Genetic Correction and Hepatic Differentiation of Hemophilia B-specific Human Induced Pluripotent Stem Cells

遗传上在人的导致的 pluripotent 干细胞(iPSCs ) 改正一个引起疾病的点变化的目的首先源于出血不止 B patient.Methods，引起疾病的变化被定序人的凝结因素 IX (F IX ) 的编码区域检测基因。Genomic DNA 从 iPSCs 被提取，并且教材被设计放大 F IX 的八 exons。下次，在那些 iPSCs 的点变化遗传上面对 129 核苷酸用 CRISPR/Cas9 技术被改正包含了二个同义的变化的相应修理模板。然后，顶 8 潜在的离开目标地点随后用定序的 Sanger 被分析。最后，改正的克隆被区分进象 hepatocyte 一样房间，并且 F IX 的分泌物被房间行厌烦的 immunocytochemistry 和 ELISA assay.Results 验证在 6 th 编码 exon (c.676 C > T ) F IX 基因。点变化的修正与在大约 22% 点的功效(10/45 ) 和没有离开目标效果在改正的 iPSC 克隆检测了的高度在 situ 经由 CRISPR/Cas9 技术被完成。F IX 分泌物，被 immunocytochemistry 进一步设想并且在 vitro 由 ELISA 确定了，在人的疾病特定的 iPSCs 在白天 21 区别 procedure.Conclusions 变化上到达了大约 6 ng/ml 能被 CRISPR/Cas9 技术精确改正，并且改正了仍然维持的房间肝的区别能力。我们的调查结果可能在临床的应用程序在基于 iPSC 的个性化的治疗上扔一盏灯，特别为出血不止 B。

Successful esophagectomy in a patient with combined esophageal cancer and hemophilia B

Patients with esophageal cancer often require esophagectomy with esophagogastrostomy.However,the incidence of complications,such as hemorrhage,during operations for esophageal cancer is high,even with minimally invasive surgery.Without the appropriate interventions,the risk of major intraoperative and postoperative hemorrhage is very high in patients with esophageal cancer and hemophilia.We report the case of a 45-year-old man with esophageal cancer and hemophilia B who underwent a successful hybrid,minimally invasive Ivor-Lewis esophagectomy with appropriate perioperative management.

血友病B治疗药物情报分析

血友病B(HB)是一种X染色体隐性遗传出血性疾病。过去几十年来,HB治疗取得了巨大进展。从凝血酶原复合物到血源性凝血因子提高了治疗安全性,从标准半衰期重组凝血因子到生物工程长效重组凝血因子改善了患者依从性和临床结局。非因子替代疗法不但能够通过皮下给药为患者减轻治疗负担,还避免了产生抑制物的风险,同时为已产生抑制物的患者提供了新的治疗方案。腺相关病毒载体基因治疗开启了HB的新篇章,目前已有一种基因治疗在美国获批上市。该文通过对欧美等发达国家及中国上市药物信息追踪,对在研药物研发管线及主要研究成果等信息进行挖掘,对HB治疗药物进行全视角、全周期情报解读,以期为医疗机构及相关研发单位提供参考。

Clinical Analysis and Mental Health Survey of Hemophilia Carriers:a Cross-sectional Study

Objective:Hemophilia carriers(HCs),who are heterozygous for mutations in the clotting factor VIII/clotting factor IX gene(F8 or F9),may have a wide range of clotting factor levels,from very low,similar to afflicted males,to the upper limit of normal,and may experience mental health issues.The purpose of this study was to provide genetic information on mothers of hemophilia patients and to understand the clotting factor activity and phenotype of HCs.Additionally,we aimed to investigate the mental health status of HCs in China.Methods:A total of 127 hemophilia mothers,including 93 hemophilia A(HA)mothers and 34 hemophilia B(HB)mothers,were enrolled in this study.Long distance PCR,multiplex PCR,and Sanger sequencing were used to analyze mutations in F8 or F9.Coagulation factor activity was detected by a one-stage clotting assay.The Symptom Checklist 90(SCL-90,China/Mandarin version)was given to HCs at the same time to assess their mental health.Results:A total of 90.6%of hemophilia mothers were diagnosed genetically as carriers,with inversion in intron 22 and missense mutations being the most common mutation types in HA and HB carriers,respectively.The median clotting factor level in carriers was 0.74 IU/mL(ranging from 0.09 to 1.74 IU/mL)compared with 1.49 IU/mL(ranging from 0.93 to 1.89 IU/mL)in noncarriers,of which 14.3%of HCs had clotting factor levels of 0.40 IU/mL or below.A total of 53.8%(7/13)of HA carriers with low clotting factor levels(less than 0.50 IU/mL)had a history of bleeding,while none of the HB carriers displayed a bleeding phenotype.The total mean score and the global severity index of the SCL-90 for surveyed HCs were 171.00(±60.37)and 1.78(±0.59),respectively.A total of 67.7%of the respondents had psychological symptoms,with obsessive-compulsive disorder being the most prevalent and severe.The pooled estimates of all nine factors were significantly higher than those in the general population(P<0.05).Conclusions:The detection rate of gene mutations in hemophilia mothers was 90.6%,with a median clotting factor level of 0.74 IU/mL,and 14.3%of HCs had a clotting factor level of 0.40 IU/mL or below.A history of bleeding was present in 41.2%of HCs with low clotting factor levels(less than 0.50 IU/mL).Additionally,given the fragile mental health status of HCs in China,it is critical to develop efficient strategies to improve psychological well-being.

Gene therapy for hemophilia B mediated by recombinant adeno-associated viral vector with hFIXR338A,a high catalytic activity mutation of human coagulation factor IX

A mutant human factor IX with arginine at 338 residual changed to alanine (hFIXR338A) by site-directed mutagenesis was introduced into AAV vectors, and a recombinant adeno-associ- ated viral vector containing hFIXR338A, prepared by rHSV/AAV hybrid helper virus system, was directly introduced to the hind leg muscle of factor IX knock out mice. The expression and the biological activity of human factor IX mutant, hFIXR338A, and the immune response against it in the treated mice were assayed and detected. The results showed that (i) the high-level expression of human factor IX mutant protein, hFIXR338A, has been detected in rAAV-hFIXR338A treated hemophilia B mice and lasted more than 15 weeks; (ii) the clotting activity of hFIXR338A in plasma is 34.2%± 5.23%, which is remarkably higher than that of (14.27% ± 3.4%) of wild type hFIX treated mice in the activated partial thromboplastin assay; (iii) immune response against factor IX R338A was absent, with no factor IX mutant protein (hFIXR338A) inhibitors development in the treated mice; and (iv) no local or systemic side-effects and toxicity associated with the gene transfer were found. It demonstrated the potential use of treating hemophilia B by recombinant adeno-associated viral vectors with mutant hFIXR338A gene, an alternative strategy for hemophilia B gene therapy to wild-type human factor IX.

Optimized human factor IX expression cassettes for hepaticdirected gene therapy of hemophilia B

Gene therapy provides a potential cure for hemophilia B, and significant progress has been achieved in liver-directed gene transfer mediated by adeno-associated viral vectors. Recent clinical trials involving the use of a self-complementary adeno-associated virus serotype 8-human codon-optimized factor IX （AAV8-hFIXco） vector demonstrated encouraging efficacy with hFIX expression stabilized at 1% to 6% of normal level in patients, but safety concerns related to high vector doses are still present. Thus, further improvement of AAV vectors and hFIX expression cassette may positively contribute to the ultimate success of hemophilia B gene therapy. In this study, to obtain a higher expression level of hFIX that potentiates the coagulant capacity of recipients, human FIX expression vector was optimized by upgrading the codon adaption index and adjusting the GC content, inserting a Kozak sequence （GCCACC）, and introducing a gain-of-function mutation, R338L （FIX Padua）. The efficiency of the published and the presently constructed cassettes was compared through in vivo screening. In addition, the regulatory elements that control the FIX gene expression in these cassettes were screened for liver-specific effectiveness. Among all the constructed cassettes, scAAV-Pre-hFIXco-SIH-R338L, which was the construct under the control of the prothrombin enhancer and prealbumin promoter, resulted in the highest level of coagulant activity, and the expression levels of two constructed cassettes （scAAV-Chi-hFIXco-SIH-R338L and scAAV-Pre- hFIXco-SIH-R338L） were also higher than that of the published cassette （scAAV-LPI-hFIXco-SJ）. In summary, our strategies led to a substantial increase in hFIX expression at the protein level or a remarkably elevated coagulant activity. Thus, these reconstructs of hFIX with AAV vector may potentially contribute to the creation of an efficacious gene therapy of hemophilia B.

Gene therapy for hemophilia B mice with scAAV8-LPI-hFIX

Hemophilia B is a hemorrhagic disease caused by the deficiency of clotting factor IX （FIX）. Gene therapy might be the ultimate strategy for the disease. However, two main problems that should be solved in gene therapy for hemophilia B are immunity and safety. Self-complementary adeno-assoeiated virus serotype 8 （scAAV8）, a non-human primate AAV featuring low immunogenicity and high transfection efficiency in liver cells, might be a potential vector for hemophilia B gene therapy. A strong fiver-specific promoter-1 （LP1） was inserted and mutant human FIX Arg338Ala was introduced into plasmid scAAV8-LP1 to develop an optimized AAV8 vector that expresses human clotting factor FIX （hFIX）. The efficiency of scAAV8-LPI-hFIX administered through normal systemic injection or hydrodynamic injection was compared. A high expression was achieved using hydrodynamic injection, and the peak hFIX expression levels in the 5 × 10^11 and 1 × 10^11 virus genome （vg） cohorts were 31.94% and 25.02% of normal level, respectively, at 60 days post-injection. From the perspective of long-term （200 days） expression, both injection methods presented promising results with the concentration value maintained above 4% of normal plasma. The results were further verified by enzyme-linked immunosorbent assay and activated partial thromboplastin time. Our study provides a potential gene therapy method for hemophilia B.

Long-term correction of hemophilia B through CRISPR/Cas9 induced homology-independent targeted integration

CRISPR/Cas9-mediated site-specific insertion of exogenous genes holds potential for clinical applications.However,it is still infeasible because homologous recombination(HR)is inefficient,especially for nondividing cells.To overcome the challenge,we report that a homology-independent targeted integration(HITI)strategy is used for permanent integration of high-specificity-activity Factor IX variant(F9 Padua,R338L)at the albumin(Alb)locus in a novel hemophilia B(HB)rat model.The knock-in efficiency reaches 3.66%,as determined by droplet digital PCR(dd PCR).The clotting time is reduced to a normal level four weeks after treatment,and the circulating factor IX(FIX)level is gradually increased up to 52%of the normal level over nine months even after partial hepatectomy,demonstrating the amelioration of hemophilia.Through primer-extension-mediated sequencing(PEM-seq),no significant off-target effect is detected.This study not only provides a novel model for HB but also identifies a promising therapeutic approach for rare inherited diseases.

A study of gene transfer and expression of human clotting factor IX in Hemophilia B mice mediated by mini-adenoviral vector

Vector GtiIX containing human clotting factor IX cDNA with intron 1 (hFIX mini-gene or Fi’IX) driven by CMV promoter was constructed based on the mini-adenoviral vector GT2073 (mini-Ad vector) with all viral protein coding sequences deleted. Mini-Ad packaging cell 293Cre4 was first transduced with GTiIX, and then was transfected with helper-adenovirus AdLC8, thus mini-Ad virions AdGTiIX were obtained. At the same time, previous normal adenoviral vector pAdSPiIX containing viral genome and hFIX mini-gene was constructed, and then previous ade-novirus (pre-Ad) AdSPiIX was obtained as control. The ratio of helper-adenovirus among purified virons AdGTiIX was less than 0.8%. 3T3 cells were transfected with AdGTiIX and AdSPiIX at a MOI of 50 per cell and ELISA result showed that transient expression level in vitro was 1.4±0.2 mg /106·24 h and 1.6±0.3 mg/106·24 h respectively. Each hemophilia B (FIX knock-out) mouse received celiac injection of 11010pfu AdGTiIX or AdSPiIX. The highest expression level of hFIX in mouse plasma was 590 ng/mL and 690 ng/mL respectively, and the expression time lasted for 16 weeks and 9 weeks respectively. The bleeding time reduced from over 30 min to 7.5 min, and 5-min blood lost reduced from 430 mL to 60 mL. The results of anti-Ad IgG assays indicated that immune response triggered by AdGTiIX was obviously weaker than that triggered by AdSPiIX. These results indicated that, compared with previous adenovirus (pre-Ad), the mini-Ad vector sys-tem prolonged the expression time of hFIX and reduced immune response, thus offering a prom-ising result for further pre-clinical study.

Expression of human clotting factor Ⅸ mediated by recom- binant lentiviral vector in cultured cells and hemophilia B mice

To explore the expression of human clotting factor Ⅸ (hFⅨ) cDNA in vitro and the feasibility of gene therapy for hemophilia B mice mediated by recombinant lentiviral vector, a recombinant hFⅨ lentiviral vector driven by ubiquitin-C promoter, FUXW, and by ABP liver specific promoter, FAXW, was constructed respectively. Recombinant lentivirus was harvested from 293T cells by calcium phosphate-mediated transient cotransfection of three plasmids (transgene vector, CMV腞8.2, VSV-G). hFⅨ expression was detected in supernatant of 293T, BHK and L-02 cells infected with FUXW virus, whereas higher expression of hFⅨ levels (630 ng/106 cells/48 h) was detected only in L-02 cells infected with FAXW virus. Serum hFⅨ antigen was detected in all hemophilia B mice treated with FAXW virus by tail vein injection, an efficiency level of hFⅨ was observed (45 ng/mL, approximately 1% of normal human levels), the expression lasted for more than 60 d. The results indicated that HIV-based lentiviral vectors offer a promising approach to the gene therapy of hemophilia B.

Muscle injection of rAAV/mFIX to secrete clotting factor IX corrects the hemorrhagic tendencies in hemophilia B mice

Recombinant AAV particles of high titer (>1013 virus genome/mL) were prepared according to the rHSV/AAV helper virus method. After intramuscular injection of viral vectors in the hind limb, a sustained elevated level (>370 ng/mL) of murine FIX expression in the plasma of hemophilia B mouse was detected and persisted for more than 350 days. The biological activity reached 30% of normal levels, and bleeding symptoms in the treated mice were significantly alleviated. No anti-FIX antibody (inhibitor) was detected, though anti-AAV antibodies were found at a very low level after single injection. Repeated injection with rAAV/mFIX led to a variation in anti-AAV antibody levels between the two groups which had received different doses. Results from tissue analysis confirmed the skeletal muscle as the origin for circulating functional mFIX. Our results suggest that AAV-mediated gene transfer offers a promising method of gene therapy for hemophilia B.

新型血友病B基因治疗的腺病毒-整合酶嵌合系统的构建及其体外表达鉴定

本研究构建一种既可高效感染靶细胞又能实现安全定点整合入宿主基因组的腺病毒嵌合载体。通过一系列DNA操作构建腺病毒-整合酶嵌合系统,该系统包含两个腺病毒载体:一个携带转基因表达框,表达框内有hFⅨ,红色荧光蛋白编码序列以及attB(phiC31识别位点),表达框两侧各有1个loxP(Cre识别位点);另一个腺病毒载体携带Cre和phiC31基因。同时构建只表达Cre和只表达phiC31的载体作为对照载体。在体外分别用脂质体转染293A细胞,用荧光显微镜观察荧光蛋白的表达,用RT-PCR鉴定各个基因的表达。结果表明,该腺病毒-整合酶嵌合系统构建成功。体外分别用脂质体转染293A细胞后,可见绿色荧光蛋白和红色荧光蛋白表达。RT-PCR鉴定表明,该系统能够成功表达各种目的蛋白。结论:成功构建了腺病毒-整合酶嵌合系统,为进一步研究其治疗作用提供良好基础。

肌细胞途径血友病B基因治疗高表达载体的构建及表达研究

构建了以ＭＣＫ（肌肉肌酸激酶）增强子增强、β－ａｃｔｉｎ启动子启动的、反向插入载体Ｇ１Ｎａ的Ｇ１ＮａＰＡＩＸｉ′ＢＡＭ。在与同一系列的、仅内含子元件有差异的载体Ｇ１ＮａＭＢＡＩＸ和Ｇ１ＮａＭＢＡｉＩＸ的体外体内表达比较证明，反向载体是表达最高最稳定的。进一步的二次体内注射研究表明，此载体是国内已报道的最适于肌细胞途径血友病Ｂ基因治疗的反转录病毒载体。

DNA测序法检测血友病B患者F9基因突变

目的分析血友病B患者凝血因子Ⅸ(F9)基因突变情况。方法检测3名非亲缘关系疑似血友病B患者的表型,确定其活性缺失因子;采用PCR结合DNA测序的方法对患者F9基因作序列分析,确定其突变位点。结果 3名患者均表现为FⅨ促凝活性(FⅨ∶C)明显偏低,分别为6.1%、14.7%及6.5%,故诊断为血友病B患者,其F9基因突变分别为G20341A(Gly133Arg)、G30116A(Ala233Thr)及G31095A(Cys336Tyr)。结论检测到3名血友病B患者的F9基因上均发生序列改变,证实了血友病B患者F9基因缺陷的分子机制。

结肠灌注重组腺相关病毒2/人凝血因子Ⅸ基因载体治疗血友病B的安全性研究

目的分析结肠灌注重组腺相关病毒2/人凝血因子Ⅸ(rAAV2/CMV-hFⅨ)基因载体治疗血友病B小鼠的安全性。方法将rAAV2/CMV-hFⅨ(剂量为1×1013 v.g/kg)结肠灌注血友病B模型小鼠,分别检测抗重组腺相关病毒2(rAAV2)抗体和抗人凝血因子Ⅸ(hFⅨ)抗体,并通过组织病理学、免疫组化和PCR技术分析病毒和hFⅨ的组织分布。结果灌注后,在小鼠体内能够检测到抗rAAV2抗体和抗hFⅨ抗体;组织病理学、免疫组化和PCR技术分析结果显示灌注部位肠组织无明显病理改变,rAAV2以及hFⅨ基因仅仅在灌注的肠上皮。结论结肠灌注重组腺相关病毒基因治疗血友病B小鼠,在所观测时间内是安全的。

甲型血友病患者输注“冷沉淀”后HBV和HCV相关指标的检测

目的:探讨甲型血友病患者大剂量反复输注“冷沉淀”后,HBV和HCV的感染情况,从而提出加强血液检测的新构想。方法:采用酶联免疫吸附法(ELISA)检测HBV和HCV,用速率散射比浊法测1g、C_3和C_4,用速率法测ALT。结果:20例患者血液中均检测出抗-HBs,而HBV-M的其他各项均为阴性,5例患者血液中检测出抗-HCV,其中1例伴ALT增高,3例伴Ig降低。结论:甲型血友病患者输注“冷沉淀”后易感HCV。治疗前接种乙肝疫苗可预防HBV感染。

血友病B的基因治疗

血友病B是一种凝血Ⅸ因子缺陷引起的X连锁隐性遗传的出血性疾病 .近年来 ,国内外学者在基因治疗方面取得的大量研究成果给血友病B患者带来了根治疾病的希望 .就血友病B的基因治疗研究进展及所存在的问题作一综述 .

同时存在血友病A及血友病B患者家系的基因诊断

目的:对1个同时存在血友病A(HA)及血友病B(HB)患者的家系进行分子发病机制研究,并对家系女性成员进行携带者检测。方法:采用活化部分凝血活酶时间(APTT)、凝血酶原时间(PT)、凝血酶时间(TT)、纤维蛋白原(Fg)、凝血因子Ⅷ(FⅧ)活性(FⅧ:C)、FⅨ活性(FⅨ:C)及血管性血友病因子(vWF)等测定进行HA及HB表型诊断;用长链聚合酶链反应(LD-PCR)进行F8基因内含子22倒位检测,2组序列特异的PCR对F8基因内含子1倒位进行检测;采用直接核苷酸测序法对F9基因各外显子及其侧翼序列进行检测,联合F9基因相关的6个微卫星位点(DXS8094、DXS1211、DXS1192、DXS102、DXS1227及DXS8013)进行家系遗传连锁分析。结果:先证者1是由F8基因内含子22倒位引起的HA。先证者2是由F9基因突变nt32772A→T突变(p.Ser365Cys,GI:22385320)引起的HB,其突变基因遗传自其母亲,来源于先证者2外公的X染色体,其外公为该突变的体细胞和生殖细胞嵌合体,其阿姨口腔细胞DNA未检出该突变。结论:该家系2名先证者的基因诊断结果与表型诊断相符。单碱基延伸法可用于突变嵌合率的检测,并为血友病散发家系的突变来源提供可靠的信息。

世界血友病同盟《全球血友病年度报告2022》解读

世界血友病同盟(World Federation of Hemophilia,WFH)于2022年10月发布了新的年度血友病全球报告(Annual Global Survey,AGS)(以下简称AGS 2022),提出了新的工作目标。在2025年前,提高识别并诊断遗传性出血性疾病能力,包括:在原有基础性上,提高25%的血友病确诊率和14%的血管性血友病(von Willebrand disease,vWD)患者确诊率;提供合适的护理和治疗,特别是要提高25%的18岁以下重型血友病患者预防治疗率,继续每年至少为20000例患者提供WFH人道主义援助。AGS 2022预估了全球的血友病年平均患病率:血友病A(hemophilia A,HA)为17.1/10万(男性),其中重型HA为6.0/10万(男性);血友病B(hemophilia B,HB)为3.8/10万(男性),其中重型HB为1.1/10万男性。根据世界人口(79亿,40亿男性),预计全球血友病患病率在10.6/10万左右,预计全球有血友病患者830895例,其中约282266例为重型患者。我国的血友病患病率在(2.73~3.09)/10万,低于全球水平。同时,AGS 2022提示,全球女性血友病患者有11700例,女性血友病占血友病患者总人数的5%;女性vWD患者有54066例,占vWD总人数的56%,女性其他出血性疾病有34370例,提示vWD是女性最常见的出血性疾病。我国的HA患者共27689例,其中0~4岁占4%,5~13岁占21%,14~18岁占12%,19~44岁占43%,45岁以上占16%,年龄不确定者占4%。相对于中低收入国家,高收入国家对于轻型血友病的确诊率高(男性40%比12%;女性86%比23%),不确定性患者比例少,而低收入国家的血友病患者早逝风险很大。经济发达地区的艾美赛珠单抗预防治疗使用显著高于我国。我国相较于欧美国家在血友病及其他出血性疾病患者的诊断及治疗方面还有较大差距,临床医务工作者需提高对血友病及其他出血性疾病的认识并不断提高诊断和治疗能力。

基于B/S架构的血友病电子健康档案管理系统的设计与实现

本文研究并设计了一种基于B/S架构的血友病电子健康档案管理系统。该系统以Access2003为首选数据库,ASP为开发语言进行开发。血友病电子健康档案管理系统经过医院的测试运行,具有实用性与全面性,减少了医患之间的交流与病情诊断的时间,实现了血友病患者信息化管理,并提供了应急查询系统和健康教育系统。为血友病患者电子健康档案管理的网络化、信息化起到了推动作用。