Gene Therapy for Haemoglobinopathies


Haemoglobinopathies, including thalassaemia and sickle cell anaemia, are common genetic diseases with significant associated morbidity and mortality. The potentially curative modality, haematopoietic stem cell (HSC) transplant, is restricted to a minority with matched donors, and has potential immunological adverse sequelae. Autologous HSC‐based therapies, using a patient's own genetically modified HSCs as donor cells, eliminates the need for an allogeneic matched donor and the immunological adverse effects of allogeneic HSC transplants. Gene therapy for haemoglobinopathies can be categorised as: (1) gene addition, (2) gene disruption, (3) gene correction, or (4) gene modification resulting in pharmacological upregulation of foetal haemoglobin. Currently, additive gene therapies are in clinical trials, while promising therapies based on gene disruption, editing and modulation of gene regulation are currently under development. Many of these therapies use the latest innovations in gene editing, the designer nucleases, including zinc‐fingers, transcription activator‐like effector nucleases, and clustered regularly interspaced short palindromic repeats/Cas technologies.

Key Concepts

  • Haemoglobin exists as a heterotetramer of two α‐globin subfamily peptides and two β‐globin subfamily peptides; adult haemoglobin primarily composed of α2β2.
  • Haemoglobinopathies are genetic diseases that affect either the function or level of globin peptides.
  • Haemoglobinopathies are the most prevalent genetic diseases with significant morbidity and mortality.
  • Of these, β‐globinopathies (sickle cell anaemia and β‐thalassaemia) are the most common monogenic diseases worldwide and manifest within 6–12 months of birth.
  • Severity of haemoglobinopathies can be ameliorated through the expression of the missing haemoglobin subunit beta (HBB), additional β‐like globins, or genes that upregulate alternative globins.
  • Additive gene therapy using lentivirus vectors has proven to be successful for both β‐thalassaemia and sickle cell anaemia clinically.
  • Gene editing strategies, using ZFNs, TALENs or CRISPR/Cas, can be used as a ‘fix and run’ approach and have the advantage over additive gene therapies by avoiding insertional genotoxicity and restoring innate regulatory mechanisms.
  • Erythroid‐specific modulation of BCL11A has been shown to increase expression of haemoglobin subunits gamma 1 (HBG1) and gamma 2 (HBG2), and may be a viable alternative treatment modality.

Keywords: gene therapy; haemoglobinopathy; thalassaemia; sickle cell anaemia; gene editing

Figure 1. General outline of steps involved in gene therapy for haematopoietic disorders. Haematopoietic stem and progenitor cell (HSPC), induced pluripotent stem cell (iPSC). HSPCs can either be modified directly, or somatic cells, e.g. fibroblasts, can be reprogrammed into iPSCs which are then modified before being differentiated into HSPCs.
Figure 2. Haemoglobin switching. Genetic structure of the α‐globin and β‐globin family loci on chromosomes 16 and 11, respectively. Arrows illustrate order of gene expression (haemoglobin switching) that occurs during development. In the α‐globin family, haemoglobin subunit zeta ( ) is expressed in early embryonic stages, before transitioning to alpha 1 ( ) and alpha 2 ( ), which are expressed during foetal and adult stages. In the β‐globin family, haemoglobin subunit epsilon 1 ( ) is expressed during embryonic stages. Expression is then switched to gamma 1 ( ) gamma 2 ( ), which is the predominant β‐globin family peptide during foetal life. Within several weeks of birth, haemoglobin subunits gamma 1 and gamma 2 are replaced by beta ( ) as the predominant β‐globin family peptide and haemoglobin subunit delta ( ) expression begins. , and expression continue throughout life, although at low levels. Predominant globin peptides after first few weeks of life indicated by red arrows. HS40 and the locus control region (LCR) are the dominant regulatory elements controlling haemoglobin switching.
Figure 3. Two mechanisms for insertional genotoxicity mediated by viral vectors. (a) Long terminal repeat (LTR) acts as an enhancer and increases the activity of a cellular proto‐oncogene promoter near insertion site. (b) Integration of the provirus within a putative tumor suppressor gene (TSG) can disrupt/deregulate the gene, even if the LTR self inactivates (SIN) by deleting the viral transcriptional elements upon integration. Here, either premature polyadenylation (pA), stop codon (STOP), or aberrant splicing may occur.


Akinsheye I, Alsultan A, Solovieff N, et al. (2011) Fetal hemoglobin in sickle cell anemia. Blood 118 (1): 19–27.

Bauer DE, Kamran SC and Orkin SH (2012) Reawakening fetal hemoglobin: prospects for new therapies for the beta‐globin disorders. Blood 120 (15): 2945–2953.

Bender MA, Gelinas RE and Miller AD (1989) A majority of mice show long‐term expression of a human beta‐globin gene after retrovirus transfer into hematopoietic stem cells. Molecular and Cellular Biology 9 (4): 1426–1434.

Breda L, Casu C, Gardenghi S, et al. (2012) Therapeutic hemoglobin levels after gene transfer in β‐thalassemia mice and in hematopoietic cells of β‐thalassemia and sickle cells disease patients. PLoS One 7 (3): e32345.

Canver MC, Smith EC, Sher F, et al. (2015) BCL11A enhancer dissection by Cas9‐mediated in situ saturating mutagenesis. Nature (advance online publication). vol. 527: 192–197.

Cavazzana‐Calvo M, Payen E, Negre O, et al. (2010) Transfusion independence and HMGA2 activation after gene therapy of human beta‐thalassaemia. Nature 467 (7313): 318–322.

Chandrakasan S and Malik P (2014) Gene therapy for hemoglobinopathies: the state of the field and the future. Hematology/Oncology Clinics of North America 28 (2): 199–216.

Chang C‐J and Bouhassira EE (2012) Zinc‐finger nuclease‐mediated correction of α‐thalassemia in iPS cells. Blood 120 (19): 3906–3914.

Costa FC, Fedosyuk H, Neades R, et al. (2012) Induction of fetal hemoglobin in vivo mediated by a synthetic gamma‐globin zinc finger activator. Anemia 2012 Article ID 507894.

Dong A, Rivella S and Breda L (2013) Gene therapy for hemoglobinopathies: progress and challenges. Translational Research 161 (4): 293–306.

Dzierzak EA, Papayannopoulou T and Mulligan RC (1988) Lineage‐specific expression of a human beta‐globin gene in murine bone marrow transplant recipients reconstituted with retrovirus‐transduced stem cells. Nature 331 (6151): 35–41.

Finotti A, Breda L, Lederer CW, et al. (2015) Recent trends in the gene therapy of beta‐thalassemia. Journal of Blood Medicine 6: 69–85.

Floch V, Le Bolc'h G, Audrézet M‐P, et al. (1997) Cationic Phosphonolipids as non viral vectors for DNA transfection in hematopoietic cell lines and CD34+ cells. Blood Cells, Molecules, and Diseases 23 (1): 69–87.

Geurts AM, Yang Y, Clark KJ, et al. (2003) Gene transfer into genomes of human cells by the sleeping beauty transposon system. Molecular Therapy 8 (1): 108–117.

Guda S, Brendel C, Renella R, et al. (2015) miRNA‐embedded shRNAs for Lineage‐specific BCL11A Knockdown and Hemoglobin F Induction. Molecular Therapy 23 (9): 1465–1474.

Hacein‐Bey‐Abina S, Von Kalle C, Schmidt M, et al. (2003) LMO2‐associated clonal T cell proliferation in two patients after gene therapy for SCID‐X1. Science 302 (5644): 415–419.

Hoban MD, Cost GJ, Mendel MC, et al. (2015) Correction of the sickle cell disease mutation in human hematopoietic stem/progenitor cells. Blood 125 (17): 2597–2604.

Huang X, Wang Y, Yan W, et al. (2015) Production of gene‐corrected adult beta globin protein in human erythrocytes differentiated from patient iPSCs after genome editing of the sickle point mutation. Stem Cells 33 (5): 1470–1479.

Kan YW and Nathan DG (1970) Mild thalassemia: the result of interactions of alpha and beta thalassemia genes. Journal of Clinical Investigation 49 (4): 635–642.

Katsantoni EZ, Langeveld A, Wai AW, et al. (2003) Persistent gamma‐globin expression in adult transgenic mice is mediated by HPFH‐2, HPFH‐3, and HPFH‐6 breakpoint sequences. Blood 102 (9): 3412–3419.

Katzourakis A, Gifford RJ, Tristem M, et al. (2009) Macroevolution of complex retroviruses. Science 325 (5947): 1512.

Levetzow GV, Spanholtz J, Beckmann J, et al. (2006) Nucleofection, an efficient nonviral method to transfer genes into human hematopoietic stem and progenitor cells. Stem Cells and Development 15 (2): 278–285.

Lucarelli G, Isgro A, Sodani P and Gaziev J (2012) Hematopoietic stem cell transplantation in thalassemia and sickle cell anemia. Cold Spring Harbor Perspectives in Medicine 2 (5): a011825.

Lung HY, Meeus IS, Weinberg RS and Atweh GF (2000) In vivo silencing of the human gamma‐globin gene in murine erythroid cells following retroviral transduction. Blood Cells, Molecules, and Diseases 26 (6): 613–619.

Ma N, Shan Y, Liao B, et al. (2015) Factor‐induced reprogramming and zinc finger nuclease‐aided gene targeting cause different genome instability in β‐thalassemia induced pluripotent stem cells (iPSCs). Journal of Biological Chemistry 290 (19): 12079–12089.

Manchinu MF, Marongiu MF, Poddie D, et al. (2014) In vivo activation of the human δ‐globin gene: the therapeutic potential in β‐thalassemic mice. Haematologica 99 (1): 76–84.

Miccio A, Poletti V, Tiboni F, et al. (2011) The GATA1‐HS2 enhancer allows persistent and position‐independent expression of a β‐globin transgene. PLoS One 6 (12): e27955.

Miller JC, Tan S, Qiao G, et al. (2011) A TALE nuclease architecture for efficient genome editing. Nature Biotechnology 29 (2): 143–148.

Moscou MJ and Bogdanove AJ (2009) A simple cipher governs DNA recognition by TAL effectors. Science 326 (5959): 1501.

Naldini L, Blomer U, Gallay P, et al. (1996) In vivo gene delivery and stable transduction of nondividing cells by a lentiviral vector. Science 272 (5259): 263–267.

Ott MG, Schmidt M, Schwarzwaelder K, et al. (2006) Correction of X‐linked chronic granulomatous disease by gene therapy, augmented by insertional activation of MDS1‐EVI1, PRDM16 or SETBP1. Nature Medicine 12 (4): 401–409.

Plavec I, Papayannopoulou T, Maury C and Meyer F (1993) A human beta‐globin gene fused to the human beta‐globin locus control region is expressed at high levels in erythroid cells of mice engrafted with retrovirus‐transduced hematopoietic stem cells. Blood 81 (5): 1384–1392.

Puthenveetil G, Scholes J, Carbonell D, et al. (2004) Successful correction of the human β‐thalassemia major phenotype using a lentiviral vector. Blood 104 (12): 3445–3453.

Ramalingam S, Annaluru N, Kandavelou K and Chandrasegaran S (2014) TALEN‐mediated generation and genetic correction of disease‐specific human induced pluripotent stem cells. Current Gene Therapy 14 (6): 461–472.

Ren S, Wong BY, Li J, et al. (1996) Production of genetically stable high‐titer retroviral vectors that carry a human gamma‐globin gene under the control of the alpha‐globin locus control region. Blood 87 (6): 2518–2524.

Sabatino DE, Seidel NE, Aviles‐Mendoza GJ, et al. (2000) Long‐term expression of gamma‐globin mRNA in mouse erythrocytes from retrovirus vectors containing the human gamma‐globin gene fused to the ankyrin‐1 promoter. Proceedings of the National Academy of Sciences of the United States of America 97 (24): 13294–13299.

Sebastiano V, Maeder ML, Angstman JF, et al. (2011) In situ genetic correction of the sickle cell anemia mutation in human induced pluripotent stem cells using engineered zinc finger nucleases. Stem Cells 29 (11): 1717–1726.

Sjeklocha LM, Wong PYP, Belcher JD, et al. (2013) β‐Globin sleeping beauty transposon reduces red blood cell sickling in a patient‐derived CD34+‐based in vitro model. PLoS One 8 (11): e80403.

Sun N and Zhao H (2014) Seamless correction of the sickle cell disease mutation of the HBB gene in human induced pluripotent stem cells using TALENs. Biotechnology and Bioengineering 111 (5): 1048–1053.

Suzuki K, Yu C, Qu J, et al. (2014) Targeted gene correction minimally impacts whole‐genome mutational load in human‐disease‐specific induced pluripotent stem cell clones. Cell Stem Cell 15 (1): 31–36.

Takahashi K and Yamanaka S (2006) Induction of pluripotent stem cells from mouse embryonic and adult fibroblast cultures by defined factors. Cell 126 (4): 663–676.

Thein SL, Menzel S, Lathrop M and Garner C (2009) Control of fetal hemoglobin: new insights emerging from genomics and clinical implications. Human Molecular Genetics 18 (R2): R216–R223.

Toneguzzo F and Keating A (1986) Stable expression of selectable genes introduced into human hematopoietic stem cells by electric field‐mediated DNA transfer. Proceedings of the National Academy of Sciences of the United States of America 83 (10): 3496–3499.

Voit RA, Hendel A, Pruett‐Miller SM and Porteus MH (2014) Nuclease‐mediated gene editing by homologous recombination of the human globin locus. Nucleic Acids Research 42 (2): 1365–1378.

Voon HP, Wardan H and Vadolas J (2008) siRNA‐mediated reduction of alpha‐globin results in phenotypic improvements in beta‐thalassemic cells. Haematologica 93 (8): 1238–1242.

Weatherall DJ (2001) The thalassemias. The Molecular Basis of Blood Diseases, 3rd edn, pp. 183–226. Philadelphia, Pennsylvania: W.B. Saunders Company.

WHO (2006) Report of a Joint WHO–March of Dimes Meeting: Management of Birth Defects and Haemoglobin Disorders. World Health Organization, Geneva Switzerland.

WHO (2011) Sickle‐Cell Disease and Other Haemoglobin Disorders, WHO Fact Sheet 308.

Xie SY, Ren ZR, Zhang JZ, et al. (2007) Restoration of the balanced alpha/beta‐globin gene expression in beta654‐thalassemia mice using combined RNAi and antisense RNA approach. Human Molecular Genetics 16 (21): 2616–2625.

Xie F, Ye L, Chang JC, et al. (2014) Seamless gene correction of β‐thalassemia mutations in patient‐specific iPSCs using CRISPR/Cas9 and piggyBac. Genome Research 24 (9): 1526–1533.

Yawn BP, Buchanan GR, Afenyi‐Annan AN, et al. (2014) Management of sickle cell disease: summary of the 2014 evidence‐based report by expert panel members. Journal of the American Medical Association 312 (10): 1033–1048.

Zou J, Mali P, Huang X, et al. (2011) Site‐specific gene correction of a point mutation in human iPS cells derived from an adult patient with sickle cell disease. Blood 118 (17): 4599–4608.

Further Reading

Breda L, Rivella S, Zuccato C and Gambari R (2013) Combining gene therapy and fetal hemoglobin induction for treatment of β‐thalassemia. Expert Review of Hematology 6 (3): 255–264.

Chandrakasan S and Malik P (2014) Gene therapy for hemoglobinopathies: the state of the field and the future. Hematology/Oncology Clinics of North America 28 (2): 199–216.

Dong A, Rivella S and Breda L (2013) Gene therapy for hemoglobinopathies: progress and challenges. Translational Research 161 (4): 293–306.

Finotti A, Breda L, Lederer CW, et al. (2015) Recent trends in the gene therapy of beta‐thalassemia. Journal of Blood Medicine 6: 669–685.

Nienhuis AW and Persons DA (2012) Development of gene therapy for thalassemia. Cold Spring Harbor Perspectives in Medicine 2 (11).

Payen E and Leboulch P (2012) Advances in stem cell transplantation and gene therapy in the β‐hemoglobinopathies. ASH Education Program Book 2012 (1): 276–283.

Persons DA and Nienhuis AW (2001) Hemoglobin Disorders: Gene Therapy, eLS. Chichester: John Wiley & Sons, Ltd.

Porteus MH (2015) Genome editing of the blood: opportunities and challenges. Current Stem Cell Reports 1 (1): 23–30.

Villamizar O, Chambers CB and Wilber A (2001) Gene Therapy for Severe Haemoglobin Disorders, eLS. Chichester: John Wiley & Sons, Ltd.

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How to Cite close
Goodman, Michael A, and Malik, Punam(May 2016) Gene Therapy for Haemoglobinopathies. In: eLS. John Wiley & Sons Ltd, Chichester. [doi: 10.1002/9780470015902.a0025347]