Notch Pathway Driven Delayed Dedifferentiation of Liver Sinusoidal Endothelium Impacts Liver-Directed Gene Transfer in Hemophilia-a Mice

Background: Hemophilia A is an X-linked recessive bleeding disorder that affects 1 in 5000 males and is caused by procoagulant factor VIII deficiency. Affected people are at danger of spontaneous bleeding into organs, which can be fatal and lead to persistent damage. Current therapy includes intravenous infusion of FVIII protein concentrate which is costly, inconvenient, and does not fully prevent bleeding. As a result of recent advancements in liver-directed gene transfer, gene therapy based innovative strategies for treating hemophilia have emerged. The Factor VIII null mouse (F8^TKO mice) has been effective in understanding the disease pathogenesis as well as the development of liver directed novel gene therapy techniques to treat hemophilia. FVIII is predominantly produced in the liver sinusoidal endothelial cells (LSECs). Thus, liver directed adenoviral and retroviral vectors have been studied by several groups to understand the gene delivery method in hemophilia.

Methods: In this study we evaluated the stability and efficacy of liver driven gene transfer mechanism in F8^TKO mouse using recombinant adeno associated virus (AAV)8 vector. AAV8-TBG-GFP was administered through IP and IV, and GFP expression was analyzed in the liver 15- and 30-days post injection.

Results: Immunofluorescence of GFP at day 15 and day 30 post injection revealed significantly fewer GFP⁺ cells (p=0.04) in the liver of F8^TKO compared with control mice post AAV8-GFP injection. This was further validated by ELISA assays and western blot for GFP. Moreover, Caspase-3 staining revealed significant enrichment (p=0.05) in the liver of F8^TKO mice compared with control mice after AAV8-GFP administration at both the 15- and 30-day time points suggestive of increased LSEC apoptosis post AAV8-GFP injection. To further confirm apoptosis of LSECs, we next used liver intravital imaging to visualize LSECs in F8^TKO mice at baseline and upon AAV8-GFP administration. TXR-dextran and AF488-anti-CD31 antibody were IV administered to visualize hepatic blood flow and LSECs, respectively. At baseline, both control and F8^TKO mice showed normal blood flow and enriched expression of AF488-anti-CD31. However, there were fewer AF488-anti-CD31⁺endothelial cells in F8^TKO than control mice at day 15 post-AAV8-GFP treatment (p=0.01), suggestive of apoptosis of LSECs in F8^TKO mice post-AAV8-GFP administration. Scanning electron microscopy revealed dramatic reduction (p=0.01) in endothelial fenestration in the liver of F8^TKO as compared with control mouse liver. The absence of fenestrae has been associated with LSEC capillarization, which promotes basement membrane formation while decreasing permeability. Remarkably, we found significant upregulation of LSEC markers associated with capillarization, including CD31, vascular endothelial growth factor (VEGF), ICAM1 (Intercellular Adhesion Molecule-1), stabilin2, ID1 (Inhibitor of DNA Binding-1), Gata4, and Ehd3 (EH Domain Containing-3) in F8^TKO mice by qRT-PCR) and western blot. Mechanistically we show significant upregulation of Notch pathway components (Notch 1, 3, and Jagged 2) by qRT-PCR and western in the liver of F8^TKO mice. IHC analysis showed significant upregulation of notch 3 early in development in F8^TKO mice leading to pseudocapillarization of LSECs. Moreover, we also show that notch activation regulates nitric oxide/soluble guanylyl cyclase signaling by upregulating downstream targets (NOS-1, 2, 3, PDE1a, b, c and 10B) in LSECs which directly controls the development of LSEC fenestration.

Conclusion: In conclusion, we demonstrate molecular characterization of LSEC-mediated liver-directed gene transfer in a null hemophilia A mouse model, which is critical for understanding the efficacy and stability of AAV-FVIII gene-based hemophilia treatment. Work is currently underway to understand how absence of FVIII can affect the LSECs mediated hepatic gene transfer in Hemophilia-A mice and how modulation of Notch and nitric oxide/sGC signaling can manipulate LSEC fenestration and improve the efficiency of liver directed gene transfer.

Ragni:Takeda: Honoraria, Other: Provided study (rVWF) drug for trial; BioMarin: Honoraria. Sundd:IHP Therapeutics: Research Funding; CSL Behring Inc: Research Funding; Novartis corporation: Research Funding; Bayer Hemophilia Award Program: Research Funding.