1
|
Mohammadian Gol T, Zahedipour F, Trosien P, Ureña-Bailén G, Kim M, Antony JS, Mezger M. Gene therapy in pediatrics - Clinical studies and approved drugs (as of 2023). Life Sci 2024; 348:122685. [PMID: 38710276 DOI: 10.1016/j.lfs.2024.122685] [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: 01/19/2024] [Revised: 04/17/2024] [Accepted: 05/03/2024] [Indexed: 05/08/2024]
Abstract
Gene therapy in pediatrics represents a cutting-edge therapeutic strategy for treating a range of genetic disorders that manifest in childhood. Gene therapy involves the modification or correction of a mutated gene or the introduction of a functional gene into a patient's cells. In general, it is implemented through two main modalities namely ex vivo gene therapy and in vivo gene therapy. Currently, a noteworthy array of gene therapy products has received valid market authorization, with several others in various stages of the approval process. Additionally, a multitude of clinical trials are actively underway, underscoring the dynamic progress within this field. Pediatric genetic disorders in the fields of hematology, oncology, vision and hearing loss, immunodeficiencies, neurological, and metabolic disorders are areas for gene therapy interventions. This review provides a comprehensive overview of the evolution and current progress of gene therapy-based treatments in the clinic for pediatric patients. It navigates the historical milestones of gene therapies, currently approved gene therapy products by the U.S. Food and Drug Administration (FDA) and/or European Medicines Agency (EMA) for children, and the promising future for genetic disorders. By providing a thorough compilation of approved gene therapy drugs and published results of completed or ongoing clinical trials, this review serves as a guide for pediatric clinicians to get a quick overview of the situation of clinical studies and approved gene therapy products as of 2023.
Collapse
Affiliation(s)
- Tahereh Mohammadian Gol
- University Children's Hospital, Department of Pediatrics I, Hematology and Oncology, University of Tübingen, Tübingen, Germany
| | - Fatemeh Zahedipour
- University Children's Hospital, Department of Pediatrics I, Hematology and Oncology, University of Tübingen, Tübingen, Germany; Department of Medical Biotechnology and Nanotechnology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Paul Trosien
- University Children's Hospital, Department of Pediatrics I, Hematology and Oncology, University of Tübingen, Tübingen, Germany
| | - Guillermo Ureña-Bailén
- University Children's Hospital, Department of Pediatrics I, Hematology and Oncology, University of Tübingen, Tübingen, Germany
| | - Miso Kim
- University Children's Hospital, Department of Pediatrics I, Hematology and Oncology, University of Tübingen, Tübingen, Germany
| | - Justin S Antony
- University Children's Hospital, Department of Pediatrics I, Hematology and Oncology, University of Tübingen, Tübingen, Germany
| | - Markus Mezger
- University Children's Hospital, Department of Pediatrics I, Hematology and Oncology, University of Tübingen, Tübingen, Germany.
| |
Collapse
|
2
|
Fischer A. Gene therapy for inborn errors of immunity: past, present and future. Nat Rev Immunol 2022:10.1038/s41577-022-00800-6. [DOI: 10.1038/s41577-022-00800-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2022] [Indexed: 11/27/2022]
|
3
|
Tucci F, Galimberti S, Naldini L, Valsecchi MG, Aiuti A. A systematic review and meta-analysis of gene therapy with hematopoietic stem and progenitor cells for monogenic disorders. Nat Commun 2022; 13:1315. [PMID: 35288539 PMCID: PMC8921234 DOI: 10.1038/s41467-022-28762-2] [Citation(s) in RCA: 65] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 02/08/2022] [Indexed: 12/12/2022] Open
Abstract
Ex-vivo gene therapy (GT) with hematopoietic stem and progenitor cells (HSPCs) engineered with integrating vectors is a promising treatment for monogenic diseases, but lack of centralized databases is hampering an overall outcomes assessment. Here we aim to provide a comprehensive assessment of the short and long term safety of HSPC-GT from trials using different vector platforms. We review systematically the literature on HSPC-GT to describe survival, genotoxicity and engraftment of gene corrected cells. From 1995 to 2020, 55 trials for 14 diseases met inclusion criteria and 406 patients with primary immunodeficiencies (55.2%), metabolic diseases (17.0%), haemoglobinopathies (24.4%) and bone marrow failures (3.4%) were treated with gammaretroviral vector (γRV) (29.1%), self-inactivating γRV (2.2%) or lentiviral vectors (LV) (68.7%). The pooled overall incidence rate of death is 0.9 per 100 person-years of observation (PYO) (95% CI = 0.37-2.17). There are 21 genotoxic events out of 1504.02 PYO, which occurred in γRV trials (0.99 events per 100 PYO, 95% CI = 0.18-5.43) for primary immunodeficiencies. Pooled rate of engraftment is 86.7% (95% CI = 67.1-95.5%) for γRV and 98.7% (95% CI = 94.5-99.7%) for LV HSPC-GT (p = 0.005). Our analyses show stable reconstitution of haematopoiesis in most recipients with superior engraftment and safer profile in patients receiving LV-transduced HSPCs.
Collapse
Affiliation(s)
- Francesca Tucci
- Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefania Galimberti
- Bicocca Bioinformatics Biostatistics and Bioimaging B4 Center, School of Medicine and Surgery, University of Milano - Bicocca, Monza, Italy
| | - Luigi Naldini
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Maria Grazia Valsecchi
- Bicocca Bioinformatics Biostatistics and Bioimaging B4 Center, School of Medicine and Surgery, University of Milano - Bicocca, Monza, Italy
| | - Alessandro Aiuti
- Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan, Italy.
- Vita-Salute San Raffaele University, Milan, Italy.
| |
Collapse
|
4
|
Mattar CNZ, Labude MK, Lee TN, Lai PS. Ethical considerations of preconception and prenatal gene modification in the embryo and fetus. Hum Reprod 2021; 36:3018-3027. [PMID: 34665851 DOI: 10.1093/humrep/deab222] [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: 06/03/2021] [Revised: 09/08/2021] [Indexed: 11/13/2022] Open
Abstract
The National Academies of Sciences and Medicine 2020 consensus statement advocates the reinstatement of research in preconception heritable human genome editing (HHGE), despite the ethical concerns that have been voiced about interventions in the germline, and outlines criteria for its eventual clinical application to address monogenic disorders. However, the statement does not give adequate consideration to alternative technologies. Importantly, it omits comparison to fetal gene therapy (FGT), which involves gene modification applied prenatally to the developing fetus and which is better researched and less ethically contentious. While both technologies are applicable to the same monogenic diseases causing significant prenatal or early childhood morbidity, the benefits and risks of HHGE are distinct from FGT though there are important overlaps. FGT has the current advantage of a wealth of robust preclinical data, while HHGE is nascent technology and its feasibility for specific diseases still requires scientific proof. The ethical concerns surrounding each are unique and deserving of further discussion, as there are compelling arguments supporting research and eventual clinical translation of both technologies. In this Opinion, we consider HHGE and FGT through technical and ethical lenses, applying common ethical principles to provide a sense of their feasibility and acceptability. Currently, FGT is in a more advanced position for clinical translation and may be less ethically contentious than HHGE, so it deserves to be considered as an alternative therapy in further discussions on HHGE implementation.
Collapse
Affiliation(s)
- Citra Nurfarah Zaini Mattar
- Experimental Fetal Medicine Group, Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Department of Obstetrics and Gynaecology, National University Health System, Singapore, Singapore
| | - Markus Klaus Labude
- Science, Health and Policy-Relevant Ethics in Singapore (SHAPES) Initiative, Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Timothy Nicholas Lee
- Science, Health and Policy-Relevant Ethics in Singapore (SHAPES) Initiative, Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Poh San Lai
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| |
Collapse
|
5
|
A Case of Severe Combined Immunodeficiency Missed by Newborn Screening. J Clin Immunol 2021; 41:1352-1355. [PMID: 33712943 PMCID: PMC7954206 DOI: 10.1007/s10875-021-01020-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 03/04/2021] [Indexed: 11/01/2022]
|
6
|
Blanco E, Izotova N, Booth C, Thrasher AJ. Immune Reconstitution After Gene Therapy Approaches in Patients With X-Linked Severe Combined Immunodeficiency Disease. Front Immunol 2020; 11:608653. [PMID: 33329605 PMCID: PMC7729079 DOI: 10.3389/fimmu.2020.608653] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 11/02/2020] [Indexed: 12/21/2022] Open
Abstract
X-linked severe immunodeficiency disease (SCID-X1) is an inherited, rare, and life-threating disease. The genetic origin is a defect in the interleukin 2 receptor γ chain (IL2RG) gene and patients are classically characterized by absence of T and NK cells, as well as presence of partially-functional B cells. Without any treatment the disease is usually lethal during the first year of life. The treatment of choice for these patients is hematopoietic stem cell transplantation, with an excellent survival rate (>90%) if an HLA-matched sibling donor is available. However, when alternative donors are used, the success and survival rates are often lower. Gene therapy has been developed as an alternative treatment initially using γ-retroviral vectors to correct the defective γ chain in the absence of pre-conditioning treatment. The results were highly promising in SCID-X1 infants, showing long-term T-cell recovery and clinical benefit, although NK and B cell recovery was less robust. However, some infants developed T-cell acute lymphoblastic leukemia after the gene therapy, due to vector-mediated insertional mutagenesis. Consequently, considerable efforts have been made to develop safer vectors. The most recent clinical trials using lentiviral vectors together with a low-dose pre-conditioning regimen have demonstrated excellent sustained T cell recovery, but also B and NK cells, in both children and adults. This review provides an overview about the different gene therapy approaches used over the last 20 years to treat SCID-X1 patients, particularly focusing on lymphoid immune reconstitution, as well as the developments that have improved the process and outcomes.
Collapse
Affiliation(s)
- Elena Blanco
- Molecular and Cellular Immunology, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Natalia Izotova
- Molecular and Cellular Immunology, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Claire Booth
- Molecular and Cellular Immunology, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
- Department of Paediatric Immunology, Great Ormond Street Hospital NHS Trust, London, United Kingdom
| | - Adrian James Thrasher
- Molecular and Cellular Immunology, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
- Department of Paediatric Immunology, Great Ormond Street Hospital NHS Trust, London, United Kingdom
| |
Collapse
|
7
|
Gennery AR. The challenges presented by haematopoietic stem cell transplantation in children with primary immunodeficiency. Br Med Bull 2020; 135:4-15. [PMID: 32676650 DOI: 10.1093/bmb/ldaa017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 05/13/2020] [Accepted: 05/21/2020] [Indexed: 12/13/2022]
Abstract
INTRODUCTION OR BACKGROUND For many primary immunodeficiencies (PIDs), haematopoietic stem cell transplantation (HSCT) offers treatment to cure disease. However, patients with PID present a unique set of challenges when considering HSCT. SOURCES OF DATA Review of recent literature. AREAS OF AGREEMENT The most significant recent impact on successful outcome is introduction of newborn screening programmes for diagnosis of severe combined immunodeficiency-wider adoption of screening in an increasing number of countries will see further improvements. Other PIDs have better outcomes when treated earlier, before development of co-morbidities-early referral for consideration of HSCT is important. Evolution of conditioning regimens is improving short- and long-term toxicities-targeted busulfan and low-toxicity myeloablative treosulfan regimens deliver good survival with reduced short-term toxicities. AREAS OF CONTROVERSY The most radical development, still in clinical trials, is the use of mono-antibody-based conditioning, which eliminates the requirement for chemotherapy and is likely to become much more important in HSCT for non-malignant disease in the future. GROWING POINTS Multidisciplinary working for optimum care is essential. AREAS TIMELY FOR DEVELOPING RESEARCH International collaborations are important to learn about rare presentations and complications, and to formulate the most effective and safe treatment strategies.
Collapse
Affiliation(s)
- A R Gennery
- Paediatric Immunology and Haematopoietic Stem Cell Transplantation, Great North Children's Hospital, Newcastle upon Tyne NE1 4LP, UK.,Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne NE1 7RU, UK
| |
Collapse
|
8
|
Fischer A, Hacein-Bey-Abina S. Gene therapy for severe combined immunodeficiencies and beyond. J Exp Med 2020; 217:132743. [PMID: 31826240 PMCID: PMC7041706 DOI: 10.1084/jem.20190607] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 10/10/2019] [Accepted: 11/06/2019] [Indexed: 12/26/2022] Open
Abstract
This review describes how gene therapy of severe combined immunodeficiency became a reality, primarily based on the expected selective advantage conferred by transduction of hematopoietic progenitor cells. Thus, it resulted in a progressive extension to the treatment of other primary immunodeficiencies. Ex vivo retrovirally mediated gene therapy has been shown within the last 20 yr to correct the T cell immunodeficiency caused by γc-deficiency (SCID X1) and adenosine deaminase (ADA) deficiency. The rationale was brought up by the observation of the revertant of SCIDX1 and ADA deficiency as a kind of natural gene therapy. Nevertheless, the first attempts of gene therapy for SCID X1 were associated with insertional mutagenesis causing leukemia, because the viral enhancer induced transactivation of oncogenes. Removal of this element and use of a promoter instead led to safer but still efficacious gene therapy. It was observed that a fully diversified T cell repertoire could be generated by a limited set (<1,000) of progenitor cells. Further advances in gene transfer technology, including the use of lentiviral vectors, has led to success in the treatment of Wiskott–Aldrich syndrome, while further applications are pending. Genome editing of the mutated gene may be envisaged as an alternative strategy to treat SCID diseases.
Collapse
Affiliation(s)
- Alain Fischer
- Imagine Institute, Paris, France.,Immunology and Pediatric Hematology Department, Assistance Publique-Hôpitaux de Paris, Paris, France.,Institut National de la Santé et de la Recherche Médicale UMR 1163, Paris, France.,Collège de France, Paris, France
| | - Salima Hacein-Bey-Abina
- Unité de Technologies Chimiques et Biologiques pour la Santé, UMR8258 Centre National de la Recherche Scientifique - U1267 Institut National de la Santé et de la Recherche Médicale, Faculté de Pharmacie de Paris, Université Paris Descartes, Paris, France.,Clinical Immunology Laboratory, Groupe Hospitalier Universitaire Paris-Sud, Hôpital Kremlin-Bicêtre, Assistance Publique-Hôpitaux de Paris, Le Kremlin Bicêtre, France
| |
Collapse
|
9
|
Zhang ZY, Thrasher AJ, Zhang F. Gene therapy and genome editing for primary immunodeficiency diseases. Genes Dis 2020; 7:38-51. [PMID: 32181274 PMCID: PMC7063425 DOI: 10.1016/j.gendis.2019.07.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 07/20/2019] [Accepted: 07/22/2019] [Indexed: 12/12/2022] Open
Abstract
In past two decades the gene therapy using genetic modified autologous hematopoietic stem cells (HSCs) transduced with the viral vector has become a promising alternative option for treating primary immunodeficiency diseases (PIDs). Despite of some pitfalls at early stage clinical trials, the field of gene therapy has advanced significantly in the last decade with improvements in viral vector safety, preparatory regime for manufacturing high quality virus, automated CD34 cell purification. Hence, the overall outcome from the clinical trials for the different PIDs has been very encouraging. In addition to the viral vector based gene therapy, the recent fast moving forward developments in genome editing using engineered nucleases in HSCs has provided a new promising platform for the treatment of PIDs. This review provides an overall outcome and progress in gene therapy clinical trials for SCID-X, ADA-SCID, WAS, X- CGD, and the recent developments in genome editing technology applied in HSCs for developing potential therapy, particular in the key studies for PIDs.
Collapse
Affiliation(s)
- Zhi-Yong Zhang
- Department of Immunology and Rheumatology, Children's Hospital of Chongqing Medical University, China
| | - Adrian J. Thrasher
- Molecular and Cellular Immunology, Great Ormond Street Institute of Child Health, University Colleage London, UK
| | - Fang Zhang
- Molecular and Cellular Immunology, Great Ormond Street Institute of Child Health, University Colleage London, UK
| |
Collapse
|
10
|
Gene therapy targeting haematopoietic stem cells for inherited diseases: progress and challenges. Nat Rev Drug Discov 2019; 18:447-462. [DOI: 10.1038/s41573-019-0020-9] [Citation(s) in RCA: 102] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
|
11
|
Chan JKY, Gil-Farina I, Johana N, Rosales C, Tan YW, Ceiler J, Mcintosh J, Ogden B, Waddington SN, Schmidt M, Biswas A, Choolani M, Nathwani AC, Mattar CNZ. Therapeutic expression of human clotting factors IX and X following adeno-associated viral vector-mediated intrauterine gene transfer in early-gestation fetal macaques. FASEB J 2018; 33:3954-3967. [PMID: 30517034 PMCID: PMC6404563 DOI: 10.1096/fj.201801391r] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Adeno-associated viral vectors (AAVs) achieve stable therapeutic expression without long-term toxicity in adults with hemophilia. To avert irreversible complications in congenital disorders producing early pathogenesis, safety and efficacy of AAV-intrauterine gene transfer (IUGT) requires assessment. We therefore performed IUGT of AAV5 or -8 with liver-specific promoter-1 encoding either human coagulation factors IX (hFIX) or X (hFX) into Macaca fascicularis fetuses at ∼0.4 gestation. The initial cohort received 1 × 1012 vector genomes (vgs) of AAV5-hFIX (n = 5; 0.45 × 1013 vg/kg birth weight), resulting in ∼3.0% hFIX at birth and 0.6–6.8% over 19–51 mo. The next cohort received 0.2–1 × 1013 vg boluses. AAV5-hFX animals (n = 3; 3.57 × 1013 vg/kg) expressed <1% at birth and 9.4–27.9% up to 42 mo. AAV8-hFIX recipients (n = 3; 2.56 × 1013 vg/kg) established 4.2–41.3% expression perinatally and 9.8–25.3% over 46 mo. Expression with AAV8-hFX (n = 6, 3.12 × 1013 vg/kg) increased from <1% perinatally to 9.8–13.4% >35 mo. Low expressers (<1%, n = 3) were postnatally challenged with 2 × 1011 vg/kg AAV5 resulting in 2.4–13.2% expression and demonstrating acquired tolerance. Linear amplification–mediated-PCR analysis demonstrated random integration of 57–88% of AAV sequences retrieved from hepatocytes with no events occurring in or near oncogenesis-associated genes. Thus, early-IUGT in macaques produces sustained curative expression related significantly to integrated AAV in the absence of clinical toxicity, supporting its therapeutic potential for early-onset monogenic disorders.—Chan, J. K. Y., Gil-Farina I., Johana, N., Rosales, C., Tan, Y. W., Ceiler, J., Mcintosh, J., Ogden, B., Waddington, S. N., Schmidt, M., Biswas, A., Choolani, M., Nathwani, A. C., Mattar, C. N. Z. Therapeutic expression of human clotting factors IX and X following adeno-associated viral vector–mediated intrauterine gene transfer in early-gestation fetal macaques.
Collapse
Affiliation(s)
- Jerry K Y Chan
- Reproductive Medicine, KK Women's and Children's Hospital, Singapore, Singapore.,Cancer and Stem Cell Biology Program, Duke-National University of Singapore (NUS) Medical School, Singapore
| | - Irene Gil-Farina
- Department of Translational Oncology, German Cancer Research Center/National Center for Tumor Diseases, Heidelberg, Germany
| | - Nuryanti Johana
- Reproductive Medicine, KK Women's and Children's Hospital, Singapore, Singapore
| | - Cecilia Rosales
- University College London (UCL) Cancer Institute, University College London, London, United Kingdom
| | - Yi Wan Tan
- Reproductive Medicine, KK Women's and Children's Hospital, Singapore, Singapore
| | - Jessika Ceiler
- Department of Translational Oncology, German Cancer Research Center/National Center for Tumor Diseases, Heidelberg, Germany
| | - Jenny Mcintosh
- Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Bryan Ogden
- SingHealth Experimental Medicine Centre, Singapore Health Services Pte, Singapore, Singapore
| | - Simon N Waddington
- Institute for Women's Health, University College London, London, United Kingdom.,Faculty of Health Sciences, Wits/South African Medical Research Council (SAMRC), Antiviral Gene Therapy Research Unit, University of the Witwatersrand, Johannesburg, South Africa; and
| | - Manfred Schmidt
- University College London (UCL) Cancer Institute, University College London, London, United Kingdom.,GeneWerk, Heidelberg, Germany
| | - Arijit Biswas
- Department of Translational Oncology, German Cancer Research Center/National Center for Tumor Diseases, Heidelberg, Germany
| | - Mahesh Choolani
- Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Amit C Nathwani
- University College London (UCL) Cancer Institute, University College London, London, United Kingdom
| | - Citra N Z Mattar
- Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| |
Collapse
|
12
|
Dighe NM, Tan KW, Tan LG, Shaw SSW, Buckley SMK, Sandikin D, Johana N, Tan YW, Biswas A, Choolani M, Waddington SN, Antoniou MN, Chan JKY, Mattar CNZ. A comparison of intrauterine hemopoietic cell transplantation and lentiviral gene transfer for the correction of severe β-thalassemia in a HbbTh3/+ murine model. Exp Hematol 2018; 62:45-55. [PMID: 29605545 PMCID: PMC5965454 DOI: 10.1016/j.exphem.2018.03.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Revised: 03/17/2018] [Accepted: 03/22/2018] [Indexed: 01/08/2023]
Abstract
Major hemoglobinopathies place tremendous strain on global resources. Intrauterine hemopoietic cell transplantation (IUHCT) and gene transfer (IUGT) can potentially reduce perinatal morbidities with greater efficacy than postnatal therapy alone. We performed both procedures in the thalassemic HbbTh3/+ mouse. Intraperitoneal delivery of co-isogenic cells at embryonic days13-14 produced dose-dependent chimerism. High-dose adult bone marrow (BM) cells maintained 0.2-3.1% chimerism over ~24 weeks and treated heterozygotes (HET) demonstrated higher chimerism than wild-type (WT) pups (1.6% vs. 0.7%). Fetalliver (FL) cells produced higher chimerism than BM when transplanted at thesame doses, maintaining 1.8-2.4% chimerism over ~32 weeks. We boosted transplanted mice postnatally with BM cells after busulfan conditioning. Engraftment was maintained at >1% only in chimeras. IUHCT-treated nonchimeras and non-IUHCT mice showed microchimerism or no chimerism. Improved engraftment was observed with a higher initial chimerism, in HET mice and with the addition of fludarabine. Chimeric HET mice expressed 2.2-15.1% engraftment with eventual decline at 24 weeks (vs. <1% in nonchimeras) and demonstrated improved hematological indices and smaller spleens compared with untreated HETmice. Intravenous delivery of GLOBE lentiviral-vector expressing human β-globin (HBB) resulted in a vector concentration of 0.001-0.6 copies/cell. Most hematological indices were higher in treated than untreated HET mice, including hemoglobin and mean corpuscular volume, but were still lower than in WT. Therefore, direct IUGT and IUHCT strategies can be used to achieve hematological improvement but require further dose optimization. IUHCT will be useful combined with postnatal transplantation to further enhance engraftment.
Collapse
Affiliation(s)
- Niraja M Dighe
- Experimental Fetal Medicine Group, Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, 119228 Singapore, Singapore
| | - Kang Wei Tan
- Experimental Fetal Medicine Group, Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, 119228 Singapore, Singapore
| | - Lay Geok Tan
- Experimental Fetal Medicine Group, Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, 119228 Singapore, Singapore
| | - Steven S W Shaw
- College of Medicine, Chang Gung University, 33302 Taoyuan, Taiwan, China; Prenatal Cell and Gene Therapy Group, Institute for Women's Health, University College London, WC1E 6AU London, United Kingdom
| | - Suzanne M K Buckley
- Gene Transfer Technology Group, Institute for Women's Health, University College London, WC1E 6AU London, United Kingdom
| | - Dedy Sandikin
- Experimental Fetal Medicine Group, Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, 119228 Singapore, Singapore
| | - Nuryanti Johana
- Department of Reproductive Medicine, KK Women's and Children's Hospital, 229899 Singapore, Singapore
| | - Yi-Wan Tan
- Department of Reproductive Medicine, KK Women's and Children's Hospital, 229899 Singapore, Singapore
| | - Arijit Biswas
- Experimental Fetal Medicine Group, Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, 119228 Singapore, Singapore
| | - Mahesh Choolani
- Experimental Fetal Medicine Group, Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, 119228 Singapore, Singapore
| | - Simon N Waddington
- Gene Transfer Technology Group, Institute for Women's Health, University College London, WC1E 6AU London, United Kingdom; MRC Antiviral Gene Therapy Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Michael N Antoniou
- Gene Expression and Therapy Group, King's College London, Faculty of Life Sciences and Medicine, Department of Medical and Molecular Genetics, Guy's Hospital, SE1 9RT London, United Kingdom
| | - Jerry K Y Chan
- Department of Reproductive Medicine, KK Women's and Children's Hospital, 229899 Singapore, Singapore; Cancer and Stem Cell Program, Duke-NUS Graduate Medical School, 169857 Singapore, Singapore
| | - Citra N Z Mattar
- Experimental Fetal Medicine Group, Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, 119228 Singapore, Singapore.
| |
Collapse
|
13
|
Preclinical Development of a Lentiviral Vector for Gene Therapy of X-Linked Severe Combined Immunodeficiency. MOLECULAR THERAPY-METHODS & CLINICAL DEVELOPMENT 2018; 9:257-269. [PMID: 29707600 PMCID: PMC5918176 DOI: 10.1016/j.omtm.2018.03.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Accepted: 03/06/2018] [Indexed: 01/27/2023]
Abstract
X-linked severe combined immunodeficiency (SCID-X1) is caused by mutations in the interleukin-2 receptor γ chain gene (IL2RG), and it is characterized by profound defects in T, B, and natural killer (NK) cell functions. Transplantation of hematopoietic stem/progenitor cells (HSPCs) genetically corrected with early murine leukemia retrovirus (MLV)-derived gammaretroviral vectors showed restoration of T cell immunity in patients, but it resulted in vector-induced insertional oncogenesis. We developed a self-inactivating (SIN) lentiviral vector carrying a codon-optimized human IL2RG cDNA driven by the EF1α short promoter (EFS-IL2RG), and we tested its efficacy and safety in vivo by transplanting transduced Il2rg-deficient Lin− HSPCs in an Il2rg−/−/Rag2−/− mouse model. The study showed restoration of T, B, and NK cell counts in bone marrow and peripheral blood and normalization of thymus and spleen cellularity and architecture. High-definition insertion site analysis defined the EFS-IL2RG genomic integration profile, and it showed no sign of vector-induced clonal selection or skewing in primarily and secondarily transplanted animals. The study enables a phase I/II clinical trial aimed at restoring both T and B cell immunity in SCID-X1 children upon non-myeloablative conditioning.
Collapse
|
14
|
Thrasher AJ, Williams DA. Evolving Gene Therapy in Primary Immunodeficiency. Mol Ther 2017; 25:1132-1141. [PMID: 28366768 DOI: 10.1016/j.ymthe.2017.03.018] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 03/10/2017] [Accepted: 03/10/2017] [Indexed: 12/29/2022] Open
Abstract
Prior to the first successful bone marrow transplant in 1968, patients born with severe combined immunodeficiency (SCID) invariably died. Today, with a widening availability of newborn screening, major improvements in the application of allogeneic procedures, and the emergence of successful hematopoietic stem and progenitor cell (HSC/P) gene therapy, the majority of these children can be identified and cured. Here, we trace key steps in the development of clinical gene therapy for SCID and other primary immunodeficiencies (PIDs), and review the prospects for adoption of new targets and technologies.
Collapse
Affiliation(s)
- Adrian J Thrasher
- Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK; University College London Great Ormond Street Institute of Child Health, London WC1N 1EH, UK.
| | - David A Williams
- Boston Children's Hospital and Dana-Farber Cancer Institute, Harvard Medical School and Harvard Stem Cell Institute, 300 Longwood Avenue, Boston, MA 02115, USA.
| |
Collapse
|
15
|
Long-term outcome of hematopoietic stem cell transplantation for IL2RG/JAK3 SCID: a cohort report. Blood 2017; 129:2198-2201. [PMID: 28209722 DOI: 10.1182/blood-2016-11-748616] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 02/12/2017] [Indexed: 01/04/2023] Open
Abstract
Hematopoietic stem cell transplantation (HSCT) cures the T-lymphocyte, B-lymphocyte, and natural killer (NK)-cell differentiation defect in interleukin-2 γ-chain receptor (IL2RG)/JAK3 severe combined immunodeficiency (SCID). We evaluated long-term clinical features, longitudinal immunoreconstitution, donor chimerism, and quality of life (QoL) of IL2RG/JAK3 SCID patients >2 years post-HSCT at our center. Clinical data were collated and patients/families answered PedsQL Generic Core Scale v4.0 questionnaires. We performed longitudinal analyses of CD3+, CD4+ naive T-lymphocyte, CD19+, and NK-cell numbers from pretransplant until 15 years posttransplant. Thirty-one of 43 patients (72%) survived. Median age at last follow-up was 10 years (range, 2-25 years). Twenty-one (68%) had persistent medical issues, mainly ongoing immunoglobulin replacement (14; 45%), cutaneous viral warts (7; 24%), short stature (4; 14%), limb lymphoedema (3; 10%), and bronchiectasis (2; 7%). Lung function was available and normal for 6 patients. Longitudinal analysis demonstrated sustained CD3+, CD19+, and NK-cell output 15 years post-HSCT. CD4+ naive lymphocyte numbers were better in conditioned vs unconditioned recipients (P, .06). B-lymphocyte and myeloid chimerism were highly correlated (ρ, 0.98; P < .001). Low-toxicity myeloablative conditioning recipients have better B-lymphocyte/myeloid chimerism and are free from immunoglobulin replacement therapy. IL2RG/JAK3 SCID survivors free from immunoglobulin replacement have normal QoL.
Collapse
|
16
|
Cavazzana M, Six E, Lagresle-Peyrou C, André-Schmutz I, Hacein-Bey-Abina S. Gene Therapy for X-Linked Severe Combined Immunodeficiency: Where Do We Stand? Hum Gene Ther 2016; 27:108-16. [PMID: 26790362 DOI: 10.1089/hum.2015.137] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
More than 20 years ago, X-linked severe combined immunodeficiency (SCID-X1) appeared to be the best condition to test the feasibility of hematopoietic stem cell gene therapy. The seminal SCID-X1 clinical studies, based on first-generation gammaretroviral vectors, demonstrated good long-term immune reconstitution in most treated patients despite the occurrence of vector-related leukemia in a few of them. This gene therapy has successfully enabled correction of the T cell defect. Natural killer and B cell defects were only partially restored, most likely due to the absence of a conditioning regimen. The success of these pioneering trials paved the way for the extension of gene-based treatment to many other diseases of the hematopoietic system, but the unfortunate serious adverse events led to extensive investigations to define the retrovirus integration profiles. This review puts into perspective the clinical experience of gene therapy for SCID-X1, with the development and implementation of new generations of safer vectors such as self-inactivating gammaretroviral or lentiviral vectors as well as major advances in integrome knowledge.
Collapse
Affiliation(s)
- Marina Cavazzana
- 1 Biotherapy Department, Necker Children's Hospital , Assistance Publique-Hôpitaux de Paris, Paris.,2 Biotherapy Clinical Investigation Center, Groupe Hospitalier Universitaire Ouest , Assistance Publique-Hôpitaux de Paris, INSERM, Paris.,3 Paris Descartes-Sorbonne Paris Cité University, Imagine Institute , Paris.,4 INSERM UMR 1163, Laboratory of Human Lymphohematopoiesis , Paris
| | - Emmanuelle Six
- 2 Biotherapy Clinical Investigation Center, Groupe Hospitalier Universitaire Ouest , Assistance Publique-Hôpitaux de Paris, INSERM, Paris.,3 Paris Descartes-Sorbonne Paris Cité University, Imagine Institute , Paris.,4 INSERM UMR 1163, Laboratory of Human Lymphohematopoiesis , Paris
| | - Chantal Lagresle-Peyrou
- 2 Biotherapy Clinical Investigation Center, Groupe Hospitalier Universitaire Ouest , Assistance Publique-Hôpitaux de Paris, INSERM, Paris.,3 Paris Descartes-Sorbonne Paris Cité University, Imagine Institute , Paris.,4 INSERM UMR 1163, Laboratory of Human Lymphohematopoiesis , Paris
| | - Isabelle André-Schmutz
- 2 Biotherapy Clinical Investigation Center, Groupe Hospitalier Universitaire Ouest , Assistance Publique-Hôpitaux de Paris, INSERM, Paris.,3 Paris Descartes-Sorbonne Paris Cité University, Imagine Institute , Paris.,4 INSERM UMR 1163, Laboratory of Human Lymphohematopoiesis , Paris
| | - Salima Hacein-Bey-Abina
- 1 Biotherapy Department, Necker Children's Hospital , Assistance Publique-Hôpitaux de Paris, Paris.,2 Biotherapy Clinical Investigation Center, Groupe Hospitalier Universitaire Ouest , Assistance Publique-Hôpitaux de Paris, INSERM, Paris.,5 UTCBS CNRS 8258-INSERM U1022, Faculté des Sciences Pharmaceutiques et Biologiques, Université Paris Descartes , Paris.,6 Immunology Laboratory, Groupe Hospitalier Universitaire Paris-Sud , AP-HP, Le-Kremlin-Bicêtre, France
| |
Collapse
|
17
|
Abstract
Severe combined immunodeficiency disorders represent pediatric emergencies due to absence of adaptive immune responses to infections. The conditions result from either intrinsic defects in T-cell development (ie, severe combined immunodeficiency disease [SCID]) or congenital athymia (eg, complete DiGeorge anomaly). Hematopoietic stem cell transplant provides the only clinically approved cure for SCID, although gene therapy research trials are showing significant promise. For greatest survival, patients should undergo transplant before 3.5 months of age and before the onset of infections. Newborn screening programs have yielded successful early identification and treatment of infants with SCID and congenital athymia in the United States.
Collapse
|
18
|
De Ravin SS, Wu X, Moir S, Anaya-O'Brien S, Kwatemaa N, Littel P, Theobald N, Choi U, Su L, Marquesen M, Hilligoss D, Lee J, Buckner CM, Zarember KA, O'Connor G, McVicar D, Kuhns D, Throm RE, Zhou S, Notarangelo LD, Hanson IC, Cowan MJ, Kang E, Hadigan C, Meagher M, Gray JT, Sorrentino BP, Malech HL, Kardava L. Lentiviral hematopoietic stem cell gene therapy for X-linked severe combined immunodeficiency. Sci Transl Med 2016; 8:335ra57. [PMID: 27099176 PMCID: PMC5557273 DOI: 10.1126/scitranslmed.aad8856] [Citation(s) in RCA: 200] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 03/03/2016] [Indexed: 12/14/2022]
Abstract
X-linked severe combined immunodeficiency (SCID-X1) is a profound deficiency of T, B, and natural killer (NK) cell immunity caused by mutations inIL2RGencoding the common chain (γc) of several interleukin receptors. Gamma-retroviral (γRV) gene therapy of SCID-X1 infants without conditioning restores T cell immunity without B or NK cell correction, but similar treatment fails in older SCID-X1 children. We used a lentiviral gene therapy approach to treat five SCID-X1 patients with persistent immune dysfunction despite haploidentical hematopoietic stem cell (HSC) transplant in infancy. Follow-up data from two older patients demonstrate that lentiviral vector γc transduced autologous HSC gene therapy after nonmyeloablative busulfan conditioning achieves selective expansion of gene-marked T, NK, and B cells, which is associated with sustained restoration of humoral responses to immunization and clinical improvement at 2 to 3 years after treatment. Similar gene marking levels have been achieved in three younger patients, albeit with only 6 to 9 months of follow-up. Lentiviral gene therapy with reduced-intensity conditioning appears safe and can restore humoral immune function to posthaploidentical transplant older patients with SCID-X1.
Collapse
Affiliation(s)
- Suk See De Ravin
- Laboratory of Host Defenses, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA.
| | - Xiaolin Wu
- Cancer Research Technology Program, Leidos Biomedical Research Inc., Frederick National Laboratory for Cancer Research, Frederick, MD 21702, USA
| | - Susan Moir
- Laboratory of Immunoregulation, NIAID, NIH, Bethesda, MD 20892, USA
| | - Sandra Anaya-O'Brien
- Laboratory of Host Defenses, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Nana Kwatemaa
- Laboratory of Host Defenses, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Patricia Littel
- Laboratory of Host Defenses, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Narda Theobald
- Laboratory of Host Defenses, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Uimook Choi
- Laboratory of Host Defenses, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Ling Su
- Cancer Research Technology Program, Leidos Biomedical Research Inc., Frederick National Laboratory for Cancer Research, Frederick, MD 21702, USA
| | - Martha Marquesen
- Laboratory of Host Defenses, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Dianne Hilligoss
- Laboratory of Host Defenses, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Janet Lee
- Laboratory of Host Defenses, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | | | - Kol A Zarember
- Laboratory of Host Defenses, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Geraldine O'Connor
- Cancer and Inflammation Program, National Cancer Institute Frederick, Frederick, MD 21702, USA
| | - Daniel McVicar
- Cancer and Inflammation Program, National Cancer Institute Frederick, Frederick, MD 21702, USA
| | - Douglas Kuhns
- Cancer Research Technology Program, Leidos Biomedical Research Inc., Frederick National Laboratory for Cancer Research, Frederick, MD 21702, USA
| | - Robert E Throm
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Sheng Zhou
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Luigi D Notarangelo
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | | | - Mort J Cowan
- Department of Pediatrics, Benioff Children's Hospital, and University of California, San Francisco, San Francisco, CA, USA
| | - Elizabeth Kang
- Laboratory of Host Defenses, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Coleen Hadigan
- Laboratory of Immunoregulation, NIAID, NIH, Bethesda, MD 20892, USA
| | - Michael Meagher
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - John T Gray
- Audentes Therapeutics, San Francisco, CA 94101, USA
| | - Brian P Sorrentino
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Harry L Malech
- Laboratory of Host Defenses, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA.
| | | |
Collapse
|
19
|
Abstract
Retroviral vector gene therapy is a promising approach to treating HIV-1. However, integrated vectors are mutagens with the potential to dysregulate nearby genes and cause severe adverse side effects. Leukemia has already been a documented severe adverse event in gene therapy clinical trials for the treatment of primary immunodeficiencies. These side effects will need to be reduced or avoided if retroviral vectors are to be used clinically for HIV-1 treatment. The addition of chromatin insulators to retroviral vectors is a potential strategy for reducing adverse side effects. Insulators have already been effectively used in retroviral vectors to reduce genotoxicity in pre-clinical studies. Here, we will review how insulators function, genotoxicity in gene therapy clinical trials, the design of insulated retroviral vectors, promising results from insulated retroviral vector studies, and considerations for the development of insulated retroviral treatment vectors for HIV-1 gene therapy.
Collapse
Affiliation(s)
- Diana L. Browning
- School of Molecular Biosciences, Washington State University, Pullman, WA 99164, USA;
| | - Grant D. Trobridge
- School of Molecular Biosciences, Washington State University, Pullman, WA 99164, USA;
- Pharmaceutical Sciences, College of Pharmacy, Washington State University Spokane, Spokane, WA 99202, USA
- Correspondence: ; Tel.: +1-509-368-6535
| |
Collapse
|
20
|
Calero-Garcia M, Gaspar HB. Gene Therapy for SCID. CURRENT PEDIATRICS REPORTS 2015. [DOI: 10.1007/s40124-014-0069-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
21
|
Sokolic R, Oden N, Candotti F. Assessment of Immature Platelet Fraction in the Diagnosis of Wiskott-Aldrich Syndrome. Front Pediatr 2015; 3:49. [PMID: 26082919 PMCID: PMC4450723 DOI: 10.3389/fped.2015.00049] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Accepted: 05/15/2015] [Indexed: 11/13/2022] Open
Abstract
Children with Wiskott-Aldrich syndrome (WAS) are often first diagnosed with immune thrombocytopenia (ITP), potentially leading to both inappropriate treatment and the delay of life-saving definitive therapy. WAS is traditionally differentiated from ITP based on the small size of WAS platelets. In practice, microthrombocytopenia is often not present or not appreciated in children with WAS. To develop an alternative method of differentiating WAS from ITP, we retrospectively reviewed all complete blood counts and measurements of immature platelet fraction (IPF) in 18 subjects with WAS and 38 subjects with a diagnosis of ITP treated at our hospital. Examination of peripheral blood smears revealed a wide range of platelet sizes in subjects with WAS. Mean platelet volume (MPV) was not reported in 26% of subjects, and subjects in whom MPV was not reported had lower platelet counts than did subjects in whom MPV was reported. Subjects with WAS had a lower IPF than would be expected for their level of thrombocytopenia, and the IPF in subjects with WAS was significantly lower than in subjects with a diagnosis of ITP. Using logistic regression, we developed and validated a rule based on platelet count and IPF that was more sensitive for the diagnosis of WAS than was the MPV, and was applicable regardless of the level of platelets or the availability of the MPV. Our observations demonstrate that MPV is often not available in severely thrombocytopenic subjects, which may hinder the diagnosis of WAS. In addition, subjects with WAS have a low IPF, which is consistent with the notion that a platelet production defect contributes to the thrombocytopenia of WAS. Knowledge of this detail of WAS pathophysiology allows to differentiate WAS from ITP with increased sensitivity, thereby allowing a physician to spare children with WAS from inappropriate treatment, and make definitive therapy available in a timely manner.
Collapse
Affiliation(s)
- Robert Sokolic
- Office of Cellular, Tissue and Gene Therapies, Center for Biologics Evaluation and Research, Food and Drug Administration , Silver Spring, MD , USA
| | - Neal Oden
- Emmes Corporation , Rockville, MD , USA
| | - Fabio Candotti
- Disorders of Immunity Section, Genetics and Molecular Biology Branch, National Human Genome Research Institute, National Institutes of Health , Bethesda, MD , USA ; Division of Immunology and Allergy, Centre Hospitalier Universitaire Vaudois , Lausanne , Switzerland
| |
Collapse
|
22
|
Braun CJ, Boztug K, Paruzynski A, Witzel M, Schwarzer A, Rothe M, Modlich U, Beier R, Göhring G, Steinemann D, Fronza R, Ball CR, Haemmerle R, Naundorf S, Kühlcke K, Rose M, Fraser C, Mathias L, Ferrari R, Abboud MR, Al-Herz W, Kondratenko I, Maródi L, Glimm H, Schlegelberger B, Schambach A, Albert MH, Schmidt M, von Kalle C, Klein C. Gene therapy for Wiskott-Aldrich syndrome--long-term efficacy and genotoxicity. Sci Transl Med 2014; 6:227ra33. [PMID: 24622513 DOI: 10.1126/scitranslmed.3007280] [Citation(s) in RCA: 388] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Wiskott-Aldrich syndrome (WAS) is characterized by microthrombocytopenia, immunodeficiency, autoimmunity, and susceptibility to malignancies. In our hematopoietic stem cell gene therapy (GT) trial using a γ-retroviral vector, 9 of 10 patients showed sustained engraftment and correction of WAS protein (WASP) expression in lymphoid and myeloid cells and platelets. GT resulted in partial or complete resolution of immunodeficiency, autoimmunity, and bleeding diathesis. Analysis of retroviral insertion sites revealed >140,000 unambiguous integration sites and a polyclonal pattern of hematopoiesis in all patients early after GT. Seven patients developed acute leukemia [one acute myeloid leukemia (AML), four T cell acute lymphoblastic leukemia (T-ALL), and two primary T-ALL with secondary AML associated with a dominant clone with vector integration at the LMO2 (six T-ALL), MDS1 (two AML), or MN1 (one AML) locus]. Cytogenetic analysis revealed additional genetic alterations such as chromosomal translocations. This study shows that hematopoietic stem cell GT for WAS is feasible and effective, but the use of γ-retroviral vectors is associated with a substantial risk of leukemogenesis.
Collapse
Affiliation(s)
- Christian Jörg Braun
- Dr. von Hauner Children's Hospital, Ludwig Maximilians University Munich, 80337 Munich, Germany
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
23
|
Braun CJ, Witzel M, Paruzynski A, Boztug K, von Kalle C, Schmidt M, Klein C. Gene therapy for Wiskott-Aldrich Syndrome-Long-term reconstitution and clinical benefits, but increased risk for leukemogenesis. Rare Dis 2014; 2:e947749. [PMID: 26942098 PMCID: PMC4755244 DOI: 10.4161/21675511.2014.947749] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Revised: 07/06/2014] [Accepted: 07/16/2014] [Indexed: 01/14/2023] Open
Abstract
Wiskott-Aldrich-Syndrome (WAS) is a rare X-linked recessive disease caused by mutations of the WAS gene. It is characterized by immunodeficiency, autoimmunity, low numbers of small platelets (microthrombocytopenia) and a high risk of cancer, especially B cell lymphoma and leukemia.
Collapse
Affiliation(s)
- Christian Joerg Braun
- Dr. von Hauner Children's Hospital; Ludwig Maximilians University Munich ; Munich, Germany
| | - Maximilian Witzel
- Dr. von Hauner Children's Hospital; Ludwig Maximilians University Munich ; Munich, Germany
| | - Anna Paruzynski
- Department of Translational Oncology; National Center for Tumor Diseases and German Cancer Research Center; Heidelberg, Germany; New address: BioNTech AG; Mainz, Germany
| | - Kaan Boztug
- Department of Pediatric Hematology/Oncology; Hannover Medical School; Hannover, Germany; Present address: CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences/Department of Pediatrics and Adolescent Medicine, Medical University of Vienna; Vienna, Austria
| | - Christof von Kalle
- Department of Translational Oncology; National Center for Tumor Diseases and German Cancer Research Center ; Heidelberg, Germany
| | - Manfred Schmidt
- Department of Translational Oncology; National Center for Tumor Diseases and German Cancer Research Center ; Heidelberg, Germany
| | - Christoph Klein
- Dr. von Hauner Children's Hospital; Ludwig Maximilians University Munich ; Munich, Germany
| |
Collapse
|
24
|
Williams DA, Thrasher AJ. Concise review: lessons learned from clinical trials of gene therapy in monogenic immunodeficiency diseases. Stem Cells Transl Med 2014; 3:636-42. [PMID: 24682287 DOI: 10.5966/sctm.2013-0206] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Thirty years ago, retroviral transfer of genetic material into hematopoietic stem and progenitor cells (HSC/Ps) led to predictions that this technology would transform modern medicine [Nature 1983;305:556-558; Nature 1984;310:476-480]. Studies in several immunodeficiency diseases in the past 15 years have demonstrated clear proof of principle that gene therapy can have long-lasting, potentially curative effects without the need to search for allogeneic donors and without risk of graft-versus-host disease. Improvement in gene transfer efficiency for target HSC/Ps brought to light issues of insertional mutagenesis caused by transfer vectors, resulting in oncogene transactivation and leukemias. Lessons from these adverse events have now led to a new generation of vectors, refinements in conditioning regimens, and manufacturing, which are paving the way for expanded applications of the current technology and recent emphasis on gene targeting/genome editing as the next advancements in the field.
Collapse
Affiliation(s)
- David A Williams
- Division of Hematology/Oncology, Boston Children's Hospital, and Department of Pediatric Oncology, Dana Farber Cancer Institute, Harvard Medical School, Harvard Stem Cell Institute, Boston, Massachusetts, USA; Centre for Immunodeficiency, Molecular Immunology Unit, Institute of Child Health, London, United Kingdom
| | | |
Collapse
|
25
|
Larochelle A, Dunbar CE. Hematopoietic stem cell gene therapy:assessing the relevance of preclinical models. Semin Hematol 2014; 50:101-30. [PMID: 24014892 DOI: 10.1053/j.seminhematol.2013.03.025] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
|
26
|
Touzot F, Hacein-Bey-Abina S, Fischer A, Cavazzana M. Gene therapy for inherited immunodeficiency. Expert Opin Biol Ther 2014; 14:789-98. [DOI: 10.1517/14712598.2014.895811] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
|
27
|
Koldej RM, Carney G, Wielgosz MM, Zhou S, Zhan J, Sorrentino BP, Nienhuis AW. Comparison of insulators and promoters for expression of the Wiskott-Aldrich syndrome protein using lentiviral vectors. HUM GENE THER CL DEV 2013; 24:77-85. [PMID: 23786330 DOI: 10.1089/humc.2012.244] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Gene therapy for the treatment of Wiskott-Aldrich syndrome (WAS) presents an alternative to the current use of allogeneic bone marrow transplantation. We describe the development of a self-inactivating lentiviral vector containing chromatin insulators for treatment of WAS and compare a gammaretroviral (MND), human cellular (EF1α), and the human WASp gene promoter for expression patterns in vivo during murine hematopoiesis using the green fluorescent protein (GFP) marker. Compared with the EF1α and the WASp promoters, expression from the MND promoter in mouse transplant recipients was much higher in all lineages examined. Importantly, there was sustained expression in the platelets of secondary recipient animals, necessary to correct the thrombocytopenia defect in WAS patients. Analysis of WAS protein expression in transduced human EBV-immortalized B-cells and transduced patient peripheral blood mononuclear cells also demonstrated stronger expression per copy from the MND promoter compared with the other promoters. In addition, when analyzed in an LM02 activation assay, the addition of an insulator to MND-promoter-containing constructs reduced transactivation of the LM02 gene. We propose a clinical trial design in which cytokine-mobilized, autologous, transduced CD34(+) cells are administered after myelosuppression.
Collapse
Affiliation(s)
- Rachel M Koldej
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | | | | | | | | | | | | |
Collapse
|
28
|
Zhang L, Thrasher AJ, Gaspar HB. Current progress on gene therapy for primary immunodeficiencies. Gene Ther 2013; 20:963-9. [PMID: 23719067 DOI: 10.1038/gt.2013.21] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Revised: 03/09/2013] [Accepted: 03/28/2013] [Indexed: 11/09/2022]
Abstract
Primary immunodeficiencies have played a major role in the development of gene therapy for monogenic diseases of the bone marrow. The last decade has seen convincing evidence of long-term disease correction as a result of ex vivo viral vector-mediated gene transfer into autologous haematopoietic stem cells. The success of these early studies has been balanced by the development of vector-related insertional mutagenic events. More recently the use of alternative vector designs with self-inactivating designs, which have an improved safety profile has led to the initiation of a wave of new studies that are showing early signs of efficacy. The ongoing development of safer vector platforms and gene-correction technologies together with improvements in cell-transduction techniques and optimised conditioning regimes is likely to make gene therapy amenable for a greater number of PIDs. If long-term efficacy and safety are shown, gene therapy will become a standard treatment option for specific forms of PID.
Collapse
Affiliation(s)
- L Zhang
- Molecular Immunology Unit, Center for Immunodeficiency, Institute of Child Health, University College London, London, UK
| | | | | |
Collapse
|
29
|
Fischer A, Hacein-Bey-Abina S, Cavazzana-Calvo M. Gene therapy of primary T cell immunodeficiencies. Gene 2013; 525:170-3. [PMID: 23583799 DOI: 10.1016/j.gene.2013.03.092] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Revised: 03/13/2013] [Accepted: 03/14/2013] [Indexed: 12/16/2022]
Abstract
Gene therapy of severe combined immunodeficiencies has been proven to be effective to provide sustained correction of the T cell immunodeficiencies. This has been achieved for 2 forms of SCID, i.e SCID-X1 (γc deficiency) and adenosine deaminase deficiency. Occurrence of gene toxicity generated by integration of first generation retroviral vectors, as observed in the SCID-X1 trials has led to replace these vectors by self inactivated (SIN) retro(or lenti) viruses that may provide equivalent efficacy with a better safety profile. Results of ongoing clinical studies in SCID as well as in other primary immunodeficiencies, such as the Wiskott Aldrich syndrome, will be thus very informative.
Collapse
|
30
|
Gene therapy for PIDs: progress, pitfalls and prospects. Gene 2013; 525:174-81. [PMID: 23566838 PMCID: PMC3725417 DOI: 10.1016/j.gene.2013.03.098] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2013] [Revised: 03/04/2013] [Accepted: 03/07/2013] [Indexed: 12/31/2022]
Abstract
Substantial progress has been made in the past decade in treating several primary immunodeficiency disorders (PIDs) with gene therapy. Current approaches are based on ex-vivo transfer of therapeutic transgene via viral vectors to patient-derived autologous hematopoietic stem cells (HSCs) followed by transplantation back to the patient with or without conditioning. The overall outcome from all the clinical trials targeting different PIDs has been extremely encouraging but not without caveats. Malignant outcomes from insertional mutagenesis have featured prominently in the adverse events associated with these trials and have warranted intense pre-clinical investigation into defining the tendencies of different viral vectors for genomic integration. Coupled with issues pertaining to transgene expression, the therapeutic landscape has undergone a paradigm shift in determining safety, stability and efficacy of gene therapy approaches. In this review, we aim to summarize the progress made in the gene therapy trials targeting ADA-SCID, SCID-X1, CGD and WAS, review the pitfalls, and outline the recent advancements which are expected to further enhance favourable risk benefit ratios for gene therapeutic approaches in the future.
Collapse
|
31
|
Digiusto DL, Kiem HP. Current translational and clinical practices in hematopoietic cell and gene therapy. Cytotherapy 2013; 14:775-90. [PMID: 22799276 DOI: 10.3109/14653249.2012.694420] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Clinical trials over the last 15 years have demonstrated that cell and gene therapies for cancer, monogenic and infectious disease are feasible and can lead to long-term benefit for patients. However, these trials have been limited to proof-of-principle and were conducted on modest numbers of patients or over long periods of time. In order for these studies to move towards standard practice and commercialization, scalable technologies for the isolation, ex vivo manipulation and delivery of these cells to patients must be developed. Additionally, regulatory strategies and clinical protocols for the collection, creation and delivery of cell products must be generated. In this article we review recent progress in hematopoietic cell and gene therapy, describe some of the current issues facing the field and discuss clinical, technical and regulatory approaches used to navigate the road to product development.
Collapse
Affiliation(s)
- David L Digiusto
- Department of Virology and Laboratory for Cellular Medicine, Beckman Research Institute of the City of Hope, Duarte, California 91010, USA.
| | | |
Collapse
|
32
|
Rivat C, Santilli G, Gaspar HB, Thrasher AJ. Gene therapy for primary immunodeficiencies. Hum Gene Ther 2012; 23:668-75. [PMID: 22691036 DOI: 10.1089/hum.2012.116] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
For over 40 years, primary immunodeficiencies (PIDs) have featured prominently in the development and refinement of human allogeneic hematopoietic stem cell transplantation. More recently, ex vivo somatic gene therapy using autologous cells has provided remarkable evidence of clinical efficacy in patients without HLA-matched stem cell donors and in whom toxicity of allogeneic procedures is likely to be high. Together with improved preclinical models, a wealth of information has accumulated that has allowed development of safer, more sophisticated technologies and protocols that are applicable to a much broader range of diseases. In this review we summarize the status of these gene therapy trials and discuss the emerging application of similar strategies to other PIDs.
Collapse
Affiliation(s)
- Christine Rivat
- UCL Institute of Child Health, Centre for Immunodeficiency, London WCIN 1EH, United Kingdom
| | | | | | | |
Collapse
|
33
|
Greene MR, Lockey T, Mehta PK, Kim YS, Eldridge PW, Gray JT, Sorrentino BP. Transduction of human CD34+ repopulating cells with a self-inactivating lentiviral vector for SCID-X1 produced at clinical scale by a stable cell line. Hum Gene Ther Methods 2012; 23:297-308. [PMID: 23075105 DOI: 10.1089/hgtb.2012.150] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Self-inactivating (SIN)-lentiviral vectors have safety and efficacy features that are well suited for transduction of hematopoietic stem cells (HSCs), but generation of vector at clinical scale has been challenging. Approximately 280 liters of an X-Linked Severe Combined Immunodeficiency Disorder (SCID-X1) SIN-lentiviral vector in two productions from a stable cell line were concentrated to final titers of 4.5 and 7.2×10(8) tu/ml. These two clinical preparations and three additional development-scale preparations were evaluated in human CD34(+) hematopoietic cells in vitro using colony forming cell (CFU-C) assay and in vivo using the NOD/Lt-scid/IL2Rγ(null) (NSG) mouse xenotransplant model. A 40-hour transduction protocol using a single vector exposure conferred a mean NSG repopulating cell transduction of 0.23 vector genomes/human genome with a mean myeloid vector copy number of 3.2 vector genomes/human genome. No adverse effects on engraftment were observed from vector treatment. Direct comparison between our SIN-lentiviral vector using a 40-hour protocol and an MFGγ(c) γ-retroviral vector using a five-day protocol demonstrated equivalent NSG repopulating cell transduction efficiency. Clonality survey by linear amplification-mediated polymerase chain reaction (LAM-PCR) with Illumina sequencing revealed common clones in sorted myeloid and lymphoid populations from engrafted mice demonstrating multipotent cell transduction. These vector preparations will be used in two clinical trials for SCID-X1.
Collapse
Affiliation(s)
- Michael R Greene
- Department of Hematology, St. Jude Children's Hospital, Memphis, TN 38105, USA.
| | | | | | | | | | | | | |
Collapse
|
34
|
Abstract
Retroviral vector-mediated gene transfer into hematopoietic stem cells provides a potentially curative therapy for severe β-thalassemia. Lentiviral vectors based on human immunodeficiency virus have been developed for this purpose and have been shown to be effective in curing thalassemia in mouse models. One participant in an ongoing clinical trial has achieved transfusion independence after gene transfer into bone marrow stem cells owing, in part, to a genetically modified, dominant clone. Ongoing efforts are focused on improving the efficiency of lentiviral vector-mediated gene transfer into stem cells so that the curative potential of gene transfer can be consistently achieved.
Collapse
|
35
|
Cavazzana-Calvo M, Fischer A, Hacein-Bey-Abina S, Aiuti A. Gene therapy for primary immunodeficiencies: Part 1. Curr Opin Immunol 2012; 24:580-4. [PMID: 22981681 DOI: 10.1016/j.coi.2012.08.008] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Accepted: 08/23/2012] [Indexed: 10/27/2022]
Abstract
Over 60 patients affected by SCID due to IL2RG deficiency (SCID-X1) or adenosine deaminase (ADA)-SCID have received hematopoietic stem cell gene therapy in the past 15 years using gammaretroviral vectors, resulting in immune reconstitution and clinical benefit in the majority of them. However, the occurrence of insertional oncogenesis in the SCID-X1 trials has led to the development of new clinical trials based on integrating vectors with improved safety design as well as investigation on new technologies for highly efficient gene targeting and site-specific gene editing. Here we will present the experience and perspectives of gene therapy for SCID-X1 and ADA-SCID and discuss the pros and cons of gene therapy in comparison to allogeneic transplantation.
Collapse
|
36
|
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.
Collapse
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.
| | | | | | | |
Collapse
|
37
|
Fischer A, Hacein-Bey-Abina S, Cavazzana-Calvo M. Strategies for retrovirus-based correction of severe, combined immunodeficiency (SCID). Methods Enzymol 2012; 507:15-27. [PMID: 22365767 DOI: 10.1016/b978-0-12-386509-0.00002-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Severe combined immunodeficiencies (SCIDs) appear as optimal disease targets to challenge potential efficacy of gene therapy. Ex vivo, retrovirally mediated gene transfer into hematopoietic progenitor cells has been shown to provide sustained correction of two forms of SCID, that is, SCID-X1 and adenosine deaminase deficiencies. In the former case, however, genotoxicity was observed in a minority of patients as a consequence of retroviral integration into proto-oncogenes loci and transactivation. Design of vectors in which the enhancer element of retroviral LTR has been deleted and an internal promoter added (self-inactivated vectors) could provide both safe and efficient gene transfer as being presently tested.
Collapse
|
38
|
Gaspar HB, Cooray S, Gilmour KC, Parsley KL, Adams S, Howe SJ, Al Ghonaium A, Bayford J, Brown L, Davies EG, Kinnon C, Thrasher AJ. Long-term persistence of a polyclonal T cell repertoire after gene therapy for X-linked severe combined immunodeficiency. Sci Transl Med 2012; 3:97ra79. [PMID: 21865537 DOI: 10.1126/scitranslmed.3002715] [Citation(s) in RCA: 147] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
X-linked severe combined immunodeficiency (SCID-X1) is caused by mutations in the common cytokine receptor γ chain. These mutations classically lead to complete absence of functional T and natural killer cell lineages as well as to intrinsically compromised B cell function. Although human leukocyte antigen (HLA)-matched hematopoietic stem cell transplantation (HSCT) is highly successful in SCID-X1 patients, HLA-mismatched procedures can be associated with prolonged immunodeficiency, graft-versus-host disease, and increased overall mortality. Here, 10 children were treated with autologous CD34(+) hematopoietic stem and progenitor cells transduced with a conventional gammaretroviral vector. The patients did not receive myelosuppressive conditioning and were monitored for immunological recovery after cell infusion. All patients were alive after a median follow-up of 80 months (range, 54 to 107 months), and a functional polyclonal T cell repertoire was restored in all patients. Humoral immunity only partially recovered but was sufficient in some patients to allow for withdrawal of immunoglobulin replacement; however, three patients developed antibiotic-responsive acute pulmonary infection after discontinuation of antibiotic prophylaxis and/or immunoglobulin replacement. One patient developed acute T cell acute lymphoblastic leukemia because of up-regulated expression of the proto-oncogene LMO-2 from insertional mutagenesis, but maintained a polyclonal T cell repertoire through chemotherapy and entered remission. Therefore, gene therapy for SCID-X1 without myelosuppressive conditioning effectively restored T cell immunity and was associated with high survival rates for up to 9 years. Further studies using vectors designed to limit mutagenesis and strategies to enhance B cell reconstitution are warranted to define the role of this treatment modality alongside conventional HSCT for SCID-X1.
Collapse
Affiliation(s)
- H Bobby Gaspar
- Centre for Immunodeficiency, Molecular Immunology Unit, Institute of Child Health, University College London, London WC1N 1EH, UK
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
39
|
Systemic delivery of scAAV9 in fetal macaques facilitates neuronal transduction of the central and peripheral nervous systems. Gene Ther 2012; 20:69-83. [DOI: 10.1038/gt.2011.216] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
|
40
|
|
41
|
Abstract
PURPOSE OF REVIEW Haematopoietic stem cell transplantation (HSCT) is the mainstay of definitive treatment for children with a wide spectrum of primary immunodeficiencies (PIDs), but outcome is heavily dependent on the availability of a human leukocyte antigen-matched donor. Gene therapy using autologous gene-corrected haematopoietic stem cells is an alternative for patients who lack an appropriate donor and has been used to treat children and adults with specific forms of PID, such as severe combined immunodeficiency, for over 10 years. This review summarizes the encouraging long-term outcome data available from these clinical trials and considers the important adverse events that have arisen. Current strategies directed towards improving the efficacy and safety profile of gene therapy will be discussed. RECENT FINDINGS Effective clinical trials have been conducted for other forms of PID including chronic granulomatous disease and Wiskott-Aldrich syndrome. Preclinical and clinical studies are now focussed on the development of improved viral vectors giving more regulated or tissue-specific transgene expression with reduced mutagenic potential. SUMMARY Gene therapy offers a valuable alternative management option for selected immunodeficiency patients who lack a suitable donor for HSCT. Clinical trials have confirmed proof-of-principle in terms of stem cell transduction and subsequent immune reconstitution, but have also highlighted the potential for clonal disturbances related to semi-random vector insertion within the genome.
Collapse
|
42
|
Fischer A, Hacein-Bey-Abina S, Cavazzana-Calvo M. Gene therapy for primary adaptive immune deficiencies. J Allergy Clin Immunol 2011; 127:1356-9. [PMID: 21624615 DOI: 10.1016/j.jaci.2011.04.030] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Revised: 04/21/2011] [Accepted: 04/21/2011] [Indexed: 01/15/2023]
Abstract
Gene therapy has become an option for the treatment of 2 forms of severe combined immunodeficiency (SCID): X-linked SCID and adenosine deaminase deficiency. The results of clinical trials initiated more than 10 years ago testify to sustained and reproducible correction of the underlying T-cell immunodeficiency. Successful treatment is based on the selective advantage conferred on T-cell precursors through their expression of the therapeutic transgene. However, "first-generation" retroviral vectors also caused leukemia in some patients with X-linked SCID because of the constructs' tendency to insert into active genes (eg, proto-oncogenes) in progenitor cells and transactivate an oncogene through a viral element in the long terminal repeat. These elements have been deleted from the vectors now in use. Together with the use of lentiviral vectors (which are more potent for transducing stem cells), these advances should provide a basis for the safe and effective extension of gene therapy's indications in the field of primary immunodeficiencies. Nevertheless, this extension will have to be proved by examining the results of the ongoing clinical trials.
Collapse
|
43
|
Gammaretroviral vectors: biology, technology and application. Viruses 2011; 3:677-713. [PMID: 21994751 PMCID: PMC3185771 DOI: 10.3390/v3060677] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2011] [Revised: 05/03/2011] [Accepted: 05/09/2011] [Indexed: 12/11/2022] Open
Abstract
Retroviruses are evolutionary optimized gene carriers that have naturally adapted to their hosts to efficiently deliver their nucleic acids into the target cell chromatin, thereby overcoming natural cellular barriers. Here we will review—starting with a deeper look into retroviral biology—how Murine Leukemia Virus (MLV), a simple gammaretrovirus, can be converted into an efficient vehicle of genetic therapeutics. Furthermore, we will describe how more rational vector backbones can be designed and how these so-called self-inactivating vectors can be pseudotyped and produced. Finally, we will provide an overview on existing clinical trials and how biosafety can be improved.
Collapse
|
44
|
Hendriks RW, Bredius RG, Pike-Overzet K, Staal FJ. Biology and novel treatment options for XLA, the most common monogenetic immunodeficiency in man. Expert Opin Ther Targets 2011; 15:1003-21. [PMID: 21635151 DOI: 10.1517/14728222.2011.585971] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION X-linked agammaglobulinemia (XLA) is the most common primary immunodeficiency in man, and is caused by a single genetic defect. Inactivating mutations in the Bruton's tyrosine kinase (BTK) gene are invariably the cause of XLA,. XLA is characterized by a differentiation arrest at the pre-B cell stage, the absence of immunoglobulins and recurrent bacterial infections, making it an insidious disease that gradually disables the patient, and can result in death due to chronic lung disease. Current treatment involves prophylactic antibiotics and immunoglobulin infusions, which are non-curative. This disease is a good candidate for curative hematopoietic stem cell (HSC)-based gene therapy, which could correct the B cell and myeloid deficiencies. AREAS COVERED This paper reviews the basic biology of BTK in B cell development, the clinical features of XLA, and the possibilities of gene therapy for XLA, covering the literature from 1995 to 2010. EXPERT OPINION Work from various laboratories demonstrates the feasibility of using gene-corrected HSCs to complement the immune defects of Btk-deficiency in mice. We propose that it is timely to start clinical programs to develop stem cell based therapy for XLA, using gene-corrected autologous HSC.
Collapse
Affiliation(s)
- Rudi W Hendriks
- Department of Pulmonary Medicine, Erasmus MC, Rotterdam, The Netherlands
| | | | | | | |
Collapse
|
45
|
Barese CN, Dunbar CE. Contributions of gene marking to cell and gene therapies. Hum Gene Ther 2011; 22:659-68. [PMID: 21261461 DOI: 10.1089/hum.2010.237] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
The first human genetic modification studies used replication-incompetent integrating vector vectors to introduce marker genes into T lymphocytes and subsequently into hematopoietic stem cells. Such studies have provided numerous insights into the biology of hematopoiesis and immune reconstitution and contributed to clinical development of gene and cell therapies. Tracking of hematopoietic reconstitution and analysis of the origin of residual malignant disease after hematopoietic transplantation has been possible via gene marking. Introduction of selectable marker genes has enabled preselection of specific T-cell populations for tumor and viral immunotherapy and reduced the threat of graft-versus-host disease, improving the survival of patients after allogeneic marrow transplantation. Marking studies in humans, murine xenografts, and large animals have helped optimize conditions for gene transfer into CD34(+) hematopoietic progenitors, contributing to the achievement of gene transfer efficiencies sufficient for clinical benefit in several serious genetic diseases such as X-linked severe combined immunodeficiency and adrenoleukodystrophy. When adverse events linked to insertional mutagenesis arose in clinical gene therapy trials for inherited immunodeficiencies, additional animal studies using gene-marking vectors have greatly increased our understanding of genotoxicity. The knowledge gained from these studies is being translated into new vector designs and clinical protocols, which we hope will continue to improve the efficiency, effectiveness and safety of these promising therapeutic approaches.
Collapse
Affiliation(s)
- Cecilia N Barese
- Hematology Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD 20852, USA
| | | |
Collapse
|
46
|
Langer B, Cichutek K. [Clinical application of gene therapy. Previous experience and the future]. PHARMAZIE IN UNSERER ZEIT 2011; 40:254-262. [PMID: 21698615 DOI: 10.1002/pauz.201100421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Barbara Langer
- Abteilung Medizinische Biotechnologie, Paul-Ehrlich-Institut, Langen
| | | |
Collapse
|
47
|
Fischer A, Hacein-Bey-Abina S, Cavazzana-Calvo M. Gene therapy for primary immunodeficiencies. Hematol Oncol Clin North Am 2011; 25:89-100. [PMID: 21236392 DOI: 10.1016/j.hoc.2010.11.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The concept of gene therapy emerged as a way of correcting monogenic inherited diseases by introducing a normal copy of the mutated gene into at least some of the patients' cells. Although this concept has turned out to be quite complicated to implement, it is in the field of primary immunodeficiencies (PIDs) that proof of feasibility has been undoubtedly achieved. There is now a strong rationale in support of gene therapy for at least some PIDs, as discussed in this article.
Collapse
Affiliation(s)
- Alain Fischer
- Developpement Normal et Pathologique du Systeme Immunitaire, INSERM U 768, Hopital Necker, 149 rue de Sevres, Paris, France
| | | | | |
Collapse
|
48
|
Grez M, Reichenbach J, Schwäble J, Seger R, Dinauer MC, Thrasher AJ. Gene therapy of chronic granulomatous disease: the engraftment dilemma. Mol Ther 2011; 19:28-35. [PMID: 21045810 PMCID: PMC3017455 DOI: 10.1038/mt.2010.232] [Citation(s) in RCA: 116] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2010] [Accepted: 09/28/2010] [Indexed: 12/13/2022] Open
Abstract
The potential of gene therapy as a curative treatment for monogenetic disorders has been clearly demonstrated in a series of recent Phase I/II clinical trials. Among primary immunodeficiencies, gene transfer into hematopoietic stem (HSC)/progenitor cells has resulted in the long-term correction of immune and metabolic defects in treated patients. In most cases, successes were augmented by a recognized biological selection for successfully treated cells in vivo, perhaps even to some extent at the HSC level. In contrast, similar achievements have not turned into reality for immunodeficiencies in which gene-transduced cells lack selective advantages in vivo. This is the case for chronic granulomatous disease (CGD), a primary immunodeficiency, characterized by deficient antimicrobial activity in phagocytic cells. Several attempts to correct CGD by gene transfer in combination with bone marrow conditioning have resulted in low-level long-term engraftment and transient clinical benefits despite high levels of gene marking and high numbers of reinfused cells. This review summarizes the data from clinical trials for CGD and provides some insights into treatment options that may lead to a successful application of gene therapy for CGD.
Collapse
Affiliation(s)
- Manuel Grez
- Institute for Biomedical Research, Georg-Speyer-Haus, Frankfurt, Germany.
| | | | | | | | | | | |
Collapse
|
49
|
Fischer A, Hacein-Bey-Abina S, Cavazanna-Calvo M. Gene Therapy for Primary Immunodeficiencies. Immunol Allergy Clin North Am 2010; 30:237-48. [DOI: 10.1016/j.iac.2010.02.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
50
|
De Ravin SS, Malech HL. Partially corrected X-linked severe combined immunodeficiency: long-term problems and treatment options. Immunol Res 2009; 43:223-42. [PMID: 18979075 DOI: 10.1007/s12026-008-8073-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Rapid progress has been made from the identification of the molecular defects causing X-linked severe combined immune deficiency (X-SCID) to the development of cutting-edge therapeutic approaches such as hematopoietic stem cell transplant and gene therapy for XSCID. Successful treatment of XSCID has created a new population of patients, many of whom are now adolescents and young adults and are facing a variety of chronic problems secondary to partial correction of their underlying disease. This review focuses on the clinical challenges facing these patients (and their caregivers) and provides an overview of some of the treatment options available, including gene therapy.
Collapse
Affiliation(s)
- Suk See De Ravin
- Genetic Immunotherapy, Laboratory of Host Defense, National Institutes of Health, Building 10, Room 5-3816, 5 West Labs CRC, 10 Center Drive MSC1456, Bethesda, MD 20892-1456, USA.
| | | |
Collapse
|