No abstract

Most reported thromboembolic AEs followed the use of rFVIIa for unlabeled indications and occurred in arterial and venous systems, often resulting in serious morbidity and mortality. Analysis of the relationship between AEs and rFVIIa is hindered by concomitant medications, preexisting medical conditions, confounding by indication, and inherent limitations of passive surveillance. Randomized controlled trials are needed to establish the safety and efficacy of rFVIIa in patients without hemophilia.

We

The feasibility, safety, and efficacy of liverdirected gene transfer was evaluated in 5 male macaques (aged 2.5 to 6.5 years) by using a recombinant adeno-associated viral (rAAV) vector (rAAV-2 CAGG-hFIX) that had previously mediated persistent therapeutic expression of human factor IX (hFIX; 6%-10% of physiologic levels) in murine models. A dose of 4 ؋ 10 12 vector genomes (vgs)/kg of body weight was administered through the hepatic artery or portal vein. Persistence of the rAAV vgs as circular monomers and dimers and high-molecularweight concatamers was documented in liver tissue by Southern blot analysis for periods of up to 1 year. Vector particles were present in plasma, urine, or saliva for several days after infusion (as shown by polymerase chain reaction analysis), and the vgs were detected in spleen tissue at low copy numbers. An enzyme-linked immunosorption assay capable of detecting between 1% and 25% of normal levels of hFIX in rhesus plasma was developed by using hyperimmune serum from a rhesus monkey that had received an adenoviral vector encoding hFIX. Two macaques having 3 and 40 rAAV genome equivalents/cell, respectively, in liver tissue had 4% and 8% of normal physiologic plasma levels of hFIX, respectively. A level of hFIX that was 3% of normal levels was transiently detected in one other macaque, which had a genome copy number of 25 before abrogation by a neutralizing antibody (inhibitor) to hFIX. This nonhuman-primate model will be useful in further evaluation and development of rAAV vectors for gene therapy of hemophilia B. IntroductionRecombinant adeno-associated viral vectors (rAAVs) hold great promise for the treatment of hemophilia B. Preclinical studies in murine and canine models of hemophilia B have demonstrated persistent therapeutic expression of factor IX (FIX) leading to correction of the bleeding phenotype after intramuscular or portal vein administration of rAAV. 1-7 Liver-targeted delivery of rAAV resulted in significantly higher levels of FIX than observed after intramuscular administration of an equivalent dose of vector in immunodeficient mice. 8 More important, the development of neutralizing antibodies (NAbs) to human FIX (hFIX) is more common after intramuscular injection of rAAV than after intraportal administration of the same dose of vector. [8][9][10][11] Mice with persistent hFIX expression after liver-targeted delivery of rAAV could not mount a substantial antibody (Ab) response when challenged repeatedly with hFIX antigen in Freund adjuvant, a result suggesting that the liver has a unique ability to induce immune tolerance to neoantigens. 12 Endothelial cells of the liver, which can efficiently process and cross-present exogenous soluble antigens to CD8 ϩ T cells, are intimately involved in antigenspecific immune tolerance after liver-targeted gene transfer with rAAV vectors. 13 The findings of sustained expression of hFIX at therapeutic levels after a single bolus injection of rAAV vector into the portal vein of mice [3][4][5][6]8 and the absence of toxicity aft...