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Kirkham AM, Bailey AJM, Shorr R, Lalu MM, Fergusson DA, Allan DS. Systematic review and meta-analysis of randomized controlled trials of mesenchymal stromal cells to treat coronavirus disease 2019: is it too late? Cytotherapy 2023; 25:341-352. [PMID: 36333234 PMCID: PMC9556962 DOI: 10.1016/j.jcyt.2022.10.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 09/08/2022] [Accepted: 10/05/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND AIMS Evidence regarding the extent that mesenchymal stromal cells (MSCs) may improve clinical outcomes in patients with coronavirus disease 2019 (COVID-19) has been limited by marked inter-study heterogeneity, inconsistent product characterization and appreciable risk of bias (RoB). Given the evolution of treatment options and trajectory of the pandemic, an updated analysis of high-quality evidence from randomized controlled trials is needed for a timely and conclusive understanding of the effectiveness of MSCs. METHODS A systematic literature search through March 30, 2022, identified all English language, full-text randomized controlled trials examining the use of MSCs in the treatment of COVID-19. RESULTS Eight studies were identified (316 patients, 165 administered MSCs and 151 controls). Controls evolved significantly over time with a broad range of comparison treatments. All studies reported mortality at study endpoint. Random effects meta-analysis revealed that MSCs decreased relative risk of death (risk ratio, 0.63, 95% confidence interval, 0.42-0.94, P = 0.02, I2 = 14%) with no significant difference in absolute risk of death. MSCs decreased length of hospital stay and C-reactive protein levels and increased odds of clinical improvement at study endpoint compared with controls. Rates of adverse events and severe adverse events were similar between MSC and control groups. Only two (25%) studies reported all four International Society for Cell & Gene Therapy criteria for MSC characterization. Included studies had low (n = 7) or some (n = 1) concerns regarding RoB. CONCLUSIONS MSCs may reduce risk of death in patients with severe or critical COVID-19 and improve secondary clinical outcomes. Variable outcome reporting, inconsistent product characterization and variable control group treatments remain barriers to higher-quality evidence and may constrain clinical usage. A master protocol is proposed and appears necessary for accelerated translation of higher-quality evidence for future applications of MSC therapy.
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Affiliation(s)
- Aidan M Kirkham
- Department of Biochemistry, Microbiology and Immunology, University of Ottawa, Ottawa, Canada; Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Adrian J M Bailey
- Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Risa Shorr
- Medical Information and Learning Services, The Ottawa Hospital, Ottawa, Canada
| | - Manoj M Lalu
- Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, Canada; Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Canada; Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Canada; Regenerative Medicine, Ottawa Hospital Research Institute, Ottawa, Canada; Department of Anesthesia, The Ottawa Hospital, Ottawa, Canada
| | - Dean A Fergusson
- Department of Medicine, University of Ottawa, Ottawa, Canada; Department of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Canada; Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Canada; Department of Medicine, The Ottawa Hospital, Ottawa, Canada
| | - David S Allan
- Department of Biochemistry, Microbiology and Immunology, University of Ottawa, Ottawa, Canada; Department of Medicine, University of Ottawa, Ottawa, Canada; Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Canada; Regenerative Medicine, Ottawa Hospital Research Institute, Ottawa, Canada; Department of Medicine, The Ottawa Hospital, Ottawa, Canada.
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Wang F, Li Y, Wang B, Li J, Peng Z. The safety and efficacy of mesenchymal stromal cells in ARDS: a meta-analysis of randomized controlled trials. Crit Care 2023; 27:31. [PMID: 36670442 PMCID: PMC9857915 DOI: 10.1186/s13054-022-04287-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 12/17/2022] [Indexed: 01/22/2023] Open
Abstract
Mesenchymal stromal cells (MSC) have shown potential efficacy in both animal and human trials of acute respiratory distress syndrome (ARDS). Especially during the COVID-19 pandemic, MSC was intensely studied for treating COVID-19-induced ARDS. The purpose of this study is to evaluate the safety and efficacy of MSC in ARDS via a meta-analysis of randomized controlled trials (RCTs). Therefore, a meta-analysis of RCTs of MSC as a therapy for ARDS was conducted. The protocol of this review was registered on Open Science Framework. With no language restriction and according to the "PICOs" principle, searches were conducted on Pubmed and Embase to retrieve any clinical literature on MSC for ARDS. Any RCT, which compared MSC to controls for ARDS, where MSC and controls were intravenously infused, of any dosage, was eligible for inclusion. A total of 13 RCTs, which evaluated MSC versus control for treating ARDS, enrolling a total of 655 cases, met the inclusion criteria and appeared in this meta-analysis. A heterogeneity assessment was carried out using the χ2 test, where a P value less than 0.05 was considered significant. The choice of a fixed-effect or a random-effect model was decided by the I2 value in each of the analyses. This meta-analysis indicated that there was no significant difference in terms of adverse events between MSC and control for ARDS (OR = 0.64, 95% CI [0.34, 1.20], P = 0.17, and I2 = 0%). In comparison with control, MSC could reduce the mortality of ARDS (OR = 0.66, 95% CI [0.46, 0.96], P = 0.03, and I2 = 10%). Based on the results of our meta-analysis, the safety of MSC was demonstrated to be non-inferior to that of standard treatment, and MSC may reduce the mortality rate of ARDS. Though the heterogeneity in the main results was low (I2 < 25%), more high-quality and large-scale clinical trials are needed to further confirm our findings.
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Affiliation(s)
- Fengyun Wang
- grid.49470.3e0000 0001 2331 6153Department of Critical Care Medicine, Zhongnan Hospital, Wuhan University, Wuhan, Hubei Province China ,Clinical Research Center of Hubei Critical Care Medicine, Wuhan, 430071 Hubei China
| | - Yiming Li
- grid.49470.3e0000 0001 2331 6153Department of Critical Care Medicine, Zhongnan Hospital, Wuhan University, Wuhan, Hubei Province China ,Clinical Research Center of Hubei Critical Care Medicine, Wuhan, 430071 Hubei China
| | - Bingqing Wang
- grid.49470.3e0000 0001 2331 6153Department of Critical Care Medicine, Zhongnan Hospital, Wuhan University, Wuhan, Hubei Province China ,Clinical Research Center of Hubei Critical Care Medicine, Wuhan, 430071 Hubei China
| | - Jianguo Li
- grid.49470.3e0000 0001 2331 6153Department of Critical Care Medicine, Zhongnan Hospital, Wuhan University, Wuhan, Hubei Province China ,Clinical Research Center of Hubei Critical Care Medicine, Wuhan, 430071 Hubei China
| | - Zhiyong Peng
- grid.49470.3e0000 0001 2331 6153Department of Critical Care Medicine, Zhongnan Hospital, Wuhan University, Wuhan, Hubei Province China ,Clinical Research Center of Hubei Critical Care Medicine, Wuhan, 430071 Hubei China ,grid.21925.3d0000 0004 1936 9000Department of Critical Care Medicine, Center of Critical Care Nephrology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213 USA
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Battaglini D, Cruz F, Robba C, Pelosi P, Rocco PRM. Failed clinical trials on COVID-19 acute respiratory distress syndrome in hospitalized patients: common oversights and streamlining the development of clinically effective therapeutics. Expert Opin Investig Drugs 2022; 31:995-1015. [PMID: 36047644 DOI: 10.1080/13543784.2022.2120801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
INTRODUCTION The coronavirus disease 2019 (COVID-19) pandemic has put a strain on global healthcare systems. Despite admirable efforts to develop rapidly new pharmacotherapies, supportive treatments remain the standard of care. Multiple clinical trials have failed due to design issues, biased patient enrollment, small sample sizes, inadequate control groups, and lack of long-term outcomes monitoring. AREAS COVERED This narrative review depicts the current situation around failed and success COVID-19 clinical trials and recommendations in hospitalized patients with COVID-19, oversights and streamlining of clinically effective therapeutics. PubMed, EBSCO, Cochrane Library, and WHO and NIH guidelines were searched for relevant literature up to 5 August 2022. EXPERT OPINION The WHO, NIH, and IDSA have issued recommendations to better clarify which drugs should be used during the different phases of the disease. Given the biases and high heterogeneity of published studies, interpretation of the current literature is difficult. Future clinical trials should be designed to standardize clinical approaches, with appropriate organization, patient selection, addition of control groups, and careful identification of disease phase to reduce heterogeneity and bias and should rely on the integration of scientific societies to promote a consensus on interpretation of the data and recommendations for optimal COVID-19 therapies.
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Affiliation(s)
- Denise Battaglini
- Dipartimento di Anestesia e Rianimazione, Policlinico San Martino, IRCCS per l'Oncologia e le Neuroscienze, Genoa, Italy
| | - Fernanda Cruz
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Chiara Robba
- Policlinico San Martino, IRCCS per l'Oncologia e Neuroscienze, Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università degli Studi di Genova, Genoa, Italy
| | - Paolo Pelosi
- Dipartimento di Anestesia e Rianimazione, Policlinico San Martino, IRCCS per l'Oncologia e le Neuroscienze, Genoa, Italy.,Policlinico San Martino, IRCCS per l'Oncologia e Neuroscienze, Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università degli Studi di Genova, Genoa, Italy
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.,COVID-19 Virus Network from Ministry of Science, Technology, and Innovation, Brazilian Council for Scientific and Technological Development, and Foundation Carlos Chagas Filho Research Support of the State of Rio de Janeiro, Rio de Janeiro, Brazil
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Kirkham AM, Bailey AJM, Monaghan M, Shorr R, Lalu MM, Fergusson DA, Allan DS. Updated Living Systematic Review and Meta-analysis of Controlled Trials of Mesenchymal Stromal Cells to Treat COVID-19: A Framework for Accelerated Synthesis of Trial Evidence for Rapid Approval-FASTER Approval. Stem Cells Transl Med 2022; 11:675-687. [PMID: 35758400 PMCID: PMC9299509 DOI: 10.1093/stcltm/szac038] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 04/18/2022] [Indexed: 12/11/2022] Open
Abstract
Background Mesenchymal stromal cells (MSCs) may reduce mortality in patients with COVID-19; however, early evidence is based on few studies with marked interstudy heterogeneity. The second iteration of our living systematic review and meta-analysis evaluates a framework needed for synthesizing evidence from high-quality studies to accelerate consideration for approval. Methods A systematic search of the literature was conducted on November 15, 2021, to identify all English-language, full-text, and controlled clinical studies examining MSCs to treat COVID-19 (PROSPERO: CRD42021225431). Findings Eleven studies were identified (403 patients with severe and/or critical COVID-19, including 207 given MSCs and 196 controls). All 11 studies reported mortality and were pooled through random-effects meta-analysis. MSCs decreased relative risk of death at study endpoint (RR: 0.50 [95% CI, 0.34-0.75]) and RR of death at 28 days after treatment (0.19 [95% CI], 0.05-0.78) compared to controls. MSCs also decreased length of hospital stay (mean difference (MD: −3.97 days [95% CI, −6.09 to −1.85], n = 5 studies) and increased oxygenation levels at study endpoint compared to controls (MD: 105.62 mmHg O2 [95% CI, 73.9-137.3,], n = 3 studies). Only 2 of 11 studies reported on all International Society for Cellular Therapy (ISCT) criteria for MSC characterization. Included randomized controlled trials were found to have some concerns (n = 2) to low (n = 4) risk of bias (RoB), while all non-randomized studies were found to have moderate (n = 5) RoB. Interpretation Our updated living systematic review concludes that MSCs can likely reduce mortality in patients with severe or critical COVID-19. A master protocol based on our Faster Approval framework appears necessary to facilitate the more accelerated accumulation of high-quality evidence that would reduce RoB, improve consistency in product characterization, and standardize outcome reporting.
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Affiliation(s)
- Aidan M Kirkham
- Department of Biochemistry, Microbiology and Immunology, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Adrian J M Bailey
- Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Madeline Monaghan
- Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Risa Shorr
- Medical Information and Learning Services, The Ottawa Hospital, Ottawa, ON, Canada
| | - Manoj M Lalu
- Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, ON, Canada.,Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada.,Regenerative Medicine, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Department of Anesthesia, The Ottawa Hospital, Ottawa, ON, Canada
| | - Dean A Fergusson
- Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Department of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.,Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - David S Allan
- Department of Biochemistry, Microbiology and Immunology, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Regenerative Medicine, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
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Kirkham AM, Monaghan M, Bailey AJ, Shorr R, Lalu MM, Fergusson DA, Allan DS. Mesenchymal stem/stromal cell-based therapies for COVID-19: First iteration of a living systematic review and meta-analysis: MSCs and COVID-19. Cytotherapy 2022; 24:639-649. [PMID: 35219584 PMCID: PMC8802614 DOI: 10.1016/j.jcyt.2021.12.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 11/22/2021] [Accepted: 12/09/2021] [Indexed: 01/27/2023]
Abstract
BACKGROUND Mesenchymal stem/stromal cells (MSCs) and their secreted products are a promising therapy for COVID-19 given their immunomodulatory and tissue repair capabilities. Many small studies were launched at the onset of the pandemic, and repeated meta-analysis is critical to obtain timely and sufficient statistical power to determine efficacy. METHODS AND FINDINGS All English-language published studies identified in our systematic search (up to February 3, 2021) examining the use of MSC-derived products to treat patients with COVID-19 were identified. Risk of bias (RoB) was assessed for all studies. Nine studies were identified (189 patients), four of which were controlled (93 patients). Three of the controlled studies reported on mortality (primary analysis) and were pooled through random-effects meta-analysis. MSCs decreased the risk of death at study endpoint compared with controls (risk ratio, 0.18; 95% confidence interval [CI], 0.04 to 0.74; P = .02; I2 = 0%), although follow-up differed. Among secondary outcomes, interleukin-6 levels were most commonly reported and were decreased compared with controls (standardized mean difference, -0.69; 95% CI, -1.15 to -0.22; P = .004; I2 = 0%) (n = 3 studies). Other outcomes were not reported consistently, and pooled estimates of effect were not performed. Substantial heterogeneity was observed between studies in terms of study design. Adherence to published ISCT criteria for MSC characterization was low. In two of nine studies, RoB analysis revealed a low to moderate risk of bias in controlled studies, and uncontrolled case series were of good (3 studies) or fair (2 studies) quality. CONCLUSION Use of MSCs to treat COVID-19 appears promising; however, few studies were identified, and potential risk of bias was detected in all studies. More controlled studies that report uniform clinical outcomes and use MSC products that meet standard ISCT criteria should be performed. Future iterations of our systematic search should refine estimates of efficacy and clarify potential adverse effects.
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Affiliation(s)
- Aidan M. Kirkham
- Departments of Biochemistry, Microbiology & Immunology, University of Ottawa, Ottawa, ON, Canada,Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Madeline Monaghan
- Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Adrian J.M. Bailey
- Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Risa Shorr
- Medical Information and Learning Services, The Ottawa Hospital, Ottawa, ON, Canada
| | - Manoj M. Lalu
- Cellular and Molecular Medicine, University of Ottawa, Ottawa, ON, Canada,Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada,Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, ON, Canada,Regenerative Medicine, Ottawa Hospital Research Institute, Ottawa, ON, Canada,Departments Anesthesia, The Ottawa Hospital, Ottawa, ON, Canada
| | - Dean A. Fergusson
- Medicine, University of Ottawa, Ottawa, ON, Canada,Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada,Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, ON, Canada,Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - David S. Allan
- Departments of Biochemistry, Microbiology & Immunology, University of Ottawa, Ottawa, ON, Canada,Medicine, University of Ottawa, Ottawa, ON, Canada,Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, ON, Canada,Regenerative Medicine, Ottawa Hospital Research Institute, Ottawa, ON, Canada,Medicine, The Ottawa Hospital, Ottawa, ON, Canada,Corresponding Author: Dr. David Allan, Ottawa Hospital Research Institute, 501 Smyth Rd, Box 704 Ottawa ON K1H 8L6, Canada, Fax +1 613-737-8861
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