Treatment of polyglandular autoimmune syndrome type 3 using co-transplantation of insulin-secreting mesenchymal stem cells and haematopoietic stem cells

Abstract

The authors report a 17-year-female and a 19-year-male with uncontrolled insulin-dependent diabetes mellitus (IDDM) for ≥10 years, treated with insulin-secreting human adipose tissue derived mesenchymal stem cells (IS-h-ADMSC). Both had hypothyroidism and were diagnosed as polyglandular autoimmune syndrome type-3 (PGAS-3). PGAS are rare polyendocrinopathies with ≥2 endocrine disorders mediated by autoimmune mechanisms leading to hypo-function and organ failure. Therapeutic options are hormone replacement, immunosuppression and avoiding infection. The authors administered autologous H-AD-IS-MSC+bone marrow-derived haematopoietic stem cells (HSC) into portal circulation with conditioning of cyclophosphamide, bortezomib, rituximab and rabbit-antithymoglobulin. Over follow-up of 38 and 16 months, respectively, both are doing well with sustained fall of glycosylated haemoglobin (Hb1Ac) from 8.1 to 6.4% and 14.2 to 8.6%, respectively and C-peptide raised from 0.01 to 0.23 ng/ml and 0.1 to 0.34 ng/ml, respectively with sustained 40% decreased insulin requirement. Thus long-term control of IDDM in PGAS-3 with co-transplantation of H-AD-IS-MSC+HSC can be achieved safely and effectively.

Background

This is the first case report to our knowledge where co-transplantation of insulin-secreting human adipose tissue derived mesenchymal stem cells (IS-h-ADMSC) with HSC was successfully carried out to treat insulin-dependent diabetes mellitus (IDDM) in polyglandular autoimmune syndrome (PGAS) type 3. This is a novel therapy which is safe and effective and will open up the avenues for millions of diabetic children all across the world.

Case presentation

A young female of 17 years presented in January,’08 with fatigue, frequent attacks of diabetic ketoacidosis (DKA) and uncontrolled blood sugars. She was known case of IDDM since last 10 years; on Huminsulin 50 IU/day.

A 19-year-male with IDDM of 17 years duration presented in January,’10 with similar complaints. He was on short-acting insulin 50 IU/day and long-acting insulin, 20 IU/day.

No insulin/islet cell/adrenal antibodies were detected in either case. Their clinical examination and growth parameters were unremarkable. They were diagnosed as PGAS type-3.

Investigations

Case 1–serum (s.) T4 was 0.84 μgm/dl (normal range: 4.8–11.6 μgm/dl), serum thyroid stimulating hormone (s.TSH) > 40 μU/ml (normal range: 0.28–6.82 μU/ml), glutamic acid decarboxylase antibodies (GAD Ab) >2000 IU/ml (normal: <10 IU/ml) and antimicrosomal Ab, 1:6400 IU/ml (reference range: >1:100: positive).

Case 2–S.T4 was 0.9 μgm/dl, s.TSH >100 μU/ml, GAD Ab, 740 IU/ ml and antimicrosomal Ab, 816.8 IU/ml.

Fasting blood sugar on admission were 458 mg/dl and 325 mg/dl and postprandial blood sugar, 500 mg/dl and 382 mg/dl, respectively, s.C-peptide, 0.01 and 0.1 ng/ml, respectively and glycosylated haemoglobin (HbA1c), 8.1% and 14.2%, respectively.

Treatment

They were subjected to stem cell transplantation (SCT) and tab thyrox, 50 and 100 mcg/day, respectively. SCT protocol consisted of bortezomib, 1.3 mg/m² body surface area on days −20, −17, −13 and −10 followed by cyclophosphamide, 20 mg/kg bw on day 10, and granulocyte colony stimulating factor, 300 ug subcutaneously twice daily (to mobilise stem cells) on days −8 and −7 (figure 1). Ten gram fat was resected from anterior abdominal wall on day 14 and subjected to in vitro mesenchymal stem cell (MSC) generation and further differentiation into insulin-secreting stem cells (IS-h-ADMSC). Bone marrow (150 ml) was aspirated from posterior superior iliac crest under local anesthesia on day 6 for in vitro generation of haematopoietic SC (HSC). Rituximab, 8 mg/kg BW and rabbit antithymocyte globulin, 1.5 mg/kg bw were administered on days 3 and 2 to delete autoantibodies. On day 0, IS-h-ADMSC+HSC (100 ml and 76 ml, respectively with CD34+content, 3.8×10⁶/ul each, glucose sensitive insulin levels of 20, 18 ng/ml, respectively) were injected into portal circulation via omental vein under short general anesthesia. SCT was uneventful.

Figure 1.

Stem cell transplantation (SCT) protocol for insulin-dependent diabetes mellitus.

Outcome and follow-up

Over follow-up of 38 and 16 months, respectively, both are doing well, maintaining euthyroid state respectively with s.T4, 6.4 μgm/dl and 7 μgm/dl, respectively, s. TSH, 8.43 μU/ml and 0.70 μU/ml, absence of DKA, HbA1c, 6.4% and 8.6% respectively, C-peptide raised to 0.23 and 0.34 ng/ml, respectively and their insulin requirement is sustained to about 40% of original requirement (figure 2).

Figure 2.

Left upper corner-glycemic control after SCT denoted by glycosylated haemoglobin (Hb1Ac in percentage) in both patients. Left lower corner-insulin requirement after SCT in both patients (in IU/ml). Right upper corner-C-peptide level after SCT in both patients (in ng/ml). Right lower corner-Blood sugar (fasting and post prandial) status (in mg/dl) in both patients.

Discussion

PGAS are rare polyendocrinopathies characterised by association of two or more endocrine disorders mediated by autoimmune mechanisms leading to a hypo-functional state.^1–4

Circulating organ/cell-specific autoantibodies and cytotoxic T cells may lead to organ failure.² Early recognition and replacement therapy is lifesaving. Long-term management includes immunosuppression and avoiding infections.^{3 4} There is a study of 23 patients treated with haematopoietic stem cell transplantation with 18.8 months follow-up showing sustained insulin-independence.⁵ We have generated H-AD-MSC in lab and treated 12 IDDM patients previously who have sustained control of IDDM with raised C-peptide levels and controlled Hb1Ac. Hence we decided to explore this protocol which has already given sustained benefits without any adverse effects.^{6 7} Interestingly, we have also observed good control of thyroid functions also. To our knowledge, this is the first report showing long-term control of IDDM in PGAS-3 using co-transplantation of insulin-secreting stem cells and HSC, which is simple, safe and effective therapy.

Learning points.

• ▶IDDM is not uncommon in children.
• ▶PGAS type 3 is a rare polyendocrinopathy and should be looked for in children with IDDM.
• ▶So far, no therapy other than hormonal replacement was available.
• ▶Co-transplantation of insulin making stem cells from autologous adipose tissue derived MSC and haematopoietic stem cells is simple, safe and effective therapy for such patients.