Myoblast transfer in the treatment of Duchenne's muscular dystrophy

Normal myoblast implantation in MDX mice prevents muscle damage by exercise

One consequence of the lack of dystrophin is a higher vulnerability of myofibers to eccentric exercise. In this study, we compared the effect of downhill running on Biceps brachii of MDX mice with or without transplantation of normal myoblasts. Exercise induced damaged was detected by Evans blue staining. In control MDX mice, 26.3% of the fibers were permeated by this dye, myoblast transplantation prevented such necrosis. In the transplanted muscles, only dystrophin negative fibers were injured. Indeed, in muscles containing at least 40% dystrophin positive fibers, the damage was significantly reduced in the grafted muscle. Thus the transplantation of normal myoblasts increases the resistance of dystrophic muscles to exercise. Our results suggest that transplantation of normal myoblasts to DMD patients may have beneficial effects.

Development of approaches to improve cell survival in myoblast transfer therapy

Myoblast transplantation has been extensively studied as a gene complementation approach for genetic diseases such as Duchenne Muscular Dystrophy. This approach has been found capable of delivering dystrophin, the product missing in Duchenne Muscular Dystrophy muscle, and leading to an increase of strength in the dystrophic muscle. This approach, however, has been hindered by numerous limitations, including immunological problems, and low spread and poor survival of the injected myoblasts. We have investigated whether antiinflammatory treatment and use of different populations of skeletal muscle-derived cells may circumvent the poor survival of the injected myoblasts after implantation. We have observed that different populations of muscle-derived cells can be isolated from skeletal muscle based on their desmin immunoreactivity and differentiation capacity. Moreover, these cells acted differently when injected into muscle: 95% of the injected cells in some populations died within 48 h, while others richer in desmin-positive cells survived entirely. Since pure myoblasts obtained from isolated myofibers and myoblast cell lines also displayed a poor survival rate of the injected cells, we have concluded that the differential survival of the populations of muscle-derived cells is not only attributable to their content in desmin-positive cells. We have observed that the origin of the myogenic cells may influence their survival in the injected muscle. Finally, we have observed that myoblasts genetically engineered to express an inhibitor of the inflammatory cytokine, IL-1, can improve the survival rate of the injected myoblasts. Our results suggest that selection of specific muscle-derived cell populations or the control of inflammation can be used as an approach to improve cell survival after both myoblast transplantation and the myoblast-mediated ex vivo gene transfer approach.

Transplantation of dermal fibroblasts expressing MyoD1 in mouse muscles

Transplantation of normal myoblasts into dystrophic muscles is a potential treatment for Duchenne muscular dystrophy (DMD). However, the success of such grafts is limited by the immune system responses. To avoid rejection problems, autologous transplantation of the patient's corrected myoblasts has been proposed. Regretfully, the low proliferative capacity of DMD myoblasts in culture (due to their premature senescence) limits such procedure. On the other hand, modification of dermal fibroblasts leading to the myogenic pathway using a master regulatory gene for myogenesis is an interesting alternative approach. In this study, the retrovirally encoded MyoD1 cDNA was introduced in dermal fibroblasts of TnI LacZ mice to provoke their conversion into myoblast-like cells. In vitro and in vivo assays were done and the results were compared to those obtained with uninfected fibroblasts and myoblasts. Some MyoD1-expressing fibroblasts were able to fuse and to express beta-galactosidase (under the transcriptional control of the Troponin I promoter), dystrophin and desmin in vitro. Thirty days following implantation of these modified fibroblasts in muscles of mdx mice, an average of 7 beta-Gal+/Dys-muscle fibers were observed. No beta-Gal+ fibers were observed after the transplantation of uninfected fibroblasts. Our results indicate that the successful implantation of myoblasts obtained from genetically modified fibroblasts is indeed feasible. However, the in vitro conversion rate and the in vivo fusion of genetically modified fibroblasts must be largely increased to consider this approach as a potential therapy for DMD and other myopathies.

Successful transplantation of genetically corrected DMD myoblasts following ex vivo transduction with the dystrophin minigene

Myoblast transplantation and gene therapy are two promising therapeutical approaches for the treatment of Duchenne Muscular Dystrophy (DMD). So far, both strategies have met many hurdles, mainly because of immune reactions. In this study, we investigated a third and novel strategy based on the combination of these two basic ones, i.e., transplantation of genetically modified myoblasts. We first derived a primary culture from a muscle biopsy of a young DMD patient (3 years old). Adenoviral-mediated dystrophin gene transfer into these DMD cultures and expression of the dystrophin transgene were achieved in vitro. The transduced cultures were then transplanted the same day in immunodeficient SCID mouse muscles. Three weeks following the graft, many human dystrophin-positive fibers were observed throughout sections of the injected muscles. However, many fibers expressed human MHC antigens without expressing human dystrophin due to the low percentage of infected primary muscle cells in vitro (even when a high MOI [400] was used) and to a reduction and even to a complete loss of transgene copy number during myoblast replication. From our results, we conclude that, although not at a high proportion, (1) DMD primary myoblast cultures are infectable by adenoviruses; (2) they can be efficiently transplanted back in a muscle, leading to normal fusion of infected myoblasts with the host fibers; and (3) they can correct the dystrophin deficiency in the host fibers by the expression of a mini-dystrophin transgene.

Induction of primary immune responses by allogeneic human myoblasts: dissection of the cell types required for proliferation, IFNgamma secretion and cytotoxicity

Non-professional antigen-presenting cells (APC) have a limited ability to activate T lymphocytes during normal and auto-immune responses. Myoblasts could play an important role as APC in the etiology of autoimmune myasthenia gravis and polymyositis, as well as during muscle graft rejection. We examined the role of different component cell subsets in the response of human peripheral blood mononuclear cells (PBMC) to allogeneic myoblasts. Treatment of myoblasts with TNFalpha or IFNgamma led to the expression of a range of immunostimulatory molecules including MHC class I and II, and CD95 (Fas), but not B7 family molecules. Whole PBMC, cultured with allogeneic myoblasts, proliferated, secreted IFNgamma, and were cytotoxic. Proliferation and IFNgamma secretion were largely dependent on the presence of CD4+ lymphocytes, but neither CD4+ nor CD8+ T cells were responsible for cytotoxicity, which was mediated by MHC class II+ non-T mononuclear cells. However, purified CD4+ lymphocytes co-cultured with allogeneic myoblasts required co-stimulation with anti-CD28 antibodies for proliferation and IFNgamma secretion, which only induced a low level of IFNgamma secretion by CD8+ lymphocytes and did not induce cytotoxic function. These results suggest that human myoblasts can act as antigen-presenting cells for naive T lymphocytes, but only with additional co-stimulation.

Muscle maturation: implications for gene therapy

Skeletal muscle is a promising target tissue for gene therapy, for both muscle and non-muscle disorders. A variety of methods have been studied to transfer genes into skeletal muscle, including retroviral, adenoviral and herpes simplex viral vectors. However, various factors impede muscle-based viral gene therapy. Here, we discuss why some viral vectors cannot efficiently transduce mature muscle fibers, and describe some new approaches to overcome this barrier.

Implications of maturation for viral gene delivery to skeletal muscle

Different viral vectors have been analyzed as gene delivery vehicles to skeletal muscle for potentially therapeutic purposes. In this review, we evaluate the application of retroviral, adenoviral, and herpes simplex viral vectors to deliver genes to skeletal muscle and focus on the dramatic loss of viral transduction detected throughout muscle maturation. Recent results suggested that there are several factors involved in the reduced viral transducibility of mature skeletal muscle: muscle cells become post-mitotic in an early stage, the extracellular matrix develops into a physical barrier, and a loss of myoblast mediation occurs since myoblasts progressively become quiescent. Approaches to improve viral gene delivery to mature skeletal muscle may include the use of particular enzymes to increase the permeability of the extracellular matrix, the pre-treatment of the muscle with a myonecrotic agent to induce myoblast mediation, or the application of the myoblast-mediated ex vivo gene transfer.

Myoblast transplantation in non-dystrophic dog

Dog myoblasts obtained from muscle biopsies were infected in vitro with a defective retroviral vector containing a cytoplasmic beta-galactosidase (beta-Gal) gene. These myoblasts were initially transplanted in the irradiated muscles of SCID mice and beta-Gal positive muscle fibers were observed. beta-Gal myoblasts were also transplanted back either in the donor dogs (autotransplantation model) or in unrelated recipient dogs (allotransplantation model). Following these myoblast injections, a rapid inflammatory reaction developed within the muscle as indicated by an expression of P-selectin and of pro-inflammatory cytokine mRNAs (interleukin 6 (IL-6) and transforming growth factor beta (TGF-beta), and by a neutrophil infiltration. Following either auto- or allotransplantation in inadequately or non-immunosuppressed dogs, a specific immune reaction also developed within 2 weeks as indicated by the infiltration of CD4+ and of CD8+ lymphocytes, the increased expression of IL-10 and granzyme B mRNAs and the presence of antibodies reacting with the injected cells. Some dogs were immunosuppressed with several combinations of FK506, cyclosporine (CsA) and RS-61443. In dogs immunosuppressed with CsA combined with RS-61443, only a few myoblasts and myotubes expressing beta-Gal were observed 1-2 weeks after the transplantation, but no muscle fibers expressing beta-Gal were observed after 4 weeks, and antibodies against the injected cells were formed. In dogs immunosuppressed with FK506 alone, although no antibodies against the injected cells were produced, there were no small cells and no muscle fibers expressing beta-Gal 1 month after the transplantation. However, FK506 triggered diarrhea and vomiting in dogs. When the dogs were immunosuppressed with FK506 combined with CsA and RS-61443, muscle fibers expressing beta-Gal were present 4 weeks after the transplantation and no antibodies reacting with donor myoblasts were detected. These results indicate that the combination of three immunosuppressive agents (i.e., FK506, CsA and RS-61443) is effective in controlling the specific immune reactions following myoblast transplantation in dogs and they underline that the outcome of myoblast transplantation is dependent in part on an adequate immunosuppression. These results obtained here in normal dogs may justify myoblast transplantation in dystrophic dogs despite the side effects of FK506.

Anti-inflammatory effect of transforming growth factor-beta1 in myoblast transplantation

BACKGROUND

The inflammatory reaction that occurs during the 5 days after transplantation led at 3 days to the death of 70% of injected myoblasts. Use of anti-inflammatory agents appeared to be a possible way to increase myoblast survival. The application of gene transfer techniques to cell transplantation offers the potential for the prevention of inflammatory reaction.

METHODS

In this study, transforming growth factor-beta1 (TGF-beta1) gene was introduced in myoblasts with a retroviral vector to permit the secretion of this anti-inflammatory cytokine. Survival of (1) infected myoblasts expressing TGF-beta1 or (2) normal myoblasts transplanted with genetically modified cloned myoblasts was compared with survival of normal myoblasts.

RESULTS

Expression of TGF-beta1 by myoblasts or by cotransplanted cells decreased myoblast mortality after 3 days by roughly 20% (66.0+/-3.0% in control vs. 46.3+/-4.2% and 46.2+/-5.9%). The increase of myoblast survival by TGF-beta1 expression was correlated with a lower polymorphonuclear cell and macrophage infiltration in muscles compared with control. In addition, cytotoxicity of neutrophils against myoblasts was assayed in vitro. The oxidation of myoblasts by activated neutrophils was decreased after infection of the myoblasts with the TGF-beta1 retroviral vector.

CONCLUSIONS

These data demonstrate that the insertion of TGF-beta1 decreases inflammatory reaction observed after myoblast transplantation and thus prolongs their survival.

Arterial gene transfer of naked DNA for therapeutic angiogenesis: early clinical results

Patients with critical limb ischemia constitute a potential target population for therapeutic angiogenesis. Because the growth of new collateral vessels can be achieved in a time interval of 1 month or less, these patients are suitable candidates for treatment with non-viral vectors intended to yield short-term gene expression. Accordingly, we applied naked plasmid DNA encoding for vascular endothelial growth factor, a secreted endothelial cell mitogen, to the hydrogel polymer coating of an angioplasty balloon. The balloon was then used to perform arterial gene transfer to the arterial circulation of the ischemic lower extremity. Using a dose-escalating strategy, it was possible to document that naked DNA was sufficient to generate evidence of new collateral growth by both magnetic resonance angiography and contrast angiography in the affected limb. These findings establish that the use of naked DNA may be suitable for gene therapy when the gene product is actively secreted from transfected cells.

Prior culture with concanavalin A increases intramuscular migration of transplanted myoblast

The effect was studied of pretreatment with concanavalin A (ConA) of primary myoblast cultures on their migration when transplanted into muscles. As donors, transgenic CD1 mice in which the beta-galactosidase gene is under the control of a CMV promoter (CMVLacZ.9) were used. The myoblasts were grown with 20 microg/mL ConA during the 2 days before injecting them in the right tibialis anterior (TA) muscles of BALB/c mice and mdx mice. As a control, myoblasts from the same primary cultures were grown without ConA and injected in the left TA muscles. The host muscles were not previously irradiated or damaged by notexin injection. The recipient mice were immunosuppressed with FK506. Four days after myoblast transplantation, the area occupied by donor cells was significantly greater (more than threefold) following culture with ConA than without ConA. This result indicates that culture of myoblasts with ConA permits them to migrate farther following their transplantation in host muscles not previously damaged by notexin injection or irradiation. This suggests that pretreatment with ConA may be helpful for myoblast transplantation in humans. The mechanism of this effect still remains to be investigated.

Oral glutamine slows down whole body protein breakdown in Duchenne muscular dystrophy

We determined whether glutamine has a protein anabolic effect in six 8-13-y-old boys with Duchenne muscular dystrophy. Children received a 5-h i.v. infusion of L-[1-13C]leucine and L-[2-15N]glutamine in the postabsorptive state on two consecutive days while drinking: 1) flavored water on one day, and 2) the same drink mixed with L-glutamine (800 micromol x kg[-1] x h[-1]), the other day. Oral glutamine administration was associated with an 8% decrease in leucine release from protein breakdown, from 116 +/- 5 to 107 +/- 6 micromol x kg(-1) h(-1) (p < 0.01), and a 35% decrease in leucine oxidation rate from 23 +/- 2 to 15 +/- 2 micromol x kg(-1) x h(-1) (p < 0.01), resulting in no change in the nonoxidative leucine disposal, an index of protein synthesis. Whole body glutamine exchange in plasma doubled from 321 +/- 22 to 623 +/- 24 micromol x kg(-1) x h(-1), p < 0.01, but glutamine from protein degradation and glutamine de novo synthesis both decreased (91 +/- 4 versus 84 +/- 5 micromol x kg(-1) x h(-1), p < 0.01, and 230 +/- 21 versus 163 +/- 25 micromol x kg(-1) x (h-1), p = 0.02, respectively). These data suggest that acute oral glutamine administration might have a protein-sparing effect in children with Duchenne muscular dystrophy, decreasing estimates of whole body protein degradation and glutamine de novo synthesis, therefore sparing nitrogen precursors.

Direct dystrophin and reporter gene transfer into dog muscle in vivo

Bacterial beta-galactosidase cDNA was injected without lipofectin into 41 sites in dog muscle and expression was seen in 22 of them. The cDNA and lipofectin was injected into 35 similar sites and expression was seen in 21. Expression was seen in a maximum of 2.5% of muscle fibers and 23.21% of nonmuscle cells. A total of 106 muscle sites were injected with the minigene with and without lipofectin. In 4 of the 45 sites injected with the minigene without lipofectin human dystrophin was expressed around the periphery of 0.3% of the fibers. Bacterial beta-galactosidase cDNA was injected into the peritoneal cavity of 4 pups, 2 of which also received lipofectin. In all 4, expression was seen in liver, spleen, and mesenteric lymph node. In the 2 pups that received lipofectin, expression was also seen in the diaphragm, intercostal, and abdominal muscles of 1 and in the diagphragm and intercostal muscles of the other. These experiments show that human dystrophin transgene expression can be obtained in dog muscle. However, other methods will be required to increase the degree of expression before gene therapy trials can be undertaken.

Genetic research as therapy: implications of "gene therapy" for informed consent

Authors argue that characterization of gene transfer research as "gene therapy" has compromised informed consent in the current environment of regulatory exceptions, routinized consent, fostered therapeutic misconceptions, and oversold research.

Transfection of myoblasts in primary culture with isomeric cationic cholesterol derivatives

Transfection of satellite cells from dog muscle (myoblasts) in primary culture has been optimized with respect to the position of the cholesteryl moiety along the polyamine chain of spermidine or spermine. Spermidine or spermine were derivatized with cholesterylchloroformate giving rise to three isomers in the case of spermidine and two isomers for spermine that were separated by reversed-phase high-performance liquid chromatography (rp-HPLC). The position of the cholesteryl moiety was assigned by 13C-NMR and coelution with synthetic isomers of defined structure. The isomeric cationic lipids were evaluated for their transfection activity in myoblasts from dog muscle and a human lung epithelial cell line (A549) using plasmid DNA expressing the luciferase reporter gene. The results showed that the position of the cholesteryl moiety is of critical importance for efficient transfection of myoblasts in primary culture with isomers having a derivatized secondary amine being significantly more effective than those with a derivatized primary amine. On the contrary, differences in the A549 cell line were less pronounced and did not follow the same pattern. The results show that slight structural differences between cationic lipids lead to significantly different transfection efficiencies for myoblasts in primary culture. This may also represent an advantage in view of cell or organ targeting.

The fate of individual myoblasts after transplantation into muscles of DMD patients

Muscle biopsies from six patients with Duchenne muscular dystrophy (DMD) participating in a myoblast transplantation clinical trial were reexamined using a fluorescence in situ hybridization (FISH)-based method. Donor nuclei were detected in all biopsies analyzed, including nine where no donor myoblasts were previously thought to be present. In three patients, more than 10% of the original number of donor cells were calculated as present 6 months after implantation. Half of the detected donor nuclei were fused into host myofibers, and of these, nearly 50% produced dystrophin. These findings demonstrate that although donor myoblasts have persisted after injection, their microenvironment influences whether they fuse and express dystrophin. Our methodology could be used for developing new approaches to improve myoblast transfer efficacy and for the analysis of future gene- and/or cell-based therapies of numerous genetic disorders.

A novel gene delivery system using urothelial tissue engineered neo-organs

PURPOSE

Presently gene delivery is most effectively achieved by ex vivo gene transfer, which includes removal of the target tissue, in vitro gene delivery to the target cells, possible selection to enhance the proportion of transfected cells and reintroduction of the gene modified cells. Reintroduction of transformed cells in vivo has been a challenging task. Based on the feasibility of tissue engineering techniques in which cells seeded on biodegradable polymer scaffolds form tissue when implanted in vivo, we explored the possibility of developing a neo-organ system for in vivo gene therapy.

MATERIALS AND METHODS

Normal human urothelial cells were harvested, expanded in vitro and seeded on biodegradable polymer scaffolds. The cell-polymer complex was then transfected with PGL3-luc, pCMV-luc and pCMV beta-gal promoter reporter gene constructs. The transfected cell-polymer scaffolds were then implanted in athymic mice and the engineered tissue was retrieved 0, 1, 3, 5 and 7 days after implantation.

RESULTS

The reporter gene assay demonstrated an expression of luciferase activity at days 1, 3, 5 and 7 with the peak at day 5. X-gal and beta-galactosidase antibody assays stained positive on the deoxyribonucleic acid treated transfection.

CONCLUSIONS

Successful gene transfer can be achieved using biodegradable polymer scaffolds as a urothelial cell delivery vehicle. The transfected cell-polymer scaffold forms an organ-like structure with functional expression of the transfected genes. This study demonstrates that urothelial tissue engineered gene transfer is safe and effective.

Replicative potential and telomere length in human skeletal muscle: implications for satellite cell-mediated gene therapy

In this study, we have evaluated the ability of human satellite cells isolated from subjects aged from 5 days to 86 years to proliferate in culture. Cells were cultivated until they became senescent. The number of cell divisions was calculated by counting the number of cells plated in culture compared to the number of cells removed following proliferation. Telomere length, which is known to decrease during each round of cell division, has been used to analyze the in vitro replicative capacity and in vivo replicative history of human satellite cells at isolation. The rate of telomere shortening in myonuclei of these muscle biopsies was also examined. Our results show that both proliferative capacity and telomere length of satellite cells decreases with age during the first two decades but that the myonuclei of human skeletal muscle are remarkably stable because telomere length in these myonuclei remains constant from birth to 86 years. The lack of shortening of mean terminal restriction fragments (TRF) in vivo confirms that skeletal muscle is a stable tissue with little nuclear turnover and therefore an ideal target for cell-mediated gene therapy. Moreover, our results show that it is important to consider donor age as a limiting factor to obtain an optimal number of cells.

Chemotaxis of skeletal muscle satellite cells

Migration of myogenic cells occurs extensively during both embryogenesis and regeneration of skeletal muscle and is important in myoblast gene therapy, but little is known about factors that promote chemotaxis of these cells. We have used satellite cells from adult rats purified by Percoll density gradient centrifugation to test growth factors and wound fluids for chemotactic activity in blind-well Boyden chambers. Of a variety of growth factors tested only hepatocyte growth factor (HGF) and transforming growth factor-beta (TGF-beta) exhibited significant chemotactic activity. The dose-response curves for both of these factors was bell-shaped with maximum activity in the 1-10 ng/ml range. Checkerboard analysis of TGF-beta showed that chemotaxis occurred only in response to a positive concentration gradient. An extract of rat platelets also exhibited chemotactic activity for satellite cells. Half-maximal activity of this material was about 3 micrograms/ml, and there was no evidence of inhibition of migration at high concentrations. Checkerboard analysis of platelet extract exhibited evidence of both chemotaxis and chemokinesis, or increase in random motility of cells. Inhibition experiments showed that most, but not all, of the chemotactic activity in platelet extract could be blocked with a neutralizing antibody to TGF-beta. A saline extract of crushed muscle was found to contain both mitogenic and motogenic factors for satellite cells. The two activities were present in different fractions after heparin affinity chromatography. We propose that the proliferation and migration of satellite cells during regeneration is regulated by overlapping gradients of several effector molecules released at the site of muscle injury. These molecules may also be useful for enhancing the dispersion of injected myoblasts during gene therapy.

Myoblast implantation in Duchenne muscular dystrophy: the San Francisco study

We evaluated myoblast implantation in 10 boys with Duchenne muscular dystrophy (DMD) and absent dystrophin (age 5-10 years) who were implanted with 100 million myoblasts in the anterior tibial muscle of one leg and placebo in the other. Cyclosporine (5 mg/kg/day) was administered for 7 months. Pre- and postimplantation (after 1 and 6 months) muscle biopsies were analyzed. Force generation (tetanic tension and maximum voluntary contraction) was measured monthly in a double-blind design. There was increased force generation in both legs of all boys, probably due to cyclosporine. Using the polymerase chain reaction, evidence of myoblast survival and dystrophin mRNA expression was obtained in 3 patients after 1 month and in 1 patient after 6 months. These studies suggest a salutary effect of cyclosporine upon muscular force generation in Duchenne muscular dystrophy; however, myoblast implantation was not effective in replacing clinically significant amounts of dystrophin in DMD muscle.

Role of non-major histocompatibility complex antigens in the rejection of transplanted myoblasts

Myoblasts obtained from donors histoincompatible for several non-major histocompatibility complex antigens (i.e., including minor histocompatibility antigens) and from syngeneic donors were transplanted without any immunosuppression into the muscles of male dystrophic C57BL/10J mdx/mdx mice. Myoblasts from syngeneic mice resulted in the formation of a high percentage of dystrophin-positive fibers 16 weeks after the transplantation. There was no evidence of a cellular immune reaction against the donor myoblasts, i.e., no infiltration by CD4 or CD8 lymphocytes and no increased expression of granzyme B and interferon-gamma mRNAs. Transplantation of myoblasts obtained from donors histoincompatible only for non- major histocompatibility complex antigens produced a transient increase of dystrophin-positive fibers at 4 weeks after transplantation for some donor strains but not for others. For donor strains that did produce an increase at 4 weeks, the number of dystrophin-positive fibers was reduced 16 weeks after the transplantation. There was evidence of a cellular immune reaction-infiltration by CD4 and by CD8 lymphocytes and increased expression of granzyme B and interferon-gamma mRNAs. Transplantation of myoblasts obtained from male C57BL/10J +/+ mice into female C57BL/10J mdx/mdx mice also led to the presence of only a few dystrophin-positive fibers with the same signs of cellular immune reaction. In this later case, the cellular immune response was attributed to the H-Y minor antigens. Finally, antibodies against fetal calf serum were detected after both syngeneic and nonsyngeneic transplantations, indicating that the culture medium may also be a source of antigens. In mice, the presence of these antibodies against culture medium did not reduce the success of a first syngeneic transplantation.

Gene therapy and vascular disease: potential applications in vascular surgery

Advances in molecular biology have generated methods that are used to enhance diagnosis and treatment of a variety of human diseases. More recently modification of gene expression in cells by gene transfer has been introduced as a new therapeutic modality. The targeting of vascular cells with this method is appealing not only for anatomical reasons, but also because endovascular techniques provide access to the vasculature and makes site-specific delivery possible. Over the past few years, gene transfer has been widely used to explore the pathophysiology of vascular diseases in experimental models and available data suggests that this method may eventually become a therapeutic alternative for vascular disorders such as restenosis, graft failure, and critical ischaemia. In the following we discuss the methodology of gene transfer, its tentative use in vascular diseases related to vascular surgery, and the problems associated with this new technology.

The maturation of human gene therapy

Human gene therapy is two things. It is the concept that human disease might be treated at the level of underlying genetic targets rather than at the level of aberrant metabolism, and it is the implementation of that concept toward a clinical reality. The conceptual aspect is established--gene therapy has become an accepted central driving force in medicine. The second aspect--that of converting the concepts into practical tools for human gene therapy--is maturing rapidly. Over the past several years, the level of expectation had risen to unrealistic proportions and recent initial clinical trials produced disappointment. These early clinical results should, however, be viewed not as failures, but rather as deliberate progress along the learning curve in this new and difficult field of biomedical science.

Immunosuppression with monoclonal antibodies and CTLA4-Ig after myoblast transplantation in mice

Various combinations of monoclonal antibodies specific for lymphocyte cell surface antigens and a recombinant molecule (CTLA4-Ig) were used to immunosuppress mice after transplantation of MHC-incompatible myoblasts. To assess the effectiveness of the immunosuppression, the donor myoblasts were obtained from a transgenic mouse (TnI LacZ1/29) containing a beta-galactosidase (beta-gal) reporter gene under the control of a muscle-specific promoter. No muscle fibers expressing beta-gal were observed 1 month after the myoblast transplantation, when the animals were not immunosuppressed or were treated with CTLA4-Ig alone. Approximately 50% of the muscle fibers expressed the beta-gal reporter gene 1 month after transplantation in mice treated with CTLA4-Ig combined with an anti-CD4 monoclonal antibody and in mice treated with a combination of anti-CD4, anti-CD8, and anti-lymphocyte function-associated antigen-1. The percentage of beta-gal-labeled muscle fibers increased to 94% when this combination of the three monoclonal antibodies was administrated weekly for 3 weeks. Although excellent graft survival rates were obtained 1 month after transplantation, reflecting an effective immunosuppression by these three treatments, no beta-gal-positive fibers were found 2 months after the transplantation, indicating the inability of these immunosuppressive agents to maintain long-term graft survival and induce tolerance to the myoblasts and muscle fibers of donor origin.

Long-term expression of erythropoietin in the systemic circulation of mice after intramuscular injection of a plasmid DNA vector

Erythropoietin (Epo)-responsive anemia is a common and debilitating complication of chronic renal failure and human immunodeficiency virus infection. Current therapy for this condition involves repeated intravenous or subcutaneous injections of recombinant Epo. In this report, we describe the development of a novel muscle-based gene transfer approach that produces long-term expression of physiologically significant levels of Epo in the systemic circulation of mice. We have constructed a plasmid expression vector, pVRmEpo, that contains the murine Epo cDNA under the transcriptional control of the cytomegalovirus immediate early (CMV-IE) promoter, the CMV-IE 5' untranslated region, and intron A. A single intramuscular (i.m.) injection of as little as 10 micrograms of this plasmid into immunocompetent adult mice produced physiologically significant elevations in serum Epo levels and increased hematocrits from preinjection levels of 48 +/- 0.4% to levels of 64 +/- 3.3% 45 days after injection. Hematocrits in these animals remained elevated at greater than 60% for at least 90 days after a single i.m. injection of 10 micrograms of pVRmEpo. We observed a dose-response relationship between the amount of plasmid DNA injected and subsequent elevations in hematocrits. Mice injected once with 300 micrograms of pVRmEpo displayed 5-fold increased serum Epo levels and elevated hematocrits of 79 +/- 3.3% at 45 days after injection. The i.m. injected plasmid DNA remained localized to the site of injection as assayed by the PCR. We conclude that i.m. injection of plasmid DNA represents a viable nonviral gene transfer method for the treatment of acquired and inherited serum protein deficiencies.

Gene therapy for cancer, the course ahead

Previous chapters have shown that there are a large number of therapeutic approaches under consideration for the gene therapy of cancer. Many of these have progressed into Phase I clinical trials. However, many of the early results are perceived to be disappointing in terms of low levels of gene transfer and systemic efficacy. In this concluding chapter, possible solutions to this state of unease are addressed, so that gene therapy of cancer can resume on its course to become a major contributor to clinical oncology in the years ahead.

Gene therapy for cancer--in the dock, blown off course or full speed ahead?

Gene therapy no longer seems to generate the unlimited optimism that it once inspired. So much so that the field has recently attracted the close scrutinies of the Director of the NIH himself. In this introductory chapter, the background is presented to the rise, and apparent decline, of the gene therapy of cancer and serves as a prelude to this issue of Cancer Metastasis Reviews which is designed to ask whether the field is worthy of its highly-priced and highly-hyped market profile.

A method to codetect introduced genes and their products in gene therapy protocols

To monitor the presence of introduced genes and the distribution of the encoded proteins in host tissues after gene transfer, we combined fluorescence in situ hybridization (FISH) and immunohistochemistry in two separate gene therapy paradigms. In brain tissue sections from animals injected with pHSVlac vector, we localized nuclei containing vector DNA both in cells expressing and not expressing beta-galactosidase (beta-gal). This suggests that the efficiency of gene transfer is affected not only by gene delivery, but also by cellular controls on gene expression. In a second paradigm, following myoblast transplantation, we detected donor nuclei in the muscle of a patient with Duchenne's muscular dystrophy. The donor nuclei were either surrounded by host nuclei or apparently fused in the patient's muscle fiber producing dystrophin. The combined FISH and immunohistochemistry assay offers greater sensitivity and more information than currently used polymerase chain reaction and protein detection methods.

Prevention of immune reactions triggered by first-generation adenoviral vectors by monoclonal antibodies and CTLA4Ig

The therapeutic potential of adenovirus-mediated gene transfer using first-generation vectors is severely limited by the fact that only transient expression is achievable in immunocompetent animals. The loss in transgene expression can be attributed at least in part to the appearance of detrimental immune responses directed toward vector and/or transgene-encoded determinants. FK506 and cyclosporin A both reduced these immune responses. These immunosuppressants, however, may induce many severe side effects during prolonged use. An alternative strategy has been developed to overcome these problems following in vivo transfection of muscles of adult immunocompetent mice with a delta E1/E3a adenoviral vector encoding a beta-galactosidase (beta-Gal) expression cassette. YTS 177 (an anti-CD4 monoclonal antibody) as well as CTLA4Ig, a recombinant protein, partially controlled the immune responses. They were indeed able to reduce the muscle infiltration by CD4+ and CD8+ cells but they failed to repress the humoral response. Co-administration of YTS 191 (an anti-CD4), YTS 169 (an anti-CD8), and TIB 213 (an anti-CD11a) was, however, very efficient in blocking both cellular and humoral immune reactions. This combination of monoclonal antibodies allowed strong and stable transgene expression over 1 month. These data underline the potential of monoclonal antibodies as immunosuppressive adjunct treatment for adenovirus-mediated gene transfer.

Overexpression of the type-1 insulin-like growth factor receptor increases ligand-dependent proliferation and differentiation in bovine skeletal myogenic cultures

Previous studies demonstrated that overexpression of the type-1 insulin-like growth factor (IGF) receptor (IGF-1R) in skeletal myogenic cell lines increased proliferation and differentiation responses to IGF. However, it was unclear if such manipulations in primary, untransformed skeletal myogenic cells would result in modulation of these responses, which may be more stringently regulated in primary cells than in myogenic cell lines. In this study, low passage untransformed fetal bovine myogenic cultures were infected with a replication-deficient retroviral expression vector (LISN) coding for the human IGF-1R or with a control retroviral vector (LNL6). Bovine myogenic cultures infected with the LISN vector (Bov-LISN) displayed ten times more IGF-1Rs than controls (Bov-LNL6). Bov-LISN myogenic cultures exhibited elevated rates of IGF-I-stimulated proliferation and increased rates of terminal differentiation which were reduced to control levels by the anti-human IGF-1R antibody alpha IR3. These findings indicate overexpression of the IGF-1R can enhance IGF sensitivity and thereby modify the proliferation and differentiation behavior of untransformed low passage myoblasts. Such manipulations may be useful to increase muscle mass in clinical or agricultural applications.

Dystrophinopathies

The discovery of the subsarcolemmal muscle fiber protein dystrophin has, to a certain extent, replaced former nosological terms of Duchenne (DMD) and Becker (BMD) muscular dystrophies by the term dystrophinopathies. The immunohistochemical and Western blot analysis of dystrophin has not only enlarged the clinical spectrum of dystrophinopathies, but has also made carrier detection of DMD more reliable, particularly in manifesting carriers without family history. Moreover, prenatal muscle biopsy, under selected circumstances, can show presence or absence of dystrophin, ie, in the latter case an affected male fetus. Molecular genetics have provided a wealth of genetic details in the dystrophinopathies, but therapy has not yet succeeded to a similar extent, on the contrary, myoblast transplantation has not resulted in any clinical improvement.

Successive injections in mdx mice of myoblasts grown with bFGF

We studied the effects of single and repeated sets of injections in the same muscle of mdx mice of myoblasts grown with or without a high concentration 100 ng ml-1 of basic fibroblast growth factor (bFGF). The injected myoblasts were obtained from non-dystrophic transgenic mice expressing the beta-galactosidase gene under the control of a muscle-specific promoter. In these experiments, the host muscle was not irradiated to prevent muscle regeneration by host myoblasts. The host muscle was not damaged before myoblast transplantation with notexin, marcaïne or cold to trigger a regeneration-degeneration cycle. Without such pretreatments, the first set of injections of myoblasts grown without bFGF produced only 8% beta-galactosidase-positive and dystrophin-positive muscle fibers 1 month after transplantation. The percentage of muscle fibers containing the donor reporter gene increased, however, to 26% following a second set of injections in the same muscle. The percentage of muscle fibers expressing the donor reporter gene was significantly higher when the myoblasts were grown with a high dose of bFGF. Indeed the first set of injections produced 34% beta-gal-positive fibers while a second set of injections raised this percentage to 54%. In all cases, the percentage of dystrophin-positive fibers was similar to that of beta-gal-positive fibers. Therefore a high percentage of muscle fibers of donor origin can be obtained without preliminary damaging treatments of the mdx muscle when myoblasts grown with bFGF are injected several times. The effects of bFGF is not produced by increasing the percentage of myoblasts in a primary muscle culture since improvement of myoblast transplantation was obtained with a pure myoblast clone even with a lower concentration (10 ng ml-1) of bFGF.

Muscle-based gene therapy: realistic possibilities for the future

The past five years have witnessed tremendous growth in the field of gene therapy, with pre-clinical and clinical gene therapy trials for diseases as diverse as cancer, AIDS and atherosclerosis. These studies have utilized many different vectors and target organs in order to achieve therapeutic effects. In this review, we examine the rationale for using skeletal muscle as a target tissue for gene therapy, discuss the wide array of vectors that have been used for muscle-based gene therapy, summarize the disease-targets that have been approached using these techniques, and discuss some of the obstacles that remain to be overcome en route to successful muscle-based human gene therapy.

Substance P and neurokinin A metabolism by cultured human skeletal muscle myocytes and fibroblasts

A recent study determined that cultured human skeletal muscle adult myoblasts, myotubes, and fibroblasts degraded angiotensins and kinins via neutral endopeptidase-24.11 (NEP-24.11: EC 3.4.24.11) and aminopeptidase N (APN: EC 3.4.11.2). Due to the possible importance of other peptides to skeletal muscle blood flow and function, the present study looked specifically at the metabolism of the neurokinins substance P (SP) and neurokinin A (NKA) by skeletal muscle peptidases. The results show that SP is degraded not only by NEP-24.11, but also sequentially by dipeptidyl(amino)peptidase IV (DAP IV: EC 3.4.14.5)/APN. NKA is unaffected by DAP IV but is metabolized by NEP-24.11 and APN. NEP-24.11 was inhibited by phosphoramidon (IC50 = 80 nM), thiorphan and ZINCOV, DAP IV by diprotin A (IC50 = 8 microM), and APN by amastatin (IC50 = 50 nM) and bestatin (IC50 = 100 microM). Skeletal muscle myocyte and fibroblast metabolism of SP and NKA may regulate local skeletal muscle vascular and extravascular functions including SP- and NKA-mediated nerve-induced vasodilation. Inhibition of both NEP-24.11 and DAP IV/APN may increase skeletal muscle blood flow and decrease peripheral vascular resistance via potentiation of local neurokinin levels.