自体骨髓干细胞移植治疗重症糖尿病足的效果:11例报告

Autologous transplantation of bone marrow stem cells for severe diabetic feet:A report of 11 cases

目的:观察自体骨髓干细胞移植治疗糖尿病足的效果和安全性。方法:回顾性分析2003-03/2004-01解放军第三○五医院应用自体骨髓干细胞移植治疗的11例重度糖尿病足患者,男7例,女4例;平均年龄70.6岁;糖尿病足左下肢6条,右下肢7条。①术前主要临床症状及体征:13条患肢中,静息痛1级1条,2级3条,3级6条,4级3条;均有不同程度的冷、凉感觉,患肢冷感2级3条,3级7条,4级3条;下肢间歇性跛行均为4级。②辅助检查:所有患者在移植前、后均进行经皮氧分压的测定,并予以侧支血管评估。③自体骨髓干细胞的提取与移植:局麻下从髂骨处抽取自体骨髓血350mL,体外分离单个核细胞悬浊液约40mL,多点肌肉注射到缺血下肢,0.8～1.0mL/点,各点间距约3.0cm×3.0cm。所有患者均进行随访,随访15～24个月。结果:11例重度糖尿病足患者均完成随访,平均18.5个月。①术后糖尿病足患者症状与体征改善情况:移植后8周,足部疼痛改善率84.6%,小腿疼痛缓解率100%,患肢冷感明显改善或消失。移植后2～6个月,3例因患足坏疽感染及再疼痛加重而截肢。移植6个月后,2例分别死于脑血管意外、心功能衰竭,死前出现患足疼痛加重,5例有不同程度再出现患足痛,1例持续缓解。②术后辅助检查结果:术前内踝部经皮氧分压值<2.66kPa的10条下肢,术后5条>3.99kPa,2条达2.66～3.99kPa之间,3条仍<2.66kPa,此3条下肢最后予以截肢;术前内踝部经皮氧分压>2.66kPa的3条下肢,术后均>3.99kPa,肢体均被保留。7例患者8条下肢于术后1～3个月接受下肢动脉造影,发现均有不同程度的新生侧支血管形成。结论:自体骨髓干细胞移植早期对于改善糖尿病足缺血、缓解缺血症状有一定作用,重症患者症状缓解时间短。

AIM： To observe the efficacy and safety of autologous transplantation of bone marrow stem cells for treating patients with diabetic feet. METHODS： Totally 11 subjects with severe diabetic feet treated by autologous transplantation of bone marrow stem cells at the 305 Hospital of Chinese PLA from March 2003 to January 2004 were enrolled for retrospective analysis. Of them, there were 7 males and 4 females; median age was 70.6 years; diabetic feet included 6 left lower extremities and 7 right lower extremities. ①Preoperative clinical symptom and physical sign： Of the 13 affected extremities, there were 1 one-grade rest pain extremity, 3 two-grade rest pain extremities, 6 three-grade rest pain extremities and 3 four-grade rest pain extremities. There was cold or cool sensation to different degree, 3 extremities with two-grade cold sensation, 7 extremities with three-grade cold sensation and 3 extremities with four-grade cold sensation. Intermittent limping of lower extremity was four-grade. ② Auxiliary examination： All the patients were treated with transcutaneous oxygen tension before and after the transplantation. The collateral branch vessel was evaluated.③Extraction and transplantation of autologous bone marrow stem cells： 350 mL autologous bone marrow stem cell was extracted from flank bone after local anesthesia. About 40 mL mononuclear cell suspension was isolated in vitro and injected into ischemic lower extremity through muhipoint muscles, 0.8-1.0 mL per point, 3.0 cm×3.0 cm interval from one point to another point. All the patients were followed up for 15- 24 months. RESULTS： Totally 11 subjects with severe diabetic feet carried out the follow up, averagely 18.5 months. ①Amelioration of symptom and physical sign in subjects with diabetic feet after operation： Eight weeks after transplantation, amelioration rate of feet pain was 84.6%; easement rate of leg pain was 100%. Cold sensation of affected extremity markedly improved or disappeared. At months 2-6 after transplantation, 3 subjects received amputated extremity because affected feet were mortification infection and pain became more serious. Six months after transplantation, 2 subjects died from cerebrovascular accident, failure of heart function, and before death pain of affected feet became severe. Five subjects had pain of affected feet to different degree, and one subject relieved continuously. ② Result of postoperative auxiliary examination： Before operation score of transcutaneous oxygen tension was less than 2.66 kPa in internal medial malleolus of 10 lower extremities. After operation the score was more than 3.99 kPa in 5 lower extremities, between 2.66 kPa-3.99 kPa in 2 lower extremities, less than 2.66 kPa in 3 lower extremities that were amputated at last. The score of transcutaneous oxygen tension in 3 lower extremities with more than 2.66 kPa before operation was more than 3.99 kPa after operation. Extremities were remained. After receiving arteriography in 7 subjects （8 lower extremities） at months 1-3, new collateral vessels were formed to different degree. CONCLUSION： Autologous transplantation of bone marrow stem cells in an early period has a certain effect in ameliorating ischemia of diabetic feet, relieving ischemic symptom. The duration of symptomatic relief for severe subjects is short.