Review: Limb regeneration in humans: Dream or reality?

Appendage regeneration occurs by a sequence of events resembling those that take place during development in the embryo. This requires embryonic conditions such as hydration and hyaluronate content where Wnt and other signaling pathways, together with non- coding RNAs, can be re-expressed. These conditions among vertebrates are fully met only in amputated limbs of amphibians, likely because they are neotenic and maintain larval characteristics, including immaturity of their immune system and permanence of numerous stem cells. Although some key genes orchestrating limb regeneration are also present in amniotes, including humans, these genes are not expressed after injury. In amniotes a key problem for regeneration derives from the efficient immune system, largely deficient in anamniotes. As a consequence, wounds and appendage loss tend to scar instead of regenerating. Efforts of regenerative medicine in the attempt to induce the regrowth of limbs in humans must produce outgrowths with high hydration and hyaluronate content in order to create the immune-suppressed conditions similar to those present during development. The induced blastema must be manipulated for long periods of time in order to maintain the same regions present during limb development, an apical epidermal ridge and a polarizing region that forms gradients of expression of Wnt, Shh, FGF, BMP and Hox-genes. Pharmacological treatments to direct the regenerating limb into normal growth without risk of inducing abnormal or tumorigenic growth must be monitored during the course of the regeneration process - a medical treatment lasting years to fully regain the size of the lost appendage.