Adverse events, side effects and complications in mesenchymal stromal cell-based therapies
Review Article

Adverse events, side effects and complications in mesenchymal stromal cell-based therapies

Denis S. Baranovskii1,2, Ilya D. Klabukov1,2,3, Nadezhda V. Arguchinskaya1, Anna O. Yakimova1, Anastas A. Kisel1, Elena M. Yatsenko1, Sergei A. Ivanov1, Peter V. Shegay1, Andrey D. Kaprin1,2

1National Medical Research Radiological Center of the Ministry of Health of the Russian Federation, Obninsk, Russia; 2Peoples’ Friendship University of Russia (RUDN University), Moscow, Russia; 3Obninsk Institute for Nuclear Power Engineering of the National Research Nuclear University MEPhI, Obninsk, Russia

Contributions: (I) Conception and design: DS Baranovskii, ID Klabukov; (II) Administrative support: PV Shegay, AD Kaprin; (III) Provision of study materials or patients: DS Baranovskii, ID Klabukov, NV Arguchinskaya, AO Yakimova, AA Kisel, EM Yatsenko; (IV) Collection and assembly of data: DS Baranovskii, ID Klabukov, NV Arguchinskaya, AO Yakimova, AA Kisel, EM Yatsenko; (V) Data analysis and interpretation: DS Baranovskii, ID Klabukov, NV Arguchinskaya, AO Yakimova; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: Anastas A. Kisel. National Medical Research Radiological Center of the Ministry of Health of the Russian Federation, Obninsk, Russia. Email:

Abstract: Numerous clinical studies have shown a wide clinical potential of mesenchymal stromal cells (MSCs) application. However, recent experience has accumulated numerous reports of adverse events and side effects associated with MSCs therapy. Furthermore, the strategies and methods of MSCs therapy did not change significantly in recent decades despite the clinical impact and awareness of potential complications. An extended understanding of limitations could lead to a wider clinical implementation of safe cell therapies and avoid harmful approaches. Therefore, our objective was to summarize the possible negative effects observed during MSCs-based therapies. We were also aimed to discuss the risks caused by weaknesses in cell processing, including isolation, culturing, and storage. Cell processing and cell culture could dramatically influence cell population profile, change protein expression and cell differentiation paving the way for future negative effects. Long-term cell culture led to accumulation of chromosomal abnormalities. Overdosed antibiotics in culture media enhanced the risk of mycoplasma contamination. Clinical trials reported thromboembolism and fibrosis as the most common adverse events of MSCs therapy. Their delayed manifestation generally depends on the patient’s individual phenotype and requires specific awareness during the clinical trials with obligatory inclusion in the patient’ informed consents. Finally we prepared the safety checklist, recommended for clinical specialists before administration or planning of MSCs therapy.

Keywords: Adverse events; cell therapy; complications; mesenchymal stromal cells (MSCs); side effects

Received: 22 August 2022; Accepted: 28 October 2022; Published: 08 November 2022.

doi: 10.21037/sci-2022-025


The past several decades have seen the rapid development of cell-based regenerative medicine (1,2). Cell therapy has shown increasing advances with numerous cell-products based on autologous peripheral blood lymphocytes, allogeneic or autologous mesenchymal stromal cells (MSCs), hematopoietic cells, fibroblasts, chondrocytes, etc. (3,4). MSCs were recognised as easy derivable and the most applicable choice among the other cell-sources for a wide range of pathologies (5-10). These cells are commonly obtained from the bone marrow (11), adipose tissue (12), umbilical cord (13), dental pulp (14), gingiva (15), perinatal tissues (16), etc. Cell profile of low differentiated MSCs is generally characterized as positive for CD73, CD105 and CD90 cell surface markers and negative for hematopoietic markers CD19, CD20, CD34 and CD45 (17). MSCs secrete multiple growth factors and cytokines that also determine their regenerative effect. In particular, being derived from human umbilical cord, MSCs release keratinocyte growth factor (KGF) (18), hepatocyte growth factor (HGF) (19), transforming growth factor-β (TGF-β) (20) and exosomes, which suppress inflammation and lead to improved vascularization and epithelialization in affected tissues (21).

The proliferation of MSCs-related studies created a ‘cure-all’ paradigm with a trend to apply MSCs for the treatment of various diseases: leukemia, anemia, autoimmune, degenerative and cardiovascular diseases, and malignant tumors (22). Recently, MSC-based cell therapy has even been used to treat coronavirus disease 2019 (COVID-19) (23,24). However, novel clinical trials dramatically increased the reports on adverse events and side effects of MSCs-based therapy. In some cases, the effectiveness of cell therapy appears to be overestimated, which potentially may lead to tragic tolls in patient outcomes (25,26).

We aimed to overview and systemate all the adverse events and side effects reported after clinical application of MSCs. Some of them occurred due to the nature of this kind of cells, and others may be related to MSCs-cell culture conditions (Figure 1). Thus, we are raising clinical and scientific awareness on reported adverse events and side effects.

Figure 1 Key factors of negative effects in mesenchymal stromal cell therapy. MSC, mesenchymal stromal cell.

Cell transformation in culture (change in morphology, growth inhibition, aberrations)

Cells are capable of transforming in culture due to modification of their regulatory activity by growth factors, cell medium, adhesion, and intercellular connections. Culture-expanded MSCs exhibit notable differences in terms of cell morphology, physiology, and function, which decisively contribute to the heterogeneity of MSC’s (27). The heterogeneity of MSCs during in vitro expansion led to morphological alterations, modifications in the gene and protein expression profile, discrepancies in the differentiation potential, and physiological changes in cells (28,29) The majority of cell cultures are characterized by heterogeneity in subpopulations due to the influence of multiple factors arising during protocol reproduction. In particular, the cell-phenotype of MSCs are influenced by confluence density at the end of each passage (30). The density of cell confluence in bone marrow MSC culture affects the expression of more than two thousand genes, leading to changes in cell profile and cytokine synthesis (31). Thus, cell products and experimental models reproducible under the same conditions may have unpredictable affinity. However, scientists generally still use a qualitative assessment of the monolayer density when checking one or several fields under the microscope. These factors may change cell profile in products prepared for clinical application, causing adverse events.

Cell proliferation in vitro may be associated with replicative stress. Kim et al. showed that in MSCs, the majority of single-nucleotide variations (C > A transversions) occur in late passages (P7-P9) (32).

Importantly, the number of passages does not equal the cell divisions. Usually passing means that cellular monolayer grown on a dish bottom plated on the same dishes as 1:4. This cell concentration completely covers the bottom of the dish within one week.

Røsland et al. reported a spontaneous malignant transformation of approximately 46% of human MSC after four weeks in culture (33). A similar effect was observed for monkey MSCs after long-term cultivation (34). Transformed cells showed changes in growth and morphology similar to those of tumor cells. Furthermore, subcutaneous administration of transformed cells into NOD/SCID mice led to tumor formation.

Some studies noted that long-term cell culture leads to accumulation of chromosomal abnormalities. Froelich et al. reported that chromosomal abnormalities in adipose-derived MSCs increased significantly starting from passage 5 (35). In general, chromosomal aberrations occur in human MSCs in 4% of cases (primary monosomies) compared to 9% (primary trisomies) in pluripotent stem cells and neuronal stem cells (36). Research by Omel’chenko et al. showed that human MSCs with a perivascular immunophenotype during cell culture expressed the HSPB6, PLAC9, FEZ1, DTWD1, APH1A, and ATP5L genes associated with cell transformation (37).

However, human MSCs obtained from chorionic villi and amniotic fluid or umbilical cord (hUC-MSC) showed no signs of malignant transformation or chromosomal aberrations after in vitro culture up to the 15th passage (38,39). hUC-MSC cells in different passages had similar morphology, biomarker expression, and cytokine secretion (40).

In vitro cultivation of MSCs does not always cause chromosomal abnormalities, however, they have been reported in <10 passage cells conditioning the need for examination of MSCs before clinical use in order to avoid undesirable consequences.

Viral and mycoplasma containment in MSCs

When using allogeneic MSCs, donors are routinely tested for the presence of viruses such as human immunodeficiency virus (HIV), however, transplanted MSCs can contain genetic material of other types of viruses (41). According to Sundin et al. MSCs derived from various tissues may contain persistent viruses (42). The authors found that the MSCs derived from healthy donors contained viral DNA of parvovirus B19. Viral DNA has also been found in human bone marrow (43). The most common were B19V and torque teno virus (TTV): 62.9%, Epstein-Barr virus (EBV): 14.8%, Merkel cell polyomavirus (MCPyV): 11.1%, and human herpesvirus 7 (HHV-7): 7.4%.

MSCs may be infected with various viruses, among which respiratory syncytial virus (RSV), avian influenza A H5N1 (44,45). The presence of viruses in MSCs may be caused not only by viral infection of a cell donor. Viral contamination of different types of cells may also occur during cell processing and culture (46). For this reason, when working with MSCs, it is necessary to strictly follow the established requirements in order to avoid viral contamination.

Mycoplasma contamination can also be a serious threat for cultured cells. Interruptions of laminar flow, incomplete sterilization cycles, inappropriate lab clothes (dirty lab coats, reuse of same gloves, etc.) and enhanced doses of antibiotics in culture can lead to mycoplasma contamination (47). Cryopreservation in Dewar tanks containing viral or mycoplasma contaminated cell-probes may cross-contaminate other cells even when infected and ‘healthy’ cells are stored in different cryovials (48,49).

Xeno-contamination reactions caused by components of culture medium

Xeno-contamination reactions are rare and commonly associated with the presence of supportive xenogenic components in cell products. Commonly cryopreservation (50,51) and expanding media containing fetal bovine serum (FBS), human serum albumin, or patient’s autologous plasma (52-54). Today, FBS is excluded from the majority of clinical protocols due to the risk of disease transmission and xenogeneic immune reactions and replaced by alternative protein sources (55,56). Currently, autologous blood plasma could be considered a ‘gold standard’ for cell cryopreservation in clinical practice, which has been well studied since the 1990s (57,58). Human cord blood plasma has also recently been described among the novel alternative FBS compounds for MSC culture (59-62).

Major adverse events after cell injection: thromboembolism and fibrosis

The issue of numerous reported adverse events has to receive considerable critical attention. Some of them could be interpreted as the result of disease progression despite the provided cell-therapy with insufficient therapeutic effect. Thus, loss of vision was a negative reaction to adipose-derived MSC therapy in three patients with age-related macular degeneration (63). In another study, MSCs therapy alone does not lead to the full-thickness restoration of ulcerated skin after topical administration (64). The effectiveness of adipose- and bone marrow-derived MSC in the treatment of lateral amyotrophic sclerosis is also controversial. For example, a clinical trial conducted by Syková et al. revealed a slow down in disease progression only in some patients within 6 months after bone marrow-derived MSC application (65). Another clinical trial did not show any positive effects after adipose-derived MSC therapy (66). This raises the point of actual clinical significance of MSCs for tissue repair. Furthermore, MSCs caused side effects in 12% of cases after COVID-19 treatment in a small cohort of patients. The safety and effectiveness of COVID-19 treatment with MSCs therapy were criticized in the sense of known blood clotting effects triggered by MSCs. In particular MSCs could promote tromboembolism via release of procoagulant tissue factor (10). In general, reported adverse events also included liver dysfunction, heart failure, and allergic rash, which are typical complications of severe pneumonia (23,67).

Wu et al. reported two cases of inflammatory associated thromboembolism in kidney transplant patients and chronic kidney disease following after infusion of hUC-MSC (68). Importantly, the overdosing of cell therapies is more likely to cause glomerular and tubular damage in the kidneys (69). MSCs-therapy may also cause pulmonary embolism (70). Importantly, the risks of thromboembolization, as well as effectiveness of cell therapy, were shown to be determined by the recipient anamnesis and phenotyping features (71).

Večerić-Haler et al. described a clinical case of a complication that mimics capillary leak syndrome with ultimate kidney graft failure after autologous MSCs transplantation in the patient with a history of acute lymphoblastic leukemia (72).

However, we have to distinguish these cases from the following major adverse events, which appeared due to weakly controllable differentiation of MSCs. Recently, interstitial tissue fibrosis and tubular atrophy have been observed in a patient with chronic kidney disease following infusion of autologous adipose-derived MSCs (73). Importantly, the capability of MSCs of differentiation into myofibroblasts with the development of fibrous tissue was already well-demonstrated in previous experimental studies (74).

In the multicenter study, 2,372 patients with degenerative joint disease treated with autologous MSCs injections were enrolled (75). The majority of adverse events were just post-procedure pain or complications of the treated disease. However, neoplasms, neurologic, and vascular signs were among the serious adverse events. The authors reported about 7 cases of neoplasms that represent 0.3% of the study population, with an incidence of 0.14/100 PY. However, the authors disclaimed associations between the neoplasms and cell therapy. Serious neurologic and vascular events were 6 and 5 cases, respectively, representing 0.25% and 0.21% of the total population.

The well-known suppression of immune responses determined by MSCs explains the success of MSC therapy for graft-versus-host reactions and other various autoimmune disorders (76). Subsequently, systemic administration of MSCs caused major adverse events due to their immunosuppressive properties. In particular, MSCs therapy increases the risk of pneumonia-related death after allogeneic hematopoietic stem cell (HSC) transplantation (77). Interestingly, stem cell transplantation is also related to alterations in different lymphocyte populations (CD4+ T-helper cells, CD8+ T-cells, CD19+ and CD20+ B-lymphocytes). The CD4/CD8 ratio as well as CD19+ and CD20+ cell populations decreased in patients responded to stem cell therapy (78).

Minor side effects after cell injection: fever and local pain

The majority of clinical studies report that the use of MSCs is safe and feasible, with only minor side effects. The most common example is fever that occurred in 22% of patients following hUC-MSC infusion for COVID-19 treatment (79), in 9.8% of patients after the hUC-MSCs therapy for treatment of Crohn’s disease (80), in 85% of patients with progressive multiple sclerosis after treatment of autologous BM-MSCs (81). The use of allogeneic MSCs for the treatment of liver failure caused fever in 19.2% of patients during 5–24 weeks of follow-up. One of the causes of fever was supposed to be a reaction to the residual phosphate-buffered saline (PBS) buffer (82). Meta-analysis of the prospective clinical trials of intravascular injections of MSCs identified a significant association between MSCs and transient fever (83). Intra-articular injection of MSC mild effusion and increased local pain in patients within 48–72 hours (84).

Effects of MSC’s cell therapy on neoplasms

Oncological anamnesis remains a well-known exclusion criterion for clinical studies, explained by the controversial impact of MSCs on the tumor growth and behavior. Nevertheless, some publications suggested that the MSCs administration had no effect on the tumor, or even inhibited its growth in vivo (85,86). However, the study by Ning et al. reported a statistically significant increase in relapse rates (60% vs. 20%, P=0.02) and a decrease in 3-year relapse-free survival (30% vs. 66.7%, P=0.035) in patients co-transplanted with HSCs and culture-expanded MSCs versus patients transplanted with HSCs only. The authors pointed out the need for additional large-scale randomized clinical trials in order to evaluate the potential benefits and hazards of MSC-cotransplantation in malignant hematopoietic diseases (87). In addition, some animal and in-vitro studies showed that MSCs administration may promote growth of different tumors through a variety of mechanisms, including expression of proangiogenic factors and immunosuppression (88,89). We consider it crucial to perform a comprehensive patient examination in order to find possible malignancy and exclude patients before initiation of a cell-based therapy. However, it is vital to understand that there are more than 100 types of cancer-related diseases (90), and that tumor diagnostics remains a complicated task and not always results in the identification of neoplasms at early-stages, imposing certain risks and limiting cell-based therapy. Safety concerns gave us reason to suggest that currently, cell-based therapy should be administered with great precaution in cases where the possible benefit outweighs the risk (Table 1).

Table 1

Adverse events, side effects and complications in mesenchymal stromal cell therapy

Adverse events and side effects Causes Implications Refs
Cell transformation in culture (change in morphology, growth inhibition, aberrations) Long-term culturing (10+ passages)
Mutagenic components of cell media
Cells differentiation in culture with specific antigen presenting
Systemic immunogenic responses on injected cells
Local inflammation and prolonged immunological reactions
Viral containment in MSCs Cryobanking with contaminated cultures
Violations of biosafety protocols during cell processing and culture
Cellular dysfunction
Viral infection
Infection complications after injection
Xeno-contamination reactions Exogenous growth factors in media
Using of cell media contained animal serum
Acute inflammation (50-62)
Major adverse events after cell injection: thromboembolism and fibrosis Injection of cell aggregates
Personal phenotyping properties
Personal sensitivity
Pulmonary and renal thromboembolism
Cardiac and liver fibrosis
Minor side effects after cell injection The injection contains remnants of the PBS buffer; Intra-articular injection Fever; local pain (79-84)
Effects on tumors and neoplasms Expression of proangiogenic factors; immunosuppression The formation of malignant neoplasms (85-90)

MSC, mesenchymal stromal cell; PBS, phosphate-buffered saline.


One of the major tasks is to ensure the effectiveness of treatment and patients safety under cell therapy. Currently limited success of MSCs-therapy could be a subsequence of transformations during cell-culture or the result of major adverse events appearing due to uncontrollable differentiation. Notably, MSCs exhibit advanced pro chondrogenic, osteogenic, and adipogenic differentiation potential. Manifestations of their mis-differentiation were evaluated in multiple animal studies. Direct transplantation of unselected bone marrow cells into the acutely infarcted myocardium was shown to induce significant intramyocardial calcification (91). Liao et al. indicated the calcification of the injured abdominal aorta after BM-MSC administration in the experimental rat model (92). Several studies reported that BM-MSC precultured under hypoxic conditions demonstrated superior vascularisation effects via miR-16 (93). Those cells also had enhanced migratory and self-renewal or clonogenic capacities (94,95). However, besides the regenerative advantages, scientists have shown increased activity in the mTOR signaling pathway leading to autophagy. Furthermore, hypoxic pre-cultured MSCs had pro-senescent cell profile and up-regulated activity of superoxide dismutase consequenced in inhibited apoptosis (96,97). Thus, routine hypoxic cell culture for therapeutic administration requires further in-depth research of modulated gene expression and metabolic changes.

The majority of clinical studies with MSCs have included a limited number of patients, which may affect the assessment of statistical significance (Figure 2). The major adverse events were reported as presumably associated with systematic intravascular administration of low differentiated cells (i.e., MSCs) (98-100). Essential part of performed studies administered MSCs in combination with biomaterials and biomolecules, that masked therapeutic effect of cells. An additional factor may have been the lack of predictive methods and quantitative approaches in the planning of cell therapies (27,101,102).

Figure 2 Complications caused by adverse events and side effects of MSCs cell therapy. MSC, mesenchymal stromal cell.

Therapeutic effect and frequency of complications after multipotent cell therapy remain questionable (103-105). The therapeutic effects are generally based on anti-inflammatory effect caused by prolonged paracrine activity of injected cells (106). Thus, special attention should be paid to the age of the donor. MSCs donated by elderly patients have altered immunomodulatory profile. Adipose-derived MSCs obtained from elderly donors with atherosclerosis were characterized by a higher level of proinflammatory cytokines IL-6 and IL-8 (107).

Multiple complications can be explained by the mesenchymal phenotype causing their migration and adhesion. Unlike multipotent cells, the use of highly differentiated somatic cells remains harmless. Hence, we conceive that highly differentiated cells could be a feature ‘gold standard’ in regenerative medicine. The reported major adverse events were generally caused by inappropriate understanding of risk factors associated with stem cell therapy. In accordance with observed clinical reports we designed a short checklist, recommended for acceptance in all cases of MSCs transplantation (Table 2).

Table 2

Recommended check-list for cell therapy planning

Before every MSCs transplantation check whether:
   The donor’s anamnesis contains no information about any infectious diseases
   MSCs are under 9 passages
   PCR testing for mycoplasma and herpesviruses were performed
   Cryobanking dewar contain no untested (i.e., mycoplasma and HHV-6) or unknown cell probes
   Cell quantity and concentration are adjusted and do not exceed the necessary therapeutic limits
   Way of systemic delivery have been chosen in accordance to expected cell homing
   Antihistamine and anti-inflammation therapy is prepared and not contraindicated

MSC, mesenchymal stromal cell; PCR, polymerase chain reaction; HHV-6, human herpesvirus 6.

Another effective alternative could be non-cultured cells, cryopreserved immediately after harvesting. This type is already well-known as minimally manipulated cells. Recent trends in legal regulations all over the world already paved the way for wide spreading of minimally manipulated cells for clinical application as a safe and effective alternative to pre-cultured cells with an unpredictable risk of phenotypic changes (108). However, regenerative products based on minimally manipulated MSCs generally contain mesenchymal stromal fraction with a minor presence of CD90-positive low differentiated cells (109).

MSCs-derived extracellular vesicles also appeared as a novel therapeutic alternative to cultured cells (110,111). Exosomes could be collected either from normal or from hypoxic cell culture (112). The advantages and limitations of promising cell-free regenerative medicine are expected to be in a focus field of upcoming publications.


Our short review set out with the aim of assessing the safety of stem cell therapy with low differentiated cells. We observed numerous adverse events associated with uncontrollable cell differentiation and transformation. We found that safety and feasibility of stem cell therapy are still weakly estimated in cases with low differentiated and multipotent cells. Currently, the privilege in clinical trials should be addressed to minimally manipulated and high-differentiated cells. Despite many positive reports, MSCs therapy remains a risky therapy with delayed adverse effects. Their manifestation generally depends on the manufacturing quality and patient individual phenotype. Possible complications should be considered for the planning and administration of clinical trials with obligatory inclusion in the patient’ informed consents.


The figures were generated using

Funding: None.


Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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doi: 10.21037/sci-2022-025
Cite this article as: Baranovskii DS, Klabukov ID, Arguchinskaya NV, Yakimova AO, Kisel AA, Yatsenko EM, Ivanov SA, Shegay PV, Kaprin AD. Adverse events, side effects and complications in mesenchymal stromal cell-based therapies. Stem Cell Investig 2022;9:7.

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