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Current Gene Therapy, 2017, 17, 43-49

REVIEW ARTICLE
ISSN: 1566-5232
eISSN: 1875-5631

Perspectives of Gene Therapies in Autosomal Dominant Polycystic Kidney Impact

Factor:
2.78

Disease
BENTHAM
SCIENCE

Yuchen Xu1, Ao Li1, Guanqing Wu1,2,* and Chaozhao Liang1,*

1
Institute/Department of Urology, The Anhui Province PKD Center, The First Affiliated Hospital of Anhui Medical Uni-
versity, Hefei, Anhui Province, 230022, China; 2State Key Laboratory of Molecular Oncology, Cancer Hospital and
Institute, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China

ARTICLE HISTORY
Received: April 03, 2017
Revised: May 07, 2017
Accepted: May 09, 2017
DOI:
10.2174/1566523217666170510152808
Current Gene Therapy
Abstract: Background: Autosomal dominant polycystic kidney disease (ADPKD) is the most com-
mon inherited kidney disease in the clinic. The predominant clinical manifestation is bilateral and pro-
gressive cysts formation in the kidneys, impairs normal renal parenchyma, and ultimately leads to end-
stage renal disease (ESRD). ADPKD is a heterogenic disease which is resulted from the mutations of
PKD1 or PKD2 genes which encode polycystin-1 (PC1) and -2 (PC2), thereby multiple cell signaling
pathways are involved.
Method: Although causative genes and aberrant signaling pathways have been investigated for dec-
ades, lack of effective and less side-effect treatment for the disease still perplex vast clinicians. There-
fore, development of new therapeutic approaches for ADPKD is currently very much desired.
Conclusion: This review will center on pathogenesis of ADPKD, and thereafter gene transfer will be
discussed as potential treatment for the disease. New therapeutic interventions will bring further hope

to improve prognosis of this incurable disease.

Keywords: Aberrant signaling pathways, ADPKD, causative genes, gene therapy, kidney disease, translational medicine.

1. INTRODUCTION 2. GENETIC CHARACTERISTICS OF ADPKD

Autosomal dominant polycystic kidney disease
(ADPKD) is the most common genetic disease of the kidney.
In the past decades, diverse morbidities (from 1/4000 to
1/400) have been reported in different regions of the world
and a European incidence of the disease is recently consid-
ered to be 1/2500 [1-3]. The main life-threatening manifesta-
tion of ADPKD is renal cyst growth which would eventually
destroy parenchyma and ruin function of the kidney. The
extrarenal lesions include cystic liver and pancreas [4-6],
intracranial aneurysm [7-10], cardiovascular abnormalities
[11-15], colon diverticulum and inguinal hernia [16, 17].
ADPKD patients account for approximate 10% population of
patients that need to receive renal replacement therapy
(RRT) and became the fourth most common disease for RRT
[1, 2]. Despite first reported 500 years ago [2], ADPKD has
not been clearly understood and still challenges clinicians as
a refractory disease due to lack of effective and safe treat-
ment. With intensive reveal of pathogenesis and translational
study towards clinic, new hopes emerging on finding potential
therapeutic targets and novel treatment interventions, which
may delay or halt progression of this disease.
*Address correspondence to these authors at the Anhui Province PKD Cen-
ter, Institute/Department of Urology, The First Affiliated Hospital, Anhui
Medical University, Hefei, 230022, China; Tel: (86) 0551+62923001; Fax:
(86)0551+62923932;
E-mails: guanqing.wu@ahmu.edu.cn; liang_chaozhao@ahmu.edu.cn
ADPKD is a heterogenic disease resulted from the muta-
tions in the PKD1 or PKD2 genes. The PKD1 gene (~50kb)
located on chromosome 16p13.3, contains 46 exons and en-
codes transcript with an open reading frame of 12909 bp
[18]. In addition, there are 6 pseudogenes on the upstream of
the same chromosomal location which are highly homolo-
gous with exons 1 to 33 of PKD1, complicating mutation
detection and molecular diagnosis [19]. Another ADPKD
causal gene PKD2 (68 kb) locates on chromosome 4q22,
contains 15 exons, encodes transcript with an ORF of 2904
bp [20]. It is generally thought that 85% mutations occur in
PKD1 and 15% in PKD2 [21-23]. However, an investigation
in North America showed a relative high prevalence of
PKD2, accounting for 26% of the patients [24], and some
reports indicated that much lower prevalence (<10%) of
PKD2 mutations was seen in Chinese populations [25, 26].
Furthermore, in approximate 10% of ADPKD patients, no
mutation was detected in PKD1 or PKD2 genes [21, 27]. The
latest study reported that mutation in the gene encoding
glucosidase IIα subunit (GANAB) could disrupt normal ex-
pression and function of PC1, thereby inducing ADPKD
phenotypes [27]. This finding indicates that other gene muta-
tions may also be responsible for the onset of ADPKD.
The PKD1 gene encodes protein with 4303 amino acids
and named as polycistin-1（PC1). PC1 consists of a giant
extracellular domain, 11 transmembrane domains and a short

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44 Current Gene Therapy, 2017, Vol. 17, No. 1
cytoplasmic tail with a coiled-coil domain [28, 29]. At the
early stage of embryonic development or cell sub-fusion
status, PC1, paxillin, α-actinin and tensin were co-localized
at the focal adhesions. While in mature epithelial cells with
polarity, PC1 and E-cadherin were located at adhesion junc-
tion of cells [30]. PC1 also exists in the primary cilia and the
centrosome of epithelial cells. It was therefore considered to
play important roles in the mechano/chemosensory functions
of primary cilia in epithelium [31-36].
PKD2 encodes polycystin-2 (PC2), a protein with 968
amino acids which contains 6 transmembrane domains and
cytoplasmic N- and C-termini [20, 37, 38]. There is a Ca2+
binding motif, EF hand domain, in the C-terminus of PC2,
and is therefore named as TRPP2 which belongs to transient
receptor potential channel superfamily [27, 39, 40]. Four
PC2 constitute a membrane cation channel which is more
selective to Na+ and K+ than Ca2+ [38, 41]. PC2 is expressed
along all segments of the nephrons except glomeruli. At sub-
cellular level, PC2 is localized in the endoreticulum and pri-
mary cilia [42, 43]. There is also a coiled-coil domain in C-
terminus of PC2 which can physically bind to the coiled-coil
domain of PC1. This interaction contributes to the formation
of PC1/PC2 complex, by which multiple downstream signal-
ing pathways are regulated [31, 37, 44-47].
As the most common causal gene, PKD1 mutations often
lead to more severe clinical manifestations in ADPKD pa-
tients, with a relative early onset of ESRD 20 years ahead
compared to the patients with PKD2 mutations (58.1 vs. 79.7
years old, respectively) [48]. Based on the data of ADPKD
Mutation Database (PKDB), 2323 mutations of PKD1 were
identified in 2080 pedigrees, and 278 PKD2 mutations were
identified in 463 pedigrees [49]. Ever-increasing list of new
mutations is continuously discovered in both causal genes
[26]. In ADPKD patients, over 70% of causal mutations was
identified to be truncating mutations, and remaining nont-
runcating mutations include missense mutations, in-frame
deletions/insertions or splicing mutations [21]. Some of these
nontruncating mutations might be hypomorphic since they
could preserve functional residues and/or exert partial func-
tions. Compared to patients with truncating mutations, pa-
tients with nontruncating mutations could have mild disease
phenotypes, presenting relative late onset of ESRD (67 vs. 55
years old, respectively) [48, 50].
3. PATHOGENESIS OF ADPKD
The most widely accepted theory of ADPKD pathogene-
sis is “two-hit hypothesis”. Since homozygous mutations of
PKD1 or PKD2 are embryonic lethal, most ADPKD patients
have typical heterozygous genotypes, and the mutant allele
obtained by inheritance is the primary hit [51-55]. The sec-
ond hit refers to mutations of the remaining normal allele
which occur in the growth and differentiation of somatic
cells, leading to the homozygous inactivation of PKD1 or
PKD2 at the cellular level. If the second hit occurred in a
renal tubular epithelium, the cell will be abnormally trans-
formed to cyst epithelium and promoted cyst formation in
the kidney [53, 56, 57].
The two-hit theory is not the only pathogenesis of
ADPKD. Our group have previously generated a mouse
model with hypomorphic Pkd2 allele (Pkd2nf3). Mice with
Xu et al.
homozygous Pkd2nf3 alleles could retain one third functional
PC2 expression and developed hepatorenal cysts without
embryonic lethality [58]. Similar result was also found in a
Pkd1 mutant mouse model (Pkd1nl) [59]. In addition, incom-
plete penetrance of mutated PKD1 or PKD2 genes has also
been discovered in human ADPKD patients [60]. If an
ADPKD patient inherited with one complete inactivated al-
lele and another allele with incomplete penetrance, early
onset diseases phenotypes would occur [61]. These finding
indicated that cysts formation could be induced when PCs
expression was under a specific threshold, and the disease
severity are dose-dependently associated with residual func-
tional PCs [58, 60, 62, 63].
Non-genetic factors such as ischemic renal injury [64-
67], toxic renal injury [68] and compensatory renal hypertro-
phy [69] could also induce or accelerate cystogenesis in the
ADPKD models and patients. Prevention of these factors
may improve prognosis of ADPKD patients.
4. TRANSLATIONAL MEDICINE IN ADPKD
Toward curing ADPKD, considerable progresses and un-
derstanding have been recently achieved in the molecular
mechanism and pathogenesis of ADPKD [1, 2, 70]. Most
studies indicated the cyst formation of ADPKD can be re-
sulted from both excessive fluid secretion into cyst lumens
and/or abnormal proliferation of the cyst-lining epithelium
[32]. The molecules rectifying the both epithelial defects by
regulating diverse associated cell signalings have been inten-
sively investigated [34, 35, 38, 46, 55, 71]. Based on the
findings, multiple clinical trials with the cell signaling acti-
vators or inhibitors have been carried out and showed low-
ered cyst formation in ADPKD patients, but only tolvaptan, a
vasopressin V2 receptor antagonist, has improved the renal
function in the patients [72-80]. Since conspicuous side ef-
fects of tolvaptan, its wide-application in clinic has been
challenged [81, 82]. Development of more effective thera-
peutic interventions for human ADPKD is clinically desired.
5. GENE THERAPY IN ADPKD
In consideration of the inherited nature of ADPKD, gene
replacement therapy holds great promise although no clinical
trial has yet been reported. Exogenously transferring wild-
type PKD1 or PKD2 genes into tubular epithelia of the kid-
ney may have an inhibiting potential on cystogenesis in
ADPKD patients. Recently, we have established a mouse
model with human PKD2 transgene (PKD2tg). Although
highly expressed human PC2 was detected in diverse tissues
and organs at varying degrees (e.g. sevenfold in the heart,
fourfold in the kidney, and twofold in the liver and pan-
creas), mice with hemizygous and homozygous PKD2 trans-
gene(s) did not exhibited any deleterious effects during em-
bryogenesis and organogenesis [83]. We applied this trans-
genic model crossing with Pkd2 mutant mice which we have
generated previously [53-55, 84]. Resulting Pkd2 mutant
mice with human PKD2 transgene(s) (e.g. Pkd2-/-; PKD2tg,
Pkd2-/-; PKD2tg/tg, Vil-Cre; Pkd2f3/f3; PKD2tg or Vil-Cre;
Pkd2f3/f3; PKD2tg/tg) rescued all disease phenotypes in PC2
dose-dependent manner [83] (and unpublished observations).
These findings suggested that functional restoration of hu-
man PC2 sufficiently delayed and arrested ADPKD progres-
Perspectives of Gene Therapies in Autosomal Dominant Polycystic Kidney Disease
sion in animals. Moreover, the findings also laid on theoreti-
cal basis for gene therapy in treatment of ADPKD [84].
To achieve therapeutic effects for ADPKD, an efficient
gene delivery system is required for transferring the target
gene into the kidney. Currently often used delivery systems
include naked plasmids, nonviral vectors and viral vectors
(Table 1). As the first and simplest delivery system been
studied, naked plasmids are easily produced and safe. How-
ever, it is not only insufficient to pass through lipophilic cell
membrane, but also prone to have transient expression in
targeted cells [85]. Other concerns are that naked plasmids
are easily degraded by serum nucleases and liver metabolism
[86].
Nonviral vectors (lipid based and polymeric vectors)
have been focused for gene delivery because of their safety
and low immunogenicity. The synthetic cationic lipid and
polymeric vectors, by which plasmid DNA was protected
from circulating nucleases and was easily absorbed by cell
membrane, were developed to improve plasmid-delivery
efficiency [87-89]. However, particles with cationic charge
may aggregated in physiological fluid, as a result of reduced
electrostatic repulsion or interaction with blood component
[90]. Aggregation during systemic administration may in-
duce rapid clearance by circulating macrophages and may
lead to blood cell aggregation even embolism [91]. In addi-
tion, vector transfer and expression efficiency did also not
reach therapeutic expectations for renal epithelia associated
diseases.
By decades of investigation, viral vectors were shown to
have the highest efficiency for transferring specific genes to
mammalian cells compared to non-viral approaches. Cur-
rently, often used viral vectors include adenovirus, lentivirus
and adeno-associated virus (AAVs) (Table 2). Adenoviral
vectors are non-integrating viruses that can infect both divid-
ing and non-dividing cells in wide spectrum of tissues, in-
cluding the kidney [92, 93]. However, adenovirus mediated
gene transfer to tubular epithelia, glomeruli and interstitial
cells of the kidney has relatively poor efficiency and only
keeps transgene expression for few weeks [94-96]. In rare
case, the adenovirus can cause severe side effects, even le-
thal in some of recipients due to immunogenic response [97].
To bypass this difficulty, the next generation of adenoviral
vectors, named as helper-dependent or gutless adenovirus in
Table 1. Advantage and disadvantage of different gene-delivery systems.
Delivery System Advantage
Naked plasmids Safe and Low immunogenicity
Easy to produce with strict quality control
Easy to store and transport
Nonviral vectors No size limitation for DNA
Low immunogenicity
Protect DNA from degradation and facilitate cell absorption
Viral vectors High transfection efficiency in a spectrum of mammalian cells
Diverse serotype targeting different tissues
Long period even persistent expression
Current Gene Therapy, 2017, Vol. 17, No. 1 45
which entire viral genome is deleted, has been developed.
This modified adenovirus exhibit very low immunogenicity
and large packaging capacity [98], but low production effi-
ciency challenges its wide application in clinic [99].
Lentivirus is another sort of well-characterized viral vec-
tors with low immunogenicity (Table 2). Lentiviral vectors
injected through renal artery and vein only obtained gene
expression in inner medullary collecting ducts (IMCDs). If
being directly injected into renal parenchyma, transgene can
be detected in the cortex of the kidney, but only along the
injection track [100]. Lentivirus-mediated transgene can be
integrated into the host genome, and persistently expressed
in the targeted cells and tissues [101]. As the flipside, this
genome integration may lead to leukemia-like mutations
which may activate or serve as some proto-oncogenes [102].
Adeno-associated virus (AAV) can be found in normal
human populations and has endemic characteristics. It is
therefore considered to be one of ideal vectors owing to its
non-pathogenicity [103], broad tropism for renal cells [104],
persistent transgene expression and rarely integrating into
host genome [105, 106]. Through renal artery injection of
AAV, successful transgene expression was observed in tubu-
lar epithelial cells of the proximal tubule and intercalated
cells of collecting duct [107]. A recent study also reported
that renal vein injection of rAAV-9 provided high transduc-
tion efficiency in both the medulla and cortex, even in
glomeruli, suggesting that AAV might be a choice in treat-
ment of renal diseases [108].
In comparison with gene deliveries through artery, vein
or parenchyma injection, retrograde transureteral gene deliv-
ery facilitates transgene to reach renal epithelia and mini-
mizes immune responses and macrophage-mediated clear-
ance, thus may has more benefits for treating ADPKD.
Through retrograde transureteral injection, successful trans-
gene expression was detected in medullary tubules of the
kidney by AAV-mediated gene transfer in mouse model
[109]. By injection of recombinant AAV2/8 and AAV2/9
with the same method, high gene transfer efficiency was
obtained in tubular epithelia of the kidney [110]. Given that
viral vectors have shown high efficiency of gene transduc-
tion and elongated duration of transgene expression, viral
mediated gene transfer combined with retrograde transuret-
eral injection may provide promising therapeutic potential
for treatment of ADPKD.
Disadvantage
Inefficient gene delivery
(Rapid clearance and difficult to enter cell)
Relative low transfer efficiency compared to viral vectors
Potential toxicities (aggregation in blood)
Limited size of recombinant DNA
Immunogeneity may lead to adverse effects or rapid clearance
Potential oncogenicity
46 Current Gene Therapy, 2017, Vol. 17, No. 1
Table 2. Compression of diverse viral-associated vectors for gene transfer.
Viral Vectors Advantage
Adenovirus Large transgene size (~8kb, up to ~36kb*)
No insertional mutagenesis
Broad tropism to tissues and cells
Lentivirus Large transgene size (~10kb)
Low immunogenicity
Persistent expression
Adeno-associated virus High transfection efficiency in a spectrum of kidney cells
(AAVs) Low immunogenicity and non-pathogenicity
Persistent expression
No insertional mutagenesis
*:gutless adenovirus.
PERSPECTIVES AND CONCLUSION
Currently, there is a lack of suitable treatment in ADPKD
patients. Conventional surgical options for ADPKD patients
seem only to relieve the patient symptoms, while there is no
evidence that it can delay disease progression and prevent
onset of ESRD [111]. As the only curative treatment, kidney
transplantation has been proven to benefit ADPKD patients
[112-116]. Lack of donors is a key issue to limit the applica-
tion of kidney transplantation in the patients [117]. Drug
therapy of ADPKD has been highly expected, but several
potential drugs did not achieve satisfying clinical effect. In
light of the inherited nature of ADPKD, gene therapy has
shown a great potential to treat this refractory disease. Our
recent results of human PKD2 transgene [83] provide an
encouraging evidence that the disease could be treated by
appropriate gene delivery system. Further, study on novel
therapeutic intervention will bring new hope and prospect in
the treatment of ADPKD.
CONFLICT OF INTEREST
The authors declare no conflict of interest, financial or
otherwise.
ACKNOWLEDGEMENTS
Declared none.
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