Quelle régulation pour l’arrêt d’un protocole de recherche clinique de thérapie génique somatique ? État des lieux auprès des cliniciens-chercheurs européens

Depuis 2002, le débat sur les risques associés à la thérapie génique est initié suite à l’annonce que deux enfants inclus dans un essai thérapeutique impliquant une thérapie génique ont développé des effets indésirables important. En Janvier 2005, le débat sur les risques reprit suite à l’interruption du protocole sur les enfants bulle du Pr Fischer à l’hôpital Necker de Paris. Nous avons donc étudié le processus impliqué ainsi que la réflexion éthique associée aux décisions d’arrêt de protocole de recherche. Notre travail a été mené par une équipe pluridisciplinaire combinant chercheurs en santé, généticiens et éthiciens. Nous avons étudié la participation des chercheurs, des patients, des institutions officielles, des comités d’éthique ainsi que des associations de patients dans le processus de décision d’interruption d’un protocole de recherche.Nous avons également analysé les critères jugés les plus pertinents dans l’arrêt d’un protocole de recherche. Enfin nous avons analysé le point de vue des personnes directement impliquées dans la thérapie génique au moyen d’un questionnaire. Toutes les personnes contactées ont présenté un poster de recherche au congrès de la Société Européenne de Thérapie Génique. 62 personnes d’autant d’équipes de recherche différentes, de 17 pays, sur les 350 contactés ont répondu. Selon eux, la décision d’arrêt d’un protocole de recherche doit être prise suite à une consultation des chercheurs, des patients, du ministère de tutelle, d’une agence nationale de régulation ou d’un comité d’éthique ; la légitimité étant accordée à des décisions prises en commun par les chercheurs, les patients et les comités d’éthique. Les incidents sérieux et de façon plus surprenante, les incidents moins graves sont jugés comme étant des critères suffisants pour interrompre un essai. Nous avons fini par analyser les conséquences éthiques, telles que balance bénéfice/risque, processus de régulation ou responsabilité, de ces critères sur l’arrêt d’un protocole de recherche.In 2002, the debate on the risks of gene therapy was initiated following the annoucement that two children included in a clinical trial developed serious adverse effects. In January 2005, the debate was reignited following the interruption of the “bubble kids protocol” at the Hôpital Necker in Paris. We have thus investigated the ethical stakes involved in decisions to stop protocols. This work was carried out by a multidisciplinary team combining ethics researchers and geneticists. We studied the specific participation of researchers, patients, official institution, ethics committees and patient associations in the processes that can lead to an interruption of trial.We also analysed the criterion judged most relevant for halting a trial. Finally, we analyzed the perspective of the actors implicated directly in the provision of gene therapy, by means of a questionnaire. All the individuals contacted had presented a scientific poster at the European Society of Gene Therapy. 62 out of 350 persons, from 17 countries, responded to our questionnaire. According to these respondants, decisions to stop a trial should be taken after consultation with researchers, patients, the ministry, national agencies or ethics committees. Legitimacy was accorded to joint decision-making by researchers, patients and committees. Serious incidents, and surprisingly less serious incidents, clearly emerge as criterion for stopping a trial. We conclude by analyzing the ethical consequences, such as risk/benefit ratios, regulatory processes and responsibility, associated with these criterions and decisions to stop a trial

Combined Immunodeficiency With Late-Onset Progressive Hypogammaglobulinemia and Normal B Cell Count in a Patient With RAG2 Deficiency

Proteins expressed by recombination activating genes 1 and 2 (RAG1/2) are essential in the process of V(D)J recombination that leads to generation of the T and B cell repertoires. Clinical and immunological phenotypes of patients with RAG deficiencies correlate well to the degree of impaired RAG activity and this has been expanding to variants of combined immunodeficiency (CID) or even milder antibody deficiency syndromes. Pathogenic variants that severely impair recombinase activity of RAG1/2 determine a severe combined immunodeficiency (SCID) phenotype, whereas hypomorphic variants result in leaky (partial) SCID and other immunodeficiencies. We report a patient with novel pathogenic compound heterozygous RAG2 variants that result in a CID phenotype with two distinctive characteristics: late-onset progressive hypogammaglobulinemia and highly elevated B cell count. In addition, the patient had early onset of infections, T cell lymphopenia and expansion of lymphocytes after exposure to herpes family viruses. This case highlights the importance of considering pathogenic RAG variants among patients with preserved B cell count and CID phenotype

Identification of CD4−CD8− Double-Negative Natural Killer T Cell Precursors in the Thymus

BACKGROUND: It is well known that CD1d-restricted Valpha14 invariant natural killer T (NKT) cells are derived from cells in the CD4(+)CD8(+) double-positive (DP) population in the thymus. However, the developmental progression of NKT cells in the earlier stages remains unclear, and the possible existence of NKT cell presursors in the earlier stages than DP stage remains to be tested. PRINCIPAL FINDINGS: Here, we demonstrate that NKT cell precursors that express invariant Valpha14-Jalpha18 transcripts but devoid of surface expression of the invariant Valpha14 receptor are present in the late CD4(-)CD8(-) double-negative (DN)4 stage and have the potential to generate mature NKT cells in both in vivo and in vitro experimental conditions. Moreover, the DN4 population in CD1d knock-out (CD1dKO) mice was similar to those with an NKT cell potential in wild-type (WT) C57BL/6 (B6) mice, but failed to develop into NKT cells in vitro. However, these precursors could develop into NKT cells when co-cultured with normal thymocytes or in an in vivo experimental setting, indicating that functional NKT cell precursors are present in CD1dKO mice. CONCLUSIONS: Together, these results demonstrate that thymic DN4 fraction contains NKT cell precursors. Our findings provide new insights into the early development of NKT cells prior to surface expression of the invariant Valpha14 antigen receptor and suggest the possible alternative developmental pathway of NKT cells

“Galectin-1 Induces Central and Peripheral Cell Death: Implications in T-Cell Physiopathology”

The immune system has a remarkable capacity to maintain a state of equilibrium even as it responds to a diverse array of foreign proteins and despite its contact exposure to self-antigens. Apoptosis is one of the mechanisms aimed at preserving the homeostasis after the completion of an immune response, thus returning the immune system to a basal state and warranting the elimination of autoagressive cells in both central and peripheral lymphoid organs. Targeted deletions in critical genes involved in the apoptotic death machinery together with natural spontaneous mutations have clearly shown the importance of apoptosis in the regulation of the immune response. This complex scenario of stimulatory and inhibitory genes has been enriched with the finding that galectin-1, a 14.5 kDa β-galactoside-binding protein, is able to induce apoptosis of immature cortical thymocytes and mature T cells by cross-linking cell surface glycoconjugates. Galectin-1 is present not only in central and peripheral lymphoid organs, but also at sites of immune privilege. In the present article we will discuss the implications of galectin-1-induced apoptosis in T-cell physiopathology in an attempt to validate its therapeutic potential in autoimmune and inflammatory diseases

Analyse moléculaire de patients présentant un déficit immunitaire combiné avec microcéphalie associé à un défaut général de la réparation de l'ADN

Analyse moléculaire de patients présentant un déficit immunitaire combiné avec microcéphalie associé à un défaut général de la réparation de l'ADN. Les cassures double-brin d'ADN (dsb) formées au cours de la recombinaison V(D)J sont modifiées et ligaturées par des facteurs généraux de la réparation de l'ADN du non homologous end joining (NHEJ), avec six protéines connues impliquées:Ku70/Ku86/DNAPKcs, Artemis et Xrcc4/Lig4. Dans un premier temps, nous avons montré que des mutations hypomorphes de Lig4 peuvent entraîner un déficit immunitaire sévère avec radiosensibilité (RS-SCID) chez l'homme, caractérisé par un défaut de la recombinaison V(D)J in vitro, qui est complémenté par la forme sauvage de Lig4. Deuxièmement, nous avons identifié un nouveau facteur V(D)J/NHEJ grâce à l'analyse fonctionnelle et génétique d'un groupe de patients présentant un phénotype similaire à celui des patients déficients e Lig4. Nous avons nommé ce facteur Cernunnos, dont le gène codant est muté chez tous les patients analysés. Le défaut du NHEJ observé dans les cellules de ces patients est complémenté par la forme sauvage de Cernunnos.PARIS5-BU-Necker : Fermée (751152101) / SudocPARIS-BIUP (751062107) / SudocSudocFranceF

An in vivo study of the impact of deficiency in the DNA repair proteins PAXX and XLF on development and maturation of the hemolymphoid system: Combined PAXX and Xlf deficiency: an in vivo study

International audienceThe repair of DNA double strand breaks (DSBs) by the non-homologous end-joining pathway (NHEJ) is central for the proper development of the adaptive immune system. This repair pathway involves eight factors, including XRCC4-like factor (XLF)/Cernunnos and the paralog of XRCC4 and XLF, PAXX non-homologous end-joining factor (PAXX). Xlf-/- and Paxx-/- mice are viable and exhibit only a mild immunophenotype. However, mice lacking both PAXX and XLF are embryonic lethal because postmitotic neurons undergo massive apoptosis in embryos. To decipher the roles of PAXX and XLF in both V(D)J recombination and immunoglobulin class switch recombination (CSR), here, using Cre/lox-specific deletion to prevent the double-KO embryonic lethality, we developed two mouse models of a conditional Xlf KO in a Paxx-/- background. Cre expressed under the control of the iVav or CD21 promoter enabled Xlf deletion in early hematopoietic progenitors and splenic mature B cells, respectively. We demonstrate the XLF and PAXX interplay during V(D)J recombination in vivo, but not during CSR for which PAXX appeared to be fully dispensable. A Xlf/Paxx-double KO in hematopoietic progenitors resulted in a shorter lifespan associated with the onset of thymic lymphomas, revealing a genome caretaking function of XLF/PAXX