Advanced age is described to be the main risk for neurodegenerative diseases. Age-related macular degeneration (AMD), a polygenic disease leading to severe vision loss in patients older than 60 years of age, belongs to the four most common causes of blindness and vision impairment1 and is expected to increase to 288 million people in 20402. Dysfunctions of the retinal pigment epithelium (RPE), a single layer of tightly packed cells located between the choriocapillaris and the retinal photoreceptors, contribute to the pathogenesis of AMD. The RPE fulfills multiple tasks that are essential for a normal retinal function3 and secretes a variety of growth factors and factors essential to maintain the structural integrity of the retina and the choriocapillaris, thereby supporting photoreceptor survival and providing a basis for the circulation and the supply of nutrients.
In healthy eyes, pigment epithelium-derived factor (PEDF) is responsible for balancing the effects of vascular endothelial growth factor (VEGF) and protects neurons against apoptosis, prevents endothelial cell proliferation, and stabilizes the capillary endothelium. A shifted VEGF-to-PEDF ratio is related to ocular neovascularization, which was observed in animal models4,5 as well as in samples of patients with choroidal neovascularization (CNV) due to AMD and proliferative diabetic retinopathy6,7,8,9,10. The enhanced VEGF concentration is the target for the current standard treatment. The anti-VEGF pharmaceuticals bevacizumab, ranibizumab, aflibercept and, most recently, brolucizumab improve visual acuity in about one third of CNV patients or rather stabilize vision in 90% of cases11,12,13. However, the frequent, often monthly, intravitreal injections bear the risk of adverse events14, impair patient compliance, and represent a significant economic burden to healthcare systems15. Moreover, a certain percentage of patients (2%-20%) do not respond or only poorly react to the anti-VEGF therapy16,17,18,19. These negative concomitants necessitate the development of alternative treatments, e.g., intraocular implants, cell and/or gene therapeutic approaches.
Gene therapy has evolved as promising treatment for hereditary and non-hereditary diseases and intends to restore non-functional gene sequences or suppress malfunctioned ones. For polygenic diseases, where identification and replacement of the causative factors is hardly possible, strategies aim for the continuous delivery of a protective factor. In the case of AMD, various additive therapies have been developed, such as the stable expression of endostatin and angiostatin20, the VEGF antagonist soluble fms-like tyrosine kinase-1 (sFLT-1)21,22, the complement regulatory protein cluster of differentiation 59 (CD59)23 or PEDF24,25. The eye, and especially the retina, is an excellent target for a gene-based medication due to the enclosed structure, good accessibility, small size, and immune privilege, thus allowing for a localized delivery of low therapeutic doses and making transplants less susceptible to rejection. Moreover, the eye enables non-invasive monitoring, and the retina can be examined by different imaging techniques.
Viral vectors are, because of their high transduction efficiency, the main vehicle to deliver therapeutic genes into target cells. However, depending on the viral vector used, different adverse reactions have been described, such as immune and inflammatory responses26, mutagenic and oncogenic effects27,28, or dissemination in other tissues29. Practical limitations include a restricted packaging size30 as well as difficulties and costs associated with the production of clinical grade lots31,32. These drawbacks have promoted the further development of non-viral, plasmid-based vectors that are transferred via lipo-/polyplexes, ultrasound or electroporation. However, genomic integration of the transgene into the host genome is usually not promoted with plasmid vectors, thus resulting in a transient expression.
Transposons are naturally occurring DNA fragments that change their position within the genome, a characteristic that has been adopted for gene therapy. Due to an active integration mechanism, transposon-based vector systems allow for a continuous and constant expression of the inserted transgene. The Sleeping Beauty (SB) transposon, reconstituted from an ancient Tc1/mariner-type transposon found in fish33 and further improved by molecular evolution resulting in the hyperactive variant SB100X34, enabled efficient transposition in various primary cells and was used for the phenotypic correction in different disease models35. At present, 13 clinical trials have been initiated using the SB transposon system. The SB100X transposon system consists of two components: the transposon, which comprises the gene of interest flanked by terminal inverted repeats (TIRs), and the transposase, which mobilizes the transposon. Following plasmid DNA delivery to the cells, the transposase binds the TIRs and catalyzes the excision and integration of the transposon into the cell's genome.
We have developed a non-viral cell-based additive therapy for the treatment of neovascular AMD. The approach comprises the electroporation-based insertion of the PEDF gene into primary pigment epithelial (PE) cells by means of the SB100X transposon system36,37,38. The genetic information of the transposase and PEDF are provided on separate plasmids, thereby enabling the adjustment of the ideal SB100X-to-PEDF transposon ratio. Electroporation is performed using a pipette-based capillary transfection system that is characterized by a maximized gap size between the electrodes while minimizing their surface area. The device was shown to achieve excellent transfection rates in a wide range of mammalian cells39,40,41. The small electrode surface area provides a uniform electric field and reduces the various side effects of electrolysis42.
The anti-angiogenic functionality of PEDF secreted by transfected pigment epithelial cells was shown in various in vitro experiments analyzing the sprouting, migration, and apoptosis of human umbilical vein endothelial cells43. In addition, transplantation of PEDF-transfected cells in a rabbit model of corneal neovascularization44 as well as a rat model of CNV43,45,46 showed decline of neovascularization.
Here, we describe a detailed protocol for the stable insertion of the PEDF gene into primary human RPE cells via the SB100X transposon system using a capillary transfection system. The transfected cells were kept in culture for 21 days and subsequently analyzed in terms of PEDF gene expression by quantitative polymerase chain reaction (qPCR) and in terms of PEDF protein secretion by immunoblotting and enzyme-linked immunosorbent assay (ELISA, Figure 1).