Mono- vs. poly-therapy by fetal precursor cell transplantation

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This discussion was begun in the chapter: ‘General principles of therapeutic application’.

Here is the explanation of the concept of simultaneous implantation of various cell transplants in accordance with the pathophysiology of the treated disease of each individual patient,, i.e. the basis of the described clinical approach to the fetal precursor cell transplantation. It is actually gradually gaining ground in the U.S. under a term ‘composite grafts’. VI.BIBLIOGRAPHY [23, 24, 25, 26, 181]

Using diabetes mellitus as an example, under this concept there is a difference between the treatment of a patient with an early IDDM, soon after the sudden onset in childhood, and of the patient with a chronic IDDM with complications. In an early IDDM the repeated implantation of cell transplants of Langerhans islets of pancreas alone is probably sufficient for the disease control. In later stages, when secondary organs and tissues of the patient have become exhausted by an over-load of having to compensate for malfunction of the diseased organ or tissue for many years, and thus eventually damaged, these secondary organs or tissues have to be treated by an implantation of appropriate fetal precursor cell transplants along with fetal cells of the primary diseased organ or tissue, i.e. Langerhans islets of pancreas.

When the clinical picture shows clear pathological changes of the retinopathy, nephropathy, etc. due to advanced stages of IDDM, it is hard to conceive that there are no pathological changes of the regulatory organ, i.e. hypothalamus, of the key organ of metabolism, i.e. liver, or of the organ that copes with a chronic metabolic stress, i.e. adrenal cortex, and that these organs do not require a direct stimulation by the fetal precursor cell transplants of the same organs.

The reasoning behind an implantation of ‘peripancreatic block’ is to transplant

1/ the tissues with the greatest supply of fetal cells of Langerhans islets of pancreas,

2/ the GALT (‘gut-associated lymphoid tissue’) and MALT (‘mucosa- associated lymphoid tissue’), intimately involved in the auto-immune pathogenesis of IDDM,

3/ other cells involved in the paracrine regulation of function of the Langerhans islets.

Placenta has been known as the source of cells capable to induce the repair of the damaged vascular system and is added for all diabetic patients with microangiopathy, the same angiopathy that is the underlying pathology of any & all ultimately deadly diabetic complications.

Undoubtedly, we are dealing with an ‘empirical science’ here, based on observation of hundreds of thousands of patients by experienced physicians over many decades. But the foundation of this intellectual process have been solid scientific facts about the structure and function of the living body. At the same time we have to be humble and acknowledge that the field of the fetal precursor cell transplantation is at the ‘beginning of the road’.

There are two schools of thought in fetal precursor cell transplantation today. The classical school, followed by the author, and developed originally by the founders of cell therapy in Germany and USSR, calls for an implantation of cell transplants of all those organs and tissues that have been damaged or malfunction as a result of a disease(s) of a particular patient. Only at a very early stage of a disease is an implantation of only one fetal precursor cell transplant of a primarily damaged organ or tissue (so called ‘monotherapy’) sufficient to repair the damage. The recent Anglophone school of thought has called for ‘monotherapy’ in every case, but lately the need to co-transplant other fetal cell transplants along with the primary one has been discussed in the U.S. as well.

Hypothalamus-pituitary system participates closely in the regulation of insulin secretion. Stress increases the activity of this system, and that applies to the metabolic derangement of decompensated IDDM as well. IDDM-induced pathological responses of hypothalamus-pituitary system cause changes in the secretion of hypothalamic release factors and pituitary tropic hormones, that in turn lead to hormonal changes in the periphery, and those trigger further metabolic dysfunction, and the vitious circle is closed. On the basis of the above a theory on the pathogenesis of diabetic angiopathies has evolved: DM-induced abnormal carbohydrate and lipid metabolism triggers a stress reaction, that includes sudden severe changes of levels of various hormones, and such hormonal changes cause a damage to blood vessels over a long time. Abnormal utilization of glucose by the cells of an organism leads to a compensatory increased activity of hypothalamus – pituitary - adrenal axis, as a result of which there is an increased secretion of insulin antagonists: glucagon, somatotropin, cortisol, and other contra-insulin hormones, all of which play a role in the mechanism of development of secondary complications of diabetes mellitus. VI.BIBLIOGRAPHY [138, 139, 140].

This theory appears more logical and correct than the newer one implicating a lack of C-peptide as the cause of microangiopathic complications of IDDM, because it is based on well-known facts of physiology, while no one has proved that C-peptide has any physiologic function in the body yet. VI.BIBLIOGRAPHY [67, 149] The recently proposed and tried addition of C-peptide to insulin as a treatment of diabetic microangiopathy does not seem logical. There probably are some other factors in the various cells of the Langerhans islets of pancreas that may play a part in the development of diabetic microangiopathy, but to try to isolate them and use them as a part of treatment seems implausible.

Another leading theory proclaims that the extensive irreversible damage of organism and development of secondary lesions after years, or decades, of disturbed metabolism in diabetes mellitus relates largely to the severity and chronicity of hyperglycaemia. It has been the basis of the DCCT approach to the treatment of DM. NIH statistics of 50% decrease of incidence of microangiopathic complications of IDDM appear convincing, but not so to many U.S. practicing diabetologists. Besides that the rigid maintenance of blood sugar level bordering on hypoglycemia makes the everyday living very hard for the patients.

Two distinct mechanisms of the development of complications of diabetes mellitus have been proposed by this theory:

1/ Protein glycosylation: Irreversible binding of glucose to free amino groups of proteins creates ‘advanced glycation end products’, in proportion to the degree of hyperglycaemia. This inactivates the function of certain proteins, and causes cross-linking of others. The cross-linking of proteins allegedly contributes to the thickening of the basement membrane, so typical of diabetes mellitus. ‘Advanced glycation end products’ are bound to cell membrane receptors that support collagen accumulation in the basal membrane of endothel. Along with collagen fibers subjected to glycosylation they cause thickening of basal membranes with blockage of passage through endothelial wall, and narrowing of lumen, i.e. microangiopathy. Clinically it appears as retinopathy, nephropathy (Kimmelstiel-Wilson syndrome, glomerulosclerosis), etc.

Nephropathy causes hypertension, which along with increased VLDL and increased blood clotting triggers macroangiopathies: myocardial infarction, CVA, peripheral arterial disease with gangrenes.

2/ Polyol pathway: Hyperglycaemia increases the uptake of glucose by tissues, not dependent on insulin, via variety of metabolic pathways, of which the polyol pathway is the best known. Such augmentation of sorbitol (‘polyol’) pathway of glucose metabolism via activation of aldose reductase leads to accumulation of sorbitol (‘sugar alcohol’ or ‘polyol’) that cannot pass through cell membrane, accumulates in cell and causes intracellular edema. The resulting blockage takes place also in blood vessel walls of retina, kidneys, aorta, and peripheral nerves, with resulting swelling, hypoxia and metabolic impairment of these structures, a very plausible pathogenesis of diabetic microangiopathy. Drugs that inhibit aldose reductase prevent the development of cataracts, retinal damage, peripheral neuropathy, and early functional derangement of kidneys.

An accumulation of sorbitol in the lens of the eye causes water retention that lowers the transparency of lens and thereby causes cataract. An accumulation of sorbitol in Schwann cells and neurons disrupts energy flow in axons, causing polyneuropathy, especially affecting autonomous nervous system, sensation, and reflexes.

Due to insufficient glucose intake and extracellular hyperosmolality, the cells are losing water and their function suffers. For example in lymphocytes this dehydration leads to creation of superoxides, with lowered defense capabilities, and predisposition toward infections in diabetics.

Hyperglycemia supports production of various plasma proteins and thereby increased blood viscosity and blood clotting, with increased risk of thromboembolism. VI.BIBLIOGRAPHY [164]

Let’s consider the atherosclerotic coronary heart disease, the major cause of death among adults with diabetes mellitus. Cerebrovascular accidents, peripheral arterial disease with obstructions, and other major vasculopathies, are also common with diabetes mellitus. The extent and severity of atherosclerotic lesions in large- and medium-sized arteries are increased in long-standing diabetes mellitus, and their development is accelerated.

The multiplicity of pathogenetic factors responsible for atherosclerosis with diabetes mellitus is the best argument in favor of described method of ‘targeted poly- therapy’ over the ‘monotherapy’:

1/ hypertension is present in one-half of diabetes mellitus patients for no obvious reason;

2/ glycosylated LDL (‘low density lipoproteins’) do not readily bind to the LDL receptor in the liver, thereby LDL-cholesterol remains in the lumen of blood vessels available for atheroma development;

3/ there is an enhanced turnover of glycosylated HDL (‘high density lipoprotein’), thereby decreasing its protection against atherosclerosis;

4/ there is cross-linking of glycosylated proteins in the arterial wall;

5/ defect of lipoprotein lipase in diabetics leads to an impaired lipolysis of chylomicrons, that are atherogenic;

6/ platelet aggregation and synthesis of thromboxane A2 is increased in diabetics;

7/ sorbitol accumulation in the cells of arterial walls could be atherogenic. VI.BIBLIOGRAPHY [164]

These seven pathogenetic factors are tied to hypothalamus (No. 1/), adrenal cortex (No’s 1/ and 5/), liver (No’s 2/, 3/ ,5/ and 7/), placenta (No’s 1/, 4/ and 6/), peripancreatic block (No. 1/), our recommended fetal precursor cell transplants to be used for treatment along with islets of pancreas.

P. Niehans stated that endocrine glands are under control of the central regulator, and have a reciprocal influence on one another, so that consequently fetal cell transplantation treatment of any endocrine disease must almost always be of a polyglandular type. As the organism does not store hormones but produces only the quantities necessary for the momentary needs, the treatment by hormones is only a temporary form of therapy and does not ever lead to a cure. To that is added, in the course of time, an atrophy of the primary endocrine gland due to competitive inhibition, and thereby a cessation of the function of its cells. VI.BIBLIOGRAPHY [18]

Besides fetal precursor cell transplants of Langerhans islets of pancreas we recommend to use in the treatment of complications of IDDM as ‘co-transplants’ liver, ‘peripancreatic block’, adrenal cortex, placenta and hypothalamus.

Liver: Liver is a key organ of metabolism, and that applies also to the metabolism of majority of hormones. So the high incidence of diabetic hepatopathy is not surprising. In liver biopsies of 100 consecutive patients undergoing surgery for morbid obesity, all those with diabetes had some steatosis of liver, and in 42% the steatosis was severe. Increased liver intake of saturated fatty acids is caused by lipolysis, secondary to the deficit of insulin, and compensatory action of cortisol. Liver fibrosis was found in 81% of diabetics, and cirrhosis in 10% of diabetics. VI.BIBLIOGRAPHY [105] In autopsy material the cirrhosis of liver is found at least twice as often in diabetic than in non-diabetics. In clinical studies of patients with chronic liver disease, such as steatosis, fibrosis, cirrhosis, chronic active hepatitis, the prevalence of diabetes ranges from 10 to 75%. VI.BIBLIOGRAPHY [105] Hepato-megaly is present in 100% of patients with diabetic ketoacidosis.

Fetal liver was found to have a positive trophic effect on fetal pancreas: when separately prepared tissue fragments of both organs were implanted next to each other, it elaborated factor(s) that promote engrafment and/or function of co-transplanted fetal pancreas. VI.BIBLIOGRAPHY [181] Time interval between transplantation and normoglycemia was shorter in the recipients of composite fetal liver / fetal pancreas grafts. There are several mediators that could be responsible for these paracrine effects. Insulin-like growth factor I (IGF-1) is elaborated by fetal liver, and it increases replication, insulin synthesis and islets’ growth in culture, induces neovascularization as well, that may be important for islet differentiation. Simultaneous intramuscular injection of IGF-1 with fetal islet transplantation increases the overall success rate, and decreases the quantity of islets needed for normoglycemia. VI.BIBLIOGRAPHY [26] The addition of IGF-1 to the culture of islets was found to be of benefit. VI.BIBLIOGRAPHY [27] Perhaps some other factor released by fetal hepatocytes may protect islet cells, such as IGF-2, VI.BIBLIOGRAPHY [23, 25, 46] or somatomedins, acting in a paracrine manner. VI.BIBLIOGRAPHY [27, 162]

After transplantation of the adult liver, epithelial progenitor cells from adult pancreas differentiate into hepatocytes, express liver-specific proteins, and become fully integrated into the liver parenchyma. Apparently adult liver and pancreas retain common progenitor cells that upon activation proliferate and differentiate along a specific foregut epithelial cell lineage. The same applies to the adult tissues of the brain, bone mesenchyme, and bronchial epithelium. VI.BIBLIOGRAPHY [24, 159]

Intrahepatic transplantation of pancreatic islets causes a modification of structure and function of hepatocytes surrounding the islets. These new, hepatocyte-like cells, contain in their cytoplasm typical insulin granules, i.e. they are hybrids that developed as a result of paracrine influence of islet cells. VI.BIBLIOGRAPHY [131]

Liver has the potential to immunologically protect other simultaneously transplanted organs from the same donor. Severity of allograft rejection can be reduced by simultaneous intrasplenic transplantation of isolated liver cells from the same donor. VI.BIBLIOGRAPHY [42]

Transplantation of unmodified fetal liver cells into allogeneic recipients results in stable multilineage chimerism with donor-specific tolerance, due to the presence of pluripotent hematopoietic stem cell in the fetal liver, which are capable of engrafment in allogeneic adult recipients. VI.BIBLIOGRAPHY [6]

Liver and gut are organized stem cell and lineage systems, with three compartments: a slow cycling stem cell compartment, with cells expressing a fetal phenotype and responding slowly to injury; an amplification compartment, with cells of intermediate phenotype rapidly proliferating in response to regeneration stimuli or acute injuries; and a terminal differentiation compartment in which cells increasingly differentiate and gradually lose their ability to divide. VI.BIBLIOGRAPHY [22]

Stomach/intestine, a ‘peripancreatic block’: Physiological abnormalities associated with diabetes have been described in every part of the digestive tract where measurements can be made. VI.BIBLIOGRAPHY [105] Prevalence of gallstones, peptic ulcer, diverticultitis, irritable bowel syndrome, un-diagnosed frequent abdominal pain, constipation, etc., has been found by National Health Interview Survey (NHIS) in 1989 significantly higher in diabetics than non-diabetics VI.BIBLIOGRAPHY [105] In 32% of all hospitalizations of diabetics there was at least one digestive disease diagnosis. VI.BIBLIOGRAPHY [105] They result from autonomic neuropathy, diabetic microangiopathy, electrolyte imbalances secondary to uncontrolled diabetes, altered levels of insulin and glucagon causing depression of gastrointestinal mobility and secretion, and increased susceptibility to gastrointestinal infections.

Diabetic gastropathy occurs in 28% of patients with IDDM. There is an association between DM and constipation. Secretory abnormalities of exocrine pancreas are common in diabetics, for example 73% had diminished carbohydrate output to secretin administration. Exocrine pancreatic atrophy is probably caused by insulin deficiency. VI.BIBLIOGRAPHY [105] The diagnosis of chronic pancreatitis was found in a high percentage of hospital discharges with diabetes VI.BIBLIOGRAPHY [105]. Prevalence of celiac disease in IDDM patients has varied from 1.1% to 11%. In reverse, 5.4% of patients with celiac disease has also IDDM. VI.BIBLIOGRAPHY [105]

The reasons for using “peripancreatic block” in the fetal precursor cell treatment of complications of diabetes mellitus are:

1/ Undifferentiated epithelium in the duodenal anlage is stimulated by the overlying mesenchyme to grow and differentiate into mature pancreas with acinar, endocrine and ductal structures. In the first, early, undifferentiated stage, endoderm evaginates as the starting step of the chain of morphogenetic events; at that time among the pancreatic cell differentiation genes only endocrine ones, for insulin and glucagons, are expressed. In the second stage, epithelial branching with a formation of primitive ducts, and differentiation and separation of islet cells from the epithelium, and from the basement membrane, takes place. In the third stage, acinar cells form with enzyme carrying zymogen granules. The purity of the islets suggests that the lineage of most or all of the original epithelial cells was channeled toward the endocrine phenotype so that it appears that the default path for growth of embryonic pancreatic epithelium is to form islets. Islet formation requires no specific embryonic signals, and neither presence of ducts nor mesenchyme nor acini. VI.BIBLIOGRAPHY [28]

In the endocrine portion of fetal pancreas, human or animal, a proliferation of respective stem cells, and their further differentiation into a new generation of islet cells, takes place. In the fetal pancreas a large quantity of ß-cells is present outside of Langerhans islands, and this status persists partially even after birth, and there are also many acinar-islet complexes present, which have been thought of as another important source of pancreatic stem cells. VI.BIBLIOGRAPHY [124, 125]

In the adult organism stem cells can perhaps re-activate, too. As examples of activation of respective stem cells can serve the adult urinary bladder epithelium induced by fetal urogenital sinus mesenchyme to form prostatic glandular tissue, adult mammary tissue induced by fetal salivary mesenchyme to produce salivary gland tissue, or adult pancreatic duct epithelium directed by fetal mesenchyme toward islet cytodifferentiation. VI.BIBLIOGRAPHY [29]

2/ Inclusion of fetal precursor cell transplants from peripancreatic lymph nodes with islet cell transplants provides a high degree of protection from autoimmune ß-cell destruction: recipient rats became chimeric for a donor auto-regulatory T cell population from the peripancreatic lymph nodes, capable to suppress the autoimmune state. In diabetic patients that are not lymphopenic, the number of auto-regulatory cells required to abrogate autoimmunity may be quite small and difficult to detect macroscopically. VI.BIBLIOGRAPHY [41]

The human gastrointestinal tract contains as much lymphoid tissue as the spleen does. The mucosal T cell population is composed of both CD4+ and CD8+ cells, with the former being twice as numerous as the latter, just as in peripheral blood. Dome cells of the lymphoid aggregate, just below the epithelium, are rich in APC's, i.e. cells capable of antigen presentation following exposure to antigens via oral feeding in vivo. VI.BIBLIOGRAPHY [108]

The lining of gastro-intestinal tract has a specific function of absorbing a food from the environment into the organism, and it excludes unwanted factors from it, such as microrganisms, etc. The principal protective tools are the GALT (‘gut-associated lymphoid tissue’) and MALT (‘mucosa-associated lymphoid tissue’). In the jejunum there are 20 intra-epithelial lymphocytes per 100 epithelial cells, mostly T-lymphocytes. Antigen from the food is presented by APC’s to the lymphocytes of GALT and MALT, and that leads to a lymphoid cell division. Dividing lymphoblasts travel with antigens via regional lymphatics to the mesenteric lymph nodes, where further cell division takes place, and here the activated lymphocytes acquire the ability to ‘home’ to the gut. Subsequently they enter blood via intestinal lymphatics and thoracic duct. Immunoblasts ultimately extravasate through high endothelial venules in the gut following the ‘homing’ principle. VI.BIBLIOGRAPHY [163]

Antigens administered directly to the gastrointestinal tract frequently elicit a local antibody response in the intestinal lamina propria, while at the same time produce a state of systemic tolerance that manifests itself as a diminished response to the same antigen, if it is administered in immunogenic form elsewhere in the body (‘split tolerance’). VI.BIBLIOGRAPHY [165] Orally administered antigens induce tolerance to themselves by a variety of mechanisms. High doses of antigen can cause anergy or deletion due to clonal exhaustion. Low doses can induce priming of T cells in the gut, primarily CD4+ cells: TH2 cells produce cytokines, such as IL-10, and TH3 cells produce TGF, that in turn inhibits the proliferation and functioning of B cells, cytotoxic T cells and NK cells, and also inhibits cytokine production in lymphocytes and antagonizes the effects of TNF. Although the induction of mucosal TH2 and TH3 is antigen specific, the suppressive activity of TGF is not. Thus the induction of oral tolerance to one antigen is able to suppress the immune response to a second, associated antigen. VI.BIBLIOGRAPHY [166, 165]

Oral unresponsiveness may be due to induction of antigen-specific suppressor T cells in Payer's patches, or due to the presence of antigen-nonspecific suppresor cells, or due to clonal inhibition (or clonal anergy) resulting from a direct effect of antigens on B or T cells in mucosal follicles. VI.BIBLIOGRAPHY [108] The mucosal system elaborates suppressor cells that interact with ubiquitous antigens and down-regulate responses not only in the mucosal but also in systemic lymphoid tissue. This could be the reason for tolerance of cell xeno-transplants prepared from organs and tissues of domestic animals used as a food by humans, particularly when also a variety of animal organs from many different animal species are consumed by the population, as is typical in Europe.

3/ The liver and exocrine pancreas may have a modulating if not causal role in the development of DM for various regulatory reasons. There is a hypothesis about independent insulin-regulating mechanism of the gastrointestinal tract, in which the key role is played by the hormones and peptides of the stomach and duodenum, functioning simultaneously with those of pancreas. VI.BIBLIOGRAPHY [105, 74] The same neuropetides produced by hypothalamic neurons are produced in the Langerhans islets of pancreas by the neuroendocrine cells of the upper portion of the gastrointestinal tract, where they function in the paracrine manner, presumably influencing the function of the pancreatic islets. VI.BIBLIOGRAPHY [155, 162]

Somatostatin is a neuropeptide synthetized by hypothalamic neurons, d-cells of islets of pancreas, and by the mucosa of the gastrointestinal tract. It is a powerful inhibitor of GH release by blocking the stimulation of the hypothalamic GHRH (‘growth hormone releasing hormone’), and TSH (‘thyroid stimulating hormone’). VI.BIBLIOGRAPHY [155, 162,163]

Somatostatin suppresses secretion of insulin, as well as the exocrine secretion of the pancreas. VI.BIBLIOGRAPHY [163] In decompensated IDDM the hyper-secretion of of somatostatin takes place, even at rest. In sub-compensated IDDM with keto-acidosis, the secretion of somatostatin goes up 250% after physical load. The strongest stimulus for secretion of somatostatin is insulin induced hypoglycaemia, however. There is a direct correlation between increased secretion of somatostatin and labile course of diabetes mellitus that leads to increased sensitivity of peripheral tissues to endogenous somatostatin.

Somatostatin stimulates glucagon-secreting alpha-cells of islets, and increases activity of enzymes involved in insulin breakdown.

Increased somatostatin in IDDM causes an augmentation of sorbitol (‘polyol) pathway of glucose metabolism, which leads to accumulation of sorbitol in cell membranes, as described above. VI.BIBLIOGRAPHY [164]

Somatomedins are produced in many tissues in response to GH, particularly in the liver. Without them GH cannot carry out its growth-promoting functions. (See further discussion below under ‘Hypothalamus’)

Gastrin is a group of 7 peptides, produced by modified cells of the mucosa of the pre-pyloric portion of stomach and duodenum, as well as beta-cells of Langerhans islets of pancreas, after gastric stimulation by food, or after stimulation of vagus nerve. C-terminal portion of gastrin and octapeptid of cholecystokinin are found in the brain in high concentrations, as well as in the cerebrospinal fluid. Besides other actions, gastrin stimulates secretion of insulin. VI.BIBLIOGRAPHY [74]

Increased serum levels of gastrin are found in diabetics after 8 - 19 years’ duration of disease. After fetal cell transplantation, serum levels of gastrin drop to normal. VI.BIBLIOGRAPHY [70]

There is a correlation between the lowered serum level of gastrin and improvement of symptoms of diabetic polyneuropathy after fetal precursor cell transplantation. VI.BIBLIOGRAPHY [70, 74]

Glucagon is produced by alpha-cells of Langerhans islands, which represent 75% of the cells of the islet. Since insulin and glucagon have opposite effect on liver, and since glucose suppresses secretion of glucagon, a theory was proposed that carbohydrate homeostasis is controlled by a molar relationship of insulin / glucagon rather than by a concentration of each of these two hormones individually. VI.BIBLIOGRAPHY [140]

Glucagon can impair glucose tolerance only when there is an absolute lack of insulin, as is the case with IDDM. In diabetes mellitus glucagon worsens the effect of insulin deficit: in decompensated diabetes mellitus, the glucagon secretion triggered by food intake causes an additional rise of hyperglycaemia after meal. VI.BIBLIOGRAPHY [141] In patients with decompensated IDDM the level of glucagon is 4 - 5 times, and in compensated IDDM 2 - 3 times, above the normal level. The level of glucagon in severe labile forms of IDDM grows accordingly. When an exogenous glucagon is injected in the amount that would increase its concentration to a level usually found in diabetics with metabolic decompensation, a significant rise of blood flow through kidneys and, in parallel, of glomerular filtration, takes place. Glucagon increases the ejection volume of the heart. As glucagon breaks down in kidneys, there is higher level of glucagon in uremia. After islet cell transplantation the concentration of glucagon drops to the normal level, or is significantly decreased, depending upon the level of compensation of IDDM. VI.BIBLIOGRAPHY [142] Glucagon increases production of ketone bodies from fatty acid progenitors. VI.BIBLIOGRAPHY [141]

There is a correlation between increased level of glucagon and higher rates of autonomous neuropathy. VI.BIBLIOGRAPHY [141]

Subcutaneous implantation of pieces of placenta, i.e. ‘Filatov treatment’, has been a treatment that countless millions of patients have taken ever since it was described by Russian opthalmologist Filatov. As he was developing the transplantation of cornea, and the clinical results were not satisfactory, regardless of what he tried, at some point he decided to implant subcutaneously to the patient / recipient at the time of corneal transplantation also pieces of human placenta. Suddenly his corneal transplantation results dramatically improved. He became obsessed with placental implantation, and this method of treatment became known world-wide. Oddly, the modern medicine, as well as regulatory agencies, have totally ignored this therapeutic method. No official statistics exist about the results, but there are no condemnations of this therapeutic method either. School of zellentherapie has used placenta as a part of the therapeutic combination for a variety of conditions, for reasons that ‘were so obvious’, that there are not too many publications explaining them.

In 58-cell human blastocyst of the human conceptus, the outer cells, destined to produce trophoblasts of the placenta, cannot be distinguished from the inner cells, destined to form the embryo. In 107-cell human blastocyst, 8 embryo-producing cells are surrounded by 99 trophoblastic cells. This explains completely the reason for frequent use of tissue fragments of the placenta by the school of zellentherapie. The absolutely unique metabolic, endocrine, and immunological properties of trophoblasts, that are the same cells as the ‘embryonic stem cells’ that just made headlines, from which the entire human being can be ‘built’, make them also the ‘universal stem cells’. VI.BIBLIOGRAPHY [110]

Placenta is the largest endocrine organ of any organism. It produces:

1/ chorionic gonadotropin (only in human and primates), with the biological activity of luteinizing hormone (LH), produced principally in the syncytiotrophoblast, with an important paracrine assistance of cytotrophoblasts;

2/ placental lactogen, combining lactogenic and potent growth hormone-like bioactivity, structurally very similar to growth hormone (GH), produced by syncytiotrophoblast alone;

3/ chorionic adrenocorticotropin, with an ACTH-like biological activity;

4/ chorionic thyrotropin;

5/ parathyroid hormone-related protein, with the biologic activity of parathyroid hormone, produced by cytotrophoblasts;

6/ hypothalamic-like-releasing hormones: for each known hypothalamic-releasing hormone there is an analog produced in placenta, i.e.

- gonadotropin-releasing hormone (GRH), present in cytotrophoblasts only,

- corticotropin-releasing hormone CRH), present in trophoblast, amnion, chorion, and decidua,

- thyrotropin-releasing hormone (TRH),

- growth hormone-releasing hormone (GHRH), present in cytotrophoblasts,

- inhibin, which inhibits action of pituitary FSH, present in syncytiotrophoblast;

7/ estrogens: estradiol and estriol, produced in enormous amounts exclusively by syncytiotrophoblasts;

8/ progesterone, produced in large amounts in syncytiotrophoblast. VI.BIBLIOGRAPHY [110].

Amnion produces vasoactive peptides: endothelin-1, potent vasoconstrictor, and parathyroid hormone-related protein, vasorelaxant, thus perhaps serving as a modulator of chorionic blood vessel tone and blood flow. VI.BIBLIOGRAPHY [110]

Pregnancy is an immunoprotected state. The fetus, only half matched to the mother, is a partial allograft, yet it is not rejected. VI.BIBLIOGRAPHY [40] Clinical evidence for depressed cell immunity during pregnancy is indisputable. Class I and class II MHC antigens are absent from trophoblasts at all stages of gestation in human and other mamalian species. VI.BIBLIOGRAPHY [110, 108] In mice low levels of class I MHC antigens present at the conception, disappear in the cytotrophoblasts, i.e. in Langhans cells, the germinal cells or cellular precursors of the syncytiotrophoblast, and secretory cells, by the time of implantation. VI.BIBLIOGRAPHY [110] The extravillous cytotrophoblasts transcribe the non-classic class I HLA-G gene, not expressed on any other human cell type, and synthetize a unique class I HLA-G protein, most likely involved in the invasion of trophoblast. VI.BIBLIOGRAPHY [110] Both trophoblasts and decidua probably produce agents that suppress lymphocyte immune responses. VI.BIBLIOGRAPHY [110] But the changes in T cell morphology and function are inconsistent, and the same applies to B cells. VI.BIBLIOGRAPHY [108] During murine pregnancy there is a weakening of TH1 responses and strengthening of TH2 responses.

The trophoblast is capable of phagocytosis, and secretes cytokines associated with macrophages, thus could be a part of macrophage-like tissues distributed throughout the body. In the fetal portion of the placenta the actively phagocytic Hofbauer cells are found. VI.BIBLIOGRAPHY [110]

Placenta cells increase the capillary collateral network by stimulating the development of collateral buds. They dilate the blood vessels and thus improve circulation of the blood throughout the organism. They have a hypotensive and a strong diuretic effect. The placenta of the very early fetus is rich in cells with pituitary-like phenotype, while the placenta of the mature fetus acts more in the manner of cells of the sex glands. VI.BIBLIOGRAPHY [18] In fetal precursor cell transplantation, placenta assures the nutrition of fetal cells. VI.BIBLIOGRAPHY [18]

Adrenals: Adrenal cortex is essential to life. In adulthood it comprises 80 - 90 % of the weight of adrenals. It consists of outer zona glomerulosa, where mineralocorticoids are produced, middle zona fasciculata, in which glucocorticoids are produced, and inner zona reticularis, where androgens are produced. The hormones of adrenal cortex play a key role in the metabolism of proteins, carbohydrates and fats, and water and electrolytes. They modulate the tissue response to injury or infection. Stress reaction is largely dependent on the adrenals: vasodilatation, increased oxidation, increased basal metabolic rate, increase blood pressure, bradycardia, hyperthermia, increased body strength, resistance to infection, etc., are all important in the ‘fight or flight’ response. VI.BIBLIOGRAPHY [162]

Glucocorticoids are insulin antagonists via

1/ their direct action on insulin-sensitive tissues:

a/ they stimulate gluconeogenesis by increased proteolysis,

b/ they decrease glucose intake by lowering the affinity of insulin to insulin receptors in muscle and fatty tissues;

2/ their indirect action by potentiating the action of other diabetogenic hormones, such as glucagon and somatostatin, while increased level of glucagon, somatostatin, or cortison, alone, causes only slight hyperglycaemia, in decompensated IDDM the combined effect of increased levels of all contra-insulin hormones multiplies on a geometric scale. As an example, cortisol alone has only weak influence on glucose production, but it enhances the short-term effect of increased glucagon level on liver into a sustained one, which leads to prolonged hyper-production of glucose.

Cortisol is required for the storage of glucose as glycogen, maintenance of plasma glucose level, and for survival during prolonged fasting. It blocks the suppresive effect of insulin on hepatic glucose output. Cortisol favors glucose output by the liver, whereas insulin inhibits it. The net result of cortisol excess is a rise in plasma glucose concentration and a compensatory increase in plasma insulin levels. When the rise in insulin is insufficient, diabetes mellitus can develop, or, if already present, greatly deteriorate.

Glucocorticoids increase the concentration of blood cholesterol, fatty acids, triglycerides and LDL lipoproteins, and this explains why their increased level in IDDM contributes to an increased incidence of vascular complications with severe, labile course of the disease. Besides that cortisol affects CNS function by modulating perceptual and emotional functioning, skeletal metabolism by a decrease of bone formation, hematopoiesis, muscle function by positive inotropic effect, renal function by water retention and hyponatremia. Cortisol supports vascular responsiveness that is important for the maintenance of normal blood pressure. So cortisol is catabolic, antianabolic, and diabetogenic hormone. VI.BIBLIOGRAPHY [162]

Cortisol is required for survival of ‘stressed’ organism. Patients with serious illnesses, or with hypoglycemia, secrete extra cortisol: the higher the cortisol level, the higher the mortality. Activation of cell-mediated immunity increases ACTH and cortisol release: a significant feedback relationship exists between immune and endocrine systems. Cortisol prevents the proliferation of thymus-derived lymphocytes, thus blocking the entire cell-mediated immunity; decreases the production of Th1 cytokine, while sparing Th2 responses; induces the production of TGFß, that inhibits immune response; and reduces the process of inflammation. Adrenal cortex synthesizes Il-1 and Il-6, that are potent stimulators of adrenal corticosteroid production, via CRH (‘corticotropin-releasing hormone’). VI.BIBLIOGRAPHY [162, 166] Adrenal cortical cells may provide local steroid secretion to protect other cell types from rejection. VI.BIBLIOGRAPHY [181]

Aldosterone sustains extracellular fluid volume by conservation of sodium, and deficiency of aldosterone produces a critical negative sodium balance, with hypovolemia and hypotension. It also prevents an overload of potassium by accelerating its excretion. The juxtaglomerular cells of kidneys and the zona glomerulosa form a feedback system for maintenance of extracellular fluid volume. VI.BIBLIOGRAPHY [162]

Fetal adrenals are the largest organ of the fetus. At term, the weight of the fetal adrenals approximates the weight of the adult adrenals. Relative to body weight, the human fetal adrenals are 25 times larger than those of the adult. More than 85% of the fetal adrenal gland is composed of the peculiar fetal zone, not found in the adult adrenals. Near term, the daily fetal adrenal steroid production is 8 - 10 times higher than that in resting adults. VI.BIBLIOGRAPHY [110]

Hypothalamus acts as an integration center controlling the autonomous, endocrine and behavioral responses, essential for the survival of the individual animal and of the species: water balance, thermoregulation, food intake, aggression, reproductive functions, sleep-wake cycle. VI.BIBLIOGRAPHY [167] It is the oldest part of the diencephalon, called ‘central gray matter’, closely connected with the frontal lobe of the cerebrum, limbic system, thalamus, basal ganglia, brain stem, eyes, and pituitary, the ‘master’ of the autonomous nervous system, regulating almost all internal body functions, including that of immune system, homeostasis, as well as motivations, and emotions. Electric stimulation of hypothalamus will cause hyperglycaemia, among many other internal changes. VI.BIBLIOGRAPHY [156]. By puncturing the mid-brain of a rabbit, Claude Bernard succeeded in inducing diabetes mellitus, i.e. ‘diabetic puncture’. Lesions of tuber cinereum cause diabetes mellitus as well. VI.BIBLIOGRAPHY [18]

Within the hypothalamus there are multiple non-distinct clusters of cells, sometimes called hypothalamic nuclei. Two of them are well defined: supraoptic and para-ventricular nuclei produce two peptide hormones, i.e. ADH and oxytocin, that are stored in the posterior lobe of the pituitary, and released as necessary. VI.BIBLIOGRAPHY [161]

Neuro-secretory cells within the medial basal hypothalamus, i.e. ‘hypophysiotropic area’, produce six neurohormones, called ‘releasing factors’, that control the synthesis and secretion of six hormones of the anterior pituitary, which they enter via a unique portal venous circulation. VI.BIBLIOGRAPHY [67, 162] Hypothalamus is a central relay station for collecting and integrating signals from different sources and funneling them into the pituitary. The output of pituitary hormones responds to changes in autonomic nervous system activity. Anterior pituitary lies outside of blood-brain barrier, but its hormones can penetrate through blood-brain-barrier via retrograde flow of pituitary portal veins, or via fenestrated cells of the capillaries that bathe hypothalamic neurons . VI.BIBLIOGRAPHY [162]

Growth hormone (GH) is a protein hormone with anabolic effects. Growth-promoting effect of GH requires participation of other peptides: somatomedins, which resemble pro-insulin in structure. They are called insulin growth factors (IGF). IGF-1 has 50% and IGF-2 has 70% aminoacid homology with A and B chains of insulin. They are produced by many tissues in response to GH. They work as endocrine hormones as well as in paracrine fashion. (See also above under ‘peripancreatic block’.)

Under normal conditions the secretion and actions of GH and insulin are metabolically coordinated. But under pathologic conditions the insulin-antagonistic nature of GH becomes apparent: by stimulation of lipolysis, and inhibition of glucose uptake, the actions of GH are diabetogenic. VI.BIBLIOGRAPHY [162]

Corticotropin-releasing hormone (CRH) - adrenocorticotropic hormone (ACTH) - cortisol axis is central to the integrated responses to stress, which involves multiple hormones: ACTH, catecholamines, ADH, angiotensin, glucagon, growth hormone. CRH-secreting cells are regulated by many different nerve impulses, with a participation of several neurotransmitters: norepinehrine, serotonine, acetylcholine, dopamine, GABA. Via a negative feedback control system, in response to CRH, the ACTH is released, and ACTH in turn stimulates cortisol production. Hypothalamic - pituitary - gonadal axis is essential for a reproductive process in both males and females. GRH (‘gonadotropin- releasing hormone’) stimulates synthesis and secretion of both FSH and LH, that in turn control the function of granulosa and luteal cells of the ovary, and of the Leyding cells and Sertoli’s cells of the testis. VI.BIBLIOGRAPHY [67, 155, 167]

The control of immune system by central nervous system is accepted today. Most lymphoid tissues receive direct sympathetic innervation. Nervous system controls output of various hormones, in particular corticosteroids, GH, thyroxine and adrenaline, that in turn affect immune system. Il-1 nd Il-6 are produced by neurons and glial cells, predominantly of hypothalamus, and by pituitary cells. VI.BIBLIOGRAPHY [165]