Cross-Referenceto Related Applications

This application claims the benefit of the filing date of U.S. application Serial No.

62/478,357, filed on March 29, 2017, the disclosure of which is incorporated by reference herein.

■Background

AAT, (SEERPNA1), a 52 kDa a serum serine protease inhibitor, functions to protect the lung from the powerful protease neutrophil elastase (NE) ^4"10 . AAT also inhibits the activity of other neutrophil-released proteases, including proteinase 3, o-defensins and cathepsin G and has anti-inflammatory and immunomodulatory properties ⁴ " ⁸ . Serum deficiency of AAT is associated w ith an imbalance betw een proteases and AAT in the lung, leading to slow destruction of the lung parenchyma, a process accelerated by cigarette smoking ^{4,5,7,8,11,12} ' ^59'81 . The consequence is the development of early-onset of panacinar emphysema at ages 35 to 40 in smokers and age 55 to 60 in nonsmokers, with a reduced life span of approximately 15 to 20 _yr 4.5.7.e2-34 -η-g _disorc | _er affects 70,000to 100,000 individuals in the USA ^82,85 . AAT deficiency is also associated w ith childhood and adult Bver cirrhosis, and rarely w ith hepatocellular carcinoma, panniculitis and vascuitis and autoimmune disorders ^88"73 . AAT is mainly produced in the liver reaching the lung by diffusion from the circulation ^{4,9,7,8,10"12,83,74} with a small percentage secreted from mononuclear phagocytes ^79,78 , neutrophils ⁷⁷ , bronchial epithelial cells ^78,79 , and small intestine epithelial cells ^80,81 . AAT in plasma diffuses into the lung, where it protects the fragile alveolar structures from proteases carried by neutrophils generated in bone marrow . The lung is the organ most susceptible to neutrophil elastase mediated proteolytic destruction (Figure 1).

Low circulating levels of AAT are the result of mutations in the SEERPINA1 gene (MM 107400) ^82,83 , with more than 120 naturally occurring alleles ^85,84 * ⁸ . The normal AAT alleles are M1(Ala213), M1(Val213), M2, M2 and M4 ⁸⁷ . The most common deficient variants are the severe Z allele, observed with high frequency in Caucasians in Northern European countries and North America, and the milder S form, with high prevalence in the toerian Peninsula ^85,70,85 . The vast majority of cases of emphysema associated with AAT deficiency are caused by homozygous inheritance of the severe Z variant, w ith a single amino acid substitution of lysine for glutamic acid at position 342 (E342K) ⁸⁸ . The Z mutation causes the AAT protein to polymerize h hepatocytes, preventing secretion into the blood ^{83,85,70,8842} . The S allele, a single amino acid substitution of a glutamic acid by a valine at position 264 (E264V), results in an unstable protein with reduced serum half-life ^93"98 . Individuals homozygous for the Z mutation (ZZ) have plasma AAT levels 10 to 15% of the normal M allele and account for approximately >95% of cases of clinically recognized AATdeficiency ^{5,7,10,11,85,71 97} Summary

Gene therapy vectors comprising an expression cassette coding for an oxidation- resistant alpha 1-antitrypsin (AAT) are provided. The oxidation-resistant alpha 1-antitrypsin nucleic acid may comprise one or mutations encoding one or more substitution(s), e.g., those described in Table 1 , and the resulting AAT protein (a variant relative to the parental AAT sequence) is oxidation- resistant compared to an AAT sequence that does not have the one or more substitutions (e.g., the parental AAT nucleic acid sequence made encode an oxidation- sensitive AAT sequence, such as a M1(Ala213) sequence). Thus, in one embodkment, the base expression cassette that encodes an oxidation-sensitive AAT that is then made oxidation- resistant, may be the M1(Ala213) variant In another embodiment, the base expression cassette that encodes an oxidation- sensitive AATthat is then made oxidation- resistant may be the M1(Vat213) variant. Also provided are methods to treat alpha 1-antitrypsin deficiency comprising administering to a subject in need thereof, a pharmaceutical composition comprising one or more vectors described herein. In one embodiment, the vector may be delivered to the pleura, h one embodiment, the vector may be intravenously delivered

Advantages of gene therapy include that 1) a single administration may permanently compensate for the genetic abnormality, obviating the requirement of weekly or monthly parenteral infusions of AAT, 2) a steady state of AAT occurs over time, 3) there is a lack of risk of viral contamination from pooled plasma, and 4) there may be a lower cost.

in one embodiment, a viral or plasmid gene therapy vector is provided comprising an expression cassette coding for an oxidation-resistant alpha 1-antitrypsin that has an oxidation- resistant amino acid at, for example, position 351, position 358, or both positions 351 and 358. In one embodiment the oxidation-resistant amino acid is leucine, valine, glycine, isoleucine, alanine, threonine, asparagine, serine, or aspartic acid. In one embodiment, the oxidation- resistant amino acid is leucine, valine, glycine, isoleucine, or alanine, h one embodiment, position 358 in alpha 1-antitrypsin has an oxidation-resistant amino acid. In one embodiment, position 351 has an oxidation- resistant amino acid. In one embodiment, position 358 has an oxidation-resistant amino acid. In one embodiment, position 351 and position 358 each has an oxidation-resistant amino acid. In one embodiment, the oxidation-resistant residue is leucine or valine. In one embodiment, the alpha 1-antitrypsin has an alanine at position 213. in one embodiment, the alpha 1-antitrypsin sequence other than the residue at position 351 and/or 358 is the M1(Ata213) variant sequence. In one embodiment, the alpha 1-antitrypsin has a valine at position 213. In one embodiment, the alpha 1-antitrypsin sequence other than the residue at positions 351 and/or 358 is the M1(Va£213) variant sequence. In one embodiment, the vector is a viral gene therapy vector, e.g., an adenovirus, adeno-associated virus (AAV), retrovirus or lentivirus vector. In one embodiment, the AAV vector is pseudotyped. In one embodiment, the AAV vector is pseudotyped with AAVrh.10, AAV8, AAV9, AAV5, AAVhu.37, AA Vhu.20, AAVhu.43, AAVhu.8, AAVhu.2, or AAV7 capskJ. h one embodiment, the AAV vector is pseudotyped w ith AA Vrh.10, AA V8, or AA V5. In one embodiment, the AAV vector is AA V2, AAV5, AAV7, AAV8, AAV9orAAVrh.10. Further provided is a pharmaceutical composition comprising an amount of the gene therapy vector described above. A dose of the viral vector may be about 1 x 10 ¹¹ to about 1 x 10 ¹⁸ genome copies, about 1 x 10 ¹² to about 1 x 10 ¹⁵ genome copies about 1 x 10 ¹¹ to about 1 x 10 ¹³ genome copies, or about 1 x 10 ¹³ to about 1 x 10 ¹⁵ genome copies.

The vector or pharmaceutical composition may be employed to prevent, inhibit or treat alpha 1 -antitrypsin deficiency. For example, an effective amount of the vector or the pharmaceutical composition may be administered to a subject in need thereof. In one embodiment, the composition is delivered to the pleura. In one embodiment, the composition is intravenously administered. In one embodiment, the subject is a human. In one embodiment, the human has emphysema.

The vector or pharmaceutical composition may also be employed to prevent, inhbit or treat emphysema, COPD, respiratory distress syndrome or f ibrotic interstitial lung disease in a mammal by administering to a mammal in need thereof, an effective amount of the vector or the pharmaceutical composition, h one embodiment, the composition is delivered to the pleura. \n one embodiment, the composition is intravenously administered. In one embodiment, the mammal is a human. In one embodiment, the human has emphysema.

The vector or pharmaceutical composition may further be employed to prevent, inhibit or treat oxidative damage to the lung, e.g., by administering to a subject in need thereof an effective amount of a composition comprising the vector or the pharmaceutical composition, h one embodiment the composition is delivered to the pleura. In one embodiment, the composition is intravenously administered, h one embodiment, the subject is a human.

Brief Description of the Drawings

Figure 1. Pathogenesis of AAT deficiency. Left. AAT produced in the liver functions to protect the lung from the burden of neutrophil elastase. Middle. With the Z mutation in the AAT gene, the AATZ protein aggregates in the liver resulting in low AAT levels in blood and hence lung. Bottom. The consequence is progressive lung destruction resulting in emphysema (scanning EEM).

Figures 2A-D. Composition. A) Structure of an embodiment, based on the serotype

AAV8 vector. Show n in the expression cassette is the coding sequence for the AAT cDNA driven by the highly active, constitutive CAG promoter, followed by an intron, the AATcDNA and the polyA signal flanked by AAV2 inverted terminal repeats (iTR). Indicated are the AAT cDNA is A213, and the 2 Met sites to be varied w ith Leu and/or Val. The genome is packaged in an AAV8 capsid. B) Crystalkxjraphic structure of the normal AAT Ml (Ala213) protein (adapted from FOB 1QLF) ¹²⁰ . AAT protects the lung from serine proteases capable of degrading the lung parenchyma. Oxidation of Met358 and Met 351 in the AAT active site renders AAT incapable of inhibiting elastase and cathepsh G. In human, oxidants in cigarette smoke, second hand smoke and pollutants oxidize and inactivate AAT, rendering the lung at risk for protease- mediated destruction. C) -Evolution of the human AAT gene. There are 5 major normal AAT variants, M1(A213), M1(V213), M2, M3 and M4. M2 could be from M3 or M4. Based on the know ledge that the common Z alele (>95% cases of AAT deficiency) is derived from the M1(A213) normal AATalele, AAV.vAATis based on the M1(Ala213) base sequence.

Figure 3. Bastase inhibitory activity in fluid from the epitheial surface of the lower respiratory tract of smoking and nonsmoking individuals. B_F was obtained by inserting a fiberoptic bronchoscope into a segmental bronchus. Five 20 rri portions of physiologic saline w ere injected through the bronchoscope; the lavage fluid w as colected in a sterile vial by aspiration, separated from the cells by centrifugation at 500 g for 5 rrtn, and concentrated by pressure dialysis (Arricon UM2 membrane) to a volume of 1 ml. The amount of AAT in each lavage sample was determined and elastase inhibitory activity of the lavage samples was measured ¹²¹ . Shown is AAT from the epithelial lining fluid of nonsmokers (*) and smokers (O).

Figures 4A-B. Inhibition of elastase by AAT(Met358) and AAT(Val358) in the absence and presence of oxidation. A) Inhibition of human neutrophil elastase w ith AAT (Met358) (*) and AAT(Val358) (▲). B) Inhibition of porcine pancreatic elastase by A AT(Met358) (·) or

AAT(Val358) (♦) in the presence of 10 mM /V-chbrosuccinimde.

Rgures 5A-C. Intrapleural administration of an AAV vector coding for AAT. A) Anatomy. B) Vector distrbution follow ing intrapleural administration, combining local lung delivery via vector transduction of the mesothelial cells lining the pleura, and systemic delivery via vector leaking to the systemic venous system and then primarBy to liver hepatocytes. C) Delivery to the alveol of AAT produced by AAV gene therapy to the pleura. The endothelial junctions are relatively loose, such that the levels of AAT (MW 52 kDa) in the interstitium are 60% of that in plasma. The epithelial junctions are tight, resulting h EELF AAT levels 5 to 10% of plasma. The locally (mesothelial eel) expressed AAT is delivered directly to the alveolar interstitium, while the liver (hepatocyte) expressed AAT diffuses from plasma to the interstitium The AAT in the interstitium, and then to alveolar epithelial lining fluid (EELF).

Rgures 6A-B. In vitro assessment of neutrophil elastase inhibition by AAT variant expression cassettes. ΗΕΞΚ293Τ cells w ere transfected with plasrrids pAAV-AAT(V213), pAAV- AAT(A213), pAAV-AAT(A213)-M351L, M358L or mock transfected. Dilutions of AAT protein collected from the supernatant w ere quantified and pre- incubated w ith or w ithoutthe oxidizer N- chlorosuccinirride (NCS). AAT was then incubated with neutrophi elastase. Neutrophil elastase inhibition was measured by the addition of N-Suc-Ala-Ala-Ala-p-nitroanilide substrate and measuring p-nitroaniBde product formation by spectrophotometric measurement at 410 nm. A) Neutrophil elastase inhibition curve. B) Neutrophil elastase inhibition in the presence of oxidizing NCS.

Rgures 7A-C. Intrapleural administration of AAV vector coding for human AAT. A) Comparison of 25 different AAV serotypes for AAT expression efficiency after intrapleural administration. The AAV vectors, pseudotypedas indicated and containing the AATexpression cassette and the AAV2 inverted terminal repeats, were administered intrapleural^ (5x10 ¹⁰ genome copies, gc) to male C57BL/6 mice (n= 5/group). Serum AAT levels were measured by ELBA up to 4 w k after administration. The data show n are percentages of means of 5 rrice, w ith the levels at w k4 of AAVrh.10 (in red) and AAV8 yielding the highest levels. The dashed line represents the assay lirrit of detection. B) Bars stent AAT levels in serum after A A Vrh.1 OA AT intrapleural administration. AAVrh.10hAAT(10 ¹¹ gc) was administered intrapteuraly to male C57BU6 mice (n = 4/group) and serum human AAT levels were assayed by BJSA up to 24 wkfollowing administration. Values shown are means 1 standard error. C) Human AAT levels in bronchoalveolar lavage fluid compared to serum at 8 w k after intrapleural administration of 10 ¹¹ gcAAVrh.10hAAT(C57BL/6 rrice, n = 4). Human AAT levels are referenced to total protein (mean ± standard error).

Figure 8. Human AATmRNA expression in the pleura of nonhuman primates 1 yr following a single intrapleural AAVrh.lOhAAT vector administration. Human AAT mRNA expression w as assayed in tissue sections by TaqMan quantitative PCR at 28, 90 and 360 days after single intrapleural administration of PBS or AAVrh.10hAAT(10 ¹² or 10 ¹³ gc, n=4 per dose). mRMA copies w ere normalized/pg total RNA. Data presented as the geometric mean ± SE

Figure 9. AAV GfvP production scheme. The center path indicates the steps in the manufacture of AAV.vAAT. Boxes to the left indicate the source of the production cells and boxes to the right of each step are the quality control assays.

Figure 10. In vitro comparison of oxidation-sensitive and oxidation- resistant variants of human AAT to inhibit neutrophil elastase. All 351 and 358 Met/Val/L variant combinations were effective at inhibiting neutrophil elastase.

Figure 11. In vitro comparison of oxidation-sensitive and oxidation- resistant variants of human AAT to inhibit neutrophil elastase in the presence of an oxidant stress. Replacement of Met358 enhances efficacy.

Figure 12. In vitro comparison of oxidation-sensitive and oxidation- resistant variants of human AAT to inhibit cathepsin G. Some single substitutions and double substitutions yield effective AAT.

Figure 13. In vitro comparison of oxidation-sensitive and oxidation-resistant variants of human AAT to inhibit cathepsin G in the presence of an oxidant stress. One single substitutions and tw o double substitutions yield effective AAT.

Figure 14. Schematic of vectors for in vivo experiments.

Figure 15. .Evaluation of AAV8- hA AT variants in a mouse model.

Figure 16. .Evaluation of serum anti-protease activity in rrice infected with A A V8- hAAT oxidation-resistant variants or wild-type AAT (oxidation-sensitive).

Figure 17. Evaluation of serum anti-protease activity in the presence of oxidant stress in serum from in rrice infected w ith AAV8- hAAT variants or w Id- type AAT.

Detailed Description In the follow ing description, reference is made to the accompanying draw ings that form a part hereof, and in w hich is show n by w ay of illustration specific embodiments w hich may be practiced. These embodiments are described in detail to enable those skilled in the art to practice the invention, and it is to be understood that other embodiments may be utilized and that logical changes may be made w ithout departing from the scope of the present invention. The follow ing description of example embodiments is, therefore, not to be taken in a limited sense, and the scope of the present invention is defined by the appended claims.

The Abstract is provided to comply w ith 37 C. F.R §1.72(b) to alow the reader to quickly ascertain the nature and gist of the technical disclosure. The Abstract is submitted with the understanding that it w II not be used to interpret or limit the scope or meaning of the claims. Definitions

A "vector" refers to a macromolecule or association of macromolecules that comprises or associates w ith a polynucleotide, and w hich can be used to mediate delivery of the

polynucleotide to a cell, either in vitro or in vivo. Ilustrative vectors include, for example, plasrrids, viral vectors, liposomes and other gene delivery vehicles. The polynucleotide to be delivered, sometimes referred to as a 'target polynucleotide'' or ^u transgene," may comprise a coding sequence of interest in gene therapy (such as a gene encoding a protein of therapeutic interest), a coding sequence of interest in vaccine development (such as a polynucleotide expressing a protein, polypeptide or peptide suitable for eliciting an immune response in a mammal), and/or a selectable or detectable marker.

"Transduction,'' "transf ection," "transformation" or "transducing" as used herein, are terms referring to a process for the introduction of an exogenous polynucleotide into a host eel leading to expression of the polynucleotide, e.g., the transgene in the cell, and includes the use of recombinant virus to introduce the exogenous polynucleotide to the host cell. Transduction, transf ection or transformation of a polynucleotide in a cell may be determined by methods w el know n to the art including, but not limited to, protein expression (including steady state levels), e.g., by EEL ISA, flow cytometry and Vvestern blot, measurement of DNA and RNA by

hybridization assays, e.g., Northern blots, Southern blots and gel shift mobiity assays. Methods used for the introduction of the exogenous polynucleotide include well-known techniques such as viral infection or transf ection, lipof ection, transformation and electroporation, as w ell as other non-viral gene delivery techniques. The introduced polynucleotide may be stably or transiently maintained in the host cel.

"Gene delivery" refers to the introduction of an exogenous polynucleotide into a cell for gene transfer, and may encompass targeting, binding, uptake, transport, localization, replicon integration and expression.

"Gene transfer" refers to the introduction of an exogenous polynucleotide into a eel w hich may encompass targeting, binding, uptake, transport, localization and replicon integration, but is distinct from and does not imply subsequent expression of the gene. "Gene expression" or "expression" refers to the process of gene transcription, translation, and post- trans lational modification.

An "infectious" virus or viral particle is one that comprises a polynucleotide component which it is capable of delivering into a cell for which the viral species is trophic. The term does not necessarily imply any repScation capacity of the virus.

The term "polynucleotide'' refers to a polymeric form of nucleotides of any length, including deoxyribonucleotides or ribonucleotides, or analogs thereof. A polynucleotide may comprise modified nucleotides, such as methylated or capped nucleotides and nucleotide analogs, and may be interrupted by non- nucleotide components. If present, modifications to the nucleotide structure may be imparted before or after assembly of the polymer. The term polynucleotide, as used herein, refers interchangeably to double- and single-stranded molecules. Unless otherw ise specified or required, any embodiment of the invention described herein that is a polynucleotide encompasses both the double-stranded form and each of two complementary single-stranded forms know nor predicted to make up the double-stranded form An "isolated" polynucleotide, e.g., plasrrid, virus, polypeptide or other substance refers to a preparation of the substance devoid of at least some of the other components that may also be present w here the substance or a similar substance naturally occurs or is initially prepared from Thus, for example, an isolated substance may be prepared by using a purification technique to enrich it from a source mixture. Isolated nucleic acid, peptide or polypeptide is present in a form or setting that is different from that in w hich it is found in nature. For example, a given DNA sequence (e.g., a gene) is found on the host eel chromosome in proximity to neighboring genes; RNA sequences, such as a specific mRNA sequence encoding a specific protein, are found in the cell as a mixture with numerous other mRNAs that encode a multitude of proteins. The isolated nucleic acid molecule may be present in single-stranded or double- stranded form. When an isolated nucleic acid molecule is to be utiized to express a protein, the molecule w ill contain at a minimum the sense or coding strand (i.e., the molecule may single- stranded), but may contain both the sense and anti-sense strands (i.e., the molecule may be double-stranded). Birichment can be measured on an absolute basis, such as weight per volume of solution, or it can be measured in relation to a second, potentially interfering substance present in the source mixture. Increasing enrichments of the embodiments of this invention are increasingly preferred. Thus, for example, a 2-f old enrichment, 10-fold

enrichment, 100-fold enrichment, or a 1000-fold enrichment.

A "transcriptional regulatory sequence" refers to a genomic region that controls the transcription of a gene or coding sequence to w hich it is operably inked. Transcriptional regulatory sequences of use in the present invention generally include at least one

transcriptional promoter and may also include one or more enhancers and/or terminators of transcription.

"Operably linked" refers to an arrangement of two or more components, w herein the components so described are in a relationship permitting them to function in a coordinated manner. By way of .lustration, a transcriptional regulatory sequence or a promoter is operably linked to a coding sequence if the TRS or promoter promotes transcription of the coding sequence. An operably linked TRS is generally joined in c/ ^' s with the coding sequence, but it is not necessarily directly adjacent to it.

"Heterologous" means derived from a genotypically district entity from the entity to w hich it is compared. For example, a polynucleotide introduced by genetic engineering techniques into a different cell type is a heterologous polynucleotide (and, w hen expressed, can encode a heterologous polypeptide). Similarly, a transcriptional regulatory element such as a promoter that is removed from its native coding sequence and operably linked to a different coding sequence is a heterologous transcriptional regulatory element

A "terminator" refers to a polynucleotide sequence that tends to diminish or prevent read- through transcription (i.e., it diminishes or prevent transcription originating on one side of the terminator from continuing through to the other side of the terminator). The degree to w hich transcription is disrupted is typically a function of the base sequence and/or the length of the terminator sequence. In particular, as is w ell know n in numerous molecular biological systems, particular DMA sequences, generally referred to as "transcriptional termination sequences" are specific sequences that tend to disrupt read-through transcription by RNA polymerase, presumably by causing the RNA polymerase molecule to stop and/or disengage from the DMA being transcrtoed. Typical example of such sequence-specific terminators include

polyadenytation ("poly A") sequences, e.g., SV40 poly A. h addition to or in place of such sequence-specific terminators, insertions of relatively long DNA sequences between a promoter and a coding region also tend to disrupt transcription of the coding region, generally in proportion to the length of the intervening sequence. This effect presumably arises because there is always some tendency for an RNA polymerase molecule to become disengaged from the DNA being transcribed, and increasing the length of the sequence to be traversed before reaching the coding region w ould generaly increase the likelihood that disengagement would occur before transcription of the coding region was completed or possibly even initiated.

Terminators may thus prevent transcription from only one direction ("uni-directionar terminators) or from both directions ("bi-directional" terminators), and may be comprised of sequence-specific termination sequences or sequence-non-specific terminators or both. A variety of such terminator sequences are know n in the art; and illustrative uses of such sequences w ithin the context of the present invention are provided below .

"Host cells," "cell lines," "cell cultures," "packaging cell line" and other such terms denote higher eukaryotic cells, such as mammalian eels including human cells, useful in the present invention, e.g., to produce recombinant virus or recombinant fusion polypeptide. These cells include the progeny of the original eel that was transduced. It is understood that the progeny of a single cell may not necessarily be completely identical (in morphology or in genomic complement) to the original parent cell. "Recombinant," as applied to a polynucleotide means that the poly nucleotide is the product of various combinations of cloning, restriction and/or ligation steps, and other procedures that result in a construct that is distinct from a polynucleotide found in nature. A recombinant virus is a viral particle comprising a recombinant polynucleotide. The terms respectively include replicates of the original polynucleotide construct and progeny of the original virus construct.

A "control element" or "control sequence" is a nucleotide sequence involved in an interaction of molecules that contributes to the functional regulation of a polynucleotide, including replication, duplication, transcription, splicing, translation, or degradation of the polynucleotide. The regulation may affect the frequency, speed, orspecificity of the process, and may be enhancing or inhibitory in nature. Control elements know n in the art include, for example, transcriptional regulatory sequences such as promoters and enhancers. A promoter is a DNA region capable under certain conditions of binding RNA polymerase and initiating transcription of a coding region usually located downstream (in the 3' direction) from the promoter. ROmoters include AAV promoters, e.g., P5, P19, P40 and AAV iTR promoters, as well as heterologous promoters.

An "expression vector" is a vector comprising a region w hich encodes a gene product of interest, and is used for effecting the expression of the gene product in an intended target cell. An expression vector also comprises control elements operatively linked to the encoding region to facilitate expression of the protein in the target The combination of control elements and a gene or genes to w hich they are operably linked for expression is sometimes referred to as an "expression cassette," a large number of w hich are know n and avaiable in the art or can be readiy constructed from components that are available in the art

The terms "polypeptide" and "protein" are used interchangeably herein to refer to polymers of amino acids of any length. The terms also encompass an amino acid polymer that has been modified; for example, disulfide bond formation, glycosylation, acetylation, phosphonylatbn, lipidation, or conjugation w ith a labeling component.

The term "exogenous," w hen used in relation to a protein, gene, nucleic acid, or polynucleotide in a cell or organism refers to a protein, gene, nucleic acid, or polynucleotide w hich has been introduced into the cei or organism by artificial or natural means. An exogenous nucleic acid may be from a different organism or cell, or it may be one or more additional copies of a nucleic acid w hich occurs naturally w ithin the organism or cel. By w ay of a non-lrriting example, an exogenous nucleic acid is in a chromosomal location different from that of natural cells, or is otherwise flanked by a different nucleic acid sequence than that found in nature, e.g., an expression cassette w hich links a promoter from one gene to an open reading frame for a gene product from a different gene.

"Transformed" or "transgenic" is used herein to include any host cell or cell line, w hich has been altered or augmented by the presence of at least one recombinant DMA sequence. The host cells of the present invention are typically produced by transf ection w ith a DNA sequence in a plasrrid expression vector, as an isolated inear DNA sequence, or infection with a recombinant viral vector.

The term "sequence homology" means the proportion of base matches between two nucleic acid sequences or the proportion amino acid matches between two amino acid sequences. Wtien sequence homology is expressed as a percentage, e.g., 50%, the percentage denotes the proportion of matches over the length of a selected sequence that is compared to some other sequence. Gaps (in either of the two sequences) are permitted to maximize matching; gap lengths of 15 bases or less are usually used, 6 bases or less are preferred with 2 bases or less more preferred. Wtien using oligonucleotides as probes or treatments, the sequence homology betw een the target nucleic acid and the oligonucleotide sequence is generally not less than 17 target base matches out of 20 possible oligonucleotide base pair matches (85%); not less than 9 matches out of 10 possible base pair matches (90%), or not less than 19 matches out of 20 possible base pair matches (95%).

Two amino acid sequences are homologous if there is a partial or complete identity betw een their sequences. For example, 85% homology means that 85% of the amino acids are identical w hen the two sequences are aligned for maximum matching. Gaps (in either of the two sequences being matched) are allow ed in maximizing matching; gap lengths of 5 or less are preferred with 2 or less being more preferred. Alternatively and preferably, two protein sequences (or polypeptide sequences derived from them of at least 30 amino acids in length) are homologous, as this term is used herein, if they have an algnment score of at more than 5 (in standard deviation units) using the program ALIGN w ith the mutation data matrix and a gap penalty of 6 or greater. The tw o sequences or parts thereof are more homologous if their amino acids are greater than or equal to 50% identical w hen optimally aigned using the ALIGN program

The term "corresponds to" is used herein to mean that a polynucleotide sequence is structurally related to all or a portion of a reference polynucleotide sequence, or that a polypeptide sequence is structurally related to all or a portion of a reference polypeptide sequence, e.g., they have at least 80%, 85%, 90%, 95% or more, e.g., 99% or 100%, sequence identity. In contradistinction, the term "complementary to" is used herein to mean that the complementary sequence is homologous to all or a portion of a reference polynucleotide sequence. For illustration, the nucleotide sequence "TATA C" corresponds to a reference sequence "TATAC and is complementary to a reference sequence "GTATA".

The term "sequence identity" means that two polynucleotide sequences are identical (i.e., on a nucleotide- by- nucleotide basis) over the window of comparison. The term

"percentage of sequence identity" means that two polynucleotide sequences are identical (i.e., on a nucleotide-by-nucleotide basis) over the w indow of comparison. The term "percentage of sequence identity" is calculated by comparing two optimally aligned sequences over the window of comparison, deterrrining the number of positions at which the identical nucleic acid base (e.g., A, T, C, G, U, or I) occurs in both sequences to yield the number of matched positions, dividing the number of matched positions by the total number of positions in the window of comparison (i.e., the w tndow size), and multiplying the result by 100 to yield the percentage of sequence identity. The terms "substantial identity" as used herein denote a characteristic of a polynucleotide sequence, w herein the polynucleotide comprises a sequence that has at least 85 percent sequence identity, preferably at least 90 to 95 percent sequence identity, more usually at least 99 percent sequence identity as compared to a reference sequence over a comparison window of at least 20 nucleotide positions, frequently over a window of at least 20-50 nucleotides, wherein the percentage of sequence identity is calculated by comparing the reference sequence to the polynucleotide sequence which may include deletions or additions w hich total 20 percent or less of the reference sequence over the w indow of comparison.

"Conservative" amino acid substitutions are, for example, aspartfc-glutarric as polar acidic amino acids; lysine/arginine/histkJine as polar basic amino acids;

leucine/isoleucine/methionine/valine/alanine/glycine/prol ine as non-polar or hydrophobic amino acids; serine/ threonine as polar or uncharged hydrophilic arrino acids. Conservative amino acid substitution also includes groupings based on side chains. For example, a group of amino acids having aiphatic side chains is glycine, alanine, vaine, leucine, and isoleucine; a group of amino acids having aliphatic-hydroxyl side chains is serine and threonine; a group of amino acids having amide-containing side chains is asparagine and glutamine; a group of amino acids having aromatic side chains is phenylalanine, tyrosine, and tryptophan; a group of amino acids having basic side chains is lysine, arginine, and histidine; and a group of amino acids having sulfur-containing side chains is cysteine and methionine. For example, it is reasonable to expect that replacement of a leucine w ith an isoleucine or valine, an aspartate w ith a glutamate, a threonine w ith a serine, or a similar replacement of an amino acid w ith a structuraly related amino acid w ill not have a major effect on the properties of the resulting polypeptide. Whether an arrino acid change results in a functional polypeptide can readiy be determined by assaying the specific activity of the polypeptide. Naturaly occurring residues are divided into groups based on common side-chain properties: (1) hydrophobic: norleucine, met, ala, val, leu, ife; (2) neutral hydrophilic: cys, ser. thr; (3) acidic: asp, glu; (4) basic: asn, gin, his, lys, arg; (5) residues that influence chain orientation: gly, pro; and (6) aromatic; trp, tyr, phe.

The invention also envisions polypeptides w ith non-conservative substitutions. Non- conservative substitutions entail exchanging a member of one of the classes described above for another.

Nucleic acid sequence w hich encodes an AAT

A AT, (SEERPHMA1), a 52 kDa a serum serine protease inhibitor, functions to protect the lung from the pow erf ul protease neutrophil elastase (NEE) ^4"10 Low circulating levels of AAT are the result of mutations in the SEERPINA1 gene (MM 107400) ⁸² · ⁸³ , w ith more than 120 naturally occurring alleles ⁸⁶ ' ⁸⁴ - ⁸⁸ . The normal AAT alleles are M\(A\a2†3), M1(Val213), M2, M2 and M4 ⁸⁷ . The most common deficient variants are the severe Z allele, observed w ith high frequency in Caucasians in Northern .European countries and North America, and the milder S form, w ith high prevalence in the toerian Ftenrisula ^65,70 ' ⁸⁵ . AAT deficiency is a common, fatal autosomal recessive disorder characterized by low (<11 μΜ) plasma levels of AAT. Generally, is it associated w ith the development of panacinar emphysema, manifesting cSnicaly in smokers ages 35-45 and in non-smokers 55-65. Current therapy is weekly or monthly intravenous administration of AAT purified pooled plasma.

The vast majority of cases of emphysema associated w ith AAT deficiency are caused by homozygous inheritance of the severe Z variant, with a single amino acid substitution of lysine for glutamic acid at position 342 (E342K) ⁸⁸ . The Z mutation causes the AAT protein to polymerize in hepatocytes, preventing secretion into the blood ^{6365,70,88"82} . The S allele, a single amino acid substitution of a glutamic acid by a valine at position 264 (E264V), results in an unstable protein with reduced serum half-life ⁰³⁴⁶ . Individuals homozygous for the Z mutation (ZZ) have plasma AAT levels 10 to 15% of the normal M allele and account for approximately >95% of cases of cinicaiy recognized AAT deficiency ^5,7,10,11,85 ' ^71,97 .

An exemplary adeno-associated virus, e.g., serotype 8 adeno-associated virus, was prepared for coding for a next generation oxidation-resistant AAT in vfvo gene therapy strategy to treat the pulmonary manifestations of A AT deficiency. Throughout this specif ication w hich includes its figures, an embodiment is at times referenced as AAV.vAAT.

A significant advantage of the compositions provided herein is that they provide an oxidation-resistant form of AATthat provides a more stable, effective therapy, despite the persistent stress of the AAT in the lung by inhaled oxidants, common in everyday life ^101,102 . In this regard, compositions described herein have the marked advantage in that, for the amount of AAT available to defend the tow er respiratory tract, AAV.vAAT is far more Ikely to make available functional AATmolecules to defend the alveolar structures fromNE, requiring less gene therapy-generated AAT to be effective.

Compositions

The parameters relevant to designing the composition include: (1) the viral vector or capsid; (2) the expression cassette including the promoter and AAT coding sequence; and (3) route of administration.

Capsid. AAV is highly effective in transducing organs in vivo, with persistent expression ¹⁰³ ' ¹⁰⁶ . AAV is a small parvovirus that does not cause human disease. There are 6 human serotypes and >50 nonhuman serotypes, primarily from nonhuman primates ¹⁰⁷ . The most effective, and most commonly used AAV vectors are serotypes 1,2,5,8,9 and rh.10 ^10S . As detailed in 4. Approach, based on evaluation of 25 serotypes, the AAV8 vector was effective in generating high, persistent levels of human AAT in experimental animals. In an embodiment, the composition comprises the AAV8 capsid w ith a genome that includes the highly active GAG promoter ¹⁰⁸ , an artificial intron, the oxidation resistant human AAT c DMA (described below) and poly A signal (Figure 2A).

Expression cassette. The AAT coding sequence is based on the normal human

M1(Ala213) cDMA, but w ith modifications at resides 351 and/or 358, to render the AAT protein produced by AAV.vAAT resistant to oxidation. The mature AAT protein is a single chain of 394 amino acids and 3 carbohydrate side chains, w ith a total MW of 52 kDa ^110,111 . AAT is a globular protein, w ith the carbohydrate side chains on the opposite end of the Met358 at the active site ¹¹² (Figure 2B). There are 9 a-helices and 3 β-sheets. Like other serpins, the Met-Ser bond at the active site serves as pseudosubstratefor NEE? ⁰ . The interaction of AAT and NE is suicide for both. How ever, w hie AAT is a potent inhibitor of serine proteases, it can be rendered ineffective by oxidants. The major sources of oxidants in the lower respiratory tract are exogenous from inhaled oxidants (cigarette smoke, air pollutants) and endogenous from activated inflammatory cells ¹¹³ . Exposure of the normal M type AATto oxidants results in oxidation of Met358 and Met351 at the active site to methionine sulfoxide, significantly reducing the ability of AATto inhibit NE ^1,32,39,114 . Consistent with these in vitro studies, the Crystal laboratory demonstrated that the AAT in lung epithelial lining fluid (ELF) of normal smokers had markedly reduced NE inhibiting capacity (Figure 3), an observation confirmed by in vrfro studies ^33"3841 . The oxidized AAT not only loses its anti-NE activity but also acts as a proinflammatory stimulus, activating monocytes and epithelial cells to generate chemoattractants ^115,118 . Further evidence that oxidation of AAT occurs in vivo is the observation of elevated levels of oxidized AAT in serum in inflammatory disorders ¹¹⁷ . Replacement of Met358 with Valor Leu generates an AAT molecule that is effective at inhibiting neutrophil elastase, but is resistant to oxidation, functioning effectively in an oxidative milieu (Figure 4). This has been confirmed by others ^{39,42,42,43,118} , w ith the additional observation that the Met351 oxidation can also be prevented by substituting Val or Leu for Met351 ^3B . The "base" AAT allele from w hich the AATexpressbn cassette derived may be the common Z allele w hich was derived from the normal M1(Ala213) allele (Figure 2C) ¹¹⁹ , and w hich 95% of all AAT deficient individuals have.

Pharmaceutical compositions

The invention provides a composition comprising, consisting essentially of, or consisting of the above-described gene transfer vector and a pharmaceutically acceptable (e.g., physiologically acceptable) carrier. VWien the composition consists essentially of the inventive gene transfer vector and a pharmaceutically acceptable carrier, additional components can be included that do not materially affect the composition (e.g., adjuvants, buffers, stabilizers, anti- inflammatory agents, solubilizers, preservatives, etc.). When the composition consists of the inventive gene transfer vector and the pharmaceutically acceptable carrier, the composition does not comprise any additional components. Any suitable carrier can be used within the context of the invention, and such carriers are well known in the art. The choice of carrier will be determined, in part, by the particular site to which the composition may be administered and the particular method used to administer the composition. The composition optionally can be sterile w ith the exception of the gene transfer vector described herein. The composition can be frozen or lyophilzed for storage and reconstituted in a suitable sterile carrier prior to use. The compositions can be generated in accordance with conventional techniques described in, e.g., Remington: The Science and Practice of Pharmacy, 21st Edition, Lippincott Vvilliams & Wilkins, Philadelphia, PA (2001).

Suitable formulations for the composition include aqueous and non-aqueous solutions, isotonic sterile solutions, which can contain antioxidants, buffers, and bacterios tats, and aqueous and non-aqueous sterile suspensions that can include suspending agents, solubilizers, thickening agents, stabiizers, and preservatives. The formulations can be presented in unit- dose or multi-dose sealed containers, such as ampules and vials, and can be stored in a freeze- dried (lyophilized) condition requiring only the addition of the sterile liquid carrier, for example, water, immediately prior to use. Extemporaneous solutions and suspensions can be prepared from sterile powders, granules, and tablets of the kind previously described. In one

embodiment, the carrier is a buffered saline solution. In one embodiment, the inventive gene transfer vector is administered in a composition formulated to protect the gene transfer vector from damage prior to administration. For example, the composition can be formulated to reduce loss of the gene transfer vector on devices used to prepare, store, or administer the gene transfer vector, such as glassware, syringes, or needles. The composition can be formulated to decrease the light sensitivity and/or temperature sensitivity of the gene transfer vector. To this end, the composition may comprise a pharmaceutically acceptable liquid carrier, such as, for example, those described above, and a stabilizing agent selected from the group consisting of polysorbate 80, L-arginine, polyvinylpyrrolidone, trehalose, and combinations thereof. Use of such a composition w ill extend the shelf life of the gene transfer vector, facilitate administration, and increase the efficiency of the inventive method. Formulations for gene transfer vector - containing compositions are further described in, for example, Wright et al., Curr. Opin. Drug Discov. Devel., 6(2): 174-178 (2003) and Wright et al., Molecular Therapy, 12. 171-178 (2005)) The composition also can be formulated to enhance transduction efficiency. In addition, one of ordinary skii in the art w il appreciate that the inventive gene transfer vector can be present in a composition w ith other therapeutic or biologically-active agents. For example, factors that control inflammation, such as ibuprofen or steroids, can be part of the composition to reduce sw elling and inflammation associated w ith in vivo administration of the gene transfer vector. Immune system stimulators or adjuvants, e.g., interleukins, lipopolysaccharide, and double-stranded RNA, can be administered to enhance the AAT activity. Antibiotics, i.e., microbicides and fungicides, can be present to treat existing infection and/or reduce the risk of future infection, such as infection associated w ith gene transfer procedures.

Injectable depot forms are made by forming rricroencapsule matrices of the subject compounds in biodegradable polymers such as polylactide-polyglycoide. Depending on the ratio of drug to polymer, and the nature of the particular polymer employed, the rate of drug release can be controlled. Examples of other biodegradable polymers include poly(orthoesters) and poly (anhydrides). Depot injectable formulations are also prepared by entrapping the drug in liposomes or rricroemulsions which are compatible with body tissue. In certain embodiments, a formulation of the present invention comprises a

biocompatible polymer selected from the group consisting of poly amides, polycarbonates, poly aky lenes, polymers of acrylic and methacryfic esters, polyvinyl polymers, polyglycolides, polysioxanes, polyurethanes and co-polymers thereof, celuloses, polypropylene, polyethylenes, polystyrene, polymers of lactic acid and glycolc acid, poly anhydrides, poly(ortho)esters, poly(butic acid), poly(valeric acid), poly(lactide-co-caprolactone), polysaccharides, proteins, polyhyaluronic acids, polycyanoacrylates, and blends, mixtures, or copolymers thereof.

The composition can be administered in or on a device that allows controled or sustained release, such as a sponge, biocompatible meshwork, mechanical reservoir, or mechanical implant Implants (see, e.g., U.S. Ratent No. 5,443,505), devices (see, e.g., U.S. Patent No. 4,863,457), suchas an implantable device, e.g., a mechanical reservoir oran implant or a device comprised of a polymeric composition, are particularly useful for administration of the inventive gene transfer vector. The composition also can be administered in the form of sustained- release formulations (see, e.g., U.S. Ratent No. 5,378,475) comprising, for example, gel foam, hyaluronic acid, gelatin, chondroitin sulfate, a polyphosphoester, suchas bis-2- hydroxyethyl-terephthalate (BHET), and/or a polylactic-glycolic acid.

The dose of the gene transfer vector in the composition administered to the mammal w ill depend on a number of factors, including the size (mass) of the mammal, the extent of any side- effects, the particular route of administration, and the Ike. in one embodiment, the inventive method comprises administering a "therapeutically effective amount" of the composition comprising the inventive gene transfer vector described herein. A "therapeuticaly effective amount" refers to an amount effective, at dosages and for periods of time necessary, to achieve a desired therapeutic result. The therapeuticaly effective amount may vary according to factors such as the extent of A AT deficiency, age, sex, and w eight of the individual, and the ability of the gene transfer vector to eicit a desired response in the individual. The dose of gene transfer vector in the composition required to achieve a particular therapeutic effect typically is administered in units of vector genome copies per cell (gc/cel) or vector genome copies/per kilogram of body weight (gc/kg). One of ordinary skill in the art can readily determine an appropriate gene transfer vector dose range to treat a patient having a particular disease or disorder, based on these and other factors that are w ell know n in the art The therapeutically effective amount may be between 1 x 10 ¹⁰ genome copies to 1x 10 ^1J genome copies.

In one embodiment of the invention, the composition is administered once to the mammal. It is believed that a single administration of the composition will result in persistent expression of AAT in the mammal with minimal side effects. However, in certain cases, it may be appropriate to administer the composition multiple times during a therapeutic period to ensure sufficient exposure of eels to the composition. For example, the composition may be administered to the mammal two or more times (e.g., 2, 3, 4, 5, 6, 6, 8, 9, or 10 or more times) during a therapeutic period. The present invention provides pharmaceutically acceptable compositions which comprise a therapeutically-effective amount of gene transfer vector comprising a nucleic acid sequence w hich encodes an oxidation- resistant AAT as described above.

Route of administration. In the normal humans, AAT is produced mainly by hepatocytes. How ever, AAT can be produced by many different cells/organs once the gene has been effectively transferred. The routes of administration that have been used for in vivo gene therapy for AAT deficiency include intravenous or intraportal vein (targeting liver hepatocytes), direct administration to skeletal muscle, intrabronchial (targeting the respiratory epithelium) and intrapleural.

All of these routes augment serum AAT levels. However, the challenge for effective AAT gene therapy is to achieve the threshold levels of AATfor successful protection of the alveolar structures from neutrophil proteolytic activity of serum AAT levels of at least about 11 uM h serum and 1.2 μΜ in alveolar B_F ^7,8,11,13 . To achieve this "biochemical efficacy," both the serum and EELF protective levels of A AT must be demonstrated. Attempts of gene therapy targeted to the lung via delivery of AAV vector to the respiratory tract epithelium have been frustrated by the anti-pathogen immune and physical defenses of the epithelium, and the deficiency of viral receptors on the respiratory epithelial apical surface ^122'125 . A variety of AAV vectors have been assessed by this route in experimental animals, including serotypes 1, 2, 5, 6, 9, 8, 9, rh.10, rh.20, rh.46, rh.64R1, hu.48R3, cy.5R4, and ΑΑνβ^ ^θΙ.) ²⁴ · ²⁵ · ³⁰ · ¹²⁵ - ¹²⁷ . None have achieved therapeutic levels, and the respiratory epithelial route has not been developed for clinical trials. The skeletal muscle route has also been evaluated in experimental animals and h human trials using AAV1 and 2 ²⁸ · ¹²⁸ . The clinical study w ith A A V2 to treat A AT deficiency, using doses of 2.1x10 ¹² -6.9x10 ¹³ vector genomes (vg), observed low transient elevations of serum AAT ¹²⁹ . A trial using AAV1 w ith doses up to 6x10 ¹² vg/kg had better success, with levels up to 5% of the target 11 μ^ ^{0 123 130 131} . h experimental animals, administration of AAV vectors by the intravenous route targets primarily the liver. Alternatively, portal vein delivery has been explored. The best results have been with AAV serotypes 8, 9 and 10 (see Chiuchiolo and Crystal ¹⁰³ for review). Neither the intravenous nor intraportal routes has been tested in humans.

AAT deficiency may also be addressed via pleural administration ^132,133 . The pleura presents several structural features that make it an attractive site for gene delivery targeting both the lung parenchyma and systemic circulation, providing a large surface area for gene transfer that is easily accessible. The pleura is a thin serous membrane that encloses the chest cavity attaching to the chest wall (parietal pleura) and to the lung parenchyma (visceral pleura) merging at the chest hilum ^134,135 . The parietal and visceral pleura contain a single layer of mesotheial cells surrounded by a thh layer of connective tissue rich in lymphatic and blood vessels connected to the systemic circulation (Figure 5A). The pleura layers are separated by a pleural fluid (0.5 to 1 mL in humans) ¹³⁵ - ¹⁴⁰ .

Compositions of the invention delivered to the pleura can genetically modify mesothelial cells lining the pleura and can also provide systemic delivery by vector leaking from the pleura via visceral pleural lymphatics to the systemic venous system and then primariy to liver hepatocytes (Figures 5B,C). Trie AAT produced by transduced pleural mesothelial cells are secreted and diffuse into the lung parenchyma. There may also be contribution from A AT carried by abundant lymphatic vessels from the visceral pleura that form an intercommunicating plexus that penetrate the lungs draining into the bronchial lymphatics ^134,135,1 * ¹ . The lymphatic system of the parietal pleura connects directly from the pleural space through stomata, a mechanism for paralel systemic distribution of the gene therapy vector to primarily the liver after intrapleural delivery ^134,135,141 . Another advantage of targeting the pleura for gene therapy is the low risk of adverse effects of any inflammation induced by the gene therapy vector; in humans, inflammation in the pleura has no significant effect on lung function ^142,143 . In regard to safety, intrapleural procedures (administration of saline or drugs, biopsies) are standard, 5-10 min procedures for pulmonary physicians, and extensive safety studies of intrapleural administration of a 1 ^st generation AAV vector coding for AATw as carried out by the Crystal laboratory in mice and nonhuman primates, with no serious adverse events associated w ith the intrapleural ¹⁰ . Subjects

The subject may be any animal, including a human, human and non-human animals. Non-human animals includes all vertebrates, e.g., mammals and non-mammals, such as non- human primates, sheep, dogs, cats, cows, horses, chickens, amphibians, and reptiles, although mammals are preferred, such as non-human primates, sheep, dogs, cats, cow s and horses. The subject may also be livestock such as, cattle, sw ine, sheep, poultry, and horses, or pets, such as dogs and cats.

Preferred subjects include human subjects suffering from or at risk for the AAT deficiency. The subject is generaly diagnosed with the condition of the subject invention by skilled artisans, such as a medical practitioner.

The methods of the invention described herein can be employed for subjects of any species, gender, age, ethnic population, or genotype. Accordingly, the term subject includes males and females, and it includes elderly, ekJerly-to-adult transition age subjects adults, adult- to-pre-adult transition age subjects, and pre- adults, including adolescents, childrens, and infants.

Examples of human ethnic populations include Caucasians, Asians, Hspanics, Africans,

African Americans, Native Americans, Semites, and Pacific Islanders. The methods of the invention may be more appropriate for some ethnic populations such as Caucasians, especially northern European populations, as well as Asian populations.

The term subject also includes subjects of any genotype or phenotype as long as they are in need of the invention, as described above. In addition, the subject can have the genotype or phenotype for any hair color, eye color, skin color or any combination thereof.

The term subject includes a subject of any body height, body weight, or any organ or body part size or shape.

The invention w ill be further described by the follow ing non- limiting examples. Example

The animal experiments are designed to guarantee unbiased experimental design ¹⁴⁸ . .Experimental animals are randomly assigned to groups, and the investigators wil be blinded w hen evaluating animal behavior. Males and females are used to address possible gender differences in AAV transduction, disease manifestation, or therapy response. The numbers of animals in each cohort have been chosen to yield statistically significant data.

Statistical considerations. The in vitro studies are performed in triplicate for 3

independent experiments. All data are presented as means ± SEEM unless otherwise stated. Animal studies are performed w ith n=5M, 5F mice/ group to minimize animal usage w hile assessing gender difference and giving a reasonable chance that differences can be evaluated. Using a simple (tw o-sided) pow er calculation, a tw o-f old difference can be seen w ith an alpha of 0.05 and a pow er of 0.9 if the variance in the measured parameter w as 50%. Statistical analysis of clinical pathology is performed using the SAS Software System version 9.2. A t-testw ilbe used for comparison of tw o groups and A NOVA for more groups to assess treatment-related effects with gender at each time point Where there w as a significant trend across groups (p<0.05) by A NOVA, Tukey's multiple comparison tests is used to assess pairwise differences among all groups, where n=10M and 10F per group.

A AT levels. EELISA, using a highly purified A AT standard ¹⁵¹ . For serum, the AAT levels are expressed as μΜ. Lung EELF is obtained by fiberoptic bronchoscopy and lavage. The recovered fluid is a mixture of the saline used to recover the EELF and the actual EELF. The volume of recovered EELF is quantified using the urea method ¹⁸⁵ , and the level of AAT expressed in μΜ using EELF volume as the denominator ¹⁴ .

AATfunction. Anti-NE capacity ± oxidants is assessed using the assays described in Figure 6. The activity in serum and EELF is expressed in μΜ ¹⁴ . Isoelectric focusing. To quantify the relative amounts of the Z AAT and AAV.vAATAATin serum and EELF, using standard methods ^2,22 . A A V.vAAT-related immunity assays. The capsid of AAV.vAAT is "foreign" to the patient, and based on prior gene therapy studies ^19,188 , there will be humoral and perhaps celufcar immunity induced to some degree against the AAV8 capsid, and although far less likely, to the AAT protein expressed by AAV.vAAT. These assays include serum anti-AAV8 antibodies

(neutralizing antibody titer using AAV8 reporter transgene expression in 2V6.11 cells ¹⁶⁷ ), blood mononuclear cells anti-AAV8 cellular immunity (EELISFOT), serum anti- AAT antibodies and blood mononuclear cells anti- A AT cellular immunity (EELISFOT).

Using the normal Μ1ΓΑ213) AATcodina sequence as a base, assess combinations of Met Leu, and Val at positions 351 and 358.

Objectives. All of the current gene therapy strategies for AAT deficiency deliver the normal human M1(Vat213) cDNA using an AAV gene transfer vector ^2,1 " ^{1 ,12e} . The expression cassette of AAV.vAAT is based on M1(Ala213) w hich 95% of the recipients of AAV.vAAT express and which was derived from the normal M1(Ala213) allele (Figure 2C) . M1(A1213) oxidant-resistant forms of A AT are assessed in vitro to determine useful variants for use in

AAV. vAAT (Table I)- Numerous studies have demonstrated that the methionine at positions 351 and 358 can be oxidized leaving AAT inactive ¹ · ^32"3δ · ^3β ·* ^{1 ,149,1 Μ} . Changing these residues to valine or leucine have been show n to prevent oxidation while maintaining the ability to inhibit ΝΕ ³⁸ · ⁴³ · ¹¹⁸ (Figure 4). The preliminary data show s that the AAT variant candidate ptasrrid w ith a Leu change at positions 351/358 w as more resistant to the oxidizing agent N-chlorosuccinirride

(NCS) compared with the M1(A213) or M1(V213) AAT (Figure 6). The basic assay is to transfectthe expression cassette plasrrids described in Figure 6 into 293T cells in anti-protease free cell culture media, and test the resulting media for anti-neutrophil elastase inhibition activity ± oxidants.

Detailed methods. Site-directed mutagenesis is used to change the methionine residues at amino acid positions 351 and 358 to valine or leucine in the M1(A213) allele cDNA in all possible combinations of single and double variants (Table I). Plasrrids encoding for the AAT oxidant variants or the parental AAT w ill be transfected into 293T cells in serum-free media and the secreted AAT proteins cotected in the supernatant after 72 hr. The amount of AAT protein in the supernatant is quantified by EELISA using a highly purified, vaidated standard ¹⁵¹ . Two approaches are used to determine the oxidation resistance of AAT candidates. First, the parental AAT and the AATvariants are pre-incubated w ith increasing concentrations of oxidizing agents such as NCS, H ₂ Q, or cigarette smoke extract before incubation w ith NE Inhibition of NE is measured by addition of the substrate N-Suc-Ala-Ala-Ala-p-nitroanilide ¹⁵² . The product of NE hydrolysis, />-nitroaniSde, is assessed by spectrophotometry measurement at 410 nm Second, the AAT constructs is pre-incubated w ith a fixed amount of oxidizing agent for varying amounts of time and then evaluated for their ability to rihbit NE The association rate (Kas _S0C ) is calculated for each of the oxidized AAT variants and parental AAT by determining the inhibition activity as a function of time ^{32,98,153,154} . The AATvariants are scored (>85% inhibition - 5 points; 70-85% - 4; 55-70% - 3; 40-55% - 2; 25-40% - 1; <25% - 0) based on their ability to inhibit neutrophil elastase after exposure to oxidizing agents at different concentrations and times.

Studies may also be carried out to evaluate variants for inhibition of catnaps in G, another serine protease that is inhibited by A AT and has been shown to play a role in the development of pulmonary emphysema ¹⁵⁵ .

Intrapleural administration of AAV.vA AT to experimental animals results in persistent. high levels of oxidation-resistant human AAT in serum and lung epithelial lining fluid.

In a mouse preclinical model, De et al ² demonstrated that an AAV5- based vector expressing human AAT produced high, sustained levels of the protein (1 mg/ml) in serum via the intrapleural route compared to intramuscular administration at the same dose. The therapy approach resulted in levels of AAT in the lung similar to that in serum ² . In a comparison of 25 different AAV serotypes in mice, De et aF demonstrated that 2 clade E AAV nonhuman primate vectors, A AVrh.10 and AAV8 were the most effective, with intrapleural administration providing high, long term delivery of human normal M type AAT; AAV8 is a bit slower than AAVrh.10, but both made the same level of expression by 4 w k, 2.5-fold above the therapeutic threshold of 11 μΜ. The Crystal laboratory chose AAVrh.10 for follow up up studies. I-Sgh serum levels w ith AAVrh.10 w ere sustained through 24 w k, the latest point of the study (Figure 7B). Importantly, similar levels w ere achieved in serum ting ELF, demonstrating "biochemical efficacy" (Figure 7C). AAVrh.10 delivered by the intrapleural route was show n to be safe in a safety and toxicology study with 280 mice and 36 nonhuman primates ¹⁹ . The intrapleural vector transfer resulted in high levels of human AATmRNA locaized to the lung pleura mesothelioma that persisted for at least 6 months in mice ¹⁹ and for at least 1 yr after a single vector administration in nonhuman primates ¹⁹ , the length of the study (Figure 8). In the conext that AAT expression following intrapleural AAV8artd AAVrh.10are similar AAV.vAAT could also be based on AAV serotypes rh.lO or 8.

AAV.vAAT may comprise the CAG promoter driving an oxidation-resistance, NE inhibiting human AAT coding sequence based on AAT(Ata213) packaged in the AAV8capsid (Figure 2A). Studies are carried out in mice to demonstrate that the intrapleural route of administration of AAV.vAAT provides sufficient levels of anti-NE, oxidation-resistant human AAT in serum and lung epithelial ining fluid (ELF). Studies of the Crystal laboratory w ith AAV8 and its similar clade E caps id AAVrh.10 (Figure 7), have shown that intrapleural route is feasible. Identical doses of AAV.vA AT variants are administered by the intravenous route, the route that delivers AAV vectors, including AAV8, primarBy to the liver, the conventional route AAV vectors are administered for systemic metabolic diseases ^157'159 . The studies are carried out as a function of dose in half-log increments (4x10 ¹⁰ , 1x10 ¹¹ and 4x10 ¹¹ gc; the 4x10 ¹¹ gc dose scales to -4x10 ¹⁴ gc in humans, the highest dose that can be used safely in adult humans without concomitant liver toxicity ¹⁵⁰ ). Over a 6 month period, serum and lung ELF (recovered by lavage) are assessed for human AAT levels and anti-NE capacity ± oxidant stress. Based on the data from the Crystal laboratory and the literature ¹⁰³ , if AAV vectors provide stable expression for 6 months, the levels can persistforthe lifetime of the experimental animal ^18,181 .

Administration by the intrapleural route provides persistent, high level expression of oxidant-resistant, NE functioning human AAT in serum and lung ELF. The cDNA from oxidant resistant a1 AT constructs are packaged into AAV8 (Figure 2A). AAV.vAATis produced using adherent 293T cells (see below for a detailed description of A A V. VvAAT manufacturing) .

In vivo assessment. AAV.vAATis administered at 3 doses (4x10 ^10, 10 ¹¹ , 4x10 ¹¹ ) by the intrapleural and intravenous routes to C57BI/6 mice (C57E5/6 are used because they do not recognize human AAT as "foreign") ²² , with controls AAV8hAAT (the identical vector as

AAV.vAATbutwiththe normal AAT(Ala213) cDNA) and AAV8Null (the identical vector as

AAV.vAAT butw ith no AAT in the expression cassette). Only the highest dose 4x10 ¹¹ gc is used for the controls. Serum and lung ELF is assessed at 0 (pre- therapy), 14, 28, 90 and 180 days fcr human AAT levels and anti-NE capacity in the absence or presence of NCS (Table 2).

Detailed methods for a formal toxicology study. Based on Crystal laboratory recent experience w ith the FDA and the Crystal laboratory experience w ith a GMP 1 ^st generation AAVrh.10 vector (same clade as AAV8) toxicology study ¹⁰⁷ , and the FDA website guidance that neither the use of multiple species nor nonhuman primates is a default ¹⁸³ , we expect that the only required toxicology study will be in rrice. The total amount of GMP vector required is 5x10 ¹⁵ gc. The study w ill evaluate two doses (10 ¹¹ and 10 ¹² genome copies; 10 ¹² gc is ½ tog greater than the likely highest dose scaled to humans) administered by either the intrapleural or intravenous route to C57BL/6 rrice to assess: (1) safety follow ing vector administration; (2) biodistribution of the vector; and (3) halAT mRNA expression in chest cavity organs (Table 3). General safety, hematology, serum chemistry, histopathotogy parameters, vector genome distribution and trans gene expression will be evaluated at 4 time points (4, 28, 90, 180 days) after a single AAV.vAAT administration.

Table 3 describes a toxicology study. The design is similar to that carried out for IND BB IND 16008 fora 1 ^st generation AAV vectorfor AAT deficiency (AAVrh.lOhAAT); this toxicology study has been published ^19,162 .

Table 3. Mouse Safety and Toxicology Study Design

Manufacturing

Many CROs have experience in producing GMP vectors for in vivo gene therapy clinical studies and in designing and carrying out formal toxicology studies, including Weill Cornell Belfer Gene Therapy Core Facility (BGTCF; a core facility run by the Crystal laboratory that carries out f ee-f or-service contract production of GMP gene therapy vectors for academia and industry) as they have experience in producing AAV8 for a clinical trial, and in producing GMP vectors expressing human AAT.

For AAV.vAATthe process uses a tw o plasmid transfection system in adherent HEK293 cells from highly characterized and quaified eel bank that meets regulatory expectations. Plasrrids are kanamycin resistant for selection and compatible with FDA guidelines for manufacturing clinical grade drug. After 5 days, cells are harvested and a crude viral lysate is made by freeze/thaw cycles followed by benzonase digestion to digest host cell derived nucleic acids followed by high salt to quench benzonase and disrupt A A V-cell membrane interactions. The resulting cell harvest is clarified by depth filtration, concentrated by tangential flow filtration (TFF) follow ed by two steps of membrane ion exchange, buffer exchange on TFF and separation of empty from full caps ids by BIA monolith column (Figure 9). Al steps are scalable and transferable to contract manufacturing for eventual large scale production. The methods, translated to GMP through SOPs and batch records will be perfected via multiple mock productions under GMP conditions with the specific AAV .vAATtransgene. Staff audits the documents to assess process yield and quality. Lots are released based on criteria agreed to by the FDA for clinical development of AAV vectors for clinical application, and include: (1) testing of the crude viral lysate for mycoplasma and on 11 different viruses; (2) testing of the bulk product fortransgene function and product, viral capsid purity, genome structure stability, empty capsids, infectious titer, viral titer, and replication competent AAV; and (3) testing of the final product lot for sterility, endotoxin, pH, appearance, and viral titer.

Phase 1 trial A clinical phase I study compares 3 doses, 8x10 ¹² , 8x10 ¹³ and 4x10 ¹⁴ genome copies administered by the intrapleural route to individuals (n=5 each dose) w ith a ZZ or Z Null genotype and serum AAT levels <11 μΜ. Besides the normal safety parameters, the goal of the therapy is to reach a sustained concentration of >1.2 μΜ AAT in ELF, the lung "protective lever ¹⁶⁴ . The completion of this study provides critical safety and preliminary efficacy data. Most of the parameters in the phase I trial utilize standard clinical assays available in all academic medical hospitals. However, there are also assays relevant to AAV.vAATf unction administered to AAT deficient patients, and assays to assess immune response to AAV.vAAT. References

1. Johnson D Travis J. The oxidative inactivation of human alpha-1-proteinase inhibitor.

Further evidence for methionine at the reactive center. J Biol Chem 1Θ7Θ; 254:4022-

4026

2. De B, Heguy A, Leopold PL, Was if N, Korst RJ, Hackett NR, Crystal RG. Intrapleural administration of a serotype 5 adeno-associated virus coding foralphal-antitrypsin mediates persistent, high lung and serum levels of alphal-antitrypsin. Mol Ther 2004; 10:1003-1010

3. Fagovich OE, Wang B, Chiuchiolo MJ, Kaninsky SM, Sondhi D, Jose CL, Price CC, Brooks SF, Mezey JG, Crystal RG. Anti-hlgE gene therapy of peanut-induced anaphylaxis in a humanized murine model of peanut allergy. J Allergy Clin Immunol 2016; 138:1652-1662

4. Brantiy M, Nukiwa T, Crystal RG. Molecular basis of alpha-1-antitrypsin deficiency. Am J Med 1988; 84:13-31

5. Brantiy ML, Paul LD, Miller BH, Falk RT, Wu M, Crystal RG. Clinical features and history of the destructive lung disease associatedw ithalpha-1-antitrypsin deficiency of adults w ith pulmonary symptoms. Am Rev Respir Dis 1988; 138:327-336

6. Carrell, R & Bosw ell, D. (1986) in Proteinase Inhibitors, eds. Barrett, A. & Salvensen, G.

(Bsevier, Amsterdam), pp. 403-420.

7. Crystal RG. Alpha 1-antrtrypsin deficiency, emphysema, and liver disease. Genetic bass and strategies for therapy. J Clin Invest 1990; 85:1343-1352

8. Gadek JE, Fells GA, Zimmerman RL, Rennard SI, Crystal RG. Antielastases of the

human alveolar structures. Impications for the protease-antiprotease theory of emphysema. J CSn Invest 1981; 68:889-898

9. Lungarella G, Cavarra E, Lucatteli M, Martorana FA. The dual role of neutrophil elastase in lung destruction and repair, ht J Biochem Cell Biol 2008; 40:1287-1296

10. Silverman EK Sandhaus RA. Clinical practice. Alphal-antitrypsin deficiency. N Engl J Med 2009; 360:2749-2757

11. Crystal RG, Brantiy ML, Hubbard RC, Curiel DT, States DJ, Holmes MD. The alpha 1- anititrypsin gene and its mutations. Clinical consequences and strategies for therapy. Chest 1989; 95:196-208

12. Tuder RM, Janciauskiene SM, Fetrache I. Lung disease associated with alphal- antitrypsin deficiency. Ffoc AmThorac Soc 2010; 7:381-386

13. Gadek JE, Klein HG, Holland FV, Crystal RG. Replacement therapy of alpha 1- antitrypsin deficiency. Reversal of protease-antiprotease imbalance within the alveolar structures of FtZ subjects. J Clin Invest 1981; 68:1158-1165 14. Wewers MD, Casolaro MA, Seiers SE, SwayzeSC, McPhaul KM, Wrttes JT, Crystal RG. Replacement therapy for alpha 1-antitrypsin deficiency associated with emphysema. N Engl J Med 1987; 316:1055-1062

15. Chapman KR, Burdon JG, Ritulainen E, Sandhaus RA, Seersholm N, Stocks JM, Stoel BC, Huang L, Yao Z, EEdelman JM, McBvaney NG. Intravenous augmentation treatment and lung density in severe alphal antitrypsin deficiency (RAPID): a randomised, double- blind, placebo-controlled trial. Lancet 2015; 386:360-368

16. Crystal RG. Augmentation treatment forafchal antitrypsin deficiency. Lancet 2015;

386:318-320

17. Crystal RG. Compelling evidence for the efficacy of alphal-antitrypsin augmentation treatment for alphal-antitrypsin deficiency. Lancet Respir Med 2017; 5:7-8

18. McBvaney NG, Burdon J, Holmes M, Glanville A, Wark FA, Thompson PJ, Hernandez P, Chlumsky J, Teschler H, Ficker JH, Seersholm N, Altraja A, Makitaro R,

Chorostow ska-Wynimko J, Sanak M, Stoicescu PI, Ritulainen E, Vit O, Wencker M, Tortorici MA, Fries M, Edelman JM, Chapman KR, Rapid Extension Trial Group. Long- term efficacy and safety of alphal proteinase inhibitor treatment for emphysema caused by severe alphal antitrypsin deficiency: an open-label extension trial (RARD-OLE). Lancet Respir Med 2017; 5:51-60

19. Chiuchiok) MJ, Karrrisky SM, Sondhi D, Hackett NR, Rosenberg JB, Frenk EZ, Hwang Y, Van de Graaf BG, Hutt JA, Wang G, Benson J, Crystal RG. Intrapleural administration of an AAVrh.10 vector coding for human alphal-antitrypsin for the treatment of alphal- antitrypsin deficiency. Hum Gene Ther CSn Dev 2013; 24:161-173

20. Chulay JD, YeGJ, Thomas DL, Knop DR, Benson JM, Hutt JA, Wang G, Humphries M, Rotte TR Preclinical evaluation of a recombinant adeno-associated virus vector expressing human alpha- 1 antitrypsin made using a recombinant herpes simplex virus production method. Hum Gene Ther 2011; 22:155-165

21. Conton TJ, Cassette T, Erger K, Choi YK, Clarke T, Scott-Jorgensen M, Song S,

CampbeB-Thompson M, Crawford J, Rotte TR. Efficient hepatic delivery and expression from a recombinant adeno-associated virus 8 pseudotyped alphal-antitrypsin vector. Mol Ther 2005; 12:867-875

22. De BP, Heguy A, Hackett NR, Ferris B, Leopold PL, Lee J, Pierre L, Gao G, Wilson JM, Crystal RG. High levels of persistent expression of alphal-antitrypsin mediated by the nonhuman primate serotype rh.10 adeno-associated virus despite preexisting immunity to common human adeno-associated viruses. Mol Ther 2006; 13:67-76

23. Rotte TR, Con Ion TJ, Poirier A, CampbelkThompson M, Byrne BJ. Preclinical

characterization of a recombinant adeno-associated virus type 1-pseudotyped vector demonstrates dose-dependent injection site inflammation and dissemination of vector genomes to distant sites. Hum Gene Ther 2007; 18:245-256

24. Halbert CL, Madtes DK, Vaughan ABE, Wang Z, Storb R, Tapscott SJ, Miller AD.

Expression of human alphal-antitrypsin in nice and dogs follow ingAAV6 vector- mediated gene transfer to the lungs. Mol Ther 2010; 18:1165-1172

Limberis MP Wilson JM Adeno-associated virus serotype 9 vectors transduce murine alveolar and nasal epithelia and can be readrrinistered. Roc Natl Acad Sci U S A 2006; 103:12993-12998 26. Limberis MP, Vandenberghe LK Zhang L, Ftekles RJ, Wilson JM. Transduction efficiencies of novel AAV vectors in mouse airw ay epithelium in vivo and human ciiated airway epithelium in vitro. Mol Ther 2009; 17:294-301

27. Lu Y, Choi YK, Campbell-Thompson M, Li C, Tang Q, Crawford JM, Flotte TR Song S.

Therapeutic level of functional human alpha 1 antitrypsin (hAAT) secreted from murine muscle transduced by adeno-associated virus (rAA V1) vector. J Gene Med 2006; 8:730- 735

28. Song S, Morgan M, Bis T, Poirier A, Chesnut K, Wang J, E3rantiy M, Muzyczka N, Byrne BJ, Atkinson M, Flotte TR Sustained secretion of human alpha-1-antitrypsin from murine muscle transduced w ith adeno-associated virus vectors. Roc Natl Acad Sci U S A 1998;

95:14384-14388

29. Song S, Bnbury J, Laipis PJ, Berns W, Crawford JM, Flotte TR. Stable therapeutic

serum levels of human alpha- 1 antitrypsin (AAT) after portal vein injection of recombinant adeno-associated virus (rAAV) vectors. Gene Ther 2001; 8:1299-1306 30. Virella-Lowel I, Zusman B, Foust K, Loiter S, Conton T, Song S, Chesnut KA, Ferkol T, Rotte TR Enhancing rAAV vector expression in the lung. J Gene Med 2005; 7:842-850

31. Xiao W, Berta SC, Lu MM, Moscioni AD, Tazelaar J, Wilson JM. Adeno-associated virus as a vector for liver-directed gene therapy. J Virol 1998; 72:10222-10226

32. Beatty K, Bieth J, Travis J. Kinetics of association of serine proteinases w ith native and oxidized alpha- 1- proteinase inhibitor and alpha- 1-antichymotrypsin. J Biol Chem 1980;

255:3931-3934

33. Carp H Janoff A. Potential mediator of inflammation. Phagocyte-derived oxidants

suppress the elastase-hhbitory capacity of alpha 1-proteinase inhibitor in vitro. J Cin Invest 1980; 66:987-995

34. Cohen AB James HL. Reduction of the elastase inhibitory capacity of alpha 1-antitrypsin by peroxides in cigarette smoke: an analysis of brands and f iters. Am Rev Respr Dis 1982; 126:

35. Evans MD Fryor WA. Cigarette smoking, emphysema, and damage to alpha 1- proteinase inhibitor. Am J Physiol 1994; 266: L593-L611

36. Matheson NR Wong PS, Travis J. Enzymatic inactivation of human alpha- 1-proteinase inhbitor by neutrophil myeloperoxidase. Biochem Biophys Res Commun 1979; 88:402- 409

37. Scott U, Russei Gl, Nixon NB, Dawes FT, Mattey DL. Oxidation of abhal-proteinase inhbitor by the myeloperoxidase-hydrogen peroxidase system promotes binding to immunoglobulin A. Biochem Biophys Res Commun 1999; 255:562-567

38. Summers FA, Morgan PE, Davies MJ, Hawkins CL. Identification of plasma proteins that are susceptible to thiol oxidation by hypochlorous acid and N-chtorajTines. Chem Res Toxicol 2008; 21:1832-1840

39. Taggart C, Cervantes- Laurean D, Kim G, McBvaney NG, Wehr N, Moss J, Levine RL Oxidation of either methionine 351 or methionine 358 in abha 1-antitrypsin causes loss of anti-neutrophil elastase activity. J Biol Chem 2000; 275:27258-27265

Bliott PR, Lomas DA, Carrell RW, Abrahams JP. Inhibitory conformation of the reactive loop of alpha 1-antitrypsin. Nat Struct Bid 1996; 3:676-681 41. Janoff A, Carp H, Lee DK, Drew RT. Cigarette smoke inhalation decreases alpha 1- antitrypsin activity in rat lung. Science 1979; 206:1313-1314

42. Courtney M, Jallat S, Tessier LH, Benavente A, Crystal RG, LeCocq JP. Synthesis in E coli of alpha 1-antitrypsin variants of therapeutic potential for emphysema and thrombosis. Nature 1985; 313:149-151

43. Jallat S, Tessier LH, Benavente A, Crystal RG, Courtney M. Antiprotease targeting: altered specif icity of apha 1-antitrypsin by amino acid replacement at the reactive centre. Rev Fr Transf us Immunohematol 1986; 29:287-298

44. Straus SD, Fells GA, Wew ers MD, Courtney M, Tessier LH, Tolstoshev P, LeCocq JP, Crystal RG. Evaluation of recombinant DNA-directed Ecoli produced alpha 1-antitrypsin as an anti-neutrophil elastase for potential use as replacement therapy of alpha 1- antitrypsin deficiency. Biochem Biophys Res Commun 1985; 130:1177-1184

45. Duranton J Beth JG. Inhibition of proteinase 3 by [alpha] 1-antitrypsin in vitro predicts very fast inhibition in vivo. Am J Respir Cell Mol Biol 2003; 29:57-61

46. Spencer LT, Paone G, Kreri PM, Rouhani FN, Rivera- Nieves J, Brantly ML. Role of human neutrophil peptides in lung inflammation associated withalphal-antitrypsin deficiency. Am J Physiol Lung Cell Mol Physiol 2004; 286:L514-L520

47. Petrache I, F|alKowska I, Medler TR, Skirball J, Cruz P, Zhen L, Petrache HI, Rotte TR, Tuder RM. a-1 Antitrypsin Inhibits Caspase-3 Activity, Reventing Lung -Endothelial Cell Apoptosis. Am J Pathol 2006; 169:1155-1166

48. Janciauskiene SM, Nrta M, Stevens T. Alphal -antitrypsin, old dog, new tricks. Alphal- antitrypsin exerts in vitro anti-inflammatory activity in human monocytes by elevating CAMP. J Biol Chem 2007; 282:8573-8582

49. Bergin DA, Reeves EEP, Meleady P, Henry M, McBvaney OJ, Carroll TP, Condron C, Chotirmall SH, Clynes M, CNeil SJ, McBvaney NG. alpha- 1 Antitrypsin regulates human neutrophil chemotaxis induced by soluble immune complexes and IL-8. J Clin Invest 2010; 120:4236-4250

50. Shahaf G, Moser H, Ozeri EE, MLzrahi M, Abecassis A, Lewis EEC. afcha-1-antitrypsin gene delivery reduces Inflammation, increases T- regulatory cell population size and prevents islet allograft rejection. Mol Med 2011; 17:1000-1011

51. Lewis EEC. EExpanding the clinical indications foralpha(1)-antitrypsin therapy. Mol Med 2012; 18:957-970

52. Jonigk D, Al-Omari M, Maegel L, Muller M, Izykow ski N, Hong J, Hong K, Krn SH,

Dorsch M, Mahadeva R, Laenger F, Kreipe H, Braun A, Shahaf G, Lew is EEC, Welte T, Dinarelto CA, Janciauskiene S. Antiinflammatory and immunomodulatory properties of alphal-antitrypsin without inhibition of elastase. Roc Natl AcadSci U S A 2013;

110:15007-15012

Bergin DA, Reeves EEP, Hurley K, Wolfe R, Jameel R, Fitzgerald S, McBvaney NG. The circulating proteinase inhibitor alpha- 1 antitrypsin regulates neutrophil degranulation and autoimmunity. Sci Transl Med 2014; 6:217ra1

54. EEhlers MR Immune-modulating effects of alpha- 1 antitrypsin. Biol Chem 2014;

395:1187-1193 55. Geraghty P, EBden E= Pllai M, Campos M, McE3vaney NG, Foronjy RF. alphal-Antitrypsin activates protein phosphatase 2A to counter lung inflammatory responses. Am J Respr Crit Care Med 2014; 190:1229-1242

56. Guyot N, Wartelle J, Malleret L, Todorov AA, Devouassoux G, Pacheco Y, Jenne DEE;

ESelaaouaj A. Unopposed cathepsin G, neutrophil elastase, and proteinase 3 cause severe lung damage and emphysema. Am J Pathol 2014; 184:2197-2100

57. Kaner Z, Ochayon DEE, Shahaf G, E3aranovski E3M, E3ahar N, Mfczrahi M, Lewis EEC. Acute Phase Protein alphal-Antitrypsin Reduces the E3acterial E3urden in Mce by Selective Modulation of Innate Cell Responses. J Infect Dis 2015; 211:1489-1498

58. Sinden NJ, E3aker MJ, Smith DJ, KreftJU, DaffornTR Stockley RA. alpha-1-antitrypsin variants and the proteriase/antiproteinase imbalance in chronic obstructive pulmonary disease. Am J Physiol Lung Cell Mol Physid 2015; 308:L179-L190

59. A lam S, Li Z, Janciauskiene S, Mahadeva R. Oxidation of Z afchal-antitrypsin by

cigarette smoke induces polymerization: a novel mechanism of early-onset emphysema. Am J Respir Cell Mol Biol 2011; 45:261-269

60. Lockett AD, Van Demark M, Gu Y, Schweitzer KS. Sigua N, Kamocki K, Rjalkowska I, Garrison J, Fisher A J, Serban K, Wise RA, Flotte TR, Mueller C, Presson RG, Jr., Fetrache HI, Tuder RM, Fetrache I. Effect of cigarette smoke exposure and structural modifications on the alpha- 1 Antitrypsin interaction w ith caspases. Mol Med 2012;

18:445-454

61. A lam S, Li Z, Atkinson C, Jonigk D, Janciauskiene S, Mahadeva R. Z alphal-antitrypsin confers a proinflammatory phenotype that contributes to chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2014; 189:909-931

62. The Alpha-1-Antitrypsin Deficiency Registry Study Group. Survival and FEEV1 decline in individuals w ith severe deficiency of alphal-antitrypsin. The Alpha-1-Antitrypsin

Deficiency Registry Study Group. Am J Respir Crit Care Med 1998; 158:49-59

63. Lomas DA Parfrey H. Alphal-antitrypsin deficiency.4: Molecular pathophysiology.

Thorax 2004; 59:529-535

64. Tanash HA, Nilsson PM, NSsson JA, Piitulainen E Survival in severe alpha- 1 -antitrypsin deficiency (PZZ) . Respir Res 2010; 11 :44

65. de Serres FJ Banco I. Prevalence of alphal-antitrypsin deficiency alleles FfS and PPZ w orldwide and effective screening for each of the five phenotypic classes ΡΓ MS, PI*MZ, R*SS, PI*SZ, and FTZZ: a comprehensive review. TherAdv Respir Dis 2012; 6:277-295

66. Ferlmutter DH Silverman GA. Hepatic fibrosis and carcinogenesis in alphal-antitrypsin deficiency: a prototype for chronic tissue damage in gain-of-f unction disorders. Cold

Spring Harb Ferspect Biol 2011; 3:a005801

67. Topic A, Ljujic M, Radojkovic D. Alpha-1-antitrypsin in pathogenesis of hepatocellular carcinoma. Hepat Mon 2012; 12:e7042

68. Inaty H Arabelovic S. alphal-Antitrypsin deficiency in a patient diagnosed w ith

granulomatosis with poly angitis. E3MJ Case Rep 2013; 2013:doi:10.1136/bcr-2013-

009045

69. Teckman JH. Liver disease in alpha- 1 antitrypsin deficiency: current understanding and future therapy. Copd 2013; 10 Suppl 1:35-43 70. Alberici F, Martorana D, Vaglk) A. Genetic aspects of anti-neutrophil cytoplasmic antibody-associated vasculitis. Nephrol Dial Transplant 2014; 30 (suppl 1):i37-i45

71. de Serres F Blanco I. Role of alpha- 1 antitrypsin in human health and disease. J Intern Med 2014; 276:311-335

72. Stone H, Fye A, StocWey RA. Disease associations in alpha-1-antitrypsin deficiency.

Respir Med 2014; 108:338-343

73. Duvoix A, Roussel BD, Lomas DA. Molecular pathogenesis of alpha- 1-antitrypsin

deficiency. Rev Mai Respir 2014; 31:992-1002

74. Greene CM, Miller SD, Carroll T, McLean C, CMahony M, Law less MW, O'Neill SJ, Taggart CC, McBvaney NG. Alpha-1 antitrypsin deficiency: a conformational disease associated with lung and liver manifestations. J Inherit Metab Dis 2008; 31:21-34

75. Mornex JF, Chytil-Weir A, Martinet Y, Courtney M, LeCocq JP, Crystal RG. Expression of the alpha- 1-antitrypsin gene in mononuclear phagocytes of normal and alpha- 1- antitrypsirvdeficient individuals. J Clin Invest 1986; 77:1952-1961

76. van 't Vvbut EEF, van SchadewijkA, Savage ND, Stolk J, l-iemstra FS. alphal-antitrypsin production by proinflammatory and antiinflammatory macrophages and dendritic ceBs. Am J Respir Cell Mol Biol 2012; 46:365-376

77. du Bois RM, Bernaudin JF, Paakko P, Hubbard R, Takahashi H, Ferrans V, Crystal RG.

Human neutrophis express the alpha 1-antitrypsin gene and produce alpha 1-antitrypsin. Blood 1991; 77:2724-2730

78. Venembre P, Boutten A, Seta N, Dehoux MS, Crestani B, Aubier M, Durand G. Secretion of alpha 1-antitrypsin by alveolar epithelial cells. FEBS Lett 1994; 346:171-174

79. Qchy J, Potempa J, Travis J. Biosynthesis of alphal-proteinase inhibitor by human lung- derived epithelial cells. J Biol Chem 1997; 272:8250-8255

80. Geboes K, Ray MB, Rutgeerts P, Callea F, Desmet VJ, Vantrappen G. Morphological identification of alpha-l-antitrypsri in the human small intestine. Histopathology 1982; 6:55-60

81. Perlmutter DH, Daniels JD, Auerbach HS, De Schryver-Kecskemeti K, Winter HS, Alpers DH. The alpha 1-antitrypsin gene is expressed in a human intestinal epithelial cell ine. J Biol Chem 1989; 264:9485-9490

82. Cox DW, Markovic VD, Teshima IE Genes for immunoglobulin heavy chains and for alpha 1-antitrypsin are localized to specif ic regions of chromosome 14q. Nature 1982; 297:428-430

83. Schroeder VvT, Miler MF, Woo SL, Saunders GF. Chromosomal localization of the

human alpha 1-antitrypsin gene (PI) to 14q31-32. Am J Hum Genet 1985; 37:868-872

84. Laurell C-B Eriksson S. The electrophoretic alphal -globulin pattern of serum in alphal- antitrypsin deficiency. Scand J Clin Lab Invest 1963; 15:132-140

85. Seixas S, Garcia O, Trovoada MJ, Santos MT, Arnorim A, Rocha J. Patterns of

haplotype diversity within the serpin gene cluster at 14q32.1: insights into the natural history of the alphal-antitrypsin polymorphism. Hum Genet 2001; 108:20-30

86. Stoller JK Aboussouan LS. A review of alphal-antitrypsin deficiency. Am J Respir Crit Care Med 2012; 185:246-259 87. Kurachi K, Chandra T, Degen SJ, White TT, Marchioro TL, Woo SL, Davie EW. Cloning and sequence of cDNA coding for alpha 1-antitrypsri. Roc Natl Acad Sci U S A 1981; 78:6826-6830

88. Jeppsson JO. Amino acid substitution Gu leads to Lys alphal-antitrypsfcn RZ. FEBS Lett 1976; 65:195-197

89. Birrer P, McBvaney NG, Chang-Stroman LM, Crystal RG. Alpha 1-antitrypsin deficiency and liver disease. J Inherit Metab Dis 1991; 14:512-525

90. Gooptu B Lomas DA. Conformational pathology of the serpins: themes, variations, and therapeutic strategies. Annu Rev Biochem 2009; 78:147-176

91. Lomas DA, B/ans DL, Finch JT, Carrell RW. The mechanism of Z alpha 1-antitrypsin accumulation in the liver. Nature 1992; 357:605-607

92. Nukiwa T, Satoh K, Brantly ML, Ogushi F, Fells GA, Courtney M, Crystal RG.

Identification of a second mutation in the protein-coding sequence of the Z type ak)ha 1- antitrypsin gene. J Biol Chem 1986; 261:15989-15994

93. Long GL, Chandra T, Woo SL, Davie EW, Kurachi K. Complete sequence of the cDNA for human alpha 1-antitrypsin and the gene for the S variant Biochemistry 1984;

23:4828-4837

94. Owen MC, Carrel RW, Brennan SO. The abnormality of the S variant of human alpha- 1- antitrypsin. Biochim Biophys Acta 1976; 453:257-261

95. YoshkJa A. Ewing C, Wessels M, Lieberman J, Gaidulis L. Molecular abnormality of R S variant of human alphal-antitrypsin. Am J Hum Genet 1977; 29:233-239

96. Ogushi F, Hubbard RC, Fels GA, Casolaro MA, Curiel DT, Brantly ML, Crystal RG.

Evaluation of the S-type of alpha- 1-antitrypsin as an in vivo and in vitro inhibitor of neutrophil elastase. Am Rev Respir Dis 1988; 137:364-370

97. Bornhorst JA, Greene DN, Ashwood ER, Grenache DG. alphal-Antitrypsin phenotypes and associated serum protein concentrations in a large clinical population. Chest 2013; 143:1000-1008

98. FDA, B. P. A. C. (2017).

99. American Thoracic S European Respiratory S. American Thoracic Society/European Respiratory Society statement: standards for the diagnosis and management of individuals with alpha- 1 antitrypsin deficiency. Am J Respir Crit Care Med 2003;

168:818-900

100. Thompson Healthcare (2010) Red Book: pharmacy's fundamental reference (Thomson Reuters: FOR Network.

101. Bernsteh JA, Alexis N, Barnes C, Bernstein L, Bernstein JA, Nel A, Peden D, Diaz- Sanchez D, Tarlo SM, Wiliams PB. Health effects of air pollution. J Allergy Clin Immunol 2004; 114:1116-1123

102. Ciencewicki J, Trivedi S, Kleeberger SR. Oxidants and the pathogenesis of lung

diseases. J Allergy Clin Immunol 2008; 122:456-468

103. Chiuchiolo MJ Crystal RG. Gene Therapy for Alpha- 1 Antitrypsin Deficiency Lung

Disease. Ann Am Thorac Soc 2016; 13 Suppl 4:S352-S369 104. Garver Rl, Jr., Chytil A, Courtney M, Crystal RG. Clonal gene therapy: transplanted mouse fibroblast clones express human alpha 1-antitrypsin gene in vivo. Science 1987; 237:762-764

105. Rosenfeld MA, Siegfried W, Yoshimura K, Yoneyama K, Fukayama M, Stier LEE; Paakko PK, Gilardi P, Stratford- Perricaudet LD, Perricaudet M, Jallat S, Pavirani A, Lecocq J-P,

Crystal RG. Adenovirus-mediated transfer of a recombinant abha 1-antitrypsin gene to the lung epithelium in vivo. Science 1991; 252:431-434

106. Daya S Berns Kl. Gene therapy using adeno-associated virus vectors. Oin Mcrobiol Rev 2008; 21:583-593

107. Gao G, Vandenberghe LH, Atvira MR, Lu Y, Calcedo R, Zhou X, Wilson JM. Clades of adeno-associated viruses are widely disseminated in human tissues. J Virol 2004;

78:6381-6388

108. Asokan A, Schaffer DV, Jude SR The AAV Vector Toolkit Poised at the Clinical

Crossroads. Mol Ther 2012; 20:699-708

109. Nwa H, Yamamura K, Myazaki J. .Efficient selection for high-expression transfectants w ith a novel eukaryotic vector. Gene 1991 ; 108: 193- 199

110. Carrell R, Owen M, Brennan S, Vaughan L Carboxy terminal fragment of human alpha- 1-antitrypsin from hydroxylarrine cleavage: homology withantithrombin IB. Biochem EEtophys Res Commun 1979; 91:1032-1037

111. Carrell RW, Jeppsson JO, Laurell CB, Brennan SO, Owen MC, Vaughan L, Boswel DR.

Structure and variation of human alpha 1-antitrypsin. Nature 1982; 298:329-334

112. Loebermann H, Tokuoka R, Deisenhofer J, Huber R Human alpha 1-proteinase

inhibitor. Crystal structure analysis of two crystal modifications, molecular model and preliminary analysis of the implications forfunction. J Mol Biol 1984; 177:531-557 113. Buhl R, Meyer A, Vogelmeier C. Oxidant- protease interaction in the lung. Prospects for antioxidant therapy. Chest 1996; 110:267S-272S

114.

115. Li Z, A lam S, Wang J, Sandstrom CS, Janciauskiene S, Mahadeva R. Oxidized {alpha} 1- antitrypsin stimulates the release of monocyte chemotactic protein- 1 from lung epithelial cells: potential role in emphysema. Am J Physiol Lung Cell Mol Physiol 2009; 297:L388- L400

116. Moraga F Janciauskiene S. Activation of primary human monocytes by the oxidized form of alphal-antitrypsin. J Biol Chem 2000; 275:7693-7700

117. Ueda M, Mashiba S, Uchida K. Valuation of oxidized alpha-1-antitrypsin in blood as an oxidative stress marker using anti-oxidative alpha1-AT monoclonal antibody. Qin Chim Acta 2002; 317:125-131

118. Rosenberg S, Barr PJ, Najarian RC, Halewell RA. Synthesis in yeast of a functional oxidation- resistant mutant of human alpha-antitrypsin. Nature 1984; 312:77-80

119. Nukiwa, T., Ogushi, F., & Crystal, R. G. (1996) in Alpha 1-antitrypsin deficiency, βύ.

Crystal, R. G. (Marcel Dekker, Inc., New York), pp. 33-43. 120. Bliott PR, Fei XY, DaffornTR, Lomas DA. Topography of a 2.0 A structure of alphal- antitrypsin reveals targets for rational drug design to prevent conformational disease. Protein Sci 2000; 9:1274-1281

121. Gadek JE, Fells GA, Crystal RG. Cigarette smoking induces functional antiprotease deficiency in the lower respiratory tract of humans. Science 1979; 206:1315-1316

122. Bals R, Xiao W, Sang N, Weiner DJ, Meegalla RL, Wilson JM Transduction of w ell- differentiated airway epithelium by recombinant adeno-associated virus is irrfted by vector entry. J Virol 1999; 73:6085-6088

123. Yang Y, Li Q, Ertl HC, Wilson JM. Cellular and humoral immune responses to viral antigens create barriers to lung-directed gene therapy w ith recombinant adenoviruses. J

Virol 1995; 69:2004-2015

124. Ferrari S, Griesenbach U, Geddes DM, Alton E Immunological hurdles to lung gene therapy. Clin Exp Immunol 2003; 132:1-8

125. Duan D, Yue Y. Yan Z, McCray PB, Jr., EEhgelhardt JF. Polarity influences the efficiency of recombinant adenoassociated virus infection in differentiated airw ay epithelia. Hum

Gene Ther 1998; 9:2761-2776

126. Liqun Wang R, McLaughin T, Cossette T, Tang Q, Foust K, CampbelkThompson M, Martino A, Cruz P, Loiler S, Mueller C, Fkrtte TR Recombinant A A V serotype and capsid mutant comparison for pulmonary gene transfer of alpha- 1 -antitrypsin using invasive and noninvasive delivery. Mol Ther 2009; 17:81-87

127. Yu H, Buff SM, Baatz JE, Virella-Lowell l. Oral instillation with surfactant phospholipid: a refiable alternative to intratracheal injection in mouse studies. Lab Anim 2008; 42:294- 304

128. Song, S., Scott-Jorgensen, M, Wang, J., Poirier, A., Crawford, J., Campbell-Thompson, M., & Rotte, T. R. (2002) United States).

129. Brantly ML, Chulay JD, Wang L, Mueller C, Humphries M, Spencer LT, Rouhani F,

Conlon TJ, Calcedo R, Betts MR, Spencer C, Byrne BJ, Wilson JM, Rotte TR. Sustained transgene expression despite T lymphocyte responses in a clinical trial of rAAV1-AAT gene therapy. Proc Natl Acad Sci U SA 2009; 106:16363-16368

130. Rotte TR, Trapnell BC, Humphries M, Carey B, Calcedo R, Rouhani F, Campbell- Thompson M, Yachnis AT, Sandhaus RA, McBvaney NG, Mueller C, Messina LM, Wison JM, Brantly M, Knop DR, Ye GJ, Chulay JD. Phase 2 clinical trial of a

recombinant adeno-associated viral vector expressing alphal -antitrypsin: interim results. Hum Gene Ther 2011; 22:1239-1247

131. Mueller C, Chulay JD, McBvaney NG, Gernoux G, Reeves EP, Rouhani FN, Humphries M, Gruntman AM, Campbell-Thompson M, Wilson JM, Rotte TR Sustained expression w ith partial correctionof neurtrophil defects 5 years after intramuscular rA AV1 gene therapy for alpha- 1 antitrypsin deficiency. Mol Ther 2016; 24:S11-S12

132. Heguy A Crystal RG. Intrapleural Outside-in' gene therapy: therapeutics for organs of the chest via gene transfer to the pleura. Current opinion in molecular therapeutics 2005;

7:440-453

133. Mae M Crystal RG. Gene transfer to the pleural mesothelium as a strategy to deiver proteins to the lung parenchyma. Hum Gene Ther 2002; 13:1471-1482

134. Rnley DJ Rusch VW. Anatomy of the pleura. Thorac Surg Clin 2011; 21:157-163 135. Wang NS. Anatomy and physiology of the pleural space. Clin Chest Med 1985; 6:3-16

136. Rennard SI, Jaurand MC, Bignon J, Kawanami O, Ferrans VJ, Davidson J, Crystal RG.

Role of pleural mesotheial cells in the production of the submesotheial connective tissue matrix of ting. Am Rev Respir Dis 1984; 130:267-274

137. Agostoni E Zocchi L. Pleural liquid and its exchanges. Respir Physiol Neurobid 2007;

159:311-323

138. Noppen M. Normal volume and cellular contents of pleural fluid. Curr Opin Puhn Med 2001; 7:180-182

139. Mutsaers SE Mesothelial cells: their structure, function and role in serosal repair.

Respirology 2002; 7:171-191

140. Noppen M, De Waele M, Li R, Gucht KV, DHaese J, Gerlo E, Vincken W. Volume and cellular content of normal pleural fluid in humans examined by pleural lavage. Am J Respir Crit Care Med 2000; 162:1023-1026

141. Negrini D Moriondo A. Pleural function and lymphatics. Acta Physiol (Qxf) 2013;

207:244-259

142. Rodriguez- Ranadero F Monies- Wbrboys A. Mechanisms of pleurodesis. Respiration; international review of thoracic diseases 2012; 83:91-98

143. van den Heuvel MM, Srrit HJ, Barbierato SB, Havenith CE, Beelen RH, Pbstmus PE Talc-induced inflammation in the pleural cavity. Eur Respir J 1998; 12:1419-1423 144. Cantin A Crystal RG. Oxidants, antioxidants and the pathogenesis of emphysema. Eur J Respir Dis Suppl 1985; 139:7-17

145. Cross CE, van d, V, ONeill CA, Louie S, Halliwell B. Oxidants, antioxidants, and

respiratory tract lining fluids. Environ Health Ferspect 1994; 102 Suppl 10:185-191

146. Wbzniak J, Wandtke T, Kopinski P, Chorostow ska-Wynimko J. Challenges and

Prospects for Alpha- 1 Antitrypsin Deficiency Gene Therapy. Hum Gene Ther 2015;

26:709-718

147. Moraga F, Lindgren S, Janciaskiene S. Effects of noninhbitory alpha- 1-antitrypsin on primary human monocyte activation in vitro. Arch Biochem Bbphys 2001; 386:221-226

148. Landis SC, Amara SG, AsadJIah K, Austin CP, Blumenstein R, Bradley EW, Crystal RG, Darnel RB, Ferrante RJ, Fillit H, Rnkelsteri R, Rsher M, Gendelman HE Golub RM,

Goudreau JL, Gross RA, Gubitz AK, Hesterlee SE, How els DW, Huguenard J, Kelner K, Koroshetz W, Krainc D, Lazic SE, Levine MS, Macleod MR, McCall JM, Moxley RT, III, Narasimhan K, Noble U, Perrin S, Porter JD, Steward O, linger E, Utz U, Silberberg SD. A call for transparent reporting to optimize the predictive value of preclinical research. Nature 2012; 490:187-191

149. Hubbard RC, Ogushi F, Fels GA, Cantin AM, Jallat S, Courtney M, Crystal RG. Oxidants spontaneously released by alveolar macrophages of cigarette smokers can inactivate the active site of alpha 1-antitrypsin, rendering it ineffective as an inhibitor of neutrophil elastase. J Clin Invest 1987; 80:1289-1295

150. Griffiths SW Cooney CL. Relations hp between protein structure and methionine

oxidation in recombinant human alpha 1-antitrypsin. Biochemistry 2002; 41:6245-6252 151. Brantly ML, Wttes JT, Vogelmeier CF, Hubbard RC, Fels GA, Crystal RG. Use of a highly purified afcha 1-antitrypsin standard to establish ranges for the common normal and deficient alpha 1-antitrypsin phenotypes. Chest 1991; 100:

152. Radrines M, Schneider- Fozzer M, Beth JG. Inhibition of neutrophil elastase by alpha- 1- proteinase inhibitor oxidized by activated neutrophils. Am Rev Respir Dis 1989; 139:783- 790

153. Jallat S, Carvallo D, Tessier LH, RoecWin D, Roitsch C, Ogushi F, Crystal RG, Courtney M. Altered specificities of genetically engineered alpha 1 antitrypsin variants. Rrotein Eng 1986; 1:29-35

154. Travis J, Matheson NR, George PM, Carrel RW. Kinetic studies on the interaction of alpha 1-proteinase inhibitor (Pittsburgh) withtrypsirvlike serine proteinases. Biol Chem Hoppe Seyler 1986; 367:853-859

155. Boudier C, Laurent P, E3ieth JG. Leukoprotehases and pulmonary emphysema:

cathepsin G and other chymotrypsin-lke proteinases enhance the elastolytic activity of elastase on lung elastin. Adv Exp Med Bio! 1984; 167:313-317

156. Adverum Botechnokxjies, I. (2016).

157. Mingozzi F high KA. Immune responses to AAV in clinical trials. Curr Gene Ther 2011;

11:321-330

158. Sands, M. S. (2011).

159. van der Laan U, Wang Y, Tilanus HW, Janssen HL, Pan Q. AAV-mediated gene therapy for liver diseases: the prime candidate for clinical application? Expert Open Biol Ther 2011; 11:315-327

160. Manno CS, Pierce GF, ArrudaVR, Glader B, Ragni M, Rasko JJ, Ozelo MC, Hoots K, Blatt P, Konkle B, Dake M, Kaye R, Razavi M, Zajko A, Zehnder J, Rustagi PK, Nakai H, Chew A, Leonard D, Wright JF, Lessard RR, Somrner JM, Tigges M, Sabatino D, Luk A, Jiang H, Mingozzi F, Couto L, BH HC, High KA. Kay MA. Successful transduction of liver in hemophilia by A A V- Factor IX and limitations imposed by the host immune response. Nat Med 2006; 12:342-347

161. Schnepp BC, Chulay JD, YeGJ, Ftotte TR, Trapnell BC, Johnson PR. Recombinant Adeno-Associated Virus Vector Genomes Take the Form of Long- Lived,

Transcriptionally Competent Episomes in Human Muscle. Hum Gene Ther 2016; 27:32- 42

162. Sondhi D, Peterson DA, Giannaris EL, Sanders CT, Mendez BS, De B, Rostkowski AB, Blanchard B, Bjugstad K, Sadek JR, Jr., Redmond DE, Jr., Leopold PL, Karrinsky SM, Hackett NR, Crystal RG. AAV2-mediated CLN2 gene transfer to rodent and non-human primate brain results in long-term TPP- 1 expression compatible w ith therapy for LINCL. Gene Tner 2005; 12:1618-1632

163. Wensky, A. (2017).

164. Chiuchblo MJ, Karrinsky SM, Sondhi D, MancenkJo D, Hollmann C, Crystal RG. Phase l/ll study of intrapleural administration of a serotype rh.10 replication-deficient adeno- associated virus gene transfer vector expressing the human alphal -antitrypsin cDNA to individuals with alphal-antitrypsin deficiency. Hum Gene Ther Clin Dev 2014; 25:112- 133 165. Rennard SI, BassetG, Lecossier D, CDonnell KM, Rnkston P, Martin PG, Crystal RG. Estimation of volume of epithelial lining fluid recovered by lavage using urea as marker of dilution. J Appl Physiol (1985 ) 1986; 60:532-538

166. Nathwani AC, Tuddenham EEG, Rangarajan S, Resales C, Mcintosh J, Linen DC,

Chowdary P, Riddell A, Re A J, Harrington C, OBeirne J, Smith K, Pasi J, Gader B, Rustagi P, Ng CY, Kay MA, Zhou J, Spence Y, Morton CL, Allay J, Coleman J, Sleep S, Cunningham JM, Srivastava D, Basner-Tschakarjan E, Mhgozzi F, high KA. Gray JT, Reiss UM, Nienhuis AW, Davidoff AM. Adenovirus-associated virus vector-mediated gene transfer in hemophilia B. N Engl J Med 2011; 365:2357-2365

167. Meiani A, Leborgne C, Triffault S, Jeanson-Leh L, Veron P, Mingozzi F. Determination cf anti-adeno-associated virus vector neutraizing antbody titer with an in vitro reporter system Hum Gene Ther Methods 2015; 26:45-53 All publications, patents and patent app.cabons are incorporated herein by reference.

While h the foregoing specification this invention has been described in relation to certain preferred embodiments thereof, and many details have been set forth for purposes of ilustration, it w il be apparent to those skilled in the art that the invention is susceptible to additional embodiments and that certain of the details described herein may be varied considerably w ithout departing from the basic principles of the invention.