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Sagar R, David AL. Fetal therapies - (Stem cell transplantation; enzyme replacement therapy; in utero genetic therapies). Best Pract Res Clin Obstet Gynaecol 2024; 97:102542. [PMID: 39298891 DOI: 10.1016/j.bpobgyn.2024.102542] [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: 08/06/2024] [Accepted: 09/02/2024] [Indexed: 09/22/2024]
Abstract
Advances in ultrasound and prenatal diagnosis are leading an expansion in the options for parents whose fetus is identified with a congenital disease. Obstetric diseases such as pre-eclampsia and fetal growth restriction may also be amenable to intervention to improve maternal and neonatal outcomes. Advanced Medicinal Therapeutic Products such as stem cell, gene, enzyme and protein therapies are most commonly being investigated as the trajectory of treatment for severe genetic diseases moves toward earlier intervention. Theoretical benefits include prevention of in utero damage, smaller treatment doses compared to postnatal intervention, use of fetal circulatory shunts and induction of immune tolerance. New systematic terminology can capture adverse maternal and fetal adverse events to improve safe trial conduct. First-in-human clinical trials are now beginning to generate results with a focus on safety first and efficacy second. If successful, these trials will transform the care of fetuses with severe early-onset congenital disease.
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Affiliation(s)
- Rachel Sagar
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, WC1E 6AU, UK.
| | - Anna L David
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, WC1E 6AU, UK; National Institute for Health and Care Research, University College London Hospitals NHS Foundation Trust Biomedical Research Centre, 149 Tottenham Court Road, London, W1T 7DN, UK.
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2
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Riley JS, Berkowitz CL, Luks VL, Dave A, Cyril-Olutayo MC, Pogoriler J, Flake AW, Abdulmalik O, Peranteau WH. Immune modulation permits tolerance and engraftment in a murine model of late-gestation transplantation. Blood Adv 2024; 8:4523-4538. [PMID: 38941538 PMCID: PMC11395771 DOI: 10.1182/bloodadvances.2023012247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 05/08/2024] [Accepted: 06/15/2024] [Indexed: 06/30/2024] Open
Abstract
ABSTRACT In utero hematopoietic cell transplantation is an experimental nonmyeloablative therapy with potential applications in hematologic disorders, including sickle cell disease (SCD). Its clinical utility has been limited due to the early acquisition of T-cell immunity beginning at ∼14 weeks gestation, posing significant technical challenges and excluding treatment fetuses evaluated after the first trimester. Using murine neonatal transplantation at 20 days postcoitum (DPC) as a model for late-gestation transplantation (LGT) in humans, we investigated whether immune modulation with anti-CD3 monoclonal antibody (mAb) could achieve donor-specific tolerance and sustained allogeneic engraftment comparable with that of the early-gestation fetal recipient at 14 DPC. In allogeneic wild-type strain combinations, administration of anti-CD3 mAb with transplantation resulted in transient T-cell depletion followed by central tolerance induction confirmed by donor-specific clonal deletion and skin graft tolerance. Normal immune responses to third-party major histocompatibility complex and viral pathogens were preserved, and graft-versus-host disease did not occur. We further demonstrated the successful application of this approach in the Townes mouse model of SCD. These findings confirm the developing fetal T-cell response as a barrier to LGT and support transient T-cell depletion as a safe and effective immunomodulatory strategy to overcome it.
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Affiliation(s)
- John S. Riley
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Cara L. Berkowitz
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Valerie L. Luks
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Apeksha Dave
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Mojisola C. Cyril-Olutayo
- Department of Hematology, Children’s Hospital of Philadelphia, Philadelphia, PA
- Drug Research and Production Unit, Faculty of Pharmacy, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Jennifer Pogoriler
- Department of Pathology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Alan W. Flake
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Osheiza Abdulmalik
- Department of Hematology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - William H Peranteau
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA
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Shi C, Li Z, Sun Z, Pan L. Maternal Administration of Busulfan before in Utero Hematopoietic Cell Transplantation Improves Congenic Bone Marrow Cell Engraftment in a Murine Model. Transplant Cell Ther 2024; 30:398.e1-398.e10. [PMID: 38331194 DOI: 10.1016/j.jtct.2024.01.081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 01/10/2024] [Accepted: 01/29/2024] [Indexed: 02/10/2024]
Abstract
In utero hematopoietic cell transplantation (IUHCT) is a nonmyeloablative procedure that leads to donor cell chimerism and donor-specific tolerance. However, most clinical applications of IUHCT have failed because of low levels or even no engraftment of donor cells in immunologically normal fetuses. It is likely that the competition from the host hematopoietic compartment is the primary barrier to successful IUHCT, suggesting that conditioning methods that provide a competitive advantage to donor cells may lead to higher-level engraftment following IUHCT. This study aimed to research whether maternal administration of low-dose total body irradiation (TBI) or busulfan (BU) before IUHCT may result in increased donor cell chimerism in postnatal bone marrow transplantation in a congenic murine model. We first determined the birth and mortality rates after maternal administration of low-dose TBI (0, 2 or 4 Gy) or BU (5, 10, 15, or 20 mg/kg) before IUHCT in B6 mice. The mice that received 2 Gy TBI plus IUHCT showed significantly lower birth rate (23.3%) and a 100% 3-day mortality rate. The mice that received 10 mg/kg BU plus IUHCT had similar birth and 3-day mortality rates (58.6% and 0%) compared to mice that received IUHCT alone (61.1% and 4.55%). We then performed maternal administration of BU at 1 of 3 dosages (5, 10, or 15 mg/kg) at 24 hours before intrauterine transplantation of 2.5 × 105 B6GFP Sca-1+ bone marrow cells (BMCs) or 2.5 × 106 B6GFP BMCs on gestational day 14 (E14). Green fluorescent protein (GFP) chimerism in peripheral blood mononuclear cells (PBMCs), RBCs, and platelets of mice at 4 weeks of age was enhanced significantly with an increase in BU dose. Moreover, GFP chimerism of PBMCs from the B6GFP BMC group was significantly higher than that of the B6GFP Sca-1+ BMC group (22.56% versus 7.20%; P = .018). Finally, the pregnant mice were treated with 10 mg/kg of BU at E13, E14, or E15, followed by intrauterine transplantation of 2.5 × 106 B6GFP BMCs 24 hours later. Except for the short-term level of chimerism in PBMCs, which showed no significant difference among the 3 study groups, the results indicate that both short-term (age 4 weeks) and long-term (age 14 weeks) engraftment in PBMCs, RBCs, and platelets was higher in group E16 compared with groups E14 and E15. We also discovered that the engraftment was stable, multilineage, and increased with time. In conclusion, maternal administration of BU, but not of TBI, along with IUHCT could significantly enhance engraftment in a congenic murine model.
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Affiliation(s)
- Chunyu Shi
- Department of Gastrointestinal Colorectal and Anal Surgery, The Third Bethune Hospital of Jilin University, Changchun, China
| | - Zhongmin Li
- Department of Gastrointestinal Colorectal and Anal Surgery, The Third Bethune Hospital of Jilin University, Changchun, China
| | - Zhanwei Sun
- National-Local Joint Engineering Laboratory of Animal Models for Human Diseases, Changchun, China; International Center of Future Science, Jilin University, Changchun, China
| | - Lu Pan
- Department of Pediatric Immunology, Allergy and Rheumatology, The First Bethune Hospital of Jilin University, Changchun, China.
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4
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Sagar RL, Walther-Jallow L, Götherström C, Westgren M, David AL. Maternal and fetal safety outcomes after in utero stem cell injection: A systematic review. Prenat Diagn 2023; 43:1622-1637. [PMID: 37975679 DOI: 10.1002/pd.6459] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 10/14/2023] [Accepted: 10/20/2023] [Indexed: 11/19/2023]
Abstract
OBJECTIVE To investigate the maternal and fetal safety of In utero stem cell transplantation (IUSCT). METHODS Medline®, Embase and Cochrane library (1967-2023) search for publications reporting IUSCT in humans. Two reviewers independently screened abstracts and full-text papers. RESULTS Sixty six transplantation procedures in 52 fetuses were performed for haemoglobinopathies (n = 14), red cell/bleeding disorders (n = 4), immunodeficiencies (n = 15), storage disorders (n = 7), osteogenesis imperfecta (n = 2) and healthy fetuses (n = 10). The average gestational age was 18.9 weeks; of procedures reporting the injection route, cells were delivered by intraperitoneal (n = 37), intravenous (n = 19), or intracardiac (n = 4) injection or a combination (n = 3); most fetuses received one injection (n = 41). Haematopoietic (n = 40) or mesenchymal (n = 12) stem cells were delivered. The cell dose was inconsistently reported (range 1.8-3.3 × 109 cells total (n = 27); 2.7-5.0 × 109 /kg estimated fetal weight (n = 17)). The acute fetal procedural complication rate was 4.5% (3/66); the acute fetal mortality rate was 3.0% (2/66). Neonatal survival was 69.2% (36/52). Immediate maternal and pregnancy outcomes were reported in only 30.8% (16/52) and 44.2% (23/52) of cases respectively. Four fetal/pregnancy outcomes would also classify as ≥ Grade 2 maternal adverse events. CONCLUSIONS Short-, medium-, and long-term maternal and fetal adverse events should be reported in all IUSCT studies.
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Affiliation(s)
- Rachel L Sagar
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
| | - Lilian Walther-Jallow
- Department of Clinical Science, Intervention and Technology, Division of Obstetrics and Gynecology, Karolinska Institutet, ANA Futura, Huddinge, Sweden
| | - Cecilia Götherström
- Department of Clinical Science, Intervention and Technology, Division of Obstetrics and Gynecology, Karolinska Institutet, ANA Futura, Huddinge, Sweden
| | - Magnus Westgren
- Department of Clinical Science, Intervention and Technology, Division of Obstetrics and Gynecology, Karolinska Institutet, ANA Futura, Huddinge, Sweden
| | - Anna L David
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
- NIHR University College London Hospitals Biomedical Research Centre, London, UK
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5
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Kihara Y, Tanaka Y, Ikeda M, Homma J, Takagi R, Ishigaki K, Yamanouchi K, Honda H, Nagata S, Yamato M. In utero transplantation of myoblasts and adipose-derived mesenchymal stem cells to murine models of Duchenne muscular dystrophy does not lead to engraftment and frequently results in fetal death. Regen Ther 2022; 21:486-493. [PMID: 36313392 PMCID: PMC9596598 DOI: 10.1016/j.reth.2022.10.003] [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: 08/23/2022] [Revised: 09/19/2022] [Accepted: 10/09/2022] [Indexed: 11/07/2022] Open
Abstract
Introduction Duchenne muscular dystrophy (DMD) is a progressive disease that leads to damage of muscle and myocardium due to genetic abnormalities in the dystrophin gene. In utero cell transplantation that might facilitate allogenic transplantation is worth considering to treat this disease. Methods We performed allogeneic in utero transplantation of GFP-positive myoblasts and adipose-derived mesenchymal stem cells into murine DMD model animals. The transplantation route in this study was fetal intraperitoneal transplantation and transplacental transplantation. Transplanted animals were examined at 4-weeks old by immunofluorescence staining and RT-qPCR. Results No GFP-positive cells were found by immunofluorescence staining of skeletal muscle and no GFP mRNA was detected by RT-qPCR in any animal, transplantation method and cell type. Compared with previous reports, myoblast transplantation exhibited an equivalent mortality rate, but adipose-derived stem cell (ASC) transplantation produced a higher mortality rate. Conclusions In utero transplantation of myoblasts or ASCs to murine models of DMD does not lead to engraftment and, in ASC transplantation primarily, frequently results in fetal death.
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Affiliation(s)
- Yuki Kihara
- Department of Pediatrics, Tokyo Women’s Medical University, School of Medicine, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666 Japan,Institute of Advanced Biomedical Engineering and Science, Tokyo Women’s Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666 Japan
| | - Yukie Tanaka
- Department of Veterinary Physiology, Graduate School of Agricultural and Life Sciences, The University of Tokyo, Bunkyo-ku, Japan
| | - Masanari Ikeda
- Department of Veterinary Physiology, Graduate School of Agricultural and Life Sciences, The University of Tokyo, Bunkyo-ku, Japan
| | - Jun Homma
- Institute of Advanced Biomedical Engineering and Science, Tokyo Women’s Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666 Japan
| | - Ryo Takagi
- Institute of Advanced Biomedical Engineering and Science, Tokyo Women’s Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666 Japan
| | - Keiko Ishigaki
- Department of Pediatrics, Tokyo Women’s Medical University, School of Medicine, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666 Japan
| | - Keitaro Yamanouchi
- Department of Veterinary Physiology, Graduate School of Agricultural and Life Sciences, The University of Tokyo, Bunkyo-ku, Japan
| | - Hiroaki Honda
- Human Disease Models, Institute of Laboratory Animals, Tokyo Women's Medical University, Tokyo, Japan
| | - Satoru Nagata
- Department of Pediatrics, Tokyo Women’s Medical University, School of Medicine, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666 Japan
| | - Masayuki Yamato
- Institute of Advanced Biomedical Engineering and Science, Tokyo Women’s Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666 Japan,Corresponding author. Fax: +81 3-3359-6046.
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6
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Shi C, Pan L, Hu Z. Experimental and clinical progress of in utero hematopoietic cell transplantation therapy for congenital disorders. Front Pharmacol 2022; 13:851375. [PMID: 36120324 PMCID: PMC9478511 DOI: 10.3389/fphar.2022.851375] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 08/08/2022] [Indexed: 11/13/2022] Open
Abstract
In utero hematopoietic cell transplantation (IUHCT) is considered a potentially efficient therapeutic approach with relatively few side effects, compared to adult hematopoietic cell transplantation, for various hematological genetic disorders. The principle of IUHCT has been extensively studied in rodent models and in some large animals with close evolutionary similarities to human beings. However, IUHCT has only been used to rebuild human T cell immunity in certain patients with inherent immunodeficiencies. This review will first summarize the animal models utilized for IUHCT investigations and describe the associated outcomes. Recent advances and potential barriers for successful IUHCT are discussed, followed by possible strategies to overcome these barriers experimentally. Lastly, we will outline the progress made towards utilizing IUHCT to treat inherent disorders for patients, list out associated limitations and propose feasible means to promote the efficacy of IUHCT clinically.
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Affiliation(s)
- Chunyu Shi
- National-Local Joint Engineering Laboratory of Animal Models for Human Diseases, The First Hospital of Jilin University, Changchun, China
- Department of Gastrointestinal Colorectal and Anal Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Lu Pan
- Department of Pediatric Immunology, Allergy and Rheumatology, The First Hospital of Jilin University, Changchun, China
| | - Zheng Hu
- National-Local Joint Engineering Laboratory of Animal Models for Human Diseases, The First Hospital of Jilin University, Changchun, China
- *Correspondence: Zheng Hu,
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7
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David AL, Spencer RN. Clinical Assessment of Fetal Well-Being and Fetal Safety Indicators. J Clin Pharmacol 2022; 62 Suppl 1:S67-S78. [PMID: 36106777 PMCID: PMC9544851 DOI: 10.1002/jcph.2126] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 07/24/2022] [Indexed: 12/03/2022]
Abstract
Delivering safe clinical trials of novel therapeutics is central to enable pregnant women and their babies to access medicines for better outcomes. This review describes clinical monitoring of fetal well-being and safety. Current pregnancy surveillance includes regular antenatal checks of blood pressure and urine for signs of gestational hypertension. Fetal and placental development is assessed routinely using the first-trimester "dating" and mid-trimester "anomaly" ultrasound scans, but the detection of fetal anomalies can continue throughout pregnancy using targeted sonography or magnetic resonance imaging (MRI). Serial sonography can be used to assess fetal size, well-being, and placental function. Carefully defined reproducible imaging parameters, such as the head circumference (HC), abdominal circumference (AC), and femur length (FL), are combined to calculate an estimate of the fetal weight. Doppler analysis of maternal uterine blood flow predicts placental insufficiency, which is associated with poor fetal growth. Fetal doppler analysis can indicate circulatory decompensation and fetal hypoxia, requiring delivery to be expedited. Novel ways to assess fetal well-being and placental function using MRI, computerized cardiotocography (CTG), serum circulating fetoplacental proteins, and mRNA may improve the assessment of the safety and efficacy of maternal and fetal interventions. Progress has been made in how to define and grade clinical trial safety in pregnant women, the fetus, and neonate. A new system for improved safety monitoring for clinical trials in pregnancy, Maternal and Fetal Adverse Event Terminology (MFAET), describes 12 maternal and 18 fetal adverse event (AE) definitions and severity grading criteria developed through an international modified Delphi consensus process. This fills a vital gap in maternal and fetal translational medicine research.
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Affiliation(s)
- Anna L. David
- Elizabeth Garrett Anderson Institute for Women's HealthUniversity College LondonLondonUK
- National Institute for Health and Care Research (NIHR) University College London Hospitals NHS Foundation Trust (UCLH)Biomedical Research CentreLondonUK
| | - Rebecca N. Spencer
- Elizabeth Garrett Anderson Institute for Women's HealthUniversity College LondonLondonUK
- School of MedicineUniversity of LeedsLeedsUK
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8
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Peddi NC, Marasandra Ramesh H, Gude SS, Gude SS, Vuppalapati S. Intrauterine Fetal Gene Therapy: Is That the Future and Is That Future Now? Cureus 2022; 14:e22521. [PMID: 35371822 PMCID: PMC8951626 DOI: 10.7759/cureus.22521] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2022] [Indexed: 12/05/2022] Open
Abstract
Researchers are looking into techniques to intervene sooner and earlier in the disease process thanks to advances in disease genetics, etiologies, and prenatal diagnosis. We conducted a literature search in PubMed-indexed journals to provide an overview of the evolution of gene therapy, rationale for prenatal gene therapy, uses and risks of gene therapy, and ethical issues following the usage of gene therapy. Recent animal research has revealed that transmitting genetic material to a growing fetus through viral and non-viral vectors is conceivable besides proving how gene-editing technology is achieved by various mechanisms that utilize zinc finger nucleases, TAL effector nucleases, and clustered short palindromic repeats-Cas9 complex. This review offers an overview of the current knowledge in the field of prenatal gene therapy, as well as potential future research avenues. In addition, it weighs the risks of prenatal gene therapy, such as oncogenesis, genetic mutation transfer from mother to child, and fetal disruption, against the expected benefits, such as preventing the development of severe early-onset illness symptoms, targeting previously inaccessible organs, and establishing tolerance to the therapeutic transgenic protein, all of which lead to permanent somatic gene correction. This review discusses the scientific, ethical, legal, and sociological implications of these groundbreaking genetic disease prevention techniques, as well as the parameters that must be satisfied for a future clinical application to be considered.
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9
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Regulatory T cells promote alloengraftment in a model of late-gestation in utero hematopoietic cell transplantation. Blood Adv 2021; 4:1102-1114. [PMID: 32203584 DOI: 10.1182/bloodadvances.2019001208] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 02/22/2020] [Indexed: 12/15/2022] Open
Abstract
In utero hematopoietic cell transplantation (IUHCT) has the potential to cure congenital hematologic disorders including sickle cell disease. However, the window of opportunity for IUHCT closes with the acquisition of T-cell immunity, beginning at approximately 14 weeks gestation, posing significant technical challenges and excluding from treatment fetuses evaluated after the first trimester. Here we report that regulatory T cells can promote alloengraftment and preserve allograft tolerance after the acquisition of T-cell immunity in a mouse model of late-gestation IUHCT. We show that allografts enriched with regulatory T cells harvested from either IUHCT-tolerant or naive mice engraft at 20 days post coitum (DPC) with equal frequency to unenriched allografts transplanted at 14 DPC. Long-term, multilineage donor cell chimerism was achieved in the absence of graft-versus-host disease or mortality. Decreased alloreactivity among recipient T cells was observed consistent with donor-specific tolerance. These findings suggest that donor graft enrichment with regulatory T cells could be used to successfully perform IUHCT later in gestation.
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10
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Irfan A, O'Hare E, Jelin E. Fetal interventions for congenital renal anomalies. Transl Pediatr 2021; 10:1506-1517. [PMID: 34189109 PMCID: PMC8192995 DOI: 10.21037/tp-2020-fs-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Congenital abnormalities of the kidney and urinary tract (CAKUT) represent 20% of prenatally diagnosed congenital abnormalities. Although the majority of these abnormalities do not require intervention either pre or postnatally, there is a subset of patients whose disease is so severe that it may warrant intervention prior to delivery to prevent morbidity and mortality. These cases consist of patients with moderate lower urinary tract obstruction (LUTO) in which vesicocentesis, shunting or cystoscopy are options and patients with early pregnancy renal anhydramnios (EPRA) in whom amnioinfusion therapy may be an option. The main causes of EPRA are congenital bilateral renal agenesis (CoBRA), cystic kidney disease (CKD) and severe LUTO. Untreated, EPRA is universally fatal secondary to anhydramnios induced pulmonary hypoplasia. The evidence regarding therapy for LUTO is limited and the stopped early PLUTO (Percutaneous Shunting in Lower Urinary Tract Obstruction) trial was unable to provide definitive answers about patient selection. Evidence for EPRA therapy is also scant. Serial amnioinfusions have shown promise in cases of EPRA due to CoBRA or renal failure and this treatment modality forms the basis of the ongoing NIH funded RAFT (Renal Anhydramnios Fetal Therapy) trial. At present, there is consensus that treatment for EPRA should only occur in the setting of a clinical trial.
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Affiliation(s)
- Ahmer Irfan
- Department of Surgery, Division of Pediatric Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Elizabeth O'Hare
- Department of Surgery, Division of Pediatric Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Eric Jelin
- Department of Surgery, Division of Pediatric Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
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11
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Tai-MacArthur S, Lombardi G, Shangaris P. The Theoretical Basis of In Utero Hematopoietic Stem Cell Transplantation and Its Use in the Treatment of Blood Disorders. Stem Cells Dev 2021; 30:49-58. [PMID: 33280478 DOI: 10.1089/scd.2020.0181] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Since its conception, prenatal therapy has been successful in correction of mainly anatomical defects, although the range of application has been limited. Research into minimally invasive fetal surgery techniques and prenatal molecular diagnostics has facilitated the development of in utero stem cell transplantation (IUT)-a method of delivering healthy stem cells to the early gestation fetus with the hope of engraftment, proliferation, and migration to the appropriate hematopoietic compartment. An area of application that shows promise is the treatment of hematopoietic disorders like hemoglobinopathies. The therapeutic rationale of IUT with hematopoietic stem cells (HSCs) is based on the proposed advantages the fetal environment offers based on its unique physiology. These advantages include the immature immune system facilitating the development of donor-specific tolerance, the natural migration of endogenous hematopoietic cells providing space for homing and engraftment of donor cells, and the fetal environment providing HSCs with the same opportunity to survive and proliferate regardless of their origin (donor or host). Maternal immune tolerance to the fetus and placenta also implies that the maternal environment could be accepting of donor cells. In theory, the fetus is a perfect recipient for stem cell transplant. Clinically, however, IUT is yet to see widespread success calling into question these assumptions of fetal physiology. This review aims to discuss and evaluate research surrounding these key assumptions and the clinical success of IUT in the treatment of thalassemia.
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Affiliation(s)
- Sarah Tai-MacArthur
- School of Basic and Medical Biosciences, Faculty of Life Sciences and Medicine, King's College London, United Kingdom
| | - Giovanna Lombardi
- Immunoregulation Laboratory, School of Immunology, Microbial Sciences, and Faculty of Life Sciences and Medicine, King's College London, United Kingdom
| | - Panicos Shangaris
- Immunoregulation Laboratory, School of Immunology, Microbial Sciences, and Faculty of Life Sciences and Medicine, King's College London, United Kingdom.,School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, United Kingdom
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12
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Rodriguez M, Porada CD, Almeida-Porada G. Mechanistic Insights into Factor VIII Immune Tolerance Induction via Prenatal Cell Therapy in Hemophilia A. CURRENT STEM CELL REPORTS 2019; 5:145-161. [PMID: 32351874 DOI: 10.1007/s40778-019-00165-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Purpose of Review Prenatal stem cell and gene therapy approaches are amongst the few therapies that can promise the birth of a healthy infant with specific known genetic diseases. This review describes fetal immune cell signaling and its potential influence on donor cell engraftment, and summarizes mechanisms of central T cell tolerance to peripherally-acquired antigen in the context of prenatal therapies for Hemophilia A. Recent Findings During early gestation, different subsets of antigen presenting cells take up peripherally-acquired, non-inherited antigens and induce the deletion of antigen-reactive T-cell precursors in the thymus, demonstrating the potential for using prenatal cell and gene therapies to induce central tolerance to FVIII in the context of prenatal diagnosis/therapy of Hemophilia A. Summary Prenatal cell and gene therapies are promising approaches to treat several genetic disorders including Hemophilia A and B. Understanding the mechanisms of how FVIII-specific tolerance is achieved during ontogeny could help develop novel therapies for HA and better approaches to overcome FVIII inhibitors.
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Affiliation(s)
- Martin Rodriguez
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Christopher D Porada
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Graҫa Almeida-Porada
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
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13
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Ekblad-Nordberg Å, Walther-Jallow L, Westgren M, Götherström C. Prenatal stem cell therapy for inherited diseases: Past, present, and future treatment strategies. Stem Cells Transl Med 2019; 9:148-157. [PMID: 31647195 PMCID: PMC6988764 DOI: 10.1002/sctm.19-0107] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 09/29/2019] [Indexed: 02/06/2023] Open
Abstract
Imagine the profits in quality of life that can be made by treating inherited diseases early in life, maybe even before birth! Immense cost savings can also be made by treating diseases promptly. Hence, prenatal stem cell therapy holds great promise for developing new and early‐stage treatment strategies for several diseases. Successful prenatal stem cell therapy would represent a major step forward in the management of patients with hematological, metabolic, or immunological disorders. However, treatment before birth has several limitations, including ethical issues. In this review, we summarize the past, the present, and the future of prenatal stem cell therapy, which includes an overview of different stem cell types, preclinical studies, and clinical attempts treating various diseases. We also discuss the current challenges and future strategies for prenatal stem cell therapy and also new approaches, which may lead to advancement in the management of patients with severe incurable diseases.
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Affiliation(s)
- Åsa Ekblad-Nordberg
- Department of Clinical Science, Intervention and Technology, Division of Obstetrics and Gynecology, Karolinska Institutet, Stockholm, Sweden
| | - Lilian Walther-Jallow
- Department of Clinical Science, Intervention and Technology, Division of Obstetrics and Gynecology, Karolinska Institutet, Stockholm, Sweden
| | - Magnus Westgren
- Department of Clinical Science, Intervention and Technology, Division of Obstetrics and Gynecology, Karolinska Institutet, Stockholm, Sweden
| | - Cecilia Götherström
- Department of Clinical Science, Intervention and Technology, Division of Obstetrics and Gynecology, Karolinska Institutet, Stockholm, Sweden
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Sagar R, Götherström C, David AL, Westgren M. Fetal stem cell transplantation and gene therapy. Best Pract Res Clin Obstet Gynaecol 2019; 58:142-153. [PMID: 30910447 DOI: 10.1016/j.bpobgyn.2019.02.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 02/26/2019] [Indexed: 12/19/2022]
Abstract
The present chapter summarizes our current knowledge on fetal stem cell and gene therapy. It focuses on these therapeutic alternatives in regard to past experiences and ongoing and planned studies in humans. Several methodological challenges are discussed that may have wide implications on how these methods could be introduced in clinical practices. Although still promising, the methods are afflicted with very special requirements not least in regard to safety and ethical questions. Furthermore, careful monitoring and extended follow-up of the child and his/hers mother who receive prenatal stem cell or gene treatments are of outmost importance. Taken these prerequisites into consideration, it is natural that this type of experimental fetal therapies requires collaboration between different disciplinaries and institutions within medicine.
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Affiliation(s)
- Rachel Sagar
- Institute for Women's Health, University College London, London, UK
| | - Cecilia Götherström
- Department of Clinical Science, Intervention and Technology, K57, Division of Obstetrics and Gynecology, Karolinska University Hospital, Huddinge Karolinska Institutet, Stockholm, Sweden
| | - Anna L David
- Institute for Women's Health, University College London, London, UK; Katholieke Universiteit Leuven, Belgium
| | - Magnus Westgren
- Department of Clinical Science, Intervention and Technology, K57, Division of Obstetrics and Gynecology, Karolinska University Hospital, Huddinge Karolinska Institutet, Stockholm, Sweden.
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15
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Alhajjat A, Shaaban A. Maternal and Fetal Immune Response to in Utero Stem Cell Transplantation. CURRENT STEM CELL REPORTS 2018; 4:182-187. [PMID: 30873337 DOI: 10.1007/s40778-018-0129-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Purpose of Review In Utero Hematopoietic Cellular Transplantation (IUHCT) is a promising intervention for the non-toxic treatment of congenital disease that hinges on the assumption of fetal immunologic immaturity and an inability to reject a hematopoietic allograft. However, clinical IUCHT has failed except in cases where the fetus is severely immunocompromised. The current review examines recent studies of engraftment barriers stemming from either the fetal or maternal immune system. Recent Findings New reports have illuminated roles for maternal humoral and cellular immunity and fetal innate cellular immunity in the resistance to allogeneic IUHCT. These experimental findings have inspired new approaches to overcome these barriers. Despite these advances, postulates regarding a maternal immune barrier to IUHCT provide an inadequate explanation for the well-documented clinical success only in the treatment of fetal immunodeficiency with normal maternal immunity. Summary Characterization of the maternal and fetal immune response to allogeneic IUHCT provides new insight into the complexity of prenatal tolerance. Future work in this area should aim to provide a unifying explanation for the observed patterns of success and failure with clinical IUHCT.
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Affiliation(s)
- Amir Alhajjat
- Division of Pediatric Surgery, Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, Arizona
| | - Aimen Shaaban
- The Chicago Institute for Fetal Health, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Abstract
BACKGROUND In utero transplantation (IUT) of hematopoietic stem cells has the potential to treat a large number of hematologic and metabolic diseases amenable to partial replacement of the hematopoietic system. METHODS A review of the literature was conducted that focused on the clinical and experimental experience with IUT and, in this context, the development of the hematopoietic and immune systems. RESULTS Successful application of IUT has been limited to the treatment of various types of immunodeficiencies that affect lymphocyte development and function. Other congenital defects such as the thalassemias have not resulted in clinically significant engraftment. Recent efforts at understanding and overcoming the barriers to engraftment in the fetus have focused on providing a selective advantage to donor stem cells and fostering immune tolerance toward the donor cells. The critical cellular components of the graft that promote engraftment and tolerance induction are being evaluated in animal models. Improvements in engraftment have resulted from the inclusion of T cells and/or dendritic cells in the graft, as well as a strategy of combined prenatal and postnatal transplantation. CONCLUSIONS The advantages, necessity, and benefits of early treatment will continue to encourage development of IUT as a means to treat hematopoietic and other types of birth defects.
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Affiliation(s)
- Marcus O Muench
- Department of Laboratory Medicine, University of California, San Francisco, CA 94143, USA.
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17
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Phithakwatchara N, Nawapun K, Panchalee T, Viboonchart S, Mongkolchat N, Wataganara T. Current Strategy of Fetal Therapy I: Principles of In-utero Treatment, Pharmacologic Intervention, Stem Cell Transplantation and Gene Therapy. JOURNAL OF FETAL MEDICINE 2017. [DOI: 10.1007/s40556-017-0129-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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18
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In Utero Stem Cell Transplantation: Potential Therapeutic Application for Muscle Diseases. Stem Cells Int 2017; 2017:3027520. [PMID: 28596791 PMCID: PMC5450178 DOI: 10.1155/2017/3027520] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 04/26/2017] [Indexed: 01/07/2023] Open
Abstract
Muscular dystrophies, myopathies, and traumatic muscle injury and loss encompass a large group of conditions that currently have no cure. Myoblast transplantations have been investigated as potential cures for these conditions for decades. However, current techniques lack the ability to generate cell numbers required to produce any therapeutic benefit. In utero stem cell transplantation into embryos has been studied for many years mainly in the context of hematopoietic cells and has shown to have experimental advantages and therapeutic applications. Moreover, patient-derived cells can be used for experimental transplantation into nonhuman animal embryos via in utero injection as the immune response is absent at such early stages of development. We therefore propose in utero transplantation as a potential method to generate patient-derived humanized skeletal muscle as well as muscle stem cells in animals for therapeutic purposes as well as patient-specific drug screening.
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Almeida-Porada G, Atala A, Porada CD. In utero stem cell transplantation and gene therapy: rationale, history, and recent advances toward clinical application. MOLECULAR THERAPY-METHODS & CLINICAL DEVELOPMENT 2016; 5:16020. [PMID: 27069953 PMCID: PMC4813605 DOI: 10.1038/mtm.2016.20] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Revised: 01/29/2016] [Accepted: 01/29/2016] [Indexed: 12/11/2022]
Abstract
Recent advances in high-throughput molecular testing have made it possible to diagnose most genetic disorders relatively early in gestation with minimal risk to the fetus. These advances should soon allow widespread prenatal screening for the majority of human genetic diseases, opening the door to the possibility of treatment/correction prior to birth. In addition to the obvious psychological and financial benefits of curing a disease in utero, and thereby enabling the birth of a healthy infant, there are multiple biological advantages unique to fetal development, which provide compelling rationale for performing potentially curative treatments, such as stem cell transplantation or gene therapy, prior to birth. Herein, we briefly review the fields of in utero transplantation (IUTx) and in utero gene therapy and discuss the biological hurdles that have thus far restricted success of IUTx to patients with immunodeficiencies. We then highlight several recent experimental breakthroughs in immunology, hematopoietic/marrow ontogeny, and in utero cell delivery, which have collectively provided means of overcoming these barriers, thus setting the stage for clinical application of these highly promising therapies in the near future.
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Affiliation(s)
- Graça Almeida-Porada
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine , Winston Salem, North Carolina, USA
| | - Anthony Atala
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine , Winston Salem, North Carolina, USA
| | - Christopher D Porada
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine , Winston Salem, North Carolina, USA
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20
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Boelig MM, Kim AG, Stratigis JD, McClain LE, Li H, Flake AW, Peranteau WH. The Intravenous Route of Injection Optimizes Engraftment and Survival in the Murine Model of In Utero Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2016; 22:991-999. [PMID: 26797401 DOI: 10.1016/j.bbmt.2016.01.017] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 01/11/2016] [Indexed: 01/16/2023]
Abstract
In utero hematopoietic cell transplantation (IUHCT) has the potential to treat a number of congenital hematologic disorders. Clinical application is limited by low levels of donor engraftment. Techniques that optimize donor cell delivery to the fetal liver (FL), the hematopoietic organ at the time of IUHCT, have the potential to enhance engraftment and the clinical success of IUHCT. We compared the 3 clinically applicable routes of injection (intravenous [i.v.], intraperitoneal [i.p.], and intrahepatic [i.h.]) and assessed short- and long-term donor cell engraftment and fetal survival in the murine model of IUHCT. We hypothesized that the i.v. route would promote direct donor cell homing to the FL, resulting in increased engraftment and allowing for larger injectate volumes without increased fetal mortality. We demonstrate that the i.v. route results in (1) rapid diffuse donor cell population of the FL compared with delayed diffuse engraftment after the i.p. and i.h. routes; (2) higher FL and spleen engraftment at early prenatal time points; (3) enhanced stable long-term peripheral blood donor cell engraftment; and (4) improved survival at higher injectate volumes, allowing for higher donor cell doses and increased long-term engraftment. These findings support the use of an i.v. route for clinical protocols of IUHCT.
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Affiliation(s)
- Matthew M Boelig
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Aimee G Kim
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - John D Stratigis
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Lauren E McClain
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Haiying Li
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Alan W Flake
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - William H Peranteau
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
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21
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McClain LE, Flake AW. In utero stem cell transplantation and gene therapy: Recent progress and the potential for clinical application. Best Pract Res Clin Obstet Gynaecol 2015; 31:88-98. [PMID: 26483174 DOI: 10.1016/j.bpobgyn.2015.08.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 08/31/2015] [Indexed: 12/20/2022]
Abstract
Advances in prenatal diagnosis have led to the prenatal management and treatment of a variety of congenital diseases. Although surgical treatment has been successfully applied to specific anatomic defects that place the fetus at a risk of death or life-long disability, the indications for fetal surgical intervention have remained relatively limited. By contrast, prenatal stem cell and gene therapy await clinical application, but they have tremendous potential to treat a broad range of genetic disorders. If there are biological advantages unique to fetal development that favor fetal stem cell or gene therapy over postnatal treatment, prenatal therapy may become the preferred approach to the treatment of any disease that can be prenatally diagnosed and cured by stem cell or gene therapy. Here, we review the field including recent progress toward clinical application and imminent clinical trials for cellular and gene therapy.
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Affiliation(s)
- Lauren E McClain
- Children's Center for Fetal Research, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Alan W Flake
- Children's Center for Fetal Research, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
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22
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Abstract
Stem cell transplantation (SCT) is an established first-line or adjunctive therapy for a variety of neonatal and adult diseases. New evidence in preclinical models as well as a few human studies show the potential utility of SCT in neuroprotection and in the modulation of inflammatory injury in at risk-neonates. This review briefly summarizes current understanding of human stem cell biology during ontogeny and present recent evidence supporting SCT as a viable approach for postinsult neonatal injury.
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Affiliation(s)
- Momoko Yoshimoto
- Assistant Research Professor, Pediatrics, Wells Center for Pediatric Research, Indiana University School of Medicine, 1044W Walnut Street R4-W116, Indianapolis, IN 46202, Tel: 317-278-0598
| | - Joyce M Koenig
- Pediatrics, E Doisy Research Center, Saint Louis University School of Medicine, 1100 South Grand Boulevard, St Louis, MO 63104, USA; Molecular Microbiology & Immunology, E Doisy Research Center, Saint Louis University School of Medicine, 1100 South Grand Boulevard, St Louis, MO 63106, USA.
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23
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Derderian SC, Moradi PW, MacKenzie TC. Placental drug delivery for treatment of congenital hematopoietic disorders. J Pediatr Surg 2015; 50:1517-20. [PMID: 25783323 DOI: 10.1016/j.jpedsurg.2014.12.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Revised: 12/24/2014] [Accepted: 12/26/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE The success of in utero hematopoietic cell transplantation (IUHCTx) hinges on successful conditioning strategies of the host to overcome barriers to engraftment. The "space" barrier is a reflection of a finite number of hematopoietic stem cell (HSC) niches within the host. Independent of the number of donor HSCs transplanted, engraftment is frequently low. By conditioning fetal mice using a monoclonal antibody against the c-kit receptor (ACK2) found on HSCs, we can effectively increase space for donor HSC engraftment. We questioned whether simple placental injection of ACK2 early in gestation could effectively deplete host HSCs within the fetal liver and neonatal bone marrow. METHODS In this set of experiments, we injected mice with ACK2 (5 μg/fetus) or PBS at E11.5-12.5 and harvested the fetal liver at 2 and 4 days and the neonatal bone marrow at 7 days following injection. Survival and total number of HSCs within the fetal liver or bone marrow were quantified and compared. RESULTS Survival between the treated and control group was similar (73% and 71%, respectively). The total number of HSCs within the fetal liver was not significantly lower following ACK2 treatment compared to PBS injected fetuses at 2 days but was by 4 days. Additionally, ACK2 resulted in a significant reduction in the number of HSCs within neonatal mice 7 days after treatment. CONCLUSION Survival following placental ACK2 injection is comparable to control animals and provides a simple non-invasive strategy to deliver ACK2 into the fetal circulation which successfully depletes the host HSCs.
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Affiliation(s)
- S Christopher Derderian
- Eli and Edythe Broad Center of Regeneration Medicine, The Department of Surgery, University of California, San Francisco, CA, USA
| | - P Wais Moradi
- Eli and Edythe Broad Center of Regeneration Medicine, The Department of Surgery, University of California, San Francisco, CA, USA
| | - Tippi C MacKenzie
- Eli and Edythe Broad Center of Regeneration Medicine, The Department of Surgery, University of California, San Francisco, CA, USA.
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24
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Ramachandra DL, Shaw SSW, Shangaris P, Loukogeorgakis S, Guillot PV, Coppi PD, David AL. In utero therapy for congenital disorders using amniotic fluid stem cells. Front Pharmacol 2014; 5:270. [PMID: 25566071 PMCID: PMC4271591 DOI: 10.3389/fphar.2014.00270] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 11/18/2014] [Indexed: 12/15/2022] Open
Abstract
Congenital diseases are responsible for over a third of all pediatric hospital admissions. Advances in prenatal screening and molecular diagnosis have allowed the detection of many life-threatening genetic diseases early in gestation. In utero transplantation (IUT) with stem cells could cure affected fetuses but so far in humans, successful IUT using allogeneic hematopoietic stem cells (HSCs), has been limited to fetuses with severe immunologic defects and more recently IUT with allogeneic mesenchymal stem cell transplantation, has improved phenotype in osteogenesis imperfecta. The options of preemptive treatment of congenital diseases in utero by stem cell or gene therapy changes the perspective of congenital diseases since it may avoid the need for postnatal treatment and reduce future costs. Amniotic fluid stem (AFS) cells have been isolated and characterized in human, mice, rodents, rabbit, and sheep and are a potential source of cells for therapeutic applications in disorders for treatment prenatally or postnatally. Gene transfer to the cells with long-term transgenic protein expression is feasible. Recently, pre-clinical autologous transplantation of transduced cells has been achieved in fetal sheep using minimally invasive ultrasound guided injection techniques. Clinically relevant levels of transgenic protein were expressed in the blood of transplanted lambs for at least 6 months. The cells have also demonstrated the potential of repair in a range of pre-clinical disease models such as neurological disorders, tracheal repair, bladder injury, and diaphragmatic hernia repair in neonates or adults. These results have been encouraging, and bring personalized tissue engineering for prenatal treatment of genetic disorders closer to the clinic.
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Affiliation(s)
- Durrgah L. Ramachandra
- Stem Cells and Regenerative Medicine, Institute of Child Health, University College London, London, UK
| | - Steven S. W. Shaw
- Department of Obstetrics and Gynaecology, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
- Department of Obstetrics and Gynaecology, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Prenatal Therapy, Institute for Women’s Health, University College London, London, UK
| | - Panicos Shangaris
- Prenatal Therapy, Institute for Women’s Health, University College London, London, UK
| | - Stavros Loukogeorgakis
- Stem Cells and Regenerative Medicine, Institute of Child Health, University College London, London, UK
| | - Pascale V. Guillot
- Stem Cells and Regenerative Medicine, Institute of Child Health, University College London, London, UK
- Cellular Reprogramming and Perinatal Therapy, Institute for Women’s Health, University College London, London, UK
| | - Paolo De Coppi
- Stem Cells and Regenerative Medicine, Institute of Child Health, University College London, London, UK
| | - Anna L. David
- Prenatal Therapy, Institute for Women’s Health, University College London, London, UK
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25
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In utero depletion of fetal hematopoietic stem cells improves engraftment after neonatal transplantation in mice. Blood 2014; 124:973-80. [PMID: 24879814 DOI: 10.1182/blood-2014-02-550327] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Although in utero hematopoietic cell transplantation is a promising strategy to treat congenital hematopoietic disorders, levels of engraftment have not been therapeutic for diseases in which donor cells have no survival advantage. We used an antibody against the murine c-Kit receptor (ACK2) to deplete fetal host hematopoietic stem cells (HSCs) and increase space within the hematopoietic niche for donor cell engraftment. Fetal mice were injected with ACK2 on embryonic days 13.5 to 14.5 and surviving pups were transplanted with congenic hematopoietic cells on day of life 1. Low-dose ACK2 treatment effectively depleted HSCs within the bone marrow with minimal toxicity and the antibody was cleared from the serum before the neonatal transplantation. Chimerism levels were significantly higher in treated pups than in controls; both myeloid and lymphoid cell chimerism increased because of higher engraftment of HSCs in the bone marrow. To test the strategy of repeated HSC depletion and transplantation, some mice were treated with ACK2 postnatally, but the increase in engraftment was lower than that seen with prenatal treatment. We demonstrate a successful fetal conditioning strategy associated with minimal toxicity. Such strategies could be used to achieve clinically relevant levels of engraftment to treat congenital stem cell disorders.
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26
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Abi-Nader KN, Rodeck CH, David AL. Prenatal gene therapy for the early treatment of genetic disorders. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/17474108.4.1.25] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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27
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Vrecenak JD, Flake AW. In utero hematopoietic cell transplantation--recent progress and the potential for clinical application. Cytotherapy 2013; 15:525-35. [PMID: 23415921 DOI: 10.1016/j.jcyt.2013.01.003] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Accepted: 01/08/2013] [Indexed: 11/27/2022]
Abstract
In utero hematopoietic stem cell transplantation (IUHCT) is a potential therapeutic alternative to postnatal hematopoietic stem cell transplantation (HSCT) for congenital hematologic disorders that can be diagnosed early in gestation and can be cured by HSCT. The rationale is to take advantage of normal events during hematopoietic and immunologic ontogeny to facilitate allogeneic hematopoietic engraftment. Although the rationale remains compelling, IUHCT has not yet achieved its clinical potential. This review will discuss recent experimental progress toward overcoming the barriers to allogeneic engraftment and new therapeutic strategies that may hasten clinical application.
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Affiliation(s)
- Jesse D Vrecenak
- Children's Center for Fetal Research, Children's Hospital of Philadelphia, and Department of Surgery, University of Pennsylvania, School of Medicine, Philadelphia, PA, USA
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28
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Abstract
The prenatal diagnosis and management of congenital disease has made significant progress over the previous decade. Currently, fetal therapy (including open surgery and fetoscopic intervention) provides therapeutic options for a range of congenital anomalies; however, it is restricted to the treatment of fetal pathophysiology. Improvements in prenatal screening and the early diagnosis of genetic disease allow for preemptive treatment of anticipated postnatal disease by stem cell or genetic therapy. While currently awaiting clinical application, in utero stem cell therapy has made significant advances in overcoming the engraftment and immunologic barriers in both murine and pre-clinical large animal models. Likewise, proof in principle for fetal gene therapy has been demonstrated in rodent and large animal systems as a method to prevent the onset of inherited genetic disease; however, safety and ethical risks still need to be addressed prior to human application. In this review, we examine the current status and future direction of stem cell and genetic therapy for the fetus.
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Affiliation(s)
- Erik G Pearson
- Children's Center for Fetal Research, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia 19104-4318, USA
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29
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Abstract
Prenatal gene therapy aims to deliver genes to cells and tissues early in prenatal life, allowing correction of a genetic defect, before irreparable tissue damage has occurred. In contrast to postnatal gene therapy, prenatal application may target genes to a large population of stem cells, and the smaller fetal size allows a higher vector to target cell ratio to be achieved. Early gestation delivery may allow the development of immune tolerance to the transgenic protein, which would facilitate postnatal repeat vector administration if needed. Moreover, early delivery would avoid anti-vector immune responses which are often acquired in postnatal life. The NIH Recombinant DNA Advisory Committee considered that a candidate disease for prenatal gene therapy should pose serious morbidity and mortality risks to the fetus or neonate, and not have any effective postnatal treatment. Prenatal gene therapy would therefore be appropriate for life-threatening disorders, in which prenatal gene delivery maintains a clear advantage over cell transplantation or postnatal gene therapy. If deemed safer and more efficacious, prenatal gene therapy may be applicable for nonlethal conditions if adult gene transfer is unlikely to be of benefit. Many candidate diseases will be inherited congenital disorders such as thalassaemia or lysosomal storage disorders. However, obstetric conditions such as fetal growth restriction may also be treated using a targeted gene therapy approach. In each disease, the condition must be diagnosed prenatally, either via antenatal screening and prenatal diagnosis, for example, in the case of hemophilias, or by ultrasound assessment of the fetus, for example, congenital diaphragmatic hernia. In this chapter, we describe some examples of the candidate diseases and discuss how a prenatal gene therapy approach might work.
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Affiliation(s)
- Anna L David
- Prenatal Cell and Gene Therapy Group, EGA Institute for Women's Health, University College London, London, UK.
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30
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Mattar CN, Biswas A, Choolani M, Chan JKY. The case for intrauterine stem cell transplantation. Best Pract Res Clin Obstet Gynaecol 2012; 26:683-95. [PMID: 22809469 DOI: 10.1016/j.bpobgyn.2012.06.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Accepted: 06/08/2012] [Indexed: 12/14/2022]
Abstract
The clinical burden imposed by the collective group of monogenic disorders demands novel therapies that are effective at achieving phenotypic cure early in the disease process before the development of permanent organ damage. This is important for lethal diseases and also for non-perinatally lethal conditions that are characterised by severe disability with little prospect of postnatal cure. Where postnatal treatments are limited to palliative options, intrauterine stem-cell therapies may offer the potential to arrest pathogenesis in the early undamaged fetus. Intrauterine stem-cell transplantation has been attempted for a variety of diseases, but has only been successful in immune deficiency states in the presence of a competitive advantage for donor cells. This disappointing clinical record requires preclinical investigations into strategies that improve donor cell engraftment, including optimising the donor cell source and manipulating the microenvironment to facilitate homing. This chapter aims to outline the current challenges of intrauterine stem-cell therapy.
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Affiliation(s)
- Citra N Mattar
- Experimental Fetal Medicine Group, Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
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31
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Mummery C, Westgren M, Sermon K. Current controversies in prenatal diagnosis 1: is stem cell therapy ready for human fetuses? Prenat Diagn 2011; 31:228-30. [PMID: 21374635 DOI: 10.1002/pd.2657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2010] [Accepted: 10/26/2010] [Indexed: 11/06/2022]
Affiliation(s)
- Christine Mummery
- Department of Anatomy and Embryology, Leiden University Medical Center, Leiden, The Netherlands
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32
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Flow cytometric methods for prenatal and neonatal diagnosis. J Immunol Methods 2011; 363:198-209. [DOI: 10.1016/j.jim.2010.09.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2010] [Accepted: 09/29/2010] [Indexed: 01/21/2023]
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Abstract
Fetal medicine covers a broad spectrum of conditions that can be diagnosed before birth. Different disorders will require different treatment strategies and there is often an important ontogenetic aspect on how and when treatment can be implemented. Due to the limited availability there is a general lack of knowledge on how pharmacotherapy can be provided in the most efficient way. Until recently most knowledge about how different drugs are transferred and metabolized in the human fetus is based on very limited observational studies on concentrations of drugs in fetal blood and other fetal compartments. It might be that the rapid development of other non-invasive methods for fetal diagnostics such as isolation of fetal DNA and RNA in maternal serum, NMR imaging and other techniques could in the future be explored in fetal pharmacotherapy. Introduction of new treatment strategies are often based on extrapolation from experience in neonates and adults. However some fetal conditions are very specific for this time period in life. This especially entails disturbances in development as malformations, early growth restriction and several congenital disorders. Here it might be required to introduce new treatment strategies without any previous experience in humans. Example of this ethical dilemma is gene therapy for lung growth in severe cases of diaphragmatic hernia and early growth restriction. The risk-benefit issues need to be discussed in all these alternatives. However, it is likely that the concept of the human fetus as a potential patient is still in its infancy and with an improved understanding about fetal patho-physiology there will be a continued need for better knowledge of pharmacotherapy during this crucial time period in life.
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Affiliation(s)
- Magnus Westgren
- Division of Obstetrics and Gynecology, Department of Clinical Science, Intervention and Technology Centre for Fetal Medicine, Karolinska University Hospital, Karolinska Institutet, S-141 86 Stockholm, Sweden.
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34
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Affiliation(s)
- Mahesh Choolani
- Division of Maternal and Fetal Medicine, Experimental Fetal Medicine Group, Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
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Roybal JL, Santore MT, Flake AW. Stem cell and genetic therapies for the fetus. Semin Fetal Neonatal Med 2010; 15:46-51. [PMID: 19540822 DOI: 10.1016/j.siny.2009.05.005] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Advances in prenatal diagnosis have led to the prenatal management of a variety of congenital diseases. Although prenatal stem cell and gene therapy await clinical application, they offer tremendous potential for the treatment of many genetic disorders. Normal developmental events in the fetus offer unique biologic advantages for the engraftment of hematopoietic stem cells and efficient gene transfer that are not present after birth. Although barriers to hematopoietic stem cell engraftment exist, progress has been made and preclinical studies are now underway for strategies based on prenatal tolerance induction to facilitate postnatal cellular transplantation. Similarly, in-utero gene therapy shows experimental promise for a host of diseases and proof-in-principle has been demonstrated in murine models, but ethical and safety issues still need to be addressed. Here we review the current status and future potential of prenatal cellular and genetic therapy.
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Affiliation(s)
- Jessica L Roybal
- Children's Center for Fetal Research, Children's Hospital of Philadelphia, PA, USA
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Abstract
At the present time, the most likely and eminent application of stem cell therapy to the fetus is in utero hematopoietic stem cell transplantation (IUHCT), and this stem cell type will be discussed as a paradigm for all prenatal stem cell therapy. The authors feel that the most likely initial application of IUHCT will use adult HSC derived from bone marrow (BM) or peripheral blood (PB), and will focus this article on this specific approach. The article also reviews the experimental data that support the capacity of IUHCT to induce donor-specific tolerance.
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Polyclonal T-cell reconstitution of X-SCID recipients after in utero transplantation of lymphoid-primed multipotent progenitors. Blood 2009; 113:4790-8. [DOI: 10.1182/blood-2007-12-129056] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Although successful in utero hematopoietic cell transplantation (IUHCT) of X-linked severe combined immune deficiency (X-SCID) with enriched stem and progenitor cells was achieved more than a decade ago, it remains applied only in rare cases. Although this in part reflects that postnatal transplantations have overall given good results, there are no direct comparisons between IUHCT and postnatal transplantations of X-SCID. The proposed tolerance of the fetal immune system to foreign human leukocyte antigen early in gestation, a main rationale behind IUHCT, has recently been challenged by evidence for a considerable immune barrier against in utero transplanted allogeneic bone marrow cells. Consequently, there is need for further exploring the application of purified stem and progenitor cells to overcome this barrier also in IUHCT. Herein, we demonstrate in a congenic setting that recently identified lymphoid-primed multipotent progenitors are superior to hematopoietic stem cells in providing rapid lymphoid reconstitution after IUHCT of X-SCID recipients, and sustain in the long-term B cells, polyclonal T cells, as well as short-lived B-cell progenitors and thymic T-cell precursors. We further provide evidence for IUHCT of hematopoietic stem cells giving superior B- and T-cell reconstitution in fetal X-SCID recipients compared with neonatal and adolescent recipients.
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In Utero Hematopoietic Stem Cell Transplantation: Progress toward Clinical Application. Biol Blood Marrow Transplant 2008; 14:729-40. [DOI: 10.1016/j.bbmt.2008.02.012] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2008] [Accepted: 02/15/2008] [Indexed: 11/22/2022]
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Abstract
Fetal stem-cell transplantation is an attractive approach to the treatment of a variety of hematological, metabolic and immunological diseases before birth. The possibility of delivering a large number of cells in an early stage of life, and of taking advantage of normal fetal stem-cell migration and development, is promising. During fetal life, the capacity to mount an immune response to allogeneic cells is impaired compared with adult life. This provides an opportunity to induce tolerance to alloantigens without the need for myeloablation, although there are possible immune barriers to foreign cells in the fetus.
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Affiliation(s)
- Eleonor Tiblad
- Center for Fetal Medicine, Department of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden
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41
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Abstract
Gene therapy uses the intracellular delivery of genetic material for the treatment of disease. A wide range of diseases - including cancer, vascular and neurodegenerative disorders and inherited genetic diseases - are being considered as targets for this therapy in adults. There are particular reasons why fetal application might prove better than application in the adult for treatment, or even prevention of early-onset genetic disorders such as cystic fibrosis and Duchenne muscular dystrophy. Research shows that gene transfer to the developing fetus targets rapidly expanding populations of stem cells, which are inaccessible after birth, and indicates that the use of integrating vector systems results in permanent gene transfer. In animal models of congenital disease such as haemophilia, studies show that the functionally immature fetal immune system does not respond to the product of the introduced gene, and therefore immune tolerance can be induced. This means that treatment could be repeated after birth, if that was necessary to continue to correct the disease. For clinicians and parents, fetal gene therapy would give a third choice following prenatal diagnosis of inherited disease, where termination of pregnancy or acceptance of an affected child are currently the only options. Application of this therapy in the fetus must be safe, reliable and cost-effective. Recent developments in the understanding of genetic disease, vector design, and minimally invasive delivery techniques have brought fetal gene therapy closer to clinical practice. However more research needs to be done in before it can be introduced as a therapy.
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Affiliation(s)
- Anna L David
- Department of Obstetrics & Gynaecology, Royal Free & University College London Medical School, 86-96 Chenies Mews, London, WC1E 6HX, UK.
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Rollini P, Faes-Van't Hull E, Kaiser S, Kapp U, Leyvraz S. Phenotypic and Functional Analysis of Human Fetal Liver Hematopoietic Stem Cells in Culture. Stem Cells Dev 2007; 16:281-96. [PMID: 17521239 DOI: 10.1089/scd.2006.0096] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Steady-state hematopoiesis and hematopoietic transplantation rely on the unique potential of stem cells to undergo both self-renewal and multilineage differentiation. Fetal liver (FL) represents a promising alternative source of hematopoietic stem cells (HSCs), but limited by the total cell number obtained in a typical harvest. We reported that human FL nonobese diabetic/severe combined immunodeficient (NOD/SCID) repopulating cells (SRCs) could be expanded under simple stroma-free culture conditions. Here, we sought to further characterize FL HSC/SRCs phenotypically and functionally before and following culture. Unexpanded or cultured FL cell suspensions were separated into various subpopulations. These were tested for long-term culture potential and for in vivo repopulating function following transplantation into NOD/SCID mice. We found that upon culture of human FL cells, a tight association between classical stem cell phenotypes, such as CD34(+) /CD38(-) and/or side population, and NOD/SCID repopulating function was lost, as observed with other sources. Although SRC activity before and following culture consistently correlated with the presence of a CD34(+) cell population, we provide evidence that, contrary to umbilical cord blood and adult sources, stem cells present in both CD34(+) and CD34(-) FL populations can sustain long-term hematopoietic cultures. Furthermore, upon additional culture, CD34-depleted cell suspensions, devoid of SRCs, regenerated a population of CD34(+) cells possessing SRC function. Our studies suggest that compared to neonatal and adult sources, the phenotypical characteristics of putative human FL HSCs may be less strictly defined, and reinforce the accumulated evidence that human FL represents a unique, valuable alternative and highly proliferative source of HSCs for clinical applications.
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Affiliation(s)
- Pierre Rollini
- Centre Pluridisciplinaire d'Oncologie, University Hospital, Lausanne, Switzerland.
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Chan J, Waddington SN, O'Donoghue K, Kurata H, Guillot PV, Gotherstrom C, Themis M, Morgan JE, Fisk NM. Widespread distribution and muscle differentiation of human fetal mesenchymal stem cells after intrauterine transplantation in dystrophic mdx mouse. Stem Cells 2006; 25:875-84. [PMID: 17185606 DOI: 10.1634/stemcells.2006-0694] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Duchenne muscular dystrophy (DMD) is a common X-linked disease resulting from the absence of dystrophin in muscle. Affected boys suffer from incurable progressive muscle weakness, leading to premature death. Stem cell transplantation may be curative, but is hampered by the need for systemic delivery and immune rejection. To address these barriers to stem cell therapy in DMD, we investigated a fetal-to-fetal transplantation strategy. We investigated intramuscular, intravascular, and intraperitoneal delivery of human fetal mesenchymal stem cells (hfMSCs) into embryonic day (E) 14-16 MF1 mice to determine the most appropriate route for systemic delivery. Intramuscular injections resulted in local engraftment, whereas both intraperitoneal and intravascular delivery led to systemic spread. However, intravascular delivery led to unexpected demise of transplanted mice. Transplantation of hfMSCs into E14-16 mdx mice resulted in widespread long-term engraftment (19 weeks) in multiple organs, with a predilection for muscle compared with nonmuscle tissues (0.71% vs. 0.15%, p < .01), and evidence of myogenic differentiation of hfMSCs in skeletal and myocardial muscle. This is the first report of intrauterine transplantation of ontologically relevant hfMSCs into fully immunocompetent dystrophic fetal mice, with systemic spread across endothelial barriers leading to widespread long-term engraftment in multiple organ compartments. Although the low-level of chimerism achieved is not curative for DMD, this approach may be useful in other severe mesenchymal or enzyme deficiency syndromes, where low-level protein expression may ameliorate disease pathology.
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Affiliation(s)
- Jerry Chan
- Experimental Fetal Medicine Group, Institute of Reproductive and Developmental Biology, Imperial College London, Hammersmith Campus, Du Cane Road, London, United Kingdom.
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Shaaban AF, Kim HB, Gaur L, Liechty KW, Flake AW. Prenatal transplantation of cytokine-stimulated marrow improves early chimerism in a resistant strain combination but results in poor long-term engraftment. Exp Hematol 2006; 34:1278-87. [PMID: 16939821 PMCID: PMC3096442 DOI: 10.1016/j.exphem.2006.05.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2006] [Revised: 05/08/2006] [Accepted: 05/08/2006] [Indexed: 01/17/2023]
Abstract
OBJECTIVE In the absence of immunodeficiency, only microchimerism (<0.1%) has been achieved in human fetal recipients or nonhuman primates following in utero hematopoietic cell transplantation (IUHCT). We hypothesized that enhanced long-term engraftment might be more reliably achieved in microchimeric systems if higher levels of chimerism existed during development of adaptive immunity. To evaluate this hypothesis, we stimulated the donor cells with vascular endothelial growth factor (VEGF) and stem cell factor (SCF) prior to IUHCT in a chimerism-resistant murine strain combination. METHODS Donor Balb/c marrow was cultured in media with or without VEGF and SCF supplementation for 12 hours prior to IUHCT into B6 fetuses at 14 days postcoitum (dpc). Donor cell phenotype, homing, and chimerism were assessed at short and long-term time points and transplanted animals received skin allografts at 8 weeks. RESULTS In pretreated allogeneic recipients, early chimerism rates were more than double that of controls (71% vs 33%, p = 0.01). These differences were associated with higher numbers of pretransplant donor cell colony-forming cells without change in donor cell homing. Despite prolonged skin allograft survival for pretreated recipients compared with controls (mean survival = 20.8 vs 8.2 days, p < 0.001), long-term engraftment was unchanged. CONCLUSIONS These findings demonstrate that higher levels of early chimerism in recipients of cytokine-stimulated marrow result in improved short-term chimerism and tolerance. Future studies are needed to confirm the existence of a "threshold" level of chimerism necessary to sustain long-term engraftment.
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Affiliation(s)
- Aimen F Shaaban
- Laboratory for Fetal Cellular Therapy, Department of Surgery, University of Wisconsin Medical School, Madison, WI 53792-7375, USA.
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Carter BM. Nursing care of the premature infant with severe combined immunodeficiency disease. Neonatal Netw 2006; 25:167-74. [PMID: 16749371 DOI: 10.1891/0730-0832.25.3.167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Diagnosis and treatment of severe combined immunodeficiency disease (SCID) is documented in fetuses, term infants, and older children; however, there is very little information on its diagnosis and treatment in premature infants. When Duke University Medical Center's first preterm infant with a known SCID history was delivered, in June 1999, there was no defined protocol for the infant's nursing care. Although many of the guidelines for nursing care of the premature infant population (< or = 36 weeks) apply, there are important considerations for preterm infants with an SCID diagnosis. This article provides background on SCID and identifies those special considerations--namely, multidisciplinary communication, infection prevention, thorough physical assessments, and parental support.
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Affiliation(s)
- Brigit M Carter
- University of North Carolina Chapel Hill School of Nursing, USA.
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Offit K, Kohut K, Clagett B, Wadsworth EA, Lafaro KJ, Cummings S, White M, Sagi M, Bernstein D, Davis JG. Cancer genetic testing and assisted reproduction. J Clin Oncol 2006; 24:4775-82. [PMID: 16840542 DOI: 10.1200/jco.2006.06.6100] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Because of increasing uptake of cancer genetic testing and the improving survival of young patients with cancer, health care practitioners including oncologists will increasingly be asked about options for assisted reproduction by members of families affected by hereditary cancer syndromes. Among these reproductive options, preimplantation genetic diagnosis (PGD) offers the opportunity to select embryos without familial cancer-predisposing mutations. METHODS A review of the published literature supplemented by a survey of PGD centers in the United States. RESULTS Prenatal diagnosis and/or embryo selection after genetic testing has already been performed in the context of more than a dozen familial cancer syndromes, including the common syndromes of genetic predisposition to colon and breast cancer. CONCLUSION While constituting new reproductive options for families affected by cancer, the medical indications and ethical acceptance of assisted reproductive technologies for adult-onset cancer predisposition syndromes remain to be defined. Continued discussion of the role of PGD in the reproductive setting is needed to inform the responsible use of these technologies to decrease the burden of heritable cancers.
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Affiliation(s)
- Kenneth Offit
- Clinical Genetics Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10021, USA.
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Affiliation(s)
- Barbara O'Brien
- Division of Genetics, Department of Pediatrics, Tufts-New England Medical Center, Boston, Massachusetts 02111, USA
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Shields LE, Gaur L, Delio P, Gough M, Potter J, Sieverkropp A, Andrews RG. The use of CD 34(+) mobilized peripheral blood as a donor cell source does not improve chimerism after in utero hematopoietic stem cell transplantation in non-human primates. J Med Primatol 2005; 34:201-8. [PMID: 16053498 DOI: 10.1111/j.1600-0684.2005.00110.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
In utero hematopoietic stem cell transplantation is a therapeutic procedure that could potentially cure many developmental diseases affecting the immune and hematopoietic systems. In most clinical and experimental settings of fetal hematopoietic transplantation the level of donor cell engraftment has been low, suggesting that even in the fetus there are significant barriers to donor cell engraftment. In postnatal hematopoietic transplantation donor cells obtained from mobilized peripheral blood engraft more rapidly than cells derived from marrow. We tested the hypothesis that use of donor hematopoietic/stem cells obtained from mobilized peripheral blood would improve engraftment and the level of chimerism after in utero transplantation in non-human primates. Despite the potential competitive advantage from the use of CD 34(+) from mobilized peripheral blood, the level of chimerism was not appreciably different from a group of animals receiving marrow-derived CD 34(+) donor cells. Based on these results, it is unlikely that this single change in cell source will influence the clinical outcome of fetal hematopoietic transplantation.
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Affiliation(s)
- Laurence E Shields
- Department of Obstetrics and Gynecology, Division of Perinatal Medicine, University of Washington, Seattle, WA, USA.
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Waddington SN, Kramer MG, Hernandez-Alcoceba R, Buckley SMK, Themis M, Coutelle C, Prieto J. In utero gene therapy: current challenges and perspectives. Mol Ther 2005; 11:661-76. [PMID: 15851005 DOI: 10.1016/j.ymthe.2005.01.015] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Over the past few years, considerable progress in prenatal diagnosis and surgery combined with improvements in vector design vindicate a reappraisal of the feasibility of in utero gene therapy for serious monogenetic diseases. As adult gene therapy gathers pace, several apparent obstacles to its application as a treatment may be overcome by pre- or early postnatal treatment. This review will examine the concepts and practice of prenatal vector administration. We aim to highlight the advantages of early therapeutic intervention focusing on diseases that could benefit greatly from a prenatal gene therapy approach. We will pay special attention to the strategies and vectors that are most likely to be used for this application and will speculate on their expected developments for the near future.
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Affiliation(s)
- Simon N Waddington
- Gene Therapy Research Group, Sir Alexander Fleming Building, Imperial College, South Kensington, London SW7 2AZ, UK
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50
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Tse DB, Ching E, Yousefzadeh N, Roque H, Young BK. Heterogeneity in fetal immunocompetence during the second trimester of gestation. Implications for treatment of nonimmune genetic disorders by in utero transplantation. Fetal Diagn Ther 2005; 20:175-81. [PMID: 15824493 DOI: 10.1159/000083900] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2003] [Accepted: 02/03/2004] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To address the role that alloreactivity may play and better define the window for histoincompatible stem cell transplantation in utero. SUBJECTS, MATERIAL AND METHODS We studied 9 fetal blood specimens obtained by cardiocentesis during elective abortions in the second trimester by multicolor flow cytometry and in vitro stimulation. RESULTS Lymphocytes ranged from adult levels (3/9) to >90% leukocytes. Six specimens had T cells within adult range. T cells in the other specimens were reduced, while B cells were conversely elevated. This variability did not correlate with gestational age, or leukocyte composition. Following 4 h of mitogenesis, fetal CD4+ and CD8+ T cells from 1 of 5 specimens showed a response similar to that of maternal T cells, while the other 4 specimens showed a diminished response (0.3 +/- 0.2-fold). This heterogeneity did not correlate with gestational age, or lymphocyte subset distribution. Following 18 h of in vitro mitogenesis, fetal T cells from 2 specimens showed a response similar to that of maternal T cells (0.8 +/- 0.2-fold). Despite that, one specimen gave a 3-fold greater response in a one-way mixed lymphocyte reaction vs. maternal cells compared to the other specimen. CONCLUSION We determine that fetal immunocompetence differs greatly during the second trimester and assessment of host vs. donor reactivity prior to in utero transplantation is likely to potentiate more favorable outcomes.
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Affiliation(s)
- Doris B Tse
- Division of Infectious Disease and Immunology, Department of Medicine, New York University School of Medicine, New York, NY 10016, USA.
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