Human umbilical cord-derived mesenchymal stem cells in the treatment of myocardial infarction: existing problems, effects and prospects

doi:10.3969/j.issn.2095-4344.0481

Abstract

Abstract:

BACKGROUND: Human umbilical cord-derived mesenchymal stem cells, because of convenient acquisition, will not bring pain and adverse effects to the fetus and their parturient. The success rate of culture is high. It has good application prospects in the treatment of myocardial infarction.
OBJECTIVE: To review the new progress of human umbilical cord-derived mesenchymal stem cells transplantation in the treatment of myocardial infarction.
METHODS: A computer-based online search of PubMed and Wanfang databases was performed to retrieve the related articles published from 1991 to 2017. We reviewed the initial data and the quotations from each document. Finally, we included randomized controlled animal experiments or clinical studies concerning human umbilical cord-derived mesenchymal stem cells for treatment of myocardial infarction.
RESULTS AND CONCLUSION: Human umbilical cord-derived mesenchymal stem cells will become a new alternative source of cells in the treatment of myocardial infarction, with extremely broad prospects. However, there is no mature conclusion about the convenient route, optimal number of transplanted cells, optimal timing, differentiation, homing and evaluation after transplantation, which limits the clinical application of these cells.

中国组织工程研究杂志出版内容重点：干细胞；骨髓干细胞；造血干细胞；脂肪干细胞；肿瘤干细胞；胚胎干细胞；脐带脐血干细胞；干细胞诱导；干细胞分化；组织工程

Key words: Myocardial Infarction, Umbilical Cord, Mesenchymal Stem Cells, Cell Transplantation, Tissue Engineering

CLC Number:

R394.2

Wang Yuan-fei, Li Ya-xiong, Zhang Ya-yong, Jiang Li-hong. Human umbilical cord-derived mesenchymal stem cells in the treatment of myocardial infarction: existing problems, effects and prospects[J]. Chinese Journal of Tissue Engineering Research, 2018, 22(9): 1470-1476.

Figures/Tables 2

2.1 huc-MSCs概述脐带由卵黄囊和尿囊所构成，是胚胎或胎儿与胎盘之间的通道。其中，脐带基质中含有的胶状物质叫沃顿胶(Wharton's jelly, WJ)，主要由多糖组成。1991年，Mcelreavey等[9]第一次从沃顿胶中分离出成纤维样细胞，这些细胞因为表达CD29、CD44、CD73、CD105，不表达CD34、CD45，并能向脂肪细胞和成骨细胞谱系分化，于2004年被确定为间充质干细胞。目前，己知人脐带中有4种间充质干细胞的来源：沃顿胶、脐血管周、脐带血和脐静脉内皮下膜，其中，沃顿胶是当前脐带源间充质干细胞的主要来源[10]。沃顿胶间充质干细胞起源于胚胎发育第13天时的中胚层或内胚层，此时，卵黄囊壁的胚外中胚层内由间充质干细胞密集形成血岛，血岛周边细胞分化为内皮细胞，内皮细胞围成内皮管，即原始血管，内皮管不断向外出芽延伸，逐渐形成一个丛状分布的内皮管网，分布于胚体内外的间充质中，被称为“心血管系统发源地”-“干细胞池”[11]。有研究证实，沃顿胶间充质干细胞能被诱导分化为表达α-肌动蛋白、肌钙蛋白T和Connexin-43的细胞，这些细胞为心肌再生所必需[12]。更多证据显示，沃顿胶间充质干细胞可诱导分化为内皮细胞、心肌细胞，它们能够融入到血管和缺血的心肌组织中，从而改善心功能[13-14]。因此，有研究者认为沃顿胶间充质干细胞才是真正意义的原始干细胞[15]。 Garzon等[16]研究沃顿胶间充质干细胞传代培养的细胞活性，发现可能存在着复杂的促凋亡基因和抗凋亡基因平衡的问题，尤其是促凋亡基因FASTKD2、BNIP3L和抗凋亡基因TNFAIP8、BCL2L2；并且指出，沃顿胶间充质干细胞的存活率最高的时期是第5代和第6代。因此，用于细胞治疗和组织工程的首选方案是第5代和第6代沃顿胶间充质干细胞。 2.2 huc-MSCs移植对动物心肌梗死模型心功能修复效果的研究由于huc-MSCs具有较低的免疫原性和较高的血管生成率使其成为移植治疗心肌梗死的重要替代细胞，得到了广泛的应用，并获得了显著效果，见表1[5,13,17-19]。"

2.3 huc-MSCs移植治疗心肌梗死的临床研究尽管huc-MSCs治疗心肌梗死的确切机制仍不清楚，但由于临床前研究的丰富成果显示出huc-MSCs移植治疗的可行性、有效性和安全性，目前正逐步开展人心肌细胞再生的临床试验。 2.3.1 移植的时间与剂量移植的时间：关于细胞移植时间的选择，目前尚没有一个系统的关于移植时机的研究。但对于急性心脏病发作后，存在一个最佳的治疗窗口，在此期间干细胞疗法可以发挥最佳的治疗作用[20]。然而，由于自体骨髓间充质干细胞难以在14 d内进行完整的分离、鉴定、纯化及获得所需的剂量，因此错过了细胞治疗的最佳时间窗口[21]。而huc-MSCs的出现为临床细胞治疗的探索提供了新的路线，因为它有经过验证的基础设施和趋于完善的操作程序，可以在最有利的时间窗口给符合条件的患者使用。此外，有研究指出huc-MSCs对陈旧性心肌梗死患者同样可以显著降低患者心肌梗死面积和提高左室射血分数，但具体机制仍不清楚[22-23]。移植剂量：与其他药物一样，干细胞的注射剂量与治疗效果存在一定的相关性，剂量过低起不到治疗效果；剂量过高，对移植区增加负担，细胞存活率低，同样达不到治疗作用。目前关于干细胞的移植数量仍没有统一的说法，可能与培养的干细胞质量和(或)活性有关。Li等[24]分别采用3×106、4×106和5×106数量级的huc-MSCs通过冠状动脉内注射治疗老年人冠状动脉慢性完全闭塞，结果发现，3种剂量的干细胞均能显著降低患者心肌梗死面积和提高左室射血分数，尤以3×106数量级最明显，但3者没有差异，说明3×106数量级的huc-MSCs治疗效果更好。但Gao等[25]采用6×106数量级的沃顿胶间充质干细胞治疗118例ST-T段抬高的急性心肌梗死患者，结果同样表明，患者的心肌存活率、梗死区再灌注和左室射血分数均显著高于对照组(P < 0.05)。然而，上述结果没有统一的最佳移植剂量，这也是限制临床应用细胞治疗疾病的因素之一。 2.3.2 移植的效果与安全性移植的效果：Gao等[25]进行18个月的随访结果显示沃顿胶间充质干细胞治疗是有效的。Li等[24]研究在2年的随访时间内发现，患者的心功能显著提高。田洪榛等[26]通过经冠状动脉移植沃顿胶间充质干细胞治疗缺血性心力衰竭指出，18个月后患者左室功能得到提高，左室容量减少，左心室重构速度减慢，甚至2年后患者的活动耐量及生活质量仍得到了提高。此外，梁晓辉等[27]指出，沃顿胶间充质干细胞移植治疗心肌梗死后心力衰竭，可以显著降低患者的NT-proBNP水平。另外，移植的效果还与心肌梗死人群、局部心肌微环境、是否与组织工程技术结合、移植后疗效评价体系均有关系。移植的安全性：Gao等[25]、Li等[24]和田洪榛等[26]研究证明了huc-MSCs经冠状动脉内注射是安全的。Musialek等[28]评价了10例使用沃顿胶间充质干细胞治疗心肌梗死的效果，随访1年后，无心脏不良事件的发生。田洪榛等[26]也发现，患者在治疗的过程中并没有出现血流减慢、肌钙蛋白异常升高等急性并发症，表明移植沃顿胶间充质干细胞时不会出现微血管及冠状动脉的梗死。此外，由于沃顿胶间充质干细胞能够低水平表达多潜能胚胎干细胞标记，如POUF1，NANOG，SOX2和LIN28等，能够明显上调多种细胞因子如IL-12A等，从而说明了其为何不引起畸胎瘤的形成和解释了具有抗癌的特性[29]。Gauthaman等[30]比较了沃顿胶间充质干细胞和胚胎干细胞在免疫缺陷小鼠中的肿瘤形成能力，结果发现所有接受人胚胎干细胞的动物均出现了免疫应答并发生了肿瘤，而接受沃顿胶间充质干细胞的动物却并没有出现免疫应答和肿瘤的发生，甚至到20周时依然没有肿瘤发生。作者认为，沃顿胶间充质干细胞在移植治疗心肌梗死时既不会引起微血管及冠状动脉的梗死也不会诱发肿瘤，在细胞治疗上是安全的。 2.4 huc-MSCs移植治疗心肌梗死的机制目前对于huc-MSCs移植治疗心肌梗死改善心功能的机制尚不明确，认为可能的机制有以下几种学说(图1)。"

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