TISSUE REPAIR,

REGENERATION, HEALING
AND FIBROSIS
DR KASONDA
PEDIATRICIAN
29/5/2017
Learning Objectives
By the end of this session, students
are expected to be able to:
Describe the nature and mechanisms
of action of growth factors
Explain the extracellular matrix
(ECM) and cell matrix interactions
Describe cell and tissue regeneration
Describe repair by connective tissue
Explain the process of wound healing
 The Control of Cell
Proliferation
To understand physiologic cell proliferation (as in
repair) and pathologic proliferation (as in cancer), it
is important to learn about the cell cycle and its
regulation.
The four sequential phases are G1 (gap 1) phase, S
phase or synthesis phase, G2 (gap 2) phase and M
(mitotic) phase.
Cell proliferation is regulated by cyclins that, when
complemented with cyclin-dependent kinases
(CDKs), regulate the phosphorylation of proteins
involved in cell cycle progression leading to DNA
replication and mitosis.
The cell cycle is tightly regulated by stimulators and
inhibitors, and contains intrinsic checkpoint controls
to prevent replication of abnormal cells.
 Tissues are divided into labile, stable and
permanent, according to the proliferative
capacity of their cells.
Continuously dividing tissues (labile tissues)
contain stem cells that differentiate to replenish
lost cells and maintain tissue homeostasis.
Stem cells from embryos are pluripotent. Adult
tissues, particularly the bone marrow, contain
adult stem cells capable of generating multiple
cell lineages.
The ability of tissues to repair themselves is
critically influenced by their intrinsic
proliferative capacity.
Based on this criterion, the tissues of the body
are divided into three groups:
1.Continuously Dividing Tissues
Cells of these tissues (also known as labile
tissues) are continuously being lost and replaced
by maturation from stem cells and by
proliferation of mature cells.
Labile cells include hematopoietic cells in the
bone marrow and the majority of surface
epithelia, such as
- The stratified squamous surfaces of the skin,
oral cavity, vagina, and cervix.
The cuboidal epithelia of the ducts draining exocrine
organs (e.g. salivary glands, pancreas, biliary tract).
The columnar epithelium of the gastrointestinal tract,
uterus, and fallopian tubes; and o The transitional
epithelium of the urinary tract.
These tissues can readily regenerate after injury as
long as the pool of stem cells is preserved.
2.Stable Tissues
Cells of these tissues are quiescent (in the G0
stage of the cell cycle) and have only minimal
replicative activity in their normal state.
These cells are capable of proliferating in
response to injury or loss of tissue mass.
Stable cells constitute the parenchyma of most
solid tissues, such as liver, kidney, and pancreas.
They also include endothelial cells, fibroblasts,
and smooth muscle cells; the proliferation of
these cells is particularly important in wound
healing. With the exception of liver, stable tissues
have a limited capacity to regenerate after injury.

3.Permanent Tissues
The cells of these tissues are considered to be
terminally differentiated and nonproliferative in
postnatal life.
The majority of neurons and cardiac muscle cells
belong to this category.
Thus, injury to brain or heart is irreversible and results
in a scar, because neurons and cardiac myocytes do
not divide.
Limited stem cell replication and differentiation occurs
in some areas of the adult brain, and there is some
evidence that heart muscle cells may proliferate after
myocardial necrosis.
Whatever proliferative capacity may exist in these
tissues, it is insufficient to produce tissue regeneration
after injury.
 Skeletal muscle is usually classified as a
permanent tissue, but satellite cells attached to
the endomysial sheath provide some
regenerative capacity for this tissue.
In permanent tissues, repair is typically
dominated by scar formation.
With the exception of tissues composed
primarily of non-dividing permanent cells
(e.g.
cardiac muscle and nerve), most mature
tissues contain variable proportions of
three cell types
a)Continuously dividing cells
b) Quiescent cells that can return to the cell cycle
c) Non-dividing cells
 STEM CELLS
In most continuously dividing tissues the mature cells
are terminally differentiated and shortlived.
As mature cells die the tissue is replenished by the
differentiation of cells generated from stem cells.
Thus, in these tissues there is a homeostatic
equilibrium between the replication and
differentiation of stem cells and the death of the
mature, fully differentiated cells.
Such relationships are particularly evident in the
multilayered epithelium of the skin and the
gastrointestinal tract, in which stem cell niches have
been identified near the basal layer of the epithelium.

Cells differentiate progressively as they migrate to

the upper layers of the epithelium. They ultimately
die and are shed from the surface of the tissue.
 Stem cells are characterized by their self-
renewal properties and by their capacity to
generate differentiated cell lineages .
Two mechanism of maintenance stem cells are:
(a) obligatory asymmetric replication, in which
with each stem cell division, one of the
daughter cells retains its self-renewing
capacity while the other enters a differentiation
pathway, and

(b) stochastic differentiation, in which a stem

cell population is maintained by the balance
between stem cell divisions that generate
either two self-renewing stem cells or two cells
that will differentiate.
 Stem cells are characterized by two important
properties:
a) Self-renewal capacity and b) asymmetric
replication.
Asymmetric replication of stem cells means that after
each cell division, some progeny enter a differentiation
pathway, while others remain undifferentiated, retaining
their selfrenewal capacity.
Stem cells with the capacity to generate multiple cell
lineages (pluripotent stem cells) can be isolated from
embryos and are called embryonic stem (ES) cells.
Stem cells are normally present in proliferative tissues
and generate cell lineages specific for the tissue.
However, it is now recognized that stem cells with the
capacity to generate multiple lineages are present in the
bone marrow and several other tissues of adult
individuals. These cells are called tissue stem cells or
adult stem cells.
 The Nature and Mechanisms of
Action of Growth Factors
Cell proliferation can be triggered by many chemical
mediators such as growth factors, hormones, and
cytokines.
The major role of polypeptide growth factors role is to
promote cell survival and proliferation, which are important
in regeneration and healing.
Expansion of cell populations usually involves an increase
in cell size (growth), cell division (mitosis), and protection
from apoptotic death (survival).
The term growth factors should be used for proteins that
increase cell size.
The mitogens and survival factor should be used for molecules
with the other activities.
Many growth factors have all these activities, and by convention
growth factor is used for a protein that expands cell populations
by stimulating cell division (usually accompanied by increased
cell size) and by promoting cell survival.
 Growth factors stimulate migration,
differentiation and contractility, and enhance
the synthesis of specialized proteins (such as
collagen in fibroblasts).
A major activity of growth factors is to stimulate the
function of growth control genes, many of which are
called proto-oncogenes because mutations in them
lead to unrestrained cell proliferation characteristic
of cancer (oncogenesis).
Many of the growth factors that are involved in
repair are produced by leukocytes that are
recruited to the site of injury or are activated at this
site, as part of the inflammatory process.
Other growth factors are produced by the
parenchymal cells or the stromal (connective tissue)
cells in response to cell injury or loss.
 The Extracellular Matrix (ECM)
and Cell Matrix Interactions
Tissue repair depends not only on growth factor activity but
also on interactions between cells and ECM components.
The ECM is a dynamic, constantly remodelling macromolecular
complex synthesized locally, which assembles into a network
that surrounds cells. It constitutes a significant proportion of
any tissue.
ECM sequesters water, providing turgor to soft tissues, and
minerals, giving rigidity to bone.
ECM regulates the proliferation, movement, and differentiation
of the cells living within it, by supplying a substratum for cell
adhesion and serving as a reservoir for growth factors.
Synthesis and degradation of ECM accompanies
morphogenesis, wound healing, chronic fibrotic processes, and
tumor invasion and metastasis.
ECM occurs in two basic forms interstitial matrix and
basement membrane.
 Roles of the Extracellular Matrix
The ECM is much more than space filler around
cells. Its various functions include:
1.Mechanical support for cell anchorage, cell
migration, and maintenance of cell polarity.
2.Control of cell growth. o ECM components can
regulate cell proliferation by signaling through
cellular receptors of the integrin family.
3.Maintenance of cell differentiation.
The type of ECM proteins can affect the degree of
differentiation of the cells in the tissue, also acting
largely via cell surface integrins.
4.Scaffolding for tissue renewal.
The maintenance of normal tissue structure requires
a basement membrane or stromal scaffold.
 The integrity of the basement membrane or the stroma
of the parenchymal cells is critical for the organized
regeneration of tissues.
Although labile and stable cells are capable of
regeneration, injury to these tissues results in restitution
of the normal structure only if the ECM is not damaged.
Disruption of these structures leads to collagen
deposition and scar formation.
5.Establishment of tissue microenvironments.
Basement membrane acts as a boundary between
epithelium and underlying connective tissue and also
forms part of the filtration apparatus in the kidney.
6.Storage and presentation of regulatory molecules.
For example, growth factors like FGF and HGF are
excreted and stored in the ECM in some tissues. o This
allows the rapid deployment of growth factors after local
injury, or during regeneration.
 Components of Extra Cellular Matrix
1.Fibrous structural proteins such as
collagens and elastins, which confer
tensile strength and recoil;
2.Water-hydrated gels such as
proteoglycans and hyaluronan , which
permit resilience and lubrication.
3.Adhesive glycoproteins that connect
the matrix elements to one another and
to cells.
 Cell and Tissue
Regeneration
Figure 1, shows mechanisms by
which ECM components (e.g.
fibronectin and laminin) and growth
factors can influence cell
proliferation, motility, differentiation,
and protein synthesis.
Mechanism Of Cell and Tissue
Regeneration
 Integrins bind ECM and interact with the cytoskeleton at
focal adhesion complexes (protein aggregates that
include vinculin, -actin, and talin).
This can initiate the production of intracellular second
messengers or can directly mediate nuclear signals.
Cell surface receptors for growth factors activate signal
transduction pathways that overlap with those activated
by integrins.
Signals received from growth factors and ECM
components are integrated by the cell to yield various
responses, including changes in cell proliferation,
locomotion, and differentiation.
Extensive regeneration or compensatory hyperplasia can
occur only if the residual tissue is structurally and
functionally intact, as after partial surgical resection.
If the tissue is damaged by infection or inflammation,
regeneration is incomplete and is accompanied by
scarring.
 Repair by Connective
Tissue
Repair cannot be accomplished by regeneration
alone if tissue injury is severe or chronic, and results
in damage to parenchymal cells and epithelia as
well as the stromal framework, or if non dividing
cells are injured.
Under these conditions, repair occurs by
replacement of the non-regenerated cells with
connective tissue, or by a combination of
regeneration of some cells and scar formation.
Repair begins within 24 hours of injury by the
emigration of fibroblasts and the induction of
fibroblast and endothelial cell proliferation.
By three to five days, a specialized type of tissue
that is characteristic of healing, called granulation
tissue is apparent.
 The term granulation tissue derives from
the pink, soft, granular gross appearance,
such as that seen beneath the scab of a
skin wound.
Its histological appearance is characterized
by proliferation of fibroblasts and new thin
walled, delicate capillaries (angiogenesis),
in a loose ECM.
Granulation tissue then progressively
accumulates connective tissue matrix,
eventually resulting in the formation of a
scar, which may remodel over time.
 Four sequential Processes of
Repair by connective Tissue
Deposition
a)Formation of new blood vessels
(angiogenesis)
b)Migration and proliferation of
fibroblasts
c)Deposition of ECM (scar formation)
d)Maturation and reorganization of the
fibrous tissue (remodelling)
 Wound Healing
It is a complex and dynamic process of restoring cellular
structures and tissue layers.
Wound healing process can be divided into 3 distinct
phases:
-Inflammatory phase
-Proliferative phase
- Remodelling phase
Within these three broad phases is a complex and
coordinated series of events that includes chemotaxis,
phagocytosis, granulation, collagen degradation,
and collagen remodeling.
In addition, angiogenesis, epithelization, and the
production of new glycosaminoglycans and proteoglycans
are vital to the wound healing.
 Types of Wound Healing
There are three categories of wound healing
which are:
1.Primary wound healing o This is also
known as healing by first intention.
Occurs within hours of repairing a full-thickness
surgical incision when edges of the wound are in
aposition.
2.Delayed primary wound healing o
Occurs if the wound edges are not
reapproximated immediately.
By the fourth day, phagocytosis of contaminated
tissues is well underway, and the processes of
epithelialisation, collagen deposition, and
maturation are occurring.
 Foreign materials are walled off by
macrophages that may metamorphose into
epithelioid cells, which are encircled by
mononuclear leukocytes, forming granulomas.
Chronic inflammation can ensue, resulting in
prominent scarring.
3.Secondary healing o This is also
known as healing by secondary intention.
Secondary healing results in an inflammatory
response that is more intense than with
primary wound healing.
In addition, a larger quantity of granulomatous
tissue is fabricated because of the need for
wound closure.
 Sequence of Events in Wound Healing
Following tissue injury the cascade of
vasoconstriction and coagulation commences
with clotted blood immediately impregnating
the wound, leading to hemostasis.
An influx of inflammatory cells follows, with the
release of cellular substances and mediators.
Angiogenesis and re-epithelialization occur and
the deposition of new cellular and extracellular
components ensues.
Sequence of events in wound healing has the
following phases:
Initial phase (Hemostasis)
Following vasoconstriction, platelets adhere to damaged
endothelium and discharge adenosine diphosphate (ADP),
promoting thrombocyte clumping, which dams the wound.
 Second phase (Inflammation)
Polymorphonuclear leukocytes (PMNs)
engorging the wound.
Third phase (Granulation)
This phase consists of subphases which are
fibroplasia, matrix deposition, angiogenesis
and re-epithelialization.
Fourth phase (Remodelling)
The wound undergoes constant alterations
which can last for years after the initial
injury occurred.
 Key Points
The control of cell proliferation is an important
effect in tissue regeneration.
Growth factors play an important role in enhancing
tissue growth.
ECM regulates the proliferation, movement, and
differentiation of the cells.
Extensive regeneration or compensatory
hyperplasia can occur only if the residual tissue is
structurally and functionally intact.
Wound healing is a complex and dynamic process
of restoring cellular structures and tissue layers
comprising of three distinct phases
Inflammatory phase o Proliferative phase o Remodelling
phase
 Evaluation

What are the roles of Extra Cellular

Matrix (ECM)?
What are the basic components of
ECM?
What are the sequential processes of
connective tissue deposition?
What are the types of wound
healing?
 THANK YO U