Review

The Emerging Role of Nanotechnology in Cell

and Organ Transplantation
Ennio Tasciotti, PhD,1,2 Fernando J. Cabrera, MD,1,2 Michael Evangelopoulos, MS,1,2
Jonathan O. Martinez, PhD,1,2 Usha R. Thekkedath, MD,1 Malgorzata Kloc, PhD,3 Rafik M. Ghobrial, MD,3,4
Xian C. Li, PhD,3 Alessandro Grattoni, PhD,1 and Mauro Ferrari, PhD1

Abstract: Transplantation is often the only choice many patients have when suffering from end-stage organ failure. Although the
quality of life improves after transplantation, challenges, such as organ shortages, necessary immunosuppression with associated
complications, and chronic graft rejection, limit its wide clinical application. Nanotechnology has emerged in the past 2 decades as
a field with the potential to satisfy clinical needs in the area of targeted and sustained drug delivery, noninvasive imaging, and tissue
engineering. In this article, we provide an overview of popular nanotechnologies and a summary of the current and potential uses of
nanotechnology in cell and organ transplantation.

(Transplantation 2016;100: 1629–1638)

GRAND CHALLENGES IN TRANSPLANTATION techniques. Nanotechnology has contributed immensely to

Over the past 2 decades, through improved surgical proce- the world of tissue engineering and has demonstrated encour-
dures and the use of powerful immunosuppressive drugs, cell aging results in drug delivery that would benefit the world of
and organ (ie, kidney, heart, liver, pancreas) transplantations transplant therapy.8,9 By improving established manufactur-
have become the standard of care for millions of patients with ing techniques and chemical modifications, many tunable
end-stage organ failure.1-4 Unfortunately, organ shortages, nanotechnologies have been successfully applied in 2 areas
graft failure, and lifelong administration of immunosuppres- of medicine: i) the localized, sustained, and controlled deliv-
sants continue to pose as critical obstacles limiting successful ery of drugs and bioactive factors; ii) the imaging of clinically
transplantation. In the case of kidney transplants, there were relevant biomarkers and functional parameters for diagnosis
only about 17 000 kidneys available, whereas approximately and treatment. In this review, we will provide a brief sum-
99 000 patients were on the waiting list in 2014, in the mary of the current achievements of nanotechnology in the
United States alone.5 In addition, an estimated 20% of the pa- field of drug delivery and will discuss some of the recent appli-
tients on the transplant list are those needing a replacement or- cations of this technology in organ transplantation (Table 1).
gan due to chronic rejection, even when undergoing broad
immunosuppression.1,2 Although immunosuppressant therapy SIGNIFICANCE AND OVERVIEW OF
has proven paramount to transplantation success, strenuous NANOTECHNOLOGY
requirements or lifelong systemic use often lead to poor patient Nanotechnology has been defined as the science of devel-
compliance causing eventual morbidity and mortality.6,7 oping and studying materials and devices that function
In an attempt to overcome these existing barriers, prom- within the nanometer scale.10 As such, materials must be syn-
ising alternatives are in development to improve transplant thesized from preexisting nanoscale building blocks exhibit-
ing unique chemical and physical characteristics proper of the
Received 5 June 2015. Revision requested 14 December 2015. nanoscale. More recently, nanomedicine has emerged as a field
Accepted 14 December 2015.
1
Department of Nanomedicine, Houston Methodist Research Institute, Houston, TX. the article. J.O.M. participated in the writing and editing of the article. M.K. partici-
2
pated in the writing of the article. U.T. participated in the writing, critical discussion,
Center for Biomimetic Medicine, Houston Methodist Research Institute, Houston, TX. and editing of the article. R.M.G. participated in the mentorship and critical discus-
3
Immunology Research Center, Houston Methodist Research Institute, Houston, TX. sion of the article. X.C.L. participated in the mentorship and critical discussion of
4
Center for Liver Disease and Transplantation, Houston Methodist Hospital, the article. A.G. participated in the mentorship and critical discussion of the article.
Houston, TX. M.F. participated in the mentorship, critical discussion, and editing of the article.

Funding was provided by Department of Defense grants W81XWH-09-1-0212 and Correspondence: Mauro Ferrari, PhD, Houston Methodist Research Institute, 6670
W81XWH-12-1-0414, National Institutes of Health grants U54CA143837 and Bertner Avenue, M.S. R12-219, Houston, TX 77030. (mferrari@tmhs.org).
U54CA151668, the CPRIT grant RP121071 from the State of Texas, the Brown Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. This is an open-
Foundation, The Cullen Trust for Health Care Foundation, The Hearst Foundation access article distributed under the terms of the Creative Commons Attribution-
and the Ernest Cockrell, Jr. Presidential Distinguished Chair. Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible
The authors declare no conflicts of interest. to download and share the work provided it is properly cited. The work cannot be
changed in any way or used commercially.
E.T. and F.J.C. contributed equally. E.T. participated in the writing, critical
discussion, and editing of the article. F.J.C. participated in the writing, critical ISSN: 0041-1337/16/10008-1629
discussion, and editing of the article. M.E. participated in the writing and editing of DOI: 10.1097/TP.0000000000001100

Transplantation ■ August 2016 ■ Volume 100 ■ Number 8 www.transplantjournal.com 1629

1630 Transplantation ■ August 2016 ■ Volume 100 ■ Number 8 www.transplantjournal.com

TABLE 1.
Application of nanotechnology in transplantation

Applications in transplantation Platforms Description

Delivery of immunosuppressants Nanoparticles Nanoparticles allow for a targeted, sustained and more controlled
and other drugs drug delivery dosage, reducing the side effects of
indiscriminate prolonged used.
Liposomes and peptide amphiphiles The use of lipid-based delivery platforms and peptide amphiphiles
help in the delivery of water-insoluble therapeutics,
increasing drug efficacy.
Donor specific tolerance and rejection Nanochannel membranes Nanochannel membranes offer a constant, sustained release and
can be tuned in channel size (2-200 nm) and density to achieve
a clinically relevant, constant delivery of drugs. It has shown
constant in vivo delivery for periods ranging from 1 to 6 months.
Nanobodies Nanobodies (therapeutic fragments of antibodies) present
advantages in size, stability, and low immunogenic potential and
can be used to stimulate inhibitory pathways and shut off
immune cells to prevent allograft rejection.
Biocapsules and nanoglands The use of biocapsules and nanogland platforms, allows the
exchange of nutrients and metabolites while inhibiting the
permeation of antibodies and the infiltration of immune cells.
They are designed to maintain cell proximity while ensuring
sufficient separation to simulate the in vivo environment.
Imaging, diagnostics, and other uses Nanoparticles (eg, gold, iron oxide, quantum dots) Often used to deliver contrast agents to assist in delineating anatomy
and physiology for medical imaging, the use of nanoparticles in
diagnostic imaging has exhibited a 6-fold contrast enhancement
compared with the use of free contrast agents.

which uses concepts from nanotechnology and medicine to carriers. Similar to liposomes, micelles have been exploited
prevent, diagnose, and treat diseases. As a result, a variety for their relative ease of production and ability to encapsulate
of nanoparticles and nanodevices have been created using a poorly water-soluble drugs.25 Regardless of the type of lipid-
variety of materials, including iron, carbon, gold, silica, and based nanoparticle, the ability to encapsulate biological agents
silicon.11 Nanoparticles have been designed to serve multiple (ie, siRNA, enzymes) has garnered great interest.
functions: drug delivery,12 receptor-mediated targeting,13 envi- Other groups have explored porous materials to encapsu-
ronmentally triggered release,14 thermal ablation,15 molecular late and deliver nanoparticles, which provide space to attach
imaging,16 and magnetism.17 On the other hand, nanofluidic additional targeting moieties, enabling greater tissue pene-
systems and nanomembranes have been developed for the tration.26 For example, porous silicon has been widely in-
selective filtration of fluids,18 diagnoses,19 and sustained de- vestigated for its biodegradability and biocompatibility.27-29
livery of drugs.20 Features, such as high surface area and tunable shape and
One of the primary goals of nanomedicine, especially in the size, have led to porous silicon being used for a variety of bio-
case of nanoparticles, is to increase the accumulation of a medical applications (eg, tissue engineering,30 biosensors,31
therapeutic or imaging agent at a target site while minimizing optics32). Recently, multistage nanovectors (ie, disk-shaped
toxicity to healthy tissue. In the context of cancer treat- porous silicon33-35) were developed to strategically overcome
ment, investigations into nanoparticles found significant the body's biological barriers through unique size and shape
therapeutic benefits through the utilization of the enhanced tailoring (Figure 1). Researchers demonstrated that the deg-
permeability and retention effect (ie, accumulation of nano- radation rates increase significantly as pore size increases.36
particles ranged 10-100 nm in tumor tissue).21 For example, Furthermore, modification of the pore size resulted in pro-
liposomes, one of the simplest forms of nanoparticles ap- longed release of a fluorescent payload and increased loading
proved by the food and drug administration, loaded with concentration as pore size increased. Additionally, Decuzzi
doxorubicin, a chemotherapeutic used to treat various can- and coworkers37 showed that particle geometry and size
cers including leukemia, were shown to significantly increase play a critical role in the biodistribution of particles in differ-
accumulation at tumor sites compared with free drug.22 In ent organs after systemic injection. When mice were injected
their most basic form, liposomes are biocompatible spherical with plateloid-shaped multistage nanovectors, smaller parti-
vesicles, with 1 or more lipid bilayer membranes, used to en- cles (600  200 nm) accumulated at a higher rate in the liver
capsulate a variety of hydrophobic and hydrophilic drugs.23 and spleen compared with larger particles (1000  400 nm),
In an effort to further increase their therapeutic potential, con- whereas the reverse was observed in the tumor tissue.
jugations with polyethylene glycol, ligands, antibodies, and Others loaded doxorubicin into polymeric micelles, then into
proteins have been explored and demonstrated promising multistage nanovectors, and showed that the toxicity to nor-
results.24 Other lipid-based nanoparticles, such as micelles mal cells was significantly reduced while toxicity to breast
(lipid molecules spherically arranged in aqueous solutions), cancer cells increased in vivo.12 Furthermore, by conjugating
have also been explored for their potential use as drug a vascular endothelium growth factor receptor-2 antibody
© 2016 Wolters Kluwer Tasciotti et al 1631

FIGURE 1. Schematic of synthesis and functionalization of particles. Size, shape, and porosity: mesoporous silicon nanoparticles with various
aspect ratios and various pore sizes (eg, Discoid nanoparticle, semispheres, nanorods). Surface modifications of particles: positive/negative
surface charges, peptides, antibodies. Payload nanoparticles: named SSNs are nanoparticles within the approximate size range of 5 to
100 nm in diameter (eg, liposomes, micelles, inorganic/metallic nanoparticles, and carbon structures). SSNs, second-stage carriers.

onto multistage nanovectors, particles displayed significant of conventional approaches and to increase the potential
adhesion to inflamed vasculature compared with unconjugated of a drug. Targeted and controlled drug delivery carriers
particles.38 Further functionalization of these nanovectors play fundamental roles in the individualization of drug-
with cellular membrane proteins isolated from leukocytes39,40 dependent therapies. Although targeted delivery relates to
gave particles the ability to avoid opsonization and macro- the transportation of drugs to a desired location, controlled
phage uptake while increasing particle circulation and accu- delivery relates to the release of the drug at a designated
mulation in a melanoma tumor mouse model, with no time, in an adequate concentration. Drug targeting and
significant immunological impact.41 controlled administration are widely investigated, using
As the gap between the availability of and the demand for the novel tools offered by nanotechnology, resulting in a se-
organs used in transplantation increases, alternative methods ries of implantable and injectable nanodelivery systems.9,43
need to be explored. Advances in nanomaterial synthesis and Substantial resources focus on the development of nano-
modification have played a significant role in tissue engineer- technologies to capitalize on their potential benefits in person-
ing and have led to promising results in regenerative medicine, alized treatments for a large number of clinical applications,
leading to possible avenues for improvements in current trans- including transplantation.44 Recent studies showed that
plant therapy.42 In the following section, we discuss nanotech- nanotechnology-based devices could deliver drugs within a
nology's current role in the treatment of organ transplantation specific therapeutic range while avoiding overdose and side
through drug delivery and imaging techniques.10 effects typically associated with conventional treatments.45
As a result, the adoption of nanosized drug delivery technol-
NANOTECHNOLOGY AS A TOOL IN ogies would improve the efficacy of treatments, reduce the
TRANSPLANT THERAPY necessary drug dosage, and minimize toxicity. Additionally,
the use of such devices would prevent issues related to
Localized, Sustained, and Controlled Delivery of patient compliance and significantly improve their quality
Drugs and Bioactive Agents of life.46 The nanochannel drug delivery system is an exam-
A number of (nanotechnology based) drug delivery strategies ple of an implantable device featuring precision-fabricated
are currently being investigated to circumvent the limitations nanochannel membranes that achieve constant release over
1632 Transplantation ■ August 2016 ■ Volume 100 ■ Number 8 www.transplantjournal.com

extended timeframes by simply tuning the channel size surface effects, and charge interactions play major roles
(2-200 nm) and density.45,47-49 in molecule transport.53,54 Charge exclusion, concentration
To maximize the therapeutic indexes and minimize the side polarization, and streaming current phenomena have been
effects of therapeutic agents, a constant concentration of observed at the nanoscale.55,56 Moreover, it was demon-
drug within the therapeutic range must be delivered to the strated that confined fluid at the nanoscale level present
plasma. This can be done by using implantable drug delivery anisotropic properties.57 Nanotechnologies allow for the ex-
devices able to sustain the constant release of drug over long quisite control of nanostructure properties and nanoscale ef-
periods (ie, weeks to years). The adoption of implantable de- fects. This control cannot be obtained at the macroscale,
livery strategies allows for the controlled release of therapeu- where drug release follows a Fickian exponential profile and
tics in a systemic or localized fashion, dramatically reducing is strongly affected by the drug concentration.58 Consequently,
required dosages and associated toxicity (Figure 2).34,50 at the nanoscale level, a constant concentration-driven drug re-
A constant, single-drug concentration in the plasma over an lease can be achieved, allowing for the enhanced delivery of
extended length of time is only achievable through zero-order therapeutics in transplant therapies.
release kinetics.51 Zero-order release is achieved when the gra-
dient of the drug molecule concentration, throughout a deliv- Liposomes, Nanochannel Membranes, and
ery device, stabilizes. Commonly, continuum-based diffusive Other Nanocarriers
processes are concentration-dependent; the diffusion of mole- Over the years, immunosuppressive drugs have provided a
cules out of a delivery device decreases at decreasing concen- significant increase in transplant patient survival. However,
trations in the reservoir. However, several technologies are complications still arise because of the therapies' potency
now available to control molecule deployment and achieve a and pharmacokinetic variability. Therefore, it is critical to
concentration-independent release. A zero-order release can modify treatments based on each individual patient to avoid
be obtained with convective driving mechanisms, such as os- any adverse effects. Unfortunately, poor bioavailability and
motic pressure, mechanical pumping, and through electro- water solubility also make the administration of immunosup-
kinetic transport.52 A constant drug release can also be pressants complex. This, coupled with the requirement to
achieved by tuning the properties of nanofluidic devices. It combine multiple therapies after organ transplants, has led
has been shown that, at the nanoscale, molecular constraints, researchers to devise alternative solutions.
Nanotechnology has provided viable alternatives to com-
bating issues related to increasing drug efficacy and solubility.
For example, lipid-based formulations, such as emulsions,59 li-
posomes,23 and polymeric micelles,12,60 have demonstrated
reliable alternatives to transport water-insoluble therapeutics.
After renal transplantation, a patient is typically required to
take oral immunosuppressant drugs. However, previous liter-
ature reported that a high-fat diet can display a pronounced
effect on the adsorption of cyclosporine, a common immuno-
suppressant.61 This led to the reformulation of cyclosporine
into a microemulsion (ie, fine dispersion system), improving
its pharmacokinetic variability.62 This formulation was shown
to be thermodynamically stable and resulted in a smaller drop-
let size (ie, <150 nm). Other immunosuppressive drugs, such
as tacrolimus63 and rapamycin,64 have also demonstrated
similar effective results when encapsulated within liposomes.
For example, rapamycin demonstrated optimal results when
encapsulated within micelles. As demonstrated by Forrest
et al65 encapsulation within micelles bypasses the need for or-
ganic cosolvents or harsh surfactants to solubilize highly con-
centrated drug solutions. In addition, the micelles were reported
to be stable when in contact with serum albumin and exhib-
ited a sustained release over the course of several days.
Although rapamycin has shown to be an effective immuno-
suppressant, its water insolubility has made it challenging to
develop an oral or intravenous formulation. Rapamycin's sol-
ubility in water is 2.6 μg/mL, far below its desired therapeutic
concentration of 1 mg/mL.66 Although some formulations
were able to overcome the solubility issue through cosolvent/
FIGURE 2. A, Scanning electron microscopy image of the cross
section of a silicon—silicon nitride nanochannel membrane designed water mixtures, its poor taste and specific storage conditions
for constant and sustained drug release. B, Three-dimensional ren- made it problematic for patients. The use of nanocrystals as
dering of the structure of a drug delivery implant incorporating a a delivery platform for water-insoluble immunosuppressant
nanochannel membrane. C, Zero-order sustained release can achieve drugs overcame this obstacle by providing improved bio-
and maintain plasma level of drugs within the therapeutic window for
the duration of treatment. This has potential for improved efficacy and availability.67 The nanocrystals provided increased surface
reduction of adverse side effects of treatment as compared to the area while maintaining increased solubility and decreased
conventional bolus administration of therapeutics. thickness of the diffusion boundary layer.
© 2016 Wolters Kluwer Tasciotti et al 1633

Another area of recent interest is the role of nanoparticles a combination of antigens and immunomodulating agents,
in the disruption of signaling pathways in T-cell activa- such as rapamycin, provide a unique technology platform
tion and donor antibody functions. This could demonstrate with the potential to enhance outcomes for the induction of
great potential to treat immunological complications during transplant tolerance.76 Nanobodies, which are therapeutic
transplantation.68 Recent studies have also shown that in- fragments of antibodies with a single-domain of the antibody
flammatory and immune responses are regulated by the variable region, have been developed for cancer therapy with
small GTPase RhoA pathway via its downstream effector, advantages in size, stability, and low immunogenic poten-
the Rho-associated protein kinase (ROCK). The inhibition tial.77,78 This formulation can be applied in a similar way
of the RhoA/ROCK pathway should interfere with immune to stimulate inhibitory pathways and shut off immune cells
cells and possibly limit or abrogate chronic rejection.69 Stud- to prevent allograft rejection.
ies in rodent models from various research groups show that
chronic rejection of allotransplants could be ameliorated by
the administration of RhoA pathway inhibitors.70-72 Recent Implantable Devices and Biocapsules
studies showed that the application of nanotechnology in As opposed to constant drug administration, multiple ther-
the sustained delivery of a ROCK inhibitor, Y-27632, to apies would benefit from the ability to tune drug release ac-
the recipients of allografts, in a rat model, resulted in the cording to the circadian cycles. It is well known that the
drastic reduction of collagen deposition, the reduction of tis- presence of biological rhythms, such as the circadian cycles,
sue fibrosis, and the marked improvement of vascularization affects body metabolism in living organisms over 24-hour cy-
in the transplanted heart (Figure 3).49 cles and inflammatory markers follow definite circadian cy-
The central innovation of this sustained delivery technol- cles. Organs, such as the kidney, liver, and gastrointestinal
ogy is the use of microfabricated nanochannel membranes tract, are very critical to drug metabolism and are highly
which, like an hourglass, passively control the release of mol- coupled with circadian rhythms. The pharmacodynamics
ecules. Nanochannel membranes bypass the issues of burst and efficacy of treatments were demonstrated to relate to
and trough release associated with other delivery technolo- the time of administration during the circadian cycle.79
gies and achieve constant drug release by imposing spatial Therefore, drug delivery strategies should consider the most
and electrostatic confinement on molecular diffusion. In ideal times for drug administration to reduce toxicity and in-
nanochannels, surface-to-molecule interactions passively con- crease treatment efficacy.
trol the drug delivery rate, rendering it constant, without the Nanotechnology-based, tunable implant devices have the
need for complex pumping mechanisms.47,73 Nanochannel potential to adjust drug release based on the circadian
membranes offer significant advantages as they achieve con- rhythms of inflammatory markers. The synchronization of
stant, sustained release and can be easily tuned in channel drug delivery to biocycles using these devices represents
size (2-200 nm) and density to achieve a clinically relevant, an additional step toward individualized medicine. Conse-
constant delivery of a broad spectrum of chemotherapeu- quently, some attempts have been made to achieve chro-
tics.74,75 The nanochannel technology has shown constant notherapy with implantable drug delivery systems56 based
in vivo delivery of testosterone, leuprolide, interferon, lyso- on degradable polymers and osmotic devices.80 Here, re-
zyme, genotropin, and octreotide in dog, rat, and mouse searchers present a nanofluidic membrane technology capa-
models for periods ranging from 1 to 6 months.43,48 Addi- ble of achieving active and tunable control of molecular
tionally, this technology demonstrated long-term (more than transport through nanofluidic channels. By applying an elec-
6 months), sustained, and constant delivery of therapeutics tric field between 2 platinum electrodes positioned on either
in an in vitro model (Figure 2C).48 The localized delivery of surface of a 5.7-nm nanochannel membrane, designed for
immunomodulator drugs in the vicinity of transplanted or- zero-order drug delivery, temporal, reproducible tuning,
gans or tissues, using a nanochannel drug delivery device, and interruption of dendritic fullerene-1 transport, was ob-
protecting the transplant from immune rejection while elimi- tained over multiday release experiments.56 This ability to ac-
nating adverse effects associated with systemic immunosup- tively control and tune delivery of drugs and particles from a
pression, would be the ideal choice in transplant therapy. subcutaneous implant device has broad applicability to vari-
Nanocarriers have also proven to be a promising platform ous current and emerging therapeutics and clinical situations
to achieve tolerogenic antigen presentation by delivering an- including organ and tissue transplantation. The tunable
tigens of interest to specific cell types. Nanocarriers delivering nanochannel drug delivery system (Figure 4) presents a

FIGURE 3. Sections of transplanted rat hearts Verhoeff-Van Gieson (VVG) stained. A, Chronically rejecting heart shows fully occluded
vessel. B, Recipient treated with RhoA inhibitor delivered from nanochamber shows healthy unoccluded vessels.
1634 Transplantation ■ August 2016 ■ Volume 100 ■ Number 8 www.transplantjournal.com

silicon-based biocapsule allowed the diffusion of essential nu-

trients while blocking the permeation of immune molecules.
In vivo studies in mice showed biocompatibility of the
biocapsule, the viability of the encapsulated cell lines without
immunosuppressants, and the secretion of insulin in response
to both basal and stimulatory conditions.89

Nanoglands and Nanoparticles in Transplant

Nanotechnology-based encapsulation systems, such as
nanogland (Figure 5) have successfully supported the engraft-
ment of pancreatic islets in animal models.90 These encapsu-
lation systems protect the transplanted cells from immune
attack and provide a physiological environment promoting
cell survival and vascularization. The new generation of
nanogland is made with biocompatible, bioinert polymers
(Polylactic acid/Polycaprolactone). It is used to house pancre-
atic islets or islet-like insulin-producing cells in wells. De-
signed to maintain cell proximity while ensuring sufficient
separation to simulate the in vivo environment, the nanogland
houses cells in a growths factor-rich matrix and presents
surface-modified microchannels that allow for rapid neovas-
cularization of the graft. This is imperative to assure long-
term transplant survival and viability.
Additionally, transplanted cells are protected from im-
mune attack by local, constant, and sustained delivery of
immunomodulator agents (eg, CTLA4Ig). The CTLA4Ig, de-
FIGURE 4. A, Three-dimensional rendering of a drug delivery im-
plant for the remotely controlled administration of therapeutics. The livered into the cell reservoir, slowly diffuses outside of the
implant comprises an electrode-coated nanochannel membrane for implant, generating a local concentration gradient, thereby
tuning a low-power applied electric field and tune drug release ac- protecting the transplanted tissue from immune attack. Con-
cording to need. B, Drug administration can be synchronized to the stant and sustained CTLA4Ig delivery is achieved from an in-
biological clock to maximize the efficacy of treatment.
ternal reservoir by means of a biocompatible, bioinert, and
microfabricated silicon nanochannel membrane. The cell and
nanofluidic membrane technology capable of achieving ac- drug reservoirs are separately fabricated by 3-dimensional
tive and tunable control of molecular transport through printing and assembled by polymeric welding.90,91
nanofluidic channels. Nanotechnology has also been considered as a tool to ad-
A promising approach for protecting cell transplantation dress the poor viability and engraftment after pancreatic islet
from immune-rejection was proposed back in the 1980s. transplantation.92 Specifically, these limitations led researchers
Microencapsulated islets implantation was used in vivo as to investigate peptide amphiphiles (PA) as a potential solution.
bioartificial endocrine pancreas resulting in the correction Peptide amphiphiles are peptide molecules that incorporate
of the diabetic state up to 3 weeks.81 By enclosing cells within
a physical barrier, the biocapsule allows the exchange of nu-
trients and metabolites while inhibiting the permeation of an-
tibodies and the infiltration of immune cells. This type of
technology would enable pancreatic islet cell transplantation,
overcoming their immune rejection without the need for im-
munosuppressive drugs and, in principle, restore normal gly-
cemia in diabetic patients, as demonstrated on numerous in
vivo studies where experimental animals have recovered for
more than 100 days.82-84
Although progress has been made in the field of cell encap-
sulation, scientists still seek more favorable synthetic and nat-
urals materials to help overcome previous obstacles, such as
chemical stability, functional performance, or the production
of uniform capsules.85 The use of photolithographic tech-
niques in the fabrication of microsilicon membranes have
helped to overcome some of these challenges by allowing pre-
cise control over the pore size and distribution in the range of FIGURE 5. Three-dimensional rendering of a nanochannel encap-
20 to 100 nm.86,87 In vitro studies showed that rat pancreatic sulation of insulin secreting cells. The encapsulation creates a protec-
tive environment to improve graft survival and to promote rapid
islets cells could maintain their functionality and viability in vascularization post transplantation. The encapsulation may supply
the 3-dimensional encapsulated environment and maintain the graft with oxygen, nutrients, growth factor and immunosuppressive
their glucose-stimulated insulin secretion.88 Moreover, the agents in situ, to promote long-term viability and abrogate rejection.
© 2016 Wolters Kluwer Tasciotti et al 1635

a hydrophobic domain on one end and a hydrophilic oligo- from the blood and limits their use for MR-based angiogra-
sequence on the other end. This promotes self-assembly into phy.105 A possible solution was to encapsulate gadolinium
nanofibers, exposing the bioactive region on the outer sur- into PEGylated liposomes, which produced significant con-
face to interact with the cell or protein of interest.93 trast enhancement of tissue vasculature enabling high spatial
With this technology, Stendahl et al94 explored the use of resolution.105 Furthermore, excessive chelation of gadolin-
heparin-binding PA scaffolds for the delivery of angiogenic ium and other contrast agents can substantially reduce
growth factors (ie, vascular endothelial growth factor and fi- their contrast enhancement. In this case, investigators used
broblast growth factor-2) to mitigate the adverse effects typ- carbon nanostructures to enclose gadolinium ions within
ically encountered with islet transplantation. Remarkably, fullerene cages106 or gadolinium ion clusters within nano-
heparin-binding PA, combined with the angiogenic growth tubes107,108 and achieved 10 and 40 times greater contrast
factors, displayed significantly superior vascularization in enhancement, respectively. The loading of these agents
the omentum (interperitoneal fat mass). In addition, this led within nanoporous silicon particles yielded a 6-fold contrast
to higher cure percentages of diabetic mice and significantly enhancement of the embedded payloads (magnevist, gado-
decreased time to achieve normoglycemia. fullerenes, gadonanotubes) attributed to their nanoscale
As is the case for organ rejection, corneal rejection is also confinement.109,110
subject to a strict regimen of immunosuppressants typically In addition to the delivery of contrast agents, some nano-
administered systemically or through eye drops.95 Currently, particles can serve as imaging agents due to their unique
the 2-year survival rate for those receiving an uncompli- nanoscaled features. For example, gold nanoparticles can
cated transplant is 90%, but this number can reach as low serve as contrast agents for computed tomography,111 iron
as 50% for those with neovascularization in the cornea or oxide nanoparticles for spin-spin relaxation (T2-weighed im-
who have previously experienced graft failure.96,97 Although aging, MRI),112-114 quantum dots for near infrared (NIR)
corticosteroids are typically administered to minimize graft fluorescence-based imaging,115,116 and carbon nanotubes
rejection, administration can often be required as often as for NIR and ultrasound imaging.117,118 In general, these
1 hour immediately after transplantation.98 This strenuous imaging properties are size-dependent, so MRI contrast en-
requirement leads to unsatisfactory patient compliance and, hancement increases with increasing diameters of iron oxide
eventually, increased rejection rates.99 Efforts have been made nanoparticles. However, large nanoparticles tend to aggre-
to address this concern including the administration of corti- gate and are more readily recognized by the immune sys-
costeroids via a subconjunctival injection immediately after tem; therefore, a certain balance must be reached depending
surgery. Unfortunately, rapid clearance of small molecules on their intended application.119 Quantum dots (2-15 nm)
(ie, drugs) from the ocular tissue significantly impacts the also show a size-dependent correlation; their fluorescence
extent of their therapeutic effects. emission can be tuned from blue to red by increasing their
Nano- and microparticles have presented a viable strategy size, representing a powerful alternative to traditional dyes,
to overcome the rapid clearance of small molecules from the permitting broad excitation spectra, high quantum yield,
occular tissue and improve therapeutic drug levels. Specifi- and remarkable resistance to photobleaching.120 Because
cally, polymer particles are being used for the delivery of ther- of the high surface area of nanoparticles, they can also be dec-
apeutic agents to the eye by harnessing various routes of orated with various recognition moieties (eg, antibodies,
administration, such as intravenous, subconjunctival, and aptamers, peptides, and so on) to target and enhance the
topical administration.100 For example, Pan et al101 demon- imaging of cancer,121 apoptosis,122 hypoxia,123 angiogene-
strated that dexamethasone sodium phosphate-loaded nano- sis,124 atherosclerosis,125 and inflammation.126 In addition,
particles provided sustained release in vitro and resulted in therapeutics and other diagnostics can be added to their
effective prevention of corneal graft rejection when injected surfaces to create particles able to provide both therapy and
subconjunctivally in a rat animal model. Conversely, when imaging (ie, theranostics), including radioactive probes for
injected with free drug, rejection occurred as soon as positron emission tomography imaging.127,128 However,
3 weeks after transplantation, with all mice experiencing re- when using metallic and semiconductor nanoparticles, one
jection at 4 weeks. needs to be cautious of possible adverse immunological and
toxicity effects.
Imaging and Functional Parameters for Diagnosis Clinical approval of iron oxide nanoparticles to diagnose
Nanotechnology has made substantial progress in the lymph node metastases and liver lesions with MRI was ob-
world of medical imaging. Similar to their ability to deliver tained in 1996 for Feridex (iron oxide nanoparticles deco-
therapeutics, nanoparticles can be used to deliver contrast rated with dextran).129 After this, other agents (eg, Resovist,
agents to assist in delineating anatomy and physiology Combidex, Clariscan, and Gastromark) received approval
for medical imaging. Examples include the use of iodine- or were in development for clinical use.130 However, the
encapsulated liposomes for x-ray computed tomography,102 production of these agents was discontinued due to safety
gadolinium within mesoporous silica nanoparticles for concerns. High false-positive rates and minimal market rep-
magnetic resonance imaging (MRI),103 and perfluorocarbons resentation (penetration?), thus, have been phased out of
within polymer nanocapsules for ultrasound.104 Nanopar- use.130,131 Several promising nanoparticle-based imaging ap-
ticles have transformed the way we use complex contrast plications are currently in clinical trials, or expected to be in
agents. Here we expand on one example, gadolinium, and the near future, including nanoparticles for MRI contrast
its contrast enhancement for MRI. Magnevist is a clinically that target an integrin commonly found on the surface of
available, and widely used, agent for MRI comprised of newly developed vessels and applying carbon nanotubes as
gadolinium chelated with an aminopolycarboxylic acid- possible x-ray sources for a new type of computed tomogra-
based agent. This formulation suffers from rapid clearance phy scanner.132 Nanoparticles with metallic components can
1636 Transplantation ■ August 2016 ■ Volume 100 ■ Number 8 www.transplantjournal.com

be used as biosensors, for imaging capability with CT (such 8. Couvreur P, Vauthier C. Nanotechnology: intelligent design to treat com-
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of administered stem cells,136-138 gauge viability of implanted prospects for their use in human medicine. Trends Biotechnol. 2008;
cells within scaffolds139,140 or within tissues,141,142 and to 26:425–433.
evaluate drug release from scaffolds.143 In summary, nano- 12. Martinez JO, Evangelopoulos M, Bhavane R, et al. Multistage nanovectors
technology has the potential to provide powerful solutions enhance the delivery of free and encapsulated drugs. Curr Drug Targets.
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to permit noninvasive imaging of organs and tissues before 13. Thierry B, Al-Ejeh F, Brown MP, et al. Immunotargeting of functional nano-
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ACKNOWLEDGMENTS 26. Yazdi IK, Ziemys A, Evangelopoulos M, et al. Physicochemical properties
affect the synthesis, controlled delivery, degradation and pharmaco-
The authors would like to thank Matthew Landry for excel- kinetics of inorganic nanoporous materials. Nanomedicine (Lond). 2015;
lent graphical support, Sebastian Powell and Megan Living- 19:3057–3075.
ston for helpful discussions. 27. Martinez JO, Evangelopoulos M, Chiappini C, et al. Degradation and
biocompatibility of multistage nanovectors in physiological systems.
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