Gene Therapy

The goal of gene therapy is to treat disease through delivery of the normal, cloned DNA for a gene into the somatic cells of a patient who has a defect in that gene as a result of a disease-causing mutation. Because somatic gene therapy changes only the targeted somatic cells, the change is not passed on to the next generation. [Note: In germline gene therapy, the germ cells are modified, and so the change is passed on. A long-standing moratorium on germline gene therapy is in effect worldwide.] There are two types of gene transfer: 1) ex vivo, in which cells from the patient are removed, transduced, and returned, and 2) in vivo, in which the cells are directly transduced. Both types require use of a viral vector to deliver the DNA.

Challenges of gene therapy include development of vectors, achievement of long-lived expression, and prevention of side effects such as an immune response. The first successful gene therapy involved two patients with severe combined immunodeficiency disease (SCID) caused by mutations to the gene for adenosine deaminase . It utilized mature T lymphocytes transduced ex vivo with a retroviral vector (Fig. 1). [Note: Human ADA cDNA is now used.] Since 1990, only a small number of patients (with a variety of disorders, such as hemophilia, cancers, and certain types of blindness) have been treated with gene therapy, with varying degrees of success.

Figure 1:  Gene therapy for severe combined immunodeficiency disease caused by adenosine deaminase deficiency. [Note: Bone marrow stem cells and a modified retroviral vector are now used.]
Gene editing, as opposed to gene addition, allows a mutated gene to be repaired. Combinations of DNA-binding molecules (proteins or RNA) and endonucleases are used to identify and cleave the mutated sequence. Cleavage activates homologous recombination repair of dsDNA breaks  that integrates DNA containing the correct sequence into the gene. [Note: An endonuclease guided to a specific DNA sequence by a custom-designed RNA has been used in gene editing in human cell lines. The technique is based on (and named for) the prokaryotic CRISPR-Cas9 (clustered regularly interspaced short palindromic repeats [CRISPR]-associated protein) system that identifies and cleaves foreign DNA in bacterial cells. CRISPR is currently used in the laboratory but not in the clinic.]