dan YY, Lim SK, Ho HK. Mesenchymal stem cell- 93. Jarmalavičiūtė A, Tunaitis V, Pivoraitė U, Venalis A, Pivoriūnas A.
derived exosomes promote hepatic regeneration in drug-induced liver Exosomes from dental pulp stem cells rescue human dopaminergic
injury models. Stem Cell Res Ther. 2014;5(3):76. neurons from 6-hydroxy-dopamine-induced apoptosis. Cytotherapy.
75. Hyun J, Wang S, Kim J, Kim GJ, Jung Y. MicroRNA125b-mediated Hedge- 2015;17(7):932–9.
hog signaling influences liver regeneration by chorionic plate-derived 94. Zhang B, Wu X, Zhang X, Sun Y, Yan Y, Shi H, et al. Human umbilical cord
mesenchymal stem cells. Sci Rep. 2015;5:14135. mesenchymal stem cell exosomes enhance angiogenesis through the
76. Lou G, Yang Y, Liu F, Ye B, Chen Z, Zheng M, et al. MiR-122 modifica- Wnt4/β-catenin pathway. Stem Cells Transl Med. 2015;4(5):513–22.
tion enhances the therapeutic efficacy of adipose tissue-derived 95. Fang S, Xu C, Zhang Y, Xue C, Yang C, Bi H, et al. Umbilical cord-derived
mesenchymal stem cells against liver fibrosis. J Cell Mol Med. mesenchymal stem cell-derived exosomal microRNAs suppress
2017;21(11):2963–73. myofibroblast differentiation by inhibiting the transforming growth
factor-β/SMAD2 pathway during wound healing. Stem Cells Transl Med. 109. Kordelas L, Rebmann V, Ludwig AK, Radtke S, Ruesing J, Doeppner TR,
2016;5(10):1425–39. et al. MSC-derived exosomes: a novel tool to treat therapy-refractory
96. Hu GW, Li Q, Niu X, Hu B, Liu J, Zhou SM, et al. Exosomes secreted by graft-versus-host disease. Leukemia. 2014;28(4):970–3.
human-induced pluripotent stem cell-derived mesenchymal stem cells 110. Nassar W, El-Ansary M, Sabry D, Mostafa MA, Fayad T, Kotb E, et al.
attenuate limb ischemia by promoting angiogenesis in mice. Stem Cell Umbilical cord mesenchymal stem cells derived extracellular vesicles
Res Ther. 2015;6(1):10. can safely ameliorate the progression of chronic kidney diseases.
97. Zhang B, Wang M, Gong A, Zhang X, Wu X, Zhu Y, et al. HucMSC- Biomater Res. 2016;20:21.
exosome mediated-Wnt4 signaling is required for cutaneous wound 111. Filho DM, de Carvalho RP, Oliveira LF, dos Santos ALRT, Parreira RC, Pinto
healing. Stem Cells. 2015;33(7):2158–68. MCX, et al. Enhancing the therapeutic potential of mesenchymal stem
98. Li X, Liu L, Yang J, Yu Y, Chai J, Wang L, et al. Exosome derived from cells with the CRISPR-Cas system. Stem Cell Rev Rep. 2019;15(4):463–73.
human umbilical cord mesenchymal stem cell mediates MiR-181c 112. Kim S, Kim TM. Generation of mesenchymal stem-like cells for produc-
attenuating burn-induced excessive inflammation. EBioMedicine. ing extracellular vesicles. World J Stem Cells. 2019;11(5):270–80.
2016;8:72–82. 113. Théry C, Amigorena S, Raposo G, Clayton A. Isolation and characteriza-
99. Liang X, Zhang L, Wang S, Han Q, Zhao RC. Exosomes secreted by tion of exosomes from cell culture supernatants and biological fluids.
mesenchymal stem cells promote endothelial cell angiogenesis by Curr Protoc Cell Biol. 2006. https://doi.org/10.1002/0471143030.cb032
transferring miR-125a. J Cell Sci. 2016;129(11):2182–9. 2s30.
100. Zhang J, Guan J, Niu X, Hu G, Guo S, Li Q, et al. Exosomes released from 114. Livshits MA, Khomyakova E, Evtushenko EG, Lazarev VN, Kulemin NA,
human induced pluripotent stem cells-derived MSCs facilitate cutane- Semina SE, et al. Correction: corrigendum: isolation of exosomes by
ous wound healing by promoting collagen synthesis and angiogenesis. differential centrifugation: theoretical analysis of a commonly used
J Transl Med. 2015;13:49. protocol. Sci Rep. 2016;6(1):21447.
101. Shabbir A, Cox A, Rodriguez-Menocal L, Salgado M, Van Badiavas E. 115. Fatemeh M-H, Leonora B, Sara A, Pierre-Yves M, Allison EH, Alexander
Mesenchymal stem cell exosomes induce proliferation and migration JT, et al. Current methods for the isolation of extracellular vesicles. Biol
of normal and chronic wound fibroblasts, and enhance angiogenesis Chem. 2013;394(10):1253–62.
in vitro. Stem Cells Dev. 2015;24(14):1635–47. 116. Cvjetkovic A, Lötvall J, Lässer C. The influence of rotor type and centrifu-
102. Willis GR, Fernandez-Gonzalez A, Anastas J, Vitali SH, Liu X, Ericsson M, gation time on the yield and purity of extracellular vesicles. J Extracell
et al. Mesenchymal stromal cell exosomes ameliorate experimental Vesicles. 2014;3(1):23111.
bronchopulmonary dysplasia and restore lung function through 117. Abramowicz A, Widlak P, Pietrowska M. Proteomic analysis of exosomal
macrophage immunomodulation. Am J Respir Crit Care Med. cargo: the challenge of high purity vesicle isolation. Mol BioSyst.
2018;197(1):104–16. 2016;12(5):1407–19.
103. Cho BS, Kim JO, Ha DH, Yi YW. Exosomes derived from human adipose 118. Salih M, Zietse R, Hoorn EJ. Urinary extracellular vesicles and
tissue-derived mesenchymal stem cells alleviate atopic dermatitis. the kidney: biomarkers and beyond. Am J Physiol Renal Physiol.
Stem Cell Res Ther. 2018;9(1):187. 2014;306(11):F1251–9.
104. Nakamura Y, Miyaki S, Ishitobi H, Matsuyama S, Nakasa T, Kamei N, et al. 119. Taylor DD, Shah S. Methods of isolating extracellular vesicles impact
Mesenchymal-stem-cell-derived exosomes accelerate skeletal muscle down-stream analyses of their cargoes. Methods. 2015;87:3–10.
regeneration. FEBS Lett. 2015;589(11):1257–65. 120. Lobb RJ, Becker M, Wen Wen S, Wong CS, Wiegmans AP, Leimgruber A,
105. Riazifar M, Mohammadi MR, Pone EJ, Yeri A, Lässer C, Segaliny AI, et al. et al. Optimized exosome isolation protocol for cell culture supernatant
Stem cell-derived exosomes as nanotherapeutics for autoimmune and and human plasma. J Extracell Vesicles. 2015;4(1):27031.
neurodegenerative disorders. ACS Nano. 2019;13(6):6670–88. 121. Gerlach JQ, Krüger A, Gallogly S, Hanley SA, Hogan MC, Ward CJ, et al.
106. Squillaro T, Peluso G, Galderisi U. Clinical trials with mesenchymal stem Surface glycosylation profiles of urine extracellular vesicles. PLoS ONE.
cells: an update. Cell Transpl. 2016;25(5):829–48. 2013;8(9):e74801.
107. Lou G, Chen Z, Zheng M, Liu Y. Mesenchymal stem cell-derived
exosomes as a new therapeutic strategy for liver diseases. Exp Mol Med.
2017;49(6):e346. Publisher’s Note
108. Börger V, Bremer M, Ferrer-Tur R, Gockeln L, Stambouli O, Becic A, et al. Springer Nature remains neutral with regard to jurisdictional claims in pub-
Mesenchymal stem/stromal cell-derived extracellular vesicles and their lished maps and institutional affiliations.
potential as novel immunomodulatory therapeutic agents. Int J Mol Sci.
2017;18(7):1450.
Ready to submit your research ? Choose BMC and benefit from:
• fast, convenient online submission

• thorough peer review by experienced researchers in your field
• rapid publication on acceptance
• support for research data, including large and complex data types
• gold Open Access which fosters wider collaboration and increased citations
• maximum visibility for your research: over 100M website views per year
At BMC, research is always in progress.
Learn more biomedcentral.com/submissions

Mesenchymal Stem Cell Derived-Exosomes: A Modern Approach in Translational Medicine

Uploaded by

Copyright:

Available Formats

Mesenchymal Stem Cell Derived-Exosomes: A Modern Approach in Translational Medicine

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Mesenchymal Stem Cell Derived-Exosomes: A Modern Approach in Translational Medicine

Uploaded by

Copyright:

Available Formats

Nikfarjam

et al. J Transl Med (2020) 18:449

REVIEW Open Access

Mesenchymal stem cell derived‑exosomes:

(See figure on next page.)

Enhanced Sirtuin 1 signaling and p-eNOS levels

Mouse LF Inactivated the TGFβ1/SMAD2 pathway

Alleviated hepatic inflammation and collagen deposition

Recovered serum AST function

Reduced collagen type I and III

cells apoptotic Bcl-xL gene

Upregulated anti-inflammatory cytokines

Triggered the number of Tregs

Decreased microgliosis and prevented reactive astrogliosis

Restored short term myelination deficits and long term microstruc-

mature neurons, and decreased neuroinflammation Recovered sensorimotor function

Deactivated STAT3 and NF-κB

Rat skin burn Stimulated β-catenin nuclear translocation

Mouse skin-defect pathway blockade and reduction of collagen deposition in vitro

hyperoxia -induced inflammation pulmonary hypertension and pulmonary vascular remod-

Enhanced levels of indoleamine 2,3-dioxygenase

In another study of AD, it was shown that AD-MSCs Other diseases

[94]. Exosomal miRNAs including miR-21, ‐23a, ‐125b,

and ‐145 from hWJ-MSCs were reported to impede

Table 3 Mesenchymal stem cell-derived exosomes in clinical trials (https​://www.clini​caltr​ials.gov/)

Lung Healthy NCT04313647 I Recruiting AD-MSC 1× level: 2.0 × 108/3 ml China

Concluding remarks the recipient cells. Exploiting these immunomodulatory

Ready to submit your research ? Choose BMC and benefit from:

• fast, convenient online submission

At BMC, research is always in progress.

Learn more biomedcentral.com/submissions

You might also like

Pfad - The Proxy pFad of © 2024 Garber Painting. All rights reserved.

Table 3 Mesenchymal stem cell-derived exosomes in clinical trials (https://www.clinicaltrials.gov/)