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.

该实验室名为“转化研究”，因为我们使用临床中发现的遗传性视网膜变性作为有关视网膜功能和功能障碍的信息来源以及治疗干预研究的目标。 目前的工作重点是人类 X 连锁青少年视网膜劈裂症 (XLRS)。 XLRS 是一种遗传性疾病，是人类男性青少年黄斑变性的主要原因。这是由于 X 染色体上的视网膜裂素 (RS) 基因突变造成的。我们正在努力了解在本实验室部分创建的小鼠模型中引起视网膜结构变化和神经元突触信号传导缺陷的疾病机制。与此同时，我们正在开发基因转移疗法，使用病毒载体向有缺陷的患者的视网膜提供正常的视网膜劈裂素基因拷贝。 我们目前的理解是基于对人类受影响患者的研究以及对 XLRS 动物模型（视网膜裂素基因敲除 (Rs1-KO) 小鼠）的分析。我们探究了视黄体分裂素蛋白的生物化学和亚细胞定位，并将其定位到光感受器和突触的特定细胞膜位点，并测量了突触中关键膜蛋白的变化。我们通过生物化学和原子力显微镜发现了视网膜裂素和光感受器膜磷脂之间的分子相互作用，这可以解释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，并确定了关键的调控位点。我们表征了 RS 基因中某些人类突变的生化后果，并表明它们导致了该蛋白质的缺失。我们已经确定了产生更严重和不太严重的临床表型的突变。 对 XLRS 小鼠长期疾病进展的详细研究揭示了退行性结构变化与功能性神经元信号异常之间的显着相关性。我们最近发表的关于成年视网膜劈裂小鼠的突触病理学和治疗性修复的研究表明，XLRS 中的 RS1 蛋白缺乏会导致视网膜神经元之间的连接（突触）出现独特的分子故障模式，这与其他突触功能障碍小鼠模型不同。限制视力。我们发现通过基因转移到成年 XLRS 小鼠视网膜提供 RS1 蛋白后，分子病理学可以逆转，这恢复了突触后神经元的正常静息电位。此类研究目前在人类中是不可能的，可以让我们更好地了解疾病机制，并为最终的人类临床试验设计适当的终点指标提供线索。 在准备通过病毒（AAV）载体视网膜分裂素基因转移进行 XLRS 临床治疗试验时，我们确定了适当的干预时间、剂量和其他参数，以挽救 XLRS 小鼠的结构和功能。我们已经证明，将基因转移到受影响的眼睛会导致视网膜结构和功能以及视网膜细胞中视网膜分裂素蛋白的表达的长期改善。在一项外部进行的临床前 GLP（良好实验室规范）安全性试验中，我们已经证明，能显着改善视网膜结构和功能的载体剂量对小鼠和兔子的眼睛没有毒性，该试验今年已完成并获得 FDA 批准。 今年，我们启动了 AAV-RS1 的 I/IIa 期、前瞻性、三剂量递增、单中心临床试验。目标是评估眼部 RS1 AAV 载体 (AAV8-scRS/IRBPhRS) 基因转移到 X 连锁青少年视网膜劈裂 (XLRS) 参与者视网膜的安全性和耐受性。九名受 XLRS 影响的男性参与者将接受眼部基因转移，三个剂量阶段的每个队列中有三名参与者。额外的参与者（最多 6 名）可以按照耐受性良好且对于总共最多 15 名参与者可能有效的确定剂量进行招募。每个参与者的一只眼睛接受通过玻璃体内注射施用的 RS1 基因载体。一旦最后一个研究队列的最终参与者接受了 18 个月的随访，该研究即告完成。参与者将在入组后或根据 FDA 现行要求继续进行长达 15 年的跟踪，以进行进一步的安全性分析。主要结果是通过评估视网膜功能、眼部结构以及不良事件和异常实验室测试的发生来确定眼部 RS1 AAV 载体的安全性。次要结果包括视功能的变化、视网膜电图 (ERG) 反应、光学相干断层扫描 (OCT) 视网膜成像、视野测量以及抗 AAV 或抗 RS1 抗体的形成。 实验室和临床的持续努力旨在提高对疾病机制、进展、基因型-表型相关性以及不同年龄治疗效果的了解。我们在高龄 XLRS 小鼠模型中看到了治疗的积极效果，这表明对老年人类进行治疗可以改善视觉功能。 临床方案： X连锁青少年视网膜劈裂症的临床和遗传学研究 ClinicalTrials.gov 标识符：NCT00055029 该登记的目的是了解 XLRS 疾病的性质，以便通过表征视网膜劈裂的解剖和功能特征来开发适当的治疗方法，并最终生成有据可查的基因型-表型相关图。至少 100 名被诊断患有 X 连锁视网膜劈裂症的男性将接受临床检查并抽血进行基因分型。还将从受影响男性的可用且同意的母亲处抽取血液。将进行眼部检查，并从任何有症状且同意的女性家庭成员中抽血。最多可招募 500 名受影响的男性和家庭成员。 NIH 以外的站点正在作为转诊中心参与以积累队列。 RS1眼部基因转移治疗X连锁视网膜劈裂症的研究 ClinicalTrials.gov 标识符：NCT02317887 该注册表的目的是了解 AAV-RS1 载体在人类中使用是否安全。根据该方案，将筛选最多 100 名 XLRS 男性参与者。九名受 XLRS 影响的男性参与者将接受眼部基因转移，三个剂量阶段的每个队列中有三名参与者。额外的参与者（最多 6 名）可以按照耐受性良好且对于总共最多 15 名参与者可能有效的确定剂量进行招募。每个参与者的一只眼睛将接受通过玻璃体内注射进行的 RS1 基因载体应用。主要结果是通过评估视网膜功能、眼部结构以及不良事件和异常实验室测试的发生来确定眼部 RS1 AAV 载体的安全性。次要结果包括视功能的变化、视网膜电图 (ERG) 反应、光学相干断层扫描 (OCT) 视网膜成像、视野测量以及抗 AAV 或抗 RS1 抗体的形成。