Intraspinal Transplantation of the Adipose Tissue-Derived Regenerative Cells in Amyotrophic Lateral Sclerosis in Accordance with the Current Experts' Recommendations: Choosing Optimal Monitoring Tools

Abstract

Stem cells (SCs) may constitute a perspective alternative to pharmacological treatment in neurodegenerative diseases. Although the safety of SC transplantation has been widely shown, their clinical efficiency in amyotrophic lateral sclerosis (ALS) is still to be proved. It is not only due to a limited number of studies, small treatment groups, and fast but nonlinear disease progression but also due to lack of objective methods able to show subtle clinical changes. Preliminary guidelines for cell therapy have recently been proposed by a group of ALS experts. They combine clinical, neurophysiological, and functional assessment together with monitoring of the cytokine level. Here, we describe a pilot study on transplantation of autologous adipose-derived regenerative cells (ADRC) into the spinal cord of the patients with ALS and monitoring of the results in accordance with the current recommendations. To show early and/or subtle changes within the muscles of interest, a wide range of clinical and functional tests were used and compared in order to choose the most sensitive and optimal set. Additionally, an analysis of transplanted ADRC was provided to develop standards ensuring the derivation and verification of adequate quality of transplanted cells and to correlate ADRC properties with clinical outcome.

Figures

Figure 1

Patient's assessment paradigm. The diagram presents the applied electrophysiological methods, psychological assessment, and functional tests, along with their assignment to specific functions.

Figure 2

Cytokine and chemokine level in CSF after ADRC application. (a) Membrane-based antibody arrays for the parallel determination of the relative levels of human cytokines and chemokines from CSF of ALS patients (resp. P1, P2, and P3). (b) Comparison of TNFα, IFN-γ, IL-1β, IL-6, bFGF, and MMP-9 level after MSC transplantation ( black graph bars—3 months after ADRC application, grey bars—24 hours after cell application). (c) Quantification of CFU frequency. ADRCs obtained after enzymatic isolation were analyzed to evaluate the stem cell/clonogenic population among a heterogeneous stromal cell population.

Figure 3

The qualification scheme of patients according to the proposal during the International Workshop on Progress in Stem Cells Research for ALS/MND in 2016.

Figure 4

Functional tests. According to Figure 1, functional tests evaluating muscle efficiency in the upper (FAT) and lower limbs (2MWT, TUG, and 5STS) and trunk (TCT) were performed in several time points before, in the course of, and after ADRC therapy. The stability or decrease in these functions was compared with the trajectory of the ALSFRS scale. Impairment in all functional tests was observed faster than decrease in ALSFRS. Although 5STS and TUG showed good correlation with other functional parameters, their longitudinal use was limited in patients who were no longer able to stand up without the help of their arms/hands (on average 6–9 months after the first transplantation; P3 and P4).

Figure 5

Muscle strength and electrophysiological assessment. The detailed clinical evaluation performed within one week of the neurosurgery procedure and repeated every 3 months throughout the project was complemented with ALS-FRS-R, MRC, MUNIX, and HHD evaluation. ALSFRS R and MRC shared a similar deterioration pattern. The slope of decline was much steeper in the case of both MUNIX and muscle strength as examined by HHD. The MUNIX and HHD showed a marked decline even when the values of ALSFRS R and MRC were still stable ( P1, P2, and P3—resp. patient 1, patient 2, and patient 3).

Figure 6

Comparison of the course of the disease before and after the cell therapy. The graphs show the course of disease preceding the use of ADRC (blue graph) and the course of disease during cell therapy.