Tissue Repair, Regeneration, repair & healing of injured tissues

REGENERATION
Refers to the growth of cells and tissues to replace lost structures
In humans, usually applied to growth of the liver and kidney after partial hepatectomy or
unilateral nephrectomy
Requires an intact connective tissue scaffold such as the basement membrane
Or if you are Dr. Who

Repair responses following Injury/Inflammation

Remember
Parenchymal tissue
Stromal tissue
There are two distinct processes involved in repair:

Regeneration or replacement of injured or dead cells by cells of the SAME type

Replacement by connective tissue or fibrosis scar tissue
o Both occur in most, but not all cells
o Involve essentially the same mechanisms
Cell proliferation, migration, differentiation, and cell-matrix interactions
Repair Involves
o A complete restore is called complete regeneration
o A repair with connective tissue is called incomplete regeneration (fibrous repair, scar
repair)
o Which do you think is stronger?
Cell Proliferation Versus Differentiation
o Cell proliferation-process of increasing cell numbers by mitotic division
o Cell Differentiation-process whereby a cell becomes more specialized in terms of
structure and function
REGENERATION: Control of normal cell growth
o Cell cycle and proliferative potential
o There are four phases:
Presynthetic (G1)
DNA synthesis (S)
Premitotic (G2)
Mitotic (M)
o Leads to cell division
Quiescent cells are in a physiologic state referred to as G0
TYPES OF CELLS
o Labile cells
o Stable cells
o Permanent cells
o Labile cells (continuously dividing cells)
Have a high rate of loss and replacement and therefore high capacity for
regeneration.
squamous and glandular epithelia
hemopoeitic cells in bone marrow
GI tract & epidermis

Stable cells (Quiescent cells)

do not normally proliferate but can be stimulated to do so after damage.

renal tubular cells

hepatocytes
osteoblasts
endothelial cells
fibroblasts
o Stable cells (proximal tubule)
o Permanent cells
unable to divide after initial development and therefore cannot regenerate when
some are lost.
Neurons
Skeletal & cardiac muscle
Regenerative Medicine
o The new field of regenerative medicine has as its goal the regeneration and
repopulation of damaged organs using Embryonic stem cells or Adult stem cells
o Various aspects include:
therapeutic cloning,
transplantation of stem cells into injured areas,
mobilization of stem cells from bone marrow to injured areas,
production of large numbers of stem cells in culture for transplantation
Stem cells
o Stem cells are characterized by their prolonged self-renewal capacity and by their
asymmetric replication:
in every cell division, one of the cells retains its self-renewing capacity while the
other enters a differentiation pathway and is converted to a mature, nondividing
population
o There is homeostasis between the death of mature cells and their regeneration by stem
cells (e.g., epithelia)
o Stem cells with the capacity to generate multiple cell lineages (pluripotent) can be
isolated from embryos
Called ES (embryonic stem cells)
o Adult stem cells (or tissue stem cells) may also generate multiple cell lineages
Seen largely in bone marrow and basal cells of epithelia
Can differentiate into fat, muscle, cartilage, bone, and endothelium
ADULT STEM CELLS
o More restricted differentiation capacity
o Usually lineage specific
o Located in sites called Niches
Bone Marrow Haematopoietic stem cells
Bone Marrow Stromal stem cells
Multipotent Adult Progenitor Cells
Growth factors
o Act on a variety of cell types
o Some are relatively specific
o Have functions related to cell locomotion, contractility, and differentiation which have a
bearing on wound healing as well as growth
o Act by paracrine, autocrine, or endocrine signaling
o Most important growth factors
Epidermal growth factor (EGF)

Transforming growth factor alpha (TGF)

Growth Factors (GFs)
Epidermal
Transforming (alpha, beta)
Hepatocyte
Vascular Endothelial
Platelet Derived
Fibroblast
Keratinocyte
Cytokines (TNF, IL-1, Interferons)
Platelet derived growth factor (PDGF) released from platelets upon platelet activation and
from activated macrophages
o Causes migration and proliferation of fibroblasts
Fibroblast growth factors (FGFs)
o Different types in different tissues
o Involved in angiogenesis, wound repair, skeletal muscle development, and lung
maturation, and hematopoiesis
Remember: Fibroblasts
o committed cell type found in many tissues.
o synthesize and maintain connective tissues by producing an extracellular matrix (ECM)
rich in collagen and proteoglycans.
o Fibroblasts with features of smooth muscle cells are called myofibroblasts and are
responsible for wound contraction
Transforming growth factor (TGF-) and related factors
o Produced by different cell types
o Functions as both an inhibitory and stimulatory substance
o Produced in low concentrations, it induces synthesis and secretion of PDGF
o Stimulates fibroblast chemotaxis
o In high concentrations it is a growth inhibitor (inhibits PDGF receptors)
Vascular endothelial growth factor (VEGF)
o Also called vascular permeability factor and placental growth factor
o Is actually a family of proteins
o Promote vessel formation in early development (vasculogenesis)
o Has a central role in growth of new blood vessels in repair and tumor growth
(angiogenesis)
o Cytokines are also involved in growth promoting activities as well as inflammation and
immune response
o Interleukin-1 (IL-1) and tumor necrosis factor (TNF) are mitogenic and chemotactic for
fibroblasts
E (Epidermal) GF
o Made in platelets, macrophages
o Present in saliva, milk, urine, plasma
o Acts on keratinocytes to migrate, divide
o Acts on fibroblasts to produce granulation tissue
T (Transforming) GF-alpha
o Made in macrophages, T-cells, keratinocytes
o Similar to EGF, also effect on hepatocytes and other epithelial cells
H (Hepatocyte) GF
o Made in mesenchymal cells
o Proliferation of epithelium, endothelium, hepatocytes
o Effect on cell motility
VE (Vascular Endothelial) GF

o Made in mesenchymal cells

o Triggered by HYPOXIA
o Increases vascular permeability
o Increases angiogenesis
o Mitogenic for endothelial cells
o KEY substance in promoting granulation tissue
PD (Platelet Derived) GF
o Made in platelets, but also MANY other cell types
o Chemotactic for MANY cells
o Mitogen for fibroblasts
o Angiogenesis
o Another KEY player in granulation tissue
F (Fibroblast) GF
o Made in MANY cells
o Chemotactic and mitogenic, for fibroblasts and keratinocytes
o Re-epithelialization
o Angiogenesis, wound contraction
o Hematopoesis
o Cardiac/Skeletal (striated) muscle
T (Transforming) GF-beta
o Made in MANY CELLS
o Chemotactic for PMNs and MANY other types of cells
o Inhibits epithelial cells
o Fibrogenic
o Anti-Inflammatory
K (Keratinocyte) GF
o Made in fibroblasts
o Stimulates keratinocytes:
Migration
Proliferation
Differentiation
I (Insulin-like) GF-1
o Made in macrophages, fibroblasts
o Stimulates:
o Sulfated proteoglycans
o Collagen
o Keratinocyte migration
o Fibroblast proliferation
o Action similar to GH (Pituitary Growth Hormone)
TNF (Tumor Necrosis Factor)
o Made in macrophages, mast cells, T-cells
o Activates macrophages (cachexin)
o KEY influence on other cytokines
The MAJOR TNF is TNF-alpha
Interleukins
o Made in macrophages, mast cells, T-cells, but also MANY other cells
o MANY functions:
Chemotaxis
Angiogenesis
REGULATION of other cytokines
SIGNALING
Autocrine (same cell)

Paracrine (next door neighbor) (many GFs)

Endocrine (far away, delivered by blood, steroid hormones)
Signaling mechanisms in Cell Growth
ExtraCellular Matrix (ECM)
o Collagen(s) I-XXVII
o Elastin
o Fibrillin
o CAMs (Cell Adhesion Molecules)
o Immunoglobulins, cadherins, integrins (cell anchors), selectins
o Proteoglycans
o Hyaluronic Acid
The Extracellular Matrix
o Roles of ECM
mechanical support for cell anchorage
determination of cell orientation (polarity)
control cell growth
maintenance of cell differentiation
scaffolding for tissue renewal
establishment of tissue microenvironments, storage and presentation of
regulatory molecules
Forms a significant proportion of the volume of tissues
Extracellular matrix (ECM) and cell-matrix interactions
o Important in the repair process
o The orderly regeneration of the epithelium of the skin and viscera requires integrity of
the basement membrane (BM)
o Provides a framework for the accurate regeneration of epithelial structures
o Disruption of the basement membrane scar formation when injured and cancer when
malignant cells transgress it
o The underlying supporting stroma of the parenchymal cells is necessary for organized
regeneration by acting as a scaffold for the replicating parenchymal cells (healing by
fibrosis, if destroyed)
o Is a dynamic, constantly remodeling macromolecular complex synthesized locally
which assembles into a network that surrounds cells
o Sequesters water (thus, maintains tissue turgor) and minerals (provides rigidity to
bone)
o Serves as a substrate for cell adhesion and a reservoir for growth factors
o Thus, regulating the proliferation, movement, and differentiation of the cells living in it
Neat mnemonic
Repair by Connective Tissue (Fibrosis)
o Fibrosis consists of four components
formation of new blood vessels (angiogenesis)
migration and proliferation of fibroblasts
deposition of ECM
maturation and reorganization of the fibrous tissue (remodeling)
Scar Remodeling
o A scar after surgical operation or trauma will become softer, smaller because of
degradation of collagens and other elements of ECM by:
metalloproteinases (collagenases)
Over growth of scar is called keloid

Wound Healing
o Induction of an acute inflammatory response
o Regeneration of parenchymal cells
o Migration and proliferation of both parenchymal and connective tissue cells
o Synthesis of extracellular matrix proteins (collagen III)
o Remodeling
o Collagenization and maturation of wound
Healing of Skin Wound
o Primary intention: the usual case with a surgical wound, in which there is a clean
wound with well-apposed edges, and minimal clot formation
Edges lined up
o Secondary intention: when wound edges cannot be apposed, (e.g., following wound
infection), then the wound slowly fills with granulation tissue from the bottom up. A
large scar usually results.
Edges not lined up
Ergo.
More granulation
More epithelialization
MORE FIBROSIS
Primary or secondary?
What is the role of macrophages in wound healing?
Cleanup of debris.
Macrophages recruit other cells and are essential for the entry of fibroblasts and angioblasts
into the wound.
Stimulation of matrix production. Macrophages are a potent source of growth factors and
interleukins that stimulate fibroblasts and angioblasts to produce the extracellular matrix.
Remodeling of the scar. They secrete collagenases and other lytic enzymes that degrade
collagen and other matrix components, thus restructuring the entire field.
At the same time, macrophages and fibroblasts, secrete tissue inhibitors of
metalloproteinases (TIMPs), which counteract the action of lytic enzymes so that the
remodeling of the scar proceeds in a regulated manner.
HEALING: Wound strength
Tensile Strength
o Tensile strength of a healing wound about one week post injury is usually only ~10% of
the tensile strength of that of never-injured skin
o About three months post injury, the healed wound attains a final strength
approximately 70-80% of the tensile strength of never-injured skin
o This final tensile strength probably will persist for life
o Scars will never be as strong as never injured tissue
Factors that Influence Wound Healing
o Type, size, and location of the wound
o Vascular supply (diabetics heal poorly)
o Infection - delays wound healing and leads to more granulation tissue and scarring
o Movement - wounds over joints do not heal well due to traction
o Radiation - ionizing radiation is bad, UV is good
o Blood Flow and Oxygen Delivery
o For healing to occur, wounds must have adequate blood flow to supply the necessary
nutrients and to remove waste, local toxins, bacteria and other debris.
o Overall nutrition: vitamin and protein deficiencies lead to poor wound healing,
especially vitamin C, which is involved in collagen synthesis

Age: younger is definitely better!

Hormones - corticosteroids drastically impair wound healing, because of their profound
effect on inflammatory cells
Wound Healing in the Elderly
o Age-related changes:
A decrease in dermal thickness
A decline in collagen content
Loss of elasticity
Elderly are more vulnerable to chronic wounds, such as pressure, diabetic, and
ischemic ulcers as compared to younger persons
Complications of Wound Healing
o Defective scar formation
o Excessive scar formation (keloid)
o Contraction
Dehiscence or ulceration is usually due to:
o Wound infection (common)
o Malnutrition (scurvy - rare)
o Hypoxia with ulceration, usually due to inadequate vascularity in a skin flap (common).
What is wound dehiscence?
o Dehiscence (latin, split apart) is opening of a healing or partially heal, of its edges.
o Often, this occurs as a result of mechanical factors, infection or ischemic necrosis of
the sutured edges.
o Inadequate formation of granulation tissue or assembly of a scar can lead to two types
of complications:
o Dehiscence or rupture of a wound is most common after abdominal surgery and is due
to increased abdominal pressure. This mechanical stress on the abdominal wound can
be generated by vomiting, coughing, or ileus.
o Wounds can ulcerate because of inadequate vascularization during healing. For
example, lower extremity wounds in individuals with atherosclerotic peripheral vascular
disease typically ulcerate
o Nonhealing wounds also form in areas devoid of sensation. These neuropathic ulcers
are occasionally seen in patients with diabetic peripheral neuropathy
What is a keloid?
o Keloids are hyperplastic scars composed of irregularly deposited collagen. They may
appear as bulging masses.
o Excessive Scar Formation
o Keloids (hypertrophic scars) are the result of over-exuberant production of scar tissue,
which is primarily composed of type III collagen
o The cause is thought to be due to genetic factors, perhaps due to lack of the proper
metalloproteinases (collagenases) to degrade type III collagen
What is wound contraction?
o Reduction in size of the wounds healing by secondary intention occurs as a result of the
action of myofibroblasts in the granulation tissue
o Accounts for a reduction in size of the defect primarily by the action of myofibroblasts
o This process produces faster healing, since only one-third to one-half of the original
defect must be repaired
o Myofibroblasts account for contraction, and represent an intermediate type of cell,
between a fibroblast and a myocyte
What are contractures?
o Contractures are deformities of extremities caused by irregular scars
o most often related to extensive burns,
o It limit the mobility (part of the extremity usually cannot fully extend).
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Excessive contraction of a wound is known as a contracture.

They are a special problem in the treatment of extensive burns
Several diseases of unknown cause are characterized by the formation of contractures
Peyronie disease of the penis

Contracture
following a major burn
Healing in Specific Tissues (heart)
Cardiac myocytes are permanent cells. They do not divide, and the heart thus heals by
resolution (dead myocytes are phagocytized by macrophages) and collagenous scar
formation.

Chronic Pyelonephritis (gross)

Cirrhosis (gross)

Coal workers pneumoconiosis