干细胞肝内移植治疗高氨血症Ⅱ型6例临床疗效观察

Clinical effect of stem cell transplantation via hepatic artery in the treatment of type II hyperammonemia: a report on 6 cases

摘要:

为探讨使用CD133+细胞、脐带间充质干细胞肝动脉内移植对高氨血症Ⅱ型患儿的临床治疗效果和可能存在的作用机制，通过采集健康胎儿脐血, 分离得干细胞悬液，或应用重组人粒细胞集落刺激因子动员患儿父亲外周血5?d后采集单个核细胞，从中分离得到CD133+细胞后，再利用导管介入经皮穿刺肝动脉将上述细胞缓慢输入患儿肝脏，观察患儿临床表现及实验室检查指标如血氨、肝功能、精氨酸、瓜氨酸的改善情况。结果显示，6例患儿移植后血氨水平均呈现明显下降，1~2周之后缓慢回升，但始终低于移植前波动的高水平；谷丙转氨酶同血氨水平变化趋势相类似；血瓜氨酸和精氨酸水平移植后明显增加，且瓜氨酸的增幅超过精氨酸。其中1例典型病例经8个月随访，发现患儿体重身高均较术前增长，睡眠改善，夜啼消失；由对逗引淡漠变为主动追视感兴趣物品，产生简单词汇，精细运动由手眼不协调到拇指中指捏取东西等，大运动方式也有很大进步；GESELL法测评该患儿术后各能区进步平均3.82个月。由此可见，高氨血症患儿移植后血氨下降、肝功能稳定改善，血瓜氨酸、精氨酸稳定增高，在运动、语言、环境适应性等方面都呈现进步趋势。推测干细胞肝动脉移植至少部分激活或补充了鸟氨酸氨甲酰转移酶，从而使血瓜氨酸、精氨酸水平增高，尿素循环障碍在一定程度上得到纠正。

Abstract:

This study aimed to investigate the clinical effect of transplantation of CD133+ peripheral blood stem cells or umbilical cord mesenchymal stem cells via the hepatic artery in children with type II hyperammonemia and its possible action mechanism. Umbilical cord mesenchymal stem cells were obtained by collecting cord blood (100-150 mL) from healthy fetuses and separating stem cell suspension (5 mL) from the cord blood by hydroxyethyl starch sedimentation. CD133+ peripheral blood stem cells were obtained by mobilizing peripheral blood from the fathers of sick children using recombinant human granulocyte colony-stimulating factor for 5 days, collecting mononuclear cells (120 mL), and separating out CD133+ cells by sorting. With catheterization and percutaneous puncture, the obtained stem cells were slowly injected into the liver of sick children via the hepatic artery. The changes in clinical symptoms and laboratory indices such as blood ammonia, liver function, and arginine and citrulline concentrations were observed. After stem cell transplantation via the hepatic artery, the 6 children showed significantly decreased blood ammonia levels, and their blood ammonia levels slowly increased 1 to 2 weeks later, but remained below 100 μmol/L, and changes in glutamic-pyruvic transaminase levels were similar to blood ammonia. Plasma citrulline and arginine concentrations increased significantly after transplantation and the increase in citrulline level exceeded the increase in arginine level. An 8 months follow-up visit for one typical patient showed that the weight and height increased after transplantation and sleep was improved without night crying. The child could actively gaze at interesting objects instead of responding indifferently and started to say simple words. With regard to fine motor skills, the child could pinch things with the thumb and middle finger instead of displaying a lack of hand-eye coordination and progress was also made in gross motor skills. Gesell test showed that the child made progress for an average of 3.82 months in all areas. It was concluded that after stem cell transplantation, children with type II hyperammonemia have decreased blood ammonia levels, stable and improved liver function and steadily increased plasma citrulline and arginine concentrations. They display a progressive trend in such aspects as movement, language and environmental adaptability. It is hypothesized that stem cell transplantation via the hepatic artery partially or totally activates, or provides supplementary ornithine carbamoyl transferase, so that plasma citrulline and arginine concentrations increase and urea cycle disorder can be corrected to some extent.