Accelerated healing of a diabetic foot ulcer using autologous stromal vascular fraction suspended in platelet-rich plasma

Evaluating the quality of studies reporting on clinical applications of stromal vascular fraction: A systematic review and proposed reporting guidelines (CLINIC-STRA-SVF)

Background

The stromal vascular fraction (SVF) has been widely explored in a number of therapeutic applications in several specialties. Its therapeutic potential is being increasingly demonstrated, although its mechanism of action is still unclear.

Objective

To evaluate the quality of studies reporting on clinical applications of SVF.

Method

This is a systematic literature review that followed the PRISMA guidelines with the search of the studies from December 1, 2012, to December 1, 2022, in the following databases: MEDLINE, LILACS and EMBASE. The level of evidence of the studies was assessed using the GRADE system, and the rigor used in the publication of the results was assessed in relation to adherence to the guidelines indicated by the EQUATOR Network Group. The CLINIC - STRA-SVF reporting guideline was developed after the completion of this systematic review.

Results

A total of 538 articles were found, and 77 articles were selected after reading the titles and abstracts and removing duplicates. Then, 15 studies were removed for not meeting the inclusion criteria, leaving 62 studies. The CLINIC - STRA-SVF was developed and consists of 33 items and two tables.

Conclusion

There is scientific evidence, although mostly with a low level of evidence, that the use of SVF in clinical applications is safe and effective. The information published in these studies should be standardized, and the CLINIC - STRA-SVF reporting guideline proposed in this study may assist in the design, conduct, recording and reporting of clinical trials and others clinical studies involving the SVF.

Ischemic wound revascularization by the stromal vascular fraction relies on host-donor hybrid vessels

Nonhealing wounds place a significant burden on both quality of life of affected patients and health systems. Skin substitutes are applied to promote the closure of nonhealing wounds, although their efficacy is limited by inadequate vascularization. The stromal vascular fraction (SVF) from the adipose tissue is a promising therapy to overcome this limitation. Despite a few successful clinical trials, its incorporation in the clinical routine has been hampered by their inconsistent results. All these studies concluded by warranting pre-clinical work aimed at both characterizing the cell types composing the SVF and shedding light on their mechanism of action. Here, we established a model of nonhealing wound, in which we applied the SVF in combination with a clinical-grade skin substitute. We purified the SVF cells from transgenic animals to trace their fate after transplantation and observed that it gave rise to a mature vascular network composed of arteries, capillaries, veins, as well as lymphatics, structurally and functionally connected with the host circulation. Then we moved to a human-in-mouse model and confirmed that SVF-derived endothelial cells formed hybrid human-mouse vessels, that were stabilized by perivascular cells. Mechanistically, SVF-derived endothelial cells engrafted and expanded, directly contributing to the formation of new vessels, while a population of fibro-adipogenic progenitors stimulated the expansion of the host vasculature in a paracrine manner. These data have important clinical implications, as they provide a steppingstone toward the reproducible and effective adoption of the SVF as a standard care for nonhealing wounds.

Platelet-rich plasma application in diabetic ulcers: A review

There are 422 million diabetic people in the world. 25% of these individuals are diagnosed with diabetic foot ulcer (DFU). 20% of patients with DFU will suffer amputation of the lower limbs. Following amputation procedures, the mortality rate of patients is over 70% in 5 years. Diabetes has no cure and, therefore, treatment aims to prevent and treat its complications. Autologous platelet-rich plasma (PRP) has been shown to be a therapeutic tool for many types of disorders, including the treatment of DFU. This manuscript aims to carry out a review to provide more knowledge about the efficacy and safety of autologous PRP for wound closure in patients with DFU. The majority of studies included in this review state that PRP promotes improvement of DFU lesions by accelerating tissue healing processes. However, many studies have a small sample size and thus require larger sample range in order to improve robustness of data in the literature.

Therapeutic application of adipose-derived stromal vascular fraction in diabetic foot

Diabetic foot is one of the severest complications of diabetes. In severe cases, this disease may be lead to amputation or even death due to secondary infection and ischemic necrosis. Since the ineffectiveness of traditional therapy, autologous stem cell transplantation has been used to treat diabetic foot. This simple, safe, and effective therapy is expected to be applied and promoted in the future.In this review, we described the detailed pathogenesis of diabetic foot and the common clinical treatments currently used. We also revealed vascular remodeling as the potential mechanism of therapeutic functions of adipose-derived stromal vascular fraction (SVF) in treating diabetic foot.

Immune Cell Therapies to Improve Regeneration and Revascularization of Non-Healing Wounds

With the increased prevalence of chronic diseases, non-healing wounds place a significant burden on the health system and the quality of life of affected patients. Non-healing wounds are full-thickness skin lesions that persist for months or years. While several factors contribute to their pathogenesis, all non-healing wounds consistently demonstrate inadequate vascularization, resulting in the poor supply of oxygen, nutrients, and growth factors at the level of the lesion. Most existing therapies rely on the use of dermal substitutes, which help the re-epithelialization of the lesion by mimicking a pro-regenerative extracellular matrix. However, in most patients, this approach is not efficient, as non-healing wounds principally affect individuals afflicted with vascular disorders, such as peripheral artery disease and/or diabetes. Over the last 25 years, innovative therapies have been proposed with the aim of fostering the regenerative potential of multiple immune cell types. This can be achieved by promoting cell mobilization into the circulation, their recruitment to the wound site, modulation of their local activity, or their direct injection into the wound. In this review, we summarize preclinical and clinical studies that have explored the potential of various populations of immune cells to promote skin regeneration in non-healing wounds and critically discuss the current limitations that prevent the adoption of these therapies in the clinics.

Porcine acellular dermal matrix accelerates wound healing through miR-124-3p.1 and miR-139-5p

BACKGROUND AIMS

Cutaneous wound management is a major health problem and imposes a huge economic burden worldwide. Previous studies have demonstrated that wound healing is a highly coordinated process including epithelialization, angiogenesis, remodeling and scarring. This progression requires self-renewal, preservation and repair properties of stem cells. However, our understanding of the detailed internal regulatory mechanism following injury and the means to accelerate wound healing are limited.

METHODS

Our previous research revealed that porcine acellular dermal matrix (ADM) effectively promotes wound healing and scar formation through epidermal stem cells (ESCs), and this process is relevant to the alteration of internal miRNA levels. In this study, we investigated the regulatory function of porcine ADM treatment on miRNAs in ESCs.

RESULTS

We report that the treatment of porcine ADM reduced the levels of miR-124-3p.1 and miR-139-5p in wounds. MiR-124-3p.1 and miR-139-5p inhibited the expression of JAG1 and Notch1, respectively, by directly targeting miRNAs in ESCs.

CONCLUSIONS

This work demonstrates that porcine ADM induced down-regulation of miR-124-3p.1/139-5p in wounds and up-regulation of JAG1/Notch1 in ESCs, thus enhancing cutaneous wound healing.

Autologous micro-fragmented adipose tissue for the treatment of diabetic foot minor amputations: a randomized controlled single-center clinical trial (MiFrAADiF)

Background

The diabetic foot ulcer (DFU) is one of the most prevalent complications of diabetes mellitus and often develops severe effects that can lead to amputation. A non-healing “minor” amputation often precedes a major amputation resulting in a negative impact on the function and quality of life of the patients. Stem cell-based therapies have emerged as a promising option to improve healing, and the adipose tissue is an abundant and easy to access source. The injection of autologous micro-fragmented adipose tissue at the amputation stump of a diabetic population undergoing a lower limb minor amputation was evaluated and compared with the standard care.

Methods

In this randomized controlled trial with two arms (parallel assignment) and no masking, 114 patients undergoing a lower limb minor amputation were randomized to standard of care or to micro-fragmented adipose tissue injection prepared using a minimal manipulation technique (Lipogems®) in a closed system. Clinical outcomes were determined monthly up to 6 months. Primary endpoint of the study was the evaluation of the healing rate and time after the minor amputation. Secondary endpoints included the assessment of safety, feasibility, technical success, relapse rate, skin tropism, and intensity of pain.

Results

At 6 months, 80% of the micro-fragmented adipose tissue-treated feet healed and 20% failed as compared with the control group where 46% healed and 54% failed (p = 0.0064). No treatment-related adverse events nor relapses were documented, and technical success was achieved in all cases. The skin tropism was improved in the treatment group, and the pain scale did not differ between the two groups.

Conclusion

The results of this randomized controlled trial suggest that the local injection of autologous micro-fragmented adipose tissue is a safe and valid therapeutic option able to improve healing rate following minor amputations of irreversible DFU. The technique overcomes several stem cell therapy-related criticisms and its potential in wound care should be better evaluated and the therapeutic indications could be expanded.

Trial registration

ClinicalTrials.gov number: NCT03276312. Date of registration: September 8, 2017 (retrospectively registered).

[New progress in the treatment of chronic wound of diabetic foot]

Diabetic foot is one of the serious complications of diabetic patients. It is caused by diabetes combined with different degrees of lower extremity vascular lesions and neuropathy, and the wound can not heal for a long time. The serious results can cause bone marrow infection, bone destruction, and have high disability and death rate. At present, there are various treatment methods for diabetic foot chronic wound. On the basis of internal medicine controlling blood sugar, anti infection, lowering blood lipid, improving microcirculation and nourishment nerve, the surgical method is adopted, including the debridement of the necrosis in a short time to prevent the infection from spreading; maggot biological debridement and ozone chemical debridement will promote the growth of granulation tissue while controlling infection. Skin grafting, skin flap transplantation, skin distraction closure can be used to repair soft tissue defects, or fat transplantation, platelet-rich plasma, and rich blood are used for the refractory wound after infection control. In patients with diabetic foot, the reconstruction of lower limb blood supply is beneficial to the recovery of chronic ischemic wounds. It is feasible to improve the blood supply of the lower extremities, improve the blood supply of the lower extremity artery bypass grafting, and improve the microcirculation of the peripheral vessels around the lower extremities. Lower extremity vascular bypass pressure perfusion therapy for vascular network expansion, tibia lateral moving technique for lower limb microcirculation reconstruction. For diabetic foot ulcer caused by peripheral neuropathy, such as Charcot foot, while the application of external fixator, total contact cast technology of affected foot for reducing treatment to promote wound healing; the preparation of orthopedic shoes can play a maximum protective effect on the healing of diabetic foot wound healing.