Cystinosis

This is a non-randomized, Phase 1/2 clinical trial to study the safety and efficacy of a single dose gene transfer vector AAV9/GLB1 (AAV9-GLB1) by intravenous infusion to subjects with Type I and Type II GM1 gangliosidosis. Type I subjects in this study will be male and female, \>= 6 months old and \<=12 months of age at the time of full ICF signing, with a diagnosis of Type I GM1 gangliosidosis. Type II subjects in this study will be male and female, \> 6 months old and \< 12 years old at the time of full ICF signing, with a diagnosis of Type II GM1 gangliosidosis. The subjects must have biallelic mutations in GLB1, a deficiency of Beta-galactosidase enzyme documented by testing in a CLIA-certified clinical laboratory, and serum AAV9 antibodies titers \<= 1:50). Other inclusion/exclusion criteria apply. In Stage 1, up to 6 Type II subjects will receive 1.5E13 vg/kg of the gene transfer agent, and up to 6 Type II subjects will receive 4.5E13 vg/kg, and up to 6 Type II subjects will recieve 7.5E13 vg/kg of the gene transfer agent. In Stage 1, up to 3 Type I subjects will receive 1.5E13 of the gene transfer agent (Cohort 1) and up to 3 will then receive 4.5E13 of the gene transfer agent (Cohort 2). Dosing will be staggered to ensure subject safety. Following the last Stage 1 subject s 6 months visit, data will be reviewed, and Stage 2 dosing will be determined. Up to 12 Type II and 6 Type I subjects are planned to be treated in Stage 2 of the study. If Stage 2 dosing is to proceed, it will be reflected in a protocol amendment. The primary objective of Stage 1 of the study is to assess the safety of the AAV9-GLB1 vector following intravenous infusion. Stage 1 secondary and exploratory objectives include assessment of gene therapy on disease biomarkers, neurologic development and motor function, brain volume and myelination, and immune tolerance to the gene transfer vector. Stage 2 of the study will assess the safety and efficacy of AAV9-GLB1 vector following intravenous infusion of the dose selected based on data from both Type I and II subjects. Type I and Type II subjects have differing disease progression and symptomatology, justifying distinct endpoints and timepoint measures. GM1 gangliosidosis is an autosomal recessive, neurodegenerative lysosomal storage disorder resulting from mutations in the GLB1 gene, encoding the enzyme Beta-galactosidase (Betagal). Betagal functions by removing terminal galactose moieties from GM1 ganglioside, a glycosphingolipid present in highest quantity in the CNS, primarily found in neurons. Betagal deficiency leads to accumulation of GM1 ganglioside and its asialo derivative (GA1) in the CNS. The age of onset and progression of GM1 gangliosidosis differs depending on the amount of residual Betagal activity, but the disease is generally divided into three clinical forms: Type I (infantile), Type IIa and IIb (late-infantile and juvenile), and Type III (adult or chronic). This clinical trial will treat GM1 Type I and Type II subjects. The Type I form is the most severe, with age of onset less than 12 months of age and death often before age 3. Clinical findings of hypotonia and developmental delay/regression are found in almost all patients. In addition to symptoms resulting from severe CNS degeneration, evidenced by the presence of cherry-red maculae, infants often exhibit peripheral signs, including hepatosplenomegaly, skeletal dysplasia, cardiomyopathy, and coarse facial features. The Type II form of GM1 generally has onset between 3 and 5 years with plateauing, then regression of developmental milestones (juvenile) or onset of symptoms after 12 months but before 24 months, plateauing of milestones then regression (late infantile). Clinical features vary but in addition to CNS manifestations typically include a degree of skeletal involvement and mild hepatosplenomegaly. The primary symptoms are frequent falls, poor coordination, dysarthria and cognitive decline. Disease progression is variable, with subjects surviving well into the third decade (juvenile) or into the late teens (late infantile), but with severe cognitive and physical disabilities. GM1 gangliosidosis is extremely rare, with an incidence estimated at 1:100,000 to 1:200,000. The disease is uniformly fatal with no effective therapy. Care is limited to symptomatic medical management. Intravenous administration of a gene transfer vector to deliver a normal copy of the GLB1 gene to the CNS could potentially provide an effective treatment for GM1 gangliosidosis.

Subject's will have the option of the database, genetic, tissue, and urine section of the study. This study does not require a clinic visit to our center. We will review past, current, and future medical information related to the database participants. Information that we will collect include: clinic notes, lab results, and physician consult reports. Subjects may be asked to sign a release of medical information form to allow the study team access to their medical records. When the information is received, the research study team will enter medical data into the Hepato-Renal Fibrocystic Diseases (HRFD) clinical database. There will be initial data entry and then annual follow up data entries lasting for the duration of this study or until subjects choose to not participate in the study anymore. We will remove subject's name or any other identifiable health information (such as name, address) from received records before entering medical data into the HRFD clinical database. If subjects choose to participate in the optional genetic material testing portion of the study, either the referring site may draw the blood sample (\~5 mL or a teaspoon) or the research team will send a mailer and a blood collection kit. Samples will be collect from the subject, subject's father, and subject's mother. Once the blood samples are collected, the samples will be sent to Children's Hospital of Philadelphia and each sample will be processed to obtain the DNA. These DNA samples will be labeled only with an identifier that is unique to the subject and stored in the BioRepository at CHOP. If blood samples are unobtainable from the subject's parents, saliva samples can be collected as an alternative. In the event of research tissue donation, we will collect tissue (kidney, liver, pancreas, lung, brain, heart, and/or placenta) samples for storage at CHOP Tissue Repository. This tissue repository will be an important source for researchers to access tissue for analysis. Dr. Lisa Guay-Woodford and team will be facilitating the consenting process for collection and storage of tissue as part of her role. For individuals that will be undergoing an autopsy or nephrectomy/hepatectomy, consent will be obtained from the study participants and/or their parents. The Pathology Department at the institution performing the procedures (autopsy or nephrectomy/hepatectomy) will collect tissue according to specified protocol provided by the study coordinator. Upon receipt, the CHOP Repository will process and store the specimens. Children's Hospital of Philadelphia will serve as a research site to store and process blood specimens, and analyze electronic medical records data via REDcap.

Nephropathic Cystinosis (NC) is an orphan inherited autosomal recessive disease characterised as a generalized lysosomal storage disease due to a deficiency of the cystine lysosomal transport protein, cystinosin. Patients with NC usually receive cysteamine. Bone impairment was recently recognized as a late complication of NC, occurring at adolescence or early adulthood. Even though the exact underlying pathophysiology is unclear, at least six hypotheses are discussed, and mainly cysteamine toxicity and/or direct bone effect of the Cystinosin (CTNS) mutation. Because of the potential dramatic impact on quality of life of this novel complication, research should aim to better understand bone disease in NC. The primary objective of this study is to evaluate the action of cysteamine on osteoclastic differentiation and resorption activity of NC patients, depending on the underlying genotype. The Secondary objective is to describe the clinical bone status of NC patients depending on their underlying genotype.

First, a literature review was conducted to identify relevant quality of life topics for the focus interviews. The development of the cystinosis-specific PROM will include three phases with patient recruitment: (1) focus interviews, (2) pilot-test and cognitive debriefing, and (3) field and re-test. 1. Focus interviews with up to 25 parents (of young patients aged 0 to 26) and 15 young patients (ages 8-26) per country (Germany, France, Spain and USA) will discuss aspects relevant to the young patient's quality of life. A pilot instrument version will be developed based on the interviews and then translated into the other project languages according to ISPOR guidelines. 2. The pilot instrument (translated) will be administered to patients and parents along with a cognitive debriefing to assess the comprehensibility, interpretation, and cultural relevance of the items. Up to 200 parents (25-50 per country) and 120 young patients (15-30 per country) will complete the pilot instrument and cognitive debriefing. 3. At least 300 parents (75 per country) and 180 young patients (45 per country) will complete the refined questionnaire as part of a field and re-test. The questionnaire will be filled out again after two weeks by at least 20% of the patients and parents to assess the test-retest reliability. The final product will be a psychometrically validated, easy to use, and conceptually appropriate quality of life instrument available in German, English, Spanish, and French for use in research and patient care.

This study is an open-label, multi-center, phase I/II study to assess the safety, tolerability, and efficacy of DFT383 in participants aged 2 to 5 years with nephropathic cystinosis, followed by a long-term extension phase. The study includes two Treatment Groups (Cohort 1 and Cohort 0) and consists of a Core Phase and a long-term Extension Phase. Participants in Cohort 1 will receive DFT383 and participate in both the Core and Extension Phase. Participants in Cohort 0 will not receive study treatment and will participate in the Core Phase only. The two cohorts will be run in parallel. Investigational sites may participate in one or both cohorts. Cohort 1 Approximately 15 participants will receive treatment with DFT383 in 3 (sub) cohorts (1A, 1B and 1C) dosed in a staggered approach. The total study duration for a participant in Cohort 1 will be up to 32 months in the core phase and up to 13 years for the long-term extension phase. Cohort 0 Approximately 15 participants meeting similar inclusion/exclusion criteria and receiving SoC will be enrolled. The Schedule of Activities will be reduced for this Cohort. This cohort 0 is not a direct control but will provide essential context for interpreting the results observed in the participants receiving DFT383. The total study duration for a participant in Cohort 0 will be up to 24 months.

This is a single center, non-randomized, non-controlled open-label phase 1b/2a trial of performing sequential αβdepleted-HSCT and KT in patients requiring KT to prevent kidney rejection post-KT, in the absence of any post-KT immunosuppression, to abrogate the need for lifelong immunosuppression, the risk of chronic rejection and, ultimately, the need for repeated transplantation.

Cystinosis is a generalized lysosomal storage disease with a reported incidence of about 1:180,000 live births. There are estimated 110-140 cases in France (approximately 500 in Western Europe). The disease is caused by mutations in the CTNS gene coding for cystinosin, a lysosomal carrier protein. The lysosomal cystine accumulation leads to cellular dysfunction in many organs. The first symptoms start at about 6 months of age. In the absence of specific therapy, end stage renal disease occurs between 6 and 12 years of age. Survival beyond this age is associated with the development of extra-renal complications. Renal transplantation and the availability of cystine-depleting medical therapy, cysteamine (EU/1/97/039/001, EU/1/97/039/003), have radically altered the natural history of cystinosis. Cystinosis is a good example of a "paediatric" disease where patients now survive into adolescence and adulthood. These individuals have complex, multisystem problems that require on-going care. Despite some progress in recent years there are still significant limitations in the knowledge of diagnostic and therapeutic procedures. A first European registry was launched in 2011, using the CEMARA application developed by the Banque Nationale de Données Maladies Rares (BNDMR, CNIL authorisation number: 1187326), allowing the collection of data from France, Belgium and Italy. The objective of the current study is to translate this database into a cohort study that will allow and facilitate the collection of a wider range of data including clinical, and personal data such as quality of life data, from an increased number of European countries, improve the monitoring, data-management and analysis of the data, offer the possibility for patients to actively participate to and benefit from the study by developing a module in which patients will enter their own data on quality of life with a direct feed-back on the general results. This project is a unique opportunity for building a consensual European academic cohort not based on company driven, "drug-oriented" objectives. The cohort will collect clinical details to analyse patient outcomes thus providing audit of patient care \& clinical effectiveness. It will be possible, through the cohort, to indicate where improvements need to be made and ultimately improve care to the highest standards.

Background and aims. Population-based newborn screening (NBS) is an important public health program that has vastly improved the course of several diseases through early detection. The selection of screened disorders generally follows the 10 principles outlined by Wilson and Jungner. In Germany, NBS has been a voluntary National Health Service program since 1969 which currently covers 17 disorders. Current NBS methods, which employ tandem mass-spectrometric analysis of newborn dried blood spots, cannot detect many potentially treatable genetic conditions. At the same time, molecular-based NBS is increasingly feasible because DNA can be extracted from a dried blood spot, next generation sequencing has become economical, and molecular diagnostics have greater reliability and increased validity as genetic databases become more refined and comprehensive. Nephropathic cystinosis and hyperoxaluria (PH) are eligible for molecular-based NBS because effective therapies are available. In a first pilot project, the scientific basis for NBS for cystinosis could already be established. The aim of this study is to demonstrate the transferability of genetic NBS for Cystinosis to other laboratories and to lay the scientific basis for screening for PH. Specifically, the study will investigate whether the inclusion of these diseases into general NBS should be recommended. By observing the identified infants in comparison to patients symptomatically diagnosed outside of the pilot project, it will be determined whether and to what extent early diagnosis and therapy lead to a more favorable prognosis. Cystinosis Nephropathic cystinosis, due to impaired transport of cystine out of lysosomes, occurs with an incidence of 1 in 100-200,000 live births. It is characterized by renal Fanconi syndrome in the first year of life and glomerular dysfunction progression to end-stage kidney disease by approximately 10 years of age. Treatment with oral cysteamine therapy helps preserve glomerular function, but affected individuals eventually require kidney replacement therapy Cysteamine treatment generally begins at the time of diagnosis in the second year of life, but some glomerular and tubular damage has already occurred by then. This situation could be ameliorated by diagnosing patients shortly after birth, employing molecular genetics-based newborn screening. Standard mass spectrometry-based methods for newborn screening cannot detect the increased cystine content of cystinosis leukocytes. For cystinosis screening, the first tier involved multiplex PCR to detect two of the three most common CTNS mutations in Germany. Heterozygous samples will be submitted to amplicon-based next-generation sequencing for 175 pathogenic CTNS mutations (Labor Limbach, Mainz). A detection rate of 96.5% is predicted using this approach. Primary Hyperoxaluria Three different defaults in the glyoxylate metabolism lead to PH. The severe type PH1 is the most common variant (1-3 out of 106 patients). Population-based studies estimate a prevalence of 1:58,000. The estimated number of unreported cases is high. The deposit of calcium oxalate crystals in the kidneys triggers a chronic inflammation which results in terminal renal failure. Decreased oxalate excretion in the urine leads to high oxalate concentrations in the plasma and subsequently deposits of calcium oxalate in the organs and tissue (systemic oxalosis). The clinical course is highly variable. Examples of infantile oxalosis with early renal function loss up to a-/oligosymptomatic patients in adulthood are described. Clinically, PH2 is calmer, but about 50% of patients develop end-stage renal failure. PH3 used to be considered a mild variant, but it is known today that PH3 patients can also develop kidney stones in childhood and develop terminal renal failure with a systemic oxalosis. The PH registry of OxalEurope (European hyperoxaluria consortium) currently lists 1137 genetically diagnosed patients, comprising 81.9% with PH1, 9.8% with PH2 and 8.4% with PH3. In the molecular genetic evaluation of the German registry, the results are: 74.1% PH1, 7.9% PH2 and 17% PH3. So far, primary hyperoxaluria has been diagnosed according to clinical findings through urine analysis (or plasma test in case of terminal renal failure). Therefore, the diagnosis is usually made once patients have already developed terminal renal failure. But existing medications (Vitamin B6) or the new RNAi medications (Lumasiran, Nedosiran) can prevent renal failure and are making the disease treatable. The purpose of this pilot project is to identify the most common mutations in the AGXT gene and in the HOGA1 gene. Workflow Study population Hospitals in Germany are free to choose between 11 certified laboratories for NBS. In this project, the Screening-Laboratory Hannover informs its senders about the possibility to extend the routinely established NBS by the genetic screening for cystinosis and PH. The study population includes newborns whose parents wish to participate in the pilot project and have provided written informed consent. Parent information and consent Before screening is performed, the newborn's parents are comprehensively informed about the possibility of screening for the various diseases by the physician responsible for NBS (gynecologist, pediatrician). An additional information and consent sheet for cystinosis and PH screening is inserted into the information brochure already available for regular NBS. Consent must be documented with the signature of at least one parent and the signature of the informing physician on the consent form. The consent form for the pilot project also includes consent for the transfer of contact data and findings to a specialized center in the event of an abnormal screening result. The laboratory must receive the consent form for the project prior to analysis. Results that turn out normal are reported to the responsible submitting physician according to the NBS guidelines for children. The sender must check whether there is a result for each blood sample taken for screening (result return control). In case of a positive result, the laboratory must first inform the sender and clarify whether the child is still hospitalized. In that case, the sender obtains the initial information from the parents and notifies an expert for the respective diagnosis (Cystinosis: Priv.-Doz. Dr. med. K. Hohenfellner, Rosenheim; Hyperoxaluria: Prof. Dr. med. B. Hoppe, Bonn). If the child has already been discharged from hospital, the laboratory will contact the relevant expert directly which is covered by the informed consent. Sampling The molecular genetic screening is performed using the same dried blood spot card as the routine NBS. In general, for all invalid results (i.e., if the control reaction fails) as well as all abnormal results (Cystinosis: homozygous or heterozygous for the 57-kb deletion and /or c.18\_21delGACT, p.T7Ffs\*7 ; PH1, c.508G\>A, PH3, C700+5G\>T, homozygous and/or heterozygous) the test will be internally repeated for confirmation using the existing blood sample. Measurements and methods A real-time quadruplex PCR is performed for the four mutations described above. Cystinosis: Detection is carried out by detection of the binding or by melting analysis of fluorescence-labeled probes. In samples with a positive result due to heterozygosity mutations, the exons of the cystinosin gene (CTNS) are sequenced using next generation sequencing (NBS) in an amplicon-based method. This ensures that only the desired exons and no other DNA areas are examined. DNA already extracted for real-time multiplex PCR can be used for NBS. With NEBNext Direct Genotyping Solution all analyzable areas of CTNS gene are covered (partial overlapping), which preserve a completely sequence information of all exons and specific introns. Therefore, the DNA will be enzymatically fragmented and then ligated with illuminable adaptors. The adaptors contain individual indices. Afterwards the biotin beads will be used for the target enrichment. They will be augmented with streptavidin beads. Afterwards off-target sequences will be removed, and the libraries will be amplified by PCR. The actual sequencing is carried out using a device from Illumina (MiniSeq). The sequences are evaluated using a software that performs an automatic comparison with a reference sequence, thereby detecting mutations. PH: The detection will be done through heat analysis with fluorescent tagged leads. In case of positive results (also due to heterozygotic constellations) a clarification is planned in collaboration with the German hyperoxaluria center. Therefore, spot urine will be tested for oxalate and further parameters in the glyoxylate metabolism. Examination results Cystinosis: If the most frequent mutations of CTNS are detected as homozygous or compound heterozygous mutations, the cystinosis screening is considered positive. Using next-generation sequencing, an additional 175 mutations recorded in the literature will be detected. In all other cases, even those involving heterozygous status, cystinosis screening is normal. PH: The hyperoxaluria screening is positive, if PH1 (AGXT-Gen:c508G\>A) and/or PH3 (HOGA-gene: c.700+5G\>T) is homozygote detected. In heterozygote genetic carrier with positive screening, a subsequent urine test performed in the Wisplinghoff laboratory in Cologne (Köln) will clarify the finding. Detection rate, false positive and false negative results An overall detection rate of above 95% is assumed for both diseases. False negative screening results are unlikely. For cystinosis, false negative results due to previously unknown rare mutations or patients carrying neither of the two most frequent mutations are possible. False positive screening results are also very unlikely. With cystinosis, a heterozygous sample due to "allelic dropout" (PCR failure of an allele due to mutations in the primer binding region) may incorrectly appear homozygous. In PH, the disease is not excluded in case of heterozygous mutation, further diagnostics is necessary and planned. In case of corresponding symptoms, cystinosis or PH must be included in the differential diagnosis, which usually takes place in one of the few treatment centers. Such cases can only be documented in the course of time via feedback of the attending centers can be documented. Confirmation of the diagnosis Cystinosis: In patients with either a homozygous or compound heterozygous mutation in the CTNS-gene, the diagnosis will be confirmed by determining the intraleukocytic cystine level from 2,3 ml EDTA blood. This sample will be sent to the metabolic laboratory in Heidelberg within the first 14 days of life. PH: In homozygous carriers of the mutations in the PH1 or PH3 genes, a control examination of spot urine or of plasma will follow, which will be carried out in the German hyperoxaluria Centre. The results of the verification tests will be transferred to the screening laboratory for quality control. Caring for affected children Cystinosis: Children with positive cystinosis screening results and their parents are referred to the nearest center for metabolic diseases. Therapy with cysteamine can be started immediately after confirmation of the diagnosis. Parents are informed about the possibility of an interdisciplinary cystinosis consultation in Rosenheim. PH: Children with a positive screening result will be primarily referred to the German hyperoxaluria center in Bonn. Further treatment of these patients is performed at the nearest hospital of their choice. Project size For financial reasons, the project is limited to 200,000 samples, with the possibility of expansion.

Background Rare diseases are arbitrarily defined as having an incidence such that they cannot be studied effectively on patient groups drawn from one or a few medical centres. A high proportion of such disorders have a genetic background and often these diseases are first expressed in childhood. The success of chronic and end-stage renal failure programmes in childhood permit increased numbers of these patients to survive into adulthood. There are 13 centres for paediatric nephrology in the UK. For a rare disorder that a paediatric nephrologist might diagnosis only once a year, and assuming 100% survival to adulthood, a renal physician might be asked to take over such a case only once in seven or eight years of practice. Research is hampered by this dilution of clinical experience. Similarly in adult practice there are rare complications of diseases or their treatment so that a nephrologist might encounter such an event less often than once in every 5 years. National aggregation of clinical experience is essential to further study. Research groups investigating a rare disease (Rare Disease Groups, RDGs) have difficulty accessing patients who are widely distributed. While rare disease groups are often successful in identifying novel genotypes in a few individuals, it is more difficult to define phenotype and undertake phenotype-genotype correlations. Moreover, the scarcity of patients makes it difficult to develop biomarkers or identify well-defined cohorts in which to test novel treatments. As a result, the progression and outcome for many rare diseases are unknown and treatment remains underdeveloped. Purpose The purpose of the National Registry of Rare Kidney Diseases (RaDaR; rare disease registry) is to facilitate translational and epidemiological research into rare kidney diseases by setting up and maintaining a comprehensive clinical database in partnership with Rare Disease Groups. RaDaR facilitates the identification of well-characterized cohorts of patients who may be invited to participate in clinical trials, the development of biomarkers, phenotype-genotype correlations or outcome studies. This will inform the development of clinical guidelines for specific rare diseases, audit treatment and outcome and further the development of future therapies. RaDaR provides an infrastructure to capture both generic and disease-specific clinical information and to collate longitudinal information. Patients and clinicians can view information about the conditions covered by RaDaR on RareRenal.org, which links closely with RaDaR. RaDaR is predominately aimed at UK patients; however international recruits who are consented in the UK by an NHS hospital are also eligible, subject to local approval.

This study will examine the safety, pharmacokinetics, and pharmacodynamics of NPI-001 oral solution in cystinosis patients, aged ≥ 10 years. The ability of NPI-001 to reduce cystine will be assessed and compared with cysteamine.