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Rojsajjakul T, Selvan N, De B, Rosenberg JB, Kaminsky SM, Sondhi D, Janki P, Crystal RG, Mesaros C, Khanna R, Blair IA. Expression and processing of mature human frataxin after gene therapy in mice. Sci Rep 2024; 14:8391. [PMID: 38600238 PMCID: PMC11006666 DOI: 10.1038/s41598-024-59060-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 04/06/2024] [Indexed: 04/12/2024] Open
Abstract
Friedreich's ataxia is a degenerative and progressive multisystem disorder caused by mutations in the highly conserved frataxin (FXN) gene that results in FXN protein deficiency and mitochondrial dysfunction. While gene therapy approaches are promising, consistent induction of therapeutic FXN protein expression that is sub-toxic has proven challenging, and numerous therapeutic approaches are being tested in animal models. FXN (hFXN in humans, mFXN in mice) is proteolytically modified in mitochondria to produce mature FXN. However, unlike endogenous hFXN, endogenous mFXN is further processed into N-terminally truncated, extra-mitochondrial mFXN forms of unknown function. This study assessed mature exogenous hFXN expression levels in the heart and liver of C57Bl/6 mice 7-10 months after intravenous administration of a recombinant adeno-associated virus encoding hFXN (AAVrh.10hFXN) and examined the potential for hFXN truncation in mice. AAVrh.10hFXN induced dose-dependent expression of hFXN in the heart and liver. Interestingly, hFXN was processed into truncated forms, but found at lower levels than mature hFXN. However, the truncations were at different positions than mFXN. AAVrh.10hFXN induced mature hFXN expression in mouse heart and liver at levels that approximated endogenous mFXN levels. These results suggest that AAVrh.10hFXN can likely induce expression of therapeutic levels of mature hFXN in mice.
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Affiliation(s)
- Teerapat Rojsajjakul
- Department of Systems Pharmacology and Translational Therapeutics Perelman School of Medicine, Penn/CHOP Friedreich's Ataxia Center of Excellence, Center of Excellence in Environmental Toxicology, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Bishnu De
- Department of Genetic Medicine, Weill Cornell College of Medicine, New York, NY, USA
| | - Jonathan B Rosenberg
- Department of Genetic Medicine, Weill Cornell College of Medicine, New York, NY, USA
| | - Stephen M Kaminsky
- Department of Genetic Medicine, Weill Cornell College of Medicine, New York, NY, USA
| | - Dolan Sondhi
- Department of Genetic Medicine, Weill Cornell College of Medicine, New York, NY, USA
| | | | - Ronald G Crystal
- Department of Genetic Medicine, Weill Cornell College of Medicine, New York, NY, USA
| | - Clementina Mesaros
- Department of Systems Pharmacology and Translational Therapeutics Perelman School of Medicine, Penn/CHOP Friedreich's Ataxia Center of Excellence, Center of Excellence in Environmental Toxicology, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Ian A Blair
- Department of Systems Pharmacology and Translational Therapeutics Perelman School of Medicine, Penn/CHOP Friedreich's Ataxia Center of Excellence, Center of Excellence in Environmental Toxicology, University of Pennsylvania, Philadelphia, PA, USA.
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Perfitt TL, Huichalaf C, Gooch R, Kuperman A, Ahn Y, Chen X, Ullas S, Hirenallur-Shanthappa D, Zhan Y, Otis D, Whiteley LO, Bulawa C, Martelli A. A modified mouse model of Friedreich's ataxia with conditional Fxn allele homozygosity delays onset of cardiomyopathy. Am J Physiol Heart Circ Physiol 2024; 326:H357-H369. [PMID: 38038720 DOI: 10.1152/ajpheart.00496.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 11/27/2023] [Accepted: 11/28/2023] [Indexed: 12/02/2023]
Abstract
Friedreich's ataxia (FA) is an autosomal recessive disorder caused by a deficiency in frataxin (FXN), a mitochondrial protein that plays a critical role in the synthesis of iron-sulfur clusters (Fe-S), vital inorganic cofactors necessary for numerous cellular processes. FA is characterized by progressive ataxia and hypertrophic cardiomyopathy, with cardiac dysfunction as the most common cause of mortality in patients. Commonly used cardiac-specific mouse models of FA use the muscle creatine kinase (MCK) promoter to express Cre recombinase in cardiomyocytes and striated muscle cells in mice with one conditional Fxn allele and one floxed-out/null allele. These mice quickly develop cardiomyopathy that becomes fatal by 9-11 wk of age. Here, we generated a cardiac-specific model with floxed Fxn allele homozygosity (MCK-Fxnflox/flox). MCK-Fxnflox/flox mice were phenotypically normal at 9 wk of age, despite no detectable FXN protein expression. Between 13 and 15 wk of age, these mice began to display progressive cardiomyopathy, including decreased ejection fraction and fractional shortening and increased left ventricular mass. MCK-Fxnflox/flox mice began to lose weight around 16 wk of age, characteristically associated with heart failure in other cardiac-specific FA models. By 18 wk of age, MCK-Fxnflox/flox mice displayed elevated markers of Fe-S deficiency, cardiac stress and injury, and cardiac fibrosis. This modified model reproduced important pathophysiological and biochemical features of FA over a longer timescale than previous cardiac-specific mouse models, offering a larger window for studying potential therapeutics.NEW & NOTEWORTHY Previous cardiac-specific frataxin knockout models exhibit rapid and fatal cardiomyopathy by 9 wk of age. This severe phenotype poses challenges for the design and execution of intervention studies. We introduce an alternative cardiac-specific model, MCK-Fxnflox/flox, with increased longevity and delayed onset of all major phenotypes. These phenotypes develop to the same severity as previous models. Thus, this new model provides the same cardiomyopathy-associated mortality with a larger window for potential studies.
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Affiliation(s)
- Tyler L Perfitt
- Rare Disease Research Unit, Worldwide Research, Development and Medical, Pfizer, Incorporated, Cambridge, Massachusetts, United States
| | - Claudia Huichalaf
- Rare Disease Research Unit, Worldwide Research, Development and Medical, Pfizer, Incorporated, Cambridge, Massachusetts, United States
| | - Renea Gooch
- Rare Disease Research Unit, Worldwide Research, Development and Medical, Pfizer, Incorporated, Cambridge, Massachusetts, United States
| | - Anna Kuperman
- Rare Disease Research Unit, Worldwide Research, Development and Medical, Pfizer, Incorporated, Cambridge, Massachusetts, United States
| | - Youngwook Ahn
- Target Sciences, Worldwide Research, Development and Medical, Pfizer, Incorporated, Cambridge, Massachusetts, United States
| | - Xian Chen
- Comparative Medicine, Worldwide Research, Development and Medical, Pfizer, Incorporated, Cambridge, Massachusetts, United States
| | - Soumya Ullas
- Comparative Medicine, Worldwide Research, Development and Medical, Pfizer, Incorporated, Cambridge, Massachusetts, United States
| | - Dinesh Hirenallur-Shanthappa
- Comparative Medicine, Worldwide Research, Development and Medical, Pfizer, Incorporated, Cambridge, Massachusetts, United States
| | - Yutian Zhan
- Drug Safety Research and Development, Worldwide Research, Development and Medical, Pfizer, Incorporated, Cambridge, Massachusetts, United States
| | - Diana Otis
- Drug Safety Research and Development, Worldwide Research, Development and Medical, Pfizer, Incorporated, Cambridge, Massachusetts, United States
| | - Laurence O Whiteley
- Drug Safety Research and Development, Worldwide Research, Development and Medical, Pfizer, Incorporated, Cambridge, Massachusetts, United States
| | - Christine Bulawa
- Rare Disease Research Unit, Worldwide Research, Development and Medical, Pfizer, Incorporated, Cambridge, Massachusetts, United States
| | - Alain Martelli
- Rare Disease Research Unit, Worldwide Research, Development and Medical, Pfizer, Incorporated, Cambridge, Massachusetts, United States
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Rojsajjakul T, Selvan N, De B, Rosenberg JB, Kaminsky SM, Sondhi D, Janki P, Crystal RG, Mesaros C, Khanna R, Blair IA. Expression and processing of mature human frataxin after gene therapy in mice. RESEARCH SQUARE 2023:rs.3.rs-3788652. [PMID: 38234818 PMCID: PMC10793484 DOI: 10.21203/rs.3.rs-3788652/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
Friedreich's ataxia is a degenerative and progressive multisystem disorder caused by mutations in the highly conserved frataxin (FXN) gene that results in FXN protein deficiency and mitochondrial dysfunction. While gene therapy approaches are promising, consistent induction of therapeutic FXN protein expression that is sub-toxic has proven challenging, and numerous therapeutic approaches are being tested in animal models. FXN (hFXN in humans, mFXN in mice) is proteolytically modified in mitochondria to produce mature FXN. However, unlike endogenous hFXN, endogenous mFXN is further processed into N-terminally truncated, extra-mitochondrial mFXN forms of unknown function. This study assessed mature exogenous hFXN expression levels in the heart and liver of C57Bl/6 mice 7-10 months after intravenous administration of a recombinant adeno-associated virus encoding hFXN (AAVrh.10hFXN) and examined the potential for hFXN truncation in mice. AAVrh.10hFXN induced dose-dependent expression of hFXN in the heart and liver. Interestingly, hFXN was processed into truncated forms, but found at lower levels than mature hFXN. However, the truncations were at different positions than mFXN. AAVrh.10hFXN induced mature hFXN expression in mouse heart and liver at levels that approximated endogenous mFXN levels. These results demonstrate that AAVrh.10hFXN may induce expression of therapeutic levels of mature hFXN in mice.
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Argirò A, Ding J, Adler E. Gene therapy for heart failure and cardiomyopathies. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2023; 76:1042-1054. [PMID: 37506969 DOI: 10.1016/j.rec.2023.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 06/28/2023] [Indexed: 07/30/2023]
Abstract
Gene therapy strategies encompass a range of approaches, including gene replacement and gene editing. Gene replacement involves providing a functional copy of a modified gene, while gene editing allows for the correction of existing genetic mutations. Gene therapy has already received approval for treating genetic disorders like Leber's congenital amaurosis and spinal muscular atrophy. Currently, research is being conducted to explore its potential use in cardiology. This review aims to summarize the mechanisms behind different gene therapy strategies, the available delivery systems, the primary risks associated with gene therapy, ongoing clinical trials, and future targets, with a particular emphasis on cardiomyopathies.
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Affiliation(s)
- Alessia Argirò
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy.
| | - Jeffrey Ding
- Division of Cardiovascular Medicine, Department of Medicine, University of California, San Diego, San Diego, CA, United States
| | - Eric Adler
- Division of Cardiovascular Medicine, Department of Medicine, University of California, San Diego, San Diego, CA, United States
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Rojsajjakul T, Hordeaux JJ, Choudhury GR, Hinderer CJ, Mesaros C, Wilson JM, Blair IA. Quantification of human mature frataxin protein expression in nonhuman primate hearts after gene therapy. Commun Biol 2023; 6:1093. [PMID: 37891254 PMCID: PMC10611776 DOI: 10.1038/s42003-023-05472-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 10/16/2023] [Indexed: 10/29/2023] Open
Abstract
Deficiency in human mature frataxin (hFXN-M) protein is responsible for the devastating neurodegenerative and cardiodegenerative disease of Friedreich's ataxia (FRDA). It results primarily through epigenetic silencing of the FXN gene by GAA triplet repeats on intron 1 of both alleles. GAA repeat lengths are most commonly between 600 and 1200 but can reach 1700. A subset of approximately 3% of FRDA patients have GAA repeats on one allele and a mutation on the other. FRDA patients die most commonly in their 30s from heart disease. Therefore, increasing expression of heart hFXN-M using gene therapy offers a way to prevent early mortality in FRDA. We used rhesus macaque monkeys to test the pharmacology of an adeno-associated virus (AAV)hu68.CB7.hFXN therapy. The advantage of using non-human primates for hFXN-M gene therapy studies is that hFXN-M and monkey FXN-M (mFXN-M) are 98.5% identical, which limits potential immunologic side-effects. However, this presented a formidable bioanalytical challenge in quantification of proteins with almost identical sequences. This could be overcome by the development of a species-specific quantitative mass spectrometry-based method, which has revealed for the first time, robust transgene-specific human protein expression in monkey heart tissue. The dose response is non-linear resulting in a ten-fold increase in monkey heart hFXN-M protein expression with only a three-fold increase in dose of the vector.
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Affiliation(s)
- Teerapat Rojsajjakul
- Penn/CHOP Friedreich's Ataxia Center of Excellence and Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Juliette J Hordeaux
- Gene Therapy Program, Departments of Medicine and Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Gourav R Choudhury
- Gene Therapy Program, Departments of Medicine and Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Christian J Hinderer
- Gene Therapy Program, Departments of Medicine and Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Clementina Mesaros
- Penn/CHOP Friedreich's Ataxia Center of Excellence and Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - James M Wilson
- Gene Therapy Program, Departments of Medicine and Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
| | - Ian A Blair
- Penn/CHOP Friedreich's Ataxia Center of Excellence and Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
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Bouchard C, Gérard C, Yanyabé SGF, Majeau N, Aloui M, Buisson G, Yameogo P, Couture V, Tremblay JP. Finding an Appropriate Mouse Model to Study the Impact of a Treatment for Friedreich Ataxia on the Behavioral Phenotype. Genes (Basel) 2023; 14:1654. [PMID: 37628705 PMCID: PMC10454134 DOI: 10.3390/genes14081654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/09/2023] [Accepted: 08/16/2023] [Indexed: 08/27/2023] Open
Abstract
Friedreich ataxia (FRDA) is a progressive neurodegenerative disease caused by a GAA repeat in the intron 1 of the frataxin gene (FXN) leading to a lower expression of the frataxin protein. The YG8sR mice are Knock-Out (KO) for their murine frataxin gene but contain a human frataxin transgene derived from an FRDA patient with 300 GAA repeats. These mice are used as a FRDA model but even with a low frataxin concentration, their phenotype is mild. We aimed to find an optimized mouse model with a phenotype comparable to the human patients to study the impact of therapy on the phenotype. We compared two mouse models: the YG8sR injected with an AAV. PHP.B coding for a shRNA targeting the human frataxin gene and the YG8-800, a new mouse model with a human transgene containing 800 GAA repeats. Both mouse models were compared to Y47R mice containing nine GAA repeats that were considered healthy mice. Behavior tests (parallel rod floor apparatus, hanging test, inverted T beam, and notched beam test) were carried out from 2 to 11 months and significant differences were noticed for both YG8sR mice injected with an anti-FXN shRNA and the YG8-800 mice compared to healthy mice. In conclusion, YG8sR mice have a slight phenotype, and injecting them with an AAV-PHP.B expressing an shRNA targeting frataxin does increase their phenotype. The YG8-800 mice have a phenotype comparable to the human ataxic phenotype.
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Affiliation(s)
- Camille Bouchard
- Centre de Recherche du CHU, Québec-Université Laval, Québec, QC G1V 4G2, Canada (N.M.); (M.A.); (G.B.)
- Département de Médecine Moléculaire, l’Université Laval Québec, Québec, QC G1V 4G2, Canada
| | - Catherine Gérard
- Centre de Recherche du CHU, Québec-Université Laval, Québec, QC G1V 4G2, Canada (N.M.); (M.A.); (G.B.)
- Département de Médecine Moléculaire, l’Université Laval Québec, Québec, QC G1V 4G2, Canada
| | - Solange Gni-fiene Yanyabé
- Centre de Recherche du CHU, Québec-Université Laval, Québec, QC G1V 4G2, Canada (N.M.); (M.A.); (G.B.)
- Département de Médecine Moléculaire, l’Université Laval Québec, Québec, QC G1V 4G2, Canada
| | - Nathalie Majeau
- Centre de Recherche du CHU, Québec-Université Laval, Québec, QC G1V 4G2, Canada (N.M.); (M.A.); (G.B.)
- Département de Médecine Moléculaire, l’Université Laval Québec, Québec, QC G1V 4G2, Canada
| | - Malek Aloui
- Centre de Recherche du CHU, Québec-Université Laval, Québec, QC G1V 4G2, Canada (N.M.); (M.A.); (G.B.)
| | - Gabrielle Buisson
- Centre de Recherche du CHU, Québec-Université Laval, Québec, QC G1V 4G2, Canada (N.M.); (M.A.); (G.B.)
| | - Pouiré Yameogo
- Centre de Recherche du CHU, Québec-Université Laval, Québec, QC G1V 4G2, Canada (N.M.); (M.A.); (G.B.)
- Département de Médecine Moléculaire, l’Université Laval Québec, Québec, QC G1V 4G2, Canada
| | - Vanessa Couture
- Centre de Recherche du CHU, Québec-Université Laval, Québec, QC G1V 4G2, Canada (N.M.); (M.A.); (G.B.)
- Département de Médecine Moléculaire, l’Université Laval Québec, Québec, QC G1V 4G2, Canada
| | - Jacques P. Tremblay
- Centre de Recherche du CHU, Québec-Université Laval, Québec, QC G1V 4G2, Canada (N.M.); (M.A.); (G.B.)
- Département de Médecine Moléculaire, l’Université Laval Québec, Québec, QC G1V 4G2, Canada
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Munoz-Zuluaga C, Gertz M, Yost-Bido M, Greco A, Gorman N, Chen A, Kooner V, Rosenberg JB, De BP, Kaminsky SM, Borczuk A, Ricart Arbona RJ, Martin HR, Monette S, Khanna R, Barth JA, Crystal RG, Sondhi D. Identification of Safe and Effective Intravenous Dose of AAVrh.10hFXN to Treat the Cardiac Manifestations of Friedreich's Ataxia. Hum Gene Ther 2023; 34:605-615. [PMID: 37166361 PMCID: PMC10354731 DOI: 10.1089/hum.2023.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 04/16/2023] [Indexed: 05/12/2023] Open
Abstract
Friedreich's ataxia (FA) is a life-threatening autosomal recessive disorder characterized by neurological and cardiac dysfunction. Arrhythmias and heart failure are the main cause of premature death. From prior studies in murine models of FA, adeno-associated virus encoding the normal human frataxin gene (AAVrh.10hFXN) effectively treated the cardiac manifestations of the disease. However, the therapeutic dose window is limited by high level of human frataxin (hFXN) gene expression associated with toxicity. As a therapeutic goal, since FA heterozygotes have no clinical manifestations of FA, we estimated the level of frataxin (FXN) necessary to convert the heart of a homozygote to that of a heterozygote. In noncardiac cells, FA heterozygotes have 30-80% of normal FXN levels (17.7-47.2 ng/mg, average 32.5 ng/mg) and FA homozygotes 2-30% normal levels (1.2-17.7 ng/mg, average 9.4 ng/mg). Therefore, an AAV vector would need to augment endogenous in an FA homozygote by >8.3 ng/mg. To determine the required dose of AAVrh.10hFXN, we administered 1.8 × 1011, 5.7 × 1011, or 1.8 × 1012 gc/kg of AAVrh.10hFXN intravenously (IV) to muscle creatine kinase (mck)-Cre conditional knockout Fxn mice, a cardiac and skeletal FXN knockout model. The minimally effective dose was 5.7 × 1011 gc/kg, resulting in cardiac hFXN levels of 6.1 ± 4.2 ng/mg and a mild (p < 0.01 compared with phosphate-buffered saline controls) improvement in mortality. A dose of 1.8 × 1012 gc/kg resulted in cardiac hFXN levels of 33.7 ± 6.4 ng/mg, a significant improvement in ejection fraction and fractional shortening (p < 0.05, both comparisons) and a 21.5% improvement in mortality (p < 0.001). To determine if the significantly effective dose of 1.8 × 1012 gc/kg could achieve human FA heterozygote levels in a large animal, this dose was administered IV to nonhuman primates. After 12 weeks, the vector-expressed FXN in the heart was 17.8 ± 4.9 ng/mg, comparable to the target human levels. These data identify both minimally and significantly effective therapeutic doses that are clinically relevant for the treatment of the cardiac manifestations of FA.
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Affiliation(s)
| | - Monica Gertz
- Department of Genetic Medicine, New York, New York, USA
| | | | | | | | - Alvin Chen
- Department of Genetic Medicine, New York, New York, USA
| | - Vikrum Kooner
- Department of Genetic Medicine, New York, New York, USA
| | | | - Bishnu P. De
- Department of Genetic Medicine, New York, New York, USA
| | | | - Alain Borczuk
- Department of Pathology, Weill Cornell Medicine, New York, New York, USA
| | - Rodolfo J. Ricart Arbona
- Center for Comparative Medicine and Pathology, Memorial Sloan Kettering Cancer Center, Weill Cornell Medicine, New York, New York, USA
| | - Heather R. Martin
- Center for Comparative Medicine and Pathology, Memorial Sloan Kettering Cancer Center, Weill Cornell Medicine, New York, New York, USA
| | - Sebastien Monette
- Center for Comparative Medicine and Pathology, Memorial Sloan Kettering Cancer Center, Weill Cornell Medicine, New York, New York, USA
| | | | | | | | - Dolan Sondhi
- Department of Genetic Medicine, New York, New York, USA
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8
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Blair I, Rojsajjakul T, Hordeaux J, Chaudhary G, Hinderer C, Mesaros C, Wilson J. Quantification of human mature frataxin protein expression in nonhuman primate hearts after gene therapy. RESEARCH SQUARE 2023:rs.3.rs-3121549. [PMID: 37461697 PMCID: PMC10350221 DOI: 10.21203/rs.3.rs-3121549/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
Deficiency in human mature frataxin (hFXN-M) protein is responsible for the devastating neurodegenerative and cardiodegenerative disease of Friedreich's ataxia (FRDA). It results primarily by epigenetic silencing the FXN gene due to up to 1400 GAA triplet repeats in intron 1 of both alleles of the gene; a subset of approximately 3% of FRDA patients have a mutation on one allele. FRDA patients die most commonly in their 30s from heart disease. Therefore, increasing expression of heart hFXN-M using gene therapy offers a way to prevent early mortality in FRDA. We used rhesus macaque monkeys to test the pharmacology of an adeno-associated virus (AAV)hu68.CB7.hFXN therapy. The advantage of using non-human primates for hFXN-M gene therapy studies is that hFXN-M and monkey FXN-M (mFXN-M) are 98.5% identical, which limits potential immunologic side-effects. However, this presented a formidable bioanalytical challenge in quantification of proteins with almost identical sequences. This was overcome by development of a species-specific quantitative mass spectrometry-based method, which revealed for the first time, robust transgene-specific human protein expression in monkey heart tissue. The dose response was non-linear resulting in a ten-fold increase in monkey heart hFXN-M protein expression with only a three-fold increase in dose of the vector.
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9
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Leyba K, Paiyabhroma N, Salvas JP, Damen FW, Janvier A, Zub E, Bernis C, Rouland R, Dubois CJ, Badaut J, Richard S, Marchi N, Goergen CJ, Sicard P. Neurovascular hypoxia after mild traumatic brain injury in juvenile mice correlates with heart-brain dysfunctions in adulthood. Acta Physiol (Oxf) 2023; 238:e13933. [PMID: 36625322 DOI: 10.1111/apha.13933] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 12/20/2022] [Accepted: 01/02/2023] [Indexed: 01/11/2023]
Abstract
AIM Retrospective studies suggest that mild traumatic brain injury (mTBI) in pediatric patients may lead to an increased risk of cardiac events. However, the exact functional and temporal dynamics and the associations between heart and brain pathophysiological trajectories are not understood. METHODS A single impact to the left somatosensory cortical area of the intact skull was performed on juvenile mice (17 days postnatal). Cerebral 3D photoacoustic imaging was used to measure the oxygen saturation (sO2 ) in the impacted area 4 h after mTBI followed by 2D and 4D echocardiography at days 7, 30, 90, and 190 post-impact. At 8 months, we performed a dobutamine stress test to evaluate cardiac function. Lastly, behavioral analyses were conducted 1 year after initial injury. RESULTS We report a rapid and transient decrease in cerebrovascular sO2 and increased hemoglobin in the impacted left brain cortex. Cardiac analyses showed long-term diastolic dysfunction and a diminished systolic strain response under stress in the mTBI group. At the molecular level, cardiac T-p38MAPK and troponin I expression was pathologic modified post-mTBI. We found linear correlations between brain sO2 measured immediately post-mTBI and long-term cardiac strain after 8 months. We report that initial cerebrovascular hypoxia and chronic cardiac dysfunction correlated with long-term behavioral changes hinting at anxiety-like and memory maladaptation. CONCLUSION Experimental juvenile mTBI induces time-dependent cardiac dysfunction that corresponds to the initial neurovascular sO2 dip and is associated with long-term behavioral modifications. These imaging biomarkers of the heart-brain axis could be applied to improve clinical pediatric mTBI management.
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Affiliation(s)
- Katherine Leyba
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, Indiana, USA
| | - Nitchawat Paiyabhroma
- PhyMedExp, INSERM/CNRS/Université de Montpellier, IPAM/Biocampus, Montpellier, France
| | - John P Salvas
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, Indiana, USA
| | - Frederick W Damen
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, Indiana, USA
| | - Alicia Janvier
- Institute de Genomique Fonctionnelle, Université de Montpellier, CNRS, INSERM, Montpellier, France
| | - Emma Zub
- Institute de Genomique Fonctionnelle, Université de Montpellier, CNRS, INSERM, Montpellier, France
| | - Corinne Bernis
- Institut des Maladies Métaboliques et Cardiovasculaires (I2MC), Inserm/Université Paul Sabatier UMR1048, Toulouse, France
| | | | | | - Jerome Badaut
- Univ. Bordeaux, CNRS, CRMSB, UMR 5536, Bordeaux, France
| | - Sylvain Richard
- PhyMedExp, INSERM/CNRS/Université de Montpellier, IPAM/Biocampus, Montpellier, France
| | - Nicola Marchi
- Institute de Genomique Fonctionnelle, Université de Montpellier, CNRS, INSERM, Montpellier, France
| | - Craig J Goergen
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, Indiana, USA
| | - Pierre Sicard
- PhyMedExp, INSERM/CNRS/Université de Montpellier, IPAM/Biocampus, Montpellier, France
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Profeta V, McIntyre K, Wells M, Park C, Lynch DR. Omaveloxolone: an activator of Nrf2 for the treatment of Friedreich ataxia. Expert Opin Investig Drugs 2023; 32:5-16. [PMID: 36708320 DOI: 10.1080/13543784.2023.2173063] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
INTRODUCTION Friedreich ataxia (FRDA) is a rare autosomal recessive degenerative disorder characterized by ataxia, dysarthria, diabetes, cardiomyopathy, scoliosis, and occasionally vision loss in late-stage disease. The discovery of the abnormal gene in FRDA and its product frataxin has provided insight into the pathophysiology and mechanisms of treatment. AREAS COVERED Although the neurologic phenotype of FRDA is well defined, there are currently no established pharmacological treatments. Omaveloxolone, a nuclear factor erythroid 2-related factor 2 (Nrf2) activator, is currently under review by the Food and Drug Administration (FDA) and has the potential to be the first approved treatment for FRDA. In the present report, we have reviewed the basic and clinical literature on Nrf2 deficiency in FRDA, and evidence for the benefit of omaveloxolone. EXPERT OPINION The present perspective suggests that omaveloxolone is a rational and efficacious therapy that is possibly disease modifying in treatment of FRDA.
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Affiliation(s)
- Victoria Profeta
- Departments of Pediatrics and Neurology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kellie McIntyre
- Departments of Pediatrics and Neurology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - McKenzie Wells
- Departments of Pediatrics and Neurology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Courtney Park
- Departments of Pediatrics and Neurology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - David R Lynch
- Departments of Pediatrics and Neurology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Gérard C, Archambault AF, Bouchard C, Tremblay JP. A promising mouse model for Friedreich Ataxia progressing like human patients. Behav Brain Res 2023; 436:114107. [DOI: 10.1016/j.bbr.2022.114107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 09/01/2022] [Accepted: 09/06/2022] [Indexed: 11/27/2022]
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12
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Payne RM. Cardiovascular Research in Friedreich Ataxia: Unmet Needs and Opportunities. JACC Basic Transl Sci 2022; 7:1267-1283. [PMID: 36644283 PMCID: PMC9831864 DOI: 10.1016/j.jacbts.2022.04.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 04/18/2022] [Accepted: 04/18/2022] [Indexed: 01/18/2023]
Abstract
Friedreich Ataxia (FRDA) is an autosomal recessive disease in which a mitochondrial protein, frataxin, is severely decreased in its expression. In addition to progressive ataxia, patients with FRDA often develop a cardiomyopathy that can be hypertrophic. This cardiomyopathy is unlike the sarcomeric hypertrophic cardiomyopathies in that the hypertrophy is associated with massive mitochondrial proliferation within the cardiomyocyte rather than contractile protein overexpression. This is associated with atrial arrhythmias, apoptosis, and fibrosis over time, and patients often develop heart failure leading to premature death. The differences between this mitochondrial cardiomyopathy and the more common contractile protein hypertrophic cardiomyopathies can be a source of misunderstanding in the management of these patients. Although imaging studies have revealed much about the structure and function of the heart in this disease, we still lack an understanding of many important clinical and fundamental molecular events that determine outcome of the heart in FRDA. This review will describe the current basic and clinical understanding of the FRDA heart, and most importantly, identify major gaps in our knowledge that represent new directions and opportunities for research.
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Affiliation(s)
- R. Mark Payne
- Address for correspondence: Dr R. Mark Payne, Division of Pediatric Cardiology, Wells Center for Pediatric Research, Indiana University School of Medicine, 1044 West Walnut, R4 302b, Indianapolis, Indiana 46202, USA.
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Sivakumar A, Cherqui S. Advantages and Limitations of Gene Therapy and Gene Editing for Friedreich's Ataxia. Front Genome Ed 2022; 4:903139. [PMID: 35663795 PMCID: PMC9157421 DOI: 10.3389/fgeed.2022.903139] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 04/21/2022] [Indexed: 12/26/2022] Open
Abstract
Friedreich's ataxia (FRDA) is an inherited, multisystemic disorder predominantly caused by GAA hyper expansion in intron 1 of frataxin (FXN) gene. This expansion mutation transcriptionally represses FXN, a mitochondrial protein that is required for iron metabolism and mitochondrial homeostasis, leading to neurodegerative and cardiac dysfunction. Current therapeutic options for FRDA are focused on improving mitochondrial function and increasing frataxin expression through pharmacological interventions but are not effective in delaying or preventing the neurodegeneration in clinical trials. Recent research on in vivo and ex vivo gene therapy methods in FRDA animal and cell models showcase its promise as a one-time therapy for FRDA. In this review, we provide an overview on the current and emerging prospects of gene therapy for FRDA, with specific focus on advantages of CRISPR/Cas9-mediated gene editing of FXN as a viable option to restore endogenous frataxin expression. We also assess the potential of ex vivo gene editing in hematopoietic stem and progenitor cells as a potential autologous transplantation therapeutic option and discuss its advantages in tackling FRDA-specific safety aspects for clinical translation.
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Affiliation(s)
| | - Stephanie Cherqui
- Division of Genetics, Department of Pediatrics, University of California, San Diego, San Diego, CA, United States
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14
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Huichalaf C, Perfitt TL, Kuperman A, Gooch R, Kovi RC, Brenneman KA, Chen X, Hirenallur-Shanthappa D, Ma T, Assaf BT, Pardo I, Franks T, Monarski L, Cheng TW, Le K, Su C, Somanathan S, Whiteley LO, Bulawa C, Pregel MJ, Martelli A. In vivo overexpression of frataxin causes toxicity mediated by iron-sulfur cluster deficiency. Mol Ther Methods Clin Dev 2022; 24:367-378. [PMID: 35252470 PMCID: PMC8866050 DOI: 10.1016/j.omtm.2022.02.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 02/04/2022] [Indexed: 12/25/2022]
Abstract
Friedreich's ataxia is a rare disorder resulting from deficiency of frataxin, a mitochondrial protein implicated in the synthesis of iron-sulfur clusters. Preclinical studies in mice have shown that gene therapy is a promising approach to treat individuals with Friedreich's ataxia. However, a recent report provided evidence that AAVrh10-mediated overexpression of frataxin could lead to cardiotoxicity associated with mitochondrial dysfunction. While evaluating an AAV9-based frataxin gene therapy using a chicken β-actin promoter, we showed that toxic overexpression of frataxin could be reached in mouse liver and heart with doses between 1 × 1013 and 1 × 1014 vg/kg. In a mouse model of cardiac disease, these doses only corrected cardiac dysfunction partially and transiently and led to adverse findings associated with iron-sulfur cluster deficiency in liver. We demonstrated that toxicity required frataxin's primary function by using a frataxin construct bearing the N146K mutation, which impairs binding to the iron-sulfur cluster core complex. At the lowest tested dose, we observed moderate liver toxicity that was accompanied by progressive loss of transgene expression and liver regeneration. Together, our data provide insights into the toxicity of frataxin overexpression that should be considered in the development of a gene therapy approach for Friedreich's ataxia.
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Affiliation(s)
- Claudia Huichalaf
- Rare Disease Research Unit, Worldwide Research, Development and Medical, Pfizer Inc., 610 Main Street, Cambridge, MA 02139, USA
| | - Tyler L Perfitt
- Rare Disease Research Unit, Worldwide Research, Development and Medical, Pfizer Inc., 610 Main Street, Cambridge, MA 02139, USA
| | - Anna Kuperman
- Rare Disease Research Unit, Worldwide Research, Development and Medical, Pfizer Inc., 610 Main Street, Cambridge, MA 02139, USA
| | - Renea Gooch
- Rare Disease Research Unit, Worldwide Research, Development and Medical, Pfizer Inc., 610 Main Street, Cambridge, MA 02139, USA
| | - Ramesh C Kovi
- Drug Safety Research and Development, Worldwide Research, Development and Medical, Pfizer Inc., Cambridge, MA 02139, USA
| | - Karrie A Brenneman
- Drug Safety Research and Development, Worldwide Research, Development and Medical, Pfizer Inc., Cambridge, MA 02139, USA
| | - Xian Chen
- Comparative Medicine, Worldwide Research, Development and Medical, Pfizer Inc., Cambridge, MA 02139, USA
| | | | - Tiffany Ma
- Rare Disease Research Unit, Worldwide Research, Development and Medical, Pfizer Inc., 610 Main Street, Cambridge, MA 02139, USA
| | - Basel T Assaf
- Drug Safety Research and Development, Worldwide Research, Development and Medical, Pfizer Inc., Cambridge, MA 02139, USA
| | - Ingrid Pardo
- Drug Safety Research and Development, Worldwide Research, Development and Medical, Pfizer Inc., Cambridge, MA 02139, USA
| | - Tania Franks
- Drug Safety Research and Development, Worldwide Research, Development and Medical, Pfizer Inc., Cambridge, MA 02139, USA
| | - Laura Monarski
- Drug Safety Research and Development, Worldwide Research, Development and Medical, Pfizer Inc., Cambridge, MA 02139, USA
| | - Ting-Wen Cheng
- Rare Disease Research Unit, Worldwide Research, Development and Medical, Pfizer Inc., 610 Main Street, Cambridge, MA 02139, USA
| | - Kevin Le
- Rare Disease Research Unit, Worldwide Research, Development and Medical, Pfizer Inc., 610 Main Street, Cambridge, MA 02139, USA
| | - Chunyan Su
- Rare Disease Research Unit, Worldwide Research, Development and Medical, Pfizer Inc., 610 Main Street, Cambridge, MA 02139, USA
| | - Suryanarayan Somanathan
- Rare Disease Research Unit, Worldwide Research, Development and Medical, Pfizer Inc., 610 Main Street, Cambridge, MA 02139, USA
| | - Laurence O Whiteley
- Drug Safety Research and Development, Worldwide Research, Development and Medical, Pfizer Inc., Cambridge, MA 02139, USA
| | - Christine Bulawa
- Rare Disease Research Unit, Worldwide Research, Development and Medical, Pfizer Inc., 610 Main Street, Cambridge, MA 02139, USA
| | - Marko J Pregel
- Rare Disease Research Unit, Worldwide Research, Development and Medical, Pfizer Inc., 610 Main Street, Cambridge, MA 02139, USA
| | - Alain Martelli
- Rare Disease Research Unit, Worldwide Research, Development and Medical, Pfizer Inc., 610 Main Street, Cambridge, MA 02139, USA
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Selvanathan A, Parayil Sankaran B. Mitochondrial iron-sulfur cluster biogenesis and neurological disorders. Mitochondrion 2021; 62:41-49. [PMID: 34687937 DOI: 10.1016/j.mito.2021.10.004] [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] [Received: 04/30/2021] [Revised: 08/26/2021] [Accepted: 10/18/2021] [Indexed: 12/20/2022]
Abstract
Iron-sulfur clusters (ISCs) are highly conserved moieties embedded into numerous crucial proteins in almost all bacteria, plants and mammals. As such, ISC biosynthesis is critical to cellular function. The pathway was first characterized in bacteria by the late 1990s, and over the subsequent 20 years there has been increasing understanding of its components in humans. Defects in the ISC pathway are now associated with many different human disease states, such as Friedreich ataxia and ISCU myopathy. Whilst the disorders have variable clinical features, most involve neurological phenotypes. There are common biochemical signatures in most of these conditions, as a lack of ISCs causes deficiencies of target proteins including Complex I, II and III, aconitase and lipoic acid. This review focuses on the disorders of ISC biogenesis that have been described in the literature to-date. Key clinical, biochemical and neuroradiological features will be discussed, providing a reference point for clinicians diagnosing and managing these patients. Therapies are mostly supportive at this stage. However, the improved understanding of the pathophysiology of these conditions could pave the way for disease-modifying therapies in the near future.
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Affiliation(s)
- Arthavan Selvanathan
- Genetic Metabolic Disorders Service, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW, Australia
| | - Bindu Parayil Sankaran
- Genetic Metabolic Disorders Service, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW, Australia; Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Australia.
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16
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Stepankova K, Jendelova P, Machova Urdzikova L. Planet of the AAVs: The Spinal Cord Injury Episode. Biomedicines 2021; 9:613. [PMID: 34071245 PMCID: PMC8228984 DOI: 10.3390/biomedicines9060613] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 05/22/2021] [Accepted: 05/25/2021] [Indexed: 12/12/2022] Open
Abstract
The spinal cord injury (SCI) is a medical and life-disrupting condition with devastating consequences for the physical, social, and professional welfare of patients, and there is no adequate treatment for it. At the same time, gene therapy has been studied as a promising approach for the treatment of neurological and neurodegenerative disorders by delivering remedial genes to the central nervous system (CNS), of which the spinal cord is a part. For gene therapy, multiple vectors have been introduced, including integrating lentiviral vectors and non-integrating adeno-associated virus (AAV) vectors. AAV vectors are a promising system for transgene delivery into the CNS due to their safety profile as well as long-term gene expression. Gene therapy mediated by AAV vectors shows potential for treating SCI by delivering certain genetic information to specific cell types. This review has focused on a potential treatment of SCI by gene therapy using AAV vectors.
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Affiliation(s)
- Katerina Stepankova
- Institute of Experimental Medicine, Czech Academy of Sciences, Vídeňská 1083, 14200 Prague, Czech Republic;
- Department of Neuroscience, Second Faculty of Medicine, Charles University, 15006 Prague, Czech Republic
| | - Pavla Jendelova
- Institute of Experimental Medicine, Czech Academy of Sciences, Vídeňská 1083, 14200 Prague, Czech Republic;
- Department of Neuroscience, Second Faculty of Medicine, Charles University, 15006 Prague, Czech Republic
| | - Lucia Machova Urdzikova
- Institute of Experimental Medicine, Czech Academy of Sciences, Vídeňská 1083, 14200 Prague, Czech Republic;
- Department of Neuroscience, Second Faculty of Medicine, Charles University, 15006 Prague, Czech Republic
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Ocana-Santero G, Díaz-Nido J, Herranz-Martín S. Future Prospects of Gene Therapy for Friedreich's Ataxia. Int J Mol Sci 2021; 22:1815. [PMID: 33670433 PMCID: PMC7918362 DOI: 10.3390/ijms22041815] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 02/04/2021] [Accepted: 02/06/2021] [Indexed: 12/18/2022] Open
Abstract
Friedreich's ataxia is an autosomal recessive neurogenetic disease that is mainly associated with atrophy of the spinal cord and progressive neurodegeneration in the cerebellum. The disease is caused by a GAA-expansion in the first intron of the frataxin gene leading to a decreased level of frataxin protein, which results in mitochondrial dysfunction. Currently, there is no effective treatment to delay neurodegeneration in Friedreich's ataxia. A plausible therapeutic approach is gene therapy. Indeed, Friedreich's ataxia mouse models have been treated with viral vectors en-coding for either FXN or neurotrophins, such as brain-derived neurotrophic factor showing promising results. Thus, gene therapy is increasingly consolidating as one of the most promising therapies. However, several hurdles have to be overcome, including immunotoxicity and pheno-toxicity. We review the state of the art of gene therapy in Friedreich's ataxia, addressing the main challenges and the most feasible solutions for them.
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Affiliation(s)
- Gabriel Ocana-Santero
- Centro de Biología Molecular Severo Ochoa (CSIC-UAM), Departamento de Biología Molecular, Universidad Autónoma de Madrid, Nicolás Cabrera 1, 28049 Madrid, Spain; (G.O.-S.); (J.D.-N.)
- Department of Physiology, Anatomy and Genetics, Sherrington Building, Parks Road, University of Oxford, Oxford OX1 3PT, UK
| | - Javier Díaz-Nido
- Centro de Biología Molecular Severo Ochoa (CSIC-UAM), Departamento de Biología Molecular, Universidad Autónoma de Madrid, Nicolás Cabrera 1, 28049 Madrid, Spain; (G.O.-S.); (J.D.-N.)
| | - Saúl Herranz-Martín
- Centro de Biología Molecular Severo Ochoa (CSIC-UAM), Departamento de Biología Molecular, Universidad Autónoma de Madrid, Nicolás Cabrera 1, 28049 Madrid, Spain; (G.O.-S.); (J.D.-N.)
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18
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Duan D. Laying the Foundation for Neuromuscular Disease Gene Therapy. Hum Gene Ther 2020; 31:785-786. [PMID: 32640898 PMCID: PMC7462027 DOI: 10.1089/hum.2020.198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Dongsheng Duan
- Department of Molecular Microbiology and Immunology, University of Missouri, Columbia, Missouri, USA
- Department of Neurology, School of Medicine, University of Missouri, Columbia, Missouri, USA
- Department of Biomedical Sciences, College of Veterinary Medicine, University of Missouri, Columbia, Missouri, USA
- Department of Biomedical, Biological and Chemical Engineering, College of Engineering, University of Missouri, Columbia, Missouri, USA
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