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Transdifferentiation of mesenchymal stem cells into Schwann cell-like myelinating cells.

Bone marrow stromal cells (MSC) are multipotent stem cells that differentiate into cells of the mesodermal lineage. Although adult, their differentiation potential is remarkable, and they are able to transdifferentiate. Transdifferentiated cultivated rat MSC (tMSC) changed morphologically into cells resembling typical spindle-shaped Schwann cells (SC) with enhanced expression of LNGF receptor, Krox-20, CD104 and S100beta protein and decreased expression of bone morphogenetic protein receptor-1A compared to untreated rat MSC (rMSC). Transdifferentiation was reversible and repeatable. To evaluate the myelinating capacity, rMSC, tMSC, or SC cultured from male rats were grafted into an autologous muscle conduit bridging a 2-cm gap in the female rat sciatic nerve. The presence of the male-specific SRY gene (as revealed by PCR analysis) and S100 immunoreactivity of pre-labeled tMSC confirmed the presence of the implanted cells in the grafts. Three weeks after grafting, an appropriate regeneration was noted in the SC and in the tMSC groups, while regeneration in the rMSC group and in the control group without any cells was impaired. In contrast to SC, in some cases, single tMSC were able to myelinate more than one axon. Our findings demonstrate that it may be possible to differentiate MSC into therapeutically useful cells for clinical applications.

Adipocytes↗

[Molecular abnormalities and clonality in myelodysplastic syndromes].

Few genes have a proven role in the pathogenesis of myelodysplastic syndromes (MDS). The most common abnormalities involve the RAS genes, most notably the N-RAS gene, and are present in 10% of cases at diagnosis and in 30% to 40% during the course of the disease. Mutations of the p53 are found in 5% to 10% of cases. Mutations of the cFMS genes are less common, abnormalities of the NF1 genes seem to occur only in children, and abnormalities of the RB genes are exceedingly rare. A few instances of t(5;12) or t(3;21) translocation have been demonstrated, and their study has provided evidence that the TEL, EVI1, MDS1, and AML1 genes are involved in some cases of MDS. The presence in MDS of recurrent chromosome 7, 5q, and 20q deletions suggests that these chromosomal segments may bear tumor suppressor genes involved in MDS. The gene(s) involved remain(s) to be identified. Clonality studies have shown that stem cell involvement usually occurs at the myeloid level and that normal multipotent stem cells persist in many patients with MDS. This opens up the promising possibility that transplantation of autologous multipotent stem cells may be an effective therapeutic approach.

Adult↗

Multipotent and restricted precursors in the central nervous system.

Acquisition of cell type-specific properties in the nervous system is likely a process of sequential restriction in developmental potential. At least two classes of pluripotent stem cells, neuroepithelial (NEP) stem cells and EGF-dependent neurosphere stem cells, have been identified in distinct spatial and temporal domains. Pluripotent stem cells likely generate central nervous system (CNS) and peripheral nervous system (PNS) derivatives via the generation of intermediate lineage-restricted precursors that differ from each other and from multipotent stem cells. Neuronal precursors termed neuronal-restricted precursors (NRPs), multiple classes of glial precursors termed glial-restricted precursors (GRPs), oligodendrocyte-type 2 astrocytes (O2As), astrocyte precursor cells (APCs), and PNS precursors termed neural crest stem cells (NCSCs) have been identified. Multipotent stem cells and restricted precursor cells can be isolated from embryonic stem (ES) cell cultures providing a non-fetal source of such cells. Analysis in multiple species illustrates similarities between rat, mouse, and human cell differentiation raising the possibility that similar factors and markers may be used to isolate precursor cells from human tissue or ES cells. Anat Rec (New Anat): 257:137-143, 1999.

Animals↗

Genetic analysis of developmental mechanisms in Hydra. XXII. Two types of female germ stem cells are present in a male strain of Hydra magnipapillata.

Three types of interstitial stem cell subpopulation were isolated from Hydra magnipapillata, and their roles in sex determination were examined. A subpopulation of interstitial stem cells restricted to the sperm differentiation pathway was isolated previously from strain nem-1 (male). Another subpopulation restricted to the egg differentiation pathway was also isolated from the same strain. Hydroxyurea treatment was used for isolation in both cases. "Pseudoepithelial hydra" containing only sperm- or egg-restricted stem cell but no other interstitial stem cell types were maintained by force-feeding for 2 years. Sex reversal from egg- to sperm-restricted stem cells occurred three times during this period. Both of these two stem cell types are numerous in the central gastric region of the pseudoepithelial hydra, but absent in the foot region below the budding zone. Foot tissue was cut out from normal nem-1 polyps (male) and allowed to regenerate. The regenerates produced eggs but no sperm upon sex induction. These and other results suggest that the foot tissue contains multipotent stem cells capable of differentiating into eggs during sexual differentiation. These observations suggest that strain nem-1 (male) contains three types of interstitial stem cell subpopulations: (1) sperm-restricted stem cells, (2) egg-restricted stem cells, and (3) multipotent stem cells capable of differentiating into nerve cells, nematocytes, and eggs. Upon sex induction, however, differentiation of eggs by the latter two types is suppressed, and only sperm are produced by the sperm-restricted stem cells. Evidence is presented which suggests that similar "phenotypic males," which normally only produce sperm but contain the stem cell types capable of differentiating into eggs, occur widely in Hydra magnipapillata. A possible relationship between phenotypic male hydra and hermaphroditic hydra is discussed.

Animals↗

Bone marrow stromal cells as targets for gene therapy.

The bone marrow (BM) is composed of the non-adherent hematopoietic and adherent stromal cell compartment. This adherent BM stromal cell fraction contains pluripotent mesenchymal stem cells (MSCs) and differentiated mesenchymal BM stromal cells. The MSCs self-renew by proliferation while maintaining their stem-cell phenotype and give rise to the differentiated stromal cells which belong to the osteogenic, chondrogenic, adipogenic, myogenic and fibroblastic lineages. A more primitive adherent stem cell was recently identified, the multipotent adult progenitor cell (MAPC) or mesodermal progenitor cell, which co-purifies with MSCs. These MAPCs differentiate into MSCs, endothelial, epithelial and even hematopoietic cells. BM stroma cells, including the primitive pluripotent MSCs and MAPCs, are attractive targets for cell and gene therapy. The BM stromal cell population and its multipotent stem cells can be engineered to secrete a series of different proteins in vitro and in vivo that could potentially treat a variety of serum protein deficiencies and other genetic or acquired diseases, including bone, cartilage and BM stromal disorders or even cancer.

Adenoviridae↗

CD30 and its ligand: possible role in regulation of teratoma stem cells.

Like the oocyte, the cells of the early embryo, and primordial germ cells, human teratocarcinoma stem cells are pluripotent, capable of giving rise to a wide range of somatic and extraembryonic tissues. Growth factors which regulate the growth of multipotent stem cells in the mouse have been identified, but none of these have been shown conclusively to have similar effects on human or primate multipotent stem cells. CD30 is a member of the tumour necrosis factor receptor superfamily with a restricted pattern of tissue distribution, limited to immune cells, decidual tissue, and human embryonal carcinoma: in common with other embryonal carcinoma markers, CD30 is found in foci of cells in a sub-population of seminomas. CD30 ligand is a transmembrane protein, structurally related to tumour necrosis superfamily members TNF alpha, TNF beta, and CD40. CD30 ligand is expressed by T and B lymphocytes, macrophages, and a variety of normal haematopoietic cells and tumours derived from them, and exerts pleiotropic effects on normal and malignant lymphoid cells, including death, differentiation, or cell division. Studies on cultured cell lines derived from human embryonal carcinomas and yolk sac carcinomas confirm CD30 expression in the former but not the latter, and show that CD30 expression is down-regulated during stem cell differentiation in vitro. Transcripts for CD30 ligand are found at highest levels in yolk sac carcinoma cell lines, but are also found in embryonal carcinoma. CD30 ligand protein is detected in yolk sac carcinoma and nullipotent embryonal carcinoma cell lines. Exogenous CD30 ligand has no effect on multipotent human stem cell growth in vitro. However, the receptor-ligand pair may function in autocrine regulation of embryonal carcinoma stem cells. CD30 and its ligand are candidate stem cell identity factors, juxtacrine regulators whose sole function is to identify a cell's position in a developmental hierarchy.

Animals↗

Isolation of multipotent adult stem cells from the dermis of mammalian skin.

We describe here the isolation of stem cells from juvenile and adult rodent skin. These cells derive from the dermis, and clones of individual cells can proliferate and differentiate in culture to produce neurons, glia, smooth muscle cells and adipocytes. Similar precursors that produce neuron-specific proteins upon differentiation can be isolated from adult human scalp. Because these cells (termed SKPs for skin-derived precursors) generate both neural and mesodermal progeny, we propose that they represent a novel multipotent adult stem cell and suggest that skin may provide an accessible, autologous source of stem cells for transplantation.

Adipocytes↗

Bone morphogenetic proteins (BMPs) induce epithelial differentiation of NT2D1 human embryonal carcinoma cells.

Human embryonal carcinoma (EC) cells represent the stem cells of testicular germ cell tumours (TGCTs) and are morphologically, antigenically and functionally related to the stem cells of early mammalian embryos. Despite the large capacity for differentiation displayed by TGCT stem cells, little is known of the factors controlling their developmental potency. We have analyzed the differentiation elicited in NT2D1 human embryonal carcinoma (EC) cells by Bone Morphogenetic Proteins (BMPs) and compared it with that elicited by retinoic acid (RA). We have found that while RA induced expression of neuronal, endodermal and epithelial markers in NT2D1 human EC cells, treatment with BMPs resulted in a predominantly epithelial phenotype. We also provide evidence to suggest that at least some of the effects elicited by RA in human EC cells might be mediated through RA-induced expression of BMP-7. Thus BMPs may play an important role in specifying the type of differentiation arising from human multipotent stem cells. The manipulation of BMP signalling in human embryonic multipotent stem cells may therefore prove a useful approach in attempts to generate specific differentiated cell types in vitro, and loss of the malignant and/or transformed phenotype.

Blotting, Northern↗

Unexpected severe calcification after transplantation of bone marrow cells in acute myocardial infarction.

BACKGROUND: There has been a rapid increase in the number of clinical trials using unselected bone marrow (BM) cells or the mononuclear fraction of BM cells for treating ischemic heart diseases. Thus far, no significant deleterious effects or complications have been reported in any studies using BM-derived cells for treatment of various cardiac diseases. METHODS AND RESULTS: Seven-week-old female Fisher-344 rats underwent surgery to induce acute myocardial infarction and were randomized into 3 groups of 16 rats, each receiving intramyocardial injection of either 7x10(5) DiI-labeled total BM cells (TBMCs), the same number of DiI-labeled, clonally expanded BM multipotent stem cells, or the same volume of phosphate-buffered saline in the peri-infarct area. Echocardiography 2 weeks after cell transplantation indicated intramyocardial calcification in 4 of 14 surviving rats (28.5%) in the TBMC group. Histological examination with hematoxylin and eosin staining and von Kossa staining confirmed the presence of extensive intramyocardial calcification. Alkaline phosphatase staining revealed strong positivity surrounding the calcified area suggestive of ongoing osteogenic activity. Fluorescent microscopic examination revealed that acellular calcific areas were surrounded by DiI-labeled TBMCs, suggesting the direct involvement of transplanted TBMCs in myocardial calcification. In contrast, in hearts receiving equal volumes of saline or BM multipotent stem cells delivered in the same manner, there was no evidence of calcification. CONCLUSIONS: These results demonstrate that direct transplantation of unselected BM cells into the acutely infarcted myocardium may induce significant intramyocardial calcification.

Animals↗

Multipotent neural stem cells from the adult tegmentum with dopaminergic potential develop essential properties of functional neurons.

Neurogenesis in the adult brain occurs within the two principal neurogenic regions: the hippocampus and the subventricular zone of the lateral ventricles. The occurrence of adult neurogenesis in non-neurogenic regions, including the midbrain, remains controversial, but isolation of neural stem cells (NSCs) from several parts of the adult brain, including the substantia nigra, has been reported. Nevertheless, it is unclear whether adult NSCs do have the capacity to produce functional dopaminergic neurons, the cell type lost in Parkinson's disease. Here, we describe the isolation, expansion, and in vitro characterization of adult mouse tegmental NSCs (tNSCs) and their differentiation into functional nerve cells, including dopaminergic neurons. These tNSCs showed neurosphere formation and expressed high levels of early neuroectodermal markers, such as the proneural genes NeuroD1, Neurog2, and Olig2, the NSC markers Nestin and Musashi1, and the proliferation markers Ki67 and BrdU (5-bromo-2-deoxyuridine). The cells showed typical propidium iodide-fluorescence-activated cell sorting analysis of slowly dividing cells. In the presence of selected growth factors, tNSCs differentiated into astroglia, oligodendroglia, and neurons expressing markers for cholinergic, GABAergic, and glutamatergic cells. Electrophysiological analyses revealed functional properties of mature nerve cells, such as tetrodotoxin-sensitive sodium channels, action potentials, as well as currents induced by GABA (gamma-aminobutyric acid), glutamate, and NMDA (N-methyl-D-aspartate). Clonal analysis demonstrated that individual NSCs retain the capacity to generate both glia and neurons. After a multistep differentiation protocol using co-culture conditions with PA6 stromal cells, a small number of cells acquired morphological and functional properties of dopaminergic neurons in culture. Here, we demonstrate the existence of adult tNSCs with functional neurogenic and dopaminergic potential, a prerequisite for future endogenous cell replacement strategies in Parkinson's disease.

Animals↗

Resting and activated subsets of mouse multipotent hematopoietic stem cells.

The fluorescent vital dye rhodamine 123 (Rh-123), which preferentially accumulates in mitochondrial membranes, can be used as a probe to indicate mitochondrial and hence cellular activity. In this study, mouse bone marrow hematopoietic stem cells were subdivided into Rh-123lo, Rh-123med, and Rh-123hi populations. The Rh-123lo (resting) population was significantly enriched in cells with a higher proliferative potential compared to the Rh-123hi (activated) population. The resting population exhibited a 20-fold greater ability to differentiate into splenic colony-forming units (CFU-S) relative to the activated population, whereas the activated population contained about 4-fold more day 13 CFU-S on primary transfer relative to the resting population. The two populations produced morphologically distinct splenic colonies; however, the frequency and morphology of in vitro colonies were very similar. Only the resting population provided sufficient stem cells to transfer long-term hematopoietic repopulation to secondary recipient animals after lethal irradiation. On a single cell level, the resting and activated populations exhibited an equivalent ability to differentiate into lymphoid and myeloid progeny. These observations provide further insight into the heterogeneous nature of CFU-S and directly demonstrate that multipotent hematopoietic stem cells are heterogeneous with regard to their clonogenic capacities.

Animals↗

Region-specific generation of cholinergic neurons from fetal human neural stem cells grafted in adult rat.

Pluripotent or multipotent stem cells isolated from human embryos or adult central nervous system (CNS) may provide new neurons to ameliorate neural disorders. A major obstacle, however, is that the majority of such cells do not differentiate into neurons when grafted into non-neurogenic areas of the adult CNS. Here we report a new in vitro priming procedure that generates a nearly pure population of neurons from fetal human neural stem cells (hNSCs) transplanted into adult rat CNS. Furthermore, the grafted cells differentiated by acquiring a cholinergic phenotype in a region-specific manner. This technology may advance stem cell-based therapy to replace lost neurons in neural injury or neurodegenerative disorders.

Acetylcholine↗

Use of fetal intestinal isografts from normal and transgenic mice to study the programming of positional information along the duodenal-to-colonic axis.

The four principal cellular constituents of the mouse intestinal epithelium are all derived from a multipotent stem cell functionally anchored near the base of its crypts. Differentiation of enterocytes, enteroendocrine, and goblet cells occurs during an orderly upward migration from monoclonal crypts supplied by a single active stem cell to adjacent polyclonal small intestinal villi or to their colonic homologs, the surface epithelial cuffs. Paneth cells differentiate as they descend to the base of crypts. This epithelium undergoes rapid and perpetual renewal yet is able to maintain cephalocaudal (duodenal-to-colonic) differences in the differentiation programs of its four cell types from the time of its initial cytodifferentiation in late fetal life (embryonic (E) days 16-17). Rat liver fatty acid-binding protein/human growth hormone transgenes (Fabpl/hGH) have been used as novel phenotypic markers to describe the biological properties of gut stem cells and the differentiation programs of their enterocytic and enteroendocrine lineages. To determine whether the multipotent stem cell is able to retain a "positional" address in the absence of luminal signals, we prepared isografts from the proximal small intestine or distal small intestine and colon of E15-E16 Fabpl/hGH transgenic mice and their normal littermates and implanted them into the subcutaneous tissues of young, adult male CBY/B6 nude mice. Immunocytochemical and histochemical studies indicate that appropriate position-specific differences in the differentiation programs of each of the four principal cell lineages are present along the cephalocaudal and crypt-to-villus (or crypt-to-epithelial cuff) axes of isografts harvested 4-6 weeks after implantation. This suggests that the gut stem cell can be characterized not only by its multipotency and enormous capacity for self-renewal but also by its ability to be programmed (? imprinted) with positional information. Transgene expression is reduced in a number of enteroendocrine subpopulations in small intestinal and colonic isografts compared to the intact gut. Moreover, the decision to express the Fabpl/hGH transgene appears to be coordinated between adjacent crypts as evidenced by (i) the presence of multicrypt patches of wholly reporter (hGH)-positive or reporter-negative cells in the intact colon and in colonic isografts and (ii) by the presence of coherent bands of reporter-positive or -negative cells that emanate from adjacent monophenotypic crypts and extend to the apical extrusion zone of distal small intestinal villi.(ABSTRACT TRUNCATED AT 400 WORDS)

Animals↗

Characterization of multipotent adult stem cells from the skin: transforming growth factor-beta (TGF-beta) facilitates cell growth.

Recently, adult stem cells have been isolated from the skin and designated as skin-derived precursors (SKPs). These SKPs, cultured in vitro, can give rise to neurons, glia, smooth muscle cells, and adipocytes. In the current study, we confirmed the clonal expansion of SKPs using a sphere-forming culture system in a medium containing methylcellulose. Among the growth factors, only transforming growth factor-beta (TGF-beta) was revealed to uniquely facilitate the sphere formation and proliferation of the SKPs in combination with EGF and bFGF. In addition, TGF-beta did not alter phenotypical characteristics of the SKPs under sphere-forming conditions. The effect of TGF-beta on sphere formation was not observed in neural stem cells, which expressed a different set of cell surface markers from SKPs, suggesting that SKPs have distinct features. Although the number of SKPs decreased with age, TGF-beta increased the sphere colony formation and proliferation in all ages. These results suggest that SKPs maintained in the presence of TGF-beta during culture are of potential use in cell-replacement therapies employing adult tissue sources.

Adipocytes↗

Investigation of multipotent postnatal stem cells from human periodontal ligament.

BACKGROUND: Periodontal diseases that lead to the destruction of periodontal tissues--including periodontal ligament (PDL), cementum, and bone--are a major cause of tooth loss in adults and are a substantial public-health burden worldwide. PDL is a specialised connective tissue that connects cementum and alveolar bone to maintain and support teeth in situ and preserve tissue homoeostasis. We investigated the notion that human PDL contains stem cells that could be used to regenerate periodontal tissue. METHODS: PDL tissue was obtained from 25 surgically extracted human third molars and used to isolate PDL stem cells (PDLSCs) by single-colony selection and magnetic activated cell sorting. Immunohistochemical staining, RT-PCR, and northern and western blot analyses were used to identify putative stem-cell markers. Human PDLSCs were transplanted into immunocompromised mice (n=12) and rats (n=6) to assess capacity for tissue regeneration and periodontal repair. Findings PDLSCs expressed the mesenchymal stem-cell markers STRO-1 and CD146/MUC18. Under defined culture conditions, PDLSCs differentiated into cementoblast-like cells, adipocytes, and collagen-forming cells. When transplanted into immunocompromised rodents, PDLSCs showed the capacity to generate a cementum/PDL-like structure and contribute to periodontal tissue repair. INTERPRETATION: Our findings suggest that PDL contains stem cells that have the potential to generate cementum/PDL-like tissue in vivo. Transplantation of these cells, which can be obtained from an easily accessible tissue resource and expanded ex vivo, might hold promise as a therapeutic approach for reconstruction of tissues destroyed by periodontal diseases.

Adult↗

Differentiation of umbilical cord blood-derived multilineage progenitor cells into respiratory epithelial cells.

BACKGROUND: Umbilical cord blood (UCB) has been examined for the presence of stem cells capable of differentiating into cell types of all three embryonic layers (i.e. endo-, ecto- and mesoderm). The few groups reporting success have typically confirmed endodermal potential using hepatic differentiation. We report differentiation of human UCB-derived multipotent stem cells, termed multilineage progenitor cells (MLPC), into respiratory epithelial cells (i.e. type II alveolar cells). METHODS: Using a cell separation medium (PrepaCyte-MLPC; BioE Inc.) and plastic adherence, MLPC were isolated from four of 16 UCB units (American Red Cross) and expanded. Cultures were grown to 80% confluence in mesenchymal stromal cell growth medium (MSCGM; Cambrex BioScience) prior to addition of small airway growth medium (SAGM; Cambrex BioScience), an airway maintenance medium. Following a 3-8-day culture, cells were characterized by light microscopy, transmission electron microscopy, immunofluorescence and reverse transcriptase (RT)-PCR. RESULTS: MLPC were successfully differentiated into type II alveolar cells (four of four mixed lines; two of two clonal lines). Differentiated cells were characterized by epithelioid morphology with lamellar bodies. Both immunofluorescence and RT-PCR confirmed the presence of surfactant protein C, a protein highly specific for type II cells. DISCUSSION: MLPC were isolated, expanded and then differentiated into respiratory epithelial cells using an off-the-shelf medium designed for maintenance of fully differentiated respiratory epithelial cells. To the best of our knowledge, this is the first time human non-embryonic multipotent stem cells have been differentiated into type II alveolar cells. Further studies to evaluate the possibilities for both research and therapeutic applications are necessary.

Cell Differentiation↗

Susceptibility of multipotent haemopoietic stem cell deficient W/Wv mice to Plasmodium berghei-infection.

The susceptibility of haemopoietic stem cell deficient W/Wv mice to infection with Plasmodium berghei was examined. The mean survival time of W/Wv mice after the infection was shorter than that of the +/+ mice. Splenomegaly, a characteristic pathological change of the host after infection with malaria parasites was not observed in W/Wv mice. When haemopoietic activity of the infected mice was examined, a substantial increase in number of multipotent haemopoietic stem cells (CFU-S) and the committed stem cells for granulocytes and macrophages (CFU-GM) or for erythrocytes (CFU-E) was observed in the bone marrow and spleen of +/+ but not of W/Wv mice. CFU-S were not detected in W/Wv mice before or after infection. The number of CFU-GM and CFU-E in bone marrow and spleen of W/Wv mice decreased after infection. Bone marrow grafting from +/+ to W/Wv mice 8 weeks before infection prolonged the mean survival time of the mice and effectively restored the number of CFU-S in the spleen of W/Wv mice. These results indicate that multi-potent haemopoietic stem cells play an important role in the host's defence mechanisms against P. berghei-infection.

Anemia, Macrocytic↗

Myocardial regeneration by activation of multipotent cardiac stem cells in ischemic heart failure.

In this study, we tested whether the human heart possesses a cardiac stem cell (CSC) pool that promotes regeneration after infarction. For this purpose, CSC growth and senescence were measured in 20 hearts with acute infarcts, 20 hearts with end-stage postinfarction cardiomyopathy, and 12 control hearts. CSC number increased markedly in acute and, to a lesser extent, in chronic infarcts. CSC growth correlated with the increase in telomerase-competent dividing CSCs from 1.5% in controls to 28% in acute infarcts and 14% in chronic infarcts. The CSC mitotic index increased 29-fold in acute and 14-fold in chronic infarcts. CSCs committed to the myocyte, smooth muscle, and endothelial cell lineages increased approximately 85-fold in acute infarcts and approximately 25-fold in chronic infarcts. However, p16(INK4a)-p53-positive senescent CSCs also increased and were 10%, 18%, and 40% in controls, acute infarcts, and chronic infarcts, respectively. Old CSCs had short telomeres and apoptosis involved 0.3%, 3.8%, and 9.6% of CSCs in controls, acute infarcts, and chronic infarcts, respectively. These variables reduced the number of functionally competent CSCs from approximately 26,000/cm3 of viable myocardium in acute to approximately 7,000/cm3 in chronic infarcts, respectively. In seven acute infarcts, foci of spontaneous myocardial regeneration that did not involve cell fusion were identified. In conclusion, the human heart possesses a CSC compartment, and CSC activation occurs in response to ischemic injury. The loss of functionally competent CSCs in chronic ischemic cardiomyopathy may underlie the progressive functional deterioration and the onset of terminal failure.

Apoptosis↗