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Wang F, Sun Z, Peng D, Gianchandani S, Le W, Boltze J, Li S. Cell-therapy for Parkinson's disease: a systematic review and meta-analysis. J Transl Med 2023; 21:601. [PMID: 37679754 PMCID: PMC10483810 DOI: 10.1186/s12967-023-04484-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 08/30/2023] [Indexed: 09/09/2023] Open
Abstract
BACKGROUND Cell-based strategies focusing on replacement or protection of dopaminergic neurons have been considered as a potential approach to treat Parkinson's disease (PD) for decades. However, despite promising preclinical results, clinical trials on cell-therapy for PD reported mixed outcomes and a thorough synthesis of these findings is lacking. We performed a systematic review and meta-analysis to evaluate cell-therapy for PD patients. METHODS We systematically identified all clinical trials investigating cell- or tissue-based therapies for PD published before July 2023. Out of those, studies reporting transplantation of homogenous cells (containing one cell type) were included in meta-analysis. The mean difference or standardized mean difference in quantitative neurological scale scores before and after cell-therapy was analyzed to evaluate treatment effects. RESULTS The systematic literature search revealed 106 articles. Eleven studies reporting data from 11 independent trials (210 patients) were eligible for meta-analysis. Disease severity and motor function evaluation indicated beneficial effects of homogenous cell-therapy in the 'off' state at 3-, 6-, 12-, or 24-month follow-ups, and for motor function even after 36 months. Most of the patients were levodopa responders (61.6-100% in different follow-ups). Cell-therapy was also effective in improving the daily living activities in the 'off' state of PD patients. Cells from diverse sources were used and multiple transplantation modes were applied. Autografts did not improve functional outcomes, while allografts exhibited beneficial effects. Encouragingly, both transplantation into basal ganglia and to areas outside the basal ganglia were effective to reduce disease severity. Some trials reported adverse events potentially related to the surgical procedure. One confirmed and four possible cases of graft-induced dyskinesia were reported in two trials included in this meta-analysis. CONCLUSIONS This meta-analysis provides preliminary evidence for the beneficial effects of homogenous cell-therapy for PD, potentially to the levodopa responders. Allogeneic cells were superior to autologous cells, and the effective transplantation sites are not limited to the basal ganglia. PROSPERO registration number: CRD42022369760.
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Affiliation(s)
- Fang Wang
- Department of Neurology, Central Hospital of Dalian University of Technology, Dalian, China
| | - Zhengwu Sun
- Department of Clinical Pharmacy, Central Hospital of Dalian University of Technology, Dalian, China
| | - Daoyong Peng
- Department of Neurology, Central Hospital of Dalian University of Technology, Dalian, China
| | - Shikha Gianchandani
- School of Life Sciences, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, UK
| | - Weidong Le
- Institute of Neurology, Sichuan Academy of Medical Sciences, Sichuan Provincial Hospital, Chengdu, China
| | - Johannes Boltze
- School of Life Sciences, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, UK
| | - Shen Li
- Department of Neurology and Psychiatry, Beijing Shijitan Hospital, Capital Medical University, No. 10 Tieyi Road, Beijing, 100038, China.
- Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China.
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Lane EL, Lelos MJ. Defining the unknowns for cell therapies in Parkinson's disease. Dis Model Mech 2022; 15:dmm049543. [PMID: 36165848 PMCID: PMC9555765 DOI: 10.1242/dmm.049543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
First-in-human clinical trials have commenced to test the safety and efficacy of cell therapies for people with Parkinson's disease (PD). Proof of concept that this neural repair strategy is efficacious is based on decades of preclinical studies and clinical trials using primary foetal cells, as well as a significant literature exploring more novel stem cell-derived products. Although several measures of efficacy have been explored, including the successful in vitro differentiation of stem cells to dopamine neurons and consistent alleviation of motor dysfunction in rodent models, many unknowns still remain regarding the long-term clinical implications of this treatment strategy. Here, we consider some of these outstanding questions, including our understanding of the interaction between anti-Parkinsonian medication and the neural transplant, the impact of the cell therapy on cognitive or neuropsychiatric symptoms of PD, the role of neuroinflammation in the therapeutic process and the development of graft-induced dyskinesias. We identify questions that are currently pertinent to the field that require further exploration, and pave the way for a more holistic understanding of this neural repair strategy for treatment of PD.
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Affiliation(s)
- Emma L. Lane
- Cardiff School of Pharmacy and Pharmaceutical Sciences, King Edward VII Avenue, Cardiff University, Cardiff CF10 3NB, UK
| | - Mariah J. Lelos
- School of Biosciences, Museum Avenue, Cardiff University, Cardiff CF10 3AX, UK
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3
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Lane EL, Harrison DJ, Ramos‐Varas E, Hills R, Turner S, Lelos MJ. Spontaneous Graft-Induced Dyskinesias Are Independent of 5-HT Neurons and Levodopa Priming in a Model of Parkinson's Disease. Mov Disord 2022; 37:613-619. [PMID: 34766658 PMCID: PMC9208367 DOI: 10.1002/mds.28856] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 09/28/2021] [Accepted: 10/20/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The risk of graft-induced dyskinesias (GIDs) presents a major challenge in progressing cell transplantation as a therapy for Parkinson's disease. Current theories implicate the presence of grafted serotonin neurons, hotspots of dopamine release, neuroinflammation and established levodopa-induced dyskinesia. OBJECTIVE To elucidate the mechanisms of GIDs. METHODS Neonatally desensitized, dopamine denervated rats received intrastriatal grafts of human embryonic stem cells (hESCs) differentiated into either ventral midbrain dopaminergic progenitor (vmDA) (n = 15) or ventral forebrain cells (n = 14). RESULTS Of the eight rats with surviving grafts, two vmDA rats developed chronic spontaneous GIDs, which were observed at 30 weeks post-transplantation. GIDs were inhibited by D2 -like receptor antagonists and not affected by 5-HT1A/1B/5-HT6 agonists/antagonists. Grafts in GID rats showed more microglial activation and lacked serotonin neurons. CONCLUSIONS These findings argue against current thinking that rats do not develop spontaneous GID and that serotonin neurons are causative, rather indicating that GID can be induced in rats by hESC-derived dopamine grafts and, critically, can occur independently of both previous levodopa exposure and grafted serotonin neurons. © 2021 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Emma L. Lane
- School of Pharmacy and Pharmaceutical SciencesCardiff UniversityCardiffUnited Kingdom
| | - David J. Harrison
- Brain Repair Group, School of BiosciencesCardiff UniversityCardiffUnited Kingdom
| | - Elena Ramos‐Varas
- Brain Repair Group, School of BiosciencesCardiff UniversityCardiffUnited Kingdom
| | - Rachel Hills
- Brain Repair Group, School of BiosciencesCardiff UniversityCardiffUnited Kingdom
| | - Sophie Turner
- Brain Repair Group, School of BiosciencesCardiff UniversityCardiffUnited Kingdom
| | - Mariah J. Lelos
- School of Pharmacy and Pharmaceutical SciencesCardiff UniversityCardiffUnited Kingdom
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4
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Elabi OF, Pass R, Sormonta I, Nolbrant S, Drummond N, Kirkeby A, Kunath T, Parmar M, Lane EL. Human Embryonic Stem Cell-Derived Dopaminergic Grafts Alleviate L-DOPA Induced Dyskinesia. JOURNAL OF PARKINSON'S DISEASE 2022; 12:1881-1896. [PMID: 35466951 DOI: 10.3233/jpd-212920] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND First-in-human studies to test the efficacy and safety of human embryonic stem cells (hESC)-derived dopaminergic cells in the treatment of Parkinson's disease (PD) are imminent. Pre-clinical studies using hESC-derived dopamine neuron transplants in rat models have indicated that the benefits parallel those shown with fetal tissue but have thus far failed to consider how ongoing L-DOPA administration might impact on the graft. OBJECTIVE To determine whether L-DOPA impacts on survival and functional recovery following grafting of hESC-derived dopaminergic neurons. METHODS Unilateral 6-OHDA lesioned rats were administered with either saline or L-DOPA prior to, and for 18 weeks following surgical implantation of dopaminergic neural progenitors derived from RC17 hESCs according to two distinct protocols in independent laboratories. RESULTS Grafts from both protocols elicited reduction in amphetamine-induced rotations. Reduced L-DOPA-induced dyskinesia preceded the improvement in amphetamine-induced rotations. Furthermore, L-DOPA had no effect on overall survival (HuNu) or dopaminergic neuron content of the graft (TH positive cells) but did lead to an increase in the number of GIRK2 positive neurons. CONCLUSION Critically, we found that L-DOPA was not detrimental to graft function, potentially enhancing graft maturation and promoting an A9 phenotype. Early improvement of L-DOPA-induced dyskinesia suggests that grafts may support the handling of exogenously supplied dopamine earlier than improvements in amphetamine-induced behaviours indicate. Given that one of the protocols will be employed in the production of cells for the European STEM-PD clinical trial, this is vital information for the management of patients and achieving optimal outcomes following transplantation of hESC-derived grafts for PD.
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Affiliation(s)
- Osama F Elabi
- School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Cardiff, UK
| | - Rachel Pass
- School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Cardiff, UK
| | - Irene Sormonta
- School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Cardiff, UK
| | - Sara Nolbrant
- Developmental and Regenerative Neurobiology, Department of Experimental Medical Science, Lund University, Lund, Sweden
| | - Nicola Drummond
- Centre for Regenerative Medicine, Institute for Stem Cell Research, School of Biological Sciences, University of Edinburgh, Edinburgh, UK
| | - Agnete Kirkeby
- Developmental and Regenerative Neurobiology, Department of Experimental Medical Science, Lund University, Lund, Sweden
- Department of Neuroscience and The Novo Nordisk Foundation Center for Stem Cell Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Tilo Kunath
- Centre for Regenerative Medicine, Institute for Stem Cell Research, School of Biological Sciences, University of Edinburgh, Edinburgh, UK
| | - Malin Parmar
- Developmental and Regenerative Neurobiology, Department of Experimental Medical Science, Lund University, Lund, Sweden
| | - Emma L Lane
- School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Cardiff, UK
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The BDNF Val66Met polymorphism (rs6265) enhances dopamine neuron graft efficacy and side-effect liability in rs6265 knock-in rats. Neurobiol Dis 2020; 148:105175. [PMID: 33188920 PMCID: PMC7855552 DOI: 10.1016/j.nbd.2020.105175] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 11/02/2020] [Accepted: 11/06/2020] [Indexed: 01/10/2023] Open
Abstract
Prevalent in approximately 20% of the worldwide human population, the
rs6265 (also called ‘Val66Met’) single nucleotide polymorphism
(SNP) in the gene for brain-derived neurotrophic factor (BDNF)
is a common genetic variant that can alter therapeutic responses in individuals
with Parkinson’s disease (PD). Possession of the variant Met allele
results in decreased activity-dependent release of BDNF. Given the resurgent
worldwide interest in neural transplantation for PD and the biological relevance
of BDNF, the current studies examined the effects of the rs6265 SNP on
therapeutic efficacy and side-effect development following primary dopamine (DA)
neuron transplantation. Considering the significant reduction in BDNF release
associated with rs6265, we hypothesized that rs6265-mediated dysfunctional BDNF
signaling contributes to the limited clinical benefit observed in a
subpopulation of PD patients despite robust survival of grafted DA neurons, and
further, that this mutation contributes to the development of aberrant
graft-induced dyskinesias (GID). To this end, we generated a CRISPR knock-in rat
model of the rs6265 BDNF SNP to examine for the first time the
influence of a common genetic polymorphism on graft survival, functional
efficacy, and side-effect liability, comparing these parameters between
wild-type (Val/Val) rats and those homozygous for the variant Met allele
(Met/Met). Counter to our hypothesis, the current research indicates that
Met/Met rats show enhanced graft-associated therapeutic efficacy and a
paradoxical enhancement of graft-derived neurite outgrowth compared to wild-type
rats. However, consistent with our hypothesis, we demonstrate that the rs6265
genotype in the host rat is strongly linked to development of GID, and that this
behavioral phenotype is significantly correlated with neurochemical signatures
of atypical glutamatergic neurotransmission by grafted DA neurons.
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Precious SV, Smith GA, Heuer A, Jaeger I, Lane EL, Dunnett SB, Li M, Kelly CM, Rosser AE. Dopaminergic Progenitors Derived From Epiblast Stem Cells Function Similarly to Primary VM-Derived Progenitors When Transplanted Into a Parkinson's Disease Model. Front Neurosci 2020; 14:312. [PMID: 32317925 PMCID: PMC7154167 DOI: 10.3389/fnins.2020.00312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 03/17/2020] [Indexed: 11/13/2022] Open
Abstract
Neural transplantation in neurodegenerative diseases such as Parkinson’s disease (PD) offers to replace cells lost during the progression of the disease process. Primary fetal ventral mesencephalon (VM), the origin of bona fide midbrain dopaminergic (DAergic) precursors, is currently the gold standard source of cells for transplantation in PD. However, the use of tissue from this source raises ethical and logistical constraints necessitating the need for alternative supplies of donor cells. The requirement of any alternative donor cell source is to have the capability to generate authentic mature DAergic neurons, which could be utilized in cell-replacement strategies. Mouse pluripotent stem cells can efficiently generate electrochemically mature midbrain DAergic precursors in vitro using a stepwise control of FGF signaling. Here, we have compared DAergic transplants derived from two progenitor cell sources in an allograft system: mouse epiblast stem cells (EpiSC) and primary fetal mouse VM tissue. Cells were transplanted into the striatum of 6-OHDA lesioned mice pre-treated with L-DOPA. Drug-induced rotations, a number of motor tests and drug-induced abnormal involuntary movements (AIMs) were assessed. Functional improvements were demonstrated post-transplantation in some behavioral tests, with no difference in graft volume or the number of TH immuno-positive cells in the grafts of the two transplant groups. L-DOPA-induced AIMs and amphetamine-induced AIMs were observed in both transplant groups, with no differences in rate or severity between the two groups. Collectively, in this mouse-to-mouse allograft system, we report no significant differences in the functional ability between the gold standard primary VM derived and pluripotent stem cell-derived DAergic transplants.
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Affiliation(s)
- Sophie V Precious
- Brain Repair Group, School of Biosciences, Cardiff University, Cardiff, United Kingdom
| | - Gaynor A Smith
- School of Medicine, UK Dementia Research Institute, Cardiff University, Cardiff, United Kingdom
| | - Andreas Heuer
- Brain Repair Group, School of Biosciences, Cardiff University, Cardiff, United Kingdom.,Behavioural Neuroscience Laboratory, Department of Experimental Medical Sciences, Lund University, Lund, Sweden
| | - Ines Jaeger
- Stem Cell Neurogenesis Group, School of Medicine and Biosciences, Neuroscience and Mental Health Research Institute, Cardiff University, Cardiff, United Kingdom
| | - Emma L Lane
- School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Cardiff, United Kingdom
| | - Stephen B Dunnett
- Brain Repair Group, School of Biosciences, Cardiff University, Cardiff, United Kingdom
| | - Meng Li
- Stem Cell Neurogenesis Group, School of Medicine and Biosciences, Neuroscience and Mental Health Research Institute, Cardiff University, Cardiff, United Kingdom
| | - Claire M Kelly
- School of Health Sciences, Cardiff Metropolitan University, Cardiff, United Kingdom
| | - Anne E Rosser
- Brain Repair Group, School of Biosciences, Cardiff University, Cardiff, United Kingdom.,Wales Brain Repair and Intracranial Neurotherapeutics Unit, School of Medicine, Cardiff University, Cardiff, United Kingdom.,MRC Centre for Neuropsychiatric Genetics and Genomics, School of Medicine, Cardiff University, Cardiff, United Kingdom
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7
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Lane EL. L-DOPA for Parkinson's disease-a bittersweet pill. Eur J Neurosci 2018; 49:384-398. [PMID: 30118169 DOI: 10.1111/ejn.14119] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 07/23/2018] [Accepted: 07/30/2018] [Indexed: 01/02/2023]
Abstract
3,4-dihydroxy-L-phenylalanine (L-DOPA) is the gold standard treatment for Parkinson's disease. It has earned that title through its highly effective treatment of some of the motor symptoms in the early stages of the disease but it is a far from perfect drug. The inevitable long-term treatment that comes with this chronic neurodegenerative condition raises the risk significantly of the development of motor fluctuations including disabling L-DOPA-induced dyskinesia. Being unsurpassed as a therapy means that understanding the mechanisms of dyskinesia priming and induction is vital to the search for therapies to treat these side effects and allow optimal use of L-DOPA. However, L-DOPA use may also have consequences (positive or negative) for the development of other interventions, such as cell transplantation, which are designed to treat or repair the ailing brain. This review looks at the issues around the use of L-DOPA with a focus on its potential impact on advanced reparative interventions.
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Affiliation(s)
- Emma L Lane
- Cardiff School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Cardiff, UK
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8
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Cell reprogramming approaches in gene- and cell-based therapies for Parkinson's disease. J Control Release 2018; 286:114-124. [PMID: 30026082 DOI: 10.1016/j.jconrel.2018.07.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 06/26/2018] [Accepted: 07/10/2018] [Indexed: 12/17/2022]
Abstract
Degeneration of dopamine (DA) neurons in the substantia nigra pars compacta is the pathological hallmark of Parkinson's disease (PD). In PD multiple pathogenic mechanisms initiate and drive this neurodegenerative process, making the development of effective treatments challenging. To date, PD patients are primarily treated with dopaminergic drugs able to temporarily enhance DA levels, therefore relieving motor symptoms. However, the drawbacks of these therapies including the inability to alter disease progression are constantly supporting the search for alternative treatment approaches. Over the past years efforts have been put into the development of new therapeutic strategies based on the delivery of therapeutic genes using viral vectors or transplantation of DA neurons for cell-based DA replacement. Here, past achievements and recent advances in gene- and cell-based therapies for PD are outlined. We discuss how current gene and cell therapy strategies hold great promise for the treatment of PD and how the use of stem cells and recent developments in cellular reprogramming could contribute to open a new avenue in PD therapy.
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Abstract
Parkinson disease is the second-most common neurodegenerative disorder that affects 2-3% of the population ≥65 years of age. Neuronal loss in the substantia nigra, which causes striatal dopamine deficiency, and intracellular inclusions containing aggregates of α-synuclein are the neuropathological hallmarks of Parkinson disease. Multiple other cell types throughout the central and peripheral autonomic nervous system are also involved, probably from early disease onwards. Although clinical diagnosis relies on the presence of bradykinesia and other cardinal motor features, Parkinson disease is associated with many non-motor symptoms that add to overall disability. The underlying molecular pathogenesis involves multiple pathways and mechanisms: α-synuclein proteostasis, mitochondrial function, oxidative stress, calcium homeostasis, axonal transport and neuroinflammation. Recent research into diagnostic biomarkers has taken advantage of neuroimaging in which several modalities, including PET, single-photon emission CT (SPECT) and novel MRI techniques, have been shown to aid early and differential diagnosis. Treatment of Parkinson disease is anchored on pharmacological substitution of striatal dopamine, in addition to non-dopaminergic approaches to address both motor and non-motor symptoms and deep brain stimulation for those developing intractable L-DOPA-related motor complications. Experimental therapies have tried to restore striatal dopamine by gene-based and cell-based approaches, and most recently, aggregation and cellular transport of α-synuclein have become therapeutic targets. One of the greatest current challenges is to identify markers for prodromal disease stages, which would allow novel disease-modifying therapies to be started earlier.
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Breger LS, Kienle K, Smith GA, Dunnett SB, Lane EL. Influence of chronic L-DOPA treatment on immune response following allogeneic and xenogeneic graft in a rat model of Parkinson's disease. Brain Behav Immun 2017; 61:155-164. [PMID: 27864045 PMCID: PMC5325122 DOI: 10.1016/j.bbi.2016.11.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 11/07/2016] [Accepted: 11/14/2016] [Indexed: 12/19/2022] Open
Abstract
Although intrastriatal transplantation of fetal cells for the treatment of Parkinson's disease had shown encouraging results in initial open-label clinical trials, subsequent double-blind studies reported more debatable outcomes. These studies highlighted the need for greater preclinical analysis of the parameters that may influence the success of cell therapy. While much of this has focused on the cells and location of the transplants, few have attempted to replicate potentially critical patient centered factors. Of particular relevance is that patients will be under continued L-DOPA treatment prior to and following transplantation, and that typically the grafts will not be immunologically compatible with the host. The aim of this study was therefore to determine the effect of chronic L-DOPA administered during different phases of the transplantation process on the survival and function of grafts with differing degrees of immunological compatibility. To that end, unilaterally 6-OHDA lesioned rats received sham surgery, allogeneic or xenogeneic transplants, while being treated with L-DOPA before and/or after transplantation. Irrespective of the L-DOPA treatment, dopaminergic grafts improved function and reduced the onset of L-DOPA induced dyskinesia. Importantly, although L-DOPA administered post transplantation was found to have no detrimental effect on graft survival, it did significantly promote the immune response around xenogeneic transplants, despite the administration of immunosuppressive treatment (cyclosporine). This study is the first to systematically examine the effect of L-DOPA on graft tolerance, which is dependent on the donor-host compatibility. These findings emphasize the importance of using animal models that adequately represent the patient paradigm.
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Affiliation(s)
- Ludivine S. Breger
- School of Pharmacy & Pharmaceutical Sciences, Redwood Building, King Edward VII Avenue, CF10 3NB Cardiff, UK,Brain Repair Group, Cardiff School of Biosciences, Museum Avenue, CF10 3AX Cardiff, UK,Corresponding author at: Dept of Experimental Medical Science, Wallenberg Neuroscience Centre, Lund University, BMC A11, 221 84 Lund, Sweden.Dept of Experimental Medical ScienceWallenberg Neuroscience CentreLund UniversityBMC A11221 84 LundSweden
| | - Korbinian Kienle
- School of Pharmacy & Pharmaceutical Sciences, Redwood Building, King Edward VII Avenue, CF10 3NB Cardiff, UK.
| | - Gaynor A. Smith
- Brain Repair Group, Cardiff School of Biosciences, Museum Avenue, CF10 3AX Cardiff, UK
| | - Stephen B. Dunnett
- Brain Repair Group, Cardiff School of Biosciences, Museum Avenue, CF10 3AX Cardiff, UK
| | - Emma L. Lane
- School of Pharmacy & Pharmaceutical Sciences, Redwood Building, King Edward VII Avenue, CF10 3NB Cardiff, UK
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11
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Lindvall O. Treatment of Parkinson's disease using cell transplantation. Philos Trans R Soc Lond B Biol Sci 2016; 370:20140370. [PMID: 26416681 DOI: 10.1098/rstb.2014.0370] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
The clinical trials with intrastriatal transplantation of human fetal mesencephalic tissue, rich in dopaminergic neurons, in Parkinson's disease (PD) patients show that cell replacement can work and in some cases induce major, long-lasting improvement. However, owing to poor tissue availability, this approach can only be applied in very few patients, and standardization is difficult, leading to wide variation in functional outcome. Stem cells and reprogrammed cells could potentially be used to produce dopaminergic neurons for transplantation. Importantly, dopaminergic neurons of the correct substantia nigra phenotype can now be generated from human embryonic stem cells in large numbers and standardized preparations, and will soon be ready for application in patients. Also, human induced pluripotent stem cell-derived dopaminergic neurons are being considered for clinical translation. Available data justify moving forward in a responsible way with these dopaminergic neurons, which should be tested, using optimal patient selection, cell preparation and transplantation procedures, in controlled clinical studies.
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Affiliation(s)
- Olle Lindvall
- Laboratory of Stem Cells and Restorative Neurology, Lund Stem Cell Center, University Hospital, 221 84 Lund, Sweden
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12
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Rylander Ottosson D, Lane E. Striatal Plasticity in L-DOPA- and Graft-Induced Dyskinesia; The Common Link? Front Cell Neurosci 2016; 10:16. [PMID: 26903804 PMCID: PMC4744851 DOI: 10.3389/fncel.2016.00016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 01/15/2016] [Indexed: 12/31/2022] Open
Abstract
One of the major symptoms of the neurodegenerative condition Parkinson's disease (PD) is a slowness or loss of voluntary movement, yet frustratingly therapeutic strategies designed to restore movement can result in the development of excessive abnormal movements known as dyskinesia. These dyskinesias commonly develop as a result of pharmacotherapy in the form of L-DOPA administration, but have also been identified following deep brain stimulation (DBS) and intrastriatal cell transplantation. In the case of L-DOPA these movements can be treatment limiting, and whilst they are not long lasting or troubling following DBS, recognition of their development had a near devastating effect on the field of cell transplantation for PD.Understanding the relationship between these therapeutic approaches and the development of dyskinesia may improve our ability to restore function without disabling side effects. Interestingly, despite the fact that dopaminergic cell transplantation repairs many of the changes induced by the disease process and through L-DOPA treatment, there appears to be a relationship between the two. In rodent models of the disease, the severity of dyskinesia induced by L-DOPA prior to the transplantation procedure correlated with post-transplantation, graft-induced dyskinesia. A review of clinical data also suggested that the worse preoperational dyskinesia causes worsened graft-induced dyskinesia (GID). Understanding how these aberrant behaviors come about has been of keen interest to open up these therapeutic options more widely and one major underlying theory is the effects of these approaches on the plasticity of synapses within the basal ganglia. This review uniquely brings together developments in understanding the role of striatal synaptic plasticity in both L-DOPA and GID to guide and stimulate further investigations on the important striatal plasticity.
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Affiliation(s)
- Daniella Rylander Ottosson
- Developmental and Regenerative Neurobiology, Department of Experimental Medical Science, Lund UniversityLund, Sweden
| | - Emma Lane
- School of Pharmacy and Pharmaceutical Sciences, Cardiff UniversityCardiff, UK
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13
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Bastide MF, Meissner WG, Picconi B, Fasano S, Fernagut PO, Feyder M, Francardo V, Alcacer C, Ding Y, Brambilla R, Fisone G, Jon Stoessl A, Bourdenx M, Engeln M, Navailles S, De Deurwaerdère P, Ko WKD, Simola N, Morelli M, Groc L, Rodriguez MC, Gurevich EV, Quik M, Morari M, Mellone M, Gardoni F, Tronci E, Guehl D, Tison F, Crossman AR, Kang UJ, Steece-Collier K, Fox S, Carta M, Angela Cenci M, Bézard E. Pathophysiology of L-dopa-induced motor and non-motor complications in Parkinson's disease. Prog Neurobiol 2015. [PMID: 26209473 DOI: 10.1016/j.pneurobio.2015.07.002] [Citation(s) in RCA: 347] [Impact Index Per Article: 38.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Involuntary movements, or dyskinesia, represent a debilitating complication of levodopa (L-dopa) therapy for Parkinson's disease (PD). L-dopa-induced dyskinesia (LID) are ultimately experienced by the vast majority of patients. In addition, psychiatric conditions often manifested as compulsive behaviours, are emerging as a serious problem in the management of L-dopa therapy. The present review attempts to provide an overview of our current understanding of dyskinesia and other L-dopa-induced dysfunctions, a field that dramatically evolved in the past twenty years. In view of the extensive literature on LID, there appeared a critical need to re-frame the concepts, to highlight the most suitable models, to review the central nervous system (CNS) circuitry that may be involved, and to propose a pathophysiological framework was timely and necessary. An updated review to clarify our understanding of LID and other L-dopa-related side effects was therefore timely and necessary. This review should help in the development of novel therapeutic strategies aimed at preventing the generation of dyskinetic symptoms.
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Affiliation(s)
- Matthieu F Bastide
- Univ. de Bordeaux, Institut des Maladies Neurodégénératives, UMR 5293, 33000 Bordeaux, France; CNRS, Institut des Maladies Neurodégénératives, UMR 5293, 33000 Bordeaux, France
| | - Wassilios G Meissner
- Univ. de Bordeaux, Institut des Maladies Neurodégénératives, UMR 5293, 33000 Bordeaux, France; CNRS, Institut des Maladies Neurodégénératives, UMR 5293, 33000 Bordeaux, France; Department of Neurology, University Hospital Bordeaux, France
| | - Barbara Picconi
- Laboratory of Neurophysiology, Fondazione Santa Lucia, IRCCS, Rome, Italy
| | - Stefania Fasano
- Division of Neuroscience, Institute of Experimental Neurology, San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Pierre-Olivier Fernagut
- Univ. de Bordeaux, Institut des Maladies Neurodégénératives, UMR 5293, 33000 Bordeaux, France; CNRS, Institut des Maladies Neurodégénératives, UMR 5293, 33000 Bordeaux, France
| | - Michael Feyder
- Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Veronica Francardo
- Basal Ganglia Pathophysiology Unit, Department of Experimental Medical Science, Lund University, Lund, Sweden
| | - Cristina Alcacer
- Basal Ganglia Pathophysiology Unit, Department of Experimental Medical Science, Lund University, Lund, Sweden
| | - Yunmin Ding
- Department of Neurology, Columbia University, New York, USA
| | - Riccardo Brambilla
- Division of Neuroscience, Institute of Experimental Neurology, San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Gilberto Fisone
- Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - A Jon Stoessl
- Pacific Parkinson's Research Centre and National Parkinson Foundation Centre of Excellence, University of British Columbia, Vancouver, Canada
| | - Mathieu Bourdenx
- Univ. de Bordeaux, Institut des Maladies Neurodégénératives, UMR 5293, 33000 Bordeaux, France; CNRS, Institut des Maladies Neurodégénératives, UMR 5293, 33000 Bordeaux, France
| | - Michel Engeln
- Univ. de Bordeaux, Institut des Maladies Neurodégénératives, UMR 5293, 33000 Bordeaux, France; CNRS, Institut des Maladies Neurodégénératives, UMR 5293, 33000 Bordeaux, France
| | - Sylvia Navailles
- Univ. de Bordeaux, Institut des Maladies Neurodégénératives, UMR 5293, 33000 Bordeaux, France; CNRS, Institut des Maladies Neurodégénératives, UMR 5293, 33000 Bordeaux, France
| | - Philippe De Deurwaerdère
- Univ. de Bordeaux, Institut des Maladies Neurodégénératives, UMR 5293, 33000 Bordeaux, France; CNRS, Institut des Maladies Neurodégénératives, UMR 5293, 33000 Bordeaux, France
| | - Wai Kin D Ko
- Univ. de Bordeaux, Institut des Maladies Neurodégénératives, UMR 5293, 33000 Bordeaux, France; CNRS, Institut des Maladies Neurodégénératives, UMR 5293, 33000 Bordeaux, France
| | - Nicola Simola
- Department of Biomedical Sciences, Section of Neuropsychopharmacology, Cagliari University, 09124 Cagliari, Italy
| | - Micaela Morelli
- Department of Biomedical Sciences, Section of Neuropsychopharmacology, Cagliari University, 09124 Cagliari, Italy
| | - Laurent Groc
- Univ. de Bordeaux, Institut Interdisciplinaire de neurosciences, UMR 5297, 33000 Bordeaux, France; CNRS, Institut Interdisciplinaire de neurosciences, UMR 5297, 33000 Bordeaux, France
| | - Maria-Cruz Rodriguez
- Department of Neurology, Hospital Universitario Donostia and Neuroscience Unit, Bio Donostia Research Institute, San Sebastian, Spain
| | - Eugenia V Gurevich
- Department of Pharmacology, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Maryka Quik
- Center for Health Sciences, SRI International, CA 94025, USA
| | - Michele Morari
- Department of Medical Sciences, Section of Pharmacology, University of Ferrara, Ferrara, Italy
| | - Manuela Mellone
- Dipartimento di Scienze Farmacologiche e Biomolecolari, Università degli Studi di Milano, 20133 Milano, Italy
| | - Fabrizio Gardoni
- Dipartimento di Scienze Farmacologiche e Biomolecolari, Università degli Studi di Milano, 20133 Milano, Italy
| | - Elisabetta Tronci
- Department of Biomedical Sciences, Physiology Section, Cagliari University, Cagliari, Italy
| | - Dominique Guehl
- Univ. de Bordeaux, Institut des Maladies Neurodégénératives, UMR 5293, 33000 Bordeaux, France; CNRS, Institut des Maladies Neurodégénératives, UMR 5293, 33000 Bordeaux, France
| | - François Tison
- Univ. de Bordeaux, Institut des Maladies Neurodégénératives, UMR 5293, 33000 Bordeaux, France; CNRS, Institut des Maladies Neurodégénératives, UMR 5293, 33000 Bordeaux, France; Department of Neurology, University Hospital Bordeaux, France
| | | | - Un Jung Kang
- Basal Ganglia Pathophysiology Unit, Department of Experimental Medical Science, Lund University, Lund, Sweden
| | - Kathy Steece-Collier
- Michigan State University, College of Human Medicine, Department of Translational Science and Molecular Medicine & The Udall Center of Excellence in Parkinson's Disease Research, 333 Bostwick Ave NE, Grand Rapids, MI 49503, USA
| | - Susan Fox
- Morton & Gloria Shulman Movement Disorders Center, Toronto Western Hospital, Toronto, Ontario M4T 2S8, Canada
| | - Manolo Carta
- Department of Biomedical Sciences, Physiology Section, Cagliari University, Cagliari, Italy
| | - M Angela Cenci
- Basal Ganglia Pathophysiology Unit, Department of Experimental Medical Science, Lund University, Lund, Sweden
| | - Erwan Bézard
- Univ. de Bordeaux, Institut des Maladies Neurodégénératives, UMR 5293, 33000 Bordeaux, France; CNRS, Institut des Maladies Neurodégénératives, UMR 5293, 33000 Bordeaux, France; Motac Neuroscience Ltd, Manchester, UK.
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14
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Yang X, Zhao H, Shi H, Wang X, Zhang S, Zhang Z, Zu J, Zhang W, Shen X, Cui G, Hua F. Intranigral administration of substance P receptor antagonist attenuated levodopa-induced dyskinesia in a rat model of Parkinson's disease. Exp Neurol 2015; 271:168-74. [PMID: 26001615 DOI: 10.1016/j.expneurol.2015.05.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Revised: 04/20/2015] [Accepted: 05/13/2015] [Indexed: 11/30/2022]
Abstract
Levodopa (L-dopa) remains the most effective drug in the treatment of Parkinson's disease (PD). However, L-dopa-induced dyskinesia (LID) has hindered its use for PD patients. The mechanisms of LID are not fully understood. Substance P (SP) receptor antagonist has been shown to reduce parkinsonism in animal models of PD, and ameliorate LID in PD rats. But the concrete mechanism is not fully understood. To address this issue, we produced a rat model of PD using 6-hydroxydompamine (6-OHDA) injections, and valid PD rats were intranigrally administrated with different doses of SP receptor antagonist LY303870 (5 nmol/day, 10 nmol/day and 20 nmol/day) following L-dopa (6 mg/kg/day, i.p.) plus benserazide (12 mg/kg/day, i.p.) for 23 days. We found that nigral SP levels were increased on days 3, 7 and 14 and decreased on day 21 after 6-hydroxydompamine lesions. But nigral SP levels kept increasing after repeated L-dopa administration in PD rats. Intranigral administration of low and moderate LY303870 reduced abnormal involuntary movements (AIMs) while improving motor deficits in PD rats treated with L-dopa plus benserazide. Microdialysis revealed that LY303870 (10 nmol/day) treatment attenuated the increase of striatal dopamine and the reduction of γ-aminobutyric acid in ventromedial thalamus of PD rats primed with L-dopa. Additionally, LY303870 (10 nmol/day) treatment prior to L-dopa administration reduced the phosphorylated levels of dopamine- and cyclic adenosine monophosphate-regulated phosphoprotein of 32 kDa at Thr 34 and extracellular signal-regulated kinases 1/2 as well as the levels of activity-regulated cytoskeleton-associated protein and Penk in L-dopa-primed PD rats. Taken together, these data showed that low and moderate SP receptor antagonists LY303870 could ameliorate LID via neurokinin 1 receptor without affecting therapeutic effect of L-dopa.
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Affiliation(s)
- Xinxin Yang
- Department of Neurology, The Affiliated Hospital of Xuzhou Medical College, China
| | - Hui Zhao
- Department of Neurology, Xuzhou Central Hospital, China
| | - Hongjuan Shi
- Department of Neurology, The Affiliated Hospital of Xuzhou Medical College, China
| | - Xiaoying Wang
- Department of Ultrasound, The Affiliated Hospital of Xuzhou Medical College, China
| | - Shenyang Zhang
- Department of Neurology, The Affiliated Hospital of Xuzhou Medical College, China
| | - Zunsheng Zhang
- Department of Neurology, The Affiliated Hospital of Xuzhou Medical College, China
| | - Jie Zu
- Department of Neurology, The Affiliated Hospital of Xuzhou Medical College, China
| | - Wei Zhang
- Department of Neurology, The Affiliated Hospital of Xuzhou Medical College, China
| | - Xia Shen
- Department of Neurology, The Affiliated Hospital of Xuzhou Medical College, China
| | - Guiyun Cui
- Department of Neurology, The Affiliated Hospital of Xuzhou Medical College, China.
| | - Fang Hua
- Department of Neurology, The Affiliated Hospital of Xuzhou Medical College, China.
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15
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Huot P, Fox SH, Brotchie JM. Monoamine reuptake inhibitors in Parkinson's disease. PARKINSON'S DISEASE 2015; 2015:609428. [PMID: 25810948 PMCID: PMC4355567 DOI: 10.1155/2015/609428] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Accepted: 12/26/2014] [Indexed: 12/13/2022]
Abstract
The motor manifestations of Parkinson's disease (PD) are secondary to a dopamine deficiency in the striatum. However, the degenerative process in PD is not limited to the dopaminergic system and also affects serotonergic and noradrenergic neurons. Because they can increase monoamine levels throughout the brain, monoamine reuptake inhibitors (MAUIs) represent potential therapeutic agents in PD. However, they are seldom used in clinical practice other than as antidepressants and wake-promoting agents. This review article summarises all of the available literature on use of 50 MAUIs in PD. The compounds are divided according to their relative potency for each of the monoamine transporters. Despite wide discrepancy in the methodology of the studies reviewed, the following conclusions can be drawn: (1) selective serotonin transporter (SERT), selective noradrenaline transporter (NET), and dual SERT/NET inhibitors are effective against PD depression; (2) selective dopamine transporter (DAT) and dual DAT/NET inhibitors exert an anti-Parkinsonian effect when administered as monotherapy but do not enhance the anti-Parkinsonian actions of L-3,4-dihydroxyphenylalanine (L-DOPA); (3) dual DAT/SERT inhibitors might enhance the anti-Parkinsonian actions of L-DOPA without worsening dyskinesia; (4) triple DAT/NET/SERT inhibitors might exert an anti-Parkinsonian action as monotherapy and might enhance the anti-Parkinsonian effects of L-DOPA, though at the expense of worsening dyskinesia.
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Affiliation(s)
- Philippe Huot
- Toronto Western Research Institute, Toronto Western Hospital, University Health Network, 399 Bathurst Street, Toronto, ON, Canada M5T 2S8
- Division of Neurology, Movement Disorder Clinic, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, Toronto, ON, Canada M5T 2S8
- Department of Pharmacology and Division of Neurology, Faculty of Medicine, Université de Montréal and Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Susan H. Fox
- Toronto Western Research Institute, Toronto Western Hospital, University Health Network, 399 Bathurst Street, Toronto, ON, Canada M5T 2S8
- Division of Neurology, Movement Disorder Clinic, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, Toronto, ON, Canada M5T 2S8
| | - Jonathan M. Brotchie
- Toronto Western Research Institute, Toronto Western Hospital, University Health Network, 399 Bathurst Street, Toronto, ON, Canada M5T 2S8
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16
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Ambasudhan R, Dolatabadi N, Nutter A, Masliah E, Mckercher SR, Lipton SA. Potential for cell therapy in Parkinson's disease using genetically programmed human embryonic stem cell-derived neural progenitor cells. J Comp Neurol 2014; 522:2845-56. [PMID: 24756727 DOI: 10.1002/cne.23617] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Revised: 04/18/2014] [Accepted: 04/21/2014] [Indexed: 12/20/2022]
Abstract
Neural transplantation is a promising strategy for restoring dopaminergic dysfunction and modifying disease progression in Parkinson's disease (PD). Human embryonic stem cells (hESCs) are a potential resource in this regard because of their ability to provide a virtually limitless supply of homogenous dopaminergic progenitors and neurons of appropriate lineage. The recent advances in developing robust cell culture protocols for directed differentiation of hESCs to near pure populations of ventral mesencephalic (A9-type) dopaminergic neurons has heightened the prospects for PD cell therapy. Here, we focus our review on current state-of-the-art techniques for harnessing hESC-based strategies toward development of a stem cell therapeutic for PD. Importantly, we also briefly describe a novel genetic-programming approach that may address many of the key challenges that remain in the field and that may hasten clinical translation.
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Affiliation(s)
- Rajesh Ambasudhan
- Del E. Webb Center for Neuroscience, Aging, and Stem Cell Research, Sanford-Burnham Medical Research Institute, 10901 North Torrey Pines Road, La Jolla, California, 92037
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17
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Petit GH, Olsson TT, Brundin P. Review: The future of cell therapies and brain repair:
P
arkinson's disease leads the way. Neuropathol Appl Neurobiol 2014; 40:60-70. [DOI: 10.1111/nan.12110] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Accepted: 12/16/2013] [Indexed: 12/22/2022]
Affiliation(s)
- G. H. Petit
- Neuronal Survival Unit, Department of Experimental Medical Science Wallenberg Neuroscience Center Lund Sweden
| | - T. T. Olsson
- Van Andel Research Institute Center for Neurodegenerative Science Grand Rapids MI USA
| | - P. Brundin
- Neuronal Survival Unit, Department of Experimental Medical Science Wallenberg Neuroscience Center Lund Sweden
- Van Andel Research Institute Center for Neurodegenerative Science Grand Rapids MI USA
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18
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Rylander D, Bagetta V, Pendolino V, Zianni E, Grealish S, Gardoni F, Di Luca M, Calabresi P, Cenci MA, Picconi B. Region-specific restoration of striatal synaptic plasticity by dopamine grafts in experimental parkinsonism. Proc Natl Acad Sci U S A 2013; 110:E4375-84. [PMID: 24170862 PMCID: PMC3831970 DOI: 10.1073/pnas.1311187110] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Intrastriatal transplantation of dopaminergic neurons can restore striatal dopamine levels and improve parkinsonian deficits, but the mechanisms underlying these effects are poorly understood. Here, we show that transplants of dopamine neurons partially restore activity-dependent synaptic plasticity in the host striatal neurons. We evaluated synaptic plasticity in regions distal or proximal to the transplant (i.e., dorsolateral and ventrolateral striatum) and compared the effects of dopamine- and serotonin-enriched grafts using a rat model of Parkinson disease. Naïve rats showed comparable intrinsic membrane properties in the two subregions but distinct patterns of long-term synaptic plasticity. The ventrolateral striatum showed long-term potentiation using the same protocol that elicited long-term depression in the dorsolateral striatum. The long-term potentiation was linked to higher expression of postsynaptic AMPA and N2B NMDA subunits (GluN2B) and was dependent on the activation of GluN2A and GluN2B subunits and the D1 dopamine receptor. In both regions, the synaptic plasticity was abolished after a severe dopamine depletion and could not be restored by grafted serotonergic neurons. Solely, dopamine-enriched grafts could restore the long-term potentiation and partially restore motor deficits in the rats. The restoration could only be seen close to the graft, in the ventrolateral striatum where the graft-derived reinnervation was denser, compared with the distal dorsolateral region. These data provide proof of concept that dopamine-enriched transplants are able to functionally integrate into the host brain and restore deficits in striatal synaptic plasticity after experimental parkinsonism. The region-specific restoration might impose limitations in symptomatic improvement following neural transplantation.
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Affiliation(s)
- Daniella Rylander
- Basal Ganglia Pathophysiological Unit, Lund University, BMC F11, 22184 Lund, Sweden
- Fondazione Santa Lucia, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), 00143 Rome, Italy
| | - Vincenza Bagetta
- Fondazione Santa Lucia, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), 00143 Rome, Italy
| | - Valentina Pendolino
- Fondazione Santa Lucia, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), 00143 Rome, Italy
| | - Elisa Zianni
- Dipartimento Scienze Farmacologiche e Biomolecolari, Università degli Studi di Milano, 20122 Milan, Italy
| | - Shane Grealish
- Developmental and Regenerative Neurobiology, Lund University, BMC A11, 22184 Lund, Sweden; and
| | - Fabrizio Gardoni
- Dipartimento Scienze Farmacologiche e Biomolecolari, Università degli Studi di Milano, 20122 Milan, Italy
| | - Monica Di Luca
- Dipartimento Scienze Farmacologiche e Biomolecolari, Università degli Studi di Milano, 20122 Milan, Italy
| | - Paolo Calabresi
- Fondazione Santa Lucia, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), 00143 Rome, Italy
- Clinica Neurologica, Università degli studi di Perugia, Ospedale Santa Maria della Misericordia, S. Andrea delle Fratte, 06156 Perugia, Italy
| | - M. Angela Cenci
- Basal Ganglia Pathophysiological Unit, Lund University, BMC F11, 22184 Lund, Sweden
| | - Barbara Picconi
- Fondazione Santa Lucia, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), 00143 Rome, Italy
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The anti-dyskinetic effect of dopamine receptor blockade is enhanced in parkinsonian rats following dopamine neuron transplantation. Neurobiol Dis 2013; 62:233-40. [PMID: 24135006 DOI: 10.1016/j.nbd.2013.09.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Revised: 09/19/2013] [Accepted: 09/24/2013] [Indexed: 11/22/2022] Open
Abstract
Graft-induced dyskinesia (GID) is a serious complication induced by dopamine (DA) cell transplantation in parkinsonian patients. We have recently shown that DA D2 receptor blockade produces striking blockade of dyskinesia induced by amphetamine in grafted 6-OHDA-lesioned rats, a model of GID. This study was designed to investigate whether blockade of DA D1 receptors could produce similar outcome, and to see whether the effect of these treatments in grafted rats was specific for dyskinesia induced by amphetamine, or could also influence L-DOPA-induced dyskinesia (LID). L-DOPA-primed rats received transplants of fetal DA neurons into the DA-denervated striatum. Beginning at 20weeks after transplantation rats were subjected to pharmacological treatments with either L-DOPA (6mg/kg) or amphetamine (1.5mg/kg) alone, or in combination with the D1 receptor antagonist SCH23390, the D2 receptor antagonist eticlopride, and the 5-HT1A agonist/D2 receptor antagonist buspirone. Grafted rats developed severe GID, while LID was reduced. Both eticlopride and SCH23390 produced near-complete suppression of GID already at very low doses (0.015 and 0.1mg/kg, respectively). Buspirone induced similar suppression at a dose as low as 0.3mg/kg, which is far lower than the dose known to affect LID in non-grafted dyskinetic rats. In agreement with our previous results, the effect of buspirone was independent from 5-HT1A receptor activation, as it was not counteracted by the selective 5-HT1A antagonist WAY100635, but likely due to D2 receptor blockade. Most interestingly, the same doses of eticlopride, SCH23390 and buspirone were found to suppress LID in grafted but not in control dyskinetic rats. Taken together, these data demonstrate that the DA cell grafts strikingly exacerbate the effect of DA D1 and D2 receptor blockade against both GID and LID, and suggest that the anti-GID effect of buspirone seen in patients may also be due to blockade of DA D2 receptors.
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20
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Breger LS, Lane EL. L-DOPA and graft-induced dyskinesia: different treatment, same story? Exp Biol Med (Maywood) 2013; 238:725-32. [PMID: 23828589 DOI: 10.1177/1535370213488478] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
One of the well-recognized problems of long-term L-3,4-dihydroxyphenylalanine (L-DOPA) therapy in the treatment of Parkinson's disease is the development of L-DOPA induced dyskinesia. These abnormal movements cause significant disability and narrow the therapeutic window of L-DOPA. Cell transplantation is one of the most promising upcoming therapies for the treatment of Parkinson's disease, and may help alleviate or avoid L-DOPA-induced dyskinesia. However, the more recently acknowledged phenomenon of graft-induced dyskinesia is posing a major obstacle to the success of this treatment. This motor side-effect closely resembles abnormal movements induced by chronic L-DOPA treatment, yet they remain after withdrawal of the medication indicating their origins lie in the transplant. In this review, we compare these two therapy-induced adverse effects, from the way they manifest in patients to the possible mechanisms underlying their development.
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Affiliation(s)
- Ludivine S Breger
- School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Cardiff, CF10 3NB, UK
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21
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Lindvall O. Developing dopaminergic cell therapy for Parkinson's disease-give up or move forward? Mov Disord 2013; 28:268-73. [DOI: 10.1002/mds.25378] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Revised: 12/25/2012] [Accepted: 01/03/2013] [Indexed: 01/24/2023] Open
Affiliation(s)
- Olle Lindvall
- Lund Stem Cell Center; University Hospital; Lund; Sweden
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22
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Smith GA, Breger LS, Lane EL, Dunnett SB. Pharmacological modulation of amphetamine-induced dyskinesia in transplanted hemi-parkinsonian rats. Neuropharmacology 2012; 63:818-28. [DOI: 10.1016/j.neuropharm.2012.06.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Revised: 05/29/2012] [Accepted: 06/06/2012] [Indexed: 01/09/2023]
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23
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García J, Carlsson T, Döbrössy M, Nikkhah G, Winkler C. Impact of dopamine versus serotonin cell transplantation for the development of graft-induced dyskinesia in a rat Parkinson model. Brain Res 2012; 1470:119-29. [DOI: 10.1016/j.brainres.2012.06.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Revised: 06/20/2012] [Accepted: 06/22/2012] [Indexed: 01/31/2023]
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24
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Smith GA, Dunnett SB, Lane EL. Amphetamine-induced rotation in the transplanted hemi-parkinsonian rat--response to pharmacological modulation. Behav Brain Res 2012; 232:411-5. [PMID: 22516841 DOI: 10.1016/j.bbr.2012.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Revised: 03/24/2012] [Accepted: 04/03/2012] [Indexed: 11/19/2022]
Abstract
The transplantation of dopamine rich foetal tissue into Parkinson's disease patients holds much promise as a therapeutic strategy. The functional efficiency of transplantation is often tested experimentally, by grafting rat derived embryonic ventral mesencephalon tissue suspensions into the denervated striatum of hemi-parkinsonian rats that were previously rendered dyskinetic with L-DOPA. The survival and integration of the grafts in rats can be assessed by a variety of behavioural tests, however amphetamine-induced rotations remain one of the most widely used and robust measures. In this test, dopamine released from the transplant typically drives net rotation in the contralateral direction, in contrast to the ipsilateral rotational bias seen post-lesion. It is unknown what contribution other neurotransmitter systems may make to this response. In this study we monitored amphetamine-induced rotation in transplanted rats that were co-administered a second pharmacological challenge with agents known to affect dopamine-mediated behavioural responses in this model. Both D₁ and D₂ receptor antagonism (by SCH23390 and raclopride respectively) reduced the rotational response. However the cannabinoid CB1 agonist WIN55,212-2 and α₁ and α₂ adrenergic receptor antagonist yohimbine had no effect on rotation. Interestingly, glutamatergic antagonists reduced (MTEP) or even reversed (MK-801) total net rotations. The serotoninergic 5-HT(1A) and 5-HT(1B) agonists (8-OH-DPAT and CP94253 respectively) altered the temporal profile of the rotational behaviour supporting a regulatory role. Although dopamine clearly drives the motor response, this data implicates both 5-HT and glutamate systems in its regulation.
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Affiliation(s)
- Gaynor A Smith
- Brain Repair Group, School of Biosciences, Cardiff University, Cardiff, Wales, UK.
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25
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Role of Serotonin Neurons in L-DOPA- and Graft-Induced Dyskinesia in a Rat Model of Parkinson's Disease. PARKINSONS DISEASE 2012; 2012:370190. [PMID: 22762012 PMCID: PMC3384974 DOI: 10.1155/2012/370190] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/16/2012] [Revised: 04/02/2012] [Accepted: 04/10/2012] [Indexed: 01/19/2023]
Abstract
L-DOPA, the most effective drug to treat motor symptoms of Parkinson's disease, causes abnormal involuntary movements, limiting its use in advanced stages of the disease. An increasing body of evidence points to the serotonin system as a key player in the appearance of L-DOPA-induced dyskinesia (LID). In fact, exogenously administered L-DOPA can be taken up by serotonin neurons, converted to dopamine and released as a false transmitter, contributing to pulsatile stimulation of striatal dopamine receptors. Accordingly, destruction of serotonin fibers or silencing serotonin neurons by serotonin agonists could counteract LID in animal models. Recent clinical work has also shown that serotonin neurons are present in the caudate/putamen of patients grafted with embryonic ventral mesencephalic cells, producing intense serotonin hyperinnervation. These patients experience graft-induced dyskinesia (GID), a type of dyskinesia phenotypically similar to the one induced by L-DOPA but independent from its administration. Interestingly, the 5-HT1A receptor agonist buspirone has been shown to suppress GID in these patients, suggesting that serotonin neurons might be involved in the etiology of GID as for LID. In this paper we will discuss the experimental and clinical evidence supporting the involvement of the serotonin system in both LID and GID.
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26
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Shin E, Garcia J, Winkler C, Björklund A, Carta M. Serotonergic and dopaminergic mechanisms in graft-induced dyskinesia in a rat model of Parkinson's disease. Neurobiol Dis 2012; 47:393-406. [PMID: 22579773 DOI: 10.1016/j.nbd.2012.03.038] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Revised: 03/23/2012] [Accepted: 03/31/2012] [Indexed: 01/17/2023] Open
Abstract
Dyskinesia seen in the off-state, referred as graft-induced dyskinesia (GID), has emerged as a serious complication induced by dopamine (DA) cell transplantation in parkinsonian patients. Although the mechanism underlying the appearance of GID is unknown, in a recent clinical study the partial 5-HT(1A) agonist buspirone was found to markedly reduce GID in three grafted patients, who showed significant serotonin (5-HT) hyperinnervation in the grafted striatum in positron emission tomography scanning (Politis et al., 2010, 2011). Prompted by these findings, this study was performed to investigate the involvement of serotonin neurons in the appearance of GID in the rat 6-hydroxydopamine model. L-DOPA-primed rats received transplants of DA neurons only, DA plus 5-HT neurons or 5-HT neurons only into the lesioned striatum. In DA cell-grafted rats, with or without 5-HT neurons, but not in 5-HT grafts, GID was observed consistently after administration of amphetamine (1.5mg/kg, i.p.) indicating that grafted DA neurons are required to induce GID. Strikingly, a low dose of buspirone produced a complete suppression of GID. In addition, activation of 5-HT(1A) and 5-HT(1B) receptors by 8-OH-DPAT and CP 94253, known to inhibit the activity of 5-HT neurons, significantly reduced GID, whereas induction of neurotransmitter release by fenfluramine administration significantly increased GID, indicating an involvement of the 5-HT system in the modulation of GID. To investigate the involvement of the host 5-HT system in GID, the endogenous 5-HT terminals were removed by intracerebral injection of 5,7-dihydroxytryptamine, but this treatment did not affect GID expression. However, 5-HT terminal destruction suppressed the anti-GID effect of 5-HT(1A) and 5-HT(1B) agonists, demonstrating that the 5-HT(1) agonist combination exerted its anti-GID effect through the activation of pre-synaptic host-derived receptors. By contrast, removal of the host 5-HT innervation or pre-treatment with a 5-HT(1A) antagonist did not abolish the anti-GID effect of buspirone, showing that its effect is independent from activation of either pre- or post-synaptic 5-HT(1A) receptors. Since buspirone is known to also act as a DA D(2) receptor antagonist, the selective D(2) receptor antagonist eticlopride was administered to test whether blockade of D(2) receptors could account for the anti-dyskinetic effect of buspirone. In fact, eticlopride produced complete suppression of GID in grafted animals already at very low dose. Together, these results point to a critical role of both 5-HT(1) and D(2) receptors in the modulation of GID, and suggest that 5-HT neurons exert a modulatory role in the development of this side effect of neuronal transplantation.
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Affiliation(s)
- Eunju Shin
- Wallenberg Neuroscience Center, Division of Neurobiology, Lund University, Lund, Sweden
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Steece-Collier K, Rademacher DJ, Soderstrom K. Anatomy of Graft-induced Dyskinesias: Circuit Remodeling in the Parkinsonian Striatum. ACTA ACUST UNITED AC 2012; 2:15-30. [PMID: 22712056 DOI: 10.1016/j.baga.2012.01.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The goal of researchers and clinicians interested in re-instituting cell based therapies for PD is to develop an effective and safe surgical approach to replace dopamine (DA) in individuals suffering from Parkinson's disease (PD). Worldwide clinical trials involving transplantation of embryonic DA neurons into individuals with PD have been discontinued because of the often devastating post-surgical side-effect known as graft-induced dyskinesia (GID). There have been many review articles published in recent years on this subject. There has been a tendency to promote single factors in the cause of GID. In this review, we contrast the pros and cons of multiple factors that have been suggested from clinical and/or preclinical observations, as well as novel factors not yet studied that may be involved with GID. It is our intention to provide a platform that might be instrumental in examining how individual factors that correlate with GID and/or striatal pathology might interact to give rise to dysfunctional circuit remodeling and aberrant motor output.
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Affiliation(s)
- Kathy Steece-Collier
- Department of Translational Science and Molecular Medicine, Michigan State University, Grand Rapids, MI 49503
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Evans JR, Mason SL, Barker RA. Current status of clinical trials of neural transplantation in Parkinson's disease. PROGRESS IN BRAIN RESEARCH 2012. [DOI: 10.1016/b978-0-444-59575-1.00008-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Lane EL, Winkler C. l-DOPA- and graft-induced dyskinesia following transplantation. PROGRESS IN BRAIN RESEARCH 2012. [DOI: 10.1016/b978-0-444-59575-1.00007-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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García J, Carlsson T, Döbrössy M, Nikkhah G, Winkler C. Extent of pre-operative L-DOPA-induced dyskinesia predicts the severity of graft-induced dyskinesia after fetal dopamine cell transplantation. Exp Neurol 2011; 232:270-9. [DOI: 10.1016/j.expneurol.2011.09.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2011] [Accepted: 09/09/2011] [Indexed: 10/17/2022]
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Abstract
The main pathology underlying motor symptoms in Parkinson's disease (PD) is a rather selective degeneration of nigrostriatal dopamine (DA) neurons. Intrastriatal transplantation of immature DA neurons, which replace those neurons that have died, leads to functional restoration in animal models of PD. Here we describe how far the clinical translation of the DA neuron replacement strategy has advanced. We briefly summarize the lessons learned from the early clinical trials with grafts of human fetal mesencephalic tissue, and discuss recent findings suggesting susceptibility of these grafts to the disease process long-term after implantation. Mechanisms underlying graft-induced dyskinesias, which constitute the only significant adverse event observed after neural transplantation, and how they should be prevented and treated are described. We summarize the attempts to generate DA neurons from stem cells of various sources and patient-specific DA neurons from fully differentiated somatic cells, with particular emphasis on the requirements of these cells to be useful in the clinical setting. The rationale for the new clinical trial with transplantation of fetal mesencephalic tissue is described. Finally, we discuss the scientific and clinical advancements that will be necessary to develop a competitive cell therapy for PD patients.
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Affiliation(s)
- Olle Lindvall
- Laboratory of Neurogenesis and Cell Therapy, Wallenberg Neuroscience Center, University Hospital, SE-22184 Lund, Sweden.
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32
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Abstract
PURPOSE OF REVIEW We review recent experiments conducted using embryonic tissue and stem cell transplants in experimental models of Parkinson's disease. We also highlight the challenges which remain to be met in order for cell therapy to become clinically effective and safe. RECENT FINDINGS The outcome of previous clinical transplantation trials was variable in terms of motor recovery. We discuss whether transplants can mitigate L-3,4-dihydroxyphenylalanine (L-DOPA)-induced dyskinesias and consider the risk factors which predispose to graft-induced dyskinesias. In addition, we introduce Transeuro, a new European Union-funded multicenter consortium which plans to perform transplantation trials.Stem cells have emerged as an alternative source for the generation of dopaminergic precursors. We briefly outline progress made in the use of human embryonic stem cells and focus predominantly on the emerging field of induced pluripotency. We conclude by introducing the exciting and novel method of direct reprogramming which involves the conversion of fibroblasts to neurons without inducing a pluripotent state. SUMMARY The area of cell transplantation has been revitalized by the identification of parameters which predispose patients to graft-induced dyskinesias and by the emergence of novel methods of generating dopaminergic neurons. Hopefully, the Transeuro clinical trials will give further impetus and act as a stepping stone to future trials employing stem-cell-derived neurons.
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Abstract
The transplantation of dopaminergic cells for the treatment of symptoms of Parkinson’s disease has several hurdles to overcome before it can be considered a successful therapeutic approach. One issue is the development of abnormal involuntary movements in the absence of L-3,4-dihydroxyphenylalanine following the transplantation of fetal ventral mesencephalon identified in three different clinical trials. Hypotheses as to the cause of these movements include: the composition of the graft, size of the graft, L-3,4-dihydroxyphenylalanine exposure and L-3,4-dihydroxyphenylalanine-induced dyskinesia prior to transplantation and inflammatory responses in and around the graft. We evaluate the clinical evidence supporting these hypotheses and the preclinical models upon which experiments are being based to resolve them.
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Affiliation(s)
- E L Lane
- Brain Repair Group, School of Bioscience, Cardiff University, Cardiff CF10 3AX, Wales, UK.
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Ma Y, Peng S, Dhawan V, Eidelberg D. Dopamine cell transplantation in Parkinson's disease: challenge and perspective. Br Med Bull 2011; 100:173-89. [PMID: 21875864 PMCID: PMC3276236 DOI: 10.1093/bmb/ldr040] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Functional imaging provides a valuable adjunct to clinical evaluation for assessing the efficacy of cell-based restorative therapies in Parkinson's disease (PD). SOURCES OF DATA In this article, we review the latest advances on the use of positron emission tomography (PET) imaging in evaluating the surgical outcome of embryonic dopamine (DA) cell transplantation in PD patients. AREAS OF AGREEMENT These studies suggest long-term cell survival and clinical benefit following striatal transplantation of fetal nigral tissue in PD patients and in models of experimental parkinsonism. AREAS OF CONTROVERSY Adverse events subsequent to transplantation have also been noted and attributed to a variety of causes. GROWING POINTS Optimal outcomes of DA cell transplantation therapies are dependent on tissue composition and phenotype of DA neurons in the graft. AREAS TIMELY FOR DEVELOPING RESEARCH Given continued progress in DA neuron production from stem cells in recent years, transplantation of neural stem cells may be the next to enter clinical trials in patients. CONCLUSION The existing data from studies of embryonic DA transplantation for advanced PD have provided valuable insights for the design of new cell-based therapies for the treatment of this and related neurodegenerative disorders.
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Affiliation(s)
- Yilong Ma
- Center for Neurosciences, The Feinstein Institute for Medical Research, Manhasset, NY 11030, USA.
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Brundin P, Barker RA, Parmar M. Neural grafting in Parkinson’s disease. PROGRESS IN BRAIN RESEARCH 2010; 184:265-94. [DOI: 10.1016/s0079-6123(10)84014-2] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Lane EL, Björklund A, Dunnett SB, Winkler C. Neural grafting in Parkinson's disease unraveling the mechanisms underlying graft-induced dyskinesia. PROGRESS IN BRAIN RESEARCH 2010; 184:295-309. [PMID: 20887881 DOI: 10.1016/s0079-6123(10)84015-4] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The development of neural transplantation as a treatment for Parkinson's disease has been compromised by a lack of functional efficacy and the appearance of transplant-induced motor side-effects in some patients. Since the first reports of these graft-induced dyskinesias (GID), and the realization of their impact on the progress of the field, a great deal of experimental work has been performed to determine the underlying cause(s) of this problematic side-effect. In this review we describe the clinical phenomenon of GID, explore the different representations of GID in rodent models, and examine the various hypotheses that have been postulated to be the cause. Based on the available clinical and preclinical data we outline strategies to avoid GID in future clinical trials using fetal cell transplants or cell preparations derived from stem cells.
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Affiliation(s)
- Emma L Lane
- Welsh School of Pharmacy, Cardiff University, South Wales, UK.
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Cenci MA, Ohlin KE. Rodent models of treatment-induced motor complications in Parkinson's disease. Parkinsonism Relat Disord 2009; 15 Suppl 4:S13-7. [DOI: 10.1016/s1353-8020(09)70828-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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