Assessing clinical implications and perspectives of the pathophysiological effects of erythrocytes and plasma free hemoglobin in autologous biologics for use in musculoskeletal regenerative medicine therapies. A review

Peter A Everts, Gerard A Malanga, Rowan V Paul, Joshua B Rothenberg, Natalie Stephens, Kenneth R Mautner, Peter A Everts, Gerard A Malanga, Rowan V Paul, Joshua B Rothenberg, Natalie Stephens, Kenneth R Mautner

Abstract

Autologous biologics, defined as platelet-rich plasma (PRP) and bone marrow aspirate concentrate (BMC), are cell-based therapy treatment options in regenerative medicine practices, and have been increasingly used in orthopedics, sports medicine, and spinal disorders. These biological products are produced at point-of-care; thereby, avoiding expensive and cumbersome culturing and expansion techniques. Numerous commercial PRP and BMC systems are available but reports and knowledge of bio-cellular formulations produced by these systems are limited. This limited information hinders evaluating clinical and research outcomes and thus making conclusions about their biological effectiveness. Some of their important cellular and protein properties have not been characterized, which is critical for understanding the mechanisms of actions involved in tissue regenerative processes. The presence and role of red blood cells (RBCs) in any biologic has not been addressed extensively. Furthermore, some of the pathophysiological effects and phenomena related to RBCs have not been studied. A lack of a complete understanding of all of the biological components and their functional consequences hampers the development of clinical standards for any biological preparation. This paper aims to review the clinical implications and pathophysiological effects of RBCs in PRP and BMC; emphasizes hemolysis, eryptosis, and the release of macrophage inhibitory factor; and explains several effects on the microenvironment, such as inflammation, oxidative stress, vasoconstriction, and impaired cell metabolism.

Keywords: BM-MSCs, bone marrow-mesenchymal cells; BMA, bone marrow aspiration; BMC, bone marrow concentrate; Bone marrow mesenchymal cells; Eryptosis; HSCs, hematopoietic stem cells; Hb, hemoglobin; Hp, haptoglobin; Hx, hemopexin; Inflammation; MIF, Macrophage migration inhibitory factor; MNCs, mononucleated cells; Macrophage migration inhibitor factor; NO, nitric oxide; OA, osteoarthritis; Oxidative stress; PAF, platelet activating factor; PFH, plasma free hemoglobin; PRP, platelet-rich plasma; PS, phosphatidylserine; Plasma free hemoglobin; Platelet-rich plasma; RBC, red blood cell; ROS, reactive oxygen species.

Figures

Fig. 1
Fig. 1
Cellular whole blood density separation following the first centrifugation procedure with the EmCyte PurePRP®SP. The whole blood cellular components (indicated by the red lines) are separated in the PurePRP®SP concentrating device as a result of the different cell densities in two basic layers . The top layer is the platelet plasma suspension, consisting of plasma and the multicomponent buffy coat layer, containing platelets, monocytes, lymphocytes, and neutrophils. The second basic layer consists of the erythrocyte cellular pack. The range of the specific cell densities varies between individuals. After a second centrifugation procedure approximately 7 mL of PurePRP is aspirated from the bottom chamber to be used for regenerative therapies. (PurePRP®SP: Pure Platelet-Rich Plasma Supra-Physiologic).
Fig. 2
Fig. 2
Bone marrow concentrate density separation following EmCyte Aspire ™ BMA harvesting and PureBMC® second spin centrifugation. Anticoagulated aspirated bone marrow was initially injected in the concentration device for the first spin cycle. After the second centrifugation procedure the separation of bone marrow components, according to their different density gradients, follows in the concentrating accessory device. The HSC’s and MSC’s are located on top of the erythrocyte and white blood cell layer and are extracted via the aspirating pipe. (BMA: bone marrow aspirate; PureBMC®: Pure Bone Marrow Concentrate; HSC: hematopoietic stem cell; MSC: mesenchymal stem cell).
Fig. 3
Fig. 3
Schematic summary illustration showing the pathophysiological effects and reactions of RBC hemolysis and eryptosis. The pathophysiological consequences of RBC hemolysis and PFH development in a biological treatment vial. Under normal circumstances PFH and its split products oxyHb (Fe2+), ferric Hb (Fe3+), and free hemin are released into plasma where they are cleared by natural occurring scavengers and compensatory mechanisms like Hp, Hx, and NO vascular reactions. However, in their absence and due to excessive PFH, a build-up of ferric and heme products continues, potentially leading to toxic consequences like direct pro-inflammation and pro-oxidant effects, endothelial cell dysfunction, and vasoconstriction. A biologic formulation which contains a high concentration of RBCs, combined with oxidative and hemolytic components, applied to tissue microenvironments, will lead to RBC cell membrane asymmetry and membrane disruption. This will lead to eryptosis, while displaying PS, leading to inflammation, and endothelial cell reactions with decreased microcirculatory activity. Another consequence of RBC disintegration and PFH is an abundant release of MIF cytokines, playing a profound role in pro-inflammatory processes (Adapted in part and modified from Schaer et al. [23]).

References

    1. Yelin E., Weinstein S., King T. The burden of musculoskeletal diseases in the United States. Semin Arthritis Rheum. 2016
    1. Andia I., Rubio-Azpeitia E., Maffulli N. Platelet-rich Plasma modulates the secretion of inflammatory/angiogenic proteins by inflamed tenocytes. Clin Orthop Relat Res. 2015;473:1624–1634.
    1. Sugaya K. Potential use of stem cells in neuroreplacement therapies for neurodegenerative diseases. Int Rev Cytol. 2003;228:1–30.
    1. Malanga G.A. Regenerative treatment for orthopedic conditions. PM R. 2015
    1. Sanchez M., Garate A., Delgado D., Padilla S. Platelet-rich plasma, an adjuvant biological therapy to assist peripheral nerve repair. Neural Regen Res. 2017;12:47–52.
    1. Senzel L., Gnatenko D., Bahou W. The platelet proteome. Curr Opin Hematol. 2009;16:329–333.
    1. Everts P.A., Knape J.T., Weibrich G., Schönberger J.P., Hoffmann J.J., Overdevest E.P. Platelet rich plasma and platelet gel: a review. J Extra Corpor Technol. 2006;38:174–187.
    1. Kovtun A., Bergdolt S., Wiegner R., Radermacher P., Huber-Lang M., Ignatius A. The crucial role of neutrophil granulocytes in bone fracture healing. Eur Cell Mater. 2016;32:152–162.
    1. Fitzpatrick J., Bulsara M., Zheng M. The effectiveness of platelet-rich plasma in the treatment of tendinopathy. a meta-analysis of randomized controlled clinical trials. Am J Sports Med. 2016
    1. Jorgensen C., Noel D. Mesenchymal stem cells in osteoarticular diseases. Regen Med. 2011;6:44–51.
    1. Oh M., Nor J. The perivascular niche and self-renewal of stem cells. Front Physiol. 2015
    1. Pittenger M.F., Mackay A.M., Beck S.C., Jaiswal R.K., Douglas R., Mosca J.D. Multilineage potential of adult human mesenchymal stem cells. Science. 1999;284:143–147.
    1. Otero-Vinas M., Falanga V. Mesenchymal stem cells in chronic wounds: the spectrum from basic to advanced therapy. Adv Wound Care (New Rochelle) 2016;5:149–163.
    1. Mithoefer K., McAdams T., Williams R.J., Kreuz P.C., Mandelbaum B.R. Clinical efficacy of the microfracture technique for articular cartilage repair in the knee: an evidence-based systematic analysis. Am J Sports Med. 2009;37:2053–2063.
    1. da Silva Meirelles L., Fontes A., Covas D., Caplan A. Mechanisms involved in the therapeutic properties of mesenchymal stem cells. Cytokine Growth Factor Rev. 2009;20:419–427.
    1. Bashir J., Sherman A., Lee H., Kaplan L., Hare J.M. Mesenchymal stem cell therapies in the treatment of musculoskeletal diseases. PMR. 2014;6:61–69.
    1. Das A., Sinha M., Datta S., Abas M., Chaffee S., Sen C.K. Monocyte and macrophage plasticity in tissue repair and regeneration. Am J Pathol. 2015;185:2596–2606.
    1. Orozco L., Munar A., Soler R., Alberca M., Soler F., Huguet M. Treatment of knee osteoarthritis with autologous mesenchymal stem cells: Two-year follow-up results. Transplantation. 2014;97:e66–e68.
    1. Hernigou P., Flouzat Lachaniette C., Delambre J., Duffiet P., Chevallier N. Biologic augmentation of rotator cuff repair with mesenchymal stem cells during arthroscopy improves healing and prevents further tears: a case-controlled study. Int Orthop. 2014;38:1811–1818.
    1. Mautner K., Malanga G.A., Smith J., Shiple B., Ibrahim V., Sampson S. A call for a standard classification system for future biologic research: the rationale for new PRP nomenclature. PM R. 2015
    1. Murray I., Robinson P., West Ch, Goudie E.B., Yong L.Y., White T.O. Reporting standards in clinical studies evaluating bone marrow aspirate concentrate: a systematic review. Arthroscopy. 2018;34:1366–1375.
    1. Magalon J., Chateau A., Bertrand B., Louis M.L., Silvestre A., Giraudo L. DEPA classification: a proposal for standardizing PRP use and a retrospective application of available devices. BMJ Open Sport Exerc Med. 2016;2:1–6.
    1. Schaer D., Buehler P., Alayash A., Belcher J.D., Vercellotti G.M. Hemolysis and free hemoglobin revisited: exploring hemoglobin and hemin scavengers as a novel class of therapeutic proteins. Blood. 2013;121:1276–1284.
    1. Klatt Ch, Krüger I., Zey S., Krott K.J., Spelleken M., Gowert N.S. Platelet-RBC interaction mediated by FasL/FasR induces procoagulant activity important for thrombosis. J Clin Invest. 2018;128:3906–3925.
    1. Karsten E., Hill C., Herbert B. Red blood cells: The primary reservoir of macrophage migration inhibitory factor in whole blood. Cytokine. 2018;102:34–40.
    1. Mazzucco L., Balbo V., Cattana E., Borzini P. Not every PRP-gel is born equal. Evaluation of growth factor availability for tissues through four PRP-gel preparations: Fibrinet, RegenPRP-Kit, Plateltex and one manual procedure. Vox Sang. 2009;97:110–118.
    1. Everts P., Hoffmann J., Weibrich G., Mahoney C.B., Schönberger J.P., van Zundert A. Differences in platelet growth factor release and leucocyte kinetics during autologous platelet gel formation. Transfus Med. 2006;16:363–368.
    1. Degen R., Bernard J., Oliver K., Dines J. Commercial separation systems designed for preparation of platelet-rich plasma yield differences in cellular composition. HSS J. 2017;13:75–80.
    1. Giusti I., Rughetti A., D’Ascenzo S. Identification of an optimal concentration of platelet gel for promoting angiogenesis in human endothelial cells. Transfusion. 2009;49:771–778.
    1. Cavallo C., Filardo G., Mariani E., Kon E., Marcacci M., Pereira Ruiz M.T. Comparison of platelet rich plasma formulations for cartilage healing: an in vitro study. J Bone Joint Surg Am. 2014;96:423–429.
    1. Dragoo J.L., Braun H.J., Durham J.L., Ridley B.A., Odegaard J.I., Luong R. Comparison of the acute inflammatory response of two commercial platelet-rich plasma systems in healthy rabbit tendons. Am J Sports Med. 2012;40:1274–1281.
    1. DeLong J., Russell R., Mazzocca A. Platelet-rich plasma: The PAW classification system. Arthroscopy. 2012;28:998–1009.
    1. Dohan Ehrenfest D., Andia I., Zumstein M., Zhang C.Q., Pinto N.R., Bielecki T. Classification of platelet concentrates (Platelet-Rich Plasma-PRP, Platelet-Rich Fibrin-PRF) for topical and infiltrative use in orthopedic and sports medicine: current consensus, clinical implications and perspectives. Muscles Ligaments Tendons J. 2014;4:3–9.
    1. Muschler G., Nitto H., Boehm C., Easley K. Age- and gender-related changes in the cellularity of human bone marrow and the prevalence of osteoblastic progenitors. J Orthop Res. 2001;19:117–125.
    1. Pontikoglou C., Deschaseaux F., Sensebé L., Papadaki H.A. Bone marrow mesenchymal stem cells: biological properties and their role in hematopoiesis and hematopoietic stem cell transplantation. Stem Cell Rev. 2011;7:569–589.
    1. Chamberlain G., Fox J., Ashton B., Middleton J. Concise review: mesenchymal stem cells: their phenotype, differentiation capacity, immunological features, and potential for homing. J. Stem Cell. 2007;2739:2739–2749.
    1. Moatsche G., Morris E., Cinque M., Pascual-Garrido C., Chahla J., Engebretsen L. Biological treatment of the knee with platelet-rich plasma or bone marrow aspirate concentrates A review of the current status. Acta Orthop. 2017;88:670–674.
    1. Pittenger M.F., Mackay A.M., Beck S.C., Jaiswal R.K., Douglas R., Mosca J.D. Multilineage potential of adult human mesenchymal stem cells. Science. 1999;284:143–147.
    1. Fong L., Chan C., Goodman S. Stem cell homing in musculoskeletal injury. Biomaterials. 2011;32:395–409.
    1. Imam M., Holton J., Ernstbrunner E., Pepke W., Grubhofer F., Narvani A. A systematic review of the clinical applications and complications of bone marrow aspirate concentrate in management of bone defects and nonunions. SICOT J. 2017
    1. Braun H.J., Kim H.J., Chu C.R., Dragoo J.L. The effect of platelet rich plasma formulations and blood products on human synoviocytes: Implications for intra-articular injury and therapy. Am J Sports Med. 2014;42:1204–1210.
    1. Hooiveld M., Roosendal G., Wenting M., van den Berg M., Bijlsma J., Lafeber F. Short term exposure of cartilage to blood results in apoptosis. Am J Pathol. 2003;162:943–951.
    1. Tajima T., Sekimoto T., Yamaguchi N., Taniguchi N., Kurogi S., Maruyama M. Hemoglobin stimulates the expression of ADAMTS-5 and ADAMTS-9 by synovial cells: a possible cause of articular cartilage damage after intra-articular hemorrhage. BMC Muskuloskelet Disord. 2017;18:449–455.
    1. Dawson J., Smith J., Aarvold A., Ridgway J.N., Curran S.J., Dunlop D.G. Enhancing the osteogenic efficacy of human bone marrow aspirate: concentrating osteoprogenitors using wave-assisted filtration. Cytotherapy. 2013;15:242–252.
    1. Chahla J., Cinque M., Piuzzi N., Mannava S., Geeslin A.G., Murray I.R. A call for standardization in platelet-rich plasma preparation protocols and composition reporting. A systematic review of the clinical orthopaedic literature. J Bone Joint Surg Am. 2017;99:1769–1779.
    1. Finch C. Erythropoiesis, erythropoietin, and iron. Blood. 1982;60:1241–1246.
    1. Mohandas N., Gallagher P.G. Red cell membrane: past, present, and future. Blood. 2008;112:3939–3948.
    1. Park Y., Best C., Badizadegan K. Measurement of red blood cell mechanics during morphological changes. Proc Natl Acad Sci. 2010;107:6731–6736.
    1. Lang K., Lang P., Bauer C., Duranton C., Wieder T., Huber S.M. Mechanisms of suicidal erythrocyte death. Cell Physiol Biochem. 2005;15:195–202.
    1. Ghashghaeinia M., Cluitmans J., Akel A., Dreischer P., Toulany M., Köberle M. The impact of erythrocyte age on eryptosis. British J Haemat. 2012;157:606–614.
    1. Frei A., Guo Y., Jones D., Pritchard K.A., Jr., Fagan K.A., Hogg N. Vascular dysfunction in a murine model of severe hemolysis. Blood. 2008;112:398–405.
    1. Gozzelino R., Jeney V., Soares M. Mechanisms of cell protection by heme oxygenase-1. Annu Rev Pharmacol Toxicol. 2010;50:323–354.
    1. Jones S. A relationship between Reynolds stresses and viscous dissipation: implications to red cell damage. Ann Biomed Eng. 1995;23:21–38.
    1. Meyer C., Heiss C., Drexhage C., Kehmeier E.S., Balzer J., Mühlfeld A. Hemodialysis-induced release of hemoglobin limits nitric oxide bioavailability and impairs vascular function. J Am Coll Cardiol. 2010;55:454–459.
    1. Figueiredo R., Fernandez P., Mourao-Sa D., Porto B.N., Dutra F.F., Alves L.S. Characterization of heme as activator of toll-like receptor 4. J Biol Chem. 2007;282:20221–20229.
    1. Kumar S., Bandyopadhyay U. Free heme toxicity and its detoxification systems in human. Toxicol Lett. 2005;157:175–188.
    1. Vinchi F., Tolosano E. Therapeutic approaches to limit hemolysis-driven endothelial dysfunction: scavenging free heme to preserve vasculature homeostasis. Oxid Med Cell Long. 2013 doi: 10.1155/2013/396527.
    1. Jeney V., Balla J., Yachie A., Varga Z., Vercellotti G.M., Eaton J.W. Pro-oxidant and cytotoxic effects of circulating heme. Blood. 2002;100:879–887.
    1. Nagy E., Eaton J.W., Jeney V., Soares M.P., Varga Z., Galajda Z. Red cells, hemoglobin, heme, iron, and atherogenesis. Arterioscler Thromb Vasc Biol. 2010;30:1347–1353.
    1. Smith A., McCulloh R. Hemopexin and haptoglobin: allies against heme toxicity from hemoglobin not contenders. Front Physiol. 2015 doi: 10.3389/fphys.2015.00187.
    1. Seixas E., Gozzelino R., Chora A., Ferreira A., Silva G., Larsen R. Heme oxygenase-1 affords protection against noncerebral forms of severemalaria. Proc Natl Acad Sci USA. 2009;106:15837–15842.
    1. Ogawa K., Sun J., Taketani S., Nakajima O., Nishitani C., Sassa S. Heme mediates derepression of Maf recognition element through direct binding to transcription repressor Bach1. EMBO J. 2001;20:283543.
    1. Alayash A. Oxygen therapeutics: can we tame haemoglobin? Nat Rev Drug Discov. 2004;3:152–159.
    1. Rother R., Bell L., Hillmen P., Gladwin M. The clinical sequelae of intravascular hemolysis and extracellular plasma hemoglobin. JAMA. 2005;293:1653–1662.
    1. Repsold L., Joubert A. Eryptosis: An erythrocyte’s suicidal type of cell death. BioMed Res Int. 2018 doi: 10.1155/2018/9405617.
    1. Berg C., Engels I., Rothbart A., Lauber K., Renz A., Schlosser S.F. Human mature red blood cells express caspase-3 and caspase-8, but are devoid of mitochondrial regulators of apoptosis. Cell Death Differ. 2015;8:1197–1206.
    1. Esmon Ch. The interactions between inflammation and coagulation. Br. J Haematol. 2005;131:417–430.
    1. Betal S., Setty B. Phosphatidylserine-positive erythrocytes bind to immobilized and soluble thrombospondin-1 via its heparin binding domain. Trans Res. 2008;152:165–177.
    1. Baugh J., Bucala R. Macrophage migration inhibitory factor. Critical Care Med. 2002;30:S27–S35.
    1. Lehmann L., Weber S., Fuchs D., Klaschik S., Schewe J.C., Book M. Intracellular detection of macrophage migration inhibitory factor in peripheral blood leukocytes. Free Radic Biol Med. 2005;38:1170–1179.
    1. Jensen M., de Nully Brown D., Lund B., Nielsen O., Hasselbalch H. Increased circulating platelet-leukocyte aggregates in myeloproliferative disorders is correlated to previous thrombosis, platelet activation and platelet count. Eur J Haematol. 2001;66:143–151.
    1. Calandra T., Bernhagen J., Metz C.N., Spiegel L.A., Bacher M., Donelly T. MIF as a glucocorticoid-induced modulator of cytokine production. Nature. 1995;377:68–71.
    1. Pohl J., Rammos C., Totzeck M., Stock P., Kelm M., Rassaf T. MIF reflects tissue damage rather than inflammation in post-cardiac arrest syndrome in a real-life cohort. Resuscitation. 2016;100:32–37.
    1. Zhang P., Liu J., Xu L., Sun Y., Sun X. Synovial fluid macrophage migration inhibitory factor levels correlate with the severity of self-reported pain in knee osteoarthritis patients. Med Sci Monit. 2016;22:2182–2186.
    1. Liu M., Hu C. Association of MIF serum and synovial fluid with severity of knee osteoarthritis. Clin Biochem. 2012;45:737–739.
    1. Michiels C. Endothelial cell functions. J Cell Physiol. 2003;196:430–443.
    1. Maitz M. Applications of synthetic polymers in clinical medicine. Biosurf Biotribology. 2015;1:161–176.
    1. Nakagawa-Tosa N., Morimatsu M., Kawasaki M., Nakatsuji H., Syuto B., Saito M. Stimulation of haptoglobin synthesis by interleukin-6 and tumor necrosis factor, but not by interleukin-1, in bovine primary cultured hepatocytes. J Vet Med Sci. 1995;57:219–223.
    1. Harrison S., Vavken P., Murray M. Erythrocytes inhibit ligament fibroblast proliferation in a collagen scaffold. J Orthop Res. 2011;29:1361–1366.
    1. Xiong C., Huang B., Zhou Y., Cun Y.P., Liu L.T., Wang J. Macrophage migration inhibitory factor inhibits the migration of cartilage end plate-derived stem cells by reacting with CD74. PLoS One. 2012 doi: 10.1371/journal.pone.0043984.
    1. Alves R., Grimalt R. A review of platelet-rich plasma: history, biology, mechanisms of action, and classification. Skin Appendage Disord. 2018;4:18–24.
    1. Grisendi G., Anneren C., Cafarelli L., Sternieri R., Veronesi E., Cervo G.L. GMP-manufactured density gradient media for optimized mesenchymal stromal/stem cell isolation and expansion. Cytotherapy. 2010;12:466–477.

Source: PubMed

Patrocinadores y Colaboradores

Condiciones médicas

Intervenciones de drogas

3
Suscribir