The whole blood-based test system described above was developed particularly for a more comprehensive and in vivo-like characterization of potential immune cell interactions with solid and semi-solid materials. The major goal of this project was to use un-touched immune cells to avoid any kind of artificial loss or gain in activities, due to handling. Such undesired activities can easily be caused by storing, shipping, or manipulations during immune cell preparation. Therefore, the cultures should be started not later than 1 h after drawing the blood (26, 27). In addition to this, shear forces and temperature shifts, often being the result of blood sample shipping, means additional stress to immune cells (28, 29). However, the most crucial point is the preparation of the immune cells prior cultivation, including centrifugation and resuspension of the cells, or exposure to buffers, different to their natural matrix, etc. (27, 30, 31).
Moreover, whole blood cultures mimic excellently the complexity of the human immune system in vivo (32–34). All types of immune cells are still available in their native composition, such as monocytes, macrophages, T cells, B cells, NK cells, or granulocytes, as well as platelets, soluble factors like complement proteins, antibodies, etc. Each of these elements do have the capacity of either triggering or at least modulating the response of immune cells to materials (35). Maintaining an in vivo-like complexity in test models enhances the translational value of results obtained with these considerably (30, 33, 36).
The most decisive component in these cultures is human whole blood. In order to obtain reliable and reproducible results, strict inclusion and exclusion criteria must be met when selecting the donors (see material and methods). These must ensure that immune cell activities have not been triggered (or suppressed) already in vivo, short before the blood is drawn, e.g. as a consequence of immunological illnesses, medication, surgery, vaccination or similar (37–41).
The easiest and also most sensitive endpoints to be measured in whole blood culture models are cytokines secreted by the different types of immune cells into the culture fluid (42). This enables a simple and quick processing of even larger series of samples by means of standard immunoassays, such as single ELISAs, or the more informative multiplexed assays like Luminex® (43). It is self-evident that, while providing a far more comprehensive overview on the activities of a whole variety of cell types, especially multiplexed assays provide the best match to the complexity represented by such organotypic cell culture systems. Besides, other parameters, such as mRNA expression, surface activation-markers, cell viability, morphology, intra-cellular cytokine levels, etc. can be determined by recovery of the cellular components from these cultures as well (33, 44, 45).
A very important aspect when developing new test models is the definition of controls and reference samples. Here, the non-stimulated negative control defined the basal level of immune cell activity. This was of great importance for further data analysis and interpretation. The stimulation control illustrated, whether immune cells of each donor could be activated properly. Both, negative control and stimulation control, were well established for static whole blood culture model (TruCulture®) (33, 33, 46). HDPE was found the most suitable negative control material for this test model with very low, almost basal cytokine levels. HDPE was also selected as negative control for cytotoxicity testing according to DIN EN ISO 10993-5. More difficult was the search for an appropriate positive control, since it was meant to activate immune cells without causing hemolysis or cytotoxicity. NelA fulfilled these criteria, although its immune cells activation was donor dependent with inter-individual variations. Only by taking into account the results of negative and stimulation control cultures, as well as those containing negative and positive material controls, will allow a reliable processing of such data.
As proof of concept, three different types of commercially available barrier membranes, used for maxillofacial surgery, were examined for their potential interactions with immune cells in this new whole blood test system. The materials, namely PTFE, collagen, and PCL, can be regarded as excellent examples for this test, representing not only different strengths of responses (low – medium – high), but also reaction patterns of different, yet reproducible complexity.
On the other hand, some results obtained with collagen indicated another interesting feature, which will surely not be limited to this material: While inducing moderate to high concentrations of several mediators, unexpectedly low values occurred for others, like MIP-1β (see Figure 3) or MMP3 (data not shown). This was likely caused by an adsorption of these proteins to the collagens, which has been shown for MIP-β (47), as well as for MMP3 (48). Besides the fact that such properties will interfere with a reliable quantitation of these mediators, properties like these will also have the potential to contribute to modulate the integration process of implants into the surrounding tissues. The whole blood test system presented in this paper is also able to detect such additional features of implant materials not only of natural origin, but also of synthetic composition. Further investigations will be needed to characterize the influence of the adhesion of specific mediators.
Follow-up experiments will focus on immune activating properties of materials used frequently for medicinal purposes and try to establish correlations between reaction patterns observed in this novel whole blood culture system and clinical outcome. Integration of this information into a database will ease the characterization of the analyzed materials. In addition, future tests will also address additional culture conditions, such as co-activation of immune cells by bacterial stimuli and other inflammatory signals, but also use of a wider spectrum of endpoints in order to characterize material properties more comprehensively.