239. Preclinical Studies for the First Hematopoietic Stem Cell (HSC) Gene Editing Trial: Phase 1 Study of Beta-Thalassemia With Autologous Transplantation of Zinc Finger Nuclease-Treated HSC To Upregulate Fetal Hemoglobin

Abstract

Beta-thalassemia (β-thal) and sickle cell disease (SCD) are monogenic diseases caused by mutations in the adult β-globin gene. Allogeneic hematopoietic cell transplantation (HCT) is the only curative treatment, but its application is limited by: (i) a paucity of HLA-matched donors and (ii) a fixed risk of graft vs host disease (GvHD) and transplant-related mortality. Sustained elevation of fetal hemoglobin (HbF) has a very strong clinical effect in both thalassemia and SCD with curative potential. HbF levels are under genetic control, and alleles of the transcription factor BCL11A that lower its expression result in elevation of HbF. BCL11A is thus an attractive target for gene editing of autologous hematopoietic stem cell (HSC) for HCT in β-hemoglobinopathies.We have designed zinc finger nucleases (ZFNs) that when transiently introduced into stem cells ex vivo can efficiently disrupt the BCL11A gene in hematopoietic stem cells (HSCs) by introduction of mutations following target site cleavage and non-homologous end joining. We have developed a clinical scale GMP process for mRNA electroporation of BC11A ZFNs into HSCs, and show that erythrocytes generated ex vivo from BCL11A-modified HSC have elevated fetal globin mRNA, and over 40% of all Hb is represented by HbF. A similar increase in HbF was seen in modified HSCs from subjects with β-thalassemia. Engraftment and differentiation potential of BCL11a modified and control HSCs in NSG mice were comparable. Furthermore, following engraftment into NSG mice, HSCs placed into erythropoiesis cultures maintained increased HbF levels. Preclinical safety studies included soft agar transformation, karyotyping, and double-strand break quantification following ZFN modification. Both bioinformatics guided and a novel, unbiased, oligonucleotide capture method were used to confirm low levels of off-target activity in BCL11A modified HSC as gauged by deep sequencing. In vivo carcinogenicity was evaluated by engraftment of HSC modified by BCL11A ZFNs in NSG mice. Engraftment and multilineage differentiation were comparable between groups and no evidence for carcinogenicity was found.The primary objective of the Phase I clinical study is to evaluate the safety of autologous BCL11A gene edited HSPC infusion after myeloablative (full dose busulfan) conditioning in subjects with transfusion dependent β-thalassemia major. The secondary objectives are to assess hematologic and immunological reconstitution, and to measure the treatment effects on anemia, RBC transfusion frequency, and iron burden.