γ-珠蛋白基因表达调控机制与临床应用

成人体内的血红蛋白是由2个 α-珠蛋白和2个β-珠蛋白组成的四聚体,负责氧气的运输。珠蛋白基因在基因组中成簇分布,其表达受到多种顺式作用元件和反式作用因子的共同调控,具有高度的组织特异性和发育时序性。β-地中海贫血和镰刀型细胞贫血是两种最常见的由于β-珠蛋白基因突变引起的常染色体隐性遗传病。γ-珠蛋白是一种主要在胎儿时期表达的类β-珠蛋白,同样具有载氧功能,但编码该蛋白的基因在上述贫血患者中却保持完好。因此,临床上优选的治疗方案之一是重新激活患者体内沉默的γ-珠蛋白基因的表达来弥补缺损的β-珠蛋白,从而缓解临床症状。目前已有多种能提高γ-珠蛋白基因表达的药物,在临床上用于治疗β-地中海贫血和镰刀型细胞贫血。随着基因组编辑技术的发展,针对这两种贫血的精准基因治疗研究也在进行中。本文着重介绍了参与γ-珠蛋白基因调控的转录因子和表观遗传修饰分子,以及目前相关的β-地中海贫血和镰刀型细胞贫血的临床治疗药物和手段,以期为深入阐明γ-珠蛋白基因的转录表达分子调控机制提供参考。     

Curative therapy for hemoglobinopathies: an International Society for Cell & Gene Therapy Stem Cell Engineering Committee review comparing outcomes,accessibility and cost of ex vivo stem cell gene therapy versus allogeneic hematopoietic stem cell transplantation

Thalassemia and sickle cell disease (SCD) are the most common monogenic diseases in the world and represent a growing global health burden. Management is limited by a paucity of disease-modifying therapies; however, allogeneic hematopoietic stem cell transplantation (HSCT) and autologous HSCT after genetic modification offer patients a curative option. Allogeneic HSCT is limited by donor selection, morbidity and mortality from transplant conditioning, graft-versus-host disease and graft rejection, whereas significant concerns regarding long-term safety, efficacy and cost limit the broad applicability of gene therapy. Here the authors review current outcomes in allogeneic and autologous HSCT for transfusion-dependent thalassemia and SCD and provide our perspective on issues surrounding accessibility and costs as barriers to offering curative therapy to patients with hereditary hemoglobinopathies.     

人胎儿γ-珠蛋白基因的再活化及在β血红蛋白病治疗中的

在个体发育过程中,人β类珠蛋白基因的表达存在从胎儿（γ）到成人（β）珠蛋白基因的表达转换（或称开关）.β-地中海贫血和镰刀型贫血症是两种最为常见的严重危害人类健康的单基因遗传病,通过诱导胎儿期血红蛋白（HbF,α2γ2）在成人期表达对该病的治疗是一种有效的策略.一些活化γ珠蛋白基因表达的转录因子和辅助因子已经被鉴定,一些可以增加胎儿血红蛋白在成人红细胞中表达的药物也已被鉴别和实验,它们的作用机制被部分揭示,这些研究为发展通过活化γ-珠蛋白基因治疗镰刀形细胞贫血和重型β-地中海贫血的方法提供了重要线索和实验依据.     

Progress and Perspectives in the Development of Lentiviral Vector Producer Cells

After two decades of clinical trials, gene therapy demonstrated effectiveness in the treatment of a series of diseases. Currently, several gene therapy products are approved and used in the clinic. Lentiviral vectors (LVs) are one of the most used transfer vehicles to deliver genetic material and the vector of choice to modify hematopoietic cells to correct primary immunodeficiencies, hemoglobinopathies, and leukodystrophies. LVs are also widely used to modify T cells to treat cancers in immunotherapies (e.g., chimeric antigen receptors T cell therapies, CAR-T). In genome editing, LVs are used to deliver sequence-specific designer nucleases and DNA templates. The approval LV gene therapy products (e.g., Kymriah, for B-cell Acute lymphoblastic leukemia treatment; LentiGlobin, for β-thalassemia treatment) reinforced the need to improve their bioprocess manufacturing. The production has been mostly dependent on transient transfection. Production from stable cell lines facilitate GMP compliant processes, providing an easier scale-up, reproducibility and cost-effectiveness. The establishment of stable LV producer cell lines presents, however, several difficulties, with the cytotoxicity of some of the vector proteins being a major challenge. Genome editing technologies pose additional challenges to LV producer cells. Herein the major bottlenecks, recent achievements, and perspectives in the development of LV stable cell lines are revised.     

A mass spectrometry assay for detection of endogenous and lentiviral engineered hemoglobin in cultured cells and sickle cell disease mice

Sickle cell disease (SCD) results from a sequence defect in the β-globin chain of adult hemoglobin (HbA) leading to expression of sickle hemoglobin (HbS). It is traditionally diagnosed by cellulose-acetate hemoglobin electrophoresis or high-performance liquid chromatography. While clinically useful, these methods have both sensitivity and specificity limitations. We developed a novel mass spectrometry (MS) method for the rapid, sensitive and highly quantitative detection of endogenous human β-globin and sickle hβ-globin, as well as lentiviral-encoded therapeutic hβAS3-globin in cultured cells and small quantities of mouse peripheral blood. The MS methods were used to phenotype homozygous HbA (AA), heterozygous HbA–HbS (AS) and homozygous HbS (SS) Townes SCD mice and detect lentiviral vector-encoded hβAS3-globin in transduced mouse erythroid cell cultures and transduced human CD34⁺ cells after erythroid differentiation. hβAS3-globin was also detected in peripheral blood 6 weeks post-transplant of transduced Townes SS bone marrow cells into syngeneic Townes SS mice and persisted for over 20 weeks post-transplant. As several genome-editing and gene therapy approaches for severe hemoglobin disorders are currently in clinical trials, this MS method will be useful for patient assessment before treatment and during follow-up.     

Recent advances in bone marrow transplantation in hemoglobinopathies

Allogeneic hematopoietic cell transplantation (HCT) is currently the only treatment with curative potential for sickle cell disease (SCD) and beta-thalassemia. HCT was first used to treat SCD and thalassemia more than two decades ago, and with increasing experience this treatment modality has shifted from being an experimental intervention to one in which selected patient populations are targeted for treatment. Recent multicenter clinical studies show an event-free survival (EFS) of 85% after human leukocyte antigen (HLA)-identical sibling transplantation for SCD, using conventional myeloablative conditioning with a backbone of busulfan (BU) and cyclophosphamide (CY) [1-3]. Results of HCT for thalassemia show very similar outcomes, with EFS probabilities that range from 81%-87% [4,5]. However, the risk of graft failure, recurrent disease, graft-versus-host-disease (GVHD), infections, and long-term sequelae of chronic GVHD and endocrinopathies related to Fe overload and myeloablative BU limit broader application of this therapy. Non-myeloablative conditioning regimens may offer a lower risk of toxicity, and investigations to identify a regimen that is sufficiently immunosuppressive to ensure stable engraftment of donor cells are ongoing. Alternative sources of donor hematopoietic cells that include HLA-matched unrelated donor (URD) and umbilical cord blood (UCB), are being pursued for hemoglobinopathies, with promising initial results. This review discusses the successes, challenges and future direction of HCT for SCD and thalassemia.     

血红蛋白疾病基因治疗研究进展

血红蛋白疾病是由于血红蛋白分子突变造成其结构或合成异常引起的一类疾病,分为血红蛋白病和地中海贫血两大类。前者表现为血红蛋白分子的珠蛋白肽链结构异常,如镰刀状贫血;后者表现为珠蛋白肽链合成速率的降低,如β-地中海贫血。本文主要以β-地中海贫血和镰刀状贫血为例,从DNA水平、RNA水平和基因调控及干细胞移植等方面介绍血红蛋白疾病基因治疗的研究进展,并结合生命科学的最新发现,对该领域将来可能出现的新的治疗方法提出展望。     

人类珠蛋白相关基因上游开放阅读框的变异分析

β-地中海贫血症是一种珠蛋白生成障碍的常染色体隐性遗传病。而γ珠蛋白基因的开放表达和胎儿血红蛋白的合成,是缓解β地中海贫血病人临床表型的一个重要因素。本研究针对202个血红蛋白相关调控基因或miRNA,对1802个β-地中海贫血症患者进行了目标区域捕获测序。通过生物信息学的分析,检测出了所有捕获区域内的突变。进一步对位于5′端非编码区(5′untranslated region, 5′UTR)的突变进行系统扫描,共计寻找到41个影响uORF(upstream open reading frame, uORF)有或无的功能性突变。从中选取了CHTOP基因(chr1:153606541 C>T)和TGFB1基因(chr19:41859418 G>A)的两个突变,通过定点诱变和双荧光素酶报告实验,在体外证实这两个突变均可显著地改变下游基因的表达。该研究结果为β-地中海贫血症临床表型的精确诊断提供了潜在的筛查靶点。     

2型腺相关病毒转导人胎肝造血细胞及其介导的β珠蛋白基因的表达

β地中海贫血是一种因β珠蛋白基因缺陷导致的遗传性贫血性疾病,基因治疗是唯一有望治愈该病的方法.2型腺相关病毒(adeno-associated virustype2,AAV2)是一种非致病性病毒,作为一种基因治疗载体,其应用潜力日益受到关注.目前还未见AAV2转导人早期胎肝造血细胞及其介导β珠蛋白基因在动物体内表达的实验报道.有研究表明,AAV2转导人造血干细胞的效率,因各实验室包装和纯化rAAV2的方法不同而存在差异,其中辅助病毒的污染被认为是一重要原因.制备了无辅助病毒污染的rAAV2,经体外检测其滴度,纯度及功能后,再转导人早期胎肝造血细胞,将被转导的胎肝造血细胞移植入受亚致死量剂量照射的8只BALB/C裸鼠体内,检测rAAV2介导的β珠蛋白基因在裸鼠体内的表达.结果显示:制备的无辅助病毒污染的rAAV2具有较高的滴度、纯度,并能够在体外介导β基因的表达;在8只受试BALB/C裸鼠中,RT-PCR在2只BALB/C裸鼠骨髓中检测到β珠蛋白基因的表达.提示,rAAV2能够转导人早期胎肝细胞并介导β珠蛋白基因的表达,但同时也存在表达量较低的缺点,应用于β地中海贫血的基因治疗还需要对AAV2生物学特性做深入的研究.     

Taking the good out of the bad: lentiviral-based gene therapy of the hemoglobinopathies

Sickle cell disease and beta-thalassemia are excellent candidates for gene therapy since transfer of a single gene into hematopoietic stem cells should theoretically elicit a therapeutic response. Initial attempts at gene therapy of these hemoglobinopathies have proved unsuccessful due to limitations of available gene transfer vectors. With the extensive research on human immunodeficiency virus-1 due to the acquired immune deficiency syndrome pandemic, researchers have realized that this lentivirus, engineered to be devoid of any pathogenic elements, can be an effective gene transfer vector. This review discusses the gene therapy strategy for the hemoglobinopathies and outlines why lentiviral-derived vectors are particularly suited for this type of application, keeping past failures at gene therapy of these hemoglobinopathies in mind. Development, improvement, and methods for preparation of lentiviral-derived vectors are examined. Recently published results of successful gene therapy treatment of beta-thalassemic and sickle cell diseased mice using lentiviral-derived vectors are described. Finally, criticisms and future directions of lentiviral-based biotechnology are considered.     

Regulation of iron absorption in hemoglobinopathies

Beta-thalassemia and sickle cell anemia (SCD) represent the most common hemoglobinopathies caused, respectively, by deficient production or alteration of the beta chain of hemoglobin (Hb). Patients affected by the most severe form of thalassemia suffer from profound anemia that requires chronic blood transfusions and chelation therapies to prevent iron overload. However, patients affected by beta-thalassemia intermedia, a milder form of the disease that does not require chronic blood transfusions, eventually also show elevated body iron content due to increased gastrointestinal iron absorption. Even SCD patients might require blood transfusions and iron chelation to prevent deleterious and painful vaso-occlusive crises and complications due to iron overload. Although definitive cures are presently available, such as bone marrow transplantation (BMT), or are in development, such as correction of the disease through hematopoietic stem cell beta-globin gene transfer, they are potentially hazardous procedures or too experimental to provide consistently safe and predictive clinical outcomes. Therefore, studies that aim to better understand the pathophysiology of the hemoglobinopathies might provide further insight and new drugs to dramatically improve the understanding and current treatment of these diseases. This review will describe how recent discoveries on iron metabolism and erythropoiesis could lead to new therapeutic strategies and better clinical care of these diseases, thereby yielding a much better quality of life for the patients.     

Association of Xmn1 −158 γG variant with severity and HbF levels in β-thalassemia major and sickle cell anaemia

Haemoglobinopathies including β-thalassemia and sickle cell anaemia (SCA) are considered to be classical monogenic diseases. There is considerable clinical variability between patients inheriting identical β-globin mutations. The reasons for this variability are not well understood. Previous studies have suggested that a variety of genetic determents influence different clinical phenotypes. The genetic variants that modulate HbF levels have a very strong impact on ameliorating the clinical phenotype. In the present study 6,500 blood samples from suspected cases were analysed using HPLC, ARMS-PCR, RDB techniques. Patients with β-thalassemia and SCA were classified into mild, moderate, severe according to the severity score based on Hb levels, age of onset, age at which patients received their first blood transfusion, the degree of growth retardation and splenectomy. Patients with β-thalassemia and SCA were analysed for Xmn1 polymorphism and association between this polymorphism and severity of β-thalassemia and SCA was evaluated. We found a significant difference in genotypic and allelic frequencies of Xmn1 polymorphism between mild and moderate and mild and severe cases. There was a significant difference in high and low percentage of HbF in CC, CT and TT bearing individuals. The TT bearing individuals were found to have a high percentage of HbF in β-thalassemia as well as SCA. This study confirms that increased γ^G-globin expression associated with Xmn1 polymorphism ameliorates the clinical severity in β-thalassemia as well as SCA in the study population.     

Design,synthesis, and optimization of a series of 2-azaspiro[3.3]heptane derivatives as orally bioavailable fetal hemoglobin inducers

Pharmacological reactivation of the γ-globin gene for the production of fetal hemoglobin (HbF) is a promising approach for the management of β-thalassemia and sickle cell disease (SCD). We conducted a phenotypic screen in human erythroid progenitor cells to identify molecules that could induce HbF, which resulted in identification of the hit compound 1. Exploration of structure–activity relationships and optimization of ADME properties led to 2-azaspiro[3.3]heptane derivative 18, which is more rigid and has a unique structure. In vivo using cynomolgus monkeys, compound 18 induced a significant dose-dependent increase in globin switching, with developable properties. Moreover, compound 18 showed no genotoxic effects and was much safer than hydroxyurea. These findings could facilitate the development of effective new therapies for the treatment of β-hemoglobinopathies, including SCD.     

Plasma levels of TGF-β1 in homeostasis of the inflammation in sickle cell disease

Sickle cell disease (SCD) represents a chronic inflammatory condition with complications triggered by the polymerization of hemoglobin S (Hb S), resulting in a series of cellular interactions mediated by inflammatory cytokines, as the transforming growth factor beta (TGF-β), which plays an important role in inflammation resolution. This study assessed the relation between SCD inflammation and the plasma concentration of TGF-β1, and also checked the influence of the presence of −509C/T polymorphism in TGFB1 gene on TGF-β1 plasma values. The plasma levels of TGF-β1 were quantified by ELISA in 115 patients with SCD (genotypes SS, SD-Los Angeles, Sβ-thalassemia and SC) and in 58 individuals with no hemoglobinopathies (Hb AA), as the control group. The −509C/T polymorphism in TGFB1 gene was screened by PCR-RFLP. The correlation between TGF-β1 plasma levels and the inflammation was based on its association with the count of platelets, total white blood cells (WBC) and neutrophils in the peripheral blood. Patients with SCD showed plasma levels of TGF-β1 higher than the control group, especially the Hb SS genotype, followed by the group with Hb SD. Polymorphism investigation showed no interference in the values obtained for the cytokine in the groups evaluated. All SCD groups showed TGF-β1 levels positively correlated to the platelets and WBC counts. The original data obtained in this study for SCD support the involvement of TGF-β1 in regulating of the inflammatory response and suggest that this marker possibly may become a potential therapeutic target in the treatment of the disease.     

Targeted vectors for gene therapy of cancer and retroviral infections

Gene therapy has developed to a technology which rapidly moved from the laboratory bench to the bedside in the clinic. This implies safe, efficient and targeted gene transfer systems for suitable application to the patient. Beside the development of such gene transfer vectors of viral or nonviral origin, improvement of cell type specific and inducible gene expression is pivotal for successful gene therapy leading to targeted gene action. Numerous gene therapy approaches for treatment of cancer and retroviral infections utilize cell type specific and/or regulatable promoter and enhancer sequences for the selective expression of therapeutic genes in the desired cell populations and tissues. In this article the recent developments and the potential of expression targeting are reviewed for gene therapy approaches of cancer and retroviral infections.     

广西地中海贫血112例临床分析

目的通过对广西112例地中海贫血病例的回顾性分析,了解地中海贫血患者的临床特点、治疗现状和并发症。方法用回顾性分析方法对广西112例地中海贫血患者(α中间型16例,β中间型30例,β重型66例)的临床特点、治疗现状和并发症进行分析。结果 (1)52例β重型地贫患者和所有需长时间频繁输血的中间型地贫患者输血前Hb90g/L。(2)不规范祛铁治疗的β中间型和β重型患者分别为84.0%和89.8%。(3)112例患者中,74例(67.9%)存在铁过载,2例α中间型,19例β中间型,53例β重型。(4)2例β中间型和1例β重型患者曾发生心力衰竭;2例β重型患者有继发性糖尿病;17例β中间型和46例β重型患者身材矮小,身材矮小与铁蛋白、输血前血红蛋白量相关(r=0.336,P0.001;r=-0.243,P=0.011)。结论本组β中间型地贫和β重型地贫患者输血和去铁治疗不规范,铁过载严重,身材矮小、心力衰竭等并发症发生率高。