51
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Langer AL, Ginzburg YZ. Role of hepcidin-ferroportin axis in the pathophysiology, diagnosis, and treatment of anemia of chronic inflammation. Hemodial Int 2017; 21 Suppl 1:S37-S46. [PMID: 28328181 DOI: 10.1111/hdi.12543] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Anemia of chronic inflammation (ACI) is a frequently diagnosed anemia and portends an independently increased morbidity and poor outcome associated with multiple underlying diseases. The pathophysiology of ACI is multifactorial, resulting from the effects of inflammatory cytokines which both directly and indirectly suppress erythropoiesis. Recent advances in molecular understanding of iron metabolism provide strong evidence that immune mediators, such as IL-6, lead to hepcidin-induced hypoferremia, iron sequestration, and decreased iron availability for erythropoiesis. The role of hepcidin-ferroportin axis in the pathophysiology of ACI is stimulating the development of new diagnostics and targeted therapies. In this review, we present an overview of and rationale for inflammation-, iron-, and erythropoiesis-related strategies currently in development.
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Affiliation(s)
- Arielle L Langer
- Division of Hematology and Oncology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Yelena Z Ginzburg
- Division of Hematology and Oncology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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52
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Abstract
Impaired iron homeostasis and the suppressive effects of proinflammatory cytokines on erythropoiesis, together with alterations of the erythrocyte membrane that impair its survival, cause anemia of inflammation. Recent epidemiologic studies have connected inflammatory anemia with critical illness, obesity, aging, kidney failure, cancer, chronic infection, and autoimmune disease. The proinflammatory cytokine, interleukin-6, the iron regulatory hormone, hepcidin, and the iron exporter, ferroportin, interact to cause iron sequestration in the setting of inflammation. Although severe anemia is associated with adverse outcomes in critical illness, experimental models suggest that iron sequestration is part of a natural defense against pathogens.
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Affiliation(s)
- Paula G Fraenkel
- Department of Medicine, Harvard Medical School, Boston, MA, USA.
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53
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Kiers D, Koch RM, Hamers L, Gerretsen J, Thijs EJM, van Ede L, Riksen NP, Kox M, Pickkers P. Characterization of a model of systemic inflammation in humans in vivo elicited by continuous infusion of endotoxin. Sci Rep 2017; 7:40149. [PMID: 28054645 PMCID: PMC5215288 DOI: 10.1038/srep40149] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 12/01/2016] [Indexed: 01/06/2023] Open
Abstract
Investigating the systemic inflammatory response in patients with critical illness such as sepsis, trauma and burns is complicated due to uncertainties about the onset, duration and severity of the insult. Therefore, in vivo models of inflammation are essential to study the pathophysiology and to evaluate immunomodulatory therapies. Intravenous bolus administration of endotoxin to healthy volunteers is a well-established model of a short-lived systemic inflammatory response, characterized by increased plasma cytokine levels, flu-like symptoms and fever. In contrast, patients suffering from systemic inflammation are often exposed to inflammatory stimuli for an extended period of time. Therefore, continuous infusion of endotoxin may better reflect the kinetics of the inflammatory response encountered in these patients. Herein, we characterize a novel model of systemic inflammation elicited by a bolus infusion of 1 ng/kg, followed by a 3hr continuous infusion of 1 ng/kg/h of endotoxin in healthy volunteers, and compared it with models of bolus administrations of 1 and 2 ng/kg of endotoxin. The novel model was well-tolerated and resulted in a more pronounced increase in plasma cytokine levels with different kinetics and more prolonged symptoms and fever compared with the bolus-only models. Therefore, the continuous endotoxin infusion model provides novel insights into kinetics of the inflammatory response during continuous inflammatory stimuli and accommodates a larger time window to evaluate immunomodulating therapies.
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Affiliation(s)
- D Kiers
- Radboud university medical center, 6500 HB, Radboud Institute for Molecular Life Sciences, Department of Intensive Care Medicine, 6500 HB, Nijmegen, The Netherlands.,Radboud university medical center, 6500 HB, Radboud Institute for Molecular Life Sciences, Department of Pediatrics, 6500 HB, Nijmegen, The Netherlands
| | - R M Koch
- Radboud university medical center, 6500 HB, Radboud Institute for Molecular Life Sciences, Department of Intensive Care Medicine, 6500 HB, Nijmegen, The Netherlands.,Radboud university medical center, 6500 HB, Radboud Institute for Molecular Life Sciences, Department of Pediatrics, 6500 HB, Nijmegen, The Netherlands
| | - L Hamers
- Radboud university medical center, 6500 HB, Radboud Institute for Molecular Life Sciences, Department of Intensive Care Medicine, 6500 HB, Nijmegen, The Netherlands.,Radboud university medical center, 6500 HB, Radboud Institute for Molecular Life Sciences, Department of Pediatrics, 6500 HB, Nijmegen, The Netherlands
| | - J Gerretsen
- Radboud university medical center, 6500 HB, Radboud Institute for Molecular Life Sciences, Department of Intensive Care Medicine, 6500 HB, Nijmegen, The Netherlands.,Radboud university medical center, 6500 HB, Radboud Institute for Molecular Life Sciences, Department of Pediatrics, 6500 HB, Nijmegen, The Netherlands
| | - E J M Thijs
- Radboud university medical center, 6500 HB, Radboud Institute for Molecular Life Sciences, Department of Intensive Care Medicine, 6500 HB, Nijmegen, The Netherlands
| | - L van Ede
- Radboud university medical center, 6500 HB, Radboud Institute for Molecular Life Sciences, Department of Intensive Care Medicine, 6500 HB, Nijmegen, The Netherlands
| | - N P Riksen
- Radboud university medical center, 6500 HB, Radboud Institute for Molecular Life Sciences, Department of Internal Medicine, 6500 HB, Nijmegen, The Netherlands
| | - M Kox
- Radboud university medical center, 6500 HB, Radboud Institute for Molecular Life Sciences, Department of Intensive Care Medicine, 6500 HB, Nijmegen, The Netherlands.,Radboud university medical center, 6500 HB, Radboud Institute for Molecular Life Sciences, Department of Pediatrics, 6500 HB, Nijmegen, The Netherlands
| | - P Pickkers
- Radboud university medical center, 6500 HB, Radboud Institute for Molecular Life Sciences, Department of Intensive Care Medicine, 6500 HB, Nijmegen, The Netherlands.,Radboud university medical center, 6500 HB, Radboud Institute for Molecular Life Sciences, Department of Pediatrics, 6500 HB, Nijmegen, The Netherlands
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54
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Abstract
PURPOSE OF REVIEW Anemia is prevalent in patients with infections and other inflammatory conditions. Induction of the iron regulatory hormone hepcidin has been implicated in the pathogenesis of anemia of inflammation. This review outlines recent discoveries in understanding how hepcidin and its receptor ferroportin are regulated, how they contribute to anemia of inflammation, and how this knowledge may help guide new diagnostic and therapeutic strategies for this disease. RECENT FINDINGS IL-6 is a primary driver for hepcidin induction in many models of anemia of inflammation, but the SMAD1/5/8 pathway also contributes, likely via Activin B and SMAD-STAT3 interactions at the hepcidin promoter. Hepcidin has an important functional role in many, but not all forms of anemia of inflammation, although hepcidin-independent mechanisms also contribute. In certain populations, hepcidin assays may help target therapy with iron or erythropoiesis-stimulating agents to patients who may benefit most. New therapies targeting the hepcidin-ferroportin axis have shown efficacy in preclinical and early clinical studies. SUMMARY Recent studies confirm an important role for the hepcidin-ferroportin axis in the development of anemia of inflammation, but also highlight the diverse and complex pathogenesis of this disorder depending on the underlying disease. Hepcidin-based diagnostic and therapeutic strategies offer promise to improve anemia treatment, but more work is needed in this area.
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55
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Abe T, Miyakawa S, Nakamura Y. [Therapeutic aptamers]. Nihon Yakurigaku Zasshi 2016; 147:362-7. [PMID: 27301311 DOI: 10.1254/fpj.147.362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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56
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Iron deficiency or anemia of inflammation? : Differential diagnosis and mechanisms of anemia of inflammation. Wien Med Wochenschr 2016; 166:411-423. [PMID: 27557596 PMCID: PMC5065583 DOI: 10.1007/s10354-016-0505-7] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 05/30/2016] [Indexed: 02/08/2023]
Abstract
Iron deficiency and immune activation are the two most frequent causes of anemia, both of which are based on disturbances of iron homeostasis. Iron deficiency anemia results from a reduction of the body’s iron content due to blood loss, inadequate dietary iron intake, its malabsorption, or increased iron demand. Immune activation drives a diversion of iron fluxes from the erythropoietic bone marrow, where hemoglobinization takes place, to storage sites, particularly the mononuclear phagocytes system in liver and spleen. This results in iron-limited erythropoiesis and anemia. This review summarizes current diagnostic and pathophysiological concepts of iron deficiency anemia and anemia of inflammation, as well as combined conditions, and provides a brief outlook on novel therapeutic options.
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57
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Malyszko J, Malyszko JS. Emerging drugs for the treatment of kidney disease-induced anemia. Expert Opin Emerg Drugs 2016; 21:315-30. [PMID: 27537859 DOI: 10.1080/14728214.2016.1220537] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Anemia has been remained one of the most characteristic and visible manifestations of chronic renal failure. Correction of anemia requires two main treatment strategies: increased stimulation of erythropoiesis, and maintenance of an adequate iron supply to the bone marrow. AREAS COVERED Erythropoiesis activating agents became a mainstay in the treatment of renal anemia for more than 25 years. Recently, there have been several attempts to introduce new drugs to stimulate erythropoiesis or affect the hepcidin-ferroportin pathway. Orally available hypoxia-inducible factor (HIF) stabilizing compounds are attractive alternatives. They not only increase hemoglobin, but also suppress hepcidin production and improve iron availability. Novel iron preparations, may also help to ameliorate anemia, with acceptable safety profile and other beneficial properties such a phosphate binding. EXPERT OPINION One should be aware of potential risks and benefits of novel sophisticated therapies and their role in the management of renal anemia remain to be established. In particular HIF stabilizers needs to be proven safe, or even safer than ESAs, in large long-term safety studies testing hard end points, due its ubiquitous nature and the regulation of variety of biological processes potentially leading to unexpected side effects. Besides safety, cost-effectiveness appears the major issue in the modern world, including nephrology.
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Affiliation(s)
- Jolanta Malyszko
- a 2nd Department of Nephrology and Hypertension with Dialysis Unit , Medical University , Bialystok , Poland.,b 1st Department of Nephrology , Medical University , Bialystok , Poland
| | - Jacek S Malyszko
- a 2nd Department of Nephrology and Hypertension with Dialysis Unit , Medical University , Bialystok , Poland.,b 1st Department of Nephrology , Medical University , Bialystok , Poland
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58
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Armitage AE, Lim PJ, Frost JN, Pasricha SR, Soilleux EJ, Evans E, Morovat A, Santos A, Diaz R, Biggs D, Davies B, Gileadi U, Robbins PA, Lakhal-Littleton S, Drakesmith H. Induced Disruption of the Iron-Regulatory Hormone Hepcidin Inhibits Acute Inflammatory Hypoferraemia. J Innate Immun 2016; 8:517-28. [PMID: 27423740 PMCID: PMC5322583 DOI: 10.1159/000447713] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 06/20/2016] [Indexed: 12/15/2022] Open
Abstract
Withdrawal of iron from serum (hypoferraemia) is a conserved innate immune antimicrobial strategy that can withhold this critical nutrient from invading pathogens, impairing their growth. Hepcidin (Hamp1) is the master regulator of iron and its expression is induced by inflammation. Mice lacking Hamp1 from birth rapidly accumulate iron and are susceptible to infection by blood-dwelling siderophilic bacteria such as Vibrio vulnificus. In order to study the innate immune role of hepcidin against a background of normal iron status, we developed a transgenic mouse model of tamoxifen-sensitive conditional Hamp1 deletion (termed iHamp1-KO mice). These mice attain adulthood with an iron status indistinguishable from littermate controls. Hamp1 disruption and the consequent decline of serum hepcidin concentrations occurred within hours of a single tamoxifen dose. We found that the TLR ligands LPS and Pam3CSK4 and heat-killed Brucella abortus caused an equivalent induction of inflammation in control and iHamp1-KO mice. Pam3CSK4 and B. abortus only caused a drop in serum iron in control mice, while hypoferraemia due to LPS was evident but substantially blunted in iHamp1-KO mice. Our results characterise a powerful new model of rapidly inducible hepcidin disruption, and demonstrate the critical contribution of hepcidin to the hypoferraemia of inflammation.
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Affiliation(s)
- Andrew E Armitage
- Department of Biochemistry, Birmingham Heartlands Hospital, Heart of England NHS Foundation Trust, Birmingham, UK
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59
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Reautschnig P, Vogel P, Stafforst T. The notorious R.N.A. in the spotlight - drug or target for the treatment of disease. RNA Biol 2016; 14:651-668. [PMID: 27415589 PMCID: PMC5449091 DOI: 10.1080/15476286.2016.1208323] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
mRNA is an attractive drug target for therapeutic interventions. In this review we highlight the current state, clinical trials, and developments in antisense therapy, including the classical approaches like RNaseH-dependent oligomers, splice-switching oligomers, aptamers, and therapeutic RNA interference. Furthermore, we provide an overview on emerging concepts for using RNA in therapeutic settings including protein replacement by in-vitro-transcribed mRNAs, mRNA as vaccines and anti-allergic drugs. Finally, we give a brief outlook on early-stage RNA repair approaches that apply endogenous or engineered proteins in combination with short RNAs or chemically stabilized oligomers for the re-programming of point mutations, RNA modifications, and frame shift mutations directly on the endogenous mRNA.
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Affiliation(s)
- Philipp Reautschnig
- a Interfaculty Institute of Biochemistry, University of Tübingen Auf der Morgenstelle , Tübingen , Germany
| | - Paul Vogel
- a Interfaculty Institute of Biochemistry, University of Tübingen Auf der Morgenstelle , Tübingen , Germany
| | - Thorsten Stafforst
- a Interfaculty Institute of Biochemistry, University of Tübingen Auf der Morgenstelle , Tübingen , Germany
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60
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Sebastiani G, Wilkinson N, Pantopoulos K. Pharmacological Targeting of the Hepcidin/Ferroportin Axis. Front Pharmacol 2016; 7:160. [PMID: 27445804 PMCID: PMC4914558 DOI: 10.3389/fphar.2016.00160] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Accepted: 05/31/2016] [Indexed: 12/22/2022] Open
Abstract
The iron regulatory hormone hepcidin limits iron fluxes to the bloodstream by promoting degradation of the iron exporter ferroportin in target cells. Hepcidin insufficiency causes hyperabsorption of dietary iron, hyperferremia and tissue iron overload, which are hallmarks of hereditary hemochromatosis. Similar responses are also observed in iron-loading anemias due to ineffective erythropoiesis (such as thalassemias, dyserythropoietic anemias and myelodysplastic syndromes) and in chronic liver diseases. On the other hand, excessive hepcidin expression inhibits dietary iron absorption and leads to hypoferremia and iron retention within tissue macrophages. This reduces iron availability for erythroblasts and contributes to the development of anemias with iron-restricted erythropoiesis (such as anemia of chronic disease and iron-refractory iron-deficiency anemia). Pharmacological targeting of the hepcidin/ferroportin axis may offer considerable therapeutic benefits by correcting iron traffic. This review summarizes the principles underlying the development of hepcidin-based therapies for the treatment of iron-related disorders, and discusses the emerging strategies for manipulating hepcidin pathways.
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Affiliation(s)
- Giada Sebastiani
- Department of Medicine, McGill UniversityMontreal, QC, Canada; Division of Gastroenterology, Royal Victoria HospitalMontreal, QC, Canada
| | - Nicole Wilkinson
- Lady Davis Institute for Medical Research, Jewish General Hospital Montreal, QC, Canada
| | - Kostas Pantopoulos
- Department of Medicine, McGill UniversityMontreal, QC, Canada; Lady Davis Institute for Medical Research, Jewish General HospitalMontreal, QC, Canada
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61
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Schmid H, Jelkmann W. Investigational therapies for renal disease-induced anemia. Expert Opin Investig Drugs 2016; 25:901-16. [DOI: 10.1080/13543784.2016.1182981] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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62
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Boyce M, Warrington S, Cortezi B, Zöllner S, Vauléon S, Swinkels DW, Summo L, Schwoebel F, Riecke K. Safety, pharmacokinetics and pharmacodynamics of the anti-hepcidin Spiegelmer lexaptepid pegol in healthy subjects. Br J Pharmacol 2016; 173:1580-8. [PMID: 26773325 PMCID: PMC4842915 DOI: 10.1111/bph.13433] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 01/11/2016] [Accepted: 01/11/2016] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND AND PURPOSE Anaemia of chronic disease is characterized by impaired erythropoiesis due to functional iron deficiency, often caused by excessive hepcidin. Lexaptepid pegol, a pegylated structured l-oligoribonucleotide, binds and inactivates hepcidin. EXPERIMENTAL APPROACH We conducted a placebo-controlled study on the safety, pharmacokinetics and pharmacodynamics of lexaptepid after single and repeated i.v. and s.c. administration to 64 healthy subjects at doses from 0.3 to 4.8 mg·kg(-1) . KEY RESULTS After treatment with lexaptepid, serum iron concentration and transferrin increased dose-dependently. Iron increased from approximately 20 μmol·L(-1) at baseline by 67% at 8 h after i.v. infusion of 1.2 mg·kg(-1) lexaptepid. The pharmacokinetics showed dose-proportional increases in peak plasma concentrations and moderately over-proportional increases in systemic exposure. Lexaptepid had no effect on hepcidin production or anti-drug antibodies. Treatment with lexaptepid was generally safe and well tolerated, with mild and transient transaminase increases at doses ≥2.4 mg·kg(-1) and with local injection site reactions after s.c. but not after i.v. administration. CONCLUSIONS AND IMPLICATIONS Lexaptepid pegol inhibited hepcidin and dose-dependently raised serum iron and transferrin saturation. The compound is being further developed to treat anaemia of chronic disease.
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Affiliation(s)
- M Boyce
- Hammersmith Medicines Research, London, UK
| | | | - B Cortezi
- Hammersmith Medicines Research, London, UK
| | | | | | - D W Swinkels
- Hepcidinanalysis.com, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - L Summo
- NOXXON Pharma AG, Berlin, Germany
| | | | - K Riecke
- NOXXON Pharma AG, Berlin, Germany
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63
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López-Gómez JM, Abad S, Vega A. Nuevas expectativas en el tratamiento de la anemia en la enfermedad renal crónica. Nefrologia 2016; 36:232-6. [DOI: 10.1016/j.nefro.2016.03.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 03/30/2016] [Indexed: 11/30/2022] Open
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64
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Wallace DF. The Regulation of Iron Absorption and Homeostasis. Clin Biochem Rev 2016; 37:51-62. [PMID: 28303071 PMCID: PMC5198508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Iron is an essential element in biology, required for numerous cellular processes. Either too much or too little iron can be detrimental, and organisms have developed mechanisms for balancing iron within safe limits. In mammals there are no controlled mechanisms for the excretion of excess iron, hence body iron homeostasis is regulated at the sites of absorption, utilisation and recycling. This review will discuss the discoveries that have been made in the past 20 years into advancing our understanding of iron homeostasis and its regulation. The study of iron-associated disorders, such as the iron overload condition hereditary haemochromatosis and various forms of anaemia have been instrumental in increasing our knowledge in this area, as have cellular and animal model studies. The liver has emerged as the major site of systemic iron regulation, being the location where the iron regulatory hormone hepcidin is produced. Hepcidin is a negative regulator of iron absorption and recycling, achieving this by binding to the only known cellular iron exporter ferroportin and causing its internalisation and degradation, thereby reducing iron efflux from target cells and reducing serum iron levels. Much of the research in the iron metabolism field has focussed on the regulation of hepcidin and its interaction with ferroportin. The advances in this area have greatly increased our knowledge of iron metabolism and its regulation and have led to the development of novel diagnostics and therapeutics for iron-associated disorders.
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65
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Abstract
Iron is required for most forms of organisms, and it is the most essential element for the functions of many iron-containing proteins involved in oxygen transport, cellular respiration, DNA replication, and so on. Disorders of iron metabolism are associated with diverse diseases, including anemias (e.g., iron-deficiency anemia and anemia of chronic diseases) and iron overload diseases, such as hereditary hemochromatosis and β-thalassemia. Hepcidin (encoded by Hamp gene) is a peptide hormone synthesized by hepatocytes, and it plays an important role in regulating the systematic iron homeostasis. As the systemic iron regulator, hepcidin, not only controls dietary iron absorption and iron egress out of iron storage cells, but also induces iron redistribution in various organs. Deregulated hepcidin is often seen in a variety of iron-related diseases including anemias and iron overload disorders. In the case of iron overload disorders (e.g., hereditary hemochromatosis and β-thalassemia), hepatic hepcidin concentration is significantly reduced.Since hepcidin deregulation is responsible for iron disorder-associated diseases, the purpose of this review is to summarize the recent findings on therapeutics targeting hepcidin.Continuous efforts have been made to search for hepcidin mimics and chemical compounds that could be used to increase hepcidin level. Here, a literature search was conducted in PubMed, and research papers relevant to hepcidin regulation or hepcidin-centered therapeutic work were reviewed. On the basis of literature search, we recapitulated recent findings on therapeutic studies targeting hepcidin, including agonists and antagonists to modulate hepcidin expression or its downstream signaling. We also discussed the molecular mechanisms by which hepcidin level and iron metabolism are modulated.Elevating hepcidin concentration is an optimal strategy to ameliorate iron overload diseases, and also to relieve β-thalassemia phenotypes by improving ineffective erythropoiesis. Relative to the current conventional therapies, such as phlebotomy and blood transfusion, therapeutics targeting hepcidin would open a new avenue for treatment of iron-related diseases.
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Affiliation(s)
- Jing Liu
- From the State Key Laboratory of Environmental Chemistry and Ecotoxicology (JL, SL), Research Center for Eco-Environmental Sciences, Chinese Academy of Sciences, Beijing, China; Department of Medicine (BS), University of California, Los Angeles, CA; Department of Cardiovascular Disease (HY), Beijing Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing; and Gansu University of Traditional Chinese Medicine (HY), Lanzhou, China
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66
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Abstract
Anaemia affects roughly a third of the world's population; half the cases are due to iron deficiency. It is a major and global public health problem that affects maternal and child mortality, physical performance, and referral to health-care professionals. Children aged 0-5 years, women of childbearing age, and pregnant women are particularly at risk. Several chronic diseases are frequently associated with iron deficiency anaemia--notably chronic kidney disease, chronic heart failure, cancer, and inflammatory bowel disease. Measurement of serum ferritin, transferrin saturation, serum soluble transferrin receptors, and the serum soluble transferrin receptors-ferritin index are more accurate than classic red cell indices in the diagnosis of iron deficiency anaemia. In addition to the search for and treatment of the cause of iron deficiency, treatment strategies encompass prevention, including food fortification and iron supplementation. Oral iron is usually recommended as first-line therapy, but the most recent intravenous iron formulations, which have been available for nearly a decade, seem to replenish iron stores safely and effectively. Hepcidin has a key role in iron homoeostasis and could be a future diagnostic and therapeutic target. In this Seminar, we discuss the clinical presentation, epidemiology, pathophysiology, diagnosis, and acute management of iron deficiency anaemia, and outstanding research questions for treatment.
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Affiliation(s)
- Anthony Lopez
- Department of Hepato-Gastroenterology and Inserm U954, University Hospital of Nancy, Lorraine University, Vandoeuvre-lès-Nancy, France
| | - Patrice Cacoub
- Sorbonne Universités, UPMC Univ Paris 06, UMR 7211, Paris, France; Inflammation-Immunopathology-Biotherapy Department, F-75005, Paris, France; AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Department of Internal Medicine and Clinical Immunology, F-75013, Paris, France
| | | | - Laurent Peyrin-Biroulet
- Department of Hepato-Gastroenterology and Inserm U954, University Hospital of Nancy, Lorraine University, Vandoeuvre-lès-Nancy, France.
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67
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Engert A, Balduini C, Brand A, Coiffier B, Cordonnier C, Döhner H, de Wit TD, Eichinger S, Fibbe W, Green T, de Haas F, Iolascon A, Jaffredo T, Rodeghiero F, Salles G, Schuringa JJ. The European Hematology Association Roadmap for European Hematology Research: a consensus document. Haematologica 2016; 101:115-208. [PMID: 26819058 PMCID: PMC4938336 DOI: 10.3324/haematol.2015.136739] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 01/27/2016] [Indexed: 01/28/2023] Open
Abstract
The European Hematology Association (EHA) Roadmap for European Hematology Research highlights major achievements in diagnosis and treatment of blood disorders and identifies the greatest unmet clinical and scientific needs in those areas to enable better funded, more focused European hematology research. Initiated by the EHA, around 300 experts contributed to the consensus document, which will help European policy makers, research funders, research organizations, researchers, and patient groups make better informed decisions on hematology research. It also aims to raise public awareness of the burden of blood disorders on European society, which purely in economic terms is estimated at €23 billion per year, a level of cost that is not matched in current European hematology research funding. In recent decades, hematology research has improved our fundamental understanding of the biology of blood disorders, and has improved diagnostics and treatments, sometimes in revolutionary ways. This progress highlights the potential of focused basic research programs such as this EHA Roadmap.The EHA Roadmap identifies nine 'sections' in hematology: normal hematopoiesis, malignant lymphoid and myeloid diseases, anemias and related diseases, platelet disorders, blood coagulation and hemostatic disorders, transfusion medicine, infections in hematology, and hematopoietic stem cell transplantation. These sections span 60 smaller groups of diseases or disorders.The EHA Roadmap identifies priorities and needs across the field of hematology, including those to develop targeted therapies based on genomic profiling and chemical biology, to eradicate minimal residual malignant disease, and to develop cellular immunotherapies, combination treatments, gene therapies, hematopoietic stem cell treatments, and treatments that are better tolerated by elderly patients.
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Affiliation(s)
| | | | - Anneke Brand
- Leids Universitair Medisch Centrum, Leiden, the Netherlands
| | | | | | | | | | | | - Willem Fibbe
- Leids Universitair Medisch Centrum, Leiden, the Netherlands
| | - Tony Green
- Cambridge Institute for Medical Research, United Kingdom
| | - Fleur de Haas
- European Hematology Association, The Hague, the Netherlands
| | | | | | | | - Gilles Salles
- Hospices Civils de Lyon/Université de Lyon, Pierre-Bénite, France
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68
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Abstract
Abstract
The anemia of chronic disease is an old disease concept, but contemporary research in the role of proinflammatory cytokines and iron biology has shed new light on the pathophysiology of the condition. Recent epidemiologic studies have connected the anemia of chronic disease with critical illness, obesity, aging, and kidney failure, as well as with the well-established associations of cancer, chronic infection, and autoimmune disease. Functional iron deficiency, mediated principally by the interaction of interleukin-6, the iron regulatory hormone hepcidin, and the iron exporter ferroportin, is a major contributor to the anemia of chronic disease. Although anemia is associated with adverse outcomes, experimental models suggest that iron sequestration is desirable in the setting of severe infection. Experimental therapeutic approaches targeting interleukin-6 or the ferroportin–hepcidin axis have shown efficacy in reversing anemia in either animal models or human patients, although these agents have not yet been approved for the treatment of the anemia of chronic disease.
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[Hepcidin for iron homeostasis and target therapy in ironrelated disorders]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2015; 36:977-80. [PMID: 26632477 PMCID: PMC7342428 DOI: 10.3760/cma.j.issn.0253-2727.2015.11.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Therapeutic oligonucleotides with polyethylene glycol modifications. Future Med Chem 2015; 7:1721-31. [PMID: 26465713 DOI: 10.4155/fmc.15.94] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
In the field of oligonucleotide drugs, the attachment of PEG is a well-established strategy to prevent enzymatic degradation and avoid renal elimination. Pegaptanib and other oligonucleotides in clinical development utilize the attachment of linear or branched high molecular weight PEG chains for increase of accumulation and duration of the effect after local or systemic application. The length of PEG chains is decisive for the pharmacokinetic and pharmacodynamic effects. Longer chains increase circulation times, but generally decrease gene-silencing efficiencies for antisense and siRNA agents and binding affinities for aptamers. Shorter chains are less efficient in preventing renal filtration, but have also less impact on the gene-silencing machinery and binding kinetics.
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Darton TC, Blohmke CJ, Giannoulatou E, Waddington CS, Jones C, Sturges P, Webster C, Drakesmith H, Pollard AJ, Armitage AE. Rapidly Escalating Hepcidin and Associated Serum Iron Starvation Are Features of the Acute Response to Typhoid Infection in Humans. PLoS Negl Trop Dis 2015; 9:e0004029. [PMID: 26394303 PMCID: PMC4578949 DOI: 10.1371/journal.pntd.0004029] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 08/03/2015] [Indexed: 12/15/2022] Open
Abstract
Background Iron is a key pathogenic determinant of many infectious diseases. Hepcidin, the hormone responsible for governing systemic iron homeostasis, is widely hypothesized to represent a key component of nutritional immunity through regulating the accessibility of iron to invading microorganisms during infection. However, the deployment of hepcidin in human bacterial infections remains poorly characterized. Typhoid fever is a globally significant, human-restricted bacterial infection, but understanding of its pathogenesis, especially during the critical early phases, likewise is poorly understood. Here, we investigate alterations in hepcidin and iron/inflammatory indices following experimental human typhoid challenge. Methodology/Principal Findings Fifty study participants were challenged with Salmonella enterica serovar Typhi and monitored for evidence of typhoid fever. Serum hepcidin, ferritin, serum iron parameters, C-reactive protein (CRP), and plasma IL-6 and TNF-alpha concentrations were measured during the 14 days following challenge. We found that hepcidin concentrations were markedly higher during acute typhoid infection than at baseline. Hepcidin elevations mirrored the kinetics of fever, and were accompanied by profound hypoferremia, increased CRP and ferritin, despite only modest elevations in IL-6 and TNF-alpha in some individuals. During inflammation, the extent of hepcidin upregulation associated with the degree of hypoferremia. Conclusions/Significance We demonstrate that strong hepcidin upregulation and hypoferremia, coincident with fever and systemic inflammation, are hallmarks of the early innate response to acute typhoid infection. We hypothesize that hepcidin-mediated iron redistribution into macrophages may contribute to S. Typhi pathogenesis by increasing iron availability for macrophage-tropic bacteria, and that targeting macrophage iron retention may represent a strategy for limiting infections with macrophage-tropic pathogens such as S. Typhi. An adequate supply of iron is essential for both human hosts and their infecting pathogens. Hepcidin is the human hormone that controls the quantity and distribution of iron throughout the body. During infections, hepcidin activity may redistribute iron away from serum and into macrophages, potentially affecting pathogen replication, depending on the niche of the invading microbe. However, the involvement of hepcidin in human bacterial infections remains poorly investigated. Similarly, the pathogenesis of typhoid fever, caused by infection with Salmonella Typhi is also poorly understood. We therefore investigated the behaviour of hepcidin and other iron/inflammation-related parameters during the course of typhoid fever in human volunteers challenged experimentally with Salmonella Typhi. Hepcidin concentrations rose rapidly during acute typhoid infection, in parallel with fever. Hepcidin induction was accompanied by a rapid decline in serum iron concentrations, likely reflecting iron sequestration in macrophages (a preferred replication site of Salmonella Typhi). The extent of hepcidin upregulation associated with the extent of serum iron starvation. We hypothesize that hepcidin activity during acute typhoid infection in humans may elevate iron levels in the niche used by the pathogen for replication. Targeting macrophage iron retention should be evaluated as a potential strategy for limiting typhoid fever.
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Affiliation(s)
- Thomas C. Darton
- Oxford Vaccine Group, Centre for Clinical Vaccinology and Tropical Medicine, Department of Paediatrics, University of Oxford, and National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Christoph J. Blohmke
- Oxford Vaccine Group, Centre for Clinical Vaccinology and Tropical Medicine, Department of Paediatrics, University of Oxford, and National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Eleni Giannoulatou
- Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia
| | - Claire S. Waddington
- Oxford Vaccine Group, Centre for Clinical Vaccinology and Tropical Medicine, Department of Paediatrics, University of Oxford, and National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Claire Jones
- Oxford Vaccine Group, Centre for Clinical Vaccinology and Tropical Medicine, Department of Paediatrics, University of Oxford, and National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Pamela Sturges
- Department of Biochemistry, Birmingham Heartlands Hospital, Heart of England NHS Foundation Trust, Birmingham, United Kingdom
| | - Craig Webster
- Department of Biochemistry, Birmingham Heartlands Hospital, Heart of England NHS Foundation Trust, Birmingham, United Kingdom
| | - Hal Drakesmith
- BRC Blood Theme, NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
| | - Andrew J. Pollard
- Oxford Vaccine Group, Centre for Clinical Vaccinology and Tropical Medicine, Department of Paediatrics, University of Oxford, and National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Andrew E. Armitage
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
- * E-mail:
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Testa U, Castelli G, Elvira P. Experimental and investigational therapies for chemotherapy-induced anemia. Expert Opin Investig Drugs 2015; 24:1433-45. [PMID: 26359222 DOI: 10.1517/13543784.2015.1085505] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
INTRODUCTION In cancer patients, anemia is frequently observed, particularly as a consequence to chemotherapy (chemotherapy-induced anemia, CIA). CIA is treated with Red Blood Cell transfusions and erythropoiesis-stimulating agents (ESAs). However, the use of ESAs in anemic cancer patients is associated with reduced survival time and time to progression. Consequently, new therapeutic options are needed. AREAS COVERED In this article, the authors discuss new erythroid-enhancing agents (EEAs) that act differently to erythropoietin. Specifically, the article summarizes the early clinical development of activin antagonists (Sotatercep [ACE-011] and ACE-536) and hepcidin antagonists [NOX-H94]). EXPERT OPINION Both Activin RIIA trap agents and hepcidin inhibitors are promising new EEAs, but their safety profile, and their impact on treating CIA, needs to be carefully assessed in controlled clinical trials over longer periods of time. It is also important to carefully evaluate CIA patients to properly assess the physiopathological mechanisms responsible for the development of their anemic condition and provide patients with the most appropriate treatment plan.
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Affiliation(s)
- Ugo Testa
- a Istituto Superiore di Sanità, Department of Hematology, Oncology and Molecular Medicine , Viale Regina Elena 299, Rome, Italy
| | - Germana Castelli
- a Istituto Superiore di Sanità, Department of Hematology, Oncology and Molecular Medicine , Viale Regina Elena 299, Rome, Italy
| | - Pelosi Elvira
- a Istituto Superiore di Sanità, Department of Hematology, Oncology and Molecular Medicine , Viale Regina Elena 299, Rome, Italy
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Serum hepcidin levels predict response to intravenous iron and darbepoetin in chemotherapy-associated anemia. Blood 2015; 125:3669-71. [PMID: 26045598 DOI: 10.1182/blood-2015-03-636407] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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Abstract
Anemia in the setting of chronic inflammatory disorders is a very frequent clinical condition, which is, however, often neglected or not properly treated given the problems often caused by the diseases underlying the development of anemia. Mechanistically, anemia is mainly caused by inflammation-driven retention of iron in macrophages making the metal unavailable for heme synthesis in the course of erythropoiesis, and further by impaired biological activity of the red blood cell hormone erythropoietin and the reduced proliferative capacity of erythroid progenitor cells. Anemia can be aggravated by chronic blood loss, as found in subjects with gastrointestinal cancers, inflammatory or infectious bowel disease, or iatrogenic blood loss in the setting of dialysis, all resulting in true iron deficiency. The identification of such patients is a clinical necessity because these individuals need contrasting therapies in comparison to subjects suffering from only classical anemia of chronic disorders. The diagnosis is challenging because no state of the art laboratory test is currently available that can clearly separate patients with inflammatory anemia from those with additional true iron deficiency. However, based on our expanding knowledge on the pathophysiology of inflammatory anemia, new diagnostic markers, including the iron-regulatory hormone hepcidin, and hematologic parameters emerge. Apart from traditional anemia treatments such as blood transfusions, recombinant erythropoietin, and iron, including new high-molecular-weight formulations, new therapeutics are currently under preclinical and clinical evaluation. These novel compounds aim at correcting anemia by multiple pathways, including antagonizing the inflammation- and hepcidin-driven retention of iron in the monocyte-macrophage system and thereby promoting the supply of iron for erythropoiesis or by stimulating the endogenous formation of erythopoietin via stabilization of hypoxia-regulated factors.
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Affiliation(s)
- Guenter Weiss
- Department of Internal Medicine VI, Infectious Diseases, Immunology, Rheumatology, Pneumology, Medical University of Innsbruck, Innsbruck, Austria.
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Vater A, Klussmann S. Turning mirror-image oligonucleotides into drugs: the evolution of Spiegelmer(®) therapeutics. Drug Discov Today 2014; 20:147-55. [PMID: 25236655 DOI: 10.1016/j.drudis.2014.09.004] [Citation(s) in RCA: 167] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Revised: 08/11/2014] [Accepted: 09/08/2014] [Indexed: 12/22/2022]
Abstract
Spiegelmers are synthetic target-binding oligonucleotides built from non-natural l-nucleotides. Like aptamers, Spiegelmers fold into distinct shapes that bind the targets with high affinity and selectivity. Furthermore, the mirror-image configuration confers plasma stability and immunological passivity. Various Spiegelmers against pharmacologically attractive targets were shown to be efficacious in animal models. Three Spiegelmer candidates: emapticap pegol (NOX-E36; anti-CCL2), olaptesed pegol (NOX-A12; anti-CXCL12) and lexaptepid pegol (NOX-H94; anti-hepcidin), underwent regulatory safety studies, demonstrated good safety profiles in healthy volunteers and were taken into Phase IIa studies in patients. Proof-of-concept for emapticap pegol has recently been demonstrated in diabetic nephropathy patients. Furthermore, promising interim Phase IIa data of olaptesed pegol and lexapteptid pegol also suggest efficacy in the respective patient populations.
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Affiliation(s)
- Axel Vater
- NOXXON Pharma AG, Max-Dohrn-Strasse 8-10, 10589 Berlin, Germany.
| | - Sven Klussmann
- NOXXON Pharma AG, Max-Dohrn-Strasse 8-10, 10589 Berlin, Germany
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