Today, we chronicle the progress of OSKM and discuss how this powerful treatment may be able to reprogram cells back into a youthful state, at least partially reversing the hallmark of epigenetic alterations and other hallmarks as well.
The birth of cellular reprogramming
In 2006, a study by Drs. Takahashi and Yamanaka showed that it was possible to reprogram cells using just four master genes named oct4, sox2, klf4, and c-myc, or OSKM for short . Prior to this, it was assumed that egg cells (oocytes) would contain a complex array of factors needed to reprogram a somatic cell into becoming an embryonic cell. After all, the feat of transforming an aged egg cell and reprogramming it to make a new animal must be controlled by many factors present in the egg cell, or so they thought.
Takahashi and Yamanaka turned this idea upside down when they showed that just four factors were needed to achieve this transformation using OSKM to reprogram adult mouse fibroblasts (connective tissue cells) back to an embryonic state called pluripotency, a state where the cell behaves like an embryonic stem cell and can become any other cell type in the body.
This discovery paved the way for research into how these programming factors might be used for cellular rejuvenation and a potential way to combat age-related diseases.
Cellular and animal rejuvenation
In 2011, a team of French researchers, including Jean-Marc Lemaitre, first reported cellular rejuvenation using OSKM . During their life, cells express different patterns of genes, and those patterns are unique to each phase in a cell’s life from young to old; this gene expression profile makes it easy to identify an old or young cell. At the time, it was also known that aged cells such as fibroblasts have short telomeres and dysfunctional mitochondria, two of the nine proposed hallmarks of aging .
Jean-Marc Lemaitre and his colleagues tested the effects of OSKM on aged fibroblasts from normal old people and also from healthy people over 100 years old. They added two additional pluripotency genetic factors to the OSKM mix, namely NANOG and LIN28, and examined the effect that this had on the gene expression, telomeres, and mitochondria of these older people.
They discovered that together, the six factors were able to rapidly reprogram these cells from old donors back into a pluripotent state; these were to be known as induced pluripotent stem cells (iPSCs). The researchers noted that the cells had a higher growth rate than the aged cells they had been reprogrammed from; they also had longer telomeres as well as mitochondria that behaved in a youthful manner and were no longer dysfunctional.
The final step for the researchers was to then guide the iPSCs to become fibroblasts again using other reprogramming factors. These fibroblasts no longer expressed the gene patterns typically associated with aged cells of this kind but instead had a gene expression profile indistinguishable from those of young fibroblasts. In addition to this, they also showed that telomere length, mitochondrial function, and oxidative stress levels had all reset to those typically observed in young fibroblasts.
This was the first evidence that aged cells, even from very old individuals, could be rejuvenated, and this was followed by a flood of independent studies confirming these findings in the same and other types of cells.
Could this be done in living animals?
While it had been demonstrated that aged cells could be rejuvenated in a petri dish in the lab, many researchers considered translating this to living animals to be impossible, as the continuous expression of OSKM was known to induce cancer in animals . This was to change in December 2016.
Professor Juan Carlos Izpisua Belmonte and his team of researchers at the Salk Institute reported the conclusion of their study, which showed for the first time that the cells and organs of a living animal could be rejuvenated . The researchers made this short video to explain this huge breakthrough in aging research.
For the study, the researchers used a specially engineered progeric mouse designed to age more rapidly than normal as well as an engineered normally aging mouse strain. Both types of mice were engineered to express OSKM when they came into contact with the antibiotic doxycycline, which was given to them via their drinking water. They allowed the OSKM genes to be expressed by including doxycycline in the water for two days then removed it so that the OSKM genes were silenced again. The mice then had a five-day rest period before another two days of exposure to doxycycline; this cycle was repeated for the duration of the study.
After just six weeks of this treatment, which steadily reprogrammed the cells of the mice, the researchers noticed improvements in their appearance, including reduced age-related spinal curvature. Some of the mice from both experiment and control groups were also euthanized at this point so that their skin, kidneys, stomachs, and spleens could be examined. The control mice showed a range of age-related changes compared to the treated mice, which had a number of aging signs halted or even reversed, including some epigenetic alterations. The treated mice also experienced a 50% increase in their mean survival time in comparison to untreated progeric control mice. It should be noted that not all aging signs were affected by partial reprogramming, and if treatment was halted, the aging signs returned.
Perhaps most importantly, while the partial reprogramming conducted in this periodic manner reset some epigenetic aging signs, it did not reset cell differentiation, which would cause the cell to revert to an embryonic state and forget what kind of cell it previously was; as you can imagine, this would be a bad thing in a living animal.
Finally, not only did OSKM expression at least partially rejuvenate cells and organs in progeric mice, but it also appeared to improve tissue regeneration in the engineered 12-month-old normally aging mouse group. The researchers observed that the partial reprogramming improved these mice’s ability to regenerate tissue in the pancreas, resulting in an increased proliferation of beta cells; additionally, there was an increase of satellite cells in skeletal muscle. Both types of cells typically decline during aging.
The future potential and challenges ahead
By far, the biggest hurdle to translating partial cellular reprogramming to people is the need to find a way to activate the OSKM factors in our cells without needing to engineer our bodies to react to a drug such as doxycycline. Doing this may require us to develop drugs capable of activating OSKM, editing every cell in our body to respond to a particular compound like doxycycline, which would be extremely challenging though plausible, or even editing the germline so that our children are born with such a modification to respond to a chosen compound, an idea that is an ethical nightmare to even consider not to mention the technical challenges of doing so successfully. Whatever the solution is, it needs to be practical.
The other major hurdle is to find a method suitable for the long term that does not require constant upkeep, lest the aging signs return rapidly, as they did in mice when treatment was interrupted. While there is some reason to believe that these signs would not return as rapidly in people given the differences between mouse and human metabolisms and our superior repair systems, it would likely return in due course. So, finding a cost-effective way to keep the cyclic treatment going is paramount; this could potentially be achieved using drugs or transient gene therapy.
Assuming that these barriers can be overcome, and the rapid advances in biotechnology offer a reason to think that they will, then partial cellular reprogramming could feasibly hold a great deal of potential for preventing or even curing the diseases of aging.
One might envision the early, first-pass use of this approach in a preventative way: older people at risk of age-related diseases could be given partial reprogramming in order to halt or at the least significantly slow down this aspect of aging and thus reduce their risk of developing age-related diseases.
More refined stages may see it being used in a more focused manner to repair a certain organ or tissue damaged by injury or disease. In another, more advanced, scenario, the gradual whole-body rejuvenation of older people might be attempted in order to totally prevent age-related diseases and keep them healthy, active and able to continue enjoying life.
The rapid progress of medical technology could potentially mean that such cellular reprogramming therapies may become available in the not too distant future. We certainly hope so.
 Takahashi, K., & Yamanaka, S. (2006). Induction of pluripotent stem cells from mouse embryonic and adult fibroblast cultures by defined factors. cell, 126(4), 663-676.
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 López-Otín, C., Blasco, M. A., Partridge, L., Serrano, M., & Kroemer, G. (2013). The hallmarks of aging. Cell, 153(6), 1194-1217.
 Abad, M., Mosteiro, L., Pantoja, C., Canamero, M., Rayon, T., Ors, I., … & Manzanares, M. (2013). Reprogramming in vivo produces teratomas and iPS cells with totipotency features. Nature, 502(7471), 340.
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