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1 Recombinant Human TFAM Stimulates Rat Brain, Rat Cervical Spinal Cord and Human Neural Stem Cell Mitochondrial Bioenergetics Ravindar R. Thomas 1, *, Paula M. Keeney 1,8, *, Stuart B. Berr 2 , Shaharyar M. Khan 3 , Francisco R. Portell 3 , Meiram Zh. Shakenov 4 , Patrick F. Antkowiak 2 , Bijoy Kundu 2 , Nicholas Tustison 2 , David G. Brohawn 1,7 , James P. Bennett, Jr. 1,5,6,8 1 Parkinson’s Center, Virginia Commonwealth University, Richmond, VA 2 University of Virginia Department of Radiology, Charlottesville, VA 3 Gencia Corporation, Charlottesville, VA 4 Department of Science and Education Republican Children's Rehabilitation Center, Astana, Kazakhstan Departments of 5 Neurology, 6 Physiology and Biophysics, and 7 Human Genetics, Virginia Commonwealth University, Richmond, VA 8 Current Address: Neurodegeneration Therapeutics, Inc., Charlottesville, VA * These authors contributed equally to this work. Correspondence: James P. Bennett, Jr. M.D., Ph.D. Neurodegeneration Therapeutics, Inc. 3050A Berkmar Drive Charlottesville, VA 22901 434-529-6457 (PH) 434-529-6458 (FAX) www.NDTherapeutics.org [email protected]

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Recombinant Human TFAM Stimulates Rat Brain, Rat Cervical Spinal Cord and

Human Neural Stem Cell Mitochondrial Bioenergetics

Ravindar R. Thomas1,*, Paula M. Keeney1,8,*, Stuart B. Berr2, Shaharyar M. Khan3,

Francisco R. Portell3, Meiram Zh. Shakenov4, Patrick F. Antkowiak2, Bijoy Kundu2,

Nicholas Tustison2, David G. Brohawn1,7, James P. Bennett, Jr.1,5,6,8

1 Parkinson’s Center, Virginia Commonwealth University, Richmond, VA

2 University of Virginia Department of Radiology, Charlottesville, VA

3 Gencia Corporation, Charlottesville, VA

4 Department of Science and Education

Republican Children's Rehabilitation Center, Astana, Kazakhstan

Departments of 5 Neurology, 6 Physiology and Biophysics, and 7Human Genetics,

Virginia Commonwealth University, Richmond, VA

8 Current Address: Neurodegeneration Therapeutics, Inc., Charlottesville, VA

* These authors contributed equally to this work.

Correspondence: James P. Bennett, Jr. M.D., Ph.D. Neurodegeneration Therapeutics, Inc. 3050A Berkmar Drive Charlottesville, VA 22901 434-529-6457 (PH) 434-529-6458 (FAX) www.NDTherapeutics.org [email protected]

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Abstract

To develop a treatment for human mitochondrial diseases, we engineered a

recombinant human mitochondrial transcription factor A (rhTFAM) that enters brain

mitochondria of animals, rapidly localizes to mitochondria of human cells and increases

mitochondrial respiration and OXPHOS capacity in human cells and animals. As part of

developing rhTFAM for use in humans, we treated rats with single or weekly i.v. injections

of highly purified rhTFAM protein and assayed brain [18F]fluorodeoxyglucose (FDG) uptake

by PET scan, forebrain mitochondrial states 3 and 4 respiration, forebrain and cervical

spinal cord mitochondrial respiratory gene expression and forebrain and cervical spinal

cord OXPHOS protein levels. rhTFAM treatments increased mitochondrial OXPHOS

function in brain and spinal cord. Total brain FDG uptake did not change, but the rate of

FDG uptake appeared to increase in the rhTFAM treated animals. Human neural stem cells

(NSC’s) exposed to 5 nM rhTFAM and analyzed by RNA-seq showed increased expression

of mitochondrial respiratory genes. 3-D gene expression visualization (Miru®) followed by

protein interaction network analysis (STRING) revealed enrichment after rhTFAM in mRNA

splicing and ribosome functions. Ingenuity Pathways Analysis showed significant over-

representation in E2F/E2F1 signaling that can modulate mitochondrial gene expression.

rhTFAM treatment could overcome mitochondrial bioenergetic deficits reported in various

human neurodegenerative conditions as well as in many “mitochondrial” diseases affecting

multiple organ systems and may use E2F signaling. (219 words).

Keywords: mitochondria, respiration, brain, spinal cord, neural stem cells, TFAM, FDG-PET

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1. Introduction

Life on Earth as we know it, in an oxygen-rich atmosphere would not be possible

without energy production by mitochondria, bacterial remnants who appeared to have

invaded early eukaryotic cells during an “endo-symbiotic” event that occurred 2-3 billion

years ago [1-5]. Mitochondria provide needed energy for differentiated tissues necessary

for complex life forms, and in addition to this critical role, control intracellular calcium

signaling [5] and initiation of cell death programs [6].

Mitochondrial density within cells varies with cellular energy demands and is

maintained by processes collectively referred to as “mitochondrial quality control”. These

include mitochondrial biogenesis (mitobiogenesis) [7, 8]) and mitochondrial removal

(mitophagy) [9, 10]), which must be balanced in order for cells to function properly.

Mitobiogenesis, in turn, depends on the coordinated expression of multiple transcription

factors that regulate respiratory gene expression (both nuclear and mitochondrial) and

replication of the mitochondrial genome needed for successful mitochondrial division [7, 8,

11, 12].

Mitochondrial transcription factor A (TFAM) is an essential downstream component

of the mitobiogenesis system, and genetic TFAM deletion is embryonic lethal [13-16].

Several years ago we described the mitobiogenesis effects of recombinant human TFAM

(rhTFAM) that we synthesized by incorporating a rapidly translocating protein transduction

domain (PTD, 11-arginines), followed by a mitochondrial matrix localization signal (MLS,

human SOD2), followed by the complete coding sequence of human TFAM [17]. We

showed that i.v. treatment with the resulting rhTFAM stimulated motor activity and brain,

skeletal muscle and cardiac mitochondrial respiration in both young and old adult mice, and

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stimulated mitobiogenesis and respiration in a variety of human cells in culture [18-21]. I.V.

rhTFAM also entered brain mitochondria and declined with a half-life of ~24-30 hrs [19].

As a result of these encouraging findings, we embarked on further pre-clinical

studies to develop rhTFAM for use in humans with mitochondrial bioenergetic deficiencies.

Essential components of these preclinical studies include demonstrations of target

engagement, signs of therapeutic activity and toxicity in experimental animals. For a

biologic therapeutic such as rhTFAM, which is a protein, the human biologic must be tested

in experimental animals, even though construction of and experimenting with animal

homologues might yield scientifically more interpretable data about TFAM actions within

mitochondria. For these reasons we tested rhTFAM in rats, even though only 146/246=59%

of amino acid residues are identical between human and rodent TFAM’s.

In the current study we used an even more highly purified rhTFAM protein than in

our earlier studies [17-19, 22-24] and extended these observations into rat forebrain and

cervical spinal cord. We initiated mechanistic studies of rhTFAM-stimulated mitobiogenesis

by exposing human neural stem cells to rhTFAM, using RNA sequencing (RNA-seq) to

define a threshold [rhTFAM] needed to stimulate mitochondrial respiratory gene expression

and develop preliminary network analyses of rhTFAM-induced gene co-expression and

protein interactions. We observed that rhTFAM treatment was free of observable toxicity,

stimulated mitochondrial functions in rat CNS and increased respiratory gene expression in

human NSC’s. These findings suggest that rhTFAM could be used to treat mitochondrial

bioenergetic deficiencies reported in adult neurodegenerative diseases and many

“mitochondrial diseases” characterized by impaired mitobiogenesis or abnormalities in

nuclear and/or mitochondrial genome-encoded proteins.

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2. Results

2.1 Acute single dose effects of rhTFAM on rat cortex and cervical spinal cord

Treatment of adult rats with a single i.v. dose of rhTFAM increased cortical

mitochondrial respiration that was greatest at 3 mg/kg dose and 24 hours after injection

(Figure 1). We did not test higher doses of rhTFAM in rats. A time course of changes in

total forebrain respiration in rats treated with 3 mg/kg i.v. rhTFAM showed highest State 3

respiration at 24 hours compared to other times after injection (Figure 2).

Because cervical spinal cord samples were limited in weight, we elected to not

assay mitochondrial respiration in spinal cord samples and instead focused on molecular

genetic studies of mtDNA-encoded gene expression. Figure 3 shows that in rat cervical

spinal cord samples, a single injection of rhTFAM increased expression of mtDNA genes

many-fold with ~equivalence at 3 compared to 7 days after injection.

2.2 Effects of multiple weekly dose of rhTFAM on rat forebrain and cervical spinal cord

mitochondrial bioenergetics

Because we are developing rhTFAM for use in human diseases characterized by

impaired CNS bioenergetics, we wished to characterize the effects of repeated rhTFAM

treatments on CNS mitochondrial function. Accordingly, we treated adult rats with 3 mg/kg

i.v. rhTFAM every week for 4 weeks (5 injections total) and assayed forebrain mitochondrial

respiration 24 hrs after the last rhTFAM injection. Because rhTFAM has a brain half-life of

~24-30 hours [19], we appreciate that this dosing schedule will not likely produce a

constant brain [rhTFAM]. However, this dosing schedule is more realistic clinically with

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humans who would receive i.v. rhTFAM. Figure 4 shows that repeated weekly rhTFAM

treatment produced a small 10-20% increase in brain mitochondrial respiration at all

respiratory complexes. The increase was significant when analyzed by matched pair 2-way

ANOVA across treatment, but no individual rat brain respiratory complexes had a

significant elevation after rhTFAM treatment compared to buffer CTL.

One month of rhTFAM injection every week also produced small elevations in

nuclear genome-encoded respiratory gene expression analyzed by SABioscience gene-

specific primer plates (Figure 5). By 2-way ANOVA rhTFAM produced a significant

elevation in Complex I and Complex IV nuclear respiratory gene expressions, but not

significant changes in nuclear gene expressions for Complexes II, III and V. We did not find

any significant increases after weekly rhTFAM treatment in forebrain OXPHOS protein

levels (not shown)

In contrast to the relatively small effects of weekly rhTFAM treatments on brain

mitochondrial bioenergetics, we found greater effects on cervical spinal cord. As shown in

Figure 6, weekly rhTFAM treatment produced greater and more significant increases in

cervical spinal cord nuclear mitochondrial gene expression (Figure 6) and increases in

representative OXPHOS proteins assayed by Western blot (Figure 7).

2.3 FDG PET Imaging

We divided the brain into 78 regions based on the publicly available Waxholm Space atlas

for Sprague Dawley rats. Using the static FDG PET images acquired 40 minutes after FDG

injection (Fig. 8), there were no statistically significant differences measured between the

rhTFAM treated versus control rats for any combination of different timepoints after rhTFAM

treatment (not shown). While there was not a difference in the overall uptake of FDG at the

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40 minute timepoint, there was a statistically significant difference in the rate at which the

FDG was taken up in the cells. Figure 9 shows the differences in the mean uptake values

for FDG at 5 minute intervals over the first 30 minutes after the injection of FDG for rhTFAM

treated rats (N=3) and control rats (N=2).

2.4 rhTFAM effects on Gene Expression in Human Neural Stem Cells

For 24 hours we exposed to 1nM or 5nM rhTFAM (or buffer) four independent

cultures of human neural stem cells we made from a 62 y.o. clinically normal male subject’s

peripheral blood mononuclear cells (PBMC). His PBMC’s were reprogrammed to iPSC’s by

electroporation of a 5-gene reprogramming plasmid [25], then neuralized as described

[26]. Following rhTFAM incubation we extracted total RNA, constructed sequencing

libraries, quantitated the libraries, then carried out multiplex paired-end RNA sequencing

using Illumina NextSeq® technology. For bioinformatic processing we used

tophat2/bowtie2 for aligning against the hg38 human genome or ENCODE human

mitochondrial genome, and quantitated gene expression using Cufflinks2.

Figure 10 shows the relationship among >20,000 gene pairs’ FPKM values in human

NSC’s in culture compared to those from averaged CTL human cervical spinal cord

sections (n=8). There was a good correlation among these gene pairs, with the greatest

scatter occurring at lower FPKM values.

Figure 11 shows that the baseline mitochondrial gene expression in the human

NSC’s was qualitatively similar to that found in CTL human cervical spinal cord sections

(n=8; Brohawn, et al, in preparation). In both groups expression levels of the two

mitochondrial rRNA’s (12S and 16S) were >20-fold higher than the highest expression level

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of any mitochondrial respiratory genes, consistent with separate transcriptional start sites in

the heavy chain of mtDNA for the 12S and 16S rRNA genes. We also found substantial

variation in expression levels of the 13 mitochondrial respiratory genes, which is puzzling,

given the current concept of single polycistronic transcription for the 13 respiratory genes

(12 from heavy chain and 1 from light chain of mtDNA). If mitochondrial protein-coding

genes are transcribed initially at ~equal levels, then our data suggest that RNA stability

varies significantly in mitochondria.

Figure 12 shows that 5 nM rhTFAM is close to a threshold [rhTFAM] for increasing

respiratory gene expression in human NSC’s. We found that 5 nM rhTFAM incubation for

24 hrs significantly increased in human NSC’s expression of ND1, ND2, ND3, CO1, CO2,

ATP6 and ATP8 determined by t-tests corrected for multiple comparisons using Holm-

Sidak method with alpha=0.05.

We then carried out 3-D visualization of gene expression in human NSC’s exposed

to 5 nM rhTFAM compared to buffer CTL. We first filtered for FPKM values >5 to reduce

noise, then calculated for each gene the expression ratio of the averaged FPKM values

after 5 nM rhTFAM divided by the averaged FPKM values for that gene from cells exposed

to buffer. We took the top 500 genes from this ratio and used Miru® (version 1.3) at high

initial correlation (Spearman r=0.9) to construct 3-D gene co-expression networks, using

the FPKM values for the rhTFAM treated cells.

Figure 13 shows the resulting 3-D gene expression network. There were two

clusters (1 and 2) that together accounted for the majority of the 500 genes. The individual

genes from each of these clusters was then analyzed for protein interactions in STRING

(www.string-db.org), yielding Figures 14 (Miru® cluster 1) and 15 (Miru® cluster 2). The

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protein clusters revealed by the STRING algorithm, when analyzed in DAVID (Database for

Analysis, Visualization and Discovery), showed very significant enrichment in processes

related to mRNA synthesis, splicing, and ribosomal function (Supplemental Table 1).

Table 1 shows the results we obtained from Ingenuity Pathways Analysis (IPA) pf

the top 500 genes used to construct Figures 13 and 14. Top canonical pathways

represented include those associated with the general transcription factor Elf2 and energy

metabolism (creatine phosphate synthesis). Top upstream regulators identified included the

mitochondrial protease LONP1 and the cell cycle regulators E2F and E2F1, both of which

have recently been shown also to control mitochondrial gene expression and mitochondrial-

mediated apoptosis [27, 28].

Thus, we found that rhTFAM, an engineered protein that localizes to mitochondria,

both appears to stimulate mitochondrial gene transcription, a process known to be

regulated by TFAM, and activates clusters of expressed genes whose proteins are involved

in critical non-mitochondrial cellular events such as mRNA splicing and protein translation

in ribosomes possibly using E2F/E2F1 signaling. How mitochondrially localized rhTFAM

brings about these non-mitochondrial cellular events is not clear and is the focus of future

studies.

3. Discussion

In the present study we treated adult rats with recombinant human TFAM (rhTFAM)

and observed increases in mitochondrial bioenergetic markers and stimulation of

mitochondrial biogenesis in forebrain (to a small extent) and cervical spinal cord (to a much

larger extent). Weekly i.v. rhTFAM treatment appeared to be non-toxic to the animals. We

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did not assay motor function as in prior studies done in adult young and old mice, where

rhTFAM treatment increased motor activity and stimulated mitobiogenesis and respiration

in both age groups of mice [19, 22].

Human TFAM is ~60% identical with rat and mouse TFAM (MacVector®, ClustaW

sequence alignment tool. Supplemental Figure 1). Given these limited identities with rodent

TFAM’s it is remarkable that any mitochondrial bioenergetic effects are observed in rodents

with the human protein that is being developed as a therapeutic for use in man.

The maximum doses used in our rat study were 3 mg/kg i.v. According to the

document “Guidance for Industry-Estimating the Maximum Safe Starting Dose in

Initial Clinical Trials for Therapeutics in Adult Healthy Volunteers” published by the US

Food and Drug Administration, 3 mg/kg in rats is equivalent to 0.48 mg/kg in humans. For

the typical 70 kg human subject, this would correspond to a dose of 33.6 mg rhTFAM.

rhTFAM has not yet been administered to humans, so we do not know about its

pharmacodynamic actions on mitochondrial function.

We observed significant bioenergetic effects of increased mitochondrial gene

expression and OXPHOS proteins in rat cervical spinal cords following weekly treatment

with rhTFAM. This was not commensurate with an increase in total brain uptake of glucose

(as measured by FDG PET), but it did seem to correlate with an increase in the rate of

glucose uptake. Because we have reported that human amyotrophic lateral sclerosis (ALS)

spinal cord sections and peripheral mononuclear cells show depressed mitochondrial gene

expression [29], our current findings support the study of rhTFAM as a mitochondrial

stimulant in human ALS. In this situation, peripheral mononuclear WBC mitochondrial gene

expression could serve as a biomarker for rhTFAM therapeutic effect.

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Our combined findings in rats (present study) and prior findings in mice [19, 22]

suggest that repeated rhTFAM treatment will at most increase slightly human cerebral

mitochondrial bioenergetics, but the limited homologies between human TFAM and TFAM’s

of rat and mice suggest caution with this prediction.

Our experiments do not provide insight into how rhTFAM, a mitochondrial matrix-

directed protein, increases expression of nuclear-encoded mitochondrial genes. We have

consistently observed this mitobiogenesis activity of rhTFAM in animals and multiple

human cell lines.

Our RNA-seq studies in human neural stem cells showed both an expected action

(increased expression of mitochondrial respiratory genes) and an unexpected action

(increased expression of gene clusters related to mRNA splicing and ribosomal functions).

Over-representation analysis (IPA) also showed nuclear-mediated effects of rhTFAM and

activation of gene programs related to E2F signaling. The E2F gene family traditionally was

associated with cell checkpoint/cell cycle regulation. More recently, this family of

transcription factors has been shown to regulate mitochondrial function and morphology,

including mitochondrial involvement in apoptosis [27, 28].

It remains unclear to us how rhTFAM brings about these nuclear genome-encoded

actions, which may represent an important component of its therapeutic effect.

There are important limitations of our studies:

First, much of our work was done using rhTFAM in rodents. This was dictated by the

regulatory need to show biological action of a human protein therapeutic in non-human

species. Clearly use of a rat TFAM would likely have provided greater insight into TFAM

molecular action, but we were not developing rat TFAM for treatment of humans.

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Second, it remains unclear why we observed such a difference between rhTFAM

mitochondrial effects in forebrain compared to spinal cord. Possible explanations include

different pharmacokinetics of rhTFAM in spinal cord compared to forebrain, greater

sensitivity of spinal cord mitochondria to rhTFAM, altered mitochondrial turnover in spinal

cord, or some combination. Other explanations are also possible.

Third, we do not yet know how our results in rodents and human cells will translate

into human persons. All indicators are that rhTFAM, being an engineered natural protein

product, will stimulate mitochondrial bioenergetics in humans, and apparently will do this

without significant toxicity. We are hopeful that soon we can begin human studies, with the

hope of improving mitochondrial function in persons with degenerative brain diseases or

peripheral mitochondrial disorders.

4. Experimental Procedures:

4.1 Animals: Normal male Sprague Dawley rats 150-200g were procured from Charles

River Laboratories and were housed two per cage in the vivarium and provided with food &

water ad libitum. The protocol was approved by the Institutional Animal Care and Use

Committees (IACUC) at Virginia Commonwealth University and the University of Virginia

and all the procedures were done in accordance with the National Institute of Health (NIH)

Guide for the Care and Use of Laboratory Animals (Eighth Edition).

4.2 rhTFAM: Recombinant human mitochondrial transcription factor A (rhTFAM) was

provided by Gencia Corporation (Charlottesville, VA) and stored at -80oC. Just before

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injection the rhTFAM was diluted in the buffer provided by Gencia to working concentration

and rats were injected intravenously (iv) by tail vein.

4.3 rhTFAM treatment Protocol:

To find out the workable concentration that will produce measurable effect rats were treated

with 1 mg/kg or 3 mg/kg rhTFAM or with control buffer (each n=1). The rats were sacrificed

after 24 hours or 3 days.

Single dose vs different time points: Based on the above experiment 3 mg/kg was

found to be effective and rats were treated at this dose and sacrificed after 0 hour, 24

hours, 3 days and 7 days (each dose n=3) along with control buffer (n=4) which were

sacrificed after 0 hour.

Chronic effect with multiple doses: To see the extended effect of rhTFAM @ 3 mg/kg

rats (n=6) were injected at 3 mg/kg per week for 5 weeks and were sacrificed 24 hours after

the last injection. Following the same protocol equal number of rats (n=6) was injected with

control buffer also.

The animals were euthanized using controlled release of CO2 in the vivarium and

the brains were removed. Half of the sagittally cut brain was snap-frozen in isopentane

chilled in dry ice and stored at -80oC until further processing. From the other half the

mitochondria were isolated and used for measuring respiration in Oxygraph.

4.4 Mitochondrial respiration: From one half of the freshly removed brain about 250 mg

was removed from the anterior forebrain and homogenized in mannitol-sucrose buffer [21].

P2 pellets were prepared by differential centrifugation method, which was rich in

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mitochondria, and dissolved in 2.4 ml MirO5 buffer

(http://www.oroboros.at/index.php?id=524#857). About 0.6 ml of this was assayed in

Oroboros Oxygraph 2 respirometer to measure mitochondrial respiration. rhTFAM or buffer

control injected brain mitochondria were assayed side by side with sequential additions of

substrates and inhibitors of Complex I to Complex IV [21]. The protein concentration of

diluted P2 pellet that was used for assay was measured (Micro BCA Protein Assay Kit,

Thermo Scientific) and was used to normalize respiration/mg protein.

4.5 RNA extraction and RT-qPCR: About 30mg brain tissue from the frontal cortex region

or spinal cord was homogenized in Qiazol and RNA was extracted using miRNeasy kit

(Qiagen). It was quantified in NanoDrop 2000C spectrometer and the quality of RNA was

analyzed by capillary electrophoresis (Experion, BioRad). 1ug of RNA was reverse

transcribed to cDNA (iScript, BioRad) using random hexamers for qPCR analysis using

CFX96 (BioRad). Primers and probes used for multiplex and SybrGreen assays were

designed by Beacon Designer®. Rat mtDNA used as external standards to quantify

mitochondrial genes, was prepared from rat liver gDNA after treating with Plasmid-Safe

ATP-Dependent DNase (Epicentre Biotechnologies) to remove all non-circular DNA.

Various genes involved in mitochondrial bioenergetics were assayed using gene specific

primers on ‘RT2 Profiler PCR Array-Rat Mitochondrial Energy Metabolism’ qPCR plates

(Qiagen). Samples were also assayed on ‘RT2 Profiler PCR Array-Rat Housekeeping

Genes’ qPCR plates (Qiagen). The qPCR data was analyzed in qbasePLUS (Biogazelle) to

select the optimal number of reference targets, which have least variability based on

GeNorm analysis in the qbasePLUS® software (Biogazelle) (Supplemental Figure 2).

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4.6 Western Blotting: Proteins extracted from brain and spinal cord samples were

electrophoresed on 4-12% Bis-Tris CriterionTM (Bio-Rad) and transferred onto nitrocellulose

membranes (iBlot, Invitrogen). MitoProfile Total OXPHOS Rodent WB Antibody Cocktail

(ab110413) was used to probe for the presence of proteins, followed by suitable secondary

antibodies (IRDye, Li-cor). The membranes were imaged in Odyssey infrared imaging

system (Li-cor) the bands were normalized by Beta-actin, which was used as loading

control.

4.7 FDG PET Imaging. We injected i.v. an average dose of 550 µCi of FDG into the rats

and imaged them on a Siemens Focus 120 PET scanner for 40 minutes. There were 5

animals in rhTFAM treatment group and 5 in the control group. Animals were injected with

rhTFAM (3 mg/kg i.v.) on Days 0, 10, 16, and 24. PET imaging was performed on Days 4,

11, 17, and 25. The Standardized Uptake Value (SUV) was calculated by normalizing the

radioactivity concentration for each voxel in the image to the animal’s body mass and the

injected dose. The PET SUV images were analyzed to see if there were significant

rhTFAM-induced alterations in glucose uptake in the 40-min static images.

To compare the 40-min static images, we combined the PET SUV data separately

for the rhTFAM treated rats and the control rats. To do this, we registered each 3D data set

to a template that was divided into 78 regions. We could then calculate the mean SUV from

each region and compared between groups to see if there was a rhTFAM-induced

significant difference in FDG uptake for any of the regions. More specifically, a region of

analysis was performed on the PET SUV images using the Advanced Normalization Tools

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(ANTs) package. Mean (shape and intensity) population-specific structural and functional

templates [30] were created from their corresponding imaging subsets. In order to create

the structural template, each PET SUV image underwent bias correction [31] and was

subsequently skull-stripped using a multi-atlas label fusion approach [32]. The structural

template was then labeled using the publicly available Waxholm Space atlas [33] providing

78 different regions over the entire brain. This atlas was registered to the population-

specific template [34] in order to transform the 78 regions to the template space. The

functional template was also normalized to the structural template in order to propagate the

Waxholm labels directly to the functional template.

After template creation, each functional image was registered to the functional

template. The labels in the template space were used to determine the mean SUV in each

ROI for each warped functional image. These mean values were used to test for

differences across regions and for each time point (Day 3, Day 16, and Day 24). False

discovery rate was used to correct for multiple comparisons [35].

In a subset of the rats (rhTFAM n=3, CTL n=2), we acquired additional data that

allowed us to see there were changes in the rate of whole-brain FDG uptake. This was

done by acquiring 5 minute scans over a period of 30 minutes, averaging the SUVs over

the whole brain, and calculating the mean and standard deviation for the SUVs for each of

the groups.

4.8 Human neural stem cell studies: We collected blood for PBMC isolation, cultured the

mononuclear cells, created iPSC’s and neuralized them to neural stem cells (NSC) as

described [26]. NSC were propagated in cell culture, and independent cultures in 6-well

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plates were incubated with 1 nM or 5 nM rhTFAM (gift of Gencia Corporation,

Charlottesville VA), or buffer, for 24 hours. All incubations were carried out in 5% oxygen.

Total RNA was isolated using Qiagen kits, depleted of ribosomal RNA, converted to cDNA

and bar-coded for multiplex RNA sequencing using Illumina Truseq® Stranded Total RNA

HT kit library construction kits, fragmented to a mean size of 150 bp, then sequenced on an

Illumina NextSeq 500 sequencer using paired-end sequencing. Raw sequencing reads

were first examined for quality (FastQC) and then trimmed of sequencing bar codes

(Trimmomatic). Trimmed reads with Phred scores >20 were aligned using tophat2/bowtie2,

and the accepted_hits.bam files were processed for FPKM values from the human hg38

transcriptome or human mitochondrial genome (ENCODE) using Cufflinks2.

4.9 Computer processing, bioinformatics algorithms and statistical analyses:

Routine graphs were constructed and t-test, ANOVA’s done using Prism® software

(GraphPad) on Macintosh computers. Tophat 2

(https://ccb.jhu.edu/software/tophat/manual.shtml) , Bowtie 2 (http://bowtie-

bio.sourceforge.net/bowtie2/index.shtml) and Cufflinks 2 (http://cole-trapnell-

lab.github.io/cufflinks/install/) algorithms were downloaded and run using native Unix on a

12-core processor, 64GB RAM MacPro with a 32TB hard drive array. Unprocessed (raw)

paired-end RNA sequences have been deposited in a public database (SRA;

www.ncbi.nlm.nih.gov/sra) as Bioproject PRJNA320380; Experiment

SRX1739676/rhTFAM_CTL42NSC; Run SRR3472844.

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5. Acknowledgements

This research was supported by the Virginia Biosciences Health Research Council

(VBHRC), the Alzheimer’s Drug Discovery Foundation (ADDF), the Parkinson’s Research

Center at Virginia Commonwealth University, the Medical College of Virginia Foundation

(MCVF) and Gencia Corporation. SMK, FRP are employees of Gencia Corporation. None

of the other authors have a financial interest in rhTFAM or Gencia Corp. None of the study

sponsors had any role in experimental design, data analysis, or manuscript preparation.

6. Figure Legends Figure1. Single i.v. rhTFAM treatments of adult rats increase brain cortex mitochondrial respiration. See Methods for details. “State 3” = respiration in the presence of ADP. “State 4” = no ADP added. “Buf” =buffer only. Figure 2. Rat forebrain mitochondrial respiration at various time points after single 3 mg/kg i.v. doses of rhTFAM. See Methods for details. “Buf” =buffer only. Figure 3. Rat cervical spinal cord mtDNA genes’ cDNA’s expression days after 3mg/kg rhTFAM treatment (outliers removed). Figure 4. Weekly rhTFAM treatment for one month increased forebrain mitochondrial respiration ~10-20%. N=6 rats each treatment. CTL=buffer only. Figure 5. Effects of weekly 3 mg/kg rhTFAM treatments on forebrain nuclear respiratory gene expression using SABiosciences gene-specific primer plates. N=6 rats each treatment. CTL=buffer only. Figure 6. Weekly 3 mg/kg rhTFAM treatments increase cervical spinal cord expression of nuclear mitochondrial genes, assayed by gene-specific primers on SABiosciences qPCR pates. N=6 rats each treatment. CTL=buffer injection. Figure 7. Effects of weekly rhTFAM (or buffer CTL) treatments on cervical spinal cord OXPHOS protein levels. N=6 rats each treatment. Figure 8. Representative FDG PET images acquired 40 minutes after injection of FDG from the three primary axes: sagittal (left), transverse (center), and coronal (right).

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Figure 9. Dynamic PET scans show an increase in the rate of FDG brain uptake in TFAM treated animals. Figure 10. X-Y plot of log2 averaged FPKM of CTL neural stem cells (1% DMSO vehicle CTL, n=2) vs. log2 of mean FPKM of CTL cervical spinal cord sections (n=8). Note the high correlation (Spearman r=0.74) for >20,000 gene pairs and that most scatter occurs at very low FPKM values. Figure 11. FPKM values for mitochondrial DNA (mtDNA)-encoded respiratory genes and 12S/16S rRNA’s in human NSC’s (top) and averaged from human CTL spinal cord sections (n=8). Although the absolute values are different, there are qualitative similarities among individuals in the two groups. Figure 12. Effects of 1 nM and 5 nM rhTFAM (incubated 24 hrs) on mtDNA gene expression in human NSC’s. I nM rhTFAM brought about minimal changes, but 5 nM rhTFAM increased expression in human NSC’s of ND1, ND2, ND3, CO1, CO2, ATP6 and ATP8 determined by t-tests corrected for multiple comparisons using Holm-Sidak method with alpha=0.05 Figure 13. 3-D output of gene co-expression from Miru® carried out with a minimum correlation of 0.9 (Spearman) for the top 500 genes in human NSC’s where ratios of FPKM’s with 5nM rhTFAM were divided by FPKM’s with buffer. Miru was asked to create co-expression networks for the FPKM’s using the four experiments with 5 nM rhTFAM, followed by Markov clustering that used the built-in “MCL” algorithm. Gene numbers in cluster 1 (top) and cluster 2 (bottom) are indicated. Note that clusters 1+ 2 accounted for 392 of the 500 genes studied. Red lines (edges) connecting spherical nodes (genes) indicate a positive association of genes’ expression. Figure 14. Protein-protein interactions determined in STRING (www.string-db.com) for the genes defined by Miru cluster 1 (see Figure 13). Note two large (circled) and 2 small clusters in the STRING output. Figure 15. Same as for Figure 14 except genes in Miru cluster 2 were used. Note two large clusters (circled) and one “hub” gene (ubiquitin). Figure 16. Results from IPA analysis of top 500 genes used to construct Figures 13-15. Supplemental Figure 1. Alignments of TFAM protein sequences from human, mouse and rat using MacVector®. Supplemental Figure 2. GeNorm analysis from qbasePLUS® (Biogazelle) of reference (“housekeeping”) gene stabilities in rat forebrain cDNA samples. geNorm analysis was carried out on 16 samples and 12 reference targets. The lower the value of geNorm M (Y-axis), the more stable is the reference gene across samples. The reference genes were provided on the SABiosciences gene-specific primer qPCR plates The optimal number of

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reference targets selected was 2, which were Pgk1 and Hprt1 (geNorm V < 0.15) and the geometric mean of these were calculated as the optimal normalization factor. Supplemental Table 1. Representative Gene Ontology (GO) terms from STRING protein network modeling of Miru® 3-D gene clusters from RNA-seq gene expression of CTL human iPSC-derived NSC’s exposed for 24 hrs to buffer or 5nM rhTFAM. 7. References Cited [1]L.Margulis,D.Bermudes,Symbiosisasamechanismofevolution:statusofcellsymbiosistheory,Symbiosis,1(1985)101-124.[2]U.Kutschera,K.J.Niklas,Endosymbiosis,cellevolution,andspeciation,TheoryBiosci,124(2005)1-24.[3]M.Elias,J.M.Archibald,Sizingupthegenomicfootprintofendosymbiosis,Bioessays,31(2009)1273-1279.[4]P.J.Keeling,Theimpactofhistoryonourperceptionofevolutionaryevents:endosymbiosisandtheoriginofeukaryoticcomplexity,ColdSpringHarbPerspectBiol,6(2014).[5]N.W.Blackstone,Theimpactofmitochondrialendosymbiosisontheevolutionofcalciumsignaling,CellCalcium,57(2015)133-139.[6]M.X.Li,G.Dewson,Mitochondriaandapoptosis:emergingconcepts,F1000PrimeRep,7(2015)42.[7]R.C.Scarpulla,Nucleus-encodedregulatorsofmitochondrialfunction:Integrationofrespiratorychainexpression,nutrientsensingandmetabolicstress,BiochimBiophysActa,(2011).[8]R.C.Scarpulla,MetaboliccontrolofmitochondrialbiogenesisthroughthePGC-1familyregulatorynetwork,BiochimBiophysActa,1813(2011)1269-1278.[9]V.Sica,L.Galluzzi,J.M.Bravo-SanPedro,V.Izzo,M.C.Maiuri,G.Kroemer,Organelle-SpecificInitiationofAutophagy,MolCell,59(2015)522-539.[10]N.M.Held,R.H.Houtkooper,Mitochondrialqualitycontrolpathwaysasdeterminantsofmetabolichealth,Bioessays,37(2015)867-876.[11]N.D.Bonawitz,D.A.Clayton,G.S.Shadel,Initiationandbeyond:multiplefunctionsofthehumanmitochondrialtranscriptionmachinery,MolCell,24(2006)813-825.[12]R.C.Scarpulla,Transcriptionalparadigmsinmammalianmitochondrialbiogenesisandfunction,Physiologicalreviews,88(2008)611-638.[13]M.I.Ekstrand,M.Falkenberg,A.Rantanen,C.B.Park,M.Gaspari,K.Hultenby,P.Rustin,C.M.Gustafsson,N.G.Larsson,MitochondrialtranscriptionfactorAregulatesmtDNAcopynumberinmammals,HumMolGenet,13(2004)935-944.[14]K.Maniura-Weber,S.Goffart,H.L.Garstka,J.Montoya,R.J.Wiesner,TransientoverexpressionofmitochondrialtranscriptionfactorA(TFAM)issufficienttostimulatemitochondrialDNAtranscription,butnotsufficienttoincreasemtDNAcopynumberinculturedcells,NucleicAcidsRes,32(2004)6015-6027.

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[31]N.J.Tustison,B.B.Avants,P.A.Cook,Y.Zheng,A.Egan,P.A.Yushkevich,J.C.Gee,N4ITK:improvedN3biascorrection,IEEETransMedImaging,29(2010)1310-1320.[32]H.Wang,J.W.Suh,S.R.Das,J.Pluta,C.Craige,P.A.Yushkevich,Multi-AtlasSegmentationwithJointLabelFusion,IEEETransPatternAnalMachIntell,(2012).[33]E.A.Papp,T.B.Leergaard,E.Calabrese,G.A.Johnson,J.G.Bjaalie,WaxholmSpaceatlasoftheSpragueDawleyratbrain,Neuroimage,97(2014)374-386.[34]B.B.Avants,N.J.Tustison,G.Song,P.A.Cook,A.Klein,J.C.Gee,AreproducibleevaluationofANTssimilaritymetricperformanceinbrainimageregistration,Neuroimage,54(2011)2033-2044.[35]Y.Hochberg,Y.Benjamini,Morepowerfulproceduresformultiplesignificancetesting,StatMed,9(1990)811-818.

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Figure 1

State

3 C I

State

3 C II

State

3 C IV

State

IV0

100

200

300

400%

buff

er C

TL

%Buffer Rat Cortex vs TFAM dose

Buf_24hrsTF 1mg/kg_24hrsTF 1mg/kg_3daysTF 3mg/kg_24hrsTF 3mg/kg_3days

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Figure 2

Comp I

Comp II

Comp IV

State

40

50

100

150

200

Resp/mg Prot of Rats iv with TFAM @ 3mg/kg

% 0

hr

Mea

n of

CTL

Buf 0 hr Buf

0 hr TF24 h3 d7 d

0 hr Buf CTL to 24 hrs TFAM has significantly increased in Comp I (p <0.03,) Comp II (p<0.03) and in Comp IV (p<0.2).

**

*

*

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Figure 3

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Figure 4

Comp I

Comp II

Comp IV

State

40

50

100

150

Rat Forebrain Respiration/mg protein after one month of qweekly doses of rhTFAM @ 3mg/kg

p=0.011 2-way ANOVA CTL vs rhTFAM (matched pairs)%

0 h

r M

ean

of C

TL B

uf

CTL rhTFAM

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Figure 5

Nduf

s4

Nduf

a2

Nduf

b9

Nduf

s2

Nduf

a9

Nduf

s8

Nduf

b7

Nduf

b5

Nduf

a5

Nduf

b3

Nduf

s1

Nduf

s3

Nduf

a6

Nduf

a8

Nduf

v2

Nduf

a11

Nduf

s6

Nduf

b2

Nduf

a1

Nduf

a7

Nduf

b8

Nduf

a10

Nduf

c2

Nduf

s7

Nduf

v1

Nduf

b6

Nduf

ab1

60

80

100

120

Complex I genes

% m

ean

CTL

Complex I genes CTL vs rhTFAM

p<0.0001 2-way ANOVA CTL vs rhTFAMCTLrhTFAM

Ucp1

Uqcr

c1

Uqcr

b

Ucp2

Uqcr

h

Uqcr

q

Uqcr

c2

Uqcr

fs1

Ucp3

50

100

150

Complex III genes

% m

ean

CTL

Complex III genes CTL vs rhTFAM

NS

CTLrhTFAM

Atp6

v1e2

At

p6vc

2 At

p5o

Atp5

i At

p5b

Atp5

d At

p5g2

At

p5j

Atp6

ap1

Atp5

l At

p6v0

a2

Atp5

c1

Atp5

a1

Atp5

h At

p4b

Atp1

2a

Atp5

f1

Atp5

g3

Atp4

a At

p6v1

g3At

p6v0

d2 50

100

150

200

Complex V genes

% m

ean

CTL

Complex V genes CTL vs rhTFAM

NS

CTL

rhTFAM

Slc2

5a10

Slc2

5a20

Sdhb

Slc2

5a15

Surf1

Sdhc

Sdhd

Sdha

50

100

150

Complex II genes

% m

ean

CTL

Complex II genes CTL vs rhTFAM

NS

CTL

rhTFAM

Cox6

c Co

x4i1

Co

x15

Cox7

a2

Cox8

a Co

x5b

Cox6

a1

Cox7

b Co

x17

Cox8

c Co

x7a2

l Co

x5a

Cox6

a2

Cyc1

Co

x4i2

50

100

150

Complex IV genes

% m

ean

CTL

Complex IV genes CTL vs rhTFAM

p=0.0005 2-way ANOVA CTL vs rhTFAM

CTL

rhTFAM

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Figure 6

Ndu

fc2

Ndu

fa1

Ndu

fb3

Ndu

fb2

Ndu

fa6

Ndu

fa2

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fb7

Ndu

fs3

Ndu

fa7

Ndu

fa5

Ndu

fa8

Ndu

fab1

Ndu

fa9

Ndu

fb8

Ndu

fa10

Ndu

fb6

Ndu

fb9

Ndu

fb5

Ndu

fs6

Ndu

fs7

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fa11

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fs4

Ndu

fs8

Ndu

fs1

Ndu

fv1

Ndu

fv2

Ndu

fs20

100

200

300

gene

%m

ean

CTL

Complex Ip<0.0001 2-way ANOVA

CTL vs rhTFAMCTLrhTFAM

Cox

7bC

ox6c

Cox

7a2

Cox

6a2

Cox

17C

ox5b

Cox

6a1

Cox

8aC

ox4i

1C

ox4i

2C

ox5a

Cox

7a2l

Cox

8cC

ox15

0

100

200

300

gene

%m

ean

CTL

Complex IVp<0.0001 2-way ANOVA

CTL vs rhTFAM

CTL

rhTFAMU

cp1

Uqc

rb

Uqc

rh

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rq

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rc2

Uqc

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rc1

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2

Ucp

30

200

400

600

gene

%m

ean

CTL

Complex IIIp=0.03 2-way ANOVA

CTL VS rhTFAM

CTLrhTFAM

Atp

5iA

tp5l

Atp

5bA

tp5j

Atp

5f1

Atp

5g2

Atp

5a1

Atp

5oA

tp5d

Atp

5c1

Atp

5hA

tp4a

Atp

5g3

Atp

6ap1

Atp

4bA

tp6v

0d2

Atp

6v1g

3A

tp6v

0a2

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6v1e

2A

tp6v

c2

0

100

200

300

gene

%m

ean

CTL

ATPasep=0.0001 2-way ANOVA

CTL vs rhTFAM

CTLrhTFAM

rat cervical spinal cordrhTFAM 3 mg/kg i.v. qweek X4

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Figure 7

CI -

ND

UFB

8

CII

- SD

HB

CIII

- U

QC

RC

2

CIV

- M

TCO

1

CV

- ATP

5A 0

100

200

300

OXPHOS protein

Nor

mal

ized

Inte

grat

ed In

tens

ity%

mea

n C

TL

%mean CTL OXPHOS proteinrat cervical spinal cord

3 mg/kg i.v. rhTFAM qWeek X4p=0.014 2-way paired ANOVA

CTL vs rhTFAM

CTL (n=6)rhTFAM (n=6)

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Figure 8

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Figure 9

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Figure 10

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Figure 11

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Figure 12

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Figure 13

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Figure 14

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Figure 15

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Figure 16

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Supplemental Figure 1

Formatted AlignmentsHuman TFAMMouse TFAMRat TFAM

1 401 401 40

MA F L R S MWG V L S A L G R S G A E L C T G C G S R L R S P F S F V Y L P RMA L F R GMW S V L K A L G R T G V E MC A G C G G R I P S S I S L V C I P KMA L F R GMWG V L R T L G R T G V E MC A G C G G R I P S P V S L I C I P KMA L F R GMWG V L . A L G R T G V E MC A G C G G R I P S P . S L V C I P K

Human TFAMMouse TFAMRat TFAM

41 8041 7941 79

W F S S V L A S C P K K P V S S Y L R F S K E Q L P I F K A Q N P D A K T T E LC F S S - MG S Y P K K P M S S Y L R F S T E Q L P K F K A K H P D A K L S E LC F S S - L G N Y P K K P M S S Y L R F S T E Q L P K F K A K H P D A K V S E LC F S S V L G S Y P K K P M S S Y L R F S T E Q L P K F K A K H P D A K . S E L

Human TFAMMouse TFAMRat TFAM

81 12080 11980 119

I R R I A Q RWR E L P D S K K K I Y Q D AY R A EWQ V Y K E E I S R F K E QV R K I A A LWR E L P E A E K K V Y E A D F K A EWK AY K E AV S K Y K E QI R K I A AMWR E L P E A E K K V Y E A D F K A EWK V Y K E AV S K Y K E QI R K I A A WR E L P E A E K K V Y E A D F K A EWK V Y K E AV S K Y K E Q

Human TFAMMouse TFAMRat TFAM

121 160120 159120 159

L T P S Q I M S L E K E I MD K H L K R K AM T K K K E L T L L G K P K R P R SL T P S Q L MGM E K E A R Q R R L K K K A L V K R R E L I L L G K P K R P R SL T P S Q L MG L E K E A R Q K R L K K K A Q I K R R E L I L L G K P K R P R SL T P S Q L MG L E K E A R Q K R L K K K A . K R R E L I L L G K P K R P R S

Human TFAMMouse TFAMRat TFAM

161 200160 199160 199

AY N V Y VA E R F Q E A K G D S P Q E K L K T V K E NWK N L S D S E K E L YAY N I Y V S E S F Q E A K D D S A Q G K L K L V N E AWK N L S P E E K Q AYAY N I Y V S E S F Q E A K D E S A Q G K L K L V N Q AWK N L S H D E K Q AYAY N I Y V S E S F Q E A K D D S A Q G K L K L V N E AWK N L S . E K Q AY

Human TFAMMouse TFAMRat TFAM

201 240200 238200 239

I Q H A K E D E T R Y H N E MK S WE E QM I E V G R K D L L R R T I K K Q R KI Q L A K D D R I R Y D N E MK S WE E QMA E V G R S D L I R R S V K R S - GI Q L A K D D R I R Y D N E MK S WE E QMA E V G R S D L I R R S V K R P P GI Q L A K D D R I R Y D N E MK S WE E QMA E V G R S D L I R R S V K R G

Human TFAMMouse TFAMRat TFAM

241 246239 243240 244

Y G A E E CD I S E H D I S E N D I S E C

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Supplemental Figure 2

Average expression stability of remaining reference targets

TfrcRplp1

Hsp90

ab1

ActbNono

B2m TbpPpih Sdh

aLdha

Pgk1Hprt1

0.120

0.125

0.130

0.135

0.140

0.145

0.150

0.155

0.160

0.165

0.170

0.175

0.180

0.185

0.190

0.195

0.200

0.205

0.210

0.215

0.220

0.225

0.230

0.235

geN

orm

M

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Supplemental Table 1. Representative Gene Ontology (GO) Terms from STRING Protein Network Modeling of Miru® 3-D Gene Clusters from RNA-seq Gene Expression of CTL Human iPSC-derived NSC’s Exposed for 24 hrs to Buffer or 5nM rhTFAM. Top 500 genes from rhTFAM/buffer gene expression. X= present; En= range of GO enrichment (fold); Bj= range of Benjamini-corrected p values

Representative Gene Ontology

(GO) terms

Cluster 1 (Fig 14,

red circle)

Cluster 1 (Fig 14,

blue circle)

Cluster 2 (Fig 15,

red circle)

Cluster 2 (Fig 15,

blue circle)

protein complex, DNA binding, RNA

polymerase, transcription

X En 28-106 fold, Bj 0.005-2.1E-8

X En 22-110

Bj 0.02-6.8E-4

ribonucleoprotein, ribonucleoprotein

complex translation,

ribosome, ncRNA

X En 4.5-132

Bj 0.004-8.7E-38

X En 9.5-49

Bj 0.03-3.5E-4

X En 7.3-339

Bj 0.008-4.2E-14

ribosome biogenesis, rRNA processing

X En 12-205

Bj 0.008-3.1E-5

RNA processing, mRNA processing

X En 25-89

Bj 1.4E-16-1.1E-22

macromolecular complex,

nucleoplasm, ribonucleoprotein complex assembly

X En 7.3-339

Bj 0.004-4.2E-14

Histone N-acetyltransferase,

chromatin organization

X En 10-73

Bj 0.035-0.003