RICARDO BASTOS, MD PhD

Transcription

1 INTRA-ARTICULAR INJECTIONS OF EXPANDED MESENCHYMAL STEM CELLS WITH AND WITHOUT ADDITION OF PLATELET-RICH PLASMA: A RANDOMIZED, DOUBLE- BLIND AND CONTROLLED CLINICAL TRIAL RICARDO BASTOS, MD PhD Renato Andrade, Ronaldo José F. C. Do Amaral, Marcelo B. Mathias, Raquel C. Bastos, Rogério Pereira, Alex Balduino, Vinicius Schott-Gameiro, Scott A. Rodeo, João Espregueira-Mendes Clínica do Dragão - Espregueira-Mendes Sports Centre FIFA Medical Centre of Excellence Dom Henrique Research Centre PORTO, PORTUGAL Universidade Federal Fluminense UFF Niterói, Brazil

2 DISCLOSURE STATEMENT Patients dislocation fares, patients feeding cost, hospitalization, surgical procedures related costs, cells storage, biological substances transportation and all other minor costs related with the study were sponsored by ESHO Empresa de Serviços Hospitalares S.A.

3 BACKGROUND AND PURPOSE Adult cartilage regeneration is still a challenge for the treatment of degenerative joint diseases owing the sparse distribution of differentiated chondrocytes, the low supply of progenitor cells, and the lack of vascularization. and the PRP therapies displayed a promising role in the treatment of knee OA. But still show conflicting results in the literature. Purpose: To compare the clinical and laboratory outcomes of intra-articular injection of culture-expanded with or without PRP to intra-articular corticosteroid injection for the treatment of knee OA.

4 Randomized double-blind three-arm controlled clinical trial. METHODS A total of 47 patients (mean age 53.3 years, 51% males) with radiographic symptomatic knee OA. Randomization into 3 groups for intra-articular injections : 1. autologous bone marrow-derived, culture-expanded (n=16) 2. autologous bone marrow-derived culture-expanded enriched with PRP (n=14) 3. corticosteroid (n=17). KOOS and ROM at baseline and 1, 2, 3, 6, 9 and 12 months follow-up. Intra-articular cytokines at baseline, and 6 and 12 months.

5 HARVESTING AND CULTURE separation Intra-articular injection expantion / culture 10mL PBS + 2% Human Albumin or autologous PRP 40x10 6 No more than 2 passages

6 PRP PREPARATION 54mL peripheral blood 2 centrifugation steps 10 6 platelet/µl in 10mL PBS + MSC

7 RESULTS The sample was homogenous for the baseline sociodemographic and clinical characteristics between the three groups. (n=16) +PRP (n=14) Corticosteroid (n=17) P value Gender Female 6 (37.5%) 9 (64.3%) 8 (47.1%) 0.336* Male 10 (62.5%) 5 (35.7%) 9 (52.9%) Age, mean ± SD 55.7 ± ± ± ** IMC, mean ± SD <30Kg/m ± % 28.9 ± % 31.0 ± % 0.434** 30Kg/m 2 57% 36% 53% Alignment, No. (%) Normal alignment 3 (18.8%) 6 (42.9%) 7 (41.2%) Varus 13 (81.3%) 5 (35.7%) 4 (23.5%) 0.047* Valgus 0 (0.0%) 3 (21.4%) 6 (35.3%) OA grade, No. (%) Grade I 1 (6.3%) 0 (0.0%) 1 (7.1%) Grade II 7 (43.8%) 4 (30.8%) 3 (21.4%) Grade III 5 (31.3%) 8 (61.5%) 6 (42.9%) Grade IV 3 (18.8%) 1 (7.7%) 4 (28.6%) ROM, mean ± SD (95% CI) Hiperextention 2.2 ± 4.1 (0.0, 4.4) 0.7 ± 2.7 (-0.8, 2.3) 1.0 ± 2.1 (-0.1, 2.1) 0.429*** Flexum 2.5 ± 5.8 (-0.6, 5.6) 3.2 ± 4.6 (0.5, 5.9) 3.9 ± 6.3 (0.4, 7.3) 0.543*** Total flexion ± 39.4 (83.4, ± 18.3 (108.2, 128.5) 0.903*** ± 26.6 (99.9, 130.6) 125.4) KOOS, mean ± SD (95% CI) Symptoms 41.5 ± 18.4 (31.7, 51.3) 44.6 ± 14.9 (36.1, 53.2) 47.4 ± 17.9 (38.2, 56.6) 0.625** Pain 34.5 ± 11.4 (28.5, 40.6) 42.3 ± 17.2 (32.3, 52.2) 40.5 ± 19.6 (30.4, 50.6) 0.402** Function, daily living 31.7 ± 19.1 (21.5, 41.9) 41.2 ± 18.2 (30.7, 51.7) 40.7 ± 21.0 (29.9, 51.4) 0.320** Sports / Recreation 13.1 ± 21.0 (2.0, 24.3) 18.9 ± 23.5 (5.4, 32.5) 18.2 ± 28.3 (3.7, 32.8) 0.821*** Quality of life 16.8 ± 12.4 (10.1, 23.4) 19.2 ± 20.3 (7.5, 30.9) 16.5 ± 16.5 (8.0, 25.0) 0.889** Global KOOS score 30.3 ± 13.1 (23.3, 37.3) 37.3 ± 16.4 (27.8, 46.7) 36.9 ± 17.8 (27.7, 46.0) 0.395** *Qui square test ** ANOVA ***Kruskall Wallis

8 RESULTS The group showed significant improvements for all KOOS domains and global score between the baseline and first month (p<0.005) and baseline and the 12-month endpoint (p<0.05). The + PRP group showed significant improvements on the KOOS domains and global score between the baseline and first month (p<0.05) except in KOOSsymptoms (p=0.148) and KOOS-QoL (p=0.054) domains - and from baseline to the 12-month endpoint (p<0.05) except the KOOS-QoL domain (p=0.06). The corticosteroid group showed significant improvement all KOOS domains from baseline and first month except the KOOS-symptoms domain (p=0.05) - and on KOOS-pain (p=0.03) and KOOS-ADL (p=0.03) from baseline and the 12-month period KOOS 0-1 Symptoms PRP Corticosteroid All groups < Pain +PRP Corticosteroid All groups ADL +PRP Corticosteroid All groups Sport/Rec +PRP Corticosteroid All groups QoL +PRP Corticosteroid All groups Global KOOS +PRP Corticosteroid All groups < < < < < < < < < < < < Overall** < < < < < < < * Wilcoxon Signed Rank Test ** Friedman Test

9 RESULTS The corticosteroid group had highest percentage for score worsening for all KOOS domains and global score, except for the KOOS-QoL domain. The addition of PRP ( + PRP group) lead to a higher percentage of expected improvement for the KOOS-pain domain. group obtained a higher percentage of expected improvement for the KOOS-QoL domain. KOOS domain Symptom s Pain ADL Sport/Rec QoL Global KOOS Group Score got worse Score unchanged Score improved Corticosteroid n=6, (35.3%) n=0, (0.0%) n=11, (64.7%) n=3, (18.8%) n=0, (0.0%) n=13, (81.2%) +PRP n=3, (2.4%) n=1, (7.1%) n=10, (90.5%) All groups n=12, (25.5%) n=1, (2.1%) n=34, (72.4%) Corticosteroid n=4, (23.5%) n=2, (11.8%) n=11, (64.7%) n=2, (12.5%) n=0, (0.0%) n=14, (87.5%) +PRP n=3, (21.4%) n=0, (4.3%) n=11, (74.3%) All groups n=9, (19.1%) n=2, (4.3%) n=36, (76.6%) Corticosteroid n=5, (29.4%) n=1, (5.9%) n=11, (64.7%) n=1, (6.3%) n=1, (6.3%) n=14, (87.4%) +PRP n=1, (7.1%) n=0, (0.0%) n=13, (92.9%) All groups n=7, (14.9%) n=2, (4.3%) n=38, (80.8%) Corticosteroid n=3, (17.6%) n=1, (5.9%) n=13, (76.5%) n=0, (0.0%) n=3, (18.8%) n=13, (81.2%) +PRP n=3, (2.4%) n=3, (21.4%) n=8, (76.2%) All groups n=6, (12.8%) n=7, (14.9%) n=34, (72.3%) Corticosteroid n=3, (17.6%) n=3, (17.6%) n=11, (64.8%) n=2, (12.5%) n=1, (6.3%) n=13, (81.2%) +PRP n=3, (21.4%) n=4, (28.6%) n=7, (50.0%) All groups n=8, (17.0%) n=8, (17.0%) n=31, (66.0%) Corticosteroid n=7, (41.2%) n=0, (0.0%) n=10, (58.8%) n=2, (12.5%) n=1, (6.3%) n=13, (81.2%) +PRP n=2, (14.3%) n=0, (0.0%) n=12, (85.7%) All groups n=11, (23.4%) n=1, (2.1%) n=35, (74.5%)

10 RESULTS SUBGROUP ANALYSIS When considering knee ROM, neither treatment showed significant superiority considering all subgroup analyses. For KOOS domains and global score, the gender, obesity and OA grading subgroup analyses did not show any significant differences between treatments. For the population older or equal to 60 years old the + PRP group showed significant superiority for the KOOS-pain (p=0.026) and KOOS-QoL (p=0.019) domains and global score (p=0.043) at 6 months, KOOS-pain (p=0.014) and KOOS-QoL (p=0.024) domains and global score (p=0.030) at 9 months, and KOOS-ADL domain at 12 months (p=0.026).

11 RESULTS Cytokine Treatment group Baseline Mean ± SD IL-17A IFN-GAMA Human-TNF Human-IL10 Human-IL6 Human-IL4 Human-IL2 6-month follow-up Mean ± SD p* 12-month follow-up Mean ± SD (n=12) PRP (n=10) Corticosteroid (n=13) Intergroup sig*** (n=12) PRP (n=10) Corticosteroid (n=13) Intergroup sig*** (n=12) PRP (n=10) Corticosteroid (n=13) Intergroup sig*** (n=12) PRP (n=10) Corticosteroid (n=13) Intergroup sig*** (n=12) PRP (n=10) Corticosteroid (n=13) Intergroup sig*** (n=12) PRP (n=10) Corticosteroid (n=13) Intergroup sig*** (n=12) PRP (n=10) Corticosteroid (n=13) Intergroup sig*** p** CYTOKINE QUANTIFICATION Overall decrease in inflammatory cytokines levels High variability among samples Higher decreases from baseline to 12 mo follow-up in MSC+PRP groups

12 DISCUSSION Corticosteroid injections have been used for conservative treatment of OA and several local and systemic undesirable effects have been reported besides its short-term efficacy. Despite the similarity of the three groups of treatment during the first and second months of treatment, corticosteroid group showed an inferior number of improved KOOS domains from baseline to 12 months and the highest percentage of score worsening for all KOOS domains and global score, excepting KOOS-QoL domain. This finding reinforces the known short-term effect of corticosteroid intra-articular injections. Conversely, the and + PRP group showed the highest percentage of improvement at 12 months in all KOOS domains and global score, in exception of + PRP group in the KOOS -sports-rec and KOOS-QoL domains.

13 CONCLUSION MSC and MSC+PRP are safe. MSC and MSC+PRP induced greater clinical benefits than corticosteroid MSC+PRP superiority in older population Decrease in cytokines levels