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Transcript of 基因治疗 张咸宁 [email protected] Tel : 13105819271; 88208367 Office: C303, Teaching...
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Learning Objectives
1. Traditional managements (传统的治疗方法)
2. Gene therapy(基因治疗)
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Wilson disease: Cu toxicity, AR
Wilson SAK. Brain, 1912; 34:295-507
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Wilson disease:Before/After (青霉胺) therapy
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Gene therapy
The medical procedure involves either replacing, manipulating, or supplementing nonfunctional genes with healthy genes.
OR
“Everyone talks about the human genome,
but what can we do with it?”
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Impact of the Genome Project on Medicine
•Facilitate identification of genes associated with complex disorders i.e. Cardiovascular disease, cancer•provides more therapeutic targets-in turn enhances our ability to treat cause of disease instead of symptoms•bioinformatics, array technology, proteomics -enable a systems approach to biomedical research
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Monogenic Diseases Which May Be Candidates For Gene Therapy
Sickle cell anemia/Thal Bone MarrowCongenital immune deficiencies Bone MarrowLysosomal storage and metabolic Bone Marrow ---------------------------------------------------------------Cystic fibrosis Lung -
airways ---------------------------------------------------------------Muscular dystrophy Muscle ---------------------------------------------------------------Hemophilia A or B LiverUrea cycle defects LiverFamilial hypercholesterolemia Liver
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Types Of Conditions That May Be Treated By Gene Therapy
Monogenic Diseases (>1 000 known)
Cancer, Leukemia
Infectious (AIDS, Hep C)
Cardiovascular
Neurologic
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Gene Delivery Can Be: I. Ex vivo(离体) – gene into isolated cells
II. In vivo(体内) – gene directly into patient
a) Systemic injection +/- targeted localization +/- targeted expression
b) Localized 1) Percutaneous 5) Bronchoscope 2) Vascular catheter 6) Endoscope 3) Stereotactic 7) Arthroscope
4) Sub-retinal
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General considerations for the use of somatic gene therapy (approved in 1988)
1. Compensate for a mutation resulting in the
loss of function
examples of monogenic disorders:
cystic fibrosis, hemophilia
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General considerations for the use of gene therapy
1. Compensate for a mutation resulting in the
loss of function
examples of monogenic disorders:
cystic fibrosis, hemophilia
stage of the research:
http://clinicaltrials.gov/ct2/results?term=gene+therapy+cystic+fibrosis
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General considerations for the use of gene therapy
1. Compensate for a mutation resulting in the
loss of function
2. Replace or inactivate a dominant mutant gene
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General considerations for the use of gene therapy
1. Compensate for a mutation resulting in the
loss of function
2. Replace or inactivate a dominant mutant gene e.g.: Huntington disease (expanded CAG repeat)
? Ribozymes or siRNA to degrade mRNA
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General considerations for the use of gene therapy
1. Compensate for a mutation resulting in the
loss of function
2. Replace or inactivate a dominant mutant gene example: Huntington disease (expanded CAG repeat)
? Ribozymes or siRNA to degrade mRNA state of research – no open studies for Huntington
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General considerations for the use of gene therapy
1. Compensate for a mutation resulting in the
loss of function
2. Replace or inactivate a dominant mutant gene3. Pharmacologic gene therapy
example: cancer
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General considerations for the use of gene therapy
1. Compensate for a mutation resulting in the
loss of function
2. Replace or inactivate a dominant mutant gene3. Pharmacologic gene therapy Yet, it is important to note that there is not yet a
single FDA-approved use of gene therapy!
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Minimal requirements that must be met(基因治疗试验的最低要求) :
• Identification of the affected gene
• A cDNA clone encoding the gene
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Minimal requirements that must be met (基因治疗试验的最低要求) :
• Identification of the affected gene
• A cDNA clone encoding the gene
• A substantial disease burden and a favorable risk-benefit ratio
• Sufficient knowledge of the molecular basis of the disease to be confident that the gene transfer will have the desired effect
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Minimal requirements that must be met(基因治疗试验的最低要求) :
• Identification of the affected gene• A cDNA clone encoding the gene• A substantial disease burden and a favorable risk- benefit ratio• Sufficient knowledge of the molecular basis of the disease to be confident that the gene transfer will have the desired effect
• Appropriate regulation of the gene expression: tissue specific and levels• Appropriate target cell with either a long half life or high replicative potential• Adequate data from tissue culture and animal studies to support the use of the vector, regulatory sequences, cDNA and target cell
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Minimal requirements that must be met(基因治疗试验的最低要求) :• Identification of the affected gene• A cDNA clone encoding the gene• A substantial disease burden and a favorable risk-benefit ratio• Sufficient knowledge of the molecular basis of the disease to be confident that the gene transfer will have the desired effect• Appropriate regulation of the gene expression: tissue specific and levels• Appropriate target cell with either a long half life or high replicative potential• Adequate data from tissue culture and animal studies to support the use of the vector, regulatory sequences, cDNA and target cell
• Appropriate approvals from the institutional and federal review bodies.
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Gene therapy• In most gene therapy studies, a "normal"
gene is inserted into the genome to replace an "abnormal," disease-causing gene.
• A carrier molecule called a vector must be used to deliver the therapeutic gene to the patient's target cells. Currently, the most common vector is a virus that has been genetically altered to carry normal human DNA.
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Gene Transfer MethodsNon-viral: Expression plasmid or other nucleic acid
(mRNA, siRNA).Challenge: Naked DNA or RNA does not enter cells.
a) Transfer into cells using physical methods such as direct micro-injection or electroporation.
b) complex to carrier to allow cross of cell membrane
liposomes,
cationic lipids,
dextrans,
cyclohexidrins
(aka nanoparticles)
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Gene Transfer Methods
Viral vectors = viruses that have been
adapted to serve as gene delivery vectors
include: retrovirus Lenti-virus adenovirus adeno-associated virus (AAV)herpes virus
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Characteristics of the Ideal Vector for Gene Therapy
• Safe• Sufficient capacity for size of therapeutic DNA• Non-Immunogenic• Allow re-administration• Ease of manipulation• Efficient introduction into target cells/tissues• Efficient and appropriate regulation of expression
•Level, tissue specificity, transient, stable?
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Types of viral vectors
• Retrovirus
• Lenti-virus
• Adenovirus
• Adeno-Associated virus (AAV)
• Herpes virus
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In vivo and ex vivo gene therapy
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Two strategies for introducing foreign genes into patients
In vivo gene therapyGene therapy vector +
therapeutic gene
Advantages: cells and organs not available ex vivo (lining of the lung)
Disadvantages: virus could spread to other cells/tissues Less control over titer and conditions of exposure
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Two strategies for introducing foreign genes into patients
Ex vivo gene therapyStem cells
Gene therapy vector +
Normal gene
Advantages:More controlled infectionhigher titer virus
Disadvantages:technically difficult
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Types of viral vectorsstable/transient infect non-dividing cells
• Retrovirus stable no
• Lenti-virus stable yes
• Adenovirus transient yes
• Adeno-Associated virus ? yes
• Herpes virus transient yes
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Use of retroviral vectors to introduce therapeutic genes into cells
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Severe Combined Immunodeficiency Syndrome (SCID)——adenine deaminase (ADA) deficiency
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Severe Combined Immune Deficiency (SCID)
SCID is popularly known as “bubble baby disease” after a boy with SCID was kept alive for more than a decade in a germ-free room.
SCID is a fatal disease, with infants dying from overwhelming infection due to the congenital absence of a functioning immune system.
More than a dozen genes have been found to be able to cause human SCID.
The first “SCID gene” to be identified in humans is ADA, which makes an enzyme needed forImmune cells to survive.
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Severe Combined Immunodeficiency Disease (SCID) is due to a defective gene for Adenosine Deaminase (ADA). A retrovirus, which is capable of transferring it's DNA into normal eukaryotic cells (transfection), is engineered to contain the normal human ADA gene. Isolated T-cell stem line cells from the patient are exposed to the retrovirus in cell culture, and take up the ADA gene. Reimplantation of the transgenic cells into the patient's bone marrow establishes a line of cells with functional ADA, which effecitvely treats SCID.
Ex vivoSomatic Therapy for SCID
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ADA deficiency (SCID): Ashanti de
Silva , 1990
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Father of GT: Anderson WF, 1990
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Clinical Trial of Stem Cell Gene Therapy for Sickle Cell Disease
β-Globin LCRβAS3 Globin
WPRERRE cPPT
ψ
SIN LTR
SIN LTR
HS2 HS3 HS4
Bone Marrow Harvest Isolate Stem CellsAdd Normal
Hemoglobin Gene
Myeloablate with Busulfan (16 mg/kg)
Transplant Gene-Corrected Stem Cells
FreezeCertify
Follow: Safety Efficacy
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Risks of Gene Therapy
1.Adverse reaction to vector or gene
1999/9/17: reaction to an adenovirus caused death
of 18-yo man, Jesse Gelsinger, Arizona, the first victim of gene therapy. OTC (ornithine transcarbamylase) important for metabolism of N
Injection of viral particles triggered massive inflammatory response in an individual with mild form of disease being treated with drugs and diet.
Subsequent FDA audit revealed protocol and IRB violations.
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Risks of Gene Therapy
2. Activation of harmful genes by viral promoters/enhancers stably integrated into the genome.
2002 retrovirus-induced leukemia
Children with otherwise fatal X-linked SCID injected with ex vivo HSC modified by introduction of the g-c chain cytokine receptor in 2000 (affects lymphocyte maturation)
Initial immune function was good
2/11 patients developed leukemia-like disorder at 2 years.
Clonal analysis shows insertion and activation of LMO2 gene.
FDA-cannot be used as first line therapy if BMT is an option
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What factors have kept GT from becoming
an effective treatment for genetic disease?
• Short-lived nature of gene therapy
• Immune response
• Problems with viral vectors • Multigene disorders
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Patient
Tissue Sample (e.g. skin biopsy)
Gene Addition or Gene Correction
De-Differentiation to Induced Pluripotent Stem cells (iPS)
Differentiation to Hematopoietic Stem Cells (HSC)
Autologous Transplant
Gene therapy using Autologous HSC Made from Induced Pluripotent Stem Cells
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Gene Therapy
Current Future
Experimental Proven
Limited Scope Curative
High Tech Off the Shelf
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Gene Therapy Clinical Trials Worldwide (updated list of all
gene therapy protocols)www.wiley.com/legacy/wileychi/genmed/clinical/