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Chan JKY, Gil-Farina I, Johana N, Rosales C, Tan YW, Ceiler J, Mcintosh J, Ogden B, Waddington SN, Schmidt M, Biswas A, Choolani M, Nathwani AC, Mattar CNZ. Therapeutic expression of human clotting factors IX and X following adeno-associated viral vector-mediated intrauterine gene transfer in early-gestation fetal macaques. FASEB J 2018; 33:3954-3967. [PMID: 30517034 PMCID: PMC6404563 DOI: 10.1096/fj.201801391r] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Adeno-associated viral vectors (AAVs) achieve stable therapeutic expression without long-term toxicity in adults with hemophilia. To avert irreversible complications in congenital disorders producing early pathogenesis, safety and efficacy of AAV-intrauterine gene transfer (IUGT) requires assessment. We therefore performed IUGT of AAV5 or -8 with liver-specific promoter-1 encoding either human coagulation factors IX (hFIX) or X (hFX) into Macaca fascicularis fetuses at ∼0.4 gestation. The initial cohort received 1 × 1012 vector genomes (vgs) of AAV5-hFIX (n = 5; 0.45 × 1013 vg/kg birth weight), resulting in ∼3.0% hFIX at birth and 0.6–6.8% over 19–51 mo. The next cohort received 0.2–1 × 1013 vg boluses. AAV5-hFX animals (n = 3; 3.57 × 1013 vg/kg) expressed <1% at birth and 9.4–27.9% up to 42 mo. AAV8-hFIX recipients (n = 3; 2.56 × 1013 vg/kg) established 4.2–41.3% expression perinatally and 9.8–25.3% over 46 mo. Expression with AAV8-hFX (n = 6, 3.12 × 1013 vg/kg) increased from <1% perinatally to 9.8–13.4% >35 mo. Low expressers (<1%, n = 3) were postnatally challenged with 2 × 1011 vg/kg AAV5 resulting in 2.4–13.2% expression and demonstrating acquired tolerance. Linear amplification–mediated-PCR analysis demonstrated random integration of 57–88% of AAV sequences retrieved from hepatocytes with no events occurring in or near oncogenesis-associated genes. Thus, early-IUGT in macaques produces sustained curative expression related significantly to integrated AAV in the absence of clinical toxicity, supporting its therapeutic potential for early-onset monogenic disorders.—Chan, J. K. Y., Gil-Farina I., Johana, N., Rosales, C., Tan, Y. W., Ceiler, J., Mcintosh, J., Ogden, B., Waddington, S. N., Schmidt, M., Biswas, A., Choolani, M., Nathwani, A. C., Mattar, C. N. Z. Therapeutic expression of human clotting factors IX and X following adeno-associated viral vector–mediated intrauterine gene transfer in early-gestation fetal macaques.
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Affiliation(s)
- Jerry K Y Chan
- Reproductive Medicine, KK Women's and Children's Hospital, Singapore, Singapore.,Cancer and Stem Cell Biology Program, Duke-National University of Singapore (NUS) Medical School, Singapore
| | - Irene Gil-Farina
- Department of Translational Oncology, German Cancer Research Center/National Center for Tumor Diseases, Heidelberg, Germany
| | - Nuryanti Johana
- Reproductive Medicine, KK Women's and Children's Hospital, Singapore, Singapore
| | - Cecilia Rosales
- University College London (UCL) Cancer Institute, University College London, London, United Kingdom
| | - Yi Wan Tan
- Reproductive Medicine, KK Women's and Children's Hospital, Singapore, Singapore
| | - Jessika Ceiler
- Department of Translational Oncology, German Cancer Research Center/National Center for Tumor Diseases, Heidelberg, Germany
| | - Jenny Mcintosh
- Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Bryan Ogden
- SingHealth Experimental Medicine Centre, Singapore Health Services Pte, Singapore, Singapore
| | - Simon N Waddington
- Institute for Women's Health, University College London, London, United Kingdom.,Faculty of Health Sciences, Wits/South African Medical Research Council (SAMRC), Antiviral Gene Therapy Research Unit, University of the Witwatersrand, Johannesburg, South Africa; and
| | - Manfred Schmidt
- University College London (UCL) Cancer Institute, University College London, London, United Kingdom.,GeneWerk, Heidelberg, Germany
| | - Arijit Biswas
- Department of Translational Oncology, German Cancer Research Center/National Center for Tumor Diseases, Heidelberg, Germany
| | - Mahesh Choolani
- Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Amit C Nathwani
- University College London (UCL) Cancer Institute, University College London, London, United Kingdom
| | - Citra N Z Mattar
- Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Tanaka KA, Mazzeffi MA, Strauss ER, Szlam F, Guzzetta NA. Computational simulation and comparison of prothrombin complex concentrate dosing schemes for warfarin reversal in cardiac surgery. J Anesth 2016; 30:369-76. [DOI: 10.1007/s00540-015-2128-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 12/19/2015] [Indexed: 10/22/2022]
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3
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Abstract
Despite the worldwide prevalence of rare bleeding disorders (RBDs), knowledge of these conditions and their management is suboptimal; health care professionals often have little diagnostic and treatment experience with variable access to diagnostic modalities required for accurate identification. Therefore, patients often experience morbidity and mortality due to delayed diagnosis. As RBDs represent a small potential commercial market, few, if any, specific therapies exist for these conditions. As a result, affected individuals commonly face delayed diagnosis, incomplete laboratory evaluation, and limited treatment options. Standardization and customization of coagulation assays, full genome sequencing, and global clotting assays will significantly improve diagnosis of patients with RBDs. In addition, new therapeutic modalities, both recombinant and plasma derived, are emerging, at least in developed countries. Registries and clinical trials have demonstrated decreased bleeding and improved outcomes when patients are appropriately diagnosed and properly treated. Expansion and harmonization of international registries has been initiated to correlate genotype, laboratory, and clinical phenotypes including bleeding severity to improve the diagnosis and therapeutic approach. This review focuses on the latest advances in our understanding, diagnosis, and treatment of RBDs.
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Cao H, Tian Q, Huang Y, Ye S, Xin Y, Lin F, Li C. Biochemical characterization of prothrombin complex concentrates in China. Biologicals 2015; 43:84-91. [PMID: 25648383 DOI: 10.1016/j.biologicals.2015.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Revised: 12/29/2014] [Accepted: 01/12/2015] [Indexed: 10/24/2022] Open
Abstract
Despite increasing use of prothrombin complex concentrates (PCCs), there is little knowledge about the biochemical characterization of Chinese PCCs. Six Chinese PCCs were investigated and compared with PCCs (Octaplex®) from Europe. The levels of coagulation factors and inhibitors were detected. The presence of activated coagulation factors was assessed. Furthermore, their thrombin inhibitory capacities, specific activity and purity were assayed. All above parameters of biochemical properties were statistically analyzed. Chinese PCCs contained FⅡ, Ⅶ, Ⅸ and Ⅹ, protein C, S and Z, heparin and extremely low level antithrombin, as well as Octaplex®. The measured FⅨ activities were similar to those declared, however the measured potency of FⅡ, Ⅶ and Ⅹ greatly exceeded the labeled. Though all preparations were negative for activated coagulation factors in non-activated partial thromboplastin time test, the activated coagulation factor Ⅶ (FⅦa) remained in all PCCs and its content differed greatly. Overall, FⅦa content of Chinese PCCs was higher than that of Octaplex®. Further, Chinese PCCs were inferior to Octaplex® in the thrombin inhibitory capacities, specific activity and purity. In summary, compared with Octaplex®, Chinese PCCs' errors about the labeled activity of coagulation factors and probably high risks of thrombosis should be considered.
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Affiliation(s)
- Haijun Cao
- Institute of Blood Transfusion, Chinese Academy of Medical Sciences & Peking Union Medical College, 610052 Chengdu, China
| | - Qian Tian
- College of Chemical Engineering, Sichuan University, 610065 Chengdu, China
| | - Yun Huang
- School of Materials Science and Engineering, Southwest Petroleum University, 610500 Chengdu, China
| | - Shengliang Ye
- Institute of Blood Transfusion, Chinese Academy of Medical Sciences & Peking Union Medical College, 610052 Chengdu, China
| | - Ye Xin
- Institute of Blood Transfusion, Chinese Academy of Medical Sciences & Peking Union Medical College, 610052 Chengdu, China
| | - Fangzhao Lin
- Institute of Blood Transfusion, Chinese Academy of Medical Sciences & Peking Union Medical College, 610052 Chengdu, China
| | - Changqing Li
- Institute of Blood Transfusion, Chinese Academy of Medical Sciences & Peking Union Medical College, 610052 Chengdu, China.
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Mumford AD, Ackroyd S, Alikhan R, Bowles L, Chowdary P, Grainger J, Mainwaring J, Mathias M, O'Connell N. Guideline for the diagnosis and management of the rare coagulation disorders: a United Kingdom Haemophilia Centre Doctors' Organization guideline on behalf of the British Committee for Standards in Haematology. Br J Haematol 2014; 167:304-26. [PMID: 25100430 DOI: 10.1111/bjh.13058] [Citation(s) in RCA: 201] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Andrew D Mumford
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, UK
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6
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Alraies MC, Kumar A. Assessing and Managing Hematologic Disorders. Perioper Med (Lond) 2012. [DOI: 10.1002/9781118375372.ch13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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7
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Zhou JG, Chen YM. Research on PEGylation of porcine prothrombin for improving biostability and reducing animal immunogenicity. Bioorg Med Chem Lett 2011; 21:3268-72. [PMID: 21524910 DOI: 10.1016/j.bmcl.2011.04.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2010] [Revised: 03/17/2011] [Accepted: 04/08/2011] [Indexed: 11/30/2022]
Abstract
Prothrombin is a vitamin K-dependent serine protease and plays pivotal roles in both procoagulant and anticoagulant pathway of hemostasis. In this study, prothrombin purified from porcine plasma was modified through PEGylation at N-terminal residue using 40 kDa PEG-phenyl-isothiocyanate (PIT-PEG40K). The monoPEGylated prothrombin enhanced biostability and remarkably prolonged circulating half-life in mice as compared with that of the nonmodified prothrombin. Moreover, the immunogenicity of PEGylated prothrombin in mice is significantly decreased compared to nonmodified prothrombin. These studies demonstrated the feasibility of PEGylating prothrombin as a promising way for the development of new prothrombin drugs.
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Affiliation(s)
- Jian-Gang Zhou
- College of Environment and Urban Construction, Wuhan Textile University, Wuhan 430073, PR China
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Todd T, Perry DJ. A review of long-term prophylaxis in the rare inherited coagulation factor deficiencies. Haemophilia 2009; 16:569-83. [PMID: 19906159 DOI: 10.1111/j.1365-2516.2009.02118.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The rare inherited coagulation factor deficiencies (deficiencies of factors I, II, V, VII, XI, XIII, combined FV + FVII deficiency, combined deficiency of the vitamin K dependent factors and von Willebrand disease type 3) have an aggregate prevalence of approximately 1:100,000. They may cause recurrent life or function threatening haemorrhage. In this article we review the available literature on long-term prophylaxis and, where possible, make recommendations on this important area.
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Affiliation(s)
- T Todd
- Department of Haematology, Royal Devon and Exeter Hospital, Exeter, UK.
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Characterization of a homozygous Gly11Val mutation in the Gla domain of coagulation factor X. Thromb Res 2009; 124:144-8. [DOI: 10.1016/j.thromres.2008.11.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2008] [Revised: 11/13/2008] [Accepted: 11/23/2008] [Indexed: 11/23/2022]
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10
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Girolami A, Scandellari R, Scapin M, Vettore S. Congenital Bleeding Disorders of the Vitamin K‐Dependent Clotting Factors. VITAMINS & HORMONES 2008; 78:281-374. [DOI: 10.1016/s0083-6729(07)00014-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Takeyama M, Sakurai Y, Shima M, Matsumoto T, Nogami K, Tanaka I, Takeda T, Giddings JC, Yoshioka A. Heparin-induced inhibitory effects of a prothrombin complex concentrate on global tests of haemostasis. Blood Coagul Fibrinolysis 2007; 18:1-7. [PMID: 17179819 DOI: 10.1097/01.mbc.0000256021.16453.de] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Prothrombin complex concentrates (PCC) have been used as bypassing agents for the treatment of haemophilia A patients with inhibitor as well as for replacement therapy in congenital and acquired deficiencies of vitamin-K-dependent clotting factors. The efficacy of PCC is variable, however, especially during long-term and high-dose use, and all currently available products of this nature contain heparin. We have examined the haemostatic properties of PCC using reconstituted whole blood made by mixing coagulation-factor-deficient plasma and washed blood cells. In rotation thromboelastometry (ROTEM), the recommended therapeutic dose of Proplex ST corrected the abnormal patterns. At higher concentrations, however, the ROTEM patterns regressed. In addition, specific assays of coagulation factors appeared unreliable in the presence of 2.5 U/ml Proplex ST; the abnormalities were corrected when protamine sulfate was added. The findings suggest that the presence of heparin in PCC might have a greater effect on global haemostasis. Careful attention to the anticoagulant effect as well as thrombogenicity of PCC is required. Monitoring therapy using such as ROTEM analysis could be highly informative.
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Affiliation(s)
- Masahiro Takeyama
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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12
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Brummel Ziedins K, Rivard GE, Pouliot RL, Butenas S, Gissel M, Parhami-Seren B, Mann KG. Factor VIIa replacement therapy in factor VII deficiency. J Thromb Haemost 2004; 2:1735-44. [PMID: 15456484 DOI: 10.1111/j.1538-7836.2004.00922.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Factor (F)VII deficiency is an autosomal recessive disorder for which a replacement therapy is not universally available; recombinant FVIIa has been utilized as a therapeutic substitute. As FVII competes with FVIIa for binding to tissue factor in initiating the extrinsic pathway of blood coagulation, a lower dose of FVIIa replacement in cross-reacting material-negative (CRM-) individuals can achieve hemostasis. Three coagulation models (computational, synthetic and in vitro whole blood) were used to predict the FVIIa levels needed to provide apparent hemostasis in a non-bleeding state. Our whole blood results show that a 'normalized' coagulation profile for FVII-deficient individuals has an initiation phase that ends at 5.8 +/- 0.5 min (clot time) and the propagation phase of thrombin generation (thrombin-antithrombin III) yields a maximum concentration of 380 +/- 29 nmol L(-1). When CRM- FVII-deficient subjects were infused with a prophylactic dose of 23 micro g kg(-1) of recombinant FVIIa, 6-8 h postinfusion resulted in a comparable normalized whole blood profile. This FVIIa concentration (0.3-0.7 nmol L(-1)/equivalent dose: 0.8-1.8 micro g kg(-1)) is approximately 1/10 that currently used in treating FVII-deficient individuals and suggests that therapies should be altered relative to the concentration of the FVII zymogen.
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Affiliation(s)
- K Brummel Ziedins
- Department of Biochemistry, University of Vermont, Burlington, Vermont 05405, USA
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Lobel JS, Majumdar S, Kovats-Bell S. Successful prophylactic treatment for bleeding in a girl with severe hereditary prothrombin deficiency using a prothrombin complex concentrate (Bebulin VH). J Pediatr Hematol Oncol 2004; 26:480-3. [PMID: 15284583 DOI: 10.1097/01.mph.0000130220.33907.5a] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The authors describe the evaluation and course of severe hereditary prothrombin deficiency in a 14-year-old girl first diagnosed at age 4 years. Detailed is the evolution of her treatment from episodic fresh-frozen plasma after bleeding events to prophylactic home infusions with the prothrombin complex concentrate Bebulin VH. Pharmacokinetic data on factor II recovery and half-life are presented. The patient has been essentially free of abnormal bleeding while on this prophylactic regimen for 17 months, with no toxicities and with a much improved quality of life.
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Affiliation(s)
- Jeffrey S Lobel
- Pediatric Hematology/Oncology Program of Michigan State University/Kalamazoo Center for Medical Studies, Kalamazoo, Michigan 49007, USA.
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McMahon C, Smith J, Goonan C, Byrne M, Smith OP. The role of primary prophylactic factor replacement therapy in children with severe factor X deficiency. Br J Haematol 2002; 119:789-91. [PMID: 12437661 DOI: 10.1046/j.1365-2141.2002.03932.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Severe factor X (FX) deficiency is one of the severest inherited coagulation disorders. Clinical manifestations include umbilical cord, mucosal, joint and central nervous system bleeding. Four Irish children with severe FX deficiency presented with umbilical cord bleeding. One developed an intraperitoneal haemorrhage and another an intracranial bleed. Prophylaxis, using intermediate purity Factor IX concentrate, was commenced within the first month of life, necessitating the insertion of central venous access devices in two of the children. All children have normal joint function, suggesting that prophylaxis commenced early in life reduces the incidence of arthropathy and improves quality of life.
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Affiliation(s)
- Corrina McMahon
- National Centre for Hereditary Coagulation Disorders, AMNCH, and St James' Hospital Dublin, Ireland
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15
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Abstract
Factor X is one of the vitamin K-dependent serine proteases. It plays a crucial role in the coagulation cascade, as the first enzyme in the common pathway of thrombus formation. The gene for factor X maps to the long arm of chromosome 13, approximately 2.8 kb downstream of the factor VII gene. The gene consists of eight exons, each of which encodes a specific functional domain within the protein. Both the gene structure and the amino acid sequence show homology to other vitamin K-dependent clotting factors, suggesting their origin in a common ancestral protein. Factor X deficiency is one of the rarest of the inherited coagulation disorders. Inheritance is in an autosomal recessive manner. The clinical phenotype is of a variable bleeding tendency. Homozygous factor X deficiency has an incidence of 1:1,000,000 in the general population. Heterozygotes are often clinically asymptomatic. Acquired factor X deficiency is rare, but when it occurs it is usually in association with amyloidosis. Treatment of factor X deficiency involves replacement of the protein with either fresh frozen plasma or prothrombin complex concentrates, although the latter should be used with caution as infusion may be associated with an increased risk of thrombosis.
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Affiliation(s)
- James Uprichard
- Haemophilia Centre and Haemostasis Unit, Royal Free Hospital, London, UK
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Xu L, Daly T, Gao C, Flotte TR, Song S, Byrne BJ, Sands MS, Parker Ponder K. CMV-beta-actin promoter directs higher expression from an adeno-associated viral vector in the liver than the cytomegalovirus or elongation factor 1 alpha promoter and results in therapeutic levels of human factor X in mice. Hum Gene Ther 2001; 12:563-73. [PMID: 11268288 DOI: 10.1089/104303401300042500] [Citation(s) in RCA: 136] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Although AAV vectors show promise for hepatic gene therapy, the optimal transcriptional regulatory elements have not yet been identified. In this study, we show that an AAV vector with the CMV enhancer/chicken beta-actin promoter results in 9.5-fold higher expression after portal vein injection than an AAV vector with the EF1 alpha promoter, and 137-fold higher expression than an AAV vector with the CMV promoter/enhancer. Although induction of the acute-phase response with the administration of lipopolysaccharide (LPS) activated the CMV promoter/enhancer from the context of an adenoviral vector in a previous study, LPS resulted in only a modest induction of this promoter from an AAV vector in vivo. An AAV vector with the CMV-beta-actin promoter upstream of the coagulation protein human factor X (hFX) was injected intravenously into neonatal mice. This resulted in expression of hFX at 548 ng/ml (6.8% of normal) for up to 1.2 years, and 0.6 copies of AAV vector per diploid genome in the liver at the time of sacrifice. Neonatal intramuscular injection resulted in expression of hFX at 248 ng/ml (3.1% of normal), which derived from both liver and muscle. We conclude that neonatal gene therapy with an AAV vector with the CMV-beta-actin promoter might correct hemophilia due to hFX deficiency.
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Affiliation(s)
- L Xu
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA
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17
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Abstract
Protein C (PC) is a vitamin K-dependent plasma protein that is structurally similar to other coagulation factors such as prothrombin and Factor X. PC is converted to its active anticoagulant form by a thrombin-thrombomodulin complex on the surface of capillary endothelial cells. Activated PC (APC) prevents the formation of blood clots by specifically inactivating factors Va and VIIIa in the clotting cascade. Both acquired and hereditary forms of PC deficiency exist, with hereditary further categorised as heterozygous, homozygous as well as doubly heterozygous. Patients suffering from symptomatic heterozygous PC deficiency present with purpura fulminans, venous thrombosis and/or pulmonary embolism. Homozygous PC deficiency is usually associated with the development of severe and often fatal, purpura fulminans and disseminated intravascular coagulation (DIC) during the neonatal period. Various therapeutic options have been described for long-term management of severe heterozygous and homozygous PC deficiencies. For the treatment of heterozygous PC deficiency, oral anticoagulation with a coumarin derivative or heparin therapy remains standard therapy. Homozygous patients may be treated with fresh frozen plasma (FFP) and iv. PC concentrate or coumarin derivatives. Other therapeutic options for the treatment of hereditary PC deficiency include the use of low-molecular weight heparin (LMWH), steroids and liver transplantation. Maintenance of a symptom-free life depends on response to therapy. Patients responding well to treatment can expect normalisation of haemostasis as well as improvement of microcirculation and resolution of purpura fulminans.
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Affiliation(s)
- S L Pescatore
- Oncology Clinical Development, GlaxoSmithKline, Inc., Five Moore Drive, Research Triangle Park, North Carolina 27709, USA.
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