自体骨髓干细胞移植治疗糖尿病足17例

Autologous bone marrow stem cell transplantation for diabetic foot in 17 cases

目的:观察自体骨髓干细胞下肢局部肌肉注射移植对糖尿病足的治疗效果。方法:①选择2004-03/2005-10郑州市中心医院内分泌内科住院确诊的糖尿病足患者17例(共17条患肢,左下肢10条,右下肢7条),男11例,女6例;年龄62～78岁,平均69岁;足部坏疽6例,静息痛或/和间歇性跛行11例。②纳入标准:不同程度的趾端坏疽、缺血性溃疡或静息痛;生活方式或职业必须解决的间歇性跛行;强烈要求缓解间歇性跛行者;血管造影证明存在周围动脉闭塞性病变,病变远端流出道差。排除标准:并发严重心、肺、肾、脑等脏器功能不全或不能耐受手术者。③分别采集患者自体骨髓,从双侧髂后上棘穿刺,每例约采集骨髓250～300mL,Ficoll液分离,配制成干细胞混悬液50mL,细胞计数为4×108～9×108。静脉麻醉下进行小腿肌肉及足部局部注射,每个位点注射0.3～0.5mL,两个位点间距约3cm,进针深度1.5～2.0cm/下肢,0.5～1.0cm/足部。④分别于术前及术后12周对患者进行肢体疼痛、冷感、间歇跛行状况评估,并采用SDW数字点温仪检测患者足背第3趾根后2cm皮肤温度,以多普勒血流探测仪及臂踝指数检查套件测量踝肱指数。观察溃疡的外观、范围、深度,有无异常症状或体症出现;血、尿、粪常规以及肝、肾功能和出、凝血时间的改变。结果:17例糖尿病足患者全部完成1年随访而进入结果分析。①基本体征指标的改变:骨髓干细胞移植后患者肢体疼痛、患肢冷感、间歇性跛行、皮肤温度及踝肱指数均得到明显缓解,与术前比较差异显著(t=-9.644～7.750,P均<0.01)。②术后足部坏疽病例创面愈合情况:5例糖尿病足患者于术后14～55d足部坏疽创面感染被控制,局部有新鲜肉芽出现,创面明显缩小并基本愈合;1例患者在接受骨髓干细胞移植的同时对足部坏疽进行彻底清创,切除坏死的左足第2趾关节远端,术后14d伤口完全愈合。③不良事件和副反应:17例糖尿病足患者骨髓干细胞移植后均未出现异常症状或体症,血、尿、粪常规及肝、肾功能和出、凝血时间均正常。随访1年,无不良反应发生。结论:自体骨髓干细胞下肢局部肌肉注射移植治疗糖尿病足患者,能够明显改善肢体疼痛、冷感、间歇跛行、踝肱指数等指标,安全有效。

AIM： To observe the therapeutic efficacy of autologous transplantation of bone-marrow mononuclear cells in treatment of patients with diabetic foot by local intramuscular injection. METHODS： ①Totally 17 patients were selected （17 injured limbs, 10 left lower limbs, 7 right lower limbs） with diabetic foot which were treated in the Department of Endocrinology, Zhengzbou Central Hospital from March 2004 to October 2005. There were 11 men and 6 women. The mean age was 69 years （range 62-78 years）. There were 6 cases of feet necrosis and 11 cases of rest pain or intermittent limp. ②inclusive criteria： Different degree of toe necrosis, ischemic ulcer or rest pain, intermittent limping which must be solved for lift style or occupation, longing for relief limp, ambient artery obturated or incommodious disease which were be proved by arteriography. Exclusive criteria： Having severe function failure in heart, lung, kidney or brain and failed to bear operation. ③Autologous bone marrow was collected from patients, and puncture was done from double ilium, about 250-300 mL bone marrow from each case, and separated by Ficoll, then confected 50 mL mixture of stem cell which took count of 4×10^6-9×10^8. Stem cells were injected into leg muscles and feet for transplantation when patients were in vein anaesthesia, 0.3-0.5 mL every point, the distance between two points was 3 cm. The depth was 1.5-2.0 cm/lower limb, 0.5-1.0 cm/foot. ④Limb ache, cold-feeling and intermittent limping were monitored and evaluated 12 weeks before and after operation. The temperature of 2 cm from third toe was measured by SDW digital subtraction arteriography. The ankle-brachial index was measured by Doppler blood stream probe. The guise, bound and depth of ulcers were observed for abnormal symptom or physical sign. It was measured for the change of blood, urine, feces, function of renal and liver, time of hemorrhage and cruor. RESULTS： All 17 patients with diabetic foot were followed up for one year and then were involved in the result analysis. ①change of essential physical sign： After transplantation, aching, cold feeling and intermittent limp, temperature of skin and ankle-brechial index were significantly relieved and compared with that before operation, the difference was significant （t =-9.644-7.750,P 〈 0.01）. ②wound surface healing condition of foot necrosis after operation： 14-55 days after operation, 5 patients with diabetic foot after operation, wound surface defection were controlled, new granulation tissue appeared in the wound region; wound surface contracted obviously and heal mostly. One patient accepted autologous transplantation of bone-marrow stem cells and meanwhile, the necrosis tissue was cleaned thoroughly of food and the end of the second toe of left foot for necrosis was cut. The wound was healed thoroughly 14 days after operation. ③adverse event and side effect： There were no abnormal symptom or physical sign in 17 patients with diabetic foot after autologous transplantation of bone-marrow stem cells, blood routine test, urine routine test, stool routine test, hepatic function test, renal function test, bleeding time and clotting time were all in normal range. After one-year following up, no adverse reaction took place. CONCLUSION： Autologous transplantation of bone-marrow stem cells for patients with diabetic foot by local intramuscular injection can ameliorate obviously leg aching, cold feeling, intermittent limping, ankle-brachial index, etc. It is safe and effective.