Repeated application of autologous bone marrow-derived stem cell therapy in patients with severe Buerger’s disease

doi:10.4236/scd.2011.11002

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Vol.1, No.1, 16-19 (201

doi:10.4236/scd.2011.11002

1) Stem Cell Discovery

Repeated application of autologous bone

marrow-derived stem cell therapy in patients

with severe Buerger’s disease

Zoltan Boda1, K. Razso1, M. Szarvas1, Zs. Olah1, P. Ilonczai1, Z. Vereb2, E. Rajnavolgyi2

1Department of Internal Medicine, University of Debrecen, Debrecen, Hungary; [email protected]

2Department of Immunology, University of Debrecen, Debrecen, Hungary

Received February 18 2011; revised March 21 2011; accepted March 28 2011.

ABSTRACT

Stem cell therapy (SCT) is a promising and

prospective approach in the treatment of pa-

tients with severe peripheral arterial disorders,

primarily with Buerger’s disease. However, very

little is known about the duration of the effect of

SCT, and to our best knowledge no data are

available on the efficacy and safety of repeated

SCT in patients with Buerger’s disease. Here we

report on two patients with severe Buerger’s

disease, who received repeated autologous

bone marrow-derived stem cell therapy. Our

results show that a second SCT, applied to a

previously treated leg 30 or 36 months after the

first treatment was efficient in both cases. After

twelve months, the clinical state of the repeat-

edly treated lower limb improved spectacularly

and non-healing ulcers healed more rapidly

than after the first SCT. No severe adverse

events were detected. Thus repeated SCT offers

a safe and efficient treatment option for relaps-

ing patients at the advanced stage of Buerger’s

disease.

Keywords: Buerger’s Disease; No n H ealing Ulcer;

Repeated Bone Marrow-Derived Stem Cell Therapy

1. INTRODUCTION

Recent publications have proved the efficacy and

safety of stem cell therapy (SCT) in patients with severe

Buerger’s disease [1-14]. However, very little informa-

tion is available on the duration of the beneficial effect

of SCT [12], and according to our best knowledge no

data exist on the efficacy and safety of repeated SCT

carried out in patients with relapsing or worsening clini-

cal states in severe Buerger’s disease. Here we report on

two cases, where the lower limb of patients with Buer-

ger’s disease, previously treated by autologous bone

marrow-derived stem cell therapy (ABMSCT) [9], have

been re-treated with freshly isolated autologous bone

marrow derived isolated CD34+ cells. Both patients re-

lapsed at 30 - 36 months after the first ABMSCT. As

they responded to the first treatment, we decided to re-

peat ABMSCT with freshly isolated bone marrow de-

rived CD34+ cells by using the same method as de-

scribed in our previous publ ication [9].

2. MATERIALS AND METHODS

As it is a repeated stem cell therapy we refer to our

previous publ ication [9].

3. RESULTS

3.1. Case Reports

Patient 1 was a 59-year-old man with Buerger’s dis-

ease since 1976. He had rest pain, 50 m walking distance

without pain, and 2 large (8 cm2) and deep non-healing

ulcers on both feet. He had sympathectomy on both sides

(1982, 1983). A mputation of the righ t toe II and left toe I

was carried out in 1991, and the amputation of the left

toe III was done in 1995. Disease stage was Ler-

ishe/Fontain-IV before ABMSCT. As his left lower limb

was in a worse condition, we treated it by ABMSCT in

August 2006. The clinical state of this limb is still ex-

cellent (rest pain disappeared, the ischaemic ulcer healed

and has not relapsed so far), whereas the clinical state of

the untreated right limb became worse (rest pain in-

Presented at the 54th Annual Meeting of German Society of Throm-

bosis Haemostasis (GTH), Nuremberg, Febru ar y 2010.

Fundings: The present study was supported by the EEA/Norway

Grants HU-0046/NA/2006-2/ÖP-9 entitled

evelopment of novel stem

cell-based therapies for the treatment of advanced peripheral arteria

disease and by the TAMOP 4.2.2-08/1-2008-0015 EU supported NFÜ

rogram entitled Establishing a stem cell and gene therapy. Research

Centre at the University of Debrecen..

Z. Boda et al. / Stem Cell Discovery 1 (2011) 16-19

1717

creased, the ischaemic ulcer got larger and deeper). In

April 2007 ABMSCT was carried out on his right foot

(Figure 1 (a)) and nine months later we observed sig-

nificant improvement of the treated right foot (Figure 1

(b)). In October 2009, 30 months after the second SCT

the condition of his right limb relapsed with a large and

deep ischaemic ulcer at the same place (Figure 1 (c)).

His good response to previous treatments prompted us to

repeat ABMSCT on his right foot. Twelve months after

the repeated treatment, a significant improvement was

observed both in the general angiological state of the

limb and in the size of the ischaemic ulcer (Figure 1

(d)).

Patient 2 was a 40-year-old man with Buerger’s dis-

ease since 1991. He had rest pain, < 50 m walking dis-

tance without pain, and a large and deep non-healing

ulcer (36 cm2) on his left foot. He had sympatectomy on

both sides (1994 and 1995). He underwent amputations

of his left toe I-III and right toe I-II (1994), and left fin-

ger III (1999). Disease stage was Lerishe/Fontain-IV

before ABMSCT. SCT was given in September 2006

(a) (b)

Figure 1. Repeated ABMSCT in a patient (D. A. 59 ys) with

severe Buerger’s disease. (a) Before first ABMSCT, (b) 9

months after first ABMSCT, (c) Relapse, 30 months after

first ABMSCT, D: 6 months after second ABMSCT.

(Figure 2 (a)) and after l2 months the clinical state of

the treated limb improved significantly as the non-heal-

ing ulcer healed and rest pain disappeared (Figure 2 (b)).

In October 2009, 36 months after SCT a large and deep

ischaemic ulcer re-appeared just at the same place as

before (Figure 2 (c)). Taken his previous clinical re-

sponse to therapy, we repeated ABMSCT and six

months after the treatment we detected complete healing

of the ischaemic ulcer (Figure 2 (d)). Simultaneously

the symptoms in the limb improved significantly.

4. DISCUSSION

Amputation is the only option for relief of rest pain or

large and deep ischaemic ulcers in patients with severe

Buerger’s disease. No effective blood-flow enhancement

therapies are available for these patients. ABMSCT is a

promising and prospective approach in the treatment of

severe peripheral arterial disorders, in particular in

Buerger’s disease. All of the published clinical trials

have reported on the affectivity and safety of ABMSCT

(a) (b)

Figure 2. Repeated ABMSCT in a patient (F.T. 40 ys) with

severe Buerger’s disease. (a) before first ABMSCT, (b) after

12 months of first ABMSCT, (c) relapse, 36 months after

first ABMSCT, (d) 6 months after second ABMSCT.

Z. Boda et al. / Stem Cell Discovery 1 (2011) 16-19

in Buerger’s disease even thou gh the variatio n of the cell

populations and protocols used for the therapy [1-16].

It is well established that the bone marrow contains

multiple stem- and progenitor cells with the potential to

support vessel regeneration. As we proposed previously

[9], when these cells interact with tissue- and immune

cells in the inflammed milieu of the obstructed vessel,

they very likely acquire novel activities and trigger a

cascade of local events that support vasculogenesis and

wound healing. These complex mechanisms may in-

volve controlled production of soluble factors, regulation

of endothelial cell functions, formation of new vessels,

tissue regeneration, and inhibition of inflammation

[17,18]. These events altogether may support increased

blood flow, healing of ischaemic ulcers and ultimately

protect the leg from amputation.

Recently, Fadini et al. collected clinical data of 700

patients with peripheral arterial disorders treated by SCT

[15]. In patients with thromboangiitis obliterans (TAO)

showed larger benefits from SCT than patients with

atherosclerosis obliterans (ASO). The survival rate and

amputation-free state were markedly better in patients

with TAO than those in patients with ASO (100% vs.

80% and 91% vs. 60%). This metaanalysis indicates that

intramuscular introduction of autologous stem cells is a

feasible, safe and effective therapeutic strategy for pa-

tients with severe peripheral arterial disorders (PAD)

[15]. Currently 22 phase I-III clinical trials, using

ABMSCT in advanced ASO and TAO are going on. The

results of these trials will provide with important infor-

mation for the fina l consideration of stem cell therapy in

these diseases [15].

Very little information is available on the long term

effects of SCT that requires the clinical follow up of the

patients for years [12]. Furthermore, there are no clinical

data on the effects of repeated SCT neither in TAO nor

in ASO. Here we report on two patients with severe

Buerger’s disease who received repeated ABMSCT. In

both cases, the relapse occurred 30 - 36 months after the

first SCT. After six months of the repeated treatment

however, the clinical state of the treated limbs improved

considerably, the non-healing ulcers healed more rapidly

than during the first SCT without any severe adverse

events. Based on these observations we conclude that

repeated ABMSCT is safe and effective even in settings

of repeated treatments.

Stem cell therapy carried out on the left lower limb of

our first patient demonstrates an excellent clinical re-

sponse to the therapy with duration of almost 4 years,

despite its worse condition as compared to the right leg.

Although SCT was performed with the same technique

on both legs, the right limb relapsed 30 month s after the

treatment. We do not have a definite explanation for the

clinically different local responses of this patient to the

therapies performed at different time points, but it may

depend on the actual composition of the functionally

relevant stem- and progenitor cells. The quality control

of the autologous bone marrow-derived stem- and pro-

genitor cell suspensions performed as detailed in our

previous publication [9] revealed that no major differ-

ences in the ratios of CD34+ and CD34+CD133+ sub-

populations of the cell fractions used for the therapy

could be detect ed.

Remarkably, the large and deep ischemic ulcers ap-

peared in both cases at the same place as for the first

time. This observation points to a transient and incom-

plete regeneration process of vessels. Nevertheless, our

present results clearly show that relapsed cases of Buer-

ger’s disease can be treated by repeated ABMSCT with

high efficacy without adverse events.

5. CONCLUSION

Stem cell therapy is a promising and prospective

novel approach in the treatment of patients with severe

Buerger’s disease. In two cases the lower limb of pa-

tients with Buerger’s disease previously treated by

ABMSCT have been re-treated with freshly isolated

autologous bone-marrow derived CD34+ cells. Both pa-

tients relapsed at 30 - 36 months after the first ABMSCT.

Our present results clearly show that relapsed cases of

advanced Buerger’s disease can be treated by repeated

ABMSCT with high efficacy without adverse events.

6. ACKNOWLEDGEMENTS

This work was supported by the EEA/Norway Grants HU-0046/

NA/2006-2/ÖP-9 entitled Development of novel stem cell-based thera-

pies for the treatment of advanced peripheral arterial disease and by

the TAMOP 4.2.2-08/1-2008-0015 EU supported NFÜ program enti-

tled Establishing a stem cell and gene therapy. Research Centre at the

University of Debrecen.

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