Stem Cell Therapy for Cerebral Palsy and Type 1 Diabetes

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1 Stem Cell Therapy for Cerebral Palsy and Type 1 Diabetes Dr Sagar Arvind Jawale Pediatric and neonatal surgeon and pediatric urologist drsagarjawale@gmail.com Mobile No: Jawale hospital, Near SBI, Jilha Peth, Gandhi Nagar, Jalgaon

2 Introduction: What are Stem Cells? Adult stem cells are of 2 types, mesenchymal and haemopoietic stem cells which have potential to duplicate indefinitely and differentiate into 22 types of cells. The doubling time is only 3 days. These cells typically divide for up to 6 months making them into billions of cells. These cells produce 50 types of growth factors and cytokines which repair and differentiate adult tissues in an epigenetic manner. Stem cells put in a particular tissue gets differentiated into cells of that tissue due to particular growth factors produced by that tissue. Since fat has 3000 times more stem cells than bone marrow, I use fat as the source instead of bone marrow. Mesenchymal stem cells have the ability to differentiate into tissues of all 3 lineages a phenomenon called plasticity.

3 Guidelines For Stem Cell Research Institutional Ethics Committee (IEC) permission taken and institutional Committee for Stem Cell Research(IC-SCR) established at city level for peer review of stem cell research. Two visiting stem cell experts attached to the center with M. Phil degree in regenerative medicine. Collaboration done with Thermo Fischer Scientific, the world s largest cell media company. Money raised from Rotary club, Lion s club, MLA fund and other NGOs and patient s were not charged for the study. In short my stem cell research in in tune with the government of India s guidelines.

4 Stem Cell Laboratory Stem cell laboratory needs a centrifuge machine(photo1), reagents(photo3) for separation of stem cells by density gradient method, a microscope(photo2) and photo activation device(photo4) for photo stimulation of stem cells and incubator. It was Set in just Rs 30,000 instead of 30 lac rupees in the market. The cost of autologous stem cell transplantation dropped to Rs 75,000 in my hospital compared to Rs 3-5 laces in India. Photo 1 Photo 2 Photo 3 Photo 4

5 Cerebral Palsy In India the incidence of cerebral palsy is around 5/1000 live births. The upper motor neuron is weak, hence the lower motor neuron becomes hyperactive leading to spasticity. The treatment involves mainly physiotherapy and prognosis is poor. The conventional therapy has failed to give any satisfactory results in these children hence something new needs to be done.

6 Stem Cell Therapy For Cerebral Palsy Materials and Methods: In last 3 years I did 28 cases of CP with age of 9 month to 19 years. 15 cases were quadriplegic, 11 paraplegic and 2 monoplegic. 18 patients had squint in the eyes. 61 cases were put as control, age range was 7 months to 33 years, 30 were quadriplegic, 28 paraplegic and 3 were monoplegic. 31 cases had squint in the control group. The patients were examine at 3 monthly intervals. Maximum follow up was 3 years and minimum of 6 months.

7 Surgical Procedure Since these children are malnourished small umbilical incision taken and half the omentum(photo1) was excised to be used as a source for stem cells. It is reported for the first time in medical literature. The fat was finely chopped and put into 4 test tubes(photo2) and stem cells obtained by enzymatic digestion of fat with Type 1 collagenase enzyme.(photo3).the whole process involves 50 steps. After hours, stem cells are ready. Half the quantity is given IV and another half intrathecally into CSF(Photo4) with 20mg/kg methylprednisolone drip. Photo 1 Photo 2 Photo 3 Photo 4

8 Results Patients in both group were examined at 3 monthly interval. Results took 3 months to appear and positive outcome came till one year since therapy. The spasticity was significantly reduced in 25 out of 28 patients in 6 months. The squint was regressed completely in 15 patients and partially in 3 in 6 months time. 7 patients had faulty deglutition and 6 of them had 75 % regression of symptoms. There was no mortality. Morbidity was negligible in the form of fever, skin rashes, irritability etc. 11 patients had improvement in hearing and 7 patients had improved vision according to parents. Compared to the therapy group, in the control group only 5 patients out of 61 had mild regression of spasticity in 6 months. Only 3 patients had mild regression of squint in 6 months. 23 patients the spasticity was worse than before.

9 Unusual results of stem cell therapy Two patients with CP had very bad bronchial asthma who had 90 % regression in symptoms just 3 months after therapy and are free of asthma with 1.5 year follow up. One 15 year old girl had extremely irregular monthly cycle. In just 3 months it got regularized and remained so for 1.5 years till date. It means that we should have separate clinical trials for stem cell therapy in Bronchial Asthma and menstrual irregularity in woman.

10 Regression of Squint Before Therapy After Therapy Before Therapy

11 Regression Of Spasticity Before Therapy After Therapy

12 Child Walking For First Time In 8 Years This child just after one month of stem cell therapy started walking for the first time in eight years. His right hand and both legs were spastic before therapy, they relaxed after 3 month after therapy. Now the right hand and arm are absolutely fine and he can lift 5 kg water bucket with right hand. He started eating without spilling the food out. He can bend forwards and touch the ground and stand back at his own. He can now write with his left hand inside a column.

13 Discussion More than 50 trophic factors and growth factors released by mesenchymal stem cells are known to stimulate repair of damaged nervous tissue in both the brain and the spinal cord. Some of these are neurotrophic factors that promote neuronal growth, induce new blood vessel growth(hemopoietic stem cells), neurogenesis and astroglial activation, encourage synaptic connection and axonal remyelination, decrease programed cell death, and regulate microglial activation. Stem cells repaired the upper motor neuron in CP that lead to regression of spasticity and squint. Animal studies show that mesenchymal stem cell put into CSF can migrate into the brain and duplicate and survive. Stem cells when added with Nerve Growth Factor(NGF) in Vitro get differentiated into neurons. Stem cells put intrathecally reversed experimentally produced brain damage in animals.

14 Future Prospects of Stem Cell Therapy In my laboratory, one billion Stem cells were cultured(photo 1) and can be given to the patient at monthly intervals without harvesting tissue again at record low cost of Rs instead of Rs. 8 crore. Stem cells can be transdifferentiated to neurons(photo 2) in laboratory and infused in the CSF at only Rs. 15,000 per billion. Stem cells and or transdifferentiated neurons can be directly implanted in the brain where ever they are necessary gives dramatic results. It requires DCGI permission. Photo 1 Photo 2

15 Conclusion It took 3 months to see the results. Positive changes were seen up to one year after therapy. Each time the therapy was done, the child had 20-25% improvement over previous base line. Best results were obtained below five years of age and moderate between age of 5-10 year. After the age of 10 year the results were average to poor and of palliative interest. In 6 patients the therapy was repeated after one year and the children had a further 20-25% improvement over previous baseline. Since Stem cell therapy is safe and effective in the treatment of Cerebral Palsy and can be repeated multiple times with an affordable cost, it is proving to be a much superior treatment option compared to the conventional therapy for Cerebral Palsy.

16 Stem Cell Therapy For Type 1 Diabetes Introduction: Type 1 diabetes is a dreadful autoimmune disease of childhood with incidence of 0.26/1000 children in India. Currently insulin injection and islet cell transplantation are the FDA approved treatments. Taking multiple insulin shots daily and its cost are both unacceptable to most of the children. Islet cell transplantation is exorbitantly costly and gives relief only for 2-5 years. Hence a new, cheap and effective method needs to be developed for the treatment of this disease.

17 Materials and Methods Last 1.5 years I treated 7 patients of Type 1 diabetes with autologous adipose derived stem cell transplantation. Age range was 5 year to 19 years. In the same timespan 21 patients were put as control group who were treated with insulin. Age range was 3 year to 26 years. Both groups were followed every 3 monthly. Blood sugar F/PP, Gad antibody titer, Glycosylated Hb and C peptide levels were done before the therapy and thereafter at every 3 monthly intervals.

18 Surgical Procedure Liposuction done to take out ml fat. Through a small umbilical incision, omentum was taken out. An omental pouch was created and no 7 IFT put into it and another into the peritoneal cavity. This operation is reported for the first time in the medical literature. Fat processed by enzymatic digestion by collagenase type 1 enzyme and after 50 steps and hours later stem cells are ready. One third quantity of stem cells are put into the omental pouch, another one third into peritoneal cavity and another third given IV in 100 ml NS with 20 mg/kg methylprednisolone infusion over 1 hour.

19 Results It took 3 months to see results. The sugar levels are regularly monitored and dose of insulin adjusted accordingly. At the end of 3 months, 3 patients went off insulin and are free of insulin till one year after therapy. Remaining 4 patients insulin requirements dropped to 50 % and sugar levels dropped from % into the normal range. GAD antibody titer dropped to about 50 % in 6 month. In the control group no patient was off insulin. 12 patients insulin requirement increased and 9 patients it was same in 1.5 year follow up. GAD antibody titer, Glycosylated Hb levels and C peptide levels were almost same in control group.

20 Discussion Scientists grew human stem cells in hyperglycemic environment in petri dishes and at the end of 3 months these cells started producing insulin a phenomenon called plasticity. Stem cells were put into the peritoneal cavity of diabetic animals and these cells produced insulin at the end of 3 months. Stem cells given IV in diabetic animals repaired the damaged islet cells and also regenerated the islets of Langerhans. Stem cells given IV repaired the faulty signatures in T cells in an epigenetic manner and reversed autoimmunity. Above experiments is the foundation of stem cell therapy for Type 1 diabetes in humans. Peritoneal cavity has only 10% cellular immunity and omentum has negligible immunity on its surface. Stem cells put into omental pouch creates a new biological pancreas which is protected from auto immunity.

21 Future Advances Stem cells were cultured and transdifferentiated into islets of Langerhans at a negligible cost or Rs. 15,000 per billion islets in my laboratory. Photographs were taken and the cells discarded as implanting them to human body requires DCGI permission. These islets can be implanted into an omental pouch creating a new biological pancreas that is protected from auto immunity.

22 Conclusions Stem cell therapy was more effective when done immediately after diagnosis of Type 1 diabetes. 3 patients who are free of insulin were recently diagnosed and received therapy within 3 months of diagnosis. Stem cell therapy is safe as no significant side effects were noted. It is cheap as it costs only Rs. 75,000. It can be easily repeated at the end of one year with further benefit. Early results of stem cell therapy for Type 1 diabetes are encouraging, although we need far bigger number and a longer follow up.

23 Thank You