MATERIALS AND METHODS FOR TREATMENT OF TRANSTHYRETIN

AMYLOIDOSIS

Related Applications

[0001 ] This application claims the benefit of U.S. Provisional Application No. 62/359,906, filed July 8, 2016, which is incorporated herein by reference in its entirety.

Field

[0002] The present application provides materials and methods for treating a patient with Transthyretin Amyloidosis, both ex vivo and in vivo. In addition, the present application provides materials and methods for genome editing to modulate the expression a Transthyretin (TTR) gene in a cell.

Incorporation by Reference of Sequence Listing

[0003] The contents of the ASCII text file named "CRIS019001 WO_ST25", which was created on June 30, 2017 and is 7,855,833 bytes in size, are hereby incorporated by reference in their entirety and forms part of the disclosure.

Background

[0004] Familial Transthyretin Amyloidosis (FT A) is one of autosomal dominantly inherited diseases, characterized by the deposit of insoluble protein fibrils. The disease is also known as Familial Amyloid Polyneuropathy (FAP), Familial

Amyloidotic Cardiomyopathy (FAC), or transthyretin-related hereditary amyloidosis, transthyretin amyloidosis (sometimes abbreviated as ATTR), or Corino de

Andrade's disease because it was first identified and described by Portuguese neurologist Mario Corino da Costa Andrade, in 1952. FTA is distinct from senile systemic amyloidosis (SSA), which is not inherited, and which was determined to be the primary cause of death for 70% of supercentenarians who have been autopsied.

[0005] The clinical manifestation of Amyloidosis includes polyneuropathy, cardiomyopathy, and gastrointestinal features, nephropathy. Life expectancy is approximately 5 to 15 years after onset of symptoms. Historically, Hereditary Amyloidoses were classified into 4 types based on symptoms and ethnic origin, type I and II are caused by mutations of Transthyretin (TTR), while III and IV are caused by mutation in other genes. Therefore, where appropriate, references to FTA herein are intended to refer to those types of Amyloidosis that are caused by mutations in the Transthyretin (TTR) genes or its regulatory elements.

[0006] TTR is a serum and cerebrospinal fluid protein playing role in transport of retinol-binding protein and thyroxine. More than 80 different mutations in this gene have been reported; most mutations are related to amyloid deposition, affecting predominantly peripheral nerve and/or the heart, and a small portion of the gene mutations is non-amyloidogenic. The protein is synthesized mainly in liver, choroid plexus, kidney, retinal epithelium, and pancreas (OMIM, on the world wide web at: proteinatlas.org/ENSG000001 18271 -TTR/tissue;

biogps.org/#goto=genereport&id=7276). A gene encoding TTR is located at 18q12.1 , (GRCh38: 18:31 ,591 ,766-31 ,599,023). The protein consists of a tetramer of identical subunits.

[0007] TTR amyloidosis is characterized by a slowly development of a peripheral sensorimotor neuropathy and autonomic neuropathy as well as cardiomyopathy, nephropathy, vitreous opacities, and CNS amyloidosis. The onset of disease varies depending on patient ethnicity (30-40 y.o. in Portuguese and Japanese patients, and later onset in patients from other origins). The sensory neuropathy usually starts in the lower extremities, followed by motor neuropathy. Importantly, three mutations are associated with amyloidosis presenting as cardiomyopathy without a significant degree of peripheral neuropathy: T60A, L1 1 1 M, V122I .

[0008] The wildtype TTR is mildly amyloidogenic and it can be deposited as amyloid primarily in the heart of up to 25% of elderly persons, a condition termed senile systemic amyloidosis (Saraiva, 2002). This variant of Amyloidosis involves the lungs, liver, and kidneys as well as the heart.

[0009] Diagnosis of Transthyretin Amyloidosis includes validation of amyloid deposition in biopsy specimens and confirmation of a pathogenic variant in TTR. DNA sequencing is a standard procedure for mutation confirmation. Mutations in TTR are the only mutations known to cause Transthyretin Amyloidosis. TTR amyloid deposition is visualized by Congo red staining and/or

immunohistochemistry. [0010] For patients younger than 60 years liver transplantation is recommended, it prevents progression of the peripheral and autonomic neuropathy. Significant cardiac and renal dysfunction will not be reversed by this treatment. Surgery is indicated for carpal tunnel syndrome.

[0011 ] A pacemaker is indicated for patients with sick sinus syndrome or 2-3 degree AV block. Emerging therapies include tafamidis, TTR stabilizer approved in Europe and currently under review by FDA, several phase III studies with generation 2+ antisense drug (lonis and GSK) and phase III siRNA therapy

(Alnylam). The following references contain additional information on current treatment approaches and the desease: Dubrey S, Ackermann E, Gillmore J. The transthyretin amyloidoses: advances in therapy. Postgrad Med J. 2015

Aug;91 (1078):439-48, doi: 10.1 136/postgradmedj-2014-133224, Epub 2015 Jun 5. Review. PubMed PMI D: 26048914; Yoshiki Sekijima, MD, PhD, Kunihiro Yoshida, MD, PhD, Takahiko Tokuda, MD, PhD, and Shu-ichi Ikeda, MD, PhD. Familial Transthyretin Amyloidosis (Synonym: Familial TTR Amyloidosis, Initial Posting: November 5, 2001 ; Last Update: January 26, 2012. Pagon RA, Adam MP, Ardinger HH, et al., editors. Seattle (WA): University of Washington, Seattle; 1993-2016; Sekijima Y. Transthyretin (ATTR) amyloidosis: clinical spectrum, molecular pathogenesis and disease-modifying treatments. J Neurol Neurosurg Psychiatry. 2015 Sep;86(9):1036-43. doi: 10.1 136/jnnp-2014-308724. Epub 2015 Jan 20. Review. PubMed PMID: 25604431 ; Saraiva MJ. Hereditary transthyretin

amyloidosis: molecular basis and therapeutical strategies. Expert Rev Mol Med. 2002 May 14;4(12):1 -1 1 . Review. PubMed PMID: 14987380; on the world wide web at: ncbi.nlm.nih.gov/books/NBK1 194/; omim.org/entry/176300;

omim.org/entry/105210; and on the world wide web at: acc.org/latest-in- cardiology/articles/2015/10/13/08/35/emerging-therapies-for- transthyretin-cardiac- amyloidosis.

[0012] An alternative treatment for patients diagnosed with FTA includes genome engineering. Genome engineering refers to the strategies and techniques for the targeted, specific modification of the genetic information (genome) of living organisms. Genome engineering is a very active field of research because of the wide range of possible applications, particularly in the areas of human health; the correction of a gene carrying a harmful mutation, for example, or to explore the function of a gene. Early technologies developed to insert a transgene into a living cell were often limited by the random nature of the insertion of the new sequence into the genome. Random insertions into the genome may result in disrupting normal regulation of neighboring genes leading to severe unwanted effects.

Furthermore, random integration technologies offer little reproducibility, as there is no guarantee that the sequence would be inserted at the same place in two different cells. Recent genome engineering strategies, such as zinc finger nucleases (ZFNs), transcription activator like effector nucleases (TALENs), homing endonucleases (HEs) and MegaTALs, enable a specific area of the DNA to be modified, thereby increasing the precision of the correction or insertion compared to early technologies. These newer platforms offer a much larger degree of reproducibility, but still have their limitations.

[0013] Despite efforts from researchers and medical professionals worldwide who have been trying to address FTA, and despite the promise of genome engineering approaches, there still remains a critical need for developing safe and effective treatments for FTA.

[0014] Prior approaches addressing FTA have limitations. The present invention solves these problems by using genome engineering tools to create permanent changes to the genome that can restore normal TTR or reduce pathogenic forms of TTR with a single treatment. Thus, the present invention corrects the underlying genetic defect causing the disease.

Summary

[0015] Provided herein are cellular, ex vivo and in vivo methods for creating permanent changes to the genome by deleting, inserting, correcting, or modulating the expression of or function of one or more mutations within or near the TTR gene or other DNA sequences that encode regulatory elements of the TTR gene, which may be used to treat Familial Transthyretin Amyloidosis (FTA). Provided herein are methods that can be used for treatment of FTA, as well as components, kits, and compositions for performing such methods. Also provided are cells produced by such methods.

[0016] Provided herein is a method for editing a TTR gene in a cell by genome editing, the method comprising the step of introducing into the cell one or more deoxyribonucleic acid (DNA) endonucleases to effect one or more single-strand breaks (SSBs) or one or more double-strand breaks (DSBs) within or near the TTR gene or other DNA sequences that encode regulatory elements of the TTR gene that results in at least one of a permanent insertion, deletion, correction of one or more mutations within or near the TTR gene.

[0017] Also provided herein is an ex vivo method for treating a patient (e.g., a human) with FTA, the method comprising the steps of: i) editing a patient specific induced pluripotent stem cell (iPSC) within or near a TTR gene of the iPSC or other DNA sequences that encode regulatory elements of the TTR gene of the iPSC; ii) differentiating the edited iPSC into a hepatocyte; and iii) administering the hepatocyte to the patient.

[0018] In some embodiments, the ex vivo method further comprises the step of creating a patient specific induced pluripotent stem cell (iPSC).

[0019] Also provided herein is an ex vivo method for treating a patient (e.g., a human) with FTA, the method comprising the steps of: i) creating a patient specific induced pluripotent stem cell (iPSC); ii) editing within or near a TTR gene of the iPSC or other DNA sequences that encode regulatory elements of the TTR gene of the iPSC; iii) differentiating the edited iPSC into a hepatocyte; and iv) administering the hepatocyte to the patient.

[0020] In some embodiments, the step of creating a patient specific induced pluripotent stem cell (iPSC) comprises: a) isolating a somatic cell from the patient; and b) introducing a set of pluripotency-associated genes into the somatic cell to induce the somatic cell to become a pluripotent stem cell. In some embodiments, the somatic cell is a fibroblast. In some embodiments, the set of pluripotency- associated genes is one or more of the genes selected from the group consisting of OCT4, SOX2, KLF4, Lin28, NANOG and cMYC.

[0021 ] The step of editing within or near a TTR gene or other DNA sequences that encode regulatory elements of the TTR gene of the iPSC or editing within or near a locus of the first exon of the TTR gene of the iPSC comprises introducing into the iPSC one or more deoxyribonucleic acid (DNA) endonucleases to effect one or more single-strand breaks (SSBs) or double-strand breaks (DSBs) within or near the TTR gene or other DNA sequences that encode regulatory elements of the TTR gene that results in a permanent insertion, deletion, correction of one or more mutations within or near the TTR gene or other DNA sequences that encode regulatory elements of the TTR gene.

[0022] In some embodiments, the step of differentiating the edited iPSC into a liver progenitor cell or a hepatocyte comprises one or more of the following:

contacting the genome edited iPSC with one or more of activin, B27 supplement, FGF4, HGF, BMP2, BMP4, Oncostatin M, Dexametason.

[0023] In some embodiments, the step of editing the TTR gene of the iPSC comprises introducing into the iPSC one or more deoxyribonucleic acid (DNA) endonucleases to effect one or more single-strand breaks (SSBs) or double-strand breaks (DSBs) within or near the TTR gene that results in permanent insertion, deletion, or mutation within or near the TTR gene that reduces or eliminates the expression or function of TTR gene products.

[0024] In some embodiments, the step of editing the TTR gene of the iPSC comprises introducing into the iPSC one or more deoxyribonucleic acid (DNA) endonucleases to effect one or more single-strand breaks (SSBs) or double-strand breaks (DSBs) within or near the TTR gene that results in permanent insertion, deletion, or correction of one or more mutations within or near the TTR gene.

[0025] In some embodiments, the step of administering the hepatocyte to the patient comprises administering the hepatocyte to the patient by transplantation, local injection, systemic infusion, or combinations thereof.

[0026] Also provided herein is an ex vivo method for treating a patient (e.g., a human) with FTA, the method comprising the steps of: i) isolating a liver specific progenitor cell or primary hepatocyte from the patient; ii) editing within or near a TTR gene or other DNA sequences that encode regulatory elements of the TTR gene of the progenitor cell or primary hepatocyte; and iii) administering the edited progenitor cell or primary hepatocyte to the patient.

[0027] Also provided herein is an ex vivo method for treating a patient (e.g., a human) with FTA, the method comprising the steps of: i) performing a biopsy of the patient's liver; ii) isolating a liver specific progenitor cell or primary hepatocyte from the patient; iii) editing within or near a TTR gene or other DNA sequences that encode regulatory elements of the TTR gene of the progenitor cell or primary hepatocyte; and iv) administering the edited progenitor cell or primary hepatocyte to the patient.

[0028] Also provided herein is an ex vivo method for treating a patient (e.g., a human) with FTA, the method comprising the steps of: i) obtaining a liver specific progenitor cell or primary hepatocyte; ii) editing within or near a TTR gene or other DNA sequences that encode regulatory elements of the TTR gene of a patient specific progenitor cell or a patient specific primary hepatocyte; and iii)

administering the edited progenitor cell or primary hepatocyte into the patient.

[0029] Also provided herein is an ex vivo method for treating a patient (e.g., a human) with FTA, the method comprising the steps of: i) editing a liver specific progenitor cell or primary hepatocyte within or near a TTR gene or other DNA sequences that encode regulatory elements of the TTR gene of a patient specific progenitor cell or a patient specific primary hepatocyte; and ii) administering the edited progenitor cell or primary hepatocyte to the patient.

[0030] In some embodiments, the step of isolating a progenitor cell or primary hepatocyte from the patient comprises perfusion of fresh liver tissues with digestion enzymes, cell differential centrifugation, cell culturing, or combinations thereof.

[0031 ] In some embodiments, the step of editing within or near a TTR gene or other DNA sequences that encode regulatory elements of the TTR gene of the progenitor cell or primary hepatocyte comprises introducing into the progenitor cell or primary hepatocyte one or more deoxyribonucleic acid (DNA) endonucleases to effect one or more single-strand breaks (SSBs) or double-strand breaks (DSBs) within or near the TTR gene or other DNA sequences that encode regulatory elements of the TTR gene that results in a permanent insertion, deletion, correction of one or more mutations within or near the TTR gene or other DNA sequences that encode regulatory elements of the TTR gene.

[0032] In some embodiments, the editing step comprises introducing into the progenitor cell or primary hepatocyte one or more deoxyribonucleic acid (DNA) endonucleases to effect one or more single-strand breaks (SSBs) or double-strand breaks (DSBs) within or near the TTR gene or other DNA sequences that encode regulatory elements of the TTR gene that results in one or more permanent insertions, deletions or mutations of at least one nucleotide within or near the TTR gene, thereby reducing or eliminating the expression or function of TTR gene products.

[0033] In some embodiments, the step of administering the edited liver specific progenitor cell or primary hepatocyte to the patient comprises administering the edited liver specific progenitor cell or primary hepatocyte to the patient by transplantation, local injection, systemic infusion, or combinations thereof.

[0034] Also provided herein is an ex vivo method for treating a patient (e.g., a human) with FTA, the method comprising the steps of: i) isolating a mesenchymal stem cell from the patient; ii) editing within or near a TTR gene or other DNA sequences that encode regulatory elements of the TTR gene of the mesenchymal stem cell; iii) differentiating the edited mesenchymal stem cell into a hepatocyte; and iv) administering the hepatocyte to the patient.

[0035] Also provided herein is an ex vivo method for treating a patient (e.g., a human) with FTA, the method comprising the steps of: i) editing a mesenchymal stem cell within or near a TTR gene or other DNA sequences that encode regulatory elements of the TTR gene of a mesenchymal stem cell; ii) differentiating the edited mesenchymal stem cell into a hepatocyte; and iii) administering the hepatocyte to the patient.

[0036] In some embodiments, the ex vivo method further comprises the step of isolating the mesenchymal cell from the patient.

[0037] In some embodiments, the mesenchymal stem cell is isolated from the patient's bone marrow or peripheral blood. In some embodiments, the step of isolating a mesenchymal stem cell from the patient comprises aspiration of bone marrow and isolation of mesenchymal cells by density centrifugation using

Percoll™.

[0038] In some embodiments, the step of editing within or near the TTR gene of the mesenchymal stem cell or other DNA sequences that encode regulatory elements of the TTR gene of the mesenchymal stem cell comprises introducing into the mesenchymal stem cell one or more deoxyribonucleic acid (DNA)

endonucleases to effect one or more single-strand breaks (SSBs) or double-strand breaks (DSBs) within or near the TTR gene or other DNA sequences that encode regulatory elements of the TTR gene that results in a permanent insertion, deletion, correction of one or more mutations within or near the TTR gene or other DNA sequences that encode regulatory elements of the TTR gene.

[0039] In some embodiments, the editing step comprises introducing into the mesenchymal stem cell one or more deoxyribonucleic acid (DNA) endonucleases to effect one or more single-strand breaks (SSBs) or double-strand breaks (DSBs) within or near the TTR gene or other DNA sequences that encode regulatory elements of the TTR gene that results in one or more permanent insertions, deletions or mutations of at least one nucleotide within or near the TTR gene, thereby reducing or eliminating the expression or function of TTR gene products.

[0040] In some embodiments, the step of differentiating the edited mesenchymal stem cell into a hepatocyte comprises contacting the edited mesenchymal stem cell with one or more of insulin, transferrin, FGF4, HGF, or bile acids.

[0041 ] In some embodiments, the step of administering the hepatocyte to the patient comprises administering the hepatocyte to the patient by transplantation, local injection, systemic infusion, or combinations thereof.

[0042] Also provided herein is an ex vivo method for treating a patient (e.g., a human) with Familial Transthyretin Amyloidosis (FTA), the method comprising the steps of: i) isolating a liver progenitor cell from the patient; ii) editing within or near a TTR gene of the liver progenitor cell or other DNA sequences that encode regulatory elements of the TTR gene of the liver progenitor cell; and iii)

administering the edited liver progenitor cell to the patient.

[0043] Also provided herein is an ex vivo method for treating a patient (e.g., a human) with Familial Transthyretin Amyloidosis (FTA), the method comprising the steps of: i) editing a liver progenitor cell within or near a TTR gene of the liver progenitor cell or other DNA sequences that encode regulatory elements of the TTR gene of the liver progenitor cell; and ii) administering the edited liver progenitor cell to the patient.

[0044] In some embodiments, the step of editing within or near a TTR gene or other DNA sequences that encode regulatory elements of the TTR gene of the hematopoietic progenitor cell comprises introducing into the hematopoietic progenitor cell one or more deoxyribonucleic acid (DNA) endonucleases to effect one or more single-strand breaks (SSBs) or double-strand breaks (DSBs) within or near the TTR gene or other DNA sequences that encode regulatory elements of the TTR gene that results in a permanent insertion, deletion, correction of one or more mutations within or near the TTR gene that results in the permanent insertion of the TTR gene or other DNA sequences that encode regulatory elements of the TTR gene .

[0045] Also provided herein is an in vivo method for treating a patient (e.g., a human) with FTA, the method comprising the step of editing a TTR gene or other DNA sequences that encode regulatory elements of the TTR gene in a cell of the patient.

[0046] In some embodiments, the step of editing a TTR gene in a cell of the patient comprises introducing into the cell one or more deoxyribonucleic acid (DNA) endonucleases to effect one or more single-strand breaks (SSBs) or double-strand breaks (DSBs) within or near the TTR gene or other DNA sequences that encode regulatory elements of the TTR gene that results in a permanent insertion, deletion, correction of one or more mutations within or near the TTR gene or other DNA sequences that encode regulatory elements of the TTR gene. The cell can be a hepatocyte, a liver progenitor cell, or combinations thereof.

[0047] In some embodiments, the editing step comprises introducing into the cell one or more deoxyribonucleic acid (DNA) endonucleases to effect one or more single-strand breaks (SSBs) or double-strand breaks (DSBs) within or near the TTR gene or other DNA sequences that encode regulatory elements of the TTR gene that results in one or more permanent insertions, deletions or mutations of at least one nucleotide within or near the TTR gene, thereby reducing or eliminating the expression or function of TTR gene products.

[0048] In some embodiments, the one or more deoxyribonucleic acid (DNA) endonuclease is one or more protein or polypeptide. In some embodiments, the one or more deoxyribonucleic acid (DNA) endonuclease is one or more

polynucleotide encoding the one or more DNA endonuclease. In some

embodiments, the one or more deoxyribonucleic acid (DNA) endonuclease is one or more ribonucleic acid (RNA) encoding the one or more DNA endonuclease. In some embodiments, the one or more ribonucleic acid (RNA) is one or more chemically modified RNA.

[0049] In some embodiments, the DNA endonuclease is a Cas9 or CPf1 endonuclease. In some embodiments, the DNA endonuclease is a Cas9 or CPf1 endonuclease or a homolog thereof, recombination of the naturally occurring molecule, codon-optimized, or modified version thereof, and combinations thereof In some embodiments, the Cas9 or Cpf1 endonuclease is selected from S.

pyogenes Cas9, S. aureus Cas9, N. meningitides Cas9, S. thermophilus CRISPR1 Cas9, S. thermophilus CRISPR 3 Cas9, T. denticola Cas9, L. bacterium ND2006 Cpfl and Acidaminococcus sp. BV3L6 Cpf1 , and variants having at least 90% homology to these enzymes. In some embodiments, the Cas9 or Cpf1

endonuclease comprises one or more nuclear localization signals (NLSs). In some embodiments, at least one NLS is at or within 50 amino acids of the amino-terminus of the Cas9 or Cpf1 endonuclease and/or at least one NLS is at or within 50 amino acids of the carboxy-terminus of the Cas9 or Cpfl endonuclease.

[0050] In some embodiments, the method comprises introducing into the cell one or more polynucleotides encoding the one or more DNA endonucleases. In some embodiments, the method comprises introducing into the cell one or more ribonucleic acids (RNAs) encoding the one or more DNA endonucleases. In some embodiments, the one or more polynucleotides or one or more RNAs is one or more modified polynucleotides or one or more modified RNAs. In some

embodiments, the method comprises introducing into the cell one or more DNA endonucleases wherein the endonuclease is a protein or polypeptide.

[0051 ] In some embodiments, the method further comprises introducing into the cell one or more guide ribonucleic acids (gRNAs). In some embodiments, the one or more gRNAs is single-molecule guide RNA (sgRNAs). In some embodiments, the one or more gRNAs or one or more sgRNAs is one or more modified gRNAs, one or more modified sgRNAs, or combinations thereof. In some embodiments, the one or more DNA endonucleases is pre-complexed with one or more gRNAs, one or more sgRNAs, or combinations thereof. [0052] In some embodiments, the method further comprises introducing into the cell a polynucleotide donor template comprising at least a portion of the wild-type TTR gene or minigene (comprised of, natural or synthetic enhancer and promoter, one or more exons, and natural or synthetic introns, and natural or synthetic 3'UTR and polyadenylation signal), DNA sequences that encode wild-type regulatory elements of the TTR gene, and/or cDNA. In some embodiments, the at least a portion of the wild-type TTR gene or cDNA is exon 1 , exon 2, exon 3, exon 4, intronic regions, fragments or combinations thereof, or the entire TTR gene or cDNA. In some embodiments, the donor template is either a single or double stranded polynucleotide. In some embodiments, the donor template has

homologous arms to the 18q12.1 region.

[0053] In some embodiments, the method further comprises introducing into the cell one guide ribonucleic acid (gRNA) and a polynucleotide donor template comprising at least a portion of the wild-type TTR gene. In some embodiments, the method further comprises introducing into the cell one guide ribonucleic acid (gRNA) and a polynucleotide donor template comprising at least a portion of a codon optimized or modified TTR gene. In some embodiments, the one or more DNA endonucleases is one or more Cas9 or Cpf1 endonucleases that effect one single-strand break (SSB) or double-strand break (DSB) at a locus within or near the TTR gene (or codon optimized or modified TTR gene) or other DNA sequences that encode regulatory elements of the TTR gene that facilitates insertion of a new sequence from the polynucleotide donor template into the chromosomal DNA at the locus that results in a permanent insertion or correction of a part of the

chromosomal DNA of the TTR gene or other DNA sequences that encode regulatory elements of the TTR gene proximal to the locus. In some embodiments, the gRNA comprises a spacer sequence that is complementary to a segment of the locus. In some embodiments, proximal means nucleotides both upstream and downstream of the locus.

[0054] In some embodiments, the method further comprises introducing into the cell two guide ribonucleic acid (gRNAs) and a polynucleotide donor template comprising at least a portion of the wild-type TTR gene. In some embodiments, the one or more DNA endonucleases is two or more Cas9 or Cpf1 endonucleases that effect or create at least two (e.g., a pair) single-strand breaks (SSBs) and/or double-strand breaks (DSBs), the first at a 5' locus and the second at a 3' locus, within or near the TTR gene or other DNA sequences that encode regulatory elements of the TTR gene that facilitates insertion of a new sequence from the polynucleotide donor template into the chromosomal DNA between the 5' locus and the 3' locus that results in a permanent insertion or correction of the chromosomal DNA between the 5' locus and the 3' locus within or near the TTR gene or other DNA sequences that encode regulatory elements of the TTR gene. In some embodiments, the first guide RNA comprises a spacer sequence that is

complementary to a segment of the 5' locus, and the second guide RNA comprises a spacer sequence that is complementary to a segment of the 3' locus.

[0055] In some embodiments, the one or more gRNAs is one or more single- molecule guide RNA (sgRNAs). In some embodiments, the one or more gRNAs or one or two sgRNAs is one or two modified gRNAs or one or more modified sgRNAs. In some embodiments, the one or more DNA endonucleases is pre- complexed with one or more gRNAs or one or more sgRNAs.

[0056] In some embodiments, the at least a portion of the wild-type TTR gene or cDNA is some or all of intron 1 , exon 1 , some or all of intron 2, exon 2, some or all of intron 3, exon 3, some or all of intron 4, exon 4, intronic regions, fragments or combinations thereof, or the entire TTR gene, DNA sequences that encode wild type regulatory elements of the TTR gene, minigene, or cDNA.

[0057] In some embodiments, the donor template is either a single or double stranded polynucleotide. In some embodiments, the donor template has

homologous arms to the 18q12.1 region.

[0058] In some embodiments, the locus, 5' locus, and/or 3' locus is in the first, second, third, fourth, exon or introns of the TTR gene or non-homologous end joining (NHEJ).

[0059] In some embodiments, the gRNA or sgRNA is directed to one or more of the following pathological variants: T60A, L1 1 1 M, V122I.

[0060] In some embodiments, the insertion or correction is by homology directed repair (HDR). [0061 ] In some embodiments, the method further comprises introducing into the cell two guide ribonucleic acids (gRNAs). In some embodiments, the one or more DNA endonucleases is one or more Cas9 or Cpf1 endonucleases that effect or create two or more (e.g., a pair) double-strand breaks (DSBs), the first at a 5' DSB locus and the second at a 3' DSB locus, within or near the TTR gene or other DNA sequences that encode regulatory elements of the TTR gene that causes a deletion of the chromosomal DNA between the 5' DSB locus and the 3' DSB locus that results in a permanent deletion of the chromosomal DNA between the 5' DSB locus and the 3' DSB locus within or near the TTR gene or other DNA sequences that encode regulatory elements of the TTR gene. In some embodiments, the first guide RNA comprises a spacer sequence that is complementary to a segment of the 5' DSB locus and the second guide RNA comprises a spacer sequence that is complementary to a segment of the 3' DSB locus.

[0062] In some embodiments, the two gRNAs are two single-molecule guide RNA (sgRNAs). In some embodiments, the two gRNAs or two sgRNAs are two modified gRNAs or two modified sgRNAs. The one or more DNA endonucleases can be pre-complexed with one or two gRNAs or one or two sgRNAs.

[0063] In some embodiments, the 5' DSB and/or 3' DSB is in or near the first exon, first intron, second exon, second intron, third exon, third intron, fourth exon, fourth intron, fifth exon, fifth intron, sixth exon, sixth intron, seventh exon, seventh intron, or eighth exon of the TTR gene.

[0064] In some embodiments, the correction is by homology directed repair (HDR).

[0065] In some embodiments, the correction is by non-homologous end joining (NHEJ).

[0066] In some embodiments, the deletion is a deletion of 1 kb or less.

[0067] In some embodiments, the Cas9 or Cpf1 mRNA, and gRNA are either each formulated separately into lipid nanoparticles or all co-formulated into a lipid nanoparticle.

[0068] In some embodiments, the Cas9 or Cpf1 mRNA, and gRNA are either each formulated separately into exosomes or all co-formulated into an exosome. [0069] In some embodiments, the Cas9 or Cpf1 mRNA is formulated into a lipid nanoparticle, and the gRNA is delivered to the cell by a viral vector. In some embodiments, the viral vector is an adeno-associated virus (AAV) vector. In some embodiments, the AAV vector is an AAV6 vector.

[0070] In some embodiments, the Cas9 or Cpf1 mRNA is delivered to the cell by electroporation.

[0071 ] In some embodiments, the Cas9 or Cpfl mRNA, gRNA, and donor template are either each formulated separately into lipid nanoparticles or all co- formulated into a lipid nanoparticle.

[0072] In some embodiments, the Cas9 or Cpfl mRNA, gRNA, and donor template are either each formulated separately into exosomes or all co-formulated into an exosome.

[0073] In some embodiments, the Cas9 or Cpfl mRNA is formulated into a lipid nanoparticle, and the gRNA and donor template is delivered to the cell by a viral vector. In some embodiments, the viral vector is an adeno-associated virus (AAV) vector. In some embodiments, the AAV vector is an AAV6 vector.

[0074] In some embodiments, the Cas9 or Cpfl mRNA is delivered to the cell by electroporation, and donor template is delivered to the cell by a viral vector. In some embodiments, the viral vector is an adeno-associated virus (AAV) vector. In some embodiments, the AAV vector is an AAV6 vector. In some embodiments, the gRNA is formulated into a lipid nanoparticle, and the gRNA is delivered to the cell by electroporation, and donor template is delivered to the cell by an adeno- associated virus (AAV) vector. In some embodiments, the AAV vector is an AAV6 vector.

[0075] A gene encoding TTR is located at TTR gene, has 4 exons and spans 6.9 kb on chromosome 18q12.1 (GRCh38: 18:31 ,591 ,766-31 ,599,023).

[0076] In some embodiments, the TTR protein activity is deleted or is restored to wild-type, non-mutated normal or reduced amyloid-forming TTR protein activity.

[0077] In some embodiments, the methods provided herein use a cell selected from a group consisting of a hepatocyte, a cell from hypothalamus, a cell from thalamus, a cell from kidney, a cell from retinal epithelium, and a cell from pancreas.

[0078] In some embodiments, the methods provided herein use a human cell.

[0079] In some embodiments, the human cell is selected from a group consisting of a hepatocyte, a cell from hypothalamus, a cell from thalamus, a cell from kidney, a cell from retinal epithelium, and a cell from pancreas.

[0080] Also provided herein is one or more guide ribonucleic acids (gRNAs) for editing a TTR gene in a cell. In some embodiments, the one or more gRNAs and/or sgRNAs comprises a spacer sequence selected from the group consisting of nucleic acid sequences in SEQ ID NOs: 1 -8,669 and SEQ ID NOs: 8,770-39,185. In some embodiments, the one or more gRNAs and/or sgRNAs comprises a spacer sequence selected from the group consisting of nucleic acid sequences in SEQ ID NOs: 1 -8,669. In some embodiments, the one or more gRNAs and/or sgRNAs comprises a spacer sequence selected from the group consisting of nucleic acid sequences in SEQ ID NOs: SEQ ID NOs: 8,770-39, 185. In some embodiments, the one or more gRNAs is one or more single-molecule guide RNAs (sgRNAs). In some embodiments, the one or more gRNAs or one or more sgRNAs is one or more modified gRNAs or one or more modified sgRNAs.

[0081 ] Also provided herein is one or more guide ribonucleic acids (gRNAs) for editing a TTR gene in a cell from a patient with FTA. In some embodiments, the one or more gRNAs and/or sgRNAs comprises a spacer sequence selected from the group consisting of nucleic acid sequences in SEQ ID NOs: 1 -8,669 and SEQ ID NOs: 8,770-39, 185. In some embodiments, the one or more gRNAs and/or sgRNAs comprises a spacer sequence selected from the group consisting of nucleic acid sequences in SEQ ID NOs: 1 -8,669. In some embodiments, the one or more gRNAs and/or sgRNAs comprises a spacer sequence selected from the group consisting of nucleic acid sequences in SEQ ID NOs: SEQ ID NOs: 8,770- 39,185. In some embodiments, the one or more gRNAs is one or more single- molecule guide RNAs (sgRNAs). In some embodiments, the one or more gRNAs or one or more sgRNAs is one or more modified gRNAs or one or more modified sgRNAs. [0082] In another aspect, provided herein are cells that have been modified by the preceding methods to permanently correct one or more mutations within the TTR gene and reduce or eliminate TTR protein. Further provided herein are methods for ameliorating Familial Transthyretin Amyloidosis (FT A) by the administration of cells that have been modified by the preceding methods to an FTA patient.

[0083] In some embodiments, the methods and compositions of the disclosure comprise one or more modified guide ribonucleic acids (gRNAs). Non-limiting examples of modifications comprise one or more nucleotides modified at the 2' position of the sugar, in some embodiments a 2'-0-alkyl, 2'-0-alkyl-0-alkyl, or 2'- fluoro-modified nucleotide. In some embodiments, RNA modifications include 2'- fluoro, 2'-amino or 2' O-methyl modifications on the ribose of pyrimidines, abasic residues, desoxy nucleotides, or an inverted base at the 3' end of the RNA.

[0084] In some embodiments, the one or more modified guide ribonucleic acids (gRNAs) comprise a modification that makes the modified gRNA more resistant to nuclease digestion than the native oligonucleotide. Non-limiting examples of such modifications include those comprising modified backbones, for example, phosphorothioates, phosphorothyos, phosphotriesters, methyl phosphonates, short chain alkyl or cycloalkyl intersugar linkages or short chain heteroatomic or heterocyclic intersugar linkages.

[0085] It is understood that the inventions described in this specification are not limited to the examples summarized in this Summary. Various other aspects are described and exemplified herein.

Brief Description of the Drawings

[0086] Various aspects of materials and methods for treatment of FTA disclosed and described in this specification can be better understood by reference to the accompanying figures, in which:

[0087] Figure 1A is an illustration depicting the type II CRISPR/Cas system.

[0088] Figure 1 B is another illustration depicting the type II CRISPR/Cas system.

[0089] Figures 2-4 describe the cutting efficiency of gRNAs with an S. pyogenes Cas9 in HEK293T cells targeting the TTR gene. Brief Description of the Sequence Listing

[0090] SEQ ID NOs: 1 -3,352 are 20 bp spacer sequences for targeting a TTR gene with a S. pyogenes Cas9 endonuclease.

[0091 ] SEQ ID NOs: 3,353-3,763 are 20 bp spacer sequences for targeting a TTR gene with a S. aureus Cas9 endonuclease.

[0092] SEQ ID NOs: 3,764-4, 1 12 are 24 bp spacer sequences for targeting a TTR gene with a S. thermophilus Cas9 endonuclease.

[0093] SEQ ID NOs: 4, 1 13-4,247 are 24 bp spacer sequences for targeting a TTR gene with a T. denticola Cas9 endonuclease.

[0094] SEQ ID NOs: 4,248-4,301 are 24 bp spacer sequences for targeting a TTR gene with a N. meningitides Cas9 endonuclease.

[0095] SEQ ID NOs: 4,302-8,669 are 24 bp spacer sequences for targeting a TTR gene with an Acidaminococcus and a Lachnospiraceae Cpf1 endonuclease.

[0096] SEQ ID NOs: 8,670-10,810 are spacer sequences for knocking-in TTR sequences into the F9 gene with a Cpf1 endonuclease.

[0097] SEQ ID NOs: 10,81 1 -1 1 , 1 10 are spacer sequences for knocking-in TTR sequences into the CCR5 gene with a Cpf1 endonuclease.

[0098] SEQ ID NOs: 1 1 , 1 1 1 -1 1 ,489 are spacer sequences for knocking-in TTR sequences into the Alb gene with a Cpf1 endonuclease.

[0099] SEQ ID NOs: 1 1 ,490-12,665 are spacer sequences for knocking-in TTR sequences into the AAVS gene with a Cpf1 endonuclease.

[00100] SEQ ID NOs: 12,666-13,301 are spacer sequences for knocking-in TTR sequences into the TF gene with a Cpf1 endonuclease.

[00101] SEQ ID NOs: 13,302-15,626 are spacer sequences for knocking-in TTR sequences into the HGD gene with a Cpf1 endonuclease.

[00102] SEQ ID NOs: 15,627-24,058 are spacer sequences for knocking-in TTR sequences into the Gys2 gene with a Cpf1 endonuclease.

[00103] SEQ ID NOs: 24,059-24,301 are spacer sequences for knocking-in TTR sequences into the Alb gene with a Cas9 endonuclease. [00104] SEQ ID NOs: 24,302-24,580 are spacer sequences for knocking-in TTR sequences into the CCR5 gene with a Cas9 endonuclease.

[00105] SEQ ID NOs: 24,581 -26,790 are spacer sequences for knocking-in TTR sequences into the HGD gene with a Cas9 endonuclease.

[00106] SEQ ID NOs: 26,791 -34,031 are spacer sequences for knocking-in TTR sequences into the TF gene with a Cas9 endonuclease.

[00107] SEQ ID NOs: 34,032-35,012 are spacer sequences for knocking-in TTR sequences into the Gys2 gene with a Cas9 endonuclease.

[00108] SEQ ID NOs: 35,013-37,317 are spacer sequences for knocking-in TTR sequences into the AAVS gene with a Cas9 endonuclease.

[00109] SEQ ID NOs: 37,318-39, 185 are spacer sequences for knocking-in TTR sequences into the F9 gene with a Cas9 endonuclease.

[00110] SEQ ID Nos: 39, 186-39, 187 are miscellaneous sequences described in the specification.

[00111] SEQ ID NOs: 39, 188 - 39,190 show sample sgRNA sequences.

Detailed Description

[00112] FTA

[00113] Historically, Hereditary Amyloidoses were classified into 4 types based on symptoms and ethnic origin, type I and II are caused by mutations of

Transthyretin (TTR), while III and IV are caused by mutation in other genes.

[00114] TTR is a serum and cerebrospinal fluid protein playing role in transport of retinol-binding protein and thyroxine. The protein is synthesized mainly in liver, choroid plexus, kidney, retinal epithelium, and pancreas (OMIM, on the worldwide web at: proteinatlas.org/ENSG000001 18271 -TTR/tissue;

biogps.org/#goto=genereport&id=7276). A gene encoding TTR is located at 18q12.1 , (GRCh38: 18:31 ,591 ,766-31 ,599,023).

[00115] TTR amyloidosis is characterized by a slowly development of a peripheral sensorimotor neuropathy and autonomic neuropathy as well as cardiomyopathy, nephropathy, vitreous opacities, and CNS amyloidosis. The onset of disease varies depending on patient ethnicity (30-40 y.o. in Portuguese and Japanese patients, and later onset in patients from other origins). The sensory neuropathy usually starts in the lower extremities, followed by motor neuropathy. Importantly, three mutations are associated with amyloidosis presenting as cardiomyopathy without a significant degree of peripheral neuropathy. T60A, L1 1 1 M, V122I. TTR gene has 4 exons and spans 6.9 kb on chromosome 18q12.1 . Mutations causing Amyloidosis are listed in Table 1 .

[00116] Table 1 . Pathological mutations of TTR

Cysl OArg (c.88T>C), Leu12Pro (c.95T>C), Asp18Gly

(c.1 13A>G), Asp18Asn (c.1 12G>A), Val20lle (c.1 18G>A),

Ser23Asn (c.128G>A), Pro24Ser (c.130C>T), Ala25Ser

(c.133G>T), Ala25Thr (c.133G>A), Val28Met (c.142G>A),

Val30Met (c.148G>A), Val30Ala (c.149T>C), Val30Leu

(c.148G>C), Val30Gly (c.149T>G), Val32Ala (c.155T>C),

Phe33lle (c.157T>A), Phe33Leu (c.157T>C), Phe33Val

(c.157T>G), Phe33Cys (c.158T>G), Arg34Thr (c.161 G>C),

Arg34Gly(c.160A>G), Lys35Asn (c.165G>C), Lys35Thr

(c.164A>C), Ala36Pro (c.166G>C), Asp38Ala (c.173A>C),

Trp41 Leu (c.182G>T), Glu42Gly (c.185A>G), Glu42Asp

(c.186G>T), Phe44Ser (c.191 T>C), Ala45Thr (c.193G>A),

Ala45Asp (c.194C>A), Ala45Ser (c.193G>T), Gly47Arg

(c.199G>A), Gly47Ala (c.200G>C), Gly47Glu (c.200G>A),

Thr49Ala (c.205A>G), Thr49lle (c.206C>T), Thr49Pro

(c.205A>C), Ser50Arg (c.210T>C), Ser50lle (c.209G>T),

Glu51 Gly (c.212A>G), Ser52Pro (c.214T>C), Gly53Glu

(c.218G>A), Gly53Ala (c.218G>C), Glu54Gly (c.221A>G),

Glu54Lys (c.220G>A), Glu54Leu (c.220_221 delGAinsCT),

Leu55Pro (c.224T>C), Leu55Arg (c.224T>G), Leu55Gln

(c.224T>A), His56Arg (c.227A>G), Gly57Arg (c.229G>A),

Leu58His (c.233T>G), Leu58Arg (c.233T>G), Thr59Lys

(c.236C>A), Thr60Ala (c.238A>G), Glu61 Lys (c.241 G>A),

Glu61 Gly (c.242A>G), Phe64Leu (c.250T>C), Phe64Ser (c.251 T>C), Ne68Leu (c.262A>T), Tyr69His

(c.265T>C), Tyr69lle (c.265_266delTAinsAT),

Lys70Asn(c.270A>C),

Val71Ala (c.272T>C), Ser77Tyr (c.290C>A), Ser77Phe

(c.290C>T), Tyr78Phe (c.293A>T), Ala81 Thr (c.301 G>A),

Ala81Val (c.302C>T), Ne84Ser (c.31 1 T>G), Ne84Asn

(c.31 1 T>A), Ne84Thr (c.31 1 T>C), His88Arg (c.323A>G),

Glu89Gln (c.325G>C), Glu89Lys (c.325G>A), His90Asp

(c.328C>G), Ala91 Ser (c.331 G>T), Glu92Lys (c.334G>A),

Val94Ala (c.341 T>C), Ala97Gly (c.350C>G), Asp99Asn

(c.355G>A), Arg103Ser (c.367C>A), Ne107Val (c.379A>G),

Ne107Met (c.381 T>C), Ne107Phe (c.379A>T),

Ala109Ser (c.386C>T), Leu1 1 1 Met (c.391 C>A), Ser1 12lle

(c.395G>T), Tyr1 14Cys (c.401A>G), Tyr1 14His (c.400T>C),

Tyr1 16Ser (c.407A>C), Val122lle (c.424G>A),

delVal122 (c.424_426delGTC), Val122Ala (c.425T>C)

[00117] Therapeutic Approach

[00118] As the known forms of FTA are monogenic disorders with dominant inheritance, the methods of the present disclosure involve editing of one or both alleles. Gene editing to modify the allele(s) has the advantage of permanently altering the target gene or gene products.

[00119] In certain aspects, correcting or deleting the mutant allele may be sufficient for correction or reduction of TTR amyloid-forming function. The correction of the mutant allele may coincide with a copy of the wild-type allele remaining. Bi-allelic correction or deletion can also occur. Various editing strategies that can be employed for specific mutations discussed below.

[00120] Another approach is to delete the TTR gene, the TTR mutation and/or TTR expression (e.g., by targeting its exons, introns, or regulatory sequences) using one or two gRNAs.

[00121] Gene editing of one or possibly both mutant alleles provides an important improvement over existing or potential therapies, such as introduction of TTR expression cassettes, siRNA, or antisense RNA through lentivirus delivery and integration. Gene editing to delete the mutation has the advantage of precise genome modification and lower adverse effects.

[00122] For example, the mutation can be corrected by the insertions or deletions that arise due to the NHEJ repair pathway. If the patient's TTR gene has an inserted or deleted base, a targeted cleavage can result in a NHEJ-mediated insertion or deletion that restores the frame. Missense mutations can also be corrected through NHEJ-mediated correction using one or more guide RNA. The ability or likelihood of the cut(s) to correct the mutation can be designed or evaluated based on the local sequence and micro-homologies. NHEJ can also be used to delete segments of the gene, either directly or by altering splice donor or acceptor sites through cleavage by one gRNA targeting several locations, or several gRNAs. This may be useful if an amino acid, domain or exon contains the mutations and can be removed or inverted, or if the deletion otherwise restored function to the protein. Pairs of guide strands have been used for deletions and corrections of inversions. NHEJ can also be used to promote targeted transgene integration at the cleaved locus, especially if the transgene donor template has been cleaved within the cell as well.

[00123] Alternatively, the donor for correction by homology directed repair (HDR) contains the corrected sequence with small or large flanking homology arms to allow for annealing. HDR is essentially an error-free mechanism that uses a supplied homologous DNA sequence as a template during DSB repair. The rate of HDR is a function of the distance between the mutation and the cut site so choosing overlapping or nearby target sites is important. Templates can include extra sequences flanked by the homologous regions or can contain a sequence that differs from the genomic sequence, thus allowing sequence editing.

[00124] In addition to correcting mutations by NHEJ or HDR, a range of other options are possible. If there are small or large deletions or multiple mutations, a cDNA can be knocked in that contains the exons affected. A full length cDNA can be knocked into any "safe harbor"-/.e., non-deleterious insertion point that is not the TTR gene itself-, with or without suitable regulatory sequences. If this construct is knocked-in near the TTR regulatory elements, it should have physiological control, similar to the normal gene. Two or more (e.g., a pair) nucleases can be used to delete mutated gene regions, though a donor would usually have to be provided to restore function. In this case, two gRNA and one donor sequence would be supplied.

[00125] Provided herein are methods to delete or correct the specific mutation in the gene by inducing a double stranded break with Cas9 and a sgRNA or a pair of double stranded breaks around the mutation using two appropriate sgRNAs, and to provide a donor DNA template to induce Homology-Directed Repair (HDR). In some embodiments, the donor DNA template can be a short single stranded oligonucleotide, a short double stranded oligonucleotide, a long single or double stranded DNA molecule. These methods use gRNAs and donor DNA molecules for each of the variants of the TTR.

[00126] Provided herein are methods to knock-in TTR cDNA or a minigene (comprised of one or more exons and introns or natural or synthetic introns) into the locus of the corresponding gene. These methods use a pair of sgRNA targeting the first exon and/or the first intron of the TTR gene. In some embodiments, the donor DNA is single or double stranded DNA having homologous arms to the 18q12.1 region.

[00127] Provided herein are methods to knock-in TTR cDNA or a minigene (comprised of one or more exons and introns or natural or synthetic introns) into the locus of the hot-spot, e.g. ALB gene. These methods use a pair of sgRNA targeting the first exon and/or the first intron of the gene located in the liver hotspot. In some embodiments, the donor DNA is single or double stranded DNA having

homologous arms to the corresponding region.

[00128] Provided herein are cellular, ex vivo and in vivo methods for using genome engineering tools to create permanent changes to the genome by: 1 ) correcting, by insertions or deletions that arise due to the imprecise NHEJ pathway, one or more mutations within or near the TTR gene or other DNA sequences that encode regulatory elements of the TTR gene, 2) correcting, by HDR, one or more mutations within or near the TTR gene or other DNA sequences that encode regulatory elements of the TTR gene, 3) deletion of the mutant TTR gene and/or TTR gene products by insertion, deletion or mutations that arise due to the imprecise NHEJ pathway, or 4) deletion of the mutant region and/or knocking-in TTR cDNA or minigene (comprised of, natural or synthetic enhancer and promoter, one or more exons, and natural or synthetic introns, and natural or synthetic 3' UTR and polyadenylation signal) into the gene locus or a safe harbor locus of the TTR gene. Such methods use endonucleases, such as CRISPR-associated (Cas9, Cpf1 and the like) nucleases, to permanently delete, insert, edit, correct, or replace one or more exons or portions thereof (i.e., mutations within or near coding and/or splicing sequences) or insert in the genomic locus of the TTR gene or other DNA sequences that encode regulatory elements of the TTR gene. In this way, the examples set forth in the present disclosure delete or decrease the expression of the TTR gene, or restore the reading frame or the wild-type sequence of, or otherwise delete or correct, the gene with a single treatment (rather than deliver potential therapies for the lifetime of the patient).

[00129] Provided herein are methods for treating a patient with FTA. An aspect of such method is an ex vivo cell-based therapy. For example, a patient specific induced pluripotent stem cell (iPSC) is created. Then, the chromosomal DNA of these iPS cells is edited using the materials and methods described herein. Next, the edited iPSCs is differentiated into hepatocytes. Finally, the hepatocytes can be administered to the patient.

[00130] Another aspect of such method is an ex vivo cell-based therapy. For example, a liver specific progenitor cell or primary hepatocyte is isolated from the patient. Next, the chromosomal DNA of these progenitor cells or hepatocytes is edited using the materials and methods described herein. Finally, the edited progenitor cells or hepatocytes is administered to the patient.

[00131] Yet another aspect of such method is an ex vivo cell-based therapy. For example, a mesenchymal stem cell is isolated from the patient, which is isolated from the patient's bone marrow or peripheral blood. Next, the chromosomal DNA of these mesenchymal stem cells are edited using the materials and methods described herein. Next, the edited mesenchymal stem cells are differentiated into hepatocytes. Finally, these hepatocytes can be administered to the patient.

[00132] A further aspect of such method is an ex vivo cell-based therapy. For example, a liver progenitor cell is isolated from the patient. Next, the chromosomal DNA of these cells is edited using the materials and methods described herein. Finally, the edited liver progenitor cells is administered to the patient.

[00133] One advantage of an ex vivo cell therapy approach is the ability to conduct a comprehensive analysis of the therapeutic prior to administration.

Nuclease-based therapeutics can have some level of off-target effects. Performing gene correction ex vivo allows one to characterize the corrected cell population prior to administration. The present disclosure includes sequencing the entire genome of the corrected cells to ensure that the off-target effects, if any, are in genomic locations associated with minimal risk to the patient. Furthermore, populations of specific cells, including clonal populations, can be isolated prior to administration.

[00134] Another advantage of ex vivo cell therapy relates to genetic correction in iPSCs compared to other primary cell sources. iPSCs are prolific, making it easy to obtain the large number of cells that will be required for a cell-based therapy.

Furthermore, iPSCs are an ideal cell type for performing clonal isolations. This allows screening for the correct genomic correction, without risking a decrease in viability. In contrast, other primary cells are viable for only a few passages and difficult to clonally expand. Thus, manipulation of iPSCs for the treatment of FTA will be much easier, and will shorten the amount of time needed to make the desired genetic correction.

[00135] An advantage of in vivo gene therapy is the ease of therapeutic production and administration. The same therapeutic approach and therapy will have the potential to be used to treat more than one patient, for example a number of patients who share the same or similar genotype or allele. In contrast, ex vivo cell therapy typically requires using a patient's own cells, which are isolated, manipulated and returned to the same patient.

[00136] Also provided herein is a cellular method for editing the TTR gene in a cell by genome editing. For example, a cell is isolated from a patient or animal. Then, the chromosomal DNA of the cell is edited using the materials and methods described herein. Most prevalent mutations, like c.148G>A (Val30Met) or others listed in Table 1 are corrected by cutting gDNA proximal to mutation by one or two gRNA and providing a short DNA template with wildtype or modified sequence in a form of ssODN, dsODN, rAAV, HSV, IDLV.

[00137] The methods provided herein, regardless of whether a cellular or ex vivo or in vivo method, involve one or a combination of the following: 1 ) correcting, by insertions or deletions that arise due to the imprecise NHEJ pathway, one or more mutations or exons within or near the TTR gene or other DNA sequences that encode regulatory elements of the TTR gene, 2) correcting, by HDR or NHEJ, one or more mutations or exons within or near the TTR gene or other DNA sequences that encode regulatory elements of the TTR gene, 3) deletion of the mutant TTR gene and/or TTR gene products by insertion, deletion or mutations that arise due to the imprecise NHEJ pathway, or 4) deletion of the mutant region and/or knocking-in a TTR cDNA or a minigene (comprised of one or more exons or introns or natural or synthetic introns) or introducing exogenous TTR DNA or cDNA sequence or a fragment thereof into the locus of the gene or at a heterologous location in the genome (such as a safe harbor locus, such as an albumin gene, an AAVS1 gene, an HRPT gene, a CCR5 gene, a globin gene, TTR gene, TF gene, F9 gene, Alb gene, Gys2 gene and PCSK9 gene. Assessment of efficiency of HDR mediated knock-in of cDNA into the first exon can utilize cDNA knock-in into "safe harbor" sites such as: single-stranded or double-stranded DNA having homologous arms to one of the following regions, for example: AAVS1 19q13.4-qter, HRPT 1 q31 .2, CCR5 3p21 .31 , Globin 1 1 p15.4, TTR 18q12.1 , TF 3q22.1 , F9 Xq27.1 , Alb 4q13.3, Gys2 12p12.1 , PCSK9 1 p32.3; 5' UTR corresponding to TTR or alternative 5' UTR, complete CDS of TTR and 3' UTR of TTR or modified 3' UTR and at least 80 nt of the first intron, alternatively same DNA template sequence will be delivered by AAV. Both the HDR and knock-in strategies utilize a donor DNA template in Homology-Directed Repair (HDR) or Non-Homologous End Joining (NHEJ). HDR in either strategy may be accomplished by making one or more single-stranded breaks (SSBs) or double-stranded breaks (DSBs) at specific sites in the genome by using one or more endonucleases.

[00138] For example, an NHEJ correction strategy involves restoring the non- mutant TTR gene by inducing one single stranded break or double stranded break in the gene of interest with one or more CRISPR endonucleases and a gRNA (e.g., crRNA + tracrRNA, or sgRNA), or two or more single stranded breaks or double stranded breaks in the gene of interest with two or more CRISPR endonucleases and two or more sgRNAs. This approach can require development and optimization of sgRNAs for the TTR gene.

[00139] For example, the HDR correction strategy involves restoring the non- mutant TTR gene by inducing one single stranded break or double stranded break in the gene of interest with one or more CRISPR endonucleases and a gRNA (e.g., crRNA + tracrRNA, or sgRNA), or two or more single stranded breaks or double stranded breaks in the gene of interest with one or more CRISPR endonucleases and two or more appropriate gRNAs, in the presence of a donor DNA template introduced exogenously to direct the cellular DSB response to Homology-Directed Repair (the donor DNA template can be a short single stranded oligonucleotide, a short double stranded oligonucleotide, a long single or double stranded DNA molecule). This approach requires development and optimization of gRNAs and donor DNA molecules for the TTR gene.

[00140] For example, the knock-in strategy involves knocking-in TTR cDNA or a minigene (comprised of, natural or synthetic enhancer and promoter, one or more exons, and natural or synthetic introns, and natural or synthetic 3'UTR and polyadenylation signal) into the locus of the gene using a gRNA (e.g., crRNA + tracrRNA, or sgRNA) or a pair of gRNAs targeting upstream of or in the first or other exon and/or intron of the TTR gene, or in a safe harbor site (such as AAVS1 ). The donor DNA will be single or double stranded DNA having homologous arms to the human 18q12.1 region.

[00141] For example, the deletion strategy involves deleting one or more mutations in one or more of the exons of the TTR gene using one or more endonucleases and two or more gRNAs or sgRNAs.

[00142] In addition to the above genome editing strategies, another strategy involves modulating expression of the TTR gene or gene products by editing in the regulatory sequence.

[00143] In addition to the editing options listed above, Cas9 or similar proteins can be used to target effector domains to the same target sites that can be identified for editing, or additional target sites within range of the effector domain. A range of chromatin modifying enzymes, methylases or demethlyases can be used to alter expression of the target gene. These types of epigenetic regulation have some advantages, particularly as they are limited in possible off-target effects.

[00144] A number of types of genomic target sites are present in addition to mutations in the coding and splicing sequences.

[00145] The regulation of transcription and translation implicates a number of different classes of sites that interact with cellular proteins or nucleotides. Often the DNA binding sites of transcription factors or other proteins can be targeted for mutation or deletion to study the role of the site, though they can also be targeted to change gene expression. Sites can be added through non-homologous end joining NHEJ or direct genome editing by homology directed repair (HDR).

Increased use of genome sequencing, RNA expression and genome-wide studies of transcription factor binding have increased the ability to identify how the sites lead to developmental or temporal gene regulation. These control systems can be direct or can involve extensive cooperative regulation that can require the integration of activities from multiple enhancers. Transcription factors typically bind 6-12 bp-long degenerate DNA sequences. The low level of specificity provided by individual sites suggests that complex interactions and rules are involved in binding and the functional outcome. Binding sites with less degeneracy can provide simpler means of regulation. Artificial transcription factors can be designed to specify longer sequences that have less similar sequences in the genome and have lower potential for off-target cleavage. Any of these types of binding sites can be mutated, deleted or even created to enable changes in gene regulation or expression (Canver, M.C. et ai, Nature (2015)).

[00146] Another class of gene regulatory regions having these features is microRNA (miRNA) binding sites. miRNAs are non-coding RNAs that play key roles in post-transcriptional gene regulation. miRNA can regulate the expression of 30% of all mammalian protein-encoding genes. Specific and potent gene silencing by double stranded RNA (RNAi) was discovered, plus additional small noncoding RNA (Canver, M.C. et ai, Nature (2015)). The largest class of noncoding RNAs important for gene silencing are miRNAs. In mammals, miRNAs are first transcribed as a long RNA transcripts, which can be separate transcriptional units, part of protein introns, or other transcripts. The long transcripts are called primary miRNA (pri-miRNA) that include imperfectly base-paired hairpin structures. These pri- miRNA can be cleaved into one or more shorter precursor miRNAs (pre-miRNAs) by Microprocessor, a protein complex in the nucleus, involving Drosha.

[00147] Pre-miRNAs are short stem loops -70 nucleotides in length with a 2- nucleotide 3'-overhang that are exported, into the mature 19-25 nucleotide miRNA:miRNA* duplexes. The miRNA strand with lower base pairing stability (the guide strand) can be loaded onto the RNA-induced silencing complex (RISC). The passenger guide strand (marked with *), can be functional, but is usually degraded. The mature miRNA tethers RISC to partly complementary sequence motifs in target mRNAs predominantly found within the 3' untranslated regions (UTRs) and induces posttranscriptional gene silencing (Bartel, D.P. Cell 136, 215-233 (2009); Saj, A. & Lai, E.C. Curr Opin Genet Dev 21 , 504-510 (201 1 )).

[00148] miRNAs can be important in development, differentiation, cell cycle and growth control, and in virtually all biological pathways in mammals and other multicellular organisms. miRNAs can also be involved in cell cycle control, apoptosis and stem cell differentiation, hematopoiesis, hypoxia, muscle

development, neurogenesis, insulin secretion, cholesterol metabolism, aging, viral replication and immune responses.

[00149] A single miRNA can target hundreds of different mRNA transcripts, while an individual transcript can be targeted by many different miRNAs. More than 28645 microRNAs have been annotated in the latest release of miRBase (v.21 ). Some miRNAs can be encoded by multiple loci, some of which can be expressed from tandemly co-transcribed clusters. The features allow for complex regulatory networks with multiple pathways and feedback controls. miRNAs can be integral parts of these feedback and regulatory circuits and can help regulate gene expression by keeping protein production within limits (Herranz, H. & Cohen, S.M. Genes Dev 24, 1339-1344 (2010); Posadas, D.M. & Carthew, R.W. Curr Opin Genet Dev 27, 1 -6 (2014)).

[00150] miRNA can also be important in a large number of human diseases that are associated with abnormal miRNA expression. This association underscores the importance of the miRNA regulatory pathway. Recent miRNA deletion studies have linked miRNA with regulation of the immune responses (Stern-Ginossar, N. et al., Science 317, 376-381 (2007)).

[00151] miRNA also have a strong link to cancer and can play a role in different types of cancer. miRNAs have been found to be downregulated in a number of tumors. miRNA can be important in the regulation of key cancer-related pathways, such as cell cycle control and the DNA damage response, and can therefore be used in diagnosis and can be targeted clinically. MicroRNAs can delicately regulate the balance of angiogenesis, such that experiments depleting all microRNAs suppresses tumor angiogenesis (Chen, S. et al., Genes Dev 28, 1054-1067 (2014)).

[00152] As has been shown for protein coding genes, miRNA genes can also be subject to epigenetic changes occurring with cancer. Many miRNA loci can be associated with CpG islands increasing their opportunity for regulation by DNA methylation (Weber, B., Stresemann, C, Brueckner, B. & Lyko, F. Cell Cycle 6, 1001 -1005 (2007)). The majority of studies have used treatment with chromatin remodeling drugs to reveal epigenetically silenced miRNAs.

[00153] In addition to their role in RNA silencing, miRNA can also activate translation (Posadas, D.M. & Carthew, R.W. Curr Opin Genet Dev il, 1 -6 (2014)). Knocking out these sites may lead to decreased expression of the targeted gene, while introducing these sites may increase expression.

[00154] Individual miRNA can be knocked out most effectively by mutating the seed sequence (bases 2-8 of the microRNA), which can be important for binding specificity. Cleavage in this region, followed by mis-repair by NHEJ can effectively abolish miRNA function by blocking binding to target sites. miRNA could also be inhibited by specific targeting of the special loop region adjacent to the palindromic sequence. Catalytically inactive Cas9 can also be used to inhibit shRNA expression (Zhao, Y. et al., Sci Rep 4, 3943 (2014)). In addition to targeting the miRNA, the binding sites can also be targeted and mutated to prevent the silencing by miRNA.

[00155] Human Cells

[00156] For ameliorating FTA, as described and illustrated herein, the principal targets for gene editing are human cells. For example, in the ex vivo methods, the human cells can be somatic cells, which after being modified using the techniques as described, can give rise to hepatocytes or progenitor cells. For example, in the in vivo methods, the human cells can be hepatocytes.

[00157] By performing gene editing in autologous cells that are derived from and therefore already completely immunologically matched with the patient in need, it is possible to generate cells that can be safely re-introduced into the patient, and effectively give rise to a population of cells that can be effective in ameliorating one or more clinical conditions associated with the patient's disease.

[00158] Progenitor cells are capable of both proliferation and giving rise to more progenitor cells, these in turn having the ability to generate a large number of mother cells that can in turn give rise to differentiated or differentiate daughter cells. The daughter cells themselves can be induced to proliferate and produce progeny that subsequently differentiate into one or more mature cell types, while also retaining one or more cells with parental developmental potential. The term "stem cell" refers then, to a cell with the capacity or potential, under particular circumstances, to differentiate to a more specialized or differentiated phenotype, and which retains the capacity, under certain circumstances, to proliferate without substantially differentiating. In one aspect, the term progenitor or stem cell refers to a generalized mother cell whose descendants (progeny) specialize, often in different directions, by differentiation, e.g. , by acquiring completely individual characters, as occurs in progressive diversification of embryonic cells and tissues. Cellular differentiation is a complex process typically occurring through many cell divisions. A differentiated cell may derive from a multipotent cell that itself is derived from a multipotent cell, and so on. While each of these multipotent cells may be considered stem cells, the range of cell types that each can give rise to may vary considerably. Some differentiated cells also have the capacity to give rise to cells of greater developmental potential. Such capacity may be natural or may be induced artificially upon treatment with various factors. In many biological instances, stem cells can also be "multipotent" because they can produce progeny of more than one distinct cell type, but this is not required for "stem-ness."

[00159] Self-renewal can be another important aspect of the stem cell. In theory, self-renewal can occur by either of two major mechanisms. Stem cells can divide asymmetrically, with one daughter retaining the stem state and the other daughter expressing some distinct other specific function and phenotype. Alternatively, some of the stem cells in a population can divide symmetrically into two stems, thus maintaining some stem cells in the population as a whole, while other cells in the population give rise to differentiated progeny only. Generally, "progenitor cells" have a cellular phenotype that is more primitive (i.e., is at an earlier step along a developmental pathway or progression than is a fully differentiated cell). Often, progenitor cells also have significant or very high proliferative potential. Progenitor cells can give rise to multiple distinct differentiated cell types or to a single differentiated cell type, depending on the developmental pathway and on the environment in which the cells develop and differentiate.

[00160] In the context of cell ontogeny, the adjective "differentiated," or

"differentiating" is a relative term. A "differentiated cell" is a cell that has progressed further down the developmental pathway than the cell to which it is being compared. Thus, stem cells can differentiate into lineage-restricted precursor cells (such as a myocyte progenitor cell), which in turn can differentiate into other types of precursor cells further down the pathway (such as a myocyte precursor), and then to an end-stage differentiated cell, such as a myocyte, which plays a characteristic role in a certain tissue type, and may or may not retain the capacity to proliferate further.

[00161 ] Induced Pluripotent Stem Cells

[00162] In some embodiments, the genetically engineered human cells described herein can be induced pluripotent stem cells (iPSCs). An advantage of using iPSCs is that the cells can be derived from the same subject to which the progenitor cells are to be administered. That is, a somatic cell can be obtained from a subject, reprogrammed to an induced pluripotent stem cell, and then re- differentiated into a progenitor cell to be administered to the subject (e.g., autologous cells). Because the progenitors are essentially derived from an autologous source, the risk of engraftment rejection or allergic response is reduced compared to the use of cells from another subject or group of subjects. In addition, the use of iPSCs negates the need for cells obtained from an embryonic source. Thus, in one aspect, the stem cells used in the disclosed methods are not embryonic stem cells.

[00163] Although differentiation is generally irreversible under physiological contexts, several methods have been recently developed to reprogram somatic cells to iPSCs. Exemplary methods are known to those of skill in the art and are described briefly herein below.

[00164] The term "reprogramming" refers to a process that alters or reverses the differentiation state of a differentiated cell (e.g., a somatic cell). Stated another way, reprogramming refers to a process of driving the differentiation of a cell backwards to a more undifferentiated or more primitive type of cell. It should be noted that placing many primary cells in culture can lead to some loss of fully differentiated characteristics. Thus, simply culturing such cells included in the term differentiated cells does not render these cells non-differentiated cells (e.g., undifferentiated cells) or pluripotent cells. The transition of a differentiated cell to pluripotency requires a reprogramming stimulus beyond the stimuli that lead to partial loss of differentiated character in culture. Reprogrammed cells also have the characteristic of the capacity of extended passaging without loss of growth potential, relative to primary cell parents, which generally have capacity for only a limited number of divisions in culture.

[00165] The cell to be reprogrammed can be either partially or terminally differentiated prior to reprogramming. In some embodiments, reprogramming encompasses complete reversion of the differentiation state of a differentiated cell (e.g., a somatic cell) to a pluripotent state or a multipotent state. In some

embodiments, reprogramming encompasses complete or partial reversion of the differentiation state of a differentiated cell (e.g., a somatic cell) to an

undifferentiated cell (e.g., an embryonic-like cell). Reprogramming can result in expression of particular genes by the cells, the expression of which further contributes to reprogramming. In certain embodiments described herein, reprogramming of a differentiated cell (e.g., a somatic cell) causes the differentiated cell to assume an undifferentiated state (e.g., is an undifferentiated cell). The resulting cells are referred to as "reprogrammed cells," or "induced pluripotent stem cells (iPSCs or iPS cells)." [00166] Reprogramming can involve alteration, e.g. , reversal, of at least some of the heritable patterns of nucleic acid modification (e.g., methylation), chromatin condensation, epigenetic changes, genomic imprinting, etc., that occur during cellular differentiation. Reprogramming is distinct from simply maintaining the existing undifferentiated state of a cell that is already pluripotent or maintaining the existing less than fully differentiated state of a cell that is already a multipotent cell (e.g., a liver stem cell). Reprogramming is also distinct from promoting the self- renewal or proliferation of cells that are already pluripotent or multipotent, although the compositions and methods described herein can also be of use for such purposes, in some embodiments.

[00167] Many methods are known in the art that can be used to generate pluripotent stem cells from somatic cells. Any such method that reprograms a somatic cell to the pluripotent phenotype would be appropriate for use in the methods described herein.

[00168] Reprogramming methodologies for generating pluripotent cells using defined combinations of transcription factors have been described. Mouse somatic cells can be converted to ES cell-like cells with expanded developmental potential by the direct transduction of Oct4, Sox2, Klf4, and c-Myc; see, e.g., Takahashi and Yamanaka, Cell 126(4): 663-76 (2006). iPSCs resemble ES cells, as they restore the pluripotency-associated transcriptional circuitry and much of the epigenetic landscape. In addition, mouse iPSCs satisfy all the standard assays for

pluripotency: specifically, in vitro differentiation into cell types of the three germ layers, teratoma formation, contribution to chimeras, germline transmission [see, e.g., Maherali and Hochedlinger, Cell Stem Cell. 3(6):595-605 (2008)], and tetraploid complementation.

[00169] Human iPSCs can be obtained using similar transduction methods, and the transcription factor trio, OCT4, SOX2, and NANOG, has been established as the core set of transcription factors that govern pluripotency; see, e.g. , Budniatzky and Gepstein, Stem Cells TransI Med. 3(4):448-57 (2014); Barrett et a/., Stem Cells Trans Med 3: 1 -6 sctm.2014-0121 (2014); Focosi et al. , Blood Cancer Journal 4: e21 1 (2014); and references cited therein. The production of iPSCs can be achieved by the introduction of nucleic acid sequences encoding stem cell- associated genes into an adult, somatic cell, historically using viral vectors.

[00170] iPSCs can be generated or derived from terminally differentiated somatic cells, as well as from adult stem cells, or somatic stem cells. That is, a non- pluripotent progenitor cell can be rendered pluripotent or multipotent by

reprogramming. In such instances, it may not be necessary to include as many reprogramming factors as required to reprogram a terminally differentiated cell. Further, reprogramming can be induced by the non-viral introduction of

reprogramming factors, e.g., by introducing the proteins themselves, or by introducing nucleic acids that encode the reprogramming factors, or by introducing messenger RNAs that upon translation produce the reprogramming factors (see e.g., Warren et al., Cell Stem Cell, 7(5):618-30 (2010). Reprogramming can be achieved by introducing a combination of nucleic acids encoding stem cell- associated genes, including, for example, Oct-4 (also known as Oct-3/4 or Pouf51 ), Soxl, Sox2, Sox3, Sox 15, Sox 18, NANOG, Klfl, Klf2, Klf4, Klf5, NR5A2, c-Myc, 1 - Myc, n-Myc, Rem2, Tert, and LIN28. In some embodiments, reprogramming using the methods and compositions described herein further comprise introducing one or more of Oct-3/4, a member of the Sox family, a member of the Klf family, and a member of the Myc family to a somatic cell. In some embodiments, the methods and compositions described herein further comprise introducing one or more of each of Oct-4, Sox2, Nanog, c-MYC and Klf4 for reprogramming. As noted above, the exact method used for reprogramming is not necessarily critical to the methods and compositions described herein. However, where cells differentiated from the reprogrammed cells are to be used in, e.g., human therapy, in one aspect the reprogramming is not effected by a method that alters the genome. Thus, in such embodiments, reprogramming is achieved, e.g., without the use of viral or plasmid vectors.

[00171] The efficiency of reprogramming (i.e., the number of reprogrammed cells) derived from a population of starting cells can be enhanced by the addition of various agents, e.g., small molecules, as shown by Shi et al. , Cell-Stem Cell 2:525-

528 (2008); Huangfu et al., Nature Biotechnology 26(7):795-797 (2008) and

Marson et al., Cell-Stem Cell 3: 132-135 (2008). Thus, an agent or combination of agents that enhance the efficiency or rate of induced pluripotent stem cell production can be used in the production of patient-specific or disease-specific iPSCs. Some non-limiting examples of agents that enhance reprogramming efficiency include soluble Wnt, Wnt conditioned media, BIX-01294 (a G9a histone methyltransferase), PD0325901 (a MEK inhibitor), DNA methyltransferase inhibitors, histone deacetylase (HDAC) inhibitors, valproic acid, 5'-azacytidine, dexamethasone, suberoylanilide, hydroxamic acid (SAHA), vitamin C, and trichostatin (TSA), among others.

[00172] Other non-limiting examples of reprogramming enhancing agents include: Suberoylanilide Hydroxamic Acid (SAHA (e.g., MK0683, vorinostat) and other hydroxamic acids), BML-210, Depudecin (e.g., (-)-Depudecin), HC Toxin, Nullscript (4-(l,3-Dioxo-IH,3H-benzo[de]isoquinolin-2-yl)-N-hydroxybuta namide), Phenylbutyrate (e.g., sodium phenylbutyrate) and Valproic Acid ((VP A) and other short chain fatty acids), Scriptaid, Suramin Sodium, Trichostatin A (TSA), APHA Compound 8, Apicidin, Sodium Butyrate, pivaloyloxymethyl butyrate (Pivanex, AN- 9), Trapoxin B, Chlamydocin, Depsipeptide (also known as FR901228 or FK228), benzamides (e.g., CI-994 (e.g., N-acetyl dinaline) and MS-27-275), MGCD0103, NVP-LAQ-824, CBHA (m-carboxycinnaminic acid bishydroxamic acid),

JNJ16241 199, Tubacin, A-161906, proxamide, oxamflatin, 3-CI-UCHA (e.g., 6-(3- chlorophenylureido)caproic hydroxamic acid), AOE (2-amino-8-oxo-9, 10- epoxydecanoic acid), CHAP31 and CHAP 50. Other reprogramming enhancing agents include, for example, dominant negative forms of the HDACs (e.g., catalytically inactive forms), siRNA inhibitors of the HDACs, and antibodies that specifically bind to the HDACs. Such inhibitors are available, e.g., from BIOMOL International, Fukasawa, Merck Biosciences, Novartis, Gloucester

Pharmaceuticals, Titan Pharmaceuticals, MethylGene, and Sigma Aldrich.

[00173] To confirm the induction of pluripotent stem cells for use with the methods described herein, isolated clones can be tested for the expression of a stem cell marker. Such expression in a cell derived from a somatic cell identifies the cells as induced pluripotent stem cells. Stem cell markers are selected from the non-limiting group including SSEA3, SSEA4, CD9, Nanog, Fbxl5, EcatI, Esgl, Eras,

Gdf3, Fgf4, Cripto, Daxl, Zpf296, Slc2a3, Rexl, Utfl, and Natl. In one case, for example, a cell that expresses Oct4 or Nanog is identified as pluripotent. Methods for detecting the expression of such markers can include, for example, RT-PCR and immunological methods that detect the presence of the encoded polypeptides, such as Western blots or flow cytometric analyses. In some embodiments, detection involves not only RT-PCR, but also includes detection of protein markers. Intracellular markers may be best identified via RT-PCR, or protein detection methods such as immunocytochemistry, while cell surface markers are readily identified, e.g., by immunocytochemistry.

[00174] The pluripotent stem cell character of isolated cells can be confirmed by tests evaluating the ability of the iPSCs to differentiate into cells of each of the three germ layers. As one example, teratoma formation in nude mice can be used to evaluate the pluripotent character of the isolated clones. The cells can be introduced into nude mice and histology and/or immunohistochemistry can be performed on a tumor arising from the cells. The growth of a tumor comprising cells from all three germ layers, for example, further indicates that the cells are pluripotent stem cells.

[00175] Hepatocytes

[00176] In some embodiments, the genetically engineered human cells described herein are hepatocytes. A hepatocyte is a cell of the main parenchymal tissue of the liver. Hepatocytes make up 70-85% of the liver's mass. These cells are involved in: protein synthesis; protein storage; transformation of carbohydrates; synthesis of cholesterol, bile salts and phospholipids; detoxification, modification, and excretion of exogenous and endogenous substances; and initiation of formation and secretion of bile.

[00177] TTR is mainly expressed in liver (hepatocytes) with secondary site of expression in islets of Langerhans and hypothalamus. Targeting TTR editing (e.g., TTR deletion) to hepatocytes will address both liver and neurological symptoms, two major complications of FTA.

[00178] Creating patient specific iPSCs

[00179] One step of the ex vivo methods of the present disclosure can involve creating a patient specific iPS cell, patient specific iPS cells, or a patient specific iPS cell line. There are many established methods in the art for creating patient specific iPS cells, as described in Takahashi and Yamanaka 2006; Takahashi, Tanabe et al. 2007. For example, the creating step comprises: a) isolating a somatic cell, such as a skin cell or fibroblast, from the patient; and b) introducing a set of pluripotency-associated genes into the somatic cell in order to induce the cell to become a pluripotent stem cell. In some embodiments, the set of pluripotency- associated genes is one or more of the genes selected from the group consisting of OCT4, SOX2, KLF4, Lin28, NANOG, and cMYC.

[00180] Performing a biopsy or aspirate of the patient's liver or bone marrow

[00181] A biopsy or aspirate is a sample of tissue or fluid taken from the body. There are many different kinds of biopsies or aspirates. Nearly all of them involve using a sharp tool to remove a small amount of tissue. If the biopsy will be on the skin or other sensitive area, numbing medicine can be applied first. A biopsy or aspirate can be performed according to any of the known methods in the art. For example, in a liver biopsy, a needle is injected into the liver through the skin of the belly, capturing the liver tissue. For example, in a bone marrow aspirate, a large needle is used to enter the pelvis bone to collect bone marrow.

[00182] Isolating a liver specific progenitor cell or primary hepatocyte

[00183] Liver specific progenitor cells and primary hepatocytes may be isolated according to any method known in the art. For example, human hepatocytes are isolated from fresh surgical specimens. Healthy liver tissue is used to isolate hepatocytes by collagenase digestion. The obtained cell suspension is filtered through a 100-mm nylon mesh and sedimented by centrifugation at 50g for 5 minutes, resuspended, and washed two to three times in cold wash medium.

Human liver stem cells are obtained by culturing under stringent conditions of hepatocytes obtained from fresh liver preparations. Hepatocytes seeded on collagen-coated plates are cultured for 2 weeks. After 2 weeks, surviving cells are removed, and characterized for expression of stem cells markers (Herrera et al., STEM CELLS 2006;24:2840-2850).

[00184] Isolating a mesenchymal stem cell

[00185] Mesenchymal stem cells can be isolated according to any method known in the art, such as from a patient's bone marrow or peripheral blood. For example, marrow aspirate can be collected into a syringe with heparin. Cells can be washed and centrifuged on a Percoll™. The cells can be cultured in Dulbecco's modified Eagle's medium (DMEM) (low glucose) containing 10% fetal bovine serum (FBS) (Pittinger MF, Mackay AM, Beck SC et a/., Science 1999; 284: 143-147).

[00186] Genome Editing

[00187] Genome editing generally refers to the process of modifying the nucleotide sequence of a genome, preferably in a precise or pre-determined manner. Examples of methods of genome editing described herein include methods of using site-directed nucleases to cut deoxyribonucleic acid (DNA) at precise target locations in the genome, thereby creating single-strand or double- strand DNA breaks at particular locations within the genome. Such breaks can be and regularly are repaired by natural, endogenous cellular processes, such as homology-directed repair (HDR) and non-homologous end joining (NHEJ), as recently reviewed in Cox et ai, Nature Medicine 21 (2): 121 -31 (2015). These two main DNA repair processes consist of a family of alternative pathways. NHEJ directly joins the DNA ends resulting from a double-strand break, sometimes with the loss or addition of nucleotide sequence, which may disrupt or enhance gene expression. HDR utilizes a homologous sequence, or donor sequence, as a template for inserting a defined DNA sequence at the break point. The homologous sequence can be in the endogenous genome, such as a sister chromatid.

Alternatively, the donor can be an exogenous nucleic acid, such as a plasmid, a single-strand oligonucleotide, a double-stranded oligonucleotide, a duplex oligonucleotide or a virus, that has regions of high homology with the nuclease- cleaved locus, but which can also contain additional sequence or sequence changes including deletions that can be incorporated into the cleaved target locus. A third repair mechanism can be microhomology-mediated end joining (MMEJ), also referred to as "Alternative NHEJ", in which the genetic outcome is similar to NHEJ in that small deletions and insertions can occur at the cleavage site. MMEJ can make use of homologous sequences of a few basepairs flanking the DNA break site to drive a more favored DNA end joining repair outcome, and recent reports have further elucidated the molecular mechanism of this process; see, e.g., Cho and Greenberg, Nature 518, 174-76 (2015); Kent ef al., Nature Structural and

Molecular Biology, Adv. Online doi: 10.1038/nsmb.2961 (2015); Mateos-Gomez et a/., Nature 518, 254-57 (2015); Ceccaldi et al., Nature 528, 258-62 (2015). In some instances it may be possible to predict likely repair outcomes based on analysis of potential microhomologies at the site of the DNA break.

[00188] Each of these genome editing mechanisms can be used to create desired genomic alterations. A step in the genome editing process can be to create one or two DNA breaks, the latter as double-strand breaks or as two single- stranded breaks, in the target locus as close as possible to the site of intended mutation. This can be achieved via the use of site-directed polypeptides, as described and illustrated herein.

[00189] Site-directed polypeptides, such as a DNA endonuclease, can introduce double-strand breaks or single-strand breaks in nucleic acids, e.g., genomic DNA. The double-strand break can stimulate a cell's endogenous DNA-repair pathways (e.g., homology-dependent repair or non-homologous end joining or alternative non-homologous end joining (A-NHEJ) or microhomology-mediated end joining). NHEJ can repair cleaved target nucleic acid without the need for a homologous template. This can sometimes result in small deletions or insertions (indels) in the target nucleic acid at the site of cleavage, and can lead to disruption or alteration of gene expression. HDR can occur when a homologous repair template, or donor, is available. The homologous donor template comprises sequences that are homologous to sequences flanking the target nucleic acid cleavage site. The sister chromatid is generally used by the cell as the repair template. However, for the purposes of genome editing, the repair template is often supplied as an exogenous nucleic acid, such as a plasmid, duplex oligonucleotide, single-strand

oligonucleotide, double-stranded oligonucleotide, or viral nucleic acid. With exogenous donor templates, it is common to introduce an additional nucleic acid sequence (such as a transgene) or modification (such as a single or multiple base change or a deletion) between the flanking regions of homology so that the additional or altered nucleic acid sequence also becomes incorporated into the target locus. MMEJ results in a genetic outcome that is similar to NHEJ in that small deletions and insertions can occur at the cleavage site. MMEJ makes use of homologous sequences of a few basepairs flanking the cleavage site to drive a favored end-joining DNA repair outcome. In some instances it may be possible to predict likely repair outcomes based on analysis of potential microhomologies in the nuclease target regions.

[00190] Thus, in some embodiments, either non-homologous end joining or homologous recombination is used to insert an exogenous polynucleotide sequence into the target nucleic acid cleavage site. An exogenous polynucleotide sequence is termed a donor polynucleotide (or donor or donor sequence or polynucleotide donor template) herein. In some embodiments, the donor polynucleotide, a portion of the donor polynucleotide, a copy of the donor polynucleotide, or a portion of a copy of the donor polynucleotide is inserted into the target nucleic acid cleavage site. In some embodiments, the donor

polynucleotide is an exogenous polynucleotide sequence, i.e., a sequence that does not naturally occur at the target nucleic acid cleavage site.

[00191] The modifications of the target DNA due to NHEJ and/or HDR can lead to, for example, mutations, deletions, alterations, integrations, gene correction, gene replacement, gene tagging, transgene insertion, nucleotide deletion, gene disruption, translocations and/or gene mutation. The processes of deleting genomic DNA and integrating non-native nucleic acid into genomic DNA are examples of genome editing.

[00192] CRISPR Endonuclease System

[00193] A CRISPR (Clustered Regularly Interspaced Short Palindromic Repeats) genomic locus can be found in the genomes of many prokaryotes (e.g., bacteria and archaea). In prokaryotes, the CRISPR locus encodes products that function as a type of immune system to help defend the prokaryotes against foreign invaders, such as virus and phage. There are three stages of CRISPR locus function:

integration of new sequences into the CRISPR locus, expression of CRISPR RNA (crRNA), and silencing of foreign invader nucleic acid. Five types of CRISPR systems (e.g., Type I, Type II, Type III, Type U, and Type V) have been identified.

[00194] A CRISPR locus includes a number of short repeating sequences referred to as "repeats." When expressed, the repeats can form secondary structures (e.g., hairpins) and/or comprise unstructured single-stranded sequences. The repeats usually occur in clusters and frequently diverge between species. The repeats are regularly interspaced with unique intervening sequences referred to as "spacers," resulting in a repeat-spacer-repeat locus architecture. The spacers are identical to or have high homology with known foreign invader sequences. A spacer-repeat unit encodes a crisprRNA (crRNA), which is processed into a mature form of the spacer-repeat unit. A crRNA comprises a "seed" or spacer sequence that is involved in targeting a target nucleic acid (in the naturally occurring form in prokaryotes, the spacer sequence targets the foreign invader nucleic acid). A spacer sequence is located at the 5' or 3' end of the crRNA.

[00195] A CRISPR locus also comprises polynucleotide sequences encoding CRISPR Associated (Cas) genes. Cas genes encode endonucleases involved in the biogenesis and the interference stages of crRNA function in prokaryotes. Some Cas genes comprise homologous secondary and/or tertiary structures.

[00196] Type II CRISPR Systems

[00197] crRNA biogenesis in a Type II CRISPR system in nature requires a trans-activating CRISPR RNA (tracrRNA). The tracrRNA is modified by

endogenous RNaselll, and then hybridizes to a crRNA repeat in the pre-crRNA array. Endogenous RNaselll is recruited to cleave the pre-crRNA. Cleaved crRNAs are subjected to exoribonuclease trimming to produce the mature crRNA form (e.g., 5' trimming). The tracrRNA remains hybridized to the crRNA, and the tracrRNA and the crRNA associate with a site-directed polypeptide (e.g., Cas9). The crRNA of the crRNA-tracrRNA-Cas9 complex guides the complex to a target nucleic acid to which the crRNA can hybridize. Hybridization of the crRNA to the target nucleic acid activates Cas9 for targeted nucleic acid cleavage. The target nucleic acid in a Type II CRISPR system is referred to as a protospacer adjacent motif (PAM). In nature, the PAM is essential to facilitate binding of a site-directed polypeptide (e.g. , Cas9) to the target nucleic acid. Type II systems (also referred to as Nmeni or CASS4) are further subdivided into Type ll-A (CASS4) and ll-B (CASS4a). Jinek et ai, Science, 337(6096):816-821 (2012) showed that the CRISPR/Cas9 system is useful for RNA-programmable genome editing, and international patent application publication number WO2013/176772 provides numerous examples and

applications of the CRISPR/Cas endonuclease system for site-specific gene editing. [00198] Type V CRISPR Systems

[00199] Type V CRISPR systems have several important differences from Type II systems. For example, Cpf1 is a single RNA-guided endonuclease that, in contrast to Type II systems, lacks tracrRNA. In fact, Cpf1 -associated CRISPR arrays are processed into mature crRNAs without the requirement of an additional trans-activating tracrRNA. The Type V CRISPR array is processed into short mature crRNAs of 42-44 nucleotides in length, with each mature crRNA beginning with 19 nucleotides of direct repeat followed by 23-25 nucleotides of spacer sequence. In contrast, mature crRNAs in Type II systems can start with 20-24 nucleotides of spacer sequence followed by about 22 nucleotides of direct repeat. Also, Cpf1 utilizes a T-rich protospacer-adjacent motif such that Cpf1 -crRNA complexes efficiently cleave target DNA preceded by a short T-rich PAM, which is in contrast to the G-rich PAM following the target DNA for Type II systems. Thus, Type V systems cleave at a point that is distant from the PAM, while Type II systems cleave at a point that is adjacent to the PAM. In addition, in contrast to Type II systems, Cpf1 cleaves DNA via a staggered DNA double-stranded break with a 4 or 5 nucleotide 5' overhang. Type II systems cleave via a blunt double- stranded break. Similar to Type II systems, Cpf1 contains a predicted RuvC-like endonuclease domain, but lacks a second HNH endonuclease domain, which is in contrast to Type II systems.

[00200] Cas Genes/Polypeptides and Protospacer Adjacent Motifs

[00201] Exemplary CRISPR/Cas polypeptides include the Cas9 polypeptides in Fig. 1 of Fonfara et al., Nucleic Acids Research, 42: 2577-2590 (2014). The CRISPR/Cas gene naming system has undergone extensive rewriting since the Cas genes were discovered. Fig. 5 of Fonfara, supra, provides PAM sequences for the Cas9 polypeptides from various species.

[00202] Site-Directed Polypeptides

[00203] A site-directed polypeptide is a nuclease used in genome editing to cleave DNA. The site-directed can be administered to a cell or a patient as either: one or more polypeptides, or one or more mRNAs encoding the polypeptide. [00204] In the context of a CRISPR/Cas or CRISPR/Cpf1 system, the site- directed polypeptide can bind to a guide RNA that, in turn, specifies the site in the target DNA to which the polypeptide is directed. In embodiments of the

CRISPR/Cas or CRISPR/Cpfl systems herein, the site-directed polypeptide is an endonuclease, such as a DNA endonuclease.

[00205] In some embodiments, a site-directed polypeptide comprises a plurality of nucleic acid-cleaving (i.e., nuclease) domains. Two or more nucleic acid-cleaving domains can be linked together via a linker. For example, the linker comprises a flexible linker. In some embodiments, linkers comprise 1 , 2, 3, 4, 5, 6, 7, 8, 9, 10, 1 1 , 12, 13, 14, 15, 16, 17, 18, 19, 20, 21 , 22, 23, 24, 25, 30, 35, 40 or more amino acids in length.

[00206] Naturally-occurring wild-type Cas9 enzymes comprise two nuclease domains, a HNH nuclease domain and a RuvC domain. Herein, the "Cas9" refers to both naturally-occurring and recombinant Cas9s. Cas9 enzymes contemplated herein comprises a HNH or HNH-like nuclease domain, and/or a RuvC or RuvC-like nuclease domain.

[00207] HNH or HNH-like domains comprise a McrA-like fold. HNH or HNH-like domains comprises two antiparallel β-strands and an a-helix. HNH or HNH-like domains comprises a metal binding site (e.g., a divalent cation binding site). HNH or HNH-like domains can cleave one strand of a target nucleic acid (e.g., the complementary strand of the crRNA targeted strand).

[00208] RuvC or RuvC-like domains comprise an RNaseH or RNaseH-like fold. RuvC/RNaseH domains are involved in a diverse set of nucleic acid-based functions including acting on both RNA and DNA. The RNaseH domain comprises 5 β-strands surrounded by a plurality of a-helices. RuvC/RNaseH or

RuvC/RNaseH-like domains comprise a metal binding site (e.g., a divalent cation binding site). RuvC/RNaseH or RuvC/RNaseH-like domains can cleave one strand of a target nucleic acid (e.g., the non-complementary strand of a double-stranded target DNA).

[00209] Site-directed polypeptides can introduce double-strand breaks or single- strand breaks in nucleic acids, e.g., genomic DNA. The double-strand break can stimulate a cell's endogenous DNA-repair pathways (e.g., homology-dependent repair (HDR) or non-homologous end-joining (NHEJ) or alternative nonhomologous end joining (A-NHEJ) or microhomology-mediated end joining

(MMEJ)). NHEJ can repair cleaved target nucleic acid without the need for a homologous template. This can sometimes result in small deletions or insertions (indels) in the target nucleic acid at the site of cleavage, and can lead to disruption or alteration of gene expression. HDR can occur when a homologous repair template, or donor, is available. The homologous donor template can comprise sequences that are homologous to sequences flanking the target nucleic acid cleavage site. The sister chromatid is generally used by the cell as the repair template. However, for the purposes of genome editing, the repair template is often supplied as an exogenous nucleic acid, such as a plasmid, duplex oligonucleotide, single-strand oligonucleotide or viral nucleic acid. With exogenous donor templates, it is common to introduce an additional nucleic acid sequence (such as a

transgene) or modification (such as a single or multiple base change or a deletion) between the flanking regions of homology so that the additional or altered nucleic acid sequence also becomes incorporated into the target locus. MMEJ results in a genetic outcome that is similar to NHEJ in that small deletions and insertions can occur at the cleavage site. MMEJ makes use of homologous sequences of a few basepairs flanking the cleavage site to drive a favored end-joining DNA repair outcome. In some instances it may be possible to predict likely repair outcomes based on analysis of potential microhomologies in the nuclease target regions.

[00210] Thus, in some embodiments, homologous recombination is used to insert an exogenous polynucleotide sequence into the target nucleic acid cleavage site. An exogenous polynucleotide sequence is termed a donor polynucleotide (or donor or donor sequence) herein. In some embodiments, the donor polynucleotide, a portion of the donor polynucleotide, a copy of the donor polynucleotide, or a portion of a copy of the donor polynucleotide is inserted into the target nucleic acid cleavage site. In some embodiments, the donor polynucleotide is an exogenous polynucleotide sequence, i.e., a sequence that does not naturally occur at the target nucleic acid cleavage site.

[00211] The modifications of the target DNA due to NHEJ and/or HDR can lead to, for example, mutations, deletions, alterations, integrations, gene correction, gene replacement, gene tagging, transgene insertion, nucleotide deletion, gene disruption, translocations and/or gene mutation. The processes of deleting genomic DNA and integrating non-native nucleic acid into genomic DNA are examples of genome editing.

[00212] In some embodiments, the site-directed polypeptide comprises an amino acid sequence having at least 10%, at least 15%, at least 20%, at least 30%, at least 40%, at least 50%, at least 60%, at least 70%, at least 75%, at least 80%, at least 85%, at least 90%, at least 95%, at least 99%, or 100% amino acid sequence identity to a wild-type exemplary site-directed polypeptide [e.g., Cas9 from S.

pyogenes, US2014/0068797 Sequence ID No. 8 or Sapranauskas et ai, Nucleic Acids Res, 39(21 ): 9275-9282 (201 1 )], and various other site-directed polypeptides. The site-directed polypeptide comprises at least 70, 75, 80, 85, 90, 95, 97, 99, or 100% identity to a wild-type site-directed polypeptide (e.g., Cas9 from S. pyogenes, supra) over 10 contiguous amino acids. The site-directed polypeptide can comprise at most: 70, 75, 80, 85, 90, 95, 97, 99, or 100% identity to a wild-type site-directed polypeptide (e.g., Cas9 from S. pyogenes, supra) over 10 contiguous amino acids.

[00213] In some embodiments, the site-directed polypeptide comprises an amino acid sequence having at least 10%, at least 15%, at least 20%, at least 30%, at least 40%, at least 50%, at least 60%, at least 70%, at least 75%, at least 80%, at least 85%, at least 90%, at least 95%, at least 99%, or 100% amino acid sequence identity to the nuclease domain of a wild-type exemplary site-directed polypeptide (e.g., Cas9 from S. pyogenes, supra).

[00214] In some embodiments, the site-directed polypeptide comprises at least: 70, 75, 80, 85, 90, 95, 97, 99, or 100% identity to a wild-type site-directed polypeptide (e.g., Cas9 from S. pyogenes, supra) over 10 contiguous amino acids in a HNH nuclease domain of the site-directed polypeptide. In some embodiments, the site-directed polypeptide comprises at most: 70, 75, 80, 85, 90, 95, 97, 99, or 100% identity to a wild-type site-directed polypeptide (e.g., Cas9 from S. pyogenes, supra) over 10 contiguous amino acids in a HNH nuclease domain of the site- directed polypeptide. In some embodiments, the site-directed polypeptide comprises at least: 70, 75, 80, 85, 90, 95, 97, 99, or 100% identity to a wild-type site-directed polypeptide (e.g., Cas9 from S. pyogenes, supra) over 10 contiguous amino acids in a RuvC nuclease domain of the site-directed polypeptide. In some embodiments, the site-directed polypeptide comprises at most: 70, 75, 80, 85, 90, 95, 97, 99, or 100% identity to a wild-type site-directed polypeptide (e.g., Cas9 from S. pyogenes, supra) over 10 contiguous amino acids in a RuvC nuclease domain of the site-directed polypeptide.

[00215] In some embodiments, the site-directed polypeptide comprises a modified form of a wild-type exemplary site-directed polypeptide. In some embodiments, the modified form of the wild- type exemplary site-directed polypeptide comprises a mutation that reduces the nucleic acid-cleaving activity of the site-directed polypeptide. In some embodiments, the modified form of the wild- type exemplary site-directed polypeptide has less than 90%, less than 80%, less than 70%, less than 60%, less than 50%, less than 40%, less than 30%, less than 20%, less than 10%, less than 5%, or less than 1 % of the nucleic acid-cleaving activity of the wild-type exemplary site-directed polypeptide (e.g., Cas9 from S. pyogenes, supra). In some embodiments, the modified form of the site-directed polypeptide has no substantial nucleic acid-cleaving activity. When a site-directed polypeptide is a modified form that has no substantial nucleic acid-cleaving activity, it is referred to herein as "enzymatically inactive."

[00216] In some embodiments, the modified form of the site-directed polypeptide comprises a mutation such that it can induce a single-strand break (SSB) on a target nucleic acid (e.g., by cutting only one of the sugar-phosphate backbones of a double-strand target nucleic acid). In some embodiments, the mutation results in less than 90%, less than 80%, less than 70%, less than 60%, less than 50%, less than 40%, less than 30%, less than 20%, less than 10%, less than 5%, or less than 1 % of the nucleic acid-cleaving activity in one or more of the plurality of nucleic acid-cleaving domains of the wild-type site directed polypeptide (e.g., Cas9 from S. pyogenes, supra). The mutation results in one or more of the plurality of nucleic acid-cleaving domains retaining the ability to cleave the complementary strand of the target nucleic acid, but reducing its ability to cleave the non-complementary strand of the target nucleic acid. The mutation can result in one or more of the plurality of nucleic acid-cleaving domains retaining the ability to cleave the non- complementary strand of the target nucleic acid, but reducing its ability to cleave the complementary strand of the target nucleic acid. For example, residues in the wild-type exemplary S. pyogenes Cas9 polypeptide, such as Asp10, His840, Asn854 and Asn856, are mutated to inactivate one or more of the plurality of nucleic acid-cleaving domains (e.g., nuclease domains). The residues to be mutated can correspond to residues Asp10, His840, Asn854 and Asn856 in the wild-type exemplary S. pyogenes Cas9 polypeptide (e.g., as determined by sequence and/or structural alignment). Non-limiting examples of mutations include D10A, H840A, N854A or N856A. One skilled in the art will recognize that mutations other than alanine substitutions can be suitable.

[00217] In some embodiments, a D1 OA mutation is combined with one or more of H840A, N854A, or N856A mutations to produce a site-directed polypeptide substantially lacking DNA cleavage activity. In some embodiments, a H840A mutation is combined with one or more of D10A, N854A, or N856A mutations to produce a site-directed polypeptide substantially lacking DNA cleavage activity. In some embodiments, a N854A mutation is combined with one or more of H840A, D10A, or N856A mutations to produce a site-directed polypeptide substantially lacking DNA cleavage activity. In some embodiments, a N856A mutation is combined with one or more of H840A, N854A, or D10A mutations to produce a site- directed polypeptide substantially lacking DNA cleavage activity. Site-directed polypeptides that comprise one substantially inactive nuclease domain are referred to as "nickases".

[00218] Nickase variants of RNA-guided endonucleases, for example Cas9, can be used to increase the specificity of CRISPR-mediated genome editing. Wild type

Cas9 is typically guided by a single guide RNA designed to hybridize with a specified -20 nucleotide sequence in the target sequence (such as an endogenous genomic locus). However, several mismatches can be tolerated between the guide

RNA and the target locus, effectively reducing the length of required homology in the target site to, for example, as little as 13 nt of homology, and thereby resulting in elevated potential for binding and double-strand nucleic acid cleavage by the

CRISPR/Cas9 complex elsewhere in the target genome - also known as off-target cleavage. Because nickase variants of Cas9 each only cut one strand, in order to create a double-strand break it is necessary for a pair of nickases to bind in close proximity and on opposite strands of the target nucleic acid, thereby creating a pair of nicks, which is the equivalent of a double-strand break. This requires that two separate guide RNAs - one for each nickase - must bind in close proximity and on opposite strands of the target nucleic acid. This requirement essentially doubles the minimum length of homology needed for the double-strand break to occur, thereby reducing the likelihood that a double-strand cleavage event will occur elsewhere in the genome, where the two guide RNA sites - if they exist - are unlikely to be sufficiently close to each other to enable the double-strand break to form. As described in the art, nickases can also be used to promote HDR versus NHEJ. HDR can be used to introduce selected changes into target sites in the genome through the use of specific donor sequences that effectively mediate the desired changes. Descriptions of various CRISPR/Cas systems for use in gene editing can be found, e.g., in international patent application publication number

WO2013/176772, and in Nature Biotechnology 32, 347-355 (2014), and references cited therein.

[00219] Mutations contemplated can include substitutions, additions, and deletions, or any combination thereof. In some embodiments, the mutation converts the mutated amino acid to alanine. In some embodiments, the mutation converts the mutated amino acid to another amino acid (e.g., glycine, serine, threonine, cysteine, valine, leucine, isoleucine, methionine, proline, phenylalanine, tyrosine, tryptophan, aspartic acid, glutamic acid, asparagines, glutamine, histidine, lysine, or arginine). In some embodiments, the mutation converts the mutated amino acid to a non-natural amino acid (e.g., selenomethionine). In some embodiments, the mutation converts the mutated amino acid to amino acid mimics (e.g.,

phosphomimics). In some embodiments, the mutation is a conservative mutation. For example, the mutation converts the mutated amino acid to amino acids that resemble the size, shape, charge, polarity, conformation, and/or rotamers of the mutated amino acids (e.g., cysteine/serine mutation, lysine/asparagine mutation, histidine/phenylalanine mutation). In some embodiments, the mutation causes a shift in reading frame and/or the creation of a premature stop codon. In some embodiments, mutations causes changes to regulatory regions of genes or loci that affect expression of one or more genes.

[00220] In some embodiments, the site-directed polypeptide (e.g., variant, mutated, enzymatically inactive and/or conditionally enzymatically inactive site- directed polypeptide) targets nucleic acid. In some embodiments, the site-directed polypeptide (e.g., variant, mutated, enzymatically inactive and/or conditionally enzymatically inactive endonbonuclease) targets DNA. In some embodiments, the site-directed polypeptide (e.g., variant, mutated, enzymatically inactive and/or conditionally enzymatically inactive endonbonuclease) targets RNA.

[00221] In some embodiments, the site-directed polypeptide comprises one or more non-native sequences (e.g., the site-directed polypeptide is a fusion protein).

[00222] In some embodiments, the site-directed polypeptide comprises an amino acid sequence comprising at least 15% amino acid identity to a Cas9 from a bacterium (e.g., S. pyogenes), a nucleic acid binding domain, and two nucleic acid cleaving domains (i.e., a HNH domain and a RuvC domain).

[00223] In some embodiments, the site-directed polypeptide comprises an amino acid sequence comprising at least 15% amino acid identity to a Cas9 from a bacterium (e.g., S. pyogenes), and two nucleic acid cleaving domains (i.e., a HNH domain and a RuvC domain).

[00224] In some embodiments, the site-directed polypeptide comprises an amino acid sequence comprising at least 15% amino acid identity to a Cas9 from a bacterium (e.g., S. pyogenes), and two nucleic acid cleaving domains, wherein one or both of the nucleic acid cleaving domains comprise at least 50% amino acid identity to a nuclease domain from Cas9 from a bacterium (e.g., S. pyogenes).

[00225] In some embodiments, the site-directed polypeptide comprises an amino acid sequence comprising at least 15% amino acid identity to a Cas9 from a bacterium (e.g., S. pyogenes), two nucleic acid cleaving domains (i.e., a HNH domain and a RuvC domain), and non-native sequence (for example, a nuclear localization signal) or a linker linking the site-directed polypeptide to a non-native sequence.

[00226] In some embodiments, the site-directed polypeptide comprises an amino acid sequence comprising at least 15% amino acid identity to a Cas9 from a bacterium (e.g., S. pyogenes), two nucleic acid cleaving domains (i.e., a HNH domain and a RuvC domain), wherein the site-directed polypeptide comprises a mutation in one or both of the nucleic acid cleaving domains that reduces the cleaving activity of the nuclease domains by at least 50%. [00227] In some embodiments, the site-directed polypeptide comprises an amino acid sequence comprising at least 15% amino acid identity to a Cas9 from a bacterium (e.g., S. pyogenes), and two nucleic acid cleaving domains (i.e., a HNH domain and a RuvC domain), wherein one of the nuclease domains comprises mutation of aspartic acid 10, and/or wherein one of the nuclease domains comprises a mutation of histidine 840, and wherein the mutation reduces the cleaving activity of the nuclease domain(s) by at least 50%.

[00228] In some embodiments, the one or more site-directed polypeptides, e.g. DNA endonucleases, comprises two nickases that together effect one double- strand break at a specific locus in the genome, or four nickases that together effect or cause two double-strand breaks at specific loci in the genome. Alternatively, one site-directed polypeptide, e.g. DNA endonuclease, effects or causes one double- strand break at a specific locus in the genome.

[00229] The site-directed polypeptide can be flanked at the N-terminus, the C- terminus, or both the N-terminus and C-terminus by one or more nuclear localization signals (NLSs). For example, a Cas9 endonuclease can be flanked by two NLSs, one NLS located at the N-terminus and the second NLS located at the C-terminus. The NLS can be any NLS known in the art, such as a SV40 NLS.

[00230] Genome-targeting Nucleic Acid

[00231] The present disclosure provides a genome-targeting nucleic acid that can direct the activities of an associated polypeptide (e.g., a site-directed polypeptide) to a specific target sequence within a target nucleic acid. The genome- targeting nucleic acid can be an RNA. A genome-targeting RNA is referred to as a "guide RNA" or "gRNA" herein. A guide RNA comprises at least a spacer sequence that hybridizes to a target nucleic acid sequence of interest, and a CRISPR repeat sequence. In Type II systems, the gRNA also comprises a second RNA called the tracrRNA sequence. In the Type II guide RNA (gRNA), the CRISPR repeat sequence and tracrRNA sequence hybridize to each other to form a duplex. In the Type V guide RNA (gRNA), the crRNA forms a duplex. In both systems, the duplex can bind a site-directed polypeptide, such that the guide RNA and site-direct polypeptide form a complex. The genome-targeting nucleic acid can provide target specificity to the complex by virtue of its association with the site-directed polypeptide. The genome-targeting nucleic acid thus can direct the activity of the site-directed polypeptide.

[00232] Exemplary guide RNAs include the spacer sequences in SEQ ID NOs: 1 -8,669 and SEQ ID NOs: 8,770-39,185, shown with the genome location of their target sequence and the associated Cas9 cut site, wherein the genome location is based on the GRCh38 human genome assembly. As is understood by the person of ordinary skill in the art, each guide RNA can be designed to include a spacer sequence complementary to its genomic target sequence. For example, each of the spacer sequences in SEQ ID NOs: 1 -8,669 and SEQ ID NOs: 8,770- 39,185can be put into a single RNA chimera or a crRNA (along with a

corresponding tracrRNA). See Jinek et al., Science, 337, 816-821 (2012) and Deltcheva et al., Nature, 471 , 602-607 (201 1 ).

[00233] The genome-targeting nucleic acid can be a double-molecule guide RNA. The genome-targeting nucleic acid can be a single-molecule guide RNA.

[00234] A double-molecule guide RNA comprises two strands of RNA. The first strand comprises in the 5' to 3' direction, an optional spacer extension sequence, a spacer sequence and a minimum CRISPR repeat sequence. The second strand comprises a minimum tracrRNA sequence (complementary to the minimum

CRISPR repeat sequence), a 3' tracrRNA sequence and an optional tracrRNA extension sequence.

[00235] A single-molecule guide RNA (sgRNA) in a Type II system can comprise, in the 5' to 3' direction, an optional spacer extension sequence, a spacer sequence, a minimum CRISPR repeat sequence, a single-molecule guide linker, a minimum tracrRNA sequence, a 3' tracrRNA sequence and an optional tracrRNA extension sequence. The optional tracrRNA extension comprises elements that contribute additional functionality (e.g., stability) to the guide RNA. The single- molecule guide linker can link the minimum CRISPR repeat and the minimum tracrRNA sequence to form a hairpin structure. The optional tracrRNA extension comprises one or more hairpins.

[00236] The sgRNA comprises a 20 nucleotide spacer sequence at the 5' end of the sgRNA sequence. The sgRNA comprises a less than a 20 nucleotide spacer sequence at the 5' end of the sgRNA sequence. The sgRNA comprises a more than 20 nucleotide spacer sequence at the 5' end of the sgRNA sequence. The sgRNA comprises a variable length spacer sequence with 17-30 nucleotides at the 5' end of the sgRNA sequence (see Table 4).

[00237] The sgRNA comprises no uracil at the 3'end of the sgRNA sequence, such as in SEQ ID NO: 39,189 of Table 4. The sgRNA comprises one or more uracil at the 3'end of the sgRNA sequence, such as in SEQ I D NO: 39,190 in Table 4. For example, the sgRNA comprises 1 uracil (U) at the 3' end of the sgRNA sequence. The sgRNA comprises 2 uracil (UU) at the 3' end of the sgRNA sequence. The sgRNA comprises 3 uracil (UUU) at the 3' end of the sgRNA sequence. The sgRNA comprises 4 uracil (UUUU) at the 3' end of the sgRNA sequence. The sgRNA comprises 5 uracil (UUUUU) at the 3' end of the sgRNA sequence. The sgRNA comprises 6 uracil (UUUUUU) at the 3' end of the sgRNA sequence. The sgRNA comprises 7 uracil (UUUUUUU) at the 3' end of the sgRNA sequence. The sgRNA comprises 8 uracil (UUUUUUUU) at the 3' end of the sgRNA sequence.

[00238] The sgRNA can be unmodified or modified. For example, modified sgRNAs comprises one or more 2'-0-methyl phosphorothioate nucleotides.

Table 4

[00239] A single-molecule guide RNA (sgRNA) in a Type V system comprises, in the 5' to 3' direction, a minimum CRISPR repeat sequence and a spacer sequence.

[00240] By way of illustration, guide RNAs used in the CRISPR/Cas/Cpf1 system, or other smaller RNAs can be readily synthesized by chemical means, as illustrated below and described in the art. While chemical synthetic procedures are continually expanding, purifications of such RNAs by procedures such as high performance liquid chromatography (HPLC, which avoids the use of gels such as PAGE) tends to become more challenging as polynucleotide lengths increase significantly beyond a hundred or so nucleotides. One approach used for generating RNAs of greater length is to produce two or more molecules that are ligated together. Much longer RNAs, such as those encoding a Cas9 or Cpfl endonuclease, are more readily generated enzymatically. Various types of RNA modifications can be introduced during or after chemical synthesis and/or enzymatic generation of RNAs, e.g. , modifications that enhance stability, reduce the likelihood or degree of innate immune response, and/or enhance other attributes, as described in the art.

[00241 ] Spacer Extension Sequence

[00242] In some embodiments of genome-targeting nucleic acids, a spacer extension sequence can modify activity, provide stability and/or provide a location for modifications of a genome-targeting nucleic acid. A spacer extension sequence can modify on- or off-target activity or specificity. In some embodiments, a spacer extension sequence can be provided. In some embodiments, the spacer extension sequence has a length of more than 1 , 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 60, 70, 80, 90, 100, 120, 140, 160, 180, 200, 220, 240, 260, 280, 300, 320, 340, 360, 380, 400, 1000, 2000, 3000, 4000, 5000, 6000, or 7000 or more nucleotides. In some embodiments, the spacer extension sequence has a length of less than 1 , 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 60, 70, 80, 90, 100, 120, 140, 160, 180, 200, 220, 240, 260, 280, 300, 320, 340, 360, 380, 400, 1000, 2000, 3000, 4000, 5000, 6000, 7000 or more nucleotides. In some embodiments, the spacer extension sequence is less than 10 nucleotides in length. In some embodiments, the spacer extension sequence is between 10-30 nucleotides in length. In some embodiments, the spacer extension sequence is between 30-70 nucleotides in length.

[00243] In some embodiments, the spacer extension sequence comprises another moiety (e.g., a stability control sequence, an endoribonuclease binding sequence, a ribozyme). In some embodiments, the moiety decreases or increases the stability of a nucleic acid targeting nucleic acid. The moiety can be a

transcriptional terminator segment (i.e., a transcription termination sequence). In some embodiments, the moiety functions in a eukaryotic cell. The moiety can function in a prokaryotic cell. In some embodiments, the moiety functions in both eukaryotic and prokaryotic cells. Non-limiting examples of suitable moieties include: a 5' cap (e.g., a 7-methylguanylate cap (m7 G)), a riboswitch sequence (e.g., to allow for regulated stability and/or regulated accessibility by proteins and protein complexes), a sequence that forms a dsRNA duplex (i.e., a hairpin), a sequence that targets the RNA to a subcellular location (e.g., nucleus, mitochondria, chloroplasts, and the like), a modification or sequence that provides for tracking (e.g., direct conjugation to a fluorescent molecule, conjugation to a moiety that facilitates fluorescent detection, a sequence that allows for fluorescent detection, etc.), and/or a modification or sequence that provides a binding site for proteins (e.g., proteins that act on DNA, including transcriptional activators, transcriptional repressors, DNA methyltransferases, DNA demethylases, histone

acetyltransferases, histone deacetylases, and the like).

[00244] Spacer Sequence

[00245] The spacer sequence hybridizes to a sequence in a target nucleic acid of interest. The spacer of a genome-targeting nucleic acid interacts with a target nucleic acid in a sequence-specific manner via hybridization (i.e., base pairing). The nucleotide sequence of the spacer thus varies depending on the sequence of the target nucleic acid of interest.

[00246] In a CRISPR/Cas system herein, the spacer sequence can be designed to hybridize to a target nucleic acid that is located 5' of a PAM of the Cas9 enzyme used in the system. The spacer may perfectly match the target sequence or may have mismatches. Each Cas9 enzyme has a particular PAM sequence that it recognizes in a target DNA. For example, S. pyogenes recognizes in a target nucleic acid a PAM that comprises the sequence 5'-NRG-3', where R comprises either A or G, where N is any nucleotide and N is immediately 3' of the target nucleic acid sequence targeted by the spacer sequence.

[00247] In some embodiments, the target nucleic acid sequence comprises 20 nucleotides. In some embodiments, the target nucleic acid comprises less than 20 nucleotides. In some embodiments, the target nucleic acid comprises more than 20 nucleotides. In some embodiments, the target nucleic acid comprises at least: 5, 10, 15, 16, 17, 18, 19, 20, 21 , 22, 23, 24, 25, 30 or more nucleotides. The target nucleic acid comprises at most: 5, 10, 15, 16, 17, 18, 19, 20, 21 , 22, 23, 24, 25, 30 or more nucleotides. The target nucleic acid sequence comprises 20 bases immediately 5' of the first nucleotide of the PAM. For example, in a sequence comprising 5'-NNNNNNNNNNNNNNNNNNNNNRG-3' (SEQ ID NO:39, 186), the target nucleic acid comprises the sequence that corresponds to the Ns, wherein N is any nucleotide, and the underlined NRG sequence is the S. pyogenes PAM. One of skill in the art would recognize that the spacer sequence hybridizes to the non- PAM strand of the target nucleic acid (Figures 1 A and 1 B).

[00248] In some embodiments, the spacer sequence that hybridizes to the target nucleic acid has a length of at least about 6 nucleotides (nt). The spacer sequence can be at least about 6 nt, at least about 10 nt, at least about 15 nt, at least about

18 nt, at least about 19 nt, at least about 20 nt, at least about 25 nt, at least about 30 nt, at least about 35 nt or at least about 40 nt, from about 6 nt to about 80 nt, from about 6 nt to about 50 nt, from about 6 nt to about 45 nt, from about 6 nt to about 40 nt, from about 6 nt to about 35 nt, from about 6 nt to about 30 nt, from about 6 nt to about 25 nt, from about 6 nt to about 20 nt, from about 6 nt to about

19 nt, from about 10 nt to about 50 nt, from about 10 nt to about 45 nt, from about 10 nt to about 40 nt, from about 10 nt to about 35 nt, from about 10 nt to about 30 nt, from about 10 nt to about 25 nt, from about 10 nt to about 20 nt, from about 10 nt to about 19 nt, from about 19 nt to about 25 nt, from about 19 nt to about 30 nt, from about 19 nt to about 35 nt, from about 19 nt to about 40 nt, from about 19 nt to about 45 nt, from about 19 nt to about 50 nt, from about 19 nt to about 60 nt, from about 20 nt to about 25 nt, from about 20 nt to about 30 nt, from about 20 nt to about 35 nt, from about 20 nt to about 40 nt, from about 20 nt to about 45 nt, from about 20 nt to about 50 nt, or from about 20 nt to about 60 nt. In some

embodiments, the spacer sequence comprises 20 nucleotides. In some

embodiments, the spacer comprises 19 nucleotides. In some embodiments, the spacer comprises 18 nucleotides. In some embodiments, the spacer comprises 22 nucleotides.

[00249] In some embodiments, the percent complementarity between the spacer sequence and the target nucleic acid is at least about 30%, at least about 40%, at least about 50%, at least about 60%, at least about 65%, at least about 70%, at least about 75%, at least about 80%, at least about 85%, at least about 90%, at least about 95%, at least about 97%, at least about 98%, at least about 99%, or 100%. In some embodiments, the percent complementarity between the spacer sequence and the target nucleic acid is at most about 30%, at most about 40%, at most about 50%, at most about 60%, at most about 65%, at most about 70%, at most about 75%, at most about 80%, at most about 85%, at most about 90%, at most about 95%, at most about 97%, at most about 98%, at most about 99%, or 100%. In some embodiments, the percent complementarity between the spacer sequence and the target nucleic acid is 100% over the six contiguous 5'-most nucleotides of the target sequence of the complementary strand of the target nucleic acid. The percent complementarity between the spacer sequence and the target nucleic acid can be at least 60% over about 20 contiguous nucleotides. The length of the spacer sequence and the target nucleic acid can differ by 1 to 6 nucleotides, which may be thought of as a bulge or bulges.

[00250] In some embodiments, the spacer sequence is designed or chosen using a computer program. The computer program can use variables, such as predicted melting temperature, secondary structure formation, predicted annealing temperature, sequence identity, genomic context, chromatin accessibility, % GC, frequency of genomic occurrence (e.g., of sequences that are identical or are similar but vary in one or more spots as a result of mismatch, insertion or deletion), methylation status, presence of SNPs, and the like.

[00251] Minimum CRISPR Repeat Sequence

[00252] In some embodiments, a minimum CRISPR repeat sequence is a sequence with at least about 30%, about 40%, about 50%, about 60%, about 65%, about 70%, about 75%, about 80%, about 85%, about 90%, about 95%, or 100% sequence identity to a reference CRISPR repeat sequence (e.g., crRNA from S. pyogenes).

[00253] A minimum CRISPR repeat sequence comprises nucleotides that hybridize to a minimum tracrRNA sequence in a cell. The minimum CRISPR repeat sequence and a minimum tracrRNA sequence form a duplex, i.e. a base-paired double-stranded structure. Together, the minimum CRISPR repeat sequence and the minimum tracrRNA sequence bind to the site-directed polypeptide. In some embodiments, at least a part of the minimum CRISPR repeat sequence can hybridize to the minimum tracrRNA sequence. At least a part of the minimum CRISPR repeat sequence comprises at least about 30%, about 40%, about 50%, about 60%, about 65%, about 70%, about 75%, about 80%, about 85%, about 90%, about 95%, or 100% complementary to the minimum tracrRNA sequence. At least a part of the minimum CRISPR repeat sequence comprises at most about 30%, about 40%, about 50%, about 60%, about 65%, about 70%, about 75%, about 80%, about 85%, about 90%, about 95%, or 100% complementary to the minimum tracrRNA sequence.

[00254] The minimum CRISPR repeat sequence can have a length from about 7 nucleotides to about 100 nucleotides. For example, the length of the minimum CRISPR repeat sequence is from about 7 nucleotides (nt) to about 50 nt, from about 7 nt to about 40 nt, from about 7 nt to about 30 nt, from about 7 nt to about 25 nt, from about 7 nt to about 20 nt, from about 7 nt to about 15 nt, from about 8 nt to about 40 nt, from about 8 nt to about 30 nt, from about 8 nt to about 25 nt, from about 8 nt to about 20 nt, from about 8 nt to about 15 nt, from about 15 nt to about 100 nt, from about 15 nt to about 80 nt, from about 15 nt to about 50 nt, from about 15 nt to about 40 nt, from about 15 nt to about 30 nt, or from about 15 nt to about 25 nt. In some embodiments, the minimum CRISPR repeat sequence is

approximately 9 nucleotides in length. In some embodiments, the minimum

CRISPR repeat sequence can be approximately 12 nucleotides in length.

[00255] In some embodiments, the minimum CRISPR repeat sequence is at least about 60% identical to a reference minimum CRISPR repeat sequence (e.g., wild-type crRNA from S. pyogenes) over a stretch of at least 6, 7, or 8 contiguous nucleotides. For example, the minimum CRISPR repeat sequence is at least about 65% identical, at least about 70% identical, at least about 75% identical, at least about 80% identical, at least about 85% identical, at least about 90% identical, at least about 95% identical, at least about 98% identical, at least about 99% identical or 100% identical to a reference minimum CRISPR repeat sequence over a stretch of at least 6, 7, or 8 contiguous nucleotides.

[00256] Minimum tracrRNA Sequence

[00257] In some embodiments, a minimum tracrRNA sequence is a sequence with at least about 30%, about 40%, about 50%, about 60%, about 65%, about 70%, about 75%, about 80%, about 85%, about 90%, about 95%, or 100% sequence identity to a reference tracrRNA sequence (e.g., wild type tracrRNA from S. pyogenes).

[00258] A minimum tracrRNA sequence comprises nucleotides that hybridize to a minimum CRISPR repeat sequence in a cell. A minimum tracrRNA sequence and a minimum CRISPR repeat sequence form a duplex, i.e. a base-paired double- stranded structure. Together, the minimum tracrRNA sequence and the minimum CRISPR repeat can bind to a site-directed polypeptide. At least a part of the minimum tracrRNA sequence can hybridize to the minimum CRISPR repeat sequence. In some embodiments, the minimum tracrRNA sequence is at least about 30%, about 40%, about 50%, about 60%, about 65%, about 70%, about 75%, about 80%, about 85%, about 90%, about 95%, or 100% complementary to the minimum CRISPR repeat sequence.

[00259] The minimum tracrRNA sequence can have a length from about 7 nucleotides to about 100 nucleotides. For example, the minimum tracrRNA sequence can be from about 7 nucleotides (nt) to about 50 nt, from about 7 nt to about 40 nt, from about 7 nt to about 30 nt, from about 7 nt to about 25 nt, from about 7 nt to about 20 nt, from about 7 nt to about 15 nt, from about 8 nt to about 40 nt, from about 8 nt to about 30 nt, from about 8 nt to about 25 nt, from about 8 nt to about 20 nt, from about 8 nt to about 15 nt, from about 15 nt to about 100 nt, from about 15 nt to about 80 nt, from about 15 nt to about 50 nt, from about 15 nt to about 40 nt, from about 15 nt to about 30 nt or from about 15 nt to about 25 nt long. In some embodiments, the minimum tracrRNA sequence is approximately 9 nucleotides in length. In some embodiments, the minimum tracrRNA sequence is approximately 12 nucleotides. In some embodiments, the minimum tracrRNA consists of tracrRNA nt 23-48 described in Jinek et al., supra.

[00260] In some embodiments, the minimum tracrRNA sequence is at least about 60% identical to a reference minimum tracrRNA (e.g., wild type, tracrRNA from S. pyogenes) sequence over a stretch of at least 6, 7, or 8 contiguous nucleotides. For example, the minimum tracrRNA sequence is at least about 65% identical, about 70% identical, about 75% identical, about 80% identical, about 85% identical, about 90% identical, about 95% identical, about 98% identical, about 99% identical or 100% identical to a reference minimum tracrRNA sequence over a stretch of at least 6, 7, or 8 contiguous nucleotides.

[00261] In some embodiments, the duplex between the minimum CRISPR RNA and the minimum tracrRNA comprises a double helix. In some embodiments, the duplex between the minimum CRISPR RNA and the minimum tracrRNA comprises at least about 1 , 2, 3, 4, 5, 6, 7, 8, 9, or 10 or more nucleotides. In some

embodiments, the duplex between the minimum CRISPR RNA and the minimum tracrRNA comprises at most about 1 , 2, 3, 4, 5, 6, 7, 8, 9, or 10 or more

nucleotides.

[00262] In some embodiments, the duplex comprises a mismatch (i.e., the two strands of the duplex are not 100% complementary). In some embodiments, the duplex comprises at least about 1 , 2, 3, 4, or 5 or mismatches. In some

embodiments, the duplex comprises at most about 1 , 2, 3, 4, or 5 or mismatches. In some embodiments, the duplex comprises no more than 2 mismatches.

[00263] Bulges

[00264] In some embodiments, there is a "bulge" in the duplex between the minimum CRISPR RNA and the minimum tracrRNA. A bulge is an unpaired region of nucleotides within the duplex. In some embodiments, the bulge contributes to the binding of the duplex to the site-directed polypeptide. In some embodiments, the bulge comprises, on one side of the duplex, an unpaired 5'-XXXY-3' where X is any purine and Y comprises a nucleotide that can form a wobble pair with a nucleotide on the opposite strand, and an unpaired nucleotide region on the other side of the duplex. The number of unpaired nucleotides on the two sides of the duplex can be different.

[00265] In some embodiments, the bulge comprises an unpaired purine (e.g., adenine) on the minimum CRISPR repeat strand of the bulge. In some

embodiments, the bulge comprises an unpaired 5'-AAGY-3' of the minimum tracrRNA sequence strand of the bulge, where Y comprises a nucleotide that can form a wobble pairing with a nucleotide on the minimum CRISPR repeat strand.

[00266] In some embodiments, a bulge on the minimum CRISPR repeat side of the duplex comprises at least 1 , 2, 3, 4, or 5 or more unpaired nucleotides. In some embodiments, a bulge on the minimum CRISPR repeat side of the duplex comprises at most 1 , 2, 3, 4, or 5 or more unpaired nucleotides. In some

embodiments, a bulge on the minimum CRISPR repeat side of the duplex comprises 1 unpaired nucleotide.

[00267] In some embodiments, a bulge on the minimum tracrRNA sequence side of the duplex comprises at least 1 , 2, 3, 4, 5, 6, 7, 8, 9, or 10 or more unpaired nucleotides. In some embodiments, a bulge on the minimum tracrRNA sequence side of the duplex comprises at most 1 , 2, 3, 4, 5, 6, 7, 8, 9, or 10 or more unpaired nucleotides. In some embodiments, a bulge on a second side of the duplex (e.g., the minimum tracrRNA sequence side of the duplex) comprises 4 unpaired nucleotides.

[00268] In some embodiments, a bulge comprises at least one wobble pairing. In some embodiments, a bulge comprises at most one wobble pairing. In some embodiments, a bulge comprises at least one purine nucleotide. In some embodiments, a bulge comprises at least 3 purine nucleotides. In some

embodiments, a bulge sequence can comprise at least 5 purine nucleotides. In some embodiments, a bulge sequence comprises at least one guanine nucleotide. In some embodiments, a bulge sequence comprises at least one adenine nucleotide.

[00269] Hairpins

[00270] In various embodiments, one or more hairpins are located 3' to the minimum tracrRNA in the 3' tracrRNA sequence.

[00271] In some embodiments, the hairpin starts at least about 1 , 2, 3, 4, 5, 6, 7, 8, 9, 10, 15, or 20 or more nucleotides 3' from the last paired nucleotide in the minimum CRISPR repeat and minimum tracrRNA sequence duplex. In some embodiments, the hairpin starts at most about 1 , 2, 3, 4, 5, 6, 7, 8, 9 or 10 or more nucleotides 3' of the last paired nucleotide in the minimum CRISPR repeat and minimum tracrRNA sequence duplex.

[00272] In some embodiments, the hairpin comprises at least about 1 , 2, 3, 4, 5, 6, 7, 8, 9, 10, 15, or 20 or more consecutive nucleotides. In some embodiments, the hairpin comprises at most about 1 , 2, 3, 4, 5, 6, 7, 8, 9, 10, 15, or more consecutive nucleotides.

[00273] In some embodiments, the hairpin comprises a CC dinucleotide (i.e., two consecutive cytosine nucleotides).

[00274] In some embodiments, the hairpin comprises duplexed nucleotides (e.g., nucleotides in a hairpin, hybridized together). For example, a hairpin comprises a CC dinucleotide that is hybridized to a GG dinucleotide in a hairpin duplex of the 3' tracrRNA sequence.

[00275] One or more of the hairpins can interact with guide RNA-interacting regions of a site-directed polypeptide.

[00276] In some embodiments, there are two or more hairpins, and in other embodiments, there are three or more hairpins.

[00277] 3' tracrRNA sequence

[00278] In some embodiments, a 3' tracrRNA sequence comprises a sequence with at least about 30%, about 40%, about 50%, about 60%, about 65%, about 70%, about 75%, about 80%, about 85%, about 90%, about 95%, or 100% sequence identity to a reference tracrRNA sequence (e.g., a tracrRNA from S. pyogenes).

[00279] The 3' tracrRNA sequence has a length from about 6 nucleotides to about 100 nucleotides. For example, the 3' tracrRNA sequence can have a length from about 6 nucleotides (nt) to about 50 nt, from about 6 nt to about 40 nt, from about 6 nt to about 30 nt, from about 6 nt to about 25 nt, from about 6 nt to about 20 nt, from about 6 nt to about 15 nt, from about 8 nt to about 40 nt, from about 8 nt to about 30 nt, from about 8 nt to about 25 nt, from about 8 nt to about 20 nt, from about 8 nt to about 15 nt, from about 15 nt to about 100 nt, from about 15 nt to about 80 nt, from about 15 nt to about 50 nt, from about 15 nt to about 40 nt, from about 15 nt to about 30 nt, or from about 15 nt to about 25 nt. In some

embodiments, the 3' tracrRNA sequence has a length of approximately 14 nucleotides.

[00280] In some embodiments, the 3' tracrRNA sequence is at least about 60% identical to a reference 3' tracrRNA sequence (e.g., wild type 3' tracrRNA sequence from S. pyogenes) over a stretch of at least 6, 7, or 8 contiguous nucleotides. For example, the 3' tracrRNA sequence is at least about 60% identical, about 65% identical, about 70% identical, about 75% identical, about 80% identical, about 85% identical, about 90% identical, about 95% identical, about 98% identical, about 99% identical, or 100% identical, to a reference 3' tracrRNA sequence (e.g., wild type 3' tracrRNA sequence from S. pyogenes) over a stretch of at least 6, 7, or 8 contiguous nucleotides.

[00281] In some embodiments, the 3' tracrRNA sequence comprises more than one duplexed region (e.g., hairpin, hybridized region). In some embodiments, the 3' tracrRNA sequence comprises two duplexed regions.

[00282] In some embodiments, the 3' tracrRNA sequence comprises a stem loop structure. In some embodiments, the stem loop structure in the 3' tracrRNA comprises at least 1 , 2, 3, 4, 5, 6, 7, 8, 9, 10, 15 or 20 or more nucleotides. In some embodiments, the stem loop structure in the 3' tracrRNA comprises at most 1 , 2, 3, 4, 5, 6, 7, 8, 9 or 10 or more nucleotides. The stem loop structure comprises a functional moiety. For example, the stem loop structure comprises an aptamer, a ribozyme, a protein-interacting hairpin, a CRISPR array, an intron, or an exon. In some embodiments, the stem loop structure comprises at least about 1 , 2, 3, 4, or 5 or more functional moieties. In some embodiments, the stem loop structure comprises at most about 1 , 2, 3, 4, or 5 or more functional moieties.

[00283] In some embodiments, the hairpin in the 3' tracrRNA sequence comprises a P-domain. In some embodiments, the P-domain comprises a double- stranded region in the hairpin.

[00284] tracrRNA Extension Sequence

[00285] In some embodiments, a tracrRNA extension sequence is provided whether the tracrRNA is in the context of single-molecule guides or double- molecule guides. In some embodiments, the tracrRNA extension sequence has a length from about 1 nucleotide to about 400 nucleotides. The tracrRNA extension sequence can have a length of more than 1 , 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 60, 70, 80, 90, 100, 120, 140, 160, 180, 200, 220, 240, 260, 280, 300, 320, 340, 360, 380, or 400 nucleotides. In some embodiments, the tracrRNA extension sequence has a length from about 20 to about 5000 or more nucleotides. In some embodiments, the tracrRNA extension sequence has a length of more than 1000 nucleotides. In some embodiments, the tracrRNA extension sequence has a length of less than 1 , 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 60, 70, 80, 90, 100, 120, 140, 160, 180, 200, 220, 240, 260, 280, 300, 320, 340, 360, 380, 400 or more nucleotides. In some embodiments, the tracrRNA extension sequence has a length of less than 1000 nucleotides. In some embodiments, the tracrRNA extension sequence comprises less than 10 nucleotides in length. T In some embodiments, the he tracrRNA extension sequence is 10-30 nucleotides in length. In some embodiments, the tracrRNA extension sequence is 30-70 nucleotides in length.

[00286] In some embodiments, the tracrRNA extension sequence comprises a functional moiety (e.g., a stability control sequence, ribozyme, endoribonuclease binding sequence). In some embodiments, the functional moiety comprises a transcriptional terminator segment (i.e., a transcription termination sequence). In some embodiments, the functional moiety has a total length from about 10 nucleotides (nt) to about 100 nucleotides, from about 10 nt to about 20 nt, from about 20 nt to about 30 nt, from about 30 nt to about 40 nt, from about 40 nt to about 50 nt, from about 50 nt to about 60 nt, from about 60 nt to about 70 nt, from about 70 nt to about 80 nt, from about 80 nt to about 90 nt, or from about 90 nt to about 100 nt, from about 15 nt to about 80 nt, from about 15 nt to about 50 nt, from about 15 nt to about 40 nt, from about 15 nt to about 30 nt, or from about 15 nt to about 25 nt. In some embodiments, the functional moiety functions in a eukaryotic cell. In some embodiments, the functional moiety functions in a prokaryotic cell. In some embodiments, the functional moiety functions in both eukaryotic and prokaryotic cells.

[00287] Non-limiting examples of suitable tracrRNA extension functional moieties include a 3' poly-adenylated tail, a riboswitch sequence (e.g., to allow for regulated stability and/or regulated accessibility by proteins and protein complexes), a sequence that forms a dsRNA duplex (i.e., a hairpin), a sequence that targets the

RNA to a subcellular location (e.g., nucleus, mitochondria, chloroplasts, and the like), a modification or sequence that provides for tracking (e.g., direct conjugation to a fluorescent molecule, conjugation to a moiety that facilitates fluorescent detection, a sequence that allows for fluorescent detection, etc.), and/or a modification or sequence that provides a binding site for proteins (e.g., proteins that act on DNA, including transcriptional activators, transcriptional repressors, DNA methyltransferases, DNA demethylases, histone acetyltransferases, histone deacetylases, and the like). In some embodiments, the tracrRNA extension sequence comprises a primer binding site or a molecular index (e.g., barcode sequence). In some embodiments, the tracrRNA extension sequence comprises one or more affinity tags.

[00288] Single-Molecule Guide Linker Sequence

[00289] In some embodiments, the linker sequence of a single-molecule guide nucleic acid has a length from about 3 nucleotides to about 100 nucleotides. In Jinek et ai, supra, for example, a simple 4 nucleotide "tetraloop" (-GAAA-) was used, Science, 337(6096):816-821 (2012). An illustrative linker has a length from about 3 nucleotides (nt) to about 90 nt, from about 3 nt to about 80 nt, from about 3 nt to about 70 nt, from about 3 nt to about 60 nt, from about 3 nt to about 50 nt, from about 3 nt to about 40 nt, from about 3 nt to about 30 nt, from about 3 nt to about 20 nt, from about 3 nt to about 10 nt. For example, the linker can have a length from about 3 nt to about 5 nt, from about 5 nt to about 10 nt, from about 10 nt to about 15 nt, from about 15 nt to about 20 nt, from about 20 nt to about 25 nt, from about 25 nt to about 30 nt, from about 30 nt to about 35 nt, from about 35 nt to about 40 nt, from about 40 nt to about 50 nt, from about 50 nt to about 60 nt, from about 60 nt to about 70 nt, from about 70 nt to about 80 nt, from about 80 nt to about 90 nt, or from about 90 nt to about 100 nt. In some embodiments, the linker of a single-molecule guide nucleic acid is between 4 and 40 nucleotides. In some embodiments, the linker is at least about 100, 500, 1000, 1500, 2000, 2500, 3000, 3500, 4000, 4500, 5000, 5500, 6000, 6500, or 7000 or more nucleotides. In some embodiments, the linker is at most about 100, 500, 1000, 1500, 2000, 2500, 3000, 3500, 4000, 4500, 5000, 5500, 6000, 6500, or 7000 or more nucleotides.

[00290] Linkers comprises any of a variety of sequences, although in some embodiments, the linker will not comprise sequences that have extensive regions of homology with other portions of the guide RNA, which might cause intramolecular binding that could interfere with other functional regions of the guide. In Jinek et ai, supra, a simple 4 nucleotide sequence -GAAA- was used, Science, 337(6096):816- 821 (2012), but numerous other sequences, including longer sequences can likewise be used.

[00291] In some embodiments, the linker sequence comprises a functional moiety. For example, the linker sequence comprises one or more features, including an aptamer, a ribozyme, a protein-interacting hairpin, a protein binding site, a CRISPR array, an intron, or an exon. In some embodiments, the linker sequence comprises at least about 1 , 2, 3, 4, or 5 or more functional moieties. In some embodiments, the linker sequence comprises at most about 1 , 2, 3, 4, or 5 or more functional moieties.

[00292] Genome engineering strategies to correct cells by deletion, insertion, correction, or replacement of one or more mutations, exons, or nucleotides within or near the TTR gene, or by knocking-in TTR cDNA or minigene into the locus of the corresponding TTR gene or safe harbor site

[00293] The methods of the present disclosure involve editing of one or both of the mutant alleles. Gene editing to delete the mutation and/or TTR gene has the advantage of decreasing and/or eliminating TTR gene expression and mutant TTR gene product available for undesirable protein aggregation.

[00294] In some embodiments, a step of the ex vivo methods of the present disclosure comprises editing the patient specific iPSC cells using genome engineering. Alternatively, a step of the ex vivo methods of the present disclosure comprises editing the hepatocyte, mesenchymal stem cell, or liver progenitor cell. Likewise, a step of the in vivo methods of the present disclosure comprises editing the cells in a FTA patient using genome engineering. Similarly, a step in the cellular methods of the present disclosure comprises editing the TTR gene in a human cell by genome engineering.

[00295] FTA patients exhibit one or more mutations in the TTR gene. Any CRISPR endonuclease may be used in the methods of the present disclosure, each CRISPR endonuclease having its own associated PAM, which may or may not be disease specific. For example, gRNA spacer sequences for targeting the TTR gene with a CRISPR/Cas9 endonuclease from S. pyogenes have been identified in SEQ ID NOs: 1 -3,352. gRNA spacer sequences for targeting the TTR gene with a CRISPR/Cas9 endonuclease from S. aureus have been identified in SEQ ID NOs: 3,353-3,763. gRNA spacer sequences for targeting the TTR gene with a CRISPR/Cas9 endonuclease from S. thermophilus have been identified in SEQ ID NOs: 3,764-4, 1 12. gRNA spacer sequences for targeting the TTR gene with a CRISPR/Cas9 endonuclease from T. denticola have been identified in SEQ ID NOs: 4, 1 13-4,247. gRNA spacer sequences for targeting the TTR gene with a CRISPR/Cas9 endonuclease from N. meningitides have been identified in SEQ ID NOs: 4,248-4,301 . gRNA spacer sequences for targeting the TTR gene with a CRISPR/Cpf1 endonuclease from Acidaminococcus and Lachnospiraceae have been identified in 4,302-8,669.

[00296] For example, expression of the TTR gene may be disrupted or eliminated by introducing random insertions or deletions (indels) that arise due to the imprecise NHEJ repair pathway. The target region may be the coding sequences of the TTR gene (i.e., exons). Inserting or deleting nucleotides into the coding sequence of a gene may cause a "frame shift" where the normal 3-letter codon pattern is disturbed. In this way, gene expression and therefore protein production can be reduced or eliminated. This approach may also be used to target any intron, intron:exon junction, or regulatory DNA element of the TTR gene where sequence alteration may interfere with the expression of the TTR gene.

[00297] As another example, NHEJ can also be used to delete segments within or near the gene, either directly or by altering splice donor or acceptor sites through cleavage by one gRNA targeting several locations, or several gRNAs. This can be useful if small random indels are inefficient to knock-out the target gene. Pairs of guide strands have been used for this type of deletions.

[00298] NHEJ can also lead to homology-independent target integration. For example, inclusion of a nuclease target site on a donor plasmid can promote integration of a transgene into the chromosomal double-strand break following in vivo nuclease cleavage of both the donor and the chromosome (Cristea.,

Biotechnol Bioeng. 2013 Mar; 1 10(3):871 -80).

[00299] NHEJ was used to insert a 15-kb inducible gene expression cassette into a defined locus in human cell lines after nuclease cleavage. (See e.g.,

Maresca, M., Lin, V.G., Guo, N. & Yang, Y., Genome Res 23, 539-546 (2013); Cristea et al. Biotechnology and Bioengineering 2013, 871 -80, 10.1002/bit.24733; Suzuki et al. Nature, 540, 144-149 (2016)). The integrated sequence may disrupt the reading frame of the TTR gene or alter the structure of the gene.

[00300] As another example, the mutation can be corrected by the insertions or deletions that arise due to the imprecise NHEJ repair pathway. If the patient's TTR gene has an inserted or deleted base, a targeted cleavage can result in a NHEJ- mediated insertion or deletion that restores the frame. Missense mutations can also be corrected through NHEJ-mediated correction using one or more guide RNA. The ability or likelihood of the cut(s) to correct the mutation can be designed or evaluated based on the local sequence and micro-homologies. NHEJ can also be used to delete segments of the gene, either directly or by altering splice donor or acceptor sites through cleavage by one gRNA targeting several locations, or several gRNAs. This may be useful if an amino acid, domain or exon contains the mutations and can be removed or inverted, or if the deletion otherwise restored function to the protein. Pairs of guide strands have been used for deletions and corrections of inversions. NHEJ can also be used to promote targeted transgene integration at the cleaved locus, especially if the transgene donor template has been cleaved within the cell as well.

[00301] Alternatively, homology directed repair (HDR) can also be used to correct a gene, knock-out a gene, or alter the gene function. HDR is essentially an error-free mechanism that uses a supplied homologous DNA sequence as a template during DSB repair. The rate of homology directed repair (HDR) is a function of the distance between the mutation and the cut site so choosing overlapping or nearest target sites is important. Templates can include extra sequences flanked by the homologous regions or can contain a sequence that differs from the genomic sequence, thus allowing sequence editing.

[00302] The HDR knock-out strategy can involve disrupting the structure or function of the TTR gene by inserting into the gene or replacing a part of the gene with a non-functional or irrelevant sequence. This can be achieved by inducing one single stranded break or double stranded break in the gene of interest with one or more CRISPR endonucleases and a gRNA (e.g., crRNA + tracrRNA, or sgRNA), or two or more single stranded breaks or double stranded breaks in the gene of interest with one or more CRISPR endonucleases and two or more gRNAs, in the presence of a donor DNA template introduced exogenously to direct the cellular DSB response to HDR (the donor DNA template can be a short single stranded oligonucleotide, a short double stranded oligonucleotide, a long single or double stranded DNA molecule). This approach can require development and optimization of gRNAs and donor DNA molecules for the TTR gene.

[00303] As a further alternative, the donor DNA template for correction by HDR contains the corrected sequence with small or large flanking homology arms to allow for annealing.

[00304] In addition to correcting mutations by NHEJ or HDR, a range of other options are possible. If there are small or large deletions or multiple mutations, a cDNA can be knocked in that contains the exons affected. A full length cDNA can be knocked into any "safe harbor", but must use a supplied or other promoter. If this construct is knocked into the correct location, it will have physiological control, similar to the normal gene. Pairs of nucleases can be used to delete mutated gene regions, though a donor would usually have to be provided to restore function. In this case two gRNA would be supplied and one donor sequence.

[00305] Some genome engineering strategies involve correction of one or more mutations in or near the TTR gene, or deleting the mutant TTR DNA, or deleting the mutant TTR DNA and knocking-in a TTR cDNA or a minigene (comprised of one or more exons and introns or natural or synthetic introns) and/or knocking-in a cDNA including some or all TTR introns into the locus of the TTR gene or a safe harbor locus. These strategies eliminate the mutant TTR gene and reverse, treat, and/or mitigate the diseased state. These strategies require a more custom approach based on the location of the patient's mutation(s). Donor nucleotides for correcting mutations often are small (< 300 bp). This is advantageous, as HDR efficiencies may be inversely related to the size of the donor molecule. Also, it is expected that the donor templates can fit into size constrained viral vector molecules, e.g., adeno- associated virus (AAV) molecules, which have been shown to be an effective means of donor template delivery. Also, it is expected that the donor templates can fit into other size constrained molecules, including, by way of non-limiting example, platelets and/or exosomes or other microvesicles. [00306] Homology direct repair is a cellular mechanism for repairing double- stranded breaks (DSBs). The most common form is homologous recombination. There are additional pathways for HDR, including single-strand annealing and alternative-HDR. Genome engineering tools allow researchers to manipulate the cellular homologous recombination pathways to create site-specific modifications to the genome. It has been found that cells can repair a double-stranded break using a synthetic donor molecule provided in trans. Therefore, by introducing a double- stranded break near a specific mutation and providing a suitable donor, targeted changes can be made in the genome. Specific cleavage increases the rate of HDR more than 1 ,000 fold above the rate of 1 in 10 ⁶ cells receiving a homologous donor alone. The rate of homology directed repair (HDR) at a particular nucleotide is a function of the distance to the cut site, so choosing overlapping or nearest target sites is important. Gene editing offers the advantage over gene addition, as correcting in situ leaves the rest of the genome unperturbed.

[00307] Supplied donors for editing by HDR vary markedly but can contain the intended sequence with small or large flanking homology arms to allow annealing to the genomic DNA. The homology regions flanking the introduced genetic changes can be 30 bp or smaller, or as large as a multi-kilobase cassette that can contain promoters, cDNAs, etc. Both single-stranded and double-stranded oligonucleotide donors have been used. These oligonucleotides range in size from less than 100 nt to over many kb, though longer ssDNA can also be generated and used. Double-stranded donors are often used, including PCR amplicons, plasmids, and mini-circles. In general, it has been found that an AAV vector is a very effective means of delivery of a donor template, though the packaging limits for individual donors is <5kb. Active transcription of the donor increased HDR three-fold, indicating the inclusion of promoter may increase conversion. Conversely, CpG methylation of the donor decreased gene expression and HDR.

[00308] In addition to wildtype endonucleases, such as Cas9, nickase variants exist that have one or the other nuclease domain inactivated resulting in cutting of only one DNA strand. HDR can be directed from individual Cas nickases or using pairs of nickases that flank the target area. Donors can be single-stranded, nicked, or dsDNA. [00309] The donor DNA can be supplied with the nuclease or independently by a variety of different methods, for example by transfection, nano-particle, microinjection, or viral transduction. A range of tethering options have been proposed to increase the availability of the donors for HDR. Examples include attaching the donor to the nuclease, attaching to DNA binding proteins that bind nearby, or attaching to proteins that are involved in DNA end binding or repair.

[00310] The repair pathway choice can be guided by a number of culture conditions, such as those that influence cell cycling, or by targeting of DNA repair and associated proteins. For example, to increase HDR, key NHEJ molecules can be suppressed, such as KU70, KU80 or DNA ligase IV.

[00311] Without a donor present, the ends from a DNA break or ends from different breaks can be joined using the several nonhomologous repair pathways in which the DNA ends are joined with little or no base-pairing at the junction. In addition to canonical NHEJ, there are similar repair mechanisms, such as alt-NHEJ. If there are two breaks, the intervening segment can be deleted or inverted. NHEJ repair pathways can lead to insertions, deletions or mutations at the joints.

[00312] In addition to genome editing by NHEJ or HDR, site-specific gene insertions have been conducted that use both the NHEJ pathway and HR. A combination approach may be applicable in certain settings, possibly including intron/exon borders. NHEJ may prove effective for ligation in the intron, while the error-free HDR may be better suited in the coding region.

[00313] The TTR gene contains 4 exons. Any one or more of the 4 exons or nearby introns can be deleted or repaired to correct a mutation in the TTR gene. Alternatively, there are various mutations associated with FTA, which are a combination of insertions, deletions, missense, nonsense, frameshift and other mutations, with the common effect of producing a mutant TTR leading to TTR protein aggregation. Any one or more of the mutations can be deleted or repaired in order to eliminate the mutant TTR. As a further alternative, TTR cDNA or minigene (comprised of, natural or synthetic enhancer and promoter, one or more exons, and natural or synthetic introns, and natural or synthetic 3'UTR and polyadenylation signal) can be knocked-in to the locus of the corresponding gene or knocked-in to a safe harbor site, such as AAVS1 . In general, a knock-in strategy occurs in combination with a deletion strategy. In some embodiments, the methods can provide one gRNA or a pair of gRNAs that can be used to facilitate incorporation of a new sequence from a polynucleotide donor template to correct one or more mutations or to knock-in a part of or the entire TTR gene or cDNA.

[00314] Some embodiments of the methods provide gRNA pairs that make a deletion by cutting the gene twice, one gRNA cutting at the 5' end of one or more mutations and the other gRNA cutting at the 3' end of one or more mutations that facilitates insertion of a new sequence from a polynucleotide donor template to replace the one or more mutations, or deletion may exclude mutant amino acids or amino acids adjacent to it (e.g., premature stop codon) and lead to a reduction in mutant TTR protein. The cutting can be accomplished by a pair of DNA

endonucleases that each makes a DSB in the genome, or by multiple nickases that together make a DSB in the genome.

[00315] Alternatively, some embodiments of the methods provide one gRNA to make one double-strand cut around one or more mutations that facilitates insertion of a new sequence from a polynucleotide donor template to replace the one or more mutations. The double-strand cut can be made by a single DNA

endonuclease or multiple nickases that together make a DSB in the genome, or single gRNA may lead to deletion (MMEJ), which may exclude mutant amino acid (e.g., premature stop codon) and lead to a reduction in mutant TTR protein.

[00316] Illustrative modifications within the TTR gene include replacements within or near (proximal) to the mutations referred to above, such as within the region of less than 3 kb, less than 2kb, less than 1 kb, less than 0.5 kb upstream or downstream of the specific mutation. Given the relatively wide variations of mutations in the TTR gene, it will be appreciated that numerous variations of the replacements referenced above (including without limitation larger as well as smaller deletions), would be expected to result in elimination of the mutant TTR gene.

[00317] Such variants include replacements that are larger in the 5' and/or 3' direction than the specific mutation in question, or smaller in either direction.

Accordingly, by "near" or "proximal" with respect to specific replacements, it is intended that the SSB or DSB locus associated with a desired replacement boundary (also referred to herein as an endpoint) can be within a region that is less than about 3 kb from the reference locus noted. In some embodiments, the SSB or DSB locus can be more proximal and within 2 kb, within 1 kb, within 0.5 kb, or within 0.1 kb. In the case of small replacement, the desired endpoint can be at or "adjacent to" the reference locus, by which it is intended that the endpoint can be within 100 bp, within 50 bp, within 25 bp, or less than about 10 bp to 5 bp from the reference locus.

[00318] Embodiments comprising larger or smaller replacements are expected to provide the same benefit. It is thus expected that many variations of the

replacements described and illustrated herein will be effective for ameliorating FTA.

[00319] Another genome engineering strategy involves exon deletion. Targeted deletion of specific exons is an attractive strategy for treating a large subset of patients with a single therapeutic cocktail. Deletions can either be single exon deletions or multi-exon deletions. While multi-exon deletions can reach a larger number of patients, for larger deletions the efficiency of deletion greatly decreases with increased size. Therefore, deletions range can be from 40 to 10,000 base pairs (bp) in size. For example, deletions can range from 40-100; 100-300; 300- 500; 500-1 ,000; 1 ,000-2,000; 2,000-3,000; 3,000-5,000; or 5,000-10,000 base pairs in size.

[00320] Deletions can occur in enhancer, promoter, 1 st intron, and/or 3'UTR leading to upregulation of the gene expression, and/or through deletion of the regulatory elements.

[00321] As stated previously, the TTR gene contains 4 exons. Any one or more of the 4 exons, or aberrant intronic splice acceptor or donor sites, may be deleted in order to restore the TTR reading frame. In some embodiments, the methods provide gRNA pairs that can be used to delete exons 1 , 2, 3, or 4, or any combination of them.

[00322] In order to ensure that TTR protein synthesis is disrupted, the

surrounding splicing signals can be deleted. Splicing donor and acceptors are generally within 100 base pairs of the neighboring intron. Therefore, in some embodiments, methods can provide all gRNAs that cut approximately +/- 100-3100 bp with respect to each exon/intron junction of interest. [00323] For any of the genome editing strategies, gene editing can be confirmed by sequencing or PCR analysis.

[00324] Target Sequence Selection

[00325] Shifts in the location of the 5' boundary and/or the 3' boundary relative to particular reference loci are used to facilitate or enhance particular applications of gene editing, which depend in part on the endonuclease system selected for the editing, as further described and illustrated herein.

[00326] In a first nonlimiting example of such target sequence selection, many endonuclease systems have rules or criteria that guide the initial selection of potential target sites for cleavage, such as the requirement of a PAM sequence motif in a particular position adjacent to the DNA cleavage sites in the case of CRISPR Type II or Type V endonucleases.

[00327] In another nonlimiting example of target sequence selection or optimization, the frequency of off-target activity for a particular combination of target sequence and gene editing endonuclease (i.e. the frequency of DSBs occurring at sites other than the selected target sequence) is assessed relative to the frequency of on-target activity. In some embodiments, cells that have been correctly edited at the desired locus can have a selective advantage relative to other cells. Illustrative, but nonlimiting, examples of a selective advantage include the acquisition of attributes such as enhanced rates of replication, persistence, resistance to certain conditions, enhanced rates of successful engraftment or persistence in vivo following introduction into a patient, and other attributes associated with the maintenance or increased numbers or viability of such cells. In some embodiments, cells that have been correctly edited at the desired locus can be positively selected for by one or more screening methods used to identify, sort or otherwise select for cells that have been correctly edited. Both selective advantage and directed selection methods can take advantage of the phenotype associated with the correction. In some embodiments, cells can be edited two or more times in order to create a second modification that creates a new phenotype that is used to select or purify the intended population of cells. Such a second modification could be created by adding a second gRNA for a selectable or screenable marker. In some embodiments, cells can be correctly edited at the desired locus using a DNA fragment that contains the cDNA and also a selectable marker.

[00328] Whether any selective advantage is applicable or any directed selection is to be applied in a particular case, target sequence selection can also be guided by consideration of off-target frequencies in order to enhance the effectiveness of the application and/or reduce the potential for undesired alterations at sites other than the desired target. As described further and illustrated herein and in the art, the occurrence of off-target activity is influenced by a number of factors including similarities and dissimilarities between the target site and various off-target sites, as well as the particular endonuclease used. Bioinformatics tools are available that assist in the prediction of off-target activity, and frequently such tools can also be used to identify the most likely sites of off-target activity, which can then be assessed in experimental settings to evaluate relative frequencies of off-target to on-target activity, thereby allowing the selection of sequences that have higher relative on-target activities. Illustrative examples of such techniques are provided herein, and others are known in the art.

[00329] Another aspect of target sequence selection relates to homologous recombination events. Sequences sharing regions of homology can serve as focal points for homologous recombination events that result in deletion of intervening sequences. Such recombination events occur during the normal course of replication of chromosomes and other DNA sequences, and also at other times when DNA sequences are being synthesized, such as in the case of repairs of double-strand breaks (DSBs), which occur on a regular basis during the normal cell replication cycle but can also be enhanced by the occurrence of various events (such as UV light and other inducers of DNA breakage) or the presence of certain agents (such as various chemical inducers). Many such inducers cause DSBs to occur indiscriminately in the genome, and DSBs are regularly induced and repaired in normal cells. During repair, the original sequence can be reconstructed with complete fidelity, however, in some embodiments, small insertions or deletions (referred to as "indels") are introduced at the DSB site.

[00330] DSBs can also be specifically induced at particular locations, as in the case of the endonucleases systems described herein, which can be used to cause directed or preferential gene modification events at selected chromosomal locations. The tendency for homologous sequences to be subject to recombination in the context of DNA repair (as well as replication) can be taken advantage of in a number of circumstances, and is the basis for one application of gene editing systems, such as CRISPR, in which homology directed repair is used to insert a sequence of interest, provided through use of a "donor" polynucleotide, into a desired chromosomal location.

[00331] Regions of homology between particular sequences, which can be small regions of "microhomology" that comprises as few as ten basepairs or less, can also be used to bring about desired deletions. For example, a single DSB can be introduced at a site that exhibits microhomology with a nearby sequence. During the normal course of repair of such DSB, a result that occurs with high frequency is the deletion of the intervening sequence as a result of recombination being facilitated by the DSB and concomitant cellular repair process.

[00332] In some circumstances, however, selecting target sequences within regions of homology can also give rise to much larger deletions, including gene fusions (when the deletions are in coding regions), which may or may not be desired given the particular circumstances.

[00333] The examples provided herein further illustrate the selection of various target regions for the creation of DSBs designed to induce replacements that result in elimination or reduction of mutant TTR protein, as well as the selection of specific target sequences within such regions that are designed to minimize off-target events relative to on-target events.

[00334] Nucleic acid modifications

[00335] In some embodiments, polynucleotides introduced into cells comprises one or more modifications that can be used individually or in combination, for example, to enhance activity, stability or specificity, alter delivery, reduce innate immune responses in host cells, or for other enhancements, as further described herein and known in the art.

[00336] In some embodiments, modified polynucleotides are used in the

CRISPR/Cas9 or CRISPR/Cpfl system, in which case the guide RNAs (either single-molecule guides or double-molecule guides) and/or a DNA or an RNA encoding a Cas9 or Cpf1 endonuclease introduced into a cell can be modified, as described and illustrated below. Such modified polynucleotides can be used in the CRISPR/Cas9 or CRISPR/Cpf1 system to edit any one or more genomic loci.

[00337] Using the CRISPR/Cas9 or CRISPR/Cpf1 system for purposes of nonlimiting illustrations of such uses, modifications of guide RNAs can be used to enhance the formation or stability of the CRISPR/Cas9 or CRISPR/Cpf1 genome editing complex comprising guide RNAs, which can be single-molecule guides or double-molecule, and a Cas or Cpfl endonuclease. Modifications of guide RNAs can also or alternatively be used to enhance the initiation, stability or kinetics of interactions between the genome editing complex with the target sequence in the genome, which can be used, for example, to enhance on-target activity.

Modifications of guide RNAs can also or alternatively be used to enhance specificity, e.g., the relative rates of genome editing at the on-target site as compared to effects at other (off-target) sites.

[00338] Modifications can also or alternatively be used to increase the stability of a guide RNA, e.g., by increasing its resistance to degradation by ribonucleases (RNases) present in a cell, thereby causing its half-life in the cell to be increased. Modifications enhancing guide RNA half-life can be particularly useful in aspects in which a Cas9 or Cpf1 endonuclease is introduced into the cell to be edited via an RNA that needs to be translated in order to generate endonuclease, because increasing the half-life of guide RNAs introduced at the same time as the RNA encoding the endonuclease can be used to increase the time that the guide RNAs and the encoded Cas9 or Cpf1 endonuclease co-exist in the cell.

[00339] Modifications can also or alternatively be used to decrease the likelihood or degree to which RNAs introduced into cells elicit innate immune responses. Such responses, which have been well characterized in the context of RNA interference (RNAi), including small-interfering RNAs (siRNAs), as described below and in the art, tend to be associated with reduced half-life of the RNA and/or the elicitation of cytokines or other factors associated with immune responses.

[00340] One or more types of modifications can also be made to RNAs encoding an endonuclease that are introduced into a cell, including, without limitation, modifications that enhance the stability of the RNA (such as by increasing its degradation by RNAses present in the cell), modifications that enhance translation of the resulting product (i.e. the endonuclease), and/or modifications that decrease the likelihood or degree to which the RNAs introduced into cells elicit innate immune responses.

[00341] Combinations of modifications, such as the foregoing and others, can likewise be used. In the case of CRISPR/Cas9 or CRISPR/Cpf1 , for example, one or more types of modifications can be made to guide RNAs (including those exemplified above), and/or one or more types of modifications can be made to RNAs encoding Cas endonuclease (including those exemplified above).

[00342] By way of illustration, guide RNAs used in the CRISPR/Cas9 or CRISPR/Cpf1 system, or other smaller RNAs can be readily synthesized by chemical means, enabling a number of modifications to be readily incorporated, as illustrated below and described in the art. While chemical synthetic procedures are continually expanding, purifications of such RNAs by procedures such as high performance liquid chromatography (HPLC, which avoids the use of gels such as PAGE) tends to become more challenging as polynucleotide lengths increase significantly beyond a hundred or so nucleotides. One approach that can be used for generating chemically-modified RNAs of greater length is to produce two or more molecules that are ligated together. Much longer RNAs, such as those encoding a Cas9 endonuclease, are more readily generated enzymatically. While fewer types of modifications are generally available for use in enzymatically produced RNAs, there are still modifications that can be used to, e.g., enhance stability, reduce the likelihood or degree of innate immune response, and/or enhance other attributes, as described further below and in the art; and new types of modifications are regularly being developed.

[00343] By way of illustration of various types of modifications, especially those used frequently with smaller chemically synthesized RNAs, modifications can comprise one or more nucleotides modified at the 2' position of the sugar, in some embodiments, a 2'-0-alkyl, 2'-0-alkyl-0-alkyl, or 2'-fluoro-modified nucleotide. In some embodiments, RNA modifications can comprise 2'-fluoro, 2'-amino or 2' O- methyl modifications on the ribose of pyrimidines, abasic residues, or an inverted base at the 3' end of the RNA. Such modifications are routinely incorporated into oligonucleotides and these oligonucleotides have been shown to have a higher Tm (i.e., higher target binding affinity) than 2'-deoxyoligonucleotides against a given target.

[00344] A number of nucleotide and nucleoside modifications have been shown to make the oligonucleotide into which they are incorporated more resistant to nuclease digestion than the native oligonucleotide; these modified oligos survive intact for a longer time than unmodified oligonucleotides. Specific examples of modified oligonucleotides include those comprising modified backbones, for example, phosphorothioates, phosphotriesters, methyl phosphonates, short chain alkyl or cycloalkyl intersugar linkages or short chain heteroatomic or heterocyclic intersugar linkages. Some oligonucleotides are oligonucleotides with

phosphorothioate backbones and those with heteroatom backbones, particularly CH ₂ -NH-O-CH2, CH,~N(CH ₃ )~0~CH ₂ (known as a methylene(methylimino) or MMI backbone), CH ₂ --0--N (CH ₃ )-CH ₂ , CH ₂ -N (CH ₃ )-N (CH ₃ )-CH ₂ and O-N (CH ₃ )- CH ₂ -CH ₂ backbones, wherein the native phosphodiester backbone is represented as O- P- O- CH,); amide backbones [see De Mesmaeker ef a/., Ace. Chem. Res., 28:366-374 (1995)]; morpholino backbone structures (see Summerton and Weller, U.S. Pat. No. 5,034,506); peptide nucleic acid (PNA) backbone (wherein the phosphodiester backbone of the oligonucleotide is replaced with a polyamide backbone, the nucleotides being bound directly or indirectly to the aza nitrogen atoms of the polyamide backbone, see Nielsen et al., Science 1991 , 254, 1497). Phosphorus-containing linkages include, but are not limited to, phosphorothioates, chiral phosphorothioates, phosphorodithioates, phosphotriesters,

aminoalkylphosphotriesters, methyl and other alkyl phosphonates comprising 3'alkylene phosphonates and chiral phosphonates, phosphinates,

phosphoramidates comprising 3'-amino phosphoramidate and

aminoalkylphosphoramidates, thionophosphoramidates, thionoalkylphosphonates, thionoalkylphosphotriesters, and boranophosphates having normal 3' -5' linkages, 2'-5' linked analogs of these, and those having inverted polarity wherein the adjacent pairs of nucleoside units are linked 3'-5' to 5'-3' or 2'-5' to 5'-2'; see US Patent Nos. 3,687,808; 4,469,863; 4,476,301 ; 5,023,243; 5, 177,196; 5, 188,897; 5,264,423; 5,276,019; 5,278,302; 5,286,717; 5,321 , 131 ; 5,399,676; 5,405,939; 5,453,496; 5,455,233; 5,466,677; 5,476,925; 5,519, 126; 5,536,821 ; 5,541 ,306; 5,550, 1 1 1 ; 5,563,253; 5,571 ,799; 5,587,361 ; and 5,625,050.

[00345] Morpholino-based oligomeric compounds are described in Braasch and David Corey, Biochemistry, 41 (14):4503-4510 (2002); Genesis, Volume 30, Issue 3, (2001 ); Heasman, Dev. Biol., 243:209-214 (2002); Nasevicius et al., Nat. Genet., 26:216-220 (2000); Lacerra et al., Proc. Natl. Acad. Sci., 97: 9591 -9596 (2000); and U.S. Pat. No. 5,034,506, issued Jul. 23, 1991 .

[00346] Cyclohexenyl nucleic acid oligonucleotide mimetics are described in Wang et al., J. Am. Chem. Soc, 122:8595-8602 (2000).

[00347] Modified oligonucleotide backbones that do not include a phosphorus atom therein have backbones that are formed by short chain alkyl or cycloalkyl internucleoside linkages, mixed heteroatom and alkyl or cycloalkyl internucleoside linkages, or one or more short chain heteroatomic or heterocyclic internucleoside linkages. These comprise those having morpholino linkages (formed in part from the sugar portion of a nucleoside); siloxane backbones; sulfide, sulfoxide and sulfone backbones; formacetyl and thioformacetyl backbones; methylene formacetyl and thioformacetyl backbones; alkene containing backbones; sulfamate backbones; methyleneimino and methylenehydrazino backbones; sulfonate and sulfonamide backbones; amide backbones; and others having mixed N, O, S, and CH ₂ component parts; see US Patent Nos. 5,034,506; 5, 166,315; 5, 185,444;

5,214, 134; 5,216, 141 ; 5,235,033; 5,264,562; 5,264,564; 5,405,938; 5,434,257; 5,466,677; 5,470,967; 5,489,677; 5,541 ,307; 5,561 ,225; 5,596,086; 5,602,240; 5,610,289; 5,602,240; 5,608,046; 5,610,289; 5,618,704; 5,623,070; 5,663,312; 5,633,360; 5,677,437; and 5,677,439.

[00348] One or more substituted sugar moieties can also be included, e.g., one of the following at the 2' position: OH, SH, SCH ₃ , F, OCN, OCH3-OCH3, OCH ₃ 0(CH ₂ ) _n CH ₃ , 0(CH ₂ ) _n NH ₂ , or 0(CH ₂ ) _n CH ₃ , where n is from 1 to about 10; Ci to C10 lower alkyl, alkoxyalkoxy, substituted lower alkyl, alkaryl or aralkyl; CI; Br; CN; CF ₃ ; OCF ₃ ; 0-, S-, or N-alkyl; 0-, S-, or N-alkenyl; SOCH ₃ ; S0 ₂ CH ₃ ; ON0 ₂ ; N0 ₂ ; N ₃ ; NH ₂ ; heterocycloalkyl; heterocycloalkaryl; aminoalkylamino; polyalkylamino; substituted silyl; an RNA cleaving group; a reporter group; an intercalator; a group for improving the pharmacokinetic properties of an oligonucleotide; or a group for improving the pharmacodynamic properties of an oligonucleotide and other substituents having similar properties. In some embodiments, a modification includes 2'-methoxyethoxy (2'-0-CH ₂ CH ₂ OCH3, also known as 2'-0-(2- methoxyethyl)) (Martin et ai., Helv. Chim. Acta, 1995, 78, 486). Other modifications include 2'-methoxy (2'-0-CH ₃ ), 2'-propoxy (2'-OCH ₂ CH ₂ CH3) and 2'-fluoro (2'-F). Similar modifications can also be made at other positions on the oligonucleotide, particularly the 3' position of the sugar on the 3' terminal nucleotide and the 5' position of 5' terminal nucleotide. Oligonucleotides can also have sugar mimetics, such as cyclobutyls in place of the pentofuranosyl group.

[00349] In some embodiments, both a sugar and an internucleoside linkage, i.e., the backbone, of the nucleotide units are replaced with novel groups. The base units are maintained for hybridization with an appropriate nucleic acid target compound. One such oligomeric compound, an oligonucleotide mimetic that has been shown to have excellent hybridization properties, is referred to as a peptide nucleic acid (PNA). In PNA compounds, the sugar-backbone of an oligonucleotide is replaced with an amide containing backbone, for example, an aminoethylglycine backbone. The nucleobases are retained and are bound directly or indirectly to aza nitrogen atoms of the amide portion of the backbone. Representative United States patents that teach the preparation of PNA compounds comprise, but are not limited to, US Patent Nos. 5,539,082; 5,714,331 ; and 5,719,262. Further teaching of PNA compounds can be found in Nielsen et ai., Science, 254: 1497-1500 (1991 ).

[00350] Guide RNAs can also include, additionally or alternatively, nucleobase

(often referred to in the art simply as "base") modifications or substitutions. As used herein, "unmodified" or "natural" nucleobases include adenine (A), guanine (G), thymine (T), cytosine (C), and uracil (U). Modified nucleobases include

nucleobases found only infrequently or transiently in natural nucleic acids, e.g., hypoxanthine, 6-methyladenine, 5-Me pyrimidines, particularly 5-methylcytosine

(also referred to as 5-methyl-2' deoxycytosine and often referred to in the art as 5-

Me-C), 5-hydroxymethylcytosine (HMC), glycosyl HMC and gentobiosyl HMC, as well as synthetic nucleobases, e.g., 2-aminoadenine, 2-(methylamino)adenine, 2-

(imidazolylalkyl)adenine, 2-(aminoalklyamino)adenine or other heterosubstituted alkyladenines, 2-thiouracil, 2-thiothymine, 5-bromouracil, 5-hydroxymethyluracil, 8- azaguanine, 7-deazaguanine, N6 (6-aminohexyl)adenine, and 2,6-diaminopurine. Kornberg, A., DNA Replication, W. H. Freeman & Co., San Francisco, pp. 75-77 (1980); Gebeyehu et al., Nucl. Acids Res. 15:4513 (1997). A "universal" base known in the art, e.g., inosine, can also be included. 5-Me-C substitutions have been shown to increase nucleic acid duplex stability by 0.6-1 .2 °C. (Sanghvi, Y. S., in Crooke, S. T. and Lebleu, B., eds., Antisense Research and Applications, CRC Press, Boca Raton, 1993, pp. 276-278) and are aspects of base substitutions.

[00351] Modified nucleobases comprise other synthetic and natural

nucleobases, such as 5-methylcytosine (5-me-C), 5-hydroxymethyl cytosine, xanthine, hypoxanthine, 2-aminoadenine, 6-methyl and other alkyl derivatives of adenine and guanine, 2-propyl and other alkyl derivatives of adenine and guanine, 2-thiouracil, 2-thiothymine and 2-thiocytosine, 5-halouracil and cytosine, 5-propynyl uracil and cytosine, 6-azo uracil, cytosine and thymine, 5-uracil (pseudo-uracil), 4- thiouracil, 8-halo, 8-amino, 8-thiol, 8- thioalkyl, 8-hydroxyl and other 8-substituted adenines and guanines, 5-halo particularly 5- bromo, 5-trifluoromethyl and other 5- substituted uracils and cytosines, 7-methylquanine and 7-methyladenine, 8- azaguanine and 8-azaadenine, 7-deazaguanine and 7-deazaadenine, and 3- deazaguanine and 3-deazaadenine.

[00352] Further, nucleobases comprise those disclosed in United States Patent

No. 3,687,808, those disclosed in The Concise Encyclopedia of Polymer Science

And Engineering', pages 858-859, Kroschwitz, J. I., ed. John Wiley & Sons, 1990, those disclosed by Englisch et al., Angewandle Chemie, International Edition',

1991 , 30, page 613, and those disclosed by Sanghvi, Y. S., Chapter 15, Antisense

Research and Applications', pages 289- 302, Crooke, ST. and Lebleu, B. ea., CRC

Press, 1993. Certain of these nucleobases are particularly useful for increasing the binding affinity of the oligomeric compounds of the disclosure. These include 5- substituted pyrimidines, 6-azapyrimidines and N-2, N-6 and 0-6 substituted purines, comprising 2-aminopropyladenine, 5-propynyluracil and 5-propynylcytosine. 5- methylcytosine substitutions have been shown to increase nucleic acid duplex stability by 0.6-1 .2°C (Sanghvi, Y.S., Crooke, ST. and Lebleu, B., eds, 'Antisense

Research and Applications', CRC Press, Boca Raton, 1993, pp. 276-278) and are aspects of base substitutions, even more particularly when combined with 2'-0- methoxyethyl sugar modifications. Modified nucleobases are described in US

Patent Nos. 3,687,808, as well as 4,845,205; 5,130,302; 5, 134,066; 5, 175,273; 5,367,066; 5,432,272; 5,457, 187; 5,459,255; 5,484,908; 5,502, 177; 5,525,71 1 ; 5,552,540; 5,587,469; 5,596,091 ; 5,614,617; 5,681 ,941 ; 5,750,692; 5,763,588; 5,830,653; 6,005,096; and US Patent Application Publication No. 2003/0158403.

[00353] Thus, the term "modified" refers to a non-natural sugar, phosphate, or base that is incorporated into a guide RNA, an endonuclease, or both a guide RNA and an endonuclease. It is not necessary for all positions in a given oligonucleotide to be uniformly modified, and in fact more than one of the aforementioned modifications can be incorporated in a single oligonucleotide, or even in a single nucleoside within an oligonucleotide.

[00354] In some embodiments, the guide RNAs and/or mRNA (or DNA) encoding an endonuclease is chemically linked to one or more moieties or conjugates that enhance the activity, cellular distribution, or cellular uptake of the oligonucleotide. Such moieties comprise, but are not limited to, lipid moieties such as a cholesterol moiety [Letsinger ef a/., Proc. Natl. Acad. Sci. USA, 86:6553-6556

(1989)]; cholic acid [Manoharan et al., Bioorg. Med. Chem. Let., 4: 1053-1060

(1994)]; a thioether, e.g. , hexyl-S- tritylthiol [Manoharan et al, Ann. N. Y. Acad. Sci.,

660:306-309 (1992) and Manoharan et al., Bioorg. Med. Chem. Let. , 3:2765-2770

(1993)]; a thiocholesterol [Oberhauser et al., Nucl. Acids Res., 20:533-538 (1992)]; an aliphatic chain, e.g., dodecandiol or undecyl residues [Kabanov et al., FEBS

Lett. , 259:327-330 (1990) and Svinarchuk et al., Biochimie, 75:49- 54 (1993)]; a phospholipid, e.g., di-hexadecyl-rac-glycerol or triethylammonium 1 ,2-di-O- hexadecyl- rac-glycero-3-H-phosphonate [Manoharan et al., Tetrahedron Lett.,

36:3651 -3654 (1995) and Shea et al., Nucl. Acids Res., 18:3777-3783 (1990)]; a polyamine or a polyethylene glycol chain [Mancharan et al. , Nucleosides &

Nucleotides, 14:969-973 (1995)]; adamantane acetic acid [Manoharan et al.,

Tetrahedron Lett., 36:3651 -3654 (1995)]; a palmityl moiety [(Mishra et al., Biochim.

Biophys. Acta, 1264:229-237 (1995)]; or an octadecylamine or hexylamino- carbonyl-t oxycholesterol moiety [Crooke et al., J. Pharmacol. Exp. Ther., 277:923-

937 (1996)]. See also US Patent Nos. 4,828,979; 4,948,882; 5,218, 105; 5,525,465;

5,541 ,313; 5,545,730; 5,552,538; 5,578,717, 5,580,731 ; 5,580,731 ; 5,591 ,584;

5, 109, 124; 5, 1 18,802; 5, 138,045; 5,414,077; 5,486,603; 5,512,439; 5,578,718;

5,608,046; 4,587,044; 4,605,735; 4,667,025; 4,762,779; 4,789,737; 4,824,941 ;

4,835,263; 4,876,335; 4,904,582; 4,958,013; 5,082,830; 5, 1 12,963; 5,214, 136; 5,082,830; 5, 1 12,963; 5,214, 136; 5,245,022; 5,254,469; 5,258,506; 5,262,536; 5,272,250; 5,292,873; 5,317,098; 5,371 ,241 , 5,391 ,723; 5,416,203, 5,451 ,463; 5,510,475; 5,512,667; 5,514,785; 5,565,552; 5,567,810; 5,574, 142; 5,585,481 ; 5,587,371 ; 5,595,726; 5,597,696; 5,599,923; 5,599, 928 and 5,688,941 .

[00355] Sugars and other moieties can be used to target proteins and

complexes comprising nucleotides, such as cationic polysomes and liposomes, to particular sites. For example, hepatic cell directed transfer can be mediated via asialoglycoprotein receptors (ASGPRs); see, e.g., Hu, et ai, Protein Pept Lett. 21 (10): 1025-30 (2014). Other systems known in the art and regularly developed can be used to target biomolecules of use in the present case and/or complexes thereof to particular target cells of interest.

[00356] These targeting moieties or conjugates can include conjugate groups covalently bound to functional groups, such as primary or secondary hydroxyl groups. Conjugate groups of the disclosure include intercalators, reporter molecules, polyamines, polyamides, polyethylene glycols, polyethers, groups that enhance the pharmacodynamic properties of oligomers, and groups that enhance the pharmacokinetic properties of oligomers. Typical conjugate groups include cholesterols, lipids, phospholipids, biotin, phenazine, folate, phenanthridine, anthraquinone, acridine, fluoresceins, rhodamines, coumarins, and dyes. Groups that enhance the pharmacodynamic properties, in the context of this disclosure, include groups that improve uptake, enhance resistance to degradation, and/or strengthen sequence-specific hybridization with the target nucleic acid. Groups that enhance the pharmacokinetic properties, in the context of this disclosure, include groups that improve uptake, distribution, metabolism or excretion of the compounds of the present disclosure. Representative conjugate groups are disclosed in

International Patent Application No. PCT/US92/09196, filed Oct. 23, 1992

(published as WO 1993/007883), and U.S. Pat. No. 6,287,860. Conjugate moieties include, but are not limited to, lipid moieties such as a cholesterol moiety, cholic acid, a thioether, e.g., hexyl-5-tritylthiol, a thiocholesterol, an aliphatic chain, e.g., dodecandiol or undecyl residues, a phospholipid, e.g., di-hexadecyl-rac- glycerol or triethylammonium l,2-di-0-hexadecyl-rac-glycero-3-H-phosphonate, a polyamine or a polyethylene glycol chain, or adamantane acetic acid, a palmityl moiety, or an octadecylamine or hexylamino-carbonyl-oxy cholesterol moiety. See, e.g., U.S. Pat. Nos. 4,828,979; 4,948,882; 5,218, 105; 5,525,465; 5,541 ,313; 5,545,730;

5,552,538; 5,578,717, 5,580,731 ; 5,580,731 ; 5,591 ,584; 5, 109, 124; 5, 1 18,802; 5, 138,045; 5,414,077; 5,486,603; 5,512,439; 5,578,718; 5,608,046; 4,587,044; 4,605,735; 4,667,025; 4,762,779; 4,789,737; 4,824,941 ; 4,835,263; 4,876,335; 4,904,582; 4,958,013; 5,082,830; 5, 1 12,963; 5,214, 136; 5,082,830; 5, 1 12,963; 5,214, 136; 5,245,022; 5,254,469; 5,258,506; 5,262,536; 5,272,250; 5,292,873; 5,317,098; 5,371 ,241 , 5,391 ,723; 5,416,203, 5,451 ,463; 5,510,475; 5,512,667; 5,514,785; 5,565,552; 5,567,810; 5,574,142; 5,585,481 ; 5,587,371 ; 5,595,726; 5,597,696; 5,599,923; 5,599,928 and 5,688,941 .

[00357] Longer polynucleotides that are less amenable to chemical synthesis and are typically produced by enzymatic synthesis can also be modified by various means. Such modifications can include, for example, the introduction of certain nucleotide analogs, the incorporation of particular sequences or other moieties at the 5' or 3' ends of molecules, and other modifications. By way of illustration, the mRNA encoding Cas9 is approximately 4 kb in length and can be synthesized by in vitro transcription. Modifications to the mRNA can be applied to, e.g., increase its translation or stability (such as by increasing its resistance to degradation with a cell), or to reduce the tendency of the RNA to elicit an innate immune response that is often observed in cells following introduction of exogenous RNAs, particularly longer RNAs such as that encoding Cas9.

[00358] Numerous such modifications have been described in the art, such as polyA tails, 5' cap analogs (e.g. , Anti Reverse Cap Analog (ARCA) or

m7G(5')ppp(5')G (mCAP)), modified 5' or 3' untranslated regions (UTRs), use of modified bases (such as Pseudo-UTP, 2-Thio-UTP, 5-Methylcytidine-5'- Triphosphate (5-Methyl-CTP) or N6-Methyl-ATP), or treatment with phosphatase to remove 5' terminal phosphates. These and other modifications are known in the art, and new modifications of RNAs are regularly being developed.

[00359] There are numerous commercial suppliers of modified RNAs, including for example, TriLink Biotech, AxoLabs, Bio-Synthesis Inc., Dharmacon and many others. As described by TriLink, for example, 5-Methyl-CTP can be used to impart desirable characteristics, such as increased nuclease stability, increased translation or reduced interaction of innate immune receptors with in vitro transcribed RNA. 5- Methylcytidine-5' -Triphosphate (5-Methyl-CTP), N6-Methyl-ATP, as well as

Pseudo-UTP and 2-Thio-UTP, have also been shown to reduce innate immune stimulation in culture and in vivo while enhancing translation, as illustrated in publications by Kormann et al. and Warren et al. referred to below.

[00360] It has been shown that chemically modified mRNA delivered in vivo can be used to achieve improved therapeutic effects; see, e.g., Kormann et al., Nature Biotechnology, 29: 154-157 (201 1 ). Such modifications can be used, for example, to increase the stability of the RNA molecule and/or reduce its immunogenicity. Using chemical modifications such as Pseudo-U, N6-Methyl-A, 2-Thio-U and 5-Methyl-C, it was found that substituting just one quarter of the uridine and cytidine residues with 2-Thio-U and 5-Methyl-C respectively resulted in a significant decrease in tolllike receptor (TLR) mediated recognition of the mRNA in mice. By reducing the activation of the innate immune system, these modifications can be used to effectively increase the stability and longevity of the mRNA in vivo; see, e.g., Kormann et al., supra.

[00361] It has also been shown that repeated administration of synthetic messenger RNAs incorporating modifications designed to bypass innate anti-viral responses can reprogram differentiated human cells to pluripotency. See, e.g., Warren, et ai, Cell Stem Cell, 7(5):618-30 (2010). Such modified mRNAs that act as primary reprogramming proteins can be an efficient means of reprogramming multiple human cell types. Such cells are referred to as induced pluripotency stem cells (iPSCs), and it was found that enzymatically synthesized RNA incorporating 5- Methyl-CTP, Pseudo-UTP and an Anti Reverse Cap Analog (ARCA) could be used to effectively evade the cell's antiviral response; see, e.g., Warren et ai, supra.

[00362] Other modifications of polynucleotides described in the art include, for example, the use of polyA tails, the addition of 5' cap analogs (such as

m7G(5')ppp(5')G (mCAP)), modifications of 5' or 3' untranslated regions (UTRs), or treatment with phosphatase to remove 5' terminal phosphates - and new

approaches are regularly being developed.

[00363] A number of compositions and techniques applicable to the generation of modified RNAs for use herein have been developed in connection with the modification of RNA interference (RNAi), including small-interfering RNAs (siRNAs). siRNAs present particular challenges in vivo because their effects on gene silencing via mRNA interference are generally transient, which can require repeat administration. In addition, siRNAs are double-stranded RNAs (dsRNA) and mammalian cells have immune responses that have evolved to detect and neutralize dsRNA, which is often a by-product of viral infection. Thus, there are mammalian enzymes such as PKR (dsRNA-responsive kinase), and potentially retinoic acid-inducible gene I (RIG-I), that can mediate cellular responses to dsRNA, as well as Toll-like receptors (such as TLR3, TLR7 and TLR8) that can trigger the induction of cytokines in response to such molecules; see, e.g., the reviews by Angart et al., Pharmaceuticals (Basel) 6(4):440-468 (2013); Kanasty et al., Molecular Therapy 20(3):513-524 (2012); Burnett et al., Biotechnol J.

6(9): 1 130-46 (201 1 ); Judge and MacLachlan, Hum Gene Ther 19(2): 1 1 1 -24 (2008); and references cited therein.

[00364] A large variety of modifications have been developed and applied to enhance RNA stability, reduce innate immune responses, and/or achieve other benefits that can be useful in connection with the introduction of polynucleotides into human cells, as described herein; see, e.g., the reviews by Whitehead KA et al., Annual Review of Chemical and Biomolecular Engineering, 2:77-96 (201 1 ); Gaglione and Messere, Mini Rev Med Chem, 10(7):578-95 (2010); Chernolovskaya et al, Curr Opin Mol Ther., 12(2): 158-67 (2010); Deleavey et al., Curr Protoc Nucleic Acid Chem Chapter 16:Unit 16.3 (2009); Behlke, Oligonucleotides

18(4):305-19 (2008); Fucini et al., Nucleic Acid Ther 22(3):205-210 (2012);

Bremsen et al., Front Genet 3: 154 (2012).

[00365] As noted above, there are a number of commercial suppliers of modified

RNAs, many of which have specialized in modifications designed to improve the effectiveness of siRNAs. A variety of approaches are offered based on various findings reported in the literature. For example, Dharmacon notes that replacement of a non-bridging oxygen with sulfur (phosphorothioate, PS) has been extensively used to improve nuclease resistance of siRNAs, as reported by Kole, Nature

Reviews Drug Discovery 1 1 :125-140 (2012). Modifications of the 2'-position of the ribose have been reported to improve nuclease resistance of the internucleotide phosphate bond while increasing duplex stability (Tm), which has also been shown to provide protection from immune activation. A combination of moderate PS backbone modifications with small, well-tolerated 2'-substitutions (2'-0-Methyl, 2'- Fluoro, 2'-Hydro) have been associated with highly stable siRNAs for applications in vivo, as reported by Soutschek et al. Nature 432: 173-178 (2004); and 2'-0- Methyl modifications have been reported to be effective in improving stability as reported by Volkov, Oligonucleotides 19:191 -202 (2009). With respect to decreasing the induction of innate immune responses, modifying specific sequences with 2'-0-Methyl, 2'-Fluoro, 2'-Hydro have been reported to reduce TLR7/TLR8 interaction while generally preserving silencing activity; see, e.g., Judge et al., Mol. Ther. 13:494-505 (2006); and Cekaite et al., J. Mol. Biol. 365:90- 108 (2007). Additional modifications, such as 2-thiouracil, pseudouracil, 5- methylcytosine, 5-methyluracil, and N6-methyladenosine have also been shown to minimize the immune effects mediated by TLR3, TLR7, and TLR8; see, e.g., Kariko, K. et al., Immunity 23: 165-175 (2005).

[00366] As is also known in the art, and commercially available, a number of conjugates can be applied to polynucleotides, such as RNAs, for use herein that can enhance their delivery and/or uptake by cells, including for example, cholesterol, tocopherol and folic acid, lipids, peptides, polymers, linkers and aptamers; see, e.g., the review by Winkler, Ther. Deliv. 4:791 -809 (2013), and references cited therein.

[00367] Codon-Optimization

[00368] In some embodiments, a polynucleotide encoding a site-directed polypeptide is codon-optimized according to methods standard in the art for expression in the cell containing the target DNA of interest. For example, if the intended target nucleic acid is in a human cell, a human codon-optimized polynucleotide encoding Cas9 is contemplated for use for producing the Cas9 polypeptide.

[00369] Complexes of a Genome-targeting Nucleic Acid and a Site-Directed Polypeptide

[00370] A genome-targeting nucleic acid interacts with a site-directed polypeptide (e.g., a nucleic acid-guided nuclease such as Cas9), thereby forming a complex. The genome-targeting nucleic acid guides the site-directed polypeptide to a target nucleic acid. [00371] Ribonucleoprotein complexes (RNPs)

[00372] The site-directed polypeptide and genome-targeting nucleic acid can each be administered separately to a cell or a patient. On the other hand, the site- directed polypeptide can be pre-complexed with one or more guide RNAs, or one or more crRNA together with a tracrRNA. The pre-complexed material can then be administered to a cell or a patient. Such pre-complexed material is known as a ribonucleoprotein particle (RNP). The site-directed polypeptide in the RNP can be, for example, a Cas9 endonuclease or a Cpf1 endonuclease. The site-directed polypeptide can be flanked at the N-terminus, the C-terminus, or both the N- terminus and C-terminus by one or more nuclear localization signals (NLSs). For example, a Cas9 endonuclease can be flanked by two NLSs, one NLS located at the N-terminus and the second NLS located at the C-terminus. The NLS can be any NLS known in the art, such as a SV40 NLS. The weight ratio of genome-targeting nucleic acid to site-directed polypeptide in the RNP can be 1 : 1 . For example, the weight ratio of sgRNA to Cas9 endonuclease in the RNP can be 1 : 1 .

[00373] Nucleic Acids Encoding System Components

[00374] The present disclosure provides a nucleic acid comprising a nucleotide sequence encoding a genome-targeting nucleic acid of the disclosure, a site- directed polypeptide of the disclosure, and/or any nucleic acid or proteinaceous molecule necessary to carry out the aspects of the methods of the disclosure.

[00375] The nucleic acid encoding a genome-targeting nucleic acid of the disclosure, a site-directed polypeptide of the disclosure, and/or any nucleic acid or proteinaceous molecule necessary to carry out the aspects of the methods of the disclosure can comprise a vector (e.g., a recombinant expression vector).

[00376] The term "vector" refers to a nucleic acid molecule capable of transporting another nucleic acid to which it has been linked. One type of vector is a "plasmid", which refers to a circular double-stranded DNA loop into which additional nucleic acid segments can be ligated. Another type of vector is a viral vector, wherein additional nucleic acid segments can be ligated into the viral genome. Certain vectors are capable of autonomous replication in a host cell into which they are introduced (e.g., bacterial vectors having a bacterial origin of replication and episomal mammalian vectors). Other vectors (e.g., non-episomal mammalian vectors) are integrated into the genome of a host cell upon introduction into the host cell, and thereby are replicated along with the host genome.

[00377] In some embodiments, vectors are capable of directing the expression of nucleic acids to which they are operatively linked. Such vectors are referred to herein as "recombinant expression vectors", or more simply "expression vectors", which serve equivalent functions.

[00378] The term "operably linked" means that the nucleotide sequence of interest is linked to regulatory sequence(s) in a manner that allows for expression of the nucleotide sequence. The term "regulatory sequence" is intended to include, for example, promoters, enhancers and other expression control elements (e.g., polyadenylation signals). Such regulatory sequences are well known in the art and are described, for example, in Goeddel; Gene Expression Technology: Methods in Enzymology 185, Academic Press, San Diego, CA (1990). Regulatory sequences include those that direct constitutive expression of a nucleotide sequence in many types of host cells, and those that direct expression of the nucleotide sequence only in certain host cells (e.g., tissue-specific regulatory sequences). It will be appreciated by those skilled in the art that the design of the expression vector can depend on such factors as the choice of the target cell, the level of expression desired, and the like.

[00379] Expression vectors contemplated include, but are not limited to, viral vectors based on vaccinia virus, poliovirus, adenovirus, adeno-associated virus, SV40, herpes simplex virus, human immunodeficiency virus, retrovirus (e.g. , Murine Leukemia Virus, spleen necrosis virus, and vectors derived from retroviruses such as Rous Sarcoma Virus, Harvey Sarcoma Virus, avian leukosis virus, a lentivirus, human immunodeficiency virus, myeloproliferative sarcoma virus, and mammary tumor virus) and other recombinant vectors. Other vectors contemplated for eukaryotic target cells include, but are not limited to, the vectors pXT1 , pSG5, pSVK3, pBPV, pMSG, and pSVLSV40 (Pharmacia).

[00380] In some embodiments, a vector comprises one or more transcription and/or translation control elements. Depending on the host/vector system utilized, any of a number of suitable transcription and translation control elements, including constitutive and inducible promoters, transcription enhancer elements, transcription terminators, etc. can be used in the expression vector. In some embodiments, the vector is a self-inactivating vector that either inactivates the viral sequences or the components of the CRISPR machinery or other elements.

[00381] Non-limiting examples of suitable eukaryotic promoters (i.e., promoters functional in a eukaryotic cell) include those from cytomegalovirus (CMV) immediate early, herpes simplex virus (HSV) thymidine kinase, early and late SV40, long terminal repeats (LTRs) from retrovirus, human elongation factor-1 promoter (EF1 ), a hybrid construct comprising the cytomegalovirus (CMV) enhancer fused to the chicken beta-actin promoter (CAG), murine stem cell virus promoter (MSCV), phosphoglycerate kinase-1 locus promoter (PGK), and mouse metallothionein-l.

[00382] For expressing small RNAs, including guide RNAs used in connection with Cas endonuclease, various promoters such as RNA polymerase III promoters, including for example U6 and H1 , can be advantageous. Descriptions of and parameters for enhancing the use of such promoters are known in art, and additional information and approaches are regularly being described; see, e.g., Ma, H. et at., Molecular Therapy - Nucleic Acids 3, e161 (2014)

doi: 10.1038/mtna.2014.12.

[00383] The expression vector can also contain a ribosome binding site for translation initiation and a transcription terminator. The expression vector can also comprise appropriate sequences for amplifying expression. The expression vector can also include nucleotide sequences encoding non-native tags (e.g., histidine tag, hemagglutinin tag, green fluorescent protein, etc.) that are fused to the site- directed polypeptide, thus resulting in a fusion protein.

[00384] In some embodiments, a promoter is an inducible promoter (e.g., a heat shock promoter, tetracycline-regulated promoter, steroid-regulated promoter, metal- regulated promoter, estrogen receptor-regulated promoter, etc.). In some embodiments, the promoter is a constitutive promoter (e.g., CMV promoter, UBC promoter). In some embodiments, the promoter is a spatially restricted and/or temporally restricted promoter (e.g., a tissue specific promoter, a cell type specific promoter, etc.).

[00385] In some embodiments, the nucleic acid encoding a genome-targeting nucleic acid of the disclosure and/or a site-directed polypeptide is packaged into or on the surface of delivery vehicles for delivery to cells. Delivery vehicles

contemplated include, but are not limited to, nanospheres, liposomes, quantum dots, nanoparticles, polyethylene glycol particles, hydrogels, and micelles. As described in the art, a variety of targeting moieties can be used to enhance the preferential interaction of such vehicles with desired cell types or locations.

[00386] Introduction of the complexes, polypeptides, and nucleic acids of the disclosure into cells can occur by viral or bacteriophage infection, transfection, conjugation, protoplast fusion, lipofection, electroporation, nucleofection, calcium phosphate precipitation, polyethyleneimine (PEI)-mediated transfection, DEAE- dextran mediated transfection, liposome-mediated transfection, particle gun technology, calcium phosphate precipitation, direct micro-injection, nanoparticle- mediated nucleic acid delivery, and the like.

[00387] Delivery

[00388] Guide RNA polynucleotides (RNA or DNA) and/or endonuclease polynucleotide(s) (RNA or DNA) can be delivered by viral or non-viral delivery vehicles known in the art. Alternatively, endonuclease polypeptide(s) can be delivered by viral or non-viral delivery vehicles known in the art, such as

electroporation or lipid nanoparticles. In some embodiments, the DNA

endonuclease is delivered as one or more polypeptides, either alone or pre- complexed with one or more guide RNAs, or one or more crRNA together with a tracrRNA.

[00389] Polynucleotides can be delivered by non-viral delivery vehicles including, but not limited to, nanoparticles, liposomes, ribonucleoproteins, positively charged peptides, small molecule RNA-conjugates, aptamer-RNA chimeras, and RNA- fusion protein complexes. Some exemplary non-viral delivery vehicles are described in Peer and Lieberman, Gene Therapy, 18: 1 127-1 133 (201 1 ) (which focuses on non-viral delivery vehicles for siRNA that are also useful for delivery of other polynucleotides).

[00390] Polynucleotides, such as guide RNA, sgRNA, and mRNA encoding an endonuclease, can be delivered to a cell or a patient by a lipid nanoparticle (LNP). [00391] A LNP refers to any particle having a diameter of less than 1000 nm, 500 nm, 250 nm, 200 nm, 150 nm, 100 nm, 75 nm, 50 nm, or 25 nm. Alternatively, a nanoparticle can range in size from 1 -1000 nm, 1 -500 nm, 1 -250 nm, 25-200 nm, 25-100 nm, 35-75 nm, or 25-60 nm.

[00392] LNPs can be made from cationic, anionic, or neutral lipids. Neutral lipids, such as the fusogenic phospholipid DOPE or the membrane component

cholesterol, can be included in LNPs as 'helper lipids' to enhance transfection activity and nanoparticle stability. Limitations of cationic lipids include low efficacy owing to poor stability and rapid clearance, as well as the generation of

inflammatory or anti-inflammatory responses.

[00393] LNPs can also be comprised of hydrophobic lipids, hydrophilic lipids, or both hydrophobic and hydrophilic lipids.

[00394] Any lipid or combination of lipids that are known in the art can be used to produce a LNP. Examples of lipids used to produce LNPs are: DOTMA, DOSPA, DOTAP, DMRIE, DC-cholesterol, DOTAP-cholesterol, GAP-DMORIE-DPyPE, and GL67A-DOPE-DMPE-polyethylene glycol (PEG). Examples of cationic lipids are: 98N12-5, C12-200, DLin-KC2-DMA (KC2), DLin-MC3-DMA (MC3), XTC, MD1 , and 7C1 . Examples of neutral lipids are: DPSC, DPPC, POPC, DOPE, and SM.

Examples of PEG-modified lipids are: PEG-DMG, PEG-CerC14, and PEG-CerC20.

[00395] The lipids can be combined in any number of molar ratios to produce a LNP. In addition, the polynucleotide(s) can be combined with lipid(s) in a wide range of molar ratios to produce a LNP.

[00396] As stated previously, the site-directed polypeptide and genome-targeting nucleic acid can each be administered separately to a cell or a patient. On the other hand, the site-directed polypeptide can be pre-complexed with one or more guide RNAs, or one or more crRNA together with a tracrRNA. The pre-complexed material can then be administered to a cell or a patient. Such pre-complexed material is known as a ribonucleoprotein particle (RNP).

[00397] RNA is capable of forming specific interactions with RNA or DNA. While this property is exploited in many biological processes, it also comes with the risk of promiscuous interactions in a nucleic acid-rich cellular environment. One solution to this problem is the formation of ribonucleoprotein particles (RNPs), in which the RNA is pre-complexed with an endonuclease. Another benefit of the RNP is protection of the RNA from degradation.

[00398] The endonuclease in the RNP can be modified or unmodified. Likewise, the gRNA, crRNA, tracrRNA, or sgRNA can be modified or unmodified. Numerous modifications are known in the art and can be used.

[00399] The endonuclease and sgRNA can be generally combined in a 1 : 1 molar ratio. Alternatively, the endonuclease, crRNA and tracrRNA can be generally combined in a 1 : 1 : 1 molar ratio. However, a wide range of molar ratios can be used to produce a RNP.

[00400] AAV (adeno associated virus)

[00401] A recombinant adeno-associated virus (AAV) vector can be used for delivery. Techniques to produce rAAV particles, in which an AAV genome to be packaged that includes the polynucleotide to be delivered, rep and cap genes, and helper virus functions are provided to a cell are standard in the art. Production of rAAV typically requires that the following components are present within a single cell (denoted herein as a packaging cell): a rAAV genome, AAV rep and cap genes separate from (i.e., not in) the rAAV genome, and helper virus functions. The AAV rep and cap genes may be from any AAV serotype for which recombinant virus can be derived, and may be from a different AAV serotype than the rAAV genome ITRs, including, but not limited to, AAV serotypes AAV-1 , AAV-2, AAV-3, AAV-4, AAV-5, AAV-6, AAV-7, AAV-8, AAV-9, AAV-10, AAV-1 1 , AAV-12, AAV-13 and AAV rh.74. Production of pseudotyped rAAV is disclosed in, for example, international patent application publication number WO 01 /83692. See Table 2.

Table 2

AAV-3B AF028705.1

AAV-4 NC_001829.1

AAV-5 NC_006152.1

AAV-6 AF028704.1

AAV-7 NC_006260.1

AAV-8 NC_006261 .1

AAV-9 AX753250.1

AAV- 10 AY631965.1

AAV-1 1 AY631966.1

AAV-12 DQ813647.1

AAV-13 EU285562.1

[00402] A method of generating a packaging cell involves creating a cell line that stably expresses all of the necessary components for AAV particle production. For example, a plasmid (or multiple plasmids) comprising a rAAV genome lacking AAV rep and cap genes, AAV rep and cap genes separate from the rAAV genome, and a selectable marker, such as a neomycin resistance gene, are integrated into the genome of a cell. AAV genomes have been introduced into bacterial plasmids by procedures such as GC tailing (Samulski et a/., 1982, Proc. Natl. Acad. S6. USA, 79:2077-2081 ), addition of synthetic linkers containing restriction endonuclease cleavage sites (Laughlin et ai, 1983, Gene, 23:65-73) or by direct, blunt-end ligation (Senapathy & Carter, 1984, J. Biol. Chem., 259:4661 -4666). The packaging cell line can then be infected with a helper virus, such as adenovirus. The advantages of this method are that the cells are selectable and are suitable for large-scale production of rAAV. Other examples of suitable methods employ adenovirus or baculovirus, rather than plasmids, to introduce rAAV genomes and/or rep and cap genes into packaging cells.

[00403] General principles of rAAV production are reviewed in, for example, Carter, 1992, Current Opinions in Biotechnology, 1533-539; and Muzyczka, 1992, Curr. Topics in Microbial, and Immunol., 158:97-129). Various approaches are described in Ratschin et al., Mol. Cell. Biol. 4:2072 (1984); Hermonat et al., Proc. Natl. Acad. Sci. USA, 81 :6466 (1984); Tratschin et al., Mo1 . Cell. Biol. 5:3251 (1985); McLaughlin et al., J. Virol., 62: 1963 (1988); and Lebkowski et al., 1988 Mol. Cell. Biol., 7:349 (1988). Samulski et al. (1989, J. Virol., 63:3822-3828); U.S. Patent No. 5, 173,414; WO 95/13365 and corresponding U.S. Patent No. 5,658,776 ; WO 95/13392; WO 96/17947; PCT/US98/18600; WO 97/09441 (PCT/US96/14423); WO 97/08298 (PCT/US96/13872); WO 97/21825 (PCT/US96/20777); WO

97/06243 (PCT/FR96/01064); WO 99/1 1764; Perrin et al. (1995) Vaccine 13: 1244- 1250; Paul et al. (1993) Human Gene Therapy 4:609-615; Clark et al. (1996) Gene Therapy 3: 1 124-1 132; U.S. Patent. No. 5,786,21 1 ; U.S. Patent No. 5,871 ,982; and U.S. Patent. No. 6,258,595.

[00404] AAV vector serotypes can be matched to target cell types. For example, the following exemplary cell types can be transduced by the indicated AAV serotypes among others. See Table 3.

Table 3

[00405] In addition to adeno-associated viral vectors, other viral vectors can be used. Such viral vectors include, but are not limited to, lentivirus, alphavirus, enterovirus, pestivirus, baculovirus, herpesvirus, Epstein Barr virus, papovavirusr, poxvirus, vaccinia virus, and herpes simplex virus.

[00406] In some cases, Cas9 mRNA, sgRNA targeting one or two sites within or near the TTR gene or other DNA sequence that encodes a regulatory element of the TTR gene, and donor DNA can each be separately formulated into lipid nanoparticles, or are all co-formulated into one lipid nanoparticle.

[00407] In some cases, Cas9 mRNA can be formulated in a lipid nanoparticle, while sgRNA and donor DNA can be delivered in an AAV vector.

[00408] Options are available to deliver the Cas9 nuclease as a DNA plasmid, as mRNA or as a protein. The guide RNA can be expressed from the same DNA, or can also be delivered as an RNA. The RNA can be chemically modified to alter or improve its half-life, or decrease the likelihood or degree of immune response. The endonuclease protein can be complexed with the gRNA prior to delivery. Viral vectors allow efficient delivery; split versions of Cas9 and smaller orthologs of Cas9 can be packaged in AAV, as can donors for HDR. A range of non-viral delivery methods also exist that can deliver each of these components, or non-viral and viral methods can be employed in tandem. For example, nano-particles can be used to deliver the protein and guide RNA, while AAV can be used to deliver a donor DNA.

[00409] Exosomes

[00410] Exosomes, a type of microvesicle bound by phospholipid bilayer, can be used to deliver nucleic acids to specific tissue. Many different types of cells within the body naturally secrete exosomes. Exosomes form within the cytoplasm when endosomes invaginate and form multivesicular-endosomes (MVE). When the MVE fuses with the cellular membrane, the exosomes are secreted in the extracellular space. Ranging between 30-120nm in diameter, exosomes can shuttle various molecules from one cell to another in a form of cell-to-cell communication. Cells that naturally produce exosomes, such as mast cells, can be genetically altered to produce exosomes with surface proteins that target specific tissues, alternatively exosomes can be isolated from the bloodstream. Specific nucleic acids can be placed within the engineered exosomes with electroporation. When introduced systemically, the exosomes can deliver the nucleic acids to the specific target tissue. [00411 ] Genetically Modified Cells

[00412] The term "genetically modified cell" refers to a cell that comprises at least one genetic modification introduced by genome editing (e.g., using the

CRISPR/Cas9 or CRISPR/Cpf1 system). In some ex vivo examples herein, the genetically modified cell is genetically modified progenitor cell. In some in vivo examples herein, the genetically modified cell can be a genetically modified liver progenitor cell. A genetically modified cell comprising an exogenous genome- targeting nucleic acid and/or an exogenous nucleic acid encoding a genome- targeting nucleic acid is contemplated herein.

[00413] The term "control treated population" describes a population of cells that has been treated with identical media, viral induction, nucleic acid sequences, temperature, confluency, flask size, pH, etc., with the exception of the addition of the genome editing components. Any method known in the art can be used to measure TTR gene or protein expression, for example Western Blot analysis of the TTR protein or real-time PCR for quantifying TTR mRNA.

[00414] The term "isolated cell" refers to a cell that has been removed from an organism in which it was originally found, or a descendant of such a cell. Optionally, the cell is cultured in vitro, e.g., under defined conditions or in the presence of other cells. Optionally, the cell is later introduced into a second organism or re-introduced into the organism from which it (or the cell from which it is descended) was isolated.

[00415] The term "isolated population" with respect to an isolated population of cells refers to a population of cells that has been removed and separated from a mixed or heterogeneous population of cells. In some embodiments, the isolated population is a substantially pure population of cells, as compared to the

heterogeneous population from which the cells were isolated or enriched. In some embodiments, the isolated population is an isolated population of human progenitor cells, e.g., a substantially pure population of human progenitor cells, as compared to a heterogeneous population of cells comprising human progenitor cells and cells from which the human progenitor cells were derived.

[00416] The term "substantially enhanced," with respect to a particular cell population, refers to a population of cells in which the occurrence of a particular type of cell is increased relative to pre-existing or reference levels, by at least 2- fold, at least 3-, at least 4-, at least 5-, at least 6-, at least 7-, at least 8-, at least 9, at least 10-, at least 20-, at least 50-, at least 100-, at least 400-, at least 1000-, at least 5000-, at least 20000-, at least 100000- or more fold depending, e.g., on the desired levels of such cells for ameliorating FTA.

[00417] The term "substantially enriched" with respect to a particular cell population, refers to a population of cells that is at least about 10%, about 20%, about 30%, about 40%, about 50%, about 60%, about 70% or more with respect to the cells making up a total cell population.

[00418] The terms "substantially enriched" or "substantially pure" with respect to a particular cell population, refers to a population of cells that is at least about 75%, at least about 85%, at least about 90%, or at least about 95% pure, with respect to the cells making up a total cell population. That is, the terms "substantially pure" or "essentially purified," with regard to a population of progenitor cells, refers to a population of cells that contain fewer than about 20%, about 15%, about 10%, about 9%, about 8%, about 7%, about 6%, about 5%, about 4%, about 3%, about 2%, about 1 %, or less than 1 %, of cells that are not progenitor cells as defined by the terms herein.

[00419] Differentiation of edited iPSCs into hepatocytes

[00420] Another step of the ex vivo methods of the present disclosure can comprise differentiating the edited iPSCs into hepatocytes. The differentiating step can be performed according to any method known in the art. For example, hiPSC are differentiated into definitive endoderm using various treatments, including activin and B27 supplement (Life Technology). The definitive endoderm is further differentiated into hepatocyte, the treatment includes: FGF4, HGF, BMP2, BMP4, Oncostatin M, Dexametason, etc. (Duan et al, Stem Cells; 2010;28:674-686, Ma et al, Stem Cells Translational Medicine 2013;2:409-419).

[00421] Differentiation of edited mesenchymal stem cells into hepatocytes

[00422] Another step of the ex vivo methods of the present disclosure can comprise differentiating the edited mesenchymal stem cells into hepatocytes. The differentiating step can be performed according to any method known in the art. For example, hMSC are treated with various factors and hormones, including insulin, transferrin, FGF4, HGF, bile acids (Sawitza I et al, Sci Rep. 2015; 5: 13320).

[00423] Implanting cells into patients

[00424] Another step of the ex vivo methods of the present disclosure can comprise implanting the hepatocytes into patients. This implanting step may be accomplished using any method of implantation known in the art. For example, the genetically modified cells can be injected directly in the patient's liver or otherwise administered to the patient.

[00425] Another step of the ex vivo methods of the present disclosure can comprise implanting the progenitor cells or primary hepatocytes into patients. This implanting step may be accomplished using any method of implantation known in the art. For example, the genetically modified cells can be injected directly in the patient's liver or otherwise administered to the patient. The genetically modified cells may be purified ex vivo using a selected marker.

[00426] Pharmaceutically Acceptable Carriers

[00427] The ex vivo methods of administering progenitor cells to a subject contemplated herein involve the use of therapeutic compositions comprising progenitor cells.

[00428] Therapeutic compositions contain a physiologically tolerable carrier together with the cell composition, and optionally at least one additional bioactive agent as described herein, dissolved or dispersed therein as an active ingredient. In some embodiments, the therapeutic composition is not substantially

immunogenic when administered to a mammal or human patient for therapeutic purposes, unless so desired.

[00429] In general, the progenitor cells described herein are administered as a suspension with a pharmaceutically acceptable carrier. One of skill in the art will recognize that a pharmaceutically acceptable carrier to be used in a cell composition will not include buffers, compounds, cryopreservation agents, preservatives, or other agents in amounts that substantially interfere with the viability of the cells to be delivered to the subject. A formulation comprising cells can include e.g., osmotic buffers that permit cell membrane integrity to be maintained, and optionally, nutrients to maintain cell viability or enhance

engraftment upon administration. Such formulations and suspensions are known to those of skill in the art and/or can be adapted for use with the progenitor cells, as described herein, using routine experimentation.

[00430] A cell composition can also be emulsified or presented as a liposome composition, provided that the emulsification procedure does not adversely affect cell viability. The cells and any other active ingredient can be mixed with excipients that are pharmaceutically acceptable and compatible with the active ingredient, and in amounts suitable for use in the therapeutic methods described herein.

[00431] Additional agents included in a cell composition can include

pharmaceutically acceptable salts of the components therein. Pharmaceutically acceptable salts include the acid addition salts (formed with the free amino groups of the polypeptide) that are formed with inorganic acids, such as, for example, hydrochloric or phosphoric acids, or such organic acids as acetic, tartaric, mandelic and the like. Salts formed with the free carboxyl groups can also be derived from inorganic bases, such as, for example, sodium, potassium, ammonium, calcium or ferric hydroxides, and such organic bases as isopropylamine, trimethylamine, 2- ethylamino ethanol, histidine, procaine and the like.

[00432] Physiologically tolerable carriers are well known in the art. Exemplary liquid carriers are sterile aqueous solutions that contain no materials in addition to the active ingredients and water, or contain a buffer such as sodium phosphate at physiological pH value, physiological saline or both, such as phosphate-buffered saline. Still further, aqueous carriers can contain more than one buffer salt, as well as salts such as sodium and potassium chlorides, dextrose, polyethylene glycol and other solutes. Liquid compositions can also contain liquid phases in addition to and to the exclusion of water. Exemplary of such additional liquid phases are glycerin, vegetable oils such as cottonseed oil, and water-oil emulsions. The amount of an active compound used in the cell compositions that is effective in the treatment of a particular disorder or condition will depend on the nature of the disorder or condition, and can be determined by standard clinical techniques. [00433] Administration & Efficacy

[00434] The terms "administering," "introducing" and "transplanting" are used interchangeably in the context of the placement of cells, e.g., progenitor cells, into a subject, by a method or route that results in at least partial localization of the introduced cells at a desired site, such as a site of injury or repair, such that a desired effect(s) is produced. The cells e.g., progenitor cells, or their differentiated progeny can be administered by any appropriate route that results in delivery to a desired location in the subject where at least a portion of the administered cells or components of the cells remain viable. The period of viability of the cells after administration to a subject can be as short as a few hours, e.g., twenty-four hours, to a few days, to as long as several years, or even the life time of the patient, i.e. , long-term engraftment. For example, in some aspects described herein, an effective amount of myogenic progenitor cells is administered via a systemic route of administration, such as an intraperitoneal or intravenous route.

[00435] The terms "individual", "subject," "host" and "patient" are used interchangeably herein and refer to any subject for whom diagnosis, treatment or therapy is desired. In some embodiments, the subject is a mammal. In some embodiments, the subject is a human being.

[00436] When provided prophylactically, progenitor cells described herein can be administered to a subject in advance of any symptom of FTA. Accordingly, the prophylactic administration of a liver progenitor cell population serves to prevent FTA.

[00437] When provided therapeutically, progenitor cells are provided at (or after) the onset of a symptom or indication of FTA, e.g., upon the onset of disease.

[00438] In some embodiments, the progenitor cell population being administered according to the methods described herein can comprise allogeneic liver progenitor cells obtained from one or more donors. "Allogeneic" refers to a liver progenitor cell or biological samples comprising liver progenitor cells obtained from one or more different donors of the same species, where the genes at one or more loci are not identical. For example, a liver progenitor cell population being administered to a subject can be derived from one more unrelated donor subjects, or from one or more non-identical siblings. In some embodiments, syngeneic liver progenitor cell populations are used, such as those obtained from genetically identical animals, or from identical twins. In some embodiments, the liver progenitor cells are autologous cells; that is, the liver progenitor cells are obtained or isolated from a subject and administered to the same subject, i.e. , the donor and recipient are the same.

[00439] The term "effective amount" refers to the amount of a population of progenitor cells or their progeny needed to prevent or alleviate at least one or more signs or symptoms of FTA, and relates to a sufficient amount of a composition to provide the desired effect, e.g., to treat a subject having FTA. The term

"therapeutically effective amount" therefore refers to an amount of progenitor cells or a composition comprising progenitor cells that is sufficient to promote a particular effect when administered to a typical subject, such as one who has or is at risk for FTA. An effective amount would also include an amount sufficient to prevent or delay the development of a symptom of the disease, alter the course of a symptom of the disease (for example but not limited to, slow the progression of a symptom of the disease), or reverse a symptom of the disease. It is understood that for any given case, an appropriate "effective amount" can be determined by one of ordinary skill in the art using routine experimentation.

[00440] For use in the various aspects described herein, an effective amount of progenitor cells comprises at least 10 ² progenitor cells, at least 5 X 10 ² progenitor cells, at least 10 ³ progenitor cells, at least 5 X 10 ³ progenitor cells, at least 10 ⁴ progenitor cells, at least 5 X 10 ⁴ progenitor cells, at least 10 ⁵ progenitor cells, at least 2 X 10 ⁵ progenitor cells, at least 3 X 10 ⁵ progenitor cells, at least 4 X 10 ⁵ progenitor cells, at least 5 X 10 ⁵ progenitor cells, at least 6 X 10 ⁵ progenitor cells, at least 7 X 10 ⁵ progenitor cells, at least 8 X 10 ⁵ progenitor cells, at least 9 X 10 ⁵ progenitor cells, at least 1 X 10 ⁶ progenitor cells, at least 2 X 10 ⁶ progenitor cells, at least 3 X 10 ⁶ progenitor cells, at least 4 X 10 ⁶ progenitor cells, at least 5 X 10 ⁶ progenitor cells, at least 6 X 10 ⁶ progenitor cells, at least 7 X 10 ⁶ progenitor cells, at least 8 X 10 ⁶ progenitor cells, at least 9 X 10 ⁶ progenitor cells, or multiples thereof. The progenitor cells are derived from one or more donors, or are obtained from an autologous source. In some embodiments described herein, the progenitor cells are expanded in culture prior to administration to a subject in need thereof. [00441] Modest and incremental decreases in the levels of mutant TTR expressed in cells of patients having FTA can be beneficial for ameliorating one or more symptoms of the disease, for increasing long-term survival, and/or for reducing side effects associated with other treatments. Upon administration of such cells to human patients, the presence of liver progenitors that are producing decreased levels of mutant TTR is beneficial.

[00442] "Administered" refers to the delivery of a progenitor cell composition into a subject by a method or route that results in at least partial localization of the cell composition at a desired site. A cell composition can be administered by any appropriate route that results in effective treatment in the subject, i.e. administration results in delivery to a desired location in the subject where at least a portion of the composition delivered, i.e. at least 1 x 10 ⁴ cells are delivered to the desired site for a period of time. Modes of administration include injection, infusion, instillation, or ingestion. "Injection" includes, without limitation, intravenous, intramuscular, intraarterial, intrathecal, intraventricular, intracapsular, intraorbital, intracardiac, intradermal, intraperitoneal, transtracheal, subcutaneous, subcuticular,

intraarticular, sub capsular, subarachnoid, intraspinal, intracerebro spinal, and intrasternal injection and infusion. In some embodiments, the route is intravenous. For the delivery of cells, administration by injection or infusion can be made.

[00443] The cells are administered systemically. The phrases "systemic administration," "administered systemically", "peripheral administration" and "administered peripherally" refer to the administration of a population of progenitor cells other than directly into a target site, tissue, or organ, such that it enters, instead, the subject's circulatory system and, thus, is subject to metabolism and other like processes.

[00444] The efficacy of a treatment comprising a composition for the treatment of FTA can be determined by the skilled clinician. However, a treatment is considered "effective treatment," if any one or all of the signs or symptoms of, as but one example, levels of functional TTR are altered in a beneficial manner (e.g., increased by at least 10%), or other clinically accepted symptoms or markers of disease are improved or ameliorated. Efficacy can also be measured by failure of an individual to worsen as assessed by hospitalization or need for medical interventions (e.g., progression of the disease is halted or at least slowed). Methods of measuring these indicators are known to those of skill in the art and/or described herein. Treatment includes any treatment of a disease in an individual or an animal (some non-limiting examples include a human, or a mammal) and includes: (1 ) inhibiting the disease, e.g., arresting, or slowing the progression of symptoms; or (2) relieving the disease, e.g., causing regression of symptoms; and (3) preventing or reducing the likelihood of the development of symptoms.

[00445] The treatment according to the present disclosure can ameliorate one or more symptoms associated with FTA by increasing the amount of functional TTR in the individual. Early signs typically associated with FTA include for example, development of Kayser-Fleischer (KF) rings, personality changes, impaired cognitive function, hemolytic anemia, dystonic syndrome, jaundice, cirrhosis and acute liver failure.

[00446] Kits

[00447] The present disclosure provides kits for carrying out the methods described herein. A kit can include one or more of a genome-targeting nucleic acid, a polynucleotide encoding a genome-targeting nucleic acid, a site-directed polypeptide, a polynucleotide encoding a site-directed polypeptide, and/or any nucleic acid or proteinaceous molecule necessary to carry out the aspects of the methods described herein, or any combination thereof.

[00448] In some embodiments, a kit can comprise: (1 ) a vector comprising a nucleotide sequence encoding a genome-targeting nucleic acid, (2) the site- directed polypeptide or a vector comprising a nucleotide sequence encoding the site-directed polypeptide, and (3) a reagent for reconstitution and/or dilution of the vector(s) and or polypeptide.

[00449] In some embodiments, a kit can comprise: (1 ) a vector comprising (i) a nucleotide sequence encoding a genome-targeting nucleic acid, and (ii) a nucleotide sequence encoding the site-directed polypeptide; and (2) a reagent for reconstitution and/or dilution of the vector.

[00450] In some embodiments of any of the above kits, the kit can comprise a single-molecule guide genome-targeting nucleic acid. In some embodiments of any of the above kits, the kit comprises a double-molecule genome-targeting nucleic acid. In any of the above kits, kit can comprises two or more double-molecule guides or single-molecule guides. In some embodiments, the kits comprises a vector that encodes the nucleic acid targeting nucleic acid.

[00451] In any of the above kits, the kit further comprises a polynucleotide to be inserted to effect the desired genetic modification.

[00452] Components of a kit can be in separate containers, or combined in a single container.

[00453] Any kit described above can further comprise one or more additional reagents, where such additional reagents are selected from a buffer, a buffer for introducing a polypeptide or polynucleotide into a cell, a wash buffer, a control reagent, a control vector, a control RNA polynucleotide, a reagent for in vitro production of the polypeptide from DNA, adaptors for sequencing and the like. A buffer can be a stabilization buffer, a reconstituting buffer, a diluting buffer, or the like. In some embodiments, a kit also comprises one or more components that can be used to facilitate or enhance the on-target binding or the cleavage of DNA by the endonuclease, or improve the specificity of targeting.

[00454] In addition to the above-mentioned components, a kit can further comprise instructions for using the components of the kit to practice the methods. The instructions for practicing the methods are generally recorded on a suitable recording medium. For example, the instructions can be printed on a substrate, such as paper or plastic, etc. The instructions can be present in the kits as a package insert, in the labeling of the container of the kit or components thereof (i.e., associated with the packaging or subpackaging), etc. The instructions can be present as an electronic storage data file present on a suitable computer readable storage medium, e.g., CD-ROM, diskette, flash drive, etc. In some instances, the actual instructions are not present in the kit, but means for obtaining the instructions from a remote source (e.g. via the Internet), can be provided. An example of this case is a kit that comprises a web address where the instructions can be viewed and/or from which the instructions can be downloaded. As with the instructions, this means for obtaining the instructions can be recorded on a suitable substrate. [00455] Guide RNA Formulation

[00456] Guide RNAs of the present disclosure are formulated with

pharmaceutically acceptable excipients such as carriers, solvents, stabilizers, adjuvants, diluents, etc., depending upon the particular mode of administration and dosage form. Guide RNA compositions are generally formulated to achieve a physiologically compatible pH, and range from a pH of about 3 to a pH of about 1 1 , about pH 3 to about pH 7, depending on the formulation and route of

administration. In some embodiments, the pH is adjusted to a range from about pH 5.0 to about pH 8. In some embodiments, the compositions comprises a

therapeutically effective amount of at least one compound as described herein, together with one or more pharmaceutically acceptable excipients. Optionally, the compositions comprises a combination of the compounds described herein, or can include a second active ingredient useful in the treatment or prevention of bacterial growth (for example and without limitation, anti-bacterial or anti-microbial agents), or can include a combination of reagents of the present disclosure.

[00457] Suitable excipients include, for example, carrier molecules that include large, slowly metabolized macromolecules such as proteins, polysaccharides, polylactic acids, polyglycolic acids, polymeric amino acids, amino acid copolymers, and inactive virus particles. Other exemplary excipients can include antioxidants (for example and without limitation, ascorbic acid), chelating agents (for example and without limitation, EDTA), carbohydrates (for example and without limitation, dextrin, hydroxyalkylcellulose, and hydroxyalkylmethylcellulose), stearic acid, liquids (for example and without limitation, oils, water, saline, glycerol and ethanol), wetting or emulsifying agents, pH buffering substances, and the like.

[00458] Other Possible Therapeutic Approaches

[00459] Gene editing can be conducted using nucleases engineered to target specific sequences. To date there are four major types of nucleases:

meganucleases and their derivatives, zinc finger nucleases (ZFNs), transcription activator like effector nucleases (TALENs), and CRISPR-Cas9 nuclease systems. The nuclease platforms vary in difficulty of design, targeting density and mode of action, particularly as the specificity of ZFNs and TALENs is through protein-DNA interactions, while RNA-DNA interactions primarily guide Cas9. Cas9 cleavage also requires an adjacent motif, the PAM, which differs between different CRISPR systems. Cas9 from Streptococcus pyogenes cleaves using a NRG PAM, CRISPR from Neisseria meningitidis can cleave at sites with PAMs including NNNNGATT, NNNNNGTTT and NNNNGCTT. A number of other Cas9 orthologs target protospacer adjacent to alternative PAMs.

[00460] CRISPR endonucleases, such as Cas9, can be used in the methods of the present disclosure. However, the teachings described herein, such as therapeutic target sites, could be applied to other forms of endonucleases, such as ZFNs, TALENs, HEs, or MegaTALs, or using combinations of nucleases. However, in order to apply the teachings of the present disclosure to such endonucleases, one would need to, among other things, engineer proteins directed to the specific target sites.

[00461] Additional binding domains can be fused to the Cas9 protein to increase specificity. The target sites of these constructs would map to the identified gRNA specified site, but would require additional binding motifs, such as for a zinc finger domain. In the case of Mega-TAL, a meganuclease can be fused to a TALE DNA- binding domain. The meganuclease domain can increase specificity and provide the cleavage. Similarly, inactivated or dead Cas9 (dCas9) can be fused to a cleavage domain and require the sgRNA/Cas9 target site and adjacent binding site for the fused DNA-binding domain. This likely would require some protein engineering of the dCas9, in addition to the catalytic inactivation, to decrease binding without the additional binding site.

[00462] Zinc Finger Nucleases

[00463] Zinc finger nucleases (ZFNs) are modular proteins comprised of an engineered zinc finger DNA binding domain linked to the catalytic domain of the type II endonuclease Fokl. Because Fokl functions only as a dimer, a pair of ZFNs must be engineered to bind to cognate target "half-site" sequences on opposite DNA strands and with precise spacing between them to enable the catalytically active Fokl dimer to form. Upon dimerization of the Fokl domain, which itself has no sequence specificity per se, a DNA double-strand break is generated between the ZFN half-sites as the initiating step in genome editing. [00464] The DNA binding domain of each ZFN is typically comprised of 3-6 zinc fingers of the abundant Cys2-His2 architecture, with each finger primarily recognizing a triplet of nucleotides on one strand of the target DNA sequence, although cross-strand interaction with a fourth nucleotide also can be important. Alteration of the amino acids of a finger in positions that make key contacts with the DNA alters the sequence specificity of a given finger. Thus, a four-finger zinc finger protein will selectively recognize a 12 bp target sequence, where the target sequence is a composite of the triplet preferences contributed by each finger, although triplet preference can be influenced to varying degrees by neighboring fingers. An important aspect of ZFNs is that they can be readily re-targeted to almost any genomic address simply by modifying individual fingers, although considerable expertise is required to do this well. In most applications of ZFNs, proteins of 4-6 fingers are used, recognizing 12-18 bp respectively. Hence, a pair of ZFNs will typically recognize a combined target sequence of 24-36 bp, not including the typical 5-7 bp spacer between half-sites. The binding sites can be separated further with larger spacers, including 15-17 bp. A target sequence of this length is likely to be unique in the human genome, assuming repetitive sequences or gene homologs are excluded during the design process. Nevertheless, the ZFN protein- DNA interactions are not absolute in their specificity so off-target binding and cleavage events do occur, either as a heterodimer between the two ZFNs, or as a homodimer of one or the other of the ZFNs. The latter possibility has been effectively eliminated by engineering the dimerization interface of the Fokl domain to create "plus" and "minus" variants, also known as obligate heterodimer variants, which can only dimerize with each other, and not with themselves. Forcing the obligate heterodimer prevents formation of the homodimer. This has greatly enhanced specificity of ZFNs, as well as any other nuclease that adopts these Fokl variants.

[00465] A variety of ZFN-based systems have been described in the art, modifications thereof are regularly reported, and numerous references describe rules and parameters that are used to guide the design of ZFNs; see, e.g., Segal et a/., Proc Natl Acad Sci USA 96(6):2758-63 (1999); Dreier B et ai , J Mol Biol.

303(4):489-502 (2000); Liu Q et ai, J Biol Chem. 277(6):3850-6 (2002); Dreier et a/., J Biol Chem 280(42):35588-97 (2005); and Dreier et al., J Biol Chem.

276(31 ):29466-78 (2001 ).

[00466] Transcription Activator-Like Effector Nucleases (TALENs)

[00467] TALENs represent another format of modular nucleases whereby, as with ZFNs, an engineered DNA binding domain is linked to the Fokl nuclease domain, and a pair of TALENs operate in tandem to achieve targeted DNA cleavage. The major difference from ZFNs is the nature of the DNA binding domain and the associated target DNA sequence recognition properties. The TALEN DNA binding domain derives from TALE proteins, which were originally described in the plant bacterial pathogen Xanthomonas sp. TALEs are comprised of tandem arrays of 33-35 amino acid repeats, with each repeat recognizing a single basepair in the target DNA sequence that is typically up to 20 bp in length, giving a total target sequence length of up to 40 bp. Nucleotide specificity of each repeat is determined by the repeat variable diresidue (RVD), which includes just two amino acids at positions 12 and 13. The bases guanine, adenine, cytosine and thymine are predominantly recognized by the four RVDs: Asn-Asn, Asn-lle, His-Asp and Asn- Gly, respectively. This constitutes a much simpler recognition code than for zinc fingers, and thus represents an advantage over the latter for nuclease design. Nevertheless, as with ZFNs, the protein-DNA interactions of TALENs are not absolute in their specificity, and TALENs have also benefitted from the use of obligate heterodimer variants of the Fokl domain to reduce off-target activity.

[00468] Additional variants of the Fokl domain have been created that are deactivated in their catalytic function. If one half of either a TALEN or a ZFN pair contains an inactive Fokl domain, then only single-strand DNA cleavage (nicking) will occur at the target site, rather than a DSB. The outcome is comparable to the use of CRISPR/Cas9or CRISPR/Cpf1 "nickase" mutants in which one of the Cas9 cleavage domains has been deactivated. DNA nicks can be used to drive genome editing by HDR, but at lower efficiency than with a DSB. The main benefit is that off- target nicks are quickly and accurately repaired, unlike the DSB, which is prone to NHEJ-mediated mis-repair.

[00469] A variety of TALEN-based systems have been described in the art, and modifications thereof are regularly reported; see, e.g., Boch, Science 326(5959): 1509-12 (2009); Mak et al. , Science 335(6069):716-9 (2012); and Moscou et al., Science 326(5959): 1501 (2009). The use of TALENs based on the "Golden Gate" platform, or cloning scheme, has been described by multiple groups; see, e.g., Cermak et al. , Nucleic Acids Res. 39(12):e82 (201 1 ); Li et al., Nucleic Acids Res. 39(14):6315-25(201 1 ); Weber et al., PLoS One. 6(2):e16765 (201 1 ); Wang et al., J Genet Genomics 47(6):339-47, Epub 2014 May 17 (2014); and Cermak T et al., Methods Mol Biol. 1239: 133-59 (2015).

[00470] Homing Endonucleases

[00471] Homing endonucleases (HEs) are sequence-specific endonucleases that have long recognition sequences (14-44 base pairs) and cleave DNA with high specificity - often at sites unique in the genome. There are at least six known families of HEs as classified by their structure, including LAGLIDADG (SEQ ID NO:39, 187), GIY-YIG, His-Cis box, H-N-H, PD-(D/E)xK, and Vsr-like that are derived from a broad range of hosts, including eukarya, protists, bacteria, archaea, cyanobacteria and phage. As with ZFNs and TALENs, HEs can be used to create a DSB at a target locus as the initial step in genome editing. In addition, some natural and engineered HEs cut only a single strand of DNA, thereby functioning as site- specific nickases. The large target sequence of HEs and the specificity that they offer have made them attractive candidates to create site-specific DSBs.

[00472] A variety of HE-based systems have been described in the art, and modifications thereof are regularly reported; see, e.g., the reviews by Steentoft et al., Glycobiology 24(8):663-80 (2014); Belfort and Bonocora, Methods Mol Biol. 7723: 1 -26 (2014); Hafez and Hausner, Genome 55(8):553-69 (2012); and references cited therein.

[00473] MegaTAL / Tev-mTALEN / MegaTev

[00474] As further examples of hybrid nucleases, the MegaTAL platform and Tev-mTALEN platform use a fusion of TALE DNA binding domains and catalytically active HEs, taking advantage of both the tunable DNA binding and specificity of the TALE, as well as the cleavage sequence specificity of the HE; see, e.g., Boissel et al., NAR 42: 2591 -2601 (2014); Kleinstiver et al., G3 4: 1 155-65 (2014); and Boissel and Scharenberg, Methods Mol. Biol. 1239: 171 -96 (2015). [00475] In a further variation, the MegaTev architecture is the fusion of a meganuclease (Mega) with the nuclease domain derived from the GIY-YIG homing endonuclease l-Tevl (Tev). The two active sites are positioned -30 bp apart on a DNA substrate and generate two DSBs with non-compatible cohesive ends; see, e.g., Wolfs et al., NAR 42, 8816-29 (2014). It is anticipated that other combinations of existing nuclease-based approaches will evolve and be useful in achieving the targeted genome modifications described herein.

[00476] dCas9-Fokl or dCpfl -Fok1 and Other Nucleases

[00477] Combining the structural and functional properties of the nuclease platforms described above offers a further approach to genome editing that can potentially overcome some of the inherent deficiencies. As an example, the

CRISPR genome editing system typically uses a single Cas9 endonuclease to create a DSB. The specificity of targeting is driven by a 20 or 22 nucleotide sequence in the guide RNA that undergoes Watson-Crick base-pairing with the target DNA (plus an additional 2 bases in the adjacent NAG or NGG PAM sequence in the case of Cas9 from S. pyogenes). Such a sequence is long enough to be unique in the human genome, however, the specificity of the RNA/DNA interaction is not absolute, with significant promiscuity sometimes tolerated, particularly in the 5' half of the target sequence, effectively reducing the number of bases that drive specificity. One solution to this has been to completely deactivate the Cas9 or Cpfl catalytic function - retaining only the RNA-guided DNA binding function - and instead fusing a Fokl domain to the deactivated Cas9; see, e.g., Tsai et al., Nature Biotech 32: 569-76 (2014); and Guilinger et al., Nature Biotech. 32: 577-82 (2014). Because Fokl must dimerize to become catalytically active, two guide RNAs are required to tether two Fokl fusions in close proximity to form the dimer and cleave DNA. This essentially doubles the number of bases in the combined target sites, thereby increasing the stringency of targeting by CRISPR- based systems.

[00478] As further example, fusion of the TALE DNA binding domain to a catalytically active HE, such as l-Tevl , takes advantage of both the tunable DNA binding and specificity of the TALE, as well as the cleavage sequence specificity of l-Tevl, with the expectation that off-target cleavage can be further reduced. [00479] Methods and Compositions of the Invention

[00480] Accordingly, the present disclosure relates in particular to the following non-limiting inventions: In a first method, Method 1 , the present disclosure provides a method for editing a TTR gene in a cell by genome editing, the method comprising the step of: introducing into the cell one or more deoxyribonucleic acid (DNA) endonucleases to effect one or more single-strand breaks (SSBs) or double- strand breaks (DSBs) within or near the TTR gene or other DNA sequences that encode regulatory elements of the TTR gene that results in a permanent insertion, deletion, correction of one or more mutations within or near the TTR gene or other DNA sequences that encode regulatory elements of the TTR gene.

[00481] In another method, Method 2, the present disclosure provides a method for editing a (Transthyretin) TTR gene in a cell by genome editing comprising the step of introducing into the cell one or more deoxyribonucleic acid (DNA) endonucleases to effect one or more single-strand breaks (SSBs) or double-strand breaks (DSBs) within or near the TTR gene or TTR regulatory elements that results in one or more permanent insertions, deletions or mutations of at least one nucleotide within or near the TTR gene, thereby reducing or eliminating the expression or function of TTR gene products.

[00482] In another method, Method 3, the present disclosure provides an ex vivo method for treating a patient with FTA, the method comprising the steps of: i) creating a patient specific induced pluripotent stem cell (iPSC); ii) editing within or near a TTR gene of the iPSC or other DNA sequences that encode regulatory elements of the TTR gene of the iPSC; iii) differentiating the edited iPSC into a hepatocyte; and iv) administering the hepatocyte to the patient.

[00483] In another method, Method 4, the present disclosure provides an ex vivo method for treating a patient with FTA, the method comprising the steps of: i) editing a patient specific induced pluripotent stem cell (iPSC) within or near a TTR gene of the iPSC or other DNA sequences that encode regulatory elements of the TTR gene of the iPSC; iii) differentiating the edited iPSC into a hepatocyte; and iv) administering the hepatocyte to the patient. [00484] In another method, Method 5, the present disclosure provides an ex vivo method as provided in Method 4, further comprising the step of creating a patient specific induced pluripotent stem cell (iPSC).

[00485] In another method, Method 6, the present disclosure provides an ex vivo method as provided in Method 5, wherein the creating step comprises: a) isolating a somatic cell from the patient; and b) introducing a set of pluripotency-associated genes into the somatic cell to induce the somatic cell to become a pluripotent stem cell.

[00486] In another method, Method 7, the present disclosure provides an ex vivo method as provided in Method 6, wherein the somatic cell is a fibroblast.

[00487] In another method, Method 8, the present disclosure provides an ex vivo method as provided in Method 6, wherein the set of pluripotency-associated genes is one or more of the genes selected from the group consisting of OCT4, SOX2, KLF4, Lin28, NANOG and cMYC.

[00488] In another method, Method 9, the present disclosure provides an ex vivo method as provided in any one of Methods 3-8, wherein the editing step comprises introducing into the iPSC one or more deoxyribonucleic acid (DNA) endonucleases to effect one or more single-strand breaks (SSBs) or double-strand breaks (DSBs) within or near the TTR gene or other DNA sequences that encode regulatory elements of the TTR gene that results in a permanent insertion, deletion, correction of one or more mutations within or near the TTR gene or other DNA sequences that encode regulatory elements of the TTR gene.

[00489] In another method, Method 10, the present disclosure provides an ex vivo method as provided in any one of Methods 3-9, wherein the differentiating step comprises one or more of the following to differentiate the genome edited iPSC into a hepatocyte: contacting the edited iPSC with one or more of activin, B27 supplement, FGF4, HGF, BMP2, BMP4, Oncostatin M, Dexametason.

[00490] In another method, Method 1 1 , the present disclosure provides an ex vivo method as provided in any one of Methods 2-7, wherein the administering step comprises administering the hepatocyte to the patient by transplantation, local injection, systemic infusion, or combinations thereof. [00491] In another method, Method 12, the present disclosure provides an ex vivo method for treating a patient with FTA, the method comprising the steps of: i) performing a biopsy of the patient's liver; ii) isolating a liver specific progenitor cell or primary hepatocyte; iii) editing within or near a TTR gene or other DNA sequences that encode regulatory elements of the TTR gene of the progenitor cell or primary hepatocyte; and iv) administering the edited progenitor cell or primary hepatocyte to the patient.

[00492] In another method, Method 13, the present disclosure provides an ex vivo method for treating a patient with FTA, the method comprising the steps of: i) editing a liver specific progenitor cell or primary hepatocyte within or near a TTR gene or other DNA sequences that encode regulatory elements of the TTR gene of a patient specific progenitor cell or a patient specific primary hepatocyte; and ii) administering the edited progenitor cell or primary hepatocyte to the patient.

[00493] In another method, Method 14, the present disclosure provides an ex vivo method for treating a patient with FTA, the method comprising the steps of: i) obtaining a liver specific progenitor cell or primary hepatocyte; ii) editing within or near a TTR gene or other DNA sequences that encode regulatory elements of the TTR gene of a patient specific progenitor cell or a patient specific primary hepatocyte; and iii) administering the edited progenitor cell or primary hepatocyte into the patient.

[00494] In another method, Method 15, the present disclosure provides an ex vivo method as provided in Method 14, wherein the isolating step comprises:

perfusion of fresh liver tissues with digestion enzymes, cell differential

centrifugation, cell culturing, or combinations thereof.

[00495] In another method, Method 16, the present disclosure provides an ex vivo method as provided in any one of Methods 12-15, wherein the editing step comprises introducing into the progenitor cell or primary hepatocyte one or more deoxyribonucleic acid (DNA) endonucleases to effect one or more single-strand breaks (SSBs) or double-strand breaks (DSBs) within or near the TTR gene or other DNA sequences that encode regulatory elements of the TTR gene that results in a permanent insertion, deletion, correction of one or more mutations within or near the TTR gene or other DNA sequences that encode regulatory elements of the TTR gene.

[00496] In another method, Method 17, the present disclosure provides an ex vivo method as provided in any one of Methods 12-15, wherein the editing step comprises introducing into the progenitor cell or primary hepatocyte one or more deoxyribonucleic acid (DNA) endonucleases to effect one or more single-strand breaks (SSBs) or double-strand breaks (DSBs) within or near the TTR gene or other DNA sequences that encode regulatory elements of the TTR gene that results in one or more permanent insertions, deletions or mutations of at least one nucleotide within or near the TTR gene, thereby reducing or eliminating the expression or function of TTR gene products.

[00497] In another method, Method 18, the present disclosure provides an ex vivo method as provided in any one of Methods 12-17, wherein the administering step comprises administering the edited progenitor cell or primary hepatocyte to the patient by transplantation, local injection, systemic infusion, or combinations thereof.

[00498] In another method, Method 19, the present disclosure provides an ex vivo method for treating a patient with FTA, the method comprising the steps of: i) isolating a mesenchymal stem cell from the patient; ii) editing within or near a TTR gene or other DNA sequences that encode regulatory elements of the TTR gene of the mesenchymal stem cell; iii) differentiating the edited mesenchymal stem cell into a hepatocyte; and iv) administering the hepatocyte to the patient.

[00499] In another method, Method 20, the present disclosure provides an ex vivo method for treating a patient with FTA, the method comprising the steps of: i) editing a mesenchymal stem cell within or near a TTR gene or other DNA sequences that encode regulatory elements of the TTR gene of a mesenchymal stem cell; ii) differentiating the edited mesenchymal stem cell into a hepatocyte; and iii) administering the hepatocyte to the patient.

[00500] In another method, Method 21 , the present disclosure provides an ex vivo method as provided in Method 20, further comprising the step of isolating the mesenchymal cell from the patient. [00501] In another method, Method 22, the present disclosure provides an ex vivo method as provided in Method 21 , wherein the mesenchymal stem cell is isolated from the patient's bone marrow or peripheral blood.

[00502] In another method, Method 23, the present disclosure provides an ex vivo method as provided in any one of Methods 21 -22, wherein the isolating step comprises: aspiration of bone marrow and isolation of mesenchymal cells by density centrifugation using Percoll™.

[00503] In another method, Method 24, the present disclosure provides an ex vivo method as provided in any one of Methods 19-23, wherein the editing step comprises introducing into the mesenchymal stem cell one or more

deoxyribonucleic acid (DNA) endonucleases to effect one or more single-strand breaks (SSBs) or double-strand breaks (DSBs) within or near the TTR gene or other DNA sequences that encode regulatory elements of the TTR gene that results in a permanent insertion, deletion, correction of one or more mutations within or near the TTR gene or other DNA sequences that encode regulatory elements of the TTR gene.

[00504] In another method, Method 25, the present disclosure provides an ex vivo method as provided in any one of Methods 19-23, wherein the editing step comprises introducing into the mesenchymal stem cell one or more

deoxyribonucleic acid (DNA) endonucleases to effect one or more single-strand breaks (SSBs) or double-strand breaks (DSBs) within or near the TTR gene or other DNA sequences that encode regulatory elements of the TTR gene that results in one or more permanent insertions, deletions or mutations of at least one nucleotide within or near the TTR gene, thereby reducing or eliminating the expression or function of TTR gene products.

[00505] In another method, Method 26, the present disclosure provides an ex vivo method as provided in any one of Methods 19-25, wherein the differentiating step comprises one or more of the following to differentiate the edited

mesenchymal stem cell into a hepatocyte: contacting the edited stem cell with one or more of insulin, transferrin, FGF4, HGF, or bile acids.

[00506] In another method, Method 27, the present disclosure provides an ex vivo method for treating a patient with Familial Transthyretin Amyloidosis (FTA), the method comprising the steps of: i) isolating a liver progenitor cell or primary hepatocyte from the patient; ii) editing within or near a TTR gene of the liver progenitor cell or primary hepatocyte or other DNA sequences that encode regulatory elements of the TTR gene of the liver progenitor cell or primary hepatocyte; and iii) administering the edited liver progenitor cell or primary hepatocyte to the patient.

[00507] In another method, Method 28, the present disclosure provides the method of Method 27, wherein the editing step comprises introducing into the hematopoietic progenitor cell one or more deoxyribonucleic acid (DNA)

endonucleases to effect one or more single-strand breaks (SSBs) or double-strand breaks (DSBs) within or near the TTR gene or other DNA sequences that encode regulatory elements of the TTR gene that results in a permanent insertion, deletion, correction of one or more mutations within or near the TTR gene or other DNA sequences that encode regulatory elements of the TTR gene.

[00508] In another method, Method 29, the present disclosure provides an ex vivo method as provided in any one of Methods 19-28, wherein the administering step comprises administering the hepatocyte to the patient by transplantation, local injection, systemic infusion, or combinations thereof.

[00509] In another method, Method 30, the present disclosure provides an in vivo method for treating a patient with FTA, the method comprising the step of editing a TTR gene or other DNA sequences that encode regulatory elements of the TTR gene in a cell of the patient.

[00510] In another method, Method 31 , the present disclosure provides an in vivo method as provided in Method 30, wherein the editing step comprises introducing into the cell one or more deoxyribonucleic acid (DNA) endonucleases to effect one or more single-strand breaks (SSBs) or double-strand breaks (DSBs) within or near the TTR gene or other DNA sequences that encode regulatory elements of the TTR gene that results in a permanent insertion, deletion, correction of one or more mutations within or near the TTR gene or other DNA sequences that encode regulatory elements of the TTR gene.

[00511] In another method, Method 32, the present disclosure provides an in vivo method as provided in Method 30, wherein the editing step comprises introducing into the cell one or more deoxyribonucleic acid (DNA) endonucleases to effect one or more single-strand breaks (SSBs) or double-strand breaks (DSBs) within or near the TTR gene or other DNA sequences that encode regulatory elements of the TTR gene that results in one or more permanent insertions, deletions or mutations of at least one nucleotide within or near the TTR gene, thereby reducing or eliminating the expression or function of TTR gene products.

[00512] In another method, Method 33, the present disclosure provides a method as provided in any one of Methods 1 , 2, 9, 16, 17, 24, 25, 28, 31 , or 32, wherein the one or more DNA endonucleases is a Cas9 or CPf1 endonuclease; or a homolog thereof, recombination of the naturally occurring molecule, codon- optimized, or modified version thereof, and combinations thereof.

[00513] In another method, Method 34, the present disclosure provides a method as provided in Method 33, wherein the method comprises introducing into the cell one or more polynucleotides encoding the one or more DNA

endonucleases.

[00514] In another method, Method 35, the present disclosure provides a method as provided in Method 33, wherein the method comprises introducing into the cell one or more ribonucleic acids (RNAs) encoding the one or more DNA endonucleases.

[00515] In another method, Method 36, the present disclosure provides a method as provided in any one of Methods 34-35, wherein the one or more polynucleotides or one or more RNAs is one or more modified polynucleotides or one or more modified RNAs.

[00516] In another method, Method 37, the present disclosure provides a method as provided in Method 33, wherein the method comprises introducing into the cell one or more DNA endonucleases wherein the endonuclease is a protein or polypeptide.

[00517] In another method, Method 38, the present disclosure provides a method as provided in any one of the preceding Methods 1 -37, wherein the method further comprises introducing into the cell one or more guide ribonucleic acids (gRNAs). [00518] In another method, Method 39, the present disclosure provides a method as provided in Method 38, wherein the one or more gRNAs are single- molecule guide RNA (sgRNAs).

[00519] In another method, Method 40, the present disclosure provides a method as provided in any one of Methods 38-39, wherein the one or more gRNAs or one or more sgRNAs is one or more modified gRNAs or one or more modified sgRNAs.

[00520] In another method, Method 41 , the present disclosure provides a method as provided in any one of Methods 38-40, wherein the one or more DNA endonucleases is pre-complexed with one or more gRNAs or one or more sgRNAs.

[00521] In another method, Method 42, the present disclosure provides a method as provided in any one of the preceding Methods 1 -41 , wherein the method further comprises introducing into the cell a polynucleotide donor template comprising at least a portion of the wild-type TTR gene or cDNA.

[00522] In another method, Method 43, the present disclosure provides a method as provided in Method 42, wherein the at least a portion of the wild-type TTR gene or minigene or cDNA is some or all of intron 1 , exon 1 , some or all of intron 2, exon 2, some or all of intron 3, exon 3, some or all of intron 4, exon 4, intronic regions, fragments or combinations thereof, or the entire TTR gene, DNA sequences that encode wild type regulatory elements of the TTR gene, minigene, or cDNA.

[00523] In another method, Method 44, the present disclosure provides a method as provided in any one of Methods 42-43, wherein the donor template is either a single or double stranded polynucleotide.

[00524] In another method, Method 45, the present disclosure provides a method as provided in any one of Methods 42-44, wherein the donor template has homologous arms to the 18q12.1 region.

[00525] In another method, Method 46, the present disclosure provides a method as provided in any one of Methods 1 , 2, 9, 16, 17, 24, 25, 28, 31 , or 32, wherein the method further comprises introducing into the cell one guide

ribonucleic acid (gRNA) and a polynucleotide donor template comprising at least a portion of the wild-type TTR gene, and wherein the one or more DNA

endonucleases is one or more Cas9 or Cpf1 endonucleases that effect one single- strand break (SSB) or double-strand break (DSB) at a locus within or near the TTR gene or other DNA sequences that encode regulatory elements of the TTR gene that facilitates insertion of a new sequence from the polynucleotide donor template into the chromosomal DNA at the locus that results in a permanent insertion or correction of a part of the chromosomal DNA of the TTR gene or other DNA sequences that encode regulatory elements of the TTR gene proximal to the locus and restoration of TTR protein activity, and wherein the gRNA comprises a spacer sequence that is complementary to a segment of the locus.

[00526] In another method, Method 47, the present disclosure provides a method as provided in Method 46, wherein proximal means nucleotides both upstream and downstream of the locus.

[00527] In another method, Method 48, the present disclosure provides a method as provided in any one of Methods 1 , 2, 9, 16, 17, 24, 25, 28, 31 , or 32, wherein the method further comprises introducing into the cell two guide ribonucleic acid (gRNAs) and a polynucleotide donor template comprising at least a portion of the wild-type TTR gene, and wherein the one or more DNA endonucleases is two or more Cas9 or Cpf1 endonucleases that effect a pair of single-strand breaks (SSBs) or double-strand breaks (DSBs), the first at a 5' locus and the second at a 3' locus, within or near the TTR gene or other DNA sequences that encode regulatory elements of the TTR gene that facilitates insertion of a new sequence from the polynucleotide donor template into the chromosomal DNA between the 5' locus and the 3' locus that results in a permanent insertion or correction of the chromosomal DNA between the 5' locus and the 3' locus within or near the TTR gene or other DNA sequences that encode regulatory elements of the TTR gene and restoration of TTR protein activity, and wherein the first guide RNA comprises a spacer sequence that is complementary to a segment of the 5' locus and the second guide RNA comprises a spacer sequence that is complementary to a segment of the 3' locus. [00528] In another method, Method 49, the present disclosure provides a method as provided in any one of Methods 46-48, wherein the one or two gRNAs are one or two single-molecule guide RNA (sgRNAs).

[00529] In another method, Method 50, the present disclosure provides a method as provided in any one of Methods 46-49, wherein the one or two gRNAs or one or two sgRNAs is one or two modified gRNAs or one or two modified sgRNAs.

[00530] In another method, Method 51 , the present disclosure provides a method as provided in any one of Methods 46-50, wherein the one or more DNA endonucleases is pre-complexed with one or two gRNAs or one or two sgRNAs.

[00531] In another method, Method 52, the present disclosure provides a method as provided in any one of Methods 46-51 , wherein the at least a portion of the wild-type TTR gene or cDNA is some or all of intron 1 , exon 1 , some or all of intron 2, exon 2, some or all of intron 3, exon 3, some or all of intron 4, exon 4, intronic regions, fragments or combinations thereof, or the entire TTR gene, DNA sequences that encode wild type regulatory elements of the TTR gene, minigene, or cDNA.

[00532] In another method, Method 53, the present disclosure provides a method as provided in any one of Methods 46-52, wherein the donor template is either a single or double stranded polynucleotide.

[00533] In another method, Method 54, the present disclosure provides a method as provided in any one of Methods 46-53, wherein the donor template has homologous arms to the 18q12.1 region.

[00534] In another method, Method 55, the present disclosure provides a method as provided in Method 52, wherein the locus, 5' locus and 3' locus are in the first, second, third, fourth exon or introns of the TTR gene.

[00535] In another method, Method 56, the present disclosure provides a method as provided in any one of Methods 1 , 2, 9, 16, 17, 24, 25, 28, 31 , or 32-51 , wherein the gRNA or sgRNA is directed to one or more of the following pathological variants: T60A, L1 1 1 M, V122I or other variant listed in Table 1 . [00536] In another method, Method 57, the present disclosure provides a method as provided in any one of Methods 1 , 2, 9, 16, 17, 24, 25, 28, 31 , or 32-56, wherein the insertion or correction is by homology directed repair (HDR) or nonhomologous end-joining (NHEJ).

[00537] In another method, Method 58, the present disclosure provides a method as provided in any one of Methods 1 , 2, 9, 16, 17, 24, 25, 28, 31 , or 32, wherein the method further comprises introducing into the cell two guide ribonucleic acid (gRNAs), and wherein the one or more DNA endonucleases is two or more Cas9 or Cpf1 endonucleases that effect a pair of double-strand breaks (DSBs), the first at a 5' locus and the second at a 3' locus, within or near the TTR gene or other DNA sequences that encode regulatory elements of the TTR gene that causes a deletion of the chromosomal DNA between the 5' locus and the 3' locus that results in a permanent deletion of the chromosomal DNA between the 5' locus and the 3' locus within or near the TTR gene or other DNA sequences that encode regulatory elements of the TTR gene, and wherein the first guide RNA comprises a spacer sequence that is complementary to a segment of the 5' locus and the second guide RNA comprises a spacer sequence that is complementary to a segment of the 3' locus.

[00538] In another method, Method 59, the present disclosure provides a method as provided in Method 58, wherein the two gRNAs are two single-molecule guide RNA (sgRNAs).

[00539] In another method, Method 60, the present disclosure provides a method as provided in Methods 57 or 58 wherein the two gRNAs or two sgRNAs are two modified gRNAs or two modified sgRNAs.

[00540] In another method, Method 61 , the present disclosure provides a method as provided in any one of Methods 57-60, wherein the one or more DNA endonucleases is pre-complexed with one or two gRNAs or one or two sgRNAs.

[00541] In another method, Method 62, the present disclosure provides a method as provided in any one of Methods 57-61 , wherein both the 5' locus and 3' locus are in or near either the first exon, first intron, second exon, second intron, third exon, third intron, or fourth exon of the TTR gene. [00542] In another method, Method 63, the present disclosure provides the method of any one of Method 57-62, wherein the deletion is a deletion of 1 kb or less.

[00543] In another method, Method 64, the present disclosure provides a method as provided in any one of Methods 1 , 2, 9, 16, 17, 24, 25, 28, 31 , or 32-63, wherein the Cas9 or Cpf1 mRNA, gRNA, and donor template are either each formulated into separate lipid nanoparticles or all co-formulated into a lipid nanoparticle.

[00544] In another method, Method 65, the present disclosure provides a method as provided in any one of Methods 1 , 2, 9, 16, 17, 24, 25, 28, 31 , or 32-63, wherein the Cas9 or Cpf1 mRNA, and gRNA are either each formulated into separate lipid nanoparticles or all co-formulated into a lipid nanoparticle.

[00545] In another method, Method 66, the present disclosure provides a method as provided in any one of Methods 1 , 2, 9, 16, 17, 24, 25, 28, 31 , or 32-63, wherein the Cas9 or Cpfl mRNA is formulated into a lipid nanoparticle, and both the gRNA and donor template are delivered to the cell by a viral vector.

[00546] In another method, Method 67, the present disclosure provides a method as provided in any one of Methods 1 , 2, 9, 16, 17, 24, 25, 28, 31 , or 32-63, wherein the Cas9 or Cpf1 mRNA is formulated into a lipid nanoparticle, and the gRNA is delivered to the cell by a viral vector.

[00547] In another method, Method 68, the present disclosure provides the method of Method 67, wherein the viral vector is an adeno-associated virus (AAV) vector.

[00548] In another method, Method 69, the present disclosure provides the method of Method 68, wherein the AAV vector is an adeno-associated virus (AAV) vector.

[00549] In another method, Method 70, the present disclosure provides the method of any one of Methods 1 , 2, 9, 16, 17, 24, 25, 28, 31 , or 32-63, wherein the Cas9 or Cpf1 mRNA, gRNA and a donor template are either each formulated into separate exosomes or all co-formulated into an exosome. [00550] In another method, Method 71 , the present disclosure provides the method of any one of Methods 1 , 2, 9, 16, 17, 24, 25, 28, 31 , or 32-63, wherein the Cas9 or Cpf1 mRNA, and gRNA are either each formulated into separate exosomes or all co-formulated into an exosome.

[00551] In another method, Method 72, the present disclosure provides a method as provided in any one of Methods 1 , 2, 9, 16, 17, 24, 25, 28, 31 , or 32-63, wherein the Cas9 or Cpf1 mRNA is formulated into a lipid nanoparticle, and the gRNA is delivered to the cell by electroporation.

[00552] In another method, Method 73, the present disclosure provides a method as provided in any one of Methods 1 , 2, 9, 16, 17, 24, 25, 28, 31 , or 32-63, wherein the Cas9 or Cpf1 mRNA is formulated into a lipid nanoparticle, and the gRNA is delivered to the cell by electroporation and donor template is delivered to the cell by a viral vector.

[00553] In another method, Method 74, the present disclosure provides the method of Method 73, wherein the viral vector is an adeno-associated virus (AAV) vector.

[00554] In another method, Method 75, the present disclosure provides the method of Method 74, wherein the AAV vector is an adeno-associated virus (AAV) vector.

[00555] In another method, Method 76, the present disclosure provides a method as provided in any one of the preceding Methods provided herein, wherein the TTR gene is located on Chromosome 18q12.1 (Genomic coordinates (GRCh38: 18:31 ,591 ,766-31 ,599,023).

[00556] In another method, Method 77, the present disclosure provides a method as provided in any one of Methods 1 , 2, 9, 16, 17, 24, 25, 28, 31 , or 32-63, wherein TTR protein activity is deleted or is restored to wild-type, non-mutated normal or reduced amyloid-forming activity.

[00557] In another method, Method 78, the present disclosure provides a method, wherein TTR is deleted TTR simultaneously with homogentisate 1 ,2- dioxygenase (HGD) (for example, by co-delivery of gRNAs). HGD-/- hepatocytes have proliferation advantage when FAH activity is absent or reduced. Inhibition of fumarylacetoacetate hydrolase (FAH) can be achieved by treatment with shRNA (AAV) targeting FAH, or siRNA (LNP formulated, or conjugate with GalNAc, or with cholesterol) or treatment with CEHPOBA (Paulk et a/., Mol Ther. 2012 Oct; 20(10): 1981 -1987). For GalNAc conjugation, see, e.g., US Patents Nos. 8,288,958 and 8, 106,022.

[00558] In another method, Method 79, the present disclosure provides a method, wherein TTR cDNA is knocked-in into the first exon of HGD, leading to disruption of HGD expression. HGD -/- hepatocytes have proliferation advantage when FAH activity is absent or reduced. Inhibition of FAH can be achieved by treatment with shRNA (AAV) targeting FAH, or siRNA (DVL formulated, or conjugate with GalNAc, or with cholesterol) or treatment with CEHPOBA (Paulk et a/., 2012, supra).

[00559] In another method, Method 80, the present disclosure provides a method of correcting a TTR gene, the method comprising knocking-in a nucleic acid sequence that encodes a corrected TTR gene product into the TTR gene and/or any one of the safe harbor sites selected from AAVS1 , HRPT, CCR5, Globin, TF, F9, Alb, Gys2, and PCSK9.

[00560] In another method, Method 90, the present disclosure provides a method of any one of the preceding methods, wherein the TTR gene is operably linked to an exogenous promoter that drives expression of the TTR gene.

[00561] In another method, Method 91 , the present disclosure provides a method of any one of the preceding methods, wherein the one or more loci occurs at a location immediately 3' to an endogenous promoter locus.

[00562] In another method, Method 92, the present disclosure provides a method of any one of the preceding methods, wherein the donor contains one or more target sites for the endonuclease:gRNA.

[00563] In another method, Method 93, the present disclosure provides a method of any one of the preceding methods, wherein the donor molecule or a molecule derived from the donor molecule is cleaved one or more times by the endonuclease:gRNA. [00564] In another method, Method 94, the present disclosure provides a method of Method 1 , wherein the cell is a human cell.

[00565] In another method, Method 95, the present disclosure provides a method of Method 94, wherein the human cell is selected from a group consisting of a hepatocyte, a cell from hypothalamus, a cell from thalamus, a cell from kidney, a cell from retinal epithelium, and a cell from pancreas.

[00566] In another method, Method 96, the present disclosure provides a method of Method 30, wherein the cell is selected from a group consisting of a hepatocyte, a cell from hypothalamus, a cell from thalamus, a cell from kidney, a cell from retinal epithelium, and a cell from pancreas.

[00567] In a first composition, Composition 1 , the present disclosure provides one or more guide ribonucleic acids (gRNAs) for editing a TTR gene in a cell, wherein the one or more gRNAs comprises a spacer sequence selected from the group consisting of nucleic acid sequences in SEQ ID NOs: 1 -8,669 and SEQ I D NOs: 8,770-39, 185 .

[00568] In a first composition, Composition 2, the present disclosure provides one or more guide ribonucleic acids (gRNAs) for editing a TTR gene in a cell from a patient with FTA, wherein the one or more gRNAs comprises a spacer sequence selected from the group consisting of nucleic acid sequences in SEQ ID NOs: 1 - 8,669 and SEQ ID NOs: 8,770-39, 185.

[00569] In another composition, Composition 3, the present disclosure provides a composition as provided in Compositions 1 or 2, wherein the one or more gRNAs are one or more single-molecule guide RNAs (sgRNAs).

[00570] In another composition, Composition 4, the present disclosure provides a composition as provided in any one of Compositions 1 -3, wherein the one or more gRNAs or one or more sgRNAs is one or more modified gRNAs or one or more modified sgRNAs.

[00571] In another composition, Composition 5, the present disclosure provides one or more guide ribonucleic acids (gRNAs) for editing a TTR gene in a cell, the one or more gRNAs comprising a spacer sequence selected from the group consisting of nucleic acid sequences in SEQ ID NOs: 1 -8,669. [00572] In another composition, Composition 6, the present disclosure provides a composition as provided in Composition 5, wherein the one or more gRNAs are one or more single-molecule guide RNAs (sgRNAs).

[00573] In another composition, Composition 7, the present disclosure provides a composition as provided in any of Compositions 5-6, wherein the one or more gRNAs or one or more sgRNAs is one or more modified gRNAs or one or more modified sgRNAs.

[00574] In another composition, Composition 8, the present disclosure provides one or more guide ribonucleic acids (gRNAs) for editing a TTR gene in a cell, the one or more gRNAs comprising a spacer sequence selected from the group consisting of nucleic acid sequences in SEQ ID NOs: 8,770-39, 185.

[00575] In another composition, Composition 9, the present disclosure provides a composition as provided in Composition 8, wherein the one or more gRNAs are one or more single-molecule guide RNAs (sgRNAs).

[00576] In another composition, Composition 10, the present disclosure provides a composition as provided in any of Compositions 8-9, wherein the one or more gRNAs or one or more sgRNAs is one or more modified gRNAs or one or more modified sgRNAs.

[00577] Definitions

[00578] The term "comprising" or "comprises" is used in reference to

compositions, methods, and respective component(s) thereof, that are essential to the invention, yet open to the inclusion of unspecified elements, whether essential or not.

[00579] The term "consisting essentially of" refers to those elements required for a given aspect. The term permits the presence of additional elements that do not materially affect the basic and novel or functional characteristic(s) of that aspect of the invention.

[00580] The term "consisting of" refers to compositions, methods, and respective components thereof as described herein, which are exclusive of any element not recited in that description of the aspect. [00581] The singular forms "a," "an," and "the" include plural references, unless the context clearly dictates otherwise.

[00582] Certain numerical values presented herein are preceded by the term "about." The term "about" is used to provide literal support for the numerical value the term "about" precedes, as well as a numerical value that is approximately the numerical value, that is the approximating unrecited numerical value may be a number which, in the context it is presented, is the substantial equivalent of the specifically recited numerical value. The term "about" means numerical values within +10% of the recited numerical value.

[00583] When a range of numerical values is presented herein, it is

contemplated that each intervening value between the lower and upper limit of the range, the values that are the upper and lower limits of the range, and all stated values with the range are encompassed within the disclosure. All the possible subranges within the lower and upper limits of the range are also contemplated by the disclosure.

[00584] The details of one or more embodiments of the invention are set forth in the accompanying description below. Although any materials and methods similar or equivalent to those described herein can be used in the practice or testing of the present disclosure, the preferred materials and methods are now described. Other features, objects and advantages of the invention will be apparent from the description. In the description, the singular forms also include the plural unless the context clearly dictates otherwise. Unless defined otherwise, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this invention belongs. In the case of conflict, the present description will control.

[00585] Any numerical range recited in this specification describes all subranges of the same numerical precision (i.e., having the same number of specified digits) subsumed within the recited range. For example, a recited range of "1 .0 to 10.0" describes all sub-ranges between (and including) the recited minimum value of 1 .0 and the recited maximum value of 10.0, such as, for example, "2.4 to 7.6," even if the range of "2.4 to 7.6" is not expressly recited in the text of the

specification. Accordingly, the Applicant reserves the right to amend this specification, including the claims, to expressly recite any sub-range of the same numerical precision subsumed within the ranges expressly recited in this specification. All such ranges are inherently described in this specification such that amending to expressly recite any such sub-ranges will comply with written description, sufficiency of description, and added matter requirements, including the requirements under 35 U.S.C. § 1 12(a) and Article 123(2) EPC. Also, unless expressly specified or otherwise required by context, all numerical parameters described in this specification (such as those expressing values, ranges, amounts, percentages, and the like) may be read as if prefaced by the word "about," even if the word "about" does not expressly appear before a number. Additionally, numerical parameters described in this specification should be construed in light of the number of reported significant digits, numerical precision, and by applying ordinary rounding techniques. It is also understood that numerical parameters described in this specification will necessarily possess the inherent variability characteristic of the underlying measurement techniques used to determine the numerical value of the parameter.

[00586] The details of one or more aspects of the present disclosure are set forth in the accompanying description below. Although any materials and methods similar or equivalent to those described herein can be used in the practice or testing of the present disclosure, the preferred materials and methods are now described. Other features, objects and advantages of the disclosure will be apparent from the description. In the description, the singular forms also include the plural unless the context clearly dictates otherwise. Unless defined otherwise, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this disclosure belongs. In the case of conflict, the present description will control.

[00587] The present invention is further illustrated by the following non-limiting examples.

Examples

[00588] The invention will be more fully understood by reference to the following examples, which provide illustrative non-limiting aspects of the invention. [00589] The examples describe the use of the CRISPR system as an illustrative genome editing technique to create defined therapeutic genomic insertions or replacements, termed "genomic modifications" herein, in the TTR gene that lead to permanent deletion or correction of mutations in the genomic locus, or expression at a heterologous locus, that reduce or eliminate TTR protein aggregation.

Introduction of the defined therapeutic modifications represents a novel therapeutic strategy for the potential amelioration of FTA, as described and illustrated herein.

Example 1 - CRISPR/SpCas9 target sites for the TTR gene

[00590] Regions of the TTR gene were scanned for target sites. Each area was scanned for a protospacer adjacent motif (PAM) having the sequence NRG. gRNA 20 bp spacer sequences corresponding to the PAM were identified, as shown in SEQ ID NOs: 1 -3,352.

Example 2 - CRISPR/SaCas9 target sites for the TTR gene

[00591] Regions of the TTR gene were scanned for target sites. Each area was scanned for a protospacer adjacent motif (PAM) having the sequence NNGRRT. gRNA 20 bp spacer sequences corresponding to the PAM were identified, as shown in SEQ ID NOs: 3,353-3,763.

Example 3 - CRISPR/StCas9 target sites for the TTR gene

[00592] Regions of the TTR gene were scanned for target sites. Each area was scanned for a protospacer adjacent motif (PAM) having the sequence NNAGAAW. gRNA 20 bp spacer sequences corresponding to the PAM were identified, as shown in SEQ ID NOs: 3,764-4, 1 12.

Example 4 - CRISPR/TdCas9 target sites for the TTR gene

[00593] Regions of the TTR gene were scanned for target sites. Each area was scanned for a protospacer adjacent motif (PAM) having the sequence NAAAAC. gRNA 20 bp spacer sequences corresponding to the PAM were identified, as shown in SEQ ID NOs: 4, 1 13-4,247.

Example 5 - CRISPR/NmCas9 target sites for the TTR gene

[00594] Regions of the TTR gene were scanned for target sites. Each area was scanned for a protospacer adjacent motif (PAM) having the sequence NNNNGATT. gRNA 20 bp spacer sequences corresponding to the PAM were identified, as shown in SEQ ID NOs: 4,248-4,301 .

Example 6 - CRISPR/Cpf1 target sites for the TTR gene

[00595] Regions of the TTR gene were scanned for target sites. Each area was scanned for a protospacer adjacent motif (PAM) having the sequence TTN. gRNA 22 bp spacer sequences corresponding to the PAM were identified, as shown in 4,302-8,669.

Example 7 - Bioinformatics analysis of the guide strands

[00596] Candidate guides will be screened and selected in a multi-step process that involves both theoretical binding and experimentally assessed activity at both on and off-target sites. By way of illustration, candidate guides having sequences that match a particular on-target site, such as a site within the TTR gene, with adjacent PAM can be assessed for their potential to cleave at off-target sites having similar sequences, using one or more of a variety of bioinformatics tools available for assessing off-target binding, as described and illustrated in more detail below, in order to assess the likelihood of effects at chromosomal positions other than those intended. Candidates predicted to have relatively lower potential for off-target activity can then be assessed experimentally to measure their on-target activity, and then off-target activities at various sites. Suitable guides have sufficiently high on-target activity to achieve desired levels of gene editing at the selected locus, and relatively lower off-target activity to reduce the likelihood of alterations at other chromosomal loci. The ratio of on-target to off-target activity is often referred to as the "specificity" of a guide.

[00597] For initial screening of predicted off-target activities, there are a number of bioinformatics tools known and publicly available that can be used to predict the most likely off-target sites; and since binding to target sites in the CRISPR/Cas9 or CRISPR/Cpf1 nuclease system is driven by Watson-Crick base pairing between complementary sequences, the degree of dissimilarity (and therefore reduced potential for off-target binding) is essentially related to primary sequence differences: mismatches and bulges, i.e. bases that are changed to a non- complementary base, and insertions or deletions of bases in the potential off-target site relative to the target site. An exemplary bioinformatics tool called COSMI D (CRISPR Off-target Sites with Mismatches, Insertions and Deletions) (available on the web at crispr.bme.gatech.edu) compiles such similarities. Other bioinformatics tools include, but are not limited to, autoCOSMID, and CCTop.

[00598] Bioinformatics were used to minimize off-target cleavage in order to reduce the detrimental effects of mutations and chromosomal rearrangements. Studies on CRISPR/Cas9 systems suggested the possibility of high off-target activity due to nonspecific hybridization of the guide strand to DNA sequences with base pair mismatches and/or bulges, particularly at positions distal from the PAM region. Therefore, it is important to have a bioinformatics tool that can identify potential off-target sites that have insertions and/or deletions between the RNA guide strand and genomic sequences, in addition to base-pair mismatches.

Bioinformatics-based tools based upon the off-target prediction algorithm CCTop were used to search genomes for potential CRISPR off-target sites (CCTop is available on the web at crispr.cos.uni-heidelberg.de/). COSMID output ranked lists of the potential off-target sites based on the number and location of mismatches, allowing more informed choice of target sites, and avoiding the use of sites with more likely off-target cleavage.

[00599] Additional bioinformatics pipelines were employed that weigh the estimated on- and/or off-target activity of gRNA targeting sites in a region. Other features that may be used to predict activity include information about the cell type in question, DNA accessibility, chromatin state, transcription factor binding sites, transcription factor binding data, and other CHIP-seq data. Additional factors are weighed that predict editing efficiency, such as relative positions and directions of pairs of gRNAs, local sequence features and micro-homologies.

Example 8 - Testing of preferred guides in cells for on-target activity

[00600] SpCas9 guides against Exons 1 -4 of TTR (GenBank Accession No. NM_000371 ) were designed using the CCTop protocol (Stemmer, M., Thumberger, T., del Sol Keyer, M., Wittbrodt, J. and Mateo, J.L. CCTop: an intuitive, flexible and reliable CRISPR/Cas9 target prediction tool. PLOS ONE (2015).

doi: 10.1371/journal. pone.0124633) to design gRNA targeting various exons. Some versions of the mRNA for this gene have seven exons. Guides were also designed against full intronic sequences in embodiments where the introns were small, and guides were designed using 100-200bp of intronic sequences flanking these exons for large introns. Also, sequences 500bp upstream from the transcriptional start site of TTR were used for guide design. 329 guides were identified in this region using the NGG PAM. Of these, 192 guides were selected for IVT screening based on their off-Target profiles and location within the TTR gene.

[00601] Single gRNAs can be used for creating indels within the coding sequence of TTR that results in a loss of function. Pairs of guide RNAs can be used to delete exon(s), exon-intron junctions (resulting in aberrant splicing leading to loss of function), or transcriptional and/or translational start sites.

[00602] Several mutations have been identified in TTR that suppress the pathogenic amyloidogenic mutations when present as compound heterozygotes. Potential therapeutic strategy could also potentially involve altering the wildtype allele to one of the more stabilized variants (Sant'Anna et al. , Scientific Reports, 2017), in addition to disrupting the mutant allele. gRNAs can be used to alter the wildtype allele to any of the stable variants by HDR. The amyloid deposits are known to recruit wildtype protein to the aggregates further enhancing the toxic deposits (Liepnieks and Benson, Amyloid, 2009). Insertion of a full-length stable variant sequence into the mutant allele may provide therapeutic benefit by disrupting the expression of the mutant allele and at the same time supplying stable monomers that may resist formation of aggregates.

[00603] gRNA(s) within upstream sequence, within exonl , or intronl can also be used for inserting exogenous genes, i.e., as a safe harbor locus for genes that need to be expressed in hepatocytes.

[00604] To identify a large spectrum of pairs of gRNAs able to edit the cognate DNA target region, an in vitro transcribed (IVT) gRNA screen was conducted. The relevant genomic sequence was submitted for analysis using a gRNA design software. The resulting list of gRNAs were narrowed to a list of about 200 gRNAs based on uniqueness of sequence (only gRNAs without a perfect match

somewhere else in the genome were screened) and minimal predicted off targets. This set of gRNAs were in vitro transcribed, and transfected using Lipofectamine MessengerMAX into HEK293T cells that constitutively express Cas9. Cells were harvested 48 hours post transfection, the genomic DNA was isolated, and cutting efficiency was evaluated using TIDE analysis (Figures 2-4).

[00605] gRNA with significant activity can then be followed up in cultured cells to measure correction of the TTR mutation. Off-target events can be followed again. A variety of cells can be transfected and the level of gene editing and possible off- target events measured. These experiments allow optimization of nuclease and donor design and delivery.

TABLE 5. gRNA sequences and cutting efficiencies in HEK293T cells

SEQ

Target Sequence Indel

ID Guide Name PAM

(20mer) (%)

NO:

3023 TTR Up Int2 T112 ACACAAATACCAGTCCAGCA AGG 98 0.9923

539 TTR Up Int2 T69 GGCCGTGCATGTGTTCAGAA AGG 97.6 0.9898

2874 TTR Up Int2 T80 GCCTCTCTCTACCAAGTGAG GGG 96.8 0.9774

3043 TTR_Up_Int2_T62 ATACTCACTTCTCCTGAGCT AGG 95.4 0.9897

2656 TTR Int2 Int3 Tl AGTCTGGATTAAGTTACGCA TGG 95.4 0.97

2948 TTR Up Int2 T64 GATGTAATGTACCATACATA GGG 95 0.9698

2933 TTR Up Int2 T63 AGACACACTGCTATCAACCA GGG 95 0.9764

536 TTR Up Int2 T85 AGGCAGTCCTGCCATCAATG TGG 93.4 0.9865

3080 TTR_Up_Int2_T56 GATGGATCCATGGGTCAACA AGG 92.8 0.9917

830 TTR Int2 Int3 T5 CTACTTCTGACTTAGTTGAG GGG 91.3 0.9904

2986 TTR Up Int2 T58 CCTAATGCACCAAAGCAATG AGG 91.2 0.9837

555 TTR Up Int2 T48 GCCCCTCACTTGGTAGAGAG AGG 91.1 0.94

534 TTR Up Int2 T7 AAAGTTCTAGATGCTGTCCG AGG 90.9 0.9837

3011 TTR Up Int2 T60 TTAGCGTGAATCTTAAATGT AGG 90.6 0.9783

860 TTR Int2 Int3 T22 AGACACCAAATCTTACTGGA AGG 90.5 0.9635

870 TTR Int2 Int3 T2 GTGAGTATACAGACCTTCGA GGG 89.9 0.9669

2876 TTR_Up_Int2_T33 CTACCAAGTGAGGGGCAAAC GGG 89.3 0.9507

2872 TTR Up Int2 T47 GAGCCTCTCTCTACCAAGTG AGG 89.3 0.976

2667 TTR Int2 Int3 Til CCTCAACTAAGTCAGAAGTA GGG 89.2 0.9759

506 TTR Up Int2 T133 AACAAAGCAACTGTTCTCAG GGG 89 0.9906

541 TTR_Up_Int2_T86 AAAGGCTGCTGATGACACCT GGG 88.9 0.9519

3035 TTR Up Int2 T54 GCCATCCTGCCAAGAATGAG TGG 88.7 0.981

3017 TTR Up Int2 T16 TCACAGAAACACTCACCGTA GGG 88 0.9559

2893 TTR Up Int2 T97 AGCCTTTCTGAACACATGCA CGG 87.7 0.9815

2969 TTR_Up_Int2_T127 ATACGTTTTGAATAACTATA GGG 87.5 0.975

2875 TTR_Up_Int2_T79 TCTACCAAGTGAGGGGCAAA CGG 87.2 0.9573

433 TTR Up Int2 T71 TGTGTCTGAGGCTGGCCCTA CGG 86.9 0.9593

496 TTR Up Int2 T120 GCAACAACTAAAATGATCTC AGG 86.5 0.9478

526 TTR Up Int2 T34 CACGTGTCTTCTCTACACCC AGG 86 0.9715 394 TTR_Up_Int2_T123 AGACAAGGTTCATATTTGTA TGG 85.3 0.8955

884 TTR Int2 Int3 T25 GGAAGGTGATGAATGACCAA AGG 85.3 0.9217

2650 TTR Int2 Int3 T29 ATGCAGCTCTCCAGACTCAC TGG 83.4 0.9584

521 TTR Up Int2 T19 ACACTTACGTTCCTGATAAT GGG 82.7 0.9592

383 TTR Up Int2 T26 TTAGTGCACGCAGTCACACA GGG 81.4 0.8835

856 TTR Int2 Int3 T33 TGTAGAAGGGATATACAAAG TGG 81.1 0.9698

854 TTR Int2 Int3 T37 CTGAGGAGGAATTTGTAGAA GGG 81 0.9321

2974 TTR Up Int2 T65 CCCCCAAATACATTTTATGG AGG 80.5 0.9692

566 TTR_Up_Int2_T22 AGGTCAAGTATGCCCTCTGA AGG 80.5 0.9728

560 TTR Up Int2 Till ACAAGTAGATTGAAAAACGT AGG 79.9 0.9134

491 TTR Up Int2 T99 ATTTTATAACAACTGGTAAG AGG 79.6 0.9821

406 TTR Up Int2 T70 GGTTTGCAGTCAGATTGGCA GGG 79.1 0.8447

869 TTR Int2 Int3 T9 GGTGAGTATACAGACCTTCG AGG 79.1 0.9399

2549 TTR Int3 Int4 T5 AACAGAGCACGTTACAAATG TGG 79 0.9217

1198 TTR Int6 Int7 T2 GGAGACTTGCCTTCCTACTA TGG 79 0.9574

3026 TTR Up Int2 T94 ATACCAGTCCAGCAAGGCAG AGG 78.7 0.8805

498 TTR Up Int2 T4 AACCTGTTTGGCCCTATGTA TGG 78.7 0.979

2250 TTR Int6 Int7 Tl CTGATGGAACCATAGTAGGA AGG 78.7 0.9733

359 TTR Up Int2 T122 ACTTAGTTTGGCTAAAATGT AGG 78.5 0.7898

865 TTR Int2 Int3 T16 CCCATTCCATGAGCATGCAG AGG 77.6 0.9133

514 TTR Up Int2 T67 GGCAGAAACCATTCTTGCTT TGG 77.3 0.8655

2633 TTR Int2 Int3 T21 GAGTAAAACTGTGCATTTCC TGG 77.1 0.9387

2630 TTR Int2 Int3 T19 GGTCATTCATCACCTTCCTT AGG 76.9 0.9313

2618 TTR Int2 Int3 T15 GTTCAAGTCATGTTACTAAG TGG 76.5 0.9466

2882 TTR Up Int2 T96 ATAAAACCAAGTCCTGTGGG AGG 76.4 0.9803

2640 TTR Int2 Int3 T26 CTCTGCATGCTCATGGAATG GGG 76 0.9271

971 TTR Int3 Int4 T7 ACTATTCTCTGGCTTAGTCA TGG 75.9 0.8966

2932 TTR Up Int2 T29 CAGACACACTGCTATCAACC AGG 75.2 0.9559

497 TTR Up Int2 T103 TGATCTCAGGAAAACCTGTT TGG 74.8 0.8801

563 TTR_Up_Int2_T100 AGATTGAAAAACGTAGGCAG AGG 74.8 0.8874

395 TTR Up Int2 T113 GACAAGGTTCATATTTGTAT GGG 74.4 0.8581

2995 TTR Up Int2 T75 TCCCAGCTCAGTAAGCTCAG TGG 73.8 0.7466

2894 TTR Up Int2 Til CACATGCACGGCCACATTGA TGG 73.7 0.88

3036 TTR_Up_Int2_T50 GAATGAGTGGACTTCTGTGA TGG 73.5 0.8295

3003 TTR_Up_Int2_T30 CCCTAGTAATAAAAGCTGGT TGG 73.1 0.9689

2887 TTR Up Int2 T39 TTCTTTGGCAACTTACCCAG AGG 71.9 0.9224

3073 TTR Up Int2 T17 TGAATGACATCTAGCTGCAC AGG 71.3 0.923

540 TTR Up Int2 T78 GAAAGGCTGCTGATGACACC TGG 70.6 0.87

527 TTR_Up_Int2_T114 ACGTGTCTTCTCTACACCCA GGG 70.5 0.8144

3077 TTR Up Int2 T21 GTTTGCACTTGATGGATCCA TGG 69.8 0.76

455 TTR Up Int2 T68 AGCATTCTACCTCATTGCTT TGG 69.6 0.9225

2546 TTR Int3 Int4 T8 AAGATCCTCACCATAGGCAG GGG 69.1 0.86

2922 TTR_Up_Int2_T38 TACACACTGATCCCATTATC AGG 68.4 0.9305

969 TTR Int3 Int4 T3 CATGAAAGGGAACTATTCTC TGG 67.8 0.9398 2545 TTR Int3 Int4 T9 GAAGATCCTCACCATAGGCA GGG 67.7 0.8596

2238 TTR Int6 Int7 T5 GACTTAGAGATTTAGCATTC TGG 67.6 0.9773

3059 TTR Up Int2 T77 AATAGGTCATTTGACCAGTT AGG 67.5 0.9402

411 TTR Up Int2 T35 AGGGATAAGCAGCCTAGCTC AGG 67.1 0.8379

427 TTR Up Int2 T66 TCCACTCATTCTTGGCAGGA TGG 66.7 0.9546

548 TTR Up Int2 T32 TTGCCAAAGAACCCTCCCAC AGG 66.6 0.8849

846 TTR Int2 Int3 T31 GTGAGTCTGGAGAGCTGCAT GGG 66.5 0.7695

550 TTR Up Int2 T83 CTTCCCGTTTGCCCCTCACT TGG 66.4 0.7801

426 TTR_Up_Int2_T20 GAAGTCCACTCATTCTTGGC AGG 66.1 0.9301

957 TTR Int3 Int4 Til TTTGAAACAGATGGCTGTCA TGG 65.6 0.9203

446 TTR Up Int2 T49 AGCTTTTATTACTAGGGCAA GGG 65.5 0.9315

2866 TTR Up Int2 T98 AAAAGAGGGCATCCTTCAGA GGG 65.4 0.9251

364 TTR_Up_Int2_T73 GGTTTTTCCTTGTTGACCCA TGG 65.1 0.839

2947 TTR_Up_Int2_T46 AGATGTAATGTACCATACAT AGG 64.9 0.9544

853 TTR Int2 Int3 T32 ACTGAGGAGGAATTTGTAGA AGG 64.6 0.8334

2873 TTR Up Int2 T61 AGCCTCTCTCTACCAAGTGA GGG 63.7 0.9051

2865 TTR Up Int2 T106 AAAAAGAGGGCATCCTTCAG AGG 63.6 0.9573

3081 TTR_Up_Int2_T128 GGTCAACAAGGAAAAACCCT TGG 63.5 0.7816

442 TTR Up Int2 T28 GCCAACCAGCTTTTATTACT AGG 63 0.8467

2628 TTR Int2 Int3 T36 ATAATAGGAAAGGGAACCTT TGG 61.5 0.8571

842 TTR Int2 Int3 T23 TATAGGAAAACCAGTGAGTC TGG 60.5 0.6906

2890 TTR_Up_Int2_T90 CCCAGAGGCAAATGGCTCCC AGG 60.4 0.8549

2666 TTR Int2 Int3 T8 CCCTCAACTAAGTCAGAAGT AGG 59.8 0.9744

828 TTR Int2 Int3 T6 CCCTACTTCTGACTTAGTTG AGG 59.2 0.9539

882 TTR Int2 Int3 T24 CCACAGAAATGTCCTAAGGA AGG 59.1 0.9241

3064 TTR Up Int2 T3 GCGTGCACTAACATTCTTGG GGG 58.7 0.6437

520 TTR Up Int2 T13 GACACTTACGTTCCTGATAA TGG 58.5 0.85

2975 TTR Up Int2 T91 CCCCAAATACATTTTATGGA GGG 58.4 0.9868

850 TTR Int2 Int3 T13 GCATGGGCTCACAACTGAGG AGG 58.2 0.776

2542 TTR Int3 Int4 T2 TGTTTGAAGATCCTCACCAT AGG 58.1 0.7806

3016 TTR Up Int2 T6 GTCACAGAAACACTCACCGT AGG 57.6 0.6957

968 TTR Int3 Int4 T6 AAAAATAGCTCGGCATGAAA GGG 56.1 0.9083

507 TTR Up Int2 T59 AAATTCATTATACACATCCC TGG 55.8 0.9473

2245 TTR Int6 Int7 T8 TGTCCCAGTCTACATTCTGA TGG 55.8 0.6954

2904 TTR_Up_Int2_T57 CAGAGGACACTTGGATTCAC CGG 55.1 0.8864

443 TTR Up Int2 T117 CCAACCAGCTTTTATTACTA GGG 54.1 0.8965

424 TTR Up Int2 T40 CACAGAAGTCCACTCATTCT TGG 53.5 0.6287

518 TTR Up Int2 T15 CGTCTGTGTTATACTGAGTA GGG 52.9 0.92

505 TTR_Up_Int2_T131 TAACAAAGCAACTGTTCTCA GGG 52.6 0.7149

382 TTR Up Int2 Tl GTTAGTGCACGCAGTCACAC AGG 51.8 0.5402

3007 TTR Up Int2 T116 AGCTGGTTGGCAAAGCTGGA AGG 51.6 0.6564

1201 TTR Int6 Int7 T3 GGTTCCATCAGAATGTAGAC TGG 50.8 0.9471

512 TTR_Up_Int2_T109 GTTGATAGCAGTGTGTCTGG AGG 50.5 0.6677

829 TTR Int2 Int3 T7 CCTACTTCTGACTTAGTTGA GGG 50.5 0.9653 839 TTR Int2 Int3 T12 TCCAGACTTTCACACCTTAT AGG 50.4 0.8834

530 TTR Up Int2 T134 TGAATCCAAGTGTCCTCTGA TGG 50.3 0.8773

528 TTR Up Int2 T121 CTTCTCTACACCCAGGGCAC CGG 50.1 0.59

2883 TTR Up Int2 T88 TAAAACCAAGTCCTGTGGGA GGG 49.3 0.81

2248 TTR Int6 Int7 T4 CATTCTGATGGAACCATAGT AGG 49.3 0.9615

858 TTR Int2 Int3 T34 AAATAGACACCAAATCTTAC TGG 49.1 0.57

3078 TTR Up Int2 T36 TTTGCACTTGATGGATCCAT GGG 49 0.8995

3063 TTR Up Int2 T9 TGCGTGCACTAACATTCTTG GGG 48.8 0.6144

544 TTR_Up_Int2_T74 CCTGGGAGCCATTTGCCTCT GGG 47.2 0.9176

418 TTR Up Int2 T108 TGAGTATAAAAGCCCCAGGC TGG 47 0.95

1202 TTR Int6 Int7 T7 GTTCCATCAGAATGTAGACT GGG 46.5 0.88

377 TTR Up Int2 T130 TGCATAGAAATATGTGAGGG AGG 45.3 0.9135

549 TTR_Up_Int2_T52 AAGAACCCTCCCACAGGACT TGG 44.3 0.9127

2896 TTR_Up_Int2_T14 TGCACGGCCACATTGATGGC AGG 44.1 0.9726

504 TTR Up Int2 T95 TTAACAAAGCAACTGTTCTC AGG 43.8 0.8106

2525 TTR Int3 Int4 Tl TTAACTCTGACCAACATGTC TGG 43.8 0.9395

2240 TTR Int6 Int7 T6 GAGATTTAGCATTCTGGAGC TGG 43.3 0.9679

3002 TTR_Up_Int2_T25 CTTGCCCTAGTAATAAAAGC TGG 42.9 0.9228

2897 TTR Up Int2 T129 CATTGATGGCAGGACTGCCT CGG 42.5 0.8095

880 TTR Int2 Int3 T17 TGTACCACAGAAATGTCCTA AGG 42.2 0.7365

492 TTR Up Int2 T125 TTTTATAACAACTGGTAAGA GGG 41.7 0.4207

470 TTR_Up_Int2_T118 CCCTCCATAAAATGTATTTG GGG 41.6 0.9654

473 TTR Up Int2 T23 GTATTTGGGGGACAAACTGC AGG 39.5 0.4454

2544 TTR Int3 Int4 T10 TGAAGATCCTCACCATAGGC AGG 39.4 0.936

3005 TTR Up Int2 T89 TAAAAGCTGGTTGGCAAAGC TGG 38.7 0.9702

400 TTR Up Int2 T93 AGTCAATAATCAGAATCAGC AGG 38.5 0.7461

2658 TTR Int2 Int3 T3 CTGGATTAAGTTACGCATGG AGG 37.9 0.9657

836 TTR Int2 Int3 T38 TTATGTGTGTTAGTTGGTGG GGG 37.8 0.9126

2918 TTR Up Int2 T119 TCTTTGTGGTATTAGAAATC TGG 37.2 0.8434

2631 TTR Int2 Int3 T28 CCTTCCTTAGGACATTTCTG TGG 36.8 0.9274

510 TTR Up Int2 T41 CTGGTTGATAGCAGTGTGTC TGG 36.5 0.5695

2906 TTR Up Int2 T8 CTTGGATTCACCGGTGCCCT GGG 36.5 0.7053

363 TTR Up Int2 T104 AAAAATGTGAGCACTGCCAA GGG 36.2 0.9755

475 TTR_Up_Int2_T101 AACTGCAGGAGATTATATTC TGG 33.4 0.6201

2637 TTR Int2 Int3 T30 TACTCACCTCTGCATGCTCA TGG 32.5 0.57

543 TTR Up Int2 T55 ACCTGGGAGCCATTTGCCTC TGG 32.2 0.7094

452 TTR Up Int2 T27 TTCCACTGAGCTTACTGAGC TGG 31.8 0.7885

453 TTR Up Int2 T51 TCCACTGAGCTTACTGAGCT GGG 31.8 0.9704

429 TTR_Up_Int2_T72 CCTCCTCTGCCTTGCTGGAC TGG 30.6 0.9636

2523 TTR Int3 Int4 T12 TCATGCCGAGCTATTTTTGA TGG 30.6 0.9724

500 TTR Up Int2 T115 TTTCAGTAATTCCACTCAAA TGG 29.6 0.9274

362 TTR Up Int2 T102 TAAAAATGTGAGCACTGCCA AGG 28.7 0.42

393 TTR_Up_Int2_T44 TGCTCTAATCTCTCTAGACA AGG 28.3 0.3311

967 TTR Int3 Int4 T4 CAAAAATAGCTCGGCATGAA AGG 27.7 0.9634 2659 TTR Int2 Int3 T35 TTACGCATGGAGGAAACAAA TGG 26.8 0.37

2884 TTR Up Int2 T24 AGTCCTGTGGGAGGGTTCTT TGG 26.7 0.9745

405 TTR Up Int2 T76 AGGTTTGCAGTCAGATTGGC AGG 25.8 0.9589

2902 TTR Up Int2 T45 TCTAGAACTTTGACCATCAG AGG 25.6 0.92

403 TTR Up Int2 T87 CAGCAGGTTTGCAGTCAGAT TGG 24.8 0.9776

417 TTR Up Int2 T31 GAAGTGAGTATAAAAGCCCC AGG 24.3 0.277

871 TTR Int2 Int3 T4 CAGACCTTCGAGGGTTGTTT TGG 24.2 0.9739

458 TTR Up Int2 T53 TGCATTAGGTTTGTAATATC TGG 23.1 0.3009

517 TTR_Up_Int2_T18 ACGTCTGTGTTATACTGAGT AGG 20.9 0.2385

2639 TTR Int2 Int3 T14 CCTCTGCATGCTCATGGAAT GGG 19.5 0.2494

486 TTR Up Int2 T105 CTAATACTATAAAATGGGTC TGG 18.6 0.9764

2653 TTR Int2 Int3 T10 TCCTATAAGGTGTGAAAGTC TGG 16.7 0.9615

357 TTR_Up_Int2_T82 AGCTTCCAAATGACTTAGTT TGG 16.5 0.9896

2950 TTR_Up_Int2_T12 TACCATACATAGGGCCAAAC AGG 13.3 0.993

3062 TTR Up Int2 T5 CTGCGTGCACTAACATTCTT GGG 13.2 0.1546

3039 TTR Up Int2 T132 GTGATGGCTGCTCCCAGCCT GGG 11.3 0.9837

3054 TTR Up Int2 T43 GTCTAGAGAGATTAGAGCAT CGG 10.7 0.1075

388 TTR_Up_Int2_T84 TTTTGTTTTGGTGACCTAAC TGG 10.5 0.117

2645 TTR Int2 Int3 T20 AAGTGCCTTCCAGTAAGATT TGG 10.3 0.1074

3038 TTR Up Int2 T126 TGTGATGGCTGCTCCCAGCC TGG 8.2 0.9886

3061 TTR Up Int2 T10 ACTGCGTGCACTAACATTCT TGG 7.9 0.0824

2652 TTR Int2 Int3 T18 GACTCACTGGTTTTCCTATA AGG 7.7 0.0785

2961 TTR Up Int2 T110 GTATTAGTTAATTCTTCTAG AGG 7.6 0.0812

457 TTR Up Int2 T42 CCTCATTGCTTTGGTGCATT AGG 7.1 0.9898

861 TTR Int2 Int3 T27 AAATCTTACTGGAAGGCACT TGG 5.6 0.06

432 TTR Up Int2 T107 CTGGTATTTGTGTCTGAGGC TGG 4.5 0.9923

445 TTR Up Int2 T37 CAGCTTTTATTACTAGGGCA AGG 4.3 0.9871

3086 TTR Up Int2 T92 TTTAGCCAAACTAAGTCATT TGG 3.4 0.9871

3076 TTR Up Int2 T124 TAGAAAATGTTTGCACTTGA TGG 1.4 0.9907

Note that the SEQ ID NOs represent the DNA sequence of the genomic target, while the gRNA or sgRNA spacer sequence will be the RNA version of the DNA sequence.

Example 9 - Testing of preferred guides in cells for off-target activity

[00606] The gRNAs having the best on-target activity from IVT screen in the above example are tested for off-target activity using Hybrid capture assays,

GUIDE Seq and whole genome sequencing, in addition to other methods. Example 10 - Testing different approaches for HDR gene editing

[00607] After testing the gRNAs for both on-target activity and off-target activity, the mutation correction and knock-in strategies will be tested for HDR gene editing.

[00608] For the mutation correction approach, the donor DNA template will be provided as a short single-stranded oligonucleotide, a short double-stranded oligonucleotide (PAM sequence intact/PAM sequence mutated), a long single- stranded DNA molecule (PAM sequence intact/PAM sequence mutated) or a long double-stranded DNA molecule (PAM sequence intact/PAM sequence mutated). In addition, the donor DNA template will be delivered by AAV.

[00609] For the cDNA knock-in approach, a single-stranded or double-stranded DNA having homologous arms to the 18q12.1 region may include more than 40 nt of the first exon (the first coding exon) of the TTR gene, the complete CDS of the TTR gene and 3' UTR of the TTR gene, and at least 40 nt of the following intergenic region. The single-stranded or double-stranded DNA having homologous arms to the 18q12.1 region may include more than 80 nt of the first exon of the TTR gene, the complete CDS of the TTR gene and 3'UTR of the TTR gene, and at least 80 nt of the following intergenic region. The single-stranded or double-stranded DNA having homologous arms to the 18q12.1 region may include more than 100 nt of the first exon of the TTR gene, the complete CDS of the TTR gene and 3'UTR of the TTR gene, and at least 100 nt of the following intergenic region. The single- stranded or double-stranded DNA having homologous arms to the 18q12.1 region may include more than 150 nt of the first exon of the TTR gene, the complete CDS of the TTR gene and 3'UTR of the TTR gene, and at least 150 nt of the following intergenic region. The single-stranded or double-stranded DNA having homologous arms to the 18q12.1 region may include more than 300 nt of the first exon of the TTR gene, the complete CDS of the TTR gene and 3'UTR of the TTR gene, and at least 300 nt of the following intergenic region. The single-stranded or double- stranded DNA having homologous arms to the 18q12.1 region may include more than 400 nt of the first exon of the TTR gene, the complete CDS of the TTR gene and 3'UTR of the TTR gene, and at least 400 nt of the following intergenic region. Alternatively, the DNA template will be delivered by AAV. [00610] For the cDNA or minigene knock-in approach, a single-stranded or double-stranded DNA having homologous arms to the 1 1 p13, which includes more than 80 nt of the second exon (the first coding exon) of the TTR gene, the complete CDS of the TTR gene and 3'UTR of the TTR gene, and at least 80 nt of the following intergenic region. Alternatively, the DNA template will be delivered by AAV.

Example 11 - Re-assessment of lead CRISPR-Cas9/DNA donor combinations

[00611] After testing the different strategies for HDR or NHEJ gene editing, the lead CRISPR-Cas9/DNA donor combinations will be re-assessed in primary human cells for efficiency of deletion, recombination, and off-target specificity. Cas9 mRNA or RNP will be formulated into lipid nanoparticles for delivery, sgRNAs will be formulated into nanoparticles or delivered as AAV, and donor DNA will be formulated into nanoparticles or delivered as AAV.

Example 12 - In vivo testing in relevant animal model

[00612] After the CRISPR-Cas9/DNA donor combinations have been reassessed, the lead formulations will be tested in vivo in an animal model. Suitable animal models include, by way of non-limiting example, relevant models referenced in Buxbaum, J.N. , FEBS Lett. 2009 Aug 20; 583(16): 2663-2673 "Animal models of human amyloidoses: Are transgenic mice worth the time and trouble?".

[00613] Culture in human cells allows direct testing on the human target and the background human genome, as described above.

[00614] Note Regarding Illustrative Examples

[00615] While the present disclosure provides descriptions of various specific aspects for the purpose of illustrating various aspects of the present invention and/or its potential applications, it is understood that variations and modifications will occur to those skilled in the art. Accordingly, the invention or inventions described herein should be understood to be at least as broad as they are claimed, and not as more narrowly defined by particular illustrative aspects provided herein.

[00616] Any patent, publication, or other disclosure material identified herein is incorporated by reference into this specification in its entirety unless otherwise indicated, but only to the extent that the incorporated material does not conflict with existing descriptions, definitions, statements, or other disclosure material expressly set forth in this specification. As such, and to the extent necessary, the express disclosure as set forth in this specification supersedes any conflicting material incorporated by reference. Any material, or portion thereof, that is said to be incorporated by reference into this specification, but which conflicts with existing definitions, statements, or other disclosure material set forth herein, is only incorporated to the extent that no conflict arises between that incorporated material and the existing disclosure material. Applicants reserve the right to amend this specification to expressly recite any subject matter, or portion thereof, incorporated by reference herein.