A Trial to Determine the Safety and Tolerability of Transplanted Stem Cell Derived Dopamine Neurons to the Brains of Individuals With Parkinson's Disease

Parkinson Disease Clinical Trial

— STEM-PD  

Official title:

STEM-PD Trial: A Multicentre, Single Arm, First in Human, Dose-escalation Trial, Investigating the Safety and Tolerability of Intraputamenal Transplantation of Human Embryonic Stem Cell Derived Dopaminergic Cells for Parkinson's Disease (STEM-PD Product)

Clinical Trial Details — Status: Recruiting

Administrative data

• NCT number: NCT05635409
• Other study ID #: CCTU0263
• Secondary ID: 2021-001366-38
• Status: Recruiting
• Phase: Phase 1
• Start date: November 30, 2022
• Est. completion date: June 2027

Study information

• Verified date: February 2024
• Source: Region Skane
• Contact: Cambridge Clinical Trials Unit - Neuroscience Theme
• Phone: +44 (0) 1223 334121
• Email: cuh.stempd_trial[@]nhs.net
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

Parkinson's disease (PD) occurs when an area of the brain begins to lose nerve cells that produce a chemical called dopamine. Dopamine is an important chemical, and one of its functions is that it helps to regulate body movement. The loss of these nerve cells leads to a reduction of dopamine in the brain. Medications used to treat PD temporarily replace this lost dopamine, but they do not repair the underlying disease. One of the most promising PD therapies to date has been the transplantation of dopamine producing cells into the brain. Unlike current treatments, these therapies may be able to repair the damage caused in PD.

In this trial, the investigators will transplant a new stem cell therapy, called the STEM-PD product, into the area of the brain affected in people with PD. These stem cells can develop into many different cell types, including dopamine-producing nerve cells. The investigators will transplant the stem cells using a device that has been previously used for similar transplants in Lund. This is the first time that the STEM-PD product will be given to humans.

The trial aims to assess whether the STEM-PD product is safe to use in people with PD. The investigators will also be looking for preliminary signs of efficacy.

The trial will recruit participants with PD from the UK and Sweden. Eight participants will undergo the STEM-PD product transplant. Participants will receive a single dose of the STEM-PD product. Participants will attend for 25 visits primarily at their local recruiting hospital. For participants from the UK, some of the imaging will be performed at Invicro (London), and the surgery (including some visits before and after) and some imaging will be performed in Lund. All participants will be followed up for 36 months following surgery

Recruitment information / eligibility

• Status: Recruiting
• Enrollment: 8
• Est. completion date: June 2027
• Est. primary completion date: January 2027
• Accepts healthy volunteers: No
• Gender: All
• Age group: 50 Years to 75 Years

Eligibility

Inclusion Criteria:

• Have given written informed consent to participate in the trial

• Diagnosed with PD as defined using Queens Square Brain Bank criteria

• Moderate disease as defined by having Hoehn and Yahr stage 2-3 in OFF state

• Disease duration > 10 years

• Male or female, aged between 50 and 75 years (inclusive)

• Have a significant response to dopamine therapies as judged by the PI or other delegated clinician

• Have symptoms that are not appropriately controlled by existing oral anti-PD medications, as judged by the PI or other delegated clinician

• Ability to travel to Lund for surgery

• Followed up for at least 12 months prior to inclusion in this trial in the TransEUro observational study

• Be fluent in English/Swedish to enable completion of questionnaires as assessed by the PI or other delegated clinician at Cambridge/Lund, respectively

• Be approved by the TMG clinical sub-group for trial participation

Exclusion Criteria:

• Tremor dominant disease, as assessed by the PI or other delegated clinician

• Significant drug induced dyskinesias as defined by a score of > 2 in the Abnormal Involuntary Movement Scale (AIMS) dyskinesias rating scale, in any body part in the ON state

• Ongoing major medical or psychiatric disorders, including depression (MADRS > 20) and psychosis, that make participation unsuitable, as judged by the PI or other delegated clinician

• Any contraindication to neurosurgery

• Unable to be imaged using MRI

• Extensive ventral striatal loss or normal findings on F-DOPA PET at screening

• Significant cognitive impairment indicative of an incipient dementia/established dementia or values consistent with MoCA score of = 24

• Unable to perform normal copying of interlocking pentagons and/or a semantic fluency score for naming animals of less than 20 over 90 seconds

• Other concomitant treatment with neuroleptics (including atypical neuroleptics) and/or cholinesterase inhibitors

• Previous neurosurgery to the brain, or cell or organ transplantation, or recipient of repeated blood transfusions

• Any contraindication to immunosuppressive therapy, prophylactic antibiotics, and/or osteoporosis prophylaxis (refer to STEM-PD Trial Immunosuppressant Manual)

• High levels of pre-formed specific anti-HLA antibodies to the cell product

• Severely reduced TPMT activity (less than half of the lower normal TPMT activity level)

• History of documented severe/significant allergy requiring treatment

• Female who is pregnant or breastfeeding

• Received an investigational drug (including investigational vaccines) or used an invasive investigational medical device within 4 weeks of the screening visit, or is currently enrolled in an interventional investigational trial

• Female of childbearing potential or male unwilling to follow contraception requirements (see protocol section 12.15)

• Any other condition which, in the opinion of the investigator, makes the patient inappropriate for entry into the trial

Related Conditions & MeSH terms

• Parkinson Disease

Intervention

Biological:
• STEM-PD
STEM-PD is a cryopreserved cell product, consisting of ventral midbrain dopaminergic progenitor cells derived from the clinical-grade hESC line RC17. STEM-PD will be administered using a non-CE marked class III neurosurgical medical device, the Rehncrona-Legradi device, bilaterally in one surgical session to the putamen.

Locations

Country	Name	City	State
Sweden	Region Skåne - Skåne University Hospital	Lund
United Kingdom	Cambridge University Hospitals NHS Foundation Trust	Cambridge	Cambridgeshire

Sponsors (4)

Lead Sponsor	Collaborator
Region Skane	Cambridge University Hospitals NHS Foundation Trust, Lund University, University of Cambridge

Countries where clinical trial is conducted

Sweden,  United Kingdom, 

References & Publications (45)

Adler AF, Cardoso T, Nolbrant S, Mattsson B, Hoban DB, Jarl U, Wahlestedt JN, Grealish S, Bjorklund A, Parmar M. hESC-Derived Dopaminergic Transplants Integrate into Basal Ganglia Circuitry in a Preclinical Model of Parkinson's Disease. Cell Rep. 2019 Sep 24;28(13):3462-3473.e5. doi: 10.1016/j.celrep.2019.08.058. — View Citation

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Grealish S, Heuer A, Cardoso T, Kirkeby A, Jonsson M, Johansson J, Bjorklund A, Jakobsson J, Parmar M. Monosynaptic Tracing using Modified Rabies Virus Reveals Early and Extensive Circuit Integration of Human Embryonic Stem Cell-Derived Neurons. Stem Cell Reports. 2015 Jun 9;4(6):975-83. doi: 10.1016/j.stemcr.2015.04.011. Epub 2015 May 21. — View Citation

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Hagell P, Schrag A, Piccini P, Jahanshahi M, Brown R, Rehncrona S, Widner H, Brundin P, Rothwell JC, Odin P, Wenning GK, Morrish P, Gustavii B, Bjorklund A, Brooks DJ, Marsden CD, Quinn NP, Lindvall O. Sequential bilateral transplantation in Parkinson's disease: effects of the second graft. Brain. 1999 Jun;122 ( Pt 6):1121-32. doi: 10.1093/brain/122.6.1121. — View Citation

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Heuer A, Kirkeby A, Pfisterer U, Jonsson ME, Parmar M. hESC-derived neural progenitors prevent xenograft rejection through neonatal desensitisation. Exp Neurol. 2016 Aug;282:78-85. doi: 10.1016/j.expneurol.2016.05.027. Epub 2016 May 25. — View Citation

Hoban DB, Shrigley S, Mattsson B, Breger LS, Jarl U, Cardoso T, Nelander Wahlestedt J, Luk KC, Bjorklund A, Parmar M. Impact of alpha-synuclein pathology on transplanted hESC-derived dopaminergic neurons in a humanized alpha-synuclein rat model of PD. Proc Natl Acad Sci U S A. 2020 Jun 30;117(26):15209-15220. doi: 10.1073/pnas.2001305117. Epub 2020 Jun 15. — View Citation

Kefalopoulou Z, Politis M, Piccini P, Mencacci N, Bhatia K, Jahanshahi M, Widner H, Rehncrona S, Brundin P, Bjorklund A, Lindvall O, Limousin P, Quinn N, Foltynie T. Long-term clinical outcome of fetal cell transplantation for Parkinson disease: two case reports. JAMA Neurol. 2014 Jan;71(1):83-7. doi: 10.1001/jamaneurol.2013.4749. — View Citation

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Kirkeby A, Nolbrant S, Tiklova K, Heuer A, Kee N, Cardoso T, Ottosson DR, Lelos MJ, Rifes P, Dunnett SB, Grealish S, Perlmann T, Parmar M. Predictive Markers Guide Differentiation to Improve Graft Outcome in Clinical Translation of hESC-Based Therapy for Parkinson's Disease. Cell Stem Cell. 2017 Jan 5;20(1):135-148. doi: 10.1016/j.stem.2016.09.004. Epub 2016 Oct 27. — View Citation

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Lehnen D, Barral S, Cardoso T, Grealish S, Heuer A, Smiyakin A, Kirkeby A, Kollet J, Cremer H, Parmar M, Bosio A, Knobel S. IAP-Based Cell Sorting Results in Homogeneous Transplantable Dopaminergic Precursor Cells Derived from Human Pluripotent Stem Cells. Stem Cell Reports. 2017 Oct 10;9(4):1207-1220. doi: 10.1016/j.stemcr.2017.08.016. Epub 2017 Sep 21. — View Citation

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* Note: There are 45 references in all — Click here to view all references

Outcome

Type	Measure	Description	Time frame	Safety issue
Other	Exploratory outcome: changes in F-DOPA uptake and dopamine transporter (DAT) binding at 6 months post transplantation on PET imaging with F-DOPA and PE2i compared to PET imaging performed pre-transplant.	PET imaging is used within the trial to allow for the assessment of the survival of dopaminergic neurons derived from the transplanted STEM-PD product. The proposed PET ligands to be used within the trial are: F-DOPA, which measures DA synthesis/storage capacity of the transplant, and PE2i, which selectively labels mature DA nerve terminals.; Positron Emission Tomography (PET) scans are performed with participants in a "practically defined OFF phase".	6 months post transplant
Other	Exploratory outcome: changes in F-DOPA uptake and dopamine transporter (DAT) binding at 12 months post transplantation on PET imaging with F-DOPA and PE2i compared to PET imaging performed pre-transplant.	PET imaging is used within the trial to allow for the assessment of the survival of dopaminergic neurons derived from the transplanted STEM-PD product. The proposed PET ligands to be used within the trial are: F-DOPA, which measures DA synthesis/storage capacity of the transplant, and PE2i, which selectively labels mature DA nerve terminals.; Positron Emission Tomography (PET) scans are performed with participants in a "practically defined OFF phase".	12 months post transplant
Other	Exploratory outcome: changes in F-DOPA uptake and dopamine transporter (DAT) binding at 24 months post transplantation on PET imaging with F-DOPA and PE2i compared to PET imaging performed pre-transplant.	PET imaging is used within the trial to allow for the assessment of the survival of dopaminergic neurons derived from the transplanted STEM-PD product. The proposed PET ligands to be used within the trial are: F-DOPA, which measures DA synthesis/storage capacity of the transplant, and PE2i, which selectively labels mature DA nerve terminals.; Positron Emission Tomography (PET) scans are performed with participants in a "practically defined OFF phase".	24 months post transplant
Other	Exploratory outcome: change in Fluctuation Dyskinesia Score (FDS) compared to baseline as determined by measurement using wearable movement monitoring devices (Parkinson KinetiGraph™ [PKG])	Fluctuation Dyskinesia Score (FDS) is measured using the PKG®, a wrist worn accelerometer from Global Kinetics Pty Ltd. The PKG® watch is worn on the most affected side of the body (same side for all tests). Registration will be done for 7 consecutive days just before a visit. Fluctuation score produced by summing the interquartile range of bradykinesia scores and dyskinesia scores produced very 2 minutes between 09:00-18:00 and expressed as an algorithm. Higher scores are associated with increasing duration of disease, higher levels of medication induced dyskinesia and overall greater degree of symptom variability from dose-to-dose and day-to-day.	36 months post transplant
Other	Exploratory outcome: change in Dyskinesia score (DKS) compared to baseline as determined by measurement using wearable movement monitoring devices	Dyskinesia score (DKS) is measured using the PKG®, a wrist worn accelerometer from Global Kinetics Pty Ltd. The PKG® watch is worn on the most affected side of the body (same side for all tests). Registration will be done for 7 consecutive days just before a visit. A higher score is considered a worse outcome.	36 months post transplant
Other	Exploratory outcome: change in Bradykinesia score (BKS) features compared to baseline as determined by measurement using wearable movement monitoring devices	Bradykinesia score (BKS) are measured using the PKG®, a wrist worn accelerometer from Global Kinetics Pty Ltd. The PKG® watch is worn on the most affected side of the body (same side for all tests). Registration will be done for 7 consecutive days just before a visit. A higher score is considered a worse outcome.	36 months post transplant
Other	Levels of donor cell specific anti-human leukocyte antigen (HLA) class I antibodies post-transplant	HLA antibodies will be monitored throughout the course of the trial via blood tests	36 months post transplant
Other	Exploratory outcome: changes in markers of inflammation in the cerebrospinal fluid (CSF)	Optional lumbar punctures will be performed for participants who consented to these. Parameters measured will be decided by the research site and may include routine parameters such as cell count, protein and glucose levels, and presence of oligoclonal bands of immunoglobulins.	18 months post transplant
Other	Exploratory outcome: change in response to a L-dopa challenge test including measuring the duration and profile of the L-dopa effects between baseline and 36 months: change in MDS-UPDRS Part III score	For the L-dopa challenge test, participants are given a challenge dose of L-dopa when they are in a practically defined OFF phase. Participants will then perform the Movement Disorder Society - Unified Parkinson's Disease Rating Scale (MDS-UPDRS) part III every 30 minutes for up to 120 minutes. A higher score is considered a worse outcome.	36 months post transplant
Other	Exploratory outcome: change in response to a L-dopa challenge test including measuring the duration and profile of the L-dopa effects between baseline and 36 months; change in AIMS score	For the L-dopa challenge test, participants are given a challenge dose of L-dopa when they are in a practically defined OFF phase. Participants will then perform the Abnormal Involuntary Movement Scale (AIMS) every 30 minutes for up to 120 minutes. A higher score is considered a worse outcome.	36 months post transplant
Primary	The number and nature of adverse events and serious adverse events in the first 12 months following transplantation	Adverse events are recorded from the point of participant informed consent and at every trial visit	12 months following transplantation
Primary	Absence of space occupying masses on cranial MRI in the first 12 months following transplantation	Magnetic resonance imaging (MRI) scans	12 months following transplantation
Secondary	Changes in clinical effects at 36 months following transplantation compared to baseline; emergence of new neurological features,	A physical examination, to include a review of all body systems as per standard practice will be performed to identify any clinical changes. Specifically, any signs of graft-induced dyskinesias (GIDs) will be looked for.	36 months following transplantation
Secondary	Changes in clinical effects at 36 months following transplantation compared to baseline; global cognitive changes assessed using the Montreal Cognitive Assessment (MoCA)	The Montreal Cognitive Assessment (MoCA) is a 30-question test of global cognitive function, which evaluates different types of cognitive abilities, including: orientation, short-term memory, executive function, visuospatial ability, language ability, abstraction, animal naming, and attention. The maximum score is 30 and a score of >26 is considered normal. A higher score is considered a better outcome.	36 months following transplantation
Secondary	Changes in clinical effects at 36 months following transplantation compared to baseline; global cognitive changes assessed using the Hopkins verbal learning task-revised (HVLT-R)	The HVLT-R consists of a 12-item word list, composed of four words each from one of three semantic categories to be learned over the course of three immediate recall learning trials. Participants are also required to undergo a delayed recall trial (requiring free recall of any of the words remembered) and a recognition trial (composed of 24 words, including the 12 target words plus 12 false-positives. A point is given for each correct word and a higher score is considered a better outcome.	36 months following transplantation
Secondary	Changes in clinical effects at 36 months following transplantation compared to baseline; global cognitive changes assessed using semantic (animal naming) fluency	Participants are asked to name as many animals as possible in 90 seconds. One point is scored for admissible response. A higher score considered a better outcome.	36 months following transplantation
Secondary	Changes in clinical effects at 36 months following transplantation compared to baseline; global cognitive changes assessed using the stroop test	The Stroop test is a measure of verbal processing speed and response inhibition, consisting of three timed trials.	36 months following transplantation
Secondary	Changes in clinical effects at 36 months following transplantation compared to baseline; global cognitive changes assessed using the Digit Span test.	Participant is read a list of numbers and asked to repeat the numbers back to the assessor. The lists of numbers gradually gets longer until the participant is unable to remember all of the digits. A backwards span assessment is also completed where the participant is asked to repeat the numbers back in a reverse order.; One point is scores for each verbatim correct repetition. The total Digit Span total score is a sum of all the forwards and backward scores. A higher score is a better outcome.	36 months following transplantation
Secondary	Changes in clinical effects at 36 months following transplantation compared to baseline; global cognitive changes assessed using the Boston naming task.	In the Boston naming task participants are shown a number of images and are asked to say what the image is. This protocol uses a shortened 15-item version (Lansing et al., 1999) designed for use in patients with neurodegenerative disease. One point for every correct response.	36 months following transplantation
Secondary	Changes in clinical effects at 36 months following transplantation compared to baseline; global cognitive changes assessed using the Wechsler Adult Intelligence Scale (WAIS) similarities test	The WAIS similarities assessment includes 14 pairs of words, where participants are asked to name how they are alike or similar. Tests are scored out of 28 and a higher score is considered a better outcome.	36 months following transplantation
Secondary	Changes in clinical effects at 36 months following transplantation compared to baseline; global cognitive changes assessed using the pentagon copying test	In the pentagon copying assessment, participants are asked to copy an intersecting double pentagon figure. Attempts are scored out of a maximum of two points and a higher score is considered a better outcome.	36 months following transplantation
Secondary	Changes in clinical effects at 36 months following transplantation compared to baseline; changes in non-motor and QOL assessments using the Parkinson's Disease Questionnaire 39 (PDQ-39)	The PDQ-39 is a self-rated questionnaire designed to measure PD-related quality of life. It contains 39 questions, covering 8 aspects of quality of life: mobility, activities of daily living (ADL), emotions, stigma, social support, cognition, communication and bodily discomfort. It will be completed by the participant. The total score can be summarised as a percentage, with the score ranging between 0 and 100. A lower scores indicate better health related quality of life.	36 months following transplantation
Secondary	Changes in clinical effects at 36 months following transplantation compared to baseline; changes in non-motor and QOL assessments using the EuroQol five-dimension, 5 level scale (EQ-5D-5L)	The EuroQol five-dimension, 5 level scale (EQ-5D-5L) is a standardised instrument for measuring generic health status in terms of five dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. It will be completed by the participant.; The maximum score of 1 indicates the best health state, by contrast with the scores of individual questions, where higher scores indicate more severe or frequent problems. In addition, there is a visual analogue scale (VAS) to indicate the general health status with 100 indicating the best health status	36 months following transplantation
Secondary	Changes in clinical effects at 36 months following transplantation compared to baseline; changes in non-motor and QOL assessments using the PD non motor symptom scale (NMSS).	The PD NMSS is a 30-point validated scale which is designed to quantify the extent and severity of non-motor symptoms of PD experienced by the patient. It will be completed by the delegated members of the local research team. Higher scores indicate higher severity and frequency of non-motor symptoms.	36 months following transplantation
Secondary	Changes in motor features in the OFF state using the Movement Disorder Society - Unified Parkinson's Disease Rating Scale (MDS-UPDRS)	Specified motor tasks will be performed in both ON and OFF states. For the OFF state, participants will be asked to stop medication at least 12 hours prior to the visit (for L-dopa/COMT inhibitors) or at least 24 hours (for long-acting dopamine agonists/MAO-B inhibitors).; This is a scale which has sections to be completed by the person with PD together with their carers (if appropriate), as well as sections to be completed by the clinician. Part I assesses the non-motor aspects of experiences of daily living in the week prior to the visit. Part II assesses the motor aspects of experiences of daily living in the week prior to the visit. Part III assesses the motor examination of a participant at the time of the visit (including the Hoehn and Yahr stage), and part IV assesses motor complications in the week prior to the visit. Each item will receive a score ranging from 0 to 4, where 0 represents the absence of impairment and 4 represents the highest degree of impairment.	36 months following transplantation
Secondary	Changes in motor features in the OFF state using the nine-hole peg test	Specified motor tasks will be performed in both ON and OFF states. For the OFF state, participants will be asked to stop medication at least 12 hours prior to the visit (for L-dopa/COMT inhibitors) or at least 24 hours (for long-acting dopamine agonists/MAO-B inhibitors).; The nine-hole peg test is used to measure finger dexterity in participants with neurological diagnoses. It is administered by asking the participant to take the pegs from a container, one by one, and placing them into the holes on the board as quickly as possible. Participants must then remove the pegs, one by one, and replace them into the container. Scores are based on the time taken to complete the test activity.	36 months following transplantation
Secondary	Changes in motor features in the OFF state using the timed sit-stand-walk test	Specified motor tasks will be performed in both ON and OFF states. For the OFF state, participants will be asked to stop medication at least 12 hours prior to the visit (for L-dopa/COMT inhibitors) or at least 24 hours (for long-acting dopamine agonists/MAO-B inhibitors).; The timed sit-stand-walk test is used as a measure of lower extremity strength and speed of walking. Participants begin the test sitting in a chair and told to come to a full stand, then walk 6 metres to a defined point, return to the chair and sit down. The time taken to complete this is measured.	36 months following transplantation
Secondary	Changes in motor features in the OFF state using the Hauser patient diary card	Specified motor tasks will be performed in both ON and OFF states. For the OFF state, participants will be asked to stop medication at least 12 hours prior to the visit (for L-dopa/COMT inhibitors) or at least 24 hours (for long-acting dopamine agonists/MAO-B inhibitors).; The Hauser patient diary card is a 24-hour diary, divided into 30-minute sections. This is used to record PD symptoms and how much time is spent in the different motor states (ON without dyskinesia, ON with non-troublesome dyskinesias, ON with troublesome dyskinesias, OFF, or asleep). Participants will be provided with the diary cards prior to attending the visits and asked to complete this for 3 consecutive days. The completed diary cards will then be collected at the relevant visits.	36 months following transplantation
Secondary	Changes in motor features in the OFF state using Parkinson KinetiGraph® (PKG®)	Specified motor tasks will be performed in both ON and OFF states. For the OFF state, participants will be asked to stop medication at least 12 hours prior to the visit (for L-dopa/COMT inhibitors) or at least 24 hours (for long-acting dopamine agonists/MAO-B inhibitors).; The PKG® is a wrist worn accelerometer from Global Kinetics Pty Ltd. The PKG® watch is worn on the most affected side of the body. Registration will be done for 7 consecutive days just before a visit. For the purposes of this trial, the following data will be collected: bradykinesia and dyskinesia index, OFF time (to correlate with the Hauser patient diary card), and registration of intake of anti-PD medications. Participants will be provided with the PKG® prior to attending the visits to complete data collection and will be asked to return the PKG® at the relevant visit.; Once the electronic data is transferred from the device to a computer platform, it is processed to generate data.	36 months following transplantation
Secondary	Changes in motor features in the OFF state using the RUSH dyskinesia scale	Specified motor tasks will be performed in both ON and OFF states. For the OFF state, participants will be asked to stop medication at least 12 hours prior to the visit (for L-dopa/COMT inhibitors) or at least 24 hours (for long-acting dopamine agonists/MAO-B inhibitors).; The RUSH dyskinesia scale is a scale to assess the severity of overall dyskinesias based on interference in activities in daily living, to distinguish chorea from dystonia (the two major types of dyskinesias in PD), and to identify the single most disabling form of dyskinesia. A higher score is considered a worse outcome.	36 months following transplantation
Secondary	Changes in motor features in the OFF state using the Abnormal Involuntary Movement Scale (AIMS)	Specified motor tasks will be performed in both ON and OFF states. For the OFF state, participants will be asked to stop medication at least 12 hours prior to the visit (for L-dopa/COMT inhibitors) or at least 24 hours (for long-acting dopamine agonists/MAO-B inhibitors).; The AIMS is used to quantify dyskinesias in the arms, legs or head, and trunk, which includes items such as facial behaviours (jaw, facial muscles, tongue and lips), full-body behaviours (upper, lower, and trunk), and incapacitation due to these movements. The items are scored from 0 to 4, where 0 is normal/healthy and 4 is severely affected.	36 months following transplantation
Secondary	Changes in motor features in the OFF state using the 30 second tap test	Specified motor tasks will be performed in both ON and OFF states. For the OFF state, participants will be asked to stop medication at least 12 hours prior to the visit (for L-dopa/COMT inhibitors) or at least 24 hours (for long-acting dopamine agonists/MAO-B inhibitors).; The 30 second tap test is a dexterity assessment where the participant is asked to finger tap for 30 seconds. It is tested on both sides, as quickly as possible with the fingers fully open. The number of taps over 30 seconds is registered and the test is performed twice on each hand.	36 months following transplantation
Secondary	Changes in motor features in the OFF state using a challenge test of levodopa	A challenge dose of L-dopa is given, calculated as the participant's average dose (total 24 hours LED/number of dosages per 24 hour period - up to a maximum of 250 mg of L-dopa).; The challenge dose is given after being off standard L-dopa/COMT inhibitors medications for at least 12 hours or at least 24 hours for long-acting dopamine agonists or L-Dopa preparations and for MAO-B inhibitors, i.e. "practically defined OFF phase". Participants are tested after a low protein breakfast, examples of which will be provided to the participants. After taking the challenge dose, participants will wait for 30 minutes and then perform the MDS-UPDRS part III and the AIMS. These two assessments will then be repeated every 30 minutes up to 120 minutes after taking the challenge dose (or longer if needed, until the L-dopa effect has worn off).	36 months following transplantation
Secondary	Change in anti-Parkinson medication as measured by change L-dopa equivalent dose	At every visit during the trial, a review of concomitant medication (including anti-PD medication) will be performed and any changes recorded. Anti-PD medication will be recorded as a LED, and the change in LED will be monitored throughout the trial.	36 months following transplantation
Secondary	Changes in F-DOPA uptake and dopamine transporter (DAT) binding at 36 months on PET imaging with F-DOPA and PE2i compared to PET imaging performed pre-transplant	The screening F-DOPA PET scans will act as the 'baseline' measurement for changes in F-DOPA uptake. The baseline PE2i will act as the 'baseline' measurement for DAT binding. Changes from this baseline measurement up to and including the 36 months post-transplant time point will be recorded.	36 months following transplantation
Secondary	The number and nature of SAEs and AEs in the 12 to 36 months period following transplantation	Adverse events are recorded from the point of participant informed consent and at every trial visit. The difference between this and the primary outcome is that this specifically relates to any safety events reported after the 12 months posttransplant time point.	12 to 36 months period following transplantation

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