AAV vector–based gene therapies face the problem that a substantial fraction of patients are not eligible for this type of therapy because of the presence of antibodies to AAV in their blood, putatively as a result of previous encounters to wild-type AAVs. This is particularly important for therapies based on intravenously applied AAVs and to a lesser extent for gene therapies applied to immune privileged sites (30). Both neutralizing and non-neutralizing antibodies play a role in pre-existing humoral immunity. While NAbs directly prevent vector transduction, non-neutralizing antibodies have the potential for complement activation and consequently increasing capsid immune responses (31). Therefore, in clinical practice both neutralizing and non-neutralizing antibodies should be determined before a possible gene therapy.
Fundamental measures are necessary to apply AAV-based gene therapy successfully despite the presence of anti-AAV antibodies. Thus, the aim of this study was to understand the efficiency and timing of anti-AAV antibody removal by IA with TheraSorb – Ig omni 5 adsorbers.
We found that anti-AAV2 NAb titers were decreased by a mean of approximately two titer steps per treatment day with an increase (rebound) of approx. one titer step over the course of 24 h before the next treatment. Higher rebound rates were observed with longer intervals between treatments which is in line with stronger IgG redistribution. In all seropositive patients, the anti-AAV pre-IA titer was reduced. Anti-AAV2 NAb titers were found to be as high as 1:10,240. Ten out of 22 patients with anti-AAV2 NAbs (all < 1:320) reached a titer below the typical cutoff of AAV gene therapy studies of 1:5 after the Ig omni 5 treatment series. Anti-AAV5 NAbs were reduced to a titer of < 1:5 in four out of five patients. Levels of AAV2 and AAV5 antibodies were decreased below the detection limit in eight out of 14 patients for AAV2 and in 12 out of 15 patients for AAV5, as determined by ELISA. Differences in the proportion of patients who had detectable anti-AAV antibody titers after the last IA treatment are due to differences in pre-IA anti-AAV titers. The magnitude of antibody titer reduction was similar throughout the study, suggesting that there are no quantitative differences in anti-AAV antibody removal between different AAV serotypes. This indicates that IA treatment with TheraSorb – Ig omni 5 is an effective option to reduce AAV antibodies. In addition, the steady decrease of all antibodies even by the fifth IA suggests that continuing the therapy by applying further IA treatments could lead to an even greater reduction of anti-AAV antibodies. This prolonged treatment may further decrease anti-AAV antibodies to lead patients with higher initial titers of ≥ 1:320 to titers below the threshold titer of 1:5 at the end of an IA treatment session. A similar scenario is the application of IA in the context of AB0-incompatible transplantation, where the number of IA treatments is adjusted to the individual antibody titer of the patients (24).
Thus far, the threshold titer, i.e., the presence or lack of neutralizing antibodies to AAV gene therapy vectors, cannot be directly correlated to a clinical outcome, because no AAV gene therapy has been performed after IA. Comparing protocols for neutralizing antibody assays and ELISAs between different groups proved to be difficult due to differences in several parameters such as vector preparations and applied AAV doses or MOI (32). Still the constant decrease of anti-AAV antibody titers throughout an IA treatment period demonstrates the correlation between IA treatment and anti-AAV antibody decrease.
Considering the data showing the titer rebound between IA treatments, it becomes clear that daily IA treatment is significantly more effective in removing antibodies to AAV2 and AAV5 from the circulation than treatment every other day. Accordingly, when planning the treatment, it is of great importance to take into account to what extent and from which body compartment antibodies shall be removed. In autoimmune diseases, a shift of autoantibodies from the tissue (i.e. non-vascular compartments) into the vascular system is intended to support immunosuppressive therapy. Therefore, pause days between the third and fourth as well as fourth and fifth IA are certainly indicated. However, if IA is used to prepare patients for AAV-vector-based gene therapies where a minimal antibody concentration in the circulation (regardless of the antibody concentration in other tissues) is intended, daily IA seems to be an appropriate regime.
Another topic to be considered is the re-occurrence of anti-AAV antibodies within the first few days after AAV gene therapy. From our experience with the preparation of patients for ABO-incompatible living-donor kidney transplantation, we know that the measurement of isoagglutinins is indispensable during the first 14 days after transplantation. In case of an increase of isoagglutinins of 1:8 during these 14 days, further treatment by IA is necessary to avoid an increased risk of antibody-mediated rejection (ABMR) (33). IA treatment after AAV dosing during AAV-based gene therapy could be similarly useful to maintain a low level of anti-AAV antibody. However, if IA is applied too soon after dosing, AAVs could potentially be removed inadvertently while passing through the adsorber where the residual amounts of anti-AAV antibodies from the blood are captured. In this context it would be of great interest to investigate the timing of a potential IA treatment after AAV vector–based gene therapy.
Regarding the effective removal of antibodies by IA, it is also important to note that the application of immunoglobulins or foreign plasma always carries the risk of introducing undesired antibodies, e.g., against AAV. This can lead to a renewed increase in antibodies that need to be removed during therapy, which was the case in one of our treated patients. Therefore giving immunoglobulins or foreign plasma under IA should be avoided. This also prevents application of plasma exchange treatments with high intensity as a potentially simpler alternative to IA. To enable high intensity plasma exchange treatments use of fresh frozen plasma as substitution solution would be required to replenish physiologically important plasma proteins such as coagulation factors, cytokines, and others, but is not possible due to the likely presence of anti-AAV antibodies. Furthermore there even seems to be an increase in proinflammatory cytokines during plasma exchange therapy with fresh frozen plasma, which could indicate an activation of the cellular immunity by fresh frozen plasma (34).
Another interesting plasmapheresis concept was suggested recently by which not all immunoglobulins, but only AAV-specific antibodies, were removed through binding to full capsids coupled to an adsorber matrix (35, 36). While in vitro analyses and studies with passive immunization models look promising, efficacy and safety need to be confirmed in further preclinical and clinical studies.
In addition, as already described, there are other approaches that circumvent pre-existing anti-AAV antibodies to make AAV vector–based gene therapy possible for a larger number of patients. These treatments and IA should not be regarded as mutually exclusive. On the contrary, a combination of these therapy strategies may result in a more efficient anti-AAV antibody removal and thus in a further increase in the number of patients amenable to AAV-based gene therapy compared to the application of a single treatment type. Combination therapies would be most relevant to the treatment of patients with high titers of anti-AAV antibodies.
In summary, our results indicate that IA with TheraSorb – Ig omni 5 adsorbers represents a potentially safe and effective strategy to increase the patient population amenable to AAV-based gene therapy by lowering pre-existing anti-AAV antibodies to threshold levels that are prerequisite for AAV gene therapy application.