Protoporphyrie érythropoïétique : thérapie génique non intégrative par oligonucléotide antisens adressé par peptides bifonctionnels RTf1-CPP

Erythropoietic protoporphyria (EPP) is a rare hereditary disease characterized by a deficiency in FECH activity responsible for the accumulation of PPIX. EPP is manifested by a very disabling photosensitivity. There is no effective treatment for EPP. 95% of the patients present a hypomorphic FECH allele (c.315-48C) in trans of a deleterious FECH mutation, resulting in a decrease in residual FECH activity in erythroblasts below a critical threshold of about 35% of normal activity. The hypomorphic allele (c.315-48C) promotes the use of a cryptic splicing site located at -63 of the intron 3 generating a FECH mRNA including a part of the intron 3 and possessing a premature stop codon. The RNA is then degraded by NMD during its maturation. We have previously identified an antisense oligonucleotide (ASO-V1) that redirects splicing to the physiological acceptor site of intron 3 and increases the production of WT FECH mRNA. Here, we developed a new ASO-V1 addressing strategy using transferrin receptor (TRf1) targeted peptides. TfR1 is expressed at a very high level in differentiating erythroid progenitors concomitantly with FECH. We developed bifunctional peptides from peptide sequences targeting TfR1 while coupling them to Cell Penetrating Peptide (CPP) sequences that facilitate the release of ASO-V1 from the endosomal vesicle. We transfected the lymphoblastoid cell lines from EPP patients by different TfR1-CPP/ASO-V1 nanocomplexes and we demonstated that several of the bifunctional peptides allowed an efficient and prolonged redirection of the cryptic splicing towards the exon3-exon4 physiological splicing and the correction of the WT FECH mRNA levels. Then, we tested the effect of TfR1-CPP/ASO-V1 nanocomplexes, ex vivo, in differentiating erythroid progenitors of different EPP subjects and we were able to increase WT FECH mRNA and decrease significantly the accumulation of the PPIX in these cells compared to those transfected by TfR1-CPP/ASO-Scr nanocomplexes. The next step of our study would be to provide a proof of concept, in vivo, in a humanized murine model of EPP after the administration of TfR1-CPP/ASOV-1 nanocomplexesLa protoporphyrie érythropoïétique (PPE) est une maladie héréditaire rare caractérisée par un déficit en activité FECH responsable d’une accumulation de PPIX. Elle se manifeste par une photosensibilité très invalidante. Il n’existe pas de traitement efficace pour la PPE. 95 % des malades présentent un allèle FECH hypomorphe (c.315-48C) en trans d'une mutation FECH délétère, ce qui entraine une diminution de l'activité FECH résiduelle dans les érythroblastes en dessous d'un seuil critique d'environ 35 % de l'activité normale. L’allèle hypomorphe (c.315-48C) favorise l'utilisation d'un site cryptique d'épissage situé en -63 de l’intron 3 générant un ARNm FECH incluant une partie de l’intron 3 et possédant un codon stop prématuré. L’ARN est alors dégradé par NMD pendant sa maturation. Nous avons déjà identifié un oligonucléotide antisens (ASO-V1) qui redirige l'épissage vers le site accepteur physiologique de l’intron 3 et augmente la production d’ARN FECH WT. Nous avons développé par ce travail une nouvelle stratégie d’adressage d’ASO-V1 en utilisant des peptides ciblant le récepteur de la transferrine (RTf1) qui est exprimé à un niveau très élevé dans les progéniteurs érythroïdes en différenciation concomitamment à la FECH. Nous avons développé des peptides bifonctionnels à partir des séquences peptidiques ciblant le RTf1 tout en les couplant à des séquences Cell Penetrating Peptide (CPP) qui facilitent la sortie de l’ASO-V1 de la vésicule endosomale. Après la transfection des lignées lymphoblastoïdes de malades PPE par différents nanocomplexes RTf1-CPP/ASO-V1, nous avons pu montrer que plusieurs des peptides bifonctionnels utilisés permettaient une redirection efficace et prolongée de l’épissage cryptique vers l’épissage physiologique exon3-exon4 et que cela permettait une correction des taux d’ARN FECH WT. Nous avons ensuite testé l’effet des nanocomplexes RTf1-CPP/ASO-V1, ex vivo, dans les progéniteurs érythroïdes en différenciation de différents sujets atteints de PPE et nous sommes arrivés à augmenter l’ARN FECH WT et diminuer significativement l’accumulation de la PPIX dans ces cellules par rapport à celles transfectées par des nanocomplexes RTf1-CPP/ASO-Mock. La prochaine étape de notre étude serait d’apporter la preuve de concept, in vivo, dans un modèle murin humanisé de PPE après l'administration de nanocomplexes RTf1-CPP/ASOV

Erythropoietic protoporphyria : non-integrative gene therapy by antisens oligonucleotide addressed by TFR1-CPP bifunctional peptides

La protoporphyrie érythropoïétique (PPE) est une maladie héréditaire rare caractérisée par un déficit en activité FECH responsable d’une accumulation de PPIX. Elle se manifeste par une photosensibilité très invalidante. Il n’existe pas de traitement efficace pour la PPE. 95 % des malades présentent un allèle FECH hypomorphe (c.315-48C) en trans d'une mutation FECH délétère, ce qui entraine une diminution de l'activité FECH résiduelle dans les érythroblastes en dessous d'un seuil critique d'environ 35 % de l'activité normale. L’allèle hypomorphe (c.315-48C) favorise l'utilisation d'un site cryptique d'épissage situé en -63 de l’intron 3 générant un ARNm FECH incluant une partie de l’intron 3 et possédant un codon stop prématuré. L’ARN est alors dégradé par NMD pendant sa maturation. Nous avons déjà identifié un oligonucléotide antisens (ASO-V1) qui redirige l'épissage vers le site accepteur physiologique de l’intron 3 et augmente la production d’ARN FECH WT. Nous avons développé par ce travail une nouvelle stratégie d’adressage d’ASO-V1 en utilisant des peptides ciblant le récepteur de la transferrine (RTf1) qui est exprimé à un niveau très élevé dans les progéniteurs érythroïdes en différenciation concomitamment à la FECH. Nous avons développé des peptides bifonctionnels à partir des séquences peptidiques ciblant le RTf1 tout en les couplant à des séquences Cell Penetrating Peptide (CPP) qui facilitent la sortie de l’ASO-V1 de la vésicule endosomale. Après la transfection des lignées lymphoblastoïdes de malades PPE par différents nanocomplexes RTf1-CPP/ASO-V1, nous avons pu montrer que plusieurs des peptides bifonctionnels utilisés permettaient une redirection efficace et prolongée de l’épissage cryptique vers l’épissage physiologique exon3-exon4 et que cela permettait une correction des taux d’ARN FECH WT. Nous avons ensuite testé l’effet des nanocomplexes RTf1-CPP/ASO-V1, ex vivo, dans les progéniteurs érythroïdes en différenciation de différents sujets atteints de PPE et nous sommes arrivés à augmenter l’ARN FECH WT et diminuer significativement l’accumulation de la PPIX dans ces cellules par rapport à celles transfectées par des nanocomplexes RTf1-CPP/ASO-Mock. La prochaine étape de notre étude serait d’apporter la preuve de concept, in vivo, dans un modèle murin humanisé de PPE après l'administration de nanocomplexes RTf1-CPP/ASOV1Erythropoietic protoporphyria (EPP) is a rare hereditary disease characterized by a deficiency in FECH activity responsible for the accumulation of PPIX. EPP is manifested by a very disabling photosensitivity. There is no effective treatment for EPP. 95% of the patients present a hypomorphic FECH allele (c.315-48C) in trans of a deleterious FECH mutation, resulting in a decrease in residual FECH activity in erythroblasts below a critical threshold of about 35% of normal activity. The hypomorphic allele (c.315-48C) promotes the use of a cryptic splicing site located at -63 of the intron 3 generating a FECH mRNA including a part of the intron 3 and possessing a premature stop codon. The RNA is then degraded by NMD during its maturation. We have previously identified an antisense oligonucleotide (ASO-V1) that redirects splicing to the physiological acceptor site of intron 3 and increases the production of WT FECH mRNA. Here, we developed a new ASO-V1 addressing strategy using transferrin receptor (TRf1) targeted peptides. TfR1 is expressed at a very high level in differentiating erythroid progenitors concomitantly with FECH. We developed bifunctional peptides from peptide sequences targeting TfR1 while coupling them to Cell Penetrating Peptide (CPP) sequences that facilitate the release of ASO-V1 from the endosomal vesicle. We transfected the lymphoblastoid cell lines from EPP patients by different TfR1-CPP/ASO-V1 nanocomplexes and we demonstated that several of the bifunctional peptides allowed an efficient and prolonged redirection of the cryptic splicing towards the exon3-exon4 physiological splicing and the correction of the WT FECH mRNA levels. Then, we tested the effect of TfR1-CPP/ASO-V1 nanocomplexes, ex vivo, in differentiating erythroid progenitors of different EPP subjects and we were able to increase WT FECH mRNA and decrease significantly the accumulation of the PPIX in these cells compared to those transfected by TfR1-CPP/ASO-Scr nanocomplexes. The next step of our study would be to provide a proof of concept, in vivo, in a humanized murine model of EPP after the administration of TfR1-CPP/ASOV-1 nanocomplexe

Iron, Heme Synthesis and Erythropoietic Porphyrias: A Complex Interplay

Erythropoietic porphyrias are caused by enzymatic dysfunctions in the heme biosynthetic pathway, resulting in porphyrins accumulation in red blood cells. The porphyrins deposition in tissues, including the skin, leads to photosensitivity that is present in all erythropoietic porphyrias. In the bone marrow, heme synthesis is mainly controlled by intracellular labile iron by post-transcriptional regulation: translation of ALAS2 mRNA, the first and rate-limiting enzyme of the pathway, is inhibited when iron availability is low. Moreover, it has been shown that the expression of ferrochelatase (FECH, an iron-sulfur cluster enzyme that inserts iron into protoporphyrin IX to form heme), is regulated by intracellular iron level. Accordingly, there is accumulating evidence that iron status can mitigate disease expression in patients with erythropoietic porphyrias. This article will review the available clinical data on how iron status can modify the symptoms of erythropoietic porphyrias. We will then review the modulation of heme biosynthesis pathway by iron availability in the erythron and its role in erythropoietic porphyrias physiopathology. Finally, we will summarize what is known of FECH interactions with other proteins involved in iron metabolism in the mitochondria

Regulation and tissue-specific expression of δ-aminolevulinic acid synthases in non-syndromic sideroblastic anemias and porphyrias

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TSPO2 translocates 5‐aminolevulinic acid into human erythroleukemia cells

International audienceBackground: 5-aminolevulinic acid (ALA) is the first precursor of heme biosynthesis pathway. The exogenous addition of ALA to cells leads to protoporphyrin IX (PPIX) accumulation that has been exploited in photodynamic diagnostic and photodynamic therapy. Several types of ALA transporters have been described depending on the cell type, but there was no clear entry pathway for erythroid cells. The 18 kDa translocator protein (TSPO) has been proposed to be involved in the transport of porphyrins and heme analogs.Results: ALA-induced PPIX accumulation in erythroleukemia cells (UT-7, K562) was impaired by PK 11195, a competitive inhibitor of both transmembrane proteins TSPO (1 and 2). PK 11195 did not modify the activity of the enzymes of heme biosynthesis, suggesting that ALA entry at the plasma membrane was the limiting factor. In contrast, porphobilinogen (PBG)-induced PPIX accumulation was not affected by PK 11195, suggesting that plasma membrane TSPO2 is a selective transporter of ALA. Overexpression of TSPO2 at the plasma membrane of erythroleukemia cells increased ALA-induced PPIX accumulation, confirming the role of TSPO2 in the import of ALA into the cells.Conclusions: ALA-induced PPIX accumulation in erythroid cells involves TSPO2 as a selective translocator through the plasma membrane. Significance: This is the first characterization of molecular mechanisms involving a new actor in ALA transport in ALA-induced PPIX accumulation in erythroleukemia cells, which could be inhibited by specific drug ligands

Renal Function Decline Under Therapy With Small Interfering RNA Silencing ALAS1 for Acute Intermittent Porphyria

International audienceIntroduction: Givosiran is an RNA interference therapeutic designed to block the synthesis of the aminolevulinic acid (ALA) synthase 1 (ALAS1) enzyme in patients with acute intermittent porphyria (AIP). Givosiran may have adverse effects on the kidney.Methods: We performed a descriptive case series of renal function parameters of all the patients who received givosiran in France. Twenty patients receiving givosiran between March 2018 and July 2020 in France were analyzed: 7 patients in the ENVISION trial and 13 patients treated in collaboration with the Centre de Référence Maladies Rares Prophyries.Results: A transient decrease in renal function was observed in all but 2 patients (90%) within the 3 months following givosiran initiation. None of the patients developed acute kidney injury or disease. Patients of the ENVISION cohort were followed for at least 30 months: 2 patients did not experience estimated glomerular filtration rate (eGFR) loss, 3 patients experienced a modest decline in renal function (–3.4 ml/min per 1.73 m2 per year in average), and 2 patients had a clearly abnormal eGFR loss (–5.8 ml/min per 1.73 m2 per year in average). None of the patients had biochemical signs of active tubular or glomerular injury. One patient’s kidney was biopsied without finding any signs of an active kidney disease and with normal ALAS1 tubular expression.Conclusions: Givosiran is associated with a transient moderate increase in serum creatinine (sCr) without sign of kidney injury. A long-term deleterious impact of ALAS1 inhibition on renal function is not excluded. Because AIP promotes chronic kidney disease, it is difficult to separate the long-term effects of givosiran from the natural progression of the renal disease

Phlebotomy as an efficient long-term treatment of congenital erythropoietic porphyria

International audienceCongenital erythropoietic porphyria (CEP) is a rare autosomal recessive disease caused by impaired activity of uroporphyrinogen III synthase, the fourth enzyme of the heme biosynthetic pathway. Massive accumulation of porphyrins in red blood cells is responsible for hemolysis and porphyrin deposition in the skin, inducing severe bullous lesions and progressive photomutilation. Treatment options are scarce, relying mainly on supportive measures and, for severe cases, on bone marrow transplantation. In CEP, gain-of-function mutations in ALAS2 can represent an aggravating factor, and iron restriction can improve disease symptoms. Herein, we present the first case of a CEP patient significantly improved by iron deficiency induced by iterative phlebotomies for almost two years. We observed discontinuation of hemolysis and a marked decrease in plasma and urine porphyrins. The patient reported a major improvement in photosensitivity. No adverse effects were observed. The characterization of 3 CEP siblings in a consanguineous family with contrasting phenotypes modulated by iron availability highlights the importance of iron metabolism in the disease. Erythroid cultures were performed, demonstrating the role of iron in the rate of porphyrin production. Thus, we propose phlebotomy as an efficient, accessible, inexpensive and well-tolerated treatment for CEP

Erythroid-Progenitor-Targeted Gene Therapy Using Bifunctional TFR1 Ligand-Peptides in Human Erythropoietic Protoporphyria

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From a dominant to an oligogenic model of inheritance with environmental modifiers in acute intermittent porphyria

International audienceAcute intermittent porphyria (AIP) is a disease affecting the heme biosynthesis pathway caused by mutations of the hydroxymethylbilane synthase (HMBS) gene. AIP is thought to display autosomal dominant inheritance with incomplete penetrance. We evaluated the prevalence, penetrance and heritability of AIP, in families with the disease from the French reference center for porphyria (CFP) (602 overt patients; 1968 relatives) and the general population, using Exome Variant Server (EVS; 12 990 alleles) data. The pathogenicity of the 42 missense variants identified was assessed in silico, and in vitro, by measuring residual HMBS activity of the recombinant protein. The minimal estimated prevalence of AIP in the general population was 1/1299. Thus, 50 000 subjects would be expected to carry the AIP genetic trait in France. Penetrance was estimated at 22.9% in families with AIP, but at only 0.5-1% in the general population. Intrafamily correlation studies showed correlations to be strong overall and modulated by kinship and the area in which the person was living, demonstrating strong influences of genetic and environmental modifiers on inheritance. Null alleles were associated with a more severe phenotype and a higher penetrance than for other mutant alleles. In conclusion, the striking difference in the penetrance of HMBS mutations between the general population and the French AIP families suggests that AIP inheritance does not follow the classical autosomal dominant model, instead of being modulated by strong environmental and genetic factors independent from HMBS. An oligogenic inheritance model with environmental modifiers might better explain AIP penetrance and heritability

Recurrent attacks of acute hepatic porphyria: major role of the chronic inflammatory response in the liver

Background: Acute intermittent porphyria (AIP) is an inherited disorder of haem metabolism characterized by life‐threatening acute neurovisceral attacks due to the induction of hepatic δ‐aminolevulinic acid synthase 1 (ALAS1) associated with hydroxymethylbilane synthase (HMBS) deficiency. So far, the treatment of choice is hemin which represses ALAS1. The main issue in the medical care of AIP patients is the occurrence of debilitating recurrent attacks. Objective: The aim of this study was to determine whether chronic hemin administration contributes to the recurrence of acute attacks. Methods: A follow-up study was conducted between 1974 and 2015 and included 602 French AIP patients, of whom 46 had recurrent AIP. Moreover, we studied the hepatic transcriptome, serum proteome, liver macrophage polarization and oxidative and inflammatory profiles of Hmbs−/− mice chronically treated by hemin and extended the investigations to five explanted livers from recurrent AIP patients. Results: The introduction of hemin into the pharmacopeia has coincided with a 4.4‐fold increase in the prevalence of chronic patients. Moreover, we showed that both in animal model and in human liver, frequent hemin infusions generate a chronic inflammatory hepatic disease which induces HO1 remotely to hemin treatment and maintains a high ALAS1 level responsible for recurrence. Conclusion: Altogether, this study has important impacts on AIP care underlying that hemin needs to be restricted to severe neurovisceral crisis and suggests that alternative treatment targeting the liver such as ALAS1 and HO1 inhibitors, and anti‐inflammatory therapies should be considered in patients with recurrent AIP