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关于干细胞移植治疗糖尿病下肢动脉病变的立场声明
发布时间:2012-12-18 00:00:00浏览次数:1852次来源:中华医学会糖尿病学分会

一、糖尿病下肢动脉病变概况

    糖尿病下肢动脉病变(peripheral arterial disease,PAD)是糖尿病最严重的慢性并发症之一,其患病率与年龄、病程、血糖控制水平以及是否合并高血压、脂质代谢紊乱等密切相关[1-2]。流行病学调查所得出的PAD患病率还受检测手段的直接影响。美国的一项研究显示,以踝肱指数(ankle-brachial index,ABI)为检测手段,ABI<0.9为诊断标准,>40岁糖尿病患者PAD患病率为20%, >50岁者为29%[3].PAD对机体的危害除了导致下肢缺血性溃疡和截肢外,更严重的是其可导致心血管事件发生风险和死亡率增加[4-9]。PAD患者常表现为两种情况:管腔狭窄早期主要表现为以行走时出现疼痛为特征的间歇性跛行,随着狭窄的加重可出现静息痛甚至丧失行走能力和伴随组织坏死与溃疡发生为特点的危重肢体缺血(critical limb ischaemia, CLI)。CLI的预后极差,5年生存率仅为50%或更低;CLI的治疗不仅仅是缓解症状、改善受累肢体的功能和防止截肢,还要防止全身动脉粥样硬化(atherosclerosis, AS)的进展以预防心脑血管事件发生[10]。目前主要的治疗手段为控制高血糖、高血压、血脂异常以及去除吸烟等危险因素[9,11-16]、强制性的运动锻炼[17-18]、应用抗血小板药物[14,18-19]和扩血管药物[12,20-23]以及行循环重建手术[外科手术(如旁路移植术或动脉内膜切除术)、血管内介入技术(如支架置入或球囊扩张术)][11,24-25]等。约40%的CLI患者经过上述治疗仍不能改善预后,对于这部分患者来说,截肢目前被认为是为挽救生命所做出的最后治疗选择,但截肢后的总死亡率大约为25%~50%。截肢术围手术期的死亡率为5%~20%,二次截肢率大约为30%[10]。由于血管弥漫性、多节段的病变和(或)远端流出道闭塞,或由于并存其他疾病,糖尿病合并PAD患者的围手术期死亡风险较非糖尿病患者明显增加。尽管目前微创介入技术和外科干预技术已有快速发展,但CLI的治疗选择仍然有限——大约40%的患者不符合进行循环重建的指征或进行循环重建不能得到有益的反应[26]。对于这些“没有其他治疗选择”的患者,药物治疗对延缓病情进展和预防截肢的作用十分有限。因此,探索缺血肢体血液循环重建的新的治疗策略对于减少患者截肢和提高患者生活质量具有非常重要的临床意义。
 

二、干细胞移植治疗PAD的历史和现状

    因目前“没有其他治疗选择”的PAD患者的预后很差,因此,促使研究者将研究重点转向寻求具有分化潜能的干细胞移植治疗糖尿病PAD,研究者们希望在病变局部能够使干细胞被诱导为血管上皮细胞来修复损坏的血管。这种疗法目前尚处于临床大规模、常规治疗应用前的研究阶段。

    基础研究发现,能分化为血管内皮细胞的干细胞类型有血管内皮祖细胞(endothelial progenitor cell, EPCs) ,骨髓源性单个核细胞(bone marrow mononuclear cell, BMMNC)和外周血单个核细胞(peripheral blood mononuclear cell, PBMNC)[27-41]。世界上最早开展自体骨髓干细胞移植治疗下肢动脉缺血的临床研究是日本学者Tateishi-Yuyama等,他们在2002年报道的应用细胞移植的治疗性血管生成试验(therapeutic angiogenesis using cell transplantation, TACT)[42],在治疗后4周和24周,患者的ABI、经皮氧分压(transcutaneous oxygen tension, TcPO2)、静息痛和无痛性行走距离均有改善。在随机对照试验部分,22例双下肢缺血患者,随机性地在一条腿移植BMMNC(阳性治疗组),在另外一条腿移植未活化的PBMNC作为对照。移植BMMNC的20例患者中,13/20例患者阳性治疗侧的ABI改善,TcPO2也得到相似的改善,16/20例患者阳性治疗侧静息痛消失,无痛性行走距离得到改善,数字减影血管造影 (digital subtraction angiography,DSA) 显示有明显的侧支血管生成;移植未活化的PBMNC对于预后指标没有有益的作用,该试验的作者提出BMMNC移植成功是由于骨髓CD34+的造血干细胞和未成熟的前体细胞数量较周围血中数量约高500倍或更多。该试验未出现任何相关的并发症,临床安全性和有效性得到了初步肯定。

TACT试验的发表大大地激发了研究者的兴趣,随后在许多国家开展应用干细胞/骨髓源性细胞治疗PAD,临床报告的数量稳步上升。截止2010年9月在PubMed上累计检索到86篇有关干细胞/骨髓源性细胞治疗PAD的文献(包括国内10篇),其中包括69项研究,共计纳入996例患者;以及1篇系统评价文献[10,26,42-79]。国内谷涌泉等[80]首先报道应用自体骨髓干细胞移植治疗严重下肢缺血,黄平平等[58]首先报道应用自体外周血干细胞移植治疗下肢动脉硬化性闭塞症,迄今共累计发表210篇有关干细胞/骨髓源性细胞治疗PAD的文献,共治疗患者1200例[58-67, 80-98]。这些研究的主要特点为:(1)超过80%的纳入患者是CLI;(2)绝大多数研究纳入的患者数量有限或仅为个案报道,没有设立对照组;(3)在设立了对照组的14项研究中,没有1项研究是随机双盲设计而且随访时间相对较短;(4)各组基线缺血的程度不一样,从Rutherford 2级/ Fontaine IIa到严重下肢缺血(Rutherford 6 / Fontaine IV);(5)干细胞移植途径为缺血肌肉中局部注射或通过动脉导管动脉内注入;(6)除3项研究应用脐血干细胞外,其余的研究均是应用自体干细胞进行移植。所有的研究结果都显示了(至少短时间内)令人鼓舞的效果,表明细胞治疗的可行性和安全性。荟萃分析结果显示自体细胞治疗可以使ABI值增加0.1~0.2,TcPO2增加10~20 mm Hg,依赖于基线值不同,步行距离改善大约100~200 m,促进溃疡愈合或好转,肢体保存较对照组得到明显的改善。但是,干细胞移植治疗在改善外周血管病变长期预后(如截肢和死亡)的疗效目前尚无临床研究的证据。

    总体来说,干细胞移植治疗PAD具有良好的安全性和耐受性,绝大多数不良反应发生在应用粒细胞集落刺激因子(granulocyte colony-stimulating factor, G-CSF)的患者(无论是单纯G-CSF治疗还是干细胞动员),包括G-CSF刺激导致的流行性感冒样症状、肌痛、发热和骨痛,骨髓穿刺造成的局部疼痛和轻度贫血以及在移植过程中出现的心脑血管缺血性并发症(如心力衰竭、心肌梗死、卒中等)、严重感染、胸痛和过敏性反应、视网膜轻微出血等[43,48,52,55,75,98],但这类不良反应报道较少。

干细胞移植的长期安全性尚有待评估,如干细胞移植治疗尚存潜在的致瘤性问题[79]。有2项研究[55,93]报道干细胞移植后,移植患者发生恶性肿瘤(共8例),虽然目前有关肿瘤发生的文献报道很少,且两者之间的因果关系尚不明确,但由于这些研究随访时间均不长、样本量不大,随着移植后的时间延长、样本量扩大,肿瘤发生率是否会增加,尚不可知;同时,绝大多数研究没有恰当的设计来评估其远期的安全性。

    在美国国立卫生研究院的临床试验网站[99]上,2010年正在进行的针对PAD患者的新一代细胞治疗试验有28项注册试验,其中23项采用不同形式的干细胞或骨髓细胞,2项采用单纯的G-CSF,1项采用脐带血干细胞,2项采用自体脂肪源性间质干细胞。根据公布的样本量大小,显示大约有993例患者将在未来的数年内参与这些试验。这些试验包括14项I期,11项II期和2项III期试验(1项未详细说明);治疗途径包括2项动脉内输注,2项缺血部位肌肉注射联合动脉内输注,其余均为缺血部位肌肉注射(4项未详细说明);试验地点遍布全球。但这些注册试验纳入的患者样本量较小,随访时间相对较短。虽然绝大多数研究是随机对照设计,试验结果有可能提供有力的细胞治疗的有效性数据,但仍需要进行大规模、长时间的随机对照试验来明确地回答尚未解决的长期疗效和安全性问题。
 

三、关于干细胞移植治疗糖尿病等下肢动脉缺血性病变的立场声明

    就采用干细胞移植治疗糖尿病等下肢动脉缺血性病变问题,中华医学会糖尿病学分会在此阐述以下立场:

(一)应加大对干细胞移植治疗糖尿病等下肢动脉缺血性病变的基础和临床研究

    自体干细胞移植技术的出现,使临床治疗下肢缺血性疾病多了一种可能有效的手段,尤其是对于下肢远端动脉流出道差无法进行下肢血管旁路手术的患者,或年老体弱或伴发其他疾病不能耐受血管旁路手术的患者。今后应该进一步开展相关的基础和临床研究,使干细胞移植治疗有可能成为严重肢体缺血的糖尿病患者的常规治疗手段之一。希望国家有关部门加强对干细胞移植治疗糖尿病等下肢动脉缺血性病变的基础和临床研究的支持力度,制定并出台相应的法规和管理规定,使干细胞移植尽早应用于临床治疗糖尿病等引起的下肢动脉缺血性病变。

(二)干细胞移植治疗尚不能作为糖尿病等下肢血管病变的常规治疗手段

    目前国内外研究结果显示干细胞移植治疗糖尿病等下肢动脉缺血性病变有一定的疗效,但绝大多数研究纳入的患者样本量均较小或仅为个案报道,很多研究没有设立对照组,且随访时间相对较短(最长时间3年),因此关于干细胞移植治疗糖尿病等下肢动脉缺血性病变疗效的证据强度较低,且该疗法存在一定的副作用和不良事件,尤其是对干细胞移植治疗所伴随的肿瘤发生问题目前观察较少,因而我们认为干细胞移植治疗糖尿病等下肢动脉缺血性病变的安全性和有效性需要更有利的循证医学证据来验证和支持,目前尚不能将干细胞移植治疗作为糖尿病等下肢血管病变的常规治疗手段。

(三)开展干细胞移植治疗糖尿病下肢动脉缺血性病变研究应遵循的原则

    中华医学会糖尿病学分会鼓励开展干细胞移植治疗糖尿病等下肢动脉缺血性病变的基础和临床研究,但研究必须遵循以下几个原则:

    1.与干细胞移植治疗糖尿病等下肢动脉缺血性病变相关的基础和临床研究须遵守国际干细胞研究学会《干细胞临床转化指南》和国内有关干细胞研究的道德伦理准则和相关指南/管理规定[100]

    2.如开展临床研究,需遵循我国临床研究的相关规定。临床研究方案必须得到实施临床试验者所在医疗或科研机构伦理委员会的批准。在实施临床试验前,必须向自愿参加临床试验的糖尿病等下肢动脉缺血性病变患者告知临床试验的内容,临床试验的可能获益和潜在的危害并获得患者书面的知情同意。

    3.不得向参加临床试验的糖尿病等下肢动脉缺血性病变患者收取与临床研究相关的费用。

    4.目前国内外大多数研究对于自体干细胞的采集方法有2种:(1)骨髓干细胞:在患者髂棘部位穿刺抽提100~500 ml骨髓血,通过密度梯度离心方法分离单个核细胞。(2) 外周血干细胞:应用血细胞分离机采集经G-CSF动员的PBMNC。但目前对于干细胞的采集方法不建议抽提采集大量的骨髓血,而是建议通过外周血造血干细胞采集。无论是采集、分离BMMNC还是外周血造血干细胞,均需要临床试验管理规范(GCP)认证的血液处理设备,一个专用的血液学单元,以及“相对无菌细胞室”或“GCP认证的细胞室”,这些均需要通过卫生管理部门的特别许可,因此在进行这些研究时应该具备相应的准入制度。

    5.临床试验要采用科学、客观的试验设计,充分评价与现行的临床常规治疗糖尿病等下肢动脉缺血性病变方法之间的优缺点,同时观察干细胞移植治疗的有效性和安全性,特别是干细胞移植治疗的长期疗效和安全性。

    6.严格掌握干细胞移植治疗糖尿病等下肢动脉缺血性病变的适应证和禁忌证,定期组织专家对多中心、大样本、长期对照研究的临床结果进行科学分析,及时总结经验教训,使我国的干细胞应用技术健康发展,最终让广大患者受益。

 

声明起草专家:冉兴无(四川大学华西医院内分泌代谢科),许樟荣(解放军第306医院糖尿病中心)

专家委员会成员(以姓氏笔划为序):于德民(天津医科大学代谢病医院内分泌科),王鹏华(天津医科大学代谢病医院足病科),冉兴无(四川大学华西医院内分泌代谢科),纪立农(北京大学人民医院内分泌科),孙子林(东南大学附属中大医院内分泌科),石勇铨(第二军医大学附属长征医院内分泌科),刘开彦(北京大学人民医院血液内科),刘建英(南昌大学第一附属医院内分泌科),许樟荣(解放军第306医院糖尿病中心),谷涌泉(首都医科大学宣武医院血管外科),吴清华(南昌大学第二附属医院心内科),严励(中山大学附属第二医院内分泌科),李红(浙江大学医学院邵逸夫医院内分泌科),李小英(上海市内分泌代谢病研究所),单忠艳(中国医科大学附属第一医院内分泌科),陆菊明(解放军总医院内分泌科),杨晓凤(解放军第463医院血液内分泌科),柳洁(山西省人民医院内分泌科),赵湜(武汉市中心医院血液内分泌科),赵纪春(四川大学华西医院肝脏及血管外科),姬秋和(第四军医大学西京医院内分泌代谢科),夏宁(广西医科大学第一附属医院代谢糖尿病中心),翁建平(中山大学附属第三医院内分泌科),葛家璞(新疆自治区人民医院内分泌科)

本声明经中华医学会糖尿病学分会全体委员审阅

 

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