Gene therapy and gene editing are revolutionising the treatment of genetic diseases, most notably haematological disorders. This paper evaluates the use of both techniques in hereditary blood disorders. Many studies have been conducted in this field, especially with gene therapy, with very promising results in diseases such as haemophilia, certain haemoglobinopathies and Fanconi anaemia. The application of these techniques in clinical practice and the foreseeable development of these approaches in the coming years suggest that it might be useful to evaluate the results achieved thus far. It is also essential to reflect on the possible bioethical concerns raised by the use of both techniques, especially in terms of safety issues for patients, potential side effects, treatment duration, accessibility and cost of treatment, and the heritability of genetic changes produced if germline cells are used.
DoudnaJASternbergSH. Una grieta en la creación. CRISPR, la edición génica y el increíble poder de controlar la evolución. Madrid: Alianza Editorial, 2020.
8.
DoudnaJASternbergSH. A Crack in Creation: Gene Editing and the Unthinkable Power to Control Evolution. Boston: Mariner Books, 2017.
9.
GollompKLDoshiBSArrudaVR. Gene therapy for hemophilia: Progress to date and challenges moving forward. Transfus Apher Sci2019; 58(5): 602–612.
10.
SharmaAEasowMMSriganeshVReissUM. Gene therapy for haemophilia. Cochrane Database of Systematic Reviews2020; 4.
11.
WongTRechtM. Current options and new developments in the treatment of haemophilia. Drugs2011; 71(3): 305–320.
12.
GitschierJWoodWIGoralkaTMWionKLChenEYEatonDH, et al.Characterization of the human factor VIII gene. Nature1984; 312: 326–330.
13.
TooleJJKnopfJLWozneyJMSultzmanLABueckerJLPittmanDD, et al.Molecular cloning of a cDNA encoding human antihaemophilic factor. Nature1984; 312(5992): 342–347.
14.
QiuXLuDZhouJWangJYangJMengP, et al.Implantation of autologous skin fibroblast genetically modified to secrete clotting factor IX partially corrects the hemorrhagic tendencies in two hemophilia B patients. Chin Med J (Engl)1996; 109: 832–839.
15.
ParkFOhashiKKayMA. Therapeutic levels of human factor VIII and IX using HIV-1-based lentiviral vectors in mouse liver. Blood2000; 96: 1173–1176.
16.
PowellJSRagniMVWhiteGCLusherJMHillman-WisemanCMoonTE, et al.Phase 1 trial of FVIII gene transfer for severe hemophilia A using a retroviral construct administered by peripheral intravenous infusion. Blood2003; 102(6): 2038–2045.
17.
NathwaniACDavidoffAMTuddenhamEG. Prospects for gene therapy of haemophilia. Haemophilia2004; 10(4): 309–318.
18.
MiaoCHThompsonARLoebKYeX. Long-term and therapeutic-level hepatic gene expression of human factor IX after naked plasmid transfer in vivo. Mol Ther2001; 3(6): 947–957.
19.
NathwaniACTuddenhamEGDRangarajanSRosalesCMcIntoshJLinchDC, et al.Adenovirus associated virus vector-mediated gene transfer in hemophilia B. N Engl J Med2011; 365: 2357–2365.
20.
NathwaniACNienhuisAWDavidoffAM. Our journey to successful gene therapy for hemophilia B. Hum Gene Ther2014; 25(11): 923–6.
21.
MonahanPWalshCEPowellJSKonkleBAJosephsonNC. ISTH – Update on a phase 1/2 open-label trial of BAX335, an adeno-associated virus 8 (AAV8) vector-based gene therapy program for hemophilia B. J Thromb Haemost2015; 13(Suppl 2): 87.
22.
GeorgeLASullivanSKGiermaszARaskoJEJSamelson-JonesBJDucoreJ, et al.Hemophilia B gene therapy with a high-specific-activity factor IX variant. N Engl J Med2017; 377: 2215–2227.
23.
RangarajanSWalshLLesterWPerryDMadanBLaffanM, et al.AAV5 – factor VIII gene transfer in severe hemophilia A. N Engl J Med2017; 377: 2519–2530.
24.
PerrinGQHerzogRWMarkusicDM. Update on clinical gene therapy for hemophilia. Blood2019; 133(5): 407–414.
25.
Study to Evaluate the Efficacy and Safety of PF-07055480 in Moderately Severe to Severe Hemophilia A Adults (AFFINE). U.S National Library of Medicine, https://clinicaltrials.gov/ct2/show/NCT04370054 (2021, accessed 13 September 2021).
26.
GoodmanMA. Malik The potential of gene therapy approaches for the treatment of hemoglobinopathies: achievements and challenges. Ther Adv Hematol2016; 7(5): 302–315.
PielFBPatilAPHowesRENyangiriOAGethingPWDewiM, et al.Global epidemiology of sickle haemoglobin in neonates: a contemporary geostatistical model-based map and population estimates. Lancet2013; 38: 142–151.
31.
KhosraviMAAbbasalipourMConcordetJPBergJVZeinaliSArashkiaA, et al.Targeted deletion of BCL11A gene by CRISPR-Cas9 system for fetal hemoglobin reactivation: A promising approach for gene therapy of beta thalassemia disease. Eur J Pharmacol2019; 854: 398–405.
32.
PielFBHaySIGuptaSWeatherallDJWilliamsTN. Global burden of sickle cell anaemia in children under five, 2010-2050: modelling based on demographics, excess mortality, and interventions. PLoS Med2013; 10(7).
33.
LocatelliFKabbaraNRuggeriAGhavamzadehARobertsILiCK, et al.Outcome of patients with hemoglobinopathies given either cord blood or bone marrow transplantation from an HLA-identical sibling. Blood2013; 122(6): 1072–1078.
34.
GhiaccioVChappellMRivellaSBredaL. Gene therapy for beta-hemoglobinopathies: milestones, new therapies and challenges. Mol Diagn Ther2019; 23: 173–186.
35.
CavazzanaMMavilioF. Gene therapy for hemoglobinopathies. Hum Gene Ther2018; 29(10): 1106–1113.
36.
MayCRivellaSCallegariJHellerGGaenslerKMLuzzattoL, et al.Therapeutic haemoglobin synthesis in β-thalassaemic mice expressing lentivirus-encoded human β-globin. Nature2000; 406: 82–86.
37.
ImrenSPayenEWestermanKAPawliukRFabryMEEavesCJ, et al.Permanent and panerythroid correction of murine beta thalassemia by multiple lentiviral integration in hematopoietic stem cells. Proc Natl Acad Sci USA2002; 99(22): 14380–14385.
38.
PersonsDAAllayERSawaiNHargrovePWBrentTPHanawaH, et al.Successful treatment of murine beta-thalassemia using in vivo selection of genetically modified, drug-resistant hematopoietic stem cells. Blood2003; 102(2): 506.
39.
RivellaSMayCChadburnARivièreISadelainM. A novel murine model of Cooley anemia and its rescue by lentiviral-mediated human beta-globin gene transfer. Blood2003; 101(8): 2932–2939.
40.
HanawaHHargrovePWKepesSSrivastavaDKNienhuisAWPersonsDA. Extended beta-globin locus control region elements promote consistent therapeutic expression of a gamma-globin lentiviral vector in murine beta-thalassemia. Blood2004; 104(8): 2281–2290.
41.
MiccioACesariRLottiFRossiCSanvitoFPonzoniM, et al.In vivo selection of genetically modified erythroblastic progenitors leads to long-term correction of beta-thalassemia. Proc Natl Acad Sci USA2008; 105: 10547–10552.
42.
Cavazzana-CalvoMPayenENegreOWangGHehirKFusilF, et al.Transfusion independence and HMGA2 activation after gene therapy of human β-thalassaemia. Nature2010; 467(7313): 318–322.
43.
Mansilla-SotoJRiviereIBouladFSadelainM. Cell and gene therapy for the beta-thalassemias: Advances and prospects. Hum Gene Ther2016; 27(4): 295–304.
44.
ScaramuzzaSMarktelSCicaleseMPGiglioFLidonniciMRRossiC, et al.ASGCT 21st annual meeting abstracts. lentiviral hematopoietic stem cells gene therapy for beta-thalassemia: Update from the phase I/II TIGET BTHAL trial. Mol Ther2018; 26(5): 450–459.
45.
MottaIGhiaccioVCosentinoABredaL. Curing hemoglobinopathies: Challenges and advances of conventional and new gene therapy approaches. Mediterr J Hematol Infect Dis2019; 11(1).
46.
MarktelSScaramuzzaSCicaleseMPGiglioFGalimbertiSLidonniciMR, et al.Intrabone hematopoietic stem cell gene therapy for adult and pediatric patients affected by transfusion-dependent ß-thalassemia. Nat Med2019; 25(2): 234–241.
47.
MadiganC. Malik Pathophysiology and therapy for haemoglobinopathies. Part I: sickle cell disease. Expert Rev Mol Med2006; 8(9): 1–23.
48.
SteinbergMHForgetBGHiggsDRNagelRL. Disorders of hemoglobin: Genetics, pathophysiology, and clinical management. Cambridge: Cambridge University Press, 2009.
49.
PielFBSteinbergMHReesDC. Sickle cell disease. N Engl J Med2017; 376: 1561–1573.
50.
RibeilJAHacein-Bey-AbinaSPayenEMagnaniASemeraroMMagrinE, et al.Gene therapy in a patient with sickle cell disease. N Engl J Med2017; 376: 848–855.
51.
Lagresle-PeyrouCLefrèreFMagrinERibeilJARomanoOWeberL, et al.Plerixafor enables safe, rapid, efficient mobilization of hematopoietic stem cells in sickle cell disease patients after exchange transfusion. Haematologica2018; 103(5): 778–786.
52.
PunamMGrimleyMQuinnCShovaACharlesLLutzkoC, et al.Gene therapy for sickle cell anemia using a modified gamma globin lentivirus vector and reduced intensity conditioning transplant shows promising correction of the disease phenotype. Blood2018; 132(Supp 1): 1021.
53.
IkawaYMiccioAMagrinEKwiatkowskiJLRivellaSCavazzanaM. Gene therapy of hemoglobinopathies: progress and future challenges. Hum Mol Genet2019; 28(1): 24–30.
54.
BrendelCGudaSRenellaRBauerDECanverMCKimYJ, et al.Lineage-specific BCL11A knockdown circumvents toxicities and reverses sickle phenotype. J Clin Invest2016; 126(10): 386.
55.
EsrickEBBrendelCManisJArmantMNegreHDansereauCH, et al.Flipping the switch: Initial results of genetic targeting of the fetal to adult globin switch in sickle cell patients. Blood2018; 132: 1023.
56.
LangevinFCrossanGPRosadoIVArendsMJPatelKJ. Fancd2 counteracts the toxic effects of naturally produced aldehydes in mice. Nature2011; 475: 53–58.
57.
HiraAYoshidaKSatoKOkunoYShiraishiYChibaK, et al.Mutations in the gene encoding the E2 conjugating enzyme UBE2T cause Fanconi anemia. Am J Hum Genet2015; 96: 1007.
58.
KniesKInanoSRamirezMJIshiaiMSurrallésJTakataM, et al.Biallelic mutations in the ubiquitin ligase RFWD3 cause Fanconi anemia. J Clin Invest2017; 127: 3013–3027.
59.
D’AndreaADGrompeM. Molecular biology of Fanconi anemia: implications for diagnosis and therapy. Blood1997; 90: 1725–1736.
60.
RíoPNavarroSBuerenJA. Advances in gene therapy for Fanconi anemia. Hum Gene Ther2018; 29(10): 1114–1123.
61.
DufourCSvahnJ. Fanconi anaemia: new strategies. Bone Marrow Transplant2008; 41(Suppl 2): 90–95.
62.
BonfimCMde MedeirosCRBitencourtMAZanis-NetoJFunkeVAMSetubalDC, et al.HLA-matched related donor hematopoietic cell transplantation in 43 patients with Fanconi anemia conditioned with 60 mg/kg cyclophosphamide. Biol Blood Marrow Transplant2007; 13: 1455–1460.
63.
MacMillanMLWagnerJE. Haematopoeitic cell transplantation for Fanconi anaemia – when and how?Br J Haematol2010; 149(1): 14–21.
64.
Peffault de LatourRPorcherRDalleJHAljurfMKorthofETSvahnJ, et al.Allogeneic hematopoietic stem cell transplantation in Fanconi anemia: the European group for blood and marrow transplantation experience. Blood2013; 122(26): 4279–4286.
65.
BeckerPSTaylorJATrobridgeGDZhaoXBeardBCChienS, et al.Preclinical correction of human Fanconi anemia complementation group A bone marrow cells using a safety-modified lentiviral vector. Gene Ther2010; 17(10): 1244–1252.
66.
TolarJBeckerPSClappDWHanenbergHde HerediaCDKiemHP, et al.Gene therapy for Fanconi anemia: one step closer to the clinic. Human gene therapy2012; 23(2): 141–144.
67.
JacomeANavarroSRíoPYañezRMGonzález-MurilloALozanoML, et al.Lentiviral-mediated genetic correction of hematopoietic and mesenchymal progenitor cells from Fanconi anemia patients. Mol Ther2009; 17(6): 1083–1092.
68.
RíoPNavarroSGuenecheaGSánchez-DomínguezRLamanaMLYañezR, et al.Engraftment and in vivo proliferation advantage of gene-corrected mobilized CD34+ cells from Fanconi anemia patients. Blood2017; 130(13): 1535–1542.
69.
KaiserJ. Tweaking genes with CRISPR or viruses fixes blood disorders. Science2020; 360(6522): 1254–1255.
70.
WangLYangYBretonCAWhiteJZhangJCheY, et al.CRISPR/Cas9-mediated in vivo gene targeting corrects hemostasis in newborn and adult factor IX–knockout mice. Blood2019; 133(26): 2745–2722.
71.
LiHHaurigotVDoyonYLiTWongSYBhagwatAS, et al.In vivo genome editing restores haemostasis in a mouse model of haemophilia. Nature2011; 475(7355): 217–221.
72.
StephensCJLauronEJKashentsevaELuZHYokoyamaWMCurielDT. Long-term correction of hemophilia B using adenoviral delivery of CRISPR/Cas9. J Control Release2019; 298: 128–141.
73.
AnguelaXMSharmaRDoyonYMillerJCLiHHaurigotV, et al.Robust ZFN-mediated genome editing in adult hemophilic mice. Blood2013; 122(19): 3283–3287.
74.
SharmaRAnguelaXMDoyonYWechslerTDeKelverRCSproulS, et al.In vivo genome editing of the albumin locus as a platform for protein replacement therapy. Blood2015; 126(15): 1777–1784.
PipeSWSelvarajSR. Gene editing in hemophilia: a “CRISPR” choice?Blood2019; 133: 2733–2734.
77.
DeverDPBakROReinischACamarenaJWashingtonGNicolasCE, et al.CRISPR/Cas9 beta-globin gene targeting in human haematopoietic stem cells. Nature2016; 539: 384–389.
78.
DeverDPPorteusMH. The changing landscape of gene editing in hematopoietic stem cells: a step towards Cas9 clinical translation. Curr Opin Hematol2017; 24(6): 481–488.
79.
BakRODeverDPReinischACruz HernandezDMajetiRPorteusMH. Multiplexed genetic engineering of human hematopoietic stem and progenitor cells using CRISPR/Cas9 and AAV6. Elife2017; 6.
80.
MettanandaSFisherCAHayDBadatMQuekLClarkK, et al.Editing an α-globin enhancer in primary human hematopoietic stem cells as a treatment for β-thalassemia. Nat Commun2017; 8(1): 424.
81.
TsangJCYuYBurkeSBuettnerFWangCKolodziejczykAA, et al.Single-cell transcriptomic reconstruction reveals cell cycle and multi-lineage differentiation defects in Bcl11a-deficient hematopoietic stem cells. Genome Biol2015; 16: 178.
82.
ChangKHSmithSESullivanTChenKZhouQWestJA, et al.Long-term engraftment and fetal globin induction upon BCL11A gene editing in bone-marrow-derived CD34+ hematopoietic stem and progenitor cells. Mol Ther Methods Clin Dev2017; 4: 137–148.
83.
CanverMCSmithECSherFPinelloLSanjanaNEShalemO, et al.BCL11A enhancer dissection by Cas9-mediated in situ saturating mutagenesis. Nature2015; 527: 192–197.
84.
VierstraJReikAChangKHStehling-SunSZhouYHinkleySJ, et al.Functional footprinting of regulatory DNA. Nat Methods2015; 12: 927–930.
85.
TraxlerEAYaoYWangYDWoodardKJKuritaRNakamuraY, et al.A genome-editing strategy to treat [beta]-hemoglobinopathies that recapitulates a mutation associated with a benign genetic condition. Nat Med2016; 22: 987–990.
86.
YeLWangJTanYBeyerAIXieFMuenchMO, et al.Genome editing using CRISPR-Cas9 to create the HPFH genotype in HSPCs: an approach for treating sickle cell disease and beta-thalassemia. Proc Natl Acade Sci USA2016; 113: 10661–10665.
87.
AntonianiCMeneghiniVLattanziAFelixTRomanoOMagrinE, et al.Induction of fetal hemoglobin synthesis by CRISPR/Cas9-mediated editing of the human β-globin locus. Blood2018; 131: 1960–1973.
88.
FrangoulHAltshulerDCappelliniMChenYDommJEustaceB, et al.CRISPR-Cas9 Gene Editing for Sickle Cell Disease and β-Thalassemia. N Engl J Med2020.
89.
WeberLFratiGFelixTHardouinGCasiniAWollenschlaegerC, et al.Editing a γ-globin repressor binding site restores fetal hemoglobin synthesis and corrects the sickle cell disease phenotype. Sci Adv2020; 6(7).
90.
FratiGAntoniouPHardouinGMlayaBWeberLFelixT, et al.Editing the LRF repressor binding site in the γ-globin promoters induces therapeutically relevant fetal hemoglobin levels for the treatment of β-hemoglobinopathies. Blood2020; 136(33).
91.
LiangPDingCSunHXieXXuYZhangX, et al.Correction of β-thalassemia mutant by base editor in human embryos. Protein Cell2017; 8(11): 811–822.
92.
HobanMDCostGJMendelMCRomeroZKaufmanMLJoglekarAV, et al.Correction of the sickle cell disease mutation in human hematopoietic stem/progenitor cells. Blood2015; 125: 2597–2604.
93.
HobanMDLumaquinDKuoCYRomeroZLongJHoM, et al.CRISPR/Cas9-mediated correction of the sickle mutation in human CD34+ cells. Mol Ther2016; 24: 1561–1569.
94.
DeWittMAMagisWBrayNLWangTBermanJRUrbinatiF, et al.Selection-free genome editing of the sickle mutation in human adult hematopoietic stem/progenitor cells. Sci Transl Med2016; 8.
GuATorres-CoronadoMTranCAVuHEppsEWChungJ, et al.Engraftment and lineage potential of adult hematopoietic stem and progenitor cells is compromised following short-term culture in the presence of an aryl hydrocarbon receptor antagonist. Hum Gene Ther Methods2014; 25(4): 221–231.
97.
AndreaniMTestiMGazievJCondelloRBontadiniATazzariPL, et al.Quantitatively different red cell/nucleated cell chimerism in patients with long-term, persistent hematopoietic mixed chimerism after bone marrow transplantation for thalassemia major or sickle cell disease. Haematol2011; 96(1): 128–133.
98.
GaudelliNMKomorACReesHAPackerMSBadranAHBrysonDI, et al.Programmable base editing of A*T to G*C in genomic DNA without DNA cleavage. Nature2017; 551(7681): 464–471.
99.
CoxDBTGootenbergJSAbudayyeheOOFranklinBKellnerMJJoungJ, et al.RNA editing with CRISPR-Cas13. Science2017; 358(6366): 1019–1027.
100.
GillinderKRLeighCMalelangSMitchellHLHoskinEWilliamG, et al.Gene editing of KLF1 to cure sickle cell disease. Blood2020; 136(Supplement 1): 30–31.
101.
Román-RodríguezFUgaldeLÁlvarezLDíezBRamírezMRisueñoC, et al.NHEJ-mediated repair of CRISPR-Cas9-induced DNA breaks efficiently corrects mutations in HSPCs from patients with Fanconi anemia. Cell Stem Cell2019; 25(5): 607–621.
102.
Pino-BarrioMGiménezYVillanuevaMHildenbeutelMSánchez-DomínguezRRodríguez-PeralesS, et al.TALEN mediated gene editing in a mouse model of Fanconi anemia. Sci Rep2020; 10: 6697.
103.
Al-SaifA. Gene therapy of hematological disorders: current challenges. Gene Ther2019; 28(7–9): 296–307.
104.
MannoCPierceGArrudaVGladerBRagniMRaskoJ. Successful transduction of liver in hemophilia by AAV-Factor IX and limitations imposed by the host immune response. Nat Med2006; 12(3): 342–347.
105.
DesineSHollisterBMAbdallahKEPersaudAHullSCBonhamVL. The meaning of informed consent: Genome editing clinical trials for sickle cell disease. AJOB Empirical Bioethics2020; 11(4): 195–207.
106.
MachinNRagniMSmithK. Gene therapy in hemophilia A: a cost-effectiveness analysis. Blood Adv2018; 2(14): 1792–1798.
BulchaJTWangYMaHPhillipWLTGuangpingG. Viral vector platforms within the gene therapy landscape. Signal Transduction Target Ther2021; 6(53).
109.
BarouchDHKikSVWeverlingGJDilanRKingSLMaxfieldLF, et al.International seroepidemiology of adenovirus serotypes 5, 26, 35, and 48 in pediatric and adult populations. Vaccine2011; 29(32): 5203–5209.
110.
WebbJShahLDBateman-HouseA. Siblings and Discordant Eligibility for Gene Therapy Research: Considering Parental Requests for Non-Trial “Compassionate Use”. Clin Ethics2021. doi:10.1177/1477750920983571
111.
LiangPXuYZhangXDingCHuangRZhangZ, et al.CRISPR/Cas9-mediated gene editing in human tripronuclear zygotes. Protein Cell2015; 6(5): 363–372.
112.
Alanis-LobatoGZohrenJMcCarthyAFogartyNKubikovaNHardmanE, et al.Frequent loss-of-heterozygosity in CRISPR-Cas9-edited early human embryos. BioRxIv2020.
113.
National Academy of Medicine, National Academy of Sciences, and the Royal Society. Heritable Human Genome Editing. 2020.
114.
AznarJTudelaJ. Bioethics of assisted reproductive technology. In: SharmaNChakrabartiSBarakYEllenbogenA (eds) Innovations in assisted reproduction technology. Londres: IntechOpen, 2020, pp.197–215.
