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TABLE OF CONTENTS

1. REPORT OVERVIEW……………...……………………………………………..…………10 1.1 Statement of the Report .............................................................................................10 1.1 Executive Summary ....................................................................................................13 2. INTRODUCTION ........................................................................................................15 3. STEM CELLS: A BRIEF OVERIVEW……………………...………………………………18 3.1 Embryonic Stem Cells ................................................................................................18 3.2 Induced Pluripotent Stem Cells ..................................................................................19 3.3 Types of Specialized Cells Derived from Stem Cells ..................................................19 3.4 Types of Stem Cells in the Human Body ....................................................................21

3.4.1 Human Embryonic Stem Cells ..............................................................................21 3.4.2 Embryonic Germ Cells ..........................................................................................21 3.4.3 Fetal Stem Cells ..................................................................................................22 3.4.4 Umbilical Cord Stem Cells ...................................................................................22

3.5 Adult Stem Cells .........................................................................................................24 3.5.1 Hematopoietic Stem Cells .....................................................................................24 3.5.2 Mesenchymal Stem Cells ....................................................................................25 3.5.3 Neural Stem Cells .................................................................................................25

3.5.3.1 NSCs’ Capacity to Migrate and Engraft ...........................................................25 3.5.3.2 Characterization of NSCs ..................................................................................26 3.5.3.3 Major Three Neuronal Lineages from NSCs ......................................................27

3.6 Characteristics of Different Types of Stem Cells .........................................................31 4. NEURAL STEM CELLS: AN OVERVIEW ....................................................................................... 33

4.1 Sources of NSCs ........................................................................................................33 4.2 Basal Properties of NSCs Obtained from Different Sources .......................................34

4.2.1 BMSCs as a Sourse for NSC-Like Cells ...............................................................35 4.2.2 UCBSCs: Express Pro-Neural Genes and Neural Markers ..................................36 4.2.3 ESCs as a Source for NSCs ................................................................................36 4.2.4 iPSCs as a Source of NSCs .................................................................................36

4.2.4.1 Methods Used to Produce iPSCs ......................................................................37 4.2.4.2 Chemicals Used for Neural Differentiation of iPSCs ..........................................38 4.2.4.3 Small-Molecule-Based Culture Protocols for Inducing hPSCs Differentiation .......39 4.2.4.4 Compounds Used for NSC Proliferation ............................................................40 4.2.4.5 Synthetic Compounds Used to Induce NSC Differentiation into Neurons ..........41 4.2.4.6 Natural Products Affecting NSC Survival, Proliferation, and Differentiation .......42

4.3 Fetal Stem Cell Transplantation for Neurodegenerative Diseases ..............................43 4.4 Adult Human Neural Stem Therapeutics .....................................................................44

4.4.1 Current Therapeutic Status of aNSCs ..................................................................46 5. DEGENERATIVE DISEASES WITH POSSIBLE CURE USING NSCS ....................................... 49

5.1 Conventional Treatments for Neurodegenerative Diseases ........................................50 5.2 NSC-Based and Traditional Approaches for Neurodenerative Diseases.....................51 5.3 The Wide Gap Between Theory and Practice in NSC Applications .............................52 5.4 Types of NSCs Used for Cell Therapy Approaches ....................................................53

5.4.1 Fetal and Adult-Derived NSCs .............................................................................53 5.4.2 NSCs from Pluripotent Stem Cells .......................................................................53

5.5 Possible Therapeutic Actions of Grafted NSCs in Neurodegenerative Diseases ........54 5.6 Most Recent Clinical Trials Using NSCs for Neurological Disorders ...........................55

5.6.1 Possible Outcome of Clinical Trials ......................................................................56 5.7 Other Clinical Trials Using NSCs for Neurodegenerative Diseases ............................56 5.8 Neurodevelopmental Disorders and Cell Therapy ......................................................59

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5.8.1 Clinical Trials for Neurodevelopmental Disorders .................................................60 6. SPINAL CORD INJURY AND CELL THERAPY ............................................................................. 62

6.1 Incidence of Spinal Cord Injury ...................................................................................62 6.2 Neurological Level and Extent of Lesion in Spinal Cord Injuries .................................63 6.3 Annual and Lifetime Cost of Treating SCI Patients in the US ......................................64 6.4 Medications and Other Treatments for Spinal Cord Injury ..........................................65 6.5 CIRM Funding for Spinal Cord Injury ..........................................................................67 6.6 Cell Therapy for Spinal Cord Injury .............................................................................69

6.6.1 Studies in Animal Models of Cell Therapy for SCI ................................................70 6.6.1.1 Preclinical Trials Using MSCs for SCI ...............................................................71 6.6.1.2 Preclinical Trials Using NPCs for SCI ................................................................73 6.6.1.3 Preclinical Studies Using Olfactory Ensheathing Cells for SCI ..........................74 6.6.1.4 Preclinical Studies Using SCs for SCI ...............................................................75

6.7 SCI Models and Effectiveness of Neuronal Regeneration...........................................75 6.8 Clinical Trials Using Stem Cells for Spinal Cord Injury ................................................77

7. ALZHEIMER’S DISEASE ................................................................................................................. 79 7.1 Incidence of Alzheimer’s Disease ...............................................................................79 7.2 Projected Number of People Aged 65 and Older with Alzheimer’s Disease in the US 80 7.3 Cost of Care by Payment Source for US Alzheimer’s Patients ...................................81

7.3.1 Total Cost of Health Care, Long-Term Care, and Hospice for US AD Patients.....82 7.4 Currently Available Medications for Alzheimer’s Disease ...........................................83 7.5 CIRM Funding for Alzheimer’s Research ....................................................................84 7.6 Transplantation of Stem Cells for AD ..........................................................................86

7.6.1 Gene Therapy for AD ...........................................................................................88 8. PARKINSON’S DISEASE ................................................................................................................ 89

8.1 Incidence of Parkinson’s Disease ...............................................................................89 8.2 CIRM Grants Targeting Parkinson’s Disease..............................................................89 8.3 Current Medications for PD ........................................................................................92 8.4 Potential for Cell Therapy in Parkinson’s Disease ......................................................93 8.5 Gene Therapy for PD .................................................................................................94

9. AMYOTROPHIC LATERAL SCLEROSIS ...................................................................................... 96 9.1 Incidence of ALS ........................................................................................................96 9.2 Symptomatic Treatments in ALS Patients ...................................................................96 9.3 CIRM Grants Targeting ALS .......................................................................................98 9.4 Companies Focusing on Stem Cell Therapy for ALS ................................................ 100 9.5 Cell Therapy for ALS ................................................................................................ 103

10. MULTIPLE SCLEROSIS ................................................................................................................ 106 10.1 Incidence of MS ........................................................................................................ 106 10.2 Medications for MS ................................................................................................... 108 10.3 Neural Stem Cells’ Application in Multiple Sclerosis ................................................. 108 10.4 Stimulation of Endogenous NSCs with Growth Factors for MS Treatment ................ 110 10.5 CIRM Grants Targeting MS ...................................................................................... 111

11. STROKE ......................................................................................................................................... 112 11.1 Incidence of Stroke ................................................................................................... 112 11.2 Currently Available Medication for Stroke ................................................................. 113 11.3 Stem Cell-Based Therapies for Stroke...................................................................... 113 11.4 Various Stem Cell Types Used in Stroke Experimental Studies ................................ 115 11.5 Ongoing Clinical Trials for Stroke Using Stem Cells ................................................. 116 11.6 CIRM Grants Targeting Stroke ................................................................................. 118 12. MARKET ANALYSIS ................................................................................................ 120 12.1 Current Stem Cell Landscape ................................................................................... 120

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12.1.1 Number of Stem Cell Product Candidates .......................................................... 121 12.1.2 Commercial Stem Cell Therapy Development by Geography ............................ 122 12.1.3 Commercially Attractive Therapeutic Areas ....................................................... 123 12.1.4 Major Companies Investing in Stem Cell Industry .............................................. 125 12.1.5 Venturing of Big Pharma into Stem Cell Therapy Sector .................................... 127

12.3 Major Clinical Milestones in Cell Therapy Sector ...................................................... 130 12.3.1 TiGenics’ Cx601 ................................................................................................ 130 12.3.2 Mesoblast Ltd. and JCR Pharmaceuticals Co., Ltd. ........................................... 130 12.3.3 Chiesi’s Holocar ................................................................................................. 131 12.3.4 ReNeuron’s Retinitis Pigmentosa Cell Therapy Candidate................................. 131 12.3.5 Orphan Drug Designation to Pluristem’s PLX-PAD Cells ................................... 132

12.4 Major Anticipated Cell Therapy Clinical Data Events in 2016 .................................... 132 12.5 Global Market for Cell Therapy Products .................................................................. 133

12.5.1 Global Market for Neural Stem Cells .................................................................. 135 13. SELECTED COMPANY PROFILES ......................................................................... 137 13.1 Asterias Biotherapeutics, Inc. ................................................................................... 137

13.1.1 AST-OPC1 ......................................................................................................... 137 13.2 Athersys Inc.............................................................................................................. 139

13.2.1 MultiStem Programs .......................................................................................... 139 13.2.2 Ischemic Stroke ................................................................................................. 139 13.2.3 Clinical Programs (Stroke Phase II) ................................................................... 140

13.3 Axiogenesis AG / Pluriomics (Merged to form Ncardia) ............................................ 141 13.3.1 Peri.4U – Human iPS Cell-Derived Peripheral Neurons ..................................... 141 13.3.2 Dopa.4U – Human iPS Cell-Derived Dopaminergic Neurons ............................. 141 13.3.3 CNS.4U—Human iPS Cell-Derived Central Nervous System Cells .................... 142 13.3.4 Astro.4U—Human iPS Cell-Derived Astrocytes ................................................. 143

13.4 AxoGen, Inc.............................................................................................................. 145 13.4.1 Avance Nerve Graft ........................................................................................... 145 13.4.2 AxoGuard Nerve Connector ............................................................................... 146 13.4.3 AxoGuard Nerve Protector ................................................................................. 146 13.4.4 AxoTouch Two-Point Discriminator .................................................................... 147

13.5 BrainStorm Cell Therapeutics ................................................................................... 148 13.5.1 NurOwn in the Clinic .......................................................................................... 148

13.6 Cellular Dynamics International, Inc. ........................................................................ 149 13.6.1 iCell Neurons ..................................................................................................... 149 13.6.2 iCell Astrocytes .................................................................................................. 150 13.6.3 iCell DopaNeurons ............................................................................................. 150

13.7 Celther Polska .......................................................................................................... 151 13.7.1 Cell Lines ........................................................................................................... 151

13.8 Cellartis AB .............................................................................................................. 153 13.8.1 hESC-Derived Mesenchymal Progenitor Cells ................................................... 153 13.8.2 Human Neural Stem Cells.................................................................................. 153 13.8.3 Culture System for iPSC .................................................................................... 154

13.9 CellCure Neurosciences Ltd. .................................................................................... 155 13.9.1 Technology ........................................................................................................ 155 13.9.2 New Candidate Treatment for Retinal Diseases ................................................. 156

13.10 Celvive, Inc. .............................................................................................................. 157 13.10.1 Spinal Cord Injury .............................................................................................. 157 13.10.2 Research and Development ............................................................................... 158

13.11 Merck Millipore ......................................................................................................... 159 13.11.1 Human Neural Stem Lines ................................................................................. 159

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13.12 International Stem Cell Corporation .......................................................................... 160 13.12.1 Neural Stem Cells .............................................................................................. 160

13.13 Kadimastem Ltd. ...................................................................................................... 162 13.13.1 Drug Discovery for Neural Diseases .................................................................. 162 13.13.2 Human Oligodendrocyte Drug-Screening Assays ............................................... 163

13.14 Living Cell Technologies Limited .............................................................................. 164 13.14.1 NTCELL ............................................................................................................. 164

13.15 MEDIPOST .............................................................................................................. 165 13.15.1 NEUROSTEM .................................................................................................... 165

13.16 Neuralstem Inc. ........................................................................................................ 166 13.16.1 NSI-566 for ALS .................................................................................................. 167 13.16.2 NSI-566 for SCI .................................................................................................. 167 13.16.3 NSI-566 for Ischemic Stroke ............................................................................... 167

13.17 NeuroGeneration Inc. ............................................................................................... 168 13.17.1 Drug Discovery .................................................................................................. 168 13.17.2 Biotherapeutics .................................................................................................. 169

13.18 Neurona Therapeutics Inc. ....................................................................................... 170 13.18.1 Technology ......................................................................................................... 170

13.19 Ocata Therapeutics Inc. (Acquired by Astellas Pharma for $379M in Nov. 2015) ..... 171 13.19.1 Focus on Neuroscience ..................................................................................... 171

13.20 Opexa Therapeutics, Inc........................................................................................... 172 13.20.1 Tcelna ................................................................................................................. 172 13.20.2 OPX-212 ............................................................................................................. 173 13.20.3 Abili-T Clinical Study ........................................................................................... 173

13.21 ReNeuron Group PLC .............................................................................................. 175 13.21.1 Products and Technologies ................................................................................ 175 13.21.3 Human Retinal Progenitor Cells .......................................................................... 176 13.21.4 Exosome Platform .............................................................................................. 176 13.21.5 ReNcell Products ............................................................................................... 177

13.22 RhinoCyte, Inc. ......................................................................................................... 178 13.22.1 Research ........................................................................................................... 178

13.23 Roslin Cells Ltd. ....................................................................................................... 179 13.23.1 Custom iPSC Generation ................................................................................... 179

13.24 SanBio, Inc. .............................................................................................................. 181 13.24.1 SB623 ................................................................................................................ 181 13.24.2 SB618 ................................................................................................................ 181

13.25 Saneron CCEL Therapeutics Inc. ............................................................................. 183 13.25.1 U-CORD-CELL Program .................................................................................... 183 13.25.2 SERT-CELL Program ........................................................................................ 183

13.26 StemCells, Inc. ......................................................................................................... 185 13.26.1 Clinical Programs ............................................................................................... 185 13.26.2 HuCNS-SC (human neural stem cells) ............................................................... 186 13.26.3 Proof of Concept ................................................................................................ 186 13.26.4 Proof of Safety and Initial Efficacy ...................................................................... 186 13.26.5 Spinal Cord Injury .............................................................................................. 187 13.26.6 Age-Related Macular Degeneration ................................................................... 187 13.26.7 Pelizaeus-Merzbacher Disease ......................................................................... 188 13.26.8 Neuronal Ceroid Lipofuscinosis ......................................................................... 188

13.27 Stemedica Cell Technologies, Inc. ............................................................................ 190 13.27.1 Technology ........................................................................................................ 190 13.27.2 Products ............................................................................................................ 190

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13.27.2.1 Stemedyne-MSC ........................................................................................... 191 13.27.2.2 Stemedyne-NSC ............................................................................................ 191 13.27.2.3 Stemedyne-RPE ............................................................................................ 191

13.28 STEMCELL Technologies, Inc. ................................................................................. 192 13.28.1 Cell Culture Media for NSC and Progenitor Cells ............................................... 192

13.29 Talisman Therapeutics Ltd. ...................................................................................... 194 13.30 Xcelthera INC ........................................................................................................... 195

13.30.1 Technology Platforms ........................................................................................ 195 13.30.2 PluriXcel-DCS Technology................................................................................. 195 13.30.3 PluriXcel-SMI Technology .................................................................................. 196 13.30.4 PlunXcel-SMI Neuron Technology ..................................................................... 196 13.30.5 PluriXcel-SMI Heart Technology ........................................................................ 196 13.30.6 Products ............................................................................................................ 196

13.30.6.1 Xcel-hNuP .................................................................................................... 197 13.30.6.2 Xcel-hNu ....................................................................................................... 197 13.30.6.3 Xcel-hCardP ................................................................................................. 197 13.30.6.4 Xcel-hcM ...................................................................................................... 197

APPENDIX Appendix 1: Globally Distributed Stem Cell and Cell Therapy Companies ............................................. 199 INDEX OF FIGURES FIGURE 3.4: Types of Specialized Cells Derived from Stem Cells .......................................................... 20 FIGURE 3.5: Major Three Neural Lineages from Neural Stem Cells ........................................................ 28 FIGURE 3.6: Structure of a Neuron ........................................................................................................... 29 FIGURE 3.7: Structure of Astrocytes ......................................................................................................... 30 FIGURE 3.8: Structure of Oligodendrocytes .............................................................................................. 31 FIGURE 5.1: Approaches for Neural Stem Replacement for Neurodevelopmental Disorders ................ 59 FIGURE 6.1: Causes of Spinal Cord Injuries ............................................................................................. 63 FIGURE 6.2: Neurological Level and Extent of Lesion in Spinal Cord Injuries ......................................... 64 FIGURE 6.3: Types and Share of Different Types of Stem Cells Used in SCI Clinical Trials .................. 77 FIGURE 7.1: Ages of People with Alzheimer’s Disease in the US ........................................................... 80 FIGURE 7.2: Number of People Aged 65 and Older with Alzheimer’s Disease in the US, 2050 ............ 81 FIGURE 7.3: Cost of Care by Payment Source for US Alzheimer’s Patients ........................................... 82 FIGURE 12.1: Stem Cell Therapy Development ..................................................................................... 121 FIGURE 12.2: Number of Therapies by Phase ....................................................................................... 122 FIGURE 12.3: Global Market for NSCs, Through 2022 .......................................................................... 136

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INDEX OF TABLES TABLE 3.1: NSCs, NPCs, and their Lineage-Specific Markers ............................................................ 26 TABLE 3.2: Characteristics of Different Types of Stem Cells ............................................................... 31 TABLE 4.1: Sources of NSCs and Advantages and Disadvantages in their Applications ................. 34 TABLE 4.2: Different Types of NSCs and their Basal Properties ......................................................... 35 TABLE 4.3: Advantages and Disadvantages of iPSCs Utilization ........................................................ 37 TABLE 4.4: Methods Used to Generate iPSCs ...................................................................................... 38 TABLE 4.5: Chemicals Used for Neural Differentiation of iPSCs ......................................................... 39 TABLE 4.6 Small-Molecule-Based Culture Protocols for Inducing hPSCs Differentiation ................. 40 TABLE 4.7: Compounds Used in Neural Stem Cell Research ............................................................. 40 TABLE 4.8: Synthetic Compounds Used to Induce NSC Differentiation into Neurons ....................... 41 TABLE 4.9: Natural Products Known to Affect NSC Survival, Proliferation, and Differentiation ........ 43 TABLE 4.10: Ongoing Clinical Trials of Fetal Stem Cell Transplantation for Neurological Diseases 43 TABLE 4.11: The Various Methods of Isolation, Culture, and Expansion of aNSCs .......................... 45 TABLE 4.12: Preclinical Results (Rat) of aNSCs against Neurodegenerative Diseases ................... 46 TABLE 4.13: Trial ID & Title of Clinical Trials of aNSCs against Neurodegenerative Diseases .............. 47 TABLE 4.14: Trial ID, Cell Source, Location, and Phases of Current Clinical Trials of aNSCs ......... 47 TABLE 5.1: Conventional Treatments for Alzheimer’s, Parkinson’s, and Huntington’s Diseases ..... 50 TABLE 5.2: NSC-Based Approaches for Neurodegenerative Diseases .............................................. 51 TABLE 5.3: Some Recent Clinical Trials Using NSCs for Treating Neurological Diseases ............... 56 TABLE 5.4: NCT Numbers & Titles of Clinical Trials Using NSCs for Neurodegenerative Diseases ...... 57 TABLE 5.5: Status of Different Clinical Trials Using NSCs for Neurodegenerative Diseases............ 58 TABLE 5.6: NCT Number and Titles of Clinical Trials for Neurodevelopmental Disorders ................ 61 TABLE 5.7: Status of Clinical Trials Using NSCs for Neurodevelopmental Diseases ........................ 61 TABLE 6.1: Annual and Lifetime Cost of Treating SCI Patients in the US ........................................... 65 TABLE 6.2: Oral Medications and Other Treatment Options for SCI ................................................... 66 TABLE 6.3: CIRM’s Grants Targeting Spinal Cord Injury ...................................................................... 68 TABLE 6.4: Genes Used for Engineering Cells ...................................................................................... 70 TABLE 6.5: Preclinical SPI Trials Using iPSCs/ESCs for SCI .............................................................. 70 TABLE 6.6: Preclinical Spinal Cord Injury Trials Using Mesenchymal Stromal Cells ......................... 72 TABLE 6.7: Preclinical Spinal Cord Injury Trials Using NSCs/NPCs ................................................... 73 TABLE 6.8: Preclinical SCI Trials Using Olfactory Ensheathing Cells ................................................. 74 TABLE 6.9: Preclinical SCI Trials Using Schwann Cells ....................................................................... 75 TABLE 6.10: SCI Models and Effectiveness of Neuronal Regeneration.............................................. 76 TABLE 6.11: Clinical Trials in Different Countries for SCI ..................................................................... 78 TABLE 7.1: Total Cost of Health Care, Long-Term Care, and Hospice for US Alzheimer’s Patients ... 83 TABLE 7.2: Currently Available Pharmacologic Therapies for Alzheimer’s Disease ............................... 84 TABLE 7.3: CIRM Funding for Alzheimer’s Research ............................................................................... 85 TABLE 7.4: Stem Cell Therapy for AD in Mice Models ............................................................................. 87 TABLE 7.5: Gene Therapy for AD ............................................................................................................. 88 TABLE 8.1: CIRM Grants Targeting Parkinson’s Disease ........................................................................ 90 TABLE 8.2: Medications for Motor Symptoms in PD ................................................................................. 92 TABLE 8.3: Advantages and Disadvantages of Stem Cell Types Used in PD ......................................... 94 TABLE 8.4: Approaches Used in Current Gene Therapy Clinical Trials for PD ....................................... 95 TABLE 9.1: Symptomatic Treatments in ALS Patients ............................................................................. 97 TABLE 9.2: CIRM Grants Targeting ALS .................................................................................................. 98 TABLE 9.4: Companies Focusing on Various Strategies for ALS .......................................................... 101 TABLE 9.6: Examples of Clinical Trials for Amyotrophic Lateral Sclerosis ............................................. 104 TABLE 10.1: Currently Available Medications for MS ............................................................................. 107 TABLE 10.2: Available Studies Related to the Use of NSCs for Multiple Sclerosis ................................ 109

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TABLE 10.3: Growth Factors and Secreted Molecules Used for Stimulating Endogenous NSCs ..... 110 TABLE 10.4: CIRM Grants Targeting MS ................................................................................................ 111 TABLE 11.1: An Overview of NSC Transplantation Experiments in Ischemic Stroke Models ............... 114 TABLE 11.2: Representative Experimental Studies of Various Cell-Based Therapies for Stroke....... 115 TABLE 11.3: Ongoing Clinical Trials of Cell-Based Therapies for Stroke ............................................... 117 TABLE 11.4: CIRM Grants Targeting Stroke ........................................................................................... 118 TABLE 12.1: Number of Therapies by Phase ......................................................................................... 122 TABLE 12.2: Stem Cell Product Candidates in Various Stages by Therapeutic Area ........................... 124 TABLE 12.3: Stem Cell Therapies in Phase III and Pre-Registration as of 2015 ................................... 125 TABLE 12.4: Companies with Active Stem Cell Therapy Pipelines ........................................................ 127 TABLE 12.5: Big Pharma’s Involvement in Stem Cell Sector ................................................................. 128 TABLE 12.6: Major Anticipated Cell Therapy Clinical Data Events ......................................................... 132 TABLE 12.7: Global Market for Neural Stem Cells (NSCs), Through 2022 ............................................ 136 TABLE 13.1: Neuralstem Inc.’s Cell Therapy Products in Development ................................................ 166 TABLE 13.2: Opexa’s Product Pipeline ................................................................................................... 174 TABLE 13.3: ReNeuron’s Pipeline Candidates ....................................................................................... 176 TABLE 13.4: SanBio’s Product Pipeline .................................................................................................. 182 TABLE 13.5: STEMCELL Technologies’ Cell Culture Media for NSCs .................................................. 193 TABLE App. 1.1: Stem Cell and Cell Therapy Companies ..................................................................... 200 TABLE App. 2.1: Sixty US Spine Surgeons on the Forefront of Biologics and Stem Cells ................ Error!

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1. REPORT OVERVIEW

The purpose of this report is to describe the current state of neural stem cell (NSC)

research, applications, and technologies, the ongoing clinical trials involving NSCs, the

late-stage NSC clinical trials, and the possible uses of NSCs in cell therapy. As NSC

cell therapy is an integrated component of other cell therapies such as those involving

mesenchymal stem cells (MSCs), induced pluripotent stem cells (iPSCs), and

embryonic stem cells (ESCs), the report also gives a brief overview of the overall cell

therapy (CT) industry.

1.1 Statement of the Report

The report is mainly focused on providing the latest information on the following:

• Overviews of different types of stem cells, including NSCs and their cell lineages

• The various methods to generate iPSCs for NSC production

• Compounds used for inducing differentiation of NSCs into neurons, astrocytes and

oligodendrocytes

• Ongoing clinical trials using fetal stem cells for treating neurological disorders

• Methods of isolation, culture and expansion of adult neural stem cells (aNSCs)

• Current clinical trials using aNSCs for the treatment of neurodegenerative diseases

• Degenerative diseases addressed by NSCs for a possible cure

• Preclinical and clinical trials using NSCs for neurodegenerative diseases

• Application of NSCs in neurodevelopmental diseases

• Cell therapy efforts for treating spinal cord injury (SCI)

• Details of clinical trials sponsored by companies in different parts of the world for

neurological diseases such as Alzheimer’s, Parkinson’s, amyotrophic lateral

sclerosis (ALS), ischemic stroke, and autism

• Funding by the California Institute for Regenerative Medicines (CIRM) for research

in various neurodegenerative diseases

• The size of the NSCs market in the overall stem cell space

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• Profiles of selected 33 companies focusing on NSCs

The report answers the following questions:

• What are stem cells and how many types are human stem cells classified into?

• What are NSCs and do they have the potential to migrate and engraft into the

intended regions in our body?

• What are the lineage-specific markers in NSCs?

• What are the characteristics of neurons, astrocytes and oligodendrocytes?

• What is the total number of cell therapy clinical trials by country?

• What types of stem cells dominate cell therapy clinical trials?

• What are the diseases addressed by cell therapy clinical trials?

• What are the different sources of NSCs?

• What are the basal properties of NSCs obtained from different sources?

• What are the synthetic and natural compounds used for the differentiation of neural

cells from iPSCs?

• Which companies are focusing on sourcing NSCs from fetal stem cells for

addressing neurodegenerative diseases?

• How many clinical trials are using adult NSCs against neurodegenerative

diseases?

• What are the conventional treatments for neurodegenerative diseases?

• What are the NSC-based approaches for neurodegenerative diseases?

• What are the most recent clinical trials using NSCs for a possible cure for

neurodegenerative diseases?

• What are the recent efforts using NSCs for the treatment of neurodevelopmental

diseases such as autism?

• How many ongoing clinical trials are focusing on autism?

• What is the total amount of grants awarded by CIRM for various research projects

associated with neurodegenerative and neurodevelopmental diseases?

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• What are the conventional medications and possible cell-based therapies for

neurodegenerative diseases such as Alzheimer’s disease, Parkinson’s disease,

amyotrophic lateral sclerosis, spinal cord injuries, and stroke?

• What is the number of stem cell product candidates?

• What are the major therapeutic areas addressed by stem cells?

• Which major companies are making investments in cell therapy sector?

• Which companies have active cell therapy pipelines?

• What is the contribution of Big Pharma to the cell therapy sector?

• What will the global market for stem cells grow into?

• What is the share of NSCs within the global stem cells market?

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1.1 Executive Summary

The concept of stem cells as a potential cure for neurodegenerative diseases is not new.

While NSCs have been explored for more than two decades for use in treating

neurodegenerative and neurodevelopmental diseases, recent progress with developing

NSCs from human-induced pluripotent cells has accelerated interest in developing cell-

based therapeutics to target neurodegenerative diseases. As safety and efficacy results

having been obtained from preclinical and clinical tests performed in animal models,

companies have moved onto human clinical trials using NSCs derived from different

sources.

Nearly one billion people in the aging population worldwide are affected by

neurodegenerative diseases, there are no medications currently available to cure or stop

the progression of these diseases. Available drugs can sometimes provide symptomatic

relief, but they do not address the underlying disease, making alternative approaches

badly needed. To date, researchers have successfully isolated, propagated, and

characterized NSCs, and there are confirmed reports of neurogenesis of transplanted

NSCs in the human brain. There has also been an upsurge in collaborative activities

among pharmaceutical companies, research institutions, and small start-up companies

within the neurodegenerative market.

Furthermore, there has been intense preclinical and clinical NSC activity, but no company

has yet achieved the commercialization of a cell-based therapy to address neurological

disease. Currently, companies producing neural stem cell products are providing NSC

lines, media, and other reagents to research centers and clinical-grade cells to company-

sponsored preclinical and clinical studies. Although a wide range of nurological diseases

exist, more of the research focus to date has centered around spinal cord injury (SPI),

amyotrophic lateral sclerosis, and ischemic stroke. Currently, 13 human clinical trials are

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in progress in various parts of the world for spinal cord injury, six of which are in phase I

and another six which are in phase II. ALS was the subject of the largest number of human

clinical trials (12), with 12 in phase I and another 12 in phase II. Stroke is another disease

that leads to the death of neural cells within the human brain. Currently, there are 20

human clinical trials underway for stroke. Eight stroke trials are in phase I, 11 are in phase

II, and one is in phase III. While many of these trials involved therapy advanced medicinal

products (ATMPs), some of these are exploring other therapeutic approaches as well.

When analyzing only clinical trials involving the use of adult NSCs, there currently eight

clinical trials underway. Four of them are in phase I and the other four are in phase II.

While most neurological trials are currently in the early stages, a single effective cell-

based therapeutic could revolutionize the treatment of neurodegenerative diseases.

Collectively, BioInformant estiamates the market for all types of stem cells to be

approximately $4.3 billion, with the neural stem cell (NSC) segment worth about $2.3

billion. Five-year projections estimation indicate that the market for all types of stem cells

will reach $8.2 billion in 2022 and that the NSC market segment will have a value of

approximately $4.9 billion at that time.

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2. INTRODUCTION

Neurodegenerative disorders cause progressive loss of cognitive and physical function

and affect approximately one billion people worldwide. Sadly, no treatments are currently

available to stop the progression of these diseases, making there a great need for

innovative new therapies. Over the past few years, NSCs have been successfully

isolated, expanded, and characterized from the adult brains of mammals, including

humans. Additionally, research has confirmed that neurogenesis occurs in the adult brain

through an endogenous population of NSCs, making cell-based treatments an interesting

treatment approach for neurological disorders.

Additionally, the private sector is demonstrating growing interest in using human stem

cells as therapeutics, with ClinicalTrials.gov returning over 6,000 clinical trials when the

database is searched using the terms: “Stem Cell” OR “Stem Cells”. ClinicalTrials.gov is

the world’s largest clinical trial database, maintained by the U.S. National Library of

Medicine (NLM) at the National Institutes of Health (NIH) and currently holding

registrations from over 230,000 trials across 195 countries in the world. It is estimately to

include approximately three-quarter of all clincal trials worldwide.

Developing drugs for central nervous system (CNS) use has a high failure rate.

Pharmaceutical companies have estimated that only nine percent of compounds that

enter phase I trials eventually make it to market to be commercialized. In the United

States, pharmaceutical companies have to spend nearly $800 million to develop a new

drug. The high failure rate is inhibiting large companies whose business model relies on

recouping research costs and clinical trial expenses through the sale of blockbuster

drugs. For this reason, pharmaceutical giants like GlaxoSmithKline and AstraZeneca

have not yet invested into neurological market segment.

The theory behind leverage cell therapies to address neurological diseases is rooted in

belief that living cells may have the capacity to induce cellular repair or exert paracrine

effects. The transplantation of neural stem cells or their derivatives and the inducement

16

of endogenous stem cells have both been proposed as mechanisms for the treatment of

neurodegenerative disorders. While the complexity of the human neurological system is

likely to be an impediment, preclinical studies as well as some early-stage human studies

have indicated the feasibility of this approach. Neural stem cells can be derived from a

variety of sources, and can subsequently be used for modeling neurodenerative diseases,

screening drugs for neurological disorders, or transplantation studies.

The following types of cells are used for generating neuronal cells:

• Neural stem cells (NSCs)

• Pluripotent stem cells (PSCs)

• Induced neural stem cells (iNSCs)

• Induced neuronal cells (iNCs)

• Mesenchymal stem cells (MSCs)

The stem cell industry is evolving rapidly, due to an increased focus on commercialization

of private and public research and accelerated regulatory pathways in many countries.

Over the past few years, the regulatory landscape for cell therapy development has grown

increasingly complex, but there are now accelerated pathways for advanced therapy

medicinal products (ATMPs) in several countries worldwide, including the U.S., Japan,

and South Korea. While the possibility for accelerated commercialization has resulted

from these changes, substantial complexity has also been introduced, making it a more

elaborate process to move cell therapy products from “bench to bedside.”

The overall stem cell market is segmented as follows:

• Stem cell products: All physical products involving stem cells or their derivatives,

including all tools and products needed to facilitate stem cell isolation, production,

cryopreservation, expansion, subculture, and more.

17

• Stem cell services: All services involing stem cells or their derivatives, including

stem cell banking, drug discovery and target identification,

isolation/characterization services, and more.

• Stem cell technologies: All technologies involving stem cells and their derivatives,

including systems, software, freezers, transportation containers, and other

technologies that facilitate the stem cell workflow.

• Stem cell applications: Regenerative medicines leveraging stem cells for the

treatment of neurological disorders, orthopedics, cancer, blood disorders,

myocardial infarction, cardiovascular diseases, injuries, diabetes, liver disorders,

and more.

The advantages of stem cell therapy are enticing a large number of companies to invest

in R&D efforts and clinical-stage programs. Stem cells used in research and to develop

stem cell therapeutics had a value of $4.3 billion in 2015 and it is estimated they will

generate revenues of approximately $8.2 billion by 2021.

18

3. STEM CELLS: A BRIEF OVERVIEW

Stem cells can multiply (self-renew) and differentiate into every cell within the human

body, giving them enormous potential for use in regenerative medicine. In a developing

embryo, stem cells can differentiate into all of the specialized embryonic tissues. In

adult humans, stem and progenitor cells act as a repair system for the body,

replenishing specialized cells.

Stem cell research has been going on for over 50 years, because stem cells have a

unique ability to divide and replicate repeatedly. In addition, their unspecialized nature

allows them to become a wide variety of tissue types, which gives them enormous

potential for use as living cell therapies.

3.1 Embryonic Stem Cells

Under the right conditions, a stem cell isolated from an embryo is capable of differentiating

into nearly all of cells within the body. After an egg is fertilized by a sperm, a single zygote

is formed. This cell has the potential to create an entire organism. In the initial hours and

days following fertilization, this single totipotent cell divides into more totipotent cells that

are exact copies of the original. Approximately four days after fertilization, the totipotent

cells start to specialize and form a cluster of cells known as a blastocyst. The blastocyst

contains another smaller group of cells known as the inner cell mass, and it is these inner

pluripotent stem cells that will go on to create most of the cells and tissues in the human

body. These pluripotent stem cells are different than totipotent stem cells because they

don’t develop into a complete organism. A pluripotent cell will not develop into placental

or other tissues that are vital for fetal development, but it will develop into other specialized

cell types in the human body, such as nerve and heart cells.

19

3.2 Induced Pluripotent Stem Cells

Induced pluripotent stem cells (iPSCs) are somatic cells that can be manipulated by

researchers to exhibit properties of embryonic stem cells (ESCs). Introduction of a set of

four factors into somatic cells, along with specific culture conditions, alters each cell’s

epigenetic signature, resetting the cell to a pluripotent ESC-like state. This process is

termed “reprogramming.” Like ESCs, iPSCs can be differentiated into many different cell

types in the laboratory.

Enthusiasm for producing patient-specific human embryonic stem cells using somatic

nuclear transfer has somewhat abated in recent years because of ethical, technical, and

political concerns. However, interest in generating iPSCs, in which pluripotency can be

obtained by transcription factor transduction of various somatic cells, has rapidly

increased. Human iPSCs are expected to create enormous opportunities in the

biomedical sciences to develop cell therapies for regenerative medicine and stem cell

modeling of human disease. On the other hand, recent reports have emphasized the

pitfalls of iPSC technology, including the potential for genetic and epigenetic

abnormalities, tumorigenicity, and immunogenicity of transplanted cells. These engender

serious safety-related concerns for iPSC-based cell therapy. However, preclinical data

supporting the safety and efficacy of iPSCs are also accumulating.

3.3 Types of Specialized Cells Derived from Stem Cells

The ability of stem cells to give rise to specialized cells is a crucial one. In this process of

differentiation, unspecialized stem cells produce specialized cells. It is thought that a cell’s

genes regulate the internal signals that trigger this process. These genes carry the

specific code, or instructions, for all the parts and functions of a cell. External signals are

those outside of the cell, including chemicals released from other cells, physical

connections with nearby cells, and various other molecules in the surrounding area.

20

FIGURE 3.4: Types of Specialized Cells Derived from Stem Cells

Source: Catherine Twomey, “Understanding Stem Cells: An Overview of Science and Issues from the National Academies”

21

3.4 Types of Stem Cells in the Human Body

Stem cells are classified into four broad types based on their origin:

• Stem cells from embryos (embryonic stem cells)

• Stem cells from the fetus (fetal stem cells)

• Stem cells from the perinatal period (umbilical cord blood and tissue stem cells,

as well as placental and amniotic stem cells)

• Stem cells from adult cells (adult stem cells)

3.4.1 Human Embryonic Stem Cells

Human embryonic stem cells (hESCs) are derived from blastocysts, a stage in the

developing embryo, and are the only controversial stem cell type. They can become

any cell type within the human body. They are totipotent cells that are derived from

embryos that have been created in vitro at fertility clinics with informed donor

consent. Embryonic stem cells are typically collected shortly after fertilization (within

4-5 days). At 5-6 days post-fertilization, embryonic stem cells begin to specialize, at

which point they become pluripotent or multipotent cells.

3.4.2 Embryonic Germ Cells

Human embryonic germ cells are also stem cells. They arise from the primordial germ

cells of a five- to nine-week-old fetus. Scientists have successfully isolated and

characterized the embryonic germ cells. They are able to produce cells of all three

germ layers, and therefore, these cells are pluripotent. Human embryonic germ

cells (EG cells) are derived from a specific part of the embryo called the gonad ridge.

These germ cells normally develop into eggs or sperm. They are isolated from fetuses

older than eight weeks of development. While EG cells are similar to embryonic stem

(ES) cells in many ways (such as being able to develop into any cell type), they are

different in the way they grow in the laboratory. ES cell cultures have been grown for

22

over two years in the laboratory as immortal cell lines, but EG cell cultures can survive

only about 70 to 80 cell divisions. This makes them less suitable for establishing cell

lines for research.

One advantage of EG cells is that they do not appear to generate tumors when

transferred into the body, as ES cells do. This could make them useful as a source of

transplant tissue and cell-based therapies. However, one of the greatest issues facing

researchers is that EG cells are derived from the destruction of a fetus. EG cells are

isolated from terminated pregnancies, and no embryos or fetuses are created for

research purposes.

3.4.3 Fetal Stem Cells

Organs of fetuses are rich in fetal stem cells. Cells such as neural crest stem cells,

fetal hematopoietic stem cells, and pancreatic islet progenitors can be isolated from

them. Fetal neural stem cells in the fetal brain can differentiate into neurons and glial

cells. Fetal hematopoietic stem cells can be obtained from fetal blood, the placenta,

and the umbilical cord. If fetal stem cells are obtained from miscarried or stillborn

fetuses, or if it is possible to remove them from fetuses alive in the womb without harm

to the fetus, then no harm is done to the donor.

3.4.4 Umbilical Cord Stem Cells

Circulating stem cells are found in umbilical cord blood. At least as great a number of

hematopoietic stem cells can be found in umbilical cord blood as can be found in bone

marrow. They produce large colonies in vitro and can be expanded in long-term

culture. Compared to bone marrow cells, they show a decreased graft-versus-host

reaction. They are also multipotent and capable of differentiating into neurons and

liver cells. The matrix of cord blood is also a source of mesenchymal stem cells.

Recent medical advances have indicated that these stem cells found in cord blood

can be used to treat the same disorders as the hematopoietic stem cells found in bone

23

marrow, but without some of the disadvantages of bone marrow transplants. Cord

blood is currently used to treat approximately 80 diseases, including leukemias,

lymphomas, anemia, and severe combined immunodeficiency (SCID).

Cord blood does not have to be as closely matched as bone marrow or peripheral

blood transplants. Bone marrow transplants typically require a 6/6 HLA match. While

a closely matched cord blood transplant is preferable, cord blood has been

transplanted successfully with matches as low as 3/6. Since cord blood is

cryogenically preserved and stored, it is more readily available than bone marrow or

peripheral blood from an unrelated donor, allowing transplants to take place within a

shorter period of time.

In 1988, only one disease was being treated with cord blood stem cells. In 1999, there

were only two. Today, that list has exploded to include nearly 80 diseases and

conditions, many of which were previously considered incurable. With over 700 clinical

trials currently in progress, scientists have estimated that approximately 1 in 100

people born in the US today will receive a stem cell transplant by the age of 70.

24

3.5 Adult Stem Cells

An adult stem cell is an undifferentiated cell, found among differentiated cells in a tissue

or organ, that can renew itself and can differentiate to yield some or all of the major

specialized cell types of that tissue or organ. The primary roles of adult stem cells in a

living organism are to maintain and repair the tissue in which they are found. Scientists

also use the term somatic instead of adult stem cell, where somatic refers to cells of the

body (not the germ cells, sperm, or eggs).

3.5.1 Hematopoietic Stem Cells

The stem cells that form blood and immune cells are known as hematopoietic stem

cells (HSCs). They are ultimately responsible for the constant renewal of blood and

the production of billions of new blood cells each day. A hematopoietic stem cell

isolated from the blood or bone marrow can renew itself, differentiate into a variety of

specialized cells, mobilize out of the bone marrow into circulating blood, and undergo

programmed cell death, called apoptosis.

The classic source of HSCs is bone marrow. For more than 40 years, doctors have

performed bone marrow transplants by anesthetizing the stem cell donor, puncturing

a bone, and drawing out the bone marrow cells with a syringe. About one in every

100,000 cells in the marrow is a long-term, blood-forming stem cell; other cells present

include stromal cells, stromal stem cells, blood progenitor cells, and mature and

maturing white and red blood cells. As a source of HSCs for medical treatments, bone

marrow retrieval directly from bone is quickly fading into history. For clinical

transplantation of human HSCs, doctors now prefer to harvest donor cells from

peripheral, circulating blood. In the past 10 years, researchers have found that they

can coax the cells to migrate from marrow to blood in greater numbers by injecting the

donor with a cytokine, such as granulocyte-colony stimulating factor (GCSF).

25

3.5.2 Mesenchymal Stem Cells

Mesenchymal stem cells (MSCs) are adult stem cells traditionally found in the bone

marrow. However, MSCs can also be isolated from other tissues, including cord blood,

peripheral blood, fallopian tubes, and fetal livers and lungs. MSCs differentiate to form

adipocytes, cartilage, bone, tendons, muscle, and skin. Morphologically, MSCs have

long thin cell bodies with a large nucleus. As with other stem cell types, MSCs have a

high capacity for self-renewal while maintaining multipotency.

In recent years, clinical trials with stem cells have taken the emerging field in many

new directions. While numerous teams continue to refine and expand the role of bone

marrow and cord blood stem cells for their vanguard uses in treating blood and

immune disorders, many others are looking to expand the uses of the various types

of stem cells found in bone marrow and cord blood, in particular MSCs, to treatments

beyond those involving replacing cells in their own lineage.

3.5.3 Neural Stem Cells

Neural stem cells (NSCs) are found to occur only in two areas of the central nervous

system. One area is the subventricular zone of the forebrain and the other is the dental

gyrus of the hippocampus. NSCs residing in these two zones consistently generate

new neurons. Potential transplantation applications of neural stem cells include

Parkinson’s disease, Huntington’s disease, stroke, early Alzheimer’s disease, and

cerebral palsy. All of these diseases are chronic and debilitating, and there is currently

no effective long-term treatment for them.

3.5.3.1 NSCs’ Capacity to Migrate and Engraft

The disease-directed migration potential of NSCs provides a powerful tool for the

treatment of both localized and diffuse disease processes within the human brain.

The majority of clinical investigations use NSCs for the treatment of neurologic

disorders such as multiple sclerosis, brain tumor, stroke, and lysosomal storage

26

diseases. All these studies are focusing on evaluating the ability of therapeutic

NSCs to successfully migrate to and function at targeted regions of pathology.

Preclinical studies have indicated that NSCs deployed in vivo into the brains of

disease-bearing mice have these capabilities. Studies of NSCs’ pathotropism have

indicated that a number of cytokine/receptor pairs are linked with the homing of

NSCs to diseased areas of the brain. These include stem cell factor (SCF)/c-Kit,

monocyte chemoattractant protein-1 (MCP-1)/chemokine receptor 2 (CCR2),

vascular endothelial growth factor/receptor (VEGF/VEGFR), hepatocyte growth

factor (HGF)/c-Met, and stromal cell-derived factor 1 (SDF-1)/CXCR4.

3.5.3.2 Characterization of NSCs

The isolated NSCs carry the risk of becoming tumorigenic after serial passaging

and transplantation. Therefore, the NSCs are to be characterized before being

used in cell therapy. For the foreseeable future, cell surface antigen markers will

continue to play a major role in the characterization of NSCs. On repeated

passages, neurospheres produce self-renewing and differentiating cells

expressing prominin-1 cell surface antigen (CD133). These cells can be effectively

isolated from the heterogeneous cell population by magnetic beads attached to

antibodies. The following table lists the markers used to identify NSCs and their

lineages within the heterogeneous mass of cells.

TABLE 3.1: NSCs, NPCs, and their Lineage-Specific Markers

Types of Cells Positive Markers Negative Markers

NSCs

Prominin-1 (CD133), CD56, Nestin, Sox-2, Oct-4, Notch-2, ABCB1, ABCG2, RBP1, RBP2, RBP7, HSPA4, HSPA9, HSPA14

CD34, CD45

Neuronal progenitors PSNCAM, P75 Neurotrphin receptor

-

27

Astrocytes progenitors CD44, A2B5 -

Oligodendrocyte progenitors

NG2, PDGFR-∞, Olig-2 -

Neurons

MAP-2, Double Cortin, β-tubilin III, RNA Binding Protein (HuC), Neuro D, Neu N

-

Astrocytes GFAP -

Oligodendrocytes Olig-1, Olig-4, Galactocerebroside (Gal C)

-

Source: Vishwakarma SK, Bardia A, Tiwari SK, Paspala SAB, Khan AA. Current concept in neural regeneration research: NSCs isolation, characterization and

transplantation

3.5.3.3 Major Three Neuronal Lineages from NSCs

Applications of NSCs to diseases affecting the nervous system are still a

pioneering field, being in the early phases of clinical scrutiny. Researchers have

yet to succeed in manipulating these cells to provide reliable, safe, and effective

outcomes in cell-replacement approaches. Immature NSCs are found in the

developing and adult central nervous system (CNS) and are characterized by their

self-renewal potential, neural tripotency, and capability for in vivo regeneration.

With their neural tripotency, they can develop into the major neural lineages, such

as neurons, astrocytes, and oligodendrocytes.

28

FIGURE 3.5: Major Three Neural Lineages from Neural Stem Cells

Source: Casarosa et al., “Neural Stem Cells: ready for therapeutic applications?” 15 October 2014

(http://molcelltherapies.biomedcentral.com/articles/10.1186/2052-8426-2-31)

Neurons

Our mental life mostly involves the activities of the nervous system, particularly the

brain. The nervous system is made of billions of cells, and the most important ones are

the nerve cells, or neurons. There are nearly 100 billion neurons in a human body. A

typical neuron has all the parts that any cell has, plus a few specialized structures that

set it apart. The main portion of the cell is called the soma, or cell body. It contains

the nucleus, which in turn contains genetic material in the form of chromosomes. Neurons

have a large number of extensions called dendrites. They often look like branches, or

spikes, extending out from the cell body. It is primarily the surfaces of the dendrites that

receive chemical messages from other neurons. One extension is different from all the

others and is called the axon. Although in some neurons the axon is hard to distinguish

from the dendrites, in others it is easily distinguished by its length.

The function of the axon is to transmit an electrochemical signal to other neurons,

sometimes over a considerable distance. In the neurons that make up the nerves running

from the spinal cord to your toes, the axons can be as long as three feet. Longer axons

are usually covered with a myelin sheath, a series of fatty cells that are wrapped around

29

an axon many times. At the very end of the axon is the axon ending, which goes by a

variety of names, such as the bouton, the synaptic knob, the axon foot, and so on. It is

there that the electrochemical signal that has traveled the length of the axon is converted

into a chemical message that travels to the next neuron.

FIGURE 3.6: Structure of a Neuron

Source: http://webspace.ship.edu/cgboer/theneuron.html

Astrocytes

Astrocytes are star-shaped cells that perform a variety of functions in the CNS. Astrocytes

provide physical support to neurons and clean up debris within the brain. They also

provide neurons with some of the chemicals needed for proper functioning and help

control the chemical composition of fluid surrounding neurons. Finally, astrocytes play a

role in providing nourishment to neurons. In order to provide physical support for neurons,

astrocytes form a matrix that keeps neurons in place. In addition, this matrix serves to

isolate synapses. This limits the dispersion of transmitter substances released by terminal

buttons, thus aiding in the smooth transmission of neural messages.

30

FIGURE 3.7: Structure of Astrocytes

Source: https://en.wikipedia.org/wiki/Astrocyte

Oligodendrocytes

Oligodendrocytes form the isolating sheath around the axons, which is essential for fast

signal conduction. A traumatic spinal cord injury causes damage to those cells, followed

by the loss of isolation sheaths. As a result, the conduction of electrical signals is

massively impaired inside the axons. The sheath formed by oligodendrocytes is

composed 80% of lipids and 20% of protein. This composition confers on the

oligodendrocyte its capacity to isolate axons from each other and, especially, to allow fast

nerve signal conduction. A single oligodendrocyte can extend its processes to 50 axons.

31

FIGURE 3.8: Structure of Oligodendrocytes

Source: https://en.wikipedia.org/wiki/Oligodendrocyte

3.6 Characteristics of Different Types of Stem Cells

In general, stem cells are classified into four categories based on their origin: embryonic

stem cells, fetal stem cells, adult stem cells, and induced pluripotent stem cells. The

characteristics of each type are shown in the following table. Due to availability of sources,

easy accessibility, and relatively few ethical issues, adult stem cells are seen as attractive

and promising in current research and regenerative medicine.

TABLE 3.2: Characteristics of Different Types of Stem Cells

Category Origin Advantages Disadvantages

Human embryonic stem cells (hESCs)

Human blastocysts Pluripotent, non-immunogenic

Insufficient sources, Ethical and religious debates

32

Human fetal stem cells (hFSCs)

Fetal blood from umbilical cord, fetal membranes and placenta

Multipotent, non- immunogenic, less ethical and religious debate

Insufficient sources

Adult stem cells

Bone marrow, adipose tissue, skin

Multipotent, abundant sources, easy access

Difficult to expand, limited use in clinical practice

Induced pluripotent stem cells (iPSCs)

Somatic cells

Pluripotent, abundant sources, no ethical and religious debate

Difficult to induce

Source: Volume 2016 (2016), Article ID 6737345, 19 pages, http://dx.doi.org/10.1155/2016/6737345

33

4. NEURAL STEM CELLS: AN OVERVIEW

One of the milestone events in the past 25 years of nervous system research was the

establishment of neural stem cells (NSCs) as a lifelong source of neurons and glia.

Neurons are nerve cells that are specialized to transmit information throughout the body.

They communicate information both in chemical and electrical forms. Glial cells surround

neurons and provide support and insulation. The discovery that NSCs can regenerate

was a phenomenal success for neuroscience researchers because until then it was

believed that the nervous system lacked regenerative power. NSCs have the ability to

generate, repair, and change nervous system functions. With the advent of

reprogramming technology, even the human somatic cells are being used to generate

NSCs. The progenies of NSCs can model neurological diseases with enhanced accuracy.

4.1 Sources of NSCs

NSCs can be isolated from skin, embryonic stem cells (ESCs), embryonic NSCs, bone

marrow, adipose-derived mesenchymal stem cells (MSCs), induced pluripotent stem cells

(iPSCs), and fetal and adult nervous systems. NSCs obtained from these sources have

demonstrated their potential for the treatment of several neurodegenerative diseases.

However, there is a need to identify a more suitable source for in vitro and in vivo trans-

differentiation into the correct phenotype. The following table summarizes the various

sources of NSCs and their advantages and disadvantages.

34

TABLE 4.1: Sources of NSCs and Advantages and Disadvantages in their Applications

BMSCs UCBSCs ESCs iPSCs fNPCs Spinal Cord Cells

Adipose MSCs

Isolation Not

easy Not easy

Not easy

Not easy

Not easy

Not easy

Easy

Ethical issues Yes No Yes No Yes Yes No

Pre-isolation storage

No Yes No No No No -

Post-isolation storage

Yes Yes Yes Yes Yes Yes Yes

Turmorigenicity No No Yes Yes No No No

Transfection Yes Yes Yes Yes Yes Yes - Source: Vishwakarma SK, Bardia A, Tiwari SK, Paspala SAB, Khan AA. Current concept in neural regeneration research

4.2 Basal Properties of NSCs Obtained from Different Sources

Researchers use ESCs, hNSCs, iPSCs-derived NSCs, and ihNSCs for preclinical and

clinical studies involving neurodenerative diseases. Embryonic stem-derived NSCs show

the same potential therapeutic effects as those obtained from the spinal cord and offer

great promise as an unlimited source of neural stem cells for transplantation. They are

capable of differentiating into motor neurons in vitro and in vivo. Additionally, soon after

their intrathecal transplantation into spinal muscular atrophy mice, the neural stem cells,

like those obtained from the spinal cord, survive and migrate to appropriate areas,

ameliorate behavioural endpoints and lifespan, and exhibit neuroprotective capability.

Neural stem cells derived from other sources also have shown promising results in

preclinical studies, and their properties are given in the following table.

35

TABLE 4.2: Different Types of NSCs and their Basal Properties

NSC Type Tissue Source Properties

ES1-derived NSCs (ESCs)

Inner cell mass of blastocyst High rate of proliferation, pluripotency

Fetal NSCs (hNSCs2)

Telencephalic-diencephalic region from 8-12 week fetal brain

Stable profile of growth and differentiation in vitro

iPSC3-derived NSCs

Skin fibroblast from adult tissue, cord blood, adult peripheral blood mono- nuclear cells

Low immunogenic potential, optimal source for disease modeling and drug screening

ihNSCs4 Fetal NSCs, ES-derived progenitors

No risk of immunorejection, high rate of proliferation, large-scale availability

Source: De Filippis L, Binda E. Concise Review: Self-Renewal in the Central Nervous System: Neural Stem Cells from Embryo to Adult, Stem Cells Translational Medicine

4.2.1 BMSCs as a Sourse for NSC-Like Cells

Under suitable culture conditions, mesenchymal stem cells obtained from bone marrow

(BMSCs) are able to differentiate into different cell types, including neural cells. BMSCs

are grown in a conditioned medium of human neural stem cells. The culture system

induces BMSCs to differentiate into NSC-like cells, which proliferate and secrete early

NSC markers. These NSC-like cells are able to differentiate into cells secreting neural

markers for neurons, astrocytes, and oligodendrocytes. Grafting of NSC-like cells into

mouse brains shows that these NSC-like cells retained their potential to differentiate into

neuronal and glial cells in vivo.

1 embryonic stem 2 human neural stem cell 3 induced pluripotent stem cells 4 immortalized human neural stem cell

36

4.2.2 UCBSCs: Express Pro-Neural Genes and Neural Markers

Umbilical cord blood stem cells (UCBSCs) are being investigated as an alternative cell

source for the repair of brain damage by transplantation. Several in vitro studies have

documented unexpected phenotypic plasticity of progenitor cells present in the

mononuclear cell fraction of cord blood. Freshly isolated human umbilical cord blood cells

have been found to express Oct3/4, Sox2, Mdr1, and Rex1 genes. These are the master

regulators of the pluripotent stem cell state. During cell culture in suitable conditions,

umbilical cord blood cells start to express pro-neural genes such as nestin, glial fibrillary

acidic protein, NF200, and then the neural markers such as β-tubulin III, MAP2, GFAP,

S100β, 04, and GalC.

4.2.3 ESCs as a Source for NSCs

ESCs are pluripotent cells and are obtained from the inner cell mass of the

preimplantation blastocyst. Producing NSCs from human embryonic stem cells holds

great promise for the study of human neurogenesis, the production of neurons for

pharmacological studies, and development of potential cell therapy applications for

treating neurological diseases, such as Parkinson's disease. However, ESCs are

controversial because human embryos are killed to obtain them. Advanced Cell

Technology is one of the only companies (StemCells is another) still using embryonic

stem cells. It has human clinical trials active in macular dystrophy and macular

degeneration.

4.2.4 iPSCs as a Source of NSCs

Induced pluripotent stem cells (iPSCs) developed by reprogramming adult somatic cells

are another source of NSCs. These cells allay ethical concerns associated with use of

human fetal/embryonic tissue and may also minimize the risk of immune rejection of

implanted cells. The procedure involves the excision of skin cells from a patient with spinal

cord injury to be reprogrammed into autologous iPSCs that would be then differentiate

into NSCs for implantation into that patient’s lesion site.

37

TABLE 4.3: Advantages and Disadvantages of iPSCs Utilization

Source: BioMed Research International, Volume 2013 (2013), Article ID 430290, 11 pages, http://dx.doi.org/10.1155/2013/430290

4.2.4.1 Methods Used to Produce iPSCs

Most methods currently in use to produce iPSCs are based on gene delivery via retroviral

or lentiviral vectors. But, these methods carry identified risks for insertional mutagenesis

and oncogenic changes. To overcome these risks, researchers are now using transgene-

free reprogramming methods based, for example, on Sendai virus, direct mRNA, or

protein delivery to transform adult cells into hiPSCs. As several new sources, such as

adipose tissue, mesenchymal cells, and umbilical cord blood, have emerged, new

methods to induce cell reprogramming have also emerged that do not use viral particles.

The new methods are aimed at the safety and efficacy of generating human induced

pluripotent stem cells (hiPSCs) for clinical use. Now, basic research has been focusing

on characterizing the hiPSCs at a cytogenetic and molecular level to see whether these

cells retain genetic stability. The following table shows the main methods used in

generating iPSCs.

Advantages Disadvantages

Avoidance of human embryo use Oncogene use for induction of iPSCs phenotype

Capacity to induce stem cell-like phenotype Use of integrative DNA methodology

New promises for cellular therapy Genomic instability and aberrations

Possibility of studying several diseases, including cancer

Increase in the risk of cancer

38

TABLE 4.4: Methods Used to Generate iPSCs

Methodology Cell Type Genome Integration

Efficiency of iPSCs Induction

Retroviral transduction

Fibroblast, neuronal, keratinocytes, blood cells, adipose, liver cells

Yes High

Lentiviral transduction

Fibroblasts, keratinocytes Yes High

Inducible lentiviral transduction

Fibroblasts, melanocytes, beta cells, blood cells, keratinocytes

Yes High

Adenoviral transduction

Fibroblasts No Low

Plasmid vector Fibroblasts No Low

Cell-free lysate Fibroblast and adipose stromal cells No Low

Cell fusion Fibroblasts and adult thymocytes No Low

Minicircle DNA Adipose stem cells No High

Episomal vectors

Mononuclear bone marrow and cord blood cells

No High

Source: BioMed Research International, Volume 2013 (2013), Article ID 430290, 11 pages, http://dx.doi.org/10.1155/2013/430290

4.2.4.2 Chemicals Used for Neural Differentiation of iPSCs

Many protocols are now available for differentiation of human ESCs and a few are

available for iPSCs. Small molecules can solve this problem. Small molecules imitate the

specific biochemical pathways and also perform many functions. One of the synthetic

small molecules associated with neural differentiation and cell survival is ROCK inhibitor

(Y27632). The following table gives a list of small molecules used for neural

differentiation.

39

TABLE 4.5: Chemicals Used for Neural Differentiation of iPSCs

Name Mechanism

Retinoic acid Morphogen/agonist of the sonic hedgehog pathway

Epidermal growth factor (EGF)

Mitogen

Fibroblast growth factor (FGF-2, FGF-8, FGF-4)

Regulation of neural stem cell proliferation and self-renewal

Platelet-derived growth factor (PDGF)

Neural induction factor

Sonic hedgehog (SHH) Morphogen induction factor

Noggin BMP antagonist

SB431542 Inhibition of the TGFβ/Activin/Nodal pathway/inhibition of SMAD

Dorsomorphin Inhibition of BMP pathway/inhibition of SMAD

LDN193189 Inhibition of BMP pathway

Purmorphamine Activation of the hedgehog pathway

Source: Skalova S, Svadlakova T, Qureshi WMS, Dev K, Mokry J. Induced Pluripotent Stem Cells and Their Use in Cardiac and Neural Regenerative Medicine

4.2.4.3 Small-Molecule-Based Culture Protocols for Inducing hPSCs Differentiation

In the undifferentiated pluripotent stage, hPSCs cannot be transplanted directly into

patients due to their tumorigenic potential. Thus, establishment of efficient stepwise

differentiation protocols for directing hPSCs into specific cell lineages is an essential

prerequisite for both therapeutic and basic research applications. A large number of

studies have shown the desirability of the use of small molecules to modulate the key

developmental signaling pathways known to regulate neural differentiation of hPSCs. A

combination of multiple small molecule signaling pathway inhibitors, comprising LDN

193189, SB 431542, SU 5402, CHIR99021, and DAPT, could effectively bring about the

neural differentiation of hPSCs. Some studies have indicated the need for a highly

efficient protocol for directing monolayer-cultured hESCs into homogenous primitive

neural stem cells (pNSCs) with combined inhibition of the GSK3, TGF-β, and Notch

signaling pathways.

40

TABLE 4.6 Small-Molecule-Based Culture Protocols for Inducing hPSCs Differentiation

Source: Yap MS, Nathan KR, Yeo Y, et al., Neural Differentiation of Human Pluripotent Stem Cells for Nontherapeutic Applications

4.2.4.4 Compounds Used for NSC Proliferation

For the generation of neural cell types from other than NSCs, certain small molecules are

required to be added to culture media. These small molecules are capable of inducing

differentiation. For instance, the compound SB 203580 selectively retards p38 MAPK

activity and triggers neural stem cell proliferation. Similarly, 1-Oleoyl lysophosphatidic

acid (LPA) sodium salt, an agonist of LPA receptors, stimulates human embryonic-stem-

cell-derived NSC differentiation. Small molecules can also improve stem cell

differentiation into cells of neuronal and glial lineages. For instance, mesenchymal stem

cells differentiate into cells of the neural lineage and secrete increased levels of the

neuronal markers beta-III Tubulin and Enolase-2 when treated with the synthetic

compound C18H17N3O3. The following table lists some small molecules used for the

purpose of neuronal cell proliferation.

TABLE 4.7: Compounds Used in Neural Stem Cell Research

Compound Application

SB 431542 Selective inhibitor of TGF-betaRI, ALK4

Y-27632 dihydroxychloride Selective P160ROCK inhibitor

CHIR 99021 Highly selective GSK-3 inhibitor

Forskolin Adenyl cyclase activator

A 83-01 Selective inhibitor of TGF-betaRI, ALK4, and ALK7

Neuronal Sublineages Small Molecules Used

Dopaminergic SB431542 together with the protein noggin

Dopaminergic Purmorphamine + CHIR99021

Dopaminergic Dorsomorphin +SB431542

GABAergic Agonists of muscarinic and GluR1 recetorp

Cholinergic motor neurons Retinoic acid + purmorphamine

Cholinergic motor neurons Retinoic acid + Purmorphamine + SMO agonist SAG

41

DAPT Gamma-secretase inhibitor

Metformin hydrochloride Activator of LKB1/AMPK, antidiabetic agent

Dorsomorphin dihydrochloride Selective AMPK inhibitor

SB203580 Selective inhibitor of p38 MAPK

Valporic acid, sodium salt Histone deacetylase inhibitor

DMH-1 Selective ALK2 inhibitor

Retinoic acid Endogenous retinoic acid receptor agonist

1-Oleoyl lysophosphatidic acid sodium salt

Endogenous agonist of LPA1 and LPA2

Fluoxetine hydrochloride 5-HT reuptake inhibitor

SU 5402 Potent FGFR and VEGFR inhibitor

BIO Potent, selective GSK-3 inhibitor

Cyclopamine Inhibitor of hedgehog signaling

INDY DYRK1A/B inhibitor

17-AAG Selective Hsp90 inhibitor

PD 173074 FGFR1 and 3 inhibitor

20(S)-hydroxycholesterol Allosteric activator of hedgehog signaling, induces Smo accumulation

Pfithrin-alpha hydrobromide P53 inhibitor, also aryl hydrocarbon receptor agonist

Source: R&D Systems, “Compounds for Neural Stem Cell Research Products”

4.2.4.5 Synthetic Compounds Used to Induce NSC Differentiation into Neurons

A number of synthetic compounds have been found to have effects on neurogenesis.

NSCs have the ability to respond to these compounds and get differentiated into multiple

cell types. As an example, sodium butyrate increases proliferation of NSCs in the

ischemic brain of adult rodents.

TABLE 4.8: Synthetic Compounds Used to Induce NSC Differentiation into Neurons

42

Compound Effects Cells/System

Retinoic acid Increases neurogenesis NSCs

Sodium butyrate Increases neurogenesis and neural proliferation

In vivo

Amitriptyline Increases neurotrophic factor levels NSCs

Fluoxetine Increases neurogenesis In vivo

Sertraline Increases neurogenesis and attenuates cellular damage

NSCs

Carbamazepine Increases neurogenesis and decreases astrocytogenesis

NSCs

Valproate Increases neurogenesis, reduces NSC death, and provides neuroprotection

NSCs

KHS101 Increases neurogenesis NSCs

Oxadiazol compounds

Enhances astrocyte differentiation NSCs

Phosphoserine Inhibits NSC proliferation, enhances neurogenesis, and increases cell survival

hESCs, NSCs

Atorvastatin Increases neurogenesis and reduces neuronal death

In vivo

Source: Kim H-J, Jin CY. Stem Cells in Drug Screening for Neurodegenerative Disease.The Korean Journal of Physiology & Pharmacolog

4.2.4.6 Natural Products Affecting NSC Survival, Proliferation, and Differentiation

Some natural products are also known to affect cell fate determination of NSCs.

Methanol-based extracts from Jeju plants are found to protect apoptosis induced by

hydrogen peroxides. Extract from the fruits of Ammi visnaga containing visnagin is used

to treat low blood pressure. This substance has protective effects on kainic acid-induced

mouse hippocampal cell death by decreasing inflammation. The following table gives

some more examples.

43

TABLE 4.9: Natural Products that Are Known to Affect NSC Survival, Proliferation, and Differentiation

Source: Kim H-J, Jin CY. Stem Cells in Drug Screening for Neurodegenerative Disease.The Korean Journal of Physiology & Pharmacology

4.3 Fetal Stem Cell Transplantation for Neurodegenerative Diseases

Since 2000, fetal cell transplantation has progressed in clinical development. A large

number of companies have developed or are developing fetal stem cell products via the

use of intracerebral or spinal transplantation. The majority of the companies are using

fetal stem cells for neurological diseases and central nervous system injury. The specific

disease conditions include amyotrophic lateral sclerosis (ALS), cerebral palsy, cerebral

atrophy, Huntington’s disease, and Parkinson’s disease. In the case of CNS injuries,

spinal cord injury and traumatic brain injury are receiving more attention in the setting of

fetal cell transplantation. TABLE 4.10: Ongoing Clinical Trials of Fetal Stem Cell Transplantation for Neurological Diseases

Trial No. Year

Started Sponsor Cell Source Indication

NCT01151124 2010 ReNeuron Ltd.

CTXE0E03 neural stem cells

Stroke

NCT01321333 2011 StemCells Inc.

HuCNS-SC Spinal cord injury

NCT01348451 2009 Neuralstem Inc.

Spinal cord-derived NSC ALS

NCT01391637 2011 StemCells Inc.

HuCNS-SC Pelizaeus-merzbacher disease

Substance Plant Effects Cells

Garcinol Garcinia indica Protective effect on apoptotic cell death

NSCs

Ginsenoside Rg5

Panax notoginseng

Increases neurogenesis, decreases astrocytogenesis

NSCs

Casticin Croton betulaster Increases neurogenesis, decreases neuronal cell death

NSCs

Curcumin Indian turmeric Increases neurogenesis, decreases neural cell death and glial cell activation

NSCs

44

NCT01632527 2012 StemCells Inc.

HuCNS-SC Age-related macular degeneration

NCT01640067 2011 Azienda Ospidaliera

Fetal neural stem cells ALS

NCT01730716 2013 Neuralstem Inc.

Spinal cord-derived NSC ALS

NCT01772810 2014 Neuralstem Inc.

Spinal cord-derived NSC Spinal cord injury

NCT01860794 2013 Bundang CHA Hospital

Mesencephalic dopamine neuronal precursor cells

Parkinson’s disease

Source: Ishii T, Eto K. Fetal stem cell transplantation: Past, present, and future, World Journal of Stem Cells. 2014;6(4):404-420. doi:10.4252/wjsc.v6.i4.404.

4.4 Adult Human Neural Stem Therapeutics

Over the past 20 years, regenerative treatments using stem cell technologies have been

developed and tested for various neurological disorders. Even though stem cell therapy

is an attractive recourse to reverse neural tissue damage and recover neurological

function, it is still under development and has not yet showed sufficiently significant

treatment effects in clinical settings. Compared to other types of stem cells, adult neural

stem cells (aNSCs) have the advantage of differentiating into functional neural cells.

However, there is difficulty in isolating them from the normal brain, which has blocked

preclinical and clinical study using aNSCs. Nevertheless, many research groups have

successfully developed novel techniques for isolating and proliferating aNSCs from

normal adult brains and showed successful applications of aNSCs to neurological

diseases.

aNSCs are tissue-resident multipotent neural progenitor cells that possess self-renewal

capacity as long as they remain undifferentiated. Under suitable culture conditions,

aNSCs have the capacity to differentiate into neural cells, such as neurons, astrocytes,

and oligodendrocytes. aNSCs occur in the developmental stage and in the mature CNS,

particularly in the subventricular zone (SVZ) and subgranular zone (SGZ).

45

Numerous preclinical animal models have tested the efficacy of aNSCs and their

derivatives. Differentiated neural cells do not have the ability to proliferate and produce

sufficient quantities of cells for transplantation. So, for the purpose of transplantation,

aNSCs are the first to be appropriately isolated, and effectively proliferated, in vitro.

Compared to other stem cells, aNSCs occur in restricted areas of the adult CNS and have

very limited capacity to proliferate. Therefore, difficulties in the primary isolation and

stable in vitro proliferation of aNSCs are major technical hurdles to the use of aNSCs in

transplantation.

TABLE 4.11: The Various Methods of Isolation, Culture, and Expansion of aNSCs

Culture Method

Cell Source Dissociating Method

Adherent culture

Temporal lobe Physical mincing and enzymatic digestion using papain

Temporal lobe Mechanical trituration and enzymatic dissociation using papain and DNAse 1

Neurosphere culture

Hippocampal and lateral ventricle wall tissue

Mechanical dissociation and enzymatic digestion using hyaluronic acid, kynurenic acid, and trypsin

Temporal lobe Enzymatic digestion with trypsin

Hippocampus amygdala frontal cortex, temporal cortex

Enzymatic digestion with hyaluronidase, kynurenic acid, and trypsin

Temporal lobe Enzymatic digestion with papain, DNase 1, and neural protease

Lateral ventricular roof Mechanical dissociation, enzymatic digestion with DNase 1 and trypsin

Hippocampus containing hilus, temporal cortex, etc.

Physical mincing and enzymatic digestion with trypsin

Biopsies from filum terminale

Physical mincing and enzymatic digestion with trypsin

Source: Nam H, Lee K-H, Nam D-H, Joo KM. Adult human neural stem cell therapeutics: Current developmental status and prospect, World Journal of Stem Cells

46

4.4.1 Current Therapeutic Status of aNSCs

The preclinical and clinical use of aNSCs is of recent origin and, therefore, results showing

treatment effects are very much limited. However, a number of previous reports have

shown that NSCs, compared with other stem cell types, are optimal for neurological

diseases, as neural functional recovery requires direct neural cell supplementation in

addition to indirect paracrine effects. The following three tables list the preclinical and

clinical results of aNSCs-based studies.

TABLE 4.12: Preclinical Results (Rat) of aNSCs against Neurodegenerative Diseases

Source: Nam H, Lee K-H, Nam D-H, Joo KM. Adult human neural stem cell therapeutics: Current developmental status and prospect,, World Journal of Stem Cells

Targeted Disease

Cell Source Result

Demyelinated SCI

Frontal cortex, temporal cortex, etc.

Cells elicited remyelination and conducted impulses at near normal

Multiple sclerosis

Temporal lobe Migrated to lesions, differentiated into oligodendrocytes

Brain ischemia Temporal lobe aNSCs survived, migrated to ischemic region, differentiated into neural cells

Focal ischemic stroke

Temporal lobe Reduced infarction volumes, enhanced motor activity

47

TABLE 4.13: Trial ID and Title of Current Clinical Trials of aNSCs against Neurodegenerative Diseases

Source: Nam H, Lee K-H, Nam D-H, Joo KM. Adult human neural stem cell therapeutics: Current developmental status and prospect,, World Journal of Stem Cells

TABLE 4.14: Trial ID, Cell Source, Location, and Phases of Current Clinical Trials of aNSCs

Source: Nam H, Lee K-H, Nam D-H, Joo KM. Adult human neural stem cell therapeutics: Current developmental status and prospect,, World Journal of Stem Cells

The three tables above indicate how aNSCs are used in preclinical and clinical trials.

There are a number of disagreements about the therapeutic effects of stem cell

Trial ID Brief Title

NCT01640067 Human neural stem cell transplantation in amyotrophic lateral sclerosis

NCT01730716 Dose escalation and safety study of human spinal cord-derived neural stem cell transplantation for the treatment of amyotrophic lateral sclerosis

NCT01348451 Human spinal cord-derived neural stem cell transplantation for the treatment of amyotrophic lateral sclerosis

NCT01151124 Pilot investigation of stem cells in stroke

NCT02117635 Pilot investigation of stem cells in stroke, phase II efficacy

NCT01772810 Safety study of human spinal cord-derived neural stem cell transplantation for the treatment of chronic SCI

NCT01321333 Study of human central nervous system stem cells in patients with thoracic spinal cord injury

NCT02163876 Study of human central nervous system stem cells in patients with cervical spinal cord injury

Trial ID Disease NSC Source Location Period Phase

NCT01640067 ALS Fetal NSCs Italy 2011-2016 I

NCT01730716 ALS Fetal NSCs US 2013-2014 II

NCT01348451 ALS Fetal NSCs US 2009-2015 I

NCT01151124 Stroke aNSCs UK 2010-2015 I

NCT02117635 Stroke aNSCs UK 2014-2015 II

NCT01772810 SCI aNSCs US 2014-2016 I

NCT01321333 SCI aNSCs Canada, Switzerland 2011-2015 I, II

NCT02163876 SCI aNSCs US 2014-2017 II

48

treatments and their treatment mechanisms. However, compared with other stem cell

sources, aNSCs have many advantages that include their potential for differentiation into

functional neural cells, limited proliferation capacity, and few ethical problems.

49

5. DEGENERATIVE DISEASES WITH POSSIBLE CURE USING NSCS

Currently, many preclinical and clinical studies are focusing on neurodegenerative

diseases and neurodevelopmental diseases. Continuous loss of neural and glial cells in

the elderly population results in nervous system dysfunctions and diseases. These

diseases are associated with aging and thought to be a consequence of depletion of the

neural stem cell pool in the affected brain regions. The endogenous neural stem cells are

generally retained throughout life and are found in specific niches of the human brain.

These cells normally cause the regeneration of new neurons to restore the normal

functions of the brain. Such endogenous neural stem cells can be isolated, expanded,

and differentiated to most types of brain cells. Also, other types of stem cells, such as

mesenchymal stem cells, embryonic stem cells, and induced pluripotent stem cells, can

be used for neural stem cell production and hold great promise for regeneration of the

brain. Both preclinical and clinical studies are now focusing on the replacement of neural

stem cells into the impaired brain so as to bring about a favorable therapeutic remedy for

neurodegenerative diseases. The various neurodegenerative and neurodevelopmental

diseases for which neural stem cell therapy is tested include the following:

• Alzheimer’s disease

• Parkinson’s disease

• Huntington’s disease

• Amyotrophic lateral sclerosis

• Spinal cord injury

• Multiple sclerosis

• Ischemic stroke

• Retinal disorders

• Autism

50

5.1 Conventional Treatments for Neurodegenerative Diseases

Parkinson’s disease (PD) is a dopamine deficiency disorder. Dopamine therapy is

effective for improving both motor and non-motor symptoms in the initial PD stages.

Levodopa (LD) is the most efficient and best-accepted anti-Parkinson’s compound.

Initiating LD as first-line therapy may achieve optimal outcomes in terms of patient

function in the early years of the disease. Catechol-O-methyltransferase (COMT)

inhibition increases the peripheral bioavailability of LD and reduces 3-O-methyldopa

formation. The administration of COMT inhibitors with LD ensures a more stable plasma

LD level and, consequently, improves motor fluctuations. The use of COMT inhibitors

improves the half-life of LD, and the triple combination carbidopa (CD)-LD-entacapone

provides the most sustained LD plasma level.

However, in the long run, this combination treatment is accompanied by fluctuations of

motor functions, dyskinesias, and neuropsychiatric manifestations. Surgical treatment is

an option for patients who have motor fluctuations and dyskinesias because these

symptoms cannot be adequately managed by medications. The principal surgical option

is deep brain stimulation, which has largely replaced neuroablative lesion surgeries for

improving motor control. However, none of the conventional treatments offer a cure for

degenerative diseases. The following table gives the conventional therapeutics used in

the treatment of neurodegenerative diseases.

TABLE 5.1: Conventional Treatments for Alzheimer’s, Parkinson’s, and Huntington’s Diseases

Source: Suksuphew S, Noisa P. Neural stem cells could serve as a therapeutic material for age-related neurodegenerative diseases. World Journal of Stem Cells

Disease Treatment

Alzheimer’s Cholinesterase inhibitors, NMDA antagonists, psychological supports

Parkinson’s Levodopa, ergot dopamine agonists, non-ergot dopamine agonists, COMPT inhibitors, MAO-B inhibitors, ablative lesions, deep brain stimulation

Huntington’s Symptomatic agents

51

5.2 NSC-Based and Traditional Approaches for Neurodenerative Diseases

Results of preclinical studies have shown that the beneficial effects of stem cells may not

be confined to cell restoration alone, but also extend to their transient paracrine actions.

NSCs have been found to secrete potent combinations of trophic factors that can regulate

the molecular composition of the environment to elicit responses from resident cells for

repairing CNS injury. Evidence suggests that human NSCs, human UCBs, and murine

BM-MSCs secrete glial cell- and brain-derived neurotrophic factors (GDNF and BDNF),

IGF-1 and VEGF, that can protect dysfunctional motor neurons and prolong the lifespan

of the animals into which they are transplanted in disease models of neurodegenerative

diseases. The secretion of GDNF, BDNF, and NGF by NSCs has been responsible for

the increased dopaminergic neuron survival in in vitro and in vivo models of PD, and the

release of anti-inflammatory molecules has been shown to weaken microglia activation,

thereby protecting dopaminergic neurons from death.

TABLE 5.2: NSC-Based Approaches for Neurodegenerative Diseases

Disease Available Treatments NSC-Based Approaches

Parkinson’s Dopamine antagonists, enzyme inhibitors, deep brain stimulation

Transplantation of hNSCs or dopaminergic neurons into striatum or substantia nigra

Alzheimer’s Β-amyloid immunotherapy Transplantation of hNSCs or basal fibroblast producing NGF or BDNF

Spinal cord injury

No pharmacological treatment

Transplantation of OPCs, BMSCs, hNSCs

Huntington’s Fluoxetine, sertraline, nortriptyline

Transplantation of hNSCs producing GDNF into the striatum

ALS Riluzole, trihexyphenidyl or amitriptyline

Delivery of motor neurons, hNSCs, hMSCs at multiple sites along the spinal cord

Multiple sclerosis

Fingolimod (Gilenya) Transplantation of hNSCs at the site of injury

Brain tumor Surgery, radiotherapy, chemotherapy

Modified NSCs to produce necessary cytokines

52

Ischemic stroke

Tissue plasminogen activator, aspirin

Cell replacement therapy using hNSCs or MSCs

Source: Vishwakarma SK, Bardia A, Tiwari SK, Paspala SAB, Khan AA, Current concept in neural regeneration research

5.3 The Wide Gap Between Theory and Practice in NSC Applications

Currently available standard pharmacological therapy for most neurodegenerative

disorders can relieve some symptoms and only rarely provide a cure or halt the

progression of the disease. Transplantation of human fetal tissue has demonstrated a

proof of concept for cell therapy approaches to neurodegenerative conditions in a large

number of clinical studies, including treatment of Parkinson’s and Huntington’s disease

patients. However, this does not represent a workable route for large-scale therapeutic

applications because of the limited availability and quality of human fetal tissue, as well

as ethical considerations.

Regardless of the benefits claimed by the NSC field and some promising preliminary

studies in animal models, there still exists a wide gap between theory and practice. While

stem cell-based therapies have become the standard of care for blood tumors and

epidermal and corneal disorders, applications of NSCs for diseases affecting the nervous

system are still a pioneering field in the early phases of clinical scrutiny. Researchers

have yet to succeed in manipulating these cells to provide reliable, safe, and effective

outcomes in cell-replacement approaches. Immature NSCs are found in the developing

and adult central nervous system (CNS) and are characterized by self-renewal potential,

neural tripotency, and capability for in vivo regeneration. With their neural tripotency, they

can develop into the major neural lineages such as neurons, astrocytes, and

oligodendrocytes.

53

5.4 Types of NSCs Used for Cell Therapy Approaches

Several studies have evaluated grafting behavior of different NSC typologies (and their

progeny) in a number of preclinical studies and in some clinical studies. NSCs obtained

from different sources have been investigated: fetal and adult CNS-derived NSCs, neural

progenitors derived from pluripotent cells, and a variety of non-neural stem cells, such as

mesenchymal and bone marrow-derived stem cells. In spite of several efforts, until now,

no ideal NSC has been made available to the clinic.

5.4.1 Fetal and Adult-Derived NSCs

NSCs can be collected from different regions of the human brain that are in different

developmental stages, as well as from germinative areas of the adult brain. The collected

NSCs are cultured as neurospheres. Neurospheres are free-floating aggregates of neural

progenitors, each, in theory, derived from a single NSC. During the culture, the

differentiating or differentiated cells die, but the NSCs divide to produce floating

aggregates (primary neurospheres) that are then dissociated and re-plated to produce

secondary neurospheres. These steps are repeated several times to obtain NSC

population.

5.4.2 NSCs from Pluripotent Stem Cells

NSCs can be generated from embryonic stem cells (ESCs) and induced pluripotent stem

cells (iPSCs). ESCs can be isolated from the inner layers of blastocyst-stage embryos.

These cells have the intrinsic capacity for self-renewal and the ability to produce all cell

types. However, the technology of producing iPSCs has entirely revolutionized the

“pluripotency” field, avoiding the need for embryos as sources of pluripotent stem cells.

Researchers have developed two major procedures to produce NSCs from pluripotent

stem cells. The first procedure depends on the formation of embryoid bodies (EBs). EBs

show many aspects of cell differentiation and produce cells of the three germ layers,

54

including neural cells. EBs dissociated and plated in adhesion on coated plastic surfaces

in specialized media produce rosette-like neural cells similar to the neuroepithelial

progenitors (NEPs) of the developing brain. NSCs produced by this process can be then

enriched, even though no effective methods for their extensive expansion have been

reported.

Electrophysiology studies have indicated that pluripotent-derived NSCs can effectively

produce fully mature neurons in vitro, as well as functionally integrated neurons after

transplantation in the mammalian CNS. However, major restraints to therapeutic uses of

pluripotent-derived NSCs are represented by safety concerns and warnings about their

clinical-grade production. As a matter of fact, transplanted pluripotent cells can form

teratomas, suggesting that, in a clinical setting, residual undifferentiated pluripotent stem

cells should be excluded from the cell preparation before grafting.

5.5 Possible Therapeutic Actions of Grafted NSCs in Neurodegenerative Diseases

Even though NSCs can divide and differentiate in vitro, we have yet to see how these

cells functionally incorporate into the recipient tissue and bring about the restoration of

compromised functions after grafting. Huntington’s disease (HD) is a genetic disorder,

whereas Alzheimer’s disease (AD), amyotrophic lateral sclerosis (ALS), and Parkinson’s

disease (PD) mostly occur spontaneously in isolated cases. The CNS is also affected by

other non-degenerative conditions, such as spinal cord injury and stroke, which have no

genetic background. In the case of PD, even a limited pattern repair can result in a

significant functional recovery, and the donor cells can be grafted directly into the target

region to bypass the problem of long-distance neuritic growth in the adult CNS. In spite

of the ectopic location, if transplanted cells can re-establish a regulated and efficient

release of dopamine, they can provide a clinically relevant functional recovery. Cell-based

treatment approaches are exceedingly difficult for other diseases, such as HD, ALS,

trauma, stroke, and AD, that require a complex pattern repair.

55

5.6 Most Recent Clinical Trials Using NSCs for Neurological Disorders

The nervous system, different from many other tissues, possesses only a limited capacity

for self-repair. Mature nerve cells do not have the ability to regenerate. The NSCs present

in the adult brain also have only a limited ability to produce new functional neurons in

response to injury. Therefore, researchers evince great interest in developing NSCs for

repairing the nervous system by transplanting new cells that can replace those lost

through damage or disease. A number of reports and data in animal models of neurologic

diseases reveal that transplanted NSCs can also reduce deleterious inflammation,

prevent the CNS from degeneration, and improve endogenous recovery processes. The

purpose of transplanting NSCs is either to induce and/or support the proliferation,

survival, migration, and differentiation of endogenous cells or to replace dying or dead

endogenous cells.

Stem cell-based therapies using umbilical cord blood, bone marrow-derived HSCs, and

MSCs have already made claims of partial recovery in patients with spinal cord injury.

Recent advances in research on human fetal brain-derived neural precursors

undoubtedly show that they may play a very important role in cell transplantation therapy

for neuronal regeneration in the human brain and spinal cord. Intrastriatal transplantation

of human fetal primary tissue, containing postmitotic neurons and glia cells, has in clinical

trials furnished proof-of-principle that neuronal replacement can have an effect in the

human diseased brain.

56

TABLE 5.3: Some Recent Clinical Trials Using NSCs for Treating Neurological Diseases

Source: Vishwakarma SK, Bardia A, Tiwari SK, Paspala SAB, Khan AA. Current concept in neural regeneration research

5.6.1 Possible Outcome of Clinical Trials

NSCs and neural derivatives of pluripotent stem cells are now under investigation in early

phase I/II trials for CNS diseases. Also, new technologies based on direct conversion of

non-neural cells into NSCs and into distinctive neuronal populations are bringing out new

possible approaches for intervention. While it is yet too early to speculate on the outcome

of these trials, available early results do not suggest safety should be of concern. Even

though the NSC field is going forward every year and new trials are successively being

planned and started, as of today, none have yielded successful results, reducing the hope

that stem cells may be effective in CNS therapies in the next few years.

5.7 Other Clinical Trials Using NSCs for Neurodegenerative Diseases

Numerous studies have been investigating the behavior of transplanted NSCs in

preclinical studies. Most of the clinical trials are using only fetal tissue-derived allogenic

NSCs. StemCells Inc.’s product candidate HuCNS-SC consists of purified allogenic NSCs

obtained from human fetal (16–20 week) brain tissue, isolated using the CD133 marker

and multiplied in culture as neurospheres.

Trial Number Trial Title Duration Country

NCT01640067 Human neural stem cell transplantation in amyotrophic lateral sclerosis

2012-2016

Italy

NCT01348451 Human spinal cord-derived neural stem cell transplantation for the treatment of amyotrophic lateral sclerosis

2009-2013

US

NCT01696591 The long-term safety and efficacy follow-up study of subjects who completed the phase I clinical trial of Neurostem-AD

2012-2013

South Korea

NCT01329926 Molecular analysis of human neural stem cells

2011-2014

US

57

The first clinical trial using NSCs in May 2006 was approved at Oregon Health and

Science University for to be tested against lysosomal storage diseases. In 2009,

StemCells Inc. concluded the phase I safety study and in October 2010 started a phase

Ib safety and efficacy trial in six children. However, the study was discontinued when the

company failed to enroll patients meeting the study criteria.

Another phase I clinical trial was sponsored by StemCell Inc. at the University of

California, San Francisco. The study used HuCNS-SC brain grafts for Pelizaeus-

Merzbacher disease (PMD). PMD is an X-linked congenital leukodystrophy disease

causing defective myelination. The phase I clinical trial enrolled four young children

suffering a form of PMD. Data related to this clinical trial, published in October 2012,

showed a good safety profile for the HuCNS-SC cells and the transplantation procedure.

Clinical evaluation indicated small improvements in motor and cognitive function in three

of the four patients, and the fourth patient remained clinically stable.

TABLE 5.4: NCT Numbers and Titles of Clinical Trials Using NSCs for Neurodegenerative Diseases

NCT Number Title

NCT00337636 Study of HuCNS-SC Cells in Patients With Infantile or Late Infantile Neuronal Ceroid Lipofuscinosis (NCL)

NCT04005004 Study of Human Central Nervous System (CNS) Stem Cells Transplantation in Pelizaeus-Merzbacher Disease (PMD) Subjects

NCT01151124 Pilot Investigation of Stem Cells in Stroke

NCT01217008 Safety Study of GRNOPC1 in Spinal Cord Injury

NCT01238315 Safety and Efficacy Study of HUCNS-SC in Subjects with Neuronal Ceroid Lipofuscinosis (trial withdrawn)

NCT01321333 Nervous System Stem Cells (HuCNS-SC) in Patients with Thoracic Spinal Cord Injury

NCT01348451 Human Spinal Cord Derived Neural Stem Cell Transplantation for the Treatment of Amyotrophic Lateral Sclerosis (ALS)

NCT01640067 Human Neural Stem Cell Transplantation in Amyotrophic Lateral Sclerosis (ALS)

58

NCT01725880 Follow-Up of Transplanted Human Central Nervous System Stem Cells (HuCNS-SC) in Spinal Cord Trauma Subjects

NCT01730716 Dose Escalation and Safety Study of Human Spinal Cord Derived Neural Stem Cell Transplantation for the Treatment of Amyotrophic Lateral Sclerosis

NCT01772810 Safety Study of Human Spinal Cord Derived Neural Stem Cell Transplantation for the Treatment of Chronic Spinal Cord Injury

NCT02117635 Pilot Investigation of Stem Cells in Stroke Phase II Efficacy Source: Casarosa et al, “Neural Stem Cells: ready for therapeutic applications?” 15 October 2014 (http://molcelltherapies.biomedcentral.com/articles/10.1186/2052-8426-2-31)

TABLE 5.5: Status of Different Clinical Trials Using NSCs for Neurodegenerative Diseases

NCT Number Indication Intervention Sponsor Phase

NCT00337636 Neuronal ceroid lipofuscinosis

HuCNS-SC StemCells Inc. I

NCT04005004 Pelizaeus-Merzbacher disease

HuCNS-SC StemCells Inc. I

NCT01151124 Stroke HTX0E03 NSC ReNeuron Ltd. I

NCT01217008 Spinal cord injury hES-derived GRNOPC1

Asterios I

NCT01321333 Spinal cord injury and trauma

HuCNS-SC StemCells Inc. I/II

NCT01348451 Amyotrophic lateral sclerosis (ALS)

Human neural spinal cord stem cells

Neuralstem Inc.

I

NCT01640067 ALS Human neural stem cells

Azienda Ospedaliera

I

NCT01725880 Spinal cord injury Observation StemCells Inc. I

NCT01730716 ALS Human spinal cord stem cells

Neuralcell Inc. II

NCT01772810 Spinal cord injury Human spinal cord stem cells

Neuralcell Inc. I

NCT02117635 Ischemic stroke CTX DP ReNeuron Ltd. II Source: Casarosa et al, “Neural Stem Cells: ready for therapeutic applications?” 15 October 2014 (http://molcelltherapies.biomedcentral.com/articles/10.1186/2052-8426-2-31)

59

5.8 Neurodevelopmental Disorders and Cell Therapy

Neurodevelopmental disorders are distinguished by abnormal development of the central

nervous system, resulting in a multitude of symptoms and diseases, including intellectual

disability, attention deficits, impairments in learning and memory, speech disorders, and

repetitive behavior. The various neurodevelopmental disorders frequently encountered in

children are autism and autism spectrum disorders, fragile X syndrome, Down syndrome,

and Rett syndrome. All these are collectively described as disorders in which the plasticity

of the brain is severely impaired.

FIGURE 5.1: Approaches for Neural Stem Replacement for Neurodevelopmental Disorders

Source: Telias M, Ben-Yosef D. Neural stem cell replacement: a possible therapy for neurodevelopmental disorders?

The proposal of replacing impaired NSCs with healthy cells in the brains of individuals

with neurodevelopmental disorders is very appealing. Following transplantation, healthy

NSCs would start re-populating the hippocampus and other brain areas with normal

neurons that can make correct synaptic connections. Moreover, if it proves successful,

such a therapy will mostly need only one surgical intervention since NSCs’ asymmetric

60

division will ensure the production of new neurons together with a sustainable pool of self-

renewing NSCs. This is in contrast to the approach of cell therapy in which post-mitotic

neurons are grafted but are limited by a relatively short lifespan, so repeated surgical

interventions may be needed for repeated cell transplantation. Another difference is that,

in degenerative disorders, the main pathological indicator is the reduced number of

neurons due to increased cell death. In the case of neurodevelopmental disorders, the

main problem is reduced synaptic plasticity and the subsequent generation of incorrect

synaptic connections between neurons.

5.8.1 Clinical Trials for Neurodevelopmental Disorders

Neurological and neuropsychiatric diseases such as epilepsy, autism, and schizophrenia

are caused by altered brain development. All these disorders result from altered

neurogenetic processes that lead to misplacement or loss of neurons and their

connections in the postnatal brain. Currently, NSCs implantation is tried in rodent models

of temporal lobe epilepsy (TLE). NSCs are ideal for transplantation in TLE because they

can be cultured and maintained for extended periods, migrate easily into the hippocampal

layers, develop into inhibitory GABAergic neurons as well as astrocytes, and produce

neurotrophic factors for stimulating hippocampal neurogenesis from endogenous pools

of NSCs.

61

TABLE 5.6: NCT Number and Titles of Clinical Trials for Neurodevelopmental Disorders

Source: Casarosa et al, “Neural Stem Cells: ready for therapeutic applications?” 15 October 2014 (http://molcelltherapies.biomedcentral.com/articles/10.1186/2052-8426-2-31)

TABLE 5.7: Status of Clinical Trials Using NSCs for Neurodevelopmental Diseases

NCT Number Indication Intervention Sponsor Phase

NCT01343511 Autism

Cord blood mononuclear cells, umbilical cord mesenchymal stem cells

Shenzhen Beike Bio-Technology

I, II

NCT01502488 Autism Fat harvesting and stem cell injection

Ageless Regenerative Institute

I, II

NCT01638819 Autism Autologous cord blood stem cell injection

Sutter Health II

NCT01740869 Autism/ Spectrum

Stem cell injection Hospital Universitario I, II

NCT01836562 Autism Autologous cord blood stem cell injection

Chaitanya Hospital I, II

NCT01974973 Autism spectrum

Autologous bone marrow mononuclear cell

Neurogen Brain and Spine Institute

I

Source: Casarosa et al, “Neural Stem Cells: ready for therapeutic applications?” 15 October 2014 (http://molcelltherapies.biomedcentral.com/articles/10.1186/2052-8426-2-31

NCT Number Title

NCT01343511 Safety and Efficacy of Stem Cell Therapy in Patients with Autism

NCT01502488 Adipose Derived Stem Cell Therapy for Autism

NCT01638819 Autologous Cord Blood Stem Cells for Autism

NCT01740869 Autologous Bone Marrow Stem Cells for Children with Autism Spectrum Disorders

NCT01836562 A Clinical Trial to Study the Safety and Efficacy of Bone Marrow Derived Autologous Cells for the Treatment of Autism

NCT01974973 Stem Cell Therapy in Autism Spectrum Disorders

62

6. SPINAL CORD INJURY AND CELL THERAPY

Spinal cord injury (SCI) occurs when the spinal cord becomes damaged, most commonly

when motor vehicle accidents, falls, acts of violence, or sporting accidents fracture

vertebrae and crush or transect the spinal cord. Damage to the spinal cord usually results

in impairment or loss of muscle movement, muscle control, sensation, and body system

control. Presently, post-accident care for SCI patients focuses on extensive physical

therapy, occupational therapy, and other rehabilitation therapies teaching the injured

person how to cope with their disability. A number of published papers and case studies

support the feasibility of treating SCI with allogeneic human umbilical cord tissue-derived

stem cells and autologous bone marrow-derived stem cells.

6.1 Incidence of Spinal Cord Injury

Every year, around the world, between 250,000 and 500,000 people suffer an SCI. The

majority of spinal cord injuries are due to preventable incidents such as road traffic

crashes, falls, and violence. People with an SCI are two to five times more likely to die

prematurely than people without one, with worse survival rates in low- and middle-income

countries. In the US, about 12,000 new cases of SCI occur each year. This does not

include people who die from an SCI before reaching the hospital. There are approximately

259,000 people in the US living with an SCI, but, because it is estimation, this number

could be higher or lower: as few as 229,000 or as many as 306,000 Americans may be

living with an SCI. The single most common cause of these injuries is vehicle accidents,

with falls not far behind.

63

FIGURE 6.1: Causes of Spinal Cord Injuries

38%

30%

14%

9%

5%4%

Vehicular

Falls

Violence

Sports

Medical/Surgical

Other

Source: National Spinal Cord Injury Statistical Center (NSCISC).

6.2 Neurological Level and Extent of Lesion in Spinal Cord Injuries

Spinal cord injury results in a change, either temporary or permanent, in the cord’s normal

motor, sensory, and/or autonomic function. Patients with spinal cord injury usually have

permanent and often devastating neurologic deficits and disability. Usually, patients will

have complete or incomplete paralysis (tetraplegia). In some cases, they sustain

complete or incomplete paraplegia. Paraplegia is a type of paralysis that affects the legs

and trunk. Tetraplegia is a paralysis that affects legs, arms and trunk. Nearly 45% of

spinal cord injury patients are affected by incomplete tetraplegia.

64

FIGURE 6.2: Neurological Level and Extent of Lesion in Spinal Cord Injuries

45%

21%

20%

14%

Incomplete tetraplegia

Incomplete paraplegia

Complete paraplegia

Complete tetraplegia

Source: National Spinal Cord Injury Statistical Center (NSCISC).

6.3 Annual and Lifetime Cost of Treating SCI Patients in the US

Spinal cord injury is a debilitating injury that has a lifelong impact on the injured person.

In addition to the physical impact of these injuries, many aspects of daily functioning are

affected, including working and taking part in social and community activities.

Neurotrauma most commonly occurs in young adults involved in transport accidents.

Advances in treatment have led to a reduction in mortality, meaning that an increasing

majority of those affected are living with the consequences of brain or spinal cord injury

for decades following injury.

The lifetime cost of new cases of brain and spinal cord injury in the US is between $2.6

million and $4.7 million. The largest cost is attributed to the burden of disease, and direct

costs such as provision of attendant care and healthcare services are also significant. At

the level of the individual, the economic impact of these injuries is comparable to or

greater than that of diseases commonly considered to be ‘high-cost’, including other

neurological conditions. Neurotrauma has a huge impact on society and on the affected

individual.

65

TABLE 6.1: Annual and Lifetime Cost of Treating SCI Patients in the US

Source: National Spinal Cord Injury Statistical Center (NSCISC).

6.4 Medications and Other Treatments for Spinal Cord Injury

Chronic pain remains a significant problem for many with spinal cord injury (SCI). The

medications tried most often for SCI are nonsteroidal anti-inflammatory drugs and

acetaminophen. These medications are being used by more than 50% of the patients

who have tried them. Opioids offer the greatest degree of pain relief but are unlikely to be

continued by those who have tried them. Nearly 38% of the patients with pain use

gabapentin, but many patients give it up, as average pain relief is only moderate. The

majority of patients try at least one and up to seven alternative medications and then

switch over to massage and marijuana, which give the greatest relief.

Anticonvulsants, most notably gabapentin, are increasingly being used for neuropathic

pain and are now considered first-line drugs. However, other anticonvulsants have not

shown efficacy in randomized controlled trials for the treatment of chronic pain in persons

with SCI. Analgesics that are typically useful for musculoskeletal pain problems, such as

nonsteroidal anti-inflammatory drugs (NSAIDS), acetaminophen, and opioids, are

generally not found as helpful in relieving neuropathic pain. Moreover, the use of opioids

is not without controversy, especially in persons with SCI, who may be particularly

sensitive to opioid side effects, such as constipation. Intrathecal administration of a bolus

Level of Injury

Average Yearly Expenses ($)

Lifetime Costs ($) by Age at Injury

First Year

Subsequent Years

20 Years Old

50 Years Old

High tetraplegia 1,064,716 184,891 4,724,181 2,596,329

Low tetraplegia 769,351 113,423 3,451,781 2,123,154

Paraplegia 518,904 68,739 2,310,104 1,516,052

Motor function at any level

347,484 42,206 1,578,274 1,113,990

66

of baclofen was shown to provide a reduction in musculoskeletal and neuropathic pain,

but long-lasting relief of neuropathic pain does not occur with the levels of this drug that

are usually delivered.

Various alternative treatments such as massage, marijuana, acupuncture, chiropractic

manipulations, biofeedback/relaxation training, magnets, and hypnosis are being tried for

the alleviation of pain. The most relief is provided by massage and marijuana, and

chiropractic care is also among the treatments that provide significant pain relief. As with

other treatments, the relief provided by these treatments lasts for only a few minutes or,

more often, hours. However, pain relief from massage and acupuncture, and from

chiropractic care, lasts for days. With hypnotic treatment, pain relief lasts only for days or

weeks and the amount of relief is very low. The following table lists the various pain-relief

drugs and other physical therapies provided for SCI patients.

TABLE 6.2: Oral Medications and Other Treatment Options for SCI

Treatment Average Relief

Oral medications

Advil, Aspirin, Aleve, Motrin 3.73 ± 2.71

Tylenol 3.70 ± 2.75

Baclofen 3.42 ± 3.05

Opioids 6.27 ± 3.05

Valium, Halcion, Xanax 4.51 ± 2.96

Neurontin (gabapentin) 3.32 ± 3.03

Tricyclic antidepressants 2.90 ± 2.71

Tegretol (carbamazepine) 2.17 ± 2.92

Dilantin (phenytoin) 2.58 ± 2.51

Mexiletine 6.00 ± 1.00

Other standard treatment modalities

Strengthening exercises 4.21 ± 2.53

Physical therapy 4.09 ± 3.09

Heat 4.29 ± 2.14

Mobility or ROM exercises 4.04 ± 2.69

Ice 3.44 ± 2.69

Counseling/psychotherapy 2.83 ± 3.06

Nerve blocks 3.85 ± 3.59 Source: Cardenas DD, Jensen MP, Treatments for Chronic Pain in Persons with Spinal Cord Injury: A Survey Study, The Journal of Spinal Cord Medicine

67

6.5 CIRM Funding for Spinal Cord Injury

The California Institute for Regenerative Medicine (CIRM) has been funding many

projects seeking to better understand spinal cord injury and translate those

discoveries into new therapies. Nearly 250,000 people in the US live with spinal

cord injuries. About half of them are quadriplegic, with paralysis affecting all four

limbs. The lifetime cost of managing these patients’ condition has been estimated

to be between $2 million and $3 million.

Spinal cord injury was the very first condition targeted in a human clinical trial using

cells derived from embryonic stem cells. That trial, started by Geron in 2010, was

later terminated by Geron for financial reasons. CIRM offers many grants for

research to move potential spinal cord injury therapies forward. The majority of

these projects are focused on evaluating which type of nerve cell is the best one to

transplant and deciding which type of stem cell is the best starting point for making

those nerve cells. Other projects are focused on determining whether transplanted

cells become part of the existing nerve system, helping to create new pathways for

transmission of nerve signals to muscles.

Research teams are also working on finding ways to improve the ability of these

transplanted cells to become part of the nerve system. One major hurdle that some

of these teams are trying to overcome is the tendency of the scar at the site of

injury to block the growth of the transplanted cells. One team is trying to overcome

that problem by combining stem cells with synthetic scaffolds that can be placed at

the site of injury to help the cells bridge the scar and restore signals. In animal

models, it has been found that this combination has led to increased mobility

compared to stem cell grafts alone.

68

TABLE 6.3: CIRM’s Grants Targeting Spinal Cord Injury

Institution/ Company

Grant Title Approved

Funds ($)

Geron Corp. Evaluation of Safety and Preliminary Efficacy of Escalating Doses of GRNOPC1 in Subacute Spinal Cord Injury

6,405.771

University of California, San Francisco

Human ES cell-derived MGE inhibitory interneuron transplantation for SCI

1,623,251

University of California, San Diego

Functional Neural Relay Formation by Human Neural Stem Cell Grafting in SCI

4,600,447

University of California, Berkeley

Developing a regeneration-based functional restoration treatment for SCI

-

StemCells Inc. Neural stem cell transplantation for chronic cervical spinal cord injury

-

University of California, San Diego

Molecular Imaging for Stem Cell Science and Clinical Application

5,920,899

University of California, Los Angeles

Assessing the mechanism by which the Bone Morphogenetic Proteins direct stem cell fate

545,962

University of California, Los Angeles

Molecular characterization of hESC and hIPSC-Derived Spinal Motor Neurons

1,229,922

Asterias Biotherapeutics

A Phase I/IIa Dose Escalation Safety (REDACTED) in patients with Cervical Sensorimotor Complete Spinal Cord Injury

14,323,318

University of California, Irvine

Repair of Conus Medullaris/Cauda Equina Injury using Human ES Cell-Derived Motor Neurons

1,527,011

Stanford University

Injectable Hydrogels for the Delivery, Maturation and Engraftment of Clinically Relevant Numbers of Human Induced Pluripotent Stem Cell-Derived Neural Progenitors to the Central Nervous System

1,347,767

University of California, San Diego

Genetic manipulation of human embryonic stem cells and its application in studying CNS development and repair

600,441

University of California, Los Angeles

Repair of Conus Medullaris/Cauda Equina Injury using Human ES Cell-Derived Motor Neurons

75,628

69

University of California, Irvine

The Immunological Niche: Effect of immune-suppressant drugs on stem cell proliferation, gene expression and differentiation in a model of SCI

695,345

University of California, Los Angeles

Development of a Relevant Preclinical Animal Model as a Tool to Evaluate Human Stem Cell-Derived Replacement Therapies for Motor Neuron Injuries and Degenerative Diseases

1,308,711

Stanford-Burnham Medical Research Institute

New Chemokine-Derived Therapeutics Targeting Stem Cell Migration

708,000

University of California, Irvine

hESC-Derived Motor Neurons for the Treatment of Cervical Spinal Cord Injury

2,158,445

University of California, San Diego

Spinal ischemic paraplegia modulation by human embryonic stem cell implant

2,356,090

University of California, San Diego

Induction of immune tolerance after spinal grafting of human ES-derived neural precursors

1,387,800

Total 55,970,139

Source: https://www.cirm.ca.gov/our-progress/disease-information/spinal-cord-injury-fact-sheet

6.6 Cell Therapy for Spinal Cord Injury

There are only limited therapeutic interventions for spinal cord injury and there is no

proper cure. However, recent preliminary studies have revealed that cell therapy may

offer help. Stem cell therapy augments neuronal regeneration after spinal cord injury

through secretion of paracrine factors, acting as a scaffold for axonal regrowth and

replacing the lost neurons or neural progenitor cells. Based on the choice of the cells

used for transplantation, cell-based therapy can be broadly classified into pluripotent stem

cells, fetal stem cells, progenitor cells, and differentiated cells. The cells can be

genetically modified to improve the therapeutic functionality of the cells. Different gene

therapy methods have been reported for treating spinal cord injury. A few of the important

genes overexpressed are transcription factors (Ngn2), neurotrophic factors (NT3, BDNF,

GDNF, and MNTS1), growth factors (bFGF, HGF), receptor tyrosine kinases (TrKC), and

cell adhesion molecule (L1CAM).

70

TABLE 6.4: Genes Used for Engineering Cells

Genes Carriers

L1 Electroporation

Ngn2 Lentivirus

Olig2 Retrovirus

bFGF Transfection

HGF Lentivirus

NT3 Adenovirus

BDNF Adenovirus

GDNF Retrovirus

MNTS1 Lentivirus

TrkC Adenovirus

Source: Stem Cells International, Volume 2015 (2015), Article ID 132172, 12 pages, http://dx.doi.org/10.1155/2015/132172

6.6.1 Studies in Animal Models of Cell Therapy for SCI

Researchers use different types of animal models, such as mice, rats, dogs, and

nonhuman primates like marmosets, to study the effects of cell therapy in SCI. Animal

studies indicate that stem cell therapy can offer some hope for cure in spinal cord injury.

ESCs and iPSCs are the predominantly used type of cells for augmenting recovery from

spinal cord injury. The following table gives some preclinical spinal cord injury trials using

iPSCs/ESCs:

TABLE 6.5: Preclinical SPI Trials Using iPSCs/ESCs for SCI

Cell Type SCI Model Neuronal Regeneration

Functional Recovery

Inflammation Repression

mESCs Mice, T8, contusion

- Yes Yes

mESCs + mMSCs Mice, T9-10, contusion

Yes - -

mESCs-neurosphere

Mice, T10, contusion

Yes Yes -

hiPSCs-neuroepithelial cells

Mice, T10, contusion

Yes Yes -

71

hiPSCs-neural cells

Marmoset, C5, contusion

Yes Yes -

L1-mESCs-neural cells

Mice, T9, compression

Yes Yes Yes

Ngn2-hESCs Rats, T9, compression

Yes Yes -

hESCs-NPCs Rat, T10, hemisection

Yes Yes -

hESCs-NPCs + SCs

Rat, T9, contusion Yes Yes -

hESCs-MPCs Rat, C5-C6, contusion

Yes Yes -

hESCs-OPCs Rat, T10, contusion

Yes Yes -

hESCs-OPCs Rat, T9, contusion Yes Yes -

hESCs-OPCs Rat, C5, contusion Yes Yes Yes

hESCs-MPCs + OPCs

Rat, T8, complete transection

Yes Yes -

hESCs-MPCs + OECs

Rat, T9, complete transection

Yes Yes -

mESCs-GABAergic

Rat, T13, lateral hemisection

Yes Yes -

Source: Stem Cells International, Volume 2015 (2015), Article ID 132172, 12 pages, http://dx.doi.org/10.1155/2015/132172

6.6.1.1 Preclinical Trials Using MSCs for SCI

MSCs are easy to produce, and can be rapidly expanded and cryopreserved. Preclinical

studies have demonstrated that use of MSCs for treatment of spinal cord injury led to

reduction in demyelination, suppression of neuroinhibitory molecules, and promotion of

axonal regeneration. Grafting of bone marrow-derived MSCs (BMMSCs) obtained from

rats into SCI rat models showed slight improvement in neural regeneration with significant

restoration of motor functions and attenuation of inflammatory response.

Administration of human BMMSCs and human UCMSCs into the SCI animal models

showed functional recovery following spinal cord injury. Differentiation of rat, canine, and

human MSCs into neuronal cells prior to grafting has demonstrated significant

augmentation of neural regeneration and motor functional recovery with reduction in

72

inflammatory cells. Coadministration of r-BMMSCs and h-BMMSCs with Schwann cells

into SCI rat models showed increased axonal remyelination and motor function along with

reduced scar formation. Grafting of genetically engineered MSCs expressing growth

factors such as bFGF and neurotrophin 3 (NT3) has demonstrated improvement of

neuronal functions.

TABLE 6.6: Preclinical Spinal Cord Injury Trials Using Mesenchymal Stromal Cells

Cell Type SCI Model Neuronal Regeneration

Functional Recovery

Inflammation Repression

r-BMMSCs Rat, compression, contusion

Partial Yes Yes

m-BMMSCs Mice, T9, compression Partial Yes -

h-BMMSCs Dog, L2-3, compression Yes Yes -

r-BMMSCs-NPCs

Rat, T8-T9, contusion/ compression

Yes Yes -

Canine-aMSCs- NPCs

Canine, L2-3, compression

Yes Yes Yes

h-BMMSCs-NPCs

Rat, T9, contusion Yes Yes -

r-BMMSCs-bFGF

Rat, T9, contusion Yes Yes -

r-BMMSCs-NT3

Rat, T9, ethydium bromide-induced demyelination

Yes Yes -

r-BMMSCs-NT3

Rat, T9, contusion Yes Yes -

h-BMMSCs-HGF

Rat, C4, hemisection Yes Yes Yes

h-BMMSCs-BDNF

Rat, T9, transaction Yes Yes -

r-BMMSCs-GDNF

Rat, T9, contusion Partial - -

r-BMMSCs-MNTS1

Rat, T8, contusion Yes Yes Yes

r-BMMSCs-TrkC

Rat, T10, complete transection

Yes Yes -

Source: Stem Cells International, Volume 2015 (2015), Article ID 132172, 12 pages, http://dx.doi.org/10.1155/2015/132172

73

6.6.1.2 Preclinical Trials Using NPCs for SCI

NPCs are capable of differentiating into neurons, astrocytes, and oligodendrocytes under

both in vitro and in vivo conditions. Several investigations have shown that

transplantation of NPCs derived from fetal sources (human/rat/mice) into SCI models

promotes efficient regeneration of neural structures with function recovery and reduced

inflammatory response. Human neurospheres isolated from the spinal cord tissue

enabled neuronal regeneration after transplantation into rat spinal cord lesions. These

cells differentiate into oligodendrocyte progenitor cells (OPCs) and significantly increase

axonal remyelination with better motor and sensory recovery.

Several combinatorial studies have shown that cotransplantation of NPCs with OECs

promotes functional recovery. It has been reported that transplantation of Olig2

expressing NPCs increases locomotory recovery with increase in myelination and

reduction in lesion cavity. Genetically engineered NSCs expressing the TrkC gene along

with a gelatin sponge scaffold seeded with NT3 enabled bridging of the injury site,

promoted axonal regeneration, and promoted partial locomotory functional recovery.

TABLE 6.7: Preclinical Spinal Cord Injury Trials Using NSCs/NPCs

Cell Type SCI Model Neuronal Regeneration

Functional Recovery

Inflammation Repression

Fetal-mNSCs Mice, T10, contusion Yes Yes -

Fetal-rNSCs Rat, C4, dorsal hemisection

No Partial -

Fetal-hNSCs Rat/mice, contusion, avulsion

Yes Yes -

Spinal Cord-hNPCs

Rat, T8, compression Yes - -

Fetal-hNPCs-OPCs5

Rat, T8, compression Yes Yes -

Fetal-hNSCs-Olig2

Rat, T9-10, contusion Yes Yes -

5 oligodendrocyte progenitor cells

74

Fetal-rNSCs + OECs6

Rat, T8, compression Yes Yes -

r-NSCs-TrkC + NT-3

Rat, T10, transaction Yes Yes -

Source: Stem Cells International, Volume 2015 (2015), Article ID 132172, 12 pages, http://dx.doi.org/10.1155/2015/132172

6.6.1.3 Preclinical Studies Using Olfactory Ensheathing Cells for SCI

Olfactory ensheathing cells (OECs) are a type of glial cells that occur in both the

peripheral nervous system (PNS) and central nervous system (CNS). Preclinical studies

have demonstrated that transplantation of rat OECs and mouse OECs into SCI models

has shown progress in functional recovery and neural tissue restoration.

Cotransplantation of OECs with motor neurons has shown significant progress in

regeneration capabilities, displaying a synergistic effect when compared to results

obtained from transplantation of OECs with MSCs. Administration of NT3 expressing

OECs into rat SCI lesions resulted in neural stimulation and longer survival of the graft

with considerable increase in motor functional recovery.

TABLE 6.8: Preclinical SCI Trials Using Olfactory Ensheathing Cells

Cell Type SCI Model Neuronal Regeneration

Functional Recovery

Inflammation Repression

rOECs Rat, contusion, compression, transaction, hemisection

Yes Yes -

rOECs + motor neurons

Rat, T9, transaction Yes Yes -

rOECs + MSCs

Rat, T8, compression Yes Partial -

rOECs-NT37 Rat, T8, compression - Partial -

Source: Stem Cells International, Volume 2015 (2015), Article ID 132172, 12 pages, http://dx.doi.org/10.1155/2015/132172

6 olfactory ensheathing cells 7 neurotrophin 3

75

6.6.1.4 Preclinical Studies Using SCs for SCI

Schwann cells (SCs) are a kind of glial cell that form the sheaths of axonal structures.

After SCI, grafting of SCs has been shown to cause axonal regeneration and

remyelination. In addition, these cells are found to secrete neurotrophic factors, such as

nerve growth factor (NGF), brain-derived neurotrophic factors (BDNF), and ciliary

neurotrophic factors (CNTF), extracellular matrix proteins that mainly include laminin and

collagens, and that upregulate cell adhesion molecules like integrins, N-cadherins, N-

CAM, L1, and contactins. Grafting of SCs into the SCI lesion has been found to augment

neuronal functional regeneration capabilities and improve axonal myelination.

Furthermore, cotransplantation of MSCs and NSCs along with SCs results in the

reduction of scar formation and restoration of neural functional potential.

TABLE 6.9: Preclinical SCI Trials Using Schwann Cells

Source: Stem Cells International, Volume 2015 (2015), Article ID 132172, 12 pages, http://dx.doi.org/10.1155/2015/132172

6.7 SCI Models and Effectiveness of Neuronal Regeneration

In 2009, Geron Corporation was the first to receive FDA approval to commence clinical

transplantation of ESC-derived OPCs (GRNOPC1) on spinal cord injury subjects. The

phase I clinical trial data did not show any positive therapeutic potential. There were no

reported adverse effects till the date of the following transplantation. In 2011, the company

suddenly cancelled its clinical trial due to financial limitations. However, the initial study

paved the way for regularizing subsequent stem cell studies. Unlike the ESCs/iPSCs-

derived cells, other cell types such as MSCs, NSCs/NPCs, OECs, and SCs are known to

Cell Type SCI Model Neuronal Regeneration

Functional Recovery

Inflammation Repression

rSCs Rat, contusion, compression, hemisection

Yes Yes -

rSCs + MSCs

Rat, contusion, 4 mm spinal cord removal

Yes Yes -

rSCs + NSCs

Rat, T8-9, transaction Yes Partial -

76

be safer. A transplantation study with 171 patients reported functional recovery after

transplantation of olfactory ensheathing cells. Another study in 2005 demonstrated that

transplantation of MSCs from human umbilical cord blood into a 37-year-old spinal cord

injury subject resulted in functional recovery. Cotransplantation of umbilical cord-derived

MSCs (UCMSCs) and CD34+ HSCs (UCHSCs) on a 29-year-old L1 SCI American Spinal

Injury Association (ASIA) Impairment Scale type A patient resulted in notable recovery of

muscle, bowel, and sexual function. There were no reported adverse effects during the

study and the patient’s ASIA Impairment Scale type was reduced to D.

TABLE 6.10: SCI Models and Effectiveness of Neuronal Regeneration

Cell Type SCI Model Neuronal Regeneration

Functional Recovery

Inflammation Repression

ESCs-OPCs Phase I, Asia Impairment Scale type A

Yes - -

OECs 171 patients Yes Yes -

UCMSCs

Phase I, T11-12, ASIA Impairment Scale type A

Yes Yes -

UCMSCs + CD34+HSCs

L1, ASIA Impairment Scale type A

Yes Yes Partial

BMMSCs

ASIA Impairment Scale type A/B/C

Yes Yes Partial

Schwann cells

ASIA Impairment Scale type A/B/C

Partial Yes -

Source: Stem Cells International, Volume 2015 (2015), Article ID 132172, 12 pages, http://dx.doi.org/10.1155/2015/132172

In another clinical investigation involving 10 SCI patients, transplantation of autologous

BMMSCs showed significant improvement in motor/sensory functional recovery in six

patients. Furthermore, MRI studies revealed neurogenesis and decrease in the cavity

77

size, and electrophysiological analysis revealed improved functional potential. There

were no reported adverse effects. Another study indicated that transplantation of

autologous BMMSCs via lumbar puncture into the cerebral spinal fluid in 11 SCI patients

resulted in borderline functional recovery in five patients.

FIGURE 6.3: Types and Share of Different Types of Stem Cells Used in SCI Clinical Trials

44%

13%

13%

7%

7%

7%

3% 3% 3%

BMMSCs

UCBCs

ASCs

BMNSCs

CNSCs

UCMSCs

SCs

OECs

Macrophages

Source: Stem Cells International, Volume 2015 (2015), Article ID 132172, 12 pages, http://dx.doi.org/10.1155/2015/132172

6.8 Clinical Trials Using Stem Cells for Spinal Cord Injury

Cell therapy can potentially enhance the quality of life of those affected by SCI. The

significant advances that have been made on the basis of preclinical studies carried out

in rodent models of SCI have enabled clinical trials demonstrating the safety of cell

therapy for SCI. Preclinical studies have shown that animals transplanted with human

ESC-derived oligodendrocytic progenitors cells (OPCs) show improvement in functional

recovery following SCI. With this background, extensive preclinical studies were

conducted by Geron to characterize the safety and efficacy of hESC-OPCs exclusively in

rodent models prior to the conduct of a clinical trial of human ESC-derived OPCs

implanted within two weeks into patients with thoracic SCI. The following table shows a

list of human clinical trials in different countries for SCI.

78

TABLE 6.11: Clinical Trials in Different Countries for SCI

NCT Number Cells Used Country Phase

NCT01162915 Autologous BMSCs US I

NCT00816803 Autologous bone marrow Egypt I/II

NCT01231893 Autologous olfactory mucosa ensheathing cells

Poland I

NCT00695149 BMSCs Japan I/II

NCT01274975 Autologous adipose-derived MSCs South Korea

I

NCT01046786 Umbilical cord blood mononuclear cells China I/II

NCT01186679 Autologous bone marrow India I/II

NCT01354483 HLA-matched umbilical cord mononuclear cells

China I/II

NCT00073853 Autologous incubated macrophages US, Israel II

NCT01217008 ESC-derived oligodendrocytic progenitors US I

NCT01328860 Autologous BMSCs US I

NCT01325103 Autologous BMSCs Brazil I

NCT01321333 HuCNS-SC Switzerland I/II

Source: Vawda R, Wilcox J, Fehlings M. Current stem cell treatments for spinal cord injury. Indian Journal of Orthopaedics.

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7. ALZHEIMER’S DISEASE

Alzheimer's disease (AD) in the elderly population is the result of neuron and

neuronal process losses due to various factors. To date, all efforts to develop

therapies for targeting specific AD-related pathways have failed in late-stage

human trials. The emerging consensus in the field is that the treatment of AD

patients with currently available medications might come too late. Therefore, cell

therapies using human embryonic stem cells or induced pluripotent stem cell-

derived neural cells hold potential for treating AD patients. With the advent of stem

cell technologies and the ability to transform these cells into different types of

central nervous system neurons and glial cells, some success in stem cell therapy

has been reported in animal models of AD.

7.1 Incidence of Alzheimer’s Disease

Worldwide, nearly 44 million people have Alzheimer’s or a related dementia. Only one in

four people with Alzheimer’s disease have been diagnosed. Alzheimer’s and dementia

are most common in Western Europe; North America is close behind. Alzheimer’s is least

prevalent in Sub-Saharan Africa. An estimated 5.3 million Americans of all ages have

Alzheimer’s disease. This number includes an estimated 5.1 million people age 65 and

older and approximately 200,000 individuals under age 65 who have younger-onset

Alzheimer’s.

80

FIGURE 7.1: Ages of People with Alzheimer’s Disease in the US

43%

38%

15%

4%

75-84 Years

>85 Years

65-74 Years

<65 Years

Source: Alzheimer’s Association, “Alzheimer’s disease Facts and Figures”

7.2 Projected Number of People Aged 65 and Older with Alzheimer’s Disease in the US

The number of Americans surviving into their 80s, 90s, and beyond is expected to grow

dramatically due to advances in medicine and medical technology as well as social and

environmental conditions. Additionally, a large segment of the American population has

begun to reach age 65 and older, which is when the risk for Alzheimer’s and other

dementias is elevated. By 2030, the segment of the US population age 65 and older will

increase substantially, and the projected 72 million older Americans will make up

approximately 20% of the total population (up from 13% in 2010). By 2050, the number

of people age 65 and older with Alzheimer’s disease may nearly triple, from 5.1 million to

a projected 13.8 million, barring the development of medical breakthroughs to prevent or

cure the disease. Previous estimates based on high-range projections of population

growth provided by the US Census suggest that this number may be as high as 16 million.

81

FIGURE 7.2: Number of People Aged 65 and Older with Alzheimer’s Disease in the US, 2050

0

2

4

6

8

10

12

14

16

2010 2020 2030 2040 2050

Nu

mb

er

in M

illio

ns

65-74 75-84 >85

Source: Alzheimer’s Association, “Alzheimer’s disease Facts and Figures”

7.3 Cost of Care by Payment Source for US Alzheimer’s Patients

The costs of health care, long-term care, and hospice for individuals with Alzheimer’s

disease and other dementias are substantial, and Alzheimer’s disease is one of the

costliest chronic diseases to US society. Total payments in 2015 for all individuals with

Alzheimer’s disease and other dementias are estimated at $226 billion. Medicare and

Medicaid covered $153 billion, or 68%, of the total health care and long-term care

payments for people with Alzheimer’s disease and other dementias. Out-of-pocket

spending is expected to be $44 billion, or 19% of total payments.

82

FIGURE 7.3: Cost of Care by Payment Source for US Alzheimer’s Patients

50%

18%

19%

13%

Medicare ($113 Billion)

Medicaid ($41 Billion)

Out of pocket ($44 Billion)

Other ($29 Billion)

Source: Alzheimer’s Association, “Alzheimer’s disease Facts and Figures”

7.3.1 Total Cost of Health Care, Long-Term Care, and Hospice for US AD Patients

The following table shows the average annual per-person payments for health care and

long-term care services for Medicare beneficiaries age 65 and older with and without

Alzheimer’s disease and other dementias. Total per-person health care and long-term

care payments from all sources for Medicare beneficiaries with Alzheimer’s and other

dementias were three times as great as payments for other Medicare beneficiaries in the

same age group ($47,752 per person for those with dementia compared with $15,115 per

person for those without dementia). About 29% of older individuals with Alzheimer’s

disease and other dementias that have Medicare also have Medicaid coverage,

compared with 11% of individuals without dementia. Average Medicaid payments per

person for Medicare beneficiaries with Alzheimer’s disease and other dementias

($11,021) were 19 times as great as average Medicaid payments for Medicare

beneficiaries without Alzheimer’s disease and other dementias ($574).

83

TABLE 7.1: Total Cost of Health Care, Long-Term Care, and Hospice for US Alzheimer’s Patients

Source: Alzheimer’s Association, “Alzheimer’s disease Facts and Figures”

7.4 Currently Available Medications for Alzheimer’s Disease

The currently marketed medications for AD, acetylcholinesterase inhibitors (Ach-Is), and

memantine, can slow the progression of AD symptoms, but no pharmacologic agents can

prevent, delay, or reverse the progression of the disease. Current evidence indicates that

these medications improve cognitive function, behavior, and activities of daily living in AD

patients. However, the clinical effects are marginal at best. Antipsychotic drugs show

evidence of only slight benefits in treating behaviors in AD in selected cases. In contrast

to drugs, non-pharmacologic therapies are low-cost interventions and can be viewed as

complementary approaches in managing patients with AD rather than as alternatives to

medications.

Payment Source

Beneficiaries by Place of Residence

Overall ($)

Community Dwelling ($)

Residential Facility ($)

Medicare 21,585 19,223 24,884

Medicaid 11,021 242 26,086

Uncompensated 297 427 117

HMO 1,083 1,681 247

Private insurance 2,463 2,707 2,122

Other payer 986 178 2,115

Out-of-pocket 10,202 3,449 19,642

Total 47,752 28,102 75,217

84

TABLE 7.2: Currently Available Pharmacologic Therapies for Alzheimer’s Disease

Drug Mechanism of Action

Donepezil 1 (Aricept) Central active reversible and non-competitive Ach-1

Galantamine 2 (Razadyne) Reversible competitive Ach-I also on nicotinic Ach receptors

Rivastigmine 3 (Exelon oral)

Reversible carbamate Ach-I preferential to AC G1

Rivastigmine 3 (Exelon patch)

Reversible carbamate Ach-I preferential to AC G1

Rivastigmine 3 (Exelon extended release)

Reversible carbamate Ach-I preferential to AC G1

Mermantine4 (Namenda) Low to moderate NMDA receptor antagonist prevents glutaminergic overstimulation at NMDA receptor

Source: Therapeutic Options in Alzheimer’s Disease, By Priya Mendiratta, MD, MPH; J. Y. Wei, MD, PhD; and Mark Pippenger, MD, Today’s Geriatric Medicine

7.5 CIRM Funding for Alzheimer’s Research

One problem that has slowed the development of new treatments for Alzheimer’s disease

is the fact that no animal model truly mimics the disease. Drugs that have effectively

treated animals with a form of Alzheimer’s haven’t worked in humans. What that means

is that we need a better way of finding new drugs. CIRM funds several awards to

researchers who are creating stem cell models of the disease in a lab dish using cells

from Alzheimer’s patients. They can then test drugs on nerve cells derived from the stem

cells of Alzheimer’s patients to look for drugs that eliminate symptoms of the disease.

These models are the only way of testing drugs in human cells.

The agency also funds teams that are in the early stages of developing potential therapies

using stem cells. Some groups are trying to mature embryonic stem cells into a cell type

that can be transplanted into the brain to replace cells that are destroyed by the disease.

Others are simply using stem cells as a way of delivering factors that appear to protect

brain cells. One team is trying to use stem cells to clear out the protein that builds up and

clogs neurons in Alzheimer’s patients.

85

TABLE 7.3: CIRM Funding for Alzheimer’s Research

Institution Grant Title Approved

Funds ($)

Coriell Institute for Medical Research

The CIRM human pluripotent stem cell biorepository – A resource for safe storage and distribution of high quality iPSCs

9,942,175

University of California, San Diego

Elucidating pathways from hereditary Alzheimer’s mutation to pathological tau phenotypes

1,050,300

Palo Alto Institute for Research and Education

Systemic protein factors as modulators of the aging neurogenic niche

1,159,806

University of California, Riverside

ES-derived cells for the treatment of Alzheimer’s disease

621,639

University of California, San Diego

Generation of forebrain neurons from human embryonic stem cells

587,591

University of California, Irvine

Development of human ES cell lines as a model system for Alzheimer’s disease drug discovery

473,963

Salk Institute for Biological Studies

Human stem cell-based development of a potent Alzheimer’s drug candidate

1,664,885

University of California, San Diego

Using human embryonic stem cells to understand and to develop new therapies for Alzheimer’s disease

3,599,997

University of California, Irvine

Neural stem cells as a developmental candidate to treat Alzheimer’s disease

3,599,997

Western University of Health Sciences

ES-derived cells for the treatment of Alzheimer’s disease

1,401,642

University of California, San Diego

Developing a method for rapid identification of high quality disease-specific hPSC lines

1,692,334

StemCells Inc. Neuroprotection to treat Alzheimer’s, a new paradigm using human central nervous system cells

90,101

University of Southern California

A CIRM disease team to develop allopregnanolone for prevention and treatment of Alzheimer’s disease

107,961

University of California, San Diego

Identifying drugs for Alzheimer’s disease with human neurons made from human IPS cells

1,774,420

86

Salk Institute for Biological Studies

Stem cell-based small molecule therapy for Alzheimer’s disease

1,673,757

StemCells Inc. Restoration of memory in Alzheimer’s disease: a new paradigm using neural stem cell therapy

8,901,641

University of California, San Diego

Collection of skin biopsies to prepare fibroblasts from patients with Alzheimer’s disease and cognitively healthy elderly controls

643,693

Cellular Dynamics International

Generation and characterization of high-quality, footprint-free human iPSC lines from 3,000 donors to investigate multigenic diseases

16,000,000

Total 54,392,915

Source: California Institute for Regenerative Medicine, “Alzheimer’s Disease Fact Sheet”

7.6 Transplantation of Stem Cells for AD

Stem cell therapy in AD has two directions. One is to induce the activation of endogenous

stem cells and the other is to regenerate injured cells or tissues through stem cell

transplantation. Endogenous stem cells can be induced by using chemical compounds

and factors for stimulating stem cells such as allopregnanolone (Apα), fluoxetine,

granulocyte colony stimulating factor (G-CSF), AMD3100, and stromal cell-derived factor-

1a (SDF-1α). Apα-induced endogenous neural precursor cells (NPCs) activation and

promoted survival of newly generated cells show significantly increased BrdU+ cells as

well as improvement of learning and memory in 3xTgAD mice.

Another study used three factors to stimulate endogenous hematopoietic progenitor cells

(HPC), GCSF and AMD3100, CXCR4 antagonist, and SDF-1α to facilitate the

mobilization and migration of bone marrow-derived hematopoietic progenitor cell (BM-

HPCs) into the brain. AD model mice had improved memory as well as hippocampal

neurogenesis in AD animal models after treatment of three factors, whereas Aβ

deposition was not changed. These factors may act synergistically to migrate HPC and

87

to produce a therapeutic effect. Fluoxetine treatment showed the neuronal differentiation

and protective effects of NSCs against Aβ-induced cell death.

It has recently been reported that Alzheimer's symptoms were alleviated by transplanting

stem cells derived from human umbilical cord, amniotic membrane-derived epithelial

cells, and mesenchyme into the brains of Alzheimer's transgenic animals. The treatment

led to improved cognitive and memory performances and increased neuronal survival as

a result of the decrease in Aβ, APP generation, and microglia activation. Another study

has reported a therapeutic effect of decreasing the size and number of Aβ as a result of

differentiating peripheral mononuclear cells into microglia by injecting stromal cell-derived

factor 1 into Alzheimer's transgenic animals.

TABLE 7.4: Stem Cell Therapy for AD in Mice Models

Cell Model Results

BM-HPCs APP-PSI mice

Induction of endogenous BM-HPCs, improved memory

Endogenous NPCs

3xTg AD mice

Survival of newly generated cells and restored cognitive performance

NSCs In vitro Enhanced neuronal differentiation

MSCs - Promoted survival, increased metabolic activity, reuse the AD cell model

HUMSCs APP/PSI mice

Increased neprilysin expression

BM-MSCs AD mice Reduction in Aβ deposits

BMM Irradiated mice

Reduced Aβ burden

NSCs APPswe mice

Colonization in white matter tracts

ADSCs APP/PSI mice

Reduction in Aβ deposits, improved memory

HAECs APP/PSI mice

Survival of HAECs for 8 weeks, migration without immune rejection

Source: Choi SS, Lee S-R, Kim SU, Lee HJ. Alzheimer’s Disease and Stem Cell Therapy. Experimental Neurobiology

88

7.6.1 Gene Therapy for AD

For the development of new medical drugs, it is necessary to gain a deeper understanding

of the genetic factors in AD, the roles of amyloid and tau proteins, and the mechanisms

involved in neuronal degeneration. The current therapeutic mechanism for Alzheimer's is

to provide maximum support for the functions of the neurons remaining in the patient's

brain. There have been recent encouraging results in animal studies with administration

of Aβ antibodies to PDAPP mice in order to decrease Aβ. They showed the recovery of

acetylcholine release and choline absorption in the hippocampus. The learning capacity

was also improved.

TABLE 7.5: Gene Therapy for AD

Cell Gene Model Results

Encapsulated Cell

Nerve growth factor (NGF)

Human AD patient

No toxicity, improved electroencephalography, improved nicotinic receptor binding

hNSC, F3.ChAT

Choline acetyltransferase (ChAT)

AD rat model

Improved learning and memory performance, increase of acetylcholine, cell migration, differentiation into neurons and glial cells

hNSC, F3.NGF

Human NGF APP/PSI TG mouse

Improved water maze performance, increase of deltaNp73 expression, improved proliferation

Source: Choi SS, Lee S-R, Kim SU, Lee HJ. Alzheimer’s Disease and Stem Cell Therapy. Experimental Neurobiology

89

8. PARKINSON’S DISEASE

In a major breakthrough for the treatment of Parkinson's disease (PD), researchers

working with laboratory rats showed it is possible to make dopamine cells from embryonic

stem cells and transplant them into the brain, replacing the cells lost to the disease. PD

is caused by the gradual loss of dopamine-producing cells in the brain. Dopamine is a

brain chemical that, among other things, helps regulate movement and emotional

responses. There are no cures for Parkinson's disease; there are drugs that ease

symptoms, but none that slow it down. Deep brain stimulation can alleviate symptoms of

PD in certain patients.

8.1 Incidence of Parkinson’s Disease

Worldwide, there are likely to be more than six million people with PD. In China alone,

there are more than 1.7 million people with PD. The community with the world’s highest

prevalence of PD is along the River Nile in Egypt. They have a prevalence rate of 1,103

per 100,000. The world’s highest prevalence of PD by far has been found among the

Amish community in the Northeast of the US. The prevalence among this community is

970 per 100,000 people. The country with the highest prevalence of PD is Albania, with

about 800 people affected per 100,000 people.

8.2 CIRM Grants Targeting Parkinson’s Disease

CIRM funds many projects seeking to better understand Parkinson's disease and to

translate those discoveries into new therapies. Stem cell scientists are taking two general

approaches to understanding and treating this disease. The first approach involves

understanding the disease and looking for new drugs to treat it. CIRM grantees have

taken skin cells from people with Parkinson’s disease, reprogrammed them back to an

embryonic-like state (turning them into the kind of stem cell that can be transformed into

any other cell in the body), then coaxed those cells to become the type of neuron that is

affected by Parkinson’s disease.

90

Being able to study human Parkinson’s disease cells in a lab dish is a major milestone.

Now, scientists can expose those cells to different drugs to find the ones that eliminate

signs of the disease. If scientists find drugs that treat the disease in a lab dish, they will

then test those same drugs in animals and develop the most promising into a therapy for

people with the disease. Several teams of CIRM-funded researchers are using stem cell

techniques to create Parkinson’s disease cells in the lab dish and then screening them

for new drugs. Other groups are creating dopamine-producing cells in the lab dish with

the hope that they could replace the neurons that are damaged in people with the disease.

TABLE 8.1: CIRM Grants Targeting Parkinson’s Disease

Institution Grant Title Approved

Funds ($)

Samford-Bumham Medical Research Institute

Derivation of Parkinson’s disease coded stem cells (PD-SCs)

1,556,448

Samford-Bumham Medical Research Institute

hESC-derived NPCs programmed with MEF2G for cell transplantation in PD

96,448

University of California, San Francisco

Identifying small molecules that stimulate the differentiation of hESCs into dopamine producing neurons

542,619

Samford-Bumham Medical Research Institute

Neural stem cell-based therapy for PD 63,952

Stanford University

Optimization of guidance response in human embryonic stem cell-derived midbrain dopaminergic neurons in development and disease

607,363

Gladstone Institutes

Common molecular mechanisms in neurodegenerative diseases using patient-based iPSC neurons

1,482,025

Samford-Bumham Medical Research Institute

Modeling Parkinson’s disease using human embryonic stem cells

701,060

Parkinson’s Institute

Stem cell pathologies in Parkinson’s disease as a key to regenerative strategies

-

91

Samford-Bumham Medical Research Institute

MEF2C-directed neurogenesis from human embryonic stem cells

2,832,000

Stanford University Dysregulated mitophagy in Parkinsonian neuro-degeneration

1,174,943

University of California, San Francisco

Derivation of inhibitory nerve cells from hESCs 2,410,874

University of California, Berkeley

Engineered biomaterials for scalable manufacturing and high viability implantation of hPSC-derived cells to treat neurodegenerative diseases

1,239,276

Salk Institute for Biological Studies

Molecular and cellular transitions from ES cells to mature functioning human neurons

2,749,293

Parkinson’s Institute

Using patient-specific iPSC-derived dopaminergic neurons to overcome a major bottleneck in PD research and drug discovery

3,698,646

Samford-Bumham Medical Research Institute

Developmental candidates for cell-based therapies for PD

5,190,752

University of California, Berkeley

Directed evolution of novel AAV variants for enhanced gene targeting in pluripotent HSC and investigation of dopaminergic neuron differentiation

918,000

Salk Institute for Biological Studies

Genetic encoding novel aminoacids in embryonic stem cells for molecular understanding of differentiation to dopamine neurons

2,587,742

Stanford University Site-specific integration of Lmx1a, FoxA2 & Otx2 to optimize dopaminergic differentiation

1,592,897

Parkinson’s Institute

Editing of Parkinson’s disease mutation in patient-derived iPSCs by zinc finger nucleases

1,327,983

Stanford University Identification and characterization of human ES-derived DA neuronal subtypes

1,404,853

University of California, San Francisco

Development and preclinical testing of new devices for cell transplantion to the brain

1,795,891

Buck Institute for Age Research

Banking transplant-ready dopaminergic neurons using a scalable process

4,983,013

University of California, Berkeley

Engineering defined and scaleable systems for dopaminergic neuron differentiation of hPSCs

1,340,816

92

Salk Institute for Biological Studies

Crosstalk inflammation in PD in a humanized in vitro model

2,472,839

Parkinson’s Institute

Understanding the role of LRRK2 in iPSCs model of PD

1,482,822

Total 44,252,555

Source: California Institute for Regenerative Medicine

8.3 Current Medications for PD

The objective of using medications for PD is only to control or manage motor symptoms.

Since these symptoms are largely due to the diminishing supply of dopamine in the brain,

most symptomatic medications are designed to replenish, mimic, or enhance the effect

of this chemical. Medication usage is only a part of the whole treatment plan for effectively

treating PD. Regular physiotherapy is an important aspect of the best treatment plan.

TABLE 8.2: Medications for Motor Symptoms in PD

Medication Indication

Carbidopa/levodopa immediate release (Sinemet)

Monotherapy or combination therapy for slowness, stiffness, and tremor

Carbidopa/levodopa oral disintegrating (Parcopa)

Monotherapy or combination therapy for slowness, stiffness, and tremor

Carbidopa/levodopa extended release (Sinemet CR)

Monotherapy or combination therapy for slowness, stiffness, and tremor

Carbidopa/levodopa/entacapone (Stalevo)

Motor fluctuations

Carbidopa/levodopa extended release capsules (Rytary)

Monotherapy for slowness, stiffness, and tremor

Carbidopa/levodopa enteral solution (Duopa)

Motor fluctuations

Ropinirole (Requip) Monotherapy or combination therapy for slowness and tremor

Ropinirole XL (Requip XL) Monotherapy or combination therapy for slowness and tremor

Pramipexole (Mirapex) Monotherapy or combination therapy for slowness and tremor

93

Pramipexole ER (Mirapex ER) Monotherapy or combination therapy for slowness and tremor

Rotigotine (Neupro) Monotherapy or combination therapy for slowness and tremor (patch delivery)

Apomorphine (Apokyn) Adjunct therapy for sudden wearing off, the only injectable, fast-acting dopominergic drug

Selegiline (l-deprenyl, Eldepryl) Monotherapy for slowness, stiffness, and tremor, adjunct therapy for motor fluctuations

Rasagiline (Azilect) Monotherapy for slowness, stiffness, and tremor, adjunct therapy for motor fluctuations

Zydis selegiline HCL (Zelapar) Monotherapy for slowness, stiffness, and tremor, adjunct therapy for motor fluctuations

Entacapone (Comtan) Combination therapy with levodopa for motor fluctuations

Tolcapone (Tasmar) Combination therapy with levodopa for motor fluctuations

Amantadine (Symmetrel) Monotherapy for slowness, stiffness, and tremor, combination therapy for motor fluctuations

Trihexyphenidyl (Artane) Monotherapy for slowness, stiffness, and tremor, combination therapy for motor fluctuations

Source: David Houton MD, MPH et al, “Parkinson’s Disease Medications”

8.4 Potential for Cell Therapy in Parkinson’s Disease

There is currently no cure for PD. As current therapeutic approaches for PD only provide

symptomatic relief with serious limitations, some alternative treatments, such as

regenerative medicine and stem cell therapy, are necessary. Different types of stem cells

have been investigated for treatment of PD with specific advantages and disadvantages.

Stem cell treatments for Parkinson's are still in the early stages of development. Some of

the most important recent advances include work on methods for making dopamine-

producing neurons in the lab, research on how to improve the effectiveness of transplants

and avoid side effects, and studies investigating how the disease develops and how cells

can help with the development of new drugs to stop it.

94

TABLE 8.3: Advantages and Disadvantages of Stem Cell Types Used in PD

Stem Cell

Advantages Disadvantages

ESCs

Highly proliferative/pluripotent, able to form all three germ layers, generate dopaminergic neurons, transplantation survival

Risk of tumor formation, ethical issues, genomic instability

iPSCs Unlimited PD patient-specific cells, transplantation survival, minimal immune reactions and ethical issues

Risk of tumor formation, in autologous transplantation risk of original pathology

MSCs Improved motor performance in mice, no adverse effects in humans, easily obtained from different tissues

Modest clinical improvements in humans

fNSCs

Lower risk of tumor formation and immune rejection, differentiates into neurons, astrocytes, oligodendrocytes, and dopamine

Limited differentiation in vivo, partial effect on PD symptoms, ethical issues, limited supply

Source: Goodarzi P, Aghayan HR, Larijani B, et al. Stem cell-based approach for the treatment of Parkinson’s disease

8.5 Gene Therapy for PD

Current drug therapies and surgical treatments for Parkinson's disease provide only

symptomatic improvements, and none have convincingly shown effects to stop the

disease progression. New approaches based on gene therapy seem to provide several

potential advantages over conventional treatment modalities. Gene therapy could be

used to offer more consistent dopamine supplementation, potentially giving superior

symptomatic relief with fewer side effects.

95

TABLE 8.4: Approaches Used in Current Gene Therapy Clinical Trials for PD

Therapeutic Approach Vector Phase

Increased dopamine biosynthesis

AADC8 alone Adeno-associated virus I

AADC, TH9 and GCH-110 Lentivirus I/II

Modulation of ganglia activity

GAD11 Adeno-associated virus I/II

Neurotrophic support

GDNF12 Adeno-associated virus -

Neuturin Adeno-associated virus I/II Source: Parkinson's Disease Volume 2012 (2012), Article ID 757305, 13 pages http://dx.doi.org/10.1155/2012/757305

8 aromatic amino acid decarboxylase 9 tyrosine hydroxylase 10 GTP-cyclohydrolase 1 11 glutamic acid decarboxylase 12 glial cell line-derived neurotrophic factor

96

9. AMYOTROPHIC LATERAL SCLEROSIS

Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease that

affects nerve cells in the brain and the spinal cord. Motor neurons reach from the brain to

the spinal cord and from the spinal cord to the muscles throughout the body. The

progressive degeneration of the motor neurons in ALS eventually leads to their demise.

When the motor neurons die, the ability of the brain to initiate and control muscle

movement is lost. With voluntary muscle action progressively affected, people may lose

the ability to speak, eat, move, and breathe.

9.1 Incidence of ALS

The incidence of ALS is 2 per 100,000 of total population, while the prevalence is around

6 per 100,000 of total population. Research has found that the incidence is higher in

people aged over 50 years. Only 10% of cases are inherited with the remaining 90%

sporadic. Although classified as a rare disease based on its prevalence, ALS/MND is, in

fact, quite common. There are approximately 140,000 new cases diagnosed worldwide

each year. That is 384 new cases every day. The disease affects each individual

differently and can have a devastating impact on family, careers, and friends. The rapidly

progressive nature of the disease requires constant adaptation to increasing and

changing levels of disability, which in turn require increased levels of support.

9.2 Symptomatic Treatments in ALS Patients

Currently the only available treatment for ALS is Riluzole, approved for use in 1995.

However, Riluzole only slows down the progression of the disease and gives the patient

an average of three months of extended life span. The exact mechanism of action of

Riluzole is unknown; several papers have demonstrated its inhibition of sodium, calcium,

potassium, and glutamate currents. The coadministration of Riluzole with other potential

therapeutic agents is constantly being assessed, usually with no promising positive

results. Melatonin is a natural hormone produced and secreted by the pineal gland. It is

97

currently used to increase sleep efficiency and improve the cardiovascular system as an

anti-aging drug. In ALS, the antioxidant, anti-inflammatory, and neuroprotective activities

of cannabinoids are expected to improve ALS symptoms. First, surveys assessed

marijuana usage in ALS patients and associated it with improvements of appetite,

depression, pain, spasticity, and drooling. ALS patients develop numerous manifestations

and problems during the disease course. Symptomatic treatment aims to improve quality

of life for ALS patients and their caregivers. Main symptoms of ALS patients and those

medications are listed in the following table.

TABLE 9.1: Symptomatic Treatments in ALS Patients

Symptom Medication

Cramps Carbamazepine

Phenytoin

Spasticity Baclofen

Tizanidine

Botulinum toxin type A

Excessive drooling Atropine

Hyoscine hydrobromide

Hyoscine butylbromide

Hyoscine scopoderm

Glycopyrronium

Amitripyline

Botulinum toxin injection to parotid glands

Irradiation of the salivary glands

Persistent saliva and bronchial secretions

Carbocisteine

Propranolol

Metoprolol

Caught assist machine

Excessive or violent yawning Baclofen

Laryngospasm Lorazepam

Pain Simple analgesics

Non-steroidal anti-inflammatory drugs

Opioids

Emotional lability Lactulose

Selective serotonin-reuptake inhibitors

Levodopa

Dextrometorphan and quinidine

98

Constipation Lactulose

Senna

Depression, anxiety Amitriptyline

Citalopram

Psychological support and counseling

Lorazepam

Insomnia Amitriptyline

Zolpidem

Fatigue Modafinil

Psychological support and counseling Source: Journal of Neurology Research, Volume 3, Number 1, February 2013

9.3 CIRM Grants Targeting ALS

California’s stem cell agency provides funds for several research projects that could help

people with ALS. Some of those projects are very basic and researchers are trying to

understand the origin of the disease and what causes the motor neurons to die. With

CIRM funding, researchers have made progress understanding which cells are

responsible for damaging the motor neurons. It turns out that the cells surrounding those

neurons—called astrocytes—are secreting a chemical that damages the neurons.

They’ve also learned how to take certain kinds of stem cells and turn them into motor

neurons and astrocytes, and this might help us better understand the relationship of these

cells and even one day prove useful in developing new ways to treat people with ALS.

The agency also provides funds for projects that are in the later stages of research leading

up to, and in some cases including, clinical trials.

TABLE 9.2: CIRM Grants Targeting ALS

Institution Grant Title Approved

Funds ($)

University of California, San Diego

Generation of disease models for neurodegenerative disorders in hESCs by gene targeting

709,829

University of California, Santa Cruz

Molecular mechanisms of neural stem cell differentiation in the developing brain

2,147,592

99

University of California, San Diego

Neural and general splicing factors control self-renewal, neural survival, and differentiation

1,287,619

Cedars-Sinai Medical Center

Stem Cells Secreting GDNF for the treatment of ALS 63,487

University of California, San Diego

Molecules to correct abberant RNA signature in human diseased neurons

1,532,323

Cedars-Sinai Medical Center

Progenitor cells secreting GDNF for the treatment of ALS

16,961,287

University of California, San Diego

Stem cell models to analyze the role of mutated CgORF72 in neurodegeneration

1,260,360

University of California, Los Angeles

Molecular characterization of hESC and hiPSC-derived spinal motor neurons

1,229,922

Gladstone Institutes

Development of novel autophagy inducers to block the progression of and treat ALS and other neurodegenerative diseases

2,278,080

University of California, San Diego

Stem cell-derived astrocyte precursor transplants in ALS

5,694,308

University of California, San Diego

Stem cell-derived astrocyte precursor transplants in ALS

4,139,754

University of California, Los Angeles

Generation of clinical grade hiPSCs 1,341,000

University of California, San Diego

Molecular imaging for stem cell science and clinical application

5,920,899

Salk Institute for Biological Studies

Development of iPSCs for modeling human diseases

1,737,720

University of California, Los Angeles

Development of a relevant preclinical animal model as a tool to evaluate human stem cell-derived replacement therapies for motor neuron injuries and degenerative diseases

1,308,711

University of California, San Diego

Genetic manipulation of hESCs and its application in studying CNS development and repair

600,441

University of California, Santa Cruz

In vitro differentiation of hESCs into corticospinal motor neurons

465,624

100

Salk Institute for Biological Studies

Gene regulatory mechanisms that control spinal neuron differentiation from hESCs

704,543

University of California, San Francisco

High throughput modeling of human neuro-degenerative diseases in ESCs

2,259,092

University of California, Irvine

hESC-derived motor neurons for the treatment of cervical spinal cord injury

2,158,445

Source: California Institute for Regenerative Medicine, “Amyotrophic Lateral Sclerosis (ALS) Fact Sheet”

9.4 Companies Focusing on Stem Cell Therapy for ALS

There are currently at least thirteen companies that are developing stem cell strategies

with applications for ALS. Some of the programs are in preclinical development or phase

I clinical trials and include the following companies: NeuralStem, Pluristem, ReNeuron,

SanBio, Saneron, StemCells, and Brainstorm Cell Therapeutics. Other companies are

utilizing strategies to upregulate the endogenous, dormant stem cell populations found in

the nervous system. This strategy is being applied to ALS by the following companies:

Fate Therapeutics and Samaritan Pharmaceuticals.

A third strategy involves modifying stem cells genetically in order to augment their natural

ability to provide trophic support with growth factors such as brain-derived growth factor

(BDNF). BioFocus, for example, is developing strategies to use stem cells and iPS cells

in assays to understand more about the disease and provide tools for research.

RhinoCyte is developing therapies based on autologous olfactory neural progenitor stem

cells that they call RhinoCytes, which are developed by culturing and isolating human

adult stem cells from the olfactory epithelium. RhinoCyte has received orphan drug status

for treatment of ALS. NeuroGeneration is pursuing stem cell-based therapeutics on both

transplantation and reprogramming approaches for neurodegenerative diseases,

including ALS.

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TABLE 9.4: Companies Focusing on Various Strategies for ALS

Company Location Target

Acetylon US, Massachusetts Protein aggregation

ALS Biopharma US, Pennsylvania Protein aggregation

ALS Therapy Development Institute

US, Massachusetts Inflammation

Amarantus Therapeutics US, California Growth factor

Amorfix Canada Vaccine

Brainstorm Cell Therapeutics US, New York; Israel Stem cells

Braintact Israel Excitotoxicity

Cambria US, Massachusetts Protein aggregation

Chaperone Therapeutics US, North Carolina Protein aggregation

Cognosci US, North Carolina Inflammation

Cytokinetics US, California Muscle contractility

Daval International UK Inflammation

Debiopharm Group/Curis Inc. Switzerland; US, Massachusetts

Protein aggregation

Enkam Denmark Growth factor

EnVivo Pharmaceuticals US, Massachusetts Protein aggregation

ExonHit Therapeutics/Allergan France Protein aggregation

Fate Therapeutics US, California Stem cells

FoldRx US, Massachusetts Protein aggregation

Genervon Biopharmaceuticals US, California Growth factors

GenKyoTex Switzerland Oxidative stress

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Isis Pharmaceuticals US, California RNA strategies

Knopp Biosciences/Biogen US, Pennsylvania, Massachusetts

Oxidative stress

miRagen Therapeutics US, Colorado RNA strategies

NeuralStem US, Maryland Stem cells

Neurimmune Therapeutics Switzerland Vaccine

Neurogeneration US, California Stem cells

NeuroNascent Inc. US, Maryland Stem cells

NeuroNova Sweden Growth factor

NeuroPhage US, Massachusetts; Israel Protein aggregation

NexGenix Pharmaceuticals US, New York Protein aggregation

Oxford Biomedica UK Growth factor

PharmaTrophix US, North Carolina Growth factor

Phytopharm UK Growth factor

Pluristem Therapeutics Israel Stem cells

Proteostasis US, Massachusetts Protein aggregation

Q-Therapeutics US, Utah Stem cells

Reata Pharmaceuticals US, Texas Protein aggregation

ReNeuron UK Stem cells

Repligen Corporation US, Massachusetts Protein aggregation

Retrotrope Inc. US, California Oxidative stress

RhinoCyte US, Kentucky Stem cells

RXi Pharmaceuticals US, Massachusetts RNA Strategies

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Samaritan Pharmaceuticals US, Nevada Stem cells

SanBio US, California Stem cells

Saneron US, Florida Stem cells

ShanaRx US, California Growth factors

Sirtris/GSK US, Massachusetts Protein aggregation

Stealth Peptides US, Maryland Oxidative stress

StemCells US, California; UK Stem cells

Takeda Japan Oxidative stress

Transition Therapeutics Canada Inflammation

Trophos France Oxidative stress

Varinel Israel Iron chelation

Vasopharm Germany Oxidative stress

ZZ Biotech US, New York Inflammation

Source: Glicksman MA. The pre-clinical discovery of Amyotrophic Lateral Sclerosis Drugs, Expert opinion on drug discovery

9.5 Cell Therapy for ALS

There has been interest in stem cell therapies to provide an alternative treatment strategy

for transplantation of stem cells for cellular replacement and neuroprotective effects. A

wide range of effects of stem cells might be beneficial for the treatment of ALS. A number

of animal studies have provided evidence that the transplantation of stem cells, including

ESC, NPC, and MSC, through various routes makes animal models live longer and

restores functions, suggesting that these therapies may improve clinical outcomes.

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Adipose tissue-derived MSC (AdMSC) transplantation has been shown to slow motor

neuronal death and alleviate clinical manifestations and pathologies in mouse models

through neuroprotection and immunomodulation. Mainly, patient-derived iPSC can be

differentiated into motor neurons, enabling autologous transplantation. ALS is not

currently practical in humans; the focus instead is on neuroprotection. The following table

shows a summary of ALS clinical trials.

TABLE 9.6: Examples of Clinical Trials for Amyotrophic Lateral Sclerosis

NCT Number Start Cell Type Autologous/ Allogenic

Location Phase

NCT00855400 2007 BM-MNC Autologous Spain I/II

NCT01984814 2008 BM-MNC Autologous India II

NCT01348451 2009 NSC Allogenic US I

NCT02193839 2010 Progenitor cells Auto BM Poland I

NCT01082653 2010 NA Auto BM US I

NCT01142856 2010 BM-MSC Autologous US I

NCT01254539 2010 BM-MNC Autologous Spain I/II

NCT01363401 2011 BM-MSC Autologous South Korea I/II

NCT01051882 2011 BM-MSC Autologous Israel I/II

NCT01640067 2011 NSC NA Italy I

NCT01494480 2012 UC-MSC NA China II

NCT01609283 2012 Ad-MSC Autologous US I

NCT01759797 2012 BM-MSC NA Iran I

NCT01933321 2012 Hematopoietic stem cells

NA Mexico II/III

NCT01777646 2012 BM-MSC Autologous Israel II

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NCT01758510 2012 BM-MSC Allogenic South Korea I

NCT01730716 2013 NSC Allogenic US II

NCT01771640 2013 BM-MSC Autologous Iran I

NCT02116634 2014 MSC NA Iran I/II

NCT02017912 2014 BM-MSC Autologous US II

NCT01759784 2014 BM-MSC NA Iran I

NCT02492516 2014 Ad-MSC Autologous Iran I

NCT02286011 2014 BM-MNC Autologous Spain I

NCT02478450 2015 GRP Allogenic US I/II

Source: Hanyang Med Rev. 2015 Nov;35(4):229-235., http://dx.doi.org/10.7599/hmr.2015.35.4.229

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10. MULTIPLE SCLEROSIS

Multiple sclerosis (MS) is a nervous system disease that affects the brain and spinal cord.

It damages the myelin sheath, the material that surrounds and protects the nerve cells.

This damage slows down or blocks messages between the brain and the body, leading

to the symptoms of MS. Symptoms can include:

• Visual disturbances,

• Muscle weakness,

• Trouble with coordination and balance,

• Sensations such as numbness, prickling, or "pins and needles," and/or

• Thinking and memory problems.

MS is the most widespread disabling neurological condition of young adults around the

world. One can develop MS at any age, but most people are diagnosed between the ages

of 20 and 40. There are relapsing and remitting types of MS and progressive types, and

the course is rarely predictable. Researchers still don’t fully understand the causes of MS

or why the rate of progression is so difficult to determine. The good news is that many

people with MS don’t become severely disabled and most have a normal or near-normal

lifespan.

10.1 Incidence of MS

The Multiple Sclerosis Foundation estimates that more than 400,000 people in the US

and about 2.5 million people around the world have MS. About 200 new cases are

diagnosed each week in the US. Rates of MS are higher farther from the equator. It is

estimated that in southern states (below the 37th parallel), the rate of MS is between 57

and 78 cases per 100,000 people. The rate is twice as high in northern states (above the

37th parallel), at about 110 to 140 cases per 100,000. The incidence of MS is also higher

in colder climates. People of northern European descent have the highest risk of

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developing MS, no matter where they live. The lowest risk appears to be among Native

Americans, Africans, and Asians.

TABLE 10.1: Currently Available Medications for MS

Drug Company Administration

Injectables

Avonex (interferon beta-1a) Biogen Intramuscular injection

Betaseron (interferon beta-1b) Bayer Healthcare Pharmaceuticals

Subcutaneous injection

Copaxone (glatiramer acetate) Teva Neuroscience Subcutaneous injection

Extavia (interferon beta-1b) Novartis Pharmaceuticals Subcutaneous injection

Glatopa (glatiramer acetate) Sandoz/Novartis Subcutaneous injection

Plegridy (pegylated Interferonbeta-1a)

Biogen Subcutaneous injection

Rebif (interferon beta-1a) EMD Serono Inc./Pfizer Inc.

Subcutaneous injection

Oral treatments

Aubagio (teriflunomide) Sanofi/Genzyme Pill

Gilenya (fingolimod) Novartis Pharmaceuticals Capsule

Tecfidera (dimethyl fumarate) Biogen Capsule

Intravenous infusion

Lemtrada (alemtuzumab) Sanofi/Genzyme 12 mg

Brand name N/A (mitoxantrone)

- 12 mg

Tysarbi (natalizumab) Biogen 300 mg

Source: National MS Society, “Disease Modifying Therapies for MS”

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10.2 Medications for MS

There are currently 13 disease-modifying medications approved by the FDA for use in

relapsing forms of MS (including secondary-progressive MS for those people who are still

experiencing relapses). Of these, one is also approved specifically for secondary-

progressive MS. None of these medications is curative and none will prevent recurring

symptoms, such as fatigue or numbness. However, each of them has a proven record of

effectiveness. Unfortunately, no disease-modifying medication has yet been approved to

treat primary-progressive MS—the type of MS that shows steady progression from the

onset of symptoms.

10.3 Neural Stem Cells’ Application in Multiple Sclerosis

Disease-modifying treatments and drug therapy can only reduce the progression rate of

MS; they give no cure. Stem cells such as neural (NSCs), embryonic (ESCs),

mesenchymal (MSCs), and hematopoietic stem cells (HSCs) have been found to show

promise. The following table gives some examples of studies using neural stem cells.

A number of studies have shown that NSCs can develop into mature oligodendrocytes in

animal models of dysmyelination and neurons cerebral degeneration. Some studies have

reported the therapeutic potential of adult neural stem cells (aNSCs) in MS. Bone

marrow-derived NSCs (BM-NSCs) also exhibit neurogeneration potential and

immunomodulatory effects. Neural progenitor cells (NPCs) are also being used in some

studies as they can differentiate into oligodendrocytes. Although these studies have

proven the enormous potential of NSCs, a lot of work that still needs to be done to prove

their clinical effectiveness and safety in therapy for patients with MS.

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TABLE 10.2: Available Studies Related to the Use of NSCs for Multiple Sclerosis

Authors Country NSCs Model Findings

Heffernan et al., 2012

Australia glial cells Human New therapeutic strategy for the treatment of MS

Payne et al., 2012

Australia 46C-NS cells Mouse

Improving the efficiency at which NSCs home to inflammatory sites may enhance their therapeutic potential in MS

Song et al., 2012

Australia iPSCs Human A novel approach for the study of MS pathophysiology and potential drug discovery

Rasmussen et al., 2011

US Sub-ventricular zone cells

Mouse

Treatments targeting chronic microglial activation have the potential for enhancing repair in MS

Huang et al., 2011

UK Oligodendrocyte precursor cells

Human

Might be useful pharmacological targets to overcoming remyelination failure in MS

Giannakopoulou et al., 2011

Greece Neural precursor cells

Mouse

NPC intraventricular transplantation should be accountable for their therapeutic effect in MS

Carbajal et al., 2011

US Oligodendrocyte- progentior cells

Mouse

Highlight the importance of the CXCL12:CXCR4 pathway in regulating homing of engrafted stem cells to sites of tissue damage in MS

Source: Ardeshiry lajimi A, Hagh MF, Saki N, Mortaz E, Soleimani M, Rahim F. Feasibility of Cell Therapy in Multiple Sclerosis: A Systematic Review of 83 Studies

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10.4 Stimulation of Endogenous NSCs with Growth Factors for MS Treatment

Inducement of endogenous NSCs with growth factors is an attractive approach for

treatment of MS and requires more research in order to evaluate its full therapeutic

potential. Use of growth factor signaling for improving oligodendrocyte replacement and

remyelination are nowadays the focus of intense study. Both in vivo and in vitro

experiments have shown that various factors act on oligodendrocyte progenitor cells

derived by the adult subventricular zone (SVZ), and promote proliferation, migration, or

differentiation properties.

TABLE 10.3: Growth Factors and Secreted Molecules Used for Stimulating Endogenous NSCs

Factor/Molecule Model Function

Factor:

HB-EGF LPC demyelinated mouse Recruitment

FGF-2 Cell culture Recruitment

CNTF LPC demyelinated rodent Recruitment

NGF EAE rat Differentiation

IGF-1 Cell culture Differentiation

PEDF Transgenic mouse Fate commitment

PDGF Transgenic mouse Proliferation

VEGF Unlesioned rat Proliferation

BDNF Unlesioned rat Proliferation

Molecule:

Reelin LPC demyelinated mouse Recruitment

Netrin 1 LPC demyelinated mouse Recruitment

Chordin LPC demyelinated mouse Recruitment

Noggin Cuprizone demyelinated mouse Proliferation Source: Michailidou I, de Vries HE, Hol EM, van Strien ME, Activation of endogenous neural stem cells for multiple sclerosis therapy, Frontiers in Neuroscience. 2014;8:454

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10.5 CIRM Grants Targeting MS

Some research groups have had success treating MS using bone marrow

transplants. Although they have been successful with this approach, the bone

marrow transplant itself is extremely risky. CIRM-funded researchers are trying to

mature stem cells into a type of cell that might be able to replace the missing

myelin. The idea is that these could be transplanted into a person with multiple

sclerosis and the cells would repair damage caused by the disease. Other groups

are trying to learn more about how the body’s natural processes should be

repairing the damage. Their goal is to find drugs that could stimulate the body’s

own stem cells to replace the damaged myelin.

TABLE 10.4: CIRM Grants Targeting MS

Institution Grant Title Approved

Funds ($)

University of California, Irvine

Human embryonic stem cells and remyelination in a viral model of demyelination

368,081

University of California, San Francisco

Human stem cell-derived oligodendrocytes for the treatment of stroke and MS

2,459,236

University of California, Irvine

Multiple sclerosis therapy: Human pluripotent stem cell-derived neural progenitor cells

4,590,219

Scripps Research Institute

Targeting stem cells to enhance remyelination in the treatment of multiple sclerosis

2,623,242

Total 10,040,777

Source: California Institute for Regenerative Medicine, “Multiple Sclerosis Fact Sheet”

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11. STROKE

A stroke is a “brain attack.” It can happen to anyone at any time. It occurs when blood

flow to an area of brain is cut off. When this happens, brain cells are deprived of oxygen

and begin to die. When brain cells die during a stroke, abilities controlled by that area of

the brain, such as memory and muscle control, are lost. The extent of functional

impairment caused by stroke depends on where the stroke occurs in the brain and how

much the brain is damaged. A person suffering a small stroke may only have minor

problems, such as temporary weakness of an arm or leg. People who have larger strokes

may be permanently paralyzed on one side of the body or lose the ability to speak. Some

people recover completely from stroke, but 60% of survivors have some type of disability.

11.1 Incidence of Stroke

Every year, 15 million people worldwide suffer a stroke. Nearly six million die and another

five million are left permanently disabled. Stroke is the second-leading cause of disability,

after dementia. Disability may include loss of vision and/or speech, paralysis, and

confusion. Globally, stroke is the second-leading cause of death above the age of 60

years, and the fifth-leading cause of death in people aged 15 to 59 years. In many

developed countries the incidence of stroke is declining even though the actual number

of strokes is increasing because of an aging population.

In the developing world, however, the incidence of stroke is increasing. In China, 1.3

million people have a stroke each year and 75% of stroke victims live with varying degrees

of disability as a result of stroke. The predictions for the next two decades suggest a

tripling in stroke mortality in Latin America, the Middle East, and sub-Saharan Africa.

About 795,000 Americans each year suffer a new or recurrent stroke. That means, on

average, a stroke occurs every 40 seconds. Stroke kills nearly 129,000 people a year. It

is the fifth-leading cause of death. On average, every four minutes someone dies of

stroke. About 40% of stroke deaths occur in males and 60% in females.

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11.2 Currently Available Medication for Stroke

The only FDA-approved treatment for ischemic stroke is tissue plasminogen activator

(tPA, also known as IV rtPA), given through an IV in the arm. tPA works by dissolving the

clot and improving blood flow to the part of the brain being deprived of blood flow. If

administered within three hours (and up to 4.5 hours in certain eligible patients), tPA may

improve the chances of recovering from a stroke. A significant number of stroke victims

don’t get to the hospital in time for tPA treatment; this is why it’s so important to identify a

stroke immediately.

11.3 Stem Cell-Based Therapies for Stroke

Exogenous cell therapy has become a novel and promising approach for the treatment of

stroke, as it has been found to provide neuroprotection and neurorepair by secreting

various neural trophic factors and replacing damaged neurons. Current basic and

translational researches are mainly focusing on three types of stem cells, including

embryonic stem cell (ESCs), neural stem cell (NSCs), and mesenchymal stem cell

(MSCs).

Exogenous NSCs can be generated from ESCs, iPSCs, bone marrow- and adipose-

derived MSCs, embryonic NSCs, and fetal and adult nervous systems. These NSCs can

expand in vitro when induced by various growth factors, such as EGF, FGF, and

leukemia-inhibiting factor, and develop into neurons, astrocytes, and oligodendrocytes

when stimulated by different factors, such as retinoic acid. Thus, NSCs seem to be

appropriate candidates for replacement of the lost neural cells in neurodegenerative

disorders including stroke.

A large number of investigations have confirmed that transplantation of NSCs obtained

from various origins via different routes reduced the infarcted area and promoted

neurological function recovery in animal models with ischemic stroke. Use of NSCs along

114

with gene modification has been found to improve the NSCs’ survival, proliferation, and

migration abilities, and secrete neurotrophic factors if as a gene therapy vehicle.

TABLE 11.1: An Overview of NSC Transplantation Experiments in Ischemic Stroke Models

Model Cell Route Time Outcome

rMCAO Fetal hNSC Intracerebral 7 days NA

rMCAO hNSC Intravenous 1 day Improved functional recovery

rMCAO hNSC Intravenous 1 day Improved functional recovery

rMCAO hESC-derived NSC

Intracerebral 7 days Improved functional recovery

pMCAO hNSC Local transplantation

1 day Improved functional recovery

rMCAO hNSC Intracerebral 1 month

Improved functional recovery

rMCAO hNPC Local transplantation

3 weeks

Improved functional recovery

PI in cortex

mNSC Intravenous 1 day Improved functional recovery

rMCAO Embryonic NSCs

Intracerebral 1 hour Improved functional recovery

mMCAO CD49d NSCs Intracarotid 2 days Improved functional recovery

rMCAO NSCs Intracerebral 7 days Improved functional recovery

mMCAO NPC Intravenous 3 days Improved functional recovery

rICH hNSC Intravenous 2 days Improved functional recovery

rMCAO rNSC and collagen I

Intracerebral 1 day Improved functional recovery

rMCAO Embryonic hNSCs

Intracerebral 1 day NA

Source: BioMed Research International, Volume 2014 (2014), Article ID 468748, 17 pages, http://dx.doi.org/10.1155/2014/468748

115

11.4 Various Stem Cell Types Used in Stroke Experimental Studies

The most appropriate cell therapies for stroke require not only the direct replacement of

multiple lost cell types and restoration of functional and appropriate neuronal connections

but also the reconstruction of disrupted vascular systems. Multiple stem/progenitor cells

are being tested for cell-based therapy for stroke. As shown in the following table, these

cells have shown their ability to survive, mature, migrate to the lesion, and decrease

neurological sequelae induced by stroke attack.

TABLE 11.2: Representative Experimental Studies of Various Cell-Based Therapies for Stroke

Cell Type Stroke Model Therapeutic Effect

ESCs 60-min MCAO13 in rats Not mentioned

NSCs Right MCA M1 segment occlusion in cynomolgus monkeys

Not mentioned

NSCs 45-min MCAO in mice Recovery improved

NSCs 17-min bilateral common carotid artery occlusion in mice

Reduced the extent of ischemic neuronal damage

iPSCs 1-h MCAO in rats Decreased infarct size; improved motor function

iPSCs 30-min MCAO in rats and mice; and permanent dMCAO + 30-min CCAO14 rat model by craniotomy

Forepaw movements recovery improved

BMSCs 2-h MCAO in rats Neurological functional recovery improved

BMSCs 2-h MCAO in rats Functional deficits were improved for 1 year

MSCs 1.5-h MCAO in neonatal rats Infarct size was reduced and motor deficits were improved

13 middle cerebral artery occlusion 14 common carotid artery occlusion

116

BMSCs 2-h MCAO in T1DM rats No functional improvement

Dental pulp-derived stem cells

Unilateral HI brain injury in P5 mice Brain-tissue loss was reduced and neurological function was improved

Adipose tissue stromal cells

1.5-h MCAO in rats Functional improvement

Umbilical cord blood cells

2-h MCAO in rats Neurological functional recovery improved

Menstrual blood-derived stem cells

60-min MCAO in rats Reduced cell death (in vitro); behavioral impairments (in vivo)

Placental MSCs 2-h MCAO in rats Decreased lesion volume; promoted functional outcome

Source: Liu X, Ye R, Yan T, et al., Cell based therapies for ischemic stroke: From basic science to bedside, Progress in neurobiology. 2014;115:92-115

11.5 Ongoing Clinical Trials for Stroke Using Stem Cells

Bone marrow-derived stem cells (BMSCs) do not raise ethical questions, and, therefore,

they are predominantly used in clinical trials. However, the longer time frame required for

obtaining cells from autologous sources restricts their potential use in patients with acute

stroke. The first use of BMSCs was reported from South Korea. The cells were

intravenously infused into five patients with chronic stroke and their neurological

improvements were compared with another 25 placebo-treated patients for one year.

They again studied the long-term (five years) safety and efficacy of BMSC transplantation

in 52 patients, among which 16 were treated with BMSCs. Side effects were not reported

following BMSC treatment. A phase I/II clinical trial in Spain indicated feasibility, safety,

and improved neurological results in MCA stroke patients transfused intra-arterially at five

and nine days after stroke with autologous bone marrow mononuclear cells. During the

follow-up period of six months, no adverse effects, deaths, tumor formation, or stroke

recurrence were reported except for two isolated partial seizures at three months. Now,

a number of clinical trials are underway in the US, Spain, France, China, and South Korea

evaluating the feasibility and efficacy of BMSCs for stroke treatment.

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TABLE 11.3: Ongoing Clinical Trials of Cell-Based Therapies for Stroke

NCT Identifier

Location Cell Type Cell Source

Phase

NCT01678534 Spain MSC from adipose tissue Allogenic II

NCT01310114 US Human placenta-derived cells Allogenic IIa

NCT01297413 US Adult BMSCs Allogenic II

NCT01287936 US Modified stromal cells Allogenic I/IIa

NCT01714167 China BMSCs Autologous I

NCT00535197 UK CD34+ stem cells Autologous I/II

NCT01468064 China BMSCs + EPCs Autologous I/II

NCT01518231 China Peripheral HSCs Autologous I

NCT01091701 Malaysia MSCs Allogenic I/II

NCT01327768 Taiwan OECs Autologous I

NCT01461720 Malaysia BMSCs Autologous I

NCT00875654 France MSCs Autologous IIa

NCT01151124 UK Neural stem cell Autologous I

NCT00859014 US Mononuclear bone marrow cells

Autologous I

NCT01273337 US ALD-401-derived bone marrow Autologous II

NCT01438593 Taiwan CD-34+ stem cells from UCB Allogenic I

NCT01453829 Mexico Adipose-derived stromal cells Autologous I/II

NCT01436487 US MultiStem Autologous II

NCT01716481 South Korea

MSCs Autologous III

NCT01239602 Taiwan CD34+ peripheral blood stem cells

Autologous N/A

Source: Liu X, Ye R, Yan T, et al., Cell based therapies for ischemic stroke: From basic science to bedside, Progress in neurobiology. 2014;115:92-115

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11.6 CIRM Grants Targeting Stroke

After a stroke, intensive physical therapy can help people regain some lost function.

However, there is currently no therapy to restore the brain cells that have died as

a result of the stroke. Stem cell scientists are attempting to use different types of

stem cells, including tissue-specific neural stem cells, embryonic stem cells, and

reprogrammed iPS cells, to replace cells lost during a stroke. They are testing the

different cell types in animal models of stroke to see which are best able to restore

movement. They also need to learn the best way of delivering those cells in to the

brain. In the US, several clinical trials are underway, testing different types of cells

and different delivery methods. Other researchers are looking at whether it is

possible to activate the stem cells in the brain to repair the damage.

TABLE 11.4: CIRM Grants Targeting Stroke

Institution Grant Title Approved

Funds ($)

Stanford University Paracrine and synaptic mechanisms underlying neural stem cell-mediated stroke recovery

1,178,370

The Scintilion Institute

Programming hESC-derived neural stem cells with MEF2C for transplantation in stroke

1,103,185

Stanford University Embryonic-derived neural stem cells for treatment of motor sequelae following subcortical stroke

17,244,851

Sanford-Bumham Medical Research Institute

New chemokine-derived therapeutics targeting stem cell migration

708,000

Gladstone Institute Defining the isoformspecific effects of apolipoprotein E on the development of iPSCs into functional neuronsi in vitro and in vivo

2,757,303

Sanford-Bumham Medical Research Institute

MEF2C-directed neurogenesis from hESCs 2,832,000

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University of California, San Francisco

Human stem cell-derived oligodendrocytes for treatment of stroke and multiple sclerosis

2,459,235

University of California, Los Angeles

Epigenic gene regulation during the differentiation of hESCs’ impact on neural repair

2,412,995

University of California, Los Angeles

Development of a hydrogel matrix for stem cell growth and neural repair after stroke

1,825,613

Stanford University Development of single cell MRI technology using egnetically encoded iron-based reporters

1,833,348

Sanford-Bumham Medical Research Institute

Programming hESCs-derived neural stem cells with MEF2C for transplantation in stroke

1,020815

Total 35,375,715

Source: California Institute for Regenerative Medicine, “Stroke Fact Sheet”

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12. MARKET ANALYSIS

12.1 Current Stem Cell Landscape

Recent advances indicate that stem cells can offer truly restorative and disease-modifying

therapies. Stem cells have been found to be useful in restoring sight to those with vision

loss, and stem cell products are in development for some of the most common and acute

conditions. These treatments can have greater potential than symptomatic therapies and

so expectations riding on these therapies are high. In the last ten years, several large

biotech and pharma companies have ventured into this high-reward, but also high-risk,

industry.

Recently, the industry witnessed a significant increase in the number of stem cell

therapies in every phase of development. Though stem cell therapies started gaining

attention in the late 1990s, the sector took off only in the early 2000s with the discovery

of human embryonic stem cells. There was an upswing in commercial interest, and a

large number of specialist cell therapy companies whose focus was mainly on the

conversion of research into commercially successful products were established. Now,

more than 87 products are in phase II, phase III, or pre-registration, whereas only 18

product candidates were in a similar stage in 2010. The stem cell industry is gradually

maturing, and nowadays it is quite common to hear about pivotal trials in the sector.

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FIGURE 12.1: Stem Cell Therapy Development

Source: Bioinformant Worldwide, LLC

12.1.1 Number of Stem Cell Product Candidates

A number of stem cell product candidates are currently in each stage of development.

For an emerging field, this is quite a healthy development with a long pipeline. Generally

drug candidates spend a much shorter time in phase I trials and spend far more time in

phase II. Thus, in the stem cell sector, phase II development is particularly busy with 73

candidates. In the past ten years, eight stem cell therapies have been launched in at least

in two countries in the world (Australia and South Korea). These products have been

developed for treating various disease conditions, such as osteoarthritis, myocardial

infarction, anal fistula, bone regeneration, and torn or damaged tendons, ligaments, and

cartilage. These successful launches indicate possible opportunities for many other

clinical candidates to progress.

0

50

100

150

200

250

300

1997 '99 '01 ‘03 '05 '07 '09 '11 '13 '15 2017

Nu

mb

er

Preclinical Phase I Phase II Phase III Launched

122

TABLE 12.1: Number of Therapies by Phase

Stage in Development No. of Product Candidates

Preclinical 99

Phase II 73

Phase I 14

Phase III 12

Launched 8

Registered 2

Pre-registration 2

Total 210 Source: Bioinformant Worldwide, LLC

FIGURE 12.2: Number of Therapies by Phase

0 10 20 30 40 50 60 70 80 90 100

Preclinical

Phase II

Phase I

Phase III

Launched

Registered

Pre-registration

Number

Source: Bioinformant, Worldwide, LLC

12.1.2 Commercial Stem Cell Therapy Development by Geography The majority of cell therapy trials sites are located in the US and the EU. Japan is fast

becoming a center of importance due to recent regulatory changes, which became

effective at the end of 2014. Earlier, Japan had enacted new legislation governing the

development, approval, and use of regenerative medicines. The new laws offer a legal

framework meant to encourage the development of novel regenerative therapies and to

accelerate product approvals in the sector. This new approval process has been designed

on the basis of regulations used in South Korea. Thus, in Japan and South Korea,

conditional approvals are now being granted on the basis of safety and efficacy data from

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phase II clinical trials instead of full phase III programs. Such approvals can allow for

commercial sales of the products, for up to seven years.

The Japanese company Sumitomo Dainippon Pharma has invested heavily in this field.

The company has a joint venture with Healios KK for commercializing induced pluripotent

cell treatments for macular degeneration. In 2015, the US-based Athersys signed a cell

therapy alliance with Chugai (Roche). According to their agreement, Chugai will develop

and sell Athersys’ MultiStem for ischemic stroke in Japan. The alliance has the value of

$10 million up front to Athersys, plus additional development and regulatory milestone

payments of about $45 million. Furthermore, in April 2015, Takeda announced that it will

work with the Center for iPS Cell Research Application of Kyoto University on stem cell

research in a 10-year program for developing clinical applications of induced pluripotent

stem cells for diseases such as heart failure, diabetes mellitus, neurological disorders,

and cancer immunotherapy.

12.1.3 Commercially Attractive Therapeutic Areas

The cardiovascular field is the hottest area for stem cell research, accounting for about a

quarter of all stem cell therapies currently being developed. The phase III pipeline for this

segment is dominated by therapies for heart failure, angina, and myocardial infarction.

The conventional therapies for heart failure do not address loss or scarring of cardiac

muscle cell mass, resulting in a high level of unmet medical need, and this provides a

great opportunity for regenerative stem cell therapies. Joint ventures between specialty

and large pharma companies are trying to move into the cardiovascular space. Such

companies include Bioheart, Teva, and Baxter International. Baxter is now conducting a

pivotal phase III trial for evaluating the efficacy and safety of adult autologous CD34+

stem cells to increase exercise capacity and amelioration of anginal symptoms in patients

with chronic myocardial ischemia. This trial has enrolled about 300 patients in more than

40 clinical sites in the US.

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Many stem cell products are also being developed in the metabolic and neurological

therapeutic areas. Some of the important conditions under study include hepatic

dysfunction, bone regeneration, spinal cord injury, and Parkinson’s disease. Retinal

disease is another up and coming area for stem cell treatment, with studies mainly

focused on corneal injury, macular degeneration, optic neuritis, macular edema, and

diabetic retinopathy. In December 2014, the EMA granted approval for Holoclar, a

treatment for moderate-to-severe limbal stem cell deficiency due to physical or chemical

burns to the eye in adults. This was the first stem cell therapy product to be approved in

the EU. If we take into account all the different types of stem cells, mesenchymal stem

cells dominate the stem cell market space. They are ahead of all the other types. They

have many advantages, including easy isolation, easy amplification from bone marrow

cells, potential to differentiate into all the different types of human cells, and less

immunogenicity even as allogeneic transplants. Other advantages are that they are

ethical and do not form teratomas.

TABLE 12.2: Stem Cell Product Candidates in Various Stages by Therapeutic Area

Therapeutic Area Preclinical Phase I Phase II Phase III

Autoimmune/inflammation 16 2 17 1

Cardiovascular 27 8 31 7

Dermatological 5 1 2 -

Gastrointestinal 1 - - -

Genitourinary 2 1 1 -

Infectious disease 3 - 3 -

Metabolic disease 30 2 14 2

Neurological 25 3 15 2

Oncology 28 - 4 2

Ophthalmology 14 - 6 -

Respiratory 4 - 6 - Source: Bioinformant Worldwide, LLC

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12.1.4 Major Companies Investing in Stem Cell Industry

If we consider companies with four or more product candidates, then there are about nine

key players in the stem cell therapy sector. Among them, Biotime is the biggest player,

with nine product candidates. Biotime is fosing on this sector through its subsidiaries,

such as Cell Cure Neurosciences and OrthoCyte, and collectively they are developing

OpRegen (a cell-based therapy for age-related macular degeneration) and therapies for

arthritis. Additionally, their subsidiary ReCyte Therapeutics is utilizing its proprietary

technology to reverse the developmental aging of human cells to produce young vascular

progenitors for treating age-related vascular disease.

TABLE 12.3: Stem Cell Therapies in Phase III and Pre-Registration as of 2015

Therapy Cell Source Cell Type Indication Company

MyoCell Myoblasts from thigh muscle

Autologous Heart failure Bioheart

Carlecortemcel-1/StemEX

Umbilical cord blood cell

Allogeneic Anemia after chemotherapy

Gamida Cell, Teva

Stem cell therapy Blood-derived CD34+ cells

Autologous Angina Baxter

CX-601 Adipose-derived stem cells

Allogeneic Anal fistula TiGenics

CEP-41750/ Revascor

Mesenchymal precursors

Allogeneic Heart failure Mesoblast, Teva

C-Cure Bone marrow derived-stem cells

Autologous Heart failure Celyad

Stemedica-1 MSCs Allogeneic Myocardial infarction

Stemedica

BMT Mesenchymal precursor cells

Allogeneic Blood cancer Mesoblast, Teva

PREOB Bone marrow-derived MSCs

Autologous Osteonecrosis, fracture healing

Bone Therapeutics

Cerecellgram-spine

Bone marrow-derived MSCs

Autologous Spinal cord injury Pharmicell

Cerecellgram-stroke

Bone marrow-derived MSCs

Autologous Cerebral ischemia

Pharmicell

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Rexlemestrocel-L Mesenchymal precursor cells

Allogeneic Back pain Mesoblast

Stempeucel Bone marrow-derived MSCs

Allogeneic Limb ischemia, osteoarthritis

Stempeutics, Cipla

GSK-2696273 CD34+ hematopoietic

Autologous Immunodeficiency GSK

Source: Bioinformant Worldwide, LLC

The Australian company Mesoblast is another important player in the sector, with eight

product candidates in development. Mesoblast’s allogeneic product candidates are

meant for repairing damaged tissues and modulation of inflammatory responses in

diseases with significant unmet medical needs. Mesoblast’s cell therapy products are

meant to focus on four major areas: orthopedic diseases, cardiovascular diseases,

systemic diseases, and improving outcomes of bone marrow transplantation in patients

with cancer or genetic diseases. The company’s remestemcel-L was acquired from Osiris

Therapeutics as an off-the-shelf adult mesenchymal stromal cell product, which was

granted approval in several countries for acute graft-versus-host disease, and it was

approved in Japan on February 24, 2016. In addition, Celgene’s recent investment of $45

million in Mesoblast is another boost.

The pharmaceutical industry has now adopted stem cells as a tool in drug discovery. The

majority of the big pharmaceutical firms are using embryonic stem cells or adult stem cells

for their internal drug discovery programs. These internal efforts are mostly strengthened

by the expertise of external partnerships with academics or biotech companies. Yet,

multinational pharma companies have historically been slow to invest in developing stem

cell-based regenerative medicine.

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TABLE 12.4: Companies with Active Stem Cell Therapy Pipelines

Company Preclinical Phase I Phase II Phase III

BioTime 7 - 2 -

Mesoblast - - 4 3

Pluristem 4 1 2 -

Stemedica 3 - 2 1

Bone Therapeutics 2 - 1 1

CHA Bio & Diostech 1 - 3 -

Ocata Therapeutics 3 - 1 -

Pharmicell 1 - 1 2

Xcelthera 4 - - -

Source: Bioinformant Worldwide, LLC

12.1.5 Venturing of Big Pharma into Stem Cell Therapy Sector

Since 2000, the stem cell industry has been witnessing a steady increase in the number

of therapeutic products in development and many well-known pharma companies have

entered the stem cell marketplace through acquisitions, investments, and licensing deals.

In addition to a growing number of stem cell assets, companies have also opened large

units and programs to support progress in this area, for example, Neusentis of Pfizer.

There is also a growing tendency for partnerships academic institutions, which is

evidence of the growth within the stem cell sector

Big pharma companies are mostly indulging in licensing products for development, putting

the onus on the stem cell developer to complete the crucial stages of the R&D journey.

Teva, with seven product candidates in development, has signed licensee agreements

with Mesoblast, BioTime, and Gamida Cell. Additionally, Teva has three more candidates

in phase III development, including Revascor, which is currently in a global, pivotal 1,700-

person trial for congestive heart failure.

Novartis strengthened its position in the stem cell sector by investing $35 million in

Gamida Cell Ltd in 2014. This new agreement came after Novartis signed, in September

2013, a partnership with Regenerex to gain access to its stem cell technology. The very

big player Johnson & Johnson has also shown its commitment to this sector by investing

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$12.5 million in Capricor Therapeutics’ cell therapy program for cardiovascular

applications, particularly CAP-1002, through its subsidiary, Janssen Pharmaceuticals,

Inc. Furthermore, through Janssen Pharmaceuticals, J&J has invested in ViaCyte’s VC-

01 combination product being developed for the treatment of type 1 diabetes. The signed

agreement gives Janssen a choice in the future to consider a transaction related to the

VC-01 combination product.

Regardless of these investments, there is also growing apprehension about just how long

a road stem cell research has to travel, and this has prompted some companies to retreat

from of the stem cell sector. For example, Osiris sold its mesenchymal stem cell platform

and Prochymal to Mesoblast, after Sanofi suddenly took a decision not to sign up for a

$1.25 billion collaboration that came with a $130 million upfront payment. Despite this

development, other companies have revealed that they are still prepared to invest. An

example of this sustained interest is seen in the agreement between Chiesi and

AstraZeneca with their own preclinical candidates.

TABLE 12.5: Big Pharma’s Involvement in Stem Cell Sector

Therapy Description Company

PRECLINICAL

Anticancer, Medimmune

Stem cells to directly attack tumor cells

AstraZeneca (orginator)

Epidermolysis bullosa

Autologous human keratinocytes Chiesi (originator)

HLS-001 iPSC-derived retinal pigment epithelial cells for AMD

Dainippon Sumitomo Pharma (licensee)

PF-05206388 ESC-derived retinal pigment epithelium for wet AMD

Pfizer (originator)

Multistem Adherent progenitor cells for stroke Roche (licensee)

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Cell Cure ESC-derived mid-brain progenitor cell therapy

Teva (licensee)

NeurArrest ESC-derived neural progenitor cells for multiple sclerosis

Teva (licensee)

PHASE II

Cenplacel-L Placenta-derived adherent stem cells for Crohn’s disease

Celgene (originator)

SB-623 Allogeneic NSCs for cerebral ischemia Dainippon Sumitomo Pharma (licensee)

GSK-2696275 CD34+ hematopoietic cells for Wiskott-Aldrich syndrome

GSK (originator)

GSK-2696274 CD34+ hematopoietic cells for metachromatic leukodystrophy

GSK (originator)

CAP-1002 Allogeneic cardiosphere-derived cells for heart failure and myocardial infarction

J&J (licensee)

HSC-835 Umbilical cord blood-derived hematopoietic stem cells for leukemia and lymphoma

Novartis (originator)

Multistem Adherent progenitor cells for irritable bowel disease and ulcerative colitis

Pfizer (licensee)

MPC-25-IC Allogeneic MSC precursor cells for acute myocardial infarction

Teva (licensee)

PDA-002 Placenta-derived stem cells for peripheral arterial disease and diabetic foot ulcers

Celgene (originator)

PHASE III

Stem cell therapy

Blood-derived CD34+ stem cell therapy for angina

Baxter (originator)

Revascor Allogeneic MSC precursor cells for heart failure and myocardial infarction

Teva (licensee)

MPC-CBE Allogeneic MSC precursor cells for bone marrow transplantation

Teva (licensee)

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Carlecortemcel-l Cord blood-derived CD34+ progenitor cells for hematopoietic reconstruction after chemotherapy

Teva (licensee)

VC-01 ESC-derived pancreatic cells for type I and type II diabetes

Pfizer (licensee)

OpRegen ESC-derived retinal pigmented epithelial cells for age-related macular degeneration

Teva (licensee)

CNTO-2476 Allogeneic umbilical cord tissue-derived cells

J&J (originator)

Pre-Registration

GSK-2696273 Autologous CD34+ hematopoietic cells engineered for ADA severe combined immune deficiency

GSK (originator)

Stempeucel Bone marrow-derived MSCs for osteoarthritis and critical limb ischemia

Cipla (licensee)

Source: Bioinformant Worldwide, LLC

12.3 Major Clinical Milestones in Cell Therapy Sector

12.3.1 TiGenics’ Cx601

On August 23, 2015, TiGenix NV (Euronext Brussels: TIG) announced that its lead

compound Cx601 met the primary endpoint in the phase III ADMIRE-CD trial in Crohn’s

disease patients with complex perianal fistulas. Cx601 is a suspension of allogeneic

expanded adipose-derived stem cells (eASC) injected intra-lesionally. A single injection

of Cx601 was statistically superior to placebo in achieving combined remission at week

24, in patients with inadequate response to previous therapies, including anti-TNFs. The

study results confirm the favorable safety and tolerability profile of Cx601.

12.3.2 Mesoblast Ltd. and JCR Pharmaceuticals Co., Ltd.

On February 24, 2016, Mesoblast launched the first allogeneic cell therapy to ever

achieve full approval in Japan, a mesenchymal stem cell product, TEMCELL HS Inj. The

product is to be used for the treatment of acute graft-versus-host disease, sold through

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Mesoblast’s Japanese licensee, JCR Pharmaceuticals. The Japanese government’s

national health insurance set reimbursement for TEMCELL at ¥868,680 ($7,700) per bag

of 72 million cells.

In Japan, the average adult patient is expected to receive at least 16, and up to 24, bags

of 72 million cells. On this basis, Mesoblast expects a treatment course of TEMCELL in

an adult Japanese patient to be reimbursed at a minimum of ¥13,898,880 ($123,000),

and up to ¥20,848,320 ($185,000). Under its agreement with JCR, Mesoblast is entitled

to receive royalties and other payments at predefined thresholds of cumulative net sales.

In the US, there are currently no approved therapies for patients with acute steroid-

refractory GVHD, and off-label options have demonstrated mixed efficacy with high

toxicity.

12.3.3 Chiesi’s Holocar

On February 20, 2015, the European Commission approved Holocar, the first advanced

therapy medicinal product containing stem cells, following a recommendation for approval

by the European Medicines Agency. Holocar uses a particular type of eye stem cell,

called a limbal stem cell, to repair the cornea after injury, restoring sight. The work is

collaboration between a public research center and a solid private pharmaceutical

company.

12.3.4 ReNeuron’s Retinitis Pigmentosa Cell Therapy Candidate

On May 22, 2015, the FDA granted a fast-track designation to ReNeuron’s human retinal

progenitor cell (hRPC) therapy candidate for retinitis pigmentosa (RP). RP is a group of

hereditary diseases of the eye that lead to progressive loss of sight due to cells in the

retina becoming damaged and eventually dying. ReNeuron’s cell therapy candidate for

RP has already been granted orphan drug designation in both Europe and the US by the

European Commission and the FDA, respectively. Products with orphan drug designation

benefit from potential market exclusivity post-approval for up to seven years in the US

and up to ten years in Europe.

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12.3.5 Orphan Drug Designation to Pluristem’s PLX-PAD Cells

On December 31, 2015, the FDA granted an orphan drug designation to Pluristem’s PLX-

PAD cells for the treatment of severe preeclampsia. Preeclampsia is among the most

common medical complications of pregnancy and a leading cause of premature births,

stillbirths, and neonatal and maternal deaths. Due to high risks to the mother, women

diagnosed with severe preeclampsia are usually delivered promptly, even if the baby will

be born prematurely and may suffer permanent disabilities as a result. Severe

preeclampsia occurs in approximately 1% of pregnancies in Western countries.

12.4 Major Anticipated Cell Therapy Clinical Data Events in 2016

There is a noticeable air of zeal and enthusiasm in the cell therapy industry as more and

more clinical developments start emerging. Over the next five to ten years, we will witness

developments on both the clinical and manufacturing sides. The following table lists the

major clinical events in cell therapy sector that occurred during 2016.

TABLE 12.6: Major Cell Therapy Clinical Data Events in 2016

Company Therapy/ Product

Therapeutic Modality

Indication Clinical Stage

Reporting Date

GSK GSK2696273 Gene therapy

ADA-SCID EMA Marketing Approval

Q1 2016

Spark Therapeutics

SPK-RPE65 Gene therapy

Retinal dystrophies

Phase III 2H 2016

Celyad CHART-1 Autologous stem cells

Congestive heart failure

Phase III Q3 2016

Mesoblast MSC-100-IV MLCs Acute GVHD Phase III Q3 2016

Mesoblast/ Teva

MPC-150-IM MLCs Chronic heart failure

Phase III Q2 2016

Mesoblast MPC-06-ID MLCs Low back pain

Phase III Q4 2016

Bluebird Bio Lenti-D Gene therapy

CCALD Phase II/III

1H 2016

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Opexa Tcelna T-cell SPMS Phase IIb 2H 2016

Brainstorm NurOwn Autologous MSCs

ALS Phase II 1H 2016

Kiadis ATIR101 Adult stem cell

AML, ALL, MDS

Phase II Q2 2016

ReNeuron CTX Stem cell Post-stroke Phase II Q2 2016

Mesoblast MPC-300-IV MLCs Arthritis Phase II Q3 2016

Sutter Autologous cord blood

Adult stem cell

Autism Phase II Q1 2016

Histogenics NeoCart Tissue engineering

Cartilage Phase II 2016

Cells for Cells

UC-MSCs IV SLE Phase IIa/IIb

Q2 2016

MEDIPOST PNEMOSTEM Adult stem cell

Broncho-pulmonary dysplasia

Phase II Q2 2016

GenSight Biologics

GS010 Gene therapy

Optic neuropathy

Phase I/IIa

Q3 2016

uniQure AAv5/FIX Gene therapy

Hemophilia B Phase I/II Q2 2016

AGTC XLRS Gene therapy

Retinoschisis Phase I/II 2H 2016

Celyad NKG2D CAR-T Leukemia Phase I 2H 2016

Athersys MultiStem Stem cell ARDS and AMI

Phase II 2016

Source: Alliance for Regenerative Medicine 2016

12.5 Global Market for Cell Therapy Products

Cell therapy technologies have already started playing an important role in the practice

of medicine, and cell therapy is likely to become a part of medical practice in the next five

to ten years. The technologies of cell therapy are overlapping with those of gene therapy,

cancer vaccines, drug delivery, tissue engineering, and regenerative medicine.

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Techniques of delivering cell therapy products vary from injections to surgical implantation

using special devices. Cell therapy products are being developed for a large number of

diseases. Two of the most important disorders being focused on are nervous system

diseases and cancer. Other areas of applications include cardiac disorders, diabetes

mellitus, diseases of bones and joints, genetic diseases, and wounds of the skin and soft

tissues.

Cell therapy product treatment is not similar to conventional therapies because it is

personalized, and this is valuable progress for personalized medicine.The majority of

traditional therapies involve use of organic compounds or proteins to alleviate symptoms,

and do not offer a permanent cure. Cell therapy products use the cell itself as medicine,

cells which are mostly produced from the patient's own tissue, manipulated and cultured

to have certain properties, and injected back into the patient. Therefore, cell therapy is

called personalized medicine, as contrasted to medications, which are produced for the

masses.

As of today, eight cell therapy products have been approved worldwide, and many other

products are currently under active investigation. Their market size is anticipated to grow

rapidly in the near future. It has been estimated that the global market for stem cell therapy

products was worth about $7.7 billion in 2017, and this has been predicted to grow and

reach $14.1 billion in 2022. The US is the single largest market, with revenues of about

$2.1 billion in 2017, and this is likely to reach $3.6 billion in 2022. The US is followed by

Europe, with a market value of $1.4 billion in 2017, which has the potential to reach $2.4

billion in 2022. Stem cell therapy has become established in South Korea, Australia, New

Zealand, and Canada, and collectively the market for the rest of the world was worth

about $4.3 billion in 2017; it has the potential to reach $8.2 billion in 2022.

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12.5.1 Global Market for Neural Stem Cells

Neural stem cells (NSCs) have the property of dividing and differentiating into neurons,

astrocytes, and oligodendrocytes. As cell therapy research has gained momentum

throughout the world, several companies have been focusing on developing NSCs from

different sources. NSCs can be generated from fetal neural tissue, ESCs, MSCs, BM-

derived stem cells, and induced pluripotent cells. NSCs find applications in neurotoxicity-

testing cellular therapies to address cental nervous system disorders, neural tissue

engineering, drug target validation, and personalized medicine. As NSCs have diverse

applications, several companies are manufacturing and marketing NSCs. The major

companies in this sector are marketing their NSC products for research purposes,

preclinical trials, and human clinical trials. These companies are often referred to as

“research supply companies.”

The major companies selling neural stem cell research products include EMD Millipore,

Life Technologies, Thermo Fisher Scientific, and STEMCELL Technologies. Now, more

than 42 companies are focusing on this market segment. EMD Millipore is the global

leader in neural stem cell product development for the scientific community. The other

important players in this field are Neural Stem, NeuroNova AB, and NeuroGeneration. In

a big way, Big Pharma is showing interest in the utilization of NSCs for designing neural

screening assays.

In developed markets, neurological diseases are major health problems and leading

causes of death. Neurological diseases such as Parkinson’s disease, amyotrophic lateral

sclerosis (ALS), spinal muscular atrophy, Alzheimer’s disease, stroke, brain, and spinal

cord injuries represent an annual cost of about $1.5 trillion in the US and Europe

combined. As of today, there is no treatment option or compound drug of molecular entity

that can be used to change the prognosis of most of these diseases or that will lead to a

dramatic functional improvement. Cell-based therapy is the therapeutic approach closest

to providing a cure and restore normal tissue and function for patients with neurological

diseases.

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TABLE 12.8: Global Market for Neural Stem Cells (NSCs), Through 2022

Disease Indication

2017 (USD $

Millions)

2018 (USD $

Millions)

2019 (USD $

Millions)

2022 (USD $

Millions)

CAGR % 2017-2023

Neural stem cell products

2,344 2,630 2,951 4,168 12.2

Other stem cell products

5,379 5,858 6,379 8,238 8.9

Total 7,723 8,488 9,330 12,406 9.8 Source: Bioinformant Worldwide, L.L.C.

FIGURE 12.4: Global Market for NSCs, Through 2022

Source: Bioinformant Worldwide, L.L.C.

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

2017 2018 2019 2022

NSCs Other Stem Cell Types

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13. SELECTED COMPANY PROFILES

In this section, leading companies competiting within the neural stem cell market are

profiled.

13.1 Asterias Biotherapeutics, Inc.

6300 Dumbarton Circle

Fremont, CA 94555

United States

Telephone: 1-510-456-3800

Fax: 1-510-456-3796

Website: www.asteriasbiotherapeutics.com

Asterias Biotherapeutics, Inc. is focused on the emerging fields of cell therapy and

regenerative medicine. The company is developing therapeutic products in the areas of

neurology and oncology. The company has been developing AST-VAC1, an autologous

product candidate that completed its phase II clinical trial, meant for acute myelogenous

leukemia treatment; AST-VAC2, an allogeneic, or non-patient-specific, cancer vaccine

candidate designed for stimulating patient immune responses to telomerase; and AST-

OPC1, which is in phase I/IIa clinical trials meant for treating spinal cord injury, multiple

sclerosis, and stroke. Earlier, the company was known as BioTime Acquisition

Corporation; it changed its name to Asterias Biotherapeutics, Inc. in March 2013. The

company was established in 2012 and is headquartered in Menlo Park, California. The

company has been operating as a subsidiary of BioTime, Inc.

13.1.1 AST-OPC1

Asteria’s AST-OPC1 clinical program tests the utility of oligodendrocyte progenitor cells

manufactured from a pluripotent embryonic stem cell platform for treating spinal cord

injuries. A large body of preclinical studies has demonstrated the safety and efficacy of

AST-OPC1 in models of thoracic (back) and cervical (neck) spinal cord injury. Four

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important reparative functions of AST-OPC1 were observed in these studies: reduction

of the size of the injury cavity, restoration of the protective “myelin” coating on nerve cells,

production of factors that stimulate nerve cell growth, and recruitment of blood vessels to

deliver oxygen and nutrients to the site. Importantly, significant improvements in

locomotor (walking) function were seen with AST-OPC1 transplantation in models of both

thoracic and cervical injuries.

Additionally, AST-OPC1 was previously tested in the world’s first human clinical trial of a

pluripotent stem cell-derived product. In this study, five patients with neurologically

complete thoracic spinal cord injury were administered two million AST-OPC1 cells at the

spinal cord injury site 7-14 days post-injury. This low dose level was selected to evaluate

safety and feasibility, given the novel mechanism of treatment.

The subjects received low-level immunosuppression for the 60 days following

administration of AST-OPC1. Delivery of AST-OPC1 was successful in all five subjects

with no serious adverse events associated with the administration of the cells, with AST-

OPC1 itself, or with the immunosuppressive regimen. In four of the five subjects, serial

MRI scans indicated that reduced spinal cord cavitation may have occurred. This trial

met the primary endpoints of safety and feasibility when administered to five patients with

neurologically complete thoracic SCI.

Following the success of the first trial, the company initiated a phase I/IIa open-label,

single-arm study (the SCI-Star study) testing three escalating doses of AST-OPC1 in

patients with subacute, C-5 to C-7, neurologically complete cervical SCI. The protocol

includes a dose escalation starting with patients being dosed with two million cells and

escalates into two patient cohorts receiving ten million and twenty million cells,

respectively. Researchers will evaluate the safety of AST-OPC1 administered once

between 14 and 30 days after injury and also assess the impact on patient hand and arm

function. Enrollment for this trial began in 2015.

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13.2 Atherdsys Inc.

3201 Carnegie Avenue

Cleveland, OH 44115-2634

United States

Telephone: 1-216-431-9900

Fax: 1-216-361-9495

Website: www.athersys.com

Athersys is focused on creating safer and more effective new therapies that can address

significant unmet medical needs and to generate substantial value for its shareholders in

the process. The company is developing a portfolio of product development opportunities

that have the potential to be safer, more effective products than the current standard of

care.

13.2.1 MultiStem Programs

The company is developing MultiStem, a proprietary stem cell product for the treatment

of multiple distinct diseases and conditions in the cardiovascular, neurological,

inflammatory, and immune disease areas. MultiStem is a biologic product that is

manufactured from human stem cells obtained from adult bone marrow or other

nonembryonic tissue sources. Unlike other cell types, after isolation from a qualified donor

MultiStem may be expanded on a large scale for future clinical use and stored in frozen

form until needed.

13.2.2 Ischemic Stroke

MultiStem has potential as a “best-in-class” cell therapy based on its ability to deliver

therapeutic benefit through multiple mechanisms of action, its ability to be delivered “off-

the-shelf” like a pharmaceutical product, and its consistent safety profile. MultiStem

appears capable of delivering a therapeutic benefit in multiple ways, such as through the

production of factors that:

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• Protect damaged or injured neurons,

• Reduce inflammation common in ischemic injury,

• Promote new blood vessel formation, and

• Augment tissue repair and healing.

13.2.3 Clinical Programs (Stroke Phase II)

Administration of MultiStem even one week after a surgically induced stroke results in

substantial and long-term therapeutic benefit, as evidenced by the improvement of treated

animals compared with controls in a battery of tests examining mobility, strength, fine

motor skills, and other aspects of neurological functional improvement. These results

have been confirmed in subsequent studies that demonstrate MultiStem treatment is well-

tolerated, does not require immunosuppression, and results in a robust and durable

therapeutic benefit even when administered well after the initial stroke event.

In April 2015, the company announced interim results from its exploratory phase 2 clinical

study of the intravenous administration of MultiStem cell therapy to treat patients who had

suffered an ischemic stroke. The study results demonstrated favorable safety and

tolerability for MultiStem, consistent with previous studies. With respect to the primary

and secondary endpoints, when considering the pre-specified efficacy population (e.g.,

allowing for treatment up to 48 hours post-stroke), the cell therapy did not show a

difference at 90 days compared to placebo. However, MultiStem treatment was

associated with higher levels of patients achieving an excellent outcome clinically, faster

recovery, and lower rates of mortality and life-threatening adverse events, infections, and

pulmonary events.

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13.3 Axiogenesis AG / Pluriomics (Merged to Form Ncardia)

Nattermannallee 1/S20

Cologne, 50829

Germany

Telephone: 49-221-998818-0

Fax: 49-221-998818-10

Website: www.axiogenesis.com

Ncardia, formed by the Merger of Axiogenesis AG and Pluriomics, is focused on

developing and commercializing stem cell-derived, in vitro differentiated cardiomyocytes

and other cell types, as well as drug development assays and disease models for use in

drug discovery and development and life sciences research primarily in Germany. Its

products comprise Cor.4U human-induced pluripotent stem cell-derived

cardiomyocytes; Dopa.4U human iPS cell-derived dopaminergic neurons that are used

to treat neurological diseases; and Peri.4U human iPS cell-derived peripheral neurons,

which are used for treating pain and peripheral nervous system diseases and as

general neurotoxicity assays.

13.3.1 Peri.4U – Human iPS Cell-Derived Peripheral Neurons

Peripheral neurons play an important role in transmitting signals between the peripheral

and central nervous systems. Axiogenesis has developed human-induced pluripotent

stem cell-derived peripheral neurons, named Peri.4U, representing a new standard for

drug development. Applications include functional and general neurotoxicity assays (e.g.,

peripheral neuropathy) as well as release testing for botulinum N toxin.

13.3.2 Dopa.4U – Human iPS Cell-Derived Dopaminergic Neurons

The disease burden of current neurological disorders, including degenerative, genetic,

and neurotoxic, require the development of new standards for drug development. To meet

this need, Axiogenesis has developed human pluripotent stem cell-derived dopaminergic

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neurons—Dopa.4U. Dopa.4U represents an excellent in vitro model for efficacy, safety,

and toxicology studies with the following advantages:

• Fully differentiated, primary-like morphological, electrophysiological, and

pharmacological characteristics

• Long-term viability (> 50 days in culture)

• Ready-to-use (just thaw and plate)

• Implementable quickly (only three days pre-culture required post-thaw)

• Suitable for HTS

• Applicable for drug development given presence of functional toxicity pathways

(e.g. Parkinson’s disease -MPP+, 6-OHDA)

Dopa.4U has been validated in the following assays and applications:

• Immunocytochemistry

• Manual and automated patch clamp

• Microelectrode array

• Calcium transients

• Neurite outgrowth assay (high content analysis)

13.3.3 CNS.4U—Human iPS Cell-Derived Central Nervous System Cells (in development)

Physiological human pluripotent stem cell-derived cell systems bear the major advantage

of having increased test system/target system compatibility. The cells are composed of

two of the key cell types present in the human central nervous system—astrocytes and

neurons. Simultaneous generation of neurons and astrocytes from the same human

iPSC line recapitulates the intercellular interactions between cell types and better mimic

inherent cellular mechanisms taking place during CNS development. CNS.4U is suitable

for drug screening, prediction of pharmacological responses in vitro, and disease

modeling in the dish. Advantages of CNS.4U human iPSC-derived cardiomyocytes are:

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• Primary-like non-artificial mixture of three major neuronal subtypes and astrocytes

of human origin

• Ready-to-use (just thaw and plate)

• Long-term viability

• Suitable for HTS

• Applicable for CNS disease modeling and neurotoxicity assays

CNS.4U has been validated in the following assays and applications:

• Immunocytochemistry

• Manual patch clamp

• Microelectrode Array

• Cell metabolism analysis

13.3.4 Astro.4U—Human iPS Cell-Derived Astrocytes (in development)

Astrocytes are specialized supportive cells of the central nervous system. They are

essential to insure its healthy functioning and are implicated in numerous disease

mechanisms. Recent advances have demonstrated the importance of the neuron-

astrocyte partnership in the progression of various neurodegenerative diseases, such as

Alzheimer’s disease and Parkinson’s disease. Axiogenesis has developed human-

induced pluripotent stem cell-derived astrocytes, named Astro.4U, to recapitulate the

neuron-astrocyte interactions of (patho) - physiological relevance. Astro.4U is terminally

differentiated astrocytes that can be cultured alone or in a co-culture system with

Axiogenesis’ neuronal cell products. To facilitate downstream analysis of astrocytes and

neurons, Astro.4U is generated from the same human iPS cells as Dopa.4U and Peri.4U

neurons, as well as CNS.4U cells.

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Advantages of Astro.4U:

• Homogenous culture of human origin

• Ready-to-use (just thaw and plate)

• Long-term viability (> two weeks)

• Xeno-free medium

• Suitable for co-culture with hiPSC-derived neurons

• Isogenic to Dopa.4U, Peri.4U and CNS.4U

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13.4 AxoGen, Inc.

13631 Progress Boulevard

Suite 400

Alachua, FL 32615

United States

Telephone: 1-386-462-6800

Fax: 1-386-462-6801

Website: www.axogeninc.com

AxoGen, Inc. is focused on providing a portfolio of nerve repair solutions for various

surgical peripheral nerve repair needs. Its Avance Nerve Graft is the alternative to

autografts and other off-the-shelf nerve repair products meant for nerve gaps up to 70mm

in length. AxoGuard Nerve Connector is a coaptation aid used in cases of transected

nerve injuries. AxoGuard Nerve Protector is a protective wrap for nerves injured by

compression, or where the surgeon wants to protect and isolate the nerve during the

healing process after surgery.

13.4.1 Avance Nerve Graft

Avance Nerve Graft is an off-the-shelf processed human nerve allograft intended for the

surgical repair of peripheral nerve discontinuities. Through a proprietary cleansing

process for recovered human peripheral nerve tissue, the graft preserves the essential

inherent structure of the ECM while cleansing away cellular and noncellular debris.

Avance Nerve Graft provides the following key advantages:

• Three-dimensional scaffolds for bridging a nerve gap

• Decellularized and cleansed extracellular matrix that remodels into patient’s own

tissue

• No donor nerve surgery, therefore no comorbidities associated with an additional

surgical site

• Available in a variety of lengths and diameters to meet a range of gap lengths and

anatomical needs

• Supplied sterile with three years shelf life (kept frozen at or below -40º C/F)

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13.4.2 AxoGuard Nerve Connector

AxoGuard Nerve Connector is the only porcine submucosa extracellular matrix (ECM)

coaptation aid for tensionless repair of transected or severed peripheral nerves. While

allowing for the close approximation of severed nerves, AxoGuard Nerve Connector

aligns and connects severed nerve ends with less than a 5 mm gap. The AxoGuard ECM

material allows the body’s natural healing process to repair the nerve by isolating and

protecting it during the healing process. The patient’s own cells incorporate into the

extracellular matrix to remodel and form a tissue similar to the nerve epineurium.

13.4.3 AxoGuard Nerve Protector

AxoGuard Nerve Protector is the only porcine submucosa extracellular (ECM) matrix

surgical implant used to protect injured nerves and to reinforce the nerve reconstruction

while preventing soft tissue attachments. Designed to protect and isolate, the AxoGuard

multi-laminar ECM separates and protects the nerve from the surrounding tissues during

the healing process. The patient’s own cells incorporate into the minimally processed

extracellular matrix to remodel and form a tissue similar to the nerve epineurium.

AxoGuard Nerve Protector is provided sterile and in a variety of sizes to meet the

surgeon’s anatomical needs. AxoGuard Nerve Protector can be used to:

• Protect injured nerves up to 40 mm,

• Minimize risk of entrapment in compressed nerves,

• Protect partially severed nerves, or

• Reinforce a coaptation site.

AxoGuard Nerve Protector has the following key advantages:

• Minimizes the potential for soft tissue attachments and nerve entrapment by

physically isolating the nerve during the healing process

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• Preserves the native architecture of the extracellular matrix

• Allows nerve gliding

• Is strong and flexible, plus easy to suture

• Is stored at room temperature with an 18-month shelf life

13.4.4 AxoTouch Two-Point Discriminator

Sensibility testing plays an important role in the evaluation of nerve function. It assists

healthcare professionals in detecting changes in sensation, assessing return of sensory

function, establishing effective treatment interventions, and providing feedback to the

patients. The AxoTouch Two-Point Discriminator tool is a set of two aluminum discs each

containing a series of prongs spaced two to 15 millimeters apart. Additionally, 20 and 25

millimeter-spacing is also provided. A circular depression on either side of the disc allows

ease of rotation. The discs can be rotated between a single prong for testing one-point

and any of the other spaced prongs for testing two-point intervals with ease. The Two-

Point Discriminator tool is used to measure the innervation density of any surface area of

the skin. The discs are useful for measuring sensation after a nerve injury, following the

progression of a repaired nerve, and during the evaluation of a person with a possible

nerve injury, such as nerve division or nerve compression.

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13.5 BrainStorm Cell Therapeutics

Three University Plaza Drive

Suite 320

Hackensack, NJ 07601

United States

Telephone: 201-488-0460

Website: www.brainstorm-cell.com

BrainStorm Cell Therapeutics is a biotechnology company developing innovative,

autologous stem cell therapies for highly debilitating neurodegenerative diseases, such

as amyotrophic lateral sclerosis (ALS), multiple sclerosis (MS), Parkinson’s disease, and

Huntington’s disease. The company’s platform technology, NurOwn, uses proprietary

culture conditions to induce mesenchymal stem cells (MSCs) to secrete high levels of

neurotrophic factors known to promote the survival of neurons.

13.5.1 NurOwn in the Clinic

Human testing of MSC-NTF cells was initiated in 2010 in ALS patients; this is a program

that has now advanced to Phase II clinical trials in the US and Israel. The company has

completed two single-arm clinical trials at Hadassah Medical Center in Jerusalem, in

which a total of 26 ALS patients received MSC-NTF cells. These studies established the

safety profile of the cells and provided indications of a treatment benefit. The company is

currently completing a randomized, double-blind, placebo-controlled phase II study of

MSC-NTF cells at three prestigious academic medical centers in the US. NurOwn has

received fast track status from the FDA in ALS and has additionally been granted orphan

status for ALS by the FDA and the European Medicines Agency.

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13.6 Cellular Dynamics International, Inc.

525 Science Drive

Madison, WI 53711

United States

Telephone: 1-608-310-5100

Website: www.cellulardynamics.com

Cellular Dynamics International, Inc. is focused on developing and manufacturing human

cells. Its principal cell products include human cells in multiple cell types (iCell products),

human-induced pluripotent stem cells (iPSCs), and custom iPSCs and iCell products

(MyCell products). The company was established in 2004 and is based in Madison,

Wisconsin. Since May 1, 2015, the company has been operating as a subsidiary of

Fujifilm Medical Systems USA, Inc. The company’s neural cell products are described

below.

13.6.1 iCell Neurons

Traditional neuroscience research tools consist largely of rodent primary cell cultures and

animal models, which are labor-intensive, costly, and poorly reflective of native human

biology. iCell Neurons represent a relevant human in vitro system for modeling and

interrogating complex neurological processes and diseases. iCell Neurons are iPS cell-

derived mixed populations of human cerebral cortical neurons that exhibit native electrical

and biochemical activity. They overcome limitations of existing models by providing the

following:

• More than 95% pure population of glutamatergic (excitatory) and GABAergic

(inhibitory) neurons

• Rapid formation of neural networks and functional synapses

• Expression of relevant neurological therapeutic targets and pathways

• Long-term viability and demonstrated reproducibility

• Reliable supply in cryopreserved format

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13.6.2 iCell Astrocytes

Astrocytes are specialized glial cells and the most abundant cell type in the central

nervous system (CNS), outnumbering neurons five to one. Astrocytes have historically

been regarded as support cells for neural tissue, with reactive astrocytes serving as

markers for damaged or diseased tissue. However, new studies reveal that astrocytes

play an essential and complex role in the maintenance of a healthy CNS and in the onset

and development of CNS disease.

13.6.3 iCell DopaNeurons

CDI’s iPS cell platform uniquely enables the large-scale manufacture of iCell

DopaNeurons, human floor plate-derived midbrain DA neurons. Only DA neurons derived

from the floor plate have been shown to engraft in animals, making them a leading

candidate for use in clinical applications. iCell DopaNeurons exhibit the relevant biology

and functionality to advance research and preclinical studies for devastating neurological

disorders:

• Fully differentiated, >80% pure midbrain DA neurons

• Expression of relevant midbrain DA neuron markers

• Functional release and uptake of dopamine

• Appropriate electrophysiology and pacemaker-like activity: spontaneous and

evoked action potentials, excitatory post-synaptic currents, and sodium ion and

potassium ion channel currents

• Compatible with a wide range of biochemical and cell-based assays: cell viability,

cell mitophagy, calcium signaling, neurite outgrowth, and retraction

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13.7 Celther Polska

Milionowa 23 Street

93-193 Lods

Poland

Telephone: 48-42-681-25-25

Website: www.celther.com

Celther provides highly specialized in vitro examination of potential drug candidate

compounds using a plethora of methods, including real-time cell observation. Celther

presents spontaneously beating human iPS-derived cardiomyocytes, an excellent tool for

cardiotoxicity testing and discovery of novel cardiac drug targets.

13.7.1 Cell Lines

Celther offers the most diverse selection of cell culture products. Celther cell lines are

available from human sources for research in areas such as cancer, cardiovascular

disease, diabetes, and neurobiology. Celther cell lines represent a useful alternative test

system for toxicological and pharmacological studies. They are well-defined and suitable

for the determination of cytotoxicity and genotoxicity. Celther consistently attains the

highest standards and uses the most reliable procedures to verify every cell line. The

company’s genetically modified cells include:

• Mouse immortalized peritoneal mesothelium (MDM),

• CLTH/EGFRvIII,

• U87MGvIII 4.12,

• T96/EGFRvIII,

• DKMG/EGFRvIII,

• CLTH/EGFR,

• CLTH EGFR/EGFRvIII, and

• Pericytes.

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The company’s human iPSC and iPSC derivatives include:

• Celther iPS cells (CLTH/iPS cells),

• Celther iNS cells (CLTS/iNS cells),

• Celther-induced cardiomyocytes,

• Celther astrocytes,

• Celther neurons,

• Celther-induced hepatocytes,

• Celther iPCs,

• Celther immortalized pericytes,

• Celther fibroblasts,

• Celther iPSCs with chromosome 21 trisomy,

• Celther iPSCs with chromosome 18 trisomy, and

• Celther iPSCs with mutation in WFS1 gene.

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13.8 Cellartis AB

Avid Wallgrens Backe 20

Gothenburg, 41346

Sweden

Telephone: 46-3-17-58-09-00

Fax: 46-3-17-58-09-10

Website: www.cellartis.com

Cellartis AB is focused on developing human embryonic stem (hES) cells and technology

for drug discovery research, toxicity testing, and regenerative medicine. The company

provides cardiomyocyte monolayers, cardiomyocyte clusters, hepatocyte-like cells, and

mesenchymal progenitor cells. It also offers hES cell lines and human ES cells. The

company was established in 2001 and is headquartered in Gothenburg, Sweden with an

additional office in Dundee, UK. Since November 4, 2011, the company has been

operating as a subsidiary of Cellectis.

13.8.1 hESC-Derived Mesenchymal Progenitor Cells

hES-MP 002.5 cells are human embryonic stem cell-derived multipotent mesenchymal

progenitors that resemble adult human mesenchymal stem cells and can be differentiated

into several mesodermal lineages. The cells are derived from the SA002.5 ES cell line, a

subclone of SA002, known for efficient osteogenic lineage differentiation and high

mineralization potential with extended culture. hES-MP 002.5 cells are a homogeneous,

robust source of mesenchymal progenitors, ideal for bulk production of mesenchymal

cells.

13.8.2 Human Neural Stem Cells The company offers several kits for the expansion and differentiation of multipotent neural

stem (NS) cell lines. These kits contain NS cell lines derived from distinct areas of the

human central nervous system, including the neural cortex, hindbrain, mid-forebrain,

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spinal cord, and temporal lobe. Cells can be used for a variety of neuroscience research

applications and compound screening assays. Each kit contains cells (~1.5 x 106 cells)

and serum-free media optimized for culturing adherent human NS cells.

13.8.3 Culture System for iPSC

The DEF-CS system is a robust culture system for efficient expansion of human-induced

pluripotent stem (iPS) cells in a feeder-free and defined environment. This system

enables a stable growth rate that is equally ideal for traditional iPS cell culture, mass

production of cells, and single cell culture. Cells grown with this culture system are

maintained in an undifferentiated state with virtually no detectable background

differentiation, eliminating the need for cell selection. Enzymatic passaging as single cells

allows for single-cell applications, including high-throughput screening, transfection, and

scaffold seeding.

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13.9 CellCure Neurosciences Ltd.

Hadassah University Hospital

Jerusalem, 911121

Israel

Telephone: 972-5-4524-5677

Fax: 972-2-642-9856

Website: www.cellcureneurosciences.com

Cell Cure Neurosciences Ltd. is focused on developing human cell-based therapies to

treat retinal and neural degenerative diseases. The company provides OpRegen, a cell

therapy that is used to treat age-related macular degeneration (dry-AMD), and OpRegen-

Plus, a product used to treat AMD that includes RPE cells that are supported on or within

a membrane instead of in suspension. CellCure is also focused on developing cells for

the treatment of macular degeneration, Parkinson’s disease, and sclerosis. The company

was established in 2005 and is headquartered in Jerusalem, Israel. The company has

been operating as a subsidiary of BioTime, Inc.

13.9.1 Technology

The company’s technologies involve developing manufacturing methods that expose

hESCs to highly specific chemicals under highly specific physical conditions and time

periods and causing them to grow and change to the therapeutic cells sought by the

medical community. The scientists in the company have also developed methods of

packaging and applying these cells so doctors can effectively use them to treat patients

in need. These technologies, protocols, and methods are strictly compliant with

requirements set forth by regulatory authorities, including manufacture under current

Good Manufacturing Practice (cGMP) regulations.

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13.9.2 New Candidate Treatment for Retinal Diseases

OpRegen and OpRegen-Plus are proprietary formulations of human embryonic stem cell-

derived retinal pigmented epithelial (RPE) cells developed to address the many unmet

medical needs of people suffering from age-related macular degeneration (AMD). RPE

cells are critical to nourish and support the retina, and when these cells are lost due to

disease, patients suffer AMD, leading to severe vision loss and sometimes blindness.

OpRegen provides RPE cells in a suspended form to replace those lost due to AMD and

is expected to be among the first hESC-based products to reach clinical trials. OpRegen

Plus provides RPE cells supported within a membrane.

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13.10 Celvive, Inc.

120 Albany Street

Tower II, Suite 850

New Brunswick, NJ 08901

United States

Telephone: 1-908-731-6610

Fax: 1-732-247-0016

Website: www.celvive.com

Celvive, Inc. is focused on developing a technology for the isolation and use of autologous

cellular therapy for regenerative medicine applications. The company’s technology

enables isolation of specific adult stem cells from the patient’s bone marrow for treating

spinal cord injury. The company was established in 2010 and is headquartered in New

Brunswick, New Jersey.

13.10.1 Spinal Cord Injury

Spinal cord injury (SCI) results from motor vehicle accidents, falls, violence, and sports-

related injuries. At the cellular level, mild contusion to the spinal cord causes massive

neuronal and glial cell loss, demyelination, cavitation, and glial scarring. These

pathological changes result in loss of sensory perception, distal motor paralysis, and

severe functional impairment. There is no cure for SCI; functional improvement depends

on the success of a combination of molecular, cellular, and rehabilitative physiotherapy.

Autologous cellular therapy for SCI patients is attractive to augment axonal sparing and

remyelination and overcome the physical and chemical barriers to repair. Celvive, Inc.

has developed a new approach, using a closed-bag system to isolate specific adult stem

cells from the patient's own bone marrow.

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13.10.2 Research and Development

The company has developed a new approach, using a closed-bag system to isolate

specific adult stem cells from the patient's own bone marrow. This strategy supports the

use of specific autologous cells, displaying the desired multipotency and secretory profiles

to enhance SCI regeneration. Celvive has generated a closed system (The StemCell bag)

that consists of sterile, single-use disposable sets of bags and attachments connected to

a microprocessor-controlled instrument to enable the isolation of matrix stem cells in a

functionally closed system. These autologous stem cells are separated in the StemCell

bag and can be injected back into the patient via intrathecal injections.

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13.11 Merck Millipore

290 Concord Road

Billerica, MA 01821-7037

United States

Telephone: 1-781-533-6000

Fax: 1-781-533-3110

Website: www.emdmillipore.com

Merck Millipore, which includes the EMD Millipore brand, is focused on providing solutions

and services for research, development, and production of biotechnology and

pharmaceutical drug therapies. The company provides bioscience products and services,

such as antibodies and assays, protein detection and quantification, inhibitors and

biochemicals, proteins and enzymes, cell culture and systems, genomic analysis, and cell

analysis; lab solutions, such as chemical and reagents, IVD/OEM materials and reagents,

microbiological testing and process monitoring, and related services; and process

solutions, including sterile filtration, virus reduction, biopharma raw materials, drug

delivery compounds, engineering, and validation services. The company was established

in 1954 and is headquartered in Billerica, Massachusetts with a location in Tokyo, Japan.

Since July 15, 2010, the company has been operating as a subsidiary of Merck KGaA.

13.11.1 Human Neural Stem Lines

EMD Millipore offers ready-to-use neural stem cells derived from a variety of different

sources. These products include novel stem cell lines derived from adult, embryonic

neural tissue, and iPS cells. Cells are provided with optimized serum-free expansion and

differentiation media along with a complete selection of antibodies and kits to characterize

both neural stem cells and differentiated progeny.

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13.12 International Stem Cell Corporation

5950 Priestly Drive

Carlsbad, CA 92008

United States

Telephone: 1-760-940-6383

Fax: 1-760-476-0600

Website: www.internationalstemcell.com

International Stem Cell Corporation (ISCO) is focused on developing therapeutic and

biomedical products. The company has been developing different cell types from its stem

cells that might result in therapeutic products. The clinical applications of the company’s

technology are neural stem cells meant for treating Parkinson’s disease and other

neurological conditions, such as spinal cord injury, traumatic brain injury, and stroke; liver

cells (hepatocytes) that may be used for treating various congenital and acquired liver

diseases; and three-dimensional eye structures for treating degenerative retinal diseases

and corneal blindness and accelerating corneal healing.

13.12.1 Neural Stem Cells

The company uses multi-decade experience in human cell culture and its pioneering

ethical pluripotent stem cell technology to create its first clinical product, human

parthenogenetic neural stem cells (hpNSCs). Neural stem cells are self-renewing

multipotent cells that are precursors for the major cells of the central nervous system.

ISCO’s master cell bank (MCB) and working cell banks (WCB) of hpNSCs are produced

under cGMP conditions and consist of cryopreserved high purity hpNSCs derived using

a highly optimized, patented, chemically defined differentiation process. To ensure the

purity of the final product, the qualification process involves testing each cell bank for cell

identity, potency, purity, safety, and sterility. For the proposed clinical trials, frozen

aliquots of QC-released hpNSCs from a WCB will be shipped to the trial site where the

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cells will be thawed and tested for viability before being used. All cells are produced at

the Oceanside, California facility.

The company’s lead product candidate hpNSC works in a very different way than

conventional treatments for Parkinson’s disease. The ability of NSCs to both differentiate

into dopaminergic neurons and express brain-protecting neurotrophic factors offers a new

approach to treating Parkinson's disease. The company believes that a one-time

transplant of hpNSCs into the mid-brain of Parkinson’s patients, replacing the dead and

dying neurons and offering protection to the remaining neurons, will alleviate current

symptoms and prevent further deterioration. Preclinical testing in mice, rats, and primates

supports this theory.

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13.13 Kadimastem Ltd.

Pinchas Sapir 7

Weizmann Science Park

Nes-Ziona

Israel

Telephone: 972-73-797-1600

Fax: 1-972-8-9100698

Kadimastem is a leading regenerative medicine company focused on the industrial

development and commercialization of stem cell-based therapeutics, primarily for

diabetes and neurodegenerative disorders. The company’s proprietary technologies and

know-how enable the differentiation of stem cells into insulin-secreting beta cells as well

as a range of neural cells (including oligodendrocytes and astrocytes). Based on its

differentiation technologies, the company is advancing two therapeutic programs focused

on diabetes mellitus and ALS, where stem cells are differentiated into beta cells (for the

diabetes program) and astrocytes (for the ALS program) with the goal of implanting them

into patients and affecting disease progression.

13.13.1 Drug Discovery for Neural Diseases

Kadimastem’s drug-screening system for research use currently includes the following:

• Oligodendrocyte progenitor cell (OPC) commitment assay—human neural stem

cells (NSCs) that commit into oligodendrocyte precursor cells

• Oligodendrocyte differentiation assay—human OPC differentiation toward mature

oligodendrocytes

• Myelination assay—human oligodendrocytes that myelinate neuron axons

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13.13.2 Human Oligodendrocyte Drug-Screening Assays

This platform enables access to an exclusive and highly sensitive drug-screening system

for therapeutic agents against human demyelinating diseases such as multiple sclerosis

and spinal cord traumas. In these demyelinating diseases, the therapeutic challenge is

how to stimulate sufficient differentiation and remyelination of OPnC in order to restore

neural functionality and prevent further deterioration. The current use of rodent OPC for

identifying active compounds that stimulate OPC has been shown as unreliable in

predicting compound efficacy in humans.

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13.14 Living Cell Technologies Limited

Hunters Corner

P.O. Box 23566

Manukau

Auckland, 2155

New Zealand

Telephone: 64-9-276-2690

Fax: 64-9-276-2691

Website: www.lctglobal.com

Living Cell Technologies Limited (LCT) is focused on discovering, developing, and

commercializing regenerative treatments that use naturally occurring cells to restore

function worldwide. The company’s products include DIABECELL, which is in late-stage

clinical trials targeting type 1 diabetes, and NTCELL, which is in phase I/IIa clinical trials

targeting Parkinson’s disease. The company was established in 1987 and is

headquartered in Auckland, New Zealand.

13.14.1 NTCELL

NTCELL is expected to be indicated for restoration of function and slowing of disease

progression in patients with middle-stage Parkinson’s disease experiencing reduced

response to standard medical therapy. LCT commenced a phase IIb study in March 2016.

The study aims to confirm the most effective dose of NTCELL, define any placebo

component of the response, and further identify the initial target Parkinson’s disease

patient subgroup. The study is being led by Dr. Barry Snow at Auckland City Hospital. If

the trial is successful the company will apply for provisional consent to treat paying

patients in New Zealand and launch NTCELL as the first disease-modifying treatment for

Parkinson’s disease in 2017.

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13.15 MEDIPOST

21, Daewangpangyo-ro

Bundang-gu

Seongnam-si

Gyeonggi-do

South Korea

Telephone: 82-2-3465-6650

Website: www.medi-post.com

MEDIPOST is a frontrunner in the field of biopharmaceuticals not only in South Korea but

also in the world. MEDIPOST’s state-of-the-art platform technology has led to the

development and approval of the world’s first allogeneic stem cell therapy product,

CARTISTEM.

13.15.1 NEUROSTEM

NEUROSTEM is a drug based on mesenchymal stem cells derived from allogeneic

umbilical cord blood. The drug is currently in phase II clinical trials in South Korea for

Alzheimer’s disease.

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13.16 Neuralstem Inc.

20271 Goldenrod Lane

Germantown, MD 20876

United States

Telephone: 301-366-4841

Website: www.neuralstem.com

Neuralstem Inc. is focused on developing and commercializing regenerative medicine

treatments based on its human neuronal stem cells and small molecule compounds. The

company’s stem cell technology is used to isolate and expand human neural stem cells

from various areas of the developing human brain and spinal cord, enabling the

production of physiologically relevant human neurons of all types. The company was

established in 1996 and is based in Germantown, Maryland.

TABLE 13.1: Neuralstem Inc.’s Cell Therapy Products in Development

Product Indication Phase

NSI-566 Amyotrophic lateral sclerosis (ALS) II

NSI-566 Spinal cord injury (SCI) I

NSI-566 Ischemic stroke I/II

NSI-566 Multiple sclerosis Preclinical

NSI-566 Optic neuritis Preclinical

HK532-IGF-1 Alzheimer’s disease Preclinical

NSI-566 Traumatic brain injury Preclinical

NSI-566 Peripheral nerve injury Preclinical

NSI-566 Diabetic neuropathy Preclinical

NSI-566 Lysosomal disease Preclinical

NSI-566 Parkinson’s disease Preclinical

NSI-566 Huntington’s disease Preclinical

NSI-566 Cerebral palsy Preclinical

Source: Company website

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13.16.1 NSI-566 for ALS

Neuralstem concluded final surgeries in the company’s NSI-566/ALS phase II trial,

primarily evaluating safety, in July 2014. After the six-month patient follow-up period, the

study was concluded in the first quarter of 2015. A larger, controlled-registration directed

NSI-566/ALS clinical trial is to commence in 2016. Nine-month phase II and combined

phase I/II NSI-566 ALS data was presented at the American Neurological Association

annual meeting in September 2015. The data showed that intraspinal transplantation of

the cells was safe and well-tolerated throughout the escalating doses, reaching a

maximum tolerated dose of 16 million cells via 20 bilateral injections. Further, there

appeared to be no acceleration in disease progression due to the therapeutic intervention.

13.16.2 NSI-566 for SCI

Neuralstem completed the final surgery in a phase I safety trial of its NSI-566 neural stem

cells for chronic spinal cord injury (cSCI) at the University of California, San Diego School

of Medicine, supported and funded by the Sanford Stem Cell Clinical Center at UC San

Diego Health, in July 2015. This phase of the trial will conclude after a six-month post-

surgery observation period of the last patient. In October 2015, the company presented

initial NSI-566/cSCI phase I safety data. The data showed that there had been no serious

adverse events, that implantation of stem cells in cSCI patients is feasible, and that

implantation of stem cells in spinal cord injury patients has been safe and well tolerated.

13.16.3 NSI-566 for Ischemic Stroke

The company was approved to commence its collaborative phase I/II clinical trial to treat

motor deficits due to ischemic stroke with its NSI-566 spinal cord stem cells at BaYi Brain

Hospital in Beijing, sponsored through its subsidiary, Neuralstem China. The phase I/II

ischemic stroke trial, which commenced in December 2013, is testing direct injections into

the brain of NSI-566.

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13.17 NeuroGeneration Inc.

8670 Wilshire Blve

Suite 201

Beverly Hills, CA

United States

Telephone: 1-310-659-6633

Website: www.neurogeneration.com

NeuroGeneration Inc. is a drug discovery and development company focusing on novel

approaches to treat aging and neurodegenerative disorders, such as Alzheimer’s

disease. Neurogeneration is developing a group of small lead molecules that tackles

Alzheimer’s disease by a strategy different from current unsuccessful approaches. These

molecules target a specific pathway of the stress response due to oligomer toxicity

causing synaptic dysfunction and secondary cell death. NeuroGeneration also develops

restorative biological products derived from neural progenitor cells for disease modeling

and therapeutic application.

13.17.1 Drug Discovery

NeuroGeneration has established a highly focused drug discovery platform built on the

company’s deep knowledge of inhibitors and inflammatory events as causative factors of

synaptic damage triggered by ABeta oligomers accumulation. The company’s lead

compound, NGN-9, is currently undergoing pharmacokinetic and hit identification studies.

NeuroGeneration’s selective novel small molecules therapy may become a new treatment

for progressive neurodegenerative changes at the synaptic and intra-neuronal levels. Its

pharmacokinetic profiles are being optimized to drive a robust therapeutic response in

various preclinical models of Alzheimer’s disease and aging disorders before its use in

clinical trials.

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13.17.2 Biotherapeutics

NeuroGeneration’s investigational new drug uses neural progenitor cells harvested from

a patient, cultured in a laboratory, characterized, differentiated and, finally, reintroduced

into the patient’s deficient circuitry. The objectives of the clinical trials are to demonstrate

on a wider scale the safety and therapeutic efficacy of progenitor cell-derived

dopaminergic neurons for the treatment of Parkinson’s disease in an open label

prospective study.

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13.18 Neurona Therapeutics Inc.

1700 Owens Street

Suite 500

San Francisco, CA 94158

United States

Telephone: 1-650-799-6465

Website: www.neuronatherapeutics.com

Neurona Therapeutics Inc. has been operating in the healthcare industry and is focused

on the biotechnology business. The company has been developing neuronal stem cells

to transplant into the brain. The company was established in 2008 and is headquartered

in San Francisco, California.

13.18.1 Technology

The central nervous system (CNS) contains both excitatory cells and inhibitory cells

(primarily neurons that express GABA). Normal brain and spinal cord function depends

on a delicate balance between these two types of neurons. This balance is normally

established during embryonic development and just after birth when the nervous system

is still assembling and developing neurologic connections. During this time, neurons are

born, migrate to proper locations, and form connections or synapses, creating complex

circuits that are maintained into adulthood. Problems arise when genetic mutations and/or

external traumas result in aberrant development and/or degeneration of particular CNS

cell types, leading to the dysregulation of neural circuits. Epileptic seizures, neuropathic

pain, spasticity, and certain types of cognitive impairments and psychoses can be

symptomatic of dysregulated neural activity. Because the genesis of new neurons and

synapses, or plasticity, is limited in the adult CNS, these diseases persist and lack

effective treatment. Neurona’s founders have discovered that transplantation of

specialized neurons in the adult CNS can rebalance neural activity and induce plasticity

to repair neural circuits. Neurona is using human stem cell technologies to develop novel

cell-based therapeutics.

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13.19 Ocata Therapeutics Inc. (Acquired by Astellas Pharma for $379M in November 2015)

33 Locke Drive

Marlborough, MA 01752

United States

Telephone: 1-508-756-1212

Fax: 1-508-229-2333

Website: www.ocata.com

Ocata Therapeutics Inc. is focused on developing and commercializing regenerative

ophthalmology therapeutics in the US. The company has been sponsoring various clinical

trials for treating Stargardt’s macular degeneration, dry age-related macular

degeneration, and myopic macular degeneration, as well as preclinical trials for the

treatment of other ocular disorders, and has preclinical stage assets in disease areas

outside the field of ophthalmology, including autoimmune, inflammatory, and wound

healing-related disorders. Earlier, the company was known as Advanced Cell Technology

Inc. and then changed its name to Ocata Therapeutics Inc. in November 2014. The

company is based in Marlborough, Massachusetts. Since February 9, 2016, the company

has been operating as a subsidiary of Astellas U.S. Holding, Inc.

13.19.1 Focus on Neuroscience

Astellas has identified neuroscience as a key focus for research and development

because of the high unmet needs and tremendous research potential in this therapeutic

area. Its efforts in neuroscience straddle both central nervous system disorders and pain

therapeutics.

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13.20 Opexa Therapeutics, Inc.

2635 Technology Forest Blvd

The Woodlands, TX 77381

United States

Telephone: 1-281-775-0600

Fax: 1-281-872-8585

Website: www.opexatherapeutics.com

Opexa Therapeutics, Inc. is a publically traded biotechnology company developing a

personalized immunotherapy with the potential to treat major illnesses, including multiple

sclerosis (MS), as well as other autoimmune diseases, such as neuromyelitis optica.

These therapies are based on Opexa’s proprietary T-cell technology, ImmPath. The

company’s leading therapy candidate, Tcelna, is a personalized T-cell immunotherapy

that is in a phase IIb clinical development program (the Abili-T trial) for the treatment of

secondary progressive MS.

13.20.1 Tcelna

Tcelna is a personalized T-cell immunotherapy in a phase IIb clinical development

program (the Abili-T trial) for the treatment of secondary progressive multiple sclerosis.

Tcelna is specifically tailored to each patient's immune response profile to myelin and is

designed to reduce the number and/or functional activity of specific subsets of myelin-

reactive T-cells (MRTC) known to attack myelin. Tcelna is manufactured using ImmPath,

Opexa’s proprietary method for the production of a patient-specific T-cell immunotherapy,

which encompasses the collection of blood from the MS patient, isolation of peripheral

blood mononuclear cells, generation of an autologous pool of myelin-reactive T-cells

(MRTCs) raised against selected peptides from myelin basic protein (MBP), myelin

oligodendrocyte glycoprotein (MOG), and proteolipid protein (PLP), and the return of

these expanded, irradiated T-cells back to the patient. These attenuated T-cells are

reintroduced into the patient via subcutaneous injection to trigger a therapeutic immune

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system response. Tcelna has been granted fast track status by the FDA in secondary

progressive MS based on the unmet need of the progressive indication and the potential

of Tcelna to benefit this patient population.

13.20.2 OPX-212

OPX-212 is an autologous T-cell immunotherapy being developed for the treatment of

neuromyelitis optica (NMO). NMO is an autoimmune disorder in which immune system

cells and antibodies attack and destroy myelin cells in the optic nerves and the spinal

cord leading to demyelination and loss of axons. There are currently no FDA-approved

therapies for NMO.

OPX-212 is specifically tailored to each patient’s immune response to a protein,

aquaporin-4, which is the targeted antigen in NMO. In NMO, the immune system

recognizes aquaporin-4 as foreign, thus triggering the attack. OPX-212 has a

hypothesized mechanism of action to reduce the number of, and/or regulate, aquaporin-

4 reactive T-cells (ARTCs), thereby reducing the frequency of clinical relapses and

subsequent progression in disability.

13.20.3 Abili-T Clinical Study

Abili-T is a phase II double blind, placebo-controlled multi-center study to evaluate the

efficacy and safety of Tcelna in subjects with secondary progressive multiple sclerosis.

The following are basic facts about the study:

• Conducted in the US and Canada

• 18-60 years of age with a diagnosis of secondary progressive multiple sclerosis

• Five subcutaneous injections annually

• Two-year treatment period

• 180 subjects (90 Tcelna; 90 placebo)

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TABLE 13.2: Opexa’s Product Pipeline

Program/Indication Research Preclinical Phase

I Phase

II

Tcelna (Imilecleucel-T) ●

Secondary progressive multiple sclerosis

●

Relapsing remitting multiple sclerosis

●

OPX-212 ●

Neuromyelitis optica ●

Source: Company website

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13.21 ReNeuron Group PLC

10 Nugent Road

Surrey Research Park

Guildford, GU2 7AF

United Kingdom

Telephone: 44-14-8330-2560

Fax: 44-14-8353-4864

Website: www.reneuron.com

ReNeuron Group PLC is focused on developing clinical-stage cell therapies worldwide.

Its major therapeutic candidate is CTX stem cell therapy, which has been in phase II

clinical trials in the treatment of patients left disabled by the effects of a stroke. ReNeuron

Group PLC was established in 1997 and is based in Guildford, UK.

13.21.1 Products and Technologies

The company has been using its cell expansion and screening technologies to develop

“off-the-shelf” stem cell therapies for serious conditions, such as stroke, where the patient

populations are significant and where few alternative treatments exist. The company has

created a pipeline of therapeutic candidates based on two core stem cell assets,

the CTX neural cell line and the human retinal progenitor cells (hRPC). The exosome

platform is yielding encouraging early preclinical data across a range of potential

indications, which are being investigated further.

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TABLE 13.3: ReNeuron’s Pipeline Candidates

Stem cell Indication Preclinical Phase I Phase II

CTX cell line Stroke disability ●

CTX cell line Critical limb ischemia ●

hRPC line Retinitis pigmentosa ●

CTX-derived In evaluation ●

Source: Company website

13.21.2 CTX Cells

The CTX stem cell therapeutic candidate is a therapy for the treatment of patients left

disabled by the effects of a stroke. The second application for the CTX cells is for the

treatment of critical limb ischemia. Both treatments are currently in clinical development.

CTX represents a standardized, clinical, and commercial-grade cell therapy product

capable of treating all eligible patients presenting with the diseases targeted, without the

need for additional immunosuppressive drug treatments.

13.21.3 Human Retinal Progenitor Cells

Human retinal progenitor cells (hRPCs) are cells that differentiate into components of the

retina. These cells are used allogeneically and are grown using a patented low-oxygen

cell expansion technology licensed from the Schepens Eye Research Institute at Harvard

Medical School. Through collaboration with Schepens, the company has developed the

ability to scale hRPCs using this technology and has established a GMP-compliant hRPC

cell bank to provide future drug products. The company has received regulatory approval

from the FDA to commence a phase I/II clinical trial in the US with the hRPC therapy

candidate for retinitis pigmentosa.

13.21.4 Exosome Platform

Exosomes are nanoparticles, released by cells, that contain a number of active proteins

and micro RNAs. They are believed to play a key role in cell-to-cell communication,

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modulate cellular immunity, and promote the activation of regenerative or repair programs

in diseased or injured cells. The CTX cells release large amounts of exosomes when

grown in the laboratory, enabling the purification and characterization of these exosomes.

The company aims to use the CTX technology and exosome platform to expand its

pipeline. It has filed a number of patents related to the composition, characterization,

manufacturing, and therapeutic uses of the exosome platform.

13.21.5 ReNcell Products

The company has licensed the ReNcell VM and ReNcell CX cell lines exclusively to Merck

Millipore for manufacture and worldwide distribution through their research reagent

catalogue. ReNcell VM is a neural cell line derived from the ventral mesencephalon

region of the brain, and ReNcell CX is derived from the cerebral cortex. A series of

specifications have been developed describing the ability of these cell lines to grow and

retain stability after culturing and to differentiate readily into the principal neural cell types,

including neurons, and the ability of the derived neurons to show physiological properties

indicative of mature neurons.

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13.22 RhinoCyte, Inc.

1044 East Chestnut Street

Louisville, KY 40204

United States

Telephone: 1-502-410-4512

Fax: 1-502-415-7472

Website: www.rhinocyte.com

RhinoCyte, Inc. is focused on developing and commercializing autologous adult olfactory-

derived stem cell therapies. The company is primarily focusing on the development and

commercialization of diagnostic tools and therapies to treat spinal cord injury and

neurodegenerative disorders, such as amyotrophic lateral sclerosis, Parkinson’s disease,

multiple sclerosis, type 1 diabetes, and other conditions. The company has signed

strategic partnerships with Greater Louisville Inc., Health Enterprises Network, Kentucky

Science and Technology Corporation, University Hospital, and University of Louisville.

The company was established in 2005 and is headquartered in Louisville, Kentucky.

13.22.1 Research

RhinoCyte, Inc. is a biotechnology company commercializing autologous adult olfactory-

derived stem cell therapies to treat spinal cord injury and neurodegenerative disorders,

such as Parkinson’s disease, amyotrophic lateral sclerosis, multiple sclerosis, and type 1

diabetes. The core technology involves the biopsy, harvesting, isolation, processing,

cryopreservation, and engraftment of adult progenitors (stem cells) into the site of injury.

RhinoCyte’s lead therapeutic candidate is an autologous cellular enhancement therapy

that provides a biologically active bridge that promotes recovery of neural damage

induced by a spinal cord injury.

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13.23 Roslin Cells Ltd.

Nine Edinburgh BioQuarter

9 Little France Road

Edinburgh

United Kingdom

Telephone: 44-131-658-5180

Website: www.roslincells.com

Roslin Cells Ltd. is the parent company of Roslin Cell Therapies and Roslin Cell

Sciences. Founded in 2006, it has developed two distinct investment and business

opportunities in the development and manufacture of cell based therapies and the

generation of stem cells to support commercial academic and drug research. Roslin Cell

Therapies is based in Edinburgh, UK, and has a wealth of expertise, capabilities and

industry recognition in process translation to GMP, development, optimization, scale-up,

and the GMP manufacture of cell therapy and advanced therapy medicinal products.

13.23.1 Custom iPSC Generation

Roslin Cell Sciences offers a complete end-to-end iPSC generation service. The

company can assist with sourcing new bio-specimens from various donor cohorts with

different disease backgrounds and with custom iPSC generation, all the way through to

delivery of custom large-scale banks of iPSCs with comprehensive quality control. The

company offers:

• Consultation and custom project design,

• Dedicated scientific project lead,

• High- and low-volume capacity,

• Options of latest reprogramming methodologies,

• Specialist bio-specimen acquisition team,

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• Expertise in ethics and donor consent,

• Extensive quality control testing options,

• Safety testing, and

• Storage.

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13.24 SanBio, Inc.

231 South Whisman Road

Mountain View, CA 94041-1522

United States

Telephone: 1-650-625-8965

Fax: 1-650-625-8969

Website: www.san-bio.com

SanBio, Inc. is focused on developing regenerative therapies for neurological disorders.

The company’s product pipeline includes SB623, which can reverse neural damages as

well as restore function to damaged neurons associated with strokes, traumatic brain

injuries, retinal diseases, and Parkinson's disease; and SB618 for the treatment of neuron

inflammatory injury conditions (multiple sclerosis and spinal cord injuries). The company

was established in 2001 and is headquartered in Mountain View, California. The company

has been operating as a subsidiary of SanBio Company Limited.

13.24.1 SB623

When administered into neural tissue, SB623 reverses neural damage. Since SB623 cells

are allogeneic, a single donor's cells can be used to treat many patients. In cell culture

and animal models, SB623 cells have been shown to restore function to damaged

neurons associated with stroke, traumatic brain injury, retinal diseases, and Parkinson's

disease. SB623 cells function by promoting the body's natural regenerative process.

SB623 is in early clinical testing for stroke.

13.24.2 SB618

SanBio is developing SB618 for the treatment of conditions involving inflammatory injury

of neurons, such as multiple sclerosis and spinal cord injury. Like SB623, SB618 cells are

allogeneic; a single donor's cells can be used to treat many patients.

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TABLE 13.4: SanBio’s Product Pipeline

Program/Product R&D Preclinical IND-Enabling Phase I & II

SB623

Stroke ●

Traumatic brain injury ●

Retinal diseases ●

Parkinson’s disease ●

Spinal cord injury ●

SB618

Spinal cord injury ●

Multiple sclerosis ● Source: Company Website

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13.25 Saneron CCEL Therapeutics Inc.

USF Center for Entrepreneurship

3101 Telecom Drive

Suite 105

Temple Terrace, FL 33617

United States

Telephone: 1-813-866-6370

Fax: 1-813-558-1102

Website: www.saneron-ccel.com

Saneron CCEL Therapeutics Inc. is focused on providing entrepreneurial and

biotechnology research and development. Saneron’s programs include U-CORD-CELL,

which is stem cell technology, and SERT-CELL which investigates Sertoli cells. The

programs are focusing on research in neurological cell therapy. The company is based in

Temple Terrace, Florida.

13.25.1 U-CORD-CELL Program

The U-CORD-CELL program is a stem cell technology platform. This program explores

dual approaches to the development of medical treatments for the replacement of

damaged cells and tissues: i) the utilization of exogenous stem cells, and ii) the

mobilization of endogenous stem cells. The current stem cell debate illustrates the need

for a reliable source of stem cells that have the potential to differentiate into any type of

human cell depending on the conditions under which the stem cell is placed.

13.25.2 SERT-CELL Program

The SERT-CELL program explores the unique potential of Sertoli cells, protein-rich cells

found in the mammalian testes, which inhibit immune reactions to foreign tissues,

including transplants. Sertoli cells provide localized immunosuppression, which mitigates

the need for a patient to undergo costly and potentially dangerous immune suppression,

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while the therapy is in effect. Sertoli cells are rich in trophic factors and have shown

promise in nervous system regeneration, both in the brain and peripheral nerves.

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13.26 StemCells, Inc.

7707 Gateway Boulevard

Suite 140

Newark, CA 94560

United States

Telephone: 1-510-456-4000

Fax: 1-510-456-4001

Website: www.stemcellsinc.com

StemCells, Inc. is focused on developing and commercializing cell-based therapeutics

and related technologies for stem cell-based research and drug discovery and

development. The company is mainly focused on clinical development of its platform

technology, HuCNS-SC, a purified human neural stem cell used as a potential treatment

for disorders of the central nervous system. StemCells Inc. has completed phase I/II

clinical trials for the treatment of chronic spinal cord injury and phase I clinical trial for the

treatment of Pelizaeus-Merzbacher disease, and has completed enrollment and

treatment in its phase I/II clinical trial in geographic atrophy of age-related macular

degeneration, which cause blindness in the elderly. StemCells, Inc. was established in

1988 and is based in Newark, California.

13.26.1 Clinical Programs

StemCells Inc.’s clinical approach is based on a vision that homologous transplantation

of tissue-derived "adult" (non-embryonic) stem cells is the most natural, promising, and

viable path to harnessing the therapeutic potential of neural stem cells. The company

believes that a single neural stem cell transplantation might lead to a long-term

therapeutic benefit.

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13.26.2 HuCNS-SC (human neural stem cells)

The HuCNS-SC human neural stem cells are manufactured by qualified personnel

working in a clean room production environment, according to current Good

Manufacturing Practices. In 1999, StemCells scientists were the first to isolate and

expand human neural stem cells. This groundbreaking research was based on using

monoclonal antibodies against specific cell surface markers to prospectively isolate the

population of neural stem cells from human brain tissue, and then purify and expand these

cells into cryopreserved cell banks. These unmodified and highly purified cells are then

prepared for direct transplantation.

13.26.3 Proof of Concept

The results of rigorous preclinical studies, including the transplantation of these cells in

thousands of immunodeficient mice, have shown that the cells engraft, migrate, and

differentiate into the three major CNS cell types (neurons, astrocytes, and

oligodendrocytes) and possess the ability to survive long-term with no evidence of tumor

formation or adverse effects. The engraftment and long-term survival of HuCNS-SC in

multiple disease-relevant animal models indicates the potential for a similar effect in

human patients.

13.26.4 Proof of Safety and Initial Efficacy

The first clinical trial of our HuCNS-SC product candidate was completed in 2009. This

phase I trial in neuronal ceroid lipofuscinosis (NCL), a rare childhood disease,

demonstrated the first clinical safety and tolerability of HuCNS-SC cells and the

transplantation procedure. Data gathered in 2011 from subjects who participated in the

first trial showed that transplanted HuCNS-SC cells can persist even after

immunosuppression has been discontinued. In 2014, the company reported long-term

evidence of safety, up to seven years post-transplantation, for the surgical transplantation

of the HuCNS-SC cells into multiple sites in the brain and at doses of up to one billion

cells.

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13.26.5 Spinal Cord Injury

The majority of spinal cord injuries occur in the cervical region, which results in loss of

arm and leg control. Even partial return of motor function in the arms and hands could

significantly improve quality of life and support greater independence for cervical spinal

cord injury patients. Patients in phase II trials in the Pathway Study have the most severe

degree of SCI as defined by the American Spinal Injury Association Impairment Scale,

with complete loss of motor control below the level of injury, and because their injuries

were sustained one to two years prior to their participation in the study, they are classified

as having chronic SCI.

The primary endpoint for the Pathway Study is to assess motor function in the upper

extremities following transplantation of HuCNS-SC human neural stem cells into the

spinal cord region of injury. In April 2015, the company completed dosing of the first cohort

of six patients in the Pathway Study. StemCells, Inc. safely transplanted more neural stem

cells into the human spinal cord than had ever been done previously. Clinicians used both

International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI)

and Graded Assessment of Strength Sensibility and Prehension (GRASSP) measures to

establish a pre-transplant baseline for each patient and to assess post-transplant

progress. An overall pattern of improvement in both muscle strength and motor function

was detected in four of the six first cohort patients, based on collective ISNCSCI and

GRASSP data, six months post-transplant. This is the first clinical evidence of a treatment

effect improving both muscle strength and motor function in chronic spinal cord injury

patients.

13.26.6 Age-Related Macular Degeneration

Based upon both the strength of preclinical studies and the positive results from phase

I/II clinical trial, StemCells, Inc. has initiated the Radiant Study, a phase II proof-of-

concept study using HuCNS-SC platform technology for the treatment of advanced dry

AMD, also referred to as geographic atrophy (GA). In June 2014, based on positive

interim results, StemCells, Inc. closed enrollment earlier than planned in its phase I/II

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clinical trial to assess the tolerability, safety, and preliminary efficacy of subretinal

HuCNS-SC transplantation in GA-AMD.

Top-line results for the phase I/II clinical trial were presented in June 2015. In addition to

a favorable safety profile for our HuCNS-SC platform technology, patients demonstrated

stable or improved visual acuity and contrast sensitivity at six and twelve months post-

transplant. Increased macular volume and foveal thickness was observed in the eye.

Analysis and assessment of changes in RPE defects and GA progression is underway.

13.26.7 Pelizaeus-Merzbacher Disease

A phase I clinical trial, conducted at the University of California, San Francisco,

transplanted HuCNS-SC cells into four patients with connatal PMD. The patients were

followed for 12 months after transplantation in the phase I study, and thereafter were

enrolled in a four-year, long-term, follow-up study. The 12-month phase I post-transplant

results indicated a favorable safety profile for the HuCNS-SC cells and the transplantation

procedure. Analysis of MRI data showed changes consistent with increased myelination

in the region of the transplantation, which progressed over time and persisted after the

withdrawal of immunosuppression at nine months. The results support the conclusion of

durable cell engraftment and the development of donor cell-derived myelin.

Interim data from the long-term follow-up study, which was presented in August 2013,

showed that the MRI evidence of myelination noted at 12 months in the phase I study

continued to persist more than two years after transplantation of the HuCNS-SC cells. In

addition, there were no safety concerns and the gains in neurological function reported

after one year were maintained. The neurological and MRI changes suggest a departure

from the natural history of the disease and signal a possible biological and clinical effect.

13.26.8 Neuronal Ceroid Lipofuscinosis

Clinical study in neuronal ceroid lipofuscinosis (NCL) produced the first evidence of

human safety involving direct implantation of up to a total of one billion HuCNS-SC cells

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into multiple sites within each cerebral hemisphere. The long-term follow-up study has

further confirmed the long-term safety of HuCNS-SC cells out to five years post-

transplant, as well as providing post-mortem evidence of donor cell survival and migration

within recipient brains. Overall, the NCL study results represent the first, and thus far only,

multi-year data set following transplantation of neural stem cells into human subjects. This

long-term data supports the feasibility of the company's approach in other potential

neurological and neurodegenerative disorders affecting the brain.

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13.27 Stemedica Cell Technologies, Inc.

5375 Mira Sorento Place

Suite 100

San Diego, CA 92121

United States

Telephone: 1-858-658-0910

Fax: 1-858-658-0986

Website: www.stemedica.com

Stemedica Cell Technologies, Inc. is focused on developing and manufacturing adult

stem cells and stem cell factors for research institutions and hospitals for preclinical and

clinical studies. The company was established in 2005 and is headquartered in San

Diego, California with a subsidiary location in Lausanne, Switzerland.

13.27.1 Technology

Using the patented and proprietary processes, the company harvests the most viable cell

colonies and manufactures them in a low-oxygen environment, enabling generation of

larger quantities of product at the highest levels of quality and consistency. This process

also enables the products to migrate, engraft, and provide more measurable, efficacious

results compared to other stem cells on the market. The company has filed 18 patent

applications and is progressing with at least six more. The technology is one of the few

licensed for clinical grade manufacturing and approved for clinical trial application by

regulatory agencies in multiple countries.

13.27.2 Products

Stemedica currently offers three allogeneic adult stem cell products that can be

purchased for basic bench research, preclinical studies, and clinical trials. The proprietary

expansion processes create cells with unique gene arrays and protein expression

profiles. This enhances proliferation, migration, and differentiation.

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13.27.2.1 Stemedyne-MSC

Stemedica obtains its allogeneic mesenchymal stem cells (MSCs) from adult bone

marrow, and then processes them in a low oxygen environment, allowing the cells to

display ischemic-tolerant properties. These MSCs have received four investigational new

drug (IND) designations and are FDA-approved for clinical trials involving the treatment

of stroke, chronic heart failure, acute myocardial infarction, and cutaneous photoaging.

Additionally, the company is currently in the process of applying for several INDs for other

ischemic conditions, including Alzheimer's disease and diabetic retinopathy.

13.27.2.2 Stemedyne-NSC

Stemedica's allogeneic neural stem cells (NSCs) are taken from donated brain tissue and

produced in a low-oxygen environment, allowing them to display ischemic-tolerant

properties. The company is currently applying for an IND to conduct a clinical trial for

spinal cord injury in the US and seeking Swiss regulatory approval to conduct clinical

studies for the treatment of Alzheimer's disease, using NSCs in conjunction with

Stemedica's MSCs.

13.27.2.3 Stemedyne-RPE

Stemedica's allogeneic retinal epithelial cells are created in a low-oxygen environment,

allowing them to display ischemic-tolerant properties. They are capable of being used for

clinical trials in the treatment of various ophthalmological indications, including retinitis

pigmentosa and age-related macular degeneration. The company is in the process of

finalizing the details regarding this particular line.

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13.28 STEMCELL Technologies, Inc.

570 West Seventh Avenue

Suite 400

Vancouver, BC V5Z 1B3

Canada

Telephone: 1-604-877-0713

Fax: 1-604-877-0704

Website: www.stemcell.com

STEMCELL Technologies, Inc. is focused on developing specialty cell culture media, cell

separation products, and ancillary reagents for life science research applications. It offers

various products, including cell isolation products, antibodies, primary cells, mammalian

cloning products, small molecules, cryopreservation media, cytokines, cell culture

substrates and matrices, other cell culture media, reagents and supplies, instruments,

software, stem cell detection kits, and proficiency testing solutions. The company was

established in 1993 and is headquartered in Vancouver, Canada. The company has its

research, manufacturing, and shipping facilities in Vancouver, Canada; Tukwila,

Washington; and Grenoble, France.

13.28.1 Cell Culture Media for NSC and Progenitor Cells

The company provides an extensive range of validated culture media, supplements and

reagents, each supported with a detailed protocol or usage guidelines. It also provides a

variety of resources to support the use of its products, including peer-reviewed

publications, webinars, videos, technical bulletins, and wallcharts. The company offers 24

products for culturing NSCs and progenitor cells as shown in the following table.

193

TABLE 13.5: STEMCELL Technologies’ Cell Culture Media for NSCs

Product Description

STEMdiff For maintenance and expansion of neural progenitor cells derived from human ES and iPS cells

NeuroCult NS-A Proliferation Kit

Medium for expansion of human NSC and progenitor cells

NeuroCult NS-A Differentiation Kit

Medium for differentiation of human NSC and progenitor cells

NeuroCult-XF Proliferation Medium

Xeno-free medium for the expansion of human neural stem and progenitor cells

BrainPhys Neuronal Medium

Serum-free neurophysiological basal medium for improved neuronal function

STEMdiff Neuron Differentiation Kit

Differentiation kit for generation of neuronal precursors from human ES and iPSC-derived neural progenitor cells

STEMdiff Astrocyte Differentiation Kit

Differentiation kit for generation of astrocytic precursors from human ES and iPSC-derived neural progenitor cells

STEMdiff Astrocyte Maturation Kit

Maturation kit for generation of astrocytes from human ES and iPSC-derived astrocyte precursor cells

STEMdiff Dopaminergic Neuron Differentiation Kit

Differentiation kit for generation of dopaminergic neuronal precursors from human ES and IPSC-derived neural progenitor cells

STEMdiff Dopaminergic Neuron Maturation Kit

Maturation kit for generation of dopaminergic neurons from human ES and iPSC-derived neural progenitor cells

STEMdiff Neuron Maturation Kit

Maturation kit for generation of functional neurons from human ES and iPSC-derived neuronal precursor cells

Source: Company website

194

13.29 Talisman Therapeutics Ltd.

Jonas Webb Building

Babraham Research Campus

Cambridge, CB22 3AT

United Kingdom

Telephone: 44-0-1223-804070

Website: www.talisman-therapeutics.com

Talisman Therapeutics is a human stem cell drug discovery company based in

Cambridge, UK. It is committed to revolutionizing the discovery of treatments for

Alzheimer’s disease (AD). Its novel human stem cell models of AD provide a

transformative platform for rapid and relevant compound identification, which significantly

accelerates drug discovery. Talisman’s primary goal is the exploitation of these systems

to identify novel pharmacological treatments for AD initiation and progression through its

in-house drug discovery program.

195

13.30 Xcelthera INC

San Diego, CA

United States

Telephone: 1-888-706-5396

Website: www.xcelthera.com

Xcelthera INC is a new biopharmaceutical company moving toward the clinical stage of

novel, advanced stem cell therapy for a wide range of neurological and cardiovascular

diseases with leading technology and groundbreaking medical innovation in regenerative

medicine, and is a major innovator in the stem cell research market and one of first

companies formed for clinical applications of hESC therapeutic utility.

13.30.1 Technology Platforms

The company’s novel PluriXcel human stem cell technology platforms include the

PluriXcel-DCS technology and PluriXcel-SMI technology. The company’s PluriXcel

technology platforms enable large-scale production or manufacture of high quality clinical-

grade human neuronal and heart muscle cell therapy products as cellular medicines that

can offer pharmacologic utility and capacity adequate for CNS and heart regeneration.

13.30.2 PluriXcel-DCS Technology

The PluriXcel-DSC technology allows all poorly characterized and unspecified biological

components and substrates in the culture system, including those derived from animals,

to be removed, substituted, and optimized with defined human alternatives for de novo

derivation and long-term maintenance of cGMP-quality xeno-free stable hESC lines and

their human cell therapy derivatives, which have never been contaminated with animal

cells and proteins, and thus are suitable for therapeutic development and clinical

applications.

196

13.30.3 PluriXcel-SMI Technology

The PluriXcel-SMI technology enables highly efficient neural or cardiac lineage-specific

differentiation direct from the pluripotent stage of hESCs using small molecule induction,

which is a major milestone toward clinical application of hESC cell therapy derivatives,

offering benefits in efficiency, stability, safety, efficacy, and large-scale production of high

quality clinical-grade human stem cell therapy products in a cGMP facility for commercial

and therapeutic uses over all other existing approaches. The PluriXcel-SMI technology

platforms include PluriXcel-SMI-Neuron technology and PluriXcel-SMI-Heart technology.

13.30.4 PlunXcel-SMI Neuron Technology

The PluriXcel-SMI-Neuron technology enables highly efficient direct conversion of

pluripotent hESCs into large-scale high-quality human neuronal progenitors (Xcel-hNuP)

and functional human neuronal cells (Xcel-hNu) adequate for clinical development of safe

and effective stem cell therapies for a wide range of neurological disorders.

13.30.5 PluriXcel-SMI Heart Technology

The PluriXcel-SMI-Heart technology enables highly efficient direct conversion of

pluripotent hESCs into large-scale high-quality human heart precursors (Xcel-hCardP)

and functional human cardiomyocytes (heart muscle cells) (Xcel-hCM) adequate for

clinical development of safe and effective stem cell therapies for heart disease and failure.

13.30.6 Products

The Xcel prototypes, generated from hESCs using the novel PluriXcel technology,

currently include Xcel-hNuP (human neuronal progenitors), Xcel-hNu (human neurons),

Xcel-hCardP (human heart precursors), and Xcel-hCM (human heart muscle

cells), which are the only available human cell sources in commercial scales with

adequate cellular pharmacologic utility and capacity to regenerate CNS neurons and

contractile heart muscles, vital for CNS and heart repair for a wide range of neurological

197

and cardiovascular diseases in the clinical setting. The company believes that its Xcel

prototypes represent the next generation of human cell therapy products, offering purity,

large-scale production, high quality, safety, and effectiveness for commercial and

therapeutic uses over all other existing human cell sources.

13.30.6.1 Xcel-hNuP

Xcel-hNuP are clinical-grade high-purity human neuronal progenitor cells for CNS neuron

regeneration. These cell therapy products can be used for a wide range of neurological

disorders, including Parkinson’s disease, amyotrophic lateral sclerosis, spinal muscular

atrophy, Alzheimer’s disease, motor neuron diseases, neurodegenerative diseases,

stroke, brain, and spinal cord injuries.

13.30.6.2 Xcel-hNu

Xcel-hNu are clinical-grade high-purity human neurons for CNS neuron regeneration.

These cell therapy products can be used for a wide range of neurological disorders,

including Parkinson’s disease, amyotrophic lateral sclerosis, spinal muscular atrophy,

Alzheimer’s disease, motor neuron disease, neurodegenerative diseases, stroke, brain,

and spinal cord injuries.

13.30.6.3 Xcel-hCardP

Xcel-hCardP are clinical-grade high-purity human heart precursor cells for contractile

heart muscle regeneration. These cell therapy products are used for cardiovascular

disease, including heart disease and failure, myocardial infarction, cardiomyopathy,

ischemic heart disease, and congestive heart failure.

13.30.6.4 Xcel-hcM

Xcel-hcM are clinical-grade high-purity human cardiomyocytes (heart muscle cells) for

contractile heart muscle regeneration. These cell therapy products can be used for

198

cardiovascular disease, including heart disease and failure, myocardial infarction,

cardiomyopathy, ischemic heart disease, and congestive heart failure.

199

Appendix 1: Globally Distributed Stem Cell and Cell Therapy Companies

The promise that stem cells will lead to cures for today’s incurable diseases instills hope

in millions of people who battle for their health every day. Stem cells also show promise

in many other layers of society— potentially benefiting a country or state politically and

economically, as scientific breakthroughs and the development of new technologies

have long been a source of economic growth, new labor markets, and national pride.

In the struggle to maximize its share of this potential, the US has many natural

advantages. The majority of the world’s stem cell scientists and companies are in the

US, and the combined investment of federal and state governments, private

foundations, and individual donors exceeds the investment made by other individual

nations. However, this lead may not always translate into scientific results and can

easily be squandered if not supported by policy. Today, stem cell companies have

gained a stronger foothold in Europe, South Korea, Australia, and Israel.

The following table (App. 1.1: Stem Cell and Cell Therapy Companies) gives a list of

stem cell and cell therapy companies worldwide.

200

Name Website Location Country Type(s) of Cell Therapies

Stem Cell Company?

Yes/No

Accellta www.accellta.com Haifa Israel Specializes in mass production of stem cells in 3D bioreators Yes

Adaptimmune Therapeutics

http://www.adaptimmune.com/ Abingdon UK

Developing engineered T-cell therapies No

Adheren www.adheren.com

Emeryville, CA USA

Developed an anti-cancer T cell therapy, called ACE-T (Antibody Conjugated Effector T cells) No

AIVITA Biomedical

http://aivitabiomedical.com Irvine, CA USA

Has a Phase II-approved immunotherapy that utilizes autologous dendritic cells loaded with irradiated tumor cells and a preclinical program developing 3D-retinal organoids for vision loss Yes

Altucell http://www.altucell.net/

New York, NY USA

Encapsulated cell technologies for diabetes No

Anagenesis Biotechnologies

http://anagenesis-biotech.com/ Boston, MA USA

Preclinical‐stage stem cell-based company Yes

Animal Cell Therapies http://actcells.com/

San Diego, CA USA

Conducting a clinical trial evaluating intra-articular allogeneic umbilical-derived stem cells in canines with elbow osteoarthritis Yes

apceth http://www.apceth.com/

Mountain View, CA USA

Developing genetically engineered MSC (gmMSC) to target tumors and diseased tissue Yes

Aposcience http://www.aposcience.at/ Vienna Austria

Developing therapies based on secretomes of white blood cells from peripheral blood No

Ascend Biopharmaceuticals

http://www.ascendbiopharma.com/

South Melbourne, VIC Australia

Developing chemo immunotherapies to treat cancer No

Asterias Biotherapeutics

http://asteriasbiotherapeutics.com/

Fremont, CA USA

Pluripotent stem cells, cancer immunotherapies Yes

Athersys http://www.athersys.com/

Cleveland, OH USA

MultiStem®, an adult-derived “off-the-shelf” stem cell product platform Yes

Autolus https://www.autolus.com

White City, London UK

Engineered T-cell therapy products for cancer No

AVROBIO http://www.avrobio.com/

Cambridge, MA USA

Genetic modification of autologous cancer cells No

AxoGen http://www.axogeninc.com/ Alachua, FL USA

Medical tech company focused on peripheral nerve repair No

Bellicum Pharmaceuticals

http://www.bellicum.com/ Houston, TX USA

Developing stem cell transplant, TCR and CAR T cell therapies No

Betalin Therapeutics

http://www.betalintherapeutics.com/ Ramat Gan Israel

Betalin Therapeutics is developing an Engineered Micro Pancreas (EMP) to treat diabetes and recently submitted a pre-pre-IND application to the US FDA

201

BioCardia http://www.biocardia.com/

San Carlos, CA USA

Clinical-stage therapeutics for cardiovascular diseases Yes

BioRestorative Therapies

http://www.biorestorative.com/ Jupiter, FL USA

Stem cell company developing brtxDISC™ (Disc Implanted Stem Cells) & ThermoStem® Yes

BlueRock Therapeutics http://bluerocktx.com/

New York, NY USA

Allogeneic cell therapies with a focus on iPS cells Yes

Bone Therapeutics

http://www.bonetherapeutics.com/en

Gosselies, Belgium Belgium Bone cell therapy company No

BrainStorm Cell Therapeutics

http://www.brainstorm-cell.com/

Kiryat Aryeh, Israel Israel

Autologous stem cell therapies for neurodegenerative disorders Yes

Bullet Biotechnology

http://www.bulletbio.com/

Redwood City, CA USA Active immunotherapies for cancer No

Caladrius Biosciences

http://www.caladrius.com/

Basking Ridge, NJ USA

Clinical-stage cell therapy company targeting diabetes and other diseases No

Capricor Therapeutics

http://capricor.com/#/home

Beverly Hills, CA USA

Allogeneic cardiosphere-derived cells (CDCs) No

CardioCell (Stemedica)

http://stemcardiocell.com/

San Diego, CA USA

Cardiovascular technology derived from allogeneic adult stem cells Yes

Celixir http://www.celixir.com/ Cardiff, UK UK Cell-based therapies (Heartcel™, Tendoncel™, Myocardion™) No

Cell Cure Neurosciences (BioTime subsidiary)

http://www.cellcureneurosciences.com/

Jerusalem , Israel Israel

Cell therapies for retinal and neural degenerative diseases; Focus on hESC-derived RPE cells Yes

Cell Design Labs (Acquied by Gilead Sciences)

www.celldesignlabs.com/

Emeryville, CA USA

Developing CAR-T and TCR T-cell therapies for solid tumors; acquired December 2017 by Gilead Sciences to bolster its cellular immmotherapy pipeline. No

Cell Medica https://cellmedica.com/ London, UK UK CAR ,TCR and T-cellerator® No

Cellect Biosciences cellect.co

Kfar Saba, Israel Israel

ApoGraft™ technology for functional separation of stem cells Yes

Cellectis http://www.cellectis.com/en/

France / New York, NY

France / USA

Genome-edited CAR-T cell technologies for cancer No

Cellenkos, Inc. http://www.cellenkosinc.com/ Houston, TX USA

Developing cord blood regulatory T-celll therapeutics for treating autoimmune diseases and inflammatory disorders

CellProthera https://www.cellprothera.com/

Mulhouse, France

France / USA

Use of blood peripheral stem cells for cardiac diseases Yes

Celltex http://celltexbank.com/ Houston, TX USA

Specializes in storing and expanding autologous adipose-derived MSC populations for use in regenerative medicine applications. Yes

202

CellTherapies http://www.celltherapies.com.au/

East Melbourne, Australia Australia

Manufacturing and distribution of cell-based therapies No

Cellular Approaches

http://cellularapproaches.com

San Diego, CA USA No

Cellular Biomedicine Group

http://www.cellbiomedgroup.com/

Palo Alto, CA USA

Immunotherapies for cancer and stem cell therapies for degenerative diseases Yes

Cellular Dynamics (Fujifilm)

https://cellulardynamics.com/ Madison, WI USA

Largest global provider of research and clincal-grade iPS cells and their derivatives; Opsis Therapeutics is a subsidiary. Yes

Celularity https://www.celularity.com Warren, NJ USA

Developing therapies using cells and tissues from the placenta and umbilical cord Yes

Celvive http://www.celvive.com/

New Brunswick, NJ USA

Autologous adult stem cell therapies Yes

Celyad https://www.celyad.com/ Boston, MA USA

Autologous and allogeneic CAR-T NK cell-based immunotherapies No

Chimera Bioengineering http://www.chimera.bio/

South San Francisco, CA USA Bioengineered CAR T-cell products No

CiMaas http://cimaas.com/

Maastricht , Netherlands

Netherlands

Developing advanced cellular therapeutic products, including dendritic and NK cell therapies No

Codiak Bio http://www.codiakbio.com

Woburn, Massachusetts USA Therapeutic exosomes Yes

Creative Medical Technology Holdings

http://www.creativemedicaltechnology.com/ Phoenix, AZ USA

Stem cell and exosome-based therapeutics Yes

Cure Cell Neurosciences (Subsidiary of BioTime, Inc.)

www.cellcureneurosciences.com/

Jerusalem, Israel Israel

ESC-derived therapies for retinal and neural degenerative diseases Yes

Cynata Therapeutics http://cynata.com/

Armadale, VIC, Australia Australia

iPSC-derived MSCs; Cymerus platform technology Yes

Cytori Therapeutics http://www.cytori.com/

Tokyo, Japan Japan

Medical devices that enable therapeutic use of adipose-derived stem and regenerative cells Yes

DaVinci Biosciences

http://dvbiosciences.com/

Yorba Linda, CA USA

Stem cell therapies for spinal cord injury, cardiovascular disease, neurological disease, and more Yes

DiscGenics http://discgenics.com

Salt Lake City, UT USA

Advanced spinal stem cell therapeutics; first product candidate, IDCT, is a homologous, allogeneic injectable cell therapy Yes

203

Emercell http://www.emercell.com/

St Mathieu de Tréviers France

Using a patented process to pre-activate and amplify effects of allogeneic NK cells No

Epibone http://epibone.com/

Brooklyn, NY USA

Custom bone grafts grown from stem cells Yes

ExCellThera http://excellthera.ca/ Montréal Canada

Expands and genetically engineers hematopoietic stem cells as therapeutics with a focus on blood cancers and gene therapy (uses UM171 and a Fed-Batch culture system) Yes

Exopharm exopharm.com/

Melbourne, VIC, Australia Australia

Manufacturing and applications of therapeutic exosomes from stem cells Yes

F1 Oncology f1oncology.com

West Palm Beach, FL USA

CAR-T cell therapies for solid tumors No

Fate Therapeutics http://fatetherapeutics.com/

San Diego, CA USA

Programmed cellular immunotherapeutics for cancer and immune disorders; Has an iPS cell product plaform YES

Fibrocell http://fibrocell.com/ Exton, PA USA

Autologous cell and gene therapy company leveraging fibroblast technology No

Formula Pharmaceuticals

http://www.formulapharma.com Berwyn, PA USA

Developing allogeneic Cytokine Induced Killer (C.I.K.) CAR immunotherapies for cancer. No

Fortuna Fix http://fortunafix.com/

Laval, QC,Canada Canada

Direct cell reprogramming for neural applications Yes

FujiFilm Holdings www.fujifilmholdings.com/

Tokyo, Japan Japan

Diverse regenerative medicine company; Parent company of CDI Yes

Gamida Cell http://www.gamida-cell.com/

Jerusalem, Israel Israel

HSCT therapies; Cord blood stem cell expansion Yes

Gilead Sciences www.gilead.com

Foster City, CA USA

Acquired Kite Pharma for $11.9B in August 2017; Kite Pharma received FDA approval for Yescarta in October 2017, the 2nd CAR-T cell therapy approved in U.S. No

Glycostem http://glycostem.com/

Kloosterstraat

The Netherlands

Allogeneic cellular immunotherapies using NK cells (oNKord®) No

GSK http://www.gsk.com/

Brentford, UK UK Cell and gene therapies No

Helocyte (Fortress Bioecth)

http://www.helocyte.com/

New York, NY USA

Immunotherapies for cancer and infectious disease No

Histogen http://www.histogen.com/

San Diego, CA USA

Grows newborn fibroblasts in a bioreactor for hair stimulation; Lead product is Hair Stimulating Complex (HSC) No

Immatics Biotechnologies http://immatics.com/

Tuebingen, Germany Germany

Immunotherapeutic substances for cancer No

Immune Therapeutics

https://www.immunetherapeutics.com/ Orlando, FL USA

CAR-T cell therapies for various applications No

204

Immusoft http://immusoft.com/ Seattle, WA USA

Immune System Programming (ISP™) technology inserts genes encoding therapeutic proteins into patients’ immune cells (B cells / plasma cells) No

inRegen (RegenMedTX)

https://www.inregen.com/

Winston-Salem, NC USA

FDA approved a Phase II Clinical Trial of its Neo-Kidney Augment (NKA) autologous cell therapy product in patients with Type 2 Diabetes and Chronic Kidney Disease No

Insigilon Therapeutics http://www.sigilon.com

Cambridge, MA USA Encapsulated cell technologies No

Intercytex http://www.intercytex.com/

Manchester, UK UK

Developing lead product ICX-RHY for skin repair and rejuvenation No

International Stem Cell

http://internationalstemcell.com/

Carlsbad, CA USA

Adult stem cell therapies utilizing human parthenogenetic stem cells (hpSC) Yes

Invitrx Therapeutics http://www.invitrx.com/ Irvine, CA USA

Harvesting and isolation of stem cells for therapeutic and cosmetic applications Yes

Juno Therapeutics

https://www.junotherapeutics.com/

Waltham, MA USA

Cell immunotherapy company; CAR T therapies No

Kadimastem www.kadimastem.com/

Nes-Ziona, Israel Israel

Stem cell-based therapeutics, primarily for diabetes and neurodegenerative disorders Yes

Kiadis Pharma www.kiadis.com

Amsterdam, Netherlands

Netherlands

Developing ATIR101 and ATIR201 as cellular products for infusion. They consist of donor lymphocytes manufactured for each patient from a haploidentical stem cell donor. Yes

Kimera Labs http://kimeralabs.com/ Miramar, FL USA Therapeutic exosomes; XOGLO™ for skin rejuvination No

Kite Pharma http://kitepharma.com/

Santa Monica, CA USA

Engineered T cell therapies for cancer; its CAR-T cell therapy product Yescarta was approved October 2017 by U.S. FDA with list price of $373K No

Lion Biotechnologies http://www.lbio.com/

Los Angeles, CA USA

Autologous cellular immunotherapies utilizing tumor infiltrating lymphocytes (TIL) No

Living Cell Technologies

http://www.lctglobal.com/

Auckland, New Zealand

New Zealand

Lead product, NTCELL®, is an alginate coated capsule containing clusters of neonatal porcine choroid plexus cells; Phase IIb trial for Parkinson's disease is now underway No

Longeveron http://longeveron.com/ Miami, FL USA Developing human Allogeneic Mesenchymal Stem Cells (LMSCs) Yes

Magenta Therapeutics

https://www.magentatx.com/

Cambridge, MA USA

Stem cell technologies to make stem cell transplantation safer Yes

205

Medeor Therapeutics

https://www.medeortherapeutics.com/

San Mateo, CA USA

Cellular immunotherapy products for kidney transplant (MDR-10X) Yes

Medipost http://www.medi-post.com

Seongnam-si

South Korea

Relesed world’s first allogeneic stem cell drug (CARTISTEM®), an allogeneic cord blood-derived MSC therapy for knee cartilage defects CARTISTEM® Yes

Mesoblast http://www.mesoblast.com/

Melbourne, VIC, Australia Australia

Stem cell therapies; Emphasis on MSC therapies Yes

Metaclipse Therapeutics

http://www.metaclipsetherapeutics.com/ Atlanta, GA USA

Developing Membrex™, a cancer immunotherapy No

Minerva Bio https://www.minervabio.com/

Waltham, MA USA Cancer and stem cell therapeutics Yes

Molecular Medicine

http://www.molmed.com/ Milan, Italy Italy

Cell-based antitumour therapeutics, including Zalmoxis® (TK), NGR-hTNF, and CAR-CD44v6 No

MolMed S.p.A. http://www.molmed.com Milano Italy

Developing anticancer therapies, including Zalmoxis® (TK) is a cell-based therapy enabling bone marrow transplants from partially compatible donors and CAR-CD44v6, an immuno-gene therapy project No

Mustang Bio (a Fortress Biotech Company)

http://www.mustangbio.com/

New York, NY USA

Developing an optimized CAR T product with CAR design and T cell engineering to improve antitumor potency and T cell persistence No

Neon Therapeutics

http://neontherapeutics.com/

Cambridge, MA USA

Personal autologous T cell therapies No

Neuralstem http://www.neuralstem.com/

Germantown, MD USA

Neural stem cell lines for potential transplantation therapies Yes

Neurogeneration http://www.neurogeneration.com/

San Diego, CA USA

Autologous stem cell treatments for Parkinson’s disease and other CNS disorders Yes

Neurona Therapeutics

http://www.neuronatherapeutics.com/

South SF, CA USA

Transplantation of specialized neurons derived from stem cells to treat neurological diseases Yes

Neuronascent http://www.neuronascent.com/

Clarksville, MD USA

Utilization of neuronal progenitor cells for therapeutic applications Yes

NexImmune http://www.neximmune.com/

Gaithersburg, MD USA

Developing immuno-therapeutics based on its Artificial IMmune (AIM™) technology No

NextCell Pharma AB

http://www.nextcellpharma.com/ Stockholm Sweden

Develping ProTrans™, consisting of stem cells for treatment of autoimmune and inflammatory diseases Yes

206

Nohla Therapeutics

http://nohlatherapeutics.com/ Seattle, WA USA

Developing an ex vivo expanded cord blood product that will be a "universal donor" therapy Yes

Novartis https://www.novartis.com Basel

Switzerland

First company to win FDA approval for a CAR-T therapy in U.S. with approval of Kymriah, an autologous immunocellular therapy priced at $475K per treatment course No

Obsidian Therapeutics http://obsidiantx.com/

Cambridge, MA USA

Develops adoptive immunotherapies for cancer No

Opexa Therapeutics

http://www.opexatherapeutics.com/

The Woodlands, TX USA

Personalized T-cell immunotherapies using Opexa’s proprietary T-cell technology No

Opsis Therapeutics https://opsistx.com Madison, WI USA Cell therapies for retinal diseases No

Orchard Therapeutics http://orchard-tx.com London UK

Developing autologous stem cell treatments using ex-vivo gene therapy technology Yes

Orgenesis, Ltd. http://www.orgenesis.com/

Germantown, MD USA

Focus on cellular transdifferentiation & Autologous Insulin Producing (AIP) cells No

ORIG3N https://orig3n.com/ Boston, MA USA World's largest blood repository; Blood cell derived iPSCs Yes

Orthocyte (BioTime Subsidiary) http://orthocyte.com/

Alameda, CA USA

Leveraing human stem cell progenitors to create therapies for bone and orthopedic soft tissue diseases No

Osiris Therapeutics http://www.osiristx.com/

Columbia, MD USA

Prominent stem cell company that developed the first cellular bone allograft and first approved stem cell drug Yes

Oxford Biomedica http://www.oxfordbiomedica.co.uk Oxford UK

Uses LentiVector® delivery platform to create gene and cell therapies No

OxStem http://www.oxstem.co.uk/

Cambridge, UK UK

Cell programming therapies to treat degenerative diseases; Endogenous Cell Activation Therapy (ECAT) to activate stem and progenitor cells Yes

Pathfinder Cell Therapy

http://www.pathfindercelltherapy.com/

Cambridge, MA USA

Cell-based therapies called Pathfinder Cells (“PCs”) for treatment of diabetes No

Plureon https://www.plureon.com/

Winston-Salem, NC USA

Pluripotent stem cells extracted from amniotic fluid and placenta Yes

Pluristem Therapeutics

http://www.pluristem.com/ Haifa, Israel Israel Placental cell therapies Yes

PolarityTE http://www.polarityte.com/

Salt Lake City, UT USA Functionally polarized tissue No

Poseida Therapeutics

Autologous and allogeneic CAR-T therapies for hematological cancers and solid tumors; gene therapies No

Promethera Biosciences

http://www.promethera.com/

Mont-Saint-Guibert, Belgium Belgium

Human liver-derived cell therapy technologies Yes

207

Regen BioPharma http://www.regenbiopharmainc.com/

La Mesa, CA USA

Cellular immunotherapy for cancer (dCellVax), modulation of cancer stem cells (CSCs), and more No

Regeneus http://regeneus.com.au/

Pymble, NSW, Australia Australia

Allogeneic stem cell and secretions technologies Yes

Regenicin http://www.regenicin.com/

Little Falls, NJ USA

Developing NovaDerm™, a cultured cell technology that uses a patient’s skin cells to generate living, tissue-engineered skin No

ReNeuron http://www.reneuron.com/

Bridgend, UK UK

Stem cell therapies; therapeutic stem cell exosomes Yes

RepliCel Life Sciences http://replicel.com/

Vancouver, BC Canada

Autologous cell therapies with a focus on hair restoration Yes

Rubius Therapeutics

http://www.rubiustx.com/

Cambridge, MA USA

Developing allogeneic genetically engineered, enucleated red cells (Red-Cell Therapeutics™) No

Rxi Pharmaceuticals

http://www.rxipharma.com

Cambridge, MA USA

Activated immune cells modified by oligonucleotides No

SanBio Co Ltd http://www.san-bio.com/

Mountain View, CA USA

Developing an allogeneic bone marrow derived MSC therapy (SB623, SB618, and SB308 cells) for ischemic stroke, brain injury, and more Yes

Saneron CCEL Therapeutics (Affiliate of Cryo-Cell International, Inc)

http://www.saneron-ccel.com/ Tampa, FL USA

Developing U-CORD-CELL® (a cord blood stem cell product) and SERT-CELL (Sertoli cells) for neurological and cardiac applications Yes

Semma Therapeutics

http://www.semma-tx.com/

Cambridge, MA USA

Generating stem cell-derived pancreatic beta cells to treat diabetes Yes

Stem Cell Medicine, Ltd.

www.stemcell-medicine.com

Jerusalem, Israel Israel Stem cell therapies Yes

Stemedica Cell Technologies

http://www.stemedica.com/

San Diego, CA USA

Distributes adult allogeneic stem cell products for human trials Yes

StemGenex https://stemgenex.com/ La Jolla, CA USA

Stem cell therapy options for inflammatory and degenerative illnesses; Has 5 clinical studies registered with NIH Yes

Steminent Biotherapeutics www.steminent.com/

Taipei City, Taiwan Taiwan

Adipose-derived stem cell therapies; Stemchymal® stem cell products Yes

Stemline Therapeutics www.stemline.com/

New York, NY USA

Therapies targeting cancer stem cells Yes

Stempeutics http://www.stempeutics.com/

Bangalore, KA, India India

Developing stem cell therapeutics, including Stempeucel®, Stempeucare™ and Stempeutron™; Stempeucel® is 1st stem cell product approved by DCGI Yes

208

Stratatech (a Mallinckrodt Pharmaceuticals Co.)

http://www.stratatechcorp.com/ Madison, WI USA

Regenerative medicine company focused on therapeutic human skin substitutes Yes

Taiga Biotechnologies http://taigabiotech.com/ Aurora, CO USA

Stem-cell therapeutics for the treatment of hematological malignancies Yes

TaiwanBio

http://www.taiwan-bio-thera.com/taiwan-bio-therapeutics

Taipei City, Taiwan Taiwan

Developing human MSC based therapeutics utilizing a proprietary cell expansion technology; Lead products are Biochymal® and Chondrochymal® Yes

Talisman Therapeutics (University of Cambridge spinout)

http://www.talisman-therapeutics.com/

Cambridge, UK UK

Develpoing novel human stem cell models of Alzheimer's disease (AD) Yes

Targazyme http://targazyme.com/

Carlsbad, CA USA

Has an ex vivo enzymatic glyco-engineering platform, fucosylation, that can be applied to therapeutic cells No

TCR2 Therapeutics http://www.tcr2.com/

Cambridge, MA USA

DevelopingT cell therapies using the signaling power of complete T cell receptors (TCR) No

Theracell www.theracellinc.co Littleton, MA USA

Demineralized Bone Fibers (DBF™) products; Selection of stem cells using a microfluidic cell sorting device No

Tigenix http://tigenix.com/

Leuven, Belgium Belgium

Stem cell therapies; Anti-inflammatory properties of stme cells Yes

Tikomed http://tikomed.com/

Viken, Sweden Sweden

Developing IBsolvMIR® to improve islet cell transplantation for patients with diabetes and chronic pancreatitis No

TissueGene http://www.tissuegene.com/

Rockville, MD USA

Allogeneic human cells that are engineered to express specific therapeutic proteins No

TxCell http://www.txcell.com/technology/entria/

Valbonne, France France

Developing personalized T cell immunotherapies for inflammatory and autoimmune diseases No

U.S. Stem Cell http://us-stemcell.com/ Sunrise, FL USA

Stem cell treatments for patients with degenerative conditions; Has numerous US and EU clinical trials underway Yes

Universal Cells http://www.universalcells.com/ Seattle, WA USA

Creating "universal donor" stem cells by editing the genes required for immune recognition Yes

Unum Therapeutics

http://www.unumrx.com/

Cambridge, MA USA

Developing cellular immunotherapies based on an antibody-coupled T-cell receptor (ACTR) No

Utah Cord Blood Bank http://stemshot.com/ Sandy, UT USA

Hybrid public-private cord blood bank entering a RMAT for its tri-product consisting of cord blood, micronized amnion and micronized umbilical cord with Wharton's Jelly Yes

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Source: BioInformant Worldwide, LLC

Vericel http://vcel.com/

Cambridge, MA USA

Autologous cell-based therapies, including Carticel (autologous cultured chondrocytes) and Epicel (cultured epidermal autograft) Yes

VetStem Biopharma

http://www.vet-stem.com/ Poway, CA USA

Concentrated autologous adipose-derived stem cells for veterinary applications Yes

ViaCyte http://viacyte.com/ Athens, GA USA

Using a ESC line to manufacture pancreatic endoderm cells (PEC-01) and developing an Encaptra cell delivery system to implant PEC-01 cells and other cell types Yes

VistaStem Therapeutics (subsidiary of VistaGen Therapeutics)

http://www.vistagen.com/

South SF, CA USA

Has a human pluripotent stem cell technology (hPSC) platform; Signed sublicense agreement with BlueRock Therapeutics for use of its technologies to produce cardiac stem cells for heart disease Yes

Vital Therapies http://vitaltherapies.com/

San Diego, CA USA

Developing ELAD®, an investigational extracorporeal human hepatic cell-based liver treatment No

Vor BioPharma http://www.vorbiopharma.com/ Boston, MA USA

Developing novel CAR-T therapies for cancer No

Xcelthera http://www.xcelthera.com/index.html

San Diego, CA USA

Developing PluriXcel human stem cell technology platforms and Xcel prototypes of human stem cell therapy products Yes

Ziopharm Oncology

http://www.ziopharm.com/ Boston, MA USA

Developing cell therapies for cancer and GvHD; Partnered with Intrexon and MD Anderson Cancer Center for immuno-oncology programs that involve CAR-T, TCR-modified T cells, and other approaches No

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