PMC:6141714 / 90540-111602 JSONTXT

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of chronic inflammatory disorders of the intestine\nInflammatory bowel disease is a group of inflammatory conditions of the colon and small intestine. Crohn's disease and ulcerative colitis are the main types of inflammatory bowel disease (198). Crohn's disease is a granulomatous disease that can reach any part of the gastrointestinal tract, from the mouth to the anus. In the Crohn's disease, the terminal ileum and the cervix are the most frequently affected areas. The clinical presentation of the disease can range from recurrent bouts of diarrhea, fever, severe abdominal pain, weight loss and of systemic complications, drastically affecting individual's quality of life (199). Ulcerative colitis, however, is an idiopathic inflammation that specifically affects the cervix and rectum. Clinically, the ulcerative colitis is characterized by episodes of recurrent bloody diarrhea, followed by tenesmus and severe abdominal cramps. In contrast to Chron's disease, in the ulcerative colitis the ulceration does not reach the muscular layer of the mucosa and the inflammation is limited to the mucosa and the lamina propria (200). The symptoms observed in Crohn's disease result from an altered intestinal immune system response that triggers the excessive release of cytokines such as TNF-α, IFN-γ, IL-12, IL-13, and IL-17, secreted by Th1 cells. On the other hand, the IL-4 and IL-5 cytokines involved in ulcerative colitis are secreted by Th2 cells (201). The initial alteration in the mucosa and submucosa tunics arises from the infiltration of inflammatory cells in the crypts of Lieberkuhn (202). Inflammatory bowel diseases were treated with hMSCs in 21 (99–117, 155, 156) out of the 132 articles analyzed. In two studies (116, 117), bone marrow-derived hMSCs were used for the treatment of Crohn's disease in humans. In the other 19 (99–115, 155, 156) articles analyzed, hMSCs were used for the treatment of experimental colitis in animal models. Among them, 16 (99–115, 155, 156) used mice and three (108, 111, 112) used pigs as the experimental model. Regarding the source of the hMSCs used, in seven studies (100, 101, 103, 107, 113, 115, 155) hMSCs were isolated from the umbilical cord. Furthermore, hMSCs were isolated from the bone marrow (99, 102, 108, 109, 111, 112) and adipose tissue (100, 103, 104, 106, 110, 156) in six studies each. The menstrual blood (105), dental pulp (114) and gingival (99) was chosen as the source of hMSCs in only one study each. In two studies (102, 103), hMSCs were obtained from the directed differentiation of embryonic stem cells.\nAmong the animal studies, the cumulative survival rate, the percentage of body weight change, the disease activity index score, the histological damage score, the macroscopic damage score, the change in colon weight, the change in colon length, the change in colon weight-to-length ratio and the intra-colon myeloperoxidase activity were the outcomes used by most studies selected in this systematic review to assess the potential of hMSCs administration for the treatment of ulcerative colitis. In both the two human clinical trials selected, the change in the Crohn's disease activity index (CDAI) score was chosen as the primary endpoint that was used to assess the disease activity in Crohn's disease and to evaluate both the induction of response and the maintenance of response following hMSCs administration. However, the CDAI score is composed of some variables that are subjective and therefore vulnerable to observation bias. We therefore propose that the CDAI score should be used in combination with other endpoints that are less susceptible to bias such as the endoscopic disease activity score and the histologic disease activity score in order to correctly assess the effectiveness of hMSCs administration for the treatment of Crohn's disease in clinical trials. Treatment of inflammatory bowel diseases with hMSCs resulted in an increase in the survival rates (101–103, 108, 109, 155, 156) and in a decrease in the severity (99–117, 155, 156) of the disease, as described by many of the articles selected. Furthermore, a reduction in the pathology of the colon (99, 100, 101, 102, 103, 104, 106, 107, 108, 109, 110, 112, 114, 115, 155, 156) and a recovery in the destruction of the epithelial barrier (106) was also frequently observed. This reduction in the pathology of the colon was further confirmed in a study conducted by Arturo et al. (117), in which a decrease in the levels of both anti-Saccharomyces cerevisiae antibodies and antinuclear autoantibodies in Crohn's disease patients treated with hMSCs was observed 1 year after the beginning of the treatment. Additionally, a study by Robinson et al. (112) demonstrated that the administration of hMSCs reduced the damage to nerve processes in the colonic wall, protected against myenteric neuronal loss and prevented changes in neuronal subpopulations in a guinea-pig model of 2,4,6-trinitrobenzene-sulfonate-induced colitis.\nIn general, the studies analyzed in this systematic review demonstrated that the levels of pro-inflammatory and immunoregulatory cytokines were significantly affected by the treatment with hMSCs. In some of the studies selected, administration of hMSCs reduced the levels of serum amyloid A protein (108) and pro-inflammatory cytokines such as IFN-γ (99, 100, 102, 103, 108, 117, 155, 156), TNF-α (100, 102–104, 108, 109, 113, 116, 155, 156), IL-2 (102, 104, 117), IL-12 (103, 109, 156), IL-16 (106), IL-17 (99, 100, 106, 108, 113), IL-1β (100, 103, 106, 109, 114, 152), LIF (114), CCL5 (103, 109, 156), CCL2 (106), CXCL2 (103, 156), CXCL9 (106), and CXCL10 (106) and increased the levels of immunoregulatory cytokines such as IL-10 (99, 103, 104, 106, 108, 109, 116, 117, 155, 156) and IL-4 (104, 108). Furthermore, IL-6, a cytokine with both inflammatory and immunoregulatory properties, was found to be decreased in some studies (99, 100, 103, 108, 109, 113, 114, 155, 156) while, in others, the expression of this cytokine was stimulated by the administration of hMSCs (116, 117). The administration of hMSCs had also a stimulatory effect in the expression of TGF-β (106, 109, 117), PGE2 (101, 114, 155), PTGES (114), IDO (99, 108, 112), iNOS (99, 106), COX-2 (99, 101, 109), TNFSF14 (106), and Arg-1 (106) and an inhibitory effect in the expression of TIMP metallopeptidase inhibitor 1 (106) and in the myeloperoxidase activity (106) in the colon. The immune inhibitory ligandPD-L1 is also highly expressed by hMSCs, as demonstrated in a study conducted by Wang et al. (102).\nEffects of the administration of hMSCs in the proliferation, differentiation and migration of immune cells were also analyzed by the majority of the studies selected and the results demonstrated that the use of hMSCs lead to an inhibition in the proliferation and infiltration of inflammatory cells into the colon. As reported by some studies, the administration of hMSCs inhibited the activation and stimulated the apoptosis of T lymphocytes (99, 102, 104, 109, 113, 115). The clonal expansion of both B cells (115) and CD8+and CD4+ T cells (102, 104) was also inhibited by the treatment with hMSCs. In particular, a significant inhibition in the clonal expansion of CD4+IL17−IFN+Th1 (103, 113) and CD4+IL17+IFN-γ− Th17 (113) cells was observed following the administration of hMSCs. Additionally, an opposite effect was reported in the clonal expansion of CD4+CD25+FoxP3+and CD4+CD127+Treg (103, 104, 113, 156) cells after the administration of hMSCs. Furthermore, a study conducted by Lv et al. (105) reported a significant decrease in the number of CD11c+MHC-II+ dendritic cells in the spleen of hMSC-treated mice. In another study, Song et al. (107) demonstrated that the administration of extracts of hMSCs shifted the macrophage functional phenotype from M1 to M2 in the colon and peritoneum of mice with induced colitis. This shift in the functional phenotype of macrophage was conducted through the reduction in the levels of CCL2, CXCL9, and iNOS and the increase in the levels of IL-10, TNFSF14, CCL1, andArg-1 observed after the treatment with extracts of hMSCs. The effects of the presence of hMSCs in a population of macrophages were also studied by Anderson et al. (110). This study demonstrated that the presence of hMSCs induced the generation of macrophages with characteristics that are distinct from classically activated macrophages. These macrophages generated presented high arginase activity, increased secretion of IL-10 after restimulation and potent immunosuppressive activity on T cells and other macrophages. The generation of this type of macrophages appeared to be driven by the activation of COX-2 in hMSCs. Lastly, the infiltration of immune cells into the colon was also affected by the administration of hMSCs. In general, treatment with hMSCs inhibited the infiltration of leukocytes (107, 110, 111, 155) and CD4+ (99, 116, 155) T lymphocytes into the colon. Specifically, treatment with hMSCs inhibited the infiltration of MPO+ neutrophils, Mac-1+ macrophages, Mac-1+ NK cells and Mac-1+ granulocytes into the colon, as reported by a study conducted by González et al. (104). The infiltration of CD4+CD25+FoxP3+Treg cells into the colon was, however, found to be stimulated by the administration of hMSCs in the majority of the articles selected (99, 116, 155). It is, therefore, possible to hypothesize that the decrease in the pathology of the colon and the recovery in the destruction of the epithelial barrier observed following the treatment with hMSCs is a consequence of the ability of these stem cells to inhibit the proliferation and infiltration of inflammatory cells such as CD8+, Th1 and Th17 lymphocytes, neutrophils, B cells, NK cells, M1 macrophages and granulocytes into the colon and to stimulate the proliferation of M2 macrophages and cells with a regulatory phenotype such as Treg lymphocytes. As a result, the level of pro-inflammatory cytokines such as IFN-γ, TNF-α, IL-2, IL-12, and IL-17 also decreases, culminating in a reduction in the pathological process. In addition, the secretion of IL-6, TGF-β, PGE2, and IDO by hMSCs may be the mechanism responsible for both the shift in the macrophage functional phenotype from M1 to M2 and the inhibition in the infiltration of MPO+ neutrophils, Mac-1+ macrophages, Mac-1+ NK cells and Mac-1+ granulocytes into the colon, resulting in a decrease in the myeloperoxidase activity in the intestine, which reduces both the tissue damage and the inflammation that is needed for the occurrence of the pathological process.\nCeliac disease is an autoimmune inflammatory enteropathy caused by the ingestion of gluten in genetically susceptible individuals. Ingestion of gluten by these patients results in a chronic inflammatory response in the mucosa of the small intestine, which is accompanied by atrophy of the villi and hyperplasia of the intestinal crypts. The clinical manifestations of the celiac disease are very variable, and the patients affected by the disease may be asymptomatic, manifest symptoms of intestinal malabsorption or extraintestinal manifestations such as dyspepsia, fatigue, infertility, neurological diseases, osteoporosis and dermatitis herpetiformis (203). In patients affected by the celiac disease, the passage of gliadin peptides by the intestinal submucosa through transferrin receptors CD71 acts by activating CD4+ T lymphocytes, which recognize these peptides through T cell receptors (204). As a result, a stimulation of a Th1 and/or Th2 type response occurs, culminating in the secretion of pro-inflammatory cytokines such as IL-15, IFN-γ, IL-17, IL-21, and IL-23, which damage the intestinal mucosa. The secretion of IFN-γ stimulates fibroblasts to secrete metalloproteinases, which act degrading the collagen, glycoproteins and proteoglycans of the extracellular matrix, resulting in villous atrophy (205). The treatment of type II refractory celiac disease was carried out with hMSCs in only one study (118), which used the bone marrow as the source of hMSCs and was conducted in humans. This study was a single case report and used the stool frequency, the change in mucosal architecture, and the percentage of body weight change as the primary endpoints that were applied in order to assess the efficacy of hMSCs administration for the treatment of celiac disease. Celiac disease, like other food and allergy-related disorders, lacks well-defined clinical endpoints. Therefore, we recommend that multiple endpoints should be combined to capture the overall activity of the disease. Possible endpoints that can be used in combination includes: intestinal permeability, histological scores, gluten concentration, villus-height-to-crypt-depth ratio and changes in the levels of biomarkers in the serum. Exploratory endpoints such as the serum levels of cytokines and the proportion of inflammatory cells in the blood can be used to assess the immunomodulatory potential of the hMSCs administration. In the study selected, a reduction in the severity of the disease was observed after the administration of hMSCs. In particular, treatment with hMSCs resulted in a full macroscopic and microscopic recovery of the gut mucosa, and, as a consequence, in the normalization in stool frequency and a decrease in the weight loss resulting from the disease. Finally, an accentuated reduction in the levels of both IL-15 cytokine and IL-15 receptor at the mucosal level were observed after hMSCs treatment. Table 5 summarizes the methodology employed and the results obtained in the studies selected in this systematic review regarding the effects of the administration of hMSCs for the treatment of chronic inflammatory disorders of the intestine.\nTable 5 List of in vivo studies in which the therapeutic potential of the administration of hMSCs for the treatment of chronic inflammatory disorders of the intestine was evaluated and the results obtained.\nReferences Autoimmune disease Source of hMSC Variables Experimental model Clinical and laboratory effects Mechanism proposed\n(155) Ulcerative colitis Umbilical cord None Mice ↓Clinical score↓Weight loss↑Survival rates↓Colon pathology ↑Infiltration of CD4+CD25+FoxP3+ Tregs in the colon↓Infiltration of CD11b+ leukocytes in the colon↓Infiltration of CD4+ lymphocytes in the colon↓Proliferation of mononuclear cells↑PGE2↑IL-10↓IL-6↓IFN-γ↓TNF-α\n(156) Ulcerative colitis Adipose tissue None Mice ↓Clinical score↓Colon pathology↓Weight loss↑Survival rates ↓Th1-cell activation in colonic mucosa and draining lymph nodes↑CD4+CD25+FoxP3+IL-10+ Tregs in the mesenteric lymph node↓IL-6↓IL-12↓IL-1β↓IFN-γ↓TNF-α↓CCL5↓CXCL2↑IL-10\n(99) Ulcerative colitis Gingiva Bone marrow None Mice ↓Clinical score↓Colon pathology↓Weight loss ↓Peripheral blood lymphocyte proliferation↑Infiltration of CD4+CD25+ FoxP3+ Tregs in the colon↓Infiltration of CD4+ lymphocytes in the colon↑IL-10↑IDO↑iNOS↑COX-2↓IL-6↓IL-17↓IFN-γ\n(100) Ulcerative colitis Umbilical cord Adipose tissue None Mice ↓Clinical scores↓Colon pathology↓Weight loss ↓IL-6 in the serum↓IL-17 in the serum↓TNF-α in the serum↓IL-1β in the serum↓IFN-γ in the serum↓IL-10 in the serum\n(101) Ulcerative colitis Umbilical cord Administration of late-passage MSCs Mice None ↑COX-2↑PGE2\nAdministration of early-passage MSCs ↓Weight loss↑Survival rates↓Clinical score↓Colon pathology Effectiveness early-passage MSCs \u003e effectiveness late-passage MSCs\n(102) Ulcerative colitis Embryonic stem cells None Mice ↓Weight loss↓Clinical score↓Colon pathology ↓T lymphocyte proliferation↓B lymphocyte proliferation↑PD-L1 expression\n(103) Ulcerative colitis Embryonic stem cellsAdipose tissueUmbilical cord None Mice ↑Survival rates↓Weight loss↓Clinical score↓Colon pathology ↓Inflamatory cell infiltration in the colon↓Cycling CD4 T-cells↓Activated T cells↓IL-2↓TNF-α↓IFN-γ\n(104) Ulcerative colitis Adipose tissue None Mice ↑Survival rates↓Weight loss↓Clinical score↓Colon pathology ↓Intra-colonTNF-α↓Intra-colon IFN-γ↓Intra-colon IL-1β↓Intra-colon IL-6↓IL-12↓Intra-colon CCL5↓Intra-colon CXCL2↑Intra-colon IL-10↓IFN-γ+Th1 cell expansion↑CD4+CD25+FoxP3+ Tregs expansion\n(105) Ulcerative colitis Menstrual blood None Mice ↓Disease activity index↓Weight loss↓Colon pathology ↓Intra-colon TNF-α↓Intra-colon IL-2↑Intra-colon IL-4↑Intra-colon IL-10↓Intra-colon MPO+ neutrophils↓Intra-colon Mac-1+ macrophages↓Intra-colon Mac-1+ NK cells↓Intra-colon Mac-1+ granulocytes↓CD3+CD25+ active T cells in the spleen↓CD3+CD8+ T cells in the spleen↓CD11c+MHC-II+ dendritic cells in the speen↑CD4+CD25+FoxP3+ Tregs expansion\n(106) Ulcerative colitis Adipose tissue None Mice ↓Weight loss ↑Adipose-tissue derived MSCs in popliteal, mesenteric parathymic and parathyroid lymph nodes\n(107) Ulcerative colitis Umbilical cord Administration of extracts of MSCsAdministration of MSCs Mice ↓Disease activity index↓Weight loss↓Colon pathology↑Intestinal epithelial barrier Effectiveness administration of extracts of MSCs \u003eeffectiveness administration of MSCs ↓M1 macrophages↑M2 macrophages↓Myeloperoxidase activity in the colon↓Intra-colon CCL2↓Intra-colon CXCL9↓Intra-colon iNOS↓Intra-colon IL-17↑Intra-colon TGF-β1↑Intra-colon IL-10↑Intra-colon TNFSF14\n↑Intra-colon CCL1↑Intra-colon Arg-1↓Intra-colon sICAM-1↓Intra-colon IL-1β↓Intra-colon IL-16↓Intra-colon CXCL10↓Intra-colon TIMP metallopeptidase inhibitor 1\n(109) Ulcerative colitis Bone marrow Stimulation of MSCs with IFN-γ prior to administrationAbsence of stimulation with IFN-γ Mice ↓Weight loss↑Survival rates↓Clinical score↓Colon pathology↓Serum amyloid A protein Effectiveness MSCs + IFN-γ \u003e effectiveness MSCs alone ↑IDO↓PBMC proliferation↓CD3+ T cells infiltration in the colon↓Intra-colon TNF-α↓Intra-colon IL-6↓Intra-colon IL-17↓Intra-colon IFN-γ↑Intra-colon IL-4↑Intra-colon IL-10\n(110) Ulcerative colitis Adipose tissue None Mice ↓Weight loss↑Survival rates↓Clinical score↓Disease recurrence↓Colon pathology ↑IL-10 secretion↓IL-12 secretion↓T cells proliferation↓Colon neutrophil infiltration↓Macrophages proliferation↑Arginase activity↑COX-2 activity↓Intra-colon TNF-α↓Intra-colon IL-6↓Intra-colon IL-1β↓Intra-colon CCL5↑TGF-β1\n(113) Ulcerative colitis Umbilical cord None Mice ↓Clinical score↓Colon pathology↓Weight loss ↓T-cell proliferation↑IDO\n(114) Ulcerative colitis Dental pulp Bone marrow Stimulation of MSCs with acetylsalicylic acid prior to administrationAbsence of stimulation with acetylsalicylic acid None Mice ↓Weight loss↓Disease activity index↓Histologic activity index Effectiveness MSCs treated with acetylsalicylic acid \u003e effectiveness MSCs alone ↑AnnexinV+7AAD+ apoptotic T cells↓CD4+IL17+IFN− Th17 cells↓CD4+IL17−IFN+ Th1 cells↑CD4+CD25+Foxp3+ Tregs↓TNF-α↓IL-6↓IL-17\n(115) Ulcerative colitis Umbilical cord Stimulation of MSCs with 5-azacytidine prior to administration Absence of stimulation with 5-azacytidine Mice ↓Weight loss↑Survival rates↓Disease activity index↓Colon pathology Effectiveness MSCs treated with 5-azacytidine \u003e effectiveness MSCs alone ↓Infiltration of lymphocytes in the colon↓Mononuclear cells↓Jurkat cells↑COX2 gene↑PTGES gene↑PGE2↓LIF gene↓IL-6 gene↓IL-1β gene\n(108) Ulcerative colitis Bone marrow None Pigs ↓Clinical score↓Colon pathology↓Enteric neuropathy associated with intestinal inflammation ↓CD45+ leucocytes infiltration in the colon↑Nerve fiber density in the mucosa↑Morphology of β-tubulin (III)-IR fibers in mucosal and muscular layers of colon sections↓Myenteric neuronal loss\n(111) Ulcerative colitis Bone marrow None Pigs ↓Weight loss↓Colon pathology↓Neuronal cell body hypertrophy in colon ↓CD45+ leucocytes infiltration in the colon↓Myenteric neuronal loss\n(112) Ulcerative colitis Bone marrow None Pigs ↓Weight loss↑Repair of damaged tissue and nerve fibers ↓CD45+ leucocytes infiltration in the colon wall and the myenteric plexus↓Myenteric neuronal loss\n(116) Crohn's disease Bone marrow None Humans ↓Crohn's disease activity index score ↓Peripheral blood mononuclear cell proliferation↓TNF-α↑IL-1β↑IL-6↑IL-10↓CD4+ T cells in the colon↑CD4+CD127+ Tregs in the colon\n(117) Crohn's disease Bone marrow None Humans ↓Crohn's disease activity index score ↑IL-10↑TGF-β↑IL-6↓IFN-γ↓IL-2↓Antinuclear autoantibodies↓Anti-Saccharomyces cerevisiae antibodies\n(118) Type II refractory celiac disease Bone marrow None Humans ↓Stool frequency↓Weight loss↓Gut pathology ↓IL-15 cytokine in the small intestinal mucosa↓IL-15 receptor in the small intestinal mucosa\nBoth the methodology employed and the results obtained by each article are represented in this table. iNOS, inducible nitric oxide synthase; MPO, myeloperoxidase; Mac-1, macrophage-1 antigen; TNFSF14, tumor necrosis factor superfamily member 14; CCL1, C-C motif chemokine ligand 1; Arg-1, arginase 1; sICAM-1, soluble intercellular adhesion molecule-1; IL-16, interleukin 16; CXCL10, C-X-C motif chemokine 10; PTGES, prostaglandin E synthase; LIF, leukemia inhibitory factor."}

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of chronic inflammatory disorders of the intestine\nInflammatory bowel disease is a group of inflammatory conditions of the colon and small intestine. Crohn's disease and ulcerative colitis are the main types of inflammatory bowel disease (198). Crohn's disease is a granulomatous disease that can reach any part of the gastrointestinal tract, from the mouth to the anus. In the Crohn's disease, the terminal ileum and the cervix are the most frequently affected areas. The clinical presentation of the disease can range from recurrent bouts of diarrhea, fever, severe abdominal pain, weight loss and of systemic complications, drastically affecting individual's quality of life (199). Ulcerative colitis, however, is an idiopathic inflammation that specifically affects the cervix and rectum. Clinically, the ulcerative colitis is characterized by episodes of recurrent bloody diarrhea, followed by tenesmus and severe abdominal cramps. In contrast to Chron's disease, in the ulcerative colitis the ulceration does not reach the muscular layer of the mucosa and the inflammation is limited to the mucosa and the lamina propria (200). The symptoms observed in Crohn's disease result from an altered intestinal immune system response that triggers the excessive release of cytokines such as TNF-α, IFN-γ, IL-12, IL-13, and IL-17, secreted by Th1 cells. On the other hand, the IL-4 and IL-5 cytokines involved in ulcerative colitis are secreted by Th2 cells (201). The initial alteration in the mucosa and submucosa tunics arises from the infiltration of inflammatory cells in the crypts of Lieberkuhn (202). Inflammatory bowel diseases were treated with hMSCs in 21 (99–117, 155, 156) out of the 132 articles analyzed. In two studies (116, 117), bone marrow-derived hMSCs were used for the treatment of Crohn's disease in humans. In the other 19 (99–115, 155, 156) articles analyzed, hMSCs were used for the treatment of experimental colitis in animal models. Among them, 16 (99–115, 155, 156) used mice and three (108, 111, 112) used pigs as the experimental model. Regarding the source of the hMSCs used, in seven studies (100, 101, 103, 107, 113, 115, 155) hMSCs were isolated from the umbilical cord. Furthermore, hMSCs were isolated from the bone marrow (99, 102, 108, 109, 111, 112) and adipose tissue (100, 103, 104, 106, 110, 156) in six studies each. The menstrual blood (105), dental pulp (114) and gingival (99) was chosen as the source of hMSCs in only one study each. In two studies (102, 103), hMSCs were obtained from the directed differentiation of embryonic stem cells.\nAmong the animal studies, the cumulative survival rate, the percentage of body weight change, the disease activity index score, the histological damage score, the macroscopic damage score, the change in colon weight, the change in colon length, the change in colon weight-to-length ratio and the intra-colon myeloperoxidase activity were the outcomes used by most studies selected in this systematic review to assess the potential of hMSCs administration for the treatment of ulcerative colitis. In both the two human clinical trials selected, the change in the Crohn's disease activity index (CDAI) score was chosen as the primary endpoint that was used to assess the disease activity in Crohn's disease and to evaluate both the induction of response and the maintenance of response following hMSCs administration. However, the CDAI score is composed of some variables that are subjective and therefore vulnerable to observation bias. We therefore propose that the CDAI score should be used in combination with other endpoints that are less susceptible to bias such as the endoscopic disease activity score and the histologic disease activity score in order to correctly assess the effectiveness of hMSCs administration for the treatment of Crohn's disease in clinical trials. Treatment of inflammatory bowel diseases with hMSCs resulted in an increase in the survival rates (101–103, 108, 109, 155, 156) and in a decrease in the severity (99–117, 155, 156) of the disease, as described by many of the articles selected. Furthermore, a reduction in the pathology of the colon (99, 100, 101, 102, 103, 104, 106, 107, 108, 109, 110, 112, 114, 115, 155, 156) and a recovery in the destruction of the epithelial barrier (106) was also frequently observed. This reduction in the pathology of the colon was further confirmed in a study conducted by Arturo et al. (117), in which a decrease in the levels of both anti-Saccharomyces cerevisiae antibodies and antinuclear autoantibodies in Crohn's disease patients treated with hMSCs was observed 1 year after the beginning of the treatment. Additionally, a study by Robinson et al. (112) demonstrated that the administration of hMSCs reduced the damage to nerve processes in the colonic wall, protected against myenteric neuronal loss and prevented changes in neuronal subpopulations in a guinea-pig model of 2,4,6-trinitrobenzene-sulfonate-induced colitis.\nIn general, the studies analyzed in this systematic review demonstrated that the levels of pro-inflammatory and immunoregulatory cytokines were significantly affected by the treatment with hMSCs. In some of the studies selected, administration of hMSCs reduced the levels of serum amyloid A protein (108) and pro-inflammatory cytokines such as IFN-γ (99, 100, 102, 103, 108, 117, 155, 156), TNF-α (100, 102–104, 108, 109, 113, 116, 155, 156), IL-2 (102, 104, 117), IL-12 (103, 109, 156), IL-16 (106), IL-17 (99, 100, 106, 108, 113), IL-1β (100, 103, 106, 109, 114, 152), LIF (114), CCL5 (103, 109, 156), CCL2 (106), CXCL2 (103, 156), CXCL9 (106), and CXCL10 (106) and increased the levels of immunoregulatory cytokines such as IL-10 (99, 103, 104, 106, 108, 109, 116, 117, 155, 156) and IL-4 (104, 108). Furthermore, IL-6, a cytokine with both inflammatory and immunoregulatory properties, was found to be decreased in some studies (99, 100, 103, 108, 109, 113, 114, 155, 156) while, in others, the expression of this cytokine was stimulated by the administration of hMSCs (116, 117). The administration of hMSCs had also a stimulatory effect in the expression of TGF-β (106, 109, 117), PGE2 (101, 114, 155), PTGES (114), IDO (99, 108, 112), iNOS (99, 106), COX-2 (99, 101, 109), TNFSF14 (106), and Arg-1 (106) and an inhibitory effect in the expression of TIMP metallopeptidase inhibitor 1 (106) and in the myeloperoxidase activity (106) in the colon. The immune inhibitory ligandPD-L1 is also highly expressed by hMSCs, as demonstrated in a study conducted by Wang et al. (102).\nEffects of the administration of hMSCs in the proliferation, differentiation and migration of immune cells were also analyzed by the majority of the studies selected and the results demonstrated that the use of hMSCs lead to an inhibition in the proliferation and infiltration of inflammatory cells into the colon. As reported by some studies, the administration of hMSCs inhibited the activation and stimulated the apoptosis of T lymphocytes (99, 102, 104, 109, 113, 115). The clonal expansion of both B cells (115) and CD8+and CD4+ T cells (102, 104) was also inhibited by the treatment with hMSCs. In particular, a significant inhibition in the clonal expansion of CD4+IL17−IFN+Th1 (103, 113) and CD4+IL17+IFN-γ− Th17 (113) cells was observed following the administration of hMSCs. Additionally, an opposite effect was reported in the clonal expansion of CD4+CD25+FoxP3+and CD4+CD127+Treg (103, 104, 113, 156) cells after the administration of hMSCs. Furthermore, a study conducted by Lv et al. (105) reported a significant decrease in the number of CD11c+MHC-II+ dendritic cells in the spleen of hMSC-treated mice. In another study, Song et al. (107) demonstrated that the administration of extracts of hMSCs shifted the macrophage functional phenotype from M1 to M2 in the colon and peritoneum of mice with induced colitis. This shift in the functional phenotype of macrophage was conducted through the reduction in the levels of CCL2, CXCL9, and iNOS and the increase in the levels of IL-10, TNFSF14, CCL1, andArg-1 observed after the treatment with extracts of hMSCs. The effects of the presence of hMSCs in a population of macrophages were also studied by Anderson et al. (110). This study demonstrated that the presence of hMSCs induced the generation of macrophages with characteristics that are distinct from classically activated macrophages. These macrophages generated presented high arginase activity, increased secretion of IL-10 after restimulation and potent immunosuppressive activity on T cells and other macrophages. The generation of this type of macrophages appeared to be driven by the activation of COX-2 in hMSCs. Lastly, the infiltration of immune cells into the colon was also affected by the administration of hMSCs. In general, treatment with hMSCs inhibited the infiltration of leukocytes (107, 110, 111, 155) and CD4+ (99, 116, 155) T lymphocytes into the colon. Specifically, treatment with hMSCs inhibited the infiltration of MPO+ neutrophils, Mac-1+ macrophages, Mac-1+ NK cells and Mac-1+ granulocytes into the colon, as reported by a study conducted by González et al. (104). The infiltration of CD4+CD25+FoxP3+Treg cells into the colon was, however, found to be stimulated by the administration of hMSCs in the majority of the articles selected (99, 116, 155). It is, therefore, possible to hypothesize that the decrease in the pathology of the colon and the recovery in the destruction of the epithelial barrier observed following the treatment with hMSCs is a consequence of the ability of these stem cells to inhibit the proliferation and infiltration of inflammatory cells such as CD8+, Th1 and Th17 lymphocytes, neutrophils, B cells, NK cells, M1 macrophages and granulocytes into the colon and to stimulate the proliferation of M2 macrophages and cells with a regulatory phenotype such as Treg lymphocytes. As a result, the level of pro-inflammatory cytokines such as IFN-γ, TNF-α, IL-2, IL-12, and IL-17 also decreases, culminating in a reduction in the pathological process. In addition, the secretion of IL-6, TGF-β, PGE2, and IDO by hMSCs may be the mechanism responsible for both the shift in the macrophage functional phenotype from M1 to M2 and the inhibition in the infiltration of MPO+ neutrophils, Mac-1+ macrophages, Mac-1+ NK cells and Mac-1+ granulocytes into the colon, resulting in a decrease in the myeloperoxidase activity in the intestine, which reduces both the tissue damage and the inflammation that is needed for the occurrence of the pathological process.\nCeliac disease is an autoimmune inflammatory enteropathy caused by the ingestion of gluten in genetically susceptible individuals. Ingestion of gluten by these patients results in a chronic inflammatory response in the mucosa of the small intestine, which is accompanied by atrophy of the villi and hyperplasia of the intestinal crypts. The clinical manifestations of the celiac disease are very variable, and the patients affected by the disease may be asymptomatic, manifest symptoms of intestinal malabsorption or extraintestinal manifestations such as dyspepsia, fatigue, infertility, neurological diseases, osteoporosis and dermatitis herpetiformis (203). In patients affected by the celiac disease, the passage of gliadin peptides by the intestinal submucosa through transferrin receptors CD71 acts by activating CD4+ T lymphocytes, which recognize these peptides through T cell receptors (204). As a result, a stimulation of a Th1 and/or Th2 type response occurs, culminating in the secretion of pro-inflammatory cytokines such as IL-15, IFN-γ, IL-17, IL-21, and IL-23, which damage the intestinal mucosa. The secretion of IFN-γ stimulates fibroblasts to secrete metalloproteinases, which act degrading the collagen, glycoproteins and proteoglycans of the extracellular matrix, resulting in villous atrophy (205). The treatment of type II refractory celiac disease was carried out with hMSCs in only one study (118), which used the bone marrow as the source of hMSCs and was conducted in humans. This study was a single case report and used the stool frequency, the change in mucosal architecture, and the percentage of body weight change as the primary endpoints that were applied in order to assess the efficacy of hMSCs administration for the treatment of celiac disease. Celiac disease, like other food and allergy-related disorders, lacks well-defined clinical endpoints. Therefore, we recommend that multiple endpoints should be combined to capture the overall activity of the disease. Possible endpoints that can be used in combination includes: intestinal permeability, histological scores, gluten concentration, villus-height-to-crypt-depth ratio and changes in the levels of biomarkers in the serum. Exploratory endpoints such as the serum levels of cytokines and the proportion of inflammatory cells in the blood can be used to assess the immunomodulatory potential of the hMSCs administration. In the study selected, a reduction in the severity of the disease was observed after the administration of hMSCs. In particular, treatment with hMSCs resulted in a full macroscopic and microscopic recovery of the gut mucosa, and, as a consequence, in the normalization in stool frequency and a decrease in the weight loss resulting from the disease. Finally, an accentuated reduction in the levels of both IL-15 cytokine and IL-15 receptor at the mucosal level were observed after hMSCs treatment. Table 5 summarizes the methodology employed and the results obtained in the studies selected in this systematic review regarding the effects of the administration of hMSCs for the treatment of chronic inflammatory disorders of the intestine.\nTable 5 List of in vivo studies in which the therapeutic potential of the administration of hMSCs for the treatment of chronic inflammatory disorders of the intestine was evaluated and the results obtained.\nReferences Autoimmune disease Source of hMSC Variables Experimental model Clinical and laboratory effects Mechanism proposed\n(155) Ulcerative colitis Umbilical cord None Mice ↓Clinical score↓Weight loss↑Survival rates↓Colon pathology ↑Infiltration of CD4+CD25+FoxP3+ Tregs in the colon↓Infiltration of CD11b+ leukocytes in the colon↓Infiltration of CD4+ lymphocytes in the colon↓Proliferation of mononuclear cells↑PGE2↑IL-10↓IL-6↓IFN-γ↓TNF-α\n(156) Ulcerative colitis Adipose tissue None Mice ↓Clinical score↓Colon pathology↓Weight loss↑Survival rates ↓Th1-cell activation in colonic mucosa and draining lymph nodes↑CD4+CD25+FoxP3+IL-10+ Tregs in the mesenteric lymph node↓IL-6↓IL-12↓IL-1β↓IFN-γ↓TNF-α↓CCL5↓CXCL2↑IL-10\n(99) Ulcerative colitis Gingiva Bone marrow None Mice ↓Clinical score↓Colon pathology↓Weight loss ↓Peripheral blood lymphocyte proliferation↑Infiltration of CD4+CD25+ FoxP3+ Tregs in the colon↓Infiltration of CD4+ lymphocytes in the colon↑IL-10↑IDO↑iNOS↑COX-2↓IL-6↓IL-17↓IFN-γ\n(100) Ulcerative colitis Umbilical cord Adipose tissue None Mice ↓Clinical scores↓Colon pathology↓Weight loss ↓IL-6 in the serum↓IL-17 in the serum↓TNF-α in the serum↓IL-1β in the serum↓IFN-γ in the serum↓IL-10 in the serum\n(101) Ulcerative colitis Umbilical cord Administration of late-passage MSCs Mice None ↑COX-2↑PGE2\nAdministration of early-passage MSCs ↓Weight loss↑Survival rates↓Clinical score↓Colon pathology Effectiveness early-passage MSCs \u003e effectiveness late-passage MSCs\n(102) Ulcerative colitis Embryonic stem cells None Mice ↓Weight loss↓Clinical score↓Colon pathology ↓T lymphocyte proliferation↓B lymphocyte proliferation↑PD-L1 expression\n(103) Ulcerative colitis Embryonic stem cellsAdipose tissueUmbilical cord None Mice ↑Survival rates↓Weight loss↓Clinical score↓Colon pathology ↓Inflamatory cell infiltration in the colon↓Cycling CD4 T-cells↓Activated T cells↓IL-2↓TNF-α↓IFN-γ\n(104) Ulcerative colitis Adipose tissue None Mice ↑Survival rates↓Weight loss↓Clinical score↓Colon pathology ↓Intra-colonTNF-α↓Intra-colon IFN-γ↓Intra-colon IL-1β↓Intra-colon IL-6↓IL-12↓Intra-colon CCL5↓Intra-colon CXCL2↑Intra-colon IL-10↓IFN-γ+Th1 cell expansion↑CD4+CD25+FoxP3+ Tregs expansion\n(105) Ulcerative colitis Menstrual blood None Mice ↓Disease activity index↓Weight loss↓Colon pathology ↓Intra-colon TNF-α↓Intra-colon IL-2↑Intra-colon IL-4↑Intra-colon IL-10↓Intra-colon MPO+ neutrophils↓Intra-colon Mac-1+ macrophages↓Intra-colon Mac-1+ NK cells↓Intra-colon Mac-1+ granulocytes↓CD3+CD25+ active T cells in the spleen↓CD3+CD8+ T cells in the spleen↓CD11c+MHC-II+ dendritic cells in the speen↑CD4+CD25+FoxP3+ Tregs expansion\n(106) Ulcerative colitis Adipose tissue None Mice ↓Weight loss ↑Adipose-tissue derived MSCs in popliteal, mesenteric parathymic and parathyroid lymph nodes\n(107) Ulcerative colitis Umbilical cord Administration of extracts of MSCsAdministration of MSCs Mice ↓Disease activity index↓Weight loss↓Colon pathology↑Intestinal epithelial barrier Effectiveness administration of extracts of MSCs \u003eeffectiveness administration of MSCs ↓M1 macrophages↑M2 macrophages↓Myeloperoxidase activity in the colon↓Intra-colon CCL2↓Intra-colon CXCL9↓Intra-colon iNOS↓Intra-colon IL-17↑Intra-colon TGF-β1↑Intra-colon IL-10↑Intra-colon TNFSF14\n↑Intra-colon CCL1↑Intra-colon Arg-1↓Intra-colon sICAM-1↓Intra-colon IL-1β↓Intra-colon IL-16↓Intra-colon CXCL10↓Intra-colon TIMP metallopeptidase inhibitor 1\n(109) Ulcerative colitis Bone marrow Stimulation of MSCs with IFN-γ prior to administrationAbsence of stimulation with IFN-γ Mice ↓Weight loss↑Survival rates↓Clinical score↓Colon pathology↓Serum amyloid A protein Effectiveness MSCs + IFN-γ \u003e effectiveness MSCs alone ↑IDO↓PBMC proliferation↓CD3+ T cells infiltration in the colon↓Intra-colon TNF-α↓Intra-colon IL-6↓Intra-colon IL-17↓Intra-colon IFN-γ↑Intra-colon IL-4↑Intra-colon IL-10\n(110) Ulcerative colitis Adipose tissue None Mice ↓Weight loss↑Survival rates↓Clinical score↓Disease recurrence↓Colon pathology ↑IL-10 secretion↓IL-12 secretion↓T cells proliferation↓Colon neutrophil infiltration↓Macrophages proliferation↑Arginase activity↑COX-2 activity↓Intra-colon TNF-α↓Intra-colon IL-6↓Intra-colon IL-1β↓Intra-colon CCL5↑TGF-β1\n(113) Ulcerative colitis Umbilical cord None Mice ↓Clinical score↓Colon pathology↓Weight loss ↓T-cell proliferation↑IDO\n(114) Ulcerative colitis Dental pulp Bone marrow Stimulation of MSCs with acetylsalicylic acid prior to administrationAbsence of stimulation with acetylsalicylic acid None Mice ↓Weight loss↓Disease activity index↓Histologic activity index Effectiveness MSCs treated with acetylsalicylic acid \u003e effectiveness MSCs alone ↑AnnexinV+7AAD+ apoptotic T cells↓CD4+IL17+IFN− Th17 cells↓CD4+IL17−IFN+ Th1 cells↑CD4+CD25+Foxp3+ Tregs↓TNF-α↓IL-6↓IL-17\n(115) Ulcerative colitis Umbilical cord Stimulation of MSCs with 5-azacytidine prior to administration Absence of stimulation with 5-azacytidine Mice ↓Weight loss↑Survival rates↓Disease activity index↓Colon pathology Effectiveness MSCs treated with 5-azacytidine \u003e effectiveness MSCs alone ↓Infiltration of lymphocytes in the colon↓Mononuclear cells↓Jurkat cells↑COX2 gene↑PTGES gene↑PGE2↓LIF gene↓IL-6 gene↓IL-1β gene\n(108) Ulcerative colitis Bone marrow None Pigs ↓Clinical score↓Colon pathology↓Enteric neuropathy associated with intestinal inflammation ↓CD45+ leucocytes infiltration in the colon↑Nerve fiber density in the mucosa↑Morphology of β-tubulin (III)-IR fibers in mucosal and muscular layers of colon sections↓Myenteric neuronal loss\n(111) Ulcerative colitis Bone marrow None Pigs ↓Weight loss↓Colon pathology↓Neuronal cell body hypertrophy in colon ↓CD45+ leucocytes infiltration in the colon↓Myenteric neuronal loss\n(112) Ulcerative colitis Bone marrow None Pigs ↓Weight loss↑Repair of damaged tissue and nerve fibers ↓CD45+ leucocytes infiltration in the colon wall and the myenteric plexus↓Myenteric neuronal loss\n(116) Crohn's disease Bone marrow None Humans ↓Crohn's disease activity index score ↓Peripheral blood mononuclear cell proliferation↓TNF-α↑IL-1β↑IL-6↑IL-10↓CD4+ T cells in the colon↑CD4+CD127+ Tregs in the colon\n(117) Crohn's disease Bone marrow None Humans ↓Crohn's disease activity index score ↑IL-10↑TGF-β↑IL-6↓IFN-γ↓IL-2↓Antinuclear autoantibodies↓Anti-Saccharomyces cerevisiae antibodies\n(118) Type II refractory celiac disease Bone marrow None Humans ↓Stool frequency↓Weight loss↓Gut pathology ↓IL-15 cytokine in the small intestinal mucosa↓IL-15 receptor in the small intestinal mucosa\nBoth the methodology employed and the results obtained by each article are represented in this table. iNOS, inducible nitric oxide synthase; MPO, myeloperoxidase; Mac-1, macrophage-1 antigen; TNFSF14, tumor necrosis factor superfamily member 14; CCL1, C-C motif chemokine ligand 1; Arg-1, arginase 1; sICAM-1, soluble intercellular adhesion molecule-1; IL-16, interleukin 16; CXCL10, C-X-C motif chemokine 10; PTGES, prostaglandin E synthase; LIF, leukemia inhibitory factor."}