Therapeutic potential of adipose-derived stem cell transplantation in amyotrophic lateral sclerosis: A combined clinical case and preclinical study

ABSTRACT

Objectives:

Amyotrophic lateral sclerosis (ALS) is an inevitably fatal neurodegenerative disease with no adequate treatment. Transplantation of adipose-derived stem cells (ADSCs) may be an effective therapeutic strategy for delaying progression or restoring neurological function in ALS.

Materials and Methods:

We evaluated the safety and therapeutic efficacy of intravenous (i.v.) and intracerebral (i.c.) ADSC injection in a late-stage ALS patient and in a SOD1 transgenic (Tg) mouse model. Magnetic resonance imaging (MRI) and computed tomography (CT) were conducted to examine potential cerebral hemorrhage and tumor generation in the treated patient. In addition, maximal inspiratory pressure, maximal expiratory pressure, tidal volume, and respiratory rate were measured as indices of respiratory function.

Results:

ADSC transplantation was safe, with MRI and CT showing no hemorrhage or tumorigenesis up to 12 months. The patient’s Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised score improved from 7 to 9 at 3 months and remained above baseline for 6 months. Respiratory function was preserved during this period. In SOD1 Tg mice, i.c. and i.v. ADSC infusion significantly prolonged survival (165.0 ± 10.4 and 147.3 ± 4.5 days vs. 129.7 ± 3.9 days) and improved motor scores (P < 0.01).

Conclusion:

This preliminary finding suggests potential therapeutic feasibility, but further studies with larger cohorts are needed to confirm its safety and efficacy.

INTRODUCTION

Amyotrophic lateral sclerosis (ALS) was recognized as a distinct clinical entity in the 1860s [1]. ALS is a rare but ultimately fatal progressive neuromuscular atrophy [2,3] that selectively destroys motor neurons in the cortex, brainstem, and spinal cord [4]. Degeneration of motor neurons impairs both voluntary skeletal muscle contractions required for routine activities (such as walking, talking, and food intake) as well as diaphragm movements essential for breathing [5]. Prevalence is currently about 2–5 cases per 100,000 individuals in the United States, Europe, and Asia [6,7]. Patients ultimately die from respiratory failure 2–6 years after onset in most cases [7].

Only about 10% of ALS cases are familial ALS (fALS), whereas 90% or more are sporadic ALS (sALS) [8]. Almost all fALS cases harbor mutations inherited in an autosomal dominant manner. To date, more than 50 potentially causative or disease-modifying genes have been identified, of which the most frequently mutated are SOD1, C9ORF72, FUS, and TARDBP [9]. The accumulation of misfolded superoxide dismutase 1 (SOD1) may contribute to cases of both fALS and sALS [10], and SOD1 mutant mice provide an excellent model to examine the pathological course of the disease as well as to test therapeutic approaches for preventing motor neuron death and preserving muscle function [11].

Among the most promising therapeutic strategies for ALS is the transplantation of pluripotent stem cells (SCs), which are believed to preserve motor neuron function either by supplying appropriate survival factors or by differentiating into replacement cells. Six major SC types have been examined for therapeutic effects in preclinical and clinical studies of ALS: neural SCs, glial progenitor cells, mesenchymal stem cells (MSCs), embryonic SCs, and various induced pluripotent stem cells (iPSCs) [12].

In addition, adipose-derived stem cells (ADSCs) can be differentiated along multiple cell lineage pathways, including mesodermal cell lineages, for therapeutic applications. Further, human ADSCs can be extracted from patients or healthy donors at any age and retain the potential to differentiate into myoblasts, chondroblasts, osteoblasts, and adipocytes [13,14,15]. To date, ADSCs have been tested for regenerative repair in ALS [16]. Such studies have demonstrated the safety and efficacy of these cells for tissue restoration, including in ALS patients, potentially by promoting host cell replacement, secreting neurotrophic factors, immunomodulating, and suppressing neuroinflammation [17].

Here, we examined whether intravenous (i.v.) ADSC injection and intracerebral (i.c.) ADSC transplantation could preserve motor and respiratory function and prolong the survival of a late-stage ALS patient and early-stage SOD1 transgenic (Tg) mice without causing adverse events such as cerebral hemorrhage and tumor formation.

MATERIALS AND METHODS

Isolation and culture of human ADSCs

Adipose tissues were washed with equal volumes of phosphate-buffered saline (PBS) and digested at 37°C with 0.075% collagenase type I (Sigma-Aldrich Co., St. Louis, MO, USA). After 30 min, enzyme activity was neutralized with keratinocyte-SFM (K-SFM) (Gibco, catalog number 10724) containing 5% fetal bovine serum (FBS; Invitrogen, Waltham, MA, USA), and the tissues were filtered through a 100-μm nylon mesh to obtain a single-cell suspension and remove larger debris. Cells were centrifuged for 10 min, resuspended in culture medium (K-SFM supplemented with 5% FBS, 100 U/mL penicillin, 100 μg/mL streptomycin), and seeded at 37°C under a humidified 5% CO₂ atmosphere. Following incubation, cultures were washed with PBS to remove residual non-adherent red blood cells. The remaining cell population, considered the stromal vascular fraction, was harvested and stored frozen in K-SFM containing 5% FBS. For propagation and expansion, cells were thawed and cultured at 37°C in K-SFM plus 5% FBS under a humidified 5% CO₂ atmosphere with medium change every 2 days. Upon reaching 80%–85% confluence, cells were replated with 0.25% trypsin/ethylenediaminetetraacetic acid at 37°C, centrifuged, and resuspended in K-SFM. Cell suspensions were plated in new flasks and cultured as described. After three passages, the cells were examined and used for transplantation.

Recipient medical history

China Medical University approved the use of human ADSCs in this study, and the hospital research ethics committee approved the clinical intervention (study ID number: CMUH103-REC2-072). The study was conducted in accordance with the Declaration of Helsinki and the informed consent was obtained from the case patient (NCT number: NCT02383654). This was a pilot clinical trial of compassionate treatment designed to examine the efficiency of ADSC transplantation for late-stage ALS. The patient, a 46-year-old male with a 10-year history of ALS, received 170 million ADSCs via multiple brain implants during a single surgical procedure and 100 million ADSCs through four separate i.v. infusions [Figure 1 for timeline]. The bilateral i.c. injection sites were (in chronological order) R1 (80.7; 104.8; 92.9), L1 (121.4; 104.1; 95.6), R2 (76.1; 108; 110.4), R3 (82.7; 102.8; 116), L2 (123.6; 108.5; 111.1), and L3 (116.0; 102.9; 117.0).

Figure 1.

Timeline of patient treatment and follow-up. A late-stage amyotrophic lateral sclerosis patient received combined ADSC implantation and four intravenous infusions on the indicated days

Outcome assessment

Follow-up examinations were conducted 1, 6, and 12 months posttreatment and included evaluation of both adverse effects and clinical changes. The safety outcome evaluations included magnetic resonance imaging (MRI) and single-photon emission computed tomography/computed tomography (SPECT/CT), while functional outcome evaluations included the Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised (ALSFRS-R) score, which correlates significantly with quality of life as measured by the Sickness Impact Profile for ALS. Survival prediction was based on the baseline ALSFRS-R score [18]. Respiratory function was evaluated by measuring maximal inspiratory pressure (PiMax), maximal expiratory force (PeMax), the volume of air moved into or out of the lungs during each breath (tidal volume [TV]), respiratory rate (RR), rapid shallow breathing index (RSBI), and minute ventilation (MV) [19].

Animal breeding and care

Tg mice expressing human SOD1 with the G93A mutation (Tg [SOD1^G93A]) were used as the model to test the efficacy of ADSC infusion for reducing the motor deficits of ALS. Briefly, male B6SJL-Tg (SOD1*G93A) 1Gur/J (#002726) Tg mice obtained from Jackson Laboratory (Bar Harbor, ME, USA) were bred with C57BL6x SJL hybrid females to establish a breeding colony of homozygous Tg (SOD1^G93A) mice on a B6SJL background. Mice were housed under a 12 h–12 h light–dark cycle with free access to food and water.

Transplantation of human ADSCs into amyotrophic lateral sclerosis transgenic mice

Animal experiments were approved by the China Medical University Institutional Animal Care and Use Committee (number: 104-193-N). Tg mice were randomly divided into three experimental groups: (1) an untreated control group (n = 7), (2) an ADSC i.v. injection group (n = 7) receiving ADSC infusion (1 × 10⁶ cells in 150 μL PBS via the orbital vein) once per week for 4 consecutive weeks, and (3) an ADSC i.c. transplantation group receiving transplanted ADSCs (2 × 10⁶ cells in 30 μL PBS) at 0.58 mm posterior, 1.67 mm lateral, and 2.6 mm ventral from bregma. All injections were conducted using a 25-μL Hamilton Gastight syringe (Hamilton, Reno, NV, USA) attached to a 26-gauge needle.

Survival analysis

To determine the effect of ADSC transplantation on mouse lifespan, the survival rates of each treatment group were calculated as the percentage of the original group numbers and compared by constructing Kaplan–Meier survival curves.

Motor function assessment

Open field locomotion scores were obtained daily in a small enclosure using the 21-point Basso–Beattie–Bresnahan (BBB) locomotor rating scale with minor alterations. In brief, each Tg mouse was allowed to walk freely for 5 min in a cage, whereas hind limb movements were evaluated using a 21-point scoring scale from no activity (0) to normal motion (21). The scoring scale considered paw rotation, toe clearance, weight support, and movement of each joint [20].

Statistical analysis

Data were analyzed using two-way analysis of variance (ANOVA), followed by Tukey’s post hoc test to assess differences among treatment groups and time points. Survival data were evaluated using the Kaplan–Meier method with log-rank testing. All results are expressed as mean ± standard error of the mean, and P < 0.05 was considered statistically significant.

RESULTS

Efficacy and safety of ADSC transplantation for late-stage amyotrophic lateral sclerosis

Clinical trial design

This pilot clinical trial was approved by the Institutional Review Board of China Medical University Hospital, Taiwan, in 2014. The patient was treated by combined i.c. and i.v. infusion of autologous ADSCs as illustrated in Figure 1.

Safety outcomes

Safety outcomes were evaluated following ADSC infusion by brain MRI and CT [Figure 2]. MRI acquired 1 month and 6 months postinfusion/transplantation and CT scans acquired at 12 months postinfusion/transplantation revealed no signs of acute tissue damage or tumorigenicity. Indeed, there were no obvious differences in brain images after treatment compared to baseline [Figure 2].

Figure 2.

Surgical procedures for combined infusion and intracerebral (i.c.) transplant of ADSCs to treat a patient with late-stage amyotrophic lateral sclerosis and subsequent perioperative safety evaluation by computed tomography (CT) and magnetic resonance imaging (MRI), and long-term follow-up. (a) Craniotomy. (b) Preparation of ADSCs for injection or transplantation. (c) i.c. transplantation with stereotaxic guidance. (d) Cell transplant locations (two-dimensional). (e) Perioperative CT and MRI. Neither CT (left panels) nor MRI (right panels) showed signs of brain hemorrhage immediately after transplantation. (f-h) Magnetic resonance images of the patient’s brain were acquired in the coronal plane at baseline (f), 30 days posttransplant (g), and 6 months posttransplant (h). (i) CT images of the patient’s brain were acquired in the coronal plane 12 months posttransplant. There were no signs of focal tissue damage, hemorrhage, or tumorigenesis. CT: Computed tomography, MRI: Magnetic resonance imaging

Longitudinal assessment of respiratory function following ADSC transplantation in a late-stage amyotrophic lateral sclerosis patient

Table 1 presents the changes in respiratory function over 12 months following adipose-derived stem cell (ADSC) transplantation in a late-stage ALS patient. Initially, Pimax declined from −5 to a nadir of −16 cmH₂O by day 44, then gradually improved to −3.8 cmH₂O by day 282, indicating partial recovery. Maximal expiratory pressure (Pemax) showed an early peak (14 cmH₂O at day 60) before declining to 4.6 cmH₂O by day 366. TV remained relatively stable early on (450–476 mL) but decreased significantly thereafter. RR peaked at 36 breaths/min on day 282 before declining. The RSBI rose markedly from 40 to a peak of 214, reflecting worsening respiratory efficiency, while MV peaked at 10.94 mL on day 60 before tapering off. These findings suggest initial stabilization or mild improvement in respiratory function within the first 2–3 months posttreatment, followed by gradual functional decline consistent with disease progression.

Table 1.

Respiratory functions following adipose-derived stem cells transplantation into an amyotrophic lateral sclerosis patient

Respiratory functions	Day 0	Day 28	Day 44	Day 60	Day 180	Day 282	Day 366
Pimax (cmH2O)	-5	-15	-16	-9	-6	-3.8	-3.8
Pemax (cmH2O)	10	10	7	14	8	7.4	4.6
TV (mL)	450	465	172.5	476	342	168	160
RR (times/min)	18	20	8	23	27	36	15
RSBI (breaths/min/L)	40	43	46.3	48	79	214	93.75
MV (mL)	8.1	9.3	1.38	10.94	9.23	6.06	2.4

TV: Tidal volume, RR: Respiratory rate, RSBI: Rapid shallow breathing index, MV: Minute ventilation, PiMax: Maximum inspiratory pressure, PeMax: Maximum expiratory pressure

Temporal trends in respiratory function after ADSC transplantation in a late-stage amyotrophic lateral sclerosis patient

Supplementary Figure 1 ^{(102.2KB, tif)} illustrates the longitudinal changes in key respiratory parameters following ADSC transplantation in a late-stage ALS patient. (A) PiMax initially declined sharply but progressively improved from day 44 to day 282, maintaining at −3.8 cmH₂O. (B) PeMax peaked at 14 cmH₂O on day 60 before gradually declining to 4.6 cmH₂O by day 366. (C) TV showed early fluctuation, briefly dropping at day 44, then gradually declined over the year. (D) RR increased steadily, peaking at 36 breaths/min at day 282, followed by a decline to 15 by day 366. These trends suggest short-term stabilization of respiratory function followed by progressive deterioration, consistent with ALS progression.

Motor functional outcomes

The patient’s (Guo XX) ALSFRS-R score was 17 points (well below the normal function score of 40) 1 year before the intervention and 7 immediately before the intervention, indicating rapid disease progression. After the intervention, however, the total ALSFRS-R score actually rose to 9 points by 3 months before declining to 5 by 12 months [Table 2 and Supplementary Figure 2 ^{(60.1KB, tif)} ]. A previous study found that an ALSFRS-R score of seven was associated with a 9-month survival rate of about 10%, so this 1-year survival was unlikely without treatment.

Table 2.

Changes in Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised score following adipose-derived stem cells transplantation

ALSFRS	Day 0	Day 28	Day 44	Day 60	Day 180	Day 282	Day 366
Speech	2	3	3	3	2	2	2
Salivation	3	3	3	3	3	2	1
Swallow	0	0	0	0	0	0	0
Writing	1	1	2	2	1	1	1
Feeding	0	0	0	0	0	0	0
Dressing	0	0	0	0	0	0	0
Turning	0	0	0	0	0	0	0
Walking	1	1	1	1	1	0	1
Climbing	0	0	0	0	0	0	0
Breathing	0	0	0	0	0	0	0
Total	7	8	9	9	7	5	5

ALSFRS: Amyotrophic Lateral Sclerosis Functional Rating Scale

Effects of ADSC transplantation on the motor function and lifespan of amyotrophic lateral sclerosis transgenic mice

As shown in Figure 3a, the experimental protocol outlines the timeline and administration routes of ADSCs, including i.c. and i.v. infusions in B6SJL-Tg (SOD1*G93A) 1Gur/J mice. The survival curves in Figure 3b demonstrate that both i.c. and i.v. ADSC treatments significantly prolonged lifespan compared with untreated Tg mice. Mice receiving i.c. ADSCs survived the longest (165.0 ± 10.4 days), followed by the i.v. group (147.3 ± 4.5 days), whereas untreated Tg mice showed the shortest lifespan (129.7 ± 3.9 days). Log-rank testing confirmed significant survival differences among the three groups (P < 0.01). As shown in Figure 3c, both treatment groups exhibited improved motor function compared with untreated Tg mice, with the i.c. group maintaining higher BBB scores throughout the observation period. A two-way ANOVA followed by Tukey’s post hoc test further confirmed the significant group and time effects. Collectively, these findings indicate that ADSC infusion, particularly via the i.c. route, effectively delays disease progression, preserves motor function, and extends survival in the ALS mouse model.

Figure 3.

Intracerebral (i.c.) and intravenous (i.v.) administration of adipose-derived stem cells (ADSCs) improved motor performance and survival in B6SJL-Tg (SOD1*G93A) 1Gur/J mice compared to untreated transgenic (Tg) controls. (a) Schematic timeline of ADSC infusion protocols. Mice in the i.v. group received four i.v. injections starting 60 days after birth, while the i.c. group received a single i.c. injection at the same age. (b) Kaplan–Meier survival curves showing extended lifespan in both i.v. and i.c. groups relative to untreated Tg mice. Log-rank testing confirmed significant survival differences among the three groups (P < 0.01). (c) Basso–Beattie–Bresnahan locomotor scores demonstrating improved motor function in ADSC-treated mice. Data are presented as mean ± standard error of the mean. *P < 0.05, **P < 0.01, ***P < 0.001 versus untreated group. i.c.: Intracerebral, i.v.: Intravenous, BBB: Basso–Beattie–Bresnahan

DISCUSSION

This pilot clinical trial, conducted in 2014, investigated the safety and efficacy of combined i.c. and i.v. autologous ADSC transplantation in a patient with late-stage ALS. Serial MRI and CT scans up to 12 months posttreatment revealed no signs of hemorrhage or tumorigenesis, confirming procedural safety. Respiratory function was temporarily stabilized, with PiMax improving from a nadir of −16 to −3.8 cmH₂O and expiratory pressure peaking at 14 cmH₂O by day 60. TV and MV initially improved but gradually declined, indicating a transient benefit. ALSFRS-R scores rose from 7 to 9 at 3 months postintervention before declining to 5 by 1 year, suggesting delayed motor deterioration. In a parallel SOD1 Tg mouse model, both i.v. and i.c. ADSC administration significantly improved motor function and extended survival (165.0 ± 10.4 days and 147.3 ± 4.5 days vs. 129.7 ± 3.9 days; P < 0.05), supporting translational therapeutic potential. Overall, ADSC transplantation demonstrated short-term functional benefits and safety in late-stage ALS.

SC therapy has emerged as a promising approach for treating ALS, a neurodegenerative disease affecting motor neurons [21]. MSCs have shown potential benefits in ALS rodent models, delaying disease progression and partially restoring motor function [22]. Clinical trials have demonstrated the safety and feasibility of MSC transplantation in ALS patients, although only partial improvements have been observed [22]. Other SC types, including neural SCs and iPSCs, are also being investigated for ALS treatment [23]. While SC therapy shows promise, challenges remain, including determining optimal treatment windows, cell types, doses, and delivery methods [21]. Future research should focus on well-designed, randomized, double-blinded, and sham-controlled clinical trials to establish the efficacy of SC therapy for ALS [24]. In the current study, we used 1.7 × 10⁸ ADSCs i.c. transplantation (one time on day 30) and 1 × 10⁸ ADSCs for four times of i.v. injections (two times before i.c.: day 0 and 14, and two times after i.c.: day 61 and 75).

Recent studies have explored the safety and efficacy of SC therapy for ALS. Multiple trials have demonstrated that bone marrow-derived MSC transplantation is generally safe, with no serious adverse reactions reported [25]. Some studies have shown temporary stabilization or improvement in ALSFRS-R scores and forced vital capacity following treatment [25]. However, results are mixed, with some trials finding no significant difference compared to control groups [26]. Various administration routes have been investigated, including intrathecal and i.v. injections [25], as well as intraspinal injections [27]. While SC therapy shows promise, more rigorous clinical trials are needed to fully assess its efficacy in treating ALS [26]. We also demonstrated the efficacy and safety of ADSC treatment, as evidenced by improved ALSFRS-R scores and preserved respiratory function in the treated patient. Importantly, no hemorrhage or tumor formation was observed following ADSC transplantation.

Recent studies suggest that ADSCs show promise as a treatment for ALS. ADSCs have demonstrated potential for neuronal repair, secretion of growth factors, and homing to injury sites [28]. Clinical trials have shown the safety of ADSC infusions and positive long-term outcomes in ALS patients, including improved ALSFRS scores and increased survival time [29,30]. In one case study, a patient receiving multiple ADSC infusions showed symptom improvement and survived for over 10 years postonset [30]. Animal studies using SOD1G93A mice, an ALS model, have demonstrated delayed disease onset, immunomodulation, and increased lifespan following i.v. injection of human ADSCs [31]. We also confirmed the therapeutic efficacy of ADSC treatment in the SOD1 Tg mouse model, with improvements in motor function and extended survival. These findings support the potential of ADSC therapy for ALS treatment, warranting further investigation through rigorous clinical trials.

The transient improvement observed in motor function, followed by a decline after approximately 60 days, may be explained by the short-lived nature of ADSC activity. ADSCs are known to exert their therapeutic effects primarily through paracrine signaling rather than long-term engraftment or neuronal replacement [32]. They secrete a range of neurotrophic, anti-inflammatory, and immunomodulatory factors that modulate the local microenvironment, reduce oxidative stress, and support neuronal survival [33]. However, these bioactive factors typically persist for only a limited duration, ranging from several weeks to a few months, after administration [34]. In the absence of repeated or sustained dosing, their concentration and biological activity decline over time, resulting in a gradual loss of therapeutic benefit [34]. Therefore, the decline in functional performance observed after 60 days in this study likely reflects the exhaustion of these transient paracrine effects, underscoring the potential need for repeated ADSC administration or sustained delivery systems to maintain long-term efficacy.

ADSCs may exert their therapeutic effects through multiple mechanisms that converge on neuroprotection and modulation of the disease microenvironment [34]. Rather than replacing damaged neurons directly, ADSCs act primarily via paracrine secretion of bioactive molecules, including neurotrophic factors (e.g., BDNF, GDNF, and VEGF), anti-inflammatory cytokines, and antioxidative enzymes, which collectively attenuate neuroinflammation, reduce oxidative stress, and promote motor neuron survival [35,36]. These mechanisms help stabilize neuromuscular function and delay disease progression in ALS models. Moreover, the timing of intervention appears to be critical for therapeutic efficacy [37,38]. Early-stage administration, when motor neurons remain partially functional, may maximize the benefits of trophic and immunomodulatory support, whereas late-stage treatment is less effective due to extensive neuronal loss and irreversible degeneration [39,40]. Therefore, optimizing both the mechanistic targeting and timing of ADSC delivery could be key to improving clinical outcomes in future studies.

Strengths and limitations

This study provides translational evidence supporting the safety and potential efficacy of combined i.v. and i.c. ADSC transplantation in a late-stage ALS patient, supplemented by parallel findings in a well-established SOD1 Tg mouse model. The integration of comprehensive imaging (MRI and CT) confirmed long-term procedural safety, with no evidence of hemorrhage or tumorigenesis up to 12 months posttreatment. Functional outcomes – including ALSFRS-R scores and respiratory metrics – were longitudinally monitored, offering objective, real-time insight into therapeutic response. The inclusion of both clinical and preclinical data enhances the robustness of the findings and demonstrates consistency across species, reinforcing the therapeutic relevance of ADSCs for neurodegenerative diseases.

The limitations of the study include, as a single-patient pilot study, the clinical results are inherently limited in generalizability and cannot exclude the possibility of placebo effects or natural variability in disease progression. The absence of a control group or blinding limits the ability to attribute observed functional improvements solely to ADSC treatment. In addition, while the transient stabilization of motor and respiratory function is encouraging, the long-term efficacy remains unclear given the gradual decline after 3–6 months. Preclinical findings, although statistically significant, were limited to one ALS mouse model and require replication across diverse genetic backgrounds and delivery protocols. A limitation of this study is the relatively small sample size of mice (n = 7), which may reduce the statistical power of the results. Another limitation of this study is the absence of additional control groups, such as vehicle-treated or wild-type mice, which would help distinguish treatment-specific effects of ADSCs from procedural or background influences.

CONCLUSION

This study demonstrates that combined i.c. and i.v. transplantation of autologous ADSCs is a safe and potentially beneficial therapeutic strategy for late-stage ALS. In the treated patient, the intervention resulted in temporary stabilization of respiratory and motor functions, with no adverse effects observed on imaging up to 12 months. Parallel experiments in SOD1 Tg mice further supported the efficacy of ADSCs in improving motor function and prolonging survival. While these findings are promising, larger controlled clinical trials are needed to validate the therapeutic value and durability of ADSC-based interventions in ALS.

Data availability statement

All data generated or analyzed during this study are included in this published article and its supplementary information files.

Conflicts of interest

Dr. Dah-Ching Ding, an editorial board member at Tzu Chi Medical Journal, had no role in the peer review process of or decision to publish this article. All authors declared no conflicts of interest in writing this paper.

SUPPLEMENTARY MATERIAL

Supplementary Figure 1

Longitudinal Changes in Respiratory Function Following ADSC Transplantation in a Late-Stage Amyotrophic Lateral Sclerosis Patient. (a) Maximal inspiratory pressure (PiMax), (b) Maximal expiratory pressure (PeMax), (c) Tidal volume (TV), and (d) Respiratory rate (RR) were measured at multiple time points up to 366 days after combined intravenous and intracerebral adipose-derived stem cell (ADSC) transplantation. PiMax showed gradual improvement after an initial drop, while PeMax peaked at day 60 before declining. TV decreased progressively after transient stabilization. RR increased until day 282 and declined thereafter. These results indicate transient respiratory stabilization post-treatment, followed by a gradual decline associated with disease progression. PiMax: Maximal inspiratory pressure, PeMax: Maximal expiratory pressure

Supplementary Figure 2

Changes in total amyotrophic lateral sclerosis functional rating scale-revised score during the pre- and post-transplantation period. The intervention reversed the downward trajectory of motor function with disease progression. ALSFRS-R: Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised

Funding Statement

This work was supported by the National Science Council (MOST 104-2314-B-309-019-MY3), Buddhist Tzu Chi Medical Foundation (grant number: TCMF-EP 110-02; TCMMP 112-01-01; TCMF-MP 113-01-02), and China Medical Hospital.