Scientific and ethical concerns in neural fetal tissue transplantation

Fetal striatal grafting slows motor and cognitive decline of Huntington's disease

OBJECTIVE

To assess the clinical effect of caudate-putaminal transplantation of fetal striatal tissue in Huntington's disease (HD).

METHODS

We carried out a follow-up study on 10 HD transplanted patients and 16 HD not-transplanted patients. All patients were evaluated with the Unified HD Rating Scale (UHDRS) whose change in motor, cognitive, behavioural and functional capacity total scores were considered as outcome measures. Grafted patients also received morphological and molecular neuroimaging.

RESULTS

Patients were followed-up from disease onset for a total of 309.3 person-years (minimum 5.3, median 11.2 years, maximum 21.6 years). UHDRS scores have been available since 2004 (median time of 5.7 years since onset, minimum zero, maximum 17.2 years). Median post-transplantation follow-up was 4.3 years, minimum 2.8, maximum 5.1 years. Adjusted post-transplantation motor score deterioration rate was reduced compared to the pretransplantation period, and to that of not-transplanted patients by 0.9 unit/years (95% CI 0.2 to 1.6). Cognitive score deterioration was reduced of 2.7 unit/years (95% CI 0.1 to 5.3). For grafted patients the 2-year post-transplantation [(18)F]fluorodeoxyglucose positron emission tomography (PET) showed striatal/cortical metabolic increase compared to the presurgical evaluation; 4-year post-transplantation PET values were slightly decreased, but remained higher than preoperatively. [(123)I]iodobenzamide single photon emission CT demonstrated an increase in striatal D2-receptor density during postgrafting follow-up.

CONCLUSIONS

Grafted patients experienced a milder clinical course with less pronounced motor/cognitive decline and associated brain metabolism improvement. Life-time follow-up may ultimately clarify whether transplantation permanently modifies the natural course of the disease, allowing longer sojourn time at less severe clinical stage, and improvement of overall survival.

Regenerative therapy for neuronal diseases with transplantation of somatic stem cells

Pluripotent stem cells, which are capable of differentiating in various species of cells, are hoped to be donor cells in transplantation in regenerative medicine. Embryonic stem (ES) cells and induced pluripotent stem cells have the potential to differentiate in approximately all species of cells. However, the proliferating ability of these cells is high and the cancer formation ability is also recognized. In addition, ethical problems exist in using ES cells. Somatic stem cells with the ability to differentiate in various species of cells have been used as donor cells for neuronal diseases, such as amyotrophic lateral sclerosis, spinal cord injury, Alzheimer disease, cerebral infarction and congenital neuronal diseases. Human mesenchymal stem cells derived from bone marrow, adipose tissue, dermal tissue, umbilical cord blood and placenta are usually used for intractable neuronal diseases as somatic stem cells, while neural progenitor/stem cells and retinal progenitor/stem cells are used for a few congenital neuronal diseases and retinal degenerative disease, respectively. However, non-treated somatic stem cells seldom differentiate to neural cells in recipient neural tissue. Therefore, the contribution to neuronal regeneration using non-treated somatic stem cells has been poor and various differential trials, such as the addition of neurotrophic factors, gene transfer, peptide transfer for neuronal differentiation of somatic stem cells, have been performed. Here, the recent progress of regenerative therapies using various somatic stem cells is described.

Increased survival and migration of engrafted mesenchymal bone marrow stem cells in 6-hydroxydopamine-lesioned rodents

Parkinson's disease is characterized by the loss of dopaminergic neurons in the substantia nigra. Attempted replacement of these neurons by stem cells has proved inconclusive. Bone marrow mesenchymal stem cells (MSC) are multipotent, differentiating into a variety of cells, including neuron-like cells. We used the 6-hydroxydopamine (6-OHDA) animal model of Parkinson's disease to assess migration and differentiation of transplanted MSC. We found in rodents that transplanted MSC survive better in the 6-OHDA-induced damaged hemisphere compared to the unlesioned side. Moreover, contralaterally engrafted MSC migrated through the corpus callosum to populate the striatum, thalamic nuclei and substantia nigra of the 6-OHDA-lesioned hemisphere. In conclusion, we demonstrate that 6-OHDA-induced damage increases the viability of transplanted MSC and attracts these cells from the opposite hemisphere.

Radiation and regeneration: behavioral improvement and GDNF expression after Gamma Knife radiosurgery in the 6-OHDA rodent model of hemi-parkinsonism

BACKGROUND

Recent research has demonstrated that the adult mammalian CNS is capable of regeneration. This regeneration is often initiated as a response to thermal, chemical or mechanical injury. The effects of radiation on the mammalian CNS have also been found to aid in certain regeneration processes.

METHOD

In our project we examined the potential therapeutic value of radiation induced regeneration of diseased mammalian rat CNS. Eleven Sprague-Dawley rats with 6-hydroxy-dopamine (6-OHDA) induced hemi-parkinsonism were treated in the Leksell Gamma Knife using a single 4 mm collimator shot targeted to the ipsilateral (parkinsonian) caudate-putamen complex. A maximum dose of 140 Gy was used to create a necrotic lesion. Animals were tested behaviorally using the apomorphine-induced rotational behavior model before and up to 6 months after radiosurgery. Histochemical analysis was performed 2 weeks, 1 month and 4 months after radiosurgery. Histological sections were obtained and immunohistochemistry was performed for glial cell line derived neurotrophic factor (GDNF).

FINDINGS

The rotational behavior for 11/11 animals (100%) was found to initially worsen at 2 weeks and 4 weeks after radiosurgery before a statistically highly significant reduction in apomorphine induced rotations was observed at 2, 3, and 4 months after radiosurgery (83% reduction by month four; p < 0.0001). For 2/11 animals the rotational behavior almost disappeared indicating near-abolition of parkinsonian behavior. On histological examination, the lesions were easily identified as areas of necrosis about 4 mm in diameter. The region immediately adjacent to the lesion was found to have highly positive expression of GDNF indicating high activity in dopamine-regenerating processes.

INTERPRETATION

In this preliminary study we demonstrated that radiosurgical lesioning with the Gamma Knife into the striatum of hemi-parkinsonian animals resulted in significant behavioral improvement of signs of parkinsonism. Since GDNF expression is tightly linked to the dopaminergic system, we conclude that focused radiation is potentially capable of inducing regeneration of dopaminergic pathways in the adult CNS. Further studies with dose deescalation and molecular biological characterization of the regeneration cascades are necessary to gain access to potential clinical value of our observations.

Transplanted neurons alter the course of neurodegenerative disease in Lurcher mutant mice

Embryonic cerebellar, neocortical, and striatal tissues derived from NSE-LacZ transgenic mice were transplanted into the right cerebellar hemisphere of 8- to 10-day-old Lurcher or wild-type mice. Host mice survived for 30-90 days and the transplanted tissue was examined by light microscopy using Nissl staining, X-gal histochemistry, and immunohistochemistry for calcium binding protein and glutamic acid decarboxylase. Transplantation of cerebellar tissue, but not neocortical or striatal progenitors, resulted in robust infiltration of the lurcher mutant host cerebellar cortex by transgenic Purkinje neurons. Deep to the infiltrated molecular layer, the host granular layer was thicker and denser than the mutant granular layer, but transgenic cells did not contribute to the spared granular layer. The host inferior olivary complex consistently exhibited a noticeable bilateral asymmetry in Nissl-stained sections. A quantitative analysis of the olivary complex was performed in 10 90-day-old host mice. The results indicate that the left inferior olivary complex of 90-day-old host mice contained more neurons than the right inferior olive of the host mice and contained more neurons than was observed in 90-day-old Lurcher control mice. Analysis by olivary subdivision indicates that increased neuron numbers were present in all subdivisions of the host left inferior olive. These studies confirm the specific attractive effect of the mutant cerebellar cortex on transplanted Purkinje neuron progenitors and indicate that neural transplants may survive the neurodegenerative period to interact with developing host neural systems. The unilateral rescue of Lurcher inferior olivary neurons in cerebellar transplant hosts indicates that transplanted neurons may interact with diseased host neural circuits to reduce transneuronal degeneration in the course of a neurodegenerative disease.

Engraftment and migration of human bone marrow stromal cells implanted in the brains of albino rats--similarities to astrocyte grafts

Neurotransplantation has been used to explore the development of the central nervous system and for repair of diseased tissue in conditions such as Parkinson's disease. Here, we examine the effects of direct injection into rat brain of human marrow stromal cells (MSCs), a subset of cells from bone marrow that include stem-like precursors for nonhematopoietic tissues. Human MSCs isolated by their adherence to plastic were infused into the corpus striatum. Five to 72 days later, brain sections were examined for the presence of the donor cells. About 20% of the infused cells had engrafted. There was no evidence of an inflammatory response or rejection. The cells had migrated from the injection site along known pathways for migration of neural stem cells to successive layers of the brain. After infusion into the brain, the human MSCs lost their immunoreactivity to antibodies for collagen I. Initially, the human cells continued to stain with antibodies to fibronectin but the region of staining with fibronectin was significantly decreased at 30 and 72 days. The results suggest that MSCs may be useful vehicles for autotransplantation in both cell and gene therapy for a variety of diseases of the central nervous system.

Fetal hippocampal cells grafted to kainate-lesioned CA3 region of adult hippocampus suppress aberrant supragranular sprouting of host mossy fibers

Selective lesion of the rat hippocampus using an intracerebroventricular administration of kainic acid (KA) represents an animal model for studying both lesion recovery and temporal lobe epilepsy. This KA lesion leads initially to loss of CA3 hippocampal neurons, the postsynaptic target of mossy fibers, and later results in aberrant mossy fiber sprouting into the dentate supragranular layer (DSGL). Because of the close association of this aberrant mossy fiber sprouting with an increase in the seizure susceptibility of the dentate gyrus, delayed therapeutic strategies capable of suppressing the sprouting of mossy fibers into the DSGL are of significant importance. We hypothesize that neural grafting can restore the disrupted hippocampal mossy fiber circuitry in this model through the establishment of appropriate mossy fiber projections onto grafted pyramidal neurons and that these appropriate projections will lead to reduced inappropriate sprouting into the DSGL. Large grafts of Embryonic Day 19 hippocampal cells were transplanted into adult hippocampus at 4 days post-KA lesion. Aberrant mossy fiber sprouting was quantified after 3-4 months survival using three different measures of Timm's staining density. Grafts located near the degenerated CA3 cell layer showed dense ingrowth of host mossy fibers compared to grafts elsewhere in the hippocampus. Aberrant mossy fiber sprouting throughout the dentate gyrus was dramatically and specifically reduced in animals with grafts near the degenerated CA3 cell layer compared to "lesion only" animals and those with ectopic grafts away from the CA3 region. These results reveal the capability of appropriately placed fetal hippocampal grafts to restore disrupted hippocampal mossy fiber circuitry by attracting sufficient host mossy fibers to suppress the development of aberrant circuitry in hippocampus. Thus, providing an appropriate postsynaptic target at early postlesion periods significantly facilitates lesion recovery. The graft-induced long-term suppression of aberrant sprouting shown here may provide a new avenue for amelioration of hyperexcitability that occurs following hippocampal lesions.

Development of fetal hippocampal grafts in intact and lesioned hippocampus

Functional recovery observed in Parkinson's disease patients following grafting of fetal substantia nigra has encouraged the development of similar grafting therapy for other neurological disorders. Fetal hippocampal grafting paradigms are of considerable significance because of their potential to treat neurological disorders affecting primarily hippocampus, including temporal lobe epilepsy, cerebral ischemia, stroke, and head injury. Since many recent studies of hippocampal transplants were carried out with an aim of laying the foundation for future clinical applications, an overview of the development of fetal hippocampal transplants, and their capability for inducing functional recovery under different host conditions is timely. In this review, we will summarize recent developments in hippocampal transplants, especially the anatomical and/or functional integration of grafts within the host brain under specific host conditions, including a comparison of intact hippocampus with various types of hippocampal lesions or injury. Improvements in grafting techniques, methods for analysis of graft integration and graft function will be summarized, in addition to critical factors which enhance the survival and integration of grafted cells and alternative sources of donor cells currently being tested or considered for hippocampal transplantation. Viewed collectively, hippocampal grafting studies show that fetal hippocampal tissue/cells survive grafting, establish both afferent and efferent connections with the host brain, and are also capable of ameliorating certain learning and memory deficits in some models. However, the efficacy of intracerebral fetal hippocampal grafts varies considerably in different animal models, depending on several factors: the mode of donor tissue preparation, the method of grafting, the state of host hippocampus at the time of grafting, and the placement of grafts within the hippocampus. Functional improvement in many models appeared to be caused partially by re-establishment of damaged circuitry and partially by a trophic action of grafts. However, exact mechanisms of graft-mediated behavioral recovery remain to be clarified due to the lack of correlative analysis in the same animal between the degree of graft integration and behavioral recovery. Issues of mechanisms of action, degree of restoration of host circuitry and amelioration of host pathological conditions will need to be sorted out clearly prior to clinical use of fetal hippocampal transplants for susceptible neurological conditions.

Adrenal chromaffin cells on microcarriers exhibit enhanced long-term functional effects when implanted into the mammalian brain

Rat adrenal chromaffin cells attached to either collagen-coated dextran (Cytodex 3) or glass bead microcarriers, both of 90-200 microns diameter, were used as dopamine-secreting implants in the caudate-putamen of rats with 6-hydroxydopamine-induced unilateral lesions of the substantia nigra. As controls, beads without cells and cells in suspension alone were implanted. Chromaffin cells adhered to microcarriers reduced apomorphine-induced rotation by 75% in lesioned animals. Animals that were lesioned but not receiving cell implants or receiving beads alone showed no reduction. Animals implanted with cells not attached to beads also showed a reduction in rotation but this effect lasted less than three months. Microcarrier-attached cells, however, maintained their effect in reducing rotation for at least eight months (rotations were reduced from a control mean of 10.9 +/- 1.4 to 3.6 +/- 1.1 turns/min) without any "drop-off" of the effect. Histological examination showed that eight months post-implant the cells pre-adhered to beads were still present and could be stained by anti-tyrosine hydroxylase antibody. Sections stained with hematoxylin-eosin showed no signs of an inflammatory response. In contrast to beads implanted into the striatum, Cytodex bead implants injected into the lateral ventricle induced a histopathological response appearing to involve the ependyma and choroid plexus. Results suggest that the striatal parenchyma but not the ventricle is amenable to studies using the microcarrier approach to transplantation.

Enhanced cell survival in fetal hippocampal suspension transplants grafted to adult rat hippocampus following kainate lesions: a three-dimensional graft reconstruction study

The success of fetal neural transplantation in alleviating neurological dysfunction depends significantly on the degree of graft cellular survival and dispersion within the host. We hypothesize that various lesion-induced host factors, such as trophic support and denervation, enhance these graft factors differentially following unilateral intracerebroventricular kainic acid lesions. We have performed quantitative graft reconstructions of embryonic day 19 fetal hippocampal cells transplanted at different post-lesion delays (four, 11, 26 and 60 days) into adult hippocampus. We have used a permanent graft prelabel (5'-bromodeoxyuridine) which allows unambiguous identification of graft cell location in the host. Cellular integration of grafted cells was rigorously assessed by calculating both absolute cell survival (cells recovered/cells injected) and quantitative cell dispersion from the graft injection site. Graft cell survival and graft volume were dramatically enhanced in transplants performed ipsilateral to the kainic acid lesion, to a maximum of 77% cell recovery at a post-lesion graft delay of four days. Cell survival decreased over time after the lesion to the level of the contralateral grafts by 60 days post-lesion (33% cell survival), though cell survival on either side remained significantly greater than grafts into normal hosts (18% survival). The time-course of post-lesion enhanced survival (four to 26 days) in hippocampus ipsilateral to the lesion strongly correlated with reported peak neurotrophic activity (four to 30 days). Graft cell dispersion was limited in this model, averaging less than 500-microns-cell movement; there were no differences compared to transplants grafted into normal hippocampus. Timm's staining demonstrated host mossy fiber innervation of transplants to be denser ipsilateral to the kainic acid lesion, resulting in a partial decrease in dentate supragranular sprouting near appropriate grafts placed at early post-lesion time points. These results suggest that lesion-induced trophic support and denervation lead to improved graft cell survival but not graft cell dispersion. The improved survival of grafts transplanted into hippocampus contralateral to the lesion, compared to transplants in normal hippocampus, suggests that denervation alone exerts a significant effect on graft cell survival. However, this denervation effect on graft cell survival is significantly less than the combination of both enhanced neurotrophic factors and denervation observed ipsilateral to the lesion.

A novel mode of immunoprotection of neural xenotransplants: masking of donor major histocompatibility complex class I enhances transplant survival in the central nervous system

To determine the role of major histocompatibility complex (MHC) class I in immunological rejection of neural xenotransplants, F(ab')2 fragments of a monoclonal antibody to porcine MHC class I were used to mask this complex on porcine fetal striatal cells transplanted into rat striata previously lesioned with quinolinic acid. Presence of MHC class I on the surface of porcine striatal cells was confirmed by fluorescence-activated cell sorting prior to F(ab')2 treatment. At three to four months post-transplantation, survival of F(ab')2-treated xenografts was assessed by means of donor-specific immunostaining and compared to that of untreated xenografts in non-immunosuppressed rats and in rats immunosuppressed with cyclosporine A. In this study, masking of donor MHC class I by F(ab')2 treatment resulted in enhanced xenografts survival compared to the non-immunosuppressed controls (graft survival rates, 52% and 7%, respectively; P < 0.005) at survival times up to four months. While xenograft survival in F(ab')2-treated animals was not significantly different from that in cyclosporine-treated rats (74% graft survival), mean graft volume in F(ab')2-treated animals was smaller than that in cyclosporine-treated animals (1.07 +/- 0.30 mm3 versus 3.14 +/- 0.51 mm3; P < 0.005). The cytoarchitectonic organization of the xenografts was similar in F(ab')2- and cyclosporine-treated animals, and grafts in both groups exhibited long distance target-directed axonal outgrowth. The pattern of immunoreactivity to porcine MHC class I in the xenografts corresponded to the regional distribution of donor glia. In xenografts undergoing rejection, infiltration with host inflammatory cells was restricted to necrotic graft remnants and spared the nearby host structures. We conclude that MHC class-I-restricted immune mechanisms play an important role in neural xenograft rejection and that masking of this complex on donor cells may provide a useful strategy for immunoprotection of neural xenografts.

Neural xenotransplantation: reconstruction of neuronal circuitry across species barriers

Selective replacement of degenerated neurons in the adult brain with allogeneic fetal neuroblasts is a promising therapeutic modality for human neurodegenerative diseases, but is confounded with practical and potential ethical problems. To evaluate the potential of xenogeneic donors as a cell source for neural transplantation, we have critically examined the available experimental evidence in animal models pertaining to the survival, integration and function of xenogeneic fetal neuroblasts in the host brain. A statistical meta-analysis across multiple studies revealed that immunologically-related transplantation parameters (immunosuppression and donor-host phylogenetic distance) were the main determinants of neural xenograft survival. The immunological basis for xenograft rejection is reviewed in the context of novel immunoprotection strategies designed to enhance xenograft survival. Furthermore, the evidence for behavioral recovery based on anatomical and functional integration of neural xenografts in the host brain is examined with an awareness of developmental considerations. It is concluded that neural xenotransplantation offers a unique opportunity for effective neuronal replacement with significant potential for clinical use.

Enhanced in vitro survival and growth of foetal human mesencephalic dopaminergic neurones on laminin and collagen: implications for cell banking

Culture of second trimester mesencephalic cells on laminin and collagen substrata has been investigated in an attempt to ascertain the effects of these extracellular matrix components on survival and growth of central dopaminergic (DA) neurones. There were 156.8-186.4% more cells attached to laminin and collagen than poly-D-lysine 6 h post-plating. By 24 h there was statistically no significant difference in the total number of cells attached to the three substrate but in terms of cell type-specific survival the proportion of mesencephalic DA neurones surviving on laminin and collagen substrata after 7 days in culture increased significantly compared with poly-D-lysine (1.4-1.6% versus 0.4% of the total cellular population), an effect augmented by bFGF treatment, which led to levels of 2% or more, with a concomitant decrease in the proportion of attritic DA neurones. These results indicate a critical requirement for ECM proteins in the survival and growth of in vitro-propagated central DA neurones at the time of plating and throughout the culture period. They also imply survival-enhancing interactions of ECM proteins and neurotrophic factors in developmental neuronal regulation and provide paradigms for obtaining high yields of these cells for neural transplantation cell banks.