Mutations in the adenosine deaminase (ADA) gene are responsible for a form of severe combined immunodeficiency (SCID) caused by the lymphotoxic accumulation of ADA substrates, adenosine and 2-deoxy-adenosine. The molecular mechanisms underlying T-cell dysfunction in humans remain to be elucidated. Here, we show that CD4 ؉ T cells from ADA-SCID patients have severely compromised TCR/CD28-driven proliferation and cytokine production, both at the transcriptional and protein levels. Such an impairment is associated with an intrinsically reduced ZAP-70 phosphorylation, Ca 2؉ flux, and ERK1/2 signaling and to defective transcriptional events linked to CREB and NF-B. Moreover, exposure to 2-deoxy-adenosine results in a stronger inhibition of T-cell activation, mediated by the aberrant A 2A adenosine receptor signaling engagement and PKA hyperactivation, or in a direct apoptotic effect at higher doses. Conversely, in T cells isolated from patients after gene therapy with retrovirally transduced hematopoietic stem/progenitor cells, the biochemical events after TCR triggering occur properly, leading to restored effector functions and normal sensitivity to apoptosis. Overall, our findings provide a better understanding of the pathogenesis of the immune defects associated with an altered purine metabolism and confirm that ADA gene transfer is an efficacious treatment for ADA-SCID. The trials in this study are enrolled at www.ClinicalTrials. gov as #NCT00598481 and #NCT0059978.
IntroductionAdenosine deaminase (ADA) is a key enzyme in the purine pathway, ubiquitously expressed, catalyzing the irreversible deamination of adenosine (Ado) and 2Ј-deoxy-adenosine (dAdo). Genetic defects in ADA gene cause an accumulation of purine metabolites in plasma and cells, leading to an inherited form of severe combined immunodeficiency (SCID). 1,2 Accordingly, broad lymphopenia, absence of humoral-and cellular-mediated immunity, recurrent infections, and failure to thrive are the prominent features of the most severe forms of ADA deficiency. 3,4 In addition, the systemic accumulation of purine metabolites can cause alterations in several organs, including the skeleton, lung, liver, gastrointestinal tract, and central nervous system. 4 The clinical phenotypes usually correlate with the severity of genetic mutations, the residual ADA activity and the extent of substrates accumulations. 5 Conflicting data exist on the relative contribution of ADA metabolites in the pathogenesis of the immune dysfunctions. The biochemical hallmarks of ADA deficiency are consistent with the general belief indicating dAdo as the primary cause of lymphotoxicity in ADA-SCID. Exerting its effects at the nucleoside level or after conversion to dATP, accumulation of intracellular dAdo may interfere with deoxynucleotide synthesis and inhibit S-adenosylmethionine-mediated transmethylation reactions, which are required for cell viability and normal differentiation. 6,7 In developing lymphocytes, dAdo has been reported to induce apoptosis through a pathway involving p53 ...