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Gene therapy for β-thalassaemia: the continuing challenge

  • Evangelia Yannaki (a1), David W. Emery (a2) (a3) and George Stamatoyannopoulos (a2) (a4)

The β-thalassaemias are inherited anaemias that form the most common class of monogenic disorders in the world. Treatment options are limited, with allogeneic haematopoietic stem cell transplantation offering the only hope for lifelong cure. However, this option is not available for many patients as a result of either the lack of compatible donors or the increased risk of transplant-related mortality in subjects with organ damage resulting from accumulated iron. The paucity of alternative treatments for patients that fall into either of these categories has led to the development of a revolutionary treatment strategy based on gene therapy. This approach involves replacing allogeneic stem cell transplantation with the transfer of normal globin genes into patient-derived, autologous haematopoietic stem cells. This highly attractive strategy offers several advantages, including bypassing the need for allogeneic donors and the immunosuppression required to achieve engraftment of the transplanted cells and to eliminate the risk of donor-related graft-versus-host disease. This review discusses the many advances that have been made towards this endeavour as well as the hurdles that must still be overcome before gene therapy for β-thalassaemia, as well as many other gene therapy applications, can be widely applied in the clinic.

Corresponding author
*Corresponding author: Evangelia Yannaki, G. Papanicolaou Hospital, Gene and Cell Therapy Center, Hematology-BMT Unit, Thessaloniki 57010, Greece. E-mail:
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3 G. Lucarelli , M. Andreani and E. Angelucci (2002) The cure of thalassemia by bone marrow transplantation. Blood Reviews 16, 81-85

4 D. Gaziev (1997) Graft-versus-host disease after bone marrow transplantation for thalassemia: an analysis of incidence and risk factors. Transplantation 63, 854-860

7 G. La Nasa (2005) Unrelated donor stem cell transplantation in adult patients with thalassemia. Bone Marrow Transplantation 36, 971-975

8 D. Gaziev (2000) Bone marrow transplantation from alternative donors for thalassemia: HLA-phenotypically identical relative and HLA-nonidentical sibling or parent transplants. Bone Marrow Transplantation 25, 815-821

9 G. Lucarelli and J. Gaziev (2008) Advances in the allogeneic transplantation for thalassemia. Blood Reviews 22, 53-63

10 L. Lisowski and M. Sadelain (2008) Current status of globin gene therapy for the treatment of beta-thalassaemia. British Journal of Haematology 141, 335-345

11 D.W. Emery (2002) Hematopoietic stem cell gene therapy. International Journal of Hematology 75, 228-236

12 D.B. Kohn (2003) American Society of Gene Therapy (ASGT) ad hoc subcommittee on retroviral-mediated gene transfer to hematopoietic stem cells. Molecular Therapy 8, 180-187

13 C. Berry (2006) Selection of target sites for mobile DNA integration in the human genome. PLoS Computation Biology 2, e157

14 D.W. Emery , M. Aker and G. Stamatoyannopoulos (2003) Chromatin insulators and position effects. In Gene Transfer and Expression in Mammalian Cells ( S.C. Makrides , ed.), pp. 381-395, EIC Laboratories, Inc., Norwood, MA, USA

15 Q. Li (2002) Locus control regions. Blood 100, 3077-3086

16 F. Grosveld (1987) Position-independent, high-level expression of the human beta-globin gene in transgenic mice. Cell 51, 975-985

17 G. Blom van Assendelft (1989) The beta-globin dominant control region activates homologous and heterologous promoters in a tissue-specific manner. Cell 56, 969-977

18 S. Karlsson (1987) Retroviral-mediated transfer of genomic globin genes leads to regulated production of RNA and protein. Proceedings of the National Academy of Sciences of the United States of America 84, 2411-2415

19 E.A. Dzierzak , T. Papayannopoulou and R.C. Mulligan (1988) Lineage-specific expression of a human beta-globin gene in murine bone marrow transplant recipients reconstituted with retrovirus-transduced stem cells. Nature 331, 35-41

21 U. Novak (1990) High-level beta-globin expression after retroviral transfer of locus activation region-containing human beta-globin gene derivatives into murine erythroleukemia cells. Proceedings of the National Academy of Sciences of the United States of America 87, 3386-3390

22 D.W. Emery (1998) Development of a condensed locus control region cassette and testing in retrovirus vectors for A gamma-globin. Blood Cells, Molecules, and Diseases 24, 322-339

23 M. Sadelain (1995) Generation of a high-titer retroviral vector capable of expressing high levels of the human beta-globin gene. Proceedings of the National Academy of Sciences of the United States of America 92, 6728-6732

26 D.W. Emery (2002) Development of virus vectors for gene therapy of beta chain hemoglobinopathies: flanking with a chromatin insulator reduces gamma-globin gene silencing in vivo. Blood 100, 2012-2019

27 H. Miyoshi (1999) Transduction of human CD34+ cells that mediate long-term engraftment of NOD/SCID mice by HIV vectors. Science 283, 682-686

28 M. Kumar (2001) Systematic determination of the packaging limit of lentiviral vectors. Human Gene Therapy 12, 1893-1905

33 L. Naldini and I.M. Verma (2000) Lentiviral vectors. Advances in Virus Research 55, 599-609

34 M.A. Kay , J.C. Glorioso and L. Naldini (2001) Viral vectors for gene therapy: the art of turning infectious agents into vehicles of therapeutics. Nature Medicine 7, 33-40

35 E. Montini (2006) Hematopoietic stem cell gene transfer in a tumor-prone mouse model uncovers low genotoxicity of lentiviral vector integration. Nature Biotechnology 24, 687-696

36 P.I. Arumugam (2009) Genotoxic potential of lineage-specific lentivirus vectors carrying the beta-globin locus control region. Molecular Therapy 17, 1929-1937

37 R. Pawliuk (2001) Correction of sickle cell disease in transgenic mouse models by gene therapy. Science 294, 2368-2371

38 S. Imren (2002) Permanent and panerythroid correction of murine beta thalassemia by multiple lentiviral integration in hematopoietic stem cells. Proceedings of the National Academy of Sciences of the United States of America 99, 14380-14385

39 D.A. Persons (2003) The degree of phenotypic correction of murine beta -thalassemia intermedia following lentiviral-mediated transfer of a human gamma-globin gene is influenced by chromosomal position effects and vector copy number. Blood 101, 2175-2183

40 S. Rivella (2003) A novel murine model of Cooley anemia and its rescue by lentiviral-mediated human beta-globin gene transfer. Blood 101, 2932-2939

41 A. Miccio (2008) In vivo selection of genetically modified erythroblastic progenitors leads to long-term correction of beta-thalassemia. Proceedings of the National Academy of Sciences of the United States of America 105, 10547-10552

42 A. Perumbeti (2009) A novel human gamma-globin gene vector for genetic correction of sickle cell anemia in a humanized sickle mouse model: critical determinants for successful correction. Blood 114, 1174-1185

43 G. Puthenveetil (2004) Successful correction of the human beta-thalassemia major phenotype using a lentiviral vector. Blood 104, 3445-3453

44 M. Aker (2007) Extended core sequences from the cHS4 insulator are necessary for protecting retroviral vectors from silencing position effects. Human Gene Therapy 18, 333-343

45 P.I. Arumugam (2007) Improved human beta-globin expression from self-inactivating lentiviral vectors carrying the chicken hypersensitive site-4 (cHS4) insulator element. Molecular Therapy 15, 1863-1871

46 C. May (2002) Successful treatment of murine beta-thalassemia intermedia by transfer of the human beta-globin gene. Blood 99, 1902-1908

47 M. Cavazzana-Calvo (2000) Gene therapy of human severe combined immunodeficiency (SCID)-X1 disease. Science 288, 669-672

48 S. Hacein-Bey-Abina (2002) Sustained correction of X-linked severe combined immunodeficiency by ex vivo gene therapy. New England Journal of Medicine 346, 1185-1193

49 H.B. Gaspar (2004) Gene therapy of X-linked severe combined immunodeficiency by use of a pseudotyped gammaretroviral vector. Lancet 364, 2181-2187

50 A. Aiuti (2009) Gene therapy for immunodeficiency due to adenosine deaminase deficiency. New England Journal of Medicine 360, 447-458

51 S. Hacein-Bey-Abina (2008) Insertional oncogenesis in 4 patients after retrovirus-mediated gene therapy of SCID-X1. Journal of Clinical Investigation 118, 3132-3142

52 S.J. Howe (2008) Insertional mutagenesis combined with acquired somatic mutations causes leukemogenesis following gene therapy of SCID-X1 patients. Journal of Clinical Investigation 118, 3143-3150

53 S. Hacein-Bey-Abina (2003) LMO2-associated clonal T cell proliferation in two patients after gene therapy for SCID-X1. Science 302, 415-419

54 M.G. Ott (2006) Correction of X-linked chronic granulomatous disease by gene therapy, augmented by insertional activation of MDS1-EVI1, PRDM16 or SETBP1. Nature Medicine 12, 401-409

55 S. Stein (2010) Genomic instability and myelodysplasia with monosomy 7 consequent to EVI1 activation after gene therapy for chronic granulomatous disease. Nature Medicine 16, 198-204

56 A. Aiuti (2007) Multilineage hematopoietic reconstitution without clonal selection in ADA-SCID patients treated with stem cell gene therapy. Journal of Clinical Investigation 117, 2233-2240

57 Z. Li (2002) Murine leukemia induced by retroviral gene marking. Science 296, 497

58 Y. Shou (2006) Unique risk factors for insertional mutagenesis in a mouse model of XSCID gene therapy. Proceedings of the National Academy of Sciences of the United States of America 103, 11730-11735

59 O. Kustikova (2005) Clonal dominance of hematopoietic stem cells triggered by retroviral gene marking. Science 308, 1171-1174

60 C.L. Li (2009) Genomic and functional assays demonstrate reduced gammaretroviral vector genotoxicity associated with use of the cHS4 chromatin insulator. Molecular Therapy 17, 716-724

61 R. Seggewiss (2006) Acute myeloid leukemia is associated with retroviral gene transfer to hematopoietic progenitor cells in a rhesus macaque. Blood 107, 3865-3867

62 M. Sadelain (2004) Insertional oncogenesis in gene therapy: how much of a risk? Gene Therapy 11, 569-573

63 C. Baum (2002) Side effects of retroviral gene transfer into hematopoietic stem cells. Blood 101, 2099-2114

64 M. Aker (2006) Integration bias of gammaretrovirus vectors following transduction and growth of primary mouse hematopoietic progenitor cells with and without selection. Molecular Therapy 14, 226-235

65 E.M. Poeschla (2008) Integrase, LEDGF/p75 and HIV replication. Cellular and Molecular Life Sciences 65, 1403-1424

66 E. Montini (2009) The genotoxic potential of retroviral vectors is strongly modulated by vector design and integration site selection in a mouse model of HSC gene therapy. Journal of Clinical Investigation 119, 964-975

67 A.R. Schroder (2002) HIV-1 integration in the human genome favors active genes and local hotspots. Cell 110, 521-529

68 W. Wu (2003) Transcription start regions in the human genome are favored targets for MLV integration. Science 300, 1749-1751

69 D. Zychlinski (2008) Physiological promoters reduce the genotoxic risk of integrating gene vectors. Molecular Therapy 16, 718-725

70 A.H. Chang and M. Sadelain (2007) The genetic engineering of hematopoietic stem cells: the rise of lentiviral vectors, the conundrum of the LTR, and the promise of lineage-restricted vectors. Molecular Therapy 15, 445-456

71 P.W. Hargrove (2008) Globin lentiviral vector insertions can perturb the expression of endogenous genes in beta-thalassemic hematopoietic cells. Molecular Therapy 16, 525-533

72 M. Gaszner and G. Felsenfeld (2006) Insulators: exploiting transcriptional and epigenetic mechanisms. Nature Reviews Genetics 7, 703-713

73 J.A. Wallace and G. Felsenfeld (2007) We gather together: insulators and genome organization. Current Opinion in Genetics and Development 17, 400-407

74 J.H. Chung , A.C. Bell and G. Felsenfeld (1997) Characterization of the chicken beta-globin insulator. Proceedings of the National Academy of Sciences of the United States of America 94, 575-580

75 S. Rivella (2000) The cHS4 insulator increases the probability of retroviral expression at random chromosomal integration sites. Journal of Virology 74, 4679-4687

76 D.W. Emery (2000) A chromatin insulator protects retrovirus vectors from chromosomal position effects. Proceedings of the National Academy of Sciences of the United States of America 97, 9150-9155

77 E. Yannaki (2002) Topological constraints governing the use of the chicken HS4 chromatin insulator in oncoretrovirus vectors. Molecular Therapy 5, 589-598

79 A. Ramezani , T.S. Hawley and R.G. Hawley (2008) Combinatorial incorporation of enhancer-blocking components of the chicken beta-globin 5′HS4 and human T-cell receptor alpha/delta BEAD-1 insulators in self-inactivating retroviral vectors reduces their genotoxic potential. Stem Cells 26, 3257-3266

80 T. Nishino (2006) Effects of human gamma-globin in murine beta-thalassaemia. British Journal of Haematology 134, 100-108

81 T. Neff (2003) Methylguanine methyltransferase-mediated in vivo selection and chemoprotection of allogeneic stem cells in a large-animal model. Journal of Clinical Investigation 112, 1581-1588

84 D.W. Emery (2005) Selection with a regulated cell growth switch increases the likelihood of expression for a linked gamma-globin gene. Blood Cells, Molecules, and Diseases 34, 235-247

85 H. Zhao (2009) Amelioration of murine beta-thalassemia through drug selection of hematopoietic stem cells transduced with a lentiviral vector encoding both gamma-globin and the MGMT drug-resistance gene. Blood 113, 5747-5756

86 L. Burroughs and R. Storb (2005) Low-intensity allogeneic hematopoietic stem cell transplantation for myeloid malignancies: separating graft-versus-leukemia effects from graft-versus-host disease. Current Opinion in Hematology 12, 45-54

87 A. Aiuti (2002) Correction of ADA-SCID by stem cell gene therapy combined with nonmyeloablative conditioning. Science 296, 2410-2413

90 C. Bordignon (1995) Gene therapy in peripheral blood lymphocytes and bone marrow for ADA-immunodeficient patients. Science 270, 470-475

91 D.B. Kohn (1995) Engraftment of gene-modified umbilical cord blood cells in neonates with adenosine deaminase deficiency. Nature Medicine 1, 1017-1023

92 H.L. Malech (1997) Prolonged production of NADPH oxidase-corrected granulocytes after gene therapy of chronic granulomatous disease. Proceedings of the National Academy of Sciences of the United States of America 94, 12133-12138

93 D.B. Kohn (1998) T lymphocytes with a normal ADA gene accumulate after transplantation of transduced autologous umbilical cord blood CD34+ cells in ADA-deficient SCID neonates. Nature Medicine 4, 775-780

94 C.E. Dunbar (1998) Retroviral transfer of the glucocerebrosidase gene into CD34+ cells from patients with Gaucher disease: in vivo detection of transduced cells without myeloablation. Human Gene Therapy 9, 2629-2640

95 F. Schuening (1997) Retrovirus-mediated transfer of the cDNA for human glucocerebrosidase into peripheral blood repopulating cells of patients with Gaucher's disease. Human Gene Therapy 8, 2143-2160

96 P. Kelly (2007) Stem cell collection and gene transfer in Fanconi anemia. Molecular Therapy 15, 211-219

97 E.M. Kang (2010) Retrovirus gene therapy for X-linked chronic granulomatous disease can achieve stable long-term correction of oxidase activity in peripheral blood neutrophils. Blood 115, 783-791

98 H.B. Gaspar (2006) Successful reconstitution of immunity in ADA-SCID by stem cell gene therapy following cessation of PEG-ADA and use of mild preconditioning. Molecular Therapy 14, 505-513

99 N. Cartier (2009) Hematopoietic stem cell gene therapy with a lentiviral vector in X-linked adrenoleukodystrophy. Science 326, 818-823

100 A. Bank , R. Dorazio and P. Leboulch (2005) A phase I/II clinical trial of beta-globin gene therapy for beta-thalassemia. Annals of the New York Academy of Sciences, 1054, 308-316

101 J. Kaiser (2010) Gene therapy. Beta-thalassemia treatment succeeds, with a caveat. Science 326, 1468-1469

103 R. Iannone (2003) Results of minimally toxic nonmyeloablative transplantation in patients with sickle cell anemia and beta-thalassemia. Biology of Blood and Marrow Transplantation 9, 519-528

104 D.A. Persons (2001) Functional requirements for phenotypic correction of murine beta-thalassemia: implications for human gene therapy. Blood 97, 3275-3282

105 A. Gratwohl (2006) EBMT activity survey 2004 and changes in disease indication over the past 15 years. Bone Marrow Transplantation 37, 1069-1085

107 C.E. Dunbar (1996) Improved retroviral gene transfer into murine and Rhesus peripheral blood or bone marrow repopulating cells primed in vivo with stem cell factor and granulocyte colony-stimulating factor. Proceedings of the National Academy of Sciences of the United States of America 93, 11871-11876

108 P.A. Horn (2004) Efficient lentiviral gene transfer to canine repopulating cells using an overnight transduction protocol. Blood 103, 3710-3716

109 B. Thomasson (2003) Direct comparison of steady-state marrow, primed marrow, and mobilized peripheral blood for transduction of hematopoietic stem cells in dogs. Human Gene Therapy 14, 1683-1686

110 P. Hematti (2003) Retroviral transduction efficiency of G-CSF + SCF-mobilized peripheral blood CD34+ cells is superior to G-CSF or G-CSF + Flt3-L-mobilized cells in nonhuman primates. Blood 101, 2199-2205

111 P. Hematti (2004) Comparison of retroviral transduction efficiency in CD34+ cells derived from bone marrow versus G-CSF-mobilized or G-CSF plus stem cell factor-mobilized peripheral blood in nonhuman primates. Stem Cells 22, 1062-1069

113 D.P. O'Malley , M. Whalen and P.M. Banks (2003) Spontaneous splenic rupture with fatal outcome following G-CSF administration for myelodysplastic syndrome. American Journal of Hematology 73, 294-295

116 M. Abboud , J. Laver and C.A. Blau (1998) Granulocytosis causing sickle-cell crisis. Lancet 351, 959

117 B.K. Adler (2001) Fatal sickle cell crisis after granulocyte colony-stimulating factor administration. Blood 97, 3313-3314

118 H.E. Broxmeyer (2005) Rapid mobilization of murine and human hematopoietic stem and progenitor cells with AMD3100, a CXCR4 antagonist. Journal of Experimental Medicine 201, 1307-1318

119 A. Larochelle (2006) AMD3100 mobilizes hematopoietic stem cells with long-term repopulating capacity in nonhuman primates. Blood 107, 3772-3778

120 K. Li (1999) Granulocyte colony-stimulating factor-mobilized peripheral blood stem cells in beta-thalassemia patients: kinetics of mobilization and composition of apheresis product. Experimental Hematology 27, 526-532

121 E. Yannaki (2010) Mobilization of hematopoietic stem cells in a thalassemic mouse model: implications for human gene therapy of thalassemia. Human Gene Therapy 21, 299-310

122 E. Yannaki and G. Stamatoyannopoulos (2010) Hematopoietic stem cell mobilization strategies for gene therapy of beta thalassemia and sickle cell disease. Annals of the New York Academy of Sciences 1202, 59-63

123 M. Sadelain (2007) Therapeutic options for patients with severe beta-thalassemia: the need for globin gene therapy. Human Gene Therapy 18, 1-9

125 V.K. Pathak and H.M. Temin (1990) Broad spectrum of in vivo forward mutations, hypermutations, and mutational hotspots in a retroviral shuttle vector after a single replication cycle: deletions and deletions with insertions. Proceedings of the National Academy of Sciences of the United States of America 87, 6024-6028

126 M. Patel and S. Yang (2010) Advances in reprogramming somatic cells to induced pluripotent stem cells. Stem Cell Reviews 6, 367-380

128 K. Takahashi and S. Yamanaka (2006) Induction of pluripotent stem cells from mouse embryonic and adult fibroblast cultures by defined factors. Cell 126, 663-676

129 J. Yu (2007) Induced pluripotent stem cell lines derived from human somatic cells. Science 318, 1917-1920

130 J. Yu (2009) Human induced pluripotent stem cells free of vector and transgene sequences. Science 324, 797-801

131 D. Kim (2009) Generation of human induced pluripotent stem cells by direct delivery of reprogramming proteins. Cell Stem Cells 4, 472-476

132 A.D. Ebert (2009) Induced pluripotent stem cells from a spinal muscular atrophy patient. Nature 457, 277-280

133 G. Lee (2009) Modelling pathogenesis and treatment of familial dysautonomia using patient-specific iPSCs. Nature 461, 402-406

134 E. Kiskinis and K. Eggan (2010) Progress toward the clinical application of patient-specific pluripotent stem cells. Journal of Clinical Investigation 120, 51-59

135 I. Park (2008) Disease-specific induced pluripotent stem cells. Cell 134, 877-886

136 J. Hanna (2007) Treatment of sickle cell anemia mouse model with iPS cells generated from autologous skin. Science 318, 1920-1923

138 L. Ye (2009) Induced pluripotent stem cells offer new approach to therapy in thalassemia and sickle cell anemia and option in prenatal diagnosis in genetic diseases. Proceedings of the National Academy of Sciences of the United States of America 106, 9826-9830

139 K. Okita and S. Yamanaka (2010) Induction of pluripotency by defined factors. Experimental Cell Research 316, 2565-2570

140 S. Yamanaka and H.M. Blau (2010) Nuclear reprogramming to a pluripotent state by three approaches. Nature 465, 704-712

142 H.B. Gaspar (2009) How I treat ADA deficiency. Blood 114, 3524-3532

D.J. Weatherall (2010) The inherited diseases of hemoglobin are an emerging global health burden. Blood 115, 4331-4336

M. Sadelain (2008) Stem cell engineering for the treatment of severe hemoglobinopathies. Current Molecular Medicine 8, 690-697

F. Urbinati , C. Madigan and P. Malik (2006) Pathophysiology and therapy of haemoglobinopathies. Part II: thalassaemias. Expert Reviews in Molecular Medicine 8, 1-26

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