1
|
Zhang Q, Ding H, Yu X, Wang Q, Li X, Zhang R, Feng J. Plasma non-transferrin-bound iron uptake by the small intestine leads to intestinal injury and intestinal flora dysbiosis in an iron overload mouse model and Caco-2 cells. SCIENCE CHINA. LIFE SCIENCES 2023; 66:2041-2055. [PMID: 37452897 DOI: 10.1007/s11427-022-2347-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 03/27/2023] [Indexed: 07/18/2023]
Abstract
Iron overload often occurs during blood transfusion and iron supplementation, resulting in the presence of non-transferrin-bound iron (NTBI) in host plasma and damage to multiple organs, but effects on the intestine have rarely been reported. In this study, an iron overload mouse model with plasma NTBI was established by intraperitoneal injection of iron dextran. We found that plasma NTBI damaged intestinal morphology, caused intestinal oxidative stress injury and reactive oxygen species (ROS) accumulation, and induced intestinal epithelial cell apoptosis. In addition, plasma NTBI increased the relative abundance of Ileibacterium and Desulfovibrio in the cecum, while the relative abundance of Faecalibaculum and Romboutsia was reduced. Ileibacterium may be a potential microbial biomarker of plasma NTBI. Based on the function prediction analysis, plasma NTBI led to the weakening of intestinal microbiota function, significantly reducing the function of the extracellular structure. Further investigation into the mechanism of injury showed that iron absorption in the small intestine significantly increased in the iron group. Caco-2 cell monolayers were used as a model of the intestinal epithelium to study the mechanism of iron transport. By adding ferric ammonium citrate (FAC, plasma NTBI in physiological form) to the basolateral side, the apparent permeability coefficient (Papp) values from the basolateral to the apical side were greater than 3×10-6 cm s-1. Intracellular ferritin level and apical iron concentration significantly increased, and SLC39A8 (ZIP8) and SLC39A14 (ZIP14) were highly expressed in the FAC group. Short hairpin RNA (shRNA) was used to knock down ZIP8 and ZIP14 in Caco-2 cells. Transfection with ZIP14-specific shRNA decreased intracellular ferritin level and inhibited iron uptake. These results revealed that plasma NTBI may cause intestinal injury and intestinal flora dysbiosis due to the uptake of plasma NTBI from the basolateral side into the small intestine, which is probably mediated by ZIP14.
Collapse
Affiliation(s)
- Qian Zhang
- Key Laboratory of Animal Feed and Nutrition of Zhejiang Province, College of Animal Sciences, Zhejiang University, Hangzhou, 310058, China
| | - Haoxuan Ding
- Key Laboratory of Animal Feed and Nutrition of Zhejiang Province, College of Animal Sciences, Zhejiang University, Hangzhou, 310058, China
| | - Xiaonan Yu
- Key Laboratory of Animal Feed and Nutrition of Zhejiang Province, College of Animal Sciences, Zhejiang University, Hangzhou, 310058, China
| | - Qiwen Wang
- Key Laboratory of Animal Feed and Nutrition of Zhejiang Province, College of Animal Sciences, Zhejiang University, Hangzhou, 310058, China
| | - Xuejiao Li
- Key Laboratory of Animal Feed and Nutrition of Zhejiang Province, College of Animal Sciences, Zhejiang University, Hangzhou, 310058, China
| | - Ruiqiang Zhang
- Key Laboratory of Animal Feed and Nutrition of Zhejiang Province, College of Animal Sciences, Zhejiang University, Hangzhou, 310058, China
| | - Jie Feng
- Key Laboratory of Animal Feed and Nutrition of Zhejiang Province, College of Animal Sciences, Zhejiang University, Hangzhou, 310058, China.
| |
Collapse
|
2
|
Singh AT, Yen TE, Mothi SS, Waikar SS, Mc Causland FR. Associations of Iron Sucrose and Intradialytic Blood Pressure. Am J Kidney Dis 2023; 81:647-654. [PMID: 36587889 PMCID: PMC10205679 DOI: 10.1053/j.ajkd.2022.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 11/02/2022] [Indexed: 12/30/2022]
Abstract
RATIONALE & OBJECTIVE Intradialytic hypotension and intradialytic hypertension are associated with morbidity and mortality in hemodialysis (HD). Many factors can contribute to intra-HD blood pressure (BP) changes, such as drugs with vasoactive properties that can destabilize an already tenuous BP. Intravenous iron sucrose is commonly administered to correct iron deficiency; however, its reported associations with altered hemodynamics have not been consistent. STUDY DESIGN Prospective cohort study. SETTING & PARTICIPANTS 950 outpatients receiving maintenance HD. EXPOSURE Iron sucrose administered during HD. OUTCOME Intradialytic hypotension, intradialytic hypertension, systolic blood pressure parameters. ANALYTICAL APPROACH Unadjusted and adjusted Poisson and linear repeated measures regression models. RESULTS The mean age of patients included in the study was 53±22 years, 43% were female, and 38% were Black. Mean pre-HD SBP was 152±26 (SD) mm Hg. At baseline, the patients who received higher doses of iron sucrose tended to have diabetes, have longer HD sessions, and have a higher frequency of erythropoiesis-stimulating agent use, compared with those who did not receive iron sucrose. In adjusted models, higher doses of iron sucrose were associated with an 11% lower rate of intradialytic hypotension (incidence rate ratio [IRR] for iron sucrose≥100mg vs 0 mg, 0.89 [95% CI, 0.85-0.94]). In adjusted analyses, the administration of higher doses of iron sucrose during HD was associated with intradialytic hypertension (IRR for iron sucrose≥100mg vs 0 mg, 1.07 [95% CI, 1.04-1.10]). LIMITATIONS Nonavailability of the precise iron sucrose formulation (volume), laboratory data for each HD session, and outpatient medications. Objective measures of volume status, home medications, and symptom data were not recorded in this study. CONCLUSIONS We observed an independent association of intravenous iron sucrose administration during HD with a lower risk of intradialytic hypotension and higher risk of intradialytic hypertension. Future studies to better understand the mechanisms underlying these associations are warranted. PLAIN-LANGUAGE SUMMARY Intradialytic hypotension and intradialytic hypertension are common among patients on hemodialysis, and they are associated with morbidity and mortality. Although many factors may contribute to these risks, medications administered during hemodialysis play an important role. We studied the significance of the intravenous iron sucrose used to treat iron deficiency and the impact it may have on blood pressure during dialysis. In our study of 950 outpatient hemodialysis patients, we observed that administration of iron sucrose was associated with higher systolic blood pressure (during and after hemodialysis sessions) as well as a lower risk of intradialytic hypotension. We also observed that higher doses of iron sucrose are associated with the development of intradialytic hypertension.
Collapse
Affiliation(s)
- Anika T Singh
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Medical School, Boston, Massachusetts.
| | - Timothy E Yen
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Medical School, Boston, Massachusetts
| | | | - Sushrut S Waikar
- Section of Nephrology, Department of Medicine, School of Medicine, and Boston Medical Center, Boston University, Boston, Massachusetts
| | - Finnian R Mc Causland
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Medical School, Boston, Massachusetts
| |
Collapse
|
3
|
Analysis of oxidative stress, inflammation and endothelial function following intravenous iron in chronic kidney disease in the Iron and Heart Trial. Sci Rep 2022; 12:6853. [PMID: 35477731 PMCID: PMC9046378 DOI: 10.1038/s41598-022-10717-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 03/30/2022] [Indexed: 11/08/2022] Open
Abstract
Iron deficiency commonly affects patients with chronic kidney disease and has an important burden in disease trajectory and quality of life; nonetheless current guidelines do not advocate treatment of iron-deficiency without anemia in this patient group. Concerns exist regarding the potential effects of intravenous iron on oxidative stress, inflammation, and endothelial function. As part of a multicenter double-blinded randomized controlled clinical trial, we examined the effects of a single dose of intravenous iron vs. placebo on biomarkers of oxidative stress, inflammation and endothelial function in non-anemic iron deficient patients (serum ferritin < 100 μg/L and/or transferrin saturation < 20%) with chronic kidney disease (stage 3b-5). Fifty-four individuals were randomized to receive ferric derisomaltose (n = 26) or placebo (n = 28). Ferric derisomaltose was associated with a non-significant decrease in mean F2-isoprostane and no effect on thiobarbituric acid reactive substances when compared to placebo throughout follow up. No effect on inflammatory markers was observed. A modest but statistically significant rise in E-selectin was noted in the intravenous iron group at 1 month and 3 month follow-up (p = 0.030 and p = 0.002 respectively). These results suggest ferric derisomaltose administration in non-dialysis dependent chronic kidney disease patients who are iron deficient does not induce prolonged oxidative stress or inflammation. Larger trials are required to quantify the benefit of intravenous iron administration in this patient group.
Collapse
|
4
|
Wang P, Guo C, Pan H, Chen W, Peng D. Iron Sucrose: A Double-Edged Sword in High Phosphate Media-Induced Vascular Calcification. Calcif Tissue Int 2021; 108:798-807. [PMID: 33439323 DOI: 10.1007/s00223-020-00804-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 12/29/2020] [Indexed: 10/22/2022]
Abstract
The high incidence of vascular calcification (VC) in patients with chronic kidney disease (CKD) has become an important clinical subject. Hyperphosphatemia is a primary cause of CKD-related VC. Intravenous iron sucrose (IS) is commonly used to treat anemia in CKD patients, and is effective and well tolerated worldwide. However, the interaction between iron and VC remains controversial, and the underlying mechanisms are yet to be clarified. In the present study, ex vivo normal rat aortic rings were cultured with various concentrations of phosphate and IS, and the levels of calcium and iron depositions, oxidative injury, as well as phenotypic marker genes were detected. To the best of our knowledge, the present study is the first to report that IS is a double-edged sword in high phosphate media-induced VC which not only alleviates VC in a dose-dependent manner but also leads to iron overload in vasculature when in high concentration. IS is a promising agent for VC prevention in patients with hyperphosphatemia and iron deficiency. Meanwhile, the appropriate blood concentration of IS in patients with hyperphosphatemia needs to be explored clinically.
Collapse
Affiliation(s)
- Ping Wang
- Nephrology Department, The First People's Hospital of Jingmen, Jingmen, 448000, Hubei, China
| | - Chengkun Guo
- Nephrology Department, The First People's Hospital of Jingmen, Jingmen, 448000, Hubei, China
| | - Hui Pan
- Nephrology Department, The First People's Hospital of Jingmen, Jingmen, 448000, Hubei, China
| | - Wangshan Chen
- Nephrology Department, The First People's Hospital of Jingmen, Jingmen, 448000, Hubei, China
| | - Dan Peng
- Neonatology Department, The First People's Hospital of Jingmen, Jingmen, 448000, Hubei, People's Republic of China.
| |
Collapse
|
5
|
Vaziri ND, Nunes ACF, Said H, Khazaeli M, Liu H, Zhao Y, Jing W, Cogburn K, Alikhani L, Lau WL. Route of intestinal absorption and tissue distribution of iron contained in the novel phosphate binder ferric citrate. Nephrol Dial Transplant 2020; 35:1136-1144. [PMID: 32514572 DOI: 10.1093/ndt/gfaa053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 01/24/2020] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Anemia of chronic kidney disease (CKD) is, in part, caused by hepcidin-mediated impaired iron absorption. However, phosphate binder, ferric citrate (FC) overcomes the CKD-induced impairment of iron absorption and increases serum iron, transferrin saturation, and iron stores and reduces erythropoietin requirements in CKD/ESRD patients. The mechanism and sites of intestinal absorption of iron contained in FC were explored here. METHODS Eight-week old rats were randomized to sham-operated or 5/6 nephrectomized (CKD) groups and fed either regular rat chow or rat chow containing 4% FC for 6 weeks. They were then euthanized, and tissues were processed for histological and biochemical analysis using Prussian blue staining, Western blot analysis to quantify intestinal epithelial tight junction proteins and real-time PCR to measure Fatty Acid receptors 2 (FFA2) and 3 (FFA3) expressions. RESULTS CKD rats exhibited hypertension, anemia, azotemia, and hyperphosphatemia. FC-treated CKD rats showed significant reductions in blood pressure, serum urea, phosphate and creatinine levels and higher serum iron and blood hemoglobin levels. This was associated with marked increase in iron content of the epithelial and subepithelial wall of the descending colon and modest iron deposits in the proximal tubular epithelial cells of their remnant kidneys. No significant difference was found in hepatic tissue iron content between untreated and FC-treated CKD or control groups. Distal colon's epithelial tight Junction proteins, Occludin, JAM-1 and ZO-1 were markedly reduced in the CKD groups. The FFA2 expression in the jejunum and FFA3 expression in the distal colon were significantly reduced in the CKD rats and markedly increased with FC administration. CONCLUSION Iron contained in the phosphate binder, FC, is absorbed by the distal colon of the CKD animals via disrupted colonic epithelial barrier and upregulation of short chain fatty acid transporters.
Collapse
Affiliation(s)
- Nosratola D Vaziri
- Division of Nephrology, University of California Irvine, Irvine, CA, USA
| | - Ane C F Nunes
- Division of Nephrology, University of California Irvine, Irvine, CA, USA
| | - Hyder Said
- School of Medicine, University of California Irvine, Irvine, CA, USA
| | - Mahyar Khazaeli
- Division of Nephrology, University of California Irvine, Irvine, CA, USA
| | - Han Liu
- Division of Nephrology, University of California Irvine, Irvine, CA, USA
| | - Yitong Zhao
- Division of Nephrology, University of California Irvine, Irvine, CA, USA
| | - Wanghui Jing
- Division of Nephrology, University of California Irvine, Irvine, CA, USA.,School of Pharmacy, Xi'an Jiaotong University, Xi'an, PR China
| | - Kyle Cogburn
- School of Pharmacy, Xi'an Jiaotong University, Xi'an, PR China
| | - Leila Alikhani
- Division of Nephrology, University of California Irvine, Irvine, CA, USA
| | - Wei Ling Lau
- Division of Nephrology, University of California Irvine, Irvine, CA, USA
| |
Collapse
|
6
|
Neu HM, Alexishin SA, Brandis JEP, Williams AMC, Li W, Sun D, Zheng N, Jiang W, Zimrin A, Fink JC, Polli JE, Kane MA, Michel SLJ. Snapshots of Iron Speciation: Tracking the Fate of Iron Nanoparticle Drugs via a Liquid Chromatography-Inductively Coupled Plasma-Mass Spectrometric Approach. Mol Pharm 2019; 16:1272-1281. [PMID: 30676753 DOI: 10.1021/acs.molpharmaceut.8b01215] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Nanomedicines are nanoparticle-based therapeutic or diagnostic agents designed for targeted delivery or enhanced stability. Nanotechnology has been successfully employed to develop various drug formulations with improved pharmacokinetic characteristics, and current research efforts are focused on the development of new innovator and generic nanomedicines. Nanomedicines, which are often denoted as complex or nonbiological complex drugs, have inherently different physicochemical and pharmacokinetic properties than conventional small molecule drugs. The tools necessary to fully evaluate nanomedicines in clinical settings are limited, which can hamper their development. One of the most successful families of nanomedicines are iron-carbohydrate nanoparticles, which are administered intravenously (IV) to treat iron-deficiency anemia. In the U.S., the FDA has approved six distinct iron-carbohydrate nanoparticles but only one generic version (sodium ferric gluconate for Ferrlecit). There is significant interest in approving additional generic iron-carbohydrate drugs; however, the lack of a direct method to monitor the fate of the iron nanoparticles in clinical samples has impeded this approval. Herein we report a novel liquid chromatography-inductively coupled plasma-mass spectrometry (LC-ICP-MS) method that allows for the direct quantification of the iron-carbohydrate drugs in clinical samples, while simultaneously measuring the speciation of the iron released from the nanoparticles in biological samples. To our knowledge, this is the first time that iron nanoparticles have been observed in clinical samples, opening the door for direct pharmacokinetic studies of this family of drugs. This method has potential applications not only for iron-nanoparticle drugs but also for any nanomedicine with an inorganic component.
Collapse
Affiliation(s)
- Heather M Neu
- Department of Pharmaceutical Sciences , University of Maryland School of Pharmacy , Baltimore , Maryland 21201 , United States
| | - Sergei A Alexishin
- Department of Pharmaceutical Sciences , University of Maryland School of Pharmacy , Baltimore , Maryland 21201 , United States
| | - Joel E P Brandis
- Department of Pharmaceutical Sciences , University of Maryland School of Pharmacy , Baltimore , Maryland 21201 , United States
| | - Anne M C Williams
- Department of Pharmaceutical Sciences , University of Maryland School of Pharmacy , Baltimore , Maryland 21201 , United States
| | - Wenjing Li
- Department of Pharmaceutical Sciences , University of Maryland School of Pharmacy , Baltimore , Maryland 21201 , United States
| | - Dajun Sun
- Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research , U.S. Food and Drug Administration , Silver Spring , Maryland 20993 , United States
| | - Nan Zheng
- Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research , U.S. Food and Drug Administration , Silver Spring , Maryland 20993 , United States
| | - Wenlei Jiang
- Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research , U.S. Food and Drug Administration , Silver Spring , Maryland 20993 , United States
| | - Ann Zimrin
- Oncology Program , University of Maryland School of Medicine , Baltimore , Maryland 21201 , United States
| | - Jeffrey C Fink
- Department of Medicine , University of Maryland School of Medicine , Baltimore , Maryland 21201 , United States
| | - James E Polli
- Department of Pharmaceutical Sciences , University of Maryland School of Pharmacy , Baltimore , Maryland 21201 , United States
| | - Maureen A Kane
- Department of Pharmaceutical Sciences , University of Maryland School of Pharmacy , Baltimore , Maryland 21201 , United States
| | - Sarah L J Michel
- Department of Pharmaceutical Sciences , University of Maryland School of Pharmacy , Baltimore , Maryland 21201 , United States
| |
Collapse
|
7
|
Santos-Silva A, Ribeiro S, Reis F, Belo L. Hepcidin in chronic kidney disease anemia. VITAMINS AND HORMONES 2019; 110:243-264. [PMID: 30798815 DOI: 10.1016/bs.vh.2019.01.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Chronic kidney disease (CKD) is associated with several complications that worsen with progression of disease; anemia, disturbances in iron metabolism and inflammation are common features. Inflammatory response starts early, releasing pro-inflammatory cytokines, acute phase reactants and hepcidin. Hepcidin production is modulated by several factors, as hypoxia/anemia, erythropoietin and erythropoiesis products, transferrin saturation (TSAT) and liver iron levels, which are altered in CKD. Treatment of CKD anemia is based on pharmaceutical intervention, with erythropoietic stimulating agents and/or iron supplementation; however, in spite of the erythropoietic benefits, this therapy, on a regular basis, involves risks, namely iron overload. To overcome these risks, some therapeutic approaches are under study to target CKD anemia. Considering the actual alerts about risk of iron overload in dialysis patients, inhibition of hepcidin, the central key player in iron homeostasis, could be a pivotal strategy in the management of CKD anemia.
Collapse
Affiliation(s)
- Alice Santos-Silva
- UCIBIO\REQUIMTE, Laboratory of Biochemistry, Department of Biological Sciences, Faculty of Pharmacy, University of Porto, Porto, Portugal.
| | - Sandra Ribeiro
- UCIBIO\REQUIMTE, Laboratory of Biochemistry, Department of Biological Sciences, Faculty of Pharmacy, University of Porto, Porto, Portugal
| | - Flávio Reis
- Institute of Pharmacology & Experimental Therapeutics, Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, CNC.IBILI Consortium & CIBB Consortium, University of Coimbra, Coimbra, Portugal
| | - Luís Belo
- UCIBIO\REQUIMTE, Laboratory of Biochemistry, Department of Biological Sciences, Faculty of Pharmacy, University of Porto, Porto, Portugal
| |
Collapse
|
8
|
Abstract
There are several options available for intravenous application of iron supplements, but they all have a similar structure:—an iron core surrounded by a carbohydrate coating. These nanoparticles require processing by the reticuloendothelial system to release iron, which is subsequently picked up by the iron-binding protein transferrin and distributed throughout the body, with most of the iron supplied to the bone marrow. This process risks exposing cells and tissues to free iron, which is potentially toxic due to its high redox activity. A new parenteral iron formation, ferric pyrophosphate citrate (FPC), has a novel structure that differs from conventional intravenous iron formulations, consisting of an iron atom complexed to one pyrophosphate and two citrate anions. In this study, we show that FPC can directly transfer iron to apo-transferrin. Kinetic analyses reveal that FPC donates iron to apo-transferrin with fast binding kinetics. In addition, the crystal structure of transferrin bound to FPC shows that FPC can donate iron to both iron-binding sites found within the transferrin structure. Examination of the iron-binding sites demonstrates that the iron atoms in both sites are fully encapsulated, forming bonds with amino acid side chains in the protein as well as pyrophosphate and carbonate anions. Taken together, these data demonstrate that, unlike intravenous iron formulations, FPC can directly and rapidly donate iron to transferrin in a manner that does not expose cells and tissues to the damaging effects of free, redox-active iron.
Collapse
|
9
|
Pai AB, Pai MP, Meyer DE, Bales BC, Cotero VE, Zheng N, Jiang W. In vitro and in vivo DFO-chelatable labile iron release profiles among commercially available intravenous iron nanoparticle formulations. Regul Toxicol Pharmacol 2018; 97:17-23. [PMID: 29857115 DOI: 10.1016/j.yrtph.2018.05.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 05/19/2018] [Accepted: 05/28/2018] [Indexed: 12/26/2022]
Abstract
Intravenous (IV) iron formulations are complex colloidal suspensions of iron oxide nanoparticles. Small changes in formulation can allow more labile iron to be released after injection causing toxicity. Thus, bioequivalence (BE) evaluation of generic IV iron formulations remains challenging. We evaluated labile iron release in vitro and in vivo using a high performance liquid chromatography chelatable iron assay to develop a relational model to support BE. In vitro labile iron release and in vivo labile iron pharmacokinetics were evaluated for Venofer®, Ferrlecit®, generic sodium ferric gluconate complex, InFeD®, Feraheme® and a pre-clinical formulation GE121333. Labile iron release profiles were studied in vitro in 150 mM saline and a biorelevant matrix (rat serum) at 0.952 mgFe/mL. In vivo plasma labile iron concentration-time profiles (t0-240 min) were studied in rats after a 40 mgFe/kg IV dose. In vitro labile iron release in saline was significantly higher compared to rat serum, especially with InFeD®. An in vitro release constant (iKr) was calculated which correlated well with maximal plasma concentrations in the in vivo rat PK model (R2 = 0.711). These data suggest an in vitro to in vivo correlation model of labile iron release kinetics could be applied to BE. Other generic IV iron formulations need to be studied to validate this model.
Collapse
Affiliation(s)
- Amy Barton Pai
- University of Michigan College of Pharmacy, 428 Church Street, Ann Arbor, MI, 48109, USA.
| | - Manjunath P Pai
- University of Michigan College of Pharmacy, 428 Church Street, Ann Arbor, MI, 48109, USA
| | - Dan E Meyer
- General Electric Global Research Center, 1 Research Circle, Niskayuna, NY, 12309, USA
| | - Brian C Bales
- General Electric Global Research Center, 1 Research Circle, Niskayuna, NY, 12309, USA
| | - Victoria E Cotero
- General Electric Global Research Center, 1 Research Circle, Niskayuna, NY, 12309, USA
| | - Nan Zheng
- Food and Drug Administration, Office of Generic Drugs, 10903 New Hampshire Avenue, Silver Spring, MD, 20903, USA
| | - Wenlei Jiang
- Food and Drug Administration, Office of Generic Drugs, 10903 New Hampshire Avenue, Silver Spring, MD, 20903, USA
| |
Collapse
|
10
|
Shah A, Mankus CI, Vermilya AM, Soheilian F, Clogston JD, Dobrovolskaia MA. Feraheme® suppresses immune function of human T lymphocytes through mitochondrial damage and mitoROS production. Toxicol Appl Pharmacol 2018; 350:52-63. [PMID: 29715466 DOI: 10.1016/j.taap.2018.04.028] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Revised: 04/19/2018] [Accepted: 04/20/2018] [Indexed: 12/31/2022]
Abstract
Despite attractive properties for both therapeutic and diagnostic applications, the clinical use of iron oxide nanoparticles (IONPs) is limited to iron replacement in severely anemic patient populations. While several studies have reported about the immunotoxicity of IONPs, the mechanisms of this toxicity are mostly unknown. We conducted a mechanistic investigation using an injectable form of IONP, Feraheme®. In the cultures of primary human T cells, Feraheme induced miotochondrial oxidative stress and resulted in changes in mitochondrial dynamics, architecture, and membrane potential. These molecular events were responsible for the decrease in cytokine production and proliferation of mitogen-activated T cells. The induction of mitoROS by T cells in response to Feraheme was insufficient to induce total redox imbalance at the cellular level. Consequently, we resolved this toxicity by the addition of the mitochondria-specific antioxidant MitoTEMPO. We further used these findings to develop an experimental framework consisting of critical assays that can be used to estimate IONP immunotoxicity. We explored this framework using several immortalized T-cell lines and found that none of them recapitulate the toxicity observed in the primary cells. Next, we compared the immunotoxicity of Feraheme to that of other FDA-approved iron-containing complex drug formulations and found that the mitochondrial damage and the resulting suppression of T-cell function are specific to Feraheme. The framework, therefore, can be used for comparing the immunotoxicity of Feraheme with that of its generic versions, while other iron-based complex drugs require case-specific mechanistic investigation.
Collapse
Affiliation(s)
- Ankit Shah
- Nanotechnology Characterization Laboratory, Cancer Research Technology Program, Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, MD 21702, USA
| | - Cassandra I Mankus
- Nanotechnology Characterization Laboratory, Cancer Research Technology Program, Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, MD 21702, USA
| | - Alison M Vermilya
- Nanotechnology Characterization Laboratory, Cancer Research Technology Program, Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, MD 21702, USA
| | - Ferri Soheilian
- Electron Microscopy Laboratory, Leidos Biomedical Research, Inc, Frederick National Laboratory for Cancer Research, Frederick, MD 21702, USA
| | - Jeffrey D Clogston
- Nanotechnology Characterization Laboratory, Cancer Research Technology Program, Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, MD 21702, USA
| | - Marina A Dobrovolskaia
- Nanotechnology Characterization Laboratory, Cancer Research Technology Program, Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, MD 21702, USA.
| |
Collapse
|
11
|
Pai AB. Complexity of intravenous iron nanoparticle formulations: implications for bioequivalence evaluation. Ann N Y Acad Sci 2017; 1407:17-25. [PMID: 29027212 DOI: 10.1111/nyas.13461] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 08/02/2017] [Accepted: 08/07/2017] [Indexed: 01/21/2023]
Abstract
Intravenous iron formulations are a class of complex drugs that are commonly used to treat a wide variety of disease states associated with iron deficiency and anemia. Venofer® (iron-sucrose) is one of the most frequently used formulations, with more than 90% of dialysis patients in the United States receiving this formulation. Emerging data from global markets outside the United States, where many iron-sucrose similars or copies are available, have shown that these formulations may have safety and efficacy profiles that differ from the reference listed drug. This may be attributable to uncharacterized differences in physicochemical characteristics and/or differences in labile iron release. As bioequivalence evaluation guidance evolves, clinicians should be educated on these potential clinical issues before a switch to the generic formulation is made in the clinical setting.
Collapse
Affiliation(s)
- Amy Barton Pai
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, Michigan
| |
Collapse
|
12
|
Suffredini DA, Xu W, Sun J, Barea-Mendoza J, Solomon SB, Brashears SL, Perlegas A, Kim-Shapiro DB, Klein HG, Natanson C, Cortés-Puch I. Parenteral irons versus transfused red blood cells for treatment of anemia during canine experimental bacterial pneumonia. Transfusion 2017; 57:2338-2347. [PMID: 28656646 DOI: 10.1111/trf.14214] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 05/09/2017] [Accepted: 05/09/2017] [Indexed: 01/28/2023]
Abstract
BACKGROUND No studies have been performed comparing intravenous (IV) iron with transfused red blood cells (RBCs) for treating anemia during infection. In a previous report, transfused older RBCs increased free iron release and mortality in infected animals when compared to fresher cells. We hypothesized that treating anemia during infection with transfused fresh RBCs, with minimal free iron release, would prove superior to IV iron therapy. STUDY DESIGN AND METHODS Purpose-bred beagles (n = 42) with experimental Staphylococcus aureus pneumonia rendered anemic were randomized to be transfused RBCs stored for 7 days or one of two IV iron preparations (7 mg/kg), iron sucrose, a widely used preparation, or ferumoxytol, a newer formulation that blunts circulating iron levels. RESULTS Both irons increased the alveolar-arterial oxygen gradient at 24 to 48 hours (p = 0.02-0.001), worsened shock at 16 hours (p = 0.02-0.003, respectively), and reduced survival (transfusion 56%; iron sucrose 8%, p = 0.01; ferumoxytol 9%, p = 0.04). Compared to fresh RBC transfusion, plasma iron measured by non-transferrin-bound iron levels increased with iron sucrose at 7, 10, 13, 16, 24, and 48 hours (p = 0.04 to p < 0.0001) and ferumoxytol at 7, 24, and 48 hours (p = 0.04 to p = 0.004). No significant differences in cardiac filling pressures or performance, hemoglobin (Hb), or cell-free Hb were observed. CONCLUSIONS During canine experimental bacterial pneumonia, treatment of mild anemia with IV iron significantly increased free iron levels, shock, lung injury, and mortality compared to transfusion of fresh RBCs. This was true for iron preparations that do or do not blunt circulating free iron level elevations. These findings suggest that treatment of anemia with IV iron during infection should be undertaken with caution.
Collapse
Affiliation(s)
- Dante A Suffredini
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Wanying Xu
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Junfeng Sun
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Jesús Barea-Mendoza
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Steven B Solomon
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Samuel L Brashears
- Department of Physics and the Translational Science Center, Wake Forest University, Winston-Salem, North Carolina
| | - Andreas Perlegas
- Department of Physics and the Translational Science Center, Wake Forest University, Winston-Salem, North Carolina
| | - Daniel B Kim-Shapiro
- Department of Physics and the Translational Science Center, Wake Forest University, Winston-Salem, North Carolina
| | - Harvey G Klein
- Department of Transfusion Medicine, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Charles Natanson
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Irene Cortés-Puch
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| |
Collapse
|
13
|
Kawano T, Kuji T, Fujikawa T, Ueda E, Shino M, Yamaguchi S, Ohnishi T, Tamura K, Hirawa N, Toya Y. Timing-adjusted iron dosing enhances erythropoiesis-stimulating agent-induced erythropoiesis response and iron utilization. RENAL REPLACEMENT THERAPY 2017. [DOI: 10.1186/s41100-017-0103-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
|
14
|
Macdougall IC, Bock AH, Carrera F, Eckardt KU, Gaillard C, Van Wyck D, Meier Y, Larroque S, Roger SD. Renal function in patients with non-dialysis chronic kidney disease receiving intravenous ferric carboxymaltose: an analysis of the randomized FIND-CKD trial. BMC Nephrol 2017; 18:24. [PMID: 28095881 PMCID: PMC5240256 DOI: 10.1186/s12882-017-0444-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 01/10/2017] [Indexed: 12/04/2022] Open
Abstract
Background Preclinical studies demonstrate renal proximal tubular injury after administration of some intravenous iron preparations but clinical data on renal effects of intravenous iron are sparse. Methods FIND-CKD was a 56-week, randomized, open-label, multicenter study in which patients with non-dialysis dependent chronic kidney disease (ND-CKD), anemia and iron deficiency without erythropoiesis-stimulating agent therapy received intravenous ferric carboxymaltose (FCM), targeting either higher (400–600 μg/L) or lower (100–200 μg/L) ferritin values, or oral iron. Results Mean (SD) eGFR at baseline was 34.9 (11.3), 32.8 (10.8) and 34.2 (12.3) mL/min/1.73 m2 in the high ferritin FCM (n = 97), low ferritin FCM (n = 89) and oral iron (n = 167) groups, respectively. Corresponding values at month 12 were 35.6 (13.8), 32.1 (12.7) and 33.4 (14.5) mL/min/1.73 m2. The pre-specified endpoint of mean (SE) change in eGFR from baseline to month 12 was +0.7 (0.9) mL/min/1.73 m2 with high ferritin FCM (p = 0.15 versus oral iron), -0.9 (0.9) mL/min/1.73 m2 with low ferritin FCM (p = 0.99 versus oral iron) and -0.9 (0.7) mL/min/1.73 m2 with oral iron. No significant association was detected between quartiles of FCM dose, change in ferritin or change in TSAT versus change in eGFR. Dialysis initiation was similar between groups. Renal adverse events were rare, with no indication of between-group differences. Conclusion Intravenous FCM at doses that maintained ferritin levels of 100–200 μg/L or 400–600 μg/L did not negatively impact renal function (eGFR) in patients with ND-CKD over 12 months versus oral iron, and eGFR remained stable. These findings show no evidence of renal toxicity following intravenous FCM over a 1-year period. Trial registrations ClinicalTrials.gov NCT00994318 (first registration 12 October 2009). Electronic supplementary material The online version of this article (doi:10.1186/s12882-017-0444-6) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Iain C Macdougall
- Department of Renal Medicine, King's College Hospital, Denmark Hill, London, SE5 9RS, UK.
| | - Andreas H Bock
- Department of Nephrology, Kantonsspital Aarau, Aarau, Switzerland
| | | | - Kai-Uwe Eckardt
- Department of Nephrology and Hypertension, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Carlo Gaillard
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | | | | | | | | |
Collapse
|
15
|
Pratt RD, Swinkels DW, Ikizler TA, Gupta A. Pharmacokinetics of Ferric Pyrophosphate Citrate, a Novel Iron Salt, Administered Intravenously to Healthy Volunteers. J Clin Pharmacol 2016; 57:312-320. [PMID: 27557937 PMCID: PMC5324677 DOI: 10.1002/jcph.819] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 08/19/2016] [Indexed: 01/01/2023]
Abstract
Ferric pyrophosphate citrate (Triferic) is a water-soluble iron salt that is administered via dialysate to maintain iron balance and hemoglobin in hemodialysis patients. This double-blind, randomized, placebo-controlled, single-, ascending-dose study was conducted to evaluate the pharmacokinetics and safety of intravenous ferric pyrophosphate citrate in 48 healthy iron-replete subjects (drug, n = 36; placebo, n = 12). Single doses of 2.5, 5.0, 7.5, or 10 mg of ferric pyrophosphate citrate or placebo were administered over 4 hours, and single doses of 15 or 20 mg of ferric pyrophosphate citrate or placebo were administered over 12 hours via intravenous infusion. Serum total iron (sFetot ), transferrin-bound iron (TBI), hepcidin-25, and biomarkers of oxidative stress and inflammation were determined using validated assays. Marked diurnal variation in sFetot was observed in placebo-treated subjects. Concentrations of sFetot and TBI increased rapidly after drug administration, with maximum serum concentrations (Cmax ) reached at the end of infusion. Increases in baseline-corrected Cmax and area under the concentration-time curve from 0 to the time of the last quantifiable concentration (AUC0-t ) were dose proportional up to 100% transferrin saturation. Iron was rapidly cleared (apparent terminal phase half-life 1.2-2 hours). No significant changes from baseline in serum hepcidin-25 concentration were observed at end of infusion for any dose. Biomarkers of oxidative stress and inflammation were unaffected. Intravenous doses of ferric pyrophosphate citrate were well tolerated. These results demonstrate that intravenous ferric pyrophosphate citrate is rapidly bound to transferrin and cleared from the circulation without increasing serum hepcidin levels or biomarkers of oxidative stress or inflammation.
Collapse
Affiliation(s)
| | - Dorine W Swinkels
- Laboratory Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - T Alp Ikizler
- Division of Nephrology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ajay Gupta
- Rockwell Medical, Inc, Wixom, MI, USA.,Division of Nephrology, University of California Irvine, Orange, CA, USA
| |
Collapse
|
16
|
Does IV Iron Induce Plasma Oxidative Stress in Critically Ill Patients? A Comparison With Healthy Volunteers. Crit Care Med 2016; 44:521-30. [PMID: 26605680 DOI: 10.1097/ccm.0000000000001420] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare the oxidative stress induced by IV iron infusion in critically ill patients and in healthy volunteers. DESIGN Multicenter, interventional study. SETTING Two ICUs and one clinical research center. SUBJECTS Anemic critically ill patients treated with IV iron and healthy volunteers. INTERVENTIONS IV infusion of 100 mg of iron sucrose. MEASUREMENTS AND MAIN RESULTS Thirty-eight anemic patients (hemoglobin, median [interquartile range] = 8.4 g/dL [7.7-9.2]) (men, 25 [66%]; aged 68 yr [48-77]; Simplified Acute Physiology Score II, 48.5 [39-59]) and 39 healthy volunteers (men, 18 [46%]; aged 42.1 yr [29-50]) were included. Blood samples were drawn before (H0) and 2, 6, and 24 hours (H2, H6, and H24) after a 60-minute iron infusion for the determination of nontransferrin bound iron, markers of lipid peroxidation-8α-isoprostanes, protein oxidation-advanced oxidized protein product, and glutathione reduced/oxidized. Iron infusion had no effect on hemodynamic parameter in patients and volunteers. At baseline, patients had much higher interleukin-6, C-reactive protein, and hepcidin levels. 8α-isoprostanes was also higher in patients at baseline (8.5 pmol/L [6.5-12.9] vs 4.6 pmol/L [3.5-5.5]), but the area under the curve above baseline from H0 to H6 was not different (p = 0.38). Neither was it for advanced oxidized protein product and nontransferrin bound iron. The area under the curve above baseline from H0 to H6 (glutathione reduced/oxidized) was lower in volunteers (p = 0.009). Eight patients had a second set of dosages (after the fourth iron infusion), showing higher increase in 8α-isoprostanes. CONCLUSIONS In our observation, IV iron infusion does not induce more nontransferrin bound iron, lipid, or protein oxidation in patients compared with volunteers, despite higher inflammation, oxidative stress, and hepcidin levels and lower antioxidant at baseline. In contrary, iron induces a greater decrease in antioxidant, compatible with higher oxidative stress in volunteers than in critically ill patients.
Collapse
|
17
|
Locatelli F, Mazzaferro S, Yee J. Iron Therapy Challenges for the Treatment of Nondialysis CKD Patients. Clin J Am Soc Nephrol 2016; 11:1269-1280. [PMID: 27185524 PMCID: PMC4934828 DOI: 10.2215/cjn.00080116] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The clinical consequences of untreated, severe anemia in patients with nondialysis CKD can be significant, but disparities exist in the anemia treatment guidelines and position papers issued from working groups and associations across the world. These differ in hemoglobin target and iron levels and their emphasis on various iron markers and other clinical outcomes. Not surprisingly, disparities are observed in anemia treatment strategies among patients with nondialysis CKD across different areas of the world. Over the past decade, the prescription and dosage of both iron therapies and erythropoiesis-stimulating agents have shifted, with notable regional differences observed. Moreover, there is ongoing debate regarding oral versus intravenous administration of iron. Compared with oral iron therapy, which often leads to gastrointestinal adverse events, low patient adherence, and low efficacy, intravenous iron administration has been associated with potential serious adverse events, such as anaphylaxis. New iron-based compounds and drugs currently under development are reviewed to describe their potential benefits in the treatment of anemia in patients with CKD. New oral compounds, including iron-based phosphate binders, heme iron polypeptide, and liposomal iron, show different rates of absorption with possibly different efficacy and improved tolerability. These new potential therapies offer health care providers additional anemia treatment options for their patients with CKD; however, the management of anemia in the CKD population continues to present challenges that require prospective studies to identify the optimal iron therapy for patients.
Collapse
Affiliation(s)
- Francesco Locatelli
- Department of Nephrology, Dialysis and Transplantation, Alessandro Manzoni Hospital, Lecco, Italy
| | - Sandro Mazzaferro
- Department of Cardiovascular, Respiratory, Nephrologic and Geriatric Sciences, Sapienza University, Rome, Italy; and
| | - Jerry Yee
- Division of Nephrology and Hypertension, Henry Ford Hospital, Detroit, Michigan
| |
Collapse
|
18
|
Fell LH, Seiler-Mußler S, Sellier AB, Rotter B, Winter P, Sester M, Fliser D, Heine GH, Zawada AM. Impact of individual intravenous iron preparations on the differentiation of monocytes towards macrophages and dendritic cells. Nephrol Dial Transplant 2016; 31:1835-1845. [PMID: 27190361 PMCID: PMC5091613 DOI: 10.1093/ndt/gfw045] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 02/10/2016] [Indexed: 12/16/2022] Open
Abstract
Background Treatment of iron deficiency with intravenous (i.v.) iron is a first-line strategy to improve anaemia of chronic kidney disease. Previous in vitro experiments demonstrated that different i.v. iron preparations inhibit differentiation of haematopoietic stem cells to monocytes, but their effect on monocyte differentiation to macrophages and mature dendritic cells (mDCs) has not been assessed. We investigated substance-specific effects of iron sucrose (IS), sodium ferric gluconate (SFG), ferric carboxymaltose (FCM) and iron isomaltoside 1000 (IIM) on monocytic differentiation to M1/M2 macrophages and mDCs. Methods Via flow cytometry and microRNA (miRNA) expression analysis, we morphologically and functionally characterized monocyte differentiation to M1/M2 macrophages and mDCs after monocyte stimulation with IS, SFG, FCM and IIM (0.133, 0.266 and 0.533 mg/mL, respectively). To assess potential clinical implications, we compared monocytic phagocytosis capacity in dialysis patients who received either 500 mg IS or IIM. Results Phenotypically, IS and SFG dysregulated the expression of macrophage (e.g. CD40, CD163) and mDC (e.g. CD1c, CD141) surface markers. Functionally, IS and SFG impaired macrophage phagocytosis capacity. Phenotypic and functional alterations were less pronounced with FCM, and virtually absent with IIM. In miRNA expression analysis of mDCs, IS dysregulated miRNAs such as miR-146b-5p and miR-155-5p, which are linked to Toll-like receptor and mitogen-activated protein kinase signalling pathways. In vivo, IS reduced monocytic phagocytosis capacity within 1 h after infusion, while IIM did not. Conclusions This study demonstrates that less stable i.v. iron preparations specifically affect monocyte differentiation towards macrophages and mDCs.
Collapse
Affiliation(s)
- Lisa H Fell
- Department of Internal Medicine IV - Nephrology and Hypertension, Saarland University Medical Center, Homburg, Germany
| | - Sarah Seiler-Mußler
- Department of Internal Medicine IV - Nephrology and Hypertension, Saarland University Medical Center, Homburg, Germany
| | - Alexander B Sellier
- Department of Internal Medicine IV - Nephrology and Hypertension, Saarland University Medical Center, Homburg, Germany
| | | | | | - Martina Sester
- Department of Transplant and Infection Immunology, Saarland University Medical Center, Homburg, Germany
| | - Danilo Fliser
- Department of Internal Medicine IV - Nephrology and Hypertension, Saarland University Medical Center, Homburg, Germany
| | - Gunnar H Heine
- Department of Internal Medicine IV - Nephrology and Hypertension, Saarland University Medical Center, Homburg, Germany
| | - Adam M Zawada
- Department of Internal Medicine IV - Nephrology and Hypertension, Saarland University Medical Center, Homburg, Germany
| |
Collapse
|
19
|
|
20
|
Macdougall IC, Bircher AJ, Eckardt KU, Obrador GT, Pollock CA, Stenvinkel P, Swinkels DW, Wanner C, Weiss G, Chertow GM, Adamson JW, Akizawa T, Anker SD, Auerbach M, Bárány P, Besarab A, Bhandari S, Cabantchik I, Collins AJ, Coyne DW, de Francisco ÁL, Fishbane S, Gaillard CA, Ganz T, Goldsmith DJ, Hershko C, Jankowska EA, Johansen KL, Kalantar-Zadeh K, Kalra PA, Kasiske BL, Locatelli F, Małyszko J, Mayer G, McMahon LP, Mikhail A, Nemeth E, Pai AB, Parfrey PS, Pecoits-Filho R, Roger SD, Rostoker G, Rottembourg J, Singh AK, Slotki I, Spinowitz BS, Tarng DC, Tentori F, Toblli JE, Tsukamoto Y, Vaziri ND, Winkelmayer WC, Wheeler DC, Zakharova E. Iron management in chronic kidney disease: conclusions from a “Kidney Disease: Improving Global Outcomes” (KDIGO) Controversies Conference. Kidney Int 2016; 89:28-39. [DOI: 10.1016/j.kint.2015.10.002] [Citation(s) in RCA: 167] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 09/22/2015] [Accepted: 09/29/2015] [Indexed: 12/21/2022]
|
21
|
Nakamura K, Kawakami T, Yamamoto N, Tomizawa M, Fujiwara T, Ishii T, Harigae H, Ogasawara K. Activation of the NLRP3 inflammasome by cellular labile iron. Exp Hematol 2015; 44:116-24. [PMID: 26577567 DOI: 10.1016/j.exphem.2015.11.002] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 10/28/2015] [Accepted: 11/01/2015] [Indexed: 01/17/2023]
Abstract
Cellular labile iron, which contains chelatable redox-active Fe(2+), has been implicated in iron-mediated cellular toxicity leading to multiple organ dysfunction. Iron homeostasis is controlled by monocytes/macrophages through their iron recycling and storage capacities. Furthermore, iron sequestration by monocytes/macrophages is regulated by pro-inflammatory cytokines including interleukin-1, highlighting the importance of these cells in the crosstalk between inflammation and iron homeostasis. However, a role for cellular labile iron in monocyte/macrophage-mediated inflammatory responses has not been defined. Here we describe how cellular labile iron activates the NLRP3 inflammasome in human monocytes. Stimulation of lipopolysaccharide-primed peripheral blood mononuclear cells with ferric ammonium citrate increases the level of cellular Fe(2+) levels in monocytes and induces production of interleukin-1β in a dose-dependent manner. This ferric ammonium citrate-induced interleukin-1β production is dependent on caspase-1 and is significantly inhibited by an Fe(2+)-specific chelator. Ferric ammonium citrate consistently induced interleukin-1β secretion in THP1 cells, but not in NLRP3-deficient THP1 cells, indicating a requirement for the NLRP3 inflammasome. Additionally, activation of the inflammasome is mediated by potassium efflux, reactive oxygen species-mediated mitochondrial dysfunction, and lysosomal membrane permeabilization. Thus, these results suggest that monocytes/macrophages not only sequestrate iron during inflammation, but also mediate inflammation in response to cellular labile iron, which provides novel insights into the role of iron in chronic inflammation.
Collapse
Affiliation(s)
- Kyohei Nakamura
- Department of Immunobiology, Institute of Development, Aging, and Cancer, Tohoku University, Sendai, Japan; Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Toru Kawakami
- Department of Immunobiology, Institute of Development, Aging, and Cancer, Tohoku University, Sendai, Japan; Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan
| | - Naoki Yamamoto
- Department of Immunobiology, Institute of Development, Aging, and Cancer, Tohoku University, Sendai, Japan
| | - Miyu Tomizawa
- Department of Immunobiology, Institute of Development, Aging, and Cancer, Tohoku University, Sendai, Japan
| | - Tohru Fujiwara
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Tomonori Ishii
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hideo Harigae
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kouetsu Ogasawara
- Department of Immunobiology, Institute of Development, Aging, and Cancer, Tohoku University, Sendai, Japan.
| |
Collapse
|
22
|
Agüera ML, Martin-Malo A, Alvarez-Lara MA, Garcia-Montemayor VE, Canton P, Soriano S, Aljama P. Efficiency of Original versus Generic Intravenous Iron Formulations in Patients on Haemodialysis. PLoS One 2015; 10:e0135967. [PMID: 26322790 PMCID: PMC4555833 DOI: 10.1371/journal.pone.0135967] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2015] [Accepted: 07/28/2015] [Indexed: 01/04/2023] Open
Abstract
AIMS The appropriate use of intravenous (i.v.) iron is essential to minimise the requirements for erythropoiesis-stimulating agents (ESAs). The clinical efficacy of generic i.v. iron compared to the original formulation is controversial. We evaluated the changes that were induced after switching from a generic i.v. iron to an original formulation in a stable, prevalent haemodialysis (HD) population. METHODS A total of 342 patients were included, and the follow-up period was 56 weeks for each formulation. Anaemia parameters and doses of ESA and i.v. iron were prospectively recorded before and after the switch from generic to original i.v. iron. RESULTS To maintain the same haemoglobin (Hb) levels after switching from the generic to the original formulation, the requirements for i.v. iron doses were reduced by 34.3% (from 52.8±33.9 to 34.7±31.8 mg/week, p<0.001), and the ESA doses were also decreased by 12.5% (from 30.6±23.6 to 27±21 μg/week, p<0.001). The erythropoietin resistance index declined from 8.4±7.7 to 7.4±6.7 IU/kg/week/g/dl after the switch from the generic to the original drug (p = 0.001). After the switch, the transferrin saturation ratio (TSAT) and serum ferritin levels rose by 6.8% (p<0.001) and 12.4% (p = 0.001), respectively. The mortality rate was similar for both periods. CONCLUSIONS The iron and ESA requirements are lower with the original i.v. iron compared to the generic drug. In addition, the uses of the original formulation results in higher ferritin and TSAT levels despite the lower dose of i.v. iron. Further studies are necessary to analyse the adverse effects of higher i.v. iron dosages.
Collapse
Affiliation(s)
- Maria Luisa Agüera
- Servicio de Nefrología. Hospital Universitario Reina Sofía, Córdoba, Spain; Instituto Maimónides de investigación biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, Spain; RedInRen, Instituto de salud Carlos III, Spain
- * E-mail:
| | - Alejandro Martin-Malo
- Servicio de Nefrología. Hospital Universitario Reina Sofía, Córdoba, Spain; Instituto Maimónides de investigación biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, Spain; RedInRen, Instituto de salud Carlos III, Spain
| | - Maria Antonia Alvarez-Lara
- Servicio de Nefrología. Hospital Universitario Reina Sofía, Córdoba, Spain; Instituto Maimónides de investigación biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, Spain; RedInRen, Instituto de salud Carlos III, Spain
| | | | | | - Sagrario Soriano
- Servicio de Nefrología. Hospital Universitario Reina Sofía, Córdoba, Spain; Instituto Maimónides de investigación biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, Spain; RedInRen, Instituto de salud Carlos III, Spain
| | - Pedro Aljama
- Servicio de Nefrología. Hospital Universitario Reina Sofía, Córdoba, Spain; Instituto Maimónides de investigación biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, Spain; RedInRen, Instituto de salud Carlos III, Spain
| |
Collapse
|
23
|
Ribeiro S, Belo L, Reis F, Santos-Silva A. Iron therapy in chronic kidney disease: Recent changes, benefits and risks. Blood Rev 2015; 30:65-72. [PMID: 26342303 DOI: 10.1016/j.blre.2015.07.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 07/31/2015] [Indexed: 12/16/2022]
Abstract
Anemia is a common complication in patients with chronic kidney disease (CKD), mainly due to inadequate renal production of erythropoietin. In hemodialysis (HD) patients this condition may be aggravated by iron deficiency (absolute or functional). The correction of this anemia is usually achieved by treatment with erythropoiesis stimulating agents (ESAs) and iron (oral or intravenous). Studies questioning the safety of ESAs (especially at higher doses) changed the pattern of anemia treatment in CKD patients. According to the new guidelines, when transferrin saturation is lower than 30% and ferritin lower than 500 ng/mL, a trial with iron should be started, to avoid therapy with ESAs or at least to reduce the doses needed to treat the anemia. Recent reports showed increasing ferritin levels, towards values above 800 ng/mL, in CKD patients treated according to the guidelines. In this review we focus on the risks of the increased iron use to treat CKD anemia, namely, iron overload and toxicity, increased risk of infections, as well as mortality.
Collapse
Affiliation(s)
- Sandra Ribeiro
- Research Unit on Applied Molecular Biosciences (UCIBIO), REQUIMTE, Department of Biological Sciences, Laboratory of Biochemistry, Faculty of Pharmacy, University of Porto, Rua Jorge Viterbo Ferreira, 228, 4050-313 Porto, Portugal.
| | - Luís Belo
- Research Unit on Applied Molecular Biosciences (UCIBIO), REQUIMTE, Department of Biological Sciences, Laboratory of Biochemistry, Faculty of Pharmacy, University of Porto, Rua Jorge Viterbo Ferreira, 228, 4050-313 Porto, Portugal.
| | - Flávio Reis
- Laboratory of Pharmacology & Experimental Therapeutics, Institute for Biomedical Imaging and Life Sciences (IBILI), Faculty of Medicine, University of Coimbra, Unidade 1, Polo 3, Azinhaga de Santa Comba, Celas, 3000-548 Coimbra, Portugal; Center for Neuroscience and Cell Biology, Institute for Biomedical Imaging and Life Sciences (CNC.IBILI) Research Unit, University of Coimbra, Polo 1, First floor, Rua Larga, 3004-504 Coimbra, Portugal.
| | - Alice Santos-Silva
- Research Unit on Applied Molecular Biosciences (UCIBIO), REQUIMTE, Department of Biological Sciences, Laboratory of Biochemistry, Faculty of Pharmacy, University of Porto, Rua Jorge Viterbo Ferreira, 228, 4050-313 Porto, Portugal.
| |
Collapse
|
24
|
Abstract
The practice of intravenous iron supplementation has grown as nephrologists have gradually moved away from the liberal use of erythropoiesis-stimulating agents as the main treatment for the anemia of CKD. This approach, together with the introduction of large-dose iron preparations, raises the future specter of inadvertent iatrogenic iron toxicity. Concerns have been raised in original studies and reviews about cardiac complications and severe infections that result from long-term intravenous iron supplementation. Regarding the iron preparations specifically, even though all the currently available preparations appear to be relatively safe in the short term, little is known regarding their long-term safety. In this review we summarize current knowledge of iron metabolism with an emphasis on the sources and potentially harmful effects of labile iron, highlight the approaches to identifying labile iron in pharmaceutical preparations and body fluids and its potential toxic role as a pathogenic factor in the complications of CKD, and propose methods for its early detection in at-risk patients.
Collapse
Affiliation(s)
- Itzchak Slotki
- Division of Adult Nephrology, Shaare Zedek Medical Center and Hadassah Hebrew University of Jerusalem, Jerusalem, Israel; and
| | - Zvi Ioav Cabantchik
- Department of Biological Chemistry, Alexander Silberman Institute of Life Sciences, The Hebrew University of Jerusalem, Jerusalem, Israel
| |
Collapse
|
25
|
Shander A, Goodnough LT, Javidroozi M, Auerbach M, Carson J, Ershler WB, Ghiglione M, Glaspy J, Lew I. Iron Deficiency Anemia—Bridging the Knowledge and Practice Gap. Transfus Med Rev 2014; 28:156-66. [DOI: 10.1016/j.tmrv.2014.05.001] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Revised: 04/24/2014] [Accepted: 05/09/2014] [Indexed: 12/18/2022]
|
26
|
Prestia K, Bandyopadhyay S, Slate A, Francis RO, Francis KP, Spitalnik SL, Fidock DA, Brittenham GM, Hod EA. Transfusion of stored blood impairs host defenses against Gram-negative pathogens in mice. Transfusion 2014; 54:2842-51. [PMID: 24840185 DOI: 10.1111/trf.12712] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Revised: 02/14/2014] [Accepted: 03/13/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND Although human red blood cell (RBC) units may be refrigerator stored for up to 42 days, transfusion of older RBCs acutely delivers a large bolus of iron to mononuclear phagocytes. Similarly, iron dextran circulates in plasma for hours to days and is progressively cleared by mononuclear phagocytes, which return iron to plasma. Finally, malaria infection continuously delivers iron to macrophages by intra- and extravascular hemolysis. Studies suggest that iron administration increases infectious risk. STUDY DESIGN AND METHODS To assess the effects of increased iron availability on susceptibility to infection, we infected mice with model Gram-negative intracellular or extracellular pathogens (Salmonella typhimurium or Escherichia coli, respectively), accompanied by RBC transfusion, iron dextran administration, or malarial coinfection. RESULTS In our mouse models, transfusion of older RBCs exacerbates infection with both Gram-negative pathogens. Although iron dextran exacerbates E. coli infection to a similar extent as transfusion of corresponding amounts of iron, higher iron doses are required to produce comparable effects with S. typhimurium. Coinfection of mice with Plasmodium yoelii and S. typhimurium produces overwhelming Salmonella sepsis. Finally, treating mice with antibiotics abrogates the enhancing effect on E. coli infection of both older RBC transfusion and iron dextran administration. CONCLUSIONS Transfusion of older RBCs exacerbates Gram-negative infection to a similar extent as malaria coinfection or iron dextran administration. Appropriate antibiotic therapy abrogates the effect of older RBC transfusions on infection with E. coli. Iron delivery to macrophages may be an underappreciated mechanism mediating, at least some, adverse effects of RBC transfusions.
Collapse
Affiliation(s)
- Kevin Prestia
- Institute of Comparative Medicine, Columbia University Medical Center-New York Presbyterian Hospital, New York, New York; Department of Pathology and Cell Biology, Columbia University Medical Center-New York Presbyterian Hospital, New York, New York
| | | | | | | | | | | | | | | | | |
Collapse
|
27
|
Fell LH, Zawada AM, Rogacev KS, Seiler S, Fliser D, Heine GH. Distinct immunologic effects of different intravenous iron preparations on monocytes. Nephrol Dial Transplant 2014; 29:809-22. [PMID: 24523357 PMCID: PMC3967833 DOI: 10.1093/ndt/gft524] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Background Iron deficiency contributes to anaemia in patients with chronic kidney disease. I.v. iron is therefore widely used for anaemia treatment, although it may induce oxidative stress and activate monocytes. Different i.v. iron preparations are available, but interestingly their substance-specific immunologic effects are poorly studied. Methods We analysed the effect of iron sucrose, ferric carboxymaltose, iron isomaltoside 1000, low-molecular-weight iron dextran and ferumoxytol on classical, intermediate and nonclassical monocyte biology. We therefore stimulated in vitro mature monocytes and haematopoietic CD34+ stem cells during their differentiation into monocytes with different concentrations (0.133, 0.266, 0.533 mg/mL) of i.v. iron preparations. Alterations of monocyte subset distribution, expression of surface markers (CD86, CCR5, CX3CR1), as well as production of pro-inflammatory cytokines (TNF-α, IL-1β) and reactive oxygen species were measured using flow cytometry. Additionally, we analysed phagocytosis and antigen presentation capacity. Results We found specific immunologic effects after stimulation with iron sucrose which were not induced by the other iron preparations. Iron sucrose activated monocyte subsets leading to significantly increased CD86 expression. Simultaneously CD16 and CX3CR1 expression and monocytic phagocytosis capacity were decreased. Additionally, differentiation of monocytes from haematopoietic CD34+ stem cells was almost completely abolished after stimulation with iron sucrose. Conclusions Our findings demonstrate that specific immunologic effects of distinct i.v. iron preparations exist. The clinical relevance of these findings requires further investigation.
Collapse
Affiliation(s)
- Lisa H Fell
- Department of Internal Medicine IV - Nephrology and Hypertension, Saarland University Medical Center, Homburg, Germany
| | | | | | | | | | | |
Collapse
|
28
|
Crist MB, Melekhin VV, Bian A, Shintani A, Milne GL, Kallianpur AR, Dageforde LA, Haas DW, Hulgan T. Higher serum iron is associated with increased oxidant stress in HIV-infected men. J Acquir Immune Defic Syndr 2013; 64:367-73. [PMID: 24169121 PMCID: PMC3816092 DOI: 10.1097/qai.0b013e3182a60f36] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND F₂-isoprostanes (F₂-IsoP) are oxidant stress biomarkers that are higher in HIV-infected women than men. We explored whether the effect of hemoglobin (Hgb), serum iron, or anemia on F₂-IsoP is different between HIV-infected women and men. METHODS Plasma F₂-IsoP were quantified by gas chromatography/mass spectrometry; clinical and laboratory data were collected at enrollment or from the medical record. Multivariable linear regression was used to assess associations between F₂-IsoP and Hgb, anemia as a dichotomous variable, and serum iron with adjustment for age, sex, race, body mass index, CD4 lymphocyte count, self-reported current smoking status, and antiretroviral therapy. RESULTS Compared with men, women had lower Hgb [median: 12.7 (interquartile range: 11.8-13.9) vs. 14.9 (13.7-15.8) g/dL, P < 0.001], lower iron levels [75 (47-97) vs. 90 (69-121) µg/dL, P = 0.004], more anemia (29% vs. 10%, P < 0.001), and higher levels of F₂-IsoP [42 (32-62) vs. 36 (25-46) pg/mL, P < 0.001]. The relationship between iron and F₂-IsoP differed significantly between men and women (interaction P = 0.02). Men had a 21% (95% confidence interval: 8 to 36) increase in F₂-IsoP per interquartile increase in iron (P = 0.001), whereas no relationship was seen among women [-4% (-17 to 13, P = 0.65]. CONCLUSIONS Although women have overall higher F₂-IsoP than men, a relationship between circulating F₂-IsoP and iron levels was observed in men but not in women with HIV infection. The association between female sex and higher F₂-IsoP is not explained by iron or Hgb levels because the association persists when controlling for these factors. The role of iron in oxidant stress and sex-specific differences among HIV-infected individuals require further study.
Collapse
Affiliation(s)
- Matthew B. Crist
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Vlada V. Melekhin
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Aihua Bian
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Ayumi Shintani
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Ginger L. Milne
- Department of Medicine, Division of Clinical Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Asha R. Kallianpur
- Departments Genomic Medicine and Medicine, Cleveland Clinic Foundation/Lerner Research Institute, Cleveland, Ohio
| | - Leigh Anne Dageforde
- Department of Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - David W. Haas
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Todd Hulgan
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, Tennessee
| |
Collapse
|
29
|
Koskenkorva-Frank TS, Weiss G, Koppenol WH, Burckhardt S. The complex interplay of iron metabolism, reactive oxygen species, and reactive nitrogen species: insights into the potential of various iron therapies to induce oxidative and nitrosative stress. Free Radic Biol Med 2013; 65:1174-1194. [PMID: 24036104 DOI: 10.1016/j.freeradbiomed.2013.09.001] [Citation(s) in RCA: 288] [Impact Index Per Article: 26.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Revised: 09/05/2013] [Accepted: 09/05/2013] [Indexed: 02/07/2023]
Abstract
Production of minute concentrations of superoxide (O2(*-)) and nitrogen monoxide (nitric oxide, NO*) plays important roles in several aspects of cellular signaling and metabolic regulation. However, in an inflammatory environment, the concentrations of these radicals can drastically increase and the antioxidant defenses may become overwhelmed. Thus, biological damage may occur owing to redox imbalance-a condition called oxidative and/or nitrosative stress. A complex interplay exists between iron metabolism, O2(*-), hydrogen peroxide (H2O2), and NO*. Iron is involved in both the formation and the scavenging of these species. Iron deficiency (anemia) (ID(A)) is associated with oxidative stress, but its role in the induction of nitrosative stress is largely unclear. Moreover, oral as well as intravenous (iv) iron preparations used for the treatment of ID(A) may also induce oxidative and/or nitrosative stress. Oral administration of ferrous salts may lead to high transferrin saturation levels and, thus, formation of non-transferrin-bound iron, a potentially toxic form of iron with a propensity to induce oxidative stress. One of the factors that determine the likelihood of oxidative and nitrosative stress induced upon administration of an iv iron complex is the amount of labile (or weakly-bound) iron present in the complex. Stable dextran-based iron complexes used for iv therapy, although they contain only negligible amounts of labile iron, can induce oxidative and/or nitrosative stress through so far unknown mechanisms. In this review, after summarizing the main features of iron metabolism and its complex interplay with O2(*-), H2O2, NO*, and other more reactive compounds derived from these species, the potential of various iron therapies to induce oxidative and nitrosative stress is discussed and possible underlying mechanisms are proposed. Understanding the mechanisms, by which various iron formulations may induce oxidative and nitrosative stress, will help us develop better tolerated and more efficient therapies for various dysfunctions of iron metabolism.
Collapse
Affiliation(s)
- Taija S Koskenkorva-Frank
- Chemical and Preclinical Research and Development, Vifor (International) Ltd., CH-9001 St. Gallen, Switzerland
| | - Günter Weiss
- Department of Internal Medicine VI, Infectious Diseases, Immunology, Rheumatology, Pneumology, Medical University of Innsbruck, Innsbruck, Austria
| | - Willem H Koppenol
- Institute of Inorganic Chemistry, Department of Chemistry and Applied Biosciences, ETH Zurich, Zurich, Switzerland
| | - Susanna Burckhardt
- Chemical and Preclinical Research and Development, Vifor (International) Ltd., CH-9001 St. Gallen, Switzerland; Institute of Inorganic Chemistry, Department of Chemistry and Applied Biosciences, ETH Zurich, Zurich, Switzerland.
| |
Collapse
|
30
|
Fishbane S, Mathew A, Vaziri ND. Iron toxicity: relevance for dialysis patients. Nephrol Dial Transplant 2013; 29:255-9. [PMID: 24166458 DOI: 10.1093/ndt/gft269] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Iron deficiency is common among patients with advanced kidney disease, particularly those requiring hemodialysis. Intravenous iron is a convenient treatment to supplement iron and is widely used among hemodialysis patients. Its efficacy is well established that, with treatment, hemoglobin levels rise and erythropoiesis-stimulating agent dose requirements are reduced. However, the safety of intravenous iron with respect to patient-centered outcomes has not been adequately studied. A variety of studies have indicated potential safety concerns, but most have been of small numbers of patients and with end points studied that have unclear clinical relevance. In this study, issues related to iron toxicity are reviewed.
Collapse
Affiliation(s)
- Steven Fishbane
- Department of Medicine, Division of Nephrology, Hofstra North Shore-LIJ School of Medicine, Great Neck, NY, USA
| | | | | |
Collapse
|
31
|
Vaziri ND. Understanding iron: promoting its safe use in patients with chronic kidney failure treated by hemodialysis. Am J Kidney Dis 2013; 61:992-1000. [PMID: 23375852 DOI: 10.1053/j.ajkd.2012.10.027] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2012] [Accepted: 10/01/2012] [Indexed: 01/13/2023]
Abstract
Although judicious use of intravenous iron preparations is an indispensable part of anemia treatment in hemodialysis patients, their excessive and indiscriminate use can have insidious but serious adverse consequences. With recent implementation of the bundling reimbursement policy, use of intravenous iron preparations in the hemodialysis population has markedly increased. Excessive use of these agents potentially can exacerbate oxidative stress, inflammation, endothelial dysfunction, cardiovascular disease, and immune deficiency and potentially increases the risk of microbial infections in this population. Most of these adverse effects are mediated by iron-catalyzed generation of reactive oxygen species and the resultant cell injury and dysfunction. This review is intended to provide an overview of the nature and mechanisms of the adverse effects of iron overload and call for the judicious use of these vitally important products.
Collapse
Affiliation(s)
- Nosratola D Vaziri
- Division of Nephrology and Hypertension, Departments of Medicine and Physiology and Biophysics, University of California, Irvine, Orange, CA 92868, USA.
| |
Collapse
|
32
|
Toblli JE, Cao G, Oliveri L, Angerosa M. Comparison of oxidative stress and inflammation induced by different intravenous iron sucrose similar preparations in a rat model. ACTA ACUST UNITED AC 2012; 11:66-78. [PMID: 22309085 PMCID: PMC3343386 DOI: 10.2174/187152812798889358] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2011] [Revised: 10/13/2011] [Accepted: 10/31/2011] [Indexed: 11/22/2022]
Abstract
Iron sucrose originator (ISORIG) has been used to treat iron deficiency and iron deficiency anemia for decades. Iron sucrose similars (ISSs) have recently entered the market. In this non-clinical study of non-anemic rats, five doses (40 mg iron/kg body weight) of six ISSs marketed in Asian countries, ISORIG or saline solution (control) were administered intravenously over four weeks to compare their toxicologic effects. Vasodilatory effects, impaired renal function and hepatic damage were only observed in the ISS groups. Significantly elevated serum iron and transferrin saturation levels were observed in the ISS groups suggesting a higher release of iron resulting in higher amounts of non-transferrin bound (free) iron compared to ISORIG. This might explain the elevated oxidative stress and increased levels of inflammatory markers and antioxidant enzymes in the liver, heart and kidneys of ISS-treated animals. Physico-chemical analyses showed that the molecular structure of most of the ISSs differed greatly from that of the ISORIG. These differences may be responsible for the organ damage and oxidative stress observed in the ISS groups. Significant differences were also found between different lots of a single ISS product. In contrast, polarographic analyses of three different ISORIG lots were identical, indicating that the molecular structure and thus the manufacturing process for ISORIG is highly consistent. Data from this study suggest that ISSs and ISORIG differ significantly. Therefore, before widespread use of these products it would be prudent to evaluate additional non-clinical and/or clinical data proving the safety, therapeutic equivalence and interchangeability of ISSs with ISORIG.
Collapse
Affiliation(s)
- Jorge Eduardo Toblli
- Laboratory of Experimental Medicine, Hospital Alemán, School of Medicine, University of Buenos Aires, Av. Pueyrredon 1640, 1118 Buenos Aires, Argentina.
| | | | | | | |
Collapse
|
33
|
Daba A, Gkouvatsos K, Sebastiani G, Pantopoulos K. Differences in activation of mouse hepcidin by dietary iron and parenterally administered iron dextran: compartmentalization is critical for iron sensing. J Mol Med (Berl) 2012; 91:95-102. [DOI: 10.1007/s00109-012-0937-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2012] [Revised: 07/06/2012] [Accepted: 07/18/2012] [Indexed: 10/28/2022]
|
34
|
Ghoti H, Rachmilewitz EA, Simon-Lopez R, Gaber R, Katzir Z, Konen E, Kushnir T, Girelli D, Campostrini N, Fibach E, Goitein O. Evidence for tissue iron overload in long-term hemodialysis patients and the impact of withdrawing parenteral iron. Eur J Haematol 2012; 89:87-93. [PMID: 22435497 DOI: 10.1111/j.1600-0609.2012.01783.x] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND/AIMS Erythropoiesis in long-term hemodialyzed (LTH) patients is supported by erythropoietin (rHuEpo) and intravenous (IV) iron. This treatment may end up in iron overload (IO) in major organs. We studied such patients for the parameters of IO in the serum and in major organs. METHODS Patients were treated with rHuEpo (6-8 x 10(3) units × 1-3/wk) and IV 100 mg ferric saccharate. RESULTS Of 115 patients, 21 had serum ferritin (SF) > 1000 ng/mL. This group was further analyzed. Their SF and transferrin saturation (TSAT) were 2688 ± 1489 ng/mL and 54.2 ± 32.7%, respectively (vs. 125-360 ng/mL and 20-50% in normal controls). Serum hepcidin was 60.1 ± 29.5 nm (vs. 10.61 ± 6.44 nm in controls) (P < 0.001). Nineteen patients had increased malonyldialdehyde, a product of lipid peroxidation, indicating oxidative stress. T2* MRI disclosed in 19 of 21 patients moderate to severe IO in the liver and spleen, in three of eight patients in the pancreas, but in no patient in the heart. After stopping IV iron for a mean of 12 months, while continuing rHuEpo, the mean SF decreased in 11 patients to 1682 ng/mL and the mean TSAT decreased to 28%, whereas hemoglobin did not change indicating that tissue iron was utilized. CONCLUSION High SF correlates with IO in the liver and spleen, but not in the heart.
Collapse
Affiliation(s)
- Hussam Ghoti
- Department of Hematology, E Wolfson Medical Center, Holon, Israel
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|