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Neurodevelopmental disorders (NDDs) include a broad spectrum of disorders that disrupt normal brain development. Though some NDDs are caused by acquired insults (i.e., toxic or infectious encephalopathy) or may be cryptogenic, many NDDs are caused by variants in a single gene or groups of genes that disrupt neuronal development or function. In this review, we will focus on those NDDs with a genetic etiology. The exact mechanism, timing, and progression of the molecular pathology are seldom well known; however, the abnormalities in development typically manifest in similar patterns such as delays or regression in motor function, social skills, and language or cognitive abilities. Severity of impairment can vary widely. At present, only symptomatic treatments are available to manage seizures and behavioral problems commonly seen in NDDs. In recent years, there has been a rapid expansion of research into gene therapy using adeno-associated viruses (AAVs). Using AAVs as vectors to replace the non- or dysfunctional gene in vivo is a relatively simple model which has created an unprecedented opportunity for the future of NDD treatment. Advances in this field are of paramount importance as NDDs lead to a massive lifelong burden of disease on the affected individuals and families. In this article, we review the unique advantages and challenges of AAV gene therapies. We then look at potential applications of gene therapy for 3 of the more common NDDs (Rett syndrome, fragile X syndrome, and Angelman syndrome), as well as 2 less common NDDs (SLC13A5 deficiency disorder and SLC6A1-related disorder). We will review the available natural history of each disease and current state of preclinical studies including a discussion on the application of AAV gene therapies for each disease.

MECP2 gene transfer has been shown to extend the survival of Mecp2−/y knockout mice modelling Rett syndrome, an X-linked neurodevelopmental disorder. However, controlling deleterious overexpression of MECP2 remains the critical unmet obstacle towards a safe and effective gene therapy approach for Rett syndrome. A recently developed truncated miniMECP2 gene has also been shown to be therapeutic after AAV9-mediated gene transfer in knockout neonates.We show that AAV9/miniMECP2 has a similar dose-dependent toxicity profile to that of a published second-generation AAV9/MECP2 vector after treatment in adolescent mice. To overcome that toxicity, we developed a risk-driven viral genome design strategy rooted in high-throughput profiling and genome mining to rationally develop a compact, synthetic microRNA target panel (miR-responsive auto-regulatory element, ‘miRARE’) to minimize the possibility of miniMECP2 transgene overexpression in the context of Rett syndrome gene therapy. The goal of miRARE is to have a built-in inhibitory element responsive to MECP2 overexpression. The data provided herein show that insertion of miRARE into the miniMECP2 gene expression cassette greatly improved the safety of miniMECP2 gene transfer without compromising efficacy. Importantly, this built-in regulation system does not require any additional exogenous drug application, and no miRNAs are expressed from the transgene cassette.Although broad applications of miRARE have yet to be determined, the design of miRARE suggests a potential use in gene therapy approaches for other dose-sensitive genes.

Disruptions in the gene encoding methyl-CpG binding protein 2 (MECP2) underlie complex neurodevelopmental disorders including Rett Syndrome (RTT), MECP2 duplication disorder, intellectual disabilities, and autism. Significant progress has been made on the molecular and cellular basis of MECP2-related disorders providing a new framework for understanding how altered epigenetic landscape can derail the formation and refinement of neuronal circuits in early postnatal life and proper neurological function. This review will summarize selected major findings from the past years and particularly highlight the integrated and multidisciplinary work done at eight NIH-funded Intellectual and Developmental Disabilities Research Centers (IDDRC) across the US. Finally, we will outline a path forward with identification of reliable biomarkers and outcome measures, longitudinal preclinical and clinical studies, reproducibility of results across centers as a synergistic effort to decode and treat the pathogenesis of the complex MeCP2 disorders.

Gene therapy has become a promising strategy to treat the genetic disorders of central nervous system (CNS). In the last five decades the development and characterization of recombinant adeno-associated virus (rAAV) as a safe and effective vector for gene delivery has revolutionized this field. Development of rAAV with better efficacy and selectivity for the CNS has resulted in increasingly successful preclinical and clinical applications. This chapter provides an overview of AAV-mediated CNS gene therapy, including discovery and engineering of novel AAV capsids, advances in preclinical models of genetic disorders, and clinical translation of AAV technology.

Rett Syndrome (RTT) is an X chromosome-linked neurodevelopmental disorder caused by inactivating mutations in the transcription regulator methyl CpG-binding protein 2 (MeCP2). Multiple studies have independently explored the therapeutic potential of adeno-associated viral (AAV) vector-mediated MECP2 gene transfer in mouse models of RTT. Historically, the primary risk anticipated for viral vector-mediated MECP2 gene transfer in vivo has been toxicity caused by supraphysiological expression of exogenous MeCP2. Despite the anticipated risk, early studies examining AAV/MECP2 in vivo have, as a whole, supported a generally optimistic assessment of MECP2 gene therapy. More recently, toxicity assessments have identified dose-dependent side effects of AAV9/MECP2 delivered directly to the cerebrospinal fluid (CSF). Ultimately, accurate monitoring and reporting of these side effects will help ensure the development of safe AAV/MECP2 treatment paradigms as researchers explore strategies to improve widespread but properly regulated MECP2 gene transfer in the central nervous system (CNS). Importantly, despite some variability in apparent safety and efficacy, all MECP2 gene therapy studies have been united by a single feat: published treatment paradigms have extended the survival of RTT mice, regardless of injection route, treatment age, or viral genome design. With the possibility of a translatable gene therapy treatment for RTT emerging, a comprehensive overview of the preclinical MECP2 gene therapy studies published thus far is warranted. This review highlights the main findings of these publications and discusses future directions.

Rett syndrome (RTT), caused by loss-of-function mutations in the MECP2 gene, is a neurological disorder characterized by severe impairment of motor and cognitive functions. The aim of this study was to investigate the impact of vector design, dosage, and delivery route on the efficacy and safety of gene augmentation therapy in mouse models of RTT. Our results show that AAV-mediated delivery of MECP2 to Mecp2 null mice by systemic administration, and utilizing a minimal endogenous promoter, was associated with a narrow therapeutic window and resulted in liver toxicity at higher doses. Lower doses of this vector significantly extended the survival of mice lacking MeCP2 or expressing a mutant T158M allele but had no impact on RTT-like neurological phenotypes. Modifying vector design by incorporating an extended Mecp2 promoter and additional regulatory 3′ UTR elements significantly reduced hepatic toxicity after systemic administration. Moreover, direct cerebroventricular injection of this vector into neonatal Mecp2-null mice resulted in high brain transduction efficiency, increased survival and body weight, and an amelioration of RTT-like phenotypes. Our results show that controlling levels of MeCP2 expression in the liver is achievable through modification of the expression cassette. However, it also highlights the importance of achieving high brain transduction to impact the RTT-like phenotypes.

Intravenous administration of adeno-associated virus serotype 9 (AAV9)/ hMECP2 has been shown to extend the lifespan of Mecp2 −/y mice, but this delivery route induces liver toxicity in wild-type (WT) mice. To reduce peripheral transgene expression, we explored the safety and efficacy of AAV9/ hMECP2 injected into the cisterna magna (ICM). AAV9/ hMECP2 (1 × 10 12 viral genomes [vg]; ICM) extended Mecp2 −/y survival but aggravated hindlimb clasping and abnormal gait phenotypes. In WT mice, 1 × 10 12 vg of AAV9/ hMECP2 induced clasping and abnormal gait. A lower dose mitigated these adverse phenotypes but failed to extend survival of Mecp2 −/y mice. Thus, ICM delivery of this vector is impractical as a treatment for Rett syndrome (RTT). To improve the safety of MeCP2 gene therapy, the gene expression cassette was modified to include more endogenous regulatory elements believed to modulate MeCP2 expression in vivo. In Mecp2 −/y mice, ICM injection of the modified vector extended lifespan and was well tolerated by the liver but did not rescue RTT behavioral phenotypes. In WT mice, these same doses of the modified vector had no adverse effects on survival or neurological phenotypes. In summary, we identified limitations of the original vector and demonstrated that an improved vector design extends Mecp2 −/y survival, without apparent toxicity.

Intravenous administration of adeno-associated virus serotype 9 (AAV9)/hMECP2 has been shown to extend the lifespan of Mecp2−/y mice, but this delivery route induces liver toxicity in wild-type (WT) mice. To reduce peripheral transgene expression, we explored the safety and efficacy of AAV9/hMECP2 injected into the cisterna magna (ICM). AAV9/hMECP2 (1 × 1012 viral genomes [vg]; ICM) extended Mecp2−/y survival but aggravated hindlimb clasping and abnormal gait phenotypes. In WT mice, 1 × 1012 vg of AAV9/hMECP2 induced clasping and abnormal gait. A lower dose mitigated these adverse phenotypes but failed to extend survival of Mecp2−/y mice. Thus, ICM delivery of this vector is impractical as a treatment for Rett syndrome (RTT). To improve the safety of MeCP2 gene therapy, the gene expression cassette was modified to include more endogenous regulatory elements believed to modulate MeCP2 expression in vivo. In Mecp2−/y mice, ICM injection of the modified vector extended lifespan and was well tolerated by the liver but did not rescue RTT behavioral phenotypes. In WT mice, these same doses of the modified vector had no adverse effects on survival or neurological phenotypes. In summary, we identified limitations of the original vector and demonstrated that an improved vector design extends Mecp2−/y survival, without apparent toxicity., Graphical Abstract

AMPK is a conserved heterotrimeric serine-threonine kinase that regulates anabolic and catabolic pathways in eukaryotes. Its central role in cellular and whole body metabolism makes AMPK a commonly proposed therapeutic target for illnesses characterized by abnormal energy regulation, including cancer and diabetes. Many AMPK modulators, however, produce AMPK-independent effects. To identify drugs that modulate AMPK activity independent of the canonical ATP-binding pocket found throughout the kinome, we designed a robust fluorescence-based high throughput screening assay biased toward the identification of molecules that bind the regulatory region of AMPK through displacement of MANT-ADP, a fluorescent ADP analog. Automated pin tools were used to rapidly transfer small molecules to a low volume assay mixture on 384-well plates. Prior to assay validation, we completed a full assay optimization to maximize the signal-to-background and reduce variability for robust detection of small molecules displacing MANT-ADP. After validation, we screened 13,120 molecules and identified 3 positive hits that dose-dependently inhibited the protein-bound signal of MANT-ADP in the presence of both full-length AMPK and the truncated “regulatory fragment” of AMPK, which is missing the kinase active site. The average Z’-factor for the screen was 0.55 and the compound confirmation rate was 60%. Thus, this fluorescence-based assay may be paired with in vitro kinase assays and cell-based assays to help identify molecules that selectively regulate AMPK with fewer off-target effects on other kinases.

In the fruit fly, Drosophila melanogaster, mono-allelic expression of AMPK-α, -β, and -γ yields a single heterotrimeric energy sensor that regulates cellular and whole-body energetic homeostasis. The genetic simplicity of Drosophila, with only a single gene for each subunit, makes the fruit fly an appealing organism for elucidating the effects of AMPK mutations on signaling pathways and phenotypes. In addition, Drosophila presents researchers with an opportunity to use straightforward genetic approaches to elucidate metabolic signaling pathways that contain a level of complexity similar to that observed in mammalian pathways. Just as in mammals, however, the regulatory realm of AMPK function extends beyond metabolic rates and lipid metabolism. Indeed, experiments using Drosophila have shown that AMPK may exert protective effects with regard to life span and neurodegeneration. This chapter addresses a few of the research areas in which Drosophila has been used to elucidate the physiological functions of AMPK. In doing so, this chapter provides a primer for basic Drosophila nomenclature, thereby eliminating a communication barrier that persists for AMPK researchers trained in mammalian genetics.

Stress may elevate ethanol drinking and anxiety associated with ethanol drinking. Studies to identify relevant neurobiological substrates are needed.To assess roles of brain regions in corticotrophin releasing factor (CRF) effects on stressor-enhanced, ethanol deprivation-induced drinking and anxiety-like behavior.Ethanol-preferring rats (P rats) were exposed to three cycles of a two-bottle choice paradigm with two 2-day deprivation periods that included 1 h exposure to a restraint stressor. To assess the role of CRF and to identify relevant brain regions, a CRF-1 receptor antagonist (SSR125543; 10 ug) was injected into the nucleus accumbens (NAC), amygdala (Amyg), or dorsal raphe nucleus (DRN) prior to exposure to the restraint stressor. In a second study, CRF (0.5 ug) was injected into one of these regions, or the ventral tegmental area (VTA), or paraventricular nucleus of the hypothalamus (PVN).Applying the restraint stressor during deprivation increased voluntary intake and sensitized anxiety-like behavior. Antagonist injection into the NAC prevented increased drinking without affecting anxiety-like behavior, whereas injection into the Amyg or DRN prevented the anxiety-like behavior without affecting drinking. To confirm CRF actions in the stressor effect, CRF was injected into selected brain regions. NAC injections (but not the VTA, Amyg, DRN, or PVN) facilitated drinking but did not change anxiety-like behavior. Injections into the DRN or Amyg (but not PVN or VTA) enhanced anxiety-like behavior.Results emphasize that a restraint stressor elevates ethanol intake and sensitizes ethanol deprivation-induced anxiety-like behavior through CRF1 receptors in the NAC and Amyg/DRN, respectively.

AMP-activated protein kinase (AMPK) is a promising therapeutic target for cancer, type II diabetes, and other illnesses characterized by abnormal energy utilization. During the last decade, numerous labs have published a range of methods for identifying novel AMPK modulators. The current understanding of AMPK structure and regulation, however, has propelled a paradigm shift in which many researchers now consider ADP to be an additional regulatory nucleotide of AMPK. How can the AMPK community apply this new understanding of AMPK signaling to translational research? Recent insights into AMPK structure, regulation, and holoenzyme-sensitive signaling may provide the hindsight needed to clearly evaluate the strengths and weaknesses of past AMPK drug discovery efforts. Improving future strategies for AMPK drug discovery will require pairing the current understanding of AMPK signaling with improved experimental designs.

Rett Syndrome (RTT) is a neurodevelopmental disorder that shortens the lifespan of patients while depriving them of the ability to walk, talk, or interact with others. RTT is caused by inactivating mutations in the X chromosome-linked gene encoding methyl-CpG-binding protein 2 (MeCP2), a transcription regulator that is highly expressed in neurons. Patients with RTT express mutant MeCP2 in ~50% of their cells due to random X-chromosome inactivation in each cell. The remaining “healthy” cells have an activated chromosome encoding functional (WT) MeCP2. Although researchers have already used MeCP2 gene therapy to reverse the RTT phenotype in mosaic mice, concerns about side effects (i.e., motor and learning deficits) resulting from MeCP2 overexpression in “healthy” cells persist. Indeed, humans suffering from MeCP2 duplication syndrome have been shown to suffer from muscular spasticity and intellectual disabilities. In addition to persistent concerns about MeCP2 overexpression, IV administration of the scAAV9/hMeCP2 vector (1×1011 vg/mouse) has been shown to cause significant liver toxicity in MeCP2-null mice (Gadalla et al, Mol Ther, 2013). We tested the hypothesis that by moving from an IV route of administration to an intraCSF route, we could lower the dose of AAV vector enough to avoid the high peripheral organ transduction that generates toxic side effects. Modeling our earlier experiment with an IV route, juvenile (4-5 week old) knock-out (KO) mice and WT littermates received a single intrathecal injection of AAV9/MeCP2 vector. RTT mice dosed intrathecally with 1×1010 vg had a 48% increase in median survival compared to vehicle-injected mice (n=6 treated; n=11 vehicle; P=0.008), nearly identical to the rescue we previously observed following the IV approach but at 1/10th the dose and avoiding overexpression-related toxicity in the liver. In conclusion, by changing the route of administration of the AAV9/MeCP2 vector from IV to intraCSF, we were able to generate a nearly identical therapeutic outcome with a 10-fold lower dose, and without excessive (toxic) gene transfer to peripheral organs. As a next step to utilize the intraCSF route of administration, DNA shuffling and directed evolution were utilized to select for AAV capsid variants that would have higher efficiency and improved biodistribution in the RTT mice after intraCSF administration. Multiple clones were selected that have CNS transduction equivalent to AAV9, but importantly, all had highly reduced peripheral organ biodistribution. Preliminary studies using two clones, RTTF1.04 and RTTF1.11, were able to confer significant survival benefits to male RTT KO mice (34% and 25% prolongation of lifespan, P = 0.03 and 0.05, respectively) after delivery of the MeCP2 transgene at a dose of 1×1010 vg. Overall, our studies support the use of an intraCSF route of administration to treat RTT using AAV vectors, and the potential to develop safer and more effective AAV-based vectors tailored to the intraCSF route of administration.We acknowledge generous support from IRSF and RSRT.