Purified CD34+ cells versus peripheral blood mononuclear cells in the treatment of angiitis-induced no-option critical limb ischaemia: 12-Month results of a prospective randomised single-blinded non-inferiority trial

Zhihui Dong, Tianyue Pan, Yuan Fang, Zheng Wei, Shiyang Gu, Gang Fang, Yifan Liu, Yang Luo, Hao Liu, Tiejun Zhang, Meiyu Hu, Daqiao Guo, Xin Xu, Bin Chen, Junhao Jiang, Jue Yang, Zhenyu Shi, Ting Zhu, Yun Shi, Peng Liu, Weiguo Fu, Zhihui Dong, Tianyue Pan, Yuan Fang, Zheng Wei, Shiyang Gu, Gang Fang, Yifan Liu, Yang Luo, Hao Liu, Tiejun Zhang, Meiyu Hu, Daqiao Guo, Xin Xu, Bin Chen, Junhao Jiang, Jue Yang, Zhenyu Shi, Ting Zhu, Yun Shi, Peng Liu, Weiguo Fu

Abstract

Background: Peripheral blood mononuclear cells (PBMNCs) and purified CD34+ cells (PCCs) are increasingly being used at treating no-option critical limb ischaemia (NO-CLI). We aimed to compare the efficacies and uncover the advantages associated with each treatment approach.

Methods: A randomised single-blinded non-inferiority trial (Number: NCT 02089828) was performed. NO-CLI patients were 1:1 randomised to the PBMNCs and PCCs groups, and compared in relation to safety and efficacy outcomes. The primary efficacy outcomes included major amputation and total amputation over 12 months. The major amputation-free survival (MAFS) and total amputation-free survival (TAFS) rates were calculated.

Findings: Fifty patients (25 per group, 47 with thromboangiitis obliterans and 3 with other angiitis) were enrolled, with a median follow-up period of 24.5 months (interquartile range: 17-34 months). One patient in the PCCs group was lost at 2 months and one major amputation occurred in the PBMNCs group at 3 months post-transplantation. The total amputation rates at 6 months post-transplantation were 28.0% in the PCCs group and 16.0% in the PBMNCs group (p = 0.343), and remained unchanged at 12 months. The groups did not differ regarding the MAFS and TAFS (Breslow-Wilcoxon test: p = 0.3014 and p = 0.3414). The PCCs group had a significantly higher probability of rest pain relief than the PBMNCs group (Breslow-Wilcoxon test: p = 0.0454).

Interpretation: PCCs was not inferior to PBMNCs at limb salvage in the treatment of angiitis-induced NO-CLI and appeared to induce earlier ischaemia relief. Each cell type had specific advantages. These outcomes require verification from longer-term trials involving larger numbers of patients. FUND: Training program for outstanding academic leaders of Shanghai health and family planning system (Hundred Talent Program，Grant No. 2018BR40); China National Natural Science Funds (Grant No. 30801122); The excellent core member training programme at Zhongshan Hospital, Fudan University, China (Grant No. 2015ZSYXGG02); and Zhongshan Funds for the Institute of Vascular Surgery, Fudan University, China.

Clinical trial registration: This study is registered with ClinicalTrials.gov (NCT 02089828).

Trial registration: ClinicalTrials.gov NCT02089828.

Keywords: Cell therapy; Critical limb ischaemia; Limb salvage; Peripheral blood mononuclear cells; Purified CD34(+) cells.

Copyright © 2018 The Authors. Published by Elsevier B.V. All rights reserved.

Figures

Fig. 1
Fig. 1
Trial design. PCCs, purified CD34+ cells; PBMNCs, peripheral blood mononuclear cells.
Fig. 2
Fig. 2
Kaplan-Meier curves showing the probabilities of (A) major amputation-free survival and (B) total amputation-free survival in both groups. The P values were calculated using the Breslow-Wilcoxon test.PCCs, purified CD34+ cells, PBMNCs, peripheral blood mononuclear cells.
Fig. 3
Fig. 3
Longitudinal pictures of the treated limb of patient 3 in the PCCs group. The patient had gangrene on the second toe and an ulcer on the dorsum of his left foot before cell therapy (A). He underwent a foot debridement during the cell transplantation (B). The wound area reduced quickly in one month (C). The foot healed in the following two months (D, E) and sustained non-ischemic for 3 years (F).
Fig. 4
Fig. 4
Longitudinal changes in the (A) Wong-Baker FacesPain Rating Scale(WBFPS) and (B)probability of rest pain relief. (A) The longitudinal changes in the WBFPS in both groups are depicted as linear graphs that show the mean values and thestandard deviation bars. *represents p + cells; PBMNCs, peripheral blood mononuclear cells; WBFPS, Wong-Baker Faces Pain Rating Scale.
Fig. 5
Fig. 5
Longitudinal changes in blood perfusion restoration and functional improvement. The assessments of blood perfusion restoration included the (A) ankle-brachial index,(B) toe-brachial index, and (C) transcutaneous oxygen pressure, and the functional improvement was assessed using (D) the pain-free walking time. The values are presented in linear graphs that show the means and standard deviations. *represents p 2, transcutaneous oxygen pressure; PFWT, pain-free walking time,PCCs, purified CD34+ cells; PBMNCs, peripheral blood mononuclear cells.
Fig. 6
Fig. 6
Quality of life at baseline and at 1-year post-transplantation. The quality of life was assessed using the Short Form-36 scoring system (version 2) in the (A) purified CD34+ cellsgroup and (B) peripheral blood mononuclear cellsgroup. *representsp<0.05 (intra-group comparison with baseline, based on the Wilcoxon signed-rank test).PCCs, purified CD34+ cells; PBMNCs, peripheral blood mononuclear cells;QoL, quality of life; PF, physical functioning; RP, role-physical; BP, bodily pain; GH, general health; VT, vitality, SF, social functioning, RE, role-emotional, MH, mental health.
Fig. 7
Fig. 7
In vivo neovascularization potential of the transplants using a non-obese diabetic/severe combined immunodeficiency mouse limb ischaemia model.The longitudinal changes in blood perfusion restoration in the purified CD34+ cells, peripheral blood mononuclear cells, CD34− cells, and the control groupsare presented as (A) laser speckle contrast images and(B) linear graphs of the blood perfusion indexesin which the data are presented as the means and standard deviations. Microvascular density comparisons among groups are presented as (C) immunostaining for mouse-specific CD31 in the ischaemic gastrocnemius muscle on day 8 post-transplantation and (D) bar graphsshowing the mean and standard deviation values. *representsp<0.05 (inter-group comparison with the control group at specific time points, based on Dunnett's t-test). PCCs, purified CD34+ cells; PBMNCs, peripheral blood mononuclear cells.

References

    1. Dormandy J., Heeck L., Vig S. The fate of patients with critical leg ischemia. Semin Vasc Surg. 1999;12:142–147.
    1. Lawall H., Bramlage P., Amann B. Treatment of peripheral arterial disease using stem and progenitor cell therapy. J Vasc Surg. 2011;53:445–453.
    1. Norgren L., Hiatt W.R., Dormandy J.A. Inter-society consensus for the management of peripheral arterial disease (TASC II) J Vasc Surg. 2007;45(Suppl S):5–67.
    1. Powell R.J. Update on clinical trials evaluating the effect of biologic therapy in patients with critical limb ischemia. J Vasc Surg. 2012;56:264–266.
    1. Minamino T., Toko H., Tateno K., Nagai T., Komuro I. Peripheral-blood or bone-marrow mononuclear cells for therapeutic angiogenesis? Lancet. 2002;360:2083–2084.
    1. Dubsky M., Jirkovska A., Bem R. Both autologous bone marrow mononuclear cell and peripheral blood progenitor cell therapies similarly improve ischaemia in patients with diabetic foot in comparison with control treatment. Diabetes Metab Res Rev. 2013;29:369–376.
    1. Huang P.P., Yang X.F., Li S.Z., Wen J.C., Zhang Y., Han Z.C. Randomised comparison of G-CSF-mobilized peripheral blood mononuclear cells versus bone marrow-mononuclear cells for the treatment of patients with lower limb arteriosclerosis obliterans. Thromb Haemost. 2007;98:1335–1342.
    1. Kawamoto A., Katayama M., Handa N. Intramuscular transplantation of G-CSF-mobilized CD34(+) cells in patients with critical limb ischemia: a phase I/IIa, multicenter, single-blinded, dose-escalation clinical trial. Stem Cells. 2009;27:2857–2864.
    1. Losordo D.W., Kibbe M.R., Mendelsohn F. Autologous CD34+ Cell Therapy for critical limb ischemia investigators. A randomized, controlled pilot study of autologous CD34+ cell therapy for critical limb ischemia. Circ Cardiovasc Interv. 2012;5:821–830.
    1. Dong Z.H., Chen B., Fu W.G. Transplantation of purified CD34+ cells in the treatment of critical limb ischemia. J Vasc Surg. 2013;5:404–411.
    1. Sahoo S., Klychko E., Thorne T. Exosomes from human CD34(+) stem cells mediate their proangiogenic paracrine activity. Circ Res. 2011;109:724–728.
    1. Kawamoto A., Iwasaki H., Kusano K. CD34-positive cells exhibit increased potency and safety for therapeutic neovascularization after myocardial infarction compared with total mononuclear cells. Circulation. 2006;114:2163–2169.
    1. Kwon S.M., Lee J.H., Lee S.H. Cross talk with hematopoietic cells regulates the endothelial progenitor cell differentiation of CD34 positive cells. PLoS One. 2014;9
    1. Asahara T., Murohara T., Sullivan A. Isolation of putative progenitor endothelial cells for angiogenesis. Science. 1997;275:964–967.
    1. Fukuhara S., Bito S., Green J., Hsiao A., Kurokawa K. Translation, adaptation, and validation of the SF-36 Health Survey for use in Japan. J Clin Epidemiol. 1998;51:1037–1044.
    1. Fukuhara S., Ware J.E., Jr., Kosinski M., Wada S., Gandek B. Psychometric and clinical tests of validity of the Japanese SF-36 health survey. J Clin Epidemiol. 1998;51:1045–1053.
    1. Moriya J., Minamino T., Tateno K. Long-term outcome of therapeutic neovascularization using peripheral blood mononuclear cells for limb ischemia. Circ Cardiovasc Interv. 2009;2:245–254.
    1. De Angelis B., Gentile P., Orlandi F. Limb rescue: a new autologous-peripheral blood mononuclear cells technology in critical limb ischemia and chronic ulcers. Tissue Eng Part C Methods. 2015;21:423–435.
    1. Fujita Y., Kinoshita M., Furukawa Y. Phase II clinical trial of CD34+ cell therapy to explore endpoint selection and timing in patients with critical limb ischemia. Circ J. 2014;78:490–501.
    1. You D., Waeckel L., Ebrahimian T.G. Increase in vascular permeability and vasodilation are critical for proangiogenic effects of stem cell therapy. Circulation. 2006;114:328–338.
    1. Shintani S., Kusano K., Ii M. Synergistic effect of combined intramyocardial CD34+ cells and VEGF2 gene therapy after MI. Nat Clin Pract Cardiovasc Med. 2006;3(Suppl. 1):S123–S128.
    1. Mathiyalagan P., Liang Y., Kim D. Angiogenicmechanisms of human CD34(+) stem cell exosomes in the repair of ischemic hindlimb. Circ Res. 2017;120:1466–1476.
    1. Kumar A.H., Caplice N.M. Clinical potential of adult vascular progenitor cells. Arterioscler Thromb Vasc Biol. 2010;30:1080–1087.
    1. Li T.S., Kubo M., Ueda K. Identification of risk factors related to poor angiogenic potency of bone marrow cells from different patients. Circulation. 2009;120:S255–S261.
    1. Fadini G.P., Agostini C., Avogaro A. Autologous stem cell therapy for peripheral arterial disease Meta-analysis and systematic review of the literature. Atherosclerosis. 2010;209:10–17.
    1. Matoba S., Tatsumi T., Murohara T. Long-term clinical outcome after intramuscular implantation of bone marrow mononuclear cells (Therapeutic Angiogenesis by Cell Transplantation [TACT] trial) in patients with chronic limb ischemia. Am Heart J. 2008;156:1010–1018.
    1. Saito Y., Sasaki K., Katsuda Y. Effect of autologous bone marrow cell transplantation on ischemic ulcer in patients with Burger's disease. Circ J. 2007;71:1187–1192.
    1. Horie T., Onodera R., Akamastu M. Long-term clinical outcomes for patients with lower limb ischemia implanted with G-CSF-mobilized autologous peripheral blood mono- nuclear cells. Atherosclerosis. 2010;208:461–466.
    1. Walter D.H., Krankenberg H., Balzer J.O. Intraarterial administration of bone marrow mononuclear cells in patients with critical limb ischemia: a randomized-start, placebo-controlled pilot trial (PROVASA) Circ Cardiovasc Interv. 2011;4:26–37.
    1. Teraa M., Sprengers R.W., Schutgens R.E. Effect of repetitive intra-arterial infusion of bone marrow mononuclear cells in patients with no-option limb ischemia: the randomized, double-blind, placebo-controlled rejuvenating endothelial progenitor cells via transcutaneous intra-arterial supplementation (JUVENTAS) trial. Circulation. 2015;131:851–860.
    1. Fang Y., Wei Z., Chen Bin. A five-year study of the efficacy of purified CD34+ cell therapy for angiitis-induced no-option critical limb ischemia. Stem Cells Transl Med. 2018 Accepted on 23 March.
    1. Vijayakumar A., Tiwari R., Kumar P.V. Thromboangiitis obliterans (Buerger's disease) – current practices. Int J Inflam. 2013:1–9.
    1. Nielubowicz J., Rosnowski A., Pruszynski B., Przetakiewicz Z., Potemkowski A. Natural history of Buerger's disease. J Cardiovasc Surg (Torino) 1980;21:529–540.
    1. Adar R., Papa M.Z., Halpern Z. Cellular sensitivity to collagen in thromboangiitis obliterans. N Engl J Med. 1983;308:1113–1116.
    1. Hagen B., Lohse S. Clinical and radiologic aspects of Buerger's disease. Cardiovasc Intervent Radiol. 1984;7:283–293.
    1. Dehaine-Bamberger N., Amar R., Touboul C., Emmerich J., Fiessinger J.N. Buerger disease, clinical prognostic aspects. 83 cases. Presse Med. 1993;22:945–948.
    1. Shionoya S., Ban I., Nakata Y., Matsubara J., Shinjo K. Diagnosis, pathology and treatment of Buerger's disease. Surgery. 1974;75:695–700.
    1. Arkkila P.E. Thromboangiitis obliterans (Buerger's disease) Orphanet J Rare Dis. 2006;1:14.
    1. Rigato M., Monami M., Fadini G.P. Autologous cell therapy for peripheral arterial disease: systematic review and meta-analysis of randomized, nonrandomized, and noncontrolled studies. Circ Res. 2017;120:1326–1340.
    1. Pan T., Wei Z., Fang Y., Dong Z., Fu W. Therapeutic efficacy of CD34(+) cell-involved mononuclear cell therapy for no-option critical limb ischemia: a meta-analysis of randomized controlled clinical trials. Vasc Med. 2018;23:219–231.

Source: PubMed

스폰서 및 공동 작업자

건강 상태

약물 개입

3
구독하다