Loco-regional perfusion of a kidney

Abstract

This invention discloses a method for treating kidney disease by perfusion of a loco-regional portion of one or both kidneys of a patient. A closed loop can be formed using a perfusion catheter positioned in the renal artery of the kidney, a recovery catheter positioned in the renal vein of the kidney, and an extracorporeal membrane oxygenator placed therebetween. The perfusion fluid containing, for example, a drug can circulate through the closed loop while simultaneously dissociating the closed loop from the patient's systemic circulation.

Description

Technical Field

[0001] This invention relates to the treatment of kidney disease, and more specifically, to the local delivery of a therapeutic agent to the patient's kidney. Prior Technology

[0002] Gene therapy and cell therapy technologies have attracted widespread attention in the treatment of various kidney conditions, such as chronic kidney disease, due to their potential for unique customization and effectiveness in addressing the underlying pathogenic mechanisms of various kidney conditions. Nevertheless, delivery-related issues remain, including vector efficiency, dosage, specificity, and safety. Therefore, further research is needed to achieve highly targeted and uniform delivery methods suitable for treating various kidney conditions, methods that are also effective, well-tolerated, and minimally invasive. Summary of the Invention

[0003] One objective of the present invention is to provide a method for perfusing a drug into one or both kidneys of a patient in a minimally invasive manner.

[0004] One objective of the present invention is to provide a method for circulating an perfusion fluid (which may contain one or more of blood or drugs) through one or both kidneys of a patient so as to separate the perfusion fluid from the patient's systemic circulation.

[0005] One objective of this invention is to provide localized delivery of pharmaco-gene therapy.

[0006] One objective of this invention is to reduce the overall dose of medication delivered to patients to treat kidney conditions.

[0007] One objective of this invention is to reduce the risk and / or adverse immune response of administering drugs suitable for treating kidney conditions.

[0008] One objective of this invention is to allow the re-administration and / or administration of pharmaceutical-gene therapy drugs to patients who have, for example, neutralizing antibodies against gene therapy vectors, otherwise they would not be suitable candidates to receive such drugs.

[0009] One objective of this invention is to allow the perfusion fluid to circulate through the kidney and to separate the renal circulation from the patient’s systemic circulation so as to allow the introduction of potentially nephrotoxic drugs into the systemic circulation while preventing or reducing the exposure of the drug to the kidney.

[0010] One objective of this invention is to treat kidney conditions such as autosomal dominant polycystic kidney disease and renal wasting disease.

[0011] One objective of this invention is to provide localized delivery of medicine-gene therapy to treat gene mutations, such as mutations in the PKD2 and NPHP1 genes.

[0012] The above and other objectives are achieved by means of the present invention, which in some embodiments relates to a method of perfusing a drug into one or both kidneys of a patient. In one embodiment, a method includes: positioning an perfusion catheter in the renal artery of the kidney; positioning a retrieval catheter in the renal vein of the kidney, thereby forming a closed perfusion circuit through the kidney together with a membrane oxygenation device; and allowing perfusion fluid to flow through the closed circuit. In some embodiments, the closed circuit separates the perfusion through the kidney from the patient's systemic circulation.

[0013] In some embodiments, the method further includes positioning a retrieval balloon catheter in the patient's bladder to measure the amount of urine excreted during perfusion.

[0014] In some embodiments, the method further includes: positioning an additional retrieval catheter in each of the patient's two ureters to differentially measure the excretion of the patient's two kidneys.

[0015] In some embodiments, the perfusion catheter is positioned in the renal artery via the femoral artery.

[0016] In some embodiments, the retrieval catheter is positioned within the renal vein, where the perfusion catheter is positioned via the femoral vein.

[0017] In some embodiments, allowing the perfusion fluid to flow through a closed loop includes passing the perfusion fluid through a membrane oxygenation device before it enters the renal artery via the perfusion catheter. In some embodiments, the method further includes adding additional perfusion fluid to the closed loop or diluting the perfusion fluid with a saline solution of about 5% to about 50% v / v to calculate the bladder excretion volume.

[0018] In some embodiments, the closed loop maintains the flow rate of the perfusion fluid at approximately 500 mL / min / 1.73 m² body surface area per kidney to approximately 650 mL / min / 1.73 m² body surface area per kidney for approximately 15 minutes to approximately 4 hours.

[0019] In some embodiments, the method further includes applying a negative pressure at the recovery catheter, such that the negative pressure is in the range of approximately -100 mmHg to 0 mmHg.

[0020] In some embodiments, one or more of the irrigation catheter and the recovery catheter are introduced percutaneously.

[0021] In some embodiments, the perfusion fluid comprises autologous blood, matched blood from a donor, or a combination thereof.

[0022] In some embodiments, blood components are selected based on one or more parameters, such that the one or more parameters include the presence or absence of the selected antibody.

[0023] In some embodiments, the perfusion is maintained for a duration of about 15 minutes, 30 minutes, 45 minutes, 1 hour, 2 hours, 3 hours, 4 hours, or any range defined therein.

[0024] In some embodiments, the perfusion fluid contains a therapeutic polynucleotide sequence. In some embodiments, the therapeutic polynucleotide sequence is present in one or more viral vectors. In some embodiments, the one or more viral vectors are selected from the group consisting of: adeno-associated virus, adenovirus, retrovirus, herpes simplex virus, bovine papillomavirus, lentiviral vector, vaccinia virus, polyomavirus, Sendai virus, orthomyxovirus, paramyxovirus, polyvesicular virus, microRNA virus, poxvirus, alpha virus, variants thereof, and combinations thereof. In some embodiments, the viral vector is adeno-associated virus (AAV). In some embodiments, the AAV is one or more of the following: AAV1, AAV2, AAV3, AAV4, AAV5, AAV6, AAV7, AAV8, AAV9, AAV10, AAV11, AAV12, variants thereof, and combinations thereof. In some embodiments, the therapeutic polynucleotide sequence contains a promoter.

[0025] In some embodiments, less than about 20% v / v, less than about 15% v / v, less than about 10% v / v, less than about 5% v / v, less than about 4% v / v, less than about 3% v / v, less than about 2% v / v, less than about 1% v / v, less than about 0.5% v / v, or substantially no (0% v / v) leakage out of the closed loop in the blood circulating through the closed loop.

[0026] In some embodiments, less than about 20% v / v, less than about 15% v / v, less than about 10% v / v, less than about 5% v / v, less than about 4% v / v, less than about 3% v / v, less than about 2% v / v, less than about 1% v / v, less than about 0.5% v / v, or substantially no (0% v / v) leakage out of the closed loop in the perfusion fluid circulated through the closed loop.

[0027] In some embodiments, one or more of the irrigation catheter or the recovery catheter are balloon catheters.

[0028] In another embodiment, a method includes: positioning an perfusion catheter in the renal artery of the kidney; positioning a retrieval catheter in the renal vein of the kidney, thereby forming a closed perfusion circuit through the kidney together with a membrane oxygenation device; and allowing oxygenated blood to flow through the closed circuit, thereby dissociating the kidney from the patient's systemic circulation. In some embodiments, the method further includes introducing a nephrotoxic drug into the patient's systemic circulation. In some embodiments, the renal exposure to the nephrotoxic drug is prevented or reduced compared to administration of the nephrotoxic drug in the absence of a closed circuit.

[0029] In another embodiment, a system for performing localized perfusion of a kidney when fluidly coupled to the kidney of a patient includes: an perfusion catheter adapted for insertion into a renal artery of the kidney; a retrieval catheter adapted for insertion into a renal vein of the kidney; a membrane oxygenation device fluidly coupled to the perfusion catheter, the retrieval catheter, and an oxygen source, such that when the perfusion catheter is inserted into the renal artery and the retrieval catheter is inserted into the renal vein, the perfusion catheter, the retrieval catheter, and the membrane oxygenation device together form a closed loop through the kidney, separating the kidney from the patient's systemic circulation; and a pump configured to drive fluid flow through the perfusion catheter and the retrieval catheter.

[0030] In some embodiments, the system further includes a retrieval balloon catheter adapted to be inserted into the patient's bladder to measure the amount of urine excreted during perfusion.

[0031] In some embodiments, the system further includes an additional retrieval catheter adapted to be inserted into each of the patient's two ureters to differentially measure the excretion of the patient's two kidneys.

[0032] In some embodiments, the membrane oxygenation device includes a reservoir configured to inject drugs into the closed loop during perfusion.

[0033] In some embodiments, the system is adapted to maintain a flow rate of perfusion fluid through the closed loop at approximately 500 mL / min / 1.73 m² body surface area per kidney to approximately 650 mL / min / 1.73 m² body surface area per kidney for approximately 15 minutes to approximately 4 hours.

[0034] In another embodiment, a system for performing localized perfusion of a patient's kidney includes: an perfusion catheter inserted into the renal artery of the kidney; a retrieval catheter inserted into the renal vein of the kidney; and a membrane oxygenation device fluidly coupled to the perfusion catheter, the retrieval catheter, and an oxygen source, thereby forming a closed loop through the kidney together with the kidney, separating the kidney from the patient's systemic circulation; and a pump configured to drive fluid flow through the perfusion catheter into the kidney and out of the kidney through the retrieval catheter.

[0035] In some embodiments, the system further includes a retrieval balloon catheter inserted into the patient's bladder to measure the amount of urine excreted during perfusion.

[0036] In some embodiments, the system further includes an additional recovery catheter inserted into each of the patient's two ureters to differentially measure the excretion of the patient's two kidneys.

[0037] In some embodiments, the membrane oxygenation device includes a reservoir configured to inject drugs into the closed loop during perfusion.

[0038] In some embodiments, the system is adapted to maintain a flow rate of perfusion fluid through the closed loop at approximately 500 mL / min / 1.73 m² body surface area per kidney to approximately 650 mL / min / 1.73 m² body surface area per kidney for approximately 15 minutes to approximately 4 hours.

[0039] In another configuration, any of the aforementioned systems is configured to perform any of the aforementioned methods.

[0040] The above and other objectives are further satisfied by the present invention, and in some embodiments, the present invention relates to a localized irrigation system configured to perform any of the foregoing methods. Simple Explanation of the Diagram

[0041] The above and other features, properties and various advantages of the present invention will become more apparent when the following embodiments are considered in conjunction with the accompanying drawings, wherein:

[0042] Figure 1 shows a schematic diagram of a first exemplary retrieval catheter having a single balloon structure according to at least one embodiment;

[0043] Figure 2 is an image of a retrieval catheter manufactured according to one embodiment of the first exemplary retrieval catheter;

[0044] Figure 3 illustrates the arrangement of a first exemplary recovery catheter according to at least one embodiment;

[0045] Figure 4 illustrates the arrangement of a second exemplary retrieval catheter with a single balloon structure according to at least one embodiment;

[0046] Figure 5 illustrates the arrangement of a third and a fourth exemplary retrieval catheter, each having a single balloon structure, according to at least one embodiment;

[0047] Figure 6 illustrates the arrangement of a fifth exemplary retrieval catheter with a single balloon structure and a sixth exemplary retrieval catheter without a balloon structure, according to at least one embodiment;

[0048] Figure 7 illustrates the arrangement of a seventh exemplary retrieval catheter having multiple balloon structures according to at least one embodiment;

[0049] Figure 8 illustrates an arrangement of an eighth exemplary recovery catheter having a partially covered and retractable stent structure according to at least one embodiment;

[0050] Figure 9 illustrates the arrangement of a ninth exemplary retrieval catheter having a deployable and retractable stent structure and a balloon structure according to at least one embodiment;

[0051] Figure 10 illustrates the arrangement of a tenth exemplary recovery catheter with a covered disc-shaped support structure according to at least one embodiment;

[0052] Figure 11A is a schematic diagram of a first exemplary perfusion catheter having a single balloon structure according to at least one embodiment;

[0053] Figure 11B is a schematic diagram of the balloon structure of a first exemplary perfusion catheter in an expanded state according to at least one embodiment;

[0054] Figure 11C is a schematic diagram of the balloon structure of a first exemplary perfusion catheter in a retracted state according to at least one embodiment;

[0055] Figure 12A is a schematic diagram of a second exemplary irrigation catheter with a distal plug according to at least one embodiment;

[0056] Figure 12B is a schematic diagram of the plug of a second exemplary irrigation catheter according to at least one embodiment;

[0057] Figure 12C is a schematic diagram of the plug of a second exemplary irrigation catheter in an extended state according to at least one embodiment;

[0058] Figure 13A is a schematic diagram of a third exemplary irrigation catheter having a distal wedge according to at least one embodiment;

[0059] Figure 13B is a schematic diagram of a wedge-shaped member of a third exemplary irrigation catheter according to at least one embodiment;

[0060] Figure 13C is another schematic diagram of the distal end of a third exemplary irrigation catheter in an extended state according to at least one embodiment;

[0061] Figure 14A illustrates the arrangement of a fourth exemplary irrigation catheter with a partially covered and retractable stent structure according to at least one embodiment;

[0062] Figure 14B shows a fourth exemplary perfusion catheter stent structure in a retracted state according to at least one embodiment;

[0063] Figure 14C shows a fourth exemplary perfusion catheter in an deployed state according to at least one embodiment;

[0064] Figure 15A illustrates an arrangement of a fifth exemplary irrigation catheter with a detachable covered braided disc according to at least one embodiment;

[0065] Figure 15B shows a braided disc of a fifth exemplary irrigation catheter in an unfolded state according to at least one embodiment;

[0066] Figure 16A is a schematic diagram of a sixth exemplary irrigation catheter with a gradually tapering lumen axis according to at least one embodiment;

[0067] Figure 16B illustrates the arrangement of a sixth exemplary perfusion conduit according to at least one embodiment;

[0068] Figure 16C shows a preformed lumen axis of a sixth exemplary irrigation catheter according to at least one embodiment;

[0069] Figure 17 shows an exemplary preformed lumen axis of an exemplary catheter according to various embodiments;

[0070] Figure 18 depicts an exemplary localized irrigation system according to an embodiment of the present invention;

[0071] Figure 19 is a schematic diagram of an exemplary localized irrigation device according to an embodiment of the present invention;

[0072] Figure 20 includes radiographic images showing the placement of the renal artery and renal vein arteries and venous ducts in a pig kidney;

[0073] Figure 21 is a diagram showing renal transduction and biodistribution after 60 minutes of renal LRP according to an embodiment of the present invention;

[0074] Figure 22A shows the number of vector genomes per milliliter of plasma measured at various time points during a 60-minute renal LRP procedure with a high dose of vector genomes;

[0075] Figure 22B shows the number of vector genes per milliliter of plasma measured at various time points during a 45-minute renal LRP procedure using a low vector gene dose;

[0076] Figure 23A is a graph showing the C3a content in the kidneys of two different animals several days after LRP treatment;

[0077] Figure 23B shows the percentage of transduction inhibition at various sample dilutions;

[0078] Figure 24A shows the flow rate during renal LRP; and

[0079] Figure 24B is a graph of pump velocity during renal LRP. Implementation

[0080] [Cross-reference to related applications] []

[0081] This application claims priority to U.S. Provisional Patent Application No. 63 / 312,029, filed February 20, 2022; U.S. Provisional Patent Application No. 63 / 305,960, filed February 2, 2022; and U.S. Provisional Patent Application No. 63 / 151,933, filed February 22, 2021, the disclosures of which are hereby incorporated herein by reference in their entirety. [definition] []

[0082] Unless the context clearly indicates otherwise, as used herein, the singular forms “a / an” and “the” include a plural reference. Thus, for example, reference to “drug” includes a single drug and a mixture of two or more different drugs; and reference to “viral vector” includes a single viral vector and a mixture of two or more different viral vectors, and so on.

[0083] Furthermore, as used herein, when used in conjunction with the quantity being measured, "about" refers to the normal variation in the quantity being measured, as would be expected by one of ordinary skill in the art, to make the measurement and operation commensurate with the target of the measurement and the accuracy of the measuring equipment at the level of interest. In some embodiments, the term "about" includes the value ±10%, whereby "about 10" would include 9 to 11.

[0084] Furthermore, as used herein, "polynucleotide" has its common and conventional meaning in this art and includes any polymeric nucleic acid, such as DNA or RNA molecules, and chemical derivatives known to those skilled in the art. Polynucleotides include not only polynucleotides encoding therapeutic proteins but also sequences (e.g., antisense, interfering, or small interfering nucleic acids) that can be used to reduce the expression of target nucleic acid sequences using techniques known in this art. Polynucleotides can also be used to initiate or increase the expression of target nucleic acid sequences or the production of target proteins within the cells of the cardiovascular system. Target nucleic acids and proteins include, but are not limited to, nucleic acids and proteins commonly found in target tissues, derivatives of such naturally occurring nucleic acids or proteins, naturally occurring nucleic acids or proteins not commonly found in target tissues, or synthetic nucleic acids or proteins. One or more polynucleotides may be used in combination, simultaneously and / or sequentially, to increase and / or decrease one or more target nucleic acid sequences or proteins.

[0085] Furthermore, as used herein, "perfusion / perfused / perfusing" has its common and conventional meaning in this technique and refers to an administration of a duration substantially longer than the technically accepted terms "injection" or "pump injection" (usually less than one minute), typically one minute or longer. The flow rate of the perfusion will depend at least in part on the volume administered.

[0086] Furthermore, as used herein, “exogenous” nucleic acids are nucleic acids that are not naturally present in vectors used for nucleic acid transfer; for example, nucleic acids that are not naturally present in viral vectors, but this term is not intended to exclude nucleic acids encoding proteins or polypeptides that are naturally present in patients or hosts.

[0087] Furthermore, as used herein, "kidney cells" includes any kidney cells that participate in maintaining kidney structure or providing kidney function.

[0088] Furthermore, as used herein, “separation,” “substantial separation,” “largely separated,” and their variations are terms that do not require complete or absolute separation of the renal or systemic circulation; in fact, they are intended to mean that most, preferably the main, or even substantially all of the specified circulation has been separated. Also, as used herein, “partial separation” means that any significant portion of the specified circulation has been separated.

[0089] Furthermore, as used herein, "non-natural limitations" include any method that restricts fluid flow through blood vessels, such as balloon catheters, sutures, etc., but do not include naturally occurring limitations, such as plaque buildup (stenosis). Non-natural limitations include, for example, substantial or complete severance of the renal circulation.

[0090] Furthermore, as used herein, "minimally invasive" is intended to include any procedure that does not require opening the kidney or the blood vessels closely connected to it. Such procedures include endoscopic access to the kidney and catheter-based access via large arteries and veins.

[0091] Furthermore, as used herein, "adeno-associated virus" or "AAV" encompasses all subtypes, serotypes, and pseudotypes, as well as naturally occurring and recombinant forms. Various AAV serotypes and viral strains are known in this technique and are publicly available from various sources, such as the ATCC, and academic or commercial sources. Alternatively, sequences from AAV serotypes and viral strains publicly available and / or obtained from various databases can be synthesized using known techniques.

[0092] Furthermore, as used herein, "serotype" refers to an AAV that is identified and distinguished from other AAVs based on capsid proteins that are reactive to a known antiserum. There are at least twelve known serotypes of human AAVs, including AAV1 to AAV12, but other serotypes are constantly being discovered, and the use of newly discovered serotypes is being considered.

[0093] Furthermore, as used herein, "pseudotyped" AAV refers to an AAV containing a capsid protein and viral genome derived from a serotype, the viral genome including 5' and 3' inverted terminal repeats (ITRs) of different or heterologous serotypes. It is anticipated that pseudotyped recombinant AAV (rAAV) will possess the cell surface binding characteristics of the capsid serotype and genetic characteristics consistent with the ITR serotype. Pseudotyped rAAV may contain AAV capsid proteins, including VP1, VP2, and VP3 capsid proteins; and ITRs from any serotype AAV, including ITRs from any primate AAV serotype from AAV1 to AAV12, provided that the capsid protein is heterologous to the ITR serotype. In pseudotyped rAAV, the 5' and 3' ITRs may be identical or heterologous. Pseudotyped rAAV is produced using the standard techniques described herein.

[0094] Furthermore, as used herein, "chimeric" rAAV vectors encompass AAV vectors containing heterologous capsid proteins; that is, rAAV vectors may be chimeric with respect to their capsid proteins VP1, VP2, and VP3, thereby ensuring that VP1, VP2, and VP3 do not all belong to the same serotype of AAV. As used herein, chimeric AAV encompasses AAVs in which the capsid proteins VP1, VP2, and VP3 differ in serotype, including, for example, but not limited to, capsid proteins derived from AAV1 and AAV2; mixtures of other parvovirus capsid proteins; or containing other viral proteins or other proteins, such as proteins that target AAV delivery to desired cells or tissues. As used herein, chimeric rAAV also encompasses rAAVs containing chimeric 5' and 3' ITRs.

[0095] Furthermore, as used herein, "pharmaceutical-acceptable excipients or carriers" means any inert component in a composition combined with an active agent in a formulation. Pharmaceutically acceptable excipients may include, but are not limited to, carbohydrates (such as glucose, sucrose, or polydextrose), antioxidants (such as ascorbic acid or glutathione), chelating agents, low molecular weight proteins, high molecular weight polymers, gelling agents, or other stabilizers and additives. Examples of other pharmaceutically acceptable carriers include wetting agents, emulsifiers, dispersants, or preservatives particularly suitable for preventing microbial growth or action. Various preservatives are well known and include, for example, phenol and ascorbic acid. Examples of carriers, stabilizers, or adjuvants can be found in Remington's Pharmaceutical Sciences, Mack Publishing Company, Philadelphia, Pa., 17th edition (1985).

[0096] Furthermore, as used herein, "patient" refers to an individual who presents with one or more specific symptoms that suggest a need for treatment, is undergoing preventative treatment for the condition, or has been diagnosed with a condition requiring treatment, particularly a human being (but may also include non-humans).

[0097] Furthermore, as used in this article, "individual" encompasses the definition of the term "patient" and does not exclude individuals who are otherwise healthy.

[0098] Furthermore, as used in this article, "treatment of / treating" includes administering medication to reduce the severity of a condition, such as kidney disease or kidney disease; or to prevent a condition, such as kidney disease or kidney disease.

[0099] Furthermore, as used in this article, "prevention of / preventing" includes avoiding conditions such as kidney conditions or kidney disease.

[0100] Furthermore, as used in this article, "condition" refers to a medical condition that can be treated, alleviated, or prevented by administering an effective dose of medication to an individual, such as kidney disease.

[0101] Furthermore, as used herein, "effective amount" means an amount of drug sufficient to produce such an effect at a level easily detectable by methods commonly used to detect beneficial or desired effects. In some embodiments, such an effect causes a change of at least 10% relative to a baseline level without drug administration. In other embodiments, this change is at least 20%, 50%, 80%, or even higher percentages relative to the baseline level. As will be described below, the effective amount of a drug can vary from person to person depending on the individual's age, general condition, severity of the condition being treated, the specific drug administered, and similar factors. In any individual case, the appropriate "effective" amount can be determined by a person generally skilled in the art by referring to relevant texts and literature and / or by using conventional experimental methods.

[0102] Furthermore, as used herein, "active agent" means any substance that is expected to produce a therapeutic, preventative or other intended effect, whether or not it has been approved by a government agency for that purpose.

[0103] Unless otherwise indicated herein, the description of ranges of values ​​herein is intended only as a shorthand for individually referring to each individual value within that range, and each individual value is incorporated into this specification as if individually described herein. Unless otherwise indicated herein or clearly contradicted by the context, all methods described herein may be performed in any suitable order. The use of any and all examples or illustrative language (e.g., "such as") provided herein is intended only to describe certain substances and methods and does not limit the scope. The language of this specification should not be construed as indicating that any non-claimed element is essential to the practice of the disclosed substances and methods.

[0104] Some embodiments of the present invention relate to systems and methods for treating kidney conditions in a minimally invasive manner. Other embodiments of the present invention relate to the selective delivery of AAV organs to the kidneys using a minimally invasive percutaneous delivery system. An exemplary method may include separating a patient's renal circulation from the patient's systemic circulation and perfusing a fluid, such as a drug-containing fluid, into the separated or substantially separated renal circulation. This perfusing may be performed in one or both kidneys and may be used to deliver one or more drugs, including but not limited to gene therapy vectors, extracellular bodies, nanoparticles, antibodies, chemotherapy, etc., without exposing systemic circulation and thus other organs to one or more selected drugs. These methods may also be used to separate renal circulation to allow, for example, nephrotoxic drugs to be administered into the patient's systemic circulation in order to protect the kidneys from adverse effects. The separation of a patient's renal circulation will be described in more detail below with reference to Figures 18 and 19. []

[0105] Kidney conditions or diseases treatable by the methods described herein may include, but are not limited to, renal wasting disease, particularly renal wasting disease caused by autosomal recessive mutations in the NPHP1 gene; and autosomal dominant polycystic kidney disease, particularly autosomal dominant polycystic kidney disease caused by haploinadequate PKD2 gene. Renal wasting disease is an autosomal recessive kidney disease that leads to end-stage renal failure. The most common form is caused by mutations in NPHP1, most commonly by double-pair deletions (Hildebrandt, F. et al., Nature Genetics, Vol. 17, 149-153, 1997; Saunier, S. et al., Human Molecular Genetics, Vol. 6, No. 13, 2317-2323, 1997). The NPHP1 gene produces a 733-amino acid protein, nephrocystin-1 (a 2199-base-long cDNA), located at adhesion junctions and focal adhesion sites on renal epithelial cells. It can be vectorized using AAV. After careful consideration, replacing nephrocystin-1 in target tissues may alleviate or treat type 1 renal wasting disease.

[0106] The incidence of autosomal dominant polycystic kidney disease (ADPKD) is approximately 1 in 1000 individuals, and about 15% of these cases are caused by mutations in the PKD2 protein. PKD2 is a polypeptide of 968 amino acids and is an integrated membrane protein confined to cilia. The primary pathogenic mechanism is haploinadequacy (Veldhuisen, B. et al., American Journal of Human Genetics, 61, 547-555, 1997). After careful consideration, AAV-mediated gene therapy to supplement PKD2 protein levels may alleviate ADPKD.

[0107] Systemic delivery of recombinant AAV vectors to solid organs is challenging due to the need for high doses and the potential for serious adverse events (SAEs), particularly hepatotoxicity and thrombotic microangiopathy. Some embodiments relate to localized delivery and perfusion systems capable of selective perfusion of solid organs. These embodiments demonstrate the possibility of targeted delivery of AAV vectors to one or both renal systems without involving excretion into the systemic circulation.

[0108] To demonstrate the efficacy of the embodiments described herein, the left renal artery and vein of AAV-negative adult domestic pigs (approximately 90 kg) were percutaneously cannulated via the internal jugular and femoral artery pathways. To isolate the kidney from the systemic circulation, a closed loop was established using heparinized blood filling (perfusion fluid) from each animal, and localized perfusion (LRP) was initiated using an extracorporeal membrane oxygenation (ECMO) system. The AAV vector containing a CMV-EGFP transfection cartridge was injected into the closed-loop LRP system, and localized perfusion of the kidney was performed for up to 2 hours. Longitudinal blood samples were collected for safety assessment, and vector titration and immunoassays (e.g., complement activation, anti-AAV antibody) were performed before, during, and after the procedure. Upon completion of the procedure, the vector-containing perfusion fluid was aspirated, and the catheter was removed. The animals were evaluated for 2 weeks, then euthanized, and the tissue was collected for tissue processing. The presence of the vector gene was detected using quantitative PCR (qPCR), and the expression of the transfected gene was assessed by qPCR, Western blot, and immunohistochemistry. The procedure was successful in all animals without perioperative complications. Animals recovered rapidly without any clinical signs of kidney injury or damage. Vector concentrations remained high and stable in the closed-loop perfusion fluid throughout the procedure, with no leakage related to systemic circulation or urine. AAV particles were uniformly distributed in the treated kidney tissue. Green fluorescent protein (GFP) was uniformly expressed in the perfused kidney. The vector was not detected in the untreated contralateral kidney, liver, or other organs. Anti-AAV neutralizing antibodies showed only a slight increase from baseline, and no complement activation was detected. Other tests will be discussed in more detail below.

[0109] In some embodiments, the system includes an arterial access catheter, which may be inserted, for example via the femoral artery, and sealed within the renal artery at a flow rate suitable for perfusion and oxygenation of the kidney, maintaining the procedure for a duration typically 500-600 mL / min (or 1000-1200 mL / 1.73 m²) per kidney for 70 adults. In some embodiments, the system includes a venous retrieval catheter, which may be inserted, for example via the femoral vein, and sealed within the renal vein at a flow rate suitable for venous retrieval. In some embodiments, the system includes an extracorporeal membrane oxygenator system that fluidly connects venous blood flow from the kidney to arterial blood flow from the kidney and enables oxygenation of the venous blood.

[0110] In some embodiments, the system includes one or more additional access lines to allow for drug administration or fluid addition. In some embodiments, a balloon catheter may be inserted into the patient's bladder to measure urine output during the procedure. In other embodiments, individual ureteral catheters are placed in each of the two ureters to differentially measure the output of both kidneys. In some embodiments, the system is adapted to replace the fluid volume of perfusion fluid lost due to bladder emptying. For example, in some embodiments, additional perfusion fluid (e.g., blood) and / or other physiologically acceptable solutions (e.g., plasma or saline solution) may be used to replace approximately 5% v / v to approximately 50% v / v of the lost perfusion fluid volume to calculate bladder emptying. []

[0111] In some embodiments, the system and method allow for localized perfusion of a kidney with a targeted drug for durations such as 15 minutes, 30 minutes, 45 minutes, one hour, two hours, three hours, four hours, or any range thereof. In some embodiments, the system and method allow for selective targeting of one or both kidneys with minimal or no exposure to the drug in the systemic circulation and other organs. In some embodiments, gene therapy drugs may be used to treat kidney conditions, utilizing viral vectors (e.g., adeno-associated virus), naked or encapsulated DNA or RNA molecules, or synthetic DNA or RNA analogs (e.g., antisense). In some embodiments, chemotherapy may be used to target kidney tumors. In some embodiments, other drugs or biologics / antibodies may be used. In some embodiments, combinations of the aforementioned drugs may be used. []

[0112] When treating kidney conditions, separating the patient’s renal circulation from the patient’s systemic circulation has many advantages. These advantages include, but are not limited to: (1) localized drug delivery, minimal drug leakage to other organs, and a reduced overall drug dose; (2) increased target drug dose; (3) reduced risks and side effects; and (4) the possibility of re-dosing selected patients or to patients who are not suitable candidates for certain therapies (such as gene therapy using viral vectors for patients with antibodies against such viral vectors). [] Exemplary catheter examples

[0113] Exemplary retrieval catheters and perfusion catheters are described herein. Those skilled in the art will understand that these catheters can be configured for the anatomy of any target organ (e.g., the kidney) to which LRP is to be performed. Furthermore, it should be understood that any catheter described as a "retrieval catheter" can also be used as an "perfusion catheter," and vice versa. The embodiments described herein are not limited to LRP of the kidney, but can also be used to separate renal circulation from systemic circulation, for example, to reduce or prevent renal exposure to drugs or other agents introduced into systemic circulation that may have harmful effects on the kidneys. Those skilled in the art will understand other uses of the catheter embodiments described herein, such as in applications where it is desirable to seal blood vessels.

[0114] Examples of exemplary catheters used as retrieval catheters in LRP systems are now described. In at least one embodiment, the retrieval catheter is designed to support fluid aspiration flow rates of about 400 mL / min or higher (e.g., about 700 mL / min or higher). For example, in some embodiments, the exemplary catheter can support an in vitro aspiration flow rate of about 800 mL / min at about -80 mmHg. []

[0115] Figures 1 through 10 depict various catheter embodiments suitable for fluid recovery in an LRP system. Any of the catheters depicted in Figures 1 through 10 can be configured to support fluid flow rates (aspiration or perfusion) of at least about 400 mL / min, at least about 450 mL / min, at least about 500 mL / min, at least about 550 mL / min, at least about 600 mL / min, at least about 650 mL / min, at least about 700 mL / min, at least about 750 mL / min, at least about 800 mL / min, at least about 850 mL / min, at least about 900 mL / min, at least about 950 mL / min, or at least about 1000 mL / min. Each catheter is compatible with a controllable guide sheath that provides stability and guides the distal end of the catheter and allows the catheter to generate directional thrust. Each catheter may also have a traction line integrated into its shaft assembly to allow bending at an angle of up to 120° in the proximal segment of the occlusion structure and to achieve better tracking and centering of the occlusion structure. []

[0116] In some embodiments, one or more catheters may be multi-lumen catheters, such as dual-lumen catheters. In some embodiments, such multi-lumen catheters allow fluid flow (e.g., perfusion fluid) and are capable of inflating one or more balloons. In some embodiments, one or more catheters may be multi-balloon catheters having two or more balloons. In some embodiments, one or more balloons may deploy or depress independently. []

[0117] Figure 1 illustrates an exemplary catheter 100 having lumen shafts 104 / 106, the catheter having a proximal end 101 and a distal end 102. Lumen shafts 104 / 106 may be formed from an outer lumen shaft 104 that at least partially surrounds an inner lumen shaft 106, exposing the distal portion of the inner lumen shaft 106 near the distal end 102. The proximal end 101 includes an outlet structure that can be fluidly coupled to an LRP system. One or more of the outer lumen shaft 104 or the inner lumen shaft 106 may be formed from a durable polymeric material, such as polyether block amide (PEBA) material (e.g., commercially available from PEBAX®). In at least one embodiment, the innermost diameter (“inner diameter”) of the inner lumen shaft 106 is at least about 4 mm to provide a fluid flow path. In at least one embodiment, the catheter 100 may be designed to include an additional lumen shaft. []

[0118] The catheter 100 includes a tip portion 108 at a distal end 102 and an expandable balloon structure 110 disposed along a portion 112 of an internal lumen axis 106. In at least one embodiment, the tip portion 108 includes an elongated axis extending from the balloon structure 110 to the distal end 102. In at least one embodiment, the length of the elongated axis of the tip portion is about 2 mm to about 35 mm, about 5 mm to about 30 mm, about 10 mm to about 25 mm, about 15 mm to 25 mm, or any subrange defined therebetween (e.g., about 2 mm to about 5 mm). In at least one embodiment, the tip portion 108 includes an opening at the distal end 102 and one or more perforations along the elongated axis. In at least one embodiment, the tip portion is formed of a flexible material that is more flexible than the material of the internal lumen axis 106.

[0119] In at least one embodiment, the internal lumen shaft 106 includes a concentric internal flow path surrounding the liquid flow path. This concentric internal flow path provides a path for gas to flow from the balloon structure 110 to the orifice 114, which can be used to inflate or deflate the balloon depending on the pressure applied at the orifice 114. In at least one embodiment, the outermost surface of the internal lumen shaft 106 at a portion 112 is removed so that the portion 112 is sealed by the balloon structure 110 to isolate gas flow from the concentric internal flow path to the balloon structure 110. In at least one embodiment, the expansion diameter of the balloon structure is about 15 mm to about 30 mm, about 15 mm to about 20 mm, about 20 mm to about 25 mm, about 24 mm to about 28 mm, or about 25 mm to about 30 mm.

[0120] Figure 2 is an image of a catheter with a balloon in its deployed state, similar in structure to catheter 100. The catheter dimensions include: a cross-profile diameter of 19 Fr (6.3 mm); an innermost diameter of 12 Fr (4.0 mm); a usable length of 80 cm; a balloon diameter of 25 mm (when deployed); and a tip length of 20 mm. The lumen axis may be formed from a polymer material such as PEBAX® 63, supported by a strong stainless steel braid. The balloon may be formed from a flexible thermoplastic / elastic material such as ChronoPrene™ 25A. The tip may be formed from a polymer material such as PEBAX® 35 and may be loaded with a radiolabeled or radiopaque filler composition, such as BaSO4.

[0121] Figure 3 illustrates, according to at least one embodiment, the exemplary catheter 300 inserted into blood vessel 352 via a larger blood vessel or chamber 350 (referred to herein as a "blood vessel"). In the depicted anatomy, blood flow from blood vessels 352 and 354 drains into blood vessel 350. The catheter 300 may be identical or similar to catheter 100, having a proximal end 301, a distal end 302, an internal lumen axis 304, an external lumen axis 306, a tip portion 308, and a balloon structure 310 disposed on a portion 312 of the internal lumen axis 304. When deployed, the balloon structure 310 is sufficiently flexible to conform to the anatomy of blood vessel 352 and occlude blood flow through blood vessel 352 into blood vessel 350 without exerting excessive force on the tissue. As shown in Figure 3, the catheter 300 is inserted across blood vessel 354 to avoid occlusion of flow from blood vessel 354 into blood vessel 350.

[0122] It should be noted that vessels or chambers 350, 352, and 354 respectively illustrate the anatomical structures of the right atrium, coronary sinus, and central cardiac vein of the heart, to illustrate various types of occlusion techniques that can be employed using the illustrative catheter. However, they are referred to herein as ordinary vessels, and it should be understood that any catheter placement described herein may be adapted to the specific anatomy of the target organ (e.g., the kidney) to which LRP or occlusion is to be performed. For example, vessels 350 and 352 may correspond to the inferior vena cava and renal vein of the kidney, respectively (vessel 354 is absent).

[0123] Figures 4 through 10 illustrate other occlusion techniques according to various embodiments of the present invention. The catheters depicted in Figures 4 through 10 may, in some cases, be similar to the catheters depicted in Figures 1 through 3, for example, in size, material, or structure.

[0124] Figure 4 illustrates a catheter 400 according to at least one embodiment, which is partially inserted into a blood vessel 352 such that it is adjacent to an opening in the blood vessel 352. The catheter 400 includes a proximal end 401, a distal end 402, an internal lumen shaft 404, an external lumen shaft 406, a tip portion 408, and a balloon structure 410 disposed on a portion 412 of the internal lumen shaft 404. In at least one embodiment, when deployed, the diameter of the balloon structure 410 is greater than about 15 mm, greater than about 20 mm, greater than about 25 mm, or greater than about 30 mm. The tip portion 408 may include one or more perforations in addition to the opening at the distal end 402 to allow blood flow from the blood vessels 352 and 354 into the catheter 400.

[0125] In at least one embodiment, during deployment, the outer lumen axis 406 may be moved distally to abut the deployed balloon structure 410, such that the balloon structure 410 exerts additional pressure on the orifice of the vessel 352 to further stabilize the position of the catheter 400. In at least another embodiment, pressure may be applied to the balloon structure 410 using a linear structure. The linear structure may, for example, have a sinusoidal shape and may be arranged as an expanding flower-like structure extending radially from the outer lumen axis 406 or the inner lumen axis 404. When in contact with the balloon structure 410, the linear structure may generate a more uniform pressure distribution across the entire surface of the balloon structure 410. Prior to deployment, the linear structure may be covered by the outer lumen axis 406 or by an additional lumen beyond the outer lumen axis 406.

[0126] Figure 5 illustrates, according to at least one embodiment, the separate occlusion and drainage of vessels 352 and 354 using a first catheter 500 and a second catheter 550, respectively. The first catheter 500 includes a proximal end 501, a distal end 502, a lumen axis 504, a tip portion 508, and a balloon structure 510 positioned on a portion 512 of the lumen axis 504. Similarly, the second catheter 550 includes a proximal end 551, a distal end 552, a lumen axis 554, a tip portion 558, and a balloon structure 560 positioned on a portion 562 of the lumen axis 554. In this configuration, the first catheter 500 is inserted into vessel 352 such that the balloon structure 510 does not occlude vessel 354, while the second catheter 550 is directly inserted into vessel 354. The selected sizes of the first catheter 500 and the second catheter 550 provide safe and effective occlusion of vessels 352 and 354, respectively.

[0127] Figure 6 shows a variation of Figure 5, which uses two catheters, only one of which has a balloon structure according to at least one embodiment. The first catheter 600 includes a proximal end 601, a distal end 602, a lumen shaft 604, a tip portion 608, and a balloon structure 610 disposed on a portion 612 of the lumen shaft 604. The second catheter 650 includes a proximal end 651, a distal end 652, a lumen shaft 654, and a tip portion 658, but does not include the balloon structure. The first catheter 600 is inserted into a blood vessel 352 such that a portion of the balloon structure 610 occludes the blood vessel 354 and is partially within both the blood vessel 350 and the blood vessel 352. The second catheter 650 is inserted directly into the blood vessel 354 and disposed between the blood vessel wall and the balloon structure 610, at least partially occluding the blood vessel 354.

[0128] Figure 7 illustrates the use of a single catheter 700 according to at least one embodiment, the catheter comprising multiple balloons. The catheter 700 includes a proximal end 701, a distal end 702, a lumen shaft 704, a tip portion 708, a first balloon structure 710 disposed on a first portion 712 of the lumen shaft 704, and a second balloon structure 720 disposed on a second portion 722 of the lumen shaft 704. In at least one embodiment, the catheter 700 is designed for insertion into a blood vessel 352 such that the first balloon structure 710 occludes the blood vessel 352, and the second balloon structure 720 adjoins an opening in the blood vessel 352 to occlude (and further occlude) the blood vessel 352. An intermediate portion 724 of the lumen shaft 704 between the first balloon structure 710 and the second balloon structure 720 includes one or more perforations allowing the blood vessel 354 to drain. In at least one embodiment, the expansion diameter of the second balloon structure 720 is greater than the expansion diameter of the first balloon structure 710. In at least one embodiment, the catheter 700 is designed as a multi-lumen catheter that allows each balloon to deploy and retract independently of the others.

[0129] Figure 8 illustrates a catheter 800 according to at least one embodiment, the catheter including a partially covered and retractable stent structure 810. The catheter 800 includes a proximal end 801 and a distal end 802, an inner lumen shaft 804 coupled to the stent structure 810, and an outer lumen shaft 806. A portion of the outer lumen shaft 806 is depicted in cross-section to show the inner lumen shaft 804 within it. The stent structure 810 is depicted in its deployed state, but may be contained within the outer lumen shaft 806 before deployment. The stent structure 810 is further depicted having a proximal covered portion 810A formed of a flexible and durable polymer material, and a distal uncovered portion 810B. When inserted into a blood vessel 352, as shown, the covered portion 810A occludes blood flow from the blood vessel 352, while the uncovered portion 810B provides structural support within the blood vessel 352 while allowing blood flow from both blood vessels 352 and 354 to flow directly into the catheter 800. In at least one embodiment, the catheter 800 can be used as an irrigation catheter connected to a supply line.

[0130] Figure 9 illustrates a catheter 900 according to at least one embodiment, comprising a deployable and retractable stent structure 920. The catheter 900 further includes a proximal end 901, a distal end 902, a lumen shaft 906, a tip portion 908, and a balloon structure 910 disposed on a portion 912 of the lumen shaft 906. The catheter 900 may further include an external lumen shaft (not shown) that substantially encloses the stent structure 920 and the balloon structure 910 before deployment. Deployment of the stent structure 920 can be performed by moving the external lumen shaft in a proximal direction, and retraction of the stent structure 920 can be performed by moving the external lumen shaft in a distal direction. The stent structure 920 may be formed of, for example, stainless steel and is disposed between the balloon structure 910 and the tip portion 908. In at least one embodiment, the lumen shaft 906 includes at least one perforation along a portion 922 between the balloon structure 910 and the stent structure 920 to allow a blood vessel 354 to drain into the catheter 900. When inserted into blood vessel 352, balloon structure 910 is adjacent to the opening of blood vessel 352.

[0131] Figure 10 illustrates a catheter 1000 according to at least one embodiment, which includes a covered disc-shaped stent structure 1010. The catheter 1000 further includes a proximal end 1001, a distal end 1002, an external lumen shaft 1006, an internal lumen shaft 1004, and a tip portion 1008. The stent structure 1010 may be formed of, for example, a stainless steel stent with a durable polymer coating. The external lumen shaft 1006 may cover the stent structure before it is deployed. After the catheter 1000 is properly positioned, the external lumen shaft 1006 can be moved in the proximal direction to deploy the stent structure 1010. In at least one embodiment, the stent structure 1010 is coupled to the tip portion 1008, which may be partially contained within the internal lumen shaft 1004, and may be actuable (using a wire) to deploy the stent structure 1010 upon movement in the proximal direction and retract the stent structure 1010 upon movement in the distal direction. In at least one embodiment, the stent structure 1010 is large enough when deployed to occlude blood vessels 352 and 354 when adjacent to the orifice of blood vessel 352. In at least one embodiment, the diameter of the stent structure 1010 is from about 10 mm to about 30 mm.

[0132] Examples of exemplary catheters used as irrigation catheters in LRP systems are now described. In at least one embodiment, the irrigation catheter is designed to support a fluid irrigation flow rate of about 400 mL / min or higher (e.g., about 700 mL / min or higher). In embodiments utilizing multiple irrigation catheters, a combined flow capacity of 700 mL / min or higher can be supported.

[0133] Figures 11 through 16 depict various catheter embodiments suitable for fluid perfusion in an LRP system. Any of the catheters depicted in Figures 11 through 16 can be configured to support fluid flow rates (aspiration or perfusion) of at least approximately 400 mL / min, at least approximately 450 mL / min, at least approximately 500 mL / min, at least approximately 550 mL / min, at least approximately 600 mL / min, at least approximately 650 mL / min, at least approximately 700 mL / min, at least approximately 750 mL / min, at least approximately 800 mL / min, at least approximately 850 mL / min, at least approximately 900 mL / min, at least approximately 950 mL / min, or at least approximately 1000 mL / min. Each catheter can be designed with a smooth profile from the proximal catheter body to the lower distal end, for example, using one or more concentric lumen axes. Furthermore, the catheters can be designed with lumen axes pre-shaped according to the anatomy of the LRP procedure to be performed, which improves overall stability during use.

[0134] In some embodiments, one or more catheters may be multi-lumen catheters, such as dual-lumen catheters. In some embodiments, such multi-lumen catheters allow fluid flow (e.g., perfusion fluid) and are capable of inflating one or more balloons. In some embodiments, one or more catheters may be multi-balloon catheters having two or more balloons. In some embodiments, one or more balloons may deploy or depress independently. []

[0135] Figures 11A and 11C illustrate an exemplary catheter 1100 having a lumen shaft 1104 / 1106, the catheter having a proximal end 1101 and a distal end 1102, the distal end having an opening from which irrigation fluid can flow out. The lumen shaft 1104 / 1106 may be formed of an external lumen shaft 1104 that at least partially surrounds an internal lumen shaft 1106, exposing the distal portion of the internal lumen shaft 1106 near the distal end 1102. The proximal end 1101 includes an outlet structure that can be fluidly coupled to an LRP system. One or more of the external lumen shaft 1104 or the internal lumen shaft 1106 may be formed of a durable polymer material, such as polyether block amide (PEBA) material (e.g., commercially available PEBAX®). In at least one embodiment, the innermost diameter of the inner cavity shaft 1106 is at least about 2 mm, at least about 2.5 mm, at least about 3 mm, at least about 3.5 mm, at least about 4 mm, at least about 4.5 mm, or at least about 5 mm to provide a liquid flow path. []

[0136] The catheter 1100 includes an expandable balloon structure 1110 disposed along a portion 1112 corresponding to an internal lumen axis 1106 and a tip portion formed by an additional lumen. In at least one embodiment, the internal lumen axis 1106 includes a concentric internal flow path around a liquid flow path. This concentric internal flow path provides a path for gas to flow from the balloon structure 1110 to an orifice 1114, which can be used to inflate or deflate the balloon structure 1110 depending on the pressure applied at the orifice 1114. In at least one embodiment, the outermost surface of the internal lumen axis 1106 at the portion 1112 is removed such that the portion 1112 is sealed by the balloon structure 1110 to isolate gas flow from the concentric internal flow path to the balloon structure 1110. In at least one embodiment, the expansion diameter of the balloon structure 1110 is about 15 mm to about 30 mm, about 15 mm to about 20 mm, about 20 mm to about 25 mm, about 24 mm to about 28 mm, about 25 mm to about 30 mm, or any sub-range defined therebetween (e.g., about 20 mm to about 28 mm). Figures 11B and 11C show the balloon structure 1110 in its expanded and contracted states.

[0137] Figures 12 and 13 show catheters including plug and wedge occlusion structures, which are advantageously shaped to fit blood vessels or orifices, formed of highly compressible and non-invasive materials for safe insertion and placement, have a shorter length than balloon structures, and do not require additional lumen expansion as is typical of balloon structures.

[0138] Figures 12A and 12C illustrate an exemplary catheter 1200 having a lumen shaft 1204 / 1206, the catheter having a proximal end 1201 and a distal end 1202, the distal end having an opening from which irrigation fluid can flow out. The lumen shaft 1204 / 1206 may be formed of an external lumen shaft 1204 that at least partially surrounds an internal lumen shaft 1206, exposing the distal portion of the internal lumen shaft 1206 near the distal end 1202. The proximal end 1201 includes an outlet structure that can be fluidly coupled to an LRP system. One or more of the external lumen shaft 1204 or the internal lumen shaft 1206 may be formed of a durable polymer material, such as polyether block amide (PEBA) material (e.g., commercially available PEBAX®). In at least one embodiment, the innermost diameter of the inner cavity shaft 1206 is at least about 2 mm, at least about 2.5 mm, at least about 3 mm, at least about 3.5 mm, at least about 4 mm, at least about 4.5 mm, or at least about 5 mm to provide a liquid flow path. []

[0139] The catheter 1200 further includes a plug 1210 proximal to the distal end 1202. In at least one embodiment, the plug 1210 is formed of a flexible material, such as polysiloxane or foam. In at least one embodiment, the plug 1210 includes an inner portion 1210A that fits onto an inner lumen shaft 1206 and a flexible outer portion 1210B shaped to be configured between a retracted state (FIG. 12A) and an extended state (FIG. 12C), in which the extended state, the outer portion 1210B extends distally from the distal end 1202. The plug 1210 in FIG. 12A is shown tapering distally. In at least one embodiment, the plug 1210 may be reversed to tape proximally. In at least one embodiment, the outer lumen shaft 1204 may be configured to cover the plug before the plug 1210 is deployed. When used as an irrigation catheter, the pressure of arterial blood flow in the hollow space between the inner portion 1210A and the outer portion 1210B of the plug 1210 can help improve the seal of the intravascular catheter 1200 when the plug is deployed.

[0140] Figures 13A to 13C illustrate an exemplary catheter 1300 having lumen shafts 1304 / 1306, the catheter having a proximal end 1301 and a distal end 1302, the distal end having an opening from which irrigation fluid can flow out. Lumen shafts 1304 / 1306 may be formed from an external lumen shaft 1304 that at least partially surrounds an internal lumen shaft 1306, exposing the distal portion of the internal lumen shaft 1306 near the distal end 1302. The proximal end 1301 includes an outlet structure that can be fluidly coupled to an LRP system. One or more of the external lumen shaft 1304 or the internal lumen shaft 1306 may be formed from a durable polymer material, such as polyether block amide (PEBA) material (e.g., commercially available PEBAX®). In at least one embodiment, the innermost diameter of the inner cavity shaft 1306 is at least about 2 mm, at least about 2.5 mm, at least about 3 mm, at least about 3.5 mm, at least about 4 mm, at least about 4.5 mm, or at least about 5 mm to provide a liquid flow path.

[0141] The catheter 1300 further includes a wedge 1310 proximal to the distal end 1302, which can be shaped to fit a blood vessel or orifice. In at least one embodiment, the wedge 1310 is formed of a flexible material, such as polysiloxane or foam. In at least one embodiment, an external lumen shaft 1304 can be configured to cover the wedge before the wedge 1310 is deployed. When deployed in the blood vessel, the shape of the wedge can utilize the backflow force from the vessel wall to further enhance stability during vascular occlusion and perfusion. []

[0142] Figures 14A and 14C illustrate an exemplary catheter 1400 according to at least one embodiment, similar to the catheter 800 described with respect to Figure 8, comprising a partially covered and retractable stent structure 1406. The catheter 1400 is shown inserted into an arterial vessel 1452 via a blood vessel or chamber 1450. In some embodiments, the catheter 1400 includes an external lumen shaft 1402 and an internal lumen shaft 1404 coupled to the stent structure 1406. The stent structure 1406 is further depicted having a proximal covered portion formed of a flexible and durable polymer material and a distal uncovered portion. Figures 14B and 14C illustrate the placement and deployment of the stent structure 1406 when inserted into the blood vessel 1452, respectively. Deployment of the stent structure 1406 is performed by moving the external lumen shaft 1402 in a proximal direction. []

[0143] Figures 15A and 15B illustrate an exemplary catheter 1500 according to at least one embodiment, which includes a detachable covered braided disc 1510. The catheter 1500 includes an outer lumen shaft 1506 and an inner lumen shaft 1504. The braided disc 1510 is contained within the outer lumen shaft 1506 during catheter 1500 placement and can be deployed by moving the outer lumen shaft 1506 in a proximal direction. In some embodiments, when deployed, the braided disc 1510 does not expand beyond the distal end 1502 and serves to stabilize the catheter 1500 against the orifice of the vessel 1452 to reduce the risk of stenosis during occlusion of the vessel 1452, while extending the distal end 1502 into the vessel 1452.

[0144] Figures 16A to 16C illustrate an exemplary catheter 1600 having a lumen shaft 1606, the catheter having a proximal end 1601 and a distal end 1602, the distal end having an opening from which irrigation fluid can flow out. The proximal end 1601 includes an outlet structure that can be fluidly coupled to an LRP system. The lumen shaft 1606 may be formed of a durable polymer material, such as a polyether block amide (PEBA) material (e.g., commercially available PEBAX®). In at least one embodiment, the innermost diameter of the lumen shaft 1606 is at least about 2 mm, at least about 2.5 mm, at least about 3 mm, at least about 3.5 mm, at least about 4 mm, at least about 4.5 mm, or at least about 5 mm to provide a fluid flow path. In at least one embodiment, the proximal portion 1606A of the lumen shaft 1606 may have a larger diameter than the distal portion 1606B of the lumen shaft 1606, and may taper gradually along the length of the lumen shaft 1606. Figure 16C shows a pre-formed lumen shaft for introduction and placement in a blood vessel of a target organ.

[0145] An example of a pre-formed catheter lumen is shown in Figure 17. The catheter lumen can be shaped to adjoin the anatomical structures when deployed, further enhancing stability during target organ occlusion and perfusion by utilizing the backflow force from the vessel wall. Exemplary LRP System Implementation Examples

[0146] Figure 18 depicts an exemplary LRP system 1800 according to an embodiment of the present invention. The LRP system 1800 is shown in a closed-loop configuration with the kidney 1810. The LRP system 1800 includes a membrane oxygenation device 1820, a blood gas analyzer (BGA) monitor 1830, a fluid source 1840, a flow measurement device 1842, an ECMO pump control console 1846 for monitoring and controlling fluid flow, and a pressure line and control console 1844 for measuring pressure within the closed loop. In some embodiments, a vacuum pump 1848 may also be used. The LRP system 1800 can be assembled by positioning a first catheter 1822 (which may be referred to herein as an "irrigation catheter") in the renal artery of the kidney 1810 and a second catheter 1824 (which may be referred to herein as a "recovery catheter," "collection catheter," or "aspiration catheter") in the renal vein of the kidney 1810. The first catheter 1822 and the second catheter 1824, together with the vascular structure of the kidney 1810, the membrane oxygenation device 1820, and one or more additional components as needed, form a closed circuit. This closed circuit can separate or substantially separate the patient's renal circulation from the patient's systemic circulation. []

[0147] The first catheter 1822 and the second catheter 1824 can be introduced percutaneously in a minimally invasive manner. In some embodiments, the first catheter 1822 and / or the second catheter 1824 can be introduced via anterograde cannulation. In other embodiments, the first catheter 1822 and / or the second catheter 1824 can be introduced via retrograde cannulation. When using catheters to deliver drugs to one or more kidneys, the first catheter 1822 may be referred to herein as a "drug delivery catheter" and the second catheter 1824 may be referred to herein as a "drug collection catheter". []

[0148] The first catheter 1822 may be a standard infusion catheter, which may include a standard guidewire and infusion pump, and is capable of delivering perfusion fluid to the kidney 1810, the perfusion fluid may contain, for example, a drug to be delivered to the kidney 1810 during localized perfusion. In some embodiments, the first catheter 1822 is positioned in the renal artery via the femoral artery. In some embodiments, the second catheter 1824 is positioned in the renal vein via the femoral vein. In some embodiments, the second catheter 1824 is a balloon catheter, whereby the balloon can inflate within the renal vein to ensure that all blood circulating through the closed loop flows through the second catheter 1824. Those skilled in the art will understand that the balloon catheter may be a Fogarty® catheter, or any other catheter suitable for the purposes discussed herein. In some embodiments, the first catheter 1822 and the second catheter 1824 may each be a balloon catheter to help reduce leakage. In some embodiments, any of these catheters may be selected from one or more of the catheters described with respect to Figures 1 through 17. []

[0149] The LRP system 1800 may further include one or more additional components, such as, but not limited to, one or more pumps (e.g., vacuum pump 1848), one or more suction mechanisms, one or more perfusion fluids, and combinations thereof. For example, the LRP system 1800 may include a pressure line and control console 1844, which in some embodiments is operatively coupled to or is part of a membrane oxygenation device 1820. The pressure line and control console 1844, along with the ECMO pump control console 1846, can be used together to control the perfusion rate (i.e., flow rate) and ensure safety by continuously monitoring renal artery pressure. A first pressure sensor and a second pressure sensor may be inserted, for example, with a first catheter 1822 and a second catheter 1824, respectively, to measure the pressure within the renal artery and renal vein, respectively. The LRP system 1800 is further described as including a BGA monitor 1830, which is operatively coupled to the membrane oxygenation device 1820 to measure, for example, the gas concentration in the perfusion fluid (e.g., when the perfusion fluid contains blood) before perfusion via the first catheter 1822 and / or after collection of the perfusion fluid via the second catheter 1824. The membrane oxygenation device 1820 and one or more additional components may be disposed between the first catheter 1822 and the second catheter 1824. []

[0150] In some embodiments, the LRP system 1800 includes a third catheter 1826 for emptying the bladder 1812. In some embodiments, the third catheter 1826 is a balloon catheter for preventing fluid leakage from the bladder 1812. A flow measurement device 1842 can be used to measure the volume of urine excreted from the bladder 1812 during the LRP procedure. In some embodiments, a fluid source 1840 can be used to replace the volume of excreted fluid lost in the perfusion fluid by injecting fluid through a fluid line 1841 into a closed loop. In some embodiments, the fluid is the same as the perfusion fluid or has fewer than all the components of the perfusion fluid (e.g., no additional medication). In some embodiments, the fluid is a physiologically acceptable solution (e.g., a saline solution). []

[0151] In some embodiments, the LRP system 1800 may be modified to simultaneously establish a closed circuit within each patient's kidney. In some embodiments, two separate LRP systems may be used for each kidney of a patient. []

[0152] In some embodiments, one or more drugs may be perfused via the patient's systemic circulation when a closed loop is established. For example, if a drug is nephrotoxic or potentially harmful to the kidneys but requires systemic delivery, establishing a closed loop through the kidneys to separate renal perfusion from systemic perfusion may help prevent or reduce drug exposure to the kidneys. []

[0153] Figure 19 is a schematic diagram of a membrane oxygenation device 1820, which can be used to oxygenate perfusion fluid, mix the perfusion fluid with other components (e.g., drugs), remove carbon dioxide from the perfusion fluid, and / or push the perfusion fluid into a first catheter 1822. The membrane oxygenation device 1820 can be any commercially available ECMO device that exchanges carbon dioxide contained in the blood with oxygen.

[0154] As shown in Figure 19, the membrane oxygenation device 1820 includes various components, including a heat exchanger 1856 (through which the perfusion fluid passes before exiting the outlet 1852 and entering the first conduit 1822), a delivery pump 1858, a reservoir 1860 (for adding components such as blood and / or medications to the perfusion fluid returned via the inlet 1854 through the second conduit 1824), sensors 1862 and 1864 at various stages of the closed loop (e.g., for measuring pressure and / or blood gas content), and a membrane oxygenator 1866. In some embodiments, deoxygenated blood enters the membrane oxygenator 1866 and is mixed with oxygen-enriched gas. The oxygen-enriched gas may be supplied by a gas mixer 1868, which can mix oxygen with carbon dioxide and nitrogen in various ratios and is regulated by a gas regulator 1870.

[0155] The perfusion fluid may contain one or more blood (or components thereof, such as plasma or serum) and / or medications suitable for treating kidney conditions and / or mediators such as saline or dextran solution. Delivery pump 1858 delivers the perfusion fluid into the first catheter 1822. In some embodiments, the perfusion fluid may be contained in an IV bag or syringe and may be directly administered into the first catheter 1822 with or without delivery pump 1858.

[0156] A negative suction pressure can be applied to the second catheter 1824 using a suction mechanism to minimize leakage of blood and / or medication outside the closed circuit. The negative suction pressure can be approximately -150 mmHg, approximately -100 mmHg, approximately -50 mmHg, approximately -20 mmHg, approximately -15 mmHg, approximately -10 mmHg, approximately -5 mmHg, 0 mmHg, or a sub-range defined by any of these points. []

[0157] The blood circulating in a closed loop can be autologous blood, matched blood from a donor, or a combination thereof. In some embodiments, blood components, such as serum or plasma, are selected based on one or more parameters. One parameter may be the presence or absence of selected antibodies. For example, when the drug is one or more viral vectors containing therapeutic nucleic acid sequences, the patient's autologous blood can be screened to determine the presence of antibodies against the one or more viral vectors. The presence of antibodies in the patient's autologous blood can reduce and / or completely negate the therapeutic effect and / or may cause an unwanted immune response. Therefore, the patient's autologous blood can be diluted or replaced with serologically negative matched blood from a donor, thereby reducing the patient's immune response to the drug and enhancing the drug's efficacy. []

[0158] Although the various components shown in Figure 19 are shown as components that are part of or separate from the membrane oxygenation device 1820, it should be understood that this schematic diagram is merely exemplary, as one or more components may be included in or separate from the membrane oxygenation device 1820 (outside of it). []

[0159] The LRP system 1800 can be set up and operated as follows: (1) Carefully place and tightly seal the recovery catheter (e.g., the second catheter 1824) in the renal vein to collect deoxygenated venous blood; (2) Place the perfusion catheter (e.g., the first catheter 1822) in the renal artery in a sealed manner; (3) Insert an additional recovery catheter (e.g., the third catheter 1826) in a sealed manner into the bladder, ureter, or both; (4) Then, connect the perfusion and recovery catheters to the arterial and venous lines of the membrane oxygenation device 1820 using standard tubing. (5) Initiate operation of the LRP system 1800 and perfuse oxygenated blood into the renal artery in an anterograde manner, while simultaneously collecting deoxygenated blood returned from the renal vein via a recovery catheter using a gentle negative pressure; (6) Next, guide the blood into reservoir 1860 and then oxygenate it by membrane oxygenator 1866, and then re-infuse it anterogradely into the kidney via first catheter 1822 (driven by delivery pump 1858); and (7) Next, measure the volume of fluid excreted through the bladder using flow meter 1842, and replace it with perfusion fluid via fluid source 1840. If a drug (e.g., a carrier) is administered, this can be added to the perfusion fluid via reservoir 1860 after filling with blood or plasma, and blood samples can be obtained, or the drug can be administered via reservoir 1860 throughout the perfusion procedure. []

[0160] In some embodiments, diluting or replacing a patient's antibody-containing autologous blood with seroreactive matched blood from a donor (e.g., by removing venous blood and flushing with antibody-free blood to exchange the volume of circulating antibodies specific to the viral vector used) can reduce adverse immune responses and / or improve drug efficacy. For example, compared to patients who have not undergone autologous blood dilution or replacement, diluting or replacing autologous blood with seroreactive matched blood from a donor can reduce the severity of the immune response by approximately 10%, approximately 20%, approximately 30%, approximately 40%, approximately 50%, approximately 60%, approximately 70%, approximately 80%, approximately 90%, or completely alleviate it. Compared to the efficacy of a drug in a patient who has not undergone autologous blood dilution or replacement, the efficacy of a drug administered after dilution or replacement with matching blood from a donor that is serologically negative can be increased by approximately 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, 100%, 150%, 200%, 300%, 400%, or 500%. []

[0161] In some embodiments, the blood portion of the perfusion fluid may be in the following ranges: about 5 mL to about 5000 mL, about 50 mL to about 2500 mL, about 100 mL to about 1000 mL, about 150 mL to about 500 mL, about 50 mL, about 75 mL, about 100 mL, about 125 mL, about 150 mL, about 175 mL, about 200 mL, about 225 mL, about 250 mL, about 275 mL, about 300 mL, about 325 mL, about 350 mL, about 375 mL, about 400 mL, about 425 mL, about 450 mL, about 475 mL, about 500 mL, about 550 mL, about 600 mL, about 650 mL, about 700 mL, about 750 mL, about 800 mL, about 850 mL, about 900 mL, about 950 mL, or about 1000 mL. []

[0162] The ratio of autologous blood to matched blood from the donor in the blood circulating through a closed loop can be adjusted as needed to obtain a blood mixture that is most readily accepted by the drug and produces the least immune response after drug introduction. In some embodiments, this ratio may be in the following ranges: about 1:100 to about 100:1, about 1:80 to about 80:1, about 1:50 to about 50:1, about 1:30 to about 30:1, about 1:20 to about 20:1, about 1:10 to about 10:1, about 1:8 to about 8:1, about 1:5 to about 5:1, about 1:3 to about 3:1, or about 1:2 to about 2:1 (volume of autologous blood): (volume of matched blood from the donor). []

[0163] The flow rate of the perfusion fluid circulating through the closed loop can be adjusted to match the patient's blood flow rate. Those skilled in this technique will understand that blood flow rate varies from patient to patient and, for any given patient, varies throughout the day. Therefore, the flow rate of the perfusion fluid circulating through the closed loop can be adjusted in situ. The flow rate can be measured within the closed loop. In some embodiments, the flow rate can be measured using a transsonic probe (such as a clamp on the tubing). In some embodiments, at any given time during perfusion, the flow rate of the perfusion fluid, in mL / min, can be within approximately 20%, 15%, 10%, 8%, 5%, 3%, 2%, 1%, or 0.5% of the patient's blood flow rate. Importantly, the flow rate of the perfusion fluid circulating through the closed loop should not deviate significantly from the patient's own blood flow rate to avoid local ischemia and / or inadequate perfusion. []

[0164] An exemplary flow rate of the perfusion fluid circulated via a closed loop may be, but is not limited to, the following ranges: about 75 mL / min to about 750 mL / min, about 100 mL / min to about 650 mL / min, about 125 mL / min to about 600 mL / min, about 150 mL / min to about 500 mL / min, about 175 mL / min to about 400 mL / min, about 200 mL / min to about 300 mL / min, about 150 mL / min, about 175 mL / min, about 200 mL / min, about 225 mL / min, about 250 mL / min, about 275 mL / min, about 300 mL / min, about 325 mL / min, or about 350 mL / min. In some embodiments, the system maintains a flow rate of the perfusion fluid in the closed loop at about 500 mL / min / 1.73 m² body surface area per kidney to about 650 mL / min / 1.73 m² body surface area per kidney for about 15 minutes to about 4 hours. []

[0165] The perfusion fluid can be circulated via a closed loop for a duration not limited to about 5 minutes to about 5 hours, about 15 minutes to about 4 hours, about 30 minutes to about 3 hours, or about 1 hour to about 2 hours. In some embodiments, the duration of treatment can occur over several days, such as 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, 7 days, etc. []

[0166] Using the systems disclosed herein, in some embodiments, a higher dose of drug than that which can be safely administered otherwise via systemic delivery can be delivered directly and only to one or more kidneys. In some embodiments, because the perfusion fluid does not substantially leak out of the one or more kidneys, a lower overall drug dose may be required to achieve the same therapeutic effect (the same therapeutic effect achieved by a larger dose that has undergone systemic circulation or only partially dissociated into renal circulation). []

[0167] In some embodiments, less than about 50% v / v, less than about 40% v / v, less than about 30% v / v, less than about 20% v / v, less than about 15% v / v, less than about 10% v / v, less than about 5% v / v, less than about 4% v / v, less than about 3% v / v, less than about 2% v / v, less than about 1% v / v, less than about 0.5% v / v, or substantially no (0% v / v) leaks out of the closed loop during the perfusion procedure in the perfusion fluid (e.g., blood and / or medication) circulated via the closed loop. []

[0168] The reduction in perfusion fluid leakage outside the closed loop (compared to other methods disclosed in this technique) can be attributed to the tight seal formed within the closed loop and to each individual component utilized within the closed loop. []

[0169] In some embodiments, some perfusion fluid may still leak out of the closed loop. For example, up to about 0.5% v / v, about 1% v / v, about 2% v / v, about 3% v / v, about 4% v / v, about 5% v / v, about 10% v / v, about 15% v / v, about 20% v / v, about 30% v / v, about 40% v / v, or about 50% v / v of the perfusion fluid circulated through the closed loop may leak out of the closed loop. Any amount of drug lost through perfusion fluid leakage can be replaced in the perfusion fluid to maintain continuous drug exposure to the kidneys for the calculated exposure time. In some embodiments, the calculated exposure time range may be about 5 minutes to about 5 hours, about 15 minutes to about 4 hours, about 30 minutes to about 3 hours, about 1 hour to about 2 hours, or any subrange therebetween. [] Therapeutic Composition

[0170] Medications suitable for treating kidney conditions (i.e., drugs included in perfusion fluid) may include therapeutic polynucleotide sequences. In some embodiments, the therapeutic polynucleotide sequence may encode a protein for treating kidney conditions. The protein for treating kidney conditions may be of human origin or may be derived from different species (e.g., not limited to mice, cats, pigs, or monkeys). In some embodiments, the protein encoded by the therapeutic polynucleotide sequence may correspond to a gene expressed in the human kidney.

[0171] Exemplary proteins may include, but are not limited to, NPHP1, PKD2, their variants, or combinations thereof. One or more proteins used may also be functional variants of the proteins mentioned herein and may exhibit substantial amino acid sequence similarity to the original protein. For example, amino acid similarity may aggregate to at least about 30%, at least about 35%, at least about 40%, at least about 45%, at least about 50%, at least about 55%, at least about 60%, at least about 65%, at least about 70%, at least about 75%, at least about 80%, at least about 85%, at least about 90%, at least about 95%, at least about 96%, at least about 97%, at least about 98%, or at least about 99%. In this context, the term "functional variant" means that the variant of a protein can partially or completely realize the function of the naturally occurring corresponding protein. Functional variants of proteins may include, for example, proteins that differ from their naturally occurring counterparts due to the substitution, deletion, or addition of one or more amino acids.

[0172] Amino acid substitution can be conservative or non-conservative. Preferably, the substitution is conservative, meaning that the amino acid residue is substituted with an amino acid of similar polarity that acts as a functional equivalent. Preferably, the amino acid residue used as the substitute is selected from the same group of amino acids as the amino acid residue to be substituted. For example, a hydrophobic residue can be substituted with another hydrophobic residue, or a polar residue can be substituted with another polar residue having the same charge. Functionally homologous amino acids that can be used for conservative substitution include, for example, nonpolar amino acids such as glycine, valine, alanine, isoleucine, leucine, methionine, proline, phenylalanine, and tryptophan. Examples of non-polar amino acids include serine, threonine, glutamic acid, aspartic acid, tyrosine, and cysteine. Examples of polar (basic) amino acids include histidine, arginine, and lysine. Examples of electrically charged (acidic) amino acids include aspartic acid and glutamic acid.

[0173] Proteins that differ from their naturally occurring counterparts due to one or more extra amino acids (e.g., 2, 3, 4, 5, 10, or 15) are also considered variants. These extra amino acids may be present within the amino acid sequence of the original protein (i.e., as an insertion), or may be added to one or both ends of the protein. Essentially, insertion can occur at any location as long as the addition of an amino acid does not impair the peptide's ability to perform the function of the naturally occurring protein in the treated individual. Furthermore, protein variants also include proteins lacking one or more amino acids compared to the original peptide. Such deletions can affect any amino acid position, limited by the condition that they do not impair the protein's ability to perform its normal function.

[0174] Finally, variants of the target protein also refer to proteins that differ from naturally occurring proteins due to structural modifications, such as modified amino acids. Modified amino acids are those modified by natural methods, such as treatment or post-translational modifications, or by chemical modification methods known in this art. Typical amino acid modifications include phosphorylation; glycosylation; acetylation; O-linked N-acetylglucosamineization; glutathioneization; acetylation; branching; ADP ribosylation; cross-linking; disulfide bridge formation; methionization; hydroxylation; carboxylation; methylation; demethylation; acetylation; cyclization; and / or covalent or non-covalent bonding with phosphatidylinositol, flavin derivatives, lipoteiic acid, fatty acids, or lipids.

[0175] Therapeutic polynucleotide sequences encoding target proteins can be delivered to the individual to be treated in the form of gene therapy vectors, i.e. nucleic acid constructs, which contain other sequences adjacent to those required to provide the expression of exogenous nucleic acids, such as promoters, kozak sequences, polyadenylate signals and similar sequences, including translation and stop codons.

[0176] For example, gene therapy vectors can be part of a mammalian expression system. Useful mammalian expression systems and expression constructs are commercially available. Additionally, several mammalian expression systems are distributed by different manufacturers and can be used in this invention, such as plasmid- or viral vector-based systems, for example, LENTI-Smart™ (InvivoGen), GenScript™ expression vectors, pAdVAntage™ (Promega), ViraPower™ lentivirus, adenovirus expression system (Invitrogen), and adeno-associated virus expression system (Cell Biolabs).

[0177] Gene therapy vectors used to express the exogenous therapeutic polynucleotide sequences of the present invention can be, for example, viral or non-viral expression vectors, suitable for introducing the exogenous therapeutic polynucleotide sequences into cells for subsequent expression of proteins encoded by the nucleic acid. The expression vector can be a free vector, i.e., a vector capable of autonomously replicating itself within the host cell; or an integrated vector, i.e., a vector stably incorporated into the cellular genome. Expression in the host cell can be constitutive or regulatory (e.g., inducible).

[0178] In one embodiment, the gene therapy vector is a viral expression vector. The viral vector used in this invention may contain a viral genome, wherein a portion of the natural sequence has been deleted to introduce heterologous polynucleotides without compromising viral infectivity. Due to the specific interaction between the viral components and the host cell receptor, the viral vector is particularly suitable for the efficient transfer of genes into target cells. Viral vectors suitable for facilitating gene transfer into mammalian cells may be derived from various types of viruses, such as AAV, adenovirus, retrovirus, herpes simplex virus, bovine papillomavirus, lentivirus, vaccinia virus, polyomavirus, Sendai virus, orthomyxovirus, paramyxovirus, papillomavirus, microRNA virus, poxvirus, alpha virus, or any other viral shuttle, variant, or combination thereof suitable for gene therapy.

[0179] "Adenoviral expression vector" or "adenovirus" is intended to include constructs containing adenoviral sequences sufficient to (a) support the packaging of therapeutic polynucleotide sequence constructs and / or (b) ultimately express tissue- and / or cell-specific constructs selected therein. In one embodiment of the invention, the expression vector comprises a genetically engineered form of adenovirus. Understanding the genetic organization of adenovirus (a 36 kb linear double-stranded DNA virus) allows for the replacement of large fragments of adenoviral DNA with foreign sequences of up to 7 kb.

[0180] Adenovirus growth and manipulation are known to those skilled in the art, and exhibit a broad host range both in vitro and in vivo. This group of viruses can be obtained at high titers, e.g., 10⁹ to 10¹¹ plaque-forming units / mL, and is highly infectious. The adenovirus life cycle does not require integration into the host cell genome. Exogenous genes delivered via adenovirus vectors are free-type and therefore exhibit low genotoxicity to host cells. No side effects have been reported in studies of vaccination with wild-type adenovirus, demonstrating its safety and / or therapeutic potential as an in vivo gene transfer vector.

[0181] Retroviruses (also known as "retroviral vectors") are chosen as gene delivery vectors because they can integrate their genes into the host genome, transfer large amounts of foreign genetic material, infect a wide range of species and cell types, and be packaged in special cell lines.

[0182] The retroviral genome contains three genes: gag, pol, and env, which encode the capsid protein, polymerase, and envelope components, respectively. A sequence upstream of the gag gene contains a signal for packaging the genome into the viral particle. Two long terminal repeat (LTR) sequences are located at the 5' and 3' ends of the viral genome. These sequences contain strong promoter and enhancer sequences and are also required for integration into the host cell genome.

[0183] To construct retroviral vectors, nucleic acids encoding the genes of interest are inserted into the viral genome instead of certain viral sequences to generate replication-defective viruses. To generate viral particles, packaging cell lines containing the gag, pol, and / or env genes but lacking the LTR and / or packaging components are constructed. When recombinant plasmids containing cDNA, the retroviral LTR, and packaging sequences are introduced into these cell lines (e.g., via calcium phosphate precipitation), the packaging sequences allow the RNA transcripts of the recombinant plasmids to be packaged into viral particles, which are then secreted into the culture medium. The culture medium containing the recombinant retrovirus is then collected, concentrated, and used for gene transfer, as needed. Retroviral vectors can infect a wide variety of cell types. However, integration and stable expression require host cell division.

[0184] Retroviruses can originate from any subfamily. For example, vectors from murine sarcoma virus, bovine leukemia virus, Rous Sarcoma Virus, murine leukemia virus, mink cell focus-inducing virus, reticuloendotheliosis virus, or avian leukosis virus can be used. Those skilled in this technique will be able to combine components from different retroviruses, such as LTRs, tRNA binding sites, and packaging signals, to provide recombinant retroviruses. These retroviruses are then typically used to generate transduction-competent retroviral vector particles. For this purpose, the vector is introduced into a suitable packaging cell line. Retroviruses can also be constructed by incorporating chimeric integrase into the retroviral particles to enable site-specific integration into the host cell's DNA.

[0185] Because herpes simplex virus (HSV) is neurotropic, it has attracted considerable attention in the treatment of neurological disorders. Furthermore, HSV's ability to induce latent infection in non-dividing neurons without integrating into the host cell chromosome or otherwise altering host cell metabolism, along with the presence of an active promoter during the latent period, makes it an attractive vector. Moreover, although much attention has focused on the neurotropic applications of HSV, its broad host range allows for its use in other tissues as well.

[0186] Another factor making HSV an attractive vector is its genome size and organization. Because HSV is large, incorporating multiple genes or expression cartridges is less of a problem compared to smaller viral systems. Furthermore, the availability of different viral control sequences with varying efficacies (time, intensity, etc.) compared to other systems makes it possible to control expression to a greater extent. It also has the advantage of containing relatively little splicing information, further facilitating genetic manipulation.

[0187] HSV is also relatively easy to handle and can grow to high titers. Therefore, delivery is not a problem in terms of both obtaining the volume required for a sufficient infection multiple (MOI) and reducing the need for repeated dosing. Non-toxic variants of HSV have been developed, and these variants can be easily used in gene therapy applications.

[0188] Lentivirals are complex retroviruses. In addition to the common retroviral genes gag, pol, and env, lentiviruses also contain other genes with regulatory or structural functions. This high complexity allows viruses to regulate their life cycle, such as during latent infection. Some examples of lentiviruses include human immunodeficiency virus (HIV-1, HIV-2) and simian immunodeficiency virus (SIV). Lentiviral vectors have been produced by repeatedly attenuating HIV pathogenicity genes, such as deleting genes env, vif, vpr, vpu, and nef, to make the vectors biologically safe.

[0189] Lentiviral vector systems are plastid- or virus-based, and are configured to carry essential sequences for incorporating foreign nucleic acids, for selection, and for transferring nucleic acids into host cells. The gag, pol, and env genes of the vector of interest are also known in this technology. Therefore, the relevant genes are selected and colonized into the chosen vector and then used to transform the target cells of interest.

[0190] Vaccinia virus vectors are widely used due to their ease of construction, relatively high expression levels, wide host range, and large capacity for carrying DNA. Vaccinia contains a linear double-stranded DNA genome of approximately 186 kb, exhibiting a clear "AT" preference. Approximately 10.5 kb of inverted terminal repeats are flanked by this genome. Most essential genes appear to be located in the central region, which is highly conserved among poxviruses. The number of open reading frames in vaccinia virus is estimated to be between 150 and 200. Despite encoding two strands, significant overlap of reading frames is not common.

[0191] At least 25 kb can be inserted into the vaccinia virus genome. The prototype vaccinia vector contains a transgenic gene inserted into the viral thymidine kinase gene via homologous recombination. The vector system is based on TK phenotypic selection. Non-translational leader sequences, including those from encephalocardiitis virus, produce higher expression levels than conventional vectors, with the transgenic gene accumulating 10% or more of the protein in infected cells within 24 hours.

[0192] Empty capsids of polyomaviruses (such as mouse polyomavirus) have attracted attention as potential vectors for gene transfer. The use of empty polyomaviruses was first described in the cultivation of polyomavirus DNA in a cell-free system and the purification of empty capsids. The DNA of the new particles is protected from pancreatic deoxyribonuclease. Transformed polyomavirus DNA fragments were transferred into rat FIII cells using reconstructed particles. Both the empty capsids and the reconstructed particles consist of all three polyomavirus capsid antigens: VP1, VP2, and VP3.

[0193] AAV belongs to the genus Dependovirus. It is a small, non-enveloped, single-stranded DNA virus that requires a helper virus for replication. Co-infection with a helper virus (such as adenovirus, herpesvirus, or vaccinia virus) is required to form a fully functional AAV viral particle. In vitro, without co-infection with a helper virus, AAV produces a latent state of viral genome in a free form, without producing infectious viral particles. Subsequently, infection with a helper virus "rescues" the genome, allowing it to replicate and be packaged in a viral capsid, thereby reconstructing an infectious viral particle. Recent data indicate that wild-type AAV and recombinant AAV in vivo primarily exist as larger, free tandem structures. In one embodiment, the gene therapy vector used herein is an AAV vector. The AAV vector may be purified replication-incompetent pseudotyped rAAV particles.

[0194] AAV is not associated with any known human diseases, is generally not considered pathogenic, and appears not to alter the physiological characteristics of host cells after integration. AAV can infect a wide range of host cells, including non-dividing cells, and can infect cells from different species. Compared to some vectors that are rapidly cleared or inactivated by both cellular and humoral responses, AAV vectors have been shown to induce persistent transgenic expression in various tissues in vivo. The persistence of recombinant AAV-mediated transgenes in non-dividing cells in vivo can be attributed to the lack of the ability of native AAV viral genes and vectors to form free tandem variants associated with the ITR.

[0195] AAV is an attractive vector system for cell transduction in this invention because it has high-frequency persistence as a free tandem and can infect non-dividing cells, including cardiomyocytes, thereby making it suitable for delivering genes into mammalian cells, such as in tissue cultures and in vivo.

[0196] Typically, rAAV is produced by co-transfecting plasmids containing the gene of interest flanked by two AAV terminal repeats and / or phenoplasts (e.g., pIM45) containing the wild-type AAV coding sequence without terminal repeats. Cells are also infected and / or transfected with adenovirus and / or plasmids carrying adenovirus genes required for AAV helper function. Stock solutions of rAAV produced in this manner are contaminated with adenovirus and must be physically separated from the rAAV particles (e.g., by cesium chloride density centrifugation or column chromatography). Alternatively, adenovirus vectors containing the AAV coding region and / or cell lines containing the AAV coding region and / or some or all of the adenovirus helper genes can be used. Cell lines carrying rAAV DNA as an integrated provirus can also be used.

[0197] Multiple AAV serotypes exist in nature, with at least twelve serotypes (AAV1-AAV12). Despite high homology, different serotypes exhibit tissue tropism. After transfection, AAV only elicits a secondary immune response in the host (if present). Therefore, AAV is particularly well-suited for gene therapy approaches.

[0198] In some embodiments, the present invention may be directed to a drug comprising an AAV vector, the AAV vector being one or more of the following: AAV1, AAV2, AAV3, AAV4, AAV5, AAV6, AAV7, AAV8, AAV9, AAV10, AAV11, AAV12, ANC AAV, chimeric AAVs derived therefrom, variants thereof, and combinations thereof, which are even more preferably suitable for efficient transduction in the tissue of interest. In some embodiments, the gene therapy vector is an AAV serotype 1 vector. In some embodiments, the gene therapy vector is an AAV serotype 2 vector. In some embodiments, the gene therapy vector is an AAV serotype 3 vector. In some embodiments, the gene therapy vector is an AAV serotype 4 vector. In some embodiments, the gene therapy vector is an AAV serotype 5 vector. In some embodiments, the gene therapy vector is an AAV serotype 6 vector. In some embodiments, the gene therapy vector is an AAV serotype 7 vector. In some embodiments, the gene therapy vector is an AAV serotype 8 vector. In some embodiments, the gene therapy vector system is AAV serotype 9. In some embodiments, the gene therapy vector system is AAV serotype 10. In some embodiments, the gene therapy vector system is AAV serotype 11. In some embodiments, the gene therapy vector system is AAV serotype 12.

[0199] The appropriate dose of AAV for humans can be in the following range: about 1×10 8 vg / kg to about 3×10 14 vg / kg, about 1×10 8 vg / kg, about 1×10 9 vg / kg, about 1×10 10 vg / kg, about 1×10 11 vg / kg, about 1×10 12 vg / kg, about 1×10 13 vg / kg or about 1×10 14 vg / kg.The total amount of viral particles or DRP is: approximately, at least, at least approximately, not exceeding or not exceeding approximately 5×10¹⁵ vg / kg, 4×10¹⁵ vg / kg, 3×10¹⁵ vg / kg, 2×10¹⁵ vg / kg, 1×10¹⁵ vg / kg, 9×10¹⁴ vg / kg, 8×10¹⁴ vg / kg, 7×10¹⁴ vg / kg, 6×10¹⁴ vg / kg, 5×10¹⁴ vg / kg, 4×10¹⁴ vg / kg, 3×10¹⁴ vg / kg, 2×10¹⁴ vg / kg, 1×10¹⁴ vg / kg, 9×10¹³ vg / kg, 8×10¹³ vg / kg, 7×10¹³ vg / kg, 6×10¹³ vg / kg, 5×10¹⁴ ... 13vg / kg, 4×10 13vg / kg, 3×10 13vg / kg, 2×10 13vg / kg, 1×10 13vg / kg, 9×10 12vg / kg, 8×10 12vg / kg, 7×10 12vg / kg, 6×10 12vg / kg, 5×10 12vg / kg, 4×10 12vg / kg, 3×10 12vg / kg, 2×10 12vg / kg, 1×10 12vg / kg, 9×10 11vg / kg, 8×10 11vg / kg, 7×10 11vg / kg, 6×10 11vg / kg, 5×10 11vg / kg, 4×10 11vg / kg, 3×10 11vg / kg, 2×10 11vg / kg, 1×10 11vg / kg, 9×10 10vg / kg, 8×10 10vg / kg, 7×10 10vg / kg, 6×10 10vg / kg, 5×10 10vg / kg, 4×10 10vg / kg, 3×10 10vg / kg, 2×10 10vg / kg, 1×10 10vg / kg, 9×10 9vg / kg, 8×10 9vg / kg, 7×10 9vg / kg, 6×10 9vg / kg, 5×10 9vg / kg, 4×10 9vg / kg, 3×10 9vg / kg, 2×10 9vg / kg, 1×10 9vg / kg, 9×10 8 vg / kg, 8×10⁸ vg / kg, 7×10⁸ vg / kg, 6×10⁸ vg / kg, 5×10⁸ vg / kg, 4×10⁸ vg / kg, 3×10⁸ vg / kg, 2×10⁸ vg / kg, or 1×10⁸ vg / kg, or within any two of these equivalent values. The dosages listed above are in vg / kg of kidney tissue.

[0200] Using the systems and methods disclosed herein, in some embodiments, a higher dose of drug than that which could be safely administered otherwise via systemic delivery can be administered directly and exclusively to the kidney, since the perfusion fluid does not substantially leak outside the kidney. Without being construed as limiting, it is believed that AAV toxicity can be attributed to systemic effects such as hepatotoxicity, platelet activation and loss, and complement activation and loss. All such toxicities and other effects can be reduced, minimized, or completely avoided by the application of localized perfusion fluid as described in the methods and systems disclosed herein. Therefore, doses of up to about 5 × 10¹⁵ vg / kg kidney tissue can be well tolerated. In some embodiments, the AAV dose administered to the kidney, expressed as vg / kg kidney tissue, can be about 2 to about 200 times, about 5 to about 150 times, about 10 to about 100 times, or any subrange thereof, higher than the highest systemic dose.

[0201] In addition to viral vectors, non-viral expression constructs can also be used to introduce genes encoding target proteins or their functional variants or fragments into patient cells. Non-viral expression vectors that allow in vivo expression of proteins in target cells include, for example, plastids, modified RNA, mRNA, cDNA, antisense oligomers, DNA-lipid complexes, nanoparticles, extracellular bodies, any other non-viral shuttles suitable for gene therapy, their variants, and combinations thereof.

[0202] In addition to viral vectors and non-viral expression vectors, nuclease systems can also be used in conjunction with vectors and / or electroporation systems to enter patient cells and introduce genes encoding target proteins or their functional variants or fragments therein. Exemplary nuclease systems may include, but are not limited to, clustered regularly spaced short palindromic repeats (CRISPR), DNA-cutting enzymes (e.g., Cas9), large-scale nucleases, TALENs, zinc finger nucleases, any other nuclease systems suitable for gene therapy, their variants, and combinations thereof. For example, in one embodiment, a viral vector (e.g., AAV) may be used with a nuclease (e.g., CRISPR) and another viral vector (e.g., AAV) may be used with a DNA-cutting enzyme (e.g., Cas9) to introduce both the nuclease and the DNA-cutting enzyme into target cells.

[0203] Other vector delivery systems that can be used to deliver therapeutic polynucleotide sequences encoding therapeutic genes into cells are receptor-mediated delivery agents. These utilize the selective uptake of macromolecules in almost all eukaryotic cells via receptor-mediated endocytosis. Due to the cell-type-specific distribution of various receptors, delivery can be highly specific. Receptor-mediated gene-targeting agents may comprise two components: cell receptor-specific ligands and DNA binders.

[0204] Methods suitable for transferring non-viral vectors into target cells include lipid transfection, calcium phosphate co-precipitation, DEAE-polydextrose, and direct DNA introduction using microtubes, ultrasound, electroporation, and similar methods. Before vector introduction, kidney cells can be treated with permeabilizing agents such as phosphatidylcholine, streptococcal lysin, sodium decanoate, decanoic acid, tartaric acid, lysophosphatidylcholine, Triton X-100, and analogues. Exosome transfer of naked DNA or AAV-captured DNA can also be used.

[0205] The gene therapy vector of the present invention may include a promoter functionally linked to a nucleic acid sequence encoding a target protein. The promoter sequence should be tight and ensure strong expression. Preferably, the promoter provides expression of the target protein in the kidney of a patient treated with the gene therapy vector. In some embodiments, the gene therapy vector includes a nephron-specific promoter operatively linked to a nucleic acid sequence encoding a target protein. As used herein, a "nephron-specific promoter" refers to a promoter whose activity in kidney cells is at least twice that in any other non-kidney cell type. Preferably, the nephron-specific promoter suitable for use in the vector of the present invention has an activity in kidney cells that is at least 5, at least 10, at least 15, at least 20, at least 25, or at least 50 times higher than its activity in non-kidney cell types. Furthermore, the nephron-specific promoter may be specific to a specific subunit of the nephron (e.g., proximal tubule, distal tubule, glomerulus, etc.) to provide high or unique expression in that specific subunit.

[0206] The nephron-specific promoter may be a selected human promoter, or a promoter containing a functionally equivalent sequence having at least about 80%, at least about 90%, at least about 95%, at least about 96%, at least about 97%, at least about 98%, or at least about 99% sequence identity with the selected human promoter. Illustrative non-restrictive promoters may include kidney-specific cadherin (KSPC), Na+ / glucose cotransporter 2 (SGLT2), sodium-potassium-chloride cotransporter 2 (NKCC2), and E-cadherin (ECAD).

[0207] The vectors used in this invention can have different transduction efficiencies. Therefore, viral or non-viral vectors can transduce more than, equal to, or at least about 10%, about 20%, about 30%, about 40%, about 50%, about 55%, about 60%, about 65%, about 70%, about 75%, about 80%, about 85%, about 90%, about 95%, about 99%, or 100% of cells in the target vascular site. More than one vector (viral or non-viral vector, or a combination thereof) can be used simultaneously or sequentially. This can be used to transfer more than one polynucleotide and / or target more than one cell type. When multiple vectors or multiple reagents are used, more than one transduction / transfection efficiency can be achieved.

[0208] Pharmaceutical compositions containing gene therapy vectors can be prepared as liquid solutions or suspensions. The pharmaceutical compositions of this invention may include commonly used pharmaceutically acceptable excipients, such as diluents and carriers. Specifically, the composition contains pharmaceutically acceptable carriers, such as water, saline, Ringer's solution, or dextran solution. In addition to carriers, the pharmaceutical compositions may also contain emulsifiers, pH buffers, stabilizers, dyes, and the like.

[0209] In some embodiments, the pharmaceutical composition will contain a therapeutically effective gene dose that is capable of preventing or treating an individual's kidney condition without being toxic to the individual. Prevention or treatment of kidney condition can be assessed by changes in phenotypic traits associated with the kidney condition, where such changes are effective in preventing or treating the kidney condition. Therefore, a therapeutically effective gene dose is typically a gene dose that, when administered in a physiologically tolerable composition form, is sufficient to improve or prevent the pathogenic kidney phenotype in the treated individual. [Exemplary Example]

[0210] The following examples are provided to aid in understanding the invention, and should not be construed as specifically limiting the embodiments described and claimed herein. Such variations of the embodiments, including substitutions for all currently known or subsequently developed equivalents within the capabilities of those skilled in the art, and minor variations in formulations or experimental designs, will be considered within the scope of the embodiments incorporated herein.

[0211] The LRP system described below comprises the following components: a percutaneous arterial catheter for anterograde perfusion (via the femoral artery) occluding the renal artery; a percutaneous venous catheter for occluding the renal vein and returning venous blood to the LRP system (via the jugular vein); and an ECMO device with a reservoir and connecting tubing for providing oxygen and removing carbon dioxide from the blood within the LRP system. The LRP procedure begins with anterograde perfusion of oxygenated blood into the artery, while deoxygenated blood is collected from the venous system via the venous catheter. The blood is then collected in the reservoir, oxygenated, and anterogradely re-infused into the organ via the arterial catheter. During the procedure, blood samples may be obtained via the reservoir, or drugs may be introduced. Example 1: LRP Program

[0212] LRP is performed on pigs using the system 1800 shown and described with respect to Figure 18. The accessory devices used in these examples are listed in Table 1, including their intended use and their application in the LRP system according to an embodiment of the invention. Table 1: Devices used in LRP procedures [project] [trademark] FlowGate 2 balloon guiding catheter Stryker Fogarty catheter Fogarty Blood pump head Medtronic Femoral artery access sheath: 12-Fr, length 25 cm Boston Scientific Guide wire (=GW) V18 Boston Scientific Conduit emitter 7-Fr AL1.0 Medtronic Standard J-type guidewire tip GW (0.035 cm, 260 mm length) Cordis Rosen heavy-duty core guidewire (0.035 cm, 180 mm length) Cordis Jugular vein access sheath Dryseal 24-Fr 33 cm Gore Endo-Vent catheter Edwards Lunderquist superhard wire guide 0.035, 260cm (REF: TSMG-35-260-LES) Cook D100 Oxygenator Kit Dideco-Livanova Bio-Medicus 550 Bio-Console (ECMO pump control console) Medtronic PressureWire X Saint Jude Medical / Abbott Quantien Measurement System Saint Jude Medical / Abbott Customized catheters -

[0213] A custom-made catheter was used as the venous retrieval catheter, and it included the following dimensions: a cross-sectional outer diameter of 19 Fr (6.3 mm); an inner diameter of 12 Fr (4.0 mm); a usable length of 80 cm; a balloon diameter of 25 mm; and a tip length of 20 mm (similar to the illustrative custom-made catheters shown in and described with respect to Figures 1 to 3). Materials included: Pebax 63 supported by a strong stainless steel braid as an axis; flexible Chronoprene 25A as the balloon; and Pebax 35 loaded with BaSO4 at the tip for radiopermeability. The custom-made catheter was designed to support an aspiration flow rate of approximately 800 mL / min at -80 mmHg.

[0214] Figure 20 includes radiographic images showing the placement of the renal artery and renal vein arteries and venous ducts in a pig kidney. In the bottom image, contrast agent is injected intravenously to expose the renal vascular structure and the overall tightness of the closed system.

[0215] The detailed scheme of the LRP procedure followed in this example is described below: (1) The animal to be studied was placed in a dorsal position; (2) Prepare research animals for endovascular catheter insertion; (3) Using angiography, the angles of the renal vein and jugular vein pathways and the inguinal pathway are assessed using the least acute angle. (4) Using the Stryker FlowGate 2 catheter, the arterial circulation of the kidney (based on the angle-determined side) is entered from the femoral artery; (5) Use the custom-made venous catheter described above to enter the venous circulation (lateral approach and entry point: determined based on individual animals); (6) Position the catheter in its final position with an open configuration (i.e., balloon down) to allow for the injection of some contrast fluid and observation of renal circulation; (7) Place the catheter in the aorta and vena cava until the procedure begins; (8) Place the PressureWire X via the Flowgate 2 catheter into a renal artery; (9) Prepare the ECMO system by degassing and filling with saline; connect the intravenous and arterial lines to the ECMO and clamp them to prevent air from being introduced; (10) Turn on the ECMO pump; (11) Release the intravenous line; (12) Begin blood exchange with saline; if everything is stable, loosen the arterial line and establish an LRP loop; the suction force on the venous side is variable and should be adjusted as needed (e.g., from -50 mmHg to 0). (13) Place the intravenous catheter in the appropriate position within the renal vein; (14) Inflate the balloon; (15) Check the tightness and positioning of the catheter containing the contrast agent injection solution; (16) If the animal is stable, then: a. Seal the renal artery using a Flowgate 2 catheter; b. Examination: the tightness and position of the catheter containing contrast agent injection solution; renal pressure; renal pressure to systemic pressure ratio (target >1); reservoir volume; ECMO pump RPM; and catheter flow rate; (17) If everything remains stable for 5 minutes, then: a. Initiate trinitroglycerin infusion via arterial line at a rate of 2 micrograms / kg body weight / minute; b. Examination: Kidney pressure; renal pressure to systemic pressure ratio (target >1); reservoir volume; ECMO pump RPM; and catheter flow rate; (18) If everything remains stable for 5 minutes, then: a. Treatment begins by injecting gene therapy drugs into a reservoir; b. For the first animal group (B1 group): administer a dose of 5.0E+13 vg (prepared by diluting 1.8 mL of a carrier solution with a potency of 2.8E+13 vg / mL with 2.2 mL of carrier); c. For the second animal group (B2 group): administer a dose of 6.0E+14 vg (equivalent to 21.4 mL of carrier solution with a potency of 2.8E+13 vg / mL); (19) Continue renal LRP for 60 minutes; (20) Every 5 minutes, check: kidney pressure; renal pressure to systemic pressure ratio (target >1); reservoir volume; ECMO pump RPM; catheter flow rate; all hemodynamic and cardiovascular parameters (pressure, HR); (21) Examine urine output at t=0, 15, 30, 45 and 60 minutes after the start of the procedure; (22) Pay attention to the volume of the LRP reservoir, as there may be overfilling due to the diaphragm, gonads and adrenal veins or volume loss due to urine production; such volume deviations can be managed dynamically; (23) Blood samples were collected at t=0, 5, 15, 30, 45 and 60 minutes: a. For detachment analysis, blood was collected from the surrounding blood. b. For vector infectivity analysis, data were collected from the LRP system; and c. For shedding analysis, data were collected from the LRP system; (24) At the end of the 60-minute renal LRP: a. Discontinue the use of trinitroglycerin; b. Compressed balloon; and c. Disconnect the catheter; (25) Dispose of the entire LRP circuit, reservoir, blood pump, and catheters in an appropriate biosafety cabinet; (26) Immediately implement postoperative care, including but not limited to compression and administration of protamine sulfate;

[0216] The above procedure demonstrates that renal LRP using a sealed closed circuit may last at least 60 minutes. No acute sequelae were observed, and indigo testing performed immediately after the LRP procedure showed normal or unaffected renal function. Example 2: Study on biological distribution

[0217] Figure 21 shows the renal transduction and biodistribution of 0.05–0.25 vg / dg (vector genome copies per diploid genome) 60 minutes after LRP at a higher dose of 6.2E+14 vg / kg. No significant contamination was detected in untreated kidneys, liver, or other organs, demonstrating the tightness of the LRP closed loop.

[0218] Intravenous control animals were also tested. It was found that renal LRP induced a relatively uniform transduction pattern across the different measured segments, while the IV control showed preferential transduction in the renal cortex. Compared to the IV control, hepatic transduction of renal LRP was less pronounced; for the IV control, 17.2 vg / dg was detected in the liver, while for the renal LRP, virtually no transduction was observed in the liver. Example 3: Quantitative Analysis of Carriers

[0219] Figures 22A and 22B show the number of vector genes per milliliter of plasma measured at various time points during renal LRP at high doses (6.2E+14 VG / kg, Figure 22A) and low doses (5.6E+13 VG / kg, Figure 22B). Results revealed high retention rates (low vector shedding) within the LRP circuit for 60 minutes, minimal vector exposure to systemic circulation, and minimal leakage of the vector into urine (Figure 22A). Vector exposure to the kidneys appeared to be the greatest throughout the procedure.

[0220] Figure 23A shows the C3a content several days after renal LRP treatment in two different animals (LRP-1 and LRP2). Figure 23B shows the percentage of transduction inhibition at various sample dilutions. Both figures indicate that the anti-AAV neutralizing factor was low in both animals, and that complement activation was absent after renal LRP.

[0221] Figures 24A and 24B are graphs of flow rate and pump speed during renal LRP, respectively, revealing a substantially constant flow rate of approximately 310 mL / min throughout the procedure.

[0222] These examples demonstrate the use of clinically relevant animal models to achieve targeted delivery of AAV to the kidneys, resulting in a uniform biodistribution of the transgenic gene. The embodiments described and illustrated herein enable the development of next-generation advanced renal therapies by minimizing systemic adverse effects, significantly reducing the required vector dose, overcoming immune limitations, and possessing the potential for repeated treatment. The LRP system and method have been considered for potential use with other therapeutic agents and strategies.

[0223] In the foregoing description, numerous specific details, such as particular materials, dimensions, and process parameters, are set forth to provide a thorough understanding of the invention. In one or more embodiments, particular features, structures, materials, or properties may be combined in any suitable manner. The terms "example" or "illustrative" are used herein to mean serving as an example, illustration, or description. No form or design described herein as "example" or "illustrative" should be construed as superior or advantageous to other forms or designs. In fact, the use of the terms "example" or "illustrative" is intended only to present the concept in a concrete manner. As used in this application, the term "or" is intended to mean an inclusive "or," not an exclusive "or." That is, unless otherwise stated or apparent from the context, "X includes A or B" is intended to mean either of the naturally inclusive substitutions. That is, if X includes A; X includes B; or X includes both A and B, then "X includes A or B" is satisfied in any of the foregoing cases. Throughout this specification, references to "an embodiment," "some embodiments," or "one embodiment" mean that a particular feature, structure, or characteristic described in connection with an embodiment is included in at least one embodiment. Therefore, the phrases "an embodiment," "some embodiments," or "one embodiment" appearing throughout this specification do not necessarily refer to the same embodiment.

[0224] The invention has been described with reference to specific exemplary embodiments thereof. Therefore, the specification and drawings should be viewed in an illustrative rather than restrictive sense. Various modifications to the invention, other than those shown and described herein, will become apparent to those skilled in the art and are intended to fall within the scope of the appended claims.

[0225] 100: Exemplary catheter 101: Proximal 102: Remote 104: External cavity shaft 106: Internal cavity shaft 108: Top section 110: Balloon structure 112: Part of the internal cavity shaft 106 114: Orifice 300: Example catheter 301: Proximal 302: Remote 304: Internal tube shaft 306: External lumen shaft 308: Top section 310: Balloon structure 312: Part of the internal cavity shaft 304 350: Blood vessel / chamber 352: Blood vessels 354: Blood Vessels 400: Catheter 401: Proximal 402: Remote 404: Internal cavity shaft 406: External lumen shaft 408: Top section 410: Balloon structure 412: Part of the internal cavity shaft 404 500: First catheter 501: Proximal 502: Remote 504: Tube Shaft 508: Top section 510: Balloon structure 512: Part of the lumen shaft 504 550: Second catheter 551: Proximal 552: Remote 554: Tube shaft 558: Top section 560: Balloon structure 562: Part of the lumen shaft 554 600: First catheter 601: Proximal 602: Remote 604: Tube Shaft 608: Top section 610: Balloon structure 612: Part of the lumen shaft 604 650: Second catheter 651: Proximal 652: Remote 654: Tube Shaft 658: Top section 700: Catheter 701: Proximal 702: Remote 704: Tube Shaft 708: Top section 710: First balloon structure 712: The first part of the lumen shaft 704 720: Second balloon structure 722: Second part of the lumen shaft 704 724: The middle part of the 704 tube shaft 800: Catheter 801: Proximal 802: Remote 804: Internal cavity shaft 806: External cavity shaft 810: Support Structure 810A: Proximal end covered portion 810B: Remote uncovered areas 900: Catheter 901: Proximal 902: Remote 906: Tube Shaft 908: Top section 910: Balloon structure 912: Part of the lumen shaft 906 920: Support Structure 922: The portion between balloon structure 910 and stent structure 920 1000: Catheter 1001: Proximal 1002: Remote 1004: Internal cavity shaft 1006: External cavity shaft 1008: Top section 1010: Support structure 1100: Example catheter 1101: Proximal end 1102: Remote 1104: External cavity shaft 1106: Internal cavity shaft 1110: Balloon structure 1112: Part of the internal cavity shaft 1106 1114: Orifice 1200: Exemplary catheter 1201: Proximal 1202: Remote 1204: External cavity shaft 1206: Internal cavity shaft 1210: Pipe plug 1210A: Internal Parts 1210B: Flexible external portion 1300: Example catheter 1301: Proximal 1302: Remote 1304: External lumen shaft 1306: Internal cavity shaft 1310: Wedge-shaped piece 1400: Example catheter 1402: External cavity shaft 1404: Internal tube shaft 1406: Support Structure 1450: Blood vessel or chamber 1452: Arteries 1500: Example catheter 1502: Remote 1504: Internal cavity shaft 1506: External cavity shaft 1510: Woven Plate 1600: Example catheter 1601: Proximal 1602: Remote 1606: Tube Shaft 1606A: Proximal portion 1606B: Remote portion 1800:LRP System 1810: Kidney 1812: Bladder 1820: Membrane oxygenation device 1822: First catheter 1824: Second catheter 1826: Third catheter 1830: Blood Gas Analyzer (BGA) Monitor 1840: Fluid Source 1841: Fluid Piping 1842: Flow measurement device 1844: Pressure Line and Control Console 1846: ECMO Pump Control Console 1848: Vacuum Pump 1852: Export 1854: Import 1856: Heat exchanger 1858: Delivery Pump 1860: Storage tank 1862: Sensor 1864: Sensor 1866: Membrane oxygenator 1868: Gas Mixer 1870: Gas Regulator

Claims

1. A system for performing localized perfusion of a kidney when fluidly coupled to a patient's kidney, the system comprising: an perfusion catheter adapted for insertion into a renal artery of the kidney; a retrieval catheter adapted for insertion into a renal vein of the kidney, wherein the retrieval catheter is configured to support an in vitro aspiration flow rate of at least about 700 mL / min; a membrane oxygenation device fluidly coupled to the perfusion catheter, the retrieval catheter, and an oxygen source, wherein when the perfusion catheter is inserted into the renal artery and the retrieval catheter is inserted into the renal vein, the perfusion catheter, the retrieval catheter, and the membrane oxygenation device together form a closed loop through the kidney, dissociating the kidney from the patient's systemic circulation; and a pump configured to drive fluid flow through the perfusion catheter and the retrieval catheter.

2. The system of claim 1, wherein positioning the perfusion catheter in the renal artery includes positioning the perfusion catheter via the femoral artery.

3. The system of claim 1, wherein positioning the retrieval catheter in the renal vein includes positioning the perfusion catheter via the femoral vein.

4. The system of claim 1, wherein allowing the perfusion fluid to flow through the closed loop comprises: passing the perfusion fluid through the membrane oxygenation device before the perfusion fluid enters the renal artery via the perfusion catheter.

5. The system of claim 4 further comprises: adding additional perfusion fluid to the closed loop or diluting the perfusion fluid with a saline solution of about 5% to about 50% v / v to calculate the bladder excretion volume.

6. The system of any one of claims 1 to 5 further includes applying a negative pressure at the recovery conduit, wherein the negative pressure is in the range of about -100 mmHg to 0 mmHg.

7. A system as described in any of claims 1 to 5, wherein one or more of the irrigation catheter and the recovery catheter are introduced percutaneously.

8. The system of any one of claims 1 to 5, wherein the perfusion fluid comprises autologous blood, matched blood from a donor, or a combination thereof.

9. The system of claim 8, wherein the blood components are selected based on one or more parameters, wherein the one or more parameters include the presence or absence of the selected antibody.

10. The system of any one of requests 1 to 5, wherein the perfusion is maintained for a duration of about 15 minutes to about 4 hours.

11. The system of any one of claims 1 to 5, wherein the perfusion fluid contains a therapeutic polynucleotide sequence.

12. The system of claim 11, wherein the therapeutic polynucleotide sequence is present in one or more viral vectors.

13. The system of claim 12, wherein the one or more viral vectors are selected from the group consisting of: adeno-associated virus, adenovirus, retrovirus, herpes simplex virus, bovine papillomavirus, lentiviral vector, vaccinia virus, polyomavirus, Sendai virus, orthomyxovirus, paramyxovirus, papillomavirus, microRNA virus, poxvirus, alpha virus, variants thereof, and combinations thereof.

14. The system of request item 12, wherein the virus carrier is adeno-associated virus (AAV).

15. The system of claim 14, wherein the AAV is one or more of the following: AAV1, AAV2, AAV3, AAV4, AAV5, AAV6, AAV7, AAV8, AAV9, AAV10, AAV11, AAV12, variants thereof, and combinations thereof.

16. The system of claim 11, wherein the therapeutic polynucleotide sequence contains a promoter.

17. A system as described in any of claims 1 to 5, wherein less than about 20% v / v of blood circulating through the closed loop leaks out of the closed loop.

18. A system as described in any of claims 1 to 5, wherein less than about 20% v / v of the perfusion fluid circulating through the closed loop leaks out of the closed loop.

19. A system as claimed in any of claims 1 to 5, wherein one or more of the irrigation catheter or the recovery catheter is a balloon catheter.

20. The system of claim 1, further comprising: a recovery balloon catheter adapted to be inserted into the patient's bladder to measure the amount of urine excreted during the irrigation.

21. The system of claim 1, further comprising: an additional retrieval catheter suitable for insertion into each of the patient's two ureters to differentially measure the excretion of the patient's two kidneys.

22. The system of claim 1, wherein the membrane oxygenation device includes a reservoir configured to inject drugs into the closed loop during perfusion.

23. The system of claim 1, wherein the system is adapted to maintain a flow rate of perfusion fluid through the closed loop at approximately 500 mL / min / 1.73 m2 body surface area per kidney to approximately 650 mL / min / 1.73 m2 body surface area per kidney for approximately 15 minutes to approximately 4 hours.

24. A system for performing localized perfusion of a patient's kidney, comprising: an perfusion catheter inserted into a renal artery of the kidney; a retrieval catheter inserted into a renal vein of the kidney, wherein the retrieval catheter is configured to support an in vitro aspiration flow rate of at least about 700 mL / min; and a membrane oxygenation device fluidly coupled to the perfusion catheter, the retrieval catheter, and an oxygen source, wherein the perfusion catheter, the retrieval catheter, and the membrane oxygenation device together with the kidney form a closed loop through the kidney, thereby isolating the kidney from the patient's systemic circulation; and a pump configured to drive fluid flow through the perfusion catheter into the kidney and out of the kidney through the retrieval catheter.

25. The system of claim 24, further comprising: a retrieval balloon catheter inserted into the patient's bladder to measure the amount of urine excreted during the irrigation.

26. The system of claim 24, further comprising: an additional recovery catheter inserted into each of the patient's two ureters to differentially measure the excretion of the patient's two kidneys.

27. The system of claim 24, wherein the membrane oxygenation device includes a reservoir configured to inject drugs into the closed loop during perfusion.

28. The system of claim 24, wherein the system is adapted to maintain a flow rate of perfusion fluid through the closed loop at approximately 500 mL / min / 1.73 m2 body surface area per kidney to approximately 650 mL / min / 1.73 m2 body surface area per kidney for approximately 15 minutes to approximately 4 hours.

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