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Gene therapy and therapeutic gene editing: what are the predictors of success?
Bobby Gaspar
Professor of Paediatrics and Immunology
Centre for Immunodeficiency
UCL Institute of Child Health/Great Ormond Street NHS Trust
Gene therapy and paediatric conditions
Cystic fibrosis
Duchenne’s MD
Inborn errorsOCT, HurlersX-ALD
Retinalabnormalities
Haemophilia Severeimmunodeficiencies
Skin conditionsEB
Fanconi’s anaemiaHaemoglobinopathiesAcute leukaemias
Primary Immunodeficiency
red blood cell
platelets
white blood cells neutrophils /monocytes
white blood cells / Immune cells
stem cells
Virus
Bacteria
Fungi
Pneumonia, diarrhoea, repeated infections
Severe combined immunodeficiency (SCID)
T B NK
HSC-multi
SCID/CID
c, IL7Ra, JAK3, ZAP-70RAG1/2, artemis, ligase IV,CernunnosADA, PNPMHC I/II, CD3//, CD45,ORAI1
Molecular defects in SCID
How do we get genes into cells?
Disabled viruses
Adenovirus
Adeno-associated virus
Non-viral vectors
Retrovirus
X
Stem cells
lymphocytes
B
BloodBone marrow
T
NK
ThymusXIn X-SCID growth of lymphocytes is blocked
a bg
Pathology of SCID-X1
MoLV U5U5 Y
RSD SA
RQ
IL2RG
LTR-driven gammaretroviral vector: MFG gC
MoLV
Criteria for entry:No matched sibling donorMolecularly confirmed diagnosis
Common gamma chain vector:PG 13 producer cells (GALV envelope)titre approximately 1x10e6 transducing units per ml
SCID-X1 gene therapy protocol
Lymphocyte recovery CD3
0 50 100 150 200 250 300
0
1000
2000
3000
4000
5000
P1
P2
P3
P4
P5
P6P7
P8
P10T L
ym
ph
ocyte
s/µ
l
Weeks
P9
Patient details
Age at therapy
(months)
Maternal graft
Mutation Gamma chain expression
Total cells infused(x10e6)
P1 10 ++ R289X ++ 180 A+W
P2 10 ++ S238N - 180 A+W
P3 4 - Y125C +/- 78 A+W
P4 3y - R289X ++ 115 A+W
P5 10 - R222C ++ 200 A+W
P6 10 - PolyA - 200 A+W
P7 6 - M1i - 84 A+W
P8 13 - C182Y + 207 A+W
P9 7 - S108P + 160 A+W
P10 12 - del - 60 A+W
Currentstatus
Biochemical defect in ADA deficiency
DNA
d-adenosine d-adenosine d-inosine
d-adenosine
d-ATPincrease is toxic to lymphocyte function
dCydK
ADA
T cell recovery post ADA gene therapy
Pre-diagnosis Pre-GT Post-GT0
10
20
30
40
50
AD
A A
cti
vit
y (n
mo
l/m
gH
b/h
)
Pre-diagnosis Pre-GT Post-GT0
20
40
60
80
800
1000
1200
1400
1600
dA
TP (
mm
ol/
L)
Metabolic correction post gene therapy
Summary of ADA-Deficient SCID Patients Retroviral Vectors, Myeloreductive Conditioning–Milan/London/CHLA-NHGRI, NIH-UCLA
Center # Pts F/U (yrs)1 Off Enzyme Survival DFS2
Milan 18 0.8 – 11.5 15/18 100% 83.3%
London 8 0.5 – 7.5 4/8 100% 50%
CHLA-NHGRIUCLA-NHGRI
68
2– 50.1-2
3/67/8
100%100%
50%87.5%
TOTAL 40 0.1 – 11.5 29/40 100% 72.5%
1 As of April 20122DFS ≡ Alive without BMT or PEG-ADA re-start
Data: Courtesy HB Gaspar (London) and Alessandro Aiuti (Milan)
Patient details
Age at therapy(months)
Maternal graft
Mutation Gamma chain expression
Total cells infused(x10e6)
P1 10 ++ R289X ++ 180 A+W
P2 10 ++ S238N - 180 A+W
P3 4 - Y125C +/- 78 A+W
P4 3y - R289X ++ 115 A+W
P5 10 - R222C ++ 200 A+W
P6 10 - PolyA - 200 A+W
P7 6 - M1i - 84 A+W
P8 13 - C182Y + 207 A+W
P9 7 - S108P + 160 A+W
P10 12 - del - 60 A+W
Currentstatus
LMO2 CAPRIN1 NAT10CD59 FBXO3
Forward Strand
Chromosome 11p13
33.65Mb 33.85Mb 34.05Mb
ABTB2C11orf41
X
VIRUS INTEGRATION
Fold difference in gene expression
0.1
1
10
100
C11orf41 CD59 FBXO3 LMO2 CAPRIN1 Nat10 ABTB2
Gene
Difference
Leukemia
DP1 T cells
DP2 T cells
Fold difference in gene expression
0.1
1
10
100
C11orf41 CD59 FBXO3 LMO2 CAPRIN1 Nat10 ABTB2
Gene
Difference
Leukemia
DP1 T cells
DP2 T cells
Fold difference in gene expression
0.1
1
10
100
C11orf41 CD59 FBXO3 LMO2 CAPRIN1 Nat10 ABTB2
Gene
Differenc
e
Leukemia
DP1 T cells
DP2 T cells
Fold difference in gene expression
0.1
1
10
100
C11orf41 CD59 FBXO3 LMO2 CAPRIN1 Nat10 ABTB2
Gene
Difference
Leukemia
DP1 T cells
DP2 T cells
Fold difference in gene expression
0.1
1
10
100
C11orf41 CD59 FBXO3 LMO2 CAPRIN1 Nat10 ABTB2
Gene
Differenc
e
Leukemia
DP1 T cells
DP2 T cells
Fold difference in gene expression
0.1
1
10
100
C11orf41 CD59 FBXO3 LMO2 CAPRIN1 Nat10 ABTB2
Gene
Difference
Leukemia
DP1 T cells
DP2 T cells
Fold difference in gene expression
0.1
1
10
100
C11orf41 CD59 FBXO3 LMO2 CAPRIN1 Nat10 ABTB2
Gene
Difference
Leukemia
DP1 T cells
DP2 T cells
Fold difference in gene expression
0.1
1
10
100
C11orf41 CD59 FBXO3 LMO2 CAPRIN1 Nat10 ABTB2
Gene
Difference
Leukemia
DP1 T cells
DP2 T cells
Fold
Diff
ere
nce
Fold difference in gene expression
0.1
1
10
100
C11orf41 CD59 FBXO3 LMO2 CAPRIN1 Nat10 ABTB2
Gene
Difference
Leukemia
DP1 T cells
DP2 T cells
Relative to:Leukaemia panel
DP1 T cellsDP2 T cells
Activation of LMO2
MoLV U5U5 Y
RSD SA
RQ
IL2RG
LTR-driven gammaretroviral vector: MFG gC
MoLV
U5U5 Y
R RQ
MP ΔSD
PREProm. IL2RG
EF1(S)SF
RSV
New gammaretroviral SIN vectors: Sin11 / SRS11
Development of a new vector for SCID-X1
SF EFS SF.HS
P < 0.001
detection limit
Control Cohort Survival (n=14)
0 100 200 300 4000
20
40
60
80
100
Days
Per
cen
t su
rviv
al
23/24 mice long term survival
Reduced mutagenesis with SIN configuration
Gene transfer for SCID-X1 using a self-inactivating (SIN)
gammaretroviral vectorA multi-institutional phase I/II trial evaluating
the treatment of SCID-X1 patients with retrovirus-mediated gene transfer
Sites:Great Ormond Street Hospital, UK (1)
Hôpital Necker Enfants Malades, France (4)Children’s Hospital Boston, US (2)
Cincinnati Children’s Hospital Medical Center, USMattel Children’s Hospital, Los Angeles, US (1)
Lentiviral vector gene therapy for ADA-SCID
Phase I/II, non-controlled, open-label, nonrandomised, trial to assess the
safety and efficacy of EF1αS-ADA lentiviralvector mediated gene modification of
autologousCD34+ cells from ADA-deficient individuals
Sites:Great Ormond Street Hospital, UK (2)
Mattel Children’s Hospital, Los Angeles, US
Vector production:Indiana University Vector Production Facility
Testing of efficacy and safety
Phase I/II study of 10 patients
Development of vector
January 2007 July 2009 December 2012 January 2018
MRC Research Grant MRC DPFS MRC DCS
Lentiviral vector mediated Gene Therapy for ADA SCID
Collaborations:UCLAIndiana University Vector Production Facility
1st patient treated Feb 20123 patients treated in total
LV Phase I/II trial for Wiskott-Aldrich syndrome
Lentiviral Vector for CGD
Prov irus pC C L c him GP91 W PR E45 4 8 7 b p
G P 91cP P T cts
HIV 1 p si W P RE * (P RE 4)
d el taU3
d el taU3
HIV 1 R HIV 1-p o lyA
HIV 1 P BS
Ch im eric p ro mo ter
HIV 1 RRE
HIV U5 HIV 1 R
HIV U5
Therapeutic gene editing
Gene therapy and paediatric conditions
Cystic fibrosis
Duchenne’s MD
Inborn errorsOCT, HurlersX-ALD
Retinalabnormalities
Haemophilia Severeimmunodeficiencies
Skin conditionsEB
Fanconi’s anaemiaHaemoglobinopathiesAcute leukaemias
Cures now available for specific SCID conditions
First ever cures with Gene Therapy
Morbidity and mortality still low compared to other treatments and prev innovations
Need new safer vectors
Each disease should be considered individually (gene regulation, expression, tissue specificity)
Gene therapy in PID
Great Ormond Street Hospital
Paul VeysPersis AmroliaKanchan RaoGraham DaviesAlison JonesCathy CaleLesley HendersonJane GasparJin Hua Xu-BayfordLucie BrownNursing and support staff
Jude CopeJodi New
Institute of Child HealthEmma BjorkerenKate ParsleyKimberly GilmourSam CoorayElena de FalcoJo SinclairDoug KingSteve HoweStuart AdamsSuzy ThornhillMichelle QuayeDaleen Lopez-BeggSue SwiftFang ZhangLin ZhangClaudia Montiel EquihaMaria Alonso-FerreroMarlene CarmoChristine RivatClaire BoothKaren BucklandSue SwiftNourredine HimoudiAnne-Marie McNicol
Purine Res Lab, Guys Hospital Lynette Fairbanks
ManchesterBrian BiggerFiona Wilkinson
Collaborators
Chris BaumAxel SchambachChristof von KalleManfred Schmidt
Mik AntoniouMarina Cavazzana-CalvoAlain FischerDavid WilliamsManuel GrezVicky BordonTheoni Petropolou
Many thanks to
Adrian ThrasherBobby Gaspar