Clinical trial NCT04255004: Autologous Peripheral Blood Mononuclear Cells in Diabetic Foot Patients With No-option Critical Limb Ischemia
Official title: Autologous Peripheral Blood Mononuclear Cells for Limb Salvage in Diabetic Foot Patients With No-option Critical Limb Ischemia
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: NA
Conditions: Critical Limb Ischemia
Diabetic Foot
Keywords: autologous peripheral blood mononuclear cell, diabetic foot
Lead sponsor: Ospedale San Donato
Sponsor class: OTHER
First posted: 2020-02-05
Enrollment: 76
Sex: ALL
Minimum age (years): 18
Maximum age (years): 90
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: NON_RANDOMIZED
Intervention model: SEQUENTIAL
Intervention model description: We would enroll a cohort of 38 consecutive diabetic patients with CLI in charge at the Diabetic Foot Unit of the San Donato Hospital in Arezzo or referred from other Italian hospitals, who have no option for revascularization or are not further eligible for revascularization according to ESVS ESC 2017 criteria to undergo PB-MNC implantation. Furthermore, an historical control group, with a 1:1 case-control ratio, will be collected backwards from our records, when PBMNCs cellular therapy was not available in our center, with same no-option CLI diagnosis.
Primary purpose: TREATMENT

Brief summary: The objective of this trial is to determine whether PBMNCs in diabetic patients with critical, non revascularizable limb ischemia can prevent major amputation and affect mortality and healing.

Detailed description: This is an interventional study with historical control group carried out to assess as primary outcome major amputations, overall mortality, number of healed patients in group of patients who received repetitive intra-muscular implant of PBMNCs (3 times; 4-week interval) in comparison to a historical internal control group with a 1:1 case-control ratio. Secondary outcomes are TCPO2, healing time and rest pain.

No-option critical limb ischaemia is defined by evidence of no run-off pedal vessels, failure after several percutaneous intervention and no longer possible re-intervention, failure after infra-genicular bypass grafting, no-walking capacity with severe comorbidities unfit for surgical or endovascular procedures.

Inclusion criteria are: a) ulcers with inadequate perfusion, as indicated by a transcutaneous oxygen pressure value (TcpO2) \<30 mmHg; b) ulcers with grade I or II or III and stage C as defined by the Texas University Classification System or W1,2,3 - I 3 - FI 0,1 as defined by the WiFI Classification System c) not eligible for angioplasty or vascular surgery or following failed revascularization; d) possibility to save foot support.

Exclusion criteria are: a) lesion site above the tibial-tarsal joint; b) moderate or severe infection according by the WiFI classification system; c) NYHA class IV; d) Anemia (Hb\<8g/dl); e) coagulation disorder/thrombocytopenia (PLT\< 50,000 per microliter); f) active cancer/leukemia or lymphoma hematological disease.

Standard of care in both groups includes: diabetes control maximization by the diabetologist, comprehensive foot assessment by the nurse together with the diabetologist, including determination of vibration perception threshold, 10-g monofilament test and TcpO2 measurement, dressings, off-loading and systemic therapy according to the IWGDF guidelines .

Informed consent for participation in the study during the progress of the clinical trial is obtained from all subjects.

Concentration of PB-MNCs autologous cell therapy is produced by a filtration-based point-of-care device with the intended for use intra-operatively, from 120 mL of anticoagulated blood. All the procedures are performed in operatory room with anaesthesiologic support (propofol and/or peripheral block). Blood withdrawal (120 ml) is collected through a peripheral venous access, than loaded and gravity filtration is allowed in about 10 minutes. During filtration, MNCs are captured in the filter while plasma, platelets (PLTs) and red blood cells (RBCs) are not retained. After appropriate surgical debridement of the wound bed multiple perilesional and intramuscular injections of PBMNC cells suspension (0.2-0.3cc in boluses) are injected along the relevant axis below the knee, at intervals of 1-2 cm and to a mean depth of 1.5-2 cm, using a 21G needle. This procedure is repeated on each patient for three times, at intervals of 30-45 days from each other.

Foot-sparing surgery, the removal of all the unviable tissue and the reconstruction of the foot to allow a functional deambulation,is performed at the same time of the last implant in the patients with increased TcpO2 value above 30 mmHg. Between the implants, diabetologists together with nurses evaluated changing in pain, infection signs, wound size, demarcation of the necrosis, granulation tissue formation, perilesional tissue trophism and TcpO2 value to optimize standard of care. After the first treatment, a two years follow-up is registered, with evaluation at 1-3-6-12-18-24 months.

A baseline assessment is carried out, in order to estimate any differences among cases and controls before the treatment. Statistical evaluation includes non-parametric tests (Mann-Whitney U test for independent samples for continuous variables and Cochrane chi-square test for discrete variables), evaluation of Relative Risk (RR), Absolute Risk Reduction (ARR), Relative Risk Reduction (RRR) and Number Needed to Treat (NNT), multivariate survival analysis (Kaplan-Meier's survival analysis model).

Eligibility criteria: Inclusion Criteria:

* ulcers with inadequate perfusion, as indicated by a transcutaneous oxygen pressure value (TcpO2) \<30 mmHg;
* ulcers with grade I or II or III and stage C as defined by the Texas University Classification System or W1,2,3 - I 3 - FI 0,1 as defined by the WiFI Classification System
* not eligible for angioplasty or vascular surgery or following failed revascularization;
* possibility to save foot support.

Exclusion Criteria:

* lesion site above the tibial-tarsal joint;
* moderate or severe infection according by the WiFI classification system;
* NYHA class IV; d) Anemia (Hb\<8g/dl);
* coagulation disorder/thrombocytopenia (PLT\< 50,000 per microliter);
* active cancer/leukemia or lymphoma hematological disease.

Primary outcomes:
measure: Amputation-free survival at 1 month
timeFrame: 1 month
measure: Amputation-free survival at 3 months
timeFrame: 3 months
measure: Amputation-free survival at 6 months
timeFrame: 6 months
measure: Amputation-free survival at 12 months
timeFrame: 12 months
measure: Amputation-free survival at 18 months
timeFrame: 18 months
measure: Amputation-free survival at 24 months
timeFrame: 24 months
measure: risk of death at 1 month
timeFrame: 1 month
measure: risk of death at 3 months
timeFrame: 3 months
measure: risk of death at 6 months
timeFrame: 6 months
measure: risk of death at 12 months
timeFrame: 12 months
measure: risk of death at 18 months
timeFrame: 18 months
measure: risk of death at 24 months
timeFrame: 24 months
measure: probability of healing at 1 month
timeFrame: 1 month
measure: probability of healing at 3 months
timeFrame: 3 months
measure: probability of healing at 6 months
timeFrame: 6 months
measure: probability of healing at 12 months
timeFrame: 12 months
measure: probability of healing at 18 months
timeFrame: 18 months
measure: probability of healing at 24 months
timeFrame: 24 months
Secondary outcomes:
measure: transcutaneous oxygen measurement (TcPO2) variation
timeFrame: 0-3 months
measure: Healing time
timeFrame: within 24 months
measure: rest pain
timeFrame: 0-1-3 months
Other outcomes:
Locations:
Study officials:
affiliation: Vascular Surgery Unit San Donato Hospital Arezzo
name: Leonardo Ercolini, MD
role: STUDY_CHAIR
References:
citation: Abu Dabrh AM, Steffen MW, Undavalli C, Asi N, Wang Z, Elamin MB, Conte MS, Murad MH. The natural history of untreated severe or critical limb ischemia. J Vasc Surg. 2015 Dec;62(6):1642-51.e3. doi: 10.1016/j.jvs.2015.07.065. Epub 2015 Sep 26.
citation: Golomb BA, Dang TT, Criqui MH. Peripheral arterial disease: morbidity and mortality implications. Circulation. 2006 Aug 15;114(7):688-99. doi: 10.1161/CIRCULATIONAHA.105.593442. No abstract available.
citation: Rigato M, Monami M, Fadini GP. Autologous Cell Therapy for Peripheral Arterial Disease: Systematic Review and Meta-Analysis of Randomized, Nonrandomized, and Noncontrolled Studies. Circ Res. 2017 Apr 14;120(8):1326-1340. doi: 10.1161/CIRCRESAHA.116.309045. Epub 2017 Jan 17.
citation: Fantin A, Vieira JM, Gestri G, Denti L, Schwarz Q, Prykhozhij S, Peri F, Wilson SW, Ruhrberg C. Tissue macrophages act as cellular chaperones for vascular anastomosis downstream of VEGF-mediated endothelial tip cell induction. Blood. 2010 Aug 5;116(5):829-40. doi: 10.1182/blood-2009-12-257832. Epub 2010 Apr 19.
citation: Baer C, Squadrito ML, Iruela-Arispe ML, De Palma M. Reciprocal interactions between endothelial cells and macrophages in angiogenic vascular niches. Exp Cell Res. 2013 Jul 1;319(11):1626-34. doi: 10.1016/j.yexcr.2013.03.026. Epub 2013 Mar 28.
citation: Wynn TA, Vannella KM. Macrophages in Tissue Repair, Regeneration, and Fibrosis. Immunity. 2016 Mar 15;44(3):450-462. doi: 10.1016/j.immuni.2016.02.015.
citation: Krzyszczyk P, Schloss R, Palmer A, Berthiaume F. The Role of Macrophages in Acute and Chronic Wound Healing and Interventions to Promote Pro-wound Healing Phenotypes. Front Physiol. 2018 May 1;9:419. doi: 10.3389/fphys.2018.00419. eCollection 2018.
citation: Awad O, Dedkov EI, Jiao C, Bloomer S, Tomanek RJ, Schatteman GC. Differential healing activities of CD34+ and CD14+ endothelial cell progenitors. Arterioscler Thromb Vasc Biol. 2006 Apr;26(4):758-64. doi: 10.1161/01.ATV.0000203513.29227.6f. Epub 2006 Jan 12.
citation: Jarajapu YP, Hazra S, Segal M, Li Calzi S, Jadhao C, Qian K, Mitter SK, Raizada MK, Boulton ME, Grant MB. Vasoreparative dysfunction of CD34+ cells in diabetic individuals involves hypoxic desensitization and impaired autocrine/paracrine mechanisms. PLoS One. 2014 Apr 8;9(4):e93965. doi: 10.1371/journal.pone.0093965. eCollection 2014.
citation: Spaltro G, Straino S, Gambini E, Bassetti B, Persico L, Zoli S, Zanobini M, Capogrossi MC, Spirito R, Quarti C, Pompilio G. Characterization of the Pall Celeris system as a point-of-care device for therapeutic angiogenesis. Cytotherapy. 2015 Sep;17(9):1302-13. doi: 10.1016/j.jcyt.2015.04.006. Epub 2015 May 30.
citation: Moriya J, Minamino T, Tateno K, Shimizu N, Kuwabara Y, Sato Y, Saito Y, Komuro I. Long-term outcome of therapeutic neovascularization using peripheral blood mononuclear cells for limb ischemia. Circ Cardiovasc Interv. 2009 Jun;2(3):245-54. doi: 10.1161/CIRCINTERVENTIONS.108.799361. Epub 2009 Mar 30.
citation: Persiani F, Paolini A, Camilli D, Mascellari L, Platone A, Magenta A, Furgiuele S. Peripheral Blood Mononuclear Cells Therapy for Treatment of Lower Limb Ischemia in Diabetic Patients: A Single-Center Experience. Ann Vasc Surg. 2018 Nov;53:190-196. doi: 10.1016/j.avsg.2018.05.036. Epub 2018 Jul 25.
citation: Armstrong DG, Lavery LA, Harkless LB. Validation of a diabetic wound classification system. The contribution of depth, infection, and ischemia to risk of amputation. Diabetes Care. 1998 May;21(5):855-9. doi: 10.2337/diacare.21.5.855.
citation: Wagner FW Jr. The dysvascular foot: a system for diagnosis and treatment. Foot Ankle. 1981 Sep;2(2):64-122. doi: 10.1177/107110078100200202. No abstract available.
citation: Lipsky BA, Aragon-Sanchez J, Diggle M, Embil J, Kono S, Lavery L, Senneville E, Urbancic-Rovan V, Van Asten S; International Working Group on the Diabetic Foot; Peters EJ. IWGDF guidance on the diagnosis and management of foot infections in persons with diabetes. Diabetes Metab Res Rev. 2016 Jan;32 Suppl 1:45-74. doi: 10.1002/dmrr.2699. No abstract available.
citation: Breivik H, Borchgrevink PC, Allen SM, Rosseland LA, Romundstad L, Hals EK, Kvarstein G, Stubhaug A. Assessment of pain. Br J Anaesth. 2008 Jul;101(1):17-24. doi: 10.1093/bja/aen103. Epub 2008 May 16.
citation: Meloni M, Giurato L, Izzo V, Stefanini M, Pampana E, Gandini R, Uccioli L. Long term outcomes of diabetic haemodialysis patients with critical limb ischemia and foot ulcer. Diabetes Res Clin Pract. 2016 Jun;116:117-22. doi: 10.1016/j.diabres.2016.04.030. Epub 2016 Apr 26.
citation: Dubsky M, Jirkovska A, Bem R, Fejfarova V, Pagacova L, Nemcova A, Sixta B, Chlupac J, Peregrin JH, Sykova E, Jude EB. Comparison of the effect of stem cell therapy and percutaneous transluminal angioplasty on diabetic foot disease in patients with critical limb ischemia. Cytotherapy. 2014 Dec;16(12):1733-8. doi: 10.1016/j.jcyt.2014.08.010. Epub 2014 Oct 7.
citation: Mustapha JA, Katzen BT, Neville RF, Lookstein RA, Zeller T, Miller LE, Jaff MR. Disease Burden and Clinical Outcomes Following Initial Diagnosis of Critical Limb Ischemia in the Medicare Population. JACC Cardiovasc Interv. 2018 May 28;11(10):1011-1012. doi: 10.1016/j.jcin.2017.12.012. No abstract available.
citation: Klaphake S, de Leur K, Mulder PG, Ho GH, de Groot HG, Veen EJ, Verhagen HJ, van der Laan L. Mortality after major amputation in elderly patients with critical limb ischemia. Clin Interv Aging. 2017 Nov 22;12:1985-1992. doi: 10.2147/CIA.S137570. eCollection 2017.
citation: Martini R, Andreozzi GM, Deri A, Cordova R, Zulian P, Scarpazza O, Nalin F. Amputation rate and mortality in elderly patients with critical limb ischemia not suitable for revascularization. Aging Clin Exp Res. 2012 Jun;24(3 Suppl):24-7.
citation: Pannell M, Labuz D, Celik MO, Keye J, Batra A, Siegmund B, Machelska H. Adoptive transfer of M2 macrophages reduces neuropathic pain via opioid peptides. J Neuroinflammation. 2016 Oct 7;13(1):262. doi: 10.1186/s12974-016-0735-z.
citation: Hasegawa T, Kosaki A, Shimizu K, Matsubara H, Mori Y, Masaki H, Toyoda N, Inoue-Shibata M, Nishikawa M, Iwasaka T. Amelioration of diabetic peripheral neuropathy by implantation of hematopoietic mononuclear cells in streptozotocin-induced diabetic rats. Exp Neurol. 2006 Jun;199(2):274-80. doi: 10.1016/j.expneurol.2005.11.001. Epub 2005 Dec 6.
citation: Molavi B, Zafarghandi MR, Aminizadeh E, Hosseini SE, Mirzayi H, Arab L, Baharvand H, Aghdami N. Safety and Efficacy of Repeated Bone Marrow Mononuclear Cell Therapy in Patients with Critical Limb Ischemia in a Pilot Randomized Controlled Trial. Arch Iran Med. 2016 Jun;19(6):388-96.
citation: Kang WC, Oh PC, Lee K, Ahn T, Byun K. Increasing injection frequency enhances the survival of injected bone marrow derived mesenchymal stem cells in a critical limb ischemia animal model. Korean J Physiol Pharmacol. 2016 Nov;20(6):657-667. doi: 10.4196/kjpp.2016.20.6.657. Epub 2016 Oct 28.
citation: Fadini GP, Albiero M, Bonora BM, Avogaro A. Angiogenic Abnormalities in Diabetes Mellitus: Mechanistic and Clinical Aspects. J Clin Endocrinol Metab. 2019 Nov 1;104(11):5431-5444. doi: 10.1210/jc.2019-00980.
citation: Cianfarani F, Toietta G, Di Rocco G, Cesareo E, Zambruno G, Odorisio T. Diabetes impairs adipose tissue-derived stem cell function and efficiency in promoting wound healing. Wound Repair Regen. 2013 Jul-Aug;21(4):545-53. doi: 10.1111/wrr.12051. Epub 2013 Apr 29.
citation: Rennert RC, Sorkin M, Januszyk M, Duscher D, Kosaraju R, Chung MT, Lennon J, Radiya-Dixit A, Raghvendra S, Maan ZN, Hu MS, Rajadas J, Rodrigues M, Gurtner GC. Diabetes impairs the angiogenic potential of adipose-derived stem cells by selectively depleting cellular subpopulations. Stem Cell Res Ther. 2014 Jun 18;5(3):79. doi: 10.1186/scrt468.
citation: Navarro A, Marin S, Riol N, Carbonell-Uberos F, Minana MD. Human adipose tissue-resident monocytes exhibit an endothelial-like phenotype and display angiogenic properties. Stem Cell Res Ther. 2014 Apr 14;5(2):50. doi: 10.1186/scrt438.
citation: Kornicka K, Houston J, Marycz K. Dysfunction of Mesenchymal Stem Cells Isolated from Metabolic Syndrome and Type 2 Diabetic Patients as Result of Oxidative Stress and Autophagy may Limit Their Potential Therapeutic Use. Stem Cell Rev Rep. 2018 Jun;14(3):337-345. doi: 10.1007/s12015-018-9809-x.
citation: Inoue O, Usui S, Takashima SI, Nomura A, Yamaguchi K, Takeda Y, Goten C, Hamaoka T, Ootsuji H, Murai H, Kaneko S, Takamura M. Diabetes impairs the angiogenic capacity of human adipose-derived stem cells by reducing the CD271+ subpopulation in adipose tissue. Biochem Biophys Res Commun. 2019 Sep 17;517(2):369-375. doi: 10.1016/j.bbrc.2019.07.081. Epub 2019 Jul 27.
citation: Wang SK, Green LA, Motaganahalli RL, Wilson MG, Fajardo A, Murphy MP. Rationale and design of the MarrowStim PAD Kit for the Treatment of Critical Limb Ischemia in Subjects with Severe Peripheral Arterial Disease (MOBILE) trial investigating autologous bone marrow cell therapy for critical limb ischemia. J Vasc Surg. 2017 Jun;65(6):1850-1857.e2. doi: 10.1016/j.jvs.2017.01.054. Epub 2017 Apr 5.
citation: Hao C, Shintani S, Shimizu Y, Kondo K, Ishii M, Wu H, Murohara T. Therapeutic angiogenesis by autologous adipose-derived regenerative cells: comparison with bone marrow mononuclear cells. Am J Physiol Heart Circ Physiol. 2014 Sep 15;307(6):H869-79. doi: 10.1152/ajpheart.00310.2014. Epub 2014 Jul 25.
citation: Kondo K, Shintani S, Shibata R, Murakami H, Murakami R, Imaizumi M, Kitagawa Y, Murohara T. Implantation of adipose-derived regenerative cells enhances ischemia-induced angiogenesis. Arterioscler Thromb Vasc Biol. 2009 Jan;29(1):61-6. doi: 10.1161/ATVBAHA.108.166496. Epub 2008 Oct 30.
citation: Bora P, Majumdar AS. Adipose tissue-derived stromal vascular fraction in regenerative medicine: a brief review on biology and translation. Stem Cell Res Ther. 2017 Jun 15;8(1):145. doi: 10.1186/s13287-017-0598-y.
citation: Zollino I, Campioni D, Sibilla MG, Tessari M, Malagoni AM, Zamboni P. A phase II randomized clinical trial for the treatment of recalcitrant chronic leg ulcers using centrifuged adipose tissue containing progenitor cells. Cytotherapy. 2019 Feb;21(2):200-211. doi: 10.1016/j.jcyt.2018.10.012. Epub 2018 Dec 22.
citation: Huang P, Li S, Han M, Xiao Z, Yang R, Han ZC. Autologous transplantation of granulocyte colony-stimulating factor-mobilized peripheral blood mononuclear cells improves critical limb ischemia in diabetes. Diabetes Care. 2005 Sep;28(9):2155-60. doi: 10.2337/diacare.28.9.2155.
citation: Fadini GP, Albiero M, Vigili de Kreutzenberg S, Boscaro E, Cappellari R, Marescotti M, Poncina N, Agostini C, Avogaro A. Diabetes impairs stem cell and proangiogenic cell mobilization in humans. Diabetes Care. 2013 Apr;36(4):943-9. doi: 10.2337/dc12-1084. Epub 2012 Oct 30.
citation: Dong Z, Pan T, Fang Y, Wei Z, Gu S, Fang G, Liu Y, Luo Y, Liu H, Zhang T, Hu M, Guo D, Xu X, Chen B, Jiang J, Yang J, Shi Z, Zhu T, Shi Y, Liu P, Fu W. 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. EBioMedicine. 2018 Sep;35:46-57. doi: 10.1016/j.ebiom.2018.08.038. Epub 2018 Aug 29.
citation: Fowkes FG, Rudan D, Rudan I, Aboyans V, Denenberg JO, McDermott MM, Norman PE, Sampson UK, Williams LJ, Mensah GA, Criqui MH. Comparison of global estimates of prevalence and risk factors for peripheral artery disease in 2000 and 2010: a systematic review and analysis. Lancet. 2013 Oct 19;382(9901):1329-40. doi: 10.1016/S0140-6736(13)61249-0. Epub 2013 Aug 1.
citation: Reinecke H, Unrath M, Freisinger E, Bunzemeier H, Meyborg M, Luders F, Gebauer K, Roeder N, Berger K, Malyar NM. Peripheral arterial disease and critical limb ischaemia: still poor outcomes and lack of guideline adherence. Eur Heart J. 2015 Apr 14;36(15):932-8. doi: 10.1093/eurheartj/ehv006. Epub 2015 Feb 2.
citation: Vas PRJ, Edmonds M, Kavarthapu V, Rashid H, Ahluwalia R, Pankhurst C, Papanas N. The Diabetic Foot Attack: "'Tis Too Late to Retreat!". Int J Low Extrem Wounds. 2018 Mar;17(1):7-13. doi: 10.1177/1534734618755582. Epub 2018 Feb 12.