Errores innatos del metabolismo. avances en el diagnostico y terapeutica / Inborn errors of metabolism. Advances in diagnosis and therapeutic

Resumen Las novedades en el campo de los errores innatos del metabolismo (EIM) son espectaculares. Se han descrito nuevos EIM, se conoce mejor sus bases fisiopatológicas y las implicaciones para el organismo. Con la llegada de las nuevas técnicas de metabolómica, lípidomica y genómica se han multiplicado los avances en el diag nóstico y permiten explorar nuevas opciones terapéu ticas. Se ha establecido una nueva clasificación de los EIM en base a los más de 1.450 EIM identificados. Está irrumpiendo una nueva especialidad, que es la medici na metabólica. El cribado neonatal se estáempezando a universalizar y nos permite hoy en día, con tándem masas, el diagnóstico de más de 20 enfermedades me tabólicas del período neonatal que tienen opciones de tratamiento. Se están creando unidades de EIM para adultos para seguir niños con EIM que sobreviven a la enfermedad y con cada vez mejor calidad de vida y se diagnostican EIM que debutan en la adolescencia o laedad adulta. Aparecen las terapias personalizadas y las guías de práctica clínica para muchos EIM. Finalmente están emergiendo cada vez nuevas opciones terapéuticas que permiten una mayor supervivencia y mejor calidad de vida. La terapia génica convencional ya se está aplicando en algunos EIM.Sin embargo, las estrategias de edición de genes con terapias de ARN pueden permitir corregir la mutación genética mini mizando los problemas asociados con la terapia génica de compensación convencional.

Abstract The advances in the field of inborn errors of metabo lism (IEM) are spectacular. New IEM have been described, their pathophysiological bases and implications for the organism are better known. With the advent of new metabolomics, lipidomics and genomics techniques, advances in diagnosis have multiplied and allow new therapeutic options to be explored. A new IEM classi fication has been established based on the more than 1.450 IEM identified. A new specialty is emerging, which is metabolic medicine. Neonatal screening is becom ing universal and allows us today, with tandem mass, to diagnose more than 20 metabolic diseases of the neonatal period, with treatment options. IEM units for adults are being created to follow-up children with IEM who survive the disease and with an increasingly better quality of life, and some IEM that start in adolescence or adulthood are diagnosed. Personalized therapies and clinical practice guidelines appear for any IEM. Finally, new therapeutic options are emerging day to day that allow a longer survival and better quality of life. Con ventional gene therapy is already being applied in some IEM. However, gene editing strategies with RNA thera pies may allow the correction of the genetic mutation, minimizing the problems associated with conventional compensation gene therapy.

Terapia genica: ¿Dónde estamos?, ¿A dónde vamos? / Gene therapy: Where are we? Where are we going?

Resumen La terapia génica ha logrado avances significativos en el tratamiento de enfermedades genéticas, especial mente en enfermedades raras y monogénicas. Se han desarrollado y aprobado terapias génicas para tratar en fermedades como la atrofia muscular espinal, brindando esperanza a los pacientes y demostrando la eficacia de esta terapia. Actualmente, se están realizando numerosos ensayos clínicos para evaluar la seguridad y eficacia de la terapia génica en diversas enfermedades, particularmente en el campo de la neurología pediátrica. Estos estudios están generando datos alentadores y contribuyen al conoci miento sobre cómo mejorar las técnicas de terapia génica. A pesar de los avances, la terapia génica enfrenta desafíos importantes. Es una terapia costosa y téc nicamente compleja, lo que limita su accesibilidad. Además, aspectos como la entrega eficiente de genes, la respuesta inmunológica a los vectores y la duración de la respuesta terapéutica requieren mejoras. se está investigando activamente. En cuanto al futuro de la terapia génica, se espera que los avances en tecnología de edición génica, como CRISPR-Cas9, permitan una mayor precisión y eficiencia en la modificación de genes. Se espera que la investigación en vectores de terapia génica mejore la capacidad de entrega y la seguridad de los tratamientos. Se están desarrollando nuevas ge neraciones de vectores virales y no virales que podrían superar las limitaciones actuales y permitir una admi nistración más eficiente y precisa de genes terapéuticos.

Abstract Gene therapy has achieved significant advancements in the treatment of genetic diseases, especially in rare and monogenic diseases. Gene therapies have been de veloped and approved to treat diseases such as spinal muscular atrophy, offering hope to patients and dem onstrating the effectiveness of this therapy. Currently, numerous clinical trials are being conduct ed to evaluate the safety and efficacy of gene therapy in various diseases, particularly in the field of pediatric neurology. These studies are generating encouraging data and contributing to the knowledge on how to im prove gene therapy techniques. Despite the advancements, gene therapy faces significant challenges. It is a costly and technically complex therapy, limiting its accessibility. Addition ally, aspects such as efficient gene delivery, immune response to vectors, and duration of therapeutic re sponse require improvements and are actively being investigated. Regarding the future of gene therapy, advances in gene editing technology, such as CRISPR-Cas9, are ex pected to allow for greater precision and efficiency in gene modification. Research on gene therapy vectors is expected to en hance the delivery capacity and safety of treatments. New generations of viral and non-viral vectors are be ing developed that could overcome current limitations and enable more efficient and precise administration of therapeutic genes.

Aplicaciones clínicas de la herramienta CRISPR-Cas / Clinical Applications of the CRISPR-Cas Tool

Resumen El desarrollo de tecnologías para la edición del genoma ha abierto la posibilidad de apuntar directamente y modificar secuencias genómicas en casi todo tipo de células eucariotas. La edición del genoma ha ampliado nuestra capacidad para dilucidar la contribución de la genética a las enfermedades al promover la creación de modelos celulares y animales más precisos de procesos patológicos y ha comenzado a mostrar su potencial en una variedad de campos, que van desde la investigación básica hasta la biotecnología aplicada y biomédica. Entre estas tecnologías, el uso de las repeticiones palindrómicas cortas agrupadas regularmente espaciadas ha acelerado, en gran medida, el progreso de la edición de genes desde el concepto hasta la práctica clínica, generando, además, interés debido, no solo a su precisión y eficiencia, sino también a la rapidez y a los costos necesarios para su implementación en comparación con otras tecnologías de edición genómica. En esta revisión se presenta información recabada de publicaciones indexadas en la base de datos PubMed que se encontraron mediante el uso de palabras claves asociadas con la tecnología y que se filtraron para retener solo aquellas con evidencias de avances clínicamente relevantes y que permiten demostrar algunas de las aplicaciones que tiene esta tecnología en la investigación, pronóstico y tratamiento de enfermedades genéticas, cardiovasculares, virales, entre otras; esto con el objetivo de dar a conocer la situación actual de los avances en aplicaciones clínicas de la herramienta CRISPR-Cas y fomentar aún más la investigación en esta tecnología, la cual, tal como se evidencia a lo largo de esta revisión, posee una gran versatilidad y un amplio rango de aplicaciones, lo que ofrece una enorme oportunidad en el campo de la medicina genómica, pero que, a su vez, requiere un mayor fomento en su investigación para mejorar la tecnología y acercarla aún más a consolidar aplicaciones clínicas de uso seguro, confiable y consistente.

Abstract The development of genome editing technologies has opened up the possibility of directly targeting and modifying genomic sequences in almost all types of eukaryotic cells. Genome editing has expanded our ability to elucidate the contribution of genetics to disease by promoting the creation of more precise cellular and animal models of disease processes and has begun to show its potential in a variety of fields, ranging from basic research to applied and biomedical biotechnology. Among these technologies, the use of clustered regularly spaced short palindromic repeats have greatly accelerated the progress of gene editing from concept to clinical practice, further generating interest due not only to its precision and efficiency, but also to the speed and costs required for its implementation compared to other genomic editing methods. This review presents information collected from indexed publications in the PubMed database that were found by using keywords associated with the technology and filtered to retain only those with evidence of clinically relevant advances that demonstrate some of the applications that this technology has in research, prognosis, and treatment of genetic, cardiovascular, and viral diseases, among others; this with the aim of show the current situation of advances in clinical applications of the CRISPR-Cas tool and further encourage research in this technology, which, as evidenced throughout this review, has a great versatility and a wide range of applications, which offers an enormous opportunity in the field of genomic medicine but which, in turn, requires greater support in its research to improve the technology and bring it even closer to consolidating clinical applications of safe, reliable and consistent use.

Gene therapy for heart failure and cardiomyopathies.

Gene therapy strategies encompass a range of approaches, including gene replacement and gene editing. Gene replacement involves providing a functional copy of a modified gene, while gene editing allows for the correction of existing genetic mutations. Gene therapy has already received approval for treating genetic disorders like Leber's congenital amaurosis and spinal muscular atrophy. Currently, research is being conducted to explore its potential use in cardiology. This review aims to summarize the mechanisms behind different gene therapy strategies, the available delivery systems, the primary risks associated with gene therapy, ongoing clinical trials, and future targets, with a particular emphasis on cardiomyopathies.

Perfil de notas técnicas para suporte técnico-científico à decisão judicial do medicamento Zolgensma® (onasemnogeno abeparvoveque) / Profile of technical notes for scientific and technical support to judicial decision on the Zolgensma® (onasemnogene abeparvovec)

Introdução: O aumento da judicialização da saúde tem destacado a importância dos centros de avaliação judicial em decisões baseadas em evidências. A atrofia muscular espinhal (AME) é uma doença neurodegenerativa caracterizada principalmente por hipotonia muscular progressiva e alta mortalidade nos primeiros dois anos de vida. Embora o medicamento Zolgensma® (onasemnogeno abeparvoveque) seja indicado para o tratamento da AME, seu custo elevado e a indisponibilidade pelo sistema público de saúde brasileiro tornam o tratamento inviável, resultando em processos judiciais. Objetivo: Descrever o perfil das informações contidas nas notas técnicas (NT) disponíveis no Sistema Nacional de Pareceres e Notas Técnicas (e-NatJus), utilizadas como apoio nas decisões judiciais relacionadas ao Zolgensma®. Material e Métodos: Foi realizado um estudo descritivo com dados de notas técnicas disponíveis no e-NatJus no período entre setembro de 2021 a setembro de 2023. Resultados: Foram identificadas 63 notas técnicas, sendo que uma foi excluída por se tratar de nota complementar. Das 62 NTs consideradas elegíveis para análise neste estudo, a idade média dos participantes foi de 2,03 (± 1,54) anos, sendo a maioria do sexo masculino. A maioria das solicitações foi para tratamento de AME tipo 1 (N= 52; 82%). Destas, somente 23 atendiam a faixa etária inferior a 2 anos. Quanto à recomendação final, 14 NTs foram favoráveis ao fornecimento do Zolgensma®. Conclusão: Os resultados revelaram o perfil das NTs baseadas em evidências científicas, que subsidiam decisões judiciais visando minimizar impactos no orçamento da saúde. Iniciativas como o Sistema e-NatJus são fundamentais para acesso a esses subsídios, embora a disseminação de informações e capacitações continuadas sejam necessárias. Pesquisas adicionais sobre o impacto dos Núcleos de Avaliação de Tecnologias em Saúde (NATS) e Núcleos de Apoio Técnico ao Judiciário (NATJUS) na judicialização da saúde são importantes.

Introduction: The increasing judicialization of health has highlighted the importance of judicial evaluation centers in evidence-based decisions. Spinal Muscular Atrophy (SMA) is a neurodegenerative disease characterized mainly by progressive muscle hypotonia and high mortality in the first two years of life. Although the medication Zolgensma® (onasemnogene abeparvovec) is indicated for the treatment of SMA, its high cost and unavailability through the Brazilian public health system make the treatment unfeasible, resulting in legal proceedings. Objective: To describe the profile of the information contained in the Technical Notes (TN) available in the e-NatJus System used as support in Zolgensma® judicial decisions. Material and Methods: A descriptive study was conducted with data from technical notes available in the National System of Opinions and Technical Notes (e-NatJus) from September 2021 to September 2023. Results: 63 Technical Notes were identified, with one excluded as a Complementary Note. Of the 62 TNs considered eligible for analysis in this study, the mean age of the participants was 2.03 (± 1.54) years, with the majority being male. Most requests were for the treatment of SMA type 1 (N= 52; 82%). Of these, only 23 met the age criteria of less than 2 years. Regarding the final recommendation, 14 TNs were favorable to the provision of Zolgensma®. Conclusion: The results revealed the profile of technical notes based on scientific evidence, which support judicial decisions aimed at minimizing impacts on healthcare budgets. Initiatives like the e-NatJus System are essential for accessing these subsidies, although the dissemination of information and continuous training are necessary. Further research on the impact of NATS and NATJUS on healthcare judicialization is important.

Possibility of genetic therapy for inherited retinal conditions.

OBJECTIVE: To evaluate the possibility of gene therapy in patients with inherited ocular conditions and established genetic diagnosis. The secondary objectives were to determine the genetic diagnostic rate and to update the list of genes for which there are ongoing clinical trials or preclinical studies that could allow for gene therapy. METHODS: Observational, retrospective, multicentric study of 177 patients with inherited ocular conditions that underwent genetic testing. RESULTS: Of 177 patients with genetic testing, 146 were enrolled for this study. Disease-causing variants were identified in 117 patients (variant detection rate of 80.1%). Pathogenic variants were found in 47 genes, with ABCA4 being the most common gene (17.9%), followed by CRB1 (11.9%). 64.1% of patients with a genetic diagnosis have a variant in genes for which gene therapy has been studied and only 40.1% have a variant in genes with studies for gene therapy in clinical phase. CONCLUSIONS: Genetic testing has opened new horizons in the management of patients with hereditary ocular diseases. About two-thirds of the patients had pathogenic variants in genes for which gene therapy has been evaluated. However, many studies are in the pre-clinical phase. The expectations of patients undergoing genetic study and their families should be managed accordingly.

Antibióticos innovadores contra la farmacorresistencia bacteriana obtenido por tecnología de edición genética CRISPR/Cas9 / Innovative antibiotics against bacterial drug resistance obtained by CRISPR/cas9 gene editing technology

Introducción: El aumento de la resistencia a los antimicrobianos constituye actualmente una peligrosa amenaza para la salud. Ante este problema global de falta de antimicrobianos, es perentorio intervenir de forma coordinada e idear fórmulas para incentivar la investigación a nivel internacional. Objetivo: Realizar una revisión actualizada sobre las causas y mecanismos de la resistencia a los antibióticos y la adaptación del sistema CRISPR/Cas para el desarrollo de innovadores antimicrobianos como parte esencial de una estrategia altamente específica en el tratamiento de infecciones producidas por bacterias resistentes. Métodos: Se realizó una revisión documental, se empleó la bibliografía nacional e internacional especializada publicada en los últimos 5 años. Se utilizó el motor de búsqueda Google Académico y se consultaron artículos de libre acceso en las bases de datos Pubmed, SciELO, LILACS, CUMED y HINARI, en el período comprendido entre marzo de 2020 hasta el mes de enero de 2021. Se revisaron un total de 41 artículos. Las consultas se hicieron en inglés y español. Para la búsqueda se tuvo en cuenta las palabras clave: eligobióticos; resistencia a antibióticos; CRISPR/Cas. Resultados: La evidencia recopilada sustenta que muchas enfermedades son inducidas por alteraciones del equilibrio de la microbiota humana y la técnica de edición genética CRISPR/Cas permitirá el desarrollo de novedosos antibióticos como los eligobióticos que eliminarán las bacterias patógenas multirresistentes y dejarán intacto el microbioma. Conclusiones: el esclarecimiento de los enigmas de la microbiota y su diseño con terapia génica permitirán el progreso de innovadores antibióticos con empleo del sistema CRISPR/Cas que ineludiblemente modificarán la práctica médica para siempre(AU)

Introduction: The increase in antimicrobial resistance is currently a dangerous threat to health. Faced with this global problem of lack of antimicrobials, it is imperative to intervene in a coordinated manner and devise formulas to encourage research at the international level. Objective: To review on the update causes and mechanisms of antibiotic resistance and the adaptation of CRISPR/Cas system for the development of innovative antimicrobials as an essential part of a highly specific strategy in the treatment of infections caused by resistant bacteria. Methods: A documentary review was carried out in the specialized national and international bibliography published in the last 5 years. Google Scholar search engine was used and free access articles were consulted in Pubmed, SciELO, LILACS, CUMED and HINARI databases, from March 2020 to January 2021. A total of 41 articles were retrieved. The consultations were made in English and Spanish. For the search, we took into account the keywords eligobiotics, antibiotic resistance, CRISPR/Cas. Results: The reviewed evidence supports that many diseases are induced by alterations in the balance of the human microbiota; and CRISPR/Cas gene editing technique will allow the development of novel antibiotics such as eligobiotics that will eliminate multi-resistant pathogenic bacteria and leave the microbiome intact. Conclusions: The clarification of the enigmas of the microbiota and its design with gene therapy will allow the progress of innovative antibiotics using CRISPR/Cas system that will inevitably change medical practice forever(AU)

Ética de la edición genética en seres humanos

Propósito/Contexto. Este artículo analiza aspectos éticos de la edición genética en seres humanos. Metodología/Enfoque. Se describe el desarrollo de las principales aplicaciones de la tecnología genética en prevención, diagnóstico y terapéutica de enfermedades genéticas en las últimas décadas, culminando con la edición genética. Resultados/Hallazgos. Se definen los principales aspectos éticos que presenta la edición genética somática y germinal en seres humanos, incluyendo cuestiones de seguridad, especificidad, precisión y certeza. Se critica la edición genética germinal y el concepto de "mejoramiento" humano por vulnerar la autonomía individual, generar cambios genéticos heredables en la progenie y aceptar la falacia del reduccionismo genético de que los rasgos de las personas dependen exclusivamente de la constitución genética, independiente del ambiente. Discusión/Conclusiones/Contribuciones. La edición genética somática puede ser ética si se siguen las normas éticas de la investigación biomédica. Por el contrario, la edición genética germinal no es pertinente ni necesaria para el tratamiento de enfermedades genéticas y presenta graves conflictos éticos, por lo cual, previo a su aplicación es necesario un consenso social por discusiones democráticas, amplias y profundas entre todos los actores sociales involucrados, seguido de mecanismos de gobernanza con regulación robusta por parte del estado, que impidan la vulneración de derechos humanos fundamentales.

Purpose/Context. This article discusses ethical aspects of gene editing in humans. Methodology/Approach. The main applications of genetic technology in the prevention, diagnosis and therapeutics of genetic diseases in recent decades, are described, culminating with genetic editing. Results/Findings. The main ethical aspects of somatic and germline gene editing in humans are discussed, including issues of safety, specificity, precision and certainty. Germline genetic editing and human "enhancement" are criticized for violating individual autonomy, for generating heritable genetic changes in the progeny and for accepting the fallacy of genetic reductionism that people's traits depend exclusively on genetic makeup, independent of the environment. Discussion/Conclusions/Contributions. Somatic gene editing can be ethical if the ethical standards of biomedical research are followed. However, germline genetic editing is not relevant nor necessary for the treatment of genetic diseases and, furthermore, it presents serious ethical conflicts. Therefore, prior to its application, a social consensus is necessary, obtained by democratic, broad and profound discussions among all the social players involved, followed by governance mechanisms with robust regulation by the state, which prevent the violation of fundamental human rights.

Finalidade/Contexto. Este artigo discute aspectos éticos da edição de genes em humanos. Metodologia/Aproximação. Descreve o desenvolvimento das principais aplicações da tecnologia genética na prevenção, diagnóstico e terapia de doenças genéticas nas últimas décadas, culminando com a edição de genes. Resultados/Descobertas. São definidos os principais aspectos éticos da edição de genes somáticos e da linha germinal no ser humano, incluindo questões de segurança, especificidade, precisão e exactidão. A edição genética da Germline e o conceito de "melhoramento" humano são criticados por violarem a autonomia individual, gerando alterações genéticas hereditárias nos descendentes e aceitando a falácia do reducionismo genético de que as características das pessoas dependem exclusivamente da sua constituição genética, independente do ambiente. Discussão/Conclusões/Contribuições. A edição somática de genes pode ser ética se os padrões éticos da investigação biomédica forem seguidos. Pelo contrário, a edição genética na linha germinal não é relevante nem necessária para o tratamento de doenças genéticas e apresenta graves conflitos éticos. Por conseguinte, antes da sua aplicação, é necessário um consenso social através de discussões democráticas, amplas e profundas entre todos os actores sociais envolvidos, seguidas de mecanismos de governação com regulação robusta por parte do Estado, que impeçam a violação dos direitos humanos fundamentais.

Reflections about the Molecular Tool That Could Change the Course of Human History: Genome Editing / Reflexiones sobre la herramienta molecular que podría cambiar el curso de la historia humana: la edición genómica / Reflexões sobre as ferramentas moleculares que poderiam mudar o rumo da história humana: a edição de genoma

Abstract Genetic editing has many applications in almost all areas of society, but may also lead to unpredictable consequences. Genome editing to modify the human germline is at the center of global discussion. Owing to the increasing number of unanswered scientific, ethical, and policy questions, the scientific community agrees that it would be inappropriate to genetically modify embryos. A serious and open debate is necessary to decide whether such research should be suspended or encouraged. Here we show some bold arguments in favor of deleting deleterious genes from the human genome and the risks liberal eugenism poses.

Resumen La edición genética tiene muchas aplicaciones en casi todos los ámbitos de la sociedad, pero también puede tener consecuencias impredecibles. La edición del genoma de la línea germinal humana es el centro de una discusión mundial. Debido al creciente número de cuestionamientos científicos, éticos y políticos, muchos sin una respuesta concreta, el consenso de la comunidad científica manifiesta que sería inapropiado modificar genéticamente embriones humanos. Se considera necesario un debate serio y abierto para decidir si se debe suspender o fomentar la investigación en este sentido. En el presente documento, se exponen algunos argumentos audaces a favor de la eliminación de los genes nocivos del genoma humano y los riesgos que supone el eugenismo liberal.

Resumo A edição de genoma tem muitas aplicações em todos os âmbitos da sociedade, no entanto pode ter consequências imprevisíveis. A edição do genoma da linha germinal humana é o centro de uma discussão mundial. Devido ao número crescente de questionamentos científicos, éticos e políticos, muitos sem resposta concreta, o consenso da comunidade científica manifesta que não seria apropriado modificar geneticamente embriões humanos. Consideramos que é necessário um debate sério e aberto para decidir se é necessário suspender ou fomentar a pesquisa nesse sentido. Aqui mencionamos alguns argumentos audazes a favor da eliminação de genes nocivos do genoma humano e os riscos decorrentes do eugenismo liberal.

Cystic fibrosis: current concepts.

Cystic fibrosis is an autosomal recessive genetic disease, mainly in Caucasian children and young adults. It is caused by pathogenic variants in the CFTR (cystic fibrosis transmembrane conductance regulator) gene, which results in increased viscosity and difficult mucus clearance. The main organ affected is the lung, the pancreas, sweat glands, intestine, liver, nasal mucosa, salivary glands, and reproductive tract. The clinical manifestations vary, ranging from the most frequent pulmonary symptoms of obstructive disease to gastrointestinal manifestations relatection of pathogenic variants in the CFTR gene allow the diagnosis to be integrated. Cystic fibrosis management consists of three main strategies: firstly, to keep the airway free of secretion; secondly, to keep the airway free of infection; and finally, to maintain an optimal nutritional status. Therapies that seek to correct alterations in the CFTR gene are focused on avoiding a pathogenic nonsense variant, correcting folding, increasing trafficking to the plasma membrane, or increasing the function of the CFTR channel. Other therapies still under development include gene therapy, genome editing, and antisense oligonucleotides to modify the expression of this gene.

La fibrosis quística es una enfermedad genética autosómica recesiva que se presenta principalmente en niños y adultos jóvenes caucásicos. Está causada por variantes patogénicas en el gen CFTR (regulador de la conductancia transmembrana de la fibrosis quística), lo que ocasiona un aumento de la viscosidad y un difícil aclaramiento del moco. El principal órgano afectado es el pulmón, seguido del páncreas, las glándulas sudoríparas, el intestino, el hígado, la mucosa nasal, las glándulas salivales y el aparato reproductor. Las manifestaciones clínicas son variables y van desde las más frecuentes, que son los síntomas pulmonares de enfermedad obstructiva, hasta manifestaciones gastrointestinales relacionadas con la malabsorción secundaria a la insuficiencia pancreática. Aunque existen múltiples pruebas diagnósticas para la fibrosis quística, el tamiz neonatal, el aumento en el tripsinógeno inmunorreactivo, la prueba de cloro en sudor y la detección de variantes patogénicas en el gen CFTR permiten integrar el diagnóstico. El manejo consta de tres niveles principales: el primero, mantener la vía aérea libre de secreción; el segundo, mantener la vía aérea libre de infección; y por último, mantener un estado nutricional óptimo. Las terapias que buscan corregir las alteraciones en el gen CFTR están enfocadas en evitar una variante patogénica sin sentido, corregir el plegamiento, aumentar el tráfico a la membrana plasmática o incrementar la función del canal CFTR. Otras terapias aún en desarrollo incluyen la terapia génica, la edición del genoma y los oligonucleótidos antisentido para modificar la expresión de este gen.

[Treatment of haemophilia: From replacement to gene therapy]. / Tratamiento de la hemofilia: de la terapia sustitutiva a la terapia génica.

Haemophilia A and B are congenital bleeding disorders characterized by missing or defective factor VIII or factor IX, respectively. Factor replacement therapy has been the gold standard for prophylaxis and treatment of bleeding complications. However, the inconvenience of regular intravenous administration, along with progression of arthropathy and development of inhibitors has driven the need for alternative treatment options, such as extended half-life products, non-factor coagulation products, such as subcutaneous emicizumab, blocking natural anticoagulants (rebalancing haemostatic agents) and gene therapy, which have been useful to control bleeding or are currently under late-phase clinical investigation.

CRISPR-Cas, el editor de genes / CRISPR, gene editor

El término CRISPR, por su acrónimo en inglés refiere a Clustered Regularly Interspaced Short Palindromic Repeats, es decir, repeticiones palindrómicas cortas, agrupadas y regularmente esparcidas, por sus características en el genoma, pertenece naturalmente al sistema de defensa de bacterias y arqueas. Este ha sido adaptado biotecnológicamente para la edición del ADN de células eucariotas, incluso de células humanas. El sistema CRISPR-Cas para editar genes consta, en forma generalizada, de dos componentes: una proteína nucleasa (Cas) y un ARN guía (sgRNA). La simplicidad del complejo lo hace una herramienta molecular reprogramable capaz de ser dirigida y de editar cualquier sitio en un genoma conocido. Su principal foco son las terapias para enfermedades hereditarias monogénicas y para el cáncer. Sin embargo, además de editor de genes, la tecnología CRISPR se utiliza para edición epigenética, regulación de la expresión génica y método de diagnóstico molecular. Este artículo tiene por objetivo presentar una revisión de las aplicaciones de la herramienta molecular CRISPR-Cas, particularmente en el campo biomédico, posibles tratamientos y diagnósticos, y los avances en investigación clínica, utilizando terapia génica con CRISPR/Cas más relevantes hasta la fecha. (AU)

CRISPR are Clustered Regularly Interspaced Short Palindromic Repeats, which naturally belong to the defense system of bacteria and archaea. It has been biotechnologically adapted for editing the DNA of eukaryotic cells, including human cells. The CRISPR-Cas system for editing genes generally consists of two components, a nuclease protein (Cas) and a guide RNA (sgRNA). The simplicity of the complex makes it a reprogrammable molecular tool capable of being targeted and editing any site in a known genome. Its main focus is therapies for monogenic inherited diseases and cancer. However, in addition to gene editor, CRISPR technology is used for epigenetic editing, regulation of gene expression, and molecular diagnostic methods. This article aims to present a review of the applications of the CRISPR-Cas molecular tool, particularly in the biomedical field, possible treatments and diagnoses, and the advances in clinical research, using the most relevant CRISPR-Cas gene therapy to date. (AU)

Gene therapy with urokinase-type plasminogen activator regenerates liver tissue.

BACKGROUND AND OBJECTIVES: Gene therapy using urokinase-type plasminogen activator (uPA) has been shown to induce extracellular matrix degradation, hepatocyte proliferation and liver tissue function restoration in liver cirrhosis models. Physiologically, uPA activates plasminogen conversion to plasmin, which leads, depending on the organ, to thrombolysis or extracellular matrix degradation. The purpose of this study was to compare the regenerative effect of gene therapy with adenoviruses encoding wild-type uPA (huPA), as well as its truncated isoform (ΔhuPA), in healthy and cirrhotic animals. In addition, possible adverse effects on coagulation were assessed. METHODS: 6 x 1011 vp/kg of Ad-huPA or Ad-ΔhuPA were administered via the iliac vein to healthy male Wistar rats or to male Wistar rats with cirrhosis induced by chronic poisoning with carbon tetrachloride (CCl4). The animals were sacrificed at day 2, 4 or 6 post-treatment. Liver fibrosis, proliferating cell nuclear antigen expression, alanine aminotransferase (ALT) and aspartate aminotransferase (AST) serum levels and coagulation markers were evaluated. RESULTS: On day 6 post-treatment, a fibrosis reversal of 48.7-41.5% was achieved. AST and ALT levels did not change in cirrhotic animals treated with ΔhuPA, but showed an elevation in healthy animals. Cell proliferation increased in healthy and cirrhotic animals with both transgene isoforms. No coagulation adverse effects were observed in the ΔhuPA group, and by day 6, they had disappeared in the huPA group. CONCLUSIONS: Gene therapy with Ad-huPA and Ad-ΔhuPA favors cell proliferation in cirrhotic animals, without important side effects.

ANTECEDENTES Y OBJETIVOS: La terapia génica empleando el activador de plasminógeno tipo urocinasa (huPA) ha demostrado que induce la degradación de matriz extracelular, la proliferación de hepatocitos y el restablecimiento de la funcionalidad tisular en modelos de cirrosis hepática. Fisiológicamente, el uPA activa la conversión del plasminógeno en plasmina, lo que conlleva, dependiendo del órgano, una trombólisis o a degradación de la matriz extracelular. El objetivo de este estudio fue comparar el efecto regenerador de la terapia génica con adenovirus codificando la forma silvestre (huPA), así como su isoforma truncada (DhuPA) en animales sanos y cirróticos. Además, se valoraron los posibles efectos adversos sobre la coagulación. MÉTODOS: Se administró 6x1011 pv/kg del Ad-huPA o Ad-ΔhuPA a ratas Wistar macho sanas o con cirrosis por intoxicación crónica con tetracloruro de carbono (CCl4) vía vena ilíaca. El sacrificio fue al día 2, 4 o 6 postratamiento. Se evaluó la fibrosis hepática, la expresión de antígeno nuclear de proliferación celular y niveles séricos de alanina aminotransferasa (ALT) y aspartato aminotransferasa (AST), y marcadores de coagulación. RESULTADOS: Al día 6 postratamiento se alcanzó una reversión de fibrosis del 48.7-41.5%. Los niveles de AST y ALT no cambiaron en animales cirróticos tratados con DhuPA, pero aumentaron en animales sanos comparados con el control sano no tratado. La proliferación aumenta en animales sanos y cirróticos con ambas isoformas del transgén. No se observaron efectos adversos en la coagulación en el grupo DhuPA y para el día 6 habían desaparecido en el grupo huPA. CONCLUSIONES: La terapia génica con Ad-uPA y Ad-ΔhuPA favorece la proliferación celular en animales cirróticos, sin efectos secundarios importantes.

Células madre como alternativa al marcapaso transvenoso / Stem cells as an alternative to the transvenous pacemaker

Resumen Objetivo: describir el estado del arte del marcapasos biológico y las perspectivas para crear tejido cardíaco de marcapasos utilizando modernas tecnologías genéticas y de ingeniería de tejidos. Métodos: revisión sistemática de la literatura. Resultados: los marcapasos se han convertido en el tratamiento primordial para cierto tipo de arritmias o bloqueos avanzados sintomáticos. Somos testigos de mejoras continuas en la tecnología del dispositivo, con avances en el diseño del cable, el tamaño del generador, la longevidad de la batería y los algoritmos de software que se han traducido en dispositivos más pequeños con funcionalidad mejorada. En la actualidad existen muchos sistemas implantables de cardioestimulación capaces de reemplazar la función de los marcapasos fisiológicos (seno y nódulos aurículo-ventriculares) que incluyen los recientemente desarrollados marcapasos secuenciales y autoprogramables. En la última década la investigación ha confirmado que el marcapasos biológico se puede crear mediante la terapia génica y la terapia celular. Hoy existen dos enfoques para construir marcapasos biológicos: uno es para introducir genes de marcapasos en células madre mesenquimales, y el otro es para inducir células madre pluripotentes en las células del nódulo sinoauricular. Conclusiones: los marcapasos biológicos, actualmente en la etapa preclínica, podrían ser una alternativa a los dispositivos electrónicos para pacientes seleccionados en el futuro.

Abstract Objective: To describe the state of the art of biological pacemakers and the perspectives for creating cardiac pacing tissue using modern genetic and tissue engineering technologies. Methods: A systematic review of the literature. Results: Pacemakers have become the first line treatment for certain types of arrhythmias and advanced symptomatic blocks. We are witnessing continuous improvements in the technology of the device, with advances in the design of the cable, the size of the generator, the longevity of the battery, as well as the software algorithms that have led to smaller devices with improved functions. There are currently many cardiac stimulation implantable systems capable of replacing the function of physiological pacemakers systems (sinus and atrial-ventricular nodes) that include the recently developed sequential and self-programmable pacemakers. In the last ten years or so, studies have confirmed that biological pacemakers can be created using gene therapy and cell therapy. There are currently to main efforts to construct biological pacemakers. One is to introduce pacemaker genes in mesenchymal stem cells, and the other is to introduce pluripotent stem cells in cells of the sinoatrial node. Conclusions: Biological pacemakers, currently in the pre-clinical stage, could be an alternative to the electronic devices for selected patients in the future.

Novel therapeutics in hypertriglyceridaemia and chylomicronaemia. / Nuevos tratamientos en la hipertrigliceridemia y en la hiperquilomicronemia.

Currently there is evidence on hypertriglyceridaemia as an independent risk factor of atherosclerosis. Chylomicronaemia associated with very high concentration of triglycerides may cause severe and recurrent acute pancreatitis. The cause of most cases is a combination of a polygenetic basis with some lifestyles and pathological conditions. Some rare and familial chylomicronaemias are mendelian diseases with an autosomal recessive pattern. On the other hand, plasma triglycerides have considerable biological variability and usually descend with non-pharmacological interventions alone. In some cases, drugs are also required for their control, but their impact on vascular risk reduction or pancreatitis prevention is more controversial. The recent advances in knowledge of molecular lipid metabolism and pharmacological technologies are resulting in the development of new therapeutic strategies, which can be applied to patients with refractory hypertrigliceridaemia. The challenge may be how the health systems can cover its high costs.

Terapia gênica de isquemia de membro é uma realidade? / Is gene therapy for limb ischemia a reality?

Resumo O conceito de terapia angiogênica surgiu no início da década de 90, o que pode ser feito com genes que codificam fatores de crescimento para promover a formação de novos vasos e o remodelamento de vasos colaterais. Como o procedimento dessa terapia geralmente consiste em apenas injeções locais de vetores, esse processo é pouco invasivo, rápido e de simples realização. Entretanto, desde as primeiras evidências clínicas do efeito de terapia gênica com o fator de crescimento de endotélio vascular (vascular endothelial growth factor, VEGF) vistos nos pacientes com doença arterial obstrutiva periférica até hoje, apenas dois fármacos de terapia angiogênica foram aprovados, um na Rússia e outro no Japão, o que parece um número muito pequeno diante do grande número de investimentos feitos por meio de estudos pré-clínicos e clínicos. Afinal, podemos considerar que a terapia angiogênica já é uma realidade?

Abstract The concept of angiogenic therapy emerged in the early 1990s. The method employs genes that encode growth factors to promote formation of new vessels and remodeling of collateral vessels. Since the procedure involved in this therapy usually only consists of local injections of vectors, the process is minimally invasive, quick, and simple to perform. However, since the first clinical evidence of the effects of gene therapy with vascular endothelial growth factor (VEGF) was observed in patients with peripheral artery disease, to date only two angiogenic therapy drugs have been approved, one in Russia and another in Japan, which seem a very small number, in view of the large volume of investment made in pre-clinical and clinical studies. After all, can we conclude that angiogenic therapy is a reality?

Hiposialia y Xerostomía Post Irradiación: Terapias Innovadoras en el Campo Biomolecular / Hyposialia and Xerostomy Post Irradiation: Innovative Therapies in the Biomolecular Field

Las glándulas salivales humanas pueden ser gravemente lesionadas por la radioterapia utilizada contra neoplasias de cabeza y cuello, produciendo hiposialia y xerostomía, las cuales afectan la salud oral y sistémica, mermando la calidad de vida de la persona. Los tratamientos convencionales actuales están diseñados para disminuir los síntomas, sin actuar sobre los cambios fisiopatológicos que se dan a nivel glandular. Esta revisión intenta analizar aquellas terapias preventivas y/o curativas que están desarrollándose en el campo biomolecular y que tienen un futuro prometedor por sus características innovadoras: terapia génica, terapia con células madre y terapia con factores de crecimiento. Se evidencia un aporte adicional de la nanotecnología, la cual está mejorando las vías de aplicación de los tratamientos.

Human salivary glands can be seriously injured by the radiotherapy used against head and neck neoplasms, producing hyposialia and xerostomy, which affect oral and systemic health, diminishing the person's quality of life. Current conventional treatments are designed to reduce symptoms, without acting on the pathophysiological changes that occur at the glandular level. This review attempts to analyze those preventive and /or curative therapies that are developing in the biomolecular field and that have a promising future due to their innovative features: Gene therapy, stem cell therapy and growth factor therapy. An additional contribution of nanotechnology is evident, which is improving the routes of treatment application.

Avances en el tratamiento de la distrofia de Duchenne / Advances in the treatment of Duchenne muscular dystrophy

La distrofia muscular de Duchenne es una enfermedad genéticamente determinada, ligada al cromosoma X y caracterizada clínicamente por producir debilidad muscular progresiva, con una incidencia de 1 por cada 3500-6000 varones nacidos. Es causada por la mutaciones en el gen DMD, el cual codifica la distrofina, una proteína sub-sarcolémica esencial para la estabilidad estructural del músculo. Los defectos genéticos en el gen DMD, se dividen en: deleciones (65%) duplicaciones (5-10%) y mutaciones puntuales (10-15%). Actualmente no se dispone de tratamiento curativo, el único fármaco que ha demostrado modificar la historia natural de la enfermedad (independientemente de la mutación genética) son los corticoides, los cuales están indicados en estadios tempranos de la enfermedad. En relación a los ensayos clínicos, en los últimos diez años se han experimentado grandes avances en el campo de las opciones terapéuticas, divididos en dos grandes dianas terapéuticas: 1) el área de las terapias génicas y 2) tratar de revertir o bloquear los procesos fisiopatológicos de la enfermedad, tales como inflamación, fibrosis, regeneración muscular, etc. Es probable que un tratamiento eficaz para la distrofia muscular de Duchenne requiera combinaciones que se apliquen tanto al defecto primario como las consecuencias fisiopatológicas secundarias.

Duchenne muscular dystrophy is a genetically determined disease, linked to the X chromosome, c haracterized clinically by producing progressive muscle weakness, with an incidence of 1 per 3500-6000 males born. It is caused by the mutation of the DMD gene, which encodes dystrophin, a sub-sarcolemmal protein essential for structural muscle stability. The genetic defects in the DMD gene are divided into: deletions (65%) duplications (5.10%) and point mutations (10-15%). At present there is no curative treatment, the only drug that has been shown to modify the natural history of the disease (independently of the genetic mutation) are corticosteroids, currently indicated in early stages of the disease. In relation to clinical trials, in the last ten years, has experienced great advances in the field of therapeutic options, divided into two major therapeutic targets: 1) the area of gene therapies and 2) trying to reverse or block the pathophysiological processes of the disease, such as inflammation, fibrosis, muscle regeneration, etc. It is likely that an effective treatment for Duchenne muscular dystrophy requires combinations of therapies that address both the primary defect and its secondary pathophysiological consequences.

Consensus on the diagnosis, treatment and follow-up of patients with Duchenne muscular dystrophy. / Consenso para el diagnóstico, tratamiento y seguimiento del paciente con distrofia muscular de Duchenne.

INTRODUCTION: Duchenne muscular dystrophy (DMD) is the most common myopathy in children, with a worldwide prevalence of approximately 0.5 cases per 10,000 male births. It is characterised by a progressive muscular weakness manifesting in early childhood, with the subsequent appearance of musculoskeletal, respiratory, and cardiac complications, causing disability, dependence, and premature death. Currently, DMD is mainly managed with multidisciplinary symptomatic treatment, with favourable results in terms of the progression of the disease. It is therefore crucial to establish clear, up-to-date guidelines enabling early detection, appropriate treatment, and monitoring of possible complications. DEVELOPMENT: We performed a literature search of the main biomedical databases for articles published in the last 10years in order to obtain an overview of the issues addressed by current guidelines and to identify relevant issues for which no consensus has yet been established. The degree of evidence and level of recommendation of the information obtained were classified and ordered according to the criteria of the American Academy of Neurology. CONCLUSIONS: DMD management should be multidisciplinary and adapted to the patient's profile and the stage of clinical progression. In addition to corticotherapy, treatment targeting gastrointestinal, respiratory, cardiac, and orthopaedic problems, as well as physiotherapy, should be provided with a view to improving patients' quality of life. Genetic studies play a key role in the management of the disease, both in detecting cases and potential carriers and in characterising the mutation involved and developing new therapies.

Desarrollo de vectores génicos basados en polímeros sintéticos: PEI y PDMAEMA / Development of genetic vectors based on synthetic polymers: PEI and PDMAEMA

RESUMEN En años recientes hubo un auge del uso de terapias génicas para el tratamiento de enfermedades de gran incidencia, como el cáncer. Generalmente, estas se basan en la liberación de material genético como plásmidos, en el núcleo celular, con lo cual se corrige una función o se induce la producción de proteínas deficientes a nivel fisiológico. Para llevar a cabo la terapia génica se requiere de vectores capaces de encapsular el material genético y garantizar su entrega en el núcleo celular. Los polímeros catiónicos sintéticos han llamado la atención como vectores, debido a su capacidad de condensar ácidos nucleicos para formar partículas que los protegen de la degradación enzimática y facilitan su captación celular. La polietilenimina y el polimetacrilato de N, N-dimetilaminoetilo son los polímeros catiónicos más eficaces para la administración génica. Sin embargo, estos requieren modificaciones químicas específicas para eliminar o disminuir algunas limitaciones tales como su alta citotoxicidad y baja biodegradabilidad. En este artículo se analizan algunas de estas modificaciones, enfocándose en avances recientes en el desarrollo de copolímeros anfifílicos como precursores de nanopartículas usadas como vectores génicos.

SUMMARY During recent years, the use of genetic therapies has taken relevance in the treatment of high-incidence diseases such as cancer. Usually, they are based on the release of genetic material, as plasmids, into the cell nucleus, which corrects a function or induces the production of a deficient protein at the physiological level. To carry out gene therapy, vectors capable of encapsulating the genetic material and guaranteeing its delivery in the target cell nucleus are required. Synthetic cationic polymers have attracted great attention as vectors due to their ability to condense nucleic acids to form particles that protect them from enzymatic degradation and facilitate their cellular uptake. Polyethylenimine and poly (N, N-dimethylaminoethyl methacrylate) are the most effective cationic polymers for gene delivery. However, these polymers require specific chemical modifications to either avoid or diminish their high cytotoxicity and low biodegradability. This review analyzes some of these modifications, focusing on recent advances in the development of amphiphilic copolymers as precursors of nanoparticles used as gene vectors.