Sequential Transplantation of Umbilical Cord Blood Stem Cells and Islet Cells in Children and Adolescents With Monogenic Immunodeficiency Type 1 Diabetes Mellitus
Phase: NA
Conditions: Diabetes Mellitus, Type 1, Immunologic Deficiency Syndromes
Sponsor: Children's Hospital of Fudan University

 
 
 
 
 
 
 
Sequential Transplantation of Umbilical Cord Blood Stem 
Cells and Islet Cells in Children and Adolescents with 
Monogenic Immunodeficiency Type 1 Diabetes Mellitus 
 
2018-10-16 
 
 
 

Background 
Children diabetes mellitus have an early onset, a long course of disease, many acute 
and chronic complications, high disability and mortality. And intensive studies of its 
etiology and pathogenesis are the focus and hotspot.  
Type 1 diabetes mellitus (T1DM) could be divided into immune-mediated T1DM and 
monogenic immunodeficiency T1DM. Immune-mediated T1DM is closely related to 
HLA, which is triggered by environmental factors such as infection. With the 
popularization of gene sequencing, especially the second generation sequencing, 
children with monogenic immunodeficiency T1DM can be isolated, such as immune 
dysregulation, polyendocrinopathy, enteropathy, X-linked syndrome (IPEX syndrome) 
caused by FOXP3 mutation. 
The monogenic defect is often accompanied by persistent and progressive aggravation 
of multi-organ damage, which not only leads to the corresponding organ dysfunction, 
but also requires continuous additional intervention and treatment, resulting in huge 
medical costs. but it is often difficult to avoid the poor outcome of early death. For 
example, FOXP3 mutation leads to the loss of regulatory T cell function and the 
inactivation of the key protein Scurfin, which controls T cell activation. Hemorrhage, 
sepsis, colitis or diabetes complications caused by IPEX syndrome can lead to early 
death in children. 
Early diagnosis and stem cell transplantation can lead to immune reconstitution, avoid 
the risk of organ toxicity and chronic immunosuppression-related infections, and may 
prevent autoimmune endocrine organ damage. While continuous advances in islet 

transplantation technology provide a basis for radical treatment of T1DM in children 
caused by monogenic immunodeficiency. 
 
Objectives 
To cure monogenic immunodeficiency T1DM, we combine the umbilical cord blood 
stem cell transplantation and islet cell transplantation together. We plan to correct 
immune deficiency by umbilical cord blood stem cell transplantation and transplant 
human islet cells after stable condition in order to correct secondary damage of immune 
deficiency and hyperglycemia, and finally achieve the goal of long-term high-quality 
survival. 
 
Methods 
Participants 
Volunteers will recruit from patients under 18 year-olds who are diagnosed monogenic 
immunodeficiency T1DM in Children’s Hospital of Fudan University. Inclusion 
Criteria include: 1. Meet the diagnostic criteria of type 1 diabetes mellitus: clinical 
manifestations of typical diabetes mellitus include polyphagia, polyuria, weight loss, or 
diabetic ketoacidosis, confirmed by blood sugar level, islet function and autoimmune 
antibody; 2. Existence of extrapancreatic organ damage: (1) inflammatory bowel 
disease, (2) impairment of renal function, (3) repeated infection of mouth, skin, anus or 
whole body, (4) immune hepatitis, (5) persistent chronic immune iridocyclitis, (6) 
immune adrenalinitis leading to adrenocortical dysfunction, (7) pituitary inflammation 

leading to hypophysis, (8) rheumatoid disease, (9) immune vasculitis, (10) systemic 
lupus erythematosus, (11) other organs besides thyroid function damage. Suffering 
from one or more of above diseases. Recurrence after receiving regular clinical 
treatment, including symptomatic treatment of organ protective drugs. 3. Gene mutation 
was found according to gene diagnosis: gene mutation was found by gene sequencing. 
Literature searches at home and abroad confirmed that the defect of the gene resulted 
in autoimmune or immune dysfunction, resulting in multiple organ dysfunction and 
poor prognosis. Exclusion Criteria include: mature and effective treatment methods are 
available; HIV, HBV and HCV were positive; at the active period of infection; at the 
active stage of malignant tumors; combination of other fatal diseases; and existence of 
mental and psychological diseases. 
Interventions 
The interventions will be divided into two stages. The first stage is the transplantation 
of umbilical cord blood stem cells: (1) T1DM children with monogenic 
immunodeficiency confirmed by islet function, autoantibody and gene analysis; (2) 
high resolution typing of histocompatibility antigens in children; (3) matching of stem 
cells in the national umbilical cord blood bank; (4) admitting children to the 
transplantation cabin to obtain matching  umbilical cord blood stem cells after 
immune clearance; (5) after successful transplantation, they were removed from the 
transplantation cabin and entered the follow-up stage of outpatient clinic. 
The second stage is islet cell transplantation. After successful umbilical cord blood 
transplantation and stable immune function, the children begin islet cell transplantation: 

(1) obtaining the pancreas of donors; (2) extracting pancreatic cells; (3) purifying islet 
cells to obtain high purity and high activity islet cells; (4) using immunosuppressive 
agent Basiliximab (Simulect) 6 hours before operation and injecting purified islet 
through portal vein puncture; (5) Tacrolimus combined with mycophenolate mofetil 
(Mycophenolate) will be used after operation, and blood concentrations will be 
measured. The amount of immunosuppressive drugs will be gradually reduced. Finally, 
gradually reduce insulin according to blood glucose. We will follow up the glucose 
metabolism, immunity and growth of patients for in long term. 
 
Flow chart to illustrate the study 
Stage1: Cord blood stem cell transplantation: 
 
 
 
 
 
 
 
 
 
 
 
Participants 
recruitment 
Diagnose of monogenic immunodeficiency type 1 diabetes 
mellitus：clinical manifestations, antibody and islet function 
determination, gene analysis and multiple organ dysfunction 
evaluation 
Psycho - psychological assessment: terminating this procedure 
for the mentally disturbed 
MDT: evaluation of indications and contraindications for 
umbilical cord blood stem cell transplantation 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
High resolution detection of HLA in 
umbilical cord blood 
Umbilical cord blood stem cell bank HLA match 
HLA 
matching 
Pretransplant evaluation and deep venous catheterization 
Cord 
blood 
stem 
cell 
transplantation 
Protective isolation in laminar flow silo and pretreatment 
chemotherapy 
Umbilical cord blood stem cells were thawed and 
transplanted, and the number of nuclear cells, cell activity 
and CD34 count were detected (blood laboratory and flow 
cytometry). 
Prevention 
and 
treatment 
of 
complications 
after 
transplantation (bacteria room, virus room and clinical 
pharmacology laboratory) 
Post-transplant 
evaluation and 
follow-up 
Implant monitoring (third-party company) 
Blood and outpatient follow-up: graft versus host 
reaction, organ function, glucose metabolism, and 
immune function 

Stage 2: Islet cell transplantation 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Requirements for brain-dead donors: no diabetes, BMI lower 
than 30kg/m2, preoperative infection indicators and other 
routine examinations are normal and meeting the requirements 
for transplantation. 
Access of the pancreas: 4 ℃ UW solution for abdominal aorta 
perfusion and quickly remove the pancreas. 
Pruning of the pancreas: to remove excess fatty blood vessels 
and connective tissue 
Obtain 
pancreas 
Islet 
extraction 
Perfusion and digestion of the pancreas 
Pancreatic fragments will be placed into the Ricordi lumen 
system, digestive fluid will be added, and the number of tissues, 
number of islets and proportion of islet fragments will be 
observed by DTZ staining. 
Islet washing, resuspension of purified solution, count islet 
purification and convert to islet equivalent (IEQ). 
The digested islet tissue will be collected in a conical flask. 
Islet 
purification 
Islet tissue will be added into gradient mixer and pumped into 
COBE2991 centrifuge bag. COBE2991 cell separator will be 
used to purify. 
Transplant
ation 
Post-
transplant 
efficacy 
evaluation 
Using immunosuppressive agent Basiliximab (Simulect) 6 
hours before operation. Make sure that portal vein pressure is 
within the normal range. Islet cell suspension will be injected, 
and the puncture route will be embolized with 4mm steel ring 
and gelatin sponge strip after the completion of the infusion.  
Tacrolimus combined with mycophenolate mofetil 
(Mycophenolate) will be used after operation。Metabolic and 
growth indicators will be evaluated. 

Adverse reactions: 
1. Pretreatment related to chemotherapy or radiotherapy: nausea, vomiting, diarrhea, 
hematuria, alopecia, oral ulcer, bone marrow suppression, liver and kidney damage, 
infection, bleeding, skin damage, etc. 
2. Graft-versus-host reaction (GVHD). 
3. Opportunistic infection of immunodeficiency. 
4. Infertility. 
5. Occurrence of other tumors. 
6. Allergic reactions caused by anesthetics, contrast agents and therapeutic drugs. 
7. Islet injection leads to vascular embolism and abnormal liver function. 
8. If puncture is difficult, open portal vein injection may be used instead. 
9. Immunosuppressive agents cause kidney and other toxic and side effects. 
10. Portal vein puncture may lead to intrahepatic and extrahepatic vascular hemorrhage. 
11. Opportunistic infections (viral fungi, etc.) occur after transplantation. 
12. Cardiovascular events, graft loss, abnormal coagulation, pulmonary embolism and 
other cardiovascular events 
 
Risk assessment and contingency plans 
1. Adverse reactions: regular assessment of organ function, monitoring of blood, 
preventive use of anti-infective drugs, use of immunosuppressive agents to prevent 
GVHD, bedside call system, ECG monitoring, suction devices and oxygen. Severe 
cases can be transferred to Laminar Flow Ward, Department of Critical Care Medicine, 

our hospital. 
2. Contamination of umbilical cord blood stem cells: to ensure that the source of 
umbilical cord blood stem cells is legitimate, and to establish a registration system for 
the source of umbilical cord blood stem cells. Umbilical cord blood stem cells for 
transplantation are collected by medical institutions that meet the technical 
management standards of umbilical cord blood stem cell collection. Strictly abide by 
the relevant technical specifications and guidelines for diagnosis and treatment of 
umbilical cord blood stem cell transplantation. Several suitable umbilical cord blood 
donors were retrieved for reserve before transplantation. 
3. Implantation failure: monitoring blood picture after implantation and regular 
chimerism examination. Before transplantation, HLA matching searches multiple 
suitable umbilical cord blood donors for consideration of secondary transplantation 
after implantation failure. 
4. The most serious complications after islet transplantation are hemorrhage and 
thrombosis caused by liver and portal vein puncture. Islet transplantation was given 
heparin to prevent thrombosis, and anticoagulant therapy was continued after operation. 
After operation, a surgical hemostatic gel / steel ring was used to close the needle 
channel outside the portal vein. 
 
Quality control measures 
1. Strictly grasp the indications of transplantation of umbilical cord blood stem cells 
and islets. According to the patient's condition, the treatment options and other factors, 

we can make a comprehensive judgment and treat the disease scientifically and 
rationally. 
2. The source of umbilical cord blood stem cells is legitimate, and the registration 
system of the source of umbilical cord blood stem cells is established to ensure that the 
source of umbilical cord blood stem cells can be traced. Umbilical cord blood stem cell 
transplantation is not allowed to seek unfair benefits, nor is it allowed to divulge the 
information of umbilical cord blood stem cell donors. 
3. Umbilical cord blood stem cells for transplantation are collected by medical 
institutions that meet the technical management criteria of umbilical cord blood stem 
cell collection. The transplanted islets were collected by medical institutions in 
accordance with the criteria for islet isolation, purification and evaluation. 
4. Inform and sign informed consent before transplantation of umbilical cord blood 
stem cells and islets. 
5. Strictly abide by the relevant technical specifications and guidelines for diagnosis 
and treatment of umbilical cord blood stem cells and islet transplantation. 
6. Establish a follow-up system after transplantation of hematopoietic stem cells and 
islets. 
7. Strictly implement the national price policy and charge fees according to regulations.