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Treatment of knee osteoarthritis with intra-articular injection of allogeneic adipose-derived stem cells (ADSCs) ELIXCYTE®: a phase I/II, randomized, active-control, single-blind, multiple-center clinical trial

Stem Cell Research & Therapy volume 12, Article number: 562 (2021) Cite this article

Abstract

Objective

To evaluate the safety and efficacy of intra-articular (IA) injection of allogeneic adipose-derived stem cells (ADSCs) ELIXCYTE® for knee osteoarthritis.

Methods

This was a patient-blind, randomized, active-control trial consisted of 4 arms including hyaluronic acid (HA) control and 3 ELIXCYTE® doses. A total of 64 subjects were screened, and 57 subjects were randomized. The primary endpoints included the changes from baseline to post-treatment visit of Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score at Week 24 and the incidence of adverse events (AEs) and serious adverse events (SAEs).

Results

No ELIXCYTE®-related serious adverse events were reported during 96 weeks of follow-up and no suspected unexpected serious adverse reaction (SUSAR) or death was reported. The changes of the primary endpoint, WOMAC pain score at Week 24, showed significant differences in all ELIXCYTE® groups, as well as in HA groups between post-treatment visit and baseline. The ELIXCYTE® groups revealed significant decreases at Week 4 compared to HA group in WOMAC total scores, stiffness scores, functional limitation scores suggested the potential of ELIXCYTE® in earlier onset compared to those from HA. The significant differences of visual analog scale (VAS) pain score and Knee Society Clinical Rating System (KSCRS) functional activities score at Week 48 after ELIXCYTE® administration suggested the potential of ELIXCYTE® in the longer duration of the effectiveness compared to HA group.

Conclusions

ELIXCYTE® for knee osteoarthritis treatment was effective, safe, and well-tolerated. The efficacy results were showed that ELIXCYTE® conferred the earlier onset of reductions in pain scores and improvements in functional scores than HA group.

Trial registration: ClinicalTrials.gov Identifier: NCT02784964. Registered 16 May, 2016—Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT02784964

Background

Knee osteoarthritis (KOA) is a chronic musculoskeletal disease that affects 7% of the global population, more than 500 million people, and has been recognized as the 15th highest cause of years lived with disability (YLDs) worldwide [1]. Current managements of KOA are aimed at pain reduction and symptom control rather than disease modification. Nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and corticosteroids are generally used, and patients are unsatisfied with their limited analgesic, short-term efficacy, and potential risk of gastrointestinal and cardiovascular disorder [2, 3]. Hyaluronic acid (HA) is a natural component that seems to be attributable to KOA therapy via its viscosupplementation properties. Even though the use of intra-articular HA has raised no major safety concerns so far, the efficacy is still controversial [4].

Novel findings on the mechanisms underlying the development of KOA promote the research of potential disease-modifying osteoarthritis drugs (DMOADs) which targeting osteoarthritis pathogenesis, such as cartilage destruction, subchondral bone remodeling, and synovial inflammation. These DMOADs are pursued not only to relief pain and improve joint function, but also inhibit the progression of structural disorder [5]. Even if no DMOADs have been licensed, several potential candidates are under development [2, 5].

Mesenchymal stem cells (MSCs) have been shown to possess broad immunoregulatory and anti-inflammatory abilities and are capable to suppress all immune cells that play an important pathogenic role in the development and progression of OA [6]. In addition, MSCs promote endogenous proliferation of chondrocyte and inhibit chondrocyte apoptosis or cartilage degeneration by paracrine signaling, achieving cartilage regeneration and cartilage protection [7, 8]. These mechanism of actions of MSCs may not only provide the effective improvement of pain and symptom control, but also provide the potential disease-modifying effects on KOA.

Preclinical research has successfully shown the benefit of intra-articular MSC therapy for OA in pain relief and functional improvement [9,10,11,12]. Moreover, the initial clinical trials have an encouraging outcome on pain relief and functional improvement in symptomatic knee OA following MSC therapy [13,14,15,16]. While most studies have used autologous MSCs, allogeneic MSCs appear to have an acceptable safety profile which is similar to autologous cells. It is worth mentioning that allogeneic MSCs allow the manufacturing of large batches of off-the-shelf MSC products, which would enhance the consistency and decrease the costs of cell therapy, and solve the problem of limited proliferation capability of MSCs from elder donors. So far, the potential concern of using allogeneic adipose-derived stem cells (ADSCs) and the data of allogenic MSC for the KOA treatment is relatively limited as compared with the autologous MSCs [14, 17,18,19,20,21,22]. Therefore, we conducted a randomized Phase I/II clinical trial to assess the safety and therapeutic potential of allogeneic ADSCs in patients with KOA.

Methods

Preparation of ELIXCYTE®

The donor who signed the informed consent for the preparation of ELIXCYTE was recruited under the supervision of an Institutional Review Board (CGMF-IRB Number: 104-1790A3) and was screened and tested in compliance with eligibility determination guidance issued by Taiwan Food and Drug Administration. The adipose tissue was collected from eligible donor via ultrasonic-assisted liposuction and was transferred to UnicoCell BioMed Company under hypothermal condition within 6 h. The stromal vascular fraction (SVF) was isolated by digesting the adipose tissue with type I collagenase, centrifuged, and cultured at 37 °C in a humidified carbon dioxide incubator for primary culture. The adherent and highly proliferated cells termed ADSCs were detached and propagated to the passage 7 and within predefined population doubling level. The ADSCs were then harvested and formulated at a density of 8 × 106 cells/mL with cryoprotectant CryoStor® CS10 (BioLife Solutions). Release testing of ELIXCYTE® for microbiological evaluation (including mycoplasma, sterility, and endotoxin tests) was employed to ensure safety. The product characteristics such as identity (including MSC markers, viable cell count, and cell viability), and tri-lineage differentiation properties were also assessed.

Trial design

This phase I/II study, named as adipose-derived stem cells (ADSCs) for knee osteoarthritis, was planned as a randomized, single-blind, active-control study to evaluate the safety and efficacy of allogeneic ADSCs (ELIXCYTE®) intra-articular injection to patients with KOA. The study was registered on clinicaltrail.gov (NCT02784964) and was approved by Institutional Review Board to the tenets of the Declaration of Helsinki. There were two study sites in this trial, including Linkou Chang Gung Memorial Hospital and Taipei Veterans General Hospital in Taiwan. Permuted block randomization stratified by the center method was applied to generate randomization codes before study start, statistician from contract research organization (CRO) generated the random allocation sequence, investigators of this study enrolled participants, and the sponsor who assigned participants to interventions. Phase I of this study schemed to recruit 6 evaluable patients, and the permute block size was 6. Eligible patients would be randomly assigned in 2:1 ratio to investigational product treatment group (ELIXCYTE® 64 × 106 cells, 64 M) or active-control group (Hya Joint Plus synovial fluid supplement 3 mL, SciVision Biotech Inc).

Phase II of this study schemed to recruit 36 evaluable patients, and the permute block size was 9. Eligible patients would be randomly assigned in 2:3:3:1 ratio to investigational product treatment group (ELIXCYTE® 64 × 106 cells, 64 M; ELIXCYTE® 32 × 106 cells, 32 M; ELIXCYTE® 16 × 106 cells, 16 M) or active-control group. Each eligible patient would have exactly one “target knee” for efficacy evaluation for this study. The target knee would be the knee meeting entry criteria and be administered on day 1 with the treatment upon the patient was randomly assigned. Subjects were followed for 96 weeks including scheduled visits at Weeks 2, 4, 12, 24 (main study), 36, 48 (extension study), 72, and 96 (structural study) after administration.

Participants

This study was planned to enroll about 56 subjects for 42 evaluable subjects. All subjects gave written informed consent to participate in the study prior to enrollment. Eligible participants included patients aged 40–80 years (inclusive) with Kellgren–Lawrence (KL) grading I–III, as determined by American College of Rheumatology (ACR) criteria for KOA and WOMAC pain score 7–17. We excluded those with surgery history on the target knee joint, previous intra-articular intervention on the target knee joint within past 3 months, hypersensitivity to any component used in the study, inadequate hematologic and hepatic function, human immunodeficiency virus (HIV) infection or body mass index (BMI) greater than 35 kg/m2. Patients already participated in any other interventional study within 4 weeks of entering the study were also excluded. Treatment applied to target knee area, or analgesics except for acetaminophen and NSAIDs would be prohibited from patients.

Efficacy outcome measures

The primary endpoint was the change in WOMAC pain score from baseline to week 24 after treatment. Secondary outcomes included change from baseline to post-treatment visit in WOMAC stiffness, physical function, and total score; VAS for pain and KSCRS score.

Safety assessment

The safety assessment was the incidence of AEs and SAEs.

Clinical laboratory evaluation

Laboratory assessments including hematology and biochemistry were performed at the Screening, Week 24, 36, 48, 72, and 96 visits. The measured items were listed as below: for hematology: white blood cells (WBC), neutrophils, lymphocytes, monocytes, eosinophils, basophils, hemoglobin, hematocrit, platelet, and red blood cells (RBC); for biochemistry: aspartate aminotransferase, alanine aminotransferase, serum creatinine, blood urea nitrogen (BUN), and albumin; for immunogenicity, tumor necrosis factor alpha (TNF-α), CD4, and CD8 were measured at screening, Week 4, and 24 visits.

Statistical analysis

All phase I and phase II data were pooled for statistical analysis. Efficacy endpoints and safety endpoints were analyzed on the intent-to-treat (ITT) population. Demographics and baseline characteristics were analyzed by using a two-sample t-test, Wilcoxon rank-sum test or Fisher’s exact test as appropriate to ensure comparability between treatments. A two-sample t-test was applied for p-value (pairwise) in the statistic table, Wilcoxon rank-sum test was applied if the normality assumption was not valid (p-value of Shapiro–Wilk normality test ≤ 0.05). The efficacy endpoints, changes in WOMAC, VAS and KSCRS were analyzed by using ANCOVA incorporating treatment effect and baseline as covariate or by Wilcoxon rank-sum test. For safety analyses, the incidence of adverse events was tabulated by treatment groups and by physiological systems as appropriate.

Pairwise treatment group comparisons were conducted with a significance level of 0.05 without alpha adjustment. For efficacy endpoints, a 95% two-sided confidence interval on the difference of each treatment was provided as appropriate.

Results

Patient disposition and baseline characteristics

Total 64 subjects were screened, where 7 were screen failures, resulted in 57 (89%) subjects being eligible and randomized. Among them, 8 (14%) subjects received HA and 17 (29.8%) subjects received ELIXCYTE® 16 M, 17 (29.8%) subjects received ELIXCYTE® 32 M, and 15 (26.3%) subjects received ELIXCYTE® 64 M within the study period (Fig. 1). The ITT population consisted of the 57 randomized patients who received at least one dose of single-blind treatment.

Fig. 1
figure 1

Patient flow diagram showing subject numbers for screening, randomization, and treatment assignment

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Table 1 shows the demographic and baseline characteristics of the ITT patient population. Among 57 enrolled study subjects, 11 (19.3%) were male and 46 (80.7%) were female. The 57 eligible subjects were (mean ± SD) 67.6 ± 6.60 years of age, 155.2 ± 7.92 cm in height, 63.9 ± 9.64 kg in weight, and 26.54 ± 3.673 kg/m2 in BMI. The baseline KL grade of the target knees was either grade II (37/57, 64.9%) or grade III (20/57, 35.1%). The average duration of KOA since diagnosed was 2.96 years. No particular differences between individual ELIXCYTE® dose and HA groups were observed in demographic data and KOA history.

Table 1 Summary of demographic data—ITT population at the screening visit
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Safety

The summary of all treatment-emergent adverse events (TEAEs) during Week 0–24 and Week 24–96 is listed in Table 2, and all the treatment-related AEs were observed during week 0–24. Forty-four subjects (77.2%) reported at least one TEAE and 25 subjects (43.9%) experiencing at least one treatment-related AEs during Week 0–24. There were 3 subjects (5.3%) reported AEs with grade ≥ 3, including 2 subjects (11.8%) in middle-dose group and 1 subject (6.7%) in high-dose group, which was judged as treatment-related AE. During Week 24–96, 31 subjects (54.4%) reported at least one TEAEs. There were 6 SAEs recorded during the whole study period (Week 0–96), and none of them were judged as treatment-related SAE. Moreover, no SUSAR or death was reported in this study.

Table 2 Summary of treatment-emergent adverse events (TEAEs)
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Table 3 shows the TEAEs during Week 0–24 by system organ class (SOC). The most frequent TEAEs during Week 0–24 in total population were “Musculoskeletal and connective tissue disorders” (40.4%), followed by “General disorders and administration site conditions” (29.8%), “Infections and infestation” (21.1%), and “Gastrointestinal disorders” (12.3%). The frequency of other TEAEs was lower than 10.0%. TEAEs observed during Week 24–96 are presented in Additional file 2: Table S1.

Table 3 Summary of adverse events during week 0–24 (early TEAEs)
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As for treatment-related AEs, the most frequent AEs were “Injection site joint pain” (15.8%), followed by “Arthralgia” (14.0%), “Injection site joint swelling” (12.3%), and “Joint swelling” (10.5%). The frequency of other treatment-related AEs was lower than 5%. There was no treatment-related AE reported during Week 24–96. The summary of treatment-related AEs is presented in Table 4.

Table 4 Summary of treatment-related adverse events during week 0–24
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Additional file 1 showed that there was no clinically significant (NCS) abnormality in hematology observed in the subjects during the study, and most biochemistry values were normal or abnormal but NCS. However, the abnormal and clinically significant laboratory values of aspartate aminotransferase (AST) were observed in 1 (7.7%) subject in 32M and 1 (8.3%) subject in the 64M at Week 48 which were not treatment related. The CS values of ALT were also observed in 1 (7.7%) subject in the 32M and 1 (8.3%) subject in the 64M at Week 48. Regarding immunogenicity, most biochemistry values were normal or abnormal but NCS, except 1 (5.9%) abnormal and clinically significant TNF-α result was found in the 32M group at Week 4. These abnormal values were mainly related to medical history or adverse events of the subjects (Additional file 1, Table 18).

Efficacy: primary outcomes

The WOMAC pain score at week 24 was used to evaluate the primary endpoint. Under no significant difference between baseline values of HA and all ELIXCYTE® groups, all groups had significant reductions of pain score from baseline to post-treatment through Week 4 to 48 (Additional file 2: Table S2 for detail p-value information). In addition, the earlier significant reductions of pain score at Week 2 were observed in 16 M, 32 M, and Pooled groups compared to those in HA group (16 M: P = 0.0024; 32 M: P = 0.0040; Pooled P < 0.0001). The significant difference in mean WOMAC pain scores was observed at Week 4 in 64 M and Pooled groups in comparison with the HA group (64 M: P = 0.0026; Pooled: P = 0.0381) (Fig. 2a, Additional file 2: Table S2).

Fig. 2
figure 2

Changes in WOMAC after intra-articular injection of ELIXCYTE® or HA at each time point. WOMAC pain (a), total (b), stiffness (c), and function limitation (d) scores are presented as mean ± SD. 16 M, 32 M, 64 M, and HA = 16, 32, 64 million of ELIXCYTE®, and hyaluronic acid, respectively. The signs of significance, *, #, $, &, § representing a p-value < 0.05 between baseline and posttreatment score comparison for HA, 16 M, 32 M, 64 M, and Pooled group

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Efficacy: secondary outcomes

The baseline values of HA and all ELIXCYTE® groups were similar in WOMAC score (total, stiffness, and functional limitation), VAS score for pain, and KSCRS score (objective knee indicators, symptoms, and functional activities), except KSCRS score-patient satisfaction for the 16 M (P = 0.0253). (Individual p values are shown in supplement tables.)

All ELIXCYTE® groups had a significant reduction in WOMAC total score, stiffness, and functional limitation score from baseline to post-treatment at Week 12 to 48 (Additional file 2: Table S3, S4, and S5 for detailed p-value information). The earlier significant decreases of WOMAC total score from baseline to post-treatment were observed at Week 2 in 16 M, 32 M, and Pooled groups (16 M: P = 0.0129; 32 M: P = 0.0088; Pooled P < 0.0001), and at Week 4 in 16 M, 32 M, 64 M, and Pooled groups (16 M: P = 0.0004; 32 M: P < 0.0001; 64 M: P = 0.0001; Pooled P < 0.0001). A significant difference in mean WOMAC total scores was observed at Week 4 in 16 M, 32 M, 64 M, Pooled groups (16 M: P = 0.0481; 32 M: P = 0.0390; 64 M: P = 0.0014; Pooled P = 0.0075), and Week 48 in 64 M group in comparison with HA group (P = 0.0113) (Fig. 2b, Additional file 2: Table S3). A significant difference of mean WOMAC stiffness scores was observed at Week 4 in 16 M, 32 M, 64 M, and Pooled groups (16 M: P = 0.0369; 32 M: P = 0.0360; 64 M: P = 0.0027; Pooled P = 0.0073), and at Week 48 in 64 M in comparison with the HA group (P = 0.0402) (Fig. 2C, Additional file 2: Table S4). In WOMAC functional limitation score, the earlier improvement from baseline to post-treatment was found at Week 2 in 16 M, 32 M, and Pooled groups (16 M: P = 0.0173; 32 M: P = 0.0155; Pooled P < 0.0001), and at Week 4 in 16 M, 32 M, 64 M, and Pooled groups (16 M: P = 0.0010; 32 M: P < 0.0001; 64 M: P = 0.0003; Pooled P < 0.0001). In the comparison of HA and 64 M group at Week 48, a significant difference in the mean of functional limitation scores of WOMAC was observed (P = 0.0070) (Fig. 2d, Additional file 2: Table S5).

The time to observe significant reductions of VAS pain scores from baseline to post-treatment for HA and individual ELIXCYTE® groups was Week 12 to 36, and Week 4 to 48 (Additional file 2: Table S6 for detail p-value information), respectively. Moreover, the earlier pain improvements were found at Week 2 in 16 M, 64 M, and Pooled groups (16 M: P = 0.0121; 64 M: P = 0.0447; Pooled: P = 0.0002). A significant difference in mean VAS scores was observed at Week 4 in 64 M and Pooled groups (64 M: P = 0.0021; Pooled: P = 0.0127), at Week 12 in 16 M, 32 M, 64 M, and Pooled groups (16 M: P = 0.0026; 32 M: P = 0.0439; 64 M: P = 0.0003; Pooled: P = 0.0014) in comparison with the HA group (Fig. 3, Additional file 2: Table S6).

Fig. 3
figure 3

Changes in VAS pain after intra-articular injection of ELIXCYTE® or HA at each time point. VAS pain scores are presented as mean ± SD. 16 M, 32 M, 64 M, and HA = 16, 32, 64 million of ELIXCYTE®, and hyaluronic acid, respectively. The signs of significance = *, #, $, &, § representing a p-value < 0.05 between baseline and posttreatment score comparison for HA, 16 M, 32 M, 64 M, and Pooled group

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There were significant increases of KSCRS objective knee indicator scores from baseline to post-treatment in 16 M and Pooled groups at Weeks 12 to 48 (16 M: P = 0.0078, 0.0264, 0.0234; Pooled: P = 0.0021, 0.0105, 0.0002) compared to a decrease of score in HA group. A significant increase of mean KSCRS scores was observed at Week 12 in 16 M, 64 M, and Pooled groups (16 M: P = 0.0113; 64 M: P = 0.0370; Pooled: P = 0.0226), at Week 24 in 16 M, 32 M, and Pooled groups (16 M: P = 0.0017; 32 M: P = 0.0039; Pooled: P = 0.0039), and at Week 48 in 16 M (16 M: P = 0.0392) in comparison with the HA group. (Fig. 4a, Additional file 2: Table S7). All groups had a significant increase in KSCRS symptoms score, patient satisfaction score, and functional activities from baseline to post-treatment at Week 4 to 48 (Additional file 2: Table S8, S9, S10 for detail p-value information). Moreover, the earlier significant symptoms relief were found at Week 2 in 16 M, 32 M, and Pooled groups (16 M: P = 0.0030; 32 M: P = 0.0061; Pooled: P < 0.0001). A significant difference of mean KSCRS Symptoms scores was observed at Week 12 in 16 M, 64 M, and Pooled group (16 M: P = 0.0341; 64 M: P = 0.0080; Pooled: P = 0.0300), and at Week 48 in 64 M group in comparison with HA group (P = 0.0322) (Fig. 4b, Additional file 2: Table S8). The earlier significant improvements of patient satisfaction were found at Week 2 in 16 M, 32 M, and Pooled groups (Additional file 2: Table S9, 16 M: P = 0.0359; 32 M: P = 0.0022; Pooled: P = 0.0014). The significant increases of mean KSCRS patient satisfaction scores were observed at Week 24 in 64 M and Pooled groups (64 M: P = 0.0437; Pooled: P = 0.0397), and at Week 48 in 32 M, 64 M, and Pooled groups in comparison with HA group (32 M: P = 0.0472; 64 M: P = 0.0038; Pooled: P = 0.0044) (Fig. 4c, Additional file 2: Table S9). The HA group had significant increase in KSCRS functional activities score from baseline to post-treatment at Week 24 to 48 (Fig. 4d, Additional file 2: Table S10, P = 0.0133, 0.0023, 0.0252), while the earlier changes in the individual ELIXCYTE® and Pooled groups were observed at Week 4 and continued to Week 48 (Additional file 2: Table S10 for detail p-value information).

Fig. 4
figure 4

Changes in KSCRS after intra-articular injection of ELIXCYTE® or HA at each time point. KSCRS objective knee indicators (a), symptoms (b), patient satisfaction (c), and functional activities (d) scores are presented as mean ± SD. 16 M, 32 M, 64 M, and HA = 16, 32, 64 million of ELIXCYTE®, and hyaluronic acid, respectively; The signs of significance = *, #, $, &, § representing a p-value < 0.05 between baseline and posttreatment score comparison for HA, 16 M, 32 M, 64 M, and Pooled group

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Discussion

This present study aimed at evaluating the safety and efficacy of intra-articular ELIXCYTE® injection in patients with KOA. ELIXCYTE® for KOA treatment was shown to be effective, safe, and well-tolerated. The earlier onset and longer duration of effect mediated by ELIXCYTE® were observed compared to HA treatment and seem to show better outcomes in WOMAC scores, VAS score, and KSCRS scores.

ELIXCYTE® was shown to be safe, well-tolerated, and exhibited a comparable safety profile to the HA control. Although the allogeneic MSCs with poorly matched HLA had been reported to induce both innate and humoral responses, however, the response extent appears to be correlated with the expression level and the balance of both immune-activating antigens, such as major histocompatibility complex (MHC), and the immune-modifying cytokines, molecules and metabolites, like tumor necrosis factor-inducible gene 6 (TSG-6), galectin-1, prostaglandin E2 (PGE2), and indoleamine 2,3-dioxygenase (IDO) [23,24,25,26,27]. Regarding the immunogenicity results of our studies, the values of TNF-α, CD4, and CD8 values were normal or abnormal but NCS. Therefore, the safety profile in present studies was similar to other human trials used adipose-derived stem cells for KOA treatment [28].

Compared to the HA group and 16 M group, 32 M and 64 M groups seemed to have a larger percentage of general disorder and administration site conditions including pain and swelling at the injection site of the joint. The limited joint space, higher volume of injection (4 or 8 ml) may be the reason for those phenomena. Meanwhile, it could be assumed that a proportion of the cells injected into the joint space have not survived and this phenomenon was more pronounced with higher cell doses. Probably, such dead cells might trigger the inflammatory reaction in knee joint and thus cause pain [29]. Similar observation was found in Gupta’s study, the adverse events, such as knee pain and swelling, were predominant in their higher-dose groups (50, 75, and 150 million cells) [30]. In another recent study, Vega et al. have conducted a study using IA injection of allogeneic bone marrow-derived MSCs (BMSC) (40 M cells suspended in 8 ml of Ringer-Lactate). And the post-implantation pain was reported in 53% to 60% of patients in both the experimental and control groups [31]. Hence, pain and local swelling are the most common post-injection complication in patients after IA injection of MSCs.

The earlier onset and longer duration of pain and symptom control mediated by ELIXCYTE® were observed in this study compared to HA treatment. Allogeneic MSCs derived from adipose tissue and bone marrow have been described with the potential for more logistic convenience than autologous options. For example, the Stempeucel® which is an off-the-shelf ex vivo expanded bone marrow-derived allogeneic MSCs, was studied in phase II randomized trial with 60 patients. A non-statistically significant trend toward improvement in VAS and WOMAC scores compared with placebo was observed at 6 and 12 months [30]. However, MSCs from bone marrow appear to have high propensity to undergo chondrocyte hypertrophy and bone formation and thus may not be ideal for the repair of articular cartilage [32,33,34]. Adipose tissue is an attractive source of therapeutic MSCs not only owing to less invasive procurement for harvest, but also due to higher MSC concentration than in bone marrow, lesser expression of MHC class I antigens, and greater replicative and secretory potential of MSC. Additionally, ADSCs has higher immunomodulatory capability that is an important property for treating of OA than BMSC [35, 36].

Although adipose tissue-derived stem cells have been reported to aid in cartilage repair as evidenced by arthroscopy and histological indications of hyaline-like cartilage regeneration [14]. It is still challenging to demonstrate a significant therapeutic improvement in cartilage structure by radiographic measures in clinical trials. Moreover, the relationship between the structural recovery of cartilage and the symptom relief of OA remains unclear. The effect of ELIXCYTE® on cartilage regeneration has also been evaluated by magnetic resonance imaging (MRI) in the present study. No cartilage regeneration or structural modification have been identified and that might be due to the small sample size, the insensitivity and variation of radiographic outcomes, and the effects covered by natural disease progression (Additional file 2: Table S11, S12). In addition, the efficacy of ELIXCYTE® was not in a dosage-dependent manner and the optimal dosage and application volume still need to be further explored. For achieving effective and durable therapeutic effect, administration of sufficient amount of MSCs is critical. Repeated dosing of MSCs has demonstrated a superior clinical outcome compared to single dose in previous study [37]. Reaching sufficient cell numbers by giving smaller volumes of repeated doses may be one of the strategies for designing treatments in the further development of ELIXCYTE®.

Conclusions

In summary, the safety and therapeutic efficacy of allogenic ADSC therapy for treating KOA patients was reported. All ELIXCYTE® groups presented a comparable safety profile to HA along with an earlier onset and longer duration of the effectiveness compared to the HA. The administration of ELIXCYTE® is low risk and these results support the continued development of ELIXCYTE®.

Availability of data and materials

The datasets used or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

ADSCs:

Adipose-derived stem cells

IA:

Intra-articular

HA:

Hyaluronic acid

WOMAC:

Western Ontario and McMaster Universities Osteoarthritis Index

AEs:

Adverse events

SAEs:

Serious adverse events

SUSAR:

Suspected unexpected serious adverse reaction

VAS:

Visual analog scale

KSCRS:

Knee Society Clinical Rating System

KOA:

Knee osteoarthritis

YLDs:

Years lived with disability

NSAID:

Nonsteroidal anti-inflammatory drug

DMOAD:

Disease-modifying osteoarthritis drug

MSCs:

Mesenchymal stem cells

SVF:

Stromal vascular fraction

CRO:

Contract research organization

M:

Million

ACR:

American College of Rheumatology

HIV:

Human immunodeficiency virus

BMI:

Body mass index

WBC:

White blood cells

RBC:

Red blood cells

BUN:

Blood urea nitrogen

TNF-α:

Tumor necrosis factor alpha

ITT:

Intent-to-treat

KL:

Kellgren–Lawrence

TEAE:

Treatment-emergent adverse event

SOC:

System organ class

NCS:

No clinically significant

AST:

Aspartate aminotransferase

MHC:

Major histocompatibility complex

TSG-6:

Tumor necrosis factor-inducible gene 6, galectin-1

PGE2:

Prostaglandin E2

IDO:

Indoleamine 2,3-dioxygenase

BMSCs:

Bone marrow-derived MSCs

MRI:

Magnetic resonance imaging

References

  1. Hunter DJ, March L, Chew M. Osteoarthritis in 2020 and beyond: a Lancet Commission. Lancet. 2020;396(10264):1711–2.

    Article  Google Scholar 

  2. Ghouri A, Conaghan PG. Update on novel pharmacological therapies for osteoarthritis. Therapeutic advances in musculoskeletal disease. 2019;11:1759720x19864492.

  3. Hunter DJ, Bierma-Zeinstra S. Osteoarthritis. Lancet (London, England). 2019;393(10182):1745–59.

    Article  CAS  Google Scholar 

  4. Migliore A, Paoletta M, Moretti A, Liguori S, Iolascon G. The perspectives of intra-articular therapy in the management of osteoarthritis. Exp Opin Drug Deliv. 2020;17(9):1213–26.

    Article  CAS  Google Scholar 

  5. Rezuş E, Burlui A, Cardoneanu A, Macovei LA, Tamba BI, Rezuş C. From pathogenesis to therapy in knee osteoarthritis: bench-to-bedside. Int J Mol Sci. 2021;22(5):2697.

    Article  Google Scholar 

  6. Harrell CR, Markovic BS, Fellabaum C, Arsenijevic A, Volarevic V. Mesenchymal stem cell-based therapy of osteoarthritis: current knowledge and future perspectives. Biomed Pharmacother Biomed Pharmacother. 2019;109:2318–26.

  7. Pers YM, Ruiz M, Noël D, Jorgensen C. Mesenchymal stem cells for the management of inflammation in osteoarthritis: state of the art and perspectives. Osteoarthritis Cartilage. 2015;23(11):2027–35.

    Article  Google Scholar 

  8. Barry F, Murphy M. Mesenchymal stem cells in joint disease and repair. Nat Rev Rheumatol. 2013;9(10):584–94.

    Article  CAS  Google Scholar 

  9. Black LL, Gaynor J, Adams C, Dhupa S, Sams AE, Taylor R, et al. Effect of intraarticular injection of autologous adipose-derived mesenchymal stem and regenerative cells on clinical signs of chronic osteoarthritis of the elbow joint in dogs. Vet Therap Res Appl Vet Med. 2008;9(3):192–200.

    Google Scholar 

  10. Lee KB, Hui JH, Song IC, Ardany L, Lee EH. Injectable mesenchymal stem cell therapy for large cartilage defects–a porcine model. Stem Cells. 2007;25(11):2964–71.

    Article  Google Scholar 

  11. Murphy JM, Fink DJ, Hunziker EB, Barry FP. Stem cell therapy in a caprine model of osteoarthritis. Arthritis Rheum. 2003;48(12):3464–74.

    Article  Google Scholar 

  12. van Buul GM, Siebelt M, Leijs MJ, Bos PK, Waarsing JH, Kops N, et al. Mesenchymal stem cells reduce pain but not degenerative changes in a mono-iodoacetate rat model of osteoarthritis. J Orthop Res. 2014;32(9):1167–74.

    Article  Google Scholar 

  13. Centeno CJ, Schultz JR, Cheever M, Robinson B, Freeman M, Marasco W. Safety and complications reporting on the re-implantation of culture-expanded mesenchymal stem cells using autologous platelet lysate technique. Curr Stem Cell Res Ther. 2010;5(1):81–93.

    Article  CAS  Google Scholar 

  14. Jo CH, Lee YG, Shin WH, Kim H, Chai JW, Jeong EC, et al. Intra-articular injection of mesenchymal stem cells for the treatment of osteoarthritis of the knee: a proof-of-concept clinical trial. Stem Cells. 2014;32(5):1254–66.

    Article  CAS  Google Scholar 

  15. Vega A, Martín-Ferrero MA, Del Canto F, Alberca M, García V, Munar A, et al. Treatment of knee osteoarthritis with allogeneic bone marrow mesenchymal stem cells: a randomized controlled trial. Transplantation. 2015;99(8):1681–90.

    Article  CAS  Google Scholar 

  16. Centeno CJ, Busse D, Kisiday J, Keohan C, Freeman M, Karli D. Increased knee cartilage volume in degenerative joint disease using percutaneously implanted, autologous mesenchymal stem cells. Pain Phys. 2008;11(3):343–53.

    Google Scholar 

  17. Song Y, Du H, Dai C, Zhang L, Li S, Hunter DJ, et al. Human adipose-derived mesenchymal stem cells for osteoarthritis: a pilot study with long-term follow-up and repeated injections. Regen Med. 2018;13(3):295–307.

    Article  CAS  Google Scholar 

  18. Lu L, Dai C, Zhang Z, Du H, Li S, Ye P, et al. Treatment of knee osteoarthritis with intra-articular injection of autologous adipose-derived mesenchymal progenitor cells: a prospective, randomized, double-blind, active-controlled, phase IIb clinical trial. Stem Cell Res Ther. 2019;10(1):143.

    Article  Google Scholar 

  19. Lee WS, Kim HJ, Kim KI, Kim GB, Jin W. Intra-articular injection of autologous adipose tissue-derived mesenchymal stem cells for the treatment of knee osteoarthritis: a phase IIb, randomized, placebo-controlled clinical trial. Stem Cells Transl Med. 2019;8(6):504–11.

    Article  CAS  Google Scholar 

  20. Freitag J, Bates D, Wickham J, Shah K, Huguenin L, Tenen A, et al. Adipose-derived mesenchymal stem cell therapy in the treatment of knee osteoarthritis: a randomized controlled trial. Regen Med. 2019;14(3):213–30.

    Article  CAS  Google Scholar 

  21. Xinxin Han BY, Fagui Zou, Jianbo Sun. Clinical therapeutic efficacy of mesenchymal stem cells derived from adipose or bone marrow for knee osteoarthritis: a meta-analysis of randomized controlled trials. J Comp Eff Res. 2020.

  22. Zhao X, Ruan J, Tang H, Li J, Shi Y, Li M, et al. Multi-compositional MRI evaluation of repair cartilage in knee osteoarthritis with treatment of allogeneic human adipose-derived mesenchymal progenitor cells. Stem Cell Res Ther. 2019;10(1):308.

    Article  Google Scholar 

  23. Caplan H, Olson SD, Kumar A, George M, Prabhakara KS, Wenzel P, et al. Mesenchymal stromal cell therapeutic delivery: translational challenges to clinical application. 2019;10(1645).

  24. Ankrum JA, Ong JF, Karp JM. Mesenchymal stem cells: immune evasive, not immune privileged. Nat Biotechnol. 2014;32(3):252–60.

    Article  CAS  Google Scholar 

  25. Consentius C, Reinke P, Volk HD. Immunogenicity of allogeneic mesenchymal stromal cells: what has been seen in vitro and in vivo? Regen Med. 2015;10(3):305–15.

    Article  CAS  Google Scholar 

  26. Berglund AK, Fortier LA, Antczak DF, Schnabel LV. Immunoprivileged no more: measuring the immunogenicity of allogeneic adult mesenchymal stem cells. Stem Cell Res Therapy. 2017;8(1):288.

  27. Lohan P, Treacy O, Griffin MD, Ritter T, Ryan AE. Anti-donor immune responses elicited by allogeneic mesenchymal stem cells and their extracellular vesicles: are we still learning? Front Immunol. 2017;8:1626.

  28. Ip HL, Nath DK, Sawleh SH, Kabir MH, Jahan N. Regenerative medicine for knee osteoarthritis—the efficacy and safety of intra-articular platelet-rich plasma and mesenchymal stem cells injections: a literature review. Cureus. 2020;12(9):e10575.

  29. Rock KL, Kono H. The inflammatory response to cell death. Annu Rev Pathol. 2008;3:99–126.

    Article  CAS  Google Scholar 

  30. Gupta PK, Chullikana A, Rengasamy M, Shetty N, Pandey V, Agarwal V, et al. Efficacy and safety of adult human bone marrow-derived, cultured, pooled, allogeneic mesenchymal stromal cells (Stempeucel(R)): preclinical and clinical trial in osteoarthritis of the knee joint. Arthritis Res Ther. 2016;18(1):301.

    Article  Google Scholar 

  31. Vega A, Martin-Ferrero MA, Del Canto F, Alberca M, Garcia V, Munar A, et al. Treatment of knee osteoarthritis with allogeneic bone marrow mesenchymal stem cells: a randomized controlled trial. Transplantation. 2015;99(8):1681–90.

    Article  CAS  Google Scholar 

  32. Vinardell T, Sheehy EJ, Buckley CT, Kelly DJ. A comparison of the functionality and in vivo phenotypic stability of cartilaginous tissues engineered from different stem cell sources. Tissue Eng Part A. 2012;18(11–12):1161–70.

    Article  CAS  Google Scholar 

  33. Scotti C, Tonnarelli B, Papadimitropoulos A, Scherberich A, Schaeren S, Schauerte A, et al. Recapitulation of endochondral bone formation using human adult mesenchymal stem cells as a paradigm for developmental engineering. Proc Natl Acad Sci USA. 2010;107(16):7251–6.

    Article  CAS  Google Scholar 

  34. De Bari C, Roelofs AJ. Stem cell-based therapeutic strategies for cartilage defects and osteoarthritis. Curr Opin Pharmacol. 2018;40:74–80.

    Article  Google Scholar 

  35. Strioga M, Viswanathan S, Darinskas A, Slaby O, Michalek J. Same or not the same? Comparison of adipose tissue-derived versus bone marrow-derived mesenchymal stem and stromal cells. Stem Cells Dev. 2012;21(14):2724–52.

    Article  CAS  Google Scholar 

  36. Melief SM, Zwaginga JJ, Fibbe WE, Roelofs H. Adipose tissue-derived multipotent stromal cells have a higher immunomodulatory capacity than their bone marrow-derived counterparts. Stem Cells Transl Med. 2013;2(6):455–63.

    Article  Google Scholar 

  37. Matas J, Orrego M, Amenabar D, Infante C, Tapia-Limonchi R, Cadiz MI, et al. Umbilical cord-derived mesenchymal stromal cells (MSCs) for knee osteoarthritis: repeated MSC dosing is superior to a single MSC dose and to hyaluronic acid in a controlled randomized phase I/II trial. Stem Cells Transl Med. 2019;8(3):215–24.

    Article  CAS  Google Scholar 

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Acknowledgements

We express our appreciation to the two institutions for sponsorship, UnicoCell BioMed and the A+ Industrial Innovative R&D Program, Ministry of Economic Affairs, R.O.C. We would also like to express our sincere gratitude to all the patients and the medical professionals who participated in this trial.

Funding

This study was funded by UnicoCell BioMed Co. Ltd. and the A+ Industrial Innovative R&D Program, Ministry of Economic Affairs, R.O.C (Grant No. 105-EC-17-A-22-I5-0007).

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Author notes

  1. Cheng-Fong Chen and Chih-Chien Hu have been contributed equally to this work

Authors and Affiliations

  1. Division of Joint Reconstruction, Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan

    Cheng-Fong Chen

  2. Department of Surgery, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan

    Cheng-Fong Chen

  3. Division of Joint Reconstruction, Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan

    Chih-Chien Hu & Yuhan Chang

  4. Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan

    Chih-Chien Hu & Yuhan Chang

  5. College of Medicine, Chang Gung University, Taoyuan, Taiwan

    Chih-Chien Hu & Yuhan Chang

  6. Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Linkou, Taiwan

    Chen-Te Wu

  7. Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan

    Hung-Ta H. Wu

  8. Department of Radiology, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan

    Hung-Ta H. Wu

  9. Craniofacial Research Center, Department of Medical Research, Department of Plastic and Reconstructive Surgery and Department of Craniofacial Orthodontics, Chang Gung Memorial Hospital, Taoyuan, Taiwan

    Chun-Shin Chang

  10. Department of Chemical and Materials Engineering, College of Engineering, Chang Gung University, Taoyuan, Taiwan

    Chun-Shin Chang

  11. UnicoCell BioMed Co. Ltd., Taipei, Taiwan

    Yi-Pei Hung & Chia-Chu Tsai

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  1. Cheng-Fong Chen
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  4. Hung-Ta H. Wu
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  8. Yuhan Chang
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Contributions

All authors made substantial contributions to all of the following: (1) the conception and design of the study, or acquisition of data, or analysis and interpretation of data, (2) drafting the article or revising it critically for important intellectual content, (3) final approval of the version to be submitted.

Corresponding author

Correspondence to Yuhan Chang.

Ethics declarations

Ethics approval and consent to participate

The protocol of the study was approved by the Institutional Review Board to the tenets of the Declaration of Helsinki. There were two study sites in this trial, including Linkou Chang Gung Memorial Hospital and Taipei Veterans General Hospital in Taiwan. The official ethical approval numbers of the study were 104-1182A (CGMF-IRB) and 2017–04-005A (VGHTPE-IRB). The study was registered at http://ClinicalTrials.gov (NCT02784964).

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Not applicable.

Competing interests

The authors declare that they have no competing interests.

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Supplementary Information

Additional file 1

: Hematology and biochemistry data from patients in trial.

Additional file 2

: Supplementary safety and efficacy data of ELIXCYTE® including Table S1-S12.

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Chen, CF., Hu, CC., Wu, CT. et al. Treatment of knee osteoarthritis with intra-articular injection of allogeneic adipose-derived stem cells (ADSCs) ELIXCYTE®: a phase I/II, randomized, active-control, single-blind, multiple-center clinical trial. Stem Cell Res Ther 12, 562 (2021). https://doi.org/10.1186/s13287-021-02631-z

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Keywords

Stem Cell Research & Therapy

ISSN: 1757-6512