The Effect of Mesenchymal Stromal Cells on the Mortality of Patients With Sepsis and Septic Shock: A Promising Therapy

Study Design and Setting The study was carried out at the Internal Medicine Intensive Care Unit (IMICU) and Anesthesiology and Reanimation Intensive Care Unit (ARICU) at Erciyes University Hospital which is a referral hospital in the Central Anatolia. The study was approved by the Erciyes University Ethics Board (2016/114; Date: 19.02.2016) and Ministry of Health of Turkey. Informed consent from surrogate decision-makers was taken for study participation after confirmation of eligibility criteria.

Patients The study was planned as prospectively. During two years, 10 patients with sepsis and septic shock were included in the study from IMICU and ARICU. Sepsis and septic shock were diagnosed according to the sepsis guidelines [1]. Inclusion criteria for this study were; patients who were between 18-80 years of age and were hospitalized at IMICU and ARICU with the diagnosis of sepsis and septic shock. Exclusion criteria were categorized that patients who were younger than 18-year-old and older than 80 years and were pregnant women or breast-feeding; patients who had terminal stage of cancer, advanced pulmonary disease receiving oxygen at home, advanced pulmonary hypertension (WHO Class III or IV), advanced heart failure (American Heart Association Class III or IV), severe liver disease (Child C), and history of anaphylaxis. Standard therapy of sepsis as suggested in the guidelines [1,2] were given to all patients and additionally MSCs treatment was applied to the patients in the study group. Control patients diagnosed sepsis and septic shock and having similar characteristics for the consideration of severity of disease based on APACHE II score and co-morbid diseases with study group were selected from IMICU and ARICU records retrospectively.

Patients' demographic characteristics, underlying diseases, clinical and laboratory outcomes were recorded.

Source and Application of MSCs MSCs were prepared in Good Manufacturing Practices (GMP) Laboratory of Genome and Stem Cell Center at Erciyes University. Cell production and quality control assessment procedures were carried out according to GMP protocols authorized by the Ministry of Health of Turkey. Allogenic adipose derived MSCs (ADMSCs) which were obtained from a healthy donor were applied to all patients in the study group. Five doses of ADMSCs were applied to the patients at 1st and 3rd day (post-thawed of frozen MSCs cryo-bag), 5th-7th and 9th day (re-plated ADMSCs vials) of therapy. Each dose of ADMSCs was prepared as 1 x 106 ADMSCs/kg. The vials containing ADMSCs were mixed with gentle motions before the usage; thus, it ensured product homogenization. ADMSCs were infused intravenously via central venous line in a physiological saline solution by using a blood transfusion set. The patients were monitored during all these procedures.

Preparation of ADMSCs Sufficient cryo-preserved ADMSCs vials were thawed to provide the required dose for administration. The frozen ADMSCs were thawed and cultured in the Dulbecco's Modified Eagle Medium (DMEM) containing 10% human serum, 1% Penicillin- Streptomycin solution, and 1% stable glutamine (Biological Industries, Kibbutz Beit Haemek, Israel) at 37°C and 5% CO2 incubator which described before [16]. Briefly, ADMSCs were recovered and resuspended in physiological saline solution and transferred to the patient with the temperature-controlled bag. The morphology of cell appearance and the viability were assessed beside the identification of phenotypic characteristics of the cells and microbiological tests. Immunophenotyping characterization of ADMSCs was performed by using flow cytometry analyses (Beckman Coulter, USA) with antibodies against CD45, CD73, CD90, CD105, CD11b, CD19, CD34, CD44 (BD Stem Flow hMSC kit).