U.S. patent application number 17/201301 was filed with the patent office on 2021-07-29 for gene therapy for treating mucopolysaccharidosis type i.
The applicant listed for this patent is The Trustees of the University of Pennsylvania. Invention is credited to Christian Hinderer, James M. Wilson.
Application Number | 20210228740 17/201301 |
Document ID | / |
Family ID | 1000005520323 |
Filed Date | 2021-07-29 |
United States Patent
Application |
20210228740 |
Kind Code |
A1 |
Hinderer; Christian ; et
al. |
July 29, 2021 |
GENE THERAPY FOR TREATING MUCOPOLYSACCHARIDOSIS TYPE I
Abstract
A suspension useful for AAV9-mediated intrathecal/intracisternal
and/or systemic delivery of an expression cassette containing a
hIDUA gene is provided herein. Also provided are methods and kits
containing these vectors and compositions useful for treating MPSI
and the symptoms associated with Hurler, Hurler-Scheie and Scheie
syndromes.
Inventors: |
Hinderer; Christian; (New
Orleans, LA) ; Wilson; James M.; (Philadelphia,
PA) |
|
Applicant: |
Name |
City |
State |
Country |
Type |
The Trustees of the University of Pennsylvania |
Philadelphia |
PA |
US |
|
|
Family ID: |
1000005520323 |
Appl. No.: |
17/201301 |
Filed: |
March 15, 2021 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
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16075056 |
Aug 2, 2018 |
10973929 |
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PCT/US2017/016133 |
Feb 2, 2017 |
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17201301 |
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62290547 |
Feb 3, 2016 |
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62323271 |
Apr 15, 2016 |
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62337178 |
May 16, 2016 |
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62367798 |
Jul 28, 2016 |
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62452560 |
Jan 31, 2017 |
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Current U.S.
Class: |
1/1 |
Current CPC
Class: |
C12N 15/8645 20130101;
C12Y 302/01076 20130101; C12N 9/2402 20130101; C12N 2830/15
20130101; A61K 48/0075 20130101; C12N 15/86 20130101; A61P 3/00
20180101; A61K 48/005 20130101; C12N 2750/14143 20130101 |
International
Class: |
A61K 48/00 20060101
A61K048/00; C12N 9/24 20060101 C12N009/24; C12N 15/86 20060101
C12N015/86; A61P 3/00 20060101 A61P003/00; C12N 15/864 20060101
C12N015/864 |
Goverment Interests
STATEMENT OF FEDERALLY FUNDED RESEARCH
[0001] This application includes work which was supported in part
by grants from the US Government, National Institutes of Health
(NIH) numbers, R01DK54481, P40OD010939, and P30ES013508. The US
government may have certain rights in this invention.
Claims
1. A pharmaceutical composition suitable for intrathecal
administration in human subjects, comprising a suspension of
replication deficient recombinant adeno-associated virus (rAAV) in
a formulation buffer, wherein: (a) the rAAV comprises a
heterologous nucleic acid encoding human .alpha.-L-iduronidase
(hIDUA), wherein said nucleic acid is operably linked to a CB7
promoter and packaged in an AAV9 capsid; (b) the formulation buffer
comprises a physiologically compatible aqueous buffer, a surfactant
and optional excipients; and (c)(i) the rAAV Genome Copy (GC) titer
is at least 1.times.10.sup.9 GC/mL (+/-20%); (ii) the rAAV
Empty/Full particle ratio is at least about 80% free of empty
capsids; and/or (iii) a dose of at least about 4.times.10.sup.8
GC/g brain mass to about 4.times.10.sup.11 GC/g brain mass of the
rAAV suspension has potency.
2. The pharmaceutical composition of claim 1, wherein potency is
measured by an in vitro assay.
3. The pharmaceutical composition of claim 2, wherein the in vitro
assay comprises transducing HEK293 or Huh7 cells with a known
multiplicity of the rAAV GC titer per cell and assaying the
supernatant for hIDUA activity 72 hours post-transduction using the
4 MU-iduronide enzymatic assay.
4. The pharmaceutical composition of claim 1, wherein the human
hIDUA coding sequence has the nucleotide sequence of SEQ ID NO: 1
or a sequence at least about 80% identical to SEQ ID NO: 1 which
encodes a functional hIDUA.
5. The pharmaceutical composition of claim 1, wherein the encoded
hIDUA has the sequence selected from: (a) about amino acid 1 to
about 653 of SEQ ID NO: 2 (Genbank NP_000193); and (b) a synthetic
human enzyme comprising a heterologous leader sequence fused to
about acids 27 to about 653 of SEQ ID NO: 2.
6. The pharmaceutical composition of claim 1, wherein the rAAV
further comprises a 5' inverted terminal repeat (ITR) sequence, a
chicken beta actin intron, a rabbit beta-globin polyadenylation
(polyA) signal, and/or a 3' ITR sequence.
7. The pharmaceutical suspension of claim 1, wherein the empty/full
ratio is between 0.01 and 0.05 (95%-99% free of empty capsids)
8. The pharmaceutical suspension of claim 1, wherein the suspension
has a pH of 6 to 8 or a pH of 6.8 to 7.8.
9. A method of treating a human subject diagnosed with
Mucopolysaccharidosis I (MPS I) and/or the symptoms associated
Hunter syndrome, comprising administering to the human subject in
need thereof by intrathecal injection, a suspension according claim
1 at a dose of 4.times.10.sup.8 GC/g brain mass to about
4.times.10.sup.11 GC/g brain mass.
10. The method of claim 9, wherein the human subject is diagnosed
with Hurler syndrome.
11. The method of claim 9, wherein the human subject is diagnosed
with Hurler-Scheie syndrome.
12. The method of claim 9, wherein the human subject is diagnosed
with Scheie syndrome.
13. The method of claim 9, further comprising co-administering the
rAAV in an immunosuppressive regimen.
14. The method of claim 9, wherein said method results in an
increase in intelligence quotient (IQ) in said subject, as assessed
using Bayley Scales of Infant Development or as assessed using
WASI.
15. The method of claim 9, wherein said method results in an
increase in functional hIDUA levels, as measured in a serum sample
from said patient.
16. The method of claim 9, wherein said method results in a
decrease in GAG levels, as measured in a sample of the patient's
serum, urine and/or cerebrospinal fluid (CSF).
17. The method of claim 9, further comprising administering to said
patient by liver-directed injection a rAAV.hIDUA.
18. The method of claim 17, wherein the liver-directed AAV.hIDUA
has a capsid selected from AAV8, AAVrh64R1, AAVrh64R2, rh8, rh10,
AAV3B, or AAVdj.
19. The method of claim 9, wherein potency is measured by an in
vitro assay.
20. The method of claim 19, wherein the in vitro assay comprises
transducing HEK293 or Huh7 cells with a known multiplicity of the
rAAV GC titer per cell and assaying the supernatant for hIDUA
activity 72 hours post-transduction using the 4 MU-iduronide
enzymatic assay.
21. The method of claim 9, wherein the suspension is formulated for
delivery via intrathecal injection.
22. The method of claim 19, wherein the suspension is formulated
for: (a) delivery to newborn patients and comprises about
1.4.times.10.sup.11 genome copies (GC) to about 1.4.times.10.sup.14
GC; (b) delivery to patients that are about 3 months to about 9
months of age and comprises about 2.4.times.10.sup.11 to about
2.4.times.10.sup.14 GC; (c) delivery to patients that are about 9
months to about 36 months of age and comprises about
4.times.10.sup.11 GC to about 4.times.10.sup.14 GC; (d) delivery to
patients that are about 3 years to about 12 years of age and
comprises about 4.8.times.10.sup.11 GC to about 4.8.times.10.sup.14
GC, (e) delivery to patients that are about 12 years of age or
older and comprises about 5.6.times.10.sup.11 GC to about
5.6.times.10.sup.14 GC; or (f) delivery to patients that are about
18 years of age or older and comprises about 1.4.times.10.sup.13 GC
to about 7.0.times.10.sup.13 GC.
23. A method of treating a human patient having MPS I and/or the
symptoms associated Hunter syndrome, the method comprising: (a)
dosing a patient having MPS I and/or the symptoms associated with
Hunter syndrome with a sufficient amount of hIDUA enzyme to induce
transgene-specific tolerance; and (b) administering an rAAV.hIDUA
to the patient, which rAAV.hIDUA directs expression of therapeutic
levels of hIDUA in the patient.
24. The method of claim 23, wherein the hIDUA of (a) is dosed as a
recombinant protein.
25. The method of claim 23, wherein the patient is an infant.
26. The method of claim 23, wherein the administering (b) is
performed about three days to about 14 days post-dosing (a).
Description
1. INTRODUCTION
[0002] The invention relates to a gene therapy approach for
treating Mucopolysaccharidosis Type I (MPS I), including patients
diagnosed with Hurler, Hurler-Scheie and/or Scheie syndromes.
2. BACKGROUND OF THE INVENTION
[0003] The mucopolysaccharidoses are a group of inherited disorders
caused by a deficiency in specific lysosomal enzymes involved in
the degradation of glycosaminoglycans (GAG), also called
mucopolysaccharides. The accumulation of partially-degraded GAG
causes interference with cell, tissue, and organ function. Over
time, the GAG accumulates within cells, blood, and connective
tissue, resulting in increasing cellular and organ damage.
[0004] One of the most serious of the mucopolysaccharidosis (MPS)
disorders, MPS I, is caused by a deficiency of the enzyme
.alpha.-L-iduronidase (IDUA). Specifically, alpha-L-iduronidase is
reported to remove terminal iduronic acid residues from two GAGs
called heparan sulfate and dermatan sulfate. Alpha-L-iduronidase is
located in lysosomes, compartments within cells that digest and
recycle different types of molecules. The IDUA gene has been
reported to provide instructions for producing the
alpha-L-iduronidase enzyme, which is essential for the breakdown of
large sugar molecules called glycosaminoglycans (GAGs). More than
100 mutations in the IDUA gene have been found to cause
mucopolysaccharidosis type I (MPS I). Mutations that change one DNA
building block (nucleotide)--single nucleotide polymorphisms or
"SNPs" are the most common.
[0005] Mutations that cause MPS I reduce or completely eliminate
the function of alpha-L-iduronidase leads to three clinical
syndromes: Hurler, Hurler-Scheie and Scheie syndromes. Each is
inherited in an autosomal recessive manner with the extent of
enzyme deficiency being directly related to the severity of the
clinical phenotype. Hurler syndrome represents the most severe
manifestation of IDUA deficiency and usually occurs in the setting
of a total absence of enzyme activity due to two null mutations.
The clinical diagnosis is established before 2 years of age and is
associated with multiple somatic pathologies. In addition, natural
history data have firmly established that patients with Hurler
syndrome genotype have CNS involvement, which leads to severe
cognitive defects and mental retardation. Hurler-Scheie syndrome is
a more attenuated form that is usually diagnosed between 2 and 8
years of age. In contrast to Hurler syndrome, Hurler-Scheie
patients have a (theoretical) small amount of residual IDUA
activity leading to a later onset of clinical manifestations and
more attenuated progression of disease. Despite a more attenuated
phenotype, some Hurler-Scheie patients experience multiple symptoms
of CNS pathology related to IDUA deficiency, including
neurocognitive decline as evidenced by drop in IQ. Scheie syndrome
is the mildest form of MPS I. Symptoms generally begin to appear
after age 5, with diagnosis most commonly made after age 10.
Children with Scheie syndrome have normal intelligence or may have
mild learning disabilities; some may have psychiatric problems.
Glaucoma, retinal degeneration, and clouded corneas may
significantly impair vision. Other problems include carpal tunnel
syndrome or other nerve compression, stiff joints, claw hands and
deformed feet, a short neck, and aortic valve disease. Some
affected individuals also have obstructive airway disease and sleep
apnea. Persons with Scheie syndrome can live into adulthood.
[0006] With respect to the clinical syndromes, the current standard
of care for Hurler syndrome is hematopoietic stem cell
transplantation (HSCT) such as bone marrow transplantation (BMT) or
umbilical cord blood transplantations (UCBT). The procedure is done
as early as possible, and before the age of two, to impact on both
somatic and CNS aspects of the disease. However, HSCT for MPS I
remains associated with a significant amount of morbidity and a 20%
mortality rate. If transplantation is not an option, then enzyme
replacement therapy (ERT) may be started which requires a weekly
infusion of enzyme for the life of the patient. ERT does not impact
on the progression of CNS disease but does partially improve the
somatic manifestations. Organomegaly is significantly improved
although aspects of the disease in the skeletal system, eye and
heart are only partially improved. Patients may require surgery to
stabilize the hip and knee and to treat carpal tunnel syndrome and
finger contractions. Cardiac disease is treated medically although
surgery may eventually be required.
[0007] ERT for MPS I provides exogenous enzyme for uptake into
lysosomes and increased catabolism of GAG. Although the lysosomal
enzymes function internally, cell-surface mannose-6-phosphate
receptors are capable of binding, internalizing, and delivering
these enzymes to the lysosomes. Recombinant IDUA (Aldurazyme.RTM.,
BioMarin) is approved by FDA for patients with Hurler and
Hurler-Scheie forms of MPS I and for patients with the Scheie form
who have moderate to severe symptoms and was shown to improve
pulmonary function and walking capacity. ERT has also been observed
to reduce hepatomegaly in MPS I patients, as well as the levels of
urinary GAG. However, because intravenous enzyme does not easily
cross into the brain, ERT does not currently address the
neurological symptoms experienced by some MPS I patients.
[0008] Complications of ERT revolve around immune response to the
recombinant enzyme which can range from mild to full-blown
anaphylaxis as well as complications of life-long peripheral access
such as local and systemic infections. Up to 91% of patients
receiving Aldurazyme develop antibodies to the enzyme, although it
is not clear how much it affects efficacy. Furthermore, ERT
requires weekly i.v. infusions, administered over a period of 3-8
hours in a hospital setting, which significantly impacts patient
quality of life and, and at a high expense, is a major strain on
health care reimbursement systems.
[0009] In light of these limitations, a treatment that can more
effectively correct the morbidity associated with MPS I remains an
unmet medical need.
3. SUMMARY OF THE INVENTION
[0010] A replication deficient adeno-associated virus ("AAV") to
deliver a human alpha-L-iduronidase (hIDUA) gene to the CNS of
patients (human subjects) diagnosed with mucopolysaccharidosis type
I (MPS I) is provided herein. The recombinant AAV ("rAAV") vector
used for delivering the hIDUA gene ("rAAV.hIDUA") should have a
tropism for the CNS (e.g., an rAAV bearing an AAV9 capsid), and the
hIDUA transgene should be controlled by specific expression control
elements, e.g., a hybrid of cytomegalovirus (CMV) enhancer and the
chicken beta actin promoter (CB7). Pharmaceutical compositions
suitable for intrathecal/intracisternal administration comprise a
suspension of rAAV.hIDUA vectors in a formulation buffer comprising
a physiologically compatible aqueous buffer, a surfactant and
optional excipients. The rAAV suspension is further characterized
in that:
[0011] (i) the rAAV Genome Copy (GC) titer is at least
1.times.10.sup.9 GC/mL to 1.times.10.sup.14 GC/mL (+/-20%);
[0012] (ii) the rAAV Empty/Full particle ratio is between 0.01 and
0.05 (95%-99% free of empty capsids) as determined by SDS-PAGE
analysis (see Example 5D), or in other embodiments at least about
50, at least about 80%, at least about 85%, or at least about 90%,
free of empty capsids; and/or
[0013] (iii) a dose of at least about 4.times.10.sup.8 GC/g brain
mass to about 4.times.10.sup.11 GC/g brain mass of the rAAV
suspension has potency. Potency can be measured by in vitro/cell
culture assays, e.g., the in vitro potency assay described in
Example 6G, in which Huh7 or HEK293 cells are transduced with a
known multiplicity of rAAV GCs per cell and the supernatant is
assayed for IDUA activity 72 hours post-transduction.
[0014] Such rAAV.hIDUA vector preparations can be administered to
human subjects by intrathecal/intracisternal injection to achieve
therapeutic levels of hIDUA expression in the CNS. Patients who are
candidates for treatment are pediatric and adult patients with MPSI
and/or the symptoms associated with Hurler, Hurler-Scheie and
Scheie.
[0015] Therapeutically effective intrathecal/intracisternal doses
of the rAAV.hIDUA for MPSI patients range from 3.8.times.10.sup.12
to 7.0.times.10.sup.14 GC (flat doses)--the equivalent of 10.sup.10
to 5.times.10.sup.11 GC/g brain mass of the patient. Alternatively,
the following therapeutically effective flat doses can be
administered to patients of the indicated age group: [0016]
Newborns: about 3.8.times.10.sup.12 to about 1.9.times.10.sup.14
GC; [0017] 3-9 months: about 6.times.10.sup.12 to about
3.times.10.sup.14 GC; [0018] 9-36 months: about 1013 to about
5.times.10.sup.14 GC; [0019] 3-12 years: about 1.2.times.10.sup.13
to about 6.times.10.sup.14 GC; [0020] 12+ years: about
1.4.times.10.sup.13 to about 7.0.times.10.sup.14 GC; [0021] 18+
years (adult): about 1.4.times.10.sup.13 to about
7.0.times.10.sup.14 GC.
[0022] In some embodiments, the dose administered to a 12+ year old
MPSI patient (including 18+ year old) is 1.4.times.10.sup.13 genome
copies (GC) (1.1.times.10.sup.10 GC/g brain mass). In some
embodiments, the dose administered to a 12+ year old MPSI patient
(including 18+ year old) is 7.times.10.sup.13 GC
(5.6.times.10.sup.10 GC/g brain mass). In still a further
embodiment, the dose administered to an MPSI patient is at least
about 4.times.10.sup.8 GC/g brain mass to about 4.times.10.sup.11
GC/g brain mass. In certain embodiments, the dose administered to
MPS I newborns ranges from about 1.4.times.10.sup.11 to about
1.4.times.10.sup.14 GC; the dose administered to infants 3-9 months
ranges from about 2.4.times.10.sup.11 to about 2.4.times.10.sup.14
GC; the dose administered to MPS I children 9-36 months ranges:
about 4.times.10.sup.11 to about 4.times.10.sup.14 GC; the dose
administered to MPS I children 3-12 years: ranges from about
4.8.times.10.sup.11 to about 4.8.times.10.sup.14 GC; the dose
administered to children and adults 12+ years ranges from about
5.6.times.10.sup.11 to about 5.6.times.10.sup.14 GC.
[0023] The goal of the treatment is to functionally replace the
patient's defective alpha-L-iduronidase via rAAV-based CNS-directed
gene therapy to treat disease. Efficacy of the therapy can be
measured by assessing (a) the prevention of neurocognitive decline
in patients with MPSI; and (b) reductions in biomarkers of disease,
e.g., GAG levels and/or IDUA or hexosaminidase enzyme activity in
the CSF, serum and/or urine, and/or liver and spleen volumes.
Neurocognition can be determined by measuring intelligence quotient
(IQ), e.g., as measured by Bayley's Infantile Development Scale for
Hurler subjects or as measured by the Wechsler Abbreviated Scale of
Intelligence (WASI) for Hurler-Scheie subjects. Other appropriate
measures of neurocognitive development and function may be
utilized, e.g., assessing developmental quotient (DQ) using Bayley
Scales of Infant Development (BSID-III), assessing memory using the
Hopkins Verbal Learning Test, and/or using Tests of Variables of
Attention (TOVA).
[0024] Prior to treatment, the MPSI patient can be assessed for
neutralizing antibodies (Nab) to the capsid of the rAAV vector used
to deliver the hIDUA gene. Such Nabs can interfere with
transduction efficiency and reduce therapeutic efficacy. MPS I
patients that have a baseline serum Nab titer .ltoreq.1:5 are good
candidates for treatment with the rAAV.hIDUA gene therapy protocol.
Treatment of MPS I patients with titers of serum Nab >1:5 may
require a combination therapy, such as transient co-treatment with
an immunosuppressant before and/or during treatment with rAAV.hIDUA
vector delivery. Optionally, immunosuppressive co-therapy may be
used as a precautionary measure without prior assessment of
neutralizing antibodies to the AAV vector capsid and/or other
components of the formulation. In certain embodiments, prior
immunosuppression therapy may be desirable to prevent potential
adverse immune reaction to the hIDUA transgene product, especially
in patients who have virtually no levels of IDUA activity, where
the transgene product may be seen as "foreign." Results of
non-clinical studies in mice, dogs and NHPs described in the
Examples infra are consistent with the development of an immune
response to hIDUA and neuroinflammation. While a similar reaction
may not occur in human subjects, as a precaution immunosuppression
therapy is recommended for all recipients of rAAV-hIDUA.
[0025] Combinations of gene therapy delivery of the rAAV.hIDUA to
the CNS accompanied by systemic delivery of hIDUA are encompassed
by the methods of the invention. Systemic delivery can be
accomplished using ERT (e.g., using Aldurazyme.COPYRGT.), or
additional gene therapy using an rAAV.hIDUA with tropism for the
liver (e.g., an rAAV.hIDUA bearing an AAV8 capsid).
[0026] In certain embodiments, the patient is administered an
AAV.hIDUA via liver-directed injections in order to tolerize the
patient to hIDUA, and the patient is subsequently administered
AAV.hIDUA via intrathecal/intracisternal injections when the
patient is an infant, child, and/or adult to express therapeutic
concentrations of hIDUA in the CNS.
[0027] The benefits of the invention are illustrated by the
Examples, infra, which demonstrate that IT administration of
rAAV9.IDUA in animal studies resulted in widespread distribution of
vector within the CNS. Moreover, single doses of rAAV9 vector
delivering fIDUA, cIDUA, or hIDUA were successful in
dose-dependently ameliorating or completely reversing the
histological and biochemical manifestations of CNS-related MPS I in
both feline and canine animal models. Similarly, single IT doses of
rAAV9.IDUA were clinically well tolerated in macaques, including
when injected as infants, for at least 2 years after injection. The
only adverse effects associated with rAAV9.IDUA administration in
the animals were related to immune responses to the transgene
across all species that were tested.
[0028] As shown in the Examples, the beneficial effect of
rAAV9.IDUA treatment was limited by development of anti-IDUA
antibody responses. At the highest doses evaluated in either
non-tolerized MPS I dogs (Example 3) or rhesus macaques (Example 7)
adverse effects were observed. The characteristics of the changes
and the time of onset indicate that these effects were mediated by
an immunologic response to the transgene product. In Example 3,
both dogs at the highest dose had high CSF WBC counts and protein
levels accompanied by pain and hindlimb weakness. These animals had
histopathologic lesions in the spinal cord and dorsal root ganglia
that were attributed to an immunologic response to the transgene
expressed in motor and sensory neurons. In a toxicology study in
rhesus macaques (Example 7), both humoral and cell-mediated
immunologic responses to hIDUA were observed and were characterized
by increased nucleated cell counts and anti-IDUA antibodies in CSF,
and weak anti-IDUA T-cell responses in peripheral blood. Unlike the
dogs, adverse clinical signs did not occur, neuronal necrosis
within the spinal cord was not observed, and the monkeys appeared
to tolerate treatment. However, CNS lesions were observed in the
spinal cord at Days 90 and 180 consisting of bilateral axonal
degeneration in the white matter dorsal funiculi. These axonal
changes are considered to be secondary to an immunologically
mediated effect on the neurons in the dorsal root ganglia.
[0029] The acquired immunologic responses to human proteins
observed in the nonclinical species may not be predictive of either
the nature or magnitude of the same responses in humans.
Nonetheless, in preferred embodiments, human subjects should be
prophylactically treated with immunosuppressive agents,
particularly individuals who do not express any hIDUA and therefore
are not expected to be tolerant to this enzyme. The data in the
Examples, infra, show that in neonatal dogs and nonhuman primates
tolerized to either cIDUA or hIDUA prior to administration of the
rAAV9.IDUA construct, sustained transduction and IDUA expression
were achieved. In contrast, animals that had not been previously
tolerized to IDUA generally mounted an immune response to both IDUA
and to AAV9 capsid antigens. In sum, the data in the examples
indicate that immunosuppressive treatment could also enhance the
efficacy of rAAV9.IDUA.
[0030] Still other aspects and advantages of the invention will be
apparent from the detailed description of the invention.
4. BRIEF DESCRIPTION OF THE FIGURES
[0031] FIG. 1 is a schematic representation of a vector genome
which is packaged into an AAV as described herein. In the vector
genome, the major components of the expression cassette flanked by
the AAV 5' and 3' inverted terminal repeat (ITR)s vector genome are
depicted. These include the cytomegalovirus immediate-early
enhancer, CB7 promoter, a chimeric intron, a human
alpha-Liduronidase coding sequence (gene), and a rabbit beta globin
poly A signal.
[0032] FIGS. 2A-2B show CSF IDUA activity in naive (FIG. 2A) or
tolerized (FIG. 2B) MPS I dogs treated with intrathecal injection
with AAV9 expressing human IDUA. Dogs were treated at one month of
age with an intrathecal injection of the vector into the cisterna
magna. IDUA activity was measured in subsequent CSF samples. Vector
doses (GC/kg) are indicated for each animal. The dashed lines
represent animals treated with intrathecal vector only. The solid
lines with filled symbols represent animals pretreated on postnatal
day 5 with intravenous AAV8 expressing human IDUA from a
liver-specific promoter. Solid lines with open symbols represent
animals pretreated on postnatal day 7 and 14 with intravenous
infusion of recombinant human IDUA. Animals I-665 and I-666 were
euthanized on day 36 due to neurological signs. The horizontal
dashed line represents mean CSF IDUA activity in normal dogs. The
dotted line indicates the assay limit of quantification.
[0033] FIG. 3 shows CSF antibody titers against human IDUA.
Antibody titers against human IDUA were measured by ELISA in CSF
samples collected 50 days post vector administration. CSF samples
tested from I-665 and I-666 were collected at the time of necropsy
(day 36 post injection). Error bars=SEM. Antibody titers were
significantly lower in the animals pre-treated as neonates with
AAV8 vector (I-652, I-653, I-602, I-607, I-601, I-606) or
recombinant human IDUA (I-663, I-664) compared with controls
treated with IT vector alone (I-604, I-608, I-605, I-665, I-666)
(Mann-Whitney test).
[0034] FIGS. 4A-4B shows CSF nucleated cell counts following
intrathecal AAV9 injection. Total nucleated cell counts were
measured in CSF samples from naive dogs treated with intrathecal
AAV9 (FIG. 4A)) as well as animals treated as neonates with
systemic recombinant human IDUA (I-663 and I-664) or an AAV8 vector
expressing IDUA before receiving intrathecal AAV9 (FIG. 4B)).
Nucleated cell counts were significantly elevated on day 21 after
vector injection in the naive animals compared with those
pre-treated as neonates with AAV8 vector or recombinant human IDUA
(Mann-Whitney test).
[0035] FIG. 5 shows normalization of brain hexosaminidase activity
in human IDUA tolerant MPS I dogs treated with intrathecal AAV9.
Hex activity was measured in samples collected from 6 brain regions
(frontal cortex, temporal cortex, occipital cortex, hippocampus,
medulla, and cerebellum). The mean activity is shown for a normal
control dog, untreated MPS I dogs, and the 8 hIDUA tolerant dogs
treated with intrathecal injection of AAV9 expressing human IDUA.
Open symbols indicate animals tolerized with infusion of
recombinant human IDUA. Hex activity was significantly reduced in
the high dose cohort compared to untreated controls (Kruskal-Wallis
test followed by Dunn's multiple comparisons test).
[0036] FIGS. 6A-6B shows dose-dependent correction of brain storage
lesions in human IDUA tolerant dogs treated with intrathecal
injection of AAV9 expressing human IDUA. Brains were sectioned and
stained for LIMP2 and GM3. Meningeal GAG accumulation was imaged
using Alcian blue staining. Automated quantification of GM3 (FIG.
6A) and LIMP2 (FIG. 6B) positive cells was performed on cortical
brain images (n=10 per animal). Open symbols indicate animals
tolerized with infusion of recombinant human IDUA. GM3 and LIMP2
were significantly reduced in the high dose cohort compared to
untreated controls (Kruskal-Wallis test followed by Dunn's multiple
comparisons test).
[0037] FIG. 7 shows partial normalization of brain hexosaminidase
activity in naive dogs treated with intrathecal injection of AAV9
expressing human IDUA. Hexosaminidase activity was measured in
samples collected from 6 brain regions (frontal cortex, temporal
cortex, occipital cortex, hippocampus, medulla, and cerebellum).
The mean activity is shown for a normal control dog, untreated MPS
I dogs, and dogs treated with intrathecal AAV9 expressing human
IDUA at one month of age with doses of 10.sup.12 GC/kg or 10.sup.11
GC/kg.
[0038] FIG. 8 shows normalization of CSF hexosaminidase activity
after IT AAV9 treatment in hIDUA tolerant dogs. Hex activity was
measured in CSF of MPS I dogs tolerized to human IDUA at the end of
the study. Open symbols indicate animals tolerized with infusion of
recombinant human IDUA. CSF hex activity was significantly reduced
in all treated animals relative to untreated MPS I controls
(Mann-Whitney test).
[0039] FIG. 9 shows resolution of cervical meningeal thickening in
hIDUA tolerant dogs treated with intrathecal AAV9 expressing human
IDUA. The average total thickness of the meninges was measured on
H&E stained sections of the cervical spinal cord. Open symbols
indicate animals tolerized with infusion of recombinant human IDUA.
Meningeal thickness was significantly reduced in all treated
animals relative to untreated MPS I controls (Mann-Whitney
test).
[0040] FIGS. 10A-10B provide a comparison of enzyme expression and
correction of brain storage lesions in MPS I mice treated with IT
AAV9. MPS I mice were treated at 2-3 months of age with an ICV
injection of AAV9.CB.hIDUA at one of three doses: 3.times.10.sup.8
GC (low), 3.times.10.sup.9 GC (mid), or 3.times.10.sup.10 GC
(high). FIG. 10A is from one cohort of animals that was sacrificed
at 3 weeks post vector injection, and brains were harvested for
measurement of IDUA activity. FIG. 10B shows a second cohort of
animals sacrificed 3 months after injection; brains were stained
for the lysosomal membrane protein LIMP2. Cells staining positive
for LIMP2 were quantified by a blinded reviewer in 4 cortical brain
sections. *p<0.05, one-way ANOVA followed by Dunnett's test.
[0041] FIG. 11 provides a manufacturing process flow diagram.
[0042] FIG. 12 is an image of apparatus (10) for intracisternal
delivery of a pharmaceutical composition, including optional
introducer needle for coaxial insertion method (28), which includes
a 10 cc vector syringe (12), a 10 cc prefilled flush syringe (14),
a T-connector extension set (including tubing (20), a clip at the
end of the tubing (22) and connector (24)), a 22G.times.5'' spinal
needle (26), an optional 18G.times.3.5'' introducer needle (28).
Also illustrated is the 4-way stopcock with swive male luer lock
(16).
[0043] FIG. 13 provides a schematic illustration of an
intracisternal injection.
[0044] FIG. 14 illustrates encephalitis and transgene specific T
cell responses in dogs treated with ICV AAV9. One-year-old MPS I
dogs were treated with a single ICV or IC injection of an AAV9
vector expressing GFP. All animals were sacrificed 14 days after
injection, except for I-567 which was found dead 12 days after
injection. Brains were divided into coronal sections, which
revealed gross lesions near the injection site (arrowheads) in ICV
treated animals. Tissue sections from the brain regions surrounding
the gross lesions were stained with hematoxylin and eosin.
Peripheral blood mononuclear cells were collected from one ICV
treated dog (I-565) at the time of necropsy, and T cell responses
against the AAV9 capsid and GFP protein were measured by
interferon-.gamma. ELISPOT (FIG. 14). T cell responses to the GFP
transgene product were measured using a single pool of overlapping
15 amino acids long peptides covering the full GFP sequence. The
peptides comprising the AAV9 capsid protein were divided into three
pools (designated pool A-C). *=positive response, defined as
>3-fold background (unstimulated cells) and greater than 55
spots per million cells. Phytohemagglutinin (PHA) and ionomycin
with phorbol 12-myristate 13-acetate (PMA) served as positive
controls for T cell activation.
[0045] FIG. 15 is a bar chart illustrating vector biodistribution
in dogs treated with ICV or IC AAV9. Dogs were sacrificed 14 days
after injection with a single ICV or IC injection of an AAV9 vector
expressing GFP, except for animal I-567 which was necropsied 12
days after injection. Vector genomes were detected in tissue
samples by quantitative PCR. Values are expressed as vector genome
copies per diploid cell (GC/diploid genome). Brain samples
collected from the hippocampus or cerebral cortex are indicated as
either injected or uninjected hemisphere for the ICV treated dogs;
for the IC treated animals these are the right and left
hemispheres, respectively. Samples were not collected for PCR from
the injected cerebral hemisphere of animal I-567.
[0046] FIG. 16 is a bar chart showing vector biodistribution in
NHPs treated with intrathecal AAV9. NHPs were sacrificed 14 days
after intrathecal injection via lumbar puncture of an AAV9 vector
diluted in 5 mL of Iohexol 180. Two of the animals were placed in
the Trendelenburg position for 10 minutes after injection. Vector
genomes were detected in tissue samples by quantitative PCR. Values
are expressed as vector genome copies per diploid cell (GC/diploid
genome).
[0047] FIGS. 17A-17B illustrate elevated CSF spermine in MPS I. A
high throughput LC/MS and GC/MS metabolite screen was performed on
CSF samples from MPS I dogs (n=15) and normal controls (n=15). FIG.
17A shows a heatmap of the top 100 differentially detected
metabolites (ANOVA). The youngest animal in the MPS I cohort (28
days of age) is indicated by an asterisk. FIG. 17B is a graph
showing spermine concentration measured by a quantitative isotope
dilution LC/MS assay in CSF samples from 6 infants with MPS I and 2
normal infants.
[0048] FIGS. 18A-18F illustrate spermine dependent aberrant neurite
growth in MPS I neurons. Cortical neurons harvested from E18
wild-type or MPS I mouse embryos were treated with spermine (50
ng/mL) or the spermine synthase inhibitor APCHA 24 hours after
plating. Neurite number, length and branching were quantified for
45-65 randomly selected neurons from duplicate cultures per
treatment condition by a blinded reviewer. FIG. 18A is a bar chart
providing neurites for MPSI, MPSI+APCHA, or MPSI+APCHA+spermine, as
compared to a wild-type. FIG. 18B is a bar chart providing branch
points for MPSI, MPSI+APCHA, or MPSI+APCHA+spermine, as compared to
a wild-type. FIG. 18C is a bar chart providing arbor length for
MPSI, MPSI+APCHA, or MPSI+APCHA+spermine, as compared to a
wild-type *** p<0.0001 (ANOVA followed by Dunnett's test). FIG.
18D is a bar chart comparing neurites/cell for wild-type treated
with spermine as compared to wild-type. FIG. 18E is a bar chart
comparing branch points/cell for wild-type treated with spermine as
compared to wild-type. FIG. 18F is a bar chart comparing arbor
length/cell for wild-type treated with spermine as compared to
wild-type.
[0049] FIGS. 19A-19C illustrate normalization of CSF spermine
levels and brain GAP43 expression in MPS I dogs following gene
therapy. Five MPS I dogs were treated with an intrathecal injection
of an AAV9 vector expressing canine IDUA at one month of age. Two
of the dogs (I-549, I-552) were tolerized to IDUA by liver directed
gene therapy on postnatal day 1 in order to prevent the antibody
response that is elicited to IDUA in some MPS I dogs. FIG. 19A is a
bar chart showing the results of IDUA activity measured in brain
tissue six months after intrathecal vector injection. FIGS. 19B and
C are graphs showing results following measurement of GAP43 in
cortical brain samples quantified relative to R-actin by
densitometry. CSF spermine was measured at the time of sacrifice by
isotope dilution LC/MS (E). Untreated MPS I dogs (n=3) and normal
dogs (n=2) served as controls. * p<0.05 (Kruskal-Wallis test
followed by Dunn's test).
[0050] FIGS. 20A-20B are graphs which illustrate the use of
spermine as a CSF biomarker for evaluation of CNS directed gene
therapy in MPS I. Six MPS I dogs tolerized to human IDUA at birth
were treated with intrathecal AAV9 expressing human IDUA (1012
GC/kg, n=2, 1011 GC/kg, n=2, 1010 GC/kg, n=2) at one month of age.
FIG. 20A provides results following measurement of CSF spermine
levels measured six months after treatment. Three MPS I cats were
treated with intrathecal AAV9 expressing feline IDUA (1012 GC/kg).
FIG. 20B provides results following quantification of CSF spermine
six months after treatment. Untreated MPS I dogs (n=3) and normal
dogs (n=2) served as controls.
[0051] FIG. 21 illustrates the mean decrease accuracy for
metabolites identified by random forest analysis.
5. DETAILED DESCRIPTION OF THE INVENTION
[0052] A replication deficient adeno-associated virus ("AAV") to
deliver a human alpha-L-iduronidase (hIDUA) gene to the CNS of
patients (human subjects) diagnosed with mucopolysaccharidosis type
I (MPS I) is provided herein. The recombinant AAV ("rAAV") vector
used for delivering the hIDUA gene ("rAAV.hIDUA") has tropism for
the CNS (e.g., an rAAV bearing an AAV9 capsid), and the hIDUA
transgene is controlled by specific expression control elements,
e.g., a hybrid of cytomegalovirus (CMV) enhancer and the chicken
beta actin promoter (CB7). In certain embodiments, pharmaceutical
compositions suitable for intrathecal, intracisternal, and systemic
administration are provided, which comprise a suspension of
rAAV.hIDUA vectors in a formulation buffer comprising a
physiologically compatible aqueous buffer, a surfactant and
optional excipients. The rAAV suspension is further characterized
in that:
[0053] (i) the rAAV Genome Copy (GC) titer is at least
1.times.10.sup.9 GC/mL to 1.times.10.sup.14 GC/mL (+/-20%);
[0054] (ii) the rAAV Empty/Full particle ratio is between 0.01 and
0.05 (95%-99% free of empty capsids), or in other embodiments at
least about 50, at least about 80%, at least about 85%, or at least
about 90%, free of empty capsids, as determined by SDS-PAGE
analysis (see Example 6D); and/or
[0055] (iii) a dose of at least about 4.times.10.sup.8 GC/g brain
mass to about 4.times.10.sup.11 GC/g brain mass of the rAAV
suspension has potency.
[0056] Potency can be measured by in vitrocell culture assays,
e.g., the in vitro potency assay described in Example 6G, in which
Huh7 or HEK293 cells are transduced with a known multiplicity of
rAAV GCs per cell and the supernatant is assayed for IDUA activity
72 hours post-transduction. The function (activity) and/or the
potency of hIDUA may be measured in a suitable in vitro assay,
e.g., by its ability to cleave a fluorogenic substrate,
4-Methylumbelliferyl alpha-L-iduronide. The specific activity is
>7,500 pmol/min/.mu.g, as measured under the described
conditions. See Activity Assay Protocol on www.RnDSystems.com.
Other suitable methods of measuring enzyme activity have been
described [see, e.g., Kakkis, E. D., et al (1994). Protein
Expression Purif 5: 225-232; Rome, L. H., et al (1979). Proc. Natl.
Acad. Sci. USA 76: 2331-2334], including those described herein.
Activity may also be assessed using the method described, e.g., E.
Oussoren, et al, Mol Genet Metab. 2013 August; 109(4):377-81. doi:
10.1016/j.ymgme.2013.05.016. Epub 2013 Jun. 4.
[0057] Patients who are candidates for treatment are pediatric and
adult patients with MPSI and/or the symptoms associated with
Hurler, Hurler-Scheie and Scheie.
[0058] The following therapeutically effective flat doses can be
administered to a MPSI patient of the indicated age group: [0059]
Newborns: about 3.8.times.10.sup.12 to about 1.9.times.10.sup.14
GC; [0060] 3-9 months: about 6.times.10.sup.12 to about
3.times.10.sup.14 GC; [0061] 9-36 months: about 1013 to about
5.times.10.sup.14 GC; [0062] 3-12 years: about 1.2.times.10.sup.13
to about 6.times.10.sup.14 GC; [0063] 12+ years: about
1.4.times.10.sup.13 to about 7.0.times.10.sup.14 GC; [0064] 18+
years (adult): about 1.4.times.10.sup.13 to about
7.0.times.10.sup.14 GC.
[0065] In some embodiments, the dose administered to a 12+ year old
MPSI patient (including 18+ year old) is 1.4.times.10.sup.13 genome
copies (GC) (1.1.times.10.sup.10 GC/g brain mass). In some
embodiments, the dose administered to a 12+ year old MPSI patient
(including 18+ year old) is 7.times.10.sup.13 GC
(5.6.times.10.sup.10 GC/g brain mass). In still a further
embodiment, the dose administered to an MPSI patient is at least
about 4.times.10.sup.8 GC/g brain mass to about 4.times.10.sup.11
GC/g brain mass. In certain embodiments, the dose administered to
MPS I newborns ranges from about 1.4.times.10.sup.11 to about
1.4.times.10.sup.14 GC; the dose administered to infants 3-9 months
ranges from about 2.4.times.10.sup.11 to about 2.4.times.10.sup.14
GC; the dose administered to MPS I children 9-36 months ranges:
about 4.times.10.sup.11 to about 4.times.10.sup.14 GC; the dose
administered to MPS I children 3-12 years: ranges from about
4.8.times.10.sup.11 to about 4.8.times.10.sup.14 GC; the dose
administered to children and adults 12+ years ranges from about
5.6.times.10.sup.11 to about 5.6.times.10.sup.14 GC.
[0066] The goal of the treatment is to functionally replace the
patient's defective alpha-L-iduronidase via rAAV-based CNS-directed
gene therapy as a viable approach to treat disease. As expressed
from the rAAV vector described herein, expression levels of at
least about 2% of normal levels as detected in the CSF, serum,
neurons, or other tissue or fluid, may provide therapeutic effect.
However, higher expression levels may be achieved. Such expression
levels may be from 2% to about 100% of normal functional human IDUA
levels. In certain embodiments, higher than normal expression
levels may be detected in CSF, serum, or other tissue or fluid.
[0067] The invention also provides for the manufacture and
characterization of the rAAv.hIDUA pharmaceutical compositions
(Example 6, infra).
[0068] As used herein, the terms "intrathecal delivery" or
"intrathecal administration" refer to a route of administration for
drugs via an injection into the spinal canal, more specifically
into the subarachnoid space so that it reaches the cerebrospinal
fluid (CSF). Intrathecal delivery may include lumbar puncture,
intraventricular, suboccipital/intracisternal, and/or C1-2
puncture. For example, material may be introduced for diffusion
throughout the subarachnoid space by means of lumbar puncture. In
another example, injection may be into the cisterna magna.
[0069] As used herein, the terms "intracisternal delivery" or
"intracisternal administration" refer to a route of administration
for drugs directly into the cerebrospinal fluid of the brain
ventricles or within the cisterna magna cerebellomedularis, more
specifically via a suboccipital puncture or by direct injection
into the cisterna magna or via permanently positioned tube. FIG. 13
provides an illustration as to how an intracisternal injection
would be made.
[0070] As used herein, a "therapeutically effective amount" refers
to the amount of the AAV9.hIDUA composition which delivers and
expresses in the target cells an amount of enzyme sufficient to
ameliorate or treat one or more of the symptoms of MPSI Hurler,
and/or Hurler-Scheie and/or Scheie syndromes. "Treatment" may
include preventing the worsening of the symptoms of one of the MPSI
syndromes and possibly reversal of one or more of the symptoms
thereof. Method of assessing therapeutic effectiveness (efficacy)
are described in detail below (see, e.g., Section 5.2.3,
infra).
[0071] A "therapeutically effective amount" for human patients may
be predicted based on an animal model. Examples of a suitable
feline model and a suitable canine model are described herein. See,
C. Hinderer et al, Molecular Therapy (2014); 22 12, 2018-2027; A.
Bradbury, et al, Human Gene Therapy Clinical Development. March
2015, 26(1): 27-37, which are incorporated herein by reference.
With respect to the canine model, the model is typically an immune
suppressed animal model, or a tolerized animal, as intravenous
administration in dogs has been observed to elicit a strong,
sustained antibody response to human IDUA, whereas in human
patients, administration is well tolerated. In these models,
reversal of certain symptoms may be observed and/or prevention of
progression of certain symptoms may be observed. For example,
correction of corneal clouding may be observed, and/or correction
of lesions in the central nervous system (CNS) is observed, and/or
reversal of perivascular and/or meningeal gag storage is
observed.
[0072] As used herein a "functional human alpha-L-iduronidase"
refers to a human alpha-L-iduronidase enzyme which functions
normally in humans without MPS1 or an associated syndrome such as
Hurler, Hurler-Scheie and/or Scheie syndromes. Conversely, a human
alpha-L-iduronidase enzyme variant which causes MPS1 or one of
these syndromes is considered non-functional. In one embodiment, a
functional human alpha-1-iduronidase has the amino acid sequence of
a wild-type human alpha-L-iduronidase described by Bremer et al,
Mol. Genet. Metab. 104 (3): 289-294 (2011), NCBI Reference Sequence
NP_000194.2, reproduced in SEQ ID NO:2 (653 amino acids). However,
several naturally occurring functional polymorphisms (variants) of
this sequence have been described and may be encompassed within the
scope of this invention. Such variants have been described; see,
e.g., in WO 2014/151341, which is incorporated herein by reference,
as well as in, e.g., UniProtKB/Swiss-Prot;
www.uniprot.org/uniprot/P35475, also incorporated by reference.
[0073] As used herein, the term "NAb titer" a measurement of how
much neutralizing antibody (e.g., anti-AAV Nab) is produced which
neutralizes the physiologic effect of its targeted epitope (e.g.,
an AAV). Anti-AAV NAb titers may be measured as described in, e.g.,
Calcedo, R., et al., Worldwide Epidemiology of Neutralizing
Antibodies to Adeno-Associated Viruses. Journal of Infectious
Diseases, 2009. 199(3): p. 381-390, which is incorporated by
reference herein.
[0074] As used herein, an "expression cassette" refers to a nucleic
acid molecule which comprises an IDUA gene, promoter, and may
include other regulatory sequences therefor, which cassette may be
delivered via a genetic element (e.g., a plasmid) to a packaging
host cell and packaged into the capsid of a viral vector (e.g., a
viral particle). Typically, such an expression cassette for
generating a viral vector contains the IDUA coding sequence
described herein flanked by packaging signals of the viral genome
and other expression control sequences such as those described
herein.
[0075] The abbreviation "sc" refers to self-complementary.
"Self-complementary AAV" refers a construct in which a coding
region carried by a recombinant AAV nucleic acid sequence has been
designed to form an intra-molecular double-stranded DNA template.
Upon infection, rather than waiting for cell mediated synthesis of
the second strand, the two complementary halves of scAAV will
associate to form one double stranded DNA (dsDNA) unit that is
ready for immediate replication and transcription. See, e.g., D M
McCarty et al, "Self-complementary recombinant adeno-associated
virus (scAAV) vectors promote efficient transduction independently
of DNA synthesis", Gene Therapy, (August 2001), Vol 8, Number 16,
Pages 1248-1254. Self-complementary AAVs are described in, e.g.,
U.S. Pat. Nos. 6,596,535; 7,125,717; and 7,456,683, each of which
is incorporated herein by reference in its entirety.
[0076] As used herein, the term "operably linked" refers to both
expression control sequences that are contiguous with the gene of
interest and expression control sequences that act in trans or at a
distance to control the gene of interest.
[0077] The term "heterologous" when used with reference to a
protein or a nucleic acid indicates that the protein or the nucleic
acid comprises two or more sequences or subsequences which are not
found in the same relationship to each other in nature. For
instance, the nucleic acid is typically recombinantly produced,
having two or more sequences from unrelated genes arranged to make
a new functional nucleic acid. For example, in one embodiment, the
nucleic acid has a promoter from one gene arranged to direct the
expression of a coding sequence from a different gene. Thus, with
reference to the coding sequence, the promoter is heterologous.
[0078] A "replication-defective virus" or "viral vector" refers to
a synthetic or artificial viral particle in which an expression
cassette containing a gene of interest is packaged in a viral
capsid or envelope, where any viral genomic sequences also packaged
within the viral capsid or envelope are replication-deficient;
i.e., they cannot generate progeny virions but retain the ability
to infect target cells. In one embodiment, the genome of the viral
vector does not include genes encoding the enzymes required to
replicate (the genome can be engineered to be "gutless"--containing
only the transgene of interest flanked by the signals required for
amplification and packaging of the artificial genome), but these
genes may be supplied during production. Therefore, it is deemed
safe for use in gene therapy since replication and infection by
progeny virions cannot occur except in the presence of the viral
enzyme required for replication.
[0079] As used herein, "recombinant AAV9 viral particle" refers to
nuclease-resistant particle (NRP) which has an AAV9 capsid, the
capsid having packaged therein a heterologous nucleic acid molecule
comprising an expression cassette for a desired gene product. Such
an expression cassette typically contains an AAV 5' and/or 3'
inverted terminal repeat sequence flanking a gene sequence, in
which the gene sequence is operably linked to expression control
sequences. These and other suitable elements of the expression
cassette are described in more detail below and may alternatively
be referred to herein as the transgene genomic sequences. This may
also be referred to as a "full" AAV capsid. Such a rAAV viral
particle is termed "pharmacologically active" when it delivers the
transgene to a host cell which is capable of expressing the desired
gene product carried by the expression cassette.
[0080] In many instances, rAAV particles are referred to as DNase
resistant. However, in addition to this endonuclease (DNase), other
endo- and exo-nucleases may also be used in the purification steps
described herein, to remove contaminating nucleic acids. Such
nucleases may be selected to degrade single stranded DNA and/or
double-stranded DNA, and RNA. Such steps may contain a single
nuclease, or mixtures of nucleases directed to different targets,
and may be endonucleases or exonucleases.
[0081] The term "nuclease-resistant" indicates that the AAV capsid
has fully assembled around the expression cassette which is
designed to deliver a transgene to a host cell and protects these
packaged genomic sequences from degradation (digestion) during
nuclease incubation steps designed to remove contaminating nucleic
acids which may be present from the production process.
[0082] As used herein, "AAV9 capsid" refers to the AAV9 having the
amino acid sequence of GenBank accession:AAS99264, is incorporated
by reference herein and the AAV vp1 capsid protein is reproduced in
SEQ ID NO:7. Some variation from this encoded sequence is
encompassed by the present invention, which may include sequences
having about 99% identity to the referenced amino acid sequence in
GenBank accession:AAS99264 and U.S. Pat. No. 7,906,111 (also WO
2005/033321) (i.e., less than about 1% variation from the
referenced sequence). Such AAV may include, e.g., natural isolates
(e.g., hu31 or hu32), or variants of AAV9 having amino acid
substitutions, deletions or additions, e.g., including but not
limited to amino acid substitutions selected from alternate
residues "recruited" from the corresponding position in any other
AAV capsid aligned with the AAV9 capsid; e.g., such as described in
U.S. Pat. Nos. 9,102,949, 8,927,514, US2015/349911; and WO
2016/049230A1. However, in other embodiments, other variants of
AAV9, or AAV9 capsids having at least about 95% identity to the
above-referenced sequences may be selected. See, e.g., US Published
Patent Application No. 2015/0079038. Methods of generating the
capsid, coding sequences therefore, and methods for production of
rAAV viral vectors have been described. See, e.g., Gao, et al,
Proc. Natl. Acad. Sci. U.S.A. 100 (10), 6081-6086 (2003) and US
2013/0045186A1.
[0083] The term "AAV9 intermediate" or "AAV9 vector intermediate"
refers to an assembled rAAV capsid which lacks the desired genomic
sequences packaged therein. These may also be termed an "empty"
capsid. Such a capsid may contain no detectable genomic sequences
of an expression cassette, or only partially packaged genomic
sequences which are insufficient to achieve expression of the gene
product. These empty capsids are non-functional to transfer the
gene of interest to a host cell.
[0084] The term "a" or "an" refers to one or more. As such, the
terms "a" (or "an"), "one or more," and "at least one" are used
interchangeably herein.
[0085] The words "comprise", "comprises", and "comprising" are to
be interpreted inclusively rather than exclusively. The words
"consist", "consisting", and its variants, are to be interpreted
exclusively, rather than inclusively. While various embodiments in
the specification are presented using "comprising" language, under
other circumstances, a related embodiment is also intended to be
interpreted and described using "consisting of" or "consisting
essentially of" language.
[0086] The term "about" encompasses a variation within and
including 10%, unless otherwise specified.
[0087] Unless defined otherwise in this specification, technical
and scientific terms used herein have the same meaning as commonly
understood by one of ordinary skill in the art and by reference to
published texts, which provide one skilled in the art with a
general guide to many of the terms used in the present
application.
[0088] 5.1. AAV.hIDUA Constructs and Formulations
[0089] 5.1.1. Expression Cassettes
[0090] In certain embodiments, an AAV vector that comprises an
expression cassette containing a hIDUA gene characterized by having
the nucleotide sequence of SEQ ID NO: 1 is provided. This sequence,
developed by the inventors, has an identity of about 83% with the
published gene coding sequence of Genbank NP000194.2 encoding SEQ
ID NO: 2. In another embodiment, the expression cassette contains a
hIDUA gene characterized by having the nucleotide sequence at least
about 80% identical to SEQ ID NO: 1 and encodes a functional human
alpha-L-iduronidase. In another embodiment, the sequence is at
least about 85% identity to SEQ ID NO: 1 or at least about 90%
identical to SEQ ID NO:1 and encodes a functional human
alpha-L-iduronidase. In one embodiment, the sequence is at least
about 95% identical to SEQ ID NO:1, at least about 97% identical to
SEQ ID NO:1, or at least about 99% identical to SEQ ID NO: 1 and
encodes a functional human alpha-L-iduronidase. In one embodiment,
this encompasses full-length hIDUA gene, including the leader
peptide sequences of the human alpha-L-iduronidase (i.e., encoding
about amino acid 26, or about amino acid 27, to about amino acid
653 of SEQ ID NO:2), corresponding to about 1 to about 78 of SEQ ID
NO:1. In another embodiment, the hIDUA gene encodes a functional
synthetic human alpha-L-iduronidase enzyme which is synthetic
peptide comprising a heterologous leader sequence fused to the
secreted portion of a functional alpha-L-iduronidase enzyme, i.e.,
about amino acids 27 to about 653 of SEQ ID NO: 2 or one of the
functional variants thereof which are identified herein. Still
further expression cassettes include those identified in SEQ ID NO:
5 and SEQ ID NO: 6. In each, the expression cassettes are flanked
by AAV2 5' and 3' ITRs. Further, each contains a promoter,
enhancer, hIDUA gene, and a polyA.
[0091] In another embodiment, a functional human
alpha-L-iduronidase may include a synthetic amino acid sequence in
which all or a portion of the first 26 amino acids of SEQ ID NO:2,
which correspond to the leader (signal) peptide, are replaced with
a heterologous leader peptide. This leader peptide, e.g., such as
the leader peptides from interleukin-2 (IL-2) or oncostatin, can
improve transport of the enzyme out of the cell through its
secretory pathway into the circulation. Suitable leader peptides
are preferably, although not necessarily of human original.
Suitable leader peptides may be chosen from
proline.bic.nus.edu.sg/spdb/zhang270.htm, which is incorporated by
reference herein, or may be determined using a variety of
computational programs for determining the leader (signal) peptide
in a selected protein. Although not limited, such sequences may be
from about 15 to about 50 amino acids in length, or about 19 to
about 28 amino acids in length, or may be larger or smaller as
required. In addition, at least one in vitro assay has been
described as being useful to assess the enzymatic activity of an
IDUA enzyme [see, e.g., Kakkis et al, Mol Genet Metabol, 2001
March; 72(3): 199-208].
[0092] Identity or similarity with respect to a sequence is defined
herein as the percentage of amino acid residues in the candidate
sequence that are identical (i.e., same residue) or similar (i.e.,
amino acid residue from the same group based on common side-chain
properties, see below) with the peptide and polypeptide regions
provided herein, after aligning the sequences and introducing gaps,
if necessary, to achieve the maximum percent sequence identity.
Percent (%) identity is a measure of the relationship between two
polynucleotides or two polypeptides, as determined by comparing
their nucleotide or amino acid sequences, respectively. In general,
the two sequences to be compared are aligned to give a maximum
correlation between the sequences. The alignment of the two
sequences is examined and the number of positions giving an exact
amino acid or nucleotide correspondence between the two sequences
determined, divided by the total length of the alignment and
multiplied by 100 to give a % identity figure. This % identity
figure may be determined over the whole length of the sequences to
be compared, which is particularly suitable for sequences of the
same or very similar length and which are highly homologous, or
over shorter defined lengths, which is more suitable for sequences
of unequal length or which have a lower level of homology. There
are a number of algorithms, and computer programs based thereon,
which are available to be used the literature and/or publically or
commercially available for performing alignments and percent
identity. The selection of the algorithm or program is not a
limitation of the present invention.
[0093] Examples of suitable alignment programs including, e.g., the
software CLUSTALW under Unix and then be imported into the Bioedit
program (Hall, T. A. 1999, BioEdit: a user-friendly biological
sequence alignment editor and analysis program for Windows
95/98/NT. Nucl. Acids. Symp. Ser. 41:95-98); the Wisconsin Sequence
Analysis Package, version 9.1 (Devereux J. et al., Nucleic Acids
Res., 12:387-395, 1984, available from Genetics Computer Group,
Madison, Wis., USA). The programs BESTFIT and GAP, may be used to
determine the % identity between two polynucleotides and the %
identity between two polypeptide sequences.
[0094] Other programs for determining identity and/or similarity
between sequences include, e.g., the BLAST family of programs
available from the National Center for Biotechnology Information
(NCB), Bethesda, Md., USA and accessible through the home page of
the NCBI at ncbi.nlm.nih.gov), the ALIGN program (version 2.0)
which is part of the GCG sequence alignment software package. When
utilizing the ALIGN program for comparing amino acid sequences, a
PAM120 weight residue table, a gap length penalty of 12, and a gap
penalty of 4 can be used; and FASTA (Pearson W. R. and Lipman D.
J., Proc. Natl. Acad. Sci. USA, 85:2444-2448, 1988, available as
part of the Wisconsin Sequence Analysis Package). SeqWeb Software
(a web-based interface to the GCG Wisconsin Package: Gap
program).
[0095] In some embodiments, the cassette is designed to be
expressed from a recombinant adeno-associated virus, the vector
genome also contains AAV inverted terminal repeats (ITRs). In one
embodiment, the rAAV is pseudotyed, i.e., the AAV capsid is from a
different source AAV than that the AAV which provides the ITRs. In
one embodiment, the ITRs of AAV serotype 2 are used. However, ITRs
from other suitable sources may be selected. Optionally, the AAV
may be a self-complementary AAV.
[0096] The expression cassettes described herein utilized AAV 5'
inverted terminal repeat (ITR) and an AAV 3' ITR. However, other
configurations of these elements may be suitable. A shortened
version of the 5' ITR, termed .DELTA.ITR, has been described in
which the D-sequence and terminal resolution site (trs) are
deleted. In other embodiments, the full-length AAV 5' and/or 3'
ITRs are used. Where a pseudotyped AAV is to be produced, the ITRs
in the expression are selected from a source which differs from the
AAV source of the capsid. For example, AAV2 ITRs may be selected
for use with an AAV capsid having a particular efficiency for
targeting CNS or tissues or cells within the CNS. In one
embodiment, the ITR sequences from AAV2, or the deleted version
thereof (.DELTA.ITR), are used for convenience and to accelerate
regulatory approval. However, ITRs from other AAV sources may be
selected. Where the source of the ITRs is from AAV2 and the AAV
capsid is from another AAV source, the resulting vector may be
termed pseudotyped. However, other sources of AAV ITRs may be
utilized.
[0097] In one embodiment, the expression cassette is designed for
expression and secretion in the central nervous system (CNS),
including the cerebral spinal fluid and brain. In a particularly
desired embodiment, the expression cassette is useful for
expression in both the CNS and in the liver, thereby allowing
treatment of both the systemic and CNS-related effects of MPSI,
Hurler, Hurler-Scheie and Scheie syndromes. For example, the
inventors have observed that certain constitutive promoters (e.g.,
CMV) do not drive expression at desired levels when delivered
intrathecally, thereby providing suboptimal hIDUA expression
levels. However, the chicken beta-actin promoter drives expression
well both upon intrathecal delivery and systemic delivery. Thus,
this is a particularly desirable promoter. Other promoters may be
selected, but expression cassettes containing same may not have all
of the advantages of those with a chicken beta-actin promoter. A
variety of chicken beta-actin promoters have been described alone,
or in combination with various enhancer elements (e.g., CB7 is a
chicken beta-actin promoter with cytomegalovirus enhancer elements,
a CAG promoter, which includes the promoter, the first exon and
first intron of chicken beta actin, and the splice acceptor of the
rabbit beta-globin gene), a CBh promoter [S J Gray et al, Hu Gene
Ther, 2011 September; 22(9): 1143-1153].
[0098] Examples of promoters that are tissue-specific are well
known for liver and other tissues (albumin, Miyatake et al., (1997)
J Virol., 71:5124-32; hepatitis B virus core promoter, Sandig et
al., (1996) Gene Ther., 3:1002-9; alpha-fetoprotein (AFP),
Arbuthnot et al., (1996) Hum. Gene Ther., 7:1503-14), bone
osteocalcin (Stein et al., (1997) Mol. Biol. Rep., 24:185-96); bone
sialoprotein (Chen et al., (1996) J. Bone Miner. Res., 11:654-64),
lymphocytes (CD2, Hansal et al., (1998) J. Immunol., 161:1063-8;
immunoglobulin heavy chain; T cell receptor chain), neuronal such
as neuron-specific enolase (NSE) promoter (Andersen et al., (1993)
Cell. Mol. Neurobiol., 13:503-15), neurofilament light-chain gene
(Piccioli et al., (1991) Proc. Nat. Acad. Sci. USA, 88:5611-5), and
the neuron-specific vgf gene (Piccioli et al., (1995) Neuron,
15:373-84), among others. Alternatively, a regulatable promoter may
be selected. See, e.g., WO 2011/126808B2, incorporated by reference
herein.
[0099] In one embodiment, the expression cassette comprises one or
more expression enhancers. In one embodiment, the expression
cassette contains two or more expression enhancers. These enhancers
may be the same or may be different. For example, an enhancer may
include an Alpha mic/bik enhancer or a CMV enhancer. This enhancer
may be present in two copies which are located adjacent to one
another. Alternatively, the dual copies of the enhancer may be
separated by one or more sequences. In still another embodiment,
the expression cassette further contains an intron, e.g., a chicken
beta-actin intron, a human .beta.-globulin intron, and/or a
commercially available Promega.RTM. intron. Other suitable introns
include those known in the art, e.g., such as are described in WO
2011/126808.
[0100] Further, an expression cassette of the invention is provided
with a suitable polyadenylation signal. In one embodiment, the
polyA sequence is a rabbit globulin poly A. See, e.g., WO
2014/151341. Alternatively, another polyA, e.g., a human growth
hormone (hGH) polyadenylation sequence, an SV50 polyA, or a
synthetic polyA. Still other conventional regulatory elements may
be additional or optionally included in an expression cassette.
[0101] 5.1.2. Production of rAAV.hIDUA Viral Particles
[0102] In certain embodiments, a recombinant adeno-associated virus
(rAAV) particle is provided which has an AAV capsid and having
packaged therein a AAV inverted terminal repeats, a human
alpha-L-iduronidase (hIDUA) gene under the control of regulatory
sequences which control expression thereof, wherein said hIDUA gene
has a sequence shown in SEQ ID NO: 1 or a sequence at least about
95% identical thereto which encodes a functional human
alpha-L-iduronidase. See also, schematic in FIG. 1. In one
embodiment, the hIDUA expression cassette is flanked by an AAV5'
ITR and an AAV3' ITR. In another embodiment, the AAV may be a
single stranded AAV.
[0103] For intrathecal delivery, AAV9 is particularly desirable.
The sequences of AAV9 and methods of generating vectors based on
the AAV9 capsid are described in U.S. Pat. No. 7,906,111;
US2015/0315612; WO 2012/112832; which are incorporated herein by
reference. Optionally, an rAAV9.hIDUA vector as described herein
may be co-administered with a vector designed to specifically
target the liver. Any of a number of rAAV vectors with liver
tropism can be used. Examples of AAV which may be selected as
sources for capsids of rAAV include, e.g., rh10, AAVrh64R1,
AAVrh64R2, rh8 [See, e.g., US Published Patent Application No.
2007-0036760-A1; US Published Patent Application No.
2009-0197338-A1; EP 1310571]. See also, WO 2003/042397 (AAV7 and
other simian AAV), U.S. Pat. Nos. 7,790,449 and 7,282,199 (AAV8),
WO 2005/033321 and U.S. Pat. No. 7,906,111 (AAV9), and WO
2006/110689], and rh10 [WO 2003/042397], AAV3B; AAVdj [US
2010/0047174]. One particularly desirable rAAV is
AAV2/8.TBG.hIDUA.co.
[0104] In many instances, rAAV particles are referred to as DNase
resistant. However, in addition to this endonuclease (DNase), other
endo- and exo-nucleases may also be used in the purification steps
described herein, to remove contaminating nucleic acids. Such
nucleases may be selected to degrade single stranded DNA and/or
double-stranded DNA, and RNA. Such steps may contain a single
nuclease, or mixtures of nucleases directed to different targets,
and may be endonucleases or exonucleases.
[0105] Methods of preparing AAV-based vectors are known. See, e.g.,
US Published Patent Application No. 2007/0036760 (Feb. 15, 2007),
which is incorporated by reference herein. The use of AAV capsids
of AAV9 are particularly well suited for the compositions and
methods described herein. Additionally, the sequences of AAV8 and
methods of generating vectors based on the AAV8 capsid are
described in U.S. Pat. No. 7,282,199 B2, U.S. Pat. Nos. 7,790,449,
and 8,318,480, which are incorporated herein by reference. However,
other AAV capsids may be selected or generated for use in the
invention. The sequences of a number of such AAV are provided in
the above-cited U.S. Pat. No. 7,282,199 B2, U.S. Pat. Nos.
7,790,449, 8,318,480, and 7,906,111, and/or are available from
GenBank. The sequences of any of the AAV capsids can be readily
generated synthetically or using a variety of molecular biology and
genetic engineering techniques. Suitable production techniques are
well known to those of skill in the art. See, e.g., Sambrook et al,
Molecular Cloning: A Laboratory Manual, Cold Spring Harbor Press
(Cold Spring Harbor, N.Y.). Alternatively, oligonucleotides
encoding peptides (e.g., CDRs) or the peptides themselves can
generated synthetically, e.g., by the well-known solid phase
peptide synthesis methods (Merrifield, (1962) J. Am. Chem. Soc.,
85:2149; Stewart and Young, Solid Phase Peptide Synthesis (Freeman,
San Francisco, 1969) pp. 27-62). These and other suitable
production methods are within the knowledge of those of skill in
the art and are not a limitation of the present invention.
[0106] The recombinant adeno-associated virus (AAV) described
herein may be generated using techniques which are known. See,
e.g., WO 2003/042397; WO 2005/033321, WO 2006/110689; U.S. Pat. No.
7,588,772 B2. Such a method involves culturing a host cell which
contains a nucleic acid sequence encoding an AAV capsid; a
functional rep gene; an expression cassette composed of, at a
minimum, AAV inverted terminal repeats (ITRs) and a transgene; and
sufficient helper functions to permit packaging of the expression
cassette into the AAV capsid protein.
[0107] To calculate empty and full particle content, VP3 band
volumes for a selected sample (e.g., in examples herein an
iodixanol gradient-purified preparation where # of GC=# of
particles) are plotted against GC particles loaded. The resulting
linear equation (y=mx+c) is used to calculate the number of
particles in the band volumes of the test article peaks. The number
of particles (pt) per 20 .mu.L loaded is then multiplied by 50 to
give particles (pt)/mL. Pt/mL divided by GC/mL gives the ratio of
particles to genome copies (pt/GC). Pt/mL-GC/mL gives empty pt/mL.
Empty pt/mL divided by pt/mL and .times.100 gives the percentage of
empty particles.
[0108] Generally, methods for assaying for empty capsids and AAV
vector particles with packaged genomes have been known in the art.
See, e.g., Grimm et al., Gene Therapy (1999) 6:1322-1330; Sommer et
al., Molec. Ther. (2003) 7:122-128. To test for denatured capsid,
the methods include subjecting the treated AAV stock to
SDS-polyacrylamide gel electrophoresis, consisting of any gel
capable of separating the three capsid proteins, for example, a
gradient gel containing 3-8% Tris-acetate in the buffer, then
running the gel until sample material is separated, and blotting
the gel onto nylon or nitrocellulose membranes, preferably nylon.
Anti-AAV capsid antibodies are then used as the primary antibodies
that bind to denatured capsid proteins, preferably an anti-AAV
capsid monoclonal antibody, most preferably the B1 anti-AAV-2
monoclonal antibody (Wobus et al., J. Virol. (2000) 74:9281-9293).
A secondary antibody is then used, one that binds to the primary
antibody and contains a means for detecting binding with the
primary antibody, more preferably an anti-IgG antibody containing a
detection molecule covalently bound to it, most preferably a sheep
anti-mouse IgG antibody covalently linked to horseradish
peroxidase. A method for detecting binding is used to
semi-quantitatively determine binding between the primary and
secondary antibodies, preferably a detection method capable of
detecting radioactive isotope emissions, electromagnetic radiation,
or colorimetric changes, most preferably a chemiluminescence
detection kit. For example, for SDS-PAGE, samples from column
fractions can be taken and heated in SDS-PAGE loading buffer
containing reducing agent (e.g., DTT), and capsid proteins were
resolved on pre-cast gradient polyacrylamide gels (e.g., Novex).
Silver staining may be performed using SilverXpress (Invitrogen,
CA) according to the manufacturer's instructions or other suitable
staining method, i.e. SYPRO ruby or coomassie stains. In one
embodiment, the concentration of AAV vector genomes (vg) in column
fractions can be measured by quantitative real time PCR (Q-PCR).
Samples are diluted and digested with DNase I (or another suitable
nuclease) to remove exogenous DNA. After inactivation of the
nuclease, the samples are further diluted and amplified using
primers and a TaqMan.TM. fluorogenic probe specific for the DNA
sequence between the primers. The number of cycles required to
reach a defined level of fluorescence (threshold cycle, Ct) is
measured for each sample on an Applied Biosystems Prism 7700
Sequence Detection System. Plasmid DNA containing identical
sequences to that contained in the AAV vector is employed to
generate a standard curve in the Q-PCR reaction. The cycle
threshold (Ct) values obtained from the samples are used to
determine vector genome titer by normalizing it to the Ct value of
the plasmid standard curve. End-point assays based on the digital
PCR can also be used.
[0109] In one aspect, an optimized q-PCR method is used which
utilizes a broad spectrum serine protease, e.g., proteinase K (such
as is commercially available from Qiagen). More particularly, the
optimized qPCR genome titer assay is similar to a standard assay,
except that after the DNase I digestion, samples are diluted with
proteinase K buffer and treated with proteinase K followed by heat
inactivation. Suitably samples are diluted with proteinase K buffer
in an amount equal to the sample size. The proteinase K buffer may
be concentrated to 2 fold or higher. Typically, proteinase K
treatment is about 0.2 mg/mL, but may be varied from 0.1 mg/mL to
about 1 mg/mL. The treatment step is generally conducted at about
55.degree. C. for about 15 minutes, but may be performed at a lower
temperature (e.g., about 37.degree. C. to about 50.degree. C.) over
a longer time period (e.g., about 20 minutes to about 30 minutes),
or a higher temperature (e.g., up to about 60.degree. C.) for a
shorter time period (e.g., about 5 to 10 minutes). Similarly, heat
inactivation is generally at about 95.degree. C. for about 15
minutes, but the temperature may be lowered (e.g., about 70 to
about 90.degree. C.) and the time extended (e.g., about 20 minutes
to about 30 minutes). Samples are then diluted (e.g., 1000 fold)
and subjected to TaqMan analysis as described in the standard
assay.
[0110] Additionally, or alternatively, droplet digital PCR (ddPCR)
may be used. For example, methods for determining single-stranded
and self-complementary AAV vector genome titers by ddPCR have been
described. See, e.g., M. Lock et al, Hu Gene Therapy Methods, Hum
Gene Ther Methods. 2014 April; 25(2):115-25. doi:
10.1089/hgtb.2013.131. Epub 2014 Feb. 14.
[0111] In brief, the method for separating rAAV9 particles having
packaged genomic sequences from genome-deficient AAV9 intermediates
involves subjecting a suspension comprising recombinant AAV9 viral
particles and AAV 9 capsid intermediates to fast performance liquid
chromatography, wherein the AAV9 viral particles and AAV9
intermediates are bound to a strong anion exchange resin
equilibrated at a pH of 10.2, and subjected to a salt gradient
while monitoring eluate for ultraviolet absorbance at about 260 and
about 280. Although less optimal for rAAV9, the pH may be in the
range of about 10.0 to 10.4. In this method, the AAV9 full capsids
are collected from a fraction which is eluted when the ratio of
A260/A280 reaches an inflection point. In one example, for the
Affinity Chromatography step, the diafiltered product may be
applied to a Capture Select.TM. Poros-AAV2/9 affinity resin (Life
Technologies) that efficiently captures the AAV2/9 serotype. Under
these ionic conditions, a significant percentage of residual
cellular DNA and proteins flow through the column, while AAV
particles are efficiently captured.
[0112] The rAAV.hIDUA vector can be manufactured as shown in the
flow diagram shown in FIG. 11, which is described in more detail in
Section 5.4 and Example 5, infra.
[0113] 5.1.3. Pharmaceutical Formulations of rAAV.hIDUA
[0114] The rAAV9.hIDUA formulation is a suspension containing an
effective amount of AAV.hIDUA vector suspended in an aqueous
solution containing saline, a surfactant, and a physiologically
compatible salt or mixture of salts. Suitably, the formulation is
adjusted to a physiologically acceptable pH, e.g., in the range of
pH 6 to 8, or pH 6.5 to 7.5, pH 7.0 to 7.7, or pH 7.2 to 7.8. As
the pH of the cerebrospinal fluid is about 7.28 to about 7.32, for
intrathecal delivery, a pH within this range may be desired;
whereas for intravenous delivery, a pH of 6.8 to about 7.2 may be
desired. However, other pHs within the broadest ranges and these
subranges may be selected for other route of delivery.
[0115] A suitable surfactant, or combination of surfactants, may be
selected from among non-ionic surfactants that are nontoxic. In one
embodiment, a difunctional block copolymer surfactant terminating
in primary hydroxyl groups is selected, e.g., such as Pluronic.RTM.
F68 [BASF], also known as Poloxamer 188, which has a neutral pH,
has an average molecular weight of 8400. Other surfactants and
other Poloxamers may be selected, i.e., nonionic triblock
copolymers composed of a central hydrophobic chain of
polyoxypropylene (poly (propylene oxide)) flanked by two
hydrophilic chains of polyoxyethylene (poly (ethylene oxide)),
SOLUTOL HS 15 (Macrogol-15 Hydroxystearate), LABRASOL (Polyoxy
capryllic glyceride), polyoxy 10 oleyl ether, TWEEN
(polyoxyethylene sorbitan fatty acid esters), ethanol and
polyethylene glycol. In one embodiment, the formulation contains a
poloxamer. These copolymers are commonly named with the letter "P"
(for poloxamer) followed by three digits: the first two
digits.times.100 give the approximate molecular mass of the
polyoxypropylene core, and the last digit.times.10 gives the
percentage polyoxyethylene content. In one embodiment Poloxamer 188
is selected. The surfactant may be present in an amount up to about
0.0005% to about 0.001% of the suspension.
[0116] In one embodiment, the formulation may contain, e.g., a
concentration of at least about 1.times.10.sup.9 GC/mL to
1.times.10.sup.14 GC/mL as measured by oqPCR or digital droplet PCR
(ddPCR) as described in, e.g., M. Lock et al, Hu Gene Therapy
Methods, Hum Gene Ther Methods. 2014 April; 25(2):115-25. doi:
10.1089/hgtb.2013.131. Epub 2014 Feb. 14, which is incorporated
herein by reference.
[0117] In one embodiment, a frozen composition which contains an
rAAV in a buffer solution as described herein, in frozen form, is
provided. Optionally, one or more surfactants (e.g., Pluronic F68),
stabilizers or preservatives is present in this composition.
Suitably, for use, a composition is thawed and titrated to the
desired dose with a suitable diluent, e.g., sterile saline or a
buffered saline.
[0118] In one example, the formulation may contain, e.g., buffered
saline solution comprising one or more of sodium chloride, sodium
bicarbonate, dextrose, magnesium sulfate (e.g., magnesium sulfate
.7H.sub.2O), potassium chloride, calcium chloride (e.g., calcium
chloride .2H.sub.2O), dibasic sodium phosphate, and mixtures
thereof, in water. Suitably, for intrathecal delivery, the
osmolarity is within a range compatible with cerebrospinal fluid
(e.g., about 275 to about 290); see, e.g.,
emedicine.medscape.com/article/2093316-overview. Optionally, for
intrathecal delivery, a commercially available diluent may be used
as a suspending agent, or in combination with another suspending
agent and other optional excipients. See, e.g., Elliotts B.RTM.
solution [Lukare Medical].
[0119] In other embodiments, the formulation may contain one or
more permeation enhancers. Examples of suitable permeation
enhancers may include, e.g., mannitol, sodium glycocholate, sodium
taurocholate, sodium deoxycholate, sodium salicylate, sodium
caprylate, sodium caprate, sodium lauryl sulfate,
polyoxyethylene-9-laurel ether, or EDTA.
[0120] In certain embodiments, a kit is provided which includes a
concentrated vector suspended in a formulation (optionally frozen),
optional dilution buffer, and devices and other components required
for intrathecal administration are provided. In another embodiment,
the kit may additional or alternatively include components for
intravenous delivery. In one embodiment, the kit provides
sufficient buffer to allow for injection. Such buffer may allow for
about a 1:1 to a 1:5 dilution of the concentrated vector, or more.
In other embodiments, higher or lower amounts of buffer or sterile
water are included to allow for dose titration and other
adjustments by the treating clinician. In still other embodiments,
one or more components of the device are included in the kit.
5.2. Gene Therapy Protocol
[0121] 5.2.1 Target Patient Populations
[0122] Provided herein are methods for treating type I
mucopolysaccharidosis comprising delivering a therapeutically
effective amount of a modified hIDUA expression cassette as
described herein is provided. In particular, provided herein are
methods for preventing, treating, and/or ameliorating
neurocognitive decline in a patient diagnosed with MPS I,
comprising delivering a therapeutically effective amount of a
rAAV.hIDUA described herein to a patient in need thereof. A
"therapeutically effective amount" of the rAAV.hIDUA vector
described herein may correct one or more of the symptoms identified
in any one of the following paragraphs.
[0123] Patients who are candidates for treatment are pediatric and
adult patients with MPSI and/or the symptoms associated with
Hurler, Hurler-Scheie and Scheie. MPSI disorders are a spectrum of
disease from early severe (Hurler) to later onset (Scheie) forms.
Hurler syndrome is typically characterized by no (0%) IDUA enzyme
activity and diagnosed early and is characterized by developmental
delay, heaptospenomegaly, skeletal involvement, corneal clouding,
joint involvement, deafness, cardiac involvement, and death during
the first decade of life. Hurler-Scheie patients have been observed
to have some IDUA enzyme activity (greater than 0% but typically
less than 2%) and by having variable intellectual effects,
respiratory disease, obstructive airway disease, cardiovascular
disease, joint stiffness/contractures, skeletal abnormalities,
decreased visual acuity, and death in teens or twenties. Patients
with Scheie syndrome typically have at least 2% of "normal" IDUA
enzyme activity, and are diagnosed later; such patients typically
have normal intelligence, but have hepatosplenomegaly, joint
involvement, nerve entrapment, deafness, cardiac involvement, and a
normal life span. See, also, Newborn Screening for
Mucopolysaccharidosis Type 1 (MPS I): A Systematic Review of
Evidence Report of Final Findings, Final Version 1.1, Prepared for:
MATERNAL AND CHILD HEALTH BUREAU.
hrsa.gov/advisorycommittees/mchbadvisory/-heritabledisorders/nominatecond-
ition/reviews/mps1finalreport.pdf.
[0124] The compositions of the present invention avoid
complications of long-term enzyme replacement therapy (ERT) related
to immune response to the recombinant enzyme which can range from
mild to full-blown anaphylaxis as well as complications of
life-long peripheral access such as local and systemic infections.
In contrast to ERT, the composition of the invention does not
require life-long, repeated weekly injections. Without wishing to
be bound by theory, the therapeutic method described herein is
believed to be useful for correcting at least the central nervous
system phenotype associated with MPSI disorders by providing
efficient, long-term gene transfer afforded by vectors with high
transduction efficiency which provide continuous, elevated
circulating IDUA levels, which provides therapeutic leverage
outside the CNS compartment. In addition, provided herein are
methods for providing active tolerance and preventing antibody
formation against the enzyme by a variety of routes, including by
direct systemic delivery of the enzyme in protein form or in the
form of rAAV-hIDUA prior to AAV-mediated delivery into CNS.
[0125] In some embodiments, patients diagnosed with Hurler syndrome
are treated in accordance with the methods described herein. In
some embodiments, patients diagnosed with Hurler-Scheie syndrome
are treated in accordance with the methods described herein. In
some embodiments, patients diagnosed with Scheie syndrome are
treated in accordance with the methods described herein. In some
embodiments, pediatric subjects with MPS I who have neurocognitive
deficit are treated in accordance with the methods described
herein.
[0126] In certain embodiments, newborn babies (3 months old or
younger) are treated in accordance with the methods described
herein. In certain embodiments, babies that are 3 months old to 9
months old are treated in accordance with the methods described
herein. In certain embodiments, children that are 9 months old to
36 months old are treated in accordance with the methods described
herein. In certain embodiments, children that are 3 years old to 12
years old are treated in accordance with the methods described
herein. In certain embodiments, children that are 12 years old to
18 years old are treated in accordance with the methods described
herein. In certain embodiments, adults that are 18 years old or
older are treated in accordance with the methods described
herein.
[0127] In one embodiment, a patient may have Hurler syndrome and is
a male or female of at least about 3 months to less than 12 months
of age. In another embodiment, a patient may be male or female
Hurler-Scheie patient and be at least about 6 years to up to 18
years of age. In other embodiments, the subjects may be older or
younger, and may be male or female.
[0128] Suitably, patients selected for treatment may include those
having one or more of the following characteristics: a documented
diagnosis of MPS I confirmed by the lacking or diminished IDUA
enzyme activity as measured in plasma, fibroblasts, or leukocytes;
documented evidence of early-stage neurocognitive deficit due to
MPS I, defined as either of the following, if not explainable by
any other neurological or psychiatric factors:--A score of 1
standard deviation below mean on IQ testing or in 1 domain of
neuropsychological function (language, memory, attention or
non-verbal ability), OR--Documented historical evidence of a
decline of greater than 1 standard deviation on sequential testing.
Alternatively, increased GAGs in urine or genetic tests may be
used.
[0129] Prior to treatment, subjects, e.g., infants, preferably
undergo genotyping to identify MPS I patients, i.e., patients that
have mutations in the gene encoding hIDUA. Prior to treatment, the
MPS I patient can be assessed for neutralizing antibodies (Nab) to
the AAV serotype used to deliver the hIDUA gene. In certain
embodiments, MPS I patients with neutralizing antibody titers to
AAV that are less than or equal to 5 are treated in accordance with
any one or more of the methods described herein.
[0130] Prior to treatment, the MPSI patient can be assessed for
neutralizing antibodies (Nab) to the capsid of the AAV vector used
to deliver the hIDUA gene. Such Nabs can interfere with
transduction efficiency and reduce therapeutic efficacy. MPS I
patients that have a baseline serum Nab titer .ltoreq.1:5 are good
candidates for treatment with the rAAV.hIDUA gene therapy protocol.
Treatment of MPS I patients with titers of serum Nab >1:5 may
require a combination therapy, such as transient co-treatment with
an immunosuppressant before and/or during treatment with rAAV.hIDUA
vector delivery. Optionally, immunosuppressive co-therapy may be
used as a precautionary measure without prior assessment of
neutralizing antibodies to the AAV vector capsid and/or other
components of the formulation. Prior immunosuppression therapy may
be desirable to prevent potential adverse immune reaction to the
hIDUA transgene product, especially in patients who have virtually
no levels of IDUA activity, where the transgene product may be seen
as "foreign." Results of non-clinical studies in mice, dogs and
NHPs described infra are consistent with the development of an
immune response to hIDUA and neuroinflammation. While a similar
reaction may not occur in human subjects, as a precaution
immunosuppression therapy is recommended for all recipients of
rAAV-hIDUA.
[0131] Immunosuppressants for such co-therapy include, but are not
limited to, a glucocorticoid, steroids, antimetabolites, T-cell
inhibitors, a macrolide (e.g., a rapamycin or rapalog), and
cytostatic agents including an alkylating agent, an
anti-metabolite, a cytotoxic antibiotic, an antibody, or an agent
active on immunophilin. The immune suppressant may include a
nitrogen mustard, nitrosourea, platinum compound, methotrexate,
azathioprine, mercaptopurine, fluorouracil, dactinomycin, an
anthracycline, mitomycin C, bleomycin, mithramycin, IL-2 receptor-
(CD25-) or CD3-directed antibodies, anti-IL-2 antibodies,
ciclosporin, tacrolimus, sirolimus, IFN-.beta., IFN-.gamma., an
opioid, or TNF-.alpha. (tumor necrosis factor-alpha) binding agent.
In certain embodiments, the immunosuppressive therapy may be
started 0, 1, 2, 7, or more days prior to the gene therapy
administration. Such therapy may involve co-administration of two
or more drugs, the (e.g., prednelisone, micophenolate mofetil (MMF)
and/or sirolimus (i.e., rapamycin)) on the same day. One or more of
these drugs may be continued after gene therapy administration, at
the same dose or an adjusted dose. Such therapy may be for about 1
week (7 days), about 60 days, or longer, as needed. In certain
embodiments, a tacrolimus-free regimen is selected.
[0132] Nevertheless, in one embodiment, patients having one or more
of the following characteristics may be excluded from treatment at
the discretion of their caring physician: [0133] Has a
contraindication for an IC injection, including any of the
following: [0134] Review of baseline MRI testing shows a
contraindication for an IC injection. [0135] History of prior
head/neck surgery, which resulted in a contraindication to IC
injection. [0136] Has any contraindication to CT (or contrast) or
to general anesthesia [0137] Has any contraindication to MRI (or
gadolinium). [0138] Has estimated glomerular filtration rate (eGFR)
<30 mL/min/1.73 nm. [0139] Has any neurocognitive deficit not
attributable to MPS I or diagnosis of a neuropsychiatric condition.
[0140] Has any history of a hypersensitivity reaction to sirolimus,
MMF, or prednisolone. [0141] Has any condition that would not be
appropriate for immunosuppressive therapy (e.g., absolute
neutrophil count <1.3.times.10.sup.3/.mu.L, platelet count
<100.times.10.sup.3/.mu.L, and hemoglobin <12 g/dL [male] or
<10 g/dL [female]). [0142] Has any contraindication to lumbar
puncture. [0143] Has undergone HSCT. [0144] Has received laronidase
via IT administration within 6 months prior to treatment. [0145]
Has received IT laronidase at any time and experienced a
significant adverse event considered related to IT administration
that would put the patient at undue risk. [0146] Any history of
lymphoma or history of another cancer, other than squamous cell or
basal cell carcinoma of the skin, that has not been in full
remission for at least 3 months before treatment. [0147] Alanine
aminotransferase (ALT) or aspartate aminotransferase (AST)
>3.times.upper limit of normal (ULN) or total bilirubin
>1.5.times.ULN, unless the patient has a previously known
history of Gilbert's syndrome and a fractionated bilirubin that
shows conjugated bilirubin <35% of total bilirubin. [0148]
History of human immunodeficiency virus (HIV)-positive test,
history of active or recurrent hepatitis B or hepatitis C, or
positive screening tests for hepatitis B, hepatitis C, or HIV.
[0149] Is pregnant, <6 weeks post-partum, breastfeeding, or
planning to become pregnant (self or partner) [0150] History of
alcohol or substance abuse within 1 year before treatment. [0151]
Has a serious or unstable medical or psychological condition that,
would compromise the patient's safety. [0152] Uncontrolled
seizures. In other embodiments, a caring physician may determine
that the presence of one or more of these physical characteristics
(medical history) should not preclude treatment as provided
herein.
[0153] 5.2.2. Dosages & Mode of Administration
[0154] Pharmaceutical compositions suitable for administration to
patients comprise a suspension of rAAV.hIDUA vectors in a
formulation buffer comprising a physiologically compatible aqueous
buffer, a surfactant and optional excipients. In certain
embodiments, a pharmaceutical composition described herein is
administered intrathecally. In other embodiments, a pharmaceutical
composition described herein is administered intracisternally. In
other embodiments, a pharmaceutical composition described herein is
administered intravenously. In certain embodiments, the
pharmaceutical composition is delivered via a peripheral vein by
infusion over 20 minutes (.+-.5 minutes). However, this time may be
adjusted as needed or desired. However, still other routes of
administration may be selected. Alternatively or additionally,
routes of administration may be combined, if desired.
[0155] While a single administration of the rAAV is anticipated to
be effective, administration may be repeated (e.g., quarterly,
bi-annually, annually, or as otherwise needed, particularly in
treatment of newborns. Optionally, an initial dose of a
therapeutically effective amount may be delivered over split
infusion/injection sessions, taking into consideration the age and
ability of the subject to tolerate infusions/injections. However,
repeated weekly injections of a full therapeutic dose are not
required, providing an advantage to the patient in terms of both
comfort and therapeutic outcome.
[0156] In some embodiments, the rAAV suspension has an rAAV Genome
Copy (GC) titer that is at least 1.times.10.sup.9 GC/mL. In certain
embodiments, the rAAV Empty/Full particle ratio in the rAAV
suspension is between 0.01 and 0.05 (95%-99% free of empty
capsids). In some embodiments, an MPS I patient in need thereof is
administered a dose of at least about 4.times.10.sup.8 GC/g brain
mass to about 4.times.10.sup.11 GC/g brain mass of the rAAV
suspension.
[0157] The following therapeutically effective flat doses of
rAAV.hIDUA can be administered to MPS I patients of the indicated
age group: [0158] Newborns: about 3.8.times.10.sup.12 to about
1.9.times.10.sup.14 GC; [0159] 3-9 months: about 6.times.10.sup.12
to about 3.times.10.sup.14 GC; [0160] 9-36 months: about 1013 to
about 5.times.10.sup.14 GC; [0161] 3-12 years: about
1.2.times.10.sup.13 to about 6.times.10.sup.14 GC; [0162] 12+
years: about 1.4.times.10.sup.13 to about 7.0.times.10.sup.14 GC;
[0163] 18+ years (adult): about 1.4.times.10.sup.13 to about
7.0.times.10.sup.14 GC.
[0164] In some embodiments, the dose administered to a 12+ year old
MPS I patient (including 18+ year old) is 1.4.times.10.sup.13
genome copies (GC) (1.1.times.10.sup.10 GC/g brain mass). In some
embodiments, the dose administered to a 12+ year old MPS I patient
(including 18+ year old) is 7.times.10.sup.13 GC
(5.6.times.10.sup.10 GC/g brain mass). In still a further
embodiment, the dose administered to an MPSI patient is at least
about 4.times.10.sup.8 GC/g brain mass to about 4.times.10.sup.11
GC/g brain mass. In certain embodiments, the dose administered to
MPS I newborns ranges from about 1.4.times.10.sup.11 to about
1.4.times.10.sup.14 GC; the dose administered to infants 3-9 months
ranges from about 2.4.times.10.sup.11 to about 2.4.times.10.sup.14
GC; the dose administered to MPS I children 9-36 months ranges:
about 4.times.10.sup.11 to about 4.times.10.sup.14 GC; the dose
administered to MPS I children 3-12 years: ranges from about
4.8.times.10.sup.11 to about 4.8.times.10.sup.14 GC; the dose
administered to children and adults 12+ years ranges from about
5.6.times.10.sup.11 to about 5.6.times.10.sup.14 GC.
[0165] Suitable volumes for delivery of these doses and
concentrations may be determined by one of skill in the art. For
example, volumes of about 1 .mu.L to 150 mL may be selected, with
the higher volumes being selected for adults. Typically, for
newborn infants a suitable volume is about 0.5 mL to about 10 mL,
for older infants, about 0.5 mL to about 15 mL may be selected. For
toddlers, a volume of about 0.5 mL to about 20 mL may be selected.
For children, volumes of up to about 30 mL may be selected. For
pre-teens and teens, volumes up to about 50 mL may be selected. In
still other embodiments, a patient may receive an intrathecal
administration in a volume of about 5 mL to about 15 mL are
selected, or about 7.5 mL to about 10 mL. Other suitable volumes
and dosages may be determined. The dosage will be adjusted to
balance the therapeutic benefit against any side effects and such
dosages may vary depending upon the therapeutic application for
which the recombinant vector is employed.
[0166] In one embodiment for intrathecal delivery, the patients are
adult subjects and the dose comprises about 1.times.10.sup.8 GC to
5.times.10.sup.14 GC. In another embodiment, the dose comprises
about 3.8.times.10.sup.12 to about 1.9.times.10.sup.14 GC. Ina
further embodiment, the patients are infant subjects of at least
about 3 months to up to 12 months of age having Hurler syndrome and
the dose comprises at least the equivalent of 4.times.10.sup.8 GC
rAAV9.hIDUA/g brain mass to 3.times.10.sup.12 GC rAAV9.hIDUA/g
brain mass. In another example, the patients are children of at
least about 6 years to up to 18 years of age having Hurler-Scheie
syndrome and the dose comprises the equivalent of at least
4.times.10.sup.8 GC rAAV9.hIDUA/g brain mass to 3.times.10.sup.12
GC rAAV9.hIDUA/g brain mass.
[0167] 5.2.3. Monitoring Efficacy
[0168] Efficacy of the therapy can be measured by assessing (a) the
prevention of neurocognitive decline in patients with MPSI; and (b)
reductions in biomarkers of disease, e.g., GAG levels and/or enzyme
activity in the CSF, serum and/or urine, and/or liver and spleen
volumes. Neurocognition can be determined by measuring intelligence
quotient (IQ), e.g., as measured by Bayley's Infantile Development
Scale for Hurler subjects or as measured by the Wechsler
Abbreviated Scale of Intelligence (WASI) for Hurler-Scheie
subjects. Other appropriate measures of neurocognitive development
and function may be utilized, e.g., assessing developmental
quotient (DQ) using Bayley Scales of Infant Development (BSID-III),
assessing memory using the Hopkins Verbal Learning Test, and/or
using Tests of Variables of Attention (TOVA). Other
neuropsychological function, such as vineland adaptive behavior
scales, visual processing, fine motor, communication,
socialization, daily living skills, and emotional and behavioral
health are monitored. Magnetic Resonance Imaging (MRI) of brain to
acquire volumetric, diffusion tensor imaging (DTI), and resting
state data, median nerve cross-sectional area by ultrasonography,
improvement in spinal cord compression, safety, liver size and
spleen size are also administered.
[0169] Optionally, other measures of efficacy may include
evaluation of biomarkers (e.g., polyamines as described herein) and
clinical outcomes. Urine is evaluated for total GAG content,
concentration of GAG relative to creatinine, as well as MPS I
specific pGAGs. Serum and/or plasma is evaluated for IDUA activity,
anti-IDUA antibodies, pGAG, and concentration of the heparin
cofactor II-thrombin complex and markers of inflammation. CSF is
evaluated for IDUA activity, anti-IDUA antibodies, hexosaminidase
(hex) activity, and pGAG (such as heparan sulfate and dermatan
sulfate). The presence of neutralizing antibodies to vector (e.g.,
AAV9) and binding antibodies to anti-IDUA antibodies may be
assessed in CSF and serum. T-cell response to vector capsid (e.g.,
AAV9) or the hIDUA transgene product may be assessed by ELISPOT
assay. Pharmacokinetics of IDUA expression in CSF, serum, and urine
as well as vector concentration (PCR to AAV9 DNA) may also be
monitored.
[0170] Combinations of gene therapy delivery of the rAAV.hIDUA to
the CNS accompanied by systemic delivery of hIDUA are encompassed
by the methods of the invention. Systemic delivery can be
accomplished using ERT (e.g., using Aldurazyme.COPYRGT.), or
additional gene therapy using an rAAV.hIDUA with tropism for the
liver (e.g., an rAAV.hIDUA bearing an AAV8 capsid).
[0171] Additional measures of clinical efficacy associated with
systemic delivery may include, e.g., Orthopedic Measures, such as
bone mineral density, bone mineral content, bone geometry and
strength, Bone Density measured by dual energy x-ray absorptiometry
(DXA); Height (Z-scores for standing height/lying-length-for-age);
Markers of Bone Metabolism: Measurements of Serum osteocalcin (OCN)
and bone-specific alkaline phosphatase (BSAP), carboxyterminal
telopeptide of type I collagen (ICTP) and carboxyterminal
telopeptide al chain of type I collagen (CTX); Flexibility and
Muscle Strength: Biodex and Physical Therapy evaluations, including
6 minute walk study (The Biodex III isokinetic strength testing
system is used to assess strength at the knee and elbow for each
participant); Active Joint Range of Motion (ROM); Child Health
Assessment Questionnaire/Health Assessment Questionnaire (CHAQ/HAQ)
Disability Index Score; Electromyographic (EMG) and/or Oxygen
Utilization to Monitor an individual's cardiorespiratory fitness:
peak oxygen uptake (VO2 peak) during exercise testing;
Apnea/Hypopnea Index (AHI); Forced Vital Capacity (FVC); Left
Ventricular Mass (LVM).
[0172] In certain embodiments, a method of diagnosing and/or
treating MPSI in a patient, or monitoring treatment, is provided.
The method involves obtaining a cerebrospinal fluid or plasma
sample from a human patient suspected of having MPSI; detecting
spermine concentration levels in the sample; diagnosing the patient
with a mucopolysaccharidosis selected from MPS I in the patient
having spermine concentrations in excess of 1 ng/mL; and delivering
an effective amount of human alpha-L-iduronidase (hIDUA) to the
diagnosed patient as provided herein, e.g., using a device as
described herein.
[0173] In another aspect, the method involves monitoring and
adjusting MPSI therapy. Such method involves obtaining a
cerebrospinal fluid or plasma sample from a human patient
undergoing therapy for MPSI; detecting spermine concentration
levels in the sample by performing a mass spectral analysis;
adjusting dosing levels of the MPSI therapeutic. For example,
"normal" human spermine concentrations are about 1 ng/mL or less in
cerebrospinal fluid. However, patients having untreated MPSI may
have spermine concentration levels of greater than 2 ng/mL and up
to about 100 ng/mL. If a patient has levels approaching normal
levels, dosing of any companion ERT may be lowered. Conversely, if
a patient has higher than desired spermine levels, higher doses, or
an additional therapy, e.g., ERT may be provided to the
patient.
[0174] Spermine concentration may be determined using a suitable
assay. For example the assay described in J Sanchez-Lopez, et al,
"Underivatives polyamine analysis is plant samples by ion pair
liquid chromatography coupled with electrospray tandem mass
spectrometry," Plant Physiology and Biochemistry, 47 (2009):
592-598, avail online 28 Feb. 2009; MR Hakkinen et al, "Analysis of
underivatized polyamines by reversed phase liquid chromatography
with electrospray tandem mass spectrometry", J Pharm Biomec
Analysis, 44 (2007): 625-634, quantitative isotope dilution liquid
chromatography (LC)/mass spectrometry (MS) assay. Other suitable
assays may be used.
[0175] In some embodiments, efficacy of a therapeutic described
herein is determined by assessing neurocognition at week 52
post-dose in pediatric subjects with MPS I who have an early-stage
neurocognitive deficit. In some embodiments, efficacy of a
therapeutic described herein is determined by assessing the
relationship of CSF glycosaminoglycans (GAG) to neurocognition in
an MPS I patient. In some embodiments, efficacy of a therapeutic
described herein is determined by evaluating the effect of the
therapeutic on physical changes to the CNS in an MPS I patient as
measured by magnetic resonance imaging (MRI), e.g., volumetric
analysis of gray and white matter and CSF ventricles. In some
embodiments, efficacy of a therapeutic described herein is
determined by evaluating the pharmacodynamic effect of the
therapeutic on biomarkers, (e.g., GAG, HS) in cerebrospinal fluid
(CSF), serum, and urine of an MPS I patient. In some embodiments,
efficacy of a therapeutic described herein is determined by
evaluating the impact of the therapeutic on quality of life (QOL)
of an MPS I patient. In some embodiments, efficacy of a therapeutic
described herein is determined by evaluating the impact of the
therapeutic on motor function of an MPS I patient. In some
embodiments, efficacy of a therapeutic described herein is
determined by evaluating the effect of the therapeutic on growth
and on developmental milestones of an MPS I patient.
[0176] As expressed from the rAAV vector described herein,
expression levels of at least about 2% as detected in the CSF,
serum, or other tissue, may provide therapeutic effect. However,
higher expression levels may be achieved. Such expression levels
may be from 2% to about 100% of normal functional human IDUA
levels. In certain embodiments, higher than normal expression
levels may be detected in CSF, serum, or other tissue.
[0177] In certain embodiments, the methods of treating, preventing,
and/or ameliorating MPS I and/or symptoms thereof described herein
result in a significant increase in intelligence quotient (IQ) in
treated patients, as assessed using Bayley's Infantile Development
Scale for Hurler subjects. In certain embodiments, the methods of
treating, preventing, and/or ameliorating MPS I and/or symptoms
thereof described herein result in a significant increase in
neurocognitive IQ in treated patients, as measured by Wechsler
Abbreviated Scale of Intelligence (WASI) for Hurler-Scheie
subjects. In certain embodiments, the methods of treating,
preventing, and/or ameliorating MPS I and/or symptoms thereof
described herein result in a significant increase in neurocognitive
DQ in treated patients, as assessed using Bayley Scales of Infant
Development.
[0178] In certain embodiments, the methods of treating, preventing,
and/or ameliorating MPS I and/or symptoms thereof described herein
result in a significant increase in functional human IDUA levels.
In certain embodiments, the methods of treating, preventing, and/or
ameliorating MPS I and/or symptoms thereof described herein result
in a significant decrease in GAG levels, as measured in a sample of
a patient's serum, urine and/or cerebrospinal fluid (CSF).
5.3. Combination Therapies
[0179] Combinations of gene therapy delivery of the rAAV.hIDUA to
the CNS accompanied by systemic delivery of hIDUA are encompassed
by the methods of the invention. Systemic delivery can be
accomplished using ERT (e.g., using Aldurazyme.RTM.), or additional
gene therapy using an rAAV.hIDUA with tropism for the liver (e.g.,
an rAAV.hIDUA bearing an AAV8 capsid).
[0180] In certain embodiments, an intrathecal administration of
rAAV9.hIDUA is be co-administered with a second AAV.hIDUA
injection, e.g., directed to the liver. In such an instance, the
vectors may be same. For example, the vectors may have the same
capsid and/or the same vector genomic sequences. Alternatively, the
vector may be different. For example, each of the vector stocks may
designed with different regulatory sequences (e.g., each with a
different tissue-specific promoter), e.g., a liver-specific
promoter and a CNS-specific promoter. Additionally, or
alternatively, each of the vector stocks may have different
capsids. For example, a vector stock to be directed to the liver
may have a capsid selected from AAV8, AAVrh64R1, AAVrh64R2, rh8,
rh10, AAV3B, or AAVdj, among others. In such a regimen, the doses
of each vector stock may be adjusted so that the total vector
delivered intrathecally is within the range of about
1.times.10.sup.8 GC to .times.1.times.10.sup.14 GC; in other
embodiments, the combined vector delivered by both routes is in the
range of 1.times.10.sup.11 to 1.times.10.sup.16. Alternatively,
each vector may be delivered in an amount of about 10.sup.8 GC to
about 10.sup.12 GC/vector. Such doses may be delivered
substantially simultaneously, or at different times, e.g., from
about 1 day to about 12 weeks apart, or about 3 days to about 30
days, or other suitable times.
[0181] In some embodiments, the patient is co-administered an
AAV.hIDUA via liver-directed and intrathecal injections. In some
embodiments a method for treatment comprises: (a) dosing a patient
having MPS I and/or the symptoms associated with Hurler,
Hurler-Scheie and Scheie syndromes with a sufficient amount of
hIDUA enzyme or liver directed rAAV-hIDUA to induce
transgene-specific tolerance; and (b) administering an rAAV.hIDUA
to the patient's CNS, which rAAV.hIDUA directs expression of
therapeutic levels of hIDUA in the patient.
[0182] In a further embodiment, a method of treating a human
patient having MPSI and/or the symptoms associated with Hurler,
Hurler-Scheie and Scheie syndromes is provided which involves
tolerizing a patient having MPSI and/or the symptoms associated
with Hurler, Hurler-Scheie and Scheie syndromes with a sufficient
amount of hIDUA enzyme or liver-directed rAAV-hIDUA to induce
transgene-specific tolerance, followed by CNS-directed
rAAV-mediated delivery of hIDUA to the patient. In certain
embodiments, the patient is administered an rAAV.hIDUA via
liver-directed injections e.g., when the patient is less than 4
weeks old (neonatal stage) or an infant in order to tolerize the
patient to hIDUA, and the patient is subsequently administered
rAAV.hIDUA via intrathecal injections when the patient is an
infant, child, and/or adult to express therapeutic concentrations
of hIDUA in the CNS.
[0183] In one example, the MPSI patient is tolerized by delivering
hIDUA to the patient within about two weeks of birth, e.g., within
about 0 to about 14 days, or about 1 day to 12 days, or about day 3
to about day 10, or about day 5 to about day 8, i.e., the patient
is a newborn infant. In other embodiments, older infants may be
selected. The tolerizing dose of hIDUA may be delivered via rAAV.
However, in another embodiment, the dose is delivered by direct
delivery of the enzyme (enzyme replacement therapy). Methods of
producing recombinant hIDUA in Chinese hamster ovary (CHO) cells
and soluble rhIDUA in tobacco cells [L H Fu, et al, Plant Science
(Impact Factor: 3.61). 12/2009; 177(6):668-675] or plant seeds [X
He et al, Plant Biotechnol J. 2013 December; 11(9): 1034-1043] have
been described in the literature.
[0184] Additionally, a recombinant hIDUA is commercially produced
as Aldurazyme.RTM. (laronidase); a fusion protein of an anti-human
insulin receptor monoclonal antibody and alpha-L-iduronidase
[AGT-181; ArmaGen, Inc] may be useful. Although currently less
preferred, the enzyme may be delivered via "naked" DNA, RNA, or
another suitable vector. In one embodiment, the enzyme is delivered
to the patient intravenously and/or intrathecally. In another
embodiment, another route of administration is used (e.g.,
intramuscular, subcutaneous, etc). In one embodiment, the MPSI
patient selected for tolerizing is incapable of expressing any
detectable amounts of hIDUA prior to initiation of the tolerizing
dose. When recombinant human IDUA enzyme is delivered, intrathecal
rhIDUA injections may consist of about 0.58 mg/kg body weight or
about 0.25 mg to about 2 mg total rhIDUA per injection (e.g.,
intravenous or intrathecal). For example, 3 cc of enzyme (e.g.,
approximately 1.74 mg Aldurazyme.RTM. (laronidase)) diluted with 6
cc of Elliotts B.RTM. solution for a total injection of 9 cc.
Alternatively, a higher or lower dose is selected. Similarly, when
expressed from a vector, lower expressed protein levels may be
delivered. In one embodiment, the amount of hIDUA delivered for
tolerizing is lower than a therapeutically effective amount.
However, other doses may be selected.
[0185] Typically, following administration of the tolerizing dose,
the therapeutic dose is delivered to the subject, e.g., within
about three days to about 6 months post-tolerizing dose, more
preferably, about 7 days to about 1 month post-tolerizing dose.
However, other time points within these ranges may be selected, as
may longer or shorter waiting periods.
[0186] As an alternative, immunosuppressive therapy may be given in
addition to the vector--before, during and/or subsequent to vector
administration. Immunosuppressive therapy can include prednisolone,
mycophenolate mofetil (MMF) and tacrolimus or sirolimus as
described supra. A tacrolimus-free regimen described infra may be
preferred."
5.4. Manufacture
[0187] The invention provides for the manufacture of the rAAv.hIDUA
pharmaceutical compositions described herein (Example 5, infra). An
illustrative manufacturing process is provided in FIG. 11. The
rAAV.hIUDA vector can be manufactured as shown in the flow diagram
shown in FIG. 11. Briefly, cells are manufactured in a suitable
cell culture (e.g., HEK 293) cells. Methods for manufacturing the
gene therapy vectors described herein include methods well known in
the art such as generation of plasmid DNA used for production of
the gene therapy vectors, generation of the vectors, and
purification of the vectors. In some embodiments, the gene therapy
vector is an AAV vector and the plasmids generated are an AAV
cis-plasmid encoding the AAV genome and the gene of interest, an
AAV trans-plasmid containing AAV rep and cap genes, and an
adenovirus helper plasmid. The vector generation process can
include method steps such as initiation of cell culture, passage of
cells, seeding of cells, transfection of cells with the plasmid
DNA, post-transfection medium exchange to serum free medium, and
the harvest of vector-containing cells and culture media. The
harvested vector-containing cells and culture media are referred to
herein as crude cell harvest.
[0188] The crude cell harvest may thereafter be subject method
steps such as concentration of the vector harvest, diafiltration of
the vector harvest, microfluidization of the vector harvest,
nuclease digestion of the vector harvest, filtration of
microfluidized intermediate, crude purification by chromatography,
crude purification by ultracentrifugation, buffer exchange by
tangential flow filtration, and/or formulation and filtration to
prepare bulk vector.
[0189] A two-step affinity chromatography purification at high salt
concentration followed by anion exchange resin chromatography are
used to purify the vector drug product and to remove empty capsids.
These methods are described in more detail in International Patent
Application No. PCT/US2016/065970, filed Dec. 9, 2016 and its
priority documents, US Patent Application Nos. 62/322,071, filed
Apr. 13, 2016 and 62/226,357, filed Dec. 11, 2015 and entitled
"Scalable Purification Method for AAV9", which is incorporated by
reference herein. Purification methods for AAV8, International
Patent Application No. PCT/US2016/065976, filed Dec. 9, 2016 and is
priority documents US Patent Application Nos. 62/322,098, filed
Apr. 13, 2016 and 62/266,341, filed Dec. 11, 2015, and rh10,
International Patent Application No. PCT/US16/66013, filed Dec. 9,
2016 and its priority documents, U.S. Patent Application No.
62/322,055, filed Apr. 13, 2016 and 62/266,347, entitled "Scalable
Purification Method for AAVrh10", also filed Dec. 11, 2015, and for
AAV1, International Patent Application No. PCT/US2016/065974, filed
Dec. 9, 2016 and its priority documents US Patent Application Nos.
62/322,083, filed Apr. 13, 2016 and 62/26,351, for "Scalable
Purification Method for AAV1", filed Dec. 11, 2015, are all
incorporated by reference herein.
5.5 Apparatus and Method for Delivery of a Pharmaceutical
Composition into Cerebrospinal Fluid
[0190] In one aspect, the vectors provided herein may be
administered intrathecally via the method and/or the device
provided in this section and described further in the Examples and
FIG. 12. Alternatively, other devices and methods may be selected.
The method comprises the steps of advancing a spinal needle into
the cisterna magna of a patient, connecting a length of flexible
tubing to a proximal hub of the spinal needle and an output port of
a valve to a proximal end of the flexible tubing, and after said
advancing and connecting steps and after permitting the tubing to
be self-primed with the patient's cerebrospinal fluid, connecting a
first vessel containing an amount of isotonic solution to a flush
inlet port of the valve and thereafter connecting a second vessel
containing an amount of a pharmaceutical composition to a vector
inlet port of the valve. After connecting the first and second
vessels to the valve, a path for fluid flow is opened between the
vector inlet port and the outlet port of the valve and the
pharmaceutical composition is injected into the patient through the
spinal needle, and after injecting the pharmaceutical composition,
a path for fluid flow is opened through the flush inlet port and
the outlet port of the valve and the isotonic solution is injected
into the spinal needle to flush the pharmaceutical composition into
the patient.
[0191] In another aspect, a device for intracisternal delivery of a
pharmaceutical composition is provided. The device includes a first
vessel containing an amount of a pharmaceutical composition, a
second vessel containing an isotonic solution, and a spinal needle
through which the pharmaceutical composition may be ejected from
the device directly into cerebrospinal fluid within the cisterna
magna of a patient. The device further includes a valve having a
first inlet port interconnected to the first vessel, a second inlet
port interconnected to the second vessel, an outlet port
interconnected to the spinal needle, and a luer lock for
controlling flow of the pharmaceutical composition and isotonic
solution through the spinal needle.
[0192] As used herein, the term Computed Tomography (CT) refers to
radiography in which a three-dimensional image of a body structure
is constructed by computer from a series of plane cross-sectional
images made along an axis.
[0193] The apparatus or medical device 10 as shown in FIG. 12
includes one or more vessels, 12 and 14, interconnected via a valve
16. The vessels, 12 and 14, provide a fresh source of a
pharmaceutical composition, drug, vector, or like substance and a
fresh source of an isotonic solution such as saline, respectively.
The vessels, 12 and 14, may be any form of medical device that
enables injection of fluids into a patient.
[0194] By way of example, each vessel, 12 and 14, may be provided
in the form of a syringe, cannula, or the like. For instance, in
the illustrated embodiment, the vessel 12 is provided as a separate
syringe containing an amount of a pharmaceutical composition and is
referred to herein as a "vector syringe". Merely for purposes of
example, the vessel 12 may contain about 10 cc of a pharmaceutical
composition or the like.
[0195] Likewise, the vessel 14 may be provided in the form of a
separate syringe, cannula, or the like that contains an amount of
saline solution and may be referred to as a "flush syringe". Merely
for purposes of example, the vessel 14 may contain about 10 cc of a
saline solution.
[0196] As an alternative, the vessels 12 and 14 may be provided in
forms other than syringes and may be integrated into a single
device, such as an integrated medical injection device have a pair
of separate chambers, one for the pharmaceutical composition and
one for saline solution. Also, the size of the chambers or vessels
may be provided as needed to contain a desired amount of fluid.
[0197] In the illustrated embodiment, the valve 16 is provided as a
4-way stopcock having a swivel male luer lock 18. The valve 16
interconnects the vessels 12 and 14 (i.e., the vector syringe and
flush syringe in the illustrated embodiment), and the swivel male
luer lock enables a path through the valve 16 to be closed or
opened to each of the vessels 12 and 14. In this way, the path
through the valve 16 may be closed to both the vector syringe and
flush syringe or may be open to a selected one of the vector
syringe and flush syringe. As an alternative to a 4-way stopcock,
the valve may be a 3-way stopcock or fluid control device.
[0198] In the illustrated embodiment, the valve 16 is connected to
one end of a length of extension tubing 20 or the like conduit for
fluid. The tubing 20 may be selected based on a desired length or
internal volume. Merely by way of example, the tubing may be about
6 to 7 inches in length.
[0199] In the illustrated embodiment, an opposite end 22 of the
tubing 12 is connected to a T-connector extension set 24 which, in
turn, is connected to a spinal needle 26. By way of example, the
needle 26 may be a five inch, 22 or 25-gauge spinal needle. In
addition, as an option, the spinal needle 26 may be connected to an
introducer needle 28, such as a three and a half inch, 18-gauge
introducer needle.
[0200] In use, the spinal needle 26 and/or optional introducer
needle 28 may be advanced into a patient towards the cisterna
magna. After needle advancement, Computed Tomography (CT) images
may be obtained that permit visualization of the needle 26 and/or
28 and relevant soft tissues (e.g., paraspinal muscles, bone,
brainstem, and spinal cord).
[0201] Correct needle placement is confirmed by observation of
Cerebrospinal Fluid (CSF) in the needle hub and visualization of a
needle tip within the cisterna magna. Thereafter, the relatively
short extension tubing 20 may be attached to the inserted spinal
needle 26, and the 4-way stopcock 16 may then be attached to the
opposite end of the tubing 20.
[0202] The above assembly is permitted to become "self-primed" with
the patient's CSF. Thereafter, the prefilled normal saline flush
syringe 14 is attached to a flush inlet port of the 4-way stopcock
16 and then the vector syringe 12 containing a pharmaceutical
composition is attached to a vector inlet port of the 4-way
stopcock 16. Thereafter, the output port of the stopcock 16 is
opened to the vector syringe 12, and the contents of the vector
syringe may be slowly injected through the valve 16 and assembled
apparatus and into the patient over a period of time. Merely for
purposes of example, this period of time may be approximately 1-2
minutes and/or any other time of desire.
[0203] After the contents of the vector syringe 12 are injected,
the swivel lock 18 on the stopcock 16 is turned to a second
position so that the stopcock 16 and needle assembly can be flushed
with a desired amount of normal saline using the attached prefilled
flush syringe 14. Merely by way of example, 1 to 2 cc of normal
saline may be used; although greater or lesser amounts may be used
as needed. The normal saline ensures that all or most of the
pharmaceutical composition is forced to be injected through the
assembled device and into the patient and so that little or none of
the pharmaceutical composition remains in the assembled device.
[0204] After the assembled device has been flushed with the saline,
the assembled device in its entirely, including the needle(s),
extension tubing, stopcock, and syringes are slowly removed from
the subject and placed onto a surgical tray for discarding into a
biohazard waste receptacle or hard container (for the
needle(s)).
[0205] A screening process may be undertaken by a principal
investigator which may ultimately lead to an intracisternal (IC)
procedure. The principal investigator may describe the process,
procedure, the administration procedure itself, and all potential
safety risks in order for the subject (or designated caregiver) to
be fully informed. Medical history, concomitant medications,
physical exam, vital signs, electrocardiogram (ECG), and laboratory
testing results are obtained or performed and provided to a
neuroradiologist, neurosurgeon, and anesthesiologist for use in
screening assessment of subject eligibility for the IC
procedure.
[0206] To allow adequate time to review eligibility, the following
procedures may be performed at any time between the first screening
visit and up to one week prior to a study visit. For example, on
"Day 0", Head/Neck Magnetic Resonance Imaging (MRI) with and
without gadolinium (i.e., eGFR >30 mL/min/1.73 m2) may be
obtained. In addition to the Head/Neck MRI, the investigator may
determine the need for any further evaluation of the neck via
flexion/extension studies. The MRI protocol may include T1, T2,
DTI, FLAIR, and CINE protocol images.
[0207] In addition, Head/Neck MRA/MRV may be obtained as per
institutional protocol (i.e., subjects with a history of
intra/transdural operations may be excluded or may need further
testing (e.g., radionucleotide cisternography)) that allows for
adequate evaluation of CSF flow and identification of possible
blockage or lack of communication between CSF spaces.
[0208] The neuroradiologist, neurosurgeon, and anesthesiologist
ultimately discuss and determine the eligibility of each subject
for the IC procedures based on all available information (scans,
medical history, physical exam, labs, etc.). An Anesthesia pre-op
evaluation may also be obtained from "Day -28" to "Day 1" that
provides a detailed assessment of airway, neck
(shortened/thickened) and head range-of-motion (degree of neck
flexion), keeping in mind the special physiologic needs of a MPS
subject.
[0209] Prior to an IC procedure, the CT Suite will confirm the
following equipment and medications are present:
[0210] Adult lumbar puncture (LP) kit (supplied per
institution);
[0211] BD (Becton Dickinson) 22 or 25 gauge.times.3-7'' spinal
needle (Quincke bevel);
[0212] Coaxial introducer needle, used at the discretion of the
interventionalist (for introduction of spinal needle);
[0213] 4 way small bore stopcock with swivel (Spin) male luer
lock;
[0214] T-connector extension set (tubing) with female luer lock
adapter, approximate length of 6.7 inches;
[0215] Omnipaque 180 (iohexol), for intrathecal administration;
[0216] Iodinated contrast for intravenous (IV) administration;
[0217] 1% lidocaine solution for injection (if not supplied in
adult LP kit);
[0218] Prefilled 10 cc normal saline (sterile) flush syringe;
[0219] Radiopaque marker(s);
[0220] Surgical prep equipment/shaving razor;
[0221] Pillows/supports to allow proper positioning of intubated
subject;
[0222] Endotracheal intubation equipment, general anesthesia
machine and mechanical ventilator;
[0223] Intraoperative neurophysiological monitoring (IONM)
equipment (and required personnel); and
[0224] 10 cc syringe containing vector; prepared and transported to
CT/Operating Room (OR) suite in accordance with separate Pharmacy
Manual.
[0225] Informed Consent for the procedure are confirmed and
documented within the medical record and/or study file. Separate
consent for the procedure from radiology and anesthesiology staff
is obtained as per institutional requirements. Subject has
intravenous access placed within the appropriate hospital care unit
according to institutional guidelines (e.g., two IV access sites).
Intravenous fluids are administered at the discretion of the
anesthesiologist. At the discretion of the anesthesiologist and per
institutional guidelines, subject may be induced and undergo
endotracheal intubation with administration of general anesthesia
in an appropriate patient care unit, holding area or the
surgical/CT procedure suite.
[0226] A lumbar puncture is performed, first to remove 5 cc of
cerebrospinal fluid (CSF) and subsequently to inject contrast
(Omnipaque 180) intrathecally to aid visualization of the cisterna
magna. Appropriate subject positioning maneuvers may be performed
to facilitate diffusion of contrast into the cisterna magna.
[0227] Intraoperative neurophysiological monitoring (IONM)
equipment is attached to the subject. Subject is placed onto the CT
scanner table in the prone or lateral decubitus position. Adequate
staff must be present to assure subject safety during transport and
positioning. If deemed appropriate, subject may be positioned in a
manner that provides neck flexion to the degree determined to be
safe during pre-operative evaluation and with normal
neurophysiologic monitor signals documented after positioning.
[0228] The following staff may be confirmed to be present and
identified on-site: Interventionalist/neurosurgeon performing the
procedure; Anesthesiologist and respiratory technician(s); Nurses
and physician assistants; CT (or OR) technicians; Neurophysiology
technician; and Site Coordinator. A "time-out" may be completed per
Joint Commission/hospital protocol to verify correct subject,
procedure, site, positioning, and presence of all necessary
equipment in the room. The lead site investigator may then confirm
with staff that he/she may proceed with prepping the subject.
[0229] The subject's skin under the skull base is shaved as
appropriate. CT scout images are performed, followed by a
pre-procedure planning CT with IV contrast, if deemed necessary by
the interventionalist to localize the target location and to image
vasculature. After the target site (cisterna magna) is identified
and needle trajectory planned, the skin is prepped and draped using
sterile technique as per institutional guidelines. A radiopaque
marker is placed on the target skin location as indicated by the
interventionalist. The skin under the marker is anesthetized via
infiltration with 1% lidocaine. A 22G or 25G spinal needle is than
advanced towards the cisterna magna, with the option to use a
coaxial introducer needle.
[0230] After needle advancement, CT images are obtained using the
thinnest CT slice thickness feasible using institutional equipment
(ideally <2.5 mm). Serial CT images using the lowest radiation
dose possible that allows for adequate visualization of the needle
and relevant soft tissues (e.g., paraspinal muscles, bone,
brainstem, and spinal cord) are obtained. Correct needle placement
is confirmed by observation of CSF in the needle hub and
visualization of needle tip within the cisterna magna.
[0231] The interventionalist confirms that the vector syringe is
positioned close to, but outside of the sterile field. Prior to
handling or administering the pharmaceutical composition in the
vector syringe, gloves, mask, and eye protection are donned by
staff assisting the procedure within the sterile field.
[0232] The extension tubing is attached to the inserted spinal
needle, which is then attached to the 4-way stopcock. Once this
apparatus is "self-primed" with the subject's CSF, the 10 cc
prefilled normal saline flush syringe is attached to a flush inlet
port of the 4-way stopcock. The vector syringe is then provided to
the interventionalist and attached to a vector inlet port on the
4-way stop cock.
[0233] After the outlet port of the stopcock is opened to the
vector syringe by placing the swivel lock of the stopcock in a
first position, the contents of the vector syringe are injected
slowly (over approximately 1-2 minutes), with care taken not to
apply excessive force onto the plunger of the syringe during the
injection. After the contents of the vector syringe are injected,
the swivel lock of stopcock is turned to a second position so that
the stopcock and needle assembly can be flushed with 1-2 cc of
normal saline using the attached prefilled flush syringe.
[0234] When ready, the interventionist then alerts staff that
he/she will remove the apparatus from the subject. In a single
motion, the needle, extension tubing, stopcock, and syringes are
slowly removed from the subject and placed onto a surgical tray for
discarding into a biohazard waste receptacle or hard container (for
the needle).
[0235] The needle insertion site is examined for signs of bleeding
or CSF leakage and treated as indicated by the investigator. Site
is dressed using gauze, surgical tape and/or Tegaderm dressing, as
indicated. Subject is then removed from the CT scanner and placed
supine onto a stretcher. Adequate staff is present to assure
subject safety during transport and positioning.
[0236] Anesthesia is discontinued and subject cared for following
institutional guidelines for post-anesthesia care. Neurophysiologic
monitors are removed from the subject. The head of the stretcher on
which the subject lies should be slightly raised (.about.30
degrees) during recovery. Subject is transported to a suitable
post-anesthesia care unit as per institutional guidelines. After
subject has adequately recovered consciousness and is in stable
condition, he/she will be admitted to the appropriate floor/unit
for protocol mandated assessments. Neurological assessments will be
followed as per the protocol and the Primary Investigator oversees
subject care in collaboration with hospital and research staff.
[0237] In one embodiment, a method for delivery of a composition
provided herein comprises the steps of: advancing a spinal needle
into the cisterna magna of a patient; connecting a length of
flexible tubing to a proximal hub of the spinal needle and an
output port of a valve to a proximal end of the flexible tubing;
after said advancing and connecting steps and after permitting the
tubing to be self-primed with the patient's cerebrospinal fluid,
connecting a first vessel containing an amount of isotonic solution
to a flush inlet port of the valve and thereafter connecting a
second vessel containing an amount of a pharmaceutical composition
to a vector inlet port of the valve; after connecting said first
and second vessels to the valve, opening a path for fluid flow
between the vector inlet port and the outlet port of the valve and
injecting the pharmaceutical composition into the patient through
the spinal needle; and after injecting the pharmaceutical
composition, opening a path for fluid flow through the flush inlet
port and the outlet port of the valve and injecting the isotonic
solution into the spinal needle to flush the pharmaceutical
composition into the patient. In certain embodiment, the method
further comprises confirming proper placement of a distal tip of
the spinal needle within the cisterna magna before connecting the
tubing and valve to the hub of the spinal needle. In certain
embodiments, the confirming step includes visualizing the distal
tip of the spinal needle within the cisterna magna with Computed
Tomography (CT) imaging. In certain embodiments, the confirming
step includes observing the presence of the patient's cerebrospinal
fluid in the hub of the spinal needle.
[0238] In the above-described method, the valve may be a stopcock
with a swivel luer lock adapted to swivel to a first position
permitting flow from the vector inlet port to the outlet port while
simultaneously blocking flow through the flush inlet port and to a
second position permitting flow from the flush inlet port to the
outlet port while simultaneously blocking flow through the vector
inlet port, and wherein the swivel luer lock is positioned into
said first position when said pharmaceutical composition is
injected the patient and is positioned into said second position
when said pharmaceutical composition is being flushed into said
patient by the isotonic solution. In certain embodiments, after
injecting the isotonic solution into the spinal needle to flush the
pharmaceutical composition into the patient, the spinal needle is
withdrawn from the patient with the tubing, valve, and first and
second vessels connected thereto as an assembly. In certain
embodiments, the valve is a 4-way stopcock with a swivel male luer
lock. In certain embodiments, the first and second vessels are
separate syringes. In certain embodiments, a T-connector is located
at the hub of the spinal needle and interconnects the tubing to the
spinal needle. Optionally, the spinal needle includes an introducer
needle at the distal end of the spinal needle. The spinal needle
may be a five inch, 22 or 24-gauge spinal needle. In certain
embodiments, the introducer needle is a 3.5 inch, 18 gauge
introducer needle.
[0239] In certain aspects, the method utilizes a device which is
composed of, at a minimum, a first vessel for containing an amount
of a pharmaceutical composition; a second vessel for containing an
isotonic solution; a spinal needle through which the pharmaceutical
composition may be ejected from the device directly into
cerebrospinal fluid within the cisterna magna of a patient; and a
valve having a first inlet port interconnected to the first vessel,
a second inlet port interconnected to the second vessel, an outlet
port interconnected to the spinal needle, and a luer lock for
controlling flow of the pharmaceutical composition and isotonic
solution through the spinal needle. In certain embodiments, the
valve is a stopcock with a swivel luer lock adapted to swivel to a
first position permitting flow from the first inlet port to the
outlet port while simultaneously blocking flow through the second
inlet port and to a second position permitting flow from the second
inlet port to the outlet port while simultaneously blocking flow
through the first inlet port. Optionally, the valve is a 4-way
stopcock with a swivel male luer lock. In certain embodiments, the
first and second vessels are separate syringes. In certain
embodiments, the spinal needle is interconnected to the valve via a
length of flexible tubing. A T-connector may interconnect the
tubing to the spinal needle. In certain embodiments, the spinal
needle is a five inch, 22 or 24-gauge spinal needle. In certain
embodiments, the device further comprises an introducer needle
connected to a distal end of the spinal needle. Optionally, the
introducer needle is a 3.5 inch, 18 gauge introducer needle.
[0240] This method and this device may each optionally be used for
intrathecal delivery of the compositions provided herein.
Alternatively, other methods and devices may be used for such
intrathecal delivery.
[0241] The following examples are illustrative only and are not a
limitation on the invention described herein.
6. EXAMPLES
Example 1: Protocol for Treatment of Human Subjects
[0242] This Example relates to a gene therapy treatment for
patients that have MPS I. In this example, the gene therapy vector,
AAV9.CB7. hIDUA, a replication deficient adeno-associated viral
vector 9 (AAV9) expressing a modified hIDUA gene encoding the
wild-type hIDUA enzyme, is administered to the central nervous
system (CNS) of the MPSI patients. Doses of the AAV vector are be
injected directly into the CNS under general anesthesia. Efficacy
of treatment is assessed using clinical measures of neurocognitive
development and/or surrogate markers, including biomarkers, e.g., a
decrease in pathogenic GAG and/or hexosaminidase concentration in
the subject's CSF or serum, as described herein.
[0243] A. Gene Therapy Vector
[0244] An illustrative gene therapy vector, AAV9.CB.hIDUA, is
described in Example 3. Expression from the transgene cassette is
driven by a CB7 promoter, a hybrid between a CMV immediate early
enhancer (C4) and the chicken beta actin promoter, while
transcription from this promoter is enhanced by the presence of the
chicken beta actin intron (CI). The polyA signal for the expression
cassette is the RBG polyA. The vector is suspended in formulation
buffer (Elliots B Solution, 0.001% Pluronic F68]. The manufacturing
process is described in more detail in Example 5 below.
[0245] B. Dosing & Route of Administration
[0246] Patients that are 18 years old or older receive a single
intrathecal/intracisternal dose of rAAV9.CB7.hIDUA of
1.4.times.10.sup.13 GC (1.1.times.10.sup.10 GG/g brain mass) (low
dose) or 7.0.times.10.sup.13 GC (5.6.times.10.sup.10 GC/g brain
mass (high dose). For administration of vector, the subject is put
under general anesthesia. A lumbar puncture is performed, first to
remove 5 cc of CSF and subsequently to inject contrast IT to aid
visualization of the cisterna magna. CT (with contrast) is utilized
to guide needle insertion and administration of rAAV9.CB7.hIDUA
into the suboccipital space. Immunosuppressive therapy may be given
in addition to the vector. Immunosuppressive therapy includes
prednisolone (60 mg PO QD Days -2 to 8), MMF (1 g PO BID Days -2 to
60), and sirolimus (6 mg PO Day -2 then 2 mg QD from Day -1 until
the Week 48 visit). Sirolimus dose adjustments can be made to
maintain whole blood trough concentrations within 16-24 ng/mL. In
most subjects, dose adjustments can be based on the equation: new
dose=current dose.times.(target concentration/current
concentration). Subjects should continue on the new maintenance
dose for at least 7-14 days before further dosage adjustment with
concentration monitoring. If neutropenia develops (absolute
neutrophil count <1.3.times.103/.mu.L), MMF dosing should be
interrupted or the dose reduced. Optionally, patients can be
permitted to remain on a stable regimen of intravenous enzyme
replacement therapy (ERT, e.g., ALDURAZYME.TM. [laronidase], as
well as any supportive measures (e.g., physical therapy). Patients
are monitored for any adverse event. Serious adverse events may
include possible drug-induced liver injury with hyperbilirubinemia
defined as ALT .about.3.times.the ULN and bilirubin
.about.2.times.ULN (>35% direct) termed "Hy's Law" events.
[0247] The following therapeutically effective flat doses are
administered to patients of the indicated age group: [0248]
Newborns: about 3.8.times.10.sup.12 to about 1.9.times.10.sup.14
GC; [0249] 3-9 months: about 6.times.10.sup.12 to about
3.times.10.sup.14 GC; [0250] 9-36 months: about 1013 to about
5.times.10.sup.14 GC; [0251] 3-12 years: about 1.2.times.10.sup.13
to about 6.times.10.sup.14 GC; [0252] 12+ years: about
1.4.times.10.sup.13 to about 7.0.times.10.sup.14 GC; [0253] 18+
years (adult): about 1.4.times.10.sup.13 to about
7.0.times.10.sup.14 GC.
[0254] In order to ensure that empty capsids are removed from the
dose of rAAV9.CB7.hIDUA that is administered to patients, empty
capsids are separated from vector particles by cesium chloride
gradient ultracentrifugation or by ion exchange chromatography
during the vector purification process, as discussed in Example 5
herein.
[0255] C. Patient Subpopulations
[0256] Suitable patients may include those: [0257] having
documented diagnosis of MPS I confirmed by enzyme activity, as
measured in plasma, fibroblasts, or leukocytes. [0258] Having
documented evidence (medical records) of early-stage neurocognitive
deficit due to MPS I, defined as either of the following, if not
explainable by any other neurologic or psychiatric factors: [0259]
A score of 2:1 standard deviation below mean on IQ testing or in 1
domain of neuropsychological function (verbal comprehension,
memory, attention, or perceptual reasoning). [0260] Documented
historical evidence (medical records) of a decline of >1
standard deviation on sequential testing. [0261] Has sufficient
auditory and visual capacity, with or without aids, to complete the
required protocol testing and willing to be compliant with wearing
the aid, if applicable, on testing days. [0262] Optionally, has
been on a stable regimen of ERT (i.e., ALDURAZYME.RTM. [laronidase]
IV) for at least 6 months.
[0263] Prior to treatment, patients are screened and one or more of
the following criteria may indicate this therapy is not suitable
for the patient: [0264] Has a contraindication for an IC injection,
including any of the following: [0265] Review of baseline MRI
testing shows a contraindication for an IC injection. [0266]
History of prior head/neck surgery, which resulted in a
contraindication to IC injection. [0267] Has any contraindication
to CT (or contrast) or to general anesthesia [0268] Has any
contraindication to MRI (or gadolinium). [0269] Has estimated
glomerular filtration rate (eGFR)<30 mL/min/1.73 m.sup.2. [0270]
Has any neurocognitive deficit not attributable to MPS I or
diagnosis of a neuropsychiatric condition. [0271] Has any history
of a hypersensitivity reaction to sirolimus, MMF, or prednisolone.
[0272] Has any condition that would not be appropriate for
immunosuppressive therapy (e.g., absolute neutrophil count
<1.3.times.10.sup.3/.mu.L, platelet count
<100.times.10.sup.3/.mu.L, and hemoglobin <12 g/dL [male] or
<10 g/dL [female]). [0273] Has any contraindication to lumbar
puncture. [0274] Has undergone HSCT. [0275] Has received laronidase
via IT administration within 6 months prior to treatment. [0276]
Has received IT laronidase at any time and experienced a
significant adverse event considered related to IT administration
that would put the patient at undue risk. [0277] Any history of
lymphoma or history of another cancer, other than squamous cell or
basal cell carcinoma of the skin, that has not been in full
remission for at least 3 months before treatment. [0278] Alanine
aminotransferase (ALT) or aspartate aminotransferase (AST)
>3.times.upper limit of normal (ULN) or total bilirubin
>1.5.times.ULN, unless the patient has a previously known
history of Gilbert's syndrome and a fractionated bilirubin that
shows conjugated bilirubin <35% of total bilirubin. [0279]
History of human immunodeficiency virus (HIV)-positive test,
history of active or recurrent hepatitis B or hepatitis C, or
positive screening tests for hepatitis B, hepatitis C, or HIV.
[0280] Is pregnant, <6 weeks post-partum, breastfeeding, or
planning to become pregnant (self or partner) [0281] History of
alcohol or substance abuse within 1 year before treatment. [0282]
Has a serious or unstable medical or psychological condition that,
would compromise the patient's safety. [0283] Uncontrolled
seizures. [0284] Suitable patients include, male or female subjects
in age: [0285] Newborns; [0286] 3-9 months of age; [0287] 9-36
months of age; [0288] 3-12 years of age; [0289] 12+ years of age
[0290] 18+ years of age
[0291] D. Measuring Clinical Objectives
[0292] Primary clinical objectives include preventing and/or
optionally reversing the neurocognitive decline associated with
MPSI defects. Clinical objectives are determined by measuring
intelligence quotient (IQ), e.g., as measured by Bayley's Infantile
Development Scale for Hurler subjects or as measured by WASI for
Hurler-Scheie subjects. Other appropriate measures of
neurocognitive development and function are utilized, e.g.,
assessing developmental quotient (DQ) using Bayley Scales of Infant
Development (BSID-III), assessing memory using the Hopkins Verbal
Learning Test, and/or using Tests of Variables of Attention
(TOVA).
[0293] Secondary endpoints include evaluation of biomarkers and
clinical outcomes. Urine is evaluated for total GAG content, as
well as MPS I specific pGAGs. Serum is evaluated for IDUA activity,
anti-IDUA antibodies, pGAG, and concentration of the heparin
cofactor II-thrombin complex. CSF is evaluated for IDUA activity,
anti-IDUA antibodies, hexosaminidase (hex) activity, and pGAG. The
presence of neutralizing antibodies to vector (e.g., AAV9) and
binding antibodies to IDUA may be assessed in CSF and serum, T-cell
response to vector capsid (e.g., AAV9) may be assessed by ELISPOT
assay, and the pharmacokinetics of IDUA expression in CSF, serum,
and urine, as well as vector concentration (PCR to AAV9 DNA) may be
monitored.
Example 2: Neonatal Systemic AAV Induces Tolerance to CNS Gene
Therapy in MPS I Dogs and Nonhuman Primates
[0294] This example demonstrates in both dogs and nonhuman primates
that liver directed gene transfer using an adeno-associated virus
(AAV) vector in neonates induces a persistent state of
immunological tolerance to the transgene, substantially improving
the efficacy of subsequent vector administration targeting the
central nervous system (CNS). This approach was applied to a canine
model of the lysosomal storage disease mucopolysaccharidosis type I
(MPS I), which is characterized by progressive CNS disease due to
deficient activity of the enzyme .alpha.-1-iduronidase (IDUA). CNS
targeted gene transfer using intrathecal AAV delivery in
one-month-old MPS I dogs resulted in antibody induction to canine
IDUA, which partially attenuated the improvement in brain lesions.
MPS I dogs treated systemically in the first week of life with a
vector expressing canine IDUA did not develop antibodies against
the enzyme and exhibited robust expression in the CNS upon
intrathecal AAV delivery at one month of age, resulting in complete
correction of brain storage lesions. Newborn rhesus monkeys treated
systemically with an AAV vector expressing human IDUA likewise
developed tolerance to the transgene, resulting in drastically
higher CSF IDUA expression and absence of antibody induction after
subsequent CNS gene therapy. These findings suggest the possibility
of improving the efficacy and safety of gene therapy by inducing
tolerance to the transgene during a critical period in
immunological development.
[0295] A. Materials and Methods
[0296] 1. Vector Production
[0297] The test articles consisted of an AAV9 capsid packaging an
expression construct consisting of a chicken beta actin promoter
(CB7), a chimeric intron (CI), a codon-optimized canine IDUA
transgene (cIDUA) and a polyadenylation signal (RBG). The
expression construct was flanked by AAV serotype 2 inverted
terminal repeats. This vector is designated as either
AAV2/9.CB7.CI.cIDUA.RBG or AAV9.CB7.CI.cIDUA.RBG. Some animals were
also treated intravenously as neonates with a different vector to
induce tolerance to the canine IDUA protein. This vector consisted
of an AAV8 capsid packaging an expression construct consisting of a
liver specific thyroid hormone binding globulin promoter (TBG), an
artificial intron (PI), the codon-optimized canine IDUA transgene
(cIDUA) and a polyadenylation signal (RBG). The expression
construct was flanked by AAV serotype 2 inverted terminal repeats.
Vectors were produced by triple transfection of 293 cells and
purified on iodixanol gradients as previously described [L Wang et
al, Human gene therapy 22, 1389-1401 (2011); published online
EpubNov].
[0298] 2. Animals
[0299] The MPS I dog colony was maintained at the University of
Pennsylvania School of Veterinary Medicine under NIH and USDA
guidelines for the care and use of animals in research. All MPS I
dog study protocols were approved by the University of Pennsylvania
Institutional Animal Care and Use Committee. For vector injections
in neonatal MPS I dogs, the AAV8 vector was diluted in 0.5-1 mL of
sterile saline, and injected via the jugular vein. Intrathecal
injections of AAV9 vectors and CSF collection were performed via
the suboccipital approach as previously described [C. Hinderer, et
al, Intrathecal Gene Therapy Corrects CNS Pathology in a Feline
Model of Mucopolysaccharidosis I. Molecular therapy: the journal of
the American Society of Gene Therapy, (2014); published online
EpubJul 16]. A total of 9 MPS I dogs were included in this study.
Genotype was confirmed at birth by PCR and serum enzyme assay. Six
dogs were administered an IV injection of the AAV serotype 8 vector
(5.times.10.sup.12 genome copies per kilogram [GC/kg] body weight)
on either the first (N=3) or seventh (N=3) day of life. One animal
died on postnatal day 3. The remaining 5 treated animals as well as
3 naive MPS I dogs were treated with intrathecal AAV9 (10.sup.12
GC/kg) at one month of age. Blood was collected from a peripheral
vessel weekly for the first seven weeks of life then monthly
thereafter. CSF (1 mL) was collected at the time of intrathecal
vector injection (one month of age), on days 7 and 21 after
injection, and monthly thereafter. Euthanasia was performed by
administration of sodium pentobarbital (80 mg/kg IV). Five animals
were euthanized at 9 months of age; were euthanized at 11 months of
age. Untreated MPS I and controls were euthanized between 6 and 26
months of age. Tissues were collected and processed as previously
described [Hinderer et al, 2014].
[0300] All animal procedures conformed to the requirements of the
Animal Welfare Act and protocols were approved prior to
implementation by the Institutional Animal Care and Use Committee
at the University of California, Davis. Activities related to
animal care were performed as per California National Primate
Research Center standard operating procedures. Normally cycling,
adult female rhesus monkeys (Macaca mulatta; N=4) with a history of
prior pregnancy were bred and identified as pregnant, using
established methods [A F Tarantal, in The Laboratory Primate.
(2005), pp. 317-352]. All dams selected for the study were
pre-screened to ensure they were seronegative for AAV antibodies.
Fetuses were monitored sonographically during gestation to confirm
normal growth and development [A F Tarantal (2005)] and newborns
were delivered by cesarean section at term (1602 days gestation)
according to established protocols [A. F. Tarantal, et al, Mol Ther
12, 87-98 (2005); published online EpubJul]. Newborns were placed
in incubators post-delivery and nursery-reared for the study.
Infant health, food intake, and body weights were recorded daily or
weekly (dependent on age) in the nursery according to established
protocols. At birth all animals were administered the selected AAV
vector IV. At one-month postnatal age and at subsequent monthly
time points (up to 2 months post-transfer, to date) infants were
sedated with ketamine (10 mg/kg intramuscularly, IM) and
dexmedetomidine (0.015-0.075 mg/kg IM) in preparation for
collection of CSF (.about.0.5 ml; pre-injection then weekly or
monthly) and for intrathecal injection via the suboccipital
approach (.about.0.5 ml volume; 1 month and immediately after
collection of CSF), all under aseptic conditions. Blood samples
were collected at birth then monthly from a peripheral vessel
(.about.3-6 ml) to monitor CBCs and clinical chemistry panels, and
for collection of serum and plasma. The reversal atipamezole was
given IM at a comparable dose to dexmedetomidine when sample
collection was completed.
[0301] DNA was isolated from tissues and vector genomes quantified
by TaqMan PCR as described [L Wang, 2011]. Assays for IDUA and Hex
activity were performed as described [Hinderer et al, 2014].
[0302] CSF pGAG measurement was performed by the Glycotechnology
Core at the University of California, San Diego using previously
described methods [R. Lawrence, et al, Nature chemical biology 8,
197-204 (2012); published online EpubFeb]. Briefly, GAG was
extracted from CSF samples and digested to disaccharides with
heparinase I, II, and III. Disaccharides were tagged with aniline
.sup.12C by reductive coupling and dried by speed vac. Dried
samples were reconstituted in LC-MS grade water and spiked with a
known concentration of .sup.12C-aniline tagged standard. Samples
were analyzed on a LTQ Orbitrap Discovery electrospray ionization
mass spectrometer (Thermo Scientific) equipped with Thermo
Scientific Ultimate 3000 HPLC system.
[0303] The ELISA for antibodies to canine IDUA was performed as
described [Hinderer et al, 2014], except that the expression
construct contained the canine cDNA under the control of the
thyroid hormone binding globulin promoter, and the cDUA protein was
produced in Huh7 cells. The detection antibody used was
HRP-conjugated sheep anti-canine (Pierce, Rockford, Ill.). The
assay for antibodies to human IDUA in rhesus monkeys was identical,
except that Aldurazyme (Genzyme, Cambridge, Mass.) 10 g/mL, was
used for coating antigen and the detection antibody was polyclonal
goat anti-human (Jackson ImmunoResearch Laboratories, West Grove,
Pa.).
[0304] Histological analysis of MPS I dog brains was performed as
previously described [C. Hinderer, 2014] with the following
modifications for quantifying neurons positive for GM3,
cholesterol, and LIMP2 storage: Images of LIMP2- and
filipin-stained sections of cerebral cortex were taken with a
10.times. objective such that the border between layer I (molecular
layer) and layer II formed the upper border of the image. A total
of 10 images were acquired from each animal. Images of GM3-stained
brain sections were taken with a 4.times. objective from the area
directly below the cerebral cortex surface including the cerebral
molecular layer. Seven images from each animal were analyzed. All
images were processed with ImageJ software (Rasband W. S., National
Institutes of Health, USA; http://rsb.info.nih.gov/ij/) using the
"Threshold" and "Analyze particles" modules as described previously
[M. Aldenboven et al, Biology of Blood and Marrow Transplantation
14, 485-498 (2008); published online EpubMay].
[0305] B. Results
[0306] 1. Antibody Induction to Canine IDUA after Intrathecal
AAV9-Mediated Gene Transfer in MPS I Dogs
[0307] The canine model of MPS I faithfully recapitulates many of
the manifestations of the human disease [E. Kakkis, et al,
Molecular genetics and metabolism 83, 163-174 (2004); published
online EpubSep-October; R. M. Shull, et al, Am J Pathol 114,
487-495 (1984)]. These animals have no detectable IDUA activity due
to a splice site mutation that results in retention of the first
intron of IDUA [K. Menon et al, (Genomics 14, 763-768 (1992)].
Given the absence of detectable IDUA expression in these animals,
we anticipated that they will model the immune response to
intrathecal gene therapy that would occur in patients with the
severe form of MPS I, as these individuals generally carry alleles
that produce no full length IDUA, leaving them immunologically
naive to the protein [N. J. Terlato, G. F. Cox, Can
mucopolysaccharidosis type I disease severity be predicted based on
a patient's genotype? A comprehensive review of the literature.
Genetics in medicine: official journal of the American College of
Medical Genetics 5, 286-294 (2003); published online EpubJul-Aug].
The brains of MPS I dogs show the characteristic pathology
associated with MPS I, including widespread storage of gangliosides
such as GM3 in neurons, as well as abnormal accumulation of
cholesterol and lysosomal membrane proteins including LIMP2 [R. M.
Shull, et al, Am J Pathol 114, 487-495 (1984)]. MPS I dogs also
exhibit prominent storage of glycosaminoglycans (GAGs) in the
meninges, resulting in significant meningeal thickening, a process
which contributes to spinal cord compression in some MPS I patients
[E. Kachur, et al, Neurosurgery 47, 223-228 (2000); published
online EpubJul; A. Taccone, et al, Pediatric Radiology 23, 349-352
(1993); published online EpubSep; S. Vijay, J. E. Wraith, Clinical
presentation and follow-up of patients with the attenuated
phenotype of mucopolysaccharidosis type I. Acta Paediatrica 94,
872-877 (2005)].
[0308] Three (3) dogs were initially treated at one month of age
with an intrathecal injection of an AAV9 vector carrying the canine
IDUA sequence under the control of a ubiquitous promoter. The
injection was well tolerated in all animals; no clinical signs were
observed throughout the study. CSF analyses were generally
unremarkable, with only a mild transient elevation of CSF
lymphocytes occurring in 2 animals. A single CSF sample in one
animal showed a marked pleocytosis consisting primarily of
monocytoid cells. A subsequent tap showed no evidence of
pleocytosis, and at the time of euthanasia, there was no
histological evidence of inflammation in the brain or spinal cord
of any treated animal. The vector was distributed throughout the
CNS, transducing cells in all analyzed regions of the brain and
spinal cord. All animals exhibited supraphysiologic expression of
IDUA in CSF, which declined to the normal range in one animal and
to below normal levels in two animals over the course of 3 months,
after which CSF enzyme levels were essentially stable for 5 months
until the animals were euthanized. The absence of clinical signs,
vector genome loss, or histological evidence of encephalitis
indicated that the decline in CSF IDUA activity was not due to
killing of transduced cells by cytotoxic T lymphocytes, which was
also supported by persistent residual CSF IDUA activity. Instead,
the decline in CSF IDUA activity was associated with the induction
of high titer antibodies against canine IDUA.
[0309] B. Induction of Tolerance to IDUA by Neonatal Gene
Transfer
[0310] To determine whether neonatal expression of canine IDUA
could induce immune tolerance to the enzyme in MPS I dogs, 6
animals were treated with an IV injection of an AAV serotype 8
vector expressing canine IDUA from a liver selective promoter on
either the first (N=3) or the seventh (N=3) day after birth. One of
the dogs treated on postnatal day one died two days after
treatment. Overall survival of neonates was similar to historical
data for untreated MPS I dogs, which have approximately 20%
mortality in the first two weeks of life [Vite, R. et al, Molecular
therapy: the journal of the American Society of Gene Therapy 15,
1423-1431 (2007); published online EpubAug]. The cause of this
early mortality in MPS I dogs has not been determined; in this
treated animal postmortem examination showed systemic lesions
typical of MPS I as well as possible evidence of a systemic
bacterial infection. Treated animals demonstrated an elevation in
serum IDUA followed by a rapid decline. This is consistent with
observations of transient expression due to vector genome loss
during hepatocyte division in previous studies utilizing
non-integrating vectors for hepatic gene transfer in newborns [L.
Wang, et al, Human gene therapy 23, 533-539 (2012); published
online EpubMay].
[0311] At one month of age, the five surviving dogs that received
IV AAV8 in the first week of life were given an injection of an
AAV9 vector using an intrathecal approach. All 5 animals exhibited
peak levels of greater than 30-fold of normal levels of IDUA in CSF
following intrathecal vector injection, with long term CSF enzyme
levels 3- to 100-fold higher than those achieved in naive animals.
Antibodies to canine IDUA were undetectable in the CSF of dogs
treated on postnatal day 1, and were only slightly above the limit
of detection in the animals treated on postnatal day 7, suggesting
a state of immune tolerance to the enzyme in both groups.
[0312] 2. Correction of Biochemical and Histological Abnormalities
in the CNS of MPS I Dogs
[0313] The lysosomal enzyme Hexosaminidase (Hex) is upregulated in
tissues of MPS I animals, and the elevated Hex activity in both
brain tissue and CSF serves as a useful marker for the aberrant
cellular processes occurring downstream of IDUA deficiency
[Hinderer et al (2014)]. Measurement of CSF Hex activity at the
time of intrathecal vector delivery (.about.1 month postnatal)
revealed abnormally elevated Hex activity in all MPS I dogs. The
animals treated with intrathecal AAV9 alone exhibited modest
reductions in CSF Hex activity, with only the animal with the
highest residual IDUA expression reaching the normal range of Hex
activity. All 5 animals treated with neonatal systemic gene
transfer followed by intrathecal vector administration demonstrated
complete normalization of CSF Hex. Hex activity in brain tissue
samples showed a greater response to therapy than CSF Hex, with
substantial reductions in brain Hex activity in all treated
animals, although the effect was slightly diminished in the two
intrathecal-only treated animals with the lowest CSF IDUA
levels.
[0314] GAG concentrations in CSF were measured using an assay
specific for the non-reducing end of the pathologic GAGs (pGAG)
that accumulate due to IDUA deficiency [R. Lawrence, et al; Nature
chemical biology 8, 197-204 (2012); published online EpubFeb]. All
animals exhibited a marked reduction in CSF pGAG concentration 3
weeks after intrathecal AAV injection. This reduction was sustained
at day 112, although the dogs that were not immune tolerant to IDUA
maintained higher residual CSF pGAG than immune tolerant dogs.
Histological analysis revealed severe storage lesions throughout
the brains of untreated MPS I dogs, with widespread neuronal
accumulation of GM3, cholesterol, and LIMP2. The animals treated
with intrathecal AAV9 alone demonstrated substantial improvements
in storage lesions, although only the animal with the highest CSF
IDUA experienced complete resolution of neuronal storage. The other
two intrathecal-treated dogs had residual storage lesions. CNS
storage lesions were completely reversed in all 5 dogs treated with
neonatal AAV8 systemic gene transfer followed by intrathecal AAV9
administration. In addition to the storage lesions in the brain
parenchyma, untreated MPS I dogs showed accumulation of GAGs in
meninges visible by Alcian blue stain. This meningeal GAG
accumulation and the resulting thickening of the meninges is
implicated in many cases of spinal cord compression requiring
surgical intervention, and also likely contributes to the
development of communicating hydrocephalus in some MPS I patients
by interfering with normal routes of CSF resorption. All treated
animals showed evidence of improvement in meningeal GAG storage.
While the meninges appeared almost completely normal in all
tolerant dogs and one nontolerant dog, the two nontolerant animals
with the lowest CSF IDUA activity retained some GAG storage.
[0315] 3. Induction of Tolerance to Human IDUA in Newborn Rhesus
Macaques
[0316] To assess whether the neonatal window for immune tolerance
induction that was observed in MPS I dogs could also be found in
primates, a similar study was performed in newborn rhesus monkeys
(N=4). Because these animals are not IDUA deficient, the human IDUA
transgene was used to model the immune response that might be
expected against a species-specific transgene in a patient lacking
active endogenous protein. Two newborn rhesus monkeys were
administered AAV8 vector expressing human IDUA from a liver
specific promoter IV at birth. Both demonstrated a brief increase
in serum IDUA activity. Two additional newborns were administered
an AAV8 vector expressing an irrelevant transgene (human factor IX)
IV at birth. All four animals were administered AAV9 vector
expressing human IDUA at one-month postnatal age by intrathecal
injection. Similar to the MPS I dogs, the IDUA naive animals
exhibited declining CSF IDUA activity 3 weeks after injection, with
a return to near baseline levels by 2 months post-administration.
These animals also developed transgene specific antibodies in the
CSF. The two animals administered IDUA gene transfer IV at birth
did not develop antibodies to human IDUA in CSF, and maintained CSF
enzyme activity greater than 10-fold normal two months after
intrathecal AAV9 administration. All animals remained robust and
healthy during the study period with no evidence of adverse
effects, normal growth trajectories, and complete blood counts
(CBCs) and chemistry panels within normal limits based on age and
when compared to historical controls.
[0317] C. Discussion
[0318] Immune activation to a wild type therapeutic protein is a
potential concern for any recessive disease. Antibody responses to
protein replacement therapy have been particularly challenging for
some LSDs, as antibodies can interfere with the distribution and
uptake of the intravenously delivered enzyme [E. J. Langereis, et
al, Molecular genetics and metabolism, (2014); published online
EpubOct 29]. Antibodies may be equally problematic for gene
therapies targeting these disorders, as they could interfere with
cross-correction mediated by enzyme secreted from transduced
cells.
[0319] This study demonstrated that intrathecal AAV9 delivery can
effectively target cells throughout the CNS in dogs and achieve
sufficient expression to correct the biochemical and histological
abnormalities associated with MPS I in the brain of a large animal.
Vector biodistribution data showed that there was less than one
vector genome per cell in the brain, indicating that the widespread
reduction in storage pathology observed was due to cross-correction
by secreted enzyme. However, of the three animals treated with
intrathecal vector alone, two developed sufficiently robust
anti-transgene antibody responses to prevent complete resolution of
CNS storage lesions. Only the animal that maintained near-normal
CSF IDUA activity after antibody induction to the transgene
demonstrated a complete response to CNS gene therapy. From this
outcome, it is concluded that IDUA activity in CSF is a reasonable
predictor of efficacy following intrathecal gene transfer, with
approximately normal levels required for full therapeutic benefit.
This is consistent with our findings with intrathecal gene therapy
in MPS I cats [Hinderer (2014)]. MPS I cats generally exhibited
weaker antibody responses to intrathecal gene transfer and more
stable CSF IDUA activity than MPS I dogs. This may relate to the
underlying mutation in the two models, as MPS I cats express an
inactive mutant IDUA, potentially rendering them partially
immunologically tolerant to the enzyme. Importantly, the present
data in MPS I dogs indicates that even for MPS I patients with
severe disease who, like the dogs, have no residual IDUA
expression, the anti-transgene antibody response that is likely to
occur after intrathecal gene transfer does not result in adverse
clinical events, and substantial efficacy is retained despite the
antibody response. However, these data also suggest that preventing
antibody responses against IDUA in the CNS could improve the
efficacy of intrathecal gene therapy for MPS I.
[0320] Using liver-directed gene transfer, the effect of early
exposure to IDUA was tested on subsequent immune responses
following intrathecal gene therapy. Neonatal IDUA expression
induced tolerance to the enzyme in MPS I dogs, which greatly
increased CSF enzyme levels achieved with intrathecal gene therapy
at one month of age. The high CSF IDUA levels in the immune
tolerant group consistently resulted in complete reversal of
neuropathology, providing a strong example of the efficacy that is
possible with intrathecal gene therapy for LSDs when interfering
antibody responses are overcome. The finding that this neonatal
window for induction of immune tolerance to a transgene also exists
in nonhuman primates appears promising for translation to the
clinic. There are several important limitations to the present
study. Due to the increased risks associated with performing
intrathecal vector injections in newborn MPS I pups, systemic gene
transfer was used as a means of inducing tolerance rather than
performing CNS directed gene therapy in neonates.
[0321] The approach used in this example had the advantage that
intrathecal gene therapy was performed in an identical manner and
at the same age in all experimental groups, allowing for direct
comparison of CSF IDUA levels between animals without the
confounding effects of differences in transduction efficiency in
animals of different ages. This study also did not rule out the
possibility that prior liver directed gene therapy contributed to
the improved correction of brain pathology in immune tolerant
animals, although this appears unlikely given that IDUA was
undetectable in CSF in these animals at the time of intrathecal
vector injection, and CSF Hex activity and pGAG concentration
showed no evidence of correction before intrathecal gene transfer.
This is consistent with prior studies in MPS I cats, in which
extremely high serum IDUA activity had no effect on brain lesions
[C. Hinderer, PNAS, 111: 14894-14899 (2014)]. Based on the
observation that detectable antibody responses began to appear in
the MPS I dogs treated on postnatal day 7, it is estimated that
this period lasts no more than one to two weeks, which could serve
as a useful starting point for human studies.
[0322] If human neonates are found to exhibit the same potential
for transgene-specific immunological tolerance that have been
demonstrated herein in dogs and nonhuman primates, neonatal gene
transfer could have enormous potential to treat many genetic
disorders for which immune responses limit the safety or efficacy
of therapy. In order for clinical trials to be feasible, prenatal
or newborn screening will be essential for identifying patients
sufficiently early for this approach to be effective. For MPS I,
newborn screening is now being implemented in several states,
providing a potential opportunity to conduct first-in-human trials
[PV Hopkins et al, J Pediatr, (2014); published online EpubOct
18].
Example 3: Induction of Transgene-Specific Immune Tolerance Enables
Accurate Evaluation of a Human Gene Therapy in a Canine Disease
Model
[0323] A. Materials and Methods [0324] The vector is a
non-replicating recombinant adeno-associated virus (AAV) vector of
serotype 9 expressing human iduronidase (hIDUA). The AAV9 serotype
allows for efficient expression of the hIDUA product in the CNS
following IC administration.
[0325] 1. Vector Production: [0326] The AAV-hIDUA vector genome
plasmid pAAV.CB7.C.hIDUAco.RBG (p3032) is 7,165 bp in size. The
vector genome derived from this plasmid is a single-stranded DNA
genome with AAV2 derived ITRs flanking the hIDUA expression
cassette. Expression from the transgene cassette is driven by a CB7
promoter, a hybrid between a CMV immediate early enhancer (C4) and
the chicken beta actin promoter, while transcription from this
promoter is enhanced by the presence of the chicken beta actin
intron (CI). The polyA signal for the expression cassette is the
RBG polyA. The plasmid was constructed by codon-optimizing and
synthesizing the hIDUA sequence and the resulting construct was
then cloned into the plasmid pENN.AAV.CB7.CI.RBG (p1044), an AAV2
ITR-flanked expression cassette containing CB7, CI and RBG
expression elements to give pAAV.CB7.CI.hIDUAco.RBG (p3032).
Description of the Sequence Elements
[0326] [0327] Inverted terminal repeats (ITR): AAV ITRs (GenBank
#NC001401) are sequences that are identical on both ends, but in
opposite orientation. The AAV2 ITR sequences function as both the
origin of vector DNA replication and the packaging signal of the
vector genome, when AAV and adenovirus helper functions are
provided in trans. As such, the ITR sequences represent the only
cis sequences required for vector genome replication and packaging.
[0328] CMV immediate early enhancer (382 bp, C4; GenBank
#K03104.1). This element is present in the vector genome plasmid.
[0329] Chicken beta-actin promoter (282 bp; CB; GenBank #X00182.1)
promoter and is used to drive high-level hIDUA expression. [0330]
Chicken beta-actin intron: The 973 bp intron from the chicken beta
actin gene (GenBank #X00182.1) is present in the vector expression
cassette. The intron is transcribed, but removed from the mature
messenger RNA (mRNA) by splicing, bringing together the sequences
on either side of it. The presence of an intron in an expression
cassette has been shown to facilitate the transport of mRNA from
the nucleus to the cytoplasm, thus enhancing the accumulation of
the steady level of mRNA for translation. This is a common feature
in gene vectors intended for increased level of gene expression.
This element is present in both vector genome plasmids. [0331]
.alpha.-L-iduronidase coding sequence: The hIDUA sequence (Genbank
NP_000194) was codon-optimized and synthesized [SEQ ID NO:1]. The
encoded protein is 653 amino acids [SEQ ID NO:2] with a predicted
molecular weight of 73 kD and an apparent molecular weight of 83 kD
by SDS PAGE. [0332] Polyadenylation Signal: The 127 bp rabbit
beta-globin polyadenylation signal (GenBank #V00882.1) provides cis
sequences for efficient polyadenylation of the antibody mRNA. This
element functions as a signal for transcriptional termination, a
specific cleavage event at the 3' end of the nascent transcript and
addition of a long polyadenyl tail. This element is present in both
vector genome plasmids. [0333] Inverted terminal repeats (ITR): AAV
ITRs (GenBank #NC001401) are sequences that are identical on both
ends, but in opposite orientation. The AAV2 ITR sequences function
as both the origin of vector DNA replication and the packaging
signal of the vector genome, when AAV and adenovirus helper
functions are provided in trans. As such, the ITR sequences
represent the only cis sequences required for vector genome
replication and packaging.
[0334] The construct was packaged in an AAV9 capsid, purified and
titered as previously described in M. Lock et al, Human Gene Ther,
21: 1259-1271 (2010)].
[0335] 2. Animal Procedures:
[0336] The MPS I dog colony was maintained at the University of
Pennsylvania School of Veterinary Medicine under NIH and USDA
guidelines for the care and use of animals in research. All study
protocols were approved by the University of Pennsylvania
Institutional Animal Care and Use Committee. For infusions of
recombinant human IDUA, laronidase (Genzyme) was diluted 5-fold in
saline immediately before use. Infusions were performed through a
peripheral venous catheter over two hours. Intrathecal injections
of AAV9 vectors and CSF collection were performed via the
suboccipital approach as previously described [C. Hinderer, et al,
(Mol. Ther. J. Am. Soc. Gene Ther. 22, 2018-2027 (2014)].
Euthanasia was performed by administration of sodium pentobarbital
(80 mg/kg IV). Tissues were collected and processed as previously
described [Hinderer (2014)].
[0337] 3. Enzyme assays: IDUA and Hex activity were measured in
tissue lysates and CSF as previously described [C. Hinderer, et al,
(Mol. Ther. J. Am. Soc. Gene Ther. 22, 2018-2027 (2014))].
[0338] 4. Anti-hIDUA ELISA: Polystyrene ELISA plates were coated
overnight at 4 degrees with recombinant human IDUA (Genzyme)
diluted to 5 .mu.g/mL in phosphate buffer pH 5.8. The plate was
washed and blocked in 2% BSA in pH 5.8 phosphate buffer. The plate
was incubated 1 hour at room temperature with CSF samples diluted
1:50 in PBS. The plate was washed and bound antibody detected with
HRP conjugated anti-canine IgG (Pierce, Rockford, Ill.) diluted
1:10,000 in phosphate buffer with 2% BSA. The ELISA was developed
with tetramethylbenzidine substrate for 15 minutes, then stopped
with 2 N sulfuric acid and absorbance was measured at 450 nm.
Titers were calculated from a standard curve of a serially diluted
positive sample.
[0339] 5. Histology, Biodistribution and Statistics: Histological
analysis brains was performed as previously described [Hinderer,
2014] with the following modifications for quantifying neurons
positive for GM3, cholesterol, and LIMP2 storage: Images of LIMP2-
and filipin-stained sections of cerebral cortex were taken with a
10.times. objective such that the border between layer I (molecular
layer) and layer II formed the upper border of the image. A total
of 10 images were acquired from each animal. Images of GM3-stained
brain sections were taken with a 4.times. objective from the area
directly below the cerebral cortex surface including the cerebral
molecular layer. Seven images from each animal were analyzed. All
images were processed with ImageJ software (Rasband W. S., National
Institutes of Health, USA; http://rsb.info.nih.gov/ij/) using the
"Threshold" and "Analyze particles" modules as described previously
[M Aldenboven et al, Biology of Blood and Marrow Transplantation
14, 485-498 (2008); published online EpubMay]. Quantification of
thickness of the cervical meninges was performed on H&E stained
sections of the cervical spinal cord. Fifteen measurements of total
meningeal thickness were made per slide at 300 .mu.m intervals.
[0340] Vector biodistribution was evaluated as follows. DNA was
isolated from tissues and vector genomes quantified by TaqMan PCR
as described [L. L. Wang, et al, Impact of Pre-Existing Immunity on
Gene Transfer to Nonhuman Primate Liver with Adeno-Associated Virus
8 Vectors. Human gene therapy 22, 1389-1401 (2011); published
online EpubNov]. Data were evaluated using Kruskal-Wallis test
followed by Dunn's test or Mann-Whitney test as appropriate.
P<0.05 was considered statistically significant. All statistical
analyses were performed using Prism 6.0 (GraphPad Software).
[0341] B. Results
[0342] 1. Intrathecal AAV9 Expressing Human IDUA Elicits Robust
Transgene-Specific Immunity in MPS I Dogs
[0343] The MPS I dog carries an IDUA mutation resulting in
inclusion of the first intron in the mature mRNA, creating an
immediate stop codon. The mutation in MPS I dogs yields no
detectable IDUA activity [K P Menon, et al, Genomics, 14: 763-768
(1992); N J Terlato, et al, Genet Med, 5: 286-294 (2003); X X He,
et al, Mol. Genet Metab, 67: 106-112 (1999)]. In the absence of
lysosomal IDUA activity, un-degraded GAGs accumulate in the cell [G
N Sando, et al Cell, 12: 619-627 (2011)]. This primary GAG storage
material in affected tissues can be directly detected
histologically by Alcian blue staining [C. Hinderer, et al, Mol.
Ther. J. Am. Soc. Gene Ther. 22, 2018-2027 (2014); N J Terloato et
al (2003); R. M. Shull, et al, Am J Pathol 114, 487-95 (1984); R.
M. Shull, et al, Proc. Natl. Acad. Sci. U.S.A. 91, 12937-12941
(1994); L. A. Clarke, et al., Pediatrics 123, 229-40 (2009); N. M.
Ellinwood, et al., Mol. Genet. Metab. 91, 239-250 (2007); M. E.
Haskins, et al, Am. J. Pathol. 112, 27 (1983); A. Chen, et al,
Apmis 119, 513-521 (2011)]. In addition to the primary GAG storage
pathology, lysosomal GAG accumulation leads to a characteristic
cascade of cellular abnormalities. The un-degraded GAGs cause
lysosomal distention, which are visible on histology by increased
staining for lysosomal membrane proteins such as LIMP2. Neurons
also exhibit secondary accumulation of substances such as
gangliosides (e.g. GM3) and un-esterified cholesterol. Lysosomal
storage also induces aberrant overexpression of lysosomal enzymes
such as hexosaminidase (Hex).
[0344] Three MPS I dogs were treated at one month of age with a
single intrathecal injection into the cisterna magna of a clinical
candidate AAV9 vector expressing human IDUA. Vector doses ranged
from 101 genome copies per kg (GC/kg) (n=2) to 10.sup.12 GC/kg
(n=1). The procedure was well tolerated in all subjects. IDUA
activity in CSF rapidly increased following vector administration,
exceeding that of normal controls by day 7 (FIG. 2A, Naive).
However, by day 21 post vector administration, CSF IDUA levels fell
to baseline, accompanied by an elevation in CSF anti-hIDUA antibody
titers (FIG. 2A, Naive). Day 21 CSF samples also revealed a
lymphocytic pleocytosis in all animals (FIG. 4A, Naive). In this
cohort, the elevated CSF antibodies and cell counts were not
associated with clinical signs or other laboratory abnormalities,
and the pleocytosis spontaneously resolved. At the time of necropsy
six months after injection, histological evaluation revealed no
evidence of pathology in the brain or spinal cord. Vector
biodistribution demonstrated widespread CNS transduction and
persistence of the vector genome.
[0345] Brain hexosaminidase overexpression was reduced relative to
untreated MPS I dogs, although it was not normalized at either dose
(FIG. 7). Histology also showed partial resolution of brain storage
lesions by LIMP2 and GM3 immunostaining, which did not appear to be
dose dependent.
[0346] Based on the favorable safety profile observed in these
dogs, two additional MPS I dogs were treated with a 10-fold higher
dose of vector (1013 GC/kg). These dogs developed CSF pleocytosis
with similar kinetics to the animals treated at the lower two doses
(FIG. 4A, Naive); however, in these two subjects the response was
more pronounced, and the pleocytosis was temporally associated with
the onset of neurological signs. Beginning 21 days after vector
administration, the animals exhibited hyporeflexia and weakness of
the hind limbs, and pain upon flexion of the neck. Pain and CSF
pleocytosis began to resolve following treatment with analgesics
and corticosteroids; however, the hind limb weakness persisted, and
the animals were euthanized two weeks after symptom onset.
Histopathology demonstrated robust transduction of spinal motor
neurons, particularly in the lumbar spinal cord, and lymphocytic
infiltrates surrounding transduced neurons. Systematic evaluation
of sections throughout the brain and spinal cord confirmed that the
pathology was primarily localized to the lumbar spinal cord,
although occasional infiltrates were observed in the brain.
[0347] 2. Neonatal Exposure to Human IDUA Through Hepatic Gene
Transfer Induces Tolerance to Subsequent Intrathecal Gene
Transfer
[0348] In order to evaluate the AAV9 vector expressing human IDUA
in the absence of an exaggerated immune response to the transgene,
we attempted to induce immunological tolerance to the human protein
through neonatal exposure. On postnatal day 5, six MPS I dogs were
treated with a single intravenous injection of an AAV serotype 8
vector (AAV8) expressing human IDUA from a liver specific promoter.
At one month of age the animals were treated with an intrathecal
injection into the cisterna magna of different doses of the AAV9
vector expressing human IDUA in three cohorts (n=2 animals per
cohort) as follows: 10.sup.10, 10.sup.11 and 10.sup.12 GC/kg. All
animals exhibited a dose-dependent elevation in CSF IDUA activity
similar to the non-tolerized dogs (FIG. 2A); however, in this
cohort CSF enzyme expression persisted beyond day 21 and remained
detectable for the duration of the experiment (FIG. 2B, Tolerized).
CSF antibody responses were blunted compared with those observed
when naive (i.e., non-tolerized) animals were dosed with
intrathecal vector; only two animals in the tolerized cohorts
(I-602 and I-606) exhibited detectable titers, which were
approximately 20-fold lower than naive animals treated with an
equivalent vector dose (FIG. 3). Only the dog with the highest
antibody titer in this cohort (I-606) exhibited elevated CSF
lymphocytes at day 21, albeit at lower levels than in the naive
animals (FIGS. 4A and 4B). There were no clinical adverse events in
these cohorts.
[0349] 3. Intrathecal AAV9-Mediated hDUA Expression Effects
Dose-Dependent Correction of Brain Biochemical Abnormalities and
Storage Lesions
[0350] The six MPS I dogs tolerized to human IDUA through neonatal
gene transfer were sacrificed 6 months post intrathecal AAV9
injection. Brain lysates demonstrated complete normalization of
hexosaminidase activity at the highest vector dose, with partial
correction at the lowest dose (FIG. 5). Hexosaminidase activity was
normalized in CSF at all vector doses (FIG. 8). The thickening of
the cervical meninges, which can contribute to spinal cord
compression in MPS I patients, was reversed in animals treated at
all doses (FIG. 9). Histological evaluation of the brain revealed
dose-dependent decreases in LIMP2 and GM3 storage in the hIDUA
tolerant dogs (FIGS. 6A-6B). Animals treated with the highest
vector does exhibited LIMP2 and GM2 staining similar to normal
controls; at the lowest dose, there were measurable improvements in
some markers (LIMP2 and Hex), whereas GM2 accumulation was not
clearly reduced. The low dose of 10.sup.10 GC/kg therefore appeared
to be the minimum effective dose (MED).
[0351] The MED of IT AAV9.CB7.hIDUA was established in 8 MPS I dogs
previously tolerized to human IDUA in order to evaluate efficacy in
the absence of a confounding immune response to the human protein.
Dogs were treated with IT AAV9.CB7.hIDUA at 1 month of age, and
were euthanized for evaluation of brain storage pathology 6 months
later. Establishment of the MED utilized well characterized
histological measures of MPS I disease in CNS tissue including
LIMP2 and GM3. All measures of lysosomal storage pathology were
normalized at the highest dose evaluated (10.sup.12 GC/kg body
weight). Consistent improvement was also observed at a ten-fold
lower dose (10.sup.11 GC/kg body weight), although animals in this
cohort did not reach the normal range for GM3 or LIMP2 storage. In
the lowest dose group (10.sup.10 GC/g body weight) histological
evidence of lysosomal storage showed modest improvement by LIMP2
staining and minimal improvement in GM3 accumulation. We therefore
estimate that 1010 GC/kg body weight is the MED for IT
AAV9.CB7.hIDUA. The dose-dependent resolution of brain storage
lesions correlated with CSF IDUA activity and was inversely
correlated with CSF spermine concentration, indicating that CSF
IDUA activity and CSF spermine could be useful biomarkers for the
evaluation of AAV9.CB7.hIDUA pharmacodynamics in clinical
studies.
[0352] These data indicate that the MED of AAV9.CB7.hIDUA is
10.sup.10 GC/kg in MPS I dogs.
[0353] AAV9.CB7.hIDUA administration was also evaluated in naive
MPS I dogs. MPS I dogs (5) received an intrathecal injection of
AAV9.MPSI test vector at 1 month of age. All animals treated at
10.sup.11 GC/kg body weight and 10.sup.12 GC/kg body weight
exhibited a mild self-limited lymphocytic pleocytosis. These
animals appeared healthy throughout the study, and at necropsy 6
months after injection there was no evidence of inflammation in the
brain, spinal cord, or meninges. The 2 dogs treated with a dose of
10.sup.13 GC/kg body weight appeared well initially, but 3 weeks
post injection developed neurologic signs which coincided with a
more severe pleocytosis and histological evidence of a T cell
response to transduced cells, with mononuclear cells surrounding
dying motor neurons in the lumbar spinal cord. These results are
consistent with dose-dependent immunological toxicity mediated by
lymphocytes targeting transduced spinal motor neurons. In view of
the differences in sequence between the human and dog IDUA
proteins, it is not surprising that human IDUA is immunogenic in
the dog.
[0354] In the non-tolerized MPS I dogs, the MTD was 10.sup.12
GC/kg. Since the MTD is based on a canine immune response to a
human protein, this is a conservative estimate of the MTD. Scaled
to the 45 g brain mass of a one-month old dog, and with an average
body weight of 2 kg, this dose would correspond to an MED of
9.times.10.sup.10 total or 2.times.10.sup.9 GC/g brain mass, or
approximately 1.4.times.10.sup.13 GC total (1.1.times.10.sup.10
GC/g brain mass) GC in an adult human (approximately 5.times.canine
MED on GC/g brain mass basis).
[0355] 4. Infusion of Recombinant hDUA in Newborn MPS I Dogs is
Sufficient to Induce Tolerance to Intrathecal AAV9-Mediated hIDUA
Expression
[0356] In order to determine whether hepatic expression of human
IDUA was necessary for tolerance induction, we treated two MPS I
dogs (I-663 and I-664) with infusions of recombinant human IDUA
(0.58 mg/kg) on postnatal day 7 and 14 before intrathecal AAV9
injection at one month of age. Similar to dogs treated as newborns
with a vector expressing human IDUA, the enzyme-treated dogs
exhibited persistently high levels of CSF IDUA activity (FIGS.
2A-2B) and minimal antibody response against human IDUA (FIG. 2) or
CSF pleocytosis (FIGS. 4A-4B3). Brain hexosaminidase activity was
reduced (FIG. 5) and storage lesions were effectively cleared in
both animals (FIGS. 6A-6B).
[0357] C. Discussion
[0358] Evaluating the efficacy of intrathecal AAV9 delivery for the
treatment of MPS I required assessment of both the vector
distribution that could be achieved via injection into the CSF, and
the impact of that degree of transduction on disease-specific
markers. These studies necessitated the use of an animal model that
could accurately reflect the disease pathophysiology while also
displaying sufficiently similar size and anatomy to allow for
meaningful evaluation of the clinical delivery method and the
resulting vector distribution. The canine model of MPS I faithfully
replicates the human phenotype, exhibiting not only the same
biochemical and histological lesions, but also many of the same
clinical manifestations [K P Menon, et al, Genomics, 14: 763-8
(1992); R M Shull, et al, (1984); R M Shull et al, (1994); C Ciron
et al, Ann Neurol, 60: 204-213 (2006); P. Dickson et al, Ann
Neurol, 60: 204-213 (2006)]. Due to the phenotypic similarity to
MPS I in humans, MPS I dogs were used extensively in the
development of enzyme replacement therapy for the treatment of
systemic disease [R M Shull et al, PNAS 91: 12937-12941 (1994); P.
Dickson et al, J Clin Invest, 118: 2868-2876 (2008)]. MPS I dogs
also mimic CNS manifestations of the disease, sporadically
developing spinal cord compression and hydrocephalus [P. Dickson,
et al, Mol. Genet. Metab. 99, S15-S15 (2010); P. I. Dickson, et al,
Mol. Genet. Metab. 98, 70-70 (2009); C. H. Vite, et al, Comp. Med.
63, 163-173 (2013)]. Though cognitive studies have not been
reported for MPS I dogs, the histological and biochemical
manifestations in the brain have been well characterized, and
faithfully recapitulate the findings in humans with the severe form
of the disease [R M Shull (1984); C. Ciron (2006); S U Walkley, et
al, Acta Neuropathol. (Berl.) 75, 611-620 (1988)]. MPS I dog brains
demonstrate accumulation of lysosomal membrane proteins (LIMP2) and
gangliosides (GM3), and upregulation of lysosomal enzymes such as
hexosaminidase (Hex). Ganglioside accumulation correlates with
cognitive function in MPS I and other lysosomal storage diseases,
and thus is a critical marker for evaluating disease severity and
therapeutic outcomes [S. U. Walkley, M. T. Vanier, Secondary lipid
accumulation in lysosomal disease, Biochim. Biophys. Acta BBA-Mol.
Cell Res. 1793, 726-736 (2009); G. Constantopoulos, et al, J.
Neurochem. 34, 1399-1411 (1980)]. MPS I dogs also exhibit changes
in neuronal morphology similar to those identified in patients [S U
Walkley, (1988)]. These striking similarities made this a
compelling model for the evaluation of intrathecal AAV delivery as
a novel therapy for the CNS manifestations of MPS I in humans. The
capacity of large animal models to replicate the route of
administration that would be used clinically for IT AAV9 delivery,
as well as the resulting vector distribution in the CNS, further
supported the relevance of the MPS I dog for these studies.
[0359] Although the MPS I dog appeared to be an excellent model for
evaluation of the clinical vector, the immune response to human
IDUA presented a critical obstacle. From previous studies it is
clear that the immune response to human IDUA in MPS I dogs is much
more extreme than that observed in patients. Intravenous delivery
of the protein in both dogs and MPS I patients often elicits
antibodies; however, in dogs these responses are more robust, less
likely to decline upon continued administration, and more often
associated with anaphylactic responses to subsequent infusions [R M
Shull, et al, 1994); E. Kakkis, et al, Proc Natl Acad Sci USA 101,
829-34 (2004)]. The difference in immune response to human IDUA in
the CNS is even more striking; MPS I dogs treated with intrathecal
infusions of the enzyme show evidence of meningitis as well as
antibody responses detectable in CSF. In contrast, for both
pediatric and adult MPS I patients treated with repeated IT
infusions of the protein, there have been no similar adverse
effects, and in the 5 patients that have been tested for CSF
antibodies against IDUA only one has been positive [C. Ciron
(2006); P. Dickson, et la, (2010); P. I. Dickson, et al, Mol.
Genet. Metab. 98, 70-70 (2009); P. I. Dickson, et al, Mol. Genet.
Metab. 101, 115-122 (2010); P. I. Dickson, et al, Mol. Genet.
Metab. 93, 247-247 (2008); E. Kakkis, et al, Mol. Genet. Metab. 83,
163-174 (2004); T. C. Lund, et al, Mol. Genet. Metab. 111, S74 (2);
M. Vera, et al, Pediatr. Res. 74, 712-720 (2013)]. Interestingly
MPS I dogs also develop CSF antibodies against canine IDUA, albeit
at lower levels than to the human enzyme, suggesting that this
model has a greater overall tendency toward immunity to IDUA, which
is exacerbated by the use of the non-species-specific protein.
These marked differences in the outcome of both intravenous and
intrathecal delivery of human IDUA in MPS I dogs and patients
indicate a consistently exaggerated immune response to human IDUA
in MPS I dogs, and suggest that preventing this response will be
necessary to replicate the anticipated vector activity in humans.
Inducing tolerance to the protein through neonatal exposure allowed
for the evaluation of the efficacy of the human vector in this
model without the interference of the exaggerated immune response.
This provided critical information, allowing for the accurate
determination of a minimum effective dose--an essential factor in
the design of first-in-human gene therapy trials--in the most
relevant animal model. More particularly, extensive dose-ranging
studies were performed in MPS I dogs. The minimum effective dose
was determined in immune-tolerant animals and is estimated to be a
dose of 2.times.10.sup.9 GC/g brain mass as determined by the oqPCR
method described herein. Dose-ranging safety was performed in
immune-competent (i.e., IDUA- and AAV-naive) dogs and toxicity was
observed at doses of 10.sup.12 GC/g. Based on the finding of
dose-limiting toxicity (DLT) at 10.sup.12 GC/g in the stringent
canine model of immune-mediated toxicity, a 10-fold lower dose will
be administered in the formal Good Laboratory Practice (GLP)
toxicology studies in rhesus macaques. The dose that will be
evaluated in the formal GLP nonhuman primate (NHP) toxicology
studies will be 1.1.times.10.sup.11 GC/g brain mass. If toxicity is
not encountered, the clinical starting dose will be
1.1.times.10.sup.10 GC/g brain mass. This starting dose is
approximately 5-fold greater than the minimum effective dose (MED)
in the canine MPS I model, and nearly as large as the doses that
demonstrated reliable histological responses in MPS I dog and cat
studies, supporting a reasonable expectation of clinical efficacy
at this dose. The starting dose is also approximately 90-fold lower
than the dose at which toxicity was observed in MPS I dogs and
10-fold lower than the dose tested in nonhuman primates, providing
an acceptable safety margin to account for the potential of human
subjects to exhibit greater sensitivity to vector- or
transgene-related toxicity. Based on these data, the starting dose
represents an acceptable benefit:risk profile, where the dose is
expected to be in the therapeutic range (and, therefore, may offer
clinical benefit), but is expected to be below toxic vector doses
(and, therefore, should be reasonably safe). The calculation below
depicts how the dose in dogs is extrapolated to a starting dose in
humans: 1-month Dog Brain=45 grams; Dog: MED 9.times.10.sup.10 GC
total (2.times.10.sup.9 GC/g brain mass). Adult Human Brain=1300
grams Human: Starting Dose (5.times.canine MED).
1.4.times.10.sup.13 GC total (1.1.times.10.sup.10 GC/g brain mass).
Without this approach, the only options would be to extrapolate
efficacy data from vectors with species-specific transgenes, which
could have important differences in potency, or move studies to a
less representative animal model that is more immune tolerant to
the human protein. Pharmacologic immune suppression can also be
employed in this setting, although the neonatal tolerance-induction
protocol has the clear advantage of avoiding secondary consequences
of the immune-suppressing drugs.
[0360] Though efficacy assessment was confounded by the immune
response and loss of circulating IDUA in the non-tolerized dogs
treated with the human vector, some useful data can be derived from
these animals. While the strong immune response is not likely to
represent the immune response in humans, it could inform monitoring
plans for first-in-human studies by demonstrating key
characteristics of immune-mediated toxicity. In this case, we
observed that immune-mediated toxicity was dose dependent, the peak
of the immune response occurred 3 weeks after vector
administration, presented with focal motor symptoms likely due to
high transduction of spinal motor neurons, and was accompanied by
CSF pleocytosis. These findings could be directly integrated into
the phase 1 trial protocol, with intensive monitoring for
immune-mediated toxicity and neurological symptoms extending for
several weeks after vector administration, and CSF analysis for
pleocytosis occurring 2-4 weeks after injection. If neurological
symptoms accompanied by pleocytosis appeared with similar kinetics
in a human study subject, the findings in naive dogs would suggest
that the toxicity is due to an immune response (as opposed to
overexpression toxicity, for example) and could guide therapeutic
decisions.
[0361] A strong correlation emerged between vector dose, CSF enzyme
levels, and correction of brain storage lesions in MPS I dogs that
were tolerized to human IDUA. The relationship between IDUA
activity in the CSF and correction of brain pathology could be a
valuable observation as this approach advances into human trials,
where IDUA activity detected in CSF may be a useful predictor of
clinical response. Even more useful would be the identification of
CSF markers that directly reflect the severity of CNS storage
pathology. CSF biomarkers would be a valuable tool for evaluating
correction of the underlying CNS pathology in MPS I patients, and
the canine model could be an ideal system for identification of
such markers. In this study, we evaluated one potential CSF
biomarker, the enzyme hexosaminidase. While substantially elevated
in brain tissue of MPS I dogs, Hex activity was only modestly
elevated in the CSF. CSF Hex was normalized in all treated animals,
regardless of the degree of tissue response. CSF Hex may therefore
be useful to confirm vector activity in clinical studies, but is
not likely to predict a therapeutic response. Future studies using
the MPS I dog model may allow for evaluation of additional CSF
markers and their correlation with brain storage lesions, which
could ultimately yield powerful new tools to non-invasively
evaluate the severity of CNS involvement in MPS I and the impact of
novel therapeutics.
[0362] The present findings indicate that neonatal exposure to
human IDUA can induce tolerance using two different sources of the
enzyme. While Example 3 shows that AAV-mediated expression could
induce transgene-specific tolerance in neonates, this Example shows
that infusion of the recombinant enzyme could also induce
tolerance. If this approach is generalizable to other proteins, it
could be useful for more accurate preclinical evaluation of many
human therapeutics in animal models. Further, if a similar approach
could induce tolerance to foreign proteins in human neonates, it
could have enormous potential to improve the efficacy of protein
replacement therapies for diseases in which antibody responses to
the normal protein limit efficacy. While most MPS I patients appear
to tolerate intrathecal IDUA infusions, the vast majority develop
serum antibodies against intravenous enzyme replacement, and these
antibodies can diminish the response to therapy. Combining neonatal
tolerance induction with a gene or protein replacement therapy may
substantially improve patient outcomes. The availability of an
approved recombinant enzyme would make MPS I an excellent candidate
for an initial human trial of this approach. If human neonates
exhibit the same window of 1-2 weeks for tolerance induction,
newborn screening would be essential for identifying patients early
enough for successful intervention. The ongoing implementation of
newborn screening for MPS I and other lysosomal storage diseases
will therefore be critically important for clinical evaluation of a
neonatal tolerance-induction protocol.
Example 4--Intrathecal AAV-mediated Human IDUA Gene Transfer in
Juvenile Rhesus Macaques
[0363] A. Intrathecal Delivery
[0364] The purpose of this study was to evaluate the safety of
intrathecal (IT) administration of AAV2/9.CB7.CI.hIDUAco.RBG, an
AAV9 vector expressing human IDUA in one-month-old rhesus macaques,
a model developmentally similar to a human infant at 6-9 months of
age. In addition, this study evaluated whether antibodies to the
transgene product in serum or cerebrospinal fluid (CSF) affected
the safety of vector administration and the activity of human
IDUA.
[0365] This study included 4 rhesus macaques. Pilot studies
indicated that macaques can develop antibodies against human
.alpha.-L-iduronidase (IDUA). As an antibody response to the human
IDUA transgene product was anticipated in macaques, 2 of the
animals were tolerized at birth by an intravenous (IV)
administration of AAV8 vector expressing human IDUA from a
liver-specific promoter (AAV2/8.TBG.PI.COhIDUA.nRBG). To control
for procedural effects and exposure to the AAV8 vector, the other 2
macaques were administered an AAV8 vector expressing an irrelevant
transgene (human coagulation factor IX
(AAV2/8.LSP.IVS2.hFIXco.WPRE.BGH) IV at birth. At 1 month postnatal
age, all 4 animals were administered AAV2/9.CB7.CI.hIDUAco.RBG, an
AAV9 vector expressing human IDUA at a dose of 3.times.1012 GC/kg
by IT injection. Animals were observed for 16 months
post-administration at the time of report issuance and will remain
on study for at least 1 more year. Endpoints assessed throughout
the study include general observations, body weight, and
comprehensive clinical pathology (blood cell counts with
differentials and serum chemistries). In addition, IDUA enzyme
activity and antibody responses to the transgene were measured in
CSF.
[0366] This study revealed no vector related pathology and no (0)
clinical sequelae. All animals exhibited normal growth
trajectories. Serum chemistries and blood cell counts were within
the normal range of historical control Rhesus macaques of
comparable age and housing conditions. Antibodies to the transgene
were detected in the CSF of the 2 non-tolerized animals, but not in
the 2 animals tolerized to human IDUA as neonates. In both
IDUA-tolerized animals, IDUA activity at least 15% greater than
baseline levels was detectable in CSF throughout the study. In the
non-tolerized animals, CSF IDUA activity rapidly increased after
AAV9.MSPI test vector administration, but fell to baseline
following antibody induction. The presence of transgene-specific
antibodies in CSF did not impact on the safety of IT AAV9.CB7.hIDUA
administration but did affect the ability to detect human IDUA
levels in CSF.
[0367] In conclusion, intrathecal administration of a single dose
of AAV9.CB7.hIDUA was well tolerated in one-month old Rhesus
macaques at a dose of 3.times.10.sup.12 GC/kg At this dose, levels
of hIDUA of at least 15% above baseline were detectable in the CSF
of animals that had been tolerized at birth to human IDUA; animals
that had not been tolerized developed antibody responses to hIDUA
that were detectable in the CSF and negatively correlated with
hIDUA expression. No effects on growth, behavior, or clinical
chemistry or hematology parameters were observed that were
attributed to treatment, either in animals that were positive for
anti-IDUA antibodies or animals that were not
antibody-positive.
[0368] A. Materials and Methods
[0369] The vectors used in this study include an rAAV9.hIDUA, an
rAAV8.hIDUA, and an AAV8 vector having an irrelevant transgene
(hFIX).
[0370] Intrathecal (IT) administration via suboccipital puncture
was selected because it is the proposed route for clinical use.
This study evaluated a single vector dose which was scaled to the
body mass of the animal. Two animals were administered with an IV
injection of rAAV8.hIDUA (10.sup.12 GC/kg) on postnatal Day 1
(study Day 0) in order to induce immunological tolerance to human
IDUA. The control animals were administered a control vector
expressing an irrelevant transgene (human factor IX) from a liver
specific promoter (rAAV8.hFIX) on postnatal day 1. All animals were
then administered IT AAV9.MPSI test vector by suboccipital puncture
at 1 month of age (study Day 30).
[0371] B. Results and Conclusion
[0372] Four one-month-old rhesus macaques (M mulatta) were
administered IT 3.times.10.sup.12 GC/kg rAAV9.hIDUA and monitored
for more than 1 year post-vector administration. Two of these
animals were tolerized at birth to the human IDUA protein.
[0373] There were no treatment-related effects on body weight or
body weight gain and no treatment-related clinical signs. There no
treatment-related effects on clinical chemistry or hematology
parameters. Antibodies to the transgene product were detectable in
the CSF of the 2 animals that were not pre-treated to induce
tolerance to the human protein. There were no differences in the
endpoints assessed (clinical signs, body weight, hematology and
clinical chemistry) between tolerized and non-tolerized animals,
indicating that CSF antibodies to the protein were not associated
with apparent toxicity. In the IDUA tolerant animals, there was
persistent IDUA expression in CSF at more than 2-fold baseline
levels in 1 animal and approximately 15% over baseline in the other
animal.
[0374] In conclusion, intrathecal administration of a single dose
of rAAV9.CB7.hIDUA was well tolerated in one-month old rhesus
macaques at a dose of 3.times.10.sup.12 GC/kg. At this dose, levels
of hIDUA of 115-200% of baseline were detectable in the CSF of
animals that had been tolerized at birth to human IDUA; animals
that had not been tolerized developed antibody responses to hIDUA
that were detectable in the CSF and negatively correlated with
hIDUA expression. No effects on growth, behavior, or clinical
chemistry or hematology parameters were observed that were
attributed to treatment, either in animals that were positive for
anti-IDUA antibodies or animals that were not
antibody-positive.
Example 5--Intrathecal AAV-Mediated Human IDUA Gene Transfer in
Cynomolgus Macaques
[0375] The vector consisted of an AAV9 capsid packaging an
expression construct consisting of a cytomegalovirus promoter
(CMV), a chimeric intron (PI), a codon-optimized human IDUA
transgene (hIDUA) and a polyadenylation signal (SV40). The
expression construct was flanked by AAV serotype 2 inverted
terminal repeats. There is one vector used in this study, but this
vector is designated as either, AAV2/9.CMV.PI.hIDUA.SV40,
AAV2/9.CMV.PI.hIDUAco.SV40, AAV2/9.CMV.PI.hIDUAco.SV40PA or AAV9.
CMV.PI.hIDUA.SV40.
[0376] A. Materials and Methods
[0377] This study included two female cynomolgus macaques (IDs
06-09 and 07-19). Both macaques received 10.sup.12 genome copies
per kilogram of body weight (GC/kg) of
AAV2/9.CMV.PI.hIDUAco.SV40PA. The intrathecal (IT) route via
suboccipital puncture was selected because it is the proposed route
for clinical use.
TABLE-US-00001 Weight at Dose/kg injection body Total Vector (kg)
weight dose AAV2/9.CMV.PI.hIDUAco.SV40PA 3.90 1.00E+12 3.90E+12
AAV2/9.CMV.PI.hIDUAco.SV40PA 4.60 1.00E+12 4.60E+12 1. Dose per
gram brain mass is based on a 90 g brain.
[0378] B. Results and Conclusions
[0379] Two adult female cynomolgus macaques were treated with an
intrathecal injection of an AAV9 vector expressing human IDUA from
a CMV promoter. Body weight, physical exams, and blood counts and
serum chemistries were assessed on study Day 1, 7, 14, 28, 91, 118,
147, 182, 208, 239, 261, 294, 322, 350, 378, 413, 434, 462, 490,
518, 561, 589, 624, and 636 after vector administration, after
which the animals were necropsied for analysis of histopathology
and vector biodistribution. There were no vector-related clinical
adverse events. One animal developed a femoral aneurysm 600 days
after vector administration. This is believed to be secondary to
repeated blood collection and is not likely to be treatment
related. There were no treatment-related effects on clinical
pathology parameters including terminal CSF parameters.
Histopathology showed no evidence of CNS pathology, and no apparent
vector-related abnormalities in peripheral organs. Biodistribution
analysis indicated vector deposition throughout the brain and
spinal cord of both NHPS that was one to two orders of magnitude
higher than in peripheral organs with one exception. Significant
liver distribution occurred in one animal without pre-existing
neutralizing antibodies to the AAV9 capsid, whereas the animal with
pre-existing serum antibodies to the vector exhibited minimal liver
transduction. Immunostaining of brain sections from both animals
demonstrated expression of human IDUA.
[0380] This study provided evidence that IT AAV9-mediated gene
transfer can allow for long-term expression of IDUA in the brain.
This study also provided preliminary evidence of the safety of this
approach.
Example 6--Intracerebroventricular (ICV) AAV9.hIDUA Delivery in
Mice in Setting of Pre-Existing Immunity to hDUA
[0381] This pilot study was designed to evaluate histological
evidence of toxicity following intracerebroventricular (ICV)
administration of an AAV9.hIDUA vector in treatment-naive mice, as
well as mice with pre-existing antibodies against the transgene
product, human iduronidase (IDUA).
[0382] The test article consisted of an AAV9 capsid packaging an
expression construct consisting of a chicken beta actin promoter
(CB7), a chimeric intron (CI), a codon-optimized human IDUA
transgene (hIDUAco) and a polyadenylation signal (RBG). The
expression construct was flanked by AAV serotype 2 inverted
terminal repeats. This vector is designated as either
AAV9.CB7.CI.hIDUA.RBG. The final product was diluted in Elliot's
Formulation Buffer (EFB).
[0383] This non-GLP study was originally planned as an aid in
designing a GLP toxicology study in pre-immunized mice, but the GLP
study was not performed based on FDA feedback that the experimental
design based on immunization against a non-species specific protein
in normal mice is unlikely to be representative of patients
previously treated with enzyme replacement therapy (ERT). At the
time that the decision was made against performing a GLP toxicology
study in pre-immunized mice, the initial pilot study was already
underway. The results of the pilot study are included in this
report.
[0384] This study included 100 adult C57BL/6 mice (50/sex). Half of
the animals were immunized against human IDUA with a single
intramuscular (IM) injection of recombinant human IDUA
(Aldurazyme.RTM.) in adjuvant (TiterMax). Six months after
immunization both the immunized animals and naive animals were
treated with an ICV injection of AAV9.hIDUA at 1 of 2 doses
(5.times.10.sup.10 GC or 2.5.times.10.sup.11 GC). Animals from each
treatment group were sacrificed at 1 of 5 time points (Day 7, 14,
30, 60 or 90) after vector administration. The brain, spinal cord,
heart, lung, liver, spleen, kidney and gonads were harvested for
histopathology.
[0385] In the naive (non-immunized) cohort (n=50, 25/sex), no
animals died before the scheduled necropsy or demonstrated clinical
abnormalities. Brain histopathology showed dilation of the lateral
ventricle and a visible needle track in some animals, consistent
with the ICV route of administration. Minimal to mild lymphocytic
infiltration of the meninges and/or brain parenchyma occurred in 12
out of the 50 mice, and did not show a clear correlation with
vector dose or time after injection. Hepatitis occurred in a manner
that was both dose dependent and correlated with the time after
vector administration. Minimal to moderate hepatitis occurred in
all 5 animals in the high dose cohort sacrificed 14 days after
vector administration. Only minimal hepatitis was observed in the
high dose animals sacrificed at 7, 30, 60 or 90 days. In the low
dose cohort only minimal hepatitis was observed; this occurred in 8
animals with no clear correlation with time after vector
administration. Moderate myocarditis occurred in one animal in the
high dose cohort 60 days after vector administration; 3 additional
animals in the high dose cohort exhibited minimal myocarditis at 30
or 90 days post vector administration. Two animals in the low dose
cohort exhibited minimal myocarditis and 1 exhibited mild
myocarditis; all occurred 60 days post vector administration. There
were no other potentially vector-related abnormalities observed in
the naive (non-immunized) cohort.
[0386] In the cohort that was immunized to human IDUA before vector
administration (n=50, 25/sex) 3 animals died (2 males, 1 female); 2
that received a high dose (2.5.times.10.sup.11 GC) of
AAV9.CB7.hIDUA, and 1 that received a low dose (5.times.10.sup.10
GC). All 3 died on study Day 18 or 19. Histopathology in the
immunized group was consistent with a severe cell-mediated immune
response to transduced cells in peripheral organs, with moderate to
severe myocarditis occurring in 8 out of 50 animals and moderate to
severe hepatitis occurring in 8 out of 50 animals. Both findings
correlated with vector dose and timing of vector administration,
with the most severe findings occurring 14 days after vector
administration. Findings in the brain were less severe; moderate
meningitis or encephalitis occurred in 3 animals treated with a
high vector dose and 1 animal treated with a low vector dose. These
findings did not correlate with the time of vector administration.
Other findings in the brain were minimal or mild.
[0387] Overall the results in the naive (non-immunized) cohort were
consistent with the induction of an immune response to the human
transgene, as evidenced by lymphocytic infiltration of the liver,
and to a lesser degree the heart, both organs which are transduced
by AAV9 that escapes to the peripheral circulation following IT
injection.sup.1,2. In this setting toxicity was evident at the
highest dose evaluated (2.5.times.10.sup.11 GC).
[0388] In the pre-immunized cohort, the immunization strategy
appeared to induce a robust cell-mediated immune response to the
transgene, resulting in moderate to severe myocarditis and
hepatitis in some vector treated animals. Toxicity correlated with
vector dose. Since the experimental design was based on
immunization against a non-species specific protein in normal mice,
the applicability to patients previously treated with ERT is
unclear.
Example 7--Safety and Biodistribution of AAV9.CB7.hIDUA Vector
Injected Intrathecally (IT) in Non-Human Primates
[0389] This study evaluated the safety and biodistribution of
AAV9.CB7.hIDUA for up to 180 days after administration by
image-guided suboccipital puncture in rhesus macaques. Adult rhesus
macaques (n=9, 6 females, 3 males, Groups 1A, B and C) were
administered a single dose of 1013 GC AAV9.CB7.hIDUA by image
guided suboccipital puncture, corresponding approximately to a dose
of 1.1.times.10.sup.11 GC/g of brain mass. An additional 3 animals
(2 females, 1 male, Groups 2A and B) were administered a single
dose of vehicle (Elliotts B.RTM. +0.001% Pluronic.RTM. F68) by
image guided suboccipital puncture. Animals were euthanized and
necropsied on Day 14 (Groups 1A and 2A), Day 90 (Groups 1B and 2B),
or Day 180 (Group IC) after test article or control article
administration. Toxicity was evaluated by daily observations, and
by physical exams, CBCs and serum chemistry panels, coagulation
panels, and analysis of CSF cell counts, protein and glucose
concentration on Study Days 0, 3, 7, 14, 21, 30, 45, 60 and 90. At
necropsy, tissues were evaluated for gross lesions and examined
microscopically by a pathologist. T cell responses against the
vector capsid and transgene product were evaluated by ELISPOT, and
antibody responses against the transgene product were measured in
serum and CSF by ELISA. Vector biodistribution was assessed by
qPCR.
[0390] There were no adverse events (AEs) associated with the
administration procedure. From the first time point evaluated,
Study Day 14, AAV vector genomes could be detected throughout the
brain and spinal cord of all treated animals (levels around 104
GC/.mu.g DNA) and were persistent at the same levels in the brain
and spinal cord of animals euthanized and necropsied on Day 90 and
180. There was also significant vector distribution to peripheral
organs, particularly the liver and spleen (105 to 106 GC/.mu.g
DNA), reticuloendothelial tissues (lymph nodes and bone marrow 103
to 104 GC/.mu.g DNA), and heart (103 to 104 GC/.mu.g DNA). These
data suggest that vector spreads to the periphery and liver
transduction is possible following intrathecal vector delivery.
[0391] An immune response, both humoral and T-cell mediated, was
elicited to the human IDUA protein. This response seemed to
correlate with transient CSF mononuclear pcytosis, and with a
histological finding of spinal cord dorsal white matter axonopathy
(observed throughout the spinal cord at Days 90 and 180). These
findings were not associated with clinical abnormalities or
histological evidence of damage to tissues other than dorsal
funiculi of the spinal cord. Based on this finding, a no observable
adverse effect level (NOAEL) could not be defined with the testing
of a single dose of 1013 GC (approximately 1.1.times.10.sup.11 GC/g
brain mass) in rhesus macaques.
[0392] A. Materials and Methods
[0393] An AAV9.hIDUA test vector was assessed (in Elliots B.RTM.
+0.001% Pluronic.RTM. F68). This study included 12 rhesus macaques.
Animals were randomly assigned to 5 groups. Study Groups 1A, 1B and
1C consisted of 1 male and 2 female macaques treated with test
vector and euthanized and necropsied on Study Day 14.+-.2; 90.+-.2;
or 180.+-.2, respectively. Animals in Group 2A and 2B were treated
with vehicle (Elliot's formulation buffer) and euthanized and
necropsied on Day 14.+-.2 or 90.+-.2, respectively.
[0394] The IT route via image-guided suboccipital puncture was
selected because it is the proposed route for clinical use. A dose
of 10.sup.13 GC was selected, as this dose is similar (on a dose
per gram brain mass basis) to the maximally tolerated dose in MPS I
dogs, and is 10-fold greater than the proposed starting dose for
first-in-human studies.
[0395] On Study Day 0, animals were anesthetized and placed on an
X-ray table in the lateral decubitus position with the head flexed
forward for CSF collection and dosing into the cisterna magna. The
site of injection was sterilely prepped. Using aseptic technique, a
21-27 gauge, 1-1.5 inch Quincke spinal needle (Becton Dickinson)
was advanced into the suboccipital space until the flow of CSF was
observed. Up to 1.0 mL of CSF was collected for baseline analysis.
Correct placement of the needle was verified via myelography, using
a fluoroscope (OEC9800 C-Arm, GE). After CSF collection, a Luer
access extension catheter was connected to the spinal needle to
facilitate dosing of Iohexol (Trade Name: Omnipaque 180 mg/mL,
General Electric Healthcare) contrast media and test or control
article. Up to 1 mL of Iohexol was administered via the catheter
and spinal needle. After confirming correct placement of the needle
by observation of the contrast agent in the cisterna magna, a
syringe containing the test article or vehicle (volume of 1.4 mL,
equivalent to 1 mL plus the volume of syringe and linker dead
space) was connected to the flexible linker and slowly injected
over 20-60 seconds. The needle was removed and direct pressure
applied to the puncture site.
[0396] B. Results
[0397] There were no adverse events associated with the vector
administration procedure. AAV vector genomes were detected
throughout the brain and spinal cord of all AAV9.hIDUA test
vector--treated animals at all measured time points and levels were
comparable across time in these tissues. There was also significant
vector distribution to peripheral organs, especially the liver, and
vector genome levels in peripheral tissues were also comparable
across time. There were no clinical, gross, or histological
findings in vehicle controls nor in test vector animals euthanized
at 14 days. A mild, transient CSF mononuclear pleocytosis was
observed in 5/6 AAV9.hIDUA--treated animals, peaking around 30 days
post-dose.
[0398] Serum and CSF antibodies to hIDUA (the transgene product)
were detected in 6/6 AAV9.hIDUA test vector--treated animals from
day 21 and peripheral T cell responses to hIDUA peptides were
observed in 4/6 test vector--greated animals at day 90, and 1/3
tested animal at day 180. Microscopically, in 6/6 AAV9.hIDUA test
vector--treated animals, there was minimal to moderate axonopathy
in the dorsal sensory white matter tracts of the spinal cord
suggestive of cell body injury within the sensory neurons of the
dorsal root ganglia (DRG not available for histological
evaluation). The anatomic location of the axonopathy in the
ascending dorsal sensory tracts suggests specific involvement of
sensory neurons from the dorsal root ganglia. The fact that those
neurons are usually heavily transduced after intrathecal AAV
administration and the time course of CSF antibodies (from day 21),
of CSF pleocytosis (peak at day 30), and the presence of transgene
specific T-cell response in the majority of animals at day 90
suggest that a cell mediated cytotoxic immune response to hIDUA
occurred in the dorsal root ganglia.
Example 8: Manufacture of rAAV9.CB7.hIDUA Vector
[0399] The AAV9.CB7.hIDUA is be produced by triple plasmid
transfection of human HEK293 MCB cells with: (i) the hIDUA vector
genome plasmid, (ii) an AAV helper plasmid termed pAAV29 containing
the AAV rep2 and cap 9 wild-type genes and (iii) a helper
adenovirus plasmid termed pAdAF6(Kan). The size of the packaged
vector genome is 4344nt.
[0400] Cloning of the plasmid pAAV.CV7.CI.hIDUAco.RGB above; the
plasmid is 7,165 bp in size. The vector genome derived from this
plasmid is a single-stranded DNA genome with AAV2 derived ITRs
flanking the hIDUA expression cassette. Expression from the
transgene cassette is driven by a CB7 promoter, a hybrid between a
cytomegalovirus (CMV) immediate early enhancer (C4) and the chicken
beta actin promoter, while transcription from this promoter is
enhanced by the presence of the chicken beta actin intron (CI). The
polyA signal for the expression cassette is the rabbit beta-globin
(RBG) polyA. The plasmid was constructed by codon-optimizing and
synthesizing the hIDUA sequence [SEQ ID NO: 1] and the resulting
construct was then cloned into the plasmid pENN.AAV.CB7.CI.RBG
(p1044), an AAV2 ITR-flanked expression cassette containing CB7, CI
and RBG expression elements to give pAAV.CB7.CI.hIDUAco.RBG
(p3032).
[0401] Cloning of the cis plasmid pAAV.CB7CIhIDUA.RGB.KanR: The
vector genome was excised from p3032 using the PacI restriction
enzyme and cloned into a pKSS-based plasmid backbone (p2017)
containing the kanamycin resistance gene. The final vector genome
plasmid is pAAV.CB7.CI.hIDUAco.RBG.KanR.
AAV2/9 Helper Plasmid pAAV29KanRRep2
[0402] The AAV2/9 helper plasmid pAAV29KanRRep2 encodes the 4
wild-type AAV2 rep proteins and the 3 wild-type AAV VP capsid
proteins from AAV9. To create the chimeric packaging construct,
first the AAV2 cap gene from plasmid p5E18, containing the wild
type AAV2 rep and cap genes, was removed and replaced with a PCR
fragment of the AAV9 cap gene amplified from liver DNA. The
resulting plasmid was given the identifier pAAV2-9 (p0008). Note
that the AAV p5 promoter which normally drives rep expression is
moved in this construct from the 5' end of rep to the 3' end of
cap. This arrangement serves to introduce a spacer between the
promoter and the rep gene (i.e. the plasmid backbone),
down-regulate expression of rep and increase the ability to support
vector production. The plasmid backbone in p5E18 is The plasmid
backbone in p5E18 is from pBluescript KS. The AAV2/9 helper plasmid
pAAV29KanRRep2 encodes the 4 wild-type AAV2 rep proteins, the 3
wild-type AAV VP capsid proteins from AAV9, and kanamycin
resistance.
[0403] pAdDeltaF6(Kan) adenovirus helper plasmid is 15,770 bp in
size. The plasmid contains the regions of adenovirus genome that
are important for AAV replication, namely E2A, E4, and VA RNA (the
adenovirus EI functions are provided by the 293 cells), but does
not contain other adenovirus replication or structural genes. The
plasmid does not contain the cis elements critical for replication
such as the adenoviral inverted terminal repeats and therefore, no
infectious adenovirus is expected to be generated. It was derived
from an EI, E3 deleted molecular clone of Ad5 (pBHG10, a pBR322
based plasmid). Deletions were introduced in the Ad5 DNA to remove
expression of unnecessary adenovirus genes and reduce the amount of
adenovirus DNA from 32 Kb to 12 kb. Finally, the ampicillin
resistance gene was replaced by the kanamycin resistance gene to
give pAdAF6 (Kan). The functional elements of the E2, E4 and VAI
adenoviral genes necessary for AAV vector production remain in this
plasmid. The adenoviral E1 essential gene functions are supplied by
the HEK293 cells. DNA plasmid sequencing was performed by Qiagen
Genomic Services and revealed 100% homology with the following
important functional elements of the reference sequence
pAdDeltaF6(Kan) p1707FH-Q: E4 ORF6 3692-2808 bp; E2A DNA binding
protein 11784-10194 bp; VA RNA region 12426-13378 bp.
[0404] A flow diagram summarizing the manufacturing process is
provided in FIG. 11.
[0405] Cell Seeding: A qualified human embryonic kidney 293 cell
line will be used for the production process. Cells will be
expanded to 5.times.109-5.times.1010 cells using Corning T-flasks
and CS-10, which will allow sufficient cell mass to be generated
for seeding up to 50 HS-36 for vector production per BDS lot. Cells
will be cultivated in medium composed of Dulbecco's Modified Eagle
Medium (DMEM), supplemented with 10% gamma irradiated, US-sourced,
Fetal Bovine Serum (FBS). The cells are anchorage dependent and
cell disassociation will be accomplished using TrypLE Select, an
animal product-free cell dissociation reagent. Cell seeding is
accomplished using sterile, single-use disposable bioprocess bags
and tubing sets. The cells will be maintained at 37.degree. C.
(.+-.2.degree. C.), in 5% (.+-.0.5%) CO2 atmosphere. Cell culture
media will be replaced with fresh, serum free DMEM media and
transfected with the three production plasmids using an optimized
PEI-based transfection method. All plasmids used in the production
process will be produced in the context of a CMO quality system and
infrastructure utilizing the most salient features of cGMP
manufacturing; traceability, document control, and materials
segregation.
[0406] Sufficient DNA plasmid transfection complex will be prepared
in the BSC to transfect up to 50 HS-36 (per BDS batch). Initially a
DNA/PEI mixture will be prepared containing 7.5 mg of
pAAV.CB7.CI.hIDUAco.RBG.KanR vector genome plasmid, 150 mg of
pAdDeltaF6(Kan), 75 mg of pAAV29KanRRep2 AAV helper plasmid and GMP
grade PEI (PEIPro, PolyPlus Transfection SA). This plasmid ratio
was determined to be optimal for AAV production in small scale
optimization studies. After mixing well, the solution is allowed to
sit at room temperature for 25 min. and then added to serum-free
media to quench the reaction and then added to the HS-36's. The
transfection mixture is equalized between all 36 layers of the
HS-36 and the cells are incubated at 37.degree. C. (.+-.2.degree.
C.) in a 5% (.+-.0.5%) CO2 atmosphere for 5 days.
[0407] Cell Media Harvesting: Transfected cells and media will be
harvested from each HS-36 using disposable bioprocess bags by
aseptically draining the medium out of the units. Following the
harvest of media, the 80-liter volume will be supplemented with
MgCl2 to a final concentration of 2 mM (co-factor for Benzonase)
and Benzonase nuclease (Cat#: 1.016797.0001, Merck Group) will be
added to a final concentration of 25 units/ml. The product (in a
disposable bioprocess bag) will be incubated at 37.degree. C. for 2
hr in an incubator to provide sufficient time for enzymatic
digestion of residual cellular and plasmid DNA present in the
harvest as a result of the transfection procedure. This step is
performed to minimize the amount of residual DNA in the final
vector. After the incubation period, NaCl will be added to a final
concentration of 500 mM to aid in the recovery of the product
during filtration and downstream tangential flow filtration (see
below steps 4 and 5).
[0408] Clarification: Cells and cellular debris will be removed
from the product using a depth filter capsule (1.2 .mu.m/0.22 um)
connected in series as a sterile, closed tubing and bag set that is
driven by a peristaltic pump. Clarification assures that downstream
filters and chromatography columns will be protected from fouling
and bioburden reduction filtration ensures that at the end of the
filter train, any bioburden potentially introduced during the
upstream production process will be removed before downstream
purification. The harvest material will be passed through a
Sartorius Sartoguard PES capsule filter (1.2/0.22 .mu.m) (Sartorius
Stedim Biotech Inc.).
[0409] Large-scale Tangential Flow Filtration: Volume reduction
(10-fold) of the clarified product will be achieved by Tangential
Flow Filtration (TFF) using a custom sterile, closed bioprocessing
tubing, bag and membrane set. The principle of TFF is to flow a
solution under pressure parallel to a membrane of suitable porosity
(100 kDa). The pressure differential drives molecules of smaller
size through the membrane and effectively into the waste stream
while retaining molecules larger than the membrane pores. By
recirculating the solution, the parallel flow sweeps the membrane
surface preventing membrane pore fouling. By choosing an
appropriate membrane pore size and surface area, a liquid sample
may be rapidly reduced in volume while retaining and concentrating
the desired molecule. Diafiltration in TFF applications involves
addition of a fresh buffer to the recirculating sample at the same
rate that liquid is passing through the membrane and to the waste
stream. With increasing volumes of diafiltration, increasing
amounts of the small molecules are removed from the recirculating
sample. This results in a modest purification of the clarified
product, but also achieves buffer exchange compatible with the
subsequent affinity column chromatography step. Accordingly, we
utilize a 100 kDa, PES membrane for concentration that is then
diafiltrated with 4 volumes of a buffer composed of: 20 mM Tris pH
7.5 and 400 mM NaCl. The diafiltered product will be stored
overnight at 4.degree. C. and then further clarified with a 1.2
m/0.22 um depth filter capsule to remove any precipitated
material.
[0410] Affinity Chromatography: The diafiltered product will be
applied to a Capture Select.TM. Poros-AAV2/9 affinity resin (Life
Technologies) that efficiently captures the AAV2/9 serotype. Under
these ionic conditions, a significant percentage of residual
cellular DNA and proteins flow through the column, while AAV
particles are efficiently captured. Following application, the
column is washed to remove additional feed impurities followed by a
low pH step elution (400 mM NaCl, 20 mM Sodium Citrate; pH 2.5)
that is immediately neutralized by collection into a 1/10th volume
of a neutralization buffer (Bis Tris Propane, 200 mM, pH 10.2).
[0411] Anion Exchange Chromatography: To achieve further reduction
of in-process impurities including empty AAV particles, the
Poros-AAV2/9 elution pool is diluted 50-fold (20 mM Bis Tris
Propane, 0.001% Pluronic F68; pH 10.2) to reduce ionic strength to
enable binding to a CIMultus Q monolith matrix (BIA Separations).
Following a low-salt wash, vector product is eluted using a 60 CV
NaCl linear salt gradient (10-180 mM NaCl). This shallow salt
gradient effectively separates capsid particles without a vector
genome (empty particles) from particles containing vector genome
(full particles) and results in a preparation enriched for full
capsids. Fractions will be collected into tubes containing 1/100th
volume of 0.1% pluronic F68 and 1/27th volume of Bis Tris pH 6.3 to
minimize non-specific binding to tubes and the length of exposure
to high pH respectively. The appropriate peak fraction will be
collected, and the peak area assessed and compared to previous data
for determination of the approximate vector yield.
[0412] Final Formulation and Sterile Filtration to yield the BDS:
TFF will be used to achieve final formulation on the pooled AEX
fractions with a 100 kDa membrane. This will be achieved by
diafiltration with 4 volumes of formulation buffer (Elliots B
solution, 0.001% Pluronic F68) and concentrated to yield the BDS,
whereby the peak area from the anion exchange chromatography will
be compared to previous data in order to estimate the concentration
factor to achieve a titer of .gtoreq.5.times.10.sup.13 GC/ml.
Samples will be removed for BDS testing (described in the section
below). The filtered Purified Bulk will be stored in sterile
polypropylene tubes and frozen at .ltoreq.-60.degree. C. in a
quarantine location until release for Final Fill. Preliminary
stability study indicates that the DP does not lose activity
following freezing and thawing in our proposed formulation buffer.
Additional studies are underway to assess stability following
prolonged storage at -80C.
[0413] Final Fill: The frozen BDS will be thawed, pooled, diluted
to the target titer using the final formulation buffer, terminally
filtered through a 0.22 um filter (Millipore, Billerica, Mass.) and
filled into West Pharmaceutical's "Ready-to-Use" (pre-sterilized) 2
ml glass vials and 13 mm stoppers and seals at a fill volume
>0.6 ml to <2.0 ml per vial. Individually labeled vials will
be labeled according to the specifications below. Labeled vials are
stored at .ltoreq.-60.degree. C.
[0414] The vector (drug product) will be vialed at a single fixed
concentration and the only variable will be the volume per vial. To
achieve lower dose concentrations, the drug product will be diluted
with Elliots B solution, 0.001% Pluronic F68. The high dose vector
will be used directly without dilution while the low vector will
require a 1:5 dilution in the formulation buffer which will be
conducted by the pharmacy at the time of dosing.
Example 9: Testing of Vector
[0415] Characterization assays including serotype identity, empty
particle content and transgene product identity are performed.
Descriptions of the assays appear below.
[0416] A. Vector Genome Identity: DNA Sequencing
[0417] Viral Vector genomic DNA will be isolated and the sequence
determined by 2-fold sequencing coverage using primer walking.
Sequence alignment will be performed and compared to the expected
sequence.
[0418] B. Vector Capsid Identity: AAV Capsid Mass Spectrometry of
VP3
[0419] Confirmation of the AAV2/9 serotype of the vector is
achieved by an assay based upon analysis of peptides of the VP3
capsid protein by mass spectrometry (MS). The method involves
multi-enzyme digestion (trypsin, chymotrypsin and endoproteinase
Glu-C) of the VP3 protein band excised from SDS-PAGE gels followed
by characterization on a UPLC-MS/MS on a Q-Exactive Orbitrap mass
spectrometer to sequence the capsid protein. A tandem mass spectra
(MS) method was developed that allows for subtraction of the host
protein products and deriving capsid peptide sequence from mass
spectra.
[0420] C. Genomic Copy (GC) Titer
[0421] The oqPCR based genomic copy titer will be determined over a
range of serial dilutions and compared to the cognate plasmid
standard (pAAV.CB7.CI.hIDUAco.RBG.KanR). The oqPCR assay utilizes
sequential digestion with DNase I and Proteinase K, followed by
qPCR analysis to measure encapsidated vector genomic copies. DNA
detection will be accomplished using sequence specific primers
targeting the RBG polyA region in combination with a fluorescently
tagged probe hybridizing to this same region. Comparison to the
plasmid DNA standard curve allows titer determination without the
need of any post-PCR sample manipulation. A number of standards,
validation samples and controls (for background and DNA
contamination) have been introduced into the assay. This assay is
currently not qualified, but will be qualified by the CMO. The
assay will be qualified by establishing and defining assay
parameters including sensitivity, limit of detection, range of
qualification and intra and inter assay precision. An internal AAV9
reference lot will be established and used to perform the
qualification studies. Note that our previous experience suggests
that the titer obtained by the optimized qPCR assay described here
is generally 2.5 fold higher than that achieved by our standard
qPCR technique which was used for the generation of the
pre-clinical data.
[0422] D. Empty to Full Particle Ratio
[0423] The total particle content of the drug product will be
determined by SDS-PAGE analysis. A reference vector preparation
purified on an iodixanol gradient is analyzed by various methods
(analytical untracentrifugation, electron microscopy and absorbance
at 260/280 nm) to established that the preparation contains >95%
genome-containing (full) particles. This reference material is
serially diluted to known genome copy numbers (and thus by
extension, particle numbers) and each dilution is run on an SDS
PAGE gel along with a similar dilution series of the drug product.
Peak area volumes of both the reference material and drug product
VP3 protein bands are determined by densitometry and the reference
material volumes are plotted versus particle number. The total
particle concentration of the drug product is determined by
extrapolation from this curve and the genome copy (GC) titer is
then subtracted to obtain the empty particle titer. The empty to
full particle ratio is the ratio of the empty particle titer to the
GC titer.
[0424] E. Infectious Titer
[0425] The infectious unit (IU) assay is used to determine the
productive uptake and replication of vector in RC32 cells (rep2
expressing HeLa cells). A 96-well end-point format has been
employed similar to that previously published. Briefly, RC32 cells
are co-infected by serial dilutions of rAAV9.CB.hIDUA and a uniform
dilution of Ad5 with 12 replicates at each dilution of rAAV.
Seventy-two hours after infection the cells are lysed, and qPCR
performed to detect rAAV vector amplification over input. An
end-point dilution TCID50 calculation (Spearman-Karber) is
performed to determine a replicative titer expressed as IU/ml.
Since "infectivity" values are dependent on particles coming into
contact with cells, receptor binding, internalization, transport to
the nucleus and genome replication, they are influenced by assay
geometry and the presence of appropriate receptors and post-binding
pathways in the cell line used. Receptors and post-binding pathways
are not usually maintained in immortalized cell lines and thus
infectivity assay titers are not an absolute measure of the number
of "infectious" particles present. However, the ratio of
encapsidated GC to "infectious units" (described as GC/IU ratio)
can be used as a measure of product consistency from lot to
lot.
[0426] The GC/IU ratio is a measure of product consistency. The
oqPCR titer (GC/ml) is divided by the "infectious unit (IU/ml) to
give the calculated GC/IU ratio.
[0427] F. Replication-Competent AAV (rcAAV) Assay
[0428] A sample will be analyzed for the presence of replication
competent AAV2/9 (rcAAV) that can potentially arise during the
production process. A 3 passage assay has been developed consisting
of cell-based amplification and passage followed by detection of
rcAAV DNA by real-time qPCR (cap 9 target). The cell-based
component consists of inoculating monolayers of HEK293 cells (P1)
with dilutions of the test sample and wild-type human adenovirus
type 5 (Ad5). 10.sup.10 GC of the vector product will be the
maximal amount of the product tested. Due to the presence of
adenovirus, replication competent AAV will amplify in the cell
culture. After 2 days, a cell lysate is generated and Ad5 heat
inactivated. The clarified lysate is then passed onto a second
round of cells (P2) to enhance sensitivity (again in the presence
of Ad5). After 2 days, a cell lysate is generated and Ad5 heat
inactivated. The clarified lysate is then passed onto a third round
of cells (P3) to maximize sensitivity (again in the presence of
Ad5). After 2 days, cells are lysed to release DNA which is then
subjected to qPCR to detect AAV9 cap sequences. Amplification of
AAV9 cap sequences in an Ad5 dependent manner indicates the
presence of rcAAV. The use of a AAV2/9 surrogate positive control
containing AAV2 rep and AAV9 cap genes enables the Limit of
Detection (LOD) of the assay to be determined (0.1, 1, 10 and 100
IU) and using a serial dilution of rAAV9.CB7.hIDUA vector
(1.times.10.sup.10, 1.times.10.sup.9, 1.times.10.sup.8,
1.times.10.sup.7 GC) the approximate level of rcAAV present in the
test sample can be quantitated.
[0429] G. In Vitro Potency
[0430] To relate the qPCR GC titer to gene expression, an in vitro
bioassay will be performed by transducing Huh7 or HEK293 cells with
a known multiplicity of GCs per cell and assaying the supernatant
for IDUA activity 72 hours post-transduction. IDUA activity is
measured by incubating sample diluted in 0.1 ml water with 0.1 ml
of 100 mmol/l 4 MU-iduronide at 37 degrees for 1-3 hours. The
reaction is stopped by the addition of 2 ml 290 mmol/l glycine, 180
mmol/l sodium citrate, pH 10.9 and liberated 4 MU is quantified by
comparing fluorescence to standard dilutions of 4 MU. Comparison to
highly active pre-clinical and tox vector preparations will enable
interpretation of product activity.
[0431] H. Total Protein, Capsid Protein, Protein Purity
Determination and Capsid Protein Ratio Vector samples are first
quantified for total protein against a Bovine Serum Albumin (BSA)
protein standard curve using a bicinchoninic acid (BCA) assay. The
determination is made by mixing equal parts of sample with a
Micro-BCA reagent provided in the kit. The same procedure is
applied to dilutions of a BSA Standard. The mixtures are incubated
at 60.degree. C. and absorbance measured at 562 nm. A standard
curve is generated from the standard absorbance of the known
concentrations using a 4-Parameter fit. Unknown samples are
quantified according to the 4-Parameter regression.
[0432] To provide a semi-quantitative determination of AAV purity,
the samples will then be normalized for genome titer and
5.times.10.sup.9 GC separated on an SDS-polyacrylamide (SDS-PAGE)
gel under reducing conditions. The gel is then stained with SYPRO
Ruby dye. Any impurity bands are quantified by densitometry by
comparison to co-electrophoresed BSA standards of 25, 50, and 100
ng of protein per lane. These quantities represent 1%, 2% and 4% of
the total AAV protein sample. Stained bands that appear in addition
to the three AAV specific proteins VP1, VP2 and VP3 are considered
protein impurities. All impurity bands are compared to the
reference proteins and the impurity mass percent as well as
approximate molecular weight are reported. The SDS-PAGE gels will
also be used to quantify the VP1, VP2 and VP3 proteins and
determine their ratio.
Example 10: Biodistribution and Brain Enzyme
[0433] Adult cynomolgus macaques are injected suboccipitally with
1.times.10.sup.12 GC/kg AAV9.CMV.hIDUA. 636 days later, tissues are
harvested and immediately frozen down to -80.degree. C. Total
cellular DNA is extracted from tissue using a QIAamp DNA Mini Kit
(Qiagen, Valencia, Calif., USA). Detection and quantification of
vector genomes in extracted DNA are performed by real-time PCR
(TaqMan Universal Master Mix, Applied Biosystems, Foster City,
Calif., USA) using primer and probe sets targeted to sequences
within the SV40 polyA. The PCR conditions are set at 100 ng total
cellular DNA as template, 300 nM primers, and 200 nM probes each.
Cycles were for 10 min at 95.8.degree. C., 40 cycles of 15 s at
95.8.degree. C., and 1 min at 60.8.degree. C.
[0434] Adult MPS I knockout mice are injected with
3.times.10.sup.8, 3.times.10.sup.9, or 3.times.10.sup.10 GC/mouse
AAV9.CB7.hIDUA into the right lateral ventricle. 21 days later
whole brains are harvested and immediately frozen down to
-80.degree. C. Tissue samples homogenized in lysis buffer (0.2%
Triton-X100, 0.9% NaCl, pH 4.0), and briefly sonicated. Samples are
then freeze-thawed and clarified by centrifugation. Protein
concentrations are determined by BCA assay. IDUA activity is
measured by incubating sample diluted in 0.1 ml water with 0.1 ml
of 100 mmol/l 4 MU-iduronide (Toronto Research Chemicals, Toronto,
Canada; Glycosynth, Warrington, England) in IDUA buffer (0.15 mol/1
NaCl, 0.05% Triton-X100, 0.1 mol/l sodium acetate, pH 3.58) at
37.degree. C. for 1-3 hours. The reaction is stopped by addition of
2 ml 290 mmol/l glycine, 180 mmol/l sodium citrate, pH 10.9. The
liberated 4 MU is quantified by comparing fluorescence to standard
dilutions of 4 MU. Units are given as nmol 4 MU liberated per hour
per mg of protein.
Example 11: MPSI Biomarker
[0435] In the present study, metabolite profiling of CSF samples
from MPS I dogs was performed, which revealed substantial disease
related alterations in the CSF metabolome. The most striking
difference was an over 30-fold elevation in spermine levels
compared to normal controls. This finding was confirmed in MPS I
patient samples, as well as in a feline model of MPS I. Spermine
binds to HS, and cellular uptake of spermine is dependent on this
interaction [M. Belting, S. Persson, L.-A. Fransson, Proteoglycan
involvement in polyamine uptake. Biochemical Journal 338, 317-323
(1999); J. E. Welch, P. Bengtson, K. Svensson, A. Wittrup, G. J.
Jenniskens, G. B. Ten Dam, T. H. Van Kuppevelt, M. Belting, Single
chain fragment anti-heparan sulfate antibody targets the polyamine
transport system and attenuates polyamine-dependent cell
proliferation. International journal of oncology 32, 749-756
(2008); published online EpubApr]. Cell surface proteoglycans such
as glypican-1 can bind spermine through their HS moieties, and
after endocytosis of the glypican protein, intracellular cleavage
of the HS chain releases bound spermine into the cell (K. Ding, S
et al, The Journal of biological chemistry 276, 46779-46791 (2001);
published online EpubDec 14. Thus, intact HS recycling is essential
for spermine uptake. In MPS I, extracellular spermine accumulation
could occur through inhibition of this uptake mechanism due to
inefficient HS recycling, or through simple binding of spermine to
the extracellular GAGS that accumulate in MPS, shifting the
spermine binding equilibrium to favor extracellular distribution.
Future studies should address the relative contribution of these
mechanisms to spermine accumulation in MPS I CSF.
[0436] We found that inhibitors of spermine synthesis blocked
excess neurite growth in MPS neurons, and that neurite growth could
be induced in WT neurons by spermine concentrations similar to
those found in patient CSF. Gene therapy in the dog model of MPS I
reversed spermine accumulation and normalized expression of GAP43,
suggesting that the same pathway was impacted in vivo. We could not
directly evaluate the impact of spermine synthesis inhibition in
vivo, as available inhibitors do not cross the blood-brain barrier,
and chronic direct CNS administration from birth is not feasible in
our animal models. While our in vitro findings support a role for
spermine in aberrant neurite growth in MPS I, it is important to
note that inhibiting spermine synthesis did not completely reverse
the phenotype, and spermine addition to normal neurons did not
increase neurite growth to the level of MPS I neurons. The effects
of spermine modulation may have been limited by the relatively
short period of treatment. It is also possible that spermine
accumulation is not the sole mediator contributing to neurite
outgrowth in MPS I. Notably many neurotrophic factors bind through
HS modified receptors, and interactions with HS in extracellular
matrix can influence neurite growth [D. Van Vactor, D. P. Wall, K.
G. Johnson, Heparan sulfate proteoglycans and the emergence of
neuronal connectivity. Current opinion in neurobiology 16, 40-51
(2006); published online EpubFeb (10.1016/j.conb.2006.01.011)].
Spermine accumulation may therefore be one of several factors
promoting abnormal neurite growth in MPS I.
[0437] Of the 15 MPS I dog CSF samples screened, only one fell
within the normal range of spermine concentration. At 28 days of
age, this was the youngest animal included in the study. This
finding indicates that spermine accumulation may be age dependent.
Future studies should evaluate CSF spermine levels longitudinally
in MPS patients. If spermine increases with age in MPS patients,
this could explain the kinetics of cognitive decline, as most
patients experience 1-2 years of normal development before the
onset of developmental delays.
[0438] The potential for impaired HS metabolism to trigger
accumulation of a metabolite that alters neuron growth could point
to a novel connection between enzyme deficiencies and the abnormal
neurite growth phenotype in MPSI, which may explain the cognitive
dysfunction associated with these disorders. These findings also
indicate that CSF spermine may be useful as a noninvasive biomarker
for assessing pharmacodynamics of novel CNS-directed therapies for
MPSI.
Materials and Methods:
[0439] Experimental design: This study was initially designed to
detect metabolites that were present at significantly different
levels in MPS I patient CSF samples compared to samples from
healthy controls. Due to the limited availability of CSF samples
from children with MPS IH and healthy controls, the initial screen
was performed using CSF samples from MPS I dogs, for which greater
numbers were available, with the intention of subsequently
evaluating candidate biomarkers in human samples. A total of 15 CSF
samples from individual untreated MPS I dogs were available for
analysis, and an additional 15 samples were obtained from healthy
controls. Following identification of elevated spermine in MPS I
dog CSF in the prospective metabolite screen, spermine was
retrospectively measured in CSF samples from previous studies of
MPS I dogs and cats treated with gene therapy, as well as patient
samples. The number of subjects included in each group for these
analyses was limited by sample availability and was not based on
statistical considerations; therefore in some cases numbers are
insufficient for statistical comparisons. For studies of in vitro
neurite growth, the number of cells quantified for each condition
was based on pilot experiments which indicated that >30 cells
per condition was required to detect a 20% difference in arbor
length, neurite number or neurite branches per cell. After cells
were plated and treated with the designated drug, the wells were
coded and the acquisition of cell images and the manual
quantification of neurite length and branching were performed by a
blinded reviewer. The comparison of wildtype and MPS mouse neurons
was repeated using a different substrate [poly-L-lysine (Sigma)
coated tissue culture plates rather than chamber slides (Sigma
S6815)] with similar results. The comparison of wildtype neurons
with and without spermine addition was performed four times using
both substrates with similar results. CSF metabolite profiling: CSF
metabolite profiling was performed by Metabolon.
[0440] Samples were stored at -80.degree. C. until processing.
Samples were prepared using the MicroLab STAR.RTM. system (Hamilton
Company). A recovery standard was added prior to the first step in
the extraction process for QC purposes. Proteins were precipitated
with methanol under vigorous shaking for 2 min followed by
centrifugation. The resulting extract was divided into five
fractions: one for analysis by reverse phase (RP)UPLC-MS/MS with
positive ion mode electrospray ionization, one for analysis by
RP/UPLC-MS/MS with negative ion mode electrospray ionization, one
for analysis by hydrophilic interaction chromatography
(HILIC)/UPLC-MS/MS with negative ion mode electrospray ionization,
one for analysis by GC-MS, and one sample was reserved for backup.
Samples were placed briefly on a TurboVap.RTM. (Zymark) to remove
the organic solvent. For LC, the samples were stored overnight
under nitrogen before preparation for analysis. For GC, each sample
was dried under vacuum overnight before preparation for
analysis.
[0441] The LC/MS portion of the platform was based on a Waters
ACQUITY ultra-performance liquid chromatography (UPLC) and a Thermo
Scientific Q-Exactive high resolution/accurate mass spectrometer
interfaced with a heated electrospray ionization (HESI-II) source
and Orbitrap mass analyzer operated at 35,000 mass resolution. The
sample extract was dried then reconstituted in solvents compatible
to each of the LC/MS methods. Each reconstitution solvent contained
a series of standards at fixed concentrations to ensure injection
and chromatographic consistency. For RP chromatography, one aliquot
was analyzed using acidic positive ion optimized conditions and the
other using basic negative ion optimized conditions Each method
utilized separate dedicated columns (Waters UPLC BEH
C18-2.1.times.100 mm, 1.7 .mu.m). The extracts reconstituted in
acidic conditions were gradient eluted using water and methanol
containing 0.1% formic acid. The basic extracts were similarly
eluted using methanol and water, however with 6.5 mM ammonium
bicarbonate. The third aliquot was analyzed via negative ionization
following elution from a HILIC column (Waters UPLC BEH Amide
2.1.times.150 mm, 1.7 m) using a gradient consisting of water and
acetonitrile with 10 mM ammonium formate. The MS analysis
alternated between MS and data-dependent MSn scans using dynamic
exclusion. The scan range varied slightly between methods but
covered 80-1000 m/z.
[0442] The samples destined for analysis by GC-MS were dried under
vacuum for a minimum of 18 h prior to being derivatized under dried
nitrogen using bistrimethyl-silyltrifluoroacetamide. Derivatized
samples were separated on a 5% diphenyl/95% dimethyl polysiloxane
fused silica column (20 m.times.0.18 mm ID; 0.18 um film thickness)
with helium as carrier gas and a temperature ramp from 60.degree.
to 340.degree. C. in a 17.5 min period. Samples were analyzed on a
Thermo-Finnigan Trace DSQ fast-scanning single-quadrupole mass
spectrometer using electron impact ionization (EI) and operated at
unit mass resolving power. The scan range was from 50-750 m/z.
[0443] Several types of controls were analyzed in concert with the
experimental samples: a pooled matrix sample generated by taking a
small volume of each experimental sample served as a technical
replicate throughout the data set; extracted water samples served
as process blanks; and a cocktail of QC standards that were
carefully chosen not to interfere with the measurement of
endogenous compounds were spiked into every analyzed sample,
allowed instrument performance monitoring and aided chromatographic
alignment. Instrument variability was determined by calculating the
median relative standard deviation (RSD) for the standards that
were added to each sample prior to injection into the mass
spectrometers. Overall process variability was determined by
calculating the median RSD for all endogenous metabolites (i.e.,
non-instrument standards) present in 100% of the pooled matrix
samples. Experimental samples were randomized across the platform
run with QC samples spaced evenly among the injections.
[0444] Metabolites were identified by automated comparison of the
ion features in the experimental samples to a reference library of
chemical standard entries that included retention time, molecular
weight (m/z), preferred adducts, and in-source fragments as well as
associated MS spectra and curated by visual inspection for quality
control using software developed at Metabolon. Identification of
known chemical entities was based on comparison to metabolomics
library entries of purified standards. Peaks were quantified using
area-under-the-curve measurements. Raw area counts for each
metabolite in each sample were normalized to correct for variation
resulting from instrument inter-day tuning differences by the
median value for each run-day, therefore, setting the medians to
1.0 for each run. This preserved variation between samples but
allowed metabolites of widely different raw peak areas to be
compared on a similar graphical scale. Missing values were imputed
with the observed minimum after normalization.
[0445] Quantitative MS assay: CSF samples (50 .mu.L) were mixed
with a spermine-d8 internal standard (IsoSciences). Samples were
deproteinized by mixing with a 4-fold excess of methanol and
centrifuging at 12,000.times.g at 4.degree. C. The supernatant was
dried under a stream of nitrogen, and then resuspended in 50 .mu.L
of water. An aliquot of 5 .mu.L was subjected to LC-MS analysis.
The LC separations were carried out using a Waters ACQUITY UPLC
system (Waters Corp., Milford, Mass., USA) equipped with an
Xbridge.RTM. C18 column (3.5 .mu.m, 150.times.2.1 mm). The
flow-rate was 0.15 mL/min, solvent A was 0.1% formic acid and
solvent B was 98/2 acetonitrile/H2O (v/v) with 0.1% formic acid.
The elution conditions were as follows: 2% B at 0 min, 2% B at 2
min, 60% B at 5 min, 80% B at 10 min, 98% B at 11 min, 98% B at 16
min, 2% B at 17 min, 2% B at 22 min, with the column temperature
being 35.degree. C. A Finnigan TSQ Quantum Ultra spectrometer
(Thermo Fisher, San Jose, Calif.) was used to conduct MS/MS
analysis in positive ion mode with the following parameters: spray
voltage at 4000 V, capillary temperature at 270.degree. C., sheath
gas pressure at 35 arbitrary units, ion sweep gas pressure at 2
arbitrary units, auxiliary gas pressure at 10 arbitrary units,
vaporizer temperature at 200.degree. C., tube lens offset at 50,
capillary offset at 35 and skimmer offset at 0. The following
transitions were monitored: 203.1/112.1 (spermine); 211.1/120.1
(spermine-d8) with scan width of 0.002 m/z, and scan time being
0.15 s.
[0446] Animal procedures: All animal protocols were approved by the
Institutional Animal Care and Use Committee of the University of
Pennsylvania. For CSF metabolite screening, samples were collected
by suboccipital puncture in normal dogs at 3-26 months of age, and
in MPS I dogs at 1-18 months of age. Gene transfer studies in MPS I
dogs and cats were performed as previously described (20, 22). CSF
samples were collected 6-8 months after vector administration. For
mouse cortical neuron experiments, primary cortical neuron cultures
were prepared from E18 IDUA-/- or IDUA+/+ embryos.
[0447] Patient samples: CSF metabolite profiling: Metabolite
profiling was performed as described (metabolon ref) Informed
consent was obtained from each subject's parent or legal guardian.
The protocol was approved by the Institutional Review Board of the
University of Minnesota. CSF was collected by lumbar puncture. All
MPS I patients had a diagnosis of Hurler syndrome and had not
received enzyme replacement therapy or hematopoietic stem cell
transplantation prior to sample collection. MPS I patients were
6-26 months of age. The healthy controls were 36 and 48 months of
age.
[0448] Statistical analysis: The random forest analysis and heat
map generation were performed using MetaboAnalyst 3.0 [R. G. Kalb,
Development 120, 3063-3071 (1994); J. Zhong, et al, Journal of
neurochemistry 64, 531-539 (1995) D. Van Vactor, D. P. W et al,
Current opinion in neurobiology 16, 40-51 (2006); published online
EpubFeb (10.1016/j.conb.2006.01.011). Raw peak data were log
transformed and normalized to the mean of normal sample values. All
other statistical analyses were performed with GraphPad Prism 6.
Cultured neuron arbor length, neurite number, and branching were
compared by ANOVA followed by Dunnett's test. CSF spermine and
cortical GAP43 were compared by Kruskal-Wallis test followed by
Dunn's test.
[0449] GAP43 western: Samples of frontal cortex were homogenized in
0.2% triton X-100 using a Qiagen Tissuelyser at 30 Hz for 5 min.
Samples were clarified by centrifugation at 4.degree. C. Protein
concentration was determined in supernatants by BCA assay. Samples
were incubated in NuPAGE LDS buffer with DTT (Thermo Fisher
Scientific) at 70.degree. C. for 1 hr and separated on a Bis-Tris
4-12% polyacrylamide gel in MOPS buffer. Protein was transferred to
a PVDF membrane, and blocked for 1 hr in 5% nonfat dry milk. The
membrane was probed with rabbit polyclonal anti-GAP43 antibody
(Abcam) diluted to 1 .mu.g/mL in 5% nonfat dry milk followed by an
HRP conjugated polyclonal anti-rabbit antibody (Thermo Fisher
Scientific) diluted 1:10,000 in 5% nonfat dry milk. Bands were
detected using SuperSignal West Pico substrate (Thermo Fisher
Scientific). Densitometry was performed using Image Lab 5.1
(Bio-Rad).
[0450] Neurite growth assay: Day 18 embryonic cortical neurons were
harvested as described above, and plated at a concentration of
100,000 cells/mL on chamber slides (Sigma S6815) or poly-L-lysine
(Sigma) coated tissue culture plates in serum-free Neurobasal
medium (Gibco) supplemented by B27 (Gibco). Treatments were applied
to duplicate wells 24 hours after plating (day 1). Phase-contrast
images for quantification were taken on a Nikon Eclipse Ti at
20.times. using a 600 ms manual exposure and 1.70.times.gain on
high contrast. An individual blind to treatment conditions captured
10-20 images per well and coded them. Images were converted to
8-bit format in ImageJ (NIH) and traced in NeuronJ(30) by a blinded
reviewer. Soma diameter, neurite number, branch points, and arbor
length were traced manually. Images traced in NeuronJ were
converted to micrometers using a conversion factor based on image
size; 2560.times.1920 pixel images were converted to micrometers
using a conversion factor of 0.17 micrometers/pixel.
[0451] Histology: Brain tissue processing and LIMP2
immunofluorescence were performed as previously described [C.
Hinderer, et al, Molecular therapy: the journal of the American
Society of Gene Therapy 22, 2018-2027 (2014); published online
EpubDec (10.1038/mt.2014.135)].
[0452] RT-PCR: Samples of frontal cortex from 3 normal dogs and 5
MPS dogs were immediately frozen on dry ice at necropsy. RNA was
extracted with TRIzol reagent (Thermo Fisher Scientific), treated
with DNAse I (Roche) for 20 min at room temperature, and purified
using an RNeasy kit (Qiagen) according to the manufacturer's
instructions. Purified RNA (500 ng) was reverse transcribed using
the High Capacity cDNA Synthesis Kit (Applied Biosystems) with
random hexamer primers. Transcripts for arginase, ornithine
decarboxylase, spermine synthase, spermidine synthase,
spermine-spermidine acetyltransferase and glyceraldehyde phosphate
dehydrogenase were quantified by Sybr green PCR using an Applied
Biosystems 7500.
[0453] Real-Time PCR System. A standard curve was generated for
each target gene using four-fold dilutions of a pooled standard
comprised of all individual samples. The highest standard was
assigned an arbitrary transcript number, and Ct values for
individual samples were converted to transcript numbers based on
the standard curve. Values are expressed relative to the GAPDH
control.
[0454] Statistical analysis: Random forest analysis and heat map
generation were performed using MetaboAnalyst 3.0 [J. Xia, et al,
MetaboAnalyst 2.0--a comprehensive server for metabolomic data
analysis. Nucleic Acids Research, (2012); published online EpubMay
2, 2012 (10.1093/nar/gks374); J. Xia, et al., MetaboAnalyst: a web
server for metabolomic data analysis and interpretation. Nucleic
Acids Research 37, W652-W660 (2009); published online EpubJul. 1,
2009 (10.1093/nar/gkp356). J. Xia, et al, MetaboAnalyst 3.0--making
metabolomics more meaningful. Nucleic Acids Research, (2015);
published online EpubApr. 20, 2015 (10.1093/nar/gkv380)].
Undetectable values in the metabolite screen were imputed with the
minimum values observed in the data set. Raw peak data were
normalized to the mean of normal sample values and log transformed.
All other statistical analyses were performed with GraphPad Prism
6. Cultured neuron arbor length, neurite number, and branching were
compared by ANOVA followed by Dunnett's test. CSF spermine and
cortical GAP43 were compared by Kruskal-Wallis test followed by
Dunn's test.
Results
[0455] 1. Identification of Elevated CSF Spermine Through
Metabolite Profiling
[0456] An initial screen of CSF metabolites was carried out using a
canine model of MPS I. These animals carry a splice site mutation
in the IDUA gene, resulting in complete loss of enzyme expression
and development of clinical and histological features analogous to
those of MPS I patients (K. P. Menon, et al, Genomics 14, 763-768
(1992); R. Shull, et al., The American journal of pathology 114,
487 (1984). CSF samples were collected from 15 normal dogs and 15
MPS I dogs. CSF samples were evaluated for relative quantities of
metabolites by LC and GC-MS. A total of 281 metabolites could be
positively identified in CSF samples by mass spectrometry. Of
these, 47 (17%) were significantly elevated in MPS I dogs relative
to controls, and 88 (31%) were decreased relative to controls. A
heat map of the 50 metabolites most different between groups is
shown in FIG. 17A. Metabolite profiling identified marked
differences in polyamine, sphingolipid, acetylated amino acid, and
nucleotide metabolism between MPS I and normal dogs. Random forest
clustering analysis identified the polyamine spermine as the
largest contributor to the metabolite differences between MPS I and
normal dogs (FIG. 21). On average spermine was more than 30-fold
elevated in MPS I dogs, with the exception of one MPS I dog that
was under 1 month of age at the time of sample collection. A stable
isotope dilution (SID)-LC-MS/MS assay was developed to
quantitatively measure spermine in CSF. Samples were screened from
6 children with Hurler syndrome (ages 6-26 months), as well as 2
healthy controls (ages 36 and 48 months). Both healthy controls had
CSF spermine levels below the limit of quantification (1 ng/mL) of
the assay, whereas CSF samples from MPS I patients were on average
10-fold above the limit of quantification (FIG. 17B). Spermine
elevation in MPS IH patients appeared consistent with the known
role of HS in spermine binding and uptake (M. Belting, et al,
Journal of Biological Chemistry 278, 47181-47189 (2003); M.
Belting, et al, Proteoglycan involvement in polyamine uptake.
Biochemical Journal 338, 317-323 (1999); J. E. Welch, et al,
International journal of oncology 32, 749-756 (2008))]. Increased
synthesis appeared unlikely as a cause of elevated CSF spermine, as
normal and MPS I dog brain samples had similar mRNA expression
levels for transcriptionally regulated enzymes in the polyamine
synthetic pathway.
[0457] 2. Role of Spermine in Abnormal Neurite Growth Associated
with MPS
[0458] Following axon injury neurons upregulate polyamine
synthesis, which promotes neurite outgrowth (D. Cai, et al, Neuron
35, 711-719 (2002); published online EpubAug 15; K. Deng, et al,
The Journal of neuroscience: the official journal of the Society
for Neuroscience 29, 9545-9552 (2009); published online EpubJul 29;
Y. Gao, et al, Neuron 44, 609-621 (2004); published online EpubNov
18; R. C. Schreiber, et al., Neuroscience 128, 741-749 (2004)). We
therefore evaluated the role of spermine in the abnormal neurite
overgrowth phenotype that has been described in MPS neurons
(Hocquemiller, S., et al, Journal of neuroscience research 88,
202-213 (2010)). Cultures of E18 cortical neurons from MPS I mice
exhibited greater neurite number, branching, and total arbor length
after 4 days in culture than neurons derived from wild type mice
from the colony (FIGS. 19A-F. Treatment of MPS neurons with APCHA,
an inhibitor of spermine synthesis, significantly reduced neurite
growth and branching. The effect was reversible by replacing
spermine (FIGS. 18A-F). The same APCHA concentration did not affect
the growth of normal neurons. Addition of spermine to wild type
neuron cultures at concentrations similar to those identified in
vivo resulted in significant increases in neurite growth and
branching (FIGS. 18A-18F).
[0459] 3. Impact of Gene Therapy on CSF Spermine and GAP43
Expression
[0460] In order to evaluate the effect of IDUA deficiency on GAP43
expression and spermine accumulation in vivo, we measured CSF
spermine and brain GAP43 levels in untreated MPS I dogs as well as
those treated with CNS directed gene therapy. We previously
described five MPS I dogs that were treated with an intrathecal
injection of an adeno-associated virus serotype 9 vector carrying
the canine IDUA transgene (C. Hinderer, et al, Molecular therapy:
the journal of the American Society of Gene Therapy 23, 1298-1307
(2015); published online Epub August). MPS I dogs can develop
antibodies to the normal IDUA enzyme, so two of the dogs were
pre-treated as newborns with hepatic IDUA gene transfer to induce
immunological tolerance to the protein. Both tolerized dogs
exhibited brain IDUA activity well above normal following AAV9
treatment. The three non-tolerized dogs exhibited varying levels of
expression, with one animal reaching levels greater than normal and
the other two exhibiting expression near normal (FIGS. 19A-D). CSF
spermine reduction was inversely proportional to brain IDUA
activity, with a 3-fold reduction relative to untreated animals in
the two dogs with the lowest IDUA expression, and more than 20-fold
reduction in the animal with the highest expression (FIGS.
19A-19D). GAP43 was upregulated in frontal cortex of MPS I dogs,
and expression was normalized in all vector treated animals (FIGS.
19A-19D).
[0461] We further evaluated the relationship between CSF spermine
levels and IDUA reconstitution in MPS I dogs treated with a range
of vector doses. MPS I dogs previously tolerized to human IDUA by
neonatal hepatic gene transfer were treated with intrathecal
injection of an AAV9 vector expressing human IDUA at one of 3 doses
(1010, 1011, 1012 GC/kg, n=2 per dose) (C. Hinderer, et al,
Neonatal tolerance induction enables accurate evaluation of gene
therapy for MPS I in a canine model. Molecular Genetics and
Metabolism, http://dx.doi.org/10.1016/j.ymgme.2016.06.006)). CSF
spermine was evaluated 6 months after injection (FIG. 20A-20B).
Reduction of CSF spermine was dose dependent, with animals at the
mid and high vector doses reaching the normal range, whereas CSF
spermine was only partially reduced in the low dose animals. For
independent verification of the connection between IDUA deficiency
and CSF spermine accumulation, we evaluated CSF spermine levels in
a feline model of MPS I. Using CSF samples from our previously
reported gene therapy studies, we found that untreated MPS I cats
exhibited elevated CSF spermine (FIG. 20A-20B) (C. Hinderer, et al,
Molecular therapy: the journal of the American Society of Gene
Therapy 22, 2018-2027 (2014); published online EpubDec
(10.1038/mt.2014.135)). Intrathecal administration of a high dose
of an AAV9 vector expressing feline IDUA normalized CSF spermine
levels (FIG. 20A).
[0462] C. Discussion
[0463] In the present study we performed metabolite profiling of
CSF samples from MPS I dogs, which revealed substantial disease
related alterations in the CSF metabolome. The most striking
difference was an over 30-fold elevation in spermine levels
compared to normal controls. This finding was confirmed in MPS I
patient samples, as well as in a feline model of MPS I. Spermine
binds directly to HS with high affinity, and cellular uptake of
spermine is dependent on this interaction (M. Belting, S. PERSSON,
L.-A. Fransson, Proteoglycan involvement in polyamine uptake.
Biochemical Journal 338, 317-323 (1999); J. E. Welch, et al,
International journal of oncology 32, 749-756 (2008)). Cell surface
proteoglycans such as glypican-1 can bind spermine through their HS
moieties, and after endocytosis of the glypican protein,
intracellular cleavage of the HS chain releases bound spermine into
the cell (Belting et al, cited above; K. Ding, et al, The Journal
of biological chemistry 276, 46779-46791 (2001); published online
EpubDec 14). Thus, intact HS recycling is essential for spermine
uptake. Inefficient HS recycling due to IDUA deficiency could
inhibit this spermine uptake mechanism, leading to extracellular
spermine accumulation. Alternatively, extracellular GAGs may
sequester spermine, shifting the equilibrium to favor extracellular
distribution. The methanol deproteinization step employed for LC-MS
sample preparation in this study also precipitates soluble HS,
suggesting that the spermine detected in CSF is unbound, and
therefore that uptake inhibition rather than GAG binding is
responsible for extracellular spermine accumulation (N. Volpi,
Journal of chromatography. B, Biomedical applications 685, 27-34
(1996); published online EpubOct 11). Formation and maintenance of
functional neural networks requires precise control of neurite
growth and synapse formation. During development, the CNS
environment becomes increasingly inhibitory to neurite formation,
with myelin associated proteins largely blocking neurite growth in
the adult brain. This developmental shift toward decreased neurite
growth is paralleled by a decrease in GAP43 expression (S. M. De la
Monte, et al, Developmental Brain Research 46, 161-168 (1989);
published online Epub4/1/). The persistent GAP43 expression and
exaggerated neurite outgrowth exhibited by MPS neurons may
interfere with this normal balance of inhibitory and growth
promoting signals, resulting in abnormal connectivity and impaired
cognition (Hocquemiller et al, cited above). How HS storage leads
to this increase in neurite growth has not been established. A
number of studies have implicated polyamines in neurite outgrowth;
following axon injury, the rate-limiting enzymes for the synthesis
of spermine and its precursors putrescine and spermidine are
elevated, allowing for enhanced neurite outgrowth even in the
presence of inhibitory signals from myelin (Cia (2002), Deng
(2009), Gao (2004), all cited above-). Further, treatment of
neurons with putrescine induces neurite growth when injected
directly into CSF, an effect that is blocked by inhibitors of
spermine synthesis (Deng (2009) cited above). The mechanism by
which polyamines exert their effect on neurite growth is not known.
One potential target is the NMDA receptor, activation of which is
potentiated by spermine binding (J. Lerma, Neuron 8, 343-352
(1992); published online
Epub2//(http://dx.doi.org/10.1016/0896-6273(92)90300-3)). NMDA
signaling induces neurite outgrowth, and the spermine sensitive
subunit of the receptor is highly expressed during development (D.
Georgiev, et al, Experimental cell research 314, 2603-2617 (2008);
published online EpubAug 15 (10.1016/j.yexcr.2008.06.009); R. G.
Kalb, Regulation of motor neuron dendrite growth by NMDA receptor
activation. Development 120, 3063-3071 (1994); J. Zhong, et al,
Journal of neurochemistry 64, 531-539 (1995). Notably many
neurotrophic factors bind through HS modified receptors, and
interactions with HS in extracellular matrix can influence neurite
growth (D. Van Vactor, et al, Current opinion in neurobiology 16,
40-51 (2006); published online EpubFeb
(10.1016/j.conb.2006.01.011)). Spermine accumulation may therefore
be one of several factors promoting abnormal neurite growth in MPS
I. Of the 15 MPS I dog CSF samples screened, only one fell within
the normal range of spermine concentration. At 28 days of age, this
was the youngest animal included in the study. This finding
indicates that spermine accumulation may be age dependent, although
this study demonstrates that it is already elevated by 6 months of
age in infants with Hurler syndrome. Future studies should evaluate
CSF spermine levels longitudinally in MPS patients. If spermine
increases with age in MPS patients, this could explain the kinetics
of cognitive decline, as most patients experience 1-2 years of
normal development before the onset of developmental delays. The
potential for impaired HS metabolism to trigger accumulation of a
metabolite that alters neuron growth could point to a novel
connection between enzyme deficiencies and the abnormal neurite
growth phenotype in MPS, which may explain the cognitive
dysfunction associated with these disorders. Future studies should
confirm spermine elevation in other MPSs. These findings also
indicate that CSF spermine may be useful as a noninvasive biomarker
for assessing pharmacodynamics of novel CNS-directed therapies for
MPS. Future trials for CNS directed therapies should evaluate the
correlation between cognitive endpoints and changes in CSF
spermine.
Example 12: CT Guided ICV Delivery Device
[0464] A. Pre-Procedural Screening Assessments
[0465] 1. Protocol Visit 1: Screening
[0466] The principal investigator will describe the screening
process that leads up to the intracisternal (IC) procedure, the
administration procedure itself, and all potential safety risks in
order for the subject (or designated caregiver) to be fully
informed upon signing the informed consent.
[0467] The following will be performed and provided to the
neuroradiologist/neurosurgeon/anesthesiologist in their screening
assessment of subject eligibility for the IC procedure: Medical
history; concomitant medications; physical exam; vital signs;
electrocardiogram (ECG); and laboratory testing results.
[0468] 2. Interval: Screening to Study Visit 2
[0469] In order to allow adequate time to review eligibility, the
following procedures should be performed at any time between the
first screening visit and up to one week prior to study Visit 2
(Day 0): [0470] Head/Neck Magnetic Resonance Imaging (MRI) with and
without gadolinium [note: Subject must be suitable candidate to
receive gadolinium (i.e., eGFR >30 mL/min/1.73 m.sup.2)] [0471]
In addition to the Head/Neck MRI, the investigator will determine
the need for any further evaluation of the neck via
flexion/extension studies [0472] MRI protocol will include T1, T2,
DTI, FLAIR, and CINE protocol images [0473] Head/Neck MRA/MRV as
per institutional protocol (note: Subjects with a history of
intra/transdural operations may be excluded or may need further
testing (e.g., radionucleotide cisternography) that allows for
adequate evaluation of CSF flow and identification of possible
blockage or lack of communication between CSF spaces. [0474]
Neuroradiologist/neurosurgeon subject procedural evaluation
meeting: The representatives from the 3 sites will have a
conference call (or web-meeting) to discuss the eligibility of each
subject for the IC procedures based on all available information
(scans, medical history, physical exam, labs, etc.). All attempts
should be made to achieve consensus on proceeding forward with the
IC procedure or screen failing the subject (i.e., each member
should be prepared to accept the decision made). [0475] Anesthesia
pre-op evaluation Day -28 to Day 1, with detailed assessment of
airway, neck (shortened/thickened) and head range-of-motion (degree
of neck flexion), keeping in mind the special physiologic needs of
the MPS subject.
[0476] 3. Day 1: Computerized Tomography Suite & Vector
Preparation for Administration. Prior to the IC procedure, the CT
Suite will confirm the following equipment and medications are
present: [0477] Adult lumbar puncture (LP) kit (supplied per
institution) [0478] BD (Becton Dickinson) 22 or 25
gauge.times.3-7'' spinal needle (Quincke bevel) [0479] Coaxial
introducer needle (e.g., 18G.times.3.5''), used at the discretion
of the interventionalist (for introduction of spinal needle) [0480]
4 way small bore stopcock with swivel (Spin) male luer lock [0481]
T-connector extension set (tubing) with female luer lock adapter,
approximate length 6.7'' [0482] Omnipaque 180 (iohexol), for
intrathecal administration [0483] Iodinated contrast for
intravenous (IV) administration [0484] 1% lidocaine solution for
injection (if not supplied in adult LP kit) [0485] Prefilled 10 cc
normal saline (sterile) flush syringe [0486] Radiopaque marker(s)
[0487] Surgical prep equipment/shaving razor [0488]
Pillows/supports to allow proper positioning of intubated subject
[0489] Endotracheal intubation equipment, general anesthesia
machine and mechanical ventilator [0490] Intraoperative
neurophysiological monitoring (IONM) equipment (and required
personnel) [0491] 10 cc syringe containing AAV9.hIDUA vector;
prepared and transported to CT/Operating Room (OR) suite in
accordance with separate Pharmacy Manual
[0492] 4. Day 1: Subject Preparation & Dosing [0493] Informed
Consent for the study and procedure will be confirmed and
documented within the medical record and/or study file. Separate
consent for the procedure from radiology and anesthesiology staff
will be obtained as per institutional requirements. [0494] Study
subject will have intravenous access placed within the appropriate
hospital care unit according to institutional guidelines (e.g., two
IV access sites). Intravenous fluids will be administered at the
discretion of the anesthesiologist. [0495] At the discretion of the
anesthesiologist and per institutional guidelines, study subject
will be induced and undergo endotracheal intubation with
administration of general anesthesia in an appropriate patient care
unit, holding area or the surgical/CT procedure suite. [0496] A
lumbar puncture will be performed, first to remove 5 cc of
cerebrospinal fluid (CSF) and subsequently to inject contrast
(Omnipaque 180) intrathecally to aid visualization of the cisterna
magna. Appropriate subject positioning maneuvers will be performed
to facilitate diffusion of contrast into the cisterna magna. [0497]
If not already done so, intraoperative neurophysiological
monitoring (IONM) equipment will be attached to subject. [0498]
Subject will be placed onto the CT scanner table in the prone or
lateral decubitus position. [0499] If deemed appropriate, subject
will be positioned in a manner that provides neck flexion to the
degree determined to be safe during pre-operative evaluation and
with normal neurophysiologic monitor signals documented after
positioning. [0500] The following study staff and investigator(s)
will be confirmed to be present and identified on-site: [0501]
Interventionalist/neurosurgeon performing the procedure [0502]
Anesthesiologist and respiratory technician(s) [0503] Nurses and
physician assistants [0504] CT (or OR) technicians [0505]
Neurophysiology technician [0506] Site Research Coordinator [0507]
The subject's skin under the skull base will be shaved as
appropriate. [0508] CT scout images will be performed, followed by
a pre-procedure planning CT with IV contrast, if deemed necessary
by the interventionalist to localize the target location and to
image vasculature. [0509] Once the target site (cisterna magna) is
identified and needle trajectory planned, the skin will be prepped
and draped using sterile technique as per institutional guidelines.
[0510] A radiopaque marker will be placed on the target skin
location as indicated by the interventionalist. [0511] The skin
under the marker will be anesthetized via infiltration with 1%
lidocaine. [0512] A 22G or 25G spinal needle will be advanced
towards the cisterna magna, with the option to use a coaxial
introducer needle. [0513] After needle advancement, CT images will
be obtained using the thinnest CT slice thickness feasible using
institutional equipment (ideally <2.5 mm). Serial CT images
should use the lowest radiation dose possible that allows for
adequate visualization of the needle and relevant soft tissues
(e.g., paraspinal muscles, bone, brainstem, and spinal cord).
[0514] Correct needle placement will be confirmed by observation of
CSF in the needle hub and visualization of needle tip within the
cisterna magna. [0515] The interventionalist will confirm the
syringe containing vector is positioned close to, but outside of
the sterile field. Prior to handling or administering vector, site
will confirm gloves, mask, and eye protection are donned by staff
assisting the procedure within the sterile field (other staff
outside of sterile field do not need to take these procedures).
[0516] The short (.about.6'') extension tubing will be attached to
the inserted spinal needle, which will then be attached to the
4-way stop cock. Once this apparatus is "self-primed" with the
subject's CSF, the 10 cc prefilled normal saline flush syringe will
be attached to the 4-way stop cock. [0517] The syringe containing
vector will be handed to the interventionalist and attached to a
port on the 4-way stop cock. [0518] Once the stop cock port to the
syringe containing vector is opened, the syringe contents are to be
injected slowly (over approximately 1-2 minutes), with care taken
not to apply excessive force onto the plunger during the injection.
[0519] Once the contents of the syringe containing AAV9.hIDUA test
vector injected, the stop cock will be turned so that the stopcock
and needle assembly can be flushed with 1-2 cc of normal saline
using the attached prefilled syringe. [0520] When ready, the
interventionist will alert staff that he/she will remove the
apparatus from the subject. [0521] In a single motion, the needle,
extension tubing, stopcock, and syringes will be slowly removed
from the subject and placed onto a surgical tray for discarding
into a biohazard waste receptacle or hard container (for the
needle). [0522] The needle insertion site will be examined for
signs of bleeding or CSF leakage and treated as indicated by the
investigator. Site will be dressed using gauze, surgical tape
and/or Tegaderm dressing, as indicated. [0523] Subject will be
removed from the CT scanner and placed supine onto a stretcher.
[0524] Anesthesia will be discontinued and subject cared for
following institutional guidelines for post-anesthesia care.
Neurophysiologic monitors can be removed from study subject. [0525]
The head of the stretcher on which the subject lies should be
slightly raised (.about.30 degrees) during recovery. [0526] Subject
will be transported to a suitable post-anesthesia care unit as per
institutional guidelines. [0527] After subject has adequately
recovered consciousness and is in stable condition, he/she will be
admitted to the appropriate floor/unit for protocol mandated
assessments. Neurological assessments will be followed as per the
protocol and the Primary Investigator will oversee subject care in
collaboration with hospital and research staff.
Example 13: Evaluation of Intrathecal Routes of Administration in
Large Animals
[0528] The purpose of this study was to evaluate more routine
methods of administration into the CSF, including intraventricular
(ICV) injection, and injection through a lumbar puncture. In brief,
in this study ICV and IC AAV administration were compared in dogs.
Vector administration was evaluated via lumbar puncture in nonhuman
primates with some animals placed in Trendelenburg position after
injection, a maneuver which has been suggested to improve cranial
distribution of vector. In the dog study, ICV and IC vector
administration resulted in similarly efficient transduction
throughout brain and spinal cord. However, animals in the ICV
cohort developed encephalitis, apparently due to a severe T cell
response to the transgene product. The occurrence of this
transgene-specific immune response only in the ICV cohort is
suspected to be related to the presence of localized inflammation
from the injection procedure at the site of transgene expression.
In the NHP study, transduction efficiency following vector
administration into the lumbar cistern was improved compared to our
previous studies by using an extremely large injection volume
(approximately 40% of total CSF volume). However, this approach was
still less efficient than IC administration. Positioning animals in
Trendelenburg after injection provided no additional benefit.
However, it was found that large injection volumes could improve
cranial distribution of the vector.
[0529] To maximize the effectiveness of intrathecal AAV delivery,
it will be critical to determine the optimal route of vector
administration into the CSF. We previously reported that vector
injection into the cisterna magna (cerebellomedullary cistern) by
suboccipital puncture achieved effective vector distribution in
nonhuman primates, whereas injection via lumbar puncture resulted
in substantially lower transduction of the spinal cord and
virtually no distribution to the brain, underscoring the importance
of the route of administration [Hinderer, Molecular
Therapy--Methods & Clinical Development. 12/10/online 2014; 1].
Others have suggested that vector delivery into the lateral
ventricles, a common clinical procedure, results in effective
vector distribution [Haurigot et al, J Clin Invest., August 2013;
123(8): 3254-3271]. It has also been reported that delivery via
lumbar puncture can be improved by placing animals in the
Trendelenburg position after injection to promote cranial vector
distribution [Meyer et al, Molecular therapy: the journal of the
American Society of Gene Therapy. Oct. 31, 2014]. In this study we
compared intraventricular and intracisternal administration of an
AAV9 vector expressing a green fluorescent protein (GFP) reporter
gene in dogs. We found that both routes achieve effective
distribution throughout the CNS, though intraventricular delivery
may carry additional risks of a transgene-specific immune response.
We also evaluated vector delivery by lumbar puncture in NHPs, and
the impact of placing animals in the Trendelenburg position after
injection. There was no clear effect of post-injection positioning,
although we did find that large injection volumes could improve
cranial distribution of the vector.
[0530] A. Materials and Methods:
[0531] 1. Vector production: The GFP vector consisted of an AAV
serotype 9 capsid carrying an expression cassette comprising a
chicken beta actin promoter with cytomegalovirus immediate early
enhancer, an artificial intron, the enhanced green fluorescent
protein cDNA, a woodchuck hepatitis virus posttranscriptional
regulatory element, and a rabbit beta globin polyadenylation
sequence. The GUSB vector consisted of an AAV serotype 9 capsid
carrying an expression cassette comprising a chicken beta actin
promoter with cytomegalovirus immediate early enhancer, an
artificial intron, the canine GUSB cDNA, and a rabbit beta globin
polyadenylation sequence. The vectors were produced by triple
transfection of HEK 293 cells and purified on an iodixanol gradient
as previously described [Lock et al, Human gene therapy. October
2010; 21(10):1259-1271].
[0532] 2. Animal experiments: All dogs were raised in the National
Referral Center for Animal Models of Human Genetic Disease of the
School of Veterinary Medicine of the University of Pennsylvania
(NIH OD P40-010939) under National Institutes of Health and USDA
guidelines for the care and use of animals in research.
[0533] 3. N H P study: This study included 6 cynomolgus monkeys
between 9 and 12 years of age. Animals were between 4 and 8 kg at
the time of injection. The vector (2.times.1013 GC) was diluted in
5 mL of Omnipaque (Iohexol) 180 contrast material prior to
injection. Injection of the vector via lumbar puncture was
performed as previously described [Hinderer, Molecular
Therapy--Methods & Clinical Development. 12/10/online 2014; 1].
Correct injection into the intrathecal space was verified by
fluoroscopy. For animals in the Trendelenburg group, the head of
the bed was lowered 30 degrees for 10 minutes immediately following
injection. Euthanasia and tissue collection were performed as
previously described [Hinderer, Molecular Therapy--Methods &
Clinical Development. 12/10/online 2014; 1].
[0534] 4. Dog study: This study included 6 one-year-old MPS I dogs.
Baseline MRIs were performed on all ICV treated dogs to plan the
injection coordinates. Intracisternal injection was performed as
previously described [Hinderer et al, Molecular therapy: the
journal of the American Society of Gene Therapy. August 2015;
23(8):1298-1307]. For ICV injection, dogs were anesthetized with
intravenous propofol, endotracheally intubated, maintained under
anesthesia with isoflurane and placed in a stereotaxic frame. The
skin was sterilely prepped, and an incision was made over the
injection site. A single burr hole was drilled at the injection
site, through which a 26-gauge needle was advanced to the
predetermined depth. Placement was confirmed by CSF return. The
vector (1.8.times.10.sup.13 GC in 1 mL) was slowly infused over one
to two minutes. Euthanasia and tissue collection were performed as
previously described [Hinderer et al, Molecular therapy: the
journal of the American Society of Gene Therapy. August 2015;
23(8):1298-1307].
[0535] 5. Histology: Brains were processed as described for
evaluation of GFP expression [Hinderer, Molecular Therapy--Methods
& Clinical Development. 12/10/online 2014; 1]. GUSB enzyme
stains and GM3 stains were performed as previously described [Gurda
et al, Molecular therapy: the journal of the American Society of
Gene Therapy. Oct. 8 2015.]
[0536] 6. ELISPOT: At the time of necropsy blood was collected from
vector treated dogs in heparinized tubes. Peripheral blood
mononuclear cells were isolated by Ficoll gradient centrifugation.
T cell responses to AAV9 capsid peptides and GFP peptides were
evaluated by interferon gamma ELISPOT. AAV9 and GFP peptide
libraries were synthesized as 15-mers with 10 amino acid overlap
(Mimotopes). The AAV9 peptide library was grouped in 3 pools: Pool
A from peptide 1 to 50, Pool B from peptide 51 to 100 and Pool C
from peptide 101 to 146. The GFP peptide library was also grouped
in 3 pools. Phorbol 12-myristate 13-acetate plus Ionomycin salt
(PMA+ION) were used as positive control. DMSO was used as negative
control. Cells were stimulated with peptide and interferon gamma
secretion was detected as described. A response was considered
positive if it was both greater than 55 Spots Forming Units (SFU)
per million lymphocytes and at least 3 times the DMSO negative
control value.
[0537] 7. Biodistribution: At the time of necropsy tissues for
biodistribution were immediately frozen on dry ice. DNA isolation
and quantification of vector genomes by TaqMan PCR was performed as
described [Wang et al, Human gene therapy. November 2011;
22(11):1389-1401].
[0538] 8. GUSB enzyme assay: GUSB activity was measured in CSF as
described [Gurda et al, Molecular therapy: the journal of the
American Society of Gene Therapy. Oct. 8 2015].
[0539] B. Results
[0540] 1. Comparison of intraventricular and intracisternal vector
delivery in dogs
[0541] Our previous studies using a canine model of the lysosomal
storage disease mucopolysaccharidosis type I (MPS I) demonstrated
that AAV9 injection into the cisterna magna could effectively
target the entire brain and spinal cord [Hinderer et al, Molecular
therapy: the journal of the American Society of Gene Therapy.
August 2015; 23(8):1298-1307]. In this study, we compared
distribution of an AAV9 vector expressing a GFP reporter gene
administered into the cisterna magna or lateral ventricle of adult
MPS I dogs. Three dogs were treated with a single 1 mL injection of
the vector (1.8.times.10.sup.13 genome copies) into the cisterna
magna. Three additional dogs received a single vector injection of
the same vector into the lateral ventricle. For dogs treated by ICV
injection, a baseline MRI was performed to select the larger
lateral ventricle for injection and to define the target
coordinates. Injection was performed using a stereotaxic frame to
accurately target the designated ventricle.
[0542] The three dogs treated with IC vector injection appeared
healthy throughout the study. They were euthanized two weeks after
vector injection for evaluation of vector biodistribution and
transgene expression. No gross or microscopic brain lesions were
observed in any IC treated dogs (FIG. 14). Measurement of vector
genomes by quantitative PCR revealed vector deposition throughout
all sampled regions of the brain and spinal cord (FIG. 15).
Consistent with the distribution of vector genomes, robust
transgene expression was detectable in most regions of cerebral
cortex, as well as throughout the spinal cord. Spinal cord
histology was notable for strong transduction of alpha motor
neurons, with a gradient of transduction favoring thoracic and
lumbar segments.
[0543] The three dogs treated with vector injected ICV initially
appeared healthy following the procedure. However, one animal
(I-567) was found dead 12 days after injection. The other two
animals survived to the designated 14 day necropsy time point,
although one animal (I-565) became stuporous prior to euthanasia,
and the other (I-568) began to exhibit weakness of facial muscles.
These clinical findings correlated with significant gross brain
lesions. Brains from all three animals exhibited discoloration
surrounding the needle track, with associated hemorrhage in the
animal that was found dead. Histological evaluation revealed severe
lymphocytic inflammation in the region surrounding the injection
site. Perivascular lymphocytic infiltration was also observed
throughout the brain of each animal. Given this evidence for
immunological toxicity, T cell responses to both the AAV9 capsid
protein and the GFP transgene were evaluated in peripheral blood
samples collected from one of the ICV-treated dogs (I-565) at the
time of necropsy. An interferon gamma ELISPOT showed a strong T
cell response directed against GFP, with no evidence of a response
to capsid peptides. This suggests that the encephalitis observed
was caused by a cell-mediated immune response against the transgene
product.
[0544] Vector distribution in the ICV treated animals was similar
to that observed in the IC treated group, although spinal cord
transduction was somewhat greater in the IC cohort (FIG. 15). GFP
expression was observed throughout the CNS regions examined in the
ICV treated animals.
[0545] The toxicity associated with ICV administration of an AAV9
vector expressing GFP was consistent with an immune response
against the transgene product. Such an immune response might be
particularly severe because the GFP transgene is entirely foreign;
animals may be more immunologically tolerant to a transgene that is
similar to an endogenous protein.
[0546] 2. Impact of the Trendelenburg Position on CNS Transduction
after AAV9 Administration by Lumbar Puncture in NHP
[0547] We previously compared AAV9 injection into the cisterna
magna or lumbar cistern of NHPs and found that the lumbar route was
10-fold less efficient for targeting the spinal cord and 100-fold
less efficient for targeting the brain [C. Hinderer, et al,
Molecular Therapy--Methods & Clinical Development. 12/10/online
2014; 1]. Other investigators have since demonstrated better
transduction using AAV9 administration by lumbar puncture, with
improvements in cranial distribution of the vector achieved by
placing animals in the Trendelenburg position after injection [Myer
et al, Molecular therapy: the journal of the American Society of
Gene Therapy. Oct. 31, 2014]. In this approach the vector is
diluted into an excess volume of contrast material to increase the
density of the solution and promote gravity driven distribution
while in Trendelenburg. Six adult cynomolgus monkeys were treated
with a single injection of AAV9 expressing GFP (2.times.10.sup.13
genome copies) in the L3-4 interspace. The vector was diluted to a
final volume of 5 mL in Iohexol 180 contrast material. Four of the
animals were positioned with the head of the procedure table at a
-30.degree. angle for 10 minutes immediately after injection. After
10 minutes fluoroscopic images were captured to verify contrast
distribution in the CSF. Notably with this large injection volume
(approximately 40% of the total CSF volume of the animal)
[Reiselbach et al, New England Journal of Medicine. 1962;
267(25):1273-1278] contrast material was rapidly distributed along
the entire spinal subarachnoid space and into the basal cisterns
even in animals that were not placed in Trendelenburg position
(FIG. 18). Analysis of vector genome distribution by PCR (FIG. 19)
and GFP expression (FIG. 20) demonstrated transduction throughout
the brain and spinal cord. There was no apparent impact of
post-injection positioning on the number or distribution of
transduced cells. As previously reported, there was vector escape
to the periphery and hepatic transduction after intrathecal AAV
administration [Hinderer et al, Molecular Therapy--Methods &
Clinical Development. 12/10/online 2014; 1; Haurigot et al, Journal
of Clinical Investigation. August 2013; 123(8): 3254-3271]. The
extent of liver transduction was dependent on the presence of
pre-existing neutralizing antibodies (NAb) against AAV9. Four out
of six animals had no detectable baseline AAV9 NAbs (titer <1:5)
and two animals (4051 and 07-11) had detectable pre-existing
antibodies to AAV9 with a titer of 1:40. Consistent with previous
results, pre-existing antibodies blocked liver transduction, and
resulted in increased vector distribution to the spleen [Wang et
al, Human gene therapy. November 2011; 22(11):1389-1401, but had no
impact on CNS transduction; Haurigot et al, Journal of Clinical
Investigation. August 2013; 123(8):3254-3271].
[0548] C. Discussion
[0549] Because suboccipital puncture is not a common procedure in
clinical practice, we evaluated more routine sites of CSF access,
including the lateral ventricle and the lumbar cistern. Here we
evaluated a method employing vector solutions with higher density
and post-injection Trendelenburg positioning to improve vector
distribution cranially from the lumbar region.
[0550] In the dog study, both IC and ICV vector injection yielded
similarly effective vector distribution, but encephalitis occurred
only in the ICV group. A T cell response against the GFP transgene
was detectable in one of the ICV treated dogs, suggesting that the
lymphocytic encephalitis observed in these animals was due to a
transgene-specific immune response. Induction of a T cell response
to a new antigen requires two elements-recognition of an epitope
from the protein by a naive T cell, and an inflammatory "danger
signal" that promotes activation of the T cell. AAV is believed to
be capable of expressing foreign transgenes without eliciting
immunity against the transgene product because it does not activate
the innate immune system, thereby avoiding inflammatory signals and
promoting tolerance rather than immunity when naive lymphocytes
encounter the newly expressed antigen. Local inflammation caused by
the trauma of penetrating the brain parenchyma, occurring at the
same location that the foreign transgene product is expressed, may
provide the danger signal needed to induce an immune response to
the transgene product. This is supported by previous studies in MPS
I dogs, which develop cell-mediated immune responses to an enzyme
expressed from an AAV vector delivered by direct brain injection
but not by IC injection [Ciron et al, Annals of Neurology. August
2006; 60(2):204-213; Hinderer, et al, Molecular therapy: the
journal of the American Society of Gene Therapy. August 2015;
23(8):1298-1307]. The potential for such an immune response will
depend on whether the transgene product is recognized as
foreign--for delivery of vectors expressing a protein that is also
produced endogenously, even an inflammatory response caused by
injection may not break tolerance to the self protein. The same may
be true for patients with recessive diseases who carry missense
mutations that allow for production of a protein similar to the
transgene product. Risk of immunity could, therefore, vary
depending on patient population and transgene product, and in some
cases immunosuppression may be necessary to prevent destructive T
cell responses to a transgene. The present findings suggest that
the risk of deleterious immune responses can likely be mitigated by
using an IC rather than ICV route of administration.
[0551] The study of AAV9 administration via lumbar puncture in NHPs
showed greater transduction throughout the CNS than we have
previously observed with this route of administration. This
difference appears to be due to the large injection volume in the
present study, which was necessary in order to dilute the vector
into an excess volume of contrast material. Previous studies have
shown that such large volume injections (approximately 40% of CSF
volume) can drive injected material directly into the basal
cisterns and even the ventricular CSF of macaques [Reiselbach,
cited above]. The potential to translate this approach to humans is
unclear, given that replicating this approach would require
extremely large injection volumes (>60 mL) that are not
routinely administered to patients. Moreover, even with this high
volume approach, injection via lumbar puncture was less efficient
than previous results with IC delivery. In this previous study,
animals were dosed by weight, so only one animal received an IC
vector dose equivalent to that used here [Hinderer, et al,
Molecular Therapy--Methods & Clinical Development. 12/10/online
2014; 1]. That animal had on average 3-fold higher vector
distribution in the brain and spinal cord, indicating that even
very large volume vector delivery to the lumbar cistern is less
efficient than IC delivery. In contrast to reports in the
literature, we found no additional benefit to placing animals in
the Trendelenburg position after lumbar vector injection [Meyer et
al, Molecular therapy: the journal of the American Society of Gene
Therapy. Oct. 31, 2014].
[0552] Together these findings support vector administration at the
level of the cisterna magna, as this approach achieves more
efficient vector distribution than administration via lumbar
puncture, and appears to carry less risk of immunity to the
transgene product than ICV administration. Vector delivery to the
cisterna magna could be carried out clinically using the
suboccipital puncture approach that was used in preclinical
studies. Additionally, injection into the subarachnoid space
between the first and second cervical vertebra using a lateral
approach (C1-2 puncture) is likely to produce similar vector
distribution given the proximity of the injection site to the
cisterna magna. The C1-2 approach has the additional advantage
that, unlike suboccipital puncture, it is widely used clinically
for CSF access, particularly for intrathecal contrast
administration.
[0553] This application contains a sequence listing, which is
hereby incorporated by reference, as are U.S. patent application
Ser. No. 16/075,056, filed Aug. 2, 2018, which is a 371 of
PCT/US2017/016133, filed Feb. 2, 2017, which claims the benefit of
U.S. Provisional Patent Application No. 62/452,560, filed Jan. 31,
2017, U.S. Provisional Patent Application No. 62/367,798, filed
Jul. 28, 2016, U.S. Provisional Patent Application No. 62/337,178,
filed May 16, 2016, U.S. Provisional Patent application No.
62/323,271, filed Apr. 16, 2016 and U.S. Provisional Patent
Application No. 62/290,547, filed Feb. 3, 2016. All publications,
patents, and patent applications cited in this application are
hereby incorporated by reference in their entireties as if each
individual publication or patent application were specifically and
individually indicated to be incorporated by reference. Although
the foregoing invention has been described in some detail by way of
illustration and example for purposes of clarity of understanding,
it will be readily apparent to those of ordinary skill in the art
in light of the teachings of this invention that certain changes
and modifications can be made thereto without departing from the
spirit or scope of the appended claims.
TABLE-US-00002 TABLE (Sequence Listing Free Text) SEQ ID NO Free
Text under <223> 3 <223> CB7.CI.hIDUAco.RBG <220>
<221> misc_feature <222> (1) . . . (130) <223>
5'' ITR <220> <221> promoter <222> (198) . . .
(579) <223> CMV IE promoter <220> <221> promoter
<222> (582) . . . (863) <223> CB promoter <220>
<221> TATA_signal <222> (836) . . . (839) <220>
<221> Intron <222> (956) . . . (1928) <223>
chicken beta-actin intron <220> <221> CDS <222>
(1990) . . . (3948) <223> human IDUA co <220>
<221> polyA_signal <222> (4000) . . . (4126)
<223> rabbit globin polyA 5 <223> Vector genome -
TBG.PI.hIDUAco.RBG <220> <221> repeat_region
<222> (1) . . . (130) <223> 5' ITR <220>
<221> enhancer <222> (221) . . . (320) <223>
Alpha mic/Bik <220> <221> enhancer <222> (327) .
. . (426) <223> Alpha mic/Bik <220> <221>
promoter <222> (442) . . . (901) <223> TBG <220>
<221> TATA_signal <222> (885) . . . (888) <220>
<221> Intron <222> (1027) . . . (1157) <220>
<221> misc_feature <222> (1251) . . . (3212)
<223> Human alpha-L-IDUA coding sequence <220>
<221> polyA_signal <222> (3261) . . . (3387)
<223> rabbit globin poly A <220> <221>
repeat_region <222> (3476) . . . (3605) 6 <223> Vector
genome: CMV.PI.hIDUAco.SV40 <220> <221> repeat_region
<222> (1) . . . (130) <223> 5' ITR <220>
<221> misc_feature <222> (143) . . . (181) <223>
CMV enhancer and promoter <220> <221> TATA_signal
<222> (910) . . . (916) <220> <221> Intron
<222> (1024) . . . (1221) <223> chimeric intron
<220> <221> misc_feature <222> (1284) . . .
(3246) <223> human IDUA coding sequence <220>
<221> polyA_signal <222> (3258) . . . (3496)
<220> <221> repeat_region <222> (3562) . . .
(3691) 7 <220> <223> hu14/Adeno-associated virus 9
[0554] The following information is provided for sequences
containing free text under numeric identifier <223>.
Sequence CWU 1
1
711971DNAHomo sapiensCDS(1)..(1971) 1atg cgg ccc ctg agg cct aga
gct gct ctg ctg gca ctg ctg gcc agt 48Met Arg Pro Leu Arg Pro Arg
Ala Ala Leu Leu Ala Leu Leu Ala Ser1 5 10 15ctg ctg gct gcc cct cct
gtg gcc cct gcc gaa gcc cct cac ctg gtg 96Leu Leu Ala Ala Pro Pro
Val Ala Pro Ala Glu Ala Pro His Leu Val 20 25 30cat gtg gat gcc gcc
aga gcc ctg tgg cct ctg cgg aga ttc tgg cgg 144His Val Asp Ala Ala
Arg Ala Leu Trp Pro Leu Arg Arg Phe Trp Arg 35 40 45agc acc ggc ttt
tgc ccc cca ctg cct cac agc cag gcc gac cag tac 192Ser Thr Gly Phe
Cys Pro Pro Leu Pro His Ser Gln Ala Asp Gln Tyr 50 55 60gtg ctg agc
tgg gac cag cag ctg aac ctg gcc tac gtg ggc gcc gtg 240Val Leu Ser
Trp Asp Gln Gln Leu Asn Leu Ala Tyr Val Gly Ala Val65 70 75 80ccc
cac aga ggc atc aaa cag gtg aga acc cac tgg ctg ctg gaa ctg 288Pro
His Arg Gly Ile Lys Gln Val Arg Thr His Trp Leu Leu Glu Leu 85 90
95gtg aca acc cgg ggc tcc acc ggc aga ggc ctg agc tac aac ttc acc
336Val Thr Thr Arg Gly Ser Thr Gly Arg Gly Leu Ser Tyr Asn Phe Thr
100 105 110cac ctg gac ggc tac ctg gac ctg ctg aga gag aac cag ctg
ctg ccc 384His Leu Asp Gly Tyr Leu Asp Leu Leu Arg Glu Asn Gln Leu
Leu Pro 115 120 125ggc ttc gag ctg atg ggc agc gcc agc ggc cac ttc
acc gac ttc gag 432Gly Phe Glu Leu Met Gly Ser Ala Ser Gly His Phe
Thr Asp Phe Glu 130 135 140gac aag cag caa gtc ttt gag tgg aag gac
ctg gtg tcc agc ctg gcc 480Asp Lys Gln Gln Val Phe Glu Trp Lys Asp
Leu Val Ser Ser Leu Ala145 150 155 160aga cgg tac atc ggc aga tac
gga ctg gcc cac gtg tcc aag tgg aac 528Arg Arg Tyr Ile Gly Arg Tyr
Gly Leu Ala His Val Ser Lys Trp Asn 165 170 175ttc gag aca tgg aac
gag ccc gac cac cac gac ttc gac aac gtg tca 576Phe Glu Thr Trp Asn
Glu Pro Asp His His Asp Phe Asp Asn Val Ser 180 185 190atg acc atg
cag ggc ttt ctg aac tac tac gac gcc tgc tcc gag ggc 624Met Thr Met
Gln Gly Phe Leu Asn Tyr Tyr Asp Ala Cys Ser Glu Gly 195 200 205ctg
aga gcc gcc agt cct gcc ctg aga ctg ggc gga ccc ggc gat agc 672Leu
Arg Ala Ala Ser Pro Ala Leu Arg Leu Gly Gly Pro Gly Asp Ser 210 215
220ttc cac acc ccc ccc aga agc ccc ctg agc tgg ggc ctg ctg aga cac
720Phe His Thr Pro Pro Arg Ser Pro Leu Ser Trp Gly Leu Leu Arg
His225 230 235 240tgc cac gac ggc acc aat ttc ttc acc ggc gag gcc
ggc gtg cgg ctg 768Cys His Asp Gly Thr Asn Phe Phe Thr Gly Glu Ala
Gly Val Arg Leu 245 250 255gac tac atc agc ctg cac cgg aag ggc gcc
aga agc agc atc agc atc 816Asp Tyr Ile Ser Leu His Arg Lys Gly Ala
Arg Ser Ser Ile Ser Ile 260 265 270ctg gaa cag gaa aag gtc gtc gcc
cag cag atc cgg cag ctg ttc ccc 864Leu Glu Gln Glu Lys Val Val Ala
Gln Gln Ile Arg Gln Leu Phe Pro 275 280 285aag ttc gcc gac acc ccc
atc tac aac gac gag gcc gac ccc ctg gtg 912Lys Phe Ala Asp Thr Pro
Ile Tyr Asn Asp Glu Ala Asp Pro Leu Val 290 295 300gga tgg tca ctg
cct cag cct tgg aga gcc gac gtg acc tac gcc gct 960Gly Trp Ser Leu
Pro Gln Pro Trp Arg Ala Asp Val Thr Tyr Ala Ala305 310 315 320atg
gtg gtg aaa gtg atc gcc cag cat cag aac ctg ctg ctg gcc aac 1008Met
Val Val Lys Val Ile Ala Gln His Gln Asn Leu Leu Leu Ala Asn 325 330
335acc acc agc gcc ttc cct tac gcc ctg ctg agc aac gac aac gcc ttc
1056Thr Thr Ser Ala Phe Pro Tyr Ala Leu Leu Ser Asn Asp Asn Ala Phe
340 345 350ctg agc tac cac ccc cac ccc ttc gcc cag aga acc ctg acc
gcc cgg 1104Leu Ser Tyr His Pro His Pro Phe Ala Gln Arg Thr Leu Thr
Ala Arg 355 360 365ttc cag gtg aac aac acc aga ccc ccc cac gtg cag
ctg ctg aga aag 1152Phe Gln Val Asn Asn Thr Arg Pro Pro His Val Gln
Leu Leu Arg Lys 370 375 380ccc gtg ctg acc gct atg gga ctg ctg gct
ctg ctg gac gag gaa cag 1200Pro Val Leu Thr Ala Met Gly Leu Leu Ala
Leu Leu Asp Glu Glu Gln385 390 395 400ctg tgg gcc gaa gtg tcc cag
gcc ggc acc gtg ctg gac agc aat cat 1248Leu Trp Ala Glu Val Ser Gln
Ala Gly Thr Val Leu Asp Ser Asn His 405 410 415aca gtg ggc gtg ctg
gcc tcc gcc cac aga cct cag gga ccc gcc gat 1296Thr Val Gly Val Leu
Ala Ser Ala His Arg Pro Gln Gly Pro Ala Asp 420 425 430gct tgg cgg
gct gcc gtg ctg atc tac gcc agc gac gat acc aga gcc 1344Ala Trp Arg
Ala Ala Val Leu Ile Tyr Ala Ser Asp Asp Thr Arg Ala 435 440 445cac
ccc aac aga tcc gtg gcc gtg acc ctg cgg ctg aga ggc gtg cca 1392His
Pro Asn Arg Ser Val Ala Val Thr Leu Arg Leu Arg Gly Val Pro 450 455
460cca ggc cct gga ctg gtg tac gtg acc aga tac ctg gac aac ggc ctg
1440Pro Gly Pro Gly Leu Val Tyr Val Thr Arg Tyr Leu Asp Asn Gly
Leu465 470 475 480tgc agc ccc gac ggc gaa tgg cgc aga ctg ggc aga
cct gtg ttc ccc 1488Cys Ser Pro Asp Gly Glu Trp Arg Arg Leu Gly Arg
Pro Val Phe Pro 485 490 495acc gcc gag cag ttc cgg cgg atg aga gcc
gct gag gat cct gtg gct 1536Thr Ala Glu Gln Phe Arg Arg Met Arg Ala
Ala Glu Asp Pro Val Ala 500 505 510gct gcc cct aga cct ctg cct gct
ggc ggc aga ctg acc ctg agg ccc 1584Ala Ala Pro Arg Pro Leu Pro Ala
Gly Gly Arg Leu Thr Leu Arg Pro 515 520 525gct ctg aga ctg cct agt
ctg ctg ctg gtg cac gtg tgc gcc agg ccc 1632Ala Leu Arg Leu Pro Ser
Leu Leu Leu Val His Val Cys Ala Arg Pro 530 535 540gag aag cct ccc
ggc cag gtg aca aga ctg aga gcc ctg ccc ctg acc 1680Glu Lys Pro Pro
Gly Gln Val Thr Arg Leu Arg Ala Leu Pro Leu Thr545 550 555 560cag
ggc cag ctg gtg ctg gtg tgg tcc gat gag cac gtg ggc agc aag 1728Gln
Gly Gln Leu Val Leu Val Trp Ser Asp Glu His Val Gly Ser Lys 565 570
575tgc ctg tgg acc tac gag atc cag ttc agc cag gac ggc aag gcc tac
1776Cys Leu Trp Thr Tyr Glu Ile Gln Phe Ser Gln Asp Gly Lys Ala Tyr
580 585 590acc ccc gtg tcc cgg aag ccc agc acc ttc aac ctg ttc gtg
ttc agc 1824Thr Pro Val Ser Arg Lys Pro Ser Thr Phe Asn Leu Phe Val
Phe Ser 595 600 605ccc gat aca ggc gcc gtg tcc ggc tct tat aga gtg
cgg gcc ctg gac 1872Pro Asp Thr Gly Ala Val Ser Gly Ser Tyr Arg Val
Arg Ala Leu Asp 610 615 620tac tgg gcc aga ccc ggc cct ttc agc gac
ccc gtg ccc tac ctg gaa 1920Tyr Trp Ala Arg Pro Gly Pro Phe Ser Asp
Pro Val Pro Tyr Leu Glu625 630 635 640gtg ccc gtg cct aga ggc ccc
cct agc ccc ggc aac cct tga gtc gac 1968Val Pro Val Pro Arg Gly Pro
Pro Ser Pro Gly Asn Pro Val Asp 645 650 655ccg 1971Pro2653PRTHomo
sapiens 2Met Arg Pro Leu Arg Pro Arg Ala Ala Leu Leu Ala Leu Leu
Ala Ser1 5 10 15Leu Leu Ala Ala Pro Pro Val Ala Pro Ala Glu Ala Pro
His Leu Val 20 25 30His Val Asp Ala Ala Arg Ala Leu Trp Pro Leu Arg
Arg Phe Trp Arg 35 40 45Ser Thr Gly Phe Cys Pro Pro Leu Pro His Ser
Gln Ala Asp Gln Tyr 50 55 60Val Leu Ser Trp Asp Gln Gln Leu Asn Leu
Ala Tyr Val Gly Ala Val65 70 75 80Pro His Arg Gly Ile Lys Gln Val
Arg Thr His Trp Leu Leu Glu Leu 85 90 95Val Thr Thr Arg Gly Ser Thr
Gly Arg Gly Leu Ser Tyr Asn Phe Thr 100 105 110His Leu Asp Gly Tyr
Leu Asp Leu Leu Arg Glu Asn Gln Leu Leu Pro 115 120 125Gly Phe Glu
Leu Met Gly Ser Ala Ser Gly His Phe Thr Asp Phe Glu 130 135 140Asp
Lys Gln Gln Val Phe Glu Trp Lys Asp Leu Val Ser Ser Leu Ala145 150
155 160Arg Arg Tyr Ile Gly Arg Tyr Gly Leu Ala His Val Ser Lys Trp
Asn 165 170 175Phe Glu Thr Trp Asn Glu Pro Asp His His Asp Phe Asp
Asn Val Ser 180 185 190Met Thr Met Gln Gly Phe Leu Asn Tyr Tyr Asp
Ala Cys Ser Glu Gly 195 200 205Leu Arg Ala Ala Ser Pro Ala Leu Arg
Leu Gly Gly Pro Gly Asp Ser 210 215 220Phe His Thr Pro Pro Arg Ser
Pro Leu Ser Trp Gly Leu Leu Arg His225 230 235 240Cys His Asp Gly
Thr Asn Phe Phe Thr Gly Glu Ala Gly Val Arg Leu 245 250 255Asp Tyr
Ile Ser Leu His Arg Lys Gly Ala Arg Ser Ser Ile Ser Ile 260 265
270Leu Glu Gln Glu Lys Val Val Ala Gln Gln Ile Arg Gln Leu Phe Pro
275 280 285Lys Phe Ala Asp Thr Pro Ile Tyr Asn Asp Glu Ala Asp Pro
Leu Val 290 295 300Gly Trp Ser Leu Pro Gln Pro Trp Arg Ala Asp Val
Thr Tyr Ala Ala305 310 315 320Met Val Val Lys Val Ile Ala Gln His
Gln Asn Leu Leu Leu Ala Asn 325 330 335Thr Thr Ser Ala Phe Pro Tyr
Ala Leu Leu Ser Asn Asp Asn Ala Phe 340 345 350Leu Ser Tyr His Pro
His Pro Phe Ala Gln Arg Thr Leu Thr Ala Arg 355 360 365Phe Gln Val
Asn Asn Thr Arg Pro Pro His Val Gln Leu Leu Arg Lys 370 375 380Pro
Val Leu Thr Ala Met Gly Leu Leu Ala Leu Leu Asp Glu Glu Gln385 390
395 400Leu Trp Ala Glu Val Ser Gln Ala Gly Thr Val Leu Asp Ser Asn
His 405 410 415Thr Val Gly Val Leu Ala Ser Ala His Arg Pro Gln Gly
Pro Ala Asp 420 425 430Ala Trp Arg Ala Ala Val Leu Ile Tyr Ala Ser
Asp Asp Thr Arg Ala 435 440 445His Pro Asn Arg Ser Val Ala Val Thr
Leu Arg Leu Arg Gly Val Pro 450 455 460Pro Gly Pro Gly Leu Val Tyr
Val Thr Arg Tyr Leu Asp Asn Gly Leu465 470 475 480Cys Ser Pro Asp
Gly Glu Trp Arg Arg Leu Gly Arg Pro Val Phe Pro 485 490 495Thr Ala
Glu Gln Phe Arg Arg Met Arg Ala Ala Glu Asp Pro Val Ala 500 505
510Ala Ala Pro Arg Pro Leu Pro Ala Gly Gly Arg Leu Thr Leu Arg Pro
515 520 525Ala Leu Arg Leu Pro Ser Leu Leu Leu Val His Val Cys Ala
Arg Pro 530 535 540Glu Lys Pro Pro Gly Gln Val Thr Arg Leu Arg Ala
Leu Pro Leu Thr545 550 555 560Gln Gly Gln Leu Val Leu Val Trp Ser
Asp Glu His Val Gly Ser Lys 565 570 575Cys Leu Trp Thr Tyr Glu Ile
Gln Phe Ser Gln Asp Gly Lys Ala Tyr 580 585 590Thr Pro Val Ser Arg
Lys Pro Ser Thr Phe Asn Leu Phe Val Phe Ser 595 600 605Pro Asp Thr
Gly Ala Val Ser Gly Ser Tyr Arg Val Arg Ala Leu Asp 610 615 620Tyr
Trp Ala Arg Pro Gly Pro Phe Ser Asp Pro Val Pro Tyr Leu Glu625 630
635 640Val Pro Val Pro Arg Gly Pro Pro Ser Pro Gly Asn Pro 645
65034344DNAArtificial
sequenceCB7.CI.hIDUAco.RBGmisc_feature(1)..(130)5"ITRpromoter(198)..(579)-
CMV IE promoterpromoter(582)..(863)CB
promoterTATA_signal(836)..(839)Intron(956)..(1928)chicken
beta-actin intronCDS(1990)..(3948)human IDUA
copolyA_signal(4000)..(4126)rabbit globin
polyAmisc_feature(4215)..(4344) 3ctgcgcgctc gctcgctcac tgaggccgcc
cgggcaaagc ccgggcgtcg ggcgaccttt 60ggtcgcccgg cctcagtgag cgagcgagcg
cgcagagagg gagtggccaa ctccatcact 120aggggttcct tgtagttaat
gattaacccg ccatgctact tatctaccag ggtaatgggg 180atcctctaga
actatagcta gtcgacattg attattgact agttattaat agtaatcaat
240tacggggtca ttagttcata gcccatatat ggagttccgc gttacataac
ttacggtaaa 300tggcccgcct ggctgaccgc ccaacgaccc ccgcccattg
acgtcaataa tgacgtatgt 360tcccatagta acgccaatag ggactttcca
ttgacgtcaa tgggtggagt atttacggta 420aactgcccac ttggcagtac
atcaagtgta tcatatgcca agtacgcccc ctattgacgt 480caatgacggt
aaatggcccg cctggcatta tgcccagtac atgaccttat gggactttcc
540tacttggcag tacatctacg tattagtcat cgctattacc atggtcgagg
tgagccccac 600gttctgcttc actctcccca tctccccccc ctccccaccc
ccaattttgt atttatttat 660tttttaatta ttttgtgcag cgatgggggc
gggggggggg ggggggcgcg cgccaggcgg 720ggcggggcgg ggcgaggggc
ggggcggggc gaggcggaga ggtgcggcgg cagccaatca 780gagcggcgcg
ctccgaaagt ttccttttat ggcgaggcgg cggcggcggc ggccctataa
840aaagcgaagc gcgcggcggg cgggagtcgc tgcgcgctgc cttcgccccg
tgccccgctc 900cgccgccgcc tcgcgccgcc cgccccggct ctgactgacc
gcgttactcc cacaggtgag 960cgggcgggac ggcccttctc ctccgggctg
taattagcgc ttggtttaat gacggcttgt 1020ttcttttctg tggctgcgtg
aaagccttga ggggctccgg gagggccctt tgtgcggggg 1080gagcggctcg
gggggtgcgt gcgtgtgtgt gtgcgtgggg agcgccgcgt gcggctccgc
1140gctgcccggc ggctgtgagc gctgcgggcg cggcgcgggg ctttgtgcgc
tccgcagtgt 1200gcgcgagggg agcgcggccg ggggcggtgc cccgcggtgc
ggggggggct gcgaggggaa 1260caaaggctgc gtgcggggtg tgtgcgtggg
ggggtgagca gggggtgtgg gcgcgtcggt 1320cgggctgcaa ccccccctgc
acccccctcc ccgagttgct gagcacggcc cggcttcggg 1380tgcggggctc
cgtacggggc gtggcgcggg gctcgccgtg ccgggcgggg ggtggcggca
1440ggtgggggtg ccgggcgggg cggggccgcc tcgggccggg gagggctcgg
gggaggggcg 1500cggcggcccc cggagcgccg gcggctgtcg aggcgcggcg
agccgcagcc attgcctttt 1560atggtaatcg tgcgagaggg cgcagggact
tcctttgtcc caaatctgtg cggagccgaa 1620atctgggagg cgccgccgca
ccccctctag cgggcgcggg gcgaagcggt gcggcgccgg 1680caggaaggaa
atgggcgggg agggccttcg tgcgtcgccg cgccgccgtc cccttctccc
1740tctccagcct cggggctgtc cgcgggggga cggctgcctt cgggggggac
ggggcagggc 1800ggggttcggc ttctggcgtg tgaccggcgg ctctagagcc
tctgctaacc atgttcatgc 1860cttcttcttt ttcctacagc tcctgggcaa
cgtgctggtt attgtgctgt ctcatcattt 1920tggcaaagaa ttcacgcgtg
gtacctctag agtcgacccg ggcggcctcg agaattcacg 1980cgtgccacc atg cgg
ccc ctg agg cct aga gct gct ctg ctg gca ctg ctg 2031 Met Arg Pro
Leu Arg Pro Arg Ala Ala Leu Leu Ala Leu Leu 1 5 10gcc agt ctg ctg
gct gcc cct cct gtg gcc cct gcc gaa gcc cct cac 2079Ala Ser Leu Leu
Ala Ala Pro Pro Val Ala Pro Ala Glu Ala Pro His15 20 25 30ctg gtg
cat gtg gat gcc gcc aga gcc ctg tgg cct ctg cgg aga ttc 2127Leu Val
His Val Asp Ala Ala Arg Ala Leu Trp Pro Leu Arg Arg Phe 35 40 45tgg
cgg agc acc ggc ttt tgc ccc cca ctg cct cac agc cag gcc gac 2175Trp
Arg Ser Thr Gly Phe Cys Pro Pro Leu Pro His Ser Gln Ala Asp 50 55
60cag tac gtg ctg agc tgg gac cag cag ctg aac ctg gcc tac gtg ggc
2223Gln Tyr Val Leu Ser Trp Asp Gln Gln Leu Asn Leu Ala Tyr Val Gly
65 70 75gcc gtg ccc cac aga ggc atc aaa cag gtg aga acc cac tgg ctg
ctg 2271Ala Val Pro His Arg Gly Ile Lys Gln Val Arg Thr His Trp Leu
Leu 80 85 90gaa ctg gtg aca acc cgg ggc tcc acc ggc aga ggc ctg agc
tac aac 2319Glu Leu Val Thr Thr Arg Gly Ser Thr Gly Arg Gly Leu Ser
Tyr Asn95 100 105 110ttc acc cac ctg gac ggc tac ctg gac ctg ctg
aga gag aac cag ctg 2367Phe Thr His Leu Asp Gly Tyr Leu Asp Leu Leu
Arg Glu Asn Gln Leu 115 120 125ctg ccc ggc ttc gag ctg atg ggc agc
gcc agc ggc cac ttc acc gac 2415Leu Pro Gly Phe Glu Leu Met Gly Ser
Ala Ser Gly His Phe Thr Asp 130 135 140ttc gag gac aag cag caa gtc
ttt gag tgg aag gac ctg gtg tcc agc 2463Phe Glu Asp Lys Gln Gln Val
Phe Glu Trp Lys Asp Leu Val Ser Ser 145 150 155ctg gcc aga cgg tac
atc ggc aga tac gga ctg gcc cac gtg tcc aag 2511Leu Ala Arg Arg Tyr
Ile Gly Arg Tyr Gly Leu Ala His Val Ser Lys 160 165 170tgg aac ttc
gag aca tgg aac gag ccc gac cac cac gac ttc gac aac 2559Trp Asn Phe
Glu Thr Trp Asn Glu Pro Asp His His Asp Phe Asp Asn175 180 185
190gtg tca atg acc atg cag ggc ttt ctg aac tac tac gac gcc tgc tcc
2607Val Ser Met Thr Met Gln Gly Phe Leu Asn Tyr Tyr Asp Ala Cys Ser
195 200 205gag ggc ctg aga gcc gcc agt cct gcc ctg aga ctg ggc gga
ccc ggc 2655Glu Gly Leu Arg Ala Ala Ser Pro Ala Leu Arg Leu Gly Gly
Pro Gly 210 215 220gat agc ttc cac acc ccc ccc aga agc ccc ctg agc
tgg ggc ctg ctg
2703Asp Ser Phe His Thr Pro Pro Arg Ser Pro Leu Ser Trp Gly Leu Leu
225 230 235aga cac tgc cac gac ggc acc aat ttc ttc acc ggc gag gcc
ggc gtg 2751Arg His Cys His Asp Gly Thr Asn Phe Phe Thr Gly Glu Ala
Gly Val 240 245 250cgg ctg gac tac atc agc ctg cac cgg aag ggc gcc
aga agc agc atc 2799Arg Leu Asp Tyr Ile Ser Leu His Arg Lys Gly Ala
Arg Ser Ser Ile255 260 265 270agc atc ctg gaa cag gaa aag gtc gtc
gcc cag cag atc cgg cag ctg 2847Ser Ile Leu Glu Gln Glu Lys Val Val
Ala Gln Gln Ile Arg Gln Leu 275 280 285ttc ccc aag ttc gcc gac acc
ccc atc tac aac gac gag gcc gac ccc 2895Phe Pro Lys Phe Ala Asp Thr
Pro Ile Tyr Asn Asp Glu Ala Asp Pro 290 295 300ctg gtg gga tgg tca
ctg cct cag cct tgg aga gcc gac gtg acc tac 2943Leu Val Gly Trp Ser
Leu Pro Gln Pro Trp Arg Ala Asp Val Thr Tyr 305 310 315gcc gct atg
gtg gtg aaa gtg atc gcc cag cat cag aac ctg ctg ctg 2991Ala Ala Met
Val Val Lys Val Ile Ala Gln His Gln Asn Leu Leu Leu 320 325 330gcc
aac acc acc agc gcc ttc cct tac gcc ctg ctg agc aac gac aac 3039Ala
Asn Thr Thr Ser Ala Phe Pro Tyr Ala Leu Leu Ser Asn Asp Asn335 340
345 350gcc ttc ctg agc tac cac ccc cac ccc ttc gcc cag aga acc ctg
acc 3087Ala Phe Leu Ser Tyr His Pro His Pro Phe Ala Gln Arg Thr Leu
Thr 355 360 365gcc cgg ttc cag gtg aac aac acc aga ccc ccc cac gtg
cag ctg ctg 3135Ala Arg Phe Gln Val Asn Asn Thr Arg Pro Pro His Val
Gln Leu Leu 370 375 380aga aag ccc gtg ctg acc gct atg gga ctg ctg
gct ctg ctg gac gag 3183Arg Lys Pro Val Leu Thr Ala Met Gly Leu Leu
Ala Leu Leu Asp Glu 385 390 395gaa cag ctg tgg gcc gaa gtg tcc cag
gcc ggc acc gtg ctg gac agc 3231Glu Gln Leu Trp Ala Glu Val Ser Gln
Ala Gly Thr Val Leu Asp Ser 400 405 410aat cat aca gtg ggc gtg ctg
gcc tcc gcc cac aga cct cag gga ccc 3279Asn His Thr Val Gly Val Leu
Ala Ser Ala His Arg Pro Gln Gly Pro415 420 425 430gcc gat gct tgg
cgg gct gcc gtg ctg atc tac gcc agc gac gat acc 3327Ala Asp Ala Trp
Arg Ala Ala Val Leu Ile Tyr Ala Ser Asp Asp Thr 435 440 445aga gcc
cac ccc aac aga tcc gtg gcc gtg acc ctg cgg ctg aga ggc 3375Arg Ala
His Pro Asn Arg Ser Val Ala Val Thr Leu Arg Leu Arg Gly 450 455
460gtg cca cca ggc cct gga ctg gtg tac gtg acc aga tac ctg gac aac
3423Val Pro Pro Gly Pro Gly Leu Val Tyr Val Thr Arg Tyr Leu Asp Asn
465 470 475ggc ctg tgc agc ccc gac ggc gaa tgg cgc aga ctg ggc aga
cct gtg 3471Gly Leu Cys Ser Pro Asp Gly Glu Trp Arg Arg Leu Gly Arg
Pro Val 480 485 490ttc ccc acc gcc gag cag ttc cgg cgg atg aga gcc
gct gag gat cct 3519Phe Pro Thr Ala Glu Gln Phe Arg Arg Met Arg Ala
Ala Glu Asp Pro495 500 505 510gtg gct gct gcc cct aga cct ctg cct
gct ggc ggc aga ctg acc ctg 3567Val Ala Ala Ala Pro Arg Pro Leu Pro
Ala Gly Gly Arg Leu Thr Leu 515 520 525agg ccc gct ctg aga ctg cct
agt ctg ctg ctg gtg cac gtg tgc gcc 3615Arg Pro Ala Leu Arg Leu Pro
Ser Leu Leu Leu Val His Val Cys Ala 530 535 540agg ccc gag aag cct
ccc ggc cag gtg aca aga ctg aga gcc ctg ccc 3663Arg Pro Glu Lys Pro
Pro Gly Gln Val Thr Arg Leu Arg Ala Leu Pro 545 550 555ctg acc cag
ggc cag ctg gtg ctg gtg tgg tcc gat gag cac gtg ggc 3711Leu Thr Gln
Gly Gln Leu Val Leu Val Trp Ser Asp Glu His Val Gly 560 565 570agc
aag tgc ctg tgg acc tac gag atc cag ttc agc cag gac ggc aag 3759Ser
Lys Cys Leu Trp Thr Tyr Glu Ile Gln Phe Ser Gln Asp Gly Lys575 580
585 590gcc tac acc ccc gtg tcc cgg aag ccc agc acc ttc aac ctg ttc
gtg 3807Ala Tyr Thr Pro Val Ser Arg Lys Pro Ser Thr Phe Asn Leu Phe
Val 595 600 605ttc agc ccc gat aca ggc gcc gtg tcc ggc tct tat aga
gtg cgg gcc 3855Phe Ser Pro Asp Thr Gly Ala Val Ser Gly Ser Tyr Arg
Val Arg Ala 610 615 620ctg gac tac tgg gcc aga ccc ggc cct ttc agc
gac ccc gtg ccc tac 3903Leu Asp Tyr Trp Ala Arg Pro Gly Pro Phe Ser
Asp Pro Val Pro Tyr 625 630 635ctg gaa gtg ccc gtg cct aga ggc ccc
cct agc ccc ggc aac cct 3948Leu Glu Val Pro Val Pro Arg Gly Pro Pro
Ser Pro Gly Asn Pro 640 645 650tgagtcgacc cgggcggcct cgaggacggg
gtgaactacg cctgaggatc cgatcttttt 4008ccctctgcca aaaattatgg
ggacatcatg aagccccttg agcatctgac ttctggctaa 4068taaaggaaat
ttattttcat tgcaatagtg tgttggaatt ttttgtgtct ctcactcgga
4128agcaattcgt tgatctgaat ttcgaccacc cataataccc attaccctgg
tagataagta 4188gcatggcggg ttaatcatta actacaagga acccctagtg
atggagttgg ccactccctc 4248tctgcgcgct cgctcgctca ctgaggccgg
gcgaccaaag gtcgcccgac gcccgggctt 4308tgcccgggcg gcctcagtga
gcgagcgagc gcgcag 43444653PRTArtificial sequenceSynthetic Construct
4Met Arg Pro Leu Arg Pro Arg Ala Ala Leu Leu Ala Leu Leu Ala Ser1 5
10 15Leu Leu Ala Ala Pro Pro Val Ala Pro Ala Glu Ala Pro His Leu
Val 20 25 30His Val Asp Ala Ala Arg Ala Leu Trp Pro Leu Arg Arg Phe
Trp Arg 35 40 45Ser Thr Gly Phe Cys Pro Pro Leu Pro His Ser Gln Ala
Asp Gln Tyr 50 55 60Val Leu Ser Trp Asp Gln Gln Leu Asn Leu Ala Tyr
Val Gly Ala Val65 70 75 80Pro His Arg Gly Ile Lys Gln Val Arg Thr
His Trp Leu Leu Glu Leu 85 90 95Val Thr Thr Arg Gly Ser Thr Gly Arg
Gly Leu Ser Tyr Asn Phe Thr 100 105 110His Leu Asp Gly Tyr Leu Asp
Leu Leu Arg Glu Asn Gln Leu Leu Pro 115 120 125Gly Phe Glu Leu Met
Gly Ser Ala Ser Gly His Phe Thr Asp Phe Glu 130 135 140Asp Lys Gln
Gln Val Phe Glu Trp Lys Asp Leu Val Ser Ser Leu Ala145 150 155
160Arg Arg Tyr Ile Gly Arg Tyr Gly Leu Ala His Val Ser Lys Trp Asn
165 170 175Phe Glu Thr Trp Asn Glu Pro Asp His His Asp Phe Asp Asn
Val Ser 180 185 190Met Thr Met Gln Gly Phe Leu Asn Tyr Tyr Asp Ala
Cys Ser Glu Gly 195 200 205Leu Arg Ala Ala Ser Pro Ala Leu Arg Leu
Gly Gly Pro Gly Asp Ser 210 215 220Phe His Thr Pro Pro Arg Ser Pro
Leu Ser Trp Gly Leu Leu Arg His225 230 235 240Cys His Asp Gly Thr
Asn Phe Phe Thr Gly Glu Ala Gly Val Arg Leu 245 250 255Asp Tyr Ile
Ser Leu His Arg Lys Gly Ala Arg Ser Ser Ile Ser Ile 260 265 270Leu
Glu Gln Glu Lys Val Val Ala Gln Gln Ile Arg Gln Leu Phe Pro 275 280
285Lys Phe Ala Asp Thr Pro Ile Tyr Asn Asp Glu Ala Asp Pro Leu Val
290 295 300Gly Trp Ser Leu Pro Gln Pro Trp Arg Ala Asp Val Thr Tyr
Ala Ala305 310 315 320Met Val Val Lys Val Ile Ala Gln His Gln Asn
Leu Leu Leu Ala Asn 325 330 335Thr Thr Ser Ala Phe Pro Tyr Ala Leu
Leu Ser Asn Asp Asn Ala Phe 340 345 350Leu Ser Tyr His Pro His Pro
Phe Ala Gln Arg Thr Leu Thr Ala Arg 355 360 365Phe Gln Val Asn Asn
Thr Arg Pro Pro His Val Gln Leu Leu Arg Lys 370 375 380Pro Val Leu
Thr Ala Met Gly Leu Leu Ala Leu Leu Asp Glu Glu Gln385 390 395
400Leu Trp Ala Glu Val Ser Gln Ala Gly Thr Val Leu Asp Ser Asn His
405 410 415Thr Val Gly Val Leu Ala Ser Ala His Arg Pro Gln Gly Pro
Ala Asp 420 425 430Ala Trp Arg Ala Ala Val Leu Ile Tyr Ala Ser Asp
Asp Thr Arg Ala 435 440 445His Pro Asn Arg Ser Val Ala Val Thr Leu
Arg Leu Arg Gly Val Pro 450 455 460Pro Gly Pro Gly Leu Val Tyr Val
Thr Arg Tyr Leu Asp Asn Gly Leu465 470 475 480Cys Ser Pro Asp Gly
Glu Trp Arg Arg Leu Gly Arg Pro Val Phe Pro 485 490 495Thr Ala Glu
Gln Phe Arg Arg Met Arg Ala Ala Glu Asp Pro Val Ala 500 505 510Ala
Ala Pro Arg Pro Leu Pro Ala Gly Gly Arg Leu Thr Leu Arg Pro 515 520
525Ala Leu Arg Leu Pro Ser Leu Leu Leu Val His Val Cys Ala Arg Pro
530 535 540Glu Lys Pro Pro Gly Gln Val Thr Arg Leu Arg Ala Leu Pro
Leu Thr545 550 555 560Gln Gly Gln Leu Val Leu Val Trp Ser Asp Glu
His Val Gly Ser Lys 565 570 575Cys Leu Trp Thr Tyr Glu Ile Gln Phe
Ser Gln Asp Gly Lys Ala Tyr 580 585 590Thr Pro Val Ser Arg Lys Pro
Ser Thr Phe Asn Leu Phe Val Phe Ser 595 600 605Pro Asp Thr Gly Ala
Val Ser Gly Ser Tyr Arg Val Arg Ala Leu Asp 610 615 620Tyr Trp Ala
Arg Pro Gly Pro Phe Ser Asp Pro Val Pro Tyr Leu Glu625 630 635
640Val Pro Val Pro Arg Gly Pro Pro Ser Pro Gly Asn Pro 645
65053605DNAArtificial sequenceVector genome -
TBG.PI.hIDUAco.RBGrepeat_region(1)..(130)5'
ITRenhancer(221)..(320)Alpha mic/Bikenhancer(327)..(426)Alpha
mic/Bikpromoter(442)..(901)TBGTATA_signal(885)..(888)Intron(1027)..(1157)-
misc_feature(1251)..(3212)Human alpha-L-IDUA coding
sequencepolyA_signal(3261)..(3387)rabbit globin poly
Arepeat_region(3476)..(3605) 5ctgcgcgctc gctcgctcac tgaggccgcc
cgggcaaagc ccgggcgtcg ggcgaccttt 60ggtcgcccgg cctcagtgag cgagcgagcg
cgcagagagg gagtggccaa ctccatcact 120aggggttcct tgtagttaat
gattaacccg ccatgctact tatctaccag ggtaatgggg 180atcctctaga
actatagcta gaattcgccc ttaagctagc aggttaattt ttaaaaagca
240gtcaaaagtc caagtggccc ttggcagcat ttactctctc tgtttgctct
ggttaataat 300ctcaggagca caaacattcc agatccaggt taatttttaa
aaagcagtca aaagtccaag 360tggcccttgg cagcatttac tctctctgtt
tgctctggtt aataatctca ggagcacaaa 420cattccagat ccggcgcgcc
agggctggaa gctacctttg acatcatttc ctctgcgaat 480gcatgtataa
tttctacaga acctattaga aaggatcacc cagcctctgc ttttgtacaa
540ctttccctta aaaaactgcc aattccactg ctgtttggcc caatagtgag
aactttttcc 600tgctgcctct tggtgctttt gcctatggcc cctattctgc
ctgctgaaga cactcttgcc 660agcatggact taaacccctc cagctctgac
aatcctcttt ctcttttgtt ttacatgaag 720ggtctggcag ccaaagcaat
cactcaaagt tcaaacctta tcattttttg ctttgttcct 780cttggccttg
gttttgtaca tcagctttga aaataccatc ccagggttaa tgctggggtt
840aatttataac taagagtgct ctagttttgc aatacaggac atgctataaa
aatggaaaga 900tgttgctttc tgagagacag ctttattgcg gtagtttatc
acagttaaat tgctaacgca 960gtcagtgctt ctgacacaac agtctcgaac
ttaagctgca gaagttggtc gtgaggcact 1020gggcaggtaa gtatcaaggt
tacaagacag gtttaaggag accaatagaa actgggcttg 1080tcgagacaga
gaagactctt gcgtttctga taggcaccta ttggtcttac tgacatccac
1140tttgcctttc tctccacagg tgtccactcc cagttcaatt acagctctta
aggctagagt 1200acttaatacg actcactata ggctagcctc gagaattcac
gcgtgccacc atgcggcccc 1260tgaggcctag agctgctctg ctggcactgc
tggccagtct gctggctgcc cctcctgtgg 1320cccctgccga agcccctcac
ctggtgcatg tggatgccgc cagagccctg tggcctctgc 1380ggagattctg
gcggagcacc ggcttttgcc ccccactgcc tcacagccag gccgaccagt
1440acgtgctgag ctgggaccag cagctgaacc tggcctacgt gggcgccgtg
ccccacagag 1500gcatcaaaca ggtgagaacc cactggctgc tggaactggt
gacaacccgg ggctccaccg 1560gcagaggcct gagctacaac ttcacccacc
tggacggcta cctggacctg ctgagagaga 1620accagctgct gcccggcttc
gagctgatgg gcagcgccag cggccacttc accgacttcg 1680aggacaagca
gcaagtcttt gagtggaagg acctggtgtc cagcctggcc agacggtaca
1740tcggcagata cggactggcc cacgtgtcca agtggaactt cgagacatgg
aacgagcccg 1800accaccacga cttcgacaac gtgtcaatga ccatgcaggg
ctttctgaac tactacgacg 1860cctgctccga gggcctgaga gccgccagtc
ctgccctgag actgggcgga cccggcgata 1920gcttccacac cccccccaga
agccccctga gctggggcct gctgagacac tgccacgacg 1980gcaccaattt
cttcaccggc gaggccggcg tgcggctgga ctacatcagc ctgcaccgga
2040agggcgccag aagcagcatc agcatcctgg aacaggaaaa ggtcgtcgcc
cagcagatcc 2100ggcagctgtt ccccaagttc gccgacaccc ccatctacaa
cgacgaggcc gaccccctgg 2160tgggatggtc actgcctcag ccttggagag
ccgacgtgac ctacgccgct atggtggtga 2220aagtgatcgc ccagcatcag
aacctgctgc tggccaacac caccagcgcc ttcccttacg 2280ccctgctgag
caacgacaac gccttcctga gctaccaccc ccaccccttc gcccagagaa
2340ccctgaccgc ccggttccag gtgaacaaca ccagaccccc ccacgtgcag
ctgctgagaa 2400agcccgtgct gaccgctatg ggactgctgg ctctgctgga
cgaggaacag ctgtgggccg 2460aagtgtccca ggccggcacc gtgctggaca
gcaatcatac agtgggcgtg ctggcctccg 2520cccacagacc tcagggaccc
gccgatgctt ggcgggctgc cgtgctgatc tacgccagcg 2580acgataccag
agcccacccc aacagatccg tggccgtgac cctgcggctg agaggcgtgc
2640caccaggccc tggactggtg tacgtgacca gatacctgga caacggcctg
tgcagccccg 2700acggcgaatg gcgcagactg ggcagacctg tgttccccac
cgccgagcag ttccggcgga 2760tgagagccgc tgaggatcct gtggctgctg
cccctagacc tctgcctgct ggcggcagac 2820tgaccctgag gcccgctctg
agactgccta gtctgctgct ggtgcacgtg tgcgccaggc 2880ccgagaagcc
tcccggccag gtgacaagac tgagagccct gcccctgacc cagggccagc
2940tggtgctggt gtggtccgat gagcacgtgg gcagcaagtg cctgtggacc
tacgagatcc 3000agttcagcca ggacggcaag gcctacaccc ccgtgtcccg
gaagcccagc accttcaacc 3060tgttcgtgtt cagccccgat acaggcgccg
tgtccggctc ttatagagtg cgggccctgg 3120actactgggc cagacccggc
cctttcagcg accccgtgcc ctacctggaa gtgcccgtgc 3180ctagaggccc
ccctagcccc ggcaaccctt gagtcgaccc gggcggcctc gaggacgggg
3240tgaactacgc ctgaggatcc gatctttttc cctctgccaa aaattatggg
gacatcatga 3300agccccttga gcatctgact tctggctaat aaaggaaatt
tattttcatt gcaatagtgt 3360gttggaattt tttgtgtctc tcactcggaa
gcaattcgtt gatctgaatt tcgaccaccc 3420ataataccca ttaccctggt
agataagtag catggcgggt taatcattaa ctacaaggaa 3480cccctagtga
tggagttggc cactccctct ctgcgcgctc gctcgctcac tgaggccggg
3540cgaccaaagg tcgcccgacg cccgggcttt gcccgggcgg cctcagtgag
cgagcgagcg 3600cgcag 360563691DNAArtificial sequenceVector genome
CMV.PI.hIDUAco.SV40repeat_region(1)..(130)5'
ITRmisc_feature(143)..(181)CMV enhancer and
promoterTATA_signal(910)..(916)Intron(1024)..(1221)chimeric
intronmisc_feature(1284)..(3246)human IDUA coding
sequencepolyA_signal(3258)..(3496)repeat_region(3562)..(3691)
6ggccttaatt aggctgcgcg ctcgctcgct cactgaggcc gcccgggcaa agcccgggcg
60tcgggcgacc tttggtcgcc cggcctcagt gagcgagcga gcgcgcagag agggagtggc
120caactccatc actaggggtt ccttgtagtt aatgattaac ccgccatgct
acttatctac 180gtagccatgc tctaggaaga tcttcaatat tggccattag
ccatattatt cattggttat 240atagcataaa tcaatattgg ctattggcca
ttgcatacgt tgtatctata tcataatatg 300tacatttata ttggctcatg
tccaatatga ccgccatgtt ggcattgatt attgactagt 360tattaatagt
aatcaattac ggggtcatta gttcatagcc catatatgga gttccgcgtt
420acataactta cggtaaatgg cccgcctggc tgaccgccca acgacccccg
cccattgacg 480tcaataatga cgtatgttcc catagtaacg ccaataggga
ctttccattg acgtcaatgg 540gtggagtatt tacggtaaac tgcccacttg
gcagtacatc aagtgtatca tatgccaagt 600ccgcccccta ttgacgtcaa
tgacggtaaa tggcccgcct ggcattatgc ccagtacatg 660accttacggg
actttcctac ttggcagtac atctacgtat tagtcatcgc tattaccatg
720gtgatgcggt tttggcagta caccaatggg cgtggatagc ggtttgactc
acggggattt 780ccaagtctcc accccattga cgtcaatggg agtttgtttt
ggcaccaaaa tcaacgggac 840tttccaaaat gtcgtaataa ccccgccccg
ttgacgcaaa tgggcggtag gcgtgtacgg 900tgggaggtct atataagcag
agctcgttta gtgaaccgtc agatcactag aagctttatt 960gcggtagttt
atcacagtta aattgctaac gcagtcagtg cttctgacac aacagtctcg
1020aacttaagct gcagaagttg gtcgtgaggc actgggcagg taagtatcaa
ggttacaaga 1080caggtttaag gagaccaata gaaactgggc ttgtcgagac
agagaagact cttgcgtttc 1140tgataggcac ctattggtct tactgacatc
cactttgcct ttctctccac aggtgtccac 1200tcccagttca attacagctc
ttaaggctag agtacttaat acgactcact ataggctagc 1260ctcgagaatt
cacgcgtgcc accatgcggc ccctgaggcc tagagctgct ctgctggcac
1320tgctggccag tctgctggct gcccctcctg tggcccctgc cgaagcccct
cacctggtgc 1380atgtggatgc cgccagagcc ctgtggcctc tgcggagatt
ctggcggagc accggctttt 1440gccccccact gcctcacagc caggccgacc
agtacgtgct gagctgggac cagcagctga 1500acctggccta cgtgggcgcc
gtgccccaca gaggcatcaa acaggtgaga acccactggc 1560tgctggaact
ggtgacaacc cggggctcca ccggcagagg cctgagctac aacttcaccc
1620acctggacgg ctacctggac ctgctgagag agaaccagct gctgcccggc
ttcgagctga 1680tgggcagcgc cagcggccac ttcaccgact tcgaggacaa
gcagcaagtc tttgagtgga 1740aggacctggt gtccagcctg gccagacggt
acatcggcag atacggactg gcccacgtgt 1800ccaagtggaa cttcgagaca
tggaacgagc ccgaccacca cgacttcgac aacgtgtcaa 1860tgaccatgca
gggctttctg aactactacg acgcctgctc cgagggcctg agagccgcca
1920gtcctgccct gagactgggc ggacccggcg atagcttcca cacccccccc
agaagccccc 1980tgagctgggg cctgctgaga cactgccacg acggcaccaa
tttcttcacc ggcgaggccg 2040gcgtgcggct ggactacatc agcctgcacc
ggaagggcgc cagaagcagc atcagcatcc 2100tggaacagga
aaaggtcgtc gcccagcaga tccggcagct gttccccaag ttcgccgaca
2160cccccatcta caacgacgag gccgaccccc tggtgggatg gtcactgcct
cagccttgga 2220gagccgacgt gacctacgcc gctatggtgg tgaaagtgat
cgcccagcat cagaacctgc 2280tgctggccaa caccaccagc gccttccctt
acgccctgct gagcaacgac aacgccttcc 2340tgagctacca cccccacccc
ttcgcccaga gaaccctgac cgcccggttc caggtgaaca 2400acaccagacc
cccccacgtg cagctgctga gaaagcccgt gctgaccgct atgggactgc
2460tggctctgct ggacgaggaa cagctgtggg ccgaagtgtc ccaggccggc
accgtgctgg 2520acagcaatca tacagtgggc gtgctggcct ccgcccacag
acctcaggga cccgccgatg 2580cttggcgggc tgccgtgctg atctacgcca
gcgacgatac cagagcccac cccaacagat 2640ccgtggccgt gaccctgcgg
ctgagaggcg tgccaccagg ccctggactg gtgtacgtga 2700ccagatacct
ggacaacggc ctgtgcagcc ccgacggcga atggcgcaga ctgggcagac
2760ctgtgttccc caccgccgag cagttccggc ggatgagagc cgctgaggat
cctgtggctg 2820ctgcccctag acctctgcct gctggcggca gactgaccct
gaggcccgct ctgagactgc 2880ctagtctgct gctggtgcac gtgtgcgcca
ggcccgagaa gcctcccggc caggtgacaa 2940gactgagagc cctgcccctg
acccagggcc agctggtgct ggtgtggtcc gatgagcacg 3000tgggcagcaa
gtgcctgtgg acctacgaga tccagttcag ccaggacggc aaggcctaca
3060cccccgtgtc ccggaagccc agcaccttca acctgttcgt gttcagcccc
gatacaggcg 3120ccgtgtccgg ctcttataga gtgcgggccc tggactactg
ggccagaccc ggccctttca 3180gcgaccccgt gccctacctg gaagtgcccg
tgcctagagg cccccctagc cccggcaacc 3240cttgagtcga cccgggcggc
cgcttcgagc agacatgata agatacattg atgagtttgg 3300acaaaccaca
actagaatgc agtgaaaaaa atgctttatt tgtgaaattt gtgatgctat
3360tgctttattt gtaaccatta taagctgcaa taaacaagtt aacaacaaca
attgcattca 3420ttttatgttt caggttcagg gggagatgtg ggaggttttt
taaagcaagt aaaacctcta 3480caaatgtggt aaaatcgata aggatcttcc
tagagcatgg ctacgtagat aagtagcatg 3540gcgggttaat cattaactac
aaggaacccc tagtgatgga gttggccact ccctctctgc 3600gcgctcgctc
gctcactgag gccgggcgac caaaggtcgc ccgacgcccg ggctttgccc
3660gggcggcctc agtgagcgag cgagcgcgca g 36917736PRTArtificial
sequencehu14/Adeno-associated virus 9 7Met Ala Ala Asp Gly Tyr Leu
Pro Asp Trp Leu Glu Asp Asn Leu Ser1 5 10 15Glu Gly Ile Arg Glu Trp
Trp Ala Leu Lys Pro Gly Ala Pro Gln Pro 20 25 30Lys Ala Asn Gln Gln
His Gln Asp Asn Ala Arg Gly Leu Val Leu Pro 35 40 45Gly Tyr Lys Tyr
Leu Gly Pro Gly Asn Gly Leu Asp Lys Gly Glu Pro 50 55 60Val Asn Ala
Ala Asp Ala Ala Ala Leu Glu His Asp Lys Ala Tyr Asp65 70 75 80Gln
Gln Leu Lys Ala Gly Asp Asn Pro Tyr Leu Lys Tyr Asn His Ala 85 90
95Asp Ala Glu Phe Gln Glu Arg Leu Lys Glu Asp Thr Ser Phe Gly Gly
100 105 110Asn Leu Gly Arg Ala Val Phe Gln Ala Lys Lys Arg Leu Leu
Glu Pro 115 120 125Leu Gly Leu Val Glu Glu Ala Ala Lys Thr Ala Pro
Gly Lys Lys Arg 130 135 140Pro Val Glu Gln Ser Pro Gln Glu Pro Asp
Ser Ser Ala Gly Ile Gly145 150 155 160Lys Ser Gly Ala Gln Pro Ala
Lys Lys Arg Leu Asn Phe Gly Gln Thr 165 170 175Gly Asp Thr Glu Ser
Val Pro Asp Pro Gln Pro Ile Gly Glu Pro Pro 180 185 190Ala Ala Pro
Ser Gly Val Gly Ser Leu Thr Met Ala Ser Gly Gly Gly 195 200 205Ala
Pro Val Ala Asp Asn Asn Glu Gly Ala Asp Gly Val Gly Ser Ser 210 215
220Ser Gly Asn Trp His Cys Asp Ser Gln Trp Leu Gly Asp Arg Val
Ile225 230 235 240Thr Thr Ser Thr Arg Thr Trp Ala Leu Pro Thr Tyr
Asn Asn His Leu 245 250 255Tyr Lys Gln Ile Ser Asn Ser Thr Ser Gly
Gly Ser Ser Asn Asp Asn 260 265 270Ala Tyr Phe Gly Tyr Ser Thr Pro
Trp Gly Tyr Phe Asp Phe Asn Arg 275 280 285Phe His Cys His Phe Ser
Pro Arg Asp Trp Gln Arg Leu Ile Asn Asn 290 295 300Asn Trp Gly Phe
Arg Pro Lys Arg Leu Asn Phe Lys Leu Phe Asn Ile305 310 315 320Gln
Val Lys Glu Val Thr Asp Asn Asn Gly Val Lys Thr Ile Ala Asn 325 330
335Asn Leu Thr Ser Thr Val Gln Val Phe Thr Asp Ser Asp Tyr Gln Leu
340 345 350Pro Tyr Val Leu Gly Ser Ala His Glu Gly Cys Leu Pro Pro
Phe Pro 355 360 365Ala Asp Val Phe Met Ile Pro Gln Tyr Gly Tyr Leu
Thr Leu Asn Asp 370 375 380Gly Ser Gln Ala Val Gly Arg Ser Ser Phe
Tyr Cys Leu Glu Tyr Phe385 390 395 400Pro Ser Gln Met Leu Arg Thr
Gly Asn Asn Phe Gln Phe Ser Tyr Glu 405 410 415Phe Glu Asn Val Pro
Phe His Ser Ser Tyr Ala His Ser Gln Ser Leu 420 425 430Asp Arg Leu
Met Asn Pro Leu Ile Asp Gln Tyr Leu Tyr Tyr Leu Ser 435 440 445Lys
Thr Ile Asn Gly Ser Gly Gln Asn Gln Gln Thr Leu Lys Phe Ser 450 455
460Val Ala Gly Pro Ser Asn Met Ala Val Gln Gly Arg Asn Tyr Ile
Pro465 470 475 480Gly Pro Ser Tyr Arg Gln Gln Arg Val Ser Thr Thr
Val Thr Gln Asn 485 490 495Asn Asn Ser Glu Phe Ala Trp Pro Gly Ala
Ser Ser Trp Ala Leu Asn 500 505 510Gly Arg Asn Ser Leu Met Asn Pro
Gly Pro Ala Met Ala Ser His Lys 515 520 525Glu Gly Glu Asp Arg Phe
Phe Pro Leu Ser Gly Ser Leu Ile Phe Gly 530 535 540Lys Gln Gly Thr
Gly Arg Asp Asn Val Asp Ala Asp Lys Val Met Ile545 550 555 560Thr
Asn Glu Glu Glu Ile Lys Thr Thr Asn Pro Val Ala Thr Glu Ser 565 570
575Tyr Gly Gln Val Ala Thr Asn His Gln Ser Ala Gln Ala Gln Ala Gln
580 585 590Thr Gly Trp Val Gln Asn Gln Gly Ile Leu Pro Gly Met Val
Trp Gln 595 600 605Asp Arg Asp Val Tyr Leu Gln Gly Pro Ile Trp Ala
Lys Ile Pro His 610 615 620Thr Asp Gly Asn Phe His Pro Ser Pro Leu
Met Gly Gly Phe Gly Met625 630 635 640Lys His Pro Pro Pro Gln Ile
Leu Ile Lys Asn Thr Pro Val Pro Ala 645 650 655Asp Pro Pro Thr Ala
Phe Asn Lys Asp Lys Leu Asn Ser Phe Ile Thr 660 665 670Gln Tyr Ser
Thr Gly Gln Val Ser Val Glu Ile Glu Trp Glu Leu Gln 675 680 685Lys
Glu Asn Ser Lys Arg Trp Asn Pro Glu Ile Gln Tyr Thr Ser Asn 690 695
700Tyr Tyr Lys Ser Asn Asn Val Glu Phe Ala Val Asn Thr Glu Gly
Val705 710 715 720Tyr Ser Glu Pro Arg Pro Ile Gly Thr Arg Tyr Leu
Thr Arg Asn Leu 725 730 735
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References