Preclinical and Clinical Development of Treatment for X-linked Retinoschisis

X连锁视网膜劈裂治疗的临床前和临床进展

• 批准号: 9147433
• 负责人: Paul Sieving
• 金额: $ 28.91万
• 依托单位: NATIONAL INSTITUTE ON DEAFNESS AND OTHER COMMUNICATION DISORDERS
• 依托单位国家: 美国
• 资助国家: 美国
• 起止时间: 至
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/9147433
• 关键词: Abnormal Laboratory Test Result; Adolescent; Adult; Adverse event; Affect; Age; Animal Genetics; Animal Model; Antibodies; Atomic Force Microscopy; Binding; Biochemical; Biochemistry; Blood; Cell membrane; Cells; Characteristics; Clinic; Clinical; Clinical Protocols; Clinical Research; Clinical Treatment; Clinical Trials; Cohort Studies; Complementary DNA; Consent; Data; Development; Diagnosis; Disease; Disease Progression; Dose; Elderly; Electroretinography; Enrollment; Eye; FDA approved; Failure; Family member; Female; Functional disorder; Gene Transfer; Genes; Genetic Models; Genetic study; Genotype; Goals; Human; Human Genetics; Image; Inherited; Intervention; Laboratories; Lead; Longitudinal Studies; Macular degeneration; Maps; Measurement; Measures; Membrane; Membrane Potentials; Membrane Proteins; Molecular; Mothers; Mus; Mutation; Nature; Neurodegenerative Disorders; Neurons; Ophthalmic examination and evaluation; Optical Coherence Tomography; Oryctolagus cuniculus; Participant; Pathology; Patients; Pattern; Phase; Phenotype; Phospholipids; Photoreceptors; Preclinical Testing; Preparation; Promoter Regions; Protein Deficiency; Proteins; Protocols documentation; Publishing; Registries; Retina; Retinal; Retinoschisis; Role; Safety; Signal Transduction; Site; Source; Structure; Synapses; Targeted Research; Therapeutic; Therapeutic Intervention; Time; Toxic effect; Translational Research; United States National Institutes of Health; Viral; Viral Vector; Vision; Visual Fields; Work; X Chromosome; X-Linked Retinoschisis; XLRS1 protein; adeno-associated viral vector; base; clinical phenotype; cohort; design; follow-up; good laboratory practice; human disease; human male; improved; inherited retinal degeneration; intravitreal injection; knockout gene; male; molecular pathology; mouse model; neurotransmission; postsynaptic neurons; pre-clinical; primary outcome; promoter; prospective; repaired; response; retinal neuron; secondary outcome; therapy development; treatment effect; treatment trial; vector

This laboratory is titled Translational Research, as we use inherited retinal degenerations identified in the clinic as both a source of information about retinal function and dysfunction and a target for research in therapeutic intervention. Current efforts focus on human X-linked juvenile retinoschisis (XLRS). XLRS is an inherited disease and is a leading cause of juvenile macular degeneration in human males. It is due to mutations in the retinoschisin (RS) gene found on the X chromosome. We are working to understand the disease mechanisms that bring about retinal structural changes and neuronal synaptic signaling deficiency in a mouse model created in this laboratory section. At the same time, we are developing gene transfer therapy using a viral vector to supply a normal copy of the retinoschisin gene to the retina of patients in which it is defective. Our current understanding is based on a study of human affected patients and on analysis of the XLRS animal model, which is a retinoschisin gene knockout(Rs1-KO)mouse . We have probed the biochemistry and sub-cellular localization of the retinoschisin protein and have localized it to particular cell membrane sites of photoreceptors and synapses and measured changes in key membrane proteins in synapses. We discovered molecular interactions between retinoschisin and photoreceptor membrane phospholipids biochemically and with atomic force microscopy that may explain its role in neuronal structure and retinal signaling. We cloned and characterized the human gene promoter region and have identified the key regulatory sites. We characterized the biochemical consequences of certain human mutations in the RS gene, and showed that they lead to an absence of the protein. We have identified mutations that produce more severe and less severe clinical phenotypes. Detailed study of long-term disease progression in the XLRS mouse revealed significant correlations between degenerative structural changes and functional neuronal signaling abnormalities. Our recently published study on synaptic pathology and therapeutic repair in adult retinoschisis mouse we show that RS1 protein deficiency in XLRS causes a unique pattern of molecular failure at the connection between retinal neurons, the synapse, different from that of other mouse models of synaptic dysfunction that limit vision. We found that molecular pathology could be reversed upon provision of the RS1 protein by gene transfer to the adult XLRS mouse retina and that this restored the normal resting potential of postsynaptic neurons. Such studies currently are not possible in human and provide us better understanding of disease mechanisms and give clues on designing appropriate endpoint metrics for eventual human clinical trial. In preparation for a clinical treatment trial for XLRS by viral (AAV) vector retinoschisin gene transfer, we have characterized appropriate intervention times, doses and other parameters that lead to rescue of structure and function in the XLRS mouse. We have shown that gene transfer to affected eyes leads to long term improvement of retinal structure and function as well as expression of retinoschisin protein in retinal cells. We have shown that doses of the vector which produce significant improvement of retinal structure and function are not toxic to the eyes of mice and rabbits in an externally conducted preclinical GLP (Good Laboratory Practices) safety trial which was completed and approved by the FDA this year. This year we initiated a phase I/IIa, prospective, three dose escalation, single-center clinical trial with AAV-RS1. The goal is to evaluate the safety and tolerability of ocular RS1 AAV vector (AAV8-scRS/IRBPhRS) gene transfer to the retina in participants affected with X-linked juvenile retinoschisis (XLRS). Nine male participants affected with XLRS will receive ocular gene transfer, with three participants in each cohort of three dose phases. Additional participants (up to 6) may be enrolled at an identified dose that is well-tolerated and potentially efficacious for a total enrollment of up to 15 participants. One eye of each participant is receiving the RS1 gene vector administered by intravitreal injection. The study will be complete once the final participant in the last study cohort has received 18 months of follow-up. Participants will continue to be followed for up to 15 years after enrollment, or per current FDA requirements, for further safety analysis. The primary outcome is the safety of ocular RS1 AAV vector as determined from assessment of retinal function, ocular structure and occurrence of adverse events and abnormal laboratory tests. Secondary outcomes include changes in visual function, electroretinogram (ERG) responses, retinal imaging with optical coherence tomography (OCT), visual field measurements and the formation of anti-AAV or anti-RS1 antibodies. Ongoing efforts in the lab and the clinic aim to improve understanding of disease mechanism, progression, genotype-phenotype correlation and effect of treatment at different ages. We have seen positive effects of treatment in the mouse model of the XLRS at advanced age, suggesting treatment of humans at an older age could improve visual function. Clinical protocols: Clinical and Genetic Studies of X-Linked Juvenile Retinoschisis ClinicalTrials.gov Identifier: NCT00055029 The objectives of this registry are to understand the nature of the XLRS disease in order to develop appropriate treatments by characterizing the anatomical and functional characteristics of retinoschisis and ultimately generate a well-documented genotype-phenotype correlation map. A minimum of 100 males diagnosed with X-linked retinoschisis will undergo clinical examination and have their blood drawn for genotyping. Blood will also be drawn from available and consenting mothers of affected males. An eye examination will be performed and blood drawn from any symptomatic available and consenting female family members. A maximum of 500 affected males and family members may be enrolled. Sites outside of NIH are participating as referral centers to accumulate the cohort. Study of RS1 Ocular Gene Transfer for X-linked Retinoschisis ClinicalTrials.gov Identifier: NCT02317887 The objective of this registry is to see if the AAV-RS1 vector is safe to use in people. Up to 100 male participants with XLRS will be screened under this protocol. Nine male participants affected with XLRS will receive ocular gene transfer, with three participants in each cohort of three dose phases. Additional participants (up to 6) may be enrolled at an identified dose that is well-tolerated and potentially efficacious for a total enrollment of up to 15 participants. One eye of each participant will receive the RS1 gene vector application administered by intravitreal injection. The primary outcome is the safety of ocular RS1 AAV vector as determined from assessment of retinal function, ocular structure and occurrence of adverse events and abnormal laboratory tests. Secondary outcomes include changes in visual function, electroretinogram (ERG) responses, retinal imaging with optical coherence tomography (OCT), visual field measurements and the formation of anti-AAV or anti-RS1 antibodies.

该实验室的标题为翻译研究，因为我们使用诊所中鉴定出的遗传性视网膜变性既是有关视网膜功能和功能障碍的信息来源，也是治疗干预研究的目标。 当前的努力集中在人类X连锁的少年视网膜（XLR）上。 XLRS是一种遗传性疾病，是男性少年黄斑变性的主要原因。这是由于在X染色体上发现的视网膜感染素（RS）基因中的突变引起的。我们正在努力理解在本实验室部分创建的小鼠模型中导致视网膜结构变化和神经元突触信号不足的疾病机制。同时，我们正在使用病毒载体开发基因转移疗法，以向视网膜感染基因的正常副本提供其缺陷患者的视网膜。 我们目前的理解是基于对人类受影响的患者的研究以及对XLRS动物模型的分析，该模型是视网膜静脉基因基因敲除（RS1-KO）小鼠。我们已经探测了视网膜蛋白的生物化学和亚细胞定位，并将其定位于光感受器和突触的特定细胞膜位点，并测量了突触中关键的膜蛋白的变化。我们在生化上发现了视网膜气概与感光膜磷脂之间的分子相互作用，并与原子力显微镜进行了解释，这可能解释了其在神经元结构和视网膜信号传导中的作用。我们克隆并表征了人类基因启动子区域，并确定了关键的调节位点。我们表征了RS基因中某些人突变的生化后果，并表明它们导致蛋白质的不存在。我们已经确定了产生更严重和更严重的临床表型的突变。 XLRS小鼠长期疾病进展的详细研究表明，退化性结构变化与功能性神经元信号异常之间存在显着相关性。我们最近发表的关于成年视网膜病变小鼠突触病理和治疗修复的研究表明，XLRS中的RS1蛋白缺乏在视网膜神经元之间的连接，突触，与其他突触突触功能障碍的其他小鼠模型不同。我们发现，通过基因转移至成年XLRS小鼠视网膜提供RS1蛋白后，可以逆转分子病理学，这恢复了突触后神经元的正常静息潜力。目前，此类研究在人类中是不可能的，并为我们提供了对疾病机制的更好理解，并提供了设计适当的终点指标以最终人类临床试验的线索。 为了准备通过病毒（AAV）载体视网膜感染基因转移对XLR进行临床治疗试验，我们表征了适当的干预时间，剂量和其他参数，这些参数导致XLRS小鼠中的结构和功能营救。我们已经表明，基因转移到受影响的眼睛会导致视网膜结构和功能的长期改善，以及视网膜细胞中视网膜感染蛋白的表达。我们已经表明，在外部执行的临床前GLP（良好的实验室实践）安全试验中，载体的剂量可显着改善视网膜结构和功能，这对小鼠和兔子的眼睛无毒，该临床前GLP（良好的实验室实践）安全试验已由FDA今年完成并批准。 今年，我们启动了I/IIA期，前瞻性，三个剂量升级，单中心临床试验，AAV-RS1。目的是评估眼部RS1 AAV载体（AAV8-SCRS/IRBPHRS）基因转移到视网膜的安全性和耐受性，该基因受X连锁少年视网膜菌（XLR）影响的参与者。受XLR影响的9名男性参与者将接受眼基因转移，每个队列中有3个参与者的三个剂量阶段。可能会招募其他参与者（最多6岁）的剂量，该剂量具有良好的耐受性且有效的有效性，可为总入学人数多达15名参与者。每个参与者的一只眼睛正在接受玻璃体内注射给药的RS1基因载体。一旦上一项研究队列的最终参与者接受了18个月的随访，该研究将完成。参与者将在入学后或根据当前的FDA要求后继续跟踪15年，以进行进一步的安全分析。主要结果是根据视网膜功能，眼癌结构和不良事件的发生和异常实验室测试的评估确定眼RS1 AAV载体的安全性。次要结果包括视觉功能的变化，电子图（ERG）响应，具有光学相干断层扫描（OCT）的视网膜成像，视野测量以及抗AAV或抗RS1抗体的形成。 实验室和诊所的持续努力旨在提高对疾病机制，进展，基因型 - 表型相关性以及治疗在不同年龄的影响的理解。我们已经看到治疗在高龄XLR小鼠模型中的积极影响，这表明在年龄较大的人类治疗可以改善视觉功能。 临床方案： X连锁少年视网膜的临床和遗传研究 临床标识符：NCT00055029 该注册表的目的是了解XLRS疾病的性质，以通过表征视网膜的解剖学和功能特征来开发适当的治疗方法，并最终产生有据可查的基因型 - 原型相关图。至少有100名被诊断为X连锁视网膜静脉曲子的男性将接受临床检查，并吸收其血液进行基因分型。血液也将从可用的和同意的男性母亲中得知。将进行眼科检查，并从任何有症状的女性家庭成员中抽血。最多可能会招募500名受影响的男性和家庭成员。 NIH以外的地点是作为推荐中心的参与，以积累该队列。 X连锁视网膜的RS1眼基因转移的研究 临床标识符：NCT02317887 该注册表的目的是查看AAV-RS1向量是否安全地用于人。在此协议下，将筛选多达100名具有XLR的男性参与者。受XLR影响的9名男性参与者将接受眼基因转移，每个队列中有3个参与者的三个剂量阶段。可能会招募其他参与者（最多6岁）的剂量，该剂量具有良好的耐受性且有效的有效性，可为总入学人数多达15名参与者。每个参与者的一只眼睛将收到玻璃体内注射给药的RS1基因载体应用。主要结果是根据视网膜功能，眼癌结构和不良事件的发生和异常实验室测试的评估确定眼RS1 AAV载体的安全性。次要结果包括视觉功能的变化，电子图（ERG）响应，具有光学相干断层扫描（OCT）的视网膜成像，视野测量以及抗AAV或抗RS1抗体的形成。