Gene Therapy: Mechanisms, Clinical Translation, Challenges, and Future Perspectives
DOI:
https://doi.org/10.69760/portuni.26050007Keywords:
Gene therapy, adeno-associated virus, lentiviral vectors, CRISPR-Cas9, base editing, prime editing, CAR-T cell therapy, lipid nanoparticles, insertional mutagenesis, precision medicineAbstract
Gene therapy has progressed from a speculative concept to a clinically validated therapeutic modality, transforming the management of monogenic disorders, hematologic malignancies, and ocular, neuromuscular, and cardiovascular diseases. Following nearly five decades of preclinical refinement and a turbulent early clinical history marked by serious adverse events, the field has matured into a regulated discipline supported by over 3,900 clinical trials worldwide. This review synthesizes the current state of gene therapy, with emphasis on viral and non-viral delivery platforms—particularly adeno-associated viral (AAV) vectors, lentiviral vectors, and ionizable lipid nanoparticles (LNPs)—as well as somatic versus germline and in vivo versus ex vivo classifications. Landmark regulatory approvals, including voretigene neparvovec (Luxturna), onasemnogene abeparvovec (Zolgensma), etranacogene dezaparvovec (Hemgenix), exagamglogene autotemcel (Casgevy), and chimeric antigen receptor (CAR)-T cell therapies, are critically appraised. Genome-editing innovations—CRISPR-Cas9, base editing, and prime editing—are discussed in the context of expanding therapeutic precision. Persistent challenges encompass immunogenicity, off-target editing, insertional mutagenesis, durability of expression, manufacturing scalability, and equitable access. The review concludes with future perspectives on next-generation vectors, in vivo CAR-T engineering, and global access frameworks essential to realizing the curative promise of genetic medicine.
References
Anzalone, A. V., Randolph, P. B., Davis, J. R., Sousa, A. A., Koblan, L. W., Levy, J. M., Chen, P. J., Wilson, C., Newby, G. A., Raguram, A., & Liu, D. R. (2019). Search-and-replace genome editing without double-strand breaks or donor DNA. Nature, 576(7785), 149–157. https://doi.org/10.1038/s41586-019-1711-4
Bushman, F. D. (2020). Retroviral insertional mutagenesis in humans: Evidence for four genetic mechanisms promoting expansion of cell clones. Molecular Therapy, 28(2), 352–356. https://doi.org/10.1016/j.ymthe.2019.12.009
Cavazzana, M., Bushman, F. D., Miccio, A., André-Schmutz, I., & Six, E. (2019). Gene therapy targeting haematopoietic stem cells for inherited diseases: Progress and challenges. Nature Reviews Drug Discovery, 18(6), 447–462. https://doi.org/10.1038/s41573-019-0020-9
Cox, D. B. T., Gootenberg, J. S., Abudayyeh, O. O., Franklin, B., Kellner, M. J., Joung, J., & Zhang, F. (2017). RNA editing with CRISPR-Cas13. Science, 358(6366), 1019–1027. https://doi.org/10.1126/science.aaq0180
Doudna, J. A. (2020). The promise and challenge of therapeutic genome editing. Nature, 578(7794), 229–236. https://doi.org/10.1038/s41586-020-1978-5
Dunbar, C. E., High, K. A., Joung, J. K., Kohn, D. B., Ozawa, K., & Sadelain, M. (2018). Gene therapy comes of age. Science, 359(6372), eaan4672. https://doi.org/10.1126/science.aan4672
Frangoul, H., Altshuler, D., Cappellini, M. D., Chen, Y.-S., Domm, J., Eustace, B. K., Foell, J., de la Fuente, J., Grupp, S., Handgretinger, R., Ho, T. W., Kattamis, A., Kernytsky, A., Lekstrom-Himes, J., Li, A. M., Locatelli, F., Mapara, M. Y., de Montalembert, M., Rondelli, D., … Corbacioglu, S. (2021). CRISPR-Cas9 gene editing for sickle cell disease and β-thalassemia. New England Journal of Medicine, 384(3), 252–260. https://doi.org/10.1056/NEJMoa2031054
Gaudelli, N. M., Komor, A. C., Rees, H. A., Packer, M. S., Badran, A. H., Bryson, D. I., & Liu, D. R. (2017). Programmable base editing of A•T to G•C in genomic DNA without DNA cleavage. Nature, 551(7681), 464–471. https://doi.org/10.1038/nature24644
Ginn, S. L., Mandwie, M., Alexander, I. E., Edelstein, M., & Abedi, M. R. (2024). Gene therapy clinical trials worldwide to 2023—an update. The Journal of Gene Medicine, 26(8), e3721. https://doi.org/10.1002/jgm.3721
Hastie, E., & Samulski, R. J. (2015). Adeno-associated virus at 50: A golden anniversary of discovery, research, and gene therapy success. Human Gene Therapy, 26(5), 257–265. https://doi.org/10.1089/hum.2015.025
High, K. A., & Roncarolo, M. G. (2019). Gene therapy. New England Journal of Medicine, 381(5), 455–464. https://doi.org/10.1056/NEJMra1706910
Hou, X., Zaks, T., Langer, R., & Dong, Y. (2021). Lipid nanoparticles for mRNA delivery. Nature Reviews Materials, 6(12), 1078–1094. https://doi.org/10.1038/s41578-021-00358-0
June, C. H., & Sadelain, M. (2018). Chimeric antigen receptor therapy. New England Journal of Medicine, 379(1), 64–73. https://doi.org/10.1056/NEJMra1706169
Komor, A. C., Kim, Y. B., Packer, M. S., Zuris, J. A., & Liu, D. R. (2016). Programmable editing of a target base in genomic DNA without double-stranded DNA cleavage. Nature, 533(7603), 420–424. https://doi.org/10.1038/nature17946
Maude, S. L., Laetsch, T. W., Buechner, J., Rives, S., Boyer, M., Bittencourt, H., Bader, P., Verneris, M. R., Stefanski, H. E., Myers, G. D., Qayed, M., De Moerloose, B., Hiramatsu, H., Schlis, K., Davis, K. L., Martin, P. L., Nemecek, E. R., Yanik, G. A., Peters, C., … Grupp, S. A. (2018). Tisagenlecleucel in children and young adults with B-cell lymphoblastic leukemia. New England Journal of Medicine, 378(5), 439–448. https://doi.org/10.1056/NEJMoa1709866
Mendell, J. R., Al-Zaidy, S., Shell, R., Arnold, W. D., Rodino-Klapac, L. R., Prior, T. W., Lowes, L., Alfano, L., Berry, K., Church, K., Kissel, J. T., Nagendran, S., L’Italien, J., Sproule, D. M., Wells, C., Cardenas, J. A., Heitzer, M. D., Kaspar, A., Corcoran, S., … Kaspar, B. K. (2017). Single-dose gene-replacement therapy for spinal muscular atrophy. New England Journal of Medicine, 377(18), 1713–1722. https://doi.org/10.1056/NEJMoa1706198
Naldini, L. (2015). Gene therapy returns to centre stage. Nature, 526(7573), 351–360. https://doi.org/10.1038/nature15818
Pipe, S. W., Leebeek, F. W. G., Recht, M., Key, N. S., Castaman, G., Miesbach, W., Lattimore, S., Peerlinck, K., Van der Valk, P., Coppens, M., Kampmann, P., Meijer, K., O’Connell, N., Pasi, K. J., Hart, D. P., Kazmi, R., Astermark, J., Hermans, C. R. J. R., Klamroth, R., … Monahan, P. E. (2023). Gene therapy with etranacogene dezaparvovec for hemophilia B. New England Journal of Medicine, 388(8), 706–718. https://doi.org/10.1056/NEJMoa2211644
Porteus, M. H. (2019). A new class of medicines through DNA editing. New England Journal of Medicine, 380(10), 947–959. https://doi.org/10.1056/NEJMra1800729
Russell, S., Bennett, J., Wellman, J. A., Chung, D. C., Yu, Z.-F., Tillman, A., Wittes, J., Pappas, J., Elci, O., McCague, S., Cross, D., Marshall, K. A., Walshire, J., Kehoe, T. L., Reichert, H., Davis, M., Raffini, L., George, L. A., Hudson, F. P., … Maguire, A. M. (2017). Efficacy and safety of voretigene neparvovec (AAV2-hRPE65v2) in patients with RPE65-mediated inherited retinal dystrophy: A randomised, controlled, open-label, phase 3 trial. The Lancet, 390(10097), 849–860. https://doi.org/10.1016/S0140-6736(17)31868-8
Sadelain, M., Rivière, I., & Riddell, S. (2017). Therapeutic T cell engineering. Nature, 545(7655), 423–431. https://doi.org/10.1038/nature22395
Wang, D., Tai, P. W. L., & Gao, G. (2019). Adeno-associated virus vector as a platform for gene therapy delivery. Nature Reviews Drug Discovery, 18(5), 358–378. https://doi.org/10.1038/s41573-019-0012-9
Downloads
Published
Issue
Section
License
This work is licensed under a Creative Commons Attribution 4.0 International License.
Authors who publish with this journal agree to the following terms: Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0), which allows others to share, adapt, and build upon the work for any purpose, provided appropriate credit is given to the original author(s) and source. Authors are permitted to enter into separate agreements for non-exclusive distribution of the published version (e.g., post to a repository or publish in a book), with acknowledgement of its initial publication in this journal.
