Keywords cell therapy - inflammation - joint pain - orthopedics - regenerative medicine - Unified
Health System
Introduction
Adipose-derived stem cells (ADSCs) have interesting results in the treatment of osteoarthritis
(OA).[1 ] Our preclinical results indicated that ADSCs, by paracrine effect and cell differentiation,
can lead to improved repair and regeneration of cartilage.[2 ] These data were important to start a clinical study which will use ADSCs in the
treatment of OA in humans, and to implement innovative therapies at the Cell Processing
Center, in partnership with the Orthopedics Service at Universitary Hospital Maria
Aparecida Pedrossian (HUMAP/EBSERH), in the city of Campo Grande, state of Mato Grosso
do Sul (MS), Brazil.
The present study reports the results of the first cell therapy with ADSCs in a patient
of the Brazilian Unified Health System (Sistema Único de Saúde, SUS).
Case report
A male patient, aged 66 years, weighing 93 kg, and 1,75m, with a diagnosis of medial
meniscus rupture in the right knee, with grade III OA (in the Kellgreen and Lawrence
classification through radiographic evaluation), and total prosthesis in the left
knee. In the clinical evaluation, he reported intermittent pain in the right knee,
presented joint cracking with movement, increased knee circumference, and decreased
range of motion (ROM), only being able to flex the leg up to 95° without feeling pain.
During the interview, we applied the Visual Analog Scale (VAS), the Short Form Health
Survey (SF-36), and the Western Ontario and McMaster Universities (WOMAC) osteoarthritis
index. The patient was then informed about the treatment with ADSCs and signed the
free and informed consent form for the use of cell therapy.
The following week, a videoarthroscopy surgery was performed according to the routine
of the Orthopedics Service (HUMAP/EBSERH) ([Fig. 1C-D ]), was performed only cleaning of the joint and light debridement of the affected
cartilage. After one week, the patient returned to the hospital for the collection
of adipose tissue, a procedure performed by liposuction.[3 ]
Fig. 1 Videoarthroscopy surgical procedure. (A ) Arthrocentesis. (B ) Collected synovial fluid. (C ) Positioning of the surgical instruments and entry sites. (D ) Visualization of articular cartilage to clean debris or areas without leveling.
Regarding of the liposuction processing, extraction, culture, characterization (immunophenotyping:
CD105, CD90, CD34 and CD133), and cell differentiation (adipogenic, chondrogenic and
osteogenic) were performed according to Schweich et al.[4 ] (2017). The cultivation of ADSCs for transplantation occurred for 25 days (3rd passage),
until reaching the necessary amount ([Fig. 2 ]).[4 ] Bacteriological testing was performed before the cell therapy. Then, the patient
returned and received an intra-articular injection containing 1 × 107 of ADSCs homogenized in 3 mL of saline solution ([Fig. 2 ]). A bandage was applied around the treated knee to avoid limb flexion in the first
12 hours.
Fig. 2 Flowchart of the procedures to obtaining and process lipoaspirate, cultivation of
adipose-derived stem cells, and application in the knee with osteoarthritis.
The collection of synovial fluid occurred in two moments: in the operating room, before
the videoarthroscopy ([Fig. 1B ]), and after six months of cell therapy. For the analysis of the inflammatory process,
we used the CBA Human Inflammatory Cytokines KIT (BD Biosciences, Franklin Lakes,
NJ, US), according to the manufacturer's instructions, by flow cytometry (Cytoflex,
Beckman Coulter, Inc., Brea, CA, US).
Regarding the results of the cell therapy, we observed that, in the evaluation of
the domains of the SF-36 questionnaire, functional capacity and limitation by physical
aspects improved by 3x pain by 2,6x, social aspects by 2,5x, the emotional aspects
by 2x, mental health by 1,4x and general health and vitality by 1.1x ([Fig. 3A ]).
Fig. 3 Values acquired after proposed evaluations, in the period before and after treatment
with ADSCs. (A ) Score of the SF-36 questionnaire applied before the intervention and after 6 months.
(B ) WOMAC questionnaire scores before the intervention, at the 3rd month and at the
6th month. (C ) EVA classification performed before the intervention, in the 3rd month and in the
6th month. (D ) Quantification of inflammatory cytokines before intervention and at the 6th month.
The WOMAC questionnaire indicated a reduction in the score of the domains in both
evaluations at three and six months after the cell therapy. In the second evaluation,
in relation to the initial condition, the decrease was 0,55x in pain intensity, 0,43x
in stiffness, 0,84x for physical activity and 0,76x in the total score ([Fig. 3B ]).
The EVA scale showed a descrease of 0,8x and 0,63x for the first (3 months) and second
(6 months) assessments, respectively ([Fig. 3C ]).
The macroscopic evaluation of the synovial fluid showed improved viscosity, reduction
of opacity, and greater homogeneity. The evaluation of inflammatory cytokines showed
a decrease of 0,73x of TNF, 0,71x of IL-1b, 0,68x of IL-8 and 0,70x of IL-10. In IL-6,
an increase of 1.48x was observed ([Fig. 3D ]).
Discussion
The way of action of ADSCs in the treatment of OA occurs through three different biological
effects: cell differentiation, inflammatory modulation (paracrine effect) and mediation
of condroprotectors.[5 ] In the present report, the scores on the SF-36, WOMAC and EVA demonstrate that cell
therapy can improve the condition of patients with OA, since it improves the functionality
of the affected limb and the patient as a whole, which reflects in the return to activities
of daily living and improvements in the overall quality of life, these results corroborate
with the current literature.[6 ]
[7 ]
In the pathogenesis of OA, the predominance of the IL-6, IL-1b and TNF cytokines stands
out. These cytokines have the ability to activate multiple inflammatory pathways,
and they may increase disease severity, joint swelling and cartilage destruction.[8 ] In the present case report, a decrease in the levels of IL-1b, IL-8, IL-10, and
mainly TNF, was also observed. With the reduction in these cytokines, it can be suggested
that there was a decrease in the local inflammatory process, which aided in the improvement
of the degenerative picture of this joint. However, with the specific decrease of
IL-10, which is an anti-inflammatory cytokine,[9 ] it is observed that there is a need for further studies that can describe/understand
how ADSCs modulate the inflammatory process in this disease. The only cytokine that
increased was IL-6, which is related to the activation of target genes involved in
cell differentiation, proliferation and apoptosis.[8 ] Thus, we infer this increase due to the mild debridement performed during the videoarthroscopy
surgery, since it stimulates proliferation/differentiation.
The reduction in the inflammatory process, suggested by the modulation of cytokines,
may explain the improvement in the viscosity of the synovial fluid, as well as the
reduction in opacity, since the inflammatory process causes an influx of cells into
the joint cavity. Therefore, with the reduction in the number of cells, there is a
reduction in opacity. In addition to this, and to the increased homogeneity, we observed
a reduction in fibrin and remnants of cartilage wear that are also favored by the
inflammatory process that has been reduced.[10 ] These facts are important, since the quality of the synovial liquid is an indicator
of the quality of the articular cartilaginous tissue.
We conclude that cell therapy with ADSCs in patients with OA refractory to the conservative
treatment can be considered a promising alternative in aiding in the management of
this disease, since there is an improvement in pain, and return of the patient to
their activities of daily living.
