Cell mediated gene therapy for muscular dystrophy: steps towards clinical efficacy.

Lead Research Organisation: University of Manchester
Department Name: Medical and Human Sciences

Abstract

This research aims to optimise a treatment that was recently tested in patients affected by Duchenne muscular dystrophy and extend it to another rare genetic diseases of the muscle, so that one strategy may in the future be adapted for more diseases.
Muscular dystrophies are caused by mutations in a single gene that leads to the impairment of function and death of muscles in the human body. This in turn causes disability of variable severity that, in the worse cases, are devastating; compromising quality of life and leading to a premature death. Although individual muscular dystrophies are rare or extremely rare, together they affect many thousands of people and represent a major challenge for National Health Services, in charge of providing palliative therapies and medical assistance, often over decades.
In order to "cure" genetic diseases it is necessary to replace or repair the defective gene and this can be achieved by using viral vectors (viruses that have been modified in the lab to deliver a correct version of the gene into cells) or stem cells (cells which can be used to generate any other type of cell in the body). To make sure they're accepted by the body, stem cells can be derived from a related donor (e.g. a sibling) or from the patient themselves, after having been "repaired" in the lab. These therapies have been successful so far for several genetic diseases affecting the blood, the skin, and the cornea. This has been possible because it is relatively easy to remove the diseased tissue and replace it. This approach is not possible for diseases affecting the heart, the liver or the brain. In these cases, healthy cells will have to correct the genetic defect and somehow help the function of the resident diseased cells.
The innovative aspect of our treatment is based on the fact that stem cells which are injected into the arteries of patients end up distributed uniformly throughout the body. Some of these stem cells can then cross out of the blood vessel, move into the surrounding tissue of the body and eventually repair it. However, the process is not yet efficient enough to result in a noticeable improvement in patients. In order to achieve this, we will study in detail each step of the transplantation procedure through a number of culture system using human stem cells. The successful completion of the research programme will rapidly lead to new clinical trials and then may be extended to more rare genetic diseases of muscle, increasing the benefit to patients.

Technical Summary

This proposal aims to reach clinical efficacy with stem-cell mediated gene therapy for Muscular Dystrophies (MD). The PI completed a phase I/IIa trial based upon intra-arterial delivery of HLA-matched donor mesoangioblasts (Mabs), vessel-associated myogenic progenitors. Since these cells can cross the vessel wall in the presence of inflammation, they can be evenly distributed to downstream muscles, an essential condition for diffuse forms of MD. The trial was safe but not efficacious (especially in comparison with pre-clinical models) for a number of reasons such as the advanced stage of the disease in older patients, the moderate ability of stem cells to engraft and, consequently the need to produce the wt copy of the mutated gene also for the vast majority of resident cells. To address these issues, we will optimise each step of the transplantation protocol with human Mabs (adhesion to the endothelium, migration, fusion with regenerating fibres and finally over-production of the therapeutic gene product) with a number of in vitro assays that will allow to monitor dynamically and at the single cell level the behaviour of human Mabs. We will test different experimental strategies to enhance each of these processes in a fast and reliable way that will also allow to reduce animal experimentation only to these strategies that will have proven efficacious in vitro. Preliminary evidence indicate that at least binding to the endothelium and amplification of dystrophic production may be increased several fold thus strongly supporting feasibility. If successful, this project will set the basis for a rapid clinical translation of autologous, genetically corrected cells in younger dystrophic patients aiming at arresting or significantly delaying the progress of the disease.

Planned Impact

The first beneficiaries of this programme will be patients affected by genetic, recessive, muscular dystrophies. In the future also patients affected by other rare genetic diseases of the mesoderm, may benefit from this therapeutic approach, if successful. It is important to stress that many recessive genetic diseases of the mesoderm are so rare that they will unlikely become the target of a specific research programme aimed at finding a possible therapy. The important added value of this project is a "one serves all" strategy, though of course adjustments will have to be made for each specific disease. However having available a common platform will dramatically cut time and costs for these patients that currently receive only palliative therapies and together present a major burden for the National Health System.
Patient associations may also benefit from this work and eventually decide to be involved in co-sponsoring further programmes and developments, as is already happening in the case of muscular dystrophy.
Beside Academic beneficiaries, students, training medical doctors, nurses and medical personnel in general may be involved and benefit for the future clinical translation of this therapeutic strategy. Moreover, although the programme is developed for rare disease that usually elicit a modest interest in companies, the possibility of applying intra-arterial delivery to MSC therapies that currently employ intra-venous injection, may significantly improve their efficacy and attract their interest, as most of these trials are sponsored by SME.
If successful this project should elicit the interest of policy-makers in the National Health Systems, both nationally and internationally for the possible adoption of new medical therapies, that, although associated with a very high cost, would lead, if successful to a dramatic reduction of the current costs related to long-term palliative treatments, medical, surgical and rehabilitation assistance. Last and most important, recovery of patient to at least partially normal and productive life will bear an additional advantage both in ethical and economic terms.
 
Title La trama della vita (The frame of life). Marsilio editor. 
Description Living forever is a long-lasting dream, present in many novels, paintings and musical pieces. Who knows whether this dream may one day come true? Regenerative medicine, the topic of the book, promises not only to cure terrible and so far incurable diseases, but also to repair or replace our cells and tissues so that, in theory, we may live "forever young and healthy". Do we really want this? Moreover, for few spectacular successes, there have been many more failures. Nevertheless, the expectations raised in patients have been exploited by commercially driven "stem cell clinics" that offer to cure any disease with stem cells in exchange for much money. These and other topics such as the impact on society and health economics are discussed in this book. 
Type Of Art Creative Writing 
Year Produced 2018 
Impact The book, currently in Italian, explains to a lay audience promises and problems of regenerative medicine and its impact on society. The book was sold out and is currently a finalist for the Galieo prize for scientific outreach. 
 
Description Fifth Meeting of the World Congress for Freedom of Scientific Research, Brussels, 11-13 of April 2018
Geographic Reach Multiple continents/international 
Policy Influence Type Implementation circular/rapid advice/letter to e.g. Ministry of Health
 
Description Lancet Commission: "Stem Cell and Regenerative Medicine", corresponding author
Geographic Reach Multiple continents/international 
Policy Influence Type Influenced training of practitioners or researchers
URL https://www.researchgate.net/publication/318082230_Lancet_Commission_Stem_Cells_and_Regenerative_Med...
 
Description Organization of a joint workshop (Brussels 26 April 2019) of EASAC (European Academies of Science Advisory Council) and FEAM (Federation of European Medical Academies) Regenerative medicine project proposal scoping paper
Geographic Reach Europe 
Policy Influence Type Implementation circular/rapid advice/letter to e.g. Ministry of Health
 
Description Particpation in the Advisory Board of the Departement of Biomedicine, University of Basel (17-19.01.19)
Geographic Reach Europe 
Policy Influence Type Participation in a advisory committee
 
Description Biomedical Catalyst
Amount £228,109 (GBP)
Funding ID MR/P016006/1 
Organisation Medical Research Council (MRC) 
Sector Public
Country United Kingdom
Start 03/2017 
End 02/2019
 
Description Recreating the ideal niche: environmental control of cell identity in regenerating and diseased muscles
Amount € 3,482,746 (EUR)
Funding ID EC H2020-MSCA-ITN-2019-860034 
Organisation European Commission 
Sector Public
Country European Union (EU)
Start 04/2020 
End 03/2024
 
Title A clinical trial on chip: a simple, cheap and reliable method to predict efficacy of a new therapy. 
Description We observed that co-cultures of myotubes and motoneurones have been used since decades and promote mytoube maturation in vitro via both electrical and chemical signals. We recently used E11 mouse embryonic motonerones to innervate cultures of adult human myotubes in a ECM gel. To our surprise we observed that within 24 hours from the establishment of synaptic connections, cultures were rhythmically and vigorously twitching, something that should not occur with a fully mature synapsis, where contraction only occurs upon motoneuron stimulation. This creates a stressful situation that leads to death and detachment of all DMD myotubes within the next 24h while healthy myotubes continue to twitch for another 3-4 days. Remarkably, DMD myotubes, genetically corrected with a small nuclear RNA (U7) engineered to skip exon 51 of the dystrophin gene, behaved as healthy myotubes, thus showing that this method reveals phenotypic conversion that revert the dystrophic phenotype. We want to develop and standardise this method, test a number of pilot therapies (e.g. steroids) to offer this tool to the scientific community. 
Type Of Material Biological samples 
Year Produced 2018 
Provided To Others? No  
Impact In these years many clinical trials have been carried out for Duchenne Muscular Dystrophy. Unfortunately they are very expensive, time consuming and so far have not provided a clear indication of efficacy, though many showed promise that they may lead to efficacy but, again after much time and money. This tool aims at developing a clinical trial on chip to offer a simple, reliable and cheap tool to predict the effect of a given therapeutic strategy. 
 
Description In vivo trasplantation of mesoangioblasts in steroid treated dystrophic mice 
Organisation University of Bari
Department Department of Biosciences, Biotechnology and Pharmacological Sciences
Country Italy 
Sector Academic/University 
PI Contribution We have completed experiments on the binding of mesoangioblasts on endothelium in the presence or absence of inflammation. We now need to complete experiments in vivo on dystrophic mice subjected to different anti-inflammatory regimes. To this end we will send cells to our collaborators and they will transplant and study the mice.
Collaborator Contribution Prof. Anna Maria De Luca, University of Bari, is an internationally recognised molecular pharmacologist with a long expertise in muscular dystrophy. Ornella Cappellari, senior post-doc has a part time appointemt in Bari and in Manchester. She has been trained i microsurgery technicques in the laboratory of Prof. Dominic Wells at the Royal Veterinary College.
Impact The collaboration has just started. It will result in ajoint publication.
Start Year 2019
 
Description Intra-arterial catheterization for systemic mesoangioblasts delivery to dystrophic rats 
Organisation Manchester University
Country United States 
Sector Academic/University 
PI Contribution We have imported a rat model of DMD, generated by genome editing and carrying a deletion of exon 52 of the dystrophin gene. To test whether this can be corrected in vivo by DMD, genetically corrected rat mesoangioblasts.
Collaborator Contribution Dr. Jason Wong, an experienced clinical and experimental microsurgeon will conduct catheterisms in the rat, possible at variance with mice, but still extremely demanding, to test distributon, engraftment and gene tici correction of cell mediated gene therapy.
Impact A joint publication will be submitted as a result of this collaboration.
Start Year 2018
 
Title Mesoangioblast-based gene therapy for Duchenne Muscular Dystrophy: a phase I/IIa study/DMD04 
Description Mesoangioblast-mediated exon 51 skipping for genetic correction of dystrophin, based upon a single injection in individual skeletal muscles of five non-ambulant patients affected by Duchenne Muscular Dystrophy: a non randomized, open-label, phase I/IIa study. We are testing safety of genetically corrected autologous mesoangioblasts by intramuscular injection in a foot muscle (Extensor digitorum brevis) of 5 non-ambulant DMD patients. Mesoangioblats were corrected with a lentivral vector expressing the U7 small nuclear RNA (snRNA) engineered to skip exon 51 of the dystrophin gene. The snRNA diffuses to neighbouring resident nuclei of the dystrophin muscle fibre thus amplifying the therapeutic effect. In case of dystrophin production = 10% of a healthy muscle, cells will also be injected in the thumb muscle, whose increased force of contraction would ameliorate the quality of patients' life. The Wellcome Trust HICF funded this first in man clinical trial that is expected to start in Manchester in 2020. 
Type Therapeutic Intervention - Cellular and gene therapies
Current Stage Of Development Early clinical assessment
Year Development Stage Completed 2020
Development Status Under active development/distribution
Impact If successful, this trial will pave the way to systemic distribution of autologous genetically corrected mesoangioblasts in young patients. This would be a subsequent trial with intent to cure. 
 
Description 2018 Spring Conferenceof the British Society of Gene and Cell Therapy, London 27 April 2018. 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact The meeting in April focused on "Lentiviral and other retroviral vectors in 2018: Applications, production and vector design relevant for translation into human".
Year(s) Of Engagement Activity 2018
 
Description A conference of gene and cell therapy to high school students 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Schools
Results and Impact The conference, organised in Rome, by the Accademia dei LIncei, was directed to students from many high school in Rome to explain the, what cell and gene therapy are and how they are changing modern medicine.
Year(s) Of Engagement Activity 2017
URL http://www.lincei.it/modules.php?name=Convegni&file=lista
 
Description Annual Meeting of the Manchester Network of Regenerative Medicine. Manchester 26 Febriary 2019 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Professional Practitioners
Results and Impact This is an annual meeting of the Manchester Network of Regenerative Medicine. Manchester. In this meeting there are long and short talks (I delivered a long talk while my post-doc Francesco Galli a short one) on regenerative medicine. The meeting is attended by researchers, clinicians and students.
Year(s) Of Engagement Activity 2019
 
Description European Society of Cell and Gene Therapy 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Postgraduate students
Results and Impact The 25th Anniversary Congress of the ESGCT took place in Berlin, Germany, at the bcc Berlin, in collaboration with the German Society for Gene Therapy DG-GT.
Year(s) Of Engagement Activity 2017
URL https://www.esgct.eu/Congress/Previous-congresses/congress-berlin-2017.aspx
 
Description Hydra XII Summer School 2017, 11-17.09.2017, Hydra, Greece 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Postgraduate students
Results and Impact An international Summer School with leading speakers in the stem cells field and approximately 50 students, mainly PhD students and post-docs, from all over the world.
Year(s) Of Engagement Activity 2017
URL https://www.eurostemcell.org/events/registration-hydra-xiii-summer-school-stem-cells-and-regenerativ...
 
Description Oragnization of a joint workshop (Brussels 26 April 2019) of EASAC (European Academies of Science Advisory Council) and FEAM (Federation of European Medical Academies) Regenerative medicine project proposal scoping paper 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact Regenerative medicine refers to approaches that aim to replace or regenerate human cells, tissues or organs, to restore or establish normal function. New approaches may have great potential to tackle untreatable diseases and ageing populations and to reduce medical costs (European Commission, 2018) but, so far, regenerative medicine has not proved itself in the clinic more widely than some specific indications. However, enthusiasm about breadth of applications has led to gaps between expectations, often inflated by media reports, and the realities of translating regenerative medicine technologies into clinical practice. A combination of poor-quality science, unrealistic hopes and unscrupulous private clinics threatens the potential of regenerative medicine (Cossu et al, The Lancet, 2018).
Year(s) Of Engagement Activity 2018,2019
 
Description XVII INTERNATIONAL CONFERENCE ON DUCHENNE AND BECKER MUSCULAR DYSTROPHY 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Patients, carers and/or patient groups
Results and Impact This is an annual international meeting of Duchenne Parent Project (Italy) dedicated to children with DMD and their parents. In these meetings leading scientists and clinicians present the results of ongoing research work and clinical trials.
Year(s) Of Engagement Activity 2019