15Prime editing is a novel genome editing technology using fusion proteins of Cas9-nickase 16 and reverse transcriptase, that holds promise to correct a wide variety of genetic defects. 17We succeeded in efficient prime editing and functional recovery of disease-causing 18 mutations in patient-derived liver and intestinal stem cell organoids. 19 20 Main
21The development of gene-editing therapies to treat monogenic diseases has long been an essential 22 goal of CRISPR/Cas9 research. Cas9-mediated homology-directed repair (HDR) can create all desired 23 base substitutions, insertions and deletions (indels). However, HDR relies on introduction of double-24 stranded DNA breaks, is inefficient and error-prone 1,2 . Base editing, that uses Cas9-nickases fused to 25 DNA-modifying enzymes, is more efficient and accurate than HDR, but can only correct four out of 26 twelve point mutations and no small insertions and deletions. Furthermore, base editing requires a 27 suitable protospacer adjacent motif (PAM) and the absence of co-editable nucleotides 3 .
28Prime editing combines a nicking-Cas9-reverse transcriptase fusion protein (PE2) with a prime 29 editing guide RNA (pegRNA) containing the desired edit. The pegRNA-spacer guides the formation of 30 a nick in the targeted DNA strand. The pegRNA-extension binds to this nicked strand and instructs 31 the synthesis of an edited DNA flap. This edited flap is then integrated by DNA repair mechanisms, 32 which can be enhanced by simultaneous nicking of the non-edited strand (Supplementary Fig. 1) 4 .
33Prime editing has been applied in human cancer cell lines and plant cells, but not in human disease 34 models 4,5,6 . Adult stem cell-derived organoids exhibit important functional properties of organs,
35allowing modeling of monogenic diseases 7 . We set out to develop and test prime editing in primary 36 patient-derived organoids.
38We first optimized prime editing for organoid cells using deletions and single-nucleotide 39 substitutions previously performed in HEK293T cells 4 . The non-edited strand was nicked by a second 40 'nicking sgRNA' to enhance editing (PE3). Our optimized protocol consisted of co-transfection of 41 prime edit plasmids with a GFP-reporter plasmid allowing selection and subsequent clonal expansion 42 of transfected cells. Prime editing of intestinal and ductal liver organoids resulted in efficient (>50%) 43 deletion of 5 nucleotides in HEK3 ( Fig. 1b and Supplementary Fig. 2). Furthermore, we were able to 44 induce a transversion mutation located 26 nucleotides downstream of the nick with substantial 45 efficiency (20%) (Fig. 1c). These results show successful prime editing of primary stem cells with 46 similar efficiency as observed in human cancer cell lines.Next, we targeted the Wnt-pathway intermediate ß-catenin (CTNNB1) in organoids. Activating 48 carcinogenic CTNNB1 mutations are found in ±40% of hepatocellular carcinoma, resulting in Wnt-49 signaling independent of exogenous stimuli 8 . We designed PE3 plasmids, containing pegRNA-50 extensions wi...