Stem Cells and Neuroregeneration

Douglas Kerr MD/PhD

Associate Professor, Neurology
Johns Hopkins Hospital
Director, JH Transverse Myelitis Center
 Outline of Talk: 3 Stem Cell
Vignettes

• Using bone marrow stem cells to

reconstitute immune tolerance in patients
with aggressive multiple sclerosis
• ES cell-derived motor neurons as a model
of Spinal Muscular Atrophy
• Glial Progenitors for Demyelinating
Disorders
 HiCy: Immune Ablation without
Transplantation
• A single course of a high dose chemotherapy
agent used to reset the immune system to a
tolerized state
• HiCy eliminates mature and maturing WBC.
• Bone marrow Stem Cells not killed by HiCy.
• Aldehyde dehydrogenase
inactivates Cy.
• Immune System reconstituted from endogenous
stem cells.
“Re-booted” Immune system may be
tolerant of autoantigen.
 HiCy Protocol

• Cy: 50 mg/Kg/day x 4 days.

Hydration, mesna, ondansetron.
Anti-infection prophylaxis.
• Follow daily until hematologic recovery:
Give RBC, platelets, etc. as needed.
• No additional immunomodulatory therapy
• Re-immunize at 1 year.
 Advantages of HiCy

• Unlike HSCT, peripheral blood cells are not

re-infused. Less likely contamination.

• Much lower cost (30K vs. 300 K)

• Lower mortality (< 0.5% vs 5-7%)

 Use of HiCy in aggressive
RRMS

• Phase 1/2 Clinical Trial with patients failing

other therapies
– 2 exacerbations in last year AND
– 2 gad enhancing lesions on each of two baseline
MRIs AND
– Increase in disability (>1.0 EDSS)

– ALL WHILE ON CONVENTIONAL

THERAPY
Hematologic Recovery
after HiCy
EDSS Change After HiCy
Summary Disability Scores

P <0.02
Summary MRI Activity

P < 0.01
 Conclusions:
HiCy Phase I/II

– HiCy is safe and induces rapid and sustained clinical and

radiologic improvement
– Patients with advanced disease continue to have progression
of disability while those with early disease have an
improvement in function
– 42% Reduction in disability at 24 months compared to
baseline in entire cohort
– Phase III Trial Being Considered
• HiCy + glatiramer vs. glatiramer vs. HiCy
• Multi-Center
The ultimate stem cells: self-renew indefinitely and
differentiate into all types of human cells

Fischbach et al, JCI, 114:2004

 Differentiation of ES cells to
Motor Neurons

ES cells/ Fibroblasts (undifferentiated)

ES cells without Fibroblasts Day -1

SHH/RA Day 0

Day +1

Sox2+ Day +2

Islet1/2+ Day +3

Hb9+ Day +4
Wichterle et al, Cell
NeuN+ Day +5 Harper et al. Proc Natl Acad Sci U S A. 2004
May 4;101(18):7123-8.
 C2C12 myoblasts

undifferentiated

Differentiated
Axon outgrowth in vitro
Neuromuscular Junction
Formation In Vitro
 Applications

• Developmental biology of motor unit

formation
• Pathologic motor unit formation
– ALS
– SMA
2) In Vivo Transplantation of ES Cell-
Derived Motor Neurons in Paralyzed
Rats
• ..\stem cells\StemCell.wmv
 Conclusions

• Transplanted motor neurons reach muscle

given the right cues
• they form synapses with muscle
• These connections are electrically active
• Rats recover 40% of hind limb grip strength
 Status: Currently in Large
Mammal Studies with hES Cells

• Ricin injection for focal weakness

– Focal fulminant weakness with α-MN loss
• Non-federally approved hES cell-derived
motor neurons
– Cells produced under FDA-compliant GLP
conditions
Initial Clinical Population: Type
1 SMA

• Universally fatal without life support

• ‘pure’ α-MN loss
• Little myelin
• Developmental cues guiding axonal growth
still present
• Shorter distance
4) Glial Restricted Precursors for
Demyelinating Disorders

Embryonic Somatic Stem Cells

Stem Cells (Fetal or Adult Tissue)

NSC
GRPs
Naturally restricted
NRP GRP fate means high
efficacy and control
with fewer side
APC OPC effects

Neurons Astrocytes Oligodendrocytes

(product growth factors) (produce myelin)
 Results: Robust
Myelination by
Implanted hGRPs-Oligos

1 mm
Ctx
A single injection
resulted in
widespread CC
myelination of the
entire forebrain LV
Striatum

• Shiverer is a mouse with a mutation that

produces defective MBP, resulting in
defective myelin.

• Human GRPs mature into oligos that

produce normal MBP (green) and myelinate
extensive regions of shiverer mouse brain. 100 µm hNA/MBP

• All myelin seen here is produced by human Data from Goldman Lab,
GRPs that matured into oligos (red nuclei). Nature Medicine 2004
Histology of the Inflammatory
Demyelinated Lesion
Focal Demyelination
H and E Myelin Stain
Imaging of TM in a Rat

3 days after injection

in vivo
GFAP 5 days
Blocked Differentiation of GRPs
Post Transplantation

A2B5
GFP
 Myelin Repair
Neural Stem Cell Oligodendrocyte  Premyelinating Myelinating Oligodendrocyte
Progenitor Oligodendrocyte

bFGF/EGF PDGF/bFGF

Shh GROa CNTF/T3

LINGO­1
MS

Astrocyte T­Cell Microglia

MBP Expression after LINGO
Treatment of GRP Cells
Rat 424077

MBP
GFP
Ex Vivo LINGO Enhances GRP
Differentiation In Vivo

MBP
GFP
 Very Late Antigen 4 (VLA-4)
• Involved in the recruitment of immune cells from
the blood to inflammation sites in chronic
inflammatory diseases (an antibody against alpha 4
is used for the treatment of MS – trade name
Tysabri)
 Initial Indication:
Transverse Myelitis
• Single focal lesion in spinal cord
– Acute, monophasic and monofocal lesion
– Pathology of demyelination and axonal loss
– Biomarkers for prognosis (IL-6)
– Easy surgery, small target. ?Vascular delivery?
– Surrogate markers: SSEPs, DTI, MTw
– Straightforward path to determination of clinical
efficacy
• Remyelination and axon survival
• Function recovery
– Benefits of orphan indication while establishing proof
of concept for larger disease targets
• Planned IND in 2009 (Q Therapeutics)