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Journal of military pharmaco-medicine no8-2019 INITIAL RESULTS OF USING MESENCHYMAL STEM CELL AND PLATELET RICH PLASMA IN TREATMENT OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE Dao Ngoc Bang1; Dong Khac Hung2; Nguyen Huy Luc1 Do Minh Trung2; Ta Ba Thang1; Le Phuong Ha3 SUMMARY Objectives: To assess initial results and the safety of stem cell and platelet rich plasma in treatment of chronic obstructive pulmonary disease. Subjects and methods: This interventional trial was carried out on 10 chronic obstructive pulmonary disease patients, with the number of patients of group C and D were 2 and 8, respectively, following to GOLD 2018. Mesenchymal stem cells were taken from the umbilical cord tissue of pregnant women, were given intravenously to patients with the dose of 1.5 milion cells per kilogram in combination with 5 mililiters of self-platelet rich plasma. These patients were followed up within 6 months. Results: Clinical and para-clinical indexes improved after 6 months of treatment: mMRC score decreased from 3 to 2, CAT score went from 22 down to 20 and CRP reduced from 5.12 to 2.68 miligram per deciliter. There was no severe complication. Conclusions: The combination of mesenchymal stem cells and platelet rich plasma is a method with its first effectiveness and safety in treatment of severe chronic obstructive pulmonary disease patients. With these initial results, the following studies are expected to carry out to assess the role of mesenchymal stem cells and platelet rich plasma in treatment of chronic obstructive pulmonary disease patients. * Keywords: Chronic obstructive pulmonary disease; Mesenchymal stem cell; Platelet rich plasma. INTRODUCTION Chronic obstructive pulmonary disease (COPD) is now a global burden of disease with high mortality. Many theories about COPD pathogenesis have been mentioned, in which the inflammatory mechanism was recognized by many authors [1, 3]. Till now, many studies have proved that the effectiveness of mesenchymal stem cells (MSCs) in treatment of anti-inflammatory proccess, increase in immune ability and regeneration of tissue. Therefore, MSCs have been studied in treatment of COPD in order to improve pulmonary fibrosis, reduction of pulmonary arterial pressure and anti-inflammation. Besides, platelet rich plasma (PLT) contains growth factors, helping regeneration of tissue. With the combination with PLT, MSCs work effectively [4, 5, 6]. In Vietnam, this combination has been firstly applied in treatment of COPD patients. By this reason, this study was carried out with the aim: To assess initial results and the safety of stem cell and platelet rich plasma in treatment of chronic obstructive pulmonary disease. 1. 103 Military Hospital 2. Vietnam Military Medical University 3. University of Science and Technology of Hanoi Corresponding author: Dao Ngoc Bang (bsdaongocbang@yahoo.com.vn) Dtae received: 29/07/2019 Date accepted: 15/10/2019 160 Journal of military pharmaco-medicine no8-2019 SUBJECTS AND METHODS 1. Subjects. 10 patients diagnosed with COPD, having indications of treatment by MSCs and PLT, treated in Respiratory Center, 103 Military Hospital from Jul 2018 to Apr 2019. * Patient selection criteria: Defined stable COPD group C and D according to GOLD standard (2018) [1]. These patients were voluntary to attend in the study. * Patient exclusion criteria: Patients had other respiratory diseases, severe codiseases (such as: heart failure, kidney failure and so on), other diseases related to tumour, contrindications of respiratory functional measurement. 2. Methods. * Study design: This is a clinical non-controlled trial with vertical follow-up. Patients underwent clinical examination, tests of biochemical blood and blood cells to assess function of organs, tumour markers, ECG and cardiosonography, chest X-ray, measurement of spirometer and plethymosgraphy, arterial blood gases test before treatment of MSCs and PLT. Patients underwent treatment by MSCs and self-PLT based on the process, accepted by the Ethics Committee of Vietnam Ministry of Health. These patients were taken sellf-blood to separate PLT. Then, 5 mL of PLT were mixed with MSCs, taken from the umbilical cord tissue, with the dose of 1.5 million of MSCs per kilogram. This combination was mixed with 100 mL of NaCl 0.9% and given intravenously to patients with the speed of 3.5 mL per minute. Definition of clinical results, blood cells, CRP and changes of respiratory function of these patients. They were re-examined by the time of 1, 3 and 6 months after treament. By each time, they were defined: changes of clinical symptoms (level of dyspnea based on mMRC scale, CAT and SMWD), number of white blood cells with the proportions of neutrophil and lymphocyte, CRP, indexes of spirometer, such as: force vital capacity (FVC), force expiratory volume in the 1st second (FEV1), arterial blood gases indexes, such as: oxygen arterial preasure (PaO2), carbondioxite arterial preasure (PaCO2). Early complications (within 1 week) and late ones (within 6 months after treament). All studied patients underwent internal treatment regularly based on Guidelines of Vietnam Ministry of Health (2018) [1]. Management and statistical analysis was performed by the SPSS 20.0 software. RESULTS AND DISCUSSION 1. Characteristics of studied patients. * Characteristics of age and gender: 100% of studied patients were male, with the average age of 67.9 ± 6.47 years old and 60% belonged to group of 60 70 years old, only 10% of patients at the age under 60 years old. These characteristics of age and gender were similar to other studies about COPD in Vietnam. Hoaang Dinh Huu Hanh and Le Thi Tuyet Lan (2008) witnessed that the average age of COPD patients was 63 ± 11.97 years old, with 87% belonged to 161 Journal of military pharmaco-medicine no8-2019 male [2]. However, the number of female patients was lower than that in other studies in the world. Weiss D.J et al (2013) treated stem cells for 30 COPD patients, having the average age of 68.1 ± 7.54 years old, with the proportion of 60% [8]. Table 1: Clinical characteristics of studied patients before treatment. Value X ± SD Min Max Age (years old) 67.9 ± 6.47 58 77 Pack-year 12.2 ± 11.11 10 40 19 ± 9.66 3 40 BMI (kg/m ) 19 ± 2.94 14.32 24.61 CAT (points) 21.5 ± 3.2 16 25 278.7 ± 78.37 128 350 3.2 ± 1.8 1 4 Indexes Duration of disease (years) 2 SMWD (meters) Number of exacerbations per year (times) The studied patients had high means of CAT and mMRC, short SMWD (278.7 ± 78.37 meters) and high number of exacerbation per year (3.2 ± 1.8 times). These characteristics were similar to other studies about stem cells for COPD patients by Weiss D.J et al (2013), Ribeiro-Paes J.T et al (2011)... [8, 9]. This is the group of severe patients, with many clinical symptoms and poor response with basic internal treatment. However, these studied patients had lower average of BMI when comparing with ones in other studies. These characteristics could affect the result of stem cells later. Table 2: Para-clinical characteristics of studied patients before treatment. Value X ± SD Min Max WBC (G/l) 8.87 ± 2.19 6.2 12.56 CRP (mg/dL) 9.1 ± 10.14 0.9 32.9 FVC (% predicted) 65.51 ± 13.5 41.64 87 FEV1 (% predicted) 37.88 ± 13.14 16.46 64 PaO2 (mmHg) 76 ± 16.35 49 100 PaCO2 (mmHg) 47.1 ± 7.36 37 65 Indexes Blood test: Spirometer: Arterial blood gases test: The studied patients had low average of FVC and FEV1, corresponding with 65.51 ± 13.5% predicted and 37.88 ± 162 13.14% predicted. About the results of arterial blood gases test, mean of PaO2 was low (76 ± 16.35 mmHg), while mean Journal of military pharmaco-medicine no8-2019 of PaCO2 was high (47.1 ± 7.36 mmHg). These characteristics were suitable with patient selection criteria for treatment of stem cells. The studied patients in the research by Weiss D.J et al (2013) had moderate or severe obstructive degree [8]. The study by Ribeiro-Paes J.T et al (2011) was also carried out to treat severe COPD patients by stem cells [9]. The studied patients had WBC at the normal limitation. However, mean of CRP increased (9.1 ± 10.14 mg/dL). These characteristics were similar to the study by Weiss D.J et al (2013), with the mean of CRP of studied patients being 7.55 mg/dL [8]. Increased CRP showed the status of inflammation and infection. By treatment of stem cells, it could reduce inflammation and inhibit infection. Therefore, CRP is also an index to assess the efficacy of stem cell therapy for COPD patients. 2. Results of treatment by stem cell and PTL. Table 3: Changes of CAT, SMWD and mMRC after treatment. Changes Indexes CAT (points) SMWD (meters) mMRC (points) Before treatment (1) After 3 months After 6 months p (2) (3) 22 (16 - 25) 21 (14 - 24) 20 (12 - 24) p3,1 < 0.05 297,5 302,5 317,5 p2,1 > 0.05 (128 - 350) (155 - 360) (160 - 365) p3,1 > 0.05 3 (3 - 3) 2,5 (2 - 3) 2,5 (2 - 3) p2,1 < 0.05 p2,1 > 0.05 p3,1 < 0.05 The results showed that SMWD changed insignificantly. CAT and mMRC improved clearly after 6 months, with p < 0.05. These results were similar to other previous published studies about stem cells. The study by Ribeiro-Paes J.T et al (2011) witnessed the COPD patients of stage 4 improved significantly their quality of life as well as more stable clinical status [9]. Patients in the study by Stolk J et al (2016) also had the improvement of clinical symptoms [10]. Table 4: Changes of FVC, FEV1 and PEF after treatment. Changes Indexes FVC (% predicted) FEV1 (% predicted) PEF (% predicted) Before treatment (1) After 3 months (2) After 6 months (3) p 64.5 54.2 60.7 p2,1 > 0.05 (41.6 - 87) (38.6 - 89.5) (34.6 - 90.8) p3,1 > 0.05 34.5 31.14 29.45 p2,1 > 0.05 (16.46 - 64) (16.88 - 47.88) (14.5 - 64.3) p3,1 > 0.05 30.5 29.05 31.1 p2,1 > 0.05 (21 - 55) (15.8 - 44.1) (20.2 - 57.7) p3,1 > 0.05 163 Journal of military pharmaco-medicine no8-2019 The studied patients witnessed no improvement in spirometer indexes. Changes of FVC, FEV1 and PEF were not statistical (p > 0.05). PaO 2 increased clearly after 6 months (p < 0.05), while PaCO2 decreased lightly (p > 0.05). SaO2 changed insignificantly after treatment (p > 0.05). These results were similar to other previous studies about stem cells. After treatment, COPD patients witnessed minimal improvement of spirometer indexes. The study by Weiss D.J et al (2013) had the conclusion that there was no statistical difference of spirometer indexes when comparing the studied group with the control one. The results showed that there was no benefit in improvement of respiratory function when treated by stem cells [8]. In the study by Ribeiro-Paes J.T et al (2011), the respiratory indexes had a trend to decline after 30 to 90 days [9]. Table 5: Changes of WBC and CRP after treatment. Changes Before treatment (1) After 3 months (2) After 6 months (3) p WBC (G/l) 8.21 (6.2 - 12.56) 7.35 (5.56 - 10.83) 9.38 (5.9 - 14) p2,1 > 0.05 p3,1 > 0.05 Neutrophil (%) 66.59 (57.3 - 92.5) 56.74 (48.8 - 69.4) 63.8 (46.81 - 75.32) p2,1 < 0.05 p3,1 < 0.05 Lymphocyte (%) 16.21 (6.1 - 30.9) 27.85 (17.18 - 34.5) 22.66 (15.99 - 40.32) p2,1 < 0.05 p3,1 < 0.05 CRP (mg/dl) 5.12 (0.9 - 32.9) 2.26 (0.6 - 18) 2,68 (0.92 - 17.21) p2,1 < 0.05 p3,1 < 0.05 Indexes The studied results showed that CRP reduced statistically at both times of 3 and 6 months after treatment (p < 0.05). The proportion of neutrophil had a trend to go down and lymphocyte go up. WBC changed insignificantly. The characteristics of reduced CRP were also witnessed in the studies of stem cells, carried out in experimental animals as well as COPD patients. The COPD patients in the trial about stem cells by Weiss D.J et al (2013) reduced CRP after 1 month. The trend of reduced CRP was witnessed continuously during the time of trial [8]. Chart 1: Changes of arterial blood gases indexes after treatment. PaO2 increased clearly after 6 months (p < 0.05) while PaCO2 decreased lightly (p > 0.05). SaO2 changed insignificantly after treatment (p > 0.05). 164 Journal of military pharmaco-medicine no8-2019 3. Complications of treatment by stem cell and PLT. hô hấp ký ở bệnh nhân BPTNMT. Tạp chí Y học TP. Hồ Chí Minh. 2008, 12 (1), tr.96-99. 20% of patients had fever after treatment of MSCs and 1 patient witnessed a moderate exacerbation. There was no anaphylaxis, dead or new tumor formation. These results were similar to other previous studies about stem cells. The patients in the study by Ribeiro-Paes J.T et al (2011) were followed up within 1 year after treatment. There was no complication [9]. The trial by Weiss et al (2013) also showed that there was no statistical clinical adverse event during the follow-up time after treatment [8]. These adverse events were mild and there was no correlation found between these ones and treatment of stem cells. This result proved that treatment of stem cells is a safe method. 3. Global Intiative for Chronic Obstructive Lung Disease. Global strategy for diagnosis, management and prevention of chronic obstructive pulmonary disease. https://goldcopd. org/gold-2017-global-strategy-diagnosismanagement-prevention-copd.2018. CONCLUSSIONS Studying the initial results of MSCs in combination with PLT in 10 COPD patients, we had some following conclusions: - CAT and mMRC improved clearly after 6 months. There was no improvement in spirometer indexes. CRP reduced statistically (p < 0.05). PaO2 increased clearly after 6 months (p < 0.05) while PaCO2 decreased lightly (p > 0.05). - Treatment by stem cells is safe: 20% of patients had fever and 1 patient had a moderate exacerbation. There was no anaphylaxis, dead or new tumor formation. REFERENCES 1. Bộ Y tế. Quản lý và điều trị BPTNMT giai đoạn ổn định. Hướng dẫn chẩn đoán và điều trị bệnh phổi tắc nghẽn mạn tính. Nhà xuất bản Y học. Hà Nội. 2018, tr.22-28. 2. Hoàng Đình Hữu Hạnh, Lê Thị Tuyết Lan. Mối liên quan giữa độ khó thở và các chỉ số 4. Gu W, Song L, Li X-M et al. Mesenchymal stem cells alleviate airway inflammation and emphysema in COPD through down-regulation of cyclooxygenase-2 via p38 and ERK MAPK pathways. Scientific Report. 2015, 5 (8733). 5. Isola L.M, Scigliano E, Skerrett D et al. A pilot study of allogeneic bone marrow transplantation using related donors stimulated with G-CSF. Bone Marrow Transplant. 1997, 20 (12), pp.1033-1037. 6. Katsha A.M, Ohkouchi S, Xin H et al. Paracrine factors of multipotent stromal cells ameliorate lung injury in an elastase-induced emphysema model. Molecular Therapy. 2011, 19 (1), pp.196-203. 7. Lee C, Mitsialis S.A, Aslam M et al. Exosomes mediate the cytoprotective action of mesenchymal stromal cells on hypoxiainduced pulmonary hypertension. Circulation. 2012, 126 (22), pp.2601-2611. 8. Weiss D.J, Casaburi R, Flannery R et al. A placebo-controlled, randomized trial of mesenchymal stem cells in COPD. Chest. 2013, 143 (6), pp.1590-1598. 9. Ribeiro-Paes J.T, Bilaqui A, Greco OT et al. Unicentric study of cell therapy in chronic obstructive pulmonary disease/pulmonary emphysema. International Jounal Chronic Obstructive Pulmonary Disease. 2011, 6, pp.63-71. 10. Stolk J, Broekman W, Mauad T et al. A phase I study for intravenous autologous mesenchymal stromal cell administration to patients with severe emphysema. An International Journal of Medicine. 2016, 109 (5), pp.331-333. 165