From gene transfer to gene therapy in lysosomal storage diseases affecting the central nervous system

Gene transfer into the central nervous system (CNS) is one of the foremost scientific challenges today. To give a brief survey of possible approaches to gene therapy in diseases affecting the CNS, we have selected the lysosomal storage diseases (LDS), which are an excellent model of both early-onset infantile neurological forms and late-onset adult psychiatric forms. Lysosomal storage diseases represent a group of about 50 monogenic metabolic disorders resulting from a deficiency in intralysosomal enzymes involved in macromolecule catabolism. The clinical severity, including neuropsychiatric symptoms, and the absence of an efficient therapy for the majority of these disorders prompted the various trials of gene therapy now in progress. Most of the genes encoding the normal lysosomal enzymes have been cloned, and the size of the corresponding cDNAs is generally compatible with their transfer by recombinant vectors. New vectors with improved immunogenicity, transduction efficacy, insert capacity, and specificity of targeting are under development. Here we discuss several gene therapy strategies for the correction of LSD-induced anomalies in the CNS. Interesting results have been obtained by animal model brain, which raises hopes that large-scale clinical trials may soon be started.     

Correction of alpha-L-fucosidase deficiency in fucosidosis fibroblasts by retroviral vector-mediated gene transfer.

A full-length cDNA clone encoding the lysosomal hydrolase alpha-L-fucosidase was cloned into two retroviral vectors, one using the human cytomegalovirus immediate-early promoter for expression, and the other, the retroviral long terminal repeat (LTR). High-titer amphotropic virus was produced for both constructs by infection of PA317 cells, and used to efficiently transduce the alpha-L-fucosidase gene into both human and canine fucosidosis fibroblasts. This resulted in correction of the alpha-L-fucosidase enzyme deficiency characteristic of these fibroblasts. The high levels of recombinant enzyme produced corrected the degradative defect normally seen in these cells, enabling them to catabolize efficiently the accumulated storage product present in lysosomes. Therefore, these retroviral constructs should allow us to start evaluating the value of gene therapy in treating the central nervous system pathology associated with fucosidosis and other lysosomal storage disorders in humans, using a canine model of fucosidosis.     

Gene therapy in lysosomal diseases

Lysosomal storage diseases are monogenic metabolic disorders resulting from a deficiency in intralysosomal enzymes involved in macromolecule catabolism. Various groups have been delineated according to the affected pathway and the accumulated substrate: mucopolysaccharidoses, lipidoses, glycoproteinoses and glycogenosis type II. Their clinical severity and the absence of efficient therapy for the majority of these disorders justify the development of gene transfer methods. Most of the genes encoding the normal lysosomal enzymes have been cloned and recently numerous animal models have been obtained for nearly all these diseases. Due to the clinical heterogeneity of lysosomal diseases, showing multivisceral involvement or affecting predominantly the reticuloendothelial system, muscle or central nervous system, various gene therapy strategies have to be developed. Vectors, ways of access, results and limits will be reviewed. Interesting results have already been obtained in the gene transfer for lysosomal diseases, but improvements are needed before a future application to humans.     

Mucolipidosis II and III. The genetic relationships between two disorders of lysosomal enzyme biosynthesis.

The genetic relationships between the multiple variants of mucolipidosis II (I-cell disease) and mucolipidosis III (pseudo-Hurler polydystrophy) were investigated with a sensitive genetic complementation analysis procedure. These clinically distinct disorders have defects in the synthesis of a recognition marker necessary for the intracellular transport of acid hydrolases into lysosomes. Both disorders are associated with an inherited deficiency of a uridine diphosphate-N-acetyl-glucosamine: lysosomal enzyme precursor N-acetyl-glucosamine-phosphate transferase activity. We had previously shown that both disorders are genetically heterogeneous. Complementation analysis between mucolipidosis II and III fibroblasts indicated an identity of mucolipidosis II with one of the three mucolipidosis III complementation groups (ML IIIA), suggesting a close genetic relationship between these groups. The presence of several instances of complementation within this group suggested an intragenic complementation mechanism. Genetic complementation in heterokaryons resulted in increases in N-acetyl-glucosamine-phosphate transferase activity, as well as in the correction of lysosomal enzyme transport. This resulted in increases in the intracellular levels of several lysosomal enzymes and in the correction of the abnormal electrophoretic mobility pattern of intracellular beta-hexosaminidase. The findings demonstrate that a high degree of genetic heterogeneity exists within these disorders. N-acetyl-glucosamine-phosphate transferase is apparently a multicomponent enzyme with a key role in the biosynthesis and targeting of lysosomal enzymes.     

Lentivirus-mediated gene transfer to the central nervous system: therapeutic and research applications

The management of disorders of the nervous system remains a medical challenge. The key goals are to understand disease mechanisms, to validate therapeutic targets, and to develop new therapeutic strategies. Viral vector-mediated gene transfer can meet these goals and vectors based on lentiviruses have particularly useful features. Lentiviral vectors can deliver 8 kb of sequence, they mediate gene transfer into any neuronal cell type, expression and therapy are sustained, and normal cellular functions in vitro and in vivo are not compromised. After delivery into the nervous system they induce no significant immune responses, there are no unwanted side effects of the vectors per se to date, and manufacturing and safety testing for clinical applications are well advanced. There are now numerous examples of effective long-term treatment of animal models of neurological disorders, such as Parkinson's disease, Alzheimer's disease, Huntington's disease, motor neuron diseases, lysosomal storage diseases, and spinal injury, using a range of therapeutic genes expressed in lentiviral vectors. Significant issues remain in some areas of neural gene therapy including defining the optimum therapeutic gene(s), increasing the specificity of delivery, regulating expression of potentially toxic genes, and designing clinically relevant strategies. We discuss the applications of lentiviral vectors in therapy and research and highlight the essential features that will ensure their translation to the clinic in the near future.     

Pathobiochemical aspects of lysosomal enzymes with special reference to lysosomal storage diseases (author's transl)]

Lysosomal hydrolases participate substantially in the degradation of all classes of biological macromolecules. They act physiologically within the lysosome. The enzymes are either primarily included within primary lysosomes or are transported to these cell organelles after secretion and subsequent adsorptive pinocytosis. The involvement of these enzymes in a variety of pathological conditions can be understood on the basis of the known functions of lysosomal hydrolases. Inactivity of one or several of the enzymes causes lysosomal storage disorders. Similar metabolic consequences are found when the enzymes are unable to be concentrated within the lysosome. Lysosomal hydrolases participate, furthermore, in the pathogenesis of numerous diseases. A distinction can be made between lysosomal overload, pathologically-increased enzyme secretion into the extracellular space, and a release of lysosomal enzymes into the cytosol.     

Correction of acid beta-galactosidase deficiency in GM1 gangliosidosis human fibroblasts by retrovirus vector-mediated gene transfer: higher efficiency of release and cross-correction by the murine enzyme

Mutations in the lysosomal acid beta-galactosidase (EC 3.2.1.23) underlie two different disorders: GM1 gangliosidosis, which involves the nervous system and visceral organs to varying extents, and Morquio's syndrome type B (Morquio B disease), which is a skeletal-connective tissue disease without any CNS symptoms. This article shows that transduction of human GM1 gangliosidosis fibroblasts with retrovirus vectors encoding the human acid beta-galactosidase cDNA leads to complete correction of the enzymatic deficiency. The newly synthesized enzyme is correctly processed and targeted to the lysosomes in transduced cells. Cross-correction experiments using retrovirus-modified cells as enzyme donors showed, however, that the human enzyme is transferred at low efficiencies. Experiments using a different retrovirus vector carrying the human cDNA confirmed this observation. Transduction of human GM1 fibroblasts and mouse NIH 3T3 cells with a retrovirus vector encoding the mouse beta-galactosidase cDNA resulted in high levels of enzymatic activity. Furthermore, the mouse enzyme was found to be transferred to human cells at high efficiency. Enzyme activity measurements in medium conditioned by genetically modified cells suggest that the human beta-galactosidase enzyme is less efficiently released to the extracellular space than its mouse counterpart. This study suggests that lysosomal enzymes, contrary to the generalized perception in the field of gene therapy, may differ significantly in their properties and provides insights for design of future gene therapy interventions in acid beta-galactosidase deficiency.     

Cell imaging and morphology: application to studies of inherited purine metabolic disorders

A number of inherited or drug-induced metabolic disorders involving dysfunctions in purines and pyrimidines are strongly associated with neurological dysfunction, e.g., Lesch Nyhan syndrome. Such disorders have been studied extensively using biochemical and molecular techniques in order to examine how such defects occur, sometimes using in vitro models based upon cultured neuroblastoma cell lines. However, these metabolic dysfunctions may manifest their effects in other ways, such as impaired synaptic transmission and gross abnormalities in neuronal growth and differentiation. This review outlines the latter novel facet of purine research. It is proposed that by employing cell imaging techniques and cultured neuroblastoma cell lines, believed to model the nervous system, significant insights into how inherited disorders of purine metabolism affect neuronal development can be obtained. This review provides an example of the application of these techniques to understand the etiology of Lesch Nyhan syndrome, and encourages further study of the role of purines and pyrimidines in the development of the nervous system.     

Histopathological and behavioral improvement of murine mucopolysaccharidosis type VII by intracerebral transplantation of neural stem cells.

The therapeutic efficacy of neural stem cell transplantation for central nervous system (CNS) lesions in lysosomal storage disorders was explored using a murine model of mucopolysaccharidosis type VII (MPS VII). We used fetal neural stem cells derived from embryonic mouse striata and expanded in vitro by neurosphere formation as the source of graft materials. We transplanted neurospheres into the lateral ventricles of newborn MPS VII mice and found that donor cells migrated far beyond the site of injection within 24 h, and some of them could reach the olfactory bulb. A quantitative measurement indicated that the GUSB activity in the brain was 12.5 to 42.3% and 5.5 to 6.3% of normal activity at 24 h and 3 weeks after transplantation. In addition, histological analysis revealed a widespread decrease in lysosomal storage in the recipient's hippocampus, cortex, and ependyma. A functional assessment with novel-object recognition tests confirmed improvements in behavioral patterns. These results suggest that intracerebral transplantation of neural stem cells is feasible for treatment of CNS lesions associated with lysosomal storage disorders.     

Intrathecal Gene Therapy Corrects CNS Pathology in a Feline Model of Mucopolysaccharidosis I

Enzyme replacement therapy has revolutionized the treatment of the somatic manifestations of lysosomal storage diseases (LSD), although it has been ineffective in treating central nervous system (CNS) manifestations of these disorders. The development of neurotrophic vectors based on novel serotypes of adeno-associated viruses (AAV) such as AAV9 provides a potential platform for stable and efficient delivery of enzymes to the CNS. We evaluated the safety and efficacy of intrathecal delivery of AAV9 expressing α-l-iduronidase (IDUA) in a previously described feline model of mucopolysaccharidosis I (MPS I). A neurological phenotype has not been defined in these animals, so our analysis focused on the biochemical and histological CNS abnormalities characteristic of MPS I. Five MPS I cats were dosed with AAV9 vector at 4–7 months of age and followed for 6 months. Treated animals demonstrated virtually complete correction of biochemical and histological manifestations of the disease throughout the CNS. There was a range of antibody responses against IDUA in this cohort which reduced detectable enzyme without substantially reducing efficacy; there was no evidence of toxicity. This first demonstration of the efficacy of intrathecal gene therapy in a large animal model of a LSD should pave the way for translation into the clinic.     

Adenovirus-mediated prenatal gene transfer to murine central nervous system

In some lysosomal storage disorders pathological alterations in the central nervous system (CNS) occur as early as the prenatal period and the neuropathology progresses rapidly soon after birth. In these diseases, postnatal therapies alone are often insufficient. Therefore prenatal gene therapy to the CNS may be necessary. In order to investigate the feasibility of gene transfer to the CNS prenatally, we administered recombinant adenovirus carrying LacZ gene to rat embryos from embryonic day 9 to 12 (E9-E12). Results showed that efficient transduction of the reporter gene to the CNS was achieved when adenoviruses were injected at E12. The regions where the reporter gene was transduced mainly localized at the telencephalon and hypophysis of the embryo, and the gene expression persisted at least 1 week after birth. In addition, when adenoviruses were injected at E9, E10 and E11, no transgene expression was detected in the CNS, but was mainly observed in the liver, the heart and the skin, respectively.     

The abdominal brain and enteric nervous system

Conventional medical treatment for neurologic disorders such as epilepsy, migraine, and autism focuses on the brain. Although standard medical treatment is often helpful, the underlying causes of these disorders are not well understood. Furthermore, some individuals respond poorly or not at all to regular medicine. Evidence is accumulating in the medical literature that the enteric nervous system (ENS)-that part of the nervous system associated with the alimentary canal-also plays a role in these disorders. Historically, the concept of an autonomous abdominal nervous system was advocated by Byron Robinson, Johannis Langley, and Edgar Cayce. The work of these three prominent historical figures is considered along with modem view-points on the abdominal nervous system. Complementary therapies that address the nervous system of the abdomen have potential as useful adjuncts to conventional treatment for certain neurologic disorders.     

The use of platelets as models for neurons: possible applications to the investigation of eating disorders

The pathogenesis of eating disorders is still unclear. However, there is evidence that neurotransmitters may be involved in the control of satiety/appetite. Investigating these disorders could be facilitated if a readily available human cell model were to reflect central nervous system (CNS) function. Platelets may satisfy, at least partially, this requirement. We discuss here the use of platelets as neuronal models with an emphasis on eating disorders.     

The Pharmacological Chaperone N-butyldeoxynojirimycin Enhances Enzyme Replacement Therapy in Pompe Disease Fibroblasts

In spite of the progress in the treatment of lysosomal storage diseases (LSDs), in some of these disorders the available therapies show limited efficacy and a need exists to identify novel therapeutic strategies. We studied the combination of enzyme replacement and enzyme enhancement by pharmacological chaperones in Pompe disease (PD), a metabolic myopathy caused by the deficiency of the lysosomal acid α-glucosidase. We showed that coincubation of Pompe fibroblasts with recombinant human α-glucosidase and the chaperone N-butyldeoxynojirimycin (NB-DNJ) resulted in more efficient correction of enzyme activity. The chaperone improved α-glucosidase delivery to lysosomes, enhanced enzyme maturation, and increased enzyme stability. Improved enzyme correction was also found in vivo in a mouse model of PD treated with coadministration of single infusions of recombinant human α-glucosidase and oral NB-DNJ. The enhancing effect of chaperones on recombinant enzymes was also observed in fibroblasts from another lysosomal disease, Fabry disease, treated with recombinant α-galactosidase A and the specific chaperone 1-deoxygalactonojirimycin (DGJ). These results have important clinical implications, as they demonstrate synergy between pharmacological chaperones and enzyme replacement. A synergistic effect of these treatments may result particularly useful in patients responding poorly to therapy and in tissues in which sufficient enzyme levels are difficult to obtain.     

Radiologic and neuroradiologic findings in the mucopolysaccharidoses

The mucopolysaccharidoses (MPS) represent a group of inheritable, clinically heterogeneous lysosomal storage disorders, in which progressive accumulation of glycosaminoglycans (GAGs) can affect organs and tissues all over the body. The current paper discusses the skeletal X-ray and neuroimaging findings in MPS patients, and the imaging techniques that can be used for diagnosing and monitoring abnormalities in the skeleton and central nervous system. Most MPS types show a typical radiologic expression, called dysostosis multiplex, which manifests as malformations of the skeletal system involving bones in the skull, thorax, spine, pelvis, long bones, and hands. Abnormalities of the spine and GAG deposits in the meninges surrounding the spinal cord can result in spinal cord compression, which, if untreated, can lead to compressive myelopathy. Magnetic resonance imaging (MRI) is the most powerful imaging technique for detecting spinal cord compression, but also radiography and computed tomography are useful. GAG deposits in the brain and surrounding tissues can result in brain anomalies, i.e. white matter lesions, brain atrophy, and hydrocephalus, which can be detected using MRI. Skeletal X-ray and neuroimaging findings can play an important role in diagnosis, follow-up, surgical or medical planning, and assessment of treatment response in MPS patients. There is a need for standardized procedures in evaluating and monitoring neurologic complications in these patients.     

Lysosomal Exocytosis in Schwann Cells Contributes to Axon Remyelination

髓鞘形成是一个包括协同性的胞吐、内吞、mRNA转运和细胞骨架的动态变化的复杂过程。尽管髓鞘的异常在溶酶体贮积症中很常见,但对溶酶体在髓鞘形成和维持中所扮演的角色仍不清楚。本文发现Schwann细胞中的晚期内涵体/溶酶体包含大量的髓鞘蛋白P0,含量占超过一半的外周神经系统中的致密髓鞘的总蛋白并且在不同的刺激下表现出Ca2+依赖性的胞吐作用。Rab27a(一种将分泌溶酶体运输至细胞膜的小GTP酶)下调,极大地阻碍了Schwann细胞中的溶酶体胞吐作用,减少了再生坐骨神经的髓鞘形成。这些发现强调了Schwann细胞中溶酶体的新角色,提示调节Schwann细胞中的溶酶体胞吐作用在外周神经系统中有很重要的生理和病理意义。     

Role of grandaxin in the treatment of functional gastrointestinal diseases

AIM: To assess efficacy of grandaxine in correction of anxiety syndrome and vegetative dysfunction in patients with gastrointestinal diseases. MATERIAL AND METHODS: The trial included 59 patients with functional gastrointestinal, emotional and vegetative disorders who failed standard therapy. 43 patients of the test group received standard therapy in combination with grandaxine. RESULTS: Anxiety (Spilberg-Khanin scale), vegetative dysfunction (Vein scale) reduced in 90% of the patients of the test group more significantly than in the control group. Intestinal passage in patients with irritable colon syndrome improved also. CONCLUSION: A pronounced role of psychovegetative disorders was confirmed in development of functional gastrointestinal disorders. Grandaxine proved efficient in correction of such disorders irrespective of location of the pathology and prevalent tonicity of the autonomic nervous system.     

Gastrointestinal motility and autonomic nerve dysfunction]

Gastrointestinal motility is greatly influenced by both the autonomic nervous system (ANS) and the enteric nervous system (ENS). Dysfunction of ANS and/or ENS produces various kinds of dysmotility from the esophagus to the colon. Generalized autonomic dysfunction, often seen in diabetics, causes abnormal peristaltic waves in the esophagus, abnormal electrical activity of the stomach, delayed gastric emptying and delayed intestinal transit. Localized disorders of the enteric nervous system is seen in patients with achalasia and Hirschsprung's diseases. Functional disorders, without evidence of organic disorders, like non-cardiac chest pain, non-ulcer dyspepsia, irritable bowel syndrome, can be partly caused by abnormal function of autonomic nervous system.     

Immunotherapeutic approaches to paraneoplastic neurological disorders

The review presents an overview on the pathogenesis of paraneoplastic neurological disorders (PNDs) and the current therapeutic immunosuppressive or immunomodulatory strategies used in these patients. PNDs are disturbances in the functioning of the nervous system in cancer patients, where the disturbances are not due to a local effect of the tumour or its metastases. Most of these clinically, well-defined syndromes in adults are associated with lung cancer (especially small cell lung cancer), lymphomas and gynaecological tumours. Since autoantibodies directed against proteins expressed in neurons and tumour cells have been found, PNDs are suspected to be autoimmune. In neuromuscular PND, immunosuppressive therapies, plasmapheresis and intravenous immunoglobulins are effective treatments. In contrast, central nervous system PNDs seen in adults are by far the most problematic group to treat. With exception of the stiff-man syndrome, immunosuppression appears to have little effect on these neurological disorders. Tumour therapy stabilises PNDs but does not cause improvement. Plasmapheresis reduces the autoantibody titre in the sera of these patients but, like tumour therapy, does not lead to a clinical improvement. In children with paraneoplastic opsoclonus-myoclonus syndrome, steroids and intravenous immunoglobulins may lead to a complete or partial remission of PNDs.     

Systemic cardiovascular effects of intracranial disorders: implications for nursing care

Autonomic nervous system imbalances are implicated in the genesis of cardiovascular systemic effects of brain disorders. With many potentially lethal cardiovascular problems, sympathetic predominance over parasympathetic stimuli prevails. Autonomic nervous system imbalances may be caused not only by over-activity or depression of either the sympathetic or parasympathetic nervous systems but also by unchanged activity of one and depression or overactivity of the other. Because the autonomic nervous system has representation in all levels of the brain, it becomes apparent why diverse brain disorders could trigger these effects. It is possible that more than one systemic effect may occur in a patient during the course of an acute brain insult. The hypothalamus, with its anterior parasympathetic nervous system centers and posterolateral sympathetic nervous system centers, plays an important role in the autonomic nervous system. Its role has been more clearly identified than other portions of the central autonomic system. Nursing implications for the care of patients with cardiovascular effects have been identified. Many of these effects may go unnoticed in the early stages because of lack of knowledge; consequently, opportunities for early therapeutic interventions are lost to the detriment of the patient. These effects, when unrecognized and untreated, compound the primary and secondary intracranial insults. They can contribute to the rapid deterioration and demise of the patient, especially if he is unstable and has lost intracranial compliance, autoregulation, and vasomotor tone. Because many of these patients, have had no evidence of cardiovascular problems prior to the acute brain insult, it behooves nurses to familiarize themselves with the signs and symptoms of the systemic cardiovascular effects and appropriately intervene to prevent or offset the complications they produce in the acutely brain-damaged patient.