Hype or hope of hyaluronic acid for osteoarthritis: Integrated clinical evidence synthesis with multi-organ transcriptomics

BACKGROUND: Intra-articular injections of hyaluronic acid (HA), the United States Food and Drug Administration approved treatment and widely utilized to delay or reserve the progression of the osteoarthritis (OA) involves. However, this treatment has shown controversial results through various clinical practice guidelines and meta-analysis evaluations, warrants more advanced researches on its safety and effectiveness. METHODS: A novel strategy of integrating medical informatics and bioinformatics was utilized. An updated meta-analysis of 16 randomized controlled trials (RCTs) out of 1820 articles was conducted, in combination with a high throughput body-wide-organ-transcriptomic (BOT) RNA-sequencing (RNA-seq) and in vitro and vivo experiments to evaluate the effect of HA at local and systemic levels, revealing the underlying mechanism. RESULTS: A sensitivity analysis was performed restricting to high quality RCTs, no significant effect of HA treatment was found on pain relief and functional improvement. Descriptive analysis of RNA-seq using Gene Ontology and Kyoto Encyclopedia of Genes and Genomes pathway analysis revealed biological process related to innate immune responses and apoptosis; BOT analysis revealed differential gene expressions (DEGs) in cartilage, lymph node, spleen, kidney, and liver, with immune cell proliferation in immune-related organs. In vitro, HA-coated plates were shown to induce macrophage responses; in vivo histological images revealed knee joint, liver, and kidney with damaged/abnormal morphologies, while immune cell proliferation was observed in the lymph node and spleen and it was found that there was no significant difference in the treatment effect for OA animal model. CONCLUSION: Conclusively, integration of meta-analysis with bioinformatics analysis exhibited that HA induces inflammatory responses both locally and systematically and not benefit for OA treatment, thus limiting the regeneration and leading to some organ-specific pathogenesis. The strategy and findings will be of important for guiding future long-term clinical studies. THE TRANSLATIONAL POTENTIAL OF THIS ARTICLE: This study illustrated that the administered HA activated both systemic and local pro-inflammatory immune responses, possibly limiting its efficacy. This novel unique strategy proposed in this study can be utilized and adapted for future meta-analysis and bioinformatics study.