Haemoglobin Disorders: Gene Therapy


The ability to transfer a globin gene into stem cells and achieve regulated expression during erythropoiesis following transplantation of genetically modified autologous cells could provide curative therapy for haemoglobin disorders such as sickle cell anaemia or β‐thalassaemia. Success has been achieved in several severe immunodeficiencies in which there is a selective advantage for gene corrected cells. The development of effective globin lentiviral vectors has resulted in resolution of the manifestations of sickle cell anaemia and β‐thalassaemia in mouse models of these diseases. However, a higher stem cell transduction efficiency must be achieved in humans than has been achieved in large animal models to date before success in treatment of haemoglobinopathies could be expected. Various strategies are being evaluated in animal models to increase the proportion of genetically modified, haematopoietic cells following infusion of transduced stem cells.

Keywords: gene therapy; sickle cell disease; β‐thalassaemia; lentiviral vector

Figure 1.

Red blood cell abnormalities and pathophysiology of β‐thalassaemia and sickle cell disease. (a) and (b) Severe β‐thalassaemia. Normal human red cells contain 30 pg of haemoglobin, which in the adult is composed of two α‐ and two β‐globin chains (α2β2). The two globin chains are synthesized in nearly equal amounts in maturing erythroblasts. Before birth, γ‐globin rather than β‐globin is present in the haemoglobin tetramer (α2γ2). During the perinatal period, there is a switch from γ‐ to β‐globin synthesis in developing red blood cells resulting in the replacement of fetal haemoglobin (α2γ2) with the adult form (α2β2). (a) A blood smear taken from a patient with severe homozygous β‐thalassaemia demonstrates red blood cells that lack adequate haemoglobin. The smear has been stained to depict the insoluble inclusions of α chains which appear as dark areas, often abutting the red cell membrane. (b) Biosynthesis of globin chains by erythroid cells from a patient with severe homozygous β‐thalassaemia is characteristically abnormal with relative excess synthesis of α‐globin and deficient synthesis of non‐α (γ‐ and β)‐globin (CPM=counts per minute). Effective gene therapy could be achieved by increasing the synthesis of β‐globin, the normal adult chain or γ‐globin, which is typically expressed during fetal life. (c) and (d) Sickle cell anaemia. The characteristic sickle shape of red blood cells (c) reflects polymerization of haemoglobin which occurs as a consequence of a single amino acid substitution, valine for glutamic acid, at position 6 of the β‐globin polypeptide chain and is located on the surface of the hemoglobin molecule. Expression of the naturally, antisickling fetal (γ) globin in red cells from patients with sickle cell anaemia reduces sickling propensity as a consequence of the formation of mixed tetramers (α2 βS γ) in red blood cells (d). The mixed tetramers are unable to participate in polymerization, thereby effectively reducing the concentration of sickle haemoglobin (HbS; α2βs2). Effective gene therapy could likely be achieved by introducing a functional γ‐globin gene that expressed at least 20% of the level of βS globin genes. From Persons DA and Nienhuis AW (2000) Gene therapy for the hemoglobin disorders: past, present and future. Commentary. Proceedings of the National Academy of Sciences of the USA 97: 5022–5024. Copyright (2000) National Academy of Sciences, USA.

Figure 2.

Currently envisioned protocols for gene transfer into stem cells of patients with sickle cell disease or thalassaemia are likely to have an outcome in which only a small proportion of the total blood forming cells are genetically modified (unshaded forms are unmodified cells, shaded forms are genetically modified cells). Use of a drug‐resistance gene in the gene therapy vector potentially offers a method to enrich the low numbers of genetically corrected stem cells and progeny (top panel, before drug) that are present in the patient following cell infusion. Subsequent drug treatment would kill the majority of unmodified cells (middle panel, drug treatment), allowing the genetically modified population to become predominant during subsequent haematopoietic recovery (bottom panel, haematopoietic recovery). The feasibility of this approach is well documented in murine models.



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Further Reading

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Persons, Derek A, and Nienhuis, Arthur W(Sep 2009) Haemoglobin Disorders: Gene Therapy. In: eLS. John Wiley & Sons Ltd, Chichester. http://www.els.net [doi: 10.1002/9780470015902.a0006041.pub2]