[Full text] Stem cells and chronic wound healing: state of the art | CWCMR https://www.



Stem cells and chronic wound healing: state of the art
Authors Leavitt T, Hu MS, Marshall CD, Barnes LA, Longaker MT, Lorenz HP

Received 16 October 2015

Accepted for publication 16 December 2015

Published 2 March 2016 Volume 2016:3 Pages 7—27

DOI https://doi.org/10.2147/CWCMR.S84369

Checked for plagiarism Yes

Review by Single-blind

Peer reviewers approved by Dr Mina Zarei

Peer reviewer comments 2

Editor who approved publication: Professor Marco Romanelli

Tripp Leavitt, Michael S Hu, Clement D Marshall, Leandra A Barnes, Michael T Longaker, H Peter Lorenz

Hagey Laboratory for Pediatric Regenerative Medicine, Division of Plastic Surgery, Department of Surgery,
Stanford University School of Medicine, Stanford, CA, USA

Abstract: Currently available treatments for chronic wounds are inadequate. A clearly effective therapy does
not exist, and treatment is often supportive. This is largely because the cellular and molecular processes
underlying failure of wound repair are still poorly understood. With an increase in comorbidities, such as
diabetes and vascular disease, as well as an aging population, the incidence of these intractable wounds is
expected to rise. As such, chronic wounds, which are already costly, are rapidly growing as a tremendous
burden to the health-care system. Stem cells have garnered much interest as a therapy for chronic wounds
due to their inherent ability to differentiate into multiple lineages and promote regeneration. Herein, we
discuss the types of stem cells used for chronic wound therapy, as well as the proposed means by which they
do so. In particular, we highlight mesenchymal stem cells (including adipose-derived stem cells), endothelial
progenitor cells, and induced pluripotent stem cells. We include the results of recent in vitro and in vivo
studies in both animal models and human clinical trials. Finally, we discuss the current studies to improve
stem cell therapies and the limitations of stem cell-based therapeutics. Stem cells promise improved
therapies for healing chronic wounds, but further studies that are well-designed with standardized protocols
are necessary for fruition.
Keywords: stem cells, chronic wounds, cell therapy, wound healing
Chronic wounds represent a significant burden both financially and in terms of lost quality of life, affecting
both individual patients and the health-care system as a whole. In North America alone, management of
complex wounds, which include chronic wounds, pressure ulcers, and nonhealing surgical wounds, carries an
annual price tag of US$10 billion. Worldwide, the global wound care market is projected to surpass US$22
billion per year by 2020.1 Whereas acute wounds are expected to eventually heal, chronic wounds are
defined by a physiologically impaired healing response. Current wound management strategies remain unable
to adequately treat chronic wounds, resulting in a vigorous pursuit of novel therapies, including those
utilizing stem cells. The inherent regenerative capabilities of stem cells make them ideal targets for
addressing the unmet clinical needs associated with chronic wounds, as well as expanding our understanding
of the wound healing process. Though numerous clinical trials have measured the effects of stem cells in
wound healing, most have been in the context of treating a more systemic illness such as critical limb
ischemia (CLI); wound healing is instead often relegated to secondary outcome measures, making analysis of
their clinical efficacy more difficult. This review will cover the clinically relevant sources of stem cells for
chronic wound therapy, the means by which they modulate wound healing, and the results of recent in vitro
and in vivo studies conducted in animals and humans. Both published and ongoing clinical trials will be
discussed, in addition to where the field is headed. While this review focuses specifically on stem cells as they
relate to chronic wound therapy, the reader is directed to the review by Li and Fu2 for a more in-depth
discussion of stem cell mechanisms involved in physiological wound healing.
Stem cell sources for regenerative medicine
Stem cells are defined by their ability to self-renew and differentiate into multiple cell types. They are
categorized as either multipotent or pluripotent based on the variety of cell lineages to which they may give
rise. Multipotent cells are equivalent to adult stem cells, with the ability to differentiate into several different
lineages. Pluripotent cells are embryonic stem cells (ESCs), with an even greater capacity for differentiation,
able to form all of the functional cell types of an organism. Various stem cell populations have been the

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which demonstrate their potential for accelerating wound healing. often following G-CSF mobilization from the bone marrow. a few of which are more practical for clinical purposes. also accelerate wound healing.11 This regenerative potential has garnered significant interest for applying MSCs in clinical interventions. EPCs circulate in the blood expressing hematopoietic and endothelial surface markers. 2 of 14 6/10/17.15 The relative dearth of MSCs in bone marrow aspirate has also led to the utilization of bone marrow mononuclear cells (BMMNCs) in clinical studies. MSCs have the ability to differentiate into bone. The angiogenic potential of these cells has made them promising targets for treating chronic wounds with underlying ischemic pathologies.28 Despite their ability to differentiate into various cell types.3 CD271+ has also been described as the most specific marker for bone marrow-derived mesenchymal stem cells (BM-MSCs) and adipose-derived stem cells (ASCs). Despite sharing the MSC moniker. Note: Dashed lines represent more ambiguously characterized populations. consensus has yet to be reached with regard to their antigen expression profile. While research has often focused on addressing the issues associated with a heterogeneous and poorly characterized cell population. hematopoietic.31 At the wound bed they contribute to vasculogenesis. Li et al18 described a coculture system that routinely produces MSCs from peripheral blood without mobilization. which is orders of magnitude higher than the corresponding proportion of MSCs in bone marrow. Mesenchymal stem cells Under suitable conditions. resulting in faster wound healing. and umbilical cord (including Wharton’s jelly and cord blood) are further sources of MSCs. and proliferation. CD45– .com/stem-cells-and-chronic-wound-healing-state-.10. cartilage. BM-MSCs are one of the most studied populations. However. Findings from in vitro experiments have elucidated a number of ways that BM-MSCs promote tissue regeneration.6 Lack of standardization can thereby impede our ability to draw comparisons across studies.21 Administering heterogeneous groups of stem cells may allow for communication between different cell types. CD19/CD73b– . fibroblasts. Peripheral blood is also considered by some to be a source of MSCs following mobilization by granulocyte-colony stimulating factor (G-CSF) injection. together promoting angiogenesis. at least in part. with variations in classification that impede standardization of their clinical applications. MSCs are understood to play a significant role in coordinating the wound healing response as it advances through phases of inflammation. The definition of EPCs overlaps with PBMNCs and BMMNCs (Figure 1). proliferation. suggesting that the secretome can promote wound healing even in the absence of the cells themselves. the process by which new vessels are formed from circulating progenitor cells. and matrix metalloproteinases. thought to contain EPCs and MSCs in addition to an array of growth factors and cytokines. and induced pluripotent stem cells (iPSCs). EPCs are harvested from the peripheral blood (except Wettstein et al32 who harvested from bone marrow). and pericytic lineages. EPCs represent another heterogeneous population.22 Applied to chronic wound therapies. localizing to sites of tissue injury and ischemia. MSCs reside in all mesenchymal tissues. but also in terms of sometimes-controversial differences in phenotype.. and keratinocytes.29 For example.24 and ASCs25 have demonstrated an ability to improve wound healing in experimental diabetic models.27 Their direct interactions with other cells. Rodriguez-Menocal et al19 demonstrated that whole bone marrow is more effective at stimulating angiogenesis relative to cultured bone marrow cells or MSCs. placental tissue. The most clinically relevant stem cell populations include mesenchymal stem cells (MSCs). including endothelial. migration. CD34– . MSCs have immunomodulatory effects at the local environments into which they are transplanted. which may lead to confusion. CD90+. endothelial progenitor cell. and HLA-DR– . Despite these shortcomings. Their ability to adhere to polystyrene tissue culture plastic remains a crude but effective means of isolating what is now understood to be a very heterogeneous population of progenitor cells.8. ASC. the International Fat Applied Technology Society together with the International Society for Cell Therapy distinguish ASCs from MSCs by their positivity for CD36 and negativity for CD106 in culture. This.14 The SVF contains a diverse population of cells.4 However. ASC-conditioned media can stimulate the migration of vascular endothelial cells.[Full text] Stem cells and chronic wound healing: state of the art | CWCMR https://www. fat. harvest of these cells necessitates painful bone marrow aspiration.000 mononuclear bone marrow cells)12 has shifted favor toward the more accessible and abundant ASCs. Abbreviations: ALDHbr. both MSCs23. collagens. and are commonly enriched for CD34 positivity. though they maintain their overall multipotent characteristics.13 ASCs are generally harvested as part of lipoaspirate within the stromal vascular fraction (SVF).9 supporting native cells via various paracrine mechanisms that promote cell survival. subjects of significant research efforts. which itself has been used for regenerative wound therapy. populations from varying sources differ in terms of cell surface markers and differentiation efficiency. on multiple cell types working in concert.dovepress. differentiated largely by their tissue of origin.7 In addition to their capacity for self-renewal. the International Society for Cell Therapy has included cell surface expression in its guidelines for defining MSCs: CD73+. In terms of clinical applications.20 Similarly. cytokines..26. and muscle. as well as MSCs. EPC. endothelial progenitor cells (EPCs). and remodeling.5 The inconstant nature of surface marker expression as these cells are removed from their native environment and expanded ex vivo merely worsens the surrounding controversy. such as keratinocytes. 10:30 PM . In addition to the aforementioned characteristics. the improved wound healing associated with MSC administration may in fact depend. CD11b/14– . though these mobilized cells would generally be classified as BMMNCs or peripheral blood mononuclear cells (PBMNCs). With regards to cell-surface expression. facilitating improved tissue regeneration.30 Endothelial progenitor cells Recruited from the bone marrow. ASCs are believed to account for up to 3% of total cells within isolated SVF. Like MSCs and ASCs. Figure 1 Stem cell populations administered in clinical trials.17 Amniotic fluid. Within the larger group of cells termed MSCs. the mechanism of action of MSCs is largely paracrine in nature. there are several described subpopulations. as is seen with coculture of MSCs together with EPCs. Recently.16. BMMNCs demonstrate superior osteogenic and angiogenic differentiation potential compared with isolated CD34+ cells. A clinical study comparing BMMNCs to MSCs corroborated these findings in patients with chronic wounds. CD105+. in addition to the scarcity of BM-MSCs (1 in 10. BMMNCs are also a heterogeneous group. including production of growth factors. aldehyde dehydrogenase bright cell.

While the first human iPSCs were derived from adult fibroblasts. with a 3 of 14 6/10/17. failed reepithelialization may perpetuate these processes. plasmid-based.45 Additionally. bone-marrow mononuclear cell. As such. excessive matrix metalloproteinases..59 Exosomes secreted by MSCs are taken up by fibroblasts from both normal and diabetic wounds leading to increased cellular migration. and recombinant protein-based strategies37.47. which may thus impede the utility of stem cell therapy in chronic wounds. at least in those with ongoing bacterial colonization with biofilm forming organisms.34 iPSCs circumvent the aforementioned barriers to ESC use in that they are derived from adult somatic cells. worldwide. 10:30 PM . but in the diabetic wound environment they display decreased proliferation and migration. the effects of chronic wounds on stem cells may impair their ability to modulate the wound microenvironment.46 Chronic wounds demonstrate a pathological level of underhealing.50 Infection The chronic inflammatory state is in part related to bacterial colonization. which may negatively impact MSCs. promoting tissue regeneration. However. these cells would be allogeneic.[Full text] Stem cells and chronic wound healing: state of the art | CWCMR https://www. Inflammation One of the proposed advantages of stem cell therapies is that their immunomodulatory effects can shift the wound equilibrium away from degradation toward tissue synthesis. UC-MSC.55 Additionally.38 continue to rely on protooncogenic reprogramming factors. In 2007.53 These findings suggest that chronic wounds provide a suboptimal environment for transplanted stem cells. chronic wound fluid is less chemotactic to ASCs and inhibits rather than stimulates their proliferation. such as those elucidated by Shabbir et al.47 This proinflammatory state can be reversed through BM-MSC suppression of T-lymphocytes48 and B-cells. including iPSC use in chronic wound therapy.57 Fibroblasts Fibroblasts are fundamental to the wound-healing cascade. restoration of fibroblast function is possible via paracrine signals from MSCs. there may be limitations to this antimicrobial effect. However. Despite demonstrating reduced tumorigenicity over previous viral integration methods. stromal vascular fraction. BM-MSC. relative to acute wound fluid. are associated with gene expression in MSCs associated with inflammation and apoptosis.. which are key instigators of wound healing. increasing paracrine secretion of transforming growth factor-β1 . granulocyte-colony stimulating factor. Long-term bacterial colonization of chronic wounds is often facilitated by polysaccharide biofilms. which in turn can restore fibroblast wound healing functionality inhibited under hypoxic conditions. Interactions between stem cells and chronic wounds Chronic wound characteristics Physiological wound healing occurs within a microenvironment conducive to tissue repair. SVF. the majority of chronic wounds share at least some of these pathological mechanisms. byproducts of tissue hypoxia may be detrimental to their regenerative capabilities.dovepress. iPSCs may overcome current limitations in wound healing therapies. the first human iPSCs were produced in vitro. bone-marrow mesenchymal stem cell. As an example. and vascular endothelial cells. when used in adults. as well as increased B-cells and plasma cells. and premature fibroblast senescence.58 However. the cellular infiltrate and extracellular matrix demonstrate a lower CD4+ (T-helper)/CD8+ (cytotoxic) T-cell ratio relative to acute wounds.51. adipose-derived stem cell. Induced pluripotent stem cells In the search for regenerative cell therapies. high levels of growth factors and mitigated degradative enzymes promote the functionality of fibroblasts.54 ASC survival and ensuing tissue regeneration in nonvascularized fat grafts via adipogenesis and angiogenesis suggests this phenomenon also applies in vivo. keratinocytes. While this Japanese study is aimed at treating age-related macular degeneration.52 However. Furthermore.56 Despite tolerance. umbilical cord mesenchymal stem cell. reduced angiogenesis.40 Conversely. and peripheral arterial disease. A common concern associated with cell-based therapies is that in utilizing cells with a nearly unlimited ability to self-renew and regenerate.36 alternative adenoviral. diabetes. not only do MSCs decrease inflammation at the wound bed. peripheral blood mononuclear cell. G-CSF. potentially resulting in immune-mediated rejection.33. The use of stem cells in addressing these lesions is geared toward restoring the wound’s ability to heal. and reducing reactive oxygen species burden.41–44 While chronic wounds have a variety of causes such as pressure. elevated lactate levels. more recent advances have allowed for faster and more efficient production from ASCs. there are currently no clinical trials utilizing iPSCs underway in the US. Reverting cells from a fully differentiated to a pluripotent state requires the use of reprogramming factors. but their use is not without risk. there is the potential for malignant transformation. ESCs provide an excellent early possibility given their pluripotent nature. BMMNC. low mitogenic activity. their first use in a clinical trial began in 2014. extracellular matrix degradation. ethical concerns regarding embryological tissue usage have limited their applications. the chronic wound bed is an environment of unabated inflammation. they also enhance bacterial clearance and improve survival in sepsis via secretion of the antimicrobial peptide LL-37. either by supplanting ineffective healing mechanisms or by augmenting muted physiological processes.com/stem-cells-and-chronic-wound-healing-state-. resulting in an overall delayed time to healing. PBMNC.39 More studies are thus needed to establish a safety profile for iPSC interventions. Exposure to biofilm-conditioned media as well as isolated soluble biofilm factors alone are both sufficient to impair MSC migration and differentiation while promoting apoptosis. Hypoxia MSCs have a high tolerance for oxidative stress in vitro. In diabetic and venous ulcers for example. Interestingly. which suggests that they are ideally suited to treating ischemic pathology.35 demonstrating further potential of MSCs in regenerative medicine. the findings from this study may hopefully assuage initial concerns allowing for further clinical study. and even activation of stem cells in hypoxic environments.49 However. allowing for autologous tissue generation without need of posttransplant immunosuppressive therapy. MSCs may promote wound healing in response to hypoxia. For example. as are found in chronic wounds.

Paclitaxel was found to be more cytotoxic to ASCs compared to fibroblasts. Because of the overall small number of true randomized trials. Radiation is another cancer-related treatment with numerous side effects. our literature search was systematic (Figure 2. critical limb ischemia. Many patients with wounds refractory to treatment over months to years may be considered to provide fairly adequate internal historical controls. however. but statistical meta-analysis was not performed. and less paracrine secretion of cytokines involved in wound healing.20 to use contralateral ischemic limbs within the same patient as an internal control. statistical significance not directly related to improved wound healing in cell therapy group vs control. IA. peripheral blood non-mobilized cells. IV. with variations between studies that include (but are not limited to) type of stem cell. The full list of relevant studies can be found in Table 1. in an off-label trial. the majority of which are early Phase I trials assessing safety and efficacy. Several meta-analyses of stem cell therapies of CLI exist. N. PAD. ASC. targeted pathophysiology. number of cells administered. bone-marrow mononuclear cell. Compared to ASCs harvested from nondiabetic mice. without sample randomization or placebo control.63 In vitro experiments by Cianfarani et al64 found ASCs isolated from diabetic mice to have lower proliferative and migration potential. if not impossible. Inconsistencies across clinical trials are often cited as making statistical comparisons difficult. and insulin-like growth factor-1. bone marrow cells harvested from chronic wound patients and EPCs from diabetic patients demonstrate reduced growth in culture and diminished stem cell potency relative to healthy controls. (*). greater increase observed in the chronic wound fibroblasts. necessitating further study. different area of wound or contralateral limb.60 suggesting patients undergoing chemotherapy may demonstrate a diminished response to stem cell-based therapies. including chronic ulcer formation. purification. PNS. complete wound closure vs improved wound healing vs time for given reduction in wound area).61 Of note. statistically significant but used internal control. BMMNC.71–73 Overall. peripheral arterial disease. Tables S1–S3). DFU. expansion. clinical outcomes were analyzed with Fisher’s exact test to calculate P-value. “*”. Altaner et al68 found that patients who responded to therapy have higher CD44 and CD90 MSC expression and greater interleukin-4 and interleukin-6 secretion.. plerixafor was found to be better than G-CSF at mobilizing hematopoietic stem cells in diabetic patients. Using a rat model. Conversely. It is unfortunate that the patients most in need of stem cell-based wound therapies are also the least likely to have an optimal progenitor population to draw from. This practice is likely to introduce confounding given the importance of paracrine-mediated MSC functionality. intramuscular. yes.. and administration. Review of the clinical evidence To the authors’ knowledge. ALDHbr. hepatocyte growth factor. graft immunophenotype. Table 1 Published studies Notes: a When not stated in original publication.[Full text] Stem cells and chronic wound healing: state of the art | CWCMR https://www.10 Given the incredible variability in trial designs that include stem cell-based wound therapy. and thus they do not represent the traditional patient sample receiving this drug. We have identified 45 published trials measuring the effects of stem cell therapies on chronic wound healing. diabetic foot ulcer. is that the patients in this trial were not undergoing chemotherapy for cancer treatment. National Clinical Trial. and follow-up time. percutaneous transluminal angioplasty. intra- arterial. IM. Systemic disease may be linked to depletion of angiogenic precursor cells both in the bone marrow and peripheral circulation. enhanced stromal vascular fraction. umbilical cord mesenchymal stem cell. PBNM. Smadja et al70 noted that BM-MSCs harvested from CLI patients and healthy controls demonstrate similar proangiogenic effects when transplanted into CLI-induced mice. The difficulty of conducting randomized controlled trials has also spurred some investigators.68 which is surprising given recent studies showing diabetes impairs the ability of ASCs to promote neovascularization (via subpopulation depletion). Impairments in wound healing vary greatly across patients undergoing cancer therapy. no systematic review has been conducted that includes all types of stem cells used to manage chronic wounds.67 In stratifying patients receiving BMMNCs for CLI based on clinical outcome. but other forms of chronic wounds are omitted. intravenous. these have sometimes been included in meta-analyses.69 Not all studies have shown that chronic systemic disease impairs stem cell functionality.64 Human ASCs harvested from ischemic limbs of diabetic patients also display muted functionality. CLI. such as Lu et al. aldehyde dehydrogenase bright cell. UC-MSC. Our own findings echo this sentiment. Abbreviations: Y. adipose-derived stem cell. e-SVF. This variability may lead to a wide variety of wound healing responses to stem cells. Internal control used eg. APC. Huang et al62 demonstrated that ASCs have the ability to accelerate healing of these ulcers.com/stem-cells-and-chronic-wound-healing-state-. 10:30 PM . the diabetic status of the patients in this trial did not correlate with response. angiogenic progenitor cell. peripheral blood mononuclear cell. bone-marrow mesenchymal stem cell.65 Similarly. muted stem cell surface marker expression. Therefore. with corresponding differences in response to autologous cell therapy between patients. thromboangiitis obliterans (Buerger’s disease). TAO. including vascular endothelial growth factor-A. though the inherent decrease in validity precludes their incorporation into meta-analysis. PTA. it is understandable that they also correlate negatively with stem cell yield and proliferative capacity. Figure 2 Literature search flowchart Abbreviations: NCT. this also translates into a blunted improvement in diabetic wound healing. method of cell harvest.dovepress. Increasing age and BMI are risk factors for chronic disease. nebulous outcome measures (eg. despite being indicated for lymphoma and multiple myeloma. (Y). the effects of long-term exposure to chronic pathophysiology on endogenous stem cell properties is likely quite variable. 4 of 14 6/10/17. no.66. However. Panax notoginseng saponins. PBMNC. Stem cells harvested from patients with chronic disease Further potential hurdles to autologous stem cell use in chronic wound therapy relate to the quality and quantity of cells harvested from patients with systemic disease. BM-MSC.59 Cytotoxicity Patients undergoing chemotherapy experience suboptimal wound healing.

78 Of the 45 selected trials. verified within the last 4 years. reducing the efficacy of ex vivo expansion. Though technically simple.44–5. certain studies also include populations enriched for particular markers. also demonstrated a clinically insignificant advantage of BMMNC administration. this trial lacks a placebo control arm. this study will likely provide valid data as to the effect of bone marrow stem cells on wound healing in a much larger population than previously studied. 1. they demonstrate suboptimal engraftment. Results from this study indicate that there is no statistical significance between the placebo and treatment groups. enhanced stromal vascular fraction. endothelial progenitor cell. 4 of 11 ongoing trials with an enrollment ≥50 do not have a placebo or sham control arms (NCT02099500.85. BM-MSC. ASC. with regard to large studies involving placebo controls. potentially due to several studies documenting the superiority of more heterogeneous cell transplants. including MSCs and EPCs. survivability.90 (95% confidence interval [CI]. adipose tissue. expanded polytetrafluoroethylene. but which have been mobilized by G-CSF into the peripheral blood (characterizing them as PBMNCs). which did exclude patients who underwent amputation. most recently Liew et al82 calculated an odds ratio of 2. 10:30 PM . and BMMNCs). Numerous study protocols. with different degrees of overlap between them.81 Table 2 Unpublished studies Notes: Results of clinicaltrials. To date. and the umbilical cord. NCT02089828. UC-MSC. bone marrow mononuclear cell.74 harvest cells originally localized to the bone marrow. Note: Chart area is proportional to sample size. adipose-derived stem cell. circumventing the need for more invasive bone marrow aspiration. allogeneic cells have been shown to significantly enhance diabetic wound healing. bone-marrow mesenchymal stem cell. and lifespan – current and future techniques Unfortunately. BMMNCs are a frequently used source of progenitor cells for clinical use comprising a heterogeneous population that includes MSCs and EPCs. Table 1). sourced from various tissues including bone marrow. randomized. and direct application) and cell populations (PBMNCs. BMMNC. only 17 include independent placebo controls (3 additional studies relied on internal controls) (Table 1). including Huang et al. However.dovepress. Many studies rely on intradermal or intramuscular injection to administer stem cells in suspension. PBMNC.80 Given that the primary outcome is improvement in Rutherford classification. Interestingly. and retention at the wound when transplanted. respectively. the measurements of wound area reduction. Abbreviations: ASC. In our literature search. which traditionally exclude these patients from analysis. Improving stem cell yield. these studies include an array of methods to administer cells (intramuscular.75–77 MSCs are another population frequently used in clinical trials. The two largest ongoing trials.. ePTFE. While there is sufficient evidence to support the belief that stem cells improve chronic wound healing in clinical trials. the JUVENTAS trial is the largest published randomized controlled trials utilizing stem cells in wound healing. peripheral blood mononuclear cell. EPC. mesenchymal stem cell. The type of cell used in chronic wound therapy varies widely across clinical trials. the published studies demonstrate that stem cell therapies can indeed lead to healing of chronic wounds resistant to traditional therapy. umbilical cord mesenchymal stem cell. The relative increase in studies utilizing ASCs coincides with a more recent appreciation for the higher yield of readily accessible stem cells existing within adipose tissue. BMMNC.79 The fact that this study categorized major amputations as nonhealing ulcers is likely to have skewed outcomes defined as complete wound healing relative to other studies. Taken together. Within a given cell population. Furthermore. there is a relative loss of therapeutic efficacy. 9 of the 17 placebo-controlled trials showed a statistically significant improvement in wound healing with cell therapy. Meta-analyses corroborate this impression.gov search showing ongoing trials or unpublished studies pertaining to stem cell therapies in patients with chronic wounds. adipose-derived stem cell. efficacy. However. or CD34+ cells. Figure 3 Relative proportions of stem cell population use in analyzed published and unpublished clinical studies. SVF represents an additional collection of progenitor cells. Abbreviations: ALDHbr. Though it does not specifically include wound healing as an outcome. Harvesting these cells from what is generally classified as biohazardous waste following liposuction may allow patients to forgo painful bone marrow aspiration. which is defined as minor tissue loss (nonhealing ulcer. CD90+. bone-marrow mononuclear cell. further complicated by often-controversial classification standards. placebo-controlled trial. NCT01245335 and NCT02099500. the limited number of placebo control groups and inconsistent means of reporting wound healing (eg. NCT01245335 is a double-blinded. SVF. though MSCs have demonstrated an ability to improve wound healing. BMMNCs appear to be favored in ongoing or unpublished trials. angiogenic progenitor cell.. potentially caused by 5 of 14 6/10/17.19–21 The number of studies and their respective sample sizes receiving allogeneic cells is also greater among ongoing trials. using median wound area84 rather than complete wound closure) prevents us from establishing the true extent of this benefit.82) when comparing stem cell therapies with control treatment for complete ulcer healing. such as aldehyde dehydrogenase bright cells (ALDHbr). predict enrollments of 200 or more each. While NCT02099500 addresses the relative scarcity of published clinical trials using ASCs for chronic wound therapy and includes a large sample size. and NCT01456819).com/stem-cells-and-chronic-wound-healing-state-. MSC. aldehyde dehydrogenase bright cell. the 2015 meta-analysis by Liu et al83 suggests that this benefit may wane with longer follow-up times. intra-arterial.[Full text] Stem cells and chronic wound healing: state of the art | CWCMR https://www. Overall. Comparisons of published studies with ongoing or unpublished studies (Table 2) demonstrate a shift in focus (Figure 3). We have attempted to categorize the cell types used in the 45 trials identified as being relevant to the use of stem cells in chronic wound therapy (Figure 1.86 with several of the underlying mechanisms discussed previously. reflecting an understanding that autologous stem cell potency may be blunted in patients with chronic systemic illness. SVF. NCT01903044. APC. Additionally. This suggests that many tissues and extraction methods offer means of reliably harvesting cells that can augment the healing process. Conversely. focal gangrene with diffuse pedal ischemia). BM-MSCs. their lifespans are short in vitro. and utilize cells from bone marrow and adipose tissue. patients must have Rutherford Category 5 peripheral artery disease to qualify for enrollment.

and the variable quality of cells depending on their source. Advances in stem cell surface modification offer a potential solution to this problem by targeting cells to specific tissues. subsequent anoikis in the absence of cell–matrix attachment or shear forces during the injection.117.105 Scaffolds are valuable additions to stem cell-based wound therapy as they provide an external niche for transplanted cells outside of the hostile wound environment. and efficacy at the wound bed are worthy goals. harvest. intravenous administration of stem cells is uncommon in chronic wound therapy because of cell entrapment in the pulmonary vasculature (the pulmonary “first-pass” effect). 10:30 PM .117 Overall. restoration of an anti-inflammatory M1/M2 macrophage equilibrium is required to allow for physiological wound healing. While this may be a greater risk with pluripotent iPSCs.77 Defining dose in heterogeneous cell populations can also be difficult. especially prior to MSCs undergoing senescence. 6 of 14 6/10/17. or at least provide a better measure of prognosis.91 The resulting decrease of ASC migration to the wound bed further elaborates on the difficulties of systemic stem cell therapy for chronic wound healing.112 Promoting stem cell yield. Novel approaches to cell population characterization such as kinome analysis may also improve clinical efficacy. In an excisional wound model. MSC immunomodulation and homing to different target organs can increase risks of opportunistic or disseminated infections. as well as improved engraftment. For example. as well as susceptibility to malignancy. and enhanced angiogenesis. Yoshikawa et al106 used a composite graft of BM-MSCs incorporated into a collagen sponge to successfully treat decubitus ulcers refractory to artificial skin grafting.. clinical trials demonstrate that stem cell applications to wound healing are safe.89 Conversely.100 Low-level light irradiation is another recent tool for increasing stem cell wound healing potency. endothelial growth factor (EGF) molecules tethered to growth scaffolds demonstrated an ability to improve MSC survival via activation of the EGF-receptor.88. the beneficial immunomodulatory properties of stem cells are also not without theoretical risks. but perhaps subpopulation composition may be less relevant (given BMMNC:MSC ratios resulted in similar clinical improvements).97 Hypoxic preconditioning has also been shown to increase paracrine secretion by MSCs.dovepress. Numerous possibilities have arisen. isolation.com/stem-cells-and-chronic-wound-healing-state-.113 Limitations Some of the limitations of stem cells in wound therapies have already been discussed.95.115 Follow-up to one of the original studies thought to demonstrate spontaneous MSC transformation has since shown a small number of malignant cells to be the culprit.90 Stem cell localization to the wound bed is notably impaired in chronic (but not acute) wounds partly due to downregulated stromal cell-derived factor 1 (a chemokine attracting MSC to wound bed) secondary to uncontrolled inflammation. The possibility of malignant transformation exists whenever stem cells are transplanted. as is the case with any medical intervention.114 the larger body of evidence suggests that the risks of malignant transformation are low. there are also potential risks.94 Efficacy is most likely related to a minimum required dose. transplant of biological material also carries risks of directly transmitting infectious agents.111 Increased automation of stem cell harvest.[Full text] Stem cells and chronic wound healing: state of the art | CWCMR https://www. It is therefore likely that their incorporation into cell-based therapies will increase markedly in the near future. this hydrogel led to longer MSC viability. ubiquitous in chronic wound microenvironments).109 The fundamental risk of contamination associated with cell products has spurred the development of closed systems for harvesting and/or culturing cells.96 Means of prolonging transplanted cell lifespan are now heavily sought. and subsequently more generalizable results. expansion. Increasing stem cell potency with adjuvants such as platelet-rich plasma or Panax notoginseng saponins are possible alternatives for decreasing the minimum required dose.118 Finally. it is also possible that truly successful chronic wound therapy requires a deeper understanding of how the various types of stem cell therapies can modulate systemic pathophysiology. While malignant transformation has been observed in long-term culture.. such as tissue bioreactors.116 Furthermore. which reduces MSC apoptosis in ischemic microenvironments. such as phenotypic drift in culture. In the presence of proapoptotic cytokines (FasL.104 Such combinations may reduce the inflammatory response to the scaffolds themselves.107. such as hyperoxic and pan-caspase pretreatment.93 though the number of administered cells has not universally been shown to correlate with response.108 Autologous MSCs applied with a fibrin spray system also resulted in some improvement in patients with chronic ulcers. study of the more commonly used multipotent MSCs has generated less of a concern.87 When compared.110 Widespread clinical use also necessitates scalable technologies. Gene therapy provides further opportunity. heterogeneity of cell populations. and expansion will allow for more standardized therapies. as MSCs must survive to influence healing. necessitating consideration when developing mechanisms of administration for translational medicine. Beyond barriers to therapeutic efficacy. wound type. However. Rustad et al87 showed both a faster time to complete wound closure and a return of skin appendages in wounds treated with a biomimetic pullulan–collagen hydrogel scaffold seeded with MSCs. cell type. Clinically. Clinical implementation of cell-based therapies has opened a new frontier in the development of biomedical devices aimed at optimizing current therapies. and administration). in type 2 diabetes. survival. Moreover. stem cells delivered intramuscularly and intra-arterially demonstrate no significant difference in terms of improved wound healing.102 Surface-tethered EGF generated a superior MSC response relative to saturating concentrations of soluble EGF.93 Scaffolds offer a viable means for enhancing stem cell engraftment and survivability.98 Mohanty et al99 showed that small molecule-induced prion protein upregulation also results in increased lifespan and yield of MSCs in culture. ASCs embedded in silk fibroin scaffolds and fibrin gels have demonstrated a similar ability to accelerate wound healing in vivo. such as protein kinase G1α overexpression via adenovirus vector to promote MSC survival. increased engraftment efficiency.101 Endogenous wound healing pathways provide further means by which to optimize MSC survival.93 while the lack of consensus may be related to inconsistent methodologies (eg. while still allowing them to facilitate wound healing. but physicians must continue to reevaluate the risks and benefits of their use as the results of more long-term follow-up studies are published.103 supporting the use of other endogenous mediators such as the matrix protein Tenascin-C combined with biosynthetic scaffolds to enhance survival of transplanted MSCs. inhibiting the local proinflammatory phenotype at the wound bed may be insufficient to completely restore wound healing.92 Poor cell engraftment and survivability are problematic considering the dose–effect relationship observed by Falanga et al.

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induced pluripotent stem cells.dovepress. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited. 2007. Tortella BJ Journal of Blood Medicine 2015. Zhang Y. 10:30 PM . 2012.20(6):806–814. Supplementary materials Table S1 CENTRAL search strategy Abbreviations: BM-MNC. adipose tissue-derived mesenchymal stem cells.2 and 5 of our Terms. PB-MNC.Lasala GP. Thromb Haemost. An SSA Clinical Interventions in Aging 2015. peripheral blood mononuclear cell. 149. The full terms of this license are available at https://www. adipose-derived stem cell..gov search strategy Abbreviations: iPS cells. 6:245-255 Published Date: 3 September 2015 13 of 14 6/10/17. Garde C. For permission for commercial use of this work. AT-MSC. Silva JA. PB-MNC. Randomised comparison of G-CSF-mobilized peripheral blood mononuclear cells versus bone marrow-mononuclear cells for the treatment of patients with lower limb arteriosclerosis obliterans.Non Commercial (unported. bone marrow mononuclear cell. ASC. MSC. ASC. Wen JC. 2012. Li SZ.php and incorporate the Creative Commons Attribution .98(6):1335–1342. provided the work is properly attributed. BM-MNC. mesenchymal stem cells. AT-MSC. Yang XF.Jimenez F. 10:1873-1879 Published Date: 19 November 2015 REVIEW Emerging and future therapies for hemophilia Carr ME.144(2):377–382. Table S3 clinicaltrials. This work is published and licensed by Dove Medical Press Limited. adipose-derived stem cell. Minguell JJ. A pilot clinical study of hair grafting in chronic leg ulcers. J Thorac Cardiovasc Surg. adipose tissue-derived mesenchymal stem cells. et al. Table S2 PubMed search strategy Abbreviations: iPS cells. peripheral blood mononuclear cell. bone marrow mononuclear cell. 150. Readers of this article also read: REVIEW Causative factors for formation of toxic islet amyloid polypeptide oligomer in type 2 diabetes mellitus Jeong HR..[Full text] Stem cells and chronic wound healing: state of the art | CWCMR https://www.Huang PP.0) License. Poblet E. 151. please see paragraphs 4. Wound Repair Regen.com/stem-cells-and-chronic-wound-healing-state-. Han ZC.com/terms. By accessing the work you hereby accept the Terms. Therapeutic angiogenesis in patients with severe limb ischemia by transplantation of a combination stem cell product.dovepress. v3. induced pluripotent stem cells.

10:30 PM .. Thulasidasan AK.. Kumar GS International Journal of Nanomedicine 2012. 10:1163-1172 Published Date: 14 July 2015 ORIGINAL RESEARCH Cross-linked acrylic hydrogel for the controlled delivery of hydrophobic drugs in cancer therapy Deepa G.dovepress. Evans AM International Journal of Nanomedicine 2011. Kim SY Clinical Interventions in Aging 2015. An SSA. Peddie F.com/stem-cells-and-chronic-wound-healing-state-. 6:1245-1251 Published Date: 20 June 2011 14 of 14 6/10/17. REVIEW Mutations in presenilin 2 and its implications in Alzheimer’s disease and other dementia-associated disorders Cai Y. Anto RJ.[Full text] Stem cells and chronic wound healing: state of the art | CWCMR https://www. 7:4077-4088 Published Date: 27 July 2012 ORIGINAL RESEARCH Particle size reduction to the nanometer range: a promising approach to improve buccal absorption of poorly water-soluble drugs Rao S. Pillai JJ. Song Y.