In this study, we analyzed 70 patients with worsening multiple sclerosis despite pharmacologic treatment who were treated with several intrathecal injections of peripheral blood cells harvested by apheresis after granulocyte-colony stimulating factor treatment. Thirty-seven patients (52%) had a reduction of Expanded Disability Status Scale score; 10 patients had relapses, although these were milder than usual and more easily controlled by corticosteroids. Because mesenchymal cells increase in the peripheral blood after granulocyte-colony stimulating factor stimulation, a peripheral blood harvest seems easier and less costly than mesenchymal cell cultivation before injection. This seems to be a reasonable treatment for progressive multiple sclerosis.
Key words : Intrathecal, Mesenchymal cells, Peripheral blood
Multiple sclerosis is a disease characterized by multifocal areas of demyelination in the brain and spinal cord, with associated inflammatory cell infiltrates, reactive gliosis, and axonal degeneration. It typically presents in young adults with episodic neurologic dysfunction. Although the exact origin of multiple sclerosis remains enigmatic, evidence suggests that it is an immune-mediated attack on myelin, with secondary disruption of axons, leading to progressive disability over time in most afflicted patients. The main clinical scoring system is the Expanded Disability Status Scale (EDSS), which is a rating system that is frequently used for classifying and standardizing the condition of people with multiple sclerosis.
Despite early introduction of disease-modifying treatments, the disease is not contained in some patients. For these individuals, aggressive immunosuppression or even immunoablative therapies are important therapeutic options. High doses of chemotherapy can be used to ablate effectively the entire immune system, which is then replaced de novo with frozen hematopoietic stem cells derived from the patient.1 An immunoablation followed by the infusion of autologous hemopoietic stem cells is able to cure multiple sclerosis, but this procedure has a measurable risk for the patient.
There is a growing hope in using cellular therapy with mesenchymal cells injected both intrathecally and intravenously.2 This therapy should be devoid of any risk for the patient. The limiting factor is the need of a Good Manufacturing Practice laboratory for the production of these cells.3
Some adult stem cells have the capability to differentiate into tissues other than the ones from which they originated; this is referred to as plasticity. Their immunosuppressive-immunomodulating effects have been exploited in the treatment of several autoimmune diseases, such as diabetes, rheumatoid arthritis, and systemic lupus erythematosus. Patients with graft-versus-host disease have also been treated,4 with other studies ongoing regarding the clinical aspects of this treatment.
Adult stem cells are able to differentiate in vitro and in vivo into neurons. Furthermore, they are able to produce soluble factors that could stimulate the growth and function of the recipient neurons. Both of these effects are the bases of the so-called neuroregenerative effect that has been exploited for treatment of patients with Parkinson disease, multiple system atrophy, spinal cord lesions, and some genetic diseases involving the central nervous system.5,6
In multiple sclerosis, cellular therapy could work through 2 effects: (1) through an immunomodulating effect, thus repairing the immune imbalance at the basis of the disease, and (2) through a neuroregenerative effect, thus possibly repairing the already existing brain lesions. Although centers that treat patients with multiple sclerosis use bone marrow-derived mesenchymal cells, it was recently demonstrated that mesenchymal cells appear in substantial numbers in the peripheral blood after granulocyte colony-stimulating factor therapy.7 Granulocyte colony-stimulating factor in conjunction with the receptor of urokinase mobilizes mesenchymal cells in the peripheral blood.8
For use in treatment, mesenchymal cells need to be cultivated in an expensive Good Manufacturing Practice laboratory so that the directives of the international health authorities are followed. If the same results could be obtained by means of a less costly process through peripheral blood, there would be advantages for both patients and institutions.
Materials and Methods
We clinically assessed 70 patients (25 males, 45 females) with primary or secondary progressive multiple sclerosis in our multiple sclerosis clinic. Patients were from Baghdad and Babylon. Patients provided consent according to the ethical committee plan, which is headed by high authorities in the Iraq Health Ministry.
The age of patients ranged from 25 to 63 years, with mean age of 44 years. The EDSS scoring system was more than 6 in all patients (from 6 to 8). All patients had an increase of EDSS score of > 1 point from the previous year despite immunosuppressive treatment. Before we began cell therapy treatment, all patients stopped all other treatment modalities. The mean period from diagnosis until start of cell therapy was 9 years.
Our procedure of peripheral hematopoietic stem cell separation was done with the use of a blood cell separator machine, which is used for blood cell separation (Cobe Spectra, version 7 lrs turbo).
Before cell separation, patients first received granulocyte colony-stimulating factor therapy (Neupogen-Roche), which was given in doses of 5 μg/kg body weight daily for 3 to 4 days subcutaneously followed by collection of peripheral hematopoietic stem cells on day 4 to 5 using white blood cell protocol of blood cell separation.
Next, we performed buffy coat separation; a total white blood cell count was done, and mononuclear cells were counted manually. The mean total mononuclear cell count per product was 5 × 108 (range, 1-8).
The final step was spinal injection of the cell product intrathecally through the fifth lumbar vertebrae. For injection, patients remained in a sitting position under local anesthesia by lidocaine within 24 hours of collection. The procedure was repeated 1 to 8 times (mean of 2.14) within 6 to 8 weeks. Our follow-up period was 12 months.
A subjective clinical improvement was shown by 56 patients soon after 1 to 2 weeks of starting therapy (80%), whereas an objective reduction in the EDSS score of more than 1 (from 1 to 1.5) was observed in 37 patients (52%). These results were obtained after 1 year.
No major changes in magnetic resonance imaging scans were seen. However, there was no increase of gadolinium enhancement in 40 patients during follow-up. Cell therapy did not prevent relapse in 10 patients; however, relapse events were milder than usual and were quickly controlled by cortisone treatment.
The only complication, shown in 90% of patients, was transient backache and meningism. There were no serious adverse effects.
Stem cell therapy in neurologic diseases such as multiple sclerosis have different approaches (mesenchymal versus CNS-derived neural stem cell precursors and autologous versus allogenic). There is currently great interest in the use of mesenchymal stem cells as a therapy for multiple sclerosis with potential to both ameliorate inflammatory processes as well as improve regeneration and repair.9,10
A previous study showed that intrathecally injected peripheral blood stem cells are safe for patients and could be as effective as the bone marrow-derived stem cells,11 which also concurs with the results of our study. However, early clinical improvement (within 1-2 weeks) was seen in our study in reverse to this previous study11 in which improvement began after 2 weeks. This might lead us to arrange for better-managed clinical trials in the field of stem cell therapy and regenerative medicine in order to elucidate more regarding the neuroprotective properties of stem cells.
Other studies also proved that intrathecal mesenchymal stem cell therapy for multiple sclerosis is generally safe and did not result in any adverse effects.12
Our results seem to assess that intrathecally injected peripheral blood stem cells are safe for patients and could be as effective as bone marrow-derived stem cells. Our procedure would be feasible in any institution that has the normal facilities of any hematology or transplant department.
Further studies should solve some questions. These include determining the number of cells that is reasonable to inject and the number of injections. We used a large number, which could guarantee that a relevant number of mesenchymal cells (since less than 1 in 1000 should be in the cell mixture) could be injected. Because a half billion cells is the threshold of discomfort for patients (with effects of fever, vomiting, headache, drowsiness), we wondered whether a reduced number could be as effective.
Volume : 15
Issue : 1
Pages : 147 - 149
DOI : 10.6002/ect.mesot2016.P26
From the Iraqi Stem Cell Center, Alyermook Teaching Hospital, Baghdad, Iraq
Acknowledgements: The authors declare that they have no sources of funding for this study, and they have no conflicts of interest to declare.
Corresponding author: Abdul Majeed Hammadi, Stem Cell Center, Alyermook Teaching Hospital, Baghdad, Iraq
Phone: +964 790 226 8105