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  • Review Article
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Immunological barriers to haematopoietic stem cell gene therapy

Nature Reviews Immunology volume 22, pages 719–733 (2022)Cite this article

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Abstract

Cell and gene therapies using haematopoietic stem cells (HSCs) epitomize the transformative potential of regenerative medicine. Recent clinical successes for gene therapies involving autologous HSC transplantation (HSCT) demonstrate the potential of genetic engineering in this stem cell type for curing disease. With recent advances in CRISPR gene-editing technologies, methodologies for the ex vivo expansion of HSCs and non-genotoxic conditioning protocols, the range of clinical indications for HSC-based gene therapies is expected to significantly expand. However, substantial immunological challenges need to be overcome. These include pre-existing immunity to gene-therapy reagents, immune responses to neoantigens introduced into HSCs by genetic engineering, and unique challenges associated with next-generation and off-the-shelf HSC products. By synthesizing these factors in this Review, we hope to encourage more research to address the immunological issues associated with current and next-generation HSC-based gene therapies to help realize the full potential of this field.

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Fig. 1: Haematopoietic stem cell gene therapy.
Fig. 2: Major landmarks in haematopoietic stem cell transplantation and gene therapy.
Fig. 3: Genetic engineering platforms for haematopoietic stem cell gene therapy.
Fig. 4: Immune barriers in haematopoietic stem cell gene therapy.

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Acknowledgements

C.T.C. is supported by the National Science Foundation (NSF). A.C.W. acknowledges support from the Medical Research Council (MRC) and the Kay Kendall Leukaemia Fund. H.N. is supported by the National Institutes of Health (NIH) (grants R01DK116944; R01HL147124) and the Virginia and D.K. Ludwig Fund for Cancer Research (D.K. Ludwig Fund).

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Author notes

  1. These authors contributed equally: Carsten T. Charlesworth, Ian Hsu.

Authors and Affiliations

  1. Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA, USA

    Carsten T. Charlesworth & Hiromitsu Nakauchi

  2. Department of Genetics, Stanford University School of Medicine, Stanford, CA, USA

    Carsten T. Charlesworth & Hiromitsu Nakauchi

  3. MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK

    Ian Hsu & Adam C. Wilkinson

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Correspondence to Adam C. Wilkinson or Hiromitsu Nakauchi.

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H.N. is a co-founder and shareholder in Megakaryon, Century Therapeutic and Celaid Therapeutics. The other authors declare no competing interests.

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Glossary

Sickle cell disease

A disease caused by a specific point mutation in the haemoglobin-β (HBB) gene, which leads to the formation of haemoglobin tetramers that can polymerize with each other and that cause red blood cells to become highly fragile and adopt a characteristic sickle shape.

Conditioning regimens

Treatments given prior to haematopoietic stem cell transplantation (HSCT) to ablate components of the haematopoietic system in the recipient in order to ensure engraftment of transplanted cells.

Autoimmune haemolytic anaemia

An autoimmune disease whereby patients produce autoantibodies that target red blood cells, causing them to lyse prematurely and thus leading to anaemia.

cGAS–STING pathway

A cytosolic DNA-sensing signalling pathway, in which binding of cGAS to double-stranded DNA (dsDNA) in the cytoplasm leads to the downstream activation of STING and, subsequently, the activation of an inflammatory transcriptional programme in cells.

Adenosine deaminase deficiency–severe combined immunodeficiency

(ADA–SCID). A disease caused by mutations in the adenosine deaminase (ADA) gene. ADA is an essential enzyme in the purine salvage pathway, deficiency of which prevents the maturation of B cells, T cells and natural killer cells.

β-Thalassaemia

A disease caused by mutations in the haemoglobin-β (HBB) gene that prevent functional HBB expression, leading to an inability of red blood cells to form haemoglobin tetramers.

CRISPR–Cas9

A CRISPR–Cas gene-editing platform adapted from bacteria that can be directed to make double-strand breaks at specific sequences of DNA.

Base editors

Gene-editing platforms that allow for the alteration of single nucleotides in the genome without requiring a double-strand break in DNA, through fusion of a catalytically dead DNA endonuclease Cas9 to a deaminase enzyme.

Prime editing

A gene-editing platform that allows for the modification of small sequences (up to ~40 bp) in the genome through fusion of a catalytically dead DNA endonuclease Cas9 to a reverse transcriptase.

Homology directed repair

A DNA repair pathway that corrects double-strand breaks using a homologous DNA sequence. This pathway may be used to change specific sequences in the genome or to introduce transgenes in specific locations in the genome.

Mucopolysaccharidosis type 1

(MPS1). A disease caused by mutations in α-l-iduronidase (IDUA), which lead to a build-up of glycosaminoglycan in lysosomes.

Small interfering RNAs

Small, 20–27 bp, double-stranded RNA molecules that bind endogenous mRNAs, leading to their downregulation through the RNA-induced silencing complex (RISC) pathway.

CRISPR–Cas13

A CRISPR–Cas gene-editing platform adapted from bacteria that can be used to target mRNAs for cleavage, preventing their translation within cells.

Chimeric antigen receptor T cell

(CAR T cell). A T cell that has been genetically modified to express a chimeric receptor that consists of the intracellular portion of the T cell receptor (TCR) fused to an extracellular domain that can bind an antigen of interest, causing the T cell to become activated.

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Charlesworth, C.T., Hsu, I., Wilkinson, A.C. et al. Immunological barriers to haematopoietic stem cell gene therapy. Nat Rev Immunol 22, 719–733 (2022). https://doi.org/10.1038/s41577-022-00698-0

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