自体外周血干细胞移植治疗糖尿病下肢血管病变与糖尿病足效果:89例自身对照观察(英文)

Autologous peripheral blood stem cells transplantation for the treatment of diabetic vascular disorder in lower extremities and diabetic feet Self-control observation of 89 patients

背景：骨髓干细胞在一定诱导条件下可分化成为血管性内皮细胞的特性，促进侧支循环的建立，从而改善缺血组织血供。目的：观察白体外周血干细胞移植治疗糖尿病下肢血管病变与糖尿病足的临床效果。设计：自身前后对照观察。单位：武汉市中心医院。对象：选择2005—07／2007—05在武汉市中心医院内分泌科收治的89例2型糖尿病下肢血管病变患者，均符合1999年WHO糖尿病诊断及分型标准，且合并糖尿病周围血管病变及糖尿病足。男61例，女28例。年龄45～90岁，平均67岁。病变部位主要为双下肢，伴足部溃疡者54例，伴坏疽者8例。所有受试对象均对检测项目知情同意，实验经过医院伦理委员会批准。实验用重组人粒细胞集落因子购自中国麒麟鲲鹏生物药业有限公司。方法：①干细胞动员：全部患者均皮下注射重组人粒细胞集落因子500～600μg/d，注射5d后采集外周血干细胞，采集物总量83～103mL，单个核细胞数量1．86～3．39×10^11L^-1，CD34^＋细胞为0．55％～1．36％。②外周血干细胞移植：患者均行静脉麻醉，将采集的外周血干细胞悬液按3cm^2×3cm^2间距进行缺血肢体肌间分层注射。主要观察指标：①白体外周血干细胞移植前及移植后1，3和6月患肢疼痛、冷感、间歇性跛行、踩肱指数、肢体皮温及深部感觉检测及评估。②应用彩色超声多普勒、CT及血管造影检测患者下肢血管形态学变化。结果：纳入患者89例，89例患者均进入结果分析，无脱落者。①临床症状评分：自体外周血干细胞移植后不同时间点患肢疼痛、冷感、间歇性跛行情况较移植前均有改善，且随着时间延长改善程度逐渐增加，差异有显著性意义（P〈0．05）。②踩肱指数：随自体外周血干细胞移植时间的延长患者踩肱指数均有不同程度增高，差异有显著性意义（P〈0．05）。③肢体皮温及深部感觉检测结果：移植后患者肢体皮温较移植前有所升高，差异有显著性意义（P〈0．05），深部感觉检测肢体感觉功能有所改善，差异无统计学意义（P〉0．05）。④影像学检测结果：移植后患者下肢血管彩色多普勒与移植前比较未见明显变化：CT及血管造影显示23例患者有不同程度新生侧支血管形成。结论：自体外周血干细胞移植可增加糖尿病下肢血管病变与糖尿病足患者的下肢血流，促进部分患者下肢血管新生。

BACKGROUND： Bone marrow stem cells can be induced to differentiate into vascular endothelial cells and facilitate establishment of compensatory circulation, so as to improve blood supply of ischemic tissues. OBJECTIVE： To observe the clinical efficacy of autologous peripheral blood stem cells （PBSCs） transplantation in the treatment of diabetic vascular disorder in the lower extremities and diabetic feet. DESIGN： Self-control observation. SETTING： Wuhan Central Hospital, Wuhan, Hubei Province, China. PARTICIPANTS： A total of 89 patients with type 2 diabetic vascular disorder in the lower extremity were enrolled from Department of Endocrinology in Wuhan Central Hospital from July 2005 to May 2007. All cases matched the criteria of diabetes by WHO in 1999, and complicated with diabetic peripheral angiopathy and diabetic feet. They included 61 males and 28 females, aged 45-90 years, with an average age of 67. Lesion was mainly located in lower extremities, 54 patients with foot ulcers while 8 patients with gangrene. All the patients signed the informed consents, and the experiment was approved by the hospital ethics committee. Recombinant human granulocyte colony stimulating factor was purchased from China Kirin Kunpeng Bio-Pharmaceutical Co.,Ltd. METHODS： Stem cell mobilization： 89 patients all received recombinant human granulocyte colony stimulating factor, 500- 600 μg per day by hypodermic injection for 5 days to mobilize stem cells. On the fifth day, PBSCs were collected with a total amount of 83-103 mL. The number of mononuclear cells was （1.86-3.39）×10^11 L^-1, while the proportion of CD34 positive cells was 0.55%-1.36%.PBSCs transplantation： After patients were treated with intravenous anesthesia, PBSCs were injected into the ischemic lower extremity and foot intramuscularly at 3 crux3 cm distance. The clinical and laboratory findings were monitored from the first day to the sixth month. MAIN OUTCOME MEASURES： The patients were evaluated before transplantation, and in the first, third and sixth months after transplantation, including affected limb pain, cool feeling, intermittent claudication, ankle brachial index （ABI）, limb skin temperature and deep feeling. Color Doppler, CT and digital subtraction angiography were applied to detect lower extremities morphous. RESULTS： All 89 included patients were involved in the result analysis. Scores of clinical symptom： The affected limb pain, cool feeling, and intermittent claudication were all improved significantly after PBSCs transplantation （P 〈 0.05）, and the improvement was more evident with time extension. ABI： After PBSCs transplantation, ABI in patients increased significantly by different degrees with the time extension （P 〈 0.05）. Skin temperature and deep feeling： Limb skin temperature increased significantly after transplantation （P 〈 0.05）, and deep feeling seemed to be improved, but the change was not significant （P 〉 0.05）. Imaging determination： There was no obvious change after transplantation checking of lower extremity by color Doppler. But CT and digital subtraction angiography results showed lower extremities in 23 patients had new collateral vessels formation with different degrees. CONCLUSION： Autologous PBSCs transplantation can increase blood flow of lower extremities in patients with diabetic vascular disorder in the lower extremities and diabetic feet, and promote the angiogenesis in lower extremity of partial patients.