Autologous cell transplantation – performed for the first time in a multiple sclerosis patient at the Riga East University Hospital

For the first time in Latvia, at the Riga East University Hospital (Riga East Hospital), a multidisciplinary team from the Clinic of Neurology and Neurosurgery and the Clinic of Haematology, carefully assessed the patient’s health condition, potential benefits, and possible risks, successfully performed autologous cell transplantation surgery on a 24-year-old multiple sclerosis patient following the decision of the Multiple Sclerosis Unit.

Although stem cell transplantation has been performed at the Riga East Hospital for at least five years, this is the first time it has been successfully performed on a multiple sclerosis patient.

“Cases where neurologists consider the need for a stem cell transplantation will remain rare. In our population, it will be two or three patients a year, because, according to clinical trials, there are now publicly funded highly effective therapies available for multiple sclerosis, immunomodulatory therapies that are equivalent in effectiveness to stem cell transplantation. I would like to emphasize that autologous stem cell transplantation is and remains the definitive method of treating the disease and can only be conducted in a multidisciplinary cooperation, with careful prior assessment of the patient’s health. It is also important to stress that now these patients will not have to seek treatment options outside Latvia but can turn to the Multiple Sclerosis Unit of the Riga East Hospital,” explains Professor Guntis Karelis, Head of the Clinic of Neurology and Neurosurgery at the Riga East Hospital.

To identify the disease and start treatment sooner, the Multiple Sclerosis Unit operates at the Riga East Hospital and is headed by Dr. Med. Daina Pastare: “Every other week, we hold consultations to evaluate patients and determine their treatment plans. Most of the time, these treatments involve medications.  Modern medications are highly effective but can be expensive.  Fortunately, these medications are 100% state-funded, which greatly benefits multiple sclerosis patients in Latvia, providing them access to this advanced therapy.”

The patient in question is a young woman with an aggressive form of multiple sclerosis. Even in the early stages of the disease, she experienced significant exacerbations leading to serious disability.  There were frequent and repeated exacerbations, and her magnetic resonance imaging scans revealed numerous demyelinating lesions. Initially, the patient received highly effective drug therapy; however, she still experienced recurrent clinical exacerbation which manifested as leg weakness, leaving her unable to walk and significantly impacting her quality of life.

Assessing the patient’s condition was very important. The guidelines state that stem cell transplantation should be performed in patients with an aggressive course of multiple sclerosis that doesn’t respond to highly effective drugs. “Aggressive” means that there are multiple lesions of the brain, and the number of lesions is increasing despite therapy and the severity of the disease continues within a year. Stem cell transplantation is the most effective in patients with a short disease duration (<10 years after the first symptoms), who are young, have no co-morbidities, and have not yet reached significant disability. They are the main criteria.

“We always start treating these patients on highly effective therapy, and only in very rare cases where the disease remains active do we offer this treatment. It’s important to understand that stem cell transplantation does not completely eliminate multiple sclerosis; it reduces disease activity for three to five years, with a maximum of ten years. A multidisciplinary medical panel of neurologists made the decision to perform stem cell transplantation for this particular patient, followed by thorough preparatory work. This process began with informing and educating the patient and discussing and implementing various important daily preparations to prepare her for life after surgery, as cell transplantation has side effects and risks of infection,” says D. Pastare.

llze Trociukas, Head of the Human Cell and Tissue Transplantation Centre at the Riga East Hospital, explains how stem cell transplantation works: “The patient’s blood is passed through a special machine, and the stem cells are extracted. It’s like extracting them.” These stem cells are then processed, frozen, stored in liquid nitrogen, and injected back into the patient. Before this, the patient is given special drugs to suppress the immune system, reducing its activity while destroying or inhibiting the multiplication of harmful cells at the same time, a process known as immunosuppressive therapy. The patient’s cells which are now good are then reintroduced to take over and stabilise the immune system. The patient must take antibiotics and antifungal therapy for a while due to the high risk of infections. After some time, the new stem cells begin to function, leading to the recovery and stabilisation of blood parameters. We use haematopoietic stem cells, which give rise to a new haematopoietic system and immune cells. Multiple sclerosis is an autoimmune disease where a person’s immune system attacks their body. This method now uses stem cells to restart your immune system. By reintroducing these cells suppressing the wrong autoimmune cells and putting these stem cells back in, we hope the immune system will begin to function properly. Once the stem cells become predominant and the immune system has restarted, it should work correctly, no longer damaging the brain and spinal cord, effectively halting the disease. This cell transplantation essentially resets the patient’s immune system.”

“The expected outcome of cell transplantation is a reduction in multiple sclerosis exacerbations and an improvement in the disease’s course, aiming to maintain the patient’s health as stable as possible for as long as possible. The key to treating multiple sclerosis is cooperation between the doctor and the patient. The patient must receive support, but there must also be feedback, compliance, and self-discipline from the patient. Whenever there is an exacerbation, our Multiple Sclerosis Unit admits the patient in a fast-track manner or, if necessary, we arrange for inpatient care.” “A very good rehabilitation program is also available at the ‘Biķernieki’ hospital,” explains D. Pastare, discussing the benefits and subsequent follow-up and treatment for the patient.

“In the past, patients who opted for this procedure on their initiative, including those who collected donations also abroad, have come to our attention at the Riga East Hospital. We support this method, but only if it is medically indicated. Guidelines and expert recommendations outline the criteria, and this patient met those criteria. However, some patients desire the procedure but do not meet the criteria. In those cases, we must refuse. “This is not a simple procedure, not a free choice, and definitely not a magic pill. It involves significant risks, and is related to the use of chemotherapy and isolation after transplantation. There are serious side effects, which is why it is considered a last resort worldwide, which is used only if the disease remains active after highly effective drug therapy,” says D. Pastare.

After the autologous stem cell transplantation, the patient feels well. Her health will continue to be monitored by the Multiple Sclerosis Unit. She will initially receive doctor consultations and regular magnetic resonance imaging scans at least every three months.

Autologous cell transplantation was planned, and performed, and the patient’s care was managed by:

• Professor Guntis Karelis, Head of the Clinic of Neurology and Neurosurgery
• Assistant Professor Daina Pastare, Head of the Clinic of Neurology and Neurosurgery and Head of the Multiple Sclerosis Unit
• Professor Sandra Lejniece, Head of the Haematology Clinic
• Ilze Trociukas, Head of the Human Cell and Tissue Transplantation Centre, along with the medical and nursing staff
• Linda Kande, Sandra Svilpe, Līga Mekša, Elīna Polunosika, Neurologists at the Multiple Sclerosis Unit
•  Līga Jaunozoliņa, radiologist at the Multiple Sclerosis Unit
• Marina Muceniece, radiology nurse at the Multiple Sclerosis Unit

The number of multiple sclerosis patients is continually increasing. The factors contributing to the disease are varied, including low vitamin D levels, various infections, as well as genetic and environmental factors. The immune system mistakenly identifies its brain cells as foreign and attacks them. Multiple sclerosis is an autoimmune disease, and it currently has no cure. All available treatments aim to influence the disease course, slow its progression, and reduce the frequency of exacerbations (with clinical symptoms). In Latvia, effective state-funded medications are accessible to patients. There is a wide selection of medications that allow for personalized treatment.

About the East Hospital

Riga East University Hospital is the country’s largest and most strategically important multi-profile hospital. The hospital consists of five clinical centers: Clinical Centre of Emergency Medicine Gailezers, Oncology Centre of Latvia, Clinical Centre Biķernieki, Centre of Tuberculosis and Lung Diseases, and Latvian Centre of Infectious Diseases with centers and clinics of different profiles. The hospital provides highly specialised inpatient and secondary outpatient healthcare, providing multidisciplinary tertiary-level treatment and care in line with modern technologies and medical knowledge. The hospital provides treatment for about 80% of all cancer patients in Latvia. The hospital provides a practical training base for both Latvian and foreign students and provides continued professional development and knowledge transfer for health professionals in our country and abroad. The hospital conducts scientific research and develops innovative methods for treating patients. The hospital is the third largest employer in the country, with around 5,000 employees.