Enzyme augmentation therapy enhances the therapeutic efficacy of bone marrow transplantation in mucopolysaccharidosis type II mice

doi:10.1016/j.ymgme.2013.09.013

Molecular Genetics and Metabolism

Volume 111, Issue 2, February 2014, Pages 139-146

https://doi.org/10.1016/j.ymgme.2013.09.013 Get rights and content

Highlights

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All of the studies were conducted using murine model of mucopolysaccaridosis type II (MPS II).
•
BMT reduced the accumulation of glycosaminoglycans (GAGs) in a variety of visceral organs, but not in the CNS.
•
The combination of BMT and ERT was additive at reducing tissue levels of GAGs in the heart, kidney and lung.
•
ERT conferred greater efficacy if the immunological response against the infused recombinant enzyme was low.
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Pathologic GAGs might represent a sensitive biomarker to monitor the therapeutic efficacy of therapies for MPS II.

Abstract

Before the availability of an enzyme replacement therapy (ERT) for mucopolysaccharidosis type II (MPS II), patients were treated by bone marrow transplantation (BMT). However, the effectiveness of BMT for MPS II was equivocal, particularly at addressing the CNS manifestations. To study this further, we subjected a murine model of MPS II to BMT and evaluated the effect at correcting the biochemical and pathological aberrations in the viscera and CNS. Our results indicated that BMT reduced the accumulation of glycosaminoglycans (GAGs) in a variety of visceral organs, but not in the CNS. With the availability of an approved ERT for MPS II, we investigated and compared the relative merits of the two strategies either as a mono or combination therapy. We showed that the combination of BMT and ERT was additive at reducing tissue levels of GAGs in the heart, kidney and lung. Moreover, ERT conferred greater efficacy if the immunological response against the infused recombinant enzyme was low. Finally, we showed that pathologic GAGs might potentially represent a sensitive biomarker to monitor the therapeutic efficacy of therapies for MPS II.

Introduction

Mucopolysaccharidosis type II (MPS II, Hunter syndrome) is an X-linked lysosomal storage disorder (LSD) caused by a deficiency in the activity of the lysosomal enzyme, iduronate-2-sulfate (IDS, EC 3.1.6.13), which degrades the glycosaminoglycans (GAGs), heparan sulfate and dermatan sulfate [1]. The widespread and progressive lysosomal accumulation of undegraded GAGs leads to a broad spectrum of clinical manifestations. These include skeletal deformities, cardiac valvular disease, cardiac hypertrophy, hepatosplenomegaly, coarse facial appearance, upper airway narrowing, hearing defect, enlarged tongue, retinopathy and CNS involvement [2]. These clinical symptoms significantly compromise the patients' quality of life.

Presently, two therapies are available to treat MPS II; one is enzyme replacement therapy (ERT) and the other is bone marrow transplantation (BMT). ERT has been shown to be effective at correcting aspects of the visceral disease [3], [4], [5] but not the CNS lesion as the enzyme dose not cross the blood–brain barrier [6], [7]. ERT also has a limited impact on the bone and valvular lesions [8]. In addition, the need for repeated infusions of the enzyme is costly and confers a heavy burden on the MPS II patients [9].

BMT has been shown to be effective at treating several neuropathic LSDs such as MPS I, MPS VI, globoid-cell leukodystrophy, metachromatic leukodystrophy, Gaucher disease and others [10], [11]. In contrast to ERT, BMT might address the CNS lesions associated with several LSDs by virtue of the migration of enzyme competent donor cells into the brain. Consequent secretion of the enzyme from these cells may allow for cross-correction of patients' enzyme deficient neuronal cells. Early studies suggested that BMT should not be indicated for MPS II patients due to disappointing outcomes, particularly the limited impact on CNS involvement [12], [13], [14], [15]. However, recent report demonstrated the long-term efficacy of BMT in CNS involvement of an MPS II patient [16]. Thus, it is not evident if BMT should be indicated for MPS II. Moreover, there have been no animal studies showing the impact of BMT at reducing the level of GAGs in the brain.

Prior to the availability of ERT, some patients were treated by BMT with the hope of improving the visceral disease and CNS disease. Now that an approved enzyme is available for these patients, we asked if ERT could enhance the therapeutic effect of BMT. This has not been demonstrated for either human or murine MPS II. In this study, we examined the effectiveness of BMT at addressing CNS disease, as well as the relative merits of the combination of BMT and ERT in a mouse model of MPS II.

Section snippets

Animal husbandry

Female mice heterozygous for the X-linked allele (IDS^+/−) on a congenic C57BL/6 background were kindly provided from Joseph Muenzer (University of North Carolina, Chapel Hill) [17]. The carrier females were bred with male wild type (WT) mice of the same genetic background strain, producing hemizygous IDS knock-out males (MPS II mouse model, IdS^−/0). The genotypes of all offspring were determined by polymerase chain reaction analysis of DNA obtained from a tail snip. B6.SJL-ptprca mice congenic

Engraftment of donor cells in mice treated with BMT and a combination of BMT and ERT

Donor cell engraftment in mice subjected to BMT and BMT + ERT was analyzed at 12 weeks and 27 weeks following BMT (Table 1). Approximately 90% donor cell engraftment in each lineage cell was achieved at 12 and 27 weeks in animals that received BMT alone or in combination with ERT. Percent engraftment of T cell lineage was lower than for other cell lineages probably because of the longer half life time of pre-existing recipient T cells.

Serum IDS activity in mice treated with BMT, ERT or a combination of BMT and ERT

Serum IDS activities at various time points were assayed

Discussion

In early 1980s, first report described the effectiveness of BMT for MPS I [23]. Subsequently, BMT was performed in many MPS I patients with encouraging results [24]. BMT was particularly effective at addressing the CNS involvement of MPS I patients when BMT was performed in patients who were < 2 years old and had an IQ ≥ 70. Animal studies also demonstrated a reduction of GAGs in brain following BMT [25]. In contrast to MPS I, there is huge controversy for indicating BMT for MPS II patients [10],

Conflict of interest

T. Ohashi, H. Ida and Y. Eto have active research support from Genzyme Japan Co., Ltd. and Shire Japan Co., Ltd. These activities have been fully disclosed and are managed under a Memorandum of Understanding with the Conflict of Interest Resolution Board of The Jikei University School of Medicine.

Acknowledgments

Authors wish to thank Joseph Muenzer at University of North Carolina at Chapel Hill for providing us the MPS II mice, Hideto Morimoto at JCR Pharmaceuticals Company Limited for providing us antibody against human IDS and Genzyme Japan Co., Ltd. for providing us Idursulfase. We also thank Seng Cheng at Genzyme Corporation for critically reviewing our manuscript, Taku Sato at Tokyo Medical and Dental University for helping us flow cytometry study and Sayoko Iizuka and Eiko Kaneshiro at The Jikei

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However, HSCT is not sufficiently effective in the CNS lesions of MPS II patients, resulting in negative reviews in the US and Europe.14–17 We have also demonstrated that ERT and HSCT are ineffective in MPS II CNS and bone lesions.18 In recent years, clinical trials of HSC gene therapy using lentiviral vectors have proven effective in adrenoleukodystrophy, metachromatic leukodystrophy, Wiskott-Aldrich syndrome, and β-thalassemia.19–22.
Mucopolysaccharidosis type II is a disease caused by organ accumulation of glycosaminoglycans due to iduronate 2-sulfatase deficiency. This study investigated the pathophysiology of the bone complications associated with mucopolysaccharidosis II and the effect of lentivirus-mediated gene therapy of hematopoietic stem cells on bone lesions of mucopolysaccharidosis type II mouse models in comparison with enzyme replacement therapy. Bone volume, density, strength, and trabecular number were significantly higher in the untreated mucopolysaccharidosis type II mice than in wild-type mice. Accumulation of glycosaminoglycans caused reduced bone metabolism. Specifically, persistent high serum iduronate 2-sulfatase levels and release of glycosaminoglycans from osteoblasts and osteoclasts in mucopolysaccharidosis type II mice that had undergone gene therapy reactivated bone lineage remodeling, subsequently reducing bone mineral density, strength, and trabecular number to a similar degree as that observed in wild-type mice. Bone formation, resorption parameters, and mineral density in the diaphysis edge did not appear to have been affected by the irradiation administered as a pre-treatment for gene therapy. Hence, the therapeutic effect of gene therapy on the bone complications of mucopolysaccharidosis type II mice possibly outweighed that of enzyme replacement therapy in many aspects.
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The therapeutic mechanism involves cross correction by brain migrated donor cells that secrete the normal enzyme and effectively correct its deficiency in the surrounding tissues [7]. HSCT has shown therapeutic benefits for peripheral tissues, but its CNS impact in cases with MPS II remains unclear [5,8–11]. Other therapies have been investigated in animal models and human patients to improve the CNS involvement in patients with MPS II [5].
Mucopolysaccharidosis type II (MPS II) is a lysosomal storage disease (LSD) caused by a deficiency of the iduronate-2-sulfatase (IDS) that catabolizes glycosaminoglycans (GAGs). Abnormal accumulations of GAGs in somatic cells lead to various manifestations including central nervous system (CNS) disease. Enzyme replacement therapy (ERT) and hematopoietic stem cell transplantation (HSCT) are the currently available therapy for MPS II, but both therapies fail to improve CNS manifestations. We previously showed that hematopoietic stem cell targeted gene therapy (HSC-GT) with lethal irradiation improved CNS involvement in a murine model of MPS II which lacks the gene coding for IDS. However, the strong preconditioning, with lethal irradiation, would cause a high rate of morbidity and mortality. Therefore, we tested milder preconditioning procedures with either low dose irradiation or low dose irradiation plus an anti c-kit monoclonal antibody (ACK2) to assess CNS effects in mice with MPS II after HSC-GT. Mice from all the HSC-GT groups displayed super-physiological levels of IDS enzyme activity and robust reduction of abnormally accumulated GAGs to the wild type mice levels in peripheral organs. However, only the mice treated with lethal irradiation showed significant cognitive function improvement as well as IDS elevation and GAG reduction in the brain.
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Mucopolysaccharidosis type I (MPS-I), a lysosomal storage disorder caused by a deficiency of alpha-L-iduronidase enzyme, results in the progressive accumulation of glycosaminoglycans and consequent multiorgan dysfunction. Despite the effectiveness of hematopoietic stem cell transplantation (HSCT) and enzyme replacement therapy (ERT) in correcting clinical manifestations related to visceral organs, complete improvement of musculoskeletal and neurocognitive defects remains an unmet challenge and provides an impact on patients' quality of life. We tested the therapeutic efficacy of combining HSCT and ERT in the neonatal period. Using a mouse model of MPS-I, we demonstrated that the combination therapy improved clinical manifestations in organs usually refractory to current treatment. Moreover, combination with HSCT prevented the production of anti-IDUA antibodies that negatively impact ERT efficacy. The added benefits of combining both treatments also resulted in a reduction of skeletal anomalies and a trend towards decreased neuroinflammation and metabolic abnormalities. As currently there are limited therapeutic options for MPS-I patients, our findings suggest that the combination of HSCT and ERT during the neonatal period may provide a further step forward in the treatment of this rare disease.
Low-dose gene therapy reduces the frequency of enzyme replacement therapy in a mouse model of lysosomal storage disease
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Enzyme replacement therapy (ERT) is the standard of care for several lysosomal storage diseases (LSDs). ERT, however, requires multiple and costly administrations and has limited efficacy. We recently showed that a single high dose administration of adeno-associated viral vector serotype 8 (AAV2/8) is at least as effective as weekly ERT in a mouse model of mucopolysaccharidosis type VI (MPS VI). However, systemic administration of high doses of AAV might result in both cell-mediated immune responses and insertional mutagenesis. Here we evaluated whether the combination of low doses of AAV2/8 with a less frequent (monthly) than canonical (weekly) ERT schedule may be as effective as the single treatments at high doses or frequent regimen. A greater reduction of both urinary glycosaminoglycans, considered a sensitive biomarker of therapeutic efficacy, and storage in the myocardium and heart valves was observed in mice receiving the combined than the single therapies. Importantly, these levels of correction were similar to those we obtained in a previous study following either high doses of AAV2/8 or weekly ERT. Our data show that low-dose gene therapy can be used as a means to rarify ERT administration, thus reducing both the risks and costs associated with either therapies.
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Enzyme augmentation therapy enhances the therapeutic efficacy of bone marrow transplantation in mucopolysaccharidosis type II mice

Highlights

Abstract

Introduction

Section snippets

Animal husbandry

Engraftment of donor cells in mice treated with BMT and a combination of BMT and ERT

Serum IDS activity in mice treated with BMT, ERT or a combination of BMT and ERT

Discussion

Conflict of interest

Acknowledgments

Genet. Med.

Mol. Genet. Metab.

Genet. Med.

J. Pediatr.

J. Pediatr.

Mol. Genet. Metab.

Mol. Genet. Metab.

Mol. Ther.

Lancet

Exp. Neurol.

Mol. Ther.

Mol. Genet. Metab.

Genet. Med.

Mol. Genet. Metab.

Genet. Med.

J. Pediatr.

Mol. Genet. Metab.

The defect in the Hunter syndrome: deficiency of sulfoiduronate sulfatase

Proc. Natl. Acad. Sci. U. S. A.

Recognition and diagnosis of mucopolysaccharidosis II (Hunter syndrome)

Pediatrics