Mesoangioblast delivery of miniagrin ameliorates murine model of merosin-deficient congenital muscular dystrophy type 1A
- Teuta Domi†1,
- Emanuela Porrello†1,
- Daniele Velardo†1,
- Alessia Capotondo2,
- Alessandra Biffi2,
- Rossana Tonlorenzi1,
- Stefano Amadio1,
- Alessandro Ambrosi3,
- Yuko Miyagoe-Suzuki4,
- Shin’ichi Takeda4,
- Markus A. Ruegg5 and
- Stefano Carlo Previtali1Email author
© Domi et al. 2015
Received: 11 February 2015
Accepted: 6 August 2015
Published: 3 September 2015
Merosin-deficient congenital muscular dystrophy type-1A (MDC1A) is characterized by progressive muscular dystrophy and dysmyelinating neuropathy caused by mutations of the α2 chain of laminin-211, the predominant laminin isoform of muscles and nerves. MDC1A has no available treatment so far, although preclinical studies showed amelioration of the disease by the overexpression of miniagrin (MAG). MAG reconnects orphan laminin-211 receptors to other laminin isoforms available in the extracellular matrix of MDC1A mice.
Mesoangioblasts (MABs) are vessel-associated progenitors that can form the skeletal muscle and have been shown to restore defective protein levels and motor skills in animal models of muscular dystrophies. As gene therapy in humans still presents challenging technical issues and limitations, we engineered MABs to overexpress MAG to treat MDC1A mouse models, thus combining cell to gene therapy.
MABs synthesize and secrete only negligible amount of laminin-211 either in vitro or in vivo. MABs engineered to deliver MAG and injected in muscles of MDC1A mice showed amelioration of muscle histology, increased expression of laminin receptors in muscle, and attenuated deterioration of motor performances. MABs did not enter the peripheral nerves, thus did not affect the associated peripheral neuropathy.
Our study demonstrates the potential efficacy of combining cell with gene therapy to treat MDC1A.
Merosin-deficient congenital muscular dystrophy type 1A (MDC1A; OMIM #607855) is a severe and progressive muscle-wasting neuromuscular disease that frequently leads to death in early childhood. The disease is inherited as autosomal recessive and is characterized by muscular dystrophy, dysmyelinating neuropathy, and minor brain abnormalities [1, 2]. MDC1A is caused by mutations in the LAMA2 gene, which encodes the α2 chain of laminin-211 (or merosin), the major component of the basement membrane of muscles and peripheral nerves . Mutations result in loss of interaction with laminin-211 receptors expressed by striated muscle and Schwann cells, primarily integrin α7β1, α6β1, and dystroglycan [4–6], thus leading to progressive tissue degeneration and ultimately to muscular dystrophy and neuropathy [7–13]. Several mouse models for MDC1A are available: the spontaneous mutant dy2J/dy2J (abbreviated as dy2J, this point on) resulting in a truncated protein, which displays a mild phenotype [14–16]; the complete null mutant dy3K/dy3K (abbreviated as dy3K, this point on), which has a severe phenotype , and the dyW/dyW mutant, a mouse that still synthesizes a very small amount of truncated laminin α2 chain .
There is currently no therapy to treat MDC1A. However, in the last years, promising therapeutic attempts have been carried out using mouse models. Recent evidence showed that overexpression of a miniaturized form of agrin, miniagrin (MAG), which binds to dystroglycan but not integrin α7β1, ameliorates the disease in MDC1A mouse models [19–21]. In fact, MAG acts as a linker between dystroglycan and other laminin isoforms (laminin-411 and -511), which are overexpressed in MDC1A but cannot bind efficiently to dystroglycan [3, 19, 22, 23]. Along with transgenic overexpression of MAG, engineered adeno-associated viral (AAV) vector to systemically deliver MAG showed similar efficacy to ameliorate muscular dystrophy in MDC1A mouse model . However, although these data point the way to a promising new therapeutic approach for MDC1A, direct gene therapy in humans still presents challenging technical issues and limitations in terms of safety and efficacy [25, 26].
Cell therapy has been considered a suitable and more feasible approach for treatment of human neuromuscular disorders, either when it has been used for tissue replacement [27, 28] or as a carrier vehicle to deliver protein of interest [29, 30]. Mesoangioblasts (MABs) are vessel-associated progenitors , which can be isolated from mesodermal tissues and expanded in vitro. MABs repopulate the skeletal muscles when injected into the blood stream or directly into the muscles. MABs have been shown to restore to a significant extent muscle structure and function in animal models of muscular dystrophy [32–36], and based on this preclinical evidence on safety and efficacy, a clinical trial with allogenic MABs transplanted in patients with Duchenne muscular dystrophy has been performed at the San Raffaele Scientific Institute in Milan (EudraCT no. 2011-000176-33).
Here, we show that by combining MAB cell therapy with MAG delivery, we ameliorated the phenotype of MDC1A mouse models. MABs were engineered to produce mouse MAG (mMAG) and were delivered into adult dy2J mice. Treated mice showed diffuse expression of mMAG at the sarcolemma surface and increased expression of laminin-211 receptors. Significant amelioration of muscle histology and reduced deterioration of motor performances were observed, whereas no effects on peripheral neuropathy were noted. This is one of the first cell therapy approaches to MDC1A, and our findings suggest a novel feasible strategy to treat MDC1A with realistically fast translation into clinical practice.
All the experiments received ethical approval and were performed in agreement with the Ospedale San Raffaele Institutional Animal Care and Use Committee (IACUC authorization #487 and #664). The dy2J/dy2J (C57BL/6J background) and NOD SCID (NOD.CB17-PrkdcSCID/J or SCID; NOD/ShiLtSz background) mice were purchased from Jackson Laboratories (Bar Harbor, USA). The dy3K/dy3K (C57BL/6J background) mice were previously described . Both dy2J/dy2J and dy3K/dy3K mice were maintained in the C57BL/6J background; double dy2J/dy2J//NOD SCID mice (abbreviated as SCIDdy2J, this point on) were in mixed background at F2/F3 generation. For routine genotyping, we isolated genomic DNA from tail biopsies, using DirectPCR solution (Viagen), according to the manufacturer’s directions. Primer sequences are available upon request.
Clone D16 and C57 of mouse MABs were previously described [34, 37]. MABs and MABs carrying miniagrin (MABs + mMAG) were maintained in culture in Dulbecco’s modified Eagle’s medium (DMEM, high glucose; Invitrogen) supplemented with 20 % of heat-inactivated fetal bovine serum (FBS; EuroClone), 2 mM glutamine, 1 mM sodium pyruvate, 100 IU ml−1 penicillin, and 100 μg ml−1 streptomycin (Invitrogen) in 5 % CO2 humidified atmosphere. Myogenic differentiation of MABs was induced by plating 75 × 103 cells onto 0.1 % poly-l-lysine hydrobromide, collagen (1 mg/ml)-coated dishes (Sigma). Differentiation medium consisted of DMEM supplemented with 2 % horse serum (Sigma), 2 mM glutamine, 1 mM sodium pyruvate, 100 U ml−1 penicillin, and 100 μg ml−1 streptomycin (Invitrogen). Cultures were incubated at 37 °C, 5 % CO2 for different periods (5–10 days) and then processed for immunofluorescence analysis. Human MABs were obtained from healthy donors as described in .
Mesoangioblast treatment with 5-azacytidine and trichostatin A
Inhibition of DNA methyl-transferase and/or histone deacetylase was performed in proliferating or differentiated murine MABs. For proliferation conditions, MABs were plated in proliferation medium (DMEM supplemented with 15 % fetal bovine serum (Invitrogen) at 1.2 × 103 cells/cm2 density on 6-well multiwells. 5-Aza-2′deoxycytidine (AZA) was added to 1 uM final concentration every 24 h for 3 days. Trichostatin A (TSA) was added to 1 uM final concentration on day 3, 12–15 h before collecting cells for analysis. For differentiation conditions, MABs were plated in proliferation medium at 1.2 × 103 cells/cm2 density on collagen (1 mg/ml) coated 6-wells multiwells (dilution 1:100). AZA was added to 1 uM final concentration every 24 h for 5–7 days, shifting to differentiation medium (DMEM supplemented with 2 % horse serum; Invitrogen) on day 3. TSA was added to 1 uM final concentration on days 5–7 (differentiation of cells should be achieved), 12–15 h before collecting cells for analysis.
Total RNA was isolated from murine-differentiated MABs using TriPure Isolation Reagent (Roche) according to the manufacturer’s instructions. In brief, cells were homogenized in the presence of TriPure Isolation Reagent, and total RNA was extracted with chloroform and precipitated with isopropanol. Two micrograms of total RNA was reverse transcribed using a High-Capacity cDNA Reverse Transcription kit (Applied Biosystems). Quantitative RT-PCR analyses were performed on a 7900HT Real-Time PCR System using the 2× TaqMan PCR Mastermix (Applied Biosystems) according to manufacturer’s recommendations. The primers used were TaqMan Gene Expression Assays ID: Mm01203489_g1 for MyoD1, Mm00446195_g1 for MyoG, and Mm99999915_g1 for Gapdh. Levels of gene expression were determined with the comparative cycle threshold (ΔΔCt) method. The mRNA level of Myod1 and MyoG gene was normalized to the level of Gapdh mRNA.
Each time point is the mean of three experiments.
Thirty dy2J mice were immunosuppressed using daily injection of tacrolimus (FK506 at 2.5 mg/kg; Astellas), started 3 days before the first cell injection (42 days of age). We then injected saline, MABs, or MABs + mMAG (ten mice per group, see scheme in Fig. 5a) into the tibialis anterior, gastrocnemius, and quadriceps muscles of dy2J mice, starting at 45 days of age. Only before this first cell (or saline) injection, all the dy2J mice were treated (intramuscular injection) with 20 μg of cardiotoxin (CTX from Naja mossambica mossambica; Sigma; 0.5 μg/μl, 40 μl vol. per muscle), injected 24 h before MAB/saline. Prior to any procedure, mice were anesthetized by intraperitoneal injection of avertin (2,2,2-tribromoethanol, Sigma-Aldrich) in 0.9 % saline solution. Intramuscular delivery was performed by the injection of approximately 1 × 106 MABs or MABs + mMAG using a 30-gauge needle. Control mice (dy2J not treated) were injected only with saline solution. All dy2J mice received saline, MABs, or MABs + mMAG (same dosage) at 55, 65, and 75 days of age (Fig. 5a) and were analyzed for treadmill and histology at 85 days of age. Dy3K mice were treated as described above at 18 days of age and analyzed 7 days after MAB injection.
Histology and immunohistochemistry
Muscle samples were rapidly frozen in liquid nitrogen cooled isopentane (Sigma). Muscle histology and hematoxylin and eosin (H&E; Bio-Optica) staining was performed according to standard laboratory protocol. Immunofluorescence was performed as previously described  and examined with confocal (Leica SP5, Leica Microsystems) and fluorescence (Olympus BX51) microscopes. For cell cultures, cells were grown on onto 0.1 % poly-l-lysine hydrobromide-coated glass coverslips, washed with PBS, and fixed with 4 % paraformaldehyde at room temperature for 10 min. After the incubation with the primary antibody, cells or tissue sections were washed in PBS, incubated with appropriate FITC- or TRITC-conjugated anti-rabbit, anti-rat or anti-mouse antibody for 30 min at RT, washed in PBS, and then mounted on glass slides with Vectashield Mounting Medium (Vector Laboratories).
Sirius Red staining for collagen deposition was performed as follows: muscle cryosections were treated overnight with Bouin solution (picric acid, formaldehyde, and 5 % acetic acid), washed and then incubated for 1 h in 1 % direct red solution and picric acid; washed in 2 % acetic acid and then in 1:1 solution ethanol/picric acid, dehydrated, cleared in xylene, and coverslipped with mounting medium.
For quantification, digitalized images were collected using light Olympus (BX51) microscope and digital camera (DFC300F Leica Microsystems). Muscle fiber size distribution and number of centrally located nuclei was determined on H&E-stained tibialis anterior muscle cross-sections by means of the QWin software (Leica Microsystems) as described . At least four random images (×10 objective), representing the dystrophic areas of histologic mid-belly muscle sections from five different mice per genotype were analyzed, corresponding to a minimum of 5000 muscle fibers per mouse. Quantification of muscle fibrosis was performed by using ImageJ software (NIH) on Sirius Red-stained cryosections, four random images (×10 objective) representing the dystrophic areas of histologic mid-belly muscle sections from five different mice per genotype. Sirius Red-stained area was calculated as a percentage of total muscle area analyzed.
Peripheral nerve semithin sections were performed as described , stained with toluidine blue, and examined by light (Olympus BX51) and electron (CEM 902; Carl Zeiss) microscopy.
Cells were homogenized in protein extraction buffer (50 mM Tris-HCl, pH 7.4, 150 mM NaCl, 5 mM EDTA, 1 % triton supplemented with proteases inhibitors). Protein concentrations were determined by Bradford protein assay (Bio-Rad). Twenty micrograms of proteins were loaded and separated on a 10 % SDS-PAGE and immunoblotted for the detection of mMAB protein, except for the detection of laminin α2 in the experiments with trichostatin and AZA, in which we loaded 150 μg of proteins per lane to be able to detect a minimal amount of laminin α2. Muscles were powdered in liquid nitrogen using a mortar and a pestle. Protein extraction was completed in ice-cold lysis buffer containing: 75 mM Tris-HCl pH 6.8, 1 % SDS supplemented with proteases inhibitors (Complete, Roche), and when needed, phosphatase inhibitors (PhosSTOP, Roche). Then, the samples were sonicated and centrifuged for 5 min at 13,000 rpm. Supernatants were collected and protein concentrations were quantified using the BCA protein assay (Pierce). Twenty micrograms of proteins of total homogenates were loaded and separated on 8–12 % SDS poliacrylamide gels at 80 V for 3 h. Proteins were then transferred to nitrocellulose membranes (Bio-Rad) at 35 V O/N at 4 °C, and membranes were stained with Ponceau (Sigma) to ensure equal protein loading. Membranes were saturated with 5 % milk in 0.1 % Tween-20 (Sigma) PBS for 1 h at RT and hybridized for 2 h at RT with the following primary antibody. Detection was carried out by incubation with horseradish peroxidase-conjugated anti-rabbit or anti-mouse IgG (Santa Cruz Biotechnology) for 1 h at RT. The proteins were visualized by ECL immunoblotting detection system (Amersham). Densitometric analyses were performed by using the Scion Image software. Averages of densitometric measurements of independent experiments, normalized by the endogenous β-actin or β-tubulin values, were compared by Student's t test. The results shown in the figures are representative of three separate experiments. Data are expressed as means ± SEM.
Antibodies used for immunohistochemistry and/or Western blot analysis included (p = polyclonal, m = monoclonal, Ch = chicken, Ms = mouse, Rb = rabbit, Gt = goat, Rt = rat): α-actin (mMs Sigma); calnexin (pRb; Sigma C4731); β-dystroglycan (mMs, 8D5, Novocastra); α-dystroglycan (mMs, nIIH6C4, Millipore) and α-dystroglycan (mMs, VIA4-1, Millipore); integrin α5 (pRb, AB1949, Millipore); integrin a6 (mRt, GoH3 from A. Sonnenberg); integrin α7 (pRb, from Dr. U. Mayer); β1 integrin (pRb; Millipore); laminin α1 (mRt, AL-1, Millipore); laminin α2 (mMs; Alexis 4H8-2) and laminin α2 (mMs; 1:200, gift from H. Hori); laminin α4 (pRb, H-194, Santa Cruz); laminin α5 (pRb, 405, from Dr. Sorokin); laminin γ1 (mRt, MAB1914, Millipore); laminin HSA (pRb, L9393, Sigma); myc tag (mMs; Cell Signaling); myosin heavy chain (mMs, Hybridoma Bank); neurofilament M (pCh; 1:1000, Covance PKC-593P); and β-tubulin (mMs; TUB2.1, Sigma).
Terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) assay was performed as described , using the fluorometric TUNEL System G3250 Kit (Promega). Briefly, cryosections (10 μm thick) of quadriceps muscles were fixed in 4 % paraformaldehyde, permeabilized in 0.1 % triton, treated with DNase solution, and finally DNA strand breaks labeled with fluorescein-12-dUTP by deoxynucleotidyl transferase (TdT)-reaction mix for 60 min before the stop reaction. Nuclei were identified by DAPI and muscle fibers by anti-total-laminin antibody. For quantification, TUNEL/DAPI double positive nuclei associated with single muscle fiber were counted and expressed as the percentage of total number of positive fibers; we counted at least 1600 fibers per mouse, three mice per genotype.
Cell transfection with lentiviral vectors
Lentiviral production and transfection was performed as previously described . Briefly, 3.2 kb of mMAG construct (including a myc tag) was sequenced and subcloned downstream of the uni-directional hPGK promoter of the pCCLSIN.PPT.hPGK.wPRE lentiviral vector (LV). Concentrated mMAG LV stocks pseudotyped with the VSV.G envelope were produced by transient co-transfection of four plasmids in 293T cells and titreted on HeLa cells. MABs were transduced at multiplicity of infection (MOI) of 100 with mMAG LV or control vector. Ten days after transduction, MABs were collected and proteins secreted in cell culture medium were precipitated to evaluate the expression of mMAG. The presence of mMAG was tested by Western blot using anti-myc tag antibody.
Functional muscle activity was measured by using the exhaustion treadmill to assess resistance to fatigue. For the pretreatment exercise test, 30 45-day-old dy2J mice were tested for functional performance with the treadmill test (Columbus Instruments, Columbus, OH, USA). MAB-treated and not-treated mice were retested for functional recovery at 85 days (Fig. 5a). For the exercise test, mice were put into treadmill at 3 m/min, then the speed was increased 1 m/min every 2 min until exhaustion. Final value is the mean (±SEM) of three different exercises per mouse. Mice were adapted to the procedure (10 min every other day; 3 m/min) for 1 week before beginning the exercise training protocol. The examiner was blind as respect to the scheme of treatment. Deterioration was expressed in percentage and measured as: B-A/A × 100; B = average time on treadmill post-treatment, A = average time on treadmill before treatment.
Neurophysiology was performed as described . The dy2J mice were analyzed before (45 days of age) and after (85 days of age) MAB treatment (see scheme in Fig. 5a). Mice were anesthetized with tribromoethanole (Avertine; Sigma) and placed under a heating lamp to avoid hypothermia. Sciatic nerve conduction velocities (NCV) were obtained by stimulating the nerve with steel monopolar needle electrodes. A pair of stimulating electrodes was inserted subcutaneously near the nerve at the ankle, and then they were moved to the sciatic notch to obtain two distinct sites of stimulation, proximal and distal along the nerve, in order to obtain the measurement of NCV between them. The muscular response to the electrical nerve stimulation (compound motor action potentials (cMAP)) was recorded with a pair of needle electrodes; the active electrode was inserted in muscles in the middle of the paw, while the reference was placed in the skin between the first and second digit. The cMAP peak-to-peak amplitude was considered for analysis. The examiner was blind as respect to the scheme of treatment.
Values were expressed as means ± SEM. Significance of the differences was assessed between means by two-tailed unpaired Student’s t test or ANOVA with Tukey’s post hoc test (GraphPad Prism software version 5). We investigated the differences between the distributions by means of the Mann-Whitney test and verified for stochastic dominance. To take into account of test multiplicity, p values were adjusted for false discovery rate . A probability of less than 5 % (p < 0.05) was considered to be statistically significant.
Mesoangioblasts do not express laminin-211 but laminin-411 and laminin-511
Finally, we tested whether impaired synthesis of laminin α2 was restricted to mouse MABs. Human MABs were derived from two healthy individuals and expanded in culture. Again, Western blot analysis revealed only minimal (if any) laminin α2 in human MABs (Fig. 3e).
Overall results show that MABs do not synthesize (or they do in minimal amount) laminin-211, suggesting that they may not be sufficient to rescue MDC1A disease.
Engineered mesoangioblasts can synthesize and secrete miniagrin in muscles of MDC1A mice
We then evaluated if MABs + mMAG (clone C57) can synthesize and deliver mMAG in the skeletal muscles and peripheral nerves when injected into MDC1A mouse model. To avoid cell rejection, as the MAB C57 clone was allogeneic to mouse mutants, we treated all mice with tacrolimus (FK506), 25 mg/kg/day, starting 3 days before the first cell injection. One million cells (MABs + mMAG, carrying myc tag) were injected intramuscularly into the tibialis anterior and gastrocnemius muscle of three 45-day-old dy2J mice (carrying laminin a2 mutation) and three 18-day-old dy3K mice (completely devoid of laminin α2). Mice were euthanized 10 days after MABs injection, and muscles were stained with anti-myc and anti-laminin antibodies. In both strains (dy2J and dy3K), we observed diffuse myc staining around muscle fibers (identified by anti-laminin γ1) in the area of injection (Fig. 4b and data not shown). In many cases, myc-positive fibers showed centrally located nuclei or were NCAM positive, suggesting that they were regenerating fibers (Fig. 4b (c) and not shown). The myc-positive staining was limited to the area of injection, in fact, the rest of the muscle appeared myc-negative (Fig. 4c), and we did not observe myc-positive staining in other muscles within the same leg or in the contralateral leg (data not shown). Interestingly, although we observed myc staining in the injected muscles of dy3K mice, indicating that MABs are present and can synthesize and secrete myc-tagged miniagrin, we did not observe any staining for laminin α2 (Fig. 4d), suggesting that even in vivo MABs cannot synthesize and secrete laminin-211.
Finally, we observed that sciatic nerve branches showed intense myc-positive staining only in the perineurium or around large perineurial blood vessels, whereas only rare myc-positive staining was detected in the endoneurium, suggesting that MABs or delivered miniagrin do not enter the peripheral nerves (Fig. 4e).
Overall, these results show that MABs can deliver miniagrin in vivo, which localizes around muscle fibers in strict correlation with laminins and laminin receptors.
dy2J Mice treated with MABs + mMAG show better motor performances and ameliorated muscle histology.
We then evaluated whether i.m. injection of MABs and miniagrin delivery may ameliorate muscle histology and motor performances of MDC1A mutants. As this would represent a proof of principle study, and due to lifespan limitation of the dy3K model, we decided to use adult dy2J mice and to inject only few large muscles of the posterior limbs.
We then analyzed muscle histology. Fibrosis is a typical feature of dystrophic mice. We evaluated fibrosis by comparing mice in the three groups. Endomysial connective tissue, identified by Sirius Red staining, was measured and expressed as percentage of the evaluated muscle area. We observed a significant decrease of the fibrotic area in dy2J mice treated with MABs + mMAG as compared to dy2J-untreated mice (Fig. 5c; ANOVA 2 tails p = 0.005, n = 5 mice) or mice treated only with MABs (ANOVA 2 tails p = 0.0004; n = 5 mice).
Mice treated with MABs + mMAG also showed amelioration of muscle histology. In fact, dy2J treated with MABs + mMAG (group 2) showed myofibers with larger diameter as compared to dy2J mice (group 1, treated with saline) and those treated with MABs alone (group 3). We observed in the tibialis anterior muscle a significant shift to the right of the histogram when fibers were plotted against diameters (Fig. 5d), as estimated by comparing differences between data distribution (test for stochastic dominance: p < 0.001); similar significant difference was also present between mice treated with MABs + mMAG as compared to those treated with MABs alone (test for stochastic dominance: p < 0.001). Accordingly, in the gastrocnemius, the number of fibers of small diameter (10–30 μm) was slightly reduced although not significantly in dy2J mice treated with MABs + mMAG (group 3; 168 ± 50 fibers per 0.1 mm2) as compared to dy2J mice treated with saline (group 1; 236 ± 45 fibers per 0.1 mm2; p = not significant, n = 4), whereas the number of fibers of larger diameter (40–60 μm) was significantly increased dy2J mice treated with MABs + mMAG (80 ± 7 fibers per 0.1 mm2) as compared to dy2J mice treated with saline (27 ± 9 fibers per 0.1 mm2; ANOVA 2 tails, p = 0.02; n = 4).
When we evaluated the number of fibers with centrally located nuclei, as representative of regenerating fibers to counteract degeneration, we did not observe significant differences between treated and untreated mice: the number of fibers with central nuclei was slightly decreased in dy2J mice treated with MABs + mMAG (31.3 ± 4.2 %) when compared to dy2J mice treated with saline (36.8 ± 3.5 %, ANOVA, p = not significant, n = 5 per group) or treated with MABs (43.5 ± 3.6 %; ANOVA, p = not significant, n = 5 per group).
Finally, as apoptosis may contribute to the disease progression of MDC1A [45–47], we evaluated the number of apoptotic muscle fibers by TUNEL labeling assay in treated and untreated dy2J mice. We did not observe significant differences of apoptotic cells in dy2J mice treated with MABs (1.06 ± 0.19 %) versus MABs + mMAG (1.44 ± 0.36 %) or versus untreated dy2J mice (1.26 ± 0.23 %;) as shown in Additional file 1: Figure S1.
MDC1A mice treated with MABs + mMAG show restored levels of laminin-211 receptors
As laminin-411 and 511 are described upregulated in muscles of Lama2 mice [3, 19, 22, 23], and we further observed that MABs can synthesize laminin chain α4 and α5, we evaluated the expression of these two laminin isoforms in MABs treated and untreated dy2J mice. As expected, dy2J mice showed increased expression of both laminin chain α4 and α5 but we did not observe further differences after treatment with MABs (either MABs alone or MABs + mMAG) as shown in Additional file 2: Figure S2. Interestingly, staining for laminin chain γ1 was changed in dy2J mice as compared to normal controls, as at similar level of detection it was reduced and discontinuous in dy2J mice, with a pattern similar to laminin α5 as shown in Additional file 2: Figure S2C. Treatment with MABs (either alone or MABs + mMAG) did not modify the staining as shown in Additional file 2: Figure S2C. This last data would be consistent with the change of the γ1 chain from the laminin-211 heterotrimer to the 411/511 heterotrimer in dy2J mice.
MABs + mMAG treatment ameliorates the clinical phenotype also in SCIDdy2J mice
As a complementary study of the efficacy of MABs + mMAG treatment for MDC1A mouse model, we generated dy2J mice in SCID background (SCIDdy2J). The aim of this experiment was to evaluate the efficacy of MAB therapy in the absence of immunoresponse and immune-suppressive therapy. Mice were divided in two groups: group 1 included ten SCIDdy2J mice treated with saline and group 2 included ten SCIDdy2J mice treated with MABs + mMAG. Cell dosage, time points of treatment, and age of treated mice were the same as described above and summarized in Fig. 5a. Motor performances of all mice were evaluated with treadmill just before the first injection (45-day-old), and 10 days after the last injection (85-day-old). As expected, also SCIDdy2J mice treated with MABs + mMAG showed a significant reduction in deterioration of treadmill performances (−29 ± 4 %) as compared to non-treated SCIDdy2J mice (−49 ± 9 %; Student’s t test, two tails, p = 0.05, n = 10), despite extreme variability in genetic background (F3/F4 generation).
Mesoangioblast treatment did not ameliorate the peripheral neuropathy of MDC1A
Loss of laminin-211 is responsible for dysmyelinating neuropathy in human MDC1A and animal models [17, 18, 49, 50]. Although we did not observe mMAG expression in the endoneurium but it was limited to the perineurium (Fig. 3d), we evaluated whether this was anyway sufficient to modify peripheral neuropathy. Five mice in group 1 (dy2J mice treated with saline solution) and group 2 (dy2J mice treated with MABs + mMAG) also underwent neurophysiological analysis at 45-day-old (before treatment) and 85-day-old (after treatment) to evaluate the effect on the peripheral neuropathy. Neurophysiology of dy2J mice did not show significant differences before and after treatment with MABs + mMAG or saline. Before treatment: group 1 showed cMAP 3.95 ± 0.7 mV and NCV 33 ± 3.5 m/s, whereas group 2 showed cMAP 3.90 ± 0.6 mV and NCV of 32 ± 4 m/s. After treatment: group 1 showed cMAP 3.2 ± 0.7 mV and NCV of 39 ± 2 m/s, whereas group 2 (MABs + mMAG treated) showed cMAP 3.2 ± 0.5 mV and NCV of 38 ± 1.5 m/s (Student’s t test, p = not significant). Accordingly, the analysis of semithin sections of the sciatic nerves did not show differences between the two groups, as shown in Additional file 4: Figure S4.
Overall, these data show that mMAG delivered by MABs injected into the skeletal muscles does not enter significantly in the peripheral nerves, and this therapy does not interfere with the progression of the peripheral neuropathy in MDC1A mutants.
We propose to associate cell (MABs) and gene (mMAG) therapy as a strategy to treat MDC1A. Results of our proof of principle study are consistent with an amelioration of morphological, molecular, and motor aspects of MDC1A-treated mice. No effect was observed on the associated peripheral neuropathy.
Although previous studies showed that MAB cell therapy is sufficient to treat recessive muscular dystrophies in preclinical models [32–36, 41], this was not considered a successful strategy in MDC1A as we observed that MABs synthesize and secrete only little (negligible) amount of laminin α2, which is the missing protein in MDC1A. Lack of laminin α2 synthesis was not restricted to mouse species, as we observed similar result with human MABs. It was even independent of epigenetic events, as neither inhibition of histone deacetylation nor of DNA methylation induced murine MABs to synthesize more laminin α2. Although this seems contradictory with the fact that MABs differentiate into myocytes, which normally produce laminin α2, and that once differentiation is triggered it will automatically lead to the full expression of the gene repertoire, this is not necessarily true. It is well known that myoblast differentiation in vitro will not give rise to the expression of adult isoforms of sarcomeric proteins . Nonetheless, previous in vivo studies showed that bone marrow-derived stem cells differentiated into myocytes could not synthesize δ-sarcoglycan .
Thus, we decided to use MABs as carrier cells to deliver in the skeletal muscle an exogenous protein, miniagrin, which is able to link laminin-211 receptors with other laminin isoforms expressed (or even overexpressed) in the extracellular matrix of MDC1A dystrophic mice . Interestingly, we showed that MABs + mMAG could profusely synthesize these other laminin isoforms, thus increasing the potential efficacy of this strategy. As expected, we observed diffuse staining for mMAG (recognized by anti-myc tag antibody) in the injected area of the skeletal muscles, which associated with signs of regeneration (centrally located nuclei and NCAM staining) when detected few days after injection, and amelioration of morphological (reduction of endomysial connective tissue and increased proportion of fibers with large diameter, suggesting muscle reconstitution and reduced fiber degeneration) and molecular (increased levels of laminin-211 receptors) features when investigated at the end of the preclinical trial. Interestingly, and consistently with previous reports [19–21], it seems that both dystroglycan and α7β1 integrin are the two laminin receptors rescued by MABs + mMAG treatment, as instead α6(β1), which forms the other main integrin-laminin receptor in the muscle , was not significantly upregulated. Moreover, α- and β-dystroglycan were differently regulated in dy2J mice, but this is not new as observed also in other Lama2 strains [19, 21], possibly due to different regulatory mechanisms for the two subunits when the ligand is absent (as in dy3K or dyW) or not functioning (as in dy2J mice).
We did not investigate the extent of MABs (and MABs + mMAG) engraftment in the injected skeletal muscles and that of MABs integration in regenerating fibers, as (1) it was diffusely proven and shown in previous published studies [32–36, 41, 55]: MABs can fuse with regenerating myotubes and restore missing proteins in loss-of-function myopathies; (2) this was not the scope of our study, as our goal was to demonstrate that injected MABs can secrete MAG in the skeletal muscles (recognized by the myc tag). Moreover, we had no useful marker to differentiate donor from endogenous nuclei in myotubes of injected MDC1A muscles. However, we may speculate that a consistent number of MABs + mMAG have been integrated into the host MDC1A muscles. This would be in line with previous published studies (as reported above), would sustain diffuse and prolonged miniagrin staining around muscle fibers of injected muscles (and not elsewhere) and would justify the enhanced expression of laminin-211 receptors (dystroglycan and integrin α7β1) in MAB + mMAG injected muscles.
MABs + mMAG-treated dy2J mice showed a significant reduction in the deterioration of motor performances with the treadmill analysis as compared to those treated with saline solution, whereas dy2J mice treated with MABs alone did not behave better than those treated with saline. Although MABs + mMAG-treated dy2J mice did not rescue motor performances towards normal values, this was expected as we injected only few muscles of the posterior limbs of dystrophic mice, and this therapy did not interfere with the ongoing peripheral neuropathy. In fact, this would simply constitute a proof-of-concept study on the feasibility of MABs + mMAG therapy for MDC1A. Nonetheless, systemic administration of MABs + mMAG through the arterial vascular system would constitute the gold standard for future translational applications in MDC1A, as already shown in other models [32, 36, 55], and recently in humans (EudraCT no. 2011–000176–33; Giulio Cossu, manuscript in preparation). In fact, MABs can cross the vessel wall and distribute into the dystrophic muscles when delivered intra-arterially. Unfortunately, repetitive intra-arterial injection of MABs in dy2J mice was not feasible for unexpected arterial fragility. Moreover, efficacy of MABs + mMAG treatment in our study was limited to dy2J mice, as more severe model as dy3K die very early due to respiratory failure and we had no chance to deliver engineered MABs directly into the respiratory muscles.
Although MABs are not known to generate neural cell types, as carrier cells, they may enter several tissues and organs and may secrete mMAG in the peripheral nerves, the other target organ of MDC1A. A progressive severe dysmyelinating neuropathy is in fact associated to MDC1A in humans and mouse models [17, 18, 49, 50], and it is already known that genetic repletion of laminin chain α2 in the skeletal muscles of mouse mutants does not completely revert the clinical phenotype due to the progression of the peripheral neuropathy . Hence, we evaluated whether MABs may engraft the peripheral nerves, secrete miniagrin, and possibly ameliorate the peripheral neuropathy associated to MDC1A. Unfortunately, only few MABs entered the endoneurium, while most were blocked in the perineurium of peripheral nerves. This was not sufficient to produce enough miniagrin to change the neuropathy outcome, as demonstrated by pathological and neurophysiological evaluations. Part of this inefficient engraftment could also be due to the presence of blood-nerve barrier. MABs administration in mouse models with disrupted blood-nerve barrier, as following nerve crush injury, showed much higher MABs engraftment in the sciatic nerve endoneurium (Stefano C. Previtali, unpublished data). As other stem cell types have been shown to be better carrier cells for peripheral nerve, i.e., hematopoietic stem cells , future studies using combinatory cell therapies such as hematopoietic stem cells to carry miniagrin in the peripheral nerves and MABs + mMAG for the skeletal muscle may constitute an ideal approach for multiorgan disorders such as MDC1A.
The combination of cell plus gene therapy by MABs engineered to produce and secrete MAG into the skeletal muscles of MDC1A mutants showed significant efficacy to ameliorate muscular dystrophy and motor performances of dystrophic mice. This approach may speed translational studies on the efficacy of miniagrin in human MDC1A, as both MABs delivery and lentiviral transduced cells have been already used in human clinical trials.
compound motor action potential
Dulbecco’s modified Eagle’s medium
merosin-deficient congenital muscular dystrophy type 1A
myosin heavy chain
nerve conduction velocity
The authors are grateful to Maurilio Sampaolesi, Silvia Brunelli, Francesco Saverio Tedesco, Davide Gabellini, and Giulio Cossu for helpful technical suggestions; Dr H. Hori (Tokyo Medical and Dental University, Tokyo, Japan) for providing anti-human laminin α2-chain antibody.
This work was supported by the Italian Telethon Foundation (GGP08037, GPP12024) and the Association Francaise contre les myopathies (AFM-14127).
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