Fetal gene therapy for neurodegenerative disease of infants


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.

Access options

Rent or Buy article

Get time limited or full article access on ReadCube.


All prices are NET prices.

Fig. 1: Brain disease at birth in nGD mice.
Fig. 2: Fetal gene therapy of nGD mice.
Fig. 3: Intracerebroventricular and intravenous gene therapy in neonatal nGD mice.
Fig. 4: In utero gene delivery to the macaque brain via ultrasound-guided intracerebroventricular injection of vector.


  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).

    CAS  Article  Google Scholar 

  2. 2.

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

    CAS  Article  Google Scholar 

  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).

    CAS  Article  Google Scholar 

  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).

    CAS  Article  Google Scholar 

  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).

    Article  Google Scholar 

  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).

    CAS  Article  Google Scholar 

  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).

    CAS  Article  Google Scholar 

  11. 11.

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

    CAS  Article  Google Scholar 

  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).

    CAS  Article  Google Scholar 

  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).

    CAS  Article  Google Scholar 

  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).

    CAS  Article  Google Scholar 

  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).

    Article  Google Scholar 

  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).

    CAS  Article  Google Scholar 

  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).

    CAS  Article  Google Scholar 

  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).

    CAS  Article  Google Scholar 

  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).

    Article  Google Scholar 

  22. 22.

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

    CAS  Article  Google Scholar 

  23. 23.

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

    Article  Google Scholar 

  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).

    Article  Google Scholar 

  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).

    CAS  Article  Google Scholar 

  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).

    CAS  Article  Google Scholar 

  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).

    CAS  Article  Google Scholar 

  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).

    CAS  Article  Google Scholar 

  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).

    CAS  Article  Google Scholar 

  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).

    CAS  Article  Google Scholar 

  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).

    CAS  Article  Google Scholar 

  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).

    CAS  Article  Google Scholar 

  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).

    Article  Google Scholar 

  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).

    CAS  Article  Google Scholar 

  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).

    CAS  Article  Google Scholar 

  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).

    CAS  Article  Google Scholar 

  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).

    CAS  PubMed  Google Scholar 

  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).

    Article  Google Scholar 

  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).

    Article  Google Scholar 

  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).

    CAS  Article  Google Scholar 

Download references


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




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.

Corresponding author

Correspondence to Simon N. Waddington.

Ethics declarations

Competing interests

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

Additional information

Publisher’s note: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Supplementary Text and Figures

Supplementary Figures 1–8 and Supplementary Tables 1–4

Reporting Summary

Supplementary Video 1

Treated knockout mouse with two knockout pups

Supplementary Video 2

Behavior of treated knockouts versus age-matched controls

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Massaro, G., Mattar, C.N.Z., Wong, A.M.S. et al. Fetal gene therapy for neurodegenerative disease of infants. Nat Med 24, 1317–1323 (2018). https://doi.org/10.1038/s41591-018-0106-7

Download citation

Further reading


Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing