Recent Advancements in the Diagnosis and

Treatment of Leukodystrophies
Allison M. Bradbury, PhD,* and Margie A. Ream, MD, PhD†

Leukodystrophies and genetic leukoencephalopathies comprise a growing group of inherited

white matter disorders. Diagnostic rates have improved with increased utilization of next gener-
ation sequencing. As treatment options continue to advance for leukodystrophies, so will candi-
dacy for inclusion in the United States’ newborn Recommended Universal Screening Panel as
was achieved for X-linked adrenoleukodystrophy. Stem cell therapies have become standard of
care for selected leukodystrophies. However, transplantation-related risks remain high and out-
comes are not fully satisfactory. Transduction of autologous hematopoietic stem cells with len-
tiviral vectors, referred to as ex vivo gene therapy, circumvents some, but not all, of the risks of
traditional transplantation and has recently been demonstrated to be safe and efficective in clin-
ical studies of X-linked adrenoleukodystrophy and metachromatic leukodystrophy. Gene ther-
apy, through direct infusion of adeno-associated virus vectors, has emerged as a safer
alternative for many monogenetic pediatric neurological disorders. Numerous preclinical stud-
ies have shown safety and efficacy of adeno-associated virus gene therapy in leukodystrophies
allowing expanded access treatment for Canavan disease prior to initiation of a clinical trial.
For inherited white matter disorders resulting from overexpression of a protein, such as Peli-
zaeus-Merzbacher disease, emerging RNA therapies have shown success in preclinical studies
and promise for rapid translation to the clinic. Lastly, small molecule and protein therapies
remain a long-term treatment option for a number of leukodystrophies, including intrathecal
enzyme replacement therapy for metachromatic leukodystrophy. Herein we review recent
advances in diagnosis and treatment of inherited white matter disorders.
Semin Pediatr Neurol 37:100876 © 2021 Elsevier Inc. All rights reserved.

Introduction neurology. The combined category of leukodystrophies and

genetic leukoencephalopathies includes “all genetically deter-

L eukodystrophies include many diseases that are individu-

ally rare but collectively common in the practice of child
From the *Center for Gene Therapy, Nationwide Children’s Hospital,
Columbus, OH.
y
Division of Neurology, Nationwide Children’s Hospital, Columbus, OH.
AMB is a beneficiary of a licensing agreement with Axovant Gene Therapies
(royalties); has received income from Neurogene (consulting and
honorarium); and is an inventor on a patent application (Gray SJ,
Lykken E, Vite CH, Bradbury AM. Optimized GALC Genes and Expression
Cassettes and Their Use. PCT/US2019/067727). MAR a member of the
Evidence Review Group for the Advisory Committee on Heritable
Disorders in Newborns and Children. The views expressed herein are
solely those of the authors and do not necessarily reflect the views of the
Advisory Committee on Heritable Disorders in Newborns and Children,
or the members of the Evidence Review Group.
Address reprint requests to Margie A Ream, MD, PhD, Division of
Neurology, Nationwide Children’s Hospital, 700 Children’s Dr.,
Columbus, OH 43205. E-mail: Margie.ream@nationwidechildrens.org
mined disorders primarily affecting central nervous system
(CNS) white matter, irrespective of the structural white matter
component involved, the molecular process affected and the
disease course.”1 There are at least 30 canonical leukodystro-
phies affecting CNS myelin and glia, with more than 700 geneti-
cally determined diseases meeting the broader classification of
leukodystrophies and genetic leukoencephalopathies.2,3
As a group, the inherited white matter disorders are
nearly as common as acquired pediatric white matter disor-
ders such as acute disseminated encephalomyelitis and mul-
tiple sclerosis.4 Estimates based on allele frequency in
genetic databases predict the incidence of leukodystrophies
to be 1 in 4733 live births, however, observational estimates
found a leukodystrophy diagnosis in 1 per 7663 children,
suggesting that many cases go undiagnosed.5,6 Unfortu-
nately, patient socioeconomic status and race impact the
likelihood of diagnosis and the true incidence can only be

https://doi.org/10.1016/j.spen.2021.100876 1
1071-9091/11/© 2021 Elsevier Inc. All rights reserved.
2 A.M. Bradbury and M.A. Ream

ascertained through population level screening.7 In this
report we review recent advances in the diagnosis and treat-
ment of leukodystrophies, rather than to provide an
exhaustive discussion of individual diseases. Emerging ther-
apies are presented which may eventually move many con-
ditions from untreatable to curable.
Recent Advances in the Clinical
Diagnosis of Leukodystrophies
The diagnostic algorithm for leukodystrophies has evolved to
encourage greater and earlier reliance on genetic testing
(Fig. 1).8 Just 10 years ago, half of patients with leukodystro-
phy did not receive a specific diagnosis.5 By 2016 this
improved to 80% by combining MRI, biochemical data, and
exome sequencing, with additional benefit of whole genome
sequencing for still undiagnosed cases.9-11 When next gener-
ation sequencing does not identify a diagnosis, given the
rapid rate of gene discovery reanalysis of data after 2-3 years
can resolve an additional 10% of cases.12,13
As we learn more about the genetics behind leukodystro-
phies, it has become apparent that affected genes are rarely
specific to myelin and may affect widespread cellular func-
tion.9 Of 399 genes causing MRI-defined leukoencephalop-
athy, the majority involve metabolic and mitochondrial
pathways. Additionally, transcription factor genes are as
commonly involved as genes for lysosomal and peroxisomal
function.3 Given the urgency of diagnosis in an increasing
number of genetic white matter disorders that have therapies
in development, next generation sequencing should be con-
sidered early in the course of evaluation.
Recent Advances in
Presymptomatic Diagnosis
Through Newborn Screening
As treatment options continue to expand, as discussed below,
many leukodystrophies will become candidates for inclusion in
the newborn Recommended Universal Screening Panel (RUSP)
in the United States. X-linked adrenal leukodystrophy (X-ALD)
was added to the RUSP in 2016 and is currently screened for in
17 states and the District of Columbia (NewSTEPS.org, Sept
23, 2020). X-ALD Newborn Screening (NBS) does not discrimi-
nate by eventual phenotype  adrenal insufficiency, childhood
cerebral disease, or adult onset adrenal myeloneuropathy 
and only clinical follow up over time will determine the ultimate
diagnosis. Krabbe disease (KD, globoid cell leukodystrophy)
was not supported by a 2009 evidence review for nomination
to the RUSP but has been on the state screening panel in New
York since 2006 and is screened for in 7 additional states. NBS
labs use galactocerebrosidase activity as a first-tier test and most
measure psychosine as a confirmatory test. Elevation in this
neurotoxic compound that is normally degraded by galactocere-
brosidase can distinguish between early infantile KD (EIKD),
late onset KD, and pseudodeficiency.14-16

MRI suggests abnormal myelinaon

(white maer T2 hyperintensity, T1 iso/hypodensity)

Rule out infecous, autoimmune

and toxic causes.

Biochemical studies to consider Genec tesng Consider tesng to define the

based on MRI paern:
serum amino acids
serum lactate and pyruvate
lysosomal enzymes
psychosine
very long chain fay acids
cholestanol
urine organic acids
urine sulfades
urine sialic acid
CSF studies: protein, cell count,
amino acids, lactate, neopterin
and interferon-alpha, sialic acid
Single gene sequencing if MRI,
the history and biochemical
studies point to a specific
disorder.
If the diagnosis uncertain, order
next generaon-based gene
panel or whole exome
sequencing.
If the diagnosis sll unknown,
consider whole genome
extent of the disease:
Nerve conducon
Auditory evoked potenals
Visual evoked potenals
Somatosensory evoked
potenals
Electroencephalogram
Developmental tesng

Figure 1 Proposed diagnostic algorithm for suspected leukodystrophies. MRI with and without contrast can be helpful
for some diseases that cause inflammation as can MR spectroscopy to evaluate for lactate (mitochondrial disorders)
and N-acetyl acetate (Canavan disease). Biochemical, genetic and clinical evaluations should be individualized accord-
ing to the clinical presentation and the pattern of abnormalities on the MRI. Using select biochemical tests at the same
time as genetic testing can help speed diagnosis and interpretation of genetic results if uncommon variants are found
(van der Knaap, 2019).
Diagnosis and treatment of leukodystrophies
NY ScreenPlus is a large United States’ National Institutes
of Health-funded pilot study of multiple rare disorders
planned in New York state and will include acid sphingo-
myelinase deficiency, cerebrotendinous xanthomatosis,
ceroid lipofuscinosis type 2, Gaucher disease, Fabry disease,
lysosomal acid lipase deficiency, metachromatic leukodystro-
phy, mucopolysaccharidoses II, IIIb, IVa, VI, and VII, and
Niemann Pick type C.17 This consented study proposes to
determine incidence, outcomes, and ethical issues related to
NBS of these conditions. The resulting data will be instru-
mental in nominations for these conditions for the RUSP.
Recent Advances in the
Management of
Leukodystrophies
For all leukodystrophies  those with and without treat-
ments  guidelines have been developed for general care
with an emphasis on quality of life.18,19 Musculoskeletal, gas-
trointestinal, respiratory, neurologic, endocrine, and psycho-
social impacts of the disease must be screened for by a
knowledgeable provider, ideally every 6 months. Epilepsy
occurs in approximately one-third of patients with leukodys-
trophy, is the presenting complaint in 7% of cases, and is
particularly common early in the course of Alexander dis-
ease.20,21 Pain in patients with leukodystrophy requires spe-
cial consideration as causes and expression of pain vary by
disease severity.18,22 Communication, school, and psychoso-
cial supports including the recognition of care giver burnout
are important elements for holistic care of affected families.19
Both in the United States and several other countries, Leuko-
dystrophy Centers of Excellence and Leukodystrophy Certi-
fied Network clinics receive recognition from advocacy
groups for their evidence-based multidisciplinary care.
Recent Advances in the
Treatment of Leukodystrophies
Treatments for leukodystrophies are under intense investiga-
tion, but few are in clinical use and none are yet considered
curative. Below we discuss examples of approaches to leukodys-
trophy treatment and associated studies (Table). Where no
human trials exist, we provide examples of preclinical studies.
Stem Cell Therapies
The longest standing treatment option for leukodystrophies
is the transplantation of stem cells, which are cells that have
the potential to differentiate into multiple cell types. The
mechanism of action is not fully understood but hematopoi-
etic stem cells (HSC) are thought to exert an anti-inflamma-
tory effect and serve as a source for normal CNS
microglia.23,24 Several sources of stem cell therapies have
been used and some are still under investigation.
3
Hematopoietic Stem Cell Transplantation
HSCs can be derived from bone marrow or peripheral blood
from unrelated matched donors or related donors. Related
donors who are disease gene carriers are not the preferred
source as they generally do not have maximal enzyme activ-
ity, even if they are asymptomatic.25 HSC derived from
umbilical cord blood (UCB) has the advantages of lower rates
of graft vs host disease, more flexibility in human leukocyte
antigen matching, and rapid procurement from storage in
cord blood banks.26,27
Criteria for assessing transplant candidacy and guidelines
for transplant-related care for X-ALD, KD, and metachro-
matic leukodystrophy (MLD) are available, and include a rec-
ommendation for seizure prophylaxis during myeloablative
conditioning.26,28 Because of the delay between transplanta-
tion and sufficient brain engraftment to affect the disease
course, HSC transplantation (HSCT) is not effective for
patients with rapidly progressive or clinically advanced dis-
ease including symptomatic infantile MLD and EIKD.26,29-32
For X-ALD, transplantation does not reverse adrenal insuffi-
ciency or prevent adrenal myeloneuropathy nor does it affect
peripheral neuropathy in KD or MLD.29,33-35
Early identification through fetal diagnostics and NBS
results in better outcomes than treatment after clinical detec-
tion because it allows HSCT prior to symptom onset. Guide-
lines exist for the rapid evaluation and treatment of NBS-
identified EIKD as well as for monitoring symptom onset in
X-ALD.36,37
Umbilical Cord Blood Transplant With the Additional
Intrathecal Administration of UCB-Derived
Oligodendrocytes
UCB stem cells can be induced to differentiate into oligoden-
drocytes. A clinical study evaluating intravenous UCB trans-
plant and intrathecal administration of UCB-derived
oligodendrocytes (referred to as DUOC) has been ongoing
since 2014. This clinical study includes ALD, Krabbe, MLD,
and Pelizaeus Merzbacher Disease (PMD) (NCT02254863).
Preclinical studies in mice demonstrated that treatment with
DUOC accelerated brain remyelination.38
Neural Stem Cells
Neural stem cells (NSC) self-renew and differentiate in vivo
into multiple cell types, including myelin-forming oligoden-
drocytes.39 Banks of cryo-preserved human embryo-derived
NSCs are available for animal studies and clinical trials.40 It
is now possible to direct human somatic cells to dedifferenti-
ate into stem cells, including NCS, then re-differentiate into
specific cell lineages. This cellular source may increase the
feasibility of NSC-based therapies by circumventing the lim-
ited availability of embryo-derived cells.41
The authors of 1 clinical study reported 4 patients with
early, severe PMD treated with human NCS. The subjects
ranged in age from 6 months to 5 years, had different muta-
tions and had varying degrees of disease progression at the
time of enrollment. There was substantial variation in disease
progression post-transplant, although all patients showed
4 A.M. Bradbury and M.A. Ream
some benefit related to respiratory status, trunk strength and
ambulation. Two of the 4 patients developed antibodies
directed to the transplanted cells indicating that immunosup-
pression post-transplant may be required.42 Overall trans-
plantation with NSCs was well tolerated during the 4 year
follow up; however, given the clinical variability at the time
of transplant, efficacy was difficult to assess.
Gene Therapy
Gene therapy involves the delivery of a healthy copy of a
gene into cells that can then produce an enzyme or other
protein needed to correct a disease process. Gene delivery
can be accomplished through direct infusion of virus par-
ticles which then incorporate into host cells or through infu-
sion of a patient’s own HSC that have been transduced with
the normal gene. Adeno-associated virus (AAV) and lentivi-
rus are the 2 most commonly used gene delivery vectors.
These 2 viruses differ in size, integration, prevalence of anti-
viral antibodies in the general population, and efficiency at
transducing different cell types.
Ex Vivo Lentiviral Gene Therapy
Ex vivo gene therapy entails collection of a patient’s own
HSCs, transduction with lentiviral vectors encoding the
transgene of interest (ex vivo transduction), and reinfusion of
the patient’s modified stem cells after chemotherapy to sup-
press endogenous HSCs. Ex vivo gene therapy does not
require a matched donor and thus mitigates the risk of rejec-
tion and prevents the need for a donor search. Additionally,
viral genetic engineering can increase the level of protein
expression over naturally expressed wild-type genes. As lenti-
virus integrates into the host genome, there is risk of inter-
ruption of other genes and such off-target effects must be
monitored.
A phase 3 clinical study of ex vivo lentiviral gene therapy in
boys with X-ALD has been ongoing since 2019
(NCT03852498). This protocol requires myeloablative con-
ditioning with busulfan and fludarabine. The authors of a
phase 2-3 study of 32 males reported on the first 17 patients,
and found that 15 had stabilization of neurologic function.
One patient withdrew from the study, underwent traditional
HSCT, and died from complications. One patient experi-
enced rapid disease progression and died 22 months after
treatment. There was a positive dose response to increasing
virus copy number. Neuroinflammation, as evidenced by
gadolinium enhancement on MRI, resolved in 16 of the 17
patients by 6 months. Such a benefit occurred faster than
would be expected from traditional HSCT.37 However,
enhancement reemerged in 4 patients at 24 months suggest-
ing that the benefit may not be permanent in all patients.
Overall this study showed no toxic effects and resulted in
clinical stabilization in most treated patients.43
Ex vivo lentiviral gene therapy has also been evaluated in
MLD. In a phase 1-2 trial of 9 patients with late infantile and
early juvenile onset, patient’s HSCs were transduced with a
lentiviral vector encoding human aryl sulfatase (ARSA) and
infused after myeloablative conditioning with busulfan.44
The gene-corrected HSCs stably engrafted and ARSA activity
in circulating haemopoietic cells increased. Nerve conduc-
tion velocity improved in 3 patients, remained stable in 4,
and decreased in 2 while the natural history of the disease
would have predicted that all patients would experience pro-
gressive decline in nerve conduction velocity. Two years
post-transplant most biopsy samples showed improvement
in myelination and reduction in sulfatide storage. Except for
1 patient, MRI scores remained substantially lower than
untreated controls and Gross Motor Function Measure scores
improved. IQ scores were within normal range (plus or
minus 1 standard deviation) for all patients except for 1, as
compared to untreated patients which all fell below the mini-
mum value since first testing. Overall this trial demonstrated
safety in all patients and marked benefit in 8 out of 9
patients. A clinical trial evaluating ex vivo lentiviral gene ther-
apy in patients with late juvenile MLD is ongoing in Italy
(NCT04283227).
AAV Gene Therapy
AAV is a nonintegrating virus which cannot replicate once in
a host and therefore avoids some of the concerns associated
with lentiviral-based therapies. Certain AAV serotypes cross
the blood brain barrier after systemic delivery and have
become a tool to replace transgenes in several monogenetic
pediatric neurological conditions. The United States’ FDA
approval of intravenous delivery of AAV9 for the treatment
of spinal muscular atrophy in 2019 accelerated interest in
AAV gene therapy for the treatment of leukodystrophies.
In an expanded access clinical trial, a single 18-month-old
patient with Canavan disease was treated with AAV9 encoding
human aspartoacylase by simultaneous intravenous and intra-
cerebroventricular injection. Prior to treatment, the subject
received immunosuppression with rituximab and sirolimus.
The first reports in 2018, 9 months after gene transfer, demon-
strated safety and functional improvements from baseline.
This was the first reported case of simultaneously employing
multiple routes of vector delivery to reach a target dose.45
Preclinical studies utilizing AAV gene therapy are under
investigation for a number of leukodystrophies including
KD, X-ALD, MLD, multiple sulfatase deficiency, Canavan dis-
ease and megalencephalic leukoencephalopathy with subcor-
tical cysts.46-53 Many of these studies are likely to translate to
the clinic in the near future.
RNA Based Therapies
Antisense oligonucleotides and microRNAs (miRNA) can
modify expression of endogenous genes through their inter-
action with messenger RNA (mRNA). These therapies offer
promise for the treatment of leukodystrophies due to overex-
pression or over activity of a gene product.
Antisense Oligonucleotides (ASO)
Antisense oligonucleotides (ASO) are small, single stranded
molecules of either RNA or DNA that bind to specific mRNA
sequences, and can alter splicing thereby modifying the
resulting protein product (as in risdiplam which was

Table Approaches to the Treatment of Leukodystrophies
Proposed Mechanism
Therapy of Action
Stem cell therapies
Hematopoietic stem cell Donor stem cells become
transplantation resident cells, namely
(HSCT). microglia in the CNS, and
produce the deficient
enzyme.
Umbilical cord blood Donor-derived oligoden-
(UCB) trans- drocytes delivered
plant + intrathecal directly to the CNS
UCB-derived oligo- engraft, enhance remyeli-
dendrocytes (DUOC). nation, and produce the
deficient enzyme in addi-
tion to traditional UCB
transplant.
Neural stem cells NSCs self-renew and dif-
(NSC). ferentiate in vivo into
multiple cell types,
including myelin-forming
oligodendrocytes.
Gene therapy
Ex vivo lentiviral gene Ex vivo gene therapy
therapy. entails collection of a
patient’s own HSCs,
transduction with lentivi-
ral vectors encoding the
transgene of interest (ex
vivo transduction), and
reinfusion of the patient’s
modified stem cells after
Diagnosis and treatment of leukodystrophies
Disadvantages and
Areas Needing Further Recent Preclinical
Advantages Study Clinical Trials Studies (2019-2020)
 Routine procedure.  Chemical ablation. FDA approved procedure.
 Risks associated with
GVHD.
 Necessity of HLA
matched donor bone mar-
row or UCB.
 Does not treat neuropa-
thy.
 Lag time between trans-
plant, engraftment, and
production of enzyme.
 DUOC cells delivered  Chemical ablation is NCT02254863:
intrathecally increase the required. ALD, KD, MLD, PMD.
rate, number, and type of  Two lots of UCB, 1 for
UCB-derived cells in the traditional UCB trans-
CNS. plant and 1 for DUOC are
required.
 Risks associated with
GVHD.
 Necessity of HLA
matched UCB.
 NSCs differentiate into  Embryo-derived NSCs PMD: PMD: (Gruenenfelder,
neurons, astrocytes, and have limited availability, (Gupta, Henry et al, 2019). McLaughlin et al, 2020).
oligodendrocytes. Direct ethical concerns. VWM:
targeting of the CNS  Potential immunogenicity (Dooves, Leferink et al,
increases the rate and to transplanted NSCs. 2019).
number of engrafted
cells.
 Does not require search  Chemical ablation is ALD
for donor match. required. (Eichler, Duncan et al,
 Negates risk of GVHD.  Risk of insertional muta- 2017): NCT03852498.
 Can restore enzyme lev- genesis. MLD
els to supraphysiological  Dose dependency- insuf- (Sessa, Lorioli et al, 2016):
levels. ficient vector copy num- NCT04283227.
ber can lead to
inadequate levels of the
5

Table (Continued )
Proposed Mechanism
Therapy of Action
chemotherapy to sup-
press their endogenous
HSC.
Intracerebral lentiviral Direct injection of lentiviral
gene therapy. vectors encoding the
transgene of choice into
multiple brain regions
where the virus integra-
tes into the genome of
the host’s cells and pro-
duces the therapeutic
protein.
AAV gene therapy Direct injection of an AAV
vector that enters the
host’s cells and produces
the therapeutic protein
without disrupting the
host DNA.
RNA based therapies
Antisense oligonucleo- ASO are small, single-
tides (ASO). stranded nucleic acids
that target RNA and can
alter protein expression.
Advantages
 Targeting of specific
brain regions.
 Does not require trans-
plantation or
conditioning.
 Small- certain serotypes
can cross BBB after sys-
temic injection.
 Nonpathogenic.
 Nonintegrating.
 Replication deficient.
 Does not require trans-
plantation or condition-
ing.
 Targetability of tissue or
cell types by altering cap-
sid or promoter.
 Target RNA instead of
DNA.
 Small size.
6
Disadvantages and
Areas Needing Further Recent Preclinical
Study Clinical Trials Studies (2019-2020)
enzyme and incomplete
correction.
 Surgical procedure with ALD: NCT03727555.
multiple bur holes. MLD:
 Limited distribution NCT03725670.
beyond the injection site.
 Restricted tropism.
 Immunogenicity.
 Risk of insertional
mutagenesis.
 Limited packaging capac- Canavan: KD: (Pan, Sands et al,
ity. (Corti, Coleman et al, 2019, Bradbury, Bagel
 Loss of vector with cell 2018). et al, 2020, Rafi, Luzi
turnover since it is nonin- et al, 2020).
tegrating. MLC: (Garcia-Lareu et al,
 High prevalence of neu- 2020).
tralizing antibodies to MSD: (Presa Ray et al,
certain serotypes in pop- 2020).
ulation.
 Manufacturing con-
straints for high dose,
systemic delivery.
 Potential toxicity to liver
and dorsal root ganglion
after high dose delivery.
 Immunogenicity.
 Off target effect. Canavan:
 Immunogenicity. (Hull, Wang et al, 2020).
 Do not cross the BBB
A.M. Bradbury and M.A. Ream
PMD: (Elitt, Barbar et al,
efficiently, so repeated 2020).
intrathecal administration
is required for CNS tar-
geting.
 May require repeat
infusions.
 Diagnosis and treatment of leukodystrophies
Table (Continued )
Disadvantages and
Proposed Mechanism Areas Needing Further Recent Preclinical
Therapy of Action Advantages Study Clinical Trials Studies (2019-2020)

MicroRNA (miRNA). miRNAs are small, noncod-  Target RNA instead of  Necessary delivery sys- PMD:
ing RNAs that target DNA. tem (Li, Okada et al, 2019).
mRNAs and regulate  Small size.  If delivered in AAV, same
gene expression.  Can be used for up or as above for AAV.
down regulation.  Off target effects.
 In vivo stability.
Small molecule and protein therapies
Inhibitors. Inhibitors interrupt dysre-  Unlike cell and gene ther-  Continual treatment AGS: NCT03921554,
gulated pathways. apies, small molecule required NCT04517253,
therapies can be discon-  Can have off target NCT02363452,
tinued in case of unto- effects on other functions NCT03304717.
ward effects or lack of of the pathway ALD:
efficacy. (Zierfuss, Weinhofer et al,
 Minimally invasive. 2020).
 Can repurpose FDA
approved drugs.
Chaperone therapy. Molecular chaperones  Unlike cell and gene ther-  Continual treatment Fabry: NCT04049760.
bind to proteins with spe- apies, small molecule required.
cific conformational qual- therapies can be discon-  Can have off target
ities in order to optimize tinued if untoward effects effects of other functions
their activity. arise or if there is lack of of the pathway.
efficacy.
Enzyme replacement Delivery of functional  Unlike cell and gene ther-  Large proteins cannot MLD:
therapy. enzyme. apies, small molecule cross the BBB so must be (Dali, Sevin et al, 2020)
therapies can be discon- delivered intrathecally NCT03771898.
tinued if untoward effects utilizing a permanent
arise or if there is lack of IDDD or repeated lumbar
efficacy. puncture.
 Risk of infection.
 Immunogenicity.
 Continual treatment
required, often weekly or
bi-weekly depending on
1
/2 life of the protein.
AAV, adeno-associated virus; AGS, Aicardi-Goutieres syndrome; ASO, antisense oligonucleotides; BBB, blood-brain barrier; CNS, central nervous system; DUOC, UCB-derived oligodendrocytes;
FDA, Food and Drug Administration; GVHD, graft vs host disease; HLA, human leukocyte antigen; HSCT, hematopoietic stem cell transplantation;IDDD, intrathecal drug delivery device; KD,
Krabbe disease (globoid cell leukodystrophy); miRNA, microRNA; MLC, megalencephalic leukoencephalopathy with subcortical cysts; MLD, metachromatic leukodystrophy; NSC, neural stem
cells; PMD, Pelizaeus Merzbacher disease; UCB, umbilical cord blood; X-ALD, X-linked adrenoleukodystrophy.

7
8 A.M. Bradbury and M.A. Ream
approved by the United States’ FDA in 2020 for spinal mus-
cular atrophy) or inhibit translation thereby reducing protein
expression. The duration of action of ASOs differ in different
disease models. ASOs have demonstrated benefit in a mouse
model of PMD, which is due to over-expression of proteoli-
pid protein 1 (PLP1) and Canavan disease, which results
from toxic effects of increased NacetylLaspartate (NAA)
production.54,55 Clinical trials for PMD are anticipated soon.
MicroRNA
MircroRNAs (miRNA) are small, noncoding RNAs that target
mRNAs and regulate gene expression. Unlike ASOs, miRNA
can be a naturally occurring intracellular mechanism for
post-transcriptional regulation of gene expression. Delivery
of miRNA targeting the PLP1 gene using an AAV vector
resulted in improved myelination and survival in a mouse
model of PMD.56
Small Molecule and Protein Therapies
A variety of small molecule and protein therapies have been
studied for the treatment of leukodystrophies. This group
includes inhibitors of dysregulated pathways, molecular
chaperones, and enzyme replacement therapy.
Inhibitors
Aicardi-Goutieres syndrome (AGS) can result from mutations
in genes related to production of nucleases, enzymes that
break down DNA and RNA, resulting in accumulation of
DNA and RNA that triggers an injurious immune response.
Use of reverse transcriptase inhibitors are under clinical
investigation for AGS including: zidovudine, lamivudine,
and abacavir (NCT02363452) or tenofovir and emtricitabine
(NCT03304717). Alternatively, AGS can be caused by muta-
tions in genes related to immune system function. Targeting
pathways such as the JAK-STAT signaling pathway with bari-
citinib, a janus kinase inhibitor, as approved for rheumatoid
arthritis, is currently in clinical study for AGS
(NCT03921554, NCT04517253).
Three patients with X-ALD who had advanced cerebral
disease and thus not eligible for HSCT or ex vivo lentiviral
gene therapy received vorinostat, a histone deacetylase inhib-
itor, to evaluate the effect on blood brain barrier integrity.
After 80 days of vorinostat treatment, the CSF levels of albu-
min and immunoglobulins normalized, suggesting a reduc-
tion in the excessive blood brain barrier permeability that is
typically associated with X-ALD. However, after vorinostat
discontinuation, CNS lesions progressed. In order to deter-
mine efficacy, vorinostat would need to be evaluated in ear-
lier disease stages with a longer duration of therapy.57
Chaperone Therapy
Molecular chaperones bind to proteins with specific confor-
mational qualities in order to optimize their activity. A given
chaperone molecule is specific to a given protein sequence
and therefore not all mutations for a disease are amenable to
treatment by the same chaperone. Miglustat, a molecular
chaperone FDA-approved to treat adult Fabry disease, is
being evaluated in a phase 3 clinical study for pediatric
patients in the United States and Spain (NCT04049760).
Enzyme Replacement Therapy
Infusion of functional enzymes can have significant benefit
replacing defective enzyme molecules. However, when deliv-
ered systemically, large proteins cannot cross the blood brain
barrier efficiently, thus direct targeting of the CNS is neces-
sary.
The first study of intrathecal delivery of recombinant
human arylsulfatase A (ARSA) for the treatment of MLD
enrolled 24 patients with symptom onset aged  30 months
using an intrathecal drug delivery device (IDDD). The treat-
ment was generally well tolerated with no deaths and no
adverse events warranting discontinuation. The most com-
mon serious adverse events were related to the IDDD. There
were dose-dependent benefits in CSF ARSA and sulfatide lev-
els and motor function.58
A modified study using higher and more frequent dosing
is underway with a plan to enroll 42 patients between the
United States, Canada, Brazil and Europe (NCT03771898).
Conclusion
As more is learned about leukodystrophies and treatments
become available, advocacy groups and specialty centers
work to maximize patient care and move the field forward.
Organizations such as the Global Leukodystrophy Initiative,
United Leukodystrophy Foundation, and disease-specific
organizations, often named after children who succumbed to
these conditions, connect families, provide education to
physicians, patients, and the public, fund research, and advo-
cate for newborn screening and other policy changes to aid in
the care and cure of leukodystrophies. With rapid advances
in cell, gene, RNA-based, and protein therapies, many of
these conditions will become treatable in the coming years.
As advancements in treatment run parallel with advance-
ments in diagnosis and screening, an increasing number of
children will benefit from the emerging science and new
technologies.
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