Administration of Adult Human Bone Marrow-Derived, Cultured, Pooled, Allogeneic Mesenchymal Stromal Cells in Critical Limb Ischemia Due to Buerger's Disease: Phase II Study Report Suggests Clinical Efficacy

Pawan K Gupta, Murali Krishna, Anoop Chullikana, Sanjay Desai, Rajkumar Murugesan, Santanu Dutta, Uday Sarkar, Radhakrishnan Raju, Anita Dhar, Rajiv Parakh, Lakshmanan Jeyaseelan, Pachaiyappan Viswanathan, Prasanth Kulapurathu Vellotare, Raviraja N Seetharam, Charan Thej, Mathiyazhagan Rengasamy, Sudha Balasubramanian, Anish S Majumdar, Pawan K Gupta, Murali Krishna, Anoop Chullikana, Sanjay Desai, Rajkumar Murugesan, Santanu Dutta, Uday Sarkar, Radhakrishnan Raju, Anita Dhar, Rajiv Parakh, Lakshmanan Jeyaseelan, Pachaiyappan Viswanathan, Prasanth Kulapurathu Vellotare, Raviraja N Seetharam, Charan Thej, Mathiyazhagan Rengasamy, Sudha Balasubramanian, Anish S Majumdar

Abstract

Critical limb ischemia (CLI) due to Buerger's disease is a major unmet medical need with a high incidence of morbidity. This phase II, prospective, nonrandomized, open-label, multicentric, dose-ranging study was conducted to assess the efficacy and safety of i.m. injection of adult human bone marrow-derived, cultured, pooled, allogeneic mesenchymal stromal cells (BMMSC) in CLI due to Buerger's disease. Patients were allocated to three groups: 1 and 2 million cells/kg body weight (36 patients each) and standard of care (SOC) (18 patients). BMMSCs were administered as 40-60 injections in the calf muscle and locally, around the ulcer. Most patients were young (age range, 38-42 years) and ex-smokers, and all patients had at least one ulcer. Both the primary endpoints-reduction in rest pain (0.3 units per month [SE, 0.13]) and healing of ulcers (11% decrease in size per month [SE, 0.05])-were significantly better in the group receiving 2 million cells/kg body weight than in the SOC arm. Improvement in secondary endpoints, such as ankle brachial pressure index (0.03 [SE, 0.01] unit increase per month) and total walking distance (1.03 [SE, 0.02] times higher per month), were also significant in the group receiving 2 million cells/kg as compared with the SOC arm. Adverse events reported were remotely related or unrelated to BMMSCs. In conclusion, i.m. administration of BMMSC at a dose of 2 million cells/kg showed clinical benefit and may be the best regimen in patients with CLI due to Buerger's disease. However, further randomized controlled trials are required to confirm the most appropriate dose. Stem Cells Translational Medicine 2017;6:689-699.

Keywords: Bone marrow; Buerger’s disease; Critical limb ischemia; Mesenchymal stromal cells; Stempeucel.

© 2016 The Authors Stem Cells Translational Medicine published by Wiley Periodicals, Inc. on behalf of AlphaMed Press.

Figures

Figure 1
Figure 1
Stempeucel treatment ameliorates ischemia‐induced limb necrosis and limb salvage in mice. (A): Representative photographs of sham control (Aa, Ad), vehicle‐treated limb ischemia (Ab, Ae), and Stempeucel‐treated (Ac, Af) LI on day 7 and day 28 after cell treatment. Stempeucel treatment significantly improved limb salvage in comparison with vehicle. (Ba, Bb, Bc): Hematoxylin and eosin‐stained sections of adductor muscle show severe necrosis (yellow arrows) and infiltration of inflammatory cells (green arrows), which were markedly reduced in the Stempeucel‐treated animals (Bc). Original magnification, ×40; scale bars = 50 µm. Abbreviation: LI, limb ischemia.
Figure 2
Figure 2
Total number of patients screened, allocated in each arm, followed up, and analyzed in the trial. Diagram as per the Consolidated Standards for Reporting Trials (CONSORT) flowchart. MITT population refers to all patients who received Stempeucel and had at least one rest‐pain assessment at visit 4. PP population refers to patients who had both the baseline and visit 6 rest‐pain assessments, with no major protocol deviation. Abbreviations: MITT, modified intention‐to‐treat; PP per protocol; SOC, standard of care.
Figure 3
Figure 3
Assessment of clinical efficacy parameters at various time points. (A): Rest pain assessment: mean change from baseline with SE shown as error bars (modified intention‐to‐treat [MITT] population). Compared with the SOC group, the 1 million cells/kg group had a 0.23 (SE, 0.13)‐unit reduction in rest pain per month (p = .0815; 95% confidence interval [CI], −0.48 to 0.03); the 2 million cells/kg group had a 0.3 (SE, 0.13)‐unit reduction in rest pain per month compared with the SOC group (p = .0193; 95% CI, −0.55 to −0.05). (B): Ulcer area: mean change from baseline, with SE shown as error bars (MITT population). Compared with the SOC group, the group receiving 1 million cells/kg had a 2% (SE, 0.06%) decrease in ulcer size per month (p = .6967; 95% CI, 0.87–1.10); the group receiving 2 million cells/kg had an 11% (SE, 0.05%) decrease in ulcer size per month (p = .0253; 95% CI, 0.80–0.99). (C): ABPI: Mean change from baseline, with SE shown as error bars (MITT population). Compared with the SOC group, the 1 million cells/kg group had a 0.02 (SE, 0.01)‐unit increase in the ABPI per month (p = .1329; 95% CI, −0.01 to 0.05); the 2 million cells/kg group had a 0.03 (SE, 0.01)‐unit increase per month compared with the SOC group (p = .0132; 95% CI, 0.01–0.06). (D): ABPI: Mean change from baseline. The group receiving 1 million cells/kg and the group receiving 2 million cells/kg had a 0.14 and 0.15 increase in ABIP at 6‐month follow‐up compared with a decrease of 0.01 in the SOC arm. (E): Total waking distance: Mean change from baseline, with SE shown as error bars (MITT population). Compared with the SOC group, the 1 million cells/kg group had a 1.03 (SE, 0.01) times greater total walking distance per month (p = .0231; 95% CI, 1–1.06); the 2 million cells/kg group had a 1.03 (SE, 0.02) times greater total walking distance per month (p = .0577; 95% CI, 1–1.07). Abbreviations: ABPI, ankle brachial pressure index; 1M/kg, 1 million cells/kg body weight; 2M/kg, 2 million cells/kg body weight; SOC, standard of care.
Figure 4
Figure 4
Magnetic resonance angiograms (left: baseline; right: 6 month) of one patient (ID number 08016) in the group receiving 2 million cells/kg body weight. Angiograms show overall increase in the vascularity of the affected limb, including development of new posterior collateral at 6‐month follow‐up after Stempeucel administration.

References

    1. Vijayakumar A, Tiwari R, Kumar Prabhuswamy V. Thromboangiitis obliterans (Buerger’s disease)‐current practices. Int J Inflamm 2013;2013:156905.
    1. Olin JW, Young JR, Graor RA et al. The changing clinical spectrum of thromboangiitis obliterans (Buerger’s disease). Circulation 1990;82(suppl):IV3–IV8.
    1. Afsharfard A, Mozaffar M, Malekpour F et al. The wound healing effects of iloprost in patients with Buerger’s disease: Claudication and prevention of major amputations. Iran Red Crescent Med J 2011;13:420–423.
    1. Idei N, Soga J, Hata T et al. Autologous bone‐marrow mononuclear cell implantation reduces long‐term major amputation risk in patients with critical limb ischemia: A comparison of atherosclerotic peripheral arterial disease and Buerger disease. Circ Cardiovasc Interv 2011;4:15–25.
    1. Fadini GP, 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 et al. 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 S, Nishikawa K, Obata H et al. Autologous bone marrow transplantation and hyperbaric oxygen therapy for patients with thromboangiitis obliterans. Angiology 2007;58:429–434.
    1. Durdu S, Akar AR, Arat M et al. Autologous bone‐marrow mononuclear cell implantation for patients with Rutherford grade II‐III thromboangiitis obliterans. J Vasc Surg 2006;44:732–739.
    1. Boda Z, Udvardy M, Rázsó K et al. Stem cell therapy: A promising and prospective approach in the treatment of patients with severe Buerger’s disease. Clin Appl Thromb Hemost 2009;15:552–560.
    1. Isner JM, Baumgartner I, Rauh G et al. Treatment of thromboangiitis obliterans (Buerger’s disease) by intramuscular gene transfer of vascular endothelial growth factor: Preliminary clinical results. J Vasc Surg 1998;28:964–973; discussion 73–75.
    1. Kim HJ, Jang SY, Park J‐I et al. Vascular endothelial growth factor‐induced angiogenic gene therapy in patients with peripheral artery disease. Exp Mol Med 2004;36:336–344.
    1. Baumann G, Stangl V, Klein‐Weigel P et al. Successful treatment of thromboangiitis obliterans (Buerger’s disease) with immunoadsorption: Results of a pilot study. Clin Res Cardiol 2011;100:683–690.
    1. Gupta PK, Chullikana A, Parakh R et al. A double blind randomized placebo controlled phase I/II study assessing the safety and efficacy of allogeneic bone marrow derived mesenchymal stem cell in critical limb ischemia. J Transl Med 2013;11:143.
    1. Mills JL, Taylor LM Jr, Porter JM. Buerger’s disease in the modern era. Am J Surg 1987;154:123–129.
    1. Yost ML. Peripheral Arterial Disease, Thromboangiitis Obliterans and Critical Limb Ischemia—Epidemiology & Markets. Beaufort, SC: The SAGE Group, 2009.
    1. Sprengers RW, Lips DJ, Moll FL et al. Progenitor cell therapy in patients with critical limb ischemia without surgical options. Ann Surg 2008;247:411–420.
    1. Kim SW, Han H, Chae GT et al. Successful stem cell therapy using umbilical cord blood‐derived multipotent stem cells for Buerger’s disease and ischemic limb disease animal model. Stem Cells 2006;24:1620–1626.
    1. Pal R, Hanwate M, Totey SM. Effect of holding time, temperature and different parenteral solutions on viability and functionality of adult bone marrow‐derived mesenchymal stem cells before transplantation. J Tissue Eng Regen Med 2008;2:436–444.
    1. Rengasamy M, Gupta PK, Kolkundkar U et al. Preclinical safety and toxicity evaluation of a pooled, allogeneic human bone marrow derived mesenchymal stromal cell product (Stempeucel). Indian J Med Res. (in press).
    1. Ranganath SH, Levy O, Inamdar MS et al. Harnessing the mesenchymal stem cell secretome for the treatment of cardiovascular disease. Cell Stem Cell 2012;10:244–258.
    1. Kinnaird T, Stabile E, Burnett MS et al. Marrow‐derived stromal cells express genes encoding a broad spectrum of arteriogenic cytokines and promote in vitro and in vivo arteriogenesis through paracrine mechanisms. Circ Res 2004;94:678–685.
    1. Ferrara N, Davis‐Smyth T. The biology of vascular endothelial growth factor. Endocr Rev 1997;18:4–25.
    1. Chen L, Tredget EE, Wu PYG et al. Paracrine factors of mesenchymal stem cells recruit macrophages and endothelial lineage cells and enhance wound healing. PLoS One 2008;3:e1886.
    1. Hocking AM, Gibran NS. Mesenchymal stem cells: Paracrine signaling and differentiation during cutaneous wound repair. Exp Cell Res 2010;316:2213–2219.
    1. Kinnaird T, Stabile E, Burnett MS et al. Local delivery of marrow‐derived stromal cells augments collateral perfusion through paracrine mechanisms. Circulation 2004;109:1543–1549.
    1. Katare R, Stroemer P, Hicks C et al. Clinical‐grade human neural stem cells promote reparative neovascularization in mouse models of hindlimb ischemia. Arterioscler Thromb Vasc Biol 2014;34:408–418.
    1. Brokelman RBG, Haverkamp D, van Loon C et al. The validation of the visual analogue scale for patient satisfaction after total hip arthroplasty. Eur Orthop Traumatol 2012;3:101–105.
    1. Chapman CR, Casey KL, Dubner R et al. Pain measurement: An overview. Pain 1985;22:1–31.
    1. Tateishi‐Yuyama E, Matsubara H, Murohara T et al. Therapeutic angiogenesis for patients with limb ischaemia by autologous transplantation of bone‐marrow cells: A pilot study and a randomised controlled trial. Lancet 2002;360:427–435.
    1. Esato K, Hamano K, Li T‐S et al. Neovascularization induced by autologous bone marrow cell implantation in peripheral arterial disease. Cell Transplant 2002;11:747–752.
    1. Miyamoto M, Yasutake M, Takano H et al. Therapeutic angiogenesis by autologous bone marrow cell implantation for refractory chronic peripheral arterial disease using assessment of neovascularization by 99mTc‐tetrofosmin (TF) perfusion scintigraphy. Cell Transplant 2004;13:429–437.
    1. Saigawa T, Kato K, Ozawa T et al. Clinical application of bone marrow implantation in patients with arteriosclerosis obliterans, and the association between efficacy and the number of implanted bone marrow cells. Circ J 2004;68:1189–1193.
    1. Iafrati MD, Hallett JW, Geils G et al. Early results and lessons learned from a multicenter, randomized, double‐blind trial of bone marrow aspirate concentrate in critical limb ischemia. J Vasc Surg 2011;54:1650–1658.
    1. Walter DH, Krankenberg H, Balzer JO et al. 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. Labs KH, Dormandy JA, Jaeger KA et al. Trans‐atlantic conference on clinical trial guidelines in PAOD (Peripheral arterial occlusive disease) clinical trial methodology. Eur J Vasc Endovasc Surg 1999;18:253–265.
    1. Dash NR, Dash SN, Routray P et al. Targeting nonhealing ulcers of lower extremity in human through autologous bone marrow‐derived mesenchymal stem cells. Rejuvenation Res 2009;12:359–366.
    1. Lu D, Chen B, Liang Z et al. Comparison of bone marrow mesenchymal stem cells with bone marrow‐derived mononuclear cells for treatment of diabetic critical limb ischemia and foot ulcer: A double‐blind, randomized, controlled trial. Diabetes Res Clin Pract 2011;92:26–36.
    1. Wu Y, Chen L, Scott PG et al. Mesenchymal stem cells enhance wound healing through differentiation and angiogenesis. Stem Cells 2007;25:2648–2659.
    1. Fu X, Fang L, Li X et al. Enhanced wound‐healing quality with bone marrow mesenchymal stem cells autografting after skin injury. Wound Repair Regen 2006;14:325–335.
    1. Lawall H, Bramlage P, Amann B. Stem cell and progenitor cell therapy in peripheral artery disease. A critical appraisal. Thromb Haemost 2010;103:696–709.
    1. Norgren L, Hiatt WR, Dormandy JA et al. Inter‐Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg 2007;45(suppl S):S5–S67.
    1. Cooper LT, Tse TS, Mikhail MA et al. Long‐term survival and amputation risk in thromboangiitis obliterans (Buerger’s disease). J Am Coll Cardiol 2004;44:2410–2411.
    1. Puéchal X, Fiessinger JN. Thromboangiitis obliterans or Buerger’s disease: Challenges for the rheumatologist. Rheumatology (Oxford) 2007;46:192–199.
    1. Takeshita S, Isshiki T, Mori H et al. Use of synchrotron radiation microangiography to assess development of small collateral arteries in a rat model of hindlimb ischemia. Circulation 1997;95:805–808.
    1. Lalu MM, McIntyre L, Pugliese C et al. Safety of cell therapy with mesenchymal stromal cells (SafeCell): A systematic review and meta‐analysis of clinical trials. PLoS One 2012;7:e47559.
    1. Zeger SL, Liang KY. Longitudinal data analysis for discrete and continuous outcomes. Biometrics 1986;42:121–130.

Source: PubMed

Sponsors en medewerkers

Medische omstandigheden

Geneesmiddelinterventies

3
Abonneren