Impact of severe diabetic kidney disease on the clinical outcome of autologous cell therapy in people with diabetes and critical limb ischaemia

The Use of Autologous Cell Therapy in Diabetic Patients with Chronic Limb-Threatening Ischemia

Autologous cell therapy (ACT) is primarily used in diabetic patients with chronic limb-threatening ischemia (CLTI) who are not candidates for standard revascularization. According to current research, this therapy has been shown in some studies to be effective in improving ischemia parameters, decreasing the major amputation rate, and in foot ulcer healing. This review critically evaluates the efficacy of ACT in patients with no-option CLTI, discusses the use of mononuclear and mesenchymal stem cells, and compares the route of delivery of ACT. In addition to ACT, we also describe the use of new revascularization strategies, e.g., nanodiscs, microbeads, and epigenetics, that could enhance the therapeutic effect. The main aim is to summarize new findings on subcellular and molecular levels with the clinical aspects of ACT.

The Potential of Anti-Inflammatory DC Immunotherapy in Improving Proteinuria in Type 2 Diabetes Mellitus

A typical consequence of type 2 diabetes mellitus, diabetic kidney disease (DKD) is a significant risk factor for end-stage renal disease. The pathophysiology of diabetic kidney disease (DKD) is mainly associated with the immune system, which involves adhesion molecules and growth factors disruption, excessive expression of inflammatory mediators, decreased levels of anti-inflammatory mediators, and immune cell infiltration in the kidney. Dendritic cells are professional antigen-presenting cells acting as a bridge connecting innate and adaptive immune responses. The anti-inflammatory subset of DCs is also capable of modulating inflammation. Autologous anti-inflammatory dendritic cells can be made by in vitro differentiation of peripheral blood monocytes and utilized as a cell-based therapy. Treatment with anti-inflammatory cytokines, immunosuppressants, and substances derived from pathogens can induce tolerogenic or anti-inflammatory features in ex vivo-generated DCs. It has been established that targeting inflammation can alleviate the progression of DKD. Recent studies have focused on the potential of dendritic cell-based therapies to modulate immune responses favorably. By inducing a tolerogenic phenotype in dendritic cells, it is possible to decrease the inflammatory response and subsequent kidney damage. This article highlights the possibility of using anti-inflammatory DCs as a cell-based therapy for DKD through its role in controlling inflammation.

Cell Therapy of Severe Ischemia in People with Diabetic Foot Ulcers-Do We Have Enough Evidence?

This current opinion article critically evaluates the efficacy of autologous cell therapy (ACT) for chronic limb-threatening ischemia (CLTI), especially in people with diabetes who are not candidates for standard revascularization. This treatment approach has been used in 'no-option' CLTI in the last two decades and more than 1700 patients have received ACT worldwide. Here we analyze the level of published evidence of ACT as well as our experience with this treatment method. Many studies have shown that ACT is safe and an effective method for patients with the most severe lower limb ischemia. However, some trials did not show any benefit of ACT, and there is some heterogeneity in the types of injected cells, route of administration and assessed endpoints. Nevertheless, we believe that ACT plays an important role in a comprehensive treatment of patients with diabetic foot and severe ischemia.

Report of a phase 1 clinical trial for safety assessment of human placental mesenchymal stem cells therapy in patients with critical limb ischemia (CLI)

BACKGROUND

Critical limb ischemia (CLI) is associated with increased risk of tissue loss, leading to significant morbidity and mortality. Therapeutic angiogenesis using cell-based treatments, notably mesenchymal stem cells (MSCs), is essential for enhancing blood flow to ischemic areas in subjects suffering from CLI. The objective of this study was to evaluate the feasibility of using placenta-derived mesenchymal stem cells (P-MSCs) in patients with CLI.

METHODS

This phase I dose-escalation study investigated P-MSCs in nine CLI patients who were enrolled into each of the two dosage groups (20 × 106 and 60 × 106 cells), delivered intramuscularly twice, two months apart. The incidence of treatment-related adverse events was the primary endpoint. The decrease in inflammatory cytokines, improvement in the ankle-brachial pressure index (ABI), maximum walking distance, vascular collateralization, alleviation of rest pain, healing of ulceration, and avoidance of major amputation in the target leg were the efficacy outcomes.

RESULTS

All dosages of P-MSCs, including the highest tested dose of 60 × 106 cells, were well tolerated. During the 6-month follow-up period, there was a statistically significant decrease in IL-1 and IFN-γ serum levels following P-MSC treatment. The blood lymphocyte profile of participants with CLI did not significantly differ, suggesting that the injection of allogeneic cells did not cause T-cell proliferation in vivo. We found clinically substantial improvement in rest pain, ulcer healing, and maximum walking distance after P-MSC implantation. In patients with CLI, we performed minor amputations rather than major amputations. Angiography was unable to demonstrate new small vessels formation significantly.

CONCLUSION

The observations from this phase I clinical study indicate that intramuscular administration of P-MSCs is considered safe and well tolerated and may dramatically improve physical performance and minimize inflammatory conditions in patients with CLI.

TRIAL REGISTRATION

IRCT, IRCT20210221050446N1. Registered May 09, 2021.

Correlation of ACR and TcPO2 in diabetic kidney disease patients: A pilot study

OBJECTIVE

Transcutaneous oxygen pressure (TcPO2) is used to assess microcirculation clinically; however, it is not widely available especially in rural hospital. The study was designed to explore potential alternatively biomarkers to assess microcirculation in diabetic kidney disease (DKD).

METHODS

A total of 404 patients from Xuzhou first hospital were recruited according to the case records system. Patients were grouped via the ratio of albuminuria and creatinine (ACR; <30 mg/g, 30-300 mg/g, >300 mg/g). Biomarkers in different ACR groups were compared by analysis of variance. Correlation analysis was determined by Pearson or Spearman analysis and binary logistic regression. The receiver operating characteristics (ROC) curve was performed to elucidate the prediction effect of ACR on TcPO2.

RESULTS

A total of 404 diabetic patients were recruited with 248 patients diagnosed as DKD and 156 non-DKDs. Age and cystatin C were significantly higher in the ACR3 group compared with those in the ACR1 group, whereas glomerular filtration rate, low-density lipoprotein cholesterol, and TcPO2 were markedly decreased in the ACR3 group (p < .05). Frequency of low TcPO2 (<40 mm Hg) was markedly increased as increment of ACR stages with 30.2% in the ACR3 group (p < .01). There was a negative correlation between TcPO2 and age, ACR, chronic kidney disease (CKD), fast blood glucose, diabetes mellitus (DM) duration, and diabetic neuropathy. Further, binary logistic regression showed ACR was an independent influence factor for low TcPO2. After adjusting for age, gender, hypertension, DM duration, body mass index, glycated hemoglobin, diabetic neuropathy, and CKD, ACR was still an independent influence factor for TcPO2 (odds ratio = 2.464, p < .01). The area under the ROC curve was 0.768 (95% confidence interval: 0.700-0.836, p < .001) for ACR. The analysis of ROC curves revealed a best cutoff for ACR was 75.25 mg/g and yielded a sensitivity of 71.7% and a specificity of 71.7%.

CONCLUSIONS

ACR could be used as an alternative biomarker for assessing microcirculation in DKD patients.

Diabetes Update 2020: das Wichtigste für die ärztliche Praxis

Bei der virtuellen Veranstaltung Diabetes Update 2020 wurden zahlreiche neue Erkenntnisse und Empfehlungen zu Diagnostik, Therapie und Management des Diabetes und benachbarter Themen vorgestellt, von denen die Bereiche Typ-2-Diabetes, Diabetes und Herz, Diabetes und Schwangerschaft sowie Impfungen im aktuellen Heft von Der Diabetologe in separaten Beiträgen ausführlich beschrieben werden. Im Folgenden sollen die aus Sicht des Autors wichtigsten und für die Praxis relevantesten Neuigkeiten aus den anderen referierten diabetesbezogenen Themengebieten in aller Kürze wiedergegeben werden.