Haemophilias: Gene Therapy


Haemophilia A and B are the two most common severe congenital bleeding disorders and each is corrected with infusion of a single plasma protein. Preliminary data from animal models and from clinical trials in humans suggest that gene therapy may be effective in the haemophilias. Advances in vector technology combined with improved trangenes and knowledge of factors VIII and IX secretion in target tissues over the past several years have improved the prospects of gene therapy for the haemophilias.

Key Concepts

  • Understand the roles of factors VIII and IX in the intrinsic coagulation cascade.

  • Understand that both haemophilia A and B are caused by single gene mutations inherited in an X‐linked recessive pattern.

  • Understand the clinical features of haemophilia A and B.

  • Understand that haemophilia A and B are excellent models for gene therapy because of the wide range of protein levels that can be both therapeutic and not toxic.

  • Understand issues that determine target tissue suitability for gene therapy.

  • Understand the importance of efficient transgene transfection and secretion and the role of bioengineered transgenes.

  • Understand the potential for accumulation of unfolded or misfolded protein accumulation with overexpression of a transgene in a target tissue and the possibility of toxicity through induction of the unfolded protein response.

  • Understand the advantages and disadvantages of available vector technologies including: nonviral delivery systems, retroviral vectors, adenoviral vectors and adeno‐associated viral vectors.

  • Become familiar with results from gene therapy clinical trials in the haemophilias.

  • Become aware of the ethical and regulatory considerations in haemophilia gene therapy.

Keywords: factor VIII; factor IX; immune response; coagulation factors

Figure 1.

The clotting cascade: Exposure of tissue factor (TF) to blood upon vascular or endothelial cell injury initiates the extrinsic pathway of blood coagulation. TF acts with factor VIIa and phospholipid (PL) to convert factor IX to IXa and factor X to Xa. The intrinsic pathway includes ‘contact’ activation by factor XI with XIIa in the presence of high molecular weight kininogen. Factor XIa converts factor IX to IXa, and factor IXa in turn converts factor X to Xa, in concert with factor VIIIa and PL. Factor Xa catalyses the conversion of prothrombin to thrombin in the presence of factor Va and PL. Thrombin cleaves fibrinogen to generate insoluble fibrin. Protein C (PC) is activated by thrombomodulin on intact endothelium to generate activated protein C (APC) that cleaves and inactivates factors VIIIa and FVa. Dashed lines represent feedback pathways.



Aljamali MN, Margaritis P, Schlachterman A et al. (2008) Long‐term expression of murine activated factor VII is safe, but elevated levels cause premature mortality. Journal of Clinical Investigation 118: 1825–1834.

Balague C, Zhou J, Dai Y et al. (2000) Sustained high‐level expression of full‐length human factor VIII and restoration of clotting activity in hemophilic mice using a minimal adenovirus vector. Blood 95: 820–828.

Burton M, Nakai H, Colosi P et al. (1999) Coexpression of factor VIII heavy and light chain adeno‐associated viral vectors produces biologically active protein. Proceedings of the National Academy of Sciences of the USA 96: 12725–12730.

Chang AH, Stephan MT, Lisowski L and Sadelain M (2008). Erythroid‐specific human factor IX delivery from in vivo selected hematopoietic stem cells following nonmyeloablative conditioning in Hemophilia B mice. Molecular Therapy 16(10): 1745–1752.

Chao H, Mao L, Bruce AT and Walsh CE (2000) Sustained expression of human factor VIII in mice using a parvovirus‐based vector. Blood 95: 1594–1599.

Chao H, Sun L, Bruce A, Xiao X and Walsh CE (2002) Expression of human factor VIII by splicing between dimerized AAV vectors. Molecular Therapy 5: 716–722.

Chen L, Zhu F, Li J et al. (2007) The enhancing effects of the light chain on heavy chain secretion in split delivery of factor VIII gene. Molecular Therapy 15: 1856–1862.

Connelly S, Andrews JL, Gallo‐Penn AM et al. (1999) Evaluation of an adenoviral vector encoding full‐length human factor VIII in hemophiliac mice. Thrombosis and Haemostasis 81: 234–239.

Gallo‐Penn AM, Shirley PS, Andrews JL et al. (2001) Systemic delivery of an adenoviral vector encoding canine factor VIII results in short‐term phenotypic correction, inhibitor development, and biphasic liver toxicity in hemophilia A dogs. Blood 97: 107–113.

Gewirtz J, Thornton MA, Rauova L and Poncz M (2008) Platelet‐delivered factor VIII provides limited resistance to anti‐factor VIII inhibitors. Journal of Thrombosis and Haemostasis 6: 1160–1166.

Herzog RW, Yang EY, Couto LB et al. (1999) Long‐term correction of canine hemophilia B by gene transfer of blood coagulation factor IX mediated by adeno‐associated viral vector. Nature Medicine 5: 56–63.

Kay MA, Manno CS, Ragni MV et al. (2000) Evidence for gene transfer and expression of factor IX in haemophilia B patients treated with an AAV vector. Nature Genetics 24: 257–261.

Kingdon HS and Lundblad RL (2002) An adventure in biotechnology: the development of haemophilia A therapeutics – from whole‐blood transfusion to recombinant DNA to gene therapy. Biotechnology and Applied Biochemistry 35: 141–148.

Lane S (1840) Haemorrhagic diathesis. Successful transfusion of blood. Lancet i: 185.

Lu H, Chen L, Wang H et al. (2001) Gene therapy for hemophilia B mediated by recombinant adeno‐associated viral vector with hFIXR338A, a high catalytic activity mutation of human coagulation factor IX. Science in China. Series C, Life Sciences 44: 585–592.

Lu DR, Zhou JM, Zheng B et al. (1993) Stage I clinical trial of gene therapy for hemophilia B. Science in China. Series B 36: 1342–1351.

Manno CS, Pierce GF, Arruda VR et al. (2006) Successful transduction of liver in hemophilia by AAV‐factor IX and limitations imposed by the host immune response. Nature Medicine 12: 342–347.

Mannucci PM (2003) Hemophilia: treatment options in the twenty‐first century. Journal of Thrombosis and Haemostasis 1: 1349–1355.

Miao HZ, Sirachainan N, Palmer L et al. (2004) Bioengineering of coagulation factor VIII for improved secretion. Blood 103: 3412–3419.

Mount JD, Herzog RW, Tillson DM et al. (2002) Sustained phenotypic correction of hemophilia B dogs with a factor IX null mutation by liver‐directed gene therapy. Blood 99: 2670–2676.

Neyman M, Gewirtz J and Poncz M (2008) Analysis of the spatial and temporal characteristics of platelet‐delivered factor VIII‐based clots. Blood 112: 1101–1108.

Pierce GF, Lillicrap D, Pipe SW and VandenDriessche T (2007) Gene therapy, bioengineered clotting factors and novel technologies for hemophilia treatment. Journal of Thrombosis and Haemostasis 5: 901–906.

Powell JS, Ragni MV, White GC II et al. (2003) Phase 1 trial of FVIII gene transfer for severe hemophilia A using a retroviral construct administered by peripheral intravenous infusion. Blood 102: 2038–2045.

Rogoff EG, Guirguis HS, Lipton RA et al. (2002) The upward spiral of drug costs: a time series analysis of drugs used in the treatment of hemophilia. Thrombosis and Haemostasis 88: 545–553.

Rosner F (1969) Hemophilia in the Talmud and rabbinic writings. Annals of Internal Medicine 70: 833–837.

Roth DA, Tawa NE Jr, O'Brien JM, Treco DA and Selden RF (2001) Nonviral transfer of the gene encoding coagulation factor VIII in patients with severe hemophilia A. New England Journal of Medicine 344: 1735–1742.

Snyder RO, Miao C, Meuse L et al. (1999) Correction of hemophilia B in canine and murine models using recombinant adeno‐associated viral vectors. Nature Medicine 5: 64–70.

Stein CS, Kang Y, Sauter SL et al. (2001) In vivo treatment of hemophilia A and mucopolysaccharidosis type VII using nonprimate lentiviral vectors. Molecular Therapy 3: 850–856.

Tabor E (1999) The epidemiology of virus transmission by plasma derivatives: clinical studies verifying the lack of transmission of hepatitis B and C viruses and HIV type 1. Transfusion 39: 1160–1168.

Toole JJ, Pittman DD, Orr EC et al. (1986) A large region (approximately equal to 95 kDa) of human factor VIII is dispensable for in vitro procoagulant activity. Proceedings of the National Academy of Sciences of the USA 83: 5939–5942.

Vanden Driessche T, Vanslembrouck V, Goovaerts I et al. (1999) Long‐term expression of human coagulation factor VIII and correction of hemophilia A after in vivo retroviral gene transfer in factor VIII‐deficient mice. Proceedings of the National Academy of Sciences of the USA 96: 10379–10384.

Further Reading

Daniel R and Smith JA (2008) Integration site selection by retroviral vectors: molecular mechanism and clinical consequences. Human Gene Therapy 19(6): 557–568.

Gura T (2001) Hemophilia. After a setback, gene therapy progresses … gingerly. Science 291: 1692–1697.

Mannucci PM and Tuddenham EG (2001) The hemophilias – from royal genes to gene therapy. New England Journal of Medicine 344: 1773–1779.

Murphy SL and High KA (2008) Gene therapy for haemophilia. British Journal of Haematology 140(5): 479–487.

Nienhuis AW (2008) Development of gene therapy for blood disorders. Blood 111(9): 4431–4444.

Schultz BR and Chamberlain JS (2008) Recombinant adeno‐associated virus transduction and integration. Molecular Therapy 16(7): 1189–1199.

Vanden Driessche T, Collen D and Chuah MK (2001) Viral vector‐mediated gene therapy for hemophilia. Current Gene Therapy 1: 301–315.

Wang L, Nichols TC, Read MS, Bellinger DA and Verma IM (2000) Sustained expression of therapeutic level of factor IX in hemophilia B dogs by AAV‐mediated gene therapy in liver. Molecular Therapy: The Journal of the American Society of Gene Therapy 1: 154–158.

Yaroovi HV, Kufrin D, Eslin DE et al. (2003) Factor VIII ectopically expressed in platelets: efficacy in hemophilia A treatment. Blood 102(12): 4006–4013.

Yarovoi HV, Kufrin D, Eslin DE et al. (2007) Progress and prospects: gene therapy clinical trials (part 2). Gene Therapy 14(22): 1555–1563.

Web Links

F8 (coagulation factor VIII, procoagulant component (hemophilia A)); Locus ID: 2157. LocusLink:http://www.ncbi.nlm.nih.gov/LocusLink/LocRpt.cgi?l=2157.

F9 (coagulation factor IX (plasma thromboplastic component, Christmas disease, hemophilia B)); Locus ID: 2158. LocusLink:http://www.ncbi.nlm.nih.gov/LocusLink/LocRpt.cgi?l=2158.

F8 (coagulation factor VIII, procoagulant component (hemophilia A)); MIM number: 306700. OMIM:http://www.ncbi.nlm.nih.gov/htbin‐post/Omim/dispmim?306700.

F9 (coagulation factor IX (plasma thromboplastic component, Christmas disease, hemophilia B)); MIM number: 306900. OMIM:http://www.ncbi.nlm.nih.gov/htbin‐post/Omim/dispmim?306900.

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How to Cite close
Callaghan, Michael, and Kaufman, Randal J(Sep 2009) Haemophilias: Gene Therapy. In: eLS. John Wiley & Sons Ltd, Chichester. http://www.els.net [doi: 10.1002/9780470015902.a0005750.pub2]