New Gene Therapy for Hemophilia


According to a multi-year, ongoing study, a new kind of gene therapy for hemophilia B could be safe and effective for human patients.

“The result was stunning,” said Timothy Nichols, MD, director of the Francis Owen Blood Research Laboratory at the University of North Carolina School of Medicine and co-senior author of the paper. “Just a small amount of new factor IX necessary for proper clotting produced a major reduction in bleeding events. It was extraordinarily powerful.”

Nichols published his work in the journal Science Translational Medicine, in which he showed that a genetically engineered retrovirus could successfully transfer new factor IX (clotting) genes into animals with hemophilia B to dramatically decrease spontaneous bleeding. To date, the new therapy has proven safe.

A new FDA-approved hemophilia treatment lasts longer than a few days but patients still require injections indefinitely at least once or twice a month. This new gene therapy only requires hemophilia patients to receive a one-time dose of new clotting genes instead of a lifetime of multiple injections of recombinant factor IX. This new gene therapy approach would involve a single injection and could potentially save money and provide a long-term solution to a life-long condition. A major potential advantage of this new gene therapy approach is that it uses lentiviral vectors, to which most people do not have antibodies that would reject the vectors and make the therapy less effective.

In human clinical studies, approximately 40 percent of the potential participants with hemophilia have antibodies in their blood against adeno-associated virus (AAV), which precludes them from entering AAV trials for hemophilia gene therapy treatment. Thus more people could potentially benefit from the lentivirus gene therapy approach.

Hemophilia is a bleeding disorder in which people lack a clotting factor. Therefore they bleed much more easily than people without the disease. People with hemophilia often bleed spontaneously into joints, which can be extremely painful and crippling. Spontaneous bleeds into soft tissues are also common and can be fatal if not treated promptly. Hemophilia A affects about one in 5,000 male births. These patients do not produce enough factor VIII in the liver. This leads to an inability to clot. Hemophilia B affects about one in 35,000 births; these patients lack factor IX.

The new method detailed in the Science Translational Medicine paper was spearheaded by Luigi Naldini, PhD, director of the San Raffaele Telethon Institute for Gene Therapy. Naldini and Nichols developed a way to use a lentivirus, a large retrovirus, to deliver factor IX genes to the livers of three dogs that have a naturally occurring form of hemophilia. They removed the genes involved in viral replication. “Essentially, this molecular engineering rendered the virus inert,” Nichols said. “It had the ability to get into the body but not cause disease.” This process turned the virus into a vector – simply a vehicle to carry genetic cargo.

Unlike some other viral vectors that have been used for gene therapy experiments, the lentiviral vector is so large that it can carry a large payload – namely, the clotting factor IX genes that people with hemophilia B lack. (This approach could also be used for hemophilia A where the FVIII gene is considerably larger.)

These viral vectors were then injected directly into the liver or intravenously. After more than three years, the three dogs in the study experienced zero or one serious bleeding event each year. Before the therapy, the dogs experienced an average of five spontaneous bleeding events that required clinical treatment. Importantly, the researchers detected no harmful effects.

“This safety feature is of paramount importance,” Nichols said. “Prior work elsewhere during the early 2000s used retroviruses for gene therapy to treat people with Severe Combined Immunodeficiency, but some patients in clinical trials developed leukemia.” Newer retroviral vectors, though, have so far proved safe for SCID patients.

To further demonstrate the safety of this new hemophilia treatment, Nichols and Naldini used three different strains of mice that were highly susceptible to developing complications, such as malignancies, when injected with lentiviruses. Fortunately, Nichols, Naldini and their coworkers found no harmful effects in these mice. Thus manipulating lentiviruses and converting them into lentiviral vectors made them safe for gene therapy.

“Considering the mouse model data and the absence of detectible genotoxicity during long-term expression in the hemophilia B dogs, the lentiviral vectors have a very encouraging safety profile in this case,” Nichols said.

This gene therapy approach requires more work before it can be used in human trials. For instance, researchers hope to increase the potency of the therapy to decrease spontaneous bleeding even more while also keeping the therapy safe.

Before the treatment, the hemophilia dogs had no sign of factor IX production. After the treatment, they exhibited between 1 and 3 percent of the production found in normal dogs. This slight increase was enough to substantially decrease bleeding events.

Nichols wants to try to boost factor IX production to between 5 and 10 percent of normal while still remaining safe. This amount of factor IX expression could potentially eliminate spontaneous bleeding events for people with hemophilia B.

Stem Cell Gene Therapy For An Inherited Neurological Disease


Scientists at the University of Manchester in the United Kingdom have used stem cell gene therapy to treat a fatal genetic brain disease in mice. Sanfilippo is a fatal, inherited condition that causes progressive dementia in children. This particular treatment strategy could also be used to treat other types of neurological, inherited diseases. The Manchester team hopes to bring this strategy to a clinical trial within two years.

Sanfilippo afects one in 89,000 children in the United Kingdom and is an untreatable “mucopolysaccharide disease ” or MPS disease. MPS diseases involve an abnormal storage of mucopolysaccharides. This abnormal storage results from the absence of a specific enzyme. Without the enzyme, the breakdown process of mucopolysaccharides is incomplete. Partially broken down mucopolysaccharides accumulate in the body’s cells causing progressive damage. The storage process can affect appearance, development, and the function of various organs of the body. Each MPS disease is caused by the deficiency of a specific enzyme.

Patients with Sanfilippo are unable to degrade heparan sulfate. There are four different types of Sanfilippo, which is also called MPS type III. MPS type IIIA results from a deficiency in the enzyme N-sulfoglucosamine sulfohydrolase, MPS type IIIB lacks N-Acetylglucosaminidase, MPS type IIIC has an absence in Acetyl-CoA:alpha-glucosaminide-acetyltransferase, and MPS type IIID lacks N-acetylglucosamine 6-sulphatase. In all four forms of MPS III, excessive heparan sulphate storage occurs in the brain, leading to its progressive deterioration; the amount of heparan sulphate storage in other tissues influences the extent of physical symptoms. Children eventually lose the ability to walk and swallow.

Brian Bigger from the University of Manchester’s Institute of Human Development led this research into therapies for MPS type IIIA. According to Bigger, bone marrow transplants have been used to treat similar diseases (e.g., Hurler syndrome). In this case, gene therapy was used to introduce the missing enzyme into the transplanted cells. Unfortunately, this did not work terribly well because the white blood cells from the bone marrow did not make enough of the enzyme to treat the disease.

A fraction of the white blood cells made bone marrow are called monocytes, and some of the monocytes traffic to the brain to become microglia. Since microglia are made by hematopoietic stem cells (HSCs) in the bone marrow, genetic engineering of cultured HSCs should increase expression of the missing enzyme in microglia. In previous experiments, HSCs were engineered with viruses to express the missing enzyme, but this expression was poor in microglia.

To fix this problem, Bigger and his team increased enzyme expression in the engineered HSCs in bone marrow. They used a gene control region from the “pyruvate kinase” gene, which is a very highly expressed gene. This increased expression of the missing enzyme to five times the normal levels and to 11% of normal levels in the microglia cells in the brain. The enzyme

This type of treatment corrects the inflammation in the brain and completely corrects the hyperactivity behavior in mice with Sanfilippo. Bigger adds, “We now hope to work to a clinical trial in Manchester in 2015.”

Bigger and his colleagues are manufacturing a viral vector to deliver genetic material into cells for use in humans and they hope to use this in a clinical trial with patients at Central Manchester University Hospital NHS Foundation Trust by 2015.

This stem cell gene therapy approach was recently shown by Italian scientists to improve conditions in patients with a similar disease that affects the brain called metachromatic leukodystrophy. Bigger refined the vector used bythe Italian group.

According to Bigger, this approach might have the potential to treat several neurological genetic diseases.

Stem Cell Gene Therapy for Sickle Cell Disease Moves Toward Clinical Trials


UCLA stem cell researchers and “gene jockeys” have successfully proven the efficacy of using genetically engineered hematopoietic (blood cell-making) stem cells from a patient’s own bone marrow to treat sickle-cell disease (SCD).

In a study led by Donald Kohn, professor of pediatrics and microbiology at the UCLA Eli & Edythe Broad Center of Regenerative Medicine & Stem Cell Research, an “anti-sickling” gene was introduced into the hematopoietic stem cells (HSCs) from patients with SCD. Because the HSCs divide continuously throughout the life of the individual, all the blood cells they make will possess the anti-sickling gene and will therefore no sickle. This breakthrough gene therapy technique is scheduled to begin clinical trials by early 2014.

SCD results from a specific mutation in the beta-globin gene. Beta-globin is one of the two proteins that makes the multisubunit protein hemoglobin. Hemoglobin is a four-subunit protein that ferries oxygen from the lungs to the tissues and carbon dioxide from the tissues to the lungs. It is tightly packed into each red blood cell.

The structure of hemoglobin, each subunit is in a different color.
The structure of hemoglobin, each subunit is in a different color.

Hemoglobin has a very high affinity for oxygen when oxygen concentrations are high, but a low affinity for oxygen when oxygen concentrations are low. Therefore, hemoglobin does a very good job of binding oxygen when it is in the lungs, where oxygen is plentiful, and a very good job of releasing oxygen in the tissues, where oxygen is not nearly as plentiful. This adaptive ability displayed by hemoglobin is the result of cooperativity between the four polypeptide chains that compose hemoglobin. Two of these polypeptide chains are alpha-globin proteins and the other two a beta globin proteins. Hemoglobin acts as though it is an alpha-beta dimer, or as though it is composed of two copies of an alpha-globin.beta-globin pair. The interactions between these polypeptide chains and the movement of the hemoglobin subunits relative to each other creates the biochemical properties of hemoglobin that are so remarkable.

A mutation in the beta-globin gene that substitutes a valine residue where there should be a glutamic acid residue (position number 6), creates a surface on the outside of the beta-globin subunit that does not like water, and when oxygen concentrations drops, the mutant hemoglobin molecule changes shape and this new water-hating surface becomes a site for protein polymerization.

Sickle cell hemoglobin

The mutant hemoglobin molecules for long, stiff chains that deform the red blood cells into a quarter moon-shaped structure that clogs capillaries.

Sickle cell RBCs

 

This new therapy seeks to correct the genetic mutation by inserting into the genome of the HSC that makes the abnormal red blood cells a gene for beta-globin that encodes a normal version of beta globin rather than a version of it that causes sickle-cell disease.  By introducing those engineered HSCs back into the bone marrow of the SCD patient, the engineered HSCs will make normal red blood cells that do not undergo sickling under conditions of low oxygen concentration.

Dr. Kohn noted that the results from his research group “demonstrate that our technique of lentiviral transduction is capable of efficient transfer and consistent expression of an effective anti-sickling beta-globnin gene in human SCD bone marrow progenitor cells, which improved the physiologic parameters of the resulting red blood cells.” Dr. Kohn’s statement may lead the reader to believe that this was done in a human patient, but that is not the case.  All this work was done in culture and in laboratory animals.

Kohn and his co-workers showed that in laboratory experiments, genetically engineered HSCs from SCD patients produced new non-sickled blood cells at a rate that would effectively allow SCD patients to show significant clinical improvement.  These new red blood cells also survived longer than those made by the nonengineered SCD HSCs.  The in vitro success of this technique has convinced the US Food and Drug Administration to grant Kohn the right to conduct clinical trials in SCD patients by early next year.

SCD affects more than 90,000 patients in the US, but it most affects people of sub-saharan African descent.  As stated before, the mutation that causes SCD produces red blood cells that are stiff, long, and get stuck in the tiny blood vessels known as capillaries that feed organs.  SCD causes multi-organ dysfunction and failure and can lead to death.

Sickle_cell_01

Treatment of SCD include bone marrow transplants, but immunological rejection of such transplants remains a perennial problem.   The success rate of bone marrow transplants is low and it is typically restricted to those patients with very severe disease who are on the verge of dying.

If Kohn’s clinical trials are successful, this stem cell-based treatment will hopefully become the gold standard for treatment of patients with SCD.  One potential problem with this technique is the use of lentiviral vectors to introduce a new gene into the HSCs.  Because lentiviruses are retroviruses, they insert their DNA into the genome of the host cells.  Such insertions can produce mutations, and it will be incumbent on Kohn and his colleagues to carefully screen each transformed HSC line to ensure that the insertion is not problematic and that the transformed cells are not sick or potentially tumorous.  However, such a vector is necessary in order to ensure permanent residence of the newly-introduced gene.

Even with these caveats, Kohn’s SCD treatment should go forward, and we wish all the best to Dr. Kohn, his team, and to the patients treated in this trial.