Patent Application
20160058889
1. Field
The present disclosure relates to the fields of molecular biology, medicine and genetics. More particularly, the disclosure relates to the use of genome editing to treat Duchenne muscular dystrophy (DMD).
2. Related Art
Duchenne muscular dystrophy (DMD) is caused by mutations in the gene for dystrophin on the X chromosome and affects approximately 1 in 3,500 boys. Dystrophin is a large cytoskeletal structural protein essential for muscle cell membrane integrity. Without it, muscles degenerate, causing weakness and myopathy (Fairclough et al., 2013). Death of DMD patients usually occurs by age 25, typically from breathing complications and cardiomyopathy. Hence, therapy for DMD necessitates sustained rescue of skeletal, respiratory and cardiac muscle structure and function. Although the genetic cause of DMD was identified nearly three decades ago (Worton et al., 1988), and several gene- and cell-based therapies have been developed to deliver functional Dmd alleles or dystrophin-like protein to diseased muscle tissue, numerous therapeutic challenges have been encountered and no curative treatment exists (Van Deutekom and Van Ommen, 2003).
RNA-guided nucleases-mediated genome editing, based on Type II CRISPR (Clustered Regularly Interspaced Short Palindromic Repeat)/Cas (CRISPR Associated) systems, offers a new approach to alter the genome (Jinek et al., 2012; Cong et al., 2013 and Mali et al., 2013a). In brief, Cas9, a nuclease guided by single-guide RNA (sgRNA), binds to a targeted genomic locus next to the protospacer adjacent motif (PAM) and generates a double-strand break (DSB). The DSB is then repaired either by non-homologous end joining (NHEJ), which leads to insertion/deletion (indel) mutations, or by homology-directed repair (HDR), which requires an exogenous template and can generate a precise modification at a target locus (Mali et al., 2013b). Unlike other gene therapy methods, which add a functional, or partially functional, copy of a gene to a patient's cells but retain the original dysfunctional copy of the gene, this system can remove the defect. Genetic correction using engineered nucleases (Urnov et al., 2005; Ousterout et al., 2013; Osborn et al., 2013; Wu et al., 2013 and Schwank et al., 2013) has been demonstrated in tissue culture cells (Schwank et al., 2013) and rodent models of rare diseases (Yin et al., 2014), but not yet in models of relatively common and currently incurable diseases, such as DMD.
Thus, in accordance with the present disclosure, there is provided a method of correcting a dystrophin gene defect in a subject comprising contacting a cell in said subject with Cas9 and a DMD guide RNA. The cell may be a muscle cell, a satellite cell, or an iPSC/iCM. The Cas9 and/or DMD guide RNA may be provided to said cell through expression from one or more expression vectors coding therefor, such as a viral vector (e.g., an adeno-associated viral vector) or a non-viral vector. The Cas9 may be provided to said cell as naked plasmid DNA or chemically-modified mRNA. The method may further comprise contacting said cell with a single-stranded DMD oligonucleotide to effect homology directed repair. The method may further comprise designing a dystrophin gene target based on reference to a Duchenne mutation database, such as the Duchenne Skipper Database.
The Cas9, DMD guide RNA and/or single-stranded DMD oligonucleotide, or expression vectors coding therefor, may be provided to said cell in one or more nanoparticles. The Cas9, DMD guide RNA and/or single-stranded DMD oligonucleotide may be delivered directly to a muscle tissue, such as tibialis anterior, quadricep, soleus, diaphragm or heart. The Cas9, DMD guide RNA and/or single-stranded DMD oligonucleotide may be delivered systemically. The correction may be permanent skipping of a mutant exon or more than one exon. The subject may exhibit normal dystrophin-positive myofibers and/or mosaic dystrophin-positive myofibers containing centralized nuclei. The subject may exhibit a decreased serum CK level as compared to a serum CK level prior to contacting. The treated subject may exhibit improved grip strength as compared to a serum CK level prior to contacting.
It is contemplated that any method or composition described herein can be implemented with respect to any other method or composition described herein.
Other objects, features and advantages of the present disclosure will become apparent from the following detailed description. It should be understood, however, that the detailed description and the specific examples, while indicating specific embodiments of the disclosure, are given by way of illustration only, since various changes and modifications within the spirit and scope of the disclosure will become apparent to those skilled in the art from this detailed description.
The following drawings form part of the present specification and are included to further demonstrate certain aspects of the present disclosure. The disclosure may be better understood by reference to one or more of these drawings in combination with the detailed description of specific embodiments presented herein.
The patent or application file contains at least one drawing executed in color. Copies of this patent or patent application publication with color drawing(s) will be provided by the Office upon request and payment of the necessary fee.
Duchenne muscular dystrophy, like many other diseases of genetic origin, present challenging therapeutic scenarios. Recently, the development of “gene editing” has increased the ability to correct genetic effects in cells. The following disclosure describes the use of the CRIPSR/Cas9 system to edit the genomes of cells carrying defects in the dystrophin gene using either non-homologous end joining (NHEJ), resulting in insertion/deletion (indel) mutations, or by homology-directed repair (HDR), that generates a precise modification at a target locus. These and other aspects of the disclosure are set out in detail below.
A. Background
Duchenne muscular dystrophy (DMD) is a recessive X-linked form of muscular dystrophy, affecting around 1 in 3,500 boys, which results in muscle degeneration and premature death. The disorder is caused by a mutation in the gene dystrophin, located on the human X chromosome, which codes for the protein dystrophin. Dystrophin is an important component within muscle tissue that provides structural stability to the dystroglycan complex (DGC) of the cell membrane. While both sexes can carry the mutation, females are rarely affected with the skeletal muscle form of the disease.
B. Symptoms
Symptoms usually appear in boys between the ages of 2 and 3 and may be visible in early infancy. Even though symptoms do not appear until early infancy, laboratory testing can identify children who carry the active mutation at birth. Progressive proximal muscle weakness of the legs and pelvis associated with loss of muscle mass is observed first. Eventually this weakness spreads to the arms, neck, and other areas. Early signs may include pseudohypertrophy (enlargement of calf and deltoid muscles), low endurance, and difficulties in standing unaided or inability to ascend staircases. As the condition progresses, muscle tissue experiences wasting and is eventually replaced by fat and fibrotic tissue (fibrosis). By age 10, braces may be required to aid in walking but most patients are wheelchair dependent by age 12. Later symptoms may include abnormal bone development that lead to skeletal deformities, including curvature of the spine. Due to progressive deterioration of muscle, loss of movement occurs, eventually leading to paralysis. Intellectual impairment may or may not be present but if present, does not progressively worsen as the child ages. The average life expectancy for males afflicted with DMD is around 25.
The main symptom of Duchenne muscular dystrophy, a progressive neuromuscular disorder, is muscle weakness associated with muscle wasting with the voluntary muscles being first affected, especially those of the hips, pelvic area, thighs, shoulders, and calves. Muscle weakness also occurs later, in the arms, neck, and other areas. Calves are often enlarged. Symptoms usually appear before age 6 and may appear in early infancy. Other physical symptoms are:
A positive Gowers' sign reflects the more severe impairment of the lower extremities muscles. The child helps himself to get up with upper extremities: first by rising to stand on his arms and knees, and then “walking” his hands up his legs to stand upright. Affected children usually tire more easily and have less overall strength than their peers. Creatine kinase (CPK-MM) levels in the bloodstream are extremely high. An electromyography (EMG) shows that weakness is caused by destruction of muscle tissue rather than by damage to nerves. Genetic testing can reveal genetic errors in the Xp21 gene. A muscle biopsy (immunohistochemistry or immunoblotting) or genetic test (blood test) confirms the absence of dystrophin, although improvements in genetic testing often make this unnecessary.
C. Causes
Duchenne muscular dystrophy (DMD) is caused by a mutation of the dystrophin gene at locus Xp21, located on the short arm of the X chromosome. Dystrophin is responsible for connecting the cytoskeleton of each muscle fiber to the underlying basal lamina (extracellular matrix), through a protein complex containing many subunits. The absence of dystrophin permits excess calcium to penetrate the sarcolemma (the cell membrane). Alterations in calcium and signalling pathways cause water to enter into the mitochondria, which then burst.
In skeletal muscle dystrophy, mitochondrial dysfunction gives rise to an amplification of stress-induced cytosolic calcium signals and an amplification of stress-induced reactive-oxygen species (ROS) production. In a complex cascading process that involves several pathways and is not clearly understood, increased oxidative stress within the cell damages the sarcolemma and eventually results in the death of the cell. Muscle fibers undergo necrosis and are ultimately replaced with adipose and connective tissue.
DMD is inherited in an X-linked recessive pattern. Females will typically be carriers for the disease while males will be affected. Typically, a female carrier will be unaware they carry a mutation until they have an affected son. The son of a carrier mother has a 50% chance of inheriting the defective gene from his mother. The daughter of a carrier mother has a 50% chance of being a carrier and a 50% chance of having two normal copies of the gene. In all cases, an unaffected father will either pass a normal Y to his son or a normal X to his daughter. Female carriers of an X-linked recessive condition, such as DMD, can show symptoms depending on their pattern of X-inactivation.
Duchenne muscular dystrophy has an incidence of 1 in 3,500 male infants. Mutations within the dystrophin gene can either be inherited or occur spontaneously during germline transmission.
D. Diagnosis
Genetic counseling is advised for people with a family history of the disorder. Duchenne muscular dystrophy can be detected with about 95% accuracy by genetic studies performed during pregnancy.
DNA test. The muscle-specific isoform of the dystrophin gene is composed of 79 exons, and DNA testing and analysis can usually identify the specific type of mutation of the exon or exons that are affected. DNA testing confirms the diagnosis in most cases.
Muscle biopsy. If DNA testing fails to find the mutation, a muscle biopsy test may be performed. A small sample of muscle tissue is extracted (usually with a scalpel instead of a needle) and a dye is applied that reveals the presence of dystrophin. Complete absence of the protein indicates the condition.
Over the past several years DNA tests have been developed that detect more of the many mutations that cause the condition, and muscle biopsy is not required as often to confirm the presence of Duchenne's.
Prenatal tests. DMD is carried by an X-linked recessive gene. Males have only one X chromosome, so one copy of the mutated gene will cause DMD. Fathers cannot pass X-linked traits on to their sons, so the mutation is transmitted by the mother.
If the mother is a carrier, and therefore one of her two X chromosomes has a DMD mutation, there is a 50% chance that a female child will inherit that mutation as one of her two X chromosomes, and be a carrier. There is a 50% chance that a male child will inherit that mutation as his one X chromosome, and therefore have DMD.
Prenatal tests can tell whether their unborn child has the most common mutations. There are many mutations responsible for DMD, and some have not been identified, so genetic testing only works when family members with DMD have a mutation that has been identified.
Prior to invasive testing, determination of the fetal sex is important; while males are sometimes affected by this X-linked disease, female DMD is extremely rare. This can be achieved by ultrasound scan at 16 weeks or more recently by free fetal DNA testing. Chorion villus sampling (CVS) can be done at 11-14 weeks, and has a 1% risk of miscarriage. Amniocentesis can be done after 15 weeks, and has a 0.5% risk of miscarriage. Fetal blood sampling can be done at about 18 weeks. Another option in the case of unclear genetic test results is fetal muscle biopsy.
E. Treatment
There is no current cure for DMD, and an ongoing medical need has been recognized by regulatory authorities. Phase 1-2a trials with exon skipping treatment for certain mutations have halted decline and produced small clinical improvements in walking Treatment is generally aimed at controlling the onset of symptoms to maximize the quality of life, and include the following:
1. Physical Therapy
Physical therapists are concerned with enabling patients to reach their maximum physical potential. Their aim is to:
2. Respiration Assistance
Modern “volume ventilators/respirators,” which deliver an adjustable volume (amount) of air to the person with each breath, are valuable in the treatment of people with muscular dystrophy related respiratory problems. The ventilator may require an invasive endotracheal or tracheotomy tube through which air is directly delivered, but, for some people non-invasive delivery through a face mask or mouthpiece is sufficient. Positive airway pressure machines, particularly bi-level ones, are sometimes used in this latter way. The respiratory equipment may easily fit on a ventilator tray on the bottom or back of a power wheelchair with an external battery for portability.
Ventilator treatment may start in the mid to late teens when the respiratory muscles can begin to collapse. If the vital capacity has dropped below 40% of normal, a volume ventilator/respirator may be used during sleeping hours, a time when the person is most likely to be under ventilating (“hypoventilating”). Hypoventilation during sleep is determined by a thorough history of sleep disorder with an oximetry study and a capillary blood gas (See Pulmonary Function Testing). A cough assist device can help with excess mucus in lungs by hyperinflation of the lungs with positive air pressure, then negative pressure to get the mucus up. If the vital capacity continues to decline to less than 30 percent of normal, a volume ventilator/respirator may also be needed during the day for more assistance. The person gradually will increase the amount of time using the ventilator/respirator during the day as needed.
F. Prognosis
Duchenne muscular dystrophy is a progressive disease which eventually affects all voluntary muscles and involves the heart and breathing muscles in later stages. The life expectancy is currently estimated to be around 25, but this varies from patient to patient. Recent advancements in medicine are extending the lives of those afflicted. The Muscular Dystrophy Campaign, which is a leading UK charity focusing on all muscle disease, states that “with high standards of medical care young men with Duchenne muscular dystrophy are often living well into their 30s.”
In rare cases, persons with DMD have been seen to survive into the forties or early fifties, with the use of proper positioning in wheelchairs and beds, ventilator support (via tracheostomy or mouthpiece), airway clearance, and heart medications, if required. Early planning of the required supports for later-life care has shown greater longevity in people living with DMD.
Curiously, in the mdx mouse model of Duchenne muscular dystrophy, the lack of dystrophin is associated with increased calcium levels and skeletal muscle myonecrosis. The intrinsic laryngeal muscles (ILM) are protected and do not undergo myonecrosis. ILM have a calcium regulation system profile suggestive of a better ability to handle calcium changes in comparison to other muscles, and this may provide a mechanistic insight for their unique pathophysiological properties. The ILM may facilitate the development of novel strategies for the prevention and treatment of muscle wasting in a variety of clinical scenarios.
A. CRISPR/CAS
CRISPRs (clustered regularly interspaced short palindromic repeats) are DNA loci containing short repetitions of base sequences. Each repetition is followed by short segments of “spacer DNA” from previous exposures to a virus. CRISPRs are found in approximately 40% of sequenced eubacteria genomes and 90% of sequenced archaea. CRISPRs are often associated with cas genes that code for proteins related to CRISPRs. The CRISPR/Cas system is a prokaryotic immune system that confers resistance to foreign genetic elements such as plasmids and phages and provides a form of acquired immunity. CRISPR spacers recognize and silence these exogenous genetic elements like RNAi in eukaryotic organisms.
Repeats were first described in 1987 for the bacterium Escherichia coli. In 2000, similar clustered repeats were identified in additional bacteria and archaea and were termed Short Regularly Spaced Repeats (SRSR). SRSR were renamed CRISPR in 2002. A set of genes, some encoding putative nuclease or helicase proteins, were found to be associated with CRISPR repeats (the cas, or CRISPR-associated genes).
In 2005, three independent researchers showed that CRISPR spacers showed homology to several phage DNA and extrachromosomal DNA such as plasmids. This was an indication that the CRISPR/cas system could have a role in adaptive immunity in bacteria. Koonin and colleagues proposed that spacers serve as a template for RNA molecules, analogously to eukaryotic cells that use a system called RNA interference.
In 2007 Barrangou, Horvath (food industry scientists at Danisco) and others showed that they could alter the resistance of Streptococcus thermophilus to phage attack with spacer DNA. Doudna and Charpentier had independently been exploring CRISPR-associated proteins to learn how bacteria deploy spacers in their immune defenses. They jointly studied a simpler CRISPR system that relies on a protein called Cas9. They found that bacteria respond to an invading phage by transcribing spacers and palindromic DNA into a long RNA molecule that the cell then uses tracrRNA and Cas9 to cut it into pieces called crRNAs.
CRISPR was first shown to work as a genome engineering/editing tool in human cell culture by 2012 It has since been used in a wide range of organisms including bakers yeast (S. cerevisiae), zebra fish, nematodes (C. elegans), plants, mice, and several other organisms. Additionally CRISPR has been modified to make programmable transcription factors that allow scientists to target and activate or silence specific genes. Libraries of tens of thousands of guide RNAs are now available.
The first evidence that CRISPR can reverse disease symptoms in living animals was demonstrated in March 2014, when MIT researchers cured mice of a rare liver disorder. Since 2012, the CRISPR/Cas system has been used for gene editing (silencing, enhancing or changing specific genes) that even works in eukaryotes like mice and primates. By inserting a plasmid containing cas genes and specifically designed CRISPRs, an organism's genome can be cut at any desired location.
CRISPR repeats range in size from 24 to 48 base pairs. They usually show some dyad symmetry, implying the formation of a secondary structure such as a hairpin, but are not truly palindromic. Repeats are separated by spacers of similar length. Some CRISPR spacer sequences exactly match sequences from plasmids and phages, although some spacers match the prokaryote's genome (self-targeting spacers). New spacers can be added rapidly in response to phage infection.
CRISPR-associated (cas) genes are often associated with CRISPR repeat-spacer arrays. As of 2013, more than forty different Cas protein families had been described. Of these protein families, Cas1 appears to be ubiquitous among different CRISPR/Cas systems. Particular combinations of cas genes and repeat structures have been used to define 8 CRISPR subtypes (Ecoli, Ypest, Nmeni, Dvulg, Tneap, Hmari, Apern, and Mtube), some of which are associated with an additional gene module encoding repeat-associated mysterious proteins (RAMPs). More than one CRISPR subtype may occur in a single genome. The sporadic distribution of the CRISPR/Cas subtypes suggests that the system is subject to horizontal gene transfer during microbial evolution.
Exogenous DNA is apparently processed by proteins encoded by Cas genes into small elements (˜30 base pairs in length), which are then somehow inserted into the CRISPR locus near the leader sequence. RNAs from the CRISPR loci are constitutively expressed and are processed by Cas proteins to small RNAs composed of individual, exogenously-derived sequence elements with a flanking repeat sequence. The RNAs guide other Cas proteins to silence exogenous genetic elements at the RNA or DNA level. Evidence suggests functional diversity among CRISPR subtypes. The Cse (Cas subtype Ecoli) proteins (called CasA-E in E. coli) form a functional complex, Cascade, that processes CRISPR RNA transcripts into spacer-repeat units that Cascade retains. In other prokaryotes, Cas6 processes the CRISPR transcripts. Interestingly, CRISPR-based phage inactivation in E. coli requires Cascade and Cas3, but not Cas1 and Cas2. The Cmr (Cas RAMP module) proteins found in Pyrococcus furiosus and other prokaryotes form a functional complex with small CRISPR RNAs that recognizes and cleaves complementary target RNAs. RNA-guided CRISPR enzymes are classified as type V restriction enzymes.
See also U.S. Patent Publication 2014/0068797, which is incorporated by reference in its entirety.
B. Cas9
Cas9 is a nuclease, an enzyme specialized for cutting DNA, with two active cutting sites, one for each strand of the double helix. The team demonstrated that they could disable one or both sites while preserving Cas9's ability to home located its target DNA. Jinek et al. (2012) combined tracrRNA and spacer RNA into a “single-guide RNA” molecule that, mixed with Cas9, could find and cut the correct DNA targets. Jinek et al. (2012) proposed that such synthetic guide RNAs might be able to be used for gene editing.
Cas9 proteins are highly enriched in pathogenic and commensal bacteria. CRISPR/Cas-mediated gene regulation may contribute to the regulation of endogenous bacterial genes, particularly during bacterial interaction with eukaryotic hosts. For example, Cas protein Cas9 of Francisella novicida uses a unique, small, CRISPR/Cas-associated RNA (scaRNA) to repress an endogenous transcript encoding a bacterial lipoprotein that is critical for F. novicida to dampen host response and promote virulence. Wang et al. showed that coinjection of Cas9 mRNA and sgRNAs into the germline (zygotes) generated nice with mutations. Delivery of Cas9 DNA sequences also is contemplated.
C. gRNA
As an RNA guided protein, Cas9 requires a short RNA to direct the recognition of DNA targets (Mali et al., 2013a). Though Cas9 preferentially interrogates DNA sequences containing a PAM sequence NGG it can bind here without a protospacer target. However, the Cas9-gRNA complex requires a close match to the gRNA to create a double strand break (Cho et al., 2013; Hsu et al., 2013). CRISPR sequences in bacteria are expressed in multiple RNAs and then processed to create guide strands for RNA (Bikard et al., 2013). Because Eukaryotic systems lack some of the proteins required to process CRISPR RNAs the synthetic construct gRNA was created to combine the essential pieces of RNA for Cas9 targeting into a single RNA expressed with the RNA polymerase type III promoter U6 (Mali et al., 2013a, b). Synthetic gRNAs are slightly over 100 bp at the minimum length and contain a portion which is targets the 20 protospacer nucleotides immediately preceding the PAM sequence NGG; gRNAs do not contain a PAM sequence.
As discussed above, in certain embodiments, expression cassettes are employed to express a transcription factor product, either for subsequent purification and delivery to a cell/subject, or for use directly in a genetic-based delivery approach. Expression requires that appropriate signals be provided in the vectors, and include various regulatory elements such as enhancers/promoters from both viral and mammalian sources that drive expression of the genes of interest in cells. Elements designed to optimize messenger RNA stability and translatability in host cells also are defined. The conditions for the use of a number of dominant drug selection markers for establishing permanent, stable cell clones expressing the products are also provided, as is an element that links expression of the drug selection markers to expression of the polypeptide.
A. Regulatory Elements
Throughout this application, the term “expression cassette” is meant to include any type of genetic construct containing a nucleic acid coding for a gene product in which part or all of the nucleic acid encoding sequence is capable of being transcribed and translated, i.e., is under the control of a promoter. A “promoter” refers to a DNA sequence recognized by the synthetic machinery of the cell, or introduced synthetic machinery, required to initiate the specific transcription of a gene. The phrase “under transcriptional control” means that the promoter is in the correct location and orientation in relation to the nucleic acid to control RNA polymerase initiation and expression of the gene. An “expression vector” is meant to include expression cassettes comprised in a genetic construct that is capable of replication, and thus including one or more of origins of replication, transcription termination signals, poly-A regions, selectable markers, and multipurpose cloning sites.
The term promoter will be used here to refer to a group of transcriptional control modules that are clustered around the initiation site for RNA polymerase II. Much of the thinking about how promoters are organized derives from analyses of several viral promoters, including those for the HSV thymidine kinase (tk) and SV40 early transcription units. These studies, augmented by more recent work, have shown that promoters are composed of discrete functional modules, each consisting of approximately 7-20 bp of DNA, and containing one or more recognition sites for transcriptional activator or repressor proteins.
At least one module in each promoter functions to position the start site for RNA synthesis. The best known example of this is the TATA box, but in some promoters lacking a TATA box, such as the promoter for the mammalian terminal deoxynucleotidyl transferase gene and the promoter for the SV40 late genes, a discrete element overlying the start site itself helps to fix the place of initiation.
Additional promoter elements regulate the frequency of transcriptional initiation. Typically, these are located in the region 30-110 bp upstream of the start site, although a number of promoters have recently been shown to contain functional elements downstream of the start site as well. The spacing between promoter elements frequently is flexible, so that promoter function is preserved when elements are inverted or moved relative to one another. In the tk promoter, the spacing between promoter elements can be increased to 50 bp apart before activity begins to decline. Depending on the promoter, it appears that individual elements can function either co-operatively or independently to activate transcription.
In certain embodiments, viral promotes such as the human cytomegalovirus (CMV) immediate early gene promoter, the SV40 early promoter, the Rous sarcoma virus long terminal repeat, rat insulin promoter and glyceraldehyde-3-phosphate dehydrogenase can be used to obtain high-level expression of the coding sequence of interest. The use of other viral or mammalian cellular or bacterial phage promoters which are well-known in the art to achieve expression of a coding sequence of interest is contemplated as well, provided that the levels of expression are sufficient for a given purpose. By employing a promoter with well-known properties, the level and pattern of expression of the protein of interest following transfection or transformation can be optimized. Further, selection of a promoter that is regulated in response to specific physiologic signals can permit inducible expression of the gene product.
Enhancers are genetic elements that increase transcription from a promoter located at a distant position on the same molecule of DNA. Enhancers are organized much like promoters. That is, they are composed of many individual elements, each of which binds to one or more transcriptional proteins. The basic distinction between enhancers and promoters is operational. An enhancer region as a whole must be able to stimulate transcription at a distance; this need not be true of a promoter region or its component elements. On the other hand, a promoter must have one or more elements that direct initiation of RNA synthesis at a particular site and in a particular orientation, whereas enhancers lack these specificities. Promoters and enhancers are often overlapping and contiguous, often seeming to have a very similar modular organization.
Below is a list of promoters/enhancers and inducible promoters/enhancers that could be used in combination with the nucleic acid encoding a gene of interest in an expression construct. Additionally, any promoter/enhancer combination (as per the Eukaryotic Promoter Data Base EPDB) could also be used to drive expression of the gene. Eukaryotic cells can support cytoplasmic transcription from certain bacterial promoters if the appropriate bacterial polymerase is provided, either as part of the delivery complex or as an additional genetic expression construct.
Of particular interest are muscle specific promoters. These include the myosin light chain-2 promoter (Franz et al., 1994; Kelly et al., 1995), the α-actin promoter (Moss et al., 1996), the troponin 1 promoter (Bhavsar et al., 1996); the Na+/Ca2+ exchanger promoter (Barnes et al., 1997), the dystrophin promoter (Kimura et al., 1997), the α7 integrin promoter (Ziober and Kramer, 1996), the brain natriuretic peptide promoter (LaPointe et al., 1996) and the αB-crystallin/small heat shock protein promoter (Gopal-Srivastava, 1995), α-myosin heavy chain promoter (Yamauchi-Takihara et al., 1989) and the ANF promoter (LaPointe et al., 1988).
Where a cDNA insert is employed, one will typically desire to include a polyadenylation signal to effect proper polyadenylation of the gene transcript. The nature of the polyadenylation signal is not believed to be crucial to the successful practice of the invention, and any such sequence may be employed such as human growth hormone and SV40 polyadenylation signals. Also contemplated as an element of the expression cassette is a terminator. These elements can serve to enhance message levels and to minimize read through from the cassette into other sequences.
B. 2A Peptide
The inventor utilizes the 2A-like self-cleaving domain from the insect virus Thosea asigna (TaV 2A peptide) (Chang et al., 2009). These 2A-like domains have been shown to function across Eukaryotes and cause cleavage of amino acids to occur co-translationally within the 2A-like peptide domain. Therefore, inclusion of TaV 2A peptide allows the expression of multiple proteins from a single mRNA transcript. Importantly, the domain of TaV when tested in eukaryotic systems have shown greater than 99% cleavage activity (Donnelly et al., 2001).
C. Delivery of Expression Vectors
There are a number of ways in which expression vectors may introduced into cells. In certain embodiments of the invention, the expression construct comprises a virus or engineered construct derived from a viral genome. The ability of certain viruses to enter cells via receptor-mediated endocytosis, to integrate into host cell genome and express viral genes stably and efficiently have made them attractive candidates for the transfer of foreign genes into mammalian cells (Ridgeway, 1988; Nicolas and Rubenstein, 1988; Baichwal and Sugden, 1986; Temin, 1986). The first viruses used as gene vectors were DNA viruses including the papovaviruses (simian virus 40, bovine papilloma virus, and polyoma) (Ridgeway, 1988; Baichwal and Sugden, 1986) and adenoviruses (Ridgeway, 1988; Baichwal and Sugden, 1986). These have a relatively low capacity for foreign DNA sequences and have a restricted host spectrum. Furthermore, their oncogenic potential and cytopathic effects in permissive cells raise safety concerns. They can accommodate only up to 8 kB of foreign genetic material but can be readily introduced in a variety of cell lines and laboratory animals (Nicolas and Rubenstein, 1988; Temin, 1986).
One of the preferred methods for in vivo delivery involves the use of an adenovirus expression vector. “Adenovirus expression vector” is meant to include those constructs containing adenovirus sequences sufficient to (a) support packaging of the construct and (b) to express an antisense polynucleotide that has been cloned therein. In this context, expression does not require that the gene product be synthesized.
The expression vector comprises a genetically engineered form of adenovirus. Knowledge of the genetic organization of adenovirus, a 36 kB, linear, double-stranded DNA virus, allows substitution of large pieces of adenoviral DNA with foreign sequences up to 7 kB (Grunhaus and Horwitz, 1992). In contrast to retrovirus, the adenoviral infection of host cells does not result in chromosomal integration because adenoviral DNA can replicate in an episomal manner without potential genotoxicity. Also, adenoviruses are structurally stable, and no genome rearrangement has been detected after extensive amplification. Adenovirus can infect virtually all epithelial cells regardless of their cell cycle stage. So far, adenoviral infection appears to be linked only to mild disease such as acute respiratory disease in humans.
Adenovirus is particularly suitable for use as a gene transfer vector because of its mid-sized genome, ease of manipulation, high titer, wide target cell range and high infectivity. Both ends of the viral genome contain 100-200 base pair inverted repeats (ITRs), which are cis elements necessary for viral DNA replication and packaging. The early (E) and late (L) regions of the genome contain different transcription units that are divided by the onset of viral DNA replication. The E1 region (E1A and E1B) encodes proteins responsible for the regulation of transcription of the viral genome and a few cellular genes. The expression of the E2 region (E2A and E2B) results in the synthesis of the proteins for viral DNA replication. These proteins are involved in DNA replication, late gene expression and host cell shut-off (Renan, 1990). The products of the late genes, including the majority of the viral capsid proteins, are expressed only after significant processing of a single primary transcript issued by the major late promoter (MLP). The MLP, (located at 16.8 m.u.) is particularly efficient during the late phase of infection, and all the mRNA's issued from this promoter possess a 5′-tripartite leader (TPL) sequence which makes them preferred mRNA's for translation.
In one system, recombinant adenovirus is generated from homologous recombination between shuttle vector and provirus vector. Due to the possible recombination between two proviral vectors, wild-type adenovirus may be generated from this process. Therefore, it is critical to isolate a single clone of virus from an individual plaque and examine its genomic structure.
Generation and propagation of the current adenovirus vectors, which are replication deficient, depend on a unique helper cell line, designated 293, which was transformed from human embryonic kidney cells by Ad5 DNA fragments and constitutively expresses E1 proteins (Graham et al., 1977). Since the E3 region is dispensable from the adenovirus genome (Jones and Shenk, 1978), the current adenovirus vectors, with the help of 293 cells, carry foreign DNA in either the E1, the D3 or both regions (Graham and Prevec, 1991). In nature, adenovirus can package approximately 105% of the wild-type genome (Ghosh-Choudhury et al., 1987), providing capacity for about 2 extra kb of DNA. Combined with the approximately 5.5 kb of DNA that is replaceable in the E1 and E3 regions, the maximum capacity of the current adenovirus vector is under 7.5 kb, or about 15% of the total length of the vector. More than 80% of the adenovirus viral genome remains in the vector backbone and is the source of vector-borne cytotoxicity. Also, the replication deficiency of the E1-deleted virus is incomplete.
Helper cell lines may be derived from human cells such as human embryonic kidney cells, muscle cells, hematopoietic cells or other human embryonic mesenchymal or epithelial cells. Alternatively, the helper cells may be derived from the cells of other mammalian species that are permissive for human adenovirus. Such cells include, e.g., Vero cells or other monkey embryonic mesenchymal or epithelial cells. As stated above, the preferred helper cell line is 293.
Racher et al. (1995) disclosed improved methods for culturing 293 cells and propagating adenovirus. In one format, natural cell aggregates are grown by inoculating individual cells into 1 liter siliconized spinner flasks (Techne, Cambridge, UK) containing 100-200 ml of medium. Following stirring at 40 rpm, the cell viability is estimated with trypan blue. In another format, Fibra-Cel microcarriers (Bibby Sterlin, Stone, UK) (5 g/l) is employed as follows. A cell inoculum, resuspended in 5 ml of medium, is added to the carrier (50 ml) in a 250 ml Erlenmeyer flask and left stationary, with occasional agitation, for 1 to 4 h. The medium is then replaced with 50 ml of fresh medium and shaking initiated. For virus production, cells are allowed to grow to about 80% confluence, after which time the medium is replaced (to 25% of the final volume) and adenovirus added at an MOI of 0.05. Cultures are left stationary overnight, following which the volume is increased to 100% and shaking commenced for another 72 h.
Other than the requirement that the adenovirus vector be replication defective, or at least conditionally defective, the nature of the adenovirus vector is not believed to be crucial to the successful practice of the invention. The adenovirus may be of any of the 42 different known serotypes or subgroups A-F. Adenovirus type 5 of subgroup C is the preferred starting material in order to obtain the conditional replication-defective adenovirus vector for use in the present invention. This is because Adenovirus type 5 is a human adenovirus about which a great deal of biochemical and genetic information is known, and it has historically been used for most constructions employing adenovirus as a vector.
As stated above, the typical vector according to the present invention is replication defective and will not have an adenovirus E1 region. Thus, it will be most convenient to introduce the polynucleotide encoding the gene of interest at the position from which the E1-coding sequences have been removed. However, the position of insertion of the construct within the adenovirus sequences is not critical to the invention. The polynucleotide encoding the gene of interest may also be inserted in lieu of the deleted E3 region in E3 replacement vectors, as described by Karlsson et al. (1986), or in the E4 region where a helper cell line or helper virus complements the E4 defect.
Adenovirus is easy to grow and manipulate and exhibits broad host range in vitro and in vivo. This group of viruses can be obtained in high titers, e.g., 109-1012 plaque-forming units per ml, and they are highly infective. The life cycle of adenovirus does not require integration into the host cell genome. The foreign genes delivered by adenovirus vectors are episomal and, therefore, have low genotoxicity to host cells. No side effects have been reported in studies of vaccination with wild-type adenovirus (Couch et al., 1963; Top et al., 1971), demonstrating their safety and therapeutic potential as in vivo gene transfer vectors.
Adenovirus vectors have been used in eukaryotic gene expression (Levrero et al., 1991; Gomez-Foix et al., 1992) and vaccine development (Grunhaus and Horwitz, 1992; Graham and Prevec, 1991). Animal studies suggested that recombinant adenovirus could be used for gene therapy (Stratford-Perricaudet and Perricaudet, 1991; Stratford-Perricaudet et al., 1990; Rich et al., 1993). Studies in administering recombinant adenovirus to different tissues include trachea instillation (Rosenfeld et al., 1991; Rosenfeld et al., 1992), muscle injection (Ragot et al., 1993), peripheral intravenous injections (Herz and Gerard, 1993) and stereotactic inoculation into the brain (Le Gal La Salle et al., 1993).
The retroviruses are a group of single-stranded RNA viruses characterized by an ability to convert their RNA to double-stranded DNA in infected cells by a process of reverse-transcription (Coffin, 1990). The resulting DNA then stably integrates into cellular chromosomes as a provirus and directs synthesis of viral proteins. The integration results in the retention of the viral gene sequences in the recipient cell and its descendants. The retroviral genome contains three genes, gag, pol, and env that code for capsid proteins, polymerase enzyme, and envelope components, respectively. A sequence found upstream from the gag gene contains a signal for packaging of the genome into virions. Two long terminal repeat (LTR) sequences are present at the 5′ and 3′ ends of the viral genome. These contain strong promoter and enhancer sequences and are also required for integration in the host cell genome (Coffin, 1990).
In order to construct a retroviral vector, a nucleic acid encoding a gene of interest is inserted into the viral genome in the place of certain viral sequences to produce a virus that is replication-defective. In order to produce virions, a packaging cell line containing the gag, pol, and env genes but without the LTR and packaging components is constructed (Mann et al., 1983). When a recombinant plasmid containing a cDNA, together with the retroviral LTR and packaging sequences is introduced into this cell line (by calcium phosphate precipitation for example), the packaging sequence allows the RNA transcript of the recombinant plasmid to be packaged into viral particles, which are then secreted into the culture media (Nicolas and Rubenstein, 1988; Temin, 1986; Mann et al., 1983). The media containing the recombinant retroviruses is then collected, optionally concentrated, and used for gene transfer. Retroviral vectors are able to infect a broad variety of cell types. However, integration and stable expression require the division of host cells (Paskind et al., 1975).
A novel approach designed to allow specific targeting of retrovirus vectors was recently developed based on the chemical modification of a retrovirus by the chemical addition of lactose residues to the viral envelope. This modification could permit the specific infection of hepatocytes via sialoglycoprotein receptors.
A different approach to targeting of recombinant retroviruses was designed in which biotinylated antibodies against a retroviral envelope protein and against a specific cell receptor were used. The antibodies were coupled via the biotin components by using streptavidin (Roux et al., 1989). Using antibodies against major histocompatibility complex class I and class II antigens, they demonstrated the infection of a variety of human cells that bore those surface antigens with an ecotropic virus in vitro (Roux et al., 1989).
There are certain limitations to the use of retrovirus vectors in all aspects of the present invention. For example, retrovirus vectors usually integrate into random sites in the cell genome. This can lead to insertional mutagenesis through the interruption of host genes or through the insertion of viral regulatory sequences that can interfere with the function of flanking genes (Varmus et al., 1981). Another concern with the use of defective retrovirus vectors is the potential appearance of wild-type replication-competent virus in the packaging cells. This can result from recombination events in which the intact-sequence from the recombinant virus inserts upstream from the gag, pol, env sequence integrated in the host cell genome. However, new packaging cell lines are now available that should greatly decrease the likelihood of recombination (Markowitz et al., 1988; Hersdorffer et al., 1990).
Other viral vectors may be employed as expression constructs in the present invention. Vectors derived from viruses such as vaccinia virus (Ridgeway, 1988; Baichwal and Sugden, 1986; Coupar et al., 1988) adeno-associated virus (AAV) (Ridgeway, 1988; Baichwal and Sugden, 1986; Hermonat and Muzycska, 1984) and herpesviruses may be employed. They offer several attractive features for various mammalian cells (Friedmann, 1989; Ridgeway, 1988; Baichwal and Sugden, 1986; Coupar et al., 1988; Horwich et al., 1990).
In order to effect expression of sense or antisense gene constructs, the expression construct must be delivered into a cell. This delivery may be accomplished in vitro, as in laboratory procedures for transforming cells lines, or in vivo or ex vivo, as in the treatment of certain disease states. One mechanism for delivery is via viral infection where the expression construct is encapsidated in an infectious viral particle.
Several non-viral methods for the transfer of expression constructs into cultured mammalian cells also are contemplated by the present invention. These include calcium phosphate precipitation (Graham and Van Der Eb, 1973; Chen and Okayama, 1987; Rippe et al., 1990) DEAE-dextran (Gopal, 1985), electroporation (Tur-Kaspa et al., 1986; Potter et al., 1984), direct microinjection (Harland and Weintraub, 1985), DNA-loaded liposomes (Nicolau and Sene, 1982; Fraley et al., 1979) and lipofectamine-DNA complexes, cell sonication (Fechheimer et al., 1987), gene bombardment using high velocity microprojectiles (Yang et al., 1990), and receptor-mediated transfection (Wu and Wu, 1987; Wu and Wu, 1988). Some of these techniques may be successfully adapted for in vivo or ex vivo use.
Once the expression construct has been delivered into the cell the nucleic acid encoding the gene of interest may be positioned and expressed at different sites. In certain embodiments, the nucleic acid encoding the gene may be stably integrated into the genome of the cell. This integration may be in the cognate location and orientation via homologous recombination (gene replacement) or it may be integrated in a random, non-specific location (gene augmentation). In yet further embodiments, the nucleic acid may be stably maintained in the cell as a separate, episomal segment of DNA. Such nucleic acid segments or “episomes” encode sequences sufficient to permit maintenance and replication independent of or in synchronization with the host cell cycle. How the expression construct is delivered to a cell and where in the cell the nucleic acid remains is dependent on the type of expression construct employed.
In yet another embodiment of the invention, the expression construct may simply consist of naked recombinant DNA or plasmids. Transfer of the construct may be performed by any of the methods mentioned above which physically or chemically permeabilize the cell membrane. This is particularly applicable for transfer in vitro but it may be applied to in vivo use as well. Dubensky et al. (1984) successfully injected polyomavirus DNA in the form of calcium phosphate precipitates into liver and spleen of adult and newborn mice demonstrating active viral replication and acute infection. Benvenisty and Neshif (1986) also demonstrated that direct intraperitoneal injection of calcium phosphate-precipitated plasmids results in expression of the transfected genes. It is envisioned that DNA encoding a gene of interest may also be transferred in a similar manner in vivo and express the gene product.
In still another embodiment of the invention for transferring a naked DNA expression construct into cells may involve particle bombardment. This method depends on the ability to accelerate DNA-coated microprojectiles to a high velocity allowing them to pierce cell membranes and enter cells without killing them (Klein et al., 1987). Several devices for accelerating small particles have been developed. One such device relies on a high voltage discharge to generate an electrical current, which in turn provides the motive force (Yang et al., 1990). The microprojectiles used have consisted of biologically inert substances such as tungsten or gold beads.
Selected organs including the liver, skin, and muscle tissue of rats and mice have been bombarded in vivo (Yang et al., 1990; Zelenin et al., 1991). This may require surgical exposure of the tissue or cells, to eliminate any intervening tissue between the gun and the target organ, i.e., ex vivo treatment. Again, DNA encoding a particular gene may be delivered via this method and still be incorporated by the present invention.
In a further embodiment of the invention, the expression construct may be entrapped in a liposome. Liposomes are vesicular structures characterized by a phospholipid bilayer membrane and an inner aqueous medium. Multilamellar liposomes have multiple lipid layers separated by aqueous medium. They form spontaneously when phospholipids are suspended in an excess of aqueous solution. The lipid components undergo self-rearrangement before the formation of closed structures and entrap water and dissolved solutes between the lipid bilayers (Ghosh and Bachhawat, 1991). Also contemplated are lipofectamine-DNA complexes.
Liposome-mediated nucleic acid delivery and expression of foreign DNA in vitro has been very successful. Wong et al., (1980) demonstrated the feasibility of liposome-mediated delivery and expression of foreign DNA in cultured chick embryo, HeLa and hepatoma cells. Nicolau et al., (1987) accomplished successful liposome-mediated gene transfer in rats after intravenous injection. A reagent known as Lipofectamine 2000™ is widely used and commercially available.
In certain embodiments of the invention, the liposome may be complexed with a hemagglutinating virus (HVJ). This has been shown to facilitate fusion with the cell membrane and promote cell entry of liposome-encapsulated DNA (Kaneda et al., 1989). In other embodiments, the liposome may be complexed or employed in conjunction with nuclear non-histone chromosomal proteins (HMG-1) (Kato et al., 1991). In yet further embodiments, the liposome may be complexed or employed in conjunction with both HVJ and HMG-1. In that such expression constructs have been successfully employed in transfer and expression of nucleic acid in vitro and in vivo, then they are applicable for the present invention. Where a bacterial promoter is employed in the DNA construct, it also will be desirable to include within the liposome an appropriate bacterial polymerase.
Other expression constructs which can be employed to deliver a nucleic acid encoding a particular gene into cells are receptor-mediated delivery vehicles. These take advantage of the selective uptake of macromolecules by receptor-mediated endocytosis in almost all eukaryotic cells. Because of the cell type-specific distribution of various receptors, the delivery can be highly specific (Wu and Wu, 1993).
Receptor-mediated gene targeting vehicles generally consist of two components: a cell receptor-specific ligand and a DNA-binding agent. Several ligands have been used for receptor-mediated gene transfer. The most extensively characterized ligands are asialoorosomucoid (ASOR) (Wu and Wu, 1987) and transferrin (Wagner et al., 1990). A synthetic neoglycoprotein, which recognizes the same receptor as ASOR, has been used as a gene delivery vehicle (Ferkol et al., 1993; Perales et al., 1994) and epidermal growth factor (EGF) has also been used to deliver genes to squamous carcinoma cells (Myers, EP 0273085).
Where clinical applications are contemplated, pharmaceutical compositions will be prepared in a form appropriate for the intended application. Generally, this will entail preparing compositions that are essentially free of pyrogens, as well as other impurities that could be harmful to humans or animals.
One will generally desire to employ appropriate salts and buffers to render drugs, proteins or delivery vectors stable and allow for uptake by target cells. Aqueous compositions of the present invention comprise an effective amount of the drug, vector or proteins, dissolved or dispersed in a pharmaceutically acceptable carrier or aqueous medium. The phrase “pharmaceutically or pharmacologically acceptable” refer to molecular entities and compositions that do not produce adverse, allergic, or other untoward reactions when administered to an animal or a human. As used herein, “pharmaceutically acceptable carrier” includes solvents, buffers, solutions, dispersion media, coatings, antibacterial and antifungal agents, isotonic and absorption delaying agents and the like acceptable for use in formulating pharmaceuticals, such as pharmaceuticals suitable for administration to humans. The use of such media and agents for pharmaceutically active substances is well known in the art. Except insofar as any conventional media or agent is incompatible with the active ingredients of the present invention, its use in therapeutic compositions is contemplated. Supplementary active ingredients also can be incorporated into the compositions, provided they do not inactivate the vectors or cells of the compositions.
The active compositions of the present invention may include classic pharmaceutical preparations. Administration of these compositions according to the present invention may be via any common route so long as the target tissue is available via that route, but generally including systemic administration. This includes oral, nasal, or buccal. Alternatively, administration may be by intradermal, subcutaneous, intramuscular, intraperitoneal or intravenous injection, or by direct injection into muscle tissue. Such compositions would normally be administered as pharmaceutically acceptable compositions, as described supra.
The active compounds may also be administered parenterally or intraperitoneally. By way of illustration, solutions of the active compounds as free base or pharmacologically acceptable salts can be prepared in water suitably mixed with a surfactant, such as hydroxypropylcellulose. Dispersions can also be prepared in glycerol, liquid polyethylene glycols, and mixtures thereof and in oils. Under ordinary conditions of storage and use, these preparations generally contain a preservative to prevent the growth of microorganisms.
The pharmaceutical forms suitable for injectable use include, for example, sterile aqueous solutions or dispersions and sterile powders for the extemporaneous preparation of sterile injectable solutions or dispersions. Generally, these preparations are sterile and fluid to the extent that easy injectability exists. Preparations should be stable under the conditions of manufacture and storage and should be preserved against the contaminating action of microorganisms, such as bacteria and fungi. Appropriate solvents or dispersion media may contain, for example, water, ethanol, polyol (for example, glycerol, propylene glycol, and liquid polyethylene glycol, and the like), suitable mixtures thereof, and vegetable oils. The proper fluidity can be maintained, for example, by the use of a coating, such as lecithin, by the maintenance of the required particle size in the case of dispersion and by the use of surfactants. The prevention of the action of microorganisms can be brought about by various antibacterial an antifungal agents, for example, parabens, chlorobutanol, phenol, sorbic acid, thimerosal, and the like. In many cases, it will be preferable to include isotonic agents, for example, sugars or sodium chloride. Prolonged absorption of the injectable compositions can be brought about by the use in the compositions of agents delaying absorption, for example, aluminum monostearate and gelatin.
Sterile injectable solutions may be prepared by incorporating the active compounds in an appropriate amount into a solvent along with any other ingredients (for example as enumerated above) as desired, followed by filtered sterilization. Generally, dispersions are prepared by incorporating the various sterilized active ingredients into a sterile vehicle which contains the basic dispersion medium and the desired other ingredients, e.g., as enumerated above. In the case of sterile powders for the preparation of sterile injectable solutions, the preferred methods of preparation include vacuum-drying and freeze-drying techniques which yield a powder of the active ingredient(s) plus any additional desired ingredient from a previously sterile-filtered solution thereof.
The compositions of the present invention generally may be formulated in a neutral or salt form. Pharmaceutically-acceptable salts include, for example, acid addition salts (formed with the free amino groups of the protein) derived from inorganic acids (e.g., hydrochloric or phosphoric acids, or from organic acids (e.g., acetic, oxalic, tartaric, mandelic, and the like. Salts formed with the free carboxyl groups of the protein can also be derived from inorganic bases (e.g., sodium, potassium, ammonium, calcium, or ferric hydroxides) or from organic bases (e.g., isopropylamine, trimethylamine, histidine, procaine and the like.
Upon formulation, solutions are preferably administered in a manner compatible with the dosage formulation and in such amount as is therapeutically effective. The formulations may easily be administered in a variety of dosage forms such as injectable solutions, drug release capsules and the like. For parenteral administration in an aqueous solution, for example, the solution generally is suitably buffered and the liquid diluent first rendered isotonic for example with sufficient saline or glucose. Such aqueous solutions may be used, for example, for intravenous, intramuscular, subcutaneous and intraperitoneal administration. Preferably, sterile aqueous media are employed as is known to those of skill in the art, particularly in light of the present disclosure. By way of illustration, a single dose may be dissolved in 1 ml of isotonic NaCl solution and either added to 1000 ml of hypodermoclysis fluid or injected at the proposed site of infusion, (see for example, “Remington's Pharmaceutical Sciences” 15th Edition, pages 1035-1038 and 1570-1580). Some variation in dosage will necessarily occur depending on the condition of the subject being treated. The person responsible for administration will, in any event, determine the appropriate dose for the individual subject. Moreover, for human administration, preparations should meet sterility, pyrogenicity, general safety and purity standards as required by FDA Office of Biologics standards.
The following examples are included to demonstrate preferred embodiments of the disclosure. It should be appreciated by those of skill in the art that the techniques disclosed in the examples which follow represent techniques discovered by the inventor to function well in the practice of the disclosure, and thus can be considered to constitute preferred modes for its practice. However, those of skill in the art should, in light of the present disclosure, appreciate that many changes can be made in the specific embodiments which are disclosed and still obtain a like or similar result without departing from the spirit and scope of the disclosure.
Plasmids.
The hCas9 plasmid (Addgene plasmid 41815) containing the human codon optimized Cas9 gene and the gRNA Cloning Vector plasmid (Addgene plasmid 41824) containing the backbone of sgRNA were purchased from Addgene. Cloning of sgRNA was done according to the Church Lab CRISPR plasmid instructions (world-wide-web at addgene.org/crispr/church/).
In Vitro Transcription of Cas9 mRNA and sgRNA.
T3 promoter sequence was added to the hCas9 coding region by PCR. T3-hCas9 PCR product was gel purified and subcloned into pCRII-TOPO vector (Invitrogen) according to the manufacturer's instructions. Linearized T3-hCas9 plasmid was used as the template for in vitro transcription using the mMESSAGE mMACHINE T3 Transcription Kit (Life Technologies). T7 promoter sequence was added to the sgRNA template by PCR. The gel purified PCR products were used as template for in vitro transcription using the MEGAshortscript T7 Kit (Life Technologies). hCas9 RNA and sgRNA were purified by MEGAclear kit (Life Technologies) and eluted with nuclease-free water (Ambion). The concentration of RNA was measured by a NanoDrop instrument (Thermo Scientific).
Single-Stranded Oligodeoxynucleotide (ssODN).
ssODN was used as HDR template and purchased from Integrated DNA Technologies as Ultramer DNA Oligonucleotides. ssODN was mixed with Cas9 mRNA and sgRNA directly without purification. The sequence of ssODN is listed in Table S1.
CRISPR/Cas9-Mediated Genomic Editing by One-Cell Embryo Injection.
All animal procedures were approved by the Institutional Animal Care and Use Committee at the University of Texas Southwestern Medical Center. B6C3F1 (C57BL/6NCr female X C3H/HeN MTV male), C57BL/6NCr, and C57BL/10ScSn-Dmdmdx/J were three mouse strains used as oocyte donors. Superovulated female B6C3F1 mice (6 weeks old) were mated to B6C3F1 stud males. Superovulated female C57BL/6NCr females (12-18 grams) were mated to C57BL/6NCr males and superovulated female homozygote C57BL/10ScSn-Dmdmdx/J (12-18 grams) were mated to hemizygote C57BL/10ScSn-Dmdmdx/J stud males. Zygotes were harvested and kept in M16 medium (Brinster's medium for ovum culture with 100 U/ml penicillin and 50 mg/ml streptomycin) at 37° C. for 1 hour. Zygotes were transferred to M2 medium (M16 medium and 20 mM HEPES) and injected with hCas9 mRNA, sgRNA and ssODN. Cas9/sgRNA was injected into the pronucleus only (termed Nuc) or pronucleus and cytoplasm (termed Nuc+Cyt). Different doses of Cas9 mRNA, sgRNA and ssODNs were injected into zygotes by Nuc or Nuc+Cyt (as detailed in Table S2). Injected zygotes were cultured in M16 medium for 1 hour at 37° C. and then transferred into the oviducts of pseudopregnant ICR female mice.
Isolation of Genomic DNA.
Tail biopsies were added to 100 μl of 25 mM NaOH/0.2 mM EDTA solution and placed at 95° C. for 15 min and then cooled to room temperature. Following the addition of 100 μl of 40 mM Tris-HCl (pH 5.5), the tubes were centrifuged at 15,000×g for 5 minutes. DNA samples were kept at 4° C. for several weeks or at −20° C. for long-term storage. Genomic DNA was isolated from muscle using TRIzol (Life Technologies) according to the manufacturer's instructions.
Amplifying the Target Genomic Region by PCR.
PCR assays contained 2 μl of GoTaq (Promega), 20 μl of 5× Green GoTaq Reaction Buffer, 8 μl of 25 mM MgCl2, 2 μl of 10 μM primer (DMD729F and DMD729R) (Table S1), 2 μl of 10 mM dNTP, 4 μl of genomic DNA, and ddH2O to 100 μl. PCR conditions were: 94° C. for 2 min; 32× (94° C. for 15 sec, 59° C. for 30 sec, 72° C. for 1 min); 72° C. for 7 min; followed by 4° C. PCR products were analyzed by 2% agarose gel electrophoresis and purified from the gel using the QIAquick PCR Purification Kit (Qiagen) for direct sequencing. These PCR products were subcloned into pCRII-TOPO vector (Invitrogen) according to the manufacturer's instructions. Individual clones were picked and the DNA was sequenced.
RFLP Analysis of PCR Products.
Digestion reactions consisting of 20 μl of genomic PCR product, 3 μl of 10×NEB buffer CS, and 1 μl of TseI (New England BioLabs) were incubated for 1 hour at 65° C. and analyzed by 2% agarose gel electrophoresis. Digested PCR product from wild-type DNA is 581 bp, while HDR-mediated genomic editing DNA from F0 mice shows an additional product at approximately 437 bp.
T7E1 Analysis of PCR Products.
Mismatched duplex DNA was obtained by denaturation/renaturation of 25 μl of the genomic PCR samples using the following conditions:
Grip Strength Test.
Muscle strength was assessed by a grip strength behavior task performed by the Neuro-Models Core Facility at UT Southwestern Medical Center. The mouse was removed from the cage, weighed and lifted by the tail causing the forelimbs to grasp the pull-bar assembly connected to the grip strength meter (Columbus Instruments). The mouse was drawn along a straight line leading away from the sensor until the grip is broken and the peak amount of force in grams was recorded. This was repeated 5 times.
Serum Creatine Kinase (CK) Measurement.
Blood was collected from the submandibular vein and serum CK level was measured by VITROS Chemistry Products CK Slides to quantitatively measure CK activity using VITROS 250 Chemistry System.
Histological Analysis of Muscles.
Skeletal muscle from wild-type, mdx, and corrected mdx-C mice were individually dissected and cryoembedded in a 1:2 volume mixture of Gum Tragacanth powder (Sigma-Aldrich) to Tissue Freezing Medium (TFM) (Triangle Bioscience). Hearts were cryoembedded in TFM. All embeds were snap frozen in isopentane heat extractant supercooled to −155° C. Resulting blocks were stored overnight at −80° C. prior to sectioning. Eight-micron transverse sections of skeletal muscle, and frontal sections of heart were prepared on a Leica CM3050 cryostat and air-dried prior to same day staining H&E staining was performed according to established staining protocols and dystrophin immunohistochemistry was performed using MANDYS8 monoclonal antisera (Sigma-Aldrich) with modifications to manufacturer's instructions. In brief, cryostat sections were thawed and rehydrated/delipidated in 1% triton/phosphate-buffered-saline, pH 7.4 (PBS). Following delipidation, sections were washed free of Triton, incubated with mouse IgG blocking reagent (M.O.M. Kit, Vector Laboratories), washed, and sequentially equilibrated with MOM protein concentrate/PBS, and MANDYS8 diluted 1:1800 in MOM protein concentrate/PBS. Following overnight primary antibody incubation at 4° C., sections were washed, incubated with MOM biotinylated anti-mouse IgG, washed, and detection completed with incubation of Vector fluorescein-avidin DCS. Nuclei were counterstained with propidium iodide (Molecular Probes) prior to cover slipping with Vectashield.
Imaging and Analysis.
Specimens were reviewed with a Zeiss Axioplan 2iE upright photomicroscope equipped with epifluiorescence illumination, CRI color wheel, and Zeiss Axiocam monochromatic CCD camera. OpenLab 4.0 acquisition and control software (Perkin-Elmer) was used to capture 4×, 10× and 20× objective magnification fields, and further used to apply indexed pseudocoloring and merge image overlays. Images were peak levels-adjusted with Adobe Photoshop CS2 and saved for image analysis. ImageJ 1.47 was used to apply stereologic morphometric randomization grid overlays and the software's counting functions used to mark and score approximately 500 aggregate myofibers (from a minimum of three interval-sections) for dystrophin positive and negative immunostaining from each muscle group. H&E stained sections of soleus muscle for each genotype were further analyzed with ImageJ 1.47 for size and characteristic. In brief, sarcolemmal boundaries of 115+ stereologically randomized myofibers were manually delineated, their cross sectional area calculated, and central-nuclear phenotype recorded.
Western Blot Analysis.
Muscles were dissected and rapidly frozen in liquid nitrogen. Protein extraction and western blot analysis were performed as described (Nicholson et al., 1989 and Kodippili et al., 2014) with modification. Samples were homogenized with a homogenizer (POLYTRON System PT 1200 E) for 2×20 seconds in 400 μL sample buffer containing 10% SDS, 62.5 mM Tris, 1 mM EDTA and protease inhibitor (Roche). Protein concentration was measured using the BCA Protein Assay Kit (Pierce). Fifty micrograms of protein from each muscle sample was loaded onto a gradient SDS-PAGE (Bio-Rad). The gel was run at 100V for 2.5 hours. Separated proteins were transferred to a PVDF membrane at 35V overnight in a cold room (4° C.). The PVDF membrane was stained for total protein using 2% Ponceau Red and then blocked for one hour with 5% w/v nonfat dry milk, 1×TBS, 0.1% Tween-20 (TBST) at 25° C. with gentle shaking. The blocked membrane was incubated with a mouse anti-dystrophin monoclonal antibody (MANDYS8, Sigma-Aldrich, 1:1,000 dilution in 5% milk/TBST) overnight at 4° C. and then washed in TBST. The blot was then incubated with horseradish peroxidase conjugated goat anti-mouse IgG secondary antibody (Bio-Rad, 1:10,000 dilution) for one hour at 25° C. After washing with TBST, the blot was exposed to Western Blotting Luminol Reagent (Santa Cruz Biotech) for 1 min to detect signal. Protein loading was monitored by anti-GAPDH antibody (Millipore, 1:10,000 dilution).
Deep sequencing of off-target sites. Off-target loci were amplified by PCR using primers listed in Table S1 for (A) mdx (B) mdx+Cas9 (C) WT and (D) WT+Cas9. PCR products were purified by MinElute PCR purification kit (QIAGEN), adjusted to the same concentration (10 ng/μL), and equal volumes (5 μL) were combined for each group. Library preparation was performed according to the manufacturer's instructions (KAPA Library Preparation Kits with standard PCR library amplification module, Kapa Biosystems). Sequencing was performed on the Hiseq 2500 from Illumina and was run using Rapid Mode 150PE chemistry. Sequencing reads were mapped using BWA (bio-bwa.sourceforge.net/). Reads with mapping quality greater than 30 were retained for variant discovery. The mean read depth across all regions and all samples was 2570-fold. The variants were called using SAMtools (samtools.sourceforge.net/) plus custom scripts. In each region, insertion and deletion of 3 base pairs or longer were counted in a 50-bp window centered on the Cas9 potential cleavage sites.
Laser Microdissection of Satellite Cells.
Frozen sections from cryoembedments of gastrocnemius were mounted onto polyethylene membrane frame slides (Leica Microsystems PET-Foil 11505151) for same-day set-up of Pax-7 immunohistochemistry. Monoclonal Pax-7 antibody (Developmental Studies Hybridoma Bank) was used as described (Murphy et al., 2011) with modifications to antigen retrieval for working with PET-foil membrane frame slides (Gjerdrum et al., 2001). In brief, gastrocnemius cryosections were air-dried, fixed with 4% paraformaldehyde, Triton-X100 delipidated and incubated in antigen-retrieval buffer (sodium citrate buffer pH 6.0) at 65° C. for 20 hours. Following antigen retrieval, sections were quenched free of endogenous peroxidases with 0.6% hydrogen peroxide, and incubated with mouse IgG blocking reagent (M.O.M. Kit, Vector Laboratories), washed with PBS, incubated with MOM protein concentrate/PBS, and followed by overnight incubation with Pax-7 antibody (2 μg/ml) in MOM protein concentrate/PBS at 4° C. Sections were washed with PBS and incubated with MOM biotinylated anti-mouse IgG, streptavidin-peroxidase (Vector Laboratories), and color developed with diaminobenzidine chromagen (DAB, Dako). Nuclei were counterstained with nuclease-free Mayer's hematoxylin. Pax-7 positive satellite cells were microscopically identified and isolated by laser microdissection at 63× objective magnification using a Leica AS-LMD. Sixty to seventy Pax-7 positive satellite cells were isolated for each genotype and pooled into 10 μl of capture buffer (DirectPCR Lysis Reagent, Viagen Biotech Inc.) and stored at −20° C. The target genomic region was amplified by PCR using primers DMD232_f and DMD232_r (Table S1), as described above.
The objective of this study was to correct the genetic defect in the Dmd gene of mdx mice by CRISPR/Cas9-mediated genome editing in vivo. The mdx mouse (C57BL/10ScSn-Dmdmdx/J) contains a nonsense mutation in exon 23 of the Dmd gene (14, 15) (
Initially, the inventors tested the feasibility and optimized the conditions of CRISPR/Cas9-mediated Dmd gene editing in wild-type mice (C57BL6/C3H and C57BL/6). The inventors designed a sgRNA to target Dmd exon 23 (
The inventors next applied the optimized CRISPR/Cas9-mediated genomic editing method to mdx mice (
The inventors tested four different mouse groups for possible off-target effects of CRISPR/Cas9-mediated genome editing: (a) mdx mice without treatment (termed mdx), (b) CRISPR/Cas9-edited mdx mice (termed mdx+Cas9), (c) wild-type control mice (C57BL6/C3H) without treatment (termed WT) and (d) CRISPR/Cas9-edited wild-type mice (termed WT+Cas9) (
Deep sequencing of PCR products corresponding to Dmd exon 23 revealed high ratios of HDR and NHEJ-mediated genetic modification in groups B and D but not in control groups A and C (
To analyze the effect of CRISPR/Cas9-mediated genomic editing on the development of muscular dystrophy, the inventors performed histological analyses of four different muscle types (quadriceps, soleus (hindlimb muscle), diaphragm (respiratory muscle) and heart muscle) from wild-type mice, mdx mice, and three chosen mdx-C mice with different percentages of Dmd gene correction at 7-9 weeks old age. mdx muscle showed histopathologic hallmarks of muscular dystrophy, including variation in fiber diameter, centralized nuclei, degenerating fibers, necrotic fibers, and mineralized fibers, as well as interstitial fibrosis (
To compare the efficiency of rescue over time, the inventors chose mdx-C mice with comparable mosaicism of rescue of approximately 40%. As shown in
The widespread and progressive rescue of dystrophin expression in skeletal muscle might reflect the multi-nucleated structure of myofibers, such that a subset of nuclei with corrected Dmd genes can compensate for nuclei with Dmd mutations. Fusion of corrected satellite cells (the stem cell population of skeletal muscle) with dystrophic fibers might also progressively contribute to the regeneration of dystrophic muscle (Yin et al., 2013). To investigate this possibility, the inventors identified satellite cells in muscle sections of mdx-C mice by Immunostaining with Pax-7, a specific-marker for satellite cells (
Serum creatine kinase (CK), a diagnostic marker for muscular dystrophy that reflects muscle leakage, was measured in wild-type, mdx and mdx-C mice. Consistent with the histological results, serum CK levels of the mdx-C mice were substantially decreased compared to mdx mice and were inversely proportional to the percentage of genomic correction (Table 1). Wild-type, mdx, and mdx-C mice were also subjected to grip strength testing to measure muscle performance, and the mdx-C mice showed enhanced muscle performance compared to mdx mice (Table 1).
Permanent Exon Skipping Via CRISPR/Cas9-Mediated Genome Editing (Myo-Editing).
A challenge to genomic editing in postnatal tissues is that HDR does not occur in postmitotic cells, such as myofibers and cardiomyocytes. However, NHEJ does occur and can be used to destroy mutations without the need for precision of mutagenesis. Exon skipping is a strategy in which sections of genes are “skipped”, allowing the creation of partially functional dystrophin (Aartsma-Rus, 2012). However, traditional antisense oligonucleotide (AON)-mediated transient exon skipping suffers from inefficiency of oligonucleotide tissue uptake, requirement for lifelong delivery of oligonucleotides and incomplete exon skipping. To circumvent this challenge, the inventors used CRISPR/Cas9 system to destroy exon splice sites preceding DMD mutations or to delete mutant or out-of-frame exons, thereby allowing splicing between surrounding exons to recreate an in-frame dystrophin protein that lack the mutations. By permanently correcting the genetic lesion responsible for DMD, genomic editing requires only one-time delivery of the editing components to heart or skeletal muscle. Moreover, the progressive improvement of muscle function over time, allows for continued restoration of muscle function long after the genomic editing has occurred.
A schematic diagram of the dystrophin protein is shown in
Given the thousands of individual DMD mutations that have been identified in humans, an obvious question is how such a large number of mutations might be readily corrected by CRISPR/Cas9-mediated genome editing. To circumvent this challenge, the inventors propose to use CRISPR/Cas9 to destroy splice acceptor/donor sites preceding DMD mutations or to delete mutant exons, thereby allowing splicing between surrounding exons to recreate the in-frame dystrophin protein lacking the mutations. A schematic diagram of this approach is shown in
CRISPR/Cas9-Mediated Permanent Dmd Exon Skipping on Mdx Mice Germline.
To begin to test Myo-editing of the exon 23 mutation in mdx mice, the inventors first generated a pool of sgRNAs (sgRNA-L and R) that target the 5′ end and 3′ end of exon 23 (
A subset of NHEJ gene-edited mdx mice harbored a genetic deletion that abolished the splice site in exon 23. The inventors analyzed these mice for possible exon skipping by sequencing the generated RT-PCR products using primers in exon 22 and 24. Sequencing results showed that exon 22 spliced directly to exon 24, excluding exon 23 (
In Vivo Rescue of Muscular Dystrophy in Mice by AAV-Mediated Myo-Editing.
AAV is one of the most promising and appropriate vehicles for safe delivery of the Cas9 protein and guide RNAs for precise Myo-editing to human skeletal muscle and heart. It is important to emphasize that the problem of delivering CRISPR/Cas9 precision Myo-editing therapy by AAV goes hand-in-hand with optimizing the efficiency of both viral delivery and the process of genome engineering. The inventors focused on developing the highest titer AAV9 preparations for delivering the CRISPR/Cas9 genome editing machinery to muscle cells in vivo. This is an area of intensive international research (Senis et al., 2014; Schmidt & Grimm, 2015).
The inventors used the verified guide RNA-mdx/R3 to generate AAV9-guide RNAs (
In a proof of concept experiment, the inventors injected recombinant AAVs by IM injection of P10 mice or IC injection of P28. Muscle tissues were analyzed by immunostaining for dystrophin protein expression 3-weeks post-injection, as shown in
Muscle tissues from mice injected with recombinant AAVs by retro-orbital injection (RO-AAV) at P14 were examined by immunohistochemistry at 4 and 8-weeks post injection (
At 4-weeks post-IP injection of P1 mdx pup, skeletal muscle and heart were examined by immunohistochemistry (
Morphometric analysis of dystrophin-positive and total myofibers and cardiomyocytes were carried out on replicates of whole step-sections of tibialis anterior muscles and hearts scanned at 20× objective magnification. Scanned images, ranging in size from 7889×7570 pixels to 27518×18466 pixels, were parsed using Nikon Imaging Solution Elements v4.20.00 Software's Annotations and Measurements functions (NIS/AM). Enumeration of dystrophin positive myofibers and cardiomyocytes were individually counted and recorded using NIS/AM, while enumeration of total myofibers and cardiomyocytes were estimated from cell-counts per field area made from the mean of eight 20× objective images and extrapolated to the whole scanned section area.
The results indicate that AAV-mediated Myo-editing can efficiently rescue the reading frame of dystrophin in mdx mice in vivo. Different AAV delivery methods have different impact on tissues. IM has the highest rescue percentage myofibers in the injected skeletal muscle (TA), while RO shows the best performance in heart.
Rescue of DMD Cardiomyocyte Function by Myo-Editing.
A long-term goal is to adapt Myo-editing to postnatal cardiac and skeletal muscle cells and to leverage this approach to correct DMD mutations in humans. The inventors have now advanced Myo-editing from mice to cells from human DMD patients by engineering the skipping of mutant exons in the genome of DMD patient-derived iPSCs. DMD mutations in patients are clustered in specific areas of the gene (“hot spot” mutations) (
For instance, the inventors designed three guide RNAs to target 5′ of exon 51 (
Next, the inventors performed Myo-editing on an iPSC line (aka Riken HPS0164) from a DMD patient with a deletion (exons 48-50), which creates a frame-shift mutation, as visualized in
To further extend the Myo-editing concept, the Myo-editing Core at UTSW generated additional DMD iPSC cell lines, which were used to test the permanent exon skipping strategy (
A 22-year old male patient has a spontaneous mutation in intron 47 (c.6913-4037T>G) which generates a novel RNA splicing acceptor site (YnNYAG) and results in a pseudoexon of exon 47A (
In conclusion, precision Myo-editing allows us not only to target on DMD “hot spots” (e.g., Riken HPS0164 DMD-iPSCs), but also to easily correct any other rare mutations (e.g., DC0160 DMD). Myo-editing represents a new and powerful approach to permanently eliminate the genetic cause of DMD. Given the potential for durable and progressive therapeutic response in post-mitotic adult tissue, the inventors feel this is an opportune time to apply Myo-editing to permanently correct the muscle abnormalities associated with DMD.
These results show that CRISPR/Cas9-mediated genomic editing is capable of correcting the primary genetic lesion responsible for muscular dystrophy (DMD) and preventing development of characteristic features of this disease in mdx mice. Because genome editing in the germline produced genetically corrected animals with a wide range of mosaicism (2 to 100%), the inventors were able to compare the percent genomic correction with the extent of rescue of normal muscle structure and function. The inventors observed that only a subset of corrected cells in vivo is sufficient for complete phenotypic rescue. As schematized in
Genomic editing could, in principle, be envisioned within postnatal cells in vivo if certain technical challenges can be overcome. For example, there is a need for appropriate somatic cell delivery systems capable of directing the components of the CRISPR/Cas9 system to dystrophic muscle or satellite cells in vivo. In this regard, the non-pathogenic adeno-associated virus (AAV) delivery system has proven to be safe and effective and has already been advanced in clinical trials for gene therapy (Nathwani et al., 2011 and Peng et al., 2005). Moreover, the AAV9 serotype has been shown to provide robust expression in skeletal muscle, heart and brain, the major tissues affected in DMD patients. Other non-viral gene delivery methods, including injection of naked plasmid DNA (Peng et al., 2005), chemically modified mRNA (Kormann et al., 2011 and L. Zangi et al., 2013), and nanoparticles containing nucleic acid (Harris et al., 2010) also warrant consideration. Another challenge with respect to the feasibility of clinical application of the CRISPR/Cas9 system is the increase in body size between rodents and humans, requiring substantial scale-up. More efficient genome editing in post-natal somatic tissues is also needed for the advancement of the CRISPR/Cas9 system into clinical use. Although CRISPR/Cas9 can effectively generate NHEJ-mediated indel mutations in somatic cells, HDR-mediated correction is relatively ineffective in post-mitotic cells, such as myofibers and cardiomyocytes, because these cells lack the proteins essential for homologous recombination (Hsu et al., 2014). Co-expression of components of the HDR pathway with the CRISPR/Cas9 system might enhance HDR-mediated gene repair. Finally, safety issues of the CRISPR/Cas9 system, especially for long-term use, need to be evaluated in preclinical studies in large animal models of disease. Despite the challenges listed above, with rapid technological advances of gene delivery systems and improvements to the CRISPR/Cas9 editing system (Hsu et al., 2014), the approach the inventors describe could ultimately offer therapeutic benefit to DMD and other human genetic diseases in the foreseeable future.
In sum, the approach here uses the CRISPR/Cas9 system to delete the exon splice acceptor upsteam of the exon containing the mutation of the dystrophin gene. This approach makes only a minor change (a few nucleotides) on the genome which will avoid disrupting other functional elements in the intron (enhancer, alternative promoter and microRNA, etc.). This mechanism for gene correction is different than that reported by others. The major spliceosome splices introns containing GU at the 5′ splice site and AG at the 3′ splice site. Cas9, guided by single-guide RNA (sgRNA), binds to a targeted genomic locus next to the protospacer adjacent motif (PAM) and generates a double-strand break (DSB). The PAM sequence for the classical Cas9 (from Streptococcus pyogenes) is NAG or NGG, which means that in principle one can target any of exon with mutations and rescue the gene expression by exon-skipping. In addition, the approach here is to direct genomic editing of satellite cells or myofibers in vivo via delivery of CRISPR/Cas9 system using AAV9 (and other delivery methods). Direct genomic editing in humans has not been reported to date. This direct approach represents a potentially promising alternative method to promote muscle repair in DMD.
All of the compositions and/or methods disclosed and claimed herein can be made and executed without undue experimentation in light of the present disclosure. While the compositions and methods of this disclosure have been described in terms of preferred embodiments, it will be apparent to those of skill in the art that variations may be applied to the compositions and/or methods and in the steps or in the sequence of steps of the method described herein without departing from the concept, spirit and scope of the disclosure. More specifically, it will be apparent that certain agents which are both chemically and physiologically related may be substituted for the agents described herein while the same or similar results would be achieved. All such similar substitutes and modifications apparent to those skilled in the art are deemed to be within the spirit, scope and concept of the disclosure as defined by the appended claims.
The following references, to the extent that they provide exemplary procedural or other details supplementary to those set forth herein, are specifically incorporated herein by reference.
This disclosure claims benefit of priority to U.S. Provisional Application Ser. No. 62/035,584, filed Aug. 11, 2014, the entire contents of which are hereby incorporated by reference.
This invention was made with government support under HL-077439, HL-111665, HL-093039, DK-099653 and U01-HL-100401 awarded by National Institutes of Health. The government has certain rights in the invention.
| Number | Date | Country | |
|---|---|---|---|
| 62035584 | Aug 2014 | US |
