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International Journal of Stem cell Research and Therapy

DOI: 10.23937/2469-570X/1410026

Circulating Progenitor Cells in Regenerative Technologies: A Realistic Strategy in Bone Regeneration?

Jessica B. Chang and Justine C. Lee*

Division of Plastic and Reconstructive Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA, USA

*Corresponding author: Justine C. Lee, MD, PhD, Division of Plastic and Reconstructive Surgery, UCLA Medical Center, 200 UCLA Medical Plaza, Suite 465, Los Angeles, CA 90095-6960, USA, Tel: (310) 794-7616, Fax: (310) 206-6833, E-mail:
Int J Stem Cell Res Ther, IJSCRT-3-026, (Volume 3, Issue 1), Review Article; ISSN: 2469-570X
Received: December 26, 2015 | Accepted: February 22, 2016 | Published: February 26, 2016
Citation: Chang JB, Lee JC (2016) Circulating Progenitor Cells in Regenerative Technologies: A Realistic Strategy in Bone Regeneration?. Int J Stem Cell Res Ther 3:026. 10.23937/2469-570X/1410026
Copyright: © 2016 Chang JB, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Strategies in skeletal regeneration research have been primarily focused on optimization of three components: cellular progenitors, biomaterials, and growth factors. With the increased understanding that circulating progenitor cells exist in peripheral blood, the question arises whether such cell types would allow for adequate osteogenesis and mineralization. In this review, we discuss the current literature on circulating progenitor cells in in vitro and in vivo studies on bone regeneration.


Cellular progenitors, Mesenchymal Stem Cells (MSCs), Osteogenesis

Short Review

The regeneration of bone is a complex physiological process involved in fracture healing as well as defects created by trauma, infection, tumor resection, congenital abnormalities, and impaired or insufficient regeneration [1]. Various bone regeneration and repair strategies exist to augment surgical reconstructive procedures, including use of alloplastic and allogenic materials, distraction osteogenesis, osteoconductive scaffolds, and bone morphogenetic proteins. Despite the numerous options, the gold standard has remained autologous bone grafting [1,2]. However, limitations to this approach, particularly donor site morbidity and an inadequate supply of graft material, have led researchers to turn to cell-based tissue engineering strategies as a novel and attractive alternative [3].

Osteoprogenitor cells have been derived from sources such as bone marrow (BM) mesenchymal stem cells (MSCs) and circulating skeletal stem/progenitor cells. While BM MSCs are the most investigated and established source for tissue engineering, circulating progenitor cells have garnered attention in regenerative medicine due to their relative ease of isolation and elevated osteogenic potential [4]. Of particular interest are endothelial progenitor cells (EPCs), since a critical step in functional bone healing is the restoration of local blood flow. Recent discoveries have shown an overlap in the progenitor cell lineages giving rise to endothelial and osteoblastic cells [4], as well as the existence of a developmental, osteogenic reciprocity between endothelial cells and osteoblasts [5]. In response to tissue ischemia, EPCs mobilize from the bone marrow into peripheral circulation where they home to bone-healing sites (i.e. fractures or distraction osteogenesis) and promote vasculo-/angiogenesis [6,7]. This is key to the healing process because angiogenic events are one of the limiting factors in bone regeneration and function as the primary regulatory mechanism that directs bony repair [8].

Clinical translation of stem cell therapies for bone regeneration has been shown to be feasibleusing a variety of techniques [9]. Delivery of MSCs via percutaneous injections or scaffold-based technologies have been demonstrated to have efficacy in mineralization of various osseous defects including fracture nonunion and critical sized cranial defects [10-12]. MSCs have also been used to arrest or reverse the progression of osteonecrosis [13] and achieve high rates of posterior spinal fusion [14].

Although human studies using EPCs have been limited, animal experiments have been successful in regenerating bone using EPCs. Systemic administration of circulating CD34+ cells allows for recruitment to the fracture site and enhancement of vasculogenesis and osteogenesis, ultimately leading to clinically functional recovery of skeletal defects [15]. However large systemic doses are likely required for a clinical effect, and these transplanted cells migrate not only to the site of injury but also to the lung, liver, thymus, and brain, potentially causing unforeseen side effects. In an effort to avoid systemic effects, EPCs were subsequently seeded locally into a fracture site. EPC-mediated bone healing was shown to occur in a dose-dependent manner, with higher doses of CD34+ cells required for enhanced effects [16]. Local EPC-treated rat femurs had abundant new bone and vessel formationwith higher torsional strength and stiffness when compared to controls [17,18]. Similar effects were demonstrated in sheep models where ex vivo expanded autologous EPCs were implanted in critical-sized bone defects in sheep [8].

While many of these approaches have demonstrated effective bone regeneration, cell-based therapies require donor tissue sampling, often followed by extensive cell expansion steps before therapeutic implantation. These ex vivo cell expansion procedures can be both time-consuming and cost-expensive [3]. Moreover, isolated tissue-derived primary cells are often heterogeneous and difficult to standardize, making the procurement of a reliable, reproducible cell source a major challenge in cell-based approaches [19]. The well-studied BM-MSCs can only be isolated via BM aspiration under anesthesia, which is considered a form of surgical intervention. In contrast, peripheral blood cells are appealing because their aspiration does not require anesthesia and their isolation can be performed in a relatively minimally invasive, safe, and efficacious fashion [4]. However, the time investment alone required in CD34+ cell selection and subsequent expansion of EPCs to therapeutic levels, which may require up to weeks, may be a hurdle considered too daunting for some. Concentrated BM may fall into favor in this case, as it can be used at the point-of-care, in a single surgical procedure, without the risks, cost or time expense of ex vivo cell expansion [9].

Alternatively, the development of a novel approach of in situ tissue generation utilizes the body's own regenerating capacity by mobilizing host endogenous stem cells or tissue-specific progenitor cells to the site of injury, eliminating any need for ex vivo cell manipulation before implantation [20]. Direct targeting of the stem cell niche can induce progenitor cell mobilization in the form of osteoblasts. For example, stimulation of the parathyroid hormone receptor promotes proliferation of osteoblasts and secretion of paracrine factors that, in turn, increases the number of hematopoieticstem cells [19]. However further work is needed to elucidate the appropriate balance in activation of these receptors to avoid hormone overdrive, as well as understanding trafficking control, homing properties, and mechanisms of activation before these methods can be utilized clinically for structural and functional bone regeneration.

Vast strides have been made in making cell-based regenerative technologies a realistic strategy in bone regeneration. Cost and time considerations will ultimately affect the application of stem cell therapies provided that they can demonstrate improved clinical outcomes or decreased hospitalization requirements. Improved methods involving cell selection, effective expansion [21], synthetic mediatorstosustain proliferation [22], effectiveuse or reuse of media and growth factors, and 3-dimensional lattices allowing for maximal expansion [23] are needed to develop cost-effective approaches [24].


JCL is supported by the US Department of Veterans Affairs under award number IK2 BX002442-01A2, the Bernard G. Sarnat Endowment, and the Jean Perkins Foundation.

  1. Dimitriou R, Jones E, McGonagle D, Giannoudis PV (2011) Bone regeneration: current concepts and future directions. BMC Med 9:66.

  2. Chenard KE, Teven CM, He TC, Reid RR (2012) Bone morphogenetic proteins in craniofacial surgery: current techniques, clinical experiences, and the future of personalized stem cell therapy. J Biomed Biotechnol 2012: 601549.

  3. Herrmann M, Verrier S, Alini M (2015) Strategies to Stimulate Mobilization and Homing of Endogenous Stem and Progenitor Cells for Bone Tissue Repair. Front Bioeng Biotechnol 3:79.

  4. Matsumoto T, Kuroda R, Mifune Y, Kawamoto A, Shoji T, Miwa M, et al. (2008) Circulating endothelial/skeletal progenitor cells for bone regeneration and healing. Bone 43: 434-439.

  5. Karsenty G, Wagner EF (2002) Reaching a genetic and molecular understanding of skeletal development. Dev Cell 2: 389-406.

  6. Lee DY, Cho TJ, Kim JA, Lee HR, Yoo WJ, et al. (2008) Mobilization of endothelial progenitor cells in fracture healing and distraction osteogenesis. Bone 42: 932-941.

  7. Takahashi T, Kalka C, Masuda H, Chen D, Silver M, et al. (1999) Ischemia- and cytokine-induced mobilization of bone marrow-derived endothelial progenitor cells for neovascularization. Nat Med 5:434–438.

  8. Rozen N, Bick T, Bajayo A, Shamian B, Schrift-Tzadok M, et al. (2009) Transplanted blood-derived endothelial progenitor cells (EPC) enhance bridging of sheep tibia critical size defects. Bone 45: 918-924.

  9. Murphy MB, Moncivais K, Caplan AI (2013) Mesenchymal stem cells: environmentally responsive therapeutics for regenerative medicine. ExpMol Med 45: e54.

  10. Goel A, Sangwan SS, Siwach RC, Ali AM (2005) Percutaneous bone marrow grafting for the treatment of tibial non-union. Injury 36: 203-206.

  11. Hernigou P, Poignard A, Beaujean F, Rouard H (2005) Percutaneous autologous bone-marrow grafting for nonunions. Influence of the number and concentration of progenitor cells. J Bone Joint Surg Am 87:1430-1437.

  12. Kim IG, Hwang MP, Du P, Ko J, Ha CW, et al. (2015) Bioactive cell-derived matrices combined with polymer mesh scaffold for osteogenesis and bone healing. Biomaterials 50:75-86.

  13. Hernigou P, Daltro G, Filippini P, Mukasa MM, Manicom O (2008) Percutaneous implantation of autologous bone marrow osteoprogenitor cells as treatment of bone avascular necrosis related to sickle cell disease. Open Orthop J 2: 62-65.

  14. Gan Y, Dai K, Zhang P, Tang T, Zhu Z, et al. (2008) The clinical use of enriched bone marrow stem cells combined with porous beta-tricalcium phosphate in posterior spinal fusion. Biomaterials 29: 3973-3982.

  15. Matsumoto T, Kawamoto A, Kuroda R, Ishikawa M, Mifune Y, et al. (2006) Therapeutic potential of vasculogenesis and osteogenesis promoted by peripheral blood CD34-positive cells for functional bone healing. Am J Pathol 169: 1440–1457.

  16. Mifune Y, Matsumoto T, Kawamoto A, Kuroda R, Shoji T, et al. (2008) Local delivery of granulocyte colony stimulating factor-mobilized CD34-positive progenitor cells using bioscaffold for modality of unhealing bone fracture. Stem Cells 26: 1395-1405.

  17. Atesok K, Li R, Stewart DJ, Schemitsch EH (2010) Endothelial progenitor cells promote fracture healing in a segmental bone defect model. J Orthop Res 28: 1007-1014

  18. Li R, Atesok K, Nauth A, Wright D, Qamirani E, et al. (2011) Endothelial progenitor cells for fracture healing: a microcomputed tomography and biomechanical analysis. J Orthop Trauma 25: 467-471.

  19. Calvi LM, Adams GB, Weibrecht KW, Weber JM, Olson DP, et al. (2003) Osteoblastic cells regulate the haematopoietic stem cell niche. Nature 425: 841-846.

  20. Ko IK, Lee SJ, Atala A, Yoo JJ (2013) In situ tissue regeneration through host stem cell recruitment. Exp Mol Med 45:e57.

  21. Mata MF, Lopes JP, Ishikawa M, Alaiti MA, Cabral JM, et al. (2015) Scaling up the ex vivo expansion of human circulating CD34(+) progenitor cells with upregulation of angiogenic and anti-inflammatory potential. Cytotherapy 17: 1777-1784.

  22. Chou S, Chu P, Hwang W, Lodish H (2010) Expansion of human cord blood hematopoietic stem cells for transplantation. Cell Stem Cell 7: 427-428.

  23. Liu Y, Liu T, Fan X, Ma X, Cui Z (2006) Ex vivo expansion of hematopoietic stem cells derived from umbilical cord blood in rotating wall vessel. J Biotechnol 124: 592-601.

  24. Dahlberg A, Delaney C, Bernstein ID (2011) Ex vivo expansion of human hematopoietic stem and progenitor cells. Blood 117: 6083-6090.

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