Liver Biopsy In Haemophilia Gene Therapy

To perform a liver biopsy in haemophilia A and B patients with endogenous FVIII:C/FIX:C expression at >1% any time after gene transfer following AAV mediated gene transfer. This is to obtain tissue for analysis, to understand if FIX/FVIII transgenic protein expression is mediated by AAV proviral DNA that is integrated into the host cell DNA or if stable expression in humans is mediated by episomal maintained AAV genome.

Study Overview

• Status: Recruiting
• Conditions: Hemophilia A, Severe; Hemophilia B, Severe
• Intervention / Treatment: Procedure: Liver biopsy

Detailed Description

To better understand the consequences of AAV gene transfer patients will be recruited to undergo a liver biopsy. Patients will have endogenous FVIII:C/FIX:C expression at >1% any time after gene transfer following AAV mediated gene transfer. Analysis of biopsy samples will:

• Provide a clearer insight into the AAV life cycle in human liver
• Define the number of human hepatocytes that are transduced
• Improve understanding at the human hepatocyte level of long-term consequences of AAV mediated transgene expression from the liver that will include (i) changes in the pattern of gene expression in human hepatocytes following AAV mediated gene transfer, (ii) information on the epigenetic signature in the liver following AAV mediated gene transfer and how this changes with time and (iii) the consequences of transgene expression in hepatocytes.

This study will provide new data addressing several unknowns with AAV mediated gene transfer in humans that will better inform on safety and efficacy following AAV gene transfer for patients who have already participated in gene therapy studies as well as those considering this treatment option.

• Study Type: Interventional
• Enrollment (Estimated): 10
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Paul Batty; Phone Number: 35921 020 7794 0500; Email: paul.batty@ucl.ac.uk

Study Locations

• United Kingdom
  • London, United Kingdom, NW3 2QG
    • Recruiting
    • Royal Free Hospital
    • Principal Investigator: Paul Batty, MBBS MRCP
    • Contact: Paul Batty, MBBS MRCP; Phone Number: 35921 020 7794 0500; Email: paul.batty2@nhs.net

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 80 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Study Population

The study population is expected to be patients with either haemophilia A or B who have previously been given gene therapy treatment enrolled one of two gene therapy trials, either being CLINICALTRIALS.GOV: NCT00979238 (AGT4HB for haemophilia B) or CLINICALTRIALS.GOV: NCT03001830 (GO-8 for haemophilia A) or CLINICALTRIALS.GOV: NCT03369444 (FLT-180a-01 for haemophilia B)

Description

Inclusion criteria:

1. Male and aged 18 to 80 years old

2. Patients who were enrolled and treated in one of the following clinical trials at Royal Free Hospital:

   • AGT4HB (EudraCT No 2005-005711-17) - FIX AAV gene therapy trial (Sponsor: St Jude Children's Research Hospital)
   • GO-8 (EudraCT No 2016-000925-38) - FVIII AAV gene therapy trial (Sponsor: UCL)
   • FLT180a-01 (EudraCT: 2017-000852-24) - FIX AAV gene therapy trial ((Sponsor: UCL) [now enrolled in long term follow up study FLT180a-04 (EudraCT No 2017-005080-40) (Sponsor: Freeline Therapeutics Ltd)
3. Patients with endogenous FVIII:C/FIX:C expression at >1% any time after gene transfer, associated with normal prothrombin (PT) and thrombin times (TT) as determined in a coagulation assay.

Exclusion Criteria:

1. Patients with a platelet count measured at <140 x109/L
2. Any condition that, in the opinion of the investigator or Sponsor would prevent the patient from fully complying with the requirements of the study and/or would influence or interfere with evaluation and interpretation of subject safety or efficacy result.
3. Patients with abnormal kidney function (estimated GFR <50ml/min)
4. Patients with a known allergy to iodine-based intravenous contrast agents
5. Patients with a known allergy to local or general anaesthetic
6. Patients with a known reaction to FVIII/FIX concentrate infusions
7. Presence of FVIII or FIX inhibitor (done within 14 weeks of biopsy)
8. Evidence of any bleeding disorder not related to haemophilia A or B
9. Patients unable and unwilling to provide and sign an informed consent.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Basic Science
• Allocation: N/A
• Interventional Model: Single Group Assignment
• Masking: None (Open Label)

Number of Arms

1

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Liver Biopsy; All patients undergo a liver biopsy only	Procedure: Liver biopsy; The study population is patients with either haemophilia A or B who have previously been administered gene therapy treatment in one of three specific gene therapy clinical trials. In this study they will have a liver biopsy performed to take up to 3 samples for laboratory analysis.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Analysis of AAV integration in hepatocytes using Target Enrichment Sequencing	The determination of AAV integration sites will be performed for each participant using Target Enrichment Sequencing (TES) analysis of their liver biopsy sample. This will identify DNA sequences flanking the vector genome. The sequencing data will be analyzed to determine; Vector-Vector Concatemers and Vector-Genome Junctions Analysis; Integration Site,read count, genomic position and nearest gene	Biopsy samples will be taken from participants who are between one month and up to 15 years post gene therapy

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Histology analysis using hematoxylin and eosin staining and immunohistochemical staining to determine histopathological changes in hepatocytes	Hematoxylin and eosin staining and immunohistochemical staining will be done on a liver biopsy sample from each participant to provide information about the structure and distribution of cells and any morphological changes within the liver biopsy sample.	Biopsy samples will be taken from participants who are between one month and up to 15 years post gene therapy

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Determination of hot-spots for integration of the AAV provirus in the liver	Determination of hot-spots for integration of the AAV provirus in the liver	single time point (day of biopsy)
Associated risk of oncogenesis at hot-spots for integration of the AAV provirus	Associated risk of oncogenesis at hot-spots for integration of the AAV provirus	single time point (day of biopsy)
Assessment of number of hepatocytes harbouring the AAV transgene by FISH	Assessment of number of hepatocytes harbouring the AAV transgene by FISH	single time point (day of biopsy)
Assessment of the number of hepatocytes expressing human FVIII/FIX transcripts	Assessment of the number of hepatocytes expressing human FVIII/FIX transcripts	single time point (day of biopsy)
Qualitative assessment of transcriptome in hepatocytes following AAV gene transfer	Qualitative assessment of transcriptome in hepatocytes following AAV gene transfer	single time point (day of biopsy)
Quantitative assessment of transcriptome in hepatocytes following AAV gene transfer	Quantitative assessment of transcriptome in hepatocytes following AAV gene transfer	single time point (day of biopsy)
Assessment of the number of hepatocytes expressing human FVIII/FIX in patients with a null mutation	Assessment of the number of hepatocytes expressing human FVIII/FIX in patients with a null mutation	single time point (day of biopsy)
Determination of Endoplasmic reticulum (ER) stress response following AAV gene transfer	Determination of Endoplasmic reticulum (ER) stress response following AAV gene transfer	single time point (day of biopsy)
Assessment of the epigenetic changes within the AAV genome in the liver	Assessment of the epigenetic changes within the AAV genome in the liver	single time point (day of biopsy)

Collaborators and Investigators

• Sponsor: University College, London
• Investigators: Principal Investigator: Paul Batty, MBBS MRCP, Royal Free Hospital NHS Foundation Trust

Study record dates

Study Major Dates

• Study Start (Actual): August 5, 2022
• Primary Completion (Estimated): July 1, 2025
• Study Completion (Estimated): July 1, 2025

Study Registration Dates

• First Submitted: February 23, 2021
• First Submitted That Met QC Criteria: March 23, 2021
• First Posted (Actual): March 26, 2021

Study Record Updates

• Last Update Posted (Actual): March 25, 2025
• Last Update Submitted That Met QC Criteria: December 16, 2024
• Last Verified: December 1, 2024

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Genetic Diseases, Inborn; Hematologic Diseases; Blood Coagulation Disorders; Hemorrhagic Disorders; Genetic Diseases, X-Linked; Blood Coagulation Disorders, Inherited; Coagulation Protein Disorders; Hemophilia A; Hemophilia B
• Other Study ID Numbers: 18/0130

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No