Phase I/II clinical trial evaluating AAV-mediated gene therapy for a severe paediatric metabolic liver disease: Ornithine Transcarbamylase deficiency

Lead Research Organisation: University College London
Department Name: Institute of Child Health

Abstract

Ornithine transcarbamylase deficiency (OTCD) is a rare X-linked genetic disorder characterized by complete or partial lack of the enzyme ornithine transcarbamylase (OTC). OTC is a key element of the urea cycle, whereby the liver breaks down and removes surplus nitrogen from the body. OTCD patients accumulate nitrogen in the form of excess ammonia (hyperammonemia) in the blood. Ammonia is toxic and patients suffer 'hyperammonaemic decompensations' with symptoms including vomiting, impaired voluntary movement, and progressive lethargy. If left untreated these may progress to coma and life-threatening complications.
Symptoms present within a few days of birth of males with severe OTCD. As well as significant risk of mortality, the neurotoxic effects of excess ammonia result in longer-term neurological abnormalities such as intellectual disability, developmental delays, and cerebral palsy. As with milder forms of this disease (which may present later in both male and female children and adults), infants are managed with ammonia-scavenging drugs and dietary intervention, however hyperammonaemic decompensations still occur.
Neonatal-onset OTCD patients require liver transplantation (LT) for long-term survival. Whilst LT can be life-saving, opportunity for this intervention remains limited and not without risk of mortality and morbidity. Advances have been made in surgical practices to facilitate access to donor liver tissue, including 'living-donor partial liver grafts' and 'reduced-liver transplantation' whereby infants and children receive a portion of an adult liver. However, both the patient and their family still remain with the challenge of life-long immunosuppression and medical follow-up. European guidelines recommend LT for those patients with severe phenotype, aged between 3 and 12 months as neonatal transplant in such metabolically unstable patients is considered too great a risk. Of 15 paediatric OTCD patients transplanted in the UK this past decade, there were only 4 of this age. All others were over 3 years old and all had long-term neurological impairment.
We have developed an Adeno associated virus (AAV)-based gene therapy (AAV-LK03-OTC) to specifically target the liver and restore functional expression of OTC. Our approach encompasses the single administration of gene therapy to OTCD infants to provide immediate normalisation of liver metabolism, thereby reducing acute risk of mortality from hyperammonaemic decompensations. Such treatment would serve as a 'bridge-to-transplant' enabling paediatric patients to continue to grow in a metabolically stable condition until such time that transplantation is possible, also minimising longer-term neurological morbidity associated with hyperammonaemia.
Our laboratory experiments have demonstrated the enhanced ability of AAV-LK03-OTC to target liver cells over other AAV, and to elicit elevated expression of functional OTC. We have demonstrated that AAV-LK03-OTC restores liver function in experimental mouse models of this genetic disease and are currently testing the safety of AAV-LK03-OTC in animal studies. Recent success with other viral gene therapies advanced to early clinical trials (e.g. AAV8 for Haemophilia B) and the increased targeting to liver cells (AAV-LK03 >10-fold more transformation of liver cells than AAV8) reinforce confidence in this approach as being safe.
We will now translate our pre-clinical findings to conduct a Phase I/II dose-finding clinical trial assessing the safety and efficacy of AAV-LK03-OTC. As children are the OTCD population with greatest unmet need, we aim to recruit 12 paediatric patients in the UK to provide early clinical data for later stage development and commercialisation of this transformative advanced therapy. This project aims to deliver a step-change in the clinical management of paediatric OTCD patients and provide critical gene therapy evidence applicable to many other liver-inherited metabolic diseases.

Technical Summary

The urea cycle is an essential pathway in the liver for the detoxification of ammonia, produced by the breakdown of proteins. Urea cycle defects (UCD) have high rates of mortality and morbidity. Ornithine Transcarbamylase deficiency (OTCD) is the most common inherited UCD (60% total) and in severe cases, symptoms present early in newborns progressing to coma and death if untreated. Patients are managed with ammonia-scavenging drugs and dietary intervention, however acute hyperammonaemic decompensations still occur with significant mortality and compromised neurological development.
Paediatric OTCD patients require liver transplant for long-term survival, curing UCD but itself carrying significant risk and need for lifelong immunosuppression. We have developed an Adeno-associated viral-based gene therapy (AAV-LK03-OTC) to specifically target the liver and restore functional expression of Ornithine Transcarbamylase. Our approach of single administration of viral gene therapy provides immediate normalisation of liver metabolism thereby reducing risk of both acute mortality and longer-term neurological morbidity thus protecting neonatal patients waiting to undergo liver transplant.
We are testing the safety of AAV-LK03-OTC in studies in animal studies. Recent success of other viral gene therapies advanced to early clinical trials (e.g. AAV8 for Haemophilia B) and the increased targeting to liver cells (AAV-LK03 >10-fold more transformation of hepatocytes than AAV8) reinforce the potential of this approach as a safe and effective therapy. We will now translate our pre-clinical findings to conduct a Phase I/II dose-finding clinical trial assessing the safety and efficacy of AAV-LK03-OTC. As children are the OTCD population with greatest unmet need, we will recruit 12 paediatric patients in the UK to provide early clinical data for later stage development and commercialisation of this transformative advanced therapy.

Planned Impact

This work aims to progress a new gene therapy treatment for children with an inherited metabolic disease of the liver (termed OTCD). New born patients with the disease are at high risk of mortality and suffer long-term neurological complications. Liver transplantation is the only current cure for this disease, however this option requires the children to grow and stabilise sufficiently (typically to over 3 years old in the UK), worsening the risk of life-threatening symptoms and long-term neurological impairment.

We have developed a liver-targeting viral gene therapy for OTCD which we aim to test for safety and efficacy initially in older children (i.e. 6-16 year old), before treating neonatal patients. This project represents the next step to address the unmet clinical need for a 'bridge-to-transplant' for paediatric OTCD patients, providing a transformative change to the clinical care and outcomes for these children, as well as providing critical gene therapy evidence applicable to many other liver-inherited metabolic diseases.

Publications

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Title Innovations in gene therapy for the treatment of OTC deficiency 
Description In collaboration with SciAni we created an animation that describes this project. It is posted on YouTube and targets general population. 
Type Of Art Film/Video/Animation 
Year Produced 2019 
Impact The movie has been seen by >1000 viewers. 
URL https://www.youtube.com/watch?v=kdHEKXaLnps
 
Description Children's Hospital of Philadelphia 
Organisation Children's Hospital of Philadelphia
Country United States 
Sector Hospitals 
PI Contribution This is a collaboration on gene therapy in OTC Deficiency. We provide the clinical trial expertise to this collaboration.
Collaborator Contribution The partners provide expertise in gene therapy vector generation.
Impact Partner contributes to the project on gene therapy in urea cycle disorders
Start Year 2017
 
Description Sydney University, Australia 
Organisation University of Sydney
Department Central Clinical School
Country Australia 
Sector Hospitals 
PI Contribution We are collaborating with Professor Alexander on the liver directed gene therapy project. We have a joint grant from the MRC DPFS where I am the PI and Prof Alexander is the co-PI. My group's contribution is the expertise in running clinical trial in rare paediatric diseases.
Collaborator Contribution Prof Alexander's group have the expertise in adeno associated vectors and specifically vector design for gene therapy in urea cycle disorders.
Impact 2 grants: NHMRC grant to Prof Alexander where I am a co-PI and the MRC DPFS grant currently.
Start Year 2014
 
Description Workshop on Gene therapies in Inherited Metabolic Disorders for Metabolic Support UK patient organisation 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Patients, carers and/or patient groups
Results and Impact With colleagues: Dr John Counsell, Dr Julien Baruteau, Prof Nick Greene and Prof Simon Waddington we engaged with Metabolic Support UK in order to organise a 2 hour webinar-style workshop on gene therapies for metabolic disorders. The webinar was well attended by the families and a small number of health professionals.
Year(s) Of Engagement Activity 2020
URL https://www.metabolicsupportuk.org/gene-therapy-webinar/