The pioneer use of a modified PRGF-Endoret® technique for wound healing in a hemodialyzed diabetic patient in a terminal stage of renal disease

Abstract

In the literature, this paper is the first to describe the use of plasma rich in growth factors (PRGF)-Endoret® in hemodialyzed diabetic patients, to promote the healing of after amputation wounds. The PRGF-Endoret® was primarily conceived to be used in maxillofacial surgery, oral implantology, etc., the innovation residing in the blood collection technique (quantity, moment of the week, rhythmicity), which was adapted to the specific conditions of the hemodialyzed patient. Moreover, in the initial phases, the two PRGF fractions were innovatively applied as single alternating layers on the wound surface. Only after the surface of the wound decreased, the two PRGF fractions were applied as overlapping layers. Nevertheless, the paper presents the optimal method to assess the clinical evolution of the wound. Histopathological examination of the biopsy performed during wound preparation for PRGF application brought additional, essential data for orienting the therapeutic approach. The exclusion of calciphylaxis, a disease with high mortality risk, encouraged the application of this method, and also demonstrated the microscopic features in hemodialyzed diabetic patients.

Figure 1

The left foot seven months after the amputation and after the necrotic tissues’ removal

Figure 2

The modality of PRGF application

Figure 3

Photomicrographs of the biopsy: (a) Recent granulation tissue, with a large number of neocapillaries, neutrophils, lymphocytes, plasma cells and macrophages, covered by a fibrinopurulent exudate; (b) Mature granulation tissue consisting in few neocapillaries, fibroblasts and collagen fibers; (c) Skin from the periphery of the lesion, with the epidermis presenting hyperkeratosis, acanthosis and elongation of the epidermal ridges, dermis with slight , visible between the superficial dermis and the reticular dermis and free dermal muscular arterioles. Masson’s trichrome staining: (a) ×100; (b) ×400; (c) ×40

Figure 4

The wound after two weeks. At the periphery of the wound, there is an incipient process of re-epithelization

Figure 5

Image of upper dermis, formed of young granulation tissue, with numerous angiogenesis vessels and a low quantity of inflammatory cells. GS trichrome staining, ×100. GS: Goldner–Szekely

Figure 6

Deep dermis rich in fibroblasts and collagen fibers with a tendency of fascicle formation. GS trichrome staining, ×200

Figure 7

Area of granulation tissue, with a rich inflammatory infiltrate, mainly formed of CD3-positive T-lymphocytes. Anti-CD3 antibody immunomarking, ×100. CD3: Cluster of differentiation 3

Figure 8

Moderately infiltrated granulation tissue with CD20-positive B-lymphocytes. Anti-CD20 antibody immunomarking, ×200. CD20: Cluster of differentiation 20

Figure 9

Area of granulation tissue infiltrated with a high quantity of macrophages. Anti-CD68 antibody immunomarking, ×100. CD68: Cluster of differentiation 68

Figure 10

Granulation tissue rich in myofibroblasts and blood vessels. Anti-α-SMA antibody immunomarking, ×100. α-SMA: Alpha-smooth muscle actin

Figure 11

Microscopic image from an area of complete re-epithelization of the wound, where there is observed the presence of a high number of blood vessels (arterioles, capillaries, venules) in the upper dermis. Anti-CD34 antibody immunomarking, ×100. CD34: Cluster of differentiation 34

Figure 12

Granulation tissue in the deep dermis, during the maturation process, with a dense network of blood vessels. Anti-CD34 antibody immunomarking, ×100

Figure 13

Macroscopic appearance of the lesion after one month of PRGF use. It is observed the reduction of the areas of tissue necrosis, the development of the granulation tissue and the epithelization of the wound on a very large surface. PRGF: Plasma rich in growth factors

Figure 14

Image of the wound after two months of treatment. There is a favorable evolution, with almost complete recovery of the skin

Figure 15

The evolution of the healing process after three months after using PRGF. The complete restoration of the skin that covered the wound can be seen. PRGF: Plasma rich in growth factors