For inherited genetic diseases, fetal gene therapy offers the potential of prophylaxis against early, irreversible and lethal pathological change. To explore this, we studied neuronopathic Gaucher disease (nGD), caused by mutations in GBA. In adult patients, the milder form presents with hepatomegaly, splenomegaly and occasional lung and bone disease; this is managed, symptomatically, by enzyme replacement therapy. The acute childhood lethal form of nGD is untreatable since enzyme cannot cross the blood–brain barrier. Patients with nGD exhibit signs consistent with hindbrain neurodegeneration, including neck hyperextension, strabismus and, often, fatal apnea1. We selected a mouse model of nGD carrying a loxP-flanked neomycin disruption of Gba plus Cre recombinase regulated by the keratinocyte-specific K14 promoter. Exclusive skin expression of Gba prevents fatal neonatal dehydration. Instead, mice develop fatal neurodegeneration within 15 days2. Using this model, fetal intracranial injection of adeno-associated virus (AAV) vector reconstituted neuronal glucocerebrosidase expression. Mice lived for up to at least 18 weeks, were fertile and fully mobile. Neurodegeneration was abolished and neuroinflammation ameliorated. Neonatal intervention also rescued mice but less effectively. As the next step to clinical translation, we also demonstrated the feasibility of ultrasound-guided global AAV gene transfer to fetal macaque brains.

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  1. 1.

    Gupta, N., Oppenheim, I. M., Kauvar, E. F., Tayebi, N. & Sidransky, E. Type 2 Gaucher disease: phenotypic variation and genotypic heterogeneity. Blood Cells Mol. Dis. 46, 75–84 (2011).

  2. 2.

    Enquist, I. B. et al. Murine models of acute neuronopathic Gaucher disease. Proc. Natl Acad. Sci. USA 104, 17483–17488 (2007).

  3. 3.

    Farfel-Becker, T. et al. Spatial and temporal correlation between neuron loss and neuroinflammation in a mouse model of neuronopathic Gaucher disease. Hum. Mol. Genet. (2011).

  4. 4.

    Farfel-Becker, T. et al. Neuronal accumulation of glucosylceramide in a mouse model of neuronopathic Gaucher disease leads to neurodegeneration. Hum. Mol. Genet. (2013).

  5. 5.

    Cabrera-Salazar, M. A. et al. Systemic delivery of a glucosylceramide synthase inhibitor reduces CNS substrates and increases lifespan in a mouse model of type 2 Gaucher disease. PLoS ONE 7, e43310 (2012).

  6. 6.

    Rahim, A. A. et al. In utero administration of Ad5 and AAV pseudotypes to the fetal brain leads to efficient, widespread and long-term gene expression. Gene Ther. 19, 936–946 (2012).

  7. 7.

    Haddad, M. R., Donsante, A., Zerfas, P. & Kaler, S. G. Fetal brain-directed AAV gene therapy results in rapid, robust, and persistent transduction of mouse choroid plexus epithelia. Mol. Ther. Nucleic Acids 2, e101 (2013).

  8. 8.

    Passini, M. A. & Wolfe, J. H. Widespread gene delivery and structure-specific patterns of expression in the brain after intraventricular injections of neonatal mice with an adeno-associated virus vector. J. Virol. 75, 12382–12392 (2001).

  9. 9.

    Sardi, S. P. et al. CNS expression of glucocerebrosidase corrects α-synuclein pathology and memory in a mouse model of Gaucher-related synucleinopathy. Proc. Natl Acad. Sci. USA (2011).

  10. 10.

    Zimmer, K. P. et al. Intracellular transport of acid β-glucosidase and lysosome-associated membrane proteins is affected in Gaucher’s disease (G202R mutation). J. Pathol. 188, 407–414 (1999).

  11. 11.

    Foust, K. D. et al. Intravascular AAV9 preferentially targets neonatal neurons and adult astrocytes. Nat. Biotechnol. 27, 59–65 (2009).

  12. 12.

    Rahim, A. A. et al. Intravenous administration of AAV2/9 to the fetal and neonatal mouse leads to differential targeting of CNS cell types and extensive transduction of the nervous system. FASEB J. 25, 3505–3518 (2011).

  13. 13.

    Mattar, C. N. et al. Systemic delivery of scAAV9 in fetal macaques facilitates neuronal transduction of the central and peripheral nervous systems. Gene Ther. 20, 69–83 (2013).

  14. 14.

    Sehara, Y. et al. Persistent expression of dopamine-synthesizing enzymes 15 years after gene transfer in a primate model of Parkinson’s disease. Hum. Gene Ther. Clin. Dev. 28, 74–79 (2017).

  15. 15.

    Nathwani, A. C. et al. Long-term safety and efficacy of factor IX gene therapy in hemophilia B. N. Engl. J. Med. 371, 1994–2004 (2014).

  16. 16.

    McCain, L. & Flake, A. W. In utero stem cell transplantation and gene therapy—recent progress and the potential for clinical application. Best Pract. Res Clin Obstet. Gynaecol. (2015).

  17. 17.

    Mendell, J. R. et al. Single-dose gene-replacement therapy for spinal muscular atrophy. N. Engl. J. Med. 377, 1713–1722 (2017).

  18. 18.

    Tardieu, M. et al. Intracerebral administration of AAV rh.10 carrying human SGSH and SUMF1 cDNAs in children with MPSIIIA disease: results of a phase I/II trial. Hum. Gene Ther (2014).

  19. 19.

    Barton, D. J., Ludman, M. D., Benkov, K., Grabowski, G. A. & LeLeiko, N. S. Resting energy expenditure in Gaucher’s disease type 1: effect of Gaucher’s cell burden on energy requirements. Metabolism 38, 1238–1243 (1989).

  20. 20.

    Prasad, K. M. R., Xu, Y., Yang, Z., Acton, S. T. & French, B. A. Robust cardiomyocyte-specific gene expression following systemic injection of AAV: in vivo gene delivery follows a Poisson distribution. Gene Ther. 18, 43–52 (2011).

  21. 21.

    Zeevi, D. A. et al. Proof-of-principle rapid noninvasive prenatal diagnosis of autosomal recessive founder mutations. J. Clin. Investig. 125, 3757–3765 (2015).

  22. 22.

    Verma, J. et al. Inherited metabolic disorders: prenatal diagnosis of lysosomal storage disorders. Prenat. Diagn. 35, 1137–1147 (2015).

  23. 23.

    Pearson, E. G. & Flake, A. W. Stem cell and genetic therapies for the fetus. Semin. Pediatr. Surg. 22, 56–61 (2013).

  24. 24.

    Nivsarkar, M. S. et al. Evidence for contribution of CD4+  CD25+ regulatory T cells in maintaining immune tolerance to human factor IX following perinatal adenovirus vector delivery. J. Immunol. Res. 2015, 397879 (2015).

  25. 25.

    Tai, D. S. et al. Development of operational immunologic tolerance with neonatal gene transfer in nonhuman primates: preliminary studies. Gene Ther. (2015).

  26. 26.

    Waddington, S. N. et al. In utero gene transfer of human factor IX to fetal mice can induce postnatal tolerance of the exogenous clotting factor. Blood 101, 1359–1366 (2003).

  27. 27.

    Gray, S. J. et al. Preclinical differences of intravascular AAV9 delivery to neurons and glia: a comparative study of adult mice and nonhuman primates. Mol. Ther. 19, 1058–1069 (2011).

  28. 28.

    U.S. National Institutes of Health, and Recombinant DNA Advisory Committee. Prenatal gene tranfer: scientific, medical, and ethical issues: a report of the Recombinant DNA Advisory Committee. Hum. Gene Ther. 11, 1211–1229 (2000).

  29. 29.

    Pressey, S. N., Smith, D. A., Wong, A. M., Platt, F. M. & Cooper, J. D. Early glial activation, synaptic changes and axonal pathology in the thalamocortical system of Niemann-Pick type C1 mice. Neurobiol. Dis. 45, 1086–1100 (2012).

  30. 30.

    Gundersen, H. J., Jensen, E. B., Kieu, K. & Nielsen, J. The efficiency of systematic sampling in stereology—reconsidered. J. Microsc. 193, 199–211 (1999).

  31. 31.

    Baddeley, A. J., Gundersen, H. J. & Cruz-Orive, L. M. Estimation of surface area from vertical sections. J. Microsc. 142, 259–276 (1986).

  32. 32.

    Mills, K., Eaton, S., Ledger, V., Young, E. & Winchester, B. The synthesis of internal standards for the quantitative determination of sphingolipids by tandem mass spectrometry. Rapid Commun. Mass Spectrometry 19, 1739–1748 (2005).

  33. 33.

    Auray-Blais, C. et al. Urinary biomarker investigation in children with Fabry disease using tandem mass spectrometry. Clin. Chim. Acta 438, 195–204 (2015).

  34. 34.

    Neville, D. C. et al. Analysis of fluorescently labeled glycosphingolipid-derived oligosaccharides following ceramide glycanase digestion and anthranilic acid labeling. Anal. Biochem. 331, 275–282 (2004).

  35. 35.

    Passini, M. A. et al. Antisense oligonucleotides delivered to the mouse CNS ameliorate symptoms of severe spinal muscular atrophy. Sci. Transl. Med. 3, 72ra18 (2011).

  36. 36.

    Ayuso, E. et al. High AAV vector purity results in serotype- and tissue-independent enhancement of transduction efficiency. Gene Ther. 17, 503–510 (2010).

  37. 37.

    Rahim, A. A. et al. Efficient gene delivery to the adult and fetal CNS using pseudotyped non-integrating lentiviral vectors. Gene Ther. 16, 509–520 (2009).

  38. 38.

    Kim, J. Y., Grunke, S. D., Levites, Y., Golde, T. E. & Jankowsky, J. L. Intracerebroventricular viral injection of the neonatal mouse brain for persistent and widespread neuronal transduction. J. Vis. Exp. (2014).

  39. 39.

    Mattar, C. N. Z. et al. Stable human FIX expression after 0.9G intrauterine gene transfer of self-complementary adeno-associated viral vector 5 and 8 in macaques. Mol. Ther. 19, 1950–1960 (2011).

  40. 40.

    Mattar, C. N., Biswas, A., Choolani, M. & Chan, J. K. Animal models for prenatal gene therapy: the nonhuman primate model. Methods Mol. Biol. 891, 249–271 (2012).

  41. 41.

    Lubics, A. et al. Neurological reflexes and early motor behavior in rats subjected to neonatal hypoxic–ischemic injury. Behav. Brain Res. 157, 157–165 (2005).

  42. 42.

    Carter, R. J., Morton, J. & Dunnett, S. B. Motor coordination and balance in rodents. Curr. Protoc. Neurosci. 15, 8.12.1–8.12.14 (2001).

  43. 43.

    Wenger, D. A., Clark, C., Sattler, M. & Wharton, C. Synthetic substrate β-glucosidase activity in leukocytes: a reproducible method for the identification of patients and carriers of Gaucher’s disease. Clin. Genet. 13, 145–153 (1978).

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S.N.W., A.A.R. and J.D.C. received funding from UK Medical Research Council grant G1000709. S.N.W. received funding from MR/N019075/1 and MR/P026494/1 and SPARKS (17UCL01). A.A.R. and S.N.W. received funding from MRC grants MR/R015325/1 and MR/N026101/1 and NC3Rs grant NC/L001780/1. G.M., A.A.R. and S.N.W. received funding from the UK Gauchers Association. A.A.R. received funding from the European Union’s Horizon 2020 research and innovation program under grant agreement no. 666918 (BATCure), Action Medical Research (GN2485), MRC grant MR/M00676X/1, Asociación Niemann Pick de Fuenlabrada, Niemann-Pick UK, Niemann Pick Research Foundation and the NBIA Disorders Association. S.M.K.B. and S.N.W. received funding from ERC grant ‘Somabio’ 260862. C.N.Z.M. received salary support from the Singapore Ministry of Health’s National Medical Research Council NMRC/TA/0003/2012 and NMRC/CSA-INV/0012/2016. M.H. is supported by Parkinson’s UK grant H-1501. F.M.P. is a Royal Society Wolfson Research Merit Award holder and a Wellcome Trust Investigator in Science. F.M.P. and D.A.P. were supported by the Mizutani Foundation for Glycoscience. J.K.Y.C. is funded by Singapore’s Ministry of Health’s National Medical Research Council NMRC CSA/043/2012, CSA(SI)/008/2016 and CIRG/1459/2016. J.D.C. received funding from the European Union’s Horizon 2020 research and innovation program under grant agreement no. 666918 (BATCure), the Batten Disease Support and Research Association (US) and Batten Disease Family Association (UK). K.M. received funding from the Peto Foundation. S.B. was supported by the National Institute of Health Research (NIHR) UCLH/UCL Biomedical Research Centre. We thank R. Baker, M. Choolani, N. Johana, N. Wen, B. Warburton, S. Richards, T. O’Mahoney, G. Sturges O. Woolmer, E.-H. Davies, T. Collin-Histed, A. Mehta and D. Hughes. Most of all, for guidance, mentorship and inspiration, we thank C. Coutelle.

Author information


  1. UCL School of Pharmacy, University College London, London, UK

    • Giulia Massaro
    •  & Ahad A. Rahim
  2. Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore

    • Citra N. Z. Mattar
    • , Arijit Biswas
    •  & Jerry K. Y. Chan
  3. Department of Basic and Clinical Neuroscience, King’s College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK

    • Andrew M. S. Wong
    •  & Jonathan D. Cooper
  4. UCL Great Ormond Street Institute of Child Health, University College London, London, UK

    • Ernestas Sirka
    •  & Kevin Mills
  5. UCL Institute for Women’s Health, University College London, London, UK

    • Suzanne M. K. Buckley
    • , Dany P. Perocheau
    •  & Simon N. Waddington
  6. Institute for Reproductive and Developmental Biology, Imperial College London, London, UK

    • Bronwen R. Herbert
  7. Division of Molecular Medicine and Gene Therapy, Lund University, Lund, Sweden

    • Stefan Karlsson
  8. Paediatric Laboratory Medicine, Great Ormond Street Hospital and UCL Great Ormond Street Institute of Child Health, London, UK

    • Derek Burke
    •  & Simon Heales
  9. Department of Neurodegenerative Disease, UCL Institute of Neurology, University College London, London, UK

    • Angela Richard-Londt
    •  & Sebastian Brandner
  10. Department of Pharmacology, University of Oxford, Oxford, UK

    • Mylene Huebecker
    • , David A. Priestman
    •  & Frances M. Platt
  11. Department of Pediatrics, Los Angeles Biomedical Research Institute at Harbor–UCLA Medical Center, David Geffen School of Medicine, University of California Los Angeles, Torrance, CA, USA

    • Jonathan D. Cooper
  12. Department of Pediatrics, Washington University School of Medicine, St Louis, MO, USA

    • Jonathan D. Cooper
  13. Department of Reproductive Medicine, KK Women’s and Children’s Hospital, Singapore, Singapore

    • Jerry K. Y. Chan
  14. Cancer and Stem Cell Biology, Duke-NUS Medical School, Singapore, Singapore

    • Jerry K. Y. Chan
  15. Sanofi, Framingham, MA, USA

    • Seng H. Cheng
  16. MRC Antiviral Gene Therapy Research Unit, Faculty of Health Sciences, University of the Witswatersrand, Johannesburg, South Africa

    • Simon N. Waddington


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G.M. contributed murine analysis, immunohistochemistry and manuscript drafting. C.N.Z.M. contributed NHP work and manuscript drafting. A.M.S.W. contributed immunohistochemistry. E.S. contributed mass spectrometry. S.M.K.B. contributed murine analysis. B.R.H. contributed murine analysis. S.K. contributed manuscript drafting. D.P.P. contributed murine analysis. D.B. and S.H. contributed blood spots. A.R.-L. contributed immunohistochemistry. S.B. contributed immunohistochemistry and manuscript drafting. M.H. and D.A.P. contributed immunohistochemistry. F.M.P. contributed immunohistochemistry and manuscript drafting. K.M. contributed mass spectrometry and manuscript drafting. A.B. contributed NHP work. J.D.C. contributed immunohistochemistry and manuscript drafting. J.K.Y.C. contributed NHP work and manuscript drafting. S.H.C. contributed vector generation. S.N.W. contributed murine analysis and manuscript drafting. A.A.R. contributed murine analysis, immunohistochemistry and manuscript drafting.

Competing interests

S.H.C. is an employee at Sanofi, a biopharmaceutical company.

Corresponding author

Correspondence to Simon N. Waddington.

Supplementary information

  1. Supplementary Text and Figures

    Supplementary Figures 1–8 and Supplementary Tables 1–4

  2. Reporting Summary

  3. Supplementary Video 1

    Treated knockout mouse with two knockout pups

  4. Supplementary Video 2

    Behavior of treated knockouts versus age-matched controls

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