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First published online March 27, 2008
Stem Cells Vol. 26 No. 6 June 2008, pp. 1474 -1483
doi:10.1634/stemcells.2007-0877; www.StemCells.com
© 2008 AlphaMed Press

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EMBRYONIC STEM CELLS

Androgenetic Embryonic Stem Cells Form Neural Progenitor Cells In Vivo and In Vitro

Timo C. Dingera, Sigrid Eckardtb, Soon Won Choia, Guadelupe Camareroa, Satoshi Kurosakab, Vroni Hornicha, K. John McLaughlinb, Albrecht M. Müllera

aInstitut für Medizinische Strahlenkunde und Zellforschung, Universität Würzburg, Würzburg, Germany;
bCenter for Animal Transgenesis and Germ Cell Research, New Bolton Center, University of Pennsylvania, Kennett Square, Pennsylvania, USA

Key Words. Embryonic stem cells • Androgenetic • Differentiation • Neural progenitor cells

Correspondence: Correspondence: Albrecht M. Müller, Ph.D., Professor, Institut für Medizinische Strahlenkunde und Zellforschung, University of Würzburg, Versbacher Strasse 5, 97078 Würzburg, Germany. Telephone: 49-931-201-45848; Fax: 49-931-201-45147; e-mail: albrecht.mueller{at}mail.uni-wuerzburg.de

Received on October 18, 2007; accepted for publication on March 18, 2008.

First published online in STEM CELLS EXPRESS  March 27, 2008.


    ABSTRACT
 Top
 Footnotes
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Summary
 Disclosure of Potential...
 Acknowledgments
 References
 
Uniparental zygotes with two paternal (androgenetic [AG]) or two maternal (gynogenetic [GG]; parthenogenetic [PG]) genomes are not able to develop into viable offspring but can form blastocysts from which embryonic stem cells (ESCs) can be derived. Although some aspects of the in vitro and in vivo differentiation potential of PG and GG ESCs of several species have been studied, the developmental capacity of AG ESCs is much less clear. Here, we investigate the potential of murine AG ESCs to undergo neural differentiation. We observed that AG ESCs differentiate in vitro into pan-neural progenitor cells (pnPCs) that further give rise to cells that express neuronal- and astroglial-specific markers. Neural progeny of in vitro-differentiated AG ESCs exhibited fidelity of expression of six imprinted genes analyzed, with the exception of Ube3a. Bisulfite sequencing for two imprinting control regions suggested that pnPCs predominantly maintained their methylation pattern. Following blastocyst injection of AG and biparental (normal fertilized [N]) ESCs, we found widespread and evenly distributed contribution of ESC-derived cells in both AG and N chimeric early fetal brains. AG and N ESC-derived cells isolated from chimeric fetal brains by fluorescence-activated cell sorting exhibited similar neurosphere-initiating cell frequencies and neural multilineage differentiation potential. Our results indicate that AG ESC-derived neural progenitor/stem cells do not differ from N neural progenitor/stem cells in their self-renewal and neural multilineage differentiation potential.

Disclosure of potential conflicts of interest is found at the end of this article.


    INTRODUCTION
 Top
 Footnotes
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Summary
 Disclosure of Potential...
 Acknowledgments
 References
 
Uniparental zygotes can be produced either by exchanging a maternal for a paternal pronucleus (androgenetic [AG] embryo) or by replacing the paternal with a maternal pronucleus (gynogenetic [GG] embryo) [1, 2]. Parthenogenetic (PG) zygotes can result from activation of unfertilized oocytes by chemical treatment or other means [3]. Uniparental embryos have been experimentally generated in several mammalian species, including mouse (AG/GG embryos [1, 2, 4]; PG embryos [5]), bovine (AG/PG embryos [6]), primate (Macaca fascicularis PG embryos [7]), and human (PG embryos [8]). Mammalian, including human, uniparental embryos are not viable but can develop sufficiently for the derivation of ESCs [9, 10]. In particular, the derivation of pluripotential monkey PG ESCs capable of differentiation into ecto-, endo-, and mesodermal derivatives has led to the discussion of using PG ESCs as a source of autologous material for transplantation [7].

PG ESCs isolated from monkey demonstrate the ability to differentiate into neural precursors and into cells with neuronal morphologies and characteristics of functional neurons. Additional in vivo analyses show the long-term survival of dopaminergic neurons derived from PG monkey ESCs after transplantation into immunosuppressed rats [11].

Addressing the problem of graft rejection, Kim et al. [12] demonstrated that murine PG ESCs can be selected for MHC compatibility and that injection of differentiated PG ESCs expressing matched major histocompatibility complex (MHC) antigens leads to teratoma formation in immune competent hosts. In addition, the isolation and characterization of six human PG ESC lines was described [8]. Human PG ESCs are able to differentiate into cell types from all three germ layers and they are MHC-matched with the oocyte donors [8]. In contrast to PG ESCs, AG ESCs have not been similarly examined, in part because of the abnormal phenotype of murine AG ESC chimeras [10, 13] and the lack of derivation of nonhuman primate and human AG ESCs.

Only recently has the functionality of GG and AG ESC-derived transplants been demonstrated in a mammalian species [14]. Both murine AG and GG ESC-derived fetal liver hematopoietic stem cells conveyed long-term and multilineage reconstitution of the entire hematopoietic system in transplant recipients with no associated pathologies. In contrast to defects observed in AG chimeras, AG ESC-derived cells in adult recipients did not exhibit any abnormal phenotypes, and expression levels of imprinted genes in lymphocytes of either AG or GG origin were typically low, without parent-of-origin-specific bias. It seems, therefore, that correct expression of imprinted genes is not required for normal function or that normal expression is re-established by resetting the imprinting status, at least in blood cells.

Studies on murine chimeric embryos developing following blastocyst injection of uniparental inner cell mass (ICM) cells or uniparental ESCs have provided insights into the parent-specific contribution to brain development. PG and GG cells distribute and differentiate preferentially to brain and less so to mesodermal tissues [1517]. Analysis of fetal brain development of AG and GG chimeras developing either from aggregation of uniparental and normal fertilized (N) morulae or following injection of uniparental ICM cells into N blastocysts reveals that AG cells contribute substantially to hypothalamic structures but less to the cortex and striatum, whereas progeny of PG and GG cells seed the cortex, striatum, and hypothalamus [18]. Also, AG ESCs contribute less to brain upon blastocyst injection, although the regional distribution of AG cells in brain was not analyzed [10]. Together, these observations argue that paternal and maternal genomes have differential influence on brain development.

The apparent bias in neural differentiation of AG and GG ICM cells could also indicate that the male-derived AG ESCs would have limited neural differentiation potential and be limited or excluded for neural tissue replacement utility. Investigating the capacity of AG ESCs to undergo neural differentiation, we found that AG ESCs exhibit neural differentiation capacity in vitro and in vivo in mid-gestation chimeras, similar to ESCs derived from N embryos. AG ESC-derived cells contributed widely to embryonic day (E) 12.5 fetal brain and exhibited normal formation of neurospheres with self-renewal and neural differentiation capacity.


    MATERIALS AND METHODS
 Top
 Footnotes
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Summary
 Disclosure of Potential...
 Acknowledgments
 References
 
Animals
All animals were bred and maintained in the animal facility at the Institut für medizinische Shahlen Kunde und Zellforschung, Universität Würzburg, or obtained from Harlan Winkelmann (Borchen, Germany, http://www.harlan-winkelmann.de) and were used for experimentation in accordance to the animal protection guidelines of the Government of Unterfranken (Würzburg, Germany).

ESC Culture
The AG and N enhanced green fluorescent protein (eGFP)+ murine ESCs used in this study have been previously described [14]. ESCs were cultured in high-glucose Dulbecco's modified Eagle's medium (DMEM) (PAA Laboratories, Cölbe, Germany, http://www.paa.at) supplemented with 15% fetal calf serum (FCS) (HyClone, Logan, UT, http://www.hyclone.com; Thermo Fisher Scientific, Schwerte, Germany, http://www.thermofisher.com), leukemia inhibitory factor-conditioned medium [19, 20], 1% nonessential amino acids (NEAA) (PAA Laboratories), penicillin (100 U/ml)/streptomycin (100 U/ml) (PAA Laboratories), L-glutamine (2 mM; PAA Laboratories), sodium pyruvate (1 mM; PAA Laboratories), and β-mercaptoethanol (0.1 mM; Sigma-Aldrich, Schnelldorf, Germany, http://www.sigmaaldrich.com) on confluent layers of primary murine embryonic fibroblasts (MEFs). Medium was changed daily. For passage of ESCs, medium was removed, cells were washed with phosphate-buffered saline (PBS), and trypsin/EDTA (PAA Laboratories) was added. After 10 minutes at 37°C, the reaction was stopped by adding 10 ml of medium containing 15% FCS. Cell suspensions were put on gelatin-coated plates (0.1% in PBS; Sigma-Aldrich) for 45 minutes at 37°C to allow separation of MEFs and ESCs. ESCs (5 x 105) were plated on new MEF layers. Passage numbers of ESCs used for in vitro differentiation and transplantation experiments ranged from 15 to 25 (in vitro analyses) and from 15 to 36 (in vivo analyses).

ESC In Vitro Differentiation
ESCs were differentiated toward neural phenotypes as described [2123]. Briefly, to obtain embryoid bodies (EBs), undifferentiated ESCs (AG line 1 [A1] and 2 [A2]; N line 1) were cultured in high-glucose DMEM supplemented with 10% FCS (Biochrom AG, Berlin, http://www.biochrom.de), HEPES (10 mM; PAA Laboratories), NEAA, penicillin (100 U/ml)/streptomycin (100 U/ml), L-glutamine (2 mM), sodium pyruvate (1 mM), and β-mercaptoethanol (0.1 mM) for 4 days in bacteriological Petri dishes. On day 4, free-floating EBs were transferred to tissue culture plates for adherent cells with DMEM/Ham's F-12 medium (F12) (PAA Laboratories) containing penicillin (100 U/ml)/streptomycin (100 U/ml), L-glutamine (2 mM), human transferrin (50 µg/ml), sodium selenite (30 nM), insulin (5 µg/ml), and fibronectin (2.5 µg/ml) (all from Sigma-Aldrich) to obtain attached EBs. Fresh medium was added on day 2. After 4 days of cultivation, attached EB were trypsinized (10 minutes, 37°C), and cells were transferred to poly-L-ornithine- and laminin-coated plates (both from Sigma-Aldrich) and cultured in DMEM/F12 containing penicillin (100 U/ml)/streptomycin (100 U/ml), L-glutamine (2 mM), insulin (25 µg/ml), progesterone (20 nM), putrescine (0.1 µM), sodium selenite (30 nM), human transferrin (50 µg/ml) (all from Sigma-Aldrich), basic fibroblast growth factor (bFGF) (50 ng/ml; Peprotech, Hamburg, Germany, http://www.peprotech.com), and laminin (0.7 µg/ml) for generation of pan-neural progenitor cells (pnPCs). On days 1, 2, and 3, fresh medium supplemented with bFGF (50 ng/ml) was added. After 4 days of cultivation, pnPCs were trypsinized and replated under neural differentiation conditions (Neurobasal medium with 2% B27 supplement [both from Gibco, Karlsruhe, Germany, http://www.invitrogen.com], penicillin [100 U/ml]/streptomycin [100 U/ml], and L-glutamine [2 mM], supplemented with 10% NeuroCult differentiation supplement [StemCell Technologies, St. Katharinen, Germany, http://www.stemcell.com]) for terminal differentiation into neural cell types on coverslips coated with poly-L-ornithine and laminin. Cells were cultured at 37°C in 5% CO2 for up to 13 days. Medium was changed every other day. Immunohistochemical staining for neuronal and astroglial differentiation markers was performed as described for in vitro-differentiated neurosphere cells (described below). Percentages of tubulin-β-III+ cells and glial fibrillary acidic protein (GFAP)+ cells were compared between differentiated AG and N pnPCs by two-sided Student's t test. Differences were considered statistically significant if p < .05.

Bisulfite Sequencing
Genomic DNA isolated from ESCs and pnPCs using the DNeasy Tissue Kit (Qiagen, Hilden, Germany, http://www1.qiagen.com) was modified using the EZ DNA Methylation-Gold kit (Zymo Research, Orange, CA, http://www.zymoresearch.com) according to the manufacturer's instructions. Modified DNA was amplified by nested and seminested polymerase chain reaction (PCR) as described [24]. The amplified DNA fragments were subcloned into pJet1/blunt (Fermentas, Glen Burnie, MD, http://www.fermentas.com) for sequencing. Analysis of sequences and diagram generation was performed using BiQ Analyzer (http://biq-analyzer.bioinf.mpi-sb.mpg.de)[25].

Quantitative Reverse Transcription-PCR
RNAs were isolated from AG and N pnPCs by using peqGOLD RNAPure (peqLab Biotechnologie, Göttingen, Germany, http://www.peqlab.de). Before generation of cDNA, RNA preparations were treated with DNase I (Ambion, Austin, TX, http://www.ambion.com; Applied Biosystems, Foster City, CA, http://www.appliedbiosystems.com). RNA was reverse-transcribed into cDNA using Moloney murine leukemia virus reverse transcriptase (Invitrogen, Karlsruhe, Germany, http://www.invitrogen.com). Reverse transcription (RT)-PCRs were performed and quantified using a Rotor-Gene 3000 (Corbett Life Science, Wasserburg, Germany, www.corbettlifescience.com) and ABsolute QPCR SYBR Green Mix (ABgene, Hamburg, Germany, http://www.abgene.com). Differences in gene expression were calculated with the 2{Delta}{Delta}CT method. The housekeeping gene β-actin was used for normalization. The 2{Delta}{Delta}CT values of N pnPCs were set to 1 for tested genes to determine expression differences between AG and N pnPCs. The primer sequences were as follows: β-actin: forward (f), 5'-GATATCGCTGCGCTGGTCGTC-3'/reverse (r), 5'-ACGCAGCTCATTGTAGAAGGTGTGG-3'; Igf2: f, 5'-CTAAGACTTGGATCCCAGAACC-3'/r, 5'-GTTCTTCTCCTTGGGTTCTTTC-3'; Impact: f, 5'-ACGTTTCCCCATTTTACAAG-3'/r, 5'-CTCTACATATGATTTTCTCTAC-3'; Igf2r: f, 5'-TAGTTGCAGCTCTTTGCACG-3'/r, 5'-ACAGCTCAAACCTGAAGCG-3'; Ube3a: f, 5'-CACATATGATGAAGCTACGA-3'/r, 5'-CACACTCCCTTCATATTCC-3' [14]; Zim1: f, 5'-GAGAAGCCGTACTGCTGTCA-3'/r, 5'-CTTGCACCGGTACCTGGAGT-3' [26]; H19: f, 5'-CATGTCTGGGCCTTTGAA-3'/r, 5'-TTGGCTCCAGGATGATGT-3' [27].

Generation of Chimeric Embryos by Blastocyst Injection
To obtain blastocysts for the injection of ESCs, 6–8-week-old female NMRI mice were superovulated by intraperitoneal injection of 10 units of pregnant mare's serum followed 48 hours later by an injection of 10 units of human chorionic gonadotropin (both from Intervet, Unterschleißheim, Germany, http://www.intervet.de), caged with stud males, and checked for vaginal plugs the next morning. The day of finding the plug was designated 0.5 days post coitum (dpc). At 3.5 dpc, pregnant mice were sacrificed, and ovaries and oviducts were removed and transferred into M16 medium (Sigma-Aldrich). Blastocysts were flushed from the oviducts and kept for 1–2 hours in M2 medium (Sigma-Aldrich) prior to the injection of ESCs. To induce pseudopregnancy in recipient foster animals, 6–8-week-old female NMRI mice were mated with vasectomized NMRI males of proven sterility. ESCs were trypsinized, and MEFs were removed by incubation on gelatin-coated plates for 45 minutes. ESC single-cell suspensions were prepared in M2 medium prior to blastocyst injection. Ten to 15 ESCs were injected per blastocyst. Afterward, blastocysts were transferred into pseudopregnant foster animals. At 12.5 and 14.5 dpc, pregnant mice were sacrificed, and embryos were isolated from the uteri. Pictures of embryos were taken, embryo sizes were measured, fetal livers were isolated and triturated, and liver single-cell suspensions were analyzed by flow cytometry (FACSCalibur; BD Biosciences, Heidelberg, Germany, http://www.bdbiosciences.com) for grade of chimerism by measuring the percentage of eGFP+ cells. Gates were defined by using fetal liver cells from wild-type and eGFP transgenic embryos [21]. Embryos were considered chimeric if the eGFP+ cell frequency was ≥1%. Heads of chimeric embryos were either fixed for cryosections and immunohistochemistry or used to establish neurosphere cultures.

Immunohistochemistry of E12.5 Brain Cryosections
For cryosections, whole E12.5 embryo heads were fixed for 12 hours in PBS/4% paraformaldehyde (Applichem, Darmstadt, Germany, http://www.applichem.de). Following fixation, tissues were dehydrated in PBS/16% glucose (Applichem), embedded in Tissue-Tek OCT Compound (Sakura Finetek, Heppenheim, Germany, http://www.sakura.com), and frozen at –80°C. Ten-micrometer sagittal sections were stained with primary chicken antibody against eGFP (Abcam, Cambridge, U.K., http://www.abcam.com) and with secondary goat anti-chicken IgY Cy2-conjugated antibody (Abcam). For neuronal cell staining, primary mouse antibody against tubulin-β-III (clone TUJ-1; R&D Systems Inc., Minneapolis, http://www.rndsystems.com) or primary mouse antibody against neuronal nuclei (NeuN) (Chemicon, Schwalbach, Germany, http://www.chemicon.com) and secondary mouse IgG Cy3-conjugated antibody (Chemicon) were used. Nuclei were counterstained with 4,6-diamidino-2-phenylindole (DAPI) (Sigma-Aldrich). For analysis of colocalization of green and red signals, 10 µm z-stacks with 1-µm picture distance were taken using a BioZero microscope (magnification, x600) (Keyence, Neu-Isenburg, Germany, http://www.keyence.de), yielding xy pictures and orthogonal xz and yz projections of z-stacks. For intranuclear staining, tissue slices were incubated for 20 minutes at 96°C in 10 mM citrate buffer (pH 6.0) for antigen retrieval. To visualize proliferating cells, 5-µm transversal sections were stained with primary rabbit antibody against proliferating cell nuclear antigen (PCNA) (BD Biosciences) and secondary goat anti-rabbit IgG Cy3-conjugated antibody (Chemicon). Apoptotic cells were detected using primary mouse antibody against cleaved-caspase-3 (Cell Signaling Technology, NEB, Frankfurt, Germany, http://www.cellsignal.com) and secondary goat anti-mouse IgG Cy3-conjugated antibody (Chemicon). Nuclei were counterstained with DAPI (Sigma-Aldrich).

Quantification of eGFP+ ESC-Derived Cell Contribution in E12.5 Chimeric Brains
To quantify the contribution of eGFP+ ESC-derived cells, the percentage of eGFP+ cells was determined for distinct brain regions by counting the numbers of DAPI-stained nuclei and the numbers of eGFP+ cells in three representative 100 x 100-µm squares per brain region. Regions analyzed were striatum, hypothalamus, cortex, and brain stem. Percentages of eGFP+ cells in striatum, hypothalamus, and cortex were calculated relative to brain stem. Means of eGFP+ cell percentages relative to brain stem for striatum, hypothalamus, and cortex from AG and N chimeric brains were considered significantly different if p < .05 (two-sided Student's t test).

Neurosphere Cell Isolation and Culture
To establish neurosphere cultures, E12.5 fetal brains were isolated from chimeric embryos. Whole brains were triturated, and single-cell suspensions were obtained by pipetting cells through a cell strainer (70 µm; BD Biosciences). Cell suspensions were cultured under neurosphere growth conditions (Neurobasal medium with 2% B27 supplement, penicillin [100 U/ml]/streptomycin [100 U/ml], and L-glutamine [2 mM], supplemented with human growth factors epidermal growth factor [20 ng/ml] and basic fibroblast growth factor [20 ng/ml] [both from Peprotech]) [28]. After 2 days of culture, free-floating neurospheres started to grow. At the day (d) of isolation (d0), d5, and d10, the grade of eGFP+ ESC-derived contribution was assessed by flow cytometry. For flow cytometric analysis at d5 and d10, single-cell suspensions of neurospheres were prepared by incubating neurospheres with AccuMax (PAA Laboratories) for 7 minutes at 37°C and pipetting cells through cell strainers. To isolate AG brain cells, single-cell suspensions were prepared from chimeric brains, and cells were expanded for two passages under neurosphere growth conditions, as primary brain cells were found to be sensitive to fluorescence-activated cell sorting (FACS). Single-cell suspensions were prepared from neurospheres, and cells were subjected to FACS according eGFP fluorescence. The purity of eGFP+ and eGFP populations after sorting was >98%. Sorted eGFP+ and eGFP neurosphere cells were expanded for two to four passages under neurosphere growth conditions to obtain sufficient cell numbers for analysis.

Neurosphere Cell Self-Renewal
To determine the neurosphere-initiating cell (NIC) number, single-cell suspensions from neurosphere cultures were produced by AccuMax treatment. Cells were counted, and viability was assessed by trypan blue exclusion. Five thousand single neurosphere cells were seeded per well, and cells were cultured under neurosphere growth conditions. After 5 days, newly formed neurospheres were counted. Percentages of NICs were calculated and considered significantly different if p < .05 (two-sided Student's t test).

Neurosphere Cell In Vitro Differentiation
For neural differentiation, single-cell suspensions from neurospheres were cultured under differentiation conditions. Single-cell suspensions from neurospheres were generated by AccuMax treatment. Thereafter, cells were seeded onto poly-L-ornithine/laminin-coated coverslips at 5 x 105 cells per coverslip and cultured for up to 13 days under neural differentiation conditions. Subsequent to differentiation, cells were stained using the following antibodies: for neurons, primary mouse antibody against tubulin-β-III and secondary goat anti-mouse IgG Cy3-conjugated antibody; for astroglia, primary rabbit antibody against GFAP (Dako, Hamburg, Germany, http://www.dako.com) and secondary goat anti-rabbit IgG Cy3-conjugated antibody (Chemicon); and for oligodendrocytes, primary mouse antibody against O4 (R&D Systems) and secondary goat anti-mouse IgG Cy3-conjugated antibody (Chemicon). Nuclei were counterstained with DAPI. Percentages of neurons, astroglia, and oligodendroglia were assessed by differential counting total cell numbers (DAPI signals) and numbers of tubulin-β-III+, GFAP+, and O4+ cells. Mean values for AG and N neurosphere cells, as well as values for AG and blastocyst-derived cells, were analyzed by two-sided Student's t test. Values were considered statistically different if p < .05.


    RESULTS
 Top
 Footnotes
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Summary
 Disclosure of Potential...
 Acknowledgments
 References
 
Neural In Vitro Differentiation of AG ESCs
To assess the neural in vitro differentiation potential of AG ESCs in comparison with N ESCs, AG and N ESCs were subject to a multistep differentiation protocol that induces differentiation of ESCs into pnPCs and later into neuronal and glial cell types [21, 22]. AG and N ESCs grew as tightly packed colonies on embryonic fibroblasts. Under differentiation conditions, AG and N ESCs formed free-floating embryoid bodies, and later cells acquired an phenotype reminiscent of neural epithelia precursor cells [22] (data not shown; Fig. 1A, 1D). To investigate the differentiation capability of AG and N ESC-derived pnPCs, pnPCs were subject to neural differentiation conditions for up to 13 days, and cultures were analyzed morphologically and by immunocytochemistry. As shown in Figure 1, both AG and N pnPCs differentiated into cells expressing the neuronal marker tubulin-β-III (Fig. 1B, 1E) and the astroglial marker GFAP (Fig. 1C, 1F). The frequency of tubulin-β-III+ and GFAP+ cells did not differ between AG cells and N cells (percentages of AG/N tubulin-β-III+ cells, 94% ± 2.7%/95% ± 2.1%; percentages of AG/N GFAP+ cells, 3.4% ± 1.9%/5.2% ± 2.8%).


Figure 1
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Figure 1. Neural in vitro differentiation of AG and N ESCs. Representative phase contrast images of pan-neural progenitor cells (pnPCs) differentiated from AG and N ESCs in vitro (A, D). Magnification, x200; n= 14. (B–F): Immunostaining of pnPC-derived neural and glial cells. pnPCs were cultured for 13 days under neural differentiation conditions. (B, E): Tubulin-β-III+ neuronal cells (red). (C, F): Glial fibrillary acidic protein-positive astroglial cells (green). Nuclei were counterstained with 4,6-diamidino-2-phenylindole. A representative analysis is shown. Magnification, x200; n= 7. Abbreviations: AG, androgenetic; N, normal fertilized.

 
We analyzed methylation of CpG islands of two imprinting regulatory regions: the differentially methylated region (DMR) 1 of the Snrpn gene and the DMR2 of the Igf2r gene in AG ESCs and pnPCs. In normal tissues, the inactive maternal allele of the Snrpn gene is methylated and the paternal allele is unmethylated. The Igf2r DMR2 carries the primary gametic imprint and is preferentially methylated on the active maternal allele. We observed that CpG islands in DMRs of Snrpn and Igf2r in AG ESCs and pnPCs were predominantly not methylated, consistent with the maintenance of parent-of-origin-specific marks (Fig. 2A). Also, using quantitative RT-PCR, we assessed the expression levels for several imprinted genes in AG and N cells (Fig. 2B). In AG and N ESCs, we observed similar expression levels of the genes analyzed. In contrast, two genes with a paternal expression bias, Igf2 and Impact, exhibited approximately twofold higher expression levels in AG-derived pnPCs compared with N-derived pnPCs, indicating conservation of genomic imprinting. Silencing of the maternally expressed Zim1 and H19 genes was preserved in AG pnPCs. For Igf2r and Ube3a, two genes with brain-specific imprinting patterns, we detected low-level and high-level expression, respectively.


Figure 2
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Figure 2. Methylation and expression of imprinted genes in androgenetic (AG) and N ESCs and pnPCs. (A): Analysis of the methylation status of the Snrpn DMR1 (promoter-exon 1 region; position 2,151–2,570) and the DMR2 (position 796–1,001) of the Igf2r gene in ESCs and pnPCs by bisulfite sequencing. Each line represents a single clone. (B): Gene expression of imprinted genes. Relative expression of imprinted genes was compared in N and AG (A1 and A2) ESCs and pnPCs. Shown are quantitative RT-PCR data from representative batches of ESCs and pnPCs. The relative expression represents the fold change of gene expression in AG to N cells. Fold change was calculated by the 2{Delta}{Delta}CT method. Expression levels of N cells were set to 1. In brain, Igf2 and Impact are preferentially paternally expressed, and Igf2r, Ube3a, Zim1, and H19 are preferentially maternally expressed. For N ESCs, CT values were as follows: β-actin, 10.7; Igf2, 19.0; Impact, 15.5; Igf2r, 17.9; Ube3a, 16.7; Zim1, 23.9; H19, 19.8. CT values for N PnPCs were as follows: β-actin, 11.0; Igf2, 13.9; Impact, 17.6; Igf2r, 17.6; Ube3a, 16.6; Zim1, 21.0; H19, 17.7. n= 3. Abbreviations: DMR, differentially methylated region; N, normal fertilized; pnPC, pan-neural progenitor cell.

 
Androgenetic Cells Contribute to the Brain in Fetal AG ESC Chimeras
Previously, the contribution of uniparental AG cells to the brain has been determined using aggregations with embryonic cells from preimplantation stage AG embryos but not for AG ESCs [17, 18]. To study the capacity of AG ESCs to participate in neural development within a developing embryo, chimeric embryos were generated by blastocyst injection of AG or, as a control, N ESCs. Embryos were isolated at E12.5 and E14.5.

As expected for AG cells, the frequency of dead or absorbed embryos increased from E12.5 to E14.5 for AG ESC-injected blastocysts. Following injection of AG ESCs, we detected that at E12.5 18 of 60 (30%) and at E14.5 15 of 40 (38%) embryos were dead or absorbed, whereas following N ESC injection at E12.5 6 of 36 (17%) and at E14.5 7 of 25 (28%) embryos were dead or absorbed. In addition, we assessed the size and appearance of embryos. The consequences of abnormal genomic imprinting associated with the AG cells in E14.5 chimeric embryos included overall larger size, as well as characteristic limb, head, and trunk growth distortion and evidence of organomegaly [10, 13] (supplemental online Fig. 1A, 1B).

Contribution of AG cells to fetuses was determined by flow cytometric analysis for eGFP expression in fetal livers, since previously it was shown that AG ESCs contribute to this organ [14]. Six independent injections of AG ESCs (four injections with line A1; two injections with line A2) yielded, in total, 42 live E12.5 embryos, of which 22 (52%) were chimeric. Heads of 8 of 22 AG chimeras were fixed and used for immunohistochemical analyses. From the brains of the remaining embryos, single-cell suspensions were prepared for further analysis of proliferation and differentiation properties (described below). In addition, of 30 living E12.5 embryos that developed out of four independent injections of N ESCs, 24 (80%) showed eGFP+ cells in the fetal liver. Fifteen of 24 E12.5 chimeric heads were processed for immunohistochemistry, and brain cell cultures were established from 9 of 24 embryos. Furthermore, 25 E14.5 embryos originating from eight independent injections of AG ESCs were analyzed, and 8 of 25 (32%) embryos showed eGFP+ cells in liver (data not shown). As controls, 18 embryos were generated by blastocyst injection of N ESCs, producing 9 (50%) chimeras. All E12.5 or E14.5 embryos with eGFP+ cells in liver also had eGFP+ cells present in the brain. Because of the elevated death rate of AG chimeras [10, 13], we did not analyze advanced developmental stages and focused on E12.5 chimeras.

Flow cytometric analysis revealed that AG ESC derivatives contributed substantially to the brains of fetal chimeras at E12.5 (supplemental online Fig. 2). We detected variation of ESC contribution between chimeras but no indication of exclusion of AG compared with N cells to fetal brain other than by stochastic variation [29]. For AG chimeric embryos, AG cell contribution ranged from 10% to 76% in the brain. The chimerism in N chimeric embryos varied from 1% to 38% in the brain.

To analyze the regional distribution of AG or N ESC-derived eGFP+ cells in E12.5 chimeric fetal brains, sagittal sections of AG and N chimeric brains were assessed for eGFP and tubulin-β-III signals. As shown in Figure 3A and 3B, AG and N ESC-derived cells displayed similarly widespread distribution in all brain regions. Sections of the striatum, hypothalamus, cortex, and brain stem region showed strong tubulin-β-III+ AG or N ESC-derived contribution (Fig. 3Aa– 3Ae, 3Ba– 3B3, insets). Staining of sagittal brain sections of AG and N chimeras for eGFP and neuronal nuclei (NeuN) also showed widespread NeuN+ AG or N ESC-derived cells contributing to these brain regions (supplemental online Fig. 3A, 3B).


Figure 3
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Figure 3. Analysis of AG and N cells in chimeric brains at embryonic day 12.5 following blastocyst injection of AG and N ESCs. (A): Immunostaining of cryosections of AG ESCs chimeric brains. (Aa): Representative samples shown are sagittal section of an AG chimeric head (image combined from 19 individual pictures). Indicated are cor, str, hyp, and bs. Also shown are higher magnifications of str (Ab), hyp (Ac), cor (Ad), and bs (Ae) regions. Insets in (Ab–Ae) show a 1-µm x-y layer and orthogonal views in the z direction of 10-µm cryosections to prove signal colocalization. * marks colocalization of eGFP and β-III-tubulin in an individual cell; ° marks an eGFP and β-III-tubulin+ cell. All panels are overlays composed of green ({alpha}-eGFP; ESC-derived cells), red ({alpha}-tubulin-β-III; neurons), and blue signals (4,6-diamidino-2-phenylindole; nuclei). n= 3. (B): Immunostaining of representative sagittal cryosections from an N chimeric E12.5 brain; n= 3. (Ba–Be): As described in (A). (C): Contribution of eGFP+ ESC-derived cells to different brain regions. Bar graph depicts frequencies of eGFP+ ESC-derived cells in cor, str, and hippocampus relative to bs for AG and N chimeric brains. n= 3. Abbreviations: AG, androgenetic; bs, brain stem; cor, cortex; eGFP, enhanced green fluorescent protein; hyp, hypothalamus; N, normal fertilized; str, striatum.

 
To assess the distribution of eGFP+ ESC-derived cells in distinct brain regions, the percentage of eGFP+ cells in striatum, hypothalamus, cortex, and brain stem was determined for AG and N chimeric fetal brains (Fig. 3C). Comparison of the percentages of eGFP+ cells for striatum, hypothalamus, and cortex relative to brain stem revealed no significant differences in the distribution of eGFP+ cells in these brain regions, and there were no significant distribution differences when comparing AG and N chimeric brains. These results show that AG ESC-derived cells can evenly seed the developing brain and contribute to early fetal neurogenesis.

Cell Proliferation and Apoptosis in AG Chimeric Fetal Brains
To evaluate the proliferative and apoptotic properties of AG cells in chimeric brains, transverse brain sections were assessed for PCNA and cleaved-caspase-3, a crucial component of the apoptosis pathway [30, 31] (Fig. 4A, 4B). As expected at this early stage of embryonic development, brain tissues are highly proliferative, with almost all cells positive for PCNA, including eGFP+ AG ESC-derived cells (Fig. 4Ad, inset). We detected no colocalization of eGFP+ AG ESC-derived signals with cleaved-caspase-3 staining (Fig. 4Bd, inset) and, overall, a very low number of apoptotic cells.


Figure 4
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Figure 4. Cell proliferation and cell death in androgenetic (AG) chimeric fetal embryonic day 12.5 brains. (A): Proliferating cell nuclear antigen (PCNA)-specific immunostaining of a transversal AG brain cryosection. (Aa): 4,6-Diamidino-2-phenylindole (DAPI) (blue channel); (Ab): enhanced green fluorescent protein (eGFP)+ ESC-derived cells (green channel); (Ac): PCNA+ cells (red channel). Inset shows control staining without primary but with secondary Cy2-labeled antibody. (Ad): Overlay of eGFP (green), PCNA (red) and DAPI (blue) signal. Inset shows a PCNA and eGFP double+ ESC-derived cell (*) and a PCNA+ and eGFP blastocyst-derived cell (°). n= 3. (B): Cleaved-capase-3-specific immunostaining of a transversal cryosection from an AG chimeric fetal brain. (Ba): DAPI staining (blue channel); (Bb): eGFP+ ESC-derived cells (green channel) (control staining with only secondary Cy2-labeled antibody is shown in the inset); (Bc): cleaved-caspase-3+ cells (red channel); (Bd): overlay of eGFP (green), cleaved-caspase-3 (red), and DAPI (blue) signal. Inset shows a cleaved-caspase-3/eGFP+ ESC-derived cell (*) and a cleaved-caspase-3+/eGFP blastocyst-derived cell (°). n= 3.

 
AG Chimeric Fetal Brain Cells in Mixed Neurosphere Cultures
To ascertain the AG cell formation of neural stem/progenitor cells when codeveloping in vivo with blastocyst-derived cells, we cultured single-cell suspensions of AG chimeric brains under neurosphere growth conditions. As chimeric brains consisted of AG ESC-derived and blastocyst-derived cells, brain cell cultures were a mixture of cells of these two origins. Before culture (d0) and at d5 and d10 of culture, the percentage of eGFP+ AG cells in neurosphere cultures was measured by flow cytometry. In total, 14 AG and, as control, 9 N E12.5-derived chimeric brain cultures were analyzed (Fig. 5). The frequencies of eGFP+ cells in individual AG and N brain-derived neurosphere cultures show variation in the proportion of eGFP+, AG or N ESC-derived cells, particularly in AG cultures at day 5. However, on average, AG and N neurosphere cultures exhibit similar frequencies of eGFP+ ESC-derived cells. Thus, in chimeric brain cultures of AG-derived cells mixed with blastocyst-derived cells, AG cells persist and form neurosphere cells.


Figure 5
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Figure 5. Proliferation of AG or N ESC-derived and blastocyst-derived cells in mixed embryonic day 12.5 brain cell cultures. Shown is the proportion of eGFP+ cells in neurosphere cultures established from (A) AG or (B) N chimeric fetal brains. Percentages of eGFP+ ESC-derived cells in freshly isolated fetal brains and in corresponding 5- and 10-day neurosphere cultures were assessed by flow cytometry. Shown are changes in eGFP levels during 10 days of in vitro culture. Percentages of the starting populations were set to 0. Brain cell cultures are from embryos shown in supplemental online Figure 2. Abbreviations: AG, androgenetic; d, day; eGFP, enhanced green fluorescent protein; N, normal fertilized.

 
Stem Cell Properties of AG Neurospheres
To estimate progenitor cell frequencies and differentiation properties of cells in brain cultures, neurosphere cultures originating from chimeric brains were separated by FACS into eGFP+ AG or N ESC-derived and eGFP blastocyst-derived cells. Sorted neurosphere cells were cultured for two to four passages, followed by analysis of NIC frequencies and neural in vitro multilineage differentiation potential. To assess the frequency of NICs in neurosphere cultures, 5,000 sorted cells obtained from eGFP+ AG, control N, and eGFP blastocyst-derived neurosphere cells were plated under neurosphere growth conditions, and after 5 days of culture the number of newly formed neurospheres was counted. As shown in Figure 6A and 6B, sorted AG brain cells formed neurospheres, and the frequencies of NICs in sorted AG brain cells were similar to the frequencies of NICs in sorted N and blastocyst-derived brain cells. The levels of ESC contribution to chimeric brains (supplemental online Fig. 2), the growth behavior in cultures grown in mixed cultures (Fig. 5A, 5B), and the NIC frequencies (Fig. 6B) did not correlate for individual embryos. Thus, the level of brain chimerism was not predictive of NIC frequencies.


Figure 6
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Figure 6. Neural differentiation and self-renewal of AG and N fetal brain-derived neurosphere cells. (A): Phase contrast images of free-floating neurospheres originating from single-cell suspensions of embryonic day (E) 12.5 chimeric brains. ESC-derived cells were isolated by sorting of eGFP+ cells from single-cell suspensions of chimeric E12.5 brains by fluorescence-activated cell sorting. Cells were cultured for two to four passages. Neurospheres originating from sorted AG (Aa) and N (Ab) brain cells are shown. Magnification, x200; n= 5 for sorted AG neurosphere cells; n= 3 for sorted N neurosphere cells. (B): Quantification of neurosphere-initiating cells of AG and N brain-derived neurosphere cultures. Also shown are neurosphere-initiating cell frequencies of fetal brain-derived eGFP-sorted blastocyst-derived neurosphere cultures. Five thousand single cells from dissociated neurosphere in 500 µl of medium per well were cultured for 5 days, and newly formed neurospheres were counted. Plotted are the frequencies of newly formed neurospheres per 100 cells (percentage of neurosphere-initiating cells) from 9 AG chimeric embryos (two individual cell lines), 6 N chimeric embryos, and 11 eGFP blastocyst-derived neurosphere cultures. n= 4. (C): Immunostainings of differentiating fetal brain-derived AG and N neurospheres. Also shown are neural and glial cells originating from eGFP blastocyst-derived neurospheres. Neurosphere cells were cultured for 13 days under neural differentiation. Shown are AG (Ca), N (Cb), and blastocyst-derived (Cc) tubulin-β-III+ neuronal cells (red); AG (Cd), N (Ce), and blastocyst-derived (Cf) glial fibrillary acidic protein-positive astroglial cells (red); and AG (Cg), N (Ch), and blastocyst-derived (Ci) O4+ oligodendroglial cells (red). Cells were subjected to nuclear counterstaining (4,6-diamidino-2-phenylindole; blue). Magnification, x100; n= 6 for AG neurosphere cells; n= 3 for N neurosphere cells; n= 9 for eGFP blastocyst-derived neurosphere cells. Abbreviations: AG, androgenetic; eGFP, enhanced green fluorescent protein; N, normal fertilized.

 
For analysis of multilineage neural differentiation potential, sorted AG, N, and blastocyst-derived cells were cultured under neural differentiation conditions. Thereafter, cells were stained with tubulin-β-III-specific (neuronal cells), GFAP-specific (astroglial cells), and O4-specific (oligodendroglial cells) antibodies (Fig. 6C). Analysis of the frequencies of neuronal and glial cell types showed no difference between AG and N or blastocyst-derived cells. Frequencies for tubulin-β-III-positive cells were as follows: AG, 1.5% ± 0.2%; N, 1.0% ± 0.8%; and eGFP-sorted blastocyst-derived, 1.6% ± 0.6%. Frequencies for GFAP-positive cells were as follows: AG, 98% ± 3.3%; N, 99% ± 0.9%; and eGFP-sorted blastocyst-derived, 96% ± 2.2%. Frequencies for O4-positive cells were as follows: AG, 1% ± 0.7%; N, 1% ± 0.3%; and eGFP-sorted blastocyst-derived, 1.5% ± 0.8%. Thus, AG ESC-derived neurosphere cultures, like N and blastocyst-derived neurosphere cultures, contain cells that form new neurospheres and differentiate into neuronal and glial cell types with similar frequencies.


    DISCUSSION
 Top
 Footnotes
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Summary
 Disclosure of Potential...
 Acknowledgments
 References
 
In this study we assayed the neural developmental potential of murine AG ESCs in vitro and in vivo. Under in vitro neural differentiation conditions, AG cells formed pnPCs that differentiated into neuronal and astroglial cells at frequencies comparable to N ESCs. Analysis of imprinted genes revealed a prevalence of conserved parent-of-origin-specific gene expression and parent-of-origin-specific methylation in AG pnPCs. In vivo differentiation of AG ESCs in chimeras revealed unrestricted contribution of AG cells to developing fetal brains with widespread distribution of proliferating AG neurons. When cultured together, AG-derived neurosphere cultures isolated from chimeric fetal brains showed similar growth properties compared with blastocyst-derived (N) cultures, indicating that the paternal origin AG cells in E12.5 brains do not have a proliferative disadvantage. Finally, we observed that AG and control N neurosphere cells from chimeric brains displayed similar self-renewal capacities and neural multilineage differentiation potentials. Therefore, both in vitro and in vivo at early fetal stages, AG ESC derivatives cells appear to be fully potent. This finding contrasts with studies that demonstrate limited and biased neural in vivo differentiation potential of AG ICM cells in developmental chimeras [18].

As shown for biparental ESCs, AG ESCs gave rise to pnPCs and neural and glial cells when subjected to appropriate culture conditions [22, 23, 32]. The analysis of methylation patterns of the imprinting control regions of Snrpn and Igf2r genes indicated that epigenetic marks did not change during neural in vitro differentiation. Gene expression analysis of a selected set of imprinted genes expressed in brain tissue [33] showed that AG pnPCs maintain parent-of-origin-specific gene expression for the majority of genes analyzed, with the exception of the maternally expressed Ube3a gene, which is substantially upregulated in AG-derived pnPCs. It is unclear whether expression of Ube3a in neural derivatives of AG ESCs is a consequence of changes in the imprinting control mechanisms for this gene during the in vitro differentiation process of AG ESCs or whether neural commitment is undergone by a subpopulation of AG ESCs with lack of silencing of this gene. Ube3a exhibits maternal-specific expression in some neural lineages [34] but is expressed biallelically in glia cells; differential imprinting is established during neurogenesis [35]. It remains to be determined to what extent these imprints are established in in vitro derivatives of AG ESCs.

The brain seeding capacity of AG ICM cells in E10–E12 embryos was previously described [17]. However, as whole brain extracts were analyzed for donor glucose-6-phosphate isomerase-1 isoform (Gpi1) contribution, this did not include analysis of regional distribution. In a second study, AG cells arising either from aggregation of AG and N morulae or from injection of AG ICM cells into N blastocysts were found to substantially contribute to the developing E13 and E17 hypothalamus but not to the cortex, and AG cell contribution was associated with smaller brain size [18]. The limited contribution of AG ICM cells to brain establishes an expectation that AG cells would show restricted neural differentiation potential compared with N cells. Despite the apparent phenotype and lethality in AG chimeras, our analyses of AG contribution to brain development at E12.5 show a widespread and balanced distribution of AG ESC-derived cells to forebrain regions, including striatum, hypothalamus, and cortex.

In addition, analyses of AG-derived compared with N-derived brain cells revealed no differences in NIC and neural differentiation frequencies. Although the ability of ICM-derived AG cells in fetal chimeras to form neurospheres is unknown, our findings indicate that AG ESCs and ICM cells differ in their developmental potential in vivo. One reason for this apparent discrepancy may be that during the establishment of ESCs from ICM cells, regulators of differentiation are modified or the epigenome undergoes changes [3638].

We observed differences in the neuronal lineage differentiation frequencies between ESC-derived and in vitro-expanded fetal brain-derived cells. This difference in neuronal differentiation capacity is probably caused by the in vitro expansion of neurosphere cells over four to six passages. It was previously reported that ESC-derived neural progenitor cells maintain their neuronal potential during in vitro expansion, whereas E12.5 fetal brain-derived neural progenitor/stem cells do not [39]. In mixed whole brain cell cultures of AG and N chimeric embryos, we detected, on average, a minor growth disadvantage for both AG and N neurosphere cells in comparison with the blastocyst-derived cells. As both AG and N cells exhibit this feature, it is likely that this is caused by the different mouse strain backgrounds of ESCs and blastocysts or is due to eGFP transgene expression [40].

Uniparental cells of AG ESC origin, like N ESCs, can generate adult-transplantable hematopoietic stem cells that can repopulate the hematopoietic system of adult transplant recipients [14]. Likewise, in vitro differentiation of AG ESCs leads to neuronal and glial cell frequencies similar to those of N ESCs [21]. Furthermore, proliferation and differentiation properties of fetal brain-derived AG and N neurosphere cells did not differ. This indicates that, outside the normal developmental paradigm, the differentiation potential of uniparental ESCs may be much less restricted than that of uniparental cells in chimeras.

What are potential strategies for the generation of patient-specific stem cells, and what are the advantages of uniparental ESCs? Pluripotent cells have been isolated from several tissues, such as bone marrow (multipotent adult progenitor cells [MAPCs] [41]) and adult testes (spermatogonial stem cells [42, 43]). Although MAPCs were reported from human sources, human spermatogonial stem cells have so far not been described. Both cell types are pluripotent in vitro and in vivo; however, such cells are rare, and their full potential is unknown. A promising approach for producing autologous pluripotent cells is the reprogramming of somatic cells to ESC-like cells by the expression of defined factors in vitro (induced pluripotent stem [iPS] cells), which has been demonstrated in mouse [44] and also in human [45, 46]. Although iPS cell derivatives have been successfully used for hematopoietic tissue replacement in the mouse [47], the developmental and therapeutic potential of human iPS cells is uncertain, in particular as some human iPS cell lines exhibit limitations in their neural differentiation potential [46].

Uniparental ESCs may represent alternative sources for patient-specific pluripotent stem cells and are derived from gametic rather than somatic genomes. Both in mouse and in human, PG ESC lines with the full MHC complement of the oocyte donor have been derived [8, 12]. Generated without using fertilized eggs and without destroying fertilized human embryos, human PG ESCs have thus far shown a differentiation capability similar to that of stem cells derived from human embryos and are considered pluripotent. Although the generation of uniparental ESCs may circumvent the destruction of viable embryos, it still requires the manipulation and destruction of donated oocytes. Although the number of imprinted genes is small, many of them are expressed in the brain, affecting neurodevelopment, and thereby influence brain function and behavior [33]. Derivation of human AG ESCs remains to be demonstrated; however, the formation of hydatidiform moles provides some evidence for the early developmental potential of human AG conceptuses [48, 49].


    SUMMARY
 Top
 Footnotes
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Summary
 Disclosure of Potential...
 Acknowledgments
 References
 
We observed that AG ESCs exhibit in vitro and early in vivo neural developmental potential similar to that of N ESCs. AG cells contribute to developing brains in early fetal stages and show a widespread and balanced distribution in chimeric brains. AG brain cells form neurospheres with self-renewal and neural differentiation capacity similar to that of N ESCs.


    DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST
 Top
 Footnotes
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Summary
 Disclosure of Potential...
 Acknowledgments
 References
 
The authors indicate no potential conflicts of interest.


    ACKNOWLEDGMENTS
 Top
 Footnotes
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Summary
 Disclosure of Potential...
 Acknowledgments
 References
 
We thank Frank Edenhofer and Oliver Brüstle for introduction into neural differentiation of ESCs. We thank N. Adrian Leu for ESC injection. This work was supported by the Deutsche Forschungsgemeinschaft Research Training Group (GRK1048 "Molecular basis of organ development in vertebrates"; to T.C.D., S.W.C., and A.M.M.), by NIH Grants 1 R03-HD045291-01, and by the Stem Cell Research Foundation (to K.J.M.).


    FOOTNOTES
 
Author contributions: T.C.D.: conception and design, collection and assembly of data, data analysis and interpretation, manuscript writing; S.E.: conception and design, provision of study material, collection and assembly of data, data analysis and interpretation, manuscript writing; S.W.C.: collection and assembly of data, data analysis and interpretation; G.C.: data analysis and interpretation; S.K. and V.H.: collection and assembly of data; K.J.M.: conception and design, provision of study material, data analysis and interpretation, manuscript writing; A.M.M.: conception and design, data analysis and interpretation, manuscript writing, final approval of manuscript.


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 Footnotes
 Abstract
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 Materials and Methods
 Results
 Discussion
 Summary
 Disclosure of Potential...
 Acknowledgments
 References
 

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