META-ANALYSIS OF STEM CELL TRANSPLANTATIONS IN

NEURODEGENERATIVE DISEASES

A dissertation Report for partial fulfillment of the

degree of

MASTERS OF SCIENCE

IN

MEDICAL BIOTECHNOLOGY

Submitted by:-
Under supervision of :-

ANJALI
DR. RASHMI BHARDWAJ

ROLL NO.-1723
Assistant professor (CMBT)

MDU,ROHTAK

1
 MAHARASHI DAYANAND UNIVERSITY
ROHTAK-124001,HARYANA(INDIA)

CERTIFICATE
This is to certify that the dissertation entitled “meta-analysis of stem cell transplantations in

neurodegenerative diseases “being submitted by Ms. Anjali Gaur to Maharashi Dayanand

University , Rohtak in partial fulfillment of the requirement of degree of Masters of science in

Medical Biotechnology. The matter embodied in this dissertation has not been submitted

elsewhere in part or full award of any other degree or diploma. The assistance and help received

during course of this investigation have been duly acknowledged.

Supervisor

Dr.Rashmi Bhardwaj Prof .Pushpa Dahiya

Assistant Professor Director

Centre for Medical Biotechnology Centre for Medical

Biotechnology

MDU,Rohtak MDU,Rohtak

DECLARATION

2
I, Anjali Gaur ,declare that the dissertation with the title “Meta analysis of stem cell

transplantation in neurodegenerative diseases” is my bonafide research work carried under

the guidance and supervision of Dr. Rashmi Bhardwaj , Assistant Professor , Centre for

Medical Biotechnology, MDU, Rohtak as supervisor for the partial fulfillment of the degree of

Masters of Science in Medical Biotechnology,Rohtak,Haryana,India.

Date:-
Anjali Gaur

3
ACKNOWLEDGEMENT

First and Foremost ,I want to express my deepest gratitude to my mentor Dr. Rashmi

Bhardwaj,Assistant Professor, Centre for Medical Biotechnology, Maharashi Dayanand

University , Rohtak for her perpetual energy and enthusiasm in research which uplifted my

momentum. With her expertise the transition in to research world was made easy and she helped

me overcome any obstacles encountered while my dissertation period. She has been always

available and willing to assist at all times by all possible means of communication sources and

has been a meticulous trainer for guiding me from basics of Stem cell transplantation.

I am grateful to Prof .Pushpa Dahiya, Director ,Centre for Medical Biotechnology ,MDU

Rohtak for providing Laboratory Facilities and Co-operation during work.

I am also thankful to the research scholars Ms.Pooja and Ms. Ravina for their constant support

and motivation to complete my work.

Last but not the least, a sincere thank to Almighty for providing me with the knowledge and

strength to face the jouney called Life and its different phases.

Date :-____________
___________________

Anjali Gaur

4
CONTENT

Page No.
Certificate 2
Candidate’s declaration 3
Acknowledgement 4
Abbreviation 6
Abstract 7
Introduction 8
Objective and Review of literature 9
Types of SCs used in study 16
SCs transplantation 18
Material and Methods 23
Result 24
Funnel plot 26
Discussion 27
Referance 28

ABBREVIATIONS
 ND- Neurodenerative diseases
 PD- Parkinson’s disease
 AD- Alzheimer’s disease
 HD- Huntington’s disease

5
  MS –Multiple sclerosis
 SC- Stem cells
 ESCs- Embryonic stem cells
 MSCs – Mesenchymal stem cells
 iPSCs- Induced pluripotent stem cells
 NSCs – Neural stem cells
 BM-MSCs- Bone marrow derived mesenchymal stem cells

ABSTRACT
Background :- Stem cell transplantation has been considered a possible therapeutic method for

neurodegenerative diseases which is characterized by progressive memory loss and gradual

impairment of cognitive function. We conducted systematic review and metaanalysis to study the

effect of stem cells on neurodegenerative diseases.

6
Methods :- We searched PubMed(http://www.ncbi.nlm.nih.gov/pubmed), SciHub, Cochrane

library (http://www.cochranelibrary.com). we used ‘stem cell’, ‘alzheimer’, ‘huntington’,

‘parkinson’, ‘multiple sclerosis’ as English search terms.

Result :- Among the 261 studies reviewed , 223 potentially relevant papers were screened. Of

these , 38 met inclusion criteria for meta-ananlysis and rest were excluded.

Statistical Analysis Result –Average mean value of the obtained data is 0.06. On the basis of the

average mean value standard deviationwas calculated i.e; 3.79.The chi-square test value is 5.15

and 95%CI value of the study included is 0.6 ±1.

Conclusion :- This study showed that stem cell transplantation could reduce cognitive deficits in

diseased animal .

INTRODUCTION
Neurodegeneration (ND) becomes a major public healthproblem worldwide. It is a progressive

loss of function and structure of neurons, including death of neuron (Greenamyre et al ;2011).

It is a major risk factor for development of diseases like Multiple sclerosis disease, Alzheimer’s

disease, parkinson’sdisease andHuntington's disease(Asif et al;2016).These disorders are

7
characterized by multifactor and have common neuropathologicalfeatures in common like (a)

degradation and aggregation of abnormal protein ,(b)neuroinflamatory processes,(c) oxidative

stress and free radical formation ,(d) mitochondrial dysfunctions(Beal et al ;2006).Regarding the

treatment of Neurodegenerative disease various therapies have been evaluated including the use

of Dimebon drug(Thompson et al ;2009), administration of Hypothalamic Proline rich –Peptide

(PRP-1) which offer neuroprotective effects (Galoyan et al ;2008)) . These promising therapies

are less curable as they neither pharmacologically nor neurosurgicallyefficient in arresting the

progression of disease.

Stem cell (SC) treatment has emerged as a breakthrough in past few decades due to their

immunomodulatory property and intrinsic regenerative capacity.Stem cell treatment enables

regeneration of neural tissue which ameliorates neural degeneration at different levels

(Naveilhan et al ;2012).Most recent advancement in Stem cell transplantation involve

ESCs(embryonic stem cells) ,MSCs (mesenchymal stem cells) , BMSCs (bone marrow derived

stem cells ), iPSCs (induced pluripotent stem cells), NSCs ( neural stem cells) as regenerative

medicine (Mahla et al ;2016).

Meta-analysis is a quantitative, formal, epidemiological study design used to systematically

assess previous research studies to derive conclusions about that body of research( Haidich et

al;2010)).

OBJECTIVE
Metaanalysis of stem cell transplantation in Neurodegenerative diseases to observe the

therapeutic efficiency of stem cells to cure neurodegenerative diseases.

REVIEW OF LITERATURE
8
Over past 20 years, Stem cell technology has become an increasingly attractive option for the

treatment of neurodegenerative disease(Feldman et al; 2011) .Neurodegenerattive disease which

is characterized by the loss of neurons in brain or spinal cord(Van Der Valk et al ;2010) is

divided in to two phases – Acute neurodegenerative disease is caused due to stroke or trauma

which result in neurons loss at the site of injury and Chronic neurodegenerative disease results

in decrease of particular neuronal subtype (Lun et al;2011).

 MAJOR NEURODEGENERATIVE DISEASES

1. PARKINSON DISEASE (PD)– It is one of the common neurodegenerative disease

which is caused by progressive loss of Dopaminergic neurons in the region of

substantianigra pars compacta (SNpc), which projects to striatum and results in decrease

of dopaminergic neurons( L Qian; et al 2013).Subsequent decrease of dopamine results

in Gamma amino butyric acid (GABA) dysfunction which leads to inhibition of

thalamus and increase cholinergic activity(Philip et al;2015).Environmental and genetic

factors initiate signaling cascades which results in dopaminergic neurons degeneration.

50-70% of dopaminergic neurons gets affected in PD patients(Jamebozorgi et al

;2018).Mutation in PARK8 gene encoding LRRK2 kinase is the most common genetic

cause of PD.

PATHOPHYSIOLOGY:- In PD,pathophysiology ischaracterised withoxidative stress,

mitochondrial dysfunction ,activation of apoptotic pathway.Lewy bodies is one of the

histopathological feature of PD which are formed due to aggregation of proteins, lipids and other

materials (watsubo et al ;1998).

9
SYMPTOMS:- Symptom of parkinson disease include bradykinesia ( slow movement )

(Hallett et al ;2001) , tremor(shaking) , rapid eye movement, dementia (Goldman et al ;2007),

cogwheel rigidity, sleep disorder, impaired posture, change in speech and writing etc.

DIAGNOSIS :- Diagnosis of parkinson disease include dopaminergic challenge test with

levodopa or apomorphine , neuropsychiatric test , sleep studies (Jankovic et al ;2008).

CURRENT TREATMENT:-Carbidopa-levodopa, dopamine agonist,

anticholinergics,amantadine,NAB2 ( NAD4 ubiquitin ligase activator) is identified as potential

antu –PD agent which can reverse pathological PD phenotype (Aguilar et al ;2008). Till now, 9

gene and 13 gene loci have been identified for PD(Brice et al ;2009).Approximately ,37 natural

products have been identified which have anti – parkisonian effects such as flavanoid ,saponin

compound, alkaloid compound (Shi, J et al ;2017) . Novel therapy like cell transplantation, gene

therapy CRISP/Cas 9 are able to correct the mutated gene for PD (Jamebozorgi et al ;2018).

2. ALZHEIMER DISEASE (AD) – It is also known as mild cognitive impairment (MCI)

which is characterized by dementia that begins with poorand subtle failure of memory(Bird et al

;2015), which is further followed by executive dysfunction, confusion and behavioural

disturbances . It is age-related neurodegenerative disease (Wang et al;1999). AD can be divided

in to following types – familial , sporadic , early onset onset , as well as late onset .

Three causative genes associated with autosome dominant familial AD are APP on

chromosome21, PSEN 1 (presenilin 1) located on chromosome 14 , PSEN 2(presenilin 2)

located on chromosome 1 and one genetic risk factor APOE e4 gene located on chromosome

19 (Murri et al ;2003).

10
STAGES :-

 Early stages of AD :- People suffering from AD at early stages shows symptoms like

Forgetfulness , confusion , language problem , difficulty in executing something (Kurz

et al ;1999).

 Moderate stages of AD :- At moderate stages AD patients showNeuropsychiatric changes

, aggression ,delusion , anosognosia .

 Advanced stages of AD :-At advanced stage Patient is completely dependent on

caregivers , more abusive and anxious (Frank et l;1994).

PATHOPHYSIOLOGY:- In AD , pathophysiology is characterized by neurofibrillary

tanglesand neuritic plaques accumulation , protein misfolding due to accumulation of

plaques(Hyman et al;2011) Enlaged axonal endings surround extracellular beta amyloid peptide

which make core of spherical lesions known as plaques(Kumarsingh et al ;2007) .

Neurofibrillary tangles are intracytoplasmic structures with in neurons which are formed by a

protein called tau (stabilize axonal microtubules) (Kumar, Anil et al; 2015).

SYMPTOMS :-Neuropsychiatric symptoms like apathy, social withdrawal, disinhibition,

agitation, psychosis (Sweet et al ; 2005) and wandering are common in mid to late stages.

Difficulty in performing motor tasks (dyspraxia), olfactory dysfunction (Doty et al;1998), sleep

disturbances, extrapyramidal motor signs like dystonia, akathisia. This is followed by primitive

reflexes, incontinence, and total dependence onthe caregivers

CURRENT TREATMENT:-There is no cure for AD, Only symptomatic treatment are available :-

Two categories of drugs are approved for the treatement of AD:-Acetyl cholinesterase inhibitors

11
,Galantamine, Revastigmine and partial N-methyl D-aspartate (NMDA) antagonists(Hazlewood et

al;2011).

DIAGNOSIS:-(i) general medical history, neuropsychiatric history,neurological history,

familyhistory, (ii) physical examination, (iii) routine laboratory examinations (iv) neuroimaging

(CT,MRI) (Armand et al;2011).

3. HUNTINGTON DISEASE(HD) –HD is aninherited neurological disorder of the central

nervous systemwhich is currently incurable. It characterized by unwanted choreatic movements,

dementia,psychiatric disturbances and behavioural changes(Roos et al;2010). HD is caused by

the CAG trinucleotide repeat’s expansion within exon 1 of the Huntingtin (HTT) gene, that

produce of a toxic mutant protein which further kills striatal medium neurons (MSN) (Maroof

et al).HD presents in two mainforms :- the most common is adult or late onset HD and juvenile

or early-onset HD (JHD) which is less common form(Nopoulos et al ;2016).

PATHOPHYSIOLOGY :-In HD, pathophysiology is characterised by the loss of striatal

medium sized spiny neurons .When the disease progress, neurons in the cerebral cortex,

hippocampus, hypothalamus, and thalamus are also lost (Levine et al ;2011). HD mainly affects

neurons in striatum and cortex, recentlyfew studies have reported that parvalbumin interneurons

are also vulnerable to the disease and getseventually degenerate

SYMPTOMS:-The symptoms of HD consist of motor, psychiatricand cognitive disturbances

(Walker et al;2007) .Motor changes involvesinvoluntary, unwanted movements. Psychiatric

symptoms are seen in the early stage of the disease,Anxiety and Obsessions also occurs

frequently and all lead to irritability and aggression(Van der Mast et al;2007) , loss of interest

12
and increasing passive behavior are seen as part of syndrome, Psychosis appears mainly in the

later stages of the disease. Decline in cognitive behaviour is the main sign of HD(Price et

al;2012) , Patients suffering from HD are no longer able to organize or plan things , They lose

flexibility of mind, Language gets relatively spared, Memory certainly becomes impaired, All

psychomotor processes become retarded ,sleep disturbances are also seen (Montplaisir et al

;2008)

Secondary symptoms and signs :-weight loss , decreased appetite, difficulty in food

swallowing ( walkeret al;2007) ,hypothalamic neuronal loss is also one of a causative factor ,

circadian rhythm disturbances are also observed in patients with HD .

TREATMENT:-Pharmacological therapy include typical neuroleptics (haloperidol),valproic

acid for myoclonic hyperkinesia,benzodiazepines, Tetrabenzine for the treatment of chorea(,

Mirtazapine is recommended for the treatment of depression (Kapfhammer et al ; 2004).

DIAGNOSIS:-Diagnosis of an individual is based on clinical symptoms . Physical examination

along with psychological examination can be performed to determine whether the onset of

disease has begun(MarderKS et al ;2009 ). Pre-manifest diagnosis of the patient should only be

performed by multidisciplinary teams to find out whether they carry mutation or not. chorionic

villus sampling or amniocentesiscan be used for prenatal diagnosis ( Verlinsky et

al;2005).Genetic test are also available (Raymund et al ;2010).Differential diagnosis is also be

performed.

4. MULTIPLE SCLEROSIS(MS):-MS is a chronic, degenerative disease that means “many

scars,” which refers to the accumulation of the lesions in the spinal cord and brain throughout the

13
disease. These lesions are made up of dead nerve cells, whose axons gets deprived of the myelin

sheaths which protects them and permit nerve impulse conduction (J.E. et al ;2001).

Types of MS :- These are considered important for prognosis as well as treatment and include:

1. Relapsing–remitting MS: It is the most common form. It is marked by flare-ups followed

by periods of remission(Prineas et al;2004).

2. Secondary progressive MS: Patients are treated with disease-modifying agents to delay

progression. Disease progression continues to get worse with or without periods of

remission (Aloisi et al ;2004).

3. Primary progressive MS :There are no relapses or remissions. This form of MS is

resistant to the drugs which are used in the treatement of disease

4. Progressive-relapsing MS : This form of MS is rare. It is progressive from the starting

with intermittent flare-ups of worsening symptoms during course of disease .

SYMPTOMS :-Neurological symptoms of MS include sensory, autonomic, motor, visual

problems (Coles et al;2008).The specific symptoms include loss of sensitivity or change in

sensation, muscle weakness, numbness, blurred vision, reflexes, muscle spasms, difficulties

with coordination , problems with speech (Svensson et al;1994), visual problems , tiredness,

pain, and bowel and bladder difficulties.Difficulty in thinking , emotional problems such

as depression is common.

PATHOPHYSIOLOGY:- The main pathophysiological characteristics of MS are the formation

of lesions also known as plaques in CNS ,inflammation in the grey and white matter of CNS,

and the destruction of myelin sheaths of neurons (Coles et al;2002).

14
DIAGNOSIS :-The diagnosis of MS is based on the demonstration of neurologic symptoms . To

differentiate MS from disorders with similar neurologic manifestations, different criteria such as

McDonald criteria(Sandberg et al ;2005) have been proposed. This criteria demonstrates the

lesions disseminated in space and time to exclude alternative diagnoses. Laboratory test such as

magnetic resonance imaging of brain and spinal cord, CSF analysis, and functional assays of the

nervous system are performed to detect MS ( Keir et al ;1994).

TREATMENT :-currently available drugs such as Interferon-β-1a (Avonex) (Johnson

etal;1987)variants and Glatiramer acetateare used as first-line therapies for the treatement of

relapsing-remitting form of MS .These drugs efficiently delay progression of neurological

diasability and reduce relapse rate.

Dimethyl fumarate (Tecfidera), used to treat psoriasis. Another compound that can be considered

beneficial for MS is Simvastatin( Hohlfeld et al ;2001)

STEM CELLS

15
These are the precursor cells having capacity to self renew( ability to undergo numerous cycle of

cell division while maintaining undifferentiated state)and potency (to give rise to different

lineages) (Tuch et al;2006).

Self renewal :- Two mechanism that ensure maintainence of stem cell population:-

1. Asymmetric differentiation : a stem cell divides into mother cell and daughter cell. Mother

cell is identical to original stem cell whereas daughter cell is in differentiated form ( Kimble et

al ;2006)

2. Symmetric differentiation: when a stem cell develops into two differentiated daughter cells,

Potency:-It is the potential of .stem cells to differentiate .Different types of potency:-

 Totipotent stem cells – They can differentiate into embryonic and extra-embryonic cell

types. Eg; hematopoietic stem cells ( Wolf et al;2009).

 Pluripotent stem cells - They are the descendants of totipotent cells that can differentiate

into all cells. Eg; Embryonic stem cells (Hu WS et al;2005).

 Multipotent stem cells – They can differentiate into a number of cell types. Eg;

Mesenchymal stem cells.

 Oligopotent stem cells – They can differentiate into few cell types.Eg; lymphoid stem

cells

 Unipotent stem cells – They can produce only one cell type .Eg; skin cells

TYPES OF STEM CELLS

16
(1) EMBRYONIC STEM CELLS:-

These are derived from the inner cell mass of a blastocyst which forms 4-5 daysafter

fertilization(Edward et al;2001).

Characteristics : –

 They are Pluripotent.

 They are capable of differentiating into different types of cells derived from germ

layers.

 surface markers :- CD9 and CD24 , alkaline phosphatase and other genes including oct -

4,sox-2,Nanog etc.(Bishop et al;2004).

(2) INDUCED PLURIPOTENT STEM CELLS :

Direct reprogramming of adult cells is done to form pluripotent stem cells by dedifferentiating

them in vitro.They are derived by introducing reprograming factors such as

Sox2,cMyc,klf4,Oct4 (Hochedlinger et al;2008).

Characteristics :-

 iPSCs are mitotically active, actively self-renewing and proliferating,.

 surface markers:- Human iPSCs expressed markers includeNanog, SSEA-3, SSEA-4,

TRA-1-60, TRA-1-81, TRA-2-49/6E( Nardi et al;2011).

 They are capable of neural differentiation,cardiac differentiation, teratoma formation.

(3)MESENCHYMAL STEM CELLS:-

17
These are multipotent stromal cells that can differentiate into a different cell types

includingmyocytes, osteoblasts, adipocytes ,chondrocytes(Karp et al;2014).

Characterisitics

 MSCs have capacity for self-renewal while maintaining their multipotency.

 They have an effect on innate and specific immune cells. MSCs can produce

antimicrobial peptides (AMPs) (Lingyun et al ; 2012).

 Surface markers :-CD73, CD90 and CD105 andexpresses adhesion molecules VCAM-1

and ICAM-1.

(4) NEURAL STEM CELLS :-

These are multipotent cells with self renewing capacity that generate radial glial progenitor

cells thatduring embryonic development further generate glia and neurons of the nervous

system of all animals (Hippenmeyer et al;2017).

Characteristics :-

 They are multipotent stem cells .

 Their proliferation decline during aging (Gage et al;1996).

 Surface Markers :- NSC subsets express markers such as nestinEGFR ,CD15, Sox2,

Musashi, CD133, GFAP ,Pax6, FABP7 .

STEM CELL TRANSPLANTATION

18
 Cure of a disease is the main purpose for SC therapy ,thus, this can be attained using different
cellular lineages including mesenchymal stem cells,neural stem cells, embryonic stem cells

STUDY TRIAL ON STEM CELL TRANSPLANTATION INPARKINSON

DISEASE

TYPE OF SCs MODEL INTERVENTION FOLLOWUP RESULT REFERANCE

PERIOD
HUMAN RAT INTRASTRIATAL 6 TO 18 WEEKS Restores motor Zhang et al;2018
EXFOLIATED TRANSPLANTATION deficits
DECIDUOUS
TEETH SCs

ADIPOSE MOUSE STRIATAL 22 DAYS Increase Chi, Kang, et

DERIVED SCs TRANSPLANTATION neurogenesis al;2018

MESENCHYMAL C57BL/6 TRANSPLANTED 4 MONTHS Higher level of

Tate, et al;2017
STROMAL SCs straital dopamine
UNILATERALLY IN
STRIATUM

MSCs RAT INTRANIGRAL 4 TO 8 WEEKS POSITIVE Chen et al;2017

TRANSPLANTATION

Table1. Trials of stem cell transplantation inPD (1)Intra striatal transplantation of SCfrom human

exfoliated deciduous teeth in rat model restores motor deficits.(2) Adiposederived stem cells

stimulated with n –butylidenephthalide showed therapeutic effect in mouse model of

PD.(3)Mesenchymal stromal SB623 cell implantation in striatum showed recovery in mouse

model.(4)Therapeutic effect of intranigral transplantation of MSC in rat model.

STUDY TRIALS ON STEM CELL TRANSPLANTATION IN ALZHEIMER DISEASE

19
TYPES OF MODEL INTERVENTION FOLLOW UP RESULT REFERANCE
SCs PERIOD
NSCs RAT STEREOTOXIC - Improved Hoveizi et al;2018
SURGERY memory

MSC APP/PS1 MICE INTRA CEREBRO 2 MONTH Reduction in Wang et al;2018

VENTRICLE plaque
accumulation

Huc MSC Ig2576 INTRAVENOUS — Reduced beta Harach et al;2017

amyloid
pathology

NSC APP/PS1 INTRACRANIAL 6 WEEKS Reduced beta MC Ginley et al;2017

MURINE MODEL amyloid
pathology

Table 2. Trials of stem cell transplantation inAD,(1) Transplantation of neural like cells in AD

Rat model improve memory,(2) MSC derived extracellular vesicles exhibits therapeutic effect in

AD Rat model, (3), Administration of human adult ischemia tolerant MSC in transgenic

APP/PS1AD mouse reduces beta amyloid pathology, (4)Human NSC transplantation in corpus

callosum of APP/PS1 AD mouse,

STUDY TRIAL OF STEM CELL TRANSPLANTATION IN HUNTINGTON DISEASE

20
TYPES OF SCs MODEL INTERVENTION FOLLOW UP RESULT REFERENC
PERIOD E
HUMAN RAT BILATERAL 1 MONTH Ameliorates Ebrahimi et
UMBLICAL STRIATAL motor al;2018
CORD DERIVED TRANSPLANTATI function
SCs ON

Ipscs DERIVED YAC 128 MOUSE INTRASTRIATAL 10 WEEKS Reduced Al-

NEURAL STEM MODEL TRANSPLANTATI behavioural Gharaibeh,
CELLS ON deficits Abeer et
al;2017

Ipsc RAT MODEL LATERAL 8 WEEK Neurotoxic

Mu, S et al
VENTRICLE effects can
be seen
2014

MSC RAT MODEL XENO- - POSITIVE Hosseini

TRANSPLANTATI et al;2015
ON

Table 3.Trials of stem cell transplantation in HD ,(1) Human umbilical cord matrix stem cell

transplantation in Rat model ameliorates motor function, (2) Ipsc derived neural stem cell

transplantation in YAC128 mouse model reduced behavioral deficits and ameliorated

neuropathology, (3) Protein regulation of Ipsc by transplantation in HD Rat model,(4)

xenotransplantation of human adipose derived MSC in rodent modelof HD.

STUDY TRIAL OF STEM CELL TRANSPLANTATION IN MULTIPLE SCLEROSIS

DISEASE

21
TYPES OF SCs MODEL INTERVENTION FOLLOW RESULT REFERANCE
UP PERIOD
BM-MSC MALE INTRAPERITONEAL 6 WEEKS Recovery from Marzban et
MOUSE demyelination al;2017

ADIPOSE DERIVED RAT - 1 MONTH Urinary infection Fernández et

MSC was seen al;2018

MSC SJL/J INTRAVENOUS — Reduced brain Laso-García et

MICE atrophy al ;2018

Table 4.Study trial of stem cell transplantation in MS ,(1) Effect of multiple intraperitoneal

injections of human BM MSC on cuprizonemodelof MS, (2) Adipose derived MSCs for

treatment of secondary progressive MS, (3) Therapeutic potential of extracellular vesicles

derived from human MSCs in MS.

MATERIAL AND METHODS

22
  Types of stem cells required

Umblical cord matrix stem cells,neural stem cells,induced pluripotent stem cells,neural

stem cells,embryonic stem cells,dental pulp stem cells.

 Search Stratergy

We searched PubMed(http://www.ncbi.nlm.nih.gov/pubmed), SciHub, Cochrane library

(http://www.cochranelibrary.com). we used ‘stem cell’, ‘alzheimer’, ‘huntington’,

‘parkinson’, ‘multiple sclerosis’ as English search terms.

 Inclusion criterion

(1) Research Type: randomized control trials(RCT), cohort study,clinical trials.

(2) Study Object: animals diagnosed with neurodegenerative disease ,no special

requirement of age and sex.

 Exclusion criterion

We excluded studies with incomplete reporting of data or studies that did not generated

proper inferences.

 Statistical Analysis

Meta-analysis was performed using QI Macros software. Average mean was calculated to

combine the effect of study. Chi square test was applied to observe significant difference

between observed and expected data. 95% CI was calculated to check uncertainity

RESULTS

23
  Literature search and study selection – The literature search and screening of titles and

literature were performed which yielded 261 studies .On the basis of inclusion and

exclusion criteria 223 were excluded. A flowchart illustrating the selection process :-

261 studies were searched and

screened through titles and
abstracts.

Excluded articles
areirrelevant,duplicat
223 studies were excluded on
es,incomplete data
the basis of exclusion criteria.

38 studies were
included for meta
analysis.

 Among the 261 studies reviewed , 223 potentially relevant papers were screened. Of these

, 38 met inclusion criteria for meta-ananlysis and rest were excluded.

 Statistical Analysis Result –Average mean value of the obtained data is 0.06.On the basis

of the average mean value standard deviationwas calculated i.e; 3.79.The chi-square test

value is 5.15 and 95%CI value of the study included is 0.6 ±1.

Table 5 - RESULT OF META –ANALYSIS

24
STUDY SEX MODEL TYPE OF SCs n D DISEASE

Jack C., et al. Male Mice NSC 8 55 HD

Abeer, et al. Male YAC128 mice Ipsc 7 28 HD

Maroof M., et al. transgenic R6/2 mice Hpsc 12 39 HD

Julien, et al transgenic R6/2 mice BM-MSC 10 29 HD

Dalous ,et al transgenic R6/2 mice UC-MSC 12 46 HD

Shi YU .et al female Rat BM-MSC 32 48 AD

XinXin ,et al - Mice huc-MSC 30 75 AD

Allal ,et al transgenic Mouse huc-MSC 5 10 AD

Marriottini ,et al - - HSC 11 52 MS

Mohsen , et al Male Mouse BM-MSC 10 40 MS

Y Qian, et al Male Rat NSC 6 30 PD

Barbara,et al Male Rat hNPC 5 19 PD

Table5:- NSC – Neural stem cell, Ipsc – Induced pluripotent stem cell ,BM-MSC – Bone

marrow derived mesenchymal stem cell , Huc-MSC – Human umbilical coord derived

mesenchymal stem cell, HSC- Hematopoeitic stem cell, Hnpc – Human neural progenitor stem

cells , HD – Huntington’s disease , AD- Alzheimer’s disease , MS – Multiple sclerosis , PD –

Parkinson’s disease , n – Number of patients who received stem cell treatment , d- Total number

of patients under care of physician.

25
 Funnel Plot For The Assessment Of Publication Bias Of The Effect Of Stem

Cell Transplantation In Neurodegenerative Disease Using QI Macros

Software

QI Macros software for excel is affordable ,easy to use software that draws pareto charts , histogram
,funnel plots and perform statistical analysis including t- test, regression analysis , ANOVA.

Funnel plot is a scatter plot of treatement effect against a measure of study precision .It is used to detect
publication bias. Due to asymmetry in the scatter of studies it is concluded that there is a possible
publication bias
26
DISCUSSION
Systematic review and meta- analysis of animal studies provide evidence on the basis of which it is

decided whether to perform clinical trials or not . Our study is based on systematic review and

metalanalysis to see the efficacy of stem cell transplantation in neurodegenerative diseases. Several

studies have assessed stem cells as therapeutic agents to reverse pathological changes or induce

neurogenesis in diseased animal model.

Overall study suggested that stem cells have neuroprotective effects in improving the symptoms of

neurodegenerative diseases. Although our study demonstrates that stem cells could improve cognitive

functions but the underlying mechanism remains is unclear.

Futhermore , potential publication bias is likely to exist in our study inferred on the basis of funnel plot

generated using QI Macros software, Our study does not take unpublished data in to account so, our

study might overestimate overall effect size .

Apart from this there exist some limitations in the studies conducted by different scientists like number of

implanted SCs, the site of transplantation , the host’s immune system after transplantation

,carcinogenicity , ethical issues , time and cost extensive method are all issues which needs to be

addressed by future studies.

Our study present systematic review with meta-analysis which indicates that transplanation of stem cells

improves cognitive functions in animal model . These result suggest that stem cell based strategies may

become alternative treatement for neurodegenerative diseases . Although trials for stem cell therapy have

been primarily performed in small animals, in order to , assess efficacy and safety of stem cells more

studies in preclinical animal models and human studies , randomised controlled design are needed.

27
REFERANCE

Cannon, J. R., &Greenamyre, J. T. (2011).The role of environmental exposures in

neurodegeneration and neurodegenerative diseases. Toxicological Sciences, 124(2), 225-250.

Khanam, H., Ali, A., & Asif, M. (2016). Neurodegenerative diseases linked to misfolded
proteins and their therapeutic approaches: A review. European journal of medicinal
chemistry, 124, 1121-1141.

Marsh, J. L., Lukacsovich, T., & Thompson, L. M. (2009).Animal models of polyglutamine

diseases and therapeutic approaches. Journal of Biological Chemistry, 284(12), 7431-7435.

Galoyan, A. A., Sarkissian, J. S., Chavushyan, V. A., Meliksetyan, I. B., Avagyan, Z. E.,
Poghosyan, M. V., ... &Abrahamyan, D. O. (2008). Neuroprotection by hypothalamic peptide
proline-rich peptide-1 in Aβ25–35 model of Alzheimer's disease. Alzheimer's & Dementia, 4(5),
332-344.

Bonnamain, V., Neveu, I., &Naveilhan, P. (2012). Neural stem/progenitor cells as promising
candidates for regenerative therapy of the central nervous system. Frontiers in Cellular
Neuroscience, 6, 17.

Mahla, R. S. (2016). Stem cells applications in regenerative medicine and disease

therapeutics. International journal of cell biology, 2016.

Haidich, A. B. (2010). Meta-analysis in medical research. Hippokratia, 14(Suppl 1), 29.

Lunn, J. S., Sakowski, S. A., Hur, J., & Feldman, E. L. (2011). Stem cell technology for
neurodegenerative diseases. Annals of neurology, 70(3), 353-36.

Amor, S., Puentes, F., Baker, D., & Van Der Valk, P. (2010).Inflammation in neurodegenerative
diseases. Immunology, 129(2), 154-169.

Lunn, J. S., Sakowski, S. A., Hur, J., & Feldman, E. L. (2011). Stem cell technology for
neurodegenerative diseases. Annals of neurology, 70(3), 353-361.

28
Qian, L., Flood, P. M., & Hong, J. S. (2010).Neuroinflammation is a key player in Parkinson’s
disease and a prime target for therapy. Journal of neural transmission, 117(8), 971-979.

DeMaagd, G., & Philip, A. (2015). Parkinson’s disease and its management: part 1: disease
entity, risk factors, pathophysiology, clinical presentation, and diagnosis. Pharmacy and
therapeutics, 40(8), 504.

Jamebozorgi, K., Taghizadeh, E., Rostami, D., Pormasoumi, H., Barreto, G. E., Hayat, S. M. G.,
&Sahebkar, A. (2018). Cellular and molecular aspects of Parkinson treatment: Future therapeutic
perspectives. Molecular neurobiology, 1-13.

Baba, M., Nakajo, S., Tu, P. H., Tomita, T., Nakaya, K., Lee, V. M., ...&Iwatsubo, T. (1998).
Aggregation of alpha-synuclein in Lewy bodies of sporadic Parkinson's disease and dementia
with Lewy bodies. The American journal of pathology, 152(4), 879.

Lesage, S., & Brice, A. (2009). Parkinson's disease: from monogenic forms to genetic
susceptibility factors. Human molecular genetics, 18(R1), R48-R59.

Zhang, H., Bai, L., He, J., Zhong, L., Duan, X., Ouyang, L., ...& Shi, J. (2017). Recent advances
in discovery and development of natural products as source for anti-Parkinson's disease lead
compounds. European journal of medicinal chemistry, 141, 257-272.

Berardelli, A., Rothwell, J. C., Thompson, P. D., & Hallett, M. (2001).Pathophysiology of

bradykinesia in Parkinson's disease. Brain, 124(11), 2131-2146.

Emre, M., Aarsland, D., Brown, R., Burn, D. J., Duyckaerts, C., Mizuno, Y., ...& Goldman, J.
(2007). Clinical diagnostic criteria for dementia associated with Parkinson's disease. Movement
disorders: official journal of the Movement Disorder Society, 22(12), 1689-1707.

Lance, J. W., Schwab, R. S., & Peterson, E. A. (1963).Action tremor and the cogwheel
phenomenon in Parkinson’s disease. Brain, 86(1), 95-110.

Jankovic J (April 2008). "Parkinson's disease: clinical features and diagnosis". Journal of
Neurology,Neurosurgery,Psychiatry. 79 (4):36876. doi:10.1136/jnnp.2007.131045. PMID 18344
392. Archived from the original on 19 August 2015.

29
Aguilar, L. G. (2008). Current approaches to the treatment of Parkinson’s
disease. Neuropsychiatric disease and treatment, 4(4), 743.

Rocchi, A., Pellegrini, S., Siciliano, G., &Murri, L. (2003). Causative and susceptibility genes
for Alzheimer’s disease: a review. Brain research bulletin, 61(1), 1-24.

Van Broeck B, Van Broeckhoven C, Kumar-Singh S (2007)."Current insights into molecular

mechanisms of Alzheimer disease and their implications for therapeutic approaches". Neuro-
Degenerative Diseases. 4 (5): 349–65.

Förstl H, Kurz A (1999). "Clinical features of Alzheimer's disease". European Archives of

Psychiatry and Clinical Neuroscience. 249 (6): 288–90.

Frank EM (September 1994). "Effect of Alzheimer's disease on communication

function". Journal of the South Carolina Medical Association.

Bacanu, S. A., Devlin, B., Chowdari, K. V., DeKosky, S. T., Nimgaonkar, V. L., & Sweet, R. A.
(2005). Heritability of psychosis in Alzheimer disease. The American journal of geriatric
psychiatry, 13(7), 624-627..

Serrano-Pozo, A., Frosch, M. P., Masliah, E., & Hyman, B. T. (2011).Neuropathological

alterations in Alzheimer disease. Cold Spring Harbor perspectives in medicine, 1(1), a006189

Mesholam, R. I., Moberg, P. J., Mahr, R. N., & Doty, R. L. (1998). Olfaction in
neurodegenerative disease: a meta-analysis of olfactory functioning in Alzheimer's and
Parkinson's diseases. Archives of neurology, 55(1), 84-90.

Winslow, B. T., Onysko, M. K., Stob, C. M., &Hazlewood, K. A. (2011).Treatment of

Alzheimer disease. American family physician, 83(12), 1403.

Roos, R. A. (2010). Huntington's disease: a clinical review. Orphanet journal of rare

diseases, 5(1), 40

Nopoulos, P. C. (2016). Huntington disease: a single-gene degenerative disorder of the

striatum. Dialogues in clinical neuroscience, 18(1), 91.

Walker FO (January 2007). "Huntington's disease". Lancet. 369 (9557): 218–28.

30
Murray ED, Buttner N, Price BH (2012)."Depression and Psychosis in Neurological Practice". In
Bradley WG, Daroff RB, Fenichel GM, Jankovic J (eds.). Bradley's neurology in clinical
practice(6th ed.). Philadelphia, PA: Elsevier/Saunders. p. 108

vanDuijn E, Kingma EM, van der Mast RC (2007). "Psychopathology in verified Huntington's
disease gene carriers". The Journal of Neuropsychiatry and Clinical Neurosciences. 19 (4): 441–
8

Ondo, William G., et al. "Tetrabenazine treatment for Huntington's disease-associated

chorea." Clinical neuropharmacology 25.6 (2002): 300-302.

Bonelli RM, Wenning GK, Kapfhammer HP (March 2004). "Huntington's disease: present
treatments and future therapeutic modalities"t. International Clinical
Psychopharmacology. 19 (2): 51–62

Rao AK, Muratori L, Louis ED, Moskowitz CB, Marder KS (April 2009). "Clinical
measurement of mobility and balance impairments in Huntington's disease: validity and
responsiveness". Gait & Posture. 29 (3): 433–6

Kuliev A, Verlinsky Y (April 2005). "Preimplantation diagnosis: a realistic option for assisted
reproduction and genetic practice". Current Opinion in Obstetrics & Gynecology. 17 (2): 179–83

Raymond, L. A., André, V. M., Cepeda, C., Gladding, C. M., Milnerwood, A. J., & Levine, M.
S. (2011). Pathophysiology of Huntington's disease: time-dependent alterations in synaptic and
receptor function. Neuroscience, 198, 252-273.

Johnston Jr, R. B., & Joy, J. E. (Eds.). (2001). Multiple sclerosis: current status and strategies for
the future. National Academies Press.

Coles A (October 2008). "Multiple sclerosis". Lancet. 372 (9648): 1502–17.

Compston A, Coles A (April 2002). "Multiple sclerosis". Lancet. 359(9313): 1221–31.

Panitch, H. S., Hirsch, R. L., Schindler, J., & Johnson, K. P. (1987). Treatment of multiple
sclerosis with gamma interferon: exacerbations associated with activation of the immune
system. Neurology, 37(7), 1097-1097.

31
Neuhaus, O., Farina, C., Wekerle, H., &Hohlfeld, R. (2001).Mechanisms of action of glatiramer
acetate in multiple sclerosis. Neurology, 56(6), 702-708

Miller, D. H., & Leary, S. M. (2007). Primary-progressive multiple sclerosis. The Lancet
Neurology, 6(10), 903-912

Serafini, B., Rosicarelli, B., Magliozzi, R., Stigliano, E., &Aloisi, F. (2004).Detection of ectopic
B‐cell follicles with germinal centers in the meninges of patients with secondary progressive
multiple sclerosis. Brain pathology, 14(2), 164-174.

Polman, C. H., Reingold, S. C., Edan, G., Filippi, M., Hartung, H. P., Kappos, L., ...&
Sandberg‐Wollheim, M. (2005). Diagnostic criteria for multiple sclerosis: 2005 revisions to the
“McDonald Criteria”. Annals of Neurology: Official Journal of the American Neurological
Association and the Child Neurology Society, 58(6), 840-846

Andersson, M., Alvarez-Cermeno, J., Bernardi, G., Cogato, I., Fredman, P., Frederiksen, J., ...&
Keir, G. (1994). Cerebrospinal fluid in the diagnosis of multiple sclerosis: a consensus
report. Journal of Neurology, Neurosurgery & Psychiatry, 57(8), 897-902

Barnett, M. H., &Prineas, J. W. (2004). Relapsing and remitting multiple sclerosis: pathology of
the newly forming lesion. Annals of neurology, 55(4), 458-468.

Tuch BE (September 2006). "Stem cells--a clinical update". Australian Family Physician. 35 (9):
719–21.

Shenghui, H. E., Nakada, D., & Morrison, S. J. (2009).Mechanisms of stem cell self-renewal.
Annual Review of Cell and Developmental, 25, 377–406

Mitalipov S, Wolf D (2009). Totipotency, pluripotency and nuclear reprogramming.Advances in

Biochemical Engineering/Biotechnology.

Ulloa-Montoya F, Verfaillie CM, Hu WS (July 2005). "Culture systems for pluripotent stem
cells". Journal of Bioscience and Bioengineering. 100 (1)

Beattie, R; Hippenmeyer, S (December 2017). "Mechanisms of radial glia progenitor cell lineage
progression”.

32
Chagastelles, P. C., &Nardi, N. B. (2011). Biology of stem cells: an overview. Kidney
international supplements, 1(3), 63-67.

Akiyama, Kentaro; Chen, Chider; Wang, DanDan; Xu, Xingtian; Qu, Cunye; Yamaza,
Takayoshi; Cai, Tao; Chen, WanJun; Sun, Lingyun (4 May 2012).

Ankrum, J. A., Ong, J. F., & Karp, J. M. (2014). Mesenchymal stem cells: immune evasive, not
immune privileged. Nature biotechnology, 32(3), 252.

Kuhn HG, Dickinson-Anson H, Gage FH (1996). "Neurogenesis in the dentate gyrus of the adult
rat: age-related decrease of neuronal progenitor proliferation" (PDF). Journal of
Neuroscience. 16 (6)

Ebrahimi, M. J., Aliaghaei, A., Boroujeni, M. E., Khodagholi, F., Meftahi, G., Abdollahifar, M.
A., ... & Sadeghi, Y. (2018). Human umbilical cord matrix stem cells reverse oxidative stress-
induced cell death and ameliorate motor function and striatal atrophy in rat model of Huntington
disease. Neurotoxicity research, 34(2), 273-284.

Hosseini, M., Moghadas, M., Edalatmanesh, M. A., & Hashemzadeh, M. R. (2015).

Xenotransplantation of human adipose derived mesenchymal stem cells in a rodent model of
Huntington’s disease: motor and non-motor outcomes. Neurological research, 37(4), 309-319.

Mu, S., Wang, J., Zhou, G., Peng, W., He, Z., Zhao, Z., ... & Zhang, J. (2014). Transplantation of
induced pluripotent stem cells improves functional recovery in Huntington's disease rat
model. PLoS One, 9(7), e101185.

Al-Gharaibeh, A., Culver, R., Stewart, A. N., Srinageshwar, B., Spelde, K., Frollo, L., ... &
Crane, A. (2017). Induced Pluripotent Stem Cell-Derived Neural Stem Cell Transplantations
Reduced Behavioral Deficits and Ameliorated Neuropathological Changes in YAC128 Mouse
Model of Huntington's Disease. Frontiers in neuroscience, 11, 628.

Harach, T., Jammes, F., Muller, C., Duthilleul, N., Cheatham, V., Zufferey, V., ... & Bolmont, T.
(2017). Administrations of human adult ischemia-tolerant mesenchymal stem cells and factors
reduce amyloid beta pathology in a mouse model of Alzheimer's disease. Neurobiology of
aging, 51, 83-96.Hoveizi, E., Mohammadi, T., Moazedi, A. A., Zamani, N., & Eskandary, A.

33
(2018). Transplanted neural-like cells improve memory and Alzheimer-like pathology in a rat
model. Cytotherapy, 20(7), 964-973.

Wang, S. S., Jia, J., & Wang, Z. (2018). Mesenchymal stem cell-derived extracellular vesicles
suppresses iNOS expression and ameliorates neural impairment in alzheimer’s disease
mice. Journal of Alzheimer's Disease, (Preprint), 1-9.

McGinley, L. M., Kashlan, O. N., Chen, K. S., Bruno, E. S., Hayes, J. M., Backus, C., ... &
Feldman, E. L. (2017). Human neural stem cell transplantation into the corpus callosum of
Alzheimer's mice. Annals of clinical and translational neurology, 4(10), 749-755.

Zhang, N., Lu, X., Wu, S., Li, X., Duan, J., Chen, C., ... & Liu, Y. (2018). Intrastriatal
transplantation of stem cells from human exfoliated deciduous teeth reduces motor defects in
Parkinsonian rats. Cytotherapy, 20(5), 670-686.

Chi, K., Fu, R. H., Huang, Y. C., Chen, S. Y., Hsu, C. J., Lin, S. Z., ... & Liu, S. P. (2018).
Adipose-derived stem cells stimulated with n-butylidenephthalide exhibit therapeutic effects in a
mouse model of Parkinson’s disease. Cell transplantation, 27(3), 456-470.

Chen, D., Fu, W., Zhuang, W., Lv, C., Li, F., & Wang, X. (2017). Therapeutic effects of
intranigral transplantation of mesenchymal stem cells in rat models of Parkinson's
disease. Journal of neuroscience research, 95(3), 907-917.

Marzban, M., Mousavizadeh, K., Bakhshayesh, M., Vousooghi, N., Vakilzadeh, G., & Torkaman-
Boutorabi, A. (2018). Effect of Multiple Intraperitoneal Injections of Human Bone Marrow Mesenchymal
Stem Cells on Cuprizone Model of Multiple Sclerosis. Iranian biomedical journal, 22(5), 31221

Fernández, O., Izquierdo, G., Fernández, V., Leyva, L., Reyes, V., Guerrero, M., ... & De la
Cuesta, A. (2018). Adipose-derived mesenchymal stem cells (AdMSC) for the treatment of
secondary-progressive multiple sclerosis: A triple blinded, placebo controlled, randomized phase
I/II safety and feasibility study. PloS one, 13(5), e0195891.

Laso-García, F., Ramos-Cejudo, J., Carrillo-Salinas, F. J., Otero-Ortega, L., Feliú, A., Gómez-de
Frutos, M., ... & Gutiérrez-Fernández, M. (2018). Therapeutic potential of extracellular vesicles
derived from human mesenchymal stem cells in a model of progressive multiple sclerosis. PloS
one, 13(9), e0202590.

34
Tate, C. C., Chou, V. P., Campos, C., Moalem, A. S., Di Monte, D. A., McGrogan, M., ... &
Manning‐Bog, A. B. (2017). Mesenchymal stromal SB623 cell implantation mitigates
nigrostriatal dopaminergic damage in a mouse model of Parkinson's disease. Journal of tissue
engineering and regenerative medicine, 11(6), 1835-1843.

35