Leber's Hereditary Optic Neuropathy: Gene Therapy Clinical Trial

描述(申请人提供)：在过去的十年里，我们在确定Leber遗传性视神经病变(LHON)的发病机制和测试治疗方法方面取得了重大进展。我们成功地在核遗传密码中表达了复合体I的野生型人NADH泛醌氧化还原酶亚单位4(ND4)。通过线粒体靶向序列的作用，蛋白质被输入到线粒体。将该基因包装成新一代酪氨酸对苯丙氨酸修饰的自补充腺相关病毒(AAV)，然后注射到啮齿类动物的眼睛内。注射后1d，在大多数视网膜内神经元中快速检测到标记有标志的野生型人ND4，并整合成复合体I。此外，在注射了与大多数LHON有关的突变型Gl 1778A ND4同系物的啮齿类动物眼中，野生型ND4恢复了缺陷的ATP合成，抑制了视力损失，减少了视网膜神经节细胞的凋亡，防止了视神经轴突的长期死亡。自补性野生型ND4以相应的滴度注射到体外人眼中，在大多数视网膜神经节细胞中表达，表明它在我们的LHON患者中也会表达。玻璃体内注射未标记ND4的灵长类动物未见不良反应，提示该载体可作为LHON临床检测的安全有效平台。我们在这项应用中的目标是在G11778A线粒体DNA突变患者的I阶段临床试验中测试AAV介导的人ND4基因传递的安全性，然后进入II阶段研究，以在该计划的最后几年证明有效性。第一阶段将包括开放标记的单侧单剂量AAV-ND4玻璃体内注射，在剂量递增研究中，在较差的眼睛内注射AAV-ND4，调查三种载体剂量(5x10e9 Vg，2.46x10e10 Vg和1xlOel1 Vg)在少数分子确认的Gl 1778A突变的线粒体DNA患者中的安全性，这些患者患有慢性双侧严重视力丧失1年以上(目标1)或急性双侧多个视力丧失1年以上(目标2)。在视力较好的眼睛，但我们知道在第一只眼睛出现视力丧失后6个月内注定会丧失显着视力(目标3)。

DESCRIPTION (provided by applicant): Over the past decade, we have made major strides towards determining the pathogenesis and testing a treatment for Leber's Hereditary Optic Neuropathy (LHON). We successfully expressed the wild-type human NADH ubiquinone oxidoreductase subunit 4 (ND4) of complex I in the nuclear genetic code. The protein was imported into the mitochondria by agency of a mitochondrial targeting sequence. The gene was packaged into next generation tyrosine to phenylalanine modified self-complementary adenoassociated virus (AAV) then injected into rodent eyes. FLAG-tagged wild-type human ND4 was detected quickly in most inner retinal neurons by 1 day post injection and it integrated into Complex I. Furthermore, in rodent eyes also injected with a mutant Gl 1778A ND4 homologue responsible for most cases of LHON, wild-type ND4 restored defective ATP synthesis, suppressed visual loss, reduced apoptosis of retinal ganglion cells and prevented demise of axons in the optic nerve that persisted long-term. The self-complementary wild-type ND4 injected at the relevant titer into the ex vivo human eye expressed in most retinal ganglion cells, suggesting that it will do so in our LHON patients. Primates vitreally injected with untagge ND4 had no adverse reactions, suggesting that this vector should be a safe and effective platform for clinical testing in LHON. Our goal in this application is to test the safety of AAV-mediated delivery of the human ND4 gene in a Phase I clinical trial of patients with mutated G11778A mtDNA and then move to a Phase II study to prove efficacy in the later years of this program. Phase I will consist of an open-label, unilateral, single-dose intravitreal injection of AAV-ND4 per patient in the worse eye in a dose-escalation study investigating the safety of three vector doses (5x10e9 vg, 2.46x10e10 vg and 1xlOel1 vg) in a small number of patients with molecularly confirmed Gl 1778A-mutated mitochondrial DNA who have chronic bilateral, severe visual loss for more than 1 year (Aim 1) or acute bilateral several visual loss for less tha 1 year (Aim 2), and then, lastly, in the eye with better vision but that we know is predestined to lose significant vision within 6 months from the onset of visual loss in the first eye (Aim 3).