DNA base editing corrects common Hemophilia A mutations and restores factor VIII expression in vitro and ex-vivo models

Background Replacement and non-replacement therapies effectively control bleedings in Hemophilia A (HA) but imply lifelong interventions. The authorized gene addition therapy could provide a cure but still poses questions on durability. F8 gene correction would definitively restore factor VIII (FVIII) production, as shown in animal models through nucleases mediating homologous recombination (HR). However, low efficiency and potential off-target double-strand break (DSB) still limit HR translatability. Objectives To correct common model single point mutations leading to severe HA through the recently developed DSB/HR-independent base (BE) and prime (PE) editing approaches. Methods Screening for efficacy of BE/PE systems in HEK293T transiently expressing FVIII variants and validation at DNA (sequencing) and protein (ELISA; aPTT) level in stable clones. Evaluation of rescue in engineered blood outgrowth endothelial cells (BOEC) by lentiviral-mediated delivery of BE. Results and Conclusions Transient assays identified the best-performing BE/PE systems for each variant, with the highest rescue of FVIII expression (up to 25% of rFVIIIwt) for the p.R2166* and p.R2228Q mutations. In stable clones we demonstrated that the mutation reversion on DNA (∼24%) was consistent with the rescue of FVIII secretion and activity 20-30%). The lentiviral-mediated delivery of the selected BE systems was attempted in engineered BOEC harboring the p.R2166* and p.R2228Q variants, which led to an appreciable and dose-dependent rescue of secreted functional FVIII.Overall data provide the first proof-of-concept for effective BE/PE-mediated correction of HA-causing mutations, which encourage studies in mouse models to develop a personalized cure for large cohorts of patients though a single intervention.