Houston, TX -- November 5, 2009 -- The Stop ALD Foundation today applauded the investigators who are reporting in the current issue of Science successful results from the pioneering use of gene therapy for adrenoleukodystrophy (ALD), a potentially crippling and fatal brain disorder in young boys.
As an organization founded by families affected by ALD, we know too well the ravages that this disorder inflicts on its victims and the heartbreak it brings to those who love them, said Amber Salzman, president of The Stop ALD Foundation. We are deeply thankful to Drs. Cartier and Aubourg and the many other scientists and physicians whose achievement is reported in Science, and we look forward to continuing to work with them to build on their success. Their pioneering work in gene therapy brings hope to those stricken not only by ALD but many other serious diseases as well.
The Stop ALD Foundation has been involved in this gene therapy initiative since 2001 by providing direct funding and by bringing together parties in the US and Europe who provided critical scientific and biomedical contributions. Given the encouraging results reported in Science, the foundation will continue to stay involved, assisting in driving forward a larger, international study including U.S. patients. It is anticipated that this next study may be open to a more diverse ALD population, including adult men who suffer from the same genetic disorder.
The promise of gene therapy in ALD is that it will enable each patient to serve as his own stem cell donor, obviating the need to find matching donors and avoiding the serious risks and sometimes lethal side effects of stem cell transplantation. The paper in Science details the cases of two boys who underwent gene therapy at Saint Vincent de Paul Hospital in Paris. The boys were born with a genetic mutation that by the time of their hospital admission had already resulted in early brain lesions. Their therapy began with removal of some of their own bone marrow stem cells. These genetically defective cells were then corrected via a laboratory procedure whereby functioning genes were inserted. Last, the treated cells were injected back into the young patients. This therapy arrested the progression of ALD, and over two years later the boys conditions have stabilized. No adverse effects of the gene therapy have been noted to date.
I know the urgency of boys stricken by ALD and the pain of their parents, said Eve Lapin, a founding member of The Stop ALD Foundation. One of her sons died of ALD, and another is confined to a wheelchair as a consequence of graft versus host disease following a stem cell transplant. These gene therapy results are exciting, but they are just the beginning. Time is of the essence in finding the safest and most effective therapies. Every day more children become afflicted with ALD, and their chances of surviving depend on the success of trials such as this.
Adrenoleukodystrophy (ALD) is a genetic disorder estimated to affect 1 in 18,000 people. Its most devastating form destroys the myelin sheath of the brain's neurons generally affecting boys between the ages of four and ten years. At first they show behavioral problems, such as withdrawal or difficulty concentrating commonly misdiagnosed as attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD). Gradually their symptoms grow worse and may include blindness, deafness, seizures, loss of muscle control, and progressive dementia. This relentless decline leads to permanent disability and death within two to five years from diagnosis. Accurate and early diagnosis is essential to an opportunity for effective therapy. The disorder can also affect adults, women as well as men, in which case it is known as adrenomyeloneuropathy (AMN). AMN tends to be less severe in adults than in boys, though some men also develop fatal demyelination in the brain.
About The Stop ALD Foundation
The Stop ALD Foundation is a registered not-for-profit medical research organization that drives research into new therapies and advances understanding of ALD. More information is available at www.stopald.org.
Citation: Hematopoietic Stem Cell Gene Therapy with a Lentiviral Vector in X-Linked Adrenoleukodystrophy. By Nathalie Cartier, Salima Hacein-Bey-Abina, Cynthia C. Bartholomae, Gabor Veres, Manfred Schmidt, Ina Kutschera, Michel Vidaud, Ulrich Abel, Liliane Dal-Cortivo, Laure Caccavelli, Nizar Mahlaoui, Vronique Kiermer, Denice Mittelstaedt, Cline Bellesme, Najiba Lahlou, Franois Lefrre, Stphane Blanche, Muriel Audit, Emmanuel Payen, Philippe Leboulch, Bruno lHomme, Pierre Bougnres, Christof Von Kalle, Alain Fischer, Marina Cavazzana-Calvo, Patrick Aubourg. Science, Vol. 326 No. 5954, November 5, 2009.
For press inquiries please contact:
Amber Salzman, Ph.D.
President, The Stop ALD Foundation
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The following meeting was co-sponsored and attended by The Stop ALD Foundation and took place February 2008 in Boston.
6:00 Reception at the Royal Sonesta Hotel
7:00 Dinner at Dante
7:30 Introduction and Welcome, Robert Brown
7:45 Tribute to Hugo W. Moser (1924 - 2007), Florian Eichler
Genetic and Molecular Pathophysiology of ALD and AMN
Moderator: Kenneth Fischbeck
8:00 Genetics of X-ALD, David Valle
8:30 Modifier genes in X-ALD, Patrick Aubourg
8:45 Animal Models of ALD, Johannes Berger
9:15 Animal Models of AMN, Alex McCampbell
9:45 Axonal Degeneration in ALD, AMN and Related Disorders, Jack Griffin (tentative)
Metabolic Aspects of ALD and AMN
Moderator: Florian Eichler
11:00 Biochemistry of X-ALD, Stephen Kemp
11:30 Cholesterol Deprivation in ALD, Marc Engelen
12:00 Biophysical Properties of Very Long Chain Fatty Acids, Jim Hamilton
1:30 Role of the Peroxisome in ALD and AMN, Steven Steinberg
2:00 Mitochondrial Dysfunction in ALD and AMN, Kirby Smith (tentative)
Inflammatory Aspects of ALD
Moderator: Gilmore O'Neill
3:00 Microglial Apoptosis in ALD and AMN, Florian Eichler
3:30 Glycolipids, ALD and Autoimmunity, Ron Schnaar (tentative)
4:30 Neurodegenerative Aspects of White Matter Disease, Bruce Trapp
5:00 Microglia in Experimental Models of Neurodegeneration, Joseph El Khoury
Therapeutic Strategies in ALD and AMN
Moderator: Ali Fatemi
8:00 Lorenzo's Oil in ALD and AMN, Gerald Raymond
8:30 Cell Based Therapies in ALD, Charles Peters
9:00 Approaches to Gene Therapy of the CNS, Miguel Esteves
9:30 Gene Therapy in ALD and AMN, Nathalie Cartier
11:00 Immunomodulatory Strategies in MS, Samia Khoury
11:30 Modifiers of Oxidative Stress in ALD, Katherine Sims
The research and clinical trial discussed in the article below was sponsored in part by The Stop ALD Foundation.
Published online 30 October 2007 | Nature | doi:10.1038/news.2007.204
Gene therapy sees early success for neurodegenerative disease
Treatment uses HIV to insert genetic material into ALD patients.
Two children with a common neurodegenerative disease are seeing early signs of success from a pioneering gene-therapy treatment, researchers report this week.
The results raise hopes for a treatment for adrenoleukodystrophy (ALD), and, the researchers add, mark the first successful use of an attenuated HIV virus to carry a therapeutic gene into a patient's cells.
HIV is a promising vector for transferring corrective genes into a host -- it can penetrate directly into cell nuclei, making it a theoretically efficient way to introduce new genetic material. But until now it hadn't been proven in a clinical setting. This early success potentially opens the door to better treatments for many other diseases involving the bone marrow and blood cells, such as leukaemia, thalassemia and sickle-cell disease, the researchers say.
The results, from two 7-year-old Spanish children with ALD, were announced on Sunday 28 October at the fifteenth Congress of the European Society of Gene and Cell Therapy in Rotterdam, the Netherlands
ALD is caused by a mutation on the X chromosome. This mutation causes degradation of the insulating sheaths that surround neurons and allow them to signal properly. The condition was made famous by Lorenzo's Oil , the Hollywood film outlining one family's fight to help their son. The most severe, cerebral form of ALD affects one in 17,000 people, with two-thirds of sufferers being children. It progresses slowly at first, but if no bone-marrow transplant is available it can quickly progress to cause brain damage and death.
At present, treatment is limited to giving preventative dietary supplements and therapeutic bone-marrow transplants, with the attendant shortages of donor tissue.
Word of caution
Patrick Aubourg and Natalie Cartier, researchers at Inserm (France's national biomedical agency) who were working at the Saint Vincent de Paul Hospital in Paris, attempted to fix the X-chromosome defect using gene therapy. Working in collaboration with the Californian biotech company Cell Genesys, they first cultured the children's bone-marrow progenitor cells which give rise to all blood cell types and transferred the corrective gene to them using the HIV virus.
They then destroyed the children's existing bone marrow using chemotherapy, and reintroduced the modified cells, which took hold within a month to produce new bone marrow and blood cells. Samples taken showed that half of the new cells contained the introduced gene, and that 20-30% expressed the corrective protein. Such expression levels in gene therapy are "exceptional" says Aubourg. The levels have remained stable for more than two months in the children, despite the fact that the cells involved are replenished every 24 hours.
Aubourg is keen to emphasize that although the initial results are encouraging, caution is warranted. The children will need to be closely monitored to check the safety of the procedure, with the main risk being that they might develop leukaemia as a result of the risk of mutagenesis during gene transfer. Many previous gene-therapy trials have failed because of serious problems with side effects.
It will also take another 18 months of follow-up before the team can be reasonably sure that their gene transfer remains stable, and that the level of corrective protein expressed is sufficient to prevent clinical symptoms from developing, he says. Both children are so far doing as well as would be expected following conventional bone-marrow transplants, he adds.
Aubourg announced the findings before publication because of the field's intense interest in using attenuated HIV vectors in gene therapy for other diseases. Given the higher efficiency of such vectors, demonstrating their feasibility would mark a "breakthrough in gene therapy", he says.
Quickly informing the field was a viable idea, says Laurence Tiennot-Herment, president of the French Muscular Dystrophy Association, which has funded Aubourg's work for a decade. "But we must wait and see, as there is no publication yet, and there are safety and other issues to consider," she adds. "I'm very cautious for the present, but it's an important step."
Expression of therapeutic gene in blood cells (lymphocytes, red cells, granulocytes) or bone marrow derived cells (macrophages in brain, liver, lung, etc..) has major therapeutic interest in many human diseases, including in particular cancers (leukemia) and a large number of rare inherited diseases. Among these rare diseases are those for which the expression of the therapeutic gene must be achieved in specific blood cell population, for example, red cells for thalassemia and sickle cell disease that affect several hundreds of thousands of patients around the world, in lymphocytes or granulocytes for several inherited inmmunodeficiency disorders, and those for which the therapeutic gene must be expressed in brain macrophages (also called microglia), as is the case in a subset of inherited neurodegenerative diseases that affect the cerebral cortex, the white matter or both (Hurler disease, metachromatic leukodystrophy and X-linked adrenoleukodystrophy).
For nearly all these diseases, the expression of the therapeutic gene and therefore the therapeutic protein must be achieved for the entire life of the patient. Given the limited half-life of lymphocytes, red cells, granulocytes and macrophages, long-term expression can be obtained only if one succeeds in expressing the therapeutic gene in bone marrow cells that give continuously rise to lymphocytes, red cells, granulocytes and macrophages during the life of human, i .e, the so-called hematopoietic stem cells.
For all the inherited diseases mentioned above, this aim has been successfully achieved through a bone marrow transplantation procedure, also called allogenic hematopoietic stem cell transplantation. Allogenic bone marrow transplantation requires however that a matched-HLA donor (unrelated voluntary donor or cord blood) be found and this procedure remains associated with significant morbidity and mortality risks (failure of/incomplete grafting, graft versus host disease, chronic immune insufficiency). Transplanting the patient's own bone marrow cells into which the therapeutic gene has been introduced would circumvent the need for a donor, and eliminate many risks of bone marrow transplantation, in particular the risk of graft versus host disease.
Up to now, this gene therapy strategy has proved to be successful in only two very rare inherited forms of severe combined immunodeficiency disorders (SCID) : the adenosine desaminase (ADA) deficiency and the deficiency of the common γ chain (SCID-X1). The γ chain is common to five cytokine receptors, all of which are necessary for the development of T lymphocytes. In ADA deficiency and SCID-X1, the transfer of the therapeutic gene in hematopoietic stem cells of patients was achieved using a defective Moloney murine leukemia virus vector. This kind of gene therapy vector is poorly effective in transferring genes into non-dividing cells such as hematopoietic stem cells. In these 2 diseases, very few early hematopoietic progenitors were corrected initially, but clinical benefits (i.e repairing the immune system of patients) were obtained because, the few lymphocytes that originate from corrected hematopoietic progenitor cells expanded because of selective advantage that corrected/normal cells have over diseased cells. This property of selective advantage occurs in very few diseases and gene transfer using Moloney murine leukemia virus vector is therefore useless for most diseases.
With progresses made in the field of AIDS research, it has been possible to design a HIV1-derived gene therapy vector that is defective for replication (non-infectious), but that keeps an essential property of HIV-1 virus : the potential to transfer DNA material and therefore the therapeutic gene into non-dividing cells.
The group of Patrick Aubourg and Nathalie Cartier in Paris (hospital Saint-Vincent de Paul, INSERM U745) reports the first attempt to transfer a therapeutic gene into hematopoietic stem cells in two patients with X-linked adrenoleukodystrophy (ALD). ALD is the most frequent form of leukodystrophy (a group of inherited disorders affecting the myelin within the central nervous system). Once symptoms have started in affected ALD boys, the disease progresses rapidly to a vegetative stage or death within 2-3 years. Patrick Aubourg showed in 1990 that allogenic bone marrow transplantation can arrest and even sometimes reverse the cerebral demyelination in ALD boys when the procedure is performed at an early stage, i.e before evident clinical symptoms occur. In ALD, the efficacy of allogenic bone marrow transplantation is mediated through the replacement of diseased brain macrophages of the patient by normal bone marrow-derived cells that penetrate into the brain and differentitate into normal brain macrophages.
In this first hematopoietic stem cell gene therapy trial with HIV1-derived lentivector (the sponsor of this trial is the french INSERM, Institut National de la Sant et de la Recherche Mdicale), CD34+ cells (a sub-population of bone marrow cells that contains hematopoietic stem cells and which is commonly used to perform allogenic bone marrow transplantation in human) from 2 ALD patients who were candidates for bone marrow transplantation but who had no HLA-matched donor were genetically corrected ex vivo with a lentivector expressing the ALD gene (vector and assay reagents provided by Cell Genesys, Inc., South San Franciso, CA, USA). After all tests assessing the safety of manipulated cells had been performed, genetically corrected CD34+ cells were re-infused to the 2 patients after myeloablation (the same chemotherapy regimen is used for allogenic bone marrow transplantation). The first patient was treated 1 year ago, the second 6 months ago. The procedure occured without complications in the two patients who had hematological recovery 15 days after transplant and full immune reconstitution 1 year for the first treated patient and 6 months for the second treated patient after the re-infusion of the cells. Thus far, all tests evaluating the safety of the procedure, in particular the safety concerns for the use of HIV1-derived vector are negative. Importantly, biological tests show stable and high expression of the therapeutic protein and at the same percentage in all blood cells (lymphocytes, granulocytes, monocytes) deriving from bone marrow cells. These data indicate for the first time that in the absence of selective advantage, a high percentage of hematopoeitic cell progenitors with self-renewal (as true hematopoietic stem cells) were corrected giving rise to expression of therapeutic protein at high level in all hematological lineages. For ALD disease, the short-term evolution was similar to that observed in patients treated with conventional allogenic bone marrow transplantation. As for allogenic bone marrow transplantation, it will be necessary to wait up to 18-24 months after the transplant to determine if this gene therapy approach will be sufficienct to arrest the cerebral disease.
These data support the hopes that have been put in HIV-1 derived lentivector, i.e, their capacity to transfer therapeutic gene at high efficiency and for long life in non-dividing cells, including hematopoietic stem cells.
However these results are still preliminary and important pending questions need to get answered long term :
1/ first all the safety issues regarding the use of HIV1-derived vector and the risk of all retrovirus vector to induce insertional mutagenesis (all retrovirus vectors integrate in or between genes in chromosomes and may activate nearby genes that play a role in oncogenesis)
2/ the real long-term (> 2years) stability of therapeutic gene expression in early hematopoietic progenitors with self renewal.
3/ whether the percentage of corrected cells achieved in this first trial will be sufficient to arrest the cerebral disease in ALD patients.
This trial was in part funded by funding from the french European Leukodystrophy Association and the US Stop-ALD Foundation.
Kick-Off / Plenary Session: Presented Sunday, 28 October 2007 at ESGCT 2007
Preliminary Data from the First Hematopoietic Stem Cell Gene Therapy Trial with Lentiviral Vector Demonstrate Expression of the Therapeutic Protein in High Percentage of Lymphocytes and Monocytes in Two Patients with X-Linked Adrenoleukodystrophy
Nathalie Cartier1,2,3; Salima Hacein-Bey-Abina4,5; Gabor Veres6; Michel Vidaud1,7; Liliane Dal-Cortivo4,5; Laure Caccavelli4,5; Nizar Malhaoui8; Veronique Kiermer9,*; Denice Mittelstaedt9,; Andrew Simmons10; Cline Bellesme3; Francoise Audat4,5; Stephane Blanche8; Pierre Charnaud10; Muriel Audit11; Bruno Lohomme1,2,13; Jing- Chao Zhao- Emmonet1,2,13; Serge Fichelson14; Francoise Pflumio14; Anne Dubart-Kupperschmitt14; Rachel Salzman15; Amber Salzman16; Pierre Bougnores3; Alain Fischer5,8; Marina Cavazzana-Calvo4,5; Patrick Aubourg1,2,3 1
INSERM U745, 2Faculty of Pharmacy, University Ren Descartes, and 3Department of Pediatric Endocrinology and Neurology, 13Hopital Saint-Vincent de Paul, Paris, France; 4Department of Biotherapies, 5U768, and 8Unit dImmunologie et Hematologie Pediatrique, Hopital Necker- Enfants Malades, Paris, France; 6Applied Genetic Technology Corporation, Alachua, FL, USA; 10R&D Development, 9Cell Genesys, Inc., South San Francisco, CA, USA; 11Institut Pasteur, CNRS-URA 3015, Paris, France; 12Gnthon, Evry, France; 14Department of Hematology,
U567, Institut Cochin, Paris, France; 15The StopALD Foundation, Houston, TX, USA; 16The StopALD Foundation and GlaxoSmithKline, Philadelphia, PA, USA; *Present address: Nature Methods, New York, NY, USA; Present address: San Diego, CA, USA
We report preliminary results in two children with cerebral X-linked adrenoleukodystrophy (ALD) who received in September 2006 and January 2007 hematopoietic stem cell (HSC) gene therapy using a HIV1-derived lentiviral vector. We have previously shown that the cerebral demyelination associated with cerebral ALD can be stopped or reversed within 18 months by allogeneic HSC transplantation. For the current HSC gene therapy procedure, mobilized peripheral blood CD34_ cells were transduced ex vivo for 18 hr with a non-replicative HIV1- derived lentiviral vector (provided by Cell Genesys, Inc.) expressing the ALD cDNA under the control of the MND promoter, and in the presence of Il-3, SCF, Flt3-ligand, MGDF, and CH-296 retro nectine. Transduced cells were frozen to perform replication-competent lentivirus (RCL) assays. After thawing and prior to reinjection, 50% and 30%, respectively, of transduced CD34_ cells expressed the ALD protein with a mean of 0.7 and 0.6 copies of integrated provirus/cell. Transduced CD34_ cells were infused to ALD patients after full myeloablation with cyclophosphamide and busulfan.
Hematopoietic recovery occurred at day 15 post-transplant, and the procedure was uneventful. The percentage of corrected lymphocytes and monocytes in the peripheral blood of treated patients remained stable from day 30 to the last follow-ups. From 25% to 30% (Patient P1, 9 months after transplant) and 20% (Patient P2, 41/2 months after transplant) of CD14_, CD3_, CD19_, and CD3_CD56_ cells expressed the ALD protein (0.4 integrated provirus copy/cell). Tests assessing vector-derived RCL and vector mobilization were negative up to the last follow-ups. These early results support that: (1) ex vivo HSC gene therapy using HIV1-derived lentiviral vector is not associated with the emergence of RCL and vector mobilization; (2) a high percentage of hematopoietic progenitors were transduced expressing ALD protein in the short term; (3) no early evidence of selective advantage of the transduced ALD cells or clonal expansion was observed; and (4) HSC gene therapy appears to have short-term neurological effects comparable with allogeneic HSC transplantation.
Sponsored by INSERM and conducted under an R&D collaboration with Cell Genesys, Inc., South San Francisco, CA.
March 29-30, 2001
World's Leading ALD and Gene Therapy Experts Meet to Progress a Cure
Philadelphia, Pennsylvania, USA
Hosted by GlaxoSmithKline In Cooperation with The Stop ALD Foundation
On March 29-30, 2001, GlaxoSmithKline, in cooperation with The Stop ALD Foundation, convened in Philadelphia a first-ever meeting of a select group of scientists to evaluate and further explore treating adrenoleukodystrophy (ALD) vis-�-vis gene therapy. The group included world specialists in the fields of ALD, bone marrow transplants, gene therapy, neurology, and cutting edge biotechnology. Also several US governmental agencies were represented including the FDA Office of Orphan Products, National Institute of Neurological Disorders and Stroke, National Institutes of Health, and the National Office of Rare Diseases. The Stop ALD Foundation brought these eminent specialists together with to gain insights from a multidisciplinary approach and to determine which specific efforts might benefit from Foundation support.
- Patrick Aubourg, Hospital Saint-Vincent de Paul in Paris
- Pierre Bougneres, Hospital Saint-Vincent de Paul in Paris
- Natalie Cartier, INSERM, Paris
- Ken Cornetta, National Gene Vector Laboratories
- Matt During, CNS Gene Therapy, Thomas Jefferson University
- Dennis Hickstein, National Institutes of Health
- Orest Hurko, Neurology Center of Excellence, GlaxoSmithKline
- Henrietta Hyatt-Knorr, Acting Director National Institutes of Health, Office of Rare Diseases
- Tal Kafri, University of North Carolina
- Don Kohn, Keck School of Medicine of the University of Southern California
- Michael Lotze, GlaxoSmithKline
- Guy McKhann, Johns Hopkins and the National Institute of Neurological Disorders and Stroke
- Hugo Moser, Kennedy Krieger Institute / Johns Hopkins
- Tan Nguyen, Food and Drug Administration Office of Orphan Products
- Amber Salzman, GlaxoSmithKline
- Rachel Salzman, The Stop ALD Foundation
- Jim Wilson, Institute for Human Gene Therapy
Current gene therapy efforts applied to this disease
Gene therapy in relation to bone marrow transplants
Gene therapy for the central nervous system
Gene therapy for other disorders
Details on vectors (the vehicles that carry the desired genetic material).
Once the scientific material had been reviewed, a guided discussion ensued. Important data was analyzed, and a methodology for making and charting progress was discussed, including:
The importance of the large amount of data that exists describing the natural progression of the disease. This may serve as control data among other uses.
The nuances of vector choice.
Considerations regarding stem cell cycling, manipulation, and selection.
Potential biosafety and biosecurity issues.
Thoughts about experiments and scientific evidence that would be required in order to initiate FDA Phase I/II trials. This refers to clinical trials to be conducted in humans.
Benefiting from tangential research efforts that may further this therapeutic goal.
The need for further understanding of the pathophysiology details of ALD.
The usefulness of finding a more clinically relevant animal model than the current knock-out mouse model.
Appreciating that this genetic defect is presumed to be carried in one of every 15,000 males, newborn screening would be a highly desirable diagnostic tool.
The meeting was adjourned with all members gaining an appreciation for the complexity of the disease coupled with a rational sequence of goals that must be accomplished. An incredible amount of work lies ahead, however, there is also a strong sense of optimism if these efforts progress. It is clear that funding will be a prerequisite for accelerating emergence of a therapy.
The Stop ALD Foundation considers this meeting to have been a tremendous success. Through the continued coordinated and dedicated efforts of GlaxoSmithKline, the Stop ALD Foundation, and the humanitarianism of this group of researchers, an important groundwork has been laid for coordinating a multi-faceted approach to seeking therapy and, eventually, a cure for ALD.