Gene therapy with bilirubin-UDP-glucuronosyltransferase in the Gunn rat model of Crigler-Najjar syndrome type 1

Developmental, Genetic, Dietary, and Xenobiotic Influences on Neonatal Hyperbilirubinemia

Hyperbilirubinemia, caused by the accumulation of unconjugated bilirubin, is one of the most common clinical diagnoses in both premature and term newborns. Owing to the fact that bilirubin is metabolized solely through glucuronidation by UDP-glucuronosyltransferase (UGT) 1A1, it is now known that immaturity of UGT1A1, in combination with the overproduction of bilirubin during the developmental stage, acts as a bottleneck to bilirubin elimination and predisposes the infant to high total serum bilirubin levels. Although neonatal jaundice is mostly benign, excessively high levels of serum bilirubin in a small percentage of newborns can cause bilirubin-induced neurologic dysfunction, potentially leading to permanent brain damage, a condition known as kernicterus Although a large portion of hyperbilirubinemia cases in newborns are associated with hemolytic diseases, we emphasize here the impaired ability of UGT1A1 to eliminate bilirubin that contributes to hyperbilirubinemia-induced neurotoxicity in the developmental stage. As a series of hereditary UGT1A1 mutations have been identified that are associated with UGT1A1 deficiency, new evidence has verified that delayed expression of UGT1A1 during the early stages of neonatal development is a tightly controlled event involving coordinated intrahepatic and extrahepatic regulation. This review recapitulates the progress that has been made in recent years in understanding the causes and physiopathology of severe hyperbilirubinemia, investigating molecular mechanisms underlying bilirubin-induced encephalopathy, and searching for potential therapies for treating pathologic hyperbilirubinemia. Several animal models have been developed to make it possible to examine bilirubin-induced neurotoxicity from multiple directions. Moreover, environmental factors that may alleviate or worsen the condition of hyperbilirubinemia are discussed.

Recent developments in transposon-mediated gene therapy

INTRODUCTION

The continuous improvement of gene transfer technologies has broad implications for stem cell biology, gene discovery, and gene therapy. Although viral vectors are efficient gene delivery vehicles, their safety, immunogenicity and manufacturing challenges hamper clinical progress. In contrast, non-viral gene delivery systems are less immunogenic and easier to manufacture.

AREAS COVERED

In this review, we explore the emerging potential of transposons in gene and cell therapy. The safety, efficiency, and biology of novel hyperactive Sleeping Beauty (SB) and piggyBac (PB) transposon systems will be highlighted for ex vivo gene therapy in clinically relevant adult stem/progenitor cells, particularly hematopoietic stem cells (HSCs), mesenchymal stem cells (MSCs), myoblasts, and induced pluripotent stem (iPS) cells. Moreover, efforts toward in vivo transposon-based gene therapy will be discussed.

EXPERT OPINION

The latest generation SB and PB transposons currently represent some of the most attractive systems for stable non-viral genetic modification of primary cells, particularly adult stem cells. This paves the way toward the use of transposons as a non-viral gene therapy approach to correct hereditary disorders including those that affect the hematopoietic system. The development of targeted integration into "safe harbor" genetic loci may further improve their safety profile.

Crigler-Najjar syndrome: therapeutic options and consequences of mutations in the UGT1A1 complex

Crigler-Najjar syndrome (CN), a rare inherited disorder characterized by failure of bilirubin glucuronidation, can lead to severe disability and death from kernicterus. Gilbert syndrome is a more common, benign familial unconjugated hyperbilirubinemia. The underlying problem in both conditions is impaired bilirubin conjugation and elimination due to a mutation in uridine 5'-diphosphate glucuronyltransferase. The mainstay of current management of CN is phototherapy, followed by liver transplantation. Here, we review other therapies, including hepatocyte transplantation, that have been successfully used to lessen the phenotype, although long-term engraftment of cells remains elusive. Gene therapy holds hope for the future whereby the patient's hepatocytes are transduced with the wild-type gene. Outstanding issues include safety of the gene vector and establishing immunotolerance to both vector and the new protein. The significant advances in understanding the relevance of mutations in UGT not only in glucuronidation of bilirubin, but other drugs and substances, are also reviewed.

Gene therapy for liver enzyme deficiencies: what have we learned from models for Crigler-Najjar and tyrosinemia?

The liver is the site of numerous metabolic inherited diseases. It has unique features that make it compliant to various gene therapy approaches. Many vector types and gene delivery strategies have been evaluated during the past 20 years in a number of animal models of metabolic liver diseases. However, the complete cure of inherited liver deficiencies by gene therapy in relevant animal models were only reported recently. These successes were achieved thanks to major advances in vector technology. In this review, we will focus on Crigler-Najjar disease and hereditary tyrosinemia, two paradigmatic examples of the two categories of enzymatic liver deficiencies: type I, in which the genetic defect does not affect liver histology; and type II, in which liver lesions are present.

Adenovirus-Mediated Gene Therapy to Restore Expression and Functionality of Multiple UDP-Glucuronosyltransferase 1A Enzymes in Gunn Rat Liver

The Gunn rat has been a valuable model for investigating the effect of UDP-glucuronosyltransferase 1A (UGT1A) deficiencies on drug metabolism and toxicity, but it is limited in some aspects. For example, the native Gunn rat model cannot distinguish between hepatic and extrahepatic UGT1A deficiencies in toxicological mechanisms. To extend the model's utility, we investigated the use of replication-defective recombinant UGT1A adenoviruses for the purpose of selectively restoring hepatic UGT1A function. Mycophenolic acid, the active metabolite of the anti-transplant rejection drug mycophenolate mofetil and suspected gastrointestinal toxicant, was used as a model UGT1A-dependent substrate. Treatment with UGT1A adenoviruses normalized the plasma mycophenolic acid and 7-O-mycophenolate glucuronide (MPAG) (concentration-time curves after mycophenolic acid administration (80 mg/kg intraperitoneally). Functional reconstitution was also apparent in the correction of the mycophenolic acid t(1/2alpha) and the area under the curve (AUC)(MPA,0-8 h)/AUC(MPAG,0-8 h) ratio. Twenty-four hours after administration of mycophenolic acid, severe signs of toxicity were noted in the naive Gunn group, including reduced food consumption. The effect on food consumption was reduced but not completely prevented in the UGT adenovirus-treated Gunn rats. In vitro analyses indicated adenovirus dose-dependent reconstitution of mycophenolic acid UGT activities and UGT1A contents in liver but not intestinal microsomes. In the highest adenovirus dose group, the liver microsomal UGT1A markers exceeded those of the heterozygote controls. The ability to selectively manipulate multiple hepatic UGT1A enzymes in Gunn rats should provide a novel way to assess the importance of intestinal or other extrahepatic UGT1A enzymes in toxicities induced by mycophenolic acid and other cytotoxic drugs and dietary agents.

Successful Treatment of UGT1A1 Deficiency in a Rat Model of Crigler–Najjar Disease by Intravenous Administration of a Liver-Specific Lentiviral Vector

Treatment of congenital and acquired liver disease is one of the main issues in the field of gene therapy. Self-inactivating lentiviral vectors have several potential advantages over alternative systems. We have constructed a self-inactivating lentiviral vector (LV-ALBUGT) that expresses the human bilirubin UDP-glucuronosyltransferase (UGT1A1) from a liver-specific promoter. UGT1A1 is involved in the clearance of heme metabolites in the liver. This enzyme is deficient in Crigler-Najjar disease, a recessive inherited disorder in humans characterized by chronic severe jaundice, i.e., high plasma bilirubin levels. Gunn rats suffer from the same defect and are used as an animal model of this disease. We have treated juvenile Gunn rats by single intravenous injection with the LV-ALBUGT vector. Over 1 year after treatment with the highest dose (5 x 10(8) transducing units), we observed a stable reduction of bilirubin levels to near normal levels and normal secretion of bilirubin conjugates in the bile, in contrast to untreated animals. In situ hybridization showed expression of the therapeutic gene in more than 30% of liver parenchymal cells. Thus, we demonstrate stable and complete clinical remission of a congenital metabolic liver disease in an animal model, after systemic administration of a therapeutic lentiviral vector.

Therapeutic lentivirus-mediated neonatal in vivo gene therapy in hyperbilirubinemic Gunn rats

Crigler-Najjar type 1 disease (CN-1) is a genetic disorder characterized by high levels of unconjugated bilirubin due to the absence of hepatic UDPglucuronosyltransferase (UGT1) activity. Here we show that in vivo neonatal hepatocyte transduction with a lentiviral vector expressing the defective enzyme resulted in long-term correction in Gunn rats, a model of CN-1. Lentiviral vectors harboring the human UGT1 cDNA (approved symbol UGT1A1) under the control of a liver-specific transthyretin promoter were produced. Two-day-old Gunn rats were injected with 50 microl of vector. Bilirubinemia was monitored at 6 weeks and monthly thereafter. At 6 weeks, bilirubinemia was completely normalized in treated animals, whereas it remained around 100 microM in control rats. The level of correction remained stable for up to 42 weeks. Large amounts of bilirubin conjugates were present in the bile of corrected animals. PCR and Western blots confirmed the presence and expression of UGT1 in liver. The estimated proportion of transduced hepatocytes was 40% and transduced cells were not detected in extrahepatic tissues except bone marrow in some animals. This work represents the first demonstration of a complete and permanent correction of hyperbilirubinemia in Gunn rats using lentiviral vectors.

Single Hepatic Venous Injection of Liver-Specific Naked Plasmid Vector Expressing Human UGT1A1 Leads to Long-Term Correction of Hyperbilirubinemia and Prevention of Chronic Bilirubin Toxicity in Gunn Rats

Previously, we have demonstrated that hepatic venous injection of pcDNA3hUGT1A1 expressing human bilirubin glucuronosyl transferase 1A1 (hUGT1A1) under the control of the cytomegalovirus promoter results in excretion of bilirubin glucuronides in bile and significant decrease in serum bilirubin for at least 2 weeks in the Gunn rat, an animal model of Crigler-Najjar syndrome type I. In this study we compared repeat delivery of pcDNA3hUGT1A1 with single injection of pBShUGT1A1 expressing hUGT1A1 under liver-specific regulatory control, for treatment of hyperbilirubinemia in the Gunn rat. Although repeat injections of pcDNA3hUGT1A1 consistently reduced serum bilirubin levels, the effect did not exceed 2 weeks; hUGT1A1 was detectable in livers only for 2 weeks, despite the presence of vector and transcript for at least 1 month. In contrast, injection of pBShUGT1A1 resulted in persistence of vector, transcript, and recombinant protein and sustained correction of hyperbilirubinemia for at least 8 months; furthermore, renal tubular damage, the principal manifestation of chronic bilirubin toxicity in the Gunn rat, was prevented. Sera from animals treated with pBShUGT1A1 consistently contained anti-hUGT1A1 antibodies, but a significant increase in the number of hepatic CD4(+) and CD8(+) cells was seen only in the pcDNA3hUGT1A1 group; thus liver-specific expression of hUGT1A1 may attenuate immune response. Our results provide further evidence of the feasibility of long-term correction of hepatic enzyme deficiencies with plasmid vectors optimized for expression in the liver.

Long-term correction of hyperbilirubinemia in the Gunn rat by repeated intravenous delivery of naked plasmid DNA into muscle

We evaluated nonviral gene delivery into skeletal muscle via femoral artery and great saphenous vein for correction of hyperbilirubinemia in the Gunn rat, the animal model of Crigler-Najjar syndrome type I. A single injection of pDNA expressing hUGT1A1 under the CMV promoter resulted in excretion of bilirubin glucuronides in bile and a significant decrease in serum bilirubin for at least 2 or 4 weeks, respectively. Loss of metabolic effect was associated with a decrease in recombinant protein in muscle, while pDNA and transcript were detectable 4 weeks after gene delivery. Monthly intravenous gene delivery maintained metabolic correction for at least 5 months. Fibrosis around vessels in the arterial group limited the number of successful repeat gene transfer sessions to 3. Animals expressing hUGT1A1 developed anti-hUGT1A1 antibodies and lymphocytic infiltrate in muscle. Immunosuppression abrogated antibody response, ameliorated lymphocytic inflammation, and enhanced metabolic correction but did not prevent a decrease in the amount of recombinant protein. In conclusion, repeated intravenous delivery of pDNA into muscle enables long-term correction of hyperbilirubinemia in the Gunn rat. The procedure is safe and simple, with great clinical potential. Further studies are needed to explain the mechanisms of loss and improve the stability of recombinant hUGT1A1 in muscle.

Lifelong elimination of hyperbilirubinemia in the Gunn rat with a single injection of helper-dependent adenoviral vector

Crigler-Najjar syndrome is a recessively inherited disorder characterized by severe unconjugated hyperbilirubinemia caused by a deficiency of uridine diphospho-glucuronosyl transferase 1A1. Current therapy relies on phototherapy to prevent kernicterus, but liver transplantation presently is the only permanent cure. Gene therapy is a potential alternative, and recent work has shown that helper-dependent adenoviral (HD-Ad) vectors, devoid of all viral coding sequences, induce prolonged transgene expression and exhibit significantly less chronic toxicity than early-generation Ad vectors. We used a HD-Ad vector to achieve liver-restricted expression of human uridine diphospho-glucuronosyl transferase 1A1 in the Gunn rat, a model of the human disorder. Total plasma bilirubin levels were reduced from >5.0 mg/dl to <<1.4 mg/dl for >2 yr after a single i.v. administration of vector expressing the therapeutic transgene at a dose of 3 x 10(12) viral particles per kg. HPLC analysis of bile from treated rats showed the presence of bilirubin glucuronides at normal WT levels >2 yr after one injection of vector, and i.v. injection of bilirubins IIIalpha and XIIIalpha in the same animals revealed excess bilirubin-conjugating capacity. There was no significant elevation of liver enzymes (alanine aminotransferase) and only transient, moderate thrombocytopenia after injection of the vector. A clinically significant reduction in serum bilirubin was observed with a dose as low as 6 x 10(11) viral particles per kg. We conclude that complete, long-term correction of hyperbilirubinemia in the Gunn rat model of Crigler-Najjar syndrome can be achieved with one injection of HD-Ad vector and negligible chronic toxicity.

Prolongation of transgene expression by coexpression of cytokine response modifier a in rodent liver after adenoviral gene transfer

The short duration of expression of the transgenes is a major barrier to the clinical application of adenovirus-mediated gene therapy for hepatic enzyme deficiencies. Previous reports show that Fas-mediated apoptosis has a pivotal role in the rapid elimination of adenovirus-infected hepatocytes. After considering this result and our recent observation that murine hepatocytes can be protected from Fas-mediated apoptosis by expressing cytokine response modifier A (CrmA) in vivo, we hypothesized that CrmA coexpression could also prevent adenovirus-infected hepatocytes from rapid elimination and that this would make prolonged transgene expression achievable in vivo. To examine this, mice with congenital deficiency of lysosomal beta-glucuronidase (GUSB) were infected with recombinant adenoviruses expressing both CrmA and GUSB, and the duration of transgene expression was evaluated. The serum GUSB activity in the mice injected with a recombinant adenovirus expressing GUSB only became undetectable 60 days after the injection, whereas higher than normal GUSB activity was observed for at least 120 days in mice injected with adenoviruses expressing both GUSB and CrmA. Furthermore, we showed that exogenous CrmA expression could prevent the adenovirus-infected hepatocytes from cell death induced by cytotoxic T lymphocytes in vitro. These observations indicate that transgene expression after administration of E1-deleted adenovirus is prolonged by coexpression of the antiapoptotic protein CrmA.

Correction of the UDP-glucuronosyltransferase gene defect in the gunn rat model of crigler-najjar syndrome type I with a chimeric oligonucleotide

Crigler-Najjar syndrome type I is characterized by unconjugated hyperbilirubinemia resulting from an autosomal recessive inherited deficiency of hepatic UDP-glucuronosyltransferase (UGT) 1A1 activity. The enzyme is essential for glucuronidation and biliary excretion of bilirubin, and its absence can be fatal. The Gunn rat is an excellent animal model of this disease, exhibiting a single guanosine (G) base deletion within the UGT1A1 gene. The defect results in a frameshift and a premature stop codon, absence of enzyme activity, and hyperbilirubinemia. Here, we show permanent correction of the UGT1A1 genetic defect in Gunn rat liver with site-specific replacement of the absent G residue at nucleotide 1206 by using an RNA/DNA oligonucleotide designed to promote endogenous repair of genomic DNA. The chimeric oligonucleotide was either complexed with polyethylenimine or encapsulated in anionic liposomes, administered i.v., and targeted to the hepatocyte via the asialoglycoprotein receptor. G insertion was determined by PCR amplification, colony lift hybridizations, restriction endonuclease digestion, and DNA sequencing, and confirmed by genomic Southern blot analysis. DNA repair was specific, efficient, stable throughout the 6-month observation period, and associated with reduction of serum bilirubin levels. Our results indicate that correction of the UGT1A1 genetic lesion in the Gunn rat restores enzyme expression and bilirubin conjugating activity, with consequent improvement in the metabolic abnormality.

Strategy of liver-directed gene therapy: present status and future prospects

The liver is particularly amenable to gene therapy as it is the site of many metabolic diseases and malignancies. Thus, liver-directed gene therapy is being actively pursued and developed as a method of treatment for various liver diseases. Strategies of liver-directed gene therapy include drug delivery to the liver, compensation of the defective gene(s), anti-tumor activity, anti-viral therapy, and immunomodulation. The strategy chosen for liver-directed gene therapy depends on the genetic basis of the disease. Many aspects are key factors to the success of the chosen strategy: intervention of genes, efficient gene delivery system, stable transgene expression, transgene regulation, target cell transfection, and timing of transgene expression. Several tactics can be used to overcome problems in the above, and these include the use of a gene switch to exogenously regulate transgene expression, targeting at the transcriptional level, circumvention of the immune response (as in the use of adenovirus vector to achieve long-term correction of genetic diseases), and genetically engineered antibodies in gene transfer. At the present rate of research activity and development, gene therapies may soon be more efficient than current standard treatments for some liver diseases.

Normal perinatal rise in serum cholesterol is inhibited by hepatic delivery of adenoviral vector expressing apolipoprotein B mRNA editing enzyme (Apobec1) in rabbits

BACKGROUND

Prenatal or neonatal hepatic gene delivery may result in more effective therapy for inborn errors of metabolism due to the immature immune system of the perinatal animal, and the ability to intervene prior to any significant cellular damage. Newborn New Zealand White rabbits have low serum levels of cholesterol at birth, with a significant and sustained rise of cholesterol while they are nursing. We used this physiologic hypercholesterolemia model to study the effect of adenovirus-mediated hepatic gene transfer of rat apolipoprotein B mRNA editing enzyme (Apobec1) on modulation of plasma cholesterol levels.

METHODS AND RESULTS

Transcutaneous injection of recombinant adenovirus expressing Apobec1 (AvApobec1) into the liver of newborn rabbits in vivo resulted in efficient Apobec1 expression until Day 50, as detected by PCR-Southern blot analysis. By in vitro editing assay, liver extracts of AvApobec1-treated rabbits were found to have apoB mRNA editing activities of approximately 12, 15, and 15%, on Days 2, 10, and 20 after AvApobec1 administration, compared with 0% editing activity in AvLacZ control vector-injected animals. This physiological level of Apobec1 expression was associated with the production of apoB-48-containing lipoprotein particles from rabbit liver, with a concomitant 30% reduction in total plasma cholesterol compared to AvLacZ-treated or untreated control animals.

CONCLUSION

Neonatal intrahepatic delivery of a first-generation adenoviral vector results in efficient gene transfer with little immune response, suggesting that repeated administration may be possible in the neonatal period.

Persistence of an [E1-, polymerase-] adenovirus vector despite transduction of a neoantigen into immune-competent mice

The ability of a uniquely modified [E1-, polymerase-] adenovirus (Ad) vector to persist after the transduction of the bacterial beta-galactosidase gene into the livers of nontolerant, immune-competent adult mice was compared with an identical gene transfer attempt with an [E1-] Ad vector. After transduction, the E1-deleted vector was rapidly eliminated, but the modified vector persisted for at least 2 months (experiment duration). Modified vector persistence was also accompanied by prolonged transgene expression and decreased hepatotoxicity profiles. This result was in contrast to several reports suggesting that the transgene expressed by an Ad vector is the primary determinant of Ad vector elimination in vivo. Our results implied that the rapid immune clearance of Ad-transduced cells in vivo is codependent on the presence of two stimuli, or "hits." Hit 1 is due to Ad vector-derived gene expression while hit 2 is due to transgene immunogenicity. Attenuation of the first hit by the use of a significantly modified vector (such as the [E1-, polymerase-] Ad vector) allowed for extended persistence, despite the continued presence of the transgene-derived stimulus (hit 2). We discuss how the two-hit hypothesis is in fact congruent with a number of other reports that have analyzed Ad vector persistence in immune-competent animals. On the basis of our results, [E1-, polymerase-] Ad vectors should have broad benefits for use in human gene therapy situations in which the encoded transgene may be perceived as a neoantigen by the intact human immune system.