Medicamento celular como alternativa terapéuticaen la isquemiacrónica crítica de miembros inferiores en pacientes diabéticos sin posibilidades de revascularización

Falta palabras claveLa diabetes mellitus (DM) es la enfermedad metabólica más común, y comprende una variedad de síndromes con distintas causas que afectan colectivamente de un 2 a un 6% de la población mundial. La diabetes lleva asociada una serie de complicaciones, siendo el principal factor de riesgo para la isquemia crónica crítica del miembro inferior (CLI; critical limb ischemia), la cual es una de las manifestaciones más severas de aterosclerosis en nuestro organismo. Se define como el cuadro caracterizado por dolor crónico en reposo, úlceras o gangrena atribuibles a enfermedad arterial oclusiva comprobada (1). Así pues, la isquemia crítica de la pierna es el final del proceso de arterosclerosis que puede conllevar la amputación del miembro e incluso la muerte si no se consigue una rápida y eficaz revascularización. En el paciente diabético el cuadro de isquemia de la pierna se desarrolla más precozmente y con mayor intensidad. Se estima que un 15% de los pacientes diabéticos desarrollarán CLI, y en la mayoría de los casos, conllevará la amputación. Las lesiones arteriales suelen afectar a los vasos más distales (2). Esta localización de las lesiones dificulta su revascularización, quirúrgica o endovascular. Por otro lado, también la presentación del cuadro en el paciente diabético es diferente, al conllevar un mayor componente de pérdida tisular y gangrena, y menor manifestación clínica de dolor. Además, en concreto los pacientes diabéticos tienen disminuidos los mecanismos fisiológicos de angiogénesis y reendotelización, por lo que el curso de la enfermedad es más severo y acelerado. El objetivo principal del tratamiento de CLI es la revascularización, bien quirúrgica o endovascular (3). Sin embargo, en una gran proporción de estos pacientes (20-30%), la extensión anatómica y la distribución de la enfermedad oclusiva arterial hacen que sean candidatos poco aptos a la revascularización, y que la enfermedad siga su inexorable curso hacia la amputación y la muerte. El tratamiento farmacológico como única alternativa para estos pacientes sin posibilidades de revascularización, no ha demostrado que afecte favorablemente el curso de CLI (4). De hecho, en la actualidad se recomienda habitualmente para estos pacientes la amputación como única opción, a pesar de su evidente implicación disfuncional, junto con su conocida morbi-mortalidad asociada (5). Es evidente que se necesitan nuevas alternativas eficaces para el tratamiento de una alta proporción de pacientes con CLI. En este contexto, la posibilidad de terapia de regeneración celular, con sus demostradas propiedades de angiogénesis y cicatrización de úlceras cutáneas, puede tener un máximo interés. La angiogénesis terapéutica es una de las estrategias utilizadas últimamente para la proliferación de los vasos colaterales. Se han descrito numerosas moléculas angiogénicas, tanto en modelos animales como en humanos con enfermedades isquémicas (6). Es por ello que la utilización de las células madre mesenquimales (MSCs; mesenchymal stem cells) está tomando gran importancia a la hora de utilizar terapia celular para la regeneración vascular en enfermedades isquémicas. Las MSCs de tejido adiposo (ATMSCs) secretan múltiples factores de crecimiento angiogénicos, como el VEGF, a niveles bioactivos (7). Por otra parte, el efecto antiinflamatorio, inmunomodulador y el carácter multipotencial de estas células ha demostrado resolver casos puntuales para los que hasta ahora no teníamos una oferta terapéutica mejor. Por este motivo, estas células pueden ser una alternativa factible a la hora de revascularizar una isquemia en miembros inferiores. En este momento, es necesario llevar a cabo ensayos clínicos piloto muy bien controlados además de seguir potenciando la investigación básica y traslacional de calidad

Bottlenecks in the efficient use of advanced therapy medicinal products based on mesenchymal stromal cells

Mesenchymal stromal cells (MSCs) have been established as promising candidate sources of universal donor cells for cell therapy due to their contributions to tissue and organ homeostasis, repair, and support by self-renewal and multidifferentiation, as well as by their anti-inflammatory, antiproliferative, immunomodulatory, trophic, and proangiogenic properties. Various diseases have been treated by MSCs in animal models. Additionally, hundreds of clinical trials related to the potential benefits of MSCs are in progress. However, although all MSCs are considered suitable to exert these functions, dissimilarities have been found among MSCs derived from different tissues. The same levels of efficacy and desired outcomes have not always been achieved in the diverse studies that have been performed thus far. Moreover, autologous MSCs can be affected by the disease status of patients, compromising their use. Therefore, collecting information regarding the characteristics of MSCs obtained from different sources and the influence of the host (patient) medical conditions on MSCs is important for assuring the safety and efficacy of cell-based therapies. This review provides relevant information regarding factors to consider for the clinical application of MSCs.The authors are supported by the Fundacion Progreso y ´ Salud, Consejer´ıa de Salud, Junta de Andaluc´ıa; FEDER cofunded grants from Consejer´ıa de Innovacion Ciencia y ´ Empresa, Junta de Andaluc´ıa (Grants CTS-6505; INP-2011- 1615-900000); FEDER cofunded grants from Instituto de Salud Carlos III (Red TerCel-Grant RD12/0019/0028; PI10/ 00964 and PI14/01015) and the Ministry of Health and Consumer Affairs (Advanced Therapies Program Grant TRA- 120); SUDOE Program-BIOREG (Regenerative Medicine Network-SOE3/P1/E750) and ACTION Cost (European Cooperation in Science and Technology-BM1305). Support from FSED and FAID allowed access to databanks. CIBERDEM is an initiative of the Instituto de Salud Carlos IIIPeer Reviewe

Mesothelial cells: A cellular surrogate for tissue engineering of corneal endothelium

[Purpose]: To evaluate whether mouse adipose tissue mesothelial cells (ATMCs) share morphologic and biochemical characteristics with mouse corneal endothelial cells (CECs) and to evaluate their capacity to adhere to the decellularized basal membrane of human anterior lens capsules (HALCs) as a potential tissue-engineered surrogate for corneal endothelium replacement. [Methods]: Adipose tissue mesothelial cells were isolated from the visceral adipose tissue of adult mice, and their expression of several corneal endothelium markers was determined with quantitative RT-PCR, immunofluorescence, and Western blotting. Adipose tissue mesothelial cells were cultured in a mesothelial retaining phenotype medium (MRPM) and further seeded and cultured on top of the decellularized basal membrane of HALCs. ATMC-HALC composites were evaluated by optical microscopy, immunofluorescence, and transmission electron microscopy. [Results]: Mesothelial retaining phenotype medium-cultured ATMCs express the corneal endothelium markers COL4A2, COL8A2, SLC4A4, CAR2, sodium- and potassium-dependent adenosine triphosphatase (Na+/K+-ATPase), b-catenin, zona occludens-1, and N-cadherin in a pattern similar to that in mouse CECs. Furthermore, ATMCs displayed strong adhesion capacity onto the basal membrane of HALCs and formed a confluent monolayer within 72 hours of culture in MRPM. Ultrastructural morphologic and marker characteristics displayed by ATMC monolayer on HALCs clearly indicated that ATMCs retained their original phenotype of squamous epithelial-like cells. [Conclusions]: Corneal epithelial cells and ATMCs share morphologic (structural) and marker (functional) similarities. The ATMCs adhered and formed structures mimicking focal adhesion complexes with the HALC basal membrane. Monolayer structure and achieved density of ATMCs support the proposal to use adult human mesothelial cells (MCs) as a possible surrogate for damaged corneal endothelium.Supported by Fondos FEDER, Fundación Progreso y Salud, Consejería de Salud, Junta de Andalucía (Grant PI-0022/2008), INNPACTO Program (INP-2011-1615-900000), and SUDOE Program-BIOREG (Intereg SOE3/P1/E750); Consejer´ıa de Innovación Ciencia y Empresa, Junta de Andalucía (Grant CTS-6505); Ministry of Science and Innovation (Red TerCel-FEDER Grant RD12/0019/ 0028); Instituto de Salud Carlos III Grant PI10/00964); the Ministry of Health and Consumer Affairs Advanced Therapies Program Grant TRA-120 (BS); and Corporación Tecnológica de Andalucía CTA (NBT). CIBERDEM is an initiative of the Instituto de Salud Carlos III.Peer Reviewe

Adipose mesenchymal stromal cells isolated from type 2 diabetic patients display reduced fibrinolytic activity

Stem cells have been successfully used for the treatment of critical limb ischemia (CLI). We conducted a clinical trial to determine the feasibility of using autologous adipose-derived mesenchymal stromal cells (AdMSCs) for the treatment of CLI. Unexpectedly, two diabetic patients developed peripheral microthrombosis. This adverse effect, which contrasts with the reported antithrombotic properties of MSCs, may stem from the diabetic environment that alters the fibrinolytic activity of AdMSCs, thereby increasing the probability of developing thrombosis. Here, we confirm this premise by demonstrating that diabetic AdMSCs cultured in the presence of blood sera expressed and released higher levels of plasminogen activator inhibitor type 1, reduced levels of tissue plasminogen activator, and lower D-dimer formation compared with nondiabetic AdMSCs. Thus, to establish an appropriate cell therapy for diabetic patients, we recommend including new preclinical safety tests, such as the D-dimer and/or the tissue plasminogen activator-to-plasminogen activator inhibitor type 1 ratio tests, to assess fibrinolytic activity of cells before implantation. © 2013 by the American Diabetes Association.The authors are supported by the Fundación Progreso y Salud, Consejería de Salud, Junta de Andalucía (Grant PI- 0022/2008) and Consejería de Innovación Ciencia y Empresa, Junta de Andalucía (Grant CTS-6505, INP-2011-1615-900000). Fondo Europeo de Desarrollo Regional (FEDER) cofunded grants from Instituto de Salud Carlos III (Red TerCel-Grant RD06/0010/0025, PI10/00964, and PI10/00871) and the Ministry of Health and Consumer Affairs (Advanced Therapies Program Grant TRA-120). Support from Fundación de la Sociedad Española de Diabetes (FSED) and Fundación Andaluza de Investigación y Desarrollo (FAID) allow access to databanks.Peer Reviewe

Adipose mesenchymal stromal cells isolated from type 2 diabetic patients display reduced fibrinolytic activity.

Journal Article; Research Support, Non-U.S. Gov't;Stem cells have been successfully used for the treatment of critical limb ischemia (CLI). We conducted a clinical trial to determine the feasibility of using autologous adipose-derived mesenchymal stromal cells (AdMSCs) for the treatment of CLI. Unexpectedly, two diabetic patients developed peripheral microthrombosis. This adverse effect, which contrasts with the reported antithrombotic properties of MSCs, may stem from the diabetic environment that alters the fibrinolytic activity of AdMSCs, thereby increasing the probability of developing thrombosis. Here, we confirm this premise by demonstrating that diabetic AdMSCs cultured in the presence of blood sera expressed and released higher levels of plasminogen activator inhibitor type 1, reduced levels of tissue plasminogen activator, and lower d-dimer formation compared with nondiabetic AdMSCs. Thus, to establish an appropriate cell therapy for diabetic patients, we recommend including new preclinical safety tests, such as the d-dimer and/or the tissue plasminogen activator-to-plasminogen activator inhibitor type 1 ratio tests, to assess fibrinolytic activity of cells before implantation.The authors are supported by the Fundación Progreso y Salud, Consejería de Salud, Junta de Andalucía (Grant PI-0022/2008) and Consejería de Innovación Ciencia y Empresa, Junta de Andalucía (Grant CTS-6505, INP-2011-1615-900000). Fondo Europeo de Desarrollo Regional (FEDER) cofunded grants from Instituto de Salud Carlos III (Red TerCel-Grant RD06/0010/0025, PI10/00964, and PI10/00871) and the Ministry of Health and Consumer Affairs (Advanced Therapies Program Grant TRA-120).Ye

PDGF restores the defective phenotype of adipose-derived mesenchymal stromal cells from diabetic patients

Diabetes is a chronic metabolic disorder that affects 415 million people worldwide. This pathology is often associated with long-term complications, such as critical limb ischemia (CLI), which increases the risk of limb loss and mortality. Mesenchymal stromal cells (MSCs) represent a promising option for the treatment of diabetes complications. Although MSCs are widely used in autologous cell-based therapy, their effects may be influenced by the constant crosstalk between the graft and the host, which could affect the MSC fate potential. In this context, we previously reported that MSCs derived from diabetic patients with CLI have a defective phenotype that manifests as reduced fibrinolytic activity, thereby enhancing the thrombotic risk and compromising patient safety. Here, we found that MSCs derived from diabetic patients with CLI not only exhibit a prothrombotic profile but also have altered multi-differentiation potential, reduced proliferation, and inhibited migration and homing to sites of inflammation. We further demonstrated that this aberrant cell phenotype is reversed by the platelet-derived growth factor (PDGF) BB, indicating that PDGF signaling is a key regulator of MSC functionality. These findings provide an attractive approach to improve the therapeutic efficacy of MSCs in autologous therapy for diabetic patients.Peer reviewe

Cost-Effective, Safe, and Personalized Cell Therapy for Critical Limb Ischemia in Type 2 Diabetes Mellitus

Cell therapy is a progressively growing field that is rapidly moving from preclinical model development to clinical application. Outcomes obtained from clinical trials reveal the therapeutic potential of stem cell-based therapy to deal with unmet medical treatment needs for several disorders with no therapeutic options. Among adult stem cells, mesenchymal stem cells (MSCs) are the leading cell type used in advanced therapies for the treatment of autoimmune, inflammatory and vascular diseases. To date, the safety and feasibility of autologous MSC-based therapy has been established; however, their indiscriminate use has resulted in mixed outcomes in preclinical and clinical studies. While MSCs derived from diverse tissues share common properties depending on the type of clinical application, they markedly differ within clinical trials in terms of efficacy, resulting in many unanswered questions regarding the application of MSCs. Additionally, our experience in clinical trials related to critical limb ischemia pathology (CLI) shows that the therapeutic efficacy of these cells in different animal models has only been partially reproduced in humans through clinical trials. Therefore, it is crucial to develop new research to identify pitfalls, to optimize procedures and to clarify the repair mechanisms used by these cells, as well as to be able to offer a next generation of stem cell that can be routinely used in a cost-effective and safe manner in stem cell-based therapies targeting CLI

Corrigendum: Cost-effective, safe, and personalized cell therapy for critical limb ischemia in type 2 diabetes mellitus (vol 10, 1151, 2019)

Reference 86 was also included as “Escacena N. Cellular medication as a therapeutic alternative in chronic critical limb ischemia in diabetic patients without the possibility of revascularization. Dissertation Thesis. Sevilla Spain: University of Sevilla. (2016)”. This reference should be included as number 107 “Escacena N. Cellular medication as a therapeutic alternative in chronic critical limb ischemia in diabetic patients without the possibility of revascularization (Dissertation Thesis). University of Sevilla, Seville, Spain (2016).