O fator IX (FIX) da coagulação sanguínea é uma proteína dependente de vitamina K de grande valor farmacêutico no tratamento da Hemofilia B, o qual é baseado na administração do fator de coagulação derivado de plasma humano ou da proteína recombinante produzida em células murinas. A terapia baseada nestas abordagens apresenta alto custo e está associada às contaminações com vírus e príons, além do desenvolvimento de inibidores de FIX. Esses efeitos aumentam o risco de morbidade e mortalidade relacionadas às hemorragias. Neste trabalho, clonamos o cDNA do FIX em um vetor lentiviral e avaliamos a expressão da proteína recombinante em duas linhagens celulares humanas. A clonagem do cDNA do FIXh no vetor de expressão lentiviral 1054 foi confirmada através da análise com enzimas de restrição específicas obtendo-se as bandas esperadas de 1407 pb e 10054 pb visualizadas em gel de agarose. As linhagens celulares 293T e SK-Hep-1 foram transduzidas com o vetor lentiviral 1054-FIX gerado em nosso laboratório e as células que apresentaram maior expressão de EGFP foram selecionadas e separadas por citometria de fluxo. A quantificação da expressão de FIXrh foi realizada por ensaios de ELISA e cromogênico. A quantificação de FIXrh total foi de 500 ng/106 células para a linhagem 293T e 803 ng/106 células para a linhagem SK-Hep-1. A atividade biológica específica de FIXh nas células 293T e SK-Hep-1 foi 0,047 UI/106 células e 0,186 UI/106 células, respectivamente. Com o intuito de avaliar o perfil de produção de FIXrh ativo ao longo do tempo, foi realizado um acompanhamento de 180 dias, no qual foi observado que a linhagem SK-Hep-1 cessou a expressão de FIX, enquanto as células 293T mantiveram a expressão durante o período. O FIXrh foi caracterizado por western blot confirmando a presença de uma banda imunoreativa esperada de 57 kDa. As linhagens 293T e SK-Hep-1 apresentaram 7,67 e 17 cópias do vetor inserido/célula, respectivamente. Considerando a importância do processo de ?-carboxilação, foi realizada uma análise da expressão gênica dos genes envolvidos neste processo, tais como o VKORC1, ?-carboxilase e o inibidor calumenina, nas linhagens celulares. Os resultados demonstraram razões elevadas entre os genes VKORC1 e calumenina e VKORC1 e ?-carboxilase nas duas linhagens. A cinética de crescimento das células foi realizada por um período de 7 dias apresentando diferenças significativas entre as células SK-Hep-1 transduzidas e não transduzidas, enquanto que as células 293T não presentaram diferenças estatísticas no crescimento celular. A suplementação do meio de cultura com íons Ca+2 e Mg+2 foi testada para avaliar sua influência na expressão de FIXrh ativo. As células 293T apresentaram melhor desempenho nas concentrações de 0,5 mmol/L de Ca+2 e 1,0 mmol/L de Mg+2 e as células SK-Hep-1 no meio de cultura não suplementado. Nossos dados indicam que a linhagem hepática SK-Hep-1 é a melhor produtora de FIXrh funcional e as comparações realizadas entre os dois tipos celulares são importantes na caracterização do comportamento de linhagens geneticamente modificadas voltadas para a expressão de proteínas recombinantes heterólogas e abre novos caminhos para futuros estudos que visam o melhoramento da produção desse tipo de proteína. / Blood coagulation factor IX is a vitamin K-dependent protein, and it has become a valuable pharmaceutical in the treatment of Hemophilia B which is based on the plasma-derived coagulation factors or recombinant protein produced in murine cells. Coagulation therapy based on these approaches has high costs and is closely associated with prion and virus contamination besides the FIX inhibitors development. These effects increase the risk for bleeding-related morbidity and mortality. The purpose of this study was to clone hFIX into a lentiviral vector and evaluate the expression of the recombinant protein in two human cell lines. The cloning of the hFIX cDNA into 1054 lentiviral expression vector was confirmed by enzymatic restriction obtaining the expected 1407 bp and 10054 bp bands in agarose gel. The 293T and SK-Hep-1 cell lines have been stable transduced with 1054-FIX lentiviral vector generated in our laboratory and the cells with higher expression of EGFP were selected and separated by flow cytometry. The quantification of the expression of rhFIX was performed by ELISA and chromogenic assays. The concentration of total rhFIX was 500 ng/106 cells in 293T cell line and 803 ng/106 cells in SK-Hep-1 cell line. The biological activity of FIX secreted by 293T and SK-Hep-1 was 0,047 UI/106 cells and 0,186 UI/106 cells, respectively. In order to evaluate the active rhFIX production profile over time, we conducted a monitoring of 180 days, which was noted that the SK-Hep-1 cell line ceased FIX expression, while 293T cells maintained the expression during this period. rhFIX was characterized by western blot analysis confirming the presence of a expected 57 kDa immunereactive band. The 293T and SK-Hep-1 cell lines showed 7.67 and 17 integrated vector copies/cell, respectively. Considering the importance of the ?-carboxylation process, we performed a gene expression analysis of genes involved in this process, such as VKORC1, ?-carboxylase and calumenin, in cell lines. The results showed high ratios among the genes VKORC1 and calumenin and among VKORC1 and ?-carboxylase in both cell lines. The cell growth kinetics was performed by a 7-day period, showed significant differences between SK-Hep-1 transduced cells and non-transduced cells, whereas 293T cells showed no difference in cell growth. Enrichment of culture medium with Ca +2 and Mg +2 ions was tested to evaluate its influence on the expression of active FIX. 293T cells showed better performance in 0.5 mmol/L Ca+2 and 1.0 mmol/L Mg +2 concentrations and SK-Hep-1 cells in culture medium control. Our data indicate that transduced SK-Hep-1 cells are the best producer of functional rhFIX, and comparisons between these two cell lines are important in characterizing the behavior of genetically modified cell lines focused on the heterologous expression of recombinant proteins and opens new avenues for future studies aimed at improving the production of this type of protein.

<p>Hemophilia B patients may have frequent, spontaneous and life-threatening bleeds that are currently managed by an invasive and expensive treatment. Mesenchymal stem cells (MSCs) are increasingly being applied to clinically therapeutic strategies and lentiviral gene vectors have been shown to be safe and efficient tools for modifying stem cells for long-term expression of high levels of transgenes. In this study, MSCs were engineered with a lentivirus to express sustained and therapeutic levels of human FIX protein <em>in vitro </em>and in mice. The modified MSCs secreted human FIX protein at levels exceeding 4 μg/10⁶ MSCs/24 h with high FIX coagulant activity of greater than 2.5 mIU/10⁶ MSCs/24 h for 6 week <em>in vitro. </em>Functional FIX transgene was continually expressed by these cells when they were induced to differentiate into adipocyte, osteoblast and chondrocyte lineages <em>in vitro</em>. However, the modified MSCs transplanted via tail vein into NOD-SCID-γ mice expressed low levels of FIX <em>in vivo</em>. The transplantation procedure had an increased risk of death that was more pronounced in mice that received cell doses exceeding 2 million cells. Organ examinations suggested the deaths resulted from entrapment of MSCs in pulmonary capillaries. Modified MSCs encapsulated in alginate-PLL microcapsules and transplanted into the peritoneal cavity of both NOD-SCID-γ and hemophilia B mice at 9 million cells/mouse resulted in therapeutic expression around 100 ng of human FIX/mL of plasma only for a few days <em>in vivo</em> as human FIX expression quickly decreased to basal values by the end of the first week. Cultured <em>ex vivo</em>, human FIX expression by retrieved capsules indicated an innate immune response to the encapsulated cells prevented sustained expression of FIX. These investigations demonstrate that lentivirally modified MSCs have the potential to express therapeutic human FIX for sustained periods <em>in vitro</em>, even after their differentiation. However, they also highlight the challenges to overcome to optimize cell engraftment and survival following transplantation, and to minimize the immune responses associated with the xenogeneic translational<em> </em>models used.</p> / Doctor of Philosophy (PhD)

Les anticorps sont les molécules effectrices de l’immunité adaptatrice humorale. Ils se lient spécifiquement et neutralisent une large panoplie d’antigènes. Au-delà de leurs fonctions classiques, les anticorps possèdent les propriétés moins explorées que sont l’activité catalytique, qui permet aux anticorps de se comporter comme des enzymes, et la polyréactivité, qui représente la capacité d’une molécule d’anticorps à se lier à plusieurs antigènes structurellement différents. Les anticorps catalytiques sont retrouvés dans plusieurs pathologies chez l’homme, telle que l’hémophilie acquise, une maladie caractérisée par la survenue d’autoanticorps anti-facteur VIII. Dans ce travail, nous décrivons des IgG hydrolysant et activant le facteur IX de la coagulation chez les patients avec hémophilie acquise. Par ailleurs, nous avons effectué une étude longitudinale de deux ans des IgG catalytiques chez les patients subissant une transplantation rénale. Les anticorps polyréactifs représentent une proportion importante du répertoire des immunoglobulines circulantes. De plus, les sites inflammatoires sont abondants en molécules, telles que l’hème libre, capables de rendre polyréactives certaines IgG monoréactives. Nous avons étudié l’influence de la nature des régions constantes de la chaîne lourde des anticorps sur leur susceptibilité à devenir polyréactifs. Ce travail apporte un nouvel éclairage sur l’importance physiopathologique des anticorps catalytiques et polyréactifs. / Antibodies are effector molecules of the humoral arm of the adaptive immune system that bind specifically and neutralize diverse array of antigens. Beyond the classical function of antibodies exist the relatively less explored properties, of “catalytic activity” that enable antibodies to act as enzymes and “polyreactivity” that confers the ability to bind to several structurally unrelated antigens. Catalytic antibodies have been associated with several autoimmune, inflammatory and infectious diseases. Acquired hemophilia is an autoimmune disease, reported with the presence of catalytic antibodies against coagulation factor FVIII. In the present work, we have investigated the presence of factor IX (FIX) hydrolyzing IgG in patients with acquired hemophilia. We investigated the molecular mechanism and the physiological relevance of FIX activation upon hydrolysis by patients’ IgG. In addition, a longitudinal follow-up for 2 years was done in patients undergone renal transplant to investigate the evolution of catalytic antibodies in the course of disease. Polyreactive antibodies constitute a major portion of the natural antibody repertoire. Additionally, sites of inflammation are abundant in protein destabilizing agents like free heme that can induce polyreactivity in monoreactive antibodies. We have investigated the effect of the antibody constant domain on heme-induced polyreactivity. The present work has allowed us a better understanding of the physiopathological relevance of catalytic and polyreactive antibodies.

Introduction : L’hémophilie B (HB) est une maladie hémorragique héréditaire caractérisée par un déficit en facteur IX (FIX) de la coagulation. La thérapie génique de l’HB par injection de virus adéno-associés (AAV) montre des résultats prometteurs, mais entraine une toxicité hépatique à forte dose. La création de nouveau transgène de FIX permettant d’injecter de moindres doses d’AAV est un réel enjeu. Matériel et Méthodes : Des transgènes thérapeutiques exprimant une protéine humaine de FIX à demi-vie prolongée par fusion à l’albumine (hFIX-Alb) ou exprimant un FIX une activité spécifique augmentée, le hFIX-E410H, ont été créés et injectés à des modèles murins. Une nouvelle molécule recombinante de hFIX à demi-vie prolongée par fusion à la sous-unité B du FXIII via un linker clivable par le facteur X activé (hFIX-LXa-FXIIIB) a été crée, produite et caractérisée. Résultats : Le transgène hFIX-Alb n’accumulait pas le niveau plasmatique du FIX par rapport au FIX sauvage. Des expériences ont été entreprises pour comprendre les mécanismes responsables du défaut d’expression. Le transgène hFIX-E410H, montrant une activité spécifique augmentée in vitro et in vivo chez les souris HB, permettait de diminuer les doses d’AAV d’environ 2,5 fois. La molécule hFIX-LXa-FXIIIB était fonctionnelle, corrigeait la génération de thrombine chez les souris HB, et présentait une demi-vie augmentée 3,9 fois chez la souris et 2,3 fois chez le rat. Conclusion : Nous avons développé et caractérisé de nouveaux transgènes de FIX modifiés et une nouvelle molécule de FIX à demi-vie prolongée, qui pourraient constituer de nouvelles perspectives thérapeutiques de l’HB / Introduction: Haemophilia B (HB) is an inherited bleeding disorder due to coagulation factor IX (FIX) deficiency. Adeno-associated virus (AAV)-based gene therapy for HB has shown promising results but can cause liver toxicity after administration of high dose of AAV vectors.The design of new transgene expressing modified FIX that would allow injecting fewer doses of AAV is a real challenge. Materials & Methods: Therapeutic transgene expressing human FIX with prolonged half-life due to fusion to mature albumin (hFIX-Alb) or expressing FIX with improved specific activity, hFIX-E410H, were designed and injected to murine animal model. A novel recombinant FIX molecule exhibiting enhanced half-life through fusion to the FXIIIB subunit via activated factor X-cleavable linker was design, produced and characterised. Results: The hFIX-Alb transgene did not increase the plasma FIX clotting activity compared to the transgene expressing wild-type hFIX. Experiments were undertaken to understand the mecanisms responsible for lower expression. The hFIX-E410H transgene, which showed improved specific activity in vitro and in vivo in HB mice, allowed injecting a 2.5-fold lower dose of AAV. The hFIX-LXa-FXIIIB molecule was functional, corrected the generation capacity in HB mice, and exhibited a 3.9-fold and 2.2-fold enhanced half-life in mice and in rats, respectively, compared to wild-type FIX. Conclusion: We have developed and characterised new transgenes expressing modified FIX, and a novel FIX molecule with prolonged half-life, which could become interesting perspectives for the treatment of HB

Background: Guidelines recommend that patients with haemophilia should preferably receive vaccination subcutaneously. COVID-19 and other vaccines, however, are only licenced for intramuscular application. Aims: To assess the safety of intramuscular COVID-19 vaccination in patients living with haemophilia. Methods: Part A of this prospective observational study enrolled consecutive patients with haemophilia A (HA) and B (HB) of all ages and severities and assessed injection site bleeding and other complications within 30 days of vaccination. Part B enrolled patients providing informed consent for detailed data collection including medication and prophylaxis around the time of vaccination. Logistic regression was performed to assess potential risk factors for bleeding. Results: Four hundred and sixty-one patients were enrolled into part A. The primary endpoint injection site bleeding occurred in seven patients (1.5%, 95% confidence interval .7–3.1%). Comprehensive analysis of 214 patients (404 vaccinations, part B) revealed that 97% of patients with severe haemophilia had prophylaxis before vaccination, either as part of their routine prophylaxis or using additional doses. 56% and 30% of patients with moderate and mild haemophilia, respectively, received prophylaxis before vaccination. Among the seven bleeds recorded, three occurred when intramuscular vaccination was done without prophylaxis (odds ratio 12). Conclusions: This is the first prospective study reporting on the safety of intramuscular vaccination in haemophilia. The rate of injection site bleeding was low in mild haemophilia, and in moderate and severe haemophilia if patients received factor prophylaxis.

<p>Mesenchymal stem cells have shown potential for success in gene therapy due to their ability to differentiate and their immunomodulatory properties <em>in vivo</em>. Although they have many inherent characteristics that are suitable for use within gene therapy, genetic modification of these cells is more difficult. Since MSCs are available in limited quantities and cannot be expanded indefinitely, the modification technique must ensure efficient expression of the transgene, a high cell survival rate and an intact ability to differentiate to various cell lineages. We optimized electroporation conditions for the genetic engineering of bone marrow-derived and umbilical cord blood-derived mesenchymal stem cells. MSCs engineered using electroporation conditions produced more transgene expression than cells engineered with cationic lipids in bone marrow-derived mesenchymal stem cells, but produced similar amounts in umbilical cord blood-derived mesenchymal stem cells. Optimal electroporation conditions also expressed more transgene than polymer based transfection reagent in umbilical cord blood-derived mesenchymal stem cells. Cell survival after optimal electroporation conditions was 67% in umbilical cord blood-derived mesenchymal stem cells. Most importantly, cells maintained their ability to differentiate into osteogenic, chondrogenic and adipogenic cell lineages. Electroporating umbilical cord blood-derived mesenchymal stem cells with a Factor IX containing plasmid lead to the FIX protein being expressed for over 12 days <em>in vitro</em>. This optimized electroporation protocol has created a fast, easy, economic and efficient method for genetically modifying mesenchymal stem cells without altering their ability to differentiate.</p> / Master of Applied Science (MASc)

Endothelial cells separate the bloodstream from the underlying tissue and play a crucial role in vascular homeostasis. They also form an important barrier for vascular drug delivery. This thesis contains preliminary studies targeted at understanding the mechanisms of binding and transport across endothelial cells cultured in vitro. Specifically, the first study investigates how the recombinant source of Factor IX (FIX), a blood coagulant protein used in the treatment of Hemophilia B, impacts surface ligand binding (FIX to its specific receptors) to bovine aortic endothelial cells (BAECs). Competitive binding experiments between 125I-FIX and FIX were undertaken to quantify the interaction of recombinant and transgenic FIX with BAECs and human collagen IV and determine if there was a measurable difference in binding affinity. Results indicate limited specific binding of 125I-FIX to BAECs and no binding to human collagen IV. Concrete conclusions were not drawn from this data due to technical issues during the experimental process. The second study investigates insulin-like growth factor-I (IGF-I) transport across both BAEC and MAC-T cells, a mammary epithelial cell line, cultured on tissue culture inserts. IGF-I is a circulatory growth factor implicated in the regulation of cell division and tissue proliferation. Competitive binding experiments between 125I-IGF-I and unlabeled protein (IGF-I, Y60L-IGF-I, a mutant of IGF-I, and IGF Binding Protein-3 (IGFBP-3)) were undertaken to quantify the binding and transport of IGF-I under various experimental conditions. Results confirmed earlier work from the Williams' laboratory indicating that 125I-IGF-I transport was enhanced by incubation with its non-receptor-binding analog, Y60L-IGF-I, but cell surface associated 125I-IGF-I was decreased by its presence. Other studies were undertaken but conclusive results could not be drawn. / Master of Science

Introduction : L'hémophilie B (HB) est une maladie hémorragique héréditaire due à un défaut en facteur IX (FIX) de la coagulation. Le traitement substitutif est efficace mais pose deux problèmes : la fréquence des injections intraveineuses de concentrés de FIX et leurs coûts. La production d'un FIX recombinant à activité améliorée et à demi-vie prolongée est un enjeu important du traitement. Matériel et méthodes : Afin d'améliorer l'activité du FIX, l'étude s'est portée sur un résidu impliqué dans l'interaction du FIX activé avec son cofacteur, le facteur VIII activé (FVIIIa). Quatre FIX mutés au niveau de l'acide aminé E410 ont été développés. Afin de prolonger la demi-vie, un ADN complémentaire de FIX chimérique a été généré de façon à produire la protéine correspondante par la lignée cellulaire humaine Huh-7. Résultats : L'activité coagulante in vitro des FIX-E410 était 3 à 5 fois plus élevée que celle du FIX wild-type (FIX-WT). De plus, le FIX-E410H induisait une génération de thrombine 5,2 fois plus élevée comparée à celle du FIX-WT. Chez la souris HB, l'activité coagulante et la capacité de génération de thrombine du FIX-E410H in vivo étaient significativement plus élevées que celles du FIX-WT. La protéine chimérique a présenté une activité molaire spécifique 10 fois augmentée in vitro et une demi-vie jusqu'à 2,8 fois plus allongée, par rapport à celles du FIX-WT. Conclusion : Nous avons développé et caractérisé quatre molécules de FIX ayant une activité améliorée in vitro et in vivo, ainsi qu'un FIX modifié à activité augmentée et à demi-vie prolongée in vivo. Ces nouvelles molécules pourraient ouvrir de nouvelles perspectives thérapeutiques de traitement de l'HB / Introduction: Hemophilia B (HB) is an inherited X-linked recessive bleeding disorder, due to a defect in human factor IX (FIX). Replacement therapy, in severe HB is very effective but is limited by FIX concentrates injections frequency and cost issues. Production of a recombinant FIX with enhanced clotting activity and prolonged half-life is one of the current challenges for HB treatment. Materials and Methods: To improve activity, we focused on an important residue known to be involved in the interaction of activated FIX with its cofactor, activated factor VIII (FVIIIa), and four mutated FIX-E410 were developed. To prolong stability, a new chimeric FIX cDNA was constructed too. Recombinant FIX molecules were produced by the human hepatoma cell line Huh-7. Results: The in-vitro clotting activity of FIX-E410 was 3 to 5-fold higher than wild-type FIX (FIX-WT) and this improvement was confirmed using thrombin generation assay. FIX-E410H induced 5.2-fold higher thrombin generation than FIX-WT. In HB mice, we observed significantly higher in-vivo clotting activity and thrombin generating capacity with FIX-E410H compared to FIX-WT, mainly explained by 2.5-fold enhanced affinity of the mutant for FVIIIa. Chimeric FIX showed a 10-fold increase in the in-vitro molar specific activity and a significantly increased half-life in mice (up to 2.8-fold), compared to FIX-WT. Conclusion: We have engineered and characterized four improved FIX proteins with enhanced in- vitro and in-vivo activity, and a new chimeric FIX with in-vivo increased activity and prolonged half- life. These results suggest that these new molecules could optimize protein replacement therapy forHB treatment

Bakgrund - Hemofili A och B är X-kromosombundna blödarsjukdomar, som beror på genetiska avvikelser i de gener som kodar för koagulationsfaktor VIII respektive IX. I dagsläget förlitar sig hemofilipatienter på kontinuerliga intravenösa injektioner med faktorkoncentrat, för att förhindra att potentiellt livshotande blödningar uppstår. Genterapi med rekombinanta adeno-associerade virus (AAV) skulle kunna erbjuda ett kurativt behandlingsalternativ, genom införandet av friska arvsanlag i hepatocyter. Syfte - Syftet med den här litteraturstudien var att undersöka huruvida genterapi medierad av AAV-vektorer är en effektiv och säker behandling mot hemofili A och B ur ett långsiktigt perspektiv. Metod - Studien är genomförd som en systematisk litteraturstudie och är baserad på sex originalartiklar framsökta via databasen PubMed, med sökorden "hemophilia AND gene therapy". Specificerade sökkriterier användes för att underlätta relevansbedömning och valet av artiklar. Resultat - En ökad endogen koagulationsfaktorproduktion kunde påvisas hos majoriteten av studiedeltagarna efter genterapibehandlingarna. Sammantaget observerades också en väsentlig blödningsreducering och en minskad faktorkoncentratanvändning. Störst förbättring noterades i de kohorter som erhållit högre genterapidoser eller den muterade faktor IX Padua-genen. Ingen immunrespons mot transgenprodukten detekterades i någon studie. Däremot sågs ett humoralt immunsvar mot AAV-kapsiden hos samtliga studiedeltagare. En mycket stor variation i T-cellssvar mot AAV-kapsiden kunde noteras. Förhöjda nivåer av alaninaminotransferas (ALAT) var den vanligast förekommande incidenten, men samtliga fall kunde framgångsrikt behandlas med glukokortikoidpreparat. Slutsats - Genterapibehandling med rekombinanta AAV-vektorer mot hemofili A och B förefaller effektiv och säker. Förhöjda ALAT-nivåer återstår dock som en behandlingsproblematik. Längre uppföljningar av fler genterapibehandlade hemofilipatienter krävs, för att kunna dra några definitiva slutsatser, väga risker mot nytta, samt optimera och individanpassa doser. / Background - Hemophilia A and B are X-linked bleeding disorders, resulting from defects in the genes encoding coagulation factors VIII and IX respectively. The current treatment for hemophiliacs entails frequent intravenous injections of coagulation factor concentrates, to prevent potentially life-threatening hemorrhages. Gene therapy utilizing recombinant adeno-associated viruses (AAV) could offer a potentially curative treatment option through the introduction of healthy genes into hepatocytes. Aim - The aim of this literature study was to investigate the long-term efficacy and safety of AAV vector-mediated gene therapy for the treatment of hemophilia A and B. Methods - The study is conducted as a systematic literature study and is based on six original articles retrieved from the search engine PubMed, using the key words "hemophilia AND gene therapy". Specific search criteria were used to facilitate the relevance assessment and selection of articles. Results - An increased endogenous coagulation factor synthesis was noted in the majority of the study participants after the gene therapy. Overall, a significant reduction in bleeding episodes and the use of factor concentrates were observed. The greatest improvements were noted in the cohorts that received the higher gene therapy doses or the mutated factor IX Padua gene. None of the study participants had an immunologic response to the transgene product. A humoral immune response against the AAV capsid was seen in all participants though. Large differences in AAV capsid-specific T-cell activation were observed. The most common adverse event was an elevation in the alanine aminotransferase (ALT) level. However, these events could be controlled with glucocorticoids. Conclusions - AAV vector-mediated gene therapy for the treatment of hemophilia A and B had a positive efficacy and safety profile. Although increased ALT levels remain a concern. Monitoring of larger numbers of study participants for longer follow-up periods is necessary for any definite conclusions to be drawn, to weigh risks against benefits and to optimize individual dosing.

In the past couple of decades, the zebrafish has been widely used to study hemostatic disorders. In this study, we generated a CRISPR/Cas9 mediated zebrafish mutant that contains a 55-nucleotide insertion in exon 29 of the von Willebrand factor (vwf) gene. The mutants had impaired ristocetin-mediated agglutination of whole blood, prolonged PTT and more bleeding in the lateral incision compared to wild-type fish. The bleeding phenotype observed here is similar to the phenotype observed in vwf knockout mice and patients with von Willebrand disease (VWD). The mutant model developed here can thus be used for exploring the role of Vwf in angiogenesis and for developing gene therapy. The deficiency of VWF causes VWD and the etiology remains unknown in 30% of Type 1 VWD cases. Previous studies have identified that the ABO blood group and ST3GAL4 (glycosyltransferases) are involved in the regulation of VWF levels. Since VWF is heavily glycosylated, we hypothesized that other glycosyltransferases may also be involved in regulating VWF. We performed a knockdown screen of 234 glycosyltransferase genes and identified 14 genes that altered Vwf levels. The sequencing of these genes in Type 1 VWD patients could help identify novel mutations to decipher the molecular basis for the unknown etiologies in Type 1 VWD. Moreover, therapeutic interventions could be designed in the future by modulation of these gene products to control bleeding or thrombosis.Zebrafish has three f9 genes, f9a, f9b, and f9l and the ortholog to human F9 is unknown. RNA analysis showed an age-dependent increase in expression of all three genes from larval stages to adults, comparable to those observed in mice and humans while mass spectrometry and immunohistochemistry confirmed the presence of all three proteins in the fish. Based on coagulation assays performed after individual gene knockdown and immunodepletion, we identified that zebrafish f9a has functional activity similar to human F9 and Fixl is functionally similar to Fx. Thus, the zebrafish could be used to identify factors controlling f9 gene expression with age and for modeling Hemophilia B in the quest to develop gene therapy protocols. In zebrafish, dilute plasma with exogenously added human fibrinogen was used for kinetic coagulation assays. Here, we developed a microkinetic assay using 25% zebrafish or 30% human plasma followed by the addition of coagulation activators and CaCl2. Our results showed both zebrafish and human plasmas yielded kinetic PT, kinetic PTT, and kinetic Russel's viper venom time curves similar to previously established human kinetic curves. Moreover, clotting times derived from these kinetic curves were identical to human PT, PTT, and Russel's viper venom time. Thus, the microkinetic assay developed here could measure blood coagulation activity in small animal models like zebrafish and human blood samples obtained from a finger prick in adults or heel prick in infants.