Clin Rheumatol (2014) 33:1611–1619
DOI 10.1007/s10067-014-2754-4
ORIGINAL ARTICLE
Allogeneic mesenchymal stem cell transplantation for lupus
nephritis patients refractory to conventional therapy
Fei Gu & Dandan Wang & Huayong Zhang & Xuebing Feng &
Gary S. Gilkeson & Songtao Shi & Lingyun Sun
Received: 10 March 2014 / Revised: 7 July 2014 / Accepted: 17 July 2014 / Published online: 14 August 2014
# International League of Associations for Rheumatology (ILAR) 2014
Abstract Allogeneic mesenchymal stem cell transplantation
(MSCT) has been shown to be clinically efficacious in the
treatment of various autoimmune diseases. Here, we analyzed
the role of allogeneic MSCT to induce renal remission in
patients with active and refractory lupus nephritis (LN). This
is an open-label and single-center clinical trial conducted from
2007 to 2010 in which 81 Chinese patients with active and
refractory LN were enrolled. Allogeneic bone marrow- or
umbilical cord-derived mesenchymal stem cells (MSCs) were
administered intravenously at the dose of 1 million cells per
kilogram of bodyweight. All patients were then monitored
over the course of 12 months with periodic follow-up visits
to evaluate renal remission, as well as possible adverse events.
The primary outcome was complete renal remission (CR) and
partial remission (PR) at each follow-up, as well as renal
flares. The secondary outcome included renal activity score,
total disease activity score, renal function, and serologic in-
dex. During the 12-month follow-up, the overall rate of sur-
vival was 95 % (77/81). Totally, 60.5 % (49/81) patients
Fei Gu and Dandan Wang contributed equally to this paper.
Electronic supplementary material The online version of this article
(doi:10.1007/s10067-014-2754-4) contains supplementary material,
which is available to authorized users.
F. Gu : D. Wang : H. Zhang : X. Feng : L. Sun (*)
Department of Rheumatology and Immunology, The Affiliated
Drum Tower Hospital of Nanjing University Medical School, 321
Zhongshan Road, Nanjing, Jiangsu 210008, People’s Republic of
China
e-mail: lingyunsun@nju.edu.cn
G. S. Gilkeson
Devision of Rheumatology, Medical University of South Carolina,
Charleston, USA
S. Shi
Center for Craniofacial Molecular Biology, University of Southern
California School of Dentistry, Los Angeles, SC, USA
achieved renal remission during 12-month visit by MSCT.
Eleven of 49 (22.4 %) patients experienced renal flare by the
end of 12 months after a previous remission. Renal activity
evaluated by British Isles Lupus Assessment Group (BILAG)
scores significantly declined after MSCT (mean ± SD, from
4.48±2.60 at baseline to 1.09±0.83 at 12 months), in parallel
with the obvious amelioration of renal function. Glomerular
filtration rate (GFR) improved significantly 12 months after
MSCT (mean ± SD, from 58.55±19.16 to 69.51±27.93 mL/
min). Total disease activity evaluated by Systemic Lupus
Erythematosus Disease Activity Index (SLEDAI) scores also
decreased after treatment (mean ± SD, from 13.11±4.20 at
baseline to 5.48±2.77 at 12 months). Additionally, the doses
of concomitant prednisone and immunosuppressive drugs
were tapered. No transplantation-related adverse event was
observed. Allogeneic MSCT resulted in renal remission for
active LN patients within 12-month visit, confirming its use as
a potential therapy for refractory LN.
Keywords Lupus nephritis . Mesenchymal stem cells .
Transplantation
Introduction
Systemic lupus erythematosus (SLE) is an autoimmune dis-
order often characterized by the development of glomerulo-
nephritis [1]. The general consensus is that 60 % of lupus
patients will develop clinically relevant nephritis at some time
in the course of their illness, and lupus nephritis (LN) is a
major cause of mortality among patients [2]. Randomized
trials indicated that long-term use of a combination of steroids
and immunosuppressive agents, such as cyclophosphamide
(CYC) or mycophenolate mofetil (MMF), was effective for
LN patients [3, 4]. However, the rate of side effects is high,
and some nonresponders were reported [5]. For refractory
1612
cases, intravenous immunoglobulins, plasma exchange,
immunoabsorption, and multitarget therapy, such as the cal-
cineurin inhibitor tacrolimus, are promising options [6–8], but
the present clinical studies are all limited to small sample size
with short follow-up visits and lack of strict criteria by which
to accurately determine complete remission [9, 10]. Novel
methods of induction therapy for refractory LN include the
use of monoclonal antibodies that (1) modulate and/or deplete
B cells, including anti-CD20 and anti-CD22 antibodies, re-
spectively, or (2) interfere with the stimulatory effects of the
soluble factor B-lymphocyte stimulator, i.e., anti-BLyS hu-
man monoclonal antibody, belimumab (BmAb). The number
of case reports is continuously increasing, and they have
shown that these biologic agents are effective in the treatment
of refractory LN. However, treatment-related adverse events
have appeared after long-term applications, and the relapse
rates observed in different studies ranged from 38 to 87 %
[11]. Additionally, these drugs cause a heavy economic bur-
den for patients, especially in developing countries [12].
Hematopoietic stem cell transplantation (HSCT) has been
reported as a promising therapy to achieve long-term remis-
sion in refractory LN [13], but the rates of relapse and
treatment-related toxicity are high as is the development of a
secondary autoimmune disorder [14].
Mesenchymal stem cells (MSCs) possess immunomodula-
tory and reparative properties through specific interactions
with immune cells that participate in both innate and adaptive
immune responses. MSCs exposed to an inflammatory micro-
environment can downregulate active immune responses.
Clinical trials focusing on MSCs to treat graft-versus-host
disease (GVHD) and other diseases are underway [15, 16].
In the past 6 years, we have applied allogeneic MSC trans-
plantation in treating patients with refractory autoimmune
disorders, including SLE, systemic sclerosis, myositis, multi-
ple sclerosis, inflammatory bowel disease, and rheumatoid
arthritis, and the clinical efficacy is encouraging [17–23].
These cases also suggested a safety profile of allogeneic
MSC transplantation (MSCT) administered intravenously
in vivo.
In the present study, we analyze the 12-month clinical
outcome and safety profile of allogeneic MSCT in 81 patients
with refractory LN, who did not respond to conventional
treatment regimens.
Methods
Patient selection
This study is an open-label clinical trial. From March 2007 to
October 2010, 81 patients with active lupus nephritis refrac-
tory to standard therapies were enrolled. All enrolled patients
had fulfilled at least 4 of 11 American College of
Clin Rheumatol (2014) 33:1611–1619
Rheumatology criteria for the classification of SLE [24].
Clinical disease activity of lupus nephritis was defined by at
least two of the following: (1) Laboratory tests documented
active lupus nephritis three consecutive times: decrease in
renal function (serum creatinine >106 μmol/L), increase in
proteinuria (defined as more than 1.0 g of protein excretion in
a 24-h urine specimen), and deterioration in microscopic
hematuria (defined as >10 red cells per high power field) or
the presence of cellular casts; (2) serologic abnormality (in-
crease of anti-double-stranded DNA (dsDNA) antibodies or
deterioration of hypocomplementemia); (3) renal biopsy
documenting lupus nephritis according to the International
Society of Nephrology/Renal Pathology Society classification
of active or active/chronic lupus nephritis in renal biopsy class
III, class IV-S or IV-G, class V, class III + V, or class IV + V
(within 3 months) [25]. All patients were resistant to at least
6 months of therapy with CYC and/or MMF in combination
with corticosteroid, according to conventional treatment stan-
dard. Written informed consent was obtained from each pa-
tient. This study was approved by the Ethics Committee at
The Affiliated Drum Tower Hospital of Nanjing University
Medical School and was conducted in compliance with cur-
rent Good Clinical Practice standards and in accordance with
the principles set forth under the Declaration of Helsinki
(1989).
Treatment protocol
Allogeneic bone marrow MSCs were isolated from bone
marrow aspirates obtained from healthy donors, i.e., members
of the patient’s immediate family, and all signed informed
consents. Briefly, 20 mL of bone marrow was aspirated on
the posterior iliac crest. Bone marrow mononuclear cells were
separated by Ficoll density centrifugation. Mononuclear cells
were cultured in a 175-cm2 flask (Corning) with low-glucose
Dulbecco’s modified Eagle’s medium (DMEM-LG, Gibco)
containing 10 % fetal bovine serum (FBS) (HyClone) and 1 %
penicillin-streptomycin (Gibco) in a humidified incubator at
37 °C under 5 % CO2. Nonadherent cells were removed when
the medium was exchanged on the third day. When the pri-
mary MSCs had expanded to 80 % confluence, they were
harvested and expanded to reach treatment dose based on the
body weight of the recipient [17].
Patients who did not have appropriate bone marrow donors
were infused with umbilical cord (UC)-derived MSCs. UC
MSCs were prepared by the Stem Cell Center of Jiangsu
Province. The cords were rinsed by phosphate-buffered saline
(PBS) in penicillin and streptomycin, and the cord blood was
removed during this process. The washed cords were cut into
1-mm2-sized pieces and floated in DMEM-LG containing
10 % FBS and 1 % penicillin-streptomycin (Gibco). The
pieces of cord were subsequently incubated at 37 °C in humid
air with 5 % CO2. Nonadherent cells were removed by
Clin Rheumatol (2014) 33:1611–1619
washing. The medium was replaced every 3 days after the
initial plating. When well-developed colonies of fibroblast-
like cells appeared after 10 days, the cultures were trypsinized
and passaged into a new flask for further expansion [18].
Criteria for release of MSCs for clinical use included
absence of visible clumps; spindle-shaped morphology; and
absence of contamination by pathogens, as documented by
aerobic and anaerobic cultures, as well as by virus for hepatitis
B surface antigen, hepatitis B core antibody, hepatitis C virus
antibody, human immunodeficiency virus antibodies I and II,
cytomegalovirus IgM, and syphilis antibody, as determined by
enzyme-linked immunosorbent assay (ELISA); cell viability
greater than 92 %, as determined by trypan blue testing and
immune phenotyping proving expression of CD73, CD105,
CD90, and CD29 (>90 %); and absence of CD45, CD34,
CD14, CD79, and HLA-DR (<2 %). In vitro osteogenic and
adipogenic induction of MSCs was also assayed. We used
good manufacturing practice (GMP) conditions and clinical
grade reagents to prepare the cells. All patients received a
single intravenous infusion of BM- or UC-derived MSCs (1
million cells per kilogram of body weight per infusion).
After MSCT, all patients were examined during follow-up
visits at 1, 3, 6, and 12 months or termination as a result of
death. Standard physical examinations, including blood pres-
sure, cutaneous, and skeletal manifestations, were performed
by the same rheumatologist. Laboratory assessments, includ-
ing complete blood cell count, routine urine test, 24-h protein-
uria, kidney and liver function, serum albumin, and anti-
dsDNA antibody, were performed at each visit at the same
laboratory. Disease activity was assessed by Systemic Lupus
Erythematosus Disease Activity Index (SLEDAI). Renal ac-
tivity index was evaluated by British Isles Lupus Assessment
Group (BILAG) score for renal system.
Outcome
The primary end points were rates of overall survival, com-
plete and partial renal remission, and relapse within 12 months.
Complete remission was defined as the return to normal
values of serum creatinine (<106 μmol/L), proteinuria
(<0.3 g/24 h), and urine sediment. Partial remission was
defined as improvement of no less than 50 % in all abnormal
renal measurements, without worsening (within 10 %) of any
measurement. A renal flare was defined as the recurrence of
serum creatinine (>33 % increase within a 1-month period
directly attributed to lupus and confirmed 1 week later) or
proteinuria (at least threefold increase within a 3-month period
accompanied by microscopic hematuria), irrespective of prior
complete or partial remission. Treatment failure was defined
as a condition requiring higher doses of corticosteroid or
immunosuppressant for disease control or failure to reach
complete or partial remission within 6 months [26, 27]. Key
secondary end points included SLEDAI score for disease
1613
activity, BILAG score of renal system, and changes in renal
function, serum albumin, and anti-dsDNA antibody levels
pre- and post-MSCT.
Safety assessments
The incidence and severity of adverse events (AEs) were
monitored. Serious adverse events (SAEs), infusion-related
AEs (an AE occurring during or within 24 h following MSC
infusion), and infection-related AEs were summarized inde-
pendently. Transplantation-related mortality included all
deaths associated with transplantation of MSCs, except those
related to recurrence of underlying disease.
Statistical analysis
Rates of overall survival, complete and partial renal remission,
and relapse at different follow-up visits were calculated by
using the Kaplan-Meier method and were statistically tested
with the log-rank test. The renal BILAG index was used to
assess response, and scores were converted to numeric values
(A=9, B=3, C=1, D=0, E=0) to enable evaluation [28]. We
calculated heart rates (HR) and their 95 % confidence intervals
(CIs) using the univariate Cox proportional hazards model.
Unpaired t tests, χ2 tests, and Fisher’s exact tests were used as
appropriate. All analyses were performed by statistical soft-
ware (SPSS 16.0). Statistical significance was set at P<0.05.
Results
Participant characteristics
Eighty-one patients (74 females and 7 males) were enrolled in
this trial, and the mean disease duration was 83.1 months (6–
264). Patient characteristics are listed in Table 1. All patients
were refractory to conventional treatments and underwent
MSCT; they then completed 12 months of follow-up visits.
Twenty-three patients (23/81, 28 %) were given bone marrow-
derived MSC infusion (two patients had son as donor, two
patients had daughter as donor, three patients had father as
donor, three patients had husband as donor, four patients had
mother as donor, four patients had sister as donor, and five
patients had brother as donor), and the other 58 patients (58/
81, 72 %) received UC-derived MSCs.
Primary outcome
Overall survival and disease remission
The overall survival rate during the 12-month follow-up peri-
od was 95 % (77/81). Survival rate was not correlated with
1614 Clin Rheumatol (2014) 33:1611–1619

Table 1 Baseline characteristics of patients renal flare, and another 5 patients (5/35, 14.3 %; 35
Demographics patients were in renal remission at 6 months) underwent
relapse in the following 6 months. The overall rate of
Age (year) 31.6 (12–55) relapse within 12 months was 22.4 % (11/49) (Fig. 1b).
Women/men (n) 74/7 Renal flare was not correlated with age (P=0.966), dis-
Duration (month) 83.1 (6–264) ease duration (P=0.939), MSC source (P=0.862), base-
Renal BILAG [n (mean)] 81 (4.48±2.60) line SLEDAI score (P = 0.919), or baseline proteinuria
Proteinuria [n, (g/24 h)] 81 (2.74±1.20) levels (P=0.187) by Cox regression analysis, but it was
Serum creatinine [n (μmol/L)] 33 (196.27±99.01) significantly correlated with baseline serum creatinine
Serum albumin [n (g/dL)] 61 (2.58±0.47) levels (P=0.003, OR=1.773, 95 % CI 1.213–2.591). A
GFR [n (mL/min)] 27 (58.55±19.16) total of 32 patients (32/81, 39.5 %) did not achieve either
Renal biopsy [n (%)] 13 (16.05) complete or partial remission within 12 months, an out-
SLEDAI score [n (mean)] 81 (13.11±4.20) come that was defined as treatment failure.
Cutaneous involvement [n (%)] 59 (72.84)
Musculoskeletal involvement [n (%)] 57 (70.37)
Hematologic involvement [n (%)] 36 (44.44) Secondary outcomes
Neuropsychiatric involvement [n (%)] 4 (4.94)
Baseline prednisolone [n (%)] 81 (100) Lupus nephritis improvements
Hydroxychloroquine [n (%)] 43 (53.09)
Cyclophosphamide [n (%)] 66 (81.48) Lupus nephritis activity assessed by BILAG score de-
Mycophenolate mofetil [n (%)] 19 (23.46) creased significantly 1 month after MSCT (mean ± SD
4.48±2.60 vs. 1.70±1.05, P<0.01) and continued to im-
BILAG British Isles Lupus Assessment Group, SLEDAI Systemic Lupus prove at 3 months (1.19 ± 0.92, P < 0.01 vs. baseline
Erythematosus Disease Activity Index levels). The average renal BILAG score at 6 months was
1.29 ± 1.33, which demonstrated significant difference
disease duration (P=0.880) or the source of MSCs (P=0.265) compared to baseline levels and 1-month follow-up visit
by Cox regression analysis. The probability of complete re- (both P <0.01). Moreover, the BILAG score decreased
mission was 17.5 % (14/80) at 3 months, 18.2 % (14/77) at significantly by the 12-month follow-up visit (1.09 ±
6 months, and 23.4 % (18/77) at 12 months. A total 30.9 % 0.83, P < 0.01 vs. baseline levels and 1-month visit;
(25/81) of patients experienced complete remission during the Fig. 2a). All enrolled patients had defined proteinuria at
12 months. By Cox regression analysis, we found that com- baseline (>0.5 g/24 h), but proteinuria decreased from
plete remission was not correlated with age (P=0.475), dis- 2.74±1.20 to 2.06±1.04 g at 1 month, 1.74±1.21 g at
ease duration (P=0.480), MSC source (P=0.916), or baseline 3 months, 1.56±1.03 g at 6 months, and 1.52±1.04 g at
SLEDAI score (P=0.231), while it was significantly correlat- 12 months, with statistical differences at each follow-up
ed with baseline proteinuria levels (P=0.003, OR=0.517, visit (P < 0.001; Fig. 2b). There was no difference in
95 % CI 0.336–0.794) and baseline serum creatinine levels amelioration of proteinuria between bone marrow and
(P=0.047, OR=0.471, 95 % CI 0.224–0.990). UC-derived MSCTs (supplementary Fig. 1).
Within the 12-month follow-up period, partial remission Thirty-three patients (33/81, 41 %) had abnormal serum
was achieved in 22.5 % (18/80) of patients at 3 months, creatinine levels at baseline (mean ± SD, 195.9 ±
27.3 % (21/77) of patients at 6 months, and 20.8 % (16/77) 98.6 μmol/L). After allogeneic MSCT, serum creatinine
of patients at 12 months. Overall, 60.5 % (49/81) of patients declined to 186.0 ± 116.8 μmol/L at 1 month, 187.8 ±
achieved complete or partial remission during 12 months 160.9 μmol/L at 3 months, 172.9 ± 124.4 μmol/L at
(Fig. 1a). We also found that partial renal remission was not 6 months, and 162.3 ± 94.7 μmol/L at 12 months, with
correlated with age (P=0.711), duration (P=0.897), MSC statistical difference at 12 months (P=0.0057, Fig. 2c).
source (P=0.202), baseline SLEDAI score (P=0.566), or For 31 patients (31/81, 38 %) who had elevated serum urea
baseline serum creatinine levels (P=0.056) by Cox regression, nitrogen at baseline (mean±SD, 18.27±9.49 μmol/L), this
but it was statistically correlated with baseline proteinuria index improved significantly 3 and 12 months post-MSCT
levels (P=0.039, OR=0.762, 95 % CI 0.588–0.986). (15.12 ± 6.81 μmol/L at 3 months, P = 0.04 vs. baseline
level; 11.74 ± 4.66 μmol/L at 12 months, P < 0.001 vs.
Relapse baseline level, Fig. 2d). Furthermore, glomerular filtration
rate (GFR) improved significantly 12 months after alloge-
By the end of 6 months, 6 out of 32 patients (18.8 %; 32 neic MSC infusion (mean ± SD, from 58.55 ± 19.16 to
patients were in renal remission at 3 months) experienced 69.51±27.93 mL/min, n=27, P=0.046).
Clin Rheumatol (2014) 33:1611–1619
Fig. 1 Cumulative probability of achieving a renal remission and b relapse for patients infused with mesenchymal stem cells (MSCs) during 12 months,
by Kaplan-Meier survival analysis
Total disease activity score and serologic ameliorations
Total disease activity assessed by SLEDAI score improved
significantly after allogeneic MSC infusions (mean ± SD, from
13.11±4.20 at baseline to 9.64±3.86 at 1 month; 7.59±3.04 at
3 months; 6.12±2.90 at 6 months; 5.48±2.77 at 12 months, n=
81, P<0.01, Fig. 3a). In addition, the mean serum albumin
concentration for 61 patients increased (2.58±0.47 g/dL at
baseline, 2.85±0.48 g/dL at 1 month, 3.24±0.51 g/dL at
3 months, 3.48±0.50 g/dL at 6 months, and 3.55±0.59 g/dL
at 12 months, all P<0.01 vs. baseline levels, Fig. 3b) in parallel
with the decline of proteinuria. Serum anti-dsDNA antibody
declined after MSCT without reaching statistical difference at
each follow-up visit (mean ± SD, from 630.1±792.6 IU/mL at
baseline to 475.5±633.5 IU/mL at 1 month, 485.0±633.9 IU/
mL at 3 months, 466.5±583.4 IU/mL at 6 months, and 410.3±
372.4 IU/mL at 12 months, n=18, P>0.05, Fig. 3c).
Maintenance therapy after mesenchymal stem cell
transplantation
Prednisone dosage was tapered 5–10 mg every 2 weeks in the
first month following transplantation according to clinical
status and laboratory indicators of disease remission. At the
end of 12 months, 64 out of 77 patients (83 %) had their
prednisone dosage tapered, and 59 out of 77 patients (77 %)
had their prednisone tapered to 5–10 mg per day (mean ± SD,
10.32±4.12 mg/day at 12 months vs. 22.24±12.78 mg/day at
baseline, n=77, P<0.001, Fig. 4a). Sixty-six out of 81 patients
(81 %) had CYC for immunosuppressive therapy at baseline,
1615
and the average dose of CYC was tapered from 0.80±0.19 to
0.46±0.19 g/month at 12 months (mean ± SD, P<0.001, n=
63, three patients died, Fig. 4b and Table 2), according to
disease remission, without the addition of other immunosup-
pressive drugs.
Safety
Serious adverse events
Four of 81 patients died after MSCT, all judged to be from
events unrelated to treatment. One patient died 156 days after
MSCT from disease relapse after an acute gastroenteritis and
heart failure. Two other patients succumbed to disseminated
pulmonary infections and uncontrolled lupus nephritis 78 and
179 days after MSCT, respectively. One patient had relapse of
her lupus at 4 months, with pulmonary hypertension, and she
died from right-sided heart failure 245 days after MSC
infusion.
Infection-related adverse events
Two patients experienced enteritis and diarrhea 3 and 4 months
after MSCT, respectively, with transient increase of serum
creatinine, which was controlled by conventional treatments.
Two other patients had herpes virus infection 1 and 6 months
after MSCT, respectively, with no renal flare. None of the AEs
were considered to be related to MSC infusion.
1616 Clin Rheumatol (2014) 33:1611–1619

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Proteinuria (g/24h)
8
Renal BILAG score

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Fig. 2 Baseline and repeated measurements of a renal BILAG score, b 24-h proteinuria, c serum creatinine, and d serum urea nitrogen for patients
infused with allogeneic mesenchymal stem cells (MSCs). *P<0.05 vs. pre-MSCT, **P<0.01 vs. pre-MSCT, ***P<0.001 vs. pre-MSCT

A
**
B ** C
** **
***
** ** * 4000
Serum anti-dsDNA antibody (IU/ml)

30 5
** *** ***
** ***
*** 3000
Serum albumin (g/dl)

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**
SLEDAI score

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Fig. 3 Measurements of a SLE Disease Activity Index score, b serum albumin, and c serum anti-dsDNA antibody for patients who underwent
allogeneic mesenchymal stem cell (MSC) transplantation. **P<0.01 vs. pre-MSCT
Clin Rheumatol (2014) 33:1611–1619 1617

A B
100 *** 2.0 ***
Dose of prednisone (mg/day)

Dose of CYC (gm/month)

80
1.5

60
1.0

40

0.5
20

0 0.0
Before MSCT 12 months Before MSCT 12 months
Fig 4 Doses of prednisone (a) and cyclophosphamide (CYC, b) were tapered for patients after allogeneic mesenchymal stem cell transplantation
(MSCT). ***P<0.001 vs. pre-MSCT

Discussion patients who were unresponsive to conventional immuno-

suppression treatments, especially previous regular intra-
MSCs provide stromal support for HSCs in the bone marrow venous CYC. In our previous studies, we reported the
compartment, as well as generate different cell types, such as effect of allogeneic MSCs on refractory SLE patients, in
osteoblasts, adipocytes, chondroblasts, and myoblasts [29, whom the changes of renal functional indices had also
30]. Recently, this cell type has been thought to possess wide been analyzed [17, 18]. However, the small number of
immunoregulatory properties on various immune cells and patients and short follow-up period limited further appli-
differential potential to multiple tissues [31, 32]. Many obser- cations. Thus, it was worthwhile studying the role of allo-
vations have illuminated the role of MSCs in acute or chronic geneic MSCT in LN patients. In the present group of
renal injury models [33, 34]. However, the clinical application patients, allogeneic MSCT could induce renal remission
of MSCs on human renal disease has been limited to prevent by the end of 12 months. Renal function obviously im-
acute renal transplant rejection [35], and to the best of our proved after MSCT. Furthermore, the total disease activity
knowledge, no study has reported on MSCT for human renal score evaluated by SLEDAI markedly improved after
disorder. MSCT. Thus, our data suggest that allogeneic MSCT is
Therefore, this open-label clinical study analyzes the role effective in inducing renal remission for both active and
of allogeneic MSCT as an alternative therapy in active LN refractory lupus nephritis within 12 months.
Further, Cox regression analysis demonstrated significant
Table 2 Treatments used pre- and post-allogeneic MSCT
correlations between complete renal remission and baseline
proteinuria, as well as serum creatinine levels, and partial renal
Drug and dosage No. of patients involved (n) remission was also correlated with baseline proteinuria.
Furthermore, renal flare was more likely to occur in patients
Pre-MSCT Post-MSCT
with higher baseline serum creatinine levels. All these data
Glucocorticoid (prednisone or its equivalence) indicate that baseline renal functional index can influence total
≥20 mg/day 49 6 prognosis by MSCT. Those who had higher proteinuria or
>10 and <20 mg/day 20 12 serum creatinine at baseline were less likely to achieve renal
≤10 mg/day 12 59 remission and had a higher incidence of renal flare. This
Cyclophosphamide (per month) observation was also confirmed by a recently published ani-
>0.8 g 7 0 mal model study performed by Chang et al. who found that
>0.6 and ≤0.8 g 45 8 UC blood-derived MSCT at an early age in lupus mice
>0.4 and ≤0.6 g 13 18 (2 months old) showed significant therapeutic effect on lupus
≤0.4 g 1 37 nephritis, as demonstrated by the inhibition of proteinuria,
Mycophenolate mofetil amelioration of survival rate, serum creatinine, as well as
1.5–2.0 g/day 15 4
glomerular proliferation, and sclerosis scores, while mice
≤1 g/day 4 8
treated at 6 months of age failed to achieve a satisfactory
clinical improvement [36]. These data support the view that
MSCT mesenchymal stem cell transplantation early MSCT may be more efficacious in lupus nephritis.
1618
Based on these findings, the clinical efficacy in LN patients
appears promising; however, mechanisms underlying the ef-
fects of MSCT in vivo remain to be elucidated. To address
this, we must first understand the homing of infused MSCs. In
an acute kidney injury model, Togel et al. have shown that
administered MSCs were predominantly detected in the glo-
meruli and attached peritubular capillaries by in vivo micros-
copy [37]. Our previous study also demonstrated that the
infused MSCs could home to the kidney of MRL/lpr lupus
mice to facilitate therapeutic potential in vivo, while no in-
fused MSCs were detected in normal mice [38]. In an animal
model of acute tubular epithelial injury, Herrera et al. also
reported the tubular localization of several MSC-GFP + cells,
with significant accumulation even after 21 days of infusion
[33]. All the data indicate that the infused MSCs could,
indeed, home to the injured kidney. Second, it is necessary
to understand how MSCs afford local renal amelioration.
Some studies have shown that the infused MSCs could differ-
entiate into functional tubular cells, which could physically
replace lost kidney cells and participate in renal repair in vivo
[34]. In contrast, primary paracrine factors can also medi-
ate the protective effects of MSCs. For example, soluble
factors, such as hepatocyte growth factor (HGF), insulin
growth factor (IGF)-1, and vascular endothelial growth
factor (VEGF), are involved in the antiapoptotic and
immunomodulatory effect in the local microenvironment
[37, 39, 40]. Finally, apart from local immunoregulation
and tissue repair, MSCs can provide general effect in the
recipient. A large number of studies found that serum
proinflammatory cytokines, such as TNF-α, interferon
gamma (IFN-γ), IL-6, and IL-1β, significantly decreased
after MSCT, while the anti-inflammatory cytokine
transforming growth factor beta (TGF-β) and regulatory
T cells increased, suggesting that MSCs can facilitate
immunobalance in vivo [36, 41]. Our animal studies
showed that UC-MSCT could inhibit renal MCP-1 and
HMGB-1 expressions but upregulate Foxp3+ Treg cells in
lupus mice models [38]. Moreover, the clinical studies did
confirm the immunoregulation of Treg and cytokines like
IL-4 and IFN-γ, as well as TGF-β, by MSCT in lupus
patients [17, 18], suggesting that immunomodulation is
the most important mechanism for MSCT in treating
lupus nephritis.
The present study has some limitations. First, this is not a
controlled and randomized study. We still lack of a group of
patients with conventional therapies, but not combined with
allogeneic MSC infusion. Therefore, the current data only
provide evidence that allogeneic MSCT could induce renal
remission on the basis of other drugs taken by patients en-
rolled in this study. Still, such evidence is sufficient to indicate
the use of allogeneic MSCT as a treatment method for refrac-
tory LN. Second, this is a single-center clinical study, and all
patients enrolled were of Asian ethnicity. Therefore, we
Clin Rheumatol (2014) 33:1611–1619
cannot draw any conclusion concerning the role of allogeneic
MSCT in patients of other ethnic backgrounds, indicating the
urgent need for a controlled randomized study with subject of
diverse ethnic origins.
In conclusion, our data suggest that treatment with alloge-
neic MSCT is efficacious for patients with active and refrac-
tory lupus nephritis, showing a favorable safety profile and
positive results within 12 months.
Acknowledgments The authors thank Professor Wanjun Chen (Muco-
sal Immunology Unit, Oral Infection and Immunity Branch, National
Institute of Dental and Craniofacial Research, National Institutes of
Health, MD, USA) for helpful comments. This work was supported by
the Major International (Regional) Joint Research Project (no.
81120108021, to Dr. Sun), National Natural Science Foundation of China
(no. 81273304, to Dr. Sun), and Jiangsu Province Kejiao Xingwei Pro-
gram (to Dr. Sun), Jiangsu Provincial Natural Science Foundation
(BK20140098, to Dr. Wang), and Jiangsu Provincial Health Department
Youth Foundation (Q201411, to Dr. Wang)and National Natural Science
Foundation of China (no. 81302557, to Dr. Gu).
Conflict of interest Fei Gu, none; Dandan Wang, none; Huayong
Zhang, none; Xuebing Feng, none; Gary S. Gilkeson, none; Songtao
Shi, none; Lingyun Sun, none.
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