Acute intermittent porphyria (AIP) results from haploinsufficiency of porphobilinogen deaminase (PBGD), the third enzyme in the heme biosynthesis pathway. Patients with AIP have neurovisceral attacks associated with increased hepatic heme demand. Phenobarbital-challenged mice with AIP recapitulate the biochemical and clinical characteristics of patients with AIP, including hepatic overproduction of the potentially neurotoxic porphyrin precursors. Here we show that intravenous administration of human PBGD (hPBGD) mRNA (encoded by the gene HMBS) encapsulated in lipid nanoparticles induces dose-dependent protein expression in mouse hepatocytes, rapidly normalizing urine porphyrin precursor excretion in ongoing attacks. Furthermore, hPBGD mRNA protected against mitochondrial dysfunction, hypertension, pain and motor impairment. Repeat dosing in AIP mice showed sustained efficacy and therapeutic improvement without evidence of hepatotoxicity. Finally, multiple administrations to nonhuman primates confirmed safety and translatability. These data provide proof-of-concept for systemic hPBGD mRNA as a potential therapy for AIP.
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The data that support the findings of this study are available from the corresponding authors upon reasonable request.
Anderson, K. E. et al. Recommendations for the diagnosis and treatment of the acute porphyrias. Ann. Intern. Med. 142, 439–450 (2005).
Bissell, D. M., Anderson, K. E. & Bonkovsky, H. L. Porphyria. N. Engl. J. Med. 377, 862–872 (2017).
Fratz, E. J., Stojanovski, B. M., Ferreira G. C. in Handbook of Porphyrin Science Vol. 26 (eds Kadish, K. M. et al.) 3–78 (World Scientific Publishing, Hackensack, NJ, USA, 2014).
Harper, P. & Sardh, E. Management of acute intermittent porphyria. Expert Opin. Orphan Drugs 2, 349–368 (2014).
Puy, H., Gouya, L. & Deybach, J. C. Porphyrias. Lancet 375, 924–937 (2010).
Marsden, J. T. et al. Audit of the use of regular haem arginate infusions in patients with acute porphyria to prevent recurrent symptoms. JIMD Rep. 22, 57–65 (2015).
Handschin, C. et al. Nutritional regulation of hepatic heme biosynthesis and porphyria through PGC-1α. Cell 122, 505–515 (2005).
Bonkovsky, H. L. et al. Acute porphyrias in the USA: features of 108 subjects from porphyrias consortium. Am. J. Med. 127, 1233–1241 (2014).
Bissell, D. M., Lai, J. C., Meister, R. K. & Blanc, P. D. Role of delta-aminolevulinic acid in the symptoms of acute porphyria. Am. J. Med. 128, 313–317 (2015).
Herrick, A. L., Moore, M. R., McColl, K. E. L., Cook, A. & Goldberg, A. Controlled trial of haem arginate in acute hepatic porphyria. Lancet 333, 1295–1297 (1989).
Meyer, U. A., Schuurmans, M. M. & Lindberg, R. L. Acute porphyrias: pathogenesis of neurological manifestations. Semin. Liver. Dis. 18, 43–52 (1998).
Pallet, N. et al. High prevalence of and potential mechanisms for chronic kidney disease in patients with acute intermittent porphyria. Kidney Int. 88, 386–395 (2015).
Bylesjö, I., Wikberg, A. & Andersson, C. Clinical aspects of acute intermittent porphyria in northern Sweden: a population-based study. Scand. J. Clin. Lab. Invest. 69, 612–618 (2009).
Tchernitchko, D. et al. A variant of peptide transporter 2 predicts the severity of porphyria-associated kidney disease. J. Am. Soc. Nephrol. 28, 1924–1932 (2017).
Willandt, B. et al. Liver fibrosis associated with iron accumulation due to long-term heme-arginate treatment in acute intermittent porphyria: a case series. JIMD Rep 25, 77–81 (2016).
Schmitt, C. et al. Recurrent attacks of acute hepatic porphyria: major role of the chronic inflammatory response in the liver. J. Intern. Med. 284, 78–91 (2018).
Yasuda, M. et al. RNAi-mediated silencing of hepatic Alas1 effectively prevents and treats the induced acute attacks in acute intermittent porphyria mice. Proc. Natl Acad. Sci. USA 111, 7777–7782 (2014).
Alnylam reports positive initial clinical results for ALN-AS1, an investigational RNAi therapeutic targeting aminolevulinic acid synthase 1 (ALAS1) for the treatment of acute hepatic porphyrias. Alnylam Pharmaceuticals http://www.businesswire.com/news/home/20150915005532/en/ (2015).
Unzu, C. et al. Sustained enzymatic correction by rAAV-mediated liver gene therapy protects against induced motor neuropathy in acute porphyria mice. Mol. Ther. 19, 243–250 (2011).
Yasuda, M. et al. AAV8-mediated gene therapy prevents induced biochemical attacks of acute intermittent porphyria and improves neuromotor function. Mol. Ther. 18, 17–22 (2010).
Unzu, C. et al. Helper-dependent adenovirus achieve more efficient and persistent liver transgene expression in non-human primates under immunosuppression. Gene Ther. 22, 856–865 (2015).
D’Avola, D. et al. Phase I open label liver-directed gene therapy clinical trial for acute intermittent porphyria. J. Hepatol. 65, 776–783 (2016).
Sahay, G. et al. Efficiency of siRNA delivery by lipid nanoparticles is limited by endocytic recycling. Nat. Biotechnol. 31, 653–658 (2013).
Sabnis, S. et al. A novel amino lipid series for mRNA delivery: improved endosomal escape and sustained pharmacology and safety in non-human primates. Mol. Ther. 26, 1509–1519 (2018).
An, D. et al. Systemic messenger RNA therapy as a treatment for methylmalonic acidemia. Cell Rep. 21, 3548–3558 (2017).
Lindberg, R. L. et al. Porphobilinogen deaminase deficiency in mice causes a neuropathy resembling that of human hepatic porphyria. Nat. Genet. 12, 195–199 (1996).
Gouya, L. et al. EXPLORE: A prospective, multinational, natural history study of patients with acute hepatic porphyria (AHP) with recurrent attacks. ICPP http://www.alnylam.com/wp-content/uploads/2017/06/ICPP-2017-EXPLORE-Presentation-Capella.pdf (2017).
Langford, D. J. et al. Coding of facial expressions of pain in the laboratory mouse. Nat. Methods 7, 447–449 (2010).
Matsumiya, L. C. et al. Using the Mouse Grimace Scale to reevaluate the efficacy of postoperative analgesics in laboratory mice. J. Am. Assoc. Lab. Anim. Sci. 51, 42–49 (2012).
Vijayasarathy, C., Damle, S., Lenka, N. & Avadhani, N. G. Tissue variant effects of heme inhibitors on the mouse cytochrome c oxidase gene expression and catalytic activity of the enzyme complex. Eur. J. Biochem. 266, 191–200 (1999).
Atamna, H., Liu, J. & Ames, B. N. Heme deficiency selectively interrupts assembly of mitochondrial complex IV in human fibroblasts: revelance to aging. J. Biol. Chem. 276, 48410–48416 (2001).
Atamna, H., Killilea, D. W., Killilea, A. N. & Ames, B. N. Heme deficiency may be a factor in the mitochondrial and neuronal decay of aging. Proc. Natl Acad. Sci. USA 99, 14807–14812 (2002).
Homedan, C. et al. Acute intermittent porphyria causes hepatic mitochondrial energetic failure in a mouse model. Int. J. Biochem. Cell Biol. 51, 93–101 (2014).
Bonkowsky, H. L., Tschudy, D. P., Weinbach, E. C., Ebert, P. S. & Doherty, J. M. Porphyrin synthesis and mitochondrial respiration in acute intermittent porphyria: studies using cultured human fibroblasts. J. Lab. Clin. Med. 85, 93–102 (1975).
Xie, L. et al. Age- and sex-based hematological and biochemical parameters for Macaca fascicularis. PLoS ONE 8, e64892 (2013).
Kim, C. Y. et al. Hematological and serum biochemical values in cynomolgus monkeys anesthetized with ketamine hydrochloride. J. Med. Primatol. 34, 96–100 (2005).
Sedic, M. et al. Safety evaluation of lipid nanoparticle-formulated modified mRNA in the Sprague–Dawley rat and cynomolgus monkey. Vet. Pathol. 55, 341–354 (2018).
Dowman, J. K. et al. Liver transplantation for acute intermittent porphyria is complicated by a high rate of hepatic artery thrombosis. Liver Transpl. 18, 195–200 (2012).
Rogers, G. W. et al. High throughput microplate respiratory measurements using minimal quantities of isolated mitochondria. PLoS ONE 6, e21746 (2011).
Anderson, P. M. & Desnick, R. J. Porphobilinogen deaminase: methods and principles of the enzymatic assay. Enzyme 28, 146–157 (1982).
Goldberg, A. & Rimington, C. Experimentally produced porphyria in animals. Proc. R. Soc. Lond. B. 143, 257–279 (1955).
Klinger, W. & Muller, D. The influence of allyl isopropyl acetamide on d-aminolevulinic acid synthetase and cytochrome P-450. Acta Biol. Med. Ger. 39, 107–112 (1980).
Tokola, O., Linden, I. B. & Tenhunen, R. The effects of haem arginate and haematin upon the allylisopropylacetamide induced experimental porphyria in rats. Pharmacol. Toxicol. 61, 75–78 (1987).
Muller-Eberhard, U., Eiseman, J. L., Foidart, M. & Alvares, A. P. Effect of heme on allylisopropylacetamide-induced changes in heme and drug metabolism in the rhesus monkey (Macaca mulatta). Biochem. Pharmacol. 32, 3765–3769 (1983).
McColl, K. E. et al. Effect of rifampicin on haem and bilirubin metabolism in man. Br. J. Clin. Pharmacol. 23, 553–559 (1987).
Innala, E., Backstrom, T., Bixo, M. & Andersson, C. Evaluation of gonadotropin-releasing hormone agonist treatment for prevention of menstrual-related attacks in acute porphyria. Acta Obstet. Gynecol. Scand. 89, 95–100 (2010).
P.B., M.A.A. and A.Fo. thank J. Prieto for his enthusiastic and continuous support of our research on porphyria. We thank S. Arcelus and I. Alkain for technical assistance; J. L. Lanciego, A. Rico, L. Guembe and A. Benito for their helpful technical and scientific support with NHPs; P. Harper and E. Sardh for supplying liver explants from patients with porphyria. T1 and T2 mouse strains were provided by U. A. Meyer (Biozentrum of University of Basel, Basel, Switzerland). This study was supported in part by grants from the Spanish Fundación Mutua Madrileña, Spanish Fundación Eugenio Rodríguez Pascual and Spanish Institute of Health Carlos III (FIS) cofinanced by European FEDER funds (grant numbers PI09/02639, PI12/02785, PI15/01951 and PI16/00668 funds). P.B. is supported by a Miguel Servet II (CPII15/00004) contract from Instituto de Salud Carlos III.
L.J., L.T.G., A.Fr., K.E.B., K.B., M.Ka., W.B., J.-S.P., X.Z., S.S., E.S.K., T.S., M.Ke., C.M.L. and P.G.V.M. are employees of Moderna Therapeutics, Inc. focusing on the development of therapeutic approaches for rare diseases. The other authors declare no competing interests.
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Jiang, L., Berraondo, P., Jericó, D. et al. Systemic messenger RNA as an etiological treatment for acute intermittent porphyria. Nat Med 24, 1899–1909 (2018). https://doi.org/10.1038/s41591-018-0199-z
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