1
|
Doshi BS, Samelson-Jones BJ, Nichols TC, Merricks EP, Siner JL, French RA, Lee BJ, Arruda VR, Callan MB. AAV gene therapy in companion dogs with severe hemophilia: Real-world long-term data on immunogenicity, efficacy, and quality of life. Mol Ther Methods Clin Dev 2024; 32:101205. [PMID: 38374963 PMCID: PMC10875295 DOI: 10.1016/j.omtm.2024.101205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 01/30/2024] [Indexed: 02/21/2024]
Abstract
The hemophilias are the most common severe inherited bleeding disorders and are caused by deficiency of clotting factor (F) VIII (hemophilia A) or FIX (hemophilia B). The resultant bleeding predisposition significantly increases morbidity and mortality. The ability to improve the bleeding phenotype with modest increases in clotting factor levels has enabled the development and regulatory approval of adeno-associated viral (AAV) vector gene therapies for people with hemophilia A and B. The canine hemophilia model has proven to be one of the best predictors of therapeutic response in humans. Here, we report long-term follow-up of 12 companion dogs with severe hemophilia that were treated in a real-world setting with AAV gene therapy. Despite more baseline bleeding than in research dogs, companion dogs demonstrated a 94% decrease in bleeding rates and 61% improvement in quality of life over a median of 4.1 years (range 2.6-8.9). No new anti-transgene immune responses were detected; one dog with a pre-existing anti-FVIII inhibitor achieved immune tolerance with gene therapy. Two dogs expressing 1%-5% FVIII post gene therapy experienced fatal bleeding events. These data suggest AAV liver-directed gene therapy is efficacious in a real-world setting but should target expression >5% and closely monitor those with levels in the 1%-5% range.
Collapse
Affiliation(s)
- Bhavya S. Doshi
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Division of Hematology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Raymond G. Perelman Center for Cellular and Molecular Therapeutics, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Benjamin J. Samelson-Jones
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Division of Hematology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Raymond G. Perelman Center for Cellular and Molecular Therapeutics, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Timothy C. Nichols
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina, Chapel Hill, NC 27516, USA
| | - Elizabeth P. Merricks
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina, Chapel Hill, NC 27516, USA
| | - Joshua L. Siner
- Divisions of Hematology and Medical Oncology, Department of Medicine, Washington University in St. Louis, St. Louis, MO 63110, USA
| | - Robert A. French
- Division of Hematology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Ben J. Lee
- Division of Hematology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Valder R. Arruda
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Division of Hematology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Raymond G. Perelman Center for Cellular and Molecular Therapeutics, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Mary Beth Callan
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| |
Collapse
|
2
|
Shamsara M, Jamshidizad A, Rahim-Tayefeh A, Davari M, Rajabi Zangi A, Masoumi F, Zomorodipour A. Generation of Mouse Model of Hemophilia A by Introducing Novel Mutations, Using CRISPR/Nickase Gene Targeting System. CELL JOURNAL 2023; 25:655-659. [PMID: 37718768 PMCID: PMC10520988 DOI: 10.22074/cellj.2023.1999800.1278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 06/08/2023] [Accepted: 06/18/2023] [Indexed: 09/19/2023]
Abstract
Developing mouse models of hemophilia A has been shown to facilitate in vivo studies to explore the probable mechanism(s) underlying the disease and to examine the efficiency of the relevant potential therapeutics. This study aimed to knockout (KO) the coagulation factor viii (fviii) gene in NMRI mice, using CRISPR/Cas9 (D10A/nickase) system, to generate a mouse model of hemophilia A. Two single guide RNAs (sgRNAs), designed from two distinct regions on NMRI mouse FVIII (mFVIII) exon 3, were designed and inserted in the pX335 vector, expressing both sgRNAs and nickase. The recombinant construct was delivered into mouse zygotes and implanted into the pseudopregnant female mice's uterus. Mutant mice were identified by genotyping, genomic sequencing, and mFVIII activity assessment. Two separate lines of hemophilia A were obtained through interbreeding the offspring of the female mice receiving potential CRISPR-Cas9-edited zygotes. Genomic DNA analysis revealed disruptions of the mfviii gene reading frame through a 22-bp deletion and a 23-bp insertion in two separate founder mice. The founder mice showed all the clinical signs of hemophilia A including; excessive bleeding after injuries, and spontaneous bleeding in joints and other organs. Coagulation test data showed that mFVIII coagulation activity was significantly diminished in the mFVIII knockout (FVIIIKO) mice compared to normal mice. The CRISPR/nickase system was successfully applied to generate mouse lines with the knockout fviii gene. The two novel FVIIIKO mice demonstrated all clinical symptoms of hemophilia A, which could be successfully inherited. Therefore, both of the developed FVIIIKO mouse lines are eligible for being considered as proper mouse models of hemophilia A for in vivo therapeutic studies.
Collapse
Affiliation(s)
- Mehdi Shamsara
- Department of Animal Biotechnology, Institute Agricultural Biotechnology, National Institute of Genetic Engineering and Biotechnology, Tehran, Iran
| | - Abbas Jamshidizad
- Department of Animal Biotechnology, Institute Agricultural Biotechnology, National Institute of Genetic Engineering and Biotechnology, Tehran, Iran
| | - Aidin Rahim-Tayefeh
- Department of Animal Biotechnology, Institute Agricultural Biotechnology, National Institute of Genetic Engineering and Biotechnology, Tehran, Iran
| | - Maliheh Davari
- Department of Molecular Medicine, Institute of Medical Genetics, National Institute of Genetic Engineering and Biotechnology, Tehran, Iran
| | - Ali Rajabi Zangi
- Department of Pharmaceutics, Faculty of Pharmacy, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Fatemeh Masoumi
- Department of Molecular Medicine, Institute of Medical Genetics, National Institute of Genetic Engineering and Biotechnology, Tehran, Iran
| | - Alireza Zomorodipour
- Department of Molecular Medicine, Institute of Medical Genetics, National Institute of Genetic Engineering and Biotechnology, Tehran, Iran.
| |
Collapse
|
3
|
Lifelong gene therapy in dogs with hemophilia A. Blood 2022; 140:2650-2652. [PMID: 36548015 DOI: 10.1182/blood.2022016359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
|
4
|
Chen X, Niu X, Liu Y, Zheng R, Yang L, Lu J, Yin S, Wei Y, Pan J, Sayed A, Ma X, Liu M, Jing F, Liu M, Hu J, Wang L, Li D. Long-term correction of hemophilia B through CRISPR/Cas9 induced homology-independent targeted integration. J Genet Genomics 2022; 49:1114-1126. [PMID: 35691554 DOI: 10.1016/j.jgg.2022.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 05/29/2022] [Accepted: 06/01/2022] [Indexed: 01/14/2023]
Abstract
CRISPR/Cas9-mediated site-specific insertion of exogenous genes holds potential for clinical applications. However, it is still infeasible because homologous recombination (HR) is inefficient, especially for non-dividing cells. To overcome the challenge, we report that a homology-independent targeted integration (HITI) strategy is used for permanent integration of high-specificity-activity Factor IX variant (F9 Padua, R338L) at the albumin (Alb) locus in a novel hemophilia B (HB) rat model. The knock-in efficiency reaches 3.66%, as determined by droplet digital PCR (ddPCR). The clotting time is reduced to a normal level four weeks after treatment, and the circulating factor IX (FIX) level is gradually increased up to 52% of the normal level over nine months even after partial hepatectomy, demonstrating the amelioration of hemophilia. Through primer-extension-mediated sequencing (PEM-seq), no significant off-target effect is detected. This study not only provides a novel model for HB but also identifies a promising therapeutic approach for rare inherited diseases.
Collapse
Affiliation(s)
- Xi Chen
- Shanghai Frontiers Science Center of Genome Editing and Cell Therapy, Shanghai Key Laboratory of Regulatory Biology, Institute of Biomedical Sciences and School of Life Sciences, East China Normal University, Shanghai 200241, China
| | - Xuran Niu
- Shanghai Frontiers Science Center of Genome Editing and Cell Therapy, Shanghai Key Laboratory of Regulatory Biology, Institute of Biomedical Sciences and School of Life Sciences, East China Normal University, Shanghai 200241, China
| | - Yang Liu
- The MOE Key Laboratory of Cell Proliferation and Differentiation, Genome Editing Research Center, School of Life Sciences, Peking-Tsinghua Center for Life Sciences, Peking University, Beijing 100871, China
| | - Rui Zheng
- Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China
| | - Lei Yang
- Shanghai Frontiers Science Center of Genome Editing and Cell Therapy, Shanghai Key Laboratory of Regulatory Biology, Institute of Biomedical Sciences and School of Life Sciences, East China Normal University, Shanghai 200241, China
| | - Jian Lu
- Shanghai Frontiers Science Center of Genome Editing and Cell Therapy, Shanghai Key Laboratory of Regulatory Biology, Institute of Biomedical Sciences and School of Life Sciences, East China Normal University, Shanghai 200241, China
| | - Shuming Yin
- Shanghai Frontiers Science Center of Genome Editing and Cell Therapy, Shanghai Key Laboratory of Regulatory Biology, Institute of Biomedical Sciences and School of Life Sciences, East China Normal University, Shanghai 200241, China
| | - Yu Wei
- Shanghai Frontiers Science Center of Genome Editing and Cell Therapy, Shanghai Key Laboratory of Regulatory Biology, Institute of Biomedical Sciences and School of Life Sciences, East China Normal University, Shanghai 200241, China
| | - Jiahao Pan
- Shanghai Frontiers Science Center of Genome Editing and Cell Therapy, Shanghai Key Laboratory of Regulatory Biology, Institute of Biomedical Sciences and School of Life Sciences, East China Normal University, Shanghai 200241, China
| | - Ahmed Sayed
- Biochemistry Laboratory, Chemistry Department, Faculty of Science, Assiut University, Assiut 71516, Egypt
| | - Xueyun Ma
- Shanghai Frontiers Science Center of Genome Editing and Cell Therapy, Shanghai Key Laboratory of Regulatory Biology, Institute of Biomedical Sciences and School of Life Sciences, East China Normal University, Shanghai 200241, China
| | - Meizhen Liu
- Shanghai Frontiers Science Center of Genome Editing and Cell Therapy, Shanghai Key Laboratory of Regulatory Biology, Institute of Biomedical Sciences and School of Life Sciences, East China Normal University, Shanghai 200241, China
| | | | - Mingyao Liu
- Shanghai Frontiers Science Center of Genome Editing and Cell Therapy, Shanghai Key Laboratory of Regulatory Biology, Institute of Biomedical Sciences and School of Life Sciences, East China Normal University, Shanghai 200241, China
| | - Jiazhi Hu
- The MOE Key Laboratory of Cell Proliferation and Differentiation, Genome Editing Research Center, School of Life Sciences, Peking-Tsinghua Center for Life Sciences, Peking University, Beijing 100871, China.
| | - Liren Wang
- Shanghai Frontiers Science Center of Genome Editing and Cell Therapy, Shanghai Key Laboratory of Regulatory Biology, Institute of Biomedical Sciences and School of Life Sciences, East China Normal University, Shanghai 200241, China.
| | - Dali Li
- Shanghai Frontiers Science Center of Genome Editing and Cell Therapy, Shanghai Key Laboratory of Regulatory Biology, Institute of Biomedical Sciences and School of Life Sciences, East China Normal University, Shanghai 200241, China.
| |
Collapse
|
5
|
Greig JA, Smith MK, Nordin JML, Goode T, Chroscinski EA, Buza EL, Schmidt N, Kattenhorn LM, Wadsworth S, Wilson JM. Determining the Minimally Effective Dose of a Clinical Candidate AAV Vector in a Mouse Model of Hemophilia A. Hum Gene Ther 2021; 33:421-431. [PMID: 34652966 PMCID: PMC9063151 DOI: 10.1089/hum.2021.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Hemophilia A, a bleeding disorder, affects 1:5,000 males and is caused by a deficiency of human blood coagulation factor VIII (hFVIII). Studies in mice and macaques identified AAVhu37.E03.TTR.hFVIIIco-SQ.PA75 as a clinical candidate gene therapy vector to treat hemophilia A. In this study, we sought to determine the minimally effective dose (MED) of this vector in a hemophilia A mouse model. Mice received one of four vector doses (3 × 1011–1 × 1013 genome copies [GCs]/kg) via intravenous tail vein injection; one cohort received vehicle as a control. Animals were monitored daily after vector/vehicle administration. Blood samples were collected to evaluate hFVIII activity levels and anti-hFVIII antibodies. Animals were sacrificed and necropsied on days 28 and 56; tissues were harvested for histopathological examination and blood was collected for serum chemistry panel analysis. We found no significant differences in liver transaminase levels in mice administered any vector dose compared to those administered vehicle (except for one group administered 3 × 1011 GC/kg). Total bilirubin levels were significantly elevated compared to the vehicle group following two vector doses at day 56 (1 × 1012 and 1 × 1013 GC/kg). We observed no vector-related gross or histological findings. Most microscopic findings were in the vehicle group and considered secondary to blood loss, an expected phenotype of this mouse model. Since we observed no dose-limiting safety markers, we determined that the maximally tolerated dose was greater than or equal to the highest dose tested (1 × 1013 GC/kg). Since we detected hFVIII activity in all cohorts administered vector, we conclude that the MED is 3 × 1011 GC/kg—the lowest dose evaluated in this study.
Collapse
Affiliation(s)
- Jenny A Greig
- University of Pennsylvania Perelman School of Medicine, 14640, Gene Therapy Program, Department of Medicine, Philadelphia, Pennsylvania, United States;
| | - Melanie K Smith
- University of Pennsylvania Perelman School of Medicine, 14640, Gene Therapy Program, Department of Medicine, Philadelphia, Pennsylvania, United States;
| | - Jayme M L Nordin
- University of Pennsylvania Perelman School of Medicine, 14640, Gene Therapy Program, Department of Medicine, Philadelphia, Pennsylvania, United States;
| | - Tamara Goode
- University of Pennsylvania Perelman School of Medicine, 14640, Gene Therapy Program, Department of Medicine, Philadelphia, Pennsylvania, United States;
| | - Edward A Chroscinski
- University of Pennsylvania Perelman School of Medicine, 14640, Gene Therapy Program, Department of Medicine, Philadelphia, Pennsylvania, United States;
| | - Elizabeth L Buza
- University of Pennsylvania Perelman School of Medicine, 14640, Gene Therapy Programa, 1225 S. 31st Street, Translational Research Labs (TRL), Suite 2000, Philadelphia, Pennsylvania, United States, 19104;
| | - Nicole Schmidt
- Bayer HealthCare Pharmaceuticals Inc, 1668, Whippany, New Jersey, United States;
| | | | - Samuel Wadsworth
- Ultragenyx Gene Therapy, Cambridge , Massachusetts, United States;
| | - James M Wilson
- University of Pennsylvania Perelman School of Medicine, 14640, Gene Therapy Program, Suite 1200 TRL, 125 S. 31st Street, Philadelphia, Pennsylvania, United States, 19104;
| |
Collapse
|
6
|
Evolutionary insights into coagulation factor IX Padua and other high-specific-activity variants. Blood Adv 2021; 5:1324-1332. [PMID: 33656538 DOI: 10.1182/bloodadvances.2019000405] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 01/20/2021] [Indexed: 12/14/2022] Open
Abstract
The high-specific-activity factor IX (FIX) variant Padua (R338L) is the most promising transgene for hemophilia B (HB) gene therapy. Although R338 is strongly conserved in mammalian evolution, amino acid substitutions at this position are underrepresented in HB databases. We therefore undertook a complete 20 amino acid scan and determined the specific activity of human (h) and canine (c) FIX variants with every amino acid substituted at position 338. Notably, we observe that hFIX-R338L is the most active variant and cFIX-R338L is sevenfold higher than wild-type (WT) cFIX. This is consistent with the previous identification of hFIX-R338L as a cause of a rare X-linked thrombophilia risk factor. Moreover, WT hFIX and cFIX are some of the least active variants. We confirmed the increased specific activity relative to FIX-WT in vivo of a new variant, cFIX-R338I, after gene therapy in an HB dog. Last, we screened 232 pediatric subjects with thromboembolic disease without identifying F9 R338 variants. Together these observations suggest a surprising evolutionary pressure to limit FIX activity with WT FIX rather than maximize FIX activity.
Collapse
|
7
|
Chen J, An B, Yu B, Peng X, Yuan H, Yang Q, Chen X, Yu T, Wang L, Zhang X, Wang H, Zou X, Pang D, Ouyang H, Tang X. CRISPR/Cas9-mediated knockin of human factor IX into swine factor IX locus effectively alleviates bleeding in hemophilia B pigs. Haematologica 2021; 106:829-837. [PMID: 31974191 PMCID: PMC7927883 DOI: 10.3324/haematol.2019.224063] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Indexed: 12/30/2022] Open
Abstract
Hemophilia B is an X-linked recessive bleeding disorder caused by abnormalities in the coagulation factor IX gene. Without prophylactic treatment, patients experience frequent spontaneous bleeding episodes. Well-characterized animal models are valuable for determining the pathobiology of the disease and for testing novel therapeutic innovations. Here, we generated a porcine model of hemophilia B (HB) using a combination of CRISPR/Cas9 and somatic cell nuclear transfer. We also tested the possibility of HB therapy by gene insertion. Frequent spontaneous joint bleeding episodes that occurred in HB pigs allowed a thorough investigation of the pathological process of hemophilic arthropathy. In contrast to the HB pigs, which showed a severe bleeding tendency and joint damage, the transgenic pigs carrying human coagulation factor IX exhibited a partial improvement in bleeding. In summary, this study not only offers a translational HB model for exploring the pathological process of hemophilic arthropathy, but also provides a possibility for the permanent correction of hemophilia in the future by genome editing in situ.
Collapse
Affiliation(s)
- Jiahuan Chen
- College of Animal Sciences, Jilin University, Changchun, China
| | - Beiying An
- Department of Medical Laboratory, the First Hospital of Jilin University, Changchun, China
| | - Biao Yu
- College of Animal Sciences, Jilin University, Changchun, China
| | - Xiaohuan Peng
- College of Animal Sciences, Jilin University, Changchun, China
| | - Hongming Yuan
- College of Animal Sciences, Jilin University, Changchun, China
| | - Qiangbing Yang
- College of Animal Sciences, Jilin University, Changchun, China
| | - Xue Chen
- College of Animal Sciences, Jilin University, Changchun, China
| | - Tingting Yu
- College of Animal Sciences, Jilin University, Changchun, China
| | - Lingyu Wang
- College of Animal Sciences, Jilin University, Changchun, China
| | - Xinwei Zhang
- College of Animal Sciences, Jilin University, Changchun, China
| | - He Wang
- College of Animal Sciences, Jilin University, Changchun, China
| | - Xiaodong Zou
- College of Animal Sciences, Jilin University, Changchun, China
| | - Daxin Pang
- College of Animal Sciences, Jilin University, Changchun, China
| | | | - Xiaochun Tang
- College of Animal Sciences, Jilin University, Changchun, China
| |
Collapse
|
8
|
Jankowska KI, Chattopadhyay M, Sauna ZE, Atreya CD. A Foundational Study for Normal F8-Containing Mouse Models for the miRNA Regulation of Hemophilia A: Identification and Analysis of Mouse miRNAs that Downregulate the Murine F8 Gene. Int J Mol Sci 2020; 21:E5621. [PMID: 32781510 PMCID: PMC7460574 DOI: 10.3390/ijms21165621] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/22/2020] [Accepted: 07/30/2020] [Indexed: 12/15/2022] Open
Abstract
Hemophilia A (HA) is associated with defects in the F8 gene, encoding coagulation factor VIII (FVIII). Our previous studies show that F8-targeting micro RNAs (miRNAs), a group of small RNAs involved in gene regulation, can downregulate F8 expression causing HA in individuals with normal F8-genotypes and increased HA severity in patients with mutations in F8. Understanding the mechanistic underpinnings of human genetic diseases caused or modulated by miRNAs require a small animal model, such as a mouse model. Here, we report a foundational study to develop such a model system. We identified the mouse 3'untranslated region (3'UTR) on murine F8-mRNA (muF8-mRNA) that can bind to murine miRNAs. We then selected three miRNAs for evaluation: miR-208a, miR-351 and miR-125a. We first demonstrate that these three miRNAs directly target the 3'UTR of muF8-mRNA and reduce the expression of a reporter gene (luciferase) mRNA fused to the muF8-3' UTR in mammalian cells. Furthermore, in mouse cells that endogenously express the F8 gene and produce FVIII protein, the ectopic expression of these miRNAs downregulated F8-mRNA and FVIII protein. These results provide proof-of-concept and reagents as a foundation for using a normal F8-containing mouse as a model for the miRNA regulation of normal F8 in causing or aggravating the genetic disease HA.
Collapse
Affiliation(s)
- Katarzyna I. Jankowska
- OBRR/DBCD/LCH in the Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD 20993, USA; (K.I.J.); (M.C.)
| | - Maitreyi Chattopadhyay
- OBRR/DBCD/LCH in the Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD 20993, USA; (K.I.J.); (M.C.)
- OTAT//DCGT/GTB in the Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD 20993, USA
| | - Zuben E. Sauna
- OTAT/DPPT/HB in the Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD 20993, USA;
| | - Chintamani D. Atreya
- OBRR/DBCD/LCH in the Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD 20993, USA; (K.I.J.); (M.C.)
| |
Collapse
|
9
|
Zhang X, Zhao W, Nguyen GN, Zhang C, Zeng C, Yan J, Du S, Hou X, Li W, Jiang J, Deng B, McComb DW, Dorkin R, Shah A, Barrera L, Gregoire F, Singh M, Chen D, Sabatino DE, Dong Y. Functionalized lipid-like nanoparticles for in vivo mRNA delivery and base editing. SCIENCE ADVANCES 2020; 6:6/34/eabc2315. [PMID: 32937374 PMCID: PMC7442477 DOI: 10.1126/sciadv.abc2315] [Citation(s) in RCA: 90] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 07/09/2020] [Indexed: 05/09/2023]
Abstract
Messenger RNA (mRNA) therapeutics have been explored to treat various genetic disorders. Lipid-derived nanomaterials are currently one of the most promising biomaterials that mediate effective mRNA delivery. However, efficiency and safety of this nanomaterial-based mRNA delivery remains a challenge for clinical applications. Here, we constructed a series of lipid-like nanomaterials (LLNs), named functionalized TT derivatives (FTT), for mRNA-based therapeutic applications in vivo. After screenings on the materials, we identified FTT5 as a lead material for efficient delivery of long mRNAs, such as human factor VIII (hFVIII) mRNA (~4.5 kb) for expression of hFVIII protein in hemophilia A mice. Moreover, FTT5 LLNs demonstrated high percentage of base editing on PCSK9 in vivo at a low dose of base editor mRNA (~5.5 kb) and single guide RNA. Consequently, FTT nanomaterials merit further development for mRNA-based therapy.
Collapse
Affiliation(s)
- Xinfu Zhang
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, OH 43210, USA
- State Key Laboratory of Fine Chemicals, Dalian University of Technology, Dalian 116024, China
| | - Weiyu Zhao
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, OH 43210, USA
| | - Giang N Nguyen
- The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Chengxiang Zhang
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, OH 43210, USA
| | - Chunxi Zeng
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, OH 43210, USA
| | - Jingyue Yan
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, OH 43210, USA
| | - Shi Du
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, OH 43210, USA
| | - Xucheng Hou
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, OH 43210, USA
| | - Wenqing Li
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, OH 43210, USA
| | - Justin Jiang
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, OH 43210, USA
| | - Binbin Deng
- Center for Electron Microscopy and Analysis, Department of Materials Science and Engineering, The Ohio State University, Columbus, OH 43210, USA
| | - David W McComb
- Center for Electron Microscopy and Analysis, Department of Materials Science and Engineering, The Ohio State University, Columbus, OH 43210, USA
- Department of Materials Science and Engineering, The Ohio State University, Columbus, OH 43210, USA
| | | | - Aalok Shah
- Beam Therapeutics, Cambridge, MA 02139, USA
| | | | | | | | - Delai Chen
- Beam Therapeutics, Cambridge, MA 02139, USA.
| | - Denise E Sabatino
- The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Yizhou Dong
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, OH 43210, USA.
- Department of Biomedical Engineering, The Ohio State University, Columbus, OH 43210, USA
- The Center for Clinical and Translational Science, The Ohio State University, Columbus, OH 43210, USA
- The Comprehensive Cancer Center, The Ohio State University, Columbus, OH 43210, USA
- Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University, Columbus, OH 43210, USA
- Department of Radiation Oncology, The Ohio State University, Columbus, OH 43210, USA
| |
Collapse
|
10
|
Vøls KK, Kjelgaard‐Hansen M, Ley CD, Hansen AK, Petersen M. Initial joint bleed volume in a delayed on-demand treatment setup correlates with subsequent synovial changes in hemophilic mice. Animal Model Exp Med 2020; 3:160-168. [PMID: 32613175 PMCID: PMC7323705 DOI: 10.1002/ame2.12118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 04/24/2020] [Accepted: 04/27/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Hemophilic arthropathy is a debilitating morbidity of hemophilia caused by recurrent joint bleeds. We investigated if the joint bleed volume, before initiation of treatment, was linked to the subsequent degree of histopathological changes and the development of bone pathology in a mouse model of hemophilic arthropathy. METHODS FVIII knock-out (F8-KO) mice were dosed with a micro-CT blood pool agent prior to induction of hemarthrosis. Eight hours after induction, the bleed volume was quantified with micro computed tomography (micro-CT) and recombinant FVIII treatment initiated. On Day 8, inflammation in the knees was characterized by fluorescence molecular tomography. On Day 14, knee pathology was characterized by micro-CT and histopathology. In a second study, contrast agent was injected into the knee of wild-type (WT) mice, followed by histopathological evaluation on Day 14. RESULTS The average joint bleed volume before treatment was 3.9 mm3. The inflammation-related fluorescent intensities in the injured knees were significantly increased on Day 8. The injured knees had significantly increased synovitis scores, vessel counts, and areas of hemosiderin compared to un-injured knees. However, no cartilage- or bone pathology was observed. The bleed volume before initiation of treatment correlated with the degree of synovitis and was associated with high fluorescent intensity on Day 8. In F8-KO and WT mice, persistence of contrast agent in the joint elicited morphological changes. CONCLUSION When applying a delayed on-demand treatment regimen to hemophilic mice subjected to an induced knee hemarthrosis, the degree of histopathological changes on Day 14 reflected the bleed volume prior to initiation of treatment.
Collapse
Affiliation(s)
- Kåre Kryger Vøls
- Global Drug DiscoveryNovo Nordisk A/SMaaloevDenmark
- Veterinary and Animal SciencesUniversity of CopenhagenFrederiksbergDenmark
| | | | | | | | - Maj Petersen
- Global Drug DiscoveryNovo Nordisk A/SMaaloevDenmark
| |
Collapse
|
11
|
Mohammed BM, Monroe DM, Gailani D. Mouse models of hemostasis. Platelets 2020; 31:417-422. [PMID: 31992118 PMCID: PMC7244364 DOI: 10.1080/09537104.2020.1719056] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 01/13/2020] [Accepted: 01/14/2020] [Indexed: 02/02/2023]
Abstract
Hemostasis is the normal process that produces a blood clot at a site of vascular injury. Mice are widely used to study hemostasis and abnormalities of blood coagulation because their hemostatic system is similar in most respects to that of humans, and their genomes can be easily manipulated to create models of inherited human coagulation disorders. Two of the most widely used techniques for assessing hemostasis in mice are the tail bleeding time (TBT) and saphenous vein bleeding (SVB) models. Here we discuss the use of these methods in the evaluation of hemostasis, and the advantages and limits of using mice as surrogates for studying hemostasis in humans.
Collapse
Affiliation(s)
- Bassem M. Mohammed
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN
- Department of Pathology and Immunology, Washington University, St. Louis, MO
| | - Dougald M. Monroe
- UNC Blood Research Center and Hematology/Oncology, University of North Carolina, Chapel Hill, NC
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN
| |
Collapse
|
12
|
Samelson-Jones BJ, Arruda VR. Translational Potential of Immune Tolerance Induction by AAV Liver-Directed Factor VIII Gene Therapy for Hemophilia A. Front Immunol 2020; 11:618. [PMID: 32425925 PMCID: PMC7212376 DOI: 10.3389/fimmu.2020.00618] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 03/18/2020] [Indexed: 12/26/2022] Open
Abstract
Hemophilia A (HA) is an X-linked bleeding disorder due to deficiencies in coagulation factor VIII (FVIII). The major complication of current protein-based therapies is the development of neutralizing anti-FVIII antibodies, termed inhibitors, that block the hemostatic effect of therapeutic FVIII. Inhibitors develop in about 20-30% of people with severe HA, but the risk is dependent on the interaction between environmental and genetic factors, including the underlying F8 gene mutation. Recently, multiple clinical trials evaluating adeno-associated viral (AAV) vector liver-directed gene therapy for HA have reported promising results of therapeutically relevant to curative FVIII levels. The inclusion criteria for most trials prevented enrollment of subjects with a history of inhibitors. However, preclinical data from small and large animal models of HA with inhibitors suggests that liver-directed gene therapy can in fact eradicate pre-existing anti-FVIII antibodies, induce immune tolerance, and provide long-term therapeutic FVIII expression to prevent bleeding. Herein, we review the accumulating evidence that continuous uninterrupted expression of FVIII and other transgenes after liver-directed AAV gene therapy can bias the immune system toward immune tolerance induction, discuss the current understanding of the immunological mechanisms of this process, and outline questions that will need to be addressed to translate this strategy to clinical trials.
Collapse
Affiliation(s)
- Benjamin J. Samelson-Jones
- The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Raymond G. Perelman Center for Cellular and Molecular Therapeutics, Philadelphia, PA, United States
| | - Valder R. Arruda
- The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Raymond G. Perelman Center for Cellular and Molecular Therapeutics, Philadelphia, PA, United States
| |
Collapse
|
13
|
Patel SR, Lundgren TS, Spencer HT, Doering CB. The Immune Response to the fVIII Gene Therapy in Preclinical Models. Front Immunol 2020; 11:494. [PMID: 32351497 PMCID: PMC7174743 DOI: 10.3389/fimmu.2020.00494] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 03/04/2020] [Indexed: 12/14/2022] Open
Abstract
Neutralizing antibodies to factor VIII (fVIII), referred to as "inhibitors," remain the most challenging complication post-fVIII replacement therapy. Preclinical development of novel fVIII products involves studies incorporating hemophilia A (HA) and wild-type animal models. Though immunogenicity is a critical aspect of preclinical pharmacology studies, gene therapy studies tend to focus on fVIII expression levels without major consideration for immunogenicity. Therefore, little clarity exists on whether preclinical testing can be predictive of clinical immunogenicity risk. Despite this, but perhaps due to the potential for transformative benefits, clinical gene therapy trials have progressed rapidly. In more than two decades, no inhibitors have been observed. However, all trials are conducted in previously treated patients without a history of inhibitors. The current review thus focuses on our understanding of preclinical immunogenicity for HA gene therapy candidates and the potential indication for inhibitor treatment, with a focus on product- and platform-specific determinants, including fVIII transgene sequence composition and tissue/vector biodistribution. Currently, the two leading clinical gene therapy vectors are adeno-associated viral (AAV) and lentiviral (LV) vectors. For HA applications, AAV vectors are liver-tropic and employ synthetic, high-expressing, liver-specific promoters. Factors including vector serotype and biodistribution, transcriptional regulatory elements, transgene sequence, dosing, liver immunoprivilege, and host immune status may contribute to tipping the scale between immunogenicity and tolerance. Many of these factors can also be important in delivery of LV-fVIII gene therapy, especially when delivered intravenously for liver-directed fVIII expression. However, ex vivo LV-fVIII targeting and transplantation of hematopoietic stem and progenitor cells (HSPC) has been demonstrated to achieve durable and curative fVIII production without inhibitor development in preclinical models. A critical variable appears to be pre-transplantation conditioning regimens that suppress and/or ablate T cells. Additionally, we and others have demonstrated the potential of LV-fVIII HSPC and liver-directed AAV-fVIII gene therapy to eradicate pre-existing inhibitors in murine and canine models of HA, respectively. Future preclinical studies will be essential to elucidate immune mechanism(s) at play in the context of gene therapy for HA, as well as strategies for preventing adverse immune responses and promoting immune tolerance even in the setting of pre-existing inhibitors.
Collapse
Affiliation(s)
- Seema R. Patel
- Hemostasis and Thrombosis Program, Department of Pediatrics, Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta and Emory University, Atlanta, GA, United States
| | - Taran S. Lundgren
- Cell and Gene Therapy Program, Department of Pediatrics, Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta and Emory University, Atlanta, GA, United States
- Graduate Program in Molecular and Systems Pharmacology, Laney Graduate School, Emory University, Atlanta, GA, United States
| | - H. Trent Spencer
- Cell and Gene Therapy Program, Department of Pediatrics, Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta and Emory University, Atlanta, GA, United States
| | - Christopher B. Doering
- Cell and Gene Therapy Program, Department of Pediatrics, Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta and Emory University, Atlanta, GA, United States
| |
Collapse
|
14
|
Barbon E, Ayme G, Mohamadi A, Ottavi J, Kawecki C, Casari C, Verhenne S, Marmier S, van Wittenberghe L, Charles S, Collaud F, Denis CV, Christophe OD, Mingozzi F, Lenting PJ. Single-domain antibodies targeting antithrombin reduce bleeding in hemophilic mice with or without inhibitors. EMBO Mol Med 2020; 12:e11298. [PMID: 32159286 PMCID: PMC7136963 DOI: 10.15252/emmm.201911298] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 02/14/2020] [Accepted: 02/18/2020] [Indexed: 01/08/2023] Open
Abstract
Novel therapies for hemophilia, including non-factor replacement and in vivo gene therapy, are showing promising results in the clinic, including for patients having a history of inhibitor development. Here, we propose a novel therapeutic approach for hemophilia based on llama-derived single-domain antibody fragments (sdAbs) able to restore hemostasis by inhibiting the antithrombin (AT) anticoagulant pathway. We demonstrated that sdAbs engineered in multivalent conformations were able to block efficiently AT activity in vitro, restoring the thrombin generation potential in FVIII-deficient plasma. When delivered as a protein to hemophilia A mice, a selected bi-paratopic sdAb significantly reduced the blood loss in a model of acute bleeding injury. We then packaged this sdAb in a hepatotropic AAV8 vector and tested its safety and efficacy profile in hemophilic mouse models. We show that the long-term expression of the bi-paratopic sdAb in the liver is safe and poorly immunogenic, and results in sustained correction of the bleeding phenotype in hemophilia A and B mice, even in the presence of inhibitory antibodies to the therapeutic clotting factor.
Collapse
Affiliation(s)
- Elena Barbon
- Genethon, Institut National de la Santé et de la Recherche Médicale U951 IntegrareUniversité Paris‐SaclayUniversity of EvryEvryFrance
| | - Gabriel Ayme
- HITh, UMR_S1176Institut National de la Santé et de la Recherche MédicaleUniversité Paris‐SaclayLe Kremlin‐BicêtreFrance
| | - Amel Mohamadi
- HITh, UMR_S1176Institut National de la Santé et de la Recherche MédicaleUniversité Paris‐SaclayLe Kremlin‐BicêtreFrance
| | | | - Charlotte Kawecki
- HITh, UMR_S1176Institut National de la Santé et de la Recherche MédicaleUniversité Paris‐SaclayLe Kremlin‐BicêtreFrance
| | - Caterina Casari
- HITh, UMR_S1176Institut National de la Santé et de la Recherche MédicaleUniversité Paris‐SaclayLe Kremlin‐BicêtreFrance
| | - Sebastien Verhenne
- HITh, UMR_S1176Institut National de la Santé et de la Recherche MédicaleUniversité Paris‐SaclayLe Kremlin‐BicêtreFrance
| | - Solenne Marmier
- Genethon, Institut National de la Santé et de la Recherche Médicale U951 IntegrareUniversité Paris‐SaclayUniversity of EvryEvryFrance
| | - Laetitia van Wittenberghe
- Genethon, Institut National de la Santé et de la Recherche Médicale U951 IntegrareUniversité Paris‐SaclayUniversity of EvryEvryFrance
| | - Severine Charles
- Genethon, Institut National de la Santé et de la Recherche Médicale U951 IntegrareUniversité Paris‐SaclayUniversity of EvryEvryFrance
| | - Fanny Collaud
- Genethon, Institut National de la Santé et de la Recherche Médicale U951 IntegrareUniversité Paris‐SaclayUniversity of EvryEvryFrance
| | - Cecile V Denis
- HITh, UMR_S1176Institut National de la Santé et de la Recherche MédicaleUniversité Paris‐SaclayLe Kremlin‐BicêtreFrance
| | - Olivier D Christophe
- HITh, UMR_S1176Institut National de la Santé et de la Recherche MédicaleUniversité Paris‐SaclayLe Kremlin‐BicêtreFrance
| | - Federico Mingozzi
- Genethon, Institut National de la Santé et de la Recherche Médicale U951 IntegrareUniversité Paris‐SaclayUniversity of EvryEvryFrance
| | - Peter J Lenting
- HITh, UMR_S1176Institut National de la Santé et de la Recherche MédicaleUniversité Paris‐SaclayLe Kremlin‐BicêtreFrance
| |
Collapse
|
15
|
Satué K, Gardon JC, Muñoz A. Clinical and laboratorial description of the differential diagnoses of hemostatic disorders in the horse. IRANIAN JOURNAL OF VETERINARY RESEARCH 2020; 21:1-8. [PMID: 32368218 PMCID: PMC7183377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 06/18/2019] [Indexed: 06/11/2023]
Abstract
The process of fibrin clot formation is a series of complex and well-regulated reactions involving blood vessels, platelets, procoagulant plasma proteins, natural inhibitors, and fibrinolytic enzymes. Vasculitis can be caused by a variety of different agents as bacteria, viruses, protozoal, rickettsial organisms, toxic, drugs, medications, and neoplasms. The most common cause of vasculitis is the purpura hemorrhagica, which is associated with exposure to Streptococcus equi ssp. equi or less commonly, equine influenza. Deficiencies or defects of the hemostatic components may result in bleeding and/or thrombosis. Inherited alterations of primary hemostasis (von Willebrand disease: vWD and Glanzmann's thrombasthenia: GT) and of secondary hemostasis (hemophilia A and prekallikrein: PK deficiency) are scarcely reported in equine clinic. On the contrary, acquired alterations of primary and secondary hemostasis are commonly found. They include thrombocytopenia, platelet dysfunction due to the administration of some drugs and targeted antiplatelet agents, decreased factor synthesis (liver disease or deficiency of vitamin K), release of inactive factors, inhibition of factor activity, or excessive consumption and depletion of factors (platelets, coagulation factors, and anticoagulants factors as antithrombin (AT) and protein C). Disseminated intravascular coagulation (DIC) is the most common and complex hemostatic disorder in horses and appears to be associated with sepsis, inflammatory and ischemic gastrointestinal tract disorders and other systemic severe diseases. These alterations are commonly found in patients in intensive care units.
Collapse
Affiliation(s)
- K. Satué
- Department of Animal Medicine and Surgery, Faculty of Veterinary, CEU-Cardenal Herrera University, Valencia, Spain
| | - J. C. Gardon
- Department of Experimental Sciences and Mathematics, Catholic University of Valencia “San Vicente Mártir”, Valencia, Spain
| | - A. Muñoz
- Department of Animal Medicine and Surgery, Faculty of Veterinary Medicine, University of Córdoba, Córdoba, Spain
| |
Collapse
|
16
|
Spronck EA, Liu YP, Lubelski J, Ehlert E, Gielen S, Montenegro-Miranda P, de Haan M, Nijmeijer B, Ferreira V, Petry H, van Deventer SJ. Enhanced Factor IX Activity following Administration of AAV5-R338L "Padua" Factor IX versus AAV5 WT Human Factor IX in NHPs. MOLECULAR THERAPY-METHODS & CLINICAL DEVELOPMENT 2019; 15:221-231. [PMID: 31709273 PMCID: PMC6834974 DOI: 10.1016/j.omtm.2019.09.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 09/19/2019] [Indexed: 10/29/2022]
Abstract
Gene therapy for severe hemophilia B is advancing and offers sustained disease amelioration with a single treatment. We have reported the efficacy and safety of AMT-060, an investigational gene therapy comprising an adeno-associated virus serotype 5 capsid encapsidating the codon-optimized wild-type human factor IX (WT hFIX) gene with a liver-specific promoter, in patients with severe hemophilia B. Treatment with 2 × 1013 gc/kg AMT-060 showed sustained and durable FIX activity of 3%-13% and a substantial reduction in spontaneous bleeds without T cell-mediated hepatoxicity. To achieve higher FIX activity, we modified AMT-060 to encode the R338L "Padua" FIX variant that has increased specific activity (AMT-061). We report the safety and increased FIX activity of AMT-061 in non-human primates. Animals (n = 3/group) received intravenous AMT-060 (5 × 1012 gc/kg), AMT-061 (ranging from 5 × 1011 to 9 × 1013 gc/kg), or vehicle. Human FIX protein expression, FIX activity, and coagulation markers including D-dimer and thrombin-antithrombin complexes were measured. At equal doses, AMT-060 and AMT-061 resulted in similar human FIX protein expression, but FIX activity was 6.5-fold enhanced using AMT-061. Both vectors show similar safety and transduction profiles. Thus, AMT-061 holds great promise as a more potent FIX replacement gene therapy with a favorable safety profile.
Collapse
Affiliation(s)
- Elisabeth A Spronck
- uniQure biopharma B.V., Paasheuvelweg 25A, 1105 BP Amsterdam, the Netherlands
| | - Ying Poi Liu
- uniQure biopharma B.V., Paasheuvelweg 25A, 1105 BP Amsterdam, the Netherlands
| | - Jacek Lubelski
- uniQure biopharma B.V., Paasheuvelweg 25A, 1105 BP Amsterdam, the Netherlands
| | - Erich Ehlert
- uniQure biopharma B.V., Paasheuvelweg 25A, 1105 BP Amsterdam, the Netherlands
| | - Sander Gielen
- uniQure biopharma B.V., Paasheuvelweg 25A, 1105 BP Amsterdam, the Netherlands
| | | | - Martin de Haan
- uniQure biopharma B.V., Paasheuvelweg 25A, 1105 BP Amsterdam, the Netherlands
| | - Bart Nijmeijer
- uniQure biopharma B.V., Paasheuvelweg 25A, 1105 BP Amsterdam, the Netherlands
| | - Valerie Ferreira
- uniQure biopharma B.V., Paasheuvelweg 25A, 1105 BP Amsterdam, the Netherlands
| | - Harald Petry
- uniQure biopharma B.V., Paasheuvelweg 25A, 1105 BP Amsterdam, the Netherlands
| | - Sander J van Deventer
- uniQure biopharma B.V., Paasheuvelweg 25A, 1105 BP Amsterdam, the Netherlands.,Department of Gastroenterology and Hepatology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| |
Collapse
|
17
|
Meeks SL, Herzog RW. The national blueprint for future basic and translational research to understand factor VIII immunogenicity: NHLBI State of the Science Workshop on factor VIII inhibitors. Haemophilia 2019; 25:595-602. [DOI: 10.1111/hae.13740] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 01/29/2019] [Accepted: 02/22/2019] [Indexed: 12/27/2022]
Affiliation(s)
- Shannon L. Meeks
- Aflac Cancer and Blood Disorders Service; Emory University; Atlanta Georgia
| | - Roland W. Herzog
- Herman B Wells Center for Pediatric Research; Indiana University; Indianapolis Indiana
| | | |
Collapse
|
18
|
Vøls KK, Kjelgaard-Hansen M, Ley CD, Hansen AK, Petersen M. Bleed volume of experimental knee haemarthrosis correlates with the subsequent degree of haemophilic arthropathy. Haemophilia 2019; 25:324-333. [PMID: 30648774 DOI: 10.1111/hae.13672] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 11/21/2018] [Accepted: 11/21/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Haemophilic arthropathy is the main morbidity of haemophilia. The individual pathological response to the same number of clinically evident joint bleeds is highly variable; thus, it remains unknown if certain joint bleeding characteristics are critical for the development of arthropathy. AIM To study the relation between bleed volume and subsequent development of arthropathy, we aimed to develop quantitative in vivo imaging of active joint bleeds in a mouse model of haemophilia. METHODS Haemophilia A (F8-KO) and wild-type (WT) mice were IV-dosed with a micro-CT blood pool contrast agent prior to an induced knee haemarthrosis or sham procedure. The mice were micro-CT scanned five times the following 2 days to characterise and quantify the induced haemarthrosis in vivo. On Day 14, the mice were euthanized and pathological changes evaluated by histology and micro-CT. Additionally, bleeding characteristics in vehicle-treated F8-KO mice were compared with those of recombinant FVIII (rFVIII)-treated F8-KO mice. RESULTS F8-KO mice had a significantly larger bleed volume than WT mice at all scan time points. The bleed volume 12 hours after induction of haemarthrosis correlated with the subsequent degree of arthropathy. Presence of µCT-detectable bone pathology was associated with a significantly increased bleed volume among F8-KO mice. rFVIII treatment significantly reduced bleed volume in F8-KO mice. CONCLUSION Quantitative in vivo contrast-enhanced micro-CT imaging can be used to characterize and quantify joint bleeds in a mouse model of haemophilic arthropathy. The bleed volume correlates with the subsequent degree of arthropathy.
Collapse
Affiliation(s)
- Kåre Kryger Vøls
- Global Drug Discovery, Novo Nordisk A/S, Maaloev, Denmark.,Veterinary and Animal Sciences, University of Copenhagen, Frederiksberg, Denmark
| | | | | | - Axel Kornerup Hansen
- Veterinary and Animal Sciences, University of Copenhagen, Frederiksberg, Denmark
| | - Maj Petersen
- Global Drug Discovery, Novo Nordisk A/S, Maaloev, Denmark
| |
Collapse
|
19
|
Wyseure T, Cooke EJ, Declerck PJ, Behrendt N, Meijers JCM, von Drygalski A, Mosnier LO. Defective TAFI activation in hemophilia A mice is a major contributor to joint bleeding. Blood 2018; 132:1593-1603. [PMID: 30026184 PMCID: PMC6182268 DOI: 10.1182/blood-2018-01-828434] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 07/11/2018] [Indexed: 02/02/2023] Open
Abstract
Joint bleeds are common in congenital hemophilia but rare in acquired hemophilia A (aHA) for reasons unknown. To identify key mechanisms responsible for joint-specific bleeding in congenital hemophilia, bleeding phenotypes after joint injury and tail transection were compared in aHA wild-type (WT) mice (receiving an anti-factor VIII [FVIII] antibody) and congenital HA (FVIII-/-) mice. Both aHA and FVIII-/- mice bled severely after tail transection, but consistent with clinical findings, joint bleeding was notably milder in aHA compared with FVIII-/- mice. Focus was directed to thrombin-activatable fibrinolysis inhibitor (TAFI) to determine its potentially protective effect on joint bleeding in aHA. Joint bleeding in TAFI-/- mice with anti-FVIII antibody was increased, compared with WT aHA mice, and became indistinguishable from joint bleeding in FVIII-/- mice. Measurements of circulating TAFI zymogen consumption after joint injury indicated severely defective TAFI activation in FVIII-/- mice in vivo, consistent with previous in vitro analyses in FVIII-deficient plasma. In contrast, notable TAFI activation was observed in aHA mice, suggesting that TAFI protected aHA joints against bleeding. Pharmacological inhibitors of fibrinolysis revealed that urokinase-type plasminogen activator (uPA)-induced fibrinolysis drove joint bleeding, whereas tissue-type plasminogen activator-mediated fibrinolysis contributed to tail bleeding. These data identify TAFI as an important modifier of hemophilic joint bleeding in aHA by inhibiting uPA-mediated fibrinolysis. Moreover, our data suggest that bleed protection by TAFI was absent in congenital FVIII-/- mice because of severely defective TAFI activation, underscoring the importance of clot protection in addition to clot formation when considering prohemostatic strategies for hemophilic joint bleeding.
Collapse
Affiliation(s)
- Tine Wyseure
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, CA
| | - Esther J Cooke
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, CA
- Department of Medicine, University of California San Diego, San Diego, CA
| | - Paul J Declerck
- Department of Pharmaceutical and Pharmacological Sciences, University of Leuven, Leuven, Belgium
| | - Niels Behrendt
- The Finsen Laboratory, Rigshospitalet/Biotech Research and Innovation Centre, University of Copenhagen, Copenhagen, Denmark
| | - Joost C M Meijers
- Department of Plasma Proteins, Sanquin Research, Amsterdam, The Netherlands; and
- Department of Experimental Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Annette von Drygalski
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, CA
- Department of Medicine, University of California San Diego, San Diego, CA
| | - Laurent O Mosnier
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, CA
| |
Collapse
|
20
|
Doshi BS, Arruda VR. Gene therapy for hemophilia: what does the future hold? Ther Adv Hematol 2018; 9:273-293. [PMID: 30210756 DOI: 10.1177/2040620718791933] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 07/09/2018] [Indexed: 01/19/2023] Open
Abstract
Recent phase I/II adeno-associated viral vector-mediated gene therapy clinical trials have reported remarkable success in ameliorating disease phenotype in hemophilia A and B. These trials, which highlight the challenges overcome through decades of preclinical and first in human clinical studies, have generated considerable excitement for patients and caregivers alike. Optimization of vector and transgene expression has significantly improved the ability to achieve therapeutic factor levels in these subjects. Long-term follow-up studies will guide standardization of the approach with respect to the combination of serotype, promoter, dose, and manufacturing processes and inform safety for inclusion of young patients. Certain limitations preclude universal applicability of gene therapy, including transient liver transaminase elevations due to the immune responses to vector capsids or as yet undefined mechanisms, underlying liver disease from iatrogenic viral hepatitis, and neutralizing antibodies to clotting factors. Integrating vectors show promising preclinical results, but manufacturing and safety concerns still remain. The prospect of gene editing for correction of the underlying mutation is on the horizon with considerable potential. Herein, we review the advances and limitations that have resulted in these recent successful clinical trials and outline avenues that will allow for broader applicability of gene therapy.
Collapse
Affiliation(s)
- Bhavya S Doshi
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Valder R Arruda
- Department of Pediatrics, The Children's Hospital of Philadelphia, 3501 Civic Center Blvd, 5056 Colket Translational Research Center, Philadelphia, PA 19104, USA
| |
Collapse
|
21
|
Advances in gene therapy for hemophilia: basis, current status, and future perspectives. Int J Hematol 2018; 111:31-41. [DOI: 10.1007/s12185-018-2513-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 07/30/2018] [Accepted: 07/31/2018] [Indexed: 02/08/2023]
|
22
|
Markusic DM, Nichols TC, Merricks EP, Palaschak B, Zolotukhin I, Marsic D, Zolotukhin S, Srivastava A, Herzog RW. Evaluation of engineered AAV capsids for hepatic factor IX gene transfer in murine and canine models. J Transl Med 2017; 15:94. [PMID: 28460646 PMCID: PMC5412045 DOI: 10.1186/s12967-017-1200-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 04/25/2017] [Indexed: 01/21/2023] Open
Abstract
Background Adeno-associated virus (AAV) gene therapy vectors have shown the best outcomes in human clinical studies for the treatment of genetic diseases such as hemophilia. However, these pivotal investigations have also identified several challenges. For example, high vector doses are often used for hepatic gene transfer, and cytotoxic T lymphocyte responses against viral capsid may occur. Therefore, achieving therapy at reduced vector doses and other strategies to reduce capsid antigen presentation are desirable. Methods We tested several engineered AAV capsids for factor IX (FIX) expression for the treatment of hemophilia B by hepatic gene transfer. These capsids lack potential phosphorylation or ubiquitination sites, or had been generated through molecular evolution. Results AAV2 capsids lacking either a single lysine residue or 3 tyrosine residues directed substantially higher coagulation FIX expression in mice compared to wild-type sequence or other mutations. In hemophilia B dogs, however, expression from the tyrosine-mutant vector was merely comparable to historical data on AAV2. Evolved AAV2-LiC capsid was highly efficient in hemophilia B mice but lacked efficacy in a hemophilia B dog. Conclusions Several alternative strategies for capsid modification improve the in vivo performance of AAV vectors in hepatic gene transfer for correction of hemophilia. However, capsid optimization solely in mouse liver may not predict efficacy in other species and thus is of limited translational utility. Electronic supplementary material The online version of this article (doi:10.1186/s12967-017-1200-1) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- David M Markusic
- Department of Pediatrics, University of Florida, Gainesville, FL, 32610, USA.
| | - Timothy C Nichols
- Department of Pathology and Laboratory Medicine, University of North Carolina-Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Elizabeth P Merricks
- Department of Pathology and Laboratory Medicine, University of North Carolina-Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Brett Palaschak
- Department of Pediatrics, University of Florida, Gainesville, FL, 32610, USA
| | - Irene Zolotukhin
- Department of Pediatrics, University of Florida, Gainesville, FL, 32610, USA
| | - Damien Marsic
- Department of Pediatrics, University of Florida, Gainesville, FL, 32610, USA
| | - Sergei Zolotukhin
- Department of Pediatrics, University of Florida, Gainesville, FL, 32610, USA
| | - Arun Srivastava
- Department of Pediatrics, University of Florida, Gainesville, FL, 32610, USA
| | - Roland W Herzog
- Department of Pediatrics, University of Florida, Gainesville, FL, 32610, USA.
| |
Collapse
|
23
|
Global measurement of coagulation in plasma from normal and haemophilia dogs using a novel modified thrombin generation test - Demonstrated in vitro and ex vivo. PLoS One 2017; 12:e0175030. [PMID: 28384182 PMCID: PMC5383133 DOI: 10.1371/journal.pone.0175030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 03/20/2017] [Indexed: 11/27/2022] Open
Abstract
Introduction Canine models of severe haemophilia resemble their human equivalents both regarding clinical bleeding phenotype and response to treatment. Therefore pre-clinical studies in haemophilia dogs have allowed researchers to make valuable translational predictions regarding the potency and efficacy of new anti-haemophilia drugs (AHDs) in humans. To refine in vivo experiments and reduce number of animals, such translational studies are ideally preceded by in vitro prediction of compound efficacy using a plasma based global coagulation method. One such widely used method is the thrombin generation test (TGT). Unfortunately, commercially available TGTs are incapable of distinguishing between normal and haemophilia canine plasma, and therefore in vitro prediction using TGT has so far not been possible in canine plasma material. Aim Establish a modified TGT capable of: 1) distinguishing between normal and haemophilia canine plasma, 2) monitoring correlation between canine plasma levels of coagulation factor VIII (FVIII) and IX (FIX) and thrombin generation, 3) assessing for agreement between compound activity and thrombin generation in ex vivo samples. Methods A modified TGT assay was established where coagulation was triggered using a commercially available activated partial thromboplastin time reagent. Results With the modified TGT a significant difference was observed in thrombin generation between normal and haemophilia canine plasma. A dose dependent thrombin generation was observed when assessing haemophilia A and B plasma spiked with dilution series of FVIII and FIX, respectively. Correlation between FVIII activity and thrombin generation was observed when analyzing samples from haemophilia A dogs dosed with canine FVIII. Limit of detection was 0.1% (v/v) FVIII or FIX. Conclusion A novel modified TGT suitable for monitoring and prediction of replacement therapy efficacy in plasma from haemophilia A and B dogs was established.
Collapse
|
24
|
Herzog RW, Nichols TC, Su J, Zhang B, Sherman A, Merricks EP, Raymer R, Perrin GQ, Häger M, Wiinberg B, Daniell H. Oral Tolerance Induction in Hemophilia B Dogs Fed with Transplastomic Lettuce. Mol Ther 2017; 25:512-522. [PMID: 28153098 PMCID: PMC5368425 DOI: 10.1016/j.ymthe.2016.11.009] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 11/01/2016] [Accepted: 11/07/2016] [Indexed: 12/25/2022] Open
Abstract
Anti-drug antibodies in hemophilia patients substantially complicate treatment. Their elimination through immune tolerance induction (ITI) protocols poses enormous costs, and ITI is often ineffective for factor IX (FIX) inhibitors. Moreover, there is no prophylactic ITI protocol to prevent anti-drug antibody (ADA) formation. Using general immune suppression is problematic. To address this urgent unmet medical need, we delivered antigen bioencapsulated in plant cells to hemophilia B dogs. Commercial-scale production of CTB-FIX fusion expressed in lettuce chloroplasts was done in a hydroponic facility. CTB-FIX (∼1 mg/g) in lyophilized cells was stable with proper folding, disulfide bonds, and pentamer assembly after 30-month storage at ambient temperature. Robust suppression of immunoglobulin G (IgG)/inhibitor and IgE formation against intravenous FIX was observed in three of four hemophilia B dogs fed with lyophilized lettuce cells expressing CTB-FIX. No side effects were detected after feeding CTB-FIX-lyophilized plant cells for >300 days. Coagulation times were markedly shortened by intravenous FIX in orally tolerized treated dogs, in contrast to control dogs that formed high-titer antibodies to FIX. Commercial-scale production, stability, prolonged storage of lyophilized cells, and efficacy in tolerance induction in a large, non-rodent model of human disease offer a novel concept for oral tolerance and low-cost production and delivery of biopharmaceuticals.
Collapse
Affiliation(s)
- Roland W Herzog
- Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Timothy C Nichols
- Department of Pathology and Laboratory Medicine, The University of North Carolina, Chapel Hill, Chapel Hill, NC 25716, USA
| | - Jin Su
- Department of Biochemistry, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Bei Zhang
- Department of Biochemistry, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Alexandra Sherman
- Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Elizabeth P Merricks
- Department of Pathology and Laboratory Medicine, The University of North Carolina, Chapel Hill, Chapel Hill, NC 25716, USA
| | - Robin Raymer
- Department of Pathology and Laboratory Medicine, The University of North Carolina, Chapel Hill, Chapel Hill, NC 25716, USA
| | - George Q Perrin
- Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Mattias Häger
- Global Research, Novo Nordisk A/S, Måløv 2760, Denmark
| | - Bo Wiinberg
- Global Research, Novo Nordisk A/S, Måløv 2760, Denmark
| | - Henry Daniell
- Department of Biochemistry, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA.
| |
Collapse
|
25
|
Balestra D, Scalet D, Pagani F, Rogalska ME, Mari R, Bernardi F, Pinotti M. An Exon-Specific U1snRNA Induces a Robust Factor IX Activity in Mice Expressing Multiple Human FIX Splicing Mutants. MOLECULAR THERAPY-NUCLEIC ACIDS 2016; 5:e370. [PMID: 27701399 PMCID: PMC5095682 DOI: 10.1038/mtna.2016.77] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 07/21/2016] [Indexed: 12/30/2022]
Abstract
In cellular models we have demonstrated that a unique U1snRNA targeting an intronic region downstream of a defective exon (Exon-specific U1snRNA, ExSpeU1) can rescue multiple exon-skipping mutations, a relevant cause of genetic disease. Here, we explored in mice the ExSpeU1 U1fix9 toward two model Hemophilia B-causing mutations at the 5′ (c.519A > G) or 3′ (c.392-8T > G) splice sites of F9 exon 5. Hydrodynamic injection of wt-BALB/C mice with plasmids expressing the wt and mutant (hFIX-2G5′ss and hFIX-8G3′ss) splicing-competent human factor IX (hFIX) cassettes resulted in the expression of hFIX transcripts lacking exon 5 in liver, and in low plasma levels of inactive hFIX. Coinjection of U1fix9, but not of U1wt, restored exon inclusion of variants and in the intrinsically weak FIXwt context. This resulted in appreciable circulating hFIX levels (mean ± SD; hFIX-2G5′ss, 1.0 ± 0.5 µg/ml; hFIX-8G3′ss, 1.2 ± 0.3 µg/ml; and hFIXwt, 1.9 ± 0.6 µg/ml), leading to a striking shortening (from ~100 seconds of untreated mice to ~80 seconds) of FIX-dependent coagulation times, indicating a hFIX with normal specific activity. This is the first proof-of-concept in vivo that a unique ExSpeU1 can efficiently rescue gene expression impaired by distinct exon-skipping variants, which extends the applicability of ExSpeU1s to panels of mutations and thus cohort of patients.
Collapse
Affiliation(s)
- Dario Balestra
- Department of Life Sciences and Biotechnology, University of Ferrara, Ferrara, Italy
| | - Daniela Scalet
- Department of Life Sciences and Biotechnology, University of Ferrara, Ferrara, Italy
| | - Franco Pagani
- Internation Centre for Genetic Engineering and Biotechnology, Trieste, Italy
| | | | - Rosella Mari
- Haemostasis & Thrombosis Center, University of Ferrara, Ferrara, Italy
| | - Francesco Bernardi
- Department of Life Sciences and Biotechnology, University of Ferrara, Ferrara, Italy.,LTTA Center, University of Ferrara, Ferrara, Italy
| | - Mirko Pinotti
- Department of Life Sciences and Biotechnology, University of Ferrara, Ferrara, Italy.,LTTA Center, University of Ferrara, Ferrara, Italy
| |
Collapse
|
26
|
Life in the shadow of a dominant partner: the FVIII-VWF association and its clinical implications for hemophilia A. Blood 2016; 128:2007-2016. [PMID: 27587878 DOI: 10.1182/blood-2016-04-713289] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 08/18/2016] [Indexed: 11/20/2022] Open
Abstract
A normal hemostatic response to vascular injury requires both factor VIII (FVIII) and von Willebrand factor (VWF). In plasma, VWF and FVIII normally circulate as a noncovalent complex, and each has a critical function in the maintenance of hemostasis. Furthermore, the interaction between VWF and FVIII plays a crucial role in FVIII function, immunogenicity, and clearance, with VWF essentially serving as a chaperone for FVIII. Several novel recombinant FVIII (rFVIII) therapies for hemophilia A have been in clinical development, which aim to increase the half-life of FVIII (∼12 hours) and reduce dosing frequency by utilizing bioengineering techniques including PEGylation, Fc fusion, and single-chain design. However, these approaches have achieved only moderate increases in half-life of 1.5- to 2-fold compared with marketed FVIII products. Clearance of PEGylated rFVIII, rFVIIIFc, and rVIII-SingleChain is still regulated to a large extent by interaction with VWF. Therefore, the half-life of VWF (∼15 hours) appears to be the limiting factor that has confounded attempts to extend the half-life of rFVIII. A greater understanding of the interaction between FVIII and VWF is required to drive novel bioengineering strategies for products that either prolong the survival of VWF or limit VWF-mediated clearance of FVIII.
Collapse
|
27
|
Lymphovenous hemostasis and the role of platelets in regulating lymphatic flow and lymphatic vessel maturation. Blood 2016; 128:1169-73. [PMID: 27385789 DOI: 10.1182/blood-2016-04-636415] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 07/02/2016] [Indexed: 12/12/2022] Open
Abstract
Aside from the established role for platelets in regulating hemostasis and thrombosis, recent research has revealed a discrete role for platelets in the separation of the blood and lymphatic vascular systems. Platelets are activated by interaction with lymphatic endothelial cells at the lymphovenous junction, the site in the body where the lymphatic system drains into the blood vascular system, resulting in a platelet plug that, with the lymphovenous valve, prevents blood from entering the lymphatic circulation. This process, known as "lymphovenous hemostasis," is mediated by activation of platelet CLEC-2 receptors by the transmembrane ligand podoplanin expressed by lymphatic endothelial cells. Lymphovenous hemostasis is required for normal lymph flow, and mice deficient in lymphovenous hemostasis exhibit lymphedema and sometimes chylothorax phenotypes indicative of lymphatic insufficiency. Unexpectedly, the loss of lymph flow in these mice causes defects in maturation of collecting lymphatic vessels and lymphatic valve formation, uncovering an important role for fluid flow in driving endothelial cell signaling during development of collecting lymphatics. This article summarizes the current understanding of lymphovenous hemostasis and its effect on lymphatic vessel maturation and synthesizes the outstanding questions in the field, with relationship to human disease.
Collapse
|
28
|
Nichols TC, Hough C, Agersø H, Ezban M, Lillicrap D. Canine models of inherited bleeding disorders in the development of coagulation assays, novel protein replacement and gene therapies. J Thromb Haemost 2016; 14:894-905. [PMID: 26924758 DOI: 10.1111/jth.13301] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Accepted: 02/08/2016] [Indexed: 01/09/2023]
Abstract
Animal models of inherited bleeding disorders are important for understanding disease pathophysiology and are required for preclinical assessment of safety prior to testing of novel therapeutics in human and veterinary medicine. Experiments in these animals represent important translational research aimed at developing safer and better treatments, such as plasma-derived and recombinant protein replacement therapies, gene therapies and immune tolerance protocols for antidrug inhibitory antibodies. Ideally, testing is done in animals with the analogous human disease to provide essential safety information, estimates of the correct starting dose and dose response (pharmacokinetics) and measures of efficacy (pharmacodynamics) that guide the design of human trials. For nearly seven decades, canine models of hemophilia, von Willebrand disease and other inherited bleeding disorders have not only informed our understanding of the natural history and pathophysiology of these disorders but also guided the development of novel therapeutics for use in humans and dogs. This has been especially important for the development of gene therapy, in which unique toxicities such as insertional mutagenesis, germ line gene transfer and viral toxicities must be assessed. There are several issues regarding comparative medicine in these species that have a bearing on these studies, including immune reactions to xenoproteins, varied metabolism or clearance of wild-type and modified proteins, and unique tissue tropism of viral vectors. This review focuses on the results of studies that have been performed in dogs with inherited bleeding disorders that closely mirror the human condition to develop safe and effective protein and gene-based therapies that benefit both species.
Collapse
Affiliation(s)
- T C Nichols
- Departments of Medicine and Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - C Hough
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada
| | - H Agersø
- Research and Development Novo Nordisk A/S, Maaloev, Denmark
| | - M Ezban
- Research and Development Novo Nordisk A/S, Maaloev, Denmark
| | - D Lillicrap
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada
| |
Collapse
|
29
|
Wang Q, Dong B, Firrman J, Wu W, Roberts S, Moore AR, Liu LS, Chin MPS, Diao Y, Kost J, Xiao W. Evaluation of the biological differences of canine and human factor VIII in gene delivery: implications in human hemophilia treatment. Gene Ther 2016; 23:597-605. [PMID: 27064790 PMCID: PMC4936945 DOI: 10.1038/gt.2016.34] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 03/17/2016] [Accepted: 03/21/2016] [Indexed: 01/25/2023]
Abstract
The canine is the most important large animal model for testing novel hemophilia A (HA) treatment. It is often necessary to use canine factor VIII (cFIII) gene or protein for the evaluation of HA treatment in the canine model. However, different biological properties between cFVIII and human FVIII (hFVIII) indicated that the development of novel HA treatment may require careful characterization of non-human FVIII. To investigate whether the data obtained using cFVIII can translate to HA treatment in human, we analyzed the differential biological properties of canine heavy chain (cHC) and light chain (cLC) by comparing with human heavy chain (hHC) and light chain (hLC). The secretion of cHC was 5-30-fold higher than hHC, with or without light chains (LCs). cHC+hLC group exhibited ~18-fold increase in coagulation activity compared with hHC+hLC delivery by recombinant adeno-associated viral vectors. Unlike hHC, the secretion of cHC was independent of LCs. cLC improves the specific activity of FVIII by two- to threefold compared with hLC. Moreover, the cLC, but not cHC, contributes to the higher stability of cFVIII. Our results suggested that the cFVIII expression results in the canine model should be interpreted with caution as the cHC secreted more efficiently than hHC and cLC exhibited a more active and stable phenotype than hLC.
Collapse
Affiliation(s)
- Q Wang
- School of Biomedical Sciences, Huaqiao University, Quanzhou, Fujian, China.,Sol Sherry Thrombosis Research Center, Temple University, Philadelphia, PA, USA
| | - B Dong
- Sol Sherry Thrombosis Research Center, Temple University, Philadelphia, PA, USA
| | - J Firrman
- Department of Microbiology and Immunology, Temple University, Philadelphia, PA, USA.,United States Department of Agriculture, ARS, ERRC, Wyndmoor, PA, USA
| | - W Wu
- Department of Laboratory Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - S Roberts
- Sol Sherry Thrombosis Research Center, Temple University, Philadelphia, PA, USA
| | - A R Moore
- Sol Sherry Thrombosis Research Center, Temple University, Philadelphia, PA, USA
| | - L S Liu
- United States Department of Agriculture, ARS, ERRC, Wyndmoor, PA, USA
| | - M P S Chin
- School of Biomedical Sciences, Huaqiao University, Quanzhou, Fujian, China
| | - Y Diao
- School of Biomedical Sciences, Huaqiao University, Quanzhou, Fujian, China
| | - J Kost
- Department of Chemical Engineering, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - W Xiao
- School of Biomedical Sciences, Huaqiao University, Quanzhou, Fujian, China.,Sol Sherry Thrombosis Research Center, Temple University, Philadelphia, PA, USA.,Department of Microbiology and Immunology, Temple University, Philadelphia, PA, USA.,Department of Laboratory Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.,Cardiovascular Research Center, Temple University, Philadelphia, PA, USA
| |
Collapse
|
30
|
Choudhury S, Plautz WE, Zacarias C, Majumder R. Mini-review on "A novel one-step purification of mouse factor IX". JOURNAL OF RARE DISEASES RESEARCH & TREATMENT 2016; 1:8-10. [PMID: 27819071 PMCID: PMC5094185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
| | | | | | - Rinku Majumder
- Correspondence: Dr. Rinku Majumder, Department of Biochemistry & Molecular Biology, LSU Health Science Center, 1901 Perdido Street, MEB-7114, New Orleans, LA-70112,
| |
Collapse
|
31
|
Lozier JN, Kloos MT, Merricks EP, Lemoine N, Whitford MH, Raymer RA, Bellinger DA, Nichols TC. Severe Hemophilia A in a Male Old English Sheep Dog with a C→T Transition that Created a Premature Stop Codon in Factor VIII. Comp Med 2016; 66:405-411. [PMID: 27780008 PMCID: PMC5073066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 12/23/2015] [Accepted: 02/28/2016] [Indexed: 06/06/2023]
Abstract
Animals with hemophilia are models for gene therapy, factor replacement, and inhibitor development in humans. We have actively sought dogs with severe hemophilia A that have novel factor VIII mutations unlike the previously described factor VIII intron 22 inversion. A male Old English Sheepdog with recurrent soft-tissue hemorrhage and hemarthrosis was diagnosed with severe hemophilia A (factor VIII activity less than 1% of normal). We purified genomic DNA from this dog and ruled out the common intron 22 inversion; we then sequenced all 26 exons. Comparing the results with the normal canine factor VIII sequence revealed a C→T transition in exon 12 of the factor VIII gene that created a premature stop codon at amino acid 577 in the A2 domain of the protein. In addition, 2 previously described polymorphisms that do not cause hemophilia were present at amino acids 909 and 1184. The hemophilia mutation creates a new TaqI site that facilitates rapid genotyping of affected offspring by PCR and restriction endonuclease analyses. This mutation is analogous to the previously described human factor VIII mutation at Arg583, which likewise is a CpG dinucleotide transition causing a premature stop codon in exon 12. Thus far, despite extensive treatment with factor VIII, this dog has not developed neutralizing antibodies ('inhibitors') to the protein. This novel mutation in a dog gives rise to severe hemophilia A analogous to a mutation seen in humans. This model will be useful for studies of the treatment of hemophilia.
Collapse
Affiliation(s)
- Jay N Lozier
- Department of Laboratory Medicine, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
| | - Mark T Kloos
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Elizabeth P Merricks
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Nathaly Lemoine
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Margaret H Whitford
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Robin A Raymer
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Dwight A Bellinger
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Timothy C Nichols
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
| |
Collapse
|
32
|
Li B, Luo X, Deng B, Wang J, McComb DW, Shi Y, Gaensler KML, Tan X, Dunn AL, Kerlin BA, Dong Y. An Orthogonal Array Optimization of Lipid-like Nanoparticles for mRNA Delivery in Vivo. NANO LETTERS 2015; 15:8099-107. [PMID: 26529392 PMCID: PMC4869688 DOI: 10.1021/acs.nanolett.5b03528] [Citation(s) in RCA: 172] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Systemic delivery of mRNA-based therapeutics remains a challenging issue for preclinical and clinical studies. Here, we describe new lipid-like nanoparticles (TT-LLNs) developed through an orthogonal array design, which demonstrates improved delivery efficiency of mRNA encoding luciferase in vitro by over 350-fold with significantly reduced experimental workload. One optimized TT3 LLN, termed O-TT3 LLNs, was able to restore the human factor IX (hFIX) level to normal physiological values in FIX-knockout mice. Consequently, these mRNA based nanomaterials merit further development for therapeutic applications.
Collapse
Affiliation(s)
- Bin Li
- Division of Pharmaceutics and Pharmaceutical Chemistry, College of Pharmacy, The Ohio State University, Columbus, Ohio 43210, United States
| | - Xiao Luo
- Division of Pharmaceutics and Pharmaceutical Chemistry, College of Pharmacy, The Ohio State University, Columbus, Ohio 43210, United States
| | - Binbin Deng
- Center for Electron Microscopy and Analysis, Department of Materials Science and Engineering, The Ohio State University, Columbus, Ohio 43212, United States
| | - Junfeng Wang
- Division of Pharmaceutics and Pharmaceutical Chemistry, College of Pharmacy, The Ohio State University, Columbus, Ohio 43210, United States
| | - David W. McComb
- Center for Electron Microscopy and Analysis, Department of Materials Science and Engineering, The Ohio State University, Columbus, Ohio 43212, United States
| | - Yimin Shi
- Department of Medicine, University of California-San Francisco, San Francisco, California 94143, United States
| | - Karin M. L. Gaensler
- Department of Medicine, University of California-San Francisco, San Francisco, California 94143, United States
| | - Xu Tan
- Tsinghua-Peking Center for Life Sciences, School of Medicine, Tsinghua University, Beijing 100084, China
| | - Amy L. Dunn
- Division of Hematology/Oncology/BMT, Nationwide Children’s Hospital, Columbus, Ohio 43205, United States
- Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, Ohio 43205, United States
| | - Bryce A. Kerlin
- Division of Hematology/Oncology/BMT, Nationwide Children’s Hospital, Columbus, Ohio 43205, United States
- Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, Ohio 43205, United States
- Center for Clinical and Translational Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio 43205, United States
| | - Yizhou Dong
- Division of Pharmaceutics and Pharmaceutical Chemistry, College of Pharmacy, The Ohio State University, Columbus, Ohio 43210, United States
- Corresponding Author:
| |
Collapse
|
33
|
High KA, Anguela XM. Adeno-associated viral vectors for the treatment of hemophilia. Hum Mol Genet 2015; 25:R36-41. [PMID: 26614390 DOI: 10.1093/hmg/ddv475] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 11/16/2015] [Indexed: 12/16/2022] Open
Abstract
Gene transfer studies for the treatment of hemophilia began more than two decades ago. A large body of pre-clinical work evaluated a variety of vectors and target tissues, but by the start of the new millennium it became evident that adeno-associated viral (AAV)-mediated gene transfer to the liver held great promise as a therapeutic tool. The transition to the clinical arena uncovered a number of unforeseen challenges, mainly in the form of a human-specific immune response against the vector that poses a significant limitation in the application of this technology. While the full nature of this response has not been elucidated, long-term expression of therapeutic levels of factor IX is already a reality for a small number of patients. Extending this success to a greater number of hemophilia B patients remains a major goal of the field, as well as translating this strategy to clinical therapy for hemophilia A. This review summarizes the progress of AAV-mediated gene therapy for the hemophilias, along with its upcoming prospects and challenges.
Collapse
Affiliation(s)
- Katherine A High
- Spark Therapeutics, Inc., 3737 Market St, Suite 1300, Philadelphia, PA, USA
| | - Xavier M Anguela
- Spark Therapeutics, Inc., 3737 Market St, Suite 1300, Philadelphia, PA, USA
| |
Collapse
|
34
|
Shetty KA, Kosloski MP, Mager DE, Balu-Iyer SV. Soy phosphatidylinositol containing nanoparticle prolongs hemostatic activity of B-domain deleted factor VIII in hemophilia A mice. J Pharm Sci 2015; 104:388-95. [PMID: 24700333 PMCID: PMC4183744 DOI: 10.1002/jps.23963] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Revised: 03/12/2014] [Accepted: 03/13/2014] [Indexed: 01/16/2023]
Abstract
Factor VIII (FVIII) replacement therapy in hemophilia A (HA) is complicated by a short half-life and high incidence of inhibitory antibody response against the protein. Phosphatidylinositol (PI) containing lipidic nanoparticles have previously been shown to reduce the immunogenicity and prolong the half-life of full length FVIII. It has not been established whether this prolongation in half-life improves hemostatic efficacy and whether this approach could be extended to the B-domain deleted form of FVIII (BDD FVIII). In the current study, we evaluated the pharmacokinetics (PK), hemostatic efficacy, and immunogenicity of BDD FVIII associated with PI nanoparticles (PI-BDD FVIII) in HA mice. Comparative human PK was predicted using an "informed scaling" approach. PI-BDD FVIII showed an approximate 1.5-fold increase in terminal half-life compared with free BDD FVIII following i.v. bolus doses of 40 IU/kg. PI-BDD FVIII-treated animals retained hemostatic efficacy longer than the free FVIII-treated group in a tail vein transection model of hemostasis. PI association reduced the development of inhibitory and binding antibodies against BDD FVIII after a series of i.v. injections. The combined improvements in circulating half-life and hemostatic efficacy could significantly prolong the time above clinically established therapeutic thresholds of prophylactic FVIII replacement therapy in humans.
Collapse
Affiliation(s)
- Krithika A. Shetty
- Department of Pharmaceutical Sciences, University at Buffalo, The State University of New York, Buffalo, NY
| | - Matthew P. Kosloski
- Department of Pharmaceutical Sciences, University at Buffalo, The State University of New York, Buffalo, NY
| | - Donald E. Mager
- Department of Pharmaceutical Sciences, University at Buffalo, The State University of New York, Buffalo, NY
| | - Sathy V. Balu-Iyer
- Department of Pharmaceutical Sciences, University at Buffalo, The State University of New York, Buffalo, NY
| |
Collapse
|
35
|
Petrini P, Valentino LA, Gringeri A, Re WM, Ewenstein B. Individualizing prophylaxis in hemophilia: a review. Expert Rev Hematol 2015; 8:237-46. [DOI: 10.1586/17474086.2015.1002465] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
|
36
|
Bhatt S, Shen GQ, Li Y, Qian S, Ragni MV, Lu L. Hepatic stellate cell-conditioned myeloid cells provide a novel therapy for prevention of factor VIII antibody formation in mice. Exp Hematol 2014; 43:277-85. [PMID: 25534204 DOI: 10.1016/j.exphem.2014.12.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2014] [Revised: 11/11/2014] [Accepted: 12/03/2014] [Indexed: 12/14/2022]
Abstract
A major complication of factor VIII (F.VIII) infusion therapies for the treatment of hemophilia A is the formation of antibodies (inhibitors) against F.VIII, a T-cell-dependent, B-cell-mediated process. To date, attempts to inhibit formation of the inhibitors have been limited in success. We have shown that hepatic stellate cells (HSCs) promote the development of myeloid-derived suppressor cells (MDSCs). The HSC-induced MDSCs are potent regulators of T-cell and B-cell responses. Here we show that MDSCs can be propagated from hemophilia A mouse bone marrow cells in coculture with HSCs. These cells exhibit a suppressive phenotype and display a marked ability to inhibit T-cell proliferation induced by dendritic cells in response to F.VIII. MDSCs can also inhibit proliferation and activation of B cells stimulated by immunoglobulin M and interleukin 4. Administration of HSC-induced MDSCs induces CD4(+) T cell and B220(+) B-cell hyporesponsiveness to F.VIII and reduces inhibitor formation in hemophilia A mice. These results suggest that MDSCs could serve as a form of immunotherapy for preventing inhibitor formation via induction of immune tolerance.
Collapse
Affiliation(s)
- Sumantha Bhatt
- Department of Molecular Medicine, Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, United States; Department of Immunology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Gong-Qing Shen
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Yan Li
- Department of Immunology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Shiguang Qian
- Department of Molecular Medicine, Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, United States; Department of Immunology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States; Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Margaret V Ragni
- Division of Hematology/Oncology, Department of Medicine, University of Pittsburgh and Hemophilia Center of Western Pennsylvania, Pittsburgh, PA, United States.
| | - Lina Lu
- Department of Molecular Medicine, Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, United States; Department of Immunology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States; Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, United States.
| |
Collapse
|
37
|
Fomin ME, Togarrati PP, Muench MO. Progress and challenges in the development of a cell-based therapy for hemophilia A. J Thromb Haemost 2014; 12:1954-65. [PMID: 25297648 PMCID: PMC4388483 DOI: 10.1111/jth.12750] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2014] [Indexed: 12/11/2022]
Abstract
Hemophilia A results from an insufficiency of factor VIII (FVIII). Although replacement therapy with plasma-derived or recombinant FVIII is a life-saving therapy for hemophilia A patients, such therapy is a life-long treatment rather than a cure for the disease. In this review, we discuss the possibilities, progress, and challenges that remain in the development of a cell-based cure for hemophilia A. The success of cell therapy depends on the type and availability of donor cells, the age of the host and method of transplantation, and the levels of engraftment and production of FVIII by the graft. Early therapy, possibly even prenatal transplantation, may yield the highest levels of engraftment by avoiding immunological rejection of the graft. Potential cell sources of FVIII include a specialized subset of endothelial cells known as liver sinusoidal endothelial cells (LSECs) present in the adult and fetal liver, or patient-specific endothelial cells derived from induced pluripotent stem cells that have undergone gene editing to produce FVIII. Achieving sufficient engraftment of transplanted LSECs is one of the obstacles to successful cell therapy for hemophilia A. We discuss recent results from transplants performed in animals that show production of functional and clinically relevant levels of FVIII obtained from donor LSECs. Hence, the possibility of treating hemophilia A can be envisioned through persistent production of FVIII from transplanted donor cells derived from a number of potential cell sources or through creation of donor endothelial cells from patient-specific induced pluripotent stem cells.
Collapse
Affiliation(s)
- Marina E. Fomin
- Cell Therapy Core, Blood Systems Research Institute, San Francisco, CA
- Department of Laboratory Medicine, University of California, San Francisco, CA
| | - Padma Priya Togarrati
- Cell Therapy Core, Blood Systems Research Institute, San Francisco, CA
- Department of Laboratory Medicine, University of California, San Francisco, CA
| | - Marcus O. Muench
- Cell Therapy Core, Blood Systems Research Institute, San Francisco, CA
- Department of Laboratory Medicine, University of California, San Francisco, CA
- Liver Center, University of California, San Francisco, CA
| |
Collapse
|
38
|
Sherman A, Su J, Lin S, Wang X, Herzog RW, Daniell H. Suppression of inhibitor formation against FVIII in a murine model of hemophilia A by oral delivery of antigens bioencapsulated in plant cells. Blood 2014; 124:1659-68. [PMID: 24825864 PMCID: PMC4155273 DOI: 10.1182/blood-2013-10-528737] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 04/29/2014] [Indexed: 11/20/2022] Open
Abstract
Hemophilia A is the X-linked bleeding disorder caused by deficiency of coagulation factor VIII (FVIII). To address serious complications of inhibitory antibody formation in current replacement therapy, we created tobacco transplastomic lines expressing FVIII antigens, heavy chain (HC) and C2, fused with the transmucosal carrier, cholera toxin B subunit. Cholera toxin B-HC and cholera toxin B-C2 fusion proteins expressed up to 80 or 370 µg/g in fresh leaves, assembled into pentameric forms, and bound to GM1 receptors. Protection of FVIII antigen through bioencapsulation in plant cells and oral delivery to the gut immune system was confirmed by immunostaining. Feeding of HC/C2 mixture substantially suppressed T helper cell responses and inhibitor formation against FVIII in mice of 2 different strain backgrounds with hemophilia A. Prolonged oral delivery was required to control inhibitor formation long-term. Substantial reduction of inhibitor titers in preimmune mice demonstrated that the protocol could also reverse inhibitor formation. Gene expression and flow cytometry analyses showed upregulation of immune suppressive cytokines (transforming growth factor β and interleukin 10). Adoptive transfer experiments confirmed an active suppression mechanism and revealed induction of CD4(+)CD25(+) and CD4(+)CD25(-) T cells that potently suppressed anti-FVIII formation. In sum, these data support plant cell-based oral tolerance for suppression of inhibitor formation against FVIII.
Collapse
Affiliation(s)
- Alexandra Sherman
- Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL; and
| | - Jin Su
- Department of Biochemistry and Department of Pathology, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA
| | - Shina Lin
- Department of Biochemistry and Department of Pathology, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA
| | - Xiaomei Wang
- Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL; and
| | - Roland W Herzog
- Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL; and
| | - Henry Daniell
- Department of Biochemistry and Department of Pathology, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
39
|
Nielsen LN, Wiinberg B, Häger M, Holmberg HL, Hansen JJ, Roepstorff K, Tranholm M. A novel F8 -/- rat as a translational model of human hemophilia A. J Thromb Haemost 2014; 12:1274-82. [PMID: 24931420 DOI: 10.1111/jth.12635] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Indexed: 01/10/2023]
Abstract
BACKGROUND In preclinical hemophilia research, an animal model that reflects both the phenotype and the pathology of the disease is needed. OBJECTIVES Here, we describe the generation and characterization of a novel genetically engineered F8(-/-) rat model. METHODS The rats were produced on a Sprague Dawley background with the zinc finger nuclease technique. A founder with a 13-bp deletion in exon 16 causing a premature translational stop in the C-terminal part of the A3 domain of factor VIII was selected, and a breeding colony was established. RESULTS Seventy per cent of the homozygous rats had clinically manifest spontaneous hemorrhagic episodes that needed treatment. The F8(-/-) rats had no detectable FVIII activity, and had a significantly prolonged activated partial thromboplastin time (APTT) and clot formation time as compared with wild-type (WT)/WT rats. In vitro spiking of rat plasma with human recombinant FVIII resulted in dose-dependent normalization of the APTT. CONCLUSION On the basis of the targeted deletion in F8, and the distinct physical and analytic characteristics of the rat, we conclude that an FVIII-deficient rat strain has been generated that has the potential to contribute greatly to translational research.
Collapse
|
40
|
Nichols TC. Lessons Learned from Animal Models of Inherited Bleeding Disorders. HEMATOLOGY EDUCATION. EUROPEAN HEMATOLOGY ASSOCIATION. CONGRESS. EDUCATION PROGRAM 2014; 8:39-46. [PMID: 26052366 PMCID: PMC4457463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Advances in treatment of hemophilia and von Willebrand disease (VWD) depend heavily on the availability of well-characterized animal models. These animals faithfully recapitulate the severe bleeding phenotype that occurs in humans with these inherited bleeding disorders. Research in these animal models represents important early and intermediate steps of translational research aimed at addressing current limitations in treatment such as the development of inhibitory antibodies to coagulation factors VIII and IX (FVIII, FIX) or von Willebrand factor (VWF), the life-long need for frequent venous access, the expense of therapy, and the ongoing need for improved ex vivo coagulation assays and in vivo methods for assessing hemostasis. The primary strengths of research that utilizes these highly relevant animal models include the development of better and safer treatments for hemophilia and VWD. Careful consideration of the strengths and limitations of the specific models is essential for optimizing chances for successful translation of advances to clinical medicine that benefits humans and animals.
Collapse
Affiliation(s)
- Timothy C Nichols
- University of North Carolina at Chapel Hill: Department of Pathology and Laboratory Medicine and Department of Medicine
| |
Collapse
|
41
|
Wang X, Moghimi B, Zolotukhin I, Morel LM, Cao O, Herzog RW. Immune tolerance induction to factor IX through B cell gene transfer: TLR9 signaling delineates between tolerogenic and immunogenic B cells. Mol Ther 2014; 22:1139-1150. [PMID: 24609143 DOI: 10.1038/mt.2014.43] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Accepted: 03/03/2014] [Indexed: 12/21/2022] Open
Abstract
A subset of patients with severe hemophilia B, the X-linked bleeding disorder resulting from absence of coagulation factor IX (FIX), develop pathogenic antibody responses during replacement therapy. These inhibitors block standard therapy and are often associated with anaphylactic reactions to FIX. Established clinical immune tolerance induction protocols often fail for FIX inhibitors. In a murine model of this immune complication, retrovirally transduced primary B cells expressing FIX antigen fused with immunoglobulin-G heavy chain prevented antibody formation to FIX and was also highly effective in desensitizing animals with preexisting response. In contrast, transplant of B cells that received the identical expression cassette via nucleofection of plasmid vector substantially heightened antibody formation against FIX, a response that could be blocked by toll-like receptor 9 (TLR9) inhibition. While innate responses to TLR4 activation or to retrovirus were minimal in B cells, plasmid DNA activated TLR9, resulting in CpG-dependent NF-κB activation/IL-6 expression and adaptor protein 3 dependent, CpG-independent induction of IFN-I. Neither response was seen in TLR9-deficient B cells. Therefore, TLR9 signaling in B cells, in particular in response to plasmid vector, is highly immunogenic and has to be avoided in design of tolerance protocols.
Collapse
Affiliation(s)
- Xiaomei Wang
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA.
| | - Babak Moghimi
- Department of Pediatrics, University of Miami, Miami, Florida, USA
| | - Irene Zolotukhin
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA
| | - Laurence M Morel
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, Florida, USA
| | - Ou Cao
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA
| | - Roland W Herzog
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA.
| |
Collapse
|
42
|
Abstract
The liver is a very complex organ with a large variety of functions, making it an attractive organ for gene replacement therapy. Many genetic disorders can be corrected by delivering gene products directly into the liver using viral vectors. In this chapter, we will describe gene delivery via portal vein administration in mice and dogs to correct the blood coagulation disorder hemophilia B. Although there are multiple delivery routes for both viral and non-viral vectors in animals, portal vein administration delivers vectors directly and efficiently into the liver. Complete correction of murine hemophilia B and multi-year near-correction of canine hemophilia B have been achieved following portal vein delivery of adeno-associated viral (AAV) vectors expressing factor IX from hepatocyte-specific promoters. Peripheral vein injection can lead to increased vector dissemination to off-target organ such as the lung and spleen. Below, we will describe portal vein injection delivery route via laparotomy.
Collapse
|
43
|
Porada CD, Stem C, Almeida-Porada G. Gene therapy: the promise of a permanent cure. N C Med J 2013; 74:526-529. [PMID: 24316783 PMCID: PMC8092353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Gene therapy offers the possibility of a permanent cure for any of the more than 10,000 human diseases caused by a defect in a single gene. Among these diseases, the hemophilias represent an ideal target, and studies in both animals and humans have provided evidence that a permanent cure for hemophilia is within reach.
Collapse
Affiliation(s)
- Christopher D Porada
- Wake Forest Institute for Regenerative Medicine, 391 Technology Way, Winston-Salem, NC 27157, USA.
| | | | | |
Collapse
|
44
|
Zollner SB, Raquet E, Müller-Cohrs J, Metzner HJ, Weimer T, Pragst I, Dickneite G, Schulte S. Preclinical efficacy and safety of rVIII-SingleChain (CSL627), a novel recombinant single-chain factor VIII. Thromb Res 2013; 132:280-7. [PMID: 23830969 DOI: 10.1016/j.thromres.2013.06.017] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Revised: 06/13/2013] [Accepted: 06/16/2013] [Indexed: 10/26/2022]
Abstract
INTRODUCTION The preclinical efficacy and safety of rVIII-SingleChain (CSL627), a novel recombinant single-chain factor VIII, was assessed in a series of animal studies. MATERIALS AND METHODS In the tail-clip bleeding model, hemophilia A mice were injected with escalating doses (1-150 IU/kg) of rVIII-SingleChain, B-domain deleted (BDD) rFVIII (ReFacto AF(®)), or full-length rFVIII products (Advate(®), Helixate(®)). Total blood loss and the percentage of animals in which hemostasis occurred were assessed in this observer-blinded, randomized study. In a second non-randomized study in hemophilia A mice, thromboelastographic analysis, thrombin generation, and activated partial thromboplastin time assays were performed. General safety and toxicity were assessed in three animal species, including determination of the prothrombotic potential of rVIII-SingleChain in a rabbit venous thrombosis model. RESULTS Under acute bleeding conditions, the effect of rVIII-SingleChain on total blood loss and hemostasis was indistinguishable from BDD and full-length rFVIII. rVIII-SingleChain and full-length rFVIII (both 20 IU/kg) corrected thromboelastographic parameters, activated partial thromboplastin time, and thrombin generation to a similar degree in hemophilia A mice. In a thrombosis model, the effect of rVIII-SingleChain on thrombus incidence was non-significant and comparable to BDD rFVIII at doses up to 500 IU/kg. Treatment with rVIII-SingleChain did not cause anaphylactic reaction or local intolerance in safety and toxicity studies, and demonstrated an excellent overall safety profile. CONCLUSIONS rVIII-SingleChain showed convincing hemostatic efficacy and excellent tolerability in animal studies, warranting continued investigation in human Phase I/III trials (AFFINITY).
Collapse
Affiliation(s)
- Sabine B Zollner
- Preclinical Research and Development, CSL Behring GmbH, 35041 Marburg, Germany.
| | | | | | | | | | | | | | | |
Collapse
|
45
|
Narkbunnam N, Sun J, Hu G, Lin FC, Bateman TA, Mihara M, Monahan PE. IL-6 receptor antagonist as adjunctive therapy with clotting factor replacement to protect against bleeding-induced arthropathy in hemophilia. J Thromb Haemost 2013; 11:881-93. [PMID: 23413986 PMCID: PMC3656980 DOI: 10.1111/jth.12176] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Accepted: 02/12/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND The most common morbidity that results from hemophilia is bleeding-induced hemophilic arthropathy (HA), which once established may not be interrupted completely even by prophylactic clotting factor replacement. Specific therapies to oppose inflammatory cytokines, including Interleukin 6 (IL-6) receptor antagonists, have become important in the management of inflammatory arthritides. OBJECTIVES We investigated combining therapy using MR16-1, a rat IgG antibody directed against mouse IL-6 receptor (anti-IL-6R), with factor VIII (FVIII) replacement to protect against bleeding-induced arthropathy in hemophilia A mice. METHODS Three recurrent hemarthroses were induced in the knee joint capsule of FVIII knockout mice. Treatment at the time of each hemorrhage included either: no treatment; FVIII replacement given at the time of hemorrhage; FVIII replacement at hemorrhage plus anti-IL-6R as 4-weekly injections; FVIII replacement with non-specific control antibody (rat IgG); and anti-IL-6R alone without FVIII replacement. Six weeks following the first hemarthosis, joints were harvested and histopathology was scored for synovitis, for cartilage integrity and for macrophage infiltration. RESULTS Animals that received anti-IL-6R as an adjunct to FVIII replacement demonstrated the best survival and the least acute joint swelling and pathology on histologic examination of the synovium and cartilage (P < 0.05 for each parameter). All histopathologic parameters in the mice receiving FVIII+anti-IL-6R were limited and were comparable to findings in injured hemostatically normal mice. The major benefits of adjunctive anti-IL-6R were decreasing synovial hyperplasia, hemosiderin deposition and macrophage infiltration. CONCLUSIONS Short-course specific inhibition of inflammatory cytokines as an adjunct to replacement hemostasis may be an approach to minimize hemophilic joint degeneration.
Collapse
Affiliation(s)
- N Narkbunnam
- Pediatric Hematology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | | | | | | | | | | | | |
Collapse
|
46
|
Orlova NA, Kovnir SV, Vorobiev II, Gabibov AG, Vorobiev AI. Blood Clotting Factor VIII: From Evolution to Therapy. Acta Naturae 2013; 5:19-39. [PMID: 23819034 PMCID: PMC3695351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Recombinant blood clotting factor VIII is one of the most complex proteins for industrial manufacturing due to the low efficiency of its gene transcription, massive intracellular loss of its proprotein during post-translational processing, and the instability of the secreted protein. Improvement in hemophilia A therapy requires a steady increase in the production of factor VIII drugs despite tightening standards of product quality and viral safety. More efficient systems for heterologous expression of factor VIII can be created on the basis of the discovered properties of its gene transcription, post-translational processing, and behavior in the bloodstream. The present review describes the deletion variants of factor VIII protein with increased secretion efficiency and the prospects for the pharmaceutical development of longer acting variants and derivatives of factor VIII.
Collapse
Affiliation(s)
- N. A. Orlova
- 1Center “Bioengineering”, Russian Academy of Sciences, 60-letija Oktyabrja av., 7/1, Moscow, Russia, 117312
- 2Shemyakin and Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences, Miklukho-Maklaya Str., 16/10, Moscow, Russia, 117997
| | - S. V. Kovnir
- 1Center “Bioengineering”, Russian Academy of Sciences, 60-letija Oktyabrja av., 7/1, Moscow, Russia, 117312
- 2Shemyakin and Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences, Miklukho-Maklaya Str., 16/10, Moscow, Russia, 117997
| | - I. I. Vorobiev
- 1Center “Bioengineering”, Russian Academy of Sciences, 60-letija Oktyabrja av., 7/1, Moscow, Russia, 117312
- 2Shemyakin and Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences, Miklukho-Maklaya Str., 16/10, Moscow, Russia, 117997
| | - A. G. Gabibov
- 1Center “Bioengineering”, Russian Academy of Sciences, 60-letija Oktyabrja av., 7/1, Moscow, Russia, 117312
- 2Shemyakin and Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences, Miklukho-Maklaya Str., 16/10, Moscow, Russia, 117997
| | - A. I. Vorobiev
- 3Research Center for Hematology, Ministry of Health and Social Development of the Russian Federation, Novij Zykovsky proezd, 4, Moscow, Russia, 125167
| |
Collapse
|
47
|
Mao J, Xi X, Kapranov P, Dong B, Firrman J, Xu R, Xiao W. In vitro and In vivo Model Systems for Hemophilia A Gene Therapy. ACTA ACUST UNITED AC 2013; Suppl 1. [PMID: 25401041 PMCID: PMC4229687 DOI: 10.4172/2157-7412.s1-014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Hemophilia A is a hereditary disorder caused by various mutations in factor VIII gene resulting in either a severe deficit or total lack of the corresponding activity. Recent success in gene therapy of a related disease, hemophilia B, gives new hope that similar success can be achieved for hemophilia A as well. To develop a gene therapy strategy for the latter, a variety of model systems are needed to evaluate molecular engineering of the factor VIII gene, vector delivery efficacy and safety-related issues. Typically, a tissue culture cell line is the most convenient way to get a preliminary glimpse of the potential of a vector delivery strategy. It is then followed by extensive testing in hemophilia A mouse and dog models. Newly developed hemophilia A sheep may provide yet another tool for evaluation of factor VIII gene delivery vectors. Hemophilia models based on other species may also be developed since hemophiliac animals have been identified or generated in rat, pig, cattle and horse. Although a genetic nonhuman primate hemophilia A model has yet to be developed, the non-genetic hemophilia A model can also be used for special purposes when specific questions need to be addressed that cannot not be answered in other model systems. Hemophilia A is caused by a functional deficiency in the factor VIII gene. This X-linked, recessive bleeding disorder affects approximately 1 in 5000 males [1–3]. Clinically, it is characterized by frequent and spontaneous joint hemorrhages, easy bruising and prolonged bleeding time. The coagulation activity of FVIII dictates severity of the clinical symptoms. Approximately 50% of all cases are classified as severe with less than 1% of normal levels of factor VIII detected [4]. This deficiency may lead to spontaneous joint hemorrhages or life-threatening bleeding. In contrast, patients with 5–30% of normal factor VIII activity exhibit mild clinical manifestations.
Collapse
Affiliation(s)
- Jianhua Mao
- Shanghai Institute of Hematology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China ; Department of Microbiology and Immunology, Sol Sherry Thrombosis Research Center, Temple University, Philadelphia, PA, USA
| | - Xiaodong Xi
- Shanghai Institute of Hematology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | | | - Biao Dong
- Department of Microbiology and Immunology, Sol Sherry Thrombosis Research Center, Temple University, Philadelphia, PA, USA
| | - Jenni Firrman
- Department of Microbiology and Immunology, Sol Sherry Thrombosis Research Center, Temple University, Philadelphia, PA, USA
| | - Ruian Xu
- Institute of Molecular Medicine, Molecular Medicine Engineering Research Center, Huaqiao University, Quanzhou 362021, China
| | - Weidong Xiao
- Department of Microbiology and Immunology, Sol Sherry Thrombosis Research Center, Temple University, Philadelphia, PA, USA
| |
Collapse
|
48
|
|
49
|
Sabatino DE, Arruda VR. Muscle Gene Therapy for Hemophilia. JOURNAL OF GENETIC SYNDROMES & GENE THERAPY 2012; Suppl 1:S1-010. [PMID: 24883231 PMCID: PMC4038336 DOI: 10.4172/2157-7412.s1-010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Muscle-directed gene therapy for hemophilia is an attractive strategy for expression of therapeutic levels of clotting factor as evident from preclinical studies and an early phase clinical trial. Notably, local FIX expression by AAV-mediated direct intramuscular injection to skeletal muscle persists for years. Development of intravascular delivery of AAV vector approaches to skeletal muscle resulted in vector in widespread areas of the limb and increased expression of FIX in hemophilia B dogs. The use of FIX variants with improved biological activity may provide the opportunity to increase the efficacy of these approaches. Studies for hemophilia A are less developed at this point, but utilizing transgenes that improve hemostasis independent of FIX and FVIII has potential therapeutic application for both hemophilia A and B. Continuous monitoring of humoral and T cell responses to the transgene and AAV capsid in human trials will be critical for the translation of these promising approaches for muscle gene therapy for hemophilia.
Collapse
Affiliation(s)
- Denise E. Sabatino
- Division of Hematology, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Valder R. Arruda
- Division of Hematology, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| |
Collapse
|