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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Clinically Relevant Abstract
Tuesday, December 9, 2008: 8:00 AM
304-306-308 - South (Moscone Center)
Marina Cavazzana-Calvo, MD, PhD1, Nathalie Cartier2*, Salima Hacein-Bey Abina1*, Gabor Veres3*, Manfred Schmidt4*, Cynthia Bartholomae4*, Michel Vidaud5*, Liliane Dal-Cortivo1*, Laure Caccavelli1*, Nizar Malhaoui6*, Pierre Frange6*, Veronique Kiermer7*, Denice Mittelstaedt7*, Andrew Simmons7*, Cline Bellesme2*, Francois Lefrore1*, Chantale Lagresle1*, Stephane Blanche6*, Pierre Charneau8*, Muriel Audit9*, Bruno L'Homme5*, Jing Chao Zhao-Emonet5*, Serge Fichelson10*, Francoise Pflumio10*, Anne Dubart-Kupperschmitt10*, <a data-cke-saved-href="http://www.stopald.org/about/people.asp" href="http://www.stopald.org/about/people.asp">Rachel Salzman11</a>*, <a data-cke-saved-href="http://www.stopald.org/about/people.asp" href="http://www.stopald.org/about/people.asp">Amber Salzman11</a>*, Pierre Bougnores2*, Christof Von Kalle4*, Alain Fischer, MD, PhD12* and Patrick Aubourg2*
1Biotharapie, Hopital Necker - Enfants Malades, Paris, France
2Endocrinologie et Neurologie Pediatrique, AP-HP Hopital Saint Vincent de Paul, Paris, France
3Applied Genetic Technologies, Corporation, Alachua, FL
4Translational Oncology, National Center for Tumor Diseases (NCT) / German Cancer Research Center (DKFZ), Heidelberg, Germany
5Facult des Sciences Pharmaceutiques et Biologiques, UMR745 Inserm, University Paris Descartes,, Paris, France
6Unit d'Immunologie et Hematologie Pediatrique, AP-HP Hopital Necker - Enfants Malades, Paris, France
7Cell Genesys, Inc., San Francisco, CA
8CNRS-URA3015, Institut Pasteur, Paris, France
9Genathon, Paris, France
10departement d'Hematologie - INSERM U567, Institut Cochin, Paris, France
11The StopALD Foundation, Houston, TX
12Service d'Immunologie et Hematologie Pediatrique, INSERM, University Paris Descartes, IFR94, AP-HP Hopital Necker Enfants-Malades, Paris, France
We report preliminary results in 3 children with cerebral X-linked adrenoleukodystrophy (ALD) who received in September 2006, January 2007 and June 2008 lentiviral vector transduced autologous hematopoietic stem cell (HSC). We have previously demonstrated that cerebral demyelination associated with cerebral ALD can be stopped or reversed within 12-18 months by allogeneic HSC transplantation. The long term beneficial effects of HCT transplantation in ALD are due to the progressive turn-over of brain macrophages (microglia) derived from bone-marrow cells. For the current HSC gene therapy procedure, we used mobilized peripheral blood CD34+ cells that were transduced ex vivo for 18 hours with a non-replicative HIV1-derived lentiviral vector (CG1711 hALD) at MOI25 and expressing the ALD cDNA under the control of the MND (myeloproliferative sarcoma virus enhancer, negative control region deleted, dl587rev primer binding site substituted) promoter, and in the presence of 4 human recombinant cytokines (Il-3, Stem Cell Factor [SCF], Flt3-ligand and Megakaryocyte Growth and Differentiation Factor [MGDF]) and CH-296 retronectine. Transduced cells were frozen to perform the required (RCL) safety tests. After thawing and prior to reinjection, 50%, 30% and 40% of transduced CD34+ cells expressed the ALD protein with a mean of 0.7, 0.6 and 0.65 copies of integrated provirus per cell. Transduced CD34+ cells were infused to ALD patients after a conditioning regimen including full doses of cyclophosphamide and busulfan. Hematopoietic recovery occured at day 13-15 post-transplant and the procedure was uneventful. In patient P1 and P2, the percentage of lymphocytes and monocytes expressing the ALD protein declined from day 60 to 6 months after gene therapy (GT) and remained stable up to 16 months post-GT. In P1, 9 to 13% of CD14+, CD3+, CD19+ and CD15+ cells expressed ALD protein 16 months post-transplant. In P2 and at the same time-point after transplant, 10 to 18% of CD14+, CD3+, CD19+ and CD15+ cells expressed ALD protein. ALD protein was expressed in 18-20% of bone marrow CD34+ cells from patients P1 and P2, 12 months post-transplant. In patient P3, 20 to 23% of CD3+, CD14+ and CD15+ cells expressed ALD protein 2 months after transplant. Tests assessing vector-derived RCL and vector mobilization were negative up to the last follow-ups in the 3 patients. Integration of the vector was polyclonal and studies of integration sites arein progress. At 16 months post-transplant, HSC gene therapy resulted in neurological effects comparable with allogeneic HSC transplantation in patient P1 and P2.
These 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 long term ; 3) no early evidence of selective advantage of the transduced ALD cells nor clonal expansion were observed.
(This clinical trial is sponsored by Institut National de la Santa et de la Recherche Medicale and was conducted in part under a R&D collaboration with Cell Genesys, Inc., South San Francisco, CA)
Supported by grants from INSERM, the European Leukodystrophy Foundation, Association Francaise contre les Myopathies, Programme Hospitalier de Recherche Clinique of the Health Ministry (AOM 3043) and the European Union Project LSHM-CT-2004-502987.
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.
This update details how The Stop ALD Foundation is successfully continuing to take an entrepreneurial approach to Adrenoleukodystrophy (ALD) and Adrenomyeloneuropathy (AMN). In this update we will cover how we continue to drive forward on our three main focus areas:
We continue to make progress and leverage our funding and resources to amplify and magnify dramatically the donations from the generous people and organizations that have funded the Foundation to date. We continue to need your financial support to drive forward in our efforts and save the children and adults devastated by this horrific and rare disease.
Please feel free to contact us if you have any questions concerning this update. Our contact information can be found by clicking on Contact Us at our web site www.stopald.org. You can also call 713.756.3232 or write to us at:
The Stop ALD Foundation
500 Jefferson Street, Suite 2000
Houston, Texas 77002-7371
Gene therapy has been a top priority for The Stop ALD Foundation since its inception. Since the discovery and description of Adrenoleukodystrophy in 1910, a comprehensive understanding of the disease process has eluded scientists. At the dawn of the new millennium, the role of very long chain fatty acids (VLCFAs), the metabolite that is abnormally high in individuals with a defective ALD gene, has yet to be determined. The reason one patient gets one form of the disease at a particular age versus another patient getting an entirely different form is completely unknown. While The Foundation fully supports furthering knowledge in these essential areas, searching for therapies the only way to help patients is The Foundation's top priority.
One important piece of the puzzle that has definitively and uniformly been determined is that all patients afflicted with ALD have a defect in the ALD gene. Therefore, in an effort to take advantage of the recent explosion of knowledge and technology in molecular biology and genetics, the simple yet elegant notion has arisen that would employ inserting a correct copy of the ALD gene DNA which codes for the ALD protein. Early work performed both in cell cultures and in mice has shown that this approach demonstrates meaningful promise as a potential therapy for patients.
The last Stop ALD Foundation update reported that the Foundation had secured the partnership of the biotechnology company, Cell Genesys, which is headquartered in California. While Cell Genesys made huge advances in this project, the company had to respond to the economic climate by narrowing its therapeutic focus during the first quarter of 2003. While this is certainly disappointing news, The Foundation is now in negotiations with the company as well as with various leading investigators in the U.S. and Europe to establish a new series of partnerships. The Foundation will be able to take advantage of much of the hundreds of thousands of dollars of investment already made by Cell Genesys on behalf of this project; it is simply a matter of filling in the gaps in the most efficient and productive ways possible.
Part of the reason Cell Genesys shifted its focus was the perceived climate shift that occurred in response to an adverse event encountered in a French SCID (bubble boy) gene therapy trial. Although the vast majority of treated children were effectively cured from this often-fatal disease, two of these boys now are battling leukemia, so far successfully.
In immediate response to this issue, The Foundation took a very proactive stance. Foundation action included a private meeting with the director of the division in the Food and Drug Administration (FDA) responsible for gene and cellular therapy. In that meeting, The Foundation stressed the importance of advancing the gene therapy agenda in diseases, such as ALD, which are so devastating. The meeting was extremely positive and productive and The Foundation firmly believes that the FDA is receptive to innovative therapies such as gene and cell therapy for deadly and rare diseases like ALD.
Multiple representatives from The Stop ALD Foundation attended and participated in several FDA and National Institutes of Health (NIH) meetings held in Washington, DC to ensure that progress in gene therapy continues. The meetings and participation worked. The FDA allowed research to continue.
The Stop ALD Foundation's gene therapy project is ongoing. Critical pre-clinical work is being conducted at laboratories in France and the U.S., all of which is necessary prior to opening the clinical trial for humans. As a result of the Foundation's work, this project continues to receive very strong encouragement from many sectors, including the FDA, NIH, the French INSERM (the equivalent of the U.S. National Institutes of Health), AFM (a very influential and well funded group that is the French equivalent of the Muscular Dystrophy Association) and leading ALD research institutions in the U.S and France. We have also been fortunate in securing the participation of the leading investigator from the French SCID trial, a dedicated researcher of international acclaim.
To ensure that the Foundation can get to human trials as quickly as possible, during this past American Society of Hematology meeting (ASH) in December 2002, The Foundation's Chief Science Officer secured the collaborative support of a research team that has one of the very few groups of monkeys that have been transplanted with cells containing the gene therapy vector quite similar to the one The Foundation proposes to use in the ALD clinical trial. This monkey colony was created for other research purposes. In clinical trials, the issue of safety comes up as well as efficacy. And quite naturally, people are often quite interested in results obtained in larger animals than mice. Non-human primates fit this interest. This is a reasonable question for the anticipated ALD gene therapy trial.
When the opportunity arises to study central nervous system tissue in these monkeys, The Foundation will help to ensure that the analysis takes place. When the original monkey experiment was conceived these scientists weren't interested in brains, let alone ALD. Now The Foundation has made a major inroad into this path of animal subjects animal subjects that are extremely costly and thus very limited in number and hard to come by. Once again, the Foundation has leveraged your funding and gotten another already funded research team interested in ALD and willing to help us to find a cure for ALD.
Mesynchymal Stem Cell (MSC) Therapy
The Mesynchymal Stem Cell (MSC) Therapy project involves scientists and physicians from St Jude's Hospital (Memphis, Tennessee), Children's Hospital of Philadelphia, Tulane (New Orleans, Louisiana), and leading researchers and physicians in Germany. This experimental therapy involves the use of MSCs taken from the bone marrow of adult donors. The MSCs would be delivered into the blood and brains of ALD patients who are at an advanced ALD stage. In the first phase trial of MSCs, these stem cells would be used in conjunction with conventional bone marrow transplants.
The theory is that these MSCs can start halting and repairing disease damage rapidly while the full bone marrow transplant takes effect. These patients are not suitable candidates for traditional bone marrow transplants due to the advanced state of their disease. These are advanced-stage ALD patients who are running out of time and cannot afford the typical 6 - 18 months it takes for a bone marrow or cord blood transplant to halt ALD disease progression. This time lag would either lead to very severe physical and mental debilitation (i.e. rapid progression to a vegetative state) or death. This unique therapeutic endeavor involving MSCs would allow for rapid and immediate delivery of donor cells to the brain the ultimate destination of importance in an ALD patient, with the hope that the positive impact on the disease can thus begin much sooner. Meanwhile, the traditional bone marrow or cord blood transplant is undergone in conjunction with the experimental therapy in order to take advantage of the well-recognized longer-term benefits of these types of transplants. The MSCs would come from the same donor as the bone marrow used for a bone marrow transplant.
In December 2002, in conjunction with the American Society of Hematology (ASH) Conference in Philadelphia, The Stop ALD Foundation hosted a workshop for all key MSC therapy participants in order to review the project. Many details were discussed and everyone agreed on what they need to do to move forward. Today, the work is moving forward in creating the MSC Phase I clinical trial protocol documents and we expect that it will be submitted to the FDA in 2004.
Up-Regulation of ALDR:
A Gene Very Similar to The ALD Gene
The human genome was sequenced, almost in its entirety, some three years ago. The successful sequencing produced myriad findings about human DNA. One is that some human genes overlap in their structure with others. It is almost as if some genes are incomplete or slightly inaccurate tracings of others. These genes are termed homologues.
Recent evidence suggests that the gene most homologous to the ALD gene (which is also known as ABCD1) may have a somewhat overlapping function. This homologous gene is called ALDR or ABCD2.
The protein of the ALD gene is either nonfunctional or not produced in someone with ALD; however, that person's homologous genes, such as ABCD2, function properly. That being said, these homologous genes are only producing at normal capacity which is not enough to make up for the original ALD genetic defect. Recent laboratory experiments have demonstrated that if one were to over express the ABCD2 gene so that there was a super-normal level of that gene's activity, it may have an impact on the course of ALD. When a gene produces a higher level of protein, which is the same as over expressing the protein for which it codes, this is termed up-regulation.
So the question arises: How can the ABCD2 gene be manipulated to be up-regulated in a safe yet effective manner? Researchers know that different drugs have direct impact on the activities of various genes. In both the public and private domain there are thousands of compounds that have only been examined in a narrow fashion. The drugs that are being investigated or even being currently used to treat, for example, acid reflux, are not also analyzed to see if they have a specific impact on any one particular gene out of the 35,000 genes. This is called cross-use. One well known example of cross-use of a drug is Viagra. This compound was originally examined for cardiovascular purposes. Its effect on male impotence was initially regarded as a side effect. Ultimately this effect became the primary indication for use of the drug.
It is highly possible that given the incredibly vast quantity of pharmaceutical compounds that have been both discovered and created over the last 100+ years, that drugs may already exist which may have the ability to up-regulate a particular gene of choice. In the case of ALD, one gene of choice would be the homologue referred to earlier ALDR. This research entails very sophisticated and very costly screening methods. In this effort, The Stop ALD Foundation has gained the cooperation and support of one of the worlds leading pharmaceutical companies, GlaxoSmithKline (GSK). After numerous meetings in the US and Europe, as well as discussions between The Foundation, GSK, and leading researchers in the field, an organized methodology was agreed upon. Certain compounds will be evaluated in a leading laboratory in Vienna, Austria headed by a world-renowned scientist, Dr. Johannes Berger, while another category of compounds will be further investigated by a leading research institute in Strasbourg France headed up by another internationally acclaimed researcher, Dr. Jean Louis Mandel. Since these are all laboratory experiments, The Foundation expects that data will begin to emerge over the next few months that will help to further refine and target ongoing research. This is a classic Stop ALD Foundation strategy: put all the potential contributing parties together, ultimately resulting in an efficient and directed series of scientific collaborations.
Following All Leads
The Stop ALD Foundation continues to investigate potential therapies for Adrenomyeloneuropathy (AMN). AMN is the name used when ALD manifests itself in adulthood. While the Foundation is not currently involved in any AMN clinical trials, the Foundation actively discusses this form of the disease at all scientific meetings it attends always looking for new ideas and potential therapies. We are in contact with leading AMN researchers in the US and Europe and are following up on their trials and seeing how we can assist them in moving forward.
Umbilical Cord Blood for Transplant in ALD Patients
Umbilical cord blood used in transplantation already has a proven track record of saving lives. The Stop ALD Foundation continues to educate patients, family members, and physicians concerning the pros and cons of cord blood. Sadly, many physicians are unaware of the effectiveness and viability of umbilical cord blood transplantation as a therapy for ALD patients who are not yet severely affected. Umbilical cord blood should be considered as an option for certain candidates. To learn more about the pros and cons of cord blood transplantation and how it compares with bone marrow transplantation, please see www.stopald.org/ald/currenttherapies.asp
In support of cord blood as a stem cell transplantation option, members of The Stop ALD Foundation have testified before the US Senate and at FDA advisory meetings, concerning a new bill being introduced that would provide funding for a US National Cord Blood Bank Network. This funding and network would increase and sustain the number of cord blood units available for transplant in diseases that would include ALD. Thus, no patient will be declined and delayed having a transplant due to a lack of suitable donor cells. Unfortunately, today, this is an ongoing reality with tragic consequences.
Screening Newborn Babies for ALD
Today every state in the US has mandated newborn screening for all newborns, however, that mandate can be for screening for as few as two diseases (Phenylketonuria (PKU) and Congenital Hypothyroidism). A few states mandate screening for up to 25 diseases. Mandated testing is on a state-by-state basis. Neo Gen Screening, Inc. (www.neogenscreening.com, phone 866-4-NEOGEN, from outside the US call +1.412.220.2300) currently offers a reasonably priced supplemental newborn screening test (less then $100) that screens newborn babies for dozens of rare diseases. Currently, that test does not include screening for Adrenoleukodystrophy (ALD). Neo Gen Screening is refining new technology that would enable ALD to be included in the test. Inclusion of an ALD test would raise the cost of the test by only one to two dollars. Neo Gen Screening is hopeful that their new newborn ALD test will be validated and ready for market by the end of 2004.
Many people mistakenly think that all newborn babies are screened for a large variety of rare diseases where early detection can save lives. Unfortunately, due to the way that the U.S. healthcare system works, the comprehensiveness of such testing (and the diseases screened for) varies widely, and families are often completely unaware of the level of screening performed on their newborn. Part of the reason that such testing is not comprehensive is that the cost involved is an expense which is not immediately recouped by the hospital or medical center where the baby is born. Even though insurance might pay for the bulk of the expenses related to having a baby, such expenses at one institution could include a post-natal screening for 45 diseases while at another institution they may only include a screen for two or three diseases. In spite of this, comprehensive post-natal testing is not even offered to new parents as an option for which parents would have to pay a small additional fee (less then $100).
Currently, if parents want to be certain that their newborn baby is screened for a wide variety of diseases, they must first check with the hospital where the child was born about what screens have already been performed and then contact a company such as Neo Gen Screening to begin the supplemental testing process. The testing company will send out a testing kit that parents take to their pediatrician. A small blood sample is taken from the baby and the kit is sent to the testing company for processing. Parents then get the results from the company. The cost for this supplemental testing is around $60 which includes the testing kit and processing fee. As well, there would be charges from the medical professional for drawing the blood sample.
Comprehensive post-natal testing is highly recommended because of the knowledge gained about the possibility of a rare disease surfacing in a newborn baby's life. For many of these diseases, including ALD, early detection, before clinical signs appear, can dramatically improve the chances of successful therapeutic intervention.
Screening for ALD is not mandated by any state, and the prospect that an ALD screen will be included in a post-natal test does not necessarily make it any more likely that such a test will be required by states.
The Stop ALD Foundation has initiated a dialogue with Dr. Michael Watson, Executive Director of the American College of Medical Genetics (www.acmg.net). Dr. Watson currently heads a federal committee of genetics experts mandated to advise the US government on neonatal screening for a wide variety of disorders. The Foundation's goal is to have ALD included in the list of diseases for which all newborns are screened. Thus, once the screening technology is in place, families and their children will not have to suffer the tragic consequences of facing an unsuccessful battle with ALD strictly because the disease was diagnosed too late. To help reach this goal of making sure that all newborn babies are screened for ALD, the Foundation made a highly scientific and very detailed submission(www.acmg.net/surveys/NBS-05_22_03/nbs.asp) to Dr. Watson which will be incorporated into the development of a critical decision making tool. We fully expect our contribution to have significant impact on the decisions and recommendations made by the committee's appointed working group.
You can help to ensure that newborn screening for ALD is mandated. Contact your state legislator by looking up their contact information at www.congress.org and let them know early intervention saves lives and saves money in terms of the prevention of costly long-term care. Please take advantage of any personal, professional, or business relationships you might have with your state legislators.
The Stop ALD Foundation is in regular contact with Neo Gen Screening and reviews progress with the scientists assigned to completing the ALD test. In an effort to collect samples that will be utilized in validating and fine tuning the test, Neo Gen Screening would like to receive anonymous samples from newborns with or without ALD. This will help Neo Gen Screening test the accuracy of their new test in order to help others. It is important to note that test results collected during this test validation phase will be processed in a completely anonymous fashion. No names or identifying information will be utilized. If you elect to assist by providing a blood sample, you will be helping a new test come to market that will help to catch ALD at birth.
If you are interested in providing a sample for testing, please contact Dr. Rachel Salzman at The Stop ALD Foundation (phone: 561.665.0455, email: email@example.com)
CHANGES COMING TO THE STOP ALD FOUNDATION'S WEB SITE
New Tools to Help Families Desperately Seeking Accurate Information, Direction, and Answers
There are a number of changes that will be coming to the web site (www.stopald.org) by the end of this year. One change will be the inclusion of a detailed Frequently Asked Questions (FAQs) section. In this section we'll put the answers that we provide to the most commonly asked questions that we receive. Monthly, we receive and quickly respond to hundreds of emails from families, researchers, and patients all over the world. Many of them have the same questions. We have been compiling our responses and plan to post them to this new Frequently Asked Questions (FAQs) section of the web site.
Another change coming to the site is a section entitled I just received a diagnosis of ALD. What do I do? Many inquiries we receive are from families that have just received the absolutely horrifying and devastating news that a loved one has been diagnosed with ALD. They are scared, confused, and lack accurate, credible, and timely information on what they need to do immediately. ALD can move extremely quickly along its destructive path. Sometimes, when the diagnosis is received, it's an early diagnosis as a related older child has been diagnosed and now a younger child is found to have the disease as well, but is not yet symptomatic. More often then not, unfortunately, the diagnosis is received and the child is already affected. At this point, sometimes, an emergency intervention can save the child's life. Time is of the essence. But for ALD patients and their families, there is a tremendous lack of accurate, up-to-date information in the medical community. Sometimes, it's too late and there is nothing that can be done to save the child. But, then again, sometimes there is a very short therapeutic window measured in days or weeks where parents must move extremely swiftly in order to even have a chance at saving that child's life.
In the I just received a diagnosis of ALD. What do I do? section of the web site, we'll include:
A check list of detailed questions to ask medical professionals (along with a brief explanation as to the meaning and importance of the questions). We have found that most people don't know the critically important questions they need to start asking immediately to ensure they are getting the best possible advice and care.
Steps that must be taken immediately
Steps that should be taken when time permits (e.g., having other children and family members tested)
Common ALD-related terms as there is a whole new set of words parents and care givers will need to understand
Plan to see this new information on The Stop ALD Foundation web site by the end of 2003.
HOW YOU CAN HELP
Now We Need Your Help
The Stop ALD Foundation's work is time consuming and takes funding to keep driving it forward. Many of us volunteer our time as we have a deep and personal passion for saving ALD patient's lives since we have family members that have or had ALD. While we are a small Foundation, we carry a big, powerful, and highly leveraged research punch. Researchers around the world continue to be impressed with our impact and how we move the ball forward in finding better and more effective therapies for ALD and AMN.
But, we can't do it without continued funding.
We ask you to make your financial contribution to The Stop ALD Foundation today, and to ask family members, friends, and co-workers to contribute as well. Unlike making contributions to very large charitable organizations (e.g., a breast cancer research foundation), donors can be assured that their funds will have a large impact and that they will be making a material difference in many children's lives.
Financial contributions should be sent to:
The Stop ALD Foundation
500 Jefferson Street, Suite 2000
Houston, Texas 77002-7371
For more information on how to make a donation online (including via credit card) and how your company may be able to double your donation with company matching funds, please click on Make aDonation on our web site www.stopald.org. You may also call 713.756.3232.
As always, please feel free to contact us at the number listed above at any time and let us know how we may be of assistance. More contact information is available by clicking on Contact Us at www.stopald.org.
Thank you for your continued support.
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.