Prospects for Prenatal Gene Therapy

Abstract

Somatic prenatal gene therapy (PGT) aims at treatment/prevention of progressive tissue/organ damage in early‐manifesting life‐threatening and otherwise incurable genetic diseases. Preclinical investigations applying different vectors and transgenes on several animal models including nonhuman primates have shown PGT to provide better access to target cells and their progenitors, induce tolerance to vector/transgenic protein and reduce the required amount of vector in comparison to postnatal gene therapy. Human application of PGT is now technically possible, however, safety issues regarding potential adverse effects on fetal development, oncogenesis‐induction and germline transmission as well as ethical considerations concerning risk–benefit assessment and alternative reproductive choices have so far prohibited human trials. Increasing the safety profile, for example, by use of novel vector systems and long‐time primate safety/efficiency studies, may prospectively validate PGT for selected human applications. High standards regarding information given to prospective patients (informed consent) and to the public on the aims, benefits and remaining risks will play an important role in any future clinical application of PGT.

Key Concepts:

  • Somatic gene therapy addresses genetic diseases of the treated individual at the level of the molecular defect.

  • Prenatal gene therapy of early onset genetic disease prevents irreparable damage to tissues and organs and induces postnatal tolerance to therapeutic transgenic proteins.

  • Prenatal gene delivery can reach proliferating precursor cell compartments more effectively than postnatal gene therapy.

  • Different animal models including models of human genetic disease are required to establish optimal vectors and routes for gene delivery including those applicable in humans, to demonstrate the therapeutic efficiency of the delivered gene therapy, and to monitor and investigate the occurrence of potential adverse effects.

  • In utero gene therapy could provide an alternative to termination of pregnancy or acceptance of an affected child after prenatal diagnosis of a genetically affected fetus, or to in vitro fertilisation followed by embryo selection in families with preconceptional knowledge of a specific genetic risk.

  • Current options to avoid birth of a genetically affected child (termination of pregnancy, preimplantation diagnosis/embryo selection) impose very high demands on the outcome of human prenatal gene therapy with respect to its level of safety and effectiveness.

  • Ethical considerations regarding the assessment and communication of the risks and benefits of prenatal gene therapy and its perception by affected families, the medical profession and the general public will play an important part in decisions on the clinical application of this novel therapeutic approach.

Keywords: prenatal (fetal, in utero) gene therapy; prenatal diagnosis of; genetic disease; fetal development; gene therapy vectors; animal models; oncogenesis; germline gene transfer; targeted gene correction (genome editing); immune tolerance; ethical considerations

Figure 1.

Topical in utero gene transfer in mouse. Topical application can be performed under ultrasound guidance or by visualisation of the fetal body parts through the uterine wall. Left: Intra‐amniotic delivery results in gene transfer to the skin, the airways and gut epithelia due to spontanious ‘breathing’ and swollowing movements of the fetus. Right: Examples of local application to the intercostal musculature, the thoracic and peritoneal cavities and to the limb musculature. Blue staining indicates gene transfer from vector expressing β‐galactosidase using enzyme reaction for detection. (a) Skin: Unpublished; (b) Airways Macro: Reproduced with permission from Buckley et al. (2005) Gene Therapy 12 (3) Fig. 1H. © Nature Publishing Group; (c) Airways histology: Unpublished; (d) Gut: Reproduced with permission from Douar et al. (1997) Gene Therapy (1997) 4, page 888 Fig. 6a (gut). © Nature Publishing Group. (e) Mouse fetus: Unpublished; (f–h) Muscle: Reproduced with permission from Gregrory et al. (2004) Gene Therapy 11, p. 1119 © Nature Publishing Group.

Figure 2.

Intravenous in utero gene transfer in mouse. Left: Schematic drawing and photograph of mouse fetus within the uterine horn. The embryonic yolk sac vessels can be seen and accessed through the uterine wall (needle puncture) as shown in the photograph. The yolk sac vessels deliver a large proportion of the blood flow directly to the liver, similar to the umbilical vein, which is used for gene delivery in larger mammals (centre). The blood flow reaches the heart through the inferior vena cava and is shunted through the foramen ovale and the ductus arteriosus into the aorta, essentially bypassing the lung circulation. Therefore, this systemic delivery route mediates gene transfer predominantly to the liver and, depending on the vector used, also to the heart, brain, visceral organs and peripheral musculature. Blue staining indicates gene transfer from the vector expressing β‐galactosidase using enzyme reaction for detection. Braun staining using immunohistochemical reaction for the detection of β‐galactosidase expression. (a) Schematic embryo: Reproduced with permission from Waddington et al. (2005) Molecular Therapy 11 (5) Fig. 1. © Nature Publishing Group. (b) Fetus in utero: Unpublished; (c) Fetal circulation: Reproduced with permission from Moore Keith. Embyologie Lehrbuch und Atlas, Schattauer 3rd German ed Fig. 14–40, p. 374. Elsevier licence © Elsevier. (d) Brain: Unpublished; (e,f) Heart, Liver in situ and histology: Reproduced with permission from Waddington (2003) Blood 101 (4) Fig. 1A and B. © American Society of Haematology.

Figure 3.

Late gestation (102 and 140th day) in utero gene transfer by umbilical vein injection in fetal sheep 1×1011 pfu adenovirus (AdRSVβgal) was injected at late gestation (0.96) into the intrahepatic umbilical vein of fetal sheep. (a) Ultrasound picture of needle insertion into umbilical vein at the time of injection. Umbilical vein injection (US): Reproduced with permission from Themis et al. (1999) Gene Therapy 6, 1239–1248 (Fig. 1). © Nature Publishing Group. (b) Braun immunohistological staining of β‐galactosidase in hepatocyte nuclei indicates successful gene transfer. Liver histology: Unpublished.

Figure 4.

First proof of principle for long‐term postnatal expression of potentially therapeutic levels of human antihaemophilic factor IX in a nonhuman primate model (Macaca fascicularis) after in utero gene therapy. 1.5×1010 vector genomes (AAV2/8 LP1‐hIX) were injected at late gestation (0.96) into the intrahepatic umbilical vein of this newborn rhesus monkey (a). hFIX‐expression was followed by consecutive blood sampling from birth. Note the stabilisation of the hFIX concentration after a first rapid drop after birth in spite of continuous expansion of blood volume (weight increase). In this animal, the hFIX level stabilises at 5.6 μg/ml, which corresponds to 112% of the normal human FIX level. In other animals from this experiment stable levels between 7% and 22% were reached. (a) New‐born Rhesus monkey: Unpublished. (b) Fix blood concentration: Reproduced with permission from Mattar et al. (). © Nature Publishing Group.

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Coutelle, Charles(Feb 2014) Prospects for Prenatal Gene Therapy. In: eLS. John Wiley & Sons Ltd, Chichester. http://www.els.net [doi: 10.1002/9780470015902.a0025275]